Integumentary Disorders
Anatomy of the skin
The skin consists of 3 layers:
1. Epidermis- non vascular outermost layer, continuously dividing cells
2. Dermis- takes the largest portion of the skin and provides strength and structure. It consists of glands (sebaceous, sweat), hair follicle, blood vessels, and nerve endings
3. Subcutaneous tissue (hypodermis)- the inner most layer. contains major vascular networks, fat, nerves, and lymphatics

Function of the skin
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Protection- protection of underlying structures from invasion by bacteria, noxious chemicals and foreign matter.

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Sensory perception- transmits pain, touch, pressure, temperature, itching, etc

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Fluid balance (excretion)- absorption of fluids and evaporation of excess.

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Temperature regulation- produced heat released through skin by radiation, conduction, and convection 1|Page

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Vitamin synthesis- skin exposed to ultra violet light can convert substances necessary for synthesizing vitamin D3 (cholecalciferol).

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Aesthetic- affects appearance

Factors influencing skin integrity
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Immoblity is the major factor leading to pressure sore development .

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The pt who is confined to bed & unable to change position is at greatest risk .

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Trauma most likely occur
– over the prominent areas
– weight bearing areas

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Prolonged pressure impairs blood flow to tissue & resulfs in ischemia & inferction
The extent of pressure necessary to cause tisue damage depnds on the tolerance of the pt's skin
& supporting stuctures .

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Tolerance to pressurs trauma is influenced by the following factors:
– Duration of pressure
– Magnitude of pressure
– Body position
– Friction
– Impaired moblity
– Malnutrition
– Dehydration

Common DermatologicTerms
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Lichenification: distinictive thickening of skin
Crust: dried exudate of body fliuds
Erusion: epithelial deficiet
Ulcer: epithelial deficiet (disruption of deep skin integrity)
Atrophy: an acquired loss of substance
Scar:change in the skin secondery to trumas or inflammation

How do we describe skin lesions?
A. Primary Lesions
1. Circumscribed , flat , nonpalpable changes in skin color
• Macule = small upto 1 cm, eg. petechia
• Patch = larger than 1 cm , eg vitilligo

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Palpable elevated solid masses
Papule: up to 0.5cm eg. elevated nevus
Plaque: elevated surface > 0.5 cm
Nodule: deeper & firmer than papule => 0.5 -12cm eg tumor
• Wheal: irregular, superficial area of localized skin edema

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Superficial elevation of skin formed by free fluid in a cavity in the skin layer.
Vesicle: up to 0.5 cm => filled c serous fluid,eg herps simplex
Bulla: > 0.5 cm, Filled of serous fluid, eg 2nd degree burn ( blister)
Pustule: filled pus, eg impetigo, acne

Pustule fggggggggg

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Secondary lesion
4. Loss of skin surface
• Erosion  loss of superficial epidermis
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Ulcer  deep loss of skin surface; May bleed & scar, eg. sphilic chancre

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Fissure  linear crack in the skin

Erosion

Ulcer

Fissure

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On skin surface:
• Crust = dried residue of serum ,pus or blood, eg Impetigo
• Scale = a thin flake of exfoliative epiderms eg.dandruff, Dry skin, Psoriasis

Crust

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Scale

Vascular skin lesions
• A lesion that originated from a blood vessel
– Petechia/Purpura
– Ecchymosis

SKIN ASSESSMENT
General Appearance:
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The general appearance of the skin is assessed by observing (Inspection) color, skin lesions, and vascularity. On palpation skin turgor and mobility, possible edema, temperature, moisture, dryness, oiliness, tenderness, and skin texture (rough and smooth).
Color change: can be hyperpigmentation, hypopigmentation or depigmentation
1. Redness- fever, alcohol intake, local inflammation due to increased blood flow to the skin.
2. Bluish color (cyanosis) - decreased oxygen supply due to chronic heart and lung disease, exposure to cold, and anxiety
3. Yellowish color (jaundice) - increased serum bilirubin concentration due to liver disease or red blood cell haemolysis
4. Brown-tan- Addison’s disease: cortisol deficiency stimulates increased melanin production; Birth mark, chloasma of pregnancy (face patches), and sun exposure
5. Pale: Albinism- total absence of pigment melanin
Ex Vitiligo- destruction of the melanocytes in circumscribed areas of the skin
Vitiligo

Diagnostic test
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Skin biopsy: removal of a piece of skin by shave, punch, or excision technique for a microscopic study of the skin to determine the histology of cells to rule out malignancy and to establish an exact diagnosis.

