Diagnosis of

Skin Diseases

Chapter Outline
2
The diagnosis of skin diseases depends on the accurate use
of the lexicon of dermatology, on the ability to identify the
History Taking" primary and secondary skin lesions, and to recognize various
patterns formed by them. The challenge lies in being able to
Presenting complaints
discern normal from the abnormal, in the ability to differentiate
Past history one lesion from another and to distinguish one pattern of
Family history distribution from another. In an era when clinical diagnosis has
Other history
been relegated to the back seat by the availability of a plethora
of lab tests, in dermatology a good history and a detailed
Examination" physical examination retain unquestionable importance.
Environment for examination
Basic morphology of lesions History Taking
Secondary changes A good history is an important tool in our armamentarium
Further description of lesions and should include questions of special significance in rela-
tion to the skin disease as well as a succinct enquiry concern-
Sites of predilection
ing major systemic symptoms.
Investigations"
Presenting Complaints
Simple but necessary tools
Patients present to the dermatologist with a variety of com-
Some important investigations
plaints, which can be grouped as:
! Subjective symptoms: Which cannot be seen by physician
and include symptoms like itching, pain, and paresthesia
(Table 2.1).
! Objective symptoms: Which can be seen by a doctor and
include symptoms like rash, ulcers, hair fall (or growth),
changes in nails, etc. (Table 2.2).
For each symptom, the following questions should be asked:
! Duration: Is the problem acute or chronic? If chronic,
about relapses and remissions.
! Site of first involvement: And spread.
! Evolution: Of lesions.
! Diurnal variation: In most dermatoses, itching is generally
more severe at night because the patient’s mind is not
diverted. But in sun-induced dermatosis, the itching is
"
Should know logically worse during the day.
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

4
Table 2.1. Detailed history of subjective symptoms # Sun exposure aggravates photodermatoses.
# Drugs may precipitate a rash, e.g., fixed drug
Symptoms Itching Pain Paresthesia
eruption.
Diurnal variation ! Relieving factors:
! Nocturnal ↑ Scabies # Response to withdrawal of antigens (drugs,
! Daytime ↑ Photo- chemicals) points to an “allergic” reaction.
dermatoses1 ! Associated features: Ask for history of rash,
Seasonal variation wheals, cyanosis, gangrene, hypopigmented
! Summer ↑ Miliaria lesions, neuritis and sensory impairment. Also
Fungal infections for nail changes, hair loss, and involvement of
Insect bites palms, soles, scalp, and mucosae (all!).
! Winter ↑ Ichthyosis Systemic
Psoriasis sclerosis
Past History
Scabies
Chilblains ! Any medication received recently should be
Precipitated by noted, including regular or intermittent self-
! Exercise Cholinergic Intermittent medication.
urticaria claudication ! Any past illness (medical, surgical) and therapy,
! Cold Cold urticaria Raynaud’s thereof, are important in drug eruptions.
phenomenon ! History of medical disorders like diabetes,
Associated features hypertension, tuberculosis, seizures is relevant.
! Rash Drug rash Herpes zoster The dermatosis could be a manifestation of the
! Wheals Urticaria disease or could be an adverse effect of the drug
! Cyanosis Raynaud’s used to treat the disease.
! Hypopigmen- phenom- Leprosy ! Past exposure to Mycobacterium tuberculosis
ted lesions enon is important, when cutaneous tuberculosis is
suspected.
Table 2.2. Detailed history of objective symptoms

