SELECTED INTEGUMENTARY SYSTEM
DISEASES & CONDITIONS
Wound Infections
Wound Dehiscence & Evisceration
Pressure Ulcers
Arterial and Venous Ulcers
Skin Cancer
Skin Diseases
Lesions/Wounds
Rashes
Herpes Zoster/ Shingles
Part I
Trivia Question
 How many square feet of skin does the
average adult have?
Trivia Question
 How many square feet of skin does the
average adult have?
 Answer: ~ 18-20 square feet……
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5’
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x
4’
Integumentary Diseases
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 Learning Outcomes:
 1. Use proper terminology to describe different skin
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lesions and problems
2. Identify signs of wound infections
3. Describe the ABCD(E) method of assessing skin
cancer
4. Identify clients at risk for pressure ulcer development
5. Differentiate between the clinical manifestations for
Stage I through Stage IV pressure ulcers, and their
treatments.
6. Identify appropriate treatment for prevention of
pressure ulcers.
7. Compare the clinical manifestations and modes of
transmission for bacterial, viral, and fungal skin
infections.
8. Identify the difference between arterial ulcers and
insufficiency versus venous stasis ulcers.
Key Terminology
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angioma
carcinoma
cellulitis
dermatitis
atopic dermatitis
contact dermatitis
eczema
edema
ecchymosis
erythema
eschar
folliculitis
furuncles
granulation
hemangioma
hirsutism
hyperbaric oxygen (HBO)
keloid
lichenification
macule
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melanoma
nevus
nodule
papule
paronychia
petechiae
pressure ulcer
pruritis
psoriasis
purpura
pustule
vacuum assisted closure
(Wound Vac)
turgor
urticaria
vesicle
wheal
xerosis
Wound Infections
Wound Dehiscence &
Evisceration
Pressure Ulcers
Arterial and Venous
Ulcers
Skin Cancer
Skin Diseases
Skin Lesions / Wounds
Rashes
Herpes Zoster/
Shingles
Raised
Depressed
Flat /Macular
Surface Change
Fluid Filled
Purpura / Vascular
Configurations
papule
plaque
nodule
cyst
comedo
keloid
horn
wheal
atrophy
erosion
ulcer
sinus
striae
burrow
poikolderma
macule
patch
erythema
erythroderma
scale
crust
excoriation
eschar
lichenification
exfoliation
ichthyosiform
vesicle
bulla
pustule
abscess
furuncle
petechiae
purpura
ecchymosis
telangiectasia
linear
grouped
scattered
polycyclic
reticular
serpinginous
targetoid
whorled
arcuate
annular
“Beauty is Only Skin Deep…”
Raised
Depressed
Flat /Macular
Surface Change
Fluid Filled
Purpura / Vascular
Configurations
papule
plaque
nodule
cyst
comedo
keloid
horn
wheal
atrophy
erosion
ulcer
sinus
striae
burrow
poikolderma
macule
patch
erythema
erythroderma
scale
crust
excoriation
eschar
lichenification
exfoliation
ichthyosiform
vesicle
bulla
pustule
abscess
furuncle
petechiae
purpura
ecchymosis
telangiectasia
linear
grouped
scattered
polycyclic
reticular
serpinginous
targetoid
whorled
arcuate
annular
“Beauty is Only Skin Deep…”
“But UGLY goes down to the bone!”
Raised
Depressed
Flat /Macular
Surface Change
Fluid Filled
Purpura / Vascular
Configurations
papule
plaque
nodule
cyst
comedo
keloid
horn
wheal
atrophy
erosion
ulcer
sinus
striae
burrow
poikolderma
macule
patch
erythema
erythroderma
scale
crust
excoriation
eschar
lichenification
exfoliation
ichthyosiform
vesicle
bulla
pustule
abscess
furuncle
petechiae
purpura
ecchymosis
telangiectasia
linear
grouped
scattered
polycyclic
reticular
serpinginous
targetoid
whorled
arcuate
annular
“Skin Changes”
Associated Terminology
Integumentary Diseases
 Review of anatomy & physiology
Integumentary diseases
 Skin Function:
 Skin, hair, and nails are external structures
 Serve a variety of specialized functions
 Sebaceous and sweat glands cool and lubricate
the body and get rid of wastes
 The skin, hair, and nails have many vital
functions, but the most important is protection.
