Common Pathologies of the Integumentary System ©Irene Mueller, EdD, RHIA Montana Hospital Association June 20, 2012 http://etc.usf.edu/clipart Objectives • Review Integumentary System Pathologies for ICD-10-CM/PCS Coding – ICD-10-CM • Chapter 12 (L00-L99) – Diseases of Skin & SubQ • Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes • Chapter 2 (C00-D49) – Malignant Neoplasms – ICD-10-PCS • 0 - Medical & Surgical Section • H – Skin and Breast • J – SubQ tissue and fascia Skin Chapter vs Other Chapters • Certain Skin Conditions in Other ICD-10 Chapters – Complications of Preg, Childbirth, Puerperium – Congenital – Infectious – Neoplasms – Parasitic – Perinatal – Systemic connective tissue disorders Outline • General Skin Lesions • Inflammations • Infections – – – – – – Abscess Cellulitis Furuncles/Carbuncles Impetigo Pilonidal cyst/sinus Warts • Lesions – – – – Bullous Cicatrix Corns/Calluses Other • Abnormal Skin Pigmentations • Pressure Ulcers, Ulcers • Scalded Skin Syndrome • Hair Pathologies – Alopecia – Folliculitis • Nail Pathologies – Paronychia • Tumors – B9, Malignant • Injuries – Burns, Wounds General Skin lesions • • Bulla • Excoriation • • • Burrow • Fissure • • Comedo • Freckle • • Comedone • Induration • • Crust • Keloid • • Cyst • Lichenification • • • Ecchymosis • Macule • • Erosion • Mole • • Eschar • Nodule Papule Petechia Plaque Purpura Pustule Scale Scleroma Telangiectasia Ulcer Vesicle Wheal • WOW: Check a good medical dictionary for pictures of these; • Should know differences between them Patterns & Distribution of Lesions • • • • • • • • • Annular Discrete Clustered Confluent Dermatomal, Zosteriform Eczematoid Follicular Guttate Iris/Target • Koebner Phenomenon, Isomorphic response • Linear Lesions • Morbilliform • Multiform • Reticular • Satellite lesions • Scarlatiniform • Serpiginous • Strawberry tongue • Universalis Skin Conditions and Stress • Many conditions – Aggravated by stress – Cause of stress Infections of Skin/SQ (L00-L08) • • • • • Abscess/Furuncle/Carbuncle Scalded Skin Syndrome Impetigo Cellulitis and Acute Lymphangitis Acute Lymphadenitis Bullous Disorders (L10-L14) • • • • Bulla = blister, bleb Latin bulla (pl. bullae), "bubble" Circumscribed elevation of skin 0.5 cm+ diameter containing a liquid – Vesicle = <0.5 cm in diameter • Acantholytic disorders • Pemphigoid • Pemphigus Acantholytic Disorders • Gk akantha, thorn or prickle, & lysis, loosening • Primary disorder of skin (sometimes mucous membranes) – characterized by loss of cohesion between epidermal cells, resulting in intraepidermal clefts, vesicles, and bullae – Inflammatory, viral & autoimmune skin diseases, particularly pemphigus complex Dermatitis (L20-L30) • Inflammation of skin • Many types/forms – Acute – Subacute – Chronic • Manifestations – Pruritus, Erythema – Cutaneous Lesions • Most common – Atopic (Eczema) – Contact – Seborrheic http://www.nlm.nih.gov/medlineplus/ency/imagepages/19323.htm Papulosquamous Disorders (L40-45) • Skin eruption – Both papular (pimple-like) AND scaly • • • • Psoriasis Parapsoriasis Pityriasis rosea Lichen planus Urticaria and Erythema (L50-L54) • Urticaria – Many types • Erythema – Multiforme – Marginatum – Many other types Radiation-Related Disorders (L55-59) • Actinic keratosis – AKA Solar keratosis • Radiodermatitis – AKA radiation dermatitis • Sunburn – 1st – 2nd – 3rd Disorders of Skin Appendages (L60-L75) • Nail Disorders – Ingrowing Nail – Onycholysis • Hair Disorders – Acne – Rosacea • Sweat Gland Disorders Hair Pathologies • Follicular cysts Alopecia areata Androgenic alopecia • Eccrine sweat disorders Nonscarring hair loss • Apocrine sweat disorders Cicatricial alopecia Hair color/shaft abnormalities • Hypertrichosis • Acne • Rosacea • • • • • http://etc.usf.edu/clipart Nail Pathologies • • • • • Ingrowing nail Onychia/Paraonychia - Gk, onyx, nail Onycholysis Onychogryphosis Psoriasis Intraop/Postop Complications of Skin (L76) • • • • Hemorrhage/hematoma of skin Accidental puncture/laceration of skin Postprocedural hemorrhage/hematoma Other information – Dermatologic procedure vs other procedure Other Disorders of Skin/SQ (L80-L99) • Vitiligo • Pigmentation Disorders • Seborrheic keratosis • Pressure Ulcers • Atopic Disorders of skin • Hypertrophic Disorders of skin • Lupus erythematosus • Vasculitis limited to skin • Non-pressure chronic ulcers • Keloid • Corns & Calluses Abscess/Furuncle/Carbuncle • Abscess - collection of pus & infected material in or on skin – anywhere on body • Furuncle (Boil) – Abscess involving hair follicle and Subq tissue • Carbuncle – Very large boil OR multiple furuncles joined by many drainage canals • Carbunculosis – Many carbuncles Acantholytic Disorders • Acquired keratosis follicularis – NOT congenital – NOT Darier Disease • Transient acantholytic dermatosis – – – – Etiology – Unknown Itchy red spots on trunk Usu. older men Usu. Lasts 6-8 mos, can be much longer – AKA Grover disease – Tx: Cortisone cream, Accutane, Tetracycline, Phototx, antifungals, Cortisone Injections Actinic Keratosis (L57.0) • Small, rough, raised area found on skin – In sun for long period of time – can become SCC • RF: Fair skin, Blue/green eyes, Blond or red hair • Kidney or other transplant • Take medicines to suppress immune system • Lot of time each day in sun • Many, severe sunburns early in life • Older Actinic Keratosis • Face, scalp, back of hands, chest, or other sun-exposed areas – Flat, scaly