Skin, Hair And Nails

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Major functions of the skin

Back 1

Keep the body in homeostasis. Heaviest single organ in body, 16% of body weight. Provides boundaries for body fluid, protects underlying tissues from microorganisms, harmful substances and radiation. Modulates body temp, synthesizes vitamin D.

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Layers of skin

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Epidermis, dermis, subcutaneous tissue. Hair, nails, and sebaceous and sweat glands are appendages of skin.

Front 3

Vellus hair

Back 3

Short, fine, less pigmentation

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Terminal hair

Back 4

Coarser, pigmented (scalp/eyebrows)

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Nails

Back 5

Protect distal ends of fingers/toes

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Sebaceous glands

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Contained in the dermis, present all surfaces except palms/soles, produce a fatty substance secreted onto skin surface through hair follicles.

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Sweat glands

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Contained in the dermis. Two types, eccrine and apocrine.

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Eccrine glands

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Widely distributed, open directly onto skin surface, help control body temp

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Apocrine glands

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Found in axilla and groin, stimulated by emotional stress.

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Detection of suspicious moles

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Clinicians play an important role in educating pts on early detection, protective measures, hazards of sun exposure. Skin cancers are most common cancers in US, most prevalent on hands, neck, and head. Pts initially detect nearly 1/2 of melanomas. It's estimated that derms miss 30% of melanomas.

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Basal cell carcinoma

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Comprises 80% of skin cancers
Shiny and translucent, they grow slowly and rarely metastasize

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Squamous cell carcinoma

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Comprises 16% of skin cancers
Crusted, scaly, and ulcerated, they can metastasize

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Melanoma

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Comprises 4% of skin cancers
Rapidly increasing in frequency, they spread rapidly

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HARRM Risk factors for melanoma

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History of previous melanoma
Age over 50
Regular dermatologist absent
Rapid mole changing
Male gender

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Additional risk factors for melanoma

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≥50 common moles
≥1-4 atypical or unusual moles (especially if dysplastic)
Red or light hair
Actinic lentigines, macular brown or tan spots (usually on sun exposed areas)
Heavy sun exposure (especially severe childhood sunburns)
Light eye or skin color (especially freckles/burns easily)
Family history of melanoma

Front 16

ABCDE Screening moles

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A for asymmetry
B for irregular borders, especially ragged, notched, or blurred
C for variation or change in color, especially blue or black
D for diameter ≥6 mm or different from other moles, especially changing, itching, or bleeding
E for elevation or enlargement

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Macule

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flat, non-palpable, circumscribed, less than 1cm. Brown, red, purple, white, tan color. (freckles, moles, Café-Au-Lait spot)

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Patch

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flat non to minimally palpable, irregular shape, a macule that is >1cm. (Vitiligo, port-wine marks, Café-Au-Lait spot)

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Papule

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elevated, palpable, firm, circumscribed, <1 cm. Brown, red, pink, tan, bluish-red color

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Plaque

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elevated, flat topped, firm, rough, a superficial papule >1cm. (psoriasis, seborrheic and actinic keratosis)

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Wheel

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elevated, irregular-shaped area of cutaneous edema, solid, transient, changing, variable diameter. Pink with lighter colored center. (Urticaria, insect bite)

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Nodule

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elevated, firm, circumscribed, palpable, deeper in dermis, 1-2 cm diameter. (Erythema nodosum, lipoma)

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Tumor

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elevated, solid, may or may not be demarcated, >2cm. (neoplasms)

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Vesicle

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elevated, circumscribed, superficial, filled with serous fluid, < 1cm. (blister, varicella)

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Bulla

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a vesicle >1cm in size. (blister, pemphigus vulgaris)

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Pustule

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elevated, superficial, similar to vesicle but filled with purulent fluid (pus). (acne, impetigo)

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Cysts

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elevated circumscribed, palpable, encapsulated, filled with liquid or semisolid. (sebaceous cyst)

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Scale

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heaped up keratinized cells, flaky exfoliation, irregular; variable thickness, moisture, and size. Silver, white, tan. (Psoriasis, exfoliative dermatitis)

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Crust

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dried serum, blood, or purulent exudate; slightly raised, varies in size. Brown, red, black, tan, or straw. (scab, abrasion, eczema)

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Lichenification

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rough, thickened epidermis, accentuated skin markings, often of flexor aspects of extremities. (chronic dermatitis)

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Keloid

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irregularly shaped, elevated progressively enlarging scar; grows beyond wound boundaries, caused by excessive collagen formation.

