Skin Anatomy & Conditions

What is the PT allowed to do with Integumentary repair and protection?

PT provides application of therapeutic methods and techniques to enhance wound perfusion and establish optimal environment for wound healing.

Mechanisms of Integumentary Repair and Protection

Removal of nonviable tissue, removal of wound exudate, elimination of peripheral edema, and management of scar tissue.

Methods and techniques of Integumentary Repair and Protection

Debridement, dressing selection, orthotic selection, protective and supportive device recommendations and modifications, biophysical agents, and topical agents.

Skin covers > __*______*__*. Skin weighs _____*

20ft^2. Between 6-8 lbs.

Skin Thickness:

Varies from 0.5 to 6mm according to its location on the body.

Skin receives ____ of the body’s circulating blood volume. What is normal pH?

1/3. Normal pH is 4-6.5 (< 7 = acid mantle “protective barrier against bacterial and fungal infections).

Integumentary System: Key functions

Protection from:

\-Fluid and electrolyte loss

\-Mechanical injury

\-UV injury

\-Pathogens

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Provide:

\-Thermoregulation

\-Excretion of sweat

\-Sensation

\-Vitamin D synthesis

What are the layers of the skin

Epidermis

Dermis

Hypodermis (subcutaneous tissue)

Epidermis

Outermost avascular layer, regenerates \~28 days. Made up of primarily keratinocyte cells.

5 layers.

.06-1.5mm thick (plantar surface of foot/palms thickest.

Epidermis Function

Protection (sun, H20 loss)

Vitamin D synthesis

Division & mobilization of cells

Maintains contact with dermis

Pigementation

Allergen recognition

5 layers of the epidermis: Stratum Croneum

Consists of dead keratinocyte cells; flakes and sheds.

5 layers of the epidermis: Stratum granulosum (granular layer)

Also contains Langerhans cells in addition to keratinocytes.

5 layers of the epidermis: Stratum Spinosum (spiny layer)

Contains Keratinocytes and Langerhans cells.

5 layers of the epidermis: Stratum Basale (germinating layer)

Single layer of epidermal cells (keratinocytes); contains melanocytes; can regenerate. **Attached to the dermis by the thin basement membrane & responsible for the mitotic activity of keratinocyte cells**

5 layers of the epidermis: Stratum Lucidum (glassy layer)

Lies between the stratum corneum and the stratum granulosum. This packed translucent line of cells is found only on the palms and soles and not seen in thin skin.

Dermis Description

Thickest layer of skin.

Major Proteins collagen and elastin

Contains nerve endings, blood vessels, lymphatics, capillaries, sweat and sebaceous glands, hair follicles.

2 layers

\-Papillary: unique pattern allows fingerprint identification, capillaries and pain/touch receptors

\-Reticular: dense collagen for shape and firmness, anchors skin to subcutaneous tissue. Contains sweat glands, hair follicles, nerves and blood vessels.

Dermis Function

Supports epidermis (Matrix)

Mechanical strength

Supplies nutrition

Resists shearing forces

Moisture retention

Lubricates skin

Inflammatory Response

Hypodermis Description (Subcutaneous tissue)

Primarily composed of adipose and connective tissue

Contains major blood vessels, nerves and lymphatic vessels

Hypodermis Function

Attaches dermis to underlying structure

Promotes an ongoing blood supply to the Dermis for regeneration.

Thermal Insulation

Storage of calories

Controls body shape

Shock absorber

Promotes skin mobility

Effects of aging

20% loss of dermal thickness

Proportional reduction in collagen fibers, blood vessels and nerve fibers

5 Elements of a Basic Skin Assessment: Temperature

Normally warm; perform B using back of hands

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Warmer- r/o inflammation or infection

Cooler- r/o poor vascularization

5 Elements of a Basic Skin Assessment: Color

Intensity/Normal color tones

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Intensity: Paleness- r/o poor circulation \n Erythema: varies with natural skin color \n Hyper- or hypo-pigmentation: may reflect variations in melanin deposits or blood flow

Color Meaning (Blue/Grey, Pallor, Yellow, Liver Spots)

●  Blue/grey – Cyanosis

●  Pallor – Anemia, arterial insufficiency

●  Yellow – Jaundice

●  Liver spots – Aging/exposure to UV radiation

5 Elements of a Basic Skin Assessment: Moisture

**Dry (xerosis) or moisture associated skin damage (MASD) (incontinence, perspiration, periwound maceration) or edema (moisture beneath surface)**

5 Elements of a Basic Skin Assessment: Turgor

**(Normally returns to original state quickly)**

● Slow return-aging or dehydration

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Pinch test

5 Elements of a Basic Skin Assessment: Integrity

No open areas

Dermatitis

* Inflammatory skin response to an agent
* Red, scaly, and itchy. May blister, ooze, develop a crust or flake off
* Examples: atopic dermatitis (Eczema), dandruff, rash caused by contact with poison ivy or certain metals.

Vasculitis

* Inflammation and necrosis of the blood vessels
* Associated with many conditions (malignancies, connective tissue and inflammatory diseases, medications, chemicals, infections)
* Usually bilateral and below knees
* Variable- erythema to widespread purpura, necrosis and ulceration
* Treatment: Elevation, compression, antihistamines, NSAIDs, steroids (P. 475 text)

Basal Cell Carcinoma

●  Most common form of skin cancer \*\*\* Note exceptions!!

●  Limited capacity to metastasize

●  Arise in the basal cells of the epidermis

●  Appearance: open sore, red patch, pink growth, shiny bump

●  Cause: UV exposure

Squamous Cell Carcinoma

●  Second most common skin malignancy \*\*\* Note exceptions!!

●  Uncontrolled growth of abnormal cells arising in the squamous cells of epidermis

●  Scaly red patches or open sores, elevated growths with a central depression

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Can metastasize; Mostly on areas exposed to sun. Major cause: UV exposure

Skin cancer and black people

* Melanoma in people of color most often occurs on areas that get little sun exposure, with up to 60-75% of tumors arising on the palms of the hands, soles of the feet and the nail areas
* Squamous cell carcinoma is the most common skin cancer in Black patients
* People of color have higher percentages of acral lentiginous melanoma

Cellulitis

* Bacterial skin infection
* Swollen, red, hot and tender, fever
* Lower legs most commonly affected
* May affect skin surface or underlying tissues and can spread to lymph nodes and bloodstream
* Can lead to antibiotic resistant infection such as MRSA (life-threatening)

Management: antibiotics, elevation, cooling

Scleroderma “hard skin”

● Chronic connective tissue disease classified as an autoimmune rheumatic disease; Excessive collagen production

●  Skin appears hard, shiny with loss of mobility, usually history of Raynaud’s

* Localized- more common in children-(waxy patches on skin and skin under patches may thicken and affect joint motion)
* Systemic-more common in adults.–May affect connective tissue (becomes hard and fibrous) in the skin, esophagus, GI tract, lungs, kidneys, heart, blood vessels, muscles and joints.

Herpes Zoster (Shingles)

● Viral disease caused by reactivation of the varicella virus responsible for chicken pox

● Contagious if not had chicken pox

●  Affects the cutaneous nerves usually in a single dermatome

●  Pain, itching and burning precede lesions by 3-5 days

●  Treatment with antiviral agents

●  Ocular complications may occur

Yeast Infection

*  Fungal overgrowth cause by candida albicans or other candida species-- typically affecting skin, genitals, throat, mouth or blood

●  Presents as red pinpoint papules frequently with satellite lesions