areas – Color -gray, pink, red, or same color as skin – Often, white/yellow crusty "scale" on top – Later – develops hard & wart-like or gritty, rough, surface – May be easier to feel than see Acne vulagis • L aknas, misreading of Gk. akmas, "points, dots” L. vulgaris “common” • Inflammatory disease of sebaceous glands & hair follicles – Overproduction of sebum, faster shedding of skin cells = plug and growth of bacteria in follicles • Papules, putules, comedones, nodules, possible scars – Face, neck, shoulders, chest, back Acne vulgaris • • • • Unknown etiology Hormonal changes Hereditary tendencies Any age, most common in Adolescents – 14-17 Girls – Late teens Boys • Precipitating factors – Food allergies, carbonated drinks, endocrine disorders, psychological factors, fatigue, steroid drugs Acute Lymphangitis • Bacterial infection in lymphatic vessels – Streptococcus pyogenes most often; Staph • “Flesh-eating” bacterium – Characterized by painful, red streaks below skin – Potentially serious/fatal infection • Can rapidly spread to bloodstream – Cut, scratch, insect bite, surgical wound, other skin injury Acute Lymphadenitis • Inflammation of lymph node – Neck, arms, or legs; chest or abdomen – Often complication of bacterial wound infection • Hemolytic Streptococci or Staphylococci – Caused by viruses/other disease agents also • Viruses, protozoa, rickettsiae, fungi, tuberculosis – Generalized: number of lymph nodes – Localized: limited to few nodes in infection area – Sometimes accompanied by lymphangitis Alopecia • Loss of hair • 2 main types • Alopecia areata = body's immune system mistakenly attacks hair follicles Androgenetic alopecia = inherited – Head hair thins & falls out • Men = male pattern hair loss • Women = female diffuse hair loss Carbuncle (L02) • Usu. caused by Staphylococcus aureus – Contagious – Back, Nape of Neck, Anywhere – Friction from clothing, shaving – More common in Men than Women • Composed of several skin boils (furuncles) • Infected mass filled w/ fluid, pus, & dead tissue – up to golf ball size – May or may not drain • RF: DM, dermatitis, weak immune system Cellulitis (L03) • Acute, diffuse, bacterial infection – Infection spreads over 2 days – Deep Skin and SubQ – Lower extremities most often, anywhere • Signs – Erythema, pitting edema – Skin is tender and hot – Red lines/streaks PROXIMAL • Along lymph vessels to lymph glands Cellulitis • Streptococcus or Staphylococcus – Small cut/lesion – Enzymes from bacteria • Break down skin cells • Prevent body responses • Can lead to – Abscesses – Bacteremia • Tx: Antibiotics (IV) http://www.nlm.nih.gov/medlineplus/ency/imagepages/8743.htm Corns & Calluses (L84) • Localized, hyperplastic areas – Stratum Corneum of Epidermis • Calluses AKA Tylosis – Larger (up to 1 inch) – Ball of foot, palms • Corns AKA Clavus – Smaller, on toes – Glassy core – More painful • Pressure/friction – – – – Shoes Orthopedic deformity Faulty weight-bearing Repeated trauma • (Musicians) • Impaired Circulation – Foot – Peripheral Neuropathy – DM Dermatitis, Atopic (Eczema) (L24) • Inflammation of skin – Patients w/ family hx of allergic conditions – Vesicular eruptions • Exudative in children • Dry, Leathery in adults – Characteristic pattern • Face, neck, elbows & knees, upper trunk – Pruritis • Idiopathic • Allergic connection assumed Dermatitis, Atopic (Eczema) Gk, ekzein, to boil over • Infants – Sensitivity to milk, OJ, other foods • Flare-up Triggered by – Stress, anxiety, conflict – Wool clothing, blankets – Frequent bathing/handwashing • May improve in summer • Tends to improve with time Dermatitis, Contact (L23-24) • Acute inflammation of skin – Irritants on surface – Allergic reaction – Erythema, edema, small vesicles, itching, stinging • Causes: Poison Ivy, Oak, Sumac; Dyes, Latex, Furs, Preservatives, Drugs, Detergents, Cleaners, Cosmetics, Chemicals, Acids, Metals, Sunshine, Tanning Beds (ICD-10-CM specific codes) Dematitis, Seborrheic (L21) • One of most common skin conditions • Inflammation of Oil glands in skin – Areas with greatest # of glands – Scalp, eyebrows, eyelids, sides of nose, behind ears, middle of chest – Skin is reddened, covered with scales (yellowish, greasy-looking) – May be itching, usu. mild Dermatitis, Seborrheic • Any age; most common during infancy – Cradle cap • Clears w/in 8-12 months (no tx) • Adults w/ CNS disorders (ex. Parkinson) • Adults w/ stress – AMI, long LOS in hospital/nursing home – Immune system disorders (AIDS) – Psoriasis • Idiopathic; heredity predisposition • Tx: Corticosteroids; dandruff shampoos Furuncle (L02) • Usu. caused by Staphylococcus aureus – Other bacteria or fungi found on skin surface • Face, neck, armpit, buttocks, thighs, anywhere • One OR many boils http://upload.wikimedia.org/wikipedia/commons/9/95/Furuncle-MIN-IMG_2589.jpg Impetigo (L01) • Superficial skin infection – Staphylococcus aureus or Streptococcus – Insect bites, scabies, poor hygiene, anemia, malnutrition, eczema (loss of skin integrity) – Highly contagious, Warm weather – Face, arms/legs, anywhere • Vesicular/Pustular lesions, – Rupture -Form thick, yellow crusts • Children, 2 – 6 yo MedlinePlus Ingrowing nail (L60.0) • Edge of nail grows down/into skin of toe – Can be pain, redness, and swelling around nail – Cause: usu. Poorly fitting shoes & improperly trimmed nails • Dangerous for DM http://www.nlm.nih.gov/medlineplus/ency/article/001237.htm Lupus erythematosus (L93.0) • AKA Local, Discoid, Chronic Cutaneous Lupus (CCLE), Discoid Lupus (DLE) • Chronic skin disease – Primarily women 20 – 40 – Characterized by eruption of red lesions over cheeks & bridge of nose – Scarring w/ altered pigmentation • Exacerbated by trauma & sunlight • Tx: Sunscreen, Topical Corticosteroids – Systemic Agents Onychia/Paraonychia (L03.0) • Onychia – AKA onychitis – Inflammation of finger/toenail matrix; may lose • Paraonychia – Superficial infection of epithelium lateral to nail plate – Acute More painful (usu. Bacterial) – Chronic (often several nails) (usu. Fungal) • Culture of exudate to determine etiology – RF – Hands in water for long periods Onycholysis (L60.1) • Spontaneous separation of nail plate – Starting at distal free margin & progressing proximally – Beginning at proximal nail & extending to free • Most often in psoriasis of nails (onychomadesis) – Just at lateral borders (Rare) • Etiology – Endogenous, exogenous, hereditary, &idiopathic Contact irritants, trauma, & moisture – Associated with many other diseases • Tx: Depends on Cause Onychogryphosis (L60.2) • Gk, onyx + gryphein, to curve • Abnormal hypertrophy & curving of nails • Gives a claw-like appearance Parapsoriasis (L41) • 2 general forms – Small plaque type, usu. B9 – Tx: emollients, topical tar, steroids, phototx – Large plaque type, precursor of cutaneous Tcell lymphoma (CTCL). – Tx: phototherapy or topical corticosteroids Parapsoriasis (L41.x) • No uniform, accepted definition • Group of skin diseases characterized by – Scaly patches OR – Slightly elevated papules and/or plaques – Resemblance to psoriasis • BUT includes several inflammatory cutaneous diseases unrelated in pathogenesis, histopathology, & tx response Pemphigoid vs Pemphigus • • • • • • Separate autoimmune diseases Both have sub types Both cause burn-like blisters Both very rare; can’t be cured PemphigoiD = Deep PemphiguS = Superficial Pemphigoid more common, less dangerous – Tends to affect older people, usually 60+ Pemphigoid (12.9) • Gk pemphix, blister • Autoantibodies – – Against basement membrane of epidermis – Not against epidermal cell junctions • Intact, tense bullae up to 3 cm – Trunk, arms, & legs – Rare in mouth Pemphigus (L10) • Group of disorders caused by autoantibodies against some part of epidermis – Including Oral mucosa – Lead to disruption of intercellular junctions and blisters – Ruptured bullae covered with scabs – Tx: Immunosuppressive agents – Prognosis is variable – Many patients - higher than normal mortality rate Pemphigus Risk Factors • Possible triggers • Non-steroidal anti-inflammatory drugs such as ibuprofen • Drugs derived from penicillamine • Herpes simplex virus • Exposure to sunlight • Long-term stress Pilonodal Cyst/Sinus • Latin - pilus (hair); nidus (nest) nest • Abnormal pocket in skin, usu. contains hair, skin debris & other abnormal tissue • Almost always located near tailbone at top of buttocks cleft (small pit) • Affect men more often; most commonly in young adults • When becomes infected (abscess) – causes pains, inflammation & usu. drainage of fluids Pilonidal Cyst (L05) • Risk Factors – Obesity, Inactive lifestyle – Occupation or sports requiring prolonged sitting – Excess body hair; Stiff or coarse hair – Poor hygiene; Excess sweating • When chronically infected pilonidal cyst isn't treated properly – Increased risk of developing squamous cell carcinoma. Pilonidal Sinus • Hair may protrude from tract below skin’s surface that connects infected pilonidal cyst to opening on skin's surface – More than one sinus tract may form • Tx: I&D, currettage – May be left open to heal MedlinePlus Psoriasis, Gk - itch • Non-infective • Thick, flaky, various-sized red patches – Covered with white, silvery scales – Scales progress to plaques, sometimes pustules • Chronic condition, most common bet. 10-30 yo • Scalp, outer arms/legs, trunk, palms/soles, nail beds (nails thicken, crumble) • Genetic basis • Maybe autoimmune • Whites - more common Psoriasis, Arthropathic (L40.50) • Several different forms – Small distal joints, fingers & toes – Joints on one side of body only – Bilateral larger joints – Back and spine – psoriatic arthritis mutilans (rare) - joints & bones destroyed (gnarled,club-like hands & feet) (L40.52) • Symptoms of psoriasis usu. Precede arthritis – Clue to possible joint disease is pitting and other changes in fingernails Psoriasis (L40) • Precipitating factors – Hormonal changes, climate changes, emotional stress, poor health • Remissions and Exacerabations • Guttate psoriasis – Rare form – Frequently follows Strep infection – L, drop MedlinePlus Psoriasis and Nails • Nail changes occur in – Up to 50 % of psoriasis patients – Up to 80 % psoriatic arthritis patients • Most common Nail problems in psoriasis – Pitting—shallow or deep holes in nail – Deformation—alterations in normal shape of nail – Thickening of nail – Onycholysis—separation of nail from nail bed – Discoloration—unusual nail coloration, such as yellow-brown Radiodermatitis (L58) • Cutaneous inflammatory reaction – Acute or Chronic – Exposure to biologically effective levels of ionizing radiation • Most common example of normal tissue damage as a result of radiotherapy – About 95% of radiation oncology patients – 87% moderate to severe radiodermatitis Radiodermatitis • Includes – Localized erythema & edema Grade 1 – Skin shedding (desquamation) – Hair loss (epilation) – Fibrosis – Necrosis (ulcers/hemorrhages) Grade 4 • Late effects (90 days to years after tx) – Result of permanent damage to dermis – Atrophy, fibrosis, telangiectasias, & pigmentation changes • Tx: Depends on Grade Rosacea L, rosaceus, rosy • Facial skin redness, where blushing occurs • Insidious onset – Mistaken for sunburn or acnes • • • • Becomes more noticeable /does not go away Dryness, pimples (pustular) Small blood vessels dilate Knobby bumps on nose, looks swollen – Usu. Male patients Rosacea (L71) • Unknown etiology – May be inherited • Lighter complexions – higher risk • Not infectious/contagious • Triggers vary from person to person – Sunlight, hard exercise, extreme heat/cold, stress, spicy foods, hot drinks, alcohol, hot/cold weather, wind • Tx: topical antibiotics, Finacea, laser surgery, sunscreens Scalded Skin Syndrome (L00) • AKA - Ritter disease; Staphylococcal scalded skin syndrome (SSS) • Infection - skin becomes damaged & sheds – certain strains of Staphylococcus – Toxin causes skin damage – Blisters as if skin were scalded • Most commonly in infants & children under 5 • Tx: IV antibiotics and fluids Seborrheic Keratosis (L82) • AKA Seborrheic Wart • B9 skin tumor • Usu. After age 40 • Runs in families • S&S • Often waxy surface • Round-to-oval • “Pasted-on" appearance • S&S, cont. • Located on face, chest, shoulders, back, or other areas • Usu. painless, but may irritate & itch • Yellow, brown, black, or other colors • Slightly raised, flat surface; rough or wart-like texture • May be single, but usually many Sunburn (L55) • Severity determined by depth of burn • 1st – Damage to epidermis – Erythema (Pain, Redness, Swelling) • 2nd – Damage to Dermis; Erythema, Blisters • 3rd degree – Damage to Hypodermis & Nerve supply – Numbness; then scars – Loss of sensation/function possible Burn Severity http://www.nlm.nih.gov/medlineplus/ency/imagepages/1078.htm Ulcers • L, ulcus, a sore • Circumscribed, craterlike lesion of he skin or mucous membrane • Resulting from necrosis accompanying some inflammatory, infectious, or malignant processes • Produced by sloughing of necrotic inflammatory tissue Ulcers, Non-Pressure (L97) • • • • Arterial ulcers Venous stasis ulcers Diabetic ulcers Neurotrophic ulcers • NOT pressure ulcers Arterial ulcers • Complete or partial arterial blockage – Causes tissue necrosis and/or ulceration of extremity • AKA Ischemic ulcer • Large/small vessel; toes, ankles, fingers • Risk Factors – Peripheral vascular disease (PVD) – Diabetes mellitus – Advanced Age • Tx: Surgical or Medical to increase circulation S&S of Arterial Ulcer • • • • No pulse in area of extremity Painful ulceration Cool or Cold skin Small, punctate ulcers; usually well defined Delayed capillary return time – Briefly push on end of toe and release – Normal color should return to toe in <3 seconds • Atrophic appearing skin (shiny, thin, dry) • Loss of digital & pedal hair • Frequently on dorsal foot; occur anywhere Venous stasis ulcers • AKA Varicose Ulcers • Venous Stasis – Cessation or impairment of venous flow – AKA phlebostasis, venostasis • Location – Below knee – usu. Inner part of leg, just above ankle. Can be uni/bilateral • Tx: Bed rest, elevation, & pressure bandages – Antibiotics if needed for infection Venous stasis ulcers (I83) • Common in patients – w/Hx of leg swelling – Varicose veins – Hx of blood clots in superficial OR deep leg veins • Affect 500,000 - 600,000 people in US yearly • Account for 80 to 90 % of all leg ulcers Diabetic ulcers (E08-E11) • Most common foot injuries leading to lower extremity amputation – Risk of LE amputation - 15 - 46 times higher in diabetics – Early detection/appropriate treatment of diabetic ulcers may prevent up to 85 % of amputations • Ulcers almost always form in patients with neuropathy – Typically painless Neurotrophic ulcers • Occur primarily in Diabetics – see Diabetic ulcer – 60 - 70 % of Diabetics - mild to severe forms of nervous system damage • Can affect anyone w/ impaired sensation in feet – Predominantly sensory neuropathy, Sensorymotor neuropathy, or Autonomic neuropathy – Essential cryoglobulinemic vasculitis Ulcers, Pressure (L 89) • Localized injury to skin and/or underlying tissue – Usually over bony prominence – Result of pressure, or – Pressure in combination w/shear and/or friction • 6 stages – NPUAP, 2007 • Tx: Decrease pressure, friction and shear Ulcers, Pressure • • • • • • • AKA Bed Sore Decubitus ulcer Plaster ulcer Pressure area Pressure sore Slough [sluf] Layer/mass of dead tissue separated from surrounding living tissue • Eschar - hard crust or scab Pressure Ulcer Stages • Suspected Deep Tissue Injury – Purple or maroon localized area of discolored intact skin or blood-filled blister – Due to damage of underlying soft tissue from pressure and/or shear • Stage I – Intact skin w/ nonblanchable redness of localized area – Usu. Over bony prominence – Darkly pigmented skin may not visibly blanch – Color may differ from surrounding area Pressure Ulcer Stages • Stage II – Partial-thickness loss of dermis – Shallow open ulcer w/ red pink wound bed, w/o slough – May also present as an intact or open/ruptured serumfilled blister • Stage III – Full-thickness tissue loss – SQ fat may be visible but bone, tendon or muscle are NOT exposed – Slough may be present but does not obscure depth of tissue loss – May include undermining and tunneling Pressure Ulcer Stages • Stage IV – Full thickness tissue