Altered Integument Concept Maps

Gary Schofield, RN

DISORDERS OF THE SKIN

INFLAMATORY

Eczema, Atopic, Dermatitis-Contact (Allergic, Irritant), Stasis, Seborrheic

Infections

Bacterial: Folliculitis, Foruncle, Carbuncles, Cellulitis, Erysipelas

Viral: Herpes (Simplex,Zoster, Varicella), Warts

Fungal: Tinea, Candidiasis

Papulosquamos

Inflamatory process associated with papules, scales, plaques, & erythema

Psoriasis, Pityriasis Rosea, Lichen Planus, Acne (Vulgarius, Rosacea), Lupus Erythematous [Dicoid (DLE) Systemic (SLE)]

Vesiculobullous (Vesicle Formation)

Pemphigus (Vulgaris,Vegetans, Foliaceus, Erythematous)

Bullous Phemphoid

Erythema Multiforme: (Steven-Johnson Syndrome & Toxic Epidermal Necrolysis)

Vascular

(Commonly assoc. with skin disease)

Cutaneous vasculitis

Urticaria

Scleroderma

Insect Bites

Ticks (Rocky Mt Spotted Fever, Lyme Disease)

Mosquitoes (Malaria, Yellow Fever)

Flies

Benign Tumors

Seborrheic Keratosis

Keratocanthoma

Actinic Keratosis

Nevi (moles)

Cancer

Basal Cell (Surface epithelial -Most Common)

Squamous Cell -Epidermis

Malignan Melanoma –originates in melanocytes

Kaposi Sarcoma –vascular malignancy

Clinical Manifestations of Skin Dysfunction

Lesions, Keloids, Pressure Ulcers, Pruritis,

Disorders of the Hair

Alopecia (Male pattern, Female pattern)

Areata – usually temporary baldness

Hirsutism – could indicate polycystic ovaries, adrenal hyperplasia, or adrenal tumor

Disorders of the Nail

Paronychia – acute or chronic infection of the cuticle

Onychomycosis – fungal or dermatophyte infectionof the nail plate

Frost Bite

Affects fingers, ears, toes, & cheeks

Skin Diagnostic Procedures

Skin Biopsy

Microscopic Immunofluorescense

Gram Stain

Culture

Wood Lamp Exam Patch & Scratch Tests

Skin Scrapings

Side Lighting

Diascopy

Tzanck

Skin Lesions

Primary SecondaryMacule – ↓ 1cm, flat, change in color

Papule – ↓ 1 cm, elevated and firm

Patch – Flat, nonpalpable, ↑ 1 cm

Plaque – elevated, firm, rough, ↑ 1cm

Wheal – elevated, irregular shape, solid, transient

Nodule – elevated, firm, circumscribed, deeper in dermis 1-2 cm

Tumor – elevated, solid, clearly demarkated, deeper in dermis ↑ 2 cm

Vesicle – elevated circumscribed, superficial, filled with serous fluid ↓ 1cm

Bulla - vesicle ↑ 1 cm

Pustule – elevated, superficial, filled with purulent fluid

Cyst – elevated, circumscribed, encapsulated, dermis/ subcutaneous layer, liquid filled or semisolid

Telangiectasa – fine, irregular red lines, capillary dilation

Scale – heaped-up, keratinized cells, flaky skin

Lichenification – rough, thickened epidermis, flexor surface of extremity

Keloid – irregular-shaped, elevated, enlarging scar, beyond boundaries of the wound, excessive collagen formation during healing

Scar – thin-thick fibrous tissue that replaces normal skin, to the dermis

Excoriation – loss of the epidermis, linear, hollowed-out, crusted area

Fissure – linear crack or break from the epidermis to dermis, may be moist or dry

Ulceration – loss of epidermis and dermis, concave, varies in size

Atrophy – thinning of the skin surface, loss of skin markings

Special Lesions

Comedone – a plug of sebaceous and keratin material lodged in a hair follicle (Blackhead

Burrow – narrow, raised, irregular cannel caused by parasite

Petechiae – circumscribed area of blood less than 0.5 cm in diameter

Purpura – circumscribed area of blood greater than 0.5 cm in diameter

Skin Disorders in Children

Minor to Severe

Localized or General

Acne Vulgaris

Most common skin disease; affects 85% population ages 12-25. Severe acne runs in families; Causes unknown

