1. Past history of skin disease.

Any past skin disease or problem?

 • How was this treated?

 • Any family history of allergies or allergic skin problem?

any known allergies to drugs, plants animals

any birthmarks, tattoos

Significant familial predisposition: allergies, hay fever, psoriasis, atopic dermatitis (eczema), acne.

Identify offending allergen.

Use of nonsterile equipment to apply tattoos increases risk for hepatitis C.

2. Change in pigmentation.

Any change in skin color or pigmentation?

a generalized color change (all over) or localized

Hypopigmentation (loss of color); hyperpigmentation (increase in color).

Generalized change suggests systemic illness: pallor, jaundice, cyanosis.

3. Change in mole.

Any change in a mole:

color, size, shape, sudden appearance of tenderness, bleeding, itching?

 • Any “sores” that do not heal?

Signs suggest neoplasm in pigmented nevus.

May be unaware of change in nevus on back or buttocks that he or she cannot see.

4. Excessive dryness or moisture.

moisture,

• Any excess dryness? Is this seasonal or constant?

Seborrhea—oily.

Xerosis—dry.

5. Pruritus.

Any skin itching?

Is this mild (prickling, tingling) or intense (intolerable)?

 • Does it awaken you from sleep?

Where is the itching? when did it start?

any other skin pain or soreness? Where?

Pruritus is the most common skin symptom; occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice.

Presence or absence of pruritus helps diagnosis. Scratching causes excoriation of primary lesion.

6. Excessive bruising.

bruising?

Where on the body?

 • How did this happen?

 • How long have you had it?

Multiple cuts and bruises, bruises in various stages of healing,

 bruises above knees and elbows, and illogical explanation—

consider physical abuse.

Frequent falls may be due to dizziness of neurologic or cardiovascular origin.

Also, frequent minor trauma may be a side effect of alcoholism or other drug abuse.

7. Rash or lesion.

rash

lesion?

 •

 Onset. When did you first notice it?

• Location. Where did it start?

• Where did it spread?

• Character or quality. Describe the color.

 • 

Is it raised or flat? Any crust, odor? Does it feel tender, warm?

• Duration. How long have you had it?

Rashes are a common cause of seeking health care.

A careful history is important;

it may predict the type of lesion you will see in the examination and its cause.

Identify the primary site—it may give clue to cause.

Migration pattern, evolution.

• Setting. Anyone at home or work with a similar rash?

Have you been camping, acquired a new pet, tried a new food, drug?

Does the rash seem to come with stress?

Identify new or relevant exposure,

any household or social contacts with similar symptom

 • Alleviating and aggravating factors.

What home care have you tried?

Bath, lotions, heat? Do they help, or make it worse?

 • Associated symptoms. Any itching, fever?

Myriad over-the-counter remedies are available.

People try them and seek professional help only when they do not work.

 • What do you think rash/lesion means?

• What do you think rash/lesion means?

 • Coping strategies. How has rash/lesion affected your self-care, hygiene, ability to function at work/home/socially?

• Any new or increased stress in your life?

Assess person's perception of cause: fear of cancer, tick-

borne illnesses, or sexually transmitted infections.

Assess effectiveness of coping strategies. Chronic skin diseases may increase risk for loss of self-esteem, social isolation, and anxiety.

Stress can exacerbate chronic skin illness.

8. Medications.

medications

 • Prescription and over-the-counter?

 • Recent change?

• How long on medication?

Drugs may cause allergic skin eruption: aspirin, antibiotics, barbiturates, some tonics.

Drugs may increase sunlight sensitivity and give burn response:

sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Drugs can cause hyperpigmentation:

 antimalarials, antineoplastic agents, hormones, metals, tetracycline.

Even after a long time on medication, a person may develop sensitivity.

9. Hair loss.

hair loss?

 • A gradual or sudden onset? Symmetric? Associated with fever, illness, increased stress?

• Any unusual hair growth?

 • Any recent change in texture, appearance?

Alopecia

Hirsutism

11. Environmental or occupational hazards.

environmental

occupational hazards?

