Integumentary Disorders

Patho

Macule

• Flat lesions that are usually less than 0.5cm in size, and same height as the rest of the skin, but different shade

Patch:

 Flat, irregular shape, skin lesions that are a different color than your skin tone and larger than 0.5 cm

Papule

• Raised, solid skin lesions that grow to 1cm in size

Plaque

Rough textured, raised lesions, larger than 1 cm

Nodule

Solid fluid-filled skin lesions that form just under skin (cyst)

Tumor

Abnormal mass of tissue that forms when cells grow uncontrollably

Wheal

Raised, red/skin, colored route that develops in response to antigenic triggers

Vesicle

• Small fluid-filled blister

Bulla

Similar to vesicle but larger in size

Pustule

Small, raised skin lesion filled with exudate

Atopic Dermatitis (Eczema)

 Itchy, inflammatory skin disorder that is characterized by poorly defined erythema with edema, vesicles, and weeping at the acute stage and skin thickening (lichenification) in chronic stage 

• Often described as an immunoglobulin (Ig) E-mediated hypersensitivity (atopic) disease, allergic causation is difficult to document 

  Treatment:

  • Underlying all treatment measures is a comprehensive education program regarding the cause of the disorder, treatment measures, and avoidance of temperature changes and stress to minimize vascular and sweat responses 

  • Corticosteroids are important for acute flare-ups but can cause local systemic side effects 

  • Wet-wrap therapy (wet-dressings over emollients in combination with topical antiseptics)

  • Secondary infection (S.auerus) is treated with antibiotics (Mupirocin ointment)

  • Antihistamines are useful for their sedative effects and during severe pruritus episode  

Herpes Simplex Virus (HSV): Infections of the skin and mucous membranes (cold sore / fever blister) are common. 

• HSV-1 is usually associated with oropharynx infections, and the organism is spread by respiratory droplets or be direct contact with infected saliva (athletics, dentistry, medicine)

• Gential herpes is usually caused by HSV-2

• Infections with HSV-1 may present as primary or recurrent infection; Symptoms include fever, sore throat, painful vesicles, ulcers of the tongue/palate/gingiva/buccal mucosa/lips

• Primary infection results in the production of antibodies to the virus so that recurrent infections are more localized and less severe 

• Recurrent lesions of HSV-1 usually begin with a burning or tingling sensation ; umbilicated vesicles and erythema follow and progress to pustules, ulcer, and crusts before healing

• Precipitating Factors: Stress/ Menses / Injury / UVB exposure 

Herpes Zoster (Shingles): Is an acute, localized vesicular eruption distributed over a dermatomal segment of skin. 

• Caused by herpesvirus, Varicella-zoster, which causes chickenpox 

• Thought to be caused by reactivation of latent varicella-zoster virus infection that was dormant in the sensory dorsal root ganglia 

• Tends to happen in adults more frequently, risk because of impaired T cell immunity, those with HIV, certain malignancies, chronic corticosteroid users and those undergoing chemo

• Lesions are preceded by a prodrome consisting of a burning pain, a tingling sensation, extreme sensitivity of the skin to touch, and pruritus along affected dermatome

• Lesions appear as an eruption of vesicles with erythematous bases that are restricted to skin areas supplied by sensory neurons of a single or an associated group of dorsal root ganglia

• Postherpetic neuralgia, which is pain that persists longer than 1-3 months after resolution of rash is an important complication of herpes zoster 

 Treatment:

• Administration of antiviral agent (Acyclovir/Valacyclovir); most effective when started within 72 hours of rash development 

• Zoster vaccine (Zostavax) is effective in either preventing or lessening severity 

• Narcotic analgesics, tricyclic antidepressants, gabapentin, anticonvulsant drugs, and nerve blocks have been used for management of postherpetic neuralgia 

• Local application of capsaicin cream or lidocaine patches 

Impetigo

Common, superficial bacterial infections caused by staphylococcus or group A beta-hemolytic streptococci, or both. It’s common among young infants and young children, although older children and adults occasionally contract the disease. Its occurrence is highest during warm summer months or in warm moist climates. 

