Skin examination

Colour
- Pale
- Red
- Bluish (Cyanosis)
- Yellow
- Brown
- Grey-brown
- Albino
 
Moisture
 
Temperature
 
Efflorescence
 
Trophics
 
Turgor
 
Oedemas
 
Skin adnexa
- Hair
- Nails

The skin is rosy, warm, and elastic, having no continuity defects.
 
When examining the skin by inspection and palpation we concentrate on colour, moisture, temperature, turgor, presence of pathological efflorescence, bleeding manifestations, and oedemas.
 
Colour
 

	Pale    Pallid appearance of the skin of the whole body (together with pallid mucous membranes) - accompanies anaemia or diffuse vasoconstriction (shock);    Localised - pallid appearance of the skin is the sign of blood circulation disorder e.g. in limbs (ischaemic ailment of the legs, diabetic microangiopathy) or in individual fingers (Raynaud's disease).
	Red    The red coloration of the whole body surface - in hyperaemia (sun exposed skin, fever);    Localised    Local hyperaemia (inflammation);    Facial rubeosis (diabetes mellitus);    Mitral stenosis - rosy-violet cheeks;    Maragnon's maculae on face and the upper half of the body (neurovegetative lability in girls);    "Palmar erythema" reddening of thenar and antithenar in cirrhotic patients;    "Flush" is observed on the upper part of the body, particularly in faces of patients suffering from carcinoid (serotonin secretion).
	Bluish colour (cyanosis) can be observed on the skin and mucous membranes. The skin acquires the bluish colour, if concentration of reduced haemoglobin reaches 50 g/l.    Central cyanosis is caused by insufficient oxygen saturation of haemoglobin in pulmonary diseases and congenital heart defects (left-right short cut). It can be found on the skin of the whole body it is particularly visible in lips, tongue, mouth mucous membranes, and acral parts. It is commonly found together with polyglobulia and clubbed fingers. (Oxygen inhalation reduces cyanosis of pulmonary origin.)    Peripheral cyanosis is caused by prolonged tissue-blood contact caused by insufficient blood circulation. It accompanies heart failure; it can appear in cold. It is observed in lips, ears, hands, feet (including toenails), the tongue is rosy.
	Yellow    Jaundice (icterus) is caused by increased plasma concentration of bilirubin. According to the cause the following types of icterus can be distinguished: praehepatic (haemolytic), hepatic (hepatocellular), posthepatic (obstructive). In addition to the skin, sclera and palatial mucous membrane are also affected.    Xantosis is caused by hypercarotinaemia. The coloration is manifested on the palms, soles, and cheeks (diabetes mellitus, hyperlipoproteinaemia).
	Brown colour generally arises from melanin accumulation or in combination with other substances.    Localised form - nipples, linea alba and chloasma uterinum during gravidity.    Diffuse form - after sunbathing, in porphyria, hyperthyroidism.   Addison's disease (peripheral form) manifests by diffuse skin hyperpigmentation (except palms and soles, where only ripples are coloured). There are graphite maculae on mouth mucous membrane.
	Grey-brown - the skin takes part in melanin and haemosiderin accumulation, e.g. in haemochromatosis.
	Albinism is caused by lack of pigmentation in skin, hair, and irises. Hair and irises have light colours, the pupils seem to be bright red. Vitiligo and leukoderma are caused by local loss of pigmentation. Those disorders are either congenital, or acquired - e.g. syphilis.

 
Moisture
 
Enhanced moisture depends on enhanced perspiration.
 

	Localised moisture in armpits, on palms, and soles, occurs in people with neurovegetative dysbalance, commonly accompanied by acrocyanosis and acrohypothermia.
	Diffuse moisture on the whole body surface is present in lytic temperature decrease, thyrotoxicosis, shock, and hypoglycaemia. Nocturnal sweating can be related to malignant tumours and tuberculosis.

 
Reduced moisture
 

	Localised form occurs in ischaemia.
	Diffusion form can be found in dehydration and cachexia. The skin is dry and wrinkled and peels off.

 
Temperature
 
Body temperature depends on the blood supply of the skin, it can be tentatively assessed by touch of hand.
 

	Locally decreased temperature is characterised by pallid; cold skin (could be cyanotic) as a result of impaired blood supply (ischaemic disease of blood vessels of lower extremities, Raynaud's disease).
	Locally increased temperature is characterised by reddening and oedema of the skin and is caused by inflammation (erysipelas, thrombophlebitis).

Anaemic face
 

Pallid skin
 

Facies mitralis
 

Erysipelas
 

 

Dupuytren's
contracture
palm erythema
 

Face cyanosis -
congenital
heart disorder
 

Face skin
icterus
 

Sclera and face
skin icterus
 

Icterus
 

Icterus
 

Icterus
 

Shank
hyperpigmentation

Skin efflorescence
 
cannot be found on the skin of a healthy person. Its presence is the sign of a skin disease or can be the secondary manifestation of the infectious or internal disease. Dermatological terminology is used for describing.
 

	macula = area blot
	papule = protruding blot
	vesicula = blister filled by clear liquid
	pustule = blister with turbid liquid

 
Findings can transform continuously. Exact description, localisation, and configuration, and even the dynamics of the disease are required for judgement.
 
