Integumentary Pathology PDF

INTEGUMENTARY PATHOLOGY G&F Chapter 10  Lesions of the Skin Lesion A lesion is any variation from normal tissue Classified by either primary or secondary Primary Skin Lesions Changes to the skin in direct response to a disease Secondary Skin Lesions Develop from prima...

INTEGUMENTARY PATHOLOGY G&F Chapter 10  Lesions of the Skin Lesion A lesion is any variation from normal tissue Classified by either primary or secondary Primary Skin Lesions Changes to the skin in direct response to a disease Secondary Skin Lesions Develop from primary lesions, from external forces, such as scratching Lesions of the Skin Examples of Primary Skin Lesions Macule Papule Nodule Tumor Plaque Wheal Vesicle Bulla Pustule Lesions of the Skin Examples of Secondary Skin Lesions Scales Crust Fissure Ulcer Scar Atrophy  BACTERIAL INFECTIONS  Acne Vulgaris Vulgaris = common or ordinary, acne vulgaris is m/c form of acne Aka acne folliculitis or acne Definition Obstructive, inflammatory condition of pilosebaceous units Overproduction of sebum forming a keratin plug which becomes infected by bacteria Forms comedones (pimples) Acne Vulgaris Epidemiology MC in younger individuals (12-25) MC trigger: puberty d/t androgen surge Males and females equally affected, males tend to have more severe cases Etiology Follicular keratinization blocks follicle Increased sebum production by sebaceous glands d/t androgens Colonized by anaerobic bacteria, Propionibacterium acnes (normal flora) Genetics play a major role  Acne Vulgaris Acne triggers Hormonal changes: puberty, menstrual periods, pregnancy, birth control pills, or stress Greasy or oily cosmetic and hair products Certain drugs (such as steroids, testosterone, estrogen) Heavy sweating and humidity Excessively touching, resting on, or rubbing the skin Massage oil Jojoba oil is an oil that does not clog pores and may help treat acne  Acne Vulgaris Signs and Symptoms Comedones, papules, pustules, cysts, and/or nodules Often in this progression Open comedones (blackheads): oxidized sebum and melanin makes black Closed comedones (whiteheads) Acne Vulgaris Acne Vulgaris Treatment Goals are to limit triggers r/t sebum production and hormone regulation Over the counter (OTC) and/or prescription (Rx) creams and medications Skin cleansers Topical or oral Ab used if acne is widespread Oral contraceptives control androgen secretion Isotretinoin (Vit A derivative) for severe cases (Accutane) *Possibly link with depression, psychosis, and suicidal thoughts* May improve in summer d/t anti-inflammatory effects of the sun Acne Vulgaris Massage and Acne Avoid affected areas, especially if inflamed Avoid use of table warmers or hot packs over affected area NOT CONTAGIOUS  Infections of Hair Follicles Folliculitis: inflammation of hair follicle Furuncle: inflammation of hair follicle that goes into deeper layers of skin Abscess (pus) forms Also known as a boil Carbuncle: a group of furuncles Infections of Hair Follicles  Infections of Hair Follicles Definition Infection of the skin with inflammation of the hair follicle Etiology MC cause is bacterial (Staphylococcus aureus) May also be caused by: Viruses or fungi Irritation from hair regrowth (folliculitis barbae) Occlusion from clothing or topical medications  Infections of Hair Follicles Symptoms Pustules formed around hair and surrounding area of erythema Furuncles and carbuncles will have more pus formation Possible pruritus Itchy Infections of Hair Follicles Treatment Topical cleansers and antibiotics Antivirals or antifungals may be used if that is the cause Antihistamines to relieve itching Furuncles and carbuncles need to drain before healing Warm compress can help by bringing pus to the surface Prognosis and complications Infection damages follicle and hair can easily be pulled out Potential for in-grown hairs Spread of infection is possible, leading to local tissues becoming involved  Carbuncle Furuncle Folliculitis Massage and inflammation of hair follicles Same principles as acne vulgaris Avoid affected areas, especially if inflamed Avoid use of table warmers or hot packs over affected area Most cases are NOT CONTAGIOUS, but some may be CONTAGIOUS  Pseudofolliculitis Barbae Definition Ingrown beard hairs Irritation of skin and hair follicles d/t shaving Hair curls into the skin causing inflammation Presentation Itchy, red papules and/or pustules DDx from folliculitis barbae (bacterial) Pseudofolliculitis typically more chronic and has firm papules, sterile Folliculitis barbae typically more acute, pustules, not sterile  Pseudofolliculitis Barbae Epidemiology More common in black men Treatment Warm compress Oral/topical Ab if infection occurs  Impetigo Definition Bacterial infection of the superficial layers of skin Deeper variant called ecthyma Epidemiology More common in children, can occur at any age Impetigo Etiology MC causes are streptococcus bacteria and