Chapter 12: Skin, Hair, Nails

Café au lait spot

A large round or oval patch of light brown pigmentation, usually present at birth.

Fissure

A linear cleavage of skin which extends into the dermis. (Secondary Lesion)

Eccrine Glands function and location?

Coiled tubules open directly onto skin surface that produce sweat, help regulate body temp. Distributed through out the body (mature after 2 months of age.)

Lesions, take note of:

Color Elevation Pattern or shape Size Location and distribution on body Any exudate: note color and odor Blanching Depth Type of tissue in the base

Erythema toxicum

Common rash that appears in first 3-4 days of life "newborn rash" Papules on cheeks, trunk, chest, back and buttocks.

Target

Concentric rings Ex: Lyme disease

Mongolian Spots

Congenital dermal melanocytosis, and dermal melanocytosis is a benign, flat, congenital birthmark with wavy borders and irregular shape. Often confused for a bruise. Present in 90% Blacks, 80% Asians & American Indians, 9% Whites.

Scale

Consists of flakes or plates that represent compacted desquamated layers of stratum corneum. Desquamation occurs when there are peeling sheets of scale following acute injury to the skin. (Secondary Lesion)

Pressure Ulcer Stage 3

Deeper crater Into SQ tissue, adipose tissue

Normal Cap Refill

Depress nail edge to blanch and release: Instant or <1-2 seconds

Abnormal Cap Refill

Depress nail edge to blanch and release: Sluggish > 1-2 seconds

Critical Thinking #2

Describe the differentiation between normal and abnormal skin color for various ethnic groups.

Critical Thinking #1

Describe the significant differences between the skin of the very young, the older adult, and the healthy adult.

Common Skin Lesions in Children

Diaper dermatitis Intertrigo (candidiasis) Impetigo Atopic dermatitis (eczema) Measles (rubeola) German measles (rubella) Chickenpox (varicella)

Discrete

Distinct, individual, separate. Ex: Acne, skin tags

Atopic Dermatitis (Eczema)

Erythematous papules and vesicles with weeping, oozing and crusts. Usually on scalp, forehead, forearms, wrists, elbows and backs of knees.

External Variables Influencing Skin Color

Fear/Anger -> False pallor Embarrassment -> False erythema Hot Room -> False erythema Chilly Room -> False pallor, coolness Cigarette Smoking -> False pallor Prolonged Elevation -> Pallor, coolness Dependent position -> Redness, warmth, distended veins Immobilization -> Pallor, coolness, pale nail beds, slow cap refill.

Spider/Star Angioma

Fiery red, star-shaped marking with solid circular center. Capillary radiations extend from central arterial body. Develops on face, neck or chest. May be associated with pregnancy, chronic liver disease, estrogen therapy or may be normal.

Lanugo

Fine downy hair of the newborn infant

Edema

Fluid accumulating in the interstitial spaces. To check, imprint your thumbs firmly for 3-4 seconds against ankle malleolus or the tibia. Normally skin surface stays smooth. Edema masks normal skin color, obscures pathologic conditions such as jaundice or cyanosis.

Skin

Largest organ system, functions: Protection, Perception, Temp Regulation, Identification, Wound Repair, Absorption and excretion, Production Vit. D

Confluent

Lesions run together. Ex: Hives

Zosteriform

Linear arranged along nerve route. Ex: Shingles

Dehydration

Look for dehydration in the oral mucous membranes, should look smooth and moist.

Cultural skin considerations

Lower incidence of skin cancer among darkly pigmented A. Americans and American Indians/Highest among Whites then Hispanics. Dark skin may hind injury, inflammation or ischemia.

Petechiae

Pinpoint, round spots that appear on the skin as a result o bleeding. Commonly appear in clusters and may look like a ash. Flat to the touch.

Common Skin Lesions

Primary Contact Dermatitis Allergic drug reactions Tinea Corporis Labial Herpes Simplex Herpes Zoster Psoriasis

Lesions Primary vs. Secondary

Primary lesions are physical changes in the skin considered to be caused directly by the disease process. Types of primary lesions are rarely specific to a single disease entity. (Macule, plaque, bullae etc.) Secondary lesions may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process. The distinction between a primary and secondary lesion is not always clear. (Crust, scale, erosion etc.)

Apocrine Glands function and location?

Produce thick, milky secretion- kick into high gear every time emotional stress occurs. Located in the axillae, anogenital area, nipples.

Carotenemia

Produces a yellow-orange color in light-skinned persons but NO yellowing of sclera or mucous membranes. Comes from ingestion of carotene-rich foods popular for infants. Should go away in 2-6 weeks of withdrawing carotene-rich foods from diet.

