Rashes

Oh, dermatology. Derm is one of the most difficult areas of medicine/nursing, in my opinion. Is it red? Does it itch? Has it traveled? Have you? Any new food? New lotion/soap/detergent/shampoo/perfume/deodorant?

I found a cheat sheet a few years back and I refer to it all the time!

When we start assessing rashes, we ask the above questions. Also, does anyone at home have it? Have you tried any treatment at home? These questions help narrow our focus. And, hopefully provide us with only 1,000 possible diagnosis' instead of 1,000,000.

First we evaluate the history; as the questions above describe. Then we investigate location; scalp, face, torso, arms, hands, genitals, legs, feet. Bilateral or unilateral? I had a patient last week who said the rash started on one side and then within a week it would start in the same location but the other side of the body! Finally, we describe the rash. Is it macular (flat)? Papular (raised)? Vesicular (like a vesicle; think chicken pox), or scaled?

For example, hives or urticaria are erythematous (red) papules (raised) lesions. "You have an erythematous popular rash!", or hives. :) Herpetic lesions are typically vesicular; think chicken pox, oral "cold sores", shingles.

The more detail you can provide us, OLD CART (remember?), the better! Not all rashes require a dermatology referral. In fact, where I work, I can consult a local dermatologist if I don't know how to proceed. This not only helps the patient (they don't have to wait for a referral, travel to a new provider), I get to learn more about the conditions I am seeing. It forces me to be more specific with my history taking and physical assessment skills.

I will leave you with the ABCs of dermatology. If you have a rash or lesion (wart or mole) that doesn't resolve/heal, bleeds, itches, or changes, review these ABCs and schedule an appointment with a dermatologist or your PCP for a derm referral.

• Assymetry
• If you cut the lesion in half, are both sides equal? No? Go see the derm.
• Border
• Most benign (normal) lesions have a smooth border. If you have a jagged, rough border, go see derm.
• Color
• The lesion should all be one color; multiple shades of tan, brown, black, maybe even green, red, or blue should merit a visit with derm.
• Diameter
• The size of the lesion should be smaller than a pencil eraser. If you notice it is growing, and growing beyond this size, go see derm.
• Elevation/evolving
• Is the lesion raised? Is it changing? Any change in elevation or the above criteria should warn you to go see the specialist.