Download Chapter 8 Skin, Hair, and Nails Physical Examination Preview Skin

Chapter 8
Skin, Hair, and Nails
Physical Examination Preview
Skin
Perform overall inspection of entire skin surface.
During evaluation of each organ system, evaluate the overlying skin for the following
characteristics:
Color
Uniformity
Thickness
Symmetry
Hygiene
Lesions
Odors
Skin (Cont.)
Palpate skin surfaces for the following:
Moisture
Temperature
Texture
Turgor
Mobility
Hair
Inspect hair for the following:
Color
Distribution
Quantity
Palpate hair for texture.
Nails
Inspect for the following:
Pigmentation of nails and beds
Length
Symmetry
Ridging, beading, pitting, peeling
Measure nail base angle.
Nails (Cont.)
Inspect and palpate proximal and lateral nail folds for the following:
Redness
Swelling
Pain
Exudate
Warts, cysts, tumors
Nails (Cont.)
Palpate nail plate for the following:
Texture
Firmness
Thickness
Uniformity
Adherence to nail bed
Anatomy and Physiology
Skin: Functions
The skin is a stratified structure composed of several functionally related layers that perform the
following integral functions:
Protect against microbial and foreign substance invasion and minor physical trauma
Retard body fluid loss by providing a mechanical barrier
Regulate body temperature through radiation, conduction, convection, and evaporation
Skin: Functions (Cont.)
Provide sensory perception via free nerve endings and specialized receptors
Produce vitamin D from precursors in the skin
Contribute to blood pressure regulation through constriction of skin blood vessels
Repair surface wounds by exaggerating the normal process of cell replacement
Excrete sweat, urea, and lactic acid
Express emotions
Skin Layers
Epidermis
Dermis
Hypodermis
Appendages
Epidermis
Outermost part of skin
Avascular and depends on the underlying dermis for its nutrition
Two major layers
Stratum corneum
Protects the body against harmful environmental substances and restricts water
loss
Cellular stratum
Keratin cells are synthesized
Basement membrane
Lies beneath the cellular stratum and connects the epidermis to the dermis
Dermis
Richly vascular connective tissue layer
Separates epidermis from cutaneous adipose tissue
Components
Elastin, collagen, and reticulin fibers
Provide resilience, strength, and stability
Sensory nerve fibers
Provide sensations of pain, touch, and temperature
Autonomic motor nerve
Innervate blood vessels, glands, and the arrectores pilorum muscles
Hypodermis
Connects dermis to underlying organs
Subcutaneous layer filled with fatty cells
Functions
Generates heat
Provides insulation
Provides shock absorption
Provides calorie reserve
Appendages
Eccrine sweat glands
Open directly onto the surface of the skin and regulate body temperature through water
secretion
Distributed throughout the body except at the lip margins, eardrums, nail beds, inner
surface of the prepuce, and the glans penis
Appendages (Cont.)
Apocrine sweat glands
Larger and located more deeply than the eccrine glands
In response to emotional stimuli, secrete a white fluid containing protein, carbohydrate,
and other substances
Secretions from these glands are odorless
Body odor produced by bacterial decomposition of apocrine sweat
Found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears
Appendages (Cont.)
Sebaceous glands
Secrete sebum, a lipid-rich substance that keeps the skin and hair from drying out
Secretory activity, which is stimulated by sex hormones (primarily testosterone), varies
according to hormonal levels throughout the life span
Appendages (Cont.)
Hair
Formed by epidermal cells that invaginate into the dermal layers
Melanocytes in the shaft provide its color
Adults have two kinds of hair:
vellus―short, fine, soft, and nonpigmented
terminal―coarser, longer, thicker, and usually pigmented
Males and females have about the same number of hair follicles that are stimulated to
differential growth by hormones
Appendages (Cont.)
Nails
Epidermal cells are converted to hard plates of keratin.
Highly vascular nail bed lies beneath the plate, giving the nail its pink color.
Stratum corneum layer of skin covering the nail root is the cuticle, or eponychium.
Soft tissue surrounding the nail border is the paronychium.
Infants and Children
Skin of infants and children appears smoother than that of adults because:
Of the absence of coarse terminal hair
Skin has not been subjected to years of exposure to the elements
Desquamation of stratum corneum may be present at birth or very shortly afterward.
Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth.
Subcutaneous fat is poorly developed in newborns, predisposing them to hypothermia.
Infants and Children (Cont.)
Lanugo is the fine silky hair that covers the newborn’s body, particularly on the shoulders and
back.
Shed within 10 to 14 days
Most of the infant’s hair is shed by about 2 to 3 months of age, to be replaced by more permanent
hair with a new texture and often a different color.
Eccrine glands function after 1 month.
Apocrine glands do not function.
Less oily texture
Inoffensive perspiration
Adolescents
Apocrine glands enlarge and become active.
Increased axillary sweating and sometimes body odor
Increased sebum production in response to increased hormone levels, primarily androgen
Oily appearance and predisposing the individual to acne
Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents,
and on the face of males
Pregnant Women
Increased blood flow to skin, especially that of the hands and feet, results from peripheral
vasodilation and increased numbers of capillaries.
Acceleration of sweat and sebaceous gland activity occurs.
Assist in dissipating the excess heat caused by the increased metabolism during
pregnancy
Vascular spiders and hemangiomas that are present may increase in size.
Pregnant Women (Cont.)
The skin thickens, and fat is deposited in the subdermal layers.
Because of increased fragility of connective tissues, separation may occur with stretching.
Most (about 90%) pregnant women have some degree of skin darkening beginning in early
pregnancy.
Face, nipples, areolae, axillae, vulva, perianal skin, and umbilicus
Older Adults
Sebaceous and sweat gland activity decreases and results in drier skin and less perspiration.
Epidermis thins and flattens, giving the skin a parchment appearance.
Dermis is less elastic; loss of collagen and elastic fibers causes wrinkled appearance of
epidermis.
Older Adults (Cont.)
Subcutaneous tissue also decreases, giving joints and bony prominences a sharp, angular
appearance.
Hollows in thoracic, axillary, and supraclavicular regions deepen
Gray hair is due to a decrease in the number of functioning melanocytes.
Axillary and pubic hair production declines due to reduced hormonal functioning.
Older Adults (Cont.)
Hair follicle size changes, and terminal scalp hair progressively transitions into vellus hair,
causing age-associated baldness in both men and women.
Opposite transition, from vellus to terminal, occurs in the hair of the nares and on the
tragus of men’s ears.
Nail growth slows because of decreased peripheral circulation.
Nails, particularly the toenails, become thicker, brittle, hard, and yellowish.
Review of Related History
History of Present Illness: Skin
Changes in skin
Temporal sequence
Symptoms
Location
Associated symptoms
Recent exposure
Apparent cause
Travel history
Treatment response
Adjustment to problem
Medications
History of Present Illness: Hair
Changes in hair
Occurrence
Associated symptoms
Exposure
Nutrition
Treatment
Adjustment
Medication
History of Present Illness: Nails
Changes in nails
Associated symptoms
Temporal sequence
Exposure
Treatment response
Medications
Past Medical History: Skin
Previous skin problems
Sensitivities, allergic reactions, or disorders
Lesions, treatments
Tolerance to sunlight
Diminished or heightened sensitivity to sensory stimuli
Cardiac, respiratory, liver, endocrine, or other systemic disease
Past Medical History: Hair
Previous hair problems
Hair loss, thinning, growth, unusual growth, brittleness, breakage, or treatments
Systemic problems
Thyroid or liver disorder
Severe illnesses
Malnutrition
Associated skin disorder
Past Medical History: Nails
Previous nail problems
Nail injury
Bacterial, fungal, or viral infection
Systemic problems
Associated skin disorder
Congenital anomalies
Respiratory, cardiac, hematologic, or other systemic diseases
Family History
Current or past dermatologic diseases or disorders in family members
Allergic hereditary diseases: asthma, hay fever
Familial hair loss or coloration patterns
Personal and Social History
Skin care habits
Cleansing routine, soaps, oils, lotions
Cosmetics, home remedies, sun screens
Recent changes in skin care habits
Skin self-examination
Nail care habits
Exposure to environmental or occupational hazards
Recent psychological or physical stress
Use of alcohol, tobacco, or recreational drugs
Infants
Feeding history
Diaper history
Types of clothing and washing practices
Bath practices
Dress habits
Temperature/humidity of home
Rubbing head against external surfaces
Children
Eating habits and types of food: sweets
Exposure to communicable diseases
Allergic disorders: eczema, urticaria, pruritus
Pets or animal exposure
Outdoor exposures: camping, hiking, picnics
Skin injury history: cuts, unexplained injuries
Chronic manipulation of hair
Nail biting
Pregnant Women
Weeks of gestation or postpartum
Hygiene practices
Exposure to irritants
Presence of skin problems before pregnancy
Effects of pregnancy on preexisting conditions
Psoriasis may remit; condylomata acuminata commonly become larger and more
numerous.
