SKIN, HAIR & NAIL EXAMINATION
I. HISTORY TAKING
A. Chief Complaints (Detailed with possibilities)
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Skin Lesions
- Site: Localized (e.g., face → acne, butterfly rash), Generalized (e.g., drug rash, viral exanthem)
- Onset: Sudden (urticaria, drug rash), Gradual (psoriasis, vitiligo)
- Duration: Acute (<6 weeks → urticaria), Chronic (>6 weeks → psoriasis, lichen planus)
- Progression: Static (mole), Progressive (psoriasis)
- Character:
- Maculopapular rash: Viral exanthem, Drug rash
- Vesicular: Herpes, Chickenpox
- Pustular: Acne, Bacterial infection
- Scaly: Psoriasis, Pityriasis rosea
- Pigmented: Melasma, Post-inflammatory
- Depigmented: Vitiligo, Pityriasis versicolor
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Itching (Pruritus)
- Character: Localized (Scabies, dermatitis), Generalized (Uremia, cholestasis, lymphoma)
- Severity: Mild (xerosis), Severe (Atopic dermatitis, scabies)
- Aggravating factors: Night-time (scabies), after bath (eczema)
- Relieving factors: Cold (eczema), scratching (psychogenic)
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Burning / Pain
- Possibilities: Herpes zoster (burning pain), Contact dermatitis, Staphylococcal infections
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Ulceration
- Site & Cause: Leg (venous ulcer, arterial ulcer, neuropathic ulcer), Mouth (Aphthous, Behçet’s)
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Swelling/Nodule/Lump
- Single (sebaceous cyst), Multiple (neurofibroma)
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Discharge from lesion
- Purulent (bacterial), Serous (viral), Bloody (malignancy)
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Photosensitivity
- SLE, Porphyria, Drug-induced
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Hair Loss
- Pattern: Diffuse (Telogen effluvium), Patchy (Alopecia areata), Frontal recession (Androgenic alopecia)
- Onset: Sudden (Telogen effluvium), Insidious (Androgenic)
- Associated symptoms: Itching, scaling
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Nail Changes
- Discoloration (Onychomycosis, Psoriasis)
- Deformity (Koilonychia, Clubbing)
- Fragility, Brittleness
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Systemic Associations
- Weight loss (Lymphoma, HIV)
- Fever (Viral exanthem, Drug rash)
- Joint pain (Psoriasis, SLE)
- Diarrhea (Dermatitis herpetiformis, Zinc deficiency)
B. Past History
- Similar lesions in past
- Chronic systemic illness (Diabetes, HIV)
- Drug intake (Antibiotics, Anticonvulsants, NSAIDs)
- Allergies
C. Family History
- Psoriasis, Atopy, Vitiligo, Alopecia areata
D. Personal History
- Occupation (Chemical exposure → Contact dermatitis)
- Hygiene
- Sexual history (STDs with skin manifestations)
- Stress (Alopecia areata, Psoriasis flare)
II. PHYSICAL EXAMINATION
1. General Examination
- Pallor (Chronic infection, malignancy)
- Icterus (Cholestasis causing pruritus)
- Lymphadenopathy (Cutaneous lymphoma, secondary infection)
- Clubbing (Pulmonary disease with hypertrophic osteoarthropathy)
- Edema
2. LOCAL EXAMINATION – SKIN
A. Inspection
Points to Note:
-
Site: Specific patterns
- Sun-exposed areas → SLE, Photosensitive dermatitis
- Flexural → Atopic dermatitis
- Extensor surfaces → Psoriasis
- Pressure points → Callosities, Decubitus ulcers
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Distribution
- Symmetrical → Psoriasis, Drug rash
- Asymmetrical → Fungal infections
- Dermatomal → Herpes zoster
- Linear → Lichen striatus, Koebner phenomenon
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Type of Primary Lesion:
- Macule (Vitiligo, Pityriasis alba)
- Papule (Lichen planus)
- Vesicle (Herpes, Chickenpox)
- Bulla (Pemphigus vulgaris)
- Pustule (Impetigo, Acne)
- Nodule (Leprosy)
- Plaque (Psoriasis)
- Wheal (Urticaria)
- Cyst (Sebaceous cyst)
-
Secondary Changes:
- Crusting (Impetigo)
- Scaling (Psoriasis, Dermatophytosis)
- Ulceration (Pyoderma gangrenosum, Vasculitis)
- Lichenification (Chronic eczema)
-
Color Changes
