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Most ED chief complaints involving skin lesions are due to infections, irritants, and allergies.1 Fortunately, few presentations represent life- or limb-threatening skin disorders. Visual diagnosis with the use of pattern recognition is the key to diagnosis. The recommended approach for the diagnosis of a skin disorder in the ED (assuming resuscitation or stabilization is not required) is to:

  1. 1. Determine the chief complaint.

    2. Obtain a brief history (duration, rate of progression, and location of lesions).

    3. Perform the dermatologic examination (morphology and distribution).

    4. Formulate the differential diagnosis based on lesion morphology and distribution.

    5. Elicit additional concerns from the history (associated complaints, comorbidity, medications, or exposures) and include or exclude syndromes in the differential diagnosis based on this information.

    6. Perform ancillary investigations, if necessary.

    7. Obtain dermatologic consultation, if necessary, and arrange for appropriate referral (primary care or dermatologic).


Determine the chief complaint and obtain a brief history (discomfort, duration, rate of progression, and location of lesions). The secondary history should include issues relating to the lesion: morphology, evolutionary nature, rate of progression, and distribution. Associated systemic complaints and mucosal systems must be identified. Ask about exposures to medications (over-the-counter, prescription, and illicit), immunizations, toxins, chemicals, foods, animals, insects, plants, and ill contacts. Sexual history, if appropriate, and medical and family histories should be reviewed. Asking about medication use, sun exposure, or particular food ingestion also may yield helpful information.


The patient should be gowned and in a room with adequate lighting. Inspect all skin and mucosal surfaces, including hair, nails, scalp, and mucous membranes. Then evaluate the specific skin lesions. A magnifying lens and a portable light are helpful aids.

Examine the skin systematically. Determine the distribution, pattern, arrangement, morphology, extent, and evolutionary changes of the lesions. Distribution is the location of the skin findings, and the pattern is their anatomic, functional, and physiologic arrangement. For example, a unilateral band-like arrangement of lesions on the thorax suggests varicella-zoster virus infection. Skin diseases often present with a predilection for certain body areas; the distribution of lesions will assist in narrowing the diagnostic possibilities. From the anatomic perspective, the skin surfaces that are usually considered as separate areas of distribution are generalized body; face and scalp; trunk and axillae; groin and skin folds; and hands, feet, and nails. The extremities may be further subdivided into upper versus lower, proximal versus distal, wrists versus ankles, and hands versus feet (Figure 243-1).

Figure 243-1.

Allergic contact dermatitis. A. Allergic contact dermatitis from exposure to poison ivy. Erythema, vesiculation, and bullae are present on the fingers and the dorsal surfaces of the hands. Note the linear streak across the right hand. This finding ...

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