Chapter_025.docx

Chapter 25 Integumentary Problems KEY POINTS ENVIRONMENTAL HAZARDS Sun safety includes sun avoidance (especially during midday hours), protective clothing, and sunscreen use. Actinic keratoses, basal cell cancer, squamous cell cancer, and melanoma are problems associated with sun exposure. NONMELANO...

Chapter 25 Integumentary Problems KEY POINTS ENVIRONMENTAL HAZARDS Sun safety includes sun avoidance (especially during midday hours), protective clothing, and sunscreen use. Actinic keratoses, basal cell cancer, squamous cell cancer, and melanoma are problems associated with sun exposure. NONMELANOMA SKIN CANCERS Nonmelanoma skin cancers are the most common form of skin cancer. Nonmelanoma skin cancers are cancers of the epidermis, most commonly occurring in sun-exposed areas. Teach patients to self-examine their skin monthly. The cornerstone of self-skin examination is the ABCDE rule. Examine skin lesions for Asymmetry, Border irregularity, Color change/variation, Diameter of 6 mm or more, and Evolving in appearance. Risk factors for skin cancer include fair skin type (blonde or red hair and blue or green eyes), history of chronic sun exposure, and family history of skin cancer. Actinic keratosis is a premalignant form of squamous cell cancer (SCC) affecting most of the older white population. A typical lesion is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn. Treatments include cryosurgery, fluorouracil, surgical removal, chemical peeling agents, laser resurfacing, and photodynamic therapy. Basal cell carcinoma (BCC) is a locally invasive cancer from epidermal basal cells. Treatment includes surgical excision, electrodessication and curettage, cryosurgery, photodynamic therapy, and radiation therapy. Squamous cell carcinoma (SCC) is a cancer of keratinizing epidermal cells. SCC can be very aggressive, has the potential to metastasize, and may lead to death if not treated early. With early detection and treatment, the cure rate is high. Pipe, cigar, and cigarette smoking contribute to SCC on the mouth and lips. Treatment includes surgical excision, electrodessication and curettage, excision, radiation therapy, photodynamic therapy, and intralesional injection of fluorouracil or methotrexate. MELANOMA Melanoma arises from melanocytes. It is the deadliest skin cancer. Its incidence is steadily rising. Important prognostic factor of melanoma is tumor thickness at the time of diagnosis. Stage 0 is 100% curable, with stage IV being mostly palliative care. The initial treatment for melanoma is surgery. A variety of therapies are available for metastatic melanoma. Melanoma can metastasize to any organ. If it has spread to lymph nodes or nearby sites, immunotherapy and targeted therapies are often needed. People with dysplastic nevus syndrome have an increased risk for melanoma. SKIN INFECTIONS AND INFESTATIONS Staphylococcus aureus and group A β-hemolytic streptococci are major types of bacteria responsible for primary and secondary skin infections. Herpes simplex, herpes zoster, and warts are the most common viral infections affecting the skin. There are many possibilities for exposure to infestations, harboring insects or worms, and insect bites. ALLERGIC DERMATOLOGIC PROBLEMS Allergies and hypersensitivity reactions may present as contact dermatitis and other lesions. A careful history involving exposure to possible offending agents and patch testing are useful in determining the causative agent. The best treatment then becomes to avoid the cause. Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening diseases that usually occur as a severe adverse drug reaction. Patients with SJS/TEN have a blistering rash with sheet-like epidermal detachment accompanied by mucosal lesions in the eye, mouth, and genital areas. Identifying and stopping the offending drug(s) is the most important action in caring for a patient with SJS/TEN. Immunotherapy may play a role in slowing disease progression and promoting skin repair. Supportive care in an intensive care unit is essential. Interventions focus on airway management, preserving renal function, maintaining fluid and electrolyte balance, and pain control. BENIGN DERMATOLOGIC PROBLEMS Common benign dermatologic problems include acne, psoriasis, and seborrheic keratoses. Psoriasis is a chronic, autoimmune dermatitis characterized by silvery, scaling plaques on the knees, elbows, scalp, hands, feet, and lower back. Psoriasis for most people is more emotionally disabling. The person may be self-conscious and withdraw from social contacts INTERPROFESSIONAL CARE: SKIN PROBLEMS Interprofessional Therapy Ultraviolet light (UVL) of different wavelengths may be used to treat many dermatologic conditions, including psoriasis, cutaneous T-cell lymphoma, atopic dermatitis, vitiligo, and itching. Light sources available to treat skin problems include broadband UVB, narrowband UVB, and long-wave UV (UVA1). Therapy for BCC and SCC varies greatly. Lasers are used for many dermatologic problems. Antibiotics are used topically and systemically to treat dermatologic problems. Common OTC topical antibiotics include bacitracin-neomycin-polymyxin (Neosporin), bacitracin, and polymyxin B. Corticosteroids are particularly effective in treating a wide variety of dermatologic conditions. They are used topically, intralesionally, or systemically. High-potency corticosteroids may produce side effects when use is prolonged, including skin atrophy, rosacea, acne, and bruising. Oral antihistamines are used to treat conditions that exhibit hives, angioedema, and itching. Antihistamines may have anticholinergic and/or sedative effects. Several different antihistamines may have to be tried to get an acceptable therapeutic effect. Topical immune response modifiers such as pimecrolimus (Elidel) and tacrolimus (Protopic) are used in atopic dermatitis. Imiquimod (Aldara) stimulates the production of α-interferon and other cytokines to enhance cell-mediated immunity. It is used for external genital warts, actinic keratoses, and superficial BCC. Diagnostic and surgical therapy techniques include skin scraping, electrodessication and electrocoagulation, curettage, punch biopsy, cryosurgery, and excision. Tissue biopsy is the definitive test for diagnosing several skin lesions, particularly skin cancer. NURSING MANAGEMENT: SKIN PROBLEMS After careful history, physical assessment with visual inspection is necessary. Wet compresses are commonly used when skin is oozing from infection and/or inflammation, to relieve itching, to suppress inflammation, and to debride superficial wounds. Baths are used to treat large body areas. They have sedative and antipruritic effects. Careful hand washing and safe disposal of soiled dressings are the best means of preventing spread of skin problems. You are able to provide patient teaching about managing itching, applying topical medications, and proper skin care. Factors affecting the outcome of long-term skin problems include skin type, history of previous exacerbations, family history, complications, intolerance to therapy, environmental factors, and lack of adherence to the prescribed regimen. It is important for you to assist with the emotional stress that can occur for persons who suffer from certain chronic skin problems or have undergone some surgical procedures. COSMETIC PROCEDURES Cosmetic procedures include chemical peels, toxin injections, collagen fillers, laser surgery, breast enlargement and reduction, face-lift, eyelid lift, and liposuction. Preoperative management includes informed consent and realistic expectations of what cosmetic surgery can accomplish. SKIN GRAFTS Skin grafts may be necessary to provide protection to underlying structures or to reconstruct areas for cosmetic or functional purposes. Ideally, wounds heal by primary intention. Two traditional types of grafts are free grafts and skin flaps. Soft tissue expansion is a technique for resurfacing a defect, such as a burn scar; removing a disfiguring mark, such as a tattoo; or as a preliminary step in breast reconstruction. Engineered skin is helpful in certain situations.