SKIN DISEASES AND DISORDERS
S TRUCTURE AND F UNCTION OF S KIN
Largest organ of the body
In adult, equals 16% of total body weight
Normal function is to separate the internal environment from the external environmental skin diseases
and infection
E PIDERMIS
Surface of the skin
Made of epithelial cells
Renewed every 15-30 days
Thickness varies with your age, sex, and location on the body of the skin
Consists of many layers
Contains Melanin (shield to protect from UV light) and Keratin (water-repellant protection)
D ERMIS
Deeper layer of skin
Has connective tissue, blood vessels, nerve endings, hair follicles, sweat and oil glands
S KIN C OLOR
Melanin- yellow to brown pigment- located in the epidermis. People with more melanin have darker
pigmented skin.
Carotene- yellow or orange pigment- abundant in Asians and babies with jaundice.
Influenced by:
Erythema
Cyanosis
Pallor
Jaundice
S KIN T EXTURE
How soft, hard, scaly, cracked, dry…..the skin appears
Norms: smooth and firm
Depends mostly on touch
H AIR AND N AILS
Located in the dermis layer
Composed of dead cells
Provide protective functions
Growth is influenced by hormones and nutrition
D RYNESS /M OISTURE
Changes in seasons can affect moisture level of skin
Wind
Heat
Cold
Dryness
Dampness
S KIN D ISEASE /D ISORDER F ACTS
1 in every 3 people in US suffer from a skin disease
The prevalence of skin disease exceeds that of obesity, HTN , or cancer
Has medical, financial and emotional toll on patients.
May not seek medical help b/c they don’t feel like needs treatment or can’t afford treatment. Will most
likely be long term treatment. Can cause emotional embarrassment.
S KIN L ESIONS
Primary lesions
Variation of color present at birth
Acne
Allergic reactions
Environmental agents such as sunburn
Secondary Lesions
Change in tone of skin resulting from primary lesion
Scratching causing further injury
Keloid- exaggerated connective tissue response of injured skin (thick and raised scar)
A SSESSMENT AND S KIN L ESIONS
Color- norm= tan/brown suspicious= mixtures of colors
Palpation- mobility, tenderness, depth
Shape- norm= round, suspicious= uneven
Arrangement- grouped or disseminated
Emotional reaction
T HERAPEUTIC B ATHS
Somewhat like a whirlpool
Soothe, decrease bacteria count, clean, hydrate, loosen scales, and relieve itching of skin
If they are completely submerged, need to have a mat so they won’t fall. Medications can make it
slippery
20-30 minutes is good time frame
Temperature 110-115 degrees
Try to avoid getting water into the eyes due to meds.
Blot the skin to dry, do not rub- could cause damage to the skin
P HARMACOLOGICAL A GENTS
Topical agents- creams, oils, lotions, shampoos……have localized effect (must wear gloves)
Systemic agents- reserved for moderate to severe cases. Most can only be used for limited time.
Examples: antihistamines, prostaglandins (anti-itch mediators), antimicrobials (antibacterial and
antifungal), corticosteroids (decreases inflammation)
E MOTIONAL C ONSIDERATIONS
Watch your face- don’t show your emotions
Many skin conditions are painful
Embarrassing
Annoying- can be life-long and can go to remission and can then flare up again
Debilitating
D ECUBITIS U LCERS
“pressure ulcer” or “bed sore”
Ischemic lesions of the skin and underlying tissue
Common locations: bony prominence (heels, greater trochanter, sacrum) and any area that is subjected to
external pressure, friction, or shearing forces
Contributing factors:
Being left in a position for an extended period time (turn or reposition every 2 hours)
Pressure on a tissue between a bony prominence and the external surface distorts capillaries and
impeded blood flow.
Causes platelets to clump and causes microthrombi
Micro thrombi impede blood flow causing ischemia and hypoxia
Hypoxia then causes necrosis of the tissue
Staging:
1. Stage 1: nonblanchable erythema of intact skin
2. Stage 2:Partial thickness skin loss involving epidermis and/or dermis. Abrasion, blister or shallow
crater
3. Stage 3: full thickness skin loss involving subcutaneous tissue
4. Stage 4: full thickness skin loss with extensive destruction
Prevention:
1. Positioning: turn at least every 2 hours and document! Allows adequate blood flow to tissues.
2. Massage: promotes blood flow to the tissues
3.
