4. the skin
TRANSCRIPT
-
7/27/2019 4. The Skin
1/19
(YDOXDWLRQ&
RS\
The Skin
C H A P T E R
The Skin 44
C H A P T E R 4 s T H E S K I N 95
ANATOMY AND PHYSIOLOGY
The major function of the skin is to keep the body in homeostasis despite thedaily assaults of the environment. It provides boundaries for body fluids while
protecting underlying tissues from microorganisms, harmful substances, andradiation. It modulates body temperature and synthesizes vitamin D.
The skin is the heaviest single organof the body, accounting for approx-imately 16% of body weight andcovering an area of roughly 1.2 to2.3 meters squared. It contains threelayers: the epidermis, the dermis,and the subcutaneous tissues.
The most superficial layer, the epi-
dermis, is thin, devoid of blood ves-sels, and itself divided into two lay-ers: an outer horny layer of deadkeratinized cells and an inner cellularlayer where both melanin and ker-atin are formed.
The epidermis depends on the un-derlying dermisfor its nutrition. Thedermis is well supplied with blood. Itcontains connective tissue, seba-ceous glands, sweat glands, and hair
follicles. It merges below with sub-cutaneous tissue, or adipose, alsoknown as fat.
Hair, nails, and sebaceousand sweat glandsare considered appendages of theskin. Adults have two types of hair: vellus hair,which is short, fine, incon-spicuous, and relatively unpigmented; and terminal hair,which is coarser,thicker, more conspicuous, and usually pigmented. Scalp hair and eyebrowsare examples of terminal hair.
Hair shaft
Horny layer
Cellular layer
Sebaceousgland
Muscle thaterects hair shaft
Sweat gland
Hair follicle
Vein
Nerve
Artery
Duct ofsweat gland
Epidermis
Dermis
Subcutaneoustissue
-
7/27/2019 4. The Skin
2/19
(YDOXDWLRQ&
RS\
Nails protect the distal ends of the fingers and toes. The firm, rectangular,and usually curving nail plategets its pink color from the vascular nail bedto which the plate is firmly attached. Note the whitish moon ( lunula) andthe free edge of the nail plate. Roughly a fourth of the nail plate (the nailroot) is covered by theproximal nail fold. The cuticleextends from this foldand, functioning as a seal, protects the space between the fold and the plate
from external moisture. Lateral nail foldscover the sides of the nail plate.Note that the angle between the proximal nail fold and the nail plate is nor-mally less than 180.
ANATOMY AND PHYSIOLOGY
96 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
Lateralnail fold Lunula
Proximalnail fold
Nail plate CuticleFreeedge
Fingernails grow at about 0.1 mm daily; toenails grow more slowly.
Sebaceous glandsproduce a fatty substance that is secreted to the skin surfacethrough the hair follicles. These glands are present on all skin surfaces exceptthe palms and soles. Sweat glandsare of two types: eccrine and apocrine. The
eccrine glandsare widely distributed, open directly onto the skin surface, andby their sweat production help to control body temperature. In contrast, theapocrine glandsare found chiefly in the axillary and genital regions, usuallyopen into hair follicles, and are stimulated by emotional stress. Bacterial de-composition of apocrine sweat is responsible for adult body odor.
The color of normal skin depends primarily on four pigments: melanin,carotene, oxyhemoglobin, and deoxyhemoglobin. The amount ofmelanin,the brownish pigment of the skin, is genetically determined and is increasedby sunlight. Caroteneis a golden yellow pigment that exists in subcutaneousfat and in heavily keratinized areas such as the palms and soles.
Hemoglobin, which circulates in the red cells and carries most of the oxygenof the blood, exists in two forms. Oxyhemoglobin, a bright red pigment, pre-dominates in the arteries and capillaries. An increase in blood flow throughthe arteries to the capillaries of the skin causes a reddening of the skin, whilethe opposite change usually produces pallor. The skin of light-colored per-sons is normally redder on the palms, soles, face, neck, and upper chest.
