IN THE NAME OWNER OF BEAUTY

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The Integumentary System

Instructor:Shahnaz Pouladi

Assisstant Proffesor in Nursing

Bushehr University of Medical Sciences

1394 2

Epidermis:

Stratified squamous epithelium; outer layer is "keratinized" or "cornified"

Dermis:

Dense irregular connective tissue

Hypodermis:

Adipose connective tissue (technically not part of system)

Three Layers of skin:

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Epidermis: Avascular. Depends on blood vessels in underlying dermis for its nutrition

Cells formed by mitosis in deepest, or basal layer, then get pushed into more superficial layers or "strata"

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Stratum Basale = Single row of dividing cells

Stratum Spinosum = Three or four layers of cells; Some cell division

Stratum Granulosum = Three or four layers of cells; Actively synthesizing protein keratin

Stratum Lucidum = One or two layers of dying cells

Stratum Corneum = Many layers of flat, dead, scale-like cells full of keratin

(Epidermis)

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Primary cell type in epidermis = keratinocytes which produce large amounts of protein keratin

Other cell types:

Langerhans cells (really macrophages) clean up debris

Merkel cells detect touch and pressure; transfer this information to sensory receptors in the dermis

Melanocytes produce pigment melanin & transfer it to keratinocytes

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Dermis:Dense irregular connective tissue

Separated from epidermis (stratified squamous epithelium) by basement membrane

Highly vascular

Highly innervated

Two Layers:

Papillary layer just below epidermis

Reticular layer forms deep 80%

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Dermis = Dense irregular connective tissue. Thus:

Cells = Fibroblasts / Fibrocytes Macrophages Mast cells Lymphocytes etc.

Fibers = Collagen (therefore strong, flexible) Elastic (therefore stretchable)

Weight gain tears collagen fibers producing striae (stretch marks)

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Hypoderm (Subcutaneous Tissue)

• Primarily is adipose tissue• Provides a cushion

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Appendages of the skin

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Appendages of the skin

Hair follicles and hair

Sweat glands

Sebaceous (oil) glands

Nails on fingers and toes

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Hair

- Distribuled over all skin except: palms of hands soles of feet nipples glans of penis & clitoris minor labia

- Formed in follicles located deep in dermis

- Consists of layers of dead, highly keratinized keratinocytes

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Shaft

Bulb

Root

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Each hair is associated with:

One or more sebacious (oil) glands

An arrector pili muscle

A plexus of nerves aroundthe root

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Hair

• The rate of growth varies• Hair loss• Hair growth by sex hormone• Different functions of hairs• Hair color• Hair quantity and distribution

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Nails

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Nails:

- Tips of fingers and toes - Thick layer of densely packed keratinocytes - Produced by nail matrix at proximal end, hidden under eponychium or cuticle

Average growth:0.5 mm per week

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GLANDS OF THE SKIN

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Sebaceous (oil) glands:

- Branched tubular glands

- Duct opens into opening of hair follicle

- Secretes sebum, consisting of lipids, proteins, carbohydrates,

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Sweat Glands

- 2 to 3 million

- Two types: Merocrine: Distributed over all skin except nipples (Eccrine) Simple coiled glands in dermis Duct leads to sweat pore on surface Secreted watery sweat for cooling Apocrine: Located only in axillary, pubic, anal regions Larger than eccrine glands Duct opens into opening of hair follicle Secretes thicker sweat, high content of proteins and fats.21

Sweat is usually 99% water with a pH between 4 and 6

Sweat glands produce 500ml of insensible perspiration (no noticable wetness)daily

Two specially modified sweat glands:

Ceruminous—found in the external ear canal. Secretion combines with sebum and dead epidermal cells to form earwax (keeps eardrum pliable, canal waterproof and has a bactericidal effect)

Mammary --milk producing glands found in the female breast (modified apocrine glands)

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Function of the Skin

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Functions of the skin

• 1. Protection– First line of defense– Keratin: protects body from water loss, barrier for

environmental factors (stratum corneum)– Melanin: keeps UV rays from penetrating– Surface film: sweat, oil, etc– Basal layer: composed of collagen(tissue

organization and regeneration, selective permeability, physical barrier, bind)

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Functions of the skin

• 2. Sensation– Pressure, touch, temp, pain, etc– Two specialized receptors:

• Meissner corpuscle – detects light pressure• Pacinian corpuscle – detects deep pressure