Staphylococcus aureus Canbe spread by contact with an infected person or by handling contaminated objects Signs and Symptoms Vesicular or pustular lesions that itch or burn Lesions rupture and ooze, releasing exudate which turn into honey-coloured crust Possible lymphadenopathy, but fever uncommon Impetigo Prevention of spreading is key Handwashing Keep wounds clean Do not share linens or utensils, etc. Treatment and Prognosis Topical or oral antibiotics Usually heals without any scars Impetigo Massage and Impetigo LOCAL CONTRAINDICATION *HIGHLY CONTAGIOUS* Skin lesions must be covered during the massage Use caution when massaging hands as client may have touched own lesions Use gloves or other barrier  Cellulitis Definition Bacterial infection of the dermis and subcutaneous tissues Often arises from previous skin wound or boil Etiology MC causes: Staphylococcus aureus; group A Streptococcus infection  Cellulitis Signs and Symptoms Redness, warmth, tenderness, and swelling in an area where skin has been damaged Left untreated, the area of redness tends to expand over time Red streaks or red lines can occur proximal to the site (lymphangitis) Group A strep can cause blistering in superficial and deep layers Systemic Sx: possible fever, chills, lymphadenopathy, headache Lymphangitis  Cellulitis Treatment and Prognosis Left untreated, cellulitis can be life- threatening Can spread to bloodstream Oral antibiotics based on suspected organism Cellulitis Massage and Cellulitis LOCAL CONTRAINDICATION Not contagious If you notice signs and symptoms of cellulitis, REFER THE CLIENT TO THEIR HEALTHCARE PROVIDER for evaluation  Erysipelas Definition Bacterial infection of upper dermis and superficial lymphatics Superficial form of cellulitis Etiology MC cause is various Streptococcus species Epidemiology MC in older and younger individuals  Erysipelas Signs and Symptoms Erythematous lesion of skin w/ sharply demarcated, raised border Orange-peel skin Warm, swollen, painful/tender Lymphadenopathy and possible lymphedema Systemic Sx: fever, chills, vomiting, headache, fatigue, and general malaise  Erysipelas Treatment and Prognosis Oral or IV antibiotics based on severity Tx should be prompt to avoid sepsis, tissue necrosis, or PSGN (post-streptococcal glomerulonephritis) Erysipelas Massage and Erysipelas LOCAL CONTRAINDICATION Not contagious If you notice signs and symptoms of erysipelas, REFER THE CLIENT TO THEIR HEALTHCARE PROVIDER for evaluation VIRAL INFECTIONS Warts Warts are caused by exposure to human papilloma virus (HPV) More than 150 types of HPV Not all cause warts, and some can lead to the development of certain types of cancer Easily spread from one body part to another on the same person Common warts are not usually contagious, unless damage to skin integrity Genital warts are HIGHLY contagious FYI: Gardisil 9 is a vaccine against 9 strains of HPV that cause cervical cancer or genital warts (HPV 16 and 18 are linked to the majority of cervical cancers)  Warts Warts can be painless or can cause nerve pain They can be isolated or clustered growths There are 4 major types of warts we will discuss: Common warts Plantar warts Flat warts Genital Warts  Warts Common Warts (verrucae vulgaris) Firm growths w/ rough surface and sharply demarcated border Round or irregular Yellow, brown, or grayish in colour < ½ inch Usually painless  Warts Plantar Warts Look similar to common warts May be more tender “Seeded” lesions that flatten with pressure and have pinpoint bleeding when trimmed Seeded = clotted vessels that appear as small black dots within the wart  Warts Flat Warts Groups of smooth, yellow-brown spots; more common in children  Warts Genital Warts (condyloma acuminata) Most common viral STI Highly contagious Soft, fleshy, cauliflower-like growths around the vagina, penis, or rectum MC cause of cervical and penile cancers Treating external warts does not influence development of cancer Warts Genital Warts  Warts Treatment Most will spontaneously resolve OTC treatments are usually successful Salicylic acid and/or lactic acid topical solution breakdown wart Oral or topical antiviral medications Wart pads or cushions can reduce pressure/discomfort If initial treatment fails Cryotherapy (liquid nitrogen) and/or laser treatment Surgical excision  Warts Massage and Warts While common warts are not highly contagious, there is still a chance of transmission Treat warts as a LOCAL CONTRAINDICATION and avoid direct contact Use gloves or other barrier Varicella Zoster (Chickenpox) Definition Highly contagious viral infection Spread via Respiratory droplets Direct contact with lesions Etiology Caused by varicella-zoster virus (VZV) Contagious 2 days before rash to 6 days after onset of rash A chickenpox is available and should be received between 12-15 months Varicella Zoster (Chickenpox) Signs and Symptoms Clusters of small, raised or flat spots that turn to fluid