Skin Assessment

Examination of the Skin
(L.CUTIS)
Dr. Sudeesh Shetty

Final Year P.G Scholar
Dept of Roganidana
GAMC Banglore.
OUTLINE
 ANATOMY and PHYSIOLOGY
 HISTORY
 EXAMINATION
drsudeeshshetty@gmail.com 2
Skin Anatomy
1.Epidermis
 The epidermis is composed of 4 or 5 layers depending on the region
of skin being considered
 The epidermis is the topmost layer, and consists primarily of
keratinocytes.
 The epidermis is separated from the dermis, its underlying tissue, by
a basement membrane.
 The epidermis is avascular, nourished by diffusion from the dermis,
constituted at 95% of keratinocytes but also containing melanocytes,
Langerhans cells, Merkel cells, and inflammatory cells.
Epidermis is divided into the following 5 sublayers or strata:

 Stratum corneum
 Stratum lucidum
 Stratum granulosum
 Stratum spinosum
 Stratum germinativum (also called "stratum basale").
Stratum corneum
Stratum lucidum
Stratum granulosum
(granular cell layer)
Stratum spinosum
(spiny layer)
Stratum besale
 Those layers in descending order are cornified layer (stratum corneum)
 Composed of 10 to 30 layers of polyhedral, anucleated corneocytes (final step
of keratinocyte differentiation), with the palms and soles having the most layers.
 Corneocytes are surrounded by a protein envelope (cornified envelope proteins), filled with water
retaining keratin proteins, attached together through corneodesmosomes and surrounded in
the extracellular space by stacked layers of lipids.
 Most of the barrier functions of the epidermis localize to this layer.[10]clear/translucent layer (stratum
lucidum, only in palms and soles)
 The skin found in the palms and soles is known as "thick skin" because it has 5 epidermal layers
instead of 4.granular layer (stratum granulosum)
 Keratinocytes lose their nuclei and their cytoplasm appears granular. Lipids, contained into
those keratinocytes within lamellar bodies, are released into the extracellular space
through exocytosis to form a lipid barrier. Those polar lipids are then converted into non-
polar lipids and arranged parallel to the cell surface. For
example glycosphingolipids become ceramides and phospholipids become free fatty
acids.[spinous layer (stratum spinosum)
 Keratinocytes become connected through desmosomes and start produce lamellar bodies, from
within the Golgi, enriched in polar lipids,glycosphingolipids, free sterols, phospholipids and
catabolic enzymes.[4] Langerhans cells, immunologically active cells, are located in the middle of
this layer.[9]basal/germinal layer (stratum basale/germinativum).
 Composed mainly of proliferating and non-proliferating keratinocytes, attached to the basement
membrane by hemidesmosomes. Melanocytes are present, connected to
numerouskeratinocytes in this and other strata through dendrites.
 Merkel cells are also found in the stratum basale with large numbers in touch-sensitive sites such
as the fingertips and lips. They are closely associated with cutaneous nerves and seem to be
involved in light touch sensation.The term Malpighian layer (stratum malpighi) is usually defined as
both the stratum basale and stratum spinosum.
2.Dermis
 The dermis lies below the epidermis, and consists
primarily of fibroblasts, collagen, and elastic fibers
 The dermis is the layer of skin beneath
the epidermis that consists of connective tissue and
.
cushions the body from stress and strain.
 The dermis is tightly connected to the epidermis by
a basement membrane.
 The dermis is structurally divided into two areas: a
superficial area adjacent to the epidermis, called
the papillary region, and a deep thicker area known as
the reticular region
 It also harbors many nerve endings that provide the
sense of touch and heat.
 It is between 1-4 mm thick (depending on age
and body location), making it much thicker
than the epidermis.
 It contains the hair follicles, sweat
glands, sebaceous glands, apocrine
glands, lymphatic vessels and blood vessels.
The blood vessels in the dermis provide
nourishment and waste removal from its own
cells as well as from the Stratum basale of the
epidermis.
Papillary
dermis
Reticular
dermis
3.Hypodermis
 Below the dermis lies fat, also called
subcutis, panniculus, or hypodermis.
 Blood capillaries are found beneath the
epidermis, and are linked to an arteriole and
a venule.
 Arterial shunt vessels may bypass the
network in ears, the nose and fingertips.
Skin Function
 Coloring/Complexion
 Protective barrier
 Mechanical barrier
 Temperature regulator
 Sensor
 Vitamin D producer
 Repairer
 Excreter
 Expresser
Review Chart
Pigments
There are at least five different pigments that determine
the color of the skin.
These pigments are present at different levels and
places.
1. Melanin: It is brown in color and present in the
germinative zone of the epidermis.
2. Melanoid: It resembles melanin but is present
diffusely throughout the epidermis.
3. Carotene: This pigment is yellow to orange in color. It
is present in the stratum corneum and fat cells of
dermis and superficial fascia.
4. Hemoglobin (also spelled haemoglobin): It is found in
blood and is not a pigment of the skin but develops a
purple color.
5. Oxyhemoglobin: It is also found in blood and is not a
15
pigment of the skin. It develops a red color.
drsudeeshshetty@gmail.com
Nutrition for healthy skin
1. Vitamin A, also known as retinoids, benefits the skin
by normalizing keratinization,
downregulating sebum production which contributes
to acne, and reversing and treating photodamage,
striae, and cellulite.
2. Vitamin D and analogs are used to downregulate
the cutaneous immune system and epithelial
proliferation while promoting differentiation.
3. Vitamin C is an antioxidant that regulates collagen
synthesis, forms barrier lipids, regenerates vitamin
E, and provides photoprotection.
4. Vitamin E is a membrane antioxidant that protects
against oxidative damage and also provides
protection against harmfuldrsudeeshshetty@gmail.com
UV rays. 16
Skin Appendages
Hair
Nails
The Skin: History
•Chief complaint
•History of present illness (HPI)
•Past medical history (PMH)-previous problems and
systemic disease,Medications,Allergies
•Family history-skin CA, psoriasis, allergy, infestations and
infections
•Psychosocial-personal habits,exposures,Health-related
behaviors
•Social history-
•Review of systems-
HPI:
• When did it start?

