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Flashcards in Skin, Hair, and Nails Deck (175):
1

The epidermis is thin but tough. Its cells are bound tightly together into sheets that form a rugged protective barrier. Jt is stratified into several zones.
The inner basal cell layer forms new skin cells. Their major ingredient is the tough, fibrous protein keratin.
From the basal layer the new cells migrate up and flatten into the outer horny cell layer. This consists of dead keratinized cells that are interwoven and closely packed. The cells are constantly being shed, or desquamated, and are replaced with new cells from below. The epidermis is completely replaced every 4 weeks. ln fact, each person sheds about 1 pound of skin each year. The epidermis is uniformly thin except on the surfaces that are exposed to friction, such as the palms and the soles.
Skin color is derived from three sources: (1) mainly from the brown pigment melanin, (2) also from the yellow-orange tones of the pigment carotene, and (3) from the red-purple tones in the underlying vascular bed.

Epidermis

2

The dermis is the inner supportive layer consisting mostly of connective tissue, or collagen. This is the tough, fibrous protein that enables the skin to resist tearing.
Also has resilient elastic tissue that allows the skin to stretch with body movements.
The nerves, sensory receptors, blood vessels, and lymphatics lie in.
Also, appendages from the epidermis- such as the hair follicles, sebaceous glands, and sweat glands-are embedded in the dermis.

Dermis

3

Is adipose tissue, which is made up of lobules of fat.
Stores fat for energy, provides insulation for temperature control, and aids in its soft cushioning layer.
Also gives skin its increased mobility over structures underneath.

Subcutaneous layer

4

Are threads of keratin.
The hair shaft is the visible projecting part, and the root is below the surface embedded in the follicle.
At the root the bulb matrix is the expanded area where new cells are produced at a high rate.
Hair growth is cyclical, with active and resting phases.
Around the hair follicle are the muscular arrector pili, which contract and elevate the hair so that it resembles "goose flesh" when the skin is exposed to cold or in emotional state.
People have two types of hair.
1.Fine, faint vellus hair covers most of the body (except the palms and soles, the dorsa of the distal parts of the fingers, covers most of the body (except the palms and soles, the dorsa of the distal parts of the fingers, the umbilicus, the glans penis, and inside the labia).
2. The other type is terminal hair, the darker, thicker hair that grows on the scalp and eyebrows and, after puberty, on the axillae, the pubic area, and the face and chest in the male.

Hair

5

These glands produce a protective lipid substance, sebum, which is secreted through the hair follicles.
Sebum oils and lubricates the skin and hair and forms an emulsion with water that retards water loss from the skin. (Dry skin results from loss of water, not directly from loss of oil.) are everywhere except on the palms and soles.
They are most abundant in the scalp, forehead, face, and chin.

Sebaceous Glands

6

The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. The evaporation of sweat reduces body temperature.
Eccrine glands are widely distributed through the body and are mature in the 2-monthold infant.
The apocrine glands produce a thick, milky secretion and open into the hair follicles. They are located mainly in the axillae, anogenital area, nipples, and navel and are vestigial in humans. They become active during puberty, and secretion occurs with emotional and sexuaJ stimulation. Bacterial flora residing on the skin surface react with apocrine sweat to produce a characteristic musky body odor. The functioning of apocrine glands decreases in the aging adult.

Sweat Glands

7

Are hard plates of keratin on the dorsal edges of the fingers and toes.
The nail plate is clear, with fine longitudinal ridges that become prominent in aging.
Nails take their pink color from the underlying nail bed of highly vascular epithelial cells.
The lunula is the white, opaque, semilunar area at the proximal end of the nail. It

Nails

8

The skin is a waterproof, almost indestructible, covering that has protective and adaptive properties: Protection. Skin minimizes injury from physical, chemical, thermal, and light-wave sources.
• Prevents penetration. Skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body.
• Perception. Skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure.
• Temperature regulation. Skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation. -Identification. People identify one another by unique combinations of facial characteristics, hair, skin color, and even fingerprints.
-Self-image is often enhanced or deterred by the way society's standards of beauty measure up to each person's perceived characteristics.
Communication. Emotions are expressed in the sign language of the face and in the body posture. Vascular mechanisms such as blushing or blanching also signal emotional states. Wound repair. Skin allows ceU replacement of surface wounds.
• Absorption and excretion. Skin allows limited excretion of some metabolic wastes, byproducts of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
• Production of vitamin D. The skin is the surface on which ultraviolet light converts cholesterol into vitamin D.

