Skin Variation with Age

Variation in Skin with Age

• Infants/young children have smoother skin, lack exposure to elements, and have less subcutaneous fat
• Infants/young children have poorer temperature control, and are more prone to hypothermia
• Eccrine sweat glands in infants/young children secrete after 1 month, producing sweat
• Acrocyanosis in newborns presents as persistent blue or cyanotic discoloration of extremities
• Acrocyanosis occurs most commonly in the hands, but can also be in feet and distal parts of the face
• Transient mottling is the appearance of uneven spots, also known as Cutis Marmorata
• Transient mottling is a physiological response to cold, blood vessels constrict and dilate unevenly, appearing bluish or reddish
• Erythema toxicum is characterized by blotchy red spots on the skin with overlying white or yellow papules or pustules
• Erythema toxicum is a common, temporary, and benign rash in neonates
• Harlequin sign is unilateral flushing and sweating of the face and neck, typically after heat or strenuous exertion
• Harlequin sign is temporary and benign, causing a distinct color change where one side turns red and the other remains pale
• Uneven blood vessel dilation causes Harlequin sign
• Mongolian spots are also known as "Mongolian blue spot", "congenital dermal melanocytosis", and "dermal melanocytosis"
• Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes
• Mongolian spots present as bluish-gray patches usually on the lower back or buttocks
• Mongolian spots are caused by melanocytes being trapped in the deeper layers of the skin during fetal development
• Telangiectatic nevi (stork bite) appear as pink or tanned, flat, irregularly shaped marks
• Telangiectatic nevi can be found on the knee, back of the neck, forehead, eyelids, and sometimes the top lip
• Telangiectatic nevi are caused by dilated blood vessels near the skin's surface
• Jaundice presents as yellowish discoloration of the skin
• Milia are also called milk spots or oil seeds
• Milia are keratin-filled cysts appearing under the epidermis or on the roof of the mouth
• Milia are commonly associated with newborns but can appear on people of all ages
• During adolescence, apocrine glands enlarge and become more active
• During adolescence, increased sebaceous glands production causes oily skin and predisposition to acne
• Also during adolescence, terminal hair appears in axillae and pubic area for both sexes, and on the face in males
• During pregnancy, blood flow to the skin increases to balance heat production from increased BMR (Basal Metabolic Rate)
• Pregnancy causes increased eccrine/sebaceous gland activity, fat deposits, and pigmentation of the face. nipples, areola, etc
• In older adults there is decreased blood flow to skin, eccrine/sebaceous gland activity, fat deposits, and pigmentation
• In older adults, hair production decreases and coarseness increases
• Pigmentation decreases first in Whites, and later in Blacks and Asians

Variation in Skin by Race

• Asians, Latinos and Blacks have varying intensity of pigmentation, and pink to light brown mucous membranes
• Asians, Latinos and Blacks often have white, gray, or light brown sclera with pigmented spots, and common Mongolian markings
• Asians, Latinos and Blacks have a visible difference in pigmentation of ventral and dorsal extremity surfaces
• Asians, Latinos, and Blacks have skin with limited apocrine/sebaceous glands, and frequent washing causes increased dryness
• Asians, Latinos and Blacks have fine-colored skin lesions that are harder to see than in Caucasians
• Pigmentary changes due to lesions may persist for months or years in Asians, Latinos and Blacks
• Lichenification is common with eczema, as well as hypertrophic scars, and keloids in Asians, Latinos and Blacks
• Whites have less variation in pigmentation intensity, pink mucous membranes, and white sclera
• Whites commonly have terminal hair on their body, and hair texture and color vary
• Whites have skin with increased apocrine glands, resulting in increased body sweat
• Whites have increased sebaceous glands that lubricate skin and scalp, requiring frequent washing

Assessment Techniques

• Assessment of skin, hair, and nails involves inspection and palpation
• Inspection involves checking for lesions, skin color, and areas of pain or itching
• Palpation involves checking for moisture, temperature, texture, turgor, mobility, capillary filling, and elevation or depression

Skin Lesions

• Primary lesions are the initial appearance of a pathological process
• A macule is a flat primary lesion less than 1 cm, a patch is wider than 1 cm
• A papule is an elevated primary lesion less than 1 cm, a plaque is wider than 1 cm
• A nodule is a deeper primary lesion between 1 and 2 cm, and a tumor if wider than 2 cm
• A vesicle is a primary lesion that makes a bubble less than 1 cm and a bulla that is wider than 1 cm
• A pustule is a primary lesion that is a purulent vesicle
• A wheal is a primary lesion that is a hive
• Secondary lesions are changes in primary lesions due to external trauma
• Scaling skin is the loss of the outer layer of the epidermis in large flakes
• A scar is areas of fibrous tissue (fibrosis) that replace normal skin after injury
• Crust or scab is the dried crusty surface of a healing skin wound or sore
• Keloid is a growth of extra scar tissue where the skin has healed after an injury
• Fissures are cutaneous conditions in which there is a linear-like cleavage of skin, sometimes extending into the dermis
• Lichenification is the hardening of the skin, usually caused by chronic irritation
• An erosion is the loss of some or all of the epidermis (the outer layer) leaving a denuded surface
• Atrophy is a condition in which the upper layers of skin get thin
• Excoriation is the act of abrading or wearing off the skin (scratching)
• An ulcer is a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue

Shapes of Lesions

• Linear: A line shape
• Round: A circular shape
• Annular: a round shape with central clearing
• Oval: an egg Shape
• Polycyclic: Interlocking circles.
• Morbilliform: Confluent, measle-like
• Zosteriform: Dermatomal (follows a skin nerve)
• Geographic patterns are white and dark pink mucous membranes on tongue's ventral surface
• Lacy: Delicate, net-like pattern
• Serpiginous: Snake-like
• Umbilicated: Depressed center
• Target / Iris/ Bullseye lesion: Concentric rings

Describing Lesions

• Erythematous: red
• Pink or Red
• Purple
• Ecchymotic: Black and blue
• Mottled: Patches of different colors
• Silver/White
• Blue
• Black
• Yellow
• Hyperpigmented
• Hypopigmented or Depigmented
• Amelanotic: lacking melanin

Describing Lesion Distribution

• Localized vs Generalized
• Symmetrical vs Asymmetrical
• Scattered vs Grouped
• Flexural or Extensor surfaces
• Intertriginous: Between folds of skin
• Sun exposed vs Covered
• Contact areas to clothing, jewelry or chemicals

Examples of Skin Conditions

• Hemangioma appears like a round papule, measuring 1 cm, situated superior to the outer canthus of the right eye, uniform dark red color
• Birthmark appears like hyperpigmented linear macules measuring 1x4.5 cm, inferior to right nipple
• Poison Ivy appears like linear vesicles on ventral surface of forearm, intensely itchy
• Measles appears like erythematous macular papular lesions spread throughout the entire body
• Herpes Zoster appears like grouped vesicles on an erythematous base scattered along R thoracic dermatome(s)
• Erythema Infectiosum presents with intense confluent redness of cheeks, lacy lesions, and mild fever
• Scabies appears like a serpigenous, elevated, itchy burrow @ 6cm on the base of R foot's toes 3-5
• Molluscum Contagiosum appears as small discrete circular papules with umbilicated center on the R elbow's inner aspect
• Café-au-lait Spot is hyperpigmented patch w/ irregular borders, 8 x 3 cm over L scapula, fades in summer
• Vitiligo presents with depigmented patches on the ventral side of the right hand; hair is also hypopigmented
• Erythema Nodosum is rapid-onset tender, raised bumps on extensor surfaces of the extremities; evolves into bruise; initially turns purple then yellow-brown
• Psoriasis Vulgaris is an erythematous plaque with silver-white patches on extensor surface of the legs
• Contact Dermatitis manifests as small white confluent papules extending across forehead onto scalp with 5cm band
• Nevus Flammeus is a Port-wine stain made of a dark red patch w/ distinct borders extending from R ear across cheek/chin
• Diaper Dermatitis can be contact related where a confluent, dry, dark red patch has well demarcated borders outlining the diaper area
• Diaper Dermatitis can be Candidiasis related when a darker red, slightly moist patch on perinuem and lower abdomen
• Acanthosis Nigricans presents as dry thickened hyperpigmented skin with linear fissures across posterior neck for obese patients
• Impetigo (Staph/Strep) has vesicles turning into honey-colored crusts on an erythematous base below the right nares & on bridge of nose
• Lichenification appears with dry thickened horizonal fissures, flexor surface knees and elbow, with intense itching
• Warts present as three dry hard verrucous (warty) papules on middle finger of R hand
• Primary Gingivostomatitis manifests with the patient presenting moist vesicles on an erythematous based encircling the mouth
• Bullous Impetigo manifests as large (20x20cm) bullae with shallow erosion, moist center in central abdominal location

Other Skin Conditions

• Urticaria presents as blotchy red irregularly shaped papules and plaques across the entire body, lesions fade and reappear rapidly
• Tinea Corporis presents as multiple oval plaques that has active, red, scaly, and prominent borders (ringworm)
• Viral exanthems unknown has etiology, present as scattered discrete erythematous papular lesions that are itchy/asymptomatic

Hair Assessment

• Hair assessments include inspection and palpation
• It includes analysis of color, texture (vellus or terminal, smooth or brittle, dry or moist), quantity, and distribution
• Other things inspected are scalp condition, hair loss and signs of infestation
• Pediculosis (head lice) appear as white ovoid eggs attached to hairshafts causing a very itchy scalp
• Tinea capitus is a type of ringworm that leads to dry crusted circulare lesions with lymph nodes on the scalp
• Traction Alopecia causes sparse hair growth which can be a result of broken hair

Nail Assessment

• Nail assessments include inspection and palpation for:
  • Color, length, symmetry, and cleanliness
  • Ridges, depressions, pitting
  • Nail base angle, evidence of clubbing
  • Firmness, thickness, separation
  • Capillary refill

Melanoma

• Melanoma can be assessed by the ABC*D rule
• A: Asymmetry of borders
• B: Border irregular
• C: Color blue-black or variegated
• D: Diameter greater than 0.6cm