Lecture 2: Skin Disorders Common to P&O Care

Integumentary System (brief description and function)

Skin

• Largest organ of the body

  • Differs anatomically and physiologically in different areas of the body

  • Example: palm of hand and bottom of foot has more sensory and calluses faster

Primary function

• Protects the underlying structures from external injury and harmful substances

Integumentary System - How does it accomplish its primary function

1. Physical and chemical protective barrier

2. Acts as insolation

3. Contributes to sensory perception

4. Assists with fluid balance

5. Temperature regulation

6. Absorbs ultraviolet radiation

   1. good but can also cause problems

7. Metabolizes vitamin D

   1. 15mins in the sun

   2. Vitamin D helps immune system

8. Synthesizes epidermal lipids

Skin Lesions (3 categories)

1. Primary – first lesion to appear on the skin

2. Secondary – changes to primary lesion – ulcer, scar etc. Causes may result from many factors scratching, rubbing, meds etc.

   1. how body responds or whatever you do responds (e.g: scab)

3. Birthmarks

Signs and Symptoms of Skin Issue

1. Pruritus (itching)

2. Urticaria (Hives)

3. Rash

4. Blisters

5. Xeroderma

Pruritus

itching – most common

• Xerosis– dry rough skin cause of itching most common cause of itching

Urticaria

Hives – vascular skin reaction marked by smooth, slightly elevated patches that are redder or paler

Rash

generalized term for an eruption on the skins, most often on the face, trunk, axilla and groin and is often accompanied by itchin

Blisters

are fluid-containing elevated skin lesions with serous or bloody contents

e.g: seen after a burn

Xeroderma

is a mild form of ichthyosis of the skin characterized by dry, rough discolorations with scaly desquamation.

• Skin starts to come off

Aging of the Integumentary System

Skin undergoes numerous changes throughout the life span.

• At birth the skin is more sensitive as it matures the sensitivity decreases

• remember of pediatrics, skin more sensitive to materials

Skin exhibits changes that denote the process of getting old

• Extrinsic aging

Extrinsic aging

Dominated by the cumulative effects of exposure to sunlight

Structural and functional changes include:

• Diminish pain perception

• Increased vulnerability to injury and irritants

• Decreased vascularity

• Decreased rate of epidermal turnover

• Decreased capacity to heal

  • partially due to rate of epidermal turnover

Skin tear prevention strategies – critical

• P&O considerations

  • Plastic needs to be perfectly smooth, especially edges

  • Padding needs to have no rolling edges

Aging

Blood vessels in the dermis is reduced and walls are thinned

• Compromised blood flow

• Impaired capacity to thermoregulate

  • why they keep house warmer but need to make sure they don’t become dehydrated

Diminished barrier function – increase risk to skin cancer

Decreased in the 7-dehydrocholesteral hormone in the skin results in decrease production of vitamin D

Why is skin important to us?

A majority of devices that are supplied by the prosthetist/orthotist will have direct contact with the skin.

• Stress to the skin is beyond normal

  • especially as you move proximal up the leg

• Normal function of the skin is impeded

Additional complications we had to consider

Many prosthetic orthotic users have experienced some trauma or have a disorder that will further hinder or complicate use of a device

1. Pain

   1. Something there’s a level of pain even without the device

2. Motor and sensory dysfunction

3. Thermoregulation problems

4. Hygiene issues

   1. Really important, patient education critical

5. Scarring

   1. Silicon helps mitigate

6. Infections

Health Comorbidities

1. Vascular disease

2. Obesity

3. Multiple limb loss

   1. If have problem with one low limb start to favor other side

   2. If bilateral hard to moderate the amount of pressure

4. Pain issues

5. Polytraumatic injuries

   1. Brain injury

      1. Hand outs with instruction on top of verbal is important

   2. Posttraumatic stress

      
      

