Skin, Hair, and Nails

Anatomy

Epidermis Stratum germinativum (basal cell layer)

Mitosis occurs here Contains melanocytes,

producing melanin Stratum corneum

As cells rise, they die and their cytoplasm is converted to keratin, which has a rough, horny texture

This layer undergoes constant shedding

Dermis Mostly connective tissue, primarily

collagen Provides support and nourishment of

epidermis Blood vessels, nerves, muscle, sweat

glands, sebaceous glands, hair follicles Subcutaneous Layer (Hypodermis)

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

Pulse oxymetry!

Used to measures what?

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

Chloasma

History

History of skin disease What was it? How was it treated? Does it run in the family?

Significant familial predispositions – allergies, hay fever, psoriasis, eczema, acne

Any know allergies? Any tattoos or birthmarks?

Use of nonsterile equipment for tattoos increases risk of Hep C Change in pigmentation

Might suggest systemic illness (jaundice) Change in a mole Pruritus

Any dryness? Is it seasonal? 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

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 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 6mm5. Elevation

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Changes in Color in Light Skinned People Pallor

Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobin

Shock, anemia Erythema

Redness due to increased blood flow (vasodilation) Fever, inflammatory process, emotions, CO poisoning

Cyanosis Bluish, purplish hue due to decreased perfusion of tissues Hypoxemia due to heart failure, shock, chronic bronchitis

Jaundice Yellow, orange hue due to jaundice (increased bilirubin in

blood) 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

Skin Assessment (cont.) Temperature

Check skin with dorsa of hands 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)*****

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.

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 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

Nails

Good indicators of respiratory system health

Nail base 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

Physiology of clubbing is not fully understood but respiratory insufficiency

seems to dilate peripheral arteries, causing a round fingernail shape

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

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.

Developmental Considerations - Adolescents

Acne 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

Open comedones (blackheads)

Closed comedones (whiteheads)

Acne

Open comedones are a less severe form of acne

Vascular Lesions - Hemangiomas

Port-Wine Stain (Nevus Flammeus) Flat macular patch of

mature capillaries Benign

Strawberry Mark (Immature hemangioma) 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

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 "non-blanchable" (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

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