In this Powerpoint, we have completely referred BATES' GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING, and also some IMAGES are been referred from the Textbook only. This is completely for Educational use only. We have mentioned about: 1. Anatomy and Physiology of SKIN, HAIR and NAILS 2. The ABCDE rules 3. Describing Primary Skin Lesions and Additional Primary Lesions; Benign Lesions, Rough Lesions, Pink Lesions and Brown Lesions 4. Acne Vulgaris: Primary and Secondary Lesions 5. Vascular and Purpuric Lesions of the Skin 6. Signs of Sun Damage 7. Systemic Diseases and Associated Skin Findings 8. Pressure Ulcers 9. Hair loss 10. Findings in or Near the Nails Hope this is useful. Thank you, Have a Good day! Dr. DURAIRAJ CHIKADZA

1. The SKIN, HAIR
and NAILS
D R . D U R A I R A J C H I K A D Z A
( R E F E R E N C E : B A T E S ' G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D
H I S T O R Y T A K I N G )

2. SKIN

3. Anatomy and Physiology
• The skin is the heaviest single
organ of the body – 16% of body
weight and covers area up to 1.2 to
2.3/m2
• Contains three layers:
• EPIDERMIS
• DERMIS
• SUBCUTANEOUS

4. Melanoma
• Melanoma is a form of skin
cancer that begins in the cells
(melanocytes) that control the
pigment in your skin. This
illustration shows melanoma
cells extending from the surface
of the skin into the deeper skin
layers.
RISK FACTORS FOR MELANOMA
• Personal or family history of previous
melanoma
• ≥50 common moles
• Atypical or large moles, especially if
dysplastic
• Red or light hair
• Solar lentigines
• Freckles
• Ultraviolet radiation from heavy sun
exposure, sunlamps or tanning booths
• Light eye or skin color, especially skin
that freckles or burns easily
• Severe blistering sunburns in childhood
• Immunosuppression from human
immunodeficiency virus (HIV) or from
chemotherapy
• Personal history of nonmelanoma skin
cancer

5. SKIN CANCER PREVENTION

6. Avoiding Ultraviolet Radiation and Tanning Beds
• Increasing life-time sun exposure correlates directly with increasing risk of skin
cancer.
• Intermittent sun exposure appears to be more harmful than chronic exposure.
• The best defense against skin cancers is to avoid ultraviolet radiation exposure by
limiting time in the sun, avoiding midday sun, using sunscreen, and wearing sun-
protective clothing with long sleeves and hats with wide brims.
Sign of chronic sun damage include numerous SOLAR LENTIGINES on the shoulders
and upper back, many melanocytic nevi, SOLAR ELASTOSIS (yellow, thickened skin
with bumps, wrinkles or furrowing), CUTIS RHOMBOIDALIS NUCHAE (leathery
thickened skin on the posterior neck), and ACTINIC PURPURA.

7. Regular use of
Sunscreen Prevents
Skin Cancer
• Advise patients to use at least
sun protective factor (SPF) 30
and broad-spectrum protection.
• For water exposure, patients
should use water-
resistant sunscreens.

8. SKIN CANCER SCREENING
SCREENING FOR MELANOMA: The ABCDE rule:
• The ABCDE method has been used for many years to teach clinicians and
patients about features suspicious for melanoma. If two or more of these are
present, risk of melanoma increases, and biopsy should be considered. Some
have suggested adding EFG to help detect aggressive nodular melanomas.

9. The ABCDE Rule: Asymmetry
ASYMMETRY MELANOMA BENIGN NEVUS
• Of one side of mole compared
to the other

10. The ABCDE Rule: Border Irregularity
BORDER IRREGULARITY MELANOMA BENIGN NEVUS
• Especially if ragged, notched
or blurred

11. The ABCDE Rule: Color Variations
COLOR VARIATIONS MELANOMA BENIGN NEVUS
• More than two colors,
especially blur-black, white
(loss of pigment due to
regression), or red
(inflammatory reaction to
abnormal cells)

