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Altered Integument Concept Maps. Gary Schofield, RN. Infections Bacterial: Folliculitis, Foruncle, Carbuncles, Cellulitis, Erysipelas Viral: Herpes (Simplex,Zoster, Varicella), Warts Fungal: Tinea, Candidiasis. INFLAMATORY

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Infections

Bacterial: Folliculitis, Foruncle, Carbuncles, Cellulitis, Erysipelas

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

Fungal: Tinea, Candidiasis

INFLAMATORY

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

DISORDERS OF THE SKIN

Vesiculobullous (Vesicle Formation)

Pemphigus (Vulgaris,Vegetans, Foliaceus, Erythematous)

Bullous Phemphoid

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

Papulosquamos

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

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

Vascular

(Commonly assoc. with skin disease)

Cutaneous vasculitis

Urticaria

Scleroderma

Insect Bites

Ticks (Rocky Mt Spotted Fever, Lyme Disease)

Mosquitoes (Malaria, Yellow Fever)

Flies

Frost Bite

Affects fingers, ears, toes, & cheeks

Cancer

Basal Cell (Surface epithelial -Most Common)

Squamous Cell -Epidermis

Malignan Melanoma –originates in melanocytes

Kaposi Sarcoma –vascular malignancy

Benign Tumors

Seborrheic Keratosis

Keratocanthoma

Actinic Keratosis

Nevi (moles)

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

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Skin Biopsy

Tzanck

Microscopic Immunofluorescense

Diascopy

Gram Stain

Skin Diagnostic Procedures

Side Lighting

Culture

Skin Scrapings

Wood Lamp Exam

Patch & Scratch Tests

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Primary

Secondary

Macule – ↓ 1cm, flat, change in color

Scale – heaped-up, keratinized cells, flaky skin

Papule – ↓ 1 cm, elevated and firm

Lichenification – rough, thickened epidermis, flexor surface of extremity

Patch – Flat, nonpalpable, ↑ 1 cm

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

Plaque – elevated, firm, rough, ↑ 1cm

Wheal – elevated, irregular shape, solid, transient

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

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

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

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

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

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

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

Bulla - vesicle ↑ 1 cm

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

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

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 Lesions

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Acne Vulgaris

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

Skin Disorders in Children

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

Minor to Severe

Localized or General

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

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

Infections

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

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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

Exposure (Sunlight) = Ultraviolet Radiation

Strongest 10:00am – 3:00pm

Protection during 1st 10-20 yrs ↓ risk

3 Stages of Growth

- Initiation

- Progression

- Metastasis

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

Outdoor Workers = ↑ incident

Basal Cell Carcinoma

Treatment

Rad Theapy, Surgery, Electrodisiccation, Cryosurgery

Mutation of p53 tumor

Suppressor Gene

Squamous Cell Carcinoma

Malignant tumor of the skin

Originates in melanocytes

Incidence is increasing

Young-Middle Age Adults ↑ risk

Malignant Melanoma

Biopsy

- Color and/or size change

- Irregular notched margin

- Itching, Bleeding, Oozing, Nodularity

- Scab formation or Ulceration

Nevus Types

● Junctional

● Compound

● Intradermal

Nevus (mole) – aggregation of melanocytes

Most are not suspicious

Suspect = Removal

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Exposure to UV Light Solar and Artificial

Risk Factors

Malignant Melanoma

Malignant Degeneration of Melanocytes

Steroid Hormone Activity

Light Skin

Easy to Sunburn

Genetic Predisposition

Basal Layer of Epidermis

Benign Melanocvtic Nevus

Facial Hair

Freckles

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

Lentigo Malignant Melanoma (LMM)

70% of Cutaneous Melanoma

Location: Legs of Females & ↑ Back Both Genders

Superficial Spreading Melanoma (SSM)

Clinical Varieties of Cutaneous Melanoma

20-60 yrs at diagnosis

Primary Nodular Melanoma (PNM)

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

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
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.