FUNCTION OF THE SKIN

9

The hair follicles develop in the fetus at 3 months' gestation; by midgestation, most of the skin is covered with lanugo, the fine downy hair of the newborn infant. In the first few months after birth, this is replaced by fine vellus hair.
Terminal hair on the scalp, if present at birth, tends to be soft and to suffer a patchy loss, especially at the temples and occiput.
Also present at birth is vernix caseosa, the thick, cheesy substance made up of sebum and shed epithelial cells.
The infant is at greater risk for fluid loss. Sebum, which holds water in the skin, is present for the first few weeks of life, producing milia (see p. 222) and cradle cap in some babies.
The sebeaous glands decrease in size and production and do not resume functioning until puberty.
At puberty, secretion from apocrine sweat glands increases in response to heat and emotional stinmli, producing body odor. Sebaceous glands become more active-the skin looks oily, and acne develops. Subcutaneous fat deposits increase, especially in females.
Secondary sex characteristics that appear during adolescence are evident in the integument (i.e., skin). In the female, the diameter of the areola enlarges and darkens and breast tissue develops. Coarse pubic hair develops in males and females.

Development competence
Infant and children

10

The change in hormone levels results in increased pigment in the areolae and nipples, vulva, and sometimes in the midline of the abdomen (linea nigra) or in the face (chloasma).
Striae gravidarum (stretch marks), which may develop in the skin of the abdomen, breasts, or thighs.
Metabolism is increased in pregnancy; as a way to dissipate heat, the peripheral vasculature dilates and the sweat and sebaceous glands increase secretion. Fat deposits are laid down, particularly in the buttocks and hips, as maternal reserves for the nursing baby.

Development competence
The pregnant women

11

The aging skin loses its elasticity; it folds and sags. By the 70s to 80s, it looks parchment thin, lax, dry, and wrinkled.
The epidermis's outer layer thins and flattens.
This allows chemicals easier access into the body. Wrinkling occurs because the underlying dermis thins and flattens. A loss of elastin, collagen, and subcutaneous fat occurs as well as a reduction in muscle tone.
The loss of collagen increases the risk for shearing, tearing injuries.
Sweat glands and sebaceous glands decrease in number and function, leaving dry skin.
Decreased response of the sweat glands to thermoregulatory demand also puts the aging person at greater risk for heat stroke. The vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas, or senile purpura.
Sun exposure and cigarette smoking further accentuate aging changes in the skin.
Coarse wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, more pigment changes, and a yellowed, leathery texture occur.
Chronic sun damage is even more prominent in pale or light-skinned persons.
An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging (e.g., less nutrition, limited financial resources), the increasingly sedentary lifestyle, and the chance of immobility. When skin breakdown does occur, subsequent cell replacement is slower and wound healing is delayed.
The female's estrogen also decreases, testosterone is unopposed and the female may have some bristly facial hairs.
Nails grow more slowly.

Developmental competence
The aging adult

12

As described earlier, mela11in is responsible for the various colors and tones of skin observed among people. Melanin protects the skin against harmful ultraviolet rays, a genetic advantage accounting for the lower incidence of skin cancer among darkly pigmented Blacks and American Indians. The incidence of melanoma is 20 times higher among whites than among Blacks and 4 times higher among whites than among Hispanics.
The apocrine and eccrine sweat glands are important for fluid balance and for tl1ennoregulation. When apocrine gland secretions are contaminated by normal skin flora, odor results.

Cultural genetics

13

I. Keloids-scars that form at the site of a wound and grow beyond the normal boundaries of the wound (see p. 235)
2. Areas of either postinflammatory hypopigmentation or hyperpigmentation that appear as dark or light spots
3. Pseudofolliculitis- "razor bumps" or "ingrown hairs" caused by shaving too closely with an electric razor or straight razor 4. Melasma-the "mask of pregnancy:' a patchy tan to dark brown discoloration of the face

Skin conditions found amount blacks

14

1.. Past history of skin disease
4. Excessive dryness or moisture (allergies, hives, psoriasis,
5. Pruritus eczema)
6. Excessive bruising
2. Change in pigmentation
7. Rash or lesion
3. Change in mole (size or color)
8. Medications
9.Hair loss
10. Change in nails
11 . Environmental or occupational hazards
12. Self-care behaviors

Subjective Data

15

Hypopigmentation (loss of color);
hyperpigmentation (increase in color).

