skin

Assessment ofthe Skin

Assessment ofthe Skin

Pat Jackson AllenRN, MS, PNP, FAAN

Yale University, School of Nursing

Pat Jackson AllenRN, MS, PNP, FAAN

Yale University, School of Nursing

Role of the SkinRole of the Skin

Protection from microbial invasion and minor trauma

Retards body fluid loss

Regulates body temperature

Provides sensory perception

Protection from microbial invasion and minor trauma

Retards body fluid loss

Regulates body temperature

Provides sensory perception



Produces vitamin D from precursors

Contributes to blood pressure regulation

Repairs surface wounds - scar formation

Excretes sweat, urea and lactic acid

Expresses emotions

Produces vitamin D from precursors

Contributes to blood pressure regulation

Repairs surface wounds - scar formation

Excretes sweat, urea and lactic acid

Expresses emotions

Anatomy of the SkinAnatomy of the Skin

Epidermis

Dermis

Hypodermis

Epidermis

Dermis

Hypodermis


Epidermis Outermost portion

composed of stratum corneum plus cellular stratum

Protective layer, water proofing layer

Provides pigment or color to skin

Forms nails and hair

Epidermis Outermost portion

composed of stratum corneum plus cellular stratum

Protective layer, water proofing layer

Provides pigment or color to skin

Forms nails and hair

Anatomy of the SkinAnatomy of the Skin Dermis

Vascular connective layer that separates epidermis from adipose tissue

Sensory nerves and autonomic motor nerves are found here

Sweat glands and hair follicles originate in dermis

Dermis Vascular connective

layer that separates epidermis from adipose tissue

Sensory nerves and autonomic motor nerves are found here

Sweat glands and hair follicles originate in dermis

Anatomy of the SkinAnatomy of the Skin Hypodermis

Dermis connected to underlying organs by the hypodermis, a loosely connected tissue filled with fatty cells

Adipose tissue generates heat, provides insulation, shock absorption and a reserve of calories

Hypodermis Dermis connected to

underlying organs by the hypodermis, a loosely connected tissue filled with fatty cells

Adipose tissue generates heat, provides insulation, shock absorption and a reserve of calories


Glands Found in Skin Eccrine Sweat Glands - sweat glands to

regulate body temperature. Aprocine Glands - secrete odorless fluid in

response to emotional or sexual stimuli. Found in the axillae, nipples, anogenital area, eyelids, and ears. Bacterial growth causes odor.

Sebaceous Glands - secrete sebum to keep skin and hair lubricated. Secretion varies in response to sex hormones (primarily testosterone).

Glands Found in Skin Eccrine Sweat Glands - sweat glands to

regulate body temperature. Aprocine Glands - secrete odorless fluid in

response to emotional or sexual stimuli. Found in the axillae, nipples, anogenital area, eyelids, and ears. Bacterial growth causes odor.

Sebaceous Glands - secrete sebum to keep skin and hair lubricated. Secretion varies in response to sex hormones (primarily testosterone).

Variation in Skin with AgeVariation in Skin with Age


Infants / Young Children Skin smoother-lack of

exposure to elements Less subcutaneous fat

layer, poorer temperature control

Eccrine sweat glands secrete after 1 month

Infants / Young Children Skin smoother-lack of

exposure to elements Less subcutaneous fat

layer, poorer temperature control

Eccrine sweat glands secrete after 1 month


Common Variations in Newborns Acrocyanosis Transient mottling Erythema toxicum Harlequin sign Mongolian spots Talangiectatic nevi (stork

bite) Jaundice Milia

Common Variations in Newborns Acrocyanosis Transient mottling Erythema toxicum Harlequin sign Mongolian spots Talangiectatic nevi (stork

bite) Jaundice Milia


Adolescence Aprocine glands enlarge and become

more active Sebaceous glands increase production

causing oily skin and predisposition to acne

Terminal hair appears in axillae and pubic area for both sexes and on face in males

