Physical examination of the patient’s skin

So far we took the medical history of the patient, we assessed her skin cancer-related risk factors, and learned about the most frequent types of skin cancer to remind ourselves what to look for during the examination of the skin.

All dermatologists use dermoscopy for the assessment of the skin. A dermatoscope is non-invasive and painless, while it allows the dermatologist to identify skin lesions more accurately. Now we’ll set out to carefully examine the skin of our patient. In this step you will learn the basics of skin examination and about helpful algorithms to recognize skin cancer. Moreover you will be provided with pictures of the lesions we observed in our patients.

During physical examination the entire skin should be inspected by the naked eye, including mucous membranes, genital and anal regions, hair-bearing surfaces, nails, and lymph nodes. In patients with multiple moles, such as our patients, the ABCDE rule and the ugly duckling sign might aid in raising suspicion of a malignant lesion. During this skin exam, we can also assess the skin phototype of the patient.

Skin phototypes

Based on the color of the skin and its sensitivity to ultraviolet radiation, which depend on the amount of melanin pigment in the skin, Fitzpatrick proposed 6 different skin phototypes:

Skin phototype is a characteristic present at birth and does not change during life. Skin cancer is especially prevalent in people with skin types I, II and III; these are also the groups that most need to be aware of skin cancer prevention practices.

Since our patient has red hair and a light skin, she is most likely to have a type 1 skin. Redheads usually have less melanin producing capacity in their skin and thus are more sun sensitive than dark haired counterparts who produce more melanin and therefore have more sun protection capacity. Besides assessing different skin lesions, it is thus also important to look at who the patient is.

The ABCDE rule analyzes pigmented lesions according to symmetry, border, color, diameter and enlargement with the aim to differentiate melanoma from common nevi and other pigmented lesions.

The ugly duckling sign describes a lesion that is obviously different from other lesions in the same patient.

The physical examination of our patient

We of course carefully examine the lesion on the nose for which the patient came to us in the first place: we see a shiny red nodule with telangiectasia, a characteristic picture of a basal cell carcinoma (Figure 1).

Figure 1. Lesion on the nose

During the examination, we also notice an irregularly formed dark brown to black lesion on the back, amongst a high number of small light brown lesions. (Figure 2)

Figure 2.Lesion on the back