Skin conditions and nursing interventions

• Therapy for skin conditions aims to prevent further damage, halt secondary infections, reverse inflammation, and alleviate symptoms.
• Nursing care involves administering medications, dressing wounds, ensuring hygiene and educating patients on self care.
• Nursing management includes obtaining health history, direct observation, physical assessment

Skin Function

• Skin protects against bacteria.
• Skin receptors monitor temperature, pain, and touch.
• The epidermis absorbs water.
• Skin prevents excessive fluid loss.
• Skin continuously produces heat.
• Skin synthesizes vitamin D.
• Skin generates immune responses.

Physical Examination

• Involves obtaining history, inspection, and palpation.
• Gloves are required during examination.
• Use PPE as indicated.

Normal Aging Changes

• Thinner skin
• Uneven pigmentation
• Wrinkling, reduced elasticity, skin folds
• Dry skin
• Diminished hair
• Increased fragility and injury potential
• Reduced healing

Pruritus (Itching)

• Most common dermatologic symptom.
• It can originate from skin conditions or systemic diseases like DM, thyroid issues, blood disorders, renal failure, liver issues, or cancer.
• Causes include medications (aspirin, opioids), chemicals, radiation therapy, heat and psychological factors.
• Itch receptors (C-fibers) in skin, mucus membranes, and corneas trigger itching.
• Scratching releases histamine.
• CBC, thyroid panel, liver function and renal function tests help diagnose the cause.

Care for Patient with Pruritus

• Apply cold compresses or cooling agents.
• Use emollients immediately after bathing to trap moisture.
• Use tepid water for baths.
• Avoid vasodilation from heat, alcohol, or hot foods

Secretory Disorders (Sebum Production)

• Related to sebum production

Acne Vulgaris

• Inflammatory disease of sebaceous follicles.
• It is a chronic follicular disorder affecting pilosebaceous follicles on the face, neck, and upper trunk.
• Characterized by comedones (white and black heads), papules, pustules, nodules, and cysts.
• Affects 80% of adolescents, more common in males.
• Increased sebum production initiates eruptions.
• Closed comedones (whiteheads) contain lipids, keratin, and oils.
• Open comedones (blackheads) are open to the environment.

Acne Medical Management

• Aim to reduce bacteria, sebaceous gland activity, plugged follicles, and secondary infections.
• Washing twice daily with cleansing soap and using over-the-counter benzoyl peroxide or salicylic acid are initial treatments.
• Oral antibiotics (tetracyclines) may cause photosensitivity, nausea, vomiting, and diarrhea.
• Oral retinoids (isotretinoin) treat severe cystic acne but cause major birth defects, contraindicated in pregnancy and increase suicide risk. Do not take vitamin A supplements when taking retinoids.
• Avoid foods high in refined sugars.

Seborrheic Dermatitis

• Chronic inflammatory skin disease affecting areas with sebaceous glands or skin folds.
• Oily and dry forms exist.
• Causes include genetics, hormones, nutrition, infection, dryness, and stress.
• No cure exists; therapy aims to allow the skin to repair itself.
• Corticosteroids and medicated shampoos offer benefits.
• It is chronic and tends to recur.
• Avoid external irritants, heat, perspiration, rubbing, and scratching since they prolong the disorder.

Infectious Dermatoses

• Bacterial skin infections: Impetigo, Folliculitis, Furuncles, Carbuncles
• Viral skin infections: Herpes Zoster, Herpes Simplex
• Fungal skin infections: Candida, Tinea (Ring Worm)
• Parasitic skin infections: Lice, Scabies

Impetigo

• Contagious superficial bacterial infection caused by staphylococci, streptococci, or multiple bacteria.
• Bullous impetigo features large, fluid-filled blisters that rupture into red areas. Non-bullous impetigo accounts for 70% of cases and affects already disrupted skin.

