Integumentary Review
NURS 6035 Advanced Physical Assessment of the Lifespan
Common Etiologies of Rash
• Medications
• Prescription and OTC
• Recent injections
• Recreational drugs
• Topical products such as soaps, deodorants, cosmetics, colognes
• Family history
• Exposure-effects of heat, cold, sunlight
• Other contributing factors
• Occupation
• Food allergies
• Alcohol
Common Causes of Pruritis
• Diffuse pruritis
• Biliary cirrhosis, lymphoma, drugs (antibiotics, allopurinol, amiodarone, ACE
inhibitors, estrogen, hydrochlorothiazide, opioids, statins)
• Other causes
• Generalized skin disorder, internal illness, diabetes, dry skin, change in
perspiration, thyroid disease, parasites, inflammatory conditions
• Histamine release
• One of the most important mediators of pruritis
Nail findings associated with systemic illnesses
Nail findings
Primary and Secondary Skin Lesions
• Primary Skin Lesions
• Rise from normal skin resulting from changes in the epidermis, dermis, or
subcutaneous tissue
• Location on body is important; distribution of eruption is crucial for diagnosis
• Characterize appearance-flat or elevated, solid or fluid-filled
• No “standard” size; dimensions indicated are only approximate
• Secondary
• Result from changes in primary lesion; develop during the course of the
cutaneous disease
• Grouped according to their occurrence below or above the plane of skin
Primary Skin Lesions
Primary Skin Lesions
Primary Skin Lesions
Special Primary Skin Lesions
Secondary Skin Lesions
Vascular Skin Lesions
Descriptive Dermatologic Terms
Descriptive Dermatologic Terms
Descriptive Dermatologic Terms
Common wart vs. Plantar wart (plantar verruca)
• Common wart-common, benign growth usually caused by an infection of an
epidermal cell by HPV
• Firm nodules with rough, keratinous surfaces that range from pinhead to pea size
• Can coalesce to form an extensive bed
• Plantar verruca-warts that occur on the soles of the feet and have a distinctive
appearance because of constant pressure
• Very painful because of constant pressure forcing keratinous material into deeper tissue
• Keratotic lesions with yellow center, areas of multiple red to black dots (hemorrhage from tips
of dermal papillae)
“ABCDE” warning signs associated with malignant melanoma
• Asymmetry
• Half of the lesion appears different from the other half
• Border irregularity
• Scalloped or poorly circumscribed contour
• Color variation
• Shades of tan and brown, black, and sometimes red, white, or blue
• Diameter larger than 6mm
• Evolving
Skin Cancer
• Squamous Cell Carcinoma
• Malignant neoplasm of keratocytes in the epidermis; locally invasive into the
dermis
• Tumor results in scaling, crusting nodule or plaque that can ulcerate and bleed
• Lesions are ulcerated with firm, raised indurated margins
• Usually found in sun-exposed areas; dangerous-can infiltrate and metastasize
Skin Cancer
• Basal Cell Carcinoma
• Malignant neoplasm of the basal cells of the epidermis (most common skin
malignancy)
• Epidermis is thickened and dermis may be invaded by the malignant basal cells
• Lesion with a pearly, rolled, well-defined margin and a central ulcerated
depression
• Sunlight is an important etiologic factor
• Most often seen on the face and rarely on other sun exposed areas
• Slow-growing tumors, rarely metastasize, locally invasive
Skin Cancer
• Melanoma
• Malignant neoplasm of the melanocytes of the epidermis; most have prolonged
superficial, or horizontal growth phase in which there is a progressive lateral
expansion
• If untreated or unrecognized, progresses to fatal metastases
• Most have atypical pigmentation in epidermis (shades of red, white, gray, blue,
brown, black) all in a single lesion
• Can present as longitudinal tan, black, or brown streak in the fingernail or
toenail
Contact Dermatitis
• Inflammatory reaction of the skin that is precipitated by contact with an
irritant or allergen (i.e. detergent, acids, alkali, plants, medicines,
solvents)
• Vesicles in epidermis and perivascular inflammation
• Linear distribution of vesicles and bullae
Psoriasis
• Most common noninfectious skin disorders; frequently inherited, often
chronic and may affect joints and nails
• Characteristics
• Well-defined
• Slightly raised, hyperkeratotic (scaling) plaques
• Frequently symmetric, extremely itchy
• Common on elbows, knees, scalp, and intergluteal cleft
Herpes Zoster (Shingles)
• An intraepidermal vesicular eruption occurring in the dermatomal
distribution
• Bullae and multinucleated giant cells present in epidermis with
perivascular inflammation in the dermis
• Caused by activation of the varicella-zoster virus
• Usually occurs in a pattern distributed along a dermatome
• Severe pain often precedes the eruption
Kaposi Sarcoma (KS)
• Classic form of the disease is a rare, slow-growing neoplasm occurring in the
lower extremities, especially ankles and soles of older men of Mediterranean
or Jewish descent
• In US, most common KS is AIDS-related KS
• Dark blue-purple macules, papules, nodules, & palques
• May have visceral involvement, oral lesions, feet, lymphadenopathy (may be
in more thatn one place at same time)
• The lower an individual’s CD4 count, the more likely they will develop KS
Erythema migrans
• Clinical, distinctive dermatologic hallmark of Lyme disease; rash is
recognized in 90% of patients with B. burgdorferi infection
• Dynamic lesion whose appearance can change dramatically over a period
of days
• Erythema begins as a red macule or papule at site of tick bite (usually occurs 7-10
days earlier)
• Rash expands as annular erythematoud plaque as spirochetes spread centrifugally
through skin
• Central clearing
