Midterm- Skin/Hair/Nails Flashcards
epidermis
outer layer. thin. tough.
DEPENDS on the DERMIS for nourishment
stratified into zones
major ingredient= KERATIN
MELANOCYTES- gives our skin the color
the epidermis is made from dead keratinized cells
we shed ONE POUND of skin/year
the entire epidermis is replaced every 4 weeks
dermis
vascular, inner supportive layer
consists mostly of CONNECTIVE TISSUE AND COLLAGEN
dermis is tough, fibrous protein that allows the skin to RESIST TEARING
dermis is resilient!! elastic tissue that allows stretching with movement
the dermis is home to nerves, blood vessels, sensory receptors, and lymphatics
includes hair follicles, sebaceous glands, and sweat glands that are embedded into the dermis
subcutaneous layer
this is ADIPOSE tissue!
subq layer anchors the dermis to the muscle and bones
consists of lobules and fat cells. stores fat for energy!!
provides insulation (temperature control), cushioning
hair follicles
embedded in dermis layer
the growth is cyclic, and each follicle functions independently
hormones can influence growth of hair (pregnancy- shiny and soft, postpartum- hair loss, thinning…)
2 types of hair
VELLUS hair: short, fine, light, covers most of the body. think arms and abdomen…
TERMINAL hair: course, thicker, and pigmented. on head, eyebrows, pubic area, axillae (face and chest on males)
nails
GREAT indication of overall health!! (especially nutrition)
if nails are growing= getting enough protein!
hard plates of keratin, found on dorsal edge of fingers and toes
growth inhibited by illness or to the elderly
average growth=1 mm/week
takes 3 months to restore a fingernail (3x as long for toenails)
lateral nail fold- where ingrown nails occur
nail matrix and nail bed (where nail arises from)
sebaceous glands
lubricates the skin and hair
produces lipid substance sebum, secreted thru hair follicles
found everywhere BUT the palms and soles
most abundant in the scalp, forehead, face, and chin (why you have more acne in these places)
sweat glands
- ECCRINE
2. APOCRINE
eccrine sweat glands
coiled tubes that open directly onto the skin, produce a dilute saline solution: SWEAT
aid in temperature control (via evaporation)
children and the elderly can easily become overheated
apocrine sweat glands
produce thick, milky secretions, open directly into hair follicle
locations of apocrine sweat glands
axilla, anogenital, nipples, and the navel
become active with puberty
when bacterial flora reacts with apocrine sweat, you have BODY ODOR!
variations in skin color
pallor (fear, anxiety, anemia, shock)
erythema (high emotion, CO poisoning, polycythemia)
cyanosis (decreased perfusion, hypoxemia, congenital heart disease)
jaundice (hepatitis, cirrhosis, sickle cell disease)
dysplastic melanocyte
atypical mole
congenital giant nevus
lot of different sizes/darkness/shapes of moles
they are concerning because they can become dysplastic
normal physiologic jaundice in infants
1/2 of all newborns, appears on 2/3rd day
peaks at day 5
**disappears within one week of birth
pathologic jaundice in infants
appears within first 24 hours
related to hemolytic disease of the newborn
**JAUNDICE THAT PERSISTS BEYOND 2-3 WEEKS SHOULD BE OF CONCERN
miliara rubra in infants
scattered vesicles on an erythematous base- sweat gland obstruction, disappears within one week
erythema toxicum in infants
looks like flea bites!
