skin lesion

onset

hours days weeks months years

new?

new known/chronic

status

improving unchanged resolved growing/spreading slowly growing/spreading rapidly

context

location

scalp face forehead cheeks periorbital upper lip chin neck
R UE shoulder arm elbow flexor forearm hand palm fingers
L UE shoulder arm elbow flexor forearm hand palm fingers
trunk L chest R chest L flank R flank L abdomen R abdomen
L upper back R upper back L lower back R lower back
groin L groin R groin genital perianal
R LE anterior thigh posterior thigh buttock knee calf flexor ankle foot toes webspaces
L LE anterior thigh posterior thigh buttock knee calf flexor ankle foot toes webspaces

symptoms

asymptomatic painful mild pruritus moderate pruritus severe pruritus drainage bleeding

treatments tried

nothing topical steroids moisturizer cold heat antihistamines

improved with

nothing topical steroids moisturizer cold heat antihistamines

other

1°morphology

macule patch papule plaque nodule vesicle bulla pustule
blanchable erythema non-blanchable erythema no erythema
tender non-tender

2°morphology

melanocytic non-melanocytic
scale: white/brown white/silver seborrheic
erosion necrosis crust impetigo sclerosis excoriations fissures papillomatosis hypertrichosis hypertrichosis lichenification vegetation eschar purpura ulceration scarring gangrene hyperpigmentation hypopigmentation telangiectasia leukoderma calcinosis poikiloderma cutaneous horn

dermoscopy

major criteria (2 points each)

+ atypical pigment network –

+ blue-white veil –

+ atypical vascular pattern –

minor criteria (1 point each)

+ irregular streaks –

+ irregular dots/globules –

+ irregular blotches –

+ regression structures –

7-point checklist score: <3 ≥3

other

Assessment:

most likely dx:

benign nevus melanoma BCC SCC seborrheic keratosis actinic keratosis
papular, papulosquamous, papulo-vesicular
molluscum common wart seborrheic dermatitis pityriasis rosea psoriasis vulgaris lichen planus miliaria rubra scabies

details/ddx

Plan:

biopsy

no yes

medication

topical steroids PO steroids topical antifungal PO antihistamines PO antibiotics moisturizer

referral

dermatology

follow-up

after pathology results 2-4 weeks PRN only

RTC

instructions given

other

SKIN LESION:

S/

- location:

O/
primary morphology:
secondary morphology:

A/

P/