Skin Assessment

Skin Assessment

Noreen Heer Nicol


An initial assessment for patients with skin disorders should be approached as you would any patient. A comprehensive assessment of a dermatologic condition includes the history given by the patient (subjective data) and the findings of the physical examination of the integumentary system (objective data). The patient history and physical examination should also occur in an appropriately private area to ensure privacy and dignity, preferably with natural lighting. A preliminary history of a dermatologic problem can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (Box 2-1).

Skin provides an opportunity for visual inspection. This makes inspection the most important part of the physical examination of the skin. Physical examinations should be done in an orderly manner to insure important diagnostic clues are not missed. The initial key impression of whether the patient appears ill or not is important to note at the beginning of the physical examination.

Lesions can be defined as primary or secondary. Primary lesions are structural changes in the skin that have specific, visual characteristics and develop without any preceding skin changes (Table 2-1). Secondary lesion is one that has changed due to natural progression or due to physical factors such as rubbing or scratching (Table 2-2). Special or “other” lesions are those that occur in the skin only and in the skin most often or can be perceived most easily on the skin (Table 2-3).

Specific terminology is used to describe the characteristics of skin lesions (number, color, type of lesion, configuration, distribution pattern, which can then be documented). These descriptive clues aid in diagnosing and managing the patient by healthcare providers. It is important to use generally accepted descriptive terminology for verbal and written documentation to ensure continuity and to assist health care providers to interpret the findings. The general examination of the skin considers normal variants and general changes in the skin. A wide range of normal variations exist in the skin across the life span, which may be due to age, genetic factors, and environmental influences (Table 2-4).


A. The traditional approach to assessment in general is to take the history prior to performing a physical examination. However, in dermatology, some providers prefer to do this
is in a reverse order to expedite the process. A preliminary history helps to establish rapport and engages the patient in the process. Then, moving to physical examination allows appropriately chosen selective questions to be asked subsequently. The general history of current illness is ideally obtained by allowing patient to use their own words regarding his/her skin condition. This gives the provider a sense of direction as to which triage questions to ask. Initially, try to allow the patient to talk uninterrupted. This preliminary history can be abbreviated to three key questions, which evaluate onset and evolution, symptoms, and treatment to date (Box 2-1). Answers to these questions provide a great deal of information about how the condition has started and evolved over time. Review of systems is indicated by the acute or chronic current condition. Symptoms often drive how far one will go in looking for an etiology. Treatment is so key as oftentimes, regardless
whether over-the-counter or prescription medications, it can be the very thing causing or contributing to the problem.

TABLE 2-1 Primary Skin Lesions and Commonly Occurring Dermatologic Conditions

Primary Skin Lesions Description

Example of Dermatologic Condition

Example of Dermatologic Condition


A circumscribed, flat discoloration, which varies widely in size, color, and shape


Becker nevus

Café au lait spot


Fixed drug eruption


Junction nevus


Lentigo maligna


Photoallergic drug eruption

Phototoxic drug eruption

Stasis dermatitis

Tinea nigra palmaris


Ink (tattoo)

Maculae ceruleae (lice)

Mongolian spot



Drug eruptions

Juvenile rheumatoid arthritis

Still disease

Rheumatic fever

Secondary syphilis

Viral exanthems


Idiopathic guttate hypomelanosis

Nevus anemicus


Postinflammatory psoriasis

Radiation dermatitis

Tinea versicolor

Tuberous sclerosis



A solid, elevated palpable lesion on the skin <1 cm. It is round and sometimes pointed, is usually red but can be white, yellow, brown, or black, and may be associated with secondary lesions like scale and crust.

Flesh colored, yellow, or white

Adenoma sebaceum

Basal cell epithelioma

Closed comedones (acne)

Flat warts

Granuloma annulare

Lichen nitidus

Lichen sclerosus et atrophicus


Molluscum contagiosum

Nevi (dermal)


Pearly penile papules

Sebaceous hyperplasia

Skin tags




Keratosis follicularis



Seborrheic keratosis

Urticaria pigmentosa



Acne vulgaris

Atopic dermatitis

Cholinergic urticaria

Chondrodermatitis nodularis chronica helicis



Insect bites

Keratosis pilaris

Leukocytoclastic vasculitis


Polymorphic light eruption




Blue or violaceous


Blue nevus

Lichen planus


Kaposi sarcoma


Mycosis fungoides

Venous lake


A solid lesion that covers more than 1 cm of surface skin, which is often elevated or thickened and formed by closely clustered papules

Atopic dermatitis

Contact dermatitis

Cutaneous T-cell lymphoma

Papulosquamous (papular and scaling) lesions

Discoid lupus erythematosus

Lichen planus

Pityriasis rosea


Seborrheic dermatitis

Syphilis (secondary)

Tinea corporis

Tinea versicolor


A solid, elevated palpable mass that is usually larger than 0.5 cm. Sometimes considered a small tumor, nodules are located in the epidermis or extend deeper to the dermis or subcutaneous tissue.