filled blisters and crust over Pruritus Prodromal Sx (show up before the diagnostic S&S) mild (headache, mild fever) or absent in kids fever, malaise, and backpain in adults Complications Pneumonia and encephalitis (rare) Pregnancy: pneumonia, rare congenital birth defects Can lead to shingles (herpes zoster) later in life  Varicella Zoster (Chickenpox) Treatment Spontaneously resolves Oatmeal baths and antihistamines reduce pruritus Antipyretics and antivirals may also be suggested VZV vaccine exists for children as early as 12 months old  Varicella Zoster (Chickenpox) Massage and Varicella Zoster (Chickenpox) Chickenpox is HIGHLY CONTAGIOUS and clients should be isolated Massage is postponed until client has completely recovered Herpes Zoster (Shingles) Definition Dermatomal rash caused by reactivation of dormant varicella-zoster virus Virus dormant in dorsal root ganglia after initial infection Can also present in face Risk Factors Immunosuppression, stress, age MC in people > 50, can occur at any age Etiology Reactivation of dormant varicella-zoster virus You cannot get shingles from someone with shingles, but if you have never had chickenpox, you may get chickenpox Vaccine available for people >50  Herpes Zoster (Shingles) Signs and Symptoms Prodrome: dermatomal tenderness (neuralgia) and paresthesia 3-5 average days before rash Rash: red, linear cluster of fluid filled vesicles Dermatomal pattern Very sensitive: pain with even light touch Dry and crust in 7 days and clear in approximately 2-3 weeks Pain resolves when vesicles crust over  Herpes Zoster (Shingles) Signs and Symptoms Systemic Sx: malaise, nausea, diarrhea, fever, difficulty urinating Complications: post herpetic neuralgia (PHN) long term dermatomal pain Loss of vision if in eye Recurrence is rare, but possible Herpes Zoster (Shingles) Herpes Zoster (Shingles) Treatment Spontaneous resolution If treatment is needed Antivirals Anti-inflammatories Analgesics  Herpes Zoster (Shingles) Massage and Herpes Zoster (Shingles) How you manage clients with shingles depends on your PMHx and your vaccination status If you have had chickenpox or received the chickenpox vaccine, and are not pregnant: Treat as a LOCAL CONTRAINDICATION as lesions may be painful If you have never had chickenpox or been vaccinated, or are pregnant There should be NO CONTACT with shingles patient Herpes Simplex Virus (HSV) Definition Highly contagious, recurrent viral infection that can either cause oral lesions (cold sores) or genital lesions depending on the strain Etiology HSV-1: Oral herpes (cold sores) Spread via oral secretions MC affected areas: mouth, face, ocular lesions HSV-2: Genital herpes Spread via genital secretions May cause neonatal herpes infections Herpes Simplex Virus (HSV) Signs and Symptoms Primary infection: lymphadenopathy, fever, malaise, and paresthesia for 24 hours before rash (not always present) Rash: painful vesicles surrounded by reddish rim that turn to pustules, erode, and crust over Latent HSV-1 remains in trigeminal ganglia, HSV-2 in dorsal root ganglia Recurrent infections: 2-24 hours of burning, itching, crawling, tingling in a dermatomal pattern Common Triggers: Stress, fever, UV exposure, immunosuppression, menstruation Can be active, but asymptomatic Herpes Simplex Virus (HSV) HSV-1 Herpes Simplex Virus (HSV) HSV-2  Herpes Simplex Virus (HSV) Treatment No cure Keep area clean and dry Topical antiviral creams sometimes effective Reduce period of symptoms and therefore period of transmission, but do not cure the disease Analgesics may help with pain Herpes Simplex Virus (HSV) Massage and Herpes Simplex Virus (HSV) Herpes lesions are a LOCAL CONTRAINDICATION  Molluscum Contagiosum (MC) Definition Highly contagious viral infection, common in children Spread via contact or indirect contact Also called water warts Etiology Molluscum contagiosum virus (MCV)  Molluscum Contagiosum (MC) Signs and symptoms Small, pink, round, raised lesions with a dimple in the centre Possible pruritus Often bleed when scratched  Molluscum Contagiosum (MC) Treatment Spontaneously resolve in 6-9 months Can be removed if the lesions are particularly bothersome. Removal techniques include: Cryotherapy Surgery Molluscum Contagiosum (MC) Massage and Molluscum Contagiosum (MC) MCV lesions are a LOCAL CONTRAINDICATION MCV is HIGHLY CONTAGIOUS Can be spread through indirect contact, so wear gloves if treating a patient’s hands FUNGAL INFECTIONS  Fungal Infections of the Skin The Basics Extremely common Fungal pathogens that affect the skin are called dermatophytes Occupy dead, topmost layer of skin Warm, moist areas where skin surfaces meet is ideal medium b/t toes, nails, groin, under the breast, head, feet  Tinea (Ringworm) Definition Common fungal infection caused by a number of different fungi called dermatophytes Classified by the location Tinea pedis (foot) Tinea unguium (nail) Tinea corporis (body) Tinea