Adolescence Aprocine glands enlarge and become

more active Sebaceous glands increase production

causing oily skin and predisposition to acne

Terminal hair appears in axillae and pubic area for both sexes and on face in males

Terminal Hair and AcneTerminal Hair and Acne


Skin Variation with AgeSkin Variation with Age

Pregnancy Increased:

Blood flow to skin to balance heat production from increased BMR

Eccrine sweat gland activitySebaceous gland activityFat depositsPigmentation of face, nipples, areolae,

axillary, and vulva

Pregnancy Increased:

Blood flow to skin to balance heat production from increased BMR

Eccrine sweat gland activitySebaceous gland activityFat depositsPigmentation of face, nipples, areolae,

axillary, and vulva


Older Adults Decreased:

Blood flow to skinEccrine sweat gland activitySebaceous gland activityFat depositsPigmentation of skin and hair, first in

Whites, later in Blacks and AsiansHair production and increased coarseness

Older Adults Decreased:

Blood flow to skinEccrine sweat gland activitySebaceous gland activityFat depositsPigmentation of skin and hair, first in

Whites, later in Blacks and AsiansHair production and increased coarseness

Variation in Skin by RaceVariation in Skin by Race

Asians, Latinos, Blacks Varying intensity of pigmentation

Mucous membranes pink to light brownSclera white, gray, light brown, often with

pigmented spotsMongolian markings common in childrenVisible difference in pigmentation of ventral

and dorsal surfaces of extremities

Asians, Latinos, Blacks Varying intensity of pigmentation

Mucous membranes pink to light brownSclera white, gray, light brown, often with

pigmented spotsMongolian markings common in childrenVisible difference in pigmentation of ventral

and dorsal surfaces of extremities


Asians, Latinos, Blacks Hair

Vellus body hairScalp hair varies in texture

Skin textureLimited aprocrine glands (less sweat)Limited sebaceous glands (less body oils)

Frequent washing causes increased dryness

Asians, Latinos, Blacks Hair

Vellus body hairScalp hair varies in texture

Skin textureLimited aprocrine glands (less sweat)Limited sebaceous glands (less body oils)

Frequent washing causes increased dryness


Asians, Latinos, Blacks Skin conditions

Fine colored lesions harder to seePigmentary changes due to lesions may

persist for months or yearsLicenification common with eczemaHypertrophic scars and keloids common

Asians, Latinos, Blacks Skin conditions

Fine colored lesions harder to seePigmentary changes due to lesions may

persist for months or yearsLicenification common with eczemaHypertrophic scars and keloids common


Whites Less variation in intensity of pigmentation

Mucous membranes pink Sclera white

Hair Terminal hair on body common Texture and color vary

Skin texture Increased aprocrine glands result in increased body

sweat Increased sebaceous glands lubricates skin and scalp

Requires frequent washing

Whites Less variation in intensity of pigmentation

Mucous membranes pink Sclera white

Hair Terminal hair on body common Texture and color vary

Skin texture Increased aprocrine glands result in increased body

sweat Increased sebaceous glands lubricates skin and scalp

Requires frequent washing

HistoryHistory

Chief Complaint / Present Problem Changes in skin, hair, nails -

Dryness, itchingRashes, lesionsOdor, colorChange in quantity, texture of hair

Chief Complaint / Present Problem Changes in skin, hair, nails -

Dryness, itchingRashes, lesionsOdor, colorChange in quantity, texture of hair

HistoryHistory Chief Complaint / Present Problem

History of chief complaint / present problem Temporal sequence -

Gradual, sudden Precipitating events Dietary changes

Associated symptoms - Itching, pain, bleeding, redness

Location - Skinfolds Extensor or flexor surfaces Exposed or covered surfaces Symmetrical or nonsymmetrical

Chief Complaint / Present Problem History of chief complaint / present problem

Temporal sequence - Gradual, sudden Precipitating events Dietary changes

Associated symptoms - Itching, pain, bleeding, redness

Location - Skinfolds Extensor or flexor surfaces Exposed or covered surfaces Symmetrical or nonsymmetrical


