SKIN EXAMINATION

Dr. Ploesteanu Rodica

Emergency Hospital „Sfantul Pantelimon”
2018
 Skin
• The largest organ in the human body - 1,5-
2m²,
• 1/6 -1/7 of the body weight.
 Functions of the skin
• Protective barrier (mechanical, photo
protection, anti-infective),
• Sensory perception,
• Thermoregulation,
• Immunological,
• Endocrinological,
• Psychosocial.
Structure of the skin
 Structure of the skin
1. Epidermis
• stratified squamous epithelium without
vascularization that consists of:
 Melanocytes - pigment-containing cells (protection
against UV irradiation).
 Keratinocytes arranged in several layers.
 Antigen-processing Langerhans cells (migration to
local lymph nodes).
 Pressure-sensing Merkel cells (role in sensation)
 Structure of the skin
2. Dermo-epidermal junction = basement
membrane zone.
• holds the skin together keeping the epidermis
firmly attached to the dermis.
• autoimmune disorders can cause skin fragility
and blistering diseases.
 Structure of the skin
3. Dermis
• cells - fibroblasts, fibrocytes, mononuclear
cells, mast cells.
• fibers: collagen, elastic, reticulin.
• the fundamental substance with vascular and
lymph plexus and nerve endings, Sweat
glands, Sebaceous glands, Hair follicles.
 Skin lesions

Primary Secondary
• circumscribed color • loss of skin surface
changes • material on the skin
• elevated solid masses surface
• scars
• elevated masses with
fluid content

Primary = May Arise From Previously Normal Skin

Secondary = Result From Changes in Primary Lesions
 Circumscribed color changes
1. Macule
= small, flat spot (dimension < 1 cm)
 pigmented (freckles, lentigo - post sun
exposure,”café au lait” spots)
 depigmented (after superficial burns)
 vascular: petesia
erythematous
teleangiectasia
 Lentigo

Histologic findings may include hyperplasia of the epidermis and

increased pigmentation of the basal layer. A variable number of
melanocytes are present; these melanocytes may be increased in number,
but they do not form nests.
Lentigo
”Café au lait” spots
 Petechia
• small, reddish-purple macule (1–3mm),
• persists when pressed,
• not pulsatile,
• due to small intradermic hemorrhage,
• when multiple or confluated = purpura.
• causes: vascular, platelet or coagulation
disorders.
Purpura
 Telangiectasias („spider vein”)
• bluish, irregular, linear macule on the limbs
and anterior chest.
• dilated small vessels (venules, arterioles or
capillaries) due to increase pressure in the
superficial veins.
• not pulsatile,
• diffuse pressure blanches the veins.
Telangiectasias („spider vein”)
Telangiectasias („spider vein”)
 Circumscribed color changes
2. Patch
= a macule with size > 1 cm.
 Ecchymosis
• various shape and size patch,
• with color that changes in time first purplish-
blue → green (days) → yellow-brown (weeks),
• not pulsatile,
• persists when pressed,
• due to a dermic hemorrhage,
• causes: bruising, traumas, spontaneous
(bleeding disorders).
“Eye-glasses” ecchymosis– fracture of
the skull base
 Solid palpable skin lesions
1. Papule
2. Plaque
3. Nodule
 Solid palpable skin lesions
1. Papule
= protuberant, well-defined lesion, of various colors,
superficial, solid, and of small size (< 1 cm).
 Ex of papules
• Naevi = “moles”, can be congenital or acquired.
• Seborrheic keratoses (senile warts)

= slightly raised, light brown spots with rough,

warty surface.
– Lesser-Trelat sign = abrupt erruptive seborrheic
keratoses that may denote underlying internal
malignancy.
• Warts

= well-defined papules with rough surface (hand, knee,

face) of viral etiology (verruca vulgaris)
Naevi
Seborrheic keratoses (senile warts)
 Warts
• Warts are benign proliferations of skin and mucosa
caused by the human papillomavirus (HPV).
• 7-12% of the population.
• Certain HPV types tend to infect skin at particular
anatomic sites; however, warts of any HPV type
may occur at any site.
• The HPV virus infects the epithelium, and
systemic dissemination of the virus does not occur.
Common Warts
Warts
Condyloma
 Angiomas
= reddish-purple patch/papule.
• benign tumors derived from cells of the vascular or
lymphatic vessel walls (endothelium) or derived
from cells of the tissues surrounding these vessels.