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Patch testing: performed to identify substances to which the patient has developed an allergy.

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Potassium hydroxide test (KOH): helps to identify fungal skin infection

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Gram stain and culture with sensitivity test: helps to identify the organism responsible for an underlying infection with the effective drug identification

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Slit Skin Smear (SSS): to identify the causative agent of leprosy (mycobacterium leprea)

DISORDERS OF THE SKIN
I . Inflammatory and allergic skin disorders
– Acne
– Psoriasis
– Atopic dermatitis (eczema)
– Contact dermatitis
II. Bacterial infections
– Impetigo
– Boil (furuncle)
– Carbuncle

– Cellilitis
III. Fungal infections
– Dermatophytes
IV. Parasitic Infections
– Scabies
V. Viral infections
– Herpes simplex (cold - sore)
– Herpes zoster (shingles)
– Warts

Inflammatory and allergic condition
A. Eczema/Dermatitis
• It is a chronic pruritic inflammatory disorder affecting the epidermis, and dermis commencing in infancy, often persisting throughout child hood but eventually remitting and sometimes recurring in adult life.
• They are a non-infectious inflammation of the skin and it can be acute, sub-acute or chronic.
• Causes : o The exact cause is unknown o Imbalance of the immune system with an increase in the immunoglobulin “E” activity and deficient of cell mediated delayed hypersensitivity. o Can be exacerbated by infection, bites, pollen, wool, silk, fur, ointments, detergents, perfume, certain foods, temperature extremes, humidity, sweating and stress
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Manifestations o Acute stage: redness, swelling, papules, blisters, oozing and crusts. o Sub-acute stage: skin is still red but becomes drier and scalier and may show pigment change. o Chronic stage: lichenification, excoriation, scaling and cracks are seen

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Types of eczema
1. Atopic eczema
- a chronic relapsing skin disorder that usually begins in infancy and is characterized principally by dry skin and pruritis, consequent rubbing and scratching lead to lichenification
- The patient has a genetic predisposition for hypersensitivity reactions such as asthma, allergic rhinitis, and chronic urticaria. - The eczema comes and goes
- The eczema is triggered by dryness of the skin, infections, heat, sweating, contact with allergens or irritants and emotional stress. - Commonly affected sites are elbow and knee folds, wrists, ankles, face, and neck; in some cases it can be generalized
2. Seborrhoic eczema
- A very common chronic dermatitis characterized by redness and scaling that occurs in regions where the sebaceous glands are most active, such as:
 Scalp, border of forehead/scalp
 Behind ears, above and in between eyebrows
 In nasolabial folds, sternum
 In between the shoulder blades, in axillae
 Groin , Perianal area
 Under the breast , umbilicus and in body folds
- Pts often complains of oily skin
- The eczema comes and goes
3. Infective eczema
- Occurs as a response to an oozing skin infection.
- Common sites are the foot, and ankle region
- Causative organisms are usually staphylococci/ streptococci
- Vaseline use aggravates this condition
4. Contact eczema:
- Caused by contact of the skin with an irritant or an allergen.
- Common causes of irritant contact eczema on hands, arms and legs are excessive use of
H2O, soap (especially if not washed off properly) detergents, chemicals, sunlight, jewellery, dyes, bleaches, perfume, nail polish/remover, etc

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General Nursing Management of Eczema
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Inform patient to stop the use of irritants (contact eczema)
Apply mild topical steroid such as hydrocortisone 1% cream twice daily until lesions clear.
In severe itching use antihistamines
In bacterial super infection use topical antibiotic ointment
Keep finger nails short and covered at night
Use non greasy or non moisturizers (seborrhoic eczema)
An imidazole cream twice daily/ketaconazole 200 mg/d 1-3 weeks (seborrhoic eczema)
The vicious cycle of itch needs to be broken , (atopic eczema)- conscious effort to stop scratching  In photo allergies – sun protection by wide rim sun hat, long sleeves, high collar, sunglasses, stay indoor, sunscreen, umbrella, etc
 Keep the site clean

