Skin Examination

Pharmacy Practice 742:Physical Assessment

The Skin: History Three important aspects to seek out:

symptoms attributed to the skin lesion chronology of appearance, change, and

disappearance of the lesions conditions of exposure, injury, or

medication that may have induced or altered the disease

The Skin: History Original lesion

exact site duration appearance distribution progression

Symptoms local

pruritis pain burning

Setting & Timing of Attacks occupation topical agents drug history season of year environment

Skin: Physical Examination Three categories of observation

should be made in sequence: First, anatomic distribution of the

lesion Second, configuration of groups of

lesions Third, the morphology of the

individual lesions

Skin: Physical Examination Inspection

natural lighting preferred, need complete exposure of all skin surfaces.

remember to scan nails, hair, mucous membranes

Location and Distribution exact, measure, symmetry?

Skin: Physical Examination Inspection

Color: variation common, even within same person. Melanin

maybe diffuse or localized increased: Addison’s Disease,

hyperthyroidism, pregnancy, sunlight exposure

decrease: albinism and vitiligo Erythema

appearance of increased amounts of oxygenated blood in dermal vasculature

Skin: Physical Examination Inspection

Color: Cyanosis

blue tint from venous blood (deoxygenated hemoglobin) seen associated with congestive heart failure, pneumonia

Extravasation of blood products ecchymosis, petechiae

Pallor decrease hemoglobin in vessels close to skin

secondary to anemia, shock

Skin: Physical Examination Inspection

Color: Depositions of abnormal pigments

Jaundice from bilirubin Carotenemia from carotene (diabetes, excess

ingestion of yellow vegetables (carrots) Gray from heavy metals (Au-gold, Ag-silver,Bi-

bismuth) Blue-gray from amiodarone

Configuration arrangement or position of lesions with each other

(grouped, linear, annular)

Skin: Physical Examination Inspection

Morphological structure primary lesions

flat elevated -- serous filled -- pus filled -- solid

Skin: Physical Examination Inspection

Morphological structure secondary lesions

loss of skin -- erosion -- ulcer -- fissure build-up of skin -- scale -- crust -- lichenification -- scar

Skin: Physical Examination

Morphology - Definitions Macules

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 examples;

rubeola, rubella, secondary syphilis, rose spots of typhoid fever, drug eruptions, petechiae, purpura, first degree burns, systemic lupus erythematosus, pityriasis rosea and vitiligo

Skin: Physical Examination

Morphology - Definitions Maculopapules

slightly elevated macules commonly seen in pityriasis rosea, erythema

multiforme, fixed drug eruptions and exanthemas Papules

lesions are solid and elevated and defined as less than 5 mm in diameter.

Borders and tops may be in various forms pointed or acuminated -- insect bites, acne and

physiologic gooseflesh flat topped -- psoriasis, atopic eczema

Skin: Physical Examination

Morphology - Definitions Papules

Borders and tops may be in various forms round or irregular --senile angiomas,

eczematous dermatitis, secondary syphilis pedunculate -- neurofibromas

Plaques any elevated area of greater than 5mm,

usually formed from confluent papules. Red scaling plaques -- psoriasis, pityriasis rosea

Skin: Physical Examination

Morphology - Definitions Plaques

Yellow -- xanthomas brown -- seborrheic warts

Nodules solid and elevated, distinguished from

papules by extending deeper into the dermis or even the subcutaneous tissue.

Usually greater than 5 mm in diameter

Skin: Physical Examination

Morphology - Definitions Nodules

depth may be inferred by palpation…when below the dermis skin slides over them, lesions within the dermis move with the skin

Wheals caused by edema of skin, areas are

circumscribed, irregular, and relatively transient

color varies from red to pale, depending on amount of fluid in the skin.

Skin: Physical Examination

Morphology - Definitions Wheals

examples: urticaria and insect bites

Vesicles accumulation of fluid between the upper

layer of the skin produces an elevation covered by a translucent epithelium that is easily punctured to release the fluid

less than 5 mm examples: acute eczematous dermatitis, second-

degree burns

Skin: Physical Examination

Morphology - Definitions Bullae

Accumulation of fluid between layer of the skin, larger than 5 mm in diameter.

Examples: contact dermatitis, second-degree burns, bullous impetigo

Pustules Vesicles or bullae that become filled with

pus and tiny abscesses in the skin contents appear milky, orange, yellow, or

green depending somewhat on the infecting organism

Skin: Physical Examination

Morphology - Definitions Pustules

frequently arise from hair follicles or sweat glands

examples: acne, furuncles, and bromide and iodide eruptions

Cysts elevated lesions containing fluid or viscous

material appear as papules or nodules distinction is made by puncturing to

examine their contents and depth examples: sebaceous and epidermal cysts

Skin: Physical Examination

Secondary or Consecutive Erosions

moist surface uncovered by the rupture of vesicles or bullae or by laceration from rubbing

Fissures cleavage of the epidermis extending into

the dermis examples: common in trauma to thickened, dry,

inelastic skin

Skin: Physical Examination

Secondary or Consecutive Ulcers

depressed lesions results from loss of epidermis and the papillary layer of the dermis

examples: traumatic ulcers, burns, and stasis ulcers

Gangrene extensive destruction of the skin -- may

leave many dead cells that become blackened

Skin: Physical Examination Palpation

Temperature localized hyperthermia from increased

blood flow due to cellulitis or injury generalized hyperthermia due to fever of

systemic infection, hyperthyroidism localized hypothermia caused by

peripheral arteriosclerosis, Raynaud’s disease

generalized hypothermia due to shock

Skin: Physical Examination Palpation

Moisture sweat - nervous (hypothermia) or thermal

(hyperthermia) in origin Texture

quality character

rough dry (hypothyroidism) smooth (hyperthermia)

Skin: Physical Examination Palpation

Elasticity decreases with age Decreased skin turgor - dehydration edema - accumulation of fluid in interstitial

spaces under the skin. Congestive heart failure

Cancer Malignant Melanoma ABCD’s

Asymmetry Border irregularity Color variation Diameter greater than 6 mm

Inquire and observe for ominous changes in color, shape, elevations, texture, surrounding skin, sensation, and consistency.

Malignant Melanoma

Bullous Impetigo

Carbuncle

Drug Eruption