Skin Disorders

1. Skin Disorders

3. 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

4. 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

5. 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

7. Furunculosis (Boils) • Etiology • Infection of hair follicle that results in pustule formation • Generally the result of a staphy. infection

8. 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

9. 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

10. Folliculitis • Etiology • Inflammation of hair follicle • Caused by non-infectious or infectious agents • Moist warm environment and mechanical occlusion contribute to condition • Psuedofolliculitis (PFB)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Tinea of the Groin (tinea cruris) • Etiology • Symmetric red-brown scaling plaque with snake-like border • Signs and Symptoms • Mild to moderate itching

21. 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

22. 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

24. 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

25. 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, re-pigmentation of the area will occur

26. 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

27. 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, swollen lymph glands and pain in area of lesions

29. 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

30. 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

31. 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

32. 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)

33. 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)

34. 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

35. 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

37. 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

38. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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