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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2683_Библиотеки_им_академика_М_И_Перельмана.pdf
Back pain and joint pain
arthroscopy for direct visualization (used for biopsy or foreign body removal).
COMMUNICATION
Ask the patient how the joint disease affects the
daily activities. Your concerns are not always the
same as those of your patient, but the eventual
management plan should be patient centred.
DIFFERENTIAL DIAGNOSIS
There are many possible causes of joint disease and back
pain, and they often occur concurrently. It is important to
adopt a systematic approach to ensure correct management.
Joint disease
A systematic approach to the differential diagnosis of joint
disease is illustrated in Fig.24.1. The most common conditions causing joint pain include:
• RA;
• osteoarthritis;
• gout;
• seronegative arthritides: ankylosing spondylitis, Reiter
syndrome and psoriatic arthritis;
• septic arthritis;
• trauma.
Arthritis and arthralgia may also be a feature of the systemic
disease, including connective tissue diseases, especially SLE,
vasculitis and neoplastic or malignant disease (leukaemia
and lymphoma, lung, breast and kidney).
Less common causes include:
• endocrine and metabolic disease (acromegaly and
hyperparathyroidism, haemochromatosis and Wilson
disease);
• other diseases: sarcoidosis, amyloidosis and sickle cell
disease.
Back pain
Back pain usually has a mechanical or structural cause (e.g.
crush fracture secondary to osteoporosis). This may have
a neuropathic element as in the case of spinal stenosis or
nerve root compression secondary to a disc prolapse.
Nonmechanical back pain is less common but is important to detect, and includes pain caused by inflammatory conditions, infection and cancer. Back pain may also
be referred from other viscera. The causes of back pain are
summarized in Table24.5.
CLINICAL NOTES
The causes of a single hot, red joint is a favourite
question. They are:
• septic arthritis – until proven otherwise
• trauma
• gout
• pseudogout
• haemarthrosis
• rheumatoid arthritis
Joint pain
Monoarticular
Acute Chronic Acute
Inflammatory
• Septic arthritis
• Pseudogout
• Acute gout
• Haemarthrosis
Fig.24.1 Differential diagnosis algorithm for joint disease. SLE, Systemic lupus erythematosus.
Noninflammatory
• Injury
• Meniscal
tear
• Loose body
Inflammatory
• Tuberculosis
• Monoarticular
presentation
of polyarticular
disease
Noninflammatory
• Osteoarthritis
• Enthesitides
Polyarticular
Inflammatory
• Rheumatic
fever
• Viral
Inflammatory
• Rheumatoid
arthritis
• Chronic gout
• Seronegative
arthritides
• Vasculitides
• Connective
tissue
disease,
e.g. SLE
148
Chronic
Noninflammatory
• Osteoarthritis
• Haemochromatosis
• Fibromyalgia
Differential diagnosis
Table24.5 Causes of back pain
Type of pain Cause Characteristics
Mechanical back pain (possibly
causing neurogenic pain)
Nonmechanical pain Neoplastic infiltration Myeloma
Referred pain from visceral disease Pelvic Prostatitis
Other Fibromyalgia
Unknown cause/nonspecific pain Lumbar strain/sprain
Degenerative disease
Disc prolapse Facet joint arthritis
Spinal fracture
Spinal stenosis Pathological fracture (e.g. due to
neoplasia or osteoporosis)
Traumatic fracture
Spondylolysis and spondylolisthesis
Metastatic carcinoma
Direct invasion of retroperitoneal tumour
Lymphoma/leukaemia
Spinal cord tumours
Infection Osteomyelitis
Discitis
Abscess
Inflammatory conditions Ankylosing spondylitis
Reactive arthritis
Enteropathic arthritis
Sacroiliitis
Paget disease
Endometriosis
Pelvic inflammatory disease
Renal Calculi
Neoplasia
Pyelonephritis
Gastrointestinal Pancreatitis
Ulcer disease
Aortic aneurysm
2424
Chapter Summary
• When assessing a patient with joint or back pain, the history and examination are crucial
in assessing the cause of the symptoms.
• Because there is a wide range of conditions affecting these systems, it is important to
maintain a systemic approach and repeat steps if necessary.
• Remember it is important to assess red flag symptoms and rule out a sinister cause of
pain and direct your investigations and then management by the clinical picture obtained.
