Chapter 31: Dermatitis and Acne

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SECTION 7 | System Disorders

Chapter 31: Dermatitis and Acne

Common skin conditions of the pediatric population include contact dermatitis, atopic dermatitis, and acne.

Contact dermatitis

Contact dermatitis is an inflammatory, hypersensitive reaction of the skin. It is caused when the skin comes into contact with chemicals or other irritants (feces, urine, soaps, poison ivy, animals, metals, dyes, medications).

Diaper dermatitis can be caused by exposure to an irritant: (urine (increased pH), stool, skin friction, chemicals, soaps, or detergents) that come in prolonged or excessive contact with the diaper/perineal area. It can also be a result of Candida albicans.

Seborrheic dermatitis (cradle cap, blepharitis, otitis externa) has an unknown etiology but is most common in infancy and puberty.

Assessment

Risk Factors

• Diaper dermatitis: Use of diapers, infrequent diaper changing, excessive stooling

• Contact dermatitis: Exposure to an irritant

Expected findings

Pruritus

Physical Assessment Findings

Depends on the cause of the irritant and the client

• Contact dermatitis

  • Red bumps that can form moist, weeping blisters

  • Skin warm and tender to the touch

  • Presence of oozing, drainage, or crusts

  • Skin becomes scaly, raw, or thickened

• Diaper dermatitis 

  • Mild: scattered erythematous papules, minor irritation

  • Moderate: erosions and macerations, extensive erythema, pain

  • Severe: extensive glistening erythema, skin erosions, papules, pustules, nodules, pain  

• Seborrheic dermatitis

  • Thick, adherent lesions

  • Patches that are yellow and scaly

Patient-Centered Care

Nursing Care

Diaper dermatitis

• Change diapers frequently. 

• Promptly remove soiled diapers.

• Cleanse diaper/perineal area with a nonirritating cleanser or plain warm water.

• Use soft cloths and commercial wipes (free of alcohol and fragrances) to cleanse the diaper/perineal area.

• Expose the affected area to air.

• Apply a skin barrier, such as zinc oxide. Do not wash it off with each diaper change.

Contact dermatitis: Remove irritant, and limit further exposure.

Poisonous plant exposure

• Cleanse exposed area as soon as possible by flushing it with cold running water​​​​​​​.

• Clothes, shoes should be cleansed in hot water with detergent.

• Apply calamine lotion, Burrow’s solution compresses, or natural colloidal oatmeal baths.

• Use topical corticosteroid gel.

• Oral corticosteroids for severe reactions or for irritation on the face, neck, or genitalia.

Seborrheic dermatitis

• Encourage parents to perform daily scalp/hair hygiene.

• Treat by gently scrubbing the scalp to remove scaly lesions and crusted patches. May apply petrolatum or mineral oil to scalp to soften lesions overnight.

• Use a fine-tooth comb to remove the loosened crusts from the scalp/hair.

• Use an antiseborrheic (contains sulfur and salicylic acid) shampoo daily.

A nurse is teaching the guardian of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for an infant who has diaper dermatitis. Which of the following actions should the nurse include in the plan of care?

Select all that apply.

Medications

Antihistamines

Hydroxyzine or diphenhydramine

Administer in cases of allergic/medication reactions.

Client Education

• Educate the child’s family on the importance of the medication and administering on schedule.

• Reinforce the sedating effect of some antihistamines and the need for parents to monitor the child and provide for safety during use. Qs​​​​​​​

Antibiotics

Used to treat secondary infections.

Client Education: Educate the family about the importance of continuing the medication as prescribed.

Antifungal ointments

Clotrimazole

Used to treat Candida albicans associated with diaper dermatitis.

Client Education: Educate the family on the importance of the medication and administering schedule.

Client Education

• Change diapers frequently.

• Avoid bubble baths and harsh soaps.

• Wear long sleeves and pants when there is risk of possible exposure to irritants.

• Remove an offending agent as soon as exposure takes place.

• Practice proper hand hygiene.

A nurse is caring for a child who has contact dermatitis due to poison ivy. Which of the following actions should the nurse take?

Select all that apply.

Complications

Bacterial infections

Caused by breaks in the skin from scratching.

Nursing Actions

• Monitor the area for manifestations of infection.

• Keep fingernails trimmed short.

• Cleanse the area with mild soap and water.

