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Assessing the Integumentary


System
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Composition of the integumentary


system
• Skin
• Hair
• Nails
• Is the largest organ of the body and the easiest of
all systems to assess
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Anatomy and Physiology Review


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Epidermis
■ Covers, protects, and waterproofs.
■ Contains four main layers:
• Stratum corneum: Keratinized layer. Prevents loss or
entry of water; protects against pathogens and
chemicals.
• Stratum lucidum: Found only on palms of hands and
soles of feet; protects against UV sunrays to prevent
sunburn.
1.Stratum granulosum
2.Stratum germinativum. The innermost layer of epidermis,
is the only layer that undergoes cell division & contains
melanin & keratin-forming cells.
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Epidermis
• The epidermis, hair, nail, dental enamel, & horny tissues
are composed of keratin.
• It is replaced every 3-4 weeks.
• Skin color depends on:
1. The amount of melanin & carotene" yellow pigment"
contained in the skin
2. The volume of blood containing hemoglobin
3. The oxygen-binding pigment that circulates in the
dermis.
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Dermis
■ Contains collagen, reticular, and elastic fibers.
■ Adds strength and elasticity to skin. Contains papillary
layer, reticular layer, sweat glands, sebaceous glands,
cholesterol, and arterioles.
Papillary Layer: Contains capillaries that supply the
stratum germinativum; also contains nerve endings,
touch receptors, and fingerprint pattern; double layer on
hands and feet.
Reticular Layer: Contains connective tissue with
collagen and elastic fibers, blood and lymphatic vessels,
nerves, free nerve endings, fat cells, sebaceous glands
and hair roots, deep pressure receptors, and smooth
muscle fibers.
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Dermis
Sweat Glands (Sudoriferous):Most numerous on
palms of hands and soles of feet. Two types are eccrine
and apocrine glands.
Eccrine Glands: Respond to external temperature and
psychological stress.
Found over most of body but most numerous on palms of
hands and soles of feet; secrete sweat, which helps
regulate body temperature and, to a lesser degree,
excretes wastes such as urea.
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Dermis
• Apocrine or Odoriferous Glands:
■ Found in axilla and genital area.
■ Respond to stress; secrete pheromones, a
substance with a barely perceptible odor; when
apocrine secretions react with bacteria, body
odor results.
■ Ceruminous glands are a type of apocrine gland
found in the external ear canal.
• They secrete cerumen, which prevents drying of
the ear drum and traps foreign substances.
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• Sebaceous Glands: Produce sebum, which


lubricates and protects skin and hair.
• Cholesterol: Converts to vitamin D when
exposed to UV lights.
• Arterioles: Dilate when hot to increase heat
loss and constrict when cold to conserve heat.
• Constrict in response to stressful situations to
shunt blood to vital organs.
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Hypodermis/Subcutaneous
• Connective Tissue: Connects skin to muscles;
contains white blood cells.
• Adipose Tissue: Contains stored energy,
cushions bony prominences, provides insulation.
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The Hair
The hair is also made up of keratinized cells.
1. Vellus, which is short, pale,and fine hair, is
located over all of the body.
2. Terminal hairs, which are dark and coarse,
are found on the scalp, brows, and, after puberty,
on the legs, axillae, and perineum.
• Hair provides protection by covering thescalp and
filtering dust and debris away from the nose, ears,
and eyes.
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The Nails
• Nails are made up of hard, keratinized cells
and grow from a nail root under the cuticle.
• The nail bed, or epithelial layer of skin: vascular
supply gives the nail a pink color
• The lunula, the proximal part of the nail. The
nailbed’s .