Older Adults
Increased or decreased sensation to touch or the environment
Generalized chronic itching, irritants
Susceptibility to skin infections
Healing response: delayed or interrupted
Frequent falls: cuts, bruises
History of diabetes mellitus or peripheral vascular disease
Hair loss history: gradual or sudden
Examination and Findings
Equipment
Centimeter ruler (flexible, clear)
Wood’s lamp (to view fluorescing lesions)
Flashlight with transilluminator
Handheld magnifying lens (optional)
Skin
Examination of the skin is performed by inspection and palpation.
The most important tools are your own eyes and powers of observation.
When gross inspection leaves you uncertain, a handheld magnifying glass or dermatoscope may
help.
Inspection
Adequate lighting is essential.
Daylight provides the best illumination for determining color variations, particularly
jaundice.
Tangential lighting is helpful in assessing contour.
Body sweep
Room temperature
Exposure
Draping
Inspection (Cont.)
Color and uniform appearance
Look for localized areas of discoloration
Thickness
Varies over the body
Symmetry
Hygiene
Inspection (Cont.)
Presence of lesions
Nevi (moles)
Vary in size and degree of pigmentation
Present on most persons regardless of skin color
Most nevi are harmless
May occur anywhere on the body
Inspection (Cont.)
Presence of lesions
Nevi (moles) (Cont.)
Dysplastic
Tend to occur on the upper back in men and on the legs in women
Palpation
Moisture
Minimal perspiration or oiliness should be present.
Temperature
Use the dorsal surface of your hands or fingers.
Texture
Smooth, soft, and even
Turgor
Altered if the patient is substantially dehydrated or if edema is present
Mobility
Move easily when pinched, and return to place immediately when released
Skin Lesions
Lesions
Any pathologic skin change or occurrence
Types:
Primary ‒ those that occur as initial spontaneous manifestations of a pathologic
process
Secondary ‒ those that result from later evolution of or external trauma to a
primary lesion
Skin Lesions (Cont.)
Characteristics
Size (measure all dimensions)
Shape
Color
Texture
Elevation or depression
Attachment at base
Pedunculated ‒ having a stalk
Sessile ‒ without a stalk
Skin Lesions (Cont.)
Characteristics (Cont.)
Exudates
Color
Odor
Amount
Consistency
Configuration
Annular (rings)
Grouped
Linear
Arciform (bow-shaped)
Skin Lesions (Cont.)
Characteristics (Cont.)
Location and distribution
Generalized or localized
Region of the body
Patterns
Discrete or confluent
Examination Tools
A small, clear, flexible ruler is necessary for measuring the size of lesions.
Centimeters are preferred.
Try to measure size in all dimensions (i.e., height, width, and depth) when possible.
Use a light for closer inspection of a particular lesion to detect its nuances of color, elevation, and
borders.
A ×5 to ×10 handheld magnifying lens is useful in evaluating the subtle details of a lesion.
Examination Tools (Cont.)
Transillumination may be used to determine the presence of fluid in cysts and masses.
Darkened room
Fluid-filled lesions will transilluminate with a red glow, whereas solid lesions will not.
Wood’s lamp can be used to evaluate epidermal hypopigmented or hyperpigmented lesions, and
to distinguish fluorescing lesions.
Darkened room
Hair
Fine vellus hair covers the body.
Coarse terminal hair occurs on the scalp, pubic, and axillary areas, on the arms and legs (to
some extent), and in the beard of men.
