Integumentary system examination

Integumentary system examination

1. INTEGUMENTARY SYSTEM DR. QURATULAIN MUGHAL (DPT) ISRA UNIVERSITY 1

2. CONTENTS CLINICAL EXAMINATION IN SKIN DISEASE TERMS USED TO DESCRIBE SKIN LESIONS HAIR DISORDERS COMMON NAIL CHANGES AND DISORDERS 2

3. CLINICAL EXAMINATION IN SKIN DISEASE Observation: The patient must be undressed, with make-up and dressings removed, and examined in good lighting. Consider the following: • Age • General health • Distress • Scratching 3

4. Distribution of rash Symmetrical vs asymmetrical Proximal vs distal vs facial Localised vs widespread 2. If symmetrical Extensor, e.g. psoriasis Flexor, e.g. eczema 3. Nail involvement Psoriatic changes in nails and peri-ungual involvement 4. Involvement of hands: including nail folds and finger webs 4

5. 5. Involvement of axillae /groin e.g. hidradenitis suppurativa 6. Individual lesions Discrete, grouped, confluent, reticulate (lace-like), linear 7. Morphology of rash Monomorphic or polymorphic 8. Morphology of individual lesions Use a hand lens in good lighting to assist Use correct terminology e.g. macules , papules, pustules Palmoplantar pustulosis 5

6. 9. Examination of scalp Hair loss Scalp changes 10. Involvement of face Central Hairline Cheeks and nasal bridge: ‘butterfly’ distribution Sparing of light-protected sites, e.g. behind ears, under chin 6

7. 11. Eye involvement e.g. Conjunctivitis/ blepharitis in rosacea or eyelash loss in alopecia areata 12. Oral and genital involvement Reticulate (lacy) network on buccal mucosa in lichen planus. May also be genital involvement 13. Joint involvement e.g. Psoriatic arthritis 14. General medical examination Including lymph nodes and other systems as indicated 7

8. Terms used to describe skin lesions Macule A circumscribed flat area of altered colour , ≤ 1 cm diameter Patch As for macule , but larger Papule A discrete elevation of skin Nodule As for papule, but > 1 cm diameter and involving dermis Plaque A raised area of skin with a flat top, > 1 cm across Excoriation A linear ulcer or erosion resulting from scratching 8

9. Terms used to describe skin lesions Vesicle/bulla A small (≤ 1 cm)/larger (> 1 cm) blister, respectively Pustule A visible accumulation of pus in a blister Abscess A localised collection of pus in a cavity Weal An evanescent discrete area of dermal oedema Scale A flake arising from the stratum corneum Crust Dried exudate of blood or serous fluid Ulcer An area from which the epidermis and the upper dermis have been lost 9

10. Terms used to describe skin lesions Petechiae , purpura , ecchymosis Petechiae are flat, pinhead-sized macules of extravascular blood in the dermis; larger ones ( purpura ) may be palpable; deeper bleeding causes ecchymosis Burrow A linear or curvilinear papule, caused by a burrowing scabies mite Comedone A plug of keratin and sebum in a dilated pilosebaceous orifice Telangiectasia Visible dilatation of small cutaneous blood vessels 10

11. Terms used to describe skin lesions Erosion An area of skin denuded by complete or partial loss of the epidermis Fissure A deep, slit-shaped ulcer, e.g. irritant dermatitis of the hands Sinus A cavity or channel that permits the escape of pus or fluid Scar Permanent fibrous tissue resulting from healing Atrophy Loss of substance due to diminution of the epidermis, dermis or subcutaneous fat Stria A linear, atrophic, pink/purple/white lesion in the connective tissue 11

12. HAIR DISORDERS Alopecia The term means nothing more than loss of hair and is a sign rather than a diagnosis. It is subdivided into localised or diffuse types and also into scarring or non-scarring alopecia. Alopecia areata Androgenetic alopecia 12

13. 1. Alopecia areata This common, non-scarring autoimmune condition appears as well-defined, non-inflamed bald patches, usually on the scalp. Pathognomonic ‘exclamation mark’ hairs are seen ( brokenoff hairs 3–4 mm long, tapering towards the scalp) during active hair loss. The condition may affect the eyebrows, eyelashes and beard. The hair usually regrows spontaneously in small bald patches, but the outlook is less good with larger patches and when the alopecia appears early in life or is associated with atopy . 13

14. 2. Androgenetic alopecia Male-pattern baldness is physiological in men > 20 yrs old, although rarely it may be extensive and develop at an alarming pace in the late teens. It also occurs in females, most obviously after the menopause. The distribution is of bitemporal recession and then crown involvement. 14

15. Common nail changes and disorders 1. Effects of trauma 2. Nail in systemic disease 15

16. 1. Effects of trauma 1. Nail biting/picking: These are very common. Repetitive proximal nail-fold trauma results in transverse ridging and central furrowing of the nail. 2. Chronic trauma: Trauma from poorly fitting shoes and sport can cause thickening, disordered nail growth ( onychogryphosis ) and subsequent ingrowing toenails. 16

17. 3. Splinter haemorrhages : Fine, linear, dark brown longitudinal streaks in the plate are usually caused by trauma, especially if distal. Uncommonly, they can occur in nail psoriasis and are a hallmark of infective endocarditis . 4. Subungual haematoma : Red, purple or grey–brown discoloration of the nail plate, usually of the big toe, is usually due to trauma, although a history of trauma may not be clear. The main differential is subungual melanoma, although rapid onset, lack of nail-fold involvement and proximal clearing as the nail grows are clues to the diagnosis of haematoma . If there is diagnostic doubt, a biopsy may be needed. 17

18. 2. nail in systemic disease 1. Beau’s lines: These transverse grooves appear at the same time on all nails, a few weeks after an acute illness, moving out to the free margins as the nails grow. 2. Koilonychia : This concave or spoon-shaped deformity of the plate is a sign of iron deficiency. 18

19. 3. Clubbing: In its most gross form, this is seen as a bulbous swelling of the tip of the finger or toe. The normal angle between the proximal part of the nail and the skin is lost. Causes include: ● Respiratory: bronchogenic carcinoma, asbestosis, suppurative lung disease ( empyema , bronchiectasis , cystic fibrosis), idiopathic pulmonary fibrosis. ● Cardiac: cyanotic congenital heart disease, subacute bacterial endocarditis . ● Other: inflammatory bowel disease, biliary cirrhosis, thyrotoxicosis , familial causes. 19

20. 4. Discoloration of the nails: Whitening is a rare sign of hypoalbuminaemia . ‘Half and half’ nails (white proximally and red-brown distally) occur occasionally in patients with renal failure. Rarely, drugs (e.g. antimalarials ) may discolour nails 20

21. THANK YOU! 21