12. The ABCDE Rule: Diameter >6 mm
DIAMETER >6 mm MELANOMA BENIGN NEVUS
• Approximately the size of a
pencil eraser

13. The ABCDE Rule: Evolving
ASYMMETRY MELANOMA BENIGN NEVUS
• Or changing rapidly in size,
symptoms, or morphology

14. Describing Primary Skin Lesions:
FLAT, RAISED and FLUID-FILLED
• FLAT SPOTS
• Macules (flat, small)
• Patches (flat, large)
• RAISED SPOTS
• Papules (raised, small)
• Plaques (raised, large)
• FLUID-FILLED LESIONS
• Vesicles (fluid-filled, small)
• Bullae (fluid-filled, large)

15. Flat spots:
Macules
• Multiple 3-8 mm erythematous
confluent round macules on
chest, back, and arms;
morbilliform drug eruption

16. Flat spots:
Macules
• Multiple 2-5 mm hypopigmented,
hyperpigmented, or tan round to
oval macules on upper neck and
back, upper chest, and arms with
slightly inducible scale on
scraping (tinea versicolor)

17. Flat spots:
Macules
• Multiple scattered 2-4 mm
round and oval brown macules,
symmetrically pigmented, on
back and chest with reticular
pattern on dermoscopy; benign
melanocytic nevi

18. Flat spots:
Macules
• Solitary 6-mm dark brown round
symmetric macule on upper
back; benign melanocytic nevi

19. Flat spots:
Macules
• Solitary dark brown, blue-gray,
and red 7-mm macule with
irregular borders and fingerlike
projections of pigment;
malignant melanoma

20. Flat spots:
Patches
• Bilaterally symmetric
erythematous patches on
central cheeks and eyebrows,
some with overlying greasy
scale; seborrheic dermatitis

21. Flat spots:
Patches
• Large confluent completely
depigmented patches on dorsal
hands and distal forearms;
vitiligo

22. Flat spots:
Patches
• Bilateral erythematous,
geographic patches with
peripheral scaling, on inner
thighs bilaterally, sparing the
scrotum; tinea cruris

23. Raised spots:
Papules
• Solitary 7-mm oval pink pearly
papule with overlying
telangiectasias on right
nasojugal fold; basal cell
carcinoma

24. Raised spots:
Papules
• Multiple 2-4 mm soft, fleshy
skin-colored to light brown
papules on lateral neck and
axillae in skin folds; skin tags

25. Raised spots:
Papules
• Multiple 3-5 mm pink firm
smooth domed papules with
central umbilications, in mons
pubis, and on penile shaft;
molluscum contagiosum

26. Raised spots:
Papules
• Scattered erythematous round
drop-like, flat-topped well-
circumscribed scaling papules
and plaques on trunk; guttate
psoriasis

27. Raised spots:
Plaques
• Scattered erythematous to
bright pink well-circumscribed
flat-topped plaques on extensor
knees and elbows, with
overlying silvery scale; plaque
psoriasis

28. Raised spots:
Plaques
• Bilateral erythematous,
lichenified (thickening from
rubbing) poorly circumscribed
plaques on flexor wrists,
antecubital fossae, and
popliteal fossae; atopic
dermatitis

29. Raised spots:
Plaques
• Single, oval, flat-topped
superficial erythematous to
skin-colored plaque on
abdomen; herald patch of
pityriasis rosea

30. Raised spots:
Plaques
• Multiple round to oval scaling
violaceous plaques on abdomen
and back; pityriasis rosea

31. Raised spots:
Plaques
• Multiple round coin-like
eczematous plaques on arms,
legs, and abdomen, with
overlying dried transudate crust;
nummular dermatitis

32. Fluid filled:
Vesicles
• Multiple 2-4 mm vesicles and
pustules on erythematous base,
grouped together on left neck;
herpes simplex virus

33. Fluid filled:
Vesicles
• Grouped 2-5 mm vesicles on
erythematous base on left
upper abdomen and trunk in a
dermatomal distribution that
does not cross the midline;
herpes zoster or "shingles"

34. Fluid filled:
Vesicles
• Scattered 2-5 mm erythematous
papules and vesicles with
transudate crust, some with
linear arrays, on forearms, neck
and abdomen; rhus dermatitis
or allergic contact dermatitis
from poison ivy

35. Fluid filled:
Bullae
• Solitary 8-cm dusky oval patch
with smaller inner violaceous
patch and central 3.5-cm tense
bulla, on right posterior lower
back; bullous fixed drug
eruption