Type of skin lesions Macules, papules, plaques, Family History

vesicules, pustules Family history is important in patients with:
Associated symptoms ! Genetic disorders like ichthyosis, neurofibro-
! Itching Drug rash matosis and epidermolysis bullosa.
! Pain Herpes zoster ! Infections and infestations, e.g., scabies, pedi-
Seasonal aggravation culosis.
! Winter Ichthyosis, psoriasis, ! Families who are exposed to similar environ-
seborrheic dermatitis mental influences may also develop same prob-
lems, e.g., arsenical keratoses.
! Summer/rainy season Fungal infections, bacterial
infections, insect bites Other History
Sites of involvement
Social, occupational, travel and recreational history
! Face, back Acne
may help the physician in reaching a diagnosis.
! Extensors, pressure points Psoriasis
! Scalp, nasolabial folds, flexors Seborrheic dermatitis
! Photo exposed parts Photosensitive eruption Examination
Before you begin, it is important to make the
! Precipitating factors:
patient comfortable. Always examine in a room
# Exercise precipitates cholinergic itching and
which is well-lit.
cholinergic urticaria.
# Many dry, scaly and ichthyotic disorders Skin lesions have to be described in three terms:
are worse in winter and so is the associated ! Morphology (Table 2.3).
itching. ! Distribution.

1. Photodermatoses: increase in day time because of sun exposure.

 Chapter 2 • Diagnosis of Skin Diseases

5
Table 2.3. Terminology of skin lesions

Morphology Small (<0.5 cm) Large (>0.5 cm)

Flat lesions
! Normal texture Macule Patch
! Indurated Plaque Plaque
Elevated lesions
! Solid Papule Nodule
! Fluid filled Vesicle Bulla
! Pus filled Pustule Pustule
Indurated lesions Plaque Plaque
(diameter>depth)
Lesions due to Petechiae Ecchymosis
extravasation of blood
A

! Configuration.
Also always remember to examine nails, hair (and
scalp) and mucosae (oral, genital and nasal).

Environment for Examination

! Examine patients in natural lighting. Oblique
B
lighting may be necessary to detect subtle eleva-
tion of lesions, while subdued lighting enhances Fig. 2.1. Macule: circumscribed, flat lesion. A: hyperpig-
subtle changes in pigmentation. mented macule. B: depigmented macule.
! Expose the area affected and do not hesitate
to ask the patient to undress if need be (in
color (Fig. 2.1). Not felt, as no change in skin
the presence of an attendant, if required). Do
texture.
not let stubbornness, shyness or the sex of the
patient put you off! ! Macules may be well-defined or ill-defined and
! Remove make-up if necessary. may be of any size.2
! Magnification: An ordinary magnifying glass ! A macule may be:
(5×, 10×) can provide much needed informa- # Hyperpigmented: e.g., fixed drug eruption, café
tion. au lait macule (Fig. 2.1A). Hyperpigmented
macules may be:
Morphology of Lesions Brown, if the melanin pigment is present
Morphology of skin lesions is more important for in the epidermis, e.g., café au lait macule.
reaching a diagnosis than their distribution. The Slate gray or violaceous, if melanin is
initial (or characteristic) lesions of a disease are present in dermis (Tyndall effect)3 e.g.,
called primary lesions; these lesions are often Mongolian spot.
modified by the scratch marks, ulcers and other Brownish grey, if melanin is present both
events (secondary changes). The rule is to find in the epidermis and dermis, e.g., nevus of
out a primary lesion and study it closely and then Ota (some patients).
note the secondary changes (Table 2.3). # Hypopigmented: when the lesion is less pig-
mented than the surrounding skin, e.g., lep-
Macules rosy. If the lesion is completely devoid of
! Macule is a circumscribed, flat lesion of skin, pigment it is labelled as depigmented, e.g.,
which is visible because of a change in skin vitiligo (Fig. 2.1B), piebaldism.

2. Macules: a large macule is often referred to as patch.

3. Tyndall effect: scattering of different wavelengths of light to different degrees. Melanin present in dermis appears violaceous
because of greater scattering of light of longer wavelengths (red), while violet is remitted back.
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

Fig. 2.3. Papule: solid, elevated lesion <0.5 cm in

diameter.

B
Fig. 2.2. Diascopy: helps to differentiate erythema due
to vascular dilatation from that due to extravasation
of RBCs. A: If redness disappears on applying pressure
(arrow shows blanching) using a glass slide, it is due to
vascular dilatation. B: If the redness stays, it is due to
extravasation of RBCs (purpura). Fig. 2.4. Nodule: solid lesion, >0.5 cm in diameter.

