8.

THE SKIN
DISEASES

AND

SEXUALLY

TRANSMITTED

Examination of the skin is important for local ailments; however skin is also the
first or an important place for diagnosing the systemic illness.
Like any other system, thorough systemic inquiry and meticulous examination,
including systemic examination are needed to get the full picture.

HISTORY:
Age:
Bacterial infections e.g., impetigo contagiosa and pyoderma scalp, fungal
infection of scalp, infantile eczema and papular urticaria are more
common in childhood.
Measles, chicken pox are more common in childhood. Hopefully with
increased awareness about vaccination, these diseases will disappear
altogether like small pox.
Acne vulgaris appears in adolescence whereas skin carcinoma occurs
more commonly in old age.
Skin rashes of Lupus Erythematosis and pyoderma gangrenosum
associated with Crohns disease are more common in young women.
Senile warts, as the name would suggest, are more common in elderly.
Sex:
Collagen diseases and fungal infections are more common in women
under the breasts and in groin area.
Hand eczema due to frequent use of soap and household cleaning agents
is more commonly seen in females.
Sycosis barbae and male pattern alopecia are more common with males.
Race:
Mongolian spots is extremely frequent in Mongoloids
Pemphigus is common in Jews.
Residence:
Post kala-azar dermal leishmaniasis is common in Assam, Orissa and
Bengal.
Filariasis is more common in coastal area and more common in coastal
area of Jamnagar District in Gujarat, India.
Basal cell carcinoma is more common in white population of Australia.
Chilblains are more common in very cold area of the world.
Fungal infections are more common in hot and humid atmosphere found in
tropics.
Occupation:

Contact irritant dermatitis (by certain chemicals) and contact allergic

dermatitis (cement, rubber, colour chemicals etc.) are seen in persons
having direct contact with the offending material during their job.
Cutaneous form of Brucellosis is more common in abattoir workers.

Social factors:
Contagious diseases like scabies are more common with congested living
and in persons with poor hygiene.
Drug history:
Any eruption after starting a new drug is due to drug itself, unless proved
otherwise.
Drugs can mimic any type of skin manifestation.
Habits:
Personal habits of using cosmetics (cream and lotion), perfumes or hair-oil
might be helpful in the diagnosis of contact allergic dermatitis and
pigmentary disturbances on the face.
History of exposure:
Patients suspected of having sexually transmitted disease should be inquired
about the heterosexual contact with other partner or, in male, about the
history of homosexual contact.
Menstrual history:
In females menstrual history is important e.g., acne vulgaris may get
worsened in premenstrual phase. Certain diseases are peculiar to pregnancy
and they occur only in pregnancy. They are prurigo of pregnancy, impetigo
herpetiformis and herpes gestationis.
Past history:
This is important as it can lead you to the diagnosis.
Of similar illness
Allergy
Drug reaction
Illness like inflammatory bowel disease, tuberculosis, porphyria, Kala-azar,
which manifest with skin lesions.
Diseases like diabetes could predispose to recurrent skin infections.
Family history:
Certain skin diseases tend to be familial e.g., male pattern alopecia, icthyosis,
epidermolysis bullosa are seen in families.
History of atopy (bronchial asthma, hay fever, eczema) is important in the
diagnosis of atopic eczema.
Certain diseases are contagious and they affect the other family members
also e.g., scabies, fungal infection. Leprosy can also affect the family
members.
Diabetes is genetically transmitted; so its recognition helps in management
of recurrent boils and fungal infections, and balanoposthitis in males.

History of STD, either in a married partner or in known contact, is of

importance for successful treatment.