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Functions of the skin

• 3. Fluid balance• The stratum corneum has the capacity to

absorb water• Skin damage (burn)• The skin is not completely impermeable to

water. (evaporation) 600cc/day

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Functions of the skin

• 4. Body temperature– Body produces heat (metabolism of foods)– Body releases 80% of heat through skin– Three major physical processes for loss of heat

[radiation, conduction (evaporation), convection].– On a hot day the skin releases almost 3000

calories of body heat (enough to boil five gallons of water)

– Heat loss is controlled by negative feedback loop – Skin blood flow

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Functions of the skin

• 3. Produces Vitamin D– Uv rays combine with skin to make cholecalciferol– Cholecalciferol is transported to the liver and

kidneys where it is changed to vit D– Vitamin D is essential for preventing osteoprosis

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Functions of the skin

• Immune response function• Langerhans cells facilitate the uptake of IgE-

associated allergens• Plays a pivotal role in the pathogenesis of

atopic dermatitis and other allergic disease

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Skin and Aging Process

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Assessment of the Skin

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Preparation

• Equipment• Well-lit Room• Comfortable Environment• Hand washing• Appropriate use of Gloves• Privacy/Draping• Organized Assessment• Explanations

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PHYSICAL ASSESSMENT

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Physical Assessment

• Inspection– Color– Bleeding– Ecchymosis– Vascularity– Lesions

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Physical Assessment

• Palpation– Moisture– Temperature– Texture– Turgor– Edema

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• Color– Normal=Uniformed whitish pink or brown – Abnormal

• Cyanosis• Jaundice• Carotenemia• Albinism• Vitiligo

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Cyanosis

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Jaundice

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Carotenemia

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Albinism

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Vitiligo

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Physical Assessment

• Bleeding, Ecchymosis, Vascularity– Normal=No areas– Abnormal

• Spontaneous Bleeding• Petechiae• Ecchymosis• Venous Star• Necrosis

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Petechiae

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Ecchymosis

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Venous Star

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Necrosis

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Lesions

• Lesions– Normal=No lesions except freckles, birthmarks,

nevi (flat moles)– Abnormal

• Rashes• Pressure Ulcers• Burns

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SKIN LESIONS

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Kind of lesions in dermatology

1- Primary Skin Lesions

2-Secondary Skin Lesions

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PRIMARY LESIONS

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macule

• Flat, circumscribed skin discoloration that lacks surface elevation or depression

• Lesser than 1cm• Vitiligo

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Patch

• Flat, circumscribed skin discoloration, a very large macule

• Vitiligo

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Papule

• Elevated, solid lesion <0.5 cm in diameter

• B.C.C• Intradermal Nevi

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Plaque

• Elevated, solid”confluence of papule”>0.5 cm in diameter that lacks a deep component

• Psoriasis

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Nodule

• Elevated, solid lesion>0.5 cm in diameter, a larger-deeper papule

• Lipoma• Rheumatoid nudule

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Vesicle

• Plaque that contains clear fluid ,a blister

• Lesser than .5 cm

• Herpes simplex• Herpes zoster• Contact dermatitis

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Bulla

• Localized fluid collection>0.5 cm in diameter, a large vesicle

• Pemphigus vulgaris• Bullous impetigo

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Pustule

• Vesicle or bulla that contains purulent material

• Folliculitis• Impetigo• Acne• Pustular psoriasis

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Wheal (Hive)

• Firm,edematous,plaque that is evanescent and pruritic

• Urticaria

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Cyst

• Nodule that contains fluid semisolidmaterial

• Sebaceous cyst• Epidermal cysts

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SECONDARY

LESIONS

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Crust

• A collection of cellular debris ,dried serum, and blood

• Impetigo• Herpes, eczema

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Erosion

• A partial focal loss of epidermis, heals without scarring

• Ruptured vesicles• Scratch marks

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Scale

• Thick stratum corneum that results from hyperproliferation or increased cohesion of keratinocytes

• dandruff• Psoriasis • Dry skin

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Ulcer

• A full-thickness, focal loss of dermis, heals with scarring

• Bed sore• Syphlis

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Fissure

• Vertical loss of epidermis and dermis with sharply defined walls, crack in skin

• Chapped lips or hands

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Scar

• A collection of new connective tissue, may be hypertrophic or atrohic scar

• Burn• Acne

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Atrophy

• Thinning of the epidermis, dermis or fat that cause depression in the skin surface

