Inflammatory
Disorders of the Skin
Objectives
1. Describe and discuss, Dermatitis, Acne Vulgaris ,
Urticaria, Psoriasis, Seborrheic Keratosis.
Scleroderma and Systemic Lupus Erythematous as
to definition, etiology, pathophysiology, signs and
symptoms, diagnosis, medical and nursing
management.
2. Apply the nursing process for clients with
inflammatory disorders of the skin.
3. Recognize systemic disorders with dermatologic
symptoms.
Content
1. Dermatitis
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
2. Acne Vulgaris
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
3. Urticaria
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
4. Psoriasis
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
Content
5. Seborrheic Keratosis
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
6. Scleroderma
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
7. Systemic Lupus Erythematous
a. Etiology
b. Pathophysiology
c. Signs and Symptoms
d. Diagnostic findings
e. Medical management
f. Nursing management
Content
8. Nursing Process
a. Assessment
b. Nursing Diagnosis
c. Planning
d. Implementation
e. Evaluation
Dermatitis
• A general term used to describe inflammation of the skin.
Description
• Most types of dermatitis are characterized by an itchy pink
or red rash.
• Contact dermatitis is an allergic reaction to something that
irritates the skin and is manifested by one or more lines of
red, swollen, blistered skin that may itch or seep.
• It usually appears within 48 hours after touching or
brushing against a substance to which the skin is sensitive.
• The condition is more common in adults than in children.
Dermatitis
Contact dermatitis of the (left) face and
(right) wrist
Contact dermatitis
• Can occur on any part of the body, but it
usually affects the hands, feet, and groin.
• Contact dermatitis usually does not
spread from one person to another, nor
does it spread beyond the area exposed to
the irritant unless affected skin comes
into contact with another part of the
body.
Contact dermatitis
• However, in the case of some
irritants, such as poison ivy, contact
dermatitis can be passed to another
person or to another part of the
body.
POISON IVY
Atopic Dermatitis
• This form of dermatitis, commonly referred to as
eczema, is a chronic condition that causes itchy,
inflamed skin.
• Most often, it occurs in the folds of the elbows,
backs of the knees or the front of the neck.
• It tends to flare periodically and then subside for
a time, even up to several years.
• The exact cause of this skin disorder is unknown,
but it may result from a malfunction in the body's
immune system.
Atopic Dermatitis
Dermatitis
• Pathophysiology and Etiology
– Types: Allergic contact; primary irritant
• Assessment Findings
– Blood vessel dilation; itching; vesiculation
– Skin patch test; visual examination
Dermatitis
• Medical Management
– Flushing skin with cool water; topical
lotions; wet dressings; corticosteroids
• Nursing Management
– Client teaching: Avoid contact with soap,
topical substances; preserve skin
integrity
Acne Vulgaris
Acne of (left) the face and (right) the
chest
Acne Vulgaris
• Pathophysiology and Etiology
– Overproduction of sebum
• Assessment Findings
– Comedones (blackhead); oily scalp
– Visual examination
• Medical Management
– Gentle facial cleansing; drying agents
containing benzoyl peroxide
– Topical and oral drugs and antibiotics
– Removal with instruments
Acne
• Develops as a result of blockages in follicles.
Hyperkeratinization and formation of a plug of
keratin and sebum (a microcomedo) is the earliest
change.
• Enlargement of sebaceous glands and an increase
in sebum production occur with increased
androgen production .
• The microcomedo may enlarge to form an open
comedo (blackhead) or closed comedo
(whitehead).
• Increased sebum production provides an
environment for the overgrowth of
Propionibacterium acnes.
Acne Vulgaris
• Surgical Management
– Dermabrasion
• Nursing Management
– Client teaching
• Cleanliness: Face and hair
• Avoid cosmetics, Manipulation of lesions
• Precautions for pregnant women: Risk
associated with systemic oral isotretinoin
Urticaria
• A vascular reaction pattern of the skin
marked by the transient appearance of
smooth, slightly elevated patches that are
more red or more pale than the
surrounding skin and are accompanied by
severe itching.
• Also called hives.
Non-allergic urticaria
– Mechanisms other than allergenantibody interactions are known to
cause histamine release from mast cells.
For instance, a diverse group of
signaling substances called
neuropeptides have been found to be
involved in emotionally induced urticaria.
Urticaria
Urticaria
• An acute or chronic condition
characterized by the appearance of
itchy weals on the skin.
• The cause may be an allergy to certain
foods , drugs, emotional stress, or
local skin irritation resulting from
contact with certain plants.