4.
5.
Clean, dry, unwrinkled bed: waste can cause chemical irritation *moisture can damage skin
(urine, perspiration, wound drainage)
Therapeutic bed covers, mattresses, and beds
Sheep skin
Egg crate
Air mattresses
Specialty beds
Pharmacological agents:
Skin Prep
Granulex
Proteolytic enzymes
B ACTERIAL S KIN I NFECTIONS
FOLLICULATE, FURUNCLES, CARBUNCLES, FELONS------IMPETIGO
Folliculitis
Inflammation of hair follicle
Small white headed pimple
Common on face, scalp, thighs, legs, and groin area
Usually occurs after hair follicle is damaged by friction or shaving
This damage makes follicle more susceptible to infection
Usually staphylococcus aureus
Treatment: warm compress and antibacterial ointments
Furuncles
“boil”
Collection of pus that presents as painful fluid-filled lump or hard nodule
Common areas: buttocks, groin, face, armpits and near waistline (friction areas)
Caused by staphylococcus aureus
Start as red pimple, then turn into fluid-filled bump
Treatment: warm compress (need to open and drain) topical bactroban or oral antibiotics
Carbuncles
When furuncles spread and form multiple tunnels
Collection of connecting furuncles
If become uncontrolled may lead to severe infection, sepsis, and possible death
Prevention: hygiene, hand washing with antibacterial soap, and do not “pop” them
Felons
“fingertip infection”
Infection in top portions of fingers, in the pad of skin above the first joint
Usually the thumb or index finger (fingernail bed)
Staph aureus
Causes: bacterial or viral infection that enters skin by wound
Treatment: MD examine/ if abscessed- incision and drainage/soak fingers 3-5 times a day,
antibiotics, 1-2 weeks to heal
Impetigo
Common, contagious, superficial skin infection
Highly contagious in children
Streptococcus and staph aureus
Starts on face and around mouth. Lesions have pus and form curst. Easily spread to other parts
of body by pus
May itch, not typically painful
Treatment: topical antibiotic ointment, isolation
Associated with kidney failure/problems
F UNGAL I NFECTIONS
TINEA CORPORIS AND TINIA CAPITIS (SCALP)
Fungus causes a characteristic lesion with clear center and a rough, scaly, circular border
Causes: contagious/spread through infected pets or through direct contact with infected individual
Treatment: antifungal meds (topical 1st), unsuccessful then PO
Treat the source (infected pet)
Capitis is common in children, can cause scaling and bald patches. No sharing hats, combs, brushes.
ATHLETE’S FOOT
Tinea Pedis
Fungus can be found on floors, socks, and clothing
Thrives on moist, warm skin (feet)
When the skin is injured by the fungus, bacteria can invade and cause cellulitis
Symptoms: itching, burning feet, skin may peel, crack and bleed
Treatment: need to make the area less suitable for growth and antifungal meds
I NFLAMMATORY S KIN I NFECTIONS
DERMATITIS
Nonspecific irritation of the skin
Cause: bacteria, fungus, parasite, or foreign substances such as detergents, perfumes, certain materials
Contact dermatitis- allergic reaction to substance that comes in contact with skin (soap)
Atopic Dermatitis- “eczema” chronic, itching inflammation
Stasis Dermatitis- “eczema” of legs” caused by poor circulation
Chronic dermatitis can cause thickening, change in pigmentation, and scaling
Acute dermatitis presents as red, itching area of blisters and oozing
Treatment: removal of offending substance and corticosteroid ointments
PSORIASIS
Chronic and non-infectious
Patches of raised, reddish skin covered by silvery-white scale. Skin usually looks very thick with different
texture.