# Erythematous: erythematous lesions can be ! Have a deeper component and some nodules
due to vascular dilatation or extravasation of are better felt than seen.
RBCs (purpura) and the two can be differen-
tiated by diascopy4 (Fig. 2.2). Plaques
! An area of altered consistency of skin which
Papules is usually elevated, but can be depressed or
! Small, solid, elevated lesion, <0.5 cm in dia- flushed with surrounding skin.
meter (Fig. 2.3). A major portion of the papule ! Are formed either by enlargement of individual
projects above the skin. papules or their confluence.
! Papules can be due to: ! Plaques (Fig. 2.5) may be discoid (uniformly
# Hyperplasia of cellular components of epi- thickened) or annular (ring shaped). Annular
dermis or dermis. plaques can form either when center of a
# Metabolic deposits in dermis. discoid plaque clears or due to confluence of
# Cellular infiltrate in dermis. papules.
! Papules may be surmounted by scales or crusts
and may evolve into vesicles and pustules. Tumors
! Tumor implies enlargement of tissues, by
Nodules
normal or pathological material or cells, to
! Solid lesions, >0.5 cm in diameter (Fig. 2.4). form a mass (Fig. 2.6).

4. Diascopy: in erythematous macules, when firm pressure is applied using a glass slide, if the redness disappears, it is due to vascular
dilatation and if it does not, it is due to extravasation of RBCs (purpura).
 Chapter 2 • Diagnosis of Skin Diseases

A B

Fig. 2.5. Plaque: an area of altered consistency of the skin which could be Fig. 2.6. Tumors: large nodules.
elevated, depressed or flat. A: discoid plaque of psoriasis. B: annular plaque
of psoriasis.

! Since this term may alarm the patient, it is better Pus-Filled Lesions
to use the term “large nodule” instead of tumor.
! Pustule: Is a pus-filled vesicle (Fig. 2.8). Pustules
can be follicular (when they are conical) or
Blisters
extrafollicular. Sometimes, level of pus can be
! Blisters (vesicles and bullae) are fluid filled, made out in a pustule.
circumscribed, elevated lesions, which form ! Abscess: Is pus-filled nodule, having a thick
due to a split in the skin. wall (Fig. 2.9). An abscess is usually deep seated
! If <0.5 cm in diameter, they are called vesicles with only a part of it visible on the surface.
(Fig. 2.7A) and if >0.5 cm in diameter, they are
called bullae (Fig. 2.7B). Lesions Due to Dermal and
The characteristics of a bulla depend on the level Subcutaneous Edema
of split (Table 2.4): ! Wheal: Is an evanescent (lasting 48–72 h)
! Subcorneal vesicle. elevated lesion produced by dermal edema
! Intraepidermal vesicle. (Fig. 2.10A). This is usually white, surrounded
! Dermoepidermal vesicle. by a red flare and subsides without any skin

Table 2.4. Characteristics of different bullae

Subcorneal Intraepidermal Dermoepidermal

Level of split Just below stratum corneum In granular layer, spinous layer At dermoepidermal junction
or suprabasal
Characteristics
! Ease of rupture Very thin roof, so rupture Thin roof; rupture less readily Thick roof; rupture least readily so persistent
very easily
! Flaccidity Very flaccid Usually flaccid Usually tense
! Contents Scanty fluid Serous/turbid fluid Serous/turbid often hemorrhagic fluid
! On rupturing Form areas of scale crust. No Form erosions covered with Form erosions/ulcers covered with crusts, often
erosions crusts hemorrhagic
! On healing Normal skin Hyperpigmentation Milia and scarring
Examples Pemphigus foliaceus Pemphigus vulgaris Bullous pemphigoid
Bullous impetigo
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

Fig. 2.9. Abscess: thick-walled collection of pus usually

deep seated, with only a part of it visible on the surface.

Fig. 2.7. Vesicles and bullae: circumscribed fluid-filled

lesions. A: vesicles are <0.5 cm. B: bullae are >0.5 cm.

