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Diseases » Skin rash » Diagnosis
 

Diagnosis of Skin rash

Skin rash Diagnosis: Book Excerpts

Diagnosis of Skin rash: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Skin rash:

Diagnostic Tests for Skin rash: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Skin rash.


RASH--DISTRIBUTION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it focal or diffuse? Focal rashes suggest the dermatophytoses, scabies, actinic dermatitis, herpes zoster, warts, contact dermatitis, erythema nodosum, actinic dermatosis, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, pyoderma, acne vulgaris, herpes simplex, impetigo, and tuberous sclerosis. Diffuse rashes suggest xanthoma, erythema multiforme, psoriasis, lichen planus, eczema, drug eruptions, dermatitis herpetiformis, secondary syphilis, exfoliative dermatitis, and pemphigus. A diffuse rash also may be due to pityriasis rosea and tinea versicolor.
  2. If diffuse, is it primarily the extremities that are involved? A diffuse rash that involves primarily the extremities would suggest smallpox and erythema multiforme, eczema, milium, lichen planus, and psoriasis.
  3. If diffuse, does it involve primarily the face and trunk? A diffuse rash that involves primarily the face and trunk suggests chickenpox, typhoid fever, German measles, pityriasis rosea, tinea versicolor, and pemphigus.
  4. If focal, does it primarily involve the extremities? A focal rash that involves primarily the extremities suggests dermatophytosis, erythema nodosum, contact dermatitis, warts, discoid lupus, actinic dermatosis, scabies, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, and pyoderma.
  5. If focal, is it primarily involving the face and head? A rash that involves primarily the face and head should suggest acne vulgaris, acne rosacea, seborrheic dermatitis, herpes simplex, actinic dermatosis, carcinoma, impetigo, contact dermatitis, Sturge-Weber syndrome, tuberous sclerosis, and tinea capitis.
  6. Is it equally distributed to the trunk and extremities? A rash that is equally distributed to the trunk and extremities would suggest herpes zoster, neurofibromatosis, scarlet fever, drug eruptions, dermatitis herpetiformis, secondary syphilis, measles, and exfoliative dermatitis.

DIAGNOSTIC WORKUP

If there are any exudates, a smear and culture for fungi and routine bacteria should be done. Skin scrapings may be examined microscopically with a saline or potassium hydroxide preparation to rule out scabies and fungi. A Wood's lamp examination is very useful in diagnosing various fungi. All isolated lesions should be biopsied.

Diffuse rashes require routine CBC, sedimentation rate, urinalysis, chemistry panel, ANA test, and VDRL test. If there is fever, blood cultures should probably be done. Skin biopsies in consultation with a dermatologist should be done in a timely fashion. Patch testing and intradermal skin testing should be done when appropriate. A dark field examination may be necessary. GI series and barium enemas may be necessary to look for GI neoplasms, Crohn's disease, and ulcerative colitis.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RASH--MORPHOLOGY: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the rash macular or papular? A macular or papular rash would suggest scarlet fever, measles, erythema multiforme, exfoliative dermatitis, pityriasis rosea, eczema, contact dermatitis, secondary syphilis, drug eruption, and actinic dermatoses.
  2. Is the rash pustular? A pustular rash suggests staphylococcus, scabies, secondary syphilis, acne, folliculitis, and dermatophytosis.
  3. Is the rash vesicular or bullous? A bullous or vesicular rash would suggest chickenpox, smallpox, dermatitis herpetiformis, contact dermatitis, pemphigus, herpes zoster, bullous impetigo, herpes simplex, dyshidrosis, and nummular eczema.
  4. Is the rash scaly? A scaly rash suggests ichthyosis, psoriasis, lichen planus, neurodermatitis, dermatophytosis, exfoliative dermatitis, and drug eruptions.
  5. Are there ulcers? The presence of ulcers in the lesions would suggest basal cell carcinoma, syphilis, lupus erythematosus, diabetic ulcers, ischemic ulcers, pyoderma gangrenosum, and ecthyma.
  6. Is there fever? The presence of fever suggests scarlet fever, measles, erythema multiforme, exfoliative dermatitis, serum sickness, chickenpox, and smallpox.

DIAGNOSTIC WORKUP

This can be found under Rash--Distribution.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS ANI: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If the physical examination is normal, examination with an anoscope is essential. Sigmoidoscopy should also be done but is not adequate to detect hemorrhoids, anal fissures, and fistulas. If these are negative, a trial of antifungal creams (Lotrimin®, etc.) should be given before other expensive diagnostic tests are ordered. A Scotch tape test and stool for ovum and parasites are useful, especially in children.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS, GENERALIZED: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the pruritus associated with a generalized rash? Almost every generalized rash may be associated with pruritus, but the most common ones are urticaria, dermatitis herpetiformis, eczema, scabies, and pemphigus.
  2. Is there hepatomegaly or jaundice? The presence of hepatomegaly or jaundice should make one think of obstructive jaundice, hepatitis, metastatic carcinoma to the liver, and biliary cirrhosis. However, almost any form of liver disease may be associated with pruritus.
  3. Is there polyuria, polydipsia, and polyphagia? These findings would suggest diabetes mellitus, hyperthyroidism, and pregnancy.
  4. Is there an unusual odor? The presence of an unusual odor should bring to mind the possibility of uremia, liver failure, or diabetic acidosis.
  5. Is there plethoric facies? The presence of plethoric facies suggests polycythemia vera.

DIAGNOSTIC WORKUP

If there is an associated skin rash, microscopic examination of a potassium hydroxide preparation of curetted burrows will be helpful. Additional examinations include Wood's lamp evaluation, a patch test, and skin biopsies. Therapeutic trials for scabies, fungal disease, or other disorders, however, are justified if testing is not economically feasible. Routine laboratory tests for the various systemic diseases that may cause pruritus include a CBC, sedimentation rate, urinalysis, chemistry panel, ANA assay, thyroid profile, and serum protein electrophoresis. A bone marrow examination and lymph node biopsy may be useful. A dermatologist, hematologist, or endocrinologist may help solve the diagnostic dilemma. Further workup may include plain films of the chest and abdomen and CT scans of the abdomen and pelvis. A bone scan may be useful in diagnosing metastatic carcinoma. HIV testing may be indicated if the patient has a history of high-risk sexual behavior.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PRURITUS, VULVAE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a vaginal discharge? The presence of a vaginal discharge should suggest candidiasis, trichomoniasis vaginitis, and bacterial vaginitis.
  2. Is there a rash? The presence of a rash would suggest eczema, herpes simplex, folliculitis, scabies, and tinea infections.
  3. Are there vulval or vaginal lesions? The presence of a lesion in the vulva or vagina would suggest kraurosis vulvae, leukoplakia or vulval carcinoma, condylomata lata, and condylomata acuminata.

DIAGNOSTIC WORKUP

If there is a discharge, microscopic examination of a potassium hydroxide preparation and saline preparation is necessary. A smear and culture of the discharge should be done for bacteria and fungi. Scrapings of the burrows for scabies may be useful. Skin biopsy may help diagnose the cause of a rash. Lesions should be biopsied also. If senile vaginitis is suspected, serum FSH and estradiol and a Pap smear may help determine if there is estrogen deficiency. A gynecologist should be consulted in all difficult diagnostic problems.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SKIN THICKENING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

In cases of diffuse thickening of the skin, a thyroid profile with T 3 , T 4 , and TSH should be done. This should also identify hypothyroidism. A positive ANA test with a speckled pattern will help identify scleroderma, but a skin biopsy should also be done. An antisclerodermal antibody titer is also useful if available. Esophageal motility studies will be helpful in early diagnosis. A skin biopsy will help identify many of the other conditions mentioned above. Urine for porphyrins will help identify porphyria.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Pruritis without Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Hepatobiliary disorders
    –Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
    –Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
    –Biliary obstruction: Pruritus not a presenting symptom
  • Endocrine disorders
    –Hypo- and hyperthyroidism
  • Hematopoietic disorders
    –Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
    –Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
    –Iron deficiency anemia
  • Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
  • Malignancies: Adenocarcinoma, squamous cell carcinomas
  • HIV: Increasing frequency with disease progression
  • Psychogenic states: May have underlying personality disorder such as OCD
  • Senescence: Elderly pruritus very common
  • Drug reactions
  • Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)

Workup and Diagnosis

  • History and physical examination
    –A focused history including past medical history, social history, family history, and sexual history is important
    –A complete review of systems may identify underlying disease (e.g., change in bowel habits with colon cancer, cold intolerance with hypothyroidism, right upper quadrant pain with hepatic disease)
    –Complete physical examination is necessary including stool exam for occult blood, and Pap smear and pelvic examination
    –Include a full body skin exam to confirm that there are no cutaneous rashes or lesions
  • Initial lab tests may include CBC with differential (look for eosinophilia associated with parasites), LFTs (alkaline phosphatase is the best screening test for hepatobiliary disorders), renal function tests, thyroid function tests
  • Rule out internal malignancies (e.g., chest X-ray, mammogram, stool for occult blood)
  • Other labs to consider: HIV test, hepatitis B and C panel, serum iron and ferritin, serum and urine protein electrophoresis, stool for ova and parasites, blind skin biopsy with or without immunofluorescence

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pruritis with Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Infectious causes
    –Fungal infections: Dermatophyte infections (tinea), candidiasis (beefy red color with satellite papules), seborrheic dermatitis (from Pityrosporum, common in hair-bearing areas, with scale)
    –Bacterial infections: Erythrasma (from Corynebacterium), frequently in axilla
    –Viral infections: Chicken pox (Varicella)
    –Insect vectors: Scabies, pediculosis or lice (also present on spouse and other family members), flea bites (typically on legs), mosquito bites (central punctum)
    –Mixed infections: Intertrigo (present at skin folds or area of friction)
  • Noninfectious causes
    –Contact dermatitis (e.g. rhus dermatitis): May be revealed in contact history, linear vesicular lesions with sharp margins
    –Atopic dermatitis: Erythematous rash in flexural areas, patient with seasonal allergies and/or asthma
    –Eczematous dermatitis: Stasis dermatitis (hyperpigmented legs of patients with vascular disease), lichen simplex chronicus (anxious patient who chronically scratches), dyshidrotic eczema (on hands and feet with scaling, erythema, and minute vesicles and painful fissures), nummular eczema (round scaly lesions on dry skin, common in the winter)
    –Pityriasis rosea: Mostly on trunk in “Christmas tree” pattern, begins as single, larger “herald” patch
    –Lichen planus: Koebner reaction (lesions occur with trauma, such as linear lesions from scratching), purple, polygonal, pruritic papules
    –Psoriasis: Koebner reaction, pink, silvery scaling plaques, extensor surfaces, nail pits
  • Less common etiologies (“zebras”) include mycoses fungoides (referred to as Sézary syndrome if erythroderma, lymphadenopathy, and atypical circulating white blood cells are present), dermatitis herpetiformis, miliaria (heat rash)

Workup and Diagnosis

  • History and physical examination
    –Past medical and family history (e.g., asthma, psoriasis) and exposure history (e.g., poison ivy, oak, or sumac) are important, including whether the lesions are occurring for the first time or are recurrent
    –Perform a total body skin exam to evaluate distribution of rash; evaluate especially for rashes on the extensor or flexor surfaces of skin folds, and interdigital spaces
    –Note the morphology of the lesion (e.g., macule, papule, pustule, plaque, crust, vesicle, bulla, wheal)
    –Note the configuration of the lesion [e.g., linear (Koebner reaction or contact), grouped, annular, geographic]
  • Scrape lesions and perform KOH test if fungal infection is suspected (hyphae visible in dermatophyte infections, and pseudohyphae visible in Candida infections)
  • Wood's lamp test: Erythrasma turns coral red
  • Scrape possible burrow site to identify a mite in scabies
  • Patch testing may be done if allergic contact dermatitis is suspected
  • Punch biopsy may be done to establish a histologic diagnosis (e.g., mycosis fungoides)
  • Anti-gliadin antibodies and/or anti-endomysial antibodies may be found in the serum of patients with dermatitis herpetiformis
  • Consider referral to a dermatologist if diagnosis remains unclear

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Viral exanthems
    –Leading cause of fever and rash in childhood
    –Most children present with low-grade fevers, viral prodromal symptoms, and a secondary diffuse exanthem that is usually nonspecific and morbilliform
    –Often last only a few days and requires only supportive management
  • Drug reactions
    –Account for a large portion of rashes with associated fever
    –Immune complex disease or serum sickness has been reported with many medications
  • Meningococcemia
    –Most common under age 1
    –After a brief prodrome; onset is abrupt with spiking fevers, diffuse purpuric lesions, delirium, and death
    –DIC and purpura fulminans with secondary necrosis of digits and limbs can occur
  • Rocky Mountain Spotted Fever
    –A fulminant and deadly rickettsial disease transmitted by a tick bite
    –Only 60% of patients are aware of tick bite
    –Characteristic rash starts acrally on wrists and ankles and spreads toward the trunk
    –Initially, pink macules evolve over 10–24 hours into red papules, then purpuric macules and violaceous patches involving most of the body surface area
    –Necrosis and DIC may occur
  • Toxic shock syndrome, Staphylococcus aureus, and streptococcal diseases
    –Most cases due to toxin production
    –Rapid onset of fever, hypotension with generalized skin (palms and soles common) and mucous membrane erythema (“erythroderma” in case definition), and subsequent multiorgan failure
    –Palmar/solar desquamation in 1–3 weeks
    –A morbilliform rash and skin “pain” or hyperesthesia is common
    –Nonsurgical and surgical wounds are often the source of infection in the more common nonmenstrual variant of TSS
  • Fifth disease
  • Measles
  • Rubella
  • Parvovirus
  • Varicella

Workup and Diagnosis

  • Because of a seemingly endless list of possible etiologies for fever and rash, a focused history and physical exam are essential to a quick, accurate diagnosis
  • Determine whether the patient appears toxic; age and presence of co-morbid conditions aid diagnosis
  • If there is any evidence of purpura;
    –Quickly consider the diagnosis of RMSF, meningococcemia, or systemic vasculitis
    –In the cases of meningococcemia and RMSF, the diagnosis must be made empirically, then later confirmed so that therapy is immediately initiated
  • Obtain bacterial cultures from any wounds, culture the pharynx if indicated, and consider skin biopsy and culture; blood cultures are indicated in toxic patients; consider immediate lumbar puncture for CSF culture and Gram stain if meningococcemia is suspected
  • Acute and convalescent antibody titers can confirm RMSF; skin biopsy with immunofluorescnce may demonstrate a vasculitis with visible rickettsial organisms within the endothelium
  • TSS is often diagnosed by history and examination alone; recent cutaneous injury and nonspecific morbilliform rash in a hypotensive patient in association with the presence of epidermal necrosis on skin biopsy can confirm the diagnosis; wound cultures with growth of staph or strep

    • » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Scalp Rash: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Seborrheic dermatitis (“cradle cap,” “dandruff”)
      –The most common scalp condition, it occurs across all age ranges
      –May be caused by Pityrosporum ovale
      –An inflammatory condition that causes itching and loose, silvery-white scale on scalp, and occasionally blepharitis
      –May also affect the eyebrows, nasolabial folds, external auditory canals, chin, anterior chest, upper back, and groin
      –Does not cause hair loss
      –The scalp is not usually erythematous, but other affected skin areas may be red, greasy, or oily
    • Tinea capitis
      –Most commonly caused by Trichophyton tonsurans or rarely Microsporum canis
      –Presents as patches of scale and/or pruritus with broken hairs, patchy hair loss (i.e., “black dot alopecia”)
      –May progress to a kerion (see below)
    • Kerion
      –A boggy, tender, subcutaneous fungal infection (dermatophyte)
      –Often has associated drainage and hair loss
  • Scalp folliculitis
    –Presents as recurrent, itchy, crusted papules or pustules
    –An overgrowth of Staphylococcus aureus
    • Psoriasis
      –Usually presents with plaques of thick, silvery, adherent scalp scale that overlies well-demarcated patches of erythema
      –Often occurs at the ears and occipital area
      –May be limited to the scalp, but often has skin disease, nail pitting, or nail dystrophy
    • Dissecting cellulitis of the scalp
      –Chronic, tender, boggy, often suppurative subcutaneous fluctuant masses
      –Occurs in black patients
      –May be associated with acne keloidalis, which can cause a scarring hair loss at the occiput
    • Discoid lupus
      –Presents initially as well-demarcated erythematous plaques of patchy, scarring scalp hair loss, then spreads centrifugally
  • Contact dermatitis

    • Workup and Diagnosis

    • History and physical examination
      –If the scalp scale is diffuse, white, and nonadherent, seborrheic dermatitis is the likely diagnosis
  • Bacterial culture from any intact scalp pustule or suppurating area may be helpful to confirm bacterial folliculitis or dissecting cellulitis
  • KOH prep of scalp scale or scalp hair can be assessed under a microscope in the office to confirm the presence of endothrix (spores within the hair shaft) in the hair or branching hyphae in the scalp scale
  • Fungal cultures can be obtained from the drainage of a kerion or from scalp scale scraped by a tongue depressor or sterile toothbrush
    –Hairs from the affected area can also be sent for fungal culture to rule out tinea capitus; the hairs must be plucked so that the root of the hair is available
    –Cultures may take several weeks and sensitivity varies widely based on clinician technique and lab handling
    • A punch or shave biopsy is usually unnecessary, but can aid in the diagnosis of seborrheic dermatitis
    • In cases of tinea capitis, only M. canis, which is uncommon in the U.S., fluoresces with a Wood's lamp

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Hand and Foot Rashes: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Dyshidrotic eczema (pompholyx)
      –Very common idiopathic skin disease
      –Affects one or both hands and/or feet in the thenar eminence, palms and/or soles, and sides of fingers and toes
      –Causes itching, scaling, and erythema, and minute vesicles and painful fissures
      –Usually chronic and intermittent, and often exquisitely pruritic
    • Irritant or allergic hand eczema
      –Very common
      –Difficult to distinguish from dyshidrosis because both are vesicular and very itchy
      –Flares occur during work/hobbies, with improvement on vacation when away from the irritant or allergen
    • Tinea manus (hand) and tinea pedis (foot)
      –Presents as itchy, diffuse, light scale, and/or maceration; prominent on palmar, plantar (moccasin distribution), and interdigital surfaces
      –Erythema is rarely present
      –Often “two hands and one foot” or “two feet and one hand” are affected
    • Scabies
      –Presents as short (a few millimeters), linear burrows and vesicles on the hands and feet (web spaces), belt region, and/or intertriginous spaces
      –Intensely pruritic, especially at night
      –Often many members of the household unit affected
      –Definitive diagnosis made by visualizing the scabies mite in a skin scraping
    • Psoriasis
      –Often affects the hands and/or feet
      –Well-demarcated, erythematous plaques
      with adherent scale, or can present as a focal or diffuse pustular eruption
      –Look for associated nail dystrophy or other skin involvement
  • Reiter's disease
    –Uveitis, urethritis, and arthritis
    • Pityriasis rubra pilaris
      –Well-demarcated bright salmon or red plaques on the palms or soles
    • Keratoderma
      –Focal or diffuse thickening of the skin of the palms or soles
  • Erythema multiforme
  • Infection (secondary syphilis, varicella meningococcemia)

    • Workup and Diagnosis

    • History and physical examination
      –Note chronic exposure to chemicals or potential irritants at work or in hobbies
      –Any family history of psoriasis or allergy/atopy
      –Look closely for the presence of small, clear “water blisters” under the skin that may indicate pompholyx
      –Examine nails for evidence of coexisting onychomycosis (very common in cases of tinea pedis and manus, and a nidus for frequent reinfection), “oil spots,” or nail pitting (may suggest psoriasis)
      –Examine joints for arthritis (psoriasis/Reiter's), eyes (Reiter's), and genitalia (psoriasis/Reiter's)
    • KOH preparation from scale scraped from the palms, soles, or between the toes to determine presence of branching hyphae of tinea or scabies mites
    • Culture any intact pustules
    • Consider performing a patch test to rule out allergic contact dermatitis
    • A punch biopsy may be helpful to distinguish psoriasis or PRP from the other common eczematous diseases of the hands and feet
    • Fungal culture of nail clipping if onycholysis (nail thickening) present
    • Dermatology referral is often indicated in resistant cases

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Dry Skin (Xerosis): Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Dry skin is a very common problem
      –Low humidity and cold temperatures make winter xerosis and “winter itch” common complaints
      –Mild xerosis can cause impaired skin barrier function and allow irritants and allergens to more easily affect the skin
      –Most common on the legs, but often affecting the entire skin surface
      –Can present with severe pruritus without much evidence of a rash
    • Severe xerosis is common in the elderly, and can cause eczema craquelé
      –Patient's legs often have scale that resembles cracked porcelain
      –Secondary erythema and excoriations occur because of the persistent itch
    • Ichthyoses vulgaris
      –Very common cause of dry skin
      –A genetic defect in skin barrier function, leading to a higher risk of atopic dermatitis
      –Patients often have hyperlinearity of their palmar skin and xerotic fish scale on their legs
    • Many genetic conditions, such as the large family of ichthyoses (including X-linked ichthyoses, Netherton's disease), lead to severely dry skin in association with other systemic manifestations
    • Hypothyroidism and hyperthyroidism can also cause marked xerosis and/or itch
    • Anemia
    • There is an uncommon association between lymphoma and marked xerosis
    • HIV
    • Sarcoidosis
    • Liver and biliary disease, and renal insufficiency, are commonly associated with xerosis and marked pruritus
    • Diabetes mellitus
    • Medications (e.g., niacinamide)
    • Atopic dermatitis

    Workup and Diagnosis

    • A complete history should be taken that includes social, family, environmental, and exposure history; past medical history; a focused physical examination should also be performed, including thyroid, entire skin surface, and other exam
    • Most cases of xerosis are secondary to environmental factors; If the xerosis is very severe or of acute onset, or is associated with intractable pruritus or other systemic symptoms, consider checking a CBC, thyroid function tests, BUN/creatine, and liver function tests
    • Young, at-risk patients with severe xerosis, especially of recent onset, may be considered for HIV testing
    • If the patient fails to respond to conservative therapy, age-appropriate malignancy screening should be considered

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Skin Pigmentation (Decreased): Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Vitiligo
      –Affects 1% of the population
      –Begins as a focal or diffuse (more common) hypopigmented patch that progresses to total loss of pigmentation of the affected skin (chalk white)
      –Usually symmetric; often tops of hands, perioral, periorbital skin, knees, elbows
    • Pityriasis alba
      –Very common, especially in black children
      –Less distinct borders than in vitiligo, does not result in complete depigmentation
      –Plaques may appear lighter than surrounding skin and may be scaly
      –Often secondary to mild inflammation, such as tinea versicolor or atopic eczema
      –Completely reversible and does not cause permanent hypopigmentation
    • Piebaldism
      –Congenital, permanent, and irreversible
      –Newborns often have a patch of white scalp hair and depigmented patches on the trunk with normally pigmented patches within these larger depigmented areas
    • Chemical leukoderma (depigmentation)
      –May be caused by phenols, germicides, and many other caustic chemicals
      –Results in confetti-like macules of depigmentation in exposed skin
      • Albinism
        –Congenital
        –Disorder of melanin synthesis with several phenotypes, ranging from complete lack of pigmentation (white hair and translucent or “red” iris) to the more common diffuse hypopigmentation or “yellow” albinism that is prevalent in the black population
        –Affects the skin, hair, and eyes
        –Photophobia, decreased visual acuity, strabismus, and risk of skin cancer are the main problems faced by these patients
      • Congenital birthmarks (e.g., nevus anemicus, nevus depigmentosis) are isolated patches of hypo- or depigmentation that remain unchanged over time
      • Tuberous sclerosis is an inherited systemic disorder that results in hypopigmented macules in the shape of an “ash leaf ” on the trunk, and confetti-type depigmented macules on the arms/legs

      Workup and Diagnosis

      • History and physical examination
        –Determine whether the skin is completely depigmented (chalk white) or merely hypopigmented (lighter than surrounding skin but with residual pigmentation)
        –Vitiligo is easily diagnosed on clinical exam alone
        –Family or personal history of thyroid disease, other endocrine disorders, diabetes, or exposure to chemicals
        –History of allergies, hay fever, or asthma, which may support the diagnosis of postinflammatory hypopigmentation from atopic dermatitis
        –History of erythema or rash at the hypopigmented spot suggests pityriasis alba or postinflammatory hypopigmentation
        –Perform an eye exam to rule out strabismus or iris translucency that can be present in albinism
      • Wood's lamp examination can be used to highlight the borders of hypo- and depigmented patches
      • Skin biopsy can support the diagnosis of vitiligo but is not specific
      • Check thyroid function tests in patients with recent-onset vitiligo, and consider fasting glucose or ACTH stimulation test to rule out diabetes and Addison's
      • CBC (anemia, macrocytosis) may be indicated to screen for pernicious anemia, if suspected in patients with vitiligo

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Genital Skin Lesions: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Herpes simplex virus (HSV-1 and HSV-2) is the most common cause of genital lesions in the U.S.
      –Presents with prodromal tingling and genital discomfort before lesions
      –Lesions are always painful and appear as grouped vesicles on an erythematous base
    • Condyloma acuminatum (“warts,” HPV)
      –Etiologic agent is human papilloma virus
      –Lesions usually painless and pearly with a smooth surface but may be filiform, fungating, and lobulated
  • Tinea cruris
    –Inguinal erythema with itch or tenderness
    –Always spares the scrotum
  • Candida intertrigo
    –Inguinal erythema with itch or tenderness
    –Often very red with satellite lesions
    –Frequently involves the labia or scrotum
  • Syphilis
    –Primary stage: Painless solitary ulcer (chancre) on labia, penis, or oral mucosa that heals in 2–3 weeks
    –Secondary stage: Condyloma lata (moist hypertrophic papules on genital and oral regions)
    –Tertiary stage: Cardiac, neurologic, and other systemic effects
    • Molluscum contagiosum
      –Multiple, very small, painless, flesh-colored nodules with umbilicated centers
    • Chancroid
      –Etiologic agent is Haemophilus ducreyi
      –Painful, solitary, and erythematous lesions
      –May present with dyspareunia and/or dysuria
  • Erythrasma
  • Lymphogranuloma venereum
  • Granuloma inguinale
  • Behçet syndrome
    –Oral and genital ulcers, retinitis, uveitis
  • Lichen planus
  • Scabies
  • Zoon's plasma cell balanitis
  • Less common etiologies (“zebras”) include inverse psoriasis, seborrheic dermatitis, genital squamous cell carcinoma, extramammary Paget's disease, plaque psoriasis, and fixed drug eruptions

    • Workup and Diagnosis

    • History and physical examination including a sexual history and a complete skin exam
      –Separate lesions into painless and painful categories; however, note that an initially painless lesion may become painful following a secondary infection
    • Viral culture is gold standard for HSV detection
    • Tzanck test may be used to detect HSV and will reveal multinucleated giant cells and intranuclear inclusions
    • RPR or VDRL serum tests screen for syphilis, but become positive only 6–8 weeks after primary infection
      –These tests have high false-positive rates
      –Serum FTA is more specific for syphilis
      –Early diagnosis of primary disease requires dark-field microscopic evaluation of infected tissue or IgM assay
      • Culture or Gram stain to detect chancroid
      • Condyloma accuminata can be diagnosed by applying acetic acid to lesions, which will turn acetowhite
      • Molluscum contagiosum is diagnosed by appearance
      • Wood's lamp may be used to detect erythrasma
      • Shave biopsy is diagnostic for psoriasis, Zoon's, and neoplasms
      • Lesions in older patients that are changing in size, appearance, or texture should always be biopsied to rule out carcinoma
      • All patients with a suspected STD require a full workup for HIV, syphilis, hepatitis B and C, and pregnancy

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Papulosquamous Lesions: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    • Allergic and irritant contact reactions and drug-induced rashes are included in the papulosquamous diseases
    • Psoriasis
      –Affects 2% of the U.S. population
      –May acutely present as guttate (drop-like), round plaques with minimal scale
      –More common is the variant called psoriasis vulgaris: Presents as thick plaques of silvery adherent scale on an erythematous base on the extensor joints
    • Seborrheic dermatitis
      –An inflammatory “dandruff” that manifests as light scale on a greasy and/or erythematous background around the hairline, upper lip, nasolabial creases, chin, external ears, eyebrow areas, scalp
      –Due to overgrowth of Pityrosporum ovale
    • Pityriasis rosea
      –A common exanthem that is self-limited; the etiology is unclear
      –Presents with initial “herald patch,” with subsequent scaly pink papules/plaques over the trunk in a “Christmas tree” distribution
      –May be very itchy and is often confused with guttate psoriasis
    • Atopic dermatitis
      –Common among children with a history of asthma, hay fever, or seasonal allergies
      –Manifests as itchy eczematous plaques on the antecubital and popliteal fossae; often becomes secondarily lichenified (i.e., thickened with chronic rubbing changes)
      –60% of patients have initial symptoms before 1 year of age
      –The disease often lasts 15–20 years
    • Fungal infections of the skin caused by dermatophytes often present as itchy, scaly papulosquamous rashes that can mimic nummular eczema
    • Nummular eczema
      –An idiopathic disease that affects many patients mostly in the winter months
    • Lichen planus
      –Present with flat topped, polygonal, and purplish papules that may have white streaks or “Wickham's striae”
  • Eczematous diseases (e.g., eczema craquelé, lichen simplex chronicus)
  • Infection (e.g., secondary syphilis meningococcemia, RMSF)

    • Workup and Diagnosis

    • Perform a focused history and physical examination
      –Evaluate for family history of psoriasis or other skin disease
      –Look for fingernail pitting, subungual debris, distal separation of the nail plate from the nail bed (called onycholysis), and “oil spots” (extravasated proteins under the nail) that are characteristic of psoriasis; always consider psoriasis if the scale is markedly silver and very thick/adherent to the skin
    • Seborrhea of the face and scalp is far more common than psoriasis of these areas, and it has a much thinner and lighter scale
    • Pityriasis rosea presents in healthy young adults after a viral prodrome; observe carefully for the larger, thicker herald patch to confirm the diagnosis; patients can often point the first patch out to you, because it appeared several days before the more diffuse eruption
    • Consider atopic dermatitis in a young patient with allergic rhinitis or asthma and a very itchy, chronic, or subacute rash that is often symmetric on the flexural skin
    • A KOH preparation and examination by light microscope can quickly establish the diagnosis of a dermatophyte infection
    • Patch testing to potential allergens and review of a patient's chemical exposure can help rule in allergic contact or irritant dermatitis, respectively

