NSG-316 Skin, Hair, and Nails Assessment: Integumentary System Notes

Integumentary System: Anatomical Structures and Their Functions

Dermis
- Composed of connective tissue or collagen, providing the skin's resistance to tearing.
- Contains nerves, sensory receptors, blood vessels, and lymphatics.
Subcutaneous Layer
- Consists of adipose tissue, which stores fat cells for energy.
- Provides insulation for temperature control.
- Offers protection through a soft cushioning effect.
Hair
- Composed of threads of keratin.
- Shaft: The visible, projecting part.
- Root: Located below the surface, embedded in the follicle.
- Bulb Matrix: An expanded area at the root where new cells are produced at a high rate.
- Hair growth is cyclical, with active and resting phases.
- Arrector Pili: Small muscles around hair follicles that contract, pulling the hair upright, creating "goose flesh" when the skin is cold or in an emotional state.
- Types of Hair:
  - Vellus Hair: Fine, faint hair covering most of the body.
  - Terminal Hair: Coarser, darker hair found on the scalp and eyebrows. After puberty, it also appears in the axillae, pubic area, face, and chest.
Glands
- Sebaceous Glands:
  - Produce a protective lipid substance called sebum, excreted through hair follicles.
  - Sebum forms an emulsion that retards water loss from the skin.
  - It is a mixture of sebum's oils.
- Eccrine Glands:
  - Open directly onto the skin surface.
  - Produce a dilute saline solution called sweat, which cools the body temperature through evaporation.
  - These glands are mature in a 2 ext{-month-old} infant.
- Apocrine Glands:
  - Produce a thick, milky secretion.
  - Open into hair follicles, predominantly in the axillae, anogenital area, nipples, and naval.
  - Become active during puberty.
  - 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
- Hard plates of keratin located on the dorsal surface of fingers and toes.
- Are clear with fine longitudinal ridges, which become more prominent in aging nails.
- Pink in color due to the underlying nail bed.
- Lunula: The white, crescent-shaped area at the proximal end of the nail.
- Cuticle: Covers and protects the nail matrix.

Functions of the Skin

Protection: Acts as a physical barrier against external threats.
Prevents Penetration: Blocks entry of harmful substances.
Perception: Contains sensory receptors for touch, pain, temperature, and pressure.
Fluid Balance: Regulates water loss and retention.
Temperature Regulation: Achieved through vasodilation/vasoconstriction and sweat production.
Identification: Unique patterns (fingerprints, facial features) contribute to individual identity.
Communication: Expresses emotions (e.g., blushing) and health status.
Wound Repair: Initiates and completes the healing process.
Absorption: Allows some substances (e.g., medications) to pass through.
Excretion: Eliminates some metabolic wastes through sweat.
Production of Vitamin D: Ultraviolet (UV) light converts cholesterol in the skin into Vitamin D.

Aging Changes in the Skin

The skin is often considered a mirror reflecting aging changes in all organ systems.
By the 70 ext{s} and 80 ext{s}, skin may appear parchment thin, lax, dry, and wrinkled.
Wrinkling occurs due to:
- Thinning and flattening of the underlying dermis.
- Loss of elastin, collagen, and subcutaneous fat.
This also increases the risk for shearing and tearing injuries.
Glandular Function:
- Sweat and sebaceous glands decrease in number and function, leading to dry skin.
- Decreased response of sweat glands puts individuals at greater risk of heat stroke.
Vascularity:
- Vascularity of the skin decreases.
- Minor trauma may produce senile purpura, which are dark red discolored areas.
Environmental Factors:
- Sun exposure and smoking further accentuate aging changes, which can include:
  - Coarse wrinkling.
  - Decreased elasticity.
  - Atrophy.
  - Speckled and uneven coloring.
  - Pigment changes.
  - Yellowed, leathery texture.
Hair Changes:
- Hair turns gray or white, becoming thinner and finer due to decreasing melanocytes.
- Axillae and pubic hair decrease.
- Women may develop bristly facial hair.
- 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.
- Scalp hair gradually turns gray because of decreased melanocyte function.
Nail Changes:
- Nail growth rate decreases with aging.
- Nail surfaces can become brittle, peel, and sometimes yellowed.
- Toenails may thicken and grow misshapen.
Skin Turgor:
- Skin turgor is decreased in older adults, and pinched skin recedes slowly or "tents."
Skin Tears:
- Loss of collagen in aging increases the risk of skin tears from minor trauma or from moving or grabbing the person.