Fig. 2.8. Pustule: pus-filled hollow lesion. This one shows

a distinct level of pus.

changes. When linear, called dermographic

urticaria (Fig. 2.10B). B
! Angioedema: Is a wheal which extends into the
Fig. 2.10. Urticaria: evanescent elevated lesion lasting
subcutaneous tissue and lasts >48 h. Most fre-
48–72 hours. A: edematous evanescent lesions. B: linear
quently occurs at the mucocutaneous junctions.
wheals called dermographic urticaria.
Lesions Due to Extravasation of Blood is pressed on the lesion (diascopy), the ery-
! Purpura : Erythematous macule due to thema persists. Lesions <0.5 cm are called
extravasation of RBCs into dermis. Lesion is petechiae and >0.5 cm are called ecchymosis
not blanchable—meaning that if a glass slide (Fig. 2.11).
 Chapter 2 • Diagnosis of Skin Diseases

Fig. 2.12. Telangiectasia: dilated capillaries. Seen in rosa-

cea and collagen vascular disorders.

Fig. 2.11. Purpura: erythematous macules which do not

blanch on diascopy.

! Hematoma: Is a swelling caused by extra-

vasation of blood.

Lesions Due to Dilatation of Vessels

! Telangiectasia: Visible dilatation of small blood
vessels of skin (Fig. 2.12). Characteristically seen Fig. 2.13. Poikiloderma: triad of telangiectasia, atrophy
on the face of a person chronically exposed to of skin and reticulate pigmentation.
sun, in lupus erythematosus, in dermatomyositis
(in periungual area), systemic sclerosis (mat-like present in acne vulgaris, in nevus comedonicus
telangiectasia on face) and rosacea. and in senile comedones. There are two types
! Poikiloderma: Triad of atrophy of skin, retic- of comedones:
ulate hyperpigmentation and telangiectasia # Open comedone: black head, in which the
(Fig. 2.13), seen in dermatomyositis and mycosis keratinous plug is black (Fig. 2.15A).
fungoides. # Closed comedone: white head, in which the
plug is covered by skin, so the lesion appears
Specific Lesions as a white shiny papule (Fig. 2.15B).
! Burrow: Is pathognomonic lesion of scabies.
Appears as a serpentine, thread-like, grayish (or Secondary Changes
darker) curvilinear lesion, varying in length from Secondary changes modify the primary lesions.
a few millimeters to a centimeter (Fig. 2.14).
The open end is marked by a papule. The bur-
row may be difficult to discern in dark-skinned Due to Collection of Cells/Exudate
individuals. ! Scale: Is a flake formed by collection of cells
! Comedones: Comedones are inspissated of horny layer of the skin (Fig. 2.16). Removal
plugs of keratin and sebum wedged in dilated of scales reveals a dry surface. Scales may be
pilosebaceous orifices. Comedones are typically characteristic in some diseases (Table 2.5).
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

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Table 2.5. Diagnostic significance of character of
scale
Disease Type of scale
Psoriasis Silvery, easily removable
Pityriasis versicolor Branny (fine)
Pityriasis rosea Collarette
Ichthyosis Fish-like
Pityriasis lichenoides Mica like, adherent
chronica

Fig. 2.14. Burrow: curvilinear lesion lodging the adult

female mite.

Fig. 2.16. Scales: flakes formed by collection of horny

layer; loosely attached silver scales are typical of psoria-
sis.

Fig. 2.17. Crust: yellow brown collection of keratin

and serum. Note erosions from where crusts have been
removed.

B
brown (sometimes hemorrhagic) in color. Removal
Fig. 2.15. Comedone is an inspissated plug of keratin
of crust reveals a moist surface (Fig. 2.17).
and sebum wedged in a dilated pilosebaceous orifice. A:
open comedones have black keratinous plugs. B: closed
comedones appear as white, shiny papules. Due to Loss of Continuity of Skin
! Erosion: Due to complete or partial loss of via-
! Crust: Is a collection of dead epidermal cells, dried ble epidermis (Fig. 2.18) with no (or minimal)
serum and sometimes dried blood. It is yellow to loss of the dermis (cf., ulcer).
 Chapter 2 • Diagnosis of Skin Diseases

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A B C D
e

d
Mouth

Fig. 2.18. Diagrammatic representation of erosion (A),

ulcer (B), fissure (C) and sinus (D). e, epidermis; d, dermis.
Fig. 2.20. Sinus: the mouth of this sinus is undermined
indicating a tubercular etiology.

e e
e
d d
d
A B C

Fig. 2.21. A: normal skin. B: epidermal atrophy. C: dermal

atrophy. e, epidermis; d, dermis.