Associated symptoms - Fever Fatigue Allergy Stress

Recent exposure to toxinsTravel historyWhat client or caretaker believes is the causeWhat remedies have been tried and their

success Is it getting better or worse


Associated symptoms - Fever Fatigue Allergy Stress

Recent exposure to toxinsTravel historyWhat client or caretaker believes is the causeWhat remedies have been tried and their

success Is it getting better or worse

HistoryHistory

HistoryHistory Past Medical History

Previous skin, hair, or nail problems, sensitivities, reactions

Cardiac, respiratory, liver, endocrine (thyroid, diabetes) cancer or other systemic diseases

Severe illness or nutritional deficit Drug or toxin exposure Congenital problems

Past Medical History Previous skin, hair, or nail problems,

sensitivities, reactions Cardiac, respiratory, liver, endocrine

(thyroid, diabetes) cancer or other systemic diseases

Severe illness or nutritional deficit Drug or toxin exposure Congenital problems

HistoryHistory Family History

Current or past skin, hair, or nail problemsSkin infectionsChronic skin conditions

Psoriasis, atopic dermatitis (eczema) Infestations

Scabies, lice Cancer

Allergic diseases such as asthma, hay fever

Family hair loss and pigmentation patterns

Family History Current or past skin, hair, or nail problems

Skin infectionsChronic skin conditions

Psoriasis, atopic dermatitis (eczema) Infestations

Scabies, lice Cancer

Allergic diseases such as asthma, hay fever

Family hair loss and pigmentation patterns

HistoryHistory Personal and Social History

Skin care habits bathing, hair care, nails diapering

Use of soaps, skin care products, sunscreen

Nutritional habits and vitamin Exposure to communicable conditions

Infectious skin conditions Infestations

Personal and Social History Skin care habits

bathing, hair care, nails diapering

Use of soaps, skin care products, sunscreen

Nutritional habits and vitamin Exposure to communicable conditions

Infectious skin conditions Infestations

HistoryHistory

Personal and Social History Exposure to environmental toxins,

animals Injury pattern or history Chronic nail biting or hair

manipulation Occupational / school / sports risks

Personal and Social History Exposure to environmental toxins,

animals Injury pattern or history Chronic nail biting or hair

manipulation Occupational / school / sports risks

HistoryHistory

Personal and Social History Cultural Variations

Chemical or thermal hair straighteners, pomades, or coloring

Hair styling, i.e., cornrows, teasing, tight braids or ponytails

Hair removal, shaving Skin bleaching Tattoos, body piercing Henna application

Personal and Social History Cultural Variations

Chemical or thermal hair straighteners, pomades, or coloring

Hair styling, i.e., cornrows, teasing, tight braids or ponytails

Hair removal, shaving Skin bleaching Tattoos, body piercing Henna application

Assessment of the Skin, Hair, Nails


Inspection

Palpation

Inspection

Palpation

Need: Good light Centimeter ruler - flexible and clear Magnifying glass Gloves (optional but recommended) Test equipment (determined by

practice), i.e. Woods lamp, KOH, biopsy

Need: Good light Centimeter ruler - flexible and clear Magnifying glass Gloves (optional but recommended) Test equipment (determined by

practice), i.e. Woods lamp, KOH, biopsy



Detailed Inspection: Must be unclothed and undraped Special attention to areas not often

seen Special attention to intertrigenous

surfaces Identify lesion descriptors

Detailed Inspection: Must be unclothed and undraped Special attention to areas not often

seen Special attention to intertrigenous

surfaces Identify lesion descriptors



Assessment of the SkinAssessment of the Skin

Inspect for: Lesions Skin color Areas of pain or itching

Inspect for: Lesions Skin color Areas of pain or itching

Palpate for: Moisture Temperature Texture Turgor Mobility Capillary filling Elevation or depression

