Comprehensive Nursing Study Guide for Skin Disorders

Overview of the Integumentary System

• Functions of the Skin

  • Protection: Acts as the primary barrier against environmental hazards, trauma, and pathogens.

  • Sensation: Contains sensory receptors for touch, pressure, temperature, and pain.

  • Fluid Balance: Controls the loss of water and electrolytes to maintain internal homeostasis.

  • Temperature Regulation: Regulates body heat through sweat production and vasodilation/vasoconstriction.

  • Vitamin D Production: Synthesizes Vitamin D upon exposure to ultraviolet (UV) light.

  • Immune Response Function: Provides a first line of defense through specialized cells in the skin layers.

  • Psychosocial: Influences body image, self-esteem, and social interaction.

Normal Aging and Lifespan Changes in Skin

• Normal Aging Process

  • Dryness: Reduced oil production and moisture retention.

  • Structural Changes: Development of wrinkling, skin folds, and a decrease in skin elasticity.

  • Pigmentation: Appearance of uneven pigmentation.

  • Thinning: The skin becomes physically thinner and more fragile.

  • Hair Changes: Diminished hair growth and volume.

  • Injury Risk: Increased potential for skin tears and injuries.

  • Healing: Decreased ability for the skin to heal and regenerate efficiently.

• Common Benign Findings in Older Adults

  • Cherry Angioma: Small, bright red, circular papules of vascular origin.

  • Lentigo (Liver Spots): Flat, brown, or black spots usually caused by sun exposure.

  • Seborrheic Keratoses: Benign warty lesions, often appearing "stuck on."

  • Spider Angiomas: Abnormal collections of blood vessels near the skin surface with a central red spot and radiating vessels.

  • Telangiectasia: Visible small linear red blood vessels (spider veins).

  • Xanthelasma: Cholesterol deposits forming at the eyelid.

Assessment of the Skin and Appendages

• Systematic Physical Assessment

  • Palpation: Used to assess skin temperature and texture.

  • Turgor: Tested to evaluate hydration status (elasticity).

  • Edema: Checking for fluid accumulation in the tissues.

  • Vascularity: Assessing blood flow and the presence of vascular lesions.

  • Ecchymosis/Bleeding: Identifying bruising or abnormal bleeding sites.

  • Hair Assessment: Evaluating distribution, quantity, and texture.

  • Nail Assessment: Inspecting for color, shape, and thickness.

• OLDCARTS Framework for Symptom Evaluation

  • Onset: When did the skin issue or pruritus (itching) start?

  • Location: Is the condition localized or generalized? Note the initial location, progression, and distribution (favored sites).

  • Duration: Is it an acute or chronic issue?

  • Character: Are symptoms described as stinging, burning, or itching?

  • Aggravating Factors: Environmental triggers, specific prescribed treatments, or over-the-counter (OTC) medications?

  • Relieving Factors: Treatments or environmental changes that improve the condition.

  • Timing: Is the symptom consistent or intermittent? Is it seasonal or related to a specific time of day? Is there a history of previous experience with this? Are there surrounding circumstances like travel, illness, or specific contacts?

  • Severity: Is the condition severe enough to disrupt sleep?

• Primary and Secondary Skin Lesions

  • Macule: Flat, non-palpable change in skin color.

  • Papule: Solid, raised lesion less than $0.5\,cm$.

  • Nodule: Solid, elevated lesion deeper in the dermis than a papule.

  • Vesicle: Small, fluid-filled blister.

  • Bulla: Large fluid-filled blister (greater than $0.5\,cm$).

  • Pustule: Elevated, pus-filled lesion.

  • Wheal: Transient, elevated, reddened area (e.g., hives).

  • Plaque: Flat, elevated, plateau-like lesion.

  • Cyst: Encapsulated fluid-filled or semi-solid mass.

  • Crust (Scab): Dried serum, blood, or pus on the skin surface.