• Administer antipruritics and antibiotics.

Client Education: Educate the family and child about avoiding offending agents. QPCC​​​​​​​

Atopic dermatitis

• Atopic dermatitis (AD) is a type of eczema (eczema describes a category of integumentary disorders, not a specific disorder with a determined etiology) that is characterized by pruritus and associated with a history of allergies that are of an inherited tendency (atopy).

• Classifications of atopic dermatitis are based on the child’s age, how the lesions are distributed, and the appearance of the lesions.

• AD cannot be cured but can be well-controlled.

Assessment

Risk Factors

• Presence of allergic condition and family history of atopy

• Previous skin disorder and exacerbation of present skin disorder

• Exposure to irritating and/or causative agents

• Genetic predisposition

• Geographic location

Expected findings

• Recent exposure to any irritant (medication, food, soap, contact with animals)

• Intense pruritus

Physical assessment findings

• Unaffected skin can appear dry and rough.

• Hypopigmentation of skin can occur in small, diffuse areas.

• Pallor surrounds the nose, mouth, and ears.

• A bluish discoloration is present underneath the eyes.

• Lymphadenopathy occurs, especially around affected areas.

Infants

Onset at 2 to 6 months of age with spontaneous remission by 3 years of age

Distribution: Generalized distribution of lesions on cheeks, scalp, neck, and feet, as well as extensor surfaces of extremities

Lesions

• Erythema

• Vesicles, papules

• Weeping, oozing, crusting, scaling

Children

Onset at 2 to 3 years of age with 90% of children having manifestations by 5 years of age; can follow infantile eczema

Distribution: Lesions in the flexural areas (antecubital and popliteal fossae, neck), wrists, ankles, and feet with symmetric involvement

Lesions

• Clusters

• Erythematous or flesh-colored papules

• Dry

• Lichenification

• Keratosis pilaris

Adolescents

Onset at age 12 and can continue into adulthood

Distribution: Similar distribution to children

Lesions

• Same as for children

• Dry, thick

• Confluent papules

A nurse is assessing an infant who has eczema.  Which of the following findings should the nurse expect?

Select all that apply.

Patient-Centered Care

Nursing Care

• Assess and monitor the skin frequently.

• Keep skin hydrated with tepid baths. Two or three baths may be given daily with one prior to bedtime.  

• Use a mild skin cleanser if needed during baths.  After bathing, pat, do not rub, skin. Apply an emollient or moisturizer immediately after bathing and drying while skin is still moist.

• Dress the child in cotton clothing. Avoid wool and synthetic fabrics.

• Avoid excessive heat and perspiration, which increases itching.

• Avoid irritants (bubble baths, soaps, perfumes, fabric softeners).

• Provide support to the child and family.

• Wash skin folds and genital area frequently with water.

• Assist in identifying causative agent.

• Keep child’s nail short and filed smooth to eliminate sharp edges.

Therapeutic Management

Medications

Antihistamines

Hydroxyzine or diphenhydramine

Used to manage severe pruritis

Client Education

• Reinforce the sedating effect of some antihistamines and the need for parents to monitor the child during use.

• Reinforce safety of the child when using sedating antihistamines. Qs

Loratadine or fexofenadine

Oral antihistamine for antipruritic effect

Nursing Actions: Administer as prescribed.

Client Education: It is preferred for use during the daytime.

Antibiotics

Antibiotics are used to treat secondary infections.

Topical corticosteroids

Topical corticosteroids may be used intermittently to reduce or control flare-ups. They can be low-, moderate-, or high-potency and are prescribed based on the degree of skin involvement (extremity versus eyelids), age of the child, and consequences from adverse effects.

Topical immunomodulators (nonsteroidal)

Tacrolimus or pimecrolimus

• Used to decrease inflammation during flare-ups

• Safe to apply to face

Nursing Actions

• Use for children older than 2 years of age.

• Use at the start of an exacerbation of AD when skin turns red and starts to itch.

Client Education

• Observe for manifestations of infection.

• Change diapers when wet or soiled.

• Keep nails short and trimmed.

• Place gloves or cotton socks over hands for sleeping.

• Dress young children in soft, cotton, one-piece, long-sleeve, long-pant outfits.

• Remove items that can promote itching (woolen blankets, scratchy fabrics). Use cotton items whenever possible.

