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Assessment Of
Dermatological Skin

PADAS FK UKRIDA

Dr. H.W.WONG Dip.Derm.
Dermatology Department
Medical Faculty
Christian University of Krida Wacana
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1. Overview of structure and function of the skin

The functions of the skin are complex. They include the
following :

The epidermis prevents water loss by evaporation
The dermis reduces risk of significant external injury.
Dermal blood flow maintains the epidermis and
permits body cooling via sweat glands and alterations
in surface blood flow.
The skin also plays a vital role in immune
surveillance.
Ultraviolet light protection.
Energy storage.
Sensory information.
Provides subtle signals associated with sexual
signalling.

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1. Overview of structure and function of the skin

Epidermis

This is approximately 0.1mm thick.
It acts as a barrier by
Preventing water loss.
Preventing UV damage.
Preventing toxin, antigen and pathogen invasion.


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Epidermis
It consists of :
Basal layer.
It is a 1 to 3 cells thick layer of proliferating stem cells.
At cell division, one daughter cell goes on to become a
differentiating keratinocyte whilst the other remains as an
undifferentiated stem cell.
It has pigment-producing melanocytes.
Prickle cell layer or stratum spinosum.
Keratinocytes in the spinous and granular layer produce keratin.
Keratinocytes are joined together by desmosomes.
Granular cell layer or stratum granulosum.
Keratinocytes in this layer produce a lipid-rich material which is
extruded onto the cell surface via membrane-coating granules
(syn. lamellar bodies, Odland bodies) formed on the Golgi
region of the cell.
Stratum corneum
This layer provides most of the barrier function of the epidermis.
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1. Overview of structure and function of the skin

Other functions of the epidermis

a) It is thickest on the palms and the soles due to thicker stratum
corneum.
b) In the epidermis, UVB irradiation converts epidermal 7-
dehydrocholesterol ultimately into vitamin D3, which is transported by a
binding protein into the circulation.
c) Pigment-producing melanocytes are situated within the basal layer of
the epidermis from where they transfer melanin into surrounding
keratinocytes, where it is stored in packages or melanosomes.
d) A significant proportion of natural photoprotection is also provided by
the stratum corneum, which becomes thicker in response to repeated UV
exposure. This natural sun screening effect is particularly important in skin
type 1 individuals who never tan but nevertheless achieve a degree
of photoprotection on chronically exposed sites.
e) Dendritic Langerhans cells are also present in the epidermis. These
make up part of the skin associated lymphoid tissues (SALT) and act
as the furthest outpost of the immune system. They are the principle antigen
presenting cells in allergic contact dermatitis.
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1. Overview of structure and function of the skin

Dermoepidermal junction

The junction between the dermis and epidermis is a complex structure called the
basement membrane zone (BMZ). Here the epidermis is literally stuck or held onto
the underlying dermis. Many blistering diseases are the result of abnormalities in the
ultrastructure of this zone.

The basement membrane zone consists of:

a) Hemidesmosones : These are focal thickenings
in the basal plasma membrane of keratinocytes.
They maintain adhesion between the epidermis
and the dermis. They consists of :
An intracellular component, the attachment plaque, which is associated with
tonofilaments in the basal cell.
An extracellular component, the sub-basal dense plate, which is located in
the lamina lucida.
b) The basement membrane : which has 3 layers
Lamina lucida consists of vertical anchoring filaments.
Lamina densa lies parallel to and below the lamina lucida.
Lamina fibroreticularis this has anchoring fibrils which are attached to the
lamina densa and the upper part of the dermis.


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1. Overview of structure and function of the skin

Dermis

Structure of the dermis
It is bounded distally by its junction with the epidermis and proximally by
the subcutaneous fat.
The dermis is the fibrous part of the skin consisting chiefly of collagen
produced by fibroblasts.
Dermal thickness varies with body site, e.g. thick on the back (4mm)
and thin around the eyes (<1mm)
Functions of the dermis
It acts as a barrier against physical trauma.
It supports the contained blood vessels, nerves and lymphatics.
It provides nutrition to the epidermis. Blood vessels stop at the BMZ so
that the epidermis has to be supplied with nutrients and oxygen by
diffusion; hence the limited thickness of the epidermis.