A
! Sinus: Is a blind track in skin; opening of the
sinus (mouth) should be examined as it may
give a clue to diagnosis, e.g., mouth of tuber-
cular sinus is undermined and hyperpigmented
(Fig. 2.20). Always look for the attachment of
sinus to the underlying tissues.

Miscellaneous Changes
! Atrophy (Fig. 2.21): Thinning of skin and could
be due to atrophy of the epidermis, dermis or
subcutaneous tissue.
B # Epidermal atrophy: it manifests as thin, shiny
skin, which may crinkle like cigarette paper
Fig. 2.19. A: Erosion: due to complete or partial loss and may show loss of surface markings, e.g.,
of viable epidermis with no loss of the dermis. B: Ulcer: in leprosy. In pure epidermal atrophy, the
destruction of the epidermis and at least the upper (papil- skin is not depressed because the mass of
lary) dermis. epidermis is small as compared to that of
dermis (Fig. 2.21B).
! Ulcer (Fig. 2.19): Loss of epidermis and at least
# Dermal atrophy: clinically manifests as an
upper (papillary) dermis, though sometimes area of depressed skin and it may be possible
ulcer may extend into the deeper tissues. A to invaginate a finger in the depressed skin
complete description of ulcer should include its (Fig. 2.21C).
site, shape, size, surface (floor) and surround-
ing skin (the five s’s) and the two b’s, base and ! Lichenification: Lichenification is the response
border (edge). of the skin to repeated scratching and is typical-
! Fissure : Is a slit in the epidermis. ly seen in lichen simplex chronicus and atopic
! Excoriation: Is linear erosion or an ulcer, dermatitis. It manifests as (Fig. 2.22):
formed when skin is scratched. # Thickening of the skin.
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

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Table 2.6. Differences between epidermal pigmen-
tation and dermal pigmentation

Epidermal Dermal
Brown Slate gray
Enhanced by Wood’s lamp5 Not enhanced
Due to an increased number of Due to the presence of melano-
melanocytes or increased mela- cytes or increased melanin in
nin synthesis in epidermis dermis

tion/depigmentation). Increased pigmentation

could be epidermal or dermal (Figs. 2.24A and
B, Table 2.6).
Fig. 2.22. Lichenification: thickening and hyperpigmen-
tation of skin with increased skin marking. Further Description of Lesions
Sharpness of Lesions
! Are the macules and plaques well-defined or
ill-defined?
! Are the nodules well-defined? Deep-seated nod-
ules (papules) appear ill-defined while superfi-
cial ones appear well-defined.

Shape/Configuration of Lesions
! Papules and nodules: Can have a variety of
shapes (Table 2.7) and this may help in the
diagnosis.
! Plaques: Can have different configuration
(Table 2.8) and this may help in diagnosis.

Fig. 2.23. Scars: depressed scar after pyoderma on the Arrangement of Lesions
nose.
An important clue to the diagnosis of skin diseases
# Hyperpigmentation. is the arrangement of lesions (Table 2.9).
# Increased skin markings.
! Scar: In scar, normal structures of skin are
Sites of Predilection
replaced by fibrous tissue, which is not laid in ! Distribution of lesions is an important clue to
an organized fashion. The normal skin mark- diagnosis (Table 2.10, Fig. 2.25). Remember,
ings are hence lost in a scar (Fig. 2.23). Scars it is not only the areas of involvement but also
are of two types: the areas, which are spared that indicate diag-
# Atrophic scars: characterized by loss of tis- nosis.
sue. ! The distribution of skin lesions depends on sev-
# Hypertrophic scars: characterized by increase eral factors:
in fibrous tissue. # Exposure to triggers: in contact dermatitis,
! Sclerosis: Is diffuse or circumscribed indura- the “rash” is limited to the sites of contact
tion of dermis/subcutaneous tissue, e.g., lichen and in photodermatoses to photoexposed
sclerosus et atrophicus. sites.
! Changes in skin color: Skin color can be darker # Regional variations: acne is predominantly
(hyperpigmentation) or lighter (hypopigmenta- localized to areas rich in sebaceous glands,

