NSG-316 Skin, Hair, and Nails Assessment
I. Anatomical Structures and Their Functions
The Dermis is composed of connective tissue or collagen, which provides resistance to tearing. This layer contains nerves, sensory receptors, blood vessels, and lymphatics. The Subcutaneous Layer consists of adipose tissue, storing fat cells for energy. It provides insulation for temperature control and offers protection through a soft cushioning effect.
Hair is composed of threads of keratin. The Shaft is the visible projecting part, while the Root is located below the surface, embedded in the follicle. The Bulb Matrix is an expanded area at the root where new cells are produced at a high rate, and hair growth is cyclical with active and resting phases. Arrector Pili are small muscles around hair follicles that contract, pulling hair upright, creating "goose flesh" when an individual is cold or in an emotional state.
There are two main Types of Hair: Vellus Hair, which is fine, faint hair covering most of the body, and Terminal Hair, which is coarser, darker hair found on the scalp and eyebrows. After puberty, terminal hair also appears in the axillae, pubic area, face, and chest.
Glands include Sebaceous Glands, which produce a protective lipid substance called sebum, excreted through hair follicles. Sebum forms an emulsion that retards water loss from the skin and is a mixture of sebum's oils. Eccrine Glands open directly onto the skin surface and produce a dilute saline solution called sweat, cooling the body temperature through evaporation. These glands are mature in a 2-month-old infant. Apocrine Glands produce a thick, milky secretion, opening into hair follicles predominantly in the axillae, anogenital area, nipples, and naval. They become active during puberty, and their activity increases with emotional and sexual stimulation. Bacterial flora on the skin surface react with apocrine sweat to produce body odor. The function of apocrine glands decreases with age.
Nails are hard plates of keratin located on the dorsal surface of fingers and toes. They are clear with fine longitudinal ridges, which become more prominent in aging nails. Their pink color is due to the underlying nail bed. The Lunula is the white, crescent-shaped area at the proximal end of the nail, and the Cuticle covers and protects the nail matrix.
II. Functions of the Skin
The skin serves multiple vital functions, including Protection, acting as a physical barrier against external threats, and preventing Penetration of harmful substances. It enables Perception through sensory receptors for touch, pain, temperature, and pressure. The skin also maintains Fluid Balance by regulating water loss and retention, and regulates Temperature through vasodilation/vasoconstriction and sweat production. It contributes to Identification through unique patterns like fingerprints and facial features and facilitates Communication by expressing emotions (e.g., blushing) and health status. The skin is essential for Wound Repair, initiating and completing the healing process. It allows Absorption of some substances (e.g., medications) and Excretion of metabolic wastes through sweat. Finally, the skin is responsible for the Production of Vitamin D, as ultraviolet (UV) light converts cholesterol into Vitamin D.
III. Aging Changes in the Skin
The skin often reflects aging changes across all organ systems. By the 70s and 80s, skin may appear parchment thin, lax, dry, and wrinkled. Wrinkling occurs due to the thinning and flattening of the underlying dermis, as well as the loss of elastin, collagen, and subcutaneous fat. This loss also increases the risk for shearing and tearing injuries.
Glandular Function declines with age, as sweat and sebaceous glands decrease in number and function, leading to dry skin. A decreased response of sweat glands puts older individuals at a greater risk of heat stroke. Vascularity of the skin also decreases, and minor trauma may produce senile purpura, which are dark red discolored areas.
Environmental Factors like sun exposure and smoking further accentuate aging changes, which can include coarse wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, pigment changes, and a yellowed, leathery texture. Hair Changes include hair turning gray or white and becoming thinner and finer due to decreasing melanocytes. Axillae and pubic hair decrease. Women may develop bristly facial hair, while in men, coarse terminal hairs develop in the ears, nose, and eyebrows. Male pattern balding or alopecia is a genetic trait, generally presenting in a W-shape in men and women, and scalp hair gradually turns gray because of decreased melanocyte function.
Nail Changes involve a decrease in nail growth rate with aging. Nail surfaces can become brittle, peel, and sometimes yellowed, while toenails may thicken and grow misshapen. Skin Turgor is decreased in older adults, causing pinched skin to recede slowly or "tent." The loss of collagen in aging also increases the risk of Skin Tears from minor trauma or from moving or grabbing the person.