• Does it itch, burn, or hurt?
• Associated symptoms
• Is this the first episode?
• Where on the body did it start?-Location
• How has it spread (pattern of spread)?
• How have individual lesions changed (evolution)?
• Provoking/Alleviating/aggravating exacerbating
factors?
• Previous treatments and response?
o Timing of Attacks
o Occupation
o Topical agents
o Drug history
o Season of year
o Environment drsudeeshshetty@gmail.com 21
 The Total Body Skin Exam (TBSE) includes
inspection of the entire skin surface, including:
• the scalp, hair, and nails
• the mucous membranes of the mouth, eyes, anus, and

genitals
History-Hair
Timing
Associated symptoms
Nutrition
Alleviating/aggravating
Treatment(s)
Exposures
History-Nails
 Timing
 Associated symptoms
 Nutrition
 Alleviating/aggravating
 Treatment(s)
 Exposures
Examination aides/Diagnostic
aids/Essential elements for the skin exam:
 Ruler  Adequate lighting

 Undressed patient, in a
 Lighting gown
• Preferably without
 Penlight
makeup, watches, jew
 Gloves elry
 Privacy
 Magnifying  An open mind about what
glass you are seeing
 Woods lamp
 Accurately records the size of a lesion on
successive examinations
 Measure in the longest axis first, then in the
perpendicular axis
• e.g., this papule is 6x4 mm
 Dermatoscopes --Magnify the lesions with a hand
lens or using epiluminescence microscopy (using a
hand lens with magnification and lighting built in to
better visualize lesions)
 Inexpensive magnifying glasses may help detect
fine details
• Avoid LED lights, which cast a blue hue
 A penlight is used for side lighting
 Detects atrophy and fine wrinkling
 Distinguishes
• Flat from raised lesions
• Whether lesions are solid or fluid-filled
 Also helps look inside the mouth
 Use diascopy (press a transparent, firm object
such as a glass slide against a lesion) to
determine if an erythematous lesion blanches.
 Use a wood’s lamp (long wavelength ultraviolet
light) to examine if a lesion is hypo or
depigmented or to see if a fungal infection
fluoresces.
Examination (exposure!)
 Inspection  Palpation
– Color – Moisture
– Uniformity – Temperature
– Thickness – Texture
– Hygiene – Turgor
– Lesions – Mobility
 Sequence
– Regional
– System
Colour
Skin- or flesh-colored
Hypopigmented vs hyperpigmented
White
Brown
Grey
Black
Red
Blue
Violaceous
Dark purple (purpura)
Yellow
Orange
Green drsudeeshshetty@gmail.com 32
Lesion Description
 Size, Shape, Color Three categories of
 Edges observation :
 Texture 1.Anatomic distribution
 Elevated or depressed of the lesion
 Exudates 2.Configuration of
groups of lesions
 Configuration
3.The morphology of
 Location&Distribution the individual lesions
 PICTURE!!
 Distribution means location on the body
 Configuration means how the lesions are
arranged or relate to each other
Distribution
Configuration
Primary skin lesion:
1 Macule 7 Bulla 13 Ecchymosis
2 Papule 8 Postule 14 Hemotoma
3 Plaque 9 Wheal 15 Poikiloderma
4 Nodule 10 Telangictasia 16 Erythema
5 Papilloma 11 Petechiae 17 Burrow
6 Vesicle 12 Purpura 18 Comedo

