Chapter 13 - Skin, Hair, and Nails Part 2

External Variables Influencing Skin Color Variable: Chilly or air-conditioned room

- Causes: Vasoconstriction - Misleading Outcome: False pallor, coolness

External Variables Influencing Skin Color Variable: Hot room

- Causes: Vasodilation - Misleading Outcome: False erythema

External Variables Influencing Skin Color Variable: Dependent position

- Causes: Venous pooling - Misleading Outcome: Redness, warmth, distended veins

Normal Range of Findings of Skin

- Color - Temperature - Moisture - Texture - Thickness - Edema - Mobility and Turgor - Vascularity or Bruising - Lesions

Normal Range of Findings: Skin Thickness

- Epidermis: uniformly thin over most of the body, although thickened callus areas are normal on palms and soles. - Callus: Circumscribed overgrowth of epidermis and is an adaptation to excessive pressure from the friction of work and weight bearing. - Abnormal findings: very thin, shiny skin (atrophic) occurs with arterial insufficiency.

Normal Range of Findings: Skin Edema

- Fluid accumulating in the intersistial spaces - To check for edema, imprint your thumbs firmly for 3-4 seconds against the ankle malleolus or the tibia. - Masks normal skin color and obscures pathologic conditions such as jaundice or cyanosis because the fluid lies between the surface and the pigmented and vascular layers. - Masks dark skin look lighter - Shows in dependent body parts (feet, ankles, and sacral areas), where the skin looks puffy and tight. - Unilateral edema has a local or peripheral cause. - Bilateral edema or edema that is generalized over the whole body (anasarca) - consider a central problem such as heart failure or kidney failure.

Danger signs: abnormal characterstics of pigmented lesions are summarized in the mnemonic *ABCDEF*:

- *A*symmetry (not regularly round or oval, two halves of lesion do not look the same) - *B*order irregularity (notching, scalloping, ragged edges, poorly defined margins) - *C*olor variation (areas of brown, tan, black, blue, red, white, or combination) - *D*iameter greater than 6 mm (ex: the size of a pencil eraser), although early melanomas may be diagnosed at a smaller size. - *E*levation or *E*volution - *F*unny looking ("ugly ducking" sign, in which the suspicous lesion stands out as looking different compared with its neighboring nevi

Normal Range of Findings: Skin Color Cyanosis

- A bluish mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood. - Best seen in the lips, nose, cheeks, ears, and oral mucous membranes and in artificial fluorescent light. - Do not confuse cyanosis with the common and normal bluish tone on the the lips of dark-skinned persons of Mediterranean origin. - Be aware that cyanosis can be a nonspecific sign. - A person who is anemic could have hypoxemia without ever looking blue, because not enough hemoglobin is present (either oxygenated or reduced) to color the skin. - Indicates hypoxemia and occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congenital heart disease

Normal Range of Findings: Skin Color Mole (Nervus)

- A clump of melanocytes, tan-to-brown color, flat or raised. - Acquired nevi have symmetry, small size (6 mm or less), smooth borders, and single uniform pigmentation.

Normal Range of Findings: Skin Color Jaundice

- A yellowish skin color indicates rising amounts of bilirubin in the blood. - First noted in the junction of the hard and soft palate in the mouth and in the sclera. - Then, the eyes appear yellow, but do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. - The scleral yellow of jaundice extends up to the edge of the iris. - As levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body. - Best assessed in direct natural daylight. - Common calluses on palms and soles often look yellow; do not interpret these as jaundice. - Occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn. - Light or clay-colored stools and dark golden urine often accompany jaundice in both light and dark-skinned people.

Normal Range of Findings: Skin Color Vitiligo

- An acquired condition, the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, and body folds and around orifices. - Occurs in all people, although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image.

