Assessment of
the Skin
Pat Jackson Allen
RN, MS, PNP, FAAN
Yale University, School of Nursing
Role of the Skin
Protection from microbial invasion
and minor trauma
Retards body fluid loss
Regulates body temperature
Provides sensory perception
Role of the Skin
Produces vitamin D from precursors
Contributes to blood pressure
regulation
Repairs surface wounds - scar
formation
Excretes sweat, urea and lactic acid
Expresses emotions
Anatomy of the Skin
Epidermis
Dermis
Hypodermis
Anatomy of the Skin
Epidermis
Outermost portion
composed of stratum
corneum plus cellular
stratum
Protective layer,
water proofing layer
Provides pigment or
color to skin
Forms nails and hair
Anatomy of the Skin
Dermis
Vascular connective
layer that separates
epidermis from
adipose tissue
Sensory nerves and
autonomic motor
nerves are found
here
Sweat glands and
hair follicles originate
in dermis
Anatomy of the Skin
Hypodermis
Dermis connected to
underlying organs by
the hypodermis, a
loosely connected
tissue filled with fatty
cells
Adipose tissue
generates heat,
provides insulation,
shock absorption and
a reserve of calories
Anatomy of the Skin
Glands Found in Skin
Eccrine Sweat Glands - sweat glands to
regulate body temperature.
Aprocine Glands - secrete odorless fluid in
response to emotional or sexual stimuli.
Found in the axillae, nipples, anogenital area,
eyelids, and ears. Bacterial growth causes
odor.
Sebaceous Glands - secrete sebum to keep
skin and hair lubricated. Secretion varies in
response to sex hormones (primarily
testosterone).
Variation in Skin with Age
Variation in Skin with Age
Infants / Young
Children
Skin smoother-lack of
exposure to elements
Less subcutaneous fat
layer, poorer
temperature control
Eccrine sweat glands
secrete after 1 month
Variation in Skin with Age
Common Variations
in Newborns
Acrocyanosis
Transient mottling
Erythema toxicum
Harlequin sign
Mongolian spots
Talangiectatic nevi (stork
bite)
Jaundice
Milia
Variation in Skin with Age
Adolescence
Aprocine glands enlarge and become
more active
Sebaceous glands increase production
causing oily skin and predisposition to
acne
Terminal hair appears in axillae and
pubic area for both sexes and on face
in males
Variation in Skin with Age
Terminal Hair and Acne
Skin Variation with Age
Pregnancy
Increased:
Blood flow to skin to balance heat
production from increased BMR
Eccrine sweat gland activity
Sebaceous gland activity
Fat deposits
Pigmentation of face, nipples, areolae,
axillary, and vulva
Variation in Skin with Age
Older Adults
Decreased:
Blood flow to skin
Eccrine sweat gland activity
Sebaceous gland activity
Fat deposits
Pigmentation of skin and hair, first in
Whites, later in Blacks and Asians
Hair production and increased coarseness
Variation in Skin by Race
Asians, Latinos, Blacks
Varying intensity of pigmentation
Mucous membranes pink to light brown
Sclera white, gray, light brown, often with
pigmented spots
Mongolian markings common in children
Visible difference in pigmentation of ventral
and dorsal surfaces of extremities
Variation in Skin by Race
Asians, Latinos, Blacks
Hair
Vellus body hair
Scalp hair varies in texture
Skin texture
Limited aprocrine glands (less sweat)
Limited sebaceous glands (less body oils)
Frequent washing causes increased dryness
Variation in Skin by Race
Asians, Latinos, Blacks
Skin conditions
Fine colored lesions harder to see
Pigmentary changes due to lesions may
persist for months or years
Licenification common with eczema
Hypertrophic scars and keloids common
Variation in Skin by Race
Whites
Less variation in intensity of pigmentation
Mucous membranes pink
Sclera white
Hair
Terminal hair on body common
Texture and color vary
Skin texture
Increased aprocrine glands result in increased
body sweat
Increased sebaceous glands lubricates skin and
scalp
Requires frequent washing
History
Chief Complaint / Present
Problem
Changes in skin, hair, nails -
Dryness, itching
Rashes, lesions
Odor, color
Change in quantity, texture of hair
History
Chief Complaint / Present Problem
History of chief complaint / present problem
Temporal sequence -