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1. Overview of structure and function of the skin

Cutaneous blood flow
Blood supply to the skin is believed to be delivered by regularly
spaced, vertically orientated arterioles that each supplies a
broadly circular-shaped area of skin at the surface.
The haemoglobin contained in dermal blood vessels is a
significant pigment or chromophore in the skin, responsible for
the pink component of skin colour.
The borders between adjacent areas of supply thus receive
blood that has a lower oxygen content and flow rate compared to
the area immediately around the central feeding vessel.
This pattern of blood supply to the skin leads to the marbled or
reticulate (net-like pattern) purplish discolouration of cold skin
seen on otherwise healthy individuals who have become cold
(i.e. physiological livedo reticularis).

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1. Overview of structure and function of the skin

Adnexal structures

a) Pilosebaceous glands
Each gland contains a hair follicle and sebaceous gland, the relative size of
each varying with the anatomical site.
Function of hair is chiefly self-adornment.
Scalp hair is useful for sun protection
b) Eccrine sweat glands
They are present all over the skin but the duct openings are only visible with
the naked eye on the fingers and toe pads.
Evaporation of sweat results in loss of latent heat of vaporization, resulting in
cooling of the skin.
c) Apocrine sweat glands
They are only found in the axillae, scalp and groin.
Their function is presumably chiefly related to scent or pheromone
production.
d) Facial musculature
It attaches to skin and enables a vast range of non-verbal signals to be
imparted.
These, along with hair, nails, and body odour production by apocrine glands,
contribute to the rich variety of social signalling produced by the skin and
used by humans.

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2. Impact of skin disease on quality of life

Chronic skin disease can have a devastating impact on the patient's life.
As most skin diseases are not associated with significant mortality, skin disease
may be disregarded when competing with life-threatening diseases for limited
funds.
To overcome these problems, various quality of life measures have been
developed. These include:
Disease specific questionnaires
e.g. for psoriasis, acne, eczema.
Dermatology specific questionnaires These can be used in any skin disease to
provide an overall measure of disease impact.
Quality of life questionnaires
These take into account the effect a skin disease has on the patient's
physical ability, their self-esteem, job opportunities, sex and social life.
Compared to objective measurements they give a more realistic estimate
of the impact of the disease on the patients life, e.g. psoriasis extent may
reduce by half after treatment, but if the same site is still affected the
patient might not perceive this as a useful improvement.
They can be used for clinical, research, audit purposes and to win
additional resources for the sufferers.

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3. Taking a dermatological history

The history is a complex and selective process based on a
variety of factors that stem from an understanding of the
implications of the diagnosis.
A more detailed history may be required after a working
diagnosis is made to elucidate the cause or plan therapy.
A structured dermatology history is suggested, though rigid or
uncritical adherence to all its components is not required in every
patient.
One must take into account the limitations of the person's
descriptive powers and recall.
Some patients need to be encouraged to express their theories
about causation and therapy in order to ensure that what he or
she perceives as important factors have not been overlooked.


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4. Examining a dermatology patient

The patient must be warm and comfortable.
The doctor needs good lighting, magnification and adequate exposure
of the affected area.
A patient with a solitary lesion rarely needs to be fully undressed and
frequently only the lesion and adjacent anatomy need to be examined.
A patient with a rash needs to be examined fully, when they are lying
flat.
The correct couch height enables the doctor to make unhurried and
adequate observations.
Always examine both hands and feet, if these sites are involved, to
exclude an id reaction
(an allergic type reactive eczema that occurs at distant sites in
someone with a fungal infection, usually of the feet) or endogenous
rashes (e.g. hand and foot eczema or psoriasis) that superficially
appear to be exogenous.
General examination of all systems is rarely required but an
examination of relevant organ systems must be made, e.g. peripheral
pulses in leg ulceration, and draining lymph nodes and organomegaly in
patients with potentially metastatic tumours.