 Once the skin has been pierced or damaged the
body is much more susceptible to infection, even
from organisms which would not normally be
pathogenic, e.g., staphylococci.
Integumentary diseases
 Wound Infections & Risks
 Risks for infection include any pathophysiological
states which cause diminished circulation, poor
immune response, or delayed repair of tissues These
include:
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Radiation or trauma
Poor circulation
Immunosuppression, drug induced or disease induced
Impaired oxygenation
Nutritional deficiencies
Coagulation disorders
Immobility
Diabetes, lupus, and other immunodeficiencies
Integumentary diseases
 Etiology:
THINK – WHAT IS CAUSING THIS?
And you might learn how to prevent it
 For example – If the patient is immobile and
starting to break down because they cannot
move, how do we prevent the skin from
breaking down?
 If the patient has an immunodeficiency, how
do we prevent skin breakdown?
 If the patient has a nutritional deficiency, how
do we promote wound healing?
Diagnostic Procedures and
Nursing Interventions
 Wound Culture and Sensitivity (swab cultures
and/or wound biopsies):
 Definitively identify and quantify wound
bacteria.
 Complete Blood Count (CBC) with Differential:
Assess immune response.
 Blood Cultures: Rule out sepsis.
 Serum Albumin (normal > 3.5 g/dL) and
Prealbumin (normal 17 to 40 mg/dL):
 Assess nutritional status (low levels indicate
malnutrition).
Therapeutic Procedures and
Nursing Interventions
 Vacuum-assisted Wound Closure (Wound-Vac) –
continuous low-level negative pressure is applied
to a sponge-covered suction tube for several
hours.
 Hyperbaric Oxygen Therapy (HBO / HBOT)–
administration of high-pressurized 100% oxygen
directly over the wound for 60 to 90 min.
 Surgical Debridement and / or Wound Grafting –
surgical excision of nonviable tissue to promote
wound healing and/or grafting of skin from
donor sites to clean granulating or freshly
excised wound bed.
Integumentary diseases
 Lesions & Infections
 Signs and symptoms of infection include:
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Drainage
Odor
Abscess
Fever
Discoloration
Heat / warmth at site
Edema
Erythema
Poor healing
Integumentary diseases
 Lesions & Infections
Integumentary diseases
 Lesions & Infections
Integumentary diseases
 Lesions & Infections
Integumentary diseases
 Lesions & Infections
Integumentary diseases
 Rashes – is it macular or papular?
Integumentary diseases
 Rashes – is it macular or papular?
 This rash is actually vesicular, and is herpes
zoster, or viral in origin
Integumentary diseases
 Rashes – is it macular or papular?
 This rash is actually vesicular, and is herpes
zoster, or viral in origin
 “chicken pox”
Integumentary diseases
 Infected hair &/or nails also count
 These are Beau’s lines
Integumentary diseases
Integumentary diseases
 Dehiscence – opening of a wound or surgical
site
Integumentary diseases
 Evisceration – internal body parts (viscera)
may protrude through a wound or opening.
See below.
Eviscerated
bowel
through a
clean stab
wound
Integumentary diseases
 Pressure sites – cause pressure ulcers, the
number one risk is immobility and boney
prominences
Integumentary diseases
 Stage I ulcer
 Defined as non-blanching erythema of intact skin, discoloration of
skins with warmth or hardness
Integumentary diseases
 Stage II Ulcer
 Defined – partial thickness skin loss involving epidermis and/or
dermis layer; the ulcer is superficial and presents clinically as an
abrasion, blister or shallow crater.
 Coccyx
Integumentary diseases
 Stage III
 Defined as a full thickness skin loss involving damage or necrosis of
subcutaneous tissue which may extend down to , but not through
underlying fascia; the ulcer presents clinically as a deep crater with
or without undermining or adjacent tissue.