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Skin lesions and rash
25
INTRODUCTION
Rashes and skin lesions can be diverse and misleading. This
chapter will focus on the most common presentations for
which through appropriate history taking, examination and
investigations can lead to the establishment of accurate differential diagnosis and management.
HISTORY AND EXAMINATION
History
The following should be assessed when you are taking the
history of a patient with skin lesions:
• Rash: its character, onset, initial site of origin and
progression, evolution of lesions and duration.
• Aggravating and relieving factors: physical or chemical
agents; cold (cold urticaria or cryoglobulinaemia) and
heat (worsens seborrhoeic conditions and superficial
skin conditions).
• Timing of change in skin lesions (e.g. moles and their
malignant transformation).
• Precipitants: stress may lead to alopecia or eczema.
• Associated hair and nail abnormalities.
• Possible infective agents: foreign travel and close
contacts (tropical infections), pets (papular urticaria
or animal scabies), farm animals (poxvirus,
ringworm).
• Chemical exposure: at home or work (ask about
occupation), acting as antigens or direct irritants. Ask
about soap and laundry detergent.
• Foods: nuts and shellfish.
• Light exposure: eruption in skin-exposed areas
(herpes simplex, systemic lupus erythematous and
vitiligo).
• Current and past medication. Have any drug therapies
been started or altered recently?
• General health and medical history.
• Family history: important in eczema, psoriasis,
inherited skin disorders.
• Patient's concerns and explanation for rash.
Systemic symptoms should also be assessed:
• Itching (Table25.1): atopy or urticaria, scabies,
eczema, dermatitis herpetiformis, lichen planus,
psoriasis;
• Pain: inflammatory conditions, skin tumours;
• Any other constitutional symptoms.
Table25.1 Possible causes of generalized and localized
itching
Generalized itching Localized itching
Uraemia Scabies and other mite
Cholestasis Contact eczema
Lymphoma Dermatitis herpetiformis
iron deficiency anaemia Urticaria (‘nettle rash’)
Hypothyroidism and
hyperthyroidism
Pregnancy Prickly heat
Carcinoma Winter itch
Allergies (e.g. atopic eczema) Aquagenic pruritus
Morphine ingestion Old age
Diabetes mellitus Pruritus ani
Multiple sclerosis Pruritus vulvae
Syphilis
Intestinal parasites
COMMUNICATION
Skin diseases affecting exposed areas such as
the face can have a devastating effect on patients
that is often disproportionate to the severity of
the disease. Careful questioning of the patient's
concerns and appropriate reassurance that the
condition can be treated are important aspects of
managing dermatological problems.
infestations
(associated with coeliac
disease)
Lichen planus
Examination
Always examine the entire skin, remembering to maintain
dignity of the patient. Look in the mouth (lesions seen, e.g.
with lichen planus, herpes virus infection and infective
exanthemata), behind the ears, on the scalp and between
finger web spaces. Look at the distribution of lesions and
their characteristics:
• If widespread and symmetrical, suspect systemic
disease.
• If only areas exposed to the sun are involved, suspect
light sensitivity.
151
Skin lesions and rash
Describe the type of lesions (Table25.2) and their site, dis-
tribution, size, shape and colour. Palpate the lesion and
examine surrounding skin. Describe the border and its
surface. Always remember to examine lymph nodes in the
adjacent area.
