SKIN SILVERMAN TRANSCRIBED NOTES

SKIN

Described under three headings: o Color o Nature of lesion o Texture (Palpation)

COLOR

First observe in various parts of the body

Mottling o Not uncommon in newborn and infants o Normal in cold room o Will clear when warm o (+) in shock crazy pavement appearance

Undue redness seen in: o Fever o Exertion o Exposure to the sun o Early stage of scarlet fever o Atropine toxicity

Undue pallor of one extremity - Arterial occlusion

Reynauds Phenomenon o Sudden onset of pallor of the fingers and

toes o On exposure to cold o Changes in color of fingers to blue to red

and then back to normal.

Cyanosis - blue color of the skin o Peripheral- distal parts of the body o Central- involves the lips and tongue

Jaundice - yellowish discoloration of the skin and conjunctiva o Very slight jaundice- Gilberts disease o Intense green yellow- Biliary Atresia o With itching and black stool- Biliary

obstruction o DEPIGMENTATION-Localized or Generalized

Generalized Localized

Congenital Albinimism -absence of melanin (scalp hair and eyebrows are pale)

Piebaldism or partial albinism forearms, anterior scalp, elbows and knees - hypopigmentation

Acquired Vitiligo localized areas of depigmentation Tuberous sclerosis- white macules shaped like an ashleaf particularly the trunk

*visible to naked eye, but may need a wood lamp

Scleroderma and Vitiligo - alternate areas of pigmentation and depigmentation

Excess pigmentation o Racial o Sun exposure

Generalized slate color- Addisons disease & Congenital adrenal hyperplasia

Addison's disease also involves the buccal mucosa

Localized o Normal areas of melanin

overproduction freckles and moles o Chronic inflammation eczema o Caf-au-lait

NATURE OF LESIONS

Described if: o Primary lesions o Secondary lesions o Distribution

Primary Lesions o Macules- flat, flush with the surface of

the skin, blanch w/ pressure (Petechiae do not blanch)

o Papules- thickened, elevated, small in size

o Desquamation - scaling of 10

lesion w/ dessicated plates of cornified epithelial cells

o Increased pigmentation around 10

lesion common

o Ulceration - depressed lesion d/t loss of epidermis & part of dermis

o Scar formation - replacement of dermis & subcutaneous tissue w/ fibrous tissue after trauma (no normal skin markings, no hair follicles, no sweat pores)

o Atrophy - ironed-out appearance & increased translucency.

DISTRIBUTION OF LESIONS

Describe the lesions if: o Primary lesion o Secondary lesion o Distribution o If elevated, is it rounded or pointed? o If vesicle, is it umbilicated? o Is there redness around it? o Does it feel more than it looks? o Is it superficial or deep? o If it is an ulcer, describe the base and

the edge of the ulcer. Also look for induration under or around the ulcer.

Acne - red pointed papules & pustules over face & back of upper trunk of adolescent.

Pityriasis Rosea seen in trunk

Scabies grayish linear lesion with a vesicle or pustule at one end

o Seen in palms, creases of the wrist, axilla, perianal, dorsum of penis

Herpes zoster - grouped vesicles along dermatomes

Contact dermatitis -rash on diaper due to moist area, sparing the folds but involving the convexities

Rash in diaper area w/ satellite lesions - 2 0

infection (fungal or bacterial) Palpation of Lesions

Texture: o Normal- smooth, soft, moist o Rough & dry- excess bathing,

congenital icthyosis (colloidon baby) o Rough coarse- allergies &

hypothyroidism

Edema: o Pitting on pressure - a good sign of

presence of edema; can be firm or non-pitting

o Subcutaneous emphysema (+) edema

Elasticity: o To test, pick up skin and let go,

normally it falls back quickly o Well demonstrated over anterior

abdominal wall. o Dehydration skin does not fall back

quickly, remains in fold tented o Ehlers-Danlos syndrome- excess

elasticity over elbow, forearm and interscapular areas and the cheek

(+) collections of pus, blood, lymph on palpation

HEMANGIOMAS o Vascular tumors (nevi) of the skin that

may be: Flat Nodular (tumorous)

o Flat type: Stork-bites in newborn

*seen in eyes, glabella, nuchal region

Port-wine stain of Sturge Weber Syndrome

Spider nevus o Nodular type:

Strawberry hemangioma *red in color w/ a well-defined border, blanching on pressure, firm

Cavernous hemangioma *ill-defined border and red blue color. *feels like bag of worms and do not fully collapse on pressure.

Mixed type characteristic of a cavernous hemangioma and surface characteristic of port-wine.

