Dermatology 1:2 SU23 PDF

7/15/2023 NURS 5524 – Primary Care of the Adult/Elderly Client Management of Dermatological Problems July 26, 2023 Gloria M. Rose, PhD, NP-C, FNP-BC 1 Skin Care    Hygiene - a factor in many skin problems, especially infection Soaps: ⚫ Avoid deodorant soap ⚫ May use antibacterial, esp. fo...

7/15/2023 NURS 5524 – Primary Care of the Adult/Elderly Client Management of Dermatological Problems July 26, 2023 Gloria M. Rose, PhD, NP-C, FNP-BC 1 Skin Care    Hygiene - a factor in many skin problems, especially infection Soaps: ⚫ Avoid deodorant soap ⚫ May use antibacterial, esp. for hands ⚫ Ideal - super fatted and fragrance-free Moisture - water is best; oil on clean dry skin helps retain moisture 2 Sun Protection    Clothing is best Chemical - topicals with SPF (sun protection factors) - ?15 adequate? Physical - screens like zinc oxide are topicals that form physical barrier 3 1 7/15/2023 Assessment of Skin  History ⚫ ⚫ ⚫ ⚫ ⚫   onset and duration aggravating/relieving factors associated events - illness, meds, emotional, others in family, travel systemic complaints-associated symptoms exposure to irritants or allergens PMH - previous illnesses, atopy FMH 4 Course of Symptoms     Continuous, progressive, cyclic, seasonal Progression - additional lesions; first versus present lesions Had before? How treated? How treating now? 5 Examination   Distribution - generalized, localized to specific area (e.g. hands and feet or trunk) Arrangement - linear, clustered, discrete, confluent 6 2 7/15/2023 Primary Skin Lesions  Macule ⚫ A macule is a flat discoloration that has a definite border. It can be brown, blue, red, or lighter than the surrounding skin. 7 Primary Skin Lesions  Patch ⚫ Flat, nonpalpable, irregular-shaped macule > 1 cm diameter 8 Primary Skin Lesions  Lichenification ⚫ Cutaneous thickening and hardening of epidermis, secondary to persistent rubbing, itching, skin irritation 9 3 7/15/2023 Primary Skin Lesions  Papule ⚫ A papule is an elevated, solid lesion that measures less than 0.5cm. Papules are the most common type of primary lesion. They can be any color 10 Primary Skin Lesions  Nodule ⚫ A nodule is a raised, solid lesion that is greater than 0.5 cm in diameter. A large nodule is called a tumor but there are no size criteria that distinguish a nodule from a tumor. 11 Primary Skin Lesions  Pustule ⚫ A pustule is an elevated lesion of any size that contains pus. 12 4 7/15/2023 Primary Skin Lesions  Plaque ⚫ A superficial, solid, elevated lesion that is greater than 0.5 cm in diameter. A plaque is often formed when multiple papules merge. 13 Primary Skin Lesions  Vesicle ⚫ A vesicle is a raised lesion that is filled with fluid and is less than 0.5 cm in diameter. 14 Primary Skin Lesions  Bulla ⚫ A bulla is a raised lesion that is greater than 0.5 cm in diameter and contains clear fluid. Bullae can get very large and are often subclassified as tense or flaccid depending on how full they are. 15 5 7/15/2023 Primary Skin Lesions  Wheal (Hive) ⚫ Firm edematous plaque; palpable, confluent, transient 16 Primary Skin Lesions  Scales ⚫ Excess dead epidermal skin; abnormal keratinization and shedding 17 Primary Skin Lesions  Crust ⚫ Collection of dried serum and cellular debris (scab) 18 6 7/15/2023 Skin Lesions  Erosions ⚫ Focal loss of epidermis; does not extend below dermo-epidermal junction 19 Skin Lesions  Ulcer ⚫ Focal loss of epidermis and dermis resulting in