• Aged skin

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Lichenification

• Focal area of thickened skin produced by chronic scratching or rubbing

• Contact Dermatitis

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Keloid

• Hypertrophied scar tissue, elevated, irregular,

• Surgical incision

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Moisture

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Moisture

• Moisture– Normal=Dry with minimum of Perspiration– Abnormal

• Xerosis• Diaphoresis

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Temperature

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Temperature

• Temperature– Normal= warm; hands & feet slightly cooler– Abnormal

• Hypothermia• Hyperthermia

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Texture

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Texture

• Texture– Normal=smooth, firm– Abnormal

• Roughness• Soft

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Turgor

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Turgor

• Turgor– Normal=when skin is released, it should return to

original contour rapidly– Abnormal

• Dehydration

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Edema

• Edema– Normal=No edema present– Abnormal

• Pitting edema is rated on 4 point scale• 1+ is if the pitting lasts 0 to 15 sec

2+ is if the pitting lasts 16 to 30sec3+ is if the pitting lasts 31 to 60sec4+ is if the pitting lasts >60sec

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ASSESSING THE NAILS

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Nail diseases• Bacterial

– Paronychia infections of the nail fold can be caused by bacteria, fungi and some viruses. The proximal and lateral nail folds act as a barrier, or seal, between the nail plate and the surrounding tissue. If a tear or a break occurs in this seal, the bacterium can easily enter. this type of infection is characterized by pain, redness and swelling of the nail folds. People who have their hands in water for extended periods may develop this condition, and it is highly contagious.

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• Beau's Lines are nails that are characterized by horizontal lines of darkened cells and linear depressions. This disorder may be caused by trauma, illness, malnutrition or any major metabolic condition, chemotherapy or other damaging event, and is the result of any interruption in the protein formation of the nail plate. Seek a physicians diagnosis.

• Koilonychia is usually caused through iron deficiency anemia. these nails show raised ridges and are thin and concave. Seek a physicians advice and treatment.

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Onychorrhexis84

Onychorrhexis

• Presence of longitudinal striations or ridges

• A sign of advanced age but it can also occur with the following:–Rheumatoid arthritis–Peripheral vascular disease

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ASSESSING THE HAIR

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• Color and texture• Distribution (cyclophosphamide)• Hair loss

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Androgenetic Alopecia - Male

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Androgenetic Alopecia - Male

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Androgenetic Alopecia - Female

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Alopecia Areata

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SKIN CONSEQUENCES OF SELECTED SYSTEMATIC DISEASE

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Figs 24,25. Legs of two patients with diabetes mellitus. The patient on the left is a teenage girl with insulin dependent diabetes. The patient on the right is an adult onset diabetic. Both have multiple atrophic hyperpigmented macules, so-called diabetic dermopathy. 93

Stasis Dermatitis - Early

• Large vessels are damaged

• The skin suffers from lack of nutrients

• Very dry and fragile

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Skin Infections

• Bacterial infections (around hair follicles)• Fungal infections (areas that remain moist all

the time)• Candida infections (around the border of the

area)• Dermatophyte infections (around the toenails

and feet)

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Leg and Foot Ulcers

• Cause : Change in peripheral nerves in diabetic cases

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DIAGNOSTIC EVALUATION

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Diagnostic Evaluation

• Skin biopsy• Immunoflurescence test- Identify the site of an immune reaction- Direct Immunoflurescence test- Indirect Immunoflurescence test• Patch testing• Skin scraping• Tzanck smear• Wood’s light examination• Clinical photographs

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Skin biopsy• Performed to obtain tissue for microscopic

examination by scalpel excision or by a skin punch instrument

• Biopsy from skin nodules, plaque, blisters for rule out of malignancy

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Immunofluorescence

• Designed to identify the site of an immune reaction

• An antigen or antibody with a flurochrome dye combine

• Antibodies can be made fluorescent• Direct immunofluorescence• Indirect immunofluorescence

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Patch testing• For detect of allergy

• Apply suspected an allergen to normal skin

• Evaluation of patient response

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Skin Scrapings

• Tissue sample are scraped from fungal lesions n• Examine microscopically

• Infestations such as scabies

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Tzank Smear• A test used to examine cells from blistering

skin conditions

• Evaluate microscopically

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Wood’s Light Examination

• Wood’s light is a special lamp that produces long-wave ultraviolet rays, which result in a characteristic dark purple fluorescence

