Skin, Hair, and Nails

Anatomy Epidermis Stratum germinativum (basal cell layer) Mitosis occurs here Contains melanocytes, producing melanin Stratum corneum As cells rise, they die and their cytoplasm is converted to keratin, which has a rough, horny texture This layer undergoes constant shedding Dermis Mostly connective tissue, primarily collagen Provides support and nourishment of epidermis Blood vessels, nerves, muscle, sweat glands, sebaceous glands, hair follicles Subcutaneous Layer (Hypodermis) Consists mostly of fat Provides protection, insulation, and caloric source

Anatomy Hair Composed of keratin Can be fine (vellus hair) or darker and thicker (terminal hair) Sebaceous glands Produce sebum through hair follicles, which make skin oily. Prevent water loss. Sweat glands Eccrine – smaller, coiled tubules which open to skin surface Apocrine – larger, open to hair follicles. Located mainly in axillae and genital area. Produce thick secretions, which react with bacteria on skin surface to produce body odor Nails Composed of keratin Clear with highly vascular bed of epithelial cells underneath Pulse oxymetry! Used to measures what?

Developmental Considerations Infants Lanugo – fine soft hair present at birth Skin is thinner, less fat – more prone to dehydration and hypothermia Pregnancy Linea nigra – line down midline of abdomen Chloasma – face of pregnancy Striae gravidarum – stretch marks Aging Stratum corneum thins, loss of collagen, elastin, and fat, decrease of sebaceous and sweat glands, More prone to dehydration and hypothermia Chloasma

History History of skin disease What was it? How was it treated? Does it run in the family? Significant familial predispositions – allergies, hay fever, psoriasis, eczema, acne Any know allergies? Any tattoos or birthmarks? Use of nonsterile equipment for tattoos increases risk of Hep C Change in pigmentation Might suggest systemic illness (jaundice) Change in a mole Pruritus Any dryness? Is it seasonal? Xerosis – dry Seborrhea - oily

History Excessive bruising Consider abuse Frequent minor trauma may be sign of alcohol abuse Rash or lesion Onset Location Spread Character or quality Duration Associative factors – pets, co-worker? Alleviating and aggravating factors – what have you tried to do? Patient’s perception - what do you think it is? Medications Prescription and over-the-counter May indicate allergy to medication

History Hair loss or growth Gradual or sudden? Hirsutism – unusual growth Change in nails Exposure to hazards May be environmental or occupational Bitten by bee, tick, mosquito? Exposure to plants or animals? Self care What cosmetics, soaps, chemicals? Possible allergies

Physical Examination - Color General pigmentation – should be even throughout Benign pigmented areas Freckles (macules) on sun exposed skin Nevi (moles) Junctional nevi – macular only Compound nevi – macular and papular Dysplastic - precancerous Birthmarks Vitiligo – absence of melanin in patchy areas ABCDE of malignant melanoma 1.Asymmetry – one lesion that is not regularly round or oval 2.Border – irregular 3.Color – variations 4.Diameter – greater than 6mm 5.Elevation *****

Changes in Color in Light Skinned People Pallor Pale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobin Shock, anemia Erythema Redness due to increased blood flow (vasodilation) Fever, inflammatory process, emotions, CO poisoning Cyanosis Bluish, purplish hue due to decreased perfusion of tissues Hypoxemia due to heart failure, shock, chronic bronchitis Jaundice Yellow, orange hue due to jaundice (increased bilirubin in blood) Due to liver problems such as hepatitis, cirrhosis

Color Changes in Darker Skinned People Pallor Brown skinned people will be more yellow. Black skinned people will be more gray Palpebral conjunctiva and nail beds should be observed Erythema Cannot be observed If fever suspected, check skin for warmth. If edema, check skin for tightness Cyanosis Darker skinned people have normal bluish tone on lips Palms, but not clearly evident, other clinical signs should be observed Jaundice Hard and soft palate must be observed in addition to sclera of eyes Dark urine also present