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16

Change in pigmentation. Any change in skin color or pigmentation?

Generalized change suggests systemic illness: pallor, jaundice, cyanosis.

17

Any change in a mole: color, size, shape, sudden appearance of tenderness, bleeding, itching?

Signs suggest neoplasm in pigmented nevus.

18

Seborrhea-oily. Xerosis-dry.

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19

Any skin itching?

Pruritus is the most common skin symptom; occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice.

20

Scratching causes excoriation of primary lesion.

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21

Any excess bruising?

Multiple cuts and bruises, bruises in various stages of healing, bruises above knees and elbows, and illogical explanation -consider physical abuse.
Frequent falJs may be due to dizziness of neurologic or cardiovascular ongm.
Also, frequent minor trauma may be a side effect of alcoho.lism or other drug abuse.

22

Rashes are a common cause of seeking health care.

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23

Drugs may cause allergic skin eruption: aspirin, antibiotics, barbiturates, some tonics.
Drugs may increase sunlight sensitivity and give burn response: sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
Drugs can cause hyperpigmentation: antimalarials, antineoplastic agents, hormones, metals, tetracycline.

What medications do you take?

24

Alopecia is a significant loss.

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25

Environmental or occupational hazards. Any environmental or occupational hazards?

People at risk: outdoor sports enthusiasts, farmers, sailors, outdoor workers; also creosote workers, roofers, coal workers.
Unprotected sun exposure accelerates aging and produces lesions. At more risk: light-skinned people, those older than 40 years, and those regularly in sun.

26

Additional History for Infants and Children

Generalized rash--consider allergic reaction to new food
irritability and general fussiness may indicate the presence of pruritus.
Occlusive diapers or infrequent changing may cause rash. Infant may be allergic to certain detergent or to disposable wipes.

27

contagious skin conditions: scabies, impetigo, lice.
communicable diseases: measles, chickenpox, scarlet fever? Or to toxic plants: poison ivy?

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28

habitual movements, such as nail-biting, twisting hair, rubbing head on mattress.

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29

Excessive sun exposure, especially severe or blistering sunburns in childhood, increases risk for melanoma in later life.

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30

Additional History for the Adolescent

Cause is unknown; acne is not caused by poor diet, oily complexion, or contagion.

31

Normal aging changes may cause distress.
Many "aging" changes are due to chronic sun damage.
Most skin cancers appear in aging people, although sun damage begins decades earlier.

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32

Pruritus is common with aging

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33

Also, some aging people tolerate chronic pain as "part of growing old" and hesitate to "complain."

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34

A bland lotion is important to retain moisture in aging skin.

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35

Dermatitis may ensue from certain cosmetics, creams, ointments, and dyes applied to achieve a youthful appearance.

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36

Aging skin has a delayed inflammatory response when exposed to irritants

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37

An acquired condition is vitiligo, the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices.
Vitiligo can occur in all races, although dark-skinned people are more severely affected and potentially suffer a greater threat to their body image.

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38

Freckles (ephelides)-small, flat macules of brown melanin pigment that occur on sun-exposed skin

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39

Mole (nevus)- a proliferation of melanocytes, tan to brown color, flat or raised. Acquired nevi are characterized by their symmetry, small size (6 mm or less), smooth borders, and single uniform pigmentation.

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40

The junctional nevus (Fig. 12-4, B) is macular only and occurs in children and adolescents. It progresses to the compound nevi in young adults (Fig. 12-4, C) that are macular and papular.

The intradermal nevus (mainly in older age) has nevus cells in only the dermis.

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41

pallor (white),
erythema (red),
cyanosis (blue), and
jaundice (yellow).

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42

Pallor. When the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly white.

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43

Erythema. Erythema is an intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries. This sign is expected with fever, with local inflammation, or with emotional reactions such as blushing in vascular flush areas (cheeks, neck, and upper chest).

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44

Erythema occurs with polycythemia, venous stasis, carbon monoxide poisoning, and the extravascular presence of red blood cells (petechiae, ecchymosis, hematoma)

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45

Cyanosis. This is a bluish mottled color that signifies decreased perfusion; the tissues do not have enough oxygenated blood.

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46

Cyanosis indicates hypoxemia and occurs with shock, heart failure, chronic bronchitis, and congenital heart disease.