INVESTIGATIONS
The history and examination may be enough to determine
the diagnosis. If the patient is not unwell, it may be possible
to examine the patient for skin changes over time, thereby
allowing the development of lesions. Otherwise the follow-
CLINICAL NOTES
In the patient presenting with subcutaneous
nodules, think of:
• rheumatoid nodules
• rheumatic fever
• polyarteritis
• xanthelasmata
• tuberous sclerosis
• neurofibromatosis
• sarcoidosis
ing investigations can be considered:
• blood tests: full blood count, urea and electrolytes,
bacterial and viral titres with immunological tests for
tropical diseases if appropriate, and blood cultures;
• skin scrapings and nail clippings (e.g. fungal
infection);
• examination of the skin under ultraviolet light
(e.g. fungal/bacterial infections, tuberous sclerosis,
porphyria);
• microscopy and culture, and virology of fluidcontaining lesions;
• allergy testing;
• skin biopsy;
Table25.2 Terms and characteristics of dermatological lesions
Term Characteristics
Alopecia Hair loss
Atrophy Loss of skin thickness
Blister or bulla Vesicle >1 cm in diameter
Crust Dried exudate on skin surface
Cyst Epithelium-lined cavity containing fluid or semisolid material
Erythema Area of reddened skin that blanches with pressure
Fissure Linear crack in epidermis
Indurated Hard and thickened
Köbner phenomenon Skin lesions occurring at sites of external injury
Lichenification Thickened skin with exaggerated skin markings
Macule Circumscribed change in the skin colour ≤1 cm in diameter. It is not elevated above the
Nodule Solid elevated skin lesion >1 cm in diameter
Papule Solid raised palpable area ≤1 cm in diameter
Patch Macule >1 cm across
Petechiae Pinpoint haemorrhages
Plaque Palpable plateau-like elevation of skin
Purpura Area of reddened skin caused by extravasation of blood that does not blanch with pressure
Pustule Circumscribed, pus-filled lesion
Scale Flake of hard skin
Scar Connective tissue replacement following loss of dermal tissue
Ulcer Irregularly shaped break in surface continuity of epithelium
Vesicle Fluid-filled lesion <1 cm in diameter
Wheal Raised, palpable lesion with pale centre
surface
152
• investigations for suspected systemic diseases or
malignancy suggested by the history and examination
or initial investigations.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis when you are considering skin disease can be difficult given the diversity of presentations. The
most commonly seen lesions are described next.
Pigmented lesions
• Freckles (ephelides): flat, brown spots arising on sunexposed areas.
• Lentigines: similar to freckles but often larger, and
not affected by sunlight, although they may develop
because of sun exposure.
• Seborrhoeic keratosis: benign, beige/brown plaques,
with a velvety or warty surface (Fig.25.1).
• Melanocytic naevus (mole): there are many subtypes,
including the blue naevus (small, slightly elevated blueblack lesions) and dysplastic naevus (usually a larger
naevus, >5 mm, with an irregular, blurred border and
mixed pigmentation and texture).
• Melanoma: flat or raised pigmented lesion with
possibly a recent change in appearance. It has various
colours and typically irregular borders.
• Melasma: well-demarcated patches of increased
pigmentation with an irregular border, usually on the
face and predominantly in women.
Differential diagnosis
Fig.25.1 Seborrheic keratosis. Benign raised warty lesions.
(Reprinted with permission from Dermatology 3rd Edition
Bolognia etal.)
• Seborrhoeic dermatitis: greasy plaques with yellowish
scale affecting the face, scalp, armpits, groin and trunk.
Can be infected (Fig.25.2).
• Lichen simplex chronicus: long-term rubbing or
scratching in response to itch, causing pigmented,
lichenified skin lesions with exaggerated markings.
• Tinea: fungal infection causing ring-shaped lesions
with a scaly border and central healing, or scaly
2525
CLINICAL NOTES
Remember to use the ABCDE approach to
examine a skin lesion for potential neoplastic
characteristics:
• A: asymmetry
• B: irregular border
• C: variable colour
• D: diameter greater than 6 mm
• E: evolving with time
Scaly lesions
• Psoriasis: silvery, scaled, well-demarcated plaques on
skin, usually over the extensor surfaces. It can also be
pustular or guttate (widespread, small, round lesions)
and involve the nails.
• Atopic dermatitis/eczema: dry, pruritic skin on the
face, neck, wrists and on the flexures, most common in
children. Over time the excoriated areas may become
lichenified.
Fig.25.2 Seborrheic dermatitis. Red, scaly rash on face.
(Reprinted with permission from Dermatology 3rd Edition
Bolognia etal.)
153
Skin lesions and rash
inflamed patches with a distinct border. Can appear
anywhere on the skin (Fig.25.3).
• Pityriasis versicolor: scaly, hypopigmented macules or
patches usually on the chest or back (Fig.25.4).
• Pityriasis rosea: oval, pink/red, scaly lesions following
the skin tension lines of the trunk preceded by a herald
patch.
• Discoid lupus erythematosus: well-defined red patches,
usually on the face. There is scaling, follicular plugging,
atrophy and telangiectasia of involved areas. The
patches may thicken and often leave scars (Fig.25.5).
