Dermatology Clinical Documentation: How to Describe, Classify, and Track Skin Lesions

Why Precise Lesion Description Matters

A dermatology record that says "patient has a spot on the back" is clinically useless. A record that says "1.2 × 0.9 cm irregularly bordered hyperpigmented macule with variegated colour on the right scapular region" is actionable — it can be compared to a follow-up photograph, referred to a colleague, or audited. Structured dermatology documentation protects the patient (through better continuity) and the clinician (through defensible records).

Morphological Terminology

Primary Lesions

• Macule: flat, non-palpable colour change, < 1 cm.

• Patch: flat, non-palpable, > 1 cm.

• Papule: elevated, palpable, < 1 cm, solid.

• Plaque: elevated, palpable, > 1 cm (often confluence of papules).

• Nodule: solid, palpable, > 1 cm, deeper than a papule.

• Vesicle: fluid-filled, < 1 cm.

• Bulla: fluid-filled, > 1 cm.

• Pustule: pus-filled, any size.

• Wheal: transient, oedematous papule/plaque (urticaria).

Secondary Lesions

• Scale: excess keratin flakes (psoriasis, tinea, eczema).

• Crust: dried serum, blood, or pus.

• Erosion: superficial epidermal loss, heals without scar.

• Ulcer: full-thickness epidermis + dermis loss, may scar.

• Lichenification: thickened skin with accentuated skin lines (chronic rubbing).

• Atrophy: thinning of skin.

Colour Descriptors

Erythematous, violaceous, hyperpigmented, hypopigmented, depigmented (leukoderma), flesh-coloured, yellow (xanthomatous), brown (melanocytic), black (necrotic/melanoma), white (vitiliginous).

The ABCDE Melanoma Criteria

Apply to all pigmented lesions:

• A — Asymmetry: one half does not mirror the other.

• B — Border: irregular, ragged, or notched edge.

• C — Colour: variegated — two or more shades of brown, black, red, white, or blue.

• D — Diameter: > 6 mm (size of a pencil eraser) — but melanoma can be smaller.

• E — Evolution: any change in size, shape, colour, or new symptom (bleeding, itching).

A score of 3 or more ABCDE features warrants urgent dermatoscopy and/or biopsy referral.

The 7-Point Dermatoscopy Checklist (for Pigmented Lesions)

Major criteria (2 points each): atypical pigment network, blue-white veil, atypical vascular pattern. Minor criteria (1 point each): irregular streaks, irregular pigmentation, irregular dots/globules, regression structures. A score ≥ 3 is suspicious for melanoma.

Tracking Lesions Over Time

For monitoring lesions (moles, actinic keratoses, seborrhoeic keratoses), use total-body photography and serial dermoscopic images. Each follow-up visit, the clinician compares current images to baseline. Documentation per lesion should include:

• Anatomical location (body map pin).

• Date first noted.

• Dimensions (two perpendicular measurements).

• Morphology using the terminology above.

• Clinical impression and management decision.

• Date of next review.

Documenting in ClinIT

ClinIT's dermatology module includes a body-map canvas where lesions are pinned to anatomical locations. Photos from the device camera are attached directly to each pin. All fields use the structured vocabulary above, enabling longitudinal comparison and search.