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INTRODUCTION TO

CLINICAL DERMATOLOGY
VMED 5365
Diseases of the Integumentary
System
Dermatology in Practice
LARGE proportion of case load
Leads to discomfort, pain sometimes death
(or euthanasia)
Quality of life issues anxiety for owner
can see and smell the problem
Dermatology in Practice
Appropriate initial work up is important
Decreases chances for chronic irreversible
changes
Attention to detail
Consistent and practical initial approach
Longer than 15 minute exam how to
handle this?
Dermatology in Practice
Use your staff wisely
Receptionist to give history form
Technician to do based TPR and complete derm
form
Summarize findings
Do basic procedures with second person assisting
(kennel help)
Summarize findings
Pharmacy items and detailed instructions
Initial phone call contact
HISTORY
Through history is at least 50% of the
information needed to solve the puzzle
Can be misleading! be careful
You can lead the client be careful
Record information
to help in memory aid!
and if multiple person practice
HISTORY
Primary complaint Any in contact
always address this animal/human with skin
Age of onset problem
Sudden vs gradual Related animals with skin
problems?
Travel history
Previous testing/results
Seasonal influence
Previous treatment/results
Body areas affected
Initial presentation has
Flea control
this changed Type of diet
Animals environment Medical history
Current medication
SIGNALMENT - AGE
Young dogs ectodermal defects; puppy
pyoderma, demodex, ringworm
Prior to one year : demodex, food and flea allergy,
atopy
1-3 years: hypersensitivities, keratinization
problems, idiopathic pyoderma
3-9 years: hypersensitivities, endocrinopathies
Over 9 endocrinopathy, NEOPLASIA
SIGNALMENT - BREED
Large breeds acne, pressure point derm
Terrier, Labs, Golden, Boxers, Setters: atopy
Boxer, Bull Terrier, Scottish Terrier, West Highland
White Terrier, Shar Pei, Doberman, Shih tzu, Lhasa Apso,
Rottweiler, Collie: demodex (regional family line)
Collie, Sheltie, G Shep, Chow chow : immune mediated
Chow chow, poodle, pomeranian, Keeshond, Husky,
Malamute: alopecia X
Boston, beagle, boxer, poodle, dachshund: Cushings
disease
SIGNALMENT SEX
RELATED
Male: Sertoli cell tumor, Perianal adenoma, Tail
gland hyperplasia, castration responsive derm
Castrated male: Testosterone responsive derm
Female: Sex hormone related alopecia, mammary
gland neoplasia
Spayed female: Estrogen responsive alopecia,
mammary neoplasia
EXAMINATION
Good general physical examination may
have skin manifestation of internal disease
Examine skin and hair coat in systematic
manner. May need coat clipped
Examine mucous membranes, ventrum,
interdigital spaces, nails, footpads
Palpate lesions
Inspect ear canals
EXAMINATION
Adequate lighting is ESSENTIAL
Identify primary and secondary
lesions
Make differential list from lesions
noted
Record observations on form
Record lesions AND lesion
distribution will be helpful in
follow-up visits
Look for evidence of pruritus
SYSTEMATIC APPROACH
TO CLINICAL EVALUATION
Appropriate DDX list based on identification of
primary and secondary lesions
Primary: papules, pustules, macules, plaques,
vesicles, wheals, nodules and tumors
Secondary: crusts, scars, ulcers, erosions,
excoriation, lichenification, hyperpigmentation,
comedo, hyperkeratosis, fissure and alopecia
Some secondary lesions helpful
Distribution of lesions can be very helpful!
PRIMARY SKIN LESIONS
Macule Pustule
Papule Wheal
Nodule Vesicle
Tumor Erosion*
Ulcer* Alopecia*
PAPULE
Circumscribed, elevation of skin
less than 1 cm
Coalescing papules can produce
plaque = raised flat top lesion
PUSTULE
<1 cm circumscribed
epidermal or dermal
accumulation of
purulent exudate
VESICLE
Circumscribed
elevation of epidermis
caused by
accumulation of clear
fluid within or beneath
the epidermis
NODULE
Circumscribed > 1cm
lesion raised above
level of the epidermis,
often involving dermis
WHEAL
Sharply circumscribed
skin elevation
produced by edema of
the superficial dermis
EROSION/ULCER
Erosion = Ulcer that
goes to the depth of
the basement
membrane

Ulcer= Loss of skin


tissue exposing dermis
or subq
ULCER
Loss of skin tissue
exposing dermis and
or subcutis
PRIMARY SKIN LESIONS
(Make DDX List)
Macule Pustule
Papule Wheal
Nodule Vesicle
Tumor Erosion*
Ulcer* Alopecia*

Distribution of lesions can help in ranking the DDX list!