unknown etiology
disappears within one week after birth
pustular melanosis in infants
seen in AA infants
can last several months
small vesiculopustular over a brown macular base
milia in infants
pinhead, smooth, white raised areas without surrounding erythema
on nose, chin, forehead
retention of sebum in sebaceous gland
abnormal texture of skin
rough- hypothyroid
velvet- hyperthyroid
cherry angiomas
small, smooth, slightly raised red dots
commonly appear on trunk of adults
this is not significant
think red mole
ecchymosis
should be CONSISTENT with trauma
bruising above the knee or below the elbow is SUSPICIOUS
bruising
bruising cycle
0-5 days: red, blue, purple, and tender
5-10 days: greenish yellow
> 10 days: brown
2-4 weeks: healed
salmon patch in infants
nervus simplex
40% of all newborns have this
flat, irregular, light pink patches
nape of neck: stork bite
almost all disappear by age 1
darkish purple lesions on face/extremities in infants
port wine stains
does not fade
laser removal to help reduce
elevation of lesions
pedunculated
rises off a stalk, think skin tags
pattern and shape of lesions
annular- ring shape
grouped- all together with no outliers
confluent- throughout
linear- line
discrete- couple of small areas
gyrate- serpentine
iris
polycyclic- round
zosteriform- follows a dermatome (herpes zoster)
fitzpatricks sign
positive when dimpling and retraction of the skin lesion beneath the skin with lateral compression
seen with DERMATOFIBROMAS
ex: when you squeeze a pimple, it sinks down
nodules derived from mesodermal and dermal cells
FIRM, RAISED PAPULES, PLAQUES, OR NODULES that very in size (3-10 mm in diameter)
color- brown, purple, red, yellow, pink…
multiple (>15) on a person may be associated with an autoimmune disorder
usually asymptomatic
NEEDS TO BE INVESTIGATED! TO MAKE SURE ITS NOT MELANOMA
abnormal hair distribution can be related to what things?
aging, PCOS, thyroid (hypo/hyper)
abnormal inspection of nails:
spoon nails- anemia
dirty- poor self care, job
bitten- anxiety
clubbing- O2 insufficiency
paronychia- red, swollen nail folds, VERY tender
paronychia
red, swollen nail folds, VERY tender
acute- bacterial infection (manicure with not sterile tools)
chronic- fungal infection (think someone who works as a dishwasher)
onycholysis
separation of nail plate from nail bed
yellow nails
white nail syndrome (leukonychia)
koilonychia
yellow nails
can indicate lung disorders
white nail syndrome (leukonychia)
arsenic poisoning
chronic renal failure
heart disease
koilonychia
iron deficiency
spooning
thin
indications of pits, grooves, lines in nails
nutritional deficiency
brown linear nail streaks in light skinned people
melanoma
splinter hemorrhages of nails
occur with endocarditis
working with hands
beau’s lines in nails
visible line on nail due to nail stop growing
can happen during serious illness
think ICU patient
body trying to preserve its work- stops producing nail
can be traced to high fever, infection, ICU stay
macule
primary lesion
flat, circumscribed, nonpalpable
small (up to 1 cm)
color change
examples of a macule
freckles, measles, nevus, solar lentigos
solar lentigos (sunspots)- sun induced, well circumscribed
patch
primary skin lesion
this is a macule that is >1cm
example: mongolian spot
vitiligo
a type of patch (primary skin lesion)
absence of melanocytes
autoimmune
M=F
cafe au lait
with vitiligo, you are at increased risk of…
thyroid disease
DM
pernicious anemia
papule
a type of primary skin lesion
solid, elevated, circumscribed
> 1cm!!
example: elevated nevus (mole)
elevated nevus (mole)
a type of papule (primary skin lesion)
molluscum
wart (verruca)
molluscum
a type of elevated nevus (mole) (which is a papule)
solid skin-colored papules with central umbilication
self-limited vital infection
wart (verruca)
a type of elevated nevus (mole) (which is a papule)
anal
plantar
plaque
a type of primary lesion
papules that are >1cm
plateau like, disc shaped
confined to superficial dermis
may result from confluence of papules
lichen planus
a type of plaque
acute/chronic inflammatory dermatosis
salmon colored base
small amount of scale
nodule
solid, elevated, hard/soft
> 1cm
extends deeper into the dermis than a papule
examples of a nodule
xanthoma, fibroma, carcinoma
tumor
solid, elevated, hard/soft
> 2cm!
examples of a tumor
lipoma (fatty tumor)
hemangioma
wheal
superficial, raised, transient
erythematous and irregular
examples of a wheal
insect bite
allergic reaction
urticaria
wheals coalesce to form extensive reaction- pruritic
vesicle
elevated cavity with free fluid
up to 1 cm
clear serum
examples of vesicles
herpes simplex
varicella
herpes zoster
bulla
elevated cavity with free fluid
> 1cm
thin walled
ruptures easily
examples of a bulla
friction blister
2nd degree burn
contact dermatitis
pustule
circumscribed, elevated
filled with pus
examples of a pustule
impetigo
folliculitis
acne
acne
a type of pustule
closed with comedomes= white head
open comedomes=black heads - oxygen turns it black
erosions
a type of secondary lesion
scooped out, shallow depression
superficial epidermis loss
moist, doesn’t bleed
heals without a scar
fissure
a type of secondary lesion
linear cracks, EXTENDS INTO THE DERMIS**
dry or moist
examples of fissures
cheilosis
athletes foot
eczema
excoriation
a type of secondary lesion
self-inflicted abrasion
superficial
from intense itching
causes of excoriation
insect bite
chicken pox
scabies
scabies
ITCHY!