Gradual, sudden
Precipitating events
Dietary changes
Associated symptoms -
Itching, pain, bleeding, redness
Location -
Skinfolds
Extensor or flexor surfaces
Exposed or covered surfaces
Symmetrical or nonsymmetrical
History
Chief Complaint / Present Problem
History of chief complaint / present problem
Associated symptoms -
Fever
Fatigue
Allergy
Stress
Recent exposure to toxins
Travel history
What client or caretaker believes is the
cause
What remedies have been tried and their
success
Is it getting better or worse
History
Past Medical History
Previous skin, hair, or nail problems,
sensitivities, reactions
Cardiac, respiratory, liver, endocrine
(thyroid, diabetes) cancer or other
systemic diseases
Severe illness or nutritional deficit
Drug or toxin exposure
Congenital problems
History
Family History
Current or past skin, hair, or nail
problems
Skin infections
Chronic skin conditions
Psoriasis, atopic dermatitis (eczema)
Infestations
Scabies, lice
Cancer
Allergic diseases such as asthma, hay
fever
Family hair loss and pigmentation
History
Personal and Social History
Skin care habits
bathing, hair care, nails
diapering
Use of soaps, skin care products,
sunscreen
Nutritional habits and vitamin
Exposure to communicable conditions
Infectious skin conditions
Infestations
History
Personal and Social History
Exposure to environmental toxins,
animals
Injury pattern or history
Chronic nail biting or hair
manipulation
Occupational / school / sports risks
History
Personal and Social History
Cultural Variations
Chemical or thermal hair straighteners, pomades, or
coloring
Hair styling, i.e., cornrows, teasing, tight braids or
ponytails
Hair removal, shaving
Skin bleaching
Tattoos, body piercing
Henna application
Assessment of the Skin, Hair,
Nails
Inspection
Palpation
Assessment of the Skin, Hair,
Nails
Need:
Good light
Centimeter ruler - flexible and clear
Magnifying glass
Gloves (optional but recommended)
Test equipment (determined by
practice), i.e. Woods lamp, KOH,
biopsy
Assessment of the Skin, Hair,
Nails
Detailed Inspection:
Must be unclothed and undraped
Special attention to areas not often
seen
Special attention to intertrigenous
surfaces
Identify lesion descriptors
Assessment of the Skin
Inspect for:
Lesions
Skin color
Areas of pain or itching
Assessment of the Skin
Palpate for:
Moisture
Temperature
Texture
Turgor
Mobility
Capillary filling
Elevation or depression
Assessment of the Skin
Guiding principles
Take a good history
Individuals’ skin reacts differently
Few skin conditions are life-threatening but
they can be great source of concern to the
individual
You need to know the standard medical
terminology
“Red bumps on the arm” just won’t sound
professional
Assessment of the Skin
Need to describe
Lesion type
Shape
Color
Distribution
Border
Surface and texture
Associated symptoms
Assessment of the Skin
Primary Lesions:
Initial appearance of pathological
process
Macule <1cm / Patch >1cm: flat lesion
Papule <1cm / Plaque >1cm: elevated
Nodule <1-2cm / Tumor >2cm: deeper
Vesicle <1cm / Bulla >1cm: bubble
Pustule: purulent vesicle
Wheal: hive
Assessment of the Skin
Secondary Lesions:
Change in primary lesion due to
external trauma
Scale Scar
Crust, scab Keloid
Fissure Lichenification
Erosion Atrophy
Excoriation (scratch) Ulcer
Assessment of the Skin
Lesion descriptors
Shape:
Linear
Round
Annular (round with central clearing)
Oval
Polycyclic (interlocking circles)
Morbilliform (confluent, measle-like)
Zosterform (dermatomal)
Hemangioma
Round papule measuring
1 cm. situated superior to
outer canthus of R eye.
Uniform deep red color.
Birthmark
Hyperpigmented linear
macules measuring 1cm
by 4.5 cm inferior to right
nipple. No indication of
Inflammation or irritation.
Poison Ivy
Linear vesicles
on ventral surface of
forearm.
Client reports lesions
are intensely itchy.
Measles
Erythematous
macular papular lesions
over entire body. Infant
observed scratching.
Lesions associated with
fever and mild URI
symptoms.
Herpes Zoster
Grouped vesicles
on an erythematous
base scattered along
R thoracic dermatome.
Client reports pain
associated with
lesions.
