Derm.pdf

NURS 5524 – Primary Care of the Adult/Elderly Client Management of Dermatological Problems: Part I July 26, 2023 Skin Care Includes the following 1. Hygiene - a factor in many skin problems, especially infection 2. Soaps: a. Avoid deodorant soap b. May use antibacterial soap especially for the hand...

NURS 5524 – Primary Care of the Adult/Elderly Client Management of Dermatological Problems: Part I July 26, 2023 Skin Care Includes the following 1. Hygiene - a factor in many skin problems, especially infection 2. Soaps: a. Avoid deodorant soap b. May use antibacterial soap especially for the hands c. Ideal soaps are supper fatted and fragrance free 3. Moisture - Water is best may use oil on clean dry skin which helps retain moisture Sun Protection includes the following 1. clothing which is best 2. Chemical protection such as topicals with SPF or sun protection factors, level 15 is adequate. 3. Physical protection includes screens like zinc oxide which are topicals that form physical barriers. Assessment of the skin includes the following 1. History a. Onset and duration b. Aggravating or relieving factors c. Associated events such as illness, medications, emotional factors, others in the family, travel. d. Systemic complaints and associated symptoms e. Past Medical History such as previous illnesses, atopy or the tendency to produce an exaggerated IgE immune response f. Family medical history Course of Symptoms include 2. Continuous, progressive , cyclic, seasonal 3. Progressive - additional lesions; first versus present lesions 4. Did they have it before? How was it treated? 5. How is it being treated now? Examination 1. Distribution - generalized, localized to a specific area such as the hands and feet or trunk? 2. Arrangement - is it linear, clustered, discrete or confluent? Primary Skin lesions 1. Macule a. A macule is a flat discoloration that has a definite border. It can be brown, blue, red, or lighter than the surrounding skin. 2. Patch a. Flat, nonpalpable, irregular shaped macule > 1 cm in diameter. 3. Lichenification a. Cutaneous thickening and hardening of the epidermis, secondary to persistent rubbing, itching, or skin irritation. 4. Papule a. A papule is an elevation, soli lesion that measures less then 0.5 cm. They are the most common type of primary lesion and can be of any color. 5. Nodule a. A nodule is a raised, solid lesion that is > 0.5 cm in diameter. A large nodule is called a tumor but there are no size criteria that distinguishes a nodule from a tumor. 6. Pustule a. A pustule is an elevation lesion of any size that contains pus. 7. Plaque a. A superficial, solid, elevated lesion that is > 0.5 cm in diameter. a plaque is often formed when multiple papules merge. 8. Vesicle a. A vesicle is a raised lesion that is filled with fluid and is < 0.5 cm in diameter 9. Bulla a. A bulla is a raised lesion that is > 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. 10. Wheal (Hive) a. Firm edematous plaque; palpable, confluent and transient. 11. Scales a. Excess dead epidermal skin; abnormal keratinization and shedding. 12. Crust a. A collection of dried serum and cellular debris (scab) 13. Erosions a. Focal loss of epidermis that does not extend below dermo-epidermal junction 14. Ulcer a. Focal loss of epidermis and dermis resulting in scarring 15. Fissure a. Linear loss of epidermis and dermis with sharply defined, nearly vertical walls. 16. Atrophy a. Depression in the skin resulting from thinning of epidermis or dermis Dermatology Diagnostic Tests 1. Microscopic a. KOH prep - for fungal b. Tzanck prep - for herpes c. Direct visualization - for parasites 2. Woods light 3. Culture a. Bacterial, viral or fungal Seborrheic Dermatitis 1. Chronic superficial disorder affecting the hairy areas of the body where many sebaceous glands are present. 2. Risk Factors: a. Emotional Stress b. Family history c. Parkinson’s disease d. HIV infection (early cutaneous manifestations) 3. Assessment - Adults a. Greasy, scaling rash b. Commonly found in the scalp, eyebrows, nasolabial area, ear canals, upper back and anterior chest c. Erythema 4. Nonpharmacologic management a. Exposure to light b. Shampoo frequently c. Apply warm peanut oil, olive, or mineral oil in PM, wash off in AM with shampoo 5. Pharmacologic management a. Scalp i. OTC anti-seborrheic shampoo containing selenium sulfide sulfur, salicylic acid, or coal tar. ii. Ketoconazole or pyrithione zinc iii. Topical steroid gel massaged into scalp 2-3 times per week; taper steroid iv. Face 1. 1% hydrocortisone cream v. Ears 1. Fluorinated hydrocortisone cream vi. Eye lids 1. Cleanse with dilute baby shampoo using a cotton swab 2. 