• With your occupation, such as dyes, toxic chemicals, radiation?

• How about hobbies? Do you perform any household or furniture repair work?

• How much sun exposure do you get from outdoor work, leisure activities, sunbathing, tanning salons?

• Recently been bitten by insect: bee, tick, mosquito?

• Any recent exposure to plants, animals in yard work, camping?

People at risk: outdoor sports enthusiasts, farmers, sailors, outdoor workers; also creosote workers, roofers, coal workers.

Unprotected sun exposure accelerates aging and produces lesions.

At more risk: light-skinned people, those older than 40 years, and those regularly in sun.

Identify contactants that produce lesions or contact dermatitis.

Tell people with chronic recurrent urticaria (hives) to keep diary of meals and environment to identify precipitating factors.

12. Self-care behaviors.

 • Clip cuticles on nails, use adhesive for false fingernails?

• If you have allergies, how do you control your environment to minimize exposure?

• Do you perform a skin self-examination?

aging adult

1. What changes have you noticed in your skin in the past few years?

Assess impact of aging on self-concept.

Normal aging changes may cause distress.

Many “aging” changes are due to chronic sun damage.

Most skin cancers appear in aging people, although sun damage begins decades earlier.

aging adult

2.

 Any delay in wound healing?

 • Any skin itching?

Pruritus is common with aging.

Consider side effects of medicine or systemic disease (e.g., liver or kidney disease, cancer, lymphoma),

but senile pruritus is usually due to dry skin (xerosis).

Exacerbated by too-frequent bathing or use of soap.

Scratching with dirty, jagged fingernails produces excoriations.

aging adult

3.

 Any other skin pain?

Some diseases, such as herpes zoster (shingles), produce more intense sensations of pain, itching in aging people.

 Other diseases (e.g., diabetes) may reduce pain sensation in extremities.

Also, some aging people tolerate chronic pain as “part of growing old” and hesitate to “complain.”

aging adult

4.

aging adult

5.

aging adult

6.

7.

A bland lotion is important to retain moisture in aging skin.

Dermatitis may ensue from certain cosmetics, creams, ointments, and dyes applied to achieve a youthful appearance.

Aging skin has a delayed inflammatory response when exposed to irritants.

If the person is not alerted by warning signs (e.g., pruritus, redness), exposure may continue and dermatitis may ensue.

General Pigmentation.

Observe the skin tone. Normally it is even and consistent with genetic background.

It varies from pinkish tan to ruddy dark tan or from light to dark brown and may have yellow or olive overtones.

Dark-skinned people normally have areas of lighter pigmentation on the palms, nail beds, and lips (Fig. 12-3, A).

An acquired condition is vitiligo, the complete absence of melanin pigment

in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices (Fig. 12-3, B).

Vitiligo can occur in all races,

although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image.

_ Freckles (ephelides)—small, flat macules of brown melanin pigment that occur on sun-exposed skin (Fig. 12-4, A).

_ Mole (nevus)—a proliferation of melanocytes, tan to brown color, flat or raised.

Acquired nevi are characterized by their symmetry, small size (6 mm or less), smooth borders, and single uniform pigmentation.

The junctional nevus (Fig. 12-4, B) is macular only and occurs in children and adolescents.

It progresses to the compound nevi in young adults (Fig. 12-4, C) that are macular and papular.

The intradermal nevus (mainly in older age) has nevus cells in only the dermis.

Danger signs: abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE:

Asymmetry (not regularly round or oval, two halves of lesion do not look the same)

Border irregularity (notching, scalloping, ragged edges, poorly defined margins)

Color variation (areas of brown, tan, black, blue, red, white, or combination)

Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early melanomas may be diagnosed at a smaller size

²⁵

Elevation or Enlargement

Additional symptoms:

rapidly changing lesion, a new pigmented lesion, and development of itching, burning, or bleeding in a mole.

Any of these signs should raise suspicion of malignant melanoma and warrant referral.

Widespread Color Change.

Note any color change over the entire body skin, such as pallor (white), erythema (red), cyanosis (blue), and jaundice (yellow).