loss w/ exposed bone, tendon or muscle – Slough or eschar may be present on some parts of wound bed – Often includes undermining & tunneling • Unstageable – Full thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray, green or brown) – and/or eschar (tan, brown or black) in wound bed http://www.nlm.nih.gov/medlineplus/ency/imagepages/19092.htm Risk Factors for Pressure Ulcers • Age – Reduced skin cell turnover, drier skin, reduction of collagen & elastin, & reduced vascularity at dermal/epidermal junction cause • Skin less resistant to shear forces • Increased surface area (potential fluid loss increase) • Increased traumatic injury risk (e.g. skin tears) • Decreased homeostasis • Reduction of barrier function RF for Pressure Ulcers • Thin Body – More prone to develop pressure ulcers over bony prominences • Nutrition & Hydration – hypoalbuminemia, weight loss, cachexias, dehydration, and malnutrition – commonly reported risk factors predisposing persons to pressure ulcer. – Pressure ulcers can generate stress response, which further adds to nutritional needs • Lower dietary protein intake RF for Pressure Ulcers • Inability to feed oneself • Particular Medical Conditions – Diabetes Malnutrition – Altered mental status – Spinal cord injury Orthopedic injury – Depression Vascular disease • Anaerobic waste products – believed to accumulate due to pressure-induced occlusion of lymphatic vessels & contribute to tissue necrosis PU Assessment Tools • Braden Scale • Norton Scale – Most researched, validated, & nationally recognized tool – Comprehensive – May not have same predictive value & accuracy in LTC – Not readily used in outpatient clinic setting – View tool at • www.bradenscale.com/imag es/bradenscale.pdf – Short, straightforward, easy to complete – Does NOT address nutrition – View tool at • http://www.ruralfamilyme dicine.org/educationalstr ategies/braden_scale_for _predicting_pres.htm Unavoidable Pressure Ulcers • CMS definition in LTC • “An unavoidable pressure ulcer occurs when facility staff evaluated resident’s clinical condition and pressure ulcer risk factors, defined and implemented interventions consistent with resident needs, goals, and recognized standards of practice, monitored and evaluated impact of interventions, and revised approaches as appropriate.” Urticaria L, urtica, nettle • • • • AKA – Hives Severe itching, then redness, then wheal Localized, various sizes Can include – GI tract – abdominal colic – Pharynx – can cause asphyxiation – Deep tissues = angioedema – more serious • Usu. Short duration, can become chronic Urticaria (L50) • • • • • Dermis Acute hypersensitivity Release of histamine Local inflammation, vasodilation, edema Allergic reaction – Shellfish, strawberries, peanuts, etc. – Insect stings • Infection, Sunlight, Temperature extremes • Tx: epinephrine, prednisone Skin Injuries & Neoplasms • Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes • Chapter 2 (C00-D49) – Malignant Neoplasms Skin Injuries in ICD-10-CM • Abrasion • Exfoliation – Desquamation – Excoriation • Avulsion – Wound, Open • Bite (nonvenomous) – Superficial – Open • • • • Blister (nonthermal) Burn Contusion Corrosion • • • • • • External Constriction Foreign Body Frostbite Incision Laceration Wound Abrasion • L: abradere, to scrape off • Rubbing away of skin surface by friction against rough surface, usu. Not deeper than epidermis, can bleed • Mild abrasion (Graze) does NOT scar • Deep abrasion may scar • AKA – Scrape, Scratch, Excoriation • Types – Rope burn, friction burn, road rash, rug burn Avulsion of Skin • L, avulsio, a pulling away • Avulsion injury - removal of all layers of skin – Chunk of tissue removed from body – Includes all 3 layers of skin at minimum • More than simple lacerations; less than amputations • Etiology: Animal bites, industrial equipment, or MVAs • Skin flap or Degloving • Higher Risk of Infection Bite (Non-venomous) • Wound or puncture made by living organism • Superficial = Skin • Open = Communicates directly with atmosphere • Pets, Humans, Insects, Snakes, etc. • Can be heavily contaminated Blister (Non-thermal) • Friction (New Shoes) – Abrasion Blister • • • • • Electricity Chemicals Radiation from sun Cold Pinched skin (blood blister) Burn (T20-T25) • Electrical heating appliances • Electricity • Flame • Friction • Hot air and hot gases • Hot objects • Leading cause of injury in US • Lightning • Radiation • Scalds • Chemical Burn (Corrosion) • NOT Sunburn Burns • 85%–90% caused by heat • 10%–15% frostbite, chemical, & electrical damage • 1.5 - 2.0 million burns each year in U.S • 60,000 to 80,000 burn victims hospitalized • 5,000 people die • 35,000 to 50,000 people - temporary or permanent disability 2ndary to burns Degrees of Burns • Older Terminology • 1st degree; outer layers of epidermis injured, erythema, but no blistering • 2nd degree; epidermis into dermis but basal layer remains, blistering • 3rd degree; all epidermis & dermis destroyed; only white eschar remains • 4th degree; muscle, nerve and bone damaged • Newer terminology • Superficial partial thickness; epidermis and upper part of dermis injured • Deep partial thickness; epidermis & large upper portion of dermis injured • Full thickness; all layers destroyed Degrees of Burns • 4th degree burns extend to tissue • 5th degree extends to bone • 6th degree burns are through bone • Old classification system http://www.ncbi.nlm.nih.gov/books/NBK27295/ Rule of