1% ophthalmic hydrocortisone preparation vii. Other Areas 1. Anti-seborrheic shampoo 2. Low potency hydrocortisone cream Psoriasis 1. A chronic, pruritic, inflammation skin disorder characterized by rapid proliferation of epidermal cells. Patients have frequent remissions and exacerbations. 2. History a. Past history - rarely see a first episode b. Family history - genetic transmission c. Exacerbating factors i. Strep, drugs such as lithium, beta blockers, systemic steroids and stress. d. Relieving factors i. Sun exposure 3. Assessment findings a. Silvery, white scales on erythematous base b. Oval shaped thick, lichenified, scaly patches c. Pruritis d. Common distribution to elbows, ears and trunk e. Nails may be pitted. f. Positive Auspitz sign g. Smooth pin lesions in the intergluteal areas 4. Prevention a. Avoid i. Sunburn, known precipitants, sudden withdrawal of steroids, stimulating drugs 5. Nonpharmacological management a. Warm soaks b. Solar radiation, UV radiation c. Oatmeal bath d. Wet Dressings (Burrow’s solution) 6. Pharmacological management a. Salicylic acid gel or ointment as a keratolytic agent b. Topical steroids of mid-range potency c. Calcipotriol (Dovonex) - Vit D analogue that inhibits epidermal cell proliferation d. UV lamps ad sunlight e. Methotrexate, Etanercept (Enbrel); used for severe cases Pityriasis Rosea 1. Idiopathic self-limiting skin disorder characterized by papulosquamous lesions distributed over the trunk and extremities. 2. Assessment Findings a. “Herald Patch” on trunk b. Resembles Tinea Corporis and precedes the generalized rash. c. Salmon-colored oval plaques 1-10 cm in diameter and with fine scales d. “Collarette” of loose scales along the border of the plaques. e. Oval shaped lesions appear parallel to each other on the trunk - XMAS Tree pattern rash f. Mild pruritis; occasional reports of severe pruritis g. In children, lesions may be popular and on face and distal extremities 3. Non pharmacologic management a. Lukewarm oatmeal bath to relieve itching b. Reassurance that condition is self-limiting c. Good hygiene to prevent bacterial secondary infections 4. Pharmacological management a. Antipruritic (topical or oral) i. Calamine lotion ii. Hydroxyzine (Atarax) Allergic Contact Dermatitis 1. Acute inflammation of the skin due to contact with an external substance or object 2. Etiology a. Chemical irritants b. Plants (Rhus-urushiol) 3. Incidence a. Common 4. Risk Factors a. Family history b. Continued contact with an offending substance: plants, chemicals, soaps, nickle c. Topical drugs: neomycin, thimerosal, paraben d. Occupation: gloves 5. Assessment Findings. a. Redness, itching, bullae, and/or surrounding erythema b. Lines of demarcation with sharp border c. Papules and/or vesicles d. Scaling, crusting, or oozing e. Initially, the dermatitis may be limited to the site of contact, but may later spread f. Palms and soles less likely to exhibit reaction g. Thin skin areas may be more sensitive 6. Differential Diagnosis a. Seborrheic Dermatitis b. Eczema c. Herpes simplex if appearance vesicular 7. Diagnostic Studies a. Usually none b. Patch test with offending substance 8. Nonpharmacologic management a. If contact with substance occurs, wash skin immediately with soap and water and rinse liberally b. Soaks with cool water may help burning and/or irritation c. Tepid bath may help with pruritis d. Emollients to prevent drying if chronic inflammation e. Monitor for bacterial secondary infection 9. Pharmacologic management a. Corticosteroids b. 3 factors affect potency of topical corticosteroids c. Absorption increases based on the vehicle d. Calamine lotion for itching e. Moisture barrier: Zinc Oxide f. Antihistamine: Topical and/or oral g. Oral corticosteroids (Prednisone) h. Topical or oral antibiotics if secondary infection occurs Atopic Dermatitis 1. Chronic, pruritic skin eruptions with acute exacerbations appearing in characteristic sites. 2. Eczema is often used interchangeably with atopic dermatitis, but the word eczema describes acute symptoms associated with atopic dermatitis. 3. Risk factors. a. Family history of atopic diseases. b. Skin infections. c. Stress. d. Temperature extremes. 4. Assessment findings. a. General: pruritus, erythema, dry skin, facial erythema, infraorbital folds (Dennie Morgan Folds). b. Adults. i. Flexural surfaces are common sights, dorsa of hands and feet. ii. Often reappears in adulthood after absence since childhood. iii. Lichenification and scaling are typical. 5. Non pharmacologic management. a. Limit bathing to avoid further drying of skin. b. Prevent skin trauma. So for 20 minutes in warm water before applying emollient. c. Wet compresses if lesions are weeping or oozing. d. Patient education regarding disease, self-care, and precipitating factors are important. 6. Pharmacologic management. a. Topical corticosteroids. b. Topical immune modulators. c. Antihistamines for itching. d. Emotions 2 - 3 times per day or as needed to correct dry skin. e. Oral corticosteroids - severe cases only. f. Intra lesion steroid injection. 7. Possible complications. a. Bacterial secondary infections from topical steroids and scratching. b. Atrophy of striae. c. Lichenification Burns. 1. An injury to skin and tissue caused by chemicals, thermal energy, radiation or electricity. 2. Etiology. a. Excessive sun exposure. b. Flames or hot water is most common. c. electrical wires, lightning. d. Chemical splashes such as acids or bases. 3. Risk factors. a. Hot water heaters set too high, especially in the elderly. b. Improper use of sunscreens. c. Insensitivity. 4. Assessment findings. a. Partial thickness: first and second degree burns. b. Full thickness: third degree burns. c. General distribution of burns may indicate source. d. Street burning lines may indicate child abuse. e. Geriatric burns heal more slowly. 5. First degree burns. a. Redness b. Tenderness. c. No blisters. 6. Second degree burns. a. Redness. b. Tenderness. c. Presence of blisters. 7. Third degree burns. a. Charred, leathery appearance of skin. b. Skin may be white with raw edges. c. Very little tenderness. 8. Prevention. a. Liberal sunscreen. b. In children, limit access to electrical cords, wires, chemicals. c. Parental supervision. d. Use of home smoke detectors and plan for evacuation of home in case of fire. e. Knowledge of proper use of home fire extinguishers. f. Set home water heaters at 120 to 130 degrees 9. non pharmacologic management. a. Do not apply ice to burns. Apply cool water or saline only to clean. May use a mild soap. b. Remove clothing, jewelry, over and around burned areas. Flush chemical burns with cool water for 30 minutes to two hours depending on the substance and severity. c. Remove blistered skin after rupturing blisters. d. Clean and redress burns 1 to 2 times a day. e. Good nutrition during convalescence. 10. Pharmacologic management. a. Apply antibacterial cream. b. Consider biologic dressings. c. analgesics to relieve pain. d. Tetanus prophylaxis if not within 10 years. 11. Consultation or referral. a. Refer to specialist all burns not considered minor. i. Second degree burns > 20% of body. ii. All third degree burns. iii. Burns of the eyes, hands, feet, or perineum. iv. Lightning burns. v. Electrical burns. vi. Burns over joints. b. Child or elderly protection for suspected abuse. Actinic keratosis. 1. Keratotic scaly lesions with erythematous papules or plaques on sun exposed skin. 2. Most common lesion seen in dermatology. 3. Most common epithelial precancerous skin lesion. 4. 10 to 20% can become squamous cell carcinoma. 5. Assessment findings. a. Described as a scaly spot that would not go away or peel and comes back. b. Round or Oval shaped scaly lesion. c. Flesh colored, pink, red, brown or black. 6. The treatment of actinic keratosis begins with prevention. a. Avoiding sun exposure. b. Sunscreens reduce the development of actinic keratosis. c. Active treatment of actinic keratosis depends upon the size of the lesion and the number of lesions present. 7. Tenderness and bleeding are concerning. 8. Pharmacologic management. a. Topic fluorouracil (5-FU) cream. b. Topical imiquimod 5% cream. c. Phototherapy. d. TCA peels. Cryotherapy. e. Liquid nitrogen. f. Dermabrasion. Skin cancer. 1. Malignant tumor of the skin arising from various skin layers. 2. Etiology - Almost always due to overexposure of the skin to ultraviolet rays. 3. Risk factors. a. Exposure to ultraviolet rays, thermal burns, or radiation. b. Fair skin color blondes and redheads. c. Light blue or green eye color. d. Improper and infrequent use of sunscreen. e. Blistering sunburn in adolescence. f. Intense, episodic sun exposure. g. Living in sunny climates. 4. Prevention. a. Actinic keratosis is a scaly patch of red or brown skin which often becomes squamous cell carcinoma. b. Avoidance of sun exposures. c. Frequent total body skin examination every 3 to 6 months after diagnosis of Melanoma. d. Teach importance of avoidance of sunlight at peak hours, use of sunscreen to patients, especially adolescents. e. Hats, long sleeve shirts while exposed to sunlight. 5. Assessment findings. a. Comment on sun exposed areas of skin. b. Lower lip is common location in smokers. c. Nodule has indistinct margins. d. Surface is firm, scaly, irregular and may bleed easily. 