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Nurs 6512: Advanced Health Assessment and Diagnostic Reasoning

Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

· Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.

· Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?

· Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.

· Consider which of the conditions is most likely to be the correct diagnosis, and why.

· Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.

· Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.

· Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

· Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.

· Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.




Week 4 Lab Assignment:
Differential Diagnosis for Skin Conditions






© 2021 Walden University

Week 4

Skin Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______


Chief Complaint (CC):

History of Present Illness (HPI):



Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:




Cardiovascular/Peripheral Vascular:








Physical Exam:

Vital signs:





Heart/Peripheral Vascular:






Diagnostic results:


This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

© 2021 Walden University Page 2 of 3

5 Chapter 2 I Skin Biopsy


CP’T Code
11 300-03

11 305- 08



Skin Biopsy
Margaret R. Colyar

Shaving of epidermal or dermal lesion; single lesion­
trunk, arms, or legs
Shaving of epidermal or dermal lesion; single lesion­
scalp, neck, hands, feet. or genitalia
Excision benign lesions-trunk, arms, or legs
Excision benign lesions-scalp, neck. hands, feet. or
Excision malignant lesions- trunk. arms, or legs
Excision malignant lesions- scalp, neck. hands, feet. or

Skin biopsy is the excision of a small piece of living tissue for microscop ic examina­
tion. The two major categories of skin biopsy are
• Partial dermal thickness-shave and curettage
• Full dermal thickness- punch and elliptical excision

• Inspect the skin periodically for lesions.
• N ote lesions that change size or color, are irregular, or are painful.

• Method / -Shave biopsy

• Use for elevated skin lesions such as
• Skin ra gs
• Benign nevi (interdermal)
• Epit helial tags
• S mall basal celJ carcinomas
• Condyloma acuminatum
• C he rry angiomas
• A ctfo lc ken1toses
• ~cbo1Thck lcei:atoscs
• Lcutlgo (frcddcs)
• Vcrnm1 vulguris (warrs)

6 Section One j Dermatological Procedures

• Method 2-Curettage b iopsy
• Use for

• Seborrheic keratoses
• Superficial basal cell carcinomas
• Crusting actinic keratoses

• Method 3-Elliptical excisional biopsy
• Use for full-dermal-thiclmess lesions such as

• Basal cell carcinoma
• Squamous cell carcinoma
• Actinic keratoses
• Seborrheic keratoses
• Lenrigo
• Lipomas
• Verruca vulgaris (warts)

• To confi rm or make a diagnosis of a skin lesion
• To determine d efinitive treatment of a skin lesion
• To remove a disfiguring or painful lesion

• Nonmalignanr skin lesions not on the eyelid, lip, face, or penis

• Superficial skin lesions

• Infection is suspected at biopsy site
• Bleeding disorder
• If melanoma is suspected, do not use shave o r curettage. Elliptical excision is

• If on eyelid, lip, face, or pen is, REFER to a physician.
• If deep lesions, REFER to a physician.
t !11.fimnt’d co11s1’JI/ 1w111ircd


Skin Biopsy
• Methods l, 2, and 3

• Antiseptic skin cleanser
• Drape-sterile
• Gloves-nonsterile
• 3- mlsyringe
• 27- LO 10-ga11ge, Vi-ii1d1 ntcd lt·

Chapter 2 j Skin Biopsy

1% lidocaine
Comainer of 10% formalin
Cautery or Monsel’s solution
Pickups-sterile (opt ional)

• Method I only
No. 15 scalpel or sterile scissors

• Method 2 only
D ermal curerre

• Med1od 3 only
N eedle driver with scissors-ste rile

Suture (see Chapter 23 for information on choosing the appropriate type and
size of suture)

Nonstick dressing (Adaptic or Telfa)
4 x 4 gauze
Topical antibiotic (Bactroban, Bacitracin , or Polysporin)



• Posit ion the client for comfort w ith the a rea of the skin lesion easily accessible.
• { ‘.lc:1nse the skin lesion and a 3-inch-diameter circle around the lesion.
• I >rape the area.
• !>111 on gloves.

• luj l’CI I % lidocaine under t he lesion using a 27- co 30-gauge needle to crcare rt

• l1 11 · i .~e lc:si on parallel ro the skin (Fig. 2.1).
• l’l:it’l: the tiSSll Cin a conrainer of 10% formalin.

• ( :. 11 11 er i~.c rhe base of the wound or apply Monsel’s solution to retard bleeding.

Mt1.’l’11 o n 2-CURETTAGE BIOPSY

• Po~ it i1111 t he patient for comfort w ith the area of the skin lesion easily acccssihlc,
• l ‘ 11′. l l lM.’ the skin lesion and a 3-inch-diameter area aro und the lesio n.
• I li.l[ll’ tl1e area.
• 1’111 1111 gloves.

• lu j1·11 I ‘Y.• lidocainc unde r the lesion using a 27- to 30-gauge needle ro c reat e a
wlh”. 11.

• 11 l ol[H’ tlt l’ lesio n with tbe curette (Fig. 2 .2).
• Jll,11 ‘ tl tt’ tissue in a container of 10% fo rmalin.

• l ollil !’ iln · t he h:ise o f rhe wound or apply Monsel’s solution to reta rd blecd l11g.

!l 11 1’11rni J –lu.1P’l’I CAL Exc1s10NAL B i opsy

!1 ‘ 1111 I) HllMAJ. T 1ll C l( NlSS)

I l’n~ ltl1 1 11 1h t· p111 le111 for eo111fo rt wi th 1lic t1rl’a o l’ thc skin 1<.:sion easil y ;1 i; ·c.~.~lh l r.1
• I )11 w 1111 n11 tl itw ol’ iii ~· tx pn:tt•d lndNlo n In t lw d ln·t’1lo 11 o f’ die skin 1rn.9l1111

111 11,, ‘f’ln• 01 1tl l1w 11 luJ1tld lw tl11·~·c 1l11w~ 1011111·1 1’1 .ir1 It 1.~ wlrk.

8 9 Section One I Dermatological Procedures

Figure 2 . 1 Shave biopsy. Incise parallel to the skin.

Figure 2.2 Curettage biopsy. Scrape the lesion with the curene.

• Cleanse the skin lesion and a 3-inch-diameter area around the lesion.
• Put on gloves.
• Inject 1% lidocaine under the lesion using a 27- ro 30-gauge needle to crea1 c ;1

wheal that covers the encire area of the proposed incision.
• Drape the area.
• Incise around the ou d im: wi1h the scalpel (Fig. 23).
• Pul l 11 p :1 co rner or skin wil h pk kups.

Chapter 2 I Skin Biopsy

Figure 2.3 Elliptical excisional biopsy. Incise arou nd the oudine
wi 1h the scalpel.

11)(1111· 2.4 Undermine the edges of the wound to release tension.

• 1’11 II 1bsm: as you excise just below fi.tll thickness of the tissue.
• S1.1 r1 :II o nc co rner and work to the center.
• ( ;n lo 1he orhcr corner and work toward the center.
• P111 al l (‘Xc iscd tissue in a co ntainer of J0% formali n.
• ( ‘lm111’l’

II .1 .~ 111:111 lesion , si mple single-layer closure with nylon s uture is appropriHl <.’
(M’l’ t :hapt1.:r 22) .

• ll bi1111 is larger wirh 1·1.:nsion
• l l11der111il 1e t he e<lges orrhe wo11nd 10 l l’ k;1 .~t the iension (Fig. 2.li) .
• 1111 l ~l’ tlw ~ 11 hc11 1ane01 1 s tiss1u.· dw l’Jltl11• lrn111 h o f’ end1 sid c nl’ du: wou11 tl

wlI h 1I1 t• ” .ii1wl.

10 Section One I Dcrmacological Procedures

Figure 2.5 Spread the incised subcutaneous tissue w ith scissors.

• Spread the incised subcutaneous tissue with scissors (Fig. 2.5).
• Suture using the simple single-layer technique.

If a larger, deeper lesion with tensio n

• Undermine the subcutaneous tissue as just described.
• Close subcutaneous tissue with absorbable suture and inverted knot (see

Chapter 22) .
• Close skin using simple closure technique.
• Apply copical antibiotic, nonstick dressing, cover with 4 x 4 gauze, and

secure with tape.

Client Instructions
• Some inflammation (redness, swelling, and p ain) is normal.
• To prevent infection, keep the dressing in p lace for 24 hours, then remove the

dressing and keep rhe area clean and dry. After the second day, you may wash
the area gently with soap and water. Monitor for signs of infection, such as
• Yellow and green drainage
~ Red streaks

Excessive pain

Elevated temperamre

• Recurn to rhe office immediately if infection occurs.
• Some bleeding and oozing are normal for the first 24 to 4 8 hours. If your

bandage becomes soaked w ith blood, reapply dry gauze and pressure. If the
bleeding does nor stop, notify your practitioner.

