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Inflammatory and Infectious Disorders of the Skin
Objectives1. Describe and discuss, Dermatitis, Acne
Vulgaris , Urticaria, Psoriasis, Seborrheic Keratosis. Scleroderma, Systemic Lupus Erythematous, Shingles,scabies, and impetigo as to definition, etiology, pathophysiology, signs and symptoms, diagnosis, medical and nursing management.
2. Apply the nursing process for clients with inflammatory and infectious disorders of the skin.
3. Recognize systemic disorders with dermatologic symptoms.
Dermatitis
A general term used to describe inflammation of the skin.
Description
Most types of dermatitis are characterized by an itchy pink or red rash
Pruritus: itching
May be localized or generalized
Types of Dematitis1. Allergic or contact dematitis is an
allergic reaction to something that irritates the skin and is manifested by one or more lines of red, swollen, blistered skin that may itch or seep.
It usually appears within 48 hours after touching or brushing against a substance
to which the skin is sensitive. More common in adults than in children.Etiology: in patients with allergies, sensitized
mast cells in the skin release histamine, causing a red rash, itching, and localized swelling
Types of Dermatitis2. Irritant dermatitis is a localized
reaction that occurs when the skin comes into contact with a strong chemical such as a detergent
Etiology: the caustic quality of the substance damages the protein structure of the skin or eliminates secretions that protect it.
Dermatitis
Contact dermatitis of the (left) face and (right) wrist
Dermatitis
Contact dermatitisVesiculation: blister formation and oozingCan occur on any part of the body, but it
usually affects the hands, feet, and groin. Contact dermatitis usually does not
spread from one person to another, nor does it spread beyond the area exposed to the irritant unless affected skin comes into contact with another part of the body.
Contact dermatitisMedical Management: Remove the source
of irritationFlushing the skin with cool waterBurow’s solution wet dressingsTopical lotions such as calamineAntihistamines such as Benadryl
(diphenhydramine)Corticosteroids: topically or orally
POISON IVY
Poison Ivy/Oak
Poison Ivy Rash
Atopic Dermatitis
This form of dermatitis, commonly referred to as eczema, is a chronic condition that causes itchy, inflamed skin.
Most often, it occurs in the folds of the elbows, backs of the knees or the front of the neck.
It tends to flare periodically and then subside for a time, even up to several years.
The exact cause of this skin disorder is unknown, but it may result from a malfunction in the body's immune system.
Atopic Dermatitis: Eczema
Eczema: Atopic Dermatitis
Dermatitis
Pathophysiology and EtiologyTypes: Allergic contact; primary irritant
Assessment FindingsBlood vessel dilation; itching; vesiculationSkin patch test; visual examination
Acne Vulgaris
Acne of (left) the face and (right) the chest
Acne VulgarisCondition which coincides with puberty;
believed to be related to hormone levels that occur when secondary sex characteristics are developing.
An inflammatory disorder that affects the sebaceous glands and hair follicles
Severity of the condition varies from minimal to severe
Acne Vulgaris Pathophysiology and Etiology
Overproduction of sebumAssessment Findings
Comedones (blackhead); oily scalpVisual examination
Medical Management Gentle facial cleansing; drying agents
containing benzoyl peroxide Topical and oral drugs and antibiotics Removal with instruments
AcneDevelops as a result of blockages in follicles.
Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change.
Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen production .
The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead).
Increased sebum production provides an environment for the overgrowth of Propionibacterium acnes.
AcneSevere cases can cause permanent
scarringMedical Management: Gentle facial
cleansing and non-prescription agentsDrug therapy: Retin-A (tretinoin) topically
or Accutane (isotretinoin) orally Antibiotics: tetracycline and erythromycin
Acne Vulgaris Surgical Management
Dermabrasion for surface scarring Nursing Management
Client teachingCleanliness: Face and hairAvoid cosmetics, Manipulation of lesionsPrecautions for pregnant women: Risk
associated with systemic oral Retin - A (isotretinoin) for birth defects
Rosacea A chronic skin disorder that manifest in a
variety of waysUsually characterized by a rosy appearanceCause is unknown: possible genetics,
immunological factors, exposure to UV light, bacterial skin infection with Helicobacter pylori
or a mite infestation of the facial hair folliclesOver time, continued dilation of facial
capillaries and arterioles causing visible streaks on the skin called telangiectases
Rosacea
RosaceaS/S: Flushing of skin, like a persistent
sunburn, face appears swollen and baggy, facial pores enlarge, nose becomes enlarged (rhinophyma)
Medical Management: Antibiotics, topical medications Laser treatments; pulsed light treatmentsNursing management: patient teaching re:
reduce sun exposure, gentle cleansing, stress-management
Furuncles, Furunculosis and CarbunclesFuruncle: a boilFurunculosis: multiple furnuculosisCarbuncle: a furuncle which drains pus
Causes: skin infections caused by bacteria which normally live harmlessly on the skin
Predisposition by: diabetes, poor diet and general health, immunodepression
Furuncle - Boil
Furuncle - TreatmentC&S of pathogenHot wet soaks, antibiotics, surgical incision
and drainage (I & D)Strict aseptic technique when changing
dressings to avoid spreading the infection to other parts of the body
Question Is the following statement true or false?