• Initially appears as a small vesicle or pustule or as a large bulla on the face or elsewhere on the body

• As primary lesion ruptures, it leaves a denuded area that discharges a honey-colored serous liquid that hardens on the skin surface and dries as a honey-colored crust 

• A possible complication of untreated streptococcal impetigo is poststreptococcal glomerulonephritis 

Treatment:

• Topical mupirocin is effective in treating impetigo 

• If a larger area is involved, systemic antibiotic may be necessary (Oral: cephalexin, dicloxacillin, clindamycin/doxycycline) 

Melasma

Characterized by darkened fascial macules, most prominent in brown-skinned people from Asia, India, South America. 

• More common in women during pregnancy or using oral contraceptives

• Is exacerbated by sun exposure

Treatment:

• Treatment measures are palliative, mostly consisting of limiting exposure to the sun and using sunscreens

• Bleaching agents, containing 2-4% hydroquinone, are standard treatment 

• Tretinoin cream and azelaic acid have been useful in treating severe cases

Psoriasis:

Is a common, chronic inflammatory skin disease characterized by circumscribed, red, thickened plaques with an overlaying silvery-white scale

Pathogenesis:

• Is characterized by increased epidermal cell turnover with marked epidermal thickening, a process called hyperkeratosis

• The granular layer (stratum granulosum) of the epidermis is thinned or absent, and neutrophils are found in stratum corneum 

• Accompanied thinning of the epidermal cell layer that overlies the tips of the dermal papillae (suprapapillary), and blood vessels in dermal papillae become tortuous and dilated 

• Capillary beds show permanent damage 

• Close proximity to the vessels in dermal papillae to the hyperkeratotic scale accounts for multiple, minute bleeding points seen when scale is lifted

Treatment for Psoriasis:

• Topical agents include emollients, keratolytic agents, coal tar products, anthralin, corticosteroids, and calcipotriene

• Keratolytic are peeling agents

• Salicylic acid is often used to remove plaques 

• Anthraliin resolves lesions in approx 2 weeks

Systemic Treatments include:

• Phototherapy, photochemotherapy, methotrexate, retinoids, corticosteroids, and cyclosporine 

Rosacea:

 Is a chronic inflammatory process that occurs in adults between 30-50 years old. Is easily confused with acne and may coexist with it, more common on fair-skinned people (white women older than 30).

• Overactive innate immunity 

• Neurovascular instability (flushing, vasodilation)

• Microbial involvement (demodex mites)

• Skin barrier (UV, increased transepidermal water loss)

• Environmental triggers (UV, heat/cold, wind, stress, spicy food, alcohol)

• Genetic & Ethnic Factors 

Treatment for Rosacea:

• Topical metronidazole and azelaic acid have been effective

• Topical antibiotics and system antibiotics

• Surgeries: electrosurgery, laser ablation, dermabrasion, cryosurgery, and excision 

Steven-Johnson Syndrome

 May be a reaction to either a drug or a virus such as HSV 

• caused by hypersensitivity reaction to drugs, the most common being sulfonamides, anticonvulsants, nonsteroidal anti-inflammatory drugs, antimalarials, and allopurinol

• Primary lesion is round erythematous papule, resembling an insect bite 

• Lesion may change, enlarge and coalesce, producing small plaques, or may change to concentric zones of color appearing as “target” or “iris” lesions

Treatment: 

• Relief of symptoms using compress, antipruritic drugs, and topical anesthetics

• For severe cases, hospitalization is required for fluid replacement, respiratory care, administrations of antibiotics and analgesics, and application of moist dressings

Vitiligo

Is a pigmentary problem of concern to darkly pigmented people of all races

• Genetic predisposition 

• Oxidative stress (initiates melanocyte destruction)

• Autoimmune destruction of melanocytes 

• Possible neural & environmental contributions 

• Hypothyroidism / Graves Disease / Addison disease / pernicious anemia / type 2 diabetes / melanoma

Pressure Injuries

 Pressure ulcers are ischemic lesions of the skin and underlying structures caused by unrelieved pressure that impairs the flow of blood and lymph. Pressure ulcers often referred to as decubitus ulcers or bedsores.

• Are most likely to develop over a bony prominence, but may occur on any part of the body that is subjected to external pressure, friction, or shearing forces

People at Risk:

• People with quadriplegia

• Older adults with restricted activity and hip fractures 

• People in a critical care setting 

• People with impaired circulation 

Other Factors:

• Type 2 diabetes

• Pressure from positioning and body weight 

• Sweating and/or incontinence 

  Prevention:

  • Frequent position changing

  • Meticulous skin care

  • Frequent and careful observation to detect early signs of skin breakdown 

  • Prevention of dehydration 

  • Maintenance of adequate nutrition