- Hyperpigmentation → Addison’s disease, Lichen planus
- Hypopigmentation → Vitiligo, Tinea versicolor
- Erythema → Acute dermatitis
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Surface
- Smooth, rough, verrucous
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Margins
- Well-defined (Psoriasis, Fungal infection)
- Ill-defined (Eczema)
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Shape
- Annular, polycyclic, linear, serpiginous
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Hair & Nail involvement
- Psoriasis, Lichen planus
B. Palpation
- Temperature
- Tenderness
- Consistency (Soft → Lipoma, Firm → Fibroma)
- Mobility (Cystic, Fixed)
- Induration
- Sensation over lesion (Leprosy)
C. Special Tests (Bedside)
- Diascopy: Blanchable lesions (Urticaria), non-blanchable (purpura)
- Nikolsky sign: Positive in Pemphigus vulgaris
- Bulla spread sign
- Koebner phenomenon: Psoriasis, Lichen planus
- Dermographism: Physical urticaria
- Sensory testing over lesions: Leprosy
3. HAIR EXAMINATION
A. Inspection
-
Distribution:
- Diffuse (Telogen effluvium)
- Localized (Alopecia areata)
- Androgenic pattern
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Quality:
- Thin, thick, brittle, dry
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Shaft Abnormalities:
- Pili torti, Trichorrhexis nodosa
-
Color Changes:
- Premature greying
- Poliosis (Vitiligo)
B. Palpation
- Texture
- Fragility
C. Specific Tests
- Hair pull test (Anagen/Telogen shedding)
- Tug test
- Hair microscopy (Shaft abnormality)
4. NAIL EXAMINATION
A. Inspection
-
Shape & Curvature
- Koilonychia (Iron deficiency)
- Clubbing (Systemic disease)
-
Surface
- Pitting (Psoriasis, Alopecia areata)
- Beau’s lines (Systemic illness)
- Longitudinal ridges (Lichen planus)
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Color
- Leukonychia (Hypoalbuminemia)
- Yellow nails (Yellow nail syndrome)
- Subungual hyperkeratosis (Psoriasis)
- Splinter hemorrhages (Endocarditis)
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Periungual Changes
- Paronychia
- Pterygium (Lichen planus)
B. Palpation
- Tenderness (Paronychia, ingrown nail)
- Texture
III. SYSTEMIC EXAMINATION
To detect systemic disease with skin manifestations:
- CVS: Vasculitis, Endocarditis (Janeway lesions)
- Respiratory: Sarcoidosis, Clubbing
- Gastrointestinal: Dermatitis herpetiformis, Porphyria
- Endocrine: Acanthosis nigricans, Addison’s pigmentation
- Neurology: Sensory loss in Hansen’s disease
- Rheumatology: SLE, Psoriasis-related arthritis
IV. CLINICAL CLUES & DIFFERENTIAL POSSIBILITIES BASED ON FINDINGS
When examining the skin, a primary lesion’s morphology immediately directs the clinical gaze toward certain pathophysiological categories. For instance, if one observes well-defined, erythematous, scaly plaques with silvery white scales predominantly over extensor surfaces, the morphological clue suggests a papulosquamous disorder; the sharply demarcated plaques and the presence of Auspitz sign make Psoriasis vulgaris the leading possibility, although tinea corporis and pityriasis rosea must be considered and excluded by distribution, scale pattern, and scraping for fungal elements.
Macular hypopigmentation over the face, particularly in children, without sensory loss and with fine scaling favors pityriasis alba; however, if the margins are well defined, with complete depigmentation and no scaling, vitiligo becomes more likely. Should hypo- or depigmented patches show sensory loss, hair loss, or peripheral nerve thickening, suspicion must shift toward Hansen’s disease, particularly borderline or tuberculoid leprosy.
Vesicular lesions clustered unilaterally along a dermatome prompt immediate consideration of Herpes zoster; burning pain preceding the eruption clinches the diagnosis. If vesicles are generalized, involve mucosa, and appear in crops, the leading differential becomes varicella infection. Conversely, if vesicles are widespread but pruritic, with predilection for flexural areas and excoriation marks, the differential tilts towards scabies.