Nines for Burn Extent • Total Body Surface Area (BSA) (Adults) • Age Infants, children, & elderly survival • Total Body Surface Area – greater area of involvement ~ prognosis • Depth of Burn— More Total BSA ~ full thickness, prognosis • Other Injuries - Prognosis concurrent injuries increase http://www.ncbi.nlm.nih.gov/books/NBK27295/ as Burn Treatment • Determined by Degree and Extent of Burns • Table of Treatment Modalities by Burn Degree – Rehabilitation of Burn Injuries – http://www.ncbi.nlm.nih.gov/books/NBK27295/ Contusion • L, contundere, to bruise • AKA Bruise • Injury that does not disrupt integrity of skin – Caused by blow to body – Characterized by swelling, discoloration, & pain Corrosion (T20-T25) • L, corrodere, to gnaw away • Tissue damage due to exposure to strong alkali or acid • Main types of irritant and/or corrosive – Acids, bases, oxidizers, solvents, reducing agents and alkylants – Types of chemical weapons • Vesicants or Urticants External Constriction • Classified as superficial injury • Ex: Hair tourniquet syndrome – AKA hair strangulation • External constriction of finger, toe, or external genitalia by hair – OR thread, ring, rubber band, other object that can go around a body part – Relatively common in infants – Can be emergency situation • Object NOT removed; infection or amputation Foreign Body • Any object or substance found in organ or tissue in which it does NOT belong under normal circumstances • Superficial • Open Wound w/FB http://upload.wikimedia.org/wikipedia/commons/7/74/Knee_puncture.JPG Foreign Body • Iatrogenic – Sutures, sponges, instruments left during surgery – Metals & plastics replacing/enhancing failing/non-functioning body parts • Accidental/unintentional – From abrasions & open wounds in various accidents or GSWs, – May elicit FB-type granuloma formationr • Intentional – Introduced in context of sexual deviancy – Anorectum or vagina vibrators, bottles, light bulbs, eggs, etc. Frostbite • Superficial – Damage to skin caused by extreme cold – Red, painful, Blisters, Gangrene – Hands, feet, nose, & ears most common areas • RF: – Beta-blockers – Peripheral vascular disease – Smoke, Diabetes – Raynaud phenomenon • IF blood vessels NOT damaged – Complete Recovery Possible Incision • Neat, Clean cut – Surgery – Sharp instrument, such as knife Wound • Laceration – Dull, Blunt instrument – Jagged, irregular wound – Some tearing, breaking of tissue • Puncture wound – Sharp, pointed object pierces skin – Can be deep; look insignificant – Anaerobic infection risk • W/Without FB Lacerations • From shallow cuts to deep gashes penetrating thru muscle to internal organs/bone – Superficial laceration involves only skin – Deeper laceration may penetrate veins or arteries – Blood vessel may require repair • Causes - include accidents at home & work, motor vehicle crashes, & violence Open Wound vs Superficial • Open wounds – Animal bites, avulsions, cuts, lacerations, puncture wounds, traumatic amputations • Superficial injuries – Animal bites that do NOT break all skin layers – Abrasions or contusions – Skin tears (Elderly, etc.) Gunshot wounds • Skin Damage = external, surface wounds caused by a bullet • Usually, entrance wound smaller/tidier than exit site • Amount of injury at entrance/exit (if present) sites related to – Caliber of bullet – Angle at which bullet traverses tissues – Distance from gun – Type of bullet Integumentary System Neoplasms • Benign usu. Need ONLY cosmetic tx • Most common cancers in US • C43-44 Melanoma and Other malignant Neoplasms of Skin – – – – BCC SCC Melanoma Merkel Cell Ca • C50 Malignant Neoplasm of Breast • C79.2 2ndary Malignant Neoplasm of Skin • C84.0 Cutaneous Lymphoma Benign Neoplasms of Skin • Acrochordon – Skin tag • Cherry angioma • Dermatofibroma • Dermatosis papulosa nigra • Ephilides – Freckles • Epidermal inclusion cyst • Lentigines – Liver spots • Lipoma • Milium • Nevus – Mole • Pyogenic granuloma • Sebaceous hyperplasia • Seborrheic keratosis Keratinocyte cancers • Most common non-melanoma skin cancers – Cells share some features of keratinocytes – Most abundant cell type of normal skin • Most common types of keratinocyte cancer – Basal cell carcinoma – Squamous cell carcinoma Other Skin Cancers • Other non-melanoma skin cancers include – Merkel cell carcinoma – Kaposi sarcoma – Cutaneous (skin) lymphoma – Skin adnexal tumors – Various types of sarcomas Basal Cell Carcinoma • • • • • • • About 80% of skin cancers Sun-exposed areas, especially head & neck Slow growing, seldom spread BUT IF left untxed; can invade & metastasize Can recur at same place Increases chance of getting BCC elsewhere Up to 50% of people will get new BCC w/in 5 years Breast Cancer • 2 main types • Ductal carcinoma – Begins in tubes (ducts) that move milk from breast to nipple – Most breast cancers • Lobular carcinoma – Begins in lobules that produce milk • Rarely, can begin in other breast areas Breast Cancer • Invasive – Spread from milk duct or lobule to other breast tissues • Noninvasive – NOT yet invaded other breast tissue – “In situ“ • Women - 1 in 8 will be DX w/breast cancer • Men - <1% of all cancers in men – < 1% of all diagnosed breast cancers Breast Ca Risk Factors • Age and gender – 50 + – Women - 100 times more likely to get than men • Family Hx of breast cancer – Close relative had breast, uterine, ovarian, or colon cancer – 20 - 30% of women w/ breast cancer have family hx • Genes – BRCA1 