Diaphoresis

Profuse perspiration, accompanies increased metabolic rate such as during heavy activity or fever.

Purpura

Purpura refers to small reddish purple discolorations on the skin that do not blanch when external pressure is applied over them Petechiae < Purpura < Ecchymosis

Diaper Dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area.

Abscess

Red, swollen, hard, tender, puss-filled lesion caused by acute, localized bacterial infection.

Measles (Rubeola)

Red-purple maculopapular blotchy skin rash. Appears on day 3 or 4 of illness. Looks "coppery" and does not blanch.

Icteric

Related to or marked by jaundice.

Atrophic Scar

Resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Ex: Striae

Abnormal Conditions of Nails

Scabies Paronychia Beau's line Splinter hemorrhages Late clubbing Onycholysis Pitting Habit-tic dystrophy

Intertrigo (Candidiasis)

Scalding red, moist patches with sharply demarcated borders, some loose scales. Aggravated by urine, feces, heat and moisture.

Psoriasis

Scaly, erythematous patch, with silvery scales on top.

Keloids

Scars that from at the site of a wound and grow beyond the norm boundaries of the wound.

Abnormal Conditions of Hair/Scalp

Seborrheic dermatitis (cradle cap) Tinea capitis (scalp ringworm) Toxic alopecia Alopecia areata Traumatic alopecia, Traction alopecia Trichotillomania Pediculosis capitis (head lice) Folliculitis Hirsutism Furuncle and abscess

Venous Ulcers

Shin, ankle Irregular edges Extensive drainage Edema No claudication

Texture

Should be smooth and firm with even surface. Abnormal findings- hyperthyroidism skin feels smoother and softer like velvet. hypothyroidism skin feels rough, dry and flaky.

Alopecia

Significant hair loss.

Pressure Ulcer Stage 1

Skin and layers intact Non-blanching erythema Heals with pressure relief

Squamous Cell Carcinoma

Skin cancer usually found in sun exposed areas of head and hands. Grows rapidly. Red scaly patch.

Malignant melanoma

Skin cancer usually found on trunk or back of legs. Scaling, flaking. 50% from nevi.

Pressure Ulcers

Skin damage and necrosis related to: -Unrelieved pressure over bony prominences -Friction, shear -Moisture -Poor nutrition -Immobility

Deep Tissue Injury (DTI)

Skin intact, deep bruising

Erosion

Slightly depressed areas of skin in which part or all of the epidermis has been lost. (Secondary Lesion)

Cherry (senile) angiomas

Small (1-5mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30

Freckles (ephelides)

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

Herpes Zoster (Shingles)

Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustles, then crusts. Most common in adults older than 50. Pain is often severe and long lasting. Usually lesion appears on one side of body.

Chickenpox (Varicella)

Small, tight vesicles first appear on trunk and spread to face, arms and legs (not palms or soles) Described as the "dewdrop on a rose pedal"

Annular

Starts in center, moves outwards. Ex: Ringworm

Critical Thinking #3

State the significance of skin tone changes. (Cyanosis, jaundice etc.)

Linear

Straight line, stripe Ex: Scratches, lacerations

Equipment to gather objective data

Strong direct lighting, gloves, penlight and small centimeter ruler.

Peau d'orange

Swelling from edema can make the hair follicles more prominent giving and "orange peal' look. (In the breast peau d'orange can be a sign of breast cancer and should NOT be ignored!)

Sebaceous Glands function and location?

produce protective lipid substance (sebum) secreted through hair follicles. Retards water, lubricates skin & hair. Mostly found on scalp, forehead, face & chin.

Melanin

responsible for various colors and ones of skin. Protects skin from UV rays.

Vernix caseosa

thick, cheesy substance made up of sebum and shed epithelial cells, present at birth

Hirsutism

unwanted, male-patter hair in women

Wheal

Is an area of edema in the upper epidermis.

Atrophy

Thinning or absence of the epidermis or subcutaneous fat. (Secondary Lesion)

Tinea Pedis (Ringworm of the foot)

"Athlete's foot", a fungal infection, first appears as small vesicles between toes and soles. Grows Scaly and hard.