As blood passes through the capillary bed, some of the oxyhemoglobin losesits oxygen to the tissues and changes to deoxyhemoglobina darker and
Nail root
Proximal nail fold
Nail plate
Cross sectionof nail plate
Nail bedDistal phalanx
-
7/27/2019 4. The Skin
3/19
(YDOXDWLRQ&
RS\
somewhat bluer pigment. An increased concentration of deoxyhemoglobinin cutaneous blood vessels gives the skin a bluish cast known as cyanosis.
Cyanosis is of two kinds, depending on the oxygen level in the arterial blood.If this level is low, cyanosis is central. If it is normal, cyanosis isperipheral.Peripheral cyanosis occurs when cutaneous blood flow decreases and slows,
and tissues extract more oxygen than usual from the blood. Peripheralcyanosis may be a normal response to anxiety or a cold environment.
Skin color is affected not only by pigments but also by the scattering of lightas it is reflected back through the turbid superficial layers of the skin or ves-sel walls. This scattering makes the color look more blue and less red. Thebluish color of a subcutaneous vein is a result of this effect; it is much bluerthan the venous blood obtained on venipuncture.
Changes With Aging
As people age their skin wrinkles, becomes lax, and loses turgor. The vascu-larity of the dermis decreases and the skin of light-skinned persons tends tolook paler and more opaque. Comedones (blackheads) often appear on thecheeks or around the eyes. Where skin has been exposed to the sun it looksweatherbeaten: thickened, yellowed, and deeply furrowed. Skin on the backsof the hands and forearms appears thin, fragile, loose, and transparent, andmay show whitish, depigmented patches known as pseudoscars. Well-demarcated, vividly purple macules or patches, termed actinic purpura, mayalso appear in the same areas, fading after several weeks. These purpuric spotscome from blood that has leaked through poorly supported capillaries andhas spread within the dermis. Dry skin (asteatosis)a common problemisflaky, rough, and often itchy. It is frequently shiny, especially on the legs,where a network of shallow fissures often creates a mosaic of small polygons.
Some common benign lesions often accompany aging: cherry angiomas(p. __), which often appear early in adulthood, seborrheic keratoses (p. __),and, in sun-exposed areas, actinic lentigines or liver spots (p. __) and ac-tinic keratoses (p. __). Elderly people may also develop two common skincancers: basal cell carcinoma and squamous cell carcinoma (p. __).
Nails lose some of their luster with age and may yellow and thicken, espe-cially on the toes.
Hair on the scalp loses its pigment, producing the well-known graying. Asearly as 20, a mans hairline may start to recede at the temples; hair loss atthe vertex follows. Many women show a less severe loss of hair in a similarpattern. Hair loss in this distribution is genetically determined.
In both sexes, the number of scalp hairs decreases in a generalized pattern,and the diameter of each hair diminishes.
Less familiar, but probably more important clinically, is the normal hairloss elsewhere on the body: the trunk, pubic areas, axillae, and limbs.
ANATOMY AND PHYSIOLOGY
C H A P T E R 4 s T H E S K I N 97
-
7/27/2019 4. The Skin
4/19
(YDOXDWLRQ&
RS\
These changes will be discussed in later chapters. Coarse facial hairs appearon the chin and upper lip of many women by about the age of 55, but donot increase further thereafter.
Many of the observations described here pertain to lighter-skinned personsand do not necessarily apply to others. For example, Native American men
have relatively little facial and body hair compared to lighter-skinned men,and should be evaluated according to their own norms.
HEALTH PROMOTION AND COUNSELING
98 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
Causes of generalized itching
without obvious reason include dry
skin, aging, pregnancy, uremia,
jaundice, lymphomas and
leukemia, drug reaction, and lice.
EXAMPLES OF ABNORMALITIES
Common or Concerning Symptoms
s Hair losss Rash
s Moles
Start your inquiry about the skin with a few open-ended questions: Haveyou noticed any changes in your skin?. . . your hair? . . . your nails?. . .Have you had any rashes? . . . sores? . . . lumps? . . . itching? Have younoticed any moles that have changed in appearance? Where? When?
It is usually best to defer further questions about the skin until the physical
examination, when you can see what the patient is talking about.