The Complete Physical Examination

- At the beginning of the examination, assessing the person's hands and fingernails is a nonthreatening way to accustom him or her to your touch. - As you move through the examination, scrutinize the outer skin surface first before you concentrate on the underlying structures. - Separate intertriginous areas (areas with skinfolds) such as under large breats, obese abdomen, and the groin and inspect them thoroughly. - These areas are dark, warm, and moist and provide the perfect conditions for irritation or infection. - Finally, always remove the person's socks and inspect the feet, the toenails, and the folds between the toes.

External Variables Influencing Skin Color Variable: Prolonged elevation

- Causes: Decreased arterial perfusion - Misleading Outcome: Pallor, coolness

External Variables Influencing Skin Color Variable: Embarrassment

- Causes: Flushing in face and neck - Misleading Outcome: False erythema

External Variables Influencing Skin Color Variable: Fear, Anger

- Causes: Peripheral vasoconstriction - Misleading Outcome: False pallor

External Variables Influencing Skin Color Variable: Immobilization, prolonged inactivity

- Causes: Slowed circulation - Misleading Outcome: Pallor, coolness, pale nail beds, prolonged capillary filling time

External Variables Influencing Skin Color Variable: Cigarette smoking

- Causes: Vasoconstriction - Misleading Outcome: False pallor

Normal Range of Findings: Skin Temperature Hypothermia

- Generalized coolness may be induced such as in hypothermia used for surgery or high fever. - Localized coolness is expected with an immobilized extremity, as when a limb is in a cast or with an intravenous infusion. - General hypothermia accompanies shock, cardiac arrest. - Localized hypothermia occurs in peripheral arterial insufficiency and Raynaud disease. - Hyperthyroidism has an increased metabolic rate, causing warm, moist skin.

Normal Range of Findings: Skin Temperature Hyperthermia

- Generalized hyperthermia occurs with an increased metabolic rate such as in fever or after heavy exericse. - A localized area feels hyperthermic with trauma, infection or sunburn.

The Regional Examination

- Help the person remove clothing and assess the skin as one entity. - Stand back at first to get an overall impression; this helps reveal distribution patterns. - Then, inspect lesions carefully. - With a skin rash, check all areas of the body because the person cannot see some locations. - Inspect mucous membranes, too, because some disorders have characteristic lesions here.

Normal Range of Findings: Skin Color Widespread Color Change

- In dark-skinned people, the amount of normal pigment may ask color changes. - Lips and nail beds vary with the person's skin color and may not be accurate signs. - The more reliable sites have the least pigmentation such as the tongue, the buccal mucosa, the palpebral conjunctiva, and the sclera.

Normal Range of Findings: Skin Color Erythema

- Intense redness of the skin is from excess blood (hyperemia) in the dilated superficial capillaries. - Is expected with fever, local inflammation, or emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest) - The erythema with fever or localized inflammation has an increased skin temperature from the increased rate of blood flow. - Because you cannot see inflammation in dark-skinned people, you must palpate the skin for increased warmth or taut or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels.

Etiology: Erythema (Skin) Carbon monoxide poisoning

- Light Skin: Bright cherry red in face and upper torso - Dark Skin: Cherry-red color in nail beds, lips, and oral mucosa

Etiology: Brown-Tan (Skin) Addison disease: Cortisol deficiency stimulates increased melanin production

- Light Skin: Bronzed appearance; an "eternal tan", most apparent around nipples, perineum, genitalia, and pressure points (inner thighs, buttocks, elbow, axillae). - Dark Skin: Easily masked; rely on laboratory and clinical findings

Etiology: Cyanosis (Skin) - Increased amount of unoxygenated hemoglobin - Central: Chronic heart and lung disease cause arterial desaturation

- Light Skin: Dusky blue - Dark Skin: Dark but dull, lifeless; only severe cyanosis is apparent in skin - Check conjunctivae, oral mucosa, nail beds

Etiology: Erythema (Skin) - Venous stasis: Decreased blood flow from area, engorged venules

- Light Skin: Dusky rubor of dependent extremities; a prelude to necrosis with pressure sore - Dark Skin: Easily masked; use palpation for warmth or edema

