Pathologies of the Integumentary System PDF

Pathologies of the Integumentary System Dr. Cody Whitefoot PT, DPT, OCS, TSAC-F  Objectives – Describe general skin structure and function – Define terms relating to signs and symptoms of integumentary pathology – Reco...

Pathologies of the Integumentary System Dr. Cody Whitefoot PT, DPT, OCS, TSAC-F  Objectives – Describe general skin structure and function – Define terms relating to signs and symptoms of integumentary pathology – Recognize macroscopic manifestations of integumentary pathology Integumentary – Classify skin lesions requiring referral to M.D. System – Describe the pathogenesis, clinical manifestation and treatment of: – Common skin infections – Skin tumors – Immunologic skin disorders – Burns – Pressure ulcers Integumentary System General Skin Structure – 3 Primary Layers – Epidermis – Dermis – Papillary Dermis – Reticular Dermis – Subcutaneous Tissue  Skin Structure Characteristics Function Epidermis Tough horny superficial layer Protection Regenerative deep basal layer Melanosome production No vessels, lymphatics First line antigen defense Integumentary System Dermis Dense layer of interlacing collagen Skin texture and elastin fibers Collagen synthesis Neurovascular structures Phagocytosis of foreign bodies Lymphatics Histamine for inflammatory response Lymphatic drainage Thermoregulation Sensation Function Epidermal Sweat and sebaceous glands Thermoregulation (perspiration) Appendages Hair and errector (goosebump) Hair production muscles Sebum production Protection Subcutaneous Tissue Loose connective tissue Energy Storage Stored fat Protection (trauma absorption) Neurovascular structures Blood vessel Integumentary Pathologies Integumentary System Pruritis – Itching; generalized symptom Xerosis – Excessive dryness of skin  Urticaria – Hives; vascular skin reaction – Wheal Integumentary – Smooth, slightly elevated patches System Dermatographism – Mechanical irritation (Skin Writing)  Erythema – Superficial reddening of the skin Integumentary System Rash – Eruption on skin; generalized symptoms on a continuum Integumentary System Lichenification Thickened & rough skin characterized by prominent skin markings; usually the result of repeated friction over area Integumentary System Plaque – Elevated flat-topped area, usually more than 5 mm across Scale Dry, horny, plate like sheet of keratin; usually the result of imperfect cornification Integumentary System Folliculitis Papule (raised) formed around single central hair follicle Staphylococcus Aureus Furuncle Focal suppurative infection of central hair shaft and surrounding subcutaneous tissue (i.e.,Boil) –  Carbuncle Cluster of furuncles with connection through sinuses Integumentary System Paronychia Soft tissue infection between the skin and the nailbed Integumentary System Blister Vesicle or bulla Cyst Membranous sac or cavity of abnormal character containing fluid  Macule Lesion measuring less than 2 cm in diameter Neither raised nor depressed Primarily representing a change in skin Integumentary color System Papules Slightly elevated induration of skin < 1 cm diameter Nodules Slightly elevated area > 1 cm diameter Integumentary System Nevus – Mole ABCDEs – Asymmetry – Borders – Color – Diameter – Elevation Asymmetry Asymmetrical Nevus Borders Irregular Border Nevus Color Nonuniform Color Diameter Larger than pencil eraser Elevation Central elevation  Reasons to Refer – Asymmetry – Asymmetry calls for referral – Borders – Ragged, blurred, irregular – Color ABCDEs – Variegated color – Change in color – Diameter – Greater than 6 mm – Elevation – Uneven elevation – Change in elevation over time Integumentary System Common Inflammatory Skin Disorders Common Skin Disorders Atopic Dermatitis – Atopy: Unusual or special – Most common chronic inflammatory skin disorder Affecting ~10% of children – Etiology: Unknown Symptoms: – Early: Red, oozing, crusting rash – Later: Xerosis and pruritus – Flexor surfaces of joints – Opportunistic secondary skin infections Common Skin Disorders – Eczema (Dermatitis) – Superficial inflammation of the skin – – Stages – Acute: Extensive erosions with serous exudate or erythematous, pruritic papules/vesicles – Subacute: Erythematous, scaling papules or plaques over erythematous skin – Chronic: Thickened skin and lichenification Common Skin Disorders Contact Dermatitis Acute or chronic skin inflammation caused by exposure to an offending agent: – Chemical – Mechanical – Biologic Manifestation: Pruritus and erythema 1-2 days post exposure if previously sensitized Management: Removal of offending agent Common Skin Disorders – Rosacea – Common skin disease that begins as tendency to blush easily – Pathogenesis: No known cause for proliferation of arterioles develop; may be associated w/ Heliobacter pylori – Manifestation: Facial erythema that can appear as pustules resembling acne – Treatment: Topical or oral anti-inflammatory medication Common Skin Infections  Bacterial – Impetigo – Cellulitis – Folliculitis – Described previously Common Skin Infections Viral – Herpes Zoster – Herpes Simplex – Musculum Contagiosum – Verrucae (Warts)  Impetigo Bacterial infection characterized by honey-crusted Bacterial Skin lesion on erythematous base Infections Staph aureus or strep pyogenes Management: Topical antibiotic (Bactroban) or wide spectrum oral antibiotics  Cellulitis – Rapidly spreading acute inflammation that spreads through tissue spaces – Risk Factors: Older adults, Bacterial Skin diabetes, steroid therapy, wounds or ulcers Infections – Manifestation: Diffuse erythema, warmth, tenderness and swelling that is rapidly progressive – Management: Oral or IV antibiotics (limb or life threatening)  Herpes Zoster – Reactivation of varicella zoster virus – Peak incidence 50-70 y/o, usually in immunocompromised individuals Viral Skin Infections – Manifestation: Vesicular eruption in unilateral distribution of dermatome – Symptoms: Pain/tingling, fever, chills, malaise 1-3 days prior to eruption of red papules – Treatment: Oral Steroids, Zovirax  Herpes Simplex – Chronic, latent, recurrent HSV infection of mucocutaneous site – HSV-1: cold sores (~ 70% > 12 y/o) – HSV-2: genital herpes (~20% > 12 y/o) Viral Infections – Manifestation: Clustered vesicles on erythematous base. Initial infection can be associated w/ fever; malaise – Treatment: Anti-virals suppress, but do not eliminate  Molluscum Contagiosum – Caused by molluscum contagiosim virus, a poxvirus – Most common in children Viral Infections from 1-10 years of age – Manifestation: Small, raised lesions with dimple in center – Treatment: Typically resolved within 6-12 months  Verrucae – Benign viral infections of the skin caused by human papillomaviruses (HPV’s) Viral Skin – Probably spread through direct contact; autoinnoculation Infections – Diagnosis: Visual exam – Treatment: Can be self-limiting; OTC salicylic acid preps; cryotherapy w/ liquid nitrogen; electrodessication or curettage  Fungal Tinea Corporis Tinea Pedis Fungal and Tinea Cruris Parasitic Skin Tinea Versicolor Infections Parasitic Scabies Pediculosis  Tinea Corporis – Spread through skin-to skin contact – Presentation: Erythematous, scaly area of varying size with potentially a central clearing that provides the name “RING” Fungal Skin – Most adults or children present with Infections multiple lesions that are hyperpigmented in Caucasians or depigmented in dark-skinned individuals – Lesions occur most often on the face, chest, abdomen and back of arms – Treatment: Topical antifungal agent  Tinea Cruris (Jock Itch) – Manifestation: Well demarcated, scaly, erythematous rash that tends to be pruritic Fungal Skin Infections – Butterfly presentation generally that spares the scrotum and penis or vagina – Treatment: Anti-fungal ointment  Tinea Pedis (Athlete’s Foot) – Macerated and scaly interdigital areas that may have a ringworm pattern on the dorsum of the foot Fungal Skin Infections – Occurs on the lateral edges and soles and demonstrate dry, scaly, erythematous areas – Treatment: Topical anti-fungal for 2-4 weeks.  Tinea Versicolor – Common yeast (fungal) infection contracted in hot/humid environments Fungal Skin – Presentation: Multiple small, round scaly macules that Infections enlarge rapidly – May present as white, brown or pink areas that will not tan when exposed to sunlight – Treatment: Selenium Sulfide Lotion (Selsun Blue Shampoo) Parasitic Infections – Scabies – Highly contagious skin eruption caused by sarcoptes scabiei – Manifestation: Inflammation/ pruritus begins 30-60 days post contact. Intense pruritus leads to skin excoriations – Treatment: Oral med (Ivermectin) and scabicide cream (permethrin) Parasitic Infections Pediculosis (Lice) – Infestation of Pediculus humanus – Infects head, body or genital areas – Transmission is through shared items such as combs, lockers, clothes, hats, or furniture – Treatment: Cleaning with special solution or an oral medication Skin Cancer  – American Cancer Society – Prevalence: – Most prevalent form of cancer – Skin Cancer Foundation – One in 5 Americans will develop skin cancer by 70 y/o – Incidence Skin Cancer – > 1M new cases of nonmelanoma skin cancers each year – 90% associated with sun exposure – Most rapidly increasing form of CA in the US w/ no evidence that the epidemic is peaking  Important Trends – 1 in 5 Americans will develop skin cancer by the age of 70 – More than 2 people die of skin cancer in the U.S. every hour Skin Cancer – Having 5 or more sunburns doubles your risk for melanoma – When detected early, the 5-year survival rate for melanoma is 99 percent – Basal and squamous cell carcinomas are most common forms of skin cancer and are highly curable if detected and treated early  – Risk Factors – Excessive exposure to natural and artificial (tanning beds) ultraviolet radiation Skin Cancer – Fair complexion – Decreased risk in POC Skin Cancer and Plan of Care (POC)  – Warning Signals – Any unusual skin condition, especially a change