PD Lecture 4 (Skin, Hair, Nails) PDF 2022

Physical Diagnosis Examination of Skin, Head and Nails Dr Joseph M Daleo DPA PA-C Skin is composed of 3 layers 1. Epidermis ◼ Most superficial layer, devoid of blood vessels ◼ Outer horney layer – Dead keratinized cells ◼ Inner cellular layer – Keratin and melanin produced 2. Dermis ◼ Contains blo...

Physical Diagnosis Examination of Skin, Head and Nails Dr Joseph M Daleo DPA PA-C Skin is composed of 3 layers 1. Epidermis ◼ Most superficial layer, devoid of blood vessels ◼ Outer horney layer – Dead keratinized cells ◼ Inner cellular layer – Keratin and melanin produced 2. Dermis ◼ Contains blood vessels, connective tissue, sebaceous glands and some hair follicles 3. Subcutaneous Tissue ◼ Contains fat, sweat glands and hair follicles SKIN STRUCTURE Skin ◼ Hair, nails, and sebaceous/sweat glands are all appendages of the skin Sebaceous glands ◼ Secrete protective fatty substance (sebum)which gains access to skin through hair follicle. Located on all skin surfaces except palms and soles Hair-2 Types ◼ Vellus – short, fine and unpigmented ◼ Terminal – Coarser and thicker Techniques of Examination Inspect and Palpate for ◼ Color Brownness, cyanosis, jaundice, redness or pallor ◼ Vascularity Evidence of bleeding or bruising ◼ Moisture Dryness, sweating or oiliness ◼ Temperature Feel skin with the back of hand ◼ Texture Roughness or smoothness ◼ Mobility and Turgor Observe Lesions of the Skin ◼ Anatomical Location Generalized or Localized ◼ Note the Arrangement Linear, clustered, annular, dermatomal etc. ◼ Identify Type of Lesion Macular, papular, vesicular etc. ◼ Note the Color Inspect and Palpate Fingernails and Toenails ◼ Color, shape and any lesions Inspect Mucus Membranes Moisture, pigmentation, cyanosis, pallor, Jaundice and any lesions ◼ Examples found in the mouth , nose, and eyelids ◼ Examine Head ◼ Hair Quality, distribution, pattern of hair loss, any nits? ◼ Scalp Part is several areas, look for scaliness, lumps etc. ◼ Skull General contour, deformities, lumps and tenderness ◼ Face Note facial expression, symmetry, facial droop ◼ Skin Color, pigment, texture, hair distribution and any lesions Head Examination Skin Lesions ◼ Primary Lesions May arise from previously normal skin ◼ Secondary Lesions Results from changes in the primary lesion Primary Lesions ◼ Flat Nonpalpable Changes in Skin Color 1. Macule ◼ Change in normal skin color without elevation or depression and less than 1 cm ◼ Freckle 2. Patch ◼ Greater than 1 cm ◼ Vitiligo, café-au-lait-spots Flat Nonpalpable Change in Skin Color Macule ◼ Change in normal skin color without elevation or depression and less than 1 cm ◼ Freckle Flat Nonpalpable Change in Skin Color Patch ◼ Greater than 1 cm ◼ Vitiligo, café-au-laitspots Palpable Elevated Solid Masses (Primary Lesions cont) 1. Papule ◼ Solid, raised and smaller than 1 cm ◼ Nevus, acne, warts and measles 2. Plaques ◼ Elevated and greater than 1 cm ◼ Psoriasis 3. Nodule ◼ 1-2 cm deeper and firmer than a papule or plaque ◼ Erythema nodosum 4. Tumor ◼ Spontaneous new growth greater 2 cm with no physiological function 5. Wheals ◼ Superficial area of localized skin edema ◼ Mosquito bite , urticaria Palpable Elevated Solid Mass Papule ◼ Solid, raised and smaller than 1 cm ◼ Nevus, acne, warts and measles Palpable Elevated Solid Mass Plaques ◼ Elevated and greater than 1 cm ◼ Psoriasis Palpable Elevated Solid Mass Tumor ◼ Spontaneous new growth greater 2 cm with no physiological function Flat Nonpalpable Change in Skin Color Wheals ◼ Superficial area of localized skin edema ◼ Mosquito bite , urticaria Free Fluid Between Skin Layers 1. Vesicle ◼ Circumscribed, elevated and up to 0.5 cm ◼ Herpes simplex, Impetigo, chicken pox and scabies 2. Bulla ◼ Fluid containing lesion greater 0.5 cm ◼ 2nd degree burn 3. Pustule ◼ Contains purulent exudate, conical and usually contain a hair in