Skin, Hair & Nails

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Review the anatomy and physiology of these structures

Review the function of these structures SUBJECTIVE DATA:

o Past history of skin disease:

*allergies *psoriasis *acne Many have familial tendencies

o Change in pigmentation:
*Hypopigmentation: loss of color *Hyperpigmentation: increase in color

o Change in moles: get someone to look at your back. o Excessive dryness or moisture:
*Seborrhea oily *Xerosisdry

o Any itching:
*Pruritus: #1 skin condition: dry skin, aging, drug reaction, allergies, lice.

o Any excessive bruising, look for:

*multiple cuts/bruises *illogical explanation *falls *side effect of alcoholism or drug abuse

o Any rashes or lesions:

*Where did it start *Has it spread *Setting. Anyone at home with similar problem *Alleviating and aggravating factors

o Medications: what do you take: prescription, over-the-counter o Any hair loss or growth:
*Alopecia: significant hair loss *Hirsutism: excess body hair

Any change in the nails: *color *brittleness *shape

Environmental or occupational hazards: *Sailors *outdoor workers

*roofers *coal workers

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Self-care behaviors: what do you do to take care of your skin, hair, nails? OBJECTIVE DATA Skin gives you information about: *circulation *nutritional status *systemic diseases You will need: *direct lighting *ruler *penlight *gloves COLOR:

o Pinkish tan to ruddy dark tan o Light to dark brown o Yellow or olive overtones o Pale or fair o Lighter pigmentation on palms, nails, lips of dark-skinned people o Vitiligo: absence of melanin pigment

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Pigmentation darker in sun-exposed areas

Common benign pigmented areas: *Freckles (ephelides): small, flat macules of brown pigment on sun-exposed skin *Mole (nevus): proliferation of melanocytes, tan to brown in color; flat or raised *Junctional nevus: macular only occurs in children and adolescents. Progresses to a compound nevi in young adults that are macular and papular

The mnemonic ABCDE Asymmetry of a pigmented lesion Border: irregularity Colored variations (brown, blue, red, white) Diameter greater than 6 mm (size of pencil eraser) Elevation & Enlargement

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Note color change over the entire body: *Is it transient and expected: *due to pathology? Most reliable sites to detect color change are those areas with least pigmentation: *under the tongue *buccal mucosa *palpebral conjunctiva *sclera

o Pallor: common in acute high-stress states such as anxiety or fear or due to

peripheral vasoconstriction from sympathetic nervous system stimulation

o Light skin: pale or whitish

o Brown-skinned: more of a yellowish-brown color o Black-skinned: ashen or gray o Generalized pallor:

*mucous membranes *lips *nail beds

o Pallor from anemia:

*palpebral conjunctiva *nail beds *pull conjunctiva to visualize near the outer and inner canthus COLOR:

o Erythema: Intense redness of the skin: o *due to excess blood in the dilated superficial capillaries o *fever o *local inflammation o *emotional states o Erythema associated with fever or inflammation is characterized by increased skin
temperature (so palpate the skin)

o Cyanosis: bluish, mottled color that signifies decreased perfusion o o

Do not confuse with common bluish tone on the lips of dark-skinned people of Mediterranean origin. Can be difficult to assess in darkly pigmented persons Most conditions that cause cyanosis also cause decreased oxygenation of the brain: get changes in levels of consciousness (LOC) and respiratory distress

o Jaundice: yellow color, indicates rising amounts of bilirubin in the blood o Physiologic jaundice in newborn is normal. All other jaundice is NOT normal. Best
to look for jaundice in the sclera (will extend up to the edge of the iris). Jaundice occurs with hepatitis, cirrhosis, sickle cell disease

o Callouses on the feet may be yellow, but is not jaundice

TEMPERATURE:

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Temperature: use the back (dorsal side) of your hand

Always check bilaterally

Warmth is a normal finding and indicates normal circulation

Hands and feet may be cooler in a cool environment

Hypothermia: generalized coolness may be induced in surgery *Expected with an immobilized extremity *May accompany shock *May occur in peripheral arterial insufficiency and Reynaud's disease

