9/16/2016

1

SKIN, HAIR, AND NAILS

2

SKIN • Body’s largest organ system • Covers 20 square feet of surface area in adults • Skin guards body • Environmental stresses, e.g., trauma, pathogens, dirt • Adapts it to other environmental influences, e.g., heat, cold • Two layers: • Epidermis • Dermis • Beneath these layers is a subcutaneous layer of adipose tissue •

3

STRUCTURE OF SKIN

4

SKIN • Epidermal appendages: • Structures formed by tubular invagination of epidermis down into underlying dermis • Hair • Sebaceous glands • Sweat glands: important for fluid balance and thermoregulation • Eccrine glands • Apocrine glands • Nails

5

STRUCTURE AND FUNCTION Skin is waterproof, protective, and adaptive • Protection from environment • Prevents penetration • Perception • Temperature regulation • Identification • Communication • Wound repair • Absorption and excretion • Production of vitamin D

6

SUBJECTIVE DATA • History of skin disease, allergies, hives, psoriasis, or eczema? • Change in pigmentation or color? • Change in mole size, shape, color, tenderness?

1

9/16/2016

Change in mole size, shape, color, tenderness? • Excessive dryness or moisture? • Pruritus--itching? • Excessive bruising? • Rash or lesions? • Medications: prescription and over-the-counter? • Hair loss? • Change in nails’ shape, color, or brittleness? • Environmental or occupational hazards? • Self-care behaviors? • 7

SUBJECTIVE DATA • Additional history for infants and children • Has child been exposed to: • Contagious skin conditions: scabies, impetigo, lice? • Communicable diseases: measles, chicken pox, scarlet fever? • Toxic plants: poison ivy? • Does child have habits such as nail biting or twisting hair? • What steps are taken to protect child from sun exposure?

8

SUBJECTIVE DATA • Additional history for adolescents • Skin problems such as pimples, blackheads? • Additional history for aging adults • What changes have you noticed in your skin in last few years? • Any delay in wound healing? • Any change in feet: toenails; bunions, wearing shoes? • Falling: bruises, trauma? • History of diabetes or peripheral vascular disease?

9

OBJECTIVE DATA • Skin assessment integrated throughout examination • Check outer skin surface first before the underlying structures • Separate intertriginous areas (areas with skinfolds) to inspect • These areas are dark, warm, and moist and provide perfect conditions for irritation or infection • Inspect lesions • With a rash, check all areas of body as you cannot rely on the history that rash is in only one location • Always inspect feet, toenails, and between toes

10

OBJECTIVE DATA • Inspect and palpate skin • Color

2

9/16/2016

Color • General pigmentation, freckles, moles, birthmarks • Widespread color change • Note color change over entire body skin, such as pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow) • Note if color change transient or due to pathology • Freckles, Moles, ABCDE 11

OBJECTIVE DATA • Inspect and palpate skin • Temperature • Skin should be warm, and temperature equal bilaterally; warmth suggests normal circulatory status • Hands and feet may be slightly cooler in a cool environment • Hypothermia • Hyperthermia • Moisture • Diaphoresis • Dehydration

12

OBJECTIVE DATA • Inspect and palpate skin • Texture • Thickness • Edema • Mobility and turgor • Vascularity or bruising • Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse • Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein

13

OBJECTIVE DATA • Inspect and palpate skin/hair • Lesions: • Color • Elevation • Pattern or shape • Size • Location and distribution on body • Any exudate: note color and odor • Wood’s light test • Primary or secondary? • Hair • Texture, distribution

3

9/16/2016

Texture, distribution 14

OBJECTIVE DATA • Inspect and palpate nails • Shape and contour • Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees • Consistency • Color • Capillary refill • Depress nail edge to blanch and then release, noting return of color; indicates status of peripheral circulation • Color return is normally instant • Sluggish color return takes longer than 1 or 2 seconds

15

ANNULAR OR CIRCULAR (TINEA CORPORIS, RINGWORM)

16

CONFLUENT (URTICARIA)

17

DISCRETE (ACNE, SKIN TAGS)

18

GYRATE (TWISTED, COILED SPIRAL, SNAKELIKE)

19

ZOSTERIFORM (FOLLOWS A NERVE, HERPES ZOSTER)

20

GROUPED (CONTACT DERMATITIS)

21

POLYCYCLIC (PSORIASIS)

22

ABNORMAL FINDINGS 1 Primary skin lesions 2 • Macules

• Papules • Patches • Plaques • Nodules • Wheals 3 • Tumors • Urticaria (hives) • Vesicles • Cysts • Bullas

4

9/16/2016

• Pustules 23

MACULE (FRECKLES, FLAT NEVI, PETECHIA, MEASLES)

24

PAPULE (ELEVATED NEVI, WART)

25

NODULE (FIBROMA, INTRADERMAL NEVI)

26

WHEAL (MOSQUITO BITE, ALLERGIC REACTION)

27

VESICLE (CHICKEN POX, SHINGLES) BULLA (FRICTION BLISTER, BURNS)

28

PUSTULE

29

ABNORMAL FINDINGS 1 Secondary skin lesions 2 • Debris on skin surface

• Crusts • Scales 3 • Break in continuity of skin surface • Fissures • Erosions • Ulcers • Excoriations • Scars • Atrophic scars • Lichenifications • Keloids 30

CRUST

31

FISSURE

32

ULCER

33

KELOID

34

ABNORMAL FINDINGS 1 Vascular Lesions 2 • Hemangiomas

• Port-wine stain (nevus flammeus) • Strawberry mark (immature hemangioma) • Cavernous hemangioma (mature) 35

ABNORMAL FINDING

5

9/16/2016

ABNORMAL FINDING NAILS • Scabies: scabies mites • Paronychia: bacterial infection, “wet work”

36

ABNORMAL FINDINGS NAILS • Onycholysis: fungal infection • Pitting • Habit-tic dystrophy

37

ABNORMAL FINDINGS NAILS • Clubbing

38

LESIONS CAUSED BY TRAUMA OR ABUSE: PATTERN INJURIES

39

LESIONS CAUSED BY TRAUMA OR ABUSE: HEMATOMAS

40

ABNORMAL FINDINGS (CONT.) • Common skin lesions in children • Diaper dermatitis • Impetigo • Atopic dermatitis (eczema) • Chickenpox (varicella)

41

ABNORMAL FINDINGS • Common skin lesions • Allergic drug reaction • Tinea corporis (ringworm of the body) • Psoriasis • Labial herpes simplex (cold sores) • Erythema migrans of Lyme disease

42

ABNORMAL FINDINGS • Malignant skin lesions • Basal cell carcinoma • Squamous cell carcinoma • Malignant melanoma • Metastic malignant melanoma

43

ABNORMAL FINDINGS 1 Abnormal conditions of hair 2 • Seborrheic dermatitis (cradle cap)

• Trichotillomania • Pediculosis capitis (head lice)

6

9/16/2016

• Folliculitis • Hirsutism

7