Chapter 12 Skin, Hair, and Nails

Papule

primary skin lesion that is something you can feel with a palpable solid elevation <1cm

Wheal

primary skin lesion that is superficial, raised, transient, and erythematous that is slightly irregular due to edema ex. Mosquito bite, allergic reaction

Erythema

redness from excessive blood

Cradle cap

scaly, crusted scalp occurs with seborrheic dermatitis

Scale

secondary lesion that are flakes of skin, dry or greasy

Keloid Scar

secondary lesion that is a benign excess of scar tissue beyond sites of original injury: surgery, acne, ear piercing, tattoos, infections, burns.16 Looks smooth, rubbery, shiny and "clawlike"; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma. Most common ages are 10-30 years; higher incidence in Blacks, Hispanics, and Asians.16

Ulcer

secondary lesion that is a deeper depression into the dermis, may bleed, leaves a scar

Fissure

secondary lesion that is a linear crack with abrupt edges; extends in the dermis; dry or moist. Ex: cheilosis- at corners of mouth caused by excess moisture; athletes foot.

Excoriation

secondary lesion that is a self inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Ex: insect bites, scabies, dermatitis, varicella

Hirsutism

shaggy or excessive hair. excess body hair

Alopecia

significant loss of hair

Pregnancy skin changes: linea nigra

skin change on the abdomen, brownish-black line down the midline

Lipoma

slow-growing, fatty benign tumor that's most often situated between your skin and the underlying muscle layer

Cherry (senile) angiomas

small, smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years. They normally increase in size and number with aging and are not significant.

Infantile skin changes: vascularity or bruising

stork bite: (salmon patch) it is a flat, irregularly shaped red or pink patch found on the forehead, eyelid, or upper lip but most commonly at the back of the neck. present at birth and usually fades during the first year.

chronically dirty nails

suggest poor self-care or the chronic staining of some occupations.

Vitiligo

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 darkskinned people are more severely affected and potentially suffer a greater threat to their body image.

vernix caseosa

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

Petechiae

tiny punctate hemorrhages less than 2mm. Due to bleeding from the superficial capillaries. May indicate thrombocytopenia.

Infantile skin changes: moisture

vernix caseosa is the moist, white, cream cheese-like substance that covers part of the skin in all newborns.

Secondary skin lesion

when a lesion changes over time or changes because of scratching or infection.

Primary skin lesion

when a lesion develops on previously unaltered skin

Jaundice

yellow color from increased amounts of bilirubin

Dermis

Dermis layer contains collagen which is thin/tough, resists tearing. Nerves, sensory receptors, blood vessels, lymph, sweat glands, hair follicles and sebaceous glands lie in the dermis.

Common shapes of lesions

1. Annular: circular, begins in center. 2. Confluent: lesions that run together 3. Discrete: distinct, individual 4. Grouped: clusters of lesions 5. Target: resembles the iris of the eye. 6. Linear: streak or line 7. Zosteriform: linear arrangement along nerve route.

Skin layers

Epidermis, Dermis, Subcutaneous layer

Epidermis

Epidermis: thin, tough, rugged protective barrier. Contains melanocytes which produce skin/hair color. Melanin levels vary with genetic influences. Avascular.

Hair (2 types)

Hair (2 types) 1. fine, faint vellus hair covers most of the body except palms and soles, dorsa of the distal parts of the fingers, umbilicus, glans of penis, and inside the labia) 2. Terminal hair is darker, thicker hair that grows on scalp, eyebrows, axilla, pubic area, face and chest. One affected by cancer Sebaceous glands produce lipid substance which lubricates, retards water loss.

How would shock show in a light and dark-skinned patient?

Light skin- generalized pallor Dark skin- brown skin appears dull yellow-brown, black skin appears dull ashen grey Check areas of least pigmentation: conjuctivea and mucous membranes. -skin loses healthy glow

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: tugor!

Mobility and Turgor - pinch up a large fold of skin on the anterior chest under the clavicle -mobility-skins ease of rising -turgor- its ability to return to place promptly when released -mobility is decreased with edema, poor turgor evident in dehydration and extreme weight loss, scleroderma

Consider the implications of petechiae and purpura Table 12-8 p.238

Most of the diseases that cause bleeding and microembolism formation-such as thrombocytopenia, subacute bacterial endocarditis, other septicemias, and scurvy are characterized by petechiae or purpura in the mucous membrane as well as the skin.