Palpate for: Moisture Temperature Texture Turgor Mobility Capillary filling Elevation or depression


Guiding principles Take a good history Individuals’ skin reacts differently Few skin conditions are life-threatening but

they can be great source of concern to the individual

You need to know the standard medical terminology “Red bumps on the arm” just won’t sound

professional

Guiding principles Take a good history Individuals’ skin reacts differently Few skin conditions are life-threatening but

they can be great source of concern to the individual

You need to know the standard medical terminology “Red bumps on the arm” just won’t sound

professional


Need to describe Lesion type Shape Color Distribution Border Surface and texture Associated symptoms

Need to describe Lesion type Shape Color Distribution Border Surface and texture Associated symptoms


Primary Lesions: Initial appearance of pathological

processMacule <1cm / Patch >1cm: flat lesionPapule <1cm / Plaque >1cm: elevated Nodule <1-2cm / Tumor >2cm: deeperVesicle <1cm / Bulla >1cm: bubblePustule: purulent vesicleWheal: hive

Primary Lesions: Initial appearance of pathological

processMacule <1cm / Patch >1cm: flat lesionPapule <1cm / Plaque >1cm: elevated Nodule <1-2cm / Tumor >2cm: deeperVesicle <1cm / Bulla >1cm: bubblePustule: purulent vesicleWheal: hive


Scale ScarCrust, scab KeloidFissure LichenificationErosion AtrophyExcoriation (scratch) Ulcer

Scale ScarCrust, scab KeloidFissure LichenificationErosion AtrophyExcoriation (scratch) Ulcer

Secondary Lesions: Change in primary lesion due to

external trauma

Secondary Lesions: Change in primary lesion due to

external trauma


Lesion descriptors Shape:

LinearRoundAnnular (round with central clearing)OvalPolycyclic (interlocking circles)Morbilliform (confluent, measle-like)Zosterform (dermatomal)

Lesion descriptors Shape:

LinearRoundAnnular (round with central clearing)OvalPolycyclic (interlocking circles)Morbilliform (confluent, measle-like)Zosterform (dermatomal)


HemangiomaHemangioma

Round papule measuring 1 cm. situated superior to outer canthus of R eye. Uniform deep red color.

Round papule measuring 1 cm. situated superior to outer canthus of R eye. Uniform deep red color.

BirthmarkBirthmark

Hyperpigmented linearmacules measuring 1cmby 4.5 cm inferior to rightnipple. No indication of Inflammation or irritation.

Hyperpigmented linearmacules measuring 1cmby 4.5 cm inferior to rightnipple. No indication of Inflammation or irritation.

Linear vesicles on ventral surface of forearm. Client reports lesionsare intensely itchy.

Linear vesicles on ventral surface of forearm. Client reports lesionsare intensely itchy.

Poison IvyPoison Ivy

Erythematous macular papular lesions over entire body. Infantobserved scratching. Lesions associated with fever and mild URI symptoms.

Erythematous macular papular lesions over entire body. Infantobserved scratching. Lesions associated with fever and mild URI symptoms.

MeaslesMeasles

Grouped vesicleson an erythematous base scattered along R thoracic dermatome. Client reports pain associated with lesions.

Grouped vesicleson an erythematous base scattered along R thoracic dermatome. Client reports pain associated with lesions.

Herpes ZosterHerpes Zoster


Lesion Descriptors Shape (con’t):

GeographicLacySerpiginous (snakelike)Umbilicated (middle indentation)Target, iris (bullseye)

Lesion Descriptors Shape (con’t):

GeographicLacySerpiginous (snakelike)Umbilicated (middle indentation)Target, iris (bullseye)

Geographic pattern ofwhite and dark pinkmucous membraneson ventral surface of tongue.

Geographic pattern ofwhite and dark pinkmucous membraneson ventral surface of tongue.

