Integumentary

Infections Conditions and Cancer

1. Folliculitis –i.e. shaving bumps

   1. Bacterial infection of the hair follicle
2. Causative organism:

   1. Staph aureus
3. Most commonly seen in males with curly hair
4. Precipitating factors:

   1. Friction on the skin
   2. Blockage of the follicle
   3. Injury to the follicle

1. S/S:

   1. Itching (pruritis)
   2. Pustules or papules with a surrounding area of erythema
   3. Abscess development

Folliculitis

Treatment

1. Treatment

   1. Topical antibiotics
   2. Saline soaks
   3. Warm moist packs
   4. Keep area clean
   5. Change razor heads
   6. Avoid using the same washcloths

1. Furuncle –boil

   1. Bacterial infection or deep folliculitis
2. Causative Organism: staph aureus
3. Most commonly seen in:

   1. Obese
   2. Malnourished
   3. Fatigued individuals
   4. Poor hygeine
   5. Debilitated
   6. Elderly
   7. DM

1. Precipitating factors

   1. Immunodeficiency
   2. Hot climate

Furuncle

S/S

1. S/S:

   1. Deep, firm, erythema, painful nodule
   2. Core turns yellow/white & "points" (looks like the tip of a cone)
   3. Develops in approx 3-5 days
   4. May rupture spontaneously’
2. Common sites: neck, axillae, buttocks, face, thigh

Furuncle

Treatment

1. Treatment

   1. Systemic or local antibiotics
   2. Warm moist compresses
   3. May incise & drain (use topical antibiotic after)
2. Prevention

   1. Do not share articles
   2. Wash hands meticulously!

1. Carbuncle -Abscess

   1. Cluster of furuncles

Carbuncle

S/S

1. S/S

   1. Fever
   2. Leukocytosis
   3. Pain
   4. Nodules contain foul smelling yellow drainage
2. Treatment

   1. IV antibiotics
   2. I & D

1. Cellulitis -infection involving the dermis, SQ, & lymphatics

   1. Diffuse & spreading in nature
   2. Causative Organism: staph aureus,Group B-hemolytic strep, MRSA

Cellulitis

S/S

1. S/S

   1. Bacteria usually invade the tissue via new or existing breaks in the skin surface area
   2. Erythema, warmth, edema, pain, poorly defined borders
   3. Chills, fever, malaise
   4. Leukocytosis

Cellulitis

Risk Factors

1. Risk Factors -

   1. DM
   2. Animal bites
   3. Human bites
   4. Trauma to the skin
   5. Insect stings
   6. Ulcers
2. IF LEFT UNTREATED, WILL SPREAD TO SURROUNDING TISSUE & MAY RESULT IN SEPSIS, GANGRENE, OR BOTH

Cellulitis

Diagnosis

1. Diagnosis

   1. Tissue & blood cultures
2. Treatment

   1. Warm moist dressings
   2. Systemic antibiotics (PO or IV)
   3. Rest with the extremity elevated
3. Prevention

   1. Teach to prevent the spread of infection:
   2. Handwashing
   3. Disposal of contaminated articles

1. Types of Herpes SimplexVirus-

   1. HSV –1 (Type 1): Herpes Febralis
   2. HSV –2 (Type 2): Herpes Genitalia
2. Other Types

   1. Human Herpes Virus 6 (HHV-6)-Roseola in children
   2. Herpes Zoster (shingles)
   3. Epstein-Barr Virus (HHV-4)
   4. Cytomegalovirus (CMV)-(HHV-5)
   5. Varicella Zoster (Chickenpox)-(HHV-3)

Skin Infections- Viral

Herpes simplex

1. Herpes Simplex –

   1. Self limiting vesicles erupt singly or in groups that contain exudate that crusts when lesions rupture
   2. Commonly infects the skin & mucus membranes
2. Type I –fever blisters, cold sores,
3. Type II –genitalia (STD)