• Use mild detergents to wash clothing and linens. The wash cycle can be repeated without soap.

• Avoid latex products, second-hand smoke, furry pets, dust, and molds.

• Encourage tepid baths (can use a mild skin cleanser if needed) at least daily. Avoid scrubbing the skin and using bubble bath.

• Soaking in bathtub is recommended for less than 10 minutes. Apply prescribed medications and moisturizers immediately after bathing when skin is still moist.

• Apply wet wraps overnight as prescribed for severe pruritis (Apply gauze that is moisten water to affected area, wrap a dry gauze over the moistened gauze.

• Follow specific directions regarding topical medications, soaks, and baths. Emphasize the importance of understanding the sequence of treatments to maximize the benefit of therapy and prevent complications.

• Use a room humidifier or vaporizer.

• Maintain treatment to prevent flare-up.

• Follow up with the provider as directed.

• Participate in support groups.

Therapeutic Procedures

• Phototherapy: affected areas exposed to UV light for at least 2-3 times per week

Complementary and alternative therapies

• Topicals: coconut/sunflower oil, vitamin B12 

• Vitamins and supplements:  Vitamin D, fish oil, melatonin, turmeric

• Other:  acupuncture, meditation, yoga, massage

Complications

Infection

Caused by breaks in the skin from scratching

Nursing Actions

• Keep nails trimmed.

• Administer antipruritics.

• Monitor the area for manifestations of infection.

• Cleanse the area with mild cleanser and water.

Client Education: Educate the family and child to avoid offending agents. QPCC​​​​​​​

Acne

• Acne also known as acne vulgaris, is the most common skin condition during adolescence.

• Acne is self-limiting and not life-threatening. However, it poses a threat to self-image and self-esteem for adolescents.

• Acne involves the pilosebaceous follicles (hair follicle and sebaceous gland complex) of the face, neck, chest, and upper back.

• Propionibacterium acnes is the bacteria associated with inflammation in acne.

Assessment

Risk Factors

• Acne has a genetic link.

• More common in males.

• Age: common during adolescence

• Hormonal fluctuations can result in acne flares.

• The use of cosmetic products containing ingredients (petrolatum and lanolin) can increase acne outbreaks.

• Adolescents working at fast-food restaurants can have an increased incidence of acne due to exposure to cooking grease.

• There is a possible dietary link with acne and the intake of high glycemic index foods and dairy products.

Expected findings

Report of exacerbations and remissions

Physical Assessment Findings

• Lesions (comedones) are either open (blackheads) or closed (whiteheads). Both are most often found on the face, neck, back, and chest.

• P. acnes can lead to inflammation manifesting as papules, pustules, nodules, or cysts.

Patient-Centered Care

Nursing Care

• Discuss the process of acne with the adolescent and family.

• Discuss the importance of adherence with the prescribed plan of care.

Client Education

• Gently wash the face and other affected areas, avoiding scrubbing and abrasive cleaners.

• Observe for adverse effects of prescribed medications.

Medications

Tretinoin

Interrupts abnormal keratinization that causes microcomedones

Client Education

• Tretinoin can irritate the skin. Wait 20 to 30 min after washing the face before applying to decrease skin irritation.

• Use a pea-size amount of medication and apply at night.

• Avoid sun exposure.

• Use sunscreen (SPF 15 or greater).

Benzoyl peroxide

Antibacterial agent

Nursing actions

• Inhibits growth of P. acnes.

• Benzoyl peroxide can bleach bed linens, towels, and clothing, but not skin.

Topical and oral antibacterial agents

Inhibits growth of P. acnes

Nursing actions

• Various topical antibacterial agents (clindamycin, azelaic acid, dapsone) may be used. Assess and monitor for allergic reactions.

• Every-other-day application decreases adverse effects (drying of the skin, burning sensations, and erythema).

• Oral antibacterial medications (tetracycline, doxycycline, erythromycin, minocycline) are indicated for severe acne that is unresponsive to topical agents.

• Avoid sun exposure due to photosensitivity.

• Use sunscreen with an SPF of 15 or greater when exposure to sun is unavoidable.

Isotretinoin

Affects factors involved in the development of acne

Nursing actions

• Isotretinoin is only prescribed by dermatologists for severe acne that is unresponsive to other therapies.

