PHYSICAL EXAMINATION OF THE SKIN

Anatomy and Physiology

Skin: heaviest single organ, 16% of body weight, 1.2-2.3 meters squared

Layers of the Skinepidermis - outer horny layer - inner cellular layerdermissubcutaneous tissue

Pigments melanin (brown) carotene (golden yellow) oxyhemoglobin deoxyhemoglobin

Inspect and Palpate Color: brown, grayish/bronze, blue, reddish blue, red,

jaundice Moisture Temperature Mobility/ Turgor Texture Lesions

Lesions Anatomic location: generalized, localized Patterns and shapes: linear, clustered, annular,

dermatomal Appearance/type of skin lesion: macules, papules,

vesicles, pustules Color Measurement or dimension Tenderness

Secondary lesions:• Loss of skin surface

• Erosion – loss of superficial epidermis• Ulcer - deeper loss of the skin surface• Fissure - linear crack of the skin

• Material on skin surface• Crust = dried residue of serum, pus or

blood

• Scale = thin flakes of exfoliated epidermis

Crust scale

Miscellaneous:• lichenification – thickening and roughing of the

skin with increased visibility of the normal skin furrows

• atrophy – thinning of the skin with loss of normalskin furrow

Lichenification atrophy

• excoriation – scratch mark• scar – replacement of destroyed tissue by fibrous

tissue• keloid – hypertrophied scar

Excoriation scar keloid

Primary circumscribed, flat, non-palpable lesions1. Macule – small up to 1 cm2. Patch - > 1 cm

Macule patch

Palpable, elevated masses1. Papule – up to 0.5 cm2. Plaque - > 0.5 cm3. Nodule – 0.5 to 1-2 cm; deeper & firmer4. Tumor - > 1 to 2 cm5. Wheal – irregular, relatively transient, superficial

area of a localized skin edema

Papule plaque nodule

Tumor wheal

Circumscribed, superficial, elevated, formed by free fluid in a cavity:1. Vesicles – up to 0.5 cm2. Bulla - > 0.5 cm3. Pustule – filled with pus

Vesicles bulla pustule

• Comedo – “blackhead”, plugged opening of a sebaceous gland

• Telangiectasia – dilated small blood vessels• Nevus – “mole”; flat to slightly elevated, round, evenly

pigmented lesion

Comedo telangiectasia nevus

Infancy:1. Cutis marmorata

• mottled appearance• common on the trunk, arms and legs• secondary to vasomotor changes of the dermis and SQ• response to cooling or chronic exposure to radiant

heat• prominent among pre-terms, cretin and Trisomy

2. Harlequin dyschromia• one side of the body is red & the other pale – a

border separates the 2 sides• transient: Unknown etiology

3. Acrocyanosis• blueness of the hands and feet• if it won’t disappear within 8 hours, rule out CHD

4. Mongolian spots • blackish-blue areas located over the buttocks and skin

of the scrotum• due to pigmented cells of the deeper layers of the skin

Acyanosis Mongolian spots

5. Lanugo • fine, downy hair mostly on the shoulders and back• shed within 2 weeks

6. Vernix caseosa • cheesy white material composed of sebum and

desquamated epithelial cells7. Milia

a. pinhead-sized, smooth, white, raised areas without surrounding erythema

b. common in the nose, chin and forehead

Lanugo vernix caseosa milia

8. Miliaria rubra • scattered vesicles on an erythematous base usually on

the face and trunks• secondary to the obstruction of ducts of sweat glands• disappear spontaneously in 1-2 weeks

9. Erythema toxicum • usually appear on the 2nd-3rd day of life• erythematous macules with central urticarial wheals or

vesicles disappear spontaneously within a week

Miliaria rubra erythema toxicum

10. Capillary hemangioma, nevus flammeus, nevus vasculasus, telangiectatic nevus • found on the nape “stork’s beak” mark• upper eyelid, forehead and upper lip “angel kisses”• disappear about 1 year of age

11. Portwine stain • larger, darker, more sharply demarcated• may involve the mucosa of the mouth or vagina• if there is involvement of the skin innervated by the

ophthalmic portion of the trigeminal nerve --- vascular network of the meninges and ocular orbit may also be affected -- meningeal calcifications, seizures, hemiparesis,mental retardation & glaucoma= Sturge- Weber Syndrome