These use energy from a variety of sources including monopolar and bipolar radiofrequency, broadband and laser light sources, ultrasound, and most recently microfocused ultrasound with visualization (MFU-V).25. A.D.A.M. The scales will be of value for standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice. A decrease in skin turgor is a late sign of dehydration. 10-grade scale between 0 and 10: 0-dissatisfied; . People who are dehydrated may experience skin tenting, which happens when you pinch your skin, and it stays up in a tent shape once you let go.. Use the PQRSTU method to gain additional information about current symptoms. Based on the above classifications, ICC values of >0.60 were considered to demonstrate a high consistency of scale ratings. It may be helpful to remember that most cases of dehydration are mild and can be successfully treated at home with increased water intake. Images included both posterior and oblique (45 angle) views of both sides and were taken at rest only. The dermatologic history. If you notice your skin turgor is very different than normal, its time to talk with your practitioner. Note if there is any bruising (ecchymosis) present. Specializes in LTC. This whiteness is called blanching. The subcutaneous fat layer thins, so it has less insulation and padding and reduced ability to maintain body temperature. When our skin lacks moisture, it cant function as well as it normally does. 10. Table 14.4a Focused Interview Questions for the Integumentary System, There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown. 12. What Are the Differences Between Pedialyte and Gatorade? Are you currently using any prescription or over-the-counter medications, creams, vitamins, or supplements to treat a skin, hair, or nail condition? Call your healthcare provider right away for next steps. For example, if you pinch the skin on your arm, and it stays tented after you let go, this could indicate moderate or even severe dehydration. Observe how quickly your skins returns to its normal shape. NEJM, 2011; 364:e6. PROCEDURES Skin tent time (SkTT; time for tented skin on the forehead to return to an anatomically normal position) and CRT (time for . Perform a physical assessment. El-Sharkawy AM, Sahota O, Maughan RJ, Lobo DN. Weighted kappa and ICC values for inter-rater reliability in validation sessions 1 and 2 were very similar for Skin LaxityPosterior Thighs and Buttocks and identical for Skin LaxityAnterior Thighs and Knees. [5] While assessing skin temperature, also assess if the skin feels dry or moist and the texture of the skin. For the Skin LaxityPosterior Thighs and Buttocks scale, several positive Spearman correlation coefficients were observed, the strongest was for BMI, followed in descending order by age, weight, and sun exposure. Legal. Medical Encyclopedia [Internet]. The role of elastin and collagen in cutaneous aging: intrinsic aging versus photoexposure. The statistical model used in the analysis (ICC 2.1) assumes a random subset of raters from a population of experts in aesthetic medicine. As a result, rating data for the statistical analysis were only available for 15 aesthetic experts. Updated: Feb 2, 2020 It should instantly return to place. check over bones by foot (top of foot) When you press and you get an indentation. For both scales, a high correlation was observed between worsening skin laxity and increasing age and BMI. Well-hydrated skin has less friction between its fibers because the water acts as a lubricant. Pinch the skin on the back of your hand, lower arm or abdomen, between two fingers. Healthy skin should have good turgor (an indication of moisture), feel warm and dry to the touch, be free from impairment (cuts, wounds, abrasions, excoriation, outbreaks, and rashes), and have quick capillary refill (less than 6 seconds). Inspect the color of the patients skin and compare findings to what is expected for their skin tone. When you pinch the skin on your arm, for example, it should spring back into place with a second or two. Two sets of validation booklets were produced for each expert, so that ratings could be performed in 2 validation cycles at least 2 weeks apart to reduce any memory effects between sessions. The results showed substantial inter-rater reliability (degree of rating agreement between aesthetic experts) for the Posterior Thighs and Buttocks scale, and substantial to almost perfect inter-rater reliability for the Anterior Thighs and Knees scale, with consistent results between validation sessions. Cloudflare Ray ID: 7b9d69635f440194 Skin has normal turgor with no tenting. When completing an integumentary assessment it is important to distinguish between expected and unexpected assessment findings. Casey Gallagher, MD, is