HS Case Study 1
Running head: INTEGUMENARY DYSFUNCTION
Case Study: Integumentary Dysfunction
Lisa Sheriff, RN
Midwestern State University
HS Case Study 2
Introduction
Family Nurse Practitioners are exposed to a variety of clinical scenarios with many being
concerns of the integumentary system. The integumentary system is the largest organ in the body
and has vital functions in sustaining life. The skin is a physical barrier against trauma and a
window into our sense of identity. To demonstrate a connection with expected normal anatomy
and physiology of the integumentary system with one type of dysfunction, a brief review and a
case study is presented.
Normal Anatomy and Physiology
The integumentary system consists of the skin and dermal appendages including nails,
hair, sebaceous glands and sweat glands. One centimeter of skin contains three yards of blood
vessels, four yards of nerves, ten hair follicles, 15 sebaceous glands, 100 sweat glands, 3,000
sensory cells, and 300,000 epidermal cells (Bryant, 2000). This organ functions as a first line of
immunity, allows for excretion of waste, synthesizes vitamins and hormones, regulates body
temperature and prevents water and extracellular fluid loss, retrieved 9/17/06 from
www.emc.maricopa.edu.
Skin is composed of three layers, the epidermis being the outer layer, the dermis, and the
hypodermis. See Appendix A for diagram. The epidermis is primarily keratinized stratified
squamous epithelium. Other cells in this layer include melanocytes that synthesize and excrete
melanin in response to sun exposure, Langerhan cells which initiate immune response with
exposure to environmental antigens, and Merkel cells associated with touch receptors. The
epidermis is five progressive layers of cells differentiation. These layers include the stratum
corneum, stratum luciderm, stratum granulosum, stratum spinosum and stratum basalis (Bryant,
2000).
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An epidermal-dermal junction separates the epidermis from the dermis with Rete ridges.
The dermis layer is the thickest layer and supplies nutrients for the epidermal layer. This layer is
where hair follicles, sebaceous glands, sweat glands, blood vessels, and lymph vessels are found.
Fibroblasts secrete the connective tissue matrix giving the skin its tensile strength and elastin
abilities. Mast cells release histamine in response to antigens, machrophages assist in immunity
through phagocytosis, and endothelial cells line the blood vessels (Bryant, 2000).
Hair follicles and sebaceous glands are integrated units and are cyclic with periods of
growth and rest over different body structures. Sebaceous glands secrete sebum to lubricate the
skin and contribute to its ph. Growth is dependent on testosterone. Sweat glands include both the
aprocrine located at the axillae, scalp, abdomen, and genital region and the eccrine at the soles of
the feet, palms of hands and forehead (McCance and Huether, 2006).
The hypodermis attaches the dermis to underlying structures and provides insulation and
cushion. This layer contains fibroblasts, machrophages and adipose tissue.
Case Study
A 55-year-old African American female, V. C., presents to the Family Nurse Practitioner
with a chief complaint of “hard bumps at her vagina.” She states, “I have some bumps that come
up and hurt terribly around my pubic hairs.”
Subjective Data
Integumentary dysfunctions require a detailed health history along with identification of
the lesions for accurate diagnosis (McCance and Huether, 2006). The patient is asked about
chronology of the “bumps”. V.C. states she has had these areas come and go since she started
having menstrual cycles at 14 years-old and seem to be worse in the summer. She tends to
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notice them at her underarms, groin, and breasts without being noticeably more on one side than
the other. She remembers the first one started at her underarm.
V. C. has pain that is slightly relieved when in the bathtub or running the shower water
over the sites. The pain is easy to pinpoint and is at a level four on a zero-to-ten scale. The pain
increases to a six with light palpation. She has been using over-the-counter Tylenol and takes
Ultram when needed.
She has not been diagnosed with any dermatological conditions in her past and denies
ever telling a healthcare provided of the condition. She states they are embarrassing and smell
bad. She denies lymphangitis. She complains of foul smelling drainage at the bump sites after a
couple of weeks and then the sites seem to resolve.
She is morbidly obese, diabetic for at least five years and smokes about a pack of
cigarettes a day and does not feel like she can stop. She is not currently working. Her children
are grown and have families of their own. She takes care of her grandchildren when she is able.