IV. Skin Cancer and Risk Factors
Melanin serves as a protective pigment against UV rays. Incidence Rates for skin cancer, including melanoma, are lower in Black individuals, Native Americans, and Asians. White people have the highest incidence, with 28 melanoma cases per 1,000,000 individuals. Before age 50, women outnumber men in melanoma cases, but by age 65, men have double the rates of women, and by age 80, triple. Melanoma is the number 1 most diagnosed cancer in 25 to 29-year-olds. Risk Factors for Melanoma include atypical, large, or numerous moles (>50 moles), high exposure to UV rays (sunlight), and natural blond or red hair. The Mechanism of UV Damage involves UV or sun exposure changing the genetic makeup, causing mutations in tumor suppressor genes, allowing tumor genes to mutate freely.
V. Common Skin Conditions and Terms
Common terms and conditions related to skin include Keloids, which are raised scars that form at a wound site and grow beyond the normal boundaries of the wound. Pseudofolliculitis refers to "razor bumps" or ingrown hairs. Melasma, also known as "mask of pregnancy," is characterized by patchy tan to dark brown discoloration on the face. Seborrhea denotes oily skin, while Xerosis indicates dry skin. Pruritus is itching, the most common skin symptom. Hirsutism is shaggy or excessive hair growth, especially in women in a male pattern (face, chest, back), indicating increased androgen hormones.
Several Factors Affect Skin Conditions. Stress can exacerbate chronic skin illnesses. Antibiotics can cause skin eruptions, and certain Drugs can increase sunlight sensitivity or cause hyperpigmentation. Actinic Keratosis is the most frequent premalignant skin lesion in white persons, directly caused by sun or artificial UV radiation exposure. Acrochordon (Skin Tags) are overgrowths of normal skin that form a stalk, appearing polyp-like on eyelids, cheeks, neck, axillae, and trunk. Sebaceous Hyperplasia consists of yellow papules with a central depression, common in men on the forehead, neck, and cheeks, giving a pebbly look.
VI. Subjective Data: Health History (Skin, Hair, Nails)
When gathering subjective data, inquire about a history of skin disease (e.g., eczema, psoriasis, hives). Ask about Changes in pigmentation (e.g., generalized or localized changes) and Changes in moles (size, shape, color, sensation). Determine if there is excessive dryness (xerosis) or moisture (diaphoresis, seborrhea), and inquire about Pruritus (itching). Assess for Bruising (frequency, location, ease) and any Rash or skin lesions. Document current Medications (prescription, over-the-counter, herbal remedies). Inquire about Hair loss (alopecia) or changes in hair texture/distribution, as well as Changes in nails (color, shape, thickness, brittleness). Document exposure to Environmental hazards (e.g., sun exposure, chemicals) and assess Patient-centered care (e.g., self-care behaviors, concerns).
VII. Objective Data: Physical Examination (Skin, Hair, Nails)
A. Preparation for Examination
Before examination, it is crucial to Know normal skin coloring, personalizing the assessment based on the individual's normal skin tone. Control external variables by ensuring hands are warm and room temperature is comfortable to avoid vasoconstriction or pallor. Begin with hands and nails to allow the person to become accustomed to your touch. Start with outer structures, assessing the skin's surface first, then examining underlying structures. For a Regional Examination, remove clothing to expose the entire body. Step back to get an overall impression and to reveal distribution patterns of any rashes. Inspect all areas of the body, including skin folds (e.g., under breasts, abdomen), between toes, and mucous membranes.
