Chapter 6: Skin, Hair, and Nails

Question 1

Physical Exam Components: Skin

Answer 1

Perform overall inspection of entire skin surface.

During evaluation of each organ system, evaluate the overlying skin for color, uniformity, thickness, symmetry, hygiene, lesions, odors.

Palpate skin surfaces for the following:
Moisture
Temperature
Texture
Turgor
Elasticity

Question 2

Physical Exam Components: Hair

Answer 2

Inspect hair for the following:
Color
Distribution
Density

Palpate hair for texture and fragility.

Question 3

Physical Exam Components: Nails

Answer 3

Inspect for pigmentation of nail plates and nail beds; length; symmetry; surface changes (ridging, beading, pitting, peeling).

Inspect and palpate proximal and lateral nail folds for redness, swelling, pain, exudate, growths (warts, cysts, tumors), shape of lunulae.

Palpate nail plate for texture, firmness, thickness, uniformity, adherence to nail bed.

Measure nail base angle.

Observe the cuticles for color, vasculature, integrity.

Question 4

Anatomy & Physiology: Skin Functions

Answer 4

The skin performs integral functions:
Protects against microbial/foreign substance invasion and minor physical trauma
Restricts body fluid loss; provides a restrictive barrier
Regulates body temperature
Provides sensory perception via free nerve endings and specialized receptors
Produces vitamin D from precursors in the skin
Contributes to blood pressure regulation through constriction of skin blood vessels
Repairs surface wounds by exaggerating the normal process of cell replacement
Excretes sweat, urea, and lactic acid
Expresses emotions

Question 5

Anatomy & Physiology: Skin Layers

Answer 5

Epidermis: outer most layer
Includes stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale

Dermis: connective tissue layer
Elastin, collagen, reticulin fibers, sensory nerve fibers, autonomic motor nerve

Hypodermis: subcutaneous layer
Heat, insulation, shock absorption, reserve of calories

Appendages
Eccrine and apocrine sweat glands, sebaceous glands, hair, nails

Question 6

Anatomy & Physiology: Infants and Children

Answer 6

Vernix caseosa, a mixture of sebum and cornified epidermis, covers the newborn’s body at birth.

Subcutaneous fat is poorly developed in newborns, predisposing them to hypothermia.

Lanugo is the fine silky hair that covers the newborn’s body, particularly on the shoulders and back.

Desquamation of stratum corneum may be present at birth or very shortly afterward.

Eccrine glands function after 1 month.

Apocrine glands do not function.

Question 7

Anatomy & Physiology: Adolescents

Answer 7

Apocrine glands enlarge and become active. Increased axillary sweating and body odor

Increased sebum production in response to increased hormone levels, primarily androgen. Oily appearance predisposing the individual to acne

Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents, and on the face of males.

Question 8

Anatomy & Physiology: Pregnant Patients

Answer 8

Increased blood flow to skin, especially that of the hands and feet, results from peripheral vasodilation and increased numbers of capillaries.

Acceleration of sweat and sebaceous gland activity occurs.

Spider angiomas and cherry hemangiomas that are present may increase in size.

Skin thickens; fat is deposited in subdermal layers.

Skin stretching, increased pigmentation, nevi changes

Question 9

Anatomy & Physiology: Older Adults

Answer 9

Sebaceous and sweat gland activity decreases: results in dry skin and less perspiration.
Epidermis thins and fragility increases.
Loss of collagen and decreasing elasticity causes wrinkles.
Subcutaneous tissue decreases.
Gray hair from decreased melanocytes occurs.
Scalp and body hair decrease; baldness.
Facial hair develops in women.
Nail growth slows.

Question 10

History of Present Illness: Skin

Answer 10

Changes in skin
Temporal sequence
Symptoms
Location
Associated symptoms
Recent exposure
Apparent cause
Travel history
Treatment response
Adjustment to problem
Medications
Trauma
Bites

Question 11

History of Present Illness: Hair

Answer 11

Changes in hair
Occurrence
Associated symptoms
Exposure
Infestation
Nutrition
Treatment
Adjustment
Medication

Question 12

History of Present Illness: Nails

Answer 12

Changes in nails
Recent history
Associated symptoms
Temporal sequence
Exposure
Treatment response
Medications

Question 13

Past Medical History: Skin and Hair

Answer 13

Skin
Previous skin problems
Lesions, treatments
Tolerance to sunlight, number of sunburns
Diminished or heightened sensitivity to touch
Cardiac, respiratory, liver, endocrine, or other systemic disease
Pruritis

Hair
Previous hair problems
Systemic problems

Question 14

Past Medical History: Nails

Answer 14

Previous nail problems
Nail injury
Bacterial, fungal, or viral infection

Systemic problems
Associated skin disorder
Congenital anomalies
Respiratory, cardiac, endocrine, hematologic, or other systemic diseases