THE HEALTH HISTORY
HEALTH PROMOTION AND COUNSELING
Important Topics for Health Promotion and Counseling
s Risk factors for melanoma
s Avoidance of excessive sun exposure
Clinicians play an important role in counseling patients about protectivemeasures for skin care and the hazards of excessive sun exposure. Basal celland squamous cell carcinomas are the most common cancers in the UnitedStates and are found most frequently in sun-exposed areas, particularlythe head, neck, and hands. Malignant melanoma, although rare, is the mostrapidly increasing U.S. malignancy, now occurring in 1 in 74 Americans.Although melanoma often arises in nonsun-exposed areas, it is associated
-
7/27/2019 4. The Skin
5/19
-
7/27/2019 4. The Skin
6/19
(YDOXDWLRQ&
RS\
TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES
100 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
Pallor due to decreased redness is
seen in anemia and in decreased
blood flow, as in fainting or arterialinsufficiency.
Causes of central cyanosis include
advanced lung disease, congenital
heart disease, and abnormal
hemoglobins.
Cyanosis in congestive heart fail-
ure is usually peripheral, reflecting
decreased blood flow, but in pul-monary edema it may also be cen-
tral. Venous obstruction may cause
peripheral cyanosis.
Jaundice suggests liver disease or
excessive hemolysis of red blood
cells.
Artificial light often distorts colors
and masks jaundice.
See Table 4-1, Basic Types of Skin
Lesions (pp. ____), and Table 4-2,
Skin Colors (p. __).
TECHNIQUES OF EXAMINATION
Observe the skin and related structures during the General Survey and
throughout the rest of your examination. The entire skin surface should beinspected in good light, preferably natural light or artificial light that re-sembles it. Correlate your findings with observations of the mucous mem-branes. Diseases may manifest themselves in both areas, and both are neces-sary for assessing skin color. Techniques of examining these membranes aredescribed in later chapters.
To make your observations more astute, acquaint yourself now with someof the skin lesions and colors that you may encounter.
Skin
Inspect and palpate the skin. Note these characteristics:
Color. Patients may notice a change in their skin color before the clini-cian does. Ask about it. Look for increased pigmentation (brownness), lossof pigmentation, redness, pallor, cyanosis, and yellowing of the skin.
The red color of oxyhemoglobin and the pallor due to a lack of it are bestassessed where the horny layer of the epidermis is thinnest and causes the
least scatter: the fingernails, the lips, and the mucous membranes, particu-larly those of the mouth and the palpebral conjunctiva. In dark-skinned per-sons, inspecting the palms and soles may also be useful.
Central cyanosis is best identified in the lips, oral mucosa, and tongue. Thelips, however, may turn blue in the cold, and melanin in the lips may simu-late cyanosis in darker-skinned people.
Cyanosis of the nails, hands, and feet may be central or peripheral in origin.Peripheral cyanosis may be caused by anxiety or a cold examining room.
Look for the yellow color of jaundice in the sclera. Jaundice may also appearin the palpebral conjunctiva, lips, hard palate, undersurface of the tongue,tympanic membrane, and skin. To see jaundice more easily in the lips, blanchout the red color by pressure with a glass slide.
-
7/27/2019 4. The Skin
7/19
(YDOXDWLRQ&
RS\
For the yellow color that accompanies high levels of carotene, look at thepalms, soles, and face.
Moisture. Examples are dryness, sweating, and oiliness.
Temperature. Use the backs of your fingers to make this assessment. Inaddition to identifying generalized warmth or coolness of the skin, note thetemperature of any red areas.
Texture. Examples are roughness and smoothness.
Mobility and Turgor. Lift a fold of skin and note the ease with whichit lifts up (mobility) and the speed with which it returns into place (turgor).
Lesions. Observe any lesions of the skin, noting their characteristics:
s Their anatomic location and distributionover the body. Are they gener-alized or 1ocalized? Do they, for example, involve the exposed surfaces,the intertriginous (skin fold) areas, or areas exposed to specific allergensor irritants such as wrist bands, rings, or industrial chemicals?
s Their arrangement. For example, are they linear, clustered, annular (in aring), arciform (in an arc), or dermatomal (covering a skin band that cor-
responds to a sensory nerve root; see pp. ____)?
s The type(s) of skin lesions(e.g., macules, papules, vesicles, nevi). If possi-ble, find representative and recent lesions that have not been traumatizedby scratching or otherwise altered. Inspect them carefully and feel them.
s Their color.