6. Expected course. a. May metastasize. Basal cell carcinoma (BCC) 1. Assessment findings. a. Common in 40 to 60 year old. b. Most common sites are head, tip of nose, and neck. c. Usual appearance is pearly domed nodule with overlying telangiectatic vessels; later, central ulceration and crusting. 2. Expected course. a. Slow growing, rarely metastasizes; Often there is recurrence within five years at another site. Malignant Melanoma. 1. Assessment findings. a. Usual age is early 40s. b. ABCDE characteristic of any lesion. i. A = asymmetry. ii. B = border is irregular. iii. C = color variegation. iv. D = diameter > 6 mm (size of pencil eraser). v. E = elevation above level of skin. c. Hypo or hyper pigmentation, bleeding, scaling, texture, or size change of an existing mole or lesion. d. Common in Caucasians on back, lower leg. e. Common in African Americans on their hands, feet, nails. 2. Expected course. a. Accounts for over 60% of skin cancer deaths. b. Metastasizes to any organ. Spider/insect bites and stings. 1. Etiology a. Bees, wasps, ants. b. Mosquitoes and fleas. c. Ticks. d. Spiders, scorpions and caterpillars. 2. Assessment findings a. bees and Wasps. b. Mosquitoes and fleas. c. Ticks. d. Spiders and caterpillars. 3. Non pharmacologic management. a. Remove Stinger. b. Do not attempt to burn or crush chick. c. Never apply heat to spider bites. 4. Pharmacologic management. a. Tetanus prophylaxis. b. Antihistamines. c. Antipruritic and steroids. Management of Dermatological Problems: Part II Bacterial infections of the skin. Folliculitis 1. Superficial infection or irritation of the hair follicles. 2. Lesions consist of a pustular or inflammatory nodule which surrounds the hair follicle. Furunculosis (Boils) 1. deep infection of the hair follicle. The nodule becomes a pustule which contains necrotic tissue and purulent exudate. 2. Neck, face, buttocks, waistline and breasts are common. Carbunculosis 1. Deep suppurative lesion with extension into the subcutaneous area. 2. The nape of the neck and posterior thigh are common areas. 1. Etiology. a. Folliculitis furunculosis Carbunculosis: i. Staphylococcus aureus is the most common causative Organism. ii. Consider MRSA to be a very common outpatient pathogen. b. Hot tub folliculitis. i. Pseudomonas aeruginosa. 2. Folliculitis. a. Very common in all age groups. b. Tends to recur frequently. 3. Furunculosis. a. Common in teenagers and adults. 4. Carbunculosis a. Males > Females b. Common in at risk populations. 5. Risk factors. a. Folliculitis. i. Poor hygiene, shaving, tight jeans. b. Furunculosis. i. Adolescents, prior furunculosis, crowded quarters, poor hygiene, diabetes. c. Carbunculosis i. Chronic disease, diabetes, alcoholism, advancing age. 6. Folliculitis. a. Superficial postural hair easily removed, mild erythema, inflammation. 7. Furunculosis a. Pustular lesion with central necrosis and a core of purulent exudate, pain, inflammation, and erythema. 8. Furunculosis a. Sometimes spontaneous drainage, but may need incision and drainage. 9. Carbunculosis a. Slow development, fever, local sloughing of tissue, drainage from multiple openings, pain. 10. Diagnostic studies. a. Folliculitis: usually none b. Furunculosis: usually none, may culture for frequent recurrences c. Carbunculosis: culture 11. Prevention. a. Good hygiene. b. For recurrent, severe infection: i. Culture nares, skin, axilla. ii. Use providine-iodine or Chlorhexidine for full body showers for 1 to 3 weeks. iii. Warning: hibiclens can cause eye damage. iv. Change towels and sheets daily. v. Frequent hand washing. 12. Non pharmacologic management. a. Folliculitis. i. Warm, moist compresses intermittently. ii. Allows spontaneous drainage. iii. Frequent hand washing. b. Furunculosis. i. Warm moist compresses intermittently for pain and to promote spontaneous drainage. ii. Good hygiene and preventive measures listed above. iii. Possible incision and drainage. iv. Consider culture and sensitivity. c. Carbunculosis i. Good hygiene and preventive measures listed above. ii. Warm moist compresses intermittently. iii. Possible incision and drainage. iv. Packing well promote drainage if wound is deep. v. Strongly consider culture and sensitivity. 13. Pharmacologic management. a. Folliculitis. i. Treatment with oral antibiotic usually not indicated. ii. Maybe use 5% benzoyl peroxide or a topical antibiotic. b. Furunculosis. i. Systemic antibiotics do not shorten the duration, but consider for lesions in the facial area. ii. Empirically treat with a first generation Cephalosporin. iii. Consider TMPS or Quinolone for MRSA. c. Carbunculosis i. Systemic antibiotics. ii. Warm moist compresses intermittently. 