Folliculitis

• Folliculitis is inflammation in hair follicles.
• Small papules or pustules appear near hair follicles, often affecting shaved areas.
• Bacterial folliculitis is common, marked by itchy white bumps from Staphylococcus aureus.
• Hot tub folliculitis causes red, itchy bumps from bacteria in hot tubs or heated pools with high chlorine.
• Razor bumps (pseudo folliculitis barbae) occur due to ingrown hairs, mainly affecting men with curly hair who shave closely.

Furuncles and Carbuncles

• Furuncles (boils) are acute inflammations in hair follicles spreading to the dermis (deep folliculitis).
• Bacteria (staphylococcus) cause tissue necrosis, forming a yellow or black center.
• Carbuncles are similar to furuncles.
• They form in areas subject to irritation, pressure, friction, and perspiration like the neck, armpits, and buttocks.

Management of Bacterial Skin Infections

• Avoid squeezing or poking lesions.
• Antibiotic selection depends on culture and sensitivity studies.
• Incision and drainage speed up recovery.
• Warm, moist compresses hasten resolution of furuncles and carbuncles.
• Supportive management includes controlling fever.
• Practice thorough handwashing to prevent staphylococcus transmission.
• Maintain a hygienic environment.
• Cover pillows with plastic and disinfect daily if lesions drain.
• Launder clothing daily.
• Use antibacterial soaps and shampoos.

Viral Infections

• Herpes Zoster (Shingles)
• Herpes Simplex

Herpes Zoster (Shingles)

• Acute inflammatory and infectious disorder.
• Painful vesicular eruption.
• Bright red plaques along nerve from posterior ganglia.
• Follows the nerve course and is almost always unilateral.
• Transmitted through direct contact or breathing in virus particles airborne and droplet precautions

Shingles Causes

• Varicella-zoster virus (like chickenpox). Incubation period is 7-21 days.
• Vesicles appear in 3-4 days, progress anteriorly and peripherally along dermatome.
• Lasts 10 days to 5 weeks.
• Complications: full-thickness skin necrosis/scarring, systemic infection from scratching.

Shingles Treatment

• Control outbreak by covering rash, avoiding scratching, washing hands, and wearing a mask.
• Reduce pain and discomfort. Prevent complications.
• Acyclovir (Zovirax) is administered IV, PO, or topically.
• Corticosteroids, antihistamines, and antibiotics can be prescribed.
• Cool compresses 2-3 times per day.
• Cleanse and dry lesions, decrease itching, and administer medication.

Herpes Simplex Virus (HSV)

• HSV-1 occurs on lips, mouth, gums, or tongue (oral herpes or cold sores).
• HSV-2 is spread sexually, causing genital herpes.
• Most contagious when lesions present.
• May cause painful blisters or ulcers that recur.

Herpes Management

• Often resolves by itself.
• Antiviral drugs like acyclovir reduce symptoms but do not cure.
• IV antivirals prescribed in severe cases. Educate patients: antiviral medication compliance. The virus can spread to sexual partners and neonates.

Fungal Skin Infections

• Candidiasis: fungal infection typically on skin or mucus membrane caused by Candida albicans.
• Types: vaginal yeast infection, cutaneous candidiasis, oral thrush.
• Use topical, oral, or IV antifungals based on symptom severity.

Tinea (Ring Worm)

• Tinea (Ring Worm) is a common and contagious fungal skin or nail infection.
• Lesions appear as rings or rounded tunnels under the skin.
• Treat Tinea Capitis (scalp) with Griseofulvin (4-6 weeks), Lamisil (2-4 weeks), and selenium sulfide shampoo for 2 weeks.
• Tinea Corporis (body), Cruris (groin), and Pedis (foot) are treated with topical, oral, or IV antifungals.
• Tinea Unguium (nails) specifically affects fingernails and toenails

Fungal Infections: Patient Education

• Instructions regarding medications, including oral and topical agents and shampoos
• Instructions regarding hygiene: Use clean towels and washcloths every day
• Do not share towels, combs, etc. (careful with pedicures)
• Keep skin folds and feet dry
• Wear clean, dry, cotton clothing, including underwear and socks; avoid synthetic underwear, tight- fitting garments, wet bathing suits and plastic shoes
• Avoid excessive heat and humidity Hair loss associated with tinea capitis is temporary.

