EXAMINATION OF THE SKIN AND MUCOSAE

GENERALITIES
TEGUMENTUM = “WHAT COVERS”
= is the outer covering of living tissue, with
complexes functions:
• sensation
• adaptive immune
system
• heat regulation
• storage and synthesis
• excretion
= “semiological map”
 Thickness = 0,2 - 0,5mm (at the level of the
eyelids)
→ 4 - 8mm (at the level of the
heels)
 Surface = 1,5 - 2 m2, with:
– folds:
• coarsely (inframammary,
intergluteal, inguinal)
• more discreet (the flexion face of
joints)
• fine (fingerprints)
• palmary and plantar folds – mark
the limits of
papillary crests
– infundibular depressions (popularly -
“pores”) –
correspond to the openings of
sudoriferous glands channels or to
sebaceous follicles
3 layers:
 The epidermis:
 Superficial, no blood vessels
 Layers of cells → melanocytes produce
melanin
 The dermis:
 Connective tissue (collagenic, elastic
and reticular fibers, fibroblasts, mast
cells)
 Nerves, blood vessels, lymphatic
vessels, muscles,
  Sebaceous glands, the channels of
sebaceous glands
 Role: dermis nutrition, skin analyzer
 The hypodermis:
 Adipose lobules separated by fibrous
tracts,
 Nerves, receptors, blood and
lymphatic vessels,
 Sudoriferous glands, the deeper
portion of bulb of hair
 Role: tegument support

SKIN GLANDS
• Sudoriferous glands:
= merocrine glands – produce sweat: water,
chloride, sodium, potassium, lactic acid, urea, fat
acids, mucopolysaccharides, glycoproteins,
hydrosoluble vitamins

• Sebaceous glands
= holocrine glands
 Open at the level of hair follicle
 produce sebum (oxycholesterin,
cholesterin, unsaturated fat acids,
soaps)
 androgens increase secretion
 estrogens decrease secretion

HAIRS AND NAILS

= Annexa of skin
- visible from the outside
• NAILS
= corneous thin sheets on the surface of the
distal phalanges
– source: nail matrix
– the lunula is a part of the
nail matrix
• HAIR
– the enlarged basal part of a hair
within the skin = ROOT
– the part of a hair projecting beyond
the skin = SHAFT
CUTANEOUS SYMPTOMS:
PRURITUS
pruritus (latin) = itch
= cutaneous symptom produced by subliminal
irritation of nervous terminations by the mediators
(histamine, acetylcholine) which determines an
“attenuated pain”
In producing pruritus, interfere:
– Genetic factors
– Psychological factors – emotional
pruritus

! Pruritus ≠ Prurigo
(Prurigo =
papulous, pruriginous lesions, determining local
pruritus)

SYSTEMIC PRURITUS
Appears in:
 Jaundice syndromes (billiary salts retention;
appears in pre-jaundice phase
 → Neoplasia; increases in night or in heat conditions)
 Paraneoplasic pruritus
(lymphoma, lymphosarcoma, carcinoma)
 Diabetes mellitus (! Early signs)
 Uremia
(calcium deposits in the tegument – irritation of
nervous
terminations)
 Gout (teenagers)
 Parasitic infections
 Hyperthyroid, hypothyroid, Cushing
syndrome, acromegaly, menopauses)
 Senile (elasticity changes; + capillary fragility)
 Drugs allergy
(usually along with urticarian eruption)
 Scabies - intensive (specially during the
night), + grattage lesions
 Other causes: psychological, gastric
hypoacidity,
feriprive anemia/pernicious, avitaminose

LOCAL PRURITUS
Has preferential localization in several affections:
• Vulvar
 Diabetes mellitus (associated to
candidose)
 menopause (“widow pruritus”)
 iron deficiency
 lack of vitamins
 uterin/anexial neoplasia
 psychogenic
• Scrotal/Penian
 Diabetes mellitus
 Prostate carcinoma
 urinary tract infections (frequent
urethritis)
 psychogenic
Has preferential localization in several affections:
• Abdomen, hips, extremities
 hepatitis, cirrhosis
• Nasal:
 asthma
 allergic rhinitis
  lambliase (children)
 uremia
 morphinomania
 hyperfoliculinemia
• Auricular
 diabetes mellitus
Has preferential localization in several affections:

• Scalp:
 alcohol abuse
 pre-/postmenstrual
• Anal:
 parasitic infections
 hemorrhoids
 intestinal diseases
 nearby infections

SKIN COLOUR CHANGES

Skin color: results from 4 natural pigments ± other
pathologic ones
 melanin (brown)
 oxyhemoglobin (bright red)–mainly within
arteries/capillaries
 deoxyhemoglobin (more bluish)– present
in venous blood
 carotene (yellow)
Special conditions/pathologic ones:
 hemosiderin
 bilirubin
 metals
Depends on:
 skin thickness
 light (artifical light distorts colours)

!!! The examination of skin color must be done in sunlight

PALLOR
= lighter color of the skin and visible mucosae,
causes by a reduced amount of oxyhemoglobin
Main causes:
  THICKENING OF THE SKIN (myxedema,
edema)
 LACK OF DEVELOPPMENT OF DERMAL
CAPPILARIES
(hypogonadism in men - “Egyptian picture”
aspect)
 VASOCONSTRICTION (strong
emotions, acute circulatory failure)
 ANAEMIA
(in association with tiredness and fatigue)