Infant Lesions

Note bruising versus mongolian spots Note café au lait spots or light brown spots Note erythema toxicum; a common rash in the first 3-4 days of life. Note acrocyanosis, should disappear with warming. Note physiological jaundice Note milia or storkbites Note skin turgor and hydration.

Aging lesions

Note senile lentigines or liver spots, no treatment required. Note keratoses; thick raised areas of crusted and scaly material. Seen on sun exposed areas, no treatment required. Note dryness of skin (xerosis). Note thickness and mobility.

permeable

Permeable: Increased risk for fluid loss in infants

Skin tugor

Poor: tented Flat: normal

Subjective Skin story

Previous history of skin disease or tattoos? Change in pigmentation, mole Excessive dryness, moisture Excessive bruising (Physical abuse?) Rashes, lesions Medications (sun sensitivity?) Hair loss, change in nails Environmental exposure, self care

Health promotion in the sun

SPF of at least 30, hats and sunglasses every 2 hours UVA penetrate glass causing damage UVB are the burning rays. 1st degree burns cause redness, 2nd degree burns cause blistering Indoor tanning beds emit UVA and UVB More than 1 million new cases of skin cancer per year

Subcutaneous layer

Subcutaneous layer is adipose tissue, stores fat for energy, provides insulation for temp control, and aids in cushioning.

Sweat glands (2 types)

Sweat glands (2 types): Eccrine glands open directly onto the skin surface producing sweat and effects body temperature. Apocrine glands produce thick, milky secretions. Bacteria react with Apocrine glands to produce body odors. **Eccrine don't open till age of 2 months p.200**

What does the shape and contour of nails reflect?

The nail is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded. 160 degrees

Melanoma Assessment: those at risk

Those at risk include: large number of typical moles, atypical mole, family hx. of melanoma, history of repeated sunburns. Those who burn easily, cannot tan. WARNING SIGNS MELANOMA:

Color Changes: p. 226-227 table 12-2

Vasoconstriction: pallor (pale) Vasodilation: red (erythema) Venous pooling: blue Jaundice: yellow underskin before sclera, press on the nose, chin or sternum and you get a circle of pink, but if there is a circle of yellow then that could mean increase in bilirubin levels -> jaundice

Autoclave

What we use in the OR

Abnormalities: table 12-4 and 12-5: reflect on the differences between primary and second lesions p.229-232

When a lesion develops on previously unaltered skin, it is primary. When a lesion changes over time or changes because of a factor such as scratching or infection, it is secondary.

Describe the steps to the skin assessment ABCDE:

• A: asymmetry • B: borders are irregular, notched, scalloped, poorly defined. • C: no uniform color, varies from tan, red, brown, black. • D: diameter tends to be larger than 6mm or size of a pencil eraser. • E: elevation or enlargement of lesions. • Also note burning, itching, bleeding.

Brown-Tan

• Brown-Tan -Addisons disease- cortisol deficiency stimulates increased melanin production -Café au lait spots-caused by increased melanin pigment in basal cell layer

Edema scale

1+ mild pitting, slight indentation, no perceptible swelling noted in leg. 2+moderate pitting, subsides rapidly. 3+deep pitting, indentation remains for a short time, leg looks swollen. 4+very deep pitting, indentation lasts a long time, leg is very swollen.

Infantile skin changes: two temporary cyanotic conditions

1. Acrocyanosis: bluish color around the lips, hands and fingernails, and feet are toenails. This may last for a few hours and disappear with warming. 2. Cutis marmorata: transient mottling in the trunk and extremities in response to cooler room temperatures. It forms a reticulated red or blue pattern over the skin.

Developmental considerations (aging adult)

1. Aging leads to a loss of elasticity, thinning and decreased muscle tone. Loss of collagen increases the risk of shearing and tearing 2. Sweat glands decrease in function. Melanocytes decrease in function so gray hair. 3. Senile purpura (a minor trauma may produce dark red discolored areas) are common. 4. Sun exposure and smoking make wrinkles worse.

Freckles

(ephelides) small, flat macules of brown melanin pigment that ocurr on sun-exposed skin

Pregnancy skin changes: vascular spiders

(spider angioma) are common in pregnancy because of increased estrogen and may resolve after childbirth. lesions have tiny red centers with radiating branches and occur on the face, neck, upper chest, and arms.