• Avoid tensio n co the wound area by limiting movement. Tension may cause the
wound to pull apart. If the wound does pull apart, notify the practitioner.

• Take Tylenol No. 3 (acetaminophen with codeine) every 4 to 6 hours as needed
fo r pain. When t he pain lessens, take Tylenol or ib1.1p rofe n ( Mo1rin) ~·vcl’y It ro
6 hou rs as needed.

• Rccurn ro the ofnce (in _______) fo r st it ch 11′ l1Hw,1l ( 1li•1111111 ~ 011 siir
SI I ru reel i St’C ‘!:ti ii<,: 22. I ).
































C H A P T E R 2 8

Rashes and skin lesions

Dermatologic problems result from a number of mechanisms, including inflammatory, infectious, immunologic,
and environmental (traumatic and exposure induced). At times, the mechanism may be readily identified, such
as the infectious bacterial etiology in impetigo. However, some dermatologic lesions may be classified in more
than one way. Most insect bites, for example, involve both environmental (the bite) and inflammatory (the
response) mechanisms. Awareness of the potential mechanism of any skin disorder is most helpful in
identifying the risk a person may have for other illnesses. For example, people with eczema are also frequently
at risk for other atopic conditions, notably asthma and allergic rhinitis. Thousands of skin disorders have been
described, but only a small number account for the majority of patient visits.
Evaluation of rashes and skin lesions depends on a carefully focused history and physical examination. The

provider needs to be familiar with the characteristics of various skin lesions; anatomy, physiology, and
pathophysiology of the skin; clinical appearance of the basic lesion; arrangement and distribution of the lesion;
and associated pathological conditions. It is also important to know common symptoms associated with specific
lesions such as itching or fever. It is necessary to quickly identify life-threatening diseases and those that are
highly contagious. Ultimately, competence in dermatologic assessment involves recognition through repetition.

Diagnostic reasoning: Initial focused physical examination

Initial inspection
Dermatologic assessment is similar to the assessment of most other body systems in that it depends on patient
history and physical assessment. However, sometimes a brief physical assessment preceding the history can
assist in the development of the initial differential diagnoses followed by a focused history and further physical

Morphologic criteria
Examination involves the classification of the lesion based on a number of morphologic features (examples are
listed in Tables 28.1 and 28.2 and illustrated in Figs. 28.1 and 28.2). Evaluation should be systematic. Generally,
morphologic features should be analyzed as follows:

• Identify the location of the lesion(s).
• Identify the distribution of the lesions as localized, regional, or generalized.
• Identify whether the lesion is primary (appearing initially) or secondary (resulting from a change in a
primary lesion).

• Identify the shape of the lesion and any arrangement if numerous lesions are present.
• Assess the margins (borders).
• Assess the pigmentation, including variations.
• Palpate to assess texture and consistency.
• Measure the size of an individual lesion or estimate the size if lesions are numerous or widespread.



FIGURE 28.1 Types of skin lesions. Source: (From, Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to
physical examination, ed. 8, St. Louis, 2015, Elsevier.)

FIGURE 28.2 Typical distribution of papulosquamous eruptions in children. A, Atopic dermatitis:
usually located on the cheeks, creases of elbows, and knees. B, Seborrheic dermatitis: usually
located on the scalp, behind the ears, in thigh creases, and in eyebrows. C, Scabies: usually
located on the axillae, webs of fingers and toes, and intragluteal area. Source: (From Berkowitz C:
Pediatrics: A primary care approach, ed. 2, Philadelphia, 2000, Saunders.)





























































Table 28.1

Morphologic Criteria of Rashes and Skin Lesions


Macule Discrete flat change in color of skin; usually
<1.5-cm diameter

Freckle, lentigo, purpura

Patch Discrete flat lesion (large macule); usually
>1.5-cm diameter

Pityriasis rosea, melasma, lentigo

Papule Discrete palpable elevation of skin; <1-cm
diameter; origin may be epidermal, dermal,
or both

Nevi, seborrheic keratosis,

Nodule Discrete palpable elevation of skin; may evolve
from papule; may involve any level of skin
from epidermis to subcutis

Nevi, basal cell carcinoma,

Plaque Slightly raised lesion, typically with flat
surface; >1-cm diameter; scaling frequently

Psoriasis, mycosis fungoides




Wheal Transient pink/red swelling of skin; often
displaying central clearing; various shapes
and sizes; usually pruritic and lasts <24 hr

Tumor Large papule or nodule; usually >1-cm

Pustule Raised lesion <0.5-cm diameter containing
yellow cloudy fluid (usually infected)

Vesicle Raised lesion <0.5-cm diameter containing
clear fluid

Bulla Vesicle >0.5-cm diameter

Cyst Semisolid lesion; varies in size from several
mm to several cm; may become infected

Basal cell carcinoma, squamous cell
carcinoma, malignant melanoma

Folliculitis, acne (closed comedones)

Herpes simplex, herpes zoster, contact
(irritant) dermatitis

Bullous pemphigoid, contact (irritant)
dermatitis, blisters of second-
degree sunburn

Sebaceous cyst





Dried exudate that may have been serous,
purulent, or hemorrhagic

Thin plates of desquamated stratum corneum
that flake off rather easily

Shallow hemorrhagic excavation; linear or
punctate; results from scratching

Lichenification Thickening of skin with exaggeration of skin
creases; hallmark of chronic eczematous

Erosion Partial break in epidermis

Impetigo, herpes zoster (late phase)

Xerosis, ichthyosis, psoriasis

Contact (irritant) dermatitis

Chronic eczema





















































Herpes simplex or zoster, pemphigus

Fissure Linear crack in epidermis Xerosis, angular cheilitis, severe


Localized Lesion appears in one small area Impetigo, herpes simplex (e.g.,
labialis), tinea corporis

Regional Lesions involve specific region of body Acne vulgaris (pilosebaceous gland
distribution), psoriasis (extensor
surfaces and skinfolds)

Generalized Lesions appear widely distributed or in
numerous areas simultaneously

Urticaria, disseminated drug eruptions


Round or discoid Coin or ring shaped (no central clearing) Nummular eczema

Oval Ovoid shape Pityriasis rosea

Annular Round, active margins with central clearing Tinea corporis, sarcoidosis


Following nerve or segment of body Herpes zoster

Polycyclic Interlocking or coalesced circles (formed by
enlargement of annular lesions)

Psoriasis, urticaria

Linear In a line Contact dermatitis

Iris/target lesion Pink macules with purple central papules Erythema multiforme

Stellate Star shaped Meningococcal septicemia

Serpiginous Snakelike or wavy line track Cutanea larva migrans

Reticulate Netlike or lacy Polyarteritis nodosa, lichen planus
lesions of erythema infectiosum

Morbilliform Confluent and salmon colored Rubeola


Discrete Well demarcated or defined; able to draw a
line around it with confidence


Indistinct Poorly defined; having borders that merge into
normal skin or outlying ill-defined papules

Nummular eczema


Active Margin of lesion shows greater activity than

Tinea species eruptions

Irregular Nonsmooth or notched margin Malignant melanoma

Border raised
above center

Center of lesion depressed compared to edge Basal cell carcinoma

Advancing Expanding at margins Cellulitis














































Central clearing





Erythematous border surrounds lighter skin

Peeling or sloughing of skin

Hypertrophic stratum corneum

Central umbilication, or dimpling

Dilated blood vessels within lesion blanch
completely; may be markers of systemic

Tinea eruptions

Rash of toxic shock syndrome

Calluses, warts

Basal cell carcinoma, molluscum

Basal cell carcinoma, actinic keratosis




Neurofibroma, some nevi

Eczema, pityriasis rosea




Tinea eruptions, psoriasis


Most nevi, pityriasis versicolor




Malignant melanoma

Basal cell carcinoma

Purpura, Kaposi sarcoma






Lichen planus





























Table 28.2

Descriptive Dermatologic Termsa




Ring shaped



Arcuate Partial rings Syphilis

Bizarre Irregular or geographic pattern not related to Factitial dermatitis
any underlying anatomic structure


Confluent Lesions run together Childhood


Discoid Disc-shaped without central clearing Lupus erythematosus


Lesions remain separate; Inflammation with Eczema
tendency to vesiculate and crust


Widespread; lesions clustered together Herpes simplex

Iris Circle within circle; bull’s-eye lesion Erythema multiforme

Keratotic Horny thickening Psoriasis

Linear In Lines Poison ivy

s reticulated

More than one type of shape or lesion
Papules or plaques associated with scaling;
lacelike network

multiforme psoriasis
Oral lichen planus

Serpiginous Snakelike, creeping Cutaneous larva
















Telangiectatic Relatively permanent dilation of superficial
blood vessels



Entire body involved
Linear arrangement along nerve

universalis; herpes

aExamples of different configurations of skin lesions and their descriptions are contained within Table 28.1.

bAlso known as dermatomal.