Assessment of the Skin
Lesion Descriptors
Shape (con’t):
Geographic
Lacy
Serpiginous (snakelike)
Umbilicated (middle indentation)
Target, iris (bullseye)
Normal Tongue
Geographic pattern of
white and dark pink
mucous membranes
on ventral surface
of tongue.
Erythema Infectiosum (Slapped-cheek)
Human Parvovirus B 19 (Fifth Disease)
Intense confluent redness
of both cheeks preceded
lacy erythematous macular
papular lesion over trunk
and extremities. Mild Fever
associated with onset of
lesions.
Scabies
Serpigenous elevated
burrow measuring
6 cm at base of
3rd-5th toes R foot.
Client reports lesion is
itchy.
Molluscum Contagiosum
Small discrete circular
papules with
umbilicated centers on
inner aspect of R elbow.
Assessment of the Skin
Lesion Descriptors
Color:
Erythematous
Pink, red
Purple
Ecchymotic (blacks & blue)
Mottled
Silver / White
Viral Exanthem unknown
Etiology (Pityriasis rosea?)
Scattered discrete
erythematous papular
lesions on trunk. No
lesions present on sun
exposed areas.
Client denies itching,
fever, or URI symptoms
with rash.
Erythema Nodosum
Abrupt onset of tender erythematous
nodules on extensor surfaces of
extremities. Lesions evolved
into bruises with color changes
to purple then yellow-brown.
Psoriasis Vulgaris
Erythematous plaque
with silver-white scale
on extensor surface of
legs.
Assessment of the Skin
Lesion Descriptors
Color (con’t):
Blue
Black
Yellow
Hyperpigmented
Hypopigmented, depigmented
Amelanotic
Café-au-lait Spot
Hyperpigmented
patch with irregular borders
measuring 8 cm by 3 cm
over L scalpula. Client reports
area seems to fade in summer.
Vitiligo
Depigmented
patches
of skin with distinct
borders on ventral
surface of R hand.
Hair within the
affected area is also
hypopigmented. No
other symptoms
reported.
Sunburn with Vitiligo
Assessment of the Skin
Lesion Descriptors
Distribution:
Localized (identify where) vs. generalized
Symmetrical or asymmetrical
Scattered, grouped
Flexural or extensor surfaces
Intertriginous (between skin folds)
Sun exposed or covered
Contact areas for clothing, jewelry, chemicals
Atopic Dermatitis (Eczema)
Symmetrical dry excoriated red
plaques on flexor surfaces of
knees and elbows. Child
reports intense itching (pruritis)
and history of asthma.
Keloids
Three discrete hairless
hyperpigmented nodules
measuring 4x2cm, 4x1.5cm,
& 3x1cm at sites of previous
mole removal.
Erythema Toxicum
(Neonatal Acne)
Scattered papules and
pustules on erythematous
bases of varying diameters.
Lesions noted to change
location within hours. No fever
associated with lesions.
Herpes Simplex Virus (Herpes Keratitis)
Grouped vesicles
on an erythematous
base located below
R eye. Conjunctiva
intact without
inflammation.
Happy Lip-Licker
Dry rough erythematous
to brown skin circumscribing
lips. Child reports licking
his lips frequently. No other
lesions noted on body.
Candidiasis (Yeast)
Dry macular papular
erythematous confluent
lesions with additional
satellite lesions
found on intertriginous
skin of L breast. Client
reports mild itching.
Contact Dermatitis
Small white confluent
papules extending
across forehead
onto scalp with a band
width of 5 cm.
(From head band worn
during exercise.)
Assessment of the Skin
Lesion Descriptors
Border / Margins:
Sharply / poorly marginated (demarcated,
defined)
Irregular
Scalloped
Raised / elevated or flat border
Active border
Lesion variation between border and center
Nevus Flammeus (Port-Wine Stain)
Dark red patch with
distinct borders extending
from R ear across lower
cheek and chin. Has been
present since birth.
Lesion does not appear to
itch and child has no
other symptoms.
Diaper Dermatitis (Contact)
Confluent dry dark red
patch with well demarcated
borders outlining diaper area.
Some sparing of intertrigenous
skin folds. No satellite lesions.
Diaper Dermatitis (Candidiasis)
Confluent dark red slightly
moist patch on perineum
and lower abdomen with
satellite papules extending
upward on abdomen
and onto thighs.
