dr.

NM Dwi Puspawati, SpKK

Bag/SMF I. Kes. Kulit & Kelamin
FK Unud/RS Sanglah Denpasar

The art of Diagnosis in General :

Anamnesis
Physical Examination
Laboratory finding
Detailed systematic history with good physical
examination, supplemented by appropriate laboratory
test will be the golden rule for the correct approach in
the diagnosis

GENERAL HISTORY
1. Race, geographical
2. Social background, ethnic tradition, dietary habits
3. Past medical history : allergy to medication, hay fever,
asthma, past major illness or operation
4. Social & occupational history: travel abroad, hobbies
and details of the type of work, substances in contact

SPECIAL HISTORY
History of present illness : duration, date & site of onset,
details of spread, evolution of rash & original morphology,
symptoms such as itchiness, pain, burning sensation, numbness,
precipitating and relieving factors such as climate, sunlight
etc., treatment (topical & systemic medication) sought or
applied
Past history of skin disorders : history of sunburn
Family history of skin disorders : e.g. skin cancers and atopic
disorders/stigmata atopic
Drugs : include herbs, topical, systemic, patient initiated or
physician prescribed. Patient's own perception on the cause of
the problem

EXAMINATION OF SKIN

1. Adequate privacy
2. Good lighting
3. Spatula, magnifying glass and transparent glass slide for
diascopy
It is a good practice if affordable to have thorough
examination of the whole body especially for new
consultation and for the elderly
Sometimes, examination of the back and buttock of the
elderly may pick up unexpected lesions, even the patient
himself or herself may not notice them e.g. persistent
chronic annular erythematous rash in the buttock found in
a case of tuberculoid leprosy

Do not skip examination of the nail, scalp and oral mucous

membrane because there may be valuable clues, find the
atopic stigmata
In dermatology : unique of physical examination by the
visual of the skin and the skin lesions EFFLORESCENCE
Good and clear description of skin lesion can be diagnosed
of some skin disease with a high degree of confidence

EFFLORESCENCE :
A skin lesion is an abnormal growth or an area of skin that
does not resemble the skin surrounding it (normal skin)
Objective appearance

DETAIL DESCRIBED OF SKIN LESION :

1.Type of skin lesion
2.Characteristic of lesion : colour, multiple or soliter,
shape, margin, size, surface characteristics, temperature
and smell
3.Arrangement and configuration
4.Distribution

1. Type of skin lesion :

1.1. Primary lesion :
Macula
Papule
Plaque
Vesicle
Pustule

Nodul
Urtica
Bula
Cyst

1.2. Secondary lesion :

Scale
Lichenification
Crust
Atrophy
Ulcer
Scar
Erosion
Fissure
Excoration

2. Characteristic of skin lesion :

Colour salmon-pink, erythematous,
hyperpigmented, skin colour, yellow
Multiple or soliter
Shape geometric shape, oval
Margin sharpness of edge, well-defined, ill-defined
Size diameter, punctata, numuler
Surface characteristics dome-shaped, umbilicated,
spike like
Temperature and smell warm on palpation, mousy
odor

3. Arrangement and configuration :

Grouped as in dermatitis herpetiformis, herpes
simplex, common warts
Annular or arciform as in granuloma annulare, mycosis
fungoides, tinea circinata, erythema annulare
centrifugum
Linear pattern as in lichen planus, lichen striatus,
morphoea, lichen sclerosis, phytophotodermatitis

4. Distribution :
symmetrical, asymmetrical
exposed area, sun exposed area
scalp region, hand
extensor aspect, flexor aspect

PRIMARY LESION
Primary lesions are the first to
appear and are due to the
disease or abnormal state

A. MACULE
flat, nonpalpable circumscribed area of color change
in the skin. Macules are < 1-2 cm in size.
Macules may be the result of
(A)inflammatory vascular dilation/hyperemia
(B)bleeding/hemorhagia/purpura
(C)change of skin pigmentation

A.1. Hyperemia (vascular dilatation)

(Latin hyper- = over; -emia = related to blood) is a
temporary skin redness due to increased blood flow in a
particular skin, or mucosalarea. The lesion blanch upon
pressure (diascopy).
1. Roseola ( 1cm/nail plate)
2. Erytematous (> 1 cm)
3. Telengictasis : dilated
superficial blood vessels,
especially of the upper
reticular dermal plexus.