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Excoriation

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loss of epidermis, linear or hollowed-out crusted area. (abrasion, scratch)

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Fissure

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linear crack or break form epidermis to dermis; small, deep, red. (athletes foot, cheilosis)

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Ulcer

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loss of epidermis and dermis; concave; red, white, or reddish blue. (decubitus ulcer, statis ulcer)

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Erosion

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loss of all or part of epidermis, depressed, moist; follows rupture of vesicle or bulla. Larger than fissure. (varicella)

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Inspect and palpate skin

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Note characteristics of:
Color
Moisture
Temperature
Texture
Mobility and turgor
Lesions

Front 37

Inspecting color

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Inspect for increased pigmentation, loss of pigmentation
Inspect for redness, pallor, cyanosis, and yellowing

Red color (normal) of oxyhemoglobin best assessed at fingertips, lips, and mucous membranes. Abnormal could be sign of anemia, hypoxia/cyanosis, ischemia
In dark-skinned people, palms and soles
For central cyanosis, look in lips, oral mucosa, and tongue
Jaundice – sclera
Pallor – decreased redness of skin found in anemia and decreased blood flow

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Vitiligo

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depigmented macules, usually face, hands, feet extensor surfaces. A hereditary disorder due to lack of melanin.

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Cafe-au-lait spot

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slightly but uniformly pigmented macule or patch with mildly irregular boarders

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Cyanosis

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somewhat bluish color of the skin, lips, oral mucosa, or nails. Cause: due to poor oxygenation of tissues. Either centrally form lack of oxygenated blood or peripherally from lack of circulation to tissues or venous return.

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Jaundice

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yellowing of the skin, most easily seen in sclera. Causes: liver disease, hemolysis of red blood cells

Front 42

Skin moisture

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Dryness, sweating, and oiliness
Dryness: hypothyroidism, renal disease
Oiliness: acne
Sweating: hyperhidrosis

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Skin temperature

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Use back of fingertips and hand
Identify warmth or coolness of skin
Increased warmth: infection (cellulitis), increased vascularity, fever
Cold: ischemic to tissues, Raynaud’s syndrome, hypothyroidism, shock

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Skin texture

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Roughness or smoothness
Roughness: renal disease, hypothyroidism, ichthyosis
Smoothness: CREST syndrome

Front 45

Skin mobility and tugor

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Lift fold of skin
Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor)
Mobility decreased – edematous states
Mobility increased – age, collagen-elastin diseases
Turgor decreased – dehydration
Turgor increased – edematous states

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Skin lesions

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Note characteristics
Anatomic location and distribution
Many skin diseases have a typical distribution
Psoriasis – knees, elbows, extensor surfaces
Candida infections – intertriginous areas (groin, armpits, areas that are always moist)
Eczema – flexor surfaces
Pityriasis rosea – back and chest in “Christmas tree pattern”

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Skin lesion patterns and shapes

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Many lesions occur is a typical pattern and shapes
Shapes: annular, serpiginous (worm like), oval, round
Patterns: dermatomal (shingles), clustered, linear

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Skin lesion types

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Type of lesion (macules, plaque, nodule/papule just depending on size, vesicles)

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Skin lesion color

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Many skin lesions have the same predictable coloring
Café-Au-Lait spot (brown, tan)
Psoriasis (silvery and red base)

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Flat, non-palpable lesions with changes in skin color

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Macule—Small flat spot, up to 1.0 cm
Patch—Flat spot, 1.0 cm or larger

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Palpable elevations: solid masses

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Papule
Plaque
Nodule
Cyst
Wheal - urticaria

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Palpable elevations with fluid-filled cavities

Back 52

Vesicle, bulla, pustule

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Burrow (scabies)

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Slightly raised tunnel in the epidermis
Commonly found on the finger webs and on the sides of the fingers
Looks like a short, linear or curved gray line and may end in a tiny vesicle
Look for the burrow of the mite that causes scabies

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Secondary skin lesions

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Scale, Crust, Lichenification, Scars, Keloids, Erosion, Excoriation, Fissure, Ulcer