center ◼ Acne, pustular psoriasis Fluid In between Skin Layers Vesicle ◼ Circumscribed, elevated and up to 0.5 cm ◼ Herpes simplex, Impetigo, chicken pox and scabies Free Fluid Between Skin Layers Bulla ◼ Fluid containing lesion greater 0.5 cm ◼ 2nd degree burn Free Fluid Between Skin Layers Pustule ◼ Contains purulent exudate, conical and usually contain a hair in center ◼ Acne, pustular psoriasis Primary Lesions Secondary Lesions Loss of Skin Surface 1. Erosion ◼ Loss of superficial epidermis, moist but does not bleed ◼ Rupture of a vesicle 2. Ulcer ◼ Deeper loss of skin surface, may bleed and scar ◼ Extreme heat, cold, trauma, syphilis, carcinoma of skin ◼ Stasis ulcer, chancre 3. Fissure ◼ Linear crack or deep groove ◼ Eczema Loss of Skin Surface Ulcer ◼ Deeper loss of skin surface, may bleed and scar ◼ Extreme heat, cold, trauma, syphilis, carcinoma of skin ◼ Stasis ulcer, chancre Loss of Skin Surface Fissure ◼ Linear crack or deep groove ◼ Eczema - There is often subsequent peeling as the skin dries out, and then the skin can become red and dry with painful cracks (skin fissures) Material On Skin Surface 1. Crust ◼ Dried residue of serum, pus or blood ◼ Eczema, impetigo and tinea 2. Scale ◼ Thin flake of exfoliated epidermis ◼ Seborrhea, psoriasis, tinea and pityriasis rosea Material On Skin Surface Crust ◼ Dried residue of serum, pus or blood ◼ Eczema, impetigo and tinea Material On Skin Surface Scale ◼ Thin flake of exfoliated epidermis ◼ Seborrhea, psoriasis, tinea and pityriasis rosea Miscellaneous Skin Lesions 1. Lichinification ◼ Thickening and toughening of skin-caused by eczema and other chronic skin conditions 2. Atrophy ◼ Thinning of skin and loss of normal skin furrows 3. Excoriation ◼ Abrasion or scratch mark of epidermis 4. Scar ◼ Replacement of destroyed tissue by fibrous connective tissue Miscellaneous Skin Lesions 5. Comedo ◼ Blocked Sebaceous gland; Blackhead 6. Telangiectasia ◼ Dilated small blood vessels 7. Sclerosis ◼ Hardening of skin 8. Keloid ◼ Elevated enlarging scar beyond boundaries of the wound Miscelaneous Lichinification ◼ Thickening and toughening of skin Skin colors 1. Cyanosis ◼ Bluish discoloration of mucus membranes and skin ◼ Seen with reduced or deoxygenated hemoglobin ◼ Modified by skin color and skin thickness ◼ Not present with severe anemia ◼ Right to left shunt greater than 25% ◼ Best seen tongue, lips, earlobes, finger and toes Cyanosis 1. Central Cyanosis ◼ Low concentration of arterial oxygen ◼ Poor oxygenation in the lungs ◼ Right to left shunt 2. Peripheral Cyanosis ◼ Due to sluggish circulation with increased extraction of oxygen by the tissues ◼ From vasoconstriction and diminished peripheral blood flow ◼ Seen with exposure to cold, heart failure and peripheral vascular disease Cyanosis Jaundice ◼ A.K.A. Icterus ◼ Yellow color of the skin and sclera caused be deposition of bilirubin ◼ Commonly found in the sclera, lips, hard palate, undersurface of tongue and skin Jaundice Types of jaundice 1. Hemolytic ◼ Massive lysis of RBC 2. Obstructive Jaundice ◼ Due to obstruction of the bile ducts 3. Hepatocellular Jaundice ◼ Damage to liver cells prevents uptake and conjugation of bilirubin Carotenemia ◼ Yellowing of skin caused by diet high in carrots and other yellow vegetables and fruits. ◼ Unlike Jaundice the sclera remains white Carotenemia Pallor ◼ Lack of color or paleness of the skin ◼ Seen with anemia or deoxygenated blood ◼ Seen where epidermis is the thinnest ◼ Fingernails , lips, and mucus membranes Skin Elasticity and Turgor 1. Elasticity ◼ Ease with which skin moves 2. Turgor ◼ Speed with which skin returns into place ◼ Dependent on interstitial volume of skin and subcutaneous tissue ◼ Check skin in thigh, calf or forearm ◼ Elasticity diminishes in the elderly, inspect inner thigh or skin overlying the sternum Changes in Melanin 1. Café-au-lait spot ◼ Uniformly