Parasitic Skin Infections (PSI)

• Higher risk conditions: poor hygiene and living in close quarters

Scabies (PSI)

• Scabies is an infection from the sarcoptes scabiei itch mite.
• Characterized by Severe Itching and a skin rash caused by the mite.
• Pruritus is more intense at night.
• Wavy tunnels are caused by Mites burrowing into upper skin layers.
• Most often found on elbows, underarms, waist, feet, abdomen, thighs, fingers, and genitals

Treatment for Scabies

• Topical sulfur preparations are applied one to two times daily.
• Launder personal items immediately.

Patient Education for Scabies

• Practice thorough hand hygiene. strict contact precautions
• Health personnel must wear gloves when providing care.
• Instruct the patient to take warm, soapy bath; allow the skin to cool; and apply prescription scabicide lindane, crotamiton or 5%permethrin to entire body, not including the face or scalp. Leave for 12 to 24 hours.
• Wash clothing and bedding in hot water and dry in hot cycle
• Treat all the contacts at the same time
• Pruritis may continue for several weeks

Lice Infestation

• Lice infestation affects people in all ages.
• Lice are ectoparasites and depend on the host body for nourishment. They feed on human blood approximately 5 times a day.
• Lice inject digestive juices and excrement, causing itching.
• Commonly seen in poor hygienic environment and those who live in close quarters.

Types of Lice

• Pediculosis Capitis: Commonly found in back of the head and behind the ears.
• Pediculosis Corporis and pubis: Commonly seen in the areas of the skin that comes in closest contact with the underclothing. Spread chiefly by sexual contact. The most common symptom of pediculosis pubis is pruritis, particularly at night. Reddish brown dust any found in the client’s underclothing.

Management of Lice Infestation

• Treatment of head and pubic lice involves washing the hair with a shampoo containing pyrethrin compounds( RID or R&C Shampoo) or rinsing with permethrin ( NIX).
• Bathe in soap and water and apply prescription or over-the -counter permethrin. If eye lashes are involved, Vaseline may be applied twice a day for 8 days, mechanically remove any nits.
• All family members and sexual contacts must be treated and instructed regarding personal hygiene.
• All clothing and bedding must be washed in hot water or dry cleaned
• Patient and partner should also be scheduled for checkup to assess for coexisting sexually transmitted diseases.

Non-Infectious Inflammatory Dermatoses

• Psoriasis
• Irritant Contact Dermatitis (Eczema)

Psoriasis

• Psoriasis is an auto immune disorder typically characterized by the appearance of reddened, round of silvery plaques.
• Abnormality in proliferation of epidermal cells in outer skin layers
• Normal cells shed every 28 days versus psoriatic cells shed every 4-5 days
• Prevalent in Caucasian
• Median age 28

Psoriasis Causes

• Cause-unknown- T cell mediated response
• Genetic predisposition
• Environmental factors, Flare up in Cold weather
• May appear after skin trauma, Sunburn, Surgery

Psoriasis Aggravation

• Improves in warmer climates
• Periods of exacerbation and remission throughout the life
• Aggravated by:
  • Infections
  • *Streptococcal throat infection
  • *Candida infections
• Hormonal changes
• Psychological stress
• Trauma

Psoriasis Medical Mangement

• Goal is to slow process
• Topical Steroids
• Occlusive dressing ( plastic cover, vinyl clothing)applied over the steroid application to increase the effectiveness ( do not keep more than 8 hrs)
• Topical non -Steroidal: ( Suppress epidermopoesis)
  • Calcipotrine (Dovonex): Vitamin D- Derivative; (Decreasing mitotic turnover of the parasitic plaque)
  • Tazarotene (Tazorac): Helps to sloughing of the scales covering the plaque.
• Phototherapy: Decrease epidermal cellular proliferation. Psoralen(Photosensitizing agent) +UVA= PUVA or One time treatment with UVB rays.
• Systemic steroids ( cause flare ups up on withdrawal)
• methotraxate
• Cyclosporine- Immuno suppressive agent
• Biological Agents: Abs of T cell