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Vesicular & Bullous Lesions: Differential Diagnosis
    (In a Page: Signs and Symptoms)

    Localized

    • Allergic contact dermatitis (e.g. rhus)
      –Localized vesicular and bullous eruptions
      • Herpes-zoster or shingles
        –Due to reactivation of latent virus
        –More common in adults
        –Presents as painful vesicles on an erythematous base in a dermatomal distribution, beginning with fever, dysesthesia, and/or malaise
      • Herpes simplex virus
        –Herpetic lesions present as painful, recurrent vesicles on an erythematous base
        –Type 1 usually affects oral mucosa and vermilion border
        –Genital HSV (most commonly HSV-2) may manifest as nonspecific symptoms (e.g., dysuria, urethritis)
      • Bullous impetigo
        –Most common in children
        –Presents as flaccid vesicles and bullae with honey-colored crust
    • Bites from many insects
    • Many viral infections of childhood can present with focal vesicles, especially hand-foot-andmouth disease
      • Burns and friction blisters
        –Common causes of bullae, especially on hands
    • Diabetics can develop bullae on the legs
    • Dyshidrotic eczema (pompholyx)
      –Causes itching, scaling, and erythema, and minute vesicles and painful fissures
      Diffuse
    • Polymorphous light eruption
      –Common reaction to ultraviolet light
      –Presents as itchy vesicles or erythematous papules on sun-exposed areas
    • Varicella or “chicken pox”
      –Presents with vesicles in crops, and in many stages of evolution
    • Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN)
      –Most commonly caused by medications
      –TEN is life threatening
    • Blistering diseases like bullous pemphigoid, pemphigus vulgaris, and porphyria cutanea tarda present with coalescing vesicles and bullae

    Workup and Diagnosis

    • History and physical examination
      –Determine whether the lesions are focal or diffuse
      –Thorough review of systems
    • Culture from bullous lesions is not usually indicated, because most bullous reactions to bacteria are due to toxin production; thus, the bacteria are not commonly found within the bulla itself
    • If HSV-2 (genital herpes) is the suspected etiology of a vesicular eruption, viral culture is the gold standard for diagnosis; obtain a culture by lancing an intact vesicle and swabbing the contents and floor of the erosion; serum IgM and IgG antibodies can also aid in the diagnosis
    • Suspected orolabial HSV-1 infection is diagnosed on the basis of a history of similar recurrent episodes
    • Consider a viral etiology if the patient has low-grade fevers, myalgias, pharyngitis, or other systemic symptoms
    • Skin biopsy is indicated if an autoimmune blistering disease is suspected. PCT, pemphigus, and pemphigoid have distinct microscopic features
    • In patients with widespread bullae, also consider incipient toxic epidermal necrolysis. Drugs such as sulfonamides, certain antibiotics, and several anticonvulsants are the most likely causative agents. Skin biopsy may also aid in this diagnosis, but frozen sections must be examined urgently, since this disease can quickly prove fatal

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Pruritus: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Urticaria
      –Hypersensitivity reaction causing edema via mast cell/basophil release of histamine, kinins, prostaglandins, and serotonin, mostly IgE-mediated
      –Hives; subcutaneous and mucous membranes
      –Angioedema: Most cases acute (resolving within 48 hours); chronic >6 weeks
      –Anaphylaxis: May be life-threatening
      • Atopic dermatitis
        –Incidence 2–10%; often begins in infancy
        –Most cases improve with age
        –Frequent remissions/exacerbations
        –Increased risk of infection (herpes, eczema herpeticum; staph, strep)
        –Can be exercise-induced
      • Xerosis (dry skin)
        –Idiopathic or due to excessive bathing, low humidity, etc.
    • Tinea (dermatophytoses, “ringworm”)
      –Fungal infection (Trichophyton, Microsporum, Epidermophyton)
      –Scalp (tinea capitis), face, trunk, extremities (t. corporis), feet (t. pedis)
      –complications: superinfection and kerion
        • Contact dermatitis
          –Allergens (poison ivy, cosmetics, dyes, drugs, foods, jewelry/nickel, animals)
          –Irritants (soap, chemicals, wool, fiberglass)
      • Scarlet fever (group A strep): “Sandpaper rash,” incubation period 1–7 days; age 5–15 years, 15–20% colonized (oropharyngeal)
      • Herpes: Varicella, zoster, herpes simplex
      • Lice (pediculosis): Head or pubic area
      • Mites (scabies [Sarcoptes scabiei])
      • Pinworms (Enterobius vermicularis)
      • Cholestasis (TPN, biliary atresia)
      • Erythema multiforme (“bull's eye rash”): Stevens-Johnson syndrome
      • Drug-induced: Opiates, barbiturates, isoniazid, phenothiazines, erythromycin
      • Systemic diseases: Malignancies, renal failure, mastocytosis, SLE, JRA, hypo- and hyperthyroidism, DM
      • Prurigo gestationis
      • Parasites (“swimmer itch,” trematodes)
      • Chronic skin diseases (psoriasis)

      Workup and Diagnosis

      • History and physical exam
        –Location, duration, rash, exposure, chronic illness, associated symptoms, ill contacts
        –Urticaria: Exposure to foods, drugs, bacteria, viruses, insect bites, etc.; wheals (erythematous, raised, well-circumscribed lesions) usually self-limited; may also have angioedema, wheezing, stridor, hoarseness, anaphylaxis, hypotension
        –Atopic dermatitis: Family history; ill-defined, erythematous, scaly plaques; in infant, head, extensor surfaces, and trunk; in child, antecubital/popliteal fossae, neck, wrist/ankle; may also have Morgan folds (lines under lower eyelids)
        –Tinea: Erythematous, scaly, circular plaque with central clearing; kerion is inflammatory, painful mass with sterile pustules and regional lymphadenopathy
        –Poison ivy: Linear streaks of vesicles, may last several weeks; exposure to poison ivy, oak, or sumac
        –Lice: Nits on hair shafts
        –Mites: 1–2 mm papules and burrows on palm, sole, interdigital web, axilla, genitalia, wrist, ankle
        –Pinworm: Nocturnal anal pruritus
        –Scarlet fever: Erythematous, finely granular rash, most prominent in axilla and groin, circumoral pallor
      • Pinworm: Apply tape to anus, see microscopic egg
      • Scarlet fever: Throat culture or antigen detection
      • Tinea: KOH preparation, culture, or Wood lamp to confirm diagnosis (usually diagnosed clinically)

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Annular Rashes: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Infectious
      –Dermatophytes: Microsporum, Trichophyton, Epidermophyton infections (tinea capitis, corporis, cruris, pedis)
      –Tinea versicolor: Superficial infection, caused by Malassezia furfur
      –Erythema migrans: Earliest sign in Lyme disease, at the site of the tick bite; typically 7–10 days after bite; initially an erythematous macule that expands to form a large, annular lesion (up to 70 cm, average 15 cm) if left untreated
      –Erythema marginatum: In about 10% of the patients with rheumatic fever and occasionally in juvenile rheumatoid arthritis; associated with active carditis
      –Pityriasis rosacea
      –Secondary syphilis
      –African trypanosomiasis: Circinate outline and normal central area
      –Larva migrans cutanata: Can present with a serpiginous rash
      –Lupus vulgaris (rare, chronic, progressive form of cutaneous tuberculosis)
    • Numular eczema
    • Pityriasis alba
    • Seborrheic dermatitis
    • Immune mediated
      –SLE
      –Urticaria
      –Erythema multiforme, minor and major (including Stevens-Johnson syndrome): Hypersensitivity syndrome to a variety of etiologies (mostly infectious in children, notably Mycoplasma, and sulfonamides) and presentations; the hallmark is the target lesion (also occasionally seen in erythema annulare centrifugum and Kawasaki disease)
      –Toxic epidermal necrolysis (Lyell disease)
    • Granuloma annulare
    • Sarcoidosis
    • Drug eruptions
    • Cutaneous T-cell lymphoma

    Workup and Diagnosis

    • History
      –Age, diet, drugs, fever, tick bites
      –History of maternal conditions (e.g., SLE)
      –Association with other signs/symptoms, such as malaise, headache, myalgia, lymphadenitis, pharyngitis, cranial nerve palsies, subcutaneous nodules, arthritis, chorea, genital chancres
    • Physical exam
      –Pattern and distribution of the rash; duration, spread mode, crops formation, presence of pruritus, involvement of the mucosal surfaces
      –Visualization of the pale or barely perceptible vascular reactive lesions can be enhanced by gentle warming of the skin
      –Wood lamp examination identifies Microsporum spp in tinea capitis, but misses Trichophyton; also useful in tinea cruris and tinea versicolor
    • Labs
      –CBC with differential, ESR/CRP
      –Serology for SLE, Lyme disease, syphilis
      –Skin scrapings, KOH preparations, fungal cultures
      –Skin biopsy is rarely needed
    • ECG if carditis is suspected
      –Prolonged PR interval
      –Atrioventricular block

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Hand & Foot Rashes: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    Infectious

    • Enterovirus infection (hand-foot-and-mouth disease, Coxsakie virus, other nonpolio enteroviruses)
    • Kawasaki disease (one of the five criteria)
    • Scabies
    • Tinea
    • Candidal skin infection
    • Ricketsial rash: Rocky Mountain spotted fever (RMSF), murine typhus
    • Mononucleosis (EBV)
    • Measles: Atypical forms start on hands/feet
    • Scarlet fever, post-streptococcal infection desquamation rash
    • Infectious endocarditis: Janeway lesions, Osler nodules
    • Spirochete infection: Secondary syphilis, Lyme disease (acrodermatitis chronica atrophicans)
    • Congenital toxoplasmosis
    • Rat-bite fever (Streptobacillus moniliformis, Spirillum minus)
      Immune-mediated
      • Urticaria: Hands and feet involved in 85% of the cases
      • Juvenile rheumatoid arthritis
      • Systemic lupus erythematosus
      • Raynaud phenomenon (acrocyanosis)
      • Acute graft-vs-host disease
        Skin disorders
      • Atopic dermatitis (infantile)
      • Dyshydrotic eczema, pompholyx
      • Chronic allergic contact dermatitis
      • Psoriasis
      • Lichen simplex
      • Papillon-Lefèvre syndrome
      • Olmsted syndrome
      • Acrodermatitis enteropathica (zinc deficiency) can be presenting sign of cystic fibrosis
      • Toxic shock syndrome: Desquamation during the recovery phase; major criteria for staphyloccocal TSS
      • Drugs: Ampicillin, especially in patients with infectious mononucleosis
      • Chronic liver disease: Cirrhosis, hepatoma
      • Metabolic disease: Gangliosidosis
      • Malignancy: Acute leukemia, lymphoma

      Workup and Diagnosis

      • History
        –Season of onset (can be a clue for various infectious etiologies)
        –Patient's age
        –Presence of fever, pruritus (typical of urticaria)
        –Tick/rat/bat bites (e.g., rat bite fever or Lyme disease)
        –Travel (to endemic areas for Lyme, RMSF)
        –Sick contacts
        –Contact allergen
      • Physical exam
        –Rash pattern and distribution, desquamation (interdigital, periungal), edema, involvement of other areas of the body
        –Other signs and symptoms associated (oral lesions, URI symptoms, arthritis, genital chancre)
        –Verify criteria for disease such as Kawasaki, Lyme, juvenile rheumatoid arthritis
        • Labs
          –CBC, ESR/CRP
          –Serologic testing for RMSF, Lyme, syphilis, toxoplasmosis, SLE
          –Throat swabs and stool culture for enterovirus serotype (no therapeutic significance)
          –KOH prep for hyphae
        • ECG, echocardiography, and cardiology consult if Kawasaki disease or endocarditis is suspected

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Morbilliform Rashes: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Measles
      –Also called rubeola, a highly contagious (>90% exposed patients acquire the disease), moderately severe viral illness
      –Characterized by fever and malaise in prodrome, cough, conjunctivitis, Koplick spots on buccal mucosa, and an exanthem on day 3–4
      –The exanthem of measles is blotchy, blanching, erythematous maculopapules beginning at the head and spreading distally
      –Severe complications, such as pneumonia, DIC, encephalitis, can occur
    • Viral exanthems
      –Adenovirus: Many types can cause a morbilliform rash that is usually generalized when first identified, often accompanied by upper respiratory symptoms
      –Rubella (German measles): Without a prodrome in young children, the exanthem is pinkish, fine maculopapules with a distribution similar to that of measles
      –Other viruses may also cause this rash
    • Drug eruptions
      –Erythematous, maculopapular rash that may be blanching or fine in nature
      –May be generalized, or begin on the trunk or face then spread to the extremities
      –Rash usually begins 1–2 weeks into therapy
      –May be pruritic
      –Drugs commonly resulting in morbilliform reactions are anticonvulsants, cephalosporins, pencillins, and sulfonamides

    Workup and Diagnosis

    • History
      –Presence of prodrome such as fever, upper respiratory symptoms
      –Onset and duration of rash, distribution and spread of the rash over time
      –Sick contacts, especially daycare or school
      –Immunization history, past medical history, medications
    • Physical exam
      –Vital signs
      –General exam of systems with special attention to mucous membranes and HEENT exam
      –Evaluation of the characteristics of the rash such as distribution, type, confluence, blanching, and other skin findings
    • Diagnostic testing is not usually needed; however, viral cultures or titers for measles can be sent if necessary to confirm diagnosis

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Vesicular Rashes: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Infection
      –HSV: Primary infection followed by latent infection in sensory ganglia; recurrences triggered by cold, UV light, stress, fever; HSV-2 (genital herpes) in child suspect sexual abuse; transmission by direct contact
      –Varicella (chickenpox) and herpes zoster (VZV): Shingles, reactivation of latent virus in sensory ganglia
      –Coxsackie virus (CV): Herpangina, “handfoot-and-mouth disease”
      –Tinea (“ringworm”): Fungal infection
      –Bullous impetigo (BI): Staph, strep
      –Scabies (mites)
      –Staphylococcal scalded skin syndrome (SSSS): Tender skin, generalized exfoliation
    • Contact dermatitis (CD): Poison ivy, drugs, foods, jewelry, chemicals
      • Erythema multiforme (EM)/Stevens-Johnson syndrome (SJS):
        –EM: “Bull's eye rash,” central vesicle, bulla or urticaria
        –SJS: More severe, two or more mucous membranes involved
        –Triggers: Drugs (sulfonamides, NSAIDs, phenytoin), infection (herpes, EM; mycoplasma, SJS), chemicals, malignancies
    • Toxic epidermal necrolysis (TEN, a.k.a. Lyell syndrome): Sudden-onset erythema, bullae, tender skin; same triggers as EM/SJS
      • Neonatal
        –Erythema toxicum: In up to 60% of newborns, disappears after 1 week
        –Miliaria: Obstructed sweat ducts
        –Pustular melanosis: Pustule then macule
        –Neonatal acne
        –Sucking blisters (bullae on hand)
        –Acropustulosis
        –Eosinophilic pustular folliculitis
        –Congenital candidiasis
    • Folliculitis: Staph and strep infections
    • Autoimmune: Dermatitis herpetiformis (DH), pemphigus vulgaris (PV), linear IgA disease, bullous pemphigoid (BP)
    • Hereditary: Incontinentia pigmenti, epidermolysis bullosa (EB)
    • Others: Mastocytosis, friction, burns

    Workup and Diagnosis

    • History and physical exam
      –Location, exposure, associated symptoms, social history
    • HSV: Tingling/burning, vesicle on red base, 7–10 days, no scar
      –HSV-1: Mouth (ulcers, vesicles), skin, cerebral (80% asymptomatic); “herpetic whitlow” (fingers); “herpetic gladiatorum” (contact sports)
      –HSV-2: Genital, congenital; encephalitis (temporal lobe), dissemination, superinfection, keratitis
    • Varicella: Red pruritic macule/papule on face, trunk; then vesicle/pustule on red macule; then noncontagious crust/scab; can get superinfection, pneumonia, encephalitis, hemorrhagic varicella
    • H. zoster: Face/trunk, single dermatome, coalescing and grouped vesicles, crust after 7 days, common in immunocompromised patients, rare in children
    • CV: Red macule/papule/vesicle on posterior oropharynx, hands, feet; may result in myocarditis
    • Tinea: Can have kerion, a fluctuant mass with pustules
    • BI: Erosion, honey-colored crust with adjacent bulla
    • SSSS: Nikolsky sign, skin rubbing leads to bulla/peeling
    • EB: Trauma, warm weather results in bulla
    • Labs/Studies
      –HSV/VZV: PCR, culture of lesions/fluids; Tzanck test: scrape from vesicle base shows multinucleated giant cells/nuclear inclusions; brain MRI/EEG (HSV)
      –Tinea: KOH preparation, culture, or Wood lamp
      –DH: Test for celiac disease (tissue transglutaminase)
      –Biopsy when diagnosis unclear

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    PRURITUS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    It should be obvious that the clinical approach to pruritus without an obvious dermatologic manifestation is to order appropriate tests. See below to rule out the above systemic disorders.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RASH, GENERAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or the if symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RASH, LOCAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis is similar to that of the general rash (see page 446).