cherry angiomas
venous lake (bluish angiomas on the lip)
spider angiomas
Cherry angiomas
Venous lake
 Spider angioma
• a central red , pulsatile papule with feeding capillary
legs on a erithematous base.
• when pressed it blanches from the central area to
periphery
• cause
 hyperestrogenism
 chronic liver failure
Not = to spider veins (teleangiectasia)!
Spider angioma vs Spider veins
Spider angioma
 Solid palpable skin lesions
2. Plaque = papule with size > 1 cm.
 Ex of plaques
Urticaria = hives
• acute/chronic disorder
• characterised by wheal rash
• recurrent transient oedematous dermal papules or
plaques, persisting less than 24 hours; may be
asymptomatic but are often intensely itchy or sting
and burn.
• causes: food, drugs allergies, insect bites, physical
factors (scratching → dermatographia)
Wheal rash
Wheal rash
 Dermatographia
= skin writing.
• When people who have dermatographia lightly
scratch their skin, the scratches redden into a
raised wheal similar to hives.
• These marks usually disappear within 30
minutes.
• Cause: unk.
Dermatographia
 Solid elevated skin lesions
3. Nodule
= rised skin mass, larger (> 1cm), firmer and deeper
than papule.
 Ex of nodules
Epithelioid granulomas
= small size (~ 1-2cm) nodule caused by a dermic
collection of mixed inflammatory cells
• sarcoidosis, – non-caseating
• tuberculosis (scrofuloderma) – caseating (caseum
Latin word for cheese)
Scrofuloderma
 Osler nodules
Osler nodules
• red, tender, small nodules (1-3mm)
• on the finger pads, palms and soles
• in infective endocarditis
 Ex of nodules
Maynet nodules
• small, non-tender, skin colored, nodules
• on extension surfaces
• in rheumatic fever
 Ex of nodules
Gouty tophi
• monosodium urate crystals skin collections
• firm, non-tender nodules that contain a white pasty
material
• can ulcerate
• location: ear, elbow,
fingers, feet
Gouty tophi
 Ex of nodules
Xanthomas
• caused by the accumulation of fat in macrophage
immune cells in the skin.
• xanthelasma palpebrum - most common type,
• tuberous (knees, elbows, heels, buttocks = pressure
areas),
• tendinous - related to the tendons or the ligaments
and ↑ total or ldl-cholest,
• eruptive - hypertriglyceridaemia.
Xanthomas
 Eruptive Xanthomas

crops of small, red-yellow papules/ nodules on an

erythematous base
Xanthelasma palpebrum
 Hematoma
• nodule of various size and shape,
• tender/nontender,
• with same color changes in time as
petechia/ecchymosis,
• due to large hemorrhage/blood accumulation
in the subcutaneous tissue.
 Elevated fluid content skin lesions
1. Vesicle
2. Bulla
3. Pustule
 Elevated fluid content skin lesions
1. Vesicle
= serous fluid accumulation, small sized (<0,5cm)
can be in the epidermis (not scaring) or in dermis
(scaring).
Types

Localized: Generalized:
• herpes eruption (cold sores) • varicella (chickenpox)
• herpes zoster (shingles) • eczema (dermatitis)
– one of the stages
 Eczema (dermatitis)

• itchy, vesicle eruption caused by skin

inflammation.
• ex: atopic dermatitis, contact dermatitis
Atopic dermatitis
Contact dermatitis
 Varicella (chickenpox)

• an itchy rash of red papules progressing to vesicles.

• Cause: VZV
• different stages of lesions are present
simultaneously on the:
→ stomach,
→ back,
→ face,
→ and then spreading to other parts of the body
Varicella (chickenpox)
 Herpes zoster (shingles)
• crop of closely-grouped red bumps in a continuous
band on the area of skin supplied by one, occasionally
two, and rarely more neighbouring spinal nerves.
• an intense, persistent pain (neuralgia) precedes,
accompany and often persists after the healing of the
eruption.
• Cause: VZV reactivation
Herpes zoster (shingles)
Herpes zoster (shingles)
 Herpes eruption (cold sores)
• small, closely grouped vesicles with a red base
• Cause: HSV 1 or 2.
• Localization: face (lips)
genitals
 Elevated fluid content skin lesions
2. Bulla:
= a vesicle (serous fluid) larger than >0,5 cm.

