Dermatitis: Types, Precautions, and Diagnosis

• Skin diseases can result from infection with bacteria, viruses, fungi, or parasites.
• Prevention requires special precautions and hand hygiene to prevent spread of infectious organisms.
• The Joint Commission's National Patient Safety Goals mandate hand hygiene as a first-line preventative measure.
• The Centers for Disease Control and Prevention (CDC) recommends contact and standard precautions for skin diseases.
• Contact precautions include using a private room, wearing gloves and gowns, discarding contaminated articles in biohazard waste, and using patient-specific equipment.
• Skin disorders requiring contact precautions include:
  • Furunculosis
  • ' Group A Streptococcus
  • Herpes simplex (disseminated, severe primary, or neonatal)
  • Disseminated herpes zoster (varicella zoster), which also requires airborne precautions
  • Impetigo
  • Bacterial infection or colonization with multiple drug resistance
  • Pediculosis
  • Scabies
  • Major skin wound or burn infection (draining and not covered)
  • Vaccinia

Dermatitis

• Dermatitis is noncontagious unless a secondary infection occurs.
• Contact dermatitis is a delayed allergic response involving cell-mediated immunity, with local skin irritation evident within hours or days after exposure to an antigen.
• Atopic dermatitis (eczema) affects about 10% of the population and results from a complex activation process involving various inflammatory cells.
• Stasis dermatitis occurs on the legs due to venous stasis and edema, often seen with varicosities or phlebitis.
• Seborrheic dermatitis is a common inflammation involving the scalp, eyebrows, eyelids, and other areas, with lesions appearing as scaly white or yellowish plaques.
• Treatment involves avoiding irritants, skin lubrication, and topical corticosteroids.
• Nursing management includes teaching patients to avoid contact irritants, apply topical agents properly, and care for their skin.

Acne

• Acne involves papules and pustules on the face, back, and shoulders, classified as mild, moderate, or severe.
• Acne rosacea typically begins between ages 30 and 50, characterized by erythema, papules, pustules, and can be worsened by tea, coffee, alcohol, spicy foods, sunlight, and emotional stress.
• Acne vulgaris is more common than acne rosacea with contributing factors include hereditary disposition, androgen levels, and hormonal fluctuations.
• Treatment for acne rosacea involves avoiding triggers and using sunscreen. Metronidazole and retinoids may be prescribed.
• Mild acne vulgaris can respond to retinoids. Nonprescription drugs containing sulfur, benzoyl peroxide, or resorcinol combinations are effective for noninflammatory acne.
• Topical retinoic acid is an effective agent for papular and pustular acne and azelaic acid (Azelex) is applied topically twice a day.
• Severe cystic acne that is resistant to other treatments can be treated with isotretinoin, which requires lab monitoring due to serious adverse effects.
• Diagnosis is by history and physical examination.
• For larger areas, Photodynamic therapy (PDT) may be used. Photosensitive solution applied to the skin followed by light to activate the chemicals and destroy the target cells.
• Dermabrasion can improve the appearance of deep scarring and pitting.

Psoriasis

• A noncontagious, chronic skin disorder marked by inflamed, edematous lesions covered with silvery-white scales.
• Affects about 2% of the U.S. population that commonly appears after an upper respiratory infection.
• Psoriatic arthritis may occur alongside skin eruptions and linked to other systemic diseases.
• Mild cases respond to steroid creams, and sunlight can help in moderate doses.
• Calcipotriene, a vitamin D analog cream, regulates skin cell production. Tar preparations may be administered.
• Severe cases are treated with combined UV radiation and coal tar or PUVA therapy.
• Antimetabolites, acitretin, cyclosporine, and biologic agents like brodalumab, infliximab, etanercept, efalizumab, and alefacept treat severe psoriasis.
• Nursing management involves teaching about the disease and its treatment, keeping the skin moist, and avoiding skin injury/irritation.

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

• Allergic reactions with skin manifestations resulting in necrosis and detachment of less than 10% (SJS) or greater than 30% (TEN) of the epidermis.
• Lesions have irregular borders and may have blistered, necrotic centers, commonly caused by medications.
• Treatment involves discontinuing the drug and providing supportive care.

Bacterial Infections

• Cellulitis is a dermis and subcutaneous tissue infection mainly caused by Staphylococcus, resulting in areas that are erythematous, swollen, and painful.
• Furuncles and Carbuncles are inflammations; furuncles in hair follicles, carbuncles a collection of boils, often caused by Staphylococcus aureus.
• Diagnosis is by history and examination, treatment involves drainage and antibiotics if indicated.
• Patient education aims at healing and preventing recurrence.