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    BLEEDING UNDER THE SKIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical approach to purpura involves taking a drug history and a good family history, and ordering appropriate coagulation studies, tourniquet testing, and other tests. Referral to a hematologist is wise in obscure cases.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN PIGMENTATION AND OTHER PIGMENTARY CHANGES: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The workup for diffuse pigmentation involves ruling out hemochromatosis, hepatobiliary disease, and Addison disease with appropriate tests for these disorders (see Appendix) and using the expertise of a dermatologist in the cases of patchy pigmentation.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN ULCERS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of a skin ulcer involves an assessment of the vascular supply to the area, a neurologic examination, and a good history (especially important is venereal disease). The laboratory can support the diagnosis with a smear and culture, skin tests for tuberculosis and fungi, and serologic tests.

    An x-ray of the bone may reveal the cause. A biopsy may be necessary. Radiographic and laboratory survey of other organs may be necessary if a systemic disease (e.g., collagen disease or ulcerative colitis) is suspected.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN DISCHARGE: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Smear and culture of the lesion are most important, although a skin biopsy is sometimes necessary. Serologic tests or cultures on special media are necessary to diagnose fungi and parasites.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A biopsy or excision is the best approach to the diagnosis. If a systemic disease is suspected because of a lesion, appropriate studies for these are listed below.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Papular rash: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

    Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Pustular rash: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

    Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Pruritus: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of  perfumes)?

    Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.

    Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Skin, mottled: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

    Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check the capillary refill time. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Butterfly rash: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus [LE])?

    Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Vesicular rash: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.

    Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Skin turgor, decreased: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol?

    Next, take the patient’s vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he’s in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/
    minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, start an I.V. line for fluids.

    Evaluate the patient’s level of consciousness (LOC) for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Also, check his jugular veins for flatness, and monitor his urine output.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Skin, clammy: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 564.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

    Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Skin, scaly: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.

    Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Rocky Mountain spotted fever: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    CONFIRMING DIAGNOSIS Diagnosis is usually based on a history of tick bite or travel to a tick-infested area and a positive complement fixation test (which shows a fourfold increase in convalescent antibody titer compared with acute titers). Blood cultures or skin biopsy at the rash site should be performed to isolate the organism and confirm the diagnosis.

    Another common but less reliable antibody test is the Weil-Felix reaction, which also shows a fourfold increase between the acute and convalescent sera titer levels. Increased titers usually develop after 10 to 14 days and persist for several months.

    Additional recommended laboratory tests consist of a platelet count for thrombocytopenia (12,000 to 150,000/µl) and a white blood cell count (elevated to 11,000 to 33,000/µl) during the second week of illness.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Pruritus ani: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    A detailed patient history is essential. Rectal examination rules out fissures and fistulas; biopsy rules out cancer. Allergy testing may also be helpful.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Staphylococcal scalded skin syndrome: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis requires careful observation of the three-stage progression of this disease. Results of exfoliative cytology and biopsy aid in differential diagnosis, ruling out erythema multiforme and drug-induced toxic epidermal necrolysis, both of which are similar to SSSS.

    CONFIRMING DIAGNOSIS Isolation of group 2 S. aureus on cultures of skin lesions confirms the diagnosis. However, skin lesions sometimes appear sterile.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Introduction: Skin Disorders: Diagnostic aids
    (Professional Guide to Diseases (Eighth Edition))

    After simple observation, and examination of the affected area of the skin with a dermatoscope for morphologic detail, the following clinical diagnostic techniques may help to identify skin disorders:

    ❑ Biopsy determines histology of cells, and may be diagnostic, confirmatory, or inconclusive, depending on the disease.

    ❑ Diascopy, in which a lesion is covered with a microscopic slide or piece of clear plastic, helps determine whether dilated capillaries or extravasated blood is causing the redness of a lesion.

    ❑ Gram’s stains and exudate cultures help identify the organism responsible for an underlying infection.

    ❑ Microscopic immunofluorescence identifies immunoglobulins and elastic tissue in detecting skin manifestations of immunologically mediated disease.

    ❑ Patch tests identify contact sensitivity (usually with dermatitis).

    ❑ Potassium hydroxide preparations permit examination for mycelia in fungal infections.

    ❑ Side-lighting shows minor elevations or depressions in lesions; it also helps determine the configuration and degree of eruption.

    ❑ Subdued lighting highlights the difference between normal skin and circumscribed lesions that are hypopigmented or hyperpigmented.

    ❑ Wood’s light examination reveals yellow, green, or blue-green fluorescence when an area is infected with certain dermatophytes (fungi).

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Papular rash: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.

    Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

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    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pustular rash: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

    Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pruritus: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after hefalls asleep. (Generally, pruritus related to dermatoses prevents—but doesn’t disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or use of perfumes)?

    Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have any pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history.

    Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Skin, mottled: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

    Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check capillary refill. Palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Assess motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Butterfly rash: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

    Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body. (See Butterfly rash: Causes and associated findings.)

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Café-au-lait spots: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient or his parents when the café-au-lait spots first appeared. Also ask about a family history of these spots and of neurofibromatosis. Review the patient’s history for seizures, frequent fractures, or mental retardation.

    Inspect the skin, noting the location and pattern of the spots. Look for distinctive skin lesions, such as axillary freckling, mottling, small spherical patches, and areas of depigmentation. Large lesions should be measured along the longest axis. A Wood’s light examination may help visualize lesions in pale-skinned individuals. Check for subcutaneous neurofibromas along major nerve branches, especially on the trunk. Also check for bony abnormalities, such as scoliosis or kyphosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Vesicular rash: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has treated the rash with a topical medication, what type did he use and when did he last apply it? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies and recent infections, insect bites, or exposure to allergens.

    Examine the patient’s skin, noting if it’s dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they’re flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky’s sign).

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Skin turgor, decreased: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol?

    Next, take the patient’s vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he’s in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, start an I.V. line for fluids.

    Evaluate the patient’s level of consciousness for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Check his neck veins for flatness and monitor his urine output.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Skin, bronze: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by asking the patient when the hyperpigmentation first appeared. Has its hue changed? When was he last exposed to the sun or artificial tanning source? Also, ask about a history of infection, illness, surgery, or trauma. Does he have abdominal pain, weakness, fatigue, diarrhea, or constipation? Has he recently lost weight? If the patient is receiving maintenance therapy for adrenal insufficiency, has his dosage been increased?

    Examine the mucosa, gums, and scars for hyperpigmentation. Check for signs of dehydration and for abdominal distention, loss of body hair, and tissue and muscle wasting. Palpate for hepatosplenomegaly.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Skin, clammy: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

    Next, examine the pupils for dilation. Check for abdominal distention and increased muscle tension.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Skin, scaly: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.

    Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Pruritus: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    The history frequently suggests whether the pruritus is primary or secondary, and often provides clues to its cause. In taking the history, ascertain the location and duration of the pruritus, exacerbating and alleviating factors, and the patient’s medications, occupation, travel, bathing habits, and family history of atopy or cancer. Also ask about possible pregnancy, diabetes mellitus, chronic renal failure, or hepatic disorders. Onset or worsening of the itching in winter would suggest xerosis. The presence of itching in family members or a household pet raises concern that the cause is an infection from a scabies or a nonscabies mite. Pruritus during or after bathing is characteristic of aquatic pruritus. Exposure to chemicals, new soaps, or detergents could cause allergic or irritant dermatitis. The review of systems often reveals other medical disorders that can be associated with pruritus (section
    I.C.    ).

    Physical examination

    The physical examination includes a thorough examination of the skin in adequate lighting. Direct special attention to skin areas not easily observed or reached by the patient. Such areas may reveal a primary skin disorder or evidence of a systemic disease because some disorders present in particular areas. For example, scabies involves the interdigital webs, volar wrists, and genitalia, whereas atopic dermatitis occurs in the antecubital or popliteal fossae. Pityriasis rosea typically has a “herald patch” on the trunk. Fungal infections tend to occur in warm, dark, moist body surfaces (e.g., genitalia, feet, and inguinal folds).

    Be able to recognize the classic signs of common skin disorders. Dematographism and wheals typically indicate uticaria (hives) (Chapter 13.7). Flat-topped polygonal papules with delicate white lines (“Wickham’s straiae”) are characteristic of lichen planus. Silver plaques on an erythematous base with a positive Auspitz sign (punctuate bleeding of the scale after blunt scraping) are characteristic of psoriasis. The application of lateral pressure on superficial, crusting lesions resulting in dislodging the epidermis, referred to as Nikolsky’s sign, indicates pemphigus foliaceus. The differential diagnosis of lymphadenopathy includes mycosis fungoides (Chapter 15.1). Pustular or lesions over hair follicles is a sign of folliculitis. Pay attention to new unscratched lesions because chronically excoriated skin from any cause has similar secondary changes. If lesions are present in unreachable areas, a systemic disease should be considered. In addition to the skin, examine other organ systems for organomegaly, lymphadenopathy, goiter, pregnancy, and signs of anemia or psychiatric disorders.

    Diagnostic tests

     If the history and physical examination do not reveal the diagnosis, certain tests can be helpful. For primary skin disorders the testing should include a wet preparation, the addition of potassium hydroxide (KOH), microscopic examination of scrapings, and as a last resort, skin biopsy. If a systemic disorder is suspected, include the following in the evaluation: a complete blood count with differential; tests for liver, renal, and thyroid function; stool for occult blood; human immunodeficiency (HIV) screen; serologic test for syphilis; and a chest radiograph. If the history and physical examination suggest other systemic diagnoses, additional recommended tests to consider include urinalysis, serum iron studies, stool for ova and parasites, serum glucose, and serum electrophoresis.

    Diagnostic assessment

    The diagnostic approach should initially be limited to the history and physical examination because most patients have a primary skin disorder (section I.A., I.B.). If the diagnosis is still unclear, 2 weeks of empirical treatment for the most common cause of pruritus (xerosis) is recommended. This includes less-frequent baths, use of lukewarm water and a mild soap, “pat” drying after a bath, immediate application of a lubricant, and avoidance of irritating fabrics (e.g., wool) (5). Further diagnostic tests for systemic disorder can be considered to rule out the more obscure diagnoses listed above. Because malignancy can present several years after pruritus, follow-up is important. Sometimes, no cause is found. Remember, a diagnosis of psychogenic pruritis is a diagnosis of exclusion. The relationship between the psyche and organic disease is unclear. Depression, anxiety, and other psychiatric disorders can be secondary instead of the primary illness. It is important to follow up with appropriate psychiatric or dermatologic consultation as needed.


    References

    1. Greco PJ, Ende J. Pruritus: a practical approach. J Gen Intern Med 1992;7:172–181.

    2. Leshaw SM. Itching in active patients. Phy and Sports Med 1998;26(1):47–53.

    3. Beacham BE. Common dermatoses in the elderly. Am Fam Physician 1993;47(6):
    1445–1450.

    4. Lober CW. Should the patient with generalized pruritus be evaluated for malignancy? [Editorial]. J Am Acad Dermatol 1988;2(Part 1):350–352.

    5. Phillips WG. Pruritus. What to do when the itching won’t stop. Postgrad Med 1992;
    92(7):34–53.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Rash Accompanied by Fever: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    History is quite important and should include standard items, such as onset, duration, aggravating factors, relieving factors, and associated symptoms. Additionally, other factors to consider, include:

     A. Exposure history. Are any other family members or close contacts ill? Is there a history of exposure to brackish water, mosquitoes, foreign travel, and so forth?

    B. Are there any underlying illnesses or a significant possibility of immunologic compromise (e.g., undiagnosed HIV infection)?

    Physical examination

    A. Examine the lesions and their distribution carefully. Classify the rash as petechial, maculopapular, vesiculobullous, erythematous, or urticarial. Note the distribution of the rash. For instance, rubella and rubeola generally begin on the face and spread to the trunk, whereas RMSF petechiae tend to occur on the ankles and wrists first.

     B. Conduct a general physical examination. Areas of particular concern are:

     1. Head, eyes, ears, nose, and throat. The presence of Koplik’s spots is pathognomic for rubeola. The discovery of a tick lends support to the diagnosis of RMSF. Sinusitis may represent a source for meningococcemia. Pharyngitis in a young adult with diffuse erythema may be caused by C. haemolyticum. Mucous membrane swelling may indicate early anaphylaxis.

     2. Lung examination. Expiratory wheezing, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis. Evidence of pneumonia is consistent with psittacosis and mycoplasma.

     3. Cardiac examination. Cardiovascular collapse is associated with meningococcemia and other sepsis. A new murmur (Chapters 7.6 and 7.7) may indicate subacute bacterial endocarditis in a patient with subungual or scleral petechiae.

     4. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea. A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

     5. Joint examination and extremities. A petechial rash near the ankles and wrists is suggestive of RMSF. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis and other rheumatologic conditions as well.

    6. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Maculopapular Rash: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Seek a history of preceding illness, concurrent fever, or ingestion of medications. A travel history and exposure history are useful.

    B. Have the lesions spread? Are they painful, itching, or simply bothersome cosmetically? Have any been on the palms or soles?

    C. Are other signs present? Joint swelling can indicate gonococcemia. Headache and confusion can indicate meningococcemia. Difficult breathing can indicate impending collapse from anaphylaxis.

    Physical examination

    A. Carefully examine the lesions and their distribution.

     1. A rash that is on the face and spreading to the trunk is characteristic of measles or rubella. Many viral illnesses have a predilection for the trunk.

