PCCR I: Integumentary System

Nail Plate

Protect nail

Nail Bed

vascular surface to which nail plate is attached

Lunula

Whitish moon at base of nail

Lateral nail folds

cover the sides of the nail plate

Proximal nail fold

covers nail root (proximal 1/4th of nail plate)

(normal angle b/t prox nail fold and nail plate <180deg)

Cuticle

Extends from proximal nail fold, acts as a seal

HPI

duration, evolution, periodicity, prior eps?

Any asso sympt? (itching (pruritis), pain)

ROS?

PMH: important! syst disease have cutaneous features and manifestations! Allergies?

SH: Occu (Potential exposures), diet (food changes), cosmetics, travel

ROS

Skins:

• changes in color, texture, appearance

• new rashes, masses, lesions, pruritis, swelling

• change in size/color of moles

Hair

• changes in color, texture, or appearance

Nails

• changes in color, texture, or appearance

Red Flag Symptoms

recurrent or poorly healing wounds/lesions/ulcerations

• often asso w/ hx of DTM, autoimmune, endocrine

WORRISOME: DTM, autoimmune - HIV, Endocrine - Cushing Disease, Venous insufficiency

HPI - Lesions

any concern abt new lseion?

PMH of skin cancer? (y - type/loca/date/self-skin exam/sunscreen)

FH of skin cancer? (y - types)

SH of self-skin exams, sunscreen?

HPI - Rashes & Pruritis

HPI of palliative/provocative factors (moisturizers or OTC products)

Asc/ROS: Pruritis (itching?) → IMPORTANT! is it b4 or after?;;; any dry skin?

PMH of season allergies, asthma, atopic dermatitis (AKA eczema)

HPI - Hair Loss and Nail Changes

HPI - any thinning or shedding (y - where: @roots or break shaft?)

SH of hair care practices (freq of shampooing, hair dyes, chem relaxers, heating appliances)

Examination of Skin - TOOLS

adequate lighting

measuring tape/small ruler

small magnifying glass/ dermoscope (dep on user skill/ knowledge)

pt gowned (unclothed expect underwear, open back)

Examination - Seated (HEAD TO TOE)

inspect hair and scalp (distribution, texture, and quantity)

• sep hair using fingers/ cotton-tip applicator

inspect head and neck, including forehead, eyebrows, eyelids, eyelashes, conjunctivae, sclerae, nose, ears, cheeks, lips, oral cavity, chin, and beard

• including terminal hair of eyelashes, eyebrows, beard

inspect upper back

• ask to lean forward and for permission to open back of gown

inspect shoulders, arms, and hands including palpation of fingernails

• including color shape, and lesion on fingernails

inspect chest and abdomen

• have pt raise/lower gown to expose area (SOLELY) you are examining (may do axilla now or w/ breasts)

inspect anterior thighs and legs

• include web0spaces b/tw toes, soles of feet, and toenails

inspect feet and toes including soles, interdigital areas and toenails

• same as above

Examination - standing

Inspect lower back

• may need to ask pt to lean forward slightly

inspect posterior thighs and legs

• (only expose buttock for exam, otherwise covered)

inspect breasts, axillae, and genitalia (axillary and pubic hair)

• ensure chaperone for safety

Directed Exam for Hair Loss

Overall pattern of loss/thinning?

Any bogginess, pustules, scaling, erythema, scarring?

PALPATE:

• hair pull test: 50-60 hairs b/tw thumb and index/middle fingers and firmly pull from scalp

• tug test: group of hairs and pull along hair shaft, abnormal for breakage

ABCDE-EFG Method for Melanoma

A - asymmetry?