14. Consultation or referral. a. Consider referral for furunculosis on face, scalp, or neck. b. Consider referral for immunocompromised individuals, diabetics, other chronic diseases. Cellulitis. 1. Acute, spreading infection of the skin and its subcutaneous structures. 2. Erysipelas - Superficial form of Cellulitis with marked dermal lymphatic involvement. 3. Assessment findings. a. Most common sites are lower legs and face. b. Erythema. c. Warmth. d. Edema e. pain. f. Fever. g. Lymphadenopathy. 4. Diagnostic studies. a. Culture and sensitivity. b. CBC. c. Blood culture if sepsis is suspected. d. ESR 5. prevention. a. Good skin hygiene. b. Avoid swimming when skin abrasion present. 6. 7. 8. 9. c. Early treatment for upper respiratory infection. Non pharmacological management. a. Elevation of extremity to help prevent edema. b. Moist heat for pain relief. Pharmacologic management. a. Antibiotics specific for Organism if culture obtained. b. Consider penicillin initially. i. If allergic to penicillin, consider first generation Cephalosporin or macrolide. Consultation or referral. a. Consider referral for infections on face, scalp, and neck; or if sepsis is suspected. b. Consider a referral for patients with chronic illness or who are immunocompromised. Follow up. a. 48 hours after initial treatment and then as patient condition indicates. Hidradenitis Suppurativa 1. inflammation of apocrine (apocrine) glands of the skin which produced tender, cysts like abscesses. 2. Common sites are the axilla, growing, trunk, and the scalp. 3. Etiology. a. Blockage of the apocrine glands leading to rupture of the ducts. 4. Incidents. a. Common from lake puberty to age 40 years. 5. Risk factors. a. Obesity. b. Diabetes mellitus. c. African American females. d. Female. 6. Assessment findings. a. Most frequent place of occurrence: i. Axilla, groin, nipples, and anus. b. Pain, c. warmth. d. Erythema. e. Discharge. f. Papules, nodules. g. Fluctuance in larger lesions. 7. Differential diagnosis. a. Furunculosis. 8. Diagnostic studies. a. Culture and sensitivity of lesion exudate. 9. Prevention. a. Avoid constrictive clothing. b. Weight loss if indicated. c. Good hygiene. 10. Non pharmacologic management. a. Aspirate, culture and sensitivity. b. Good hygiene. c. Avoid antiperspirants or other irritants. d. Rest. e. Moist heat. f. Surgical excision for large persistent lesions. 11. Pharmacologic management. a. Systemic antibiotics not curative. b. Topical Clindamycin. c. Oral retinoids: if recurrent and severe. Impetigo. 1. Superficial infection of the skin which begins as small superficial vesicles which rupture and form honey colored crusts. 2. Etiology. a. Staphylococcus aureus. b. Group A beta hemolytic streptococcus. 3. Assessment findings. a. 1-2 mm Vesicles with rupture. b. Honey colored crusts. c. Weeping shallow red ulcer. d. Common in mouth, face, nose, or sight of insect bite or trauma. 4. Prevention. a. Good hygiene. b. Good hand washing especially by household members. 5. Non pharmacologic management. a. Washing of lesions 2-3 times per day. b. Good hygiene. c. Good hand washing especially by household members. 6. Pharmacologic management. a. Antibacterial soap to cleanse lesions. b. Topical is preferred: mupirocin ointment. c. First generation Cephalosporin for large areas of infection. d. May consider macrolide if unable to use Cephalosporin. e. Some resistance to erythromycin encountered in the US. i. Dicloxacillin may be substituted. Warts. 1. Painless, benign skin tumors. 2. Etiology. a. Human papillomavirus. b. Different genotypes cause different warts. i. Common wart: verruca vulgaris. ii. Plantar wart color verruca plantaris. c. Assessment findings. i. Common wart (Verruca Vulgaris) 1. rough surface, elevated, flesh colored papules. ii. Plantar wart. 1. Rough, flat surface, flesh colored,2-3 cm in diameter usually located on the sole of the foot d. Non pharmacologic management. i. Paring with debridement of wart prior to any treatment. ii. Soaking of wart in warm water. iii. Occlude the wart with waterproof tape. iv. Cryotherapy. v. Excision. e. Pharmacologic management. i. Lactic salicylic acid daily for 3 months. ii. Salicylic acid in propylene glycol: rub into wart daily. iii. Salicylic acid transdermal delivery system. iv. Benzoyl peroxide BID for 4-6 weeks. v. Cimetidine for 3 months. vi. Podophyllin vii. Trichloroacetic acid. viii. Imiquimod. Herpes zoster. 1. Description. a. A reactivation of the varicella zoster that has lain dormant in nerve cells. b. This involves the skin of the single dermatome or less commonly, several dermatomes. 