EVALUATING THE BEDBOUND PATIENT
People who are confined to bed, especially when they are emaciated, elderly,or neurologically impaired, are particularly susceptible to skin damage andulceration. Pressure soresresult when sustained compression obliterates arte-riolar and capillary blood flow to the skin. Sores may also result from theshearing forces created by bodily movements. When a person slides down inbed from a partially sitting position, for example, or is dragged rather thanlifted up from a supine position, the movements may distort the soft tissuesof the buttocks and close off the arteries and arterioles within. Friction andmoisture further increase the risk.
Carotenemia
Dryness in hypothyroidism; oiliness
in acne
Generalized warmth in fever,
hyperthyroidism; coolness in
hypothyroidism. Local warmth of
inflammation or cellulitis
Roughness in hypothyroidism
Decreased mobility in edema,
scleroderma; decreased turgor in
dehydration
Many skin diseases have typical
distributions. Acne affects the
face, upper chest, and back;
psoriasis, the knees and elbows
(among other areas); and
Candidainfections, the inter-
triginous areas.
Vesicles in a unilateral dermatomal
pattern are typical of herpes zoster.
See Table 4-1, Basic Types of Skin
Lesions (pp. ____); Table 4-3,
Vascular and Purpuric Lesions of
the Skin (p. __); Table 4-4, Skin
Tumors (p. __); and Table 4-5, Be-
nign and Malignant Nevi (p.__).
See Table 4-6, Pressure Ulcers(p. __).
EXAMPLES OF ABNORMALITIESTECHNIQUES OF EXAMINATION
C H A P T E R 4 s T H E S K I N 101
-
7/27/2019 4. The Skin
8/19
(YDOXDWLRQ&
RS\
Local redness of the skin warns of
impending necrosis, although
some deep pressure sores develop
without antecedent redness. Ulcers
may be seen.
See Table 4-7, Findings In or Near
the Nails (pp. ____).
Alopeciarefers to hair lossdiffuse,patchy, or total.
Sparse hair in hypothyroidism; fine
silky hair in hyperthyroidism
See Table 4-8, Skin Lesions in Con-
text (pp. ____).
TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES
102 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
Hair
Inspect and palpate the hair. Note its quantity, distribution, and texture.
Skin Lesions in Context
After familiarizing yourself with the basic types of lesions, review their ap-pearances in Table 4-8 and in a well-illustrated textbook of dermatology.Whenever you see a skin lesion, look it up in such a text. The type of lesions,their location, and their distribution, together with other information from
the history and the examination, should equip you well for this search and,in time, for arriving at specific dermatologic diagnoses.
Assess every susceptible patient by carefully inspecting the skin that overliesthe sacrum, buttocks, greater trochanters, knees, and heels. Roll the patientonto one side to see the sacrum and buttocks.
Nails
Inspect and palpate the fingernails and toenails. Note their color and shape,and any lesions. Longitudinal bands of pigment may be seen in the nails ofnormal people who have darker skin.
-
7/27/2019 4. The Skin
9/19
(YDOXDWLRQ&
RS\
TABLE 4-1 s Basic Types of Skin Lesions
C H A P T E R 4 s T H E S K I N 103
TABLE4-
1
s
BasicTypesofSkinLesions
PrimaryLesions(MayAriseFromPreviouslyNormalSkin)
Circumscribed,
Flat,N
onpalpable
ChangesinSkinColor
MaculeSmallflatspot,up
to1.0
cm
Examp
les:freckle,petechia
Patch
Flatspot,1.0cmor
larger
PalpableElevatedSolidMasses
PapuleUpto1.0cm.
Example:anelevatednevus
PlaqueElevatedsuperficial
lession1.0cmorlarger,
oftenformedbycoalescence
ofpapules
NoduleMarble-l
ikelesion
largerthan0.5cm,often
deeperandfirmerthana
papule
WhealAsomewhat
irregular,relativelytransient,
superficialareaoflocalized
skinedema.Examples:
mosquitobite,hive
CircumscribedSuperficia
lElevationsof
theSkinFormedbyFree
Fluidina
CavityWithintheSkinLa
yers
VesicleU
pto1.0cm;filled
withserou
sfluid.
