skin, hair, and nails

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Skin, Hair, and Nails. By InnaKorda, MD, Institute of Nursing, TSMU. Anatomy. Epidermis Stratum germinativum (basal cell layer) Mitosis occurs here Contains melanocytes, producing melanin Stratum corneum - PowerPoint PPT Presentation


  • Skin, Hair, and NailsBy InnaKorda, MD, Institute of Nursing, TSMU

  • AnatomyEpidermisStratum germinativum (basal cell layer)Mitosis occurs hereContains melanocytes, producing melaninStratum corneumAs cells rise, they die and their cytoplasm is converted to keratin, which has a rough, horny textureThis layer undergoes constant sheddingDermisMostly connective tissue, primarily collagenProvides support and nourishment of epidermisBlood vessels, nerves, muscle, sweat glands, sebaceous glands, hair folliclesSubcutaneous Layer (Hypodermis)Consists mostly of fatProvides protection, insulation, and caloric source

  • AnatomyHairComposed of keratinCan be fine (vellus hair) or darker and thicker (terminal hair)Sebaceous glandsProduce sebum through hair follicles, which make skin oily. Prevent water loss.Sweat glandsEccrine smaller, coiled tubules which open to skin surfaceApocrine larger, open to hair follicles. Located mainly in axillae and genital area. Produce thick secretions, which react with bacteria on skin surface to produce body odorNailsComposed of keratinClear with highly vascular bed of epithelial cells underneathPulse oxymetry!Used to measures what?

  • Developmental ConsiderationsInfantsLanugo fine soft hair present at birthSkin is thinner, less fat more prone to dehydration and hypothermiaPregnancyLinea nigra line down midline of abdomenChloasma face of pregnancyStriae gravidarum stretch marksAging Stratum corneum thins, loss of collagen, elastin, and fat, decrease of sebaceous and sweat glands,More prone to dehydration and hypothermiaChloasma

  • HistoryHistory of skin diseaseWhat was it? How was it treated?Does it run in the family?Significant familial predispositions allergies, hay fever, psoriasis, eczema, acneAny know allergies?Any tattoos or birthmarks?Use of nonsterile equipment for tattoos increases risk of Hep CChange in pigmentationMight suggest systemic illness (jaundice)Change in a molePruritusAny dryness? Is it seasonal?Xerosis drySeborrhea - oily

  • HistoryExcessive bruisingConsider abuseFrequent minor trauma may be sign of alcohol abuseRash or lesionOnsetLocationSpreadCharacter or qualityDurationAssociative factors pets, co-worker?Alleviating and aggravating factors what have you tried to do?Patients perception - what do you think it is?MedicationsPrescription and over-the-counterMay indicate allergy to medication

  • HistoryHair loss or growthGradual or sudden?Hirsutism unusual growthChange in nailsExposure to hazardsMay be environmental or occupationalBitten by bee, tick, mosquito?Exposure to plants or animals?Self careWhat cosmetics, soaps, chemicals?Possible allergies

  • Physical Examination - ColorGeneral pigmentation should be even throughoutBenign pigmented areas Freckles (macules) on sun exposed skinNevi (moles)Junctional nevi macular onlyCompound nevi macular and papularDysplastic - precancerousBirthmarksVitiligo absence of melanin in patchy areasABCDE of malignant melanoma

    Asymmetry one lesion that is not regularly round or ovalBorder irregular Color variations Diameter greater than 6mmElevation


  • Changes in Color in Light Skinned PeoplePallorPale, white color caused by decrease of blood flow (vasoconstriction) or decrease in hemoglobinShock, anemiaErythemaRedness due to increased blood flow (vasodilation)Fever, inflammatory process, emotions, CO poisoningCyanosisBluish, purplish hue due to decreased perfusion of tissuesHypoxemia due to heart failure, shock, chronic bronchitisJaundiceYellow, orange hue due to jaundice (increased bilirubin in blood)Due to liver problems such as hepatitis, cirrhosis

  • Color Changes in Darker Skinned PeoplePallorBrown skinned people will be more yellow. Black skinned people will be more grayPalpebral conjunctiva and nail beds should be observedErythemaCannot be observedIf fever suspected, check skin for warmth. If edema, check skin for tightnessCyanosisDarker skinned people have normal bluish tone on lipsPalms, but not clearly evident, other clinical signs should be observedJaundiceHard and soft palate must be observed in addition to sclera of eyesDark urine also presentTable 12.2

  • Skin Assessment (cont.)TemperatureCheck skin with dorsa of handsHyperthyroidism may cause increase of tempMoistureDiaphoresis may occur during fever or exerciseDehydration can be observed by dry mucous membranes in mouth and cracked skinMobility and TurgorMobility is ease of skin rising when pinched. Turgor is returning back to its placeSlow turgor can be indicative of dehydration. Tenting if severe dehydration.LesionsA lesion is any traumatic or pathological change in skinDescribe using ABCDE, also noting location and exudateRoll nodule gently between fingers to assess depthUltraviolet light is used if fungal infection suspected (Woods light)*****

