Ch. 10 Skin, Hair and Nails - Bickley and Bates

Ch.
10 Skin, Hair Nails (Bickley/Bate’s)

I. Anatomy and Physiology
a. Skin: epidermis, dermis, and subcutaneous tissue
b. Epidermis: thin vascular keratinized epithelium
i. Outer horny layer: stratum corneum: dead keratinized cells
ii. Inner cellular layer: stratum basale and the stratum
spinosum or Malpighian layer (melanin and keratin formed)
iii. Dermis: dense layer of interconnecting collagen and elastic
fibers containing epidermal appendages:
1. Pilosebaceous glands, sweat glands, follicles,
cutaneous nerves.
iv. Adipose tissue beneath: subcutaneous fatty tissue
v. Melanin: brownish pigment
vi. Oxyhemoglobin: bright red pigment in arteries
vii. Deoxyhemoglobin: darker bluer pigment in veins
c. Hair:
i. Vellus hair: short, fine, inconspicuous, unpigmented
ii. Terminal hair: coarser, thicker, conspicuous, pigmented
d. Nails:
i. Nail plate: rectangular and usually curving: pink
ii. Nail bed: vascular, plate is firmly attached
1. Lunula: whitish moon, free edge of the nail plate
2. Nail root: covered by the proximal nail fold
3. Cuticle is a seal, protects the space between the fold and the plate from external moisture
a. Angle between the proximal nail fold and the nail plate is less than 180 deg.
b. Fingernails grow 0.1 mm daily
e. Pilosebaceous glands: oil glands
i. Sweat glands:
1. Eccrine: widely distributed, open directly to the skin surface; help to control body temperature
2. Apocrine: found in axillary and genital region; usually open into hair follicles; responsible for body
order
II. Health Hx: General approach
a. Certain relevant aspects of skin disease processes such as duration, evolution, periodicity and prior episodes of
a similar type are often familiar to the patient; careful interview should be obtained.
b. Lesions: single layer of altered skin (look for lesions suggesting melanoma, basil cell carcinoma (BCC),
squamous cell carcinoma (SCC)
i. Ask about personal and family hx of lesions, sunscreen use, self-exam
c. Rashes and itching: widespread eruption of lesions
i. Ask about pruritus (most imp. s/s of rash)
ii. Allergies, itching at night, products; other accompanying s/s
iii. Causes of generalized itching, without apparent rash, include dry skin, pregnancy, uremia, jaundice,
lymphomas and leukemia, drug reactions and less commonly, polycythemia Vera and thyroid disease.
d. Hair loss and nail changes: Sudden, shedding thinning; from the root or shaft
i. Ask about product, shampooing.
ii. Common nail changes: onychomycosis, habit tic deformity, melanonychia
iii. Most common cause of diffuse hair thinning are male and female pattern baldness.
iv. Hair shedding at the roots is common in telogen effluvium and alopecia areata. Hair brakes along the shaft
suggest damage from her care or Tina capitis.
III. Describing skin lesions:
a. Number, size, color, shape, texture, primary lesion, location, and configuration.
i. Screening for Melanoma call using the ABCDE- EFG method
ii. Asymmetry; Border irregularity (ragged, notched or blurred); Color variation (blue-black, white
or red); Diameter > 6 mm; Evolving or changing rapidly in size, symptoms or morphology;
Elevation; Firmness to palpation and progressive Growing over several weeks.
1. Most sensitive is Evolution and is reliable for change.
b. Primary lesion: develop as direct result of, and therefore are most characteristic of the disease process.
c. Size: mm or cm
d. Number: single or multiple
e. Distribution: how skin lesions are scattered or spread out, random or patterned, symm or asymmm.
f. Configuration: linear or striate; annular/ring-like w/ central clearing; nummular or discoid (coin-shaped) no
central clearing; target or bull’s eye or iris; serpiginous or gyrate (having linear, branched and curving
elements)
g. Texture: smooth, fleshy, or rough, verrucous or warty, or scaly
h. Color
IV. Pressure injury staging:
a. Stage one: intact skin with a localized area a non-blanchable erythema, which may appear differently in darkly
pigmented skin
b. Stage two: partial thickness loss of skin with exposed dermis
c. Stage 3: full thickness skin loss, in which adipose/fat is visible in the ulcer and granulation tissue in rolled
wound edges, is often present
d. Stage 4: full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament,
cartilage, or bone in the ulcer
e. Unstageable: full thickness and tissue loss in which the extent of tissue damage within the answer cannot be
confirmed because it is obscured by sloth or eschar
f. Deep tissue pressure injury: persistent non blanchable deep red, maroon, or purple discoloration

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