Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.7 Examination of the Skin, Hair, and Nails
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4.7.1 Skin Examination 1. Inspection
Inspect the skin color. Check for jaundice, pallor, cyanosis, or plethora. Note the uniformity of the skin, hygiene, and any abnormal odors. Also, look for any:
(a) Skin lesion: Inspect and palpate the lesion to determine the following:
• Morphology (the type of the lesion)
– Primary skin lesions: result from the disease itself and are unmodified by external factors [30]
Macule: flat discoloration, <1 cm in diameter, e.g., freckles Patch: flat discoloration, >1 cm in diameter, e.g., port wine stains Papule: elevated, superficial, <1 cm in diameter, e.g., molluscum
contagiosum
Plaque: elevated, superficial, >1 cm in diameter, e.g., psoriasis
Nodule: elevated with a deeper component, >1 cm in diameter, e.g., erythema nodosum
– Temperature – Edema 2. Hair Examination
• Inspection – Color – Cleanliness – Quantity – Distribution
– Abnormalities (e.g., hair loss, excessive hair, seborrhea, or nits)
• Palpation – Texture 3. Nails Examination
• Inspection
– Shape and contour – Length
– Color and any abnormal pigmentation – Symmetry
– Cleanliness – Nail-base angle
– Proximal and lateral nail folds – Abnormalities
• Palpation
– Palpate the nail plate for the following: texture, firmness, thickness, and uniformity
– Palpate the proximal and lateral nail folds for tenderness
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Pustule: collection of pus, <1 cm in diameter, e.g., folliculitis Vesicle: collection of clear fluid, <1 cm in diameter, e.g., herpes simplex Bulla: collection of clear fluid, >1 cm in diameter, e.g., bullous
impetigo
Wheal: transient, elevated, flat-topped lesion, occurs due to dermal edema, e.g., urticaria
– Secondary skin lesions: evolve from primary lesions or caused by external factors, such as scratching or trauma
Scale: flakes of dead epidermal cells (e.g., seborrheic dermatitis)
Crust: a collection of cellular debris, dried serum, blood, or pus (e.g., impetigo) Scar: an abnormal formation of fibrous tissue after wound healing (e.g., scar
of acne)
Fissure: a linear slit in the skin (e.g., angular cheilitis)
Atrophy: a depression in the skin as a result of thinning of the epidermis, dermis, or subcutis (e.g., lichen sclerosis)
Lichenifcation: a thickening of the epidermis with accentuation of normal skin markings (e.g., chronic eczema)
Erosion: a complete or partial focal loss of epidermis, heals without scar (e.g., impetigo)
Excoriation: an erosion occurring due to an exogenous injury (e.g., atopic dermatitis)
Ulcer: a full-thickness focal loss of epidermis with loss of at least part of der-mis, or even subcutis, healed with a scar (e.g., pressure ulcers)
• Configuration (the shape or outline of a single skin lesion or the arrange-ment of lesions with each other), for example:
– Dermatomal (e.g., herpes zoster) – Clustered (e.g., herpes simplex) – Linear (e.g., linear epidermal nevi) – Target or iris (e.g., erythema multiforme) – Reticular (e.g., erythema infectiosum) – Annular (e.g., tinea corporis)
– Nummular (e.g., nummular eczema)
• Location and distribution
– Localized (e.g., impetigo) or generalized (e.g., urticaria)
– Region of the body: in the exposed area (e.g., photodermatitis, sun-burn); on the face, shoulder, and back (e.g., acne); and on the extensors aspect of the extremities (e.g., psoriasis)
– Single or multiple lesions
– Symmetrical or asymmetrical distribution
• Color of the lesion
– Red (e.g., port-wine stains) – Yellow (e.g., xanthomas) – Blue (e.g., deep dermal nevi) – Black (e.g., melanoma)
• Borders: Regular or irregular, well-demarcated or blurred
• Pus or exudate: Note color, odor, amount, and consistency.
4 Examination of the Older Child
(b) Abnormal pigmentations and birthmarks (see Chap. 3).
(c) Bleeding into the skin or mucosa, which does not blanch on pressure:
• Petechiae: non-blanching, red-purple, fine spots, <1 mm in diameter
• Purpura: non-blanching, red-purple spots, 2–10 mm in diameter
– Palpable (e.g., meningococcal septicemia and Henoch–Schönlein purpura) – Non-palpable (e.g., thrombocytopenia)
• Ecchymosis: a non-blanching, large bruise
• Hematoma: a bleeding into the skin large enough to produce a tender elevation
2. Palpation
After the inspection, palpate the skin to determine the following:
(a) Texture (the character of the skin surface): Normally, the skin has an even, soft, and smooth texture.
(b) Moisture: Wetness and oiliness of the skin
(c) Turgor (normal fullness state; it reflects skin tension or elasticity): Assess the skin turgor by pinching a fold of the skin on the sternal area (or on the abdomen near the umbilicus), and gently twist it with your fingertips and release. Normally, it lifts easily and returns back to its resting position imme-diately. Skin turgor is reduced or lost in dehydration and marasmus [5].