5. Wood’s lamp: device which emits ultraviolet rays of wavelength 360 nm.
 Chapter 2 • Diagnosis of Skin Diseases

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Table 2.7. Vertical profile of skin lesions
Shape Example
Dome shaped Trichoepithelioma

Flat topped Plane warts

Umbilicated Molluscum contagiosum

Acuminate Condyloma acuminata

Verrucous Verruca vulgaris

Pedunculated Skin tags

Table 2.8. Horizontal profile of skin lesions

Configuration Example
A Nummular (discoid) Nummular dermatitis
Psoriasis
Annular Tinea corporis
Borderline leprosy
Psoriasis
Circinate/polycyclic Herpes simplex

Arcuate (arciform) Granuloma annulare

Retiform (reticulate) Lichen amyloidosis

Table 2.9. Arrangement of skin lesions

Arrangement Example
Grouped Herpes simplex
Linear Verrucous epidermal nevus
Dermatomal Herpes zoster
Arcuate Granuloma annulare

B Investigations

Fig. 2.24. Pigmentation: A: epidermal pigmentation is Simple but Necessary Tools

brown. B: dermal pigmentation is slate gray.
Magnifying Lens
A magnifying lens amplifies subtle changes in the
while diseases of apocrine glands are local-
skin. A 5× or 10× convex lens produces optimum
ized to axillae and pubic region.
magnification.
# Variations in blood supply: e.g., vasculitic
lesions on legs, stasis dermatitis on legs. Glass Slides
# Variations in thickness of horny layer: thin
skin of eyelids is more susceptible to devel- Glass slides are used for diascopy (pressing the
oping contact dermatitis than palms and lesion with a glass slide to blanch the lesion).
soles because horny layer is thin on the lids. Diascopy is useful in the following situations:
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

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Seborrheic dermatitis,
psoriasis, tinea capitis Macules: Chloasma, freckles, leprosy.
Papulopustules: Acne, rosacea
Xanthelasma

Herpes labialis Nodules: Basal cell carcinoma,

Squamous cell carcinoma
Acanthosis nigricans Plaques: Discoid lupus erythematous
Seborrheic keratosis
Skin tags

Seborrheic dermatitis

Cherry angioma

Atopic dermatitis

Ichthyosis vulgaris Psoriasis

T. manuum,
psoriasis
Scabies
Eczematous dermatitis

Tinea cruris Tinea unguium

Candidiasis
Psoriasis

Atopic dermatitis
Sexually transmitted
diseases
Psoriasis

Ichthyosis vulgaris

Stasis dermatitis
Stasis ulcer Tinea pedis
Tinea unguium

Fig. 2.25. Sites of predilection of common skin diseases.

Table 2.10. Distribution of skin lesions ! To differentiate purpuric lesions (due to

Diseases Distribution extravasation of blood) from erythema (due to
Acne
vasodilatation). Erythema blanches on diascopy
Face, upper trunk, deltoid region
while purpura does not.
Photodermatitis Face, V of neck, dorsolateral aspect of fore-
arms; sparing of covered parts ! In granulomatous lesions to appreciate the
true color of the lesion, e.g., in lupus vulgaris,
Seborrheic Scalp, nasolabial folds, front of the chest,
dermatitis
blanching reveals apple jelly nodules.
axillae, groins
Airborne contact Face, especially eye lids, retroauricular
dermatitis region, cubital fossae Wood’s Lamp
Scabies Webs of fingers, ulnar aspect of forearm,
Wood’s lamp is a device which emits ultraviolet
lower trunk, genitalia; sparing of face in
adults rays (wavelength, 360 nm).
 Chapter 2 • Diagnosis of Skin Diseases

