integumentary problems

sunscreen

UVA: tanning

UVB: sunburn

broad spectrum blocks UVA and UVB, must be at least SPF 15

daily protection: SPF 15

hx of skin cancer or photosensitivity: minimum SPF 30

apply 20-30 min before going outside, reapply every 2 hours

not waterproof

precancerous lesion

atypical or dysplastic nevus are atypical moles

irregular boarders, various shades of color, some ABCDE characteristics but less pronounced

increased risk of developing melanoma

skin cancer etiology and risk factors

most commonly diagnosed type of cancer, nonmelanoma or melanoma, most lesions are easily visible leading to early detection and diagnosis→ visible cancer

risk factors:

fair skin, blonde/red hair, blue eyes, outdoor sunbathing, living near the equator or high altitudes, hx of skin cancer, outdoor occupation/recreation, indoor tanning

nonmelanoma skin cancer

basal cell and squamous cell cancers most common from of skin cancer

do not develop from melanocytes

most common cause fro nonmelanoma skin is sun exposure

commonly found on the face, neck, back of the hands and arms

actinic keratosis

most common precancerous skin lesions

affect most of the older white population

sun exposure is the key factor

impossible to tell from squamous cell cancer→ aggressive treatment

characteristics: irregularly shaped, flat, pinkish/red papule with indistinct borders with an overlaying hard scale or horn

treatment: excision, topical meds (fluorouracil), photodynamic therapy, biopsy

basal cell carcinoma

basal cell layer of the epidermis

most common type of skin cancer and least deadly

UV exposure is most common cause

middle aged to older adults

found on head, neck, extremities, and trunk

characteristics: small, slowly enlarging papule, borders semitranslucent or pearly with telangiectasia red, erosion, ulceration, depressed center

treatment: surgical excision, curettage, cryosurgery, radiation, various targeted therapy meds

squamous cell carcinoma (SCC)

keratinizing epidural cells

aggressive and potential to metastasize

risk factors: sun exposure and immunosuppression post organ transplant

pipe, cigar and cigarette smoking contribute to SCC on mouth and lips

characteristics: thin, scaly red plaques with indistinct borders and ulcerations

treatment: surgical excision, radiation, curettage, medications, immunotherapy (metastatic lesions)

melanoma

arising from melanocytes

causes most skin cancer deaths

sun exposure is the greatest risk factor

may start as a benign mole with changes, itching/bleeding

⭐️ highly metastatic; survival depends on early diagnosis and treatment

characteristics: irregular color, surface, border, flat or elevated, men-back and chest, women-legs and back

treatment: excision, lymph. node dissection, immunotherapy and targeted therapy, chemotherapy

malignant melanoma

risk factors:

red/blond hair

blue or light colored eyes

light colored skin that freckles

chronic UV exposure

family Hx of melanoma

ABCDE rule

Asymmetry

Border irregularity

Color change

Diameter greater than 6 mm

Evolving in appearance

health promotion

most effective way to prevent skin cancer is avoiding or reducing exposure to the sun or tanning beds

wear sunscreen as appropriate

protect skin with hats, long sleeve clothing, umbrella, canopy

stay out og the sun during hottest part of the day 11am-3pm

educate about self screenings and when to contact provider

⭐️ if you notice a new or changed lesion, have it looked at ASAP

skin infections and infestations

bacterial infections: primary or secondary infection, staph and group a b-hemolytic strep are most common

viral infections: virus infects a cell or from an inflammatory response, create lesions that can be hard to treat

infestation and insect bites: allergy to venom, reaction to infestation of eggs, feces, parasite

folliculitis

bacterial: inflammation of the hair follicles

cause: staph bacteria; found in areas exposed to friction, moisture, rubbing, oil

symptoms: small pustule at hair follicle, mild redness, tender

treatment: topical antibiotic, chlorhexidine, warm saline compresses

no scarring, if extensive may have hair loss and systemic antibiotics, proper hygiene methods teaching

furuncle

bacterial: deep infection of the hair follicle

cause: staph, often occurs with severe acne

symptoms: tender, red, painful area around hair follicle, drainage of pus upon rupture; can be found on face, back of neck, axillae, breastes, buttocks, perineum, thighs

treatment: warm, moist compress; if abscess develops, will need incision and drainage and antibiotics, resolves slowly with scaring, teach proper hygiene

carbuncle

bacterial: collection of infected hair follicles (furuncles)

cause: staph bacteria

symptoms: pustules forming in reddened area firm lesion that is red, painful, and swollen, drainage, abscess may be present; most common on nape of neck, also on upper back, lateral thighs

treatment: warm, moist compress, if abscess develops will need incision and drainage, antibiotics, slowly with scarring, proper hygiene teaching

cellulitis

bacterial: deep inflammation of subcutaneous tissues from enzymes produced by bacteria; primary or secondary

