Integumentary Disorders: Diagnosis and Treatment

Unit 7: Integumentary Disorders

• Unit 7 focuses on integumentary disorders.

Terminal Learning Objectives

• Upon completion of this unit, one should be able to determine necessary exams/questions, accurately identify diagnoses, and formulate treatment plans for common integumentary disorders from a patient scenario.

Enabling Learning Objectives

• Analyze and interpret facts and principles for integumentary disorders.
• Appropriately identify red flags
• Differentiate common and life-threatening integumentary disorders by their signs, symptoms, and findings.
• Comprehend the importance of patient interviewing to arrive at the correct diagnosis.
• Differentiate integumentary disorders.
• Calculate appropriate treatment plans and patient education

Key Points

• Most diagnoses listed do not have good descriptions or pictorial representations in the medical literature for people of color, so one should take a thorough and careful history and examination of each patient as presentations may vary with skin tones.
• Skin exams have the potential to be a sensitive situation.

Integumentary Anatomy Review

• The integumentary system has two layers: dermis and epidermis.
• Epidermis: comprised of 5 cell layers and 3 cell types, lacks blood vessels
  • Keratinocytes: provide strength and waterproofing.
  • Melanocytes: provide pigment; absorb/scatter UV radiation.
  • Langerhan’s cells: macrophages.
• Dermis: comprised of fibrous connective tissues, nervous tissue, and blood.
  • Accessory structures arise here: hair follicles, nails, skin glands (eccrine & apocrine sweat glands), sensory receptors, blood vessels, smooth muscle fibers.
• Subcutaneous layer (hypodermis) functions
  • Connects skin to underlying organs.
  • Contains major blood vessels that supply skin.
  • No sharp boundary between it and dermis.
  • Insulation for thermoregulation: Conserves body heat and keeps heat out.

Terminology

• Macule
• Patch
• Papule
• Plaque
• Nodule
• Pustule
• Vesicle
• Bulla
• Wheal
• Scale
• Crust
• Erosion
• Fissure
• Ulcer
• Hypertrophic scar
• Keloid
• Excoriation
• Lichenification
• Comedones
• Milia
• Cyst
• Telangiectasia
• Petechia
• Purpura

Calluses and Corns: Introduction

• Hyperkeratosis in areas of intermittent pressure/friction.
  • Usually over a bony prominence such as heel or metatarsal heads.
• Calluses: generally superficial, can cover broad areas of skin, lack a central plug, usually asymptomatic.
• Corns: deeper, more focal and painful/tender when pressure is applied.

Calluses and Corns: Subjective

• Calluses: superficial lesions on skin, usually asymptomatic but may become thick and irritated with extreme friction.
• Corns: deeper lesions on skin, frequently painful/tender when pressure is applied.
• Focused History: shoe type worn, especially military boots, and recent changes in activity level.

Calluses and Corns: Objective

• Calluses: Lack a central plug and have a more even appearance, shows smooth translucent skin after paring.
• Corns: sharply circumscribed keratinous plug (pea-sized or slightly larger), extends through most of the underlying dermis.
  • After paring shows sharply outlined yellowish to tan translucent core.
  • Soft Corns: between toes
  • Hard Corns: occur over prominent bony protuberances

Calluses and Corns: Assessment

• Differential diagnosis to consider:
  • Bunion (valgus deformity of the great toe).
  • Metatarsalgia (pain on the plantar surface of the 2nd and 3rd metatarsals).
  • Plantar wart (verrucous papule that may have pain with pressure).
  • Molluscum contagiosum (pearly umbilicated papules).
  • Furuncle (painful inflammatory swelling).

Calluses and Corns: Plan

• Can manually remove hyperkeratotic tissue.
• Can use a nail file, emery board or pumice stone immediately after bathing in order to remove hyperkeratotic tissue.
• Use keratolytic (salicylic acid) treatments, while avoiding application to healthy surrounding skin.

Calluses and Corns: Patient Education

• Pressure of affected surface should be reduced or redistributed.
• Cushioning and altering foot biomechanics can help prevent corns and help existing corns.
• One can use pads, rings, and moleskin to help.
• Wear soft, well-fitting shoes where toes can move freely.
• Symptoms should improve within a month.

Subungual Hematoma: Introduction

• Blood becomes trapped between the nail plate and the nail bed, usually as a result of trauma.

Subungual Hematoma: Subjective

• Pain from the pressure in a confined space and possible eventual separation and temporary loss of the nail plate.
• Focus on trauma/injury history.

Subungual Hematoma: Objective

• Swelling/ecchymosis, and disruption of nail plate.
• Blood may be visible under the nail and the nail may be tender to palpation.

Subungual Hematoma: Assessment

• If trauma is suspected, obtain x-rays.
• Symptoms include fracture.
• Subungual melanoma: Consider a pigmented nail, painless, nail that grows and a spot that will not move; no trauma history.
• Subungual keratoacanthoma: Consider as a tumor of the finger/nail beds, presents suddenly with pain, swelling and inflammation however no trauma history.

