This document provides descriptions and images of normal and abnormal skin, nail, and hair findings that may be observed during a physical assessment. It discusses various lesions including macules, papules, plaques, vesicles, pustules, nodules, and subcutaneous masses. It also covers assessments of hair including patterns of hair loss, focal hair loss conditions like alopecia areata, and nail findings such as paronychia and clubbing of the fingers. The document is intended as a guide for healthcare providers to identify potential dermatological conditions based on physical exam findings.

1. Findings During Skin, Nail and Hair Assessment
Prepared By:
Afza Malik (BScN ,CCRN)
Coordinator,
CON National Hospital & Medical Centre,
Lahore.
Normal & Abnormal Findings
during Skin Nail and Hair
Assessment

2. Flat Spots
 If you run your finger over the lesion but do not feel the lesion, the lesion is
flat. If a flat spot is small (<1 cm), it is a macule. If a flat spot is larger (>1
cm), it is a patch.
 Multiple 3–8-mm erythematous confluent round macules on chest, back,
and arms; morbilliform(a rash that looks like measles) drug eruption.

3. Conti…
 Multiple 2–5-mm hypopigmented, hyperpigmented, or tan round to oval
macules on upper neck and back, upper chest, and arms with slight inducible
scale on scraping (tinea versicolor) an overgrowth of a type of yeast
(fungus) that's naturally found on your skin.

4. Conti….
 Multiple scattered 2–4-mm round and oval brown macules, symmetrically
pigmented, on back and chest with reticular pattern (net-like or
consective pattern) on dermoscopy; benign melanocytic nevi.
 Melanocytic nevi commonly form during early childhood. Their onset is
believed by some authorities to be, at least in part, a response to sun
(ultraviolet) exposure. However, genetic factors are also clearly involved in
the development of some types of melanocytic nevi.

5. Conti….
Solitary 6-mm dark brown round
symmetric macule on upper back;
benign melanocytic nevus
Solitary dark brown, blue-gray, and red
7-mm macule with irregular borders and
fingerlike projections of pigment, on right
forearm; malignant melanoma

6. Patches (flat, large)
Bilaterally symmetric
erythematous patches on
central cheeks and
eyebrows, some with
overlying greasy scale;
seborrheic dermatitis
Large confluent
completely
depigmented patches
on dorsal hands and
distal forearms; vitiligo
Bilateral
erythematous,
geographic patches
with peripheral
scaling, on inner
thighs bilaterally,
sparing the scrotum;
tinea cruris

7. Raised Spots
 If you run your finger over the lesion and it is palpable above the skin, it is
raised. If a raised spot is small (<1 cm), it is a papule. If a raised spot is larger
(>1 cm), it is a plaque.
 Papules (raised, small)
Solitary 7-mm oval pink pearly papule with overlying
telangiectasias(Telangiectasias (commonly known as "spider veins") are dilated or
broken blood vessels located near the surface of the skin or mucous membranes.
They often appear as fine pink or red lines, which temporarily whiten when
pressed. ) on right nasojugal fold;(Nasolabial folds are creases in your skin
extending from both sides of your nose to the corners of your mouth. ) Basal
cells (Basal cells are found at the bottom of the epidermis — the outermost
layer of skin. produce new skin cells. As new skin cells are produced, they push
older cells toward the skin's surface, where the old cells die and are sloughed off )
carcinoma

8. Conti….
Skin Tags
Multiple 2–4-mm soft, fleshy skin-colored to light
brown papules on lateral neck and axillae in
skin folds; skin tags.
Skin tags occur when extra cells grow in the
top layers of the skin. They tend to develop
when the skin rubs against itself, so are more
common in people who are overweight and
therefore have folds of skin. They grow both in
men and women and are more common in older
people and people living with type 2 diabetes.

9. Conti….
Multiple 3–5-mm pink firm smooth domed
papules with central umbillications( a depression
resembling a navel an umbilication in the center of
a lesion also : the state or condition of having such
depressions a tendency to umbilication), in mons
pubis, and on penile shaft; molluscum
contagiosum(an infection caused by a poxvirus
(molluscum contagiosum virus)).

10. Conti…..
Scattered erythematous round drop-like, flattopped
well-circumscribed scaling papules and plaques on
trunk; guttate psoriasis(Guttate psoriasis is a skin
disease that often appears without warning and
usually follows an infection like strep throat. It's
most common in young adults but can also
happen in adults. The hallmark symptom of this
condition is breaking out in small, red scaly
patches.)