Comedone

"Blackhead" a primary sign of acne

Pseudofolliculitis

"razor bumps" caused by shaving too closely

4-point Edema Pitting scale

1+ Mild pitting; slight indentation; no perceptible swelling of the leg 2+ Moderate pitting; indentation subsides rapidly 3+ Deep pitting; indentation remains for a short time; legs look swollen 4+ Very deep pitting; indentation lasts a long time; leg is very swollen

2 Cyanotic Conditions in Neonate

1. Acrocyanosis 2.Cutis marmorata

3 Erythematous States Common in Neonate

1. Newborns skin beefy red flush first 24 hours 2. Harlequin color change 3. Erythema toxicum

Subjective Data points to cover with patient

1. Past history of skin disease 2. Change in pigmentation 3. Change in mole 4. Excessive dryness or moisture 5. Pruritus 6. Excessive bruising 7. Rash or lesion 8. Medications 9. Hair loss 10. Change in nails 11. Environmental/occupational hazards 12. Self care Additional data for infants and children: 1. Birthmarks 2. Any change in skin color as a newborn 3. Any rash or sores? What brings it on? 5. Any diaper rash? 6. Any burns or bruises? 7. Exposure to contagious skin conditions (chickenpox, lice) 8. Child's habits such as nail-biting, hair twisting etc. 9. Steps taken to protect child from sun exposure? Additional data for aging adults: 1. Any delay in wound healing? 2. Any skin itching or pain? 3. Any change in feet or toenails? 4. Have you had any falls? Any history of diabetes?

Macule

A change in the color of the skin. It is flat. Greater than 1 cm. (Primary Lesion)

Mole (nevus)

A clump of melanocytes, tan-to-brown color, flat or raised.

Hematoma

A collection of blood outside of a blood vessel.

Port-Wine Stain (Nevus Flammeus

A large, flat, macular patch covering the scalp or face, frequently along the distribution of the cranial nerve V. Dark red, bluish or purplish color. Present and birth and usually does not fade.

Ecchymosis

A purplish patch caused by extravasation of blood into the skin, differing from petechiae only in size (larger than 3mm diameter)

Nodule

A raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue.

Crust

A result of the drying of plasma or exudate on the skin. Please remember that crusting is different from scaling. The two terms refer to different phenomena and are not interchangeable. One can usually be distinguished from the other by appearance alone. (Secondary Lesion)

Tumor

A solid mass of the skin or subcutaneous tissue; it is larger than a nodule.

Papule

A solid raised lesion that has distinct borders and is less than 1 cm in diameter.

Plaque

A solid, raised, flat-topped lesion greater than 1 cm. in diameter.

Lichenification

A thickening of the epidermis seen with exaggeration of normal skin lines. It is usually due to chronic rubbing or scratching of an area. (Secondary Lesion)

Cutis marmorata

A transient mottling in the trunk and extremities in response to cooler room temperatures.

AIDS-related Kaposi Sarcoma

A vascular tumor considered an AIDS-defining illness. Easily mistaken for bruises or nevi.

Physiologic jaundice

A yellowing of the skin, sclera and mucous membranes develops after the 3rd or 4th day of life due to increased bilirubin.

Subcutaneous Layer

Adipose tissue. Stores fat for energy, provides insulation for temp control, aids in protection by its soft cushioning effect.

Scleroderma

An abnormal mobility/turgor finding-- Scleroderma is a group of rare diseases that involve the hardening and tightening of the skin and connective tissues — the fibers that provide the framework and support for your body.

Polycyclic

Annular lesions grow together Ex: Psoriasis

Pustule

Are circumscribed elevated lesions that contain pus.

Bullae

Are circumscribed fluid-filled lesions that are greater than 1 cm. in diameter.

Vesicle

Are raised lesions less than 1 cm. in diameter that are filled with clear fluid.

ABCDE of pigmented lesions

Asymmetry (not regularly round or oval, two halves of lesion do not look the same) Border irregularity (notching, scalloping, ragged edges, poorly defined margins) Color variation Diameter greater than 6mm (pencil eraser) Evolution (changing)

Aging Adult Skin considerations

Atrophy of skin structures, loss of elasticity, increase risk for shearing/tearing injuries. Dryer skin/hair. Fragile blood vessels. Skin wrinkles, hair grays and thins. Psychological/self-esteem impacts.

Un-stageable Pressure Ulcer

Base of wound is obscured by dead tissue Blood-filled blister

Acrocyanosis

Bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.

Cyanosis

Bluish color from decreased perfusion. Best seen in lips, nose, cheeks, ears, and oral mucous membranes.

Clubbing

Bulbous swelling of the terminal phalanges of the fingers and toes. May indicate pulmonary disease, heart disease, liver disorders or disorders of GI tract.

Telangiectases

Caused by vascular dilation; permanently enlarged and dilated blood vessels visible on skin surface.

Skin Temperature

Check bilaterally. Use dorsal side of your hand. Skin should be warm. Hands and feet may slightly cooler.

Assessment of Surgical Incisions

Closure method (sutures, staples, glue, etc) Location Length Periwound skin Drainage

Grouped

Clustered together Ex: Contact dermatitis

What is hair? 2 types?