(d) Temperature: Palpate for the temperature with the dorsum of your hand, comparing side by side. The temperature may reflect the blood flow through the dermis. Normal skin is warm.
(e) Edema: Pitting or non-pitting
4.7.2 Hair Examination
• Inspection
• Inspect the scalp, eyebrows, eyelashes, axillary, and body hair, looking for the color, cleanliness, distribution, and quantity, and note any abnormalities, such as:
– Hair loss: localized or diffuse
– Excessive hair: hypertrichosis or hirsutism
– Others: seborrhea, lice, nits, or dandruff, and note any associated skin conditions
• Palpation
– Palpate scalp hair for texture, noting whether it has fine, medium, or coarse texture (see Key Points 4.1).
• If there is a skin lesion, in addition to palpation for its texture, it is important to ascertain whether it is blanchable (i.e., disappears with pressure, occurs due to vasodilatation) or non-blanchable (i.e., occurs due to extravasation of red blood cells into the tissue, e.g., purpura).
Clinical Tips 4.5
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4.7.3 Nails Examination
• Inspection
Inspect the nails, looking for:
– Shape and contour.
– Color: Normal nail-bed color should be a variation of pink.
– Length, symmetry, and configuration.
– Cleanliness.
– Nail-base angle: Normally this measures 160°. In case of clubbing of the fin-ger, it may exceed 180° (see Fig. 4.8 and Box 4.3).
A B
C
>180°
A 160°B C
a b
c d
Schamorth’s window present
Fig. 4.8 Finger clubbing. (a) Normal finger. (b) Clubbed finger. (c) Schamroth’s window test for a normal finger. (d) Schamroth’s window test for a clubbed finger
• Scalp hair is straight or curly, coarse or fine, smooth, shiny, and resilient, while dry and brittle hair is abnormal.
• Dry, coarse hair may occur in hypothyroidism, while fine, thin hair may be a sign of homocystinuria.
• When there is a localized hair loss, it is very important to inspect the scalp for accompanied scarring or inflammation.
• The hair of infants tends to fall out by the third month of life and is replaced by hair that may differ markedly in color, distribution, and texture.
Key Points 4.1
4 Examination of the Older Child
– The proximal and lateral nail folds: Inspect the proximal and lateral nail folds, noting the following: redness, discharge, swelling, and any lesions, such as warts.
– Abnormalities, e.g., absent nail, platonychia (flat nails with loss of normal convexity), koilonychia (spoon-shaped nails), leukonychia (due to chronic states of hypoalbuminemia, e.g., nephrotic syndrome, protein-losing enter-opathy), splinter hemorrhage (may suggest trauma, vasculitis, nail psoriasis, or endocarditis), and pitted nails (suggests psoriasis, eczema, or alopecia areata).
• Palpation
– Palpate the nail plate for the following: texture, firmness, thickness, and uni-formity, noting its adherence to the nail bed by gently squeezing the nail plate with your thumb and index finger.
– Palpate the proximal and lateral nail folds for tenderness.
• Changes in nail color may indicate pathology (e.g., green–black discoloration is suggestive of pseudomonas infection; periungual brown–black discolor-ation may suggest melanoma, while a completely blue nail suggests diseases that may cause cyanosis, such as cyanotic congenital heart disease).
• The normal nail plate should be smooth and hard, with a uniform thickness.
• The complete absence of a nail may suggest congenital syndromes (e.g., nail–patella syndrome).
Key Points 4.2
• A clubbed finger is characterized by swelling of the soft tissue of the terminal phalanges and obliteration of the normal angle between the nail plate and the proximal nail fold.
• It starts as softening and increased boggy fluctuation of the nail bed, followed by loss of the normal angle between the nail plate and the proximal nail fold, then the increment in thickness and curvature of the nail plate, and finally the fingers may have a drumstic appearance. Finger clubbing occurs due to many causes listed in Table 4.7.
• A simple way to measure the nail-base angle is the Schamroth’s technique, having the child place together the dorsal surface of the nail of the index fin-gers or thumbs of both hands; disappearance of the diamond-shaped window indicates finger clubbing (see Fig. 4.8c, d).
Box 4.3: Finger Clubbing
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Table 4.7 Causes of clubbing of fingers and toes [3, 4]
Familial causes (5–10%) Acquired causes
Respiratory diseases Cardiovascular
diseases Gastrointestinal
diseases Miscellaneous
• Chronic suppurative lung disease
– Bronchiectasis – Lung abscess – Cystic fibrosis – Empyema
• Progressive pulmonary tuberculosis
• Pulmonary fibrosis
• Lung cancer
• Cyanotic congenital heart disease
• Infective endocarditis
• Arteriovenous shunts and aneurysms
• Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
• Celiac disease
• Tropical sprue
• Multiple polyposis
• Liver cirrhosis
• Chronic active hepatitis
• Thyrotoxicosis (thyroid acropathy)
• Hodgkin lymphoma
• Syringomyelia