Overview of Integumentary Disorders

Disorders of the Nails Disorders

Clubbing – abnormal curving / increased angle at the nail bed (often related to O2 deficiency)

Koilonychia– “spoon nail” = malformation of the nail in which the outer surface is concaved or scooped out (often indicates iron deficiency anemia)

Onychia/Onychitis (onych = fingernail) = inflammation of the matrix of the nail

Onychocryptosis (onych = mail, crypt = hidden, osis = abnormal condition)

NDisorders of the Nails Continuedil Diseases and Disorders Onychomycosis = fungal infection of the nail

(myc= fungus) Onychophagia = nail biting (phagia = eating) Paronychia – infection of the skin fold at the

margins of a nail (par = along side) Subungual hematoma – collection of blood

under a nail

HaiDisorders of the Hairr Diseases and Disorders Hirsutism = excessive hairiness (hirsut = hairy) Abnormal Hair Loss

Alopecia = partial or complete loss of hair (alopec = baldness)

alopecia areatea = autoimmune disorder; well defined bald areas

alopecia capitis totalis alopecia universalis Female pattern baldness – hair thins in front and sides Male pattern baldness- Horseshoe shape area of hair

remains in the back and temples

Disorders of the Skin

Acne vulgaris – Caused by increased secretion of oil related to increased hormones during puberty

Albinism – Inherited disorder in which melanin is not produced

Athlete’s foot– Contagious fungal infection of the foot

Acne Vulgaris

Description: Self-limiting inflammatory process of the hair follicle and pilosebaceous glands

Cause/Incidence: Etiology unknown; predominately during adolescence

Manifestations: Inflammatory acne - pimples, pustule, nodules, and cysts Non-inflammatory: open and closed comedones

(blackheads or whiteheads) Treatment:

Drying agents - e.g., Benzoyl peroxide/Retin-A Topical antibiotic (clindamycin, erytromycin) Systemic antibiotic/Accutane

Disorders of the Integumentary System (continued) Cellulitis

– Bacterial infection of the dermis and subcutaneous layer of the skin

Chloasma– Patchy discoloration of the face

Cleft lip or cleft palate– Upper lip has a cleft where the nasal palate doesn’t meet properly

Contact dermatitis– Allergic reaction that may occur after initial contact or as an acquired response

Cellulitis

Description: A deep locally diffuse infection of the skin with systemic manifestations and life-threatening potential

Cause/Incidence: Usually involves face or an extremity. History of trauma, impetigo, recent otitis media, or

sinusitis In children less than 3 years, facial cellulitis frequently

is caused by Haemophilus influenza type b. Cellulitis of extremities is more often associated with S.

aureus and Group a Streptococci.

Cellulitis: Manifestations:

Most children look and feel ill, often febrile

Pitting edema over affected area

Classic signs of inflammation, redness, swelling, heat and tenderness/pain

Leucocytosis

Cellulitis

Management/Treatment: Systemic antibiotics Immobilization of affected area Incision and Drainage with culture

Nursing Considerations: warm compresses, elevation Non-occlusive dressing if skin rear or rupture

Disorders of the Skin (continued) Decubitus ulcers

– Sores or areas of inflammation that occur over bony prominences of the body

Eczema– Group of disorders caused by allergic or irritant reactions

Atopic Dermatitis (Eczema)

Description- An inflammatory dermatitis that refers to a descriptive category of dermatologic disorders. Eczema is characterized histologically by epidermal changes of intracellular edema, spongiosis, or vesiculation.

Cause/Incidence: Often inherited. Inhaled allergens or food allergens are thought to induce mast-cell responses.

ECZEMA: MANIFESTATIONS

Usually symmetrical, scaly, erythematous patches or plaques with possible exudate and crusting

Pruritus Unaffected skin dry and

rough. Chronically, relapsing

course Immediate skin test

reactivity. Elevated serum IgE

Atopic Dermatitis (Eczema) Management/Treatment

Burow solution (aluminum acetate) compresses. Topical Steroids Antihistamines to control itching Oral antibiotics is widespread breakdown or

infection Moderate amount of bathing followed by

application of a lubricating lotion Humidified heat in the winter.

Disorders of the Skin (continued) Fungal skin infections

– Skin infections that live on dead outer surface or epidermis

Furuncle– Boil, or bacterial infection of a hair follicle

Impetigo– Very contagious bacterial skin infection that occurs most often in children

Kaposi’s sarcoma– Form of cancer that originates in blood vessels and spreads to skin

Impetigo

Description: Contagious bacterial skin infection

Cause/Incidence: Staphylococcus, streptococcus or a combination of both. Incubation period is 7-10 days.

Types: Impetigo contagiosa (nonbullous) Bullous Impetigo

Impetigo

Manifestations: Small papule that becomes vesicular, pustular and then forms a honey-colored crust. Usually no

systemic manifestation.

Impetigo

Management/Treatment Topical bactericidal ointment. If no response to topical ointment in 72 hours:

give systemic antibiotics Good hand washing. Limit person to person

contact.