Skin Assessment (cont.) Temperature Check skin with dorsa of hands Hyperthyroidism may cause increase of temp Moisture Diaphoresis may occur during fever or exercise Dehydration can be observed by dry mucous membranes in mouth and cracked skin Mobility and Turgor Mobility is ease of skin rising when pinched. Turgor is returning back to its place Slow turgor can be indicative of dehydration. “Tenting” if severe dehydration. Lesions A lesion is any traumatic or pathological change in skin Describe using ABCDE, also noting location and exudate Roll nodule gently between fingers to assess depth Ultraviolet light is used if fungal infection suspected (Wood’s light)*****

Skin Assessment - shapes Annular Circular, beginning in center and spreading to periphery (ringworm) Polycyclic Annular lesions that grow together Confluent Lesions run together (hives) Discrete Individual lesions that remain separate

Shapes Grouped Clusters of lesions (contact dermatitis) Gyrate Twisted, coiled Target Concentric rings of color Linear Scratch like, stripe Zosteriform Follow nerve route (shingles)

Primary vs. Secondary Primary skin lesions Variations in color or texture that may be present at birth, such as moles or birthmarks, or that may be acquired during a person's lifetime, such as those associated with infectious diseases (e.g. warts, acne, or psoriasis), allergic reactions (e.g. hives or contact dermatitis), or environmental agents (e.g. sunburn, pressure, or temperature extremes). Secondary skin lesions Changes in the skin that result from primary skin lesions, either as a natural progression or as a result of a person manipulating (e.g. scratching or picking at) a primary lesion.

Primary Skin Lesions Macule color change and less than 1 cm may be to darker or lighter Freckles, flat nevi, hypopigmentation, petechiae Patch Color change and greater than 1cm Mongolian spots, vitiligo, chloasma

Primary Skin Lesions Papule Elevated lesion less than 1cm in diameter Due to elevation in epidermis Ex: wart, elevated nevus Plaque Elevation greater than 1cm in diameter Ex: psoriasis

Primary Skin Lesions Nodule Elevated solid greater than 1cm Extending deeper into dermis Tumor Greater than few cm in diameter May be firm or soft

Primary Skin Lesions Wheal Superficial, raised, transient, and erythematous lesion Ex. Mosquito bite, allergic reaction

Primary Skin Lesions Cyst Encapsulated fluid filled cavity in dermis or subcutaneous layer Vesicle Elevated cavity containing free fluid, clear Less than 1cm diameter Ex: herpes simplex, varicella zoster

Primary Skin Lesions Bulla Larger than 1cm in diameter Superficial in epidermis, thin walled Ex: blisters, burns Pustule Pus in cavity Ex: impetigo, acne

Secondary Skin Lesions Crust Thick, dry exudate after rupture or drying up of vesicle or pustule Ex: Impetigo, scab following abrasion Scale Dry or greasy flakes of skin resulting from shedding of excess keratin cells Ex: psoriasis, eczema, seborrheic dermatitis

Secondary Skin Lesions Fissure Linear cracks extending into dermis Ulcer Deep depression extending into dermis May bleed. Leave scar. Excoriation Self inflicted abrasion often from scratching

Secondary Skin Lesions Lichenification Tightly packed papules from prolonged intense scratching Keloid Hypertrophic scar Cannot be removed surgically More common in black people

Skin Lesions associated with AIDS – Kaposi’s Sarcoma Patch stage Early lesions are faint and pink Advanced stage Widely disseminated lesions involving skin, mucous membranes, and visceral organs Violet colored tumors on nose and face Epidemic stage Lesions develop into raised papules of thickened plaques. Oval in shape and vary in color from red to brown.

