Chapter 16: Dermatologic Exam

INTRODUCTION

Unlike many other organ systems, the skin is one that can be examined even during casual encounters with patients. A thorough skin exam, however, requires focused attention and a systematic approach.

Getting Started

• Adequate lighting is imperative when performing an accurate skin exam. This includes bright overhead light and an additional focused light source, such as a penlight, flashlight, or phone light. The ability to adjust the direction of the light source is useful for providing tangential illumination, which may help in revealing subtle surface changes (Figure 16-1).

• For a comprehensive skin exam, the patient should change into a gown, open to the back, and leave undergarments on. Ask them to avoid wearing or to remove any makeup, jewelry, nail polish, or anything else that may obscure visualization of portions of the skin.

• The patient may either remain seated during the exam (and stand for examination of back, posterior lower extremities, and buttocks) or lie down supine for the exam, and turn to prone for exam of their back side (Figure 16-2).

Gown Management and Appropriately and Respectfully Touching Your Patients

• Always perform hand hygiene prior to and after each exam. Doing this in the exam room, in front of the patient, is ideal.

• Keep any portions of skin that you are not actively examining covered. Uncover sensitive areas only with the patient’s permission, and do not leave these areas uncovered longer than necessary to complete the exam. Bandages and dressings should be removed when feasible to evaluate the skin underneath.

• If there is a concern in the genital, rectal, or breast areas, directly ask patients if they are comfortable with an exam of these sensitive areas and arrange for a chaperone to be present for the exam. For example:

  • “Would you like me to examine the areas covered by your undergarments? If not, do you have any concerns about your skin in those areas?”

• Communicate your actions and explain the purpose of each component of the exam (eg, “I’ll need to move your hair around to get a clear look at your scalp,” or “Skin cancers can occur even in areas protected from the sun; I’m going to take a look at the bottoms of your feet and in between the toes for any lesions.”) This can help you to keep track of what you have done and put the patient at ease.

• At all times, pay attention to your patient. If they seem to be in discomfort or distress during portions of ...