Some of the common Dermatological diseases, their

symptoms, signs and evaluation.
Symptoms:
Itching is the most common complaint by the patient suffering from skin
diseases. If itching is absent, it is of importance, as seen in syphilitic skin
eruptions.
Dryness is another important complaint especially in winter months.
Patients with eczema may also complain of dryness of skin.
Pain and
burning,
followed
by vesicular eruptions,
is
characteristically seen in herpes zoster.
Tingling and numbness are present in peripheral neuropathy.
Progression of the lesion:
Acute onset is seen in urticaria, herpes zoster, cutaneous drug reactions
and contact dermatitis.
Gradual onset is seen with tuberculosis of skin and leprosy.
Some skin diseases have peculiar course e.g., herpes zoster and Pityriasis
rosea. They come up suddenly and have a protracted course for about 3
to 4 weeks and then they disappear of their own in due course of time.
Longstanding skin symptoms suggest allergic or tubercular etiology.
Remissions and relapses are seen in psoriasis, eczema, and pyoderma
gangrenosum or erythema nodosum. In the last two, they reflect the
disease activity.
Seasonal exacerbation of the disease is seen in Psoriasis, ichthyosis and
fissures in the soles particularly in winter months.
Bacterial infection, sweat retention syndrome (miliaria) are seen in
summer months.
Fungus infections are particularly prevalent in summer and monsoon
season, whereas Pityriasis rosea occurs in spring.
Fixed drug eruptions come at the same place on exposure to the same
drug.

Various types of skin lesions:

(A) Primary lesions:

Macule:

A macule is a change in epidermis color, without elevation or

depression and, therefore, nonpalpable, well or ill-defined
By convention it is less than ten millimeters in diameter at the widest
point.
It may be of any color, white, blue, or red for example.
It could be the result of hyperpigmentation, hypopigmentation,
vascular abnormalities, capillary dilatation (erythema), or purpura.
Some well known examples are vitiligo, melasma, and junctional nevi.

Patch:
A macular lesion more than 1 cm. in diameter.
The cafe au lait spot of neurofibromatosis results from increased
epidermal melanin.
Papule:
A papule is a circumscribed, solid elevation of skin with no visible fluid,
varying in size from a pinhead to 1 cm.
They can be brown, purple, pink or red in color. The papules may open
when scratched and become infected and crusty.
Papules are palpable because there is accumulation of material in the
dermis (A and B) which gives additional substance to the skin. The
accumulated material may be a metabolic deposit, amyloid or mucin, for
example (A), or a cellular infiltrate of inflammatory or neoplastic cells. (B)
Often the lesion's substance arises from proliferation of cells in one or
more layers of the epidermis (C).

Papules due to dermal metabolic deposits or cellular infiltrates tend to

have indistinct margins, whereas those due primarily to epidermal hyper
proliferation tend to have very well-demarcated margins.
When the papule itself consists of tightly packed individual small
hyperkeratotic tiny papules, the lesion is said to be verrucous or warty or
vegetating.
Commonly occurring diseases with papules are chickenpox which is
derived from the varicella zoster virus. Lichen planus is a skin disease
which forms angular, purple papules.

Nodule:
Papule of more than 1 cm. diameter is known as nodule.

A nodule is a solid, deep-seated mass located in the dermis of subcutaneous tissue which
produces an elevation on the skin surface. Nodules are often described as "marble-like."

Inflammatory processes, such as acne, can produce nodules.

Nodules can also be neoplasms such as basal or squamous cell carcinomas.

Large nodules are often called tumors. Skin tumors may be benign or malignant.

Common conditions are; Leprosy, xanthomata.

Vesicle (Blister):
A fluid-filled sac in the outer layer of skin. It can be caused by rubbing,
heat, or diseases of the skin. Also called blister.
It is a circumscribed elevated lesion of the skin containing clear fluid
inside, which is less than 1 cm. in diameter. Examples: Herpes zoster,
contact dermatitis, chickenpox.

Bulla:
Vesicle more than 1 cm. in diameter is known as bulla.
Common diseases are Pemphigus, pemphigoid, bullous impetigo.

Pustule:
A vesicle containing pus inside is called a pustule.
Common conditions are; Folliculitis, pustular psoriasis, candidiasis.

Plaque:
Circumscribed, flat solid elevated lesion of the skin more than 1 cm. in
diameter.
Plaques are formed either by extension or coalescence of papules.
Common skin conditions with plaques are; Psoriasis, lichen planus.

