Integumentary Disorders & Associated Pharmacology

Arthropod Infestation: Scabies

• Scabies - A mite, Sarcoptes scabiei, burrows into the epidermis

• Transmitted person-to-person, includes sexual contact

• Healthcare facilities via sheets (can live up to 2 days on sheets)

• Affected areas: interdigital web of the finger, flexor surface of the wrist, inner surface of the elbow, axilla, nipple, penis, belt line, and gluteal crease

• Main symptom pruritus and accompanying bites on skin

• Diagnosis – skin scraping showing + mites, ova, or feces

• Treatment – Topical medication (permethrin, malathion) applied on entire body AFTER bathing. Leave on for 12 hours.

Arthropod Infestation: Lice

Lice – Pediculosis, insects that live off of human blood.

• Cannot survive outside the host

• Types: Pediculus humanus corporis (body lice), Phthirus pubis (pubic lice), and Pediculus humanus capitis (head lice)

• Spread via close personal contact

Diagnosis – presence of lice or nits, pruritus, papules and wheals

Treatment

• Eradicate louse and nits on body/clothing/bedding.

• Shampoos or topical preparations of malathion or other pediculicides. May require multiple treatments!

• Discard hairbrush, combs, etc

Contact Dermatitis: Allergic vs Irritants

Allergic Contact Dermatitis

• Inflammation of the skin

• Cell-mediated, type IV hypersensitivity, such as to poison ivy

• Usually, mild erythema but can be vesicle or bullae

• Location and pattern can help identify cause

Irritant Contact Dermatitis

• Caused by chemicals irritating skin.

• Soaps, fragrances, harsh chemicals, etc.

• Can be classified as subjective, acute, chronic, and chemical burns

• Characterized by dryness and erythema or edema, inflammation, and vesicles

Treatment

• Patch test

• Remove allergen, treat symptoms; if systemic effects may need corticosteroids or antihistamines

Atopic Dermatitis & Nummular Eczema

Atopic Dermatitis (aka atopic eczema)

• Itchy, inflammatory skin disorder

• Poorly defined erythema with edema, vesicles, and weeping at the acute stage and skin thickening (lichenification) in the chronic stage.

• Although often described as an immunoglobulin IgE– mediated hypersensitivity (atopic) disease, allergic causation is difficult to document.

• Viewed as a skin disease that predisposes to allergies.

Nummular Eczema

• Idiopathic but common to have a history of allergy- related disorders

• Lesions are coin shaped, papulovesicular patches mainly involving the arms and legs.

• Lichenification and secondary bacterial infections are common.

• Mostly chronic, with weeks to years between exacerbations.

• Exacerbations are more frequent in the cold winter months.

Eczema Treatment

• Remove allergen if indicated

• Anti-pruritic creams/lotions

• Topical emollients

• Topical corticosteroids

• May need systemic meds like corticosteroids or antihistamines

• May need immunosuppressive agents in severe cases (cyclosporine, tacrolimus, and azathioprine)

• Phototherapy (use of UV light for flare ups, itching, redness)

Acne Vulgaris

Background Information

• Issue with pilosebaceous unit, which comprises a tiny vellus hair, hair follicle, and sebaceous gland

• Comprised of non-inflammatory and inflammatory lesions

• Non-Inflammatory – comedones (whiteheads and blackheads)

• Inflammatory – Papules, pustules, and nodules

• Acne vulgaris is most common type

Etiology

• Cause unknown, possible genetic

• Possible contributing factors include: ↑ sebum production, ↑ proliferation of the keratinizing epidermal cells forming sebaceous cells, colonization/proliferation of Propionibacterium acnes, and inflammation.

• Diagnosed as mild, moderate, or moderately severe

Treatment

• Mild - Topical retinoids, benzoyl peroxide, and azelaic acid

• Moderate – same as mild + systemic antibiotics

*look like acne opposed to, look at lesions

Rosacea

Background information

• Chronic inflammatory process that occurs in adults between the ages of 30 and 50 years

• Fair skinned people, most common in white women >30 y/o

• Etiology

• Unknown, but believed to be an inflammatory process accompanied by vascular instability with leakage of fluid and inflammatory mediators into the dermis

4 types

• Erythematotelangiectatic (flushing and persistent central facial erythema)

• Papulopustular (inflammatory)

• Phymatous (thickening of the skin with irregular surface nodularities and enlargement)

• Ocular (involving the eyes)

• Starts as “blushing”, evolves into permanent dark red erythema of nose and cheeks

Treatment

• Topical metronidazole and azelaic acid, topical and systemic abx

• If rhinophyma is present can be treated using surgical methods, including electrosurgery, laser ablation, dermabrasion, cryosurgery, and excision

Psoriasis

Background Information

• Common, chronic inflammatory skin disease characterized by circumscribed, red, thickened plaques with an overlying silvery-white scale.

