SKIN, HAIR, AND NAILS

The skin and its appendages are our primary physical presentation to the world.
- stratified structure composed of several functionally related layers

Functions: - protect against microbial and foreign substance invasion and

minor physical trauma
- retard body fluid loss (mechanical barrier)
- regulate body temperature through radiation, conduction,
convection and evaporation
- provide sensory perception
- contribute to blood pressure regulation
- repair surface wounds by exaggerating normal process of cell
replacement
- excrete sweat, urea, and lactic acid
- express emotions

I. HISTORY OF PRESENT ILLNESS

A. SKIN
1. Changes: dryness, pruritus, sores, rashes, lumps, color, texture, odor,
amount of perspiration,
changes in wart or mole, lesion that does not heal or is chronically
irritated

2. Temporal Sequence: date of initial onset, time sequence of

occurrence and development, sudden
or gradual onset, date of recurrence, if any

3. Symptoms: itching, pain, exudates, bleeding, color changes, seasonal

or climate variations

4. Location: skinfolds, extensor or flexor surfaces, localized or

generalized

5. Associated Symptoms: presence of systemic disease or high fever,

relationship to stress or leisure
activities

6. Recent exposure to drugs, environmental or occupational toxins or

chemicals, to persons with
similar skin condition

7. Apparent cause, patient’s perception of cause

8. Travel History: where, when, length of stay, exposure to diseases,

contact with travelers

9. What the patient has been doing for the problem, response to
treatment, what makes the condition
worse or better
 10. How the patient is adjusting to the problem

11. Medications: topical or systemic, nonprescription or prescription

B. HAIR
1. Changes: loss or growth, distribution, texture, color

2. Occurrence: sudden or gradual onset, symmetric or asymmetric

pattern, recurrence

3. Associated Symptoms: pain, itching, lesions, presence of systemic

disease or high fever, recent
psychologic or physical stress
4. Recent exposure to drugs, environmental or occupational toxins or
chemicals, commercial hair
chemicals

5. Nutrition: dietary changes, dieting

6. What the patient has been doing for the problem, response to
treatment, what makes the condition
worse or better

7. How the patient is adjusting to the problem

8. Medications: nonprescription or prescription, minoxidil

C. NAILS
1. Changes: splitting, breaking, discoloration, ridging, thickening,
markings, separation from nail bed

2. Recent History: systemic illness, high fever, trauma, psychological or

physical stress

3. Associated Symptoms: pain, swelling, exudates

4. Temporal Sequence: sudden or gradual onset, relationship to injury of

nail or finger

5. Recent exposure to drugs, environmental or occupational toxins or

chemicals, frequent immersion
in water

6. What the patient has been doing for the problem, response to
treatment, what makes the condition
worse or better

7. Medications: nonprescription or prescription

II. PAST MEDICAL HISTORY
A. SKIN
1. Previous problems: sensitivities, allergic skin reactions, allergic skin
disorders (e.g., infantile
eczema), lesions, treatment

2. Tolerance to sunlight

3. Diminished or heightened sensitivity to sensory stimuli

4. Diseases: cardiac, respiratory, liver, endocrine or other systemic

disorders

B. HAIR
1. Previous problems: loss, thinning, unusual growth or distribution,
brittleness, breakage, treatment

2. Systemic Problems: thyroid or liver disorder, any severe illness,

malnutrition, associated skin
disorder

C. NAILS
1. Previous Problems: injury bacterial, fungal or viral infection

2. Systemic Problems: associated skin disorder; congenital anomalies;

respiratory, cardiac,
endocrine, hematologic, or other systemic disease
III. FAMILY HISTORY
1. Current or past dermatologic diseases or disorders in family members;
skin cancer; psoriasis;
allergic skin disorders; infestations; bacterial, fungal or viral
infections

2. Allergic hereditary diseases such as asthma or hay fever

3. Familial hair loss or coloration patterns

IV. PERSONAL AND SOCIAL HISTORY

1. Skin care habits: cleansing routine; soaps, oils, lotions, or local
application used; cosmetics; home
remedies or preparations used; sun exposure patterns; use of sun
screen agents; recent
changes in skin care habits