15
Uses Table 2.11. Specimens for potassium hydroxide
! Disorders of pigmentation: Wood’s lamp preparation
enhances epidermal pigmentation but not der- Disease suspected Specimen
mal pigmentation and so can be used to: Tinea corporis Scales/roof of vesicles
# Differentiate epidermal from dermal pigmen-
Tinea cruris Scales/roof of vesicles
tation.
Tinea capitis Plucked hair, scales
# Enhance subtle hypopigmented lesions, e.g.,
ash leaf macule of tuberous sclerosis. Onychomycosis Nail clippings, subungual debris
! Infections: Fluorescence of different colors is Pityriasis versicolor Scales
emitted on exposure to Wood’s lamp. Candidiasis Contents of pustule, vaginal discharge
# Tinea capitis : green
# Pityriasis versicolor : yellow
Method
# Erythrasma : coral pink
! If the burrow is identified, the mite appears
Dermoscopy as a black (gray) dot at the end of the burrow
under a magnifying lens. If the burrow is not
! Uses a hand lens (magnification 10× or 30×) visible, doubtful papules are used to collect
with in-built light. Surface reflection is elemi- the sample.
nated by covering lesion with mineral oil or ! The dot/papule is vigorously scraped with a ster-
water. ile scalpel blade on which a drop of mineral oil
! Helps in noninvasive inspection of dermoepi- has been applied till the whole dot/papule has
dermal junction. been picked up and tiny flecks of blood appear
! Useful in differentiating benign from malignant in the oil. The oil is transferred on to a glass slide
lesions. and examined under a microscope for mite, eggs
and feces.
Some Important Investigations
! Mites have four pairs of legs.
Certain tests are easy to perform and aid substan-
tially in the diagnosis of a dermatologic disease. Tzanck Smear
Potassium Hydroxide Mount ! Is cytological examination of skin blisters.
! After rupturing roof of the blister, the floor is
This simple bedside test should always be done, if scraped with a surgical blade and material trans-
a fungal infection is suspected. ferred on to a microscopic slide and fixed.
Specimens to be taken (Table 2.11)
Method
! Skin sample is put on a glass slide and an
aqueous solution of 20% potassium hydroxide6
is added before applying the cover slip.
! After 20–30 min (60–90 min in case of nail clip-
pings), mount is examined under microscope
with condenser lens lowered to enhance con-
trast.
! Fungal hyphae/pseudohyphae/spores are looked
for (Fig. 2.26).

Scrapings for Scabies Mite Fig. 2.26. Potassium hydroxide mount for fungal hyphae:
Though presence of a burrow is diagnostic of sca- hyphae appear as septate tube-like structures while
bies, burrows may not be visible in many patients. pseudohyphae are elongated sausage shaped.

6. Potassium hydroxide: used to remove keratin.

 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

16
! The slides are stained with Giemsa stain, ! If these are not known, a standard battery9 of
Wright’s stain or toluidine blue and examined antigens can be used.
under the microscope (Table 2.12, Fig. 2.27).
Method
Patch Test ! Antigens are used in standardized dilutions and
are applied to the back under occlusion.10
Patch test detects antigens (allergens) responsible ! The patches are removed after 48 h and the
for type IV allergy, as in allergic contact dermati- site on which the antigens had been applied is
tis. marked (Fig. 2.28).
! Areas are inspected after ½–1 h and then at 96 h
Antigens (to detect delayed reactions), if necessary.
! Suspected antigens as well as antigens, which
are likely to be used as substitutes are tested. Reading
Reaction in the form of erythema, edema, pap-
ulation and vesiculation is noted. (Fig. 2.28).
Table 2.12. Role of Tzanck smear in the diagnosis
Depending on the degree of inflammation, the
of blistering diseases
reaction is graded from 0 to 3+ (Table 2.13).
Microscopic finding Diagnosis
7
Acantholytic cells Pemphigus Table 2.13. Interpretation of patch tests
Multinucleated giant cells8 Herpes simplex, herpes zoster, Clinical findings Grading
varicella No reaction Normal skin 0
Doubtful reaction Minimal macular ery- ?
thema
Weak reaction Erythema and edema 1+
Strong reaction Erythema, papules, 2+
edema, vesicles
Extreme reaction Erythema, papules, 3+
and bullae
Irritant reaction Cauterization IR

B
Fig. 2.27. Tzanck smear. A: showing acantholytic cells. Fig. 2.28. Patch testing: confirms the cause of allergic
B: showing multinucleated giant cells. dermatitis.