B. Acne
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A common disorder of the sebaceous gland associated with excess production of sebum and blockage of the duct resulting in a variety of inflammatory manifestations.
Common in puberty and usually regresses in early adult hood
Occurs on the face, upper trunk and shoulders
Appears to be multiple inflammatory papules, pustules and nodules
Causes: genetic, hormone and bacteria
Manifestations:
o Red nodules, cyst , red papules, scars, pustules, keloids o There may be mild soreness, pain or itching o Inflammatory papules, pustules, pores acne cyst, scarring
Diagnosis
o Clinical Assessment o Cyst formation, slow resolution, scarring
Management
o Stop the use of vaseline, oil, ointment, greasy cosmetics which further blocks sebaceous ducts. o Benzoyl per oxide 5-10% gel or tretinoin 0.01-0.1% cream or gel may be applied at night, as ordered. o Salicylic acid 1-10% in alcoholic solution for removal of excess sebum. o For pustular/inflammatory lesions use topical clindamycin 1% solution, erythromycin 2% lotion o In severe cases, long term antibiotics like doxycycline is given as ordered. o Surgical treatment – extraction of comedones, incision and drainage of large fluctuant, nodulocystic lesions

C. Psoriasis
• A chronic recurrent, hereditary, non infectious disease of the skin caused by abnormally fast turn over of the epidermis
• The turn over may be up to 40 times than normal and as a result the epidermis is not able to develop normally, therefore it doesn’t allow formation of the normal protective layer of the skin. • Skin become red, inflamed, and the scales are thicker than normal
• It produces a so called candle-wax phenomenon, when you scratch such a patch it becomes silvery white.
• Sites can be extensor areas of extremities especially elbow, knees, buttocks, shoulder and scalp
• Manifestations: o May itch severely in body folds covered with silvery scales o Finger and toenails may show pitting and thickening o Associated arthritis
• Management o Explain to the Pt the recurrent nature of the disease. o Salicylic acid 2-10% ointment twice daily to reduce scaling o Moisturizers (Vaseline, paraffin oil, or cream) o Treat any super infection with KMNO4 , or antibiotics if necessary o Psoriatic arthritis NSAIDS E.g.: Ibuprofen, Indomethacin, and ASA
Infection of the Skin
1. Cellulitis
• A diffuse, acute streptococcal or staphylococcal infection of the skin and subcutaneous tissue
Cause
• Caused by bacteria’s like streptococcus/staphylococcus aureus • Results from break in skin
• Infection rapidly spread through lymphatic system
• Manifestations:
O Tender, red, hot, indurated and swollen area that is well demarcated
O Possible fluctuant abscess or purulent drainage
O Fever, chills, and malaise

Large abscess, possibly up to a cup of pus when opened, crinkling of the skin suggests the swelling is going down

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Necrotizing fasciitis  When the bacteria in a cellulitis or abscess start spreading quickly between the fat layer and the muscle underneath; o Necrotizing means turning living flesh to dead flesh o Fasciitis means the infection is spreading along the space between the fat and the muscle underneath o The infection cuts off the blood supply to the tissue above it and the tissue dies o The bacteria also enter the bloodstream and cause severe systemic illness called
“sepsis”

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……Cellulitis
• Management o Oral antibiotics o Parentral/systemic antibiotics for hands, face, or lymphatic spread o Surgical drainage and debridement

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Furunculosis
An acute painful infection of perifollicular abscess (boils)
Common microorganism: staphylococcus aureus
Most common on persons who are carriers of staphylococcus, contact with oils or grease, diabetes, poor habits of personal hygiene, immunosuppression, alcoholism, obese, malnutrition, etc
The lesion begins in the opening of hair follicle or sebaceous gland
Manifestations:
o Hard nodule initially then fluctuant abscess with centrally yellow pustule, then ruptures in to an ulcer. o It can be isolated single lesion or few multiple lesion o Hotness and pain at the site.
Diagnostics:
o Gram stain of the pus o Culture and sensitivity test of blood/pus
Treatment:
o Warm compresses (to soothe and hasten maturation of lesion) o Warn patient not to squeeze or incise the lesion o Incision and drainage when it is fluctuance. o Systemic antibiotics (cloxacillin, erythromycin) o Analgesics for pain

