Transcript 02. Assessment of Skin, Hair, and Nails

Skin, Hair, and Nails
Anatomy
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Epidermis
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Stratum germinativum (basal cell layer)
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Stratum corneum
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As cells rise, they die and
their cytoplasm is converted
to keratin, which has a rough,
horny texture
This layer undergoes
constant shedding
Dermis
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Mitosis occurs here
Contains melanocytes,
producing melanin
Mostly connective tissue, primarily
collagen
Provides support and nourishment of
epidermis
Blood vessels, nerves, muscle, sweat
glands, sebaceous glands, hair follicles
Subcutaneous Layer (Hypodermis)
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Consists mostly of fat
Provides protection, insulation, and
caloric source
Anatomy
 Hair
Composed of keratin
 Can be fine (vellus hair) or darker and thicker (terminal hair)
 Sebaceous glands
 Produce sebum through hair follicles, which make skin oily. Prevent
water loss.
 Sweat glands
 Eccrine – smaller, coiled tubules which open to skin surface
 Apocrine – larger, open to hair follicles. Located mainly in axillae
and genital area. Produce thick secretions, which react with
bacteria on skin surface to produce body odor
 Nails
 Composed of keratin
 Clear with highly vascular bed of epithelial cells underneath
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Used to
measures
what?
Pulse oxymetry!
Developmental Considerations
 Infants
Lanugo – fine soft hair present at
birth
 Skin is thinner, less fat – more
prone to dehydration and
hypothermia
 Pregnancy
 Linea nigra – line down midline of
abdomen
 Chloasma – face of pregnancy
 Striae gravidarum – stretch
marks
 Aging
 Stratum corneum thins, loss of
collagen, elastin, and fat,
decrease of sebaceous and
sweat glands,
 More prone to dehydration and
hypothermia
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Chloasma
History
 History of skin disease
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What was it? How was it treated?
Does it run in the family?
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Significant familial predispositions – allergies, hay fever,
psoriasis, eczema, acne
Any know allergies?
Any tattoos or birthmarks?
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Use of nonsterile equipment for tattoos increases risk of Hep C
 Change in pigmentation
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Might suggest systemic illness (jaundice)
 Change in a mole
 Pruritus
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Any dryness? Is it seasonal?
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Xerosis – dry
Seborrhea - oily
History
 Excessive bruising
Consider abuse
 Frequent minor trauma may be sign of alcohol abuse
 Rash or lesion
 Onset
 Location
 Spread
 Character or quality
 Duration
 Associative factors – pets, co-worker?
 Alleviating and aggravating factors – what have you tried to
do?
 Patient’s perception - what do you think it is?
 Medications
 Prescription and over-the-counter
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May indicate allergy to medication
History
 Hair loss or growth
 Gradual or sudden?
 Hirsutism – unusual growth
 Change in nails
 Exposure to hazards
 May be environmental or occupational
 Bitten by bee, tick, mosquito?
 Exposure to plants or animals?
 Self care
 What cosmetics, soaps, chemicals?
 Possible allergies
Physical Examination - Color
 General pigmentation –
should be even
throughout
 Benign pigmented areas
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Freckles (macules) on
sun exposed skin
Nevi (moles)
 Junctional nevi –
macular only
 Compound nevi –
macular and papular
 Dysplastic precancerous
Birthmarks
 Vitiligo – absence of
melanin in patchy areas
*****
ABCDE of malignant melanoma
1. Asymmetry – one lesion that is
not regularly round or oval
2. Border – irregular
3. Color – variations
4. Diameter – greater than 6mm
5. Elevation
Changes in Color in Light Skinned
People
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Pallor
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Pale, white color caused by decrease of blood flow
(vasoconstriction) or decrease in hemoglobin
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Shock, anemia
Erythema
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Redness due to increased blood flow (vasodilation)
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Fever, inflammatory process, emotions, CO poisoning
Cyanosis
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Bluish, purplish hue due to decreased perfusion of tissues
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Hypoxemia due to heart failure, shock, chronic bronchitis
Jaundice
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Yellow, orange hue due to jaundice (increased bilirubin in
blood)
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Due to liver problems such as hepatitis, cirrhosis
Color Changes in Darker Skinned
People
 Pallor
Brown skinned people will be more yellow. Black skinned people
will be more gray
 Palpebral conjunctiva and nail beds should be observed
 Erythema
 Cannot be observed
 If fever suspected, check skin for warmth. If edema, check skin
for tightness
 Cyanosis
 Darker skinned people have normal bluish tone on lips
 Palms, but not clearly evident, other clinical signs should be
observed
 Jaundice
 Hard and soft palate must be observed in addition to sclera of
eyes
 Dark urine also present
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Skin Assessment (cont.)