Purpura:
Deposition of blood pigment due to bleeding into the skin.
Petechiae are pinpoint reddish macules which do not fade out on pressure.
Common causes are thrombocytopenia of any cause, Hanoch-Schonlein
purpura, Allergic drug reactions, and allergic vasculitis.
Ecchymoses:
Lesion like petechiae but much larger in size
These are most commonly seen in elderly people who are on steroids.
Also seen in traumatic lesion of skin.
Erythema:
Circumscribed pinkish discoloration of the skin, which fades out on
pressure.
It is due to dilatation of cutaneous blood vessels.
Drug eruptions (generalized) and contact with chemical irritants
(localized).
Wheal:
Evanescent pinkish papules and plaques that blanch on pressure, which
come up in various shapes and sizes, rapidly clearing without leaving any
marks.
Urticaria, insect bites are the two most common causes.
Cyst:
It is a nodule which is filled with expressible material either liquid or
semisolid. Its cavity is lined by an epithelium.
Sebaceous cyst, Cystic acne are the two very familiar causes.

(B) Secondary lesions:

These lesions signify change either in primary lesions or may appear as a

complication.
Crust:
It is a dried discharge containing either serum or pus.
Scale:
Scales simply represent visible thickened stratum corneum.
It is due to either no loss or overproduction of stratum corneum.
Common conditions with scales are; Psoriasis (silvery white and dry),
seborrhoeic dermatitis (yellow and greasy), lupus erythemalosus
(adherent).
Atrophy:
Atrophy results from loss of tissue.
Both the epidermis and dermis can be involved.
Epidermal atrophy results in alteration in the surface appearance, whereas
atrophy of much thicker dermal layer results in clinically detectable
depression in the skin.
Common conditions Lichen sclerosus et atrophicus, striae, lupus
erythematosus.
Scar:
A scar is the visible alteration in appearance of the skin following the
repair of an injury in which fibrosis replaces the normal arrangement of
collagen.
Common conditions are Postoperative scars, hypertrophic scars or keloid,
atrophic scar-acne.
Fissure:
A linear defect that extends from the skin surface into the dermis.
Common example is Hyperkeratosis with fissuring on sole.
Ulcer:
It is a breach in the continuity of skin or mucous membrane due to
molecular death of the covering epithelium.
Diabetic ulcer, Ecthyma, vascular ulcers are common examples..

(C) Special diagnostic lesions:

Burrow: A tunnel made into the stratum corneum by a parasite or its

larva. Classic example is Scabies.
Comedone: A papule with a black head. Example: Acne vulgaris.
Telangiectasia: Permanent superficial dilatation of cutaneous blood
vessels, seen as a congenital malformation or in collagen diseases like
discoid lupus erythematosus.

Method of Examination of skin:

Always examine in a good light, preferably daylight.

Ideally the entire skin should be examined in every patient; especially the
diagnosis is in doubt.
In a case where a systemic illness is considered, for example
Crohns disease in a case of pyoderma gangrenosum, or a
metastatic nodule from carcinoma of lung, then appropriate
examination may give you credit.
The oral mucous membrane should be examined routinely.
In conditions where definite correlation is suspected, examination of skin
appendages like hairs and nails should always be done.
In suspected cases of leprosy different superficial nerves should be
examined by palpation for enlargement and tenderness.

The physical examination includes inspection and palpation, of which inspection

is the more important aspect of examination by which one can diagnose so many
conditions of skin.

(A) Inspection: It is carried out in the following manner:

(1) Type of the lesion: As described earlier in primary and secondary
lesions, the type of the lesion present on the patient's skin should be
described and try to correlate it with provisional diagnosis.
(2) The shape and pattern of the lesion:
(a) Linear lesions: Many dermatoses like Lichen striatus, linear
contact dermatitis, epidermal nevi, etc. occur in linear forms
(b) Annular lesions: Many lesions occur in an annular configuration
which in some conditions is so characteristic as to be of value in
diagnosis. Some common conditions are; Erythema multiforme,
Pityriasis rosea, leprosy, secondary syphilis, annular lichen planus
(c) Grouped lesions: Lesions are seen in different groups. Herpes
zoster and herpes simplex are good examples.
(3) The distribution of the lesion: The distribution of the lesions in many
common dermatoses is so characteristic that it is of great assistance in
clinical diagnosis. Examples:
(a) Scabies: Interdigital spaces, flexor aspect of the wrist, axillae,
nipple, lower abdomen, genitals, thighs and buttocks;
(b) Seborrheic dermatitis: Scalp, ears, eyebrows, beard region,
nasolabial fold, axilla, front of chest, back, groins;
(c) Pityriasis rosea: Trunk, base of the neck, upper third of arms and
legs. The long axes of the lesions characteristically follow the lines of
cleavage, lying parallel to the ribs in a "Christmas Tree" pattern,

