Skin,Hair, Nail Assessment Flashcards
Dermatological HPI
- changes in hair, skin, nails
- Temporal sequence
- symptoms
- Location
- associated symptoms
- recent exposure
- Apparent cause
- Travel history
- Treatments tried
- Adjustment made
- Diet status
Dermatological Medical History
- previous hair problems
- previous skin problems
- previous nail problems
- tolerance to sunlight
- cardiac, respiratory, liver, endocrine, autoimmune.
Skin exam includes?
Skin surface, hair, nails, conjunctiva, oral, genital mucosa.
1- observe patient skin color
2- palpate patient level of moisture, temperature, texture, mobility and turgor
- Melanoma
- can appear anywhere , if you don’t look you going to miss it
Oral erosion in SLE
1- observe skin color
( Brown) Epiderms
Melanin
1- observe skin color Epiderms
( yellow)
Carotenoids
red, located in arterial plexus
Dermis
Oxyhemoglobin
bluish-
red, located in the venous plexusDermis
hemoglobin
Increased pigmentation may suggest Addison’s disease or metastatic
melanoma
Cyanosis or a bluish color to the lips may suggest hypoxia
2- palpate
Dry, rough
hypothyroidism
2- palpate
Moist, warm
underlying febrile illness or
hyperthyroidism
2- palpate
excoriations
pruritic skin eruption such as scabies or
an underlying systemic disease such as lymphoma
2- palpate
tight, bound-down skin over the hands or face
diagnosis of autoimmune condition like scleroderma
Beau’s lines
Mees’ bands
Lindsay’s nails
Terry’s nails
Koilonychia
Clubbing
Psoriasis
Features based on touch or palpation
• Consistency
• soft, doughy, rubbery, firm, hard
• Dry, flaky, moist
• Temperature
Skin Lesions based on touch:
• Fixed vs mobile
• Presence or absence of tenderness
• Surface characteristics
• smooth, velvety, pebbled
Examples of Skin Features Based on Touch
Rubbery, Mobile, Non-tender
Examples of Skin Features Based on Touch
Firm, Fixed, Rough, Non- tender
Examples of Skin Features Based on Touch
Tender, hard,
Warm to touch
Examples of Skin Features Based on Touch
Dry, flaky, cool, non- tender
Examples of Skin Features Based on Touch
Firm, tight, bound-down, moist
Examples of Skin Features Based on Touch
Wet, Tender, ulcerated
Identify and describe any lesions
Dr. FACT
◦ Distribution
◦ Arrangement
◦ Type of lesion
◦ Primary lesion
◦ Secondary lesion
◦ Color
◦ Features based on touch/palpation
A- Distribution
Examples of Distributions
Sun-exposed: a malar rash of acute cutaneous lupus
Examples of Distributions
Symmetric, generalized rash from a drug reaction
Examples of Distributions
Dermatomal pattern: Herpes zoster
Examples of Distributions
Flexor pattern: atopic dermatitis
B- Arrangements
Examples of Arrangements
Linear
Examples of Arrangements
Grouped herpetiform
Examples of Arrangements
Annular
Examples of Arrangements
Reticulated
C. Type of lesions
( Non-palpable lesion with distinct borders, less than 1 cm in diameter)
Macule
C. Type of lesions
( Non-palpable lesion with distinct borders, greater than 1 cm in diameter)
Patch
C. Types of lesions
( Palpable, solid lesion less than 1 cm in diameter)
Papule
C. Types of lesions
( Palpable, solid lesion greater than 1 cm in diameter)
Plaque
C. Types of lesions
( Palpable, lesion more than 1 cm in diameter which is taller than it is wide)
Nodule
C. Types of lesions
( Fluid- containing, superficial, thin-walled cavity less than 1 cm )
Vesicle
C. Types of lesions
( Fluid-containing ,superficial, thin-walled cavity greater than 1 cm )
Bulla
C. Types of lesions
( A skin defect where there has been loss of the epidermis only )
Erosion
C. Types of lesions
( A skin defect where there has been loss of the epidermis and dermis)
Ulcer
C. Types of lesions
( Pus containing, superficial, thin-walled cavity )
Pustule
C. Types of lesions
( Thick-walled cavity containing pus )
Abscess
C. Color
Erythematous
C. Color
Hyperpigmented
C. Color
Black
Skin cancers & keratosis
Actinic keratosis
Skin cancers & keratosis
Seborrheic keratosis
Skin cancers & keratosis
Squamous cell carcinoma
Skin cancers & keratosis
Malignant melanoma
Skin cancers & keratosis
Basal cell carcinoma
screening for melanoma
A - for asymmetry
B - for irregular borders, especially ragged, notched, or blurred
C - for variation or change in color, especially blue or black
D - for diameter ≥6 mm or different from other moles, especially changing, itching, or bleeding E for elevation or enlargement
1 - Rash
In regard to a rash, it is first important to know he context in which the rash developed:
◦ On what part of the body did it start? Where did it spread to next?