Skin Cancer and Risk Factors

Melanin: A protective pigment against UV rays.
Incidence Rates:
- Black individuals, Native Americans, and Asians account for a lower incidence of skin cancer, including melanoma.
- White people have the highest incidence, with 28 melanoma cases per 1,000,000 individuals.
- Before age 50, women outnumber men in melanoma cases. By age 65, men have double the rates of women, and by age 80, triple.
Melanoma: Number 1 most diagnosed cancer in 25 ext{ to } 29 ext{-year-olds}.
Risk Factors for Melanoma:
- Atypical, large, or numerous moles (>$ 50 moles).
- High exposure to UV rays (sunlight).
- Natural blond or red hair.
Mechanism of UV Damage: UV or sun exposure changes the genetic makeup, causing mutations in tumor suppressor genes, allowing tumor genes to mutate freely.

Common Skin Conditions and Terms

Keloids: Raised scars that form at a wound site and grow beyond the normal boundaries of the wound.
Pseudofolliculitis: "Razor bumps" or ingrown hairs.
Melasma: "Mask of pregnancy" - patchy tan to dark brown discoloration on the face.
Seborrhea: Oily skin.
Xerosis: Dry skin.
Pruritus: Itching (the most common skin symptom).
Hirsutism: Shaggy or excessive hair growth, especially in women in a male pattern (face, chest, back), indicating increased androgen hormones.
Factors Affecting Skin Conditions:
- Stress: Can exacerbate chronic skin illnesses.
- Antibiotics: Can cause skin eruptions.
- Drugs: Can increase sunlight sensitivity or cause hyperpigmentation.
Actinic Keratosis: The most frequent premalignant skin lesion in white persons, directly caused by sun or artificial UV radiation exposure.
Acrochordons (Skin Tags): Overgrowths of normal skin that form a stalk; polyp-like. Occur on eyelids, cheeks, neck, axillae, and trunk.
Sebaceous Hyperplasia: Yellow papules with a central depression, common in men on the forehead, neck, and cheeks, giving a pebbly look.

Subjective Data: Health History (Skin, Hair, Nails)

History of skin disease (e.g., eczema, psoriasis, hives).
Changes in pigmentation (e.g., generalized or localized changes).
Changes in moles (size, shape, color, sensation).
Excessive dryness (xerosis) or moisture (diaphoresis, seborrhea).
Pruritus (itching).
Bruising (frequency, location, ease).
Rash or skin lesions.
Medications (prescription, over-the-counter, herbal remedies).
Hair loss (alopecia) or changes in hair texture/distribution.
Changes in nails (color, shape, thickness, brittleness).
Environmental hazards (e.g., sun exposure, chemicals).
Patient-centered care (e.g., self-care behaviors, concerns).

Objective Data: Physical Examination (Skin, Hair, Nails)

Preparation for Examination

Know normal skin coloring: Personalize assessment based on the individual's normal skin tone.
Control external variables: Ensure hands are warm and room temperature is comfortable to avoid vasoconstriction or pallor.
Begin with hands and nails: Allows the person to become accustomed to your touch.
Start with outer structures: Assess the skin's surface first, then examine underlying structures.
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.