MACULE
 Macule – A flat, colored lesion, <2cm in
diameter, not raised above the surface of
surrounding skin
 Freckle – prototype of pigmented macule
 Non-palpable lesion with distinct borders,
less than 1 cm in diameter
 Non-palpable change in skin color with
distinct borders localized changes in skin
color.
 Areas may be small or large; occur in many
shapes and colors.
 Not palpable
 may be associated with desquamation or
scaling
 e.g- rubeola, rubella, secondary syphilis,
rose spots of typhoid fever, drug eruptions,
petechiae, purpura, first degree burns,
systemic lupus erythematosus, pityriasis
rosea and vitiligo 40
MACULE
PATCH
Non-palpable lesion with distinct borders,

greater than 1 cm in diameter
Non-palpable change in skin color with
distinct borders
PATCH
VESICLE
 Fluid-containing, superficial, thin-walled
cavity less than 1 cm
 Small, raised, fluid-filled lesions are
called vesicles
 e.g-varicella with vesicles and bullae
acute eczematous dermatitis, second-
degree burns
VESICLE
BULLA
Fluid-containing ,superficial, thin-walled
cavity greater than 1 cm
e.g-bullous pemphigoid, contact

dermatitis, second-degree burns,
bullous impetigo
BULLA
Pustule
*Pus containing, superficial,thin-walled
cavity, frequently arise from hair follicles or
sweat glands. Pus is made up of leukocytes and
a thin fluid called liquor puris (L. “pus liquid”)
examples: acne,furuncles,and bromide and iodide

eruptions, Inflammatory acne, furuncles, and
bromide and iodide eruptions. 49
Pustule
Papule
 *Palpable, solid lesion less than 1 cm in diameter
 *A small, solid lesion, <0.5 cm in diameter,
raised above the surface of surrounding skin &
hence palpable
 Borders and tops may be in various forms
–round or irregular --senile angiomas,
eczematous dermatitis, secondary
syphilis
–pedunculate – neurofibromas
Eg: white head in acne, blue nevus 52
Papule
NODULES
*A large ( 0.5 – 5.0 cm ), firm lesion raised above
the surface of surrounding skin.
*A raised area in the skin where the overlying
epidermis looks and feels normal, but there is a
proliferation of cells in deeper tissues is called a
nodule.
*Differs from papule only in size
*Rubbery, Mobile, Non-tender

NODULES
Tumor
*A solid, raised growth >5cm in diameter
Plaque
Palpable, solid lesion greater than 1 cm in
diameter.
A large >1cm, flat topped raised lesion, edges may
either be distinct ( in psoriasis ) or gradually blend
with surrounding skin ( in eczematous dermatitis )
Yellow -- xanthomas
brown -- seborrheic warts
Red scaling plaques -- psoriasis, pityriasis rosea
E.g- Urticaria, psoriasis
Plaque
WHEAL /Hives
A raised, erythematous, edematous, papule

/ plaque, usually representing short-lived
vasodilatation and vasopermeability
Eg: urticaria and insect bites
WHEAL
Telangiectasia
A dilated superficial blood vessel.
*Angioectasias (also known as spider veins) are small dilated blood
vessels near the surface of the skin or mucous membranes,
measuring between 0.5 and 1 millimeter in diameter.
*They can develop anywhere on the body but are commonly seen on the
face around the nose, cheeks, and chin.
*They can also develop on the legs, specifically on the upper thigh,
below the knee joint, and around the ankles.
*They may be composed of abnormal aggregations
of arterioles, capillaries, or venules.
*Because telangiectasias are vascular lesions, they blanch when tested
withdiascopy.
*Telangiectasia is a component of the CREST variant of scleroderma
(CREST is an acronym that stands for calcinosis, Raynaud's
phenomenon,esophageal dysmotility,drsudeeshshetty@gmail.com
sclerodactyly, and telangiectasia.)
61
Telangiectasias may develop anywhere within the body but can
be easily seen in the skin, mucous membranes, and whites of
the eyes. Usually, they do not cause symptoms. However, some
telangiectasias bleed and cause significant problems.
Telangiectasias may also occur in the brain and cause major
problems from bleeding.
e.g-Cushing's syndrome Venous hypertension

