ess familiar, but probably more important clinically, is the normal hair ss elsewhere on the body: the trunk, pubic areas, axillae, and limbs.

These changes will be discussed in later chapters. Coarse facial hairs appear on the chin and upper lip of many women by about the age of 55, but do not increase further thereafter.

Many of the observations described here pertain to lighter-skinned persons and do not necessarily apply to others. For example, Native American men have relatively little facial and body hair compared to lighter-skinned men, and should be evaluated according to their own norms.

Common or Concerning Symptoms

Start your inquiry about the skin with a few open-ended questions: "Have you noticed any changes in your skin?". . . your hair? . . . your nails?. . . "Have you had any rashes? . . . sores? . . . lumps? . . . itching?" "Have you noticed any moles that have changed in appearance?" "Where?" "When?"

It is usually best to defer further questions about the skin until the physical examination, when you can see what the patient is talking about.

Causes of generalized itching without obvious reason include dry skin, aging, pregnancy, uremia, jaundice, lymphomas and leukemia, drug reaction, and lice.

Important Topics for Health Promotion and Counseling

■ Risk factors for melanoma

■ Avoidance of excessive sun exposure linicians play an important role in counseling patients about protective leasures for skin care and the hazards of excessive sun exposure. Basal cell id squamous cell carcinomas are the most common cancers in the United tates and are found most frequently in sun-exposed areas, particularly ie head, neck, and hands. Malignant melanoma, although rare, is the most ipidly increasing U.S. malignancy, now occurring in 1 in 74 Americans. Jthough melanoma often arises in non-sun-exposed areas, it is associated with intermittent and intense sun exposure and blistering sunburns in childhood. Other risk factors include family history of melanoma, light skin, presence of atypical moles (dysplastic nevi) or >50 common moles, and immunosuppression.

Protective measures are three-fold: avoiding unnecessary sun exposure, using sunscreen, and inspecting the skin. Caution patients to minimize direct sun exposure, especially at midday when ultraviolet B rays (UV-B), the most common cause of skin cancer, are most intense. Sunscreens fall into two categories—thick pastelike ointments that block all solar rays, and light-absorbing sunscreens rated by "sun protective factor" (SPF). The SPF is a ratio of the number of minutes for treated versus untreated skin to redden with exposure to UV-B. An SPF of at least 15 is recommended and protects against 93% of UV-B. (There is no scale for UV-A, which causes photoaging, or UV-C, the most carcinogenic ray but blocked in the atmosphere by ozone.) Water-resistant sunscreens that remain on the skin for prolonged periods are preferable.

Detection of skin cancer rests on visual inspection, preferably of the total body surface. Current detection rates are higher for clinicians than patients, but the benefits of self-examination are not well studied. Recommendations about screening intervals are variable. The American Cancer Society recommends monthly self-examination, clinician screening at 3-year intervals for persons aged 20 to 39, and annual clinical examination for persons over age 40. Clinicians and patients should know the "ABCDEs" for melanoma: A for asymmetry, B for irregular borders, C for color variation or change (especially blue or black), D for diameter larger than 6 mm, and E for elevation. Look in sun-exposed areas for ulcerated nodules with translucent or pearly surfaces (seen in basal cell carcinoma) and roughened patches of skin with accompanying erythema (common in squamous cell carcinoma). Patients with suspicious lesions should be referred to a dermatologist for further evaluation and biopsy.

Preview: Recording the Physical Examination—The Skin c c c

Note that initially you may use sentences to describe your findings; later you will use phrases. The style below contains phrases appropriate for most write-ups. Unfamiliar terms are explained in the next section, "Techniques of Examination."

"Color good. Skin warm and moist. Nails without clubbing or cyanosis.

No suspicious nevi. No rash, petechiae, or ecchymoses."

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