Skin, Hair, and Nails

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Skin, Hair, and Nails

• B.Lokay, MD, PhD
• Institute of Nursing, TSMU

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Anatomy

• Epidermis
• Stratum germinativum (basal cell layer)
• Mitosis occurs here
• Contains melanocytes, producing melanin
• Stratum corneum
• As cells rise, they die and their cytoplasm is
  converted to keratin, which has a rough, horny
  texture
• This layer undergoes constant shedding
• Dermis
• Mostly connective tissue, primarily collagen
• Provides support and nourishment of epidermis
• Blood vessels, nerves, muscle, sweat glands,
  sebaceous glands, hair follicles
• Subcutaneous Layer (Hypodermis)
• Consists mostly of fat
• Provides protection, insulation, and caloric
  source

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Anatomy

• Hair
• Composed of keratin
• Can be fine (vellus hair) or darker and thicker
  (terminal hair)
• Sebaceous glands
• Produce sebum through hair follicles, which make
  skin oily. Prevent water loss.
• Sweat glands
• Eccrine smaller, coiled tubules which open to
  skin surface
• Apocrine larger, open to hair follicles.
  Located mainly in axillae and genital area.
  Produce thick secretions, which react with
  bacteria on skin surface to produce body odor
• Nails
• Composed of keratin
• Clear with highly vascular bed of epithelial
  cells underneath

Used to measures what?
Pulse oxymetry!
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Developmental Considerations

• Infants
• Lanugo fine soft hair present at birth
• Skin is thinner, less fat more prone to
  dehydration and hypothermia
• Pregnancy
• Linea nigra line down midline of abdomen
• Chloasma face of pregnancy
• Striae gravidarum stretch marks
• Aging
• Stratum corneum thins, loss of collagen, elastin,
  and fat, decrease of sebaceous and sweat glands,
• More prone to dehydration and hypothermia

Chloasma
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History

• History of skin disease
• What was it? How was it treated?
• Does it run in the family?
• Significant familial predispositions allergies,
  hay fever, psoriasis, eczema, acne
• Any know allergies?
• Any tattoos or birthmarks?
• Use of nonsterile equipment for tattoos increases
  risk of Hep C
• Change in pigmentation
• Might suggest systemic illness (jaundice)
• Change in a mole
• Pruritus
• Any dryness? Is it seasonal?
• Xerosis dry
• Seborrhea - oily

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History

• Excessive bruising
• Consider abuse
• Frequent minor trauma may be sign of alcohol
  abuse
• Rash or lesion
• Onset
• Location
• Spread
• Character or quality
• Duration
• Associative factors pets, co-worker?
• Alleviating and aggravating factors what have
  you tried to do?
• Patients perception - what do you think it is?
• Medications
• Prescription and over-the-counter
• May indicate allergy to medication

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History

• Hair loss or growth
• Gradual or sudden?
• Hirsutism unusual growth
• Change in nails
• Exposure to hazards
• May be environmental or occupational
• Bitten by bee, tick, mosquito?
• Exposure to plants or animals?
• Self care
• What cosmetics, soaps, chemicals?
• Possible allergies

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Physical Examination - Color

• General pigmentation should be even throughout
• Benign pigmented areas
• Freckles (macules) on sun exposed skin
• Nevi (moles)
• Junctional nevi macular only
• Compound nevi macular and papular
• Dysplastic - precancerous
• Birthmarks

• Vitiligo absence of melanin in patchy areas

• ABCDE of malignant melanoma
• Asymmetry one lesion that is
• not regularly round or oval
• Border irregular
• Color variations
• Diameter greater than 6mm
• Elevation

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Changes in Color in Light Skinned People