B. Inspection & Palpation of Skin
General Pigmentation
Normal skin tone should be consistent with the person's genetic background. Abnormal pigmentation includes Vitiligo, which is a complete absence of melanin in patchy areas (face, neck, hands, feet, body folds, or orifices), more severely affecting dark-skinned individuals and posing a greater threat to body image. Pigmentation can be darker in sun-exposed areas, and common benign variations include freckles and moles.Moles (Nevi) and Freckles
Normal moles are small (<6 ext{ mm}), have smooth borders, and uniform pigmentation. Danger Signs (ABCDEF) for a suspicious mole include: Asymmetry (one half does not match the other); Border irregularity (edges are ragged, notched, or blurred); Color variation (different shades of tan, brown, black, sometimes red, white, blue); Diameter greater than 6 ext{ mm}; Elevation/Evolution (rapidly changing size, shape, color; new bleeding, itching, crusting); and Funny Looking (distinctively different from other moles, known as the "ugly duckling" sign).Widespread Color Change
Note any color changes over the body. In dark-skinned people, normal pigment can sometimes mask color changes. Nails and lips vary with a person's skin color and are not always accurate indicators of generalized color changes. The Most Reliable Sites for Assessing Color Changes (least pigmented) are the tongue, buccal mucosa, palpebral conjunctiva, and sclera.
Specific Color Changes include Pallor (White), which occurs when hemoglobin in the blood is lost, causing the skin to take on the color of collagen (white). This is common in acute high-stress states (e.g., anxiety or fear) due to peripheral vasoconstriction from sympathetic nervous system (SNS) stimulation. Pallor can also be pale from exposure to cold or cigarette smoking, or in cases of edema. In dark-skinned individuals with marked pallor, skin appears ashen gray. In light-skinned individuals, pallor occurs with anemia, shock, arterial insufficiency. In brown-skinned individuals, it appears yellowish-brown, and in black-skinned individuals, it appears ashen or gray. Anemia can also present with spoon-shaped nails that have a concave shape.
Erythema (Redness) is due to excess blood in superficial capillaries. It is expected with fever, inflammation, or emotional reactions like blushing, and is accompanied by increased skin temperature from increased blood flow. In dark-skinned individuals, palpate the skin for warmth or taut/tightly pulled surfaces, which can indicate edema or hardening of deep tissues/blood vessels. Erythema occurs with polycythemia, venous stasis, carbon monoxide poisoning, and extravascular red blood cells.
Cyanosis (Bluish) results from decreased perfusion, leading to high levels of deoxygenated blood. It is best seen in the lips, nose, cheeks, ears, and oral mucous membranes. It should not be confused with the normal bluish tone observed in some dark-skinned people of Mediterranean origins. Cyanosis indicates hypoxemia and occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease. An anemic person might have hypoxemia without turning blue, and cyanosis is difficult to detect in darkly pigmented individuals.
Jaundice (Yellowish) is a yellowish skin color due to excess bilirubin in the blood (except for physiologic jaundice in newborns). It is noted in the junction of the hard and soft palate in the mouth and in the sclera of the eyes. Scleral jaundice with normal yellow subconjunctival fatty deposits is common in dark-skinned individuals. Jaundice occurs with hepatitis, cirrhosis, sickle cell disease, transfusion reactions, and hemolytic disease in the newborn. It is best assessed in direct daylight. Calluses on palms may appear yellow and should not be confused with jaundice. Light or clay-colored stool and dark golden urine often accompany jaundice in both light and dark-skinned individuals.Temperature
Normal skin should be warm, and temperature should be equal bilaterally, suggesting normal circulatory status, though hands and feet may be cooler. Chronic cigarette smoking causes vasoconstriction, noted by cool, pale hands. Hyperthyroidism leads to an increased metabolic rate, causing warm, moist skin.Moisture
Normal perspiration is expected on the face, hands, axillae, and skin folds. Diaphoresis, or excessive perspiration, occurs with thyrotoxicosis, heart attack, anxiety, and pain. Dehydration is indicated by dry mucous membranes, cracked/parched lips, and extremely dry, fissured skin.Texture
Normal skin is smooth and firm with an even surface. Hyperthyroid skin is smoother, softer, like velvet, while hypothyroid skin is rough, dry, and flaky.Thickness
The epidermis is thin over most of the body. Callus Areas are normal on palms and soles; a callus is a circumscribed overgrowth of the epidermis, an adaptation to excessive pressure from friction of work and weight-bearing. Atrophic skin, which is very thin and shiny, occurs with arterial insufficiency.Edema
Edema is not normally present. Pitting Edema is present if pressure (imprint thumb for 3-4 seconds against the ankle) leaves a dent upon release. Edema masks normal skin color and obscures pathologic conditions such as jaundice or cyanosis because fluid lies between the surface and pigmented/vascular layers; it can make dark skin look lighter. Unilateral edema suggests a local or peripheral cause. Bilateral edema or anasarca, which is edema of the whole body, may indicate systemic issues like heart failure or kidney failure.Mobility and Turgor