Basal cell carcinoma

Erythema nodosum



Kaposi sarcoma





Metastatic carcinoma

Mycosis fungoides


Prurigo nodularis

Sporotrichosis squamous cell carcinoma




Firm, edematous plaque resulting from infiltration of the dermis with fluid. Wheals are transient and a hypersensitivity response. Shape is often irregular. Sizes usually range from 3 mm to 12 cm.




Insect bites

Urticaria pigmentosa (mastocytosis)


A circumscribed elevated lesion containing whitish or yellowish elevations of the skin filled with purulent exudate, usually a collection of leukocytes and free fluid

Acne vulgaris


Dermatophyte infection




Hidradenitis suppurativa

Herpes simplex

Herpes zoster



Pyoderma gangrenosum




A round, raised lesion containing clear or purulent fluid that is up to <1 cm. They are either sparsely scattered or specifically grouped.

Herpes simplex

Herpes zoster

Contact dermatitis





This is a circumscribed collection of free fluid that is larger than 1 cm in diameter. It is mostly superficial in nature, and ruptures easily.

Bullous pemphigoid

Pemphigus vulgaris

Bullous impetigo

Bullous lichen planus

A primary lesion is a visually recognized structural change in the skin. It has specific characteristics and develops without any preceding skin change.

Adapted from Habif, T. P. (1996). Clinical dermatology: A color guide to diagnosis and therapy (3rd ed., pp. 3-11). St. Louis, MO: Mosby-Yearbook, Inc.

B. Information regarding other family members with similar symptoms, past medical history, previous and current drug therapy (including all over-the-counter preparations like herbs, vitamins, and natural supplements), occupation, and social history are all important parts of the initial interview.

1. Family history is important. Conditions such as psoriasis, eczema, skin cancer, or even keratosis pilaris have a genetic tendency. Patients may claim that another family member shares similar symptoms. For example, the diagnosis of atopic dermatitis is supported when the child presenting with chronic pruritic rash in antecubital fossa has a family history of atopic diseases (asthma, hay fever, and atopic dermatitis).

TABLE 2-2 Secondary Skin Lesions and Commonly Occurring Dermatologic Conditions

Secondary Skin Lesions Description

Commonly Occurring Dermatologic Conditions


Excess dead epidermal cells that are produced by abnormal keratinization and shedding

Fine to stratified

Erythema craquele

Ichthyosis (quadrangular)

Lupus erythematosus (carpet tack)

Pityriasis rosea (collarette)

Psoriasis (silvery)

Scarlet fever (fine, on trunk)

Seborrheic dermatitis

Syphilis (secondary)

Tinea (dermatophytes)

Xerosis (dry skin)

Scaling in sheets

Scarlet fever (hands and feet)

Staphylococcal scalded skin syndrome


A collection of dried serum and cellular debris; a scab

Acute eczematous inflammation

Atopic dermatitis (face)

Impetigo (honey colored)

Pemphigus foliaceus

Tinea capitis


A focal loss of epidermis; erosions do not penetrate below the dermoepidermal junction and therefore heal without scarring.


Dermatophyte infection

Eczematous diseases



Senile skin

Toxic epidermal necrolysis

Vesiculobullous diseases


A focal loss of epidermis and dermis; ulcers heal with scarring.






Necrobiosis lipoidica diabeticorum


Pyoderma gangrenosum


Syphilis (chancre)

Stasis ulcers


A linear loss of epidermis and dermis with sharply defined, nearly vertical walls

Chapping (hands, feet)

Eczema (fingertip)




A depression in the skin resulting from thinning of the epidermis or dermis



Discoid lupus erythematosus

Lichen sclerosus et atrophicus


Necrobiosis lipoidica diabeticorum



Topical and intralesional steroids overuse


An abnormal formation of connective tissue implying dermal damage; after injury or surgery, scars are initially thick and pink, but with time, scars become white and atrophic.



Herpes zoster

Hidradenitis suppurativa



A secondary lesion is a lesion that has changed due to its natural evolution or due to physical change (scratching, irritation, or secondary infection).

TABLE 2-3 Special Lesions/Other


Hemorrhages from superficial blood vessels, <5 mm


Hemorrhages from superficial blood vessels, 5 mm to 5 cm


Bleeding into the tissue affecting large areas


Thickening of the skin with exaggerated markings due to prolonged rubbing or scratching


Dermal hypertrophy causing the skin to become thicker and firmer. The skin markings remain unchanged.