Objective Data
Physical exam reveals an overall intact integumentary system with exceptions at the
axilla and in the folds of the genital region. There are five areas of raised hardened boils. She is
not febrile and denies having been recently. One site at the axillae has come to a head and has an
obvious malodorous purulent yellow discharge with light palpation. Multiple sites of keloid
formation are present bilaterally in areas of aprocrine glands.
Pathophysiology of Presented Dysfunction
V.C. is suffering from a chronic condition known as Hidradenitis Supprativa (HS).
Jamec (2004) states the following:
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The clinical presentation of the disease is characteristic and allows simple diagnosis. See
Appendix B for typical physical presentation of condition.
Hidradentitis Supprativa is a “disease of the hair follicle of the inverse areas of the body,
predominantly the axillae and genitofemoral areas. The pathogenesis is thought to
involve inflammation of diseased follicles and subsequent formation of draining sinus
tracts which from the histological main feature of the disease. It has been suggested that
specific cells are recruited from the hair follicle epithelium to form sinus tracts following
inflammation. ( p. 1767)
It is thought that the aprocrine gland may not have completely developed and when the
follicle is occluded, the aprocrine gland is occluded leading to perifolliculitis. It is therefore
considered a disorder of the terminal follicular epithelium located in the aprocrine gland,
retrieved September 17, 2000 from http://www.emedicine.com/emerg/topic259.htm.
Caring Holistically
V.C. should be educated that this condition is not related to poor hygiene and while it
may not be cured, there are treatment options available. She can decrease the severity and
frequency of occurrences by not smoking, weight reduction, not shaving in areas of concern, and
ensuring clothing is not tight fitting. She should use antibacterial soap to keep the areas clean
and dry. An antibiotic may be prescribed and should be completed as directed. Application of a
warm wash cloth to the areas is encouraged 3-5 times a day. Once the areas form a head and
begin to drain, they will resolve. If the sites become too painful to tolerate, the areas may be
incised and drained. Individual lesions generally resolve in 10-30 days, retrieved September 17,
2000 from http://www.emedicine.com/emerg/topic259.htm.
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Provide V.C. with information on her condition. HS has three stages. The primary stage
is when the non-inflamed boil appears. Secondary stage includes the formation of sinus tracts
with scaring that may link individual lesions. And tertiary, inflammation and discharge appear.
If left untreated, HS can lead to the development of squamous cell carcinoma. Retrieved
September 17, 2006 from http://en.wikipedia.org/wiki/Hidradenitis_suppurativa.
The incidence rate is not well known, but has been estimated as being between 1:24
(4.1%) and 1:600 (0.2%), retrieved September 17, 2006 from
http://en.wikipedia.org/wiki/Hidradenitis_suppurativa. The condition tends to occur more in
females than males and more often in African Americans. It is possibly due to the tightly curled
hair predisposing the person to ingrown hairs, retrieved September 17, 2000 from
http://www.emedicine.com/emerg/topic259.htm.
While thought to be a rare condition, it was chosen to be presented because of the three
encounters the student has witnessed in the past year. The condition has a profound effect on
the patient’s daily life. It is crucial that we as Family Nurse Practitioner assure the patient that
they are not to blame and offer hope that they can live a productive life with HS.
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References
American Osteopathic College of Dermatology. (n.d.). Dermatologic Disease Database.
Retrieved September 17, 2006 from Web site:
http://www.aocd.org/skin/dermatologic_diseases/hidradenitis_suppu.html
Bryan, R. (2000). Acute & Chronic Wounds: Nursing Management. Saint Louis: C.V. Mosby.
Estrella Mountain Community College. (n.d.). Retrieved September 17, 2006 from
ttp://www.emc.maricopa.edu/
Fite, D. (2006, May 22). Hidradenitis Supprativa. Retrieved September 17, 2000 from
E Medicine Web site: http://www.emedicine.com/emerg/topic259.htm
Hidradenitis Suppurativa. (n.d.). Retrieved 9/17/06 from the Wikipedia Web site:
http://en.wikipedia.org/wiki/Hidradenitis_suppurativa
McCance, K. & Huether, S. (2006). Pathophysiology: The Biological Basis for Disease in Adults
and Children. Saint Louis: C.V. Mosby.
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Appendix A
Diagram of layers of human skin
Retrieved from http://en.wikipedia.org/wiki/Image:Skin.jpg
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Appendix B
Retrieved September 17, 2006 from
http://www.aocd.org/skin/dermatologic_diseases/hidradenitis_suppu.html