Assessment of Skin, Hair, and Nails

Assessment of the skin, hair, and nails should be completed as part of a comprehensive assessment or as a focused assessment if your patient is experiencing issues that affect the integumentary system. The methods of skin, hair, and nails assessment include inspection and palpation.

Alright, start with a general inspection of the skin, which should be intact and without discoloration or lesions. Remember to check areas that are not commonly visible, such as the axillae, perineum, and between the toes.

Begin by noting the thickness of the skin, which will vary depending on the body area. For example, calluses can appear on hands and feet due to frequent use, whereas the skin of the eyelids will be thin and delicate.

Also note your patient's skin color, which will range from shades of black, brown, and tan, to shades of pink and white. These variations in pigmentation are often due to factors like genetics and sun exposure. Remember to consider these natural variations in skin color and tone when assessing your patient's skin. For example, in patients with lighter skin, rashes may appear pinkish-red, but in patients with darker skin, rashes may appear hyperpigmented or purplish in color. Bruising can appear purple, blue, or green in lighter skin but deep blue or black in darker skin.

Likewise, cyanosis in lighter skin appears blue or purple, while cyanosis in darker skin can appear gray or green, and is more easily seen in the mucous membranes, lips, conjunctiva, and nail beds. Likewise, the yellow discoloration in jaundice can be obvious in those with lighter skin but can be subtle in those with darker skin, so looking at the sclera and palms of the hands may more easily reveal the discoloration.

Some of the lesions you may see during inspection include macules, papules, vesicles, bullae, pustules, and plaques. A macule is a flat lesion, usually less than 1 centimeter in diameter that's a different pigmentation from the rest of the skin. Examples include freckles and petechiae, which are tiny spots of bleeding under the skin.

In contrast, a papule is an elevated, solid, demarcated lesion that's less than 1 centimeter in diameter. Examples of papules are warts and some moles.

Then there are vesicles, which are elevated lesions, usually less than 1 centimeter in size, filled with serous fluid. These are typically seen with chickenpox or shingles.

On the other hand, a bulla is a vesicle that's greater than 1 centimeter; a common example is a blister. Next, pustules are elevated lesions, less than 1 centimeter, and filled with pus. Pustules commonly occur with impetigo or acne. Lastly, plaques are elevated, firm and coarse or scaly lesions that are larger than 1 centimeter, as seen in conditions like psoriasis or seborrheic dermatitis.

Next, inspect your patient's hair for distribution and quantity. Asymmetrical hair loss is an unexpected finding, and in women, it can indicate a pathological condition such as adrenal androgenic female-pattern alopecia, which is characterized by hair thinning and loss that begins at the middle of the scalp. Hirsutism is also associated with a high androgen level in women, which can cause hair to develop in a male pattern on the face, body, and pubic area. Lack of hair on the lower extremities is an abnormal finding which can be associated with poor perfusion.

As you inspect your patient's nails, assess their color, texture, and shape. Nails should appear smooth, translucent, and slightly convex. Nail color can vary between patients; and the presence of streaks of color called pigment bands, is a normal finding in those with dark skin. Yellow nails can be a sign of fungal infection or the result of nicotine staining in patients who smoke; and splinter hemorrhages may occur in patients with endocarditis or due to trauma.

For texture, longitudinal ridges are an expected variation commonly associated with aging. Transverse ridges, on the other hand, are unexpected, and can result from repeated trauma to the nail. Transverse depressions, called Beau lines, are an indication that the nail growth has been temporarily interrupted by a serious illness.

Other unexpected findings include broken nails and ragged cuticles, which can indicate nail-biting; nails with small pits or peeling across the nail plate is associated with psoriasis; and a crumbling nail plate is associated with a fungal infection. When inspecting the nails for shape, unexpected findings are clubbing, that is often related to hypoxia from chronic respiratory and cardiovascular disease; and spooning, or a concave shape that can be seen in patients with severe iron deficiency anemia. Finally, inspect the nail folds, which should be without redness or edema; if these are present you should assess for an ingrown nail or infection.

Okay, moving on to palpation. While palpating the skin, you should assess moisture, texture and temperature. Skin should be relatively dry and smooth, and contain minimal oil. You can assess your patient's skin turgor, which can help evaluate their hydration status, by gently pinching their skin on the forearm or under the clavicle and releasing it. Normally, the skin should return to normal almost immediately. Skin that remains tented is associated with dehydration. However, in older patients, skin may remain tented due to the loss of skin elasticity.

You may note areas of superficial hyperkeratosis, where the skin's outer layer thickens due to overproduction of keratin, often in response to friction. This causes areas of localized scaling, roughness, calluses, or corns. The temperature can vary from cool to warm and should be symmetrical. If you notice unilateral temperature changes, such as one leg that's cool and one foot that's very warm, this can be an indication of deep vein thrombosis or cellulitis.

Next, palpate the hair and scalp for texture, dryness, tenderness, and lesions. There should be uniform texture, minimal dryness or flaking, and there should be no tenderness or lesions. After that, palpate the nail beds, which should be smooth, firm, and nontender. A nail that feels soft is associated with clubbing, and a nail that's overly thick may occur with a fungal infection.

Alright, as a quick recap…Assessment of the skin, hair, and nails should be completed as part of a comprehensive assessment or as a focused assessment if your patient is experiencing issues with their skin, hair, or nails. The methods of skin, hair, and nails assessment include inspection and palpation.