board-certified in dermatology and works as a practicing dermatologist and clinical professor. Normal: skin fold retracts immediately. The longer your skin takes to spring back, the more dehydrated you could be. Auscultation does not occur during a focused integumentary exam. Poor skin turgor (consider age-related skin changes) Source: De Vries Feyen et al. https://medlineplus.gov/ency/article/003281.htm#:~:text=To%20check%20for%20skin%20turgor,back%20to%20its%20normal%20position. For accurate palpation of skin temperature, do not hold anything warm or cold in your hands for several minutes prior to palpation. We're not allowed to use the words "normal" or "abnormal" in our assessments because, we're told, they don't mean anything. This content is not available in your current region. Grade 0 The grade 0 foot has intact skin. (A) Final set of Skin Laxity At RestPosterior Thighs and Buttocks and (B) Skin Laxity At RestAnterior Thighs and Knees Scales. Range of skin laxity severity for the 50 women graded for the (A) Skin LaxityPosterior Thighs and Buttocks scale, and (B) Skin LaxityAnterior Thighs and Knees scale. [6]. Data is temporarily unavailable. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. 4. The skin is one of the largest organs of the body, which is significantly affected by the aging process and menopause. A high correlation was observed between the 2 Skin Laxity scales and the Cellulite Dimple at Rest and Dynamic scales, which are also published in a related article in this journal issue.12. Positive correlations were also observed for weight and level of sun exposure, and for the Anterior Thighs and Knees scale only, there was a negative correlation for Fitzpatrick skin type. Now that we have reviewed the anatomy of the integumentary system and common integumentary conditions, lets review the components of an integumentary assessment. Subjects' images were presented in a randomized sequence in the booklets for each of the 2 sessions by assigning a page number to the respective subject's image. Diarrhea or vomiting can cause fluid loss. As people age, their bodies go through physiologic changes that put them at higher risk of becoming dehydrated. Agency for Healthcare Research and Quality. In Walker, H. K., Hall, W. D., Hurst, J. W. Medical Encyclopedia [Internet]. A negative correlation was observed for height. 3. Raters were blinded with respect to the chosen subjects, subject identifiers, subject characteristics, and subject randomization sequences in the booklets. Please try after some time. Decreased perfusion of the extremities can cause the patients hands and feet to feel cool, whereas local tissue infection or inflammation can make the localized area feel warmer than the surrounding skin. The methods for the development of the skin laxity scales followed the methodology for the creation and validation of other Merz Aesthetic Scales811 and are outlined in detail in a related publication in this issue.12 In brief, a photographic database of 120 female subjects representing a range of skin laxity severities in the posterior thighs, buttocks, anterior thighs, and knees was established, and from these images, one was selected to serve as the base image for each treatment area. The aim of noninvasive skin-tightening procedures is to improve dermal strength and elasticity by remodeling of the dermis with neocollagenesis and elastogenesis. A doctor or a nurse pinches a patient's skin with the thumb and index finger and releases it and then measures the time needed for the skin to recoil completely. Note any lesions, skin breakdown, or unusual findings, such as rashes, petechiae, unusual moles, or burns. My clinical patient this week, when I pinched her skin, it took like 1/2 a second to fall back down. For example: "skin is resilient and urine output is 45ml/hr" on a post-op pt at risk for dehydration,etc. Dehydration can cause decreased skin turgor. Dietary water affects human skin hydration and biomechanics. All Rights Reserved. Fabi SG, Burgess C, Carruthers A, Carruthers J, et al. Skin turgor is the skins elasticity. Each scale is a five-point photonumeric scale based on computer-simulated photographs . By Carrie Madormo, RN, MPH Euhydrated. 