Hyperthermia

-hyperthermia- generalized hotness, occurs with increased metabolic rate like with fever, trauma, infection, or sunburn

Hypothermia

-hypothermia- generalized coolness such as from 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.

Pressure Ulcers

1. Appear over bony prominences. 2. Immobilization has a definite effect on oxygenation of tissues and waste removal. Can result in tissue death. 3. Common sites are heel, ankle, knee, hip, sacrum, elbow, scapula, individual vertebra. 4. Look closely in all patients but particularly those with fragile skin, impaired mobility, decreased sensory feeling, impaired LOC, moisture or perspiration issues, poor nutrition, infection, wounds.

Describe clinical changes that can occur in the hair

1. Color-should have graying with age 2. Texture-should be shiny - abnormal if dull, coarse, or brittle scalp hair 3. Distribution -conforms to normal patterns in puberty - hirsutism- excess body hair 4. Lesions -separate hair and look for lesions -should have no irritation, having dandruff (seborrhea) is normal -abnormal if head/pubic lice

Secondary Lesions

1. Crusts: thickened dry exudate. 2. Scale: flakes of skin, dry or greasy. 3. Fissure: linear crack in the dermis. 4. Erosion: shallow depression, no bleeding. 5. Ulcer: deeper depression into the dermis, may bleed, leaves a scar. 6. Excoriation: self inflicted abrasion 7. Scars/Keloids.

Skin Basics

1. Largest organ of the body 2. Guards against environmental stressors 3. Prevents penetration 4. Aids in sensory perception 5. Temperature regulator 6. Production of Vitamin D 7. Identification of system status and unique personal characteristics.

Primary Lesions

1. Macule is flat, nonpalpable, <1cm. 2. Papule is palpable solid elevation <1cm. 3. Nodule is elevated solid mass deeper and firmer than papule, usually <2cm in size. 4. Tumor is solid mass that extends deep through subcutaneous tissue. 5. Wheal is irregularly shaped elevation of skin varies in size due to edema. 6. Vesicle: circumscribed elevation of skin filled with serous fluid. 7. Pustule: a circumscribed elevation but filled with pus or purulent fluid. 8. Bulla: > 1 cm, can be ruptured like a blister 9. Cyst: encapsulated fluid filled cavity

Cultural considerations

1. Melanoma occurs 20x higher in whites than blacks and 4x higher than Hispanics. 2. Apocrine gland activity and normal skin flora produce different levels of odor in people. 3. Keloid scarring occurs more often in Blacks.

Skin developmental changes (infants and children)

1. Newborn's skin is thin, smooth, elastic, more permeable than adults. Increased risk for fluid loss. 2. Temperature regulation is ineffective until age 3 months. Subcutaneous layer is thin, inefficient, decrease protection from the cold. 3. Eccrine sweat glands begin at 3 months. 4. As child grows skin thickens, toughens, darkens, with increased lubrication. 5. Puberty increases Apocrine gland secretion.

Inspect and Palpate nails

1. Note shape, contour, splitting, color marks, linear streaks, or clubbing 2. Note capillary refill. 3. Note clubbing of the upper and lower nails with chronic heart or pulmonary disease.

Purpuric Lesions

1. Petechiae: tiny punctate hemorrhages less than 2mm. Due to bleeding from the superficial capillaries. May indicate thrombocytopenia. 2. Purpura: confluent extensive patch of petechiae and bruising. 3. Hematoma: bruise you can feel 4. Ecchymosis: bruise usually from trauma.

Vascular Lesions

1. Portwine stain: large flat macular patch covering the scalp or face. Present at birth. 2. Strawberry Mark: a raised bright red area about 2-3cms. Which does not blanch with pressure. Consists of immature capillaries.Disappears by age 5-7 years. 3. Cavernous hemangioma: reddish-blue spongy irregularly shaped mass of blood vessels present at birth. Do not go away.

Developmental considerations (pregnant women)

1. Pregnancy increased pigmentation: linea nigra (midline of abdomen) and chloasma (in the face), 2. Pregnancy fat deposits increased. 3. Striae gravidarum: stretch marks on abdomen, breasts, and thighs.

Infantile skin changes: Physiologic jaundice

1. common variation in about half of all newborns. 2. yellowing of the skin, sclera, and mucous membranes develps after the 3rd or 4th day of life. p.218

Infantile skin changes: Mongolian spot

1. common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns. 2. It is a blue-black-to-purple macular area at the sacrum or buttocks but sometimes on the abdomen, thighs, shoulders, or arms 3. caused by deep dermal melanocytes. gradually fades during the first year.