7. Acantholytic cells: rounded keratinocytes with a perinuclear halo.

8. Multinucleated giant cells: large epithelial cells with 10–12 nuclei.
9. Standard battery: this contains common antigens to which a patient is likely to be exposed and different batteries are used in dif-
ferent geographic areas.
10. Occlusion: encourages penetration of allergens.
 Chapter 2 • Diagnosis of Skin Diseases

17
It is not necessary that the antigen which has Processing of skin biopsy
been tested positive in patch test is the cause of
Skin biopsy can be sent for:
current episode of dermatitis, so results of patch
test should be interpreted keeping the clinical pic- ! Routine hematoxylin and eosin (H and E)
ture in mind. staining.
! Special stains (Table 2.15) for various tissues
Photopatch Test (collagen and elastic fibers) to identify dif-
ferent organisms (mycobacteria, fungi), and
Photopatch test is done to find cause of photo- deposits.
allergic contact dermatitis. ! Special procedures like immunofluorescence
Method and electron microscopy.
! Culture, if an infectious etiology is suspected.
Antigens are applied (as in routine patch testing)
but in duplicate. At 24 h, one set of patches is Precautions while taking a skin biopsy
irradiated with UVA and covered again. Both sets ! Biopsy a “new” lesion and the active edge of a
are then read at 48 h. progressing lesion.
Interpretation ! Avoid legs (slow healing), upper trunk (tendency
Photoallergic contact dermatitis, if present, mani- to keloid formation), exposed parts (cosmetic
fests at 48 h. The negative control patch which objections), and bony prominences (infection).
! Do not crush the tissue.
has not been irradiated rules out allergic contact
! Place in proper fixative: formalin (for light
dermatitis (Table 2.14).
microscopy), glutaraldehyde (for electron
Skin Biopsy microscopy) or immunofluorescence fluid (for
immunofluorescence) and if the sample is
Skin biopsy is a very useful diagnostic tool in der- being sent for culture, send in normal saline.
matology. ! Label samples correctly (patient’s name, age,
sex, hospital record number). Fill in the rel-
Technique of taking biopsy evant details in the biopsy form.
! Depending on the size of tissue needed, there
are two common techniques of taking skin
biopsy: Table 2.15. Stains used in dermatology
# Punch biopsy: used for the superficial
Stain Color
lesions.
# Scalpel biopsy: used for deeper lesions, e.g., Skin components
those involving subcutaneous tissue. ! Collagen Masson’s trichrome Green
! Both techniques generally require local anes- Verhoeff–van Gieson Red
thesia. ! Elastic fibers Verhoeff–van Gieson Black
! Mast cell granules Toluidine blue Purple

Table 2.14. Interpretation of photopatch test Organisms

! Mycobacteria Fite stain Pink
Reading at Reading at site Interpretation
unexposed site exposed to UVA ! Fungi PAS11 Red
– – No allergy Deposits
– ++ Photocontact allergy ! Glycogen PAS Red
++ ++ Contact allergy ! Acid mucopoly- Toluidine blue Blue
saccharides Alcian blue
+ +++ Contact allergy with
photoaggravation ! Amyloid Congo red Orange pink12

11. PAS: periodic acid schiff.

12. Amyloid: gives orange pink color with congo red with apple green birefringence.
 Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases

18
Intradermal Tests ! Serological tests for syphilis.
! Serological tests for HIV infection.
The following tests are useful in dermatological ! Serological tests for collagen vascular disor-
settings: ders, e.g., antinuclear antibody.
! Tuberculin test. ! Serological tests in bullous disorders, e.g., des-
! Lepromin test. moglein levels in pemphigus.

Serological Tests
The following serological tests are frequently
done: