Nur 509 Skin I Student PDF

The Integumentary System I Wencan Lu DNP, FNP-BC Nur 509 Learning Objectives Review the anatomy and physiology of integumentary system Discuss the pathophysiology, epidemiology, clinical presentation, diagnosis, and treatment of common alterations in the i...

The Integumentary System I Wencan Lu DNP, FNP-BC Nur 509 Learning Objectives Review the anatomy and physiology of integumentary system Discuss the pathophysiology, epidemiology, clinical presentation, diagnosis, and treatment of common alterations in the integumentary system, including inflammatory, papulosquamous, vesiculobullous, and infectious skin disorders Describe the physiological changes in the integumentary system associated with aging The Integumentary System Review of anatomy and physiology of the skin Disorders of the skin Inflammatory Allergic contact dermatitis Seborrheic dermatitis Papulosquamous Psoriasis Lichen planus Acne vulgaris Hidradenitis suppurativa (Inverse acne) Vesiculobullous Erythema multiforme Stevens-Johnson syndrome Infections Bacterial: Folliculitis, cellulitis, Lyme disease Viral: Herpes simplex virus1, Herpes zoster Fungal: Tinea, candidiasis Geriatric considerations Anatomy and Physiology Major function of skin is to keep the body in homeostasis Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D Heaviest single organ in body 16% of body weight Anatomy and Physiology Three layers Epidermis: thin avascular keratinized epithelium Keratin forms a protein layer that protects the epithelium Dermis: a dense layer of collagen and elastic fibers, contains appendages (Hair, nails, sebaceous and sweat glands) Sebaceous gland: secrete sebum Sweat glands: regulate body temperature Eccrine sweat glands: The major sweat glands, produce a clear, odorless substance, consisting primarily of water and NaCl; discharge secretion directly onto the surface of the skin to regulate body temperature Apocrine sweat glands: Least responsible for thermoregulation and mostly responsible for body odor, discharge secretion in the canals of hair follicles Pilosebaceous unit Hair follicle, sebaceous gland, and arrector pili muscle Anatomy and Physiology Anatomy and Physiology Primary lesions Flat – cannot palpate with eyes closed Macule: 1cm Raised – can palpate with eyes closed Papule: 1cm, not fluid filled Vesicle: 1cm, fluid filled Secondary lesions Example: scars from acne Inflammatory Allergic contact dermatitis Seborrheic dermatitis Inflammatory /Allergic Contact Dermatitis T-cell mediated or delayed hypersensitivity (type IV) First exposure: sensitization. No dermatitis Reexposure: symptoms Erythema, swelling, pruritus, and papular-vesicular lesions in areas of allergen contact Poison Ivy Inflammatory/Seborrheic Dermatitis Description: A common chronic inflammation of the skin characterized by redness and scaling, which occurs in regions where the sebaceous glands are most active, such as the face and scalp, eyelid margins, ears, nasolabial folds, and in the body folds Presentation: Red, flaking skin, scalp flaking (i.e., dandruff). Usually worse in winter, better in summer Papulosquamous Psoriasis Lichen planus Acne vulgaris Hidradenitis suppurativa (Inverse acne) Papulosquamous/Psoriasis Description: a chronic, relapsing, proliferative, inflammatory skin disorder Pathophysiology Polygenic predisposition and environmental triggers, such as bacterial infection, trauma, or drugs T-cell autoimmune-mediated inflammatory skin disease Dermal and epidermal thickening due to keratinocyte hyperproliferation Epidermal turnover faster than normal (from 26 to 30 days to 3 to 4 days) Cells do not have time to mature or keratinize → epidermis thickens and plaques Commonly associated conditions Psoriasis arthritis Nail disease Cardiovascular disease Papulosquamous/Psoriasis Clinical Presentation Varies among individuals, from those with only a few localized plaques to those with generalized skin involvement Most common type: plaque psoriasis (90%) Typical lesions are chronic, recurring, scaly papules, and plaques, covered with a silvery white buildup of dead skin cells Pustular eruptions and erythroderma can occur Papulosquamous/Lichen Planus Benign disorder of the skin and mucous membranes due to cell-mediated immune response of unknown antigen Immunoreactivity against keratinocytes, may also involve T cells and inflammatory cytokines Nonscaling papules, with bothersome pruritus Common sites: wrists, ankles, lower legs, and genitalia Self-limiting, may last for months to years Papulosquamous/Acne Vulgaris A chronic skin condition of pilosebaceous units, characterized by noninflammatory open and/or closed comedones (blackheads and whiteheads) and inflammatory lesions (papules, pustules, cysts or nodules) Typically on the face, neck, back, chest, and upper arms Affect 85% of adolescents Androgen causes excessive sebum production and blocks hair follicles contributes to comedones formation Propionibacterium on the skin contributes to inflammation Papulosquamous/Acne Vulgaris May be a reflection of endocrine disorders (polycystic ovarian disease) May be associated with the use of some medications (anabolic steroids) Papulosquamous/Acne Vulgaris Acne grading scale by the American Academy of Dermatology Mild - scattered open and/or closed comedones are the predominant lesion type, with few inflammatory lesions Moderate - superficial inflammatory lesions (papulopustular or polymorphic) predominate with some comedones Severe - numerous large papules and/or pustules and/or multiple nodules (nodulocystic) and deep lesions, evidence of scarring, and/or involvement of large areas Images from: https://www.aafp.org/afp/2004/0501/p2123.html Papulosquamous /Hidradenitis Suppurativa (Inverse acne) An inflammatory disease of the pilosebaceous unit in the apocrine gland-bearing skin with chronic, recurrent follicular occlusion, and painful, sometimes debilitating, cutaneous draining lesions and subcutaneous abscesses Most common in the axilla, inguinal and anogenital regions Female > male Starts with occlusion of hair follicles that lead to occlusion of surrounding apocrine glands Can lead to sinus tracts, draining fistulas and progressive scarring Risk factor: Obesity, smoking, and tight-fitting clothing Papulosquamous /Hidradenitis suppurativa Tender, firm, nodular lesions May open and drain pus spontaneously and heal slowly over 10 to 30 days Surrounding cellulitis Chronic recurrences result in thickened sinus tracts Vesiculobullous Erythema multiforme Stevens-Johnson syndrome Vesiculobullous/Erythema Multiforme Erythema multiforme Acute recurring disorder of skin and mucous membranes Associated with allergic or toxic reactions to drugs or microorganisms Caused by immune complexes formed and deposited around dermal blood vessels, basement membranes, and keratinocytes “Bull’s eye” or target lesion Erythematous regions surrounded by rings of alternating edema and inflammation Erosions and crusts are formed when the lesions rupture  Vesiculobullous/Erythema Multiforme https://www.aafp.org/afp/2019/0715/p82.html Vesiculobullous /Stevens-Johnson Syndrome (SJS) SJS is a minor form of toxic epidermal necrolysis (TEN) A type IV hypersensitivity reaction that typically involves the skin and the mucous membranes Antigen → production of tumor necrosis factor (TNF) → recruitment and augmentation of T cytotoxic lymphocytes → Apoptosis of keratinocytes → separation of the epidermis from the dermis Drug-induced, infectious, malignancy-related, idiopathic Vesiculobullous /Stevens-Johnson Syndrome (SJS) Vesicles and bullae Large areas of necrotic epidermis may be shed, leaving open, weeping, painful areas of underlying skin Mucosal involvement may be extensive and involve the Consultant 360 mouth, air passages, esophagus, urethra, and conjunctiva Blindness can result from corneal ulcerations American Academy of Pediatrics Infections Bacterial Folliculitis Cellulitis Lyme disease Viral Herpes simplex virus 1 Herpes zoster Fungal Tinea Candidiasis Infections/Bacterial/Folliculitis Description: Bacterial infection of the hair follicles Abscessed tender nodules, furuncles, carbuncle Furuncle: Inflamed hair follicle Carbuncle: multiple furuncles together Infection /Bacterial/Cellulitis Acute infection of the subcutaneous tissue and skin Risk factors: surgical incision, insect bite, or trauma Most common in the extremities Warm, red, edema with sharp demarcated borders Infection/Bacterial/Lyme Disease Multisystem infection from the spirochete Borrelia burgdorferi transmitted by tick bites Stages (although 50% of infected are asymptomatic) Localized infection Erythema migrans: A bull's-eye rash Fever, fatigue, malaise, myalgias, and may be arthralgias Disseminated infection Arthralgias, meningitis, neuritis, or Lyme carditis Late persistent infection Can continue for years with arthritis, encephalopathy, polyneuropathy, or heart failure Infection/Viral/Herpes Simplex Virus 1(HSV1) HSV1 infection Transmitted through infected saliva contact Most commonly presents in oral area as a rash or clusters of inflamed and painful vesicles https://www.downtowndermnyc.com/articles/aad_education_library/563481-cold-sores Infection/Viral/Herpes Zoster (Shingles) Cause: Varicella-zoster virus (VZV) (chicken pox) Initial infection with varicella, followed years later by herpes zoster Pain and paresthesia localized to a dermatome, followed by vesicular eruptions along a facial, cervical, or thoracic lumbar dermatome Penn Medicine Infection/Fungal/Tinea Superficial skin infection caused by dermatophytes Itchy, scaly rash, shapes depending on location Tinea pedis Tinea facialis Infection/Fungal/Candidiasis Fungal infection caused by Candida albicans Is normally found on the mucosa membrane, in the GI tract and vagina C. albicans can change from a commensal organism to a pathogen Risk factors: systemic administration of antibiotics, pregnancy, DM, immunosuppression Thin-walled pustule that produces a whitish-yellow, curd-like substance https://www.britannica.com/science/thrush-medicine Geriatric Considerations Loss of adipose tissue volume and elastin fiber; sebaceous gland, eccrine and apocrine gland atrophy; decreased vascular compliance due to aging skin microcirculation → Thinner, drier, wrinkled, less elastic skin Compromised temperature regulation → increased risk for heat stroke and hypothermia Delayed wound healing Reduced number of melanocytes → decreased protection against UV radiation References Bickley, L. (2017). Bates' Guide to Physical Examination and History- Taking (11th ed). Lippincott Williams & Wilkins. Bolognia, J. L., Schaffer, J. V. & Cerroni, L. (2018). Dermatology (4th ed.). Elsevier. Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (2020). The 5-minute consult (28th ed.). Wolters Kluwer. Rogers, J. L. & Brashers, V. L. (Eds.) (2023). McCance & Huether’s Pathophysiology: The biologic basis for disease in adults and children (9th ed.). Elsevier. Web references are with slides