Tissue integrity

Concepts: Perfusion, Gas Exchange, Nutrition, Motion, Tactile Sensory Perception, Elimination, and Pain

Functions of the skin

Protects the body, helps retain fluids and electrolytes, enables sensation, thermoregulates, synthesizes vitamin D, and excretes sweat, urea, lactic acid, expresses emotions, and replaces dead cells.

Epidermis

Avascular w/melanocytes and active cells generated in the stratum germinativum that fill the stratum corneum with 30 of these layers

Keratinization

A process in which Keratin (protein) flattens, hardens, and makes newly generated cells waterproof. 30 of these layers make up the Basale layer.

Melanocytes

Produced in the basal cell layers, it secretes melanin to give pigment to skin and hair and protects from UV lights

Dermis

Highly vascular (supplies epidermis) w/ connective tissue (contract w/body movement). Controls dilation and constriction of blood vessels, and uses sensory nerve fibers to detect pain, touch, and temperature.

Hypodermins (Subcutaneous)

Anchor to upper layers. Has loose connective tissue and is filled with subcutaneous fat that helps retain heat, cushions, and provide calories.

Eccrine sweat glands

Controlled by the nervous system, these glands allow regulation of body temperature by secreting water through the surface of the skin

Aprocrine sweat glands

Only in axillae, nipples, areolae, anogenital area, eyelids, and external ear. Begin at puberty and secrete odorless fluid filled w/protein, carbs, and others. Its decomposition is associated w/body odor.

Sebaceous glands

A lipid-rich substance called sebum keeps hair and skin lubricated. Stimulated by sex hormone activity, accelerates during puberty

Which of the following is a risk factor for skin cancer?

A. Personal history of skin cancer
B. Family history of skin cancer
C. Older age
D. Exposure to UV light (lifetime sun exposure, sunburn, or indoor tanning)
E. Light skin (blonde or red hair)
F. Blue/green eyes
G. Moles

All of the above

Skin cancer primary preventions

Protect skin (wear hats, tight woven clothes, sunglasses, and SPF sunscreen +15)

Seek the shade

Avoid sunbathing + indoor tanning

What is an additional primary prevention from the U.S. service task force

Avoid UV light exposure from ages 6m-24yrs

Skin cancer secondary prevention

Examine new or unusual lesions immediately and use ABCDE melanoma mnemonics

what does ABCDE stand for in melanoma mnemonics

Asymmetrical

Border poorly defined/irregular

Color uneven/variegated

Diameter larger than 6mm

Evolving, changes shape, size, color

Pruritis, Red/purpleish rash, and dry skin

History of chronic illness from present health status

Current medications from present health status

allergic reactions/hives, thinning of skin/acne

Past health history of present health status

Hx of skin/nails disease serve as clue to current skin lesions

Family history from present health status

Family hx of skin cancers manifesting w/rash and alopecia

Personal and psychosocial history from present health status

Health care use of preventive measures, or exposure to chemicals due to work like cosmetology, health care, etc.

Cyanosis, pallor, jaundice, hypopigmentation, and hyperpigmentation

Unexpected findings when inspecting the generalized color for skin

Hypopigmentation

albinism or the absence of pigmentation

Hyperpigmentation

Increased melanin may indicate an endocrine disorder like Addison’s disease or liver disease

Melanoma, vitiligo, maceration, discoloration, rashes and localized hyperpigmentation

Unexpected finding when inspecting localized color of the skin

Pigmented nevi (moles), freckles, patches, and striae that is white or pink

Expected findings when inspecting localized color of the skin

Maceration

Too much moisture on skin. Unexpected finding of localized skin color w/discoloration and rashes.

Melanoma

Moles below the waist, on scalp, or breast are not normal, may have abnormal characteristics. Unexpected in localized skin color

Vitiligo

Development of unpigmented patch or patches, more common in dark-skinned people w/autoimmune disorder. Unexpected in localized skin color

Pigmented Nevi

Moles, common on chest, back, arms, legs, and face or sun-exposed areas. Normal finding in localized inspection of skin color

Striae

Stretch marks that are silver or pink, secondary to weight gain or pregnancy. Normal finding when inspecting the localized color of skin

Coining

Common practice by many, particularly Southern Asian’s that uses coins or spoon and rubs over bony prominences of rib cage on back and chest.

Cupping

Practiced by Russians and Latin Americans, a form of alternative medicine for arthritis, stomach aches bruises, and paralysis. Uses heated glass cups to create negative pressure to adhere to skin, leaving red marks

Palpate the skin for: Texture

Expected: Must be smooth, soft, and intact (calluses may be present)

Unexpected: Dry, flaking, crackling, or scaling skin (nutritional deficiency)

Palpate the skin for: Temperature

Use back of hand to find the unexpected:

Generalized cool skin → Hypothermia or poor peripheral perfusion

Generalized hot skin → Hyperthermia, increased BMR, hyperthyroidism, inflammation, infection, sunburn, or traumatic injury

Palpate the skin for: Moisture

Unexpected: Diaphoresis or excessive sweating in the absence of physical activity.

Indicates hyperthermia, anxiety, pain, or shock. Excess moisture can be due to hyperthyroidism

Palpate the skin for: Mobility and Turgor

Unexpected:

Scleroderma→ connective tissue disorder decreasing skin mobility

Tenting → Slow return of skin to original condition (indicates weight loss or dehydration)

Turgor positive

Slow receding of the skin back to its original place (tenting)

Palpate the skin for: Thickness

Unexpected: thick and thin skin caused by

• Diabetes mellitus → Due to collagen resulting in hyperglycemia.