Look for hirsutism in women—growth of terminal hair in a male distribution pattern on the face,
body, and pubic area.
May be a sign of an endocrine disorder
Inspection
Color
Varies from very light blond to black to gray and may show alterations with rinses, dyes,
or permanents
Distribution
Symmetric or asymmetric
Inspect feet and toes for hair loss that may indicate poor circulation or nutritional deficit
Quantity
Varies according to individual genetic makeup
Palpation
Texture
Palpate the scalp hair for dryness and brittleness that could indicate a systemic disorder.
Note whether the hair shafts are broken off or are completely absent.
Nails
The condition of the fingernails can provide important insight to the patient’s sense of self.
The condition of the hair and nails gives a clue about the patient’s level of self-care and some
sense of emotional order and social integration.
Nail edges should be smooth and rounded.
Examine the proximal and lateral nail folds for redness, swelling, pus, warts, cysts, and tumors.
Inspection (Cont.)
Color
Length
Configuration
Symmetry
Cleanliness
Palpation (Cont.)
Hardness, smoothness, and uniform thickness
Test for adhesion to nail bed
Infants and Children
Inspection and palpation of skin for:
Expected color changes
Jaundice or hyperbilirubinemia
Defects signaling systemic conditions
Contour distortions
Skin creases indicating congenital abnormalities
Lesions indicating internal problems
Pinch skin for test of turgor
Adolescents
Examination same as for adult
Inspect for:
Increased oiliness and perspiration
Acne
Maturational changes
Pregnant Women
Inspect for:
Striae gravidarum (stretch marks)
Telangiectasias/hemangiomas
Cutaneous tags
Increased pigmentation
Palmar erythema
Itching
Altered hair growth
Older Adults
Inspect for: (Cont.)
Skin changes
Breakdown over bony prominences
Lesions
Hair changes
Nail changes
Abnormalities
Skin: Inflammatory and Infectious Conditions
Eczematous Dermatitis
Most common inflammatory skin disorder:
Irritant contact dermatitis
Allergic contact dermatitis
Atopic dermatitis
Skin: Inflammatory and Infectious Conditions (Cont.)
Folliculitis
Inflammation and infection of the hair follicle and surrounding dermis
Skin: Inflammatory and Infectious Conditions (Cont.)
Furuncle (boil)
Deep-seated infection of the pilosebaceous unit
Skin: Inflammatory and Infectious Conditions (Cont.)
Cellulitis
Diffuse, acute, infection of the skin and subcutaneous tissue
Tinea (dermatophytosis)
Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair
Skin: Inflammatory and Infectious Conditions (Cont.)
Pityriasis rosea
Self-limiting inflammation of unknown cause
Psoriasis
Chronic and recurrent disease of keratin synthesis
Skin: Inflammatory and Infectious Conditions (Cont.)
Rosacea
Chronic inflammatory skin disorder
Herpes zoster (shingles)
Varicella-zoster viral infection
Skin: Inflammatory and Infectious Conditions (Cont.)
Herpes simplex
Type 1: associated with oral infection
Type 2: associated with genital infection
Herpes Zoster
Skin: Cutaneous Reactions
Drug eruptions
Immunologically mediated cutaneous reactions to medications
Acanthosis nigricans
Nonspecific reaction pattern associated with obesity, certain endocrine syndromes or
malignancies, or as an inherited disorder
Skin: Biologic Warfare
Anthrax
Spore-forming bacterium Bacillus anthracis
Pruritic macule or papule that enlarges into a round ulcer by day 2
Central necrosis develops with a painless ulcer covered by black eschar
Smallpox
Variola virus
Flat red lesions that evolve at the same rate
Lesions become vesicular, then pustular and crust
Skin: Malignant/Neoplastic
Basal cell carcinoma
Most common form of skin cancer
Squamous cell carcinoma
Second most common skin cancer
Skin: Malignant/Neoplastic (Cont.)
Malignant melanoma
Lethal form of skin cancer that develops from melanocytes
Kaposi sarcoma
Neoplasm of the endothelium and epithelial layer of the skin caused by Kaposi sarcoma
herpes virus 8
Commonly associated with human immunodeficiency virus (HIV) infection
Hair Disorders
Alopecia areata
Sudden, rapid, patchy loss of hair, usually from the scalp or face
Scarring alopecia
Skin disorders of the scalp or follicles result in scarring and destruction of hair follicles
and permanent hair
Hair Disorders (Cont.)