Furuncles, furunculosis, and carbuncles are treated with antibiotic therapy.
AnswerTrue.
Furuncles, furunculosis, and carbuncles are the result of skin infection or diabetes mellitus. A culture and sensitivity lab result indicates the proper antibiotic to use in treatment.
Psoriasis
Pathophysiology, Etiology: Likely genetic predisposition; Keratinocytes; Plaque
Assessment Findings: Signs and Symptoms Erythema with silvery scales; Lesions
Diagnostic Findings: Visual examination; Skin biopsy
Medical Management: Symptomatic treatment; Drug therapy; Biologic therapy;
Photochemotherapy
PsoriasisNamed for the Greek word psōra meaning
"itch," psoriasis is a chronic, non-contagious disease characterized by inflamed lesions covered with silvery-white scabs of dead skin.
Psoriasis
Psoriasis
Psoriasis on the elbows
Psoriasis
PathophysiologyNormal skin cells mature and replace
dead skin every 28–30 days. Psoriasis causes skin cells to mature in
less than a week. Because the body can't shed old skin as
rapidly as new cells are rising to the surface, raised patches of dead skin develop on the arms, back, chest, elbows, legs, nails, folds between the buttocks, and scalp.
Psoriasis is considered mild if it affects less than 5% of the surface of the body; moderate, if 5–30% of the skin is involved, and severe, if the disease affects more than 30% of the body surface.
Nursing Process: The Client With Psoriasis
AssessmentSkin integrity; appearanceFamily history of psoriasisTriggering factors
Diagnosis, Planning, and Interventions Impaired skin integrity Disturbed body image
Nursing Process: The Client With Psoriasis
Evaluation of Expected OutcomesImproved integrity and appearance of skinReduced itching; copes effectively with
altered appearance
PediculosisDIAGNOSIS
Head and pubic lice infestations are diagnosed by finding lice or viable eggs (nits) on examination. Excoriations and pyoderma (any pus-containing skin infection) also may be present.
Pediculosis - TreatmentTopical Agents - Over-the-counter agents
approved by the U.S. Food and Drug Administration (FDA) belong to the pyrethrum group of insecticides (pyrethroids). Both 4 percent piperonyl butoxide 0.33 percent pyrethrins (e.g., Rid, Pronto) and 1 percent permethrin (Nix) are safe and effective. Experts consider permethrin as the treatment of choice.
Oral Agents. Ivermectin (Stromectol), in an oral dose of 200 mcg per kg, effectively kills nymphs and lice, but not eggs. To kill newly hatched nymphs, a second dose should be given seven to 10 days after the first dose..
Scabies Pathophysiology, Etiology: Itch mite; Spread by
skin-to-skin contactAssessment Findings: Signs and Symptoms
Itching; Excoriation Diagnostic Findings: Visual examination; Ink or
mineral oil test Medical Management: Scabicide application;
Thorough bathing, clean clothing, avoiding contact with those infected
Nursing Management
Scabies Mite
Scabies
TreatmentApply a mite-killer like permethrin (brand name: Elimite). These creams are applied from the neck down, left on
overnight, then washed off. This application is usually repeated in seven days. An
alternative treatment is 1 ounce of a 1% lotion or 30 grams of cream of lindane, applied from the neck down and washed off after approximately eight hours.
Since lindane can cause seizures when it is absorbed through the skin, it should not be used if skin is significantly irritated or wet, such as with extensive skin disease, rash, or after a bath.
As an additional precaution, lindane should not be used in pregnant or nursing women or children younger than 2 years old.
Lindane is only recommended if patients cannot tolerate other therapies or if other therapies have not been effective.
2. An oral medication, ivermectin, is an effective scabicide that does not require creams to be applied.
3. Antihistamines, such as diphenhydramine (Benadryl) can be useful in helping provide relief from itching.
4. Wash linens and bedclothes in hot water. Because mites don't live long away from the body, it is not necessary to dry-clean the whole wardrobe, spray furniture and rugs, and so forth.