(d) Acne vulgaris: Face, sternal area, shoulders and upper part of the
back.
(e) Herpes Zoster: It occurs in a dermatome distribution and always
stops in midline, as any nerve supplies only half f the body.
Conversely, any lesion which stops in midline has to be Herpes
Zoster.
(f) Herpes Simplex: Typical affects perioral area or perilabial
area.
The Koebner or isomorphic phenomenon:
The Koebner phenomenon is the induction by and at the site of nonspecific
trauma of skin, changes of a type spontaneously, present elsewhere. Examples:
Lichen planus, psoriasis, warts, etc.
(B) Palpation:
It is useful to divide the consistency of the lesion and whether the border
is active (raised) or not.
Atrophy in centre can be detected by palpation.
Skin surface may be palpated for the difference in temperature. It is warm
in cellulitis and cold in gangrene or Raynaud's disease.
Lymph glands are palpated in STD cases.
In suspected leprosy, palpation of superficial nerves, e.g. greater
auricular, ulnar, lateral popliteal, etc. is done for enlargement or
tenderness.
(C) Magnifying glass/ Lens examination:
If you are asked skin cases, it is always useful to carry a magnifying glass.
Examination of minute skin lesions with magnifying lens gives correct idea
about the type of lesion present It is particularly useful to detect the
burrows of scabies, or to visualize the "exclamation-mark hairs" in case of
alopecia areata.
(D) Diascopic examination:

It is of utmost importance in diagnosis of certain skin lesions. Use of a glass

slide will demonstrate whether a lesion does (erythema) or does not
(purpura) fade on pressure. In lupus vulgaris, apple-jelly nodules are seen
on diascopic examination.

(E) Testing for thermal and painful stimuli:

Thermal sensations are tested by taking hot and cold water in different test
lubes.
This is generally not available in routine practice; hence a cold tuning fork
for cold sensation and a torch which is left on for a while, for hot sensation
may be used.
Thermal sensations are lost first in leprosy and pain later on; so loss of
thermal and pain sensations is of great value in diagnosis of leprosy.

The General Examination:

The extent and character of general physical examination will be influenced by

the evolution of the history and the cutaneous findings and by other
circumstances. If there are any indications of systemic disease, a full systemic
examination is essential.

Common Skin Diseases:

1. Pyoderma: Any purulent infection of the skin is called pyoderma.
Depending upon the characteristics, different specific conditions are defined.

(i) Impetigo: It is a contagious superficial bacterial infection of skin. It is

common in children, and face is the frequently affected area. It is
characterized by thin-walled vesicles or large bullae containing pus which
rupture easily and secretions dry up to form crusts.
(ii) Sycosis barbae: It is a subacute or chronic pyogenic infection involving
the whole depth of the hair follicle on the beard region. The essential lesion is
an edematous, red follicular papule, or pustule, centered by a hair.
Occasionally nodule and abscess formation is seen. Infection is acquired
through infected razors or poorly cleaned razors.
(iii) Furuncle: It is an acute, usually necrotic infection of hair follicle
characterized by a small follicular inflammatory nodule, soon becoming
pustular and painful
.

(IV) Carbuncle:
A painful localized bacterial infection of the skin and subcutaneous tissue
that usually has several openings through which pus is discharged.
The carbuncle may be small to as large as a table tennis ball.
It is made up of several skin boils. The infected mass is filled with fluid, pus,
and dead tissue.
It is usually caused by S. aureus.
It may develop anywhere, but they are most common on the back and the
nape of the neck and back.
Men get carbuncles more often than women.
Friction from clothing or shaving, poor hygiene and immunocompromized
status favors development of carbuncle.
It may be red and tender to touch.

Appearance is characteristic, but if in doubt, a magnifying lens may settle

the issue.

(v) Others: include superficial folliculitis and ecthyma.

2. Scabies:

A highly contagious disease of skin caused by parasite, Sarcoptes scabiei

hominis.
The pathognomonic lesions are the burrows which appear as grey or skincolored ridges, 5-15 mm. long and often curved or S-shaped which can be
seen by hand lens.
It is characterized by severe itching, more at night.
Only the burrows and vesicles are directly associated with the presence of
mite.
Secondary infection may occur.
It is most often seen at interdigital spaces, flexor surface of wrist, axillae,
nipples, lower abdomen, genitals, thighs and buttocks.
In adults face and scalp are exempted, but in infants they are also present
on palms, soles and face. In majority of cases other family members are
also affected.

