Integumentary (Skin, Hair, Nail) Exam INTEGUMENTARY (SKIN, HAIR, NAIL) EXAM FINDINGS

Integumentary (Skin, Hair, Nail) Exam INTEGUMENTARY (SKIN, HAIR, NAIL) EXAM FINDINGS Terminology for Assessment Functions of the Skin Environmental protection Maintenance of fluids Temperature regulation Sensation Communication Synthesis of Vitamin D Excrete sweat, urea, and lactic acid Assist in regulation of blood pressure History General HPI questions Skin care habits • Soap, cleansing routine, oils, lotions, cosmetics, home remedies Recent activities: • Anything new Environmental or occupational hazards • Dyes, chemicals, plants, water immersion, sun exposure, toxic substances Recent psychological or physiological stress General constitutional and other symptoms Past Medical and Family History Previous skin problems History of allergies Tolerance to sun Skin cancer Systemic disease Psoriasis • Cardiac Infestations • Renal Infections • Liver Medications Exam Equipment Adequate lighting Centimeter ruler Magnifying glass Gloves!!!!! Wood’s light • Useful for identifying fungal infections which will often fluoresce blue-green Observing and describing lesions Color Size (measure): use metric measurements Elevation: raised, flat Feel: soft, hard, fluid-filled, immobile, rough smooth Shape Distribution Onset/duration Primary and secondary characteristics • Primary: o Arise from previously normal skin • Secondary: o Arise from change in primary lesion o May see loss of skin or gathering of material on skin. Skin symptoms (itch, burn, dryness. Etc.) Primary Characteristics of Lesions Macule Flat Non-palpable lesion Nothing raised, flush to skin 1 cm in diameter Pustule Vesicle filled with purulent fluid Patch Flat Non-palpable 1 cm in diameter Bulla Vesicle 0.5cm in diameter Papule Solid (not fluid filled) Elevated lesion 0.5 cm in diameter Nodule 0.5 cm Both width and depth Plaque Elevated lesion 0.5 cm in diameter Minimal depth Cyst Nodule containing a liquid or semisolid which can be expressed Wheal Transitory papule or plaque due to edema of the dermis (comes and goes) Tumor Solid lesion 2 cm in both width and depth Vesicle Blister 0.5cm in diameter Filled with clear fluid Lichenification Resembles fish scales Due to chronic irritation DRUG REACTION SKIN FINDINGS Acne Papules and pustules on face, shoulders, and chest Anabolic steroids Corticosteroids Iodides Bromides Phenytoin Fixed Drug Eruptions Red or purple macules progressing to bullae confined to particular area Drug exposure results in reaction in the same area Acetaminophen, ASA, NSAIDs Antibiotics (PCN, sulfonamides, metronidazole, tetracycline) each time. Lesion appears within 8 hours of ingestion Usually limited to one lesion Face and genitalia are common sites Uticaria (Hives) Itchy, raised red and white bumps Quinone OCs ASA ANTI-INFLAM DRUGS/ Q.Oral.A Continued exposure may progress to anaphylaxis Antibiotics (PCN, cephalosporin, sulfonamides) CCBs ACEIs Histamine-releasing agents (amphetamines, atropine, opiates) NSAIDs Radiographic contrast media Morbiliform (measle-like) Drug Induced Photosensitivity Maculo-papular rash of small raised red bumps, symmetrical on extremities and trunk, may coalesce +/- fever Appear 2 days- 3 weeks after medication exposure May not recur with same drug exposure Local or generalized eczema-like red, scaling rash Photo toxicity: looks like an exaggerated sunburn well demarcated along area of sun exposure Photo allergy: more commonly topical meds, may spread to non-sun exposed area Antibiotics (PCN) Barbiturates, BZDs NSAIDs Almost any drug Petechia and Purpura Purple, bruise-like areas Anti-coagulants Diuretics Steven-Johnson Syndrome (SJS) Prodromal phase with flu-like syndrome with skin & joint pain Blisters or hive-like rash first on mucus membranes than progressing to skin; usually covers most of the body More severe variant is TEN (Toxic Epidermal Necrolysis) • Rash progresses to sloughing of large areas of epidermis (appears like a 3rd degree burn) Antibiotics (PCN, Sulfonamides, cephalosporin) NSAIDs HTN and DM meds Contact Dermatitis History of contact with new or unknown substance Pruritus Finding the item may take extensive questioning Physical Exam • Erythematous, well-demarcated plaques • Superimposed vesicles • Punctate erosion exuding serum crusts • Note pattern of distribution (may be your best clue) Soaps, detergents Cosmetics Solvents, acids, alkali Plants (poison ivy and oak) Metals (nickel) Latex and rubber Local anesthetics Neomycin (topical antibiotics) PABA Common Infectious Diseases Folliculitis Localized infection of hair follicle (pseudomonas) Common in beard area, especially in men with kinky hair Usually presents as a pustule, mild to moderate pain Furuncles and Carbuncles Boils (BOIL THE FURUNCLES. Boiling makes it RED AND WARM) Localized skin infections usually due to staph or strep Red, indurated warm area Papular eventually developing a soft, fluctuant pus-filled center Carbuncle is coalescence of several adjacent furuncles Varicella Zoster – Chicken Pox PAPULEVESICLEPUSTULECRUS T More common in winter and spring Mild prodrome of fever, abdominal pain, malaise Red papular rash New lesions continue to appear for 3-7 days Varicella Stages • Papules • Quickly evolve to vesicles o Superficial and thin-walled with surrounding erythema Patient remains crusted all lesions • Rapidly evolve to pustules and crusts over 8-12 hours • Crust fall of in 1-3 weeks leaving pink, depressed base *All stages of evolution