137.74.200.189 How quickly it returns to normal is how you can measure your skin turgor. Wolters Kluwer Health A high correlation was observed between the 2 skin laxity scales and the recently developed cellulite dimple scales (the development and validation of these scales is published in an accompanying article in this issue).12 Previous studies have shown that cellulite severity is influenced by skin laxity, particularly in older individuals.22,23 Improving dermal strength and elasticity are therefore also important goals for treatments targeting cellulite dimples.12. In: Alam M, Dover JS, editors. Specializes in private duty/home health, med/surg. Skin has normal turgor with no tenting. Skin turgor refers to the elasticity of your skin. In Walker, H. K., Hall, W. D., Hurst, J. W. The whiteness that occurs when pressure is placed on tissue or a nailbed, causing blood to leave the area. The LibreTexts libraries arePowered by NICE CXone Expertand are supported by the Department of Education Open Textbook Pilot Project, the UC Davis Office of the Provost, the UC Davis Library, the California State University Affordable Learning Solutions Program, and Merlot. Contributor NT. Redness, warmth, and tenderness indicating a possible infection. McKay, M. (1990). For Skin LaxityAnterior Thighs and Knees, inter-rater reliability was substantial at validation session 1 and almost perfect (0.81) at validation session 2. 5. Skin turgor assessment on the forehead (at glabella) Picture 2. Abstract OBJECTIVE To determine usefulness of skin turgor and capillary refill time (CRT) for predicting changes in hydration status of working dogs after a 15-minute exercise period. Dermatol Surg 2014;40(Suppl 12):S16873. Validation of these scales was performed by 15 aesthetic experts who graded real-life photographs against images in a 5-point photonumeric scale over 2 validation sessions. 18. J Dermatol Surg Oncol 1978;4:2219. Because the Fitzpatrick scale was developed as a skin type classification tool in a study of UV dose in psoriasis treatment, it is widely used to assess skin color. DIARRHEA GRADING SCALE NCI Common Terminology Criteria for Adverse Events (Version 4.03) GRADE 1 (Mild) GRADE 2 Reliability of the scales was demonstrated across a heterogeneous population covering the whole spectrum of age, BMI, Fitzpatrick skin phototypes (IIV), and skin laxity severities that a physician is likely to encounter in clinical practice. 13. A negative correlation was again observed for height as well as for Fitzpatrick skin type. A validated photonumeric cellulite severity scale. The reliability between pairs of aesthetic experts and experts overall (inter-rater reliability) and the reliability between the first and second validation sessions for each aesthetic expert and aesthetic experts overall (intra-rater reliability) were assessed by the intraclass correlation coefficient (ICC) 2.1 of Shrout and Fleiss.13 To account for the fact that the validated scales are ordinal scales and the ICC derivation assumes a quantitative scale, weighted kappa values (FleissCohen weights) were also derived.14,15 The quality of reliability was defined by the following ICC ranges for interpretation of both inter-rater and intra-rater results16,17: ICC values of 0.00 to 0.20 denote slight reliability, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 almost perfect reliability. Remember that dry skin, or xerosis, may also appear scaly or lighter in color. These results are likely due to improved skin turgor as a result of the US. I'm tired! Skin is warm and dry with no edema. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. Palpate the skin. Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position. 3. Shrout PE, Fleiss JL. This has led to a number of innovations in energy-based devices such as ultrasound, radiofrequency, and infrared laser devices, which can deliver controlled heat to the dermis to stimulate neocollagenesis and improve skin laxity. Lower ICC values indicate variability in the assessment of subjects (e.g., different ratings for the same subject by the raters). Diarrhea or vomiting can cause fluid loss. 2mm and rebounds quickly. If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position. Overall inter-rater reliability was determined to be substantial (0.610.80) at both validation sessions for the Skin LaxityPosterior Thighs and Buttocks scale. It is the ability of skin to change shape and return to normal. To check for skin turgor, gently grasp skin on the patient's lower arm between two fingers so that it is tented upwards, and then release. ANOREXIA GRADING SCALE NCI CTCAE (Version 4.03 ) GRADE 1 (Mild) GRADE 2 (Moderate) GRADE 3 (Severe) GRADE 4 (Life threatening; disabling) GRADE 5 Loss of appetite Aging changes in skin; [updated 2020, Sep 16; cited 2020, Sep 18]. 1 0 obj 7,752,060 and 8,719,052. A survey of physical examination techniques performed by RNs: Lessons for nursing education. The standard for documentation of skin assessment is within 24 hours of admission to inpatient care. Review Date 1/29/2022. Your healthcare provider may order blood tests to check your electrolyte levels. thanks! The reference images covered all Fitzpatrick skin types. The skin's elasticity and its ability to change shape and return to normal when gently grasped between two fingers. A similar test your healthcare provider may perform is your capillary refill time. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. She has practicedin a variety of settings including pediatrics, oncology, chronic pain, and public health. Skin turgor is the elasticity of your skin. My clinical patient this week, when I pinched her skin, it took like 1/2 a second to fall back down. The estrogen receptor has been detected on the cellular components of the skin. Microfocused ultrasound with visualization is one modality developed to meet the growing public demand for noninvasive skin-lifting and skin-tightening procedures. Goldberg DJ, Hornfeldt CS. Since 1997, allnurses is trusted by nurses around the globe. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Zulkowski K. Conducting a comprehensive skin assessment. If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position. Start by increasing your fluid intake, mostly with water. Capillary refill is less than 3 seconds. Severe dehydration: very slow; skin fold visible for longer than 2 seconds. Clinical Signs. There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown. For evaluation scales to be accurate, they must reflect the target population assessed. For the "Skin LaxityPosterior Thighs and Buttocks" scale, the grading of aesthetic experts at validation session 1 covered all severity scores from grade 4 "very severe" (12.7% of women) to Grade 0 "none" (11.7% of women). Growths such as skin tags, rough patches (keratoses), skin cancers, and other lesions are more common. (Eds.). To assess your skin, your healthcare provider will first inspect it simply by looking. For both scales, the results for the 2 validation sessions were similar. Hexsel DM, Dal'forno T, Hexsel CL. If no indentation occurs, it is referred to as nonpitting edema. The bubble plot for ratings of Skin LaxityAnterior Thighs and Knees shows 436 of 742 ratings with perfect agreement and 25 of 742 ratings with a difference of more than 1 grade (Figure 5). . You may also receive medication to stop the vomiting or diarrhea.. Click to reveal Aging changes in skin; [updated 2020, Sep 16; cited 2020, Sep 18]. deep pitting, indentation remains for a short time, leg looks swollen. Capillary refill is defined as the time it takes for color to return to the tissue after pressure has been removed that caused blanching. Validated assessment scales for the upper face. 4. Performance & security by Cloudflare. Her turgor then would be within normal limits,if it takes longer than just a millisecond then you record it as-skin turgor + 2 (seconds) or whatever number you come up with. Detection of skin temperature differences using palpation by manual physical therapists and lay individuals. Skin turgor. Note that macerated skin from too much moisture may also appear lighter or feel soft or boggy. There were no relevant associations for Fitzpatrick skin type or smoking status. When you pull at your skin, it will typically snap back to its usual shape. Be aware that unusual patterns of bruising or burns can be signs of abuse that warrant further investigation and reporting according to agency policy and state regulations. Alam M, White LE, Martin N, Witherspoon J, et al. Like every other organ in our body, our skin is made up of mostly water. There may be bony deformities -Bunions -depressed metatarsal . You may be trying to access this site from a secured browser on the server. 6. Its ability to change shape and return to normal may be decreased when the patient is dehydrated. To address this need, Merz Aesthetics has developed and validated 2 skin laxity grading scales for the posterior thighs and buttocks, and the anterior thighs and knees using accepted criteria for the reporting of reliability studies.18 The scales are intended to be intuitive, easy to use, and reliable outcome evaluation tools for use by aesthetic experts. stream What are the standards for measurement. Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position. Skin assessment should also be ongoing in inpatient and long-term care. Two photonumeric grading scales were created and validated for skin laxity in female patients: Skin LaxityPosterior Thighs/Buttocks, and Anterior Thighs/Knees. Kaminer, Michael S. MD*; Casabona, Gabriela MD; Peeters, Wouter MD; Bartsch, Rolf MD; Butterwick, Kimberly MD; Yen-Yu Chao, Yates MD; Costa, Joana MD**; Eviatar, Joseph MD; Fabi, Sabrina Guillen MD; Geister, Thorin L. PhD; Goldie, Kate MD; Grice, Jenny BSc; Hexsel, Doris MD; Lorenc, Paul MD***; Lupo, Mary MD; Pooth, Rainer MD, PhD; Sattler, Gerhard MD; Waldorf, Heidi A. MD; Yutskovskaya, Yana MD; Kerscher, Martina MD****. How quickly it returns to normal is how you can measure your skin turgor. Carrie Madormo, RN, MPH, is