Skin Assessment



Skin Assessment


Noreen Heer Nicol






I. OVERVIEW

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).


II. PATIENT HISTORY (SUBJECTIVE DATA)

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


Macule


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


Brown


Becker nevus


Café au lait spot


Erythrasma


Fixed drug eruption


Freckle


Junction nevus


Lentigo


Lentigo maligna


Melasma


Photoallergic drug eruption


Phototoxic drug eruption


Stasis dermatitis


Tinea nigra palmaris


Blue


Ink (tattoo)


Maculae ceruleae (lice)


Mongolian spot


Ochronosis


Red


Drug eruptions


Juvenile rheumatoid arthritis


Still disease


Rheumatic fever


Secondary syphilis


Viral exanthems


Hypopigmented


Idiopathic guttate hypomelanosis


Nevus anemicus


Piebaldism


Postinflammatory psoriasis


Radiation dermatitis


Tinea versicolor


Tuberous sclerosis


Vitiligo


Papule


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


Milium


Molluscum contagiosum


Nevi (dermal)


Neurofibroma


Pearly penile papules


Sebaceous hyperplasia


Skin tags


Syringoma


Brown


Dermatofibroma


Keratosis follicularis


Melanoma


Nevi


Seborrheic keratosis


Urticaria pigmentosa


Warts


Red


Acne vulgaris


Atopic dermatitis


Cholinergic urticaria


Chondrodermatitis nodularis chronica helicis


Eczema


Folliculitis


Insect bites


Keratosis pilaris


Leukocytoclastic vasculitis


Miliaria


Polymorphic light eruption


Psoriasis


Scabies


Urticaria


Blue or violaceous


Angiokeratoma


Blue nevus


Lichen planus


Lymphoma


Kaposi sarcoma


Melanoma


Mycosis fungoides


Venous lake


Plaque


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


Psoriasis


Seborrheic dermatitis


Syphilis (secondary)


Tinea corporis


Tinea versicolor



Nodule


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


Furuncle


Hemangioma


Kaposi sarcoma


Keratoacanthoma


Lipoma


Lymphoma


Melanoma


Metastatic carcinoma


Mycosis fungoides


Neurofibromatosis


Prurigo nodularis


Sporotrichosis squamous cell carcinoma


Warts


Xanthoma


Wheal


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.


Angioedema


Dermatographism


Hives


Insect bites


Urticaria pigmentosa (mastocytosis)



Pustule


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


Candidiasis


Dermatophyte infection


Dyshidrosis


Folliculitis


Gonococcemia


Hidradenitis suppurativa


Herpes simplex


Herpes zoster


Impetigo


Psoriasis


Pyoderma gangrenosum


Rosacea


Varicella


Vesicle


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


Dyshidrosis


Impetigo


Chickenpox



Bulla


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


Scales


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


Crusts


A collection of dried serum and cellular debris; a scab


Acute eczematous inflammation


Atopic dermatitis (face)


Impetigo (honey colored)


Pemphigus foliaceus


Tinea capitis


Erosions


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


Candidiasis


Dermatophyte infection


Eczematous diseases


Intertrigo


Petechiae


Senile skin


Toxic epidermal necrolysis


Vesiculobullous diseases


Ulcers


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


Aphthae


Chancroid


Decubitus


Factitial


Ischemic


Necrobiosis lipoidica diabeticorum


Neoplasms


Pyoderma gangrenosum


Radiodermatitis


Syphilis (chancre)


Stasis ulcers


Fissure


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


Chapping (hands, feet)


Eczema (fingertip)


Intertrigo


Petechiae


Atrophy


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


Aging


Dermatomyositis


Discoid lupus erythematosus


Lichen sclerosus et atrophicus


Morphea


Necrobiosis lipoidica diabeticorum


Radiodermatitis


Striae


Topical and intralesional steroids overuse


Scar


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.


Acne


Burns


Herpes zoster


Hidradenitis suppurativa


Porphyria


Varicella


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










































Petechia


Hemorrhages from superficial blood vessels, <5 mm


Purpura


Hemorrhages from superficial blood vessels, 5 mm to 5 cm


Ecchymosis


Bleeding into the tissue affecting large areas


Lichenification


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


Induration


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


Sclerosis


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


Maceration


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


Excoriation


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


Cyst


A sac containing liquid or semisolid material


Furuncle


Deep form of folliculitis with pus accumulation


Abscess


Localized accumulation of purulent material deep within the dermis


Burrow


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


Comedo


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.


Uniformity


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


Moisture


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




Texture


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


Thickness


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


Turgor


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).


Hygiene


Clean, free of odor




Alterations


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

Only gold members can continue reading. Log In or Register to continue

Mar 9, 2021 | Posted by in NURSING | Comments Off on Skin Assessment
Premium Wordpress Themes by UFO Themes