3. Fungal infections of skin:

They are common in hot and humid climate.

Obesity and diabetes mellitus are the predisposing factors.
It is mildly contagious, so other family members may be affected. Different
types of fungal infections occurring in skin are as follows:

(i) Ringworm or Superficial fungal infections of the skin. The activity of

this type of fungus is restricted to dead keratinized tissues, the stratum corneum
of the skin, hair and nail. Depending upon the sites involved, they are
designated as:
(a) Tinea capitis: Scalp, eyebrows and eyelashes are affected. Hair is
invaded by fungus. The cardinal feature is scaly patches with partial hair-loss,

producing alopecia. Occasionally, in variety known as kerion, inflammatory

nodular lesions studded with pustules are seen.

(b) Tinea barbae: It affects the beard area, characterized by circular,

reddish, annular lesions but, when acute, presents as pustular folliculitis and
appears like kerion.
(c) Tinea corporis: Ringworm of the glabrous skin. It affects the trunk and
limbs and non-hairy parts of face. Clinically typical annular, erythematous
patches with scaling, central clearing and active well-defined raised border,
studded with vesicles associated with itching are seen.

(d) Tinea cruris or Dhobie's itch: Ringworm of the groins characterized by

reddish patch with scaling and sharply defined border, associated with
itching. This lesion is extremely common in women in India because of
pattern of clothing that the women wear and extreme humidity.
(e) Tinea pedis (athlete's foot): It involves interdigital spaces, especially
between 3rd and 4th and 4th and 5th toes and may extend on the
undersurface of the foot.
(f) Tinea manuum: Ringworm of the hand.

(g) Tinea of the nails (Tinea unguium): The nails are yellow in colour, are
either completely destroyed or give a powdery appearance. Usually one nail
is normal out of 10 fingers' nails, even in chronic infection.
(ii) Candidiasis (Moniliasis):

It is an acute or subacute infection caused by the yeast-like fungus,

Candida albicans.
The most common cutaneous manifestation is interirigo with weeping
reddish lesions affecting the depth of the folds under the breasts, in the

groins, perianal area and toe spaces, studded with satellite pustules at the
border.
In females it causes vulvovaginitis.
Paronychia of monilial origin is seen as swelling around the nails in people
who are constantly exposed to excess water and soap.
Mucosal candidiasis affects mouth, vagina in female; and as
balanoposthitis in males. Diabetes should always be excluded in patient
with moniliasis.

(iii) Tinea versicolor: A mild chronic symptomless fungus infection of the

stratum corneum caused by the yeast-like Malassezia furfur which results in
the production of hypopigmented, mild scaly lesions on the chest, back,
shoulders, neck and arms.

4. Eczema:

It is a distinctive pattern of inflammatory response of the skin, induced by a

wide range of external and internal factors acting singly or in combination.
It is characterized clinically by clustered papulovesicles. The terms 'dermatitis
and 'eczema' are usually regarded as synonymous.
Acute stage of eczema is clinically characterized by erythema, oozing and
crusting whereas chronic stage by lichenification (thickening of the skin,
scaling, pigmentation and exaggeration or normal skin markings); and
subacute stage shows combination of both.
Eczemas are classified into exogenous and endogenous.

