Managing Common Skin Disorders

Objectives in Managing Skin Disorders

• Discussing the epidemiology, pathophysiology, and clinical manifestations of common skin disorders.
• Common skin disorders include bacterial infections, herpes simplex, fungal infections, and psoriasis.
• Describing diagnostic methods and results to confirm the presence of skin disorders is key in diagnostic evaluation.
• Interprofessional management involves collaborative efforts across multiple healthcare disciplines
• This is important when managing bacterial infections, herpes simplex, fungal infections, and psoriasis.
• Developing comprehensive nursing care plans for patients with skin disorders is crucial for nursing care planning
• These plans incorporate pharmacological treatments, dietary modifications, and lifestyle interventions to promote optimal outcomes.
• Identifying potential complications associated with skin disorders and strategies for prevention and management is key for complications and risk management.

Functions of the Integumentary System

• Protection from external elements
• Provides a barrier from bacteria and viruses
• Insulation and temperature regulation
• Sensory perception, such as touch, pain, and temperature
• Enables movement
• Facilitates vitamin D metabolism

Factors Influencing Skin Health

• Nutrition
• Hydration
• Age
• Hygiene
• Environment
• Mobility
• Lifestyle
• Medications

Skin Infections: Uncomplicated vs. Complicated

• Uncomplicated Infections: Feature no systemic symptoms, localized signs, localized warmth, mild to moderate pain, and no changes in blood work.
• Complicated Infections: Characterized by systemic symptoms (tachycardia, fever, lethargy, disproportionate pain), spreading cellulitis (lymph nodes), edema, ischemia, tissue necrosis, elevated WBC & CRP, and moderate pain.

Bacterial Skin Infections: Epidemiology

• Can be community or healthcare-acquired
• Most skin and soft tissue infections stem from Staphylococcus aureus and Streptococcus pyogenes.
• Methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery can affect up to 33% of patients.

Bacterial Skin Infections: Pathophysiology

• Non-necrotizing infections involve a portal of entry through breaches in skin integrity.
• Necrotizing infections spread rapidly and destroy tissue.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• Resistant to many previously effective antibiotics
• Thrives in overcrowded living conditions and via skin-to-skin contact
• Can be spread by sharing contaminated objects
• Linked to previous MRSA infections and hospital professions
• Immunocompromised individuals and those with poor hygiene are more susceptible
• Can also cause infection in healthy/younger patients

Impetigo

• Caused by strep, staph, or a combination of both
• Typically affects the face
• Characterized by a honey-colored crust
• Redness surrounding the affected area
• Treated with topical antibiotic prescriptions
• Very contagious

Folliculitis

• Caused by staph
• Area is tender to the touch
• Most common areas affected are the scalp, beard, and extremities
• Recommend soaps such as Hibiclens or Dial
• Treated with topical antibiotics
• Systemic antibiotics may be needed for extensive, deep lesions

Cellulitis

• Caused by staph aureus or strep
• Characteristics - hot, tender, red, swollen area with diffuse borders
• May have chills, malaise, and fever
• Treatment - systemic antibiotics and elevation

Necrotizing Fasciitis

• Potentially life-threatening infection
• Rapid spread
• Fever, tachycardia, and hypotension
• Disproportionate pain
• Disorientation
• Edema
• Possible loss of feeling due to vascular occlusion
• Can lead to sepsis

Bacterial Skin Infections: Medical Management - Diagnosis

• Medical Diagnosis uses laboratory data which includes; culture and sensitivity tests, complete blood count (CBC), serum electrolytes, C-reactive protein (CRP)
• Diagnosis can also be achieved through biopsies and nasal swabs

Bacterial Skin Infections: Complications

• Overuse and misuse of systemic antibiotics
• Necrotizing infection

Bacterial Skin Infections: Nursing Management — Assessment and Analysis

• Clinical manifestations depend on organism, tissues involved, and comorbidities

Bacterial Skin Infections: Nursing Interventions — Assessments

• Vital signs
• Wound and skin condition
• Complete blood count
• Culture results
• Nutritional status

Bacterial Skin Infections: Nursing Interventions — Actions

• Administer antibiotics based on culture results
• Wound care
• Surgical evaluation

Bacterial Skin Infections: Nursing Interventions — Teaching

• Hand washing
• Wound care
• Clinical manifestations of infections

Bacterial Skin Infections: Nursing Management — Evaluating Care Outcomes

• Recovery of infection

Herpes Simplex Virus: Epidemiology

• HSV-1 affects 60% to 95% of adults; also causes 71.2% of genital herpes
• HSV-2 affects 16.2% of people aged 14 to 49

