Skin Flashcards
Layers of the skin
Epidermis: outer layer- horny; dead keratin
inner layer-cellular, melatonin and keratin formed
inner layer migrates to outer layer in a month
superficial thin layer, no blood vessles
Dermis: nourish epidermis, connective tissue, sweat glands, sebaceous glands, hair follicles
Subcutaneous: adipose tissue/fat
Skin pigmentation
Melanin- brownish
Carotene- golden yellow
Oxyhemoglobin- bright red
Deoxyhemoglobin- dark blue pigment
Cyanosis
depends on oxygen concentration
Central; low O2 level in blood
Advanced lung disease, congenital HD, hemoglobinopathys
Peripheral; occurs when cutaneous blood flow decreased and slow- may be normal
CHF, reflects low blood flow, venous obstruction
PEdema can e both
Tissues extract more oxygen than usual from the blood
Can be normal response to anxiety or cold
Hair
Vellus: short, fine, inconspicuous, relatively unpigmented
Terminal: coarser, thicker, more conspicuous, usually pigmented, scalp hair and eyebrows
Changes with hair distribution d/t systemic effects from Thyroid gland
Nails
protect distal ends of fingers and toes
fingernails grow 0.1mm daily
toenails grow slower
angle between nail fold and plate <180degrees
Glands
Sebaceous: produce fatty substance screened onto the skin surface through the hair follicles. Absent from palms and soles
Sweat :
Eccrine: widely distributed, open directly onto skin, sweat production helps control body temp.
Apocrine: Axillary & genital regions, usually opens into hair follicle, stimulated by emotional stress, bacterial decomposition of apocrine sweat is responsible for adult body odor
Health History
Changes with hair, nails, skin??
Noticed: rash, sores, lumps, itching
Family Hx of skin CA
Personal Hx of skin Bx
Seen Dermatologist
Any special skin products
Pruritis
causes: dry skin, aging, pregnancy, uremia, jaundice, lymphoma, leukemia, lice, drugs
Moles
Concerning moles?
Changes with size, shape, color, sensation, new moles?
A- asymmetry
B-borders
C-color change
D-diameter >/= 6mm
E-elevation/evolving
Skin Cancer
Basal Cell: 80%- basal level of epidermis, pearly white, head and neck, slow growth, no mets
Squamos Cell: 16%- upper layer, crusted, red, ulcerated, mets
Melanoma: 4% Lethal, mets to lymph, int organs. Half detected by patient
Skin 4 letter words
skin
itch
burn
peel
rash
ROS
onset pruritis, repsonse to Tx
Associated constitution or systemic Sx
home/OTC Tx/response
skin lesions: change in size/color
Bleeding
Unusual dryness/ Increased sweating
painful lesions
hair changes
nail changes
Dyshydrotic
related to water or sweat
Hyperhydrosis
excessive/profuse sweating
Xerosis
excessive dryness
Induration
process of becoming firm or hard
Usual Suspects
Contact Dermatitis
Pyodermas- Bacterial Infection
Viral infection
fungal infection
candida/monolial overgrowth
BCC/SCC potential for overlap
Medication effects
Derm Principles
Be alert and integrate exams
keep a good derm text near
Find out what pt has beend oing, treating with, what they think, their Dx
Maintain low threshold for Bx for any lesions that don’t respond to Tx- esp ulcers and nodules
Speak and write language fluently
ID by location, distribution, morphology, pregression, symptomatology- can always reference treatment
ABCDE of moles
Physical Exam
General Survey:
Closely inspect hair, nail, skin. Palms, soles, web spaces, mucous membranes
Bedridden patient: sacrum, coccyx, buttock, greater trocanter, knees, heels
Skin
Color- cyanosis, pallor
Moisture
Temperature- warm=Hyperthroid, fever: cool= hypothyroid: local warmth=inflammation/cellulitis
Texture: rough=hypothyroid: velvety=hyperthyroid
Mobilty/Turgor: decr mobility with edema & scleroderma, decr turgor=dehyration
Lesions
Alopecia
Hair loss
Causes: genetic, local inflammatory process, systemic disease
diffuse patchy or total
Hypothyroid=sparse
Hyperthyroid=fine/silky
Distribution
Acne: face chest, back
psoriasis: knees, elbows
Candida: intertriginous
Herpes Zoster: unilateral dermatomal pattern
Skin Lesions
location: general/local
distribution
blanchable?
pattern/shape: linear, clustered, annular, arciform, geographical, serpiginous
size
shape
type- macule,papule, vesicle, nevi
color
Scabies
Mites can be loosened with scapel blade
Derm Colors
Flesh
Erythematous- red
Violaceous- blue
brawny- brown
jaundice- yellow- seen in sclera
hyperpigmented- dark
hypopigmented- light
vitiligo- absense of melanin
heliotropic- changing
Cafe Au Lait Spots
uniformly pigmented spots, macule/papule (0.5-1.5 cm diameter). Benign. 6 or more with diameter > 1.5cm c/w neurofibrmatosis
Heliotrope
viloceous eruptions over eyelids in collagen vascular disease, dermatoyositis
Tinnea Versicolor
sup fungal infection->decr pigmentation, scaly macules on neck and upper arms
easy to see dark skin, light skin may be red/tan instead of pale
Fifth’s Disease
Slapped cheeks, erythema infection
Vitiligo
depigmented macules on face, hands, feet, ext surfaces. May coalecse into large areas without melatonin: hereditary
Herpes Zoster
Shingles, reactivation of chicken pox virus (Varicella).
follow dermatomal pattern
often preceded by prodromal symptoms of pain, burning, tingling
vesicles erupt on erythematous base
can be painful
may need long term pain management
Pityrisis Rosea
scaly fine paules/plaques
dull pink or tawny
christmas tree distribution- on trunk and prox ext.