3. Carbuncles (multiple furuncles)
• An aggregation of interconnected furuncles that drain through multiple openings in the skin.
• Microorganism: Staphylococcus aureus
• Manifestations: Same as furunculosis but with fever, chills, extreme pain, malaise.
• Diagnosis o Gramstain of the pus o Culture of pus/blood o Leucocytosis (12,000-20,000 mm3) normal 4,000-10,000mm3
• Treatment is the same as furuncle, plus avoid friction and irritation from tight clothing.
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4. Folliculitis
• Inflammation of the hair follicle
• Manifestations o Single or multiple papules or pustules o Commonly seen in the beard area of men and women’s legs from shaving
Management
• Warm compress to relieve pain
• Clean with antibacterial soap
• Topical antibiotic ointment
• Systemic antibiotics for recurrent cases

5. Impetigo
• An acute, contagious, rapidly spreading cutaneous infection and is a very common bacterial infection of the superficial skin
• Causative agents are stap. aureus or a Bhemolytic streptococcus or both
• Manifestations o Superficial pustules or blisters which becomes oozing with yellow crusts o Blisters are contagious and they break easily and form golden crusts
• Diagnosis
1. Clinical assessment
2. Culture and sensitivity
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Management o KMNO4 bath or wet dressing-in mild forms o Prevent spreading by not sharing towels and ointment, change clothes, towels and sheets frequently. o In sever forms give cloxacillin 250-500mg QID daily for 7-10 days in adults, and 50100mg/kg/24 hours divided in to 4 doses for children.

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o o Erythromycin 250-500mg 4 times daily for 7-10 days in adults, and 25-50mg/kg/24hrs divided in to 4 doses for children
Cut finger nails short to minimize damage to lesion and to prevent autoinoculation from scratching Fungal skin disorders
Dermatophytoses (Mycoses)  fungal infection of the skin, hair and nails
Types
1. Tinea pedis (Athlete’s foot)
• Itchy, whitish scaling lesions and inflammation of the superficial skin of the feet and interdigital spaces of the toes
• Common between the 4th and 5th toe.
• Often seen in people wearing rubber boots/shoes
• Management o Keep the space in between the toes dry o wear cotton socks o Avoid shoe that are too tight/hot o changing socks daily prevents reinfection. o Imidazole cream/ whitfield’s ointment twice daily until symptoms disappear for a total of 4 weeks o Treat secondary bacterial infection if present

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Tinea corporis (Tinea circinata)
A fungal infection of the skin commonly seen in exposed surfaces of the body.
Sites are face, arms and shoulders.
Intensive itching is common
Frequent causes of tinea corporis is the prescence of an infected pet in the home
Management
o Antifungal ointment twice daily for a minimum of 4 weeks o Multiple, widespread lesions may be treated systematically o Antifungal meds can be given per orem, as ordered o When there is sever itching antihistamines /mild steroids can be added

3. Tinea unguium
• A chronic fungal and some times mixed yeast infection of the toe/finger nails • Commonly occurs in people who frequently wet the hands such as domestic workers, cleaners, kitchen and laundry staff
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Manifestations: o Nail become thickened, friable (easily crumbled), lusterless o Accumulation of debris under the free edge of the nail o The nail may be destroyed

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Treatment: o Antifungal ointment o Keep the site dry

4. Tinea cruris (Jock itch)
• A fungal infection of the groin, pubic region and thighs
• Manifestations o Scaling at the periphery o A patch that may spread to buttocks o Starts from groin and advancing down to inner thigh o Itching and irritation
• Management
• Treat with topical antifungal or systemic antifungal for severe cases
• Reduction of moisture in groin
• Wash contaminated under wear in hot water