2. Skin self-examination
- always use good light, minimizing distracting glare
- be aware of locations and appearance of moles and birthmarks
- examine back and other hard-to-see areas using full-length and
hand-held mirrors
 - begin with face and scalp and proceed downward
- be aware of dysplastic nevi (those with unexpected changes)
around the shoulders and
back
- be aware of scalp, breast, buttocks, soles of feet and
between toes
- see rather than feel any early signs of mole changes
- consult physician promptly if any pigmented skin spots look like
melanoma

V. OBJECTIVE: EXAMS AND FINDINGS

A. SKIN
- exam of skin is performed by inspection and palpation
- most important tools are your eyes and powers of observation
- hand-held magnifying glass or episcope may help

1. Inspection – adequate lighting is essential

- daylight provides the best illumination
- overhead fluorescent lighting is a sufficient supplement
- tangential lighting is helpful, but inadequate lighting can result in
inadequate assessment
- make a brief but careful overall visual sweep; “bird’s-eye-view”
gives a good idea of the
distribution and extent of any lesions

a. skin symmetry - detect differences between body areas, compare

sun-exposed to
non-sun-exposed areas
- adequate exposure of skin is necessary
- essential to remove encumbering clothing
- remove drapes or coverings as each section of the body is
examined
- make room temperature comfortable
- look carefully at axillae, buttocks, perineum, backs of
thighs, inner upper thighs
- remove shoes and socks to look at feet
- begin by inspecting skin and mucous membranes
(especially oral) for oral and
uniform appearance, thickness, symmetry, hygiene
and presence of any
lesions
- note callusing on the hands or feet

b. color - ranges from dark brown to light tan with pink or yellow
overtones
- callused areas may appear yellow
- vascular flush areas (cheeks, neck, upper chest, genital
area) may appear pink or
red
- may be masked by cosmetics and tanning agents
 - look for localized areas of discoloration
- variations include nonpigmented striae (silver or pink
“stretch marks”), freckles,
birthmarks, nevi
- women commonly have chlaosma (melasma) –
hyperpigmentation on the face
and neck associated with pregnancy or use of
hormones

c. Nevi (moles) - forms vary in size and degree of pigmentation

- present on most persons regardless of skin color
- may occur anywhere
- may be flat, slightly raised, dome-shaped, smooth, rough,
hairy
- color ranges from tan, gray and shades of brown to black
- may be dysplastic, precancerous, or cancerous
- dysplastic tend to occur on the upper back in men
and legs in women

d. color hues in dark-skinned persons are best seen in sclera,

conjunctiva, buccal mucosa,
tongue, lips, nail beds, and palms
- heavily callused palms will have an opaque yellow cast
- palms and soles are lighter in color than the rest of the
body
- hyperpigmented macules on soles of feet are common
- freckling of buccal cavity, gums, and tongue is common
- sclera may appear yellowish brown (“muddy”) or contain
brownish pigment that
looks like petechiae
- bluish hue of lips and gums can be normal (some people
have very blue lips,
giving a false impression of cyanosis)

e. systemic disorders can produce generalized or localized color

changes
- localized redness often results from an inflammatory
process
- pale, shiny skin of lower extremities may reflect peripheral
changes from things like
diabetes and cardiovascular disease
- injury, steroids, vasculitis, and several systemic disorders
can cause localized
hemorrhage into cutaneous tissues, producing red-
purple discolorations

echymoses – discolorations produced by injury

petechiae – if smaller than 0.5 cm in diameter,
discolorations produced by causes
other than injury
 purpura – if larger than 0.5 cm in diameter, discolorations
produced by causes
other than injury

2. Palpation - describe lesions, particularly in relation to elevation or

depression
a. moisture - minimal perspiration or oiliness should be present
- increased perspiration may be associated with activity,
warm environment, obesity,
anxiety or excitement
- may be noticeable on palms, scalp, forehead, and in axillae
- pay close attention to areas that get little or no exposure
to circulating air (folds of
large breasts, obese abdomens, or inguinal area)

b. temperature – should range from cool to warm to the touch

- use dorsal surface of hands or fingers
- looking for bilateral symmetry

c. texture – should feel smooth, soft, and even

- roughness on exposed areas or areas of pressure (elbows,
soles, palms) may be
caused by heavy or woolen clothing, cold weather,
soap
- extensive or widespread roughness may be result of
keratinization disorder or
healing lesions
- hyperkeratoses, especially of palms and soles, may be sign
of systemic disorder

d. turgor and mobility – “instant recall”