cruris (groin) Tinea capitis (head) Contagious through direct contact Tinea (Ringworm) Common Signs and Symptoms Circular rash surrounded by an outer ring Produce keratolytic enzyme causing scaling, crumbling nails, breaking hairs Risk factors Immunosuppression Hyperhidrosis Tight clothing Warm environment Tinea (Ringworm) Treatment Keep area clean and dry Antifungal creams are most effective (OTC) Powders are less effective Topical corticosteroids Rx for pain and pruritus relief  Tinea (Ringworm) Massage and Tinea (Ringworm) All tinea infections are a LOCAL CONRAINDICATION The lesions should not be massaged as they can cause more pain and are CONTAGIOUS Candidiasis Definition Fungal infection of skin and mucous membranes MC affected areas: groin, mouth, and b/t digits Etiology Candida albicans, a vaginal/intestinal yeast and natural flora Risk factors Immunosuppression, hyperhidrosis, incontinence, excessive corticosteroid or antibiotic use, being pregnant, obese, diabetic, and/or a child  Candidiasis Vaginal Candida Infections (yeast infection) Signs and Symptoms Thick white or yellow vaginal discharge with burning, itching, and redness of the groin May cause dysuria or dyspareunia  Candidiasis Penile Candida Infections Signs and Symptoms Painful red, scaling lesions with raised, white border on the underside of the penis Common in diabetics and men with infected sexual partners  Candidiasis Oral Candida Infections (thrush) Signs and Symptoms Painful, cream-coloured patches that adhere to oral mucosa Bleed when scraped off Common in children and immunocompromised persons Candidiasis Diagnosis Based on observation of distinctive rash/pasty discharge Treatment Antifungal creams Vaginal suppositories Medicated mouthwash Keep skin dry to clear and prevent return Candidiasis Massage and Candidiasis Vaginal and penile candidiasis No special considerations exist, continue as normal Oral candidiasis LOCAL CONTRAINDICATION as you work around neck and face Tinea Versicolor Definition Fungal infection of skin causing patches of discolouration Etiology Malassezia globosa, a yeast naturally found on skin Less commonly caused by other yeasts Risk factors Immunosuppression, hyperhidrosis, hot and humid climates, young adults  Tinea Versicolor Signs and Symptoms Hypo- or hyperpigmented patches of skin Sometimes the patches may cause scaling Patches don’t tan evenly, so sun exposure makes them more noticeable Sometimes called “sun fungus” for this reason Tinea Versicolor Diagnosis Typically diagnosed by visual symptoms Can also use a special dye that glows under UV light Treatment Topical antifungal cream Oral antifungals exist, but there are concerns of organ damage and other systemic interactions with these medications Used only if the topical medications are ineffective Tinea Versicolor Massage and Tinea Versicolor Lesions are not painful and NOT CONTAGIOUS LOCAL CONTRAINDICATION  PARASITIC INFECTIONS Scabies Definition Mite infestation of the itch mite Sarcoptes scabiei Female mite burrows under top layer of skin and lays eggs Young mites hatch in a few days and then burrow deeper Highly contagious spreads skin to skin; can live longer than two days w/o host and be spread on items (fomites) Signs and Symptoms Tiny, red pimple-like rash with wavy lines with severe, persistent pruritus Worse at night, worse after a bath MC affected areas: waistline, axillae, groin, feet, between fingers, creases of elbows, wrists, and knees Rarely above neck Scabies Scabies Scabies Diagnosis Based on history of pruritus and observation of rash Treatment Topical cream for mites and hydrocortisone cream for pruritus Antihistamines for itch Wash all bedding and clothes in hot water Fumigation not necessary  Scabies Massage and Scabies HIGHLY CONTAGIOUS and spread by direct contact, therefore treatment should be POSTPONED until infestation clear Wash all linens in hot water if come in contact  Pediculosis (Lice) Definition Louse: barely visible mites that cannot jump or fly and can infect any area of the skin There are three types of lice: Head louse Body louse Pubic louse Signs and Symptoms Severe pruritus and possible red bumps on skin Visible lice in the area of infestation Visible egg sacs on shaft of hair near scalp Pediculosis (Lice) Head Louse (Pediculus humanus capitis) Spread by personal contact and by shared personal items; common in schools Body Louse (Pediculus humanus corporis) Less easily transmitted, usually infect people who have poor hygiene and those living in close quarters Largest louse Pubic Louse (Pthirus pubis) Infestation of genital area typically spread by sexual contact Wide, short body that resembles a crab Pediculosis (Lice) Head lice Pediculosis (Lice) Treatment Medicated cream, lotion, or shampoo Reapplication after 10 days to kill newly hatched lice Daily combing to remove eggs Re-infection possible through infected objects Fomite control: disinfect