Nursing Process

• Assessment
  • Appearance of the skin- silvery plaque
  • Assess Nail and scalp involvement
  • Coping the patient with condition

Psoriasis Nursing

• Diagnosis
  • Deficient Knowledge
  • Impaired skin integrity
  • Disturbed body image Complicated psoriasis lesion can lead to Infection and psoriatic arthritis

Psoriasis Planning

• Understand the psoriasis and the treatment regimen
• Achievement of smoother skin with control of lesions
• Development of self acceptance
• Absence of complications

Psoriasis Patient Education

• Education regarding the disease, skin care, and treatment regimen
• Measures to prevent skin injury: Avoid picking or scratching
• Prevent skin dryness: Use emollients, use warm water, pat dry, Avoid excessive washing Use of therapeutic relationship for support and to aid coping

Irritant Contact Dermatitis (Eczema)

• Contact dermatitis is an inflammatory reaction of the skin to physical, chemical or biologic agents.
• The epidermis is damaged by repeated physical and chemical irritations (irritate the c fiber ending in the epidermis, and activation of inflammatory mediators)
• Pre disposing Factors: extreme heat or cold, frequent contact with chemical, soap and water and pre existing skin conditions.

Contact Dermatitis S/S

• pruritis
• burning
• erythema
• papules
• vesicles
• oozing
• crusting
• drying
• fissuring and peeling
• repeated reactions can cause lichenification and pigmentation. Bacterial invasion may follow

Contact Dermatitis Medical Management

• Objective:
  • Sooth and heal the involved skin
• Apply barrier cream containing ceramide ( Cera ve, Impruv) or Dimethicone ( Cetaphil)
• Thin layer of cortico steroid cream Identify the irritant and avoid contact with the irritant ( Get detailed history)

Blistering Diseases

• Blistering skin diseases that are mainly resulted from immunoglobulin G (IgG) mediated autoimmune reactions are mainly classified as pemphigus (Blister)
  • Pemphigus Vulgaris
  • Bullous Pemphigoid Toxic Epidermal Necrolysis and Steven-Johnson Syndrome

Pemphigus Vulgaris

• characterized by the appearance of bullae of various sizes on the skin and mucus membrane due to an autoimmune disease
• Drug Induced ( phenobarbital, Ace inhibitors, penicillin)
• Genetic Factors
• Population ( Jewish or Mediterranean descent)
• Idiopathic

Pemphigus Assessment

• Clients with irregular shaped skin and oral erosions that are painful, bleed easily and heal slowly Positive Nikolsky’s Sign

Pemphigus Diagnostic Test

• Skin Biopsy ( Shows auto antibodies (IgG) in between epidermal cells
• Immuno fluroscent test ( Illuminate a net shape pattern due to presence of Abs between the cells)

Pemphigus Management

• Prevent Dehydration
• Maintain fluid and electrolyte balance
• Reduce the chance for secondary infection
• Promote Re- epithelization
• Medical Management:
  • Systemic Steroids
• Immuno modulators while weaning off the steroids (Immuno suppressive agents: Imuran and cellcept)
• IF Unresponsive to steroids, treat the patient with Rituximab and IVIG
• Bullous Pemphigoid
• Commonly seen in older adults with a peak incidence at about 65 yrs
• Commonly seen in the flexor surface of the arms The blisters are deep and heal quickly

Toxic Epidermal Necrolysis and Steven Johnson Syndrome (TEN & SJS)

• Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute skin disorders characterized by wide spread erythema and macule formation with blistering resulting in epidermal detachment or sloughing and erosion formation.
• (cell mediated Cyto-toxic reaction)
• TEN: Mortality rate is 25-35%
• SJS: 1-5% Mean age : 46-63 yrs.

TEN & SJS Common Causes

Medication reaction ( Antibiotics, Anti consultants, NSAIDS, Allopurinol etc.)