varicose and telangiectatic leg veins liver disease. Chronic
treatment withuse,Aging,Genetics,Pregnancy,Sun
Causes----Alcohol topical corticosteroids exposure
Diseases associated with this condition include:
Ataxia - telangiectasia
Bloom syndrome
Cutis marmorata telangiectatica congenita
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Klippel-Trenaunay-Weber syndrome
Nevus flammeus such as port-wine stain
Rosacea
Spider angioma
Sturge-Weber disease
Xeroderma pigmentosa
Telangiectasia
Petechiae
 Petechiae – pinhead-sized macules of extravascular
blood in the dermis.
 Petechiae are flat.
 A petechia (Lural petechiae) is a small (1 - 2 mm) red or
purple spot on the body, caused by a
minor hemorrhage (brokencapillary blood vessels).
 "Petechiae" refers to one of the three major classes
of purpuric skin conditions.
 Purpuric eruptions are classified by size into three broad
categories.
 Petechiae is generally used to refer to the smallest of the
three classes of purpuric skin eruptions, those that
64
measure less than 3 mm. drsudeeshshetty@gmail.com
Petechiae
Purpura
 The larger ones are referred to as purpura
 Purpura (from Latin: purpura, meaning
"purple") is the appearance of red or
purple discolorations on the skin that do
not blanch on applying pressure.
 They are caused by bleeding underneath the skin usually
secondary to vasculitis or dietary deficiency of vitamin C
(scurvy).
 Purpura measure 0.3–1 cm (3–10 mm),
whereas petechiae measure less than 3 mm,
and ecchymoses greater than 1 cm.
 This is common with typhus and can be present
with meningitis caused by meningococcal meningitis
or septicaemia.
 In particular, meningococcus (Neisseria meningitidis), a Gram-
negative diplococcus organism, releases endotoxin when it
lyses.
 Endotoxin activates the Hageman factor (clotting factor XII),
which causes disseminated intravascular coagulation (DIC).
 The DIC is what appears as a rash on the affected individual.
Purpura
Ecchymosis
 If bleeding involves deeper structures
then it is an ecchymosis
 a discoloration of the skin resulting from
bleeding underneath, typically caused by
bruising.
 An ecchymosis is the medical term for a
subcutaneouspurpura (extravasation of blood)
larger than 1 centimeter or a hematoma,
commonly, but erroneously, called a bruise.
 That is, bruises are caused by trauma whereas
ecchymoses, a type of purpura, are not caused
by trauma.
 A broader definition of ecchymosis is the
escape of blood into the tissues from ruptured
blood vessels.
 The term also applies to the subcutaneous
discoloration resulting from seepage of blood
within the contused tissue.
Ecchymosis
Erythema
 Erythema is a skin condition characterized by
redness or rash.
 Erythema (from the Greek erythros, meaning red)
is redness of the skin, caused by hyperemia of the
capillaries in the lower layers of the skin.
 There are many types of erythema, including
photosensitivity, erythema multiforme, and
erythema nodusum.
 It occurs with any skin injury, infection, or
inflammation.
 Photosensitivity is caused by a reaction to sunlight and tends to occur
when something, such as an infection or a medication, increases your
sensitivity to ultraviolet radiation.
 Erythema multiforme is characterized by raised spots or other lesions
on the skin. It is usually caused by a reaction to medications,
infections (especially herpes simplex virus), or illness.
 Erythema nodosum is a form of erythema that is accompanied by
tender lumps, usually on the legs below the knees, and may be caused
by certain medications or diseases.
 Erythema ab igne
 Erythema chronicum migrans
 Erythema induratum
 Erythema infectiosum (or fifth disease)
 Erythema marginatum
 Erythema migrans
 Erythema multiforme (EM)
 Erythema nodosum
 Erythema toxicum
 Keratolytic winter erythema drsudeeshshetty@gmail.com 73
Erythema
Hematoma
 A hematoma or haematoma, is a localized
collection of blood outside the blood vessels, usually
in liquid form within the tissue.
 An ecchymosis, commonly called a bruise, is a
hematoma of the skin larger than 10mm.
 Internal bleeding is generally considered to be a
spreading of blood within the abdomen or skull, not
within muscle
 It is not to be confused with hemangioma which is an
abnormal build up of blood vessels in the skin or
internal organs. drsudeeshshetty@gmail.com 75
Types
 Subdermal hematoma (under the skin)
 Head/brain:
– Subgaleal hematoma – between the galea aponeurosis and periosteum
– Cephalohematoma – between the periosteum and skull. Commonly caused by
vacuum delivery and vertex delivery.
– Epidural hematoma – between the skull and dura mater
– Subdural hematoma – between the dura mater and arachnoid mater
– Subarachnoid hematoma – between the arachnoid mater and pia
mater (the subarachnoid space)
– Othematoma – between the skin and the layers of cartilage of the ear
 Perichondral hematoma (ear)
 Perianal hematoma (anus)
 Subungual hematoma (nail)
Degrees
 Petechiae – small pinpoint hematomas less than 3 mm in diameter
 Purpura (purple) – a bruise about 1 cm in diameter, generally round in shape
 Ecchymosis – subcutaneous extravasation of blood in a thin layer under the skin,
i.e. bruising or "black and blue," over 1 cm in diameter
Hematoma
Morphology
Comedones
 A plug of keratin and sebum wedged in dilated pilosebaceous orifice.
 Comedones are the skin-coloured, small bumps (papules) frequently found on
the forehead and chin of those with acne.
 Open comedones are blackheads; black because of surface pigment (melanin)
rather than dirt
 Closed comedones are whiteheads; the follicle is completely blocked
 Macrocomedones are facial closed comedones that are larger than 2-3 mm in
diameter
 Solar comedones are found on the cheeks and chin of older people, and are
thought to be due to sun damage.
 Larger and deeper uninflamed bumps are called nodules. They are more
common on the trunk than on the face
 The cells lining the sebaceous duct proliferate excessively in acne (cornification)
and may block the sebaceous duct forming a comedone.
 These may be so small that they are not visible to the naked eye
(microcomedones). drsudeeshshetty@gmail.com 79
• A comedo is a clogged hair follicle (pore) in the
skin.[1] Keratin (skin debris) combines with oil to block the follicle.
• A comedo can be open (blackhead) or closed by skin (whitehead),