• It is possible to differentiate epidermal from dermal lesions and hypopigmented and hyperpigmented from normal skin

• Light is not harmful to skin or eyes• Lesions that contain melanin be disappeared under ultraviolet

light• Lesions that are devoid of melanin increases in whiteness

under ultraviolet light

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Clinical Photographs

• For detecting of the nature and extend of the skin condition and progress or improvement resulting from treatment

• Used if the characteristics of the mole are changing

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Hidradenitis Suppurativa

• H.S is a chronic suppurative folliculitis of the perineal, axillary, and genital area or under the bereasts

• The cause is unknown but have a genetic basis• Pathophysiology:• Abnormal blockage of the sweat glands• Management• Hot compress and oral antibiotic• Isotretinoin or acitretin drugs• Incision and drainage

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ISOTRETINOIN, ATB,ISOTRETINOIN, ATB,PREDNISONPREDNISON

Hidradenitis suppurativaPacient č. 1

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Hidradenitis suppurativaPacient č. 1

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Hidradenitis suppurativaPacient č. 2

ATB, ISOTRETINOIN,ATB, ISOTRETINOIN,PREDNISON PREDNISON 109

PO CHIRURGICKÉ LÉČBĚ PO CHIRURGICKÉ LÉČBĚ

Hidradenitis suppurativaPacient č. 2

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Hidradenitis suppurativaPacient č. 3

ATB, ISOTRETINOIN,ATB, ISOTRETINOIN,PREDNISON PREDNISON 111

PO CHIRURGICKÉ LÉČBĚ PO CHIRURGICKÉ LÉČBĚ VPRAVOVPRAVO

Hidradenitis suppurativaPacient č. 3

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PO CHIRURGICKÉ LÉČBĚ PO CHIRURGICKÉ LÉČBĚ VPRAVOVPRAVO

Hidradenitis suppurativaPacient č. 3

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BEZ CHIRURGICKÉ LÉČBYBEZ CHIRURGICKÉ LÉČBYVLEVO VLEVO

Hidradenitis suppurativaPacient č. 3

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BEZ CHIRURGICKÉ LÉČBYBEZ CHIRURGICKÉ LÉČBYVLEVO VLEVO

Hidradenitis suppurativaPacient č. 3

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SEBORRHEIC DERMATOSIS

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Seborrheic Dermatosis

• Seborrhea is excessive production of sebum• Exist in areas where sebaceous glands• Is a chronic inflammatory of the skin • Clinical manifestations:- Two forms: oily form and dry form- Oily form: moist or greasy, patches of yellow, with or

without scaling, slight erythema- Forehead, nasolabial fold, scalp, axillae, groin,

breasts,

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Seborrheic Dermatosis

• Dry form:- Flaky desquamation of the scalp with a profuse amount of

fine, powdery scales (dandruf)- Medical management:- Corticosteroid cream (glaucoma and cataract)- In this disease develop secondary candida infection- Treatment of dandruff: frequent shampooing (containing

selenium sulfide suspension, zinc pyrithione, salicylic acid, sulfur compounds)

- Nursing management:- Avoid external irritant, exessive heat, perspiration, rubbing118

Seborrheic Dermatosis

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Acne Vulgaris

• A.V is a common disorder affecting susceptible hair follicles• Face, neck, upper trunk 85% adolescents experience it Affects 12-35 year olds• Pathophysiology:• During puberty, androgens stimulate the sebaceous glands• C/M• Close and open comedones (impacted of lipids, oils, keratin)• A.V is seen as erythematous papules, inflammatory pustule,

inflammatory cyst

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Acne Vulgaris

• M/M• Goal:• Reduce bacterial colonies• Decrease sebaceous gland activity• Prevent of plugged• Reduce inflammation• Combat secondary infection• Minimize scarring121

Acne Vulgaris

• 1) Nutrition and Hygiene Therapy• Diet is not believed to play a major role• Good nutrition for increase of immune system• Washing of face two/day• Oil free cosmetic and cream

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Acne Vulgaris

• Pharmacologic therapy• 2) Topical Therapy:• Salicylic acid or benzoyl peroxide are effective in removing

of plugs (some persons are sensitive)• Use once daily and cause redness and scaling• Benzoyl erythromycin• Benzoyl sulfur• Vitamin A acid (tretinoin)• Avoid of sun• Topical antibiotics123

