ALTERATION IN SKIN INTEGRITY

1. ALTERATION IN SKIN INTEGRITY Prof. Unn Hidle Updated Spring 2010

2. INTEGUMENTARY DISORDERS

3. STRUCTURE AND FUNCTION OF SKIN • Structure: 3 layers • Epidermis • Dermis • Subcutaneous (inner layer of adipose tissue) • Function • First line of defense • Temperature regulation • Excretion of water • Production of vitamin D • Sensation of touch, pain, heat and cold • The skin is controlled by: • The autonomic nervous system • The endocrine glands • Sebaceous glands – production of sebum • Eccrine sweat glands (present at birth; functioning by age 3 years) versus apocrine glands (controlled by adrogens; mature at puberty) • Pediatric differences in skin: Can you think of any?

6. ASSESSMENT OF THE SKIN • Involves inspection and palpation: • Texture • Turgor • Color (circulation, rash, birthmarks) • Areas of pressure • Inflammation • Breakdown or emaciation • Bacterial infection (infant/child = high risk) • Systemic symptoms • Reaction of primary irritants • Toxic erythema (increased risk in children) • Diaper rash: lacerations, infections and sweat retention

7. CONDITIONS TO BE DISCUSSED • Eczema • Bulleous Impetigo • Pediculosis Capitis (head lice) • Ringworm • Acne • Psoriasis • Neurofibromatosis 1 • Lyme disease • Smallpox

8. ECZEMA • Description • = Atopic Dermatitis • A superficial inflammatory process involving primarily the epidermis • A common allergic reaction in children (atopy = genetic predisposition) • Family history of allergies: asthma, allergic rhinitis, hay fever, food allergies, etc. • Childhood eczema often begins in infancy and the rash appears on the face, neck, and folds of elbows and knees • May persist for several years or return after the child is older • Sometimes caused by an allergic sensitivity to foods such as milk, fish, or eggs • Seasonal: gets worse in the fall/winter with artificial heating/decreased humidity in homes

9. Eczema – 3 types • Infantile eczema: • 2-6 months of age • Usually spontaneous remission by 3 years of age • Generalized lesions (erythema, vesicles, papules, scaling, crusting, oozing, weeping) • Usually symmetrical • Cheeks, scalp, trunk and extensor surfaces of extremities • Childhood eczema: • Occurs at about 2-3 years of age • May follow the infantile form • Flexural areas, wrists, ankles, feet • S/S may include Lichenification (thikenied skin with accentuation of creases from scratching) and Keratosis pilaris (overgrowth & thickening of cornifiec epithelium) • Preadolescent and adolescent eczema • May begin at 2 years of age and continue into adulthood • Similar to childhood lesions with lichenified plaques

10. ECZEMA

11. ECZEMA • Assessment • As discussed • NO CURE! • Goal of treatment • Relieve pruritus - # 1 FOCUS!!!! • Hydrate skin • Decrease inflammation • Prevent or control secondary infection • Treatment methods • Dry method baths • Wet method – most common • Relieving pruiritis • Secondary infections • Nursing: What is your role in this picture?

12. ECZEMA

13. Infantile eczema

14. Infantile eczema

16. Childhood eczema

17. BULLOUS IMPETIGO • = impetigo neonatorum • Superficial bacterial skin infection • Most commonly caused by Staphylococcus aureus • Assessment: • Eruption of bulleous vesicular lesions on previously untraumatized skin (compared to impetigo – secondary to trauma) • Usually on buttocks, perineum, trunk, face • Size varies • Bullae contain turbid fluid (vs impetigo – honey crust) • Rupture in 1-2 days – leaves superficial red denuded area with minimal crusting • Differential diagnosis – thermal injury

18. IMPETIGO

22. Treatment • Warm saline compresses applied to lesions followed by gentle cleansing • Apply topical antibiotics and sometimes administer oral antibiotics as prescribed • Nursing • Isolation until therapy is instituted • Investigate: persons who have come in contact with infant/child; nursery • Teaching: prevent spread of infection

23. PEDICULOSIS CAPITIS (LICE) • Description: • = Head lice or “cooties” • Caused by Pediculus humanus capitis • A common parasite in school-aged children (ridicule!) • The “louse” is a blood-sucking organism • Can live away from human host for about 48 hours • Female lays eggs at night • Nits or eggs hatch in approximately 7-10 days

24. Incubation Period: Eggs incubate for about 1 week (7-10 days) and lice reach sexual maturity in about 2 weeks (life span = approx. 1 month) • Infectious Period: During infestation prior to treatment • Transmission: Direct contact with infected person and indirect contact with infected person’s belongings (scarf, hat, pillow, etc. – NOT PETS!) • Season: Nonspecific, a common problem in schools

26. PEDICULOSIS CAPITIS (LICE) • Assessment • Adult lice are small gray specks that may be difficult to see • Nits are visible, tiny silver or gray specks resembling dandruff that are firmly attached to the hairshaft near the scalp • S/S • Itching – caused by the crawling insect and insect-saliva • Mostly in scalp, but may be on other places of body (facial hair, chest, groin, etc.) • Dx: • Observing the white eggs (nits) • Differential diagnosis: dandruff, lint, hair spray etc.