Elbow, knees, back and scalp, but can be anywhere on the body
May itch, scratch, and bleed
No cure- have flare up and remission
May develop “psoriatic arthritis”- causing inflammation of joints
Treatments: topical-mild, phototherapy- mild to mod, systemic (orally or inject) mod-severe
Incidence: 4.5 million adults in the US
150,000 new cases each year
20% have moderate to severe cases
Equally distributed in males and females
Ethnic link: Caucasian
Usually starts between ages of 15-35 years old.
Predisposing factors: stress, skin injury, strep infections, and weather will all trigger psoriasis
ECZEMA
General term encompassing various inflamed skin conditions, “atopic dermatitis”
Chronic, relapsing, itchy rash
Non contagious
No cure
10-20% of the world population is affected by eczema.
Usually appears during childhood- may clear or disappear with age
Dry, red, extremely itchy patches on skin
Chronic scratching leads to leathery skin
What makes them itch? Triggers include rough or coarse material, soaps, detergents, dander, stress…)
No known cause but associated with allergies
Have increased risk of allergic rhinitis and asthma
ECZEMA PREVENTION
Moisturize frequently
Avoid sudden temperature and/or humidity changes
Decrease stress
Avoid scratchy materials
Avoid harsh soaps and detergents
Avoid environmental triggers
Prevention: does not need to bathe everyday or use too hot water
If has eczema need to look to respiratory systems due to link with asthma and allergies
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Chronic inflammation caused by autoimmune disease (pg. 1065)`
Body produces abnormal antibodies in their blood that target tissues within their own body rather than
foreign infectious agents.
Internal organs are involved
Can affect skin, heart, lungs, kidneys, joints, and nervous system
More women than men (worse prior to menstrual period) female hormone link
Usually 20-45 years old when diagnosed
Ethnic link: more African American and Asians
Causes: genetic link, viruses, drugs that stimulate immune system, UV light exposure)
Complain of fatigue, aches and pains, arthritis, may have low grade fever, Reynaud’s phenomenon
(change in the coloration of the fingers, will be cold and numb with stress, and become pink, purple, or
pale)
Have low blood clotting factors so they have a high risk of excessive bleeding
Butterfly rash on the face
Fingers become white due to lack of blood flow, then blue as vessels dilate to keep blood in tissues, finally red as
blood flow returns (Reynaud’s syndrome)
Treatment: no permanent cure the goal is to relieve symptoms and protect organs by decreasing
inflammation and/or the level of autoimmune activity in the body
Mild- Intermittent anti-inflammatory meds
Severe- corticosteroids
Increase rest during active disease
May use NSAIDS for pain (ibuprofen, Motrin) anti-inflammatory
ACNE VULGARIS
“common acne”
Inflammatory condition of sebaceous glands of skin.
Results from excessive stimulus of the skin by androgens (hormones).
Red, elevated areas on the skin that may develop into pustules and even further into cysts that can cause
scarring
Common in teenagers because of the hormonal factor
ACNE TREATMENT
Dietary: no support for chocolate or iodine in diet in clinical research
Topical: (mild cases) astringent lotions, oil-removing pads, acne soaps, clean skin often to decrease the
bacterial count
Oral: (severe) oral antibiotics
Accutane: form of Vitamin A that decreases the amount of sebum (oil) released by the sebaceous glands.
Avoid Accutane if pregnant or could become pregnant for 1 month after taking because it can cause
severe birth defects. They need to avoid sunlight.
V IRAL S KIN I NFECTIONS
HERPES SIMPLEX
“Fever Blister” or “Cold Sore”
Caused by 2 types of Herpes viruses: HSV1 and HSV2
Transmission is by direct contact with lesions
Lives in nerve ganglia, triggered by sunlight, menstruation, injury or stress
S/S: burning, tingling, erythema, vesicle formation, pain
Vesicles-pustules-ulcers-crusting
Healing time is 10-14 days for the exterior portion and then grows dormant
May cause systemic reactions such as fever and sore throat
HERPES ZOSTER
“shingles”
Caused by varicella zoster (same herpes virus that causes chicken pox)
Decreased immune system makes you more susceptible to Herpes Zoster
After infected with chicken pox, the varicella virus remains dormant in the sensory dorsal ganglia. Years
after the initial chicken pox infections, the virus become inactivated.