• The purpose of the nails is to protect the distal


portions of the digits and aid in picking up objects
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Relationship of the Integumentary


System to Other Systems
• ENDOCRINE
• Thyroid affects growth and texture of skin, hair
and nails.
• Hormones stimulate sebaceous glands.
• Sex hormones affect hair growth and
distribution, fat and subcutaneous tissue
distribution and activity of apocrine sweat
glands.
• Adrenal hormones affect dermal blood supply
and mobilize lipids from adipocytes.
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Relationship of the Integumentary


System to Other Systems
• URINARY
• Kidneys remove waste and maintain normal pH.
• Skin helps eliminate water and waste.
• Skin prevents excess fluid loss.
• DIGESTIVE
• Skin synthesizes vitamin D for calcium and
phosphorous absorption.
• Supplies nutrients while skin stores lipids.
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Relationship of the Integumentary


System to Other Systems
• CARDIOVASCULAR
• Mast cell stimulation produces localized changes in
blood flow and capillary permeability.
• CV system provides nutrients and removes wastes.
• Delivers hormones and lymphocytes.
• Provides heat for skin temperature.
• SKELETAL
• Skin synthesizes vitamin D needed for calcium and
phosphorus absorption.
• Skeletal system provides a framework for skin.
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Relationship of the Integumentary


System to Other Systems
• LYMPHATIC/IMMUNE
• Skin is first line of defense.
• Langerhan cells and macrophages resist infection.
• Mast cells trigger inflammatory responses.
• Lymphatic system protects skin by sending more
macrophages and lymphocytes when needed.
• RESPIRATORY
• Provides oxygen to and removes carbon dioxide from
integumentary system.
• Color of skin and nails can reflect changes in respiratory
system.
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Relationship of the Integumentary System Kony

to Other Systems
• MUSCULAR
• Skin synthesizes vitamin D needed for calcium
absorption for muscle contraction.
• Gives shape to and supports skin.
• Contraction of facial muscles allows communication
through expressions.
• NEUROLOGICAL
• Sensory receptors in dermis to touch, temperature,
pressure, vibration and pain.
• Provides communication with external environment.
• Controls blood flow and sweating through
thermoregulation.
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Symptom Analysis
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Change in Mole or Lesion

• Skin cancer is the most common type of cancer,


and changes in a mole (nevus) or skin lesion
can often evoke fear in the patient.
Types of skin cancer:
• Basal cell
• Squamous cell carcinomas, which affect the
epidermal keratinocytes
• Melanoma which affects the melanocytes of the
basal layer of the epidermis.
• Sun exposure is a risk factor in all types
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Nonhealing Sore or Chronic


Ulceration
• A nonhealing wound or chronic irritation is often
associated with an underlying disease.
• The most common types of nonhealing wounds or
chronic skin ulcerations are caused by vascular
disease or pressure or by diabetes.
Pruritus : is severe itching.
• May be localized or generalized
• Caused by a dermatologic problem or underlying
systemic problem.
• Pruritus is often accompanied by a rash. Itching,
when not associated with a rash, may be indicative
of significant systemic disease or simply dry skin.
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Causes of pruritis
• External stimuli, such as:
• heat
• dryness
• Inflammation
• Vasodilatation

• Psychological factors, such as depression, can


influence the perception of itching, which
explains the varied responses to it
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Rashes
• Like itching, may be localized or generalized,
acute or chronic,
• Caused by an obvious dermatologic problem or
an underlying systemic problem.
Seasonal Skin Disorders
• Seasonal skin problems include those caused by
temperature fluctuations, air humidity, and
exposure to contaminants.
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Seasonal Skin Disorders


• Spring: Chickenpox, Acne flare-ups
• Summer: Contact dermatitis, Tinea, Candida,
Impetigo, Insect bites
• Fall: Senile pruritus/winter itch, Pityriasis
rosea, Urticaria, Acne flare-ups
• Winter: Contact dermatitis of hands, Senile
pruritus/winter itch, Psoriasis, Eczema
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Hair Changes
• Hair loss (alopecia) is probably the most distressing
change in hair that can occur because of its cosmetic effect.
• Alopecia not only refers to scalp hair but also to body hair.
Scalp hair grows about 0.25mm/d, and about 70- 100
strands of hair are lost per day.
• Hair loss can occur for many reasons.
Alopecia classification:
• Alopecia scaring (resulting from injury such as burns,
radiation, or traction with irreversible damage to the hair
follicles)
• Nonscarring (resulting from hormonal changes, medications,
infectious diseases, or thyroid disease, in which the follicles
remain intact with a potential to reverse the process).
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Nail Changes
• Changes in the nails also often reflect an
underlying systemic problem
• Changes in color and texture are frequent
complaints.
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Assessing Lesions
• Primary lesion is one that appears in
response to some change in the internal or
external environment of the skin and is not
altered by trauma.
• Secondary lesions result from changes in
primary lesions. They either add to or take
away from an existing primary lesion.
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Pressure Ulcers