Inspection & Palpation of Skin

General Pigmentation
- Normal: Skin tone should be consistent with the person's genetic background.
- Abnormal: Vitiligo - complete absence of melanin in patchy areas (face, neck, hands, feet, body folds, or orifices). More severely affects dark-skinned individuals, 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: Small (< ext{ }6 ext{ mm}), smooth borders, uniform pigmentation.
- Danger Signs (ABCDEF) for a suspicious mole:
  - A: Asymmetry - one half does not match the other.
  - B: Border irregularity - edges are ragged, notched, or blurred.
  - C: Color variation - different shades of tan, brown, black, sometimes red, white, or blue.
  - D: Diameter - greater than 6 ext{ mm}.
  - E: Elevation or Evolution - rapidly changing size, shape, or color; new bleeding, itching, or crusting.
  - F: Funny Looking - distinctively different from other moles (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.
- Most Reliable Sites for Assessing Color Changes (least pigmented): Tongue, buccal mucosa, palpebral conjunctiva, and sclera.
- Specific Color Changes:
  - Pallor (White):
    - Occurs when hemoglobin in the blood is lost, causing the skin to take on the color of collagen (white).
    - Common in acute high-stress states (e.g., anxiety or fear) due to peripheral vasoconstriction from sympathetic nervous system (SNS) stimulation.
    - Can also be pale from exposure to cold or cigarette smoking, or in cases of edema.
    - In dark-skinned individuals with marked pallor: Appears ashen gray.
    - In light-skinned individuals: Occurs with anemia, shock, arterial insufficiency.
    - In brown-skinned individuals: Appears yellowish-brown.
    - In black-skinned individuals: Appears ashen or gray.
    - Anemia: Can also present with spoon-shaped nails that have a concave shape.
  - Erythema (Redness):
    - Due to excess blood in superficial capillaries.
    - Expected with fever, inflammation, or emotional reactions like blushing.
    - Accompanied by increased skin temperature from increased blood flow.
    - In dark-skinned individuals: Palpate skin for warmth or taut/tightly pulled surfaces, which can indicate edema or hardening of deep tissues/blood vessels.
    - 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.
    - Best seen in the lips, nose, cheeks, ears, and oral mucous membranes.
    - Do not confuse with the normal bluish tone observed in some dark-skinned people of Mediterranean origins.
    - 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.
    - Cyanosis is difficult to detect in darkly pigmented individuals.
  - Jaundice (Yellowish):
    - Yellowish skin color due to excess bilirubin in the blood (except for physiologic jaundice in newborns).
    - 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.
    - Occurs with hepatitis, cirrhosis, sickle cell disease, transfusion reactions, and hemolytic disease in the newborn.
    - Jaundice is best assessed in direct daylight.
    - Calluses on palms may appear yellow; these 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. Hands and feet may be cooler.
- Chronic cigarette smoking causes vasoconstriction, noted by cool, pale hands.
- Hyperthyroidism: Increased metabolic rate causing warm, moist skin.
Moisture
- Normal: Perspiration is normal on the face, hands, axillae, and skin folds.
- Diaphoresis: Excessive perspiration, occurs with thyrotoxicosis, heart attack, anxiety, and pain.
- Dehydration: Dry mucous membranes, cracked/parched lips, and extremely dry, fissured skin.
Texture
- Normal: Skin is smooth and firm with an even surface.
- Hyperthyroid skin: Smoother, softer, like velvet.
- Hypothyroid skin: Rough, dry, and flaky.
Thickness
- The epidermis is thin over most of the body.
- Callus Areas: 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: Very thin, shiny skin occurs with arterial insufficiency.
Edema
- Not normally present.
- Pitting Edema: If pressure (imprint thumb for 3 ext{-4} seconds against the ankle) leaves a dent upon release, it is present.
- 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: 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.
- Mobility: The ease of skin to rise.
- 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: "Hard skin," a chronic connective tissue disorder associated with decreased mobility.
Vascularity or Bruising
- Cherry (Senile) Angiomas: Small (1 ext{ 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. Inspect tattoos 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.