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47

Jaundice. A yellowish skin color indicates rising amounts of bilirubin in the blood.

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48

Jaundice occurs with hepatitis, cirrhosis, sickle-cell disease, transfusion reaction, and hemolytic disease of the newborn.

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49

Light or clay-colored stools and dark golden urine often accompany jaundice in both light- and dark-skinned people.

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50

Hypothermia. Generalized coolness may be induced, such as in hypothermia used for surgery or high fever. Localized coolness is expected with an immobilized extremity, as when a limb is in a cast or with an intravenous infusion.

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51

General hypothermia accompanies central circulatory problem such as shock.

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52

Localized hypothermia occurs in peripheral arterial insufficiency and Raynaud's disease.

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53

Hyperthermia. Generalized hyperthermia occurs with an increased metabolic rate, such as in fever or after heavy exercise. A localized area feels hyperthermic with trauma, infection, or sunburn.

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54

Hyperthyroidism has an increased metabolic rate, causing warm, moist skin.

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55

Diaphoresis, or profuse perspiration, accompanies an increased metabolic rate, such as occurs in heavy activity or fever.

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56

Diaphoresis occurs with thyrotoxicosis and with stimulation of the nervous system with anxiety or pain.

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57

Be aware that dark skin may normally look dry and flaky, but this does not necessarily indicate systemic dehydration.

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58

With dehydration, mucous membranes are dry, and lips look parched and cracked.

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59

reason for seeking care

CC

60

health habits

tobacco alcohol drugs

61

vitamin A

apricotts peaches caarrots spinach

62

vitamin C

oranges lemons grapefruit strawbarries tomatooes

63

vitamin E

lettuce alflfa and vegtable oills

64

Hyperthyroidism-skin feels smoother and softer, like velvet.
Hypothyroidism-skin feels rough, dry, and flaky.

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65

Very thin, shiny skin (atrophic) occurs with arterial insufficiency.

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66

1+ Mild pitting, slight indentation, no perceptible swelling of the leg
2+ Moderate pitting, indentation subsides rapidly
3+ Deep pitting, indentation remains for a short time, leg looks swollen
4+ Very deep pitting, indentation lasts a long time, leg is very swollen

Pitting edema grading scale

67

Edema makes the hair follicles more prominent, so you note a pigskin or orange-peel look (called peau d'orange).

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68

Bilateral edema or edema that is generalized over the whole body (anasarca)-consider a central problem such as heart failure or kidney failure.

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69

Poor turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands by itself.

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70

Scleroderma, literally "hard skin," is a chronic connective tissue disorder associated with decreased mobility

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71

Cherry (senile) angiomas are smaH (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years

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72

When a lesion develops on previously unaltered skin, it is primary.

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73

when a lesion changes over time or changes because of a factor such as scratching or infection, it is secondary

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74

Hirsutism-excess body hair.

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75

seborrhea (dandruff),

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76

Head or pubic lice. Distinguish dandruff from nits (eggs) of lice, which are oval, adherent to hair shaft, and cause intense itching

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77

In early clubbing, the angle straightens out to 180 degrees and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows

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78

Cyanotic nail beds or sluggish color return: consider cardiovascular or respiratory dysfunction.

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79

The mongolian spot is a common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns (Fig. 12-12). It is a blueblack to purple macular area at the sacrum or buttocks but sometimes on the abdomen, thighs, shoulders, or arms.

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80

The cafe au lait spot is a large round or oval patch of light brown pigmentation (hence, the name "coffee with milk"), which is usually present at birth

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81

Six or more cafe au lait macules, each more than 1.5 em in diameter, are diagnostic of neurofibromatosis, an inherited neurocutaneous disease.

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82

harlequin color change, occurs when the baby is in a side-lying position. The lower half of the body turns red and the upper half blanches with a distinct demarcation ljne down the midline. The cause is unknown, and its occurrence is transient

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83

erythema tox:icum is a common rash that appears in the first 3 to 4 days of life. Sometimes called the "flea bite" rash or newborn rash, it consists of tiny punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks (Fig. 12-14 ). The cause is unknown; no treatment is needed

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84

acrocyanosis, a bluish color around the lips, hands and fingernails, and feet and toenails. This may last for a few hours and disappear with warming.

