Chapter 75: Skin Disorders

Chapter 75: Skin Disorders

Psoriasis: Chronic inflammatory skin disorder caused by overproduction of keratin leading to rapid epidermal turnover

Cell turnover rate increases up to 7 times normal

Autoimmune component with exacerbations and remissions

Common locations: elbows, knees, trunk, scalp, sacrum, lateral extremities

Can involve joints causing psoriatic arthritis (joint pain and stiffness)

Related Skin Condition

• Dermatitis: Inflammatory skin reaction due to allergen exposure (internal or external)

  • Lesions vary in borders and distribution

  • Can progress from acute to chronic

  • Increased risk of secondary bacterial infection due to scratching

  • Types: nonspecific eczematous, contact, atopic

Infection Prevention

• Skin infections may be bacterial, viral, or fungal

• Emphasize daily bathing or showering and hand hygiene

Psoriasis

Infections: Severe streptococcal throat infection, Candida, upper respiratory infection

Skin trauma: Surgery, sunburn (Koebner phenomenon)

Genetics

Stress (immune overstimulation)

Seasonal variation: Warm weather improves symptoms

Hormonal changes: Puberty, menopause

Medications: Lithium, beta-blockers, indomethacin

Obesity

Psoriasis (image)

Psoriasis

Psoriasis vulgaris: Reddened, thickened skin with silvery-white scales, bilateral distribution

Exfoliative psoriasis: Diffuse erythema and scaling without clear lesions

• Risk for dehydration and hypothermia or hyperthermia

Palmoplantar pustulosis: Hyperkeratotic plaques and pustules on palms and soles

• Pustules darken, peel, crust

Disease course: Cyclic

Pruritus with periods of exacerbation and remission

Classification by Body Surface Area

• Mild: Less than 5 percent BSA

• Moderate: 5 to 10 percent BSA

• Severe: Greater than 10 percent BSA

Physical Assessment Findings

• Scaly plaques

• Bleeding with removal of scales (Auspitz sign)

• Pruritic lesions on scalp, elbows, knees, sacrum, lateral extremities

• Nail pitting

Psoriasis Care

Treatment Goal

• No cure

• Reduce symptom severity and epidermal cell turnover

Tar Preparations (coal tar, tar blends)

• Suppress keratinocyte proliferation and inflammation

Nursing Actions

• Monitor for irritation

• Teach proper application

Client Education

• Burning or stinging may occur

• Causes skin and clothing staining

• Apply at night and cover with old clothing

Vitamin D Analogs (calcipotriene, calcitriol)

• Regulate cell division and reduce proliferation

Nursing Actions

• Monitor for itching, erythema, irritation

• Monitor for hypercalcemia (muscle weakness, fatigue, anorexia)

Client Education

• Limit sun exposure

• Do not apply to face

• Monitor for skin cancer changes

Vitamin A Derivative (tazarotene)

• Slows epidermal cell growth and reduces inflammation

Nursing Actions

• Contraindicated in pregnancy

• Monitor for burning, irritation, desquamation

Client Education

• Avoid sun and artificial UV light

• Use reliable contraception (teratogenic)

• Discontinue and notify provider if pregnancy occurs

A nurse is reviewing information about a new prescription for corticosteroid cream with a client who has mild psoriasis. Which of the following instructions should the nurse include?

Select all that apply.

a

Apply an occlusive dressing after application.

b

Apply three to four times per day.

c

Wear gloves after application to lesions on the hands.

d

Avoid applying in skin folds.

e

Use medication continuously over a period of several months.

a

Apply an occlusive dressing after application.

c

Wear gloves after application to lesions on the hands.

d

Avoid applying in skin folds.

The client should avoid applying to skin folds because this increases the risk for fungal infections.

---

The nurse should instruct the client to apply the corticosteroid cream 1-4 times daily.

