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Chapter 6

The Skin, Hair, and Nails

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Anatomy and Physiology
• Major function of skin is to keep the body in
homeostasis
– Provides boundaries for body fluid
– Protects underlying tissues from microorganisms,
harmful substances, and radiation
– Modulates body temperature
– Synthesizes vitamin D
• Heaviest single organ in body
– 16% of body weight
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Anatomy and Physiology (cont.)

• Three layers
– Epidermis
– Dermis
– Subcutaneous tissue
• Hair, nails, and sebaceous and sweat glands
are appendages of skin
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Anatomy and Physiology (cont.)
• Hair
– Vellus hair – short, fine, less pigmentation
– Terminal hair – coarser (rough and thick), pigmented
(scalp/eyebrows)
• Nails - protect distal ends of fingers/toes
• Sebaceous glands – present all surfaces except palms/soles;
produce a fatty substance secreted onto skin surface through
hair follicles
• Sweat glands
– Eccrine glands – widely distributed, open directly onto
skin surface, help control body temperature
– Apocrine glands – found in axilla and groin, stimulated by
emotional stress
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The Health History
• Common or concerning symptoms
– Hair loss
– Rash
– Moles
• Ask the patient
– “Have you noticed any changes in your skin or your
hair?”
– “Have you noticed any moles that have changed size,
shape, color, or sensation?”
– “Have you noticed any new moles?” 5

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Health Promotion and Counseling

• Clinicians play an important role in educating


patients
– Early detection of suspicious moles
– Protective measures for skin care
– Hazards of excessive sun exposure
• Skin cancers are most common cancers in the U.S.
– Most prevalent on hands, neck, and head

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Skin Cancers
• Basal cell carcinoma
– Comprises 80% of skin cancers
– Shiny and translucent, they grow slowly and rarely
metastasize
• Squamous cell carcinoma
– Comprises 16% of skin cancers
– Crusted (covered), scaly, and ulcerated, they can
metastasize
• Melanoma
– Comprises 4% of skin cancers
– Rapidly increasing in frequency, they spread rapidly 7

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


HARRM Risk Factors for Melanoma

• History of previous melanoma

• Age over 50

• Regular dermatologist absent

• Mole changing

• Male gender

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Additional Risk Factors for Melanoma
• ≥50 common moles
• ≥1-4 atypical or unusual moles (especially if
dysplastic- dysplasia)
• Red or light hair
• 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 9
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
ABCDE: Screening Moles for
Possible Melanoma
• A for asymmetry
• B for irregular borders,
• 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 10

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Question

Which of the following is not considered a risk


factor for the development of melanoma?

a. Light hair and eyes

b. Female gender

c. Severe sunburns in childhood

d. 1-4 dysplastic moles

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Answer

b. Female gender

Males have an increased risk of melanoma (1:4)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Techniques of Examination
• Examination of the skin, hair, and nails begins with the
general survey of the patient
• Make sure the patient wears a gown
– Drape appropriately to facilitate close inspection of
hair, anterior and posterior surfaces of body, palms
and soles,
– Inspect entire skin surface in good light
– Preferably in natural light (or artificial light that
resembles natural)
o Artificial light often distorts colors
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Techniques of Examination (cont.)

• Inspect and palpate skin


• Note characteristics of:
– Color
– Moisture
– Temperature
– Texture
– Mobility and turgor
– Lesions
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Techniques of Examination (cont.)
• Color
– Patients often notice change in color before physician
– Look for increased pigmentation, loss of pigmentation
– Look for redness, pallor, cyanosis, and yellowing
o Red color of oxyhemoglobin best assessed at
fingertips, lips, and mucous membranes
 In dark-skinned people, palms and soles
o For central cyanosis, look in lips, oral mucosa,
and tongue
o Jaundice - sclera
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Techniques of Examination (cont.)
• Moisture
– Dryness, sweating, and oiliness
• Temperature
– Use back of fingertips
– Identify warmth or coolness of skin
• Texture
– Roughness or smoothness
• Mobility and turgor
– Lift fold of skin
– Note ease with which it lifts up (mobility) and
speed with which it returns to place (turgor)
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Techniques of Examination (cont.)

• Lesions
– Note characteristics
o Anatomic location and distribution
o Patterns and shapes
o Type of lesion (macules, papules, nevi,
vesicles)
o Color 17

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Techniques of Examination (cont.)

• Skin lesions in context

– Whenever you see a skin lesion, look it up


in a well-illustrated textbook of dermatology

– To arrive at a dermatologic diagnosis, consider


the type of lesions, location, and distribution,
along with the patient’s history and physical

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins


Techniques of Examination (cont.)
• Hair
– Inspect and palpate
– Note quantity, distribution, and texture
• Nails
– Inspect and palpate fingernails/toenails
– Note color and shape
– Note lesions
o Longitudinal bands of pigment may be a
normal finding in people with darker skin
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Evaluating the Bedbound Patient

• People confined to bed are particularly susceptible


to skin damage and ulceration
– Pressure sores result when sustained
compression obliterates arteriolar and capillary
blood flow to the skin
• Assess these patients by carefully inspecting the
skin that overlies the sacrum, buttocks, greater
trochanters, knees, and heels
• Roll patient onto one side to see sacrum and
buttocks
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Recording the Physical Examination

• Initially you may use sentences to describe findings;


later you will use phrases
• Examples:
– “Color good. Skin warm and moist. Nails without
clubbing or cyanosis. No suspicious nevi. No rash,
petechiae, or ecchymoses.”
– “Marked facial pallor, with circumoral cyanosis. Palms
cold and moist. Cyanosis in nailbeds of fingers and
toes. One raised blue-black nevus, 1x2 cm, with
irregular border on right forearm. No rash.” 21

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