2. Etiology. a. Varicella zoster virus. 3. Assessment findings. a. Prodrome. i. Itching. ii. Burning. iii. Photophobia. iv. Fever, headache, malaise. b. Acute phase. i. Dermatomal rash erupts over 3 to 4 days. ii. Fever, malaise, headache. iii. Maculopapular rash which progresses to grouped vesicles on erythematous base, and then pustules in 3 to 4 days. iv. Successive crops of vesicles may appear for a week. c. d. e. f. g. h. v. Pain, Possibly severe. Convalescent phase. i. Within 2 to 3 weeks, rash resolves. ii. Pain. Assessment findings. i. Convalescent phase. 1. Maybe prolonged an elderly or immunocompromised patients. 2. Postherpetic neuralgia common in the elderly. Non pharmacologic management. i. Wet compresses of Domeboro solution several times per day. ii. Avoid contact with known patients if member of high risk group. Pharmacologic management. i. NSAIDs or narcotic analgesics for pain. ii. Antiviral agents if patient presents within 72 hours of symptoms and is a member of a high risk group. iii. Silver sulfadiazine or mupirocin for secondary infections. iv. Capsaicin cream for postherpetic neuralgia. v. Avoid corticosteroids. vi. Amitriptyline, gabapentin may reduce incidence and pain associated with postherpetic neuralgia. Consultation or referral. i. Consult specialist for dermatomes involving the eyes, and face. ii. Consider referral for elderly, neonate or immunocompromised patients. Follow up. i. Usually recheck in 3 to 5 days after diagnosis, then in 1 to 2 weeks. Paronychia 1. Description. a. Skin surrounding finger or toenails become infected. b. Maybe acute or chronic. 2. Etiology. a. Staphylococcus aureus. b. streptococcus species c. pseudomonas species d. candida albicans. 3. Risk factors. a. Diabetes. b. Trauma to skin around nail or ingrown nails. c. Nail biting. d. Frequent and continuous wet hands. 4. Assessment findings. a. Nail fold separates from nail plate. b. Pain around skin of nail plates. c. Erythema, tenderness around nail plate. 5. 6. 7. 8. 9. d. Changes in nail plate or nail. Prevention. a. Avoid long term contact with moisture to hands. b. Wear gloves to wash dishes. c. Adequate glycemic control in diabetics. Non pharmacologic management. a. Keep your fingers dry. b. Warm compresses or soaks for acute infection. c. incision and debridement if necessary for Abscess if present. d. Possible nail removal if severe. Pharmacologic management. a. Oral antibiotic. b. Topical antifungal cream for fungal infections. c. Oral antifungals for severe fungal infections. Consultation or referral. a. Dermatology dermatologist for infection or inflammation which does not resolve after routine treatment. Follow up. a. Recheck as needed by patients condition. Scabies. 1. Description. a. Infection of human skin by mites. 2. Etiology. a. Infection with sarcoptes scabiei, A human skin might. 3. Risk factors. a. Crowded living conditions. b. Skin to skin contact with infected patients or infected bedding, cloth furniture etc. c. immunocompromised patients. 4. Assessment findings. a. Itching. b. small itching blisters in a thin line. c. Might Burrows between finger webbing, feet, wrists, axilla, scrotum, penis, waist and or buttocks. d. Scaling. e. Erythema. f. Vesicles, papules. 5. Prevention. a. Treat all intimate contacts, household contacts, roommates, etcetera. b. Maintain good personal hygiene. c. Longer clothes off it. d. Wash hands. 6. Differential diagnosis. a. Atopic dermatitis; Contact dermatitis; Insect bites; psychogenic causes. 7. Diagnostic studies. a. Burrow ink test. b. Recovery of might from the burrow. 8. Non pharmacologic management. a. Wash all clothing, bedding, towels etcetera. b. Wash toys used prior to treatment and during treatment. c. Carpets, floors do not need special treatment under usual circumstances. 9. Pharmacologic management. a. Alternative treatment. i. Lindale 1% applied to skin and washed off in 10 to 12 hours. ii. Oral antihistamines for aching. Pediculosis. 1. Description. a. An infestation of the body, head, or pubic area by lice. 2. Etiology. a. Lice are ectoparasites which feed on human blood. b. Knits are the eggs laid by the females which may survive up to 3 weeks when removed from the human host. c. Head lice: pediculus humanus capitus. d. Body lice: pediculus humanus corporis. e. Pubic lice: phthirus pubis. 3. Incidents. a. Head and body lice are more common in children. b. Public lies are more common in adults. c. Females > males. 4. Risk factors. a. Head lice i. crowded conditions. ii. Sharing of hats. Combs. iii. Poor hygiene is not a risk factor. b. Body lice i. poor hygiene. ii. Infrequent laundering of clothes. iii. Crowded conditions. iv. Contact with infected bed linen, towels, clothing, etc. c. Pubic lice. i. Sexual contact with an infected person. 