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

By: Kara N. Roman, MMS, PA-C

Diagnosing the “Mysterious Red 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, each diagnosis can 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 GAPA’s Summer 2019 Conference – Dermatology Track 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 improve 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 ( 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 Track will allow the participant to put these newly polished diagnostic skills into practice. Conditions highlighted will include dermatitis presentations, pediatric exanthems and other common pediatric rashes, and the evaluation of pigmented lesions as they relate to the superficial skin cancers and melanoma detection. The day’s sessions will conclude with a 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.


  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 )


You can see Kara N. Roman, MMS, PA-C speak at the 2019 GAPA Summer Conference.


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