36. Fluid filled:
Bullae
• Several tense bullae on lower
legs; insect bites

37. Fluid filled:
Bullae
• 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

38. Additional Primary Lesions:
• PUSTULES
• FURUNCLES
• NODULES
• CYSTS
• WHEALS
• BURROWS

39. Pustule:
Small palpable collection of neutrophils or keratin that appears white
• ~15-20 pustules and acneiform papules
on buccal and parotid cheeks bilaterally;
acne vulgaris

40. Pustule:
Small palpable collection of neutrophils or keratin that appears white
• ~30 2-5 mm erythematous papules
and pustules on frontal, temporal, and
parietal scalp; bacterial folliculitis

41. Furuncle:
Inflamed hair follicle; multiple furuncles together form a carbuncle
• Two large (2-cm) furuncles on
forehead, without fluctuance;
furunculosis (Note: fluctuant deep
infections are abscesses)

42. 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

43. Nodule:
Larger and deeper than a papule
• Solitary 4-cm pink and brown scar-like
nodule on central chest at site of
previous trauma; keloid

44. Subcutaneous mass/cyst:
Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid
• Solitary 2-cm tethered subcutaneous
cyst with overlying punctum releasing
caseous whitish yellow substance with
foul odor; epidermal inclusion cyst

45. Subcutaneous mass/cyst:
Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid
• Three 6-8-mm mobile subcutaneous
cysts on vertex scalp, that on excision
reveal pearly white balls; pilar cysts

46. Subcutaneous mass/cyst:
Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid
• Solitary 9-cm mobile rubbery
subcutaneous mass on left temple;
lipoma

47. 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
• Many variably sized (1-10-cm) wheals
on lateral neck, shoulders, abdomen,
arms and legs; urticaria

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

49. DERMATOLOGY SAFARI: BENIGN LESIONS
Cherry angiomas

50. DERMATOLOGY SAFARI: BENIGN LESIONS
Seborrheic keratosis

51. DERMATOLOGY SAFARI: BENIGN LESIONS
Solar lentigines

52. DERMATOLOGY SAFARI: BENIGN LESIONS
Benign melanocytic nevi

53. DERMATOLOGY SAFARI: BENIGN LESIONS
Dermatofibroma

54. DERMATOLOGY SAFARI: BENIGN LESIONS
Keloids

55. DERMATOLOGY SAFARI: BENIGN LESIONS
Epidermal inclusion cyst

56. DERMATOLOGY SAFARI: BENIGN LESIONS
Pilar cyst

57. DERMATOLOGY SAFARI: BENIGN LESIONS
Lipoma

58. Rough Lesions: Actinic Keratoses,
Squamous Cell Carcinoma, and
their Mimics

59. ACTINIC KERATOSIS AND
SQUAMOUS CELL CARCINOMA MIMICS
Actinic keratosis Superficial xerosis or seborrheic dermatitis
• Often easier to feel than to see
• Superficial keratotic papules "come and go"
on sun-damaged skin
• May occur in same distribution on forehead,
central face
• Scale is less keratotic and will improve with
moisturizers, mild topical steroids

60. ACTINIC KERATOSIS AND
SQUAMOUS CELL CARCINOMA MIMICS
Cutaneous horn/keratotic scale Warts
• The protypic keratotic scale of actinic
keratoses and SCC is formed by keratin and
can result in a cutaneous horn
• Cutaneous horns should generally be
biopsied to rule out SCC
• Usually skin-colored to pink, texture more
verrucous than keratotic
• May be filiform
• Often have hemorrhagic punctuate that can
be seen with a magnifying glass or
dermatoscope

61. ACTINIC KERATOSIS AND
SQUAMOUS CELL CARCINOMA MIMICS
Squamous cell carcinoma Seborrheic keratosis
• Keratoacanthomas are SCCs that arise
rapidly and have a crateriform center
• Often have a smooth but firm border
• SCCs can become quite large if left untreated
(Note: highest sites of metastasis are the
scalp, lips and ears)
• Often have a verrucous texture
• Appear like a "stuck-on" or flattened ball of
wax
• May crumble or bleed if picked
• Specific features on dermoscopy such as
milia-like cysts or comedone-like openings
are reassuring, if present
• May be erythematous if inflamed