Integumentary diseases
 Stage IV
 Defined as full-thickness skin loss with extensive destruction,
tissue necrosis, or damage to muscle,
bone, or supporting structures
Bone visible under damage
Integumentary diseases
 Venous Stasis Ulcers – no stages
 Caused by poor circulation and poor venous
return (PVD) Peripheral vascular disease
Integumentary diseases
 Venous Stasis Ulcers – no stages
 Caused by poor circulation and poor venous
return (PVD) Peripheral vascular disease
Harder to heal,
May need a bypass
to restore circulation,
in addition to
dressings.etc.
Edema and discoloration
are primary symptoms prior
to skin breakdown.
Integumentary diseases
 Treatments of ulcers
 #1 = prevention and turning, ROM
 Dressings and packings, from simple to
complex colloids
Integumentary diseases
 Drug therapy
 Debridement
 Diet therapy with vitamins and
supplements
 wound – vacuum (Wound Vac)
 Hyperbaric oxygenation (HBO)
 Surgical repair
Integumentary diseases
 Documentation of ulcers
 It is necessary to identify any skin damage
or breakdown on admission, as if these are
missed, the hospital or facility can be liable
 If it was not documented, it was not done
Integumentary diseases
 Documentation of ulcers
 Documentation should include a photograph,
measuring the ulcer or wound with a sterile
paper tape or circle; the depth, the width, the
breadth and the total area involved, and any
breaking of the skin, any color and any
drainage (including color and odor). Then
“stage” it.
Integumentary diseases
 The ABCDE’s of Skin Cancer:
Asymmetry
Border Irregularity
Color - changes
Diameter – increasing
 (Elevation--variable)
Integumentary diseases
 A-B-C-D----What is it?
Integumentary diseases
 Malignant Melanoma - Stage I
Integumentary diseases
 Malignant Melanoma – an aggressive form of
cancer, that is mostly preventable, has a
genetic component, and may spread into
other systems before it is noticed.
Integumentary diseases
 Rashes and Lesions – Dermatology, the great
mimic- is it bacterial, auto-immune, infected,
viral, or parasitic?
Integumentary diseases
 Psoriasis –
 an autoimmune disease which causes overstimulation of the keratinocytes in the skin.
 This can be caused initially by skin trauma,
irritation,
or stress.
Integumentary diseases
 Psoriasis – may appear like eczema at first,
but the plaques become thicker and
widespread. Eczema tends to be lighter and
scalier
eczema
psoriasis
Integumentary diseases
 Psoriasis – can erode and disfigure fingers
and toes that are affected
Integumentary diseases
 Psoriasis Treatments
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Steroids
Topical zinc ointments
Topical steroids
Tar and oil preparations
Ultraviolet light therapy – sunlight
often helps
Integumentary diseases
 Psoriasis Treatments
 ‘Older’ drugs include methotrexate &
cyclosporine to suppress the immune
system, but this requires monitoring of
liver enzymes.
 New treatments include monoclonal
antibodies (A form of chemotherapy—the
‘-mabs’ i.e. efalizumab (Raptiva) for
severe forms
Integumentary diseases
 Lesions – see handouts of definitions and
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terms, be able to use these.
A rash is a rash is a rash….or is it?
Common causes of rashes include
Allergic dermatitis, usually localized to the
areas of contact, hives
Drug reactions, usually all over the body
Bacterial infections
Viral infections
Integumentary diseases
 What kind of rash is this? If you can’t tell,
describe it. Describe the area as well.
Integumentary diseases
 ‘Ringworm’ – tinea capitus – a fungal
infection
Integumentary diseases
 Etiology: Systemic or local?
toxic epidermal necrolysis (T.E.N.)
Stevens-Johnson Syndrome
Integumentary diseases
 ‘Viral rashes’
Integumentary diseases
Chicken POX
(Herpes Zoster)
Note however:
Staphlococcus
skin
infections may
look
the same
Integumentary diseases
Terminology Appendix
The “ABCDE’s of Skin Cancer”
Asymmetry
Border
Irregularity
Color
Diameter:
¼ inch
<or> 6 mm
Elevation
angioma
 Angiomas : benign
tumors that are made
up of small blood
vessels or lymph
vessels.
