Approach to the Patient with a Skin Disorder
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Approach to the Patient with a Skin Disorder
Thomas J. Lawley
Kim B. Yancey
The challenge of examining the skin lies in distinguishing normal from abnormal, significant findings from trivial ones, and in integrating pertinent signs and symptoms into an appropriate differential diagnosis. The fact that the largest organ in the body is visible is both an advantage and a disadvantage to those who examine it. It is advantageous because no special instrumentation is necessary and because the skin can be biopsied with little morbidity. However, the casual observer can be misled by a variety of stimuli and overlook important, subtle signs of skin or systemic disease. For instance, the sometimes minor differences in color and shape that distinguish a malignant melanoma from a benign pigmented nevus can be difficult to recognize. To aid in the interpretation of skin lesions, a variety of descriptive terms have been developed to characterize cutaneous lesions and to formulate a differential diagnosis (Table 3).
Nail disorders
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Introduction
Nail problems are a frequent source of concern to patients. Tinea unguium and psoriasis account for the vast majority of nail disorders, but there are numerous other causes of nail dystrophies.The nail is important functionally and cosmetically. Fine motor skills such as picking up a pin from a flat surface are impossible without fingernails. The toenails—in particular the great toenails—provide counter-traction when walking and running, and the loss of these nails may lead to pain or an abnormal gait.The nail frequently suffers trauma in day-to-day activities and is also the focus of compulsive behaviours such as nail biting, picking, cleaning and polishing.
Oral lesion
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Introduction
Oral lesions can be the result of local disease, a manifestation of cutaneous disease or even a sign of systemic disease. Of the cutaneous diseases that affect the oral mucosa, some affect it as the presenting complaint (such as pemphigus vulgaris) and others affect it as the most persistent complaint (lichen planus). For a full skin examination to be complete it must include the oral cavity, an easily accessible and examinable mucosal surface. A wide variety of infections, developmental lesions, benign and malignant tumours can occur in the oral cavity, but the following discussion is limited to common presentations of oral disease.
Acne
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Acne
Most adolescents and young adults show evidence of acne. It is most prevalent between 15 and 24 years, and is more common and more severe in males than in females. Onset peaks early in puberty and usually resolves in males during their early 20s. Females can develop acne for the first time after puberty and are more likely to suffer ongoing acne, which can persist into their 30s and 40s. Acne mainly affects the face, neck, chest, shoulders and upper back; areas which have the highest density of sebaceous glands.To help tailor management, acne lesions can be divided into noninflammatory (open and closed comedones), inflammatory (pustules, red papules, nodules and cysts), and resolving lesions (macules and scars) (see Box 1).
Psoriasis
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Introduction
Psoriasis is an inflammatory and hyperplastic disease of the skin, characterised by erythema and scale. It is common and affects about 0.5% to 3% of different population groups. It is strongly familial. The presentation is variable and the course frequently difficult to predict. The clinical manifestations are numerous and may range from minor inflammation at one or two sites on the skin to total skin involvement with pustulation and constitutional symptoms. There is an associated arthritis in up to 7% of patients.
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