Pinch a large fold of skin on the anterior chest under the clavicle to assess Mobility, the ease of skin to rise, and Turgor, the ability of skin to return to place when released. This reflects the elasticity of the skin. Mobility decreases with edema. Poor turgor is evidence of severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands. Scleroderma, or "hard skin," is a chronic connective tissue disorder associated with decreased mobility.Vascularity or Bruising
Cherry (Senile) Angiomas are small (1 to 5 ext{ mm}), smooth, slightly raised bright red dots that appear on the trunk in all adults older than 40. They increase in size and number with aging and are not clinically significant. Bruising could be consistent with expected trauma of life. Normally, there are no venous dilations or varicose veins. Multiple bruises at different stages of healing and excessive bruises above the knees or elbows raise concern for physical abuse.Tattoos and Needle Marks
Document the presence of tattoos on the patient's chart and inspect them for signs of infection or inflammation. Needle marks from IV street drug use can be visible on the antecubital fossae, forearms, or any available vein.
C. Inspection & Palpation of Lesions
If lesions are present, note the following characteristics: color, elevation, pattern or shape, size, location and distribution on the body, and any exudate (e.g., color, odor, consistency). A Primary Lesion develops on unaltered skin, while a Secondary Lesion is a primary lesion that changes over time or from infection/scratching. During Palpation, always wear gloves. Roll a nodule between the thumb and forefinger to assess depth. Gently scrape scale with a tongue blade to see if it comes off.
D. Inspection & Palpation of Hair
Color
Hair color comes from melanin production. Graying can begin in the early 30s due to reduced melanin production in the follicles, with genetic factors affecting the onset of graying.Texture
Scalp hair can be fine or thick, straight, curly, or kinky, and should look shiny. Hair can be lost or damaged due to dyes, rinses, or permanents. Note full, coarse, brittle scalp hair. Gray scale with well-defined areas of broken hairs accompanies tinea capitis (a ringworm infection found mostly in school-aged children).Hair Loss
Abnormal hair loss (e.g., eyebrows, scalp hair) is expected with chemotherapy or hypothyroidism.Distribution
Fine vellus hair coats most of the body, while coarser terminal hair grows at eyebrows, eyelashes, and scalp. During puberty, terminal hair develops in the axillae, pubic area, face, and chest, conforming to normal male and female patterns. Coarse, curly hair may develop in the pubic area. Female pubic hair is typically in a triangle shape, while male pubic hair may extend up to the umbilicus. In Asians, body hair may be diminished. Absent or sparse genitalia hair suggests endocrine abnormalities.Scalp
Separate hair into sections and lift to observe the scalp for lesions. Inquire about a history of itching. Inspect hair behind the ears and in the occipital area as well. All areas should be clean and free of any lesions or pests (dandruff can sometimes be seen).
E. Inspection & Palpation of Nails
Surface
The nail surface is slightly curved or flat. Posterior and lateral nail folds are smooth and rounded. Nail edges are smooth, rounded, and clean. Jagged nails, bitten to the quick, or traumatized nail folds may suggest nervous picking habits.Profile Sign
View the index finger at a profile. The angle of the nail base should be 160 degrees. The nail base should be firm to palpation. Curved nails are a variation of normal with a convex profile; they may look like clubbed nails but lack the spongy base. Clubbing of Nails occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases; a spongy nail base accompanies clubbing.Surface Smoothness and Thickness
The surface should be smooth and regular, not brittle or splitting. Pits, transverse grooves, or lines indicate nutrient deficiency or acute illness disturbing nail growth. Nail thickness should be uniform. Nails are thickened and ridged with arterial insufficiency.Adherence to Nail Bed
The nail should firmly adhere to the nail bed. The translucent nail plate provides a "window" to the even pink nail bed underneath (besides cases of cyanosis or pallor).Color Variations
Leukonychia refers to white hairline linear markings on the nail from trauma or picking at the cuticle. Dark-skinned people may have brown or black pigmented areas or linear bands on their nails. Note any other abnormal markings.Capillary Refill
Perform a capillary refill test by depressing the nail edge of the index fingertip at heart level for at least 5 seconds to blanch, then release. Note the return of color. Color should return instantly or at least within a few seconds (in a cold environment) and indicates the status of peripheral circulation. A healthy capillary refill takes 1 to 2 seconds to return. Cyanotic nail beds or sluggish color return (more than 3 seconds) indicates clinical decline, such as cardiovascular or respiratory failure, or septic shock.