Inspection & Palpation of Lesions

If lesions are present, note the following characteristics:
- Color
- Elevation
- Pattern or shape
- Size
- Location and distribution on the body
- Any exudate (e.g., color, odor, consistency)
Primary Lesion: Develops on unaltered skin.
Secondary Lesion: A primary lesion that changes over time or from infection/scratching.
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.

Inspection & Palpation of Hair

Color
- Hair color comes from melanin production.
- Graying can begin in the early 30 ext{s} due to reduced melanin production in the follicles.
- Genetic factors affect 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.
- 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: Typically in a triangle shape.
- Male pubic hair: May extend up to the umbilicus.
- 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).

Inspection & Palpation of Nails

Surface
- 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: A variation of normal with a convex profile; 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
- 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: 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 capillary refill test: With the index fingertip at heart level, depress the nail edge 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 ext{ 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.

Common Shapes and Configurations of Lesions

Annular or Circular: 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: Distinct, individual lesions that remain separate (e.g., acrochordons/skin tags, acne).
Gyrate: Twisted, coiled spiral, or snake-like.
Grouped: Clusters of lesions (e.g., vesicles of contact dermatitis).
Linear: A scratch, streak, line, or stripe.
Target or Iris: Resembles the iris of an eye, with concentric rings of color in the lesions (e.g., erythema multiforme).
Zosteriform: Linear arrangement along a unilateral nerve route (e.g., herpes zoster).
Polycyclic: Annular lesions that grow together (e.g., psoriasis).

Primary Skin Lesions

(Lesions that develop on unaltered skin)

Macule: Color change, flat, and circumscribed, less than 1 ext{ cm} (e.g., freckles, measles, scarlet fever, hypopigmentation, flat nevi, petechiae).
Papule: 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).
Patch: Macules that are larger than 1 ext{ cm} (e.g., chloasma, measles rash, vitiligo).
Plaque: Papules coalesce to form a surface elevation wider than 1 ext{ cm}; a disk-shaped lesion (e.g., psoriasis).
Nodule: Solid, elevated, hard or soft, larger than 1 ext{ cm}; may extend deeper into the dermis than a papule (e.g., fibroma).
Wheal: Superficial, raised, transient, and erythematous with a slightly irregular shape from edema (e.g., a mosquito bite, allergic reaction).
Tumor: Larger than a few centimeters, firm or soft, deeper into the dermis; can be benign or malignant (e.g., lipoma, hemangioma).
Urticaria (Hives): Wheals coalesce to form an extensive reaction, intensely pruritic.
Vesicle: Elevated cavity containing free fluid, up to 1 ext{ cm}; a blister with clear serum flow if the wall is ruptured (e.g., herpes simplex, chickenpox, contact dermatitis).
Bulla: Larger than 1 ext{ cm}, single-chambered (unilocular), superficial in the epidermis, thin-walled, and can rupture easily (e.g., friction blister, pemphigus).
Cyst: Encapsulated fluid-filled cavity in the dermis or subcutaneous layer; tensely elevated skin (e.g., sebaceous cyst, ganglion cyst).
Pustule: Turbid fluid (pus) in the cavity; it is elevated (e.g., acne, impetigo).

Secondary Skin Lesions

(Changes over time or from infection/scratching of primary lesions)

Crust: Thickened, dried-out exudate left when vesicles or pustules burst or dry up (e.g., impetigo, weeping eczematous dermatitis).
Scale: Compact, desiccated flakes of skin (dry or greasy, silvery or white) from shedding of excess keratin cells (e.g., psoriasis, eczema, dry skin).