Aging skin changes: senile lentigines

1. common variations of hyperpigmentation. 2. commonly called liver spots, these are small, flat, brown macules. 3. clusters of melanocytes that appear after extensive sun exposure 4. appear on forearms and dorsa of hands 5. not malignant and require no treatment.

Aging skin changes: sebaceous hyperplasia

1. consists of raised yellow papules with a central depression 2. more common in men, occurring over the forehead, nose, or cheeks. 3. pebbly look

Adolescent skin changes

1. increase in sebaceous gland increases oiliness and acne. 2. acne is the most common skin problem of adolescence. 3. blackheads (opened comedones) and whiteheads (closed comedones)

Infantile skin changes: cafe au lait spot

1. large round or oval patch of light brown pigmentation (coffee with milk), which is usually present at birth. 2. Usually these patches are normal 3. 6 or more, each more than 1.5cm in diamter are diagnostic of neurofibromatosis, an inherited neurocutaneous disease

Aging skin changes: actinic (senile or solar) keratosis

1. less common 2. lesions are red-tan scaly plaques that increase over years to become raised and roughened. 3. may have a silvery-white scale adherent to the plaque 4. occur on sun-exposed surfaces and are directly related to sun exposure!!!! 5. they are premalignant and may develop into squamous cell carcinoma!!! examples: bald heads, arms, ears, nose b/c of sun

Aging skin changes: seborrheic keratosis

1. looks dark, greasy, and stuck on. 2. they develop mostly on the trunk but also on the face and hands and on both unexposed and sun-exposed areas. 3. they do not become cancerous

Infantile skin changes: 3 erythematous states are common variations in the neonate

1. newborns skin has a beefy red flush for the first 24 hours b/c of vasomotor instability; then the color fades to its normal color 2. Harlequin color changes: occurs when the baby is in a side-lying position. The lower half of the body turns red, and the upper half blanches with a distinct demarcatin line down the midline. Cause is unknown it is transient. 3. Erythema toxicum: common rash that appears in the first 3 to 4 days of life. Sometimes called the flea bite rash or newborn rash, it consists of tiny punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks. cause is unknown; no treatment is needed

Infantile skin changes: Carotenemia

1. produces a yellow-orange color in light-skinned persons but no yellowing in the sclera or mucous membranes. 2. comes from ingesting large amounts of foods containing carotene, vit A precursor.

Aging skin changes: Keratoses

1. raised, thickened areas of pigmentation that look crusted, scaly, and warty

Aging skin changes: acrochordons

1. skin tags which are overgrowths of normal skin that form a stalk and are polyp-like 2. occur frequently on eyelids, cheeks and neck, and axillae and trunk

Describe the steps to the skin assessment ABCDE

Danger signs: abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE A: asymmetry (not regularly round or oval, two halves of lesion do not look the same) B: borders are irregular (notched, scalloped, poorly defined margins) C: Color variation (no uniform color, varies from tan, red, brown, black.) D: diameter tends to be larger than 6mm or size of a pencil eraser. although early melanomas may be diagnosed at a smaller size!! E: elevation or enlargement of lesions. Also note burning, itching, bleeding. p.208 p.215

Skin self exams

Check whole body at least once a month. Use a well lit room and mirror Study full front and back of body, include upper arms, thighs, ankles, hair and feet. Use the ABCDE rule for assessment

Clubbing of nails

Clubbing of nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. 180 degrees

Macula

primary skin lesion that is solely a color change, flat and circumscribed of less than 1 cm ex. Freckles, petechiae, flat nevi, hypopigmentation, measles, scarlet fever

Hemangioma

a benign proliferation of blood vessels in the dermis • Portwine stain: large flat macular patch covering the scalp or face. Present at birth. • Strawberry Mark: a raised bright red area about 2-3cms. Which does not blanch with pressure. Consists of immature capillaries.Disappears by age 5-7 years. • Cavernous hemangioma: reddish-blue spongy irregularly shaped mass of blood vessels present at birth. Do not go away.

Cyanosis

blue skin from decreased perfusion (increased amount of unoxygenated hemoglobin)

Thrombocytopenia

bruising out of no where

Annular

circular shape, begins in center and spreads to periphery (ex: tinea corporis or ringworm, tinea versicolor, pityriasis rosea)

Purpura

confluent extensive patch of petechiae and bruising.

cyanotic nail beds or sluggish color return

consider cardiovascular or respiratory dysfunction

Xerosis

dry skin

Aging skin changes: moisure

dry skin is common (xerosis) b.c of decline in the number and ouput of sweat glands and sebaceous glands.

