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

GENERAL HISTORY
1. Race, geographical
2. Social background, ethnic tradition, dietary habits
3. Past medical history : allergy to medication, 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.
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

EXAMINATION OF
THE SKIN

1. Adequate privacy
2. Good lighting
3. 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
Do not skip examination of the nail, scalp and oral mucous
membrane because there may be valuable clues, find the
atopic stigmata

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, 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
Annular or arciform as in granuloma annulare, tinea
circinata
Linear pattern as in lichen planus, lichen striatus

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. The
lesion blanch upon pressure (diascopy).
1. Roseola ( 1cm/nail plate)
2. Erytematous (> 1 cm)
3. Telengictasis : dilated
superficial blood vessels

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)
2.Vibises
3.Ecchimoses (large, > 3 mm)

A.3. Change of skin pigmentation

1. Hyperpigmentation increase of pigmentation
o. Melasma gravidarum
o. Mongolian spot
2. Hypopigmentation decrease of pigmentation
o. Pithyriasis versicolor
o. Leucoderma
3. Depigmentasi no pigment
o. Vitiligo

Hipopigmentation

Hiperpigmentation

B. PAPULE
Small solid elevation of skin generally < 0,5 cm in diameter.
Papules may be flat-topped, dome shaped, or spicular
Papules may result from localized hyperplasia of dermal or
epidermal cellular elements

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.

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 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.

F. PUSTULE
superficial, elevated lesion that contains pus (pus in a
blister). Pustules may vary in size and shape. Pus is
composed of leukocytes with or without cellular debris. It
may also contain bacteria or may be sterile.

G. NODULE
Nodule is a solid, round, or ellipsoidal palpable lesion that has a
diameter larger than 0,5 cm. Nodules can involve any layer of the skin.
Based on the anatomical components involved, there are five types of
nodules: epidermal, epidermal-dermal, dermal, dermal-subdermal, and
subcutaneous.

H. CYST
An encapsulated or 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).
(A) epidermal cysts, lined by
squamous epithelium and produce
keratinous material. (B) Pilar
cysts, lined by multilayered
epithelium

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

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. They may be fine,
white and silvery, or large and fish-like, as in
ichtyosis

B. ULCER
circumscribed area of skin loss
extending through the epidermis
and at least part of the dermis
(papillary).
Basically, it's a "hole in the skin".
Ulcers usually result from the
impairment of vascular and
nutrient supply to the skin.

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.
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.

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
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 the site of injury
to the dermis. Scars may be
hypertrophic, atrophic,
sclerotic or hard due to
collagen proliferation.
(A) Hypertrophic or (B)
atrophic scar

Hypertrophic
scar

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

SHAPE, ARRANGEMENT
AND CONFIGURATION

Annular = Ring shaped

Granuloma
annulare,tinea
corporis,erythema
annulare centrifugum

Numular/discoid = Coin
shaped with uniform
morphology from the
edges to the center.

Nummular eczema,
plaque-type
psoriasis,discoid lupus

Polycyclic = formed from

coalesing circle

Urtikaria,subacute
cutaneus

Arcuate = arc shape,

result from incomplate
formation of an annular
lesion

Urtikaria,subacute
cutaneus lupus
eritematosus

Linear = straight line

Scabies burrow,
poison ivy dermatitis,
lichen nitidus, lichen
planus(lesi multipel

Reticular = net-like

Livedo reticularis

Serpiginous = snake-like

Cutaneus larva
migrans

Targetoid = target-like

Erytema multiforme

Whorled = like marbel

cake

Incontinentia pigment

Herpetiformi
s

Lesions clustered together

(e.g. herpes simplex)

Scattered

Irregularly
distributed

DISTRIBUTION OF SKIN
LESION

EXAMINATION OF
THE HAIR

 Evaluate hair quantity and quality

its length, density, colour and texture
Look for associated skin conditions,
especially those affecting the scalp
Hair loss associated with excessive
shedding positive Hair pull test

HAIR PULL TEST

Grasp a lock of hairs to determine if any
can be extracted with firm pull
Normally 0-2 telogen hairs can be
extracted: these are hairs in the resting
phase, identified using magnification by a
rounded bulb at the proximal end
An elongated or tapered end indicates
anagen hair (growing phase). Anagen hairs
extracted by the gentle hair pull test are
pathologic.

Thinned or absent hair

Thinning hair or balding (alopecia) may be localised or
diffuse.
Localised alopecia may affect a single or multiple areas.
Evaluate :
1. Round/oval, moth-eaten or linear bald patches
2. Short hairs: these may be tapered at the tip (normal
re-growth), exclamation mark (hairs tapered near
scalp), broken-off, singed or cut
3. Negative or positive hair pull test
4. Scarring (cicatricial alopecia) i.e. no follicles, or nonscarring alopecia (follicular orifices present)
5. Multiple hairs in single follicle (tufted folliculitis).