29. Implementation: • Anti-lice shampoo (medicated) • Permetrhin 1% crème rinse (Nix) • Lindane shampoo 1% (Kwell, Scabane) • Do NOT administer after a warm bath or shower (vasodilation and increased absorption) • Manual removal of nits = KEY!!! • Comb • Tweezers or fingernails • Wash clothes, bedlinen • Remove all hats, scarves, etc • Vacuum all rugs and clean house • TEACHING! • PREVENTION! • “Psychological support” – ANYBODY can get it! • National Pediculosis Association – Established guidelines for schools

30. RINGWORM • Dermatophytosis = fungal infection: entire category • Types: • Tinea capitis = head fungi • Tinea cruris and Tinea inguinalis = “Jock itch” • Tinea corporis = fungal infection of skin/nails • Candidiasis/moniliasis = moniliasis in chronically moist areas • Tinea pedis = “athlete’s foot” • Description • Superficial infections (ON the skin, not IN) • Annular lesion where the fungi are found in the edge of the inflamed border • Oval or round, erythematous, scaling patches • Pruritic • May develop alopecia • Contagious, also animal to humans (versus lice)

31. Dx • Physical exam • Scrapings • Treatment • Oral griseofulvin (EXCEPT for Jock itch and moniliasis) • Precautions when on griseofulvin • Topical antifungal agent: tolnaftate liquid (i.e. for jock itch) EXCEPT for moniliasis • For moniliasis the treatment is amphotericin B or nystatin ointment (both topical) • TEACHING

35. ACNE • Involves pilosebaceous units (consists of the sebaceous glands and hair follicles) • Etiology: • Familial aspect • Hormonal cause • Stress and acne ??? • Cosmetic agents • Exposure to oil and grease • Dietary intake ???? • Hygiene????

36. 3 Main Pathophysiologic factors: • Excessive sebum production • Comadogenesis • Overgrowth of Propionibacterium acne • Two types of lesions seen: • Noninflamed lesions = comadones • Closed comadones = “whiteheads” • Open comadones = “blackheads” • Inflamed lesions

41. Treatment: • No single treatment has been effective: combination therapies are usually used • Note on ACCUTANE (isotretinoin) • Retinoic acid / Vit A derivative: decreases sebum production • General measures • Improved health • Food restrictions or elimination if applicable • Topical antibacterial agents (comadonal acne) • Tretinoin (retinoic acid) - topical • Systemic antibiotics – inflamed lesions • Oral contraceptive pills • Nursing considerations

42. PSORIASIS • Immune-mediated, genetic skin disorder • Etiology = unknown • Known to be triggered by stress • S/S • May vary from a spot or two to extensive coverage on their body • Round, thick, dry reddish patches covered with coarse, silvery scales • Commonly appears on scalp first and facial lesions (more common in children) • May develop psoriatic arthritis

45. Treatment • Sunlight or artificial ultraviolet light • Topical corticosteroids • Tar derivates (coal tar act synergistically with UV light therapy) – give before! • Keratolytic agents (i.e. salicylate acid) will enhance the absorption of corticosteroids • Emollients • Vitamin A • Humidifiers • Nursing • Direct skin care • Teaching • Psycho-social • National Psoriasis Foundation

46. NEUROFIBROMATOSIS 1 (NF 1) • Von Recklinghousen disease • Common genetic disorder • Autosomal dominant inheritance • 1:3000 persons • Appears as a result from a defect that alters peripheral nerve differentiation and growth • Slow growing cutaneous or subcutanous neurofibromas that grow along the peripheral nerves later in childhood or adolescence • 50% chance to transmit NF 1 to offspring • S/S • Café-au-lait spots (>6) • Axillary or inguinal freckling • Lisch nodules - iris • Elephantiasis – esp. genitalia & lower extremities • Other characteristics

48. CAFÉ-AU-LAIT

50. Dx – will cover under neuro! • Made by physical findings • Criteria for diagnosis: need at least 2 findings** • In doubtful cases: nodule biopsy • Treatment • No cure! • Limited only to excision of tumors which produce pain or impair function • Symptomatic management • Nursing • Recognize signs of the disease • Referral • Family counseling (National Neurofibromatosis Foundation) • Support