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85

Cutis marmorata is a transient mottling in the trunk and extremities in response to cooler room temperatures (Fig. 12-JS). It forms a reticulated red or blue pattern over the skjn.

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86

Green-brown discoloration of the skin, nails, and cord occurs with passing of meconium in utero, indicating fetal distress.

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87

Persistent or pronounced cutis marrnorata occurs with Down syndrome or prematurity.

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88

Physiologic jaundice is a common variation in about half of all newborns. A yellowing of the skin, sclera, and mucous membranes develops after the 3rd or 4th day of life because of the increased numbers of red blood cells that hemolyze after birth. The hemoglobin in the red blood cells is metabolized by the liver and spleen; its pigment is converted into bilirubin.

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89

Jaundice after 2 weeks of age may indicate biliary tract obstruction

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90

Carotenemia also produces a yellow-orange color in light-skinned persons but no yellowing in the sclera or mucous membranes. It comes from ingesting large amounts of foods containing carotene, a vitamin A precursor.

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91

In children, excessive sweating may accompany hypoglycemia, heart disease, or hyperthyroidism.

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92

Milia are tiny while papules on the cheeks and forehead and across the nose and chin caused by sebum that occludes the opening of the follicles. Tell parents not to squeeze the lesions; milia resolve spontaneously within a few weeks

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93

Common in new borns
Milia are tiny while papules on the cheeks and forehead and across the nose and chin caused by sebum that occludes the opening of the follicles. Tell parents not to squeeze the lesions; milia resolve spontaneously within a few week

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94

A storkbite (salmon patch) is a flat, irregularly shaped red or pink patch found on the forehead, eyelid, or upper lip but most commonly at the back of the neck (nuchal area) (Fig. 12-17). It is present at birth and usually fades during the first year.

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95

Scaly, crusted scalp occurs with seborrheic dermatitis, "cradle cap"

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96

Adolescents
The increase in sebaceous gland activity creates increased oiliness and acne.

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97

The Pregnant Woman
Striae are jagged linear "stretch marks" of silver to pink color that appear during the second trimester on the abdomen, breasts, and sometimes thighs. They occur in one half of all pregnancies. They fade after delivery but do not disappear.
linea nigra, a brownish black line down the midline (see Fig. 29-3 on p. 807). Chloasma is an irregular brown patch of hyperpigmentation on the face. It may occur with pregnancy or in women taking oral contraceptive pills.
Chloasma disappears after delivery or stopping the pills
Vascular spiders occur in two thirds of pregnancies in white women and less often in Blacks. These lesions have tiny red centers with radiating branches and occur on the face, neck, upper chest, and arms.

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98

The Aging Adult
Senile Lentigines. Commonly called liver spots, these are small, flat, brown macules (Fig. 12-20). These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure.
They appear on the forearms and dorsa of the hands.
seborrheic keratosis, looks dark, greasy, and "stuck on" (Fig. 12-21). They develop mostly on the trunk but also on the face and hands and on une.xposed as well as on sun-exposed areas. They do not become cancerous.
actinic (senile or solar) keratosis, is less common (Fig. 12-22). These lesions are red-tan scaly plaques tl1at increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma.

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99

acrochordons, or "skin tags,"

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100

The aging adult
Sebaceous hyperplasia consists of raised yellow papules with a central depression. They are more common in men, occurring over the forehead, nose, or cheeks. They have a pebbly look

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101

ANNULAR, or circular, begins in center and spreads to periphery
CONFLUENT, lesions run together
DISCRETE, distinct, individual lesions that remain separate
GYRATE, twisted, coiled spiral, snakelike.
LINEAR, a scratch, streak, line, or stripe.
ZOSTERIFORM, linear arrangement along a unilateral nerve route (e.g., herpes zoster).

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102

GROUPED, clusters of lesions
TARGET, or iris, resembles iris of eye, concentric rings of color in the lesions (
POLYCYCLIC, annular lesions grow together

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103

Macule Solely a color change, flat and circumscribed, of less than 1 em. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

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104

Patch Macules that are larger than 1 em. Examples: mongolian spot, vitiligo, cafe au lait spot, chloasma, measles rash.

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105

Nodule Solid, elevated, hard or soft, larger than I em. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.

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106

Tumor Larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "tumor" implies "cancer" to most people. Examples: lipoma, hemangioma.