Traction alopecia
Prolonged tension of the hair from traction breaks the hair shaft
Hirsutism
Growth of terminal hair in women in the male distribution pattern on the face, body, and
pubic areas
Nails: Infection
Paronychia
Inflammation of the paronychium
Onychomycosis
Fungal infection of the nail
Nails: Injury
Ingrown nails
Nail pierces lateral nail fold; grows into the dermis
Subungual hematoma
Trauma to the nail plate severe enough to cause immediate bleeding and pain
Leukonychia punctata
White spots in the nail plate
Nails: Injury (Cont.)
Median nail dystrophy
Nail deformity as result of nail picking or biting habit
Onycholysis
Loosening of the nail plate with separation from the nail bed that begins at the distal
groove
Nails: Changes Associated with Systemic Disease
Koilonychia (spoon nails)
Central depression of the nail with lateral elevation of the nail plate
Beau lines
Transverse depression in the nail bed
Nails: Changes Associated with Systemic Disease (Cont.)
White banding (Terry nails)
Transverse white bands
Psoriasis
Chronic and recurrent disease of keratin synthesis
Nails: Periungual Growths
Warts
Epidermal neoplasms caused by viral infection
Digital mucous cysts
Cystlike structures that contain a clear jelly-like substance
Infants and Children
Seborrheic dermatitis
Little known about etiology
Condition most commonly occurs in infants within the first 3 months of life
Miliaria (prickly heat)
Caused by sweat retention from occlusion of sweat ducts during periods of heat and high
humidity
Impetigo
Common, contagious superficial skin infection
Infants and Children (Cont.)
Acne vulgaris
Impaction and obstruction of the outflow of sebum
Chickenpox (varicella)
Acute, highly communicable disease common in children and young adults
Infants and Children (Cont.)
Measles (rubeola)
Measles virus infects by invasion of the respiratory epithelium
German measles (rubella)
Mild, febrile, highly communicable viral disease
Infants and Children (Cont.)
Hair pulling (trichotillomania)
Loss of scalp hair can be caused by physical manipulation
Patterns of injury in physical abuse
Bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages,
dental trauma, and head and abdominal injuries
Skin and hair abnormalities may be the most visible clues in detecting this problem
Pregnant Women
Pruritic urticarial papules and plaques of pregnancy (PUPPP)
Benign dermatosis that usually arises late in the third trimester of a first pregnancy
Herpes gestationis (pemphigoid gestationis)
Rare autoimmune disorder of pregnancy
Not related to the herpes virus infection
Older Adults
Stasis dermatitis
Occurs on the lower legs in some patients with venous insufficiency
Solar keratosis (actinic keratosis)
Squamous cell carcinoma confined to the epidermis
Physical abuse in older adults
Look for bruising, burns, abrasions, or areas of tenderness
Particularly on hidden areas such as the axillae, inner thighs, soles of the feet, palms,
and abdomen
Question 1
The nail base angle should measure:
A. 120 degrees
B. 140 degrees
C. 160 degrees
D. 180 degrees
Question 2
Fluorescing lesions are best distinguished using a(n):
A. Incandescent lamp
B. Magnifying glass
C. Transilluminator
D. Wood’s lamp
Question 3
Which of the following objective findings would you expect to see in folliculitis:
A. Acute onset of tender red nodule
B. Acute onset of papules and pustules
C. Pale, erythematous and macular
D. Telangiectasia, erythema and papules
Question 4
The adipose tissue in the hypodermis serves to:
A. Provide sensory input
B. Generate heat and insulate
C. Create tensile strength
D. Restrict water loss
Question 5
Koilonychia (spoon nails) are a central depression of the nail with lateral elevation of the nail
plate. This is commonly seen with which of the following systemic diseases:
A. Iron deficiency anemia, syphilis
B. Diabetes mellitus and hypothyroidism
C. Chronic congestive heart failure and cirrhosis
D. Psoriasis and hyperthyroidism