ALTERATION IN SKIN INTEGRITY

Prof. Unn Hidle

Updated Spring 2010

INTEGUMENTARY DISORDERS

STRUCTURE AND FUNCTION OF SKIN

• Structure: 3 layers– Epidermis– Dermis– Subcutaneous (inner layer of adipose tissue)

• Function– First line of defense– Temperature regulation– Excretion of water– Production of vitamin D– Sensation of touch, pain, heat and cold

• The skin is controlled by:– The autonomic nervous system– The endocrine glands

• Sebaceous glands – production of sebum• Eccrine sweat glands (present at birth; functioning by age 3

years) versus apocrine glands (controlled by adrogens; mature at puberty)

• Pediatric differences in skin: Can you think of any?

ASSESSMENT OF THE SKIN

• Involves inspection and palpation:• Texture• Turgor• Color (circulation, rash, birthmarks)• Areas of pressure• Inflammation• Breakdown or emaciation• Bacterial infection (infant/child = high risk)• Systemic symptoms• Reaction of primary irritants• Toxic erythema (increased risk in children)• Diaper rash: lacerations, infections and sweat

retention

CONDITIONS TO BE DISCUSSED

• Eczema• Bulleous Impetigo• Pediculosis Capitis (head lice)• Ringworm• Acne• Psoriasis• Neurofibromatosis 1• Lyme disease • Smallpox

ECZEMA• Description

– = Atopic Dermatitis– A superficial inflammatory process involving

primarily the epidermis– A common allergic reaction in children (atopy =

genetic predisposition)– Family history of allergies: asthma, allergic

rhinitis, hay fever, food allergies, etc.– Childhood eczema often begins in infancy and

the rash appears on the face, neck, and folds of elbows and knees

– May persist for several years or return after the child is older

– Sometimes caused by an allergic sensitivity to foods such as milk, fish, or eggs

– Seasonal: gets worse in the fall/winter with artificial heating/decreased humidity in homes

Eczema – 3 types• Infantile eczema:

– 2-6 months of age– Usually spontaneous remission by 3 years of age– Generalized lesions (erythema, vesicles, papules, scaling,

crusting, oozing, weeping)– Usually symmetrical– Cheeks, scalp, trunk and extensor surfaces of extremities

• Childhood eczema:– Occurs at about 2-3 years of age– May follow the infantile form– Flexural areas, wrists, ankles, feet– S/S may include Lichenification (thikenied skin with

accentuation of creases from scratching) and Keratosis pilaris (overgrowth & thickening of cornifiec epithelium)

• Preadolescent and adolescent eczema– May begin at 2 years of age and continue into adulthood– Similar to childhood lesions with lichenified plaques

ECZEMA

ECZEMA• Assessment

– As discussed

– NO CURE!

• Goal of treatment– Relieve pruritus - # 1 FOCUS!!!!– Hydrate skin

– Decrease inflammation

– Prevent or control secondary infection

• Treatment methods– Dry method baths

– Wet method – most common

– Relieving pruiritis

– Secondary infections

• Nursing: What is your role in this picture?

ECZEMA

Infantile eczema

Infantile eczema

Childhood eczema

BULLOUS IMPETIGO

• = impetigo neonatorum• Superficial bacterial skin infection• Most commonly caused by Staphylococcus

aureus• Assessment:

– Eruption of bulleous vesicular lesions on previously untraumatized skin (compared to impetigo – secondary to trauma)

– Usually on buttocks, perineum, trunk, face– Size varies– Bullae contain turbid fluid (vs impetigo –

honey crust)– Rupture in 1-2 days – leaves superficial red

denuded area with minimal crusting– Differential diagnosis – thermal injury

IMPETIGO

• Treatment– Warm saline compresses applied to

lesions followed by gentle cleansing– Apply topical antibiotics and sometimes

administer oral antibiotics as prescribed

• Nursing– Isolation until therapy is instituted– Investigate: persons who have come in

contact with infant/child; nursery– Teaching: prevent spread of infection

PEDICULOSIS CAPITIS (LICE)• Description:– = Head lice or “cooties”– Caused by Pediculus humanus capitis– A common parasite in school-aged

children (ridicule!)– The “louse” is a blood-sucking

organism – Can live away from human host for

about 48 hours– Female lays eggs at night– Nits or eggs hatch in approximately 7-

10 days

– Incubation Period: Eggs incubate for about 1 week (7-10 days) and lice reach sexual maturity in about 2 weeks (life span = approx. 1 month)

– Infectious Period: During infestation prior to treatment

– Transmission: Direct contact with infected person and indirect contact with infected person’s belongings (scarf, hat, pillow, etc. – NOT PETS!)

