TABLE 4-6 Ten Pointers and Pitfalls in Dermatologic Diagnosis Approach each and every evaluation ith patience

e and thoroughness! Be are of "snap#" "cur$side#" or "door ay" diagnoses! E%amine the entire mucocutaneous surface# as ell as the hair and nails! A ne or changing mole should $e carefully evaluated! Do not remove tissue ithout sending a portion for histologic e%amination! &f the dermatopathologic findings are not consistent ith the clinical impression# o$tain another $iopsy! 0 &f forced to choose $et een H incongruent clinical and r n pathologic impression# follo H clinical lead 'cautiously(! H )enerali*ed pruritus of more & than + month,s duration mandates a complete systemic K or-up! ( .eemingly non-specific rashes o may /ust $e camouflaged specific disorders! Drug-induced eruptions can mimic most s-in conditions! Be ary of the "atypical" diagnosis! Atypical "this" may $e "typical" that to someone ho has seen it $efore! 0onsider all other reasona$le possi$ilities $efore ma-ing a diagnosis of fact1tial disorder!

or immunologists2 $ut ithout competency in dermatologic diagnosis they cannot 3ualify as dermatologists! This s-ill# ho ever# is not specific to dermatologists! Any physician ho ma-es the effort to study the s-in and learn the dermatologic le%icon can develop a functional appreciation of the fundamentals of diagnosis! The advanced diagnostic eye can only $e ac3uired $y endlessly repeated encounters in hich the physician is forced not only to loo- at# $ut also to o$serve# die rash hile an e%perienced mentor points the ay! The most common error in dermatologic diagnosis is to regard the lesions as non-specific "rashes" rather than as aggregates of specific individual lesions! As in surveying a $lood smear# a "general impression" is not enough4 The morphologic aspects of each individual cell must $e carefully scrutini*ed and /udged to $e normal or a$normal! Too often# physicians adopt a speedy# superficial approach to the s-in that they ould not apply to any other organ that they e%amine 'Ta$le 46(! Le is Thomas has said that "5edicine is no longer the laying on of hands# it is more li-e the reading of signals from machines!" &n dermatology# there can $e no replacement for the laying on of hands# and the physi-

cian is repeatedly gratified $y reading signals not from machines# $ut from people! .6))E.TED 7EAD&8). Bemhard 1D et al4 5aculopapularism! Am 9 Dematopathol :4+;<# +=:6 Bemhard 1D 'ed(4 &tch4 5echanisms and 5anagement of Pruritus! 8e >or-# 5c)ra -?ill# +==4 Bolognia 1L et al4 Lines of Blasch-o! 1 Am Acad Dermatol <+4+@;# +==4 Dermatology Le%icon Pro/ect! http4AA ! futurehealth!rochester!eduAdlpBA a$outDLPAa$tDLP!htm Cederman# D) et al4 Cull-$ody s-in e%aminations4 the patient,s perspective! Arch Dermatol +4D4@<D# BDD4 Ceinstein A74 0linical 1udgment! Baltimore# Eilliams F Eil-ins# +=6; ?a%thausen ?4 ?o are dermatological diagnoses madeGTrans .i 1ohns ?asp Derma-tol .oc <D4<# +=@+ 1ac-son 74 The importance of $eing visually literate! Arch Dermalol +++ 46<B# +=;@ 1ac-son 74 5orphological Diagnosis of .-in Disease! Hntario# )rims$y# +==: Leider 5# 7osen$lum 54 A Dictionary of Dermatological Eords# Terms# and Phrases! 8e >or-# 5c)ra ?ili# +=6: Thomas L4 The >oungest .cience! 8otes of a 5edicine-Eatcher! 8e >or-# Ii-ing Press# +=:<# p @: Ein-filmann 7J 'chairman(4 The &nternational League of Dermatologic .ocieties 0ommittee on 8omenclature! )lossary of $asic dermatologic lesions! Aaa Derm Ienereal .uppl '.toc-h( +<D4+# +=:;

H 0 D 0?APTE7 @ H a o c o Diagnostic 0 Procedures and Devices Alon .cope Allan 0! ?alpern "Don,l /ust stand there and loo-4 do something" L.helley EB and .helley ED+ Eith a clinically ell-trained eye and appropriate patient history# the ma/ority of s-in lesions can $e diagnosed ith simple visual inspection! ?o ever# details seen $y the na-ed eye are limited in depth# and 4D magnification# contrast! &n this chapter# e discuss procedures and

devices that can aid the clinician in ma-ing the correct diagnosis! Ee present the diagnostic aids in an order that escalates in terms of invasiveness# cost# and technical comple%ity 'see eCig! @-D!+ in online edition(! MN ?O E8?A80E >H67 LHHJ4 I&.6AL A&D. TH &8.PE0T&H8 5agnifying Lens 5agnification of surface pathology can $e achieved ith a hand-held lens! 5agnifying instruments ith $uilt-in lighting and a magnification of B- to +D-fold are readily availa$le! M/ . a$$ing the s-in surface - ith alcohol or application of a drop of oil $efore magnification can eliminate dirt particles and enhance the transparency of the stratum comeum! Diascopy Diascopy is performed $y firmly pressing a transparent# hard# fiat o$/ect 'such as

t o microscope slides( on the surface of the s-in! The user should $e careful not to in/ure the patient,s or his or her o n s-in Pvith the sharp edge of the slide! Diascopy can $e useful in distinguishing erythema secondary to vasodila-tion# hich is $lancha$le ith pressure# from erythrocyte e%travasation 'purpura( hich retains its red color! &n nevus anemicus# in hich the $lood vessels in the lesion are vasoconstricted# pressure on the edge of the lesion ma-es the margins inapparent! Diascopy is also useful in detection of the yello ish-$ro n '"apple /elly"( color in papules or nodules of granulomatous processes# such as sarcoidosis# granu-loma annulare# and tu$erculosis! Eood,s Light The Eood,s light '"$lac- light"(# first descri$ed in +=D<# is a useful device for the clinical evaluation of varied cutaneous diseases such as pigment disorders# s-in infections# and porphyrias! The Eood,s