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Skin
 Perform overall inspection of entire skin surface.
 During evaluation of each organ system, evaluate
the overlying skin for the following characteristics:
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Color
Uniformity
Thickness
Symmetry
Hygiene
Lesions
Odors
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Skin (Cont.)
 Palpate skin surfaces for the following:
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Moisture
Temperature
Texture
Turgor
Mobility
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Hair
 Inspect hair for the following:
 Color
 Distribution
 Quantity
 Palpate hair for texture.
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Nails
 Inspect for the following:
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Pigmentation of nails and beds
Length
Symmetry
Ridging, beading, pitting, peeling
 Measure nail base angle.
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Nails (Cont.)
 Inspect and palpate proximal and lateral nail folds
for the following:
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Redness
Swelling
Pain
Exudate
Warts, cysts, tumors
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Nails (Cont.)
 Palpate nail plate for the following:
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Texture
Firmness
Thickness
Uniformity
Adherence to nail bed
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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
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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
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Figure 8-01. Anatomic Structures of the Skin.
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Epidermis
 Outermost part of skin
 Avascular and depends on the underlying dermis
for its nutrition
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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
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Hypodermis
 Connects dermis to underlying organs
 Subcutaneous layer filled with fatty cells
 Functions
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Generates heat
Provides insulation
Provides shock absorption
Provides calorie reserve
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Glands
 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
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Glands (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
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Glands (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
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Hair/ Nails
 Hair
 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
 Nails
 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.
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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.
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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
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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
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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
 Most (about 90%) pregnant women have some degree
of skin darkening beginning in early pregnancy.
 Face, nipples, areolae, axillae, vulva, perianal skin, and
umbilicus
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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.
 Subcutaneous tissue also decreases, giving joints and
bony prominences a sharp, angular appearance.
 Gray hair is due to a decrease in the number of
functioning melanocytes.
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History of Present
Illness: Skin
 Changes in skin
 Apparent cause
 Temporal sequence
 Travel history
 Symptoms
 Treatment response
 Location
 Adjustment to problem
 Associated symptoms
 Medications
 Recent exposure
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History of Present
Illness: Hair
 Changes in hair
 Nutrition
 Occurrence
 Treatment
 Associated symptoms
 Adjustment
 Exposure
 Medication
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History of Present
Illness: Nails
 Changes in nails
 Associated symptoms
 Temporal sequence
 Exposure
 Treatment response
 Medications
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Past Medical History:
Skin
 Previous skin problems
 Sensitivities, allergic reactions, or disorders
 Lesions, treatments
 Diminished or heightened sensitivity to sensory
stimuli
 Cardiac, respiratory, liver, endocrine, or other
systemic disease
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Past Medical History:
Hair
 Previous hair problems
 Hair loss, thinning, growth, unusual growth,
brittleness, breakage, or treatments
 Systemic problems
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Thyroid or liver disorder
Severe illnesses
Malnutrition
Associated skin disorder
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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
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Family History
 Current or past dermatologic diseases
or disorders in family members
 Allergic hereditary diseases: asthma,
hay fever
 Familial hair loss or coloration patterns
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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
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Infants
 Feeding history
 Diaper history
 Types of clothing and washing practices
 Bath practices
 Dress habits
 Temperature/humidity of home
 Rubbing head against external surfaces
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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
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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.
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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
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Equipment
 Centimeter ruler (flexible, clear)
 Wood’s lamp (to view fluorescing lesions)
 Flashlight with transilluminator
 Handheld magnifying lens (optional)
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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.
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Inspection
 Adequate lighting is essential.
 Daylight provides the best illumination for determining
color variations, particularly jaundice.
 Tangential lighting is helpful in assessing contour.
 Color and uniform appearance
 Look for localized areas of discoloration
 Thickness
 Varies over the body
 Symmetry
 Hygiene
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Inspection (Cont.)
