Skin, Hair, and Nails

Skin

• Changes in skin: dryness, pruritus, sores, rashes, growths, color, texture, odor, amount of perspiration; changes in wart or nevus; lesion that does not heal or is chronically irritated (see Risk Factors boxes)

• Temporal sequence: date of initial onset; time sequence of occurrence and development; intermittent; sudden or gradual onset; date of recurrence, if any

• Symptoms: itching, pain, exudate, bleeding, color changes, seasonal or climate variations

• Location: skinfolds, extensor or flexor surfaces, localized or generalized, sun exposed or protected, mucosal involvement

• Associated symptoms: recent illness, presence of systemic disease or fever, relationship to stress or leisure activities

• Recent exposure to environmental or occupational toxins or chemicals, new skin or personal care products, new household cleaning products (aerosols)

• Recent exposure to persons with similar skin condition

• Apparent cause of problem, patient’s perception of cause

• Travel history: where, when, length of stay, exposure to diseases, contact with travelers

• What the patient has been doing for the problem, response to treatment, what makes the condition worse or better

• How the patient is adjusting to the problem

• Medications: antibiotics, any new medications; either over-the-counter or prescription, topical preparations to treat—steroids, antifungals

Hair

• Changes in hair: loss or growth, distribution, texture, color

• Occurrence: sudden or gradual onset, symmetric or asymmetric pattern, recurrence

• Associated symptoms: pain, itching, lesions, presence of systemic disease or high fever, recent stress, hair-pulling, infection

• Exposure to drugs, environmental or occupational toxins or chemicals, commercial hair care chemicals

• Nutrition: dietary changes, dieting

• What the patient has been doing for the problem, response to treatment, what makes the problem worse or better

• How the patient is adjusting to the problem

• Medications: drugs or preparations for hair loss (minoxidil, finasteride, dihydrotestosterone [DHT] inhibitors)

Nails

• Changes in nails: splitting, breaking, discoloration, ridging, thickening, markings, separation from nail bed

• Recent history: systemic illness, high fever, trauma, stress, biting

• Associated symptoms: pain, swelling, exudate

• Temporal sequence: sudden or gradual onset, relationship to injury of nail or finger

• Recent exposure to drugs, environmental or occupational toxins or chemicals; frequent immersion in water

• What the patient has been doing for the problem, response to treatment, what makes the problem worse or better

• Medications: chemotherapy (taxanes, anthracyclines), psoralens, retinoids, tetracyclines, antimalarials

Skin

• Previous skin problems: sensitivities, allergic skin reactions, skin disorders (e.g., atopic dermatitis), congenital or acquired lesions, treatment

• Tolerance to sunlight ( Box 9.1 )

• Diminished or heightened sensitivity to touch

• Cardiac, respiratory, liver, endocrine, or other systemic diseases

• Hair

• Previous hair problems: loss, thinning, unusual growth or distribution, brittleness, breakage, treatment

• Systemic problems: thyroid disorder, rheumatologic disease, any severe illness, malnutrition, associated skin disorder

Nails

• Previous nail problems: injury; bacterial, fungal, or viral infection

• Systemic problems: associated skin disorder; congenital anomalies; respiratory, cardiac, endocrine, hematologic, or other systemic disease

Inspection

Adequate lighting is essential. Direct, overhead lighting should be used when examining patients. Tangential lighting is helpful in assessing contour. Inadequate lighting can result in inadequate assessment.

Although the skin is commonly observed as each part of the body is examined, it is important to make a brief but careful overall visual sweep of the entire body. This “bird’s-eye view” gives a good idea of the distribution, extent, and symmetry of any lesions. It also allows for identification of “ugly duckling” lesions that stand out. The gross view will allow the practitioner to know where to pay particular attention during the remainder of the examination ( Box 9.3 ).

