Skin, scaly
Scaly skin results when cells of the uppermost skin layer (stratum corneum) desiccate and shed, causing excessive accumulation of loosely adherent flakes of normal or abnormal keratin. Normally, skin cell loss is imperceptible; the appearance of scale indicates increased cell proliferation secondary to altered keratinization.
Scaly skin varies in texture from fine and delicate to branlike, coarse, or stratified. Scales are typically dry, brittle, and shiny, but they can be greasy and dull. Their color ranges from whitish gray, yellow, or brown to a silvery sheen.
Usually benign, scaly skin occurs with fungal, bacterial, and viral infections (cutaneous or systemic), lymphomas, and lupus erythematosus; it’s also common in those with inflammatory skin disease. A form of scaly skin—generalized fine desquamation—commonly follows prolonged febrile illness, sunburn, and thermal burns. Red patches of scaly skin that appear or worsen in winter may result from dry skin (or from actinic keratosis, common in elderly patients). Certain drugs also cause scaly skin. Aggravating factors include cold, heat, immobility, and frequent bathing.
History and physical examination
Begin the history by asking how long the patient has had scaly skin and whether he has had it before. Where did it first appear? Did a lesion or skin eruption, such as erythema, precede it? Has the patient used a new or different topical skin product recently? How often does he bathe? Has he had recent joint pain, illness, or malaise? Ask the patient about work exposure to chemicals, use of prescribed drugs, and a family history of skin disorders. Find out what kinds of soap, cosmetics, skin lotion, and hair preparations he uses.
Next, examine the entire skin surface. Is it dry, oily, moist, or greasy? Observe the general pattern of skin lesions, and record their location. Note their color, shape, and size. Are they thick or fine? Do they itch? Does the patient have other lesions besides scaly skin? Examine the mucous membranes of his mouth, lips, and nose, and inspect his ears, hair, and nails.
Medical causes
Bowen’s disease
This common form of intraepidermal carcinoma causes painless, erythematous plaques that are raised and indurated with a thick, hyperkeratotic scale and, possibly, ulcerated centers.
Dermatitis
Exfoliative dermatitis begins with rapidly developing generalized erythema. Desquamation with fine scales or thick sheets of all or most of the skin surface may cause life-threatening hypothermia. Other possible complications include cardiac output failure and septicemia. Systemic signs and symptoms include low-grade fever, chills, malaise, lymphadenopathy, and gynecomastia.
With nummular dermatitis, round, pustular lesions commonly ooze purulent exudate, itch severely, and rapidly become encrusted and scaly. Lesions appear on the extensor surfaces of the limbs, posterior trunk, and buttocks.
Seborrheic dermatitis begins with erythematous, scaly papules that progress to larger, dry or moist, greasy scales with yellowish crusts. This disorder primarily involves the center of the face, the chest and scalp and, possibly, the genitalia, axillae, and perianal regions. Pruritus occurs with scaling.
Dermatophytosis
Tinea capitis produces lesions with reddened, slightly elevated borders and a central area of dense scaling; these lesions may become inflamed and pus-filled (kerions). Patchy alopecia and itching may also occur. Tinea pedis causes scaling and blisters between the toes. The squamous type produces diffuse, fine, branlike scales. Adherent and silvery white, they’re most prominent in skin creases and may affect the entire dorsum of the foot. Tinea corporis produces crusty lesions. As they enlarge, their centers heal, causing the classic ringworm shape.
Discoid lupus erythematosus
This cutaneous form of lupus may occur without systemic signs and symptoms. Separate or coalescing lesions (macules, papules, or plaques), ranging from pink to purple, are covered with a yellow or brown crust. Enlarged hair follicles are filled with scales, and telangiectasia may be present. After this inflammatory stage, the lesions heal and hypopigmentation or hyperpigmentation and noncontractile scarring and atrophy may occur. Discoid lupus commonly involves the face or sun-exposed areas of the neck, ears, scalp, lips, and oral mucosa. Alopecia may also occur.
Lichen planus
With this disorder, small, flat, violet lesions with a fine scale and gray lines on the surface usually affect the lumbar region, genitalia, wrists, ankles, and anterior lower legs.