DIFFERENTIAL DIAGNOSES
Primary pustular
Impetigo
Folliculitis
PF, PE
With vesicles: DE, PV, Contact
Puppy strangles
SCPD
Eosinophilic Folliculitis
Sterile furunculosis
Contact dermatitis
DIFFERENTIAL DIAGNOSES
Primarily papular
Folliculitis: bacterial,
dermatophytic, demodectic
Parasitic: sarcoptes, flea allergy,
insect allergy, cheyletiella, lice
Immune mediated: atopy, food,
contact, DE, PF, Lupus
DIFERENTIAL DIAGNOSIS
-VESICULAR

Viral Infection
Autoimmune Disease
(PV, BP, SLE)
Contact Irritant
DIFFERENTIAL DIAGNOSIS
EROSION/ULCER
Non-self inflicted:
Trauma/toxin
(thermal/chemical burn)
Infectious (Deep bacterial,
deep fungal, genl demodex,
panniculitis)
Neoplastic (SCC esp),
metabolic (Renal, vasculitis,
NME)
Autoimmune (DE, EM,
TEN, SLE, BP, PV, VKH,
panniculitis)
DIFFERENTIAL DIAGNOSES
No primary eruption
Atopy
Food allergy
Cheyletiella
Seborrhea
SYSTEMATIC APPROACH
TO CLINICAL EVALUATION
Complete thorough physical examination
Complete thorough dermatologic
examination
Well lighted room
Hair coat can hide the dermatitis
Use animal outline in chart
SYSTEMATIC APPROACH
TO CLINICAL EVALUATION
Examine mucous Identify primary
membranes lesions
Check axilla, groin, Recognize useful
interdigital spaces, secondary lesions
nails, foot pads Record observations
Palpate lesions Look for evidence of
Inspect ear canals pruritus
Adequate lighting
DIAGNOSTIC METHODS
Diagnostics chosen to rule in or rule out
DDX list will be based on
History
Examination physical and dermatologic
Non-invasive, less expensive tests
Consider order to perform tests rule in/out
common diseases
Minimum Data Base
Skin scraping
Superficial
Deep
Flea comb
Ear swabs
Wood lamp
Ringworm culture
Surface cytology (sticky slides/double sided tape)
Cytology of exudate
More Diagnostic Tests
Sterile culturette
Skin biopsy
Intradermal or blood testing for atopy
Food trial
Patch testing
Endocrine work up for thyroid or cushings
Sex hormone assay
Therapeutic Trial
Response to flea control/other parasite
control
Response to scabicidal therapy
Response to antibiotics
Response to steroids (be careful)
Response to topical therapy/bathing
Skin Scrape
Performed at initial work up
Clip hair
Dull clean #10 scalpel blade
Mineral oil on skin
Coverslip
100 x magnification
For deep scrapings demodex- focal area must see
blood
For superficial scraping broad area stratum
corneum only
Direct Examination of Hair and Scale
Trichogram
Pluck hairs from follicle arrange orderly
Cover slip examine ends
Examine roots
Examine for superficial fungi
Clear with KOH, KOH and DMSO or
Chlorphenolac
IMPRESSION SMEARS AND
ASPIRATES
Aspirate nodules, pustules, vesicles
Cells blown from needle onto glass slide
Impression smear from exudate lesion
Touch glass slide to exudate and smear
Sticky slides or double sided tap to perform
surface cytology
Air dry/slide warmer
Various stains
Wrights cell morphology
Gram stain pathogens/ear swabs
New methylene blue wet mounts
SURFACE CYTOLOGY
Clip hair
Press to skin
Stain
Exam microscopically
for year or bacteria
Dermatophyte Culture
Select hairs at periphery of lesion (active area)
Clip to within inch
Prep with alcohol
Pull hairs in direction of growth
Inoculate on media
Send to microbiology lab or check daily
Perform macroconidia prep to ID type of
ringworm IF media turns red as the colony grows!
SKIN BIOPSY
For ears, face, mucous
membranes, deep lesions
general anesthesia or
heavy sedation
General skin biopsy with
local anesthesia, +/- mild
sedation
Punch biopsy superficial
lesion, infiltrate with
lidocaine
No surgical prep may
scrub off pathology!
SKIN BIOPSY
Large lesions or
lesions that are
not uniform
Remove entire
lesion
Perform a
wedge biopsy
SKIN BIOPSY
Thin biopsies air dry on small piece of
cardboard prevents curling
Place in buffered formalin for routine
histopathology
Biopsy for culture scrub first aseptic
technique place in sterile container
SKIN BIOPSY
Several very important things to remember
Have a good reason to biopsy DDX list!
Choose a good primary lesion
Choose many lesions in different phases
Choose a good pathologist with a special interest
in dermatopathology!
Give the pathologist as much information as
possible
Garbage inGarbage out