!!! Pallor is best appreciated where the epidermis is

thinnest: the fingernails, the lips, tongue, palpebral
conjunctiva, palmar skin

Different colors associated with pallor could be

correlated with the causes of the anemia
+ flavinic shade – hemolytic anemia
+ yellowish shade - pernicious anemia
+ verdinic shade – young girls chlorosis (“green
sickness”) = hypchromic anemia
+ lighter yellow shade – gastric neoplasia
+ “cafe au lait” shade – bacterial endocarditis
+ “white like paper” shade – acute hemorrhagic
anemia

Pallor is associated with “clue” signs that could

ascertain the origins of anemia:
 Koilonychia= “spoon nails” - anemia
due to iron deficiency (the nails are
flattened and have concavities)
 Hunter glossitis – pernicious anemia
 Inappetence &loss of weight -
neoplasia
 Cutaneous hemorrhagic
manifestations (petechia, ecchymoses,
hematomas) –acute leukemia, loss of blood

CYANOSIS
= bluish color of the skin and mucosal surfaces due
to the presence in the circulating blood of an
increased quantity of reduced Hb (more than 5g/dl)
or a different type of Hb
- Disappears with digital pressure
CYANOSIS ≠ FALSE CYANOSIS
= discoloration of the skin induced by
deposition of gold salts (chrysiasis), silver salts
(argyria), arsenic or other compounds
N.B.
False cyanosis doesn’t disappear with digital
pressure

CYANOSIS DUE TO ABNORMAL Hb/rare Hb

Appears in patients without a cardiac and pulmonary
disease. They are rare conditions.
METHEMOGLOBINEMIA:
 Oxidative substances- intoxication with
nitrites, fenacetin, clorat de potasiu, derivati
anilinici
 Congenital/genetic - hemoglobin M
 Idiopatic Methemoglobinemia
nefamiliala
SULPHURETTED HEMOGLOBIN:
 Hijmans van der Bergh toxic cyanosis
- due to presence of sulphuretted hydrogen in
intestine
 Administration of drugs like fenacetin or
sulphamides
CYANOSIS DUE TO AN ↑↑↑ QUANTITY OF REDUCED Hb
 The bluish color appears when the
quantity of reduced Hb in the arterial blood is
more than 5 g/dl (Normally: <3g/dl)
  Cyanosis = indicates a bad oxygenation of
arterial blood (hypoxemia)!!! The degree of
cyanosis depends on quantity of Hb → pay
attention to the anemic patients because of the
small quantity of Hb, cyanosis appears when
hypoxemia is extremely severe

PULMONARY CENTRAL CYANOSIS

This is the sign of respiratory insufficiency
 Bad oxygenation (low arterial saturation)
of arterial blood in the lungs
 Caused by:
 Low alveolar oxygen pressure
 Disturbances in gas exchange
 Ventilation/perfusion mismatch
• Characteristics:
 Generalized (even the tongue is
cyanotic)
 Warm (hypoxia induces
vasodilatation)
 Negative Lewis test (rubbing the ear
lobe with the fingertips does not make
cyanosis to disappear)
 Oxygen supplementation of the
inspired air may correct cyanosis

CENTRAL CYANOSIS WITH RIGHT-TO-LEFT SHUNT

 It is also called “the blue syndrome”
 Causes:- Congenital heart disease (CHD)
with right-to-left shunt (Fallot tetralogy)
  Associated with retarded growth and
physical development, dyspnea on exertion,
clubbing of the fingers and toes
 Position – squatting.
 Anoxic episodes (spells).
 It is not influenced by oxygen
administration

CENTRAL GENERALIZED PERIPHERAL CYANOSIS (STASIS)

 The sign of right heart failure
 Accompanied by gravitational edema
 Characters of peripheral cyanosis:
 Respects blood peripheral circuits
 DOESN’T affect the tongue
 COLD (because of the low velocity of
blood: stasis + vasoconstriction)
 Positive Lewis test –rubbing the ear
lobe with the fingertips makes cyanosis to
disappear becoming red)
 In CARDIOGENIC SHOCK patient presents
“pale cyanosis” due to vasoconstriction,
marmoreal teguments, which remain cold and
cyanotic when adopting a declive position

LOCALIZED CYANOSIS ERYTHROCYANOSIS

 Appears in POLYCYTHEMIA VERA
 It is also called “red cyanosis”
 Described by Osler in XIX century, as “red
like roses in summer and blue like indigo in
winter“
 Color changes are more obvious in the
areas exposed to temperature variations (face
and hands)
 It is associated with pruritus “sine
materia” which commonly starts after a bath
LOCALIZED CYANOSIS
 It is due to an increased tissue oxygen
extraction of arterial blood produced by 2
mechanisms:
• Decreased arterial supply
• Slowing down of venous-capillary
circulation
 Thrombophlebitis
ACUTE Phlegmatia )
(coerulea
Arterial embolus
LOCALIZED
CYANOSIS

Peripheral chronic
ischemia syndrome
CHRONIC Acrocyanosis

 ACROCYANOSIS
= refers to a persistent blue or cyanotic
discoloration of the digits, most commonly
occurring in the hands although also occurring in
the face and feet as well
– Appears in: cold exposure, phlebitis,
chronic venous failure, Raynaud syndrome
– Causes: functional anomalies in
capillary circulation
 LIVEDO RETICULARIS
- a “lace-like” purplish discoloration
- a particular aspect: RACEMOS LIVEDO –
permanent red-violet arborizations?? – in SLE, PAN
- abdomen: acute pancreatitis
 FACE CYANOSIS
– venous thrombosis, superior cave vein
syndrome