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4. Examining a dermatology patient
Explanation of terms used in examination (plaque, nodule etc.) with photographic
examples

Macules
A macule is a flat (i.e. not palpably raised) coloured lesion, usually red, brown or
depigmented.
Any associated fine scale indicates abnormal keratinocyte function as well as
melanocyte or blood vessel involvement.
Example: Lentigo simplex. This benign, flat, tan-coloured epidermal macule is
due to a localised increase in basal epidermal melanocyte numbers.
Papules
A papule is a palpably raised lesion <1cm in diameter
Nodules
A nodule is a palpably raised lesion >1cm in diameter.
Most of the nodule may lie beneath the skin surface (e.g. lipoma).
Example: Basal cell carcinoma (BCC) pearly telangiectatic nodule. Sometimes
the centre of the tumour degenerates, producing central necrosis, so that only
the edge is raised up forming the so-called rolled edge.
Plaques
Plaques are flat-topped, slightly raised, or palpably different areas of skin; scaling
is commonly present.
Example: Psoriasis. Scaly, well-defined red plaques are characteristic of
psoriasis.

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4. Examining a dermatology patient
Weals
Weals are the result of rapid leak of
fluid from the blood vessels into the dermis.
Vessels and lymphatics quickly reabsorb this fluid so that in simple urticaria the
individual weals last for less than 24 hours, although
new weals may be continually formed.
The whole episode may last for many days
if not controlled by oral antihistamines.
Differential diagnoses of Weals
a) Urticaria
The weals can adopt any shape and size and may appear as papules, nodules,
annular or arciform lesions.
They do not show any surface changes as they are entirely due to dermal
oedema.
They do not last for more than 24 hours as vessels and lymphatics quickly
absorb the dermal fluid.
Idiopathic urticaria. Urticaria has a variety of causes but commonly no cause is
found. Patients develop multiple raised, itchy, red weals.
b) Urticated plaques or papules
Here the weals last for more than 24 hours.
They occur in conditions like vasculitis, lupus erythematosus and some drug
reactions.
c) Weals with surface changes
This indicates presence of associated epidermal disease and is therefore not
simple urticaria.
d) Blisters
Patients often mistakenly describe weals as blisters.
Blisters leak fluid and collapse when pricked, weals do not.

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4. Examining a dermatology patient
Vesicles
These are small fluid filled blisters, < 5mm in diameter.
They are usually intra-epidermal.
Example. acute eczema
Bullae
These are large fluid filled blisters, > 5mm in diameter.
Bullae and vesicles contain fluid and when pricked, the liquid leaks out
and the blister collapses.
They can arise within the epidermis, e.g. pemphigus vulgaris, or just
beneath the epidermis, e.g. dermatitis herpetiformis or bullous
pemphigoid where blisters arise on an urticated base
Pustules
Pustules result from the accumulation of large numbers of leukocytes in
the epidermis or upper dermis.
Surface pustules have a turbid yellowish colour.
Pustules can begin either as clear-fluid-filled blisters which then attract
pus cells (e.g. Herpes simplex), or directly by accumulation of
polymorphs e.g. acne, pustular psoriasis.
A deeper collection of pus produces a palpable nodule or abscess and
the yellow pus is not visible.

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4. Examining a dermatology patient
Erosion, Ulcer, Fissure And Excoriation.

Ulcers, erosions, excoriations and fissures represent breaks in the skin surface:
Erosions are produced by surface loss chiefly involving only the epidermis, e.g. a
burst bullous pemphigoid blister.
Ulcers extend the tissue loss into the dermis, e.g. leg ulcer.
A fissure is a narrow, deep, cleft-shaped ulcer, e.g. angular cheilitis.
Excoriations are scratch marks. They may result in erosions or ulcers.
Scale
Surface scale or flaking of the skin is the result of loss of a damaged stratum
corneum (e.g. a fungal infection or abnormal stratum corneum (e.g. psoriasis).
Do not confuse with hyperkeratosis, i.e. thickening of stratum corneum, which
can occur with scaling, e.g. psoriasis, or without scaling, e.g. a keratin horn
The presence of scaling indicates an abnormality of the epidermis.
When scratched, a scale usually fragments into layers and becomes whiter.
Crust
A crust, or scab, is a dried surface exudate
of blood or serous fluid.
It is usually a single adherent scab that can be picked off.
The presence of a crust indicates that tissue fluid or blood has leaked through
the epidermis as a result of inflammation or some other abnormality of the
epidermis.
Scaling and crusting may be difficult to distinguish and the two may occur together,
e.g. Bowens disease
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4. Examining a dermatology patient
Atrophy
Atrophy indicates thinning of epidermis, dermis, or both.
Dermal Atrophy