Example:
herpessim
plex
Bulla1.0cmorlarger;
filledwith
serousfluid.
Example:2nd-degreeburn
PustuleFilledwithpus.
Examples:acne,impetigo
SecondaryLesions(ResultFromChangesinPrima
ryLesions)
LossofSkinSurface Er
osion
Lossofthe
superfi
cialepidermis;surface
ismoistbutdoesnotbleed.
Examp
le:moistareaafterthe
ruptureofavesicle,asin
chickenpox
MaterialontheSkinS
urface
Crust
Thedriedresidueof
serum,pus,orblood.
Examp
le:impetigo
UlcerAdeeperlossof
epidermisanddermis;may
bleedandscar.
Examples:
stasisulcerofvenous
insufficiency,syphilitic
chancre
FissureA
linearcrackin
theskin.E
xample:athletes
foot
ScaleAthinflakeof
exfoliatedepidermis.
Examples:dandruff,
dryskin
,
psoriasis
(tablecontinuesnextpage)
-
7/27/2019 4. The Skin
10/19
(YDOXDWLRQ&
RS\
TABLE 4-1 s Basic Types of Skin Lesions
104 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TABLE4-
1
s
BasicTypesofSkinLesions(C
ontinued)
MiscellaneousLesions
ExcoriationAnabrasionorscratch
mark.Itmaybelinear
,asillustrated,or
rounded,asinascratc
hedinsectbite.
ScarReplacementof
destroyedtissuebyfibrous
tissue.Maybethickan
d
pink(hypertrophic)or
thin
andwhite(atrophic),but
doesnotextendbeyon
d
theinjuredarea
BurrowofScabiesAperson
withscabieshas
intenseitching.
Skinlesionsincludesmall
papules,pustules,lichenified
areas,and
excoriations.Withamagnifyinglens,lookfor
theburrowofthemitethatc
ausesit.
A
burrowisaminute,slightlyraisedtunnelin
theepidermisandiscommonlyfoundonthe
fingerwebsandonthesides
ofthefingers.It
lookslikeashort(51
5mm),linearorcurved,
graylineandmayendinatinyvesicle.
AdditionalTerms:
s
ComedoThecommon
blackheadthatmarksthepluggedopeningofasebaceousgland,
frequentlyseenwithacne
s
NevusThecommonm
ole;appearsflattoslightlyelevated,rou
ndandevenlypigmented;however,som
enevilookquitedifferent,asinthepigmentedneviof
melanoma.
s
TelangiectasiasDilated
smallvessels(canbevenules,arterioles,
includingspiderangiomas,orcapillaries)thatlookeitherredorbluish.
Mayappearby
themselvesoraspartsof
otherlesions,asinabasalcellcarcinom
aorradiodermatitis(skininjuryfromio
nizingradiation).
(Sourcesofphotos:Lichenification,Excoriation,Scar,BurrowofScabiesGoodheartHP:APhotoguideofCommonS
kinDisorders:DiagnosisandManagement.
Philadelphia,
LippincottWilliams&Wilkins,1999;AtrophyFitzpatrickJE,
AelingJL:
DermatologySecretsinColor,2nded.
Phila
delphia,
LippincottWilliams&Wilkins,200
0)
LichenificationThickenin
gand
rougheningoftheskinwithincreased
visibilityofthenormalskin
furrows.
Example:atopicdermatitis
Atroph
yThinningoftheskinwithloss
ofthe
normalskinfurrows;theskinlooks
shinierandmoretranslucentthannormal.