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Hyperthermia: occurs with increased metabolic rate, such as in fever, or after heavy exercise Persons with hyperthyroidism have an increased metabolic rate causing warm, moist skin Moisture:

o Perspiration: normal on face, hands, axilla, & skin-folds with activity/anxiety o Diaphoresis: or profuse perspiration, accompanies increased metabolic rate such
as with fever. Also occurs with stimulation of the nervous system with anxiety/pain

o Dehydration: look at oral mucous membranes: will look dry and lips will look
parched and cracked

o Darker skin may look dry and flaky, but does not indicate dehydration
Texture:

o Normal finding is smooth, firm skin with an even surface o Hypothyroidism: rough, dry, flaky o Hyperthyroidism: smoother, softer, feels like velvet
Edema

o Fluid accumulating in the intercellular spaces; not normally present o To check for edema, press your thumb along the tibia or on the ankle malleolus

o Normal finding is the skin stays firm and smooth o If the pressure leaves a dent, called pitting edema
Pitting edema is graded:

o 1+ mild pitting, slight indentation o 2+ moderate pitting, indentation subsides rapidly o 3+ deep pitting; indentation remains for a short time o 4+ very deep pitting; indentation lasts a long time o Edema evident in dependent areas:
*Ankles *Feet *Sacral area

o Often has an orange-peel look (peau dorange)

Turgor

o Pinch up a fold of skin on the anterior chest under the clavicle (use the abdomen in
elderly as the clavicular area does not have much subcutaneous tissue

o Poor turgor evident in dehydration or extreme weight loss; the skin recedes slowly or
tents Skin findings:

o Cherry (senile) angioma: are small (1-5 mm) smooth, slightly raised bright red dots
common on the trunk in adults over 30

o Increase in size and number with age; of no significance

Lesions

o If present, note the following:

*Color *Elevation: flat, raised *Pattern or shape *Size: centimeters, use a ruler *Location on body *Any exudates

o Primary: develops on previously unaltered skin

Secondary: a lesion that changes over time or changes because of a factor such as scratching Primary Lesions: Macule: is a color change; flat, circumscribed; less than 1 cm Ex: freckles, flat nevi, measles Patch: A macule that is larger than 1 cm Ex: Mongolian spot, vitiligo Papule: solid, elevated, circumscribed, less than 1 cm; due to thickening in the epidermis Ex: wart (verruca), elevated nevus (mole) Plaque: papules that have coalesced to form surface elevation wider than 1 cm Ex: psoriasis Nodule: solid, elevated, hard or soft, larger than 1 cm Ex: fibroma

Tumor: firm or soft, larger than a few centimeters in diameter; benign or malignant; Ex: lipoma, hemangioma Wheal: superficial, raised, erythematous Ex: mosquito bite, allergic reaction Urticaria (Hives): wheals that have coalesced to form an extensive reaction, very pruritic (itches) Vesicle: elevated cavity containing free fluid, up to 1 cm Ex: chickenpox, herpes zoster (shingles) Bulla: larger than 1 cm in diameter; thin walled, so it ruptures easily. Ex: burns, blister, contact dermatitis Cyst: encapsulated, fluid-filled cavity. Ex: sebaceous cyst Pustule: turbid fluid (pus) in a cavity, elevated. Ex: impetigo, acne Secondary Lesions: Crust: dried-out exudate left when a vesicle/pustule bursts or dries up; can be redbrown, honey, or yellow. Ex: weeping eczematous dermatitis, scab after an abrasion Scale: flakes of skin, from shedding of dead excess keratin cells. Ex: psoriasis or eczema Fissure: linear crack that extends into the dermis; is dry or moist. Ex: cheilosis (seen at corners of the mouth due to excess moisture), athletes foot Erosion: scooped out shallow depression involving only the epidermis Ulcer: deeper depression extending into the dermis, may bleed, scars when it heals Ex: stasis ulcer, pressure sore Excoriation: self-inflicted abrasion; scratches from intense itching. Ex: insect bites, varicella (chickenpox) Scar: collagen replaces normal tissue after a skin lesion is repaired. Ex: healed area or surgery, acne Atrophic scar: thinning of the epidermis. Ex: striae Lichenification: intense scratching eventually thickens the skin; looks like surface of moss or lichen (hence the name) Keloid: hypertrophic scar; higher incidence among darker skin tones Shape & Configuration of Lesions:

Annular (circular): begins in the center and spreads to the periphery Ex: tinea corporis or ringworm Confluent: lesions run together Ex. Hives Zosteriform: linear arrangement along a nerve route Ex. herpes zoster Discrete: distinct, individual lesions Ex. molluscum Hair Color: comes from melanin production. Texture: fine or thick; straight or curly Distribution: fine vellus hair coats the body; coarser hairs grow at the eyebrows, eyelashes, and scalp Hirsutism: refers to excess body hair; often indicates endocrine abnormalities Nails Shape and contour: normal slightly curved/flat Profile sign: use to note the angle of the nail base. Should be about 160 degrees *In early clubbing the angle changes to 180 degrees or more and the nail base feels spongy *Clubbing often occurs with congenital cyanotic heart disease, emphysema, and chronic bronchitis

o Dark-skinned people may have brown-black pigmented areas or linear bands along
the nail edge

o Many people have white linear markings from trauma