   1. Male: head of penis/shaft, inner thigh, buttocks
   2. Female: vaginal opening, labia, cervix, buttocks

1. Transmission

   1. Physical contact
   2. Oral sex
   3. Kissing
   4. Child birth
2. Factors involved in reoccurrence

   1. Sunlight exposure
   2. Menstruation
   3. Stress
   4. Wind exposure
   5. Fever
   6. Physical injury
   7. Immunosuppression

Herpes Simplex

S/S

1. S/S:

   1. Initial burning & itching
   2. Painful small group of vesicles
   3. Honey colored crust forms
   4. Usually lasts 2-3 wks, but may up to 6 wks
   5. Nearby lymph glands maybe swollen
2. Teaching:

   1. Wear gloves
   2. Transmitted by direct contact
   3. The body does not eradicate the virus!
   4. Careful inspection at child birth

Herpes Simples

Treatment

1. •Treatment
   1. •Symptomatic relief
   2. Analgesics
   3. •Abreva or Zilactin (gel)
   4. •Acyclovir (Zovirax): topical, IV, po
   5. •Famvir or Valtrex
   6. •Lysine-supplement > 10 Gms/day

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1. Herpes Zoster -Shingles

   1. Acute vesicular eruption along a nerve pathway
   2. Reactivation of the varicella –zoster virus
   3. It can NOT be transmitted by someone who has chicken pox or shingles

Herpes Zoster

Risk Factors

1. Risk Factors:

   1. Elderly: > 80 y.o. (1/100 occurrence)
   2. Cancer
   3. Chemotherapy
   4. Immunosuppressant medications

Herpes Zoster

Symptoms

1. Symptoms:

   1. Starts with flu-like symptoms w/out fever and tingling at the site
   2. Cluster of vesicles along course of peripheral sensory nerves
   3. Unilateral
   4. Primarily affects the face, neck, trunk, chest
   5. Crust develops & drops off 10-14 days after development
   6. PAIN!!!, malaise, fever, erythema, vesicles, itching

Herpes Zoster

Treatment

1. Treatment

   1. Acylcovir (Zovirax)
   2. Valtrex
   3. Analgesics
   4. Rest
   5. Calamine lotion
   6. Steroids to decrease incidence of neuralgia
   7. Cool compresses
   8. Antihistamines

Herpes Zoster

Complications

1. Complications

   1. Postherpetic neuralgia (PHN)
   2. Dx-pain longer than 3 months
   3. Treatment -sedatives, analgesics, antidepressants
   4. Usually lasts up to 1 yr post infection
   5. Ophthalmic -blindness
   6. Facial/Auditory nerve involvement -
   7. Hearing deficits, vertigo, & facial weakness

Herpes Zoster

More Complications

1. Complications

   1. Postherpetic neuralgia (PHN)
   2. Dx-pain longer than 3 months
   3. Treatment -sedatives, analgesics, antidepressants
   4. Usually lasts up to 1 yr post infection
   5. Ophthalmic -blindness
   6. Facial/Auditory nerve involvement -
   7. Hearing deficits, vertigo, & facial weakness

1. HSV infection of the finger

   1. Caused from a positive HSV infection spreading to finger
   2. Adults: usually in one finger (thumb or index)-usually HSV-2
   3. Children: any finger-usually HSV-1
   4. Healthcare workers-not wearing gloves
2. S/S:

   1. Flushing of the skin
   2. Clear, yellow, pus filled vesicles on the finger
   3. Tenderness
   4. Preceded by intense itching/pain
   5. Fever, chills, malaise may occur

Herpetic Whitlow

Treatment

1. •Treatment -primary symptoms
   1. •Elevation & immobilization of finger
   2. •Analgesics
   3. •Acyclovir

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1. Benign growth made up of keratin
2. Caused by: HPV = more than 60 types
3. Transmitted = direct skin contact
4. Types of warts:

   1. Plantar warts = soles of feet
   2. Condylomata accuminata warts = anogenital warts
   3. Periungal warts = around the fingernails
   4. Verrucae vulgaris warts = hands, arms, legs

Verruca

S/S

1. S/S

   1. Small, circumscribed, painless, hyperkeratotic papules found usually on hands, feet, legs, face
   2. May disappear spontaneously
   3. Extremely painful with plantar warts
   4. Itching with anogenital warts

Verruca

Treatment

1. •Treatment
   1. •Removal by electrodessication or cryosurgery
   2. •Colloidal solution
   3. 16% salicylic acid
   4. 16% lactic acid
   5. •Usually takes 2-3 weeks to disappear
   6. •Duct tape!

