Skin Disorders: Chapter 48

Skin Disorders

• Chapter 48 covers skin disorders, a patho approach and HESI pearls.

Functions of the Skin

• The skin serves several functions, including protecting the body against trauma
• Additional functions of the skin include regulating body temperature
• The skin further maintains water and electrolyte balance
• Sensing painful and pleasant stimuli is another function of the skin
• The skin participates in vitamin D synthesis
• The skin is the largest organ of the body

Review of Normal Skin

• The layers of the skin are: epidermis, dermis, and subcutaneous tissue (hypodermis)

Age-Related Skin Changes

• Slower epidermal regeneration thins the skin
• Collagen bundles shrink, leading to wrinkles
• Erratic melanin production causes gray hair and senile lentigo
• Reduced cohesion in tissue layers increases the risk of skin tears
• Decreased sensory receptors increase the risk for burns and injury
• Loss of subcutaneous tissue elevates pressure injury risk and reduces thermal insulation
• Decreased immunocompetence elevates infection and cancer risk
• Reduced blood flow delays wound healing in the skin
• Increased capillary fragility results in bruising

Factors Affecting Skin Integrity

• Skin integrity is affected by age and overall health status
• Mobility, nutrition, hydration, and sensation levels affect skin health
• Impaired circulation, medications, moisture, and fever can impact skin integrity
• Infection and lifestyle are additional factors

Diseases That Cause Skin Disorders

• Diabetes can cause trouble healing wounds, especially on the feet
• Lupus can cause skin problems like rashes, sores, or scaly patches
• Inflammatory bowel disease (IBD) can cause skin problems like eczema or vitiligo, based on the medications taken
• Scleroderma is an autoimmune disease that causes the skin to thicken and harden
• Skin cancer is caused by ultraviolet light from the sun's rays
• Skin lymphoma is a rare form of skin cancer not linked to sun exposure

Diseases That Cause Skin Disorders

• Shingles is a painful, blistering rash caused by the virus that causes chickenpox
• Cellulitis is a bacterial skin infection that's not contagious
• Impetigo is a bacterial skin infection that can spread through direct skin contact or contaminated food or water
• Athlete's foot and yeast infections are caused by fungi
• Body lice, head lice, and scabies are caused by parasites

Skin Lesions

• The physical appearance of a lesion is necessary to make a diagnosis
• Skin lesions may be caused by systemic disorders or infections
• Allergies to ingested food or drugs may cause skin lesions
• Localized factors may also cause skin lesions

Skin Lesions Continued

• Types of lesions vary in location and length of time present
• Changes occurring over time and physical appearance are important factors
• Physical appearance includes color, elevation, texture, and type of exudate
• Presence of pain or pruritus (itching) is also considered

Pruritus

• Pruritus, or "itching," is due to allergies, insect bites, or parasites, such as scabies
• Its mechanism is not totally understood
• It is often caused by the release of histamine in a hypersensitivity response
• Infection may result from breaking the skin barrier

General Skin Treatment Measures

• Topical agents are used to reduce sensation in skin
• Skin may be treated by antihistamines or glucocorticoids
• It is important to avoid allergens and to reduce the risk of recurrence
• Infections may require antibiotic treatment

General Skin Treatment Measures

• Precancerous lesions may be treated by surgery, laser therapy, electrodessication, or cryosurgery

Contact Dermatitis

• Contact dermatitis is caused by exposure to an allergen.
• Direct chemical or mechanical irritation can also cause contact dermatitis
• The location of lesions is clue to identity of the allergen

Contact Dermatitis

• Pruritic, erythematous, and edematous areas are characteristics of contact dermatitis
• Area is often covered with small vesicles
• Treatment includes removal of irritant and topical glucocorticoid

Contact Dermatitis

• Contact dermatitis is a form of eczema when skin is exposed to irritants or allergens
• Symptoms include rash, pruritus, swelling, burning, stinging, blistering, oozing, and scaling
• Nonpharmacologic and pharmacologic measures can be taken
• Burrow solution and zinc oxide lotions are used for pharmacologic treatment
• Oral and topical antihistamines and topical anesthetics and corticosteroids can also be applied

Urticaria

• Urticaria (hives) results from type I hypersensitivity after ingestion
• It presents as an eruption of hard, raised, erythematous lesions
• Lesions are highly pruritic and widespread, possibly in the pharyngeal mucosa
• Treatment includes antihistamines, steroids, and Xolair

