Assessing the Skin

chapter 19 Assessing the Skin





Problems of the skin or its appendages are very common in children, and it is therefore important to be able to assess the skin in a logical and organized manner. In fact, a skin condition is the chief complaint for approximately 15% of patients in a family doctor’s or pediatrician’s office and is a secondary concern for other patients. A number of cutaneous conditions occur almost exclusively in infants and children, and most dermatoses (skin conditions) that are seen in adults are also seen in children. There are many hereditary and congenital skin conditions (genodermatoses). Most of the common infectious diseases of childhood have cutaneous manifestations, and skin involvement is a major feature of several multisystem disorders.


A child’s skin is more reactive than that of an adult. It is more likely to blister and is more susceptible to warts and certain other infections. When children are ill, they are more likely than adults to have multisystem manifestations of illness. For example, they may demonstrate a complex of symptoms that could include rash, fever, anorexia, lethargy, and diarrhea. Paradoxically, physicians often regard skin diseases as relatively trivial (i.e., the least of the patient’s problems) in the vast scope of medicine, but the patient may be more concerned about cutaneous problems than about a more serious internal problem that is not visible to others. For example, a teenager with psoriasis and cystic fibrosis may consider the psoriasis the more difficult of the two to accept.


Some physicians consider skin diseases difficult to diagnose for a variety of reasons. Because skin has a limited repertoire of reaction patterns, several disease processes may cause similar rashes. In addition, there are many variations in the appearance, location, and severity of both common and rare diseases of the skin, so a condition may look quite different in different patients. Finally, many skin conditions have one or more unhelpful protracted Latin names that are difficult to remember.


Despite these factors, it is possible to develop a simple, practical approach to most dermatologic problems. If you can assign a skin condition to a broad morphologic group on the basis of its appearance, you can learn or refer to lists of the conditions within the group. After a time, you will find it easier to recognize the primary lesions that identify the morphologic groups and the variations in common skin conditions in each group. Table 19–1 lists the most common skin problems seen in children and classifies them by morphologic appearance.


TABLE 19–1 Morphologic Classification of Common Pediatric Skin Conditions










































Skin Lesion Examples
Macules Freckles, junctional nevi, tinea versicolor
Patches Café au lait spots port-wine stains, vitiligo
Maculopapular rashes Viral exanthems, drug eruptions
Papules Warts, molluscum contagiosum, insect bites, compound nevi
Papules with burrows Scabies
Papules with comedones Acne
Plaques (nonscaly) Mastocytomas, sebaceous nevus
Papulosquamous eruptions Psoriasis, pityriasis rosea, lichen planus, fungal infections
Vesiculobullous eruptions Friction blisters, acute contact dermatitis, herpes infections, bullous impetigo, staphylococcal scalded skin syndrome
Eczematous eruptions Atopic dermatitis, seborrheic dermatitis, contact dermatitis, diaper dermatitis
Nodules or tumors Epidermoid or pilar cysts, neurofibromas, lipomas
Alopecia Alopecia areata, trichotillomania, tinea capitis

This chapter reviews the history and physical examination of the skin and illustrates the approach to diagnosis through case history examples. Color plates illustrate many of the problems discussed and some nevi commonly seen by pediatricians. Details and photographs of most pediatric dermatologic conditions can be found in the works cited in the Suggested Readings.




Obtaining the History of Skin Problems


As always, a detailed history is fundamental in assessing each child’s problem. Clues from casual inspection may direct your line of questioning and make the interview more efficient; but even if the diagnosis is obvious from a single glance, take the time to obtain a thorough history.


When children are too young to give a history firsthand, you can generally rely on the parents’ interpretations. A baby who scratches constantly is almost certainly experiencing pruritus, although some itchy infants are irritable and sleep poorly but scratch very little, and very young infants are not developmentally able to scratch. Children are suggestible; a 7-year-old who is asked, “Does your rash itch?” will almost certainly answer, “Yes.” Instead, ask the child whether the rash bothers him or her in any way, and ask the parent whether the child sleeps well at night or is scratching frequently. Pruritus from any cause is always worse at night because




Some skin conditions, such as poison ivy, dermatitis, and lichen planus, are intensely itchy, and relieving the pruritus may be more important than improving the rash.


Remember that you are seeing the child’s skin problem at a particular moment in its evolution. The parents’ description of its appearance at the onset and careful documentation of its evolution are therefore very important. Acute skin eruptions are usually dynamic, and the distribution or morphology may change rapidly. By contrast, chronic eruptions are more likely to have a stable appearance.



Some patients and parents are incredibly observant when it comes to skin, and others notice no details at all. Let both the patient and the parents give their descriptions, then ask for clarification. Use terms they will understand, such as those suggested in Table 19–2.