Poor tugor

evident in severe dehydation or extreme weight loss; the pinched skin recedes slowly or tents and stands by itself.

Lanugo

fine downy hair of the newborn infant.

Compound nevus

in young adults it progresses to this which is macular and papular.

Pregnancy skin changes: chloasma

irregular brown patch of hyperpigmentation on the face. may occur with pregnancy or women taking BCP. disappears after delivery or discontinuation of pills.

Pruritis

itching. Most common skin symptom; occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice Common with aging

Pregnancy skin changes: striae

jagged linear "stretch marks" of silver-to-pink color that appears during the second trimester on the abdomen, breasts, and sometimes high thighs.

Confluent

lesions run together (ex: urticaria [hives])

Zosterform

linear arrangement along a unilateral route ex. Herpes zoster

Junctional nevus

macular only and occurs in children and adolescents.

Intradernal nevus

mainly in older age, has nevus cells in only the dermis.

Birthmarks

may be tan to brown in color

Newborns nail beds

might be cyanotic for the first few hours and then they turn pink.

Infantile skin changes: texture

milia is a common variation; tiny white papules on the cheeks and forehead and across the nose and chin caused by sebum that occludes the opening of the follicles.

Nevus

mole, proliferation of melanocytes that is tan to brown in color

jagged nails, bitten to the quick, or traumatized nail fold

nervous picking habits

seborrhea

oily

Abnormalities: Table 12-2. under the causes of color variations which occur in patients and why

p.226-227

Abnormalities Table 12-3: identify various shapes and configurations of lesions

p.227-228

Abnormalities

p.239-249. One question on hair!

Pallor

paleness

Nodule

primary lesion that is an elevated solid mass deeper and firmer than papule, usually <2cm in size

Vesicle

primary skin lesion that has circumscribed elevation of skin filled with serous fluid

Pustule

primary skin lesion that is a circumscribed elevation but filled with pus or purulent fluid

Objective Data

• Color o What colors of skin can be found? o What does a change of color indicate? • Pallor, erythema, cyanosis, jaundice, brown-tan o Note freckles, moles, and birth marks. o Note bruising or lesions. • Note overall skin temperature • Note if skin is dry or diaphoretic • Note if skin feels smooth or rough in texture. • Is edema present? • What is skin turgor like?

Cyanosis

• Cyanosis-blue -decreased perfusion/increased amount of unoxygenated hemoglobin -hypoxemia with shock, heart failure, chronic bronchitis, congenital heart failure, cardiac arrest

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: Edema

• Edema-fluid accumulating in intracellular spaces makes dark skin look lighter

Erythema

• Erythema-red -hyperemia (excess blood) in dilated superficial capillaries -expected with fever with local inflammation, blushing -with fever, increased skin temperature from increased rate of blood flow -polycythemia-increased RBC -venous stasis- decreased blood flow from area, engorged venules

Jaundice

• Jaundice-yellow -rising amounts of bilirubin in the blood -uremia, carotenemia -occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion of reaction, and hemolytic disease of the newborn.

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: Moisture!

• Moisture -diaphoresis- profuse perspiration, accompanies an increased metabolic rate such as occurs in heavy activity or fever. thyrotoxicosis, heart attack, anxiety, or pain -dehydration-looks parched, cracked. in the oral mucous membranes.

What descriptors are important to assess when a skin lesion is present?

• Note color • Note elevation • Note pattern or shape • Note size • Note location and distribution • Note exudate

Pallor

• Pallor-white -lose oxygenation -vasoconstriction, anxiety, decreased hematocrit, decreased perfusion, local arterial insufficiency

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: Temperature!

• Temperature -use back of the hand to palpate, should be warm and bilateral. Hands and feet may be slightly cooler in a cool environment.

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: Texture!

• Texture -should feel smooth, firm and even -hyperthyroidism-skin feels smoother and softer like violet -hypothyroidism- skin feels dry, rough, flaky

Recognize how temperature, moisture, texture, thickness, edema and turgor can change in a patient's skin during palpation and why this data is important: thickness

• Thickness - usually epidermis is uniformly thin -with arterial insufficiency skin is very thin and shiny