Note whether the color change is transient and expected or whether it is due to pathology.

In dark-skinned people, the amount of normal pigment may mask color changes.

Lips and nail beds show some color change, but they vary with the person's skin color and may not always be accurate signs.

The more reliable sites are those with the least pigmentation, such as under the tongue, the buccal mucosa, the palpebral conjunctiva, and the sclera.

See Table 12-2 for specific clues to assessment.

Pallor.

Look for pallor in dark-skinned people by the absence of the underlying red tones that normally give brown or black skin its luster.

 The brown-skinned individual has a more yellowish brown color, and the black-skinned person will appear ashen or gray.

Generalized pallor can be observed in the mucous membranes, lips, and nail beds.

The palpebral conjunctiva and nail beds are preferred sites for assessing the pallor of anemia.

When inspecting the conjunctiva, lower the lid sufficiently to visualize the conjunctiva near the outer canthus as well as the inner canthus.

The coloration is often lighter near the inner canthus.

Ashen gray color in dark skin or marked pallor in light skin occurs with anemia, shock, arterial insufficiency (see Table 12-2, Detecting Color Changes in Light and in Dark Skin, p. 229).

The pallor of impending shock presents with rapid pulse rate, oliguria, apprehension, and restlessness.

Chronic iron deficiency anemia may show “spoon” nails, with a concave shape.

Fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function accompany most severe anemias.

Erythema.

expected

The erythema with fever or localized inflammation has an increased skin temperature from the increased rate of blood flow.

Because you cannot see

inflammation in dark-skinned persons,

it is necessary to palpate the skin for increased warmth, taut or tightly pulled surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.

Erythema

occurs with polycythemia, venous stasis, carbon monoxide poisoning,

and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma) (see Table 12-2 and Table 12-8, Vascular Lesions).

Cyanosis.

Cyanosis is difficult to observe in darkly pigmented persons (see Table 12-2).

 Given that most conditions causing cyanosis also cause decreased oxygenation of the brain,

other clinical signs—such as changes in level of consciousness and signs of respiratory distress—will be evident.

Cyanosis indicates hypoxemia and occurs with

shock,

heart failure,

chronic bronchitis,

and congenital heart disease.

Jaundice.

222), jaundice does not occur normally.

Jaundice is first noted in the junction of the hard and soft palate in the mouth and in the sclera.

But do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

The scleral yellow of jaundice extends up to the edge of the iris.

As levels of serum bilirubin rise, jaundice is evident in the skin over the rest of the body.

This is best assessed in direct natural daylight.

Common calluses on palms and soles often look yellow—do not interpret these as jaundice.

Jaundice occurs with

hepatitis,

cirrhosis,

sickle-cell disease,

transfusion reaction,

and hemolytic disease of the newborn.

Light or clay-colored stools and dark golden urine often accompany jaundice in both light- and dark-skinned people.

Temperature

Note the temperature of your own hands.

Then use the backs (dorsa) of your hands to palpate the person and check bilaterally.

The skin should be warm, and the temperature should be equal bilaterally;

warmth suggests normal circulatory status. Hands and feet may be slightly cooler in a cool environment.

Hypothermia.

General hypothermia accompanies central circulatory problem such as shock.

Localized hypothermia occurs in peripheral arterial insufficiency and Raynaud's disease.

Hyperthermia.

Generalized hyperthermia occurs with an increased metabolic rate,

such as in fever or after heavy exercise.

A localized area feels hyperthermic with trauma, infection, or sunburn.

Moisture

Perspiration appears normally on the face, hands, axilla, and skinfolds in response to activity, a warm environment, or anxiety.

Diaphoresis, or profuse perspiration, accompanies an increased metabolic rate, such as occurs in heavy activity or fever.

Look for dehydration in the oral mucous membranes.

Normally there is none, and the mucous membranes look smooth and moist.

Be aware that dark skin may normally look dry and flaky, but this does not necessarily indicate systemic dehydration.

Diaphoresis occurs with thyrotoxicosis

and with stimulation of the nervous system with anxiety or pain.