and occur with or without acne.
• The word comedo comes from Latin to suggest the worm-like look
of a blackhead that has been secreted.
• The plural of comedo is comedones.
• The chronic inflammatory condition that usually includes both
comedones and inflamed papules and pustules (pimples) is
called acne.[2][4] Infection causes inflammation and the
development of pus.
• Whether or not a skin condition classifies as acne depends on the
amount of comedones and infection.
• Comedo-type ductal carcinoma in situ (DCIS) is not related to the
skin conditions discussed here.
• DCIS is a non-invasive form of breast cancer, but comedo-type
DCIS may be more aggressive and so may be more likely to
become invasive.
open Comedones closed
Burrow
 A linear or cuvillinear papule, caused by
burrowing scabies mite
 Burrows are linear lesions produced by infestation
of the skin and formation of tunnels (e.g., with
infestation by the scabitic mite or by cutaneous
larva migrans)
 Linear or serpiginous (wavy, serpent-like
borders) tunnels within the epidermis. The small
and short tunnels ofscabies are an example.
 Microscopic examination of a skin biopsy or the skin
scrapings done at time of clinical examination. The
outer layers of eggs ( called ‘egg casings) and mites
appear eosinophilic (pink) and scybala (feces)
appear brown. These are present in the stratum
corneum. The dermal inflammation contains
eosinophils, as a response to the parasitic infection.
Burrow
CYST
 A cyst is a closed tumorous lesion covered
by a membranous lining, which does not
always elevate above the skin.
 examples: sebaceous and epidermal cysts
 The covering consists of epithelial tissue
or connective tissue containing keratinous
substances (observed in epidermal cysts,
for example) or fluid components (e.g., in
eccrine and apocrine hydrocystomas)
elevated lesions containing fluid or
viscous material appear as papules or
nodules
 distinction is made by puncturing to
examine their contents and depth
CYST
Abscess
 Thick-walled cavity containing pus
 The organisms or foreign materials kill
the local cells, resulting in the release
of cytokines.
 The cytokines trigger an inflammatory
response, which draws large numbers
of white blood cells to the area and
increases the regional blood flow.
 An abscess (Latin: abscessus) is a collection of pus (neutrophils)
that has accumulated within a tissue because of an inflammatory
process in response to either an infectious process (usually
caused by bacteria or parasites) or other foreign materials (e.g.,
splinters, bullet wounds, or injecting needles). It is a defensive
reaction of the tissue to prevent the spread of infectious materials
to other parts of the body.
 The organisms or foreign materials kill the local cells, resulting in
the release of cytokines. The cytokines trigger an inflammatory
response, which draws large numbers of white blood cells to the
area and increases the regional blood flow.
 The final structure of the abscess is an abscess wall, or capsule,
that is formed by the adjacent healthy cells in an attempt to keep
the pus from infecting neighboring structures. However, such
encapsulation tends to prevent immune cells from attacking
bacteria in the pus, or from reaching the causative organism or
foreign object.
 Abscesses must be differentiated from empyemas, which are
accumulations of pus in a preexisting rather than a newly formed
89
anatomical cavity. drsudeeshshetty@gmail.com
Abscess
Papilloma
o Papilloma is a general medical term for
a tumor of the skin or mucous
membrane with finger-like projections.
o Papillomas are also known as neoplasms.
o While the vast majority of papillomas
are benign (noncancerous), they can
occasionally be dysplastic (precancerous)
or malignant (cancerous).
o Papillomas can occur in areas throughout the body.
o Papillomas on the skin (cutaneous papillomas) are commonly
referred to as warts.
o They occur on areas such as the hands, feet and knees.
Papillomas can also occur in the nose, brain, genitals,
conjunctiva of the eye, and female breast ducts.
o Papilloma in the throat, windpipe and lungs is a rare disease
called recurrent respiratory papillomatosis (RRP).
o Most papillomas are caused by a virus.
o The human papillomaviruses (HPVs) are a group of more than
150 viruses that can cause papillomas. HPVs can cause
papillomas of the skin, genitals, mouth, eyes and throat.
Certain HPVs can cause cervical cancer in women.
o Some types of papilloma have other, nonviral, causes.
o For example, nasal papilloma may be caused by a tissue
injury. In addition, there are types of papillomas that do not
have known causes. These include intraductal (breast duct)
papilloma and choroid plexus papilloma (a rare benign brain
tumor most often seen in young children).
A benign papillomatous tumor derived from epithelium. Cauliflower-
like projections that arise from the mucosal surface. It may appear
white or normal colored. It may be pedunculated or sessile. The
average size is less than 2.0 cm. No strong sex preference. The most
common site was the palate-uvula area followed by tongue and lips.
The durations ranged from weeks to 10 years. There is no evidence
that papillomas are premalignant.
 Papilloma (plural papillomas or papillomata) refers to
a benign epithelial tumor growing exophytically (outwardly
projecting) in nipple-like and often finger-like fronds.
 In this context papilla refers to the projection created by the tumor,
not a tumor on an already existing papilla (such as the nipple).
 When used without context, it frequently refers to infections
(squamous cell papilloma) caused by human papillomavirus (HPV),
such as warts.
 There are, however, a number of other conditions that cause
papilloma, as well as many cases in which there is no known
cause.Human papillomavirus infection is a major cause of cervical
cancer, although most HPV infections do not cause cancer.
Papilloma
Poikiloderma
 Poikiloderma is a skin condition that consists of
areas of
hypopigmentation, hyperpigmentation, telangiec
tasias and atrophy.
 Poikiloderma is most frequently seen on the
chest or the neck, characterized by red colored
pigment on the skin that is commonly associated
with sun damage.
e.g--Poikiloderma vasculare , atrophicans Poikiloderma of