pigmented macule or patch ◼ Most are 0.5-1.5 cm ◼ Six or more larger than 1.5 cm suggest neurofibromatosis 2. Vitiligo ◼ Depigmented macules on face, hands, feet and may coalesce into extensive areas that lack pigmentation 3. Tinea Versicolor ◼ Superficial fungal infection ◼ Hypopigmented macules on trunk and upper extremities ◼ Easier to see on dark people or after tanning Changes in Melanin Café-au-lait spot ◼ Uniformly pigmented macule or patch ◼ Most are 0.5-1.5 cm ◼ Six or more larger than 1.5 cm suggest neurofibromatosiscondition in which tumors grow in nervous system Changes in Melanin Vitiligo ◼ Depigmented macules on face, hands, feet and may coalesce into extensive areas that lack pigmentation Tinea Versicolor Tinea versicolor is a common, benign, superficial cutaneous fungal infection usually characterized by hypopigmented or hyperpigmented macules and patches on the chest and the back. In patients with a predisposition, tinea versicolor may chronically recur Vascular and Purpuric Lesions 1. Spider Angioma ◼ Bright red, pulsatile lesion with central arteriole and slender projections ◼ Compression of central vessel obliterates the lesion ◼ Small number of lesions insignificant ◼ Patients with hepatic cirrhosis develop a significant amount 2. Spider Veins ◼ Bluish vessels of no significance ◼ Found on chest and lower legs ◼ Pressure over center does not cause blanching Vascular and Purpuric Lesions 3. Cherry Angioma ◼ Bright red macule or papule 1-3 mm in size, no significance 4. Petechia ◼ Deep red or purple fading over time, smaller than 0.5cm 5. Purpura ◼ Larger than 0.5 cm 6. Ecchymosis ◼ Blood outside the vessels ◼ Usually due to trauma or bleeding disorders ◼ Color fades with time Vascular and Purpuric Lesions Spider Angioma ◼ Bright red, pulsatile lesion with central arteriole and slender projections ◼ Compression of central vessel obliterates the lesion ◼ Small number of lesions insignificant ◼ Patients with hepatic cirrhosis develop a significant amount Vascular and Purpuric Lesions Spider Veins ◼ Bluish vessels of no significance ◼ Found on chest and lower legs ◼ Pressure over center does not cause blanching Vascular and Purpuric Lesions Cherry Angioma ◼ Bright red macule or papule 1-3 mm in size, no significance Vascular and Purpuric Lesions Petechia ◼ Deep red or purple fading over time, smaller than 0.5cm Purpura ◼ Larger than 0.5 cm Vascular and Purpuric Lesions Ecchymosis ◼ Blood outside the vessels ◼ Usually due to trauma or bleeding disorders ◼ Color fades with time Atopic Dermatitis ◼ Pruritic inflammation of the epidermis ◼ 2/3 with family or personnel history of allergic rhinitis, hay fever or asthma ◼ Pruritis is essential for the DX ◼ The itch that rashes ◼ Itch-Scratch-Rash-itch Atopic Dermatitis ◼ Poorly defined erythematous patches, papules and plaques ◼ Skin is edematous and puffy may have excoriations from scratching ◼ Lichinification from repeated scratching ◼ Itching may be severe Atopic Dermatitis ◼ Distribution typically affects face neck and upper trunk ◼ The bends of the arms and knees frequently involved ◼ In infants eruptions on the cheeks are common ◼ Food allergy accounts for 30% Atopic Dermatitis ◼ Must avoid anything which dries the skin ◼ Avoid hot showers ◼ Drying soaps ◼ Use mineral oils ◼ Dairy and wheat product s are most common food offenders ◼ Corticosteroids in lotion or ointment work quite well Atopic Dermatitis Atopic Dermatitis Seborrheic Dermatitis / Dandruff ◼ Very common dermatosis ◼ Redness and scaling occurring where sebaceous glands are most active ◼ Scalp, face, chest, eyelids and body folds may be oily with dry yellowish scales ◼ +/- pruritis ◼ Mild scalp scaling without erythema termed simple dandruff ◼ Zink, tar or selenium containing shampoos, topical steroids when necessary Seborrheic Dermatitis / Dandruff Candidiasis ◼ Candida Albicans common flora ◼ Opportunistic pathogen ◼ Can typically be cultured from mouth, feces and vagina ◼ Increase in fungal infections due to use of broad spectrum antibiotics and number of immunocompromised patients Oral Candidiasis (Thrush) ◼ Creamy white curd like patches ◼ Underlying erythema ◼ Seen with denture wearers, diabetics, anemia, chemotherapy, corticosteroids or broad-spectrum antibiotics ◼ Often seen prior to manifestation of HIV ◼ Confirm spores on wet slide ◼ Tx with Fluconizole Oral Candidiasis (Thrush) Esophageal Candida ◼ Patient presents with odynophagia, reflux, may have substernal chest pain ◼ Oral Candida not always present ◼ Therapy varies ◼ Tx. Fluconazole Vulvovaginal Candida ◼ 75% of females during lifetime ◼ Risk factors include; pregnancy, diabetes, antibiotics, corticosteroids and HIV ◼ Symptoms include; acute vulvar pruritis, burning vaginal discharge and dyspareunia ◼ Tx. with topical preparations such as Miconizole Tinea / Ringworm Superficial infection caused by dermatophytes; fungi which invade dead skin cells ◼ Scaling, erythema, and reddish patches Types ◼ Tinea Corporis – Body ◼ Tinea Pedis – feet ◼ Tinea Unguium - nails ◼ Tinea Capitis - Scalp ◼ Tinea Cruris - Jock itch ◼ Tinea Barbae- Bearded areas ◼ Tinea Diagnosis and Treatment ◼ Scrapings of the affected tissue demonstrate the pathogenic fungus under the microscope ◼ Treatment with topical antifungal preparations and systemic treatment for difficult cases Tinea Capitus Tinea Psoriasis ◼ Acute or chronic skin condition ◼ Genetic predisposition ◼ Injury or irritation induces lesions (Koebners phenomenon) ◼ Sliver scales on clearly demarcated red plaques ◼ Typically affects scalp and the extensor side of knees and elbows. May have nail pitting and seperation Psoriasis ◼ Differential diagnosis ◼ Atopic dermatitis poorly demarcated lesions on the flexor surfaces ◼ Seborrheic dermatitis diffuse pathcy redness ◼ Candida differentiated by scrapings and cultures Psoriasis Basal Cell Carcinoma ◼ Most common skin cancer ◼ Sun exposed skin of fair skinned patients ◼ Seen in 20-30’s not uncommon in 50’s ◼ Papule or nodule ◼ Waxy, pearly appearance with telangiectatic vessels. Has a translucent quality ◼ Typically found on eyelids, medial canthi, nose, lips and behind the ears ◼ Does not metastasize ◼ May cause cosmetic deformity ◼ Biopsy, excise and suture Basal Cell Carcinoma Squamous Cell Carcinoma ◼ Sun exposed, fair skinned patients Red, conical, hard nodules that may ulcerate ◼ Most (95% to 98%) of squamous cell carcinomas can be cured if they are treated early. Can develop from a precancerous skin growth called actinic keratosis ◼ Biopsy, excision and suture ◼ ◼ Close follow-up needed ◼ Very common in organ transplant patients (immunocompromised) Squamous Cell Carcinoma Malignant Melanoma ◼ Leading cause of death from skin disease Vary from macules to nodules and may vary in color ◼ ABCDEF Warning Signs of Melanoma ◼ A. Asymmetry of shape B. Boarder irregularity C. Color variation D. Diameter greater than 6 mm E. Elevation irregularity F. Friable- easily crumbled or broken apart ◼ ◼ ◼ ◼ ◼ ◼ Melanoma Detection Malignant Melanoma Actinic Keratosis ◼ Superficial flattened papules covered by dry scales. ◼ Appear on sun exposed skin of older fair skinned patients ◼ Benign but may give rise to Squamous cell carcinoma Actinic Keratosis Seborrheic Keratosis ◼ Common, benign yellowish to brown raised lesions ◼ Have a greasy or velvety feel ◼ Generally appears on face and trunk ◼ Normally benign Seborrheic Keratosis Disorders of the hair 1. Alopecia Areata ◼ Common disorder of unknown etiology ◼ Usually appears in early adulthood ◼ Ranges from small circular loss of hair to total loss of hair over the entire body 2. Male pattern Alopecia ◼ Genetically determined autosomal dominant- inherited from only one parent 3. Hirsutism ◼ Excessive growth of hair with many causes Alopecia