Chapter 13: Skin, Hair, and Nails

Epidermis

Thinnest, outer layer of skin

Dermis

Middle layer of skin, made of collagen, elastic fibers, blood/lymph vessels, and nerve endings

Subcutaneous

Bottom layer of skin, connects skin to underlying organs, stores energy, absorbs shock, and insulates

High Risk Areas

Between the toes, skin folds, under medical devices, bony prominences, and pressure points

First Level Priorites

Severe dehydration, cyanosis, and extensive burns

Second Level Priorites

Suspicious lesions that have irregular borders, color changes, or rapid growth

Clubbing

Tips of fingers become wide and round, >180 degrees angle at nail base, caused by respiratory or cardiac dysfunction

Schamroth Window Test

Clubbing test in which the patient places dorsal surfaces of opposite fingers together, with clubbing there would be no diamond shaped window

Skin Turgor

The skin’s ability to snap back when pinched up, indicates hydration level, for older adults test the sternum/forehead and for children test the abdomen or medial thigh

Grade 1+

Pitting edema grade with 2 mm depression, mild pitting, and slight indentation

Grade 2+

Pitting edema scale with 4 mm depression, moderate pitting, and indentation subsides rapidly

Grade 3+

Pitting edema scale with 6 mm depression, deep pitting, and indentation remains for short time

Grade 4+

Pitting edema scale with 8 mm depression, very deep pitting, and long lasting indentation

Pressure Injuries

Localized damage to skin and underlying soft tissue, usually over a bony prominence due to constant pressure on the site

Braden Scale

Tool used to assess a patient’s risk for developing pressure injuries, includes sensory perception, moisture, activity, mobility, nutrition, and friction/shear, a score <9 is severe risk and between 15-18 is a baseline

ABCDEs

Melanoma detection tool, includes asymmetry, border irregularity, color, diameter of more than 6 mm, and evolution of lesion over time

Vellus Hair

Fine, faint hair that covers most of the body

Terminal Hair

Darker, thicker hair that grows on the scalp and eyebrows and after puberty the armpits, pubic area, and face/chest in men

Eccrine Glands

Sweat glands that produce a diluted saline solution onto the skin, matures at 2 months old

Apocrine Glands

Sweat glands that produce a thick, milky secretion onto the armpits, genital area, nipples, and navel, become active during puberty

Lanugo

Fine hair on newborns

Keloids

Raised scars that form at a wound site and grow beyond the normal boundaries of the wound

Pseudofolliculitis

Razor bumps/ingrown hairs, occur when shaving too closely

Melasma

Patchy brown discoloration of the face

Mongolian Spot

Blue/black/purple hyperpigmentation area at the sacrum or butt due to deep dermal melanocytes, found in black, asian, native American, and latino newborns

Cafe Au Lait Spot

Large round/oval patch of light brown pigmentation

Harlequin Color Change

Distinct line of red/pale color down the midline or horizontal found in newborns, one half of body turns red and blanches

Erythema Toxicum

Common rash in the first 3 to 4 days of life, consists of tiny punctate red macules and papules on the cheeks, trunk, check, back, and butt

Acrocyanosis

Bluish color around the lips, hands, fingernails, toes, and toenails, disappears without warning

Cutis Marmorata

Transient mottling in the trunk and extremities in response to cooler room temps

Physiologic Jaundice

Normal variation of jaundice in about half of all newborns, develops after 3-4 days of life because of increased RBCs

Carotenemia

Yellow/orange color is light skinned people without yellowing of the sclera/mucous membranes, occurs due to ingesting large amounts of foods containing carotene

Milia

Tiny white papules on the face of babies due to sebum occluding opening of follicles

Nevus Simplex

Common vascular birthmark that is flat, irregularly shaped red/pink patch typically on the face or back of neck, usually fades during first year

Striae

Jagged linear stretch marks of pink/silver color that appear during 2nd trimester of pregnancy

Linea Nigra

Brownish/black line down the midline during pregnancy

Solar Lintigines

Common, circumscribed clusters of melanocytes due to chronic sun exposure

Keratoses

Raised, thickened areas of pigmentation that look crusted, scaly, and warty, mostly on the trunk

Actinic Keratosis

Red/tan scaly plaques, premalignant, caused by sun/UV exposure

Acrochordons

Overgrowths of normal skin that form a stalk and are polyp like (skin tags)

Sebaceous Hyperplasia

Raised yellow papules with central depression on the face, more common in men

Annular Lesion

Circular lesion, begins at center and spread (ringworm)

Confluent Lesion

Lesions that run together (hives)

Discrete Lesions

Distinct, individual lesions that remain separate (acne)

Gyrate Lesions

Lesions that are twisted/coiled

Grouped Lesions

Cluster of lesions (contact dermatits)

Linear Lesion

Scratch/streak

Target Lesions

Iris, concentric rings of color

Zosteriform Lesions

Linear arrangement of lesions along a unilateral nerve route (shingles)

Polycyclic Lesions

Annular lesions that grow together (psoriasis)

Macule

Flat, circumscribed primary lesion, less than 1 cm (freckles/measles)

Papule

Solid, elevated, circumscribed primary lesion, less than 1 cm, caused by superficial thickening of epidermis (mole)

Patch

Macules that are larger than 1 cm (vitiligo)

Plaque

Papules that coalesce to form surface elevation wider than 1 cm (psoriasis)

