Chapter 28: Skin Disorders
Skin Lesions Defined
• Skin pigment - melanin
– Variations may be due to anatomic, physiologic
or pathophysiologic changes in skin blood flow
• Normal skin appearance
– Altered by external and internal factors
• Cellulitis
– Infectious inflammation of deep skin structures
Skin Trauma
• Mechanical Forces that Cause Injury
– Friction
– Compression
– Shearing
– Stretching
– Scraping
– Tearing
– Avulsing
– Puncturing
Friction and Pressure Problems
• Hyperkeratosis of the Hands and Feet
– Etiology
• Friction and pressure over bony protuberances
• Painful when subcutaneous fat becomes inelastic
– Prevention
• Cushioning devices; wearing 2 socks
• Lubricants to reduce friction, shaving calluses
• For calluses on hands, special gloves or protective
gear
– Sign and Symptoms
• Thickening, of horny layer of skin, ovular, elongated
and brown
• Painful with pressure
– Management
• Avoid emery boards and pumice as the increase in
friction will stimulate skin to produce added callus
• Use moisturizer
• Pair off callus with scalpel
• Padding
• Blisters
– Etiology
• Result of a shearing force that produces a raised area
that accumulates with fluid
– Prevention
• Use of dust or powder or lubricant to reduce friction
• Tubular socks, 2 pairs of socks if feet are sensitive
or perspire excessively
• Appropriate shoes that are broken in
• Padding and lubricants
– Signs and Symptoms
• Hot spot, sharp burning sensation, painful
• Superficial area of skin raised with clear fluid
– Management (intact blister)
• Leave intact for 24 hours
• Clean with antiseptic
• Cut small incision to drain fluid (large enough that it
won’t re-seal)
• Prevent refilling with a pressure pad
• Clean again with antiseptic
• Use doughnut to prevent irritation
• Monitor for infection, replace wet bandaging
• Debridement can be performed when tenderness is
gone
– Management (open/torn blister)
• Keep clean to avoid infection
• Keep skin in place and apply non-adhering sterile
dressing and padding
• Monitor daily for infection
– Management (denuded blister)
• If blister is torn 1/2 inch or more remove skin flap
• Clean and expose area, apply antiseptic with
occlusive dressing
• Second skin can be applied to raw area
• Soft Corns and Hard Corns
– Etiology
• Caused by pressure of improperly fitting shoes and
anatomic abnormalities
• Soft corns are the result of pressure and perspiration,
also associated with exostosis
– Signs and Symptoms
• Hard corns form on the tops of toes and tend to be
painful and dry
• Soft corns result in thickening of skin, white and
sometimes painful (between 4th and 5th toes)
– Prevention
• Wear properly fitting shoes
– Management
• Surgical removal if painful
• Padding; maintain clean dry feet; wear appropriate
shoes
• Excessive Perspiration (hyperhidrosis)
– Etiology
• Syrup-like perspiration, high in sodium chloride
• Increases risk of other skin irritation
• Makes adherence of bandages difficulty
– Management
• Use of astringent such as alcohol or an absorbent
powder
• Aluminum chloride or electric current can be used to
treat condition
• Chafing of Skin
– Etiology
• Occurs particularly in athletes that are obese or
heavy limbed
• Result of friction and maceration of skin in climate
of heat and moisture
– Signs and Symptoms
• Separation of keratin from granular layer of skin
• Causes oozing wounds that crust and crack
– Prevention
• Keep skin dry, clean, and friction free
• For the groin, soft, loose, cotton underwear is
recommended
– Management
• Clean area with soap and water and treat with
medicated solution and hydrocortisone cream
• Xerotic (Dry) Skin
– Etiology
• Drying of skin due to exposure of cold, excessive
bathing, decrease in humidity causing skin to lose
water
– Signs and Symptoms
• Dry skin w/ variable redness and scaling; itching
– Management
• Prevent water loss and replace lost water
• Bathe in tepid water, use moisturizer
• If condition worsens, refer to physician
• Ingrown Toenails
– Etiology
• Generally occurs in
great toe
• Nail grows laterally
into skin
• Result of lateral
pressure from
shoes, poor nail
trimming, and
repeated trauma
– Signs and Symptoms
• Pain and swelling
• Penetrated skin becomes inflamed and purulent with
lateral nail fold swollen and irritated
– Prevention
• Properly fitting shoes and socks are essential
• Weekly toenail trimming (cut straight across)
• Leave nail long enough to clear skin
– Management
• Conservative management includes soaking the
inflamed toe in warm water (20 minutes)
• Place cotton under edge of nail to clear from skin
• If chronic, remove wedge of nail and apply
antiseptic compress until inflammation resides
Wounds
• Abrasions
– Scraping of skin against rough surface (top