• Athletes sometimes develop hives
while exercising (exercise-induced
urticaria). The hives are small and
seem to develop in response to the
release of histamines associated with
the increase in body temperature
produced by exercise.
Urticaria
Treatment & Management
• Most treatment plans for urticaria involve
being aware of one's triggers.
• If one's triggers can be identified then
outbreaks can often be managed by
limiting one's exposure to these situations.
Drug treatment
• Typically in the form of Antihistamines such as
diphenhydramine, hydroxyzine, cetirizine and other H1
receptor antagonists. These are taken on a regular basis to
protective effect, lessening or halting attacks.
• For some people, H2-receptor antagonists such as
cimetidine (Tagamet) and ranitidine (Zantac) can also help
control symptoms either protectively or by lessening
symptoms when an attack occurs.
• When taken in combination with a H1 antagonist it has been
shown to have a synergistic effect which is more effective
than either treatment alone.
Psoriasis
• Pathophysiology and Etiology
– Likely genetic predisposition
– Keratinocytes; plaque
• Assessment Findings
– Erythema with silvery scales; lesions
– Visual examination; skin biopsy
• Medical Management
– Symptomatic treatment
– Drug therapy; biologic therapy
(immunotherapy - interferon)
– Photochemotherapy (fiberoptic probe)
Psoriasis
• Named for the Greek word psōra
meaning "itch," psoriasis is a chronic,
non-contagious disease characterized
by inflamed lesions covered with
silvery-white scabs of dead skin.
Psoriasis
Psoriasis
Pathophysiology
• Normal skin cells mature and replace dead
skin every 28–30 days.
• Psoriasis causes skin cells to mature in less
than a week.
• Because the body can't shed old skin as
rapidly as new cells are rising to the
surface, raised patches of dead skin
develop on the arms, back, chest, elbows,
legs, nails, folds between the buttocks,
and scalp.
• Psoriasis is considered mild if it
affects less than 5% of the surface
of the body; moderate, if 5–30% of
the skin is involved, and severe, if
the disease affects more than 30%
of the body surface.
Nursing Process:
The Client With Psoriasis
• Assessment
– Skin integrity; appearance
– Family history of psoriasis
– Triggering factors
• Diagnosis, Planning, and Interventions
– Impaired skin integrity
– Disturbed body image
Nursing Process:
The Client With Psoriasis
• Evaluation of Expected Outcomes
– Improved integrity and appearance of
skin
– Reduced itching; copes effectively with
altered appearance
Seborrheic Keratosis
A superficial, benign, verrucose
lesion consisting of proliferating
epidermal cells enclosing horn cysts,
usually appearing on the face, trunk,
or extremities in adulthood.
Seborrheic Keratosis
Sign And Symptoms
• The growths resemble flattened
or raised warts, but have no viral
origins and may exhibit a variety
of colors, from pink or yellow
through brown and black.
• Because only the top layers of
the epidermis are involved,
seborrheic keratoses are often
described as having a "pasted-on"
appearance.
Etiology
• A mutation of a gene coding for a
growth factor receptor (FGFR3), has
been associated with seborrheic
keratosis.
Treatment
• Because the tumors are rarely painful,
treatment is not often necessary.
• If a growth becomes excessively itchy, or
if it is irritated by clothing or jewelry,
cryosurgery has been found to be highly
effective in their removal.
• With resemblance to malignant melanomas,
which has sometimes led to a misdiagnosis
of the cancerous lesions. If there is any
doubt, a skin biopsy will allow a physician
to make a correct diagnosis.
Scleroderma
• Scleroderma is a progressive disease
that affects the skin and connective
tissue (including cartilage, bone, fat, and
the tissue that supports the nerves and
blood vessels throughout the body).
• There are two major forms of the
disorder. Localized scleroderma mainly
affects the skin. Systemic scleroderma,
which is also called systemic sclerosis,
affects the smaller blood vessels and
internal organs of the body.
SCLERODERMA
Scleroderma
• Is an autoimmune disorder, which means
that the body's immune system turns
against itself. In scleroderma, there is an
overproduction of abnormal collagen (a
type of protein fiber present in connective
tissue). This collagen accumulates
throughout the body, causing hardening
(sclerosis), scarring (fibrosis), and other
damage.
Therapy
• There is no cure for every patient with
scleroderma, though there is treatment for some
of the symptoms, including drugs that soften the
skin and reduce inflammation. Some patients may
benefit from exposure to heat.
• A range of NSAIDs (nonsteroidal antiinflammatory drugs) can be used to ease
symptoms, such as naproxen. If there is
esophageal dysmotility .Care must be taken with
NSAIDs as they are gastric irritants, and so a
proton pump inhibitor (PPI) such as omeprazole
can be given in conjunction.