and BRCA2 genes • Menstrual cycle – Early periods (before age 12) – Menopause late (after age 55) Breast Ca Risk Factors • Alcohol use – 1 - 2 glasses + daily • Childbirth • DES – – Increased risk of breast cancer after age 40 – NO children or after age • HRT – 30 – Estrogen for several years – Being pregnant 2+ times • Obesity – reduces risk – Link is controversial – Pregnancy at early age • Radiation Tx reduces risk – Child or young adult • Dense Breast tissue – Treat ca of chest area • Being White Breast Cancer Tx • Six types of standard treatment – Surgery – Sentinel lymph node biopsy followed by surgery – Adjuvant Tx • Radiation therapy • Chemotherapy • Hormone therapy – Targeted therapy • Various combinations based on Pt and Stage Breast Cancer Surgery • Breast-conserving surgery – Remove cancer but not breast – Lumpectomy: Surgery to remove a tumor (lump) & small amount of normal surrounding tissue – Partial mastectomy: Remove part of breast w/cancer & some normal tissue • Lining over chest muscles below cancer may be removed • AKA segmental mastectomy – Lymph Node Dissection (separate incision) Breast Ca Surgery • Total (Simple) Mastectomy – All breast tissues • Modified Radical Mastectomy – Whole breast, many of lymph nodes, lining over chest muscles; sometimes, part of chest wall muscles • Breast Reconstruction – At same time OR later Radiation for Breast Ca • External radiation therapy – Machine outside body sends radiation to cancer • Internal radiation therapy – Radioactive substance sealed in needles, seeds, wires, or catheters – Placed directly into or near cancer Chemotx for Breast Cancer • Systemic chemotherapy – Chemotherapy taken by mouth or injected into vein or muscle – Drugs enter bloodstream, & can reach cancer cells throughout body • Regional chemotherapy − Chemotherapy placed directly into CSF, organ, body cavity (such as abdomen) − Drugs mainly affect cancer cells in those areas Hormone Tx for Breast Ca • Hormone therapy – Removes hormones OR blocks action – Stops cancer cells from growing • Some hormones can cause certain Ca • When tests show cancer cells have hormone receptors – Drugs, surgery, or radiation tx used to reduce production of hormones or block them from working Targeted Tx for Breast Ca • Uses drugs or other substances – ID & attack specific cancer cells without harming normal cells – Monoclonal antibodies and Tyrosine kinase • Used to treat Breast Ca Cutaneous (skin) lymphoma • Cancers of lymphocytes (white blood cells) – Primarily involving skin • Classification is based on lymphocyte type – B-lymphocytes (B-cell) – T-lymphocytes (T-cell) (CTCL) • Most common • Red, scaly patches or thickened plaques of skin – Often mimic eczema or chronic dermatitis • More common in men; after age 50 CTCL • Most common type of Skin Lymphoma – Red, scaly patches or thickened plaques of skin – Often mimics eczema or chronic dermatitis • More common in men; after age 50 • Two most common types – Mycosis fungoides & Sezary syndrome • Treatment – Topical • Corticosteroids, Topical Chemo, Retinoids – Systemic • IV Steroids • IV Retinoids • IV/ Oral Chemo – Light Therapy – Immunotherapy – Radiation Therapy Melanoma • Less than 5% of skin cancer cases • BUT causes large majority of skin ca deaths • 2012 - About 76,250 new melanomas dx – 44,250 men & 32,000 women – Incidence rates for melanoma rising for 30+ yrs • 9,180 are expected to die of melanoma – 6,060 men & 3,120 women – 2004 to 2008 - Death rate in whites • Dropped those < 50 • Stable in women • Rising in men > 50 Melanoma • Lifetime risk – 2% (1 in 50) for whites – 0.1% (1 in 1,000) for blacks – 0.5% (1 in 200) for Hispanics • Risk increase with age – One of more common cas in young adults Melanoma Risk Factors • Ultraviolet (UV) light exposure – Sun and Tanning beds • Dysplastic nevi • Congenital melanocytic nevi • Fair skin, freckling, & light hair • Personal Hx of melanoma • • • • Immune suppression Age Gender (Male) Xeroderma pigmentosum S&S of Melanoma • ABCDE rule – Asymmetry One half of mole or birthmark does not match other half – Border Edges irregular, ragged, notched, or blurred – Color NOT same all over & may include shades of brown/black, sometimes patches of pink, red, white, or blue. – Diameter Spot >6 mms across– size of pencil eraser, BUT melanomas can be smaller – Evolution Any changes in skin lesions, new skin lesions, or growths that look different from moles S&S of Melanoma • Other warning signs – Sore doesn’t heal – Pigment spreads from border of spot to surrounding skin – Redness or new swelling beyond border – Change in sensation • itchiness, tenderness, or pain – Change in surface of a mole • scaliness, oozing, bleeding, or bump/nodule appears Melanoma Staging • The American Joint Committee on Cancer (AJCC) TNM system • T ~ Tumor 0-4 a, b • N ~ Node 0-3 a, b, c • M ~ Metastasis • Tx: Based on Stage • Surgery Chemotherapy • Immunotherapy Radiation therapy Melanoma Survival Rates Stage IA 5-year ~ 97% 10-year ~ 95% Stage IB 5-year ~ 92% 10-year ~ 86% Stage IIA 5-year ~ 81% 10-year ~ 67% Stage IIB 5-year ~ 70% 10-year ~ 57% Stage IIC 5-year ~ 53% 10-year ~ 40% • Stage IIIA • 5-year ~ 78% • 10-year ~ 68% • Stage IIIB – 5-year ~ 59% – 10-year ~ 43% • Stage IIIC – 5-year ~ 40% – 10-year ~ 24% • Stage IV – 5-year ~ 15%-20% – 10-year ~ 10%-15% http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001853/figure/A000850.B3200/?report=objectonly Merkel Cell