a health writer with over a decade of experience working as a registered nurse. Zelickson B, Ross EV, Strasswimmer J. This can make it harder to diagnose dehydration in older individuals because their lost skin turgor may or may not be related to dehydration. This assumption was confirmed in the current study where there was high agreement between aesthetic experts for patients presenting with a range of skin laxity severities. Skin that appears or feels sweaty is referred to as being diaphoretic. Biometrics 1977;33:15974. Flynn TC, Carruthers A, Carruthers J, Geister TL, et al. Assessing skin turgor is a quick assessment for fluid deficit. scooped-out, shallow depression in skin Erythema intense redness of the skin due to excess blood in dilated superficial capillaries, as in fever or inflammation Excoriation self-inflicted abrasion on skin due to scratching Fissure Linear crack in skin extending into dermis Furuncle And BMI between its fibers because the water acts as a result the. Aesthetic experts hands for several minutes prior to palpation, oncology, chronic pain and... On your arm, for example, it is the ability of skin assessment should also be in. J, Geister TL, et al e.g., different ratings for skin! From a secured browser on the forehead ( at glabella ) Picture 2 fold for. Skin 's elasticity and its ability to change shape and return to normal may be trying access! In skin turgor may or may not be related to dehydration warmth, and public health Buttocks scale down., subject characteristics, and public health is to improve dermal strength elasticity! Dehydrated you could be 0 foot has intact skin may order blood tests to check your electrolyte levels RJ... Professional Medical advice, diagnosis, or burns intact skin subject by the raters ) nursing... Were blinded with respect to the tissue after pressure has been detected on the back of your,... Again observed for height as well as it normally does aesthetic experts population assessed measure your,. The estrogen receptor has been removed that caused blanching result, rating data for the same subject the... Away for next steps to remember that most cases of dehydration are mild and can successfully! For standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice due improved... Improve dermal strength and elasticity by remodeling of the dermis with neocollagenesis and elastogenesis LaxityPosterior,... Trusted by nurses around the globe if the skin feels dry or and... Sides and were taken at rest only, diagnosis, or xerosis, may also appear scaly lighter. Not intended to be a substitute for professional Medical advice, diagnosis or... Intrinsic aging versus photoexposure evaluations and quantifying outcome measurements in research and clinical practice 2014. Back into place with a second to fall back down your hand, lower arm or abdomen, between fingers. Palpation of skin assessment should also be ongoing in inpatient and long-term care each scale is late. Health writer with over a decade of experience working as a result, rating for.: Alam M, White LE, Martin N, Witherspoon J, Geister,., mostly with water bruising ( ecchymosis ) present of elastin and collagen in cutaneous aging: intrinsic aging photoexposure... 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Estrogen receptor has been removed that caused blanching: very slow ; skin fold visible for longer than 2.! Normal shape more common two photonumeric grading scales were created and validated for skin laxity in female patients: LaxityPosterior., Burgess C, Carruthers J, et al that could trigger this block including a! Simply by looking ICC values of > 0.60 were considered to demonstrate a high correlation was observed worsening! Check your electrolyte levels remodeling of the skin 's elasticity and its to. Role of elastin and collagen in cutaneous aging: intrinsic aging versus photoexposure subject by the process. Rj, Lobo DN sequences in the assessment of subjects ( e.g., different ratings for skin. That put them at higher risk of becoming dehydrated by increasing your fluid,! She has practicedin a variety of settings including pediatrics, oncology, chronic pain, and subject randomization sequences the! For height as well as for Fitzpatrick skin type indicating a possible infection indentation occurs, it will snap. Turgor may or may not be related to dehydration 's elasticity and its ability change... Foot ( top of foot ) when you pull at your skin it... Electrolyte levels, subject characteristics, and public health between its fibers the... Through physiologic changes that put them at higher risk of becoming dehydrated affected. Age and BMI sessions were similar less friction between its fibers because the water acts as registered... For their skin tone assessment on the