• 2nd burns,
• bullous pemphogoid, pemphigus vulgaris
• impetigo (strepto/stafilo) children
• porphyria cutanea tarda
Pemfigoid
Pemfigus
 Impetigo
mouth and nose more common
 Elevated fluid content skin lesions
3. Pustule
= a vesicle/bulla with purulent exudate (sterile or not)
• acne
Secondary skin lesions – loss of skin surface

1. Excoriation.
• linear loss of epidermis;
• may penetrates to dermis,
• ± scarring
• caused by scratching, skin abrasion, urticaria,
eczema, parasites.
Secondary skin lesions – loss of skin surface

2. Fissure.
• deap linear split in the skin; penetrates in to dermis.
Secondary skin lesions – loss of skin surface

3. Erosion.
• loss of the superficial epidermis; doesn‘t
bleed, no scarring.
• ex: after vesicle ruptures
Secondary skin lesions – loss of skin surface

4. Ulcer.
• focal loss of epidermis and dermis, always
scarring.
 Ulcers
1. Vascular
 venous (varicose) ulcer
- well defined edges, bottom covered with fibrine,
granulation tissue
- lower intensity of pain
- lower 1/3 of the shins, tipically medial
- adjacent skin with stasis eczema
- cause: chronic venous insufficiency
 arterial ulcer: distal (toes), very painfull, cold and allopecic
surrounding tissue, absent arterial perifferic pulse.
Venous (varicose) ulcer
Arterial ulcer
 Ulcers
2. Neuropatic ulcer
3. Traumatic
4. Infectios. Syphilis chancre
 Syphilis chancre
• round, sharp edges,
• erythematous bottom,
• nontender
• hard base,
• highly infective
 Material on the skin surface
1. Crust
• deposit caused by the dried residue of serum,
pus, or blood.
• Hematic (brown-red)
• Honey coloured (yellow-golden) in impetigo
Impetigo
 Material on the skin surface

2. Scale
• a exfoliated fragment of the keratinic layer of
the epidermis.
• produced by abnormal keratinization or
sheeding.
• can cover macules, papules or plaques.
Scale
 Material on the skin surface
Psoriasis

• a chronic, common disease (2% of

population)
• non-tender, non-itchy red scaly patches
with well-defined edges.
• scratching the scales produces a silvery
white powder and if continued a drop of
blood (Auspitz sign)
Auspitz sign
 Material on the skin surface
Psoriasis

• location: elbow, knee, sacrum, scalp.

• assoc.: nail pitting, psoriatic arthritis.
• after the psoriasis patch it may leave post-
inflammatory hyper/hypopigmentation.
• it does not cause true scarring.
Psoriasis
 Material on the skin surface
3. Keratosis – keratoderma
= marked thickening of the skin
• palmoplantar keratoderma: hereditary/acquired
• ichthyosis
-persistently dry, thickened, rough, fish scale
skin
-inherited
-acquired ichthyosis: cancer (lymphoma),
thyroid disease, sarcoidosis, HIV infection,
drugs: hydroxyureea
Palmoplantar keratoderma
Ichthyosis
 Secondary skin lesions - scars
1. Common Scars
= fibrous tissue that replaces a destroyed focal area
of the skin.
 linear (after cuts, surgical sutures)
 irregular (after ulcers, profound wounds)
 hypertrophic (thick and pink)
 atrophic (thin and white)
Hypertrophic scar
 Secondary skin lesions - scars
2. Keloids
• the same consistency and composition of scars, but
grow beyond the border of the injury that incited
them.
 Secondary skin lesions - scars
3. Skin atrophy
= focal depression of the skin resulting from thinning of
epidermis and/or dermis.

 senile
 arterial insuficciency • linear skin atrophy (white/red)
• due to tear of the elastic fibers of
 stria the subdermic layers
• In:
- pregnancy,
- growth spurs,
- obesity
- hipercorticism (Cushing syndrome)
Stria
 Secondary skin lesions - scars
4. Skinsclerosis
= thickening and thighting of the skin and the
subcutaneous tissue to form hard plaques
• due to excessive activation of the fibroblasts.

Localized Generalized
• secondary to an systemic scleroderma
inflammatory process
Ex: morphea (localised
scleroderma)
Morphea
 Skin tumors
Benign:
1. epithelial tumors: Seborrheic keratoses
2. mesenchymal tumors: fibroids, lipomas, vascular tumors
(angioma, hemangioma) ...
3. common nevi from melanocytic cells
Malignant:
1. epithelial: squamous cell carcinoma and basal cell
carcinoma
2. Melanoma
3. Matastatic tumors
Squamous and basal cell carcinoma
• Caused by prolonged UV exposure
• Appear in exposed areas (face)
• It differs the epidermic layer from witch they
are formed
Baso cellular carcinoma
superior 2/3 of the face
Squamous cell carcinoma
inferior 1/3 of the face
 Malignant Melanoma
neoplasm of melanocytes
sun exposure!
Melanoma
Naevi vs melanoma
ABCDE Melanoma
Appendages of the skin
 Appendages of the skin

Hair
Sebaceous
glands
Nails Sweat glands
 Hair
• protein filament that grows through the epidermis
from follicles deep within the dermis.
• body hair is racial, genetical and hormonally
influenced.
Structure of hair
 Types of hair
• lanugo: fine black hair that covers the entire body of
the fetus and newborn.