TABLE 19–2 Examples of Terminology Most Parents Understand







































Medical Term Lay Term
Macule Dot
Papule Little bump
Nodule Big bump
Plaque Raised or thickened area
Vesicle Little blister
Bulla Big blister
Pustule Pus pocket, pimple
Desquamation Scaling, flaking
Crusts Scabs
Excoriations Scratch marks
Comedones Blackheads, whiteheads


History of present illness


Your questions should cover the following points:








Some words used to describe skin eruptions are nonspecific and are often used improperly by patients or physicians. An example of such nonspecificity is the word blister. It is important to confirm that they are referring to true vesicles or bullae because that will narrow your differential diagnosis. If a child presents with a blistering eruption, in addition to the described history, you should ask the following questions (in words that the parents can understand):










For a rash, ask what the child and parents think caused it. Their suspicions may turn out to be correct, or they may have an unfounded fear (e.g., skin cancer) that can be put to rest.


Ask for details of exacerbating or relieving factors and of seasonal influences on the course of the skin problem. Some types of dermatitis become worse in the winter because of the lower humidity. The influence of sun exposure is an important factor. Conditions, such as lupus erythematosus, are exacerbated by sun exposure, whereas psoriasis usually improves significantly with sun exposure. In some cases, it is important to have a history of recent travel and exposures to wooded areas, animals, and insects.



Skin care regime, topical treatments, and medication history


Often, you need to find out what routine care is given to the skin and the clothing that is in contact with it. For instance, in eczematous eruptions, you must learn how often the child is bathed, what kind of soap and detergent are used, and what moisture creams or other preparations have been applied to the skin.


Frequently, several topical agents have been applied before the child visits a physician, and it is important to find out what has been used before and after the problem began.


Some proprietary medications may be bland and soothing and provide symptomatic relief. Others may contain active ingredients that are inappropriate for the child’s problem or are in the wrong concentration. Some may contain ingredients that are common topical sensitizers and may aggravate the skin problem. Ask about any prescribed topical medications used before the current assessment of the child. Often, parents may not remember the names of topical preparations. If necessary, call the pharmacist to find out what was prescribed.


Obtain a detailed history of all prescribed or over-the-counter oral medications, including doses and duration of administration. Ask specifically about nonprescription medications, such as acetylsalicylic acid, acetaminophen, and cold remedies. Drugs can cause rashes of all descriptions, although the most common are maculopapular eruptions, urticaria, and erythema multiforme. Ask about any previous reactions to medications, and document the type and severity of each.




Family history


Obtaining a family history is important, because numerous skin conditions are genetically determined, and many chronic dermatoses are considered hereditary, although they may be polygenic or exhibit incomplete penetrance. Sometimes an environmental trigger may unmask a disease in an individual who is genetically predisposed. For example, a streptococcal sore throat commonly precedes the development of guttate psoriasis.


A patient presenting with a genodermatosis or a neurocutaneous syndrome may or may not have a known family history of the disorder. Absence of a family history may be due to the following factors:






At times, the family history is not as important for diagnosis as for prognosis. For example, a teenager with multiple large and irregular nevi who has a family history of malignant melanoma is at significant risk for development of a melanoma; therefore, advise him or her about sun protection, regular self-examinations, and periodic professional examination to prevent melanoma or detect it in an early, curable stage. The positive family history is a significant risk factor in this case.



Approach to the Physical Examination


When you begin the physical examination of the child’s skin, you should have in mind a general differential diagnosis based on the details of the history. Sometimes, after examining the skin, you will find that additional history is required. For example, if the history suggests an exacerbation of atopic dermatitis and you note multiple crusted vesicles on examination, you need to ask about the patient’s contact with people who have cold sores because eczema herpeticum is a likely cause of this flare-up.


Good light is essential to adequate examination of the skin. Its importance is often overlooked. Natural light is best, and it may help to move the patient near a window. However, natural light is not always available in clinics and hospital rooms, and fluorescent light may distort colors and minimize subtle skin changes. For the examination of localized lesions, using a spotlight can help. Also, a magnifying glass helps you appreciate details.



Examine the entire skin surface


Always look at the entire skin surface, even if the history suggests a localized problem. The dermatologic examination includes the entire skin, the visible mucous membranes, and the skin appendages (hair, nails, and sweat glands), for the following reasons:





The extent, distribution, and severity of a skin problem are best appreciated by undressing the child and viewing most of the skin at once. You can, however, perform this step after the child is more comfortable with the examination procedure. Older children feel more self-conscious about being unclothed for a skin examination than they are by the same extent of undress for a chest or neurologic examination. Give the child a gown, and leave the room while he or she changes into it. It is acceptable to uncover and examine one area at a time in a gowned patient, but do not try to peek under tight clothing. For children younger than 2 years, a gown is unnecessary. The toddler’s sense of modesty is relatively undeveloped, and it is much easier to examine the child properly when he or she is wearing nothing more than a diaper or underpants.


Wear examining gloves if the child has eroded or oozing lesions, when you examine the mucous membranes, and if you suspect a contagious condition such as scabies. Generally, however, gloves are not necessary and tend to make the youngster feel uncomfortable.



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Jul 3, 2016 | Posted by in PEDIATRICS | Comments Off on Assessing the Skin

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