11. Plaques (raised, large)
Scattered erythematous to bright pink well-
circumscribed flat-topped plaques on extensor knees
and elbows, with overlying silvery scale; plaque
psoriasis(The most common type of psoriasis, plaque
psoriasis causes dry, itchy, raised skin patches
(plaques) covered with scales. There may be few or
many. They usually appear on the elbows, knees,
lower back and scalp. The patches vary in color,
depending on skin color.)

12. Conti….
Bilateral erythematous, lichenified (thickened from
rubbing) poorly circumscribed plaques on flexor
wrists, antecubital fossae, and popliteal fossae;
atopic dermatitis(Atopic dermatitis (eczema) is a
condition that causes dry, itchy and inflamed
skin. It's common in young children but can occur
at any age. Atopic dermatitis is long lasting
(chronic) and tends to flare sometimes. It can be
irritating but it's not contagious.)

13. Conti
Single, oval, flat-topped superficial erythematous to
skin-colored plaque on right abdomen; herald
patch(The cause of pityriasis rosea is not known,
but it is commonly believed to be caused by a virus
or bacteria. Some patients may have a cold before the
rash. It is usually seen in children, adolescents, and
young adults. Most people with the rash are 10 to 35
years of age) of pityriasis rosea(Pityriasis rosea is
caused by a viral infection. The virus has recently
been identified as one of the herpes viruses. Children
and young adults are more susceptible, for reasons
unknown. Recurrences are rare - a person who
develops the skin rash has only a two per cent chance
of experiencing it again).

14. Conti…..
Multiple round to oval scaling
violaceous(purpuric -blue-grey -variegated –
hypopigmented) plaques on abdomen and
back; pityriasis rosea

15. Conti…
Multiple round coin-like eczematous(dry, itchy and
inflamed skin) plaques on arms, legs, and
abdomen, with overlying dried transudate crust (an
ultrafiltrate of plasma that contains few, if any,
cells and does not contain large plasma proteins,
such as fibrinogen.); nummular
Dermatitis(features scattered circular, often itchy
and sometimes oozing patches. The word
“nummular” comes from the Latin word for “coin,” as
the spots can look coin-shaped on the skin.

16. Fluid-filled Lesions
 If the lesion is raised, filled with fluid, and small (<1 cm), it is a vesicle. If a
fluid-filled spot is larger (>1 cm), it is a bulla.
 Vesicles (fluid-filled, small)
Multiple 2–4-mm vesicles and
pustules (a small blister or pimple on
the skin containing pus.)on
erythematous base, grouped together
on left neck; herpes simplex virus

17. Conti…
Grouped 2–5-mm vesicles (A vesicle, or blister,
is a thin-walled sac filled with a fluid, usually
clear and small. Vesicle is an important term
used to describe the appearance of many rashes
that typically consist of or begin with tiny-to-small
fluid-filled blisters)on erythematous base on left
upper abdomen and trunk in a dermatomal
distribution that does not cross the midline; herpes
zoster or “shingles”

18. Conti…
Scattered 2–5-mm erythematous papules and
vesicles with transudate crust, some with linear
arrays, on forearms, neck, and abdomen; rhus
dermatitis(a general term that describes a
common skin irritation) or allergic contact
dermatitis from poison ivy (Poison ivy is a type of
allergenic plant in the genus Toxicodendron)

19. Bullae (fluid-filled, large)
Solitary 8-cm dusky (used in euphemistic or
poetic reference to black or other dark-skinned
people ) oval patch with smaller inner violaceous
(a purple discoloration, usually of the skin)
patch and central 3.5-cm tense bulla, on right
posterior lower back; bullous fixed drug eruption
Several tense bullae on lower legs; insect bites

20. Conti…
Many vesicles and tense bullae up to 4 cm, some
having unroofed and left large (4-cm) erosions, on
lower legs bilaterally up to the line of the top of combat
boots; an inherited skin fragility disorder (Fragile X
syndrome is a genetic condition that causes a range
of developmental problems including learning
disabilities and cognitive impairment. Usually, males
are more severely affected by this disorder than
females. Affected individuals usually have delayed
development of speech and language by age 2.)