– Season: Nonspecific, a common problem in schools

PEDICULOSIS CAPITIS (LICE)

• Assessment – Adult lice are small gray specks that may

be difficult to see– Nits are visible, tiny silver or gray specks

resembling dandruff that are firmly attached to the hairshaft near the scalp

• S/S– Itching – caused by the crawling insect and

insect-saliva– Mostly in scalp, but may be on other

places of body (facial hair, chest, groin, etc.)

• Dx:– Observing the white eggs (nits)– Differential diagnosis: dandruff, lint, hair

spray etc.

• Implementation: – Anti-lice shampoo (medicated)

• Permetrhin 1% crème rinse (Nix)• Lindane shampoo 1% (Kwell, Scabane)

– Do NOT administer after a warm bath or shower (vasodilation and increased absorption)

– Manual removal of nits = KEY!!! • Comb• Tweezers or fingernails

– Wash clothes, bedlinen– Remove all hats, scarves, etc– Vacuum all rugs and clean house– TEACHING!– PREVENTION!– “Psychological support” – ANYBODY can get it!– National Pediculosis Association – Established guidelines for

schools

RINGWORM• Dermatophytosis = fungal infection: entire category• Types:

– Tinea capitis = head fungi– Tinea cruris and Tinea inguinalis = “Jock itch”– Tinea corporis = fungal infection of skin/nails– Candidiasis/moniliasis = moniliasis in chronically

moist areas– Tinea pedis = “athlete’s foot”

• Description– Superficial infections (ON the skin, not IN)– Annular lesion where the fungi are found in the edge

of the inflamed border– Oval or round, erythematous, scaling patches– Pruritic– May develop alopecia– Contagious, also animal to humans (versus lice)

• Dx– Physical exam– Scrapings

• Treatment– Oral griseofulvin (EXCEPT for Jock itch and

moniliasis)– Precautions when on griseofulvin– Topical antifungal agent: tolnaftate liquid (i.e.

for jock itch) EXCEPT for moniliasis– For moniliasis the treatment is amphotericin B or

nystatin ointment (both topical)• TEACHING

ACNE• Involves pilosebaceous units

(consists of the sebaceous glands and hair follicles)

• Etiology:– Familial aspect– Hormonal cause– Stress and acne ???– Cosmetic agents– Exposure to oil and grease– Dietary intake ????– Hygiene????

• 3 Main Pathophysiologic factors:– Excessive sebum production– Comadogenesis– Overgrowth of Propionibacterium

acne• Two types of lesions seen:– Noninflamed lesions = comadones• Closed comadones =

“whiteheads”• Open comadones = “blackheads”

– Inflamed lesions

• Treatment: – No single treatment has been effective: combination

therapies are usually used

• Note on ACCUTANE (isotretinoin)

– Retinoic acid / Vit A derivative: decreases sebum production

• General measures

– Improved health

• Food restrictions or elimination if applicable

• Topical antibacterial agents (comadonal acne)

– Tretinoin (retinoic acid) - topical

• Systemic antibiotics – inflamed lesions

• Oral contraceptive pills

• Nursing considerations

PSORIASIS• Immune-mediated, genetic skin disorder• Etiology = unknown• Known to be triggered by stress

• S/S– May vary from a spot or two to extensive

coverage on their body– Round, thick, dry reddish patches covered with

coarse, silvery scales– Commonly appears on scalp first and facial

lesions (more common in children)– May develop psoriatic arthritis

• Treatment– Sunlight or artificial ultraviolet light– Topical corticosteroids – Tar derivates (coal tar act synergistically with

UV light therapy) – give before!– Keratolytic agents (i.e. salicylate acid) will

enhance the absorption of corticosteroids– Emollients– Vitamin A– Humidifiers

• Nursing– Direct skin care– Teaching– Psycho-social– National Psoriasis Foundation

NEUROFIBROMATOSIS 1 (NF 1)

• Von Recklinghousen disease• Common genetic disorder• Autosomal dominant inheritance• 1:3000 persons• Appears as a result from a defect that alters

peripheral nerve differentiation and growth• Slow growing cutaneous or subcutanous

neurofibromas that grow along the peripheral nerves later in childhood or adolescence

• 50% chance to transmit NF 1 to offspring

• S/S– Café-au-lait spots (>6)– Axillary or inguinal freckling– Lisch nodules - iris– Elephantiasis – esp. genitalia & lower extremities– Other characteristics

CAFÉ-AU-LAIT

• Dx – will cover under neuro!– Made by physical findings– Criteria for diagnosis: need at least 2 findings**– In doubtful cases: nodule biopsy

• Treatment– No cure!– Limited only to excision of tumors which produce

pain or impair function– Symptomatic management

• Nursing– Recognize signs of the disease– Referral– Family counseling (National Neurofibromatosis

Foundation)– Support

LYME DISEASE• The most common tick-borne disorder

in the United States• Caused by the spirochete, Borrilia

burgdorferi, which enters the bloodstream through the saliva and feces of ticks

• Deer is usually the vector • Different deer tick depending on the

location in the US• Tick = 2-4mm in length

• S/S: 3 stages:• Stage 1:– Tick bite at the time of inoculation– 3-32 days after inoculation– ECM = erythema chronicum

migrains at site of the tickbite– Location of lesions– Other S/S– S/S disappear in 3-4 weeks if

untreated

• Stage 2:– S/S appears 2-11 weeks after the cutaneous phase– Most serious stage of the disease– Systemic involvement: neurological, cardiac and

musculoskeletal– Most common s/s is HEADACHE followed by other

neurological features due to neurological involvement– Cardiac s/s usually occurs after 4-5 weeks

• Stage 3:– Also called the late stage– Includes musculoskeletal pains: tendons, bursae,

muscle and synovia + chronic arthritis– May develop moths or years later– Chronic arthritis– Late neurological problems: deafness, keratitis

(leading to decreased vision) and chronic encephalopathy

• Dx– Based primarily on

• History• Assessment of the lesion• Development of clinical manifestation

– Laboratory diagnosis – in the LATER stages through serologic testing:• Indirect immunoflurescence (IFA)• Enzyme immunoassay (EIA)• Plymerase chain reaction (PCR) – enables

identification of spirochetes with a high degree of accuracy

– Note: • Serology testing at time of recognized tick

bite is NOT diagnostic• Serology testing is not standardized

• Treatment

– Symptom relief with aspirin (preferred) or prednisone

– Oral Doxycycline or Amoxicillin (>8/9 years)

– Amoxicillin or Penicillin (<8/9 years old)

– Other antibiotics if PCN allergy

– Length of treatment depends on the clinical response

– Goal of early treatment

– Later stages – IV/IM antibiotics; more serious i.e. cardiac involvement

– More intense treatment specific for systems

– VACCINE: LYMErix

• Nursing– PREVENTION!!!!!– Education

• Environmental exposure• What to wear – white, light, fully covered• Examine for ticks• Skin repellents in children > 1 year:

– DEET (Diethyltoluamide)– Permathrin (Permanone Tick Repellent)– Use ONLY on clothing!!!

• How to remove ticks appropriately (see hand-out)

• National Lyme Borrelliosis Foundation• National Lyme Disease Association

SMALLPOX• Serious, contagious and sometimes fatal infection

• No specific treatment, ONLY PREVENTION = Vaccine (currently available for the majority of the population in the US)

• 2 clinical forms of smallpox– Variola major – severe and most common: 4 types– Variola minor – less common and less severe with

only 1% death rate

• Disease is eradicated (vaccine) – no longer used

• Last case of smallpox in the US was in 1949

• Last naturally occurring case was in Somalia in 1977

• Why are we concerned?– Agent of bioterrorism!

• Transmission– Face-to-face contact

– NOT airborn!

– HUMANS are the only hosts

• Stages of Smallpox – Incubation period – NOT contagious!

– Predome phase – usually not contagious until rash appears

– Early rash = MOST contagious

– Pustular rash

– Pustules and scabs

– Resolving scabs

– Scabs resolved – no longer contagious

• PREVENTION:

– Vaccine!!!

– Live vaccine (made from virus called vaccinia = “pox” type virus related to smallpox)

– Present vaccine is 95% effective

– Immunity from vaccine is 3-5 year

– Administration of the vaccine:

• Bifurcated (two-pronged) needle

• “pox” at vaccine site can last up to 2 weeks

– Vaccination within 3 days of EXPOSURE to smallpox will prevent or significantly lessen the severity of smallpox symptoms

– Contraindication for vaccine – eczema, asthma

SMALLPOX VACCINE

SMALLPOX will lead us into

SG# 13…… Neuro

THE END!