     2. A maculopapular rash occurring on the palms initially should prompt concern about syphilis. RMSF rash also occurs on the palms; usually, however, this rash is not raised until 3 or so days into the course of illness and it is accompanied by purpura on the ankles and wrists. Disseminated gonorrhea lesions are usually on the fingers and quickly become pustular. Meningococcemia can spread widely, but can present as a macule with central petechiae, which progressively becomes nodular.

     B. Conduct a general physical examination. Areas of particular concern are:

     1. Head, eyes, ears, nose, and throat. Although measles is becoming rare, the presence of Koplik’s spots is pathognomic for the illness. A common location for ticks is in the scalp hair, and the discovery of a tick lends support to the diagnosis of RMSF. Rarely, meningococcemia will be a complication of sinusitis, and often it develops following complaints of pharyngitis. Mucous membrane swelling may indicate early anaphylaxis.

     2. Lung examination. Wheezing on examination, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis.

     3. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea (Chapter 10.9). A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

     4. Joint examination. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis as well.

    5. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Vesicular and Bullous Eruptions: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

     A. Age. Newborns develop epidermolysis bullosa, pemphigus neonatorum, and syphilitic pemphigus. Children are more likely to have varicella (if unimmunized); primary herpes simplex; hand, foot, and mouth disease (HFM); and bullous impetigo. Recurrent herpes simplex, porphyria cutanea tarda (PCT), pemphigus vulgaris, dyshidrotic eczema, and dermatitis herpetiformis occur primarily in adults. Bullous pemphigoid and herpes zoster are more common in the elderly. Other vesiculobullous diseases that have no particular age predilection include allergic contact dermatitis, allergic vasculitis, erythema multiforme bullosum (EMB), toxic epidermal necrolysis (TEN), insect bites, and second-degree burns.

     B. Season. Varicella, HFM, and primary herpes simplex are often seen in epidemics after gatherings of children. Summer brings more bullous impetigo (from staphylococcal infection) and dyshidrotic eczema (increased sweating of hands and feet). Contact dermatitis caused by Rhus species can be seen in the spring, as people landscape their yards; in the summer, as people spend more time outdoors; and in the fall, as people rake leaves and cut firewood.

     C. Special precipitators. Recurrent herpes simplex can be precipitated by trauma, sunlight, wind, menses, dry skin, smoking, drinking alcohol, lack of sleep, and fever. PCT is precipitated by exposure to sunlight, ingestion of drugs metabolized in the liver, and by drinking alcohol (1). EMB can be caused by a viral or bacterial infection or by drug ingestion within 3 weeks preceding the eruption (Chapter 13.2). Allergic vasculitis is usually caused by drugs. Persons with contact dermatitis have been exposed to the allergen 12 to 48 hours before the rash appears.

     D. Pain or pruritus. Itching is very common with acute contact dermatitis, dyshidrotic eczema, varicella, dermatitis herpetiformis, and bullous pemphigoid (Chapter 13.5). Before the eruption of recurrent herpes simplex, the site may itch or tingle for a few hours or days; before herpes zoster erupts, the area may burn or mimic internal or visceral pain.

     E. Duration. Some diseases are chronic with exacerbations: dermatitis herpetiformis, dyshidrotic eczema, bullous pemphigoid, epidermolysis bullosa, and PCT. Some are episodically recurrent: acute contact dermatitis and herpes simplex. Some occur acutely without preceding episodes: EMB, varicella, bullous impetigo, herpes zoster, allergic vasculitis, HFM, TEN, and pemphigus vulgaris.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Scaling Rash: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Eczema

    ❑ Atopic dermatitis

    ❑ Seborrheic dermatitis

    ❑ Tinea versicolor

    ❑ Pityriasis rosea

    ❑ Psoriasis

    ❑ Contact dermatitis

    ❑ Tinea corporis

    ❑ Tinea manuum

    ❑ Stasis dermatitis

    ❑ Drugs

    ❑ Lichen planus

    ❑ Secondary syphilis

    ❑ Reiter

    ❑ Bowen disease

    ❑ Cutaneous T-cell lymphoma

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Staphylococcal scalded skin syndrome: Diagnosis
    (Handbook of Diseases)

    Careful observation of the three-stage progression of this disease allows diagnosis. Results of exfoliative cytology and a biopsy aid in the differential diagnosis, ruling out erythema multiforme and drug-induced toxic epidermal necrolysis, both of which are similar to SSSS.

    CLINICAL TIP: A blood culture is necessary to rule out sepsis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Skin, mottled: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient isn’t in distress, obtain his medical history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything relieve it? Does he have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes? 

    Physical examination

    Observe the patient’s skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check capillary refill. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Assess motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Skin, clammy: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient’s condition permits, obtain his medical history. Does he have type 1 diabetes mellitus or a cardiac disorder? Is he taking medication? If so, determine whether he takes an antiarrhythmic. Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination? 

    Physical examination

    Check the patient’s vital signs. Perform a complete cardiovascular assessment, followed by a physical assessment. Check the patient’s blood glucose level. Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Papular rash: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Find out when the rash erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have the patient describe associated signs and symptoms, such as fever, headache, and GI distress.

    Obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or a rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Pustular rash: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Pruritus: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after hefalls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (exercising, bathing, applying makeup, or using perfumes)?

    Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have any pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Skin, mottled: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn’t in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it go away? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Butterfly rash: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Vesicular rash: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask your patient when the rash began, how it spread, and whether it has appeared before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Also, ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Skin, bronze: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by asking the patient when the hyperpigmentation first appeared. Has its hue changed? When was he last exposed to the sun or artificial tanning source? Also, ask about a history of infection, illness, surgery, or trauma. Does he have abdominal pain, weakness, fatigue, diarrhea, or constipation? Has he recently lost weight? If the patient is receiving maintenance therapy for adrenal insufficiency, has his dosage been increased?

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Skin, clammy: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Skin, scaly: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Skin Lesions and Rashes: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Blistering (Vesiculobullous) Lesions

    Miliaria

  • Miliariacrystallina is produced by obstruction of sweat ducts in stratumcorneum. Clear, thin-walled, 1- to 2-mm vesicles usually occur onface, neck, and upper trunk in neonates or in areas of sunburn inolder children.
  • Characteristic lesions of miliariarubra (heat rash) are 2- to 4-mm papules or vesicles surroundedby erythema, which are commonly seen in neck, axilla, and groinareas.

    • Allergic Contact Dermatitis

  • Delayedhypersensitivity reaction to contact allergens, which include poisonivy, oak, and sumac; nickel-containing earrings or belt buckles;nail polishes; hair dyes; perfumes; cosmetics; and deodorants.
  • Presence of linear or geometric areasof vesiculation usually indicates allergic contact dermatitis.
  • Patch testing for contact allergenscan be useful in diagnosis.

    • Chemical and Thermal Burns

    Both chemical and thermal burns produce blisteringof skin with vesicle and bulla formation. Exposed areas are commonlyinvolved where rubbing against hot object has occurred. Cigaretteburns on skin or scald burns of feet suggest child abuse.

    Friction Blisters

    Mild trauma may produce friction with blisteringand vesicle formation of skin. Common cause is wearing of new shoesor skates.

    Frostbite

    Affects fingers, toes, nose, and ears mostcommonly. Rewarming produces erythema, swelling, and burning painfollowed by vesicles and bullae.

    Bullous Impetigo

  • Skin infectioncaused most commonly by S. aureus. Group A Streptococcus is commoncopathogen but does not form bullae alone.
  • Bullae containing clear fluid on erythematousbase may become pustular, with subsequent oozing and crusting.
  • Diagnosis is usually clinical. Positivebacterial culture of lesion is definitive.

    • Papular Urticaria (Insect Bites)

  • Insect bitesby fleas (most common), mosquitoes, bedbugs, fire ants, spiders,and chigger mites often produce urticarial papules, which may befollowed by vesicle formation.
  • Observing particular insect causingbite is diagnostic. Otherwise, inquiry into which insects may havebeen seen in house or immediate surroundings helps narrow possibilities.

    • Hand-Foot-Mouth Disease

  • Infectionusually associated with coxsackievirus A16.
  • Characteristic findings are fever andvesicles on erythematous base located on hands, feet, and in themouth.
  • Usually a clinical diagnosis, whichmay be confirmed by culture of skin vesicle.

    • Varicella-Zoster Virus Infections

  • Primaryinfection causes varicella (chickenpox). Incubation period is 10–21 days.
  • Illness begins with fever and macularrash; subsequently, lesions become papular, vesicular, and crusted.
  • When all stages of skin lesions occurat once, diagnosis is easily made clinically. Positive viral cultureis confirmatory.
  • Small number of children who receivevaricella vaccine may develop mild rash consisting of macules, papules,and vesicles within 1 mo of vaccination.
  • Reactivation of varicella-zoster viruscauses herpes zoster (shingles). Groups of painful vesicles on erythematousbase follow ≥1 of skin dermatomes. Diagnosis is usually clinical.Polymerase chain reaction (PCR) or positive viral culture confirmsdiagnosis.

    • Herpes Simplex Virus Infections

  • Infectionusually produces painful vesicles on erythematous base.
  • In neonates, herpes simplex virus (HSV)may be transmitted by mothers who have active infection of cervix,vulva, or perineum; however, positive history of maternal herpesinfection is often lacking. Neonates may develop localized lesionsinvolving skin, eye, or pharynx; encephalitis; or disseminated infectionwith hepatitis, pneumonia, and encephalitis.
  • In infancy and childhood, lesions alsomay occur on the lips and mouth (gingivostomatitis), fingers, andgenitalia.
  • Herpes genital infection is transmittedalmost exclusively by sexual contact and occurs in sexually activeindividuals or in younger children who have been sexually abused.
  • Diagnosis may be made by culture ofskin vesicles, nasopharynx, eyes, urine, blood, rectum, or CSF.Direct fluorescent antibody staining of vesicle scrapings or enzymeimmunoassay detection of HSV antigen are other diagnostic techniques.PCR is sensitive method to detect HSV DNA, especially in evaluationof spinal fluid for suspected herpes encephalitis.

    • Erythema Multiforme

  • Most commoncauses are infection, especially with HSV, and drugs (e.g., penicillins, sulfonamides,and barbiturates).
  • Oval or round, fixed, symmetric, violaceousmacules and papules 1–2 cm in diameter may occur anywhereon body, but their occurrence on palms and soles is characteristic.Lesions progress over a few days to develop concentric zones ofcolor with dusky center that can develop blisters. These are calledtarget or iris lesions.
  • When there is extensive skin and mucousmembrane involvement along with systemic symptoms (e.g., fever),this is known as Stevens-Johnson syndrome. Severe exfoliative variantof Stevens-Johnson syndrome is called toxic epidermal necrolysis.

    • Staphylococcal Scalded Skin Syndrome

  • S. aureusphage group II produces exfoliative toxins A and B, which causescalded skin syndrome.
  • Most common in children <5yrs of age.
  • Usual source of this pathogen is conjunctivitisor nasopharyngitis.
  • Clinical spectrum varies from mildillness with erythema, skin tenderness, and mild desquamation totoxic illness with high fever and widespread skin exfoliation. Skincan often be peeled off just by rubbing it (Nikolsky'ssign). Vesicles, bullae, and pustules may occur during exfoliativephase. Mucous membranes are generally spared, although crustingmay occur around eyes and mouth.
  • S. aureus may be cultured from skin,pharynx, eyes, ears, nose, and rectum. Cultures of blood and bullaeare usually negative.
  • Skin biopsy shows absence of epidermalnecrosis and inflammatory cells in contrast to toxic epidermal necrolysis,which shows epidermal necrosis and perivascular dermal inflammatory cells.

    • Epidermolysis Bullosa

  • Group ofgenetic disorders characterized by noninflammatory blisters. 3 majortypes are epidermolysis bullosa simplex, junctional epidermolysisbullosa, and dystrophic epidermolysis bullosa.
  • All types may appear similarly in neonateswith blisters, erosions, and mucous membrane involvement.
  • Diagnosis is based on clinical findings,routine histopathology, electron microscopy, and immunofluorescentantibody mapping of basement membrane.

    • Chronic Bullous Dermatitis of Childhood (Linear ImmunoglobulinA Dermatosis)

  • This raredisorder usually occurs in first decade of life.
  • Polycyclic lesions with blisters atedges can appear on trunk, perineum, legs, hands, and feet. Mucousmembranes are uninvolved.
  • Skin biopsy with immunofluorescentstaining shows linear immunoglobulin A (IgA) deposits within basementmembrane adjacent to blister.

    • Dermatitis Herpetiformis

  • Characteristiclesions of this rare disorder occur in school-aged children andconsist of pruritic groups of vesicles and blisters that appearin symmetric distribution over elbows, knees, back, and buttocks.Mucous membranes are uninvolved.
  • Diagnostic skin biopsy adjacent tovesicles shows granular IgA deposits at tips of dermal papillae.These individuals also may be gluten sensitive.

    • Bullous Pemphigoid

  • Large tensebullae on trunk and flexural areas of extremities characterize thisdisorder, which may last months to years. Mucous membrane involvementoccurs in some cases.
  • Skin biopsy with immunofluorescencereveals linear IgG and C3 deposits in basement membrane. CirculatingIgG against basement membrane also may be found in serum.

    • Incontinentia Pigmenti

  • Transmittedas X-linked dominant trait and only occurs in girls because it islethal in boys. In early infancy, vesicles and pustules appear.
  • Second stage occurs 2–6 wkslater and consists of papules and verrucous lesions.
  • Third stage usually occurs at 3–6mos of age with whorls of skin hyperpigmentation appearing in thelines of Blaschko.
  • Fourth stage consists of skin atrophyand hypopigmentation. In some cases, microcephaly, seizures, andmental retardation may occur.

    • Pustular Lesions

  • Pustularlesions commonly seen in neonates include erythema toxicum, transientneonatal pustular melanosis, miliaria, acne neonatorum, folliculitis,candidiasis, herpes simplex, and local bacterial infections usuallycaused by S. aureus.
  • Pustular lesions seen in infants, children,and adolescents include acne, folliculitis, candidiasis, scabies,infantile acropustulosis, and local bacterial infections.
  • Some of these disorders are discussedin other sections of this chapter.

    • Erythema Toxicum

    Rash of erythema toxicum consists of blotchy,erythematous macules 2–3 mm in diameter with tiny centralpustule or vesicle. May appear anywhere from 1–2 days ofage up to 10 days of age on the face, trunk, and extremities. Resolutionusually occurs in 4–5 days.

    Transient Neonatal Pustular Melanosis

    Characterized by 2- to 3-mm pustular lesionsdistributed over face, neck and upper chest, and less often on extremities.When lesions rupture, they leave hyperpigmented macules surroundedby collarette of fine white scale. Fade in a few weeks or months.

    Acne

  • Accumulationof sebum and keratin produce basic lesion of acne, which is calledmicrocomedo.
  • These firm papules, which are <1mm in diameter, usually appear at 2–8 wks of age on face, chest,and back.
  • When they become red and inflamed,they may evolve into pustules.
  • During puberty, acne lesions commonlyappear on face, chest, and back (see discussion of skin-coloredpapules and nodules below).