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107

Papule Something you can feel (i.e., solid, elevated, circumscribed, less than 1 em diameter) caused by superficial thickening in the epidermis. Examples: elevated

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108

Plaque Papules coalesce to form surface elevation wider than 1 em. A plateau-like, disk-shaped lesion. Examples: psoriasis, lichen planus.

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109

Wheal Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.

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110

Wheal Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.

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111

Urticaria (Hives) Wheals coalesce to form extensive reaction, intensely pruritic.

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112

Vesicle Elevated cavity containing free fluid, up to 1 em; a "blister." Clear serum flows if wall is ruptured. Examples: herpes . simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.

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113

Bulla Bulla Larger than 1 em djameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis.

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114

Cyst Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen.

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115

Pustule Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne.

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116

Crust The thickened, dried-out exudate left when vesicles/pustules burst or dry up. Color can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus). Examples: impetigo (dry, honey-colored), weeping eczematous dermatitis, scab after abrasion.

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117

Scale Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin.

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118

Pustule Turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne.

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119

Fissure Linear crack with abrupt edges, extends into dermis, dry or moist. Examples: cheilosis-at corners of mouth due to excess moisture; athlete's foot.

Ulcer Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure sore, chancre.

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120

Erosion Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis.

Excoriation Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella.

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121

Scar After a skin lesion is repajred, normal tissue is lost and replaced with connective tissue (coUagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne.
Lichenification Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen).

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122

Atrophic Scar The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example: striae.

Keloid A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and "clawlike" and has a higher incidence among Blacks

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123

Hematoma A hematoma is a bruise you can feel. It elevates the skin and is seen as swelling. Multiple petechiae and purpura may occur on the face when prolonged, vigorous crying or coughing raises venous pressure.

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124

Contusion (Bruise) A mechanical injury (e.g., a blow) results in hemorrhage into tissues. Skin is intact. Color in a light-skinned person is usually (I) red-blue or purple immediately after or within 24 hours of trauma, then generally progresses to (2) blue to purple, (3) blue-green, (4) yellow, and (5) brown to disappearing. A recent bruise in a dark-skinned person is deep, dark purple.

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125

Port-Wine Stain (Nevus Flammeus) A large, flat, macular patch covering the scalp or face, frequently along the distribution of cranial nerve V. The color is dark red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat or cold. The marking consists of mature capillaries. It is present at birth and usually does not fade. The use of yellow light lasers now makes photoablation of the lesion possible, with minimal adverse effects.

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126

Strawberry Mark (Immature Hemangioma) A raised bright red area with well-defined borders about 2 to 3 em in diameter. It does not blanch with pressure. It consists of immature capillaries, is present at birth or develops in the first few months, and usually disappears by age 5 to 7 years. Requires no treatment, although parental and peer pressure may prompt treatment.

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127

Cavernous Hemangioma (Mature) A reddish blue, irregularly shaped, solid and spongy mass of blood vessels. It may be present at birth, may enlarge during the first 10 to IS montl1s, and will not involute spontaneously.

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128

Telangiectasia Caused by vascular dilation; permanently enlarged and dilated blood vessels that are visible on the skin surface.

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129

Spider or Star Angioma
A fiery red, star-shaped marking with a solid circular center. Capillary radiations extend from the central arterial body. With pressure, note a central pulsating body and blanching of extended legs. Develops on face, neck, or chest; may be associated with pregnancy, chronic liver disease, or estrogen therapy, or may be normal.

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130

Venous Lake
A blue-purple dilation of venules and capillaries in a starshaped, linear, or flaring pattern. Pressure causes them to empty or disappear. Located on the legs near varicose veins and also on the face, lips, ears, and chest.

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131

Ecchymosis
A purplish patch resultjng from extravasation of blood into the skin, >3 mm in diameter.

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132

Purpura
Confluent and extensive patch of petechiae and ecchymoses, >3 mm flat, red to purple, macular hemorrhage. Seen in generalized disorders such as thrombocytopenia and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

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133

Diaper Dermatitis
Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal folds.

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134

Intertrigo (Candidiasis)
Scalding red, moist patches with sharply demarcated borders, some loose scales. Usually in genital area extending along inguinal and gluteal folds. Aggravated by urine, feces, heat, and moisture, the Candida fungus infects the superficial skin layers.

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135

Impetigo
Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crusts. Contagious bacterial infection of skin; most common in infants and children.