  • Fissure: Linear crack in the skin extending into the dermis.

  • Ulcer: Deep loss of skin surface that may extend into the dermis.

  • Lichenification: Thickening and roughening of skin, often from chronic scratching.

Risk Factors and Diagnostics

• Risk Factors for Skin Disorders

  • Exposure to chemical or environmental pollutants.

  • UV/Sun exposure.

  • Nutritional deficiencies and Stress.

  • Infections and Genetics.

  • Use of harsh soaps or cosmetics.

  • Poor personal hygiene.

  • Long-term medication use (e.g., steroids, anticoagulants).

• Diagnostic Procedures

  • Skin Biopsy: Removal of a lesion for microscopic diagnosis by a pathologist. Performed under local anesthetic. Routine results typically available within $48$ hours; specialized staining takes longer.

  • Patch Testing: Identifies allergens by applying suspected substances to the skin.

  • Skin Scrapings: Microscopic examination of tissue samples for parasites or fungi.

  • Tzanck Smear: Used to examine cells from blistering diseases (e.g., herpes).

  • Wood Light Examination: Use of UV light to identify specific fungal or bacterial infections.

  • Photographs: Used for monitoring progression or changes in lesions.

Pharmacological Management of Skin Disorders

• Topical Therapies

  • Forms include lotions, creams, gels, pastes, and ointments.

  • Topical Corticosteroids: Used for anti-inflammatory, antipruritic, and vasoconstrictive effects. Patients should wash the area with soap and water before application.

  • Powders: Used for moisture absorption.

  • Intralesional Therapy: Injection of medication (like corticosteroids) directly into or below a lesion.

• Systemic and Therapeutic Baths

  • Therapeutic Baths: Aid in removing crusts and scales; relieve inflammation and itching.

  • Note: Some topical medications can have systemic effects depending on absorption.

Management of Pruritus (Itching)

• Etiology

  • Can occur with or without rashes/lesions.

  • Often the first sign of systemic disease: Chronic Renal Disease, Liver Diseases, Endocrine Disorders, Hodgkin’s Disease, HIV.

  • Drug-induced: Aspirin, antibiotics, hormones, opioids.

  • Chemical/Psychological: Soaps, chemicals, psychological factors.

• Nursing Management

  • Identify and treat the underlying cause.

  • Use cool compresses or cool baths.

  • Avoid excessive soap usage.

  • Apply occlusive ointments to damp skin to lock in moisture.

  • Monitor skin for signs of secondary infection.

• Medical Management

  • Cooling lotions.

  • Topical corticosteroids and antipruritics.

  • Oral antihistamines.

Acne Vulgaris

• Background

  • Affects up to $80\%$ of Americans.

  • Prevalence: Predominantly males during adolescence; predominantly females during adulthood.

  • Characterized by chronic dermatitis and comedones (the most common skin disorder).

  • Risks: Genetic, hormonal, and bacterial factors.

  • There is no cure; the goal of therapy is to minimize breakouts to prevent scarring.

• Treatments

  • Over-the-Counter (OTC): Benzoyl peroxide and Salicylic acid.

  • Retinoids: Tretinoin, Adapalene, Tazoretene. (Caution: Avoid sun exposure).

  • Isotretinoin: Powerful systemic retinoid with severe risks. Must use contraceptives due to teratogenic effects. Adverse reactions include depression, suicidal ideation, and violent behavior.

  • Topical Antibacterials: Clindamycin, Erythromycin, Tetracycline (can be used with Benzoyl peroxide).

  • Additional Therapies: Hormonal therapies and light therapy.

Bacterial Infectious Dermatoses

• Common Types

  • Impetigo: Superficial, highly contagious infection caused by Staphylococci or Streptococci. Features small red macules that rupture and form a "honey yellow crust." Risks: poor hygiene, malnutrition.