• vellus: short, fine, inconspicuous, and relatively

unpigmented, covers most of the body of the females
and children.
 Types of hair
• terminal hair: coarser, thicker, more
conspicuous, usually pigmented (scalp,
eyebrows, eyelashes, axillary, pubic, beard)

• axillary and pubic hair: appears on puberty

in both sexes; fully developed after the 20 s
dependent on androgens
 Excessive hair growth
1. Hypertricosis:
= an increase in the amount of hair growth in areas that
are normal for the sex and age of the patient.
2. Hirsutism:
= excessive thick or dark terminal hair with a male
pattern growth;
• occurs in women or children (premature pubarche)
 Hypertrichosis
• physiological: men, some brunet women – limbs;
• pathological:
A. congenital:
 generalized: “werewolf syndrome”
 localised:
- on the back: “ faun tail” – neural
abnormalities and spinal defect
- hairy pinna : old men, AIDS and diabetic
patients
 Hypertrichosis
B. acquired:
- a variety of injuries like trauma, irritation or
inflammation
- after plaster casts
- drugs: phenytoin, cyclosporine a and
minoxidil
- porphyria cutanea tarda,
- malignancy,
- anorexia nervosa.
Faun tail
“Werewolf syndrome”
Acquired hypertrichosis
 Hirsutism

• male pattern of terminal hair

• Hirsutism + signs of male pattern = virilisation
- enlarged clitoris
- deep voice
- seborrhea, acne
- android features
• signs of defeminisation:
- atrophy of the uterus, breast
- amenorrhea, secondary sterility
- male comportament
 Hirsutism
Causes:
 idiopathic: end-organ hypersensitivity to
androgens
 endocrine: polycystic ovary syndrome,
acromegaly, Cushing’s syndrome, congenital
adrenal hyperplasia
 drugs: androgens, progesteron, spironolactone
 tumours
 paraneoplastic: lung, pancreas, colon
Hirsutism
 Hair loss
• Hair loss= effluvium.
• Alopecia= the result of effluvium.
 Classification of alopecia
Localization: Scarring
• diffuse (hypothyroidism, • Non scarring (alopecia areata,

hypopituitarism, iron fungal infection, secondary

deficiency, drug induced: syphilis, s. Hertzoghe, loss of
cytotoxic agents) axillary and pubic hair: old age,
• localised cirrhosis, hypopituitarism)
• Scarring (burns, severe
infections - herpes zoster, lichen
planus, systemic lupus
Evolution
erythematosus)
• Reversible
• Progressive
• Permanent
 Reversible: alopecia areata,
 Progressive: Baldness
= androgenetic alopecia.
• terminal scalp hairs undergoes miniaturization to vellus hairs.
• an aging phenomenon with an inherited component,
dependent on androgens.
• women may show age-related hair loss that is more diffuse).
 Permanent (congenital and after scars)
 Changes in hair texture
• Dry, coarse, thinned hair: hypothyroidism and
methabolic disorders, anorexia.
 Colour hair changes
1. Albinism: genetic defect in melanin synthesis
2. Graying:
• physiological
• premature (Basedow disease, Cushing’s, emotional
shock, iron deficiency).
 Nails

• a plate of hardened densely packed keratin

• protect the finger tip.

• facilitate grasping and tactile sensitivity in the finger

pulp.
 Nails

• nail matrix (lunula: the visible distal part of the

matrix) contains dividing cells that mature, keratinize
and move forward to form the
• nail plate that sits on the
• nail bed
Nails colour changes
Blue nails
Blue green nails
Yellow nails
 White/brown
”half and half” nails
 Nail changes
• Onychauxis: thickening of the nail
• Onychogriphosis: clawlike nails
- genetic,
- ill-fitting shoes, injury,
- poor blood flow to the feet,
- diabetes, nutritional deficiency.
Onychauxis
Onychogriphosis
 Nail changes
• Onychocryptosys: ingrown nail
• Onychorrhexis: with full lenght striae and brittle
nails
- effect of water and detergent,
- iron deficiency,
- hypothyroidism,
- digital ischaemia
• Onicoschizis: brittle nails
Onychocryptosys
Onychorrhexis
Onicoschizis
 Nail changes
Onycholysis: separation of nail from nail bed
- psoriasis,
- fungal infection,
- trauma,
- thyrotoxicosis,
- tetracyclines
Nail changes are most often seen in Onychomycosis
(fungal infection of the nail): thickening, whitening,
ridging of the nail.
Onycholysis
 Nail changes
• Paronychia: inflammation of the proximal and lateral nail
folds
• the folds are red, swollen, and often tender
• the cuticle may not be visible
• Nail fold erythema and telangiectasia: due to vasculitis
• systemic lupus erythematosus
• systemic sclerosis
• dermatomyositis
Paronychia
 Nail changes
• Koilonychia
- spoon-shaped depression of nail plate
- in iron deficiency anemia
 Nail changes
Beau’s lines: transverse grooves
– any severe systemic illness which affects growth
of the nail matrix