Treatment
• Immunosuppressant drugs, such
as mycophenolate mofetil
(Cellcept®) or cyclophosphamide
are sometimes used to slow the
progress.
• Digital ulcerations and pulmonary
hypertension can be helped by
prostacyclin (iloprost) infusion.
Iloprost increases blood flow by
relaxing the arterial wall.
Sytemic Lupus
Erythematous
• Lupus is a condition characterized by
chronic inflammation of body tissues
caused by autoimmune disease.
• Autoimmune diseases are illnesses
that occur when the body's tissues
are attacked by its own immune
system.
SLE - NECK
Etiology
• The precise reason for the abnormal
autoimmunity that causes lupus is not
known.
• Inherited genes, viruses, ultraviolet
light, and drugs may all play some
role.
What is drug-induced
lupus?
• Dozens of medications have been reported to
trigger SLE; however, more than 90% of this
"drug-induced lupus" occurs as a side effect of
one of the following six drugs: hydralazine (used
for high blood pressure), quinidine and
procainamide (used for abnormal heart rhythm),
phenytoin (used for epilepsy), isoniazid ( used for
tuberculosis), d-penicillamine (used for
rheumatoid arthritis). These drugs are known to
stimulate the immune system and cause SLE.
The 11 criteria used for diagnosing systemic
lupus erythematosus are:
• Molar (over the cheeks of the face) "butterfly" rash
• Discoid skin rash: patchy redness that can cause scarring
• Photosensitivity: skin rash in reaction to sunlight exposure
• Mucus membrane ulcers: ulcers of the lining of the mouth, nose
or throat
• Arthritis: two or more swollen, tender joints of the extremities
• Pleuritis/pericarditis: inflammation of the lining tissue around
the Heart or lungs, usually associated with chest pain with
breathing
• Kidney abnormalities: abnormal amounts of urine protein or
clumps of cellular elements called casts
• Brain irritation: manifested by seizures (convulsions) and/or
psychosis
• Blood count abnormalities: low counts of white or red blood
cells, or platelets
• Immunologic disorder: abnormal immune tests include antiDNA or anti-Sm (Smith) antibodies, falsely positive blood
test for syphilis, anticardiolipin antibodies, lupus
anticoagulant, or positive LE prep test
• Antinuclear antibody: positive ANA antibody testing
Treatment
• There is no permanent cure for SLE.
• The goal of treatment is to relieve symptoms and
protect organs by decreasing inflammation and/or
the level of autoimmune activity in the body.
• Many patients with mild symptoms may need no
treatment or only intermittent courses of anti inflammatory medications.
• Damage to internal organ(s) may require high
doses of corticosteroids in combination with
other medications that suppress the body's
immune system.
Heat and Cold Applications
Heat Application
• Heat – causes vasodilation which increases
blood flow to the area where heat was
applied.
• Heat – increases the amount of oxygen,
nutrients, and white blood cells delivered
to body tissues.
• Heat - also aids in removal of waste
products from injured tissues.
Purposes of Heat
Application
• Relieves local pain, stiffness or aching,
particularly of muscle and joints
• Assists in wound healing
• Reduces inflammation
• Makes the chilly client more comfortable
• Raise the body temperature
• Promotes drainage
Nursing Care Guidelines:
Heat Therapy
• Heat application should be ordered by MD
• Specific body parts such as the eyelids,
neck, and inside the arm are especially
sensitive to heat.
• Infants and older people have less heat
resistance.
• Client complaints are very important.
Listen to the client.
Cold Application
• Indirect application of ice or a cold compress is often the
first line of treatment for an acute sports injury.
• The low temperature decreases the metabolic rate of
injured tissue and constricts blood vessels.
• Since most internal bleeding occurs a few minutes after an
injury, immediate application of ice for about 10 minutes
reduces bruising and swelling.
• The low temperature also stops muscle spasms and deadens
pain receptors in the injured tissue.
• The pain killing effect of ice is sometimes too effective. A
victim who feels no pain may return to activity prematurely
and exacerbate the injury.
Approximate Range of Temperatures for Hot
& Cold Applications
•
•
•
•
•
Hot
Warm
Tepid
Cool
Cold
37.7 – 40.5 °C
35 - 37.7 °C
26.6 – 35 °C
18.3 – 26.6 °C
10 - 18.3 °C
100-105 °F
95 – 100 °F
80 – 95 °F
65 – 80 °F
50 – 65 °F
» To convert F to C = ( F-32) x 5/9
» To convert C to F = (C x9/5) x 32