Etiology: Pallor (Skin) - Anemia: Decreased hematocrit - Shock: Decreased perfusion, vasoconstriction

- Light Skin: Generalized pallor - Dark Skin: Brown skin appears yellow-brown, dull; black skin appears ashen gray, dull; skin loses, its healthy glow -- Check areas with least pigmentation such as conjunctivae, mucous membranes

Etiology: Pallor (Skin) Local arterial insufficiency

- Light Skin: Marked localized pallor (ex: lower extremities, especially when elevated) - Dark Skin: Ashen gray, dull; cool to palpation

Etiology: Cyanosis (Skin) - Peripheral: Exposure to cold, anxiety

- Light Skin: Nail beds dusky - Dark Skin: N/A

Etiology: Jaundice (Skin) Uremia: Renal failure causes retained urochrome pigments in the blood

- Light Skin: Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura. - Dark Skin: Easily masked; rely on laboratory and clinical findings

Etiology: Erythema (Skin) - Hyperemia: Increased blood in engorged arterioles (ex: inflammation, fever, alcohol intake, blushing)

- Light Skin: Red, bright pink - Dark Skin: Purplish tinge but difficult to see; palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues

Etiology: Erythema (Skin) - Polycythemia - Increased red blood cells, capillary stasis

- Light Skin: Ruddy blue in face, oral mucosa, conjunctiva, hands and feet - Dark Skin: Well concealed by pigment; check for redness in lips

Etiology: Brown-Tan (Skin) Cafe au lait spots: Caused by increased melanin pigment in basal cell layer

- Light Skin: Tan to light brown, irregularly shaped, oval patch with well-defined borders. - Dark Skin: N/A

Etiology: Pallor (Skin) - Albinism: Total absence of pigment melanin throughout the integument

- Light Skin: Whitish pink - Dark Skin: Tan, cream, white

Etiology: Jaundice (Skin) - Increased serum bilirubin from liver inflammation or hemolytic disease such as after severe burns, some infections

- Light Skin: Yellow in sclera, hard palate, mucous membranes, then over skin - Dark Skin: Check sclera for yellow near limbus; do not mistake normal yellowish fatty deposits in the scleral periphery for jaundice; jaundice best noted in junction of hard and soft palate, also palms

Etiology: Jaundice (Skin) Carotenemia: Increased serum carotene from ingestion of large amounts of carotene-rich foods

- Light Skin: Yellow-orange in forehead, palms and soles, nasolabial folds, but no yellowing in sclera or mucous membranes - Dark Skin: Yellow-orange tinge in palms and soles

Normal Range of Findings: Skin Mobility and Turgor

- Mobility is the ease of skin to rise, and turgor is its ability to return to place promptly when released. - This reflects the elasticity of the skin. - Mobility decreased with edema. - Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands by itself. - Scleroderma, literally "hard skin," is a chronic connective tissue disorder associated with decreased mobility.

Normal Range of Findings: Skin Moisture Dehydration

- Mucous membranes are dry, and lips look parched and crackled. - With extreme dryness the skin is fissured, resembling cracks in a dry lake bed.

Normal Range of Findings: Skin Lesions Instructions

- Palpation lesions. - Wear a glove if you anticipate contact with blood, mucosa, or any body fluid. - Roll a nodule between the thumb and index finger to assess depth. - Gently scrape a scale to see if it comes off. - Note the nature of its base or whether it bleeds when the scale comes off. - Note the surrounding skin temperature. - However, the erythema associated with rashes is not always accompanied by noticeable increases in skin temperature.

Normal Range of Findings: Skin Moisture Diaphoresis

- Profuse perspiration, accompanies an inceeased metabolic rate such as occurs in heavy activity or fever. - Occurs with thyrotoxicosis, heart attack, anxiety, or pain.

Additional symptoms of malignant melanoma and warrant referral

- Rapidly changing lesion; a new pigmented lesion; development of itching, burning, or bleeding in a mole.