From Swartz MH: Textbook of physical diagnosis: history and examination, ed. 6, Philadelphia, 2009, Saunders.

Perform a systematic physical examination before obtaining the majority of the history to provide greater relevance to the information
given by the patient. Use gloves when palpating rashes and lesions.

Diagnostic reasoning: Focused history

Is the rash associated with an immediate life-threatening condition?

Key Questions
 Do you have a fever?

 Are you short of breath?


• Do you have difficulty swallowing?
• Is the rash tender, and does it involve mucous membranes?

Fever is common in viral exanthems (rashes), and the accompanying condition is usually not life threatening.
However, fever, irritability, hypotension, and a macular or petechial rash may indicate meningococcemia.
Treatment needs to be immediate to be lifesaving.

Allergic reaction
Urticarial allergic reactions may be associated with angioedema (swelling) of the extremities, face, lips, tongue,
or airway. Other symptoms include cough, wheezing, shortness of breath, and heart palpitations. The sooner
symptoms occur after the exposure to the allergen, the more severe the reaction will be. Treatment needs to be
instituted immediately.

Rash with mucosal involvement
Toxic epidermal necrolysis (TEN), and Stevens­Johnson syndrome are severe mucocutaneous reactions, most
often to medications, characterized by extensive necrosis, and epidermis detachment. These conditions are
considered variants of a continuum, based on the percentage of body surface involved. TEN is a more severe
condition involving more than 30% of the body surface. Reactions include a tender, morbilliform, erythematous
rash accompanied by fever, conjunctivitis, oral ulcers, and diarrhea. Immediate hospitalization is required to
treat exfoliation of large areas of skin.

Is the rash acute or chronic (recurrent)?
Key Questions

• How long have you had this rash?
• Have you ever had a rash like this before?

The diagnosis of skin lesions is initially aided by categorizing the lesion as acute, chronic, or recurrent. Acute
eruptions, such as urticaria or various fungal rashes (tinea), are classified as such because they have a tendency
to be self­limiting with no recurrence after effective treatment. Chronic rashes, such as psoriasis or eczema, may
persist or be recurrent with exacerbations and remissions. Box 28.1 shows common rashes categorized by
duration. Ascertain the duration of the eruption when symptoms are described by the patient; however, the
initial occurrence of a chronic rash may be an acute presenting symptom. Conversely, an acute eruption not
optimally treated may become a chronic problem.

Box 28.1

D u r a t i o n o f R a s h

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• Allergic or contact dermatitis
• Candida dermatitis (diaper rash, intertrigo)
• Erythema infectiosum (fifth disease)
• Erythema multiforme
• Fixed drug eruptions
• Folliculitis
• Herpes simplex virus
• Herpes zoster/varicella zoster
• Impetigo
• Infestations (scabies, pediculosis)
• Insect bites
• Kawasaki disease
• Pityriasis rosea
• Septicemia (meningococcal)
• Scarlet fever
• Tinea (corporis, pedis, versicolor)
• Urticaria
• Viral exanthems (measles)

• Acne vulgaris
• Bullous pemphigus
• Eczema
• Erythema nodosum
• Kaposi sarcoma
• Mycosis fungoides
• Polyarteritis nodosa
• Psoriasis
• Rosacea
• Seborrheic dermatitis
• Systemic lupus erythematosus

Where is the rash in its evolution?
Key Questions

• What did this look like initially?
• Has the rash changed? If so, how?
• Has it spread? Where?

Initial presentation
Most skin lesions evolve over time, although this varies from minutes with urticaria to weeks or even months
with psoriasis or cutaneous T­cell lymphoma.

Change in lesion
Determining whether there has been a change from the initial appearance of a lesion provides diagnostic clues.
The eruption of pityriasis rosea classically begins with a “herald patch,” a single, scaly, erythematous patch
usually on the trunk followed within days by a regional outbreak of numerous smaller erythematous patches,
thus providing a key diagnostic clue. The rash may look like that of ringworm, but it appears too quickly to be
ringworm. Another example of evolutionary change is the eruption of herpes simplex virus (HSV), which
begins with a prodrome of burning, tingling, or itching, followed by the development of small vesicles that later
umbilicate, possibly ooze, and eventually crust before healing. A rash may appear in different ways, depending
on the point at which evaluation is sought.

The way in which a rash spreads is helpful in diagnosing the specific rash. There are three general ways in
which a rash can spread: centripetal, or moving to the center; centrifugal, or moving away from the center; and
caudal, or moving down.

What does the presence of pruritus tell me?
Key Questions

• Does it itch?

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All dermatoses can be classified into three groups: a small group that always itches, those that never itch, and an
intermediate group in which itching is variable (Box 28.2). Pruritus is often reported to be worse at night; during
the day, pruritus is less troublesome because the patient is distracted by daily routines. At bedtime the slightest
sensation of pruritus may become overwhelming because the patient is focusing on trying to sleep. When the
patient scratches the area, histamine is released from the inflammatory cells (especially mast cells), and this
causes more pruritus, and an itch–scratch cycle is established.

Box 28.2

I t c h i n g C o m p a r i s o n


• Atopic dermatitis
• Urticaria
• Insect bites
• Scabies
• Pediculosis
• Lichen planus
• Chickenpox


• Psoriasis
• Impetigo
• Tinea
• Pityriasis rosea


• Warts
• Neurofibromatosis
• Vitiligo
• Nevi

Swimmer’s itch, also called cercarial dermatitis, occurs in areas unprotected by a swimsuit. It is an allergic
reaction to a microscopic parasite that burrows under the skin. Seabather’s itch occurs in areas under the
swimsuit. Nocturnal pruritus most typically occurs in scabies infestations. Itching in the absence of a rash may
be an important clue to internal disease.

What does associated pain tell me?
Key Questions

• Is it painful or sore?
• Does it burn?

Pain is a rare symptom with skin rashes. Skin lesions that ulcerate or are associated with swelling can be
painful. The classic painful rash is associated with herpes zoster (HZ), including postherpetic neuralgia. Severe
psoriasis or eczema with fissures and bleeding may also be described as painful by some patients. Soreness is a
more common symptom and is associated with numerous rashes. Tender erythema may be associated with

Burning is infrequently reported. It is most notable preceding the rash in herpes virus infections (e.g., HSV or

What do associated symptoms tell me?
Key Questions

• Do you have a fever? Sore throat? Headache?
• How are you feeling in general?

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Fever, sore throat, and headache
Fever is a common presenting complaint in infectious diseases accompanied by rash, such as HZ, erythema
infectiosum, scarlet fever, endocarditis, or Kawasaki disease. Malaise, sore throat, nausea, or vomiting can occur
with mononucleosis.

General health
In a patient with a maculopapular eruption, the two most common causes are drug reaction and viral illness.
Inquire about viral symptoms, such as fever, malaise, and upper respiratory tract or gastrointestinal symptoms.

Are there possible contacts or sources of contagion?
Key Questions

• Does anyone with whom you live or have close contact have something similar? If so, how long have
they had it?

• Have you traveled recently? Where?
• What do you do for a living? What are your hobbies or leisure activities?
• Do you have any pets? Have you been around animals?

Living situation
Explore the patient’s living situation. The geographic details of his or her daily activities may help provide
diagnostic clues, particularly for rashes caused by infectious or infestation mechanisms. Children, in particular,
may contract scabies, pediculosis (lice), or impetigo by direct contact in school or daycare.

A patient may develop a rash weeks or months after travel exposure. Diseases endemic to other parts of the
world may have presenting symptoms of rash, including erythema nodosum, which is common in Southeast
Asia, or leprosy, which is common in many parts of the world, especially in tropical and subtropical climates.
Both eruptions may also occur secondary to tuberculosis. About 40% of erythema nodosum is idiopathic and
can be related to inflammatory disease and malignancy. Leishmaniasis is a parasitic infection spread by the bite
of phlebotomine sand flies. It is seen in the tropics, subtropics, and southern Europe. Camping trips to wooded
areas, especially in the Eastern and upper Midwestern United States, may result in a bite by a deer tick, causing
Lyme disease, the leading vector­borne infectious disease. The resultant skin eruption in Lyme disease is known
as erythema chronicum migrans, which begins 4 to 20 days after the bite of the tick; only one third of patients
remember being bitten. Rocky Mountain spotted fever (Rickettsia rickettsii) is transmitted by a tick bite and is
common in the south Atlantic region of the United States. Initial symptoms are nonspecific; later symptoms are
a petechial rash and fever, usually requiring hospitalization.