• Exfoliative dermatitis: widespread skin erythema
(erythroderma) with scaling or peeling.
• Actinic (solar) keratoses: small, pink lesions that are
rough, crusted and scaly in texture. They are due to sun
damage, and are considered to be premalignant.
• Bowen disease (intraepidermal squamous cell
carcinoma): small, well-demarcated, slightly raised,
pink-to-red, scaly plaques.
• Intertrigo: rash in body/skin folds due to excess
moisture and often infection, causing fissuring,
erythema and superficial denudation.
Fig.25.5 Discoid lupus erythematous on scalp with
associated scaring alopecia. (Reprinted with permission
from Dermatology 3rd Edition Bolognia etal. Courtesy
Joyce Rico.)
Fig.25.3 Tinea corporis. Characteristic ring with central
healing. (Reprinted with permission from Dermatology
3rd Edition Bolognia etal.)
Fig.25.4 Pityriasis versicolour and its hypopigmented
lesions. (Reprinted with permission from Dermatology
3rd Edition Bolognia etal.)
CLINICAL NOTE
‘Dermatitis’ and ‘eczema’ are interchangeable
terms (although 'eczema' is commonly used to
refer to the atopic form). There are several types,
and different types may exist simultaneously.
Vesicular lesions
• Herpes simplex: recurrent, small, grouped vesicles on
an erythematous base, especially around the oral and
genital areas.
• Herpes zoster (shingles): vesicular lesions in a
dermatomal distribution, usually preceded by pain and
general malaise (Fig.25.6).
• Pompholyx (dyshidrotic eczema): small, intensely
pruritic vesicles or bullae on the palms, soles and sides
of fingers.
• Dermatitis herpetiformis: pruritic papulovesicular
lesions mainly on the elbows, knees, buttocks,
shoulders and scalp. It is associated with glutensensitive enteropathy.
• Miliaria (heat rash): superficial, aggregated, small
vesicles, papules or pustules on covered areas of
the skin.
154
Fig.25.6 Herpes zoster with vesicular lesion. Reprinted
with permission from Dermatology 3rd Edition Bolognia
etal.)
Differential diagnosis
It ranges from mild, purely comedonal to pustular
inflammatory acne. Scarring can occur.
• Acne rosacea: papules, pustules and erythema over the
forehead, cheeks and nose, with telangiectasia and a
tendency to flush easily. Hyperplasia of the soft tissue
of the nose (rhinophyma) may occur.
• Folliculitis: infection of the hair follicles causing
pustular, erythematous lesions (Fig.25.8).
2525
Figurate erythema
These are lesions that look like rings or arcs:
• Urticaria: eruptions of evanescent (short-lasting)
wheals or hives.
• Erythema multiforme: erythematous lesions in a
symmetrical distribution, initially over the extensor
surfaces of the limbs, spreading to the trunk (Fig.25.9).
Palms, soles and mucous membranes may be involved.
Lesions start as macules which evolve to become papular,
• Scabies: pruritic vesicles and pustules especially
between the fingers with characteristic burrows
(Fig.25.7).
Weepy or pustular lesions
• Impetigo: vesiculopustular lesions with thick, goldencrusted exudate, associated with group A streptococci
or Staphylococcus aureus.
• Acne vulgaris: the most common skin condition,
characterized by open and closed comedones and
frequently accompanied by cysts, papules and pustules.
Fig.25.8 Folliculitis on scalp. (Reprinted with permission
from Dermatology 3rd Edition Bolognia etal.)
Fig.25.7 Scabies causing skin erythema with burrows.
(Reprinted with permission from Dermatology 3rd Edition
Bolognia etal.)
Fig.25.9 Erythema multiforme. (Reprinted with permission
from Dermatology 3rd Edition Bolognia etal.)
155
Skin lesions and rash
urticarial, bullous or purpuric. Target lesions with clear
centres and surrounding erythema are common.
• Erythema migrans: an enlarging red patch or ring
around an initial papule. The centre may clear or
become indurated, vesicular or necrotic. It is a feature
of Lyme disease (Fig.25.10).