Example:arterialinsufficiency
-
7/27/2019 4. The Skin
11/19
-
7/27/2019 4. The Skin
12/19
(YDOXDWLRQ&
RS\
TABLE 4-3 s Vascular and Purpuric Lesions of the Skin
106 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TABLE4-
3
s
Vasc
ularandPurpuricLesionsoftheSkin
Vascular
Purpuric
Spider
Angioma
SpiderVein
CherryAngioma
Petechia/Purpura
Ecchymosis
Color
Size
Shape
Pulsatility
Effectof
Pressure
Distribution
Significance
Fieryre
d
Fromverysmallto
2cm
Centralbody,
sometim
esraised,
surroun
dedby
erythem
aand
radiatin
glegs
Oftend
emonstrablein
thebod
yofthespider,
whenpressurewitha
glassslideisapplied
Pressureonthebody
causesb
lanchingof
thespid
er.
Face,neck,arms,and
uppertrunk;almost
neverbelowthewaist
Liverdisease,
pregnan
cy,vitaminB
deficien
cy;alsooccurs
normallyinsome
people
Bluish
Variable,
fromvery
small
toseveralinches
Variable.
Mayresemblea
spiderorbelinear,
irregular,cascading
Absent
Pressureoverthecenter
doesnotcauseblan
ching,
butdiffusepressure
blanchestheveins.
Mostoftenonthelegs,
nearveins;alsoonthe
anteriorchest
Oftenaccompanies
increasedpressureinthe
superficialveins,as
in
varicoseveins
Brightorrubyred;
maybecomebrownish
withage
13mm
Round,
flator
sometimesraised,may
besurroundedbya
palehalo
Absent
Mayshowpartial
blanching,especiallyif
pressureisappliedwith
theedgeofapinpoint
Trunk;alsoextremities
None;increaseinsize
andnumberswith
aging
Deepredorreddish
purple,
fadingawayover
time
Petechia,
13mm;
purpura,
larger
Rounded,sometimes
irregular;flat
Absent
None
Variable
Bloodoutsidethevessels;
maysuggestableeding
disorderor,ifpetechiae,
embolitoskin
Purpleorpurplishblue,
fadingtogreen,yellow,
andb
rownwithtime
Variable,
largerthan
petechiae
Rounded,oval,or
irregu
lar;mayhavea
centralsubcutaneousflat
nodule(ahematoma)
Absent
None
Variable
Blood
outsidethe
vessels;oftensecondary
tobruisingortrauma;
alsoseeninbleeding
disorders
(Sourcesofphotos:SpiderAng
iomaMarksR:SkinDiseaseinOldAge.Philadelphia,
JBLippincott,
1987;Petechia/PurpuraKelleyWN:TextbookofInternalMe
dicine.Philadelphia,
JBLippincott,
1989)
-
7/27/2019 4. The Skin
13/19
(YDOXDWLRQ&
RS\
TABLE 4-4 s Skin Tumors
C H A P T E R 4 s T H E S K I N 107
TABLE4-
4
s
Skin
Tumors
BasalCellCarcinoma
Abasalcellcarcinoma,thoughmalignant,grows
slowlyandseldommetastasizes.Itismost
commoninfair-s
kinnedad
ultsoverage40,and
usuallyappearsontheface.
Aninitialtranslucent
nodulespreads,leavingad
epressedcenteranda
firm,elevatedborder.
Telangiectaticvesselsare
oftenvisible.
Squamo
usCellCarcinoma
Squamouscellcarcinomausuallyappearsonsun-
exposedskinoffair-s
kinnedadultsover60.
Itmay
developin
anactinickeratosis.Itusuallygrows
morequic
klythanabasalcellcarcinoma,isfirmer,
andlooks
redder.
Thefaceandthebackofthe
handareo
ftenaffected,asshownhere.
KaposisSarcomainAIDS
WhenKaposissarcoma,amalign
anttumor,
accompaniesAIDS,
itmayappearinmanyforms:
macules,papules,plaques,ornodulesalmost
anywhereonthebody.Lesionsa
reoftenmultiple
andmayinvolveinternalstructur
es.
Ontheleftare
ovoid,pinkishredplaquesthattypicallylengthen
alongtheskinlines.
Theymaybecomepigmented.
Ontherightisapurplishrednoduleonthefoot.
SeborrheicKeratosis
Seborrheickeratosesarecommon,
benign,
yellowishtobrown,raisedlesionsthatfeelslightly
greasyandvelvetyor
warty.