– gently pinch small section of skin on forearm or sternal
area then release
- skin should feel resilient, move easily when pinched, and
return to place
immediately when released
- turgor will be altered if patient is substantially dehydrated
or edema is present
- connective tissue diseases (scleroderma) will affect skin
mobility

3. Skin Lesions – catchall term that collectively describes any pathologic

skin change or occurrence
- if uncertain about a lesion, use the descriptor rather than the
name
- characteristics include size, shape, color, texture, elevation
or depression,
pedunculation, exudates, configuration, annular
(rings), grouped, location,
 arciform (bow-shaped), diffuse, generalized or
localized, patterns

primary – occur as initial spontaneous manifestations of a pathologic

process

NAME DESCRIPTION EXAMPLES

MACULE Flat, circumscribed area change in color, Freckles, flat moles
< 1 cm in diameter
PAPULE Elevated, firm, circumscribed area, <1 cm Wart, elevated moles
in diameter
PATCH Flat, non-palpable, irregular shaped Port wine stains,
macule >1 cm in diameter vitiligo
PLAQUE Elevated, firm, and rough lesion > 1 cm in Psoriasis, actinic
diameter keratoses
WHEAL Elevated, irregular-shaped are of Insect bites, allergic
cutaneous edema; solid, transient, reaction
variable diameter
NODULE Elevated, firm, deeper in dermis than Erythema nodosum,
papule; 1 – 2 cm in diameter; VERY lipomas
obvious where lesion starts
TUMOR Elevated, solid lesion; deeper in dermis; > Benign tumor,
2 cm in diameter; difficult to define hemangioma
borders
VESICLE Elevated, cirumscribed superficial, not Varicella (chicken pox),
into dermis, filled with serous fluid, < 1 herpes, shingles
cm in diameter
BULLA Vesicle > 1 cm in diameter Blister
PUSTULE Elevated, superficial lesion, similar to Acne, infected ant bite
vesicle but filled with purulent fluid
CYST Elevated, circumscribed encapsulated Sebaceous cyst, cystic
(deep), in dermis or subcutaneous layer, acne
filled with liquid or semi-solid material
TELANGIECTAS Fine, irregular, red lines produced by Telangiectasia in
IA capillary dilation (spider veins) rosacea

secondary – result from later evolution of or external trauma to a

primary lesion

NAME DESCRIPTION EXAMPLES

SCALE Flaky skin, irregular, thick or thin, Flaking with dermatitis
dry or oily, variation in size following scarlet fever
LICHENIFICATI Rough, thickened epidermis Chronic dermatitis
ON secondary to persistent rubbing,
itching, or skin irritation (deep)
KELOID Irregular shaped, elevated enlarging Keloid formation
scar, more common in dark skinned following surgery
 SCAR Thin to thick fibrous tissue that Healed wound or
replaces normal skin following injury surgical incision
or laceration
EXCORIATION Loss of epidermis, hollowed-out Abrasion or scratch,
crusted area scabies
FISSURE Linear crack or break, may be moist Athlete’s foot, cracks on
or dry corner of mouth
EROSION Follows rupture of vesicle or bulla Varicella (chicken pox)
ULCER Concave, varies in size Deubiti, stasis ulcers
CRUST Dried serum, blood, or purulent Scab on abrasion,
exudate, slightly elevated, brown, eczema
red, black, tan, or strawberry colored
ATROPHY Thinning of skin surface, loss of skin Striae, aged skin
markings, translucent and paperlike

B. HAIR
a. texture - scalp hair may be coarse or fine, curly or straight, and
should be shiny, smooth, and
resilient
- palpate scalp hair for dryness and brittleness that could indicate
systemic disorder

b. color – varies from very light blond to black to gray

c. distribution and quantity – varies according to individual genetic

makeup
- present on scalp, lower face, neck, nares, ears, chest, axillae,
back and shoulders, arms,
legs, toes, pubic area, around nipples
- hair loss on feet and toes may indicate poor circulation or
nutritional deficit
- note whether hair shafts are broken off or completely absent
- asymmetric hair loss may indicate pathologic condition
- women in their 20s and 30s may develop adrenal androgenic
female-pattern alopecia (hair
loss)
- fine vellus hair covers body, coarse terminal hair occurs on scalp,
pubic, and axillary areas,
on arms and legs, in beard of males