personal objects and vacuum Pediculosis (Lice) Massage and Pediculosis (Lice) HIGHLY CONTAGIOUS and spread by direct contact, therefore treatment should be POSTPONED until infestation clear Wash all linens in hot water if come in contact  INFLAMMATORY REACTIONS OF THE SKIN Psoriasis Definition Chronic, non-contagious, inflammatory autoimmune disease of hyper-proliferation Etiology Auto-immune, but idiopathic in acquisition May be r/t genetics (inheritance is possible) Smoking, obesity and alcohol use have been linked to psoriasis Infections (both bacterial and viral) have been linked to worsening psoriasis Epidemiology More common in certain age ranges, but can occur at any age More common in Caucasians vs other ethnicities Psoriasis Signs and Symptoms Erythematous papules and plaques covered with silvery scales Extremely pruritic Scraping of plaques often causes punctate bleeding (Auspitz’s sign) Development of new psoriasis at sites of skin trauma (Koebner phenomenon) MCaffected areas: scalp, extensor surfaces of elbow and knee, back, chest, groin, and armpit Different classifications present in different ways. Plaque psoriasis is most common Psoriasis Psoriasis Psoriasis Common Comorbidities Psoriatic arthritis An extensive form of psoriasis that affects joints ~5-30% of patients with psoriasis develop psoriatic arthritis Characterized by stiffness, pain, swelling and tenderness of the joints and their surrounding ligaments and tendons DDx from RA Nail bed involvement 1/3 of those affected by psoriasis also have nail involvement Pitting, discolouration, and nail separation Psoriasis Nail involvement Psoriasis Diagnosis Clinical examination Skin biopsy can be helpful for challenging cases Treatment Topical corticosteroids OTC ointments and creams to keep areas moist Controlled UV light and sunbathing Avoid overexposure d/t risk of skin CA Antihistamines for pruritus  Psoriasis Massage and Psoriasis LOCAL CONTRAINDICATION if there is the presence of broken skin at lesions If there is no presence of open skin, LIGHT massage may be performed over areas with the consent of patient Non Contagious Rosacea Definition Chronic, progressive, erythematic skin condition causing facial redness Etiology Idiopathic May be r/t genetics and/or overactive immune system Epidemiology MC age: 30-50 More common in females and those with fair complexion Rosacea Signs and Symptoms Persistent facial erythema, dryness, warmth, swelling Tiny pustules may appear, resembling acne Telangiectasia and thickened skin can develop Potential for rhinophyma Erythematous, bulbous, nose caused by sebaceous gland hypertrophy MC affected area: face, particularly the middle one-third (nose, cheeks, chin) Rosacea Signs and Symptoms In general, S&S tend to go through flare up/remission phases There are known triggers for flare ups (listed later) Some people only ever present with some of the symptoms listed above In others, the disease is more progressive (flushing -> rhinophyma) Rosacea (FYI) Phase I (Pre-rosacea phase) Rosacea (FYI) Phase II (Vascular stage of rosacea) Rosacea (FYI) Phase III (Inflammatory phase of rosacea) Rosacea (FYI) Phase IV (Late stage of rosacea) Rosacea Treatment No cure Avoid triggers Direct sunlight Strenuous exercise Extreme temperatures Spicy foods, hot beverages, alcohol Topical antibiotics for inflammatory phase Prognosis More likely to suffer from migraines Rosacea also linked with IBD, celiac disease, SIBO/IBS Rosacea Massage and Acne Rosacea Depends on the severity of the disease Inquire about sensitivity over affected areas Non Contagious, but AVOID areas containing PUSTULES  Hidradenitis Suppurativa Definition Chronic, scarring, acne-like inflammatory process MC in axillae, groin, and around the nipples and anus Etiology Idiopathic: develops when hair follicles become blocked, but why this blockage occurs isn't known Could be connected to hormones, genetic predisposition, cigarette smoking or excess weight Hidradenitis Suppurativa Symptoms Small, swollen, painful nodules under the skin Pain followed by sudden, random draining of pus In chronic cases: cord-like fibrotic bands form d/t inflamed nodules adhering together Painful and produce foul odor Treatment and Prognosis Drug therapy not usually beneficial, but may be Rx topical antibiotics and steroids Warm compress to drain Laser hair removal for prophylaxis Surgical excision may be necessary Often leads to significant scarring Hidradenitis Suppurativa Hidradenitis Suppurativa Hidradenitis Suppurativa Massage and Hidradenitis Suppurativa Not Contagious but any pustules would be a LOCAL CONTRAINDICATION Inquire about sensitivity over affected areas Drug Eruptions and Reactions Various drugs can cause varying skin reactions. We will cover 3 of these: Erythema Multiforme Stevens-Johnson Syndrome Urticaria Fixed Drug Reaction Purpuric Eruptions Acneiform Eruptions Toxic Epidermal Necrolysis (more