Psoriasis

• Psoriasis is a chronic inflammatory skin disorder affecting 1% to 3% of the population
• It is believed to be genetic in origin with onset usually in the teenage years
• It's marked by remission and exacerbations and cases varying in severity
• It results from abnormal T cell activation
• Excessive proliferation of keratinocytes occurs
• Increased mitosis leads to thickening of the dermis and epidermis
• Epidermal shedding occurs in one day, rather than two week intervals

Psoriasis Symptoms

• Psoriasis presents red patches of skin covered with silvery scales
• The condition includes small scaling spots commonly seen in children
• Dry, cracked skin that may bleed, with itching, burning, or soreness
• Thickened, pitted, or ridged nails are key signs
• Swollen and stiff joints may occur

Psoriasis Treatment

• Psoriasis is treated with topical corticosteroid treatment using Hydrocortisone, or triamcinolone acetonide
• Tar preparations, antimetabolic methotrexate, and exposure to sunlight is often part of treatment
• Usual course of topical treatment is 4 weeks
• Side effects include skin atrophy, telangiectasia, striae distensae, acne, folliculitis, purpura and worsening of existing conditions

Psoriasis Treatment cont.

• Systemic drug treatment includes methotrexate, cyclosporine, acitretin, etanercept, and biologic response modifiers
• Methotrexate can cause side effects like stomatitis, GI distress, fatigue, teratogenic effects, and liver/lung toxicity
• Cyclosporine side effects are hypertrichosis, fatigue, hypertension, nephrotoxicity, cephalgia, myalgia, arthralgia, paresthesia

Pemphigus

• Pemphigus is autoimmune disorder in which autoantibodies disrupt cohesion between epidermal cells
• Blisters (bullae) form in the mouth and on the skin
• Blisters in the mouth can cause difficulty breathing
• Severity varies but can be life threatening
• Treatment includes steroids and immunosuppressants

Scleroderma

• Scleroderma involves increased collagen deposition
• It may affect the skin or viscera
• Inflammation and fibrosis occur with decreased capillary networks
• Hard, shiny, tight, immovable areas of skin, with narrowed/shortened fingertips signal scleroderma
• Renal failure, intestinal obstruction, or respiratory failure caused by distorted tissues may be apparent

Skin Infections

• Skin infections may be caused by bacteria, viruses, fungi, other types of microbes, or parasites
• Caused by opportunistic microbes, minor abrasions or cuts
• Serious infections may develop, and an identified causative organism enables appropriate treatment

Bacterial Infections

• Bacterial infections are prevalent on the skin and are often primary
• Infections are often caused by resident flora
• Secondary infections develop in wounds or pruritic lesions

Acne Vulgaris

• Acne vulgaris is a disorder of hair and sebaceous glands that affects 80% of teenagers
• Open or closed comedones, inflammatory pustules, cysts, and deeper lesions may result in scarring
• Graded as mild, moderate, or severe
• Treatment includes gentle washing of face twice daily and OTC keratolytics (benzoyl peroxide, salicylic acid)

Acne Vulgaris cont.

• Resolution usually takes 4 to 6 weeks with benzoyl peroxide, a mild acne treatment
• Benzoyl peroxide releases free radical oxygen species that oxidize bacterial proteins of P. acnes
• Stronger concentrations of benzoyl peroxide, topical antibiotics, retinoids and salicylic acid are often used

Acne Vulgaris cont.

• Doxycycline or tetracycline antibiotics are systemic antiacne drugs
• Topical antibiotics accumulate in the hair follicles and exert anti-inflammatory and antibacterial effects
• Isotretinoin is a systemic antiacne drug and a vitamin A derivative
• This drug decreases sebum formation/secretion and has anti-inflammatory and antikeratinizing effects

Acne Vulgaris cont.

• Isotretinoin is used for severe cystic acne unresponsive to conventional therapy
• Side effects include skin irritation, pruritus, cheilitis, cephalagia, myalgia, and arthralgia
• Conjunctivitis, photosensitivity, epistaxis, temporary hair thinning and depression have been reported
• Monitor liver functions, in association with an iPledge risk-management program

Rosacea

• Rosacea is an inflammatory skin disorder, mainly on the face, affecting those in the 30-50 age group
• Small papules without pus swell, thicken and become painful, leading to a reddened flushed appearance: rhinophyma
• It's exacerbated by sunlight, stress, temperature, alcohol, spicy foods, warm beverages, and skin care products
• Treatment includes topical metronidazole, azelaic acid, benzoyl peroxide, antibiotics, oxymetazoline, or ivermectin.

