Physical Examination for Pruritic Rash on Bilateral Arms, Chest, and Back
A thorough physical examination should focus on assessing the distribution, morphology, and characteristics of the rash, with special attention to evidence of scratching and potential underlying causes.
Skin Examination Components
General Assessment
- Document vital signs including temperature (to assess for fever which may accompany certain rashes)
- Assess overall skin condition including hydration status and presence of xerosis (dry skin)
Rash Characteristics
- Distribution: Document bilateral involvement of arms, chest, and back
- Morphology: Note if macular, papular, vesicular, pustular, or mixed presentation
- Color: Document color (erythematous, salmon-pink, purpuric, etc.)
- Size and shape: Measure representative lesions
- Borders: Note if well-defined or poorly demarcated
- Elevation: Determine if flat or raised
- Pattern: Document if confluent, discrete, linear, annular, etc.
Evidence of Scratching
- Document excoriations, scratch marks, and lichenification
- Note presence of crusting or secondary infection from scratching
- Assess severity of scratch marks (superficial vs deep)
Additional Skin Areas to Examine
- Examine all skin surfaces including:
- Face and scalp
- Oral mucosa
- Distal extremities
- Anogenital region
- Interdigital spaces
- Periumbilical area
- Axillae and groin folds
Associated Findings
- Check for lymphadenopathy (particularly regional to affected areas)
- Assess for facial or distal extremity swelling
- Look for signs of systemic involvement (jaundice, pallor, etc.)
Documentation of Findings
- Photograph lesions if possible for baseline comparison
- Document percentage of body surface area (BSA) involved
- Note any Koebner phenomenon (development of lesions at sites of trauma)
- Document any dermographism (skin writing)
Special Considerations
- Assess for signs of secondary bacterial infection (pustules, honey-colored crusting)
- Look for evidence of other dermatological conditions that may cause pruritus
- Document any patterns suggestive of contact exposure (linear or geometric patterns)
Management should be based on the extent of body surface area involved, severity of symptoms, and presence of any concerning features suggesting systemic disease 1, 2.
Remember that a complete physical examination is essential for proper grading of the rash and determining appropriate treatment strategies, particularly when evidence of scratching is present 1.