62. Pink Lesions: Basal Cell Carcinoma
and its Mimics

63. BASAL CELL CARCINOMAS MIMICS
Superficial Basal Cell Carcinoma
Actinic keratosis and
Squamous cell carcinoma in situ
• Pink patch that does not heal
• May have focal scaling
• Actinic keratosis or squamous cell carcinoma
in situ usually has keratotic scaling

64. BASAL CELL CARCINOMAS MIMICS
Nodular basal cell carcinoma Sebaceous hyperplasia
• Pink papule, often with translucent or pearly
appearance and overlying telangiectasias
• May have focal pigmentation
• Dermoscopy shows arborizing vessels, focal
pigment globules, and other specific patterns
• Yellowish globular papules, often with
central dell, on forehead and cheeks
• Dermoscopy shows telangiectasis that go
around sebaceous glands rather than over
them as in BCC

65. BASAL CELL CARCINOMAS MIMICS
Nodular Basal Cell Carcinoma (cont) Fibrous papule
• 1 cm pearly pink plaque with central
depression and overlying arborizing
telangiectasias on nasal ala
• Skin-colored to pink papule on the nose,
without telangiectasias
• May become excoriated

66. BASAL CELL CARCINOMAS MIMICS
Ulcerated Basal Cell Carcinoma Squamous Cell Carcinoma
• Non-healing ulcer, resulting in "rolled border" • May also be ulcerated
• Firmer at edges than BCC

67. Brown Lesions: Melanoma and
its Mimics

68. MELANOMAS MIMICS
Amelanotic melanoma Skin tags or intradermal nevi
• Usually in very fair-skinned people
• Evolution or rapid change is the most
important feature, because variegation or
dark pigment is missing in this type
• Soft and fleshy
• Often around neck, axillae, or back
• Sessile nevi may have a hint of brown
pigmentation

69. MELANOMAS MIMICS
Melanoma in situ Solar lentigo
• On sun-exposed or sun-protected skin
• Look for ABCDE features
• On sun-exposed skin
• Light brown and uniform in color but may be
asymmetric

70. MELANOMAS MIMICS
Melanoma Dysplastic nevus
• May arise de novo or in existing nevi and
exhibits ABCDEs
• Patients with many dysplastic nevi have
increased risk of melanoma
• May have macular base and papular central
"fried egg" component
• Compare to the patient's other nevi and
monitor changes

71. MELANOMAS MIMICS
Melanoma Inflamed seborrheic keratosis
• May have variegated color (browns, red)
• Has melanocytic features on dermoscopy
• Can sometimes mimic a melanoma if it has
an erythematous base
• Dermoscopy helps the trained eye
distinguish these

72. MELANOMAS MIMICS
Melanoma Seborrheic keratosis
• May be uniform in color but asymmetric; key
feature is rapid change or Evolution
• Stuck-on and verrucous, may be darkly
pigmented

73. MELANOMAS MIMICS
Acral melanoma Acral nevus
• Rapid change or evolution helps detect acral
melanoma
• Consider biopsies if >7 mm, rapidly growing,
or concerning features on dermoscopy
• Likely benign if <7 mm and has a
reassurance pattern on dermoscopy; such as
the parallel furrow or lattice pattern

74. MELANOMAS MIMICS
Melanoma with blue-black areas Blue nevus
• Blue-black areas are concerning for
melanoma, especially if they are asymmetric
• Blue nevi have a homogenous blue-gray
appearance, clinically and on dermoscopy

75. Acne Vulgaris: Primary and
Secondary Lesions

76. Primary Lesions
Mild Acne: Open and closed comedones, occasional papules

77. Primary Lesions
Moderate Acne: Comedones, papules, pustules

78. Primary Lesions
Severe Cystic Acne

79. Secondary Lesions
Acne with Pitting and Scars

80. Vascular and Purpuric Lesions
of the Skin

81. Vascular Lesions
• Spider Angioma
• Spider Vein
• Cherry Angioma
Purpuric Lesions
• Petechia/Purpura
• Ecchymosis

82. Vascular Lesions

83. Spider Angioma
• Color and Size: Fiery red; from very small to 2 cm
• Shape: Central body, sometimes raised, surrounded by
erythema and radiating legs
• Pulsatility and Effect of Pressure: Often seen in
center of the spider when pressure with a glass slide is
applied; pressure on the body causes blanching of the
spider
• Distribution: Face, neck, arms and upper trunk, almost
never below the waist
• Significance: Single spider angiomas are normal and
are common on the face and chest; also seen in
pregnancy and liver disease