cause: staph or group b strep

symptoms: hot, tender, red, edematous area with diffuse borders; gangrene is left untreated

treatment: topical→ moist heat, elevation, immobilization; systemic→ antibiotics

may need to be hospitalized for IV antibiotics

impetigo

bacterial: skin infection; primary or secondary

cause: staph, group B strep or both

symptoms: vesiculopustular lesions that develope thick, honey-colored crust surrounded by redness and itchiness; contagious, most commonly on face

treatment: topical→wound care with special solution or warm, soapy water, topical antibiotic cream, good personal hygiene; systemic→ oral antibiotics: doxycycline, cephalexin, clindamycin

preventing the spread of MRSA

Methicillin Resistant Staphylococcus Aureus (MRSA)

avoid close contact with others

keep areas covered

change dressing prn and dispose of soiled dressings appropriately

wash hands often, clean surfaces with bleach

private room, maintain contact precautions

take antibiotics as prescribed

shower rather than bathe, antibacterial soap

wash soiled linen separately

avoud sharing personal care items

herpes simplex virus

recurrent, lifelong viral infection; worsened by sunlight, trauma, menses, stress, systemic infection; contagious, can be transmitted from one area to another by contact.

HSV1: primarily on mouth (cold sore, fever blisters)

HSV2: primarily found on the genitalia (genital warts)

symptoms: first→ develop 2days-2weeks after contact; itchy, painful vesicles may form and become pustules and burst, weep, then crust, lesions last 2-6 weeks, contagious; recurrent→ similar spot, same symptoms.

treatment: soothing, moist compresses, topical agents (abreva); antiviral oral agents: acyclovir (Zovirax), valacyclovir (Valtrex)

herpes zoster virus

activated by the varicella-zoster virus

virus causes shingles→incidence increases with age

risk for infection increases if no previous varicella infection or immunocompromised

symptoms: painful lesions are unilateral and follow nerve root; commonly found on anterior/posterior trunk, face, eye; burning, painful and neuralgia before outbreak, mild to severe pain during outbreak

treatment: topical→ wet compresses, silver sulfadiazine (Silvadene) to ruptured vesicles; systemic→antivirals (Acyclovir) should be given within 72 hours of eruption; pain relief→ analgesia, gabapentin may be prescribed for neuralgia

prevention: CDC reccomends single dose of Zostavax vaccine for adults 50 years and older

candidiasis

fungal infection of the skin

cause: associated with candida albicans

symptoms: oral mucosa→ white, cheesy plaques on roof of mouth, tongue, can be irritating; skin→ diffuse, red rash, odor usually present

treatment: topical→ Nystatin powder or ointment, keep skin clean, cool and dry; systemic→oral antifungal therapy, Fluconazole (Diflucan)

tinea corporis (ringworm)

caused by various dermatophytes

manifestations: red, annular (ringlike) scaly appearance, well-defined borders

management: contagious, keep skin covered, don’t share personal care items, cool compresses, topical antifungals (creams ending in -zole) usually OTC

tinea cruris (jock itch)

caused by various dermatophytes

manifestations: well-defined, scaly plaque in groin area

management: keep skin clean and dry, no sharing of personal care items, topical antifungal creams or solutions

tinea pedis (athlete’s foot)

caused by various dermatophytes

manifestations: interdigital scaling and maceration; scaly skin, may be peeling

treatment: topical antifungal agents, keeping feet clean and dry, allow feet to have air, wear shoes in public showers

tinea unguium (toenail fungus)

caused by various dermatophytes, incidence increases with age

manifestations: affects toenails most often, may affect fingernails on one hand; brittle, thickened, broken, or crumbling nails with yellowish discoloration

management: oral/topical antifungals, podiatry consult, thinning of toenails or nail removal

pediculosis (lice)

lice infestation of either head, body, or pubic area

most common symptom is itching, observe hair for nits, pubic lice cause severe itching of the vulvar or perirectal area→ can be contracted through bed linens or during sexual intercourse with infected person

treatment: topical sprays, creams, and shampoos; otic lice kits, topical permethrin cream or malathion lotion, oral ivermectin, wash contaminated linens and personal items in hot water with detergent

scabies

contagious skin infection caused by mite infestation

characteristics of linear or curved ridge, intense itching, worse at night; transmitted through close contact with an infected individual or bedding/clothing; common in nursing homes and other crowded living areas, those with poor hygiene; infestation is confirmed with scraping of a lesion

treatment: scabisides→ topical permethrin or oral/topical ivermectin, launder all clothing and personal items with hot water and detergent

bedbugs

common parasite with infestations increasing due to travel and resistance to pesticides

live in mattresses, fabrics, cracks/crevices of furniture

feed on human blood at night, do not live on humans, bites resemble mosquito bites, resolve on own, hydrocortisone cream or oral antihistamine to help with itching