BOX 9.3

Cutaneous Manifestations of Traditional Health Practices

The use of certain traditional health practices by various cultural groups can produce cutaneous manifestations that could be wrongly confused with disease or physical abuse. Two such practices are “coining” and “cupping” as used by some Asian subcultures. In coining, a coin dipped in mentholated oil is vigorously rubbed across the skin in a prescribed manner, causing a mild dermabrasion. This practice is believed to release excess force from the body and hence restore balance. In cupping, a series of small, heated glasses are placed on the skin, forming a suction that leaves a red or purpuric circular mark, drawing out the bad force. The skin markings may alarm the healthcare provider who is unaware of such practices. The lesson: in the history, ask about home remedies or practices.

Adequate exposure of the skin is also necessary. It is essential to remove clothing and to fully remove drapes or coverings as each section of the body is examined, while keeping in mind the patient’s sense of privacy. Make sure that the room temperature is comfortable. Look carefully at all areas, remembering to inspect areas that are usually not exposed, such as the axillae, buttocks, perineum, backs of thighs, and inner upper thighs. Remove shoes and socks to look at the feet, and pay careful attention to intertriginous surfaces (areas where two skin surfaces may touch, e.g., axillae and groin), especially in infants, older adults, and bedridden patients. As you complete the examination for each area, re-drape or cover the patient. When inspecting the skin, it is important to have a systematic routine in place to ensure that no areas are forgotten or overlooked. Skin thickness varies over the body, with the thinnest skin being on the eyelids and the thickest present in areas subject to increased pressure or rubbing; most notably the soles, palms, and elbows. Make note of calluses on the hands or feet and look for corns on pressure points. Corns are flat or slightly elevated with a central core, circumscribed, painful lesions with a smooth, hard surface ( Fig. 9.3 ). A superficial area of hyperkeratosis is called a callus. Calluses usually occur on the weight-bearing areas of the feet and on the palmar surface of the hands. Calluses are not as well demarcated as corns and are usually not as tender, if at all ( Fig. 9.4 ).

The range of expected skin color varies from dark brown to white with pink or yellow overtones. Although color should assume an overall uniformity, there is often pigment variation that may be sun related, trauma induced, or simply normal (e.g., knuckles may be darker in dark-skinned patients). Callused areas may appear yellow. Vascular flush areas (e.g., cheeks, neck, upper chest, and genital area) may appear pink or red, especially with anxiety or excitement. Be aware that skin color may be masked by cosmetics and tanning agents. Look for localized areas of discoloration.

Individuals with dark skin may show pigmentary demarcation lines. These lines, a normal variation, mark the border between deeply pigmented skin and lighter pigmented skin. They are most commonly seen on the arms, legs, chest, and back and have been reported most often in Black and Japanese populations. Accentuation of preexisting lines or appearance of new lines may occur during pregnancy.

Nevi (moles) occur in forms that vary in size and degree of pigmentation. Nevi are present on most persons regardless of skin color and may occur anywhere on the body. They may be flat, raised, dome-shaped, smooth, rough, or hairy. Their color ranges from pink, tan, gray, blue, and shades of brown, to black. Table 9.1 describes the features and occurrence of various types of pigmented nevi.

Nevi occur more often in lighter-skinned than in darker-skinned individuals. There is a strong association between sun exposure and the number of nevi. They increase in number throughout infancy and childhood, with peak incidence in the fourth to fifth decades. Nevi frequently involute and diminish in number with advancing age and rarely develop after 40 years of age.

Although most nevi are harmless, some may be atypical or develop into melanoma. Table 9.2 describes differences in the features of normal and atypical nevi. Atypical nevi tend to occur on heavily sun damaged skin, classically upper back in men and on the legs in women ( Box 9.4 “Atypical Nevi or Melanoma?”).

Several variations in skin color occur in almost all healthy adults and children, including nonpigmented striae (i.e., silver or pink “stretch marks” that occur during pregnancy, adolescent growth spurts, or weight gain), freckles in sun-exposed areas, birthmarks, and nevi ( Fig. 9.5 ). Adult women (and sometimes men) will commonly have melasma ( Fig. 9.6 ), areas of hyperpigmentation on the face and neck that are associated with pregnancy or hormonal variation. This condition is more noticeable in darker-skinned patients. The absence of melanin produces patches of unpigmented skin or hair, such as with vitiligo ( Fig. 9.7 ).