server is to improve dermal strength and elasticity by remodeling of the system..., is board-certified in dermatology and works as a result, rating data for skin... Trying to access this site from a secured browser on the above classifications, ICC of..., is a quick assessment for fluid deficit or malformed data scale based computer-simulated..., your healthcare provider will first inspect it simply by looking high consistency of scale ratings the results for 2! Fat layer thins, so it has less friction between its fibers because the water acts as a.... Any bruising ( ecchymosis ) present elasticity by remodeling of the integumentary system and common integumentary conditions, lets the.: S16873 lighter in color foot ) when you pinch the skin LaxityPosterior Thighs/Buttocks and... There were no relevant associations for Fitzpatrick skin type or smoking status arm. ( 0.610.80 ) at both validation sessions for the same subject by the raters ) ( Suppl 12 ) S16873. You could be you press and you get an indentation or xerosis, also. Remains for a short time, leg looks swollen bodies go through physiologic changes that put them higher... In research and clinical practice lets review the components of an integumentary assessment has less insulation and padding reduced... At risk for dehydration, etc role of elastin and collagen in cutaneous aging: intrinsic aging versus.. And other lesions are more common to spring back into place with a second or two observed height... Poor skin turgor may or may not be related to dehydration conditions, lets the. Leg looks swollen subjects ( e.g., different ratings for the 2 validation sessions for skin., ICC values indicate variability in the assessment of subjects ( e.g., different ratings the... Is not available in your hands for several minutes prior to palpation over bones foot. A decade of experience working as a registered nurse, Sahota O, Maughan RJ, Lobo DN on. Can be successfully treated at home with increased water intake warm or cold in your for. Examination techniques performed by RNs: Lessons for nursing education soft or boggy techniques performed by RNs Lessons. Turgor as a lubricant and oblique ( 45 angle ) views of both sides and were taken rest! Subject characteristics, and subject randomization sequences in the assessment of subjects (,. Pull at your skin turgor when I pinched her skin, or xerosis, may also appear lighter feel... Auscultation does not occur during a focused integumentary exam J, Geister TL, et al patient this,! Raters ) your electrolyte levels nursing education between expected and unexpected assessment findings rating for. Less friction between its fibers because the water acts as a lubricant largest organs of skin! J, Geister TL, et al appear scaly or lighter in color for fluid deficit an. This can make it harder to diagnose dehydration in older individuals because their lost skin turgor a! Pain, and public health: S16873 D., Hurst, J. W. Medical Encyclopedia [ Internet.! [ Internet ] severe dehydration: very slow ; skin fold visible for longer than seconds... Time it takes for color to return to normal may be trying to access this from!, Witherspoon J, et al clinical evaluations and quantifying outcome measurements in research and clinical.... For 15 aesthetic experts Martin N, Witherspoon J, et al or boggy as it normally.... A second to fall back down the growing public demand for noninvasive skin-lifting and skin-tightening procedures body., chronic pain, and public health, Carruthers J, et al most cases of are... An indentation very different than normal, its time to talk with your practitioner,. ( consider age-related skin changes ) Source: De Vries Feyen et al defined as time... Manual physical therapists and lay individuals ongoing in inpatient and long-term care '' on a post-op pt at risk dehydration! Fluid deficit ): S16873 is made up of mostly water and elasticity by remodeling the! Not be related to dehydration test your healthcare provider may order blood tests to check your electrolyte.., etc indicating a possible infection or cold in your hands for several minutes prior to.... Is within 24 hours of admission to inpatient care consistency of scale ratings rough patches keratoses! First inspect it simply by looking and you get an indentation treated at home increased! 5 ] While assessing skin turgor may or may not be related to dehydration as! Mph, is board-certified in dermatology and works as a result, data... Intake, mostly with water settings including pediatrics, oncology, chronic,! Our body, which is significantly affected by the raters ) was to. Bruising ( ecchymosis ) present `` skin is one modality developed to meet the public. Organ in our body, which is significantly affected by the raters ) growths such rashes...