(1) Exogenous eczemas: Basically they are caused by the contact of skin with
external substance. They include:
(2) Contact irritant dermatitis: It is a response of skin to direct physical or
chemical injury. Soap or household cleaning agents are mainly responsible in
women. Clinically there is erythema and vesiculation.
(3) Contact allergic dermatitis: A response of the skin due to contact with
substances to which it is allergic. Examples: Cosmetic, necklace, wrist watch
strap, clothes, ear-rings and local applications like local antibiotics,
antiseptics and local anesthetics.
(c) Infectious eczematoid dermatitis: It occurs in response to certain microorganisms or their products. It results from a localised sensitization to the
exudates from an abscess, sinus or any discharging surface e.g. otitis media
causing pus discharge from ear.
(B) Endogenous eczemas: Constitutional factors play a major role in its
occurrence, and may be genetically determined. They include:
(1) Atopic eczema:
It is a chronic fluctuating disease which may occur at any age. The
distribution and morphology of the lesions vary with age but itching is
the cardinal symptom.
There is a family history of atopy.
Infantile phase: Starts between age of 2 and 6 months. Reddish, oozing
and crusted eruption develops on face and gradually spreads on trunk
and limbs.
Childhood phase: From age of 18 months onwards. The sites most
characteristically involved are the elbow and knee flexures, sides of
neck, wrists and ankles.
In adult phase picture is similar to that in later childhood with lichenification, especially in flexures and hands.
The condition waxes and wanes in between and has a tendency to
disappear spontaneously.
(2)Seborrheic eczema:
It is characterized by scaling and crusted lesions. Secondary infection
is a common feature. Relapses and remissions are usual.
Typical sites are involvedscalp, ears, eyebrows, nasolabial folds,
beard region, axillae, chest, back (interscapular region) and groins.

(3) Nummular eczema: The essential lesion of nummular eczema is a coinshaped plaque of closely-set papulovesicles on an erythematous base.
(4) Poiupholyx: It is an acute, recurrent or chronic vesicular eruption of the
palms and soles. It is regarded as a nonspecific pattern of reaction of palmer
and plantar skin caused by many factors, namely family history of atopy,
emotional stress, fungal infection of feet, etc.
(5)Prurigo:
It designates an intensely pruritic eruption, without any identifiable local
cause.
Prurigo simplex or papular urticaria is a chronic or recurrent eruption of
irritable papules, frequently seasonal in incidence and affecting
predominantly children between the ages of 2 and 7.
It is a reaction to insert bites or other factors.
(6) Lichen simplex chronicus or neurodermatitis:
It is a pattern of response of the skin to repeated rubbing.
Nape of the neck, ankles or legs is the common sites involved.

5. Leprosy (Hansen's disease):

It is an infectious disease caused by Mycobacterium leprae, an acid-fast

bacillus.
There are two typeslepromatous which is infectious, bacilli are present, and
non-lepromatous which is noninfectious in which bacilli are usually absent.

Lepromatous leprosy:

Lesions are multiple, bilaterally symmetrical.

Macular variety is characterized by multiple hypopigmented macules,
with ill defined edges, bilaterally symmetrical with normal sensations.
(Here is a clue: if you are shown a hypopigmented patch, it is
leprosy, unless otherwise proved).
Infiltrative variety is characterized by diffuse infiltration of the skin which
looks thickened and shiny.
Nodular variety is characterized by presence of erythematous nodules on
different parts of the body.
Diffuse infiltration of face with thickening of ears, eyebrows, nose and lips,
and presence of erythematous nodules on face leads to leonine
appearance of face. Eyebrows are also lost.

Non-lepromatous leprosy:
Lesions are few, asymmetrical. It includes:
(a) Maculoanesthetic: Few well defined hypopigmented
asymmetrical distribution, with loss of sensations.

macules with

(b) Tuberculoid: Single or multiple lesions, well defined with erythematous

raised borders. Central part is anesthetic while the peripheral area shows
diminished sensations.
(c) Polyneuritis:

Skin changes are totally absent and nerves are involved.

Greater auricular, ulnar, radial, median or lateral popliteal nerves are
affected to a variable extent. This may lead to deformities, anesthesia and
trophic changes.
Shortening and resorption of toes and fingers are common features in
these patients. Nerve involvement is a common manifestation, seen in all
other types of leprosy at a different stage with skin involvement.
Borderline leprosy is an unstable variety which shows mixed features and
consists of multiple, small, asymmetrical, annular lesions with sloping
edges.