  • Skin Assessment - shapesAnnularCircular, beginning in center and spreading to periphery (ringworm)PolycyclicAnnular lesions that grow togetherConfluentLesions run together (hives)DiscreteIndividual lesions that remain separate

  • ShapesGroupedClusters of lesions (contact dermatitis)GyrateTwisted, coiledTargetConcentric rings of colorLinearScratch like, stripeZosteriformFollow nerve route (shingles)

  • Primary vs. SecondaryPrimary skin lesions Variations in color or texture that may be present at birth, such as moles or birthmarks, or that may be acquired during a person's lifetime, such as those associated with infectious diseases (e.g. warts, acne, or psoriasis), allergic reactions (e.g. hives or contact dermatitis), or environmental agents (e.g. sunburn, pressure, or temperature extremes). Secondary skin lesions Changes in the skin that result from primary skin lesions, either as a natural progression or as a result of a person manipulating (e.g. scratching or picking at) a primary lesion.

  • Primary Skin LesionsMaculecolor change and less than 1 cmmay be to darker or lighterFreckles, flat nevi, hypopigmentation, petechiaePatchColor change and greater than 1cm Mongolian spots, vitiligo, chloasma

  • Primary Skin LesionsPapuleElevated lesion less than 1cm in diameterDue to elevation in epidermisEx: wart, elevated nevusPlaqueElevation greater than 1cm in diameterEx: psoriasis

  • Primary Skin LesionsNoduleElevated solid greater than 1cmExtending deeper into dermisTumorGreater than few cm in diameterMay be firm or soft

  • Primary Skin LesionsWhealSuperficial, raised, transient, and erythematous lesionEx. Mosquito bite, allergic reaction

  • Primary Skin LesionsCystEncapsulated fluid filled cavity in dermis or subcutaneous layerVesicleElevated cavity containing free fluid, clearLess than 1cm diameterEx: herpes simplex, varicella zoster

  • Primary Skin LesionsBullaLarger than 1cm in diameterSuperficial in epidermis, thin walledEx: blisters, burnsPustulePus in cavityEx: impetigo, acne

  • Secondary Skin LesionsCrustThick, dry exudate after rupture or drying up of vesicle or pustuleEx: Impetigo, scab following abrasionScaleDry or greasy flakes of skin resulting from shedding of excess keratin cellsEx: psoriasis, eczema, seborrheic dermatitis

  • Secondary Skin LesionsFissureLinear cracks extending into dermisUlcerDeep depression extending into dermisMay bleed. Leave scar.ExcoriationSelf inflicted abrasion often from scratching

  • Secondary Skin LesionsLichenificationTightly packed papules from prolonged intense scratchingKeloidHypertrophic scarCannot be removed surgicallyMore common in black people

  • Skin Lesions associated with AIDS Kaposis SarcomaPatch stageEarly lesions are faint and pinkAdvanced stageWidely disseminated lesions involving skin, mucous membranes, and visceral organsViolet colored tumors on nose and faceEpidemic stageLesions develop into raised papules of thickened plaques. Oval in shape and vary in color from red to brown.

  • Hair and ScalpRingworm may develop in scalp of school age childrenAbnormalities in amounts and location of hair can be attributed to hormonal problemsHirsutism excess body hairObserve for head or pubic lice, which are white ovals on hair shafts.Dandruff is indicated by loose white flakes

  • Abnormal Conditions of HairTinea capitis (scalp ringworm)Lesions fluoresce blue-green under Woods lightHighly contagiousToxic alopeciaAsymmetric balding that accompanies severe illness or chemotherapyRegrowth after discontinuation of toxin

  • Abnormal Conditions of HairFolliculitisSuperficial infection of hair folliclesMultiple pustulesFuruncle and AbscessRed, swollen, hard, tender, pus-filled lesion due to acute localized bacteria (staph)Usually on back of neck, buttocks, wrists, or anklesFuruncle is due to infected hair folliclesAbscess is due to traumatic introduction of bacteria into the skin. Deeper than furuncle

  • NailsGood indicators of respiratory system healthNail baseNormal is about 160Clubbing is the decrease of the angle of nail base (
  • NailsConsistencyVariant thickness may suggest malnutritionThickening of nails is sign of arterial insufficiencyColorNote any pigmentations melanoma?Cyanotic nail beds poor peripheral circulationCapillary refillIndicator of peripheral circulationMeasured by depressing the nail bed until it is white and observing the time it takes for blood to return back to the nailNormal time is less than 1-2 seconds and is indicated as brisk. Sluggish if greater than 2 seconds.

  • Developmental Considerations - InfantsMongolian spotsHyperpigmentation of sacrum, buttocks, abdomen, thighs, shoulders, or armsVery common in blacks, Asians, and Native AmericansShould not be confused with abuseCaf au laitCoffee with milkPatches of hyperpigmentationNormal

  • Devel

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