Cellulitis

• Cellulitis (erysipelas) is an infection of the dermis and subcutaneous tissue, secondary to an injury
• Usually caused by Staphylococcus aureus, sometimes Streptococcus
• Frequently in lower trunks and legs
• Signs/Symptoms: red, edematous area, pain, red streaks

Furuncles

• Furuncles (boils) are usually caused by S. aureus and drain purulent exudate
• They begin at hair follicles: face, neck, and back
• Signs and Symptoms include a firm, red nodule that becomes a painful abscess
• Carbuncles are a collection of furuncles that coalesce to form a large infected mass

Treatments for Furuncles

• Treatment involves warm compress, analgesics, antibiotics, and drainage of abscess

Impetigo and Acute Necrotizing Fascitis

• Impetigo is a bacterial infection common in infants and children, spread by close physical contact
• Characterized as small red vesicles, which enlarge, rupture, and form yellowish-brown crusty masses
• Additional vesicles develop around the primary site by autoinoculation with hands, towels, or clothes.
• Treatment involves topical/systemic antibiotics
• Acute necrotizing fasciitis is a severe infection involving a mix of aerobic and anaerobic bacteria at the infection site

Necrotizing Fascitis cont.

• In necrotizing fascitis, severe inflammation and tissue necrosis may occur
• Often, there is a history of minor trauma or infection in the skin and subcutaneous tissue of an extremity Signs/Symptoms: inflamed area, severe pain, spreading rapidly, leading to dermal gangrene
• Systemic manifestations include fever, tachycardia, and hypotension
• Mental confusion and disorientation are related, with possible organ failure

Treatment for Necrotizing Fascitis

• Treatment requires aggressive antimicrobial therapy and fluid replacement
• Excision of infected tissue or amputation may be indicated
• High oxygen flow in hyperbaric chambers may be utilized
• Delay in diagnosis and treatment = greater tissue loss and a higher probability of mortality

Leprosy

• Leprosy (Hansen Disease) is caused by the bacteria Mycobacterium leprae
• Clinical signs and symptoms vary and the disease generally affects skin, mucous membranes, and peripheral nerves
• Damage can lead to loss of limbs
• The mechanism of pathogenicity is largely unknown
• Diagnosis is through microscopic examination of skin biopsy
• Treatment involves primarily antibiotics

Herpes and Shingles

• Herpes Simplex viruses include: herpes simplex type 1 (HSV-1) – cold sores; fever blisters and Herpes simplex type 2 (HSV-2) – genital herpes, spread by direct contact with fluid from lesion
• Recurrence may be triggered by common cold, sun, stress, or mild tingling before lesion formation
• Antiviral drugs limit acute phase and viral shedding; acyclovir, and valcyclovir
• Shingles caused by the varicella-zoster virus (VZV), the same virus that causes cause chickenpox

Shingles cont.

• The varicella-zoster virus (VZV) can reactivate after lying dormant in after a person has chickenpox
• Physical trauma (burns, cuts, or sunburns) may trigger shingles
• Shingles is treated with antiviral medications, pain relievers, and treatments for symptom relief
• Isolation and covering lesions are key steps patients undergoing nursing intervention for shingles

Shingles Nursing Interventions

• Patients with shingles should be restricted from caring for high-risk patients; immunocompromised or varicella susceptible
• The lesion site must be kept clean and non-adhered with loose clothing
• Antiviral treatment should be started within 72 hours of shingles

Causes of Shingles and Warts

• The likelihood of women developing Shingles is higher in perimenopause, due to hormonal changes
• Verrucae (Warts) are caused by the human papillomavirus (HPV) types 1 to 4
• It commonly develops in children and young adults
• May resolve spontaneously with time, although genital warts are also caused by (HPV types 6 and 11)

Fungal Infections

• Fungal infections (Mycoses) are mostly superficial
• A Candida infection is linked to diabetes and may spread systemically in immunocompromised patients
• Diagnosed from skin scrapings and detected via fluorescence in ultraviolet light
• Culturing may be performed