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136

Atopic Dermatitis (Eczema)
Erythematous papules and vesicles, with weeping, oozing, and crusts. Lesions usually on scalp, forehead, cheeks, forearms and wrists, elbows, backs of knees. Parm.:ysmal and severe pruritus. Family history of allergies.

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137

German Measles (Rubella)
Pink, papular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik. spots

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138

Chickenpox (Varicella)
Small, tight vesicles first appear on trunk, then spread to face, arms, and legs (not palms or soles). Shiny vesicles on an erythematous base are commonly described as the "dewdrop on a rose petal." Vesicles erupt in succeeding crops over several days, then become pustules, and then crusts. Intensely pruritic.

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139

Allergic Drug Reaction
Erythematous and symmetric rash, usually generalized. Some drugs produce urticarial rash or vesicles and bullae. History of drug ingestion.

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140

Labial Herpes Simplex (Cold Sores)
Herpes simplex virus (HSV) infection has a prodrome of skin tingling and sensitivity. Lesion then erupts with tight vesicles followed by pustules and then produces acute gingivostomatitis with many shallow, painful ulcers. Common location is upper lip, also in oral mucosa and tongue

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141

Herpes Zoster (Shingles)
Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by the varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox. Acute appearance, unilateral, does not cross midline. Commonly on trunk, can be anywhere. If on ophthalmic branch of cranial nerve V, it poses risk to eye. Most common in adults older than 50 years. Pain is often severe and long lasting in aging adults, called postherpetic neuralgia.

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142

Tinea Versicolor
Fine, scaling, round patches of pink, tan, or white that (hence the name) do not tan in sunlight, caused by a superficial fungal infection. Usual distribution is on neck, trunk, and upper arms- a short-sleeved turtleneck sweater area. Most common in otherwise healthy young adults. Responds to oral antifungal medication.

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143

Erythema Migrans of Lyme Disease Lyme disease (LD)
is not fatal but may have serious arthritic, cardiac, or neurologic sequelae. It is caused by a spirochete bacterium carried by the black or dark brown deer tick. Deer ticks are common in the Northeast, upper Midwest, and California (with cases occurring in peopl

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144

Psoriasis
Scaly, erythematous patch, with silvery scales on top. Usually on scalp, outside of elbows and knees, low back, and anogenital area.

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145

Basal Cell Carcinoma
Usually starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). Then develops rounded, pearly borders with central red ulcer, or looks like large open pore with central yellowing. Most common form of skin cancer; slow but inexorable growth. Basal cell cancers occur on sunexposed areas of face, ears, scalp, shoulders.

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146

Squamous Cell Carcinoma
Squamous cell cancers arise from actinic keratoses or de novo. Erythematous scaly patch with sharp margins, 1 em or more. Develops central ulcer and surrounding erythema. Usually on hands or head, areas exposed to UV radiation; above, on habitually sun-exposed bald scalp. Less common than basal cell carcinoma but grows rapidly.

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147

Toxic Alopecia Patchy
, asymmetric balding that accompanies severe illness or use of chemotherapy where growing hairs are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin

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148

Alopecia Areata
Sudden appearance of a sharply circumscribed, round or oval balding patch, usually with smooth, soft, hairless skin underneath. Unknown cause; when limited to a few patches, person usually has complete regrowth.

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149

Tinea Capitis (Scalp Ringworm)
Rounded, patchy hair loss on scalp, leaving broken-off hairs, pustules, and scales on skin. Caused by fungal infection; lesions may fluoresce blue-green under Wood's light. Usually seen in children and farmers; highly contagious, may be transmitted by another person, by domestic animals, or from soil.

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150

Traumatic Alopecia:
Traction Alopecia ..,.. Linear or oval patch of hair loss along hair line, a part, or scattered distribution; caused by trauma from hajr rollers, tight braiding, tight ponytail, barrettes

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151

Seborrheic Dermatitis {Cradle Cap)
Thick, yellow to white, greasy, adherent scales with mild erythema on scalp and forehead; very common in early infancy. Resembles eczema lesions except cradle cap is distinguished by absence of pruritus, "greasy" yellow-pink lesions, and negative family history of allergy

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152

Folliculitis
Superficial infection of hair follicles. Multiple pustules, "whiteheads," with hair visible at center and erythematous base. Usually on anns, legs, face, and buttocks.