Normal TongueNormal Tongue

Intense confluent redness of both cheeks precededlacy erythematous macularpapular lesion over trunkand extremities. Mild Fever associated with onset of lesions.

Intense confluent redness of both cheeks precededlacy erythematous macularpapular lesion over trunkand extremities. Mild Fever associated with onset of lesions.

Erythema Infectiosum (Slapped-cheek)Human Parvovirus B 19 (Fifth Disease)Erythema Infectiosum (Slapped-cheek)Human Parvovirus B 19 (Fifth Disease)

Serpigenous elevatedburrow measuring6 cm at base of 3rd-5th toes R foot.Client reports lesion is itchy.

Serpigenous elevatedburrow measuring6 cm at base of 3rd-5th toes R foot.Client reports lesion is itchy.

ScabiesScabies

Small discrete circularpapules with umbilicated centers oninner aspect of R elbow.

Small discrete circularpapules with umbilicated centers oninner aspect of R elbow.

Molluscum ContagiosumMolluscum Contagiosum


Lesion Descriptors Color:

ErythematousPink, redPurpleEcchymotic (blacks & blue)MottledSilver / White

Lesion Descriptors Color:

ErythematousPink, redPurpleEcchymotic (blacks & blue)MottledSilver / White

Scattered discrete erythematous papular lesions on trunk. No lesions present on sun exposed areas.Client denies itching, fever, or URI symptoms with rash.

Scattered discrete erythematous papular lesions on trunk. No lesions present on sun exposed areas.Client denies itching, fever, or URI symptoms with rash.

Viral Exanthem unknown Etiology (Pityriasis rosea?)Viral Exanthem unknown

Etiology (Pityriasis rosea?)

Erythema Nodosum Erythema Nodosum

Abrupt onset of tender erythematous nodules on extensor surfaces ofextremities. Lesions evolvedinto bruises with color changes to purple then yellow-brown.

Abrupt onset of tender erythematous nodules on extensor surfaces ofextremities. Lesions evolvedinto bruises with color changes to purple then yellow-brown.

Erythematous plaquewith silver-white scaleon extensor surface oflegs.

Erythematous plaquewith silver-white scaleon extensor surface oflegs.

Psoriasis VulgarisPsoriasis Vulgaris


Lesion Descriptors Color (con’t):

BlueBlackYellowHyperpigmentedHypopigmented, depigmentedAmelanotic

Lesion Descriptors Color (con’t):

BlueBlackYellowHyperpigmentedHypopigmented, depigmentedAmelanotic

Hyperpigmentedpatch with irregular bordersmeasuring 8 cm by 3 cmover L scalpula. Client reports area seems to fade in summer.

Hyperpigmentedpatch with irregular bordersmeasuring 8 cm by 3 cmover L scalpula. Client reports area seems to fade in summer.

Café-au-lait SpotCafé-au-lait Spot

VitiligoVitiligo

Depigmented patchesof skin with distinctborders on ventral surface of R hand. Hair within the affected area is also hypopigmented. Noother symptoms reported.

Depigmented patchesof skin with distinctborders on ventral surface of R hand. Hair within the affected area is also hypopigmented. Noother symptoms reported.

Sunburn with VitiligoSunburn with Vitiligo


Lesion Descriptors Distribution:

Localized (identify where) vs. generalized Symmetrical or asymmetrical Scattered, grouped Flexural or extensor surfaces Intertriginous (between skin folds) Sun exposed or covered Contact areas for clothing, jewelry, chemicals

Lesion Descriptors Distribution:

Localized (identify where) vs. generalized Symmetrical or asymmetrical Scattered, grouped Flexural or extensor surfaces Intertriginous (between skin folds) Sun exposed or covered Contact areas for clothing, jewelry, chemicals

Atopic Dermatitis (Eczema)Atopic Dermatitis (Eczema)

Symmetrical dry excoriated redplaques on flexor surfaces ofknees and elbows. Child reports intense itching (pruritis) and history of asthma.