• Adverse effects include dry skin and mucous membranes, dry eyes, decreased night vision, headaches, photosensitivity, elevated cholesterol and triglycerides, depression, suicidal ideation, and/or violent behaviors.

• Monitor for mood or behavioral changes.

• Isotretinoin is teratogenic. Therefore, it is contraindicated in women of childbearing age who are not taking oral contraceptives. If sexually active, the client must agree to use two forms of effective contraception for 1 month before and during treatment, and at least 1 month following treatment.

Client education: Adverse effects include dry skin and mucous membranes, dry eyes, decreased night vision, headaches, photosensitivity, elevated cholesterol and triglycerides, depression, suicidal ideation, and violent behaviors.

Oral contraceptive pills

Decreases endogenous androgen production and bioavailability, resulting in decreased acne development

Nursing Actions

• Indicated only for adolescent females.

• Therapy is combined with a topical acne treatment.

A nurse is caring for an adolescent who has acne and is receiving prescribed isotretinoin.  Which of the following laboratory findings should the nurse plan to monitor?

Client Education

• Reinforce that adherence to the therapeutic plan is essential to preventing acne flares.

• Encourage the child to eat a balanced, healthy diet.

• Encourage sleep, rest, and daily exercise.

• Wash the affected area gently with a mild cleanser once or twice daily, and not to pick or squeeze comedones.

• Encourage frequent shampooing of hair.

• Encourage support of the adolescent and family members to assist the adolescent in coping with body-image changes. QPCC​​​​​​​

• Wear protective clothing and sunscreen when outside.

• Use sunscreen with an SPF of 15 or greater when exposure to sun is unavoidable.

• Reinforce the need for follow-up and monitoring of cholesterol and triglycerides for adolescents who are taking isotretinoin.

• Reinforce the importance of using effective contraception while taking isotretinoin.

Complications

Psychosocial impairment

Causes:  stress, decreased self-esteem, depression (related to cosmetic appearance)

Nursing Actions

• Monitor for mood or behavioral changes

• ​​​​​​​Encourage verbalization of feelings

Client Education

• Encourage adherence to treatment plan

• Report changes in mood

Skin scarring​​​​​​​

Caused by lesions skin from scratching or delay in treatment of acne, that causes permanent scaring

• Scars can be atrophic (loss of tissue damage) or hypertrophic (increased tissue formation such as keloids).

• Therapeutic management: topical medications, injectable steroids, silicone dressings, punch excision, cryosurgery, dermabrasion, microdermabrasion.

• Explain to adolescent and family that therapy will improve the appearance of skin.

Active Learning Scenario

A nurse is teaching a guardian of a child who has eczema. Use the ATI Active Learning Template: System Disorder to complete this item.

Alteration in health (diagnosis)

Client Education: Include at least five teaching points.

Click to download this file.

Active Learning Scenario Key

Click to reveal sample responses.

Alteration in health (diagnosis): Eczema describes a category of integumentary disorders, not a specific disorder with a determined etiology, that is characterized by pruritus and associated with a history of allergies that are of an inherited tendency (atopy).

Client Education

• Observe for manifestations of infection.

• Change diapers when wet or soiled.

• Keep nails short and trimmed.

• Place gloves or cotton socks over hands for sleeping.

• Dress young children in soft, cotton, one-piece, long-sleeve, long-pant outfits.

• Remove items that can promote itching (woolen blankets, scratchy fabrics). Use cotton items whenever possible.

• Use mild detergents to wash clothing and linens. The wash cycle can be repeated without soap.

• Avoid latex products, second-hand smoke, furry pets, dust, and molds.

• Encourage tepid baths (can use a mild skin cleanser if needed) at least daily. Avoid scrubbing the skin and using bubble bath.

• Soaking in bathtub is recommended for less than 10 minutes. Apply prescribed medications and moisturizers immediately after bathing when skin is still moist.

• Apply wet wraps overnight as prescribed for severe pruritis (Apply gauze that is moisten water to affected area, wrap a dry gauze over the moistened gauze.)

• Follow specific directions regarding topical medications, soaks, and baths. Emphasize the importance of understanding the sequence of treatments to maximize the benefit of therapy and prevent complications.

• Use a room humidifier or vaporizer.

• Maintain treatment to prevent flare-up.

• Follow up with the provider as directed.

• Participate in support groups.

NCLEX Connection: Physiological Adaptation, Illness Management