84. Spider Vein
• Color and Size: Bluish; size variable, from very small to
several inches
• Shape: Variable; may resemble a spider or be linear,
irregular, cascading
• Pulsatility and Effect of Pressure: Absent; pressure
over the center does not cause blanching, but diffuse
pressure blanches the veins
• Distribution: most often on the legs, near veins; also on
the anterior chest
• Significance: often accompanies increased pressure in
the superficial veins, as in varicose veins

85. Cherry Angioma
• Color and Size: bright on ruby re; may become purplish
with age; 1-3 mm
• Shape: round, flat, or sometimes raised; may be
surrounded by a pale halo
• Pulsatility and Effect of Pressure: absent, may show
partial blanching, especially if pressure applied with
edge of a pinpoint
• Distribution: Trunk; also extremities
• Significance: none; increases in size and numbers with
aging

86. Purpuric Lesions

87. Petechia/Purpura
• Color and Size: deep red or reddish purple, fading
away over time; petechia, 1-3 mm; purpura are
larger
• Shape: rounded, sometimes irregular; flat
• Pulsatility and Effect of Pressure: absent; no
effect from pressure
• Distribution: variable
• Significance: blood outside the vessels; may
suggest a bleeding disorder or, if petechiae, emboli
to skin; palpable purpura in vasculitis

88. Ecchymosis
• Color and Size: purple or purplish blue, fading to
green, yellow and brown with time; ariable size, larger
than petechiae, >3 mm
• Shape: rounded, oval, or irregular; may have a central
subcutaneous flat nodule (a hematoma)
• Pulsatility and Effect of Pressure: absent; no effect
from pressure
• Distribution: variable
• Significance: blood outside the vessels; often
secondary to bruising or trauma; also seen in bleeding
disorders

89. Signs of Sun Damage

90. Solar lentigo
Bilaterally symmetric brown macules located on sun-exposed skin, including the face,
shoulders, and arms and hands

91. Solar elastosis
Yellowish white macules or papules in sun-exposed skin, especially on the forehead

92. Actinic purpura
Ecchymoses limited to the dorsal forearms and hands but not extending above the
"shirt-sleeve" line on the upper arm

93. Poikilodermis
Red patches in sun-damaged areas, especially the V of the neck, and lateral neck
(usually sparing the shadow inferior to the chin) with fine telangiectasias, and both
hyper- and hypopigmentation

94. Wrinkles
Increased sun damage and tanning leads to deeper wrinkles at an earlier age

95. Cutis rhomboidalis nuchae
Deep wrinkles on the posterior neck that "criss-cross"

96. Systemic Diseases and Associated
Skin Findings

97. • ADDISON DISEASE: Hyperpigmentation of oral mucosa as well as sun-exposed skin,
sites of trauma, and creases of palms and soles
• ACQUIRED IMMUNE DEFICIENCY SYNDROME: Human papillomavirus, herpes
simplex virus, varicella zoster virus, cytomegalovirus, molluscum
contagiosum, bacterial abscesses, mycobacterium (tuberculosis, leprae, avium)
infections, candidiasis, deep fungal infections (cryptococcus, histoplasmosis), oral
hairy leukoplakia, Kaposi sarcoma, oral and anal squamous cell carcinoma, acquired
ichthyosis, severe psoriasis, severe seborrheic dermatitis, eosinophilic folliculitis
• CHAGAS DISEASE (AMERICAN TRYPANOSOMIASIS): Unilateral conjunctivitis and
lid edema associated with preauricular lymphadenopathy
• CHRONIC RENAL DISEASE: Pallor, xerosis, uremic frost, pruritus, "half and half"
nails, calciphylaxis
• CREST SYNDROME: Calcinosis, Raynaud phenomenon, sclerodactyly, matted
telangiectasias of face and hands (palms)