Symmetrical dry excoriated redplaques on flexor surfaces ofknees and elbows. Child reports intense itching (pruritis) and history of asthma.

Three discrete hairless hyperpigmented nodulesmeasuring 4x2cm, 4x1.5cm, & 3x1cm at sites of previousmole removal.

Three discrete hairless hyperpigmented nodulesmeasuring 4x2cm, 4x1.5cm, & 3x1cm at sites of previousmole removal.

KeloidsKeloids

Erythema Toxicum(Neonatal Acne)

Erythema Toxicum(Neonatal Acne)

Scattered papules and pustules on erythematous bases of varying diameters. Lesions noted to change location within hours. No fever associated with lesions.

Scattered papules and pustules on erythematous bases of varying diameters. Lesions noted to change location within hours. No fever associated with lesions.

Grouped vesicleson an erythematousbase located below R eye. Conjunctiva intact without inflammation.

Grouped vesicleson an erythematousbase located below R eye. Conjunctiva intact without inflammation.

Herpes Simplex Virus (Herpes Keratitis)Herpes Simplex Virus (Herpes Keratitis)

Dry rough erythematousto brown skin circumscribinglips. Child reports lickinghis lips frequently. No other lesions noted on body.

Dry rough erythematousto brown skin circumscribinglips. Child reports lickinghis lips frequently. No other lesions noted on body.

Happy Lip-LickerHappy Lip-Licker

Dry macular papular erythematous confluent lesions with additional satellite lesionsfound on intertriginousskin of L breast. Clientreports mild itching.

Dry macular papular erythematous confluent lesions with additional satellite lesionsfound on intertriginousskin of L breast. Clientreports mild itching.

Candidiasis (Yeast)Candidiasis (Yeast)

Small white confluent papules extending across foreheadonto scalp with a band width of 5 cm.(From head band worn during exercise.)

Small white confluent papules extending across foreheadonto scalp with a band width of 5 cm.(From head band worn during exercise.)

Contact Dermatitis Contact Dermatitis

Assessment of the SkinAssessment of the Skin Lesion Descriptors

Border / Margins:Sharply / poorly marginated (demarcated,

defined) Irregular ScallopedRaised / elevated or flat borderActive borderLesion variation between border and center

Lesion Descriptors Border / Margins:

Sharply / poorly marginated (demarcated, defined)

Irregular ScallopedRaised / elevated or flat borderActive borderLesion variation between border and center

Dark red patch with distinct borders extending from R ear across lower cheek and chin. Has been present since birth. Lesion does not appear to itch and child has no other symptoms.

Dark red patch with distinct borders extending from R ear across lower cheek and chin. Has been present since birth. Lesion does not appear to itch and child has no other symptoms.

Nevus Flammeus (Port-Wine Stain)Nevus Flammeus (Port-Wine Stain)

Confluent dry dark redpatch with well demarcatedborders outlining diaper area.Some sparing of intertrigenousskin folds. No satellite lesions.

Confluent dry dark redpatch with well demarcatedborders outlining diaper area.Some sparing of intertrigenousskin folds. No satellite lesions.

Confluent dark red slightlymoist patch on perineumand lower abdomen withsatellite papules extendingupward on abdomenand onto thighs.

Confluent dark red slightlymoist patch on perineumand lower abdomen withsatellite papules extendingupward on abdomenand onto thighs.

Diaper Dermatitis (Contact)Diaper Dermatitis (Contact)

Diaper Dermatitis (Candidiasis)Diaper Dermatitis (Candidiasis)


Lesion Descriptors Surface and texture:

SoftBoggyHard, firmThickenedVerrucous, wartyMoist, oozing, weeping

Lesion Descriptors Surface and texture:

SoftBoggyHard, firmThickenedVerrucous, wartyMoist, oozing, weeping

Three hard dry verrucous (warty)papules on middle finger of R hand.

Three hard dry verrucous (warty)papules on middle finger of R hand.