• Pressure ulcers are a type of secondary lesion


caused by unrelieved pressure.
• Assessment begins with identifying those at risk
for pressure ulcer development and developing a
plan to prevent pressure ulcer formation.
• If a pressure ulcer develops, assessment focuses
on staging pressure ulcers and developing and
evaluating pressure ulcer treatment plans.
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Clinical Description of Lesions


Size: Major determinant of correct category for primary
lesions.
• Pigmented lesions are typically 0.5 cm. If larger,
consider potential for malignancy.
• Depth of pressure ulcers is major determinant of
assigned grad
Shape
■ Macules, wheals, and vesicles are circumscribed.
■ Fissures are linear.
■ Irregular borders are associated with melanoma.
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Clinical Description of Lesions


Color
Variegated-colored lesions may signal melanoma.
■ Pustules are usually yellow-white.
■ New scars are red and raised; old scars, white or silver.
■ Petechiae are red.
■ Purpura are red to purplish.
■ Vitiligo is white
Texture
■ Macules are smooth.
■ Warts are rough.
■ Psoriasis is scaly.
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Clinical Description of Lesions


Surface Relationship
■ Flat (nonpalpable): Macules, patches, purpura,
ecchymoses, spider angioma, venous spider.
■ Raised (palpable) solid: Papules, plaques,
nodules, tumors, wheals, scale, crust.
■ Raised (palpable) cystic: Vesicles, pustules,
bullae, cysts.
■ Depressed: Atrophy, erosion, ulcer, fissures.
■ Pedunculated: Skin tags, cutaneous horn
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Exudate
■ Clear or pale, straw-yellow exudate: Serous
oozing/weeping from noninfected lesion.
■ Thicker, purulent discharge: Infected lesion.
■ Clear serous exudates: Vesicles, as seen with herpes
simplex; or bullae, larger than
vesicles, as seen with second-degree burns.
■ Yellow pus exudates: Pustules, as seen with
impetigo or acne.
• Tenderness or Pain associated with a lesion
depends on the underlying cause. May be associated
with bullae from a burn or ecchymoses (bruise).
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Clinical Description of Lesions


Petechiae or Purpura
■ Extravasations of blood into skin.
■ Caused by steroids, vasculitis, systemic diseases.
■ Does not blanch.
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Vascular Lesions
Ecchymosis
Petechiae or Purpura
■ Extravasation of blood into ■ Extravasations of blood into skin.
skin layer. ■ Caused by steroids, vasculitis, systemic
■ Caused by trauma/injury. diseases.
■ Does not blanch. ■ Does not blanch.
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Vascular Lesions
Venous Star Telangiectasia
■ Blue color. ■ Red color.
■ Irregular-shaped, linear, spider. ■ Very fine and irregular vessels.
■ Does not blanch. ■ Blanches.
■ Caused by increased pressure on ■ Seen with dilation of
superficial veins. capillaries.
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Vascular Lesions
Spider Angioma Capillary Hemangioma
■ Red color, type of ■ Red color.
telangiectasis. ■ Irregular-shaped macula patch.
■ Looks like a spider, with
central body and fine radiating
legs.
■ Blanches; seen in liver disease,
vitamin B deficiencies, idiopathic
origin.
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Primary Lesions
• Flat, Nonpalpable
• Macule:< 1 cm
• Patch: >1 cm