B - border irregularities

C- color variation? (2+ not good)

D- Diameter >6mm? (~size of pencil eraser)

E- Evolving/ rapid changing

E- Elevation

F- FIRM on palpation

G - Growing progressively over sev weeks

Pressure Injury Stg I

Intact skin w/ localized area of nonblanchable erythema, MAY appear DIFFERENT in darkly pigmented skin

Pressure Injury Stg 2

Partial-thickness skin loss of skin w/ exposed dermis

Pressure Injury Stg 3

Full-thickness skin loss, in which adipose is visible in ulcer and granulation tissue and rolled wound edges is often present

Unstageable Pressure Injury

Full-thickness skin and tissue loss in which the extent of tissue damage w/in ulcer cannot be confirmed b/c it is obscured by slough/eschar

Pressure Injury Stg 4

Full-thickness skin and tissue loss in w/ exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in ulcer

Deep Tissue Pressure Injury

Persistent nonblanchable deep red/maroon/purple discoloration

can be intact/non-intact skin!!

Wheal (aka hives/urticaria): circumscribed area of dermal edema

Burrow: small, linear/serpiginous (snake-like/curved/branching) paths in epidermis

created bhy scabies mite!!!

Pustule: small circumscribed elevated epidermis w/ purulent fluid

EX:

• bacterial folliculitis (erythematous, pus0filled lesions around hair follicles)

• abscesses (fluctuant deep infections, can arise from furuncles, folliculities, or other primary lesions)

Bacterial Folliculitis: erythematous, puss-filled lesions around hair follicles

Abscesses: fluctuant deep infections, can arise for furuncles (inflamed hair follicles), folliculitis (bacterial folliculitis), or other primary lesions

Cyst: encapsulated collection of fluid or semisolid substance

Furuncle (Inflamed hair follicle!!!)

mult = carbuncle

Nodule: raised area of skin → large, solid elevation extending DEEPER into skin layers (>1cm)

ref papule (<1cm) and plaque (flat, >1cm)

Vesicle: raised and fluid filled (<1cm)

ref bullae (>1cm)

EX:

• bullous drug reaction: dusky patch w/ inner violaceous (purple) patch and central tense bulla

• herpes simples: vesicles (sometimes pustules) grouped together

• herpes zoster (AKA shingles): grouped vesicles in single dermatomal distribution that DOESN’T cross midline

• allergic dermatitis: often papules (solid elevation of skin <1cm) and vesicles due to allergic trigger

  • poison ivy (may have transudative crust)

Bullous Drug Reaction: dusky patch w/ inner violaceous patch and central tense bulla (raised and fluid-filled >1cm)

Allergic Dermatitis: often papules (solid elev of skin <1cm) and vesicles (raised and fluid-filled <1cm) due to allergic trigger

Herpes Simplex: vesicles (sometimes pustules -small circumscribed elev epidermis w/ purulent fluid) grouped together

Herpes Zoster (AKA shingles): grouped vsicles in single dermatomal distribution that DOESN’T cross midline

Papule: raised area of skin → solid elevation <1cm

EX:

• skin tags: fleshy skin-colored to light brown papules, often located in skin folds (Lateral neck, axillae)

• molluscum contagiosum: firm, smooth-domed papules w/ central unbilications

• guttae psoriasis: scatted erthematous, well circumscribed scaling papules (+plauques too!)

Skin tags: should know

Molluscum contagiosum: firm smooth-domed papules w/ central umbilications (indents in middle!)

guttae psoriasis: scatted erythematous, well-circumscribed scaling papules (+Plaques! - large flat elev of skin >1cm)

Bullae: raised and fluid-filled (>1cm)

Plaque: raised area of skin with large, flat elevation >1cm

EX:

• plaque psoriasis: scattered, erythematous or bright pink, flat-tooped plaques w/ overlying silvery scale MC on extensor surfaces in childhood (eg. elbow crease)

• atopic dermatitis: bilateral eczamatous plaques, poorly circumscribed and often lichenified (thickened skin from rubbing/scratching) MC of flexor surfaces (eg. knees/elbows)

• nummular dermatitis: mult, round coin-like exzematous plaques w/ overlying transudative crust