• Incidence lower in warmer, sunnier climates

• Etiology

• Genetic component; apparent association of arthritis and psoriasis

• Activated T lymphocytes produce chemical messengers that stimulate abnormal growth of keratinocytes and dermal blood vessels.

Accompanying inflammatory changes are caused by infiltration of neutrophils and monocytes.

• Köbner reaction

Patho

• Increased epidermal cell turnover with marked epidermal thickening (hyperkeratosis)

• Permanent damage to capillary beds even in the presence of remission or resolution

Types

• Plaque-type psoriasis (most common)

• Guttate psoriasis

• Pustular psoriasis (localized and generalized)

• Erythrodermic psoriasis

Assessment

• Primarily located on elbows, knees, and scalp

• Primary lesions are sharply demarcated, thick, red plaques with a silvery scale, vary in size/shape. In darker skinned people, plaques may appear purple. Lesions may have excoriation, thickening, or oozing.

• Auspitz sign

• Treatment

• NO CURE

• Goal: Sign and symptom management and suppression

• Topical: Emollients, keratolytic agents, coal tar products, anthralin, corticosteroids, and calcipotriene.

• Systemic: phototherapy, photochemotherapy, methotrexate, retinoids, corticosteroids, and cyclosporine

Which pathophysiological alteration is the primary cause of clinical manifestations in Psoriasis?

A. A delayed hypersensitivity reaction mediated by mast cells and histamine release.

B. An accelerated rate of keratinocyte proliferation and shedding in the epidermis.

C. An autoimmune reaction causing progressive destruction of the joints.

D. Obstruction and inflammation of the pilosebaceous unit by excess sebum and keratin.

B. An accelerated rate of keratinocyte proliferation and shedding in the epidermis.

Integumentary System: Glucocorticoids: hydrocortisone

Glucocorticoids

Prototype: hydrocortisone (ointments, creams, gel)

Indications for use

• Eczema, contact dermatitis, psoriasis, allergic dermatitis,

• Seborrheic dermatitis

Mechanism of action

• Synthetic cortisol

• Inhibition of pro-inflammatory molecules

Route

• topical

Adverse Drug Reactions

• Skin irritation

• Skin thinning

• Striae/spider veins

• Excessive hair growth

• Delayed wound healing

• Systemic effects: avoid excess use

Interventions/Nursing Actions

• Monitor skin

• Monitor for s/sx of infxn

Client Instructions

• Apply thin layer, rub it in

• Avoid excess use

• Avoid contact with eyes

• Limit duration

• Monitor for side effects

Contraindications

• Pregnancy/lactation

• Skin infections, active lesions

• Hypersensitivity

Drug Interactions

• Other topical steroids

• Antifungals (can cause irritation)

Precautions

• Children

• Pre-existing skin conditions

• Long term use

Integumentary System: Keratolytic Agents: Salicylic Acid, sulfur, benzoyl peroxide

Keratolytic Agents

Salicylic Acid, sulfur, benzoyl peroxide

Indications for use

• Salicylic acid: warts, corns

• Sulfur: acne, dandruff, psoriasis, seborrheic dermatitis

• Benzoyl Peroxide: Acne

Mechanism of Action

• Burn off top of skin, highly keratinized = not easy to take off

• Promotes shedding of thickened outer layer of skin

• Kills microbes, exfoliates, decreases inflammation

Route: topical

When teaching an older adult patient about applying a mid-potency topical corticosteroid for localized eczema, the nurse should prioritize education on which risk factor, specific to the geriatric population?

A. Increased risk of skin atrophy, bruising, and skin tears due to age-related dermal thinning.

B. A paradoxical increase in pruritus following application.

C. The potential for systemic immunosuppression leading to opportunistic infections.

D. The drug's impact on renal clearance due to decreased kidney function.

A. Increased risk of skin atrophy, bruising, and skin tears due to age-related dermal thinning