 Temperature
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Check skin with dorsa of hands
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Hyperthyroidism may cause increase of temp
 Moisture
Diaphoresis may occur during fever or exercise
 Dehydration can be observed by dry mucous membranes in mouth and
cracked skin
 Mobility and Turgor
 Mobility is ease of skin rising when pinched. Turgor is returning back to
its place
 Slow turgor can be indicative of dehydration. “Tenting” if severe
dehydration.
 Lesions
 A lesion is any traumatic or pathological change in skin
 Describe using ABCDE, also noting location and exudate
 Roll nodule gently between fingers to assess depth
 Ultraviolet light is used if fungal infection suspected (Wood’s light)*****
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Skin Assessment - shapes
 Annular
 Circular, beginning in center
and spreading to periphery
(ringworm)
 Polycyclic
 Annular lesions that grow
together
 Confluent
 Lesions run together (hives)
 Discrete
 Individual lesions that remain
separate
Shapes
 Grouped
 Clusters of lesions (contact
dermatitis)
 Gyrate
 Twisted, coiled
 Target
 Concentric rings of color
 Linear
 Scratch like, stripe
 Zosteriform
 Follow nerve route
(shingles)
Primary vs. Secondary
 Primary skin lesions
 Variations in color or texture that may be present at
birth, such as moles or birthmarks, or that may be
acquired during a person's lifetime, such as those
associated with infectious diseases (e.g. warts, acne,
or psoriasis), allergic reactions (e.g. hives or contact
dermatitis), or environmental agents (e.g. sunburn,
pressure, or temperature extremes).
 Secondary skin lesions
 Changes in the skin that result from primary skin
lesions, either as a natural progression or as a result of
a person manipulating (e.g. scratching or picking at) a
primary lesion.
Primary Skin Lesions
 Macule
 color change and less
than 1 cm
 may be to darker or
lighter
 Freckles, flat nevi,
hypopigmentation,
petechiae
 Patch
 Color change and
greater than 1cm
 Mongolian spots,
vitiligo, chloasma
Primary Skin Lesions
 Papule
 Elevated lesion less
than 1cm in diameter
 Due to elevation in
epidermis
 Ex: wart, elevated
nevus
 Plaque
 Elevation greater than
1cm in diameter
 Ex: psoriasis
Primary Skin Lesions
 Nodule
 Elevated solid greater
than 1cm
 Extending deeper into
dermis
 Tumor
 Greater than few cm in
diameter
 May be firm or soft
Primary Skin Lesions
 Wheal
 Superficial, raised,
transient, and
erythematous lesion
 Ex. Mosquito bite,
allergic reaction
Primary Skin Lesions
 Cyst
 Encapsulated fluid
filled cavity in dermis
or subcutaneous layer
 Vesicle
 Elevated cavity
containing free fluid,
clear
 Less than 1cm
diameter
 Ex: herpes simplex,
varicella zoster
Primary Skin Lesions
 Bulla
 Larger than 1cm in
diameter
 Superficial in
epidermis, thin walled
 Ex: blisters, burns
 Pustule
 Pus in cavity
 Ex: impetigo, acne
Secondary Skin Lesions
 Crust
 Thick, dry exudate
after rupture or drying
up of vesicle or pustule
 Ex: Impetigo, scab
following abrasion
 Scale
 Dry or greasy flakes of
skin resulting from
shedding of excess
keratin cells
 Ex: psoriasis, eczema,
seborrheic dermatitis
Secondary Skin Lesions
 Fissure
 Linear cracks
extending into dermis
 Ulcer
 Deep depression
extending into dermis
 May bleed. Leave
scar.
 Excoriation
 Self inflicted abrasion
often from scratching
Secondary Skin Lesions
 Lichenification
 Tightly packed papules
from prolonged intense
scratching
 Keloid
 Hypertrophic scar
 Cannot be removed
surgically
 More common in black
people
Skin Lesions associated with AIDS –
Kaposi’s Sarcoma
 Patch stage
Early lesions are faint and
pink
 Advanced stage
 Widely disseminated lesions
involving skin, mucous
membranes, and visceral
organs
 Violet colored tumors on
nose and face
 Epidemic stage
 Lesions develop into raised
papules of thickened
plaques.
 Oval in shape and vary in
color from red to brown.
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Hair and Scalp
 Ringworm may develop in scalp of school
age children
 Abnormalities in amounts and location of hair
can be attributed to hormonal problems
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Hirsutism – excess body hair
 Observe for head or pubic lice, which are
white ovals on hair shafts.
