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Dermatologic Problems/ Integumentary System

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Sweat glands Apocrine gland Found chiefly in the axilla and genital regions. They open into the hair follicle and stimulated by emotional stress. Eccrine glands They are widely distributed and they directly open into the skin and help to controlee the body temperature through sweat production.

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Physical Examination Obtain history Inspection Palpation Gloves are worn during examination

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The skin color depends on the melanin pigment, genetically determined and it increases by sunlight. Oxyhemoglobin Bright red pigment predominates. present in capillaries and arteries.

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Carotene is golden yellow pigment found in subcutaneous fat and heavily keratinized area such as palms and soles.

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Deoxyhemoglobin darker and blue pigment occurs when oxyhemoglobin looses its oxygen

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Hair Vellus hair-short, fine inconspicuous and unpigmented Terminal hair coarser, thicker,more conspicuous and pigmented. Scalp hair and eyebrows

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Physical Examination Observe for: Color Temperature Moisture Dryness

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Physical Examination Skin texture (rough-smooth) Lesions Vascularity Mobility Texture of hair and nails Skin turgor

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Physical Examination Color Varies from person to person Pigmentations Sunburn, inflammation- Pink or Reddish hue Pallor Decreased skin tones

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Physical Examination Color Vascularity Observed in Conjunctivae Mucous membranes Bluish hue Cyanosis = cellular hypoxia Jaundice Yellow pigment sclera mucous membrane

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Physical Examination Color Dark skinned persons Have reddish base and undertones Buccal mucosa, tongue, lips,nails normally appear pink Cyanosis-skin assumes grayish cast Age related changes

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Physical Examination Topical medications Lotions, suspensions Clear solutions, liniment, Powders, creams, Gels, pastes, Ointments, sprays, Corticosteroids etc.

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Wounds Abrasion skin is rubbed or scraped off Lacerations torn, ragged, irregular edges made by blunt objects Avulsions the tearing away of tissue from a body part Incisions cuts made by sharp cutting instruments Punctures caused by objects that penetrate tissue while leaving a small surface opening Amputations traumatic is the nonsurgical removal of a limb from the body

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petechiaetelangiectasia:purpura Vascular Lesions

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Psoriasis well demarcated, raised, red, scaly plaques typically elevated, >10 mm with thick silvery scale hyperproliferation, inflammation of dermis and epidermis common, ~1 to 5% population bimodal onset 16-22 & 57-60 yrs unknown cause, ~50% familial non-mendelian inheritance, associated MHC CW6, B13, B17 environmental trigger; injury, sunburn, HIV, haem Strep., stress, alcohol, drugs; blockers chloroquine

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Clinical Variants Plaque psoriasis; large well- demarcated plaques usually on arms, legs, back or scalp is the most common form Gutate psoriasis; lesions appear as multiple small red raised scaly patches, usually all over the trunk. Occurs in young people following a Strep throat infection.

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Pityriasis Rosea mild inflammatory skin disease diffuse scaly plaques or papules unknown cause, virus suspected mostly women 10-35 yr, peaks in cooler months begins with herald patchon trunk centripetal eruption 7 -14 days later prodromal malaise and headache Rose or fawn coloured, raised edge collarette (tinea) Remits in 5 weeks, recurrence rare, sun hastens resolution

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Lichen Planus hepatitis C liver disease graft versus host disease recurrent, pruritic, inflammatory rash small polygonal flat violaceous papules may coalesce in scaly patches often accompanied by oral lesions T cell autoimmune reaction to basal keratinocytes + genetic disposition triggered by a variety of blockers antimalarials NSAIDS drugs; symetrically distributed on wrists, legs trunk, penis

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Insect Bites A variety of insect bite can cause a blisters; fleas (pets) bedbugs scabies, knats/midges, bees wasps more common in young children sometimes misdiagnosed eg as chickenpox.

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Dermatitis superficial inflammation of the skin characterized byredness oedema oozing crusting scaling (vesicles) Eczema used interchangeably with dermatitis pruritis

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chronic phase, scratching rubbing causes skin to lichenify may become generalised, often present in flexural creases associated food intolerance, wool, sensitivity to sweating often improves by age 5; early asthma, Atopic Dermatitis

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Diagnostic Tests/Treatments Cultures Skin biopsy Woods light examination Skin testing (allergies)

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Herpes simplex is a common viral infection that presents with localised blistering There are two main types of herpes simplex virus (HSV), although there is considerable overlap. Type 1, which is mainly associated with facial infections (cold sores or fever blisters) Type 2, which is mainly genital (genital herpes)genital herpes

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Recurrences can be triggered by: Minor trauma to the affected area Other infections including minor upper respiratory tract infections Ultraviolet radiation (sun exposure) Hormonal factors (in women, flares are not uncommon prior to menstruation) Emotional stress Operations or procedures performed on the face Dental surger

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Herpes Zoster {Shingles} Acute inflammatory and infectious disorder Painful vesicular eruption Bright red edematous plaques along the nerve from one or more posterior ganglia

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Herpes Zoster {Shingles} contd Eruption follows the course of the nerve Almost always unilateral

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Cause Varicella-zoster virus (like chicken-pox) Incubation period 7-21 days Vesicles appear in 3-4 days Occur posteriorly Progress anteriorly & peripherally Along dermatome Duration 10 days to 5 weeks

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Occurs most frequently in Elderly Immunosuppressed Malignancy or injury to spinal or cranial nerve