Parasitic Infection of the Skin
1. Scabies
• An infection of the skin caused by a parasite called mite
Sarcoptes scabiei, a mite which lays its eggs in burrow in the stratum and induces an intensively itchy allergic respons
• Manifestations o Small blisters and papules o Sever itching, when warm particularly at night o Scratch marks and very common secondary infection with pustules o Common sites are between fingers, sides of the hands, sides of the wrists, buttocks
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Management: o Treat all close contacts of the patient and family o Benzyl benzoate 25% emulsion for adult, dilute with one part water (1:1) for children, dilute with 3 parts water (1:3) for infants. Apply for 3 consecutive nights.
Wash off each morning. o Sulphur 5-20% ointment twice daily for 1-2 Weeks

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2. Pediculosis
• An infestation with a louse which may be found in the:
 Scalp- Pediculosis capitis
 Body- Pediculosis corporis
 Hair bearing region- Pediculosis pubis (phthiriasis)
• Manifestations o Itching (excoriation) o The presence of lice and nits
• Causes: Over crowding, poor personal hygiene, prolonged wearing of the same cloth
• Management : o Improve personal hygiene o Improve living condition o Change clothing o Treat secondary bacterial infection if present

Viral Skin Infection
1. Herpes zoster (shingles)
• Is an acute unilateral and segmental inflammation of the dorsal root ganglia of a nerve by a latent varicella zoster infection in the partially immune host.
• Much more common in HIV patients, old patients, and malignancy cases
• Manifestations: o A localized vesicles in cluster form on one side of the body/unilateral/ o Itching, tenderness and severe pain on the site o **The thoracic, cervical and ophthalmic nerves are frequently affected o After 1-2 weeks crusts begin to fall off with residual scaring o Over 10% of patients develop a persistent burning sensation
• Management o Analgesia with NSAIDs o Antibiotics for secondary infections o If the eye is involved immediately refer to ophthalmologist o For immunocompromised patients , antiviral Acyclovir is given.

2. Warts
• Common benign skin tumors caused by infection with the Human Papilloma Virus.
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Types:
a. Plantar warts- warts on the sole of the foot
b. Plane (flat/Juvenile) warts- warts on the face of children
c. Genital warts/condylomata acuminate/- warts that appear on genital organs
d. Molluscum contagiosum- a wart which appear on small children which has typical characteristics of central dimple and dome shaped papules

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Manifestations o Found at any age but most common in children and teenagers o They can spread by contact o The infected person immune system clears the warts with in 2 years in 2/3 cases
Management
o Freeze with liquid nitrogen- Molluscum contagiosum o Salicylic acid 50% twice daily followed by scraping the warts –Plantar warts o Salicylic acid 2-5% ointement twice daily for 4-8 weeks –Plane warts o Silver nitrate pencil touch- daily - Plane warts o Podophyllin 10-25% solution apply weekly by using match sticks and wash off after 4-6 hours- Genital warts o Treat partners - Genital warts

Malignant Skin Disorder
Skin cancer
• Cancer is a disease of the cell in which the normal mechanism of control of growth and proliferation are disturbed. The malignant cell is able to invade the surrounding tissue and regional lymph nodes.
• Metastasis is the secondary growth of the primary cancer in another organ.
• Skin assessment Guidelines:
 -20-39 age-every 3 years
 >40 age-annually

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Skin Interventions:
Plastic surgery (Cosmetic surgery)
• A type of reconstructive surgery performed to reconstruct or to alter congenital or acquired defects or to restore or improve the body’s appearance
• Purpose of plastic surgery
 To repair defect (reconstruction)
 To restore function (restoration)
 To replace lost part
 For better appearance
 To install prosthetic implants
 For complete change of identity
• Possible complications of plastic surgery
 Pigment change- chemical peeling
 Infection-surgery
 Milia- chemical peeling
 Scarring- surgery
 Atrophy- surgery
 Sensitivity change- chemical peeling
 Long term (4 to 5 months) erythema or pruritis- chemical peeling
 Hematoma- surgery

Skin graft
• A technique in which a section of skin is detached from its own blood supply from the donor site and transferred as free tissue to a distant (recipient)
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Purpose o To enhance wound healing o To repair defects o To cover wounds in which insufficient skin is available o To improve appearance
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Sources of skin graft can be: o Autograft- use of tissue from self o Allograft- use of tissue from the same species o Xenograft- use of tissue from different species o Isograft- use of tissue from genetically identical persons o Engineered- graft sources from combined biological and synthetic materials o Synthetic graft- substance from non-biological source

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