21. Pustule
Small palpable collection of neutrophils or keratin that appears white
•15–20 pustules and acneiform(raised bumps)
papules on buccal and parotid cheeks bilaterally;
acne vulgaris(Acne develops when sebum — an
oily substance that lubricates your hair and skin
— and dead skin cells plug hair follicles) Caused
by Excess oil (sebum) production , Hair follicles
clogged by oil and dead skin cells and Bacteria

22. Conti….
30 2–5-mm erythematous papules and pustules
on frontal, temporal, and parietal scalp; bacterial
folliculitis
This common type is marked by itchy, white,
pus-filled bumps. It occurs when hair follicles
become infected with bacteria, usually
Staphylococcus aureus (staph). Staph bacteria live
on the skin all the time

23. Furuncle
 Furuncle: Inflamed hair follicle; multiple furuncles together form a
carbuncle.(A carbuncle is a cluster of boils that form a connected area
of infection under the skin. Boils (furuncles) usually start as reddish
or purplish, tender bumps. The bumps quickly fill with pus, growing
larger and more painful until they rupture and drain.)
Two large (2-cm) furuncles on forehead, without
fluctuance; furunculosis (Note: fluctuant deep
infections are abscesses(a painful collection of
pus, usually caused by a bacterial infection))

24. Nodule
 Nodule: Larger and deeper than a papule
Solitary blue-brown 1.2-cm firm nodule with
positive dimple sign and hyperpigmented rim
on left lateral thigh; dermatofibroma(a
commonly occurring cutaneous entity
usually centered within the skin's dermis)

25. Conti…
Solitary 4-cm pink and brown scar-like
nodule on central chest at site of previous
trauma; keloid(a type of raised scar)

26. Subcutaneous mass/cyst
 Subcutaneous mass/cyst: Whether mobile or fixed, cysts are
encapsulated collections of fluid or semisolid
Solitary 2-cm tethered subcutaneous cyst
with overlying punctum(Hole ) releasing
caseous(Caseous necrosis is a type of
cellular death that occurs in tissues.) whitish
yellow substance with foul odor; epidermal
inclusion cyst (follicular infundibulum is
disrupted).

27. Conti
Three 6–8-mm mobile subcutaneous cysts on
vertex scalp, that on excision reveal pearly white
balls; pilar cysts(relatively rare benign cysts that
grow from your hair follicles. Most pilar cysts
surface on your scalp (head), but they can appear
on your face, neck, arms and legs. Pilar cysts are
sometimes called trichilemmal cysts or wens.)

28. Conti…..
Solitary 9-cm mobile rubbery subcutaneous
mass on left temple; lipoma(a fatty tumor
located just below the skin)

29. Conti…
Wheal: Area of localized dermal edema that
evanesces (comes and goes) within a period of 1–
2 days; this is the essential primary lesion of
urticaria(a raised, itchy rash that appears on the
skin) Many variably sized (1–10-cm) wheals on
lateral neck, shoulders, abdomen, arms, and legs;
urticaria

30. Conti…
Burrow: Small linear Multiple small (3–6
mm) erythematous papules on abdomen,
buttocks, scrotum, and shaft and head of
penis, with four burrows noted on
interdigital web spaces; scabies ear or
serpiginous pathways in the epidermis
created by the scabies mite

31. Generalized or Diffuse Hair Loss
Male pattern hair loss
(MPHL)
Female pattern hair loss
(FPHL)

32. Telogen Effluvium and Anagen Effluvium
In telogen effluvium, overall, the patient’s scalp and hair distribution appear
normal, but a positive hair pull test reveals most hairs have telogen bulbs. In
anagen effluvium, there is diffuse hair loss from the roots. The hair pull test
shows few if any hairs with telogen bulbs.
Telogen effluvium is the name for a common cause of temporary hair loss
due to the excessive shedding of resting or telogen hair after some
shock to the system.

33. Conti
Normal hair part width
in telogen effluvium
Positive hair pull test in
telogen effluvium
showing all hairs have
telogen bulbs
Anagen
effluvium

34. Focal Hair Loss
Alopecia Areata
There is sudden onset of clearly demarcated,
usually localized, round or oval patches of hair
loss leaving smooth skin without hairs, in
children and young adults. There is no visible
scaling or erythema.

35. Tinea Capitis (“Ringworm”)
 There are round scaling patches of alopecia, mostly seen in children. There
may be “black dots” of broken hairs and comma or corkscrew hairs on
dermoscopy. Usually caused by Trichophyton tonsurans from humans, and
less commonly, Microsporum canis from dogs or cats. Boggy plaques are
called kerions.