5. Treat sexual contacts or relevant family members (who either have either symptoms or have the kind of relationship that makes transmission likely).
Dermatophytoses
Dermatophytose: Tinea: Caused by a parasitic fungi; which invade skin, scalp, and nailsRingworm; Athlete’s foot; Jock itch
Assessment Findings: Rings of papules or vesicles; Sore skin
Medical Management: Oral, topical antifungal agents
Burow’s solution, Micatin (miconazole)Nursing Management: keeping skin day, avoid
excessive heat and humidity, dry socks, don’t go barefoot in locker rooms
Ringworm - fungus (tinea corporis)
Ringworm - fungus
Athelete’s foot - fungus (tinea pedis)
Dermatophytoses
Tinea named after the location on the bodyTinea pedis - footTinea capitis - headTinea corporis - bodyTinea cruris - groin
Shingles - Viral infection
Also called Herpes Zoster: Varicella-zoster virus; Inflammation in dermatome
Virus remains dormant in the nerve rootsMore common in older adults and people who
are immunocompromised Assessment Findings: Signs and Symptoms
Fever; Headache; Vesicles; Itching, pain Medical Management: Oral or topical Zoviraz
(acyclovir); CorticosteroidsNursing Management : warm soaks, avoid
contact with immunocompromised patients
Shingles - Herpes Zoster
ShinglesPatient is placed on AIRBORNE
PRECAUTIONS: (particles are less than 5 mcg)
Private room or cohort room; Masks, gowns and gloves for all patient care
Door to room should remain closedShould be negative air pressure roomPregnant health care personnel who have
not had chickenpox probably should not care for the patient
Shingles
Herpes Simplex - A recurrent viral disease caused by the herpes simplex virus
a. type one - marked by the eruption of fluid-containing vesicles on the mouth, lips, or face.
b. type two - marked by the eruption of fluid-containing vesicles on the genitals
Treatment
Acyclovir (Zovirax) is the drug of choice for herpes infection and can be given intravenously or taken by mouth or ointment but is not very useful in this form. A liquid form for children is also available.
Herpes Simplex
UrticariaA vascular reaction pattern of the skin
marked by the transient appearance of smooth, slightly elevated patches that are more red or more pale than the surrounding skin and are accompanied by severe itching.
Also called hives.
Non-allergic urticaria
Mechanisms other than allergen-antibody interactions are known to cause histamine release from mast cells. For instance, a diverse group of signaling substances called neuropeptides have been found to be involved in emotionally induced urticaria.
Urticaria
Uticaria - Hives
UrticariaAn acute or chronic condition
characterized by the appearance of itchy weals on the skin.
The cause may be an allergy to certain foods , drugs, emotional stress, or local skin irritation resulting from contact with certain plants.
Athletes sometimes develop hives while exercising (exercise-induced urticaria). The hives are small and seem to develop in response to the release of histamines associated with the increase in body temperature produced by exercise.
Urticaria
Treatment & Management
Most treatment plans for urticaria involve being aware of one's triggers.
If one's triggers can be identified then outbreaks can often be managed by limiting one's exposure to these situations.
Drug treatmentTypically in the form of Antihistamines such as
diphenhydramine, hydroxyzine, cetirizine and other H1 receptor antagonists. These are taken on a regular basis to protective effect, lessening or halting attacks.
For some people, H2-receptor antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) can also help control symptoms either protectively or by lessening symptoms when an attack occurs.
When taken in combination with a H1 antagonist it has been shown to have a synergistic effect which is more effective than either treatment alone.
Seborrheic Keratosis
A superficial, benign, verrucose lesion consisting of proliferating epidermal cells enclosing horn cysts, usually appearing on the face, trunk, or extremities in adulthood.
Seborrheic Keratosis
Sign And SymptomsThe growths resemble flattened or
raised warts, but have no viral origins and may exhibit a variety of colors, from pink or yellow through brown and black.
Because only the top layers of the epidermis are involved, seborrheic keratoses are often described as having a "pasted-on" appearance.
EtiologyA mutation of a gene coding for a
growth factor receptor (FGFR3), has been associated with seborrheic keratosis.
Treatment
Because the tumors are rarely painful, treatment is not often necessary.
If a growth becomes excessively itchy, or if it is irritated by clothing or jewelry, cryosurgery has been found to be highly effective in their removal.
With resemblance to malignant melanomas, which has sometimes led to a misdiagnosis of the cancerous lesions. If there is any doubt, a skin biopsy will allow a physician to make a correct diagnosis.