◦ Determine the date of onset of the eruption – evaluate if any other
significant events occurred at that time (new medications, exposure to new substance or food)
◦ Have you ever had a rash like this before?
Next, gather more accessory information about the rash itself:
◦ Is the rash itchy? Is it painful or tender when you touch it?
◦ Have you tried anything to make it better? Did it help?
Rash - Alarm symptoms
Although the vast majority of skin conditions are not life-thre
life threatening processes like anaphylaxis, severe systemic infections, and severe drug reactions :
◦ severely painful skin
◦ diffuse erythema
◦ erythroderma (redness and scaling involving > 90% of the skin)
◦ dusky or grayish-purple skin (signals impending necrosis)
◦ widespread blistering or sloughing skin
◦ painful erosions of the mucous membranes
◦ palpable purpura
◦ swelling of the lips or tongue
◦ high fever
◦ difficulty breathing
Rash - Differential diagnosis
Exanthematous eruptions
•Drug eruption
•Scarlet fever
•Viral exanthems, such as measles (rubeola), rubella (German measles
Rash - Differential diagnosis
Papulosquamous dermatoses
•Psoriasis
•Seborrheic dermatitis •Lupus erythematosus •Tinea corporis/cruris/faciei (ringworm, jock itch)
Rash - Differential diagnosis
Eczematous dermatoses
•Atopic dermatitis
•Irritant contact dermatitis (80% of contact dermatitis)
•Venous stasis dermatitis
Rash - Differential diagnosis
Vesiculobullous disorders
•Stevens-Johnson syndrome/toxic epidermal necrolysis
•Bullous pemphigoid
•Herpes simplex viral infection (cold sores, fever blisters)
•Varicella (chickenpox)
•Zoster (shingles)
Rash - Differential diagnosis
Pustular dermatoses
•Acne vulgaris
•Acne rosacea
•Folliculitis
Rash - Differential diagnosis
Purpuras
•Thrombocytopenic purpura
•Acute bacterial endocarditis
•DIC
Rash - Differential diagnosis
Erythemas and urticaria
•Urticaria
•Cellulitis
•Necrotizing fasciitis
•Lyme disease
2 - Pruritus
First, allow the patient to describe the itching and when it began and where it is located:
◦ When did the itching first start?
◦ Is it in a single area of the body, or is it widespread?
After listening to the itching history, consider possible alarm symptoms and ask questions to narrow the differential diagnosis
Pruritus - itching without rash ?
Itching, without rash, is usually a systemic problem and will likely require a full exam and possibly laboratory evaluations so do not expect a clear diagnosis at the end of your history and physical.
3 - Hair Loss
The first goal is to determine whether the alopecia is scarring or nonscarring. Ask the patient to precisely describe the hair
loss:
◦ When did the hair loss start? Was it sudden or gradual?
◦ What is the pattern of the hair loss? Is it breaking, coming out at
the root, patchy, overall thinning? ◦ Were there any precipitating events? Frequent hair treatments?
Medications? Systemic illness?
Hair loss - Alarm symptoms
◦ Itching
◦ Pain
◦ Crusting
◦ Bleeding
◦ Pustulation
◦ Scaling of the scalp
Hair loss - Types
Hair loss - Differential diagnosis
( Sudden hair loss that starts with one or more circular bald patches that may overlap )
Alopecia areata
Cause:
Autoimmune diseases – not reversible
Hair loss - Differential diagnosis
( Hair is lost in a well-defined pattern, beginning above both temples. Over time, the hairline recedes to form a characteristic “M” shape )
Androgenetic alopecia
Cause:
Common genetic hair loss – not reversible
Hair loss - Differential diagnosis
( Itching, scaly, inflamed balding areas on the scalp )
Tinea capitis
Cause:
Fungal infection - reversible
Hair loss - Differential diagnosis
( Overall thinning and shedding of hair that begins within 2 months of starting a new drug or after a serious illness )
Drug-related hair loss or serious illness related
Cause:
Drug or stress, reversible
Hair loss - Differential diagnosis
( Itching, Pain, Crusting, Bleeding, Scaling of the scalp )
Inflammatory alopecias
• Discoid lupus
•Lichen planopilaris •Autoimmune blistering disorders
Cause:
Typically autoimmune disorders
Hair loss - Differential diagnosis
( hair loss that’s caused by repeatedly pulling on hair (braids, hair clips, ponytails)
Traction alopecia
Cause:
May not be reversible due to scaring
