Integrated clinical assessment
5.23 Swollen optic disc and papilloedema
5.25 Retinitis pigmentosa and chorioretinitis
5.26 Central retinal vein occlusion
5.27 Central retinal artery occlusion
5.28 Retinal detachment and vitreous haemorrhage
5.29 Age-related macular degeneration and other retinal problems – drusen, angioid streaks and myelinated nerve fibres
5.30 Red eye and other anterior eye problems – uveitis, cataracts, glaucoma
Other problems in acute and general medicine and elderly care
Skin problems
Examination of the skin
Introduction
Skin comprises an inner dermis of collagen and elastic tissue lying on subcutaneous fat, and an outer, continuously replenishing epidermis extending from a basal layer of cells with scattered melanocytes to a top layer of protective keratinocytes. These continuously degenerate and slough off to be replaced by cells from beneath. The epidermal–dermal junction is demarcated by a basement membrane. Skin disease can originate in any of these structures and skin, the only visible organ, can be a window to the world of systemic disease, for example: diabetes mellitus (necrobiosis lipoidica, infections); sarcoidosis (erythema nodosum, lupus pernio); inflammatory bowel disease (erythema nodosum); internal malignancy (dermatomyositis, paraneoplastic pemphigus); porphyria cutanea tarda, Graves’ disease (pretibial myxoedema, thyroid acropachy, palmar erythema); Cushing’s syndrome (thin skin, striae, bruising); Addison’s disease (hyperpigmentation).
History
• Duration of symptoms, e.g. urticaria is rapid, psoriasis lesions are chronic
• Point of origin, e.g. extensors for psoriasis, flexors for atopic dermatitis
• Symptoms, e.g. dermatitis and scabies are itchy, herpes zoster is painful
• Provoking and relieving factors, e.g. sunlight relieves psoriasis but induces the rash of lupus and polymorphic light eruption
• Social history, e.g. environment, travel, contacts
• Occupational history, e.g. contact dermatitis
• Family history, e.g. psoriasis and atopic dermatitis have a genetic basis.
Examination
In skin cases, be prepared to do two things:
• Look at the distribution of a rash (pattern recognition is important, e.g. photosensitivity)
• Describe lesions (the morphology may be diagnostic, e.g. psoriasis; if it not diagnostic, comment on differential diagnoses).
Distribution of skin lesions
You are likely to be asked to examine a particular region, e.g. the scalp, face, mouth, hands, nails or shins. If not, work from scalp to sole. Always attempt to describe the distribution of skin lesions, noting particularly if they are bilateral or symmetrical. As a rule, endogenous causes are more likely to produce bilateral lesions (e.g. psoriasis, see Fig. 5.1; Case 5.1) and exogenous causes produce a more random distribution.
Description of skin lesions
Central to dermatology is your ability to describe skin lesions (Table 5.1).
Table 5.1
Term | Description |
Macule | Flat area of discoloration ranging from pale (loss of melanin) to brown or black (increased melanin); many macules are red, indicating vascular dilatation or an inflammatory process |
Patch | Large macule |
Papule | Raised lesion > 1 cm in diameter |
Nodule | Raised lesion < 1 cm in diameter |
Plaque | Raised lesion with a flattened top, or plateau |
Vesicle | Fluid-filled lesion or ‘blister’ < 0.5 cm in diameter |
Bulla | Larger blister |
Pustule | Vesicle filled with neutrophils (not necessarily infection) |
Telangiectasia | Dilated, superficial blood vessels (capillaries, post-capillary venules) – idiopathic or associated with cold outdoor exposure, pulmonary hypertension, scleroderma, systemic lupus erythematosus, rosacea, lupus pernio or necrobiosis lipoidica diabeticorum |
Discoid | Flat and disc-like lesion (term sometimes overlapping with nummular or coin-like lesions) |
Annular | Ring shaped |
Reticular | ‘Net-like’ lesions, e.g. erythema ab igne (Granny’s tartan) and livedo reticularis (physiological or associated with sepsis, connective tissue disease or malignancy) |
Atrophy | Loss of tissue – loss of dermis or subcutaneous fat usually leaves a depression in the skin; loss of epidermis causes wrinkling and a translucent, hypopigmented appearance |
Lichenification | Characteristic skin thickening (resembling lichen on rocks or trees) often produced by chronic inflammation or rubbing |
Erosion | Area of lost epidermis that generally heals without scarring |
Excoriation | Linear erosions often produced by scratching |
Ulcer | Area of skin loss involving the dermis |
Fissures | Slit through whole thickness of skin |
Cases
Case 5.1 Psoriasis
Patient information
You are a 33-year-old woman in the outpatient clinic for follow-up of recent pneumonia. You have had a recurring rash, predominantly on your knees, elbows and hands but also around your scalp, for some years, but worse in the last few months since being unwell with asthma. It does not cause you particular problems but it is scaly, and worse in times of stress and relieved by sunlight. It also seems to flare up whenever you stop courses of steroid for asthma. It is rather irritating and you would be happy if there were some treatment available. You tried some coal tar treatment once and it was incredibly messy.