With dehydration, mucous membranes are dry, and lips look parched and cracked.

With extreme dryness, the skin is fissured, resembling cracks in a dry lake bed.

Texture

Normal skin feels smooth and firm, with an even surface.

Hyperthyroidism—skin feels smoother and softer, like velvet.

Hypothyroidism—skin feels rough, dry, and flaky.

Thickness

The epidermis is uniformly thin over most of the body,

although thickened callus areas are normal on palms and soles.

A callus is a circumscribed overgrowth of epidermis

and is an adaptation to excessive pressure from the friction of work and weight bearing.

Edema

Edema is fluid accumulating in the intercellular spaces; it is not present normally.

To check for edema, imprint your thumbs firmly against the ankle malleolus or the tibia.

Normally the skin surface stays smooth.

If your pressure leaves a dent in the skin, “pitting” edema is present. Its presence is graded on a four-point scale:

1+ Mild pitting, slight indentation, no perceptible swelling of the leg

2+ Moderate pitting, indentation subsides rapidly

3+ Deep pitting, indentation remains for a short time, leg looks swollen

4+ Very deep pitting, indentation lasts a long time, leg is very swollen

This scale is somewhat subjective; outcomes vary among examiners (see further content on grading scale in Chapter 20).

Edema masks normal skin color and obscures pathologic conditions

such as jaundice or cyanosis because the fluid lies between the surface and the pigmented and vascular layers.

It makes dark skin look lighter.

Edema is most evident in dependent parts of the body (feet, ankles, and sacral areas),

where the skin looks puffy and tight.

Edema makes the hair follicles more prominent, so you note a pigskin or orange-peel look (called peau d'orange).

Unilateral edema—consider a local or peripheral cause.

Bilateral edema or edema that is generalized over the whole body (anasarca)

—consider a central problem such as heart failure or kidney failure.

Mobility and Turgor

Pinch up a large fold of skin on the anterior chest under the clavicle (Fig. 12-5).

Mobility is the skin's ease of rising, and turgor is its ability to return to place promptly when released.

This reflects the elasticity of the skin.

Mobility is decreased with edema.

Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or “tents” and stands by itself.

Scleroderma, literally “hard skin,”

is a chronic connective tissue disorder associated with decreased mobility (see Table 13-5, p. 277).

Vascularity or Bruising

Cherry (senile) angiomas

Any bruising (contusion) should be consistent with the expected trauma of life.

There are normally no venous dilations or varicosities.

Document the presence of any tattoos (a permanent skin design from indelible pigment) on the person's chart.

Advise the person that the use of tattoo needles and tattoo parlor equipment of doubtful sterility increases the risk for hepatitis C.

Multiple bruises at different stages of healing and excessive bruises above knees or elbows raise concern about physical abuse

(see Table 12-7,

Lesions Caused by Trauma or Abuse).

Needle marks or tracks from intravenous injection of street drugs may be visible on the antecubital fossae, forearms, or on any available vein.

Lesions

If any lesions are present, note the:

1 Color.

2 Elevation: flat, raised, or pedunculated.

3 Pattern or shape: the grouping or distinctness of each lesion (e.g., annular, grouped, confluent, linear). The pattern may be characteristic of a certain disease.

4 Size, in centimeters: Use a ruler to measure. Avoid household descriptions such as “quarter size” or “pea size.”

5 Location and distribution on body: Is it generalized or localized to area of a specific irritant; around jewelry, watchband, around eyes?

6 Any exudate. Note its color and any odor

Lesions are traumatic or pathologic changes in previously normal structures.

When a lesion develops on previously unaltered skin, it is primary.

However, when a lesion changes over time or changes because of a factor such as scratching or infection, it is secondary.

Study Table 12-3 for the shapes and Tables 12-4 and 12-5 for the characteristics of primary and secondary skin lesions.

The terms used (e.g., macule, papule) are helpful to describe any lesion you encounter.

Lesions cont.

Palpate lesions. Wear a glove if you anticipate contact with blood, mucosa, any body fluid, or skin lesion.