WartsWarts

Licenification(Secondary to Eczema)

Licenification(Secondary to Eczema)

Dry thickened skin withhorizontal fissures. Symmetrical pattern of lesions on flexor surfaces of knees and elbows. Client reports intense itching.

Dry thickened skin withhorizontal fissures. Symmetrical pattern of lesions on flexor surfaces of knees and elbows. Client reports intense itching.

Dry thickened hyperpigmented skin with linear fissuresacross posterior neck.Also found under arms.Child has BMI of 30.

Dry thickened hyperpigmented skin with linear fissuresacross posterior neck.Also found under arms.Child has BMI of 30.

Acanthosis Nigricans Acanthosis Nigricans

Vesicles turning tohoney-colored crustson erythematous base, below R nares and on bridge of nose.

Vesicles turning tohoney-colored crustson erythematous base, below R nares and on bridge of nose.

Impetigo (Staph or Strep)Impetigo (Staph or Strep)

Moist vesicles on anerythematous base encirclingthe mouth, covering the lipsand extending onto the mucous membranes of the mouth.Child has a fever, is irritable and reports pain when attempting to eat or drink.

Moist vesicles on anerythematous base encirclingthe mouth, covering the lipsand extending onto the mucous membranes of the mouth.Child has a fever, is irritable and reports pain when attempting to eat or drink.

Primary Gingivostomatitis Primary Gingivostomatitis

Bullous Impetigo (Staph or Strep)Bullous Impetigo (Staph or Strep)

20 by 10 cm bullaewith shallow erosionand moist centermid abdomen superior to umbilicus.Smaller similar lesionsuperior to largelesion medial to L nipple.

20 by 10 cm bullaewith shallow erosionand moist centermid abdomen superior to umbilicus.Smaller similar lesionsuperior to largelesion medial to L nipple.

Blotchy red irregularly shaped papules and plaques with prominentelevated borders in irregular pattern over entire body. Some lesions with central clearing.Noted to fade and reappear within minutes. Child isscratching lesions.

Blotchy red irregularly shaped papules and plaques with prominentelevated borders in irregular pattern over entire body. Some lesions with central clearing.Noted to fade and reappear within minutes. Child isscratching lesions.

Urticaria (Hives)Urticaria (Hives)

Multiple oval plaques with active (red and scaly) prominent borders and partial central clearing. Client reports mild itching.

Multiple oval plaques with active (red and scaly) prominent borders and partial central clearing. Client reports mild itching.

Tinea Corporis (Ringworm)Tinea Corporis (Ringworm)


Lesion Descriptors Associated Symptoms:

PruriticBurning, stingingPainful, tenderSwellingAsymptomatic

Lesion Descriptors Associated Symptoms:

PruriticBurning, stingingPainful, tenderSwellingAsymptomatic

Assessment of the HairAssessment of the Hair

Inspection and palpation of hair: Color Texture (vellus or terminal, smooth or brittle, dry or

moist) Distribution Quantity Indications of hair loss Infestations Scalp condition

Inspection and palpation of hair: Color Texture (vellus or terminal, smooth or brittle, dry or

moist) Distribution Quantity Indications of hair loss Infestations Scalp condition

White ovoid firm 1 mm bodies attached to hair shafts. Child reports scalp itches intensely.

White ovoid firm 1 mm bodies attached to hair shafts. Child reports scalp itches intensely.

Pediculosis (Head Lice)Pediculosis (Head Lice)

Dry crusted circularlesion with erythematousbase on scalp withoutevidence of hair follicles.Papable lymphnodes present.

Dry crusted circularlesion with erythematousbase on scalp withoutevidence of hair follicles.Papable lymphnodes present.

Tinea Capitus (Ringworm)Tinea Capitus (Ringworm)

Areas of sparse hair growth lateral to braided hair withevidence of brokenHairs. No signs ofinfection or infestation.

Areas of sparse hair growth lateral to braided hair withevidence of brokenHairs. No signs ofinfection or infestation.