SclerodermaScleroderma is a progressive disease that
affects the skin and connective tissue (including cartilage, bone, fat, and the tissue that supports the nerves and blood vessels throughout the body).
There are two major forms of the disorder. Localized scleroderma mainly affects the skin. Systemic scleroderma, which is also called systemic sclerosis, affects the smaller blood vessels and internal organs of the body.
Scleroderma
SCLERODERMA
SclerodermaIs an autoimmune disorder, which
means that the body's immune system turns against itself. In scleroderma, there is an overproduction of abnormal collagen (a type of protein fiber present in connective tissue). This collagen accumulates throughout the body, causing hardening (sclerosis), scarring (fibrosis), and other damage.
TherapyThere is no cure for every patient with
scleroderma, though there is treatment for some of the symptoms, including drugs that soften the skin and reduce inflammation. Some patients may benefit from exposure to heat.
A range of NSAIDs (nonsteroidal anti-inflammatory drugs) can be used to ease symptoms, such as naproxen. If there is esophageal dysmotility .Care must be taken with NSAIDs as they are gastric irritants, and so a proton pump inhibitor (PPI) such as omeprazole can be given in conjunction.
TreatmentImmunosuppressant drugs, such as
mycophenolate mofetil (Cellcept®) or cyclophosphamide are sometimes used to slow the progress.
Digital ulcerations and pulmonary hypertension can be helped by prostacyclin (iloprost) infusion. Iloprost increases blood flow by relaxing the arterial wall.
Sytemic Lupus ErythematousLupus is a condition characterized by
chronic inflammation of body tissues caused by autoimmune disease.
Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system.
SLE - NECK
Systemic Lupus Erythematosus• Medical Management: Producing remission; Prevent/Treat
exacerbations; Medications
– Renal, Cardiac, GI, CNS symptomatic treatment
• Nursing Management
Systemic Lupus Erythematosus (SLE)
Pathophysiology, Etiology: Unknown triggering mechanism; Destruction of diffuse connective tissues; Affects multiple body systems; Autoimmune; Great imitator
Assessment Findings: Signs and SymptomsClinical signs; Facial rash; Behavioral
disturbances; Fluid retention; Proteinuria; Hematuria; Many others
Diagnostic Findings: Presenting symptoms; Blood tests; Renal biopsy; Urinalysis
EtiologyThe precise reason for the abnormal
autoimmunity that causes lupus is not known.
Inherited genes, viruses, ultraviolet light, and drugs may all play some role.
What is drug-induced lupus?
Dozens of medications have been reported to trigger SLE; however, more than 90% of this "drug-induced lupus" occurs as a side effect of one of the following six drugs: hydralazine (used for high blood pressure), quinidine and procainamide (used for abnormal heart rhythm), phenytoin (used for epilepsy), isoniazid ( used for tuberculosis), d-penicillamine (used for rheumatoid arthritis). These drugs are known to stimulate the immune system and cause SLE.
Criteria used for diagnosing SLE:
Molar rash (over the cheeks of face) “butterfly rash
Discoid skin rash: patchy redness that can cause scarring
Photosensitivity: skin rash in reaction to sunlight exposure
Mucus membrane ulcers: ulcers of the lining of the mouth, nose or throat
Arthritis: two or more swollen, tender joints of the extremities
Kidney abnormalities: abnormal amounts of urine protein or clumps of cellular elements called casts
Pleuritis/pericarditis: inflammation of the lining tissue around the Heart or lungs, usually associated with chest pain with breathing
Brain irritation: manifested by seizures (convulsions) and/or psychosis
Blood count abnormalities: low counts of white or red blood cells, or platelets
Immunologic disorder: abnormal immune tests include anti-DNA or anti-Sm (Smith) antibodies, falsely positive blood test for syphilis, anticardiolipin antibodies, lupus anticoagulant, or positive LE prep test
Antinuclear antibody: positive ANA antibody testing
TreatmentThere is no permanent cure for SLE. The goal of treatment is to relieve symptoms
and protect organs by decreasing inflammation and/or the level of autoimmune activity in the body.
Many patients with mild symptoms may need no treatment or only intermittent courses of anti - inflammatory medications.
Damage to internal organ(s) may require high doses of corticosteroids in combination with other medications that suppress the body's immune system.