• pityriasis rosea rash: mult, round, violaceous plaques

• herald patch of pityriasis rosea: single oval, raised but flat-topped plaque

  • initial sign of pityriasis rosea

plaque psoriasis: scattered, erythematous or bright pink, flat-tooped plaques w/ overlying silvery scale MC on extensor surfaces in childhood (eg. elbow crease)

atopic dermatitis: bilateral eczamatous plaques, poorly circumscribed and often lichenified (thickened skin from rubbing/scratching) MC of flexor surfaces (eg. knees/elbows)

nummular dermatitis: mult, round coin-like exzematous plaques w/ overlying transudative crust

pityriasis rosea rash: mult, round, violaceous plaques

herald patch of pityriasis rosea: single oval, raised but flat-topped plaque

• initial sign of pityriasis rosea

Patch: flat area of color change of skin >1cm

EX:

• vitiligo: confluent, depigmented patches

• tinea cruris: erythematous, geographic patches w/ peripheral scaling

vitiligo: confluent, depigmented patches

tinea cruris: erythematous, geographic patches w/ peripheral scaling

Macule: flat area of color change <1cm

EX:

• morbilliform drug reactions: erythematous, confluent round cacules

• tinea versicolor: mult. hypopigmented or hyperpigmented or tan macule

• benign melanocytic nevi: symmetrical pigmented, round/oval, brown macules

Benign Skin Lesions

Seborrheic Keratosis

Solar Lentigines

Benign Melanocytic Nevi (macule)

NODULES:

• Dermatofibroma

• keloids

• epidermal inclusion cyst

• pilar cysts

• lipomas

Dermatofibroma: firm nodule, often w/ hyperpig

Epidermal Inclusion Cysts: tethered subcut cyts, often w/ malodorous whitish-yellow substance/discharge

Lipomas: rubbery, may be mass like BUT freely mobile

Pilar Cyst: MOBILE cysts that on excision reveals pearly-white balls

Seborrheic Keratosis

• verrucous (“warty lesions”) texture

• appear like sutck on/flattened ball of wax

• erytheme (if inflamed), may crumble/bleed if picked

mimic for squamous cell carcinoma

Solar Lentigo: light brown, uniform color BUT may be asymmetric

mimic for melanoma in situ

Cancerous/Pre-cancerous skin lesions

Actinic keratosis

cutaneous horn/keratotic scale

squamous cell carcinoma (SCC)

basal cell carcinoma (BCC)

• superficial

• nodular

• ulcerated

Melanoma

• amelanotic

• melanoma in situ

• acral melanoma

• blue-black melanoma

Actinic Keratosis (precursor to SCC): superficial keratotic papules

• “come and go” on sun damaged skin

• easier to feel than see

MIMIC: superficial xerosis/ seborrheic dermatitis

• scale is less keratotic (more dry)

• improves w/ moisturizers or mild topical steroids

Cutaneous horn/keratotic scale

• scale of keratin

• occurs w/ actinic keratoses and SCC

• cutaneous horn should be biopsied to r/o SCC

MIMIC: warts

• skin-colored/pink

• often have hemorrhagic punctae (tiny, pinpt spot of bleeding <3mm, appear like small red/purple dots)

Squamous Cell Carcinoma (SCC)

• keratocanthomas are rapidly arising SCC w/ crateriform center w/ smooth, firm border

• Highest areas of metastasis: lips/ears/scalp

MIMIC: Seborrheic Keratosis (benign skin lesions)

• stuck on/flattened ball of wax

Superficial Basal Cell Carcinoma

• pink patch, often w/ focal scaling (localized, distinct area of dry, flaking skin cells)

• will NOT heal

MIMIC: Actinic Keratosis (precursor SCC) & SCC in Situ

• due to keratotic scaling of SCC

Nodular Basal Cell Carcinoma

• pink papule w/ translucent or pearly white appearance (maybe focal pig)

• usually w/ overlying telangiectasias

MIMIC: Sebaceous Hyperplasia

• yelllowish globular papules, usually w/ central depression

• telangeictasis go AROUND

Basal Cell Carcinoma (BCC): pearly pink plaque w/ central depression and TELANGIESTASIAS