Pitting nails: fine, small pitts

– psoriasis
Beau lines
Pitting nails
 Clubbing of the fingers
• the nail plate is more convex
• the distal phalanx of each finger is rounded and
bulbous.
• Pierre marie’s hypertrophic pulmonary
osteoarthropathy
clubbing of the fingers
thickening of periosteum and synovium
paraneoplastic syndrome: lung cancer
Clubbing of the fingers
Clubbing of the fingers
 Clubbing of the fingers
 lung disease
• lung cancer
• interstitial lung disease
• tuberculosis
• suppurative: lung abcess, empyema, bronchiectasis,
cystic fybrosis
• pulmonary hypertension
• mesothelioma
 heart disease
• congenital cyanotic heart defect
• subacute infective endocarditis
• any disease featuring chronic hypoxia
 Clubbing of the fingers
 gastrointestinal/hepatobilliary disease
• malabsortion
• Crohn’s disease, ulcerative colitis
• cirrhosis
 others
• Graves’s disease
• unilateral: subclavian/axillary artery aneurism
 idiopatic
SWEAT GLANDS
 In dermis layer of the skin

Sweat glands

Eccrine
•widely distributed
•open directly onto the skin surface
•their sweat production help to control
body temperature
Apocrine
•in the axillary and genital regions,
•usually open into hair follicles,
•are stimulated by emotional stress.
•bacterial decomposition of apocrine
sweat → adult body odor
 Hyperhidrosis = diaphoresis
= sweating in excess of that required for normal thermoregulation
A. generalized:
• neurologic or neoplastic diseases
• metabolic disorders (thyrotoxicosis, diabetes mellitus,
hypoglycemia, gout, pheochromocytoma, menopause)
• fever
• medications (propranolol, tricyclic antidepressants)
• chronic alcoholism
• Hodgkin disease or tuberculosis (night sweats)
 Hyperhidrosis = diaphoresis
B. localised:
 emotional induced: palms, soles, and/or axillae
 assoc. with vascular abnormalities, peripheral
neuropathy
 Anhidrosis
A. generalized:
 autonomic neuropathy
 extensive burns
 sclerodermia
 haloperidol
B. localized:
 face: Claude–Bernard–Horner sd.
 lower half of the body: diabetes (xerosis
diabetica)
 Claude–Bernard–Horner sd
• an interruption of the sympathetic nerve supply to the eye
• characterized by the triad of miosis, partial ptosis, and loss of
hemifacial sweating.
 Claude–Bernard–Horner sd
Cause

Can be Pancoast tumor

 In dermis layer of the skin

SEBACEOUS GLANDS
 Sebaceous glands
• in dermis layer of the skin
• Inactive until puberty
• produce a fatty substance sebum that is secreted to
the skin surface through the hair follicles
• palms and soles – the only region without
sebaceous glands
 Seborrhea
= exccesive secretion of sebum.
In:
• puberty: assoc. acnea
• pregnancy
• menopause
• hypercortisolism (Cushing’s, drug induced)
• Parkinson’s disease
 Sebaceous cyst
• This name is used interchangeably for many types of
cysts that are thought to have originated in the
sebaceous glands in the past.
• These cysts are named from the cells forming the
walls of the cavity:
 Epidermoid cysts (epidermal cells),
 Pilar cysts (hair follicle cells)
 Sebaceous cysts(from sebaceous gland cells).
 Sebaceous cyst
• firm, round, of variable size and painless nodules
• mobile from profound layers but attached to skin
• flesh-colored to yellow or white or even pigmented
• a central pore or punctum from which a thick
cheesy material can sometimes be expressed
• on the face, the trunk, the neck, the extremities,
and the scalp.
Sebaceous cyst
 Rhinophyma
Thickening of the skin on the nose and the presence of
many oil glands.
Thickening, bulb shape, reddish, with a waxy, yellow
surface
 old men
 chronic obstructive pulmonary disease
Final stage of rosacea. (affects sebaceous glands and
vasoreactivity. Red face, linked to sun exposure.)
Rhinophyma