Port-wine stain (Nevus Flammeus) o (+) birth o Flat, well circumscribed, pink/purple,

varies in size o involves the neck & face o Nevus Unna- (+) back of neck o If present as part of Sturge-Weber

Syndrome- (+) seen over of the face. o Purple color o Port wine stain associated with:

Klippel-Trenaunay-Weber and Trisomy 13.

Capillary Hemangiomata (Strawberry nevi) o Bright in color, clearly circumscribed o Slightly elevated o Compressible and blanch on pressure o Solitary/multiple o If seen in newborn flat lesion over the

bridge of the nose and nape of the skin called stork-bite lesion.

o (+) birth usually first 2mos of life o Gradually increase in size then regress

mostly by 9 years o Commonly seen in: face, scalp, back,

anterior chest

Cavernous Hemangiomata o Located in deeper in the skin o Margins are not clear o Bluer than red or purple o Nodular or cystic o Gradually grow bigger before

regression o Chances of clearing are less w/ capillary

hemangioma

NEVI o Any birthmark/ pigmented skin lesion o Vascular nevi

due to blood vessels started at birth or later described by their:

*location *size *inc or dec in size *depth of lesion *margin *compressibility

o Pigmented nevi (J,I,C) Originating from nevus cells

are different from hyperpigmentation arising from mature melanocyte

o Junctional nevi most common, appearing

most often in early childhood. Any part of body Various sizes, flat Varying shades of tan to

brown o Intradermal nevi

Seen in adults Any part of body Varying sizes and colors Dome-shaped or elevated With coarse hair

o Compound nevi (+)birth but more often older

children Elevated and flesh colored (+) Dark coarse hair

Giant congenital pigmented nevi o Very large, elevated w/ angular margin o Upper back, shoulders and thigh o In a dermatome distribution - bathing

trunk, coat sleeve, stocking nevi o Associated w/ (+) Coarse brown hair

and neurologic problems

Nevus of Ota o Bluish gray lesion o Present at birth o At the Trigeminal area of face o May have bluish discoloration on the

affected side

HYPERPIGMENTED LESIONS (FRECKLES)

LENTIGENES

Light or dark brown

Sun-exposed parts of the body (face)

Not present at birth

Dark brown

Any part of the body

Present at birth

Cafe-au-lait spots o Hyperpigmented tan macules of

varying sizes o (+) birth or develop in childhood o Normal children-

Qualitative *Color *Surface *Consistency *Adherence to nail bed

Quantitative Changes o Acromegaly best example of

increased total area of the nail. o Hyperparathyroidism

Nails are large in surface area, broad and rounded, NOT clubbed!

Thick nail plate Thick nail bed

*Chronic Fungal Infection

*Chronic inflammatory condition *Fibrous tumor

o Decreased amount of nail nail bites, epidermolysis

Qualitative

o Color red or blue area under the

nails subungual hematoma subungal hemorrhage

subacute bacterial endocarditis

blue- cyanosis (peripheral and central)

white flecks to yellow patches- Kala-azar, Addisons disease, fungal infections

o Surface Normal smooth with slight

convexity; normally increase convexity in adults

Koilonychias (concave nails)- IDA

loss of continuity w/ pits - Psoriasis & Eczema

Longitudinal and transverse ridges (common in adults, rare in children) malnutrition, severe chronic infections such as eczematous dermatitis

o Consistency Excessively soft chemical

injury, malnutrition Brittle chemical injury,

polish removers Very friable fungus, psoriasis

o Adherence Partial separation of nail to

nailbed, commonly due to trauma, severe dermatitis/exanthema (erythema multiforme exudativum, exfoliative dermatitis)

o Paronychia- acute nail fold infection Staphylococci, candida, HSV

o Pterygium layer of the cuticle that grows over the proximal portion of the nail; seen in dermatomyositis

o Periungual erythema also seen in dermatomyositis

o Scleroderma is seen in - Pterygium telangiectasis

HAIR o Quantitative:

Increase: generalized/localized Decrease:generalized/ localized

o Qualitative Color Texture Surface characteristics

(straight, curled, beaded) Strength (brittle)

Generalized Localized

Increase *Cushing Syndrome *Steroid therapy *deLange Syndrome *Dilantin therapy *Porphyria

*nevus(nevus pilosus) *Areas placed in a cast (hypertrichosis)

Decrease *Hypothyroidism *Congenital Ectodermal Defect *Drug toxicity (thallium, cytotoxic drugs, vit A)

*Alopecia areata *local infections *Psychologic pulling (trichotillomania)

o Color Better appreciated in relation

to scalp If pale albinism

Texture o dry coarse hair hypothyroidism o fine thin hair homocytsinuria

Surface characteristics o beaded appearance monilethrix o nodular swellings trichorrhexis

nodosa

Lice and nits check in adolescents pubic hair

Fragile hair congenital syndromes. Fungal infections

ESGUERRA, WINSTON L. 3F