scarring 20 Skin Lesions  Fissure ⚫ Linear loss of epidermis and dermis with sharply defined, nearly vertical walls 21 7 7/15/2023 Skin Lesions  Atrophy ⚫ Depression in skin resulting from thinning of epidermis or dermis 22 Dermatology Diagnostic Tests  Microscopy ⚫ ⚫ ⚫   KOH prep - fungal Tzanck prep - herpes direct visualization - parasites Woods light Culture ⚫ bacterial, viral, or fungal 23 Seborrheic Dermatitis  Description ⚫ Chronic, superficial disorder affecting the hairy areas of the body where many sebaceous glands are present 24 8 7/15/2023 Seborrheic Dermatitis  Risk Factors ⚫ ⚫ ⚫ ⚫  Emotional stress Family history Parkinson disease HIV infection (early cutaneous manifestation) Assessment – Adults ⚫ ⚫ ⚫ Greasy, scaling rash Commonly found in scalp, eyebrows, nasolabial area, ear canals, upper back/anterior chest Erythema 25 Seborrheic Dermatitis  Nonpharmacologic management ⚫ ⚫ ⚫   Exposure to light Shampoo frequently Apply warm peanut, olive, or mineral oil in PM, wash off in AM with shampoo Pharmacologic Management Scalp ⚫ OTC antiseborrheic shampoo containing selenium sulfide, sulfur, salicytic acid, coal tar 26 Seborrheic Dermatitis   Pharmacologic Management Scalp (cont’d) ⚫ Ketoconazole or pyrithione zinc Topical steroid gel massaged into scalp 2-3 times per week; taper steroid Face ⚫ Ears and scalp margin ⚫ ⚫   1% hydrocortisone cream Fluorinated hydrocortisone cream 27 9 7/15/2023 Seborrheic Dermatitis   Pharmacologic Management Eyelids ⚫ ⚫  Cleanse with dilute baby shampoo using a cotton swab 1% ophthalmic hydrocortisone preparation Other areas ⚫ ⚫ Antiseborrheic shampoo Low potency hydrocortisone cream 28 Psoriasis  Description ⚫ A chronic, pruritic, inflammatory skin disorder characterized by rapid proliferation of epidermal calls. Have frequent remissions and exacerbations 29 Psoriasis - History     Past history - rarely see first episode Family history - genetic transmission Exacerbating factors - strep, drugs (lithium, beta blockers, systemic steroids), stress Relieving factors -sun exposure 30 10 7/15/2023 Psoriasis  Assessment Findings ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Silvery, white scales on erythematous base Oval shaped thick, lichenified, scaly patches Pruritus Common distribution to elbows, knees, scalp May also appear on eyebrows, ears, trunk Nails may be pitted 31 Psoriasis  Assessment Findings ⚫ ⚫ Positive Auspitz sign Smooth pink lesions in the intergluteal areas 32 Psoriasis  Prevention ⚫ ⚫ ⚫ ⚫  Avoid Avoid Avoid Avoid sunburn known precipitants sudden withdrawal of steroids stimulating drugs Nonpharmacologic Management ⚫ ⚫ ⚫ ⚫ Warm soaks Solar radiation, ultraviolet radiation Oatmeal bath Wet dressings (Burrow’s solution) 33 11 7/15/2023 Psoriasis  Pharmacologic Management ⚫ ⚫ ⚫ ⚫ Emollients to hydrate skin Topical steroids: consider plastic occlusion in adults and older children (with caution) to hasten resolution; increases skin penetration 10-fold Intralesional steroid injections Tar solution alone or in combination with topical steroid 34 Psoriasis  Pharmacologic Management Salicylic acid gel or ointment as a keratolytic agent Topical steroids of mid-range potency Calcipotriol (Dovonex) - Vitamin D analogue that inhibits epidermal cell proliferation Ultraviolet lamps and sunlight Methotraxate, Etanercept (Enbrel): used for severe cases ⚫     35 Pityriasis Rosea  Description ⚫ Idiopathic self-limiting skin disorder characterized by