• Excessively thin skin looks shiny and is due to hyperthyroidism, arterial insufficiency, and aging

Inspect and palpate the scalp and hair for surface characteristics, hair distribution, texture, quantity, and color

Unexpected:

• Parasitic infections (lice)

• Alopecia (hair loss) → autoimmune disorders, anemic conditions, treatment w/radiation, or antineoplastic agents.

• Dull, coarse, and brittle hair → malnutrition.

Alopecia

Hair loss different from balding (doesn’t happen gradually, symmetrically, by high androgen, and genetic disposition like balding)

Inspect facial and body hair for distribution, quantity, and texture

Unexpected:

• Hirsutism → Deviation from normal hair growth pattern (triangle for men, inverted triangle for women)

• Thinning of the eyebrows (hypothyroidism)

Hirsutism

Hair growth in women with an increase of hair on the face, body, and pubic area

Inspect the nails for shape, contour, and color; palpate for thickness and firmness

Unexpected:

• Excessive length or damage to edges, grooves, depressions, pitting, and ridges.

• Pitting→ Psoriasis caused (minor pitting may also be normal)

Beau’s lines

Grooves or transverse depression running across the nails. Grooves move from cuticle to top of nail. Caused by stressors like trauma.

Koilonychia

Spoon nail, present as thin depressed with lateral edges turned upward (can be anemia or congenital problem)

Leukonychia

White spot-on nail plate, associated w/minor trauma or manipulation of the cuticle.

Clubbing

Angle of nail base exceeds 180. Common in COPD or cardiovascular disease, caused by proliferation of the connective tissue, enlarging distal fingers

Why inspect and palpate skin lesions?

When new lesions appear, changes occur, or pain is identified. Inspect primary, secondary, and vascular lesions

Primary lesions

Expected variations in the skin like freckles, moles (nevi), patches, comedones (acne). Use Wood’s lamp to identify infections

Secondary lesions

Expected variations like Scars

Vascular lesions

Common variations of the skin like Ecchymosis (bruising), Telangiectasis, and cherry angioma

Telangiectasis (vascular lesion)

Permanent dilation of preexisting small blood vessels (capillaries, arterioles, or venules) resulting in superficial, fine, irregular red lines within the skin

Ecchymosis (vascular lesion)

Flat, reddish-purple, nonblanchable bruising spot of variable size. Blue/purple in light skin; blue or black tone in dark skin.

Vascular spider (spider angioma) (vascular lesion)

Type of telangiectasia characterized by a small central red area with radiating spiderlike legs; this lesion blanches with pressure

Occur in absence of disease, with pregnancy, in liver disease, or with vitamin B deficiency.

angioma (e.g. cherry angioma) (vascular lesions)

Benign tumor consisting of a mass of small blood vessels; can vary in size from very small to large.

Capillary hemangioma (nervous flammeus) (vascular lesions)

Type of angioma that involves the capillaries within the skin producing an irregular patch that can vary from light red to dark red to purple in color.

Purpura (vascular lesion)

Flat, reddish-purple, nonblanchable discoloration in the skin greater than 0.5 cm in diameter. Infection or bleeding disorders resulting in hemorrhage of blood into the skin.

Venous star

Type of telangiectasia characterized by a nonpalpable bluish, star-shaped lesion that may be linear or irregularly shaped. Unexpected vascular lesion, caused by increased pressure on superficial veins.

Petechiae

tiny red spots less than 5 cm big. Tiny hemorrhages within the dermal or submucosa—caused by intravascular defects and infection. Unexpected in vascular lesions.

Scale

Secondary skin lesions, heaped-up keratinized cells; flaky, irregular, thick or thin, dry or oily. Unexpected. Can follow drug reaction, eczema, seborrheic dermatitis, follows scarlet fever.

Lichenification

Secondary skin lesions, unexpected rough, thickened epidermis secondary to persistent rubbing, pruritus, or skin irritation in chronic dermatitis or psoriasis

Keloid

Secondary skin lesion. Irregular shaped elevated, enlarging scar. Follows after surgery. Unexpected

Scar

Secondary skin lesion. Surgical or healed wound, thin or thick fibrous tissue replacing normal skin. Unexpected.

Excoriation

Secondary skin lesion. Unexpected loss of epidermis, linear hollowed-out crusted area from abrasions or scratches, scabies.

Fissure

Secondary skin lesion unexpected linear crack or breaks from epidermis to the dermis found in athlete’s foot, cracked skin, chapped hand,

Crust

Secondary skin lesion unexpected, dried drainage or blood, slightly elevated with mix colors by scab on abrasion or eczema.

Erosion

Secondary skin lesion unexpected loss or part of the epidermis. Depressed, moist, glistening that may be due to varicella or following rupture of bulla

Ulcer

Secondary skin lesion expected loss of epidermis or dermis, concave by pressure ulcers, stasis ulcers, or syphilis chancre.

Macule

Primary lesion like freckles, nevi, petechiae, measles, or scarlet fever

papule

primary lesion unexpected wart or elevated mole, cherry angioma, or skin tag that is firm and less than 1 cm diameter

patch

primary lesion unexpected nonpalpable, irregular-shaped

plaque

primary lesion unexpected by psoriasis, elevated, firm, rough, with flat top surface greater than 1 cm

wheal

primary lesion unexpected caused by insect bites or allergic reactions and even urticaria

nodule

primary lesion, elevated, deeper than dermis, unexpected in dermatofibroma erythema.

Tumor

Primary lesion unexpected solid lesion, not clearly demarcated, neoplasm

Vesicle

Primary lesion unexpected caused by varicella filled w/serous fluid

Bulla

primary lesion unexpected vesicle greater than 1 cm, blister

Pustule

primary lesion unexpected in impetigo, acne, and folliculitis elevated and similar to a vesicle but filled with purulent fluid like acne

Cyst

Primary lesion unexpected and encapsulated lesion in dermis or subcutaneous layer.