severe form of SJS) Drug Eruptions and Reactions Erythema Multiforme Definition Erythema multiforme is an inflammatory reaction, characterized by target shaped skin lesions Oral mucosa is sometimes involved Considered type IV hypersensitivity reaction (more on this in later classes) Triggers = drugs and infections Etiology MC trigger = herpes simplex virus (~50% of cases) Drug Eruptions and Reactions Erythema Multiforme Signs and Symptoms Mildly itchy, symmetrically distributed patches of red, raised skin with target- like lesions, blistering, and mucous membrane involvement Blisters can ooze blood Systemic sx = fatigue, joint pain, and fever Drug Eruptions and Reactions Erythema Multiforme Drug Eruptions and Reactions Erythema Multiforme Drug Eruptions and Reactions Erythema Multiforme Drug Eruptions and Reactions Erythema Multiforme Treatment Self-limiting condition that lasts 2-4 weeks No intervention required Sometimes antivirals given if HSV is the cause Erythema Multiforme Massage and Erythema Multiforme Not contagious but is a LOCAL CONTRAINDICATION Allow for full healing of lesions before direct treatment Drug Eruptions and Reactions Stevens-Johnson Syndrome (SJS) Definition A life-threatening type IV hypersensitivity reaction where necrosis causes the dermis to separate from the epidermis Also involves mucous membranes Etiology Medications (sulfa drugs are MC), infections Drug Eruptions and Reactions Stevens-Johnson Syndrome (SJS) Symptoms Severe blistering Pain with closing mouth/eating (leads to drooling) Dysphagia d/t pain Painful swelling of eyes w/ sealing of eyelids d/t pus Dysuria w/ genital involvement Systemic sx: fever, fatigue, sore throat Treatment Aimed at supportive care: analgesics, IV fluids, NG tube or parenteral nutrition Drug Eruptions and Reactions Stevens-Johnson Syndrome Drug Eruptions and Reactions Stevens-Johnson Syndrome Drug Eruptions and Reactions Stevens-Johnson Syndrome Stevens-Johnson Syndrome Massage and Stevens-Johnson Syndrome CONTRAINDICATION Wait until patient has recovered fully Not contagious Drug Eruptions and Reactions Urticaria Definition Inflammatory skin disorder usually associated with allergic reactions Type I hypersensitivity Transient, edematous papules mediated by histamine Etiology Allergen triggers immunologic response Medications, insect bites, foods, idiopathic Drug Eruptions and Reactions Urticaria Signs and Symptoms Itching followed by wheal and flare response Wheals: small, smooth, slightly elevated lesions Usually only last a few hours Flares: redness that shortly follows the wheal If it affects deeper tissues, causes edema with warm, red, painful skin called angioedema Angioedema of the mouth and throat can be life threatening Drug Eruptions and Reactions Urticaria Drug Eruptions and Reactions Urticaria Drug Eruptions and Reactions Urticaria Treatment Oral antihistamines to reduce itching and swelling Topical corticosteroids Monitor for lesions around mouth Hives in the throat can be life-threatening Difficulty breathing and/or swallowing EpiPen for anaphylaxis  Urticaria (Hives) Massage and Urticaria (Hives) In acute/allergic urticaria, massage is CONTRAINDICATED and should be postponed In chronic urticaria, massage is a LOCAL CONTRAINDICATION Decubitus Ulcers (Bed Sores/Pressure Sores) Definition Breakdown of skin integrity d/t lack of blood flow and irritation from prolonged pressure Tissue necrosis can occur in as little as 12 hours MC affected areas: sacrum, greater trochanter, heels Areas of skin over a bony prominence Etiology Prolonged pressure on the skin resulting in reduced blood flow Bed/wheelchair bound, cast/splint Paralysis, coma, diabetes Decubitus Ulcers (Bed Sores/Pressure Sores) Categorized by four stages (Stage I – Stage IV) where different signs and symptoms appear: Stage I Non-blanchable erythema of intact skin No ulcer at this stage Stage II Partial thickness skin loss with exposed dermis Erythema, edema, and blistering No visualization of adipose or muscle layers  Decubitus Ulcers (Bed Sores/Pressure Sores) Stage III Full thickness skin loss Deeper layers of skin and adipose tissue exposed; not muscle or bone Undermining and tunneling may occur Stage IV Full thickness skin and tissue loss Destruction of tissue with visualization of muscle or bone Decubitus Ulcers (Bed Sores/Pressure Sores) Decubitus Ulcers (Bed Sores/Pressure Sores) Decubitus Ulcers (Bed Sores/Pressure Sores) Decubitus Ulcers (Bed Sores/Pressure Sores) Treatment Stage I and Stage II ulcers are treated by repositioning the client Stage III and Stage IV will need medical treatment from a wound care specialist Antibiotics may be given to prevent infection  Decubitus Ulcers (Bed Sores/Pressure Sores) Massage and Decubitus Ulcers LOCAL CONTRAINDICATION If the ulcer shows signs of infection, odour or discharge, treatment should be postponed and the client should be referred to MD for treatment DERMATITIDES