Acne Vulgaris

• Pharmacologic therapy• 3) Systemic Therapy• Oral antibiotics (tetracycline family

contraindicate)• Synthetic vitamin A compound(retinoid) such as

isotretinoin that reduce sebaceous gland size (side effect: cheilitis, dry and chafed skin)

• Isotretinoin is toratogen • Estrogen therapy for female124

Acne Vulgaris

• 4) Surgical Management• Comedo extraction• Injection of corticosteroid in lesions• Incision and drainage of nodular cystic

leasions• Cryosurgery(freezing with liquid nitrogen)• Abrasive therapy (dermabrasion)

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BACTERIAL SKIN INFECTIONS

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Bacterial Skin Infections

• Impetigo• Impetigo is a superfatial infection of the skin caused by

staph., strep.• Bullous impetigo• The exposed areas of the skin involved• Is contagious• In all ages is seen but in children with poor hygiene is

common • Follows pediculosis capitis, scabies, herpes simplex,

insect bites, poison ivy, eczema128

Bacterial Skin Infections

• Impetigo (cont.)• C/M• Red macules• Thin-walled vesicles• Crust

• M/M• Systemic antibiotic therapy• Non bullous impetigo: benzathin penicillin, oral penicillin, • Bullous impetigo: penecillinase resistant penicillin (cloxacillin, dicloxacillin• Topical antibiotic therapy• Mupirocin (in small area) several times daily/week• Lesion must soaked before topical antibiotic

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Impetigo

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Folliculitis, Furuncles, Carbuncles

• Folliculitis is an infection of bacterial or fungal origin that arises within the hair follicles

• Lesions may be superficial or deep • Single or multiple papules or pustules appear

close to the hair folicle• Beard area in men and women’s leg• Usually caused by staph.• Pseudofolliculitis barbae (shaving bumps)

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Folliculitis

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Furuncle

• An acute inflammation arising deep in one or more hair follicle and spreading into the surrounding dermis

• Furunculosis is multiple or recurrent lesions• Occur anywhere and more in pressure area• Start as a small, red, raised, painful pimple after a

few days convert to furuncle (center become yellow or black)

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Furuncle

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Carbuncle

• An abscess of the skin and subcutaneous tissue that represents an extension of a furuncle that has invaded several follicles and is large and deep seated.

• Usually caused by a staph • Appear most commonly in thick skin and inelastic• Result fever, pain, leukocytosis• More likely in pt. with underlying systemic disease

(diabetes, hematologic malignancy, in person that use immune suppressive drugs)

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Carbuncle

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Medical management

• Not to rupture protective wall of leasons• The boil or pimple should never be squeezed• Systematic antibiotic therapy:• Oral cloxacillin and dicloxacillin• Cephalosporin and erythromycin• When the pus has localized small, incision and

drainage induced

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VIRAL INFECTIONS

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Herpes Zoster

• Commonly known as “shingles”• Reactivation of latent VZV in dorsal root or

cranial nerve ganglion cells• 10% of patients are > 50 & 50% of patients are

> 85 years old• Lesions appear over several days, usually

resolve in 1-3 weeks• Disease more severe/longer duration in

immunocompromised patients

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Herpes Zoster

• Severe HZ can be first sign of HIV of underlying malignancy (often Hodgkin’s disease)

• Average adult has one episode over lifetime• Patients with multiple episodes over a short

period of time indicate further investigation

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HZ – clinical manifestation

• Lesions often preceded by pruritis, tenderness and pain and/or neurologic changes

• This pain often confused with Sciatica, renal/urinary stones, cholecystitis (gallbladder disease,) and pleural/cardiac disease

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HZ – clinical manifestation

• Lesions appear posteriorly, the progress in anterior direction

• Presents as grouped papules, vesicles, pustules and crusts on erythematous base

• Lesions spontaneously heal in 1-2 weeks

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HZ – clinical manifestation

• 50% of cases involve thoracic nerves• 15-20% cervical or lumbar nerves• Remainder involve sacral and cranial

nerve roots

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HZ – clinical manifestation

• Be wary of lesions presenting on nasal tip as this defines involvement of nasociliary branch of ophthalmic division of trigeminal nerve (CN V1)

• ~33% of cases of ophthalmic zoster involve CN V1

• Ophthalmic Zoster can be extremely destructive to eyeball apparatus

• Zoster with nasal tip involvement indicates immediate referral to ophthalmology for further investigation!