Childhood chicken pox- dormant to sensory dorsal ganglia along sensory nerve fibers, reactivated and
travels from ganglia via sensory nerves to corresponding skin dermatone area.
Begins as papules and then develops into vesicles with erythematous base unilaterally on face, trunk,
and/or thorax. Stay for 3-5 days and then erupt, crust, and dry.
Recovery takes 2-3 weeks
Pain is associated with lesion eruption and it may stay after the lesion is gone because nerve ganglia had
been exposed
Treatment: Acyclovir or Famvir (antiviral agents) topical, oral, Parenteral. Pain=over-the-counter antiinflammatory or prescription pain meds.
Infectious until lesions dry and decreased risk if never had varicella
N ON -M ALIGNANT S KIN D ISORDERS
NEVUS
“moles”
Benign (not cancerous) overgrowth of skin pigment forming cells called melanocytes on the skins surface
Present at birth (congenital) or appearing early in life (acquired)
Check any changes in the skin. Use the ABCD rule.
ABCD RULE
A.
B.
C.
D.
Asymmetry; one-half of the nevus does not match the other half
Border Irregularity (edges are ragged, blurred, or notched)
Color variation or dark black color
Diameter greater than 5 mm ( size of a pencil eraser)
SKIN INSPECTION INTERVENTION
Assess ABCD
Look for any parallel growth around surgical incision
Vertical growth- determine metastasis and treat accordingly
WARTS
“verrucae”
Caused by the human papilloma virus (HPV)
Can affect the skin or the mucous membranes
Most warts in the non-genital area are benign, but most genital warts are precancerous
Transmitted by skin contact
3 most common types
I.
Common wart: skin/mucous membranes and grows above skin surface
II.
Plantar wart: on feet- extend deep into skin- painful
III.
Condylomata Acuminata: (venereal wart) moist areas, cauliflower-like appearance- pink purple
color.
WART TREATMENT
Skin:
salicylic acid “Compound W”
Liquid nitrogen- freezes the wart off
Burning the wart off
Genital
Liquid nitrogen
Chemical treatment
Laser surgery
Interferon injections to the site
M ALIGNANT T UMORS OF THE S KIN
1) Basal Cell Carcinomas:
most common form,
any area that has constant sun exposure,
does require treatment,
stay out of the sun,
slow-growing and rarely metastasize
2) Squamous cell carcinomas:
Develop in the middle layer of epidermis
Can spread
Life threatening if not treated
3) Malignant Melanoma:
Abnormal growth of melanocytes
Most aggressive cancer with faster growth rate
Much greater potential for metastasis if untreated
Fair skin at most risk
S KIN I NFESTATIONS
PEDICULI
“lice”
Parasite that live on blood of animal or human host
“louse” living parasite
“nit” is the un-hatched egg laid by female louse on hair shaft. Pearl-gray or brown color.
Not sharing clothes, hats, coats, hair accessories, especially with children
SCABIES
“itch mite”
Between fingers, inner surface of wrist, elbows, and belt line
Small red-brown burrows- 2mm in length
Puritis- always present especially at night
Highly contagious- wear gloves with care to clients
3 TYPES OF LICE
i.
ii.
iii.
Pediculosis Corporis: body lice
*live on clothing and bed linens
*bites cause macule and itching
Pediculosis Capitis: Head lice
*Common behind ears, nape of the neck
*transmitted by contact (hat, comb, coat)
Pediculosis Pubis: pubic Lice
*spread through sexual activity or contact with infested clothing or linens
*skin irritation and itching
LICE TREATMENT
RID: Over-the-counter
Pesticide in the form of a shampoo/gel/home spray
Safe
Lindane: prescription
Pesticide
Potentially neurotoxic
Not recommended for 1st line treatment
B URNS
STATISTICS
2.5 million per year
35% are children (newborn-4 years old kitchen/bathroom)(5-7 years old outdoors/kitchen)
Causes:
Heat (most common)
Electricity
Chemicals (caustic Chemicals)
Radiation (radioactive energy)
BURN CLASSIFICATION BY DEPTH
1.