Vitiligo
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Primary Lesions
• Palpable, Raised, but • Kaposi’s sarcoma
Superficial • Psoriasis
• Papule: <1 cm
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Primary Lesions
Raised, Superficial, Palpable, Solid With
Temporary Depth Into Dermis
Examples: Examples:
■ Allergic reaction ■ Bartholin’s cyst
■ Hives (urticaria) ■ Erythema nodosum
■ Insect bite ■ Lipoma
Nodule:<2 cm
If fluid filled and encapsulated,
called a cyst
• Cyst
• ■ Tumor: >2 cm
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Primary Lesions
Vesicle (serous):<1 cm Bulla (serous):> 1 cm
• Palpable, Fluid Filled Examples:
Examples: ■ Blister
■ Blister ■ Burn
■ Contact dermatitis ■ Contact dermatitis
■ Herpes simplex
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Primary Lesions
• Pustule(pus filled)
Examples:
■ Acne vulgaris
■ Impetigo
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Secondary Lesions
Lichenification: Thickening
and Scaling With Increased
Skin Markings
Examples:
■ Contact dermatitis
■ Eczema
■ Lipoma
■ Psoriasis
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Secondary Lesions
• Scales: Shedding, Dead Skin
Cells; Scales Can Be Either Dry
or Oily, Adherent or Loose,
Variable in Color
Examples:
■ Psoriasis
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Secondary Lesions
• Crust: Dried Exudates
Examples:
■ Dried herpes simplex
■ Impetigo
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Secondary Lesions
• Scar: Replacement
Connective Tissue
Formations
Examples:
■ Surgical site
■ Trauma site
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Secondary Lesions
• Keloid: Hypertrophic
scarring because of
excess collagen
formation; raised and
irregular
Examples:
■ Surgical site
■ Tattoo
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Secondary Lesions: Secondary


lesions that take away
• Excoriation: Abrasion
or other loss that Does
not extend beyond the
superficial epidermis
Examples:
■ Atopic dermatitis
■ scratch marks
■ Insect bite
■ Scabies
■ Vascular rupture site
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Secondary lesions that take away


• Erosion: Loss of
superficial epidermis
Examples:
■ Abrasion
■ Candidiasis erosion
■ Fragile skin
■ Impetigo
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Secondary lesions that take away


Fissure: Linear breaks in the skin
with well-defined borders, may
extend to the Dermis
Examples:
■ Athlete’s foot
■ Cheilitis
■ Hand dermatitis (chapped
hands)
■ Syphilis
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Secondary lesions that take away


• Ulcer: Irregularly
shaped loss extending to
or through the dermis;
may be Necrotic
Examples:
■ Pressure ulcer
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Secondary lesions that take away


• Atrophy: Thinning of
skin with transparent
appearance and loss of
markings
Examples: ■ Aging
■ Arterial insufficiency
■ Topical corticosteroids
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Common Abnormalities
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Acne Vulgaris
■ Caused by sebaceous gland overactivity with plugging of
hair follicles and retention of sebum,
resulting in comedones, papules, and pustules. Onset is
typically at puberty, but acne may last into advanced age.
Greater incidence in males.
■ Aggravated by:
1. Emotional distress
2. Greasy topical applications (cosmetics)
3. Medications (oral contraceptives, lithium,
phenobarbital).
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ASSESSMENT FINDINGS
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■ Pimples present as papules or


pustules.
■ Cysts may develop and leave
extensive scarring.
■ Most common on face, back,
and shoulders.
■ Bacillus is cause.
■ Lesions may be sore and
painful.
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Basal Cell Carcinoma


■ An epidermoid cancer, one of the most common malignant
skin diseases, but rarely metastatic.
■ Typically has pearly, flesh-colored or transparent “rolled”
border.
■ Central area develops telangiectasia and may ulcerate.
■ Variations can present with nodular, sclerotic, and/or
pigmented appearance.
■ Usually occurs on sun-exposed surfaces, especially the face.
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Contact Dermatitis
■ Localized skin irritation, inflammation, and pruritus
from contact with an irritating substance.
1. Additive effect of multiple irritants (soaps, detergents,
or chemicals)
2. Allergy to a specific agent (topical to a specific agent,
topical medication, plant oils, or metals).
3. Secondary infections may occur at the site.
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ASSESSMENT FINDINGS
■ Edema may occur, with development of vesicles and
bullae.
■ Vesicles or bullae may rupture, causing crusting.
■ Edema may be very significant, particularly when face or
genitalia are involved.
■ Person may have history of previous reaction to agent
and recent exposure.
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Eczema/Atopic Dermatitis

