Skin, Hair, and Nails Lecture

Inspection and palpation

The techniques used to simultaneously assess the skin, hair, and nails

Color awareness acknowledges that injuries may appear differently in certain skin tones, color blindness is ignoring this fact

The difference between color awareness and color blindness

Natural when available

Which is more preferable, natural or fluorescent light?

Albinism

Lack of melanin can lead to this variation in skin color

Vitiligo

Melanocytes being destroyed due to an autoimmune disorder, appears as white/lighter patches on skin

Melasma

Due to hormonal changes and worsened with exposure to sunlight, also known as chloasma or “mask of pregnancy” as

Hemosederin staining

Blood pooling in lower extremities and staining them red

Striae

Normal finding, stretch marks, start out red and fade to silver color

Cyanosis

Due to lack of oxygen, grayish blue on light skin and ashen gray on darker skin

Looking at mucous membranes

How can you better inspect cyanosis on darker skin?

Eccyhymosis

Bruise, appears dark red, purple, yellow, or green in light skin and deeper bluish or black in dark skin

Palpation and ask if tender

How can you better assess a bruise in darker skin tones?

Erythema

Redness, appears red in light skin and deep brown or purple in dark skin

Cellulitis

Infection of the skin, temperature increases

Excoriation

Abrasion or scratch, causes loss of epidermis

Pallor

Paleness, whiter skin in light skin and lighter, more yellowish brown or ashen in dark skin

In the conjunctiva of the eye

How can you better assess pallor in dark skin?

Petechiae

Pinpoint bruises from broken capillaries, reddish purple in light skin and dark skin

Oral mucosa or sclera

How can you better assess for petechiae in darker skin tones?

Jaundice

Excess bilirubin and common in liver failure, yellowish color in light skin and yellowish-green in darker skin

Sclera of the eye, palms of hands, soles of feet

How can you better assess for jaundice in darker skin tones?

Palpation, patient will present with similar symptoms

How can you better assess for a rash in darker skin tones?

Urticaria/Hives/Wheals

Usually caused by allergy, can be treated with antihistamines, can be palpated on skin

Palpation, patient will state it itches

How can you better assess hives on darker skin tones?

Nevi (mole)

Located in sun exposed areas typically less than 5 mm

Papule

Raised lesions or mole

Macule

Flat mole, non-palpable change in skin tone (freckle)

A - asymmetry or symmetric
B - border is defined or undefined
C - color is uniform or different colors
D - diameter/size (less than 5 mm is ideal)
E - elevated or flat, any changes?
F - what does it feel like to pt

What does the ABCDEF model assess for in moles? Highlighted is normal finding

Use sunscreen, no tanning beds, wear hats and sun protection

What are ways that we can promote and primarily prevent melanoma?

Basal cell carcinoma (BCC)

Most common skin cancer, not metastatic

Squamous cell carcinoma (SCC)

2nd most common skin cancer, metastatic

If its unilateral

When is a difference in temperature of skin concerning?

Dorsal

Which part of the hand best palpates temperature?

Dry but not excessively dry

How should the skin feel in terms of moisture?

Diaphoresis

Excessive moisture on skin abnormal with absence of activity, can indicate low sugar

More thin and loses elasticity

As we age, the skin gets…

Acanthosis nigricans

Increased thickness in the skin causing discoloration, due to insulin resistance and NOT poor hygiene

Turgor

Testing hydration, pinching forearm or clavicle and assessing if tenting is or is not present

Clavicle

Where should you assess turgor on an older adult?

