Skin, Nail, and Hair Assessment

Skin, Nail, Hair Assessment Overview

• Assessment involves subjective data collection, objective data collection, technique and normal findings, and documentation of normal subjective and objective findings

Subjective Data Collection: Questions to Assess History and Risks

• Important to gather information on family history, past history, and medications
• Inquire about first-degree family members with a history of melanoma
• Determine who had the problem among family members
• Establish whether first-degree relatives exhibit multiple dark or irregular moles
• Ask about the frequency of skin self-examinations
• Establish timing of last clinical skin examination
• Inquire about any pigmented skin lesions, including their number, location, changes (itching, bleeding, non-healing, color, size, borders)
• Determine of any severe sunburns occurred, particularly during youth
• Establish how long the patient can be in the sun before their skin begins to turn red
• Inquire about skin cancer history, including when, where, and how it was treated
• Questions regarding any medications being taken
• Identify allergies to medications, latex, nuts, bees, or other items
• Establish how the patient reacted to the allergy and whether the patient is allergic to sunscreen

Subjective Data Collection: Lifestyle, Occupational History, and Personal Behaviors

• Questions about Lifestyle, occupational history and Personal Behaviors is important
• Inquire about the patient's occupation and hobbies
• Determine whether they are exposed to excessive sunlight or other sources of radiation
• Establish methods of protection against excessive sun exposure
• Determine the risk for skin breakdown
• Check for diabetes mellitus, peripheral vascular disease, or any known sensory loss

Objective Data Collection: Equipment Needed

• Examination gown
• Tape measure
• Adequate light source
• Magnifying glass

Technique and Normal Findings: Inspection

• All body areas must be inspected, starting with the head and progressing to the feet
• Visualize the scalp by parting the hair
• Make sure to assess the soles and separate the toes
• Note general skin color
• Consistent body pigmentation is a normal finding
• Patients with dark skin may have hypopigmented palms and soles

Technique and Normal Findings: Inspection of Lesions

• If lesions are observed, identify their morphology, configuration, distribution pattern, size, and exact location
• Common benign lesions include freckles, birthmarks, skin tags, moles, and cherry angiomas

Lesion Configurations

• Annular: Ring-like, circular
• Arciform: Half-ring
• Linear: Line-shaped
• Polymorphous: Several different shapes
• Serpiginous: Curving, snake-like
• Nummular/Discoid: Coin-shaped
• Umbilicated: Central depression
• Punctuate: Small, points or dots
• Filiform: Papilla-like, like tongue papillae

Lesion Distribution Patterns

• Asymmetric: Distributed solely on one side of body
• Diffuse: Distributed widely across affected area without any pattern
• Localized: Located at distinct area
• Symmetric: Distributed equally on both sides of body

Primary and Secondary Skin Lesions: Definitions

• Primary skin lesions are present at the onset of a disease
• Secondary skin lesions arise from changes over time, disease progression, manipulation, or treatment
• Secondary lesions evolve from primary lesions or result from patient activities

Primary Skin Lesions

• Macule
• Papule
• Patch
• Plaque
• Nodule
• Vesicle
• Bulla

Secondary Skin Lesions

• Ulcer
• Crust
• Atrophy
• Scar
• Erosion
• Fissure

Skin Tumors and Growths

• Lipoma: Tumors of fat cells, commonly found on the back of the neck, torso, arms, and legs (benign, some are painful)
• Lentigo: Benign, acquired, circumscribed, pigmented macules on sun-exposed skin
• Squamous Cell Carcinoma: Related to actinic keratosis and sun exposure. Lesions are papular, modular, or plaques
• Kaposi Sarcoma: Opportunistic skin infection due to impaired immune status. Lesions occur on the nose, penis, and extremities; with advanced HIV, distribution may be generalized.
• Basal Cell Carcinoma: Modular or papular skin cancer that appears shiny with a rolled pearly border and spider veins. It grows slowly and rarely metastasizes

Technique and Normal Findings: Additional Inspection Procedures

• Inspect for infections using infection-control principles
• Note inflammatory lesions and observe for growths, tumors, or vascular lesions
• Shape, length, width, and depth of wounds or incisions
• For deep or tunneled wounds, use a cotton applicator to measure depth
• Describe wounds related to trauma. Assess blood supply and note bleeding or ecchymosis
• Identify risk for skin breakdown, especially in hospitalized or inactive patients
• Classify the wound and identify the stage if a pressure ulcer is present
• Note size, depth, margins, surrounding tissues, drainage, odor, and necrotic tissue of wounds
• Note color and texture of the tissue.
• Note characteristics of non-pressure ulcers

Technique and Normal Findings: Inspection of Nails

• Inspect each fingernail and toenail for color, thickness, and consistency
• Nails should be smooth, translucent, and consistent in color and thickness
• Longitudinal ridging is common in aging patients
• Longitudinal pigmentation in dark-skinned patients is a normal variant
• Assess the nail angle by having the patient place their fingernails together
• A diamond-shaped opening should be visible between the two fingernails, indicating a nail angle of at least 160 degrees

Technique and Normal Findings: Inspection of Hair

• Inspect the hair noting color, consistency, distribution, areas and condition of the hair shaft
• Hair should be equally and symmetrically distributed across the scalp
• Note areas of decreased or absent hair and any lesions or color changes
• Scalp skin color should be consistent with the rest of the body

Abnormal Nail Findings

• Koilonychia (Spoon Nails), Longitudinal Ridging, Pitted Nails, Yellow Nails, Clubbing and Beau's Lines

Alopecia Areata

• Autoimmune disorder resulting in noninflammatory loss of hair in a circumscribed distribution

Technique and Normal Findings: Palpation

• Use the dorsal surface of the hands to assess skin temperature, which should be consistently warm or cool and appropriate to the environment
• Use the palmar surface of the fingers and hands to assess skin moisture and texture
• Skin moisture should be consistent throughout with evenly smooth skin texture

Technique and Normal Findings: Palpation - Skin Turgor

• Grasp a fold of skin between the fingers and pull up, then release
• Skin should promptly recoil to its normal position

Technique and Normal Findings: Palpation - Vasularity & Hair

• Assess for vascularity by applying direct pressure to the skin surface with the pads of the fingers
• Color should promptly return to normal upon releasing
• Palpate lesions for tenderness, mobility, and consistency
• Palpate each fingernail; they should be smooth, nontender, and firmly adherent to the nail bed
• Lateral and proximal nail folds should be nontender and nonswollen
• Grasp 10 to 12 hairs and gently pull to assess hair loss; only a few hairs should be removed

Documentation of Normal Subjective and Objective Findings

• The patient denies pruritus, skin lesions, and excessive dryness of the skin, as well as any changes to existing moles
• Skin is evenly colored, smooth, soft, consistently warm, with intact turgor, and without suspicious lesions
• Nails are smooth and translucent, with lateral and proximal folds free from swelling or erythema
• Hair has a smooth texture, is symmetrically distributed on the scalp, exhibiting consistent coloration and hydration, without excessive breakage or loss
• Scalp shows consistent pigmentation with no lesions noted