Tinea Fungal infections

• Tinea capitis infects the scalp with apparent erythema
• Common in school-aged children, treated with oral antifungal medication
• Tinea corporisis an infection of the body, particularly on non-hairy parts
• Round lesion with clear center (ringworm) may be present, treated with topical antifungal medication
• Tinea Pedis (Athlete's foot)involves feet, toes
• Associated with pools/gyms, treated with antifungal medication, possible secondary bacterial infection

Tinea Unguium and Other Infections

• Tinea Unguium infects the nails, turning them white, then brown, thickening with cracks
• Infection tends to spread to other nails.
• Other infections include Scabies, in which a female burrows into epidermis and lays eggs
• Burrows appear on skin as tiny, light brown lines and is treated topically
• Pediculosis (lice) includes body, head, and pubic lice, diagnosed by the presence of nits at base of hair shaft

Lice and Scabies

• Lice are spread by clothing or personal contact
• Scabies are spread, the louse's bite releases saliva causing intense scratching, treatment is pediculicide and comb
• Mites live on host and burrow to lay eggs, rash is reaction to mites, eggs, and feces
• Presentation of red papules with burrow lines between digits, axillae, and genitalia
• Treatment involves environment decontamination and twice treatment with a scabicide applied to the skin
• Airborne precautions should be initiated

Skin Tumors

• Keratoses are benign lesions associated with aging or skin damage
• Seborrheic Keratoses: proliferation of basal cells; oval elevation
• Actinic Keratoses: on skin exposed to UV radiation; appear as pigmented, scaly patch

Warning Signs of Skin Cancer

• Seek medical attention if there's: unhealing sore, a change in shape, size, color, or texture of a lesion, new or odd moles, or a a skin lesion that repeatedly bleeds

Squamous Cell Carcinoma

• Squamous Cell Carcinoma is a painless, malignant tumor of the epidermis most often found on skin exposed areas: face, neck, and base of tongue
• There is an excellent prognosis when lesion is removed within reasonable time
• An invasive type arises from pre-malignant conditions

Malignant Melanoma

• A malignant melanoma is a highly metastatic form of skin cancer that develops in melanocytes (mole)
• Appears as a multi-colored lesion with irregular border; and increases in size
• Treatment includes surgical removal, radiation, and/or chemotherapy

Melanoma ABCD

• Any nevus that shows: change in appearance or border, change in color, and/or increases in diameter could be melanoma

Kaposi Sarcoma

• Kaposi Sarcoma occurs in those with AIDS and other immunosuppressed conditions
• It may affect viscera as well as skin (malignant cells arise from endothelium in small blood vessels)
• Purplish macules that are nonpruritic or painful develop rapidly over upper body of immunocompromised patients
• There is a combination of radiation, chemotherapy, surgery, and biological therapy

Drug-Induced Dermatitis and Burns

• Drug-induced dermatitis is a life-threatening skin reaction.
• Symptoms include rash, urticaria, papules, and vesicles.
• Examples include Erythema multiforme, Stevens-Johnson syndrome and Toxic epidermal necrolysis
• With suspected drug hypersensitivity, caution is needed, and patients should be watched
• Burns: nursing priorities include airway management, fluid resuscitation to prevent shock, and pain management

Burns Management

• Assess for airway compromise, provide oxygen, and calculate burn fluid resuscitation needs
• Followed by administering ordered pain medication before wound care procedures
• Implement strict infection control practices related to increased risk of sepsis related to burn wounds
• Assess nutritional needs, and provide adequate caloric intake, and psychological support

Preventing Burns

• Use sunscreens to block UV rays (prevent sunburn, skin cancer, premature aging, cold sores)
• Both chemical and physical protective measures, like avoiding the sun between 10 am and 2 pm
• Preventive measures: Reapply sunscreen every 2 hours
• Silver sulfadiazine: active against both gram-positive/-negative organisms/yeast and burn infection

Silver Sulfadiazine side effects in burn prep

• Burning, Burning, rash, erythema photosensitivity, skin discoloration, and skin necrosis

Escharotomy Care for Burns

• Circumferential third-degree burn of the limbs results in non-distensible and leathery eschar
• Due to massive fluid accumulation the non-compliant nature of the circumferential eschar will eventually lead to an increase in compartment pressure
• Progression to ischemia of the tissues can occur with subsequent tissue loss infection or contracture