5. Differential diagnosis. a. Live versus might infestation. b. Empty Nets fluoresce gray. 6. assessment findings. a. Head lice. b. c. d. e. f. i. Itching prickly sensation on the scalp. ii. Dandruff that moves. iii. Knits attached to the hair shaft. iv. Back of head, neck and behind ear are common places of attachment. Body lice. i. Pruritus. ii. Papules 2 to 4 mm in diameter. iii. Skin of the axilla, trunk and groin are common sites of attachment. Pubic likes. i. Pruritus ani. ii. knits found at the base of pubic hair shafts. iii. Inflammation in groin, adenopathy. iv. Macular rash in area of infestation. v. Commonly found in pubic hair. Prevention. i. Laundry clothes and hot water. ii. Net removal: soak care and equal parts of water and white vinegar for at least 15 minutes. iii. Good hygiene. iv. Careful monitoring and or treatment by parents and school personnel afterlife discovered. v. Washing/not sharing Combs, hats, bed linen towels etc. Non traumatologist management. i. Patient education about means of transmission and mechanism to break life cycle. See prevention. Pharmacologic management. i. Head lice. 1. Synergized pyrethrins: piperonyl butoxide - wash off in 10 minutes. 2. 1% Permethrin colon's most effective treatment. 3. Frequently need repeat treatments. 4. Alternative treatment: lindane - avoid use in pregnancy and infants. ii. Body lice. 1. Same as head lice. iii. Pubic lice. 1. Synergized pyrethrins. 2. 1% Permethrin colon's most effective treatment. 3. Alternative treatment: lindane. iv. Eyelash infestation. 1. Do not use any medication listed above. 2. Manually remove knits is necessary. 3. May use petroleum Jelly 3 to 4 times per day for a week. 4. Fluorescein drops 10 to 20%. g. Consultation or referral. i. School personnel. ii. Parents. iii. Consult dermatologist for life unresponsive to treatment. Tinea infections. 1. Description. a. Fungal infections affecting various parts of the body. 2. Etiology. a. Trichophyton species: most common. b. Microsporum species c. Epidermophyton species: Causative agent for some tinea cruris and tinea pedis infections. d. Pityrosporum Species: Tinea versicolor. 3. Risk factors. a. Tinea capitus i. daycare age group. ii. Contact with infected items. iii. Poor hygiene. b. Tinea corporis. i. Close contact with animals. ii. Warm climates. iii. Obesity. iv. Prolonged use of topical steroids. c. Tinea Cruris. i. Wearing wet clothing. ii. Excessive sweating. iii. Obesity. iv. Prolonged use of topical steroids. v. Immunocompromised state. d. Tinea Pedis. i. Occlusive footwear. ii. Damped footwear. iii. Prolonged use of topical steroids. iv. Immunocompromised state. e. Tinea Versicolor i. Hot, Humid climates. ii. Wearing wet clothing. iii. Prolonged use of topical steroids. iv. Immunocompromised state. f. Diagnostic studies. i. KOH Scraping. ii. Woods lamp exam. g. Assessment findings. i. Tinea Capitis 1. Round patchy scales on scalp. 2. Occasionally alopecia will develop. 3. Most commonly found in pediatric patients. ii. Tinea corporis. 1. Rash. 2. Pruritus. 3. Well circumscribed, red, plaque usually found on the trunk. 4. May occur in groups of three or more. iii. Tinea Cruris 1. Pruritus. 2. Well marginated Half Moon plaques in the groin and or upper thighs. 3. May take on eczematous appearance from chronic scratching. 4. Does not affect the scrotum or penis. 5. may appear as vesicles. iv. Tinea Pedis 1. Itching and interdigital spaces. 2. Maceration in affected areas. 3. Scaling. 4. Can affect the soul and arch. 5. elderly more susceptible. v. Tinea Versicolor 1. Well marginated lesions of varying colors. 2. Rare itching. 3. Common and axilla, shoulders, chest, back. h. Prevention. i. Good personal hygiene. ii. Identification and treatment of infected humans and pets. iii. Remove wet clothing as soon as possible. iv. Drive between toes after showering and bathing. i. j. v. Avoid direct contact with surfaces in public bathing facilities. Non-Pharmacologic management. i. Tinea Capitis. 1. Good hygiene. 2. Consider left monitoring for oral antifungal. 3. Teach patient to wear sunscreen and minimize exposure. 4. Treat family members and infected pets. 5. Shaving head is not necessary for treatment. ii. Tinea Corporis 1. Good hygiene. 2. Avoid contact with lesions. iii. Tinea Cruris 1. Keep area as dry as possible. 2. Do not scratch. iv. Tinea Pedis 1. Dry between toes. 2. Trimmed dead skin. v. Tinea Versicolor 1. Keep area as dry as possible. Pharmacological management. i. Tinea Capitis 1. Oral griseofulvin ii. Tinea Corporis 1. Topical antifungal cream. 