PHYSICAL ASSESSMENT OF
THE INTEGUMENTARY SYSTEM
LUCY MENG’ANYI
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Functions of skin
◦ Protection: chemical, physical, biological
◦ Regulates body temperature
◦ Insulation + fat storage
◦ Prevents water loss from deeper tissues
◦ Houses sensory receptors sensitive to pain,
temperature, touch, pressure
◦ Makes biochemicals such as vitamin D
◦ Excretes some waste
◦ Blood reservoir – has an extensive vascular
supply (5% of body’s blood supply)
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Layers of the skin
1. Epidermis
Outer layer made of keratinized stratified squamous
epithelium.
Functions of the skin depend on it’s properties
Specialized in areas to form the various skin
appendages, which include hair, nails, and glandular
structures.
Contains openings for 2 types of glands sweat glands,
which pro-duce watery secretions, and sebaceous glands,
which produce an oily secretion called sebum.
Has 4 principal types of cells:
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Keratinocytes –
Major cell, comprising 95% of the cells of this layer.
Protect the skin and underlying tissues from heat, microbes, and
chemicals.
Produce keratin, a protein that forms the surface of the skin & is
the structural protein of hair & nails.
Play a role in the immunobiology of the skin by communicating &
regulating cells of the immune response & secreting cytokines &
inflammatory mediators
Melanocytes – produce melanin: contributes to skin color and
absorbs damaging UV light
Langerhans cells -participate in immune responses mounted against
microbes that invade the skin
Merkel cells - exact function unclear, but they are believed to be
neuroendocrine cells (i.e., they release hormones into the blood in
response to neural stimuli) & function as specific, slowly adapting
sensory touch receptors in cutaneous sensation.
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• Epidermal cells undergo keratinization as they
mature & are pushed toward the surface
• The outermost layer, the stratum corneum, is
made of dead epidermal cells which are
eventually shed
• Totally new epidermis in 25-45 days!
• The rate of cell division increases where skin is
rubbed off regularly forming calluses & corns
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Dermis
Composed of strong, flexible connective
tissue
Binds the epidermis to underlying tissues
Supports the epidermis & serves as its
primary source of nutrition. Made up of 2
layers papillary dermis & reticular dermis
Dermal blood vessels supply nutrients to all
skin cells & help regulate body temperature
(vasoconstriction, vasodilation)
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Dermis cont..
Contains hair follicles, sweat glands, &
sebaceous (oil) glands
Nerve fibers are scattered throughout the
dermis- Pacinian corpuscles, Meissner
corpuscles & Ruffini corpuscles
Immune cells in the dermis
◦ Dermal dendrocytes- found in the reticularis layer are
spindle shaped that have both phagocytic & dendritic
properties. Also involved in wound healing, blood
clotting & inflammation
◦ Macrophages, T cells, Fibroblasts, Mast cells
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Subcutaneous Tissue
• 3rd layer of the skin & consists primarily of
fat cells & connective tissues that lend
support to the vascular & neural structures
supplying the outer layers of the skin.
• Has varying levels of thickness depending on
its location.
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Accessory Organs of
the Skin→
Hair
• Originates from hair follicles in the dermis
• New cells push older cells closer to the surface where they
become keratinized & die
• An arrector pili muscle attaches to each hair follicle & this
pulls the hair erect when stimulated = goose bumps
• Most hair follicles are ass with sebaceous glands i.e. combine
to form the pilosebaceous unit
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Accessory Organs of the Skin→
Sebaceous glands
• Located over the entire skin surface except for the palms,
soles & sides of the feet
• Part of the pilosebaceous unit
• Secrete sebum = mixture of free fatty acids, triglycerides,
diglycerides, monoglycerides, sterol esters, wax esters &
squalene
• Sebum keeps skin & hair soft, pliable, & waterproof
• Acts as a bacteriocide & conserves body heat by
preventing loss of water during cold weather
- Function begins at puberty. Become inflamed in acne
• Greatest numbers on face, chest, back with modified glands
on eyelids, lips, nipples, glans penis, prepuce 15
Accessory Organs of the Skin
Sweat glands = sudoriferous glands
• Eccrine sweat glands - respond to elevated body temp. All over
but more in palms of hands, soles of feet, forehead. Not found
in the lips & part of the external genitalia
• Apocrine sweat glands – Fewer in number. Located in axillae,
scalp, face, abdomen, genital area. The major difference
between them & eccrine glands is that they secrete an oily
substance. In animals,
• Apocrine secretions give rise to distinctive odors that enable
• animals to recognize the presence of others. In humans, apo-
rine secretions are sterile until mixed with the bacteria on the
• skin surface. They then produce what is commonly known as
• “body odor
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Accessory Organs of
the Skin→
• Nails
• Hardened keratinized plates, called fingernails
• & toenails, which protect the fingers & toes &
enhance dexterity.