Question 15

Past Medical History: family

Answer 15

Current or past dermatologic diseases or disorders in family members
Allergic hereditary diseases: asthma, allergic rhinitis
Familial hair loss or pigmentation patterns

Question 16

Past Medical History: personal and social history

Answer 16

Skin, hair, nail care habits
Skin self-examination
Exposure to environmental/occupational hazards
Recent psychologic or physical stress
Use of alcohol, tobacco, or recreational drugs
Sexual history

Question 17

History for Infants

Answer 17

Temperature
Nutrition/feeding habits
Allergies
Birthmarks
Common rashes
Worrisome rashes
Bathing/hygiene practices
Sun exposure; sunscreen use
Appropriate attire
Temperature/humidity of home

Question 18

History for Children and Adolescents

Answer 18

Eating habits and types of food
Food allergies
Allergic disorders
Sun exposure
Exposure to infectious diseases; rashes
Pets or animal exposure
Outdoor exposures
Skin injury history
Chronic hair-pulling or manipulation
Nail-biting

Question 19

History for Pregnant Patients

Answer 19

Weeks of gestation or postpartum
Hygiene practices
Presence of skin problems before pregnancy
Effects of pregnancy on preexisting conditions
Rashes

Question 20

History for Older Adults

Answer 20

Increased or decreased sensation to touch or the environment
Changes in skin with aging
Generalized chronic itching, irritants
Susceptibility to skin infections
Healing response: delayed or interrupted
Frequent falls: cuts, bruises
History of chronic medical conditions
Medications and polypharmacy

Question 21

Physical Examination: Skin Inspection

Answer 21

Adequate lighting is essential.
Body sweep
Exposure
Draping
Color and uniform appearance
Skin lesions
Thickness
Symmetry
Hygiene

Question 22

Physical Examination: Skin Palpation

Answer 22

Moisture
Minimal perspiration or oiliness should be present.

Temperature
Use the dorsal surface of your hands or fingers

Texture
Smooth, soft, and even

Turgor
Altered if the patient is substantially dehydrated or if edema is present

Elasticity
Moves easily when pinched, and returns to place immediately when released

Question 23

Physical Examination: Skin Lesions

Answer 23

Characteristics:
Size (measure all dimensions)
Shape
Color
Blanching
Texture
Elevation or depression
Attachment at base
Exudates
Configuration
Location and distribution

Question 24

Physical Examination: Hair Inspection and Palpation

Answer 24

Inspection
Texture
Color
Distribution
Quantity

Palpation
Texture
Lesions

Question 25

Physical Examination: Nail Inspection and Palpation

Answer 25

Inspection
Color
Length
Configuration
Symmetry
Cleanliness

Palpation
Hardness
Smoothness
Thickness
Adhesion to nail bed

Question 26

Infants and children skin inspection/palpation

Answer 26

Expected color changes
Jaundice or hyperbilirubinemia
Birthmarks
Lesions/defects associated with systemic conditions
Contour distortions
Skin creases indicating congenital abnormalities
Pinch skin for test of turgor
Blanching

Question 27

Adolescents skin inspection

Answer 27

Examination is same as for adults.
Increased oiliness and perspiration
Acne
Maturational changes

Question 28

Physical Examination: Pregnant Patients

Answer 28

Skin inspection:
Striae gravidarum (stretch marks)
Telangiectasias/hemangiomas
Cutaneous tags
Increased pigmentation
Palmar erythema
Itching
Altered hair growth

Question 29

Physical Examination: Older Adults

Answer 29

Inspect for:
Skin changes
Breakdown over bony prominences
Lesions
Hair changes
Nail changes

Question 30

Skin: Inflammatory and Infectious Conditions

Answer 30

Eczematous dermatitis
Most common inflammatory skin disorder
Irritant contact dermatitis
Allergic contact dermatitis
Atopic dermatitis

Folliculitis
Inflammation and infection of the hair follicle and surrounding dermis

Furuncle (boil)
Deep-seated infection of the pilosebaceous unit

Cellulitis
Diffuse, acute, infection of the skin and subcutaneous tissue

Tinea (dermatophytosis)
Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair

Pityriasis rosea
Self-limiting inflammation of unknown cause

Psoriasis
Chronic and recurrent disease of keratinocyte proliferation

Rosacea
Chronic inflammatory skin disorder

Herpes zoster (shingles)
Varicella-zoster viral infection

Herpes simplex
Type 1: associated with oral infection
Type 2: associated with genital infection

Tick-borne diseases that can lead to multisystemic failure
Lyme disease
Rocky Mountain Spotted Fever
Colorado Tick Fever

Question 31

Skin: Cutaneous Reactions

Answer 31

Drug eruptions
Cutaneous reactions to medications

Acanthosis nigricans
Nonspecific reaction pattern associated with obesity, certain endocrine syndromes or malignancies, or as an inherited disorder