C. NAILS – condition of hair and nails gives a clue about the patient’s level of self-
care and some sense of
emotional order and social integration

1. Inspection
a. color and length – shape and opacity vary considerably
- nail bed color should be variations of pink
- pigment deposits or bands may be present in dark skinned
- edges should be smooth and rounded
- look for nail ridging, grooves, depressions, and pitting
 b. configuration and symmetry – nail base angle should measure 160
degrees
- in clubbing, the angle increases and approaches or exceeds 180
degrees
- associated with a variety of respiratory and cardiovascular
diseases, cirrhosis,
colitis, and thyroid diseases
- boggy nail base

2. Palpation – nails should feel hard and smooth with a uniform thickness
- thickening may occur from tight-fitting shoes, chronic trauma,
and some fungal infections
- thinning of the nail may also accompany some nail diseases
- gently squeeze the nail between your thumb and pad of finger to
test for adherence of nail
to nail bed

D. DEVELOPMENTAL VARIATIONS
1. Infants, Children
- first few hours of life, skin may look very red progressing to more
gentle pink
- color is partly determined by chubbiness (less subcutaneous fat,
the redder and more
transparent)
- dark skinned do not always manifest intensity
- exceptions are the nail beds and skin of scrotum
- all newborns are covered to some degree by vernix caseosa
(whitish, moist, cheeselike
substance)
- turgor is an important indication of hydration and nutrition
- seriously dehydrated or very poorly nourished skin will
retain “tenting” after it is
pinched

EXPECTED COLOR CHANGES DESCRIPTION

ACROCYANOSIS
CUTIS MARMORATA
ERYTHEMA TOXICUM
HARLEQUIN COLOR CHANGE
MONGOLIAN SPOTS
TELANGIECTATIC NEVI (STORK
BITES)
SKIN LESIONS: EXTERNAL
CLUES TO INTERNAL PROBLEMS
CAFE’ AU LAIT PATCHES
Cyanosis of hands and feet
Transient mottling when infant is exposed to
decreased temperature
Pink popular rash with vesicles superimposed on
thorax, back, buttocks, and abdomen
Clearly outlined color change as infant lies on
side; dependent lower half of body becomes pink
and upper half is pale
Irregular areas of deep blue pigmentation (sacral
and gluteal areas), common in dark skinned
Flat, deep pink localized areas usually on back of
neck
Flat, evenly pigmented spots varying from light

FACIAL PORT-WINE STAIN
SUPERNUMERARY NIPPLES
brown to dark brown or black, > 5mm in
diameter
In opthalmic division:
Most notable glaucoma, may be accompanied
by
angiomatous malformation of meninges
Limb or Trunk:
Venous varicosities, and hypertrophy, may
result in
bleeding and/or orthopedic problems
Congenital Lymphedema w/ or w/out
hemangiomas:
Caused by absence of X chromosome
Congenital accessory nipples w/ or w/out
glandular tissue, located along mammary ridge

B. Adolescents
- examination of skin is the same as that for the adult
- may have increased oiliness and perspiration, and increased hair
oiliness
- increased sebum production predisposes to development
of acne
- body odors increase with increased perspiration

C. Pregnant Women
- stretch marks may appear over abdomen, thighs, and breasts
- telangiectasis (vascular spiders) may increase five-fold and will
be found on face, neck,
chest, and arms
- cutaneous tags are either pedunculated or sessile skin tags that
are most often found on
neck and upper chest