highly contagious
web of hands and feet=classic
mites
ulcers
type of secondary lesion
deep depressions, extends into dermis and beyond
irregular shape
may bleed
leaves a scar
causes of scar of ulcers
stasis, pressure chancre
scar
a type of secondary lesion
connective tissue (collagen) that replaces healed damaged normal tissue
lichenification
a type of secondary lesion
prolonged, intense itching THICKENS the skin
increased visibility of skin furrows
leathery-like skin
keloid
a type of secondary lesion
hypertrophic scar
elevated, invasive
surface debris
scale
crust
atopic dermatitis
seborrhea dermatitis
seborrheic keratosis
scale
a type of surface debris
compact desiccated flakes on skin
dry or greasy
from shedding of dead excess keratin cells
examples of a scale
psoriasis
sebhorric dermatitis
dry skin
crust
a type of surface debris
thickened, dried out exudates LEFT WHEN PUSTULES BURST AND DRY UP, color depends on fluid ingredients
examples of crust
impetigo- dry honey colored
weeping eczema
scab after abrasion
atopic dermatitis
a type of surface debris
ECZEMA
erythematous papules/plaques
itching!!
weeping and crusting can occur
TRIAD OF A
stress and cold weather are triggers
triad of A
atopic dermatitis
asthma
allergies
seborrhea dermatitis
a type of surface debris
dandruff
erythematous papules and plaques, greasy appearance
yellow crust and scales
occurs in hair and non-hairy skin
seborrheic keratosis
a type of surface debris
MOST COMMON NONCANCEROUS SKIN GROWTH!!!
common in older adults
brown/black/pale growth
face, chest, shoulders, back
round/oval, warty, scaly appearance
single or multiple
“stuck on” look
vascular lesions
cherry angioma
spider angioma
petechiae
venous star/spider vein
erysipelas
dermoid cysts
secondary syphilis
rosacea
nikolsky’s sign
purpura
MRSA
cherry angioma
a type of vascular lesion
bright red- ruby
1-3 mm
round/flat, raised no pulse!!
may blanch
on trunk/extremities
what is the significance of a cherry angioma?
none
spider angioma
a type of vascular lesion
fiery red, small (<2cm)
central body with radiating legs
may BLANCH (HAS BLOOD FLOW)
face, neck, arms- r/t hepatic disease, pregnancy, vitamin B deficiency, can be benign too
the central body with radiating legs of a spider angioma may do what?
may pulse in the spider body
petechiae
a type of vascular lesion
deep red/reddish purple
1-2 mm, round, flat, no pulsation, no blanching
variable distribution
formed by blood escaping from the vessels
may indicate… BLEEDING TENDENCY
venous start/spider vein
a type of vascular lesion
bluish in color (venous)
size is variable
shape may vary (spider, linear, irregular)
NO pulsation- DOES NOT blanch
seen on lower extremities near veins and anterior chest
accompanied by an increase in pressure in superficial veins
erysipelas
a type of vascular lesion
infection caused by: BETA HEMOLYTIC STREP
can be caused by staph aureus
spreading infection of dermal and subq tissue differs from cellulitis because it is raised with a clear edge
dermoid cysts
a type of vascular lesion
cheese like substance within it
non-cancerous
very common in face/hands
slow growing
secondary syphilis
a type of vascular lesion
papulosquamous eruption on the trunk
bigger than cherry angiomas
rosacea
a type of vascular lesion
common (but poorly understood) disorder of facial skin
nikolsky’s sign
a type of vascular lesion
top layers of the skin SLIP away from the lower layers when slightly RUBBED
documented as + or -
area beneath is pink, moist, tender
causes of nikolsky’s sign
autoimmune condition (pemphigus vulgaris)
bacterial infection (scaled skin syndrome)
toxic drug reaction
autoimmune condition (pemphigus vulgaris) that causes nikolsky’s sign
immune system produced antibodies and fights bone between skin cells
leads to formation of blister
meds such as PCN and ACE inhibitors can cause
purpura
a type of vascular lesion
non-palpable
ecchymosis from trauma or hemorrhage
MRSA
a type of vascular lesion
people can be carriers!