Other exposures
Outdoor occupations or leisure activities may expose individuals to a variety of sources for rashes and lesions,
including insect bites as well as allergic or contact dermatitis from poison ivy, excessive sun exposure, and
chemical substances. People exposed to animal skins contaminated with Bacillus anthracis may develop
cutaneous anthrax, which is characterized by lesions that evolve from a papule through a vesicular stage to a
depressed eschar. Sun exposure can also worsen chronic eruptions such as rosacea or the malar butterfly rash in
systemic lupus erythematosus. Ringworm is common in farmers and ranchers who work with cattle.

Flea bites produce an urticarial lesion with a central punctum. The reaction is an immunologic one, making it
different in each individual. Bites are usually on the legs; infants may have bites on the arms or trunk. New
lesions may appear daily, and itching is variable but sometimes intense. Fleas on a cat or dog are usually the
culprits. An atypical form of scabies can be transmitted from dogs to humans; the presenting symptom is
usually a single lesion in an area under occlusion and it lasts about 1 to 2 weeks.

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Is there anything that exacerbates or triggers the reaction?
Key Questions

• Does anything seem to make this worse?
• Do you have any known allergies?

Patients often easily identify aggravating factors. Any rash involving vasodilation will become more vivid and
likely more pruritic with heat exposure, whether via sunlight, sweating, or a hot shower. Localized eruptions,
especially on the hands or forearms, prompt many patients to consider chemicals or other products as causes.
People with eczema whose hands are frequently exposed to water are vulnerable to the development of irritant
eczema on the exposed skin. Some foods occasionally exacerbate skin lesions. Rosacea is a vasomotor instability
disorder characterized by exacerbation with dietary consumption of vasodilators such as coffee, tea, alcohol, or
spicy foods. Stress, whether physiological (e.g., menstruation, pregnancy) or psychological, is widely believed to
trigger or worsen many chronic rashes, especially eczema, acne, and psoriasis. Stress also may facilitate
recurrent eruptions of HSV.

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E V I D E N C E – B A S E D P R A C T I C E

What Is the Evidence About the Prevention and Diagnosis of Melanoma?
This review summarizes findings from 17 systematic reviews and two guidelines on skin cancer between
April 2008 and 2009. Melanoma primary­prevention measures, such as education, are more likely to be
successful in younger children than adolescents. The evidence does not currently support population
screening for melanoma by whole­body examination. Sunburn later in life increases the risk of melanoma as
much as sunburn early in life. Superior diagnostic accuracy of dermoscopy over naked­eye examination for
melanoma was mixed.

Reference: Macbeth et al, 2011.

Could this rash be caused by a medication?
Key Questions

• Are you taking any medications (prescription or over­the­counter medications)?
• Do you have any medication allergies?
• Have you had a recent vaccination?

Medication and medication allergies
There are four types of dermatologic side effects of drugs: light sensitivity (e.g., photodermatitis), allergic
reactions (e.g., urticaria, fixed drug eruptions, morbilliform eruptions), commensal skin eruptions (e.g.,
pityriasis versicolor in a patient on systemic corticosteroids), and worsening of existing skin eruptions (e.g.,
tinea eruptions mistakenly treated as eczema with topical corticosteroids). Medications used after the onset of a
rash may be irritants or sensitizers and worsen the condition.

Recent vaccination
Infants and children who have recently had a measles vaccination may display a rash 10 to 14 days after

Is there a significant dermatologic family history?
Key Questions

• Does anyone in your family have chronic skin problems?

Family history
A family history of dermatologic problems may add insight to the diagnosis. Atopic disease (eczema, asthma,
hay fever) tends to cluster in families. Psoriasis, seborrheic dermatitis, and rosacea are also frequently noted to
have a familial inheritance pattern. Multiple café­au­lait spots with a positive family history for
neurofibromatosis can help identify children with this autosomal dominantly inherited disease.

Diagnostic reasoning: Focused physical examination

Look at all the skin and mucous membranes
A “peephole” diagnosis should be avoided; the whole organ should be examined. If the patient is not fully
undressed, relevant lesions could be missed. However, it is useful to select one typical well­defined lesion to
describe in detail followed by an orderly and sequential system of examination so that no areas of the body are
missed. The feet should always be examined in the presence of hand dermatitis so that a hypersensitivity

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reaction to a tinea infection or a concomitant hand tinea will not be missed. Erythema in dark­skinned people
may be difficult to appreciate; it often is seen as postinflammatory hyperpigmentation.

Inspect for distribution
Determine if the lesion is widespread or localized, unilateral or bilateral, symmetrical or asymmetrical.
Symmetrical lesions commonly have internal causes (e.g., eczema, psoriasis); asymmetrical lesions have external
causes (e.g., bacterial or fungal infections, allergic contact eczema). Is the lesion predominantly on the flexor (as
in atopic dermatitis) or extensor (as in psoriasis) surfaces? A rash on the soles or palms occurs with erythema
multiforme, secondary syphilis, and rickettsial infections. Determine if the distribution is confined either to
protected areas or to light­exposed areas such as in collagen­vascular diseases, photosensitive reactions to
drugs, and airborne contact dermatitis. Is the lesion predominantly centrifugal (affecting the extremities), as
seen in erythema multiforme, Rocky Mountain spotted fever, and insect bites, or centripetal (sparing the
extremities and concentrated on the trunk)? Intertriginous distribution (neck, axilla, groin) is found in
candidiasis, some inflammatory fungal infections, and some forms of psoriasis.

Inspect the mouth
Drug eruptions from sulfonamides, penicillin, streptomycin, quinine, and atropine often have associated
mucosal erosions (enanthems) and crusts. Mucosal involvement is common in hand and foot lesions (e.g., hand,
foot and mouth disease), herpes, and syphilis. Oral lesions occur in lichen planus, autoimmune blistering
diseases, and malignancies such as squamous cell carcinoma.

Inspect the hair
In children, a triad of hair loss, scaling, and lymphadenopathy is diagnostic of tinea capitis. A high index of
suspicion is warranted in inner­city urban areas, where the condition is common.

Evaluate for hair loss that is diffuse or localized and compare areas such as the temporal and crown region to
the occiput. Psoriasis and seborrheic dermatitis may present as scaling and desquamation. A hair pull test will
reveal any increased hairs shed with a gentle pull.

Palpate the skin
Palpate skin lesions to assess for tenderness, texture and consistency, firmness, fluctuance, and depth. Smooth
skin has no irregularity. Uneven skin has fine scaling or some warty lesions. Rough skin feels like sandpaper
and is characteristic of keratin (horn) or crusts. Assessing the superficial skin for texture is done by palpation
with the fingertips. Deeper palpation is done using the thumb and index fingers. Soft skin feels like the lips,
normal skin like the cheeks, firm skin like the tip of the nose, and hard skin like the forehead. The depth of the
lesion determines if it is on the surface or located within the dermis or subcutaneous tissue. An indurated base
is a thickening in the depths of the lesion rather than on the surface.

Palpate the regional lymph glands
Many viral exanthems present with rash and lymphadenopathy. Palpation of the regional lymph glands may be
of assistance in the diagnosis if neoplasm is suspected.

Perform an abdominal examination
The detection of hepatic or splenic enlargement may assist in the diagnosis of a systemic cause of skin disorders.

Laboratory and diagnostic studies

Diascopy is used to assess for blanching on pressure and is accomplished by pressing a glass or clear plastic
slide on the lesion and observing for color changes. It is used to determine whether a lesion is vascular
(inflammatory or congenital), nonvascular (nevus), or hemorrhagic (petechia or purpura). Diascopy is most

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helpful in evaluating purpuric lesions; blood that is outside vessels (as in petechiae) will not blanch, but blood
that is entrapped within dilated vessels (as in telangiectasias) will blanch.

Dermoscopy uses a skin surface microscope (dermatoscope) with or without the application of oil on a skin
lesion to illuminate and magnify a lesion. This technique allows a more detailed inspection of the surface of
pigmented skin lesions to confirm a diagnosis of melanoma and to determine which skin lesions require biopsy
or removal. Dermoscopy requires special training and expertise.

Wood’s light
Long­wave ultraviolet (UV) light is used in the diagnosis of lesions caused by fungal

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infections. Many but not all fungal rashes fluoresce different colors. Trichophyton organisms and Tinea tonsurans,
dermatophytes that are frequently identified in tinea eruptions in the United States, do not fluoresce;
Microsporum organisms, which can cause tinea eruptions, do fluoresce.

Skin scraping and potassium hydroxide preparation
Microscopically examine a sample of cells retrieved from a lesion, assessing for the presence of fungal or
dermatophytic spores and hyphae. The lesion should be gently scraped using a scalpel (collect cells from an
active area such as the border of the lesion); the cells are treated with a drop of 20% potassium hydroxide (KOH)
and then warmed or allowed to stand a few minutes to soften the keratin. The addition of 40% dimethyl
sulfoxide (DMSO) to the KOH solution accelerates diagnosis. Chlorazol black E stain highlights fungal hyphae
as dark, blue­black against a light gray background.