in the size or color of a mole or other darkly pigmented growth or spot Skin Cancer – Treatment – Surgery – Electrodessication – Radiation therapy  Benign Tumor: Precancerous Conditions Actinic Keratosis – Abnormal cell growth resulting from long term sun exposure Skin Cancer – Well-defined, crusty growth (horny, dry, rough) that develops to 3-6 mm diameter – Known risk of malignant degeneration and possible metastasis – Extremely common in Caucasians > 65 y/o Skin Cancer – Malignant Skin Tumors Basal Cell Carcinoma – Overview: Slow growing skin tumor from the undifferentiated epidermis basal cells – Rarely metastasizes but can cause local destruction – Manifestation: Slightly elevated; pearly or ivory appearance; rolled edges; visible blood vessels. May ulcerate centrally. – Diagnosis: Inspection confirmed by biopsy – Treatment: Curettage with lab confirmation of clean margins.  Malignant Skin Tumors Squamous Cell Carcinoma – Overview: Tumor of the epidermal keratinocytes that arises in sun- damaged skin of whites. Can be Skin Cancer non-invasive or invasive – Manifestation: Poorly defined margins with tumor that can present as ulcer, flat red area, cutaneous horn, plaque, or nodule. – Diagnosis: Inspection confirmed by biopsy – Treatment: Dependent on location, depth, size of tumor  Malignant Skin Tumors – Malignant Melanoma – Neoplasm of the skin originating from melanocytes Skin Cancer – Incidence – up to 5% of all cancers – 1 person dies of melanoma every hour – 62,190 new cases in 2006; 7,910 deaths – 178,560 new cases in 2018; 9,320 deaths  Superficial Spreading Melanoma Nodular Melanoma Skin Cancer Lentigo Maligna Melanoma Acral Lentiginous Melanoma Integumentary System Malignant Skin Tumors Malignant Melanoma – Risk Factors: Sun and tanning bed exposure, family history – Diagnosis: Inspection confirmed by biopsy – Treatment: Surgical excision (combined w/ radiation and/or chemotherapy if evidence of metastasis) – Prognosis: Can spread quickly, insidiously: however, 100% curable if detected early Immunologic Skin Disorders Immunologic Skin Disorders Psoriasis – Chronic, inherited, recurrent inflammatory dermatosis – Characterized by erythematous plaques covered w/ silvery scale – Pathogenesis: Increased turnover time of psoriatic skin which does not allow basal cells to mature; immature cells build up resulting in thick, flaky stratum corneum  Psoriasis – Manifestations: lesions on scalp, chest, nails, elbows, knees, groin, skin folds. Persistence and recurrence characterize this disorder. Immunologic – Treatment – Topical Preparations Skin Disorders – Phototherapy – Antimetabolites – Oral Retinoid Therapy – Immunosuppressants – Prognosis: no cure, treatment brings relief in 85-90% of flare-ups. High risk of secondary infection. Immunologic Skin Disorders Systemic Sclerosis – Acquired, non-contagious, rare disease of unknown etiology. – Incidence of 19 cases per million per year in the US. – More common in women of child bearing age, age range 35-65. – Family history of other connective tissue disease is common – Excessive accumulation of the extra cellular matrix (collagen), is the pathologic hallmark and leads to the clinical manifestation of taut skin and is designated as “scleroderma” Immunologic Skin Disorders Systemic Sclerosis – Diffuse fibrous thickening causes sclerodactyly (dermal fibrosis of the hands/fingers) and a tight “expressionless” face with a small mouth (mouse- like face) – Raynaud’s Phenomenon- Ischemic episodes involving fingers and sometimes toes with triphasic color change (red/white/blue) – Ulcerations are common Introduction to Burns Burns Cutaneous Burns – Pathophysiologic changes vary with extent and depth of burn  Cutaneous Burns – Rule of nines provides a quick method for estimating extent of damaged tissue Burns – < 25% body surface area: Local response – >25% body surface area: Systemic response  Cutaneous Burns – Systemic Effects – Integumentary Burns – CV Changes – Renal/GI Changes – Pulmonary Artery Hypertension – Immune System Suppression Introduction to Integumentary Ulcers Pressure Ulcers – Caused by unrelieved pressure damaging underlying tissue – Risk Factors: Diabetes, arterial insufficiency, radiation damage, systemic scleroderma, vasculitis, immobility – Can be sometimes easily remedied by removing or modifying the causative factor  Incidence – New US cases estimated 2.5 million/year Pressure Ulcers – 500K nursing home residents – 400K diabetic foot ulcers Pressure Ulcers Causative Factors – External Pressure – Friction – Shearing Forces – Maceration (softening caused by moisture) – Dehydration – Malnutrition – Decreased Circulation Pressure Ulcers: Pathogenesis External compression Reduced blood flow Platelet aggregation Endothelial cell disruption Microthrombi occlusion Anoxic necrosis  Manifestations – Generally, over bony prominences Pressure – Greatest ischemia over bone – “Tip of the iceberg” Effect Ulcers – Described/measured – Surface area – Exudates – Tissue involved