Typicallymultipleand
symmetricallydistribu
tedonthetrunkofolder
people,theymayalso
appearonthefaceand
elsewhere.Inblackpeople,oftenyoungerwomen,
theymayappearassm
all,deeplypigmented
papulesonthecheeksandtemples(dermatosis
papulosanigra).
(Sourcesofphotos:BasalCell
Epithelioma:RapiniR.SquamousCellCarcinoma,ActinicKeratosis,andSeborrheicKeratosisSauerGC:ManualofSkinDiseases,5thed.Philadelphia,JB
Lippincott,1985;KaposisSarcomainAIDSDeVitaVTJr,HellmanS,RosenbergSA[eds]:AIDS:Etiology,Diagnosis
,Treatment,andPrevention.Philadelphia,JBLippincott,1985)
ActinicKeratosis
Actinickeratosesaresuperficial,
flatten
edpapules
coveredbyadryscale.Oftenmultiple,theymay
beroundorirregular,andarepink,tan,or
grayish.
Theyappearonsun-exposedskinofolder,
fair-s
kinnedpersons.Thoughthemselvesbenign,
theselesionsmaygiverisetosquamou
scell
carcinoma(suggestedbyrapidgrowth
,induration,
rednessatthebase,andulceration).Keratoseson
faceandhand,typicallocations,aresh
own.
-
7/27/2019 4. The Skin
14/19
(YDOXDWLRQ&
RS\
TABLE 4-5 s Benign and Malignant Nevi
108 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TABLE4-
5
s
BenignandMalignantNevi
BenignNevus
Thebenignnevus,orcomm
onmole,usuallyappearsin
thefirstfewdecades.
Severalnevimayariseatthesame
time,buttheirappearanceusuallyremainsunchanged.
Notethefollowingtypicalfeaturesandcontrastthem
withthoseofatypicalneviandmelanoma:
s
Roundorovalshape
s
Sharplydefinedborders
s
Uniformcolor,especially
tanorbrown
s
Diameter6mm(Fig.
C)
s
Elevation,thoughalsomaybeflat(Fig.
C).
Reviewmelanomariskfactorssuchasintenseyear-
roundsunexposure,
blisteringsunburnsin
childhood,
fairskinthatfrecklesorburnseasily
(especiallyifblondorredhair),
familyhistoryof
melanoma,andnevithatarechangingoratypical,
especiallyif>50.
Changingnevimayhavenew
swellingorrednessbeyondtheborder,scaling,
oozing,orbleeding,orsensatio
nssuchasitching,
burning,orpain.
Ondarkerskin,
lookformelano
masunderthe
nails,onthehands,orontheso
lesofthefeet.
(CourtesyofAmericanCancerSociety;AmericanAcademyofDermatolog
y)
Malig
nantMelanoma
LearntheABCDEsofmelanomafromthese
referen
cestandardphotographsfromthe
AmericanCancerSociety:
A
B
C
-
7/27/2019 4. The Skin
15/19
-
7/27/2019 4. The Skin
16/19
(YDOXDWLRQ&
RS\
TABLE 4-7 s Findings In or Near the Nails
110 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TABLE4-
7
s
Find
ingsinorNeartheNails
ClubbingoftheFingers
Inclubbing,thedistalphalanxofeachfingerisroundedandbulbo
us.Thenail
plateismoreconvex,andt
heanglebetweentheplateandtheproximalnail
foldincreasesto180orm
ore.
Theproximalnailfold,whenpalpa
ted,
feels
spongyorfloating.
Causes
aremany,includingchronichypoxiafro
mheart
diseaseorlungcancerandhepaticcirrhosis.
Paronychia
Aparonychiaisaninfl
ammationoftheproximalandlateralnailfolds.Itmaybe
acuteor,asillustrated,chronic.
Thefoldsarered,swollen,an
doftentender.
Thecuticlemaynotb
evisible.
Peoplewhofrequentlyimmersetheirnailsin
waterareespeciallysusceptible.
Multiplenailsareoftenaffected.
Onycholysis
Onycholysisreferstoapainlessseparationofthenailplatefromt
henailbed.
Itstartsdistally,enlarging
thefreeedgeofthenailtoavaryingdegree.