38

1. Plant-like organism that feeds on organic matter
2. Fungal skin infections = thrive on keratin
3. Types of fungal skin infections:

   1. Tinea pedis = "athlete’s foot"
   2. Tinea cruris = groin
   3. Tinea capitis = scalp
   4. Tinea corporis = body

Fungi

Transmission

S/S

1. Transmission: direct contact or inanimate objects
2. S/S:

   1. Pruritic circular lesions
   2. Lesions may have a raised border, scaly center
3. Treatment

   1. Antifungal cream: Ketoconazole, Nystatin, Miconazole, Nizoral, Lamisil
   2. Antifungal medication: po
   3. Griseofulvin

1. Candidiasis

   1. Overgrowth of fungus: candida albicans
   2. Thrives in warm, moist environments
   3. Common sites: vagina, mouth, esophagus, lungs, skin, rectum and under breasts
   4. S/S:
   5. Mouth: white spots or red lesions
   6. Vagina:
   7. cheesy or milky discharge
   8. Itching, burning

1. •Precursor to candidiasis infections:
   1. Immunosuppression
   2. Elderly
   3. Diabetic
   4. Pregnancy
   5. Oral contraceptive use
   6. Antibiotic therapy
   7. Chemotherapy/Radiation therapy
   8. Obesity
   9. Steroid therapy
   10. Menstruation

42

Candidiasis Albicans

Treatment

1. Treatment

   1. Vaginal creams –Mycelex 1, 3, 7, day treatments
   2. PO medications
   3. Diflucan, Nystatin, Gentian Violet
   4. Topical creams
   5. Nystatin, Monistat,
   6. Systemic antifungal: IV Diflucan

1. •Tinea Pedis –"athlete’s foot"
   1. •Fungal infection between & under toes
   2. •Most common fungal infection
   3. •Commonly affects up to 70 % of adult population at some time in lifespan
2. •Transmission:
   1. •Contagious by direct contact or item contact
   2. Shower floors
   3. Shoes
   4. Pool surfaces
   5. Stockings

44

Dermatophytoses

Risk Factors

1. Risk factors:

   1. Living in hot climates
   2. Poor nutrition
   3. Poor hygiene
   4. Immunosuppression
   5. Debilitating disease
   6. Occlusive footwear
   7. Skin or nail injuries
   8. Obesity

Dermatophytoses

S/S

1. S/S:

   1. Intense itching, burning & erythema
   2. Cracks between toes
   3. Maceration
   4. Vesicular lesions
   5. Toenails may become thickened & discolored

Dermatophytoses

Treatment

1. Treatment -

   1. Topical agents: antifungals
   2. Keep feet dry, change socks frequently
   3. Avoid plastic or rubber soled footwear, rubber boots, tight shoes
   4. Wear sandals to showers
   5. Systemic antifungal TX: Diflucan IV

Parasitic Infections

Scabies

1. Scabies –Female itch mite burrows under the skin & lays her eggs!

   1. The mite makes a "zigzag" blister as she lays the eggs
2. Transmission:

   1. Direct Contact =
   2. Clothing
   3. Bedding
   4. Towels
   5. Sleeping together
   6. Shaking hands

Scabies

S/S

1. S/S:

   1. Severe itching especially at bedtime
   2. Wavy (zigzag) brownish, threadlike lines seen mostly on hands, arms, fingers, wrists, heels, body folds & genitalia
   3. Takes about 4 weeks from time of contact to time of symptoms

Scabies

Diagnosis

1. Diagnosis:

   1. Clinical presentation
   2. Skin scrapings
   3. Wipe off with ETOH swab, then take a magic marker & mark over site. Wipe site, if marker stays & sinks in pits of skin or burrows of skin = scabies!