A.2. Hemorhagia/purpura
A purpura (Latin purpura = purple) is asmall (3mm
1 cm) purplish bruise/ violaceous color due to
extravasations of blood into the tissue. It does not
blanch on applying the pressure.
1.Petechia : (Latin petecchia (plural = petechiae)=
spot on skin) is a small (< 3 mm) red or purple bruise
2.Vibises
3.Ecchimoses (large, > 3 mm)
Ecchimoses, purpurae, and petechiae are caused by
trauma, or disorders of the blood or vessels

A.3. Change of skin pigmentation

1. Hyperpigmentation increase of pigmentation
o. Melasma gravidarum
o. Efelides/frikel
o. Drugs : Sulfonamide, Kina
o. Addisons disease
o. Mongolian spot

Hiperpigmentation

2. Hypopigmentation decrease of pigmentation

o. Pithyriasis versicolor
o. Leucoderma
3. Depigmentasi no pigment
o. Vitiligo

Hipopigmentation

B. PAPULE
Small solid elevation of skin generally < 5 mm in diameter.
Papules may be flat-topped, as in lichen planus; or dome shaped, as
in xanthomas; or spicular, ifrelated to hair follicles
Papules may result from :
(A) dermal metabolic deposits
(B) localized dermal cellular infiltrates
(C) localized hyperplasia of dermal or epidermal cellular
elements

Two firm dome-shaped papules - dermal

melanocytic nevi
Multiple well-defined and coalescing papules lichen planus.

C. PLAQUE
palpable, plateau-like elevation of skin, usually more than 2
cm in diameter and rarely more than 5 mm in height. Often
formed by a convergence of papules, as in psoriasis.

Plaques occupy a relatively large

surface area in comparison with its
height above the skin.

Well-defined, reddish,
scaling plaques

D. VESICLE

Vesicles are raised lesions less than 1 cm. in diameter

that are filled with clear fluid. Vesicle walls can be so
thin that the contained serum, lymph, blood, or
extracellular fluid is easily seen. Fluid can be
accumulated within or below the epidermis.

E. BULA (BLISTER)
Bula (Lat. bulla = bubble) is a vesicle that exceeds 1 cm in size
circumscribed, elevated lesion that is > 1 cm in diameter, containing
serous (clear) fluid. A vesicle/bulla is the technical term for
blisters.

F. PUSTULE
superficial, elevated lesion that contains pus (pus in
a blister). Pustules may vary in size and shape. The
color may appear white, yellow, or greenish-yellow
depending on the color of the pus. Pus is composed
of leukocytes with or without cellular debris. It
may also contain bacteria or may be sterile.

Superficial, subcorneal
pustules - pustular psoriasis

A pustule is basically a papule

containing pus

G. NODULE
palpable, solid, round, or ellipsoidal lesion. Its depth of involvement
and/or palpability differentiate it from a papule rather than its
diameter (although nodules are usually larger than papules: > 5 mm
diameter). Nodules can involve any layer of the skin and can be
edematous or solid. Based on the anatomical component(s) involved,
there are five types of nodules: epidermal, epidermal-dermal, dermal,
dermal-subdermal, and subcutaneous.Telangiectasia can be seen

H. CYST
An epithelial lined cavity containing
liquid or semisolid material (fluid, cells,
and cell products). A spherical or oval
papule or nodule may be a cyst if, when
palpated, is resilient (feels like an
eyeball).
1. Most common are (A) epidermal
cysts, lined by squamous epithelium and
produce keratinous material. (B) Pilar
cysts, lined by multilayered epithelium
which does not mature through the
granular layer.
2. Bluish, resilient cyst filled with
mucous material - adnexal tumor
(cystic hidradenoma).

I. WHEAL OR URTICA
Transitory, compressible papule
or plaque of dermal edema.
The papule or plaque is usually
rounded or flat-toped, and
evanescent, disappearing within
hours. The borders of a wheal
are sharp, but not stable and
can move from involved to
adjacent uninvolved areas over
hours.
A wheal may be large coalescing
plaques as in this allergic
reaction.