Some diseases are accompanied by distinctive findings:
 
Scarlet fever (scarlatina): small-macular red exanthema is localised on the skin of the abdomen, it spreads onto the legs and the rest of the body; it does not appear at the vicinity of the mouth.
If untreated, the disease can lead to skin exfoliations.
 
Measles (morbilli): macular exanthemas localised initially on the face and neck; they tend to merge together later. There are so called Koplik's spots at the mucous membrane of the mouth.
 
Chickenpox (varicella): begins as a macular, later vesicular exanthema on the surface of the whole body (including areas with hair), gradually it dry out. Eruption of efflorescence runs in the cycles.
 
Shingles (herpes zoster): vesicular, later pustular efflorescences are arranged in the groups that follow peripheral nerves route, but also branch of the nervus trigeminus. The disease is caused by the varicella - zoster virus in adult patients weakened by other diseases (e.g. tumours).
 
Cold sore (herpes labialis, nasalis): vesicular or pustular efflorescences are found on the lips, below the nose or by the nose orifices in febrile diseases (croupous pneumonia, viral infections), or in insolation.
 
Allergic exanthemas take the form of either urticarial (nettle-rash) exanthema or their appearance may resemble findings present in infectious diseases. In that case, they are called according to the disease they resemble (e.g. morbiliform, scarlatiniform etc.) Itchy white or rosy buds of a map-like appearance are typical for urticaria. Allergic exanthemas manifest as local affections, most commonly caused by direct contact (plants, cosmetics), or generalised affections of various appearance - on the skin of the trunk and limbs. They tend to mingle and their eruption is recurrent (drugs, food).
 
Transient oedematous swelling on the face, neck, or perhaps other areas is the sign of Quincke's oedema.
 
Erythema nodosum are specific painful red and violet infiltrates located on the shanks (sarcoidosis, idiopathic intestinal inflammations, or the origin may be unclear).
 
"Butterfly exanthema" is distinguished by symmetrical reddening of the face that is distinctively shaped (lupus erythematosus).
 
Osler nodes are bright, red coloured lentil size nodes, which can be found on the fingertips. They are caused by mycotic micro-embolisation in infectious endocarditis.
 
Various morphological findings in the form of petechiae, haematomas, maculopapular efflorescences, or area infiltrations can all represent evolutionary changes of vasculitis.
 
Xanthelasma is a shallow protruding area on the eyelid, close to the nose. It is caused by the accumulation of fat (hyperlipoproteinaemia, rarely in a healthy person too).
 
Xanthoma (tuberosum) is generally larger, commonly located on the muscle tendons (some hyperlipoproteinaemias).
 
"Naevus arachnoideus" (spider angioma) is red, made of a central arteriole wrapped by venules into periphery. Usually, they are located in the upper part of the trunk and in the face. In more advanced cases of hepatic cirrhosis they can appear on the arms as well (they may appear non-specifically e.g. during pregnancy). When subjected to pressure they become anaemic.
 
Haemangiomata are most commonly of lentil appearance, but also they may be of irregular shape, at various locations in elderly people.
 
Bleeding manifestations (haemorrhagic diatheses) on the skin and mucous membranes arise spontaneously in cases of primary and secondary haemocoagulation disorders.
 
Petechiae are ecchymoses, dotty haemorrhages in thrombocytopenia, thrombocytopathia, and vasculitis.
 
Purpura arises of multiplex petechiae.
 
Haematoma has its origin in substantial subcutaneous bleeding in case of e.g. coagulopathy. They gradually decolourise over time (haemophilia, incorrect anticoagulation therapy, blunt trauma, hepatic cirrhosis).

Maculo-papular
skin changes
 

Papule
 

Allergic skin
reaction cased
by plaster
 

Allergic skin
reaction cased
by plaster
(on the hip)
 

Erythema nodosum
 

Erythema nodosum
on the legs
 

Xanthelasmata
 

Spider angiomata
 

Spider angiomata
 

Spider angiomata
 

Detail of a
spider angioma
 

Vasculopatia
 

Large haematomas
on the chest and
arms
 

Haematomas

Postoperative scars have distinctive shapes and localisations. The appearance and colour allow to estimate the type of operation, history of healing, and the time elapsed since opening the skin.
 
So called keloid scars are bulging, protruding, reddish, found in person with individual redisposition.
 
Post-injury scars are irregular, in various locations.

 

Scars
 

Scars on the
legs caused by
extraction of
venous grafts
 

 

Scar after surgical
revascularisation
of myocardium
 

Scar after
sternototomy
 

Scars of healed
furuncles
(back of a woman
suffering from
diabetes)

Trophic skin changes
 
are caused by vascular (ischaemic) and innervation disorders.
 