Viral Infections

• Herpes simplex type 2 is associated with genital herpes, herpes simplex virus type 1 primarily orofacial, and can be spread by direct contact.
• The only species affected are humans.
• Prevent the spread through direct contact.
• Lemon balm (concentrated in a cream base) has been used to provide relief for cold sores and fever blisters.
• The virus embeds in a nerve ganglion and reactivates due to triggers like UV light, irritation, fever, fatigue, or stress.
• Lesions are commonly called cold sores or fever blisters that results in painful sores/fever blisters on the lips and nares. The disease usually subsides on its own, it can reoccur.
• Physical examination and history are important before diagnosis.
• Topical and oral acyclovir, famciclovir, or valacyclovir, may hasten healing.
• Herpes varicella-zoster causes chickenpox/shingles.
• Reactivation is caused by trauma, malignancy, stress, or local radiation.
• Approximately 1 million cases per year occur in the US (1 in 3 people will be affected in their lifetime).
• Those over 80 years of age are at risk of developing shingles.
• Approximately 50% of people who live to age 80 develop shingles.
• The CDC recommends Shingrix; the Zostavax vaccine is contraindicated in immunocompromised patients.
• No healthcare worker/visitor should be in contact with patients diagnosed with chickenpox/shingles if they never doses of the varicella vaccination.
• A pregnant woman should not care for a patient with chickenpox/herpes zoster (fetus can be harmed).

Fungal Infections

• Fungal infections are called mycoses.
• Systemic fungal infections involving the lungs and other internal organs are called systemic mycoses.
• Diagnosis is confirmed by microscopic examination of skin scrapings with potassium hydroxide (KOH) solution.
• Fungal specimens generally show the typical filaments of fungal organisms.
• Tinea pedis (athlete's foot) affects the feet, particularly between the toes and spreads with contact in public facilities.
• Cases are of tinea pedis contract/spread in swimming pools, spas, showers, and other public facilities.
• Treatment of tinea pedis consists of keeping the area dry/clean, being exposed to sunlight.
• Topical antifungals, such as ciclopirox, miconazole, clotrimazole, econazole, ketoconazole, and naftifine, may be prescribed by professionals.
• Stubborn infections can be treated through itraconazole & terbinafine.

Parasitic Infections

• The parasites that cause pediculosis and scabies are found throughout the world in all types of climates.
• Occurence of pediculosis and scabies in the united states has recently increased significantly because of homelessness and communal living.
• Systemic infections are not commonly associated with louse infestation, but they carry bacteria that can cause epidemics.
• The scabies mites burrow under the top layers of the skin and live their entire lives there.
• Scabies causes curved or linear white/erythematous ridges in the skin that are easily visible.
• The drugs most commonly used against lice and scabies are permethrin, pyrethrins, and malathion, while Benzyl alcohol suffocates the lice.

Noninfectious Disorders of Skin

• Basal and squamous cell cancers are highly curable.
• Susceptibility to skin cancer tends to run in families.
• Early diagnosis and treatment can prevent melanoma deaths.
• Heavy exposure to UV radiation can cause skin cancer, labeled "carcinogenic to humans" by the International Agency for Research on Cancer.
• Three main types of skin malignancy are:
  • Basal cell carcinoma.
  • Squamous cell carcinoma.
  • Melanoma.

Pressure Injury (ULCERS)

• Can develop when pressure occurs against the skin in areas and interferes w/ circulation.
• Pressure injury is defined as injury to the skin caused by pressure alone/in combination w/ shear.
• Term ulcer is used only if an ulceration is present.
• Risk factors include confinement, immobility, incontinence, malnutrition, decreased level of consciousness, obesity, diabetes mellitus, dehydration, edema, excessive sweating, and extreme age.
• Pressure injury can be very costly to the health care system, costing about $10 billion and 60,000 deaths annually.
• Increased energy (calories); protein; zinc; and vitamins A, C, and E have been shown to reduce pressure injury.
• Once a patient has developed a pressure injury, treatment depends on the stage of the lesion.
• Best practice for the prevention of pressure injuries:
  • Assess the skin of all patients every 8-24 hours
  • Reposition bedrest patients every 2 hours.
  • etc.
• Removal of any eschar (dead, necrotic tissue) must occur for a pressure ulcer to heal.
• Many hospitals and larger long-term care facilities have a wound care nurse specialist who oversees wound treatment.
• Normal saline or other nontoxic solutions, are a way of cleansing that prevents disruption of granulation tissue.

Burns

• Burns are injuries to the skin caused by exposure to extreme heat, hot liquids, electrical agents, strong chemicals, or radiation.
• The emergent phase averages 24 to 48 hours but may last for as long as 3 days.
• Burn severity depends cause, the temperature and duration of contact, the extent of the burned area, and the anatomic site of the burn.
• Signs and symptoms include:
  • Slight reddening of the skin to full loss of tissue down to bone with black.
  • Charred areas.
  • Blisters may form.
  • Dry scablike crust forms over a superficial burn.
• Parkland formula for fluid resuscitation is:
  • 4 mL Ringer's lactate (RL) × % burn x weight in kg
• Enteral feedings are started within 24 to 28 hours after injury.
• Patients may take medications to reduce gastric acid to prevent ulceration (Curling ulcer).
• Goals during treatment during this phase include management of pain and anxiety, prevention of wound infection, promotion of nutritional intake, and rehabilitation therapy.
• Signs that indicate infection include:
  • Strong odor
  • Color change to dark red or brown
  • etc.
• Private rooms are needed for wound treatment.
• Use topical ointments.
• Burns can be distressful for years after the burn occurs.
• There are various ways to implement gentle care for the patient.

Explore different types of dermatitis, including herpes zoster, contact dermatitis, and venous stasis. Learn the necessary precautions to prevent transmission and the immunological mechanisms at play. Identify the most likely cause of dermatitis based on symptoms.