skin disorders

what does physical examination of skin include?

* entire skin surface
* nails
* scalp
* palms and soles
* mucous membranes
* natural light important
* rash

COVID skin changes

purple/red toes

purpuric rash

nonblanchable

What does nonblanchable mean?

when you press injury, it stays red and does not change color

erythematous rash

blanchable

what does blanchable mean?

when you press injury, the color gets pale and comes back

what do all skin diseases produce?

characteristic primary skin lesions

what should a skin assessment history include?

- systemic disorders
- exposures (chemical, physical, home/work environments)
- medications (prescription, OTC, alternative and topical)

stage I pressure injury

intact skin with non-blanchable erythema

stage II pressure injury

partial loss of dermis

stage III pressure injury

complete loss of dermis

stage IV pressure injury

exposures bone, tendon or muscle

unstagable pressure injury

slough or sachar obscuring depth

suspected deep tissue injury (DTI)

purple or maroon discoloration of intact skin

what type of pressure injury required further scans and testing to diagnose?

SDTI (deep tissue injury)

what kind of common primary lesion may be nonpalpable?

freckles

what kind of common primary lesions are palpable and solid?

* elevated nevus (mole)


* lipoma (benign lump)

what kind of common primary lesions are palpable and fluid filled?

* herpes simplex
* acne vulgaris

melanocytic nevi (mole)

- small
- uniform
- well-demarcated
- may darken & get larger during pregnancy

atypical nevi

- larger
- ill-defined (no clear border)
- irregular
- multiple colors

blue nevi

- common in Asian descent
- malignancy is rare
- small
- elevated
- blue/black

description of lesions

- asymmetry (2 sided don't match)
- border (irregular)
- color (multiple, very dark)
- diameter ( \> 6mm)

what changes increases in aging?

- capillary fragility (easy bruising)
- collagen stiffens
- focal melanocytes (age spots)

what changes decreases in aging?

- melanocytes
- function of sweat & subcutaneous glands
- sensory nerves
- degeneration of elastic fibers

systemic disorders

- jaundice (yellow sclera bilaterally)
- lupus (butterfly rash)

which systemic disorder has an in trade in yellow pigmentation?

jaundice

which systemic disorder presents as a butterfly rash?

lupus

which systemic disorder presents with erythema all over the face?

rosacea

alterations in pigmentation: vitiligo (leukoderma)

* pigment disappears from an area of skin
* sudden onset
* pernicious anemia
* hyperthyroidism
* usually before age 21

albinism

- recessive trait
- impaired or absent synthesis of melanin

what education is important for albinism?

excessive sun exposure can lead to increased risk of skin cancer

why is skin important?

one of the largest defense mechanisms we have in the body

what happens if there is breach in the skin?

susceptible to invasion of organisms

type of infection depends on what?

- depth of infiltration
- type & virulence of organism
- host defenses

what are the most common organisms that cause infectious disorders?

staph and strep

foliculitis

inflammation of a hair follicle

folliculitis s/s

painful, yellow pustules surrounded by erythema with presence of central hair

hot tub folliculitis

- pseudomonas aeruginosa
- 1-4 days after poorly chlorinated hot tub use

what organism causes hot tub folliculitis?

pseudomonas aeruginosa

how does hot tub folliculitis present itself?

erythematous pustules on torso, buttocks, limbs

carbuncle

multiple infected hair follicles in big area

furuncle

singular infected hair follicle

folliculitis treatment

- cleanse the area - chlorhexidine, and apply saline compresses
- 2% mupirocin ointment for limited bacterial folliculitis
- pseudomonas treated with ciprofloxacin
- S. aureus treated with dicloxacillin 250 mg QID x 10 days

how is S. aureus folliculitis treated?

dicloxacillin

how do you treat folliculitis?

cleanse the area with chlorhexidine, and apply saline compresses

how do you treat hot tub folliculitis?