Subungual Hematoma: Plan

• Nail trephination: perform within in 24-48 hours.
  • Create a hole in the nail plate (escape for the blood) using an 18-gauge needle in a rotary, drilling motion or electrocautery device (unless there is nail polish).
  • Do not perform if nail is injured or obviously deformed.

Subungual Hematoma: Education

• Follow up for further evaluation if symptoms do not improve within 1-2 days.

Ingrown Toenail: Introduction

• Incurvation or impingement of a nail border into its adjacent nail fold, causing pain
• Cause: tight shoes, abnormal gait, bulbous toe shape, excessive trimming of nail plate, congenital variations in nail contour
• Can cause paronychia: infection can occur along the nail margin

Ingrown Toenail: Subjective

• Symptoms: pain along corner of nail fold or along its entire lateral margin, mild discomfort initially (especially with shoes) pain can increase
• History focus: -Shoe type (Military boots?) -Activity level -History of nail trauma, trimming - too short or rounded edges rather than straight across

Ingrown Toenail: Objective

• Physical Exam finding is incurvation or impingement of a nail border into its adjacent nail fold.

Ingrown Toenail: Assessment

• Osteochondroma: benign bone tumor common in young adults, x-rays needed
• Paronychia: infection of the periungual tissues that causes pain along the nail margin
• Amelanotic melanoma: occurs in older adults, granulation tissue around toe Tinea unguium (onychomycosis): lusterless, brittle, discolored, hypertrophic nails
• Bunion: valgus deformity of great toe

Ingrown Toenail: Plan

• Mild cases: Insert cotton between ingrown nail plate and painful fold using a thin instrument
• Moderate cases or development of infection: Nail partial or occasionally total nail excision
• Recurrent ingrown nail: Consider destruction of adjacent nail matrix with phenol or trichloroacetic acid (ask for preceptor guidance as this is a permanent solution)

Ingrown Toenail: Plan

• Wear well-fitting shoes (larger toe box may help)
• Warm Epsom salt soaks may help
• Proper nail trimming cutting straight across nail
• Change socks (Wool) often if in field environment
• Symptoms do not improve within 1 week or sooner if symptoms worsen

Paronychia: Introduction

• Infection of the periungual tissues that causes pain along the nail margin Usually acute, but chronic cases may occur
• Causative organisms are usually Staphylococcus aureus or streptococci Organisms enter through a break in the epidermis resulting from a hangnail, trauma to nail fold, loss of cuticle, or chronic irritation
• Toes, infection often begins as an ingrown toenail

Paronychia: Subjective

• Pain along the nail margin Can develop over hours to days with pain, warmth, redness, and swelling
• Discharge usually develops along nail margin and sometimes beneath nail

Paronychia: Objective

• Redness, swelling, pain along nail border
• Possible discharge/pus
• Nail border tender to palpation
• If on feet, gait abnormalities due to pain

Paronychia: Assessment

• Differential:
  • Felon: Painful swollen pad of digit (“fingertip”), often requires incision and drainage -Osteochondroma: benign bone tumor common in young adults, x-rays needed -Amelanotic melanoma: occurs in older adults, granulation tissue around toe -Ingrown toenail: incurvation or impingement of a nail border into its adjacent nail fold, causing pain Bunion: valgus deformity of great toe

paronychia: Plan

• Antistaphylococcal Antibiotics: -Dicloxacillin or cephalexin -If CA-MRSA (community acquired methicillin-resistant S. aureus) Consider rimethoprim-sulfamethoxazole or doxycycline Drainage:
• If fluctuant swelling or visible pus, drain using a #11 scalpel blade inserted between nail and nail fold (skin incision is unnecessary)
• Infected ingrown toenail: Nail excision

Paronychia : Patient Education

• Warm compresses and Epsom salt soaks may help, especially initially Return for further evaluation if symptoms do not improve within 1 week or sooner if symptoms worsen"

Urticaria and Angioedema: Introduction

• Migratory, well-circumscribed, erythematous, pruritic plaques on the skin
• Can be Immunologic/nonimmunologic basis. -Commonly mediated by IgE: -Non-Immune-mediated is mast cell activation by certain drugs, stimuli - mechanism is poorly understood.
• Acute urticaria incidents are often acute (1-2 weeks)
  • food ingestion, infection, insect bite or sting, medications Chronic urticaria are 6 weeks +, consider autoimmune or idiopathic causes.
• Angioedema -involvement of deeper subcutaneous tissue with swelling of the lips, eyelids, palms, soles, and genitalia.
  • assess the patient immediately for signs of airway compromise.

Urticaria and Angioedema: Subjective

• Transient welts on the dermis and its defined edge
• Red and vary in size. Can be intensely pruritic
• Individual lesions in true urticaria duration <24 hours. Recent History exposure to foods, infections, medications.