Herpes Simplex Virus: Pathophysiology

• Primary infection occurs through direct contact with an individual with HSV
• Secondary infection occurs following an exogenous or endogenous trigger that reactivates the dormant virus
• Triggers include ultraviolet (UV) light exposure, febrile illness, and stress

Herpes Simplex Virus: Clinical Manifestations

• Fever
• Malaise
• Myalgia
• Anorexia
• Irritability
• Cervical or inguinal lymphadenopathy
• Lesions on the lip, face, and mucous membranes

Herpes Simplex Virus: Medical Management — Diagnosis

• Includes an assessment of clinical presentation
• Virological testing
• Serological type-specific glycoprotein

Herpes Simplex Virus: Medical Management — Treatment

• Systemic antiviral therapy
• Episodic or suppressive therapy

Herpes Simplex Virus: Complications

• Psychosocial stress
• Risk factor for HIV acquisition
• Disseminated neonatal herpes (passed on during pregnancy)

Herpes Simplex Virus: Nursing Management — Assessment and Analysis

• HSV infection may be asymptomatic

Herpes Simplex Virus: Nursing Interventions — Assessments

• Pain and fever
• Oral cavity lesions
• Genital lesions
• Sexual history
• Skin and mucous membranes
• Knowledge of HSV transmission
• Test for pregnancy
• Ability to cope with diagnosis

Herpes Simplex Virus: Nursing Interventions — Actions

• Laboratory testing
• Administer medications as ordered
• Collaborate with interprofessional team

Herpes Simplex Virus: Nursing Interventions — Teaching

• Actions of antiviral medications
• Safe sex practices
• Considerations of HSV infection in pregnancy

Herpes Simplex Virus: Nursing Management — Evaluating Care Outcomes

• Engage in safe sexual practices
• Learn to cope with feelings of isolation and depression

Herpes Simplex Virus (HSV)

• Most common viral infection
• Presence of two types (HSV 1 and HSV 2)
• HSV 1 (cold sores)
• HSV 2 (genital)
• Is a lifelong virus
• Transmission can occur within 2 weeks
• Signs and symptoms include; fever, malaise, cervical/inguinal lymph node enlargement, facial or genital lesions

Chicken Pox & Shingles (Varicella Zoster Virus)

• Varicella vaccine for immunization!
• Signs & Symptoms include; skin lesions, fever, and itching
• Supportive care if acquired - antivirals, antihistamines, and pain relief medication

Molluscum Contagiosum (Poxvirus)

• Raised, “fluid-filled” bumps
• Associated with pain and itch
• No antiviral treatment

Viral Skin Infections: Nursing Management

• Administration of antiVIRals such as acyclovir and valacyclovir
• Assessment
• Monitoring of vital signs
• Pain management
• Emotional support
• Education
• Side Effects of antiviral medications are often unpleasant for most patient: severe nausea, fatigue, irritability, flu-like symptoms, and body aches
• Requires strict adherence to regimen and patient compliance
• Supportive care required.

Fungal Infections: Epidemiology

• 4 million healthcare visits per year on account of infection

Fungal Infections: Pathophysiology

• Yeasts
• Dermatophytes

Fungal Infections: Medical Management — Diagnosis

• History and physical examination
• Potassium hydroxide microscopy

Fungal Infections: Medical Management — Treatment

• Antifungal agents

Fungal Infections: Complications

• Critically ill and immunocompromised patients.
• High mortality of invasive candida.

Fungal Infections: Nursing Management — Assessment and Analysis

• Careful assessment of high risk patients

Fungal Infections: Nursing Interventions — Assessments

• Assess skin
• Pruritus; itching
• Recent and current infections
• Liver function
• Health history

Fungal Infections: Nursing Interventions — Actions

• Meticulous hand washing
• Perform cultures as needed
• Administer antifungal medications as prescribed
• Cleanse incontinent episodes ASAP
• Separation skin folds with gauze or dressing to keep dry

Fungal Infections: Nursing Interventions — Teaching

• Avoid tight fitting clothes
• Clinical manifestations of fungal infections
• Complete antifungal infection medications as prescribed

Fungal Infections: Nursing Management — Evaluating Care Outcomes

• Knowledge of clinical manifestations
• Avoidance of complications - Bloodstream infection

Tinea Capitis

• Location: Scalp
• Scaly scalp
• Alopecia
• Broken Hair
• Treatment
• Oral antifungals (Fluconazole)
• Topical antifungals (Lamisil)