Question 32

Skin: Malignant/Neoplastic

Answer 32

Basal cell carcinoma
Most common form of skin cancer

Squamous cell carcinoma
Second most common skin cancer

Malignant melanoma
Lethal form of skin cancer that develops from melanocytes

Kaposi sarcoma
Neoplasm of the endothelium and epithelial layer of the skin
Commonly associated with human immunodeficiency virus (HIV) infection

Question 33

Hair Disorders

Answer 33

Alopecia areata
Sudden, rapid, coin-shaped loss of hair, usually from the scalp or face

Scarring alopecia
Replacement of hair follicles with scar tissue

Traction alopecia
Hair loss that is the result of prolonged, tightly pulled hairstyles

Hirsutism
Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas

Question 34

Nails: Infection

Answer 34

Paronychia
Inflammation of the paronychium

Onychomycosis
Fungal infection of the nail

Question 35

Nails: Injury

Answer 35

Ingrown nails
Nail pierces lateral nail fold; grows into the dermis

Nail avulsion

Subungual hematoma
Trauma to the nail plate severe enough to cause immediate bleeding and pain

Onycholysis
Loosening of the nail plate from the nail bed that begins at the distal groove

Question 36

Nails: Changes Associated With Systemic Disease

Answer 36

Koilonychia (spoon nails)
Central depression of the nail with lateral elevation of the nail plate

Beau lines
Transverse depression in the nail bed

White banding (Terry nails)
Whitening of the proximal half to three-quarters of the nail bed

Psoriasis
Chronic and recurrent disease of keratinocyte proliferation

Question 37

Nails: Periungual Growths

Answer 37

Warts
Epidermal neoplasms caused by viral infection

Digital mucous cysts
Cystlike structures that contain a clear jelly-like substance

Question 38

Abnormalities in Pregnant Patients

Answer 38

Polymorphic eruption of pregnancy
Benign dermatosis that usually arises in the third trimester of a first pregnancy

Question 39

Abnormalities in Infants and Children

Answer 39

Seborrheic dermatitis
Chronic, recurrent, erythematous scaling eruption localized in areas where sebaceous glands are concentrated

Miliaria rubra (prickly heat)
Caused by blocked sweat ducts and trapped sweat beneath the skin

Newborn acne

Common childhood rashes

Impetigo
Common, contagious superficial skin infection

Acne vulgaris
Impaction and obstruction of the outflow of sebum

Chickenpox (varicella)
Acute, highly communicable disease common in children and young adults

Measles (rubeola)
Measles virus infects by invasion of the respiratory epithelium

German measles (rubella)
Mild, febrile, highly communicable viral disease

Hair-pulling (trichotillomania)
Loss of scalp hair caused by physical manipulation

Patterns of injury in physical abuse
Bruises, burns, lacerations, hair loss, anogenital warts (under 2 years of age)

Question 40

Abnormalities in Older Adults

Answer 40

Stasis dermatitis
Occurs on the lower legs in some patients with venous insufficiency

Actinic keratosis
Atypical squamous cells confined to the upper layers of epidermis

Physical abuse in older adults
Physical abuse, neglect, sexual abuse, psychologic abuse, financial abuse, violation of rights

Question 41

Fluorescing lesions are best distinguished using a(n):
Incandescent lamp
Magnifying glass
Transilluminator
Wood’s lamp

Answer 41

ANS: D

Rationale: Fluorescing lesions (e.g., some tinea lesions) show a characteristic yellow-green color under a Wood’s lamp.

Question 42

Which objective findings would you expect to see in folliculitis?
Acute onset of tender red nodule
Acute onset of papules and pustules
Pale, erythematous, and macular
Telangiectasia, erythema, and papules

Answer 42

ANS: B

Rationale: In folliculitis, there is an acute onset of papules and postulates associated with deep folliculitis. Primary lesions are small pasta shells 1 to 2 cm in diameter.

Question 43

The adipose tissue in the hypodermis serves to:
Provide sensory input
Generate heat and insulate
Create tensile strength
Restrict water loss

Answer 43

ANS: B

Rationale: The hypodermis layer consists of adipose tissue that serves to generate heat and to provide insulation, shock absorption, and a reserve of calories.

Question 44

Koilonychia (spoon nails) are a central depression of the nail with lateral elevation of the nail plate. This is commonly seen with which systemic diseases?
A. Iron deficiency anemia, syphilis
B. Diabetes mellitus and hypothyroidism
C. Chronic congestive heart failure and cirrhosis
D. Psoriasis and hyperthyroidism

Answer 44

ANS: A

Rationale: Koilonychia is associated with iron deficiency anemia, syphilis, fungal dermatosis, and hypothyroidism.