Areata Hirsutism Trichotillomania ◼ Compulsive hair pulling. An impulse control disorder characterized by the repeated urge to pull out scalp hair, eyelashes, eyebrows, or other body hair. Treatment may include cognitive-behavior therapy and medications. Trichotillomania Examination of the Nails 1. Onychomycosis ◼ Fungal infection of the nails ◼ Lusterless and brittle nails ◼ Scrapings examined under microscope for hyphae ◼ Difficult to treat especially toenails ◼ Systemic treatment often required ◼ Griseofulvin- oral antifungal Onychomycosis Examination of the Nails 2. Beau’s Lines ◼ Horizontal depression across nail beds ◼ Transient arrest in cell growth ◼ Due to acute stress from trauma or infection ◼ Nail plate takes 3-4 months to grow out Beau’s Lines Examination of the Nails 3. Clubbing ◼ Bulbous enlargement of the fingertips ◼ Angle of proximal nail fold and nail plate exceeds 180 degrees ◼ Nail has a spongy, floating quality ◼ Typical of chronic pulmonary and cardiac disease ◼ Takes 4 weeks to develop and disappears 6 weeks after cure Clubbing and Cyanosis Examination of the Nails 4. Koilonychia ◼ Called spoon nails ◼ Seen with Iron deficiency Also seen with Plummer –Vinson Syndrome ( rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs, also hemochromatosis and Raynaud’s syndrome Koilonychia-spoon nails Examination of the Nails 5. Onycholysis ◼ Distal separation of the nail plate from the nail bed. ◼ Excessive exposure to water and soaps ◼ Also seen with psoriasis and thyroid disease Onycholysis Examination of the Nails 6. Paronychia ◼ Inflammation of the proximal and lateral nail folds. Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacteria Staph aureus, or gradually when it is commonly caused by Candida albicans. Folds are swollen, red, and tender. People who immerse their hands in water are susceptible Paronychia Capillary Refill (special test) The time taken for color to return to an external capillary bed after pressure is applied to cause blanching. It can be measured by holding a hand higher than heartlevel, pressing the soft pad of a finger or fingernail until it turns white, and taking note of the time needed for the color to return once pressure is released Normal is < 2 seconds The Head and Face 1. Acromegaly ◼ Hyper secretion of growth hormone ◼ In childhood leads to gigantism ◼ In adulthood leads to acromegaly ◼ Coarsening of facial features, bony prominence of forehead, nose and lower jaw Acromegaly The Head and Face 2. Nephrotic Syndrome ◼ Increase in glomerular permeability ◼ Allows proteins to escape in urine ◼ Features proteinuria, hypoalbuminemia, edema and hyperlipidemia ◼ Swollen eyes in the morning Nephrotic Syndrome A kidney disorder that causes your body to pass too much protein in your urine. The Head and Face 3. Cushing's syndrome ◼ Over secretion of cortisol from adrenal gland or from exogenous source ◼ Moon Face with red cheeks ◼ May have excessive hair growth Cushing’s Syndrome Cushing syndrome occurs when your body is exposed to high levels of the hormone cortisol for a long time. Cushing syndrome, sometimes called hypercortisolism, may be caused using oral corticosteroid medication. The Head and Face 4. Myxedema ◼ Characteristic of severely advanced hypothyroidism ◼ Dull puffy face ◼ Edema pronounced around the eyes and does not pit ◼ The hair and eyebrows are thin and coarse Myxedema The Head and Face 5. Parkinson's disease ◼ Degenerative CNS disease ◼ Decreased facial mobility with blunt expression, mask like face ◼ Face and upper neck flexed forward ◼ Facial skin oily Parkinsons Facial Features Sample write up Write Up: ◼ Skin: warm and moist, good turgor. Nonicteric, without lesions, scars, tattoos. ◼ Hair: Average quantity and distribution ◼ Nails: No clubbing; Capillary refill < 2 sec throughout ◼ Head: Normocephalic, atraumatic, non tender, no masses ◼ Clinical Scenarios