Focused history and examination
Initial history
• Ask about duration of symptoms. Psoriasis is a chronic condition that waxes and wanes.
• Ask about precipitating and relieving factors. Psoriasis is often worse in stress and flares up after stopping steroids, and improves with relaxation and sunlight.
• Ask about the distribution. Chronic plaque psoriasis is usually symmetrical, affecting extensor surfaces.
Initial examination
• Be aware of the commonest type of psoriasis – chronic plaque psoriasis, and of psoriasis variants (Table 5.2). Looks at the skin lesions and at the hands and nails.
There are numerous symmetrically distributed plaques (Fig. 5.1) most prominent on extensor surfaces (elbows, knees), the scalp and hairline and behind the ears, the lower back (sacrum), the shin and the umbilicus. Plaques may range in size from a few millimetres to a large area of the limbs or trunk. These are sharply marginated and pink / red with silvery-white scaling surfaces (sometimes said to resemble limpets).
Further assessment
• Ask about joint symptoms. Psoriatic arthropathy affects up to 10% of patients with psoriasis and may precede or follow skin disease by months or even years. There are, in theory, five types, although overlap is common (Table 5.3). If there is arthropathy, consider the tendency for HLA B27 spondyloarthropathies to overlap, common features being sacroiliac discomfort and enthesopathies such as plantar fasciitis.
Table 5.3
Type | Features |
Asymmetrical distal interphalangeal joint arthropathy | Relatively uncommon but the form most strongly associated with psoriasis; affected digits often show nail changes such as pitting |
Rheumatoid-like hands | The commonest type; seronegative |
Asymmetrical large-joint mono- or oligoarthropathy | Large joint pain or swelling |
Spondyloarthropathy and sacroiliitis | Low back pain |
Arthritis mutilans | Very uncommon, severely destructive type |
Case 5.2 Dermatitis
Patient information
You are a 35-year-old woman admitted to hospital yesterday with worsening asthma. You mention to the admitting doctor that you have had a chronic itchy skin condition on the flexor surface of your arms and legs for many years but that it is worse. You are also concerned that the skin is breaking down much more easily than it used to, especially on the hands, where water and soap and possibly chemicals (you are a hairdresser) and the hot atmosphere appears to be preventing it from ever fully healing. You cannot give up work. You take occasional over-the-counter emollients.
Focused history and examination
Initial examination
• Note the distribution of the rash and its appearances. The skin is red, swollen and blistering or dry, thickened and leathery, with erythema, scaling and evidence of scratching. Both extremes are itchy.
Dermatitis and eczema are interchangeable terms. The term ‘eczema’ means skin ‘boiling over’. There are many types of dermatitis and the clinical appearance can fall anywhere between the two extremes. Pathologically, there is breakdown in the skin’s horny barrier and there may be oedema high in the dermis. Any blisters tend to have a honeycomb, multiloculated core, not typical of other blistering diseases such as pemphigus.
Further assessment
• Features of the history that should be further explored are atopy, occupation and exposure to irritants.