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Vascular and purpura lesions

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Spider angioma, spider vein, hemangioma, petechia (smaller), purpura (larger), ecchymosis

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Janeway lesion

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Small nontender hemorrhagic macular to nodular lesions present on the palms and soles of patients with infectious endocarditis. (septic emboli)

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Osler nodes

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Similar to Janeway however they are erythematous tender and slightly raised, more common on the fingers and toes

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Squamous cell carcinoma

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Location: Appear on sun exposed areas, typically fair skinned and older than 60 yo.
Pattern: none
Type: papule to tumor, with scaling/crusting or ulceration
Color: reddened

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Actinic keratosis

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Superficial, flattened papules covered by a dry scale; round or irregular; tan, brown, or grayish. Appears on sun exposed skin, and can develop into SCC

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Basal cell carcinoma

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Mostly fair skinned, >40 yo, slow growing seldom metastasizes
Location: Face
Pattern: none
Type: nodule, occasionally depressed center
Color: pearly to gray, with telangiectasia

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Seborrheic keratosis

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Common, benign, “stuck on lesion”
Location: typically trunk and face
Pattern: symmetric to none
Types: papule to plaque, texture: greasy/velvety
Color: brown, tan, yellow, gray

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Melanoma

Back 62

Remember ABCD

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Benign nevus

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Common mole, may arise over time, usually unchanged in ABCD’s.
Round, defined boarders, uniform color, flat or raised

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Corn and callus

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Toughened areas of skin due to repeated friction exposure
Location: typical feet and hands
Pattern: none
Types: scale
Color: skin colored to yellowed

Front 65

Lentigo (sun spot)

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Benign pigmented spot
Location: sun exposed areas, dorsal hands, arms, face
Pattern: irregular
Type: macule with defined boarders
Color: tan to brown

Front 66

Wart

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Viral infection of the skin (HPV)
Location: any (typically hands, feet, genitalia)
Pattern: grouped to single
Type: papule to domed to tumor
Color: flesh colored with cauliflower appearance

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Dermatofibroma

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Benign slow growing firm lesion
Location: any
Pattern: none
Type: roundish nodule, dimples or involutes with squeezing
Color: usually brown or tan

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Rosacea

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Chronic erythema of nose and face with acne-like lesions and telangiectasia. Onset 30-60 yo.

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Psoriasis

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Location: mainly extensor surfaces
Pattern: irregular
Type: plaque, papule
Color: silvery on a erythematous base
Auspitz sign – Pulling off the scale causes bleeding

Front 70

Pityriasis rosea

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Benign self limiting rash
Location: trunk
Pattern: “christmas tree”, annular
Type: maculopapular, scaly
Color: reddish, tan
Herald Patch

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Eczema

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Location: mainly flexor surfaces
Pattern: area
Type: dry, scaling, fissured, lichenification, maculopapular
Color: skin colored to slightly red

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Tinea versicolor

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Infection of the skin due to fungus (Tinea)
Location: usually trunk
Pattern: diffuse
Type: macular, scaly
Color: tan

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Molluscum contagiosum

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Due to a viral infection of the skin
Location: typically extremities to any
Pattern: may form in autoinoculation patterns
Type: dome shaped vesicle with central umblication
Color: flesh colored or translucent

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Folliculitis

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Infection of the hair follicle typically by Staph or Strep
Location: any
Pattern: grouped to none
Type: pustules
Color: red

Front 75

Herpes zoster (shingles)

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Reactivation of Varicella Zoster causing painful rash
Location: typically trunk or face
Pattern: dermatomal
Type: vesicles
Color: clear vesicles on erythematous base

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Varicella zoster (chicken pox)

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Infection of Varicella
Location: begins trunk and spreads peripherally
Pattern: crops with different stages of healing
Type: vesicle
Color: clear vesicle on red base “dew on a rose petal”

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Acne

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Location: face, chest, back
Pattern: variable
Type: pustules, closed and open comedones, papules, cysts
Color: red

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Inspect and palpate hair

Back 78

Note quantity, distribution and texture.

Front 79

Alopecia areata

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Clearly demarcated round or oval patches of hair loss, usually affecting young adults and children.
No visible scaling or inflammation, no broken shafts

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Trichotillomania

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Hair loss from pulling, plucking, or twisting hair.
Hair shafts are broken and of varying lengths.
More common in children, often in settings of family or psychosocial stress.