surface of skin is worn away)
– Increased probability of infection due to
exposure of dirt and foreign material
– Clean and debride
• Punctures
– Direct penetration of skin with pointed object
– Must be referred to physician
• Lacerations
– Object tears tissue, giving wound appearance of
jagged edge (sometimes result of blunt trauma)
– Presents environment susceptible to infection
• Skin Incision
– Smooth cut in skin - not jagged
• Skin Avulsion
– Skin torn away from body (should be placed in
moist gauze w/in a plastic bag that is then
immersed in cold water)
– Transport to hospital with athlete for possible
reattachment
• Skin Bruises
– Result of blunt trauma; causes disruption of
superficial blood vessels and results in black
and blue discoloration
– Treatment requires RICE to control
hemorrhaging
Wound Management
• All wounds must be assumed contaminated
• Pay close attention to all universal precautions
• Clean all wounds with soap and water to minimize
infection
• Apply a dressing with antiseptic (unless physician
examination is necessary)
• Lacerations and punctures should be treated by a
physician
• Use of occlusive dressings
– Minimizes scab formation, perceived pain from
exposed nerves, cost and time effective, provide
adequate barrier
• Antibiotic ointment used to prevent secondary
infection (SEE TABLE 28-4 for added instruction)
Athletic Training Room Practice
in Wound Care
•
•
•
•
Use clean and sterile instruments
Clean hands thoroughly and use gloves
Clean in and around skin lesion
Use a non-medicated covering if athlete is
to be sent for medical attention
• Avoid touching any part of sterile dressings
that will contact the wound
• Place medication on pad
• Secure the dressing in place
Bacterial Infections
• Bacteria are single celled micro-organisms
– Spherical, doublets, and spirochetes
• Staphylococcus
– Gram positive bacteria that appears in clumps in
skin and upper respiratory tract
• Streptococcus
– Chain bacteria often associated with systemic
disease and skin infections
• Bacillus
– Spore forming, aerobic, and occasionally mobile
– Can cause systemic damage
• Impetigo Contagiosa
– Etiology
• Caused by A-beta-hemolytic streptococci, S aureus
or combination of these bacteria
• Spread through close contact
– Signs and Symptoms
• Mild itching and soreness followed by eruption of
small vesicles and pustules that rupture and crust
• Generally develops in body folds that are subject to
friction
– Management
• Cleansing and topical antibacterial agents
• Systemic antibiotics
• Furunculosis
(Boils)
– Etiology
• Infection of
hair follicle
that results
in pustule
formation
• Generally
the result of
a staphy.
infection
– Signs and Symptoms
• Pustule that becomes reddened and enlarged as well
as hard from internal pressure
• Pain and tenderness increase with pressure
• Most will mature and rupture
– Management
• Care involves protection from additional irritation
• Referral to physician for antibiotics
• Keep athlete from contact with other team members
while boil is draining
• Carbuncles
– Etiology
• Similar in terms of early stage development as
furuncles
– Signs and Symptoms
• Larger and deeper than furuncle and has several
openings in the skin
• May produce fever and elevation of WBC count
• Starts hard and red and over a few days emerges into
a lesion that discharges yellowish pus
– Management
• Surgical drainage combined with the administration
of antibiotics
• Warm compress is applied to promote circulation
• Folliculitis
– Etiology
• Inflammation of
hair follicle
• Caused by noninfectious or
infectious agents
• Moist warm
environment and
mechanical
occlusion contribute
to condition
• Psuedofolliculitis
(PFB)
– Signs and Symptoms
• Redness around follicle that is followed by
development of papule or pustule at the hair follicle
• Followed by development of crust that sloughs off
with the hair
• Deeper infection may cause scarring and alopecia in
that area
– Management
• Management is much like impetigo
• Moist heat is used to increase circulation
• Antibiotics can also be used depending on the
condition
• Hidradenitis Suppurativa
– Etiology
• Primary inflammation event of the hair follicle
resulting in secondary blockage of the apocrine
gland
– Signs and Symptoms
• Begins as small papule that can develop into deep
dermal inflammation
– Management
• Avoid use of antiperspirants, deodorants and
shaving creams
• Use medicated soaps and systemic antibiotics
• Acne Vulgaris
– Etiology
• Inflammatory disease of the hair follicle and the
sebaceous glands
• Sex hormones may contribute
– Signs and Symptoms
• Present with whiteheads, blackheads, flesh or red
colored papules, pustules or cysts