    • Folliculitis

  • Manifestationsof folliculitis, an infection of hair follicles, depend on depthof bacterial invasion. Superficial folliculitis appears as tinypustules 1–2 mm in diameter, whereas deep folliculitis orfurunculosis appears as tender, erythematous nodules. Confluenceof lesions may produce an abscess.
  • Usual pathogen is S. aureus. P. aeruginosafolliculitis may be associated with use of hot tubs.

    • Eosinophilic Pustular Folliculitis

    Uncommon disorder characterized by recurrentcrops of pruritic papules and pustules that occur on scalp, trunk,and extremities in infants. In some cases, peripheral eosinophiliamay be found at the time of outbreak of pustules.

    Infantile Acropustulosis

    Benign, self-limited disorder of unknowncause that usually occurs at 2–10 mos of age. Crops of pruriticpapules, pustules, and vesicles occur on fingers, palms, and soles,and occasionally on scalp, face, trunk, and extremities. Lesionslast for 7–10 days, but new crops can occur every 2–3wks, usually disappearing by 2–3 yrs of age.

    Skin-Colored Papules and Nodules

    Smooth Surface

    Milia

    Firm, white or yellow, 1- to 2-mm papules,usually appearing on cheeks, forehead, and nose. May also may beseen on palate (Epstein pearls) and gingiva (Bohn nodules). Theyrepresent keratin-filled epidermal inclusion cysts and usually disappeara few weeks after birth.

    Molluscum Contagiosum

  • DNA poxviruscauses this viral disease involving the skin. Transmission occursby person-to-person contact or fomites.
  • Lesions are discrete, flesh-colored,dome-shaped papules, 1–5 mm in diameter, with umbilicatedcenter.
  • Diagnosis is usually clinical; however,Wright stain of papule contents can demonstrate characteristic intracytoplasmicinclusion bodies, known as molluscum bodies.

    • Acne

    Closed comedones (whiteheads) and open comedones(blackheads) are noninflammatory lesions that do not scar. Withrupture of walls of hair follicles. inflammatory papules and pustulesappear. Involvement of many follicles may produce cysts and noduleswith more pronounced scarring. See the section Pustular Lesions: Acne.

    Epidermal Cyst

    This firm, round nodule may be 1–15cm in diameter. In neonates, may be seen on lateral border of eyebrowor in scalp.

    Granuloma Annulare

    This annular lesion consists of firm papulesand nodules, which form semicircle or circle with uninvolved orslightly discolored central area. Lesions are 1–15 cm indiameter and may be multiple. Often involve fingers, wrists, ankles,and dorsa of hands and feet. Lack of scaling and deep palpable portionhelp distinguish this lesion from tinea corporis.

    Lipoma

    Soft, mobile, nontender nodule composed offat and commonly found on arms, chest, and neck.

    Juvenile Xanthogranuloma

    Characterized by skin-colored or orange-brownpapules or nodules, which can appear anywhere on the skin. Whenblanched, underlying color is usually yellow. Spontaneous involutionmay occur over several years.

    Xanthoma

    Papule, plaque, nodule, or tumor that containslipid. Usually associated with increased serum lipids but is unusualin childhood.

    Neurofibroma

  • Skin-coloredlesion that can occur anywhere on skin and at any age.
  • May be solitary or associated withneurofibromatosis.
  • Biopsy is confirmatory.

    • Rough Surface

    Epidermal Nevi

    Raised, linear or oval, hairless, flesh-coloredor brown lesions, often present at birth, and their long axis parallelslong axis of dermatome. May become scaly, verrucous-like, inflamed,and pruritic.

    Warts

  • Caused byvarious types of human papilloma virus.
  • Common warts (verruca vulgaris) aresingle, flesh-colored papules with roughened, irregular, scaly surface.Commonly occur on hands and periungual areas but may occur anywhereon skin.
  • Plantar warts are common warts thatoccur on soles of feet.
  • Filiform warts appear as projectionsfrom stalk and usually are seen on nose, eyelids, or lips.
  • Flat warts (verruca plana) are flat,broad, multiple, flesh-colored or tan papules, 2–5 mm in diameter,that usually appear in groups on face and extremities.
  • Venereal warts (condyloma acuminata)are flesh-colored papules with irregular surface that are usuallyconfluent. Appear on genital mucosa, adjacent skin, or in both areas.
  • In most circumstances, diagnosis isclinical.

    • Corns and Calluses

  • Corns areareas of thickened skin, usually appearing because of prolongedfriction or pressure. Occur primarily on feet and have central core,when surface is pared off lesion.
  • Calluses are diffuse areas of thickenedskin, not as circumscribed as corns, which occur on palmar surfacesof hands or fingers and on weight-bearing areas of feet. Paringsurface of calluses reveals normal skin grooves.

    • Keratosis Pilaris

    Stratum corneum follicular plugs, 1–2mm in diameter, usually occur on exterior aspects of arms and legs,buttocks, and lateral aspects of facial cheeks.

    White Lesions

    Flat Lesions

    Postinflammatory Hypopigmentation

    Irregular hypopigmentation may occur followingany inflammation of skin. Particularly noticeable in African-Americanchildren and usually resolves in a few months.

    Pityriasis Alba

    Oval, flat, scaly, poorly demarcated, hypopigmentedmacules 0.5–2 cm in diameter may occur on face, upper trunk,thighs, or arms. Sometimes lesions are associated with atopic dermatitis.

    Tinea Versicolor

  • Yeastlikeorganism M. furfur produces lesions of tinea versicolor.
  • Oval macules with fine scale occuron neck, upper back, shoulders, and upper arms.
  • Although they appear as hypopigmentedmacules in tanned or dark-skinned individuals, with fading of skinpigmentation in winter, they appear as tan-brown macules.
  • Wood light exam reveals orange fluorescence.Diagnostic KOH preparation using skin scrapings reveals short curvedhyphae and circular spores.

    • Vitiligo

  • Cause isunknown but is thought to involve autoimmune destruction of melanocytes.
  • Characterized by appearance of well-demarcated,depigmented macules and patches. Distribution of lesions on face,neck, and extensor surfaces of extremities is often symmetric.
  • May be associated with alopecia areata,Addison disease, hypoparathyroidism, Hashimoto thyroiditis, myastheniagravis, and pernicious anemia.

    • Piebaldism

    In this autosomal-dominant disorder, circumscribedareas of skin with absence of pigment may be noted in neonates.These white patches may occur on face, chest, abdomen, and extremities.

    Ash-Leaf Macules

    These hypopigmented macules, which may beleaf shaped, may be only sign of tuberous sclerosis in newborns.Usually occur on trunk or extremities. Other cutaneous manifestationsof tuberous sclerosis are angiofibromas of nose and face (adenomasebaceum), which usually appear at 5–10 yrs of age. See furtherdiscussion of tuberous sclerosis in Chap.13, Developmental Delay.

    Hypomelanosis of Ito

    Bizarre hypopigmented swirls in lines ofBlaschko characterize hypomelanosis of Ito. Mental retardation maybe associated finding.

    Chediak-Higashi Syndrome

    Individuals with Chediak-Higashi syndromemay have patches of hypopigmented skin. Have recurrent infectionsbecause of inability to kill bacteria (see Chap. 53, Recurrent Infection).

    Waardenburg Syndrome

    Characteristic features of this autosomal-dominantdisorder include white forelock and eyelashes, white patches ofskin, heterochromia of irides, and sensorineural deafness. Genelocus has been mapped to chromosome 2q35.

    Raised Lesions

    Milia, microcomedones of acne, keratosispilaris, and molluscum contagiosum are discussed in previous sections.

    Brown, Blue-Black, or Black Lesions

    Flat Lesions

    Freckles (Ephelides)

    1- to 4-mm brown macules that occur on sun-exposedskin. More common in light-haired children, they become darker duringsummer and lighter and smaller during winter.

    Mongolian Spots (Dermal Melanosis)

  • Melanocytesdeep in dermis produce blue-black areas of discoloration calledMongolian spots.
  • Occur most commonly on buttocks, sacrum,and back.
  • Can be single or multiple and rangein size up to 20 cm in diameter. Lesions usually disappear overseveral years, although some may persist to adulthood.

    • Café au Lait Spots

  • These flat,oval or round, tan macules of varying size and shape with usuallyregular margins are present at birth or appear during first yearof life. May occur anywhere on body but usually are found on trunkand extremities.
  • Presence of ≥6 lesions >5mm in diameter in prepubertal children or >15 mm in diameterin postpubertal children is presumptive evidence of neurofibromatosis.
  • McCune-Albright syndrome, which usuallyoccurs in females, is characterized by café au lait spotswith irregular margins, polyostotic fibrous dysplasia, and sexualprecocity.

    • Lentigines

  • Tan, darkbrown, or black macules 1–5 mm in diameter, which are scatteredover body. Darker than freckles and do not change with sun exposure.
  • May be seen in normal individuals,in Peutz-Jeghers syndrome (pigmented mucocutaneous lesions and generalizedintestinal polyposis), and in Leopard syndrome (LEOPARD is acronymfor lentigines, electrocardiographic conduction defects, ocularhypertelorism, pulmonic stenosis, abnormal genitalia, retardationof growth, and deafness).

    • Nevi of Ota and of Ito

    Blue-gray patches of dermal melanosis whoseborders may be distinct or indistinct, regular or irregular. Nevusof Ota typically involves sclera and area of 1 side of face innervatedby first 2 branches of trigeminal nerve. Nevus of Ito occurs inacromioclavicular area.

    Congenital Nevocellular Nevi

  • Round oroval, brown or brown-black macules with well-demarcated border seenat birth.
  • Vary in size from 1–2 mm toseveral cm in diameter and can appear anywhere on skin.
  • Giant nevocellular nevi (>10–20cm in diameter) have small risk of evolving into cutaneous melanoma.Infants with smaller congenital nevi also probably have above-normalrisk of melanoma in adult life.
  • Small lesions are followed until about10 yrs of age and then excised. If excision is possible withoutsevere mutilation, giant nevi should probably be excised in infancy.

    • Acquired Nevocellular Nevi

  • May be junctional,intradermal, or compound. Junctional nevi arise from junction betweenepidermis and dermis, intradermal nevi arise from dermis, and compoundnevi arise from both epidermis and dermis.
  • Junctional nevocellular nevi are usuallyflat, round or oval, brown or brown-black macules with well-demarcatedborder. Vary in size from 1–2 mm to several cm in diameterand can appear anywhere on skin, usually after 6 mos of age. Raisedpapular intradermal or compound nevi usually occur in older children.
  • Diagnosis is usually clinical; however,skin biopsy can distinguish them.

    • Nevus Spilus (Speckled Lentiginous Nevus)

    Consists of light brown or tan macule thatis sometimes dotted with smaller, darker macules. They are 1–12cm in diameter.

    Spitz Nevi (Spindle Epithelioid Nevi)

  • Pink, brown,black, or blue-black, round or oval papules, up to 1.5 cm in diameter, withdistinct regular border.
  • Usually appear on face, shoulders,or extremities in school-aged children.
  • Excisional biopsy is diagnostic.

    • Epidermal Nevi

    See section on Skin-Colored Papules and Nodules.

    Raised Lesions

    Postinflammatory Hyperpigmentation

    In children with dark skin, healing inflammatorylesions may be hyperpigmented.

    Mastocytoma and Urticaria Pigmentosa

  • Mastocytomais single red or red-brown lesion appearing in first months of life.
  • Multiple red-brown papules 1–3cm in diameter are characteristic of urticaria pigmentosa. Usuallyappear on trunk, extremities, or face before 2 yrs of age.
  • Rubbing these lesions releases histaminefrom mast cells with production of wheal and flare (Darier sign).

    • Pyogenic Granuloma

    Single, reddish-brown, firm nodule 1–10mm in diameter, which may be smooth but also may ulcerate and crust.Usually occurs on hands, fingers, or trunk in children <5yrs of age but can occur at any age.

    Dysplastic Melanocytic Nevi

  • Usuallyappear around puberty and may be precursors of melanoma.
  • Individual lesions can be various colors(e.g., brown, pink, or fleshtone). Usually ≥5 mm in diameter.Skin surface is raised, and borders tend to be irregular and poorlydemarcated.
  • Risk of melanoma is high when thereis family history of dysplastic melanocytic nevi and melanoma.
  • Excisional biopsy is diagnostic.

    • Melanoma

  • This raremalignant lesion appears as pigmented nodule that may have variouscolors, including tan, brown, blue, red, and white.
  • Nonuniform irregular surfaces withnotched borders and rapid growth should raise suspicion of thislesion, which may arise in preexisting nevi, especially congenitalor atypical ones.
  • Biopsy is diagnostic.

    • Yellow Lesions

    Jaundice

    Jaundice is yellow color of skin due to bilirubindeposition and is discussed in Chap.36, Jaundice.

    Carotenemia

    Yellow-orange hue of skin due to ingestionof carotene, which is found in carrots and squash. Commonly occursbefore 2 yrs of age.

    Sebaceous Gland Hyperplasia

    Yellow macules and papules, 1–2mm in diameter, occur on nose and cheeks of infants and usually recedeby 4–6 mos of age.

    Nevus Sebaceous of Jadassohn

    Nevus sebaceous appears on scalp as slightlyraised, smooth or pebbly, linear or oval, yellow or orange, waxyplaque. These lesions do not contain any hair. Adnexal tumors canappear within lesions after puberty.

    Inflammatory Papules and Nodules

    Insect Bites

    Common feature of insect bites is erythematouspapule with central punctum. Wheals and even bullae may occur.

    Acne

    Mild acne consists of inflammatory papulesand pustules. Nodules are seen with moderate involvement. In severeacne, extensive number of inflamed papules, pustules, and nodulesoccur.

    Roseola (Exanthem Subitum)

  • Human herpesvirus6 infection.
  • Usually presents with fever for severaldays in children 6 mos–3 yrs of age.
  • Within 24 hrs after fever subsides,macular or papular rose-colored rash appears on trunk and spreadsto face and extremities with gradual fading over next 2–3days.
  • Diagnosis is usually clinical.

    • Enteroviruses (Coxsackie A and B Viruses, Echoviruses)

  • Coxsackieand echoviruses may cause various rashes, which can be macular orpapular. Rash usually appears 1–2 days after onset of fever.Headache, malaise, and vomiting also may occur.
  • These self-limited illnesses usuallylast for a few days.
  • Positive viral culture or PCR of respiratorytract secretions is diagnostic.

    • Epstein-Barr Virus

  • This virusis responsible for infectious mononucleosis.
  • Characteristic features include fever,malaise, sore throat, lymphadenopathy, and splenomegaly. Liver alsomay be enlarged. Macular, papular, or morbilliform rash may occuron trunk and proximal extremities. There is usually lymphocytosiswith ≥10–20% atypical lymphocytes.
  • Slide test for heterophil antibodyis generally positive in older children, but it is often negativein children <4 yrs of age.
  • Elevated antibody titer against viralcapsid antigen (IgM anti-VCA) confirms diagnosis.
  • Fever may last several weeks, whereasfatigue and lassitude may last ≥3 mos in severe cases.

    • Parvovirus B19 (Fifth Disease)

  • Viral infectionalso called erythema infectiosum. Usually affects children ≥3yrs of age.
  • Erythematous rash is most prominenton cheeks and gives "slapped cheek" appearance. Lacelike,macular or papular rash also may occur on arms, trunk, and thighsfor up to 3 wks. Fever may or may not occur.
  • This is usually clinical diagnosis,which can be confirmed by presence of IgM antibodies to parvovirus-specificantigens.