VIII. Common Shapes and Configurations of Lesions
Shapes and configurations of lesions include Annular or Circular, which begins in the center and spreads to the periphery (e.g., tinea corporis or ringworm, tinea versicolor, pityriasis rosea). Confluent lesions run together (e.g., hives/urticaria). Discrete lesions are distinct, individual lesions that remain separate (e.g., acrochordons/skin tags, acne). Gyrate lesions are twisted, coiled spiral, or snake-like. Grouped lesions appear in clusters (e.g., vesicles of contact dermatitis). Linear lesions form a scratch, streak, line, or stripe. Target or Iris lesions resemble the iris of an eye, with concentric rings of color (e.g., erythema multiforme). Zosteriform lesions have a linear arrangement along a unilateral nerve route (e.g., herpes zoster). Polycyclic lesions are annular lesions that grow together (e.g., psoriasis).
IX. Primary Skin Lesions (Lesions that develop on unaltered skin)
Primary skin lesions include Macule, a color change that is flat and circumscribed, less than 1 ext{ cm} (e.g., freckles, measles, scarlet fever, hypopigmentation, flat nevi, petechiae). A Papule is something you can feel, solid and elevated, less than 1 ext{ cm}, caused by superficial thickening in the epidermis (e.g., moles, lichen planus, molluscum, wart/verruca). A Patch consists of macules that are larger than 1 ext{ cm} (e.g., chloasma, measles rash, vitiligo). A Plaque is formed when papules coalesce to create a surface elevation wider than 1 ext{ cm}; it is a disk-shaped lesion (e.g., psoriasis). A Nodule is solid, elevated, hard or soft, larger than 1 ext{ cm}; it may extend deeper into the dermis than a papule (e.g., fibroma). A Wheal is superficial, raised, transient, and erythematous with a slightly irregular shape from edema (e.g., a mosquito bite, allergic reaction). A Tumor is larger than a few centimeters, firm or soft, deeper into the dermis; it can be benign or malignant (e.g., lipoma, hemangioma). Urticaria (Hives) occurs when wheals coalesce to form an extensive, intensely pruritic reaction. A Vesicle is an elevated cavity containing free fluid, up to 1 ext{ cm}; it is a blister with clear serum flow if the wall is ruptured (e.g., herpes simplex, chickenpox, contact dermatitis). A Bulla is larger than 1 ext{ cm}, single-chambered (unilocular), superficial in the epidermis, thin-walled, and can rupture easily (e.g., friction blister, pemphigus). A Cyst is an encapsulated fluid-filled cavity in the dermis or subcutaneous layer, presenting as tensely elevated skin (e.g., sebaceous cyst, ganglion cyst). A Pustule contains turbid fluid (pus) in the cavity and is elevated (e.g., acne, impetigo).
X. Secondary Skin Lesions (Changes over time or from infection/scratching of primary lesions)
Secondary skin lesions include a Crust, which is a thickened, dried-out exudate left when vesicles or pustules burst or dry up (e.g., impetigo, weeping eczematous dermatitis). A Scale consists of compact, desiccated flakes of skin (dry or greasy, silvery or white) from shedding of excess keratin cells (e.g., psoriasis, eczema, dry skin).