• Pallor
• Pale, white color caused by decrease of blood
  flow (vasoconstriction) or decrease in hemoglobin
• Shock, anemia
• Erythema
• Redness due to increased blood flow
  (vasodilation)
• Fever, inflammatory process, emotions, CO
  poisoning
• Cyanosis
• Bluish, purplish hue due to decreased perfusion
  of tissues
• Hypoxemia due to heart failure, shock, chronic
  bronchitis
• Jaundice
• Yellow, orange hue due to jaundice (increased
  bilirubin in blood)
• Due to liver problems such as hepatitis, cirrhosis

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Color Changes in Darker Skinned People

• Pallor
• Brown skinned people will be more yellow. Black
  skinned people will be more gray
• Palpebral conjunctiva and nail beds should be
  observed
• Erythema
• Cannot be observed
• If fever suspected, check skin for warmth. If
  edema, check skin for tightness
• Cyanosis
• Darker skinned people have normal bluish tone on
  lips
• Palms, but not clearly evident, other clinical
  signs should be observed
• Jaundice
• Hard and soft palate must be observed in addition
  to sclera of eyes
• Dark urine also present

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Skin Assessment (cont.)

• Temperature
• Check skin with dorsa of hands
• Hyperthyroidism may cause increase of temp
• Moisture
• Diaphoresis may occur during fever or exercise
• Dehydration can be observed by dry mucous
  membranes in mouth and cracked skin
• Mobility and Turgor
• Mobility is ease of skin rising when pinched.
  Turgor is returning back to its place
• Slow turgor can be indicative of dehydration.
  Tenting if severe dehydration.
• Lesions
• A lesion is any traumatic or pathological change
  in skin
• Describe using ABCDE, also noting location and
  exudate
• Roll nodule gently between fingers to assess
  depth
• Ultraviolet light is used if fungal infection
  suspected (Woods light)

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Skin Assessment - shapes

• Annular
• Circular, beginning in center and spreading to
  periphery (ringworm)
• Polycyclic
• Annular lesions that grow together
• Confluent
• Lesions run together (hives)
• Discrete
• Individual lesions that remain separate

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Shapes

• Grouped
• Clusters of lesions (contact dermatitis)
• Gyrate
• Twisted, coiled
• Target
• Concentric rings of color
• Linear
• Scratch like, stripe
• Zosteriform
• Follow nerve route (shingles)

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Primary vs. Secondary

• Primary skin lesions
• Variations in color or texture that may be
  present at birth, such as moles or birthmarks, or
  that may be acquired during a person's lifetime,
  such as those associated with infectious diseases
  (e.g. warts, acne, or psoriasis), allergic
  reactions (e.g. hives or contact dermatitis), or
  environmental agents (e.g. sunburn, pressure, or
  temperature extremes).
• Secondary skin lesions
• Changes in the skin that result from primary skin
  lesions, either as a natural progression or as a
  result of a person manipulating (e.g. scratching
  or picking at) a primary lesion.

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Primary Skin Lesions

• Macule
• color change and less than 1 cm
• may be to darker or lighter
• Freckles, flat nevi, hypopigmentation, petechiae
• Patch
• Color change and greater than 1cm
• Mongolian spots, vitiligo, chloasma

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Primary Skin Lesions

• Papule
• Elevated lesion less than 1cm in diameter
• Due to elevation in epidermis
• Ex wart, elevated nevus
• Plaque
• Elevation greater than 1cm in diameter
• Ex psoriasis

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Primary Skin Lesions

• Nodule
• Elevated solid greater than 1cm
• Extending deeper into dermis
• Tumor
• Greater than few cm in diameter
• May be firm or soft

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Primary Skin Lesions

• Wheal
• Superficial, raised, transient, and erythematous
  lesion
• Ex. Mosquito bite, allergic reaction

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Primary Skin Lesions

• Cyst
• Encapsulated fluid filled cavity in dermis or
  subcutaneous layer
• Vesicle
• Elevated cavity containing free fluid, clear
• Less than 1cm diameter
• Ex herpes simplex, varicella zoster