Nodule

Solid, elevated primary lesion, larger than 1 cm, may extend into dermis (fibroma)

Wheal

Superficial, raised, transient, and erythematous primary lesion, slightly irregular shape (mosquito bite)

Tumor

Primary lesion larger than a few cm, extends into dermis, can be benign or malignant (lipoma)

Urticaria

Wheals that coalesce to form extensive reaction (hives)

Vesicle

Elevated cavity containing free fluid, up to 1 cm (herpes simplex)

Bulla

Primary lesion larger than 1 cm, usually chambered, superficial, and thin walled (friction blister)

Cyst

Encapsulated fluid filled cavity in dermis or subcutaneous layer, causes tensely elevated skin

Pustule

Turbid fluid (pus) in a cavity of a primary lesions, circumscribed and elevated (acne)

Primary Lesion

Lesion that develops on previously unaltered skin

Secondary Lesion

Lesion that develops overtime due to scratching/infection of a previous lesion

Crust

Thickened, dried out exudate left when vesicles/pustules burst or dry up (impetigo)

Scale

Compact, desiccated flakes of skin, silver/white color, caused by shedding of dead excess keratin cells (eczema)

Fissure

Linear crack with abrupt edges, extends into dermis, secondary lesion (cheilosis)

Erosion

Scooped out, but shallow depression, superficial, most, heals without a scar, secondary lesion

Ulcer

Deeper depression extending into dermis, irregular shape, may bleed, will scar, secondary lesion (pressure injury)

Exocoriation

Self induced abrasion, superficial, usually due to scratching

Scar

Connective tissue replaces normal tissue at site of an injury

Atrophic Scar

Scar in which the resulting skin level is depressed with loss of tissue

Lichenification

Tightly packed sets of papules resulting from prolonged, intense scratching, looks like moss

Stage 1

Pressure injury that has non-blanchable erythema and unbroken skin

Stage 2

Pressure injury in which there is epidermal skin loss, exposed dermis, and a red/pink wound bed

Stage 3

Pressure injury that extends into subcutaneous tissue but no muscle/bone/tendon is visible

Stage 4

Pressure injury that exposes muscle, tissue, or bone

Deep Tissue Pressure Injury

Pressure injury with localized, non-blanchable color change to deep red/purple, begins in muscle closest to bone

Hemangioma

Benign proliferation of blood vessels in dermis

Port Wine Stain

Large, flat, hemangioma on the scalp or face, usually along CN V, dark red/purple color, consists of mature capillaries, present at birth (nevus flammeus)

Strawberry Mark

Raised bright red hemangioma with well defined borders, about 2-3 cm, does not blanch, consists of benign growth of endothelial cells (infantile hemangioma)

Deep Hemangioma

Reddish-blue, irregularly shaped, solid, spongy hemangioma

Telangiectasia

Permanently enlarged and dilated blood vessels that are visible on the skin

Spider Telangiectasia

Fiery red, star shaped telangiectasia with solid circular center, develops on face, neck, or chest

Venous Lake

Blue/purple dilation of venules and capillaries in a star-shaped, linear, or flaring pattern, pressure will cause them to empty, common on lips, ears, or face of older adults

Petechiae

Tiny punctuate hemorrhages, 1-3 mm, round, discrete, dark red/purple, caused by bleeding from superficial capillaries, will not blanch, may indicate abnormal clotting factors

Purpura

Confluent and extensive patch of petechiae and ecchymoses, >3 mm, flat, red/purple, occur with old age and thrombocytopenia

Ecchymosis

Purplish patch resulting from excavation of blood into the skin, > 3 mm

Diaper Dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area, caused by skin irritation from ammonia, moisture, or occlusive diapers

Candidiasis

Scalding red, moist patches with sharply demarcated borders, usually in genital area, caused by candida fungus and aggravated by urine, feces, head, and moisture

Impetigo

Moist, thin roofed vesicles with thin red base caused by a highly contagious bacterial infection of skin

Atopic Dermatitis

Chronic inflammatory skin lesion caused by overstimulated immune system, genetics, and environment, causes itchy, localized dry patches and red papules/vesicles (eczema)

Varicella

Small, tight vesicles that are shiny with a red base, extremely itchy, first appears on trunk then face, arms, and legs, not on palms/soles (chickenpox)

Measles

Disease that begins with 2-4 day fever and one or more of a cough, coryza, or conjunctivitis, then rash appears in cephalocaudal direction, does not blanch

German Measles

Pink papular rash first appears on face then spreads, causes neck lymphadenopathy, no Koplik spots

Tinea Corporis

Scales on chest, abdomen, and back of arms forming multiple circular lesions with clear centers (ring worm of the body)

Tinea Pedis

Fungal infection appearing first as small vesicles between toes, on sides of feet, and on soles, grows scaly and hard, found in chronically moist, warm, feet (ring worm of the feet/athletes foot)

Tinea Versicolor

Fine, scaling, round, hypomelanotic patches of pink, tan, or white caused by superficial fungal infection, usually symmetric on neck, trunk, and upper arms

Herpes Zoster

Small, grouped vesicles that emerge along route of sensory nerve, caused by dormant chickenpox, does not cross midline, usually in adults >50

Erythema Migrans

Distinctive bull’s eye, red rash associated with lyme disease, fades in 4 weeks