What Are the Three Skin Signs?

You Can Learn a Lot from How a Patient Looks

Hot day, dehydration
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One of the first things I teach paramedic students is to look at their patients. I know that seems to be a little basic, but you can learn a whole lot simply by paying attention to a person's skin color and moisture, two things that you are likely to see as you enter the room.

Skin temperature is also important. The triad—skin color, temperature, and moisture—is collectively known as the skin signs.

In most emergency situations, the skin is one of the first organs to react to a dangerous condition.

Skin Color

Skin comes in a variety of hues. It can be olive or rosy. It can be extremely dark or almost completely white. These color variations come from hereditary pigmentation in the skin (melanin) and have absolutely nothing to do with medical conditions.

It's not the pigment color of the skin that we are concerned with—think of that as the permanent coat of paint—but the color under it. The primer, if you will. This undercoat comes from blood circulating in capillaries (tiny blood vessels running through the tissues of the skin). Blood perfuses these itty-bitty channels one red blood cell at a time.

Red blood cells have a substance called hemoglobin that binds to oxygen. Hemoglobin is primarily made of iron. Expose iron to moisture and oxygen and what do you get? Rust. Red rust.

Like rust, hemoglobin turns bright red when it's bound to oxygen.

Lots of red blood cells with plenty of oxygen and you get lots of bright red color. Not enough red blood cells flowing through the capillaries provides very little red and looks pale. Blood that has a normal amount of red blood cells, but not enough oxygen, looks very dark and might even appear blue.

It's this range of dark blue to pale to bright red that we are looking at when we describe skin color:

  • Purple or bluish skin (cyanosis) typically indicates a problem with oxygen. Couple this color with someone who looks like he or she isn't breathing enough or appears to have shortness of breath, and you know they are suffering from a lack of oxygen (hypoxia).
  • Pale skin is a sign of dehydration or shock. It means the body is not allowing blood to flow all the way to the skin. This happens because there isn't enough blood or water in the system and to conserve it, the body is shunting it toward the core and away from the surface.
  • Flushed skin indicates too much blood flow to the surface of the skin. This is an indication of high blood pressure, heat illness (the body is routing as much blood as possible to the surface to let heat out), or fever (for the same reason as heat illness).

It doesn't matter what the pigmentation is. Very dark-skinned people look just as pale when they don't have a lot of blood flow to the skin's surface. And those with extremely light skin can be a lot more pale than you might think possible when they're sick.

Your brain will recognize it, even if you don't at first.

How many times have you seen a coworker on a bad day and remarked how ill he or she looked? More often than not, it's the color of the blood flowing—or not flowing—under the surface that your brain is noticing.

Skin Moisture

Next to skin color is moisture. This one is pretty simple, at least in the extremes. Wet skin is noticed if it's dripping or feels wet to the touch. Overly dry skin is noticed especially when it's scaly.

Supple, not scaly, and not moist skin is preferred. Sometimes the moisture is under the surface. If skin is really dry (like pale, an indicator of poor blood flow), it can lead to poor skin turgor.

Turgor is the elasticity of skin. It's that ability of skin to snap back to it's original shape. If you lightly pinch the skin and it stays that way when you let go (like clay), it is very dry and said to have poor turgor.

Overly sweaty skin is called diaphoresis. Sweating for a workout is fine, but skin is typically said to be diaphoretic if it is wet for no apparent reason. The other nickname for diaphoresis is cold sweats.

Skin Temperature

The final skin sign is temperature. This one requires human touch. It's very hard to assess skin temperature by looking at the patient. You might even say it's impossible. This skin sign is pretty subjective and could be misleading without practice.

Temperature is perceived through touch as a comparison. In other words, when your hands are cold, everything else feels warmer. Likewise, if your hands are warm, everything (and everyone else) feels cooler. If you know that and you are aware of your own temperature, it's a more useful tool.

One thing that skin temperature can clearly demonstrate is if there is one area of a patient's body that is warmer than other areas. Try to keep the comparisons apples-to-apples, if possible. For instance, it's not a good sign if one leg is hot to the touch compared to the other. Indeed, even more alarming if the hot leg is also swollen, red, and dry.

Hot skin is similar to flushed skin; it's an indicator of heavy blood flow to the surface. In some cases, it can indicate a fever or a heat illness. Cool skin indicates poor circulation. Cool, wet skin suggests a significant problem, especially if the patient is struggling to breath or appears fatigued or unconscious.

Definitely Sick at a Glance

Paramedics are taught to recognize when their patients are very sick at first glance. It's a good habit that you might already have. Medical training puts all sorts of other things in our heads that can have the effect of dulling our instincts. It's a good bet that you know right away when somebody in the office drank a little too much last night or might be coming down with the flu.

Trust your gut, even—or especially—once you've received a little medical training. Don't let the extra information make you doubt yourself. If a patient looks sick, she is.

Sources:

Kenefick, R., Sollanek, K., Charkoudian, N., & Sawka, M. (2014). Impact of skin temperature and hydration on plasma volume responses during exercise. Journal Of Applied Physiology117(4), 413-420. doi:10.1152/japplphysiol.00415.2014

Popov, T. (2005). Review: capillary refill time, abnormal skin turgor, and abnormal respiratory pattern are useful signs for detecting dehydration in children. Evidence-Based Nursing8(2), 57-57. doi:10.1136/ebn.8.2.57

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