• Local symptoms of pruritis or tenderness are hardly noticeable
Erythema migrans
• Stage 2
• Early disseminated Lyme disease occurs weeks to months after initial tick bite
• S/S weakness or paralysis in the muscles of the face, muscle pain and/or pain or
swelling in knees and other large joints
• May experience chest pain/palpitations
• Stage 3
• Late disseminated Lyme disease occurs months or years after initial infection
• S/S muscle and joint pain, abnormal muscles movement, muscle weakness,
numbness & tingling, speech problems
Typical distribution of common skin conditions
Typical distribution of common skin conditions
Jaundice in infants (hyperbilirubinemia)
• Visible jaundice in newborns doesn’t appear until serum bilirubin is
approximately 5 mg/dL
• Pathologic jaundice
• Result of an ongoing pathological process that interrupts normal bilirubin metabolism
• Icterus appearing before the 3rd day, may indicate pathologic condition
• Associated disorders include
• Hemolytic anemia
• Galactosemia
• Biliary Atresia
• Bacterial/viral infection
Jaundice in infants (hyperbilirubinemia)
• Physiologic jaundice
• A newborn’s immature may not be ab to remove bilirubin quicky enough causing
an excess of bilirubin
• May be secondary to:
• Accelerated destruction of erythrocytes
• Low activity of the bilirubin-conjugating enzyme
• Breastfeeding
• Usually occurs after the 2nd or 3rd day of life
Dermal Melanocytosis
• Previously referred to as “Mongolian spots” and a normal variants
• Large slate-blue, well-demarcated areas of pigmentation on the
sacrogluteal area (90%) or may be found along back, extremities, or face
• Fade and disappear by 5-6-years of age in the majority of children who
have them
• Occurrence based on race in newborns
• African-American-90%
• Asian-American- 70%
• Caucasian- <10%
Eczema
• Infantile eczema is very common and begins at approximately 6-8 weeks
of age
• Characterized by:
• Dryness of skin, pruritis, erythematous papules and vesicles
• If infected-serous discharge and crusting
• 6-month-old-most commonly found on the face with sparing of the nose (headlight
sign)
• 8-10-months- arms and legs are common sites
Impetigo
• One of the most common skin conditions of early childhood (ages 1-4year-old)
• Highly contagious, superficial infection caused by group A Beta-hemolytic
streptococcus, Staphylococcus aureus, or both
• Primary lesion- vesicopustule, once ruptures it produces a honey-colored
crust surrounded by rim of erythema
• Bullous impetigo results in vesicles or larger bullae (see in any part of the
body, but face is most common location)
Lacerations
• Imaging to detect foreign bodies
• X-Ray
• Highly sensitive for radiopaque foreign bodies as small as 1-2 mm
• Less sensitive for wood, plastic, and vegetation
• Ultrasound
• Highly sensitive for radiolucent objects (thorns, wood, glass, plastic)
• CT scan
• Superior to plain x-ray in detection of radiopaque and radiolucent objects
• Applies more ionizing radiation than x-ray
• Can be more sensitive that ultrasound if foreign body is in an air-filled cavity, less sensitive if
object is near a bone
• Not the first choice for detection of foreign bodies
Lacerations
• The Advisory Committee on Immunization Practices recommends
• Tetanus toxoid, reduced diphtheria vaccine, and acellular pertussis vaccine (Tdap) for all
patients >10-years-old who require tetanus prophylaxis
• Animal bites are different from regular woulds
• At higher risk of infection because the oral flora of the biter can be easily inoculated into the
victim
• In dogs, cats, and humans staphylococcus and streptococcus
• Should consider antimicrobials in patients who have puncture wounds, hand injuries, and those
that are surgically closed
• Most common regimen Amoxicillin-clavulanic acid (Augmentin) x 5 days
Disseminated Intravascular Coagulation (DIC)
Screening Test
• Group of tests for patients suspected for having DIC
• Platelets- Decreased
• PT- Prolonged**
• aPTT- prolonged
• D-Dimer-Increased
** Several factors can interfere with prothrombin time
-alcohol intake
-diet high in green leafy vegetables
-malabsorption syndromes
-plasma administration
CBC
• RBC count-Closely related to H/H and represents different way of evaluating
number of RBCs in the peripheral blood
• Hemoglobin-A direct measure of hemoglobin in the blood
• Hematocrit- An indirect measurement of RBC number and volume
• Platelet count-actual count of the number of platelets
• Individuals at risk for spontaneous bleeding with counts < 20,000
CBC
• Peripheral Blood Smear
• MCV (Mean Corpuscular Volume)-measures the average size of red blood cells
• Microcytic (Decreased)- Can be related to iron deficiency, thalassemia, hemoglobinopathies
• Macrocytic (Increased)- Vitamin B12 or folic acid deficiency, reticulocytosis secondary to
increased erythropoiesis
• MCH (Mean Corpuscular hemoglobin concentration)-measure of concentration of
hemoglobin in a given volume of packed red blood cells
• Hypochromic (Decreased)- Iron deficiency, thalassemia
• Hyperchromic (Increased)-Concentrated hemoglobin usually due to dehydration
CBC
• WBC with differential
• Leukocytosis (Increased WBC count)- can be see in infection, leukemic neoplasia,
myeloproliferative disorders, malignancy, trauma/stress/hemorrhage, tissue
necrosis, inflammation, steroid use
• Leukopenia (Decreased WBC count)- Drug toxicity, bone marrow failure,
overwhelming infections, congenital marrow aplasia, autoimmune disease,
hypersplenism
CBC
• Lymphocytosis- associated with chronic bacterial infection
• Basophilia- associated with myeloproliferative disease
• Monocytosis- associated with viral infection
• Eosinophils= associated with allergic reaction