How should I properly perform a physical examination of the skin?

How to Properly Perform a Physical Examination of the Skin

A complete skin examination requires systematic inspection of all skin surfaces including non-exposed areas, with documentation of lesion characteristics using standardized terminology and assessment for high-risk features using the ABCDE criteria. 1, 2, 3

Systematic Approach to Skin Examination

Complete Body Surface Inspection

• Examine ALL skin surfaces thoroughly, not just exposed areas, as complete skin examinations detect melanoma 6.4 times more frequently than partial examinations 2
• Include examination of the scalp, between toes and fingers, soles of feet, palms, and anogenital region 1
• Pay particular attention to non-sun-exposed areas, especially in patients with darker skin, as melanomas in these locations are often diagnosed at later stages 2, 3
• Examine mucosal sites including eyes, mouth, nose, and genitalia for mucositis, blisters, and erosions 1, 4

Specific Skin Findings to Assess

When examining HIV-infected patients or immunocompromised individuals, look specifically for:

• Seborrheic dermatitis, Kaposi sarcoma, folliculitis, fungal infections, psoriasis, and prurigo nodularis 1
• Oral candidiasis, oral hairy leukoplakia, mucosal Kaposi sarcoma, aphthous ulceration, and periodontal disease in the oropharynx 1
• Evidence of condylomata and herpes simplex infection in the anogenital region 1

Documentation Requirements

• Record the date when any rash first appeared and document progression of the eruption 4
• Identify and document target lesions, purpuric macules, blisters, and areas of epidermal detachment 4
• Use a body map to estimate percentage of body surface area involved, recording extent of erythema and epidermal detachment separately 4
• Serial clinical photography can be valuable for monitoring changes over time 4

Lesion Assessment Using ABCDE Criteria

Apply the ABCDE criteria to identify suspicious lesions requiring further evaluation 2, 3:

• Asymmetry: Look for moles with irregular shapes or halves that don't match 3
• Border irregularity: Identify lesions with jagged, notched, or blurred edges 3
• Color variation: Note moles with multiple colors or uneven distribution of color 3
• Diameter: Pay attention to lesions larger than 6mm 3
• Evolution: Document changes in size, shape, color, or symptoms over time 3

Additional Assessment Tools

• Apply the "ugly duckling" sign: identify moles that look different from surrounding moles on the patient 2, 3
• This pattern recognition approach helps identify lesions that warrant closer scrutiny or dermatology referral 2, 3

Critical Pitfalls to Avoid

• Never perform only partial skin examinations when screening is indicated, as this dramatically reduces melanoma detection rates 2
• Do not overlook non-sun-exposed areas, particularly in patients with darker skin 2, 3
• Avoid delaying evaluation of rapidly progressive purpuric rashes, as this may indicate life-threatening conditions like meningococcal sepsis 4
• Do not neglect mucosal examination, as this can lead to significant morbidity 4
• Failing to document baseline findings and progression makes it impossible to assess evolution of lesions over time 4

Accuracy Considerations

Primary care physicians demonstrate moderate accuracy in diagnosing melanoma, with sensitivity ranging from 42% to 100% and specificity of 70% to 98% 1. However, most accuracy studies used images of confirmed lesions rather than whole-body examinations in screening settings, so real-world accuracy may differ 1. When uncertain about suspicious lesions, referral to dermatology is appropriate 2.