Herald pattern- 2-5cm bright red slightly raised plaque with fine scale at periphery
more common fall/spring
sontaneous recovery in ~ 6 wks
Intertriginous
dark in skin folds
Macule
<1cm spot, different color, not raised or depressed
Patch
> or = 1 cm spot different in color, nat raised or depressed
Papule
circumscribed solid elevation < 1 cm
Plaque
circumscribed solid elevation > or = 1 cm
confluence of papule
Nodule
palpable solid round elevated mass/lesion > 0.5cm
Tumor
palpable solid round elevated mass/lesion > 2cm
Erosion
breakdown of epidermis to dermis
Lichenification
thickening of skin
Atrophy
thinning of skin layers
Ecchymosis
bruising
Scale
small thin plate of horny epithelium heaved up keratin
Crust
accumulation of debris: thick/thin
Ulcer
open area caused by superficial loss of tissue, usually with inflammation
Keloid
hypertrophic scarring extending beyond borders of the initiating injury
Fissure
deep furrow, cleft or slit
Warts
Caused by HPV, > 65 types
subclinical infection/ benign lesion
skin/mucus membranes affected
infect keratinized skin
firm papular lesions
plaque may have hyper keratotic surface, studded with black/brown dots
Tx: cyrotherapy, slaicylic acid, duct tape
Skin tags
Acrochordon/cutaneous papilloma/soft fibroma
common
soft, skin colored/tan/brown, round/oval pedunculated fleshy skin lesion (polyp)
tender after trauma/torsion, may crust/bleed
common in skin folds
often increase with pregnancy, insulin resistance
Trichotillomania
compulsion to pul out hair
Nail DO
Paronychia: sup inf of prox/lat nail fold(staph/strep)
Pitting: punctuate depression of nails
Clubbing: nail angle >180 degrees
Transverse/Linear depression: Beau’s line: transverse depress of nail plate, usually following illness: severe febrile, malnutrition, trauma, coronary occlusion
Longitudinal bands of pigment may be normal in people with darker skin
Nail inspection
inspect, palpate nails/toenails
color, shape, lesion
Seborrheic Keratosis
starts as macule
skin colored lesion or light tan with more pigment over time
flat to raised
stuck on warty looking lesions
plaque-like
yellow brown velvety/warty
white pearly nodules within
not associated with risk for malignancy
Tx: cryotherapy
Actinic Keratosis
superficial flattened papules covered by dry scale
often multiple
can be round/irregular
pink/tan/grey
appear on sun-exposed skin of older, fair skinned of people
1/1000 per year develop into squamos cell carcinoma
Basal Cell
80% skin cancer
pearly white
round border, depressed center/firm elevated borders
flesh color
central divot
translucent
telegectacias
ulcerates/bleeds
rarely metatasized
slow growing
fairskinned > 40 years
Squamos Cell
Suddenly shows up, grows quick
upper layer of epidermis
crusted/scaly/ firm red
inflammed/ulcerated
can metastasize on skin exposed to sun
can be evolving AK, usually > 60yo
Melanoma
from pigmented layer of epidermis
lethal, most rapidly increasing US malignancy
Inc risk with severe blistering sunburn
80% of deaths from skin cancer
rare cases of amelneous melanoma
HARRM Risk Model
Hx previous melanoma
Age > 50yo
Reg derm absent
mole changing
male gender
Spider Bite Epidemic
Community acquired MRSA
MRSA
often difficult to Tx d/t resistance
PCP
Can be sup pyoderma
absess, impetigo, folliculitis, cellulitis
visual Dx inadequate
secondary infection
Derm Emergencies
Urticaria w/Angiodedema
Anaphylactic Reaction
Toxic Epidermoid Necrolysis (TEN)
Necrotizing Fascititis
TSS
Health Promotion
Risk factors
Skin self exams
Avoid tanning beds
Avoid excessive sun exposure: daily SPF UVA/UVB 15 or greater, reapply every 2 hours or if skin wet
Bedbound patient
shaering, sustained compression, friction
localized redness,warmth sign of impending necrosis
Age related Skin changes
Flattening of dermoepidermal junction: less resistance to shearing forces/thinning of skin
Reduced collagen/elastin: wrinkling
Decr epidermal cell turnover rate: reduce healing
Decr vasc responsiveness: red vasodil(cooling) and dec transdermal absorption
Decr subq fat: dim bony protection of prominences & thermoreg
Decr epidermal :angerhan cells: decr hypersensitivity response
Atrophy of eccrine/sebaceous gland: reduce oil/sweat, decr thermoreg. and pliabilibty of skin