Nursing Considerations Measures to prevent the spread

Disorders of the Integumentary System (continued) Lupus

– Benign dermatitis or chronic systemic disorder

Psoriasis– Chronic skin disorder in which too many epidermal cells are produced. (lesions of psoriasis are plaques – solid raised area of skin > 0.5 cm in diameter)

Rashes– May result from viral infection, especially in children

Disorders of the Integumentary System (continued)

Scleroderma– Rare autoimmune disorder that affects blood vessels and connective tissues of the skin

Streptococcus – Non-motile bacteria that affect many parts of the body

Carcinoma

Cancerous Tumor

Basal Cell Carcinoma

Most common Least malignant Slow growing Papules that erode in the center Pearly edge 99% cure rate with early excision

Squamous Cell Carcinoma

In keratinocytes of stratum spinosum Scaly red papule (rounded elevation) Rapid growth Meets lymph Good cure rate if caught early followed by

radiation treatment

Malignant Melanoma

Cancer of melanocytes Most dangerous, death 1:4 cases Accounts for 5% of skin cancers Nevus mole becomes dark, spreads

unevenly, bleeds some Metastatic Cause: overexposure to UV radiation (sun or

tanning bed)

American Cancer Society ABCD Rule for Skin Cancer A – Asymmetry B – Border Irregularity C – Colors Different D – Diameter (larger than 6 mm –pencil

eraser)

Kaposi’s Sarcoma

Purple papules spread to lymph nodes and other organs

Opportunistic disease of AIDS

Disorders of the Skin (continued)

Vitiligo– Condition in which a loss of melanocytes results in whitish areas of skin bordered by normally pigmented areas

Warts (Verrucae)– Papule caused by human papillomavirus

Burns

Description: injury to skin and possibly subcutaneous tissue, caused by chemical, thermal, radiation or electrical causes

Cause/Incidence: May be accidental or non-accidental; second leading cause of injury child < 14

Types of Burns

Superficial (first degree) – no blisters, superficial damage to the epidermis (e.g., sun burned)

Partial Thickness (second degree) – blisters, superficial damage to the epidermis

Full Thickness (third degree) – damage to the epidermis, corium, and subcutaneous layers

Rule of Nines

Burns: Management

Skin Care: Promote healing/Prevent infection Pain Management Fluid Replacement High calorie, high carb, high protein diet Active/Passive ROM if possible Emotional Support

Overview of Communicable Disease/Rashes

Scarlet Fever: Manifestations

Sore throat, chills, fever, headache (occ. vomiting)

Erythematous papular rash on trunk and extremities (feels like sandpaper)

Strawberry “white” or “red” tongue

Circumoral pallor with erythema of lips, soles and palms

Scarlet Fever: Management

Management/Treatment: Antibiotics

Nursing Considerations: Bed rest during febrile stage Analgesics/Antipyretic Fluids Prevention of complications and control of

spread of disease

Communicable Diseases:Scabies Description: Contagious skin condition caused by

human mite - Sarcoptes scabiei

Incidence/Pathophysiology: Transmitted by close personal contact, Female mite burrow into outer layer of the epidermis to lay eggs, larvae hatch in several days and move toward the skin surface, Mite secretions, ova and feces are highly irritating so itching begins about 1 mo after infestation

Scabies: Manifestations

Intense pruritis, esp at rest/ bedtime

Infants/young child may be irritable, sleep fitfully

Lesions are linear, grayish burrows 1 to 10 cm long ending in a pinpoint vesicle, papule, or nodules

Skin excoriation from scratching

Scabies: Management

Management/Treatment: Scabicida medications crotamiton (Eurax),

permethrin 5% (Elimite), or lindane (Kwell, Scavene)

Oral antihistamines, soothing creams, lotions to reduce itching

Antibiotic is secondary infection Nursing Considerations:

Pt/family education Prevent spread: Treat all family/close

contacts, wash clothes/linens

Communicable Diseases:Varicella Description: A viral disease characterized

by a pruritic vesicular rash that appears in crops

Cause/Incidence: Varicella-zoster virus, transmitted by direct contact with vesicular fluid; Incubation period 14 to 21 days: Contagious day before rash appears to 1 week after first lesion crusted. Immunity from vaccination or disease

Varicella: Manifestations

Prodromal: mild fever and malaise for 24 hrs

Acute: Rash that progresses from macule to vesicle to crusts; eruptions last 5 days and lesions of all types are present at once

Varicella: Management

Management/Treatment: Varicella immunoglobulin for

immunocompromised pt within 72 to 96 hrs Antipruritic lotions

Nursing Considerations: Avoid Aspirin (assoc with Reyes) Prevent spread of infection Mitten hands if necessary Prevention: Vaccine

Communicable Diseases:Rubeola (“Red” Measles)

Description: Highly contagious, acute viral infection

characterized by fever, cough, coryza, conjunctivitis, maculopapular skin rash and Koplik’s spots

Cause/Incidence: Viral etiology; 7 to 14 day incubation, Communicable several days before rash appears to 5 days after rash; Immunity = vaccination or disease