Tzanck smear
In a Tzanck smear, an indirect test for herpes virus infections (herpes simplex virus, herpes zoster), cells are
retrieved by swabbing the base of a lesion (usually a vesicle), smearing it onto a glass slide, and then staining it
with Giemsa or Wright solution. Examined microscopically, the presence of multinucleated giant cells confirms
the presence of herpes virus but cannot differentiate between herpes simplex virus or varicella­zoster virus
infections. Viral culture is diagnostic.

Bacterial or viral culture
For a bacterial culture, exudate from a lesion is collected on a sterile swab and cultured for growth. Gram
staining may also be done. When a bacterial isolate is known, antibiotic sensitivity testing is performed.

For a viral culture, cells from the base of a lesion (usually a vesicle) are collected on a Dacron swab and
cultured for identification of viral infections, particularly HSV or HZ.

Punch biopsy
In a punch biopsy, a cylindrical­shaped tissue sample is assessed histopathologically for identification. Select a
punch size about 3 to 4 mm larger than the lesion or sample an active area if the lesion is large. First the skin is
cleansed and local anesthesia is administered. While stretching the skin with the other hand, gently rotate the
biopsy instrument while exerting slight downward pressure. When well into the dermis, remove the punch and
excise the sample at its base. The defect may be closed using electrocautery, with suture(s), or left open to heal
by second intention. Place the fresh specimen on gauze with normal saline for immediate transport to pathology
to be processed. If the specimen is being sent for culture or immunofluorescent staining, place in a preservative
such as formaldehyde solution.

Excisional biopsy
In excisional biopsy, a tissue sample is assessed histopathologically for identification. Excise the entire lesion,
usually making an elliptical incision around the lesion beyond its margins. Excise the base and close the defect
with sutures or cauterize bleeding vessels. Handle the specimen in the same manner used for a punch biopsy.

Differential diagnosis
The following conditions represent many of the most common skin eruptions observed in primary care.

Follicular eruptions

Acne vulgaris
Acne presents as a chronic eruption of the pilosebaceous unit, with noninflammatory lesions (open or closed
comedones) or inflammatory lesions (e.g., papules, pustules, cysts), and is most commonly a problem of
adolescents. Its distribution follows that of the sebaceous glands: face, neck, chest, back, and upper arms.
Neonatal acne first occurs between 2 and 4 weeks of age, lasting until 4 to 6 months of age. Persistence beyond

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12 months may indicate endocrine dysfunction. Dark­skinned individuals need aggressive treatment to prevent
postinflammatory hyperpigmentation.

Rosacea is a vasomotor instability disorder characterized by sebaceous gland hypertrophy, papules, pustules,
persistent erythema, and telangiectasias. It shows a predilection for the face.

Infectious eruptions

Impetigo presents as a superficial pustular, bullous, or nonbullous eruption followed by crusting (often honey
colored). The causative organism is usually staphylococci or streptococci. Contagion occurs via direct
inoculation. It is typically a localized eruption that can occur anywhere on the body, with a predilection for the
face and trunk.

Folliculitis is a superficial pustular infection of the hair follicles. Causative organisms are usually staphylococci
and occasionally streptococci or gram­negative organisms, including Pseudomonas, Klebsiella, and Proteus spp. It
is typically a localized eruption that can occur anywhere on the body, with a predilection for hairy areas and
flexural regions.

A furuncle, often referred to as a boil, is a more extensive infection secondary to folliculitis (see Folliculitis).

A carbuncle is an abscess of conjoined or adjacent furuncles (see Furuncle).

Macular and papular eruptions

Erythema infectiosum (fifth disease)
Fifth disease, also known as slapped cheek disease, is a systemic illness of sudden onset characterized by a
coalescing, red, maculopapular eruption on the face. A reticular eruption occurs on the extremities 2 to 3 days
later. The causative organism is parvovirus B19. This is a self­limiting condition.

Children with underlying hemolytic anemia may experience an aplastic crisis.

Measles (rubeola)
Measles are caused by a viral exanthem, and the systemic illness that results is characterized by a fine,
erythematous, morbilliform eruption on the face that spreads to the trunk over 4 to 7 days, and becomes
confluent and reticulate. White patches on red mucosa (Koplik spots) appear on the buccal mucosa. Cough,
purulent coryza, photophobia, and fever precede the rash. This is a self­limiting condition and less common
with widespread childhood immunization.

Rubella results from a viral exanthem similar to measles, starts as fine macules and papules on the face, and
progresses caudally within 24 hours. Lymphadenopathy of postauricular nodes is characteristic of this disease.

Pityriasis rosea
The presenting symptom of pityriasis rosea is a rapidly evolving papulosquamous eruption of possible viral
etiology. An initial “herald patch” is characteristic followed within days by numerous faintly erythematous
patches on the trunk and upper extremities (“T­shirt and shorts” distribution). The lesions follow the lines of
cleavage and have a “Christmas tree” pattern on the back. The patches demonstrate fine scaling, and mild to
severe pruritus may be present. It is more common in the spring and fall and among adolescents. In African
American children, the eruption may consist only of occasional oval lesions along the cleavage lines. The

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remaining lesions are discrete, scattered follicular or nonfollicular papules over the trunk and proximal
extremities. The face may also be involved.

Scarlet fever
Scarlet fever is a systemic illness associated with group A β­hemolytic streptococci (GABHS) (strep throat)

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and is easily treatable with antibiotics. It is characterized by a macular erythema of the face (flushing), except
around the mouth (circumoral pallor), followed by a disseminated fine papular erythema (scarlatiniform),
which may then desquamate. The rash is intensified in the flexor folds (Pastia lines). Associated symptoms are
sore throat, malaise, fever, circumoral pallor, and a white or strawberry tongue. Scarlet fever is a rarely
occurring infectious disease in the United States.

Roseola is a viral infection caused by human herpesvirus 6. It is characterized by 2 to 3 days of sustained fever
in an irritable infant who otherwise appears well. Mild edema of the eyelids and posterior cervical
lymphadenopathy are occasionally seen. After the patient’s temperature decreases, a pink, morbilliform,
cutaneous eruption appears transiently and fades within 24 hours. This is a self­limiting condition.

Vesicular and bullous eruptions

Hand, foot, and mouth disease
Coxsackievirus A16 is the causative organism of this viral exanthem and systemic illness. Painful mouth ulcers
followed by painful white vesicles with a surrounding erythema on the fingers, palms, toes, and soles
characterize the condition. Patients usually have a low­grade fever, sore throat, and malaise for 1 to 2 days.
Some develop submandibular or cervical lymphadenopathy. This is a self­limiting condition.

Insect bites
Mosquito and horsefly bites can cause a common blistering reaction that is surrounded by faint erythema,
central pallor if swollen, and usually a visible central punctum. The bites may be arranged in groups if they are
multiple. The lesions are pruritic or sore; the condition is self­limiting. The deer tick bite causes a bull’s­eye rash
at the site of the bite.

Bed bugs
The bed bug, Cimex lectularius, is a pest that feeds on blood, causes itchy bites, and generally irritates their
human hosts. The Environmental Protection Agency, Centers for Disease Control and Prevention, and United
States Department of Agriculture all consider bed bugs a public health pest. However, bed bugs are not known
to transmit or spread disease.

Bites on the skin are a poor indicator of a bed bug infestation. Bed bug bites can look like bites from other
insects (e.g., mosquitoes, spiders), rashes (e.g., eczema, fungal infections), or even hives. Some people do not
react to bed bug bites at all. Bed bug bites can be misidentified, which gives the bed bugs time to spread to other
areas of the house.

A more accurate way to identify a possible infestation of bed bugs is to look for physical signs of the pest. For
example, noting spots on bedding (about this size: •) that are bed bug excrement is one of the earliest and most
accurate methods. The increase in bed bugs in the United States may be caused by more travel, lack of
knowledge about preventing infestations, increased resistance of bed bugs to pesticides, and ineffective pest
control practices.

Herpes simplex virus
Herpes simplex virus lesions have grouped vesicles that are surrounded by an erythematous base, with discrete,
well­demarcated areas that later crust. The condition is associated with soreness or pain and may be preceded
by tingling. There is a predilection for lips and genitalia. Recurrences in the same location are common and
usually milder.

Herpes zoster (shingles)
Herpes zoster lesions present as clustered vesicles that follow a dermatome. Lesions are surrounded by an
erythematous base, with discrete, well­demarcated lesions that later crust. Intense burning and pain often
precede the eruption. Herpes zoster along the ophthalmic branch of the trigeminal nerve requires an immediate
ophthalmology visit, as this can lead to zoster of the eye and resultant blindness.