Hair and Scalp Ringworm may develop in scalp of school age children Abnormalities in amounts and location of hair can be attributed to hormonal problems Hirsutism – excess body hair Observe for head or pubic lice, which are white ovals on hair shafts. Dandruff is indicated by loose white flakes

Abnormal Conditions of Hair Tinea capitis (scalp ringworm) Lesions fluoresce blue-green under Wood’s light Highly contagious Toxic alopecia Asymmetric balding that accompanies severe illness or chemotherapy Regrowth after discontinuation of toxin

Abnormal Conditions of Hair Folliculitis Superficial infection of hair follicles Multiple pustules Furuncle and Abscess Red, swollen, hard, tender, pus-filled lesion due to acute localized bacteria (staph) Usually on back of neck, buttocks, wrists, or ankles Furuncle is due to infected hair follicles Abscess is due to traumatic introduction of bacteria into the skin. Deeper than furuncle

Nails Good indicators of respiratory system health Nail base Normal is about 160° Clubbing is the decrease of the angle of nail base (<160°) that occurs as a result of respiratory insufficiency, common in COPD (emphysema, chronic bronchitis) In early clubbing, the angle actually increased to about 180° Spongy nails Physiology of clubbing is not fully understood but respiratory insufficiency seems to dilate peripheral arteries, causing a round fingernail shape

Nails Consistency Variant thickness may suggest malnutrition Thickening of nails is sign of arterial insufficiency Color Note any pigmentations – melanoma? Cyanotic nail beds – poor peripheral circulation Capillary refill Indicator of peripheral circulation Measured by depressing the nail bed until it is white and observing the time it takes for blood to return back to the nail Normal time is less than 1-2 seconds and is indicated as “brisk.” “Sluggish” if greater than 2 seconds.

Developmental Considerations - Infants Mongolian spots Hyperpigmentation of sacrum, buttocks, abdomen, thighs, shoulders, or arms Very common in blacks, Asians, and Native Americans Should not be confused with abuse Café au lait “Coffee with milk” Patches of hyperpigmentation Normal

Developmental Considerations - Infants Acrocyanosis Bluish color around lips, hands, and feet Usually is due to coolness and disappears after warming up Persistent cyanosis is indicative of congenital heart disease Cutis marmorata Mottling of trunk and extremities due to coolness If persistent, usually indicative of Down syndrome Physiological jaundice Common yellowing of skin in newborns, which usually appears after 4 th day. UV light helps. Carotenemia Yellowing of skin due to ingestion of large amts of carotene.

Developmental Considerations - Adolescents Acne Most common skin problem Acne occurs when the hair follicles, which are connected to sebaceous glands, become plugged with oil and dead skin cells. Usually appear on face, shoulders, back, and chest Can include papules, pustules, and nodules Open comedones (blackheads) Closed comedones (whiteheads)

Acne Open comedones are a less severe form of acne

Vascular Lesions - Hemangiomas Port-Wine Stain (Nevus Flammeus) Flat macular patch of mature capillaries Benign Strawberry Mark (Immature hemangioma) Raised bright red area Usually disappears by age 7 Cavernous Hemangioma

Developmental Considerations - Pregnancy Striae Linea nigra Chloasma Vascular spiders

Developmental Considerations - Aging Senile lentigines Liver spots – melanocyte clusters Usually on hands and face Seborrheic keratosis Raised, thick, crusted “mole” Dry skin is common Acrochordons Overgrowths of skin – normal Frequently occur on back, eyelids, axillae

Developmental Considerations - Aging Decreased turgor, tenting of skin occurs Hair growth decreases, thins Fungal infections of toenails

Teaching Self-Exam

Pressure Ulcers Stage I A reddened area on the skin that, when pressed, is "non- blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop. Stage II The skin blisters or forms an open sore. The area around the sore may be red and irritated.

Pressure Ulcers Stage III The skin breakdown now looks like a crater where there is damage to the tissue below the skin. Stage IV The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.

Braden Scale Sensory Perception Activity Mobility Skin Moisture Friction and Shear Nutrition 1-4 with the exception of friction & shear subscale 1-3 Range 4-23 The lower the score the higher the risk Eighteen or less: high risk older adult