    • Postnatal Rubella

  • Since rubellavaccine licensure in U.S. in 1969, this infection has become muchless common.
  • Initial sign of illness may be malaise,which lasts 1–2 days. Macular or papular rash appears onface and spreads to trunk and extremities. Postauricular, posteriorcervical, and occipital adenopathy is also common. Rash usuallyresolves by fourth day and does not become confluent. Fever mayor may not occur.
  • Positive rubella virus culture fromnasal secretions, 4-fold increase in antibody titer, or seroconversionconfirms diagnosis.

    • Measles (Rubeola)

  • Althoughincidence of measles (rubeola) has decreased since immunizationbegan in 1963, outbreaks continue to occur.
  • Initial findings are fever, coryza,hacking cough, and nonpurulent conjunctivitis. In 2–3 days,white macular 1-mm lesions called Koplik spots appear on buccalmucosa, especially opposite the lower premolars. Their appearanceis pathognomonic for measles. Within 12–24 hrs after thesespots become visible, macular or papular rash that often becomesconfluent appears on forehead and behind ears and spreads downwardto involve trunk and extremities, only to fade in the same orderin which it began.
  • Although diagnosis of measles usuallycan be made clinically, single elevated IgM level, 4-fold increasein antibody titer with paired sera, or positive nasopharyngeal cultureconfirms diagnosis.

    • Scarlet Fever

  • Toxin releasedfrom group A streptococci produces scarlet fever, which usuallyoccurs in children 2–10 yrs of age.
  • Usual presenting findings are feverand sore throat. In 1–2 days a diffuse, papular, erythematousrash appears around neck and spreads over trunk and extremities.Rash has sandpaper-like feel and is more prominent in elbow creasesand inguinal areas. Perioral pallor, flushed cheeks, strawberrytongue, and generalized adenopathy also may occur. Rash usuallyfades in 3–4 days, with desquamation beginning around fingertipsin 10–20 days.
  • Positive pharyngeal group A streptococcalantigen test or culture confirms diagnosis.
  • Scarlet fever also can occur followingpyoderma or infection of a wound.

    • Cellulitis

    Inflammation of soft tissues that may beassociated with fever and localized adenopathy. Skin abrasion orpenetrating wound may have preceded infection. Most common pathogensare S. aureus and group A Streptococcus.

    Furuncle

    Is a deep folliculitis that appears as tender,erythematous nodule. Confluence and abscess formation can occur.S. aureus is usual pathogen.

    Candidiasis

  • Candidallesions commonly involve diaper area in infants. Satellite lesions(scaly papules, pustules, vesicles) and inflammatory involvementof creases are common features.
  • Diagnosis is usually clinical but maybe confirmed by positive KOH preparation (budding yeasts) or bypositive culture.
  • Inflammation around base of nail alsomay be caused by Candida infection.

    • Kawasaki Disease

  • Vasculitiswhose cause is unknown. Usually occurs in children <5 yrsof age.
  • Diagnostic criteria are presence offever for ≥5 days associated with at least 4 of the following5 signs in absence of any other disease process:

  • Bilateralconjunctival injection
  • Cervical lymphadenopathy
  • Erythematous macular, papular, or scarlatiniformrash primarily on trunk
  • Mucous membrane involvement, includingdry fissured lips, strawberry tongue, pharyngeal injection, anderythema of lips
  • 1 or more changes in extremities (e.g.,palmar erythema and peripheral edema)
  • Desquamation around nails and involvingpalms, soles, or perineal area may develop 1–2 wks followingonset of illness (see Chap. 21,Fever).

    • Mycoplasma Infections

  • Macularor papular rashes may occur in some children with M. pneumoniaeinfection. Usual clinical presentation consists of low-grade fever,malaise, and persistent cough.
  • Typically, chest radiograph shows patchy,unilateral or bilateral, segmental or subsegmental involvement.
  • Serologic tests are diagnostic.

    • Erythema Marginatum

    Transient eruption consisting of curvilinearmigrating areas of erythema that form incomplete circles and moveover the skin within a few hours. It is 1 of the major Jones criteriafor rheumatic fever but also can be seen with streptococcal infectionswithout evidence of rheumatic fever.

    Panniculitis

  • Inflammationof subcutaneous fat tissue may produce painful, erythematous nodules.
  • Cold panniculitis can be caused bypopsicles held too long in a child's mouth.
  • Another type of panniculitis is subcutaneousfat necrosis of newborns.

    • Erythema Chronicum Migrans

  • Earliestfeature of Lyme disease is erythema chronicum migrans that begins4–20 days after tick bite.
  • Red papule occurs at site of bite andenlarges over several weeks to form ring with flat red border andclearing of its center. Multiple secondary rings may develop 1–6days after primary lesion appears. Skin lesion is associated withheadache, fatigue, myalgia, and low-grade fever.
  • About 1 mo after tick bite, other complicationsmay occur, including arthritis, meningitis, myocarditis, peripheralneuropathy, and facial nerve palsy (see Chap. 37, Limp).

    • Cutaneous Larva Migrans

  • Infectivelarvae of dog and cat hookworms are usual causes of cutaneous larvamigrans, which is most common in southeastern U.S.
  • Pruritic red papules occur at siteof entry, usually on feet or hands, and intensely pruritic serpiginoustracks are formed in the skin.
  • Diagnosis is usually clinical.

    • Urticaria (Hives)

  • Characterizedby oval or round, flat or papular wheals and flares that are pruritic. Usuallytransient phenomenon lasting few hours or a few days. Clinical characteristicis their disappearance and reappearance within hours. Angioedemaof eyelids, lips, face, scrotum, and larynx also may occur.
  • Some known causes are

  • Drugs (penicillins,sulfonamides, opiates, radiocontrast media)
  • Foods (milk, shellfish, nuts, eggs,chocolate)
  • Inhalants (pollens, molds)
  • Infectious agents (enteroviruses, adenoviruses,group A Streptococcus)
  • Insect and arthropod bites and stings(bees, wasps, fleas, mites, bedbugs, mosquitoes, scorpions, spiders,jellyfish)
  • Skin contactants (cosmetics, animaldanders, chemicals)
  • Physical factors (heat, cold, stress,exercise, prolonged local pressure, sunlight)
  • Diagnosis is usually clinical. Evenafter exhaustive history, specific cause may remain unknown.

    • Vascular Reactions

    Blanching

    Erythema toxicum, urticaria, viral exanthems,scarlet fever, erythema multiforme, Kawasaki disease, toxic shocksyndrome, erythema chronicum migrans, syphilis, pyogenic granuloma,and early lesions of pityriasis rosea and guttate psoriasis arediscussed in other sections of this chapter.

    Mottling (Cutis Marmorata)

    When exposed to decrease in temperature,lacelike pattern of erythema called mottling appears on extremities,only to disappear with rewarming.

    Salmon Patch

  • Formed byectatic dermal capillaries. Most common of vascular nevi.
  • Pink macules and patches 1–3cm in size and appear most commonly on nape of neck, glabella, andupper eyelids. They blanch with pressure and become more intensewith crying. Most of them fade or regress with age.

    • Spider Angioma

  • Telangiectaticlesions that have legs radiating from central punctum (arteriole). Rangein size from a few mm to 2 cm in diameter and may occur anywhereon body, usually on face and hands.
  • They are found in normal children,in individuals with chronic liver disease, and during pregnancy.Most involute at puberty.

    • Port-Wine Stains

  • Is a typeof capillary malformation which is a purple-red, macular lesionthat may present on face or extremity at birth.
  • Port-wine stain that involves distributionof ophthalmic branch of trigeminal nerve is known as Sturge-Webersyndrome. Clinical manifestations include seizures, ipsilateralglaucoma, contralateral hemiparesis, and mental retardation. Angiomasof cerebral cortex are likely with involvement of upper eyelid.CT is diagnostic.
  • Port-wine stain of an extremity associatedwith overgrowth of subcutaneous tissue and bone is known as Klippel-Trenaunay-Webersyndrome. Parkes-Weber syndrome is similar but includes arteriovenousmalformations rather than venous malformations.

    • Hemangiomas

  • May be superficial,deep, or mixed (possessing both superficial and deep components).
  • At birth, only blanched macule withfine telangiectasias may occur, but after a few weeks of age, brightred, raised capillary hemangioma develops. They are usually 1–3cm in diameter, although they can be larger. During the first 6–12mos of life, they often increase in size. Involution begins at about 1yr of age and slowly progresses during next 5–10 yrs.
  • Deep capillary hemangiomas often havebluish hue and indistinct borders. They regress but not to sameextent as capillary hemangiomas.

    • Drug Hypersensitivity Reactions

  • Can be associatedwith almost any type of rash, although macular and papular rashes, urticaria,and erythema multiforme are most common.
  • Most common drugs implicated in causinghypersensitivity reactions are penicillins, sulfonamides, barbiturates,and phenytoin.
  • Drug-related macular or papular rashesusually begin a few days after initiation of drug therapy and seldomoccur >1 wk later. Eruption may be diffuse, generalized,and confluent, with resolution usually 1–2 wks after drughas been discontinued.
  • Presence of fever, lymphadenopathy,and eosinophilia, and increase in serum aminotransferases supportdiagnosis. Clinical diagnosis depends on likelihood that a givendrug can cause particular rash, temporal relationship between administrationof drug and onset of rash, and associated findings.

    • Nonblanching (Purpuric Rashes)

  • Purpuraare macular discolorations that do not blanch or disappear withpressure.
  • Types of purpura include petechiae(<3 mm in diameter) and ecchymoses (larger lesions).
  • Purpuric rashes are discussed in Chap. 52, Purpura and Bleeding,but 3 life-threatening causes are discussed here.

    • Meningococcemia

  • Petechialor purpuric rash occurs in about 50% of cases of meningococcemia.In severe cases, purpura fulminans may be seen.
  • Acute onset of fever and spreadingpetechial or purpuric rash in ill child is meningococcemia untilproven otherwise.
  • Gram-stained smear of petechial lesionmay show gram-negative intracellular diplococci. Confirmatory testsinclude positive blood or spinal fluid culture.

    • Toxic Shock Syndrome

  • Usuallycaused by toxin produced by certain strains of S. aureus. May alsobe caused by group A Streptococcus. Some cases occur in adolescentfemales following menstrual period in which tampons were used.
  • Clinical features include fever, vomiting,diarrhea, headache, myalgia, diffuse macular or papular rash, hypotension,and alteration in consciousness. Desquamation of extremities, palms,and soles occurs 1–2 wks after onset of the illness.
  • Lab tests may reveal leukocytosis,pyuria, azotemia, thrombocytopenia, elevated serum aminotransferasesand bilirubin, and abnormal coagulation studies.
  • Initially, diagnosis is clinical, andtreatment must begin without delay. Isolation of toxin-producingstrains of S. aureus or group A Streptococcus from nose, pharynx,vagina, cervix, or blood in this clinical setting is diagnostic.

    • Rocky Mountain Spotted Fever

  • Tick bitetransmits R. rickettsii, which causes Rocky Mountain spotted fever.History of recent exposure to ticks usually exists, but negativehistory is not uncommon.
  • Prodrome consists of fever, headache,vomiting, and myalgia. Rash, which initially consists of red macules,appears in 2–4 days on wrists, ankles, and lower legs,and may involve palms and soles. Rash usually becomes petechialand is more intense on extremities than on face and trunk.
  • Presumptive diagnosis is based on clinicalfindings alone. Affected children must be treated immediately becausethis can be a fatal disease. Diagnosis can be confirmed by serologic tests.

    • Papulosquamous Disorders

    Diaper Dermatitis (Irritant Dermatitis)

  • Most commonform of diaper rash is irritant dermatitis, which occurs when skin comesinto direct contact with an irritant.
  • Erythematous plaques with minimal scaleoccur in diaper area, sparing the creases.
  • Common causes of irritant dermatitisbesides urine and stool are detergents, perfumed baby lotions andoils, and harsh soaps.

    • Atopic Dermatitis

  • Usuallyoccurs at 1–4 mos of age with dry, itchy, scaly rash. Before2 yrs of age, commonly occurs on cheeks, trunk, and extensor surfacesof elbows and knees. Later in childhood, flexural areas, includingantecubital and popliteal fossae, and neck are affected. Diaperarea characteristically is spared. Excoriation with secondary staphylococcalinfection is common. Atopic dermatitis also can produce scalingof scalp.
  • There is often personal or family historyof allergic rhinitis, hay fever, or asthma.

    • Nummular Eczematous Dermatitis

    Characterized by scaly, symmetric, coin-shapedlesions, which usually occur on extremities and are 1–10cm in diameter.

    Juvenile Plantar Dermatosis (Foot Eczema)

    Dryness, redness, cracking, and scaling ofweight-bearing surface of foot characterizes juvenile planter dermatosis.Common in childhood and represents a form of atopic dermatitis.

    Seborrheic Dermatitis (Infantile)

    Rash is erythematous, dry, and scaly andoccurs in diaper area, in flexural areas, and behind ears. Greasy,yellow scales are seen on scalp (cradle cap).

    Contact Dermatitis

  • May be producedby local exposure to irritating substance (irritant contact dermatitis) orby allergic response to sensitizing substance (allergic contactdermatitis).
  • Rash is erythematous and pruritic andmay consist of macules, papules, and vesicles.
  • Common causes of irritant dermatitisinclude detergents, harsh soaps, and rough sheets or clothes. Allergicdermatitis is seen with exposure to poison ivy, oak, and sumac aswell as nickel-containing jewelry.

    • Tinea Corporis

  • T. mentagrophytesis dermatophyte that most commonly causes tinea corporis, which canoccur anywhere on skin.
  • Lesions are round and reddish withraised, scaly, papular border and clearer center.
  • Diagnosis is usually clinical, butpositive KOH preparation or culture is confirmatory.

    • Tinea Pedis

  • Tinea pedis(athlete's foot) presents with dryness, redness, and crackingof skin between toes. Erythematous papules or vesicles on solesor scale around borders of foot in "moccasin" distributionalso may occur.
  • More common in adolescence but canoccur at all ages.
  • Diagnosis is usually clinical.

    • Candidiasis

  • C. albicansproduces intensely red, confluent rash in diaper area that may beaccompanied by scaly, erythematous papules and pustules. May producesimilar lesions in neck, axilla, and gluteal folds.
  • Diagnosis is usually clinical. PositiveKOH preparation or fungal culture is confirmatory.

    • Sunburn

    Produces painful erythema, which may be followedby blistering and desquamation.

    Pityriasis Rosea

  • Cause isnow thought to be human herpesvirus 7.
  • Usually presents with annular, scaly,erythematous lesion (herald patch). In 1–2 wks, oval, papular,scaly lesions appear and follow lines of skin cleavage on back,chest, and abdomen. Rash usually resolves within 1–3 mos.Pruritus is variable finding.

    • Drug Eruptions

    Certain drugs (e.g., penicillins, sulfonamides,barbiturates, and phenytoin) may be associated with exfoliativedermatitis. Diffuse erythema is followed by bullae and loss of largesheets of epidermis.

    Scabies

  • Human miteS. scabiei produces papular, pustular, and vesicular pruritic lesionsthat can occur anywhere on body.
  • Hallmark lesion is linear tract orburrow that is a few millimeters long, with central black dot (themite). However, burrows may not be found because of frequent itchingand scratching. Generalized urticarial or "id" reactionmay develop occasionally.
  • Microscopic visualization of mites,eggs, or fecal pellets from skin scraping confirms diagnosis.

