• Clinical science

Principles of dermatology

Summary

Dermatology is the branch of medicine concerned with the skin, hair, and nails, as well as the conditions associated with them. Basic knowledge of dermatology is essential for every physician, as approximately 50% of skin-related consultations are initially assessed by non-dermatologists. In the United States, the most common conditions seen by dermatologists include acne, actinic keratoses, non-melanoma skin cancers, benign tumors, and contact dermatitis. Skin lesions may be primary or secondary. Primary lesions (e.g., macules or papules) appear as a direct result of a disease process. Secondary lesions such as scales or ulcers may develop from primary lesions or result from external trauma (e.g., infections, scratching). Dermatological conditions can often be diagnosed based on patient history and physical examination but may require laboratory testing or biopsy to confirm the diagnosis. Dermatological diseases are managed with medication (topical and systemic) and procedures such as surgery, cryotherapy, radiotherapy, or phototherapy. Topical treatments are often the first choice because they cause fewer systemic side effects and are easily administered.

Patient history

Physical examination

  • Goal: Examine the skin (including of the hands, mouth, and scalp) and nails to help in determining a working diagnosis or differentials and any potential diagnostic/management steps based on observations.
  • Examination techniques
    • Inspection
    • Palpation: evaluation of consistency (e.g., softness, firmness) and depth
    • Typical skin tests as indicated
    • Dermatoscope inspection as indicated

The hands, mouth, scalp, and nails should not be overlooked during a dermatological examination.

Skin examination [1]

  • Determine the type of lesion: See primary skin lesions, secondary skin lesions, and complex skin lesions below.
  • Describe lesion characteristics
    • Location
    • Number (single/multiple)
    • Size
    • Color: e.g., pinkish discoloration
    • Texture: e.g., atrophic, calloused, crusty, verrucous
    • Shape: e.g., round, oval, annular
    • Distribution
      • Symmetric/asymmetric
      • Unilateral/bilateral
      • Diffuse/grouped
    • Secondary changes (e.g., as a result of scratching)

Nail examination

Alterations of the nails
Clinical findings Possible underlying disease
  • Koilonychia (spoon nails)
  • White, grey, or yellowish color with dullness and crumbling of the nail

Alterations of the hands

Exam technique Clinical findings Possible underlying disease
Inspection
  • Palmar erythema
  • Trauma or idiopathic
Palpation
  • Reduced skin turgor ("standing skin folds")

Many systemic diseases can manifest with findings on the patient's hands.

Primary skin lesions

Primary Lesions Description

Macule

Patch (dermatology)
  • A flat skin lesion > 1 cm in size that differs in color from surrounding skin (e.g. congenital nevus)
Papule
Nodule (dermatology)
  • An elevated lesion, > 1 cm in both diameter and depth
Plaque (dermatology)
Vesicle (dermatology)
Bulla
Wheal
Pustule

References:[2][3]

Secondary skin lesions

Secondary Lesions Description
Scale (dermatology)
Crust
Fissure (cleft)
Ulcer (dermatology)
  • Rounded or irregularly shaped deeper lesions that result from loss of the epidermis and some portion of the dermis.
Erosion
Excoriation (scratch marks)
  • Abrasion produced by mechanical force, usually involving the epidermis (but sometimes reaching the outer layer of the dermis)
Necrosis
Skin atrophy
Scar
  • Composed of new connective tissue that has replaced lost substance
  • An overgrowth of scar tissue manifests as keloid (thickened, raised tissue that grows beyond the borders of the scar and shows no regression).

References:[2][3]

Complex skin lesions

Complex lesions Description

Hemorrhage

Hematoma

  • Caused by bleeding into subcutaneous tissue, muscle, organ tissue or a cavity
    • Immediately after trauma: red
    • After 24–96 h: dark red; purple; blue/black
      • Cause: The blood coagulates and hemoglobin is degraded into bile pigment.
    • After 4–7 days: dark green
    • After 7 days: yellow; brownish
Subtypes of hematomas = purpura Nonpalpable purpura

Petechiae

Ecchymosis
  • Flat, red-purple, larger form of petechiae, > 5 mm in size
Palpable purpura
  • Raised, red-purple lesions
Rashes Exanthem
  • Extended uniform rash (localized or generalized)
Enanthem
  • Rash confined to the mucous membranes
Erythema
  • Reddening of the skin as a result of vasodilation (blanches if pressure is applied)
Erythroderma
  • Generalized reddening of the skin
Maculopapular rash
Further lesions Lichenification
  • Thickening of the skin with accentuated skin markings
Eczema

References:[4][5][6][7]

Diagnostic measures

  • Most skin disorders can be diagnosed via skin examination
  • Some may require further diagnostic measures for confirmation or monitoring, including:
    • Biopsy for histopathological examination
    • Laboratory studies

Dermatopathology

Dermatopathology
Histopathologic finding Characteristics Examples
Acantholysis
Acanthosis
Hypergranulosis
Hyperkeratosis
Parakeratosis
Spongiosis

Overview of management steps

Treatment options

The external nature of the skin allows a variety of treatment options, including:

  • Systemic medications
  • Topical medications
  • Physical procedures

Types of topical preparations

Drugs must be absorbed into the skin to be effective, so choosing the proper type of topical preparation for the pharmacological agent is important. Examples include:

  • Creams
  • Ointments
  • Lotions, foams, and gels

Topical steroids

Topical steroids are the most frequently used topical treatment in dermatology.

  • Advantages
    • High therapeutic value
    • Relatively safe: few local and systemic adverse effects
  • Most common side effects
  • Common examples
Agent Potency Indication
Hydrocortisone (1%) Low For mild and chronic dermatoses and for use on the face
Triamcinolone (0.1%) Medium For intermediate severity
Clobetasol (0.05%) High For more severe dermatoses

References:[8][9]