Cherry angiomas
Spider angiomas
asymmetric
 asymmetric
 1. Pertaining to an
individual lesion:
Unequal shape from
side to side.
 2. Pertaining to a body
distribution: Unequal
distribution of lesions
on both sides of body.
Beau’s lines
 Beau's lines
Transverse depressions
or grooves in the nail
plate typically occurring
at corresponding
positions within each nail
plate.
 Often a sign of a prior
severe illness such as
malnutrition, a systemic
disease, or trauma.
carcinoma
 Carcinoma refers to an invasive
malignant tumor consisting of
transformed epithelial cells.
 Alternatively, it refers to a
malignant tumor composed of
transformed cells of unknown
histogenesis, but which possess
specific molecular or histological
characteristics that are
associated with epithelial cells,
such as the production of
cytokeratins or intercellular
bridges.
 Carcinoma in situ (CIS) refers to
a small, localized focus of
carcinoma that has not yet
invaded
Basal Cell Carcinoma
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dermatitis
Atopic dermatitis~
atopic dermatitis is a very common,
often chronic (long-lasting) skin
disease that affects a large
percentage of the world's
population.
It is also called eczema, dermatitis,
or atopy. Most commonly, it may be
thought of as a type of skin allergy
or sensitivity.
The atopic dermatitis triad includes
asthma, allergies (hay fever), and
eczema. There is a known hereditary
component of the disease, and it is
seen more in some families. The
hallmarks of the disease include skin
rashes and itching.
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Contact dermatitis~
Contact dermatitis is an
inflammation of the skin caused by
direct contact with an irritating
substance. Symptoms: Itching
(pruritus) of the skin in exposed
areas ; Skin redness or inflammation
in the exposed area.
Treatment: remove irritating
exposure; topical corticosteroids.
café’ au lait patch
 café au lait patch
 A well circumscribed
macule or patch
varying from pale
brown in lighter skin to
dark brown in darker
skin patients.
 The macule or patch
may have a serrated or
irregular margin.
Clubbing
 clubbing
 (Hippocratic fingers, watch-glass
nails, drumstick fingers)
Transverse and longitudinal
over-curvature of the nail plate.
The distal digit may have
associated enlargement.
Lovibond's angle is greater than
180 degrees.
 Typically associated with chronic
hypoxia, e.g in those with
congenital heart disease, or
COPD..
Dermal
 dermal
 Relating to the layer of
skin below the
epidermis, but above
the panniculus,
consisting of papillary
and reticular layers and
containing blood and
lymphatic vessels.
eczema
 eczema :
 a general term for
many types of skin
inflammation, also
known as dermatitis.
 The most common
form of eczema is
atopic dermatitis
(some people use these
two terms
interchangeably).
edema
 Edema is swelling that is caused
by fluid trapped in your body’s
tissues.
 Edema happens most often in
the feet, ankles, and legs.
 Other parts of the body, such as
the face and hands, can also be
affected
ecchymosis
 ecchymosis
Extravasation of blood
into the skin or mucous
membranes forming
large macules or
patches; flat color
changes over time may
go from blue-black, to
brown-yellow, or
green.
excoriation
 excoriation
A focal erosion usually
due to scratching.
erythema
 erythema
 Localized, blanchable
redness of the skin or
mucous membranes.
eschar
 eschar
 An adherent, thick, dry
black crust.
folliculitis
 Folliculitis is inflammation of
one or more hair follicles.
 It can occur anywhere on the
skin.
 Common symptoms include a
rash, itching, and pimples or
pustules near a hair follicle in the
neck, groin , or other areas...