Circumscribed or diffuse hardening or induration of the skin resulting from dermal or subcutaneous edema, cellular infiltration, or collagen proliferation


Thickening and whitening of the horny cell layer caused by excessive moisture


A linear or “dug out” traumatized area, usually self-inflicted


A sac containing liquid or semisolid material


Deep form of folliculitis with pus accumulation


Localized accumulation of purulent material deep within the dermis


A characteristic linear lesion caused by tunneling in the stratum corneum produced by an animal parasite


Mass of keratin and sebum within the dilated orifice of a hair follicle

2. Medical history is significant, including illnesses—particularly chronic illness, which may manifest in the skin—and surgical procedures, for example, if the patient presents with diffuse hair loss or perhaps an unusual rash that may be due to an unresolved strep infection or recent infections occupied by high fever. In another scenario, a past history of chickenpox is helpful in evaluating the patient suspected with herpes zoster.

3. Medication history and medication allergy can take time to update in a comprehensive manner. Then for example, obtaining information regarding current prescription therapy or medicines recently used, including all topicals; systemic medications including steroids; vitamins, and dietary supplements complementary or over-the-counter medications; and home remedies. Drugs or medications can cause multiple types of skin conditions.

4. Occupational history is important in skin disease when patients have occupation-associated symptoms or those which improve over a weekend or resolve while on vacation. In conditions such as occupational contact dermatitis, significant short- and long-term disability, and legal issues may coexist.

TABLE 2-4 Normal Skin Findings and Variations Across the Life Span

Areas of Concern

Normal Adult Findings

Variations in Children

Variations in Older Adults

Color and tone

Deep to light brown in blacks; whitish pink to ruddy with olive or yellow overtones in whites.

Newborn reddish first 8 to 24 h and then pale pink with transparent tone; slight jaundice starting 2nd or 3rd day of life; mottled appearance of hands and feet in newborns disappears with warming; in black newborns, melanotic pigmentation not intense with exception of nail beds and scrotum

Skin of white persons tends to look paler and more opaque.


Sun-darkened areas; areas of lighter pigmentation in dark-skinned persons (palms, lips, nail beds); labile pigmentation areas associated with use of hormones or pregnancy; callused areas appear yellow; crinkled skin areas darker (knees and elbows); darkskinned (Mediterranean origin) persons may have lips with bluish hue; vascular flush areas (cheeks, neck, upper chest, or genital area) may appear red, especially with excitement or anxiety; skin color masked through use of cosmetics or tanning agents

Upper and lower extremities similar in color

More freckles; uneven tanning; pigment deposits; hypopigmented patches


Minimum perspiration or oiliness felt; dampness in skin folds; increased perspiration associated with warm environment of activity; wet palms, scalp, forehead, and axilla associated with anxiety

Perspiration present in all children over 1 mo of age

Increased dryness, especially of extremities; decreased perspiration

Surface temperature

Cool to warm


Smooth, even, and soft; some roughness on exposed areas (elbows and soles of feet)

Smooth, soft, flexible, dryness, and flakiness of skin in infants <1 mo of age (shedding of vernix caseosa); may appear as white cheesy skin; presence of milia; small white papules over nose and cheeks (plugged sebaceous glands) may remain for 2 mo.

Flaking and scaling associated with dry skin, especially on lower extremities


Wide body variation; increased thickness in areas of pressure or rubbing (hands and feet)

Varying degrees of adipose tissue; dimpling of skin over joint areas

Thinner skin, especially over dorsal surface of hands and feet, forearms, lower legs, and bony prominences


Skin moves easily when lifted and returns to place immediately when released.

Skin moves easily when lifted but falls quickly when released; skin over extremities taut.

General loss of elasticity; skin moves easily when lifted but does not return to place immediately when released; skin appears lax; increased wrinkle pattern more marked in sun-exposed areas, in fair skin, and in expressive areas of face; pendulous parts sag or droop (under chin, earlobes, breasts, and scrotum).


Clean, free of odor


Striae (stretch marks) usually silver or pinkish; freckles (prominent in sun-exposed areas); some birthmarks

Café au lait spots (light, cream-colored spots on darkened background); some nevi; stork bites (small red or pink spots on back of neck, upper lip, or upper eyelid; usually disappear by 5 y of age)

Nevi often become lighter or disappear; seborrheic keratoses (pigmented raised, warty, slightly greasy lesions most often found on trunk or face); senile (actinic) keratoses on exposed surfaces; first seen as small reddened areas and then as raised, rough, yellow to brown lesions; senile sebaceous adenomas (yellowish flat papules with central depressions); cherry adenomas (tiny, bright, ruby red, round); may become brown with age

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Mar 9, 2021 | Posted by in NURSING | Comments Off on Skin Assessment

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