Severalorallnailsareusua
llyaffected.
Causesaremany.
TerrysNails
Terrysnailsaremostlywhitishwithadistalbandofreddishbrown.
Thelunulae
ofthenailsmaynotbevisible.
Thesenailsmaybeseenwithagingandinpeople
withchronicdiseasess
uchascirrhosisoftheliver,congestiveh
eartfailure,and
non-insulin-dependentdiabetes.
-
7/27/2019 4. The Skin
17/19
(YDOXDWLRQ&
RS\
TABLE 4-7 s Findings In or Near the Nails
C H A P T E R 4 s T H E S K I N 111
WhiteSpots(Leukony
chia)
Traumatothenailsiscommonlyfollowedbywhitespotsthatgrowslowlyout
withthenail.Spotsinthepatternillustratedaretypicalofoverlyvigorousand
repeatedmanicuring.
Thecurvesinthisexampleresemblethecurv
eofthe
cuticleandproximalnailfo
ld.
TransverseWhite
Lines(MeesLines)
Thesearetransverselines,notspots,andtheircurvesaresim
ilartothoseof
thelunula,notthecu
ticle.Theseuncommonlinesmayfollo
wanacuteor
severeillness.Theyem
ergefromundertheproximalnailfoldsandgrowout
withthenails.
Psoriasis
Smallpitsinthenailsmaybeearlysignsofpsoriasisbutarenotspecificforit.
Additionalfindings,notshownhere,includeonycholysisandacircumscribed
yellowishtandiscoloration
knownasanoilspotlesion.
Markedthickeningof
thenailsmaydevelop.
BeausLines
Beauslinesaretransversedepressionsinthenailsassociatedw
ithacutesevere
illness.Thelinesemer
gefromundertheproximalnailfoldsw
eekslaterand
growgraduallyoutwiththenails.
AswithMeeslines,cliniciansmaybeableto
estimatethetimingofacausalillness.
(Sourcesofphotos:ClubbingoftheFingers,Paronychia,Onycholyis,TerrysNails
HabifTP:ClinicalDermatology:AC
olorGuidetoDiagnosisandTherapy,2nded.
St.Louis,
CV
Mosby,1990;WhiteSpots,Tra
nsverseWhiteLines,Psoriasis,BeausLinesSamsWMJr,
LynchPJ:PrinciplesandPract
iceofDermatology.NewYork,
ChurchillLivingstone,1990)
-
7/27/2019 4. The Skin
18/19
(YDOXDWLRQ&
RS\
TABLE 4-8 s Skin Lesions in Context
112 B A T E S G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G
TABLE4-
8
s
Skin
LesionsinContext
Thistableshowsavarietyo
fprimaryandsecondaryskinlesions.Try
toidentifythem,includingthoseindicatedbyletters,
beforereadingtheaccompanyingtext.
Maculesonthedorsumof
thehand,wrist,
andforearm(actiniclentigines)
Pustulesonthepalm(inpustularpsoriasis)
Vesiclesonthechin(inpemphigus)
(A)Bulla(inerythemamultiforme),
(B)target(oriris)lesion
(A)T
elangiectasia,
(B)nodule,
(C)ulcer(in
squamouscell
carcinoma)
BC
A
Papulesontheknee(inlichenplanus)
A
B
-
7/27/2019 4. The Skin
19/19
(YDOXDWLRQ&
RS\
TABLE 4-8 s Skin Lesions in Context
C H A P T E R 4 s T H E S K I N 113
Wheals(urticaria)inadrugeruption
inaninfant
(A)Patch,
(B)nodulesa
combinationtypicalof
neurofibromatosis.Thispatchisa
caf-au-laitspot.
A
B
B
(A)Vesicle,
(B)pustule,
(C)erosions,(D)crust,on
thebackofaknee(ininfectedatopicdermatitis)
A
B
DC
Plaqueswithscalesonthefrontofa
knee(inpsoriasis)
(A)Excoriation,
(B)lichenificationon
theleg
(inatopicdermatitis)
A
B
(SourceofallphotosexceptforMacules:SauerGC:ManualofSkinDiseases,5thed.
Philadelphia,
JBLippincott,
1985)