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Primary Skin Lesions

• Bulla
• Larger than 1cm in diameter
• Superficial in epidermis, thin walled
• Ex blisters, burns
• Pustule
• Pus in cavity
• Ex impetigo, acne

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Secondary Skin Lesions

• Crust
• Thick, dry exudate after rupture or drying up of
  vesicle or pustule
• Ex Impetigo, scab following abrasion
• Scale
• Dry or greasy flakes of skin resulting from
  shedding of excess keratin cells
• Ex psoriasis, eczema, seborrheic dermatitis

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Secondary Skin Lesions

• Fissure
• Linear cracks extending into dermis
• Ulcer
• Deep depression extending into dermis
• May bleed. Leave scar.
• Excoriation
• Self inflicted abrasion often from scratching

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Secondary Skin Lesions

• Lichenification
• Tightly packed papules from prolonged intense
  scratching
• Keloid
• Hypertrophic scar
• Cannot be removed surgically
• More common in black people

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Skin Lesions associated with AIDS Kaposis
Sarcoma

• Patch stage
• Early lesions are faint and pink
• Advanced stage
• Widely disseminated lesions involving skin,
  mucous membranes, and visceral organs
• Violet colored tumors on nose and face
• Epidemic stage
• Lesions develop into raised papules of thickened
  plaques.
• Oval in shape and vary in color from red to brown.

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Hair and Scalp

• Ringworm may develop in scalp of school age
  children
• Abnormalities in amounts and location of hair can
  be attributed to hormonal problems
• Hirsutism excess body hair
• Observe for head or pubic lice, which are white
  ovals on hair shafts.
• Dandruff is indicated by loose white flakes

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Abnormal Conditions of Hair

• Tinea capitis (scalp ringworm)
• Lesions fluoresce blue-green under Woods light
• Highly contagious
• Toxic alopecia
• Asymmetric balding that accompanies severe
  illness or chemotherapy
• Regrowth after discontinuation of toxin

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Abnormal Conditions of Hair

• Folliculitis
• Superficial infection of hair follicles
• Multiple pustules
• Furuncle and Abscess
• Red, swollen, hard, tender, pus-filled lesion due
  to acute localized bacteria (staph)
• Usually on back of neck, buttocks, wrists, or
  ankles
• Furuncle is due to infected hair follicles
• Abscess is due to traumatic introduction of
  bacteria into the skin. Deeper than furuncle

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Nails

• Good indicators of respiratory system health
• Nail base
• Normal is about 160
• Clubbing is the decrease of the angle of nail
  base (lt160) that occurs as a result of
  respiratory insufficiency, common in COPD
  (emphysema, chronic bronchitis)
• In early clubbing, the angle actually increased
  to about 180
• Spongy nails

Physiology of clubbing is not fully understood
but respiratory insufficiency seems to dilate
peripheral arteries, causing a round fingernail
shape
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Nails

• Consistency
• Variant thickness may suggest malnutrition
• Thickening of nails is sign of arterial
  insufficiency
• Color
• Note any pigmentations melanoma?
• Cyanotic nail beds poor peripheral circulation
• Capillary refill
• Indicator of peripheral circulation
• Measured by depressing the nail bed until it is
  white and observing the time it takes for blood
  to return back to the nail
• Normal time is less than 1-2 seconds and is
  indicated as brisk. Sluggish if greater than
  2 seconds.

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Developmental Considerations - Infants

• Mongolian spots
• Hyperpigmentation of sacrum, buttocks, abdomen,
  thighs, shoulders, or arms
• Very common in blacks, Asians, and Native
  Americans
• Should not be confused with abuse
• Café au lait
• Coffee with milk
• Patches of hyperpigmentation
• Normal

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Developmental Considerations - Infants

• Acrocyanosis
• Bluish color around lips, hands, and feet
• Usually is due to coolness and disappears after
  warming up
• Persistent cyanosis is indicative of congenital
  heart disease
• Cutis marmorata
• Mottling of trunk and extremities due to coolness
• If persistent, usually indicative of Down
  syndrome
• Physiological jaundice
• Common yellowing of skin in newborns, which
  usually appears after 4th day. UV light helps.
• Carotenemia
• Yellowing of skin due to ingestion of large amts
  of carotene.