COMMUNITY ACQUIRED
clusters of infections among athletes, military recruits, children
prevention
presentation
treatment
community acquired MRSA
considered this if you have not been hospitalized/had a procedure within the last year
MRSA clusters of infections among athletes, military recruits, children…
pacific islands, alaskan native, native american
homosexual men
prisoners
prevention of MRSA
good hand hygiene
keep cuts/scrapes clean, cover with a bandage until healed
avoid contact with others who have wounds or bandages
avoid sharing personal items
presentation of MRSA
furuncle (big, deep pimple)
deep-seated folliculitis
impetigo
abscesses
treatment of MRSA
- culture and sensitivity
- **I&D
- ABX if needed (such as multiple sites, area difficult to drain, comorbidities)
classification of skin lesions
flat, nonpalpable
raised, solid palpable
raised, cystic, palpable
depressed
flat, nonpalpable skin lesions
macules, patches, purpura, ecchymosis, spider angioma, venous spider
raised, solid palpable skin lesions
papules, plaques, nodules, tumors, wheals, scale, crust
raised, cystic, palpable skin lesions
vesicles, pustules, bullae, cysts (have stuff in them!!)
depressed skin lesions
atrophy, erosion, ulcer, fissue
tinea corporis
ringworm!!
body, feet, head, hands, groin, nails, everywhere!!
they eat keratin to survive, it has a central clearing because they have moved outward to find new keratin to eat
can get from animals
other types of tinea (besides corporis)
tinea curis- jock itch
tinea pedis- athlete’s foot
tinea scapula- scalp
tinea manus- hand
psoriasis
hereditary disorder
silvery white scales
sharply demarcated erythematous pupules and plaques of varying size/shape with white overlaying scales
IF YOU REMOVE A SCALE AND THERE IS A DOT OF BLOOD=AUSPITZ SIGN**
M=F
30% psoriasis patients will develop a related form of arthritis: PSORIATIC ARTHROPATHY
trigger and risk factors for psoriasis
weight gain, smoking, stress
meds such as: beta blockers, lithium
fifth’s disease
“slapped cheek”
mild rash, most common in children
lacey red rash on FACE, TRUNK, AND LIMBS
rash may itch
low grade fever or a cold a few days before the rash appears
rash resolves in 7-10 days
edema
palpate for accumulation of fluid in the intercellular spaces
firmly imprint thumb against a dependent portion of the body, release pressure
observe for indentation of skin
legs, feet, and ankles are good places to do this
pitting
non-pitting
angioedema
dependent edema
inflammatory
non-inflammatory
lymphedema
degrees of edema
0=no pitting
+1= 0-1/2, mild
+2= 1/4-1/2 (moderate)
+3= 1/2-1 (severe)
+4= >1 (severe)
measure circumference
check symmetry
pitting edema
indention remains on skin when pressure is applied
“my ankles swell in the evening and are better in the morning”
nocturia
non pitting edema
EDEMA THAT IS FIRM WITH DISCOLORATION/THICKENING OF SKIN
lymphedema
angioedema
recurring episodes of non-inflammatory swelling of the skin, brain, viscera, MM
onset may be RAPID
r/t reaction of medications
dependent edema
localized
dependent limb or area (turn the patient, leave a handprint in the buttocks)
inflammatory edema
swelling d/t extracellular fluid effusion surrounding an area of inflammation
ankle sprain is an example
non-inflammatory edema
swelling due to mechanical causes
lymphedema
obstruction of a lymphatic vessel
pressure ulcers
localized damage to the skin and underlying soft tissue
usually over a bony prominence or related to a medical/other device
injury can present as intact skin to open ulcer
may be painful
impacted by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue
causes- pressure, friction, shear, maceration
risks- advanced age, high acuity, immobility, incontinence, poor nutrition
stage 1 pressure ulcer
PRESSURE INJURY, NON-BLANCHABLE ERYTHEMA OF INTACT SKIN
color changes DO NOT include purple or maroon discoloration
presence of blanchable erythema/change sin sensation, temperature, or firmness may precede visual changes
purple or maroon discoloration on a pressure ulcer may indicate what?
