Chapter 052. Approach to the Patient with a Skin Disorder (Part 7)

Allergic contact dermatitis (ACD). A. An example of ACD in its acute phase, with sharply demarcated, weeping, eczematous plaques in a perioral distribution. B. ACD in its chronic phase demonstrating an erythematous, lichenified, weeping plaque on skin chronically exposed to nickel in a metal snap. (B, Courtesy of Robert Swerlick, MD; with permission.)As in other branches of medicine, a complete history should be obtained to emphasize the following features:1. Evolution of lesionsa. Site of onsetb. Manner in which the eruption progressed or spreadc. Durationd. Periods of resolution or improvement in chronic eruptions2. Symptoms associated with the eruptiona. Itching, burning,...
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Chapter 052. Approach to the Patient with a Skin Disorder (Part 7) Chapter 052. Approach to the Patient with a Skin Disorder (Part 7) Allergic contact dermatitis (ACD). A. An example of ACD in its acute phase, with sharply demarcated,weeping, eczematous plaques in a perioral distribution. B. ACD in its chronicphase demonstrating an erythematous, lichenified, weeping plaque on skinchronically exposed to nickel in a metal snap. (B, Courtesy of Robert Swerlick,MD; with permission.) As in other branches of medicine, a complete history should be obtained toemphasize the following features: 1. Evolution of lesions a. Site of onset b. Manner in which the eruption progressed or spread c. Duration d. Periods of resolution or improvement in chronic eruptions 2. Symptoms associated with the eruption a. Itching, burning, pain, numbness b. What, if anything, has relieved symptoms c. Time of day when symptoms are most severe 3. Current or recent medications (prescribed as well as over-the-counter) 4. Associated systemic symptoms (e.g., malaise, fever, arthralgias) 5. Ongoing or previous illnesses 6. History of allergies 7. Presence of photosensitivity 8. Review of systems 9. Family history (particularly relevant for patients with melanoma, atopy, psoriasis, or acne) 10. Social, sexual, or travel history as relevant to the patient DIAGNOSTIC TECHNIQUES Many skin diseases can be diagnosed on gross clinical appearance, butsometimes relatively simple diagnostic procedures can yield valuable information.In most instances, they can be performed at the bedside with a minimum ofequipment. Skin Biopsy A skin biopsy is a straightforward minor surgical procedure; however, it isimportant to biopsy a lesion that is most likely to yield diagnostic findings. Thisdecision may require expertise in skin diseases and knowledge of superficialanatomic structures in selected areas of the body. In this procedure, a small area ofskin is anesthetized with 1% lidocaine with or without epinephrine. The skinlesion in question can be excised or saucerized with a scalpel or removed bypunch biopsy. In the latter technique, a punch is pressed against the surface of theskin and rotated with downward pressure until it penetrates to the subcutaneoustissue. The circular biopsy is then lifted with forceps, and the bottom is cut withiris scissors. Biopsy sites may or may not need suture closure, depending on sizeand location. KOH Preparation A potassium hydroxide (KOH) preparation is performed on scaling skinlesions where a fungal infection is suspected. The edge of such a lesion is scrapedgently with a no. 15 scalpel blade, and the removed scale is collected on a glassmicroscope slide then treated with 1 to 2 drops of a solution of 10–20% KOH.KOH dissolves keratin and allows easier visualization of fungal elements. Briefheating of the slide accelerates dissolution of keratin. When the preparation isviewed under the microscope, the refractile hyphae will be seen more easily whenthe light intensity is reduced and the condenser is lowered. This technique can beutilized to identify hyphae in dermatophyte infections, pseudohyphae and buddingyeast in Candida infections (see Fig. 196-1), and spaghetti and meatballs yeastforms in tinea versicolor. The same sampling technique can be used to obtain scalefor culture of selected pathogenic organisms.