papulosquamous lesions distributed over the trunk and extremities 36 12 7/15/2023 Pityriasis Rosea  Assessment Findings ⚫ ⚫ ⚫ “Herald patch” on trunk resembles tinea corporis and precedes the generalized rash Salmon-colored oval plaques 1-10 cm in diameter and with fine scales “Collarette” of loose scales along the border of the plaques 37 Pityriasis Rosea  Assessment Findings ⚫ ⚫ ⚫ Oval shaped lesions appear parallel to each other on the trunk – Christmas tree” pattern rash Mild pruiritis; occasional reports of severe pruiritis In children, lesions may be papular and on face and distal extremities 38 Pityriasis Rosea 39 13 7/15/2023 Pityriasis Rosea  Nonpharmacologic Management ⚫ ⚫ ⚫  Lukewarm oatmeal bath to relieve itching Reassurance that condition is selflimiting Good hygiene to prevent bacterial secondary infections Pharmacologic Management ⚫ Antipruritics (topical or oral)   Calamine lotion Hydroxyzine (Atarax) 40 Allergic Contact Dermatitis  Description ⚫  Etiology ⚫ ⚫  Acute inflammation of the skin due to contact with an external substance or object Chemical irritants Plants (rhus-urushiol) Incidence ⚫ Common 41 Allergic Contact Dermatitis  Risk Factors ⚫ ⚫ ⚫ ⚫  Family history Continued contact with an offending substance: plants, chemicals, soaps,nickle Topical drugs: neomycin, thimerosal, paraben Occupation: gloves Assessment Findings ⚫ ⚫ Redness, itching, bullae, and/or surrounding erythema Lines of demarcation with sharp borders 42 14 7/15/2023 Allergic Contact Dermatitis  Assessment Findings ⚫ ⚫ ⚫ ⚫ ⚫ Papules and/or vesicles Scaling, crusting, or oozing Initially, the dermatitis may be limited to the site of contact, but may later spread Palms and soles less likely to exhibit reaction Thin skin areas may be more sensitive 43 Allergic Contact Dermatitis 44 Allergic Contact Dermatitis 45 15 7/15/2023 Allergic Contact Dermatitis 46 Allergic Contact Dermatitis  Differential Diagnosis ⚫ ⚫ ⚫  Seborrheic dermatitis Eczema Herpes simplex if appearance vesicular Diagnostic studies ⚫ ⚫ Usually none Patch test with offending substance 47 Allergic Contact Dermatitis  Nonpharmacologic Management ⚫ ⚫ If contact with substance occurs, wash skin immediately with soap and water and rinse liberally Soaks with cool water may help burning an/or irritation 48 16 7/15/2023 Allergic Contact Dermatitis  Nonpharmacologic Management ⚫ ⚫ ⚫  Tepid bath may help with pruritus Emollients to prevent drying if chronic inflammation Monitor for bacterial secondary infection Pharmacologic Management ⚫ ⚫ ⚫ ⚫ Corticosteroids 3 factors affect potency of topical corticosteroids Absorption increases based on the vehicle Calamine lotion for itching 49 Allergic Contact Dermatitis  Pharmacologic Management ⚫ ⚫ ⚫ ⚫ Moisture barrier: zinc oxide Antihistamine: topical and/or oral Oral corticosteroids (Prednisone) Topical or oral antibiotics if secondarily infected 50 Atopic Dermatitis  Description ⚫ ⚫ Chronic, pruritic skin eruption with acute exacerbations appearing in characteristic sites. Eczema is often used interchangeably with atopic dermatitis, but the word eczema describes acute symptoms associated with atopic dermatitis 51 17 7/15/2023 Atopic Dermatitis  Risk Factors ⚫ ⚫ ⚫ ⚫  Family history of atopic diseases Skin infections Stress Temperature extremes Assessment Findings ⚫ General: pruritus, erythema, dry skin, facial erythema, infraorbital folds (Dennie Morgan folds) 52 Atopic Dermatitis  Assessment Findings ⚫ Adults Flexural surfaces are common sites, dorsa of the hands and feet  Often reappears in adulthood after absence since childhood  Lichenification and scaling are typical  53 Atopic Dermatitis 54 18 7/15/2023 Atopic Dermatitis 55 Atopic Dermatitis  Nonpharmacologic Management ⚫ ⚫ ⚫ ⚫ ⚫ Limit bathing to avoid further drying of skin Prevent skin trauma Soak for 20 minutes in warm water before applying emollient Wet compresses if lesions are weeping or oozing Patient education regarding disease, self-care, and precipitating factors 56 Atopic Dermatitis  Pharmacologic Management ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Topical corticosteroids Topical immune modulators Antihistamine for itching Emollients 2-3 times per day or as needed to correct dry skin Oral corticosteroids – severe cases Intralesion steroid injection 57 19 7/15/2023 Atopic Dermatitis  Possible complications ⚫ ⚫ ⚫ Bacterial secondary infections from topical steroid and scratching Atrophy or striae Lichenification 58 Burns  Description ⚫  Injury to skin and tissues caused by chemicals, thermal energy, radiation, or electricity Etiology ⚫ ⚫ ⚫ ⚫ Excessive sun exposure Flames or hot water most common Electrical wires, lightning Chemical splashes: acids or bases 59 Burns  Risk Factors ⚫ ⚫ ⚫  Hot water heaters set too high, especially in the elderly Improper use of sunscreens Insensitivity Assessment Findings ⚫ ⚫ Partial thickness: first and second burns Full thickness: third degree burns 60 20 7/15/2023 Burns  Assessment Findings ⚫ ⚫ ⚫ General distribution of burns may indicate source Straight burn lines may indicate child abuse Geriatric burns heal more slowly 61 Burns  First-degree ⚫ ⚫ ⚫  Redness Tenderness No blisters Second degree ⚫ ⚫ ⚫ Redness Tenderness Presence of blisters 62 First Degree Burn 63 21 7/15/2023 Second Degree Burn 64 Burns  Third degree ⚫ ⚫ ⚫ Charred, leathery appearance of skin Skin may be white with raw edges Very little tenderness 65 Burns  Prevention ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Liberal sunscreen In children, limit access to electrical cords, wires, chemical, etc. Parental supervision Use of home smoke detectors and plan for evacuation of home in case of fire Knowledge of proper use of home fire extinguisher Set home water heater 120-130º 66 22 7/15/2023 Burns  Nonpharmacologic Management ⚫ ⚫ ⚫ ⚫ Do not apply ice to burns. Apply cool water or saline only to clean. May use a mild soap Remove clothing, jewelry, over and around burned areas Flush chemical burns with cool water for 30 minutes to 2 hours depending on substance and severity Remove blistered skin after rupturing blisters 67 Burns ⚫ ⚫  Clean and redress burn 1-2 times/day Good nutrition during convalescence Pharmacologic Management ⚫ ⚫ ⚫ ⚫ Apply antibacterial cream Consider biologic dressings Analgesics to relieve pain Tetanus prophylaxis if not within 10 years 68 Burns  Consultation/Referral ⚫ Refer to specialist all burns not considered minor Second-degree burns > 20% of body All third degree burns  Burns of the eyes, hands, feet, or perineum  Lightening burns  Electrical burns  Burns over joints   ⚫ Child/elderly protection for suspected abuse 69 23 7/15/2023 Actinic Keratosis     Keratotic scaly lesions with erythematous papules or plaques on sun exposed skin Most common lesion seen in dermatology Most common epithelial precancerous skin lesion 10-20% can become squamous cell carcinoma 70 Actinic Keratosis 71 Actinic Keratosis  Assessment Findings ⚫ ⚫ ⚫ Described as a scaly spot that would not go away or peels and comes back Round or oval shaped scaly lesions Flesh colored, red, pink, brown or black 72 24 7/15/2023 Actinic Keratosis  The treatment of AKs begins with prevention. ⚫ ⚫ ⚫ Avoiding sun exposure sunscreens reduce the development of AKs Active treatment of AKs depends upon the size of the lesion and the number of lesions present. 