deep tissue pressure injury
stage 2 pressure ulcer
PARTIAL THICKNESS LOSS OF SKIN WITH EXPOSED DERMIS
wound bed is viable (pink or red, moist)
may also present as an intact or ruptured serum-filled blister
adipose (fat) NOT visible
deeper tissues not visible
granulation tissue, slough, and eschar do not present
injuries commonly result from adverse microclimate and shear in skin over pelvis and shear in the heel
this stage should not be used to describe moisture associated skin damages (MASD)
stage 3 pressure ulcer
FULL-THICKNESS SKIN LOSS
ADIPOSE TISSUE VISIBLE
can have granulation tissue (red base)
ROLLED WOUND EDGES
slough (yellow proteins)
eschar (hard, black covering)- keep
deepness varies by location
UNDERMINING AND TUNNELING MAY OCCUR
fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed
IF SLOUGH OR ESCHAR OBSCURES THE EXTENT OF TISSUE LOSS, THIS IS AN UNSTAGEABLE PRESSURE INJURY
stage 4 pressure ulcer
FULL THICKNESS SKIN AND TISSUE LOSS
WITH EXPOSED, DIRECTLY PALPABLE FASCIA, MUSCLE, TENDON, LIGAMENT, CARTILAGE OR BONE IN THE ULCER
SLOUGH OR ESCHAR MAY BE VISIBLE
epibole (rolled edges), undermining and/or tunneling often occur
depth varies by anatomical location
IF SLOUGH OR ESCHAR OBSCURES THE EXTENT OF TISSUE LOSS, THIS IS AN UNSTAGEABLE PRESSURE INJURY
unstageable pressure injury
obscured full-thickness skin and tissue loss
if too much slough/eschar
stable eschar
what is stable eschar?
dry
adherent
intact without erythema or fluctuance
on the hell or ischemic limb
SHOULD NOT BE SOFTENED OR REMOVED
deep tissue pressure injury
persistent non-blanchable, deep red or maroon or purple discoloration
intact or non-intact skin
CAN RAPIDLY EVOLVE
pain and temperature change often precede skin color changes
caused by pressure
if any necrotic tissue, subcutaneous tissue, granulation tissue etic, can then stage
skin cancer
most common cancer
1/5 americans will develop by age 70
9500 diagnosed every day
incidence rises yearly
more than 2 people die every your from skin cancer (1 of the 2 from melanoma)
most cancers caused by the skin
having 5 or more sunburns doubles your risk for melanoma!!
causes of the rise in skin cancer incidence
ozone layer depletion, tanning beds
why is important to detect melanoma early
5 year survival rate for melanoma is 99%!