Rubeola: Manifestations

Prodomal: fever, lethargy, cough, coryza, photophobia, Koplik’s spots on buccal mucosa

Acute: red, flat rash (lasting about a wk) begins behind ears, spreads to face, trunk, and extremities

Rubeola: Management

Management/Treatment: Symptomatic

Nursing Considerations: Monitor for complications - bacterial super-

infections, pneumonia, otitis media, encephalitis

Communicable Diseases:Rubella (German Measles)

Description: Mild disease characterized by

erythematous maculopapular discrete rash; postauricular and suboccipital lymphandenopathy

Cause/Incidence:RNA virus classified as rubivirus, transmitted by direct contact with nasopharyngeal secretions. Incubation - 14 to 21 days; Communicable 1 wk before and 5 days after onset of rash. Immunity=disease or vaccination

Rubella (German Measles): Continued

Manifestations: Prodromal: low grade fever, headache, sore throat

and cough Acute: Flat rash begins on face and spreads to

body; lasts 3 days

Management/Treatment: Antipyretics/symptomatic Complications: rare Prevent spread of infection

Communicable Diseases: Mumps (Parotitis)

Description: Viral, communicable disease characterized by swelling of the parotid glands

Cause/Incidence: Mumps virus; Transmission: droplet or direct contact; Incubation 14 to 21 days; Communicability:1 week before parotoid swelling until 1 week after swelling begins

Immunity: from disease or vaccination

Mumps: Manifestations

Prodromal: fever, headache, earache that worsens with chewing

Acute: Swelling of parotid glands

Mumps: Management

Management/Treatment: antipyretics fluids and soft diet

Nursing Considerations: Monitor for complications: Orchitis,

encephalitis, deafness Prevent spread Prevention: vaccination

Communicable Diseases: Roseola (exanthema subitum) Description:

mild, viral disease Cause/Incidence:

caused by herpes virus type 6 (HHV-6) common 6 mos to 2 yrs

Roseola: Continued

Manifestations: Starts with high fever > 103 and irritability lasting 2-

3 days Followed by rosy pink rash develops - first on trunk

then to neck, face, & extremities Cause/Incidence:

Control fever (febrile seizures common) Fluids

Fifth Disease - erythema infectiosum

Description: A communicable disease of childhood that causes a rash

Cause/Incidence: Etiology unknown; possibly spread thru resp tract; most contagious 1 week before rash appears. Once rash appears no longer contagious

Risk to developing fetus and to immuno-suppressed children

Treatment: supportive Complications rare: self-limiting arthritis or

arthragia, encephalitis, or myocarditis

Fifth Disease: Manifestations

Red rash on face that looks like “slapped cheeks”

Lacy pink rash on the backs of the arms and legs, torso, and buttock

Stevens-Johnson Syndrome

Description: an acute cutaneous disorder, severe form of erythema multiforme

Cause/Incidence: Possible hypersensitivity to certain drugs; secondary to resp infection

Management: Identification and elimination of underlying

cause (Antibiotic if necessary) Prevention of secondary infection Pain relief

Stevens-Johnson Syndrome: Manifestations Fever, malaise, cough, sore

throat, diarrhea, vomiting, chest pain, myalgia

Bulla with a grayish-white membrane on the mucous membranes of the lips, eyes, oral/nasal mucosa, genitalia, and rectum

Extensive skin lesions

Fungal Infections

Descriptions: Superficial infections that live on the skin and not “in” the skin.

Cause/Incidence: Fungi grow best in warm, moist places Causative fungi are usually opportunistic and

not usually pathogenic unless they enter a compromised host

Fungal Infections: Tinea Pedis

Description: - fungal infection of the foot (Althelete’s foot )

Cause/Incidence: Most common fungal infection. Caused by species of the genera Microsporum and Trichophyton. Transmitted by direct contact with skin containing fungi, and fungi in damp areas

Tinea Pedis: Continued

Manifestations: Interdigital lesions (fissures); Vesicles/erosions on instep, Pruritus, Diffuse scaling

Management: Miconazole, clortrimazole, or haloprogin Burrow solution compresses

Nursing Considerations: Teach foot hygiene Observe for secondary infection Prevent transmission

Fungal Infections: Ringworm (Tinea Capitis or Tinea Corporis) Description: A fungal infection of the scalp or body

Cause/Incidence: Microsporum and Trichophyton; transmitted by direct contact

Management: Oral grisofulvin Selenium Sulfate shampoo to reduce fungi on hair Topical antifungal agents - e.g.,Miconazole Antihistamine for itching Prevention of secondary infection Education regarding transmission

Ringworm: Manifestations

One or more irregular, erythematous, slightly raised, scaly patches

Lesions tend to spread but central clearing occurs resulting in “ring”

Pruritus

Fungal Infections: Candida

Description: A yeast infection that occurs in the mouth, esp in infants

Cause/Incidence: may be acquired in newborns from maternal vaginal infection or transmitted by poor hygiene

Manifestations: Oral thrush = white plaques on the mucous membrane; Diaper Dermatitis- char by “beefy” red erythematous areas with surrounding papules and pustules

Management: Nystatin; no isolation required