What is involved in a normal skin assessment?

Normal Skin Assessment

A comprehensive skin assessment should include inspection of the skin, assessment of skin integrity, neurological assessment, and vascular assessment, examining the entire body surface systematically for abnormalities, lesions, or signs of disease.

Components of a Normal Skin Assessment

General Inspection

• Examine the entire skin surface under adequate lighting
• Assess overall appearance, color, texture, and moisture
• Note any asymmetry, border irregularity, color variation, diameter >6mm, or evolving lesions (ABCDE rule) 1
• Look for the "ugly duckling" sign (moles that look different from other moles) 1

Specific Areas to Assess

1. Head and Face

   • Examine scalp, ears, face for seborrheic dermatitis, psoriasis, lesions
   • Check for abnormal pigmentation or rashes

2. Oropharynx

   • Inspect for candidiasis, oral hairy leukoplakia, aphthous ulceration, and periodontal disease 1

3. Trunk and Extremities

   • Examine chest, abdomen, back, buttocks, and extremities
   • Note any evidence of:
     • Folliculitis
     • Fungal infections
     • Psoriasis
     • Prurigo nodularis
     • Kaposi sarcoma (in immunocompromised patients) 1

4. Anogenital Region

   • Assess for lesions, ulcers, warts, or other abnormalities 1

5. Hands and Feet

   • Inspect for ulcers, calluses, deformities
   • Assess nail condition (discoloration, thickening, separation)
   • For diabetic patients: perform comprehensive foot examination including skin inspection, assessment of foot deformities, neurological assessment, and vascular assessment 1

Skin Integrity Assessment

• Assess for:
  • Dryness, scaling, flaking
  • Erythema (redness)
  • Edema (swelling)
  • Maceration (softening due to moisture)
  • Excoriation (scratches)
  • Rashes or lesions
  • Pressure injuries or skin tears

Special Assessment Techniques

• Wood's light examination when indicated (for certain fungal infections or pigmentation disorders) 2
• Dermoscopy for suspicious lesions 2
• Photography for documentation and monitoring changes over time 2

Risk Assessment Considerations

• Skin cancer risk factors:

  • Fair complexion
  • History of sunburns or indoor tanning bed use
  • Previous skin cancer
  • Family history of melanoma
  • Multiple (≥100) nevi or dysplastic nevi 1

• Pressure injury risk factors:

  • Limited mobility
  • Poor nutrition
  • Incontinence
  • Sensory deficits

Documentation

Document all findings including:

• Location, size, shape, color, and characteristics of any lesions
• Changes from previous examinations
• Photographs when appropriate
• Any areas requiring follow-up or intervention

Clinical Pearls and Pitfalls

• Complete examination is essential: Studies show that 0.6% of patients may have potentially lethal skin malignancies and 3.3% may have basal cell carcinomas that would be missed without a complete skin examination 3
• Don't rush: Systematic examination of all skin surfaces is necessary to avoid missing lesions in less visible areas
• Don't forget hidden areas: Examine between toes, behind ears, scalp, and genital regions
• Consider cultural sensitivity: Explain the need for complete examination and provide appropriate draping and privacy
• Patient education: Provide information on skin self-examination, sun protection, and signs of skin cancer 1

Remember that early detection of skin abnormalities can significantly reduce morbidity and mortality, particularly for skin cancers. A thorough skin assessment should be part of routine healthcare for all patients, with increased vigilance for those with risk factors.