Civatte, Hereditary sclerosing poikiloderma
 The exact cause of poikiloderma is unknown; however, extended sun
exposure, namely the ultraviolet light emitted by the sun, is the primary factor
Causes
 Congenital
 Rothmund-Thompson Syndrome
 Dyskeratosis Congenita
 Mendes da Costa Syndrome
Other Heriditary Causes
 Hereditary Sclerosing Poikiloderma of Weary
 Weary-Kindler Syndrome
 Kindler Syndrome
 Diffuse and Macular Atrophic Dermatosis
 Degos-Touraine Syndrome
 Acquired
 Injury to cold, heat, ionizing radiation, exposure to sensitizing chemicals
 Lichen Planus
 Dermatomyositis
 Lupus Erythematosus
 Systemic Sclerosis
 Cutaneous T Cell Lymphomas 96
Poikiloderma
Secondary skin lesion:
Changes in skin which are superimposed or are
the consequence of the primary process
1 Scale 7 Ulcer
2 Crust 8 Sinus
3 Excoriation 9 Scar
4 Lichenification 10 Keloid
5 Fissure 11 Atrophy
6 Erosion 12 Stria
SCALINING
 Scaling is the abnormal thickening of the skin surface
and formation of scaly white lamellae from the
accumulation of horny cell layers.
 Detachment of scales from the skin surface is called
desquamation. Since the normal horny cell layers
exfoliate individually, individual desquamation
lamellae cannot be seen by the naked eye.
 Scales are observed when multiple horny cell layers
pathologically exfoliate in diseases such as psoriasis
e.g-desquamating layers of stratum corneum in