Dermatitides Dermatitides is the plural of dermatitis Definition of dermatitis Superficial inflammation of the skin Common presentation: pruritus, redness, edema, oozing, crusting, and scaling May be acute, subacute, or chronic Types of dermatitis Atopic dermatitis (eczema), contact dermatitis, phototoxic and photoallergic dermatitis, stasis dermatitis, seborrheic dermatitis, perioral dermatitis Atopic Dermatitis (Eczema) Definition Most common inflammatory skin condition Immune-mediated inflammation of the epidermis and dermis Etiology Genetics (inherited tendency to over-produce IgE - atopy) Between 75-80% of affected individuals have Hx of asthma and/or allergic rhinitis Food allergies, environmental allergies, emotional stress, humidity, irritation of skin by clothing, bacterial infection  Atopic Dermatitis (Eczema) Signs and Symptoms Chronic, itchy inflammation of the upper layers of skin Leads to dry, scaly, leathery, or crusty skin Skin may be lighter or darker than surrounding areas Possible to crack, ooze fluid, and bleed Potential for “itch-scratch-rash” cycle Scratching induces itchiness Atopic Dermatitis (Eczema)  Atopic Dermatitis (Eczema) Treatment Treating eczema can be tricky hard to identify triggers need to be discovered and removed before any improvement can be seen OTC moisturizers Topical corticosteroids Atopic Dermatitis (Eczema) Massage and Atopic Dermatitis (Eczema) Non Contagious LOCAL CONTRAINDICATION if the skin is broken Proceed with caution and with client permission if skin is intact Affected areas should never be treated with vigorous pressure  Primary Irritant Contact Dermatitis Definition Inflammation of the skin d/t contact with an irritant Cause Any irritating substance Cleaning products such as chlorine bleach Laundry detergents or soaps/shampoos Dyes Fertilizers Fiberglass Latex Certain metals in jewelry  Primary Irritant Contact Dermatitis Signs and Symptoms Itchy or painful rash of erythematic, scaling or blistering lesions with demarcated borders MC affected area: hands Treatment Resolves a few days after irritant is removed Antihistamines and corticosteroids can help to ease pruritus and inflammation Primary Irritant Contact Dermatitis Primary Irritant Contact Dermatitis Primary Irritant Contact Dermatitis Massage and Irritant Contact Dermatitis Non Contagious LOCAL CONTRAINDICATION Allergic Contact Dermatitis (ACD) Definition Type IV delayed, cell-mediated hypersensitivity reaction causing rash at site of contact First exposure creates Ab-Ag complexes without rash Immunity builds and subsequent exposures create pruritus and dermatitis 4-24 hours after exposure Etiology Cosmetics, metal compounds, plants, drugs, skin creams, chemicals in clothing Allergic Contact Dermatitis (ACD) Symptoms Symptoms include intense pruritus (itching), and pain is usually the result of excoriation (scratching) or infection Vesicles may form and ooze Treatment Avoid offending allergen Oral and/or topical antihistamines Topical corticosteroids to relieve itching and pain Allergic Contact Dermatitis (ACD) Allergic Contact Dermatitis Massage and Allergic Contact Dermatitis Non Contagious LOCAL CONTRAINDICATION Phototoxic Dermatitis Definition Cutaneous reaction within minutes to hours following sun exposure Light-absorbing free radicals and inflammatory mediators are activated by over- exposure to sunlight An increase in energy damages skin Etiology Over 100 topical and oral substances are known to cause reaction Topical substances (perfumes, sunscreens, aftershave, oils, coal tar) Ingested substances (tri and tetracyclic antibiotics) Phototoxic Dermatitis Signs and Symptoms Painful, swollen, erythematic lesions Burn like characteristics Will only affect sun exposed skin Highly variable reactions Phototoxic Dermatitis Massage and Phototoxic Dermatitis Non Contagious LOCAL CONTRAINDICATION Photoallergic Dermatitis Definition Type IV cell-mediated immune response 1-3 days after sun exposure Light absorption causes structural changes in a drug or substance, allowing it to bind to tissue protein and function as an antigen Etiology Topical medications or photosensitizing agents (aftershave, sunscreens, sulfonamides)  Photoallergic Dermatitis Signs and Symptoms Erythematic vesicles and pruritus Prior exposure to the sun is required Reaction may affect non-sun exposed areas of the skin Photoallergic Dermatitis Massage and Photoallergic Dermatitis Non Contagious LOCAL CONTRAINDICATION Stasis Dermatitis Definition “Stasis” or blood/fluid pooling and inflammation of the lower legs due to chronic venous insufficiency Etiology Chronic venous insufficiency Risk factors: History of deep vein thrombosis (most important) Varicose veins or a family history of varicose veins Obesity Pregnancy Not getting enough physical activity Smoking and tobacco use  Stasis Dermatitis Signs and Symptoms Chronic, bilateral redness, warmth, swelling, and