	Bedsores (decubitus) are the most common. They constitute in immobile patients on the heels, and sacral and gluteal areas first as a superficial local ischaemia, gradually worsening to necrosis.
	Varicose ulcers localised on shanks are of various shapes, sizes, and depths and can be observed in patients with chronic venous insufficiency.
	In chronic ischaemia trophic skin defects on the toes (ischaemic disease of blood vessels of lower extremities, diabetic microangiopathy) can be observed.

 
Skin turgor
 
depends on hydration of the skin, the epidermis and its structure.
 
Decreased turgor is common in older age and is caused by decreased elasticity of epidermis.
In other cases dehydration caused by fluid loss contributes to decreased turgor (decompensated diabetes mellitus, diabetes insipidus, intensive diuretic therapy) or dehydration can be caused by insufficient intake of fluids (reduced thirst feelings in elderly people). The combinations of both causes are frequent, too.

Shank ulcer
 

Large
shank ulcer
 

Trofic defect
on the big toe
of a diabetic
 

 

State after the
amputation of
the toes in a
diabetic
 

 

Diabetic foot
 

Gangrene of the
right leg, detail
 

Secondary
skin changes
 

Secondary
skin changes
on the face

Oedemas
 
Oedemas are caused by an accumulation of extracellular fluid in the interstitium. Local or generalised oedemas can be recognised.
 
Local oedemas
 

	Inflammatory oedemas appear in the site of inflammation. The oedema is painful; the skin is warm and erythematous.
	Venostasic oedemas occur in the blockage of the venous system (phlebothrombosis). The skin is taut, sensitive, palpation causes a shallow dimple; cyanosis can be observed.
	Lymphoedemas are caused by the obstruction of lymaticph vessels or nodes by tumours, metastases, or parasites. The skin is pallid, rigid, and painless. After palpation, no dimple occurs. The long-lasting obstruction causes induration of the epidermis.
	Allergic oedemas can be found anywhere in the body, including mucous membranes (Quincke's angioneurotic oedema, contact allergy, insect stings). They tend to be flat, painless; they keep the colour and temperature of the surrounding skin. Even eyelid oedemas in patients with acute glomerulonephritis are considered of allergic origin.

 
Systemic oedemas occur in case of massive fluid retention. From etiopathogenetic point of view there is various participation of venostatic constituent, hypoproteinaemia and changes of vessel wall permeability.
 

	Cardiac oedema occurs in case of the right heart insufficiency. In walking patients they constitute in area perimaleolaris; they advance to the shanks and thighs. In recumbent patients they are found on the shanks, the lower part of the thighs and in the loins. In the most severe cases they stretch to the abdominal area and they affect the outer genitals. Ascites, hydrothorax, or hydropericarditis occur. The state is called anasarca.
	Renal oedemas can be found in nephrotic syndrome. They occur on the eyelids, in the face, on the genitals, and in lumbosacral parts of back.
	Hepatic oedemas manifest in decompensated hepatic cirrhosis. Ascites is predominant, but lower extremities oedemas may occur as well.
	Hypoproteinaemic oedemas in case of hypalbuminaemia are soft, with persisting dimple after palpation.
	Myxoedemas form by accumulation of mucopolysacharides in the face and forearm ("iron sheet forearm"); they are of tough consistence.

 
Hair
 
has typical appearance and position depending on the sex.
 

	Thin hair can be found in both sexes in hypogonadism, hypopituitarism, hypothyroidism, and hepatic cirrhosis and in males treated by oestrogens.
	Stronger and denser hair (hypertrichosis, hirsutism) is important in women. Mild forms can be observed in older women on the face and in case of Cushing's syndrome. More severe forms accompany androgenic tumours of the adrenal cortex and androgen treatment (doping!).
	Alopecia is diffuse or local loss of hair. It occurs in cytostatic treatment, in abdominal typhus, and thyrotoxicosis. In some men, the diffuse alopecia is a common finding. Local alopecia (alopecia areata) is rather rare to find.

Venostatic oedemas,
ileofemoral
phlebothrombosis
of the right leg
 

 

Lymphatic oedemas
 

Lymphoedema of the
lower extremity,
detail
 

Symmetrical
cardiac oedemas
of lower
extremities
 

Wrinkled skin
of the lower
extremity after
oedema subsidence
 

Right-sided cardiac
decompression in
cor pulmonale
 

Anasarca

Nails
 
are generally strong, smooth, resistant and of distinctive appearance and colour.
 

	Fragile and fraying nails are most common in thyrotoxicosis and sideropenic anaemia.
	Spoon-shape bent nails (koilonychia) occur in thyrotoxicosis.
	Spherical nails accompany congenital heart disorders, chronic pulmonary diseases; less frequently can be found in hepatic cirrhosis as a part of clubbed fingers (the shape of wrist watch glass).
	"White" (hepatic) nails occur in hepatic cirrhosis (the white part of the nail, so called lunula occupies a significant part of the nail area).
	Nails deformed with uneven surface, thick, changed in colour (particularly on toes) are affected by mycosis (onychomycosis).

Detail -
clubbed fingers
with cyanosis
in central part in
congenital
heart disorder
 

Spherical nails