73 Actinic Keratosis   Tenderness and bleeding are concerning Pharmacologic Management ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Topical fluorouracil (5-FU) cream Topical imiquimod 5% cream Phototherapy TCA peels Cryotherapy Liquid Nitrogen Dermabrassion 74 Skin Cancer  Description ⚫  Etiology ⚫  Malignant tumors of the skin arising from various skin layers Almost always due to overexposure of the skin to ultraviolet rays Risk Factors ⚫ ⚫ Exposure to ultraviolet rays, thermal burns, or radiation Fair skin: blondes and redheads 75 25 7/15/2023 Skin Cancer  Risk Factors ⚫ ⚫ ⚫ ⚫ ⚫ Light blue or green eye color Improper and infrequent use of sunscreen Blistering sunburn in adolescence Intense, episodic sun exposure Living in sunny climates 76 Skin Cancer  Prevention ⚫ ⚫ ⚫ ⚫ ⚫ Actinic keratosis is a scaly patch of red or brown skin which often becomes SCC Avoidance of sun exposures Frequent total body skin examination every 36 months after diagnosis of melanoma Teach importance of avoidance of sunlight at peak hours, use of sunscreen to patients, especially adolescents Hats, long sleeve shirts while exposed to sunlight 77 Squamous cell carcinoma (SCC)  Assessment Findings ⚫ ⚫ ⚫ ⚫  Common on sun exposed areas of the skin Lower lip is common location in smokers Nodule has indistinct margins Surface is firm, scaly, irregular and may bleed easily Expected Course ⚫ May metastasize 78 26 7/15/2023 Squamous Cell Carcinoma 79 Basal cell carcinoma (BCC)  Assessment Findings ⚫ ⚫ ⚫  Common in 40 to 60 year olds Most common sites are head (tip of nose) and neck Usual appearance is pearly domed nodule with overlying telangiectatic vessels; later, central ulceration and crusting Expected Course ⚫ Slow growing, rarely metastasizes; often there is recurrence within 5 years at another site 80 Basal Cell Carcinoma 81 27 7/15/2023 Malignant Melanoma  Assessment Findings ⚫ ⚫ ⚫ Usual age is early forties ABCDE characteristic of any lesion  A = asymmetry  B = border is irregular  C = color variegation  D = diameter > 6 mm (size of pencil eraser)  E = elevation above level of skin Hypo or hyperpigmentation, bleeding, scaling, texture, or size change of an existing mole or lesion 82 Malignant Melanoma 83 Malignant Melonama 84 28 7/15/2023 Malignant Melanoma  Assessment Findings ⚫ ⚫ Common in Caucasians on back, lower leg Common in African Americans on hands, feet, nails 85 Malignant Melanoma  Expected course ⚫ ⚫ Accounts for over 60% of skin cancer deaths Metastasizes to any organ 86 Spider/Insect Bites and Stings  Etiology ⚫ ⚫ ⚫ ⚫ Bees/wasps/ants Mosquitoes/fleas Ticks Spiders/scorpions/caterpillars 87 29 7/15/2023 Spider/Insect Bites and Stings  Assessment Findings ⚫ ⚫ ⚫ ⚫ Bees/wasps Mosquitoes/fleas Ticks Spiders/caterpillars 88 Spider/Insect Bites and Stings  Nonpharmacologic Management ⚫ ⚫ ⚫  Remove stinger Do not attempt to burn or crush tick Never apply heat to spider bites Pharmacologic Management ⚫ ⚫ ⚫ Tetanus prophylaxis Antihistamines Antipruritics/Steroids 89 90 30