- chloasma (mask of pregnancy) – found on the forehead, cheeks,

bridge of nose, and chin
- blotchy appears and usually symmetric
- increase in pigmentation affecting areolae and nipples, vulvar
and perianal regions, axillae,
and linea alba

linea nigra – pigmentation of linea alba

- extends from sumphysis pubis to top of fundus in midline

D. OLDER ADULTS
- may appear more transparent and paler
- pigment deposits, increased freckling, and hypopigmented
patches
- flaking or scaling over extremities
- skin becomes thinner (especially over bony prominences, dorsal
surface of hands and feet,
 forearms, and lower legs) and takes on a parchment like
appearance and texture
- skin often appears to hang loosely
- turgor may not be reliable or valid estimate of hydration status
- greater risk of pressure sores
STAGING OF PRESSURE SORES
Stage I Skin red but not broken
Stage II Damage through epidermis and
dermis
Stage III Damage through to
- subcutaneous tissue
expected findings Stage IV Muscle and possible bone
include: involvement
• Cherry angiomas = tiny, bright ruby-red, round papules that may
brown with time
• Cutaneous tags = small, soft tags of skin usually appearing on
neck and upper chest
• Senile lentigines (age spots) = irregular, round, gray-brown lesions
with rough surface

VI. COMMON ABNORMALITIES

Corn – flat or slightly elevated, circumscribed painful lesions with smooth,
hard surface
Callus – superficial area of hyperkeratosis, usually occurring on weight-
bearing area of feet and palmar
surface of hands
Eczematous Dermatitis – inflammatory skin disorder of epidermal
breakdown, usually as a result of
intracellular vesiculation
Furuncle – acute localized staph. infection, developing initially as a small
perifollicular abscess and spreads
to surrounding dermis and subcutaneous tissue

Folliculitis – staph. Infection of hair follicle and surrounding dermis produces

folliculitis
- small pustule 1 to 2 cm in diameter located over a pilosebaceous
orifice and may be perforated by
a hair
Cellulitis – diffuse, acute, strep. or staph. Infection of skin and subcutaneous
tissue
- skin is red, hot, tender, and indurated
Tinea – goup of noncandidal infections that involve stratum corneum, nails, or
hair
- classified according to anatomic location and can occur on nonhairy
parts of body
- referred to as “ring worms”
Pityriasis Rosea – self-limiting inflammation of unknown cause
 - sudden onset with primary (herald) oval or round plaque with fine,
superficial scaling
Psoriasis – chronic and recurrent disease of keratin synthesis characterized
by well-circumscribed, dry,
silvery, scaling papules and plaques
Rosacea – chronic inflammatory skin disorder characterized by
telangiectasia, erythema, papules, and
pustules that occur particularly in central area of face
Herpes Zoster – viral infection, that consists of red, swollen plaques or
vesicles that become filled with
purulent fluid
- pain, itching, or burning of dermatome area
- referred to as “shingles
Herpes Simplex – viral infection that produces tenderness, pain, paresthesia,
or mild burning at infected site
before onset of lesions
- associated with oral infection and type 2 genital infection

Pathogens used in Biologic Warfare

Communicabil Incubation Skin Lesions
ity
Cutaneo Direct person- Up to 12 days Pruritic macule or papule that
us to person following enlarges into round ulcer by day
Anthrax spread deposition of 2. Central necrosis develops with
extremely organism into skin painless ulcer covered by black
unlikely with previous eschar which dries and falls off.
abrasion May have 1 – 3 mm vesicles that
discharge clear or
serosanguinous fluid
Small Direct 12 days (range 7 – Rash appears 2 – 3 days after
Pox transmission by 17 days) following systemic symptoms, 1st on
infected saliva exposure mucosa of mouth and pharynx,
droplets face and forearms, spreading to
trunk.
Starts with flat red lesions that
evolve at same rate
Lesions become vesicular then
pustular and begin to crust

VII. SKIN: MALIGNANT ABNORMALITIES

ABCD Rule of Melanoma
Asymmetry of lesion Borders; irregular Color blue / black or
variegated
Diameter > 6 mm Evolution (growth)

Basal Cell Carcinoma – most common cutaneous neoplasm commonly found

on the face
 - fair skin and solar exposure are risk factors
- forms include nodular, pigmented, cystic, sclerosing, and superficial

Squamous Cell Carcinoma – tumor arises in epithelium

- occurs most in sun exposed areas, particularly the scalp, back of
hands, lower lip, and ear
- lesions are soft, mobile, elevated masses with surface scale
Malignant Melanoma – skin cancer that develops from cells that migrate
into the skin, eye, central nervous
system, and mucous membranes during fetal development
Kaposi Sarcoma – tumor of endothelium and epithelial layer of skin
- lesions are soft, vascular, bluish-purple, and painless; may be either
macular or papular and may
appear as plaques, keloids, or eccymotic areas
Alopecia Areata – sudden, rapid, patchy loss of hair, usually from scalp or
face
- hair shaft is poorly formed and breaks off at the skin surface
- regrowth begins in 1 – 3 months
Hirsutism – growth of terminal hair in women in the male distribution pattern
on face, body, and pubic area