MIMIC: Fibrous Papule

• skin-colored NO telangeictasias

• may become excoriated (loss of skin’s surface)

Ulcerated Basal Cell Carcinoma: non-healing ulcer, resulting in rolled border/edge

MIMIC: SCC

• may be ulcerated

• on exam edges FIRMER to palpation than BCC

Amelanotic Melanoma:

• MC in very fair-skin

• evolution or rapid change #1 FEATURE

MIMIC: Skin tags/Intradermal Nevi

• soft, fleshy, typ around neck/axillae/back

• may have hint of brown pig

Melanoma in Situ

MIMIC: Solar Lentigo (benign skin lesion)

• light brown, uniform color BUT may be asymmetric

Melanoma:

• can arise from existing nevi (benign)

• varigated color (brown/reds)

MIMIC: Dysplastic Nevus

Acral Melanoma:

• rapid change/evolution

• consider biopsy >7mm, rapidly growing, or concerning features on dermoscopy

MIMIC: Acral Nevus

• likely benign <7mm; dermoscopy reassuring (parallel fullow/lattice pattern)

Melanoma w/ blue-black areas:

• blue-black areas very concerning ESP if asymmetric

MIMIC: Blue Nevus

• homogenous blue-gray appearance both clinically and dermoscopy

Vascular/Purpuric Skin Lesions

Spider Angioma

Spider Vein

Cherry Angioma

Petechia/purpura

Ecchymosis

Ecchymosis: blood outside vessels; often secondary to bruising/trauma (seen in bleeding disorders)

Color/size: purple/purplish blue, fading green, yellow, and brown w/ TIME.; variable size, >petechiae mm

shape: rounded/oval/irregular; maybe subcut flat nodules (HEMATOMA)

Pulsatility and Effect of Pressure: NONE

Distribution variable

Petechia/Purpura: blood outside vessels possible suggestive of bleeding disorder.

Petechia → emboli to skin

palpable purpura in vasculitis

Color/size: DEEP red/ reddish purple; FADE over time

• petechia 1-3 mm; purpura larger

Shape: rounded/ smt irregular; flat

Pulsatility and Effect of Pressure: NONE

Distribution Variable

Cherry Angioma: NO SIG, increases in size and numbers w/ age

Color/SIze: bright/ruby red (w/ age purplish) 1-3mm

Shaped: Round/flat/smt riase; may have purple halo

Pulsatility and Effect of Pressure: NONE (partial blanching)

Distribution around TRUNK and extremities

Spider Vein: accom increased pressure in SUPerficial veins (AKA varicose veins)

Color/Size: Bluish w/ variable size

Shape: variable ~spider/linear/irregular/cascading

Pulsatility and Effect of Pressure: NONE (no blanching, but diffuse blanches vein)

Distribution often ON LEGS near veins. also ant chest

Spider Angioma: singles are normal and common on face/chest. Typ of preg and liver disease

Color/Size: Fiery Red; v small-2cm

Shape: central body (smt raised) surrounded by erythema and radiating legs

Pulsatility and Effect of Pressure: often seen in center of spider when pressure with a glass slide is applied; pressure causes blanching of spider

Distribution around face/neck/arms/upper trunk almost never below waist

Acne Vulgaris Primary Lesions

Mild Acne: comedonal, occasional papules (solid raised elev of skin <1cm)

Moderate Acne: Inflammatory; comedones, papules and pustules (small circumscrib elev of purulent fluid)

Severe Cystic Acne: nodulocystic (deep, painful, inflamed lumps/nodules under skin)

Acne Vulgaris Secondary Lesions

Pitting and Scarring

Sun Damage: Solar Lentigo

Bilat Symmetric; brown macule (<1cm flat area of color change) on sun exposed skin

not freckle

Sun Damage: Solar Elastosis

Yellowish white macules (<1cm flat skin color change) on sun-exposed skin, ESP forehead