Scabies

Treatment

1. Treatment

   1. Lindane (Kwell): all members of the household should be treated simultaneously
   2. Corticosteroids: systemic/topical = for itching
   3. Wash clothing & linens in soap & hot water or have them dry cleaned & ironed = these help to kill the eggs
   4. Personal care items are boiled to kill the parasites

Pediculosis

Crab Louse

1. Crab Louse

   1. 3 varieties of lice:
   2. Head
   3. Body
   4. Pubic
2. Crab louse is a blood sucking parasite
3. During feeding, they release toxins into the skin
4. These toxins cause = itching, purpuric spots due to the inflammatory response
5. They lay their eggs (nits) on the body hair & clothing fibers

Pediculosis

Transmission and treatment

1. Transmission

   1. Direct contact, bedding, clothing, linens
2. S/S

   1. Severe pruritis
   2. Matted hairs
   3. Wheals
3. Treatment

   1. Kwell (Lindane) = neurological precautions!
   2. Nix/RID (Elimite)
   3. Ovide
   4. Septra

1. Symptom, not a disease!
2. Subjective itching sensation that produces an urge to scratch (similar to painful sensation)
3. Associated with many primary skin lesions or generalized diseases
4. Localized or generalized
5. Can lead to damage if scratching injures the skin’s protective barrier

Pruritus

Can also manifest due to a systemic disease/condition

1. Can also manifest due to a systemic disease/conditions

   1. Chronic renal failure
   2. Fe deficiency
   3. Opiate drugs
   4. Liver disease
   5. Chicken pox
   6. Drug hypersensitivity
   7. DM
   8. Insect bites

Purtitis

Management : ID and Eliminate tjhe causative factor

Management: ID & eliminate the causative factor

Environmental irritants

Drug therapy

Medical history

Allergens

Insects

Pruritis

Nursing care and teaching

Nursing care and teaching

Inflammatory Skin disorders

Exogenous

Endogenous

Exogenous

Common inflammatory, often eczema-like condition

Contact Dermatitis

Causative Agents

Contactive Dermatitis

Predisposing Factors

Predisposing Factors

Pre-existing irritant dermatitis

Exposure to extremes of heat & cold

Frequent immersion in soap & water

Friction

Clinical Manifestation -begins at the site of exposure

Itching, stinging, erythema, edema

Contact Dermatitis

Diagnosis

Nursing Care and Teaching

Diagnosis

Contact Dermatitis

Nursing Care & TEaching Continued

Nursing care & Teaching: (cont)

Atopic Dermatitis

Overview

Overview:

Atopic Dermatitis

Family History

Family history -genetic in nature

Atopic Dermatitis

Results from comples activation

Results from complex activation of

Atopic Dermatitis

Treatment

Treatment

Atopic Dermatitis

Nursing care & Teaching

Nursing Care & Teaching

Wash new clothes before wearing

Avoid temp extremes

Use mild detergents & rinse clothes twice

Wear loose, cotton, open weave clothing

Wear sunscreen in moderation

Inspect skin for infection

Keep fingernails short

Decrease psych stress

Seborrheic Dermatitis

Common chronic Inflam,ation of the skin

Common chronic inflammation of the skin:

Seborrheic Dermatitis

Treatment

Treatment

Relapsing, proliferative skin disorder of the immune system, enzymes, & other biochemical substances that regulate skin cell division

Psoriasis

Production of epidermal cells

Production of epidermal cells occurs at a rate approx 6-9x faster than normal!