Alopecia

Hair loss due to autoimmune disease or anemia, male pattern baldness and patches of balding

Alopecia Areata

Hair loss due to follicles being chronically inflamed, affects any gender

Hirsutism

Too much unwanted hair due to hormonal changes, i.e. women with PCOS have hair on upper lip

Pediculosis

Head lice

Seborrheic dermatitis

Dandruff, common in light skin, cured with certain shampoo

Melanonychia

Dark, longitudinal lines in nails

Beau’s lines

Transverse groove in nails caused by trauma

Koilonychia

Spoon nail, typically caused by anemia

Leukonychia

White spots on nails caused by trauma

Clubbing

Angle of 180 degrees or greater at nailbed, sign of chronic hypoxemia

Paronychia

Infected hangnail, redness, swelling, and pus can all be present, often happens with nail biters of frequent exposure to moisture

Onychomycosis

Fungus in the nails, becomes thick, yellow, and brittle

Ingrown toenail

Nail grows laterally into the skin

Acrocyanosis

Blue or gray discoloration of the hands and feet found in newborns, normal

Acrocyanosis, jaundice, melanocytosis, patch and vascular birthmarks

Expected findings in newborns

Melanocytosis

Increased melanocytes in newborns, fades with age

Patches

Large, round/oval birthmarks that are flat and pigmented

Nevus Simplex (Stork bites)

Vascular birthmark, can be caused by dilation or abnormal growth of blood vessels, fades with age, small red or pink spot seen on the back of neck or eyelids, disappears usually with age

Nevus flammeus, infantile hemangioma, cavernous hemangioma

Abnormal findings in newborns

Nevus flammeus (port wine stain)

Large, bluish/purple macule along 5th cranial nerve on face in newborns, does not disappear by itself and laser treatment may be able to remove

Infantile hemangioma (Strawberry hemangioma)

Slightly raised red spot that typically disappears with age in newborns but may require laser treatment

Cavernous hemangioma

More problematic reddish/blue mass of blood vessels located on newborns, may need surgery if it affects eyesight or breathing

Milia (Milk spots)

Small papules on cheeks, nose, chin, and forehead of newborn that should disappear within 3 weeks of birth

Erythema toxicum neonatorum (baby acne)

Common rash located on newborns that goes away within 2 weeks, can be anywhere except palms of hands or soles of feet

Lanugo

Newborn hair that is fine and soft, most common on the back but can also be found on scalp, ears, and shoulders

Infantile Seborrheic Dermatitis (Cradle cap)

Crusty, oit scales on scalp in newborns (can also be on ears, nose, and groin), disappears over time

Serous

Vesicles are filled with this type of fluid

Purulent (pus)

Pustules are filled with this type of fluid

Seborrheic Keratoses (SK)

Noncancerous benign growth on older adults that is rough and elevated, typically tan, brown, or black in color, can appear anywhere

Dermatosis Papulosa Nigra (DPNs)

Variant of SK but is smaller (typically 1-5 mm), not moles, seen in sun exposed areas

Solar lentigo

Flat patches or sun spots on older adults, round or irregular

Acrochordon (Skin tags)

Fleshy, benign lesions in older adults

Multiple bruises in different stages, located in areas that aren’t typically fallen on

When assessing for bruises, what is a sign they are products of abuse?

Skin tears

Risk in older adults with thinner, more fragile skin

Geri sleeves

Sleeves that help to prevent skin tears

Areas with excessive pressure

Where do pressure ulcers happen?

Heels, sacrum, along back, back of the head

Most common areas for pressure ulcers when pt is in supine position

Hip

Most common area for pressure ulcer if patient is laying on the side

Blanch

White spot appears when pressing down on skin

Stage 1

Pressure ulcer that is nonblanchable but skin is still intact

Stage 2

Pressure ulcer that has partial thickness skin loss, shallow and open ulcer, no slough

Stage 3

Pressure ulcer where the subcutaneous fat is visible but no bone, tendon, or muscle is visible yer, presence of purulent drainage (slough)

Stage 4

Pressure ulcer where bone, tendon, and muscle are exposed, slough and escar are present

Kennedy Terminal Ulcer (KTU)

Pressure ulcer that progresses rapidly and is associated with terminally ill patients, typically seen on sacrum

Unstageable

Pressure ulcer that has too much slough or escar present to see into the ulcer

Deep Tissue Injury (DTI)

Pressure ulcer that looks like a bruise but is really deep tissue damage