Skin issues posed by use of a device

Air circulation – heat loss is impeded

Perspiration is likely to increase

Exposure of moist skin to new materials, chemicals and added forces

Shows critical need for a perfect fit

Characteristics of socket to skin interface

1. High stress

2. Friction

   1. Neoprene with nylon mesh can help

   2. Shear band for spot reduces

3. Suction or negative pressure

Makes amputees be at a higher risk of skin issues than non-users

• Hygiene very important

Daily Hygiene

Body - residual limb – preferably in the evening to allow the skin to thoroughly dry

Interface components - insure they are cleaned and dry before use

• Perspiration – removal of gel liner and drying during the day

• they should receive 2 liners, should alternate everyday

Washing methods

Cleansers – near neutral PH level

Warm water

Soap should be completely rinsed off – less than 15 minutes

Blot dried with a towel – no rubbing motion

Common skin disorders for Amputee

1. Contact Dermatitis

2. Psoriasis

3. Intertrigo

4. Heat Rash

5. Skin Infections

Contact Dermatitis

An acute or chronic skin inflammation caused by exposure to an external agent, that may act as an irritant or allergen.

• One of the most common environmental skin diseases and can occur at any age.

Types

• Irritant contact dermatitis

• Allergic contact dermatitis

Irritant contact dermatitis

occurs when a physical agent is applied long enough or in a concentration high enough to damage cells and disrupt skin integrity and function

• Limited to site of contact

• Chronic washing of the limb

• Avoid contact with offending agent – sock use

  • Make sure they wash the sock

Allergic contact dermatitis

delayed hypersensitivity reaction to an allergen developed on re-exposure

• Triggers an immunologic hypersensitivity

• Visible reaction to second exposure

• Not all will react to the offending agent

Psoriasis

Common, chronic immune-mediated systemic inflammation condition that is characterized by a well–demarcated erythematous patch or plaque with white to silver colored scales

• Patient predisposed

• Lesions on extensor surfaces and areas of high friction

  • Residual limb, elbows, knees, groin, digits

  • Skin over reacts to the friction

• If suspected refer to doctor

Intertrigo

A dermal inflammatory response to friction between two skin surfaces that are in constant opposition

• common on residual limb of an amputee – two skin surfaces on either side of an invaginated scar are in constant direct contact while squeezed together inside an artificial interface

  • prevalence increase with use of gel liners

• Optimize fit of the socket

• Ensure proper hygiene is being performed

• Refer to physician

Heat Rash

Obstruction or malfunction of eccrine sweat ducts

In prosthetic users it occurs due to sustained exposure to friction and heat

Pausing usage of the prosthesis for a day usually resolves the condition

• with orthotics can sometimes add holes, or switch to conventional system

Skin Infections

Bacterial, viral, fungal and parasitic

• Contagious

  • wear glove and protect yourself

Predisposing factors

1. Decreased resistance

2. Dehydrated skin

   1. Scratching

3. Burns

4. Pressure injuries

5. Decreased perfusion

6. Contamination from nasal discharge

7. Poor hygiene

8. Crowded living conditions

Skin Cancer

Most common form of cancer in the US

No evidence that it has peaked

Solar radiation is believed to be the major risk factor

People with lighter skin are at the highest risk

Darker skinned individuals run a risk of masking the initial subtle color changes

Other complications

1. Volume changes

2. Negative Pressure Hyperemia

   • Suction and Vacuum

3. Verrucous Hyperplasia

   • Lack of distal contact on residual limb

     • don’t see as much as we did before b/c suction and gel liners

Integumentary Ulcer Causes

1. Neuropathy

2. Vascular insufficiency

3. Radiation

4. Vasculitis

5. Prolonged pressure

Pressure Injuries

Defined – a lesion caused by unrelieved pressure, resulting in damage

to underlying tissue

Pressure tolerance factors

• General health and nutrition

• Skin perfusion

• Microclimate – temperature and moisture

Over bony prominences- heels, sacrum, ischial tuberosities, greater trochanters

Classifying pressure injuries into stages

• Initially based off of extent of soft tissue damage

• Latest is reflective on the range of skin pigmentation

  • National Pressure Injury Advisory Panel