Tinea Corporis

• Location: Body
• Patches/Plaques
• Raised borders
• Central Clearing
• Treatment: Topical Antifungals

Tinea Cruris

• Location: Groin (Jock itch)
• Red/brown plaques
• Central clearing
• Vesicles or pustules to borders
• Pruritus
• Scrotum spared
• Treatment: Topical Antifungals

Tinea Pedis

• Location: Feet
• Maceration between toes
• Dry scaling of soles of feet
• Treatment: keep feet dry/ventilated, topical antifungal, PO antifungal

Oral Candidiasis "Oral Thrush"

• Location: Mouth
• Clinical Manifestations: creamy, white plaques and/or thick white coating on tongue
• Treatment: Swish & swallow PO antifungal (Nystatin), or PO tablet (Fluconazole)

Vaginal Yeast Infection (vulvovaginal candidiasis)

• Location: Vagina and Vulva
• Thick discharge
• Pruritis
• Treatments - topical antifungals, intravaginal antifungals (miconazole), or PO antifungals (fluconazole)

Intertrigo

• Location: Skin folds (armpits, under breasts/abdomen)
• Maceration & Erythema
• Itching & Burning
• Eliminate causative factors
• Separate skin folds (InterDry)
• Keep skin dry
• Topical Antifungal powders (Nystatin)

Onychomycosis

• Location: Nails
• Yellow nails
• Brittle/thick nails
• Subungual hyperkeratosis
• Treatment - topical/PO antifungals, nail lacquer solutions, laser treatments, or nail removal)

Antifungal Medications: General Nursing Points

• Minimal side effects
• Many antifungals are over-the-counter (OTC) available for people
• Antifungals can inhibit healthy bacteria growth and result in a secondary bacterial infection needing antibiotics
• Skin issues should always be looked at by a physician/dermatologist – fungal versus bacterial plays an important role in the treatment

Psoriasis: Epidemiology

• Affects 7.5 million people, or 2% of the population

Psoriasis: Pathophysiology

• Cause unknown
• Characterized by epidermal thickness with increased vascularity and inflammation

Psoriasis: Medical Management — Diagnosis

• Diagnosis based on clinical manifestations, with no laboratory tests required.

Psoriasis: Medical Management — Treatment

• Includes the reduction of clinical manifestations
• Topical creams
• UV light therapy
• Systemic medication.

Psoriasis: Complications

• High risk of other diseases such as cancer, cardiovascular disease, Crohn's disease, metabolic syndrome, uveitis, and liver disease
• Can also lead to depression, anxiety,

Psoriasis: Nursing Management — Assessment and Analysis

• Assessment of full health history, family history, and quality of life are imperative

Psoriasis: Nursing Interventions — Assessments

• Checking of vital signs
• Pain levels
• Skin assessment
• Mood assessment

Psoriasis: Nursing Interventions — Actions

• Administering prescribed medications
• Monitoring side effects of treatment
• Topical preparations
• Provide emotional support
• Referral to counseling

Psoriasis: Nursing Interventions — Teaching

• Proper hand washing techniques
• Understanding clinical manifestations
• Recognizing signs of skin infection
• Limiting sunlight exposure

Psoriasis: Nursing Management — Evaluating Care Outcomes

• The use of emotional support and referrals and family education will help enhance patient’s quality of life.

Psoriasis: Autoimmune Skin Disease

• No cure
• Can experience Exacerbation and Remission
• Strongly linked to Genes, Immune system and Environment
• Two types: plaque psoriasis and erythroderma
• Possibly lead to psoriatic arthritis

Nursing Management of Psoriasis

• Skin assessments
• Reduce symptoms
• UV light therapy
• Topical steroid creams
• Systemic medications
• Education *Dry patches can lead to open sores = risk for infection
• Emotional support
• Referral to counseling/support groups

General Nursing Notes regarding the Skin

• Be the physician’s eyes
• Become informed with organization’s policy on skin assessment
• Use 4-Eyed Skin Assessment
• Implement orders as written -If there is a dressing, there should be an order
• Assist patient in turning/repositioning
• Assist patient in hygiene practices

Skin Breakdown Prevention

• Utilize pressure mattresses and surfaces
• Elevate HOB at an appropriate degree
• If patient is sitting use waffle cushions
• Use approved padded dressing
• Utilize pillows for arms & knees
• Moisture barriers for incontinence (IE: zinc oxide ointment)
• Moisturize dry skin
• Always use gauze wrap if possible, avoid tape
• Focus on Braden Scale Score for breakdown risk