Chapter 50: Coordinating Care for Patients with Skin Disorders

Skin and soft tissue infections categorized by:

-Depth of infection

-Tissues involved

-Interventions necessary to resolve the infeciton

Cellulitis:

Diffuse spreading infection of the dermis and subcutaneous tissues, uncomplicated

Folliculitis:

Inflammation of the hair follicles, uncomplicated

Furuncles:

Boils, uncomplicated

Debridement:

Removal of dead or infected skin to facilitate healing

Uncomplicated bacterial infections:

-Respond to abx therapy alone

-Surgical drainage with or without abx therapy

Complicated bacterial infections:

Invasion of deeper tissues and require debridement

MRSA:

Community or healthcare acquired

Symptoms of uncomplicated bacterial infections:

-Usually no systemic sx

-Localized signs

-Warmth

-Mild to moderate pain

-No changes in blood work

Symptoms of complicated bacterial infections:

-Fever, hypotension, sepsis

-Spreading

-Edema

-Moderate pain

-Elevated WBC

Type 1 herpes simplex virus:

Found on the face, oral cavity, lips and skin

Type 2 herpes simplex virus:

STD resulting in painful anogenital lesions

Herpetic whitlow:

Herpes 1 and 2 can cause this, painful lesions on the the fingers

Mucocutaneoua:

Region of the body where mucosa transitions to skin

Assessment of herpes simplex virus:

-Pain

-Inspection of lesions

-Review sexual hx

-Asses hCG levels

-Coping

Actions taken with herpes simplex virus:

-Viral cultures

-Administer antiviral meds

-Analgesic meds

-Warm sitz baths

-Collaborate counseling PRN

Teaching with herpes simplex virus:

-Antiviral medications

-Safe sex practices

-HSV considerations with pregnancy

Dermtophytes:

Aerobic fungi

Epidemiology of fungal infections:

Spread directly from person to person, animal contact or indirectly through contact with inanimate objects

Fungal infections caused by:

-Dermatophytes

-Yeast

Psoriasis:

Lifelong inflammatory disorder characterized by exacerbations and remission of raised, scaling, erythematous plaques usually seen on the extensor surfaces of the body

Epidemiology of psoriasis:

-Unknown etiology

-No cure

-Pts better in warm climate

-UV radiation kills rapidly proliferating skin cells

Symptoms of psoriasis:

Well-circumscribed, thick, reddened papules or plaques with silvery scaling flakes

Treatment of psoriasis:

-Corticosteroids

-Retinoids

-Salicylic acid

-Immunosuppressants

-Methotrexate

Psoriasis tx: Corticosteroids:

Prevent the formation of new lesions

Psoriasis tx: Salicylic acid:

Decreases scaling and softens plaques

Psoriasis tx: Coal tar:

Suppresses cell division and decreases inflammation

Psoriasis tx: Retinoids (vitamin A):

Diminish proliferations of keratinocytes and decrease inflammation

Psoriasis tx: Biologic agents (humira/adalimumab):

Suppress the stimulation of the keratinocytes

Traumatic skin injuries:

-Lacerations

-Abrasions

-Excoriations

-Friction blisters

-Skin tears

-Pressure injuries

-Burns

4 Phases of wound healing:

-Hemostasis

-Inflammatory

-Proliferative

-Maturation

Hemostasis (immediate):

-Activation of platelets and clotting factors

-Fibrin deposition

-Platelet release of cytokines

-Fibroblasts activate production of collagen

Inflammatory (from 24 hours to 2 weeks):

-Surrounding vasculature begins to "leak" in response to mast cells

-Fluid escapes into the wound and causes edema

-Macrophages remove additional bacteria, residual foreign bodies, necrotic tissue

Proliferative:

-Angiogenesis

-Epithelialization

-Fibroplasia with formation of granulation tissue

-Collagen deposition

-Wound contraction

Maturation (up to 2 years):

-Decreased fluid within would

-Decreased metabolic rate

-Reorganization of collagen fibers

-Continued collagen synthesis and degradation

3 Surgical closure approaches:

-Primary intention

-Secondary intention

-Tertiary intention

Primary intention:

Approach used with typical surgical incisions with well-approximated edges that are closed with sutures or staples

Secondary intention:

Wound is left open and allowed to fill in with granulation tissue

Tertiary intention:

Often uses skin grafts for wound closure, after a period of observation following initial surgical debridement

Pressure injuries:

-Common in pts that are immobile or bedridden

-Mostly in pts over 65

-Usually over bony prominences

-Due to shear and/or pressure

Risk factors for pressure ulcers:

-Impaired mobility

-Increased age

-Comorbid conditions

-Use of steroids

-Impaired blood flow

-Cognitive impairment

-Incontinence

-Malnutrition

-Hx of pressure ulcers

-Terminal illness

Stage 1 pressure ulcer:

Non-blanchable erythema of intact skin

Stage 2 pressure ulcer:

Partial-thickness loss with exposed dermis

Stage 3 pressure ulcer:

Full-thickness skin loss, adipose tissue is visible in ulcer

Stage 4 pressure ulcer:

Full-thickness and tissue loss with muscle exposed muscle, tendon, ligament, bone

Unstageable pressure ulcer:

Obscured full-thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of slough or eschar

Deep Tissue Pressure Injury (DTPI):

Persistent non-blanchable deep-red, maroon or purple discoloration revealing a dark wound bed or blood-filled blister

Non-melanoma skin cancers:

Basal cell and squamous cell carcinomas

Actinic keratoses:

Atypical keratinocytes found in the epidermis and represent the most common form of precancerous lesions

Management of skin cancer:

-Surgical excision

-Curettage and electrodesiccation

-Mohs' micrographic surgery

-Photodynamic therapy

-Cryotherapy

-Radiotherapy

-Topical chemotherapy

Malignant melanoma ABCDE rule:

-Asymmetric appearance

-Irregular Borders variation in Color

-Diameter >6 mm

-Elevation/evolving/enlarging or changing existing lesion

Malignant melanoma:

-Incurable

-Median survival of 7.5 months following diagnosis

Patients requiring reconstructive surgery:

-Congenital defects or disfiguring birthmarks

-Trauma, tumor excisions, infections or chronic wounds

Management and complications of reconstructive surgery:

-High risk infection

-Lab values

-Abx ordered prophylactically for tx

-Nutrition must be optimized for healing to occur