Varicella zoster (chickenpox)

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Varicella lesions are discrete vesicles with a disseminated distribution; lesions develop in crops or in succession.
Vesicles later crust, and occasionally secondary impetigo develops. The illness is associated with malaise and
fever. This is a self­limiting condition. Varicella zoster can later be reactivated as shingles in patients over 50 or
those who are immunosuppressed. A shingles vaccination is recommended for all adults 60 years and older to
reduce the risk of shingles.

Fungal infections

Candidiasis is a yeast that produces rashes at a variety of sites; these rashes are called vulvovaginitis, thrush,
intertrigo (groin, axilla, gluteal), and diaper dermatitis. The lesion is an erythematous maculopapular eruption
that is well demarcated, occasionally with satellite lesions (pinpoint papules) at the periphery with maceration
in moist areas. It is associated with mild to intense pruritus; the causative organism usually is Candida albicans.

Tinea is a fungal eruption that causes rashes at a variety of sites: body (corporis), foot (pedis), beard (barbae),
groin (cruris), and scalp (capitis). Lesions have erythematous scaling areas with a discrete border and central
clearing that is often associated with pruritus or soreness. The causative organisms are Trichophyton,
Microsporum, and Epidermophyton spp.

Pityriasis (tinea) versicolor
Pityriasis versicolor is a yeast infection characterized by a macular eruption of many colors, hypopigmentation
to hyperpigmentation, and fine scaling. Macules begin insidiously, may take weeks to months to fully develop,
and may coalesce. The condition is usually asymptomatic but occasionally pruritic. There is a predilection for a
sebaceous gland distribution (neck, trunk). The causative organism is Pityrosporum orbiculare (Malassezia globosa).
Repigmentation may take years or may never occur. Recurrences are common.

Immunologic and inflammatory eruptions

Eczema is a chronic relapsing inflammatory condition that can take several forms (atopic, nummular, or
dyshidrotic). Erythematous macules, papules, and vesicles that occasionally weep or crust characterize eczema.
When severe, eczema may produce fissuring and bleeding. It is associated with mild to intense pruritus. In
dark­skinned people, scaling and dryness associated with eczema give an “ashy” appearance to the skin.

Contact or allergic dermatitis
Contact dermatitis is an inflammatory reaction to many substances (e.g., poison ivy, nettles, rubber, nickel).
Papulovesicular or bullous eruptions surrounded by erythema, with weeping of exudate (noncontagious), are
characteristic of the condition. It may be associated with moderate to intense pruritus.

Psoriasis is a chronic, relapsing autoimmune disorder characterized by well­demarcated erythematous plaques,
patches, and papules, which typically present with silvery scales. There is a predilection for the elbows, knees,
hands, nails (pitting), scalp, and gluteal cleft. The condition may be pruritic or sore. The lesions may
demonstrate Auspitz sign: pinpoint bleeding when the surface is scraped.

Seborrheic dermatitis
Seborrheic dermatitis is a chronic, relapsing disorder characterized by erythematous scaling

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patches, which are poorly demarcated and may be pruritic. There is a predilection for the scalp, nasolabial folds,
ears, face, central chest, and genitals. The condition is aggravated by cold weather, dry skin, and stress.

Allergic reactions

Erythema multiforme
Erythema multiforme is an immune complex disorder involving the skin and occasionally the mucous
membranes. Iris (target) lesions appear on the extremities and desquamation often follows. Common causes
include medications (especially sulfonamides, penicillins, barbiturates, salicylates), histoplasmosis, Mycoplasma,
HSV, mononucleosis, hepatitis B, and malignancies. Erythema multiforme minor is often self­limited. More
severe forms are Stevens­Johnson syndrome, characterized by widespread involvement with vesicobullous
lesions and TEN. Both involve the mucous membranes, conjunctiva, and urethra. The more severe forms can
involve the lungs, gastrointestinal tract, and kidneys.

Urticaria is characterized by a well­demarcated, usually disseminated eruption that is evanescent over minutes
to about 24 hours. The condition usually has an asymmetrical distribution.

Neoplastic eruptions

Malignant melanoma
Melanoma is an aggressive cancer with a tendency to spread rapidly and metastasize early. Characterized by
asymmetry (half of a mole or lesion does not look like the other half), melanoma has an irregular, scalloped, or
not clearly defined border with a color that varies or is not uniform (whether the color is tan, brown, black,
white, red, or blue). The diameter is usually larger than 6 mm. However, any change in the size of a mole should
be viewed with suspicion. The three most significant risk factors for the development of melanoma include a
history of melanoma in a first­degree relative, a large number of moles (>50–100), and atypical moles as
designated by biopsy. Other factors that increase the risk of melanoma include adulthood, blond or red hair,
blue or light­colored eyes, changed or persistently changing mole, white race, fair complexion, freckles, personal
history of melanoma, immunosuppression, inability to tan, severe sunburns in childhood, and presence of a
congenital mole. In addition, UV light from tanning beds can both cause melanoma and increase the risk of a
benign mole progressing to melanoma.

Basal cell carcinoma
Basal cell carcinoma usually appears as a small, fleshy bump or nodule on the head, neck, or hands.
Occasionally, these nodules may appear on the trunk of the body, usually as flat growths. These basal cell
tumors do not spread quickly. It may take many months or years for one to reach a diameter of 1/2 inch.
Untreated, the carcinoma will begin to bleed, crust over, and then repeat the cycle. Although this type of cancer
rarely spreads to other parts of the body, it can extend below the skin and cause considerable local damage. The
cure rate for basal cell carcinoma (sometimes referred to as nonmelanoma carcinoma) is 95% when properly

Squamous cell carcinoma
Squamous cell carcinoma presents as an indurated papule, plaque, or nodule with a thick scale that is often
eroded, crusted, or ulcerated. It can be found on sun­exposed skin surfaces, in areas of radiodermatitis, or on
old burn scars. Although slow growing, squamous cell carcinomas arising on the lip, mouth, or ears may be
associated with regional lymphadenopathy and metastasis. If promptly and properly treated, it has a cure rate
of 95%.

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DIFFERENTIAL DIAGNOSIS OF Common Causes of Rashes and Skin Lesions



Acne vulgaris Comedones and/or
papules, pustules, cysts

Flushing, persistent

redness, sebaceous


erythematous papules,

telangiectasias, ocular

involvement in up to



Any hair­bearing
body surface,
but especially
scalp, beard,
legs, axillae





Vesicular infection; honey­
colored crusts and

Superficial perifollicular
papules and pustules

Very tender, deep­seated
inflammatory nodule
that develops from

Carbuncle Multiple coalescing



Bright­red rash or
“slapped cheeks,”
followed by diffuse
maculopapular rash on
trunk and extremities,
leading to a lacy
appearance as
exanthem fades





Face, neck, back,
chest, upper

usually face
only; may
involve eyes

Face; any area of
body with a
minor wound,

Same as folliculitis

Same as furuncle

Cheeks, then trunk
and extremities



Onset of puberty,
topical steroids,
anabolic steroids,
lithium, phenytoin

Topical steroids,

Usually none

Usually none

Scratching as a result of
insect bites, atopic
dermatitis, scabies


Shaving, hot tubs,
contact with mineral
oils, occlusive


May have fever Incision and
drainage for

Same as furuncle Same as

Aplastic anemia in IgM, IgG can be
children with measured
hemolytic anemias;
fetal hydrops has
been reported in
pregnant women
infected with
parvovirus B19





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Patient develops three
Cs: cough, coryza,
and conjunctivitis;
Koplik spots are
evident on buccal
mucosa; rash
begins with spike
of convalescent
fever; rash is
centripetal in
possibly becoming
hemorrhagic in
severe cases

Rubella Tender
of postauricular,
posterior occipital
and confluent rash
that is lacy and not
pruritic; rash lasts
3 days

Rash begins on face and
spreads to trunk and
extremities within
first 24 hr



Fine, mildly
papules and
rash found on

Roseola High fever for 3–4
days in infants and
young children; as
fever returns to
normal, a diffuse
rash erupts

Rash begins on trunk and
quickly spreads to
arms, face, neck, and

Rash starts on neck and
ears faintly, then
covers face, arms, and
chest; on second day
rash covers lower
torso and legs; on
third day rash is on
feet and face; rash
begins to fade on the
fourth day

Multiple oval
lesions with an
inner fine circle of
scale; ovals line up
along skin
cleavage lines on
trunk, producing a
Christmas tree
–like pattern

Trunk, proximal
extremities, rarely on
face; rash is preceded
by a “herald patch,”
appearing from a few
days to 3 wk before
generalized eruption

Rash begins in axillae,
groin, and neck; it
avoids face, but there
is circumoral pallor