• If chronic and deep = may scar
• Psychological impact
– Management
• Topical and systemic agents used to treat acne
• Mild soaps are recommended
• Paronychia and Onychia
– Etiology
• Caused by staph, strep and or fungal organisms that
accompany contamination of open wounds or
hangnails
• Damage to cuticle puts finger at risk
– Signs and Symptoms
• Rapid onset; painful with bright red swelling of
proximal and lateral fold of nail
• Accumulation of purulent material w/in nail fold
– Management
• Soak finger or toe in hot solution of Epsom salt 3
times daily
• Topical antibiotics, systemic antibiotics if severe
• May require pus removal through skin incision
• Tetanus Infection (lockjaw)
– Etiology
• Acute infection of the CNS caused by tetanus
bacillus
• Bacteria enters through the blood and open wounds
– Signs and Symptoms
• Stiffness of the jaw and muscles of the neck
• Muscles of facial expression produce contortion and
become painful
• Fever may become markedly elevated
– Management
• Treat in intensive care unit
• Childhood immunization
Fungal Infections
• Group of organisms that include yeast and
molds which are usually not pathogenic
• Grow best in unsanitary conditions with
warmth, moisture and darkness
• Infections generally occur in keratinized
tissue found in hair, nails and stratum
corneum
• Dermatophytes (Ringworm fungi)
– Cause of most skin, nail and hair fungal
infections
• Tinea of the Scalp (tinea capitis)
– Signs and Symptoms
• Ringworm of the scalp begins as a small papule that
spreads peripherally
• Appears as small grayish scales resulting in
scattered balding
• Easily spread through close physical contact
– Management
• Topical creams and shampoos are ineffective in
treating fungus in hair shaft
• Systemic antifungal agents are replacing older
agents due to increased resistance
• Some topical agents are used in conjunction
• Tinea of the Body
(tinea corporis)
– Signs and
Symptoms
• Commonly involve
extremities and
trunk
• Itchy red-brown
scaling annular
plaque that expands
peripherally
– Management
• Topical antifungal
cream
• Tinea of the Nail (tinea unguium/
onchomycosis)
– Signs and Symptoms
• Fungal infection of the nail -- found commonly in
those engaged in water sports or who have chronic
athlete’s foot
• Nail becomes thick, brittle and separated from its bed
– Management
• Some topical antifungal agents have proved useful
• Systemic medications are most effective
• Surgical removal of nail may be necessary if extremely
infected
• Tinea of the Groin
(tinea cruris)
– Etiology
• Symmetric redbrown scaling
plaque with snakelike border
– Signs and
Symptoms
• Mild to moderate
itching
– Management
• Treat until cured
• Will respond to many of the non-prescription
medications
• Medications that mask symptoms should be avoided
• Failure to respond to normal management may
suggest a non-fungal problem (such as bacteria) and
should be referred to a physician
• May require additional topical medications and oral
prescriptions
• Athlete’s Foot (tinea pedis)
– Etiology
• Most common form of superficial fungal infection
• Tricophyton species are most common cause of
athlete’s foot
• Webs of toes may become infected by a combination
of yeast and dermatophytes
– Signs and Symptoms
• Extreme itching on soles of feet, between and on top
of toes
• Appears as dry scaling patch or inflammatory
scaling red papules forming larger plaques
• May develop secondary infection from itching and
bacteria
– Management
• Topical antifungal agents and good foot hygiene
• Candidiasis (Moniliasis)
– Etiology
• Yeast-like fungus that can produce skin, mucous
membrane and internal infections
• Ideal environment includes hot humid weather, tight
clothing, and poor hygiene
– Signs and Symptom
• Infections w/in body folds
• Presents as beefy red patches and possible satellite
pustules
• White, macerated border may surround the red area;
deep painful fissures may develop at skin creases
– Management
• Maintain dry area
• Use antifungal agents to clear infection
• Tinea Versicolor
– Etiology
• Caused by a yeast
• Appears commonly in areas in which sebaceous
glands actively secrete body oils
– Signs and Symptoms
• Fungus produces multiple, small, circular macules
that are pink, brown, or white
• Commonly occur on chest, abdomen, and neck
• Do not tan when exposed to sun and usually are
asymptomatic
– Management
• Straightforward treatment - recurrences are common
• Use selenium shampoo (Selsun) and topical
econazole nitrate (or something similar)
• When microorganism has been eradicated, repigmentation of the area will occur
Viral Infections
• Ultramicroscopic organisms that require
host cells to complete their life cycle
– May stimulate cell chemically to produce more
