Evaluation of the Patient

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Chapter 637 Evaluation of the Patient

History and Physical Examination

Although many skin disorders are easily recognized by simple inspection, the history and physical examination are often necessary for accurate assessment. The entire body surface, all mucous membranes, conjunctiva, hair, and nails should always be examined thoroughly under adequate illumination. The color, turgor, texture, temperature, and moisture of the skin and the growth, texture, caliber, and luster of the hair and nails should be noted. Skin lesions should be palpated, inspected, and classified on the bases of morphology, size, color, texture, firmness, configuration, location, and distribution. One must also decide whether the changes are those of the primary lesion itself or whether the clinical pattern has been altered by a secondary factor such as infection, trauma, or therapy.

Primary lesions are classified as macules, papules, patches, plaques, nodules, tumors, vesicles, bullae, pustules, wheals, and cysts. A macule represents an alteration in skin color but cannot be felt. When the lesion is >1 cm, the term patch is used. Papules are palpable solid lesions <1 cm. Aggregations of papules are referred to as plaques. Nodules are larger in diameter and deeper in the skin than papules. Tumors are usually larger than nodules and vary considerably in mobility and consistency. Vesicles are raised, fluid-filled lesions <0.5 cm in diameter; when larger, they are called bullae. Pustules contain purulent material. Wheals are flat-topped, palpable lesions of variable size, duration, and configuration that represent dermal collections of edema fluid. Cysts are circumscribed, thick-walled lesions; they are covered by a normal epidermis and contain fluid or semisolid material.

Primary lesions may change into secondary lesions, or secondary lesions may develop over time where no primary lesion existed. Primary lesions are usually more helpful for diagnostic purposes than secondary lesions. Secondary lesions include scales, ulcers, erosions, excoriations, fissures, crusts, and scars. Scales consist of compressed layers of stratum corneum cells that are retained on the skin surface. Erosions involve focal loss of the epidermis, and they heal without scarring. Ulcers extend into the dermis and tend to heal with scarring. Ulcerated lesions inflicted by scratching are often linear or angular in configuration and are called excoriations. Fissures are caused by splitting or cracking; they usually occur in diseased skin. Crusts consist of matted, retained accumulations of blood, serum, pus, and epithelial debris on the surface of a weeping lesion. Scars are end-stage lesions that can be thin, depressed and atrophic, raised and hypertrophic, or flat and pliable; they are composed of fibrous connective tissue. Lichenification is a thickening of skin with accentuation of normal skin lines that is caused by chronic irritation (rubbing, scratching) or inflammation.

If the diagnosis is not clear after a thorough examination, one or more diagnostic procedures may be indicated.

Immunofluorescence Studies

Immunofluorescence studies of skin can be used to detect tissue-fixed antibodies to skin components and complement; characteristic staining patterns are specific for certain skin disorders (Table 637-1). Serum can be used for identifying circulating antibodies. Skin biopsy specimens for direct immunofluorescence preparations should be obtained from involved sites except in those diseases for which perilesional skin or uninvolved skin is required. A punch biopsy sample is obtained, and the tissue is placed in a special transport medium or immediately frozen in liquid nitrogen for transport or storage. Thin cryostat sections of the specimen are incubated with fluorescein-conjugated antibodies to the specific antigens.

Serum of patients can be examined by indirect immunofluorescence techniques using sections of normal human skin, guinea pig lip, or monkey esophagus as substrate. The substrate is incubated with fresh or thawed frozen serum and then with fluorescein-conjugated antihuman globulin. If the serum contains antibody to epithelial components, its specific staining pattern can be seen on fluorescence microscopy. By serial dilution, the titer of circulating antibody can be estimated.

637.1 Cutaneous Manifestations of Systemic Diseases

Selected diseases have signature skin findings, often as the presenting signs of illness, that can facilitate the assessment of patients with complex medical status (see Table 637-2 on the Nelson Textbook of Pediatrics website at www.expertconsult.com).

Connective Tissue Diseases

Lupus Erythematosus

Lupus erythematosus (LE; Chapter 152) is an idiopathic autoimmune inflammatory disease that may be multisystemic or confined to the skin.

Neonatal Lupus Erythematosus

Neonatal LE (NLE; Chapter 152.1) manifests during the 1st weeks to months of life as annular, erythematous, scaly plaques, typically on the head, neck, and upper trunk (Fig. 637-3

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