Psoriasis Meds

Corticosteroids (triamcinolone, betamethasone)

• Decrease inflammation and suppress cell proliferation

Nursing Actions

• Monitor for skin thinning, striae, hypopigmentation

• Reinforce correct application

Client Education

• Use high-potency steroids only as prescribed

• Periodic medication breaks recommended

• Occlusive dressings may enhance absorption

• Avoid face and skin folds

• Can be applied to scalp

• Report signs of skin atrophy

Systemic Medications

Cytotoxic Agents (methotrexate, acitretin)

• Used for severe or refractory psoriasis

Nursing Actions

• Monitor liver and renal function

• Monitor for bone marrow suppression (leukopenia, thrombocytopenia, anemia)

• Contraindicated in pregnancy

Client Education

• Avoid alcohol

• Use effective contraception

Biologic Agents (adalimumab, etanercept, ustekinumab, alefacept, infliximab)

• Suppress immune response and keratinocyte activity

Nursing Actions

• Screen for tuberculosis and hepatitis

• Inspect injection sites

• Rotate injection sites

• Use infection control precautions

Client Education

• Do not use if pregnant or breastfeeding

• Administer subcutaneous injections correctly

• Report signs of infection

• Increased cancer risk

• No live vaccines

Immunosuppressants (cyclosporine, azathioprine)

• Used when other therapies fail

Key Points

• Increased risk for infection and nephrotoxicity

• Short-term use recommended (less than 6 months)

Client Education

• Monitor blood pressure (risk of hypertension)

Psoriasis Procedures

Photochemotherapy (PUVA)

• Methoxsalen given orally followed by UVA exposure

• Decreases epidermal proliferation

• Given 2 to 3 times weekly on nonconsecutive days

Nursing Actions

• Monitor response

• Ensure eye protection during treatment and for 24 hours after

Client Education

• Report erythema, swelling, discomfort

• Long-term risks: premature aging, cataracts, skin cancer

• Obtain regular eye exams

• Use sunscreen

Narrow-Band UVB Therapy

• No photosensitizing medication

• Fewer treatments required

Laser Therapy

• Used for mild to moderate psoriasis

• Targets lesions and limits damage to surrounding skin

Nursing Interventions

• Teach lifestyle modifications and coping strategies

• Collaborate on individualized treatment plan

Client Education

• Use comfort measures: emollient creams, oatmeal baths

• Do not scratch or pick lesions

Dermatitis

Health Promotion and Disease Prevention

• Avoid exposure to harsh chemicals

Dermatitis Risk Factors

External exposure to allergens

Internal exposure to allergens or irritants

Stress (eczema-related)

Genetic predisposition (eczematous dermatitis)

Cause may be unknown

Dermatitis Findings

Nonspecific Eczematous

• Thickened areas of skin (lichenification)

• Dry or moist, crusted lesions

• Pruritus

• Symmetrical involvement anywhere on the body

Contact

• Caused by direct contact with allergen, chemical, or mechanical irritant

• Rash is well-demarcated and localized

• Distribution depends on exposure pattern

Atopic

• Chronic inflammatory rash

• Triggered by allergens or chronic skin disease

• Thickened skin with scaling and desquamation

• Severe pruritus

• Common locations: face, neck, upper torso, skin folds (antecubital, popliteal)

Dermatitis Care

Avoidance Therapy

• Avoid known triggers if identified

• Do not scratch lesions (prevents secondary infection)

• Use fragrance-free soaps, detergents, cosmetics

• Avoid fabric softener dryer sheets

• Wash skin after irritant exposure

• Apply cool, damp compresses to reduce inflammation

• Use colloidal oatmeal baths for itching

Dermatitis Meds

Corticosteroids
Topical, intralesional, systemic (hydrocortisone, betamethasone, triamcinolone, prednisone)

• Reduce inflammatory response

Nursing Actions

• Monitor for adrenal suppression with prolonged use

• Teach correct application technique

Client Education

• Taper doses if used long-term

• Do not apply to infected lesions

• Warm, moist dressings may increase absorption

• Avoid occlusive dressings over steroid-treated rash

Antihistamines
Topical or systemic (diphenhydramine, cetirizine, fexofenadine)

• Decrease redness, pruritus, edema

Nursing Actions

• Monitor for urinary retention (systemic use)

Client Education

• Can cause photosensitivity

• Avoid driving or machinery with systemic use

• Take systemic forms at bedtime (drowsiness)

