Dermatological skin examination

Assessing lesions

• Distribution and size
  • e.g. acral (distal), central, flexor/extensor, localised/generalised, dermatomal, follicular, seborrhoeic 
• Characteristics (SEC)
  • Shape, e.g. circular, linear, annular, irregular
  • Edge and elevation, e.g. well-demarcated, ill-defined, raised/flat
  • Colour, e.g. erythematous, depigmented/pigmented, purpuric
• Secondary features 
  • e.g. crust, scale, pigmentation, keratosis, lichenification, erosion, excoriation, fissure, ulceration

Definitions in dermatology

	<1 cm	>1 cm
Flat	Macule	Patch  Plaque (palpable)
	<0.5 cm	>0.5 cm
Raised	Papule  Vesicle (fluid-filled) Pustule (pus-filled)	Nodule Bulla (fluid-filled)

Introduction

• Wash hands
• Introduce self;
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent
• Get a chaperone
• Expose patient to underwear

General inspection

• Patient: well/unwell, pain/discomfort
• Describe the pattern of any rash: site, number of lesions, distribution pattern

Hands

• Nails
  • Psoriatic nail changes (pitting, onycholysis, subungual hyperkeratosis)
• Hands

Upper limbs

• Anterior arms
• Ask patient to put hands behind head
  • Posterior arms
  • Axilla

Head and neck

• Scalp: look through hair and behind ears
• Face
• Inside mouth

Torso

• Chest
• Abdomen
• Back
• ‘At this point, I would also like to look at the genital region.’

Lower limbs

• Legs
• Feet and toe nails

To complete

• Thank patient and restore clothing
• ‘To complete my examination, I would examine any suspicious moles with a dermatoscope and perform other relevant system examinations (e.g. vascular for an arterial ulcer).’ 
• Summarise and suggest further investigations you would consider after a full history

Try some questions

Try some OSCE stations

1. Try a normal exam first
2. Psoriasis
3. Actinic keratosis
4. Eczema
5. Neurofibromatosis
6. Find more OSCE stations here