What is the documentation process for a small area of skin with xerosis (dryness) and suspicious characteristics?

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Last updated: May 22, 2025 • View editorial policy

From the Guidelines

To document a small area of dry and suspicious skin, first describe the exact location using anatomical landmarks, note the size, appearance, and any specific features, and consider referral for dermatological evaluation or biopsy if the lesion appears concerning for malignancy, as recommended by the most recent guidelines 1. When documenting the lesion, consider the following key points:

  • Location: describe the exact location using anatomical landmarks (e.g., "2 cm superior to the left lateral malleolus" or "on the right upper back, 3 cm inferior to the scapula") 1
  • Size: note the size of the lesion in centimeters, measuring length, width, and height if elevated
  • Appearance: document the appearance including color (e.g., red, hyperpigmented, hypopigmented), texture (e.g., scaly, rough, smooth), borders (e.g., well-defined, irregular, raised), and any specific features like bleeding, crusting, or ulceration
  • Symptoms: include whether the area is painful, itchy, or changing over time
  • Photography: photograph the lesion if possible, including a ruler for scale, to monitor changes over time and communicate findings to other healthcare providers If the lesion appears concerning for malignancy, consider the "ABCDE" rule, which looks for lesions with asymmetry, border irregularity, nonuniform color, diameter greater than 6 mm, and evolution over time 1. In high-risk populations, a low threshold for performing skin biopsies of suspect lesions is necessary, as skin lesions may be difficult to assess clinically 2, 3. A skin biopsy should include deep reticular dermis if the lesion is suspected to be more than a superficial process, and imaging studies may be performed if extensive disease is suspected 2, 4.

From the FDA Drug Label

Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily The FDA drug label does not answer the question.

From the Research

Documenting a Small Area of Skin

To document a small area of skin that is dry and suspicious, the following steps can be taken:

  • Take a thorough history of the lesion, including its duration, progression, and any associated symptoms 5
  • Inspect the whole skin, not just the affected area, to look for any other lesions or abnormalities 6
  • Describe the location, distribution, form, and type of lesion in detail, using internationally approved definitions to describe skin changes 6
  • Document the findings in writing, including any notable features such as color, size, shape, and texture 6

Characteristics of Suspicious Lesions

When documenting a suspicious lesion, it is important to note any atypical features that may raise clinical suspicion, such as:

  • Asymmetry, border irregularity, color variation, or diameter greater than 6mm 7
  • Changes in size, shape, or color over time 7
  • Bleeding, crusting, or oozing from the lesion 7

Next Steps

If a lesion is deemed suspicious, further investigation may be necessary, such as:

  • Biopsy to obtain histopathologic information 8
  • Referral to a dermatologist for further evaluation and treatment 7
  • Patient education on self-skin checks and sun protection measures to prevent further skin damage 7

References

Guideline

basal cell skin cancer, version 1.2016, nccn clinical practice guidelines in oncology.

Journal of the National Comprehensive Cancer Network : JNCCN, 2016

Guideline

basal cell and squamous cell skin cancers.

Journal of the National Comprehensive Cancer Network : JNCCN, 2010

Guideline

basal cell and squamous cell skin cancers.

Journal of the National Comprehensive Cancer Network : JNCCN, 2010

Research

Dermatological assessment: history-taking and examination.

British journal of nursing (Mark Allen Publishing), 2024

Research

[Examination procedure and description of skin lesions].

Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete, 2017

Research

Skin Biopsy Techniques.

Primary care, 2022

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.