Roll a nodule between the thumb and index finger to assess depth.

Gently scrape a scale to see if it comes off.

Note the nature of its base or whether it bleeds when the scale comes off.

Note the surrounding skin temperature.

However, the erythema associated with rashes is not always accompanied by noticeable increases in skin temperature.

Lesions cont.

Does the lesion blanch with pressure or stretch?

Stretching the area of skin between your thumb and index finger decreases (blanches) the normal

underlying red tones, thus providing more contrast and brightening the macules.

Red macules from dilated blood vessels will blanch momentarily, whereas those from extravasated blood (petechiae) do not.

Blanching also helps identify a macular rash in dark-skinned people.

Use a magnifier and light for closer inspection of the lesion (Fig. 12-7).

Use a Wood's light (i.e., an ultraviolet light filtered through a special glass) to detect fluorescing lesions. With the room darkened, shine the Wood's light on the area.

Color

Hair color comes from melanin production and may vary from pale blonde to total black.

Graying begins as early as the third decade of life because of reduced melanin production in the follicles.

Genetic factors affect the onset of graying.

Texture

Scalp hair may be fine or thick and may look straight, curly, or kinky.

It should look shiny, although this characteristic may be lost with the use of some beauty products such as dyes, rinses, or permanents.

Note dull, coarse, or brittle scalp hair.

Gray, scaly, well-defined areas with broken hairs accompany tinea capitis, a ringworm infection found mostly in school-age children (see Table 12-12).

Distribution

Fine vellus hair coats the body, whereas coarser terminal hairs grow at the eyebrows, eyelashes, and scalp.

During puberty, distribution conforms to normal male and female patterns.

At first, coarse curly hairs develop in the pubic area, then in the axillae, and last in the facial area in boys.

In the genital area, the female pattern is an inverted triangle; the male pattern is an upright triangle with pubic hair extending up to the umbilicus.

In Asians, body hair may be diminished.

Absent or sparse genital hair suggests endocrine abnormalities.

Hirsutism—excess body hair.

In females, this forms a male pattern on the face and chest and indicates endocrine abnormalities (see Table 12-12).

Lesions

Separate the hair into sections and lift it, observing the scalp.

With a history of itching, inspect the hair behind the ears and in the occipital area as well.

All areas should be clean and free of any lesions or pest inhabitants.

 Many people normally have seborrhea (dandruff), which is indicated by loose white flakes

Head or pubic lice.

Distinguish dandruff from nits (eggs) of lice, which are oval, adherent to hair shaft, and cause intense itching (see Table 12-12).

INSPECT AND PALPATE THE NAILS

Shape and Contour

The nail surface is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded.

Nail edges are smooth, rounded, and clean, suggesting adequate self-care.

Jagged nails, bitten to the quick, or traumatized nail folds suggest nervous picking habits.

Chronically dirty nails suggest poor self-care or some occupations in which it is impossible to keep them clean.

The Profile Sign.

Clubbing of nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases.

In early clubbing, the angle straightens out to 180 degrees and the nail base feels spongy to palpation.

Then the nail becomes convex as the digit grows (see Late Clubbing, p. 249).

Consistency

The surface is smooth and regular, not brittle or splitting.

Nail thickness is uniform.

The nail firmly adheres to the nail bed, and the nail base is firm to palpation.

Pits, transverse grooves, or lines may indicate a nutrient deficiency or may accompany acute illness that disturbs nail growth (see Table 12-13, Abnormal Conditions of the Nails).

Nails are thickened and ridged with arterial insufficiency.

A spongy nail base accompanies clubbing.

Color

The translucent nail plate is a window to the even, pink nail bed underneath.

Dark-skinned people may have brown-black pigmented areas or linear bands or streaks along the nail edge (Fig. 12-9).

All people normally may have white hairline linear markings from trauma or picking at the cuticle (Fig. 12-10).

Note any abnormal marking in the nail beds.

Cyanosis or marked pallor.

Brown linear streaks (especially sudden appearance) are abnormal in light-skinned people and may indicate melanoma.