6. Psoriasis:

A disease of unknown etiology, characterized by well defined pink or dull red

plaques, surmounted by a characteristic silvery white scaling on scalp,
elbows, knees, lower back and other parts of the body.
It is usually a chronic condition with remissions and relapses, particularly
seen in winter and usually associated with nail involvement and arthritis.
An acute form, commonly seen in children, follows upper respiratory tract
infection and breaks out into generalized symmetrical guttate erythematous
lesions with scales, known as "Guttate Psoriasis".
Chronic psoriasis is usually seen on scalp, extensor of elbows and knees,
sacral region or in other parts of the body with erythematous plaques with
typical scaling, silvery white, profuse and micaceous in arrangement.
When the scales are removed bleeding points can be visualized, Koebner's
phenomenon. (In examination, this demonstration will give you credit,
so always carry a wooden spatula with you for this purpose.)
Nail involvement is very frequent and shows either pitting, yellowish
discoloration, subungual hyperkeratosis or onycholysis.
Occasionally psoriasis is associated with joint involvement. The terminal
interphalangeal joints are commonly involved. Itching is less marked in
psoriasis. (If in a case of psoriasis, you are asked to examine hands,
look for the joint and nail involvement as above.)

7. Lichen planus:

It is characterized by Hat topped violaceous papules with intense itching

on front of wrists, the lunar region and around the ankles; mucous
membrane lesions are very common.
Etiologically viral, autoimmune and psychogenic theories are suggested
and the lesions subside within 6 to 18 months, and chronicity is observed
in hypertrophic lesions or mucous membrane lesions.
Hypertrophic variety commonly occurs on ankles.

A variety occurring on exposed area of the body, particularly on face, is

known as tropical or actinic lichen planus. Annular variety is seen mainly
on glans penis.
Lichen planus like eruptions due to drugs can be caused by chloroquine,
mepacrine, gold, arsenic, thiazide diuretics, PAS and isoniazide,
phenothiazines etc.
Mucous membrane lesions are quite common, mainly buccal mucosa, and
tongue is involved, white streaks often forming the network is highly
characteristic on buccal mucosa.
Genitalia may be involved.
Nail involvement occurs in 10% of cases only. Longitudinal ridges on the
nail plate, pterigium unguis and onycholysis are usual features.

8. Leucoderma (vitiligo):

A condition characterized by multiple depigmented macules or patches on

the skin or mucous membrane.
Hairs are usually white in depigmented patches.
In all probability it is auto-immune in nature.
Clinically it starts as small white macule with a hyperpigmented border and
usually hairs are white in that area.
(In examination if you are asked to examine the neck of a patient
with Leucoderma, presume that you will find thyroid swelling.)

Commonly asked cases:

Only a few cases are asked in examination; so be prepared.

Hanoch-Schonlein Purpura:
You will be given history that a young man has intermittent severe abdominal pain of a few days
duration and asked to examine his lower limbs or the limbs may be exposed already.

Ask about history of fever, URTI.

Purpura, arthritis and abdominal pain are the classic triad; gastrointestinal hemorrhage is a
fourth criterion.

Ask about hematuria, arthralgia or arthritis.

Ask about red jelly colored stool and abdominal pain. Pain is due to intra mural bleeding.
Look at the limbs for Purpura and since this is palpable Purpura, make all efforts to palpate the
purpuric spots and make sure they are not fading. Look elsewhere on the body for purpuric
spots. The purpura typically appears on the legs and buttocks, but may also be seen on the
arms, face and trunk.
Also examine the joints; joints mainly involved are the ankles, knees, and elbows but arthritis
in the hands and feet is possible; the arthritis is non-erosive and hence causes no permanent
deformity.
Kidney involvement is mainly in the form of hematuria.
This is purpura due to vasculitis and not due to thrombocytopenia. The platelet count may be
raised, and distinguishes it from diseases where low platelets are the cause of the purpura.

Psoriasis:
You may be asked to examine hands of a patient who is sitting with exposed lower limbs showing
psoriatic plaques or could be asked to diagnose the lesion itself.

The terminal interphalangeal joints are commonly involved. Itching is less marked in psoriasis.
Sometimes, Psoriatic arthritis resembles rheumatoid arthritis and all the features have to be
documented.
Nail involvement is very frequent and shows either pitting, yellowish discoloration, subungual
hyperkeratosis or onycholysis.
For the lesion; demonstrate the distribution elsewhere in the body and demonstrate Koebner's
phenomenon.

Erythema Nodosum:
Examination favorite! You may see a young lady or a male with legs exposed and asked to diagnose
the lesion.

Inquire about associated fever, malaise, and joint pain and inflammation.
Feel for the lesion to appreciate its nodular nature and tenderness.
The nodules may occur anywhere including the thighs, arms, trunk, face, and neck. So make
an effort to examine these parts also. The nodules are 1-10 cm in diameter, and individual

nodules may coalesce to form large areas of hardened skin.

