Jaundice makes the skin diffusely yellow. Note this patient's skin color, contrasted with the examiner's hand. The color of jaundice is seen most easily and reliably in the sclera, as shown here. It may also be visible in mucous membranes. Causes include liver disease and hemolysis of red blood cells.
The yellowish palm of carotenemia, shown on the left, is compared with a normally pink palm—a useful technique for a sometimes subtle finding. Unlike jaundice, carotenemia does not affect the sclera, which remains white. The cause is a diet high in carrots and other yellow vegetables or fruits. Carotenemia is not harmful, but indicates the need for assessing dietary intake.
Cyanosis is the somewhat bluish color that is visible in these toenails and toes. Compare this color with the normally pink fingernails and fingers of the same patient. Impaired venous return in the leg caused this example of peripheral cyanosis. Cyanosis, especially when slight, may be hard to distinguish from normal skin color.
A widespread increase in melanin may be caused by Addison's disease (hypofunction of the adrenal cortex) or some pituitary tumors. More common are local areas of increased or decreased pigment:
The common cafe-au-lait spot is a slightly but uniformly pigmented macule or patch with a somewhat irregular border. Most of these spots are 0.5 cm to 1.5 cm in diameter and are of no consequence. Six or more such spots, each with a diameter of >1.5 cm, however, suggest neurofibromatosis (p._). (The small, darker macules are unrelated.)
More common than vitiligo is this superficial fungus infection of the skin. It causes hypopigmented, slightly scaly macules on the trunk, neck, and upper arms. They are easier to see in darker skin and may become more obvious after tanning. In lighter skin, the macules may look reddish or tan instead of pale. The macules may be much more numerous than in this example.
In vitiligo, depigmented macules appear on the face, hands, feet, and other regions and may coalesce into extensive areas that lack melanin. The brown pigment on this woman's legs is her normal skin color; the pale areas are due to vitiligo. The condition may be hereditary. These changes may be distressing to the patient.
TABLE 4-3 ■ Vascular and Purpuric Lesions of the Skin
Effect of Pressure
From very small to 2 cm
Central body, sometimes raised, surrounded by erythema and radiating legs
Often demonstrable in the body of the spider, when pressure with a glass slide is applied
Pressure on the body causes blanching of the spider.
Face, neck, arms, and upper trunk; almost never below the waist
Liver disease, pregnancy, vitamin B deficiency; also occurs normally in some people
Variable, from very small to several inches
Variable. May resemble a spider or be linear, irregular, cascading
Pressure over the center does not cause blanching, but diffuse pressure blanches the veins.
Most often on the legs, near veins; also on the anterior chest
Often accompanies increased pressure in the superficial veins, as in varicose veins
Bright or ruby red; may become brownish with age
Round, flat or sometimes raised, may be surrounded by a pale halo
May show partial blanching, especially if pressure is applied with the edge of a pinpoint
Trunk; also extremities
None; increase in size and numbers with aging
Deep red or reddish purple, fading away over time
Petechia, 1-3 mm; purpura, larger
Rounded, sometimes irregular; flat
Blood outside the vessels; may suggest a bleeding disorder or, if petechiae, emboli to skin
Purple or purplish blue, fading to green, yellow, and brown with time
Variable, larger than petechiae
Rounded, oval, or irregular; may have a central subcutaneous flat nodule (a hematoma)
Blood outside the vessels; often secondary to bruising or trauma; also seen in bleeding disorders
(Sources of photos: Spider Angioma—Marks R: Skin Disease in Old Age. Philadelphia, JB Lippincott, 1987; Petechia/Purpura—Kelley WN: Textbook of Internal Medicine. Philadelphia, JB Lippincott, 1989)
Actinic keratoses are superficial, flattened papules covered by a dry scale. Often multiple, they may be round or irregular, and are pink, tan, or grayish. They appear on sun-exposed skin of older, fair-skinned persons. Though themselves benign, these lesions may give rise to squamous cell carcinoma (suggested by rapid growth, induration, redness at the base, and ulceration). Keratoses on face and hand, typical locations, are shown.
Seborrheic keratoses are common, benign, yellowish to brown, raised lesions that feel slightly greasy and velvety or warty. Typically multiple and symmetrically distributed on the trunk of older people, they may also appear on the face and elsewhere. In black people, often younger women, they may appear as small, deeply pigmented papules on the cheeks and temples (dermatosis papulosa nigra).
Basal Cell Carcinoma
A basal cell carcinoma, though malignant, grows slowly and seldom metastasizes. It is most common in fair-skinned adults over age 40, and usually appears on the face. An initial translucent nodule spreads, leaving a depressed center and a firm, elevated border. Telangiectatic vessels are often visible.
Squamous Cell Carcinoma
Squamous cell carcinoma usually appears on sun-exposed skin of fair-skinned adults over 60. It may develop in an actinic keratosis. It usually grows more quickly than a basal cell carcinoma, is firmer, and looks redder. The face and the back of the hand are often affected, as shown here.
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