 Presence of lesions
 Nevi (moles)
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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
Dysplastic
 Tend to occur on the upper back in men and on the legs in
women
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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
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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
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Skin Lesions (Cont.)
 Characteristics
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Size (measure all dimensions)
Shape
Color
Texture
Elevation or depression
Attachment at base
 Pedunculated ‒ having a stalk
 Sessile ‒ without a stalk
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Skin Lesions (Cont.)
 Characteristics (Cont.)
 Exudates
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Color
Odor
Amount
Consistency
 Configuration
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Annular (rings)
Grouped
Linear
Arciform (bow-shaped)
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Skin Lesions (Cont.)
 Characteristics (Cont.)
 Location and distribution
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Generalized or localized
Region of the body
Patterns
Discrete or confluent
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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.
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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
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Hair (Inspection)
 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
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Hair (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
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Hair (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.
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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.
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Nails (Inspection)
 Color
 Length
 Configuration
 Symmetry
 Cleanliness
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Nails (Palpation)
 Hardness, smoothness, and uniform thickness
 Test for adhesion to nail bed
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Infants and Children
 Inspection and palpation of skin for:
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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
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Adolescents
 Examination same as for adult
 Inspect for:
 Increased oiliness and perspiration
 Acne
 Maturational changes
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Pregnant Women
 Inspect for:
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Striae gravidarum (stretch marks)
Telangiectasias/hemangiomas
Cutaneous tags
Increased pigmentation
Palmar erythema
Itching
Altered hair growth
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Older Adults
 Inspect for: (Cont.)
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Skin changes
Breakdown over bony prominences
Lesions
Hair changes
Nail changes
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Skin: Inflammatory and
Infectious Conditions
 Eczematous Dermatitis
 Most common inflammatory skin disorder:
 Irritant contact dermatitis
 Allergic contact dermatitis
 Atopic dermatitis
 Folliculitis
 Inflammation and infection of the hair follicle and
surrounding dermis
 Furuncle (boil)
 Deep-seated infection of the pilosebaceous unit
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Skin: Inflammatory and
Infectious Conditions
(Cont.)
 Pityriasis rosea
 Self-limiting inflammation of unknown cause
 Psoriasis
 Chronic and recurrent disease of keratin synthesis
 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
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Skin: Inflammatory and
Infectious Conditions
(Cont.)
 Rosacea
 Chronic inflammatory skin disorder
 Herpes simplex
 Type 1: associated with oral infection
 Type 2: associated with genital infection
 Herpes zoster (shingles)
 Varicella-zoster viral infection
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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
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Skin:
Malignant/Neoplastic
 Basal cell carcinoma
 Most common form of skin cancer
 Squamous cell carcinoma
 Second most common skin cancer
 Malignant melanoma
 Lethal form of skin cancer that develops from
melanocytes
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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
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Hair Disorders
 lopecia 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
 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
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Nails: Infection
 Paronychia
 Inflammation of the paronychium
 Onychomycosis
 Fungal infection of the nail
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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
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Nails: Changes Associated
with Systemic Disease
 White banding (Terry nails)
 Transverse white bands
 Koilonychia (spoon nails)
 Central depression of the nail with lateral elevation
of the nail plate
 Beau lines
 Transverse depression in the nail bed
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Nails: Periungual
Growths
 Warts
 Epidermal neoplasms caused by viral infection
 Digital mucous cysts
 Cystlike structures that contain a clear jelly-like
substance
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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
 Acne vulgaris
 Impaction and obstruction of the outflow of sebum
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Infants and Children
(Cont.)
 Chickenpox (varicella)
 Acute, highly communicable disease common in children
and young adults
 Measles (rubeola)
 Measles virus infects by invasion of the respiratory
epithelium
 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
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Pregnant Women
 Pruritic urticarial papules and plaques of
pregnancy (PUPPP)
 Benign dermatosis that usually arises late in the
third trimester of a first pregnancy
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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
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