Breaks in Continuity of Surface

Fissure: A linear crack with abrupt edges, extending into the dermis; can be dry or moist (e.g., cheilosis at corners of mouth, athlete's foot).
Erosion: Scooped out but shallow depression; superficial, moist, no bleeding; heals without a scar (e.g., after a vesicle ruptures).
Ulcer: Deeper depression extending into the dermis; irregular in shape and may bleed; leaves a scar when healed (e.g., stasis ulcer, pressure injury, chancre).
Excoriation: Self-inflicted abrasion; superficial, sometimes crusted; can be from scratches due to intense itching (e.g., insect bites, scabies, dermatitis).
Scar: After a skin lesion is repaired, normal tissue was lost and replaced with connective tissue (fibrous). This is a permanent fibrotic change (e.g., healed surgery or injury).
Atrophic Scar: The resulting skin level is depressed with loss of tissue; a thinning of the epidermis (e.g., striae/stretch marks).
Lichenification: Prolonged, intense scratching eventually thickens the skin, producing tightly packed sets of papules; looks like surface of moss or lichen.
Keloid: A benign excess of scar tissue beyond the site of original injury; results from surgery, acne, ear piercing, tattoos, infections, or burns.

Pressure Injuries (Decubitus Ulcers)

Appear over bony prominences when circulation is impaired, often due to being confined to bed or immobilized.
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

Stage 1 Pressure Injury: Non-blanchable erythema. Skin is intact, red, and unbroken. May appear darker in dark-skinned individuals.
Stage 2 Pressure Injury: Partial-thickness skin loss of the epidermis and exposes the dermis. No visible fat or deeper tissues. Resembles an open blister with a red-pink wound bed.
Stage 3 Pressure Injury: Full-thickness skin loss. Extends into the subcutaneous tissue, resembling a crater. Visible fat, granulation tissue, and rolled edges. No muscle, bone, or tendon exposed.
Stage 4 Pressure Injury: Involves all skin layers. Exposes muscle, tendon, or bone. May have slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue).
Deep Tissue Pressure Injury (DTPI): Non-blanchable color change to deep red, maroon, or purple. Skin may be intact or non-intact. Dark skin appears much darker but does not blanch. The epidermis may separate, revealing a dark wound bed or a blood-filled blister. It is often preceded by pain and temperature change and begins in the muscle closest to the bone.

Contusion (Bruising) Color Stages

Stage 1: Red-blue or purple right after trauma.
Stage 2: Blue to purple.
Stage 3: Blue-green.
Stage 4: Yellow.
Stage 5: Brown to disappearing.

Other Specific Conditions and Cancers

Tinea Corporis (Ringworm of the Body): Multiple circular lesions with clear centers.
Tinea Pedis (Ringworm of Foot/Athlete's Foot): Fungal infection between toes, sides of feet, and on the soles; grows scaly and hard. Commonly found in warm, moist feet.
Psoriasis: Immune chronic inflammatory skin disease with environmental triggers and genetic factors.
Tinea Versicolor: Fine scaling, round hypomelanotic patches of pink, tan, or white.
Type I Hypersensitivity: An allergic reaction that occurs 15 ext{ to } 30 minutes after antigen exposure; also called immediate hypersensitivity.
Herpes Zoster (Shingles): Presents as a zosteriform lesion pattern.
Basal Cell Carcinoma:
- Lesions start as small pink-red papules with a pearly translucent top.
- Then develops 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.
- Occurs on sun-exposed areas like the face, ears, scalp, and shoulders.
Squamous Cell Carcinoma:
- Arises from actinic keratoses or de novo (newly formed).
- Presents as an erythematous scaly patch with sharp margins (1 ext{ cm or more}).
- Develops a central ulcer and surrounding erythema.
- Usually found on hands or head areas exposed to UV radiation.
Malignant Melanoma:
- Often cutaneous; 80$$ percent of cutaneous melanomas arise in areas with sun/artificial UV exposure, with a risk of genetic mutation.
- Usually brown but can be tan, black, pink, red, purple, or mixed pigmentation.
- Often has irregular or notched borders.
- Can have a scaling, flaking, or oozing texture.