An eruption of wheals is termed urticaria and

usually itches

J. SPECIAL LESION
- Comedo acne
- Telengiectasion
- Burrow scabies

SECONDARY LESION
Result from the natural
evolution of primary lesions

A. SCALE
Scale accumulation or abnormal shedding of horny
layer keratin (stratum corneum) in perceptible
flakes. Scales usually indicate inflammatory change
and thickening of the epidermis. The may be fine,
as in pityriasis; white and silvery, as in psoriasis; or
large and fish-like, as in ichtyosis

(A) Parakeratotic scale (with

retained nuclei) can be seen in
psoriasiform epidermal
hyperplasia

(B) Actinic keratosis is a

densely adherent scale with
gritty feel due to a localized
increase in stratum corneum

Typical psoriasis scaling

Scales may build up to form an asbestos-like layer

covering the underlying lesion.

B. ULCER
circumscribed area of skin loss
extending through the epidermis
and at least part of the dermis
(papillary).
1. Basically, it's a "hole in the
skin". Ulcers usually result from
the impairment of vascular and
nutrient supply to the skin.
2. Gigantic ulcer, red granulating
base with punched out borders.

C. CRUST
Dried serum, blood, or pus
on the surface of skin.
May be thin, delicate, and
friable or thick and
adherent.

Crusts are yellow, if from

serum; green or yellow-green
if from pus; or brown or
dark red if formed from
blood. Characteristic of
pyogenic infections.
Crusts that occur as
honey-coloured, delicate,
glistening particulates are
typical of - Impetigo.

D. EROSION & EXCORATION

Erosion: moist, circumscribed,
slightly depressed areas of skin
due to loss of all or part of the
epidermis
1. Often results from eruptions
of vesicles and bullae. Seen in
infection from herpes viruses and
in pemphigus.
2. Toxic epidermal necrosis
causes erosion.

Excoriation: linear or
punctate superficial
excavations of epidermis
caused by scratching,
rubbing, or picking.

E. LICHENIFICATION
Chronic thickening of the skin along with increased skin
markings. Results from scratching or rubbing.

F. ATROPHY
There is loss of normal skin texture
Paper-thin, wrinkled skin with easily visible
vessels. Results from loss of epidermis,
dermis or both. Seen in aged, some burns,
and longterm use of highly potent topical
corticosteroids.
(A) Dermal atrophy manifests as a
depression in the skin
(B) Epidermal atrophy manifests as thin
almost transparent skin; may not retain
normal skin lines.

G. SCAR
Replacement of normal
tissue by fibrous connective
tissue at eh site of injury to
the dermis. Scars may be
hypertrophic, atrophic,
sclerotic or hard due to
collagen proliferation.
Reflects pattern of healing
in the affected area.
1. (A) Hypertrophic or (B)
atrophic scar.
2. Hypertrophic scar.

H. FISSURE (RHAGADE)
A fissure is linear cleavage of skin which extends
into the dermis.

ARRANGEMENT AND
CONFIGURATION

1. LINEAR LESION
Linear lesions occur in a line
or band-like configuration.
This descriptive term may
apply to a wide variety of
disorders. One should be
certain that the lesions are
not following a dermatome

2. KOEBNER PHENOMENON
The Koebner phenomenon,
also called the isomorphic
response, refers to the
appearance of lesions along
a site of injury. This
phenomenon is seen in a
variety of conditions; for
example, lichen planus,
warts, molluscum
contagiosum, psoriasis,
lichen nitidus, and the
systemic form of juvenile
rheumatoid arthritis.

3. GUTTATE

Guttate lesions look as

though someone took a
dropper and dropped this
lesion on the skin. Guttate
lesions are characteristic
of one form of psoriasis,
though that is not the only
example.

5. ANNULAR
Annular lesions are seen in a ring shape. Tinea corporis,
erythema migrans (the lesion associated with lyme
disease), and granuloma annulare are three common
examples.

6. CONFLUENT
Confluent lesions tend to run together

DISTRIBUTION OF SKIN
LESION