Dermatitis may have endogenous or exogenous causes, the latter generally contact dermatitis and photosensitivity (Table 5.6). Bilateral dermatitis is more likely to have an endogenous cause and unilateral dermatitis an exogenous cause (but contact dermatitis commonly affects both hands if dipped in chemical irritants). It is worth remembering that the differential diagnoses of acute ‘dermatitis’ include infectious skin conditions such as scabies (intensely itchy and worse after hot showers or baths and at night; burrows of the scabies mite Sarcoptes scabei may be seen) and Tinea pedis in foot dermatitis, often unilateral, dry, scaly and interdigitate.
Dermatitis can be severe and even life threatening, especially with secondary infection. Apparent dermatitis occasionally represents a more sinister aetiology. An eruption resembling flexural atopic dermatitis is occasionally the result of agammaglobulinaemia, coeliac disease or mycosis fungoides.
Case 5.3 Lichen planus
Candidate information
Scenario
You have 10 minutes. The examiners will alert you when 6 minutes have elapsed, stop you at 8 minutes, and in the remaining 2 minutes ask you to report your findings, the diagnosis or differential diagnosis, and a management plan.
Focused history and examination
Initial examination
• There are well-demarcated, polygonal, raised plaques on the flexor surfaces, especially the wrists and ankles (Fig. 5.4). Their flat tops are shiny with a violaceous colour, interrupted by milky white streaks – Wickham’s striae. They are very likely to be intensely itchy. There may be Köbner’s phenomenon. Lesions usually resolve over a period of months to leave brownish macules.
Figure 5.4 Lichen planus.
Lichenification is a feature of many skin diseases such as eczema and itchy drug eruptions. The shiny, purplish flat tops of lichen planus, and their distribution, usually aid diagnosis.
Further assessment
• Look at the oral mucosa and nails. There may be white, ‘net-like’ lesions on the buccal mucosa (Fig. 5.5) or tongue (Fig. 5.6), often with ulceration. Atrophy and longitudinal grooves may affect the nail plates; sometimes nails disappear altogether.
Figure 5.5 Lichen planus of buccal mucosa.
Feedback to examiners
Outline an investigation and management plan
Lesions usually resolve over a period of months to leave brownish macules. The cause is uncertain, with no family history and no definite association with stress. The epidermis is thickened, with increased keratin (the white streaks imply a thickened granular layer and the basal layer is infiltrated with T lymphocytes in a band pattern). Moderately potent topical (occasionally systemic) steroids are effective for this condition, which appears to have an immune basis. Lichen planus is self-limiting but tends to relapse and remit over months or even years.
Case 5.4 Blistering skin disorders
Patient information
You are a 74-year-old man in hospital for investigation of altered bowel habit. You mention to the doctor that you have a rather severe blistering rash on your thighs and trunk that has developed in the past fortnight, with tense, itchy lesions of varying sizes. You do not have any oral lesions. You are, however, keen to get home very soon as you wife has Alzheimer’s disease, although family are looking after her.
Focused history and examination
Initial examination
There are tense blisters of variable size (much more variable than pemphigus, from a few millimetres to a few centimetres, but large, tense blisters up to 3 cm in diameter are typical) on the flexor surfaces spreading to the trunk (Fig. 5.7) on an erythematous base. Blisters may be broken because of excoriation. Early disease may appear as a pruritic, urticarial rash. Oral lesions are less frequent than in pemphigus, occurring in around one-third of patients and seldom a presenting feature. The anus, vagina and oesophagus are occasionally involved.
Figure 5.7 (A–D) Pemphigoid.
There is a bullous eruption (in a middle-aged / older patient) comprising flaccid, fragile, thin-walled blisters on the trunk 1–2 cm in diameter (Fig. 5.8). Many have burst, leaving red, exuding, tender patches (even rubbing of normal skin can cause sloughing of the epidermis – Nikolsky’s sign). Oral erosions (Fig. 5.9) are common and painful and may precede the rash. Pemphigus foliaceous is characterised by superficial blisters that affect only the skin. Pemphigus vulgaris is characterised by mucosal involvement and subsequent skin involvement with blisters and erosions.
Figure 5.8 (A, B) Pemphigus – trunk.

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