• May need IV antivirals

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HZ - Diagnosis

• Usually a clinical diagnosis based on characteristic prodromal symptoms and appearance

• Usually do viral culture for VZV• Can also do skin biopsy for histopathology,

Tzanck smear, Antibody studies, etc.

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HZ - Treatment• Immunization ~80% effective (Zostavax)• Anti viral agents:- Acyclovir (zovirax)-Valacyclovir (valtrex)- Famciclovir (famvir)• Systemic corticostroid for pt.>50 years • Triamcinolone injection under painful area as anti

inflammation

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PHN – Post Herpetic Neuralgia

• Syndrome defined by pain and/or other neurologic symptoms

• Can last months to years beyond the illness itself

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Herpes Zoster

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Herpes Simplex Virus (HSV)

• Two Strains of HSV: HSV 1 and HSV 2• HSV 1 generally face/lips and HSV 2 generally

genitals/anal area.• Virus doesn’t follow any rules: HSV 1 can appear on

genital and HSV 2 can appear on face

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Herpes Simplex Virus (HSV)

• On lips, also known as herpes labialis, cold sore or “fever blister”

• On fingers, called herpetic whitlow• On wrestlers and other athletes, called herpes

gladiatorum• Inside mouth, called herpes gingivostomatitis• Remember, can occur anywhere!

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Herpes Simplex Virus (HSV)

• HSV is a recurrent disease, which after initial exposure and infection, ascends peripheral sensory nerves to the nerve ganglion, where it then resides in a latent fashion

• Virus contagious skin-to-skin contact or exposure to fluid from active blisters.

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HSV – Clinical Presentation

• +/- malaise, fever, fatigue, headache• burning/tingling• 12-24 hours later, erythematous macules/patches

appear, soon followed by rapid development of painful, yellow, fluid-filled vesicles

• Vesicles rupture 24-48 hours later leaving painful, crusted ulcerations and erosions.

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HSV – Clinical Presentation

• Can present as pruritic red macules and patches, or red papules mimicking acne vulgaris.

• Majority of patients with HSV are asymptomatic carriers

• Trigger factors for eruption: Physical/emotional stress, sunburn, trauma, fever, menstruation

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Complications

• Eczema herpeticum (managed with oral IV acyclovir)

• Herpetic whitlow• Intra uterine neonatal infection

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HSV - Diagnosis

• Often a clinical diagnosis• Viral Culture for HSV 1/HSV 2• Tzanck Smear

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HSV – Treatment

• Topicals: Acyclovir 5% ointment, Penciclovir 1% cream

• Oral meds: Acyclovir, valcyclovir (valtrex), famciclovir (famvir)

• For severe, disseminated infections: IV acyclovir, foscarnet

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Herpes Simplex Virus (HSV)

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FUNGAL SKIN INFECTIONS

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Fungal Skin Infections

• In some cases affect only the skin and its appendages• In other cases internal organs are involved• Secondary infection appear with bacteria or candida• The most common fungal skin infection is tinea that is called

ringworm• Tinea infections affect the head, body, groin, feet, nails• For diagnosis the scales are dropped onto a slide and added

potassium hydroxide• Wood’s light be helpful

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Parasitic skin infections

• Pediculosis (lice) and Scabies (itch mite)• Pediculosis • Affects all ages• Three varieties of lice:

– Pediculus humanus capitis– Pediculus humanus corporis– Phthirus pubis– Feeding of human blood– Causes itching

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Pediculus humanus capitis

• Eggs close the scalp• The young lice hatch in about 10 days and

reach maturity in 2 weeks• Transmitted direct or indirect

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Pediculus corporisand pubis

• An infestation of the body• Appear in unwashed people or who live in

close sites• Pediculosis pubis is more common

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Clinical manifestation

• Head lice are found most in back of the head and behind the ears

• The eggs look like silvery , oval bodies• Cause intense pruritus and lead to bacterial

infections such as impetigo and frunculosis• Body lice lives in seams of cloths• Pubic lice may coexist with STD such as

gonorrhea, herpes,or syphilis

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Medical Management

• Washing the hair with shampoo lindane or pyrethrin compounds with piperonyl butoxide

