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Skin: a bare bones covering

21 November 2016

As you’ve heard countless times, the skin is the largest organ of the human body. What doesn’t come more immediately to mind is that it is one of the few organs exposed constantly to the outside world. This gives it quite a lot to deal with: infections, allergens, trauma, UV radiation, chemicals – I could go on. The ironic thing is that on a day-to-day basis, physical therapy practitioners such as osteopaths see a lot more of their patients’ skin than a GP does in an average consultation. This places you in a privileged position to help your patient – and maybe even save a life or two. I write this not to turn you into an expert dermatologist able to diagnose skin conditions from across the room, but as a guide to spotting a skin problem, treating the patient appropriately and advising them that they should seek medical attention.

The basics

Always keep in mind the psychological morbidity associated with skin conditions. The patient may not want to talk about or have the sometimes quite obvious rash pointed out.

Instead, what’s appreciated is showing consideration of the skin problem and the patient’s feelings. Ask if any areas of their body are sore or should be avoided. Wash your hands in front of them for their reassurance, offer a thin sheet whilst they are lying exposed – it’s common sense but I make no apologies for reminding you.

Patients may sometimes complain that their skin condition flared up after treatment with you, and in particular point the finger at the oil or cream you used.

 It is highly likely that it was the act of rubbing the skin that caused some redness – but again, for the patient’s reassurance, ask them if they prefer to bring their own usual cream in next time and use that instead.

Common skin conditions

Next, we try to recognise common skin conditions such as eczema, psoriasis and acne.

The latter most of us are familiar with – the hallmark of acne is comedones (AKA blackheads) or whiteheads. These are often accompanied by pustules and raised red “pimples” called papules. Deeper acne has painful, lumpy nodules. Acne is found on the face, neck and upper trunk but can affect the entire back.

Eczema is a pink-red, scaly, itchy, patchy rash that can cause breaks in the skin and thickening of scratched areas. The rash is typically, but not always, symmetrical and affects flexures of the body such as the ante cubital fossa of the elbow, popliteal fossa of the knee and neck (flexural eczema) but the face, hands and other parts of the body may be involved.

Eczema is often genetic and is immune-based. There is usually a history of eczema from childhood, although it frequently onsets in adult life. There may be associated asthma and hayfever. Food allergy does not cause eczema. Fewer than one in ten children have eczema that is triggered by a food allergy, and this figure is much lower in adults. Some known irritant triggers are swimming pool water, the weave of fabrics and central heating.

Psoriasis, like eczema, is also an immune-based skin rash. There is usually a family history. Psoriasis is typically symmetrical and this time it’s the extensor aspects of the joints that are affected – fronts of knees and cubital fossae. Other common sites are the scalp, ears, umbilicus, hands, nails, feet and then anywhere else.

Lesions of psoriasis are called plaques. These are well defined with “sharp cut-off at the edges” and can have a white or “silvery” scale. They feel dry and itchy and can be raised and thickened.

All of the above conditions are non-infectious. If the patient is in pain due to their skin condition, particularly over a joint, it is best to postpone treatment until the skin has improved.

Both eczema and psoriasis are frequently worsened by stress – psychological or physical. The hormones produced during times of stress stimulate the immune system, and immune-based skin conditions worsen as a result.

One should be mindful of this when seeing a patient who reports a flare-up of their eczema or psoriasis; they may be going through a “bad patch”.

Skin cancer

By the age of 70, two in three Australians will be diagnosed with skin cancer. The vast majority of these will be non-melanoma skin cancers. Melanoma, which kills one Australian every six hours, has an incidence of 49 cases for every 100,000 people.

It is the duty of every healthcare professional to do everything within their power to help towards early diagnosis of skin cancer.

There are some very simple steps and useful guidelines, which can help you advise your patients appropriately.


Have a look at as much of the skin as you can. A suspicious lesion most often looks different to the rest of the patient’s moles, freckles and skin tags. This standing out and looking odd is called the “Ugly Duckling” sign.

Equally, if the patient reports a lesion on their skin that hasn’t healed for months or is growing or won’t stop scabbing/weeping – ask them to see their doctor.

Tumours on the back and less visible areas are most likely to escape the patient’s notice, especially for elderly patients.

A bleeding, scabbing, raised lesion needs urgent attention.

If you see something that worries you, consider the patient’s risk factors to help you decide further if it may be malignant. Common factors include very fair skin, a history of bad peeling or blistering sunburn, previous skin cancer and a family history of skin cancer, radiotherapy or immunosuppressant treatment.


Pigmented (brown or black) lesions would arouse suspicion if they had different shades of brown in them, asymmetric or patchy colouring, or an irregular outline – especially if it was jagged. Sometimes the brown colour is so dark and deep in the dermis that it looks black.

Remember, melanomas can be flat or raised. People sometimes get a false sense of reassurance if a lesion with the above suspicious features is flat. This notion is misplaced. It can still very well be a melanoma.


The bulk of non-melanoma skin cancers are basal cell carcinoma, which can very rarely lead to loss of life or squamous cell carcinoma, which can spread and cause death.

The earlier these skin cancers are detected, the easier and less problematic the treatment.

Non-melanoma cancers are typically pink– red and they can be raised nodules or scabbing, or ulcerated lesions.

Basal cell carcinoma has a common variant, which is a nodule with rolled edges and sometimes has visible red capillaries running over its pale surface.

Squamous cell carcinoma tends to be a pink nodule that can feel firm and be ulcerated or scabbed. It can also feel a bit rough as it sometimes has some keratin over its surface.

The above descriptions are not exhaustive but if you consider the wider picture, you can hone in on a potentially malignant lesion with more accuracy. As you become more confident in examining specific lesions, purposefully looking at skin should become an instinctive part of your patient care.


Dr Manu Mehra


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