2.
3.
First Degree: damage to outer layer of skin. Pain, redness, swelling (superficial)
Second Degree: “partial thickness: 1st layer (epidermis) burned all the way through and some level of
burning to dermis. Bright red skin, blistered, swollen, and moist- very painful!
Superficial partial thickness burn- involves the entire epidermis
Deep partial thickness burn- involves the entire dermis plus hair follicles, dermis is damaged
o *pink skin with blisters*
Extremely painful. May leave permanent scars
Treatment:
Do not break the blisters.
Don’t try to remove stuck clothing
Use cool running water for 5-10 minutes (no ice)
Elevate above the heart level
Keep clean to prevent infection (may cover with a clean sheet)
Depth and tissue damage- may need burn center care or wound management
Third Degree: “full thickness”- extends into hypodermis, causing destruction of the full thickness of skin
with its nerve supply (numbness). Leaves scars and may cause loss of function and/or sensation.
Will need hospital management
Will need to monitor for I&O, infection, pain, and respiratory problems
May not be painful- nerve endings are destroyed
Skin will be white, brown, black , or red with no blanching
Look at color of urine, may be dark red or ruby colored, this is caused by muscle breakdown. The
myoglobin is excreted through the urine.
Life threatening depending on % of body surface injured
`Will have to look at possible skin grafting. The skin will not regenerate when damaged down to
the hypodermis area. Monitor for signs and symptoms of rejection.
Graft site- burned area covered with skin graft
Will need dressing for 2-5 days
Donor site- unburned area that was removed to cover burned site, “skinned knee”
Dressing for 1-2 weeks
TYPES OF SKIN GRAFTS
Autograft: transplant of the client’s own tissue. This is the most successful. These are considered
“permanent grafts:. Immobilize area after grafted.
Xenograft- skin transplants from animal species to a human. Not very successful. Pig skin commonly used
for temporary coverage for a massive burn.
Homograft: fresh skin from a human cadaver- may be a precursor to an autograft.
INFECTION CONTROL AND BURNS
Infection control begins at admission and continues until grafting is complete
Use reverse isolation
Septicemia can occur at any time during hospitalization
CLASSIFICATION BY SEVERITY
Age: less than 4 or greater than 60 years, higher chance of complications and death from severe burns.
Infants: poor antibody response and fluid requirements can be very tricky
Older patients: may have underlying complications- cause exacerbations and complicate situation
THE RULE OF NINES
% of body surface burned
Each leg=18%
Each arm=9%
Front torso=18%
Back torsos=18%
Head=9%
Genital area=1%
*Not used in infants (larger head to body ratio)
*Not good with short, obese, or very thin individuals
*Don’t need to remember actual percentages
PARTS OF THE BODY AND BURNS
Head, neck and chest: risk of respiratory problems
Neck: prone to contractures
Perineum: very susceptible to infection
COMPLICATIONS AND BURNS
All burns result in complications
Common complications
Septicemia
Renal failure
Pneumonia
Heart failure/disease
PATHOPHYSIOLOGY AND BURNS
Immediate effect is destruction of protective skin area. This leads to disruption of homeostasis, diffusion
of vascular components into extra-vascular tissue, electrolyte imbalance, and diminished blood volume.
Can lead to multisystem trauma.
1st 24 hours: protect airway- airway edema leads stridor, hoarseness, wheezing (usually on inspiration),
and mental status change. Position for airway intubation and correct fluid loss.
FLUID SHIFTS
With exposure to heat, capillaries are damaged and become permeable to fluid. They let fluid leak out of
the capillaries and into the interstitial spaces resulting in edema and blister formation.
The resulting fluid shifts are directly proportional to the depth and extent of the burn.
Treatment- fluid therapy is going to be directly related to the severity of the burn.
Really watch intake and output
They will lose a lot of plasma through burn surface. Urine output is going to decrease drastically.