Chronic iron deficiency anemia

- Show "spoon" nails, with a concave shape. - Fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function accompany most severe anemias.

Normal Range of Findings: Skin Vascularity or Bruising Cherry (senile) angiomas

- Small (1-5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years. - Normally increase in size and number with aging and are not significant. - Any bruising (contusion) should be consistent with the expected trauma of life. - Normally there are no venous dilations or varicosities. - Document the presence of any tattoos (a permanent skin design from indelible pigment) on the person's chart. - Inspect skin of tattoo for any infection or inflammation; normally there are no reactions.

Normal Range of Findings: Skin Lesions Reactions

- Stretching the area of the skin between your thumb and index finger decreases (blanches) the normal underlying red tones, thus providing more contrast and brightening the macules. - Red macules from dilated blood vessels will blanch momentarily, whereas those from extravasated blood (petechiae) do not. - Blanching also helps identify macular rash in dark-skinned people. - Use a magnifier and light for closer inspection of the lesion. - Use a Wood's light (ex: a UV light filtered through a special glass) to detect fluorescing lesions. - With the room darkened, shine the Wood's light on the area. - Under the Wood's light, lesions with blue-green fluroescence indicate fungal infection (ex: tinea capitis [scalp ringworm]).

Normal Range of Findings: Skin Lesions

- Traumatic or pathologic changes in previously normal structures. - When a lesion develops on previously unaltered skin, it is *primary*. - When a lesion changes over time or changes because of scratching or infection, it is *secondary*. - If any lesions are presents, note the: 1. Color 2. Elevation: flat, raised, or pedunculated 3. Pattern or shape: the grouping or distinctness of each lesion (ex: annular, grouped, confluent, linear). The pattern may be characteristic of a certain disease 4. Size, in centimeters: use a ruler to measure. Avoid household prescriptions such as "quarter size" or "pea size". 5. Location and distribution on body: is it generalized or localized to area of specific irritant; around jewelry, watchband, eyes? 6. Any exudate. Note its color and any odor.

Normal Range of Findings: Skin Color Pallor

- When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white. - Common in acute high-stress states such as anxiety or fear because of the powerful peripheral vasoconstriction from sympathetic nervous system stimulation. - Also looks pale with vasoconstriction from exposure to cold and from cigarette smoking and in the presence of edema. - Look for pallor in dark-skinned people by the absence of the luster of the underlying red tones. - The brown-skinned individual shows yellowish-brown color, and the black-skinned person appears ashen or gray. - Observe generalized pallor in the mucous membranes, lips, and nail beds. - Look for the pallor of anemia in the peripheral conjunctiva and nail beds. - Inspect the conjunctiva near the outer and inner canthi. - The coloration is often lighter near the inner canthus.

Normal Range of Findings: Skin Color Junctional nevus

Macular only and occurs in children and adolescents

Normal Range of Findings: Skin Color Intradermal nervus

Mainly in older age, has nevus cells in only the dermis

Normal Range of Findings: Skin Color Birthmarks

May be tan to brown in color

Erythema occurs with

Polycythemia, venous stasis, carbon monoxide poisoning, and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma)

Normal Range of Findings: Skin Color Compound nervus

Progresses in young adults, which is macular and papular.

The pallor of shock presents

Rapid pulse rate, oliguria, apprehension, and restlessness

Normal Range of Findings: Skin Texture Hypothyroidism

Skin feels rough, dry, and flaky

Normal Range of Findings: Skin Texture Hyperthyroidism

Skin feels smoother and softer, like velet

Normal Range of Findings: Skin Color Freckles (Ephelides)

Small, flat macules of brown melanin pigment that occur on sun-exposed skin.

Equipment Needed

•Strong direct lighting (natural daylight is ideal to evaluate skin characteristics, but halogen light will suffice) •Small centimeter ruler •Penlight •Gloves •Needed for special procedures: •Wood's light (filtered UV light) •Lighted magnifier