TEN & SJS Clinical Manifestations

• Starts with conjunctival irritation, burning , fever, cough, sore throat, headache, extreme malaise and myalgia.
• Followed by rapid onset of erythema involving much of the skin surface and mucus membranes, including oral mucosa, conjunctiva and genitalia.
• In severe cases- the laryngeal, bronchial and esophageal mucosal involvement
• Large flaccid bullae develop in some areas, in other areas, large sheets of epidermis are shed, exposing the underlying dermis Finger nails, toe nails and eye brows are shed along with surrounding epidermis

Pressure injury

• Ulcers, (bed sores)**injury to skin and underlying tissue resulting from prolonged pressure on the skin(reducing circulation)

Pressure Injury Highest Risk

• Impaired Immobility
• Impaired sensory perception or cognition
• Decreased tissue perfusion
• Decreased nutritional status
• Friction and shear
• Increased moisture

Pressure injury Stages

• Stage 1- skin red but not broken
• Stage 2- Damage through epidermis and dermis
• Stage 3- Damage through subcutaneous Stage 4-Muscle and possible bone involvement

Pressure Injury Stage 1

• Non-blanchable erythema
• Tissue swelling
• C/O discomfort

Pressure Injury Stage 2

• Break in skin
• Epidermis
• Dermis
• Necrosis

Pressure Injury Stage 3

• Subcutaneous tissue
• Deep crater
• With undermining
• Without undermining

Pressure injury Stage 4

• Underlying structures
• May have large undermined area

Pressure Injury Nursing Care

• Relieve pressure
• Proper positioning (Q2 hours position changes)
• Improve mobility
• Improve sensory perception
• Improve tissue perfusion
• Improve nutritional status (high protein)
• Reduce friction and shear
• Minimize moisture
• Barrier creams, negative pressure wound therapy

Precancerous Changes of Skin

• Photo damage-refers to spectrum of medical conditions cause by the sun.
• Sunburn-acute inflammatory skin response that occurs as a reaction to excessive exposure to sunlight.
• Actinic Keratosis-usually high intensity chronic sun exposure(scaly reds pots on face, chest and hands

Actinic Keratosis

• Pre-malignant lesions
• Cells of epidermis
• Chronically sun-damaged skin (UV light)
• Can lead to squamous cell carcinoma
• Skin Cancer*out-of-control growth of abnormal cells in the epidermis—caused by unrepaired DNA damage that triggers mutations
• Most common type of cancer caused by prolonged or intermittent, repeated exposure to UVL radiation from the sun, resulting to sunburn and blistering.

Skin Cancer Most Common Types

• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma

Basal Cell Carcinoma

• Basal cell Carcinoma-most common form; a malignant epithelial tumor of the skin arises from the basal cell of epidermis
• Can be sore or bleed on the face but can be superficial in chest, back or legs
• Treated with cream if superficial and micrographically oriented histographic surgery (Mohs) if deeper.
• Cure rates are high if caught early

Squamous Cell Carcinoma

• *squamous cells in the skin change their dna
• more dangerous than Basal cell carcinoma
• Tumor of epidermal keratinocytes and rarely occurs in dark skin people
• May infiltrate to surrounding structures and metastasized to lymph nodes
• As a sore, crusted and rapidly growing bump on sun exposed sites
• Biopsy is needed

Malignant Melanoma

• *the pigment-producing cells (melanocytes) become cancerous
• Most dangerous type of skin Cancer
• spreads to lymph nodes and distant sites
• Risk factors: fair complexion, excessive childhood sun exposure and blistering sunburns, increased number of common and dysplastic moles, family Hx of melanoma, and presence of changing mole on the skin.
• Treatment: surgery, radiation, medications, possible chemotherapy
• On average-Clients live

This lesson covers recognizing skin conditions, appropriate lab tests, age-related changes, itch receptors, nursing interventions for pruritus, and patient education for acne and seborrheic dermatitis. It also touches on treatments like oral retinoids and hot compresses.