The dermatologic examination
Eleven stations, always in the same order, so nothing is skipped on a busy day. Each one ends with the question an experienced examiner is silently asking.
- 1
General inspection
Adequate light, adequate exposure. Stand back first: overall pattern before individual lesions.
“Is this one lesion, a regional rash, or a generalized eruption?”
- 2
Primary lesion
Find the youngest, least-scratched lesion and name it precisely, macule, papule, plaque, vesicle…
“What would this lesion have looked like the day it appeared?”
- 3
Secondary change
Scale, crust, erosion, lichenification, excoriation, what has time and scratching added?
“Which changes are the disease, and which are the patient's fingernails?”
- 4
Colour
Erythematous, violaceous, dusky, hyper- or hypopigmented, and always: does it blanch?
“Would this colour read differently at a different baseline pigmentation?”
- 5
Configuration
The shape lesions draw: annular, linear, grouped, targetoid, serpiginous, reticular.
“Is there geometry here that biology alone would not produce?”
- 6
Distribution
Map it: flexural, extensor, dermatomal, photodistributed, acral, generalized, and what is spared.
“Why is the rash HERE and not somewhere else?”
- 7
Palpation
Texture, depth, tenderness, temperature, induration. Gloves when the surface is broken.
“Is it rough (scale), infiltrated (deep), tender (inflamed), or warm (infected)?”
- 8
Hair and scalp
Pattern of any loss, scale, follicular openings present or absent, hair-shaft calibre.
“Are the follicular openings still there?”
- 9
Nails
Pits, onycholysis, bands, ridges, fold changes, twenty small windows on skin and systemic disease.
“Do the nails vote for any diagnosis on my differential?”
- 10
Mucosa
Mouth, eyes, genitals, the sites patients do not volunteer and blistering diseases love.
“If I do not look, what would I be missing?”
- 11
Systemic context
Fever, lymph nodes, joints, and the drug chart complete the picture.
“Is the skin the whole story, or the visible part of one?”
Put it to work