Abdominal pain, otitis
media, and
are commonly
associated; severe
cases can cause

Infection with virus
while pregnant
results in
congenital rubella

More common in
spring and fall

Strawberry tongue;
Pastia lines: areas
of linear
in deep creases

Posterior cervical


IgM can be
measured for
measles as
well as acute
and IgG

Confirmation by
acute and
IgG titers, or
by direct
of rubella

If present on
palms and/or
soles and
check RPR to
rule out

Culture for
group A




Insect bites

Bed bugs





Systemic illness
caused by
A16; painful white
vesicles with
surrounding red

Flea, tick bites most
common; intensely
pruritic eruption,
usually in groups
of three; bull’s­eye

Bites may be present,
examine bed for
small reddish
brown spots

Primary infection
with grouped
vesicles on an
erythematous base
at site of
may be preceded
by prodrome of
tingling, itching,
burning, or

Unilateral pain,
itching, or burning
preceded by 3–5
days of eruption of
vesicles or bullae;
followed by
crusting and

Painful mouth ulcers
followed in 24 hr by
painful vesicles on
fingers, palms, toes,
and soles

Lower legs, but may
appear anywhere on
body if pets allowed
on furniture or beds

General distribution

Can occur anywhere on
body, but most
common areas are
genitals, thighs,
mouth, lips, and chin;
may be disseminated
in patients who are

Can occur anywhere on
body but is unilateral,
following a
dermatomal pattern;
requires prompt
referral to
ophthalmologist if
eye involved (Note:
See lesion on tip or
side of nose for

Low­grade fever, sore
throat, and
malaise; cervical

Exposure to dogs or
cats, or to carpeted
areas previously in
contact with
infected animals;
outdoor exposure

Travel, sleeping in a
different bed

Other STIs, HIV;
triggered by sun,
stress, fatigue,
fever, trauma

older age, local
trauma in children

Viral culture,


for bugs,

Viral culture
smear; screen
for STIs, HIV
if history


Generalized pruritic
vesicular lesions
that are in
different stages of
vesicles, ruptured
vesicles, and
crusted vesicles
with scabs


Beefy­red, well­
plaques, often
with scaling edge
and satellite
areas may also
show erosions and

Variable, depending
on body part
affected; hair:
scaling, hair loss,
pustules; skin: red,
scaly patch that
may develop
central clearing;
feet: vesicles or



Pityriasis Variably colored

(tinea) white to pink to

versicolor brown scaling,

round or oval
macules of
varying sizes;
often coalescing to
form large areas of

Lesions usually
begin on
trunk and
spread to
face and

Diaper area in
infants, body
nails, and
nail folds

Herpes zoster occurs with
reactivation of virus

diabetes, steroid
inhalants, pregnancy,
oral contraceptives,
antibiotics, systemic
and topical steroids

Skin, hair, feet,

KOH, culture

Upper trunk,
axillae, neck,
upper arms,

Heat, humidity, tropical
climates, exercise,
systemic corticosteroids,
seborrheic dermatitis

KOH shows
hyphae and
spores in

systemic corticosteroids,
farmers and others with
animal contact, hot
humid weather with
tight clothing or
occlusive footwear

ELISA titers can

KOH, culture


Eczema or

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0028-print-1559937554.xhtml 6/7/2019

crusts, pruritus
always present

Vesicles and
erosions with
edema and
giving way to
crusts and


Seborrheic Chronic scaling,
dermatitis flaking,


Contact or


Erythema Hypersensitivity
multiforme reaction seen

as annular
target or iris

Urticaria Transient wheals
that may be
acute or
chronic (lasting
>6 wk);

plaques and
papules with
silvery scale;
pruritus is

Symmetrical; infant:
face, flexures;
children: flexural
creases; adults:
may be discrete
round patches or
be regionalized
to specific area

Localized, often
may be
generalized with
allergens or
poison ivy;
linear pattern
with plant

Favors elbows and
knees, scalp;
areas may
involve nails

Areas where
glands are most
active: face,
scalp, eyebrows,
eyelashes, body
folds, ear folds,
presternal area,
mid and upper
back, genitalia

Begins on upper
extremities and

Localized, regional,
or generalized

Personal or family
history of asthma,
seasonal allergies, and
eczema; secondary
colonization with
Staphylococcus aureus
or HSV

recreational pursuits

Streptococcal infection,
arthritis, HIV
medications, alcohol,
family history

Atopic history, HIV

Herpesvirus, Mycoplasma
pneumoniae infections,
drugs (especially

Angioedema may also be
present, may be life
threatening; chronic
infection, SLE,


Serum IgE;
culture for
bacteria or
HSV if

Patch testing

ASO titer or
strep culture
if indicated;
HIV if

HIV if indicated

Skin biopsy may
assist in
chest film for

Biopsy; general
workup to
rule out



Basal cell

Squamous cell

individual systemic
lesions tend to disease in
come and go chronic
within hours; urticaria


Skin biopsy,

Skin biopsy

Skin biopsy,

irregular, has
color variation
within lesion
and is >6 mm

Papular or
lesions, with
raised pearly
borders, and

Indurated papule,
plaque, or
nodule; may be
crusted, or

Anywhere on body,
including scalp

Sun­damaged areas;
also seen in
covered areas
when there is
predisposition to
basal cell

Sun­damaged areas,
areas of
old burn scars;
can occur
anywhere on

Usually asymptomatic,
unless bleeding,
ulceration, discharge

Usually asymptomatic

Usually asymptomatic;
can be associated with
topical nitrogen
mustard, oral PUVA,
chronic ulcers,
carcinogens, arsenic

ELISA, enzyme-linked immunosorbent assay; HIV, human immunodeficiency virus; HPV, human papillomavirus; HSV,
herpes simplex virus; IgG, immunoglobulin G; IgM, immunoglobulin M; KOH, potassium hydroxide; PUVA, psoralen plus
ultraviolet A (light therapy); RPR, rapid plasma regain; SLE, systemic lupus erythematosus; STI, sexually transmitted

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  • 386-387
  • 388-389
  • 390-391
  • 392-393
  • 394-395
  • 396-397
  • 398-399
  • 400
  • 401-402

 Choose one skin condition graphic (identify by number in your Chief Complaint)
to document your assignment in the SOAP (Subjective, Objective, Assessment, and
Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the
Sullivan text and the Comprehensive SOAP Template in this week’s Learning
Resources for guidance. Remember that not all comprehensive SOAP data are
included in every patient case.

 Use clinical terminologies to explain the physical characteristics featured in the
graphic. Formulate a differential diagnosis of three to five possible conditions for the
skin graphic that you chose. Determine which is most likely to be the correct diagnosis
and explain your reasoning using at least 3 different references from current evidence
based literature.

Comprehensive SOAP

Patient Initials: __JJ_____ Age: __54_____ Gender: __M_____


Chief Complaint (CC): Small, itchy, raised patches on lower back

History of Present Illness (HPI): Jeremiah Jergens is a 54-year-old Caucasian
male who presents today with a large cluster of thick, red, raised patches on his
lower back. Jeremiah first noticed the patches 4 years ago, a few days after he
recovered from a strep throat infection. He has associated symptoms of
tenderness, itchiness and flaking of the patches. They often bleed when he
accidently scratches off a patch. He reported the he is “embarrassed by the look
of it” and will not take his shirt off at the beach. He has also noticed both his
knees, joints in his fingers and back are very stiff in the mornings but lessens
after walking and using his joints for a bit. He has been using Tylenol to help with
the joint pain and for the patches, he reports using Benadryl ointment for the
itching. Both provide minimal relief. He rates his discomfort a 4/10 today but in
mornings 7/10 due to the joint pain.

1. Over-the-counter Tylenol 500mg PO once daily in the morning

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2. Over-the-counter Benadryl Extra Strength topical ointment as needed
3. Atenolol 75 mg PO twice daily
4. Over-the-counter Aspirin 325 mg PO once daily
5. Men’s Multivitamin once daily
6. Epi-Pen as needed

1. Penicillin – rash
2. Salmon – anaphylaxis
3. Peaches – lip itching

Past Medical History (PMH):
1. Chicken Pox – age 5
2. Streptococcal Pharyngitis, recurrent– age 50
3. Morbid obesity

Past Surgical History (PSH):
1. Gastric bypass surgery – age 52
2. Appendectomy – age 23
3. Tonsillectomy – pt states “I was about 7 years old”
4. Vasectomy – age 32

Sexual/Reproductive History:
Vasectomy – age 32

Personal/Social History:
He quit smoking 8 months ago after smoking 2.5 packs daily x 31 years; has an
occasional beer during social outings; denies any drug use; enjoys hiking, riding
his motorcycle, spending time at the beach with his 5 grandchildren; exercise 5
days a week; eating habits have been “much better since the weight loss

Immunization History:
Agrees to receive his influenza and Pneumococcal today. All other immunizations
are up to date.