A. Breaks in Continuity of Surface
Breaks in continuity of the surface include a Fissure, a linear crack with abrupt edges, extending into the dermis; it can be dry or moist (e.g., cheilosis at corners of mouth, athlete's foot). Erosion is a scooped out but shallow depression; it is superficial, moist, causes no bleeding, and heals without a scar (e.g., after a vesicle ruptures). An Ulcer is a deeper depression extending into the dermis; it is irregular in shape, may bleed, and leaves a scar when healed (e.g., stasis ulcer, pressure injury, chancre). Excoriation is a self-inflicted abrasion; it is superficial, sometimes crusted, and can result from scratches due to intense itching (e.g., insect bites, scabies, dermatitis). A Scar forms after a skin lesion is repaired, where normal tissue was lost and replaced with connective tissue (fibrous), resulting in a permanent fibrotic change (e.g., healed surgery or injury). An Atrophic Scar is a depressed skin level with loss of tissue and thinning of the epidermis (e.g., striae/stretch marks). Lichenification occurs when prolonged, intense scratching eventually thickens the skin, producing tightly packed sets of papules that look like the surface of moss or lichen. A Keloid is a benign excess of scar tissue beyond the site of original injury, resulting from surgery, acne, ear piercing, tattoos, infections, or burns.
XI. Pressure Injuries (Decubitus Ulcers)
Pressure injuries appear over bony prominences when circulation is impaired, often due to being confined to bed or immobilized. This impedes the delivery of blood carrying oxygen and nutrients to the skin and impedes venous drainage carrying metabolic wastes away from the skin, resulting in ischemia and cell death.
Stages of Pressure Injury include: Stage 1 Pressure Injury, characterized by non-blanchable erythema, where the skin is intact, red, and unbroken; it may appear darker in dark-skinned individuals. Stage 2 Pressure Injury involves partial-thickness skin loss of the epidermis and exposes the dermis, with no visible fat or deeper tissues, resembling an open blister with a red-pink wound bed. Stage 3 Pressure Injury is full-thickness skin loss that extends into the subcutaneous tissue, resembling a crater; visible fat, granulation tissue, and rolled edges are present, but no muscle, bone, or tendon is exposed. Stage 4 Pressure Injury involves all skin layers, exposing muscle, tendon, or bone; it may have slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue). Deep Tissue Pressure Injury (DTPI) presents as a non-blanchable color change to deep red, maroon, or purple; the skin may be intact or non-intact, and dark skin appears much darker but does not blanch. The epidermis may separate, revealing a dark wound bed or a blood-filled blister. DTPI is often preceded by pain and temperature change and begins in the muscle closest to the bone.
A. Contusion (Bruising) Color Stages
The stages of contusion color are: Stage 1, red-blue or purple right after trauma; Stage 2, blue to purple; Stage 3, blue-green; Stage 4, yellow; and Stage 5, brown to disappearing.
XII. Other Specific Conditions and Cancers
Other specific conditions include Tinea Corporis (Ringworm of the Body), which presents as multiple circular lesions with clear centers. Tinea Pedis (Ringworm of Foot/Athlete's Foot) is a fungal infection between toes, sides of feet, and on the soles; it grows scaly and hard and is commonly found in warm, moist feet. Psoriasis is an immune chronic inflammatory skin disease with environmental triggers and genetic factors. Tinea Versicolor is characterized by fine scaling, round hypomelanotic patches of pink, tan, or white. Type I Hypersensitivity is an allergic reaction that occurs 15 to 30 minutes after antigen exposure, also called immediate hypersensitivity. Herpes Zoster (Shingles) presents as a zosteriform lesion pattern.
Skin cancers include Basal Cell Carcinoma, where lesions start as small pink-red papules with a pearly translucent top, then develop rounded, pearly borders with a central red ulcer to look like a large open pore. It is the most common form of skin cancer, with slow but inexorable growth, occurring on sun-exposed areas like the face, ears, scalp, and shoulders. Squamous Cell Carcinoma arises from actinic keratoses or de novo (newly formed), presenting as an erythematous scaly patch with sharp margins (1 ext{ cm} or more), developing a central ulcer and surrounding erythema, usually found on hands or head areas exposed to UV radiation. Malignant Melanoma is often cutaneous, with 80 percent of cutaneous melanomas arising in areas with sun/artificial UV exposure, carrying a risk of genetic mutation. It is usually brown but can be tan, black, pink, red, purple, or mixed pigmentation, often has irregular or notched borders, and can have a scaling, flaking, or oozing texture.