scaling of lower legs Dark brown hyperpigmentation from increased blood MC affected area: ankles Complication: venous ulcers may form Stasis Dermatitis Massage and Stasis Dermatitis Non Contagious LOCAL CONTRAINDICATION Do not work over venous ulcers Have to be cautious about blood clots (DO NOT WANT TO MASSAGE) Neurodermatitis Aka Localized Scratch Dermatitis or Lichen Simplex Chronicus Definition Chronic, itchy inflammation that leads to thickening of the epidermis Linked to psychogenic factors (anxiety, depression, etc.) Etiology Unknown; psychological factors are a possible cause Anxiety and nonspecific emotional stress Epidemiology More common in ages 20-50 and among Asians and Native Americans Neurodermatitis Signs and Symptoms Itchy, dry, scaling rash with dark, thickened patches Repeated skin scratching and/or rubbing, causing further itching and then further scratching and/or rubbing, creating a vicious circle (itch–scratch cycle) MC affected areas: arms, legs, neck, anus, and vagina Treatment Treat the cause of the itching (possible psychological factors) Pt education re: effects of scratching Topical corticosteroids Antihistamines Neurodermatitis Neurodermatitis Massage and Neurodermatitis Non Contagious LOCAL CONTRAINDICATION Seborrheic Dermatitis Definition Chronic, inflammatory disease of skin rich with sebaceous glands “Cradle cap” Cause No known cause but has been associated with the normal yeast Malassezia furfur (can also cause tinea versicolor) Linked to weakened immune system and possibly genetics Also linked to stress, cold & dry climate, and diet Higher incidence and intensity w/ Parkinson’s and HIV patients Seborrheic Dermatitis Signs and Symptoms Pruritus, extensive dandruff, and yellow, greasy-appearing flakes MC affected areas: face, hairline, and scalp Treatment Anti-inflammatory shampoos Antifungal topicals Seborrheic Dermatitis Seborrheic Dermatitis Massage and Seborrheic Dermatitis Inquire about history Inquire about sensitivity of affected areas and adjust pressure accordingly Use thin, water-based lubricants rather than oil-based Perioral Dermatitis Definition Dermatitis that is found surrounding the mouth Can be mistaken for acne or acne rosacea Etiology Idiopathic Many factors have been suggested, but one of the most common is topical steroid use Perioral Dermatitis Signs and Symptoms Often limited to the area immediately surrounding the mouth, but can spread toward the eyes Acne-like papules and pustules, scaling, and erythema Treatment Removal of possible triggers Antibiotic creams Anti-inflammatory creams NEOPLASMS OF THE SKIN Melanocytic Nevi (Moles) How to know if a mole is concerning? Atypical or dysplastic nevi may indicate melanoma The ABCDEs of moles A = asymmetry B = borders C = colour D = diameter E = evolving  Malignant Melanoma Malignant melanoma Main cause is UV light exposure Extremely dangerous Has a variety of presentations Cancerous melanocytes grow rapidly and metastasize through lymphatic system If detected early and removed surgically, the 5-year survival rate is 99 percent If not detected until after metastasis, the 5-year survival rate drops to 14%  Basal Cell Carcinoma (BCC) Basal cell carcinoma (BCC) Most common form of skin cancer Originates in stratum basale due to mutations caused by overexposure to UV radiation Appears as a transparent or pearly white nodule Although there are a variety of appearances Virtually no metastasis and most people survive ~100% 5-year survival rate  Basosquamous Carcinoma (BSC) Basosquamous carcinoma (BSC) Rare, aggressive cancer Appears to be a BCC that has undergone mutation and differentiation as if it were a squamous cell Caused by overexposure to UV radiation  Sebaceous Neoplasm Sebaceous Neoplasms Group of tumours involving sebaceous glands Usually benign, but can be malignant Can often be mistaken for other tumours such as BCC or BSC  Cutaneous Papilloma Cutaneous Papilloma (aka Skin Tag) Extremely common, benign skin growth typically found in areas where skin rubs together Base of the neck, flexor surfaces or limbs, etc Possibly associated with human papilloma virus (HPV) Skin Neoplasms Massage and Skin Neoplasms All LOCAL CONTRAINDICATIONS Follow guidelines for working with clients who have cancer Observe client’s skin for other suspicious lesions and encourage patient to be evaluated by doctor if anything new is noticed. ICHTHYOSIS  Ichthyosis Definition Group of over 30 diseases with similar presentations including red, itchy skin Etiology Genetic mutation or inheritance  Ichthyosis Signs and Symptoms Vary, depending on the exact type of ichthyosis Common: redness, pruritus, flaky skin, leathery skin, skin that forms large, hard plates Treatment Dependant on type of ichthyosis Typically involve creams to hydrate the skin Icthyosis Massage and Icthyosis Non contagious No contraindications Skin may be sensitive, so make sure to check in with the patient