“Hot Tub Folliculitis”:
furuncle
 furuncle
A follicle-centered
nodule caused by a
suppurative infection
characterized by pain,
redness,and potentially
visible pus. Usually
greater than 1 cm in
diameter.
hematoma
 hematoma
A collection of
extravasated blood that
is relatively or
completely confined
within a space. The blood
is usually clotted (or
partly clotted), and
depending on time may
manifest various degrees
of organization and
color.
hirsutism
 hirsutism
 Unwanted, excess hair
growth; generally in
women.
Hyperbaric oxygen (HBO)
 Hyperbaric oxygen therapy
(HBO) involves the breathing of
pure oxygen while in a sealed
chamber that has been
pressurized at 1 1/2 to 3 times
normal atmospheric pressure.
 used in conventional treatment
for decompression sickness (the
bends); severe carbon monoxide
poisoning; certain kinds of
wounds, injuries, and skin
infections; delayed radiation
injury; and certain bone or brain
infections.
keloid
 keloid
A firm, usually
elevated, proliferation
of scar tissue
exceeding the area of
the preceding skin
injury or wound.
lichenification
 lichenification
Thickened skin with
accentuated markings
usually due to repeated
rubbing and scratching
of skin.
maceration
 maceration
 Softened or broken
down skin resulting
from prolonged
exposure to wetness
causing whitening and
thickening of the
keratin sometimes
with redness, oozing,
and/or scaling.
macule
 A flat, generally less
than .5 cm area of skin
or mucous membrane
with different color
from surrounding
tissue. Macules may
have non-palpable, fine
scale.
melanoma
 Melanoma is a malignant tumor
that originates in melanocytes,
the cells which produce the
pigment melanin that colors our
skin, hair, and eyes.
 The majority of melanomas are
black or brown. However, some
melanomas are skin-colored,
pink, red, purple, blue or white.
 Melanoma is the most serious
form of skin cancer.
nevus

Nevus (singular); nevi (plural)

1. Any birthmark.
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2. A benign pigmented spot on the skin such
as a mole (a cluster of melanocytes and
supportive tissue that appears as a tan,
brown, or flesh-colored spot on the skin).
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3. A benign blood vessel tumor on the skin
such as a vascular nevus, a local collection of
capillaries of the skin (a strawberry
birthmark, stork mark, or port wine stain).
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From the Latin naevus meaning a body
mole, especially a birthmark. The plural of
nevus is nevi.
nodule
 nodule
A dermal or
subcutaneous firm,
well-defined lesion
usually greater than .5
cm in diameter.
papule
 papule
A discrete, solid,
elevated body usually
less than .5 cm in
diameter. Papules are
further classified by
shape, size, color, and
surface change.
paronychia
 Paronychia: Inflammation
of the folds of tissue
surrounding the nail due to
infection.
 The infection may be
bacterial (most commonly,
staph or strep species) or
fungal.
 The term "paronychia" is
compounded from "para-",
next to + the Greek "onyx",
nail = next to the nail.
Paronychia is synonymous
with perionychia.
petechiae
 petechiae
 Tiny, 1-2 mm nonblanchable purpuric
macules resulting from
tiny hemorrhages.
plaque
 plaque
A discrete, solid,
elevated body usually
broader than it is thick
measuring more than
.5 cm in diameter.
Plaques may be further
classified by shape,
size, color, and surface
change.
Pressure ulcer
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…an area of skin that breaks down
when you stay in one position for
too long without shifting your
weight.
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Pressure ulcers are categorized by severity,
from Stage I (earliest signs) to Stage IV
(worst):
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 Stage I: A reddened area on the
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skin that, when pressed, is
"nonblanchable" (does not turn
white). This indicates that a pressure
ulcer is starting to develop.
Stage II: The skin blisters or forms
an open sore. The area around the
sore may be red and irritated.
Stage III: The skin breakdown now
looks like a crater where there is
damage to the tissue below the skin.
Stage IV: The pressure ulcer has
become so deep that there is
damage to the muscle and bone,
and sometimes tendons and joints.
pruritis
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Pruritus is an itch or a sensation that
makes a person want to scratch.
Pruritus can cause discomfort and
be frustrating. If it is severe, it can
lead to sleeplessness, anxiety, and
depression.
The exact cause of an itch is
unknown.