Front 81

Tinea capitis (ringworm)

Back 81

Round scaling patches of alopecia. Hairs are broken off close to the surface of the scalp. Mimics seborrheic dermatitis.

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Inspect and palpate nails

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Note color and shape, lesions. Longitudinal bands of pigment may be a normal finding in people with darker skin.

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Paronychia

Back 83

A superficial infection of the proximal and lateral nail folds adjacent to the nail plate.
The nail folds are often red, swollen, and tender.
Most common infection of the hand, usually from Staphylococcus aureus or Streptococcus species.
Arises from local trauma due to nail biting, manicuring or frequent hand immersion in water.

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Clubbing of the fingers

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Bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold.
The angle increases to 180° or more, and the nail bed feels spongy or floating.
Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies

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Onychomycosis

Back 85

Nail is thickened and discolored: white, black, yellow or green.
Nail can become brittle, with pieces breaking off or coming away from the toe or finger completely.
If left untreated, the skin can become inflamed and painful underneath and around the nail.
There is usually no pain or other bodily symptoms
People experience significant psychosocial problems due to the appearance of the nail

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White spots (leukonychia)

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Trauma to the nails is commonly followed by non-uniform white spots that grow slowly out with the nail.
Spots in the pattern illustrated are typical of overly vigorous and repeated manicuring.
The curves in this example resemble the curve of the cuticle and proximal nail fold.

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Transverse linear depressions (Beau's lines)

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Bilateral transverse depressions of the nail plates resulting from temporary disruption of proximal nail growth from systemic illness.
Timing of the illness may be estimated by measuring the distance from the line to the nail bed
nails grow approximately 1 mm every 6 to 10 days
Seen in severe illness, trauma, and cold exposure if Raynaud's disease is present.

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Mee's lines

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Transverse white bands that cross the nail parallel to lunula.
Seen with arsenic poisoning, heart failure, Hodgkin’s disease, chemotherapy, carbon monoxide poisoning, and leprosy

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Pitting

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Punctate depressions of the nail plate caused by defective layering of the superficial nail plate by the proximal nail matrix. Associated with psoriasis

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Subungual hemorrhage

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A collection of blood beneath the nail due to trauma. If there is not a broken bone underneath it, you can simply remove it. If there is a fracture of the nail plate, and you drain this out, you’ve just opened it up for infection! BAD.

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AIDS and skin conditions

Back 91

Hairy leukoplakia, Kaposi's sarcoma, herpes simplex virus (HSV), human papillomavirus (HPV), cytomegalovirus (CMV), molluscum contagiosum, candidiasis, squamous cell carcinoma, psoriasis (often severe), seborrheic dermatitis (often severe)

Front 92

Diabetes and skin conditions

Back 92

Acanthosis nigricans, candidiasis, neuropathic ulcers, peripheral vascular disease

Front 93

Dyslipidemia and skin conditions

Back 93

Xanthomas (tendon, eruptive, and tuberous), xanthelasma (may occur in healthy people)

Front 94

Hypothyroidism and skin conditions

Back 94

Dry, rough, and pale skin; coarse and brittle hair; myxedema; skin cool to touch; thin and brittle nails

Front 95

Hyperthyroidism and skin conditions

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Warm, moist, soft, and velvety skin; thin and fine hair; vitiligo; pretibial myxedema (in Graves' disease); hyperpigmentation (local or generalized)

Front 96

Chronic renal disease and skin conditions

Back 96

Pallor, pruritus, hyperpigmentation, uremic frost

Front 97

Liver disease and skin conditions

Back 97

Jaundice, spider angiomas and other telangiectasias, palmar erythema

Front 98

Peripheral vascular disease and skin conditions

Back 98

Dry, scaly, shiny atrophic skin; dystrophic, brittle toenails; cool skin; hairless shins; ulcers; pallor; cyanosis; gangrene

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Pregnancy and skin conditions

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Melasma, increased pigmentation of areolae, linea nigra, palmar erythema, varicose veins, striae, spider angiomas, hirsutism

Front 100

Rocky mountain spotted fever and skin conditions

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Erythematous rash that begins on wrists and ankles, then spreads to palms and soles; becomes more purpuric as it generalizes