VIII. NAILS: INFECTION

Tinea Unguium – fungal infection of nail occurs in four distinct patterns
- most common form, distal nail plate turns yellow or white as
hyperkeratotic debris accumulates,
causing nail to separate from nail bed
- fungus grows in nail plate, causing it to crumble
Ingrown Nails – involve large toe, nail pierces the lateral nail fold and grows
into the dermis, causing pain
and swelling
Onycholysis – loosening of the nail plate with separation from nail bed that
begins at the distal groove
- associated with minor trauma

IX. NAILS: CHANGES ASSOCIATED WITH SYSTEMIC DISEASE

Koilonychia – central depression of the nail with lateral elevation of the nail
plate produces a concave
curvature and spoon appearance
- associated with iron deficiency anemia, syphilis, fungal dermatoses,
and hypothyroidism
Beau Lines – after stress temporarily interrupts nail formal, transverse
depressions appear at the bases of
the lunulae in nails
- associated with coronary occlusion, hypercalcemia, skin disease
White Banding (Terry Nails) – transverse white bands cover the nail except
for a narrow zone at the distal
tip - associated with cirrhosis and hypoalbuminemia
Psoriasis – can produce pitting, onycholysis, discoloration, and subungual
thickening
 - yellow scaly debris often accumulates, elevating nail plate
- severe psoriasis of the matrix and nail bed results in grossly
malformed nails and splinter
hemorrhages
Warts – epidermal neoplasms caused by viral infection
- occur at nail folds and extend under the nail

X. CHILDREN
Café au lait Patches – coffee-colored patches may be either harmless or
indicative of underlying disease
- presence of more than 5 patches with diameters of more than 1 cm in
children under 5 suggests
neurofibromatosis
Seborrheic Dermatitis – chronic, recurrent, erythematous scaling eruption is
localized where sebaceous
glands are concentrated (scalp, back, intertriginous and diaper
diseases)
- scalp lesions are scaling, adherent, thick, yellow, and crusted (cradle
cap) and can spread over the
ear and down the nape of the neck

Impetigo – highly contagious staph. or strep. infection of epidermis causes

pruritus, burning, and regional
lymphadenopathy
- initial lesion is small erythematous macule changing into vesicle or
bulla with a thin roof
- crust with characteristic honey color from exudate rupture
Acne Vulgaris – inflamed lesions of acne involve stagnation of sebum an d
comedo formation in
pilosebaceous follicle, with bacterial invastion
Reddened Patchiness – irregular reddened areas suggest richer capillary
bed can occur on nape of neck,
upper eyelids, forehead, and upper lip
- causes of lesions include capillary hemangioma, nevus flammeus,
nevus vaculosus, and
telangiectatic nevus
- usually appear by 1 yr. old
Chicken Pox (Varicella) – acute, highly communicable disease common in
children and young adults
- characterized by fever, mild malaise, and pruritic maculopapular skin
eruption then becomes
vesicular
- start on scalp and trunk then spread to extremities
- preventable by immunization
Measles (Rubeola) – also called hard measles or red measles, highly
communicable viral disease
- prodromal fever, conjunctivitis, coryza, and bronchitis occur, followed
by red, blotchy rash on the
face and neck spreading to the trunk and extremities
 German Measles (Rubella) – mild, febrile, highly communicable viral
disease characterized by generalized
light pink to red maculopapular rash
- low-grade fever, coryza, sore throat and cough develop followed by
appearance of macular rash on
face and trunk that rapidly becomes popular spreading to trunk
and lower extremities

XI. OLDER ADULTS

Stasis Dermatitis – lower legs and ankles are affected with erythematous,
scaling, weeping patches
- secondary to edema of chronic peripheral vascular disease
Solar Keratosis (Senile Actinic Keratosis) – slightly raised erythematous
lesion usually less than 1 cm in
diameter with irregular, rough surface
- common on dorsal surface of hands, arms, neck and face
- secondary to chronic sun damage and has malignant potential