importance of geographic location to the equator for skin cancer
closer to equator (sun)
high altitudes with winter skiing
tanning bed/sunlamp use
in group 1 with cigarettes, plutonium, solar radiation
DANGER
radiation 10-15x more than the sun
more people develop skin cancer from tanning than develop lung cancer from cigarettes
any history of indoor tanning increases risk of skin cancer (even once)
tan color went from being a sign of lower class to total opposite
effect of ethnicity on skin cancer
much higher risk of death in african american
blacks, asian americans, and native hawaiians- can be harder to see changes, melanoma most often occurs in non-exposed skin with less pigment
in non-white, plantar part of the foot the most common place
genetics effect on skin cancer
fair-skin, blue/green eyes, red/blonde hair, easily burn or freckle and tan poorly
non melanoma
due to exposure to UV
genetic predisposition
immunosuppression
chemical exposure
TOBACCO/ETOH: SCC
genetic predisposition for nonmelanoma
fair skin, blue or green eyes, red/blonde hair, easily burn, freckle, tan poorly
personal history of skin cancer, family history of skin cancer
chemical exposure for nonmelanoma
arsenic
tar pitch
tar oil
carbon black
crude paraffin and asphalt
basal cell carcinoma
most common skin cancer
arises from abnormal and uncontrolled growth of basal cells
malignant, slow growing, but can be invasive and destructive
sore that comes and goes but eventually stays
sun exposure sites such as ear, neck, and head
> 40 yo, M>F
squamous cell carcinoma
second most common
MAINLY CAUSED BY CUMULATIVE UV EXPOSURE OVER THE COURSE OF A LIFETIME
daily year-round exposure to the sun’s UV lights
TANNING BEDS
INTENSE EXPOSURE DURING SUMMER MONTHS
older than 55
men more than women
occupation requiring long outdoor hours
sports
sun exposure sites
sports that lead to squamous cell carcinoma
golf and skiing
sun exposure sites that lead to squamous cell carcinoma
ERYTHEMATOUS SCALY PATCH WITH SHARP MARGINS 1 CM OR >
develops central ulcer
solar (actinic) keratosis precancerous for SCC
ANY PERSISTENT (>1 MO) NODULE, PLAQUE, OR ULCER IS SUSPICIOUS
solar (actinic) keratosis precancerous for SCC
yellow corn looking covering
flat scaly, raised, crusty, rough
actinic cheilitis- variant off lower lip
melanoma
EXPOSURE TO UV LIGHT/TANNING BEDS
HARMM
melanoma risk assessment tool
only 1% of skin cancers but 75% of deaths
caucasian men over 50 are at the highest risk
darker patients at less risk but doesn’t mean they can’t get
2nd most common cancer for young adults
risk factors
exposure to uv light/tanning beds that affects melanoma
intense intermittent
H/O 2 OR MORE BLISTERING SUNBURNS BEFORE 20
triggers mutations (genetic defects)
genetic disposition
family history
personal history
NEVI- dysplastic, congenital nevomelanocytic (>1/5mm), numerous acquired nevi
immunosuppression
HARMM for melanoma
history
age over 50
no regular dermatology appts
male gender
mole changes
risk factors for melanoma
fair
light eyes/hair
MORE THAN 100 MOLES OR 50 IF UNDER AGE 20
ABCDEF melanoma assessment
asymmetry in shape- 1/2 unlike others
color is mottled, many shades
diameter is large >6mm (pencil eraser)
elevation is usual- tangential lighting to see
enlargement, evolving- h/o increased size- most important
feeling (presence of sensation, itching, tenderness, pain)
melanoma types
superficial spreading
lentigo maligna
acral lentiginous
subungal melanoma
nodular
superficial spreading melanoma
grows along top layer before penetrating
grow out of pre-existing nevi
flat irregular in shape and color, with different shades of black/brown
most commonly in caucasians
most common- 70%
lentigo maligna melanoma
OFTEN IN SITU- ONE SPOT
sun damaged skin
appear large/flat
tan with areas of brown coloring
found most in the elderly on face/neck/arms
acral lentiginous melanoma
lesion is flat with irregular margins and pigmentation, becomes raised and nodular
spreads superficially before penetrating
occurs on nails and is more common in african americans and asians
**50% of diagnosed melanomas in asians/individuals with dark skin
subungal melanoma
rare subtype of acral lentiginous
involve thumb/great toe
no truma with mark
nodular melanoma
invasive at diagnosis- grows down first
starts as a raised area
dark blackish-blue or bluish red
most aggressive
10-15% of all cases
sophie brings in her husband nathan age 72 who is in a wheelchair. on his sacral area he has a deep crater with a full thickness skin loss involving necrosis of subcutaenous tissue that extends down to the underlying muscle. what stage?
stage 4
you assess a child with a crusted, weeping lesion…
impetigo
what physical exam finding would lead you to suspect hyperlipidemia?
xanthoma of inner canthus
you diagnose ms. lime with contact dermatitis. in your description you would most likely note…
multiple bulla on right ring finger
your patients presents with an area of itchy dry skin that you describe as thickened, normal in color, without drainage, vesicles, edema, it is most likely…
lichenification (thickened skin from continual rubbing)
you are teaching your patient to note changes in her skin lesions.. you tell her to be alert for all of the following EXCEPT…
change in temp.
SHOULD look for change in shape, color, sensation
you are describing a lesion noted on mr. smith, a 55 yo male. it is flat, nonpalpable lesion less than 1 cm in size…
macule