Psoriasis

Predisposing Factor

Predisposing factors:

Psoriasis

S/S

S/S:

Psoriasis

Lesion Severity

Lesion severity ranges from benign cosmetic source of annoyance to a physically disabling & disfiguring affliction with signs of morbidity

Complications

Psorasis Treatment

Goal

Goal

Psoriasis Treatment

Topical Corticosteroids

Topical corticosteroids

Psoriasis Treatment

Topical anthralin

Topical anthralin (dithranol) –antipsoriatics

Psoriasis Treatment

Photochemotherapy

Photochemotherapy-(PUVA)

Psoriasis Treatment

Photochemotherapy continued

Photochemotherapy (continued)

Psoriasis Treatment

Photochemotherapy

Disadvantages

Photochemotherapy

Psoriasis Treatment

Ultraviolet

Ultraviolet A/B Therapy Alone

Psoriasis Treatment

Goeckerman's Regimen

Goeckerman’s Regimen (since 1925)

Impaired Skin Integrity

Psoriasis Nursing

Body Image Disturbance

Body Image Disturbance

Psoriasis Teaching

Eat Healthy

Eat healthy, well –balanced diet

Avoid extreme temperature –cold & heat

Relaxation techniques –decrease stress

Adequate rest & regular exercise

Expose skin to sunlight, avoid sunburns

Avoid trauma to the skin

Avoid exposure to contagious illnesses

Discuss current medications with doctor

Most common skin disease

Affects 85% of the population between the ages of 12 & 25 (more common in males)

Inflammatory disorder of pilosebaceous gland affecting the hair follicle

Occurs most commonly with adolescence

Acne Vulgaris

Etiology

Etiology

Acne Vulgaris

Pathophyisology

Pathophysiology

Inflammatory –pustules, papules, & nodules

Acne Vulagaris Treatment

Treatment depends on the severity of the acne

Acne Vulgaris treatment

Systemic

Systemic

Acne Vulgaris Treatment

Surgery

Surgery

Comedo extraction

Intralesional steroids

Cryosurgery

Severe scarring

Dermabrasion

Chemical peel

Acne Vulgaris Treatment

General Skin Care

General skin care

Keep skin clean, wash 2 –3 times per day

Use medicated soap/cleanser or agent prescribed

Avoid vigorous rubbing of the skin

Water based cosmetics

Acne Vulgaris Treatment

During Therapy

During therapy

Inflammation of the skin

Middle aged adults 30 –50 years

More common in fair skinned individuals with a history of easy facial flushing

Affects females more frequently than males

Acne Rosacea

Lesions

Avoid hot drinks & alcohol (vasodilation)

Chronic disorder that results in blisters (bullae)

Pemphigus Vulgaris

S\S

S/S

Flaccid bullae –rupture easily –foul smelling

Drainage leaving crusted, denuded skin

Lesions –face, back, chest, groin, umbilicus, & mucous membranes often involved

Pemphigus Vulgaris

Treatment

Treatment

Skin Tumors

Skin Cancer

Skin cancer

Skin tumors

Keratosis

Keratosis

Benign proliferation of basal cells

Usually seen in older people

Occurs as multiple lesions on the chest, back, & face

Color varies from tan to waxy yellow

From few mm to several cm

Often oval & greasy appearing with hyperkeratotic scale

Seborrheic Keratosis

Treatment

Cryotherapy with liquid Nitrogen

Atinic Keratosis

Senile or Solar Keratosis

Most common epithelial precancerous lesion among whites

Typically

Atinic Keratosis Treatment

Surgical

Surgical

Basal Cell Carcinoma

Basal Cell Carcinoma

S/S

S/S

•Painless, slow growing

•Sun –exposed areas –face, ears, head, neck, hands

•Most common –nodular lesion, dome shaped papule with well defined border

Almost never metastasize

Tumor of epidermal keratinocytes

Removal of all malignant tissue

Causative factors

Genetic predisposition

Solar radiation

Steroid hormone therapy & fair skin

Dysplastic Nevi

Lentigo maligna

Malignant Melanoma types

Lentigo malignant melanoma

Malignant Melanoma Types

Superficial

Superficial spreading melanoma

Malignant Melanoma types

Primary Nodular Melanoma

Depends on the depth of the invasion with in the skin

Biopsy lesion

Malignant Melanoma Treatment

Surgery

Chemotherapy

Surgery –excision

Malignant disease involving T helper cells

Cutaneous T-cell Lymphoma

Treatment

Prevent secondary infections

A –Asymmetry