Significant Family History:
Diabetes – mother dx late 30s
Hypertension – maternal grandparents, mother, brother all dx in late 30s
Arthritis – paternal grandfather, father both dx early 40s
Psoriasis – father dx date unknown
2 healthy daughters and 2 grandchildren


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He is married to his wife of 32 years. Together they travel the country in their RV
and motorcycles. He has owned his home for the past 28 years in the suburbs.
At 25 years as a U.S. Marine, he retired and receives full benefits of $75,000
annually. He and his wife both receive social security benefits. No financial
issues. First born daughter rents the basement with her 2 children ages 5 and

Following his gastric bypass surgery, his health taken a turn for the better by
decreasing his meat and increasing his vegetable intake. His total weight loss
since the surgery is 143 lbs. He is now only taking one blood pressure
medication, down from two. 5 days a week, he exercises at the local YMCA.
When he is not traveling the country, he attends church Mondays and Thursdays
for Bible study. He also leads the marriage ministry for newlyweds. He has a
great support system including his friends and family.

Review of Systems:

General: Negative for recent sudden weight changes, weakness, fatigue,
anorexia, malaise, or fever

HEENT: negative for headache, head injury, visual changes, blurring of vision,
itching, last eye exam 2/15/18. Negative for diplopia, floaters, loss of any visual
fields, history of cataracts or glaucoma, pain, redness, excessive tearing.
Negative for tinnitus, recent ear infections, hearing loss, change in hearing.
Negative for epistaxis, frequent colds, nasal congestion, discharge, pain, post-
nasal drip, change in ability to smell, history of nasal polyps, hay fever, and sinus
trouble. Negative for mouth soreness, dryness, bleeding gums, throat soreness,
pyorrhea, ulcers, and teeth dentures. Positive for recurrent strep throat infections
(3 within 5 months) and dental caries.

Neck: negative for painful lymphnodes, enlarged lymphnodes, goiter

Breasts: negative for new or changing breast lumps, nipple changes or nipple
discharge, gynecomastia

Respiratory: negative for cough, hemoptysis, wheezing, shortness of breath,
dyspnea, pleuritic chest pain, cyanosis, recurrent pneumonia, environmental
exposure, history of exposure to TB, last TB skin test 4/3/17-negative

Cardiovascular/Peripheral Vascular: negative for chest pain, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, edema,
palpitations, murmur, varicosities, history of rheumatic fever, syncope,
claudication, thrombophlebitis. Positive for hypertension and history of abnormal

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Gastrointestinal: negative for abdominal pain, nausea, vomiting, hematemesis,
constipation, diarrhea, hemorrhoids, dysphagia, odynophagia, food intolerance,
early satiety, indigestion, heartburn, change in appetite, change in bowel pattern,
rectal bleeding, melena, excessive flatulence or belching, liver or gallbladder
problems, jaundice, history of hepatitis

Genitourinary: negative for dysuria, penile discharge, lesions, incontinence,
changes in voiding, hematuria, frequency, suprapubic pain, nocturia, trouble
initiating urinary stream, incomplete emptying, polyuria, stones, history of urinary
tract infections, history of sexually transmitted infections, testicular pain, or
swelling, scrotal mass, sexual difficulties, impotence, hernias. Positive for
vasectomy at age 32

Musculoskeletal: negative for new gait disturbance, new weakness, recent fall,
gout, arthritis. Positive for lower back pain, pain in joints of fingers, bilateral knee
pain and stiffness with limited range of motion especially in the mornings

Psychiatric: negative for depression, anxiety, hallucinations, suicidal ideation,
homicidal ideation, nightmares, nervousness, irritability, hypersomnia, insomnia,
phobias. Positive for low self-esteem due to finger nail changes and patches on

Neurological: negative for headaches, numbness/tingling, visual changes,
seizures, falls, blackouts, local weakness, tremors, memory changes, muscle
atrophy, vertigo or dizziness

Skin: negative for skin lesion changes, petechiae, bruising, sores, changed in
moles, changes in hair.

Hematologic: negative for hematemesis, hematochezia, hemoptysis, prolonged
bleeding, other bleeding problems, blood transfusion

Endocrine: negative for polyphagia, polyuria, polydipsia, heat intolerance, cold
intolerance, sudden weight gain, sudden weight loss, history of diabetes or
thyroid issues

Allergic/Immunologic: negative for seasonal allergies, recurrent serious
infections. Positive for food allergy to salmon and peaches. Positive for drug
allergy for Penicillin.


Physical Exam:
Vital signs: BP 119/72 (right arm, large cuff, sitting) | Pulse 78 | Temp 98 °F
(36.7 °C) (Oral) | Resp 18 (non-labored) | Ht 6′ 3.75″ (1.924 m) | Wt 196 lb (85
kg) | BMI 24 kg/m²

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General: Alert and orientated to time, place, and person, well appearing, and in
no distress. Appears comfortable during history taking

HEENT: Skull normocephalic, atraumatic, sparse hair with balding. PERRLA,
light reflex present, oronasopharynx is clear

Neck: supple, no palpable thyroid, midline trachea, no enlarged neck nodes,
bruit, jugular vein distension, tmegally

Chest/Lungs: clear to auscultation, no wheezes, rales or rhonchi, rubs,
symmetric air entry, resonance on percussion, fremitus on palpation

Heart: normal rate, regular rhythm, normal S1, S2, no murmurs, thrills, rubs,
clicks or gallops

Peripheral Vascular: peripheral pulses normal, no pedal edema, no clubbing or

Abdomen: Abdomen soft, nontender, nondistended, no scars, masses hernia,
aortic pulsations, or organomegaly, bowel sounds present

Genital/Rectal: No penile lesions or discharge, testicular lump, no hernias,
uncircumcised. Rectal exam: negative without mass, lesions or tenderness.

Musculoskeletal: Bilateral knee exam –positive for crepitation on left knee, no
swelling good ROM right knee -no swelling, no crepitation good ROM. Muscle
strength symmetric 5/5 all groups. Positive for mild swelling in joint of all fingers

Neurological: reveals alert, oriented, normal speech, no focal findings or
movement disorder noted. Gait regular, no involuntary movements. Cranial
nerves II-XII grossly intact, DTR’s intact

Skin: normal coloration and turgor, has benign small moles on chest, has cluster
of well-demarcated red plaques >20% BSA macules and coarse scales on lower
back, elbows, and along hairline (Gladman, Shuckett, Russell, Thorne, &
Schachter, 1987). Onycholysis, thickening, and pitting of fingernails (Mcgonagle,


Lab Test and Results:
1. Skin biopsy and Periodic acid–Schiff–diastase (PAS-D) stain – positive for

epidermal hyperplasia
2. RH factor – negative
3. HLA-B27 – positive

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4. Nail culture using Potassium hydroxide (KOH) preparation – negative for nail

5. Auspitz sign – positive (Bernhard, 1990)
6. Radiology — “pencil-in-cup” phenomenon in both index fingers and right ring

finger (Siannis, Farewell, Cook, Schentag, & Gladman, 2006).
7. Serum Urate – 5.2 mg/dL

Priority Diagnostics:
A. Chronic Plaque Psoriasis
B. Nail Psoriasis
C. Psoriasis Arthritis

Differential Diagnosis (DDx):

a. Nummular eczema
b. Seborrheic Dermatitis
c. Atopic Dermatitis

a. Superficial fungal infection
b. Onychomycosis
c. Lichen Planus

a. Rheumatoid Arthritis
b. Reactive Arthritis
c. Gout

Diagnoses/Client Problems:
1. HTN, controlled
2. Allergy to Penicillin (rash), salmon (anaphylaxis), peaches (lip itching),



Bernhard, J. D. (1990). Auspitz sign is not sensitive or specific for psoriasis. Journal of

the American Academy of Dermatology, 22(6), 1079-1081.

doi:10.1016/0190- 9622(90)70155-b

Gladman, D. D., Shuckett, R., Russell, M. L., Thorne, J. C., & Schachter, R. K. (1987).

Psoriatic arthritis (PSA) – An analysis of 220 patients. QJM: An International

Journal of Medicine, 62(238-241), 127.


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Mcgonagle, D. (2009). Enthesitis: An autoinflammatory lesion linking nail and joint

involvement in psoriatic disease. Journal of the European Academy of

Dermatology and Venereology, 23(S1), 9-13. doi:10.1111/j.1468-


Siannis, F., Farewell, V. T., Cook, R. J., Schentag, C. T., & Gladman, D. D. (2006).

Clinical and radiological damage in psoriatic arthritis. Annals of the Rheumatic

Diseases, 65(4), 478-81. doi:10.1136/ard.2005.039826

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