logo Examination of the skin

Introduction to dermatology

Examination of the skin

Objectives

To develop skills in examination of the skin.

Key points

Skin examination should include:

  • Examination of the entire skin surface, hair, nails and mucous membranes.
  • Assessment of distribution, morphology and arrangement of skin lesions.
  • Palpation of skin lesions.

The entire skin surface should be examined as well as hair, nails and mucosal surfaces. This may require a chaperone. Explain the necessity of complete examination to the patient, who may wear their normal underwear e.g. in females, underpants and bra. Often it is easiest to do so in two stages, i.e. undress the upper limbs and trunk, examine these areas, replace clothing and then do the same for the lower limbs.

Use an appropriate light source and magnification. Identify the presenting complaint and incidental skin conditions (especially skin cancers). Have you found solitary lesions or a widespread rash?

Assess distribution, morphology and arrangement i.e. the number, size and colour of skin lesions, which sites are involved, their symmetry, shape and arrangement. What types of lesions are present?

Touch the skin to palpate individual lesions and more diffuse rashes, noting surface and deep characteristics. Does the lesion involve epidermis, dermis or subcutis? If scaly, does the surface flake off easily? If crusted, what is underneath?

Look carefully for signs of systemic disease, such as xanthomas (hyperlipidaemia), café-au-lait macules (neurofibromatosis), acanthosis nigricans (insulin resistance) etc.

Examine the hair and nails. Mucosal surfaces include conjunctivae, lips, gums, tongue, and buccal mucosa. Genital examination is only required if related to the presenting complaint. Specific permission should be obtained for genital examination and a chaperone should be available to the patient.

Finally, where indicated by symptoms or clinical signs, perform a general physical examination that may include height, weight, temperature, cardiovascular/respiratory assessment and so on.