Signs and symptoms:


Redness
Pruritus
Scratching
Skin lesions in a person with a predisposition to
skin irritations
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ASSESSMENT FINDINGS
■ Red to red-brown, slightly scaly lesions.
■ Skin markings common.
■ Exudative
■ As sites resolve, skin pigmentation is often permanently
altered.
■ Common sites include:
Face and Neck
Upper trunk
Wrists and Hands
Flexor surfaces (folds) of knees and elbows.
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ASSESSMENT FINDINGS
■ Person also often has asthma or allergic rhinitis;
family history is often positive for asthma, rhinitis,
eczema, or other allergy problems.
■ Itching can be quite severe.
■ Sites may develop secondary infection.
■ May be triggered by changes in temperature,
emotional stress, or food allergies.
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Herpes Simplex
■ A common, contagious disease caused by the
herpes simplex virus type 1.
More prevalent in women than in men.
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ASSESSMENT FINDINGS
■ Recurrent clusters of small vesicles on erythematous
base.
■ Sites burn and sting; neuralgia often occurs.
■ Typically found on perineal and genital areas.
■ May initially follow a minor infection.
■ Later recurrences may be triggered by trauma,
stress, or sun exposure.
■ Often associated with lymphadenopathy of regional
nodes.
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Herpes Zoster

■ Also called shingles; an acute, infectious disease


caused by the varicella zoster virus.
Postzoster neuralgia discomfort can last for
months.
Ocular involvement can lead to blindness.
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■ Pain along a nerve dermatome is often the first symptom.


■ Discomfort followed in 2 to 4 days by erythematous area
that develops papules or plaques followed by painful
grouped vesicles unilaterally along the dermatome.
■ Vesicles or bullae rupture with crusting.
■ Most common sites are face and trunk.
■ Most common in people over age 60 and those with
impaired immunity.
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Psoriasis
■ A common dermatitis that has genetic causes
and may begin at any age.
■ Silvery scales on bright red papules.
■ Scales generally thick; area beneath bleeds if scale is
removed.
■ Usually occurs on extensor surfaces of knees, elbows,
and scalp.
■ Can occur elsewhere, including between buttocks.
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Psoriasis
■ Nails may develop a stippled, “pitted” appearance
and separations.
■ Itching may be mild or severe.
■ A genetic predisposition is suggested by family
history.
■ May occur with arthritis.
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Tinea
Tinea Capitis
■ A fungal infection of the scalp.
■ Scaling, itching.
■ Dry, brittle hair.
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Tinea Corporis
■ Ringworm, a fungal skin disease occurring
anywhere on the body.
■ Ring-shaped erythematous lesions on body.
■ Central clearing.
■ Advancing border with small vesicles.
■ Pruritic.
■ Most often on exposed surfaces.
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Tinea Cruris
■ Jock itch, a fungal skin disease occurring in the
genital and anal areas in males.
■ reddened areas.
■ Central clearing.
■ Severe pruritus.
■ Intertriginous area in groin.
■ When it occurs on scalp, proper term is tinea
capitis.
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Tinea Pedis
■ Athlete’s foot, a fungal skin disease occurring in the foot.
Tinea manum occurs on the palms.
■ Exfoliating, fissuring, macerated area of erythema.
■ Sites itch, burn, and/or sting.
■ Tinea manum occurs in interdigital folds of fingers or on
palms.
■ Tinea pedis occurs in interdigital folds between toes or
on soles of feet.
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Vitiligo

■ Characterized by white patches of skin surrounded


by areas of normal pigmentation. Progresses slowly
and is more common in dark-skinned people.
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■ Irregular areas of depigmentation.


■ May have hyperpigmented border.
■ Flat, nonraised, with smooth surface.
■ Most common sites are face, hands, and feet.
■ Probably autoimmune cause; also associated with
various endocrine disorders.