BURN SEVERITY
Severity is based on:
Size of the burn (expressed in % of total body area using Rule of Nine’s)
Depth of the burn
Past medical history
Part of the body that is burned
FLUID REPLACEMENT AND BURNS
Parkland Formula- 4mL X wt/kg X % burned
Use rule of nines for percent burned with no decimals
Physician will determine and nurse will check behind
If possible, give half the calculated amount over the first eight hours from the time of injury and the
remaining half over the next 16 hours.
CHILDREN AND REHYDRATION POST BURN
Dehydrate more rapidly than adults (increase ratio of body surface area to weight, increased metabolism,
and thinner skin)
Need more fluids than adults
Use formal and add 1,500 mL of LR per square meter of surface area, and adjust this based on urine
output monitored hourly
Keep child’s minimum hourly output at 1 mL/kg/hr
FLUID OVERLOAD
Edema, dyspnea, neck vein distension, ascites, weight gain
Must continually assess for these signs and symptoms
They may be weighed twice a day
1ST 48 HOURS
Monitor for shock (<BP, >HR, pale, clammy skin, blue lips,…), monitor electrolyte and protein loss (caused
by volume shifts from intravascular to extra vascular compartment secondary to > in capillary
permeability)
Any partial thickness burn over 9% can cause shock. Immediate < in BP treat for shock.
Prevent shock with LR and Albumin
48-72 hours: eschar (scabbing over the burned area) forms- initially is sterile, in absence of topical
antimicrobial, bacteria will colonize. Primary source of bacterial infections secondary to burns is the
intestinal tract, whether from vomitus, diarrhea, etc.
Should not have anything PO for first 48 hours due to N/V. After 48 hours and free from respiratory
problems and shock, then can give small amounts of fluids (1-2 ounces an hour). If unable to tolerate, will
switch back to NPO.
TOPICAL ANTIMICROBIALS AND BURNS
Goal is to reduce bacterial count, not to sterilize
Sulfamylon Acetate- broad bacteriostatic action against many gram negative and gram positive organisms
(pseudomonas). Easy to apply, but tends to be painful with application b/c it burns. Must pre-medicate
with use.
May cause acid-base imbalances and should not be used on large areas of the body- use on ears
and nose
Silver Nitrate- Liquid, used to kill antibiotic resistant strains of bacteria. Not used much anymore. Cover
with moist dressing. If allowed to dry out, further burns site! Turns everything brown.
Silvadene- (topical crème) antibacterial/antifungal- wear sterile gloves and use sterile technique- easy to
use and painless. Do not use if allergic to septra.
Betadine: broad spectrum antiseptic- used for > 30 years. To prevent and treat wound infections. Active
agent providone iodine (prevents infection and does not harm wound).
Neosporin and Bacitracin- used commonly on 1st degree facial wounds. Antimicrobial effects.
WOUND CARE
Exposure- “open method” – mainly used with 1st degree burns. Not used much for advanced burns- dries
out surface, and impeded delivery of nutrients to skin cells.
Use an occlusive dressing: works by excluding atmospheric oxygen while promoting growth of new blood
vessels.
Advantages: Decreased dressing changes and decreased cost
Disadvantages: adhere to skin- pain, and can’t control wound discharge and odor
Wet Dressing: prevents scab formation, and debrides wound. Needs to be sterile
Hydrotherapy- dilates blood vessels, removes wastes from body tissues. May do mechanical debridement
during hydrotherapy. Do not use for more than 30 minutes to prevent metabolic stress and to keep the
client from getting cold.
CLIENT MANAGEMENT AND BURNS
Pain Management: NSAIDS- minor burns. Morphine for more advanced burns. IV preferred (SQ, IM not
well absorbed) Pre-medicate before dressing changes. May be on a morphine drip or PCA. (Make sure
that respirations are at least 12 before administering morphine)
Nutrition: high calorie (metabolic rate triples), high protein (wound-healing) not including high fat.
Vitamin C assists in collagen formation.
Environment: temperature should be greater than 84 degrees, air currents will cause tremendous pain.
Positioning: prevent contractures- change position frequently, don’t bend at joints for extended time,
encourage ROM, Supine- flat
Don’t use Fowler’s position which promotes contractures. Do not use knee gatch or pillows
Follow order with splints and exercise programs initiated by physical therapy.