• Grow out from a curved transverse groove, the nail
groove. The floor of this groove, the nail matrix, is
the germinal region of the nail plate.
• Are the end product of dead matrix cells that are
pushed outward from the nail matrix
• Unlike hair they grow continuously rather than
cyclically, unless permanently damaged or diseased
• Changes in the nails help dx skin or systemic
diseases.
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Effects of aging:
1) Skin thins
2) Lubricating substances become deficient, so skin gets dry
& itchy
3) Elastic fibers clump, skin loses elasticity
4) Subcutaneous fat layer diminishes, often cold
• 3 & 4 cause wrinkles
5) Less melanocytes & Langerhan’s cells enhance the risk of
skin cancer
6) Hair thins due to fewer active hair follicles
7) There is decrease in skin capillaries & Flattening of the
dermal rete ridges= less surface area for exchange of
fluids btwn the dermis, epidermis & skin surface.
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Manifestations of Skin Disorders -
1. Lesions & Rashes
• Rashes- temporary eruptions of the skin. Can be
associated with childhood illnesses, heat, diaper irritation
or drug-induced reactions
• Lesion- refers to a traumatic or pathologic loss of normal
tissue continuity, structure, or function
• The components of a rash are often referred to as lesions.
• Primary lesions - areas of tissue that are altered because of a
pathological condition - arising from previously normal skin
• Secondary lesions result from changes in the primary lesions.
• Vascular lesions - blood vessel lesions that show through the
skin.
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Manifestations of Skin Disorders -
2. Pruritus
• The sensation of itch
• Symptoms range from mild to severe
• Can also provide a valuable clue to internal
disorders such as chronic renal disease,
diabetes or billiary disease
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Manifestations of Skin Disorders -
3. Dry Skin (Xerosis)
• May be a natural occurrence (aging) or may be
symptomatic of an underlying systemic disease or skin
disorder (contact dermatitis or diabetes mellitus)
• People with diabetes mellitus often experience xerosis
especially on the extremities
• Often due to extreme winter weather when there is little
humidity in the air.
• Most cases of dry skin are caused by dehydration of the
stratum corneum.
• Some drugs e.g. Epidermal growth factor receptor
inhibitors (EFRRIs) cause adverse effects like dry skin
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PRIMARY DISORDERS OF THE SKIN
Pigmentary Skin Disorders Allergic and Hypersensitivity
Dermatoses
• Vitiligo
• Contact and Allergic Dermatitis
• Albinism
• Atopic Dermatitis and Nummular
• Melasma Eczema
Infectious Processes • Urticaria
• Superficial Fungal • Drug-Induced Skin Eruptions
Infections
Papulosquamous Dermatoses
• Bacterial Infections
• Psoriasis
• Viral Infections
• Pityriasis Rosea
• Acne and Rosacea
• Lichen Planus
• Acne Vulgaris
• Lichen Simplex Chronicus
• Acne Conglobata
Arthropod Infestations
• Rosacea
• Scabies
• Pediculosis
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Ultraviolet Radiation, Thermal, and
Pressure Injury
Skin Damage Caused by • Pressure Ulcers
Ultraviolet Radiation
• Drug-Induced
Photosensitivity
• Sunburn
Thermal Injury
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Nevi and Skin Cancers
• Nevi
• Skin Cancer
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Pigmentary Skin Disorders
Vitiligo
•Appears at any age
(however half of the cases
begin before age 20)
•Affects people of all races
regardless of gender
Vitiligo
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Melasma
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Tinea Faciale (ringworm of the face)- caused by T.
mentagrophytes or T. rubrum.
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Tinea Pedis (Athlete’s foot)
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Tinea Unguium- Tinea of the Nail
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Tinea Unguium- Tinea of the Nail
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Pityriasis versicolor- Pityrosporum orbiculare
(Malassezia furfur)
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Tinea Cruris
• Affects groin, ‘jock
itch’
• Red/scaly rash on inner
thighs/inguinal creases;
occasionally the
buttock, not scrotum or
labia
• Common in obese
patients & athletes in
tight fitting clothes
• Common in hot/humid
weather
• Rx: topical antifungal
creams
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Impetigo, caused by staph and strep,
usually in small kids
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Verrucae plana, or flat warts
• Common on the face or dorsal surfaces of the
hands.
• Are slightly elevated, flat, smooth, tan papules that
are slightly larger than verrucae vulgaris
• Verrucae plantaris & verrucae palmaris
(plantar & palmar warts)
• Occur on the soles of the feet & palms of the
hands,
• Appear as rough, scaly lesions that may reach 1 to 2
cm in diameter, coalesce,& be confused with
ordinary calluses
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Condylomata acuminata /
venereal warts
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Stasis Dermatitis
Stasis Dermatitis
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Burn Size: Body Surface
Area
▪ Rule of 9 for adults
▪ For children: Lund-Browder
burn chart
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