Urticaria and Angioedema: Medications

• Medications: -First generation antihistamines are sedating but can be quite effective, such as Hydroxzine, diphenhydramine. -Second generation antihistamines are less sedating and should be used first line. such as Fexofenadine, cetirizine, loratadine. H2-blockers (cimetidine), aSystemic corticosteroids if very severe and diffuse symptoms. Not effective in chronic urticaria

Urticaria and Angioedema: Introduction

• Avoid known or inciting factors such as foods, drugs, cold exposure, hot air, and stress
• Track/episode diary can help if cause is unknown Follow Up Actions:
• Assess if airway patency is compromised
• Assess treatment plan is not improving

Blue Directive: Contact Preceptor Immediately

Contact Dermatitis: Introduction

• Types Acute or Chronic by direct skin contact Irritant
• Non-immune, modulated
• 80% of occupational exposure (cleaners, health care, food industry) Allergic Skin changes occur with re-exposure
• Most Common: poison ivy and oak

Contact Dermatitis: Subjective

• Acute or Chronic Irritant: -Acute is more painful, than pruritic -Scaling/edema through erosions, crushtin, and blistering Allergic Less painful, Scaling/edema through vesicles to sever edema and bullae. Look for -Hair products or dyes
  • face creams -cosmetics -soaps/shampoos

Contact Dermatitis: Introduction

PE Irritant:

• Sharp border
• edema, erythma, bullae Acute or Chronic Allergic Lesion Linear
• Vesicles and Bullae
• Possible localized infections History Occupational exposure
• Products (hairs sprays shampoos) Travel Exposure & Clothing/Cosmetics

Contact Dermatitis: Differential

• Seborrheic dermatitis- scalp and face, greasy and scaly lesions Consider oppurtunistic infections opportunistic hyperacute,

• Atopic dermatitis, weepy flares of atopic dermatitis Atopic- lichenified plaques, flexor regions Lichen planus

• Psoriasis- plaque w.extensor surfaces

Contact Dermatitis: Plans

• Steroids for localized Triamcinolone 0.1% ointment -localized vs use systemic Prednisone (Preceptors)
• Localized = No face

Contact Dermatitis: Pt Education/Discharge Planning

• Avoid Triggers
• If severe - poison IVY- Removal of contaminate oils is vital

Preceptor Directive: Routine Review IAW 44-103

Atopic Dermatitis

• Also called "Eczema", it is a chronic relapsing inflammatory skin disorder
• Involves: Genetic, Immunologic disorders (IgE), and epidermal barrier dysfunction.

Atopic Dermatitis: Diagnostics

• Prutitus: Itch, Dry skin, lichenification

Atopic Dermatitis: Symptoms

• It can be from your face upper truck which is all over hands, neck and popliteal folds to cause: -Flexure and prolonged itching.

Atopic Dermatitis: HPI

• Personal and Traids related
  • Asthma: Allergic Rhinitis, Dermatitis and atopic issues

Atopic Dermatitis: Objectives: Dx

• Rough reddish plaque may have vesicles on hand & Palms

Atopic Dermatitis: Differentials

• Seorhea: scales and quick response
• Staph: is the pt having oppurtunisti flare

Atopic Dermatitis Notes

1. Must access severity if the pt is mild and use low-mid cordic

• If Pt is Severe Chronic go for something high level
• Always use the Preceptors when assessing*

Atopic Dermatitis: Management

• Cool Compressed and Antihistamines can help.

Atopic Dermatitis: Treatment

• The plan includes: If mild- moderate and with topical localized withlocalized steriod (no face)! -If is severe: (Prednisone, but use Prepcetor and Steroids

Atopic Dermatitis: pt education/ D/c

1. Gentle Skin Care Bathing 1x/day.
2. Gentle cleansers, and mosturizer

Next visit schedule to help within "1-2 week range"

Green Directive: Routine Review by Preceptor IAW 44-103

Tinea

Tinea = dermatophytes

• Corporis/Circinata is bady ringworm
• Tinea Cruris is Jockage itch
• Tinea manum is: hands have fungus
• Tinea Peids: Feet fungus
• Tinea Versicolor is Versi colored

Tinea Subjective

• Tinea Corporis or tineas circinata can be Hypon and Red if lighskin or dark is light skin Tinea - Jock Ick: Can cause serve itching which can not occur at the scrotum Versicolor - Usually asymptomatic legions which can range from "White to tan to brown to pink". Tinea- nail dystrophic of nails- which are deformed and white- yellow

Tinea: Objective: PE

• Tinea: body ring looks like it, advancing in circle pattern
• Tinea cruris: Spreading is at a higher level (Sharp central)
• Tinea pedia and Tinea manun- Can can scalic may develop into fissure and masertion may form.
• Versa colored- Can have tan, pink or white maculae that won't change in sun

1. May want to obtain KOH in this case can be use for may

Basic Tools:

Onych: Luster's brittiles

• *The nails have luster

Green Directive: Routine Review by Preceptor IAW 44-103

Differential (Have Negative Fugnal study)

• Contact
• Psoriasis: plate with scales.
• Dermatitis,
• Intertigio
• Candidia

Always used Topical and AntiFungals. Exceptions

Severe disease with systemic and nails use the terbinafine and use a perceptor only .

Tips

Moistness can build use talc and dryer products

Need them Back within 2-3 weeks

Green Directive: Routine Review by Preceptor IAW 44-103

Intertrigo introduction

•Skin maceration in body folds caused by heat, friction and moisture and/or by infection.

•obesity factors-Poor hygene