 Dandruff is indicated by loose white flakes
Abnormal Conditions of Hair
 Tinea capitis (scalp ringworm)
 Lesions fluoresce blue-green
under Wood’s light
 Highly contagious
 Toxic alopecia
 Asymmetric balding that
accompanies severe illness or
chemotherapy
 Regrowth after discontinuation
of toxin
Abnormal Conditions of Hair
 Folliculitis
Superficial infection of hair
follicles
 Multiple pustules
 Furuncle and Abscess
 Red, swollen, hard, tender,
pus-filled lesion due to acute
localized bacteria (staph)
 Usually on back of neck,
buttocks, wrists, or ankles
 Furuncle is due to infected
hair follicles
 Abscess is due to traumatic
introduction of bacteria into
the skin. Deeper than
furuncle
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Nails
 Good indicators of
respiratory system health
 Nail base
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Physiology of clubbing is not fully
understood but respiratory insufficiency
seems to dilate peripheral arteries,
causing a round fingernail shape
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Normal is about 160°
Clubbing is the decrease
of the angle of nail base
(<160°) that occurs as a
result of respiratory
insufficiency, common in
COPD (emphysema,
chronic bronchitis)
In early clubbing, the
angle actually increased to
about 180°
Spongy nails
Nails
 Consistency
 Variant thickness may suggest malnutrition
 Thickening of nails is sign of arterial insufficiency
 Color
 Note any pigmentations – melanoma?
 Cyanotic nail beds – poor peripheral circulation
 Capillary refill
 Indicator of peripheral circulation
 Measured by depressing the nail bed until it is white
and observing the time it takes for blood to return back
to the nail
 Normal time is less than 1-2 seconds and is indicated
as “brisk.” “Sluggish” if greater than 2 seconds.
Developmental Considerations Infants
 Mongolian spots
Hyperpigmentation of
sacrum, buttocks,
abdomen, thighs,
shoulders, or arms
 Very common in blacks,
Asians, and Native
Americans
 Should not be confused
with abuse
 Café au lait
 “Coffee with milk”
 Patches of
hyperpigmentation
 Normal
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Developmental Considerations Infants
 Acrocyanosis
Bluish color around lips, hands, and feet
 Usually is due to coolness and disappears after warming
up
 Persistent cyanosis is indicative of congenital heart
disease
 Cutis marmorata
 Mottling of trunk and extremities due to coolness
 If persistent, usually indicative of Down syndrome
 Physiological jaundice
 Common yellowing of skin in newborns, which usually
appears after 4th day. UV light helps.
 Carotenemia
 Yellowing of skin due to ingestion of large amts of
carotene.
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Developmental Considerations Adolescents
 Acne
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Most common skin problem
Acne occurs when the hair
follicles, which are
connected to sebaceous
glands, become plugged
with oil and dead skin cells.
Usually appear on face,
shoulders, back, and chest
Can include papules,
pustules, and nodules
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Open comedones
(blackheads)
Closed comedones
(whiteheads)
Acne
 Open comedones are
a less severe form of
acne
Vascular Lesions - Hemangiomas
 Port-Wine Stain (Nevus
Flammeus)
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Flat macular patch of
mature capillaries
Benign
 Strawberry Mark
(Immature hemangioma)
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Raised bright red area
Usually disappears by
age 7
 Cavernous Hemangioma
Developmental Considerations Pregnancy
 Striae
 Linea nigra
 Chloasma
 Vascular spiders
Developmental Considerations Aging
 Senile lentigines
Liver spots – melanocyte
clusters
 Usually on hands and
face
 Seborrheic keratosis
 Raised, thick, crusted
“mole”
 Dry skin is common
 Acrochordons
 Overgrowths of skin –
normal
 Frequently occur on
back, eyelids, axillae
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Developmental Considerations Aging
 Decreased turgor, tenting of skin occurs
 Hair growth decreases, thins
 Fungal infections of toenails
Teaching Self-Exam
Pressure Ulcers
 Stage I
 A reddened area on
the skin that, when
pressed, is "nonblanchable" (does
not turn white). This
indicates that a
pressure ulcer is
starting to develop.
 Stage II
 The skin blisters or
forms an open sore.
The area around the
sore may be red and
irritated.
Pressure Ulcers
 Stage III
 The skin breakdown
now looks like a
crater where there is
damage to the tissue
below the skin.
 Stage IV
 The pressure ulcer
has become so deep
that there is damage
to the muscle and
bone, and sometimes
tendons and joints.
Braden Scale
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Sensory Perception
Activity
Mobility
Skin Moisture
Friction and Shear
Nutrition
 1-4 with the exception
of friction & shear
subscale 1-3
 Range 4-23
 The lower the score
the higher the risk
 Eighteen or less:
high risk older adult