Dermatitis

Atopic – most common cause of eczema in children

Diaper – most common skin disorder of infancy/early childhood Insect Bites/

Paracites

Scabies – contagious; caused by itch mite

Pediculosis -lice

Fleas

Bedbugs

Infections

Vascular Disorders

Strawberry Hemangioms – raised vascular lesions

Cavernous Hemangioma –larger more mature vessels than above

Salmon Patches – macular, pink lesions fade with age

Port-Wine stains – congenital malformations of dermal capillaries; does not fade with age

Other

Milaria –dematosis common in infants

Erythema Toxicum

Neonatorum

Toxic Epidermal Necrolysis – hypersensitive reactions to drugs usual cause; treat like burn; must differientiate with biopsy

Viral

Molluscum Contagiosum – highly contagious

Rubella- German Measles

Rubeola – highly contagious

Roseola – 6mos – 2 y/o

Chicken Pox/ Herpes Zoster - Varicella

Bacterial

Impetigo – Bullous (Staph aureus), Vesicular (Group A Strep), Staphyloccal Scalded-Skin Syndrome [(SSSS)- usually seen in infants and children <5 years]

Fungal

Tina Capitis- involves scalp; most common fungal infection 2-10 yrs

Tina Corporis- superficial dermatophyte

Thrush – Candida in mucous membranes of month

Exposure (Sunlight) = Ultraviolet Radiation

Strongest 10:00am – 3:00pm

Protection during 1st 10-20 yrs ↓ risk

Mutation of p53 tumor

Suppressor Gene

Outdoor Workers = ↑ incident

Basal Cell Carcinoma

Squamous Cell Carcinoma

Malignant Melanoma

3 Stages of Growth

- Initiation

- Progression

- Metastasis

Treatment

Rad Theapy, Surgery,

Electrodisiccation, Cryosurgery

No metastasizes beyond the skin

Less common in dark-skinned people Melanin- Protective Factor

Slow Growth Rate

Results of a defect that prevents shedding of cells by normal keratinization process

Lack of normal keratin proteins

Start as a nodule

Affects epidermis

Significantly more malignant than basal cell if untreated

75% of cases located on neck and head

Countries with high arsenic in drinking water have ↑ predonminance

Malignant tumor of the skin

Originates in melanocytes

Incidence is increasing

Young-Middle Age Adults ↑ risk

Nevus (mole) – aggregation of melanocytes

Most are not suspicious

Suspect = Removal

Biopsy

- Color and/or size change

- Irregular notched margin

- Itching, Bleeding, Oozing, Nodularity

- Scab formation or Ulceration

Nevus Types

● Junctional

● Compound

● Intradermal

Clinical Varieties of Cutaneous Melanoma

Primary Nodular Melanoma (PNM)

Superficial Spreading Melanoma (SSM)

Lentigo Malignant Melanoma (LMM)

Malignant Degeneration of

Melanocytes

Basal Layer of Epidermis

Benign Melanocvtic Nevus

10-15% of cutaneous menanoma

50-80 yrs old at diagnosis

Location: Head, Neck, Dorsum of Hands

Pigmentation According to Thickness

● <1.5 mm (Level I,II) Tan & Brown

● >1.5mm (Level III) Tan, Brown Blue-Black

● >1.5mm (Level IV,V) Nodule

70% of Cutaneous Melanoma

Location: Legs of Females & ↑ Back Both Genders

20-60 yrs at diagnosis

12% of Cutaneous Melanoma

No Specific Site Preference

>1.5 mm (Level III) small nodule, any hue

>1.5 (Level IV,V) large nodule, any hue

Risk Factors

Malignant Melanoma

Genetic Predisposition

Facial Hair

Freckles

Light Skin

Easy to Sunburn

Steroid Hormone Activity

Exposure to UV Light Solar and Artificial

Acral-Lentiginous Melanoma

2-8% Whites, 75% Blacks, Hispanic, Asian

20-60 yrs old

Palms, Soles of Feet, Mucous Membranes Affected

Blue-Black in hue

References:Corwin, E. J. (2000). Handbook of Pathophysiology (2nd ed.). Philadelphia, PA: Lippincott.

Nicol, N. H. & Huether, S. E. (2006). Alterations of the integument in children. In K. L. McCance & S. Huether (Eds.), Pathophsiology: The Biologic Basis for Disease in Adults & Children (pp.1609- 1623). St Louis, MO: ElSevier Mosby.

Nicol, N. H., Huether, S. E. & Weber, R. (2006). Structure, function, and disorders of the integument. In K. L. McCance & S. Huether (Eds.), Pathophsiology: The Biologic Basis for Disease in Adults & Children (pp.1573-1607). St Louis, MO: ElSevier Mosby.