  • Furuncles (Boils) & Carbuncles (Abscesses): Inflammatory nodes involving hair follicles. Common in patients with Diabetes Mellitus (DM), hematologic disorders, or who are immunocompromised. Management: moist compresses, Incision & Drainage (I&D), antibiotics. Do NOT squeeze or pop.

  • Cellulitis: Bacteria invades subcutaneous tissue through a skin break. Symptoms: swelling, redness, warmth, pain, fever, chills, sweating, elevated White Blood Cell (WBC) count and neutrophils. Management: elevate extremity, outline redness with a marker to monitor spread, antibiotics, compression stockings.

  • Folliculitis & Pyoderma: Other bacterial skin infections.

• Patient Education

  • Infections are contagious; do not share towels or combs.

  • Bathe daily with antibacterial soap.

  • Wash clothes and linens in hot water daily ($130^\circ F$).

  • Return to activities/school $24$ hours after starting antibiotics.

Viral Infectious Dermatoses

• Herpes Zoster (Shingles)

  • Caused by Varicella-zoster virus.

  • Symptoms: Painful, vesicular lesions following sensory nerves (dermatomes).

  • Three Phases: Preeruptive, Acute, and Postherpetic Neuralgia.

  • Contagion: Contagious during the first phase when blisters are fluid-filled.

  • Management: Oral antivirals (Acyclovir, Famcyclovir, Valacyclovir), corticosteroids, pain management.

  • Prevention: Vaccines (Zostavax and Shingrix).

• Herpes Simplex (HSV)

  • Type 1: Lips, mouth, gums, tongue.

  • Type 2: Genital area.

  • Note: Both types can be found in either area.

  • Symptoms: Burning/tingling days prior to vesicle formation.

  • Management: Acyclovir/Valacyclovir, Lidocaine, occlusive dressings, sitz baths.

Fungal Infectious Dermatoses (Tinea)

• Specific Varieties

  • Tinea Capitis (Head): Oval, scaling red patches; brittle hair/patchy alopecia. Treated with Griseofulvin ($4\text{-}6$ weeks) and selenium sulfide shampoo.

  • Tinea Unguium (Toenails/Onychomycosis): Thick, crumbly, white/opaque nails. Treated with Terbinafine.

  • Tinea Corporis (Body): Red macules leading to papules/vesicles; intense pruritus.

  • Tinea Cruris (Groin/Jock Itch): Red scaling patches with pustule clusters at borders.

  • Tinea Pedis (Foot/Athlete's Foot): Scaling/redness in toe webs and soles; may have clear vesicles.

• Management

  • Topical Antifungals: Clotrimazole, Econazole, Ketoconazole.

  • Systemic Antifungals (for extensive cases): Fluconazole ($2\text{-}4$ weeks), Itraconazole ($1$ week), Terbinafine ($2$ weeks).

Parasitic Skin Infestations

• Pediculosis (Lice)

  • Pediculosis Capitis (Head Lice): Found on back of head/ears; eggs (nits) are silvery oval bodies. Can lead to secondary impetigo.

  • Pediculosis Pubis ("Crabs"): Spread via sexual contact in genital region; appears as reddish brown dust.

  • Management: Pyrethrin shampoo with piperonyl butoxide; Permethrin $1\%$ (kills live lice, not nits; requires second treatment in $9\text{-}10$ days); Ivermectin lotion $0.5\%$.

• Scabies

  • Caused by mites; characterized by burrows (straight/wavy lines under skin) and increased itching in the evening.

  • Management: Warm soapy bath to remove scales, followed by Scabicide (Permethrin $5\%$) applied thinly from neck down for the entire body (not face/scalp).

• General Parasite Precautions

  • Seal non-washable items in bags for $14$ days.

  • Wash linens in water >130^\circ F.

  • Contact precautions until treatment is complete.

Non-Infectious Inflammatory Dermatoses

• Atopic Dermatitis (Eczema)

  • Chronic rash caused by allergens or genetics. Characteristics vary by age:

  • Infants ($2\text{