2. Use for one week after resolution occurs iii. Tinea Cruris 1. topical antifungal cream. 2. Used for at least 10 days even if resolution occurs. iv. Tinea Pedis 1. Topical antifungal cream. v. Tinea Versicolor 1. Selenium sulfide shampoo. 2. Topical antifungal creams. Lyme disease. 1. Description. a. Multisystem infection transmitted by a tick. b. Disease ranges in severity from mild to severe. 2. Etiology. a. Borrelia Burgdorferi is the spirochete transmitted by the Ixodid tick. 3. Risk factors. a. Exposure to bite of infected tick during May to September. b. Exposure to outdoors, hunting, hiking, camping or living in wooded areas. 4. Diagnostic studies. 5. 6. 7. 8. a. EILISA for Borrelia Burgdorferi antibodies. b. Lumbar puncture for neurological symptoms. c. ELISA of CSF for Borrelia Burgdorferi Antibodies. Assessment findings. a. Stage one. i. Asymptomatic. ii. Erythema migrans. iii. Fever. iv. Headache. v. Myalgias and arthralgias. b. Stage two. i. Erythema migrans ii. aseptic meningitis. iii. Iritis. iv. Heart block. v. Pericarditis. vi. Orchitis. vii. Hepatitis. viii. Arthritis of large joints. c. Stage three. i. Aches and pains of the joints and soft tissues. ii. Neurological impairment. iii. Iritis. iv. Optic neuritis. Prevention. a. Teach patients to protect themselves from ticks while in potentially tick infested areas. b. Use of insect repellents. c. Self-examination after exposure In tick infested areas. d. Prompt removal of ticks with tweezers. Non pharmacologic management. a. Self-examination for ticks. b. Remove ticks by using tweezers and grasping the tick as near to the skin as possible. c. Examine area for remaining tick parts. Attempt to remove. d. Teach patients that to contact Lyme disease, tick must be infected and remain in place for at least 24 hours. Pharmacologic management. a. Stage one. i. Doxycycline (vibramycin) 14-21 days or amoxicillin for 14 to 21 days. b. Stage 2: no CSF involvement. i. Doxycycline or amoxicillin for 28 days. ii. Short course of steroids for one week. c. Stage 2: CSF involvement. i. Ceftriaxone or cefotaxine or penicillin G for 21 to 28 days. d. Stage 3. i. Doxycycline or amoxicillin for 28 days. ii. If oral treatment fails intravenous ceftriaxone or cefotaxime or penicillin G for 14 to 21 days. e. Do not use doxycycline in children < nine years of age. 9. Consultation or referral. a. Refer patients with cardiac or neurologic involvement. b. Consult obstetrician for pregnant patients. 10. Follow up. a. Depends on stage and severity. b. Follow up for stages 2 and 3 patients may be months to years. Candida. 1. 2. 3. 4. A yeast like fungal - candida albicans. Normal skin flora that overgrows. Areas seen include diaper, intertriginous areas, perineum, male genitals and mouth. Exam. a. Reddened skin with clear borders may have developing satellite lesions. b. Mouth - thick white sticky plaque some localized inflammation. 5. Management. a. Clean with lots of cool water and mild soap. b. Air dry. c. Then topical antifungals. Vitiligo. 1. Vitiligo is an acquired skin deep pigmentation that affects all races but is far more disfiguring and blacks. 2. peaks in a second and third decades. 3. The this pigmentation has a predilection for Acral areas and around body orifices such as the mouth, eyes, nose, and anus. 4. The usual course usually is slowly progressive. 5. The diagnosis of vitiligo is based upon the clinical presence of deep pigmented patches of skin. 6. Hypopigmented macular lesions 5 mm to 5 cm or more. 7. Etiology is unknown, there are three hypotheses. h. Autoimmune i. neurogenic. j. Self-destruct. 8. Patterns of deep pigmentation. a. Focal - lesions in single general area. b. Segmental - lesions on one side of the body. c. Generalized - widespread distribution. 9. Treatment. a. Short burst topical steroids. b. Protopic 0.1% ointment bid, short exposure to sun after application. c. Calcineurin Inhibitors (cyclosporine). d. Ultraviolet light. e. Sunscreen and sun protection education. Alopecia Areata 1. Skin condition that causes sudden loss of patches of hair on scalp and other parts of the body. 2. Non scarring a. No permanent damage to hair follicle. 3. Most people - hair eventually grows back, with 80% of people recovering in one year. 4. Occurs equally in men and women, all races equally, can develop at any age. 5. Not life threatening. a. No physical pain. b. Cosmetic effect can be devastating. 6. Thought to be the body attacking the pigment in hair follicle. 7. Stress can be a trigger. 8. Pharmacologic management. a. High potency topical steroid. b. Kenalog injections.