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Macular, Papular, Lichenified, Oh My…Why, Oh, Why?

By: Kara Roman, MMS, PA-C

Diagnosing the “Generalized Rash” is…frustrating, challenging, invigorating, discouraging, bottom line…difficult. With over 3000 different dermatologic diagnoses and more than 50% of patients with these conditions presenting first to primary care, it is an important skill to prioritize for any health care provider (1). Primary care clinicians often feel inadequately prepared to deal with dermatologic complaints, and that may contribute to the variety of emotional responses provoked by the “Mysterious Red Rash”.

Not only are there thousands of possible diagnoses for each lesion or rash you may encounter, but each diagnosis can also look different on different types of skin – oily or dry, darker or lighter, thicker or thinner. The exponential variations of individual lesion presentations are staggering, scary, and can sometimes cause the primary care clinician – diagnostic paralysis.

There is hope for even the most hardened “dermato-phobe”. The
first session in SBHPP 2020 – Dermatology Day will focus on giving the primary
care clinician the tools needed to make confident dermatologic diagnoses.
Components of a focused dermatologic history will be reviewed, and then
hundreds of images will be utilized to underscore the two most helpful physical
exam components to master – morphology and distribution (2).

Morphology – How
would you describe the primary lesion?

  • < or > 5 mm
  • flat or raised
  • round, annular, serpiginous
  • smooth or scaly
  • pigmented or not
  • contain fluid or pus

Distribution – Where
is it located on the body?

  • clustered together or discrete
  • one side of the body or more generalized
  • intertriginous
  • scalp only

Once learned, the foundational skills of lesion morphology and distribution recognition, accompanied by a careful and targeted history, should allow diagnosis of the majority of skin conditions. Lesion and pattern recognition improves with time, so challenge yourself to see as many dermatologic conditions in your patients as possible. To assist with building a differential diagnosis, a program/app such as VisualDx (www.visualdx.com) may increase your accuracy as you build up to the volume needed for confident and consistent dermatologic diagnoses (3). Providers can click on the lesion type and the distribution, along with providing a few patient identification basics, to see a generated list of differentials with this online or app program. The massive image database will allow for immediate comparison between the patient sitting on your exam table and the suspected conditions.

The sessions to follow in the Dermatology Day will allow the
conference attendee to put these newly polished diagnostic skills into
practice. Conditions highlighted will include dermatitis presentations, common
infections, skin conditions associated with allergies, and the evaluation of
pigmented lesions as they relate to the superficial skin cancers and melanoma
detection. The day will also include a session dedicated to the review of
common topical medications, how they work and how much to dispense, and will
highlight a few exciting new products available for use in primary care
settings. You won’t leave without brushing up on nearly everything that
presents in primary care today as it relates to dermatology, and you might even
have a little fun along the way! See you there!


1. Wilmer EN, Gustafson CJ, Ahn CS, Davis SA, Feldman SR,
Huang WW Most common dermatologic conditions encountered by dermatologists and
nondermatologists. Cutis. 2014;94(6):285.

2. Armstrong, CA. Approach to the clinical dermatologic
diagnosis. In: UpToDate, Corona, R (Ed) UpToDate, Waltham, MA. (Accessed on 12/31/2018
at https://www.uptodate.com )

3.  www.visualdx.com

See Kara Roman, MMS, PA-C speak in 2020 at a Skin, Bones, Hearts & Private Parts event in AtlantaMyrtle BeachVirginia BeachOrlando