Skin Examination

1. Skin Examination Pharmacy Practice 742: Physical Assessment

2. 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

3. Original lesion exact site duration appearance distribution progression Symptoms local pruritis pain burning Setting & Timing of Attacks occupation topical agents drug history season of year environment The Skin: History

4. 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

5. 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?

6. Skin: Physical Examination • Inspection • Color: • variation common, even within same person. • Melanin • maybe diffuse or localized • increased: Addison’s Disease, hyperthyroidism, pregnancy, sunlight exposure • decrease: albinism and vitiligo • Erythema • appearance of increased amounts of oxygenated blood in dermal vasculature

7. 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

8. 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)

9. Skin: Physical Examination • Inspection • Morphological structure • primary lesions • flat • elevated • -- serous filled • -- pus filled • -- solid

10. Skin: Physical Examination • Inspection • Morphological structure • secondary lesions • loss of skin • -- erosion • -- ulcer • -- fissure • build-up of skin • -- scale • -- crust • -- lichenification • -- scar

11. 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

13. 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

15. 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

17. 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

19. Skin: Physical Examination • Morphology - Definitions • Nodules • depth may be inferred by palpation…when 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.

21. 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

23. 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

25. 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

28. 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

31. 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

33. 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, Raynaud’s disease • generalized hypothermia due to shock

34. Skin: Physical Examination • Palpation • Moisture • sweat - nervous (hypothermia) or thermal (hyperthermia) in origin • Texture • quality • character • rough • dry (hypothyroidism) • smooth (hyperthermia)

35. 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

36. Cancer • Malignant Melanoma • ABCD’s • 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.

37. Malignant Melanoma

38. Bullous Impetigo

39. Carbuncle

41. Drug Eruption