This results in loss of collagen, the major component of the dermis.
The skin feels thinner and becomes more transparent so that blood vessels,
tendons, etc. can be seen through it.
The body sometimes reacts to dermal atrophy by producing scar tissue (e.g.
lichen sclerosis et atrophicus) although scarring and atrophy are not the same.
Example: Topical corticosteroid induced dermal atrophy.

Leads to loss of dermal collagen; the skin is thinner and transparent.
This is frequently associated with steroid induced purpura.
Purpura results because blood vessels are not properly supported by, or
packed around with, normal collagen, so that a small shearing force easily
results in the blood vessel bursting.

Epidermal atrophy
Epidermal atrophy results in a featureless, often shiny, hairless skin surface.
Sclerosis (Hard Skin)
Sclerotic skin feels firm and indurated, but it may look relatively normal.
The surface of the sclerotic skin is often white and shiny with loss of skin ridges
and markings.
Sclerosis can occur due to:
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An expansion of the collagen by ground substance material (e.g. mucin)
A change in the collagen quality, e.g. the increased cross-linking between
individual collagen fibres that occurs in insulin-dependent diabetes.
An increase in the amount of dermal collagen, e.g. in morphoea. Here
inflammation within the dermis and epidermis results in a damaged and
hardened dermal collagen. On the fingers the loss of normal skin mobility means
that the skin may appear to be thickened rather than just immobile and hard.
Erythema, Telangiectasia, Purpura, Petechiae and Ecchymosis
These result from changes in dermal blood vessels.
Erythema is diffuse redness caused by vasodilatation and/or increased blood
flow in vessels deep in the skin so that the individual vessels are not visible.

Telangiectasia are distinguishably visible vessels close to the surface.

Purpura is caused by blood that has leaked from dermal blood vessels and
therefore cannot be blanched by pressure.

Pinpoint spots of purpura are called petechiae; extravasated blood in fat and
muscle is an ecchymosis or bruise.
Poikiloderma
This is the combination of atrophy, pigmentation and telangiectasia and may occur after
radiation therapy to the skin.


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4. Examining a dermatology patient
Shapes and patterns
a) Discoid or Nummular
These are circular or coin-shaped lesions, e.g. discoid eczema and psoriasis.
In solitary discoid lesions the edge or border is characteristically regular in
benign conditions (e.g. in psoriasis) and irregular in malignant conditions (e.g. in
Bowen's disease).
b) Annular
This describes a ring shape and can be produced by many skin conditions.
Annular urticaria lesions are non-scaling and come and go within 24 hours.
Erythema annulare centrifugum lesions have a trailing scaly edge and take
weeks to change.
Fungal annular lesions are diffusely scaly with a scaly trailing edge and change
in weeks to months.
c) Target
Concentric rings of different colours or shades occur in vascular-based
inflammatory conditions
Occurs presumably because the effect of the vascular insult has different
consequences at different distances from the central damaged vessel e.g.
erythema multiforme, vasculitis, lupus erythematosus and urticaria.

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4. Examining a dermatology patient

d) Oval and Digitate
These are often seen together in exanthematous rashes.
On the trunk these are usually uniformly aligned with long axes orientated
downwards and outwards. The best example is the fir-tree pattern seen in
pityriasis rosea.
Digitate lesions are more elongated ovals, and typically occur in digitate
dermatosis, a benign variant of chronic superficial dermatitis or parapsoriasis.
e) Serpiginous, Rippled or Gyrate
These 3 terms describe wavy line variants.
A serpiginous or snake-like wavy line is the pattern left by larva migrans and
scabies mites as they burrow through the skin.
Rippled or gyrate describes a series of wavy but parallel lines.
f) Dermatomal
Rashes (e.g. herpes zoster, zosteriform psoriasis) or lesions (e.g. epidermal
naevus) may follow a dermatome distribution.