Assessment of the Skin
Lesion Descriptors
Surface and texture:
Soft
Boggy
Hard, firm
Thickened
Verrucous, warty
Moist, oozing, weeping
Warts
Three hard dry
verrucous (warty)
papules on middle
finger of R hand.
Licenification
(Secondary to Eczema)
Dry thickened skin with
horizontal fissures.
Symmetrical pattern of
lesions on flexor surfaces
of knees and elbows.
Client reports intense
itching.
Acanthosis Nigricans
Dry thickened
hyperpigmented skin
with linear fissures
across posterior neck.
Also found under arms.
Child has BMI of 30.
Impetigo (Staph or Strep)
Vesicles turning to
honey-colored crusts
on erythematous
base, below R nares
and on bridge of
nose.
Primary Gingivostomatitis
Moist vesicles on an
erythematous base encircling
the mouth, covering the lips
and extending onto the mucous
membranes of the mouth.
Child has a fever, is irritable
and reports pain when
attempting to eat or drink.
Bullous Impetigo (Staph or Strep)
20 by 10 cm bullae
with shallow erosion
and moist center
mid abdomen superior
to umbilicus.
Smaller similar lesion
superior to large
lesion medial to L nipple.
Urticaria (Hives)
Blotchy red irregularly
shaped papules and
plaques with prominent
elevated borders in
irregular pattern over
entire body. Some
lesions with central
clearing.
Noted to fade and
reappear within
minutes. Child is
scratching lesions.
Tinea Corporis (Ringworm)
Multiple oval plaques with
active (red and scaly)
prominent borders and
partial central clearing.
Client reports mild itching.
Assessment of the Skin
Lesion Descriptors
Associated Symptoms:
Pruritic
Burning, stinging
Painful, tender
Swelling
Asymptomatic
Assessment of the Hair
Inspection and palpation of hair:
Color
Texture (vellus or terminal, smooth or brittle, dry or
moist)
Distribution
Quantity
Indications of hair loss
Infestations
Scalp condition
Pediculosis (Head Lice)
White ovoid firm 1
mm bodies attached
to hair shafts. Child
reports scalp itches
intensely.
Tinea Capitus (Ringworm)
Dry crusted circular
lesion with erythematous
base on scalp without
evidence of hair follicles.
Papable lymph
nodes present.
Traction Alopecia
Areas of sparse
hair growth lateral
to braided hair with
evidence of broken
Hairs. No signs of
infection or infestation.
Assessment of the Nails
Inspection and palpation
Color, length, symmetry, and
cleanliness
Ridges, depressions, pitting
Nail base angle, evidence of clubbing
Firmness, thickness, separation
Capillary refill
Bitten Nails
Pitting of Nails
Paronychia Clubbing of Fingers
Onycholysis
(Psoriasis or Tinea)
Nail changes
associated
with Aging
Normal Nails Needing a
Capillary Refill Little Care
A*B*C*D Rule of
Melanoma
A - Asymmetry of borders
B - Border, irregular
C - Color blue-black or variegated
D - Diameter greater than .6 cm
A
D
Melanoma
A
B
C
D
Malignant Melanoma
Assessment for Melanoma
Educating clients for self
assessment
Know location and appearance of
moles
Regularly check for changes using
good light source and mirror
Be particularly vigilant with moles in
strange places
Provide sunscreen protection for all
moles
Be seen by provider if changes in
Assessment of the Skin
Body Piercing
Risk of infection with organisms found
on the skin and in the oral pharynx
Potential for trauma to skin with
tearing of tissue
Tattooing
Risk of infection
Difficult (impossible) to remove
Tattooing
Assessment of the Skin
Indications of abuse
History does not correspond to injuries
Injuries too severe for history
Injuries not developmentally plausible
History changes or varies by person
Caretaker or person delays treatment
Injuries not seen as serious
Evidence of previous injuries or lack of
consistent care, i.e., absent immunizations
Assessment of the Skin
Indications of abuse
Patterned injuries (belt, hand, iron, etc.)
Pattern of injuries (injuries over time)
Location of injuries (face, back, abdomen)
Bruising pattern:
Within 24 hours red to blue
1-3 days deep purple or black
3-6 days green to gradually brown
6-15 days green to tan to yellow
Restraint Injuries
Bruises Caused
by Abuse
Burn Injuries
Scalding Injuries
The Skin Is The Window To
The Body
Examine It Carefully
