Clinical exam · General exam and vital signs

Pallor, cyanosis and jaundice !

Sign

Three colour changes of skin and mucosae that point to anemia, lack of oxygen or excess bilirubin.

Updated 2026-11-01

See it in 3D: Skin · Sclera · Tongue

What it is

Pallor, cyanosis and jaundice are colour changes best seen in the mucosae, conjunctivae, sclerae, nail beds and palms, especially in darker skin. Pallor suggests anemia or vasoconstriction; cyanosis, more deoxygenated hemoglobin; jaundice, raised bilirubin. They are looked for in daylight, as artificial light can hide them.

The anatomy it tests

The conjunctiva and nail bed have visible vessels under a thin epithelium, so they show pallor and cyanosis well.
The sclera is rich in elastin, which binds bilirubin; that is why jaundice shows there first.
Cyanosis appears when deoxygenated hemoglobin in the capillaries exceeds about five grams per decilitre.

How to elicit it

Examine in daylight or white light, never yellowish light.
Gently pull down the lower eyelid and look at the colour of the palpebral conjunctiva.
Ask the patient to look down, lift the upper lid and look at the sclera for a yellow tint.
Ask them to open the mouth and lift the tongue; look at the tongue, lips and the floor of the mouth.
Look at the nail beds, palms and palmar creases; compare with the examiner's hand.
If the fingers are cyanotic, warm the hand and see whether it clears (peripheral) or persists.
Record the colour, where it is seen and how it relates to oxygen saturation.

What a positive result means

Pallor: iron deficiency anemia (common in children and women in Colombia), bleeding, shock and vasoconstriction from cold or fear.
Central cyanosis: severe pneumonia, COPD, pulmonary embolism, congenital heart disease with right-to-left shunt and methemoglobinemia.
Peripheral cyanosis: cold, heart failure with low output, arterial obstruction and Raynaud phenomenon.
Prehepatic (hemolysis), hepatic (viral hepatitis, cirrhosis) and posthepatic (biliary obstruction) jaundice; in newborns it is often physiological but always assessed.
No cyanosis does not rule out hypoxemia, especially with anemia or dark skin; measure saturation.

Usefulness and limits

Clinical detection of anemia and mild jaundice is insensitive; they are confirmed with serum hemoglobin and bilirubin.
Jaundice usually becomes visible when bilirubin exceeds about two to three milligrams per decilitre.

Test yourself

Think of the answer, then tap the question to see it.

How is central cyanosis told apart from peripheral cyanosis?

Central cyanosis affects the tongue and oral mucosa; peripheral affects only the fingers and cold areas, with pink mucosae, and improves when the limb is warmed.

Where does jaundice show first?

In the sclerae and under the tongue, because these tissues bind bilirubin before the skin is stained.

How is carotenemia distinguished from jaundice?

Carotenemia turns the palms and soles yellow but spares the sclerae; jaundice stains them.

Why might a patient with severe anemia not look cyanotic despite hypoxemia?

Because cyanosis depends on the absolute amount of deoxygenated hemoglobin, and in anemia total hemoglobin is low.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: Blue discoloration of the skin: MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine (MedlinePlus), 2025); Jaundice | Icterus | MedlinePlus (U.S. National Library of Medicine (MedlinePlus), 2025).

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