psoriasis drsudeeshshetty@gmail.com 100
SCALINING
CRUSTING
 Crust is solidified keratin and exudate that
forms on an erosion or on ulcerous skin.
 A crust of clotted blood is called a bloody crust
(commonly called a scab).
 Crusts are a sign of pyogenic infection
e.g-Impetigo with honey colored crust
CRUSTING
Dried serum, blood or

purulent exudate
Impetigo with honey
colored crust
Morphology
Erosion
 Erosions are loss of the epidermis
 They may occur after a vesicle forms and the top peels
off
 A skin defect where there has been loss of the
epidermis only e.g-toxic epidermal necrolysis
 A skin defect where there has been loss of the
epidermis only
 They weep and become crusted
 This is an example of a secondary change or
characteristic
 Area of skin denuded by complete or partial loss of
epidermis.
105
 No associated loss of dermis
Erosion
Toxic epidermal
necrolysis
Ulcer
 If an erosion involves the dermis, it is
called an…ulcer.
 An area of skin from which the whole of
epidermis & atleast the upper part of
dermis has been lost
 A skin defect where there has been loss of
the epidermis and dermis
 e.g- Pyoderma gangrenosum traumatic
ulcers, burns, and stasis ulcers
 (L. ulcus, “sore”)
 Ulcers often heal with scarring; erosions usually
do not
 Erosions and ulcers are secondary lesions
 Secondary lesions (or changes) may evolve from
primary lesions, or may be caused by external
forces such as scratching, trauma, infection, or
the healing process.
Gangrene---extensive destruction of the skin -- may leave

many dead cells that become blackened
Ulcer
Pyoderma
gangrenosum
EXCORIATION
 Linear, angular erosions that may be
covered by crust and are caused by
scratching.
 Superficial excavation of the epidermis
that results from scratching
 E.g- Linear excoriations in a patient with
atopic dermatitis
EXCORIATION
FISSURE
o A slit- shaped deep ulcer
o In anatomy,a fissure (Latin fissura, plural fissurae
) is a groove, natural division, deep furrow,
elongated cleft, or tear in various parts of the
body.
Eg: Irritant dermatitis of hands/foot.
 A skin fissure is a cutaneous condition in
which there is a linear-like cleavage
of skin, sometimes defined as extending
into the dermis.
 It is smaller than a skin laceration. A skin
area on which there are many skin
fissures is called cracked skin, and is
most commonly a result of skin dryness.
 Ichthyosis is a genetic disorder where
there is often severe skin cracking.
FISSURE
ATROPHY
 A accquired loss of substance .
 In skin,this may appear as a depression with intact
epidermis ( loss of dermal /subdermal tissues ) Or appear as
sites of shiny, delicate, wrinkled lesions (epidermal atrophy
)
 Epidermal atrophy results from a decrease in the number of
epidermal cell layers.
 Dermal atrophy results from a decrease in the dermal
connective tissue.
e.g-Steroid Induced Atrophy:Many years of inappropriate

application of topical steroids have led to local changes and
atrophy. drsudeeshshetty@gmail.com 115
ATROPHY
LICHENIFICATION
 A distinctive thickening of skin that is
characterized by accenuated skin-fold
markings.
 Lichenification – skin thickening that is the
result of chronic rubbing leading to
accentuation of normal skin lines.
LICHENIFICATION
Atopic
dermatitis with
lichenification
Scar
 A change in the skin secondary to trauma or
inflammation
 Sites may be erythematous,hypopigmented or
hyperpigmented depending upon their age
/character.
 Scar- a lesion formed as a result of dermal
damage.
Scar
HYPERTROPHIC SCAR
KELOID
Keloid is a benign overgrowth of the connective
tissue of the skin consequent to an abnormal
healing process of the skin in predisposed
individuals.
Keloid can cause serious aesthetic and
occasionally functional disabilities.
Keloid occur in all races but it is most common
and severe in the black race.
• A keloid (also keloidal scar) is the formation that a
type of scar which, depending on its maturity, is
composed mainly of either type III (early) or type I
(late) collagen.
• It is a result of an overgrowth of granulation tissue
(collagen type 3) at the site of a healed skin injury
which is then slowly replaced by collagen type 1.
• Keloids are firm, rubbery lesions or shiny,
fibrous nodules, and can vary from pink to flesh-
coloured or red to dark brown in colour.
• A keloid scar is benign and not contagious, but
sometimes accompanied by severe itchiness,
pain,[2] and changes in texture.
• In severe cases, it can affect movement of skin.
• Keloids should not be confused with hypertrophic
scars, which are raised scars that do not grow
beyond the boundaries of the original wound. 122
KELOID
Sinus
A cavity or channel that permits the escape of
pus or fluid
e.g-Pilonidal sinus, preauricular sinus, sinus

caused by dental absces….
Sinus
Striae
A streak like, linear , atrophic, pink, purple or