Localized alopecia

Localised alopecia areata

Tufted folliculitis

Scarring alopecia

Diffuse alopecia
Diffuse alopecia is most often due to pattern balding,
and more
prominent over the vertex of the scalp

Pattern balding
(male)

Pattern balding
(female)

Scalp skin
Evaluate the appearance of the scalp oily or dry
Look for localized lesions and inflammatory skin
diseases.
Evaluate:
1. Diffuse, patchy or perifollicular erythema
2. Diffuse, patchy or follicular flaking or scaling
3. Follicular or non-follicular papules, erosions or
pustules
4. Nits (louse egg cases)
5. Excoriations (an indication of severity of itching)

pityriasis amiantacea

Perifollicular erythema:
frontal fibrosing alopecia

Excessive hair
Excessive hair may be due to localised or diffuse
hypertrichosis or in women, hirsutism, which
refers to an adult male pattern of hair growth.
Hypertrichosis describes localised or diffuse
excessive hair on face, arms, legs or trunk. It may
be due to increase in lanugo (soft, fine and blond)
or terminal hair.

Elsewhere
A complete examination inspection of terminal
hair of the eyebrows, eyelashes, beard, axilla &
pubic area
In adolescents note stage of pubertal
development (Tanner growth charts)
Premature pubarche appearance of pubic hair
without other signs of puberty :
- < 9 years in boys
- < 7 years in white girls
- < 6 years in black girls

EXAMINATION OF THE
NAILS

Introduction
Nails are a specialised
form
of stratum corneum
and are
made predominantly of
keratin. Their primary
functions are for
protection,
scratching and picking
up
small objects.

Examination of the nails evaluate :

Abnormalities of nail plate surface
Nail plate discolouration
Abnormalities of the cuticle and nail fold
Abnormalities of nail shape
Complete loss of nails
Lesions around nails

Abnormalities of the nail plate

surface

Nail plate abnormalities are often due to

inflammatory conditions affecting the matrix or
nail bed. Specific diagnoses may be made from
characteristic appearances, which are generally
self-explanatory

PITTING
Eczema, psoriasis, Alopesia
areata

TRANSVERSE RIDGING
Psoriasis, trauma, acute
systemic illness

LONGITUDINAL RIDGING +
LONGITUDINAL SPLITTING

Aging, trauma, lichen planus,

psoriasis

LONGITUDINAL
GROOVE
Cyst or tumour of matrix,
Trauma

Onychogryphosis (thick
hard curved nail plate)
Ageing, Psoriasis, Trauma

Nail plate thinning

Lichen Planus, trauma

Nail plate
crumbling

Psoriasis,
Onychomycosis

Distal lamellar
splitting; brittle
nails

Water/detergent
damage, Nail
polish removers,
Traumatic
removal or
artificial nails

Rough nails

Lichen planus,
Twenty Nail
Dystrophy

Discolouration of nails
Yellow
Yellow nail syndrome,
Onychomycosis, Psoriasis
Staining from nail enamel

white or yellow distally

Psoriasis, dermatitis,
lichen planus, Nail
infection

Green
Infection

Brown or black
Staining, Drugs Infection,
Melanocytic naevus,
Melanoma Racial

Cuticle and nail fold

abnormalities

Ragged cuticles &

telangiectases

Trauma: hang nail

Connective tissue disease

Distal digital infarcts

Vasculitis

Distal subungual
hyperkeratosis
Psoriasis, Onychomycosis,
Norwegian scabies

Paronychia

Lesions around nails

EXAMINATION OF THE
MUCOSA

Examination of the mucosa :

1.Mucosa oral
2.Mucosa genetalia

Examination of mucosa oral

Observe the color & its consistency
The presence or absence of saliva in the floor of mouth
The tongues appearance distinct on the dorsal,
ventral and lateral aspect
The dentition and whether there are grossly carious
teeth
The use of removable prosthesis
Observe : lesion, ulcer

Disorder of the oral mucosa

Granulomatosa Cheilitis

Fissured tongue

Disorder of the oral mucosa

Geographic tongue

Hairy tongue

Disorder of the oral mucosa

Mucocele

Erosion on lips, tongue

and palate

Disorder of the oral mucosa

Kaposi sarcoma

Aphthous ulcer

Examination of mucosa
genitalia
Lesion of the Mucosa genitalia may be any of the
following :
Normal variant
Manifestations of STD
Dermatoses that may be generalized or found at extragenital site but that have a predilection for the
genitalia
Dermatoses that are spesific to the genitalia

Normal variant

Pearly penile papules

Sebaceous gland
prominence

Manifestation of STD

Ulkus durum
Herpes genitalis

Dermatoses with a
predilection for the genitalia

Lichen planus
Psoriasis

Primary genital dermatoses

Squamous cell
carcinoma
Lichen sclerosus