Documentation Reference

We recommend the following documentation steps and attributes as a guideline for use.

1. Describe the distribution pattern :

asymmetrical = unilateral or uneven

confluent = merging together

corymbiform = grouped with central large lesion & surrounding smaller lesions

diffuse = widely distributed

discrete = separate from other lesions

generalized = distributed diffusely

group(ed) = cluster(s) of lesions

herpetiform = pattern of clusters of vesicles

large = the distribution covers a large portion of the dermis

linear = in a line

localized = limited area of involvement

moderate = the distribution covers a moderate portion of the dermis

poikilodermatous = poorly marginated patches with telangiectasia & hyper- and hypopigmented areas

polymorphous = occurring in several different configurations

satellite = single lesion in close proximity to large group

small = the distribution covers a small amount of the dermis

solitary = single lesion

striae = depressed bands of thin, hypopigmented, stretched, shiny skin

symmetrical = even, bilateral involvement

zosteriform = band-like pattern in a dermatomal distribution

2. Describe the color of the lesion :

Achromia = skin that is devoid of melanin

Argyria = shades of blue, silver, or grey

Ecchymosis = describes bruising’s various colors: red, purple, green, yellow, brown

Erythema = reddened skin

Erythroderma = the skin is red all over

Flesh-colored = same color as the surrounding dermis

Hypercarotenemia = orange skin coloration. Tends to be pronounced on palms and soles. Does not affect cornea

Hyperpigmentation =  darker skin color than surrounding area

Hypopigmentation =  skin color that is paler than normal but not completely white

Jaundice = yellow or green skin color, prominent in cornea.

Necrotic = Black

Pink = Pink

Telangiectasia = prominent cutaneous blood vessels

Violet/Purple = cutaneous hemorrhage or vasculitis, hemangiomas

3. Describe the shape of the lesion :

acuminate = pointed

annular = ring-shaped

arciform = arc-shaped

discoid = coin-like, round

guttate = drop-like

gyrate = ring or spiral shape

iris lesion = concentric rings; bulls-eye

nummular = coin-like, round  (same as discoid)

punctate = pointed or dotted

reticular = lacy, network pattern

serpiginous = snake-like

4. Describe the primary type of lesion :

abscess = localized fluctuant tissue surrounded by normal tissue

boil = infected abscess; infected furuncle

bulla = elevated defined vesicle >1 cm containing serous fluid or blood

carbuncle = multiple, coalescing furuncles

cyst = closed cavity lined by epithelium

furuncle = a tense pustule > 1 cm

hematoma = large bruise, collection of blood under the skin

keloid = benign overgrowth of connective tissue following skin injury

macule = flat (non-palpable) skin color change < 1 cm

maculopapular = consisting of both macules and papules

mass = a large neoplasm; implies benignity

neoplasm = a new malignant growth

nodule = elevated solid contour change > 1 cm (extends into dermis)

papule = elevated (palpable) solid contour change < 1 cm

patch = flat, non-palpable skin color change > 1 cm

petechiae = violet hemorrhagic pinpoint macules

plaque = solid skin contour change > 1 cm

purpura = scattered macules; dark purple to red

pustule = purulent (pus-filled) papule

tumor = a large neoplasm (> 2-3 cm); implies malignancy

ulcer (ulceration) = depressed exudative plaque into or through the dermis

vesicle = elevated fluid-filled papule < 1 cm containing serous fluid

wheal = an edematous raised, transient, irregularly-shaped papule or plaque

5. Describe the secondary characteristics of the lesion :

atrophy = loss of the epidermis leading to thin, transparent skin

cool = area is cooler than the surrounding skin structures

crust = dried exudate (serum, sebum, blood, or pus) on skin surface

dell = small depression of skin (typically circular)

depression = indentation in skin

erosion = loss of epidermis; demarcated, moist, indented patch

eschar = necrotic tissue that sloughs; most often associated with burn injury

excoriation = linear abrasion of epidermis from scratching; leaves characteristic linear crusted plaques

exudate = purulent or clear fluid seeping from tissue, white patches on tonsils

fissure = linear splitting of skin into the dermis

gangrene = black or brown, hard, firmly attached, covering >50% of wound

hardening = thickened skin with hypo/hyperpigmentation from prolonged irritation

hot = area is warmer than the surrounding skin structures

lichenification=epidermal thickening on an elevated plaque usually from chronic rubbing or scratching

pruritic = has itch sensation

6. Describe any drainage from the lesion :

odor = description of smell (foul, none, etc)

purulent = thick, yellowish, grayish or greenish

sanguineous = bloody

serous = thin, clear or straw-colored fluid

seropurulent = thin, watery, cloudy, yellow to tan color

serosanguinous = thin, watery, pale red to pink

7. Then, document the lesion location(s) on the body

 

That’s it! 

 

 

References: 

http://www.dermnetnz.org/topics/terminology/

http://www.dermadvocate.net/library/articles/derm-terms

Advertisements