prevention: examine hotel room bedding especially box springs, place luggage away from bed when traveling, soiled clothing goes in sealed plastic bag when traveling, observe and clean items bought at garage sales, thrift stores, other resales before bringing into home

eradication: usually requires exterminator

allergic contact dermatitis

reaction of the skin most often r/t allergic immune response

cause: contact with allergen, specific cause not always known

symptoms: red papules and plaques, itching, area of irritation may take shape of causative agent

treatment: topical or oral corticosteroids, antihistamines, skin lubrication, cool, moist compresses, lukewarm colloidal oatmeal baths, elimination of contact allergen, avoid irritating affected area, if severe symptoms IV steroids may be needed

atopic dermatitis

reaction to the skin most often r/t type 1 hypersensitivity immune response→ chronic, relapse disease, skin response to environmental allergens, associated with asthma and allergic rhinitis

symptoms: acute→redness, oozing vesicles, extreme itching; subacute→scaly, light red to red-brown plaques, itching; chronic→thickened, dry skin with lichenification, possible hypo/hyper-pigmentation

treatment: topical immunodulators, moisturize dry skin, stress reduction; antibiotics for secondary; severe inflammation and itching→ steroids, phototherapy

urticaria (hives)

allergic reaction to the skin

cause: histamine release in response to allergic reaction

symptoms: rash of white or red raised areas (wheals) of various sizes, can occur anywhere on the body

treatment: removal of triggering agent, oral antihistamine, possible need for systemic corticosteroids

skin drug allergies

rare, life-threatening immune-mediated hypersensitivity reaction, most commonly caused by certain medications.

results in acute destruction and detachment of the epidermis and mucous membrane epithelium, leading to extensive skin loss and impaired barrier function.

common drugs: allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, NSAIDs, sulfonamides

symptoms: 4-21 days after medication start; initial→proceed skin reaction by 1-3 days, fever, cough, headache, anorexia, myalgia, and nausea; skin→ red, macular rash with purpuric centers, over hours to days, blisters form with sheets of epdermal detachment

management: stop med immediately, airway management, kidney function, fluid/electrolyte balance, pain control, wound care, parenteral/enteral nutrition, supportive care

Stevens-Johnson syndrome

skin drug reaction

skin detachment of less than 10% of body surface

toxic epidermal necrolysis

skin drug reaction

skin detachment of more than 30% of the body surface

acne vulgaris

benign: inflammatory disorder of the sebaceous glands; more common in teenagers, may worsen with hormone fluctuations

symptoms: various sizes of blackheads and whiteheads, may include papules and pustules, most common of face, neck and upper back

treatment: topical→mechanical removal of multiple lesions with extractor, topical solutions (benzoyl peroxide, retinoids, antimicrobials); systemic→antibiotics (Isotrerinoin)

acrochordons (skin tags)

benign growths

cause: unknown

symptoms: small, skin colored, soft, pedunculated papules; can become irritated in friction areas; common on neck, axillae and upper trunk

treatment: none necessary; surgical removal when needed, snipping without anesthesia

lentigo

benign: increased number of normal melanocytes in the basal layer of the epidermis; aka liver spots or age spots

cause: sun exposure and aging

symptoms: hyper pigmented, brown to black macule or patch on the sun-exposed skin

treatment: evaluated regularly for changes (biopsy if needed), may want removed for cosmetic purposes

psoriasis

benign: autoimmune chronic skin disorder marked by rapid turnover of epidermal cells; periods of exacerbations and remissions; family predisposition

symptoms: silver scaling plaques on reddish skin; often found on scalp, elbows, palms, soles, and fingernails; itching, burning, pain; mild-severe symptoms

treatment: reduce inflammation and suppress rapid turnover of epidermal cells; no cure; topical→corticosteroids, various other topical meds, phototherapy; systemic→methotrexate, Otezla; biologic therapies (Enbrel, Skyrizi, Humira)

rosacea

benign; common disorder of the central face; unknown cause

manifestations: redness, flushing of the face

management: avoid triggers; sun, extreme heat/cold, spicy food, alcohol; oral and topical agents

seborrheic keratoses

benign; common, noncancerous skin growth that often looks waxy, scaly, or like it was ‘stuck on’ the skin

management: biopsy if necessary, remove by curettage or cryosurgery

punch biopsy

no sutures, cover with dressing

Mohs surgery

layers of the tissue are shaved away and placed under a microscope

shaving continues until there id no longer presence of the lesion

Nursing management of skin problems

wet compresses

colloidal oatmeal baths

good hygiene practices

correct application of topical medications

educate on ways to control itching

prevent spread of skin infections

prevention of secondary infections

educate about postprocedure care

offer patient support