• Comb hair with a fine-toothed comb dipped in vinegar• All articles should wish in hot water• The room should be vacuumed frequently• All family members have to treat • Complication such as sever pruritus, pyoderma,

dermatitis treated with antipruritics, systemic antibiotics, topical corticosteroids

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SCABIES

• An infestation of the skin by the itch mite sarcoptes scabiei

• Appear In who with substandard hygieine• + or – with sexual activity• Involve the fingers and hand contact may

produce infection

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Clinical Manifestation

• Appear symptoms after 4 weeks• Pt. complain of sever itching • Ask from of the pt. about site of sever itching• Use of magnifying glass and penlight• Other site: elbows, knees, the edge of the feet, the point of

the elbows, around the nipples, axillary fold, under breasts, the groin or gluteal fold, penis or scrotum

• One classic sign is itching at night• Secondary lesions appear such as vesicle, papule, excoriation,

crust

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Assessment and Diagnostic Findings

• Confirm with Sarcoptes. scabiei or the mite’s hyproducts from the skin

• M/M• Instruction for take a warm, soapy shower and after dry and

cooling of the skin prescribe of scabicides• Prescription of scabicide such as: lindane, crotamiton, or 5%

permetrin from the neck down for 12 to 24 hours• One application may be enough

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Scabies

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CONTACT DERMATITIS

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Contac Dermatitis

• An inflammatory reaction of the skin to physical, chemical, or biologic agents

• Common causes of irritant dermatitis are soap, detergents, scouring compounds, industrial chemicals

• C/M• Pruritis, burning, erythema, edema, papules, vesicles, oozing,

secondary bacterial infections• M/M• Soap is not used until healing• Cool, wet dressing• Corticosteroid 170

NONINFECTIOUS INFLAMMATORY DERMATOSIS

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Psoriasis • The most common skin disease• 2% of population• A chronic disease stem from a hereditary defect that cause

overproduction of keratin• Most common in 15-35 years

• Pathophysiology - Immunologic basis• Trigger factors- Emotional stress, trauma, infections, seasonal and hormonal

changes- The cell in the basal layer of the skin divide too quickly and the

normal events of cell maturation and growth cannot occur

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Psoriasis

• C/M• Red lesions with raised patches of skin covered

with silvery scales that are pruritic• Involve the nails in one half of the pt. with pitting,

discoloration, beneath the free edges, and separation of the nail plate

• Bilateral symmetry of lesions • Most in scalp, elbow, knee, back, genitalia, nail• Arthritis

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Psoriasis

• Assessment and diagnostic finding- Presence of the classic plaque-type

lesions- Sign of nail and scalp- Skin biopsy has little diagnostic value

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Psoriasis • M/M- Control of stress- Pharmacologic therapy: - Topical agents: topical corticosteroids and covering skin with occlusive

dressing, nonsteroidal treatments are calcipotriene ( a synthetic derivative of calcitriol or vitamin D) and tazarotene ( topical retinoid)

- Systemic agents: - Infliximab (a monoclonal antibody against tumour necrosis factor alpha (

TNF-α) used to treat autoimmune diseases)- Etanercept (a TNF inhibitor)- Efalizumb ( monoclonal antibody)- Alefacept ( immunosuppressive drug)- Adalimumab (the third TNF inhibitor)

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M/M in Psoriasis

- Oral agents: methotrexate, cyclosporine A (an immunosuppressant drug )oral retinoids (Etretinate)

- Photochemotherapy: photosensitizing oral medication with exposure to ultraviolet-A light (PUVA).

- Photosensitizing medication (8-methoxypsoralen)

- Phototherapy in the ultraviolet-B (UVB) 176

Psoriasis

177

BLISTERING DISEASE

178

Pemphigus • Pemphigus is a group of serious disease of the skin

characterized by the appearance of bullae. • An autoimmune disease involving IgG• A blister forms from the antigen-antibody• Highest incidence in Jewish or Mediterranean• Associated with penicillins and captopril and myasthenia gravis • C/M• Oral lesions that are painful, bleed easily and oozing, Nikolsky’s

sign• Complications : secondary bacterial infection, fluid and

electrolyte imbalance, hypoalbuminemia

179

Pemphigus

• M/M• Goals : prevent loss of serum and the

development of secondary infection and to promote reepithelization

• Corticosteroid priscription• Immunosuppressive agents : azathioprine,

cyclophosphamide, gold• plasmapheresis

180

Pemphigus

181