Skin Examination

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Skin Examination

• Pharmacy Practice 742
• Physical Assessment

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The Skin History

• Three important aspects to seek out
• symptoms attributed to the skin lesion
• chronology of appearance, change, and
  disappearance of the lesions
• conditions of exposure, injury, or medication
  that may have induced or altered the disease

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The Skin History

• Setting Timing of Attacks
• occupation
• topical agents
• drug history
• season of year
• environment

• Original lesion
• exact site
• duration
• appearance
• distribution
• progression
• Symptoms
• local
• pruritis
• pain
• burning

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Skin Physical Examination

• Three categories of observation should be made in
  sequence
• First, anatomic distribution of the lesion
• Second, configuration of groups of lesions
• Third, the morphology of the individual lesions

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Skin Physical Examination

• Inspection
• natural lighting preferred, need complete
  exposure of all skin surfaces.
• remember to scan nails, hair, mucous membranes
• Location and Distribution
• exact, measure, symmetry?

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Skin Physical Examination

• Inspection
• Color
• variation common, even within same person.
• Melanin
• maybe diffuse or localized
• increased Addisons Disease, hyperthyroidism,
  pregnancy, sunlight exposure
• decrease albinism and vitiligo
• Erythema
• appearance of increased amounts of oxygenated
  blood in dermal vasculature

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Skin Physical Examination

• Inspection
• Color
• Cyanosis
• blue tint from venous blood (deoxygenated
  hemoglobin) seen associated with congestive heart
  failure, pneumonia
• Extravasation of blood products
• ecchymosis, petechiae
• Pallor
• decrease hemoglobin in vessels close to skin
  secondary to anemia, shock

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Skin Physical Examination

• Inspection
• Color
• Depositions of abnormal pigments
• Jaundice from bilirubin
• Carotenemia from carotene (diabetes, excess
  ingestion of yellow vegetables (carrots)
• Gray from heavy metals (Au-gold,
  Ag-silver,Bi-bismuth)
• Blue-gray from amiodarone
• Configuration
• arrangement or position of lesions with each
  other (grouped, linear, annular)

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Skin Physical Examination

• Inspection
• Morphological structure
• primary lesions
• flat
• elevated
• -- serous filled
• -- pus filled
• -- solid

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Skin Physical Examination

• Inspection
• Morphological structure
• secondary lesions
• loss of skin
• -- erosion
• -- ulcer
• -- fissure
• build-up of skin
• -- scale
• -- crust
• -- lichenification
• -- scar

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Skin Physical Examination

• Morphology - Definitions
• Macules
• localized changes in skin color. Areas may be
  small or large occur in many shapes and colors.
• Not palpable
• may be associated with desquamation or scaling
• examples
• rubeola, rubella, secondary syphilis, rose spots
  of typhoid fever, drug eruptions, petechiae,
  purpura, first degree burns, systemic lupus
  erythematosus, pityriasis rosea and vitiligo

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Skin Physical Examination

• Morphology - Definitions
• Maculopapules
• slightly elevated macules
• commonly seen in pityriasis rosea, erythema
  multiforme, fixed drug eruptions and exanthemas
• Papules
• lesions are solid and elevated and defined as
  less than 5 mm in diameter.
• Borders and tops may be in various forms
• pointed or acuminated -- insect bites, acne and
  physiologic gooseflesh
• flat topped -- psoriasis, atopic eczema

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Skin Physical Examination

• Morphology - Definitions
• Papules
• Borders and tops may be in various forms
• round or irregular --senile angiomas, eczematous
  dermatitis, secondary syphilis
• pedunculate -- neurofibromas
• Plaques
• any elevated area of greater than 5mm, usually
  formed from confluent papules.
• Red scaling plaques -- psoriasis, pityriasis
  rosea

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Skin Physical Examination

• Morphology - Definitions
• Plaques
• Yellow -- xanthomas
• brown -- seborrheic warts
• Nodules
• solid and elevated, distinguished from papules by
  extending deeper into the dermis or even the
  subcutaneous tissue.
• Usually greater than 5 mm in diameter

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Skin Physical Examination

• Morphology - Definitions
• Nodules
• depth may be inferred by palpationwhen below the
  dermis skin slides over them, lesions within the
  dermis move with the skin
• Wheals
• caused by edema of skin, areas are circumscribed,
  irregular, and relatively transient
• color varies from red to pale, depending on
  amount of fluid in the skin.

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Skin Physical Examination

• Morphology - Definitions
• Wheals
• examples urticaria and insect bites
• Vesicles
• accumulation of fluid between the upper layer of
  the skin produces an elevation covered by a
  translucent epithelium that is easily punctured
  to release the fluid
• less than 5 mm
• examples acute eczematous dermatitis,
  second-degree burns

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Skin Physical Examination

• Morphology - Definitions
• Bullae
• Accumulation of fluid between layer of the skin,
  larger than 5 mm in diameter.
• Examples contact dermatitis, second-degree
  burns, bullous impetigo
• Pustules
• Vesicles or bullae that become filled with pus
  and tiny abscesses in the skin
• contents appear milky, orange, yellow, or green
  depending somewhat on the infecting organism

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Skin Physical Examination

• Morphology - Definitions
• Pustules
• frequently arise from hair follicles or sweat
  glands
• examples acne, furuncles, and bromide and
  iodide eruptions
• Cysts
• elevated lesions containing fluid or viscous
  material appear as papules or nodules
• distinction is made by puncturing to examine
  their contents and depth
• examples sebaceous and epidermal cysts

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Skin Physical Examination

• Secondary or Consecutive
• Erosions
• moist surface uncovered by the rupture of
  vesicles or bullae or by laceration from rubbing
• Fissures
• cleavage of the epidermis extending into the
  dermis
• examples common in trauma to thickened, dry,
  inelastic skin

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Skin Physical Examination

• Secondary or Consecutive
• Ulcers
• depressed lesions results from loss of epidermis
  and the papillary layer of the dermis
• examples traumatic ulcers, burns, and stasis
  ulcers
• Gangrene
• extensive destruction of the skin -- may leave
  many dead cells that become blackened

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Skin Physical Examination

• Palpation
• Temperature
• localized hyperthermia from increased blood flow
  due to cellulitis or injury
• generalized hyperthermia due to fever of systemic
  infection, hyperthyroidism
• localized hypothermia caused by peripheral
  arteriosclerosis, Raynauds disease
• generalized hypothermia due to shock

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Skin Physical Examination

• Palpation
• Moisture
• sweat - nervous (hypothermia) or thermal
  (hyperthermia) in origin
• Texture
• quality
• character
• rough
• dry (hypothyroidism)
• smooth (hyperthermia)

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Skin Physical Examination

• Palpation
• Elasticity
• decreases with age
• Decreased skin turgor - dehydration
• edema - accumulation of fluid in interstitial
  spaces under the skin.
• Congestive heart failure

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Cancer

• Malignant Melanoma
• ABCDs
• Asymmetry
• Border irregularity
• Color variation
• Diameter greater than 6 mm
• Inquire and observe for ominous changes in color,
  shape, elevations, texture, surrounding skin,
  sensation, and consistency.

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Malignant Melanoma
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Bullous Impetigo
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Carbuncle
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Drug Eruption
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