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g) Reticulate, Livedo And Cribriform
These terms describe the net-like pattern that may be seen in certain rashes,
erythema and scarring respectively.
Reticulate (retiform) describes a lace-like pattern of a rash (e.g. Rothmann
Thompson Syndrome), or of individual lesions (e.g. Wickhams striae in lichen
planus)
Livedo mottling
This describes the reticulate pattern produced by the inequalities of cutaneous
blood supply that arise as a consequence of the pattern of skin vascular
supply.
The darker areas result from deoxygenated blood flow in the low flow or
watershed areas between the higher flow, central, pink areas that are better
supplied with blood by the feeding arteriole.
Diseases may be selectively localised into these low blood flow areas, e.g.
polyarteritis nodosa.
Cribriform describes a colander or sieve-like pattern of scarring seen in areas of
resolved pyoderma gangrenosum.

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4. Examining a dermatology patient
Arrangements of multiple lesions.

a) Grouped lesions
Grouped lesions are multiple but separate lesions centred around one
area for example, insect bite reactions and herpes simplex virus
infection.
b) Scattered and disseminated
Multiple lesions at different sites without any other specific patterns are
disseminated (small lesions) or scattered (irregular lesions).
c) Exanthematous
Exanthematous describes the multiple, red, usually truncal, scaly
lesions that occur in some drug eruptions or viral exanthems. They
usually do not have the same uniform fir-tree pattern of distribution seen
in pityriasis rosea.
d) Confluent
Multiple lesions becoming merged together either because there are
so many or the individual lesions have enlarged are called confluent,
for example, pityriasis versicolor and psoriasis.
e) Erythroderma
This describes total, or virtually total, redness of the skin as a result of
eczema, psoriasis, drug eruptions, Sezary syndrome or other rarer skin
diseases (e.g. pityriasis rubra pilaris and lichen planus).

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4. Examining a dermatology patient
Other useful patterns

a) Symmetry and asymmetry
A symmetrical distribution (e.g. psoriasis, atopic dermatitis, viral exanthemata)
implies an endogenous or systemic cause of the rash. An asymmetrical rash
suggests the possibility of an exogenous cause, such as a skin infection and
fungal infection in particular.
b) Photosensitive
Skin reactions caused by sun exposure affect the face, nape and V of the neck,
and dorsum of the hands and arms. Characteristically there is sparing of
naturally shaded sites.
c) Linear, angulated or geometric shapes
Geometrically shaped lesions for example, linear, square, perfect circles, or
oddly shaped should raise the possibility of an external cause, especially if the
surface is eroded or ulcerated.
The injury may be accidental in normal or fragile skin, or deliberately induced by
the patient (i.e. dermatitis artefacta) or others (i.e. non-accidental injury in
children). Remember the odd patterns produced by reactions to adhesive
dressing plasters and so on.
d) Sparing
Observing which body sites are not affected by a rash can be diagnostically very
helpful.
Patients with generalised pruritus, scratch very vigorously, producing multiple
excoriations. However, the observation that areas are spared where the patient
cannot reach to scratch (usually the upper back) demonstrates that the visible
changes are a result and not a cause of the itch.
Similarly, sparing in sun-protected sites in a light-induced or light-aggravated
dermatosis, or the selective involvement of skin flexures in airborne contact
allergic reactions, can be helpful.

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5. References
Finlay AY. Quality of life measurement in dermatology: a practical guide. Br J
Dermatol.1997 Mar;136(3):305-14.
Ashton R The art of describing skin lesions
Part 2 Dermatology in Practice May/June 1998.
Ashton R The art of describing skin lesions Part 3 Dermatology in Practice
July/August 1998.
Physical Signs in Dermatology, 2nd ed. Clifford Lawrence, Neil H Cox. Mosby,
London, 2001 ISBN 0-7234-3184-1