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Developmental Considerations - Adolescents

• Acne
• Most common skin problem
• Acne occurs when the hair follicles, which are
  connected to sebaceous glands, become plugged
  with oil and dead skin cells.
• Usually appear on face, shoulders, back, and
  chest
• Can include papules, pustules, and nodules
• Open comedones (blackheads)
• Closed comedones (whiteheads)

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Acne

• Open comedones are a less severe form of acne

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Vascular Lesions - Hemangiomas

• Port-Wine Stain (Nevus Flammeus)
• Flat macular patch of mature capillaries
• Benign
• Strawberry Mark (Immature hemangioma)
• Raised bright red area
• Usually disappears by age 7
• Cavernous Hemangioma

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Developmental Considerations - Pregnancy

• Striae
• Linea nigra
• Chloasma
• Vascular spiders

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Developmental Considerations - Aging

• Senile lentigines
• Liver spots melanocyte clusters
• Usually on hands and face
• Seborrheic keratosis
• Raised, thick, crusted mole
• Dry skin is common
• Acrochordons
• Overgrowths of skin normal
• Frequently occur on back, eyelids, axillae

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Developmental Considerations - Aging

• Decreased turgor, tenting of skin occurs
• Hair growth decreases, thins
• Fungal infections of toenails

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Teaching Self-Exam
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Pressure Ulcers

• Stage I
• A reddened area on the skin that, when pressed,
  is "non-blanchable" (does not turn white). This
  indicates that a pressure ulcer is starting to
  develop.
• Stage II
• The skin blisters or forms an open sore. The area
  around the sore may be red and irritated.

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Pressure Ulcers

• Stage III
• The skin breakdown now looks like a crater where
  there is damage to the tissue below the skin.
• Stage IV
• The pressure ulcer has become so deep that there
  is damage to the muscle and bone, and sometimes
  tendons and joints.

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Braden Scale

• Sensory Perception
• Activity
• Mobility
• Skin Moisture
• Friction and Shear
• Nutrition

• 1-4 with the exception of friction shear
  subscale 1-3
• Range 4-23
• The lower the score the higher the risk
• Eighteen or less high risk older adult

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Question 1

• A nurse is reviewing the health care records of
  clients scheduled to be seen at the health care
  clinic. The nurse determines that which of the
  following individuals is at the greatest risk for
  development of an integumentary disorder?
• An elderly female
• An adolescent
• An outdoor construction worker
• A physical education teacher

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Question 2

• A clinic nurse notes that the physician has
  documented a diagnosis of herpes zoster in a
  clients chart. On the basis of an understanding
  of the cause of this disorder, the nurse would
  determine that this definitive diagnosis was made
  following which diagnostic test?
• Skin biopsy
• Woods light examination
• Culture of the lesion
• Patch test

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Question 3

• A nurse is assessing for the presence of cyanosis
  in a dark-skinned client. The nurse understands
  that which body are would provide the best
  assessment?
• Back of hands
• Earlobes
• Palms of hands
• Sacrum

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Question 4

• Which of the following clients would least likely
  be at risk for the development of skin breakdown?
• A client who is unable to move about and is
  confined to bed
• A client incontinent of urine and feces
• A client with chronic nutritional deficiencies
• A client with a lowered mental awareness

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Question 5

• A nurse provides home care instructions to a
  client diagnosed with impetigo. Which of the
  following would not be a component of the
  teaching plan?
• Continue with the antibiotics prescribed
• Wash the clients dishes separately from those of
  other household members
• It is not necessary to separate the clients
  linin and towels from those of other household
  members
• Wash hands thoroughly and frequently throughout
  the day