Hairs are threads of keratin. Vellus hair (fine, faint) covers most of the body. Terminal hair (darker, thick) grows on scalp, brows, axillae and pubic area. (Face & Chest/males)

Nails

Hard plates of keratin on the dorsal edges of fingers & toes. Profile sign: view index finger at its profile and note angle of nail base; it should be about 160 degrees

Pregnant woman Skin considerations

Hormone levels results in increased pigment in areolae, nipples, vulva and sometimes midline abdomen (linea nigra) and face (chloasma.) Connective tissue developes increased fragility resulting in striae gravidarum (stretch marks)

Bruise/Contusion

Injury of the soft tissue, breakage of local capillaries and leakage of blood cells. Reddish-prple discoloration that does not blanch when pressed.

Dermis

Inner supportive layer consisting mostly of connective tissue (collagen.) Contains nerves, sensory receptors, blood vessels and lymphatics. Hair follicles, sebaceous glands and sweat glands are embedded here.

Erythema

Intense redness of skin from excess blood in the dilated superficial capillaries. Normal in fever, local inflammation and emotional reactions (can't see inflammation in dark skin, check for warmth).

Pressure Ulcer Stage 2

Interruption of skin layers Serum-filled blister Shallow, popped blister Epidermis in base

Impetigo

Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crusts. Highly contagious bacterial infection.

Newborn Skin considerations

More permeable. Skin functions not fully developed. Ineffective temp regulation; Eccrine sweat glands do not secrete in response to heat. Skin cannot contract and shiver to protect from cold.

Basal Cell Carcinoma

Most common skin cancer. Pearly, translucent. Usually found in sun-exposed areas of face, ears, scalp, shoulders. Slow growing.

Abuse Indicators

Multiple bruises at different stages of healing and excessive bruises above knees

Arrector Pili

Musculature around hair follicle which contract and elevate hair. Resembles 'goose bumps"

General Pigmentation

Normally even and consistent with ethnic background. Varies from pinkish tan to ruddy dark tan or from light to dark brown and may have yellow or olive overtones. Abnormal finding: vitiligo, the complete absence of melanin leading to patchy areas of white.

Hair Inspection

Note color, texture and distribution. Lesions (lice?) Absent genital hair suggests endocrine abnormalities.

Ulcerations

Occur when there is necrosis of the epidermis and dermis and sometimes of the underlying subcutaneous tissue. (Secondary Lesion)

Harlequin color change

Occurs when baby is side-laying. Lower half of body turns red, upper half blanches with a distinct demarcation line down the midline.

Epidermis

Outermost and nonvascular layer of the skin. Thin but tough. Has 5 layers. Basal cell layer forms new skin sells, contains melanocytes.

Mobility and Turgor

Pinch fold of skin on anterior chest under the clavicle. Should not tent. Tenting is a sign of severe dehydration.

German Measles (Rubella)

Pink, papluar raush (similar to measles but paler). First appears on face then spreads.

Scars

The permanent fibrotic changes that occur on the skin following damage to the dermis. Scars may have secondary pigment characteristics. (Secondary Lesion)

Petechiae, purpura, and Ecchymoses

Three terms that refer to bleeding that occurs in the skin are petechiae, purpura, and ecchymoses. Generally, the term "petechiae" refers to smaller lesions. "Purpura" and "ecchymoses" are terms that refer to larger lesions. In certain situations purpura may be palpable. In all situations, petechiae, ecchymoses, and purpura do not blanch when pressed. If there is any question, press on the lesions carefully with a glass slide. Don't break the slide or cut the patient. (Secondary Lesions)

Pressure Ulcer Stage 4

Through fascia into muscle, bone

Arterial Ulcers

Tips of toes, between toes Periwound skin tight, hard, shiny, hairless, cool, atrophic Claudication (pain c walking) Pedal pulse absent Round, smooth edges Little odor or drainage

Excoriation

Traumatized or abraded skin caused by scratching or rubbing. (Secondary Lesion)

Gyrate

Twisted, coiled Ex: Wheals, hives

Diabetic Ulcers

Unknown, mixed etiology Sole, ball of foot, metatarsal heads Loss of sensation Painless or burning Most frequent reason for diabetic hospitalization

Skin Self-Examination

Using a well-lighted room, full-length mirror and small handheld mirror systematically check for skin lesions with ABCDE factors.

Pallor

When the red-pink tones from oxygenated hemoglobin in the blood are lost. Common in acute high stress. Observed in mucous membranes, lips and nail beds. Inspect the conjunctiva near the outer and inner canthi. In dark-skinned people look for the absence of underlying red tones that give brown skin its luster.

Jaundice

Yellowish skin color indicates rising amounts of bilirubin in the blood.