Alterations in color in dark-skinned persons are best seen in the sclera, conjunctiva, buccal mucosa, tongue, lips, nail beds, and palms. Particular variations in skin color may be the result of physiologic pigment distribution. The palms and soles are lighter in color than the rest of the body and should be assessed when concerned for diffuse skin changes such as erythroderma, which is an intense, widespread reddening of the skin. Hyperpigmented lentigos on the palms and soles of the feet are common in darker skinned patients. These are small pigmented spots on the skin with a clearly demarcated edge that is surrounded by normal-appearing skin. It is a harmless (benign) hyperplasia of melanocytes. Freckling of the buccal cavity, gums, and tongue commonly occurs and is benign. The sclera may appear yellowish brown (often described as “muddy”) or may contain brownish pigment that resemble nevi. A bluish hue of the lips and gums can be a normal finding in persons with dark skin. Some dark-skinned persons have very blue lips, giving a false impression of cyanosis.

Systemic disorders can produce generalized or localized color changes; these are described in Table 9.3 . Localized redness often results from an inflammatory process. Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic diseases such as diabetes mellitus and peripheral vascular disease. Injury, steroids, vasculitis, stasis, and several systemic disorders can cause localized hemorrhage into the skin, producing red-purple discolorations. Bleeding into the skin results in ecchymoses (i.e., bruising); pinpoint bleeding from capillaries is called petechiae (smaller than 0.5 cm in diameter) ( Fig. 9.8 ) or purpura (larger than 0.5 cm in diameter) ( Fig. 9.9 ). Vascular skin lesions are characterized in Fig. 9.10 (see Clinical Pearl, “Telangiectasias: Spider Angioma”). Box 9.5 describes some characteristic odors that you may note as you examine the skin.

Palpation

As you inspect, palpate the skin for moisture, temperature, texture, turgor, and elasticity. Palpation may yield additional data for describing lesions, particularly in relation to elevation or depression.

Minimal perspiration or oiliness should be present. Increased perspiration may be associated with activity, a warm environment, obesity, anxiety, or excitement; it may be especially noticeable on the palms, scalp, forehead, and in the axillae. The intertriginous areas, or skin in body folds, may also be damp leading to development of intertrigo ( Fig. 9.11 ).

The skin should range in temperature from cool to warm-to-the-touch. Use the dorsal surface of your hands or fingers in this case because these areas are most sensitive to temperature perception. At best, this assessment is a rough estimate of skin temperature; what you are really looking for is bilateral symmetry. Environmental conditions, including the temperature of the examining room, as well as body location may affect surface temperature.

The texture should feel smooth, soft, and even. Roughness on exposed areas or areas of pressure (particularly the elbows, soles, and palms) may be caused by dry skin or irritation. Extensive or widespread roughness may be the result of a keratinization disorder or damaged skin. Hyperkeratosis, especially of the palms and soles, may be a sign of a systemic disorder such as exposure to arsenic, other toxins, or a sign of internal malignancy.

Assessment of skin elasticity can be helpful in detecting certain conditions. Gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then release the skin ( Fig. 9.12 ). The skin should move easily when pinched and return to place immediately when released. Poor skin turgor can indicate severe dehydration. In this case, the skin is very slow to return to normal and “tents” up. This may occur with excessive vomiting, diarrhea, or dehydration from another cause. Skin that is firm or cannot be pinched may suggest an underlying connective tissue disease such as scleroderma.

Skin Lesions

As you assess the skin, pay particular attention to any lesions that may be present. “Skin lesion” is a general term that collectively describes any pathologic skin change or occurrence. Lesions may be primary (i.e., those that occur as initial spontaneous manifestations of a pathologic process) or secondary (i.e., those that result from later evolution of or external trauma to a primary lesion).