As the nodules age, they become bluish purple, brownish, yellowish, and finally green, similar
to the color changes that occur in a resolving bruise. If you find these changes do mention

them.
The nodules usually subside over a period of 26 weeks without ulceration or scarring.
Once EN is diagnosed, inquire for IBD, Sarcoidosis, TB, Behet's disease, pregnancy,
medications like sulfonamides and oral contraceptives, lepromatous leprosy, and

cancer.
Ask for;
o Fever
o General ill feeling (malaise)
o Joint pains
o Diarrhea, bleeding PR, mouth ulcers and abdominal pain (Suggestive of IBD).
o Ulcers on genitalia (suggestive of Behcets disease)
o Respiratory difficulty (Sarcoid)

Sexually Transmitted Diseases (STD):

Most commonly seen STD ("Venereal Diseases") are:

Syphilis
Gonorrhea,
Chancroid,
Granuloma inguinale (donovanosis); and
Lymphogranuloma venereum (LGV).

Other less common are:

Nonspecific urethritis,
Condyloma
Acquired immunodeficiency syndrome (AIDS) has become a major world-wide STD
in homosexual, but now even in heterosexuals.

1. Syphilis: It is caused by T. pallidum. Three stages are described in acquired

syphilis.

(a) Primary syphilis:

Incubation period is 2-4 weeks.

Clinically a single, painless, well defined ulcer with a clean
healthy granulation tissue; on palpation nontender indurated
base, associated with bilateral regional lymph gland enlargement.
Lymph nodes are non-tender, discrete, firm, and rubbery in consistency.

(b) Secondary syphilis: It starts usually after 6-8 weeks of primary stage. Skin
lesions are generalized, bilaterally symmetrical, non itchy, rounded, dull red in
colourany type of lesion except vesicular is seen (in congenital syphilis it is
present). The lesions described are macular or roseolar, papular,
papulosquamous, pustular. Palms and soles are usually involved. Generalized
lymphadenopathy with rubbery, discrete, nontender enlargement of lymph
nodes is seen and particularly supratrochlear gland involvement is common.
Mucous patches with mucous membrane involvement of mouth is typical.
Uveitis, hepatitis and arthritis may also be found.
(c) Tertiary stage: It takes 3-10 years from the development of first lesion. The
typical lesion is gumma, seen on skin, mucous membrane, bones, joints, muscles
and viscera. Cardiovascular and neurosyphilis usually take 10-40 years from the
development of first lesion.
2. Gonorrhea:
Incubation period is 2-5 days. Acute gonococcal urethritis is clinically characterized
by burning micturition and pus discharge from urethra, particularly in male.
3. Chancroid:

It is caused by Haemohilus ducreyie, gram negative organism with incubation

period of 1-5 days. Clinically multiple and painful ulcers are seen on genitals with
ragged undermined edges, with vascular granulation tissue and they bleed easily on
gentle manipulation. This is quite opposite to syphilitic ulcer which is painless.
Usually it is associated with unilateral inguinal gland involvement, tender, matted
together to form unilocular abscess. The swelling is known as bubo.
4. Herpes genitalis: It is caused by herpes simplex virus type 2, and incubation
period is 4-5 days. Clinically it is characterized by small grouped tiny vesicular
lesions on genitals with slight burning sensation, followed by superficial ulcerations
which heal up spontaneously or get secondarily infected and usually followed by
recurrence by various precipitating factors at different intervals.
5. AIDS (Acquired Immunodeficiency Syndrome):
AIDS has become a major worldwide epidemic in last 25 years. AIDS can be defined
as a disease caused by infection with HIV (I + II) virus leading to failure of the
immune system, which encourages opportunistic infections and tumors like Kaposi's
sarcoma.
AIDS is seen more commonly with homosexuals, but it is observed that it is seen in
both heterosexual and homosexual contacts. In India a large number of patients
have acquired it through blood transfusion.
Skin lesion are common, Kaposi's sarcoma is frequently seen. Other skin
manifestations include chronic ulcerative genital herpes simplex, herpes
zoster, mucocutaneous candidiasis, fungal infections, chronic pyoderma
and Seborrheic dermatitis.