98. • CROHN DISEASE: Erythema nodosum, pyoderma gangrenosum, enterocutaneous
fistulas, aphthous ulcers
• CUSHING DISEASE: Striae, atrophy, purpura, ecchymoses, telangiectasias, acne,
moon facies, buffalo hump, hypertrichosis
• DERMATOMYOSITIS: Violaceous erythema as macules, patches or papules in
periocular region (heliotrope), on interphalangeal joints (Gottron sign), and on upper
back and shoulders (shawl sign); poikiloderma in sun-exposed areas; periungual
telangiectasia, ragged cuticles (Samitz sign)
• DIABETES: Pruritus, diabetic dermopathy, acanthosis nigricans, candidiasis,
neuropathic ulcers, necrobiosis, lipoidica, eruptive xanthomas
• DISSEMINATED INTRAVASCULAR COAGULATION: Purpura, petechiae, hemorrhagic
bullae, induration, necrosis
• DYSLIPIDEMIAS: Xanthomas (tendon, eruptive, and tuberous), xanthelasma (may also
occur in healthy people)

99. • GONOCOCCEMIA: Purple to grey macules, papules or hemorrhagic pustules
distributed over acral and periarticular surfaces
• HEMOCHROMATOSIS: Skin bronzing and hyperpigmentation
• HYPOTHYROIDISM: Dry, rough, and pale skin; coarse and brittle hair; myxedema;
alopecia (lateral third of the eyebrows to diffuse); skin cool to touch; thin and brittle
nails
• HYPERTHYROIDISM: Warm, moist, soft, and velvety skin; thin and fine hair; alopecia;
vitiligo; pretibial myxedema (in Graves disease); hyperpigmentation (local or
generalized)
• INFECTIVE ENDOCARDITIS: Janeway lesions, Osler nodes, splinter hemorrhages,
petechiae
• KAWASAKI DISEASE: Mucosal erythema (lips, tongue, and pharynx), strawberry
tongue, cherry red lips, polymorphous rash (primarily on trunk), erythema of alms and
soles with later desquamation of fingertips

100. • LIVER DISEASE: Jaundice, spider angiomas and other telangiectasis, palmar
erythema, Terry nails, pruritus, purpura, caput medusae
• LEUKEMIA/LYMPHOMA: Pallor, exfoliative erythroderma, nodules, petechiae,
ecchymoses, pruritus, vasculitis, pyoderma gangrenosum, bullous diseases
• LEUKOCYTOCLASTIC VASCULITIS (POST-CAPILLARY VENULES): Palpable
purpura, purpuric wheals, hemorrhagic bullae in dependent areas
• LYMPHOGRANULOMA VENEREUM: Lymphadenopathy above and below Poupart
ligament (groove sign)
• MEDIUM VESSELS VASCULITIDES (e.g., POLYARTERITIS
NODOSA, GRANULOMATOSIS WITH POLYATERITIS, EOSINOPHILIC
GRANULOMATOSIS WITH POLYANGIITIS, MICROSCOPIC POLYANGIITIS): Livedo
racemose, purpuric nodules, ulcers
• MENINGOCOCCEMIA: Angular or stellate purpuric patches and plaques
with gunmetal gray center. Progresses to ecchymoses, bullae, necrosis

101. • NEUROFIBROMATOSES 1 (VON RECKLINGHAUSEN SYNDROME): Neurofibromas,
café-au-lait spots, freckling in the axillae (Crowe sign), plexiform neurofibroma
• PANCREATITIS (HEMORRHAGIC): Bruising and induration over the costovertebral
angle (Grey Turner sign), Cullen sign, panniculitis)
• PANCREATIC CARCINOMA: Panniculitis, migratory thrombophlebitis (Trousseau sign)
• PORPHYRIA CUTANEA TARDA: Photosensitivity with bullae and skin fragility on
dorsal hands and forearms; bullae rupture and heal with scarring and
milia; hypertrichosis of the face; bronzing of skin when associated with
hemochromatosis
• PYODERMA GANGRENOSUM: Painful pustule quickly progressing to ragged ulcer
with sharply marginated violaceous border and undermined edges
• ROCKY MOUNTAIN SPOTTED FEVER: Pink or reddish papules progressing to
purpuric papules; starts on wrists and ankles and spreads to palms and soles and then
to trunk and face