36. Conti…
 Scarring Alopecia
 Scarring on the scalp is characterized by shiny skin, complete loss of hair
follicles, and often, discoloration. Presence of any scarring should prompt
referral to a dermatologist for possible scalp biopsy if the patient desires
treatment. Examples of scarring alopecia include central centrifugal
scarring alopecia and discoid lupus erythematosus, among others
Central
centrifugal
Discoid lupus
scarring

37. Conti….
 Hair Shaft Disorders
Patients with abnormal hair from birth, as in this patient with a genetic
condition called monilethrix, should be referred to dermatology.

38. Nail Assessment
Paronychia
A superficial infection of the proximal and lateral nail
folds adjacent to the nail plate. The nail folds are
often red, swollen, and tender. Represents the most
common infection of the hand, usually from
Staphylococcus aureus or Streptococcus species,
and may spread until it
completely surrounds the nail plate. Creates a felon if
it extends into the pulp space of the finger. Arises
from local trauma due to nail biting, manicuring, or
frequent hand immersion in water. Chronic infections
may be related to Candida.

39. Conti…
Clubbing of the Fingers
Clinically, a bulbous swelling of the soft tissue at
the nail base, with loss of the normal angle
between the nail and the proximal nail fold. The
angle increases to 180 or more, and the nail bed
feels spongy or floating. The mechanism is still
unknown but involves vasodilatation with increased
blood flow to the distal portion of the digits and
changes in connective tissue, possibly from
hypoxia, changes in innervation, genetics, or a
platelet derived growth factor from fragments of
platelet clumps. Seen in congenital heart disease,
interstitial lung disease and lung cancer,

40. Conti….
Habit Tic Deformity
There is depression of the central nail with a
“Christmas tree” appearance from small
horizontal depressions, resulting from
repetitive trauma from rubbing the index
finger over the thumb or vice versa.
Pressure on the nail matrix causes the nail
to grow out abnormally. Avoidance of the
behavior leads to normal nail growth.

41. Melanonychia
Melanonychia is caused by increased
pigmentation in the nail matrix, leading to
a streak as the nail grows out. This may
be a normal ethnic variation iff found in
multiple nails. A thin uniform streak may
be caused by a nevus, but a wide streak,
especially if growing or irregular, could
represent a subungual melanoma.

42. Conti….
Onycholysis
A painless separation of the whitened opaque nail
plate from the pinker translucent nail bed.
Fingernails that extend past the fingertip are more
likely to result in the traumatic shearing forces that
produce onycholysis. Starts distally and progresses
proximally, enlarging the free edge of the nail. Local
causes include trauma from excess manicuring,
psoriasis, fungal infection, and allergic reactions to
nail cosmetics. Systemic causes include diabetes,
anemia, photosensitive drug reactions,
hyperthyroidism, peripheral ischemia,
bronchiectasis, and syphilis.

43. Conti…
Onychomycosis
The most common cause of nail thickening and
subungual debris is onychomycosis, most often from the
dermatophyte Trichophyton rubrum, but also from other
dermatophytes and some molds such as Alternaria and
Fusarium species. Onychomycosis affects 1 in 5 over age
60. The best prevention is to treat and prevent tinea
pedis. Only half of all nail dystrophies are caused by
onychomycosis, so a positive fungal culture, potassium
hydroxide exam, or pathologic evaluation of nail clippings
is recommended before treating with oral antifungals.

44. Conti….
Terry Nails
Nail plate turns white with a ground-glass
appearance, a distal band of reddish brown,
and obliteration of the lunula. Commonly
affects all fingers, although may appear in only
one finger. Seen in liver disease, usually
cirrhosis, heart failure, and diabetes. May arise
from decreased vascularity and increased
connective tissue in nail bed.

45. Conti…..
Transverse Linear Depressions (Beau Lines)
Transverse depressions of the nail plates, usually
bilateral, resulting from temporary disruption of
proximal nail growth from systemic illness. Timing of
the illness may be estimated by measuring the
distance from the line to the nail bed (nails grow
approximately 1 mm every 6 to 10 days). Seen in
severe illness, trauma, and cold exposure if
Raynaud disease is present.

46. Conti…
Pitting
Punctate depressions of the nail plate caused by
defective layering of the superficial nail plate by
the proximal nail matrix. Usually associated with
psoriasis but also seen in Reiter syndrome,
sarcoidosis, alopecia areata, and localized atopic
or chemical dermatitis.

47. Any Question ?

48. Thank You….!