Traction Alopecia Traction Alopecia

Assessment of the NailsAssessment of the Nails

Inspection and palpation Color, length, symmetry, and

cleanliness Ridges, depressions, pitting Nail base angle, evidence of clubbing Firmness, thickness, separation Capillary refill

Inspection and palpation Color, length, symmetry, and

cleanliness Ridges, depressions, pitting Nail base angle, evidence of clubbing Firmness, thickness, separation Capillary refill

Bitten NailsBitten Nails

Pitting of NailsPitting of Nails

Clubbing of FingersClubbing of FingersParonychiaParonychia

Onycholysis(Psoriasis or Tinea)Onycholysis(Psoriasis or Tinea)

Nail changes associatedwith Aging

Nail changes associatedwith Aging

Capillary RefillCapillary RefillNormal Nails Needing a

Little CareNormal Nails Needing a

Little Care

A*B*C*D Rule of Melanoma

A*B*C*D Rule of Melanoma

A - Asymmetry of borders

B - Border, irregular

C - Color blue-black or variegated

D - Diameter greater than .6 cm

A - Asymmetry of borders

B - Border, irregular

C - Color blue-black or variegated

D - Diameter greater than .6 cm

AA

BB

CC

DD

MelanomaMelanoma

AA

BB

CC

DD

Malignant Melanoma Malignant Melanoma

Assessment for MelanomaAssessment for Melanoma

Educating clients for self assessment Know location and appearance of moles Regularly check for changes using good

light source and mirror Be particularly vigilant with moles in

strange places Provide sunscreen protection for all moles Be seen by provider if changes in

numbers, size, color, borders, or surface area occur

Educating clients for self assessment Know location and appearance of moles Regularly check for changes using good

light source and mirror Be particularly vigilant with moles in

strange places Provide sunscreen protection for all moles Be seen by provider if changes in

numbers, size, color, borders, or surface area occur


Body Piercing Risk of infection with organisms found

on the skin and in the oral pharynx Potential for trauma to skin with

tearing of tissue Tattooing

Risk of infection Difficult (impossible) to remove

Body Piercing Risk of infection with organisms found

on the skin and in the oral pharynx Potential for trauma to skin with

tearing of tissue Tattooing

Risk of infection Difficult (impossible) to remove

TattooingTattooing

Assessment of the SkinAssessment of the Skin Indications of abuse

History does not correspond to injuries Injuries too severe for history Injuries not developmentally plausibleHistory changes or varies by person

Caretaker or person delays treatment Injuries not seen as seriousEvidence of previous injuries or lack of

consistent care, i.e., absent immunizations

Indications of abuse History does not correspond to injuries

Injuries too severe for history Injuries not developmentally plausibleHistory changes or varies by person

Caretaker or person delays treatment Injuries not seen as seriousEvidence of previous injuries or lack of

consistent care, i.e., absent immunizations

Assessment of the Skin Assessment of the Skin

Indications of abuse Patterned injuries (belt, hand, iron, etc.) Pattern of injuries (injuries over time) Location of injuries (face, back, abdomen) Bruising pattern:

Within 24 hours red to blue 1-3 days deep purple or black 3-6 days green to gradually brown 6-15 days green to tan to yellow

Indications of abuse Patterned injuries (belt, hand, iron, etc.) Pattern of injuries (injuries over time) Location of injuries (face, back, abdomen) Bruising pattern:

Within 24 hours red to blue 1-3 days deep purple or black 3-6 days green to gradually brown 6-15 days green to tan to yellow

Restraint InjuriesRestraint Injuries

Bruises Causedby Abuse

Bruises Causedby Abuse

Burn InjuriesBurn Injuries

Scalding InjuriesScalding Injuries

The Skin Is The Window To The Body

The Skin Is The Window To The Body

Examine It CarefullyExamine It Carefully

skin

Documents

erythematous base

flexor surfaces

central clearing

race asians

history personal

entire body

skin indications

blood flow