Tables 9.4 and 9.5 show the characteristics of primary and secondary lesions. The nomenclature is often used inaccurately; if you are uncertain about a lesion, use the descriptors rather than the name. Be aware that several types of lesions may occur concurrently and that secondary changes may obscure primary characteristics.

TABLE 9.4

Primary Skin Lesions

Description	Examples
Macule
A flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter	Freckles, flat nevi, petechiae	Measles.
Papule
An elevated, firm, circumscribed area; less than 1 cm in diameter	Wart (verruca), lichen planus	Lichen planus.
Patch
A flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter	Vitiligo, port-wine stains, café au lait patch	Vitiligo.
Plaque
Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter	Psoriasis, atopic dermatitis	Psoriasis.
Wheal
Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter	Insect bites, urticaria, allergic reaction
Nodule
Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1–2 cm in diameter	Erythema nodosum, dermatofibroma	Dermatofibroma.
Tumor
Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter	Neoplasms, benign tumor, lipoma	Lipoma.
Vesicle
Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter	Varicella (chickenpox), herpes zoster (shingles)	Vesicles caused by varicella.
Bulla
Vesicle greater than 1 cm in diameter	Bullous pemphigus, pemphigus vulgaris	Bullous pemphigoid.
Pustule
Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid	Impetigo, acne	Acne.
Cyst
Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material	Epidermal inclusion cyst, cystic acne	Epidermal inclusion cyst.
Telangiectasia
Fine, irregular, red lines produced by capillary dilation	Telangiectasia in rosacea	Telangiectasia.

TABLE 9.5

Secondary Skin Lesions

• Photos from Public Health Image Library (PHIL), Centers for Disease Control and Prevention: macule/measles, Heinz F. Eichenwald, MD, Bob Craig; Patch/Vitiligo, Brian Hill, New Zealand; Plaque/psoriasis, Richard S. Hibbets; Vesicle/varicella, Dr. John Noble, Jr.; sebaceous cyst, Dr. Gavin Hart; fissure/tinea pedis, Dr. Lucille K. Georg.

• Hypertrophic nodule; hypertrophic scar, from Goldman and Fitzpatrick (1994) .

• Bulla/blister; papule/lichen planus; keloid, from Weston et al. (2007).

• Pustule/acne, from Ferri (2009) .

• Tumor/lipoma; telangiectasia; excoriation; lichenification, from Lemmi and Lemmi (2000) .

• Scaling, from Baran et al (1991).

• Stasis ulcer, from Pozez et al. (2007).

• Striae, courtesy Antoinette Hood, MD, Department of Dermatology, Indiana University School of Medicine, Indianapolis.

Description	Examples
Scale
Heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size	Flaking of skin with seborrheic dermatitis or after a drug reaction; dry skin	Fine scaling.
Lichenification
Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity	Chronic atopic dermatitis	Lichenification (chronic atopic dermatitis).
Keloid
Irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing	Keloid formation after surgery	Keloid.
Scar
Thin to thick fibrous tissue that replaces normal skin after injury or laceration to the dermis	Healed wound or surgical incision	Hypertrophic scar.
Excoriation
Loss of the epidermis; linear hollowed-out, crusted area	Abrasion or scratch, scabies	Excoriation from tree branch.
Fissure
Linear crack or break from the epidermis to the dermis; may be moist or dry	Athlete’s foot, cracks at the corner of the mouth	Scaling and fissures from tinea pedis.
Erosion
Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla	Varicella, variola after rupture	Erosion—in varicella (chickenpox after rupture of blister).
Ulcer
Loss of epidermis and dermis; concave; varies in size	Decubiti, stasis ulcers	Stasis ulcer.
Crust
Dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored	Scab on abrasion, eczema	Scab.
Atrophy
Thinning of skin surface and loss of skin markings; skin translucent and paper-like	Striae; aged skin	Striae.

Describe lesions according to characteristics ( Table 9.6 ), exudates, configuration, and location and distribution: