Skin - Hair - Nails

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

B.

10.

How the patient is adjusting to the problem

11.

Medications: topical or systemic, nonprescription or prescription

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. disorders

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

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

IV.

2.

Allergic hereditary diseases such as asthma or hay fever

3.

Familial hair loss or coloration patterns

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

A.

SKIN

AND

FINDINGS

- 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. sun-exposed to

skin symmetry - detect differences between body areas, compare 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 redpurple 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 MACULE PAPULE PATCH PLAQUE WHEAL NODULE TUMOR VESICLE BULLA PUSTULE CYST TELANGIECTAS IA

DESCRIPTION Flat, circumscribed area change in color, < 1 cm in diameter Elevated, firm, circumscribed area, <1 cm in diameter Flat, non-palpable, irregular shaped macule >1 cm in diameter Elevated, firm, and rough lesion > 1 cm in diameter Elevated, irregular-shaped are of cutaneous edema; solid, transient, variable diameter Elevated, firm, deeper in dermis than papule; 1 – 2 cm in diameter; VERY obvious where lesion starts Elevated, solid lesion; deeper in dermis; > 2 cm in diameter; difficult to define borders Elevated, cirumscribed superficial, not into dermis, filled with serous fluid, < 1 cm in diameter Vesicle > 1 cm in diameter Elevated, superficial lesion, similar to vesicle but filled with purulent fluid Elevated, circumscribed encapsulated (deep), in dermis or subcutaneous layer, filled with liquid or semi-solid material Fine, irregular, red lines produced by capillary dilation (spider veins)

EXAMPLES Freckles, flat moles Wart, elevated moles Port wine stains, vitiligo Psoriasis, actinic keratoses Insect bites, allergic reaction Erythema nodosum, lipomas Benign tumor, hemangioma Varicella (chicken pox), herpes, shingles Blister Acne, infected ant bite Sebaceous cyst, cystic acne Telangiectasia in rosacea

secondary – result from later evolution of or external trauma to a primary lesion NAME SCALE LICHENIFICATI ON

KELOID

DESCRIPTION Flaky skin, irregular, thick or thin, dry or oily, variation in size Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation (deep) Irregular shaped, elevated enlarging scar, more common in dark skinned

EXAMPLES Flaking with dermatitis following scarlet fever Chronic dermatitis Keloid formation following surgery

SCAR EXCORIATION FISSURE EROSION ULCER CRUST ATROPHY

Thin to thick fibrous tissue that replaces normal skin following injury or laceration Loss of epidermis, hollowed-out crusted area Linear crack or break, may be moist or dry Follows rupture of vesicle or bulla Concave, varies in size Dried serum, blood, or purulent exudate, slightly elevated, brown, red, black, tan, or strawberry colored Thinning of skin surface, loss of skin markings, translucent and paperlike

Healed wound or surgical incision Abrasion or scratch, scabies Athlete’s foot, cracks on corner of mouth Varicella (chicken pox) Deubiti, stasis ulcers Scab on abrasion, eczema Striae, aged skin

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. c. makeup

color – varies from very light blond to black to gray distribution and quantity – varies according to individual genetic

- 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 selfcare and some sense of emotional order and social integration 1. a.

Inspection 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. degrees

configuration and symmetry – nail base angle should measure 160 - 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 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

DESCRIPTION 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 B.

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

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 Skin red but not broken Damage through epidermis and dermis Stage III Damage through to subcutaneous tissue Stage IV Muscle and possible bone involvement Stage I Stage II

expected findings include: • 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 weightbearing 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 Cutaneo us Anthrax

Small Pox

Communicabil ity Direct personto person spread extremely unlikely

Direct transmission by infected saliva droplets

Incubation Up to 12 days following deposition of organism into skin with previous abrasion 12 days (range 7 – 17 days) following exposure

Skin Lesions Pruritic macule or papule that enlarges into round ulcer by day 2. Central necrosis develops with painless ulcer covered by black eschar which dries and falls off. May have 1 – 3 mm vesicles that discharge clear or serosanguinous fluid Rash appears 2 – 3 days after systemic symptoms, 1st on mucosa of mouth and pharynx, 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