The presence of lichenification, excoriation, and pigmentation over flexural surfaces points to chronic eczema, especially in atopic individuals. However, the clinician must differentiate this from lichen simplex chronicus, where a single area is repeatedly scratched leading to lichenification, and from lichen planus, characterized by violaceous flat-topped papules with Wickham striae.
Generalized pruritus without primary skin lesions demands systemic evaluation. The possibility of chronic renal failure (uremic pruritus), cholestasis (bile salt deposition), hematologic malignancies (Hodgkin’s lymphoma, polycythemia vera), or HIV-related pruritus must be considered based on associated systemic features like lymphadenopathy, splenomegaly, jaundice, or anemia.
In hair examination, diffuse non-scarring hair loss with positive pull test, history of febrile illness, childbirth, or stress suggests telogen effluvium. If hair loss is in well-defined patches without inflammation or scarring, and exclamation mark hairs are seen, alopecia areata is the likely diagnosis. However, when hair loss is scarring, with loss of follicular ostia, the differentials narrow to discoid lupus erythematosus, lichen planopilaris, or folliculitis decalvans.
Hypertrichosis or hirsutism necessitates differentiation: when excessive terminal hair is distributed in a male pattern in females, associated with menstrual irregularities or virilization, polycystic ovarian syndrome, androgen-secreting tumors, Cushing’s syndrome, or congenital adrenal hyperplasia are considered. Diffuse non-androgenic hypertrichosis may result from medications (phenytoin, minoxidil), porphyria, or systemic illnesses.
Nail findings also yield systemic clues. Clubbing, when identified, prompts evaluation for pulmonary (bronchiectasis, lung carcinoma), cardiac (cyanotic congenital heart disease, infective endocarditis), or gastrointestinal (ulcerative colitis, cirrhosis) causes. Koilonychia demands iron studies to evaluate for iron deficiency anemia but also triggers consideration of Plummer-Vinson syndrome. Beau’s lines reflect systemic stressors such as high-grade fever, chemotherapy, or severe malnutrition during the period of nail matrix insult.
Pitting of nails typically suggests psoriasis, especially when accompanied by onycholysis, subungual hyperkeratosis, or oil drop sign. However, it may also occur in alopecia areata and, less commonly, in eczema. Leukonychia may be due to trauma, hypoalbuminemia, or systemic illnesses like cirrhosis. Splinter hemorrhages require careful evaluation for infective endocarditis, vasculitis, or trauma.
Yellow nail syndrome characterized by slow-growing, thickened, yellow nails, is often associated with lymphoedema, pleural effusion, and bronchiectasis — a key paraneoplastic and systemic clue.
Generalized hyperpigmentation particularly involving mucosa, palmar creases, and pressure areas suggests Addison’s disease; associated hypotension and hyponatremia may confirm this. In contrast, hyperpigmentation with weight loss and hepatosplenomegaly warrants evaluation for hemochromatosis or chronic liver disease.
If one encounters cutaneous nodules that are non-tender, shiny, and multiple over cooler parts of the body (ears, elbows, face), and associated peripheral nerve thickening with glove-and-stocking anesthesia, the possibility of lepromatous leprosy becomes evident.
In ulcer examination, the character of edges provides diagnostic clues. Punched out edges point towards trophic or neuropathic ulcers (diabetes, leprosy). Undermined edges suggest tuberculous ulcers. Raised everted edges immediately prompt concern for squamous cell carcinoma, while rolled edges make basal cell carcinoma more probable.
Livedo reticularis with purpuric lesions is a vascular clue, possibly pointing to antiphospholipid syndrome, cryoglobulinemia, or vasculitis.
Butterfly-shaped facial erythema sparing nasolabial folds with photosensitivity is a strong pointer toward systemic lupus erythematosus; however, if the rash is papular, scaly, and involves nasolabial folds, seborrheic dermatitis is considered.
Erythema nodosum, presenting as tender, erythematous subcutaneous nodules over the shins, leads to evaluation for streptococcal infection, tuberculosis, sarcoidosis, inflammatory bowel disease, or drug reaction.
Targetoid lesions with central dusky zone, erythematous middle ring, and peripheral pale ring suggest erythema multiforme, which is often related to herpes simplex virus infection, medications, or Mycoplasma infection.
In examining generalized dryness of skin (xerosis), especially in elderly or renal failure patients, the clinician considers senile xerosis, ichthyosis vulgaris, hypothyroidism, or chronic renal disease.
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