102. • SARCOIDOSIS: Red-brown plaques, often annular, typically involving the head and
neck and especially the nose and ears; may show apple jelly color with dermoscopy
• SYSTEMIC LUPUS ERYTHEMATOUS: Malar erythema (mid cheeks, spans bridge of
nose), relative sparing of nasolabial folds, periungual erythema, interphalangeal
erythema

103. Pressure Ulcers

104. Risk factors for Pressure Ulcers
• Decreased mobility, especially if accompanied by increased pressure or
movement causing friction or shear stress
• Decreased sensation, from brain or spinal cord lesions or peripheral nerve
disease
• Decreased blood flow from hypotension or microvascular disease such as
diabetes or atherosclerosis
• Fecal or urinary incontinence
• Presence of fracture
• Poor nutritional status or low albumin
Stages: Stage I, Stage II, Stage III, Stage IV

105. Stage I
• Presence of a reddened area that fails
to blanch with pressure, and changes
in temperature (warmth or coolness),
consistency (firm or boggy), sensation
(pain or itching), or color (red, blue, or
purple on darker skin; red on lighter
skin)

106. Stage II
• The skin forms a blister or sore.
Partial-thickness skin loss or
ulceration involving the epidermis,
dermis, or both

107. Stage III
• A crater appears in the skin, with
fill-thickness skin loss and damage
to or necrosis of subcutaneous
tissue that may extend to, but not
through, underlying muscle

108. Stage IV
• The pressure ulcer deepens. There
is full-thickness skin loss, with
destruction, tissue necrosis, or
damage to underlying muscle, bone,
and sometimes tendons and joints

109. HAIR

110. Anatomy and Physiology
• Adults have two types of hair:
Vellus hair, which is short, fine,
inconspicuous, and relatively
unpigmented; and Terminal hair,
which is coarser, thicker, more
conspicuous, and usually
pigmented. Scalp hair and
eyebrows are examples of terminal
hair.

111. Hair Loss
GENERALIZED OR DIFFUSE HAIR LOSS
• Telogen Effluvium and Anagen Effluvium
FOCAL HAIR LOSS
• Alopecia Areata
• Tinea Capitis ("Ringworm")
• Scarring Alopecia
• Hair Shaft Disorders

112. 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.

113. Telogen Effluvium
and Anagen
Effluvium
• In anagen effluvium, there is
diffuse hair loss from the roots.
The hair pull test shows few if
any hairs with telogen bulbs

114. 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

115. 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.

116. Scarring Alopeica
• 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.

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

118. NAILS

119. Anatomy and Physiology
Fingernails grow approximately 0.1 mm daily; toenails grow more slowly

120. Findings in or near the Nails
• Paronychia
• Clubbing of the fingers
• Habit Tic Deformity
• Melanonychia
• Onycholysis
• Terry Nails
• Transverse Linear Depressions (Beau Lines)
• Pitting

121. 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 .

122. 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 degrees or more, and the nail bed feels spongy or
floating. The mechanism is still unknown but involves
vasodilation with increased blood flow to the distal
portion of the digits and changes in connective
tissue, possible 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, inflammatory bowel diseases, and
malignancies.

123. 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 .

124. 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 if 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.

125. Onycholysis
• A painless separation of the whitened opaque nail
plate from the pinker translucent nail bed. 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.

126. Onychomycosis
• The most common cause of nail thickening and
subungual debris, most often from the
dermatophyte Trichophyton rubrum, but also from
other dermatophytes and some molds such as
Alternaria and Fusarium species. 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 this condition, so a
positive fungal culture, potassium hydroxide exam,
or pathologic evaluation of nail clippings is
recommended before treating with oral
antifungals.

127. 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.

128. Transverse Linear Depressions (Beau Lines)
• Transverse depressions of the nail plates, usually
bilateral, resulting from temporary disruption of
proximal nail growth from systemic illness. As with
Mees' lines, 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's disease is present.

129. 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's syndrome, sarcoidosis,
alopecia areata, and localized atopic or
chemical dermatitis.

130. Thank you, Have a Good Day!