Lymphoma
Hodgkin’s disease and non-Hodgkin’s lymphoma commonly cause scaly rashes. Hodgkin’s disease may cause pruritic scaling dermatitis that begins in the legs and spreads to the entire body. Remissions and recurrences are common. Small nodules and diffuse pigmentation are related signs. This disease typically produces painless enlargement of the peripheral lymph nodes. Other signs and symptoms include fever, fatigue, weight loss, malaise, and hepatosplenomegaly.
Non-Hodgkin’s lymphoma initially produces erythematous patches with some scaling that later become interspersed with nodules. Pruritus and discomfort are common; later, tumors and ulcers form. Progression produces nontender lymphadenopathy.
Parapsoriasis (chronic)
This disorder produces small or moderate-sized maculopapular, erythematous eruption, with a thin, adherent scale on the trunk, hands, and feet. Removal of the scale reveals a shiny brown surface.
Pityriasis
Pityriasis rosea, an acute, benign, and self-limiting disorder, produces widespread scales. It begins with an erythematous, raised, oval herald patch anywhere on the body. A few days or weeks later, yellow-tan or erythematous patches with scaly edges erupt on the trunk and limbs and sometimes on the face, hands, and feet. Pruritus also occurs.
Pityriasis rubra pilaris, an uncommon disorder, initially produces seborrheic scaling on the scalp, progressing to the face and ears. Later, scaly red patches develop on the palms and soles, becoming diffuse, thick, fissured, hyperkeratotic, and painful. Lesions also appear on the hands, fingers, wrists, and forearms and then on wide areas of the trunk, neck, and limbs.
Psoriasis
Silvery white, micaceous scales cover erythematous plaques that have sharply defined borders. Psoriasis usually appears on the scalp, chest, elbows, knees, back, buttocks, and genitalia. Associated signs and symptoms include nail pitting, pruritus, arthritis, and sometimes pain from dry, cracked, encrusted lesions.
Syphilis (secondary)
Papulosquamous, slightly scaly eruptions characterize this disorder. A ring-shaped pattern of copper-red papules usually forms on the face, arms, palms, soles, chest, back, and abdomen. Annular papules may occur. Systemic findings include lymphadenopathy, malaise, weight loss, anorexia, nausea, vomiting, headache, sore throat, and low-grade fever.
Systemic lupus erythematosus
This disorder produces a bright-red maculopapular eruption, sometimes with scaling. Patches are sharply defined and involve the nose and malar regions of the face in a butterfly pattern—a primary sign. Similar characteristic rashes appear on other body surfaces; scaling occurs along the lower lip or anterior hair line. Other primary signs and symptoms include photosensitivity and joint pain and stiffness. Vasculitis (leading to infarctive lesions, necrotic leg ulcers, or digital gangrene), Raynaud’s phenomenon, patchy alopecia, and mucous membrane ulcers also can occur.
Tinea versicolor
This benign fungal skin infection typically produces macular hypopigmented, fawn-colored, or brown patches of varying sizes and shapes. All are slightly scaly. Lesions commonly affect the upper trunk, arms, and lower abdomen, sometimes the neck and, rarely, the face.
Other causes
Drugs
Many drugs—including penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, and isoniazid—can produce scaling patches.
Special considerations
If scaling results from corticosteroid therapy, withhold the drug. Prepare the patient for such diagnostic tests as a Wood’s light examination, skin scraping, and skin biopsy.
Pediatric pointers
In children, scaly skin may stem from infantile eczema, pityriasis rosea, epidermolytic hyperkeratosis, psoriasis, various forms of ichthyosis, atopic dermatitis, a viral infection (especially hepatitis B virus, which can cause Gianotti-Crosti syndrome), seborrhea capitis (cradle cap), or an acute transient dermatitis. Desquamation may follow a febrile illness.
Patient counseling
Teach the patient proper skin care, and suggest lubricating baths and emollients. Instruct him not to use hot water to bathe or shower.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Skin infections
» Next page: Staphylococcal scalded skin syndrome (Handbook of Diseases)
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