Bullous lesions
• Pemphigus: relapsing crops of flaccid bullae appearing
on normal skin, which rupture easily leaving erosions
and ulcerations. Mucous membrane (especially oral)
involvement is usually the first sign. There may be
superficial exfoliation after slight pressure (Nikolsky sign).
• Bullous pemphigoid: tense blisters, typically in
flexural areas. They may be preceded by urticarial or
eczematous lesions.
• Porphyria cutanea tarda: blistering on sun-exposed areas.
Papular and nodular lesions
• Hyperkeratotic: warts, corns, seborrhoeic keratoses.
• Purple: lichen planus (see Chapter35); Kaposi
sarcoma – malignant skin lesions with dark plaques or
nodules on cutaneous or mucosal surfaces, common in
people with HIV infection.
• Flesh coloured and umbilicated: molluscum
contagiosum – a viral infection causing single or
multiple, rounded, dome-shaped, waxy papules,
which are umbilicated and contain a caseous plug;
keratoacanthoma – a rapidly growing, usually benign
skin tumour with a crater topped with keratin debris.
• Pearly: basal cell carcinoma – most commonly nodular
with a central erosion and rolled edges, although it can
be superficial, waxy or pigmented; intradermal naevi.
• Small, red and inflammatory: acne, miliaria,
candidiasis, intertrigo, scabies, folliculitis.
• Erythema nodosum: painful red nodules without
ulceration on the anterior aspects of the legs; they may
regress over weeks to resemble contusions (Fig.25.11).
Photodermatoses
Painful erythema, oedema and vesiculation on sun-exposed
surfaces. Causes include drugs (e.g. amiodarone, phenothiazines and sulphonamides), polymorphic light eruption
and systemic lupus erythematous.
Maculopapular lesions
• Morbilliform drug eruptions, most commonly due to
antibiotics and antiepileptics.
• Exanthemata due to viral (e.g. measles) or bacterial
infection (e.g. scarlet fever).
• Secondary syphilis.
HINTS AND TIPS
Drug eruptions may mimic any inflammatory skin
condition. They usually start abruptly and are a
widespread, symmetrical, erythematous eruption.
Constitutional symptoms such as malaise,
arthralgia, headache and fever may be present.
Fig.25.10 Erythema migrans of Lyme disease. (Reprinted
with permission from Dermatology 3rd Edition Bolognia
etal.)
156
Fig.25.11 Erythema nodosum on shins. (Reprinted with
permission from Dermatology 3rd Edition Bolognia etal.
Courtesy, Kenneth E. Greer.)
Differential diagnosis
2525
Ulcerated lesions
• Decubitus ulcers: bed sores or pressure sores.
• Skin cancers commonly ulcerate.
• Parasitic infections (e.g. leishmaniasis).
• Syphilis: primary chancre.
• Venous or arterial insufficiency.
• Neuropathic ulcers: particularly in diabetes.
Petechial and purpuric lesions
• Thrombocytopenia: primary or secondary.
• Coagulation disorders (e.g. disseminated intravascular
coagulation).
• Vascular disorders (e.g. vasculitis).
Miscellaneous lesions
• Candidiasis: superficial, denuded, red areas with or
without satellite vesicopustular lesions. There are
whitish, curd-like concretions on the oral and vaginal
mucous membranes.
Chapter Summary
• Cellulitis: a hot, red, diffuse, spreading infection of the
skin.
• Erysipelas: oedematous, spreading, circumscribed, hot,
erythematous area, with or without vesicle or bulla
formation.
• Stevens–Johnson syndrome and toxic epidermal
necrolysis: usually caused by a reaction to
medication. There is a rapidly spreading
erythematous rash which may merge to form large
areas of skin detachment. Mucosal involvement is
common and mortality is high.
• Staphylococcal scalded skin syndrome: widespread
erythematous blistering skin lesions due to release of
staphylococcal toxins.
• The wide array of skin lesions sometimes makes it very difficult for an unexperienced eye
to correctly identify the underlying disease.
• There are therefore specific characteristics that dermatology describes to aid in correct
diagnosis and therefore optimal management.
• Remember the history and examination are extremely important in directing the clinical
train of thought.
• Appropriate description of lesions, including their progression and associated features, is
pivotal in understanding disease processes.
• Make sure the patient is assessed in a systemic way and that the psychological impact of
the condition is elucidated.
157