Sun Damage: Actinic Purpura (skin lesion)

Ecchymosis (bruise) to dorsal forearms and hands

doesn’t extend about “shirt-sleeve” on upper arm

Sun Damage: Poikiloderma

Red patches in sun-damaged areas w/ fine telangiectasias and area of BOTH hyperpig and hypopig

Sun Damage: Wrinkles

Start earlier age

Sun Damage: Cutis Rhomboidalis Nuchae

Deep wrinkles on POSTerior neck in “crisscross” pattern

Male Pattern Hair Loss

Frontal hairline regression

thinning on posterior vertex

Female Hair Pattern Loss

Thinning from crown down hairline w/o hairline regression

Alopecia Areata

Sudden onset of clearly demarcated hair loss

SMOOTH skin w/o hair

NO visible scaling or erythema

Scarring Alopecia

Shiny skin w/ complete loss of hair follicles

Discoloration

Tinea Capitis

Round scaling patches of alopecia

Dermoscopy: broken hairs/corkscrew hair visible

maybe boggy on palpation

Onchomhycosis: nail thickening and subungal debris

• usually from dermatophyte but also molds (athletes ft)

• tinea pedia precursor

• typ in older folk, unable to keep toe hygeine

Terry Nails: nail plate turn white w/ ground-glass appearance, distal reddish brown, and obliteration of lunula

• typ affects ALL nails

• asso w: liver diease, heart failure, DTM

Onycholysis: painless separation of whitened nail plate from nail bed (=enlarged free edge)

• usually result of trauma (distal → prox)

Melanonychia: linear streak formed as the nail grows out, caused by increased pigmentation in nail matrix

• NEVUS: thin and uniform

• SUBUNGAL MELANOMA: wide and/or irregular

• in mult nails? may be from ethnic variation

Paronychia: superficial infection of proximal and/or lateral nail folds

• S/Sxs: red, swollen, tender

• caused by localized trauma: nail biting, manicure, freq immersion in water (hand washing!)

Clubbing of Fingers

Bulbous swelling of soft tissue at base of nail ( angle >180deg b/tw nail and prox fold)

• Asso w: congenital heart disease, interstitial lung disease, lung cancer, IBD, malignancies

  • related to vasodilation (maybe hypoxia? not largely understood)

Pitting of Nail

punctate depression of nail plate (defective layering by prox nail matrix)

• asso w: reactive arthritis, sarcoidosis, alopecia areata, atopic/chemical dermatitis

Transverse Linear Depressions (Beau Lines) of Nail

Transverse depression of nail plate usually bilaterally

• result of: severe illness, trauma (manicure), cold exposure

Self Examination

USE: mirror in well lit room

Steps

1: Examine full body front/back then left/right

2: Check elbows, forearms, underarms and palms

3: Look at backs of legs, feet, webspaces b/t toes and soles of feet

4: Examine neck and scalp w/ hand mirror, separate hair

5: Check back and buttock using hand mirror

Patient Education

Avoid UV radiation and tanning beds

Regular use of suncreen: SPF 30+ w/ reapp every 2 hrs outside/in water

USPSTF

United States Preventative Services Task Force

Counsel adults 24yr+ w/ fair skin types regarding minimizing exposure

AAD

American Academy of Dermatology

High risk persons should follow with dermatology for regular clinical skin exmas

ACS

Doesn’t have specific guidelines!

Recommends self-exams for persons at increased risk

Point-of-Care Ultrasound (POCUS)

Purpose?

Help visualize structures of the skin, differentiate skin lesions

Helps determine need for non-invasive vs invasive management

• Ex: cellulitis vs abscess

POCUS: Cellulitis

Red Swollen area w/..

Tenderness, warmth, pain

Possible fever if severe

Induration to palpation

POCUS Abscess

Red swollen lump w/… tenderness, warmth, often more intense pain, and central pocket of pus

Possible fever (esp not drained)

Will feel induration (hardening) esp around lump and fluctuance (liquidy under pressure)