It is a complex process involving
nerves that respond to certain
chemicals like histamine that are
released in the skin, and the
processing of nerve signals in the
brain.
Pruritus can be a part of skin
diseases, internal disorders, or due
to faulty processing of the itch
sensation within the nervous
system.
psoriasis
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A common skin condition that causes
skin redness & irritation. Most persons
with psoriasis have thick, red skin with
flaky, silver-whit patches called scales.
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There are five main types of psoriasis.
Erythrodermic -- The skin redness is very
intense and covers a large area.
Guttate -- Small, pink-red spots appear
on the skin.
Inverse -- Skin redness and irritation
occurs in the armpits, groin, and in
between overlapping skin.
Plaque -- Thick, red patches of skin are
covered by flaky, silver-white scales. This
is the most common type of psoriasis.
Pustular -- White blisters are surrounded
by red, irritated skin.
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purpura
 purpura
Hemorrhage into skin
or mucous membranes
which varies in size and
ranges in color related
to duration. Types of
purpura include
palpable purpura,
ecchymosis, and
petechiae.
pustule
 pustule
A circumscribed
elevation that contains
pus. Pustules are
usually less than .5 cm
in diameter.
splinter hemorrhages
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splinter hemorrhages
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Dark-red, sometimes black thin
longitudinal lines appearing to be
within the nail plate or nail bed.
The shape of the hemorrhages is
due to the longitudinal orientation
of nail bed capillaries.

Splinter hemorrhages are caused
by injury to the nail or by certain
drugs and diseases. However,
trauma is the most common
cause. Splinter hemorrhages
resolve spontaneously
symmetric
 symmetric
1. Pertaining to an
individual lesion: Equal
shape from side to
side. 2. Pertaining to a
body distribution:
Equal distribution of
lesions on both sides of
body.
striae
 striae
A flat or atrophic,
usually linear, area of
skin that may vary in
color from pink to red
that
eventually becomes
hypopigmented.
telangiectasia
 telangiectasia
Visible, persistent,
dilation of small,
superficial cutaneous
blood vessels.
ulcer
 ulcer
A circumscribed loss of
the epidermis and at
least upper dermis.
Ulcers are further
classified by their
depth, border, shape,
edge, and tissue at its
base.
Vacuum assisted closure
(Wound VAC)

Under negative pressure, V.A.C. Therapy
with proprietary V.A.C. GranuFoam
Dressings applies mechanical forces to
the wound to create an environment that
promotes wound healing. These forces
are known as macrostrain and
microstrain.
 Macrostrain:
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Draws wound edges together
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Provides direct and complete wound bed contact
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Evenly distributes negative pressure
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Removes exudate and infectious materials
 Microstrain
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Reduces edema
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Promotes perfusion
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Promotes granulation tissue formation by facilitating cell
migration and proliferation
vesicle
 vesicle
A fluid filled cavity or
elevation less than .5
cm in diameter. Fluid
may be clear, serous,
hemorrhagic or pusfilled.
turgor
 Skin turgor test



a fold of skin is picked up and then
quickly let go. The amount that it
will stretch is an indication of its
extensibility.
The speed with which it returns to a
normal position is determined by
the degree of hydration of the skin
and subcutaneous tissue and the
amount of fat in the subcutaneous
tissue, e.g. in an animal that is 10 to
12% dehydrated the skin fold will
not disappear until 20 to 45 seconds
have elapsed.
The best place to assess skin
turgor on a patient who has been
laying in the bed for prolonged
amounts of time is: forehead or
sternum.
urticaria
urticaria (“hives”)
An edematous, transitory
papule or plaque having a
ring of erythema known as
a flare and surrounded
often by a narrow
peripheral zone of pallor or
vasoconstriction.
Also known as a wheal.
wheal
 Wheal
 An edematous,
transitory papule or
plaque having a ring of
erythema known as a
flare and surrounded
often by a narrow
peripheral zone of pallor
or vasoconstriction.
 Also known as urticaria.
xerosis
 xerosis
 Dry flaking skin