virus until host cell dies
– Lies within bud-like structure that does not
damage cell or virus, w/out causing infection
• A number of skin infections are caused by
viruses
• Herpes Simplex Labialis, Gladiatorum, and
Herpes Zoster
– Etiology
• Highly contagious and is usually transmitted directly
through a lesion in the skin or mucous membrane
• Resides in sensory nerve neurilemmal sheath
following initial outbreak
• Recurrent attacks stimulated by sunlight, emotional
disturbances, illness, fatigue, or infection
• Type I vs. Type II
– Signs and Symptoms
• Early indication = tingling or hypersensitivity in an
infected area 24 hours prior to appearance of lesions
• Local swelling followed by outbreak of vesicles
• Athlete may feel ill w/ headache, sore throat,
– Signs and Symptoms (continued)
• Vesicles generally rupture in 1-3 days spilling serous
material
• Heal in generally 10-14 days
• If an athlete has an outbreak they should be
disqualified from competition due to contagious
nature of condition
– Management
• Herpes simplex lesions are self limiting - reduce
pain and promote early healing
• Use of antiviral drugs can reduce recurrence and
shorten course of outbreak
– Complications
• Can lead to secondary infection
Verruca Virus and Warts
• Varied of forms exist
– verruca plana (flat wart), verruca plantaris
(plantar wart), and condyloma acuminatum
(venereal wart)
• Different types of human papilloma virus
have been identified
– Uses epidermal layer of skin to reproduce and
growth
• Wart enters through lesion in skin
• Common Wart
– Signs and Symptoms
• Small, round, elevated lesion
with rough dry surfaces
• Painful if pressure is applied
• May be subject to secondary
bacterial infection
– Management
• If vulnerable, they should be protected until treated
by a physician
• Use of electrocautery, topical salicylic acid or liquid
nitrogen are common means of managing this
condition
• Plantar Warts
– Etiology
• Spread through papilloma virus
– Signs and Symptoms
• Located on sole of foot, on or adjacent to areas of
abnormal weight bearing
• Areas of excessive epidermal thickening
• Discomfort, point tenderness
• Hemorrhagic puncta (black seeds)
– Management
• While in competition, protect and prevent spreading
• Pair away callus and apply keratolytic
• Following season, wart can be removed by freezing
it or by electrodessication (maintain protection until
removal)
• Molluscum Contagiosum
– Etiology
• Poxvirus infection which is more contagious than
warts (especially during direct body contact)
– Signs and Symptoms
• Small, flesh or red colored, smooth-domed papules
with central umbilication
– Management
• Physician referral is necessary
• Cleansing and destructive procedure (counterirritant
such as cantharidin, surgical removal or cryosurgery)
Allergic, Thermal, and Chemical
Skin Reactions
• Allergies are immunologically mediate responses
to molecules in dyes and proteins against which
the body’s immune system is sensitized
• Allergens may be food, drugs, clothing, dusts,
pollens, plants, animals, heat, cold, or light
• The skin will reflect an allergy in many ways such
as reddening and swelling of the tissue, uticaria or
hives, burning or itching
• ATC’s must recognize gross signs of allergic
responses and be prepared to remove allergens and
treat topically or systemically with antipruritic
agents
• Contact Dermatitis (allergic and irritant)
– Etiology
• Plants are the most common cause (poison ivy, poison
oak, sumac, ragweed, primrose)
• Topical medications
• Chemicals found in fragrances and preservatives of
soaps, detergents
– Signs and Symptoms
• Onset may range from 1 day to 1 week
• Redness, swelling, formation of vesicles that ooze fluid
and form crust, constant itching
• May change from redness and blistering to
erythematous scaling, lichenified papules and plaques
– Management
• Avoid allergen
• Tap water compresses or soaks, topical corticosteroids
• Milaria (Prickly Heat)
– Etiology
• Continued exposure to heat and moisture causing
retention of perspiration by sweat glands
– Signs and Symptoms
• Itching and burning vesicles and pustules
• Occurs most often on arms, trunks, and bending
areas of the body
– Management
• Avoidance of overheating, frequent bathing with
non-irritating soap, wearing loose-fitting clothing
and use of antipruritic lotions
• Chilblains (pernio)
– Etiology
• Caused by excessive exposure to cold
– Signs and Symptoms
• Tissue does not freeze but reacts with edema,
reddening and possibly blistering along with a
sensation of burning and itching after exposure to
cold
– Management
• Exercise and gradual warming of the part
• Massage and application of heat are contraindicated