ciprofloxacin

herpes simplex virus

HSV-1 (above the waist) and HSV-2 (genital)

herpes simplex virus s/s

- burning or itching
- vesicles & erythema
- pustules, ulcers, crusts
- persists (trigeminal & other ganglia)

palliative treatment of herpes simplex virus

- ease pain
- lidocaine (xylocaine)
- diphenhydramine (benadryl)

treatments for herpes simplex genitalis

- acyclovir
- famciclovir
- valacyclovir

herpes zoster

shingles

shingles

- inflammatory
- follows dermatome
- post-herpetic neuralgia

how does shingles present?

unilateral, painful vesicles along a single dermatome or associated group

shingles treatment

- shingrix (inactivated recombinant vaccine)
- zostavax (live vaccine)
- antiviral
- analgesia

tinea

ringworm, fungal infection

tineapedis

athlete's foot

tineacorporis

ringworm of the trunk

tineacapitis

ringworm of the scalp

tineabarbae

ringworm of the beard

tineacruris

fungal infection of the groin; jock itch

tineamanus

Ringworm of the hand

tineafaciei

ringworm in face

Candida albicans

- thrush
- intertrigo
- mucocutaneous candidiasis
- vaginal

thrush

a fungal infection in the mouth and/or throat caused by Candida albican

intertrigo

infection in skin folds

what are azoles?

antifungals

candida albicans treatment

- azoles (itraconazole, fluconazole, ketoconazole)
- polyene antibiotic (nystatin)

cellulitis

- superficial inflammation of the skin caused by bacteria
- infection can penetrate into subcutaneous tissues

cellulitis s/s

erythema, warmth, tenderness of involved area, swelling/edema

cellulitis risk factors

- immunocompromised host
- poor venous circulation

what causes cellulitis?

Staphylococcus aureus and Streptococcus pyogenes

what are the most common sites for cellulitis?

face and lower extremities

Vibrio vulnificus

* liver disease & immunocompromised host
* salt water exposure

Erysipelothrix rhusiopathiae

handling fish, poultry, meat

Aeromonas hydrophila

contaminen wound in fresh water

Fournier's gangrene

dangerous cellulitis in male genitals

cellulitis male genital region

- requires surgical attention
- fournier's gangrene

periorbital cellulitis

- potentially life threatening
- may develop from ethmoid sinusitis
- pain with EOM's
- mental status changes
- severe systemic symptoms

what does a brown recluse spider bite look like?

bulleyes with a necrotic center

cellulitis vs deep vein thrombosis

cellulitis has more profound redness while DVT is just redness around the clot

cellulitis history

- underlying disease state
- saphenous venectomy or axillary node dissection
- exposure to salt or fresh water
- bites
- insects

Rule of 9's

Calculations for assessing percentage of body surface burned

why is rule of 9s important?

- burns
- medications
- topical corticosteroids

cellulitis treatment

* immobilize and elevate limb
* dicloxacillin, nafcillin
* vancomycin
* antibiotics

cellulitis treatment timeline

* apparent lack of response in 24-48 hours
* pathogen spills contents & invokes further inflammatory response

what if cellulitis treatment fails in 2-3 days?

* need for reevaluation
* CT or ultrasound may show abscess

gas gangrene predisposing factors

trauma, surgical wound

gas gangrene incubation

1-4 days

gas gangrene organism

Clostridia

gas gangrene pain

severe

gas gangrene skin

tense, yellow-bronze, hemorrhagic bullae

gas gangrene discharge

foul-smelling odor

gas gangrene surgical tx

extensive, amputation

necrotizing fasciitis predisposing factors

DM, trauma, surgery, perineal infection

necrotizing fasciitis incubation

1-4 days

necrotizing fasciitis organisms

mixed aerobic and anaerobic

necrotizing fasciitis pain

minimal to moderate

necrotizing fasciitis skin

Blanched, hemorrhagic bullae

is there gas present with necrotizing fasciitis?

no

necrotizing fasciitis discharge

Seropurulent, dishwater or putrid