Scalp and Hair Disorders: Seborrhea, Seborrheic Dermatitis, Dandruff
Pathophysiology, Etiology: Pityrosporum ovale Assessment Findings: Signs and Symptoms
Oily hair; Red or scaly patches on scalp; White flakes from hair; Itching
Diagnostic Findings: Laboratory blood work; Skin biopsy
Medical Management: Medicated shampoos; Corticosteroids
Nursing Management
Alopecia Pathophysiology, Etiology: Alopecia areata;
Androgenetic alopecia (male pattern baldness)Assessment Findings: Signs and Symptoms
Thinning hair Diagnostic Findings: Determined by suspected
physical disorderMedical, Surgical Management: Treating the
underlying medical disorder; Drug therapy; Hair replacement surgery; Hair grafting; Scalp reduction; Skin flap transfer
Nursing Management
Patterns of Hair loss
Head Lice
Pathophysiology, Etiology: Transmitted through direct contact
Assessment Findings: Signs and Symptoms Itching of scalp; Small, yellowish-white ovals
(nits) attached to hair shafts; Small grey nymphs; Silvery eggs (nits) attached to hair shafts
Diagnostic Findings: Scalp, hair inspectionMedical Management: Pediculicides;
Mechanical removal Nursing Management
Head Lice
Head Lice
Head Lice
Nail Disorders: Onychomycosis
Pathophysiology, Etiology: Fungal infectionAssessment Findings: Signs and Symptoms
Thick, distorted; Yellow, friable nailsDiagnostic Findings: Visual inspection;
Microscopic examinationMedical, Surgical Management: Prolonged
systemic drug therapy; Nail removal; SurgeryNursing Management
Onychomycosis - fungal infection of toenails
Onychocryptosis - Ingrown toenail
Pathophysiology, Etiology: Inherited trait; Fungal nail infections
Assessment Findings: Signs and Symptoms Swelling; Pain; Purulent drainage; Odor
Diagnostic Findings: Physical examination Medical, Surgical Management: Local, systemic
antibiotic therapy; SurgeryNursing Management
Onychocryptosis
Onychomycosis and Onychocryptosis
Both conditions usually treated by a podiatrist
May require surgeryNursing Management: foot-soaks, wear
wide shoes and loose socks; keep feet clean and dry
INFECTIOUS DISORDERS OF THE SKIN
Bacteria, viruses, fungi, or parasites can cause infectious disorders of the skin.
Treatment includes topical and systemic medications.
Preventing the spread of infection to others is important.
Impetigo
Bacterial Infection- Impetigo Impetigo : caused by the bacteria
Staphylococcus aureus, (staph), and less frequently, by group A beta-hemolytic streptococci, (strep)
Highly contagious. Spreads quickly from one part of the body to another through scratching. It can also be spread to other people if they touch the infected sores or if they have contact with the soiled clothing, diapers, bed sheets, or toys of an infected person.
Such factors as heat, humidity, crowded conditions, and poor hygiene increase the chance that impetigo will spread rapidly among large groups.
DiagnosisObservation of the appearance, location
and pattern of sores is the usual method of diagnosis. Fluid from the vesicles can be cultured and examined to identify the causative bacteria.
Treatment
Uncomplicated impetigo is usually treated with a topical antibiotic cream such as mupirocin (Bactroban).
Oral antibiotics are also commonly prescribed. Patients are advised to wash the affected areas
with an antibacterial soap and water several times per day, and to otherwise keep the skin dry.
Scratching is discouraged, and the suggestion is that nails be cut or that mittens be worn—especiallly with young children.
Ecthyma is treated in the same manner, but at times may require surgical debridement, or removal of the affected area.
Exfoliative DermatitisExfoliative dermatitis is widespread scaling
of the skin, often with itching (pruritus), skin redness (erythroderma), and hair loss. It may occur in severe cases of many common skin conditions, including eczema, psoriasis, and allergic reactions.
A person with erythroderma or exfoliative dermatitis often needs hospital care or admission to an intensive-care burn unit.
EXFOLIATIVE DERMATITIS
Localized symptoms include erythema, severe pruritis, extensive scaling, skin sloughing.
Affects the entire body.Chills, fever, and malaise.Treatment includes fluids, corticosteroids,
antibiotics, medicated baths, analgesia.
Exfoliative Dermatitis
Exfoliative Dermatitis
Stevens Johnson Syndrome
Stevens Johnson SyndromeA severe, occasionally fatal, inflammatory
disease of children and young adultsA form of toxic epidermal necrolysis in
which the epidermis separates from the dermis, leaving the client with a skin loss similar to a second degree burn
Characterized by fever, bullae of the skin, and ulcers of the mucous membranes of the nose, mouth, eyes, and genitalia.
May occur from a hypersensitivity reaction to drugs