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Complications Facial and acoustic nerve involvement Hearing loss Tinnitus Facial paralysis Vertigo painful

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Complications Full thickness skin necrosis and scarring Systematic infection from scratching, causing virus to enter blood stream

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Medical treatment Control outbreak Reduce pain and discomfort Prevent complications Acyclovir (Zovirax) IV, PO, topically Corticosteroids Antihistamines Antibiotics

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Parasitic Skin Infections (PSI) Higher risk situations? Poor hygiene Living in close quarters

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Pediculosis- Lice (PSI) Infestation by human lice Pediculosis capitis-head Pediculosis corporis-body Pediculosis pubis- pubic or crab

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Scabies (PSI) Contagious skin disease, caused by itch mite Sarcoptes scabiei. Transmitted by Close-prolonged contact with Infested companion Infested bedding

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Scabies (PSI) Characterized by Epidermal curved or linear ridges Follicular papules Pruritus Palms More intense and unbearable at night White visible epidermal ridges by Mite burrowing into outer layers of skin

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Scabies (PSI) Hypersensitivity reaction Excoriated erythematous papules Pustules, crusted lesions Elbows Axillary folds Lower abdomen Buttocks, thighs Between fingers Genitalia

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Scabies (PSI) Treatment Topical sulfur preparations One-two applications daily Launder personal items No disinfectant

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scabies

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Ringworm (PSI) Ringworm - an infection caused by a fungus Jock itch form of ringworm on groin area Athletes foot fungal infection of foot (feet) Fungus live and spread on the top layer of the skin and on the hair grow best in warm, moist areas, contagious via skin-to-skin contact with a person or animal that has it or when you share things like towels, clothing, or sports gear. You can also get ringworm by touching an infected dog or cat, although this form of ringworm is not common.

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Tinea vesicular

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Psoriasis Lifelong disorder Exacerbations Remissions Cannot be cured

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Psoriasis Pathophysiology Scaling disorder Underlying dermal inflammation Abnormality in proliferation of epidermal cells in outer skin layers Normal 28 days to shed cells Psoriasis Cells shed every 4-5 days

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Psoriasis Cause-unknown Genetic predisposition Environmental factors May appear after skin trauma Sunburn Surgery

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Psoriasis Improves in warmer climates Aggravated by Infections Streptococcal throat infection Candida infections Hormonal changes Psychological stress

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Psoriasis Assessment History Family history Age at onset Disease progression Pattern of recurrences Gradual or sudden

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Psoriasis Vulgaris {Ordinary/Common} Most common Thick erythematous papules or plaques Surrounded by silvery white scales

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Psoriasis Vulgaris {Ordinary/Common} Common sites Scalp Elbows Trunk Knees Sacrum Extensor surfaces of limbs

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Skin Cancers Overexposure to sunlight Common skin cancers Squamous cell carcinoma Basal cell carcinoma Melanoma

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Actinic Keratosis Pre-malignant lesions Cells of epidermis Chronically sun-damaged skin Can lead to squamous cell carcinoma

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Squamous Cell Carcinoma Malignant neoplasms of epidermis Invade locally Potentially metastic Ear Lip External genitalia Cause Repeated irritation or injury

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Basal Cell Carcinoma Basal cell layer of epidermis Lesions go unnoticed Metastasis rare Underlying tissue destruction progresses to underlying vital structure

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Melanomas Pigmented malignant lesions Originate in melanin-producing cells of epidermis

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Melanomas Risk factors Genetic predisposition Excessive exposure to UV light Precursor lesions resembling unusual moles Highly metastatic Survival depends on early diagnosis and treatment

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Skin Cancers Prevention Avoid exposure to sunlight Use of sunscreen SPF30 or greater

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Skin Cancers Assessment Age Race Family history Removal of skin growths

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Skin Cancers Assessment Change in Size, Color, Sensation Of any Mole, Birthmark, Wart, Scar Hair-bearing areas of body

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Skin Cancers Interventions: Radiation therapy Elderly Large, deeply invasive basal cell tumors Poor risk for surgery Malignant melanoma resistant May be used in combination with systemic chemotherapy

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Pressure Ulcers Etiology

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Pressure Ulcers Etiology Immobility Impaired sensory perception or cognition Decreased tissue perfusion Decreased nutritional status Friction and shear Increased moisture

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Pressure Ulcers Stages

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Pressure Ulcers Stages Stage I Non-blanchable erythema Tissue swelling C/O discomfort Stage II Break in skin Epidermis Dermis Necrosis

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Pressure Ulcers Stages Stage III Subcutaneous tissue Deep crater With undermining Without undermining Stage IV Underlying structures May have large undermined area

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Burns 1 st degree partial- thickness (superficial) 2 nd degree partial- thickness (deep) 3 rd degree full- thickness

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Chemical burns Electrical burns Thermal burns Sunburn

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Burns Tests Wound cultures CBC, BUN, glucose, electrolytes, urine studies Interventions IV fluid replacement Antibiotic/antimicrobial agents Analgesics

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Nails Paranychia Koilonychias

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Clubbing

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pick-like depressions in the nails (nail pitting) are common in people who have psoriasis a condition characterized by scaly patches on the skin.

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Terry's nails most of the nails appear white except for a narrow pink band at the tip. Terry's nails can sometimes be attributed to aging. In other cases, Terry's nails can be a sign of a serious underlying condition, such as liver disease, congestive heart failure, kidney failure or diabetes.