• Some systemic drugs can be used in severe cases
• Sunburns
– Etiology
• Inflammatory response to injury caused by
ultraviolet solar radiation
• Must be cautious of physical characteristics,
chemicals, food and drugs that make individuals
more susceptible
– Signs and Symptoms
•
•
•
•
Varies from erythema to severe blistering
May experience shock if severe enough
Can cause malfunctioning of organs w/in the skin
Will appear 2-8 hours following exposure, with
symptoms becoming most severe at 12 hours
• S&S will dissipate w/in 72-96 hours
• Sunburns (continued)
– Management
• Can be prevented through the use of sunscreen (sun
protection factor or SPF)
– Filters ultraviolet light
– Water/sweat resistant sunscreen is recommended
• Treat a burn according to the degree of
inflammation
• Cool water, aloe based solutions
• More severe burns may require bathing in a bath of
cornstarch or vinegar
• Severe burns require physician assistance
• Psoriasis
– Etiology
• Exact cause is unknown -- genetic factors may play
a role in condition
• Infection, smoking, some drugs and possible
hormonal factors may cause an outbreak
– Signs and Symptoms
• Lesion begins as reddish papules that progress to
plaques
• Lesions progress to yellowish white scaly condition
that tends to be located on the elbows, knees, trunk,
genitalia, and umbilicus
• Psoriasis (continued)
– Management
• Teaching patient self management
• Glucocorticoids and kerolytic agents can be used in
conjunction with each other
• Long term oral medications may be necessary
• Counseling may be necessary for psychological
aspects of condition
Infestation and Bites
• Scabies
– Etiology
• Caused by mites which cause extreme nocturnal itching
(tunnels and lays eggs)
– Signs and Symptoms
• Appear as dark lines between fingers and toes, body
flexures, nipples and genitalia
• Excoriations, pustules and papules caused by itching
tends to hide true cause
• Skin develops hypersensitivity to the mite
– Management
• Permethrin 5% is treatment of choice
• Washing of bedding and clothes is necessary
• Topical corticosteroids may be necessary to treat
itching
• Lice (Pediculosis)
– Etiology
• Manifestation by the louse (louse of head, pubic
region and body)
– Signs and Symptoms
• Bites cause itching dermatitis through subsequent
scratching -- promotes pustule and excoriations to
develop
– Management
• Cure is rapid with use of any number of agents
• Good hygiene is paramount
• To prevent re-infestation all clothing and bedding
should be washed in hot soapy water or discarded
• Fleas
– Etiology
• Small wingless insects that suck blood
• Can transmit systemic diseases
– Signs and Symptoms
• Great deal of discomfort can be felt if come into
contact with a high number of fleas
• Concentrate bites on ankles and lower legs
– Management
• Following a bite, itching must be prevented with
antipruritic lotion
• Avoid scratching to prevent secondary infection
• Insecticides can also be effective
• Ticks
– Etiology
• Parasitic insects that have an affinity for blood
• Carriers of a variety of microorganisms that can
transmit Rocky Mountain spotted fever and Lyme
disease
– Signs and Symptoms
• Headaches, fever, malaise, myalgia, and rash,
perechiae and prupura, enlarging annular red ring w/
or w/out central red papule
– Management
• Remove tick (mineral oil or fingernail polish)
– Grasping head of tick is an acceptable method
• Systemic treatment is necessary to prevent
morbidity and mortality associated with RMSF and
Lyme disease
• Mosquitoes
– Etiology
• Unless carrying a disease, mosquitoes produce bites
that cause only mild discomfort
• Attracted to lights, dark clothing and warm moist
skin
– Signs and Symptoms
• Small reddish papule with associated itching
– Management
• Topical medication
• Use of repellents can also be used on the skin to
prevent contact with mosquitoes
• Stinging Insects
– Etiology
• Bees, wasps, hornets, yellow jackets -- inflict
venomous sting
• Hypersensitive individuals may experience an
allergic reaction
– Signs and Symptoms
• If an allergic reaction occurs an increase in heart rate
and breathing will occur, along with chest tightness,
dizziness, sweating and even LOC
• Insect Stings (continued)
– Management
• To prevent, avoid wearing scented lotions or
shampoos, brightly colored clothes, jewelry, suede,
or leather, and avoid going barefoot.
• If an athlete is susceptible to anaphylactic reactions
instructions on use of an EpiPen are necessary
• If uncomplicated, the stinger should be removed
with tweezers or a credit card and soothing
medications should be applied
• Soap detergent will also lessen symptoms
• In cases of anaphylactic reaction immediate
physician referral is necessary