may be noted simultaneously *For small pox, lesion appear in order Herpes Zoster – Shingles Impetigo Prodrome of pain and parasthesia in the involved dermatome Erythematous base with clear vesicles Oval or round *Follows dermatomal distribution *Usually affect 1 or 2 dermatomes only secondary infections of chicken pox or other lesions Usually staph but may be other organisms Characteristic appearance of yellow stuck-on crusts Herpes Simplex Virus – HSV Scabies Groups vesicles on an erythemous based Rupture to ulcerations which may be crusted or moist May evolve to pustules due to secondary infections Initial attack: • Fever • Malaise • Generalized aches • Localized symptoms First symptom is intense itching, over widespread area Mites often leave tell-tale burrow Recurrence: • Tingling, itching, burning sensation precedes visible skin changes by 24 hours Regional lymph nodes enlarged or tender Usually prefer warm, moist, areas (skin folds) and spares the face (except in infants) Eczematous dermatitis at sites of heaviest infestation Pediculosis-Lice Tinea Parasites that live on the scalp or other hairy regions Most common in young children and their families Adult louse is tan and about the size of a sesame seed Small to large scaling plaques with central clearing Sharp margins with small vesicles at the edge Single or several lesions Slow outward growth Mild pruritus Nits (eggs) are white and usually attached to hair shaft Sensation of something moving in the hair, itching, and sores from scratching Manis – hands Pedis- feet Capitis – head Cruris – groin Measles (Rubeola) Erythema Infectiosum (Fifth’s Disease) Prodrome of irritability, red eyes, runny nose, cough, and fever Fever peaks with rash appearance Rash begins on the face a spreads downward to trunk and extremities Flat red-brown spots that coalesce Rash lasts about 6 days then fades and peels Prodrome of low-grade fever, coryza, cough, headache, and malaise Classic “slapped check” rash appears in 3-7 days of onset of symptoms Skin Findings of Systemic Disease Lupus Erythematosus Autoimmune disorder Malar “butterfly” rash F M Multi-organ system disease including kidneys, MS, cardiac, lungs, brain, eyes Onsted 20-40 years Erythema Nodosum Tender, red lesions typically on the shins that appear Immunologic response to a variety of causes over the course of days (inflammation of fat cells) • infection disease • autoimmune disease • Diabetes • Drugs (sulfa antibiotics, iodides, bromides, OCs) HIV – Kaposi’s Sarcoma Caused by herpes virus Usually painless Nodules or blotches (red, purple, brown, or black) Mainly dangerous if obstruct circulation, breathing, or eating Diabetes Mellitus Acanthosis nigricans Hyper pigmentation of skin that is poorly defined Found on neck, axilla, and groin Usually brown to black Granuloma Annular A benign vascular tumor which can be present in otherwise healthy individuals but is common in diabetics Candida Infections Erythema with papules or pustules Itching or burning sensation Satellite lesions Injection complications Localized infection Localized skin allergic reactions Lipoatrophy Localized disappearance of the cutaneous/subcutaneous fat tissue Seen in the past with insulin of non-human origin Hyperlipidemia Xanthomas Lipids deposited in the skin Common site: Can also be present in healthy individuals • Elbows and knees • Eyelids • Hands Chronic Scaling Skin Lesions Atopic Dermatitis – Eczema A skin disease categorized by persistent or recurring scaling red, itchy lesions Onset in childhood, familial Personal or family history of allergies or asthma Itch typically precedes rash Erythematous patches, papules, and plaques +/- scales Edema Erosions (crusted) Excoriation (from scratching) Secondary infection Common sites: • Flexor creases • Neck, face • Dorsa of hands and feet • Behind knees • Buttocks Seborrheic Dermatitis Yellow or white scaling macules and papules of varying size, sharply marinated, often greasy Scattered, discrete on the face and trunk Diffuse involvement of scalp Sites: • Ear, scalp, eyebrows • Nasolabial folds • Axillae, groin • Sub mammary Psoriasis Chronic often hereditary condition Patches of thickened red skin often covered by thick white scale More common on extensor surfaces Age Related, Precancerous, and Cancerous Lesions Actinic Keratosis PRECURSOR Rough, red, scaly patches often with erosions Difficult to distinguish from skin cancers without biopsy Usually appears in sun-exposed areas Often precursors to carcinomas Basal Cell Carcinoma Slow growing, most common skin cancer Pearly papule or nodule with a rolled border and often with a crust, Not deadly but can be disfiguring central depression Risk factors: Fine telangiectasia (small dilated blood vessels near skin surface) • Fair skin people with prolonged sun exposure Firm and hard to touch Squamous Cell Slow growing Soft, mobile, elevated masses Mainly on scalp, back of hands, lower lip and ear Often with scaling and eroded/ulcerated area Suspect in any skin lesion that persists over a month May have a keratotic plug in center Melanoma The most dangerous form of skin Risk Factors: ABCD rule of Melanoma cancer • Pre-existing pigmented lesions A. Asymmetry of lesion Can be deadly • Family history B. Borders are irregular Fast growing, invasive, and may • Light colored skin that tans poorly C. Color is blue/black or metastasize • Excessive sun exposure (blistering sunburn) variegated especially pre-adolescence D. Diameter 6 mm (pencil eraser)