white lesion d/t changes in connective tissue
Eg: cushings syndrome, pregnancy induced
 Stretch marks or striae (singular stria), as they are called
in dermatology, are a form of scarring on the skin with an off-
color hue.
 They are caused by tearing of the dermis, which over time
may diminish, but will not disappear completely.
 Stretch marks are often the result of the rapid stretching of
the skin associated with rapid growth or rapid weight
changes.
 Stretch marks may also be influenced by hormonal changes
associated with puberty, pregnancy, bodybuilding, hormone
replacement therapy, etc.[1]
 Medical terminology for these kinds of markings includes
striae atrophicae, vergetures, stria distensae, striae cutis
distensae, lineae atrophicae, linea albicante, or simply striae.
 Stretch marks formed during pregnancy, usually during the
last trimester, and usually on the belly, but also commonly
occurring on the breasts, thighs, hips, lower back and
buttocks, are known as striae gravidarum.
Striae
Sclerosis
*(Greek. Sklerosis - a hardening) Sclerosis is an
induration or hardening of the skin. It is often due to
fibrosis.
*Sclerosis or sclerotizis (also spelled sclerosus in the

names of a few disorders) is a hardening of tissue and
other anatomical features
*In medicine, sclerosis refers to the stiffening of a

structure, usually caused by a replacement of the
normal organ-specific tissue with connective tissue.
Amyotrophic lateral sclerosis, sometimes known as motor neuron disease or Lou
Gehrig's disease, a progressive, incurable, usually fatal disease of motor neurons.
Atherosclerosis, a deposit of fatty materials, such as cholesterol, in the arteries
which causes hardening.
Focal Segmental Glomerulosclerosis is a disease that attacks the kidney's filtering
system (glomeruli) causing serious scarring and thus a cause of nephrotic
syndrome in children and adolescents,[1] as well as an important cause of kidney
failure in adults.[2]
Hippocampal sclerosis, a brain damage often seen in individuals with temporal
lobe epilepsy.
Lichen sclerosus, a disease that hardens the connective tissues of the vagina of
women and the penis of men. An autoimmune disorder.
Liver sclerosis is a common misspelling of cirrhosis of the liver.
Multiple sclerosis, or Focal Sclerosis,[3] is a central nervous system disease which
affects coordination.
Osteosclerosis, a condition where the bone density is significantly increased.
Otosclerosis, a disease of the ears.
Systemic sclerosis (progressive systemic scleroderma), a rare, chronic disease
which affects the skin, and in some cases also blood vessels and internal organs.
Tuberous sclerosis, a rare genetic disease which affects multiple systems.
Primary sclerosing cholangitis, a hardening of the bile duct by scarring and
repeated inflammation.
Primary lateral sclerosis, progressive muscle weakness in the voluntary muscles.
Sclerosis
Primary and Secondary Lesions
Raised Flat Depresse Fluid- Vascular

d filled
Papule Macule Erosion Vesicle Telangiecta
sia
Plaque Patch Ulcer Bulla Petechiae
Nodule Atrophy Pustule Ecchymosi
s
Tumor Sinus Furuncle
Wheal Stria Abscess
Burrow
Scar drsudeeshshetty@gmail.com 132
EXAMINATION NAILS
EXAMINATION NAILS
Spooning - kiolonychia
EXAMINATION NAILS
Example Documentation
 No abnormalities - General Statement
about overall skin assessment:
– Skin is warm, smooth and well hydrated.
Full hair distribution on scalp, axilla, and
genitalia. Nails are neatly trimmed and
without deformity. No discrete lesions
noted.

Skin Assessment

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Skin Assessment

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Examination of the Skin

Dr. Sudeesh Shetty

Epidermis is divided into the following 5 sublayers or strata:

• When did it start?

• the scalp, hair, and nails

• the mucous membranes of the mouth, eyes, anus, and

 Ruler  Adequate lighting

2 Papule 8 Postule 14 Hemotoma

3 Plaque 9 Wheal 15 Poikiloderma

4 Nodule 10 Telangictasia 16 Erythema

5 Papilloma 11 Petechiae 17 Burrow

6 Vesicle 12 Purpura 18 Comedo

Non-palpable lesion with distinct borders,

e.g-bullous pemphigoid, contact

examples: acne,furuncles,and bromide and iodide

*Differs from papule only in size

*Rubbery, Mobile, Non-tender

A raised, erythematous, edematous, papule

Eg: urticaria and insect bites

e.g-Cushing's syndrome Venous hypertension

e.g--Poikiloderma vasculare , atrophicans Poikiloderma of

e.g-desquamating layers of stratum corneum in

Dried serum, blood or

Gangrene---extensive destruction of the skin -- may leave

e.g-Steroid Induced Atrophy:Many years of inappropriate

e.g-Pilonidal sinus, preauricular sinus, sinus

A streak like, linear , atrophic, pink, purple or

Eg: cushings syndrome, pregnancy induced

*Sclerosis or sclerotizis (also spelled sclerosus in the

*In medicine, sclerosis refers to the stiffening of a

Raised Flat Depresse Fluid- Vascular

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