Assessment Skin

skin layers

epidermis
dermis
subcutaneous tissues

What influences skin color

Melanin: brown, genetically determined, pregnancy might change
hemoglobin: red, hemoglobin binds to oxygen for color, cyanosis
carotene: yellow, subcutaneous tissues, palms, and soles
bilirubin: yellow, RBC and liver

Hair

vellus hair: fine (peach fuzz)
terminal hair: coarse ex: hair on head, eyebrows

Seborrheic karatosis

warty, stuck on, benign growth

Benign nevi

“mole”
brown round symmetric macules
single hyperpigmented round symmetric macule

Hand, foot, and mouth

palmar / plantar aspect, unruptured vesicles
virus

Melanoma

ABCDEFG
A: asymmetry
B: border irregularity
C: Color variations
D: Diameter >6mm
E: Elevation and / or evolution
F: Firm to palpation
G: Growing rapidly over several weeks

Hair loss

diffuse: iron deficiency anemia, hyper or hypothyroidism, pregnancy / post partum, male or female pattern hair loss
patchy: alopecia areata, tinea capitis, hypothyroidism: lateral 1/3 of eyebrow

Onychomycosis

fungal infection of nail
thick, yellow, pulled away

What causes pruritus

dry skin
pregnancy
renal failure (uremia)
jaundice
lymphoma or leukemia
hyperglycemia (diabetes)

Skin history: dryness, moisture, oiliness

dryness: hypothyroidism
sweating (diaphoresis): hyperthyroidism, angina
oiliness: acne vulgaris

excessive bruising

thrombocytopenia
hematologic malignancies
vonWillebrand’s disease
hemophilia
vitamin K deficiency

Diabetes mellitus skin manifestation

velvety hyperpigmented plaques
mostly on neck, flexural surfaces, intertriginous surfaces
ex: axilla

systemic lupus erythathematosus (SLE) skin manifestation

malar rash
symmetric erythema on bridge of nose and cheeks
looks like a butterfly rash
small discrete erythematous macules / papules with scaling
dark skin: purple

Hypercholesterolemia skin manifestation

xanthoma
flat fatty plaques
high cholestrol
anywhere, mostly on joints, hands, feet eyelids

liver cirrhosis skin manifestation

spider angioma, caput medusa

Hyperthyroidism skin manifestation

pretibial myxedema
thickening of anterior skin with slight redness and papules

HIV / AIDS skin manifestation

Kaposi sarcoma
scattered purple plaques on skin and mucous membranes

Scabies skin manifestation

highly contangious due to person to person contact
intertriginous areas, flexor space of wrist, belt line
like to burrow in a linear distribution

hair palpation

finer hair: hyperthyroidism
coarser hair: hypothyroidism

Cyanosis

reaction to cold
raynaud’s phenomenon
heart or lung disease

jaundice

RBC hemolysis ex: sickle cell disease
liver disease

pallor

anemia

Hyperpigmentation

melasma / linea nigra: pregnancy
bronze hyperpigmentation: primary adrenal insufficiency (Addison’s disease - adrenal glands can’t produce enough hemoglobin), hemochronotosis

Hypopigmentation

vitiligo
tinea versicolor: fungal, ringworm

varicose veins

distended superficial veins

cherry angioma

benign made of small cluster of blood

ecchymosis

trauma / abuse
bleeding disorders

petechia / purpura

meningitis, bleeding disorders, vasculitis (autoimmune inflammation of blood vesicle)

ulcers

poor arterial supply, poor venous return, diabetes

edema causes

heart failure
liver disease
renal disease
myxedema (thyroid disease)
venous disease: poor venous return, thrombosis

Macule

primary lesion
flat, non palpable < 1 cm

drug eruption macule

erythematous confluent macules on arms, chest, and back

patch

primary lesion
macule > 1 cm

tinea cruris

bilateral reddish brown, geographic patches with peripheral scaling on inner thighs, sparing the scrotum

seborrheic dermatitis

bilaterally symmetric erythematous patches on central cheeks, eyebrows, and nasolabial folds with overlying greasy scale

papule

primary lesion
raised, palpable <1 cm

squamous cell carinoma

rough papule that bleeds easily and don’t completely heal, firm borders, central umbilication

basal cell carcinoma

oval pink pearly papule with overlying telangiectasias

plaque

primary lesion
papule >1 cm

nodule

primary lesion
larger deeper papule

vesicle

primary lesion
fluid filled, raised, <1 cm

bulla

primary lesion
vesicle >1 cm

pustule

primary lesion
exudate filled, raised, <1 cm

wheal

primary lesion
localized migratory edema

crust

secondary lesions
dried exudate overlying

erosion

secondary lesions
loss of epidermis that heals without scarring

Ulcer

secondary lesions
full thickness loss of epidermis with damage to the dermis

Fissure

secondary lesions
linear break in the skin

Scale

secondary lesions
increased accumulation of keratinized skin with shedding / exfoliation