    • Polymorphous Light Eruption

    Patchy dermatitis that usually occurs onface and extremities on exposure to sun in spring or early summer.Papules and vesicles may occur with crusting.

    Psoriasis

  • Familialdisorder of unknown cause in which red, well-demarcated plaqueswith silvery scales commonly occur on elbows, knees, and scalp;around eyebrows; and in genital region. Nail changes include pitting,thickening, and crumbling.
  • Streptococcal infection often precedesflare of psoriasis.
  • Skin biopsy is diagnostic.

    • Parapsoriasis

  • This disorderof unknown cause has 2 distinct forms: childhood acute parapsoriasis [pityriasislichenoides et varioliformis acuta (PLEVA)] and guttateparapsoriasis (pityriasis lichenoides chronica).
  • Onset of both forms is usually 5–15yrs of age. In acute parapsoriasis, erythematous papules with scale,2–4 mm in diameter, occur mainly on trunk. They crust overand heal with scars. Eruption may last for several months with lesionsin different stages. In guttate parapsoriasis, salmon-colored papules withcentral thin scales occur primarily on trunk, thighs, and perinealarea. These lesions may persist for several years. Itching seldomoccurs with either form.
  • Skin biopsy is diagnostic.

    • Lichen Nitidus

    Groups of pinpoint, shiny, flesh-coloredor hypopigmented papules in linear array are most often seen onabdomen, trunk, or forearm. Köbner's phenomena(rash found in areas of skin trauma) may be seen.

    Lichen Striatus

    This benign disorder is composed of flat-toppedpapules arranged in linear fashion along lines of Blaschko. Papulesare first red and scaly and become flesh-colored in whites and hypopigmentedin African-Americans.

    Lichen Planus

  • Disorderof unknown cause characterized by flat-topped, shiny, blue-red orpurple, intensely pruritic, polygonal papules, which commonly occuron volar surfaces of wrists and forearms, knees and lower legs,and shaft of the penis. Surface of papules may have white cross-hatchingcalled Wickham striae. Nails are often pitted and dystrophic.
  • Resolution usually occurs in 9–18mos, leaving areas of hyperpigmentation where lesions had been.

    • Lupus Erythematosus

  • More commonin girls than boys and can be systemic or limited to skin.
  • Most common skin manifestation is erythematousmacular rash over cheeks and nose in butterfly distribution andcovered by fine scale. Next most common lesion consists of discoid,scaly, red macules, which commonly occur on face, hands, and scalp.
  • Positive antinuclear antibody is screeningtest for this disease. Presence of antibody against double-strandedDNA is diagnostic. In most cases, direct immunofluorescence of skinbiopsy is positive for granular deposits of IgG or C3 at dermal-epidermaljunction.

    • Dermatomyositis

    Erythematous plaques with fine scale areusually seen over elbows and knees. Flat-topped red papules alsomay be seen over knuckles (Gottron papules). Violaceous hue of eyelids,periorbital edema, and photosensitive facial rash involving malarareas also may occur (see Chap.33, Hypotonia and Weakness).

    Langerhans Cell Histiocytosis

  • Skin findingsconsist of crusting, scaling dermatitis that may involve scalp,perineum, and axillae. Presence of purpuric papules or nodules withinor peripheral to dermatitis is characteristic. In dark-skinned children,papules may be hypopigmented.
  • Skin biopsy is diagnostic.
  • See Chap.38, Lymphadenopathy.

    • Acrodermatitis Enteropathica

  • This autosomal-recessivedisorder is due to impaired zinc transport in intestine.
  • Characteristic features include bullousdermatitis with plaquelike scaly lesions, diarrhea, failure to thrive,and alopecia of scalp, eyebrows, and eyelashes.
  • Diagnosis is confirmed by low plasmazinc level.

    • HIV Infection

    Dermatitis that mimics seborrheic dermatitismay be seen with HIV (see Chap.53, Recurrent Infection).

    Secondary Syphilis

  • Morbilliformrash of secondary syphilis occurs on any skin surface, especiallytrunk, palms, and soles. Pustules, nodules, and papulosquamous lesionsalso may occur. Clues to diagnosis are history of primary chancre,condyloma lata, or white mucous patches on tongue or buccal mucosa.Associated findings include generalized adenopathy, fatigue, headache,and fever.
  • Positive serologic tests (rapid plasmareagin and fluorescent treponemal antibody absorption tests) confirmdiagnosis.

    • Ichthyoses

    Refers to excessive scaling of the skin ("fishskin"). Major types are

  • Ichthyosisvulgaris
  • X-linked ichthyosis
  • Classic lamellar ichthyosis and congenitalnonbullous ichthyosiform erythroderma
  • Congenital bullous ichthyosiform erythroderma(epidermolytic hyperkeratosis)

    • Ichthyosis Vulgaris

  • This autosomal-dominantdisorder is most common of the ichthyoses.
  • Onset is usually after 3 mos of agewith fine white scales that are often larger and coarser on lowerextremities. Abdomen, neck, and face are much less involved, andflexural areas and axillae are usually spared.
  • Skin biopsy shows hyperkeratosis anddecreased or absent granular layer but is usually unnecessary.

    • X-Linked Ichthyosis

  • This formof ichthyosis involves deficiency of steroid sulfatase, which hydrolyzes cholesterolsulfate and other sulfated steroids. Gene locus has been mappedto Xp22.3.
  • Presents in infancy with scales overextensor surfaces of extremities and upper trunk. Palms and solesare usually spared in contrast to other ichthyoses.
  • Diagnosis can be confirmed by moleculargenetic analysis.

    • Classic Lamellar Ichthyosis and Congenital Nonbullous IchthyosiformErythroderma

  • Both ofthese autosomal-recessive disorders usually present as collodionbabies.
  • Infants with lamellar ichthyosis havelarger platelike scales, whereas those with nonbullous ichthyosiformerythroderma have increased erythroderma with finer whiter scales.
  • There is evidence that mutations ingene encoding keratinocyte transglutaminase located on chromosome14q11.2 are responsible for these disorders.

    • Congenital Bullous Ichthyosiform Erythroderma (EpidermolyticHyperkeratosis)

  • Onset ofthis autosomal-dominant disorder is usually at birth, with generalizederythroderma, scaling, and bulla formation. Hyperkeratosis, especiallyon arms and legs, begins later. Tendency toward blistering tendsto decrease with age.
  • Histopathologic pattern is diagnostic.
  • Mutations in keratin genes on chromosomes12q13 and 17q21-22 have been found in this disorder.

    • Diagnostic Approach

  • Classificationof skin lesions into 1 of the 9 types described above is helpfulin diagnosis. Knowledge of specific skin lesions, especially theirmorphology and distribution, is necessary for diagnosis. Age ofchild, mode of inheritance, whether child is well or ill, presenceof fever and other systemic symptoms, and nature of primary lesionhelp narrow diagnostic possibilities. In most cases, history andphysical exam are diagnostic.
  • Most important tests to confirm someof disorders discussed above include the KOH preparation; bacterial,viral, and fungal cultures; PCR; and skin biopsy, including immunepathology and electron microscopy, if necessary.
    • >'>>>>'>

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Papular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient's body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

    Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pustular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

    Examine the entire skin surface, noting if it's dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Pruritus: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents—but doesn't disturb—sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?

    Ask the patient how he cleans his skin and clothes. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient's general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Obtain a complete drug history. Ask about abdominal pain and the appearance of stools.

    Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses. Note any jaundice. Check for hepatomegaly or abdominal pain.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin, mottled: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Mottled skin may indicate an emergency condition requiring rapid evaluation and intervention. (See Mottled skin: Knowing what to do.) However, if the patient isn't in distress, obtain a history. Ask if the mottling began suddenly or gradually. What precipitated it? How long has he had it? Does anything make it better? Does anything make it worse? Does the patient have other symptoms, such as pain, numbness, or tingling in an extremity? If so, do they disappear with temperature changes?

    Take the patient's vital signs. Observe the patient's skin color, and palpate his arms and legs for skin texture, swelling, and temperature differences between extremities. Check the capillary refill time. Also, palpate for the presence (or absence) of pulses and for their quality. Note breaks in the skin, muscle appearance, and hair distribution. Also, assess motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Butterfly rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of drug-induced lupus erythematosus)?

    Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Vesicular rash: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask your patient when the rash began, how it spread, and whether it has occurred before. Did other skin lesions precede eruption of the vesicles? Obtain a thorough drug history. If the patient has used a topical medication, what type did he use and when was it last applied? Ask about associated signs and symptoms. Find out if he has a family history of skin disorders, and ask about allergies, recent infections, insect bites, and exposure to allergens.

    Examine the patient's skin, noting if it's dry, oily, or moist. Observe the general distribution of the lesions and record their exact location. Note the color, shape, and size of the lesions, and check for crusts, scales, scars, macules, papules, or wheals. Palpate the vesicles or bullae to determine if they're flaccid or tense. Slide your finger across the skin to see if the outer layer of epidermis separates easily from the basal layer (Nikolsky's sign).

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin turgor, decreased: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If your examination reveals decreased skin turgor, ask the patient about food and fluid intake and fluid loss. Has he recently experienced prolonged fluid loss from vomiting, diarrhea, draining wounds, or increased urination? Has he recently had a fever with sweating? Is the patient taking a diuretic? If so, how often? Does he frequently use alcohol? How much fluid, especially water, does he ingest daily?

    Next, take the patient's vital signs. Note if his systolic blood pressure is abnormally low (90 mm Hg or less) when he's in a supine position, if it drops 15 to 20 mm Hg or more when he stands, or if his pulse increases by 10 beats/minute when he sits or stands. If you detect these signs of orthostatic hypotension or resting tachycardia, insert an I.V. catheter for fluid administration.

    Evaluate the patient's level of consciousness for confusion, disorientation, and signs of profound dehydration. Inspect his oral mucosa, the furrows of his tongue (especially under the tongue), and his axillae for dryness. Also, check his jugular veins for flatness, and monitor his urine output.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin, clammy: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 562.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

    Next, take the patient's vital signs and pulse oximetry. Examine the pupils for dilation and check his level of consciousness. Note respiratory rate. Assess for respiratory distress. Auscultate the heart and lungs. Place the patient on a cardiac monitor and assess heart rhythm. Also, check for abdominal distention and increased muscle tension.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Skin, scaly: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, detergents, dryer sheets, cosmetics, skin lotion, and hair preparations he uses.

    Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails. Then assess the skin over the remaining areas of the body.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    PRURITUS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    It should be obvious that the clinical approach to pruritus without an obvious dermatologic manifestation is to order appropriate tests. See below to rule out the above systemic disorders.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Bleeding Under the Skin: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The clinical approach to purpura involves taking a drug history and a good family history, and ordering appropriate coagulation studies, tourniquet testing, and other tests. Referral to a hematologist is wise in obscure cases.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN PIGMENTATION AND OTHER PIGMENTARY CHANGES: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The workup for diffuse pigmentation involves ruling out hemochromatosis, hepatobiliary disease, and Addison disease with appropriate tests for these disorders (see Appendix A) and using the expertise of a dermatologist in the cases of patchy pigmentation.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN ULCERS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of a skin ulcer involves an assessment of the vascular supply to the area, a neurologic examination, and a good history (especially important is venereal disease). The laboratory can support the diagnosis with a smear and culture, skin tests for tuberculosis and fungi, and serologic tests. An x-ray of the bone may reveal the cause. A biopsy may be necessary. Radiographic and laboratory survey of other organs may be necessary if a systemic disease (e.g., collagen disease or ulcerative colitis) is suspected.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN DISCHARGE: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Smear and culture of the lesion are most important, although a skin biopsy is sometimes necessary. Serologic tests or cultures on special media are necessary to diagnose fungi and parasites.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A biopsy or excision is the best approach to the diagnosis. If a systemic disease is suspected because of a lesion, appropriate studies for these are listed below.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RASH, GENERAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or if the symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RASH, LOCAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis is similar to that of the general rash .

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Rash - Case 9-2: 7-Week-Old Girl: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 7-week-old Caucasian girl had initially presented to a hematologist for evaluation of bruising. Her mother had noted several small purple bruises on her right arm and a linear bruise across her left cheek at age 3 weeks. At 5 weeks of life, she had been noted to have linear and circular bruises along her buttocks and legs. Laboratory evaluation at that time revealed a normal complete blood count and differential, normal prothrombin time (PT) and partial thromboplastin time (PTT), and normal platelet aggregation studies in response to adenosine diphosphate (ADP), collagen, and ristocetin. Epinephrine-induced platelet aggregation studies were mildly low but consistent with testing variability. Factor XIII level was normal.
    At 11 weeks of life, she was brought to the emergency department after having had a possible seizure at home. Her father reported that she had an episode of stiffening of her arms and body during her afternoon feeding. Her eyes had rolled back in her head. After stiffening, her body became limp and she had shallow breathing, but no cyanosis. The child had had decreased oral intake during the day before the episode. There was no recent history of fever, vomiting, diarrhea, or trauma. Immunizations, including diphtheria-tetanus-pertussis (DTaP) vaccine, had been given 2 days before the episode.

    II. Past Medical History

    The child was born at full term, of an uncomplicated pregnancy and delivery, and weighed 3,500 g at birth. She was delivered vaginally without complication. She had previously been evaluated for the bruising at her pediatrician 's office at 3 and 5 weeks of age, as noted. Child protective services had been contacted by the pediatrician for the bruising, but the case was determined to be unfounded and was closed. Family history was significant for an uncle with frequent nosebleeds and a first cousin who was born with a “platelet problem” that necessitated platelet transfusion at birth.

    III. Physical Examination

    T, 37.0°C; RR, 43/min; HR, 180 bpm; BP, 113/53 mm Hg
    Height, 50th percentile; weight, 50th percentile
    The physical examination was remarkable for a hemangioma of the left occiput, a hematoma of the tip of the tongue, and two ecchymotic areas on the right mandible, each about 1 cm in diameter. She had three 3- to 4-cm ecchymotic areas on the left back. A caf é-au-lait macule (1 cm) was seen on the left thigh. Lungs were clear. Cardiac examination revealed tachycardia but no murmurs, rubs, or gallops. There was no hepatosplenomegaly and no prominent adenopathy. Neurologically she was alert, crying, and moving all extremities. Funduscopic examination revealed right retinal hemorrhages. The rest of her examination was normal.

    VI. Diagnostic Studies

    Laboratory analysis revealed 18,800 WBCs/mm3, with 39% segmented neutrophils, 49% lymphocytes, and 11% monocytes. The hemoglobin was 11.4 g/dL, and there were 406, 000 platelets/mm 3. PT and PTT were normal. Electrolytes, BUN, and creatinine were normal. Alkaline phosphatase was 270 mU/mL. Other liver function studies were as follows: alanine aminotransferase, 100 IU/L; aspartate aminotransferase, 220 IU/L; and γ-glutamyltransferase, 46 IU/L. Examination of the cerebrospinal fluid revealed 8 WBCs/mm 3and 5,250 red blood cells/mm3. The glucose concentration was 60 mg/dL, and the protein concentration was 36 mg/dL. There were no organisms on Gram staining of the CSF.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Signs of Skin rash

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