Ca • • • • Rare skin ca, but incidence increasing world-wide Metastasizes quickly Merkel cells at base of epidermis Nodule – flesh-colored OR bluish-red, shiny, painless • Usu. on face, head, neck; also on limbs or trunk • Risk Factors – Age, sun exposure, weak immune system, other skin ca, light skin – 80% of 10 Merkel cell cas are thought to be related to MCV (Merkel Cell Polyomavirus) • AKA – Neuroendocrine carcinoma of skin Merkel Cell Ca • Metastasis – Liver, Bones, Lungs, Brain • Prognosis – 33% fatality rate • Diagnosis – PE, Bx, Sentinel Node Bx, x-rays, CT, PET, octreotide scan • Tx – Surgery (Mohs), Radiation, Chemo Squamous Cell Carcinoma • About 20% of skin cas are SCC • Sun-exposed areas of body • Sometimes begin in actinic keratoses • Genital area skin – Face, ears, neck, lips, & backs of hands • Scars or skin ulcers elsewhere http://www.nlm.nih.gov/medlineplus/ency/imagepages/2475.htm Squamous Cell Ca • More aggressive than BCC – More likely to invade fatty tissues just under skin – More likely to spread to lymph nodes and/or metastasize • Squamous cell carcinoma in situ – AKA Bowen disease – Still w/in the epidermis http://www.nlm.nih.gov/medlineplus/ency/ima gepages/1516.htm 2ndary Skin Cancers • Cancer cells can grow in skin – NOT skin cancer, melanoma, or cutaneous T cell lymphoma – Secondary cancer may start to grow • On/ near operation scar where primary cancer was removed • In other parts of body • Secondary skin cancer looks like a pink/red raised lump – These nodules can be treated Questions from Last Session • ICD-10-CM/PCS Implementation date – Proposed Rule – 10-1-2014 • Federal Register on April 17, • Proposed rule available for comment for 30 days – Announcement in June? • http://www.cms.gov/Medicare/Coding/ ICD10/index.html Questions from Last Session • Timeline for Required ICD-10-CM/PCS CEs? – “CCHIIM will send out a communiqué within 30 days of final decision by HHS on ICD-10 implementation date to address ICD-10 CEU requirements and launch date for ICD-10 compliant exams. Certified professionals are still encouraged to obtain their ICD-10 required CEU’s for submission by December 31, 2013.” – Please be aware that delay is not finalized until official notice is send out from HHS • Linda DeViller, AHIMA 6/18/2012 Query Example • Liposuction of lipomas • ICD-10-CM – Location of lipomas • ICD-10-PCS – INTENT of Root operation • Medical reason ~ Extraction • Cosmetic reason ~ Alteration What is missing from above statement? What would we need to query for? Homework • Pressure Ulcer Online Training. The National Database of Nursing Quality Indicators® – https://www.nursingquality.org/NDNQIPressureUlcer Training/ • Four Modules – – – – CEs Pressure Ulcers and Staging Other Wound Types and Skin Injuries Pressure Ulcer Survey Guide Community vs. Hospital/Unit Acquired Pressure Ulcers • CE certificate when all completed w/tests General Resources • Cohen, B. A., Lehmann, C. U. Dermatology Image Atlas. Johns Hopkins University, 2000-2012. – http://dermatlas.med.jhmi.edu/derm/ • Dermatology A to Z. AAD. – http://www.aad.org/skin-conditions/dermatology-a-to-z • MedlinePlus • Swanson, J. R. & Melton, J. L. Dermatology Atlas. Chicago: Loyola University Dermatology Medical Education Website – http://www.meddean.luc.edu/lumen/MedEd/medicine/der matology/melton/title.htm Resources • About Cutaneous Lymphoma. Cutaneous Lymphoma Foundation. – http://www.clfoundation.org/about-cutaneous-lymphoma • Acute Lymphangitis. Medical Dictionary Article. – http://medicaldictionary.thefreedictionary.com/Acute+Lymphangitis • Armstrong, D. G. & Lavery. L. A. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. AAFP. – http://www.aafp.org/afp/1998/0315/p1325.html Resources • Breast Cancer Treatment (PDQ®). National Cancer Institute. – http://www.cancer.gov/cancertopics/pdq/treatment/breast /Patient/page1 • Characteristics of Arterial Ulcers. Wound Educators. YouTube. – http://www.youtube.com/watch?v~QDbknssi5H4&feature ~related • Common Benign Growths. Dermatology. Cleveland Clinic. – http://www.clevelandclinicmeded.com/medicalpubs/disea semanagement/dermatology/common-benign-growths/ Resources • Cutaneous Lupus Erythematosus. Family Practice Notebook. – http://www.fpnotebook.com/rheum/Derm/CtnsLpsEryth mts.htm • Evaluation of an Acute Wound. Chapter 6. – http://practicalplasticsurgery.org/docs/Practical_06.pdf • Gunshot Wounds. Chapter 7. – http://practicalplasticsurgery.org/docs/Practical_07.pdf Resources • Gun Shot Wounds. Wheeless' Textbook of Orthopaedics. Duke Orthopedics. – http://www.wheelessonline.com/ortho/gun_shot_wounds • Lymphadenitis. Medical Dictionary Article. – http://medical-dictionary.thefreedictionary.com/lymphadenitis • Practical Plastic Surgery. – http://practicalplasticsurgery.org/the-book/ Resources • Peripheral Neuropathy Fact Sheet. NINDS. – http://www.ninds.nih.gov/disorders/peripheralneuropathy/ detail_peripheralneuropathy.htm • Rashes: MedlinePlus Medical Encyclopedia. – http://www.nlm.nih.gov/medlineplus/ency/article/003220. htm Resources • Rose, L. C. Recognizing Neoplastic Skin Lesions: A Photo Guide. Am Fam Physician. 1998 Sep 15: 58 (4): 873-884. – http://www.aafp.org/afp/1998/0915/p873.html • Skin Lesions. Article. Medical Dictionary. – http://medicaldictionary.thefreedictionary.com/Skin+Lesions • ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002 – http://www.cdc.gov/nchs/data/icd9/agendadec02.pdf ILEMten@gmail.com