Scar

secondary lesions
permanent fibrosis

molluscum contagiosum

multiple small pink firm smooth domed papules with central umbillications

psoriasis

scattered erythematous to pink well circumcised flat topped plaques on extensor surfaces, with overlying silvery scale
auspitz sign: pinpoint bleeding when scale is removed
koebner’s phenomenon: psoriatic lesions at site of trauma

atopic dermatitis (eczema)

pruritic erythematous lichenified (thickened from rubbing) poorly circumcised plaques

pityriasis rosea

herald patch is a single oval, flat topped superficial erythematous to skin colored plaque

sebacious cyst (epidermal inclusion cyst)

firm nodule with overlying black comedone or punctum with expressible foul smelling cheesy material

lipoma

painless, slow growing rubbery nodule composed of adipose tissue

herpes zoster

grouped 2-5 mm vesicles on erythematous base in a dermatomal distribution that does not cross the midline

contact dermatitis

scattered 2-5 mm erythematous papules and vesicles with transudate crust, some with linear arrays

acne vulgaris

noninflammatory open and / or closed comedones (blackheads and whiteheads) and inflammatory lesions (papules, pustules, cysts, or noduels) typically located on face, neck, back, chest and upper arms

rosacea

inflammatory facial flushing, erythema, papules, pustules, and telangiectasias
“adult acne” looks like flushing

abscess

collection of pus, often with central pustule or drainage site
furuncle: at hair follicle
carbuncle: collection that connect and drain

uritcaria

migratory edematous geographical wheals of various sizes

Impetigo

red macule or papule that progressed to a vesicle and then to a honey colored crusted lesion

herpes simplex labialis or genitalis

papules on erythematous base within 24 hours of produme, progress to vesicle within hours, vesicles rupture leaving erosion that crusts then heals
primary HSV lesions start off as gingivostomatitis typically on vermillion border of lip / hard palate
HSV genitalis typically 4-7 days after sexual exposure

arterial insufficiency

ulcer from poor arterial flow occurring on toes and sites of trauma; may occur with gangrene

Venous insufficiency

ulcer from venous stasis occurring on medial ankle without gangrene

diabetic ulcer

ulcer often precipitated by trauma on distal or dorsal toes, plantar metatarsal heads, and the heel, may occur with gangrene

tinea pedis (athletes foot)

fungal infection of the foot that commonly presents with interdigital erythema, scaling, maceration, and fissures

keloid scar

raised hypertrophied scar that extends beyond the original wound barriers

acne vulgaris

pitting and scarring secondary to severe nodulocystic acne

Calor

increased temperature
infection or inflammation

poikilothermia

decreased arterial flow, decreased temperature

clubbing

convex angle of the nail plate associated with hypoxemia

spoon nails

concave angle of the nail plate associated with iron deficiency anemia

beau’s lines

transverse depressions on nails associated with severe disease

paronychia

abscess and / or cellulitis adjacent to nail

splinter hemorrhages

red / brown linear streaks in the nails bed associated with acute infectious endocarditis

tinea versicolor

multiple 2-5 mm hypopigmented, hyperpigmented, or tan round to oval macules on upper neck and back, upper chest, and arms with slight inducible scale on scrapping

skin tags

multiple 2 - 4 mm soft fleshy skin colored to light brown papules on lateral neck and axillae folds

guttate psoriasis

scattered erythematous round drop like flat topped well circumscribed scaling papules and plaques on trunk

plaque psoriasis

scattered erythematous to bright pink well circumscribed flat topped plaques on extensor knees and elbows with salivary scale

nummular dermatitis

multiple round coin like eczematous plaques on arms and legs and abdomen with overlying dried transudate crust