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153

Pediculosis Capitis {Head Lice)
History includes intense itching of the scalp, especially the occiput. The nits (eggs) of lice are easier to see in the occipital area and around the ears, appearing as 2- to 3-mm oval translucent bodies, adherent to the hair shafts. Common among school-age children. Over-the-counter pediculicide shampoos are available; however, nit removal by daily combing of wet hajr with a fine-tooth metal comb is especially important.

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154

Trichotillomania
Traumatic self-induced hair loss usually the result of compulsive twisting or plucking. Forms irregularly shaped patch, with broken-off, stublike hairs of varying lengths; person is never completely bald. Occurs as child rubs or twists area absently while falling asleep, reading, or watching television. In adults, it can be a serious problem and is usually a sign of a personality disorder.

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155

Hirsutism
Excess body hair in females forming a male sexual pattern (upper lip, face, chest, abdomen, arms, legs); caused by endocrine or metabolic dysfunction or occasionally idiopathic.

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156

Furuncle and Abscess
Red, swollen, hard, tender, pus-filled lesion caused by acute, localized bacterial (usually staphylococcal) infection; usually on back of neck, buttocks, occasional.ly on wrists or ankles. Furuncles are due to infected hair follicles, whereas abscesses are due to traumatic introduction of bacteria into the skin. Abscesses are usually larger and deeper than furuncles.

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157

Scabies
An intensely pruritic contagion caused by the scabies mite. Mites form a linear or curved elevated burrow on the fingers, web spaces of hands, and wrists. Other family members are usually infected. The patient cannot stop scratching. 10

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158

Paronychia
Red, swollen, tender inflammation of the nail folds. Acute paronychia is usually a bacterial infection; chronic paronychia is most often a fungal infection from a break in the cuticle in those who perform "wet" work.

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159

Beau's Line
Transverse furrow or groove. A depression across the nail that extends down to the nail bed. Occurs with any trauma that temporarily impairs nail formation, such as acute illness, tox.ic reaction, or local trauma. Dent appears first at the cuticle and moves forward as nail grows.

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160

Splinter Hemorrhages
Red-brown linear streaks, embolic lesions, occur with subacute bacterial endocarditis; also may occur with minor trauma.

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161

Onycholysis
This is a slow, persistent fungal infection of fingernails and, more often, toenails, common in older adults. Fungus causes change in color (green where nail plate separated from bed), texture, thickness, with nail crumbling or breaking, and loosening of the nail plate, usually beginnjng at the distal edge and progressing prox.imaJJy.

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162

Pitting
Sharply defined pitting and crumbling of the nails with distal detachment often occurs with psoriasis.

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163

Larger amounts of eumelanin produce darker skin and hair

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164

Late Clubbing
Inner edge of nail elevates; nail bed angle is greater than 180 degrees. Distal phalanx looks rounder and wider. Recent research links clubbing with the physiology of platelet production.21 Diseases that disrupt normal pulmonary circulation (chronic lung inflammation, bronchial tumors, heart defects with right-to-left shunts) cause fragmented platelets to become trapped in the fingertip vasculature, releasing platelet-derived growth factor and promoting growth of vessels, which shows as clubbing. Clubbing usually develops slowly over years; if the primary disease is treated, clubbing can reverse.

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165

Melasma,
increased pigmentation of the face in response to the hormonal changes of pregnancy, occurs mainly on the chin, cheeks, and upper lip and generally resolves postpartum but can be permanent

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166

A score of 14 to 18 on the Braden scale indicates a high risk of pressure ulcer development.

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167

A patient presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

B
The patient had a recent infestation

168

larger amounts of pheomelanin are responsible for lighter skin and lighter hair.

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169

Annular lesions grow together is called

Polycyclic

170

The most accurate site for assessing for skin turgor in adults is on the anterior chest, just below the midclavicular area.

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171

A comprehensive assessment includes a health history and complete physical examination and is usually conducted when a patient first enters a healthcare setting.
A)true
B)false

A

172

A focused assessment is conducted to assess a specific problem.
A)true
B)false

A

173

An emergency assessment is a type of rapid focused assessment conducted to determine a potentially fatal situation.
A)true
B)false

A

174

An ongoing partial assessment is conducted at regular intervals during care of the patient and concentrates on identified health problems and the effectiveness of interventions.
A)true
B)false

.a

175

SKIN

The skin has two layers-the outer, highly differentiated epidermis and the inner, supportive dermis (Fig. 12-1 ). Beneath these layers is a third layer, the subcutaneous layer of adipose tissue.