Topical Immunosuppressants
Tacrolimus, pimecrolimus

• Used for eczema unresponsive to steroids

Nursing Actions

• Monitor for erythema and burning

• Avoid occlusive dressings

Client Education

• Do not use if infection present

• Discontinue once rash clears

• Avoid direct sunlight and tanning beds

Skin Infections

Health Promotion and Disease Prevention

• Avoid exposure to infectious organisms

• Maintain proper skin hygiene

• Perform effective hand hygiene

• Use isolation precautions when indicated (MRSA)

Bacterial Infections (Furuncles, carbuncles, cellulitis, MRSA) Findings

Expected Findings

• Fever, malaise, chills, pain (variable)

• Single or multiple lesions (pustules, papules, nodules)

• Skin may be erythematous, edematous, painful, warm

Medication Management

• Mild infections: topical antibiotics

• Cellulitis or extensive infection: systemic antibiotics (penicillin or cephalosporin)

• Penicillin or cephalosporin allergy: tetracycline, erythromycin, azithromycin, tobramycin

• MRSA: vancomycin IV or oral linezolid or clindamycin

Nursing Actions and Client Education

• Bathe daily with antibacterial soap

• Do not squeeze lesions

• Remove crusts so medication penetrates

• Apply warm compresses for comfort

• Do not share personal items

• Keep area exposed to air when possible

• Avoid occlusive dressings

Viral Infections (Herpes simplex, herpes zoster) Findings

Expected Findings

• Itching, pain, or tingling

• Vesicular lesions that may ulcerate and crust

• Common locations: face, oral mucosa, genitals, trunk

Medication Management

• Antivirals: acyclovir, valacyclovir, famciclovir

• Burrow solution compresses (aluminum acetate) 20 minutes, three times daily

Nursing Actions and Client Education

• Avoid close contact during active lesions

• Avoid triggers (stress, UV light)

• Use soothing measures (calamine, warm compresses)

• Avoid tight clothing

• Allow lesions to air dry

• Practice strict hand hygiene

• Do not share personal items

Fungal Infections (Tinea, mycosis, candidiasis) Findings

Expected Findings

• Itching or burning

• Single or multiple lesions

• Oral candidiasis: white plaques

• Body folds: erythematous, moist lesions

Medication Management

• Antifungals: nystatin, clotrimazole, miconazole

Nursing Actions and Client Education

• Apply medication as prescribed

• Clean and dry skin before application

• Avoid sharing footwear and clothing

• Reposition frequently to increase airflow to skin

A nurse is providing teaching with a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include?

a

Apply vitamin A cream before each treatment.

b

Administer a psoralen medication before the treatment.

c

Use this treatment every evening.

d

Remove the scales gently following each treatment.

b

Administer a psoralen medication before the treatment.

PUVA treatments involve the administration of psoralen because this would enhance photosensitivity.

---

PUVA treatment does not involve the use of vitamin A cream and is two to three times per week on non-consecutive days.

A nurse is providing teaching with the guardian of a child who has contact dermatitis. Which of the following information should the nurse include?

a

Use fabric softener dryer sheets when drying the child’s clothing.

b

Apply a warm, dry compress to the rash area.

c

Place the child in a bath with colloidal oatmeal.

d

Leave the child’s hands uncovered during the night.

c

Place the child in a bath with colloidal oatmeal.

A nurse is providing teaching with a client who has a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include?

a

“This cream reduces the discomfort for viral lesions.”

b

“This cream to treat bacterial infections.”

c

“Apply the topical medication for up to 2 weeks after the lesions are gone.”

d

“Apply the cream to lesions while they are moist.”

c

“Apply the topical medication for up to 2 weeks after the lesions are gone.”

A nurse is providing discharge instructions with a client who has a bacterial infection of the skin. Which of the following instructions should the nurse include?

a

Bathe daily with moisturizing soap.

b

Apply antibacterial topical medication to the crusted exudate.

c

Apply warm compresses to the affected area.

d

Cover affected area with snug-fitting clothing.

C Apply warm compresses to the affected area.