Splinter hemorrhages, transverse ridges, or Beau's lines (see Table 12-13).

Capillary Refill.

Inspect the toenails.

Separate the toes and note the smooth skin in between.

Cyanotic nail beds or sluggish color return:

consider cardiovascular or respiratory dysfunction.

PROMOTING HEALTH AND SELF-CARE

Teach Skin Self-Examination

Teach all adults to examine their skin once a month, using the ABCDE rule (see pp. 212-213) to raise warning signals of any suspicious lesions.

Use a well-lighted room that has a full-length mirror.

It helps to have a small handheld mirror.

 Ask a family member to search skin areas difficult to see (e.g., behind ears, back of neck, back).

Follow the sequence outlined in Fig. 12-11, and report any suspicious lesions promptly to a physician or nurse.

aging adult

Skin Color and Pigmentation. Common variations of hyperpigmentation are:

Senile Lentigines

. Commonly called liver spots, these are small, flat, brown macules (Fig. 12-20).

These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure.

They appear on the forearms and dorsa of the hands.

They are not malignant and require no treatment.

aging adult

Keratoses

seborrheic keratosis,

Fig. 12-21

aging adult

Another type, actinic (senile or solar) keratosis, is less common (Fig. 12-22).

These lesions are red-tan scaly plaques that increase over the years to become raised and roughened.

They may have a silvery-white scale adherent to the plaque.

They occur on sun-exposed surfaces and are directly related to sun exposure.

They are premalignant and may develop into squamous cell carcinoma.

aging adult

Moisture.

Texture.

acrochordons,

Fig. 12-23

Sebaceous hyperplasia

Fig. 12-24

aging adult

Thickness.

Mobility and Turgor.

Fig. 12-25

Hair.

W

aging adult 

Nails.

Solely a color change, flat and circumscribed, of less than 1 cm.

Examples:

freckles,

flat nevi,

hypopigmentation,

petechiae,

measles,

scarlet fever.

Macules that are larger than 1 cm.

Examples:

mongolian spot,

vitiligo,

café au lait spot,

chloasma,

measles rash.

Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis.

 Examples:

elevated nevus (mole),

lichen planus,

molluscum,

wart (verruca).

Papules coalesce to form surface elevation wider than 1 cm.

A plateau-like, disk-shaped lesion.

Examples:

psoriasis,

lichen planus.

Solid, elevated, hard or soft, larger than 1 cm.

May extend deeper into dermis than papule.

Examples:

xanthoma,

fibroma,

 intradermal nevi.

Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although “tumor” implies “cancer” to most people.

Examples:

lipoma,

hemangioma.

Superficial, raised, transient, and erythematous;

slightly irregular shape due to edema (fluid held diffusely in the tissues).

Examples:

mosquito bite,

allergic reaction,

dermographism.

Elevated cavity containing free fluid, up to 1 cm;

a “blister.”

Clear serum flows if wall is ruptured.

Examples:

herpes simplex,

early varicella (chickenpox),

 herpes zoster (shingles),

contact dermatitis.

Larger than 1 cm diameter; usually single chambered (unilocular);

superficial in epidermis; it is thin walled, so it ruptures easily.

Examples:

friction blister,

pemphigus,

burns,

contact dermatitis.

Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin.

Examples:

sebaceous cyst,

wen.

Turbid fluid (pus) in the cavity.

Circumscribed and elevated.

Examples:

impetigo,

acne.

debris on skin surface

crust

The thickened, dried-out exudate left when vesicles/pustules burst or dry up.

Color can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus).

Examples:

impetigo (dry, honey-colored),

weeping eczematous dermatitis,

 scab after abrasion.

debris on skin surface

scale

Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells.

Examples:

after scarlet fever

or drug reaction (laminated sheets),

psoriasis (silver, mica-like),

seborrheic dermatitis (yellow, greasy),

eczema,

ichthyosis (large, adherent, laminated),

dry skin.

break in continuity of surface

fissure

Linear crack with abrupt edges, extends into dermis, dry or moist.

Examples:

cheilosis—at corners of mouth due to excess moisture;

athlete's foot.

break in continuity of surface

erosion

Scooped out but shallow depression.

Superficial; epidermis lost;

moist but no bleeding;

heals without scar because erosion

does not extend into dermis.

breaks in continuity of surface

ulcer

Deeper depression extending into dermis,

irregular shape;

 may bleed;

leaves scar when heals.

Examples:

stasis ulcer,

pressure sore,

chancre.

breaks in continuity of surface

excoriation

Self-inflicted abrasion;

superficial;

sometimes crusted;

scratches from intense itching. Examples:

insect bites,

scabies,

dermatitis,

varicella.

breaks in continuity of surface

scar

After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen).

This is a permanent fibrotic change.

Examples:

healed area of surgery or injury,

acne.

breaks in continuity of surface

atrophic scar

The resulting skin level is depressed with loss of tissue;

a thinning of the epidermis.

Example:

striae.

breaks in continuity of surface

lichenification

Prolonged, intense scratching eventually thickens the skin

and produces tightly packed sets of papules;

looks like surface of moss (or lichen).

breaks in continuity of surface

keloid

A hypertrophic scar.

The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury.

May increase long after healing occurs.

Looks smooth, rubbery, and “clawlike” and has a higher incidence among Blacks

pressure ulceer

stage I

Intact skin appears red but unbroken.

Localized redness in lightly pigmented skin will blanch (turns light with fingertip pressure).

Dark skin appears darker but does not blanch.

pressure ulcer

stage II

Partial-thickness skin erosion with loss of epidermis or also the dermis.

Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed.

pressure ulcer

Stage III

Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater.

May see subcutaneous fat but not muscle, bone, or tendon.

pressure ulcer

Stage IV

Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue.

Exposes muscle, tendon or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).

Local inflammatory reaction to an irritant in the environment or an allergy.

Characteristic location of lesions often gives clue.

Often erythema shows first, followed by swelling, wheals (or urticaria), or maculopapular vesicles, scales.

Frequently accompanied by intense pruritus. Example here: poison ivy.

Scales—hyperpigmented in whites, depigmented in dark skinned persons

—on chest, abdomen, back of arms forming multiple circular lesions with clear centers.

“Athlete's foot,” a fungal infection,

first appears as small vesicles between toes, sides of feet, and soles and then grows scaly and hard.

Found in chronically warm, moist feet:

children after gymnasium activities, athletes, aging adults who cannot dry their feet well.

Scaly, erythematous patch, with silvery scales on top.

Usually on scalp, outside of elbows and knees, low back, and anogenital area.

Usually starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel).

Then develops rounded, pearly borders with central red ulcer, or looks like large open pore with central yellowing.

Most common form of skin cancer; slow but inexorable growth.

Basal cell cancers occur on sun-exposed areas of face, ears, scalp, shoulders.

Squamous cell cancers arise from actinic keratoses or de novo.

Erythematous scaly patch with sharp margins, 1 cm or more.

Develops central ulcer and surrounding erythema.

Usually on hands or head, areas exposed to UV radiation; above, on habitually sun-exposed bald scalp.

Less common than basal cell carcinoma but grows rapidly.

Half of these lesions arise from preexisting nevi.

Usually brown; can be tan, black, pink-red, purple, or mixed pigmentation.

Often irregular or notched borders.

May have scaling, flaking, oozing texture.

Common locations are on the trunk and back in men and women, on the legs in women, and on the palms, soles of feet, and nails in Blacks.

Inner edge of nail elevates; nail bed angle is greater than 180 degrees.

Distal phalanx looks rounder and wider.

Recent research links clubbing with the physiology of platelet production.²¹

Diseases that disrupt normal pulmonary circulation

(chronic lung inflammation,

bronchial tumors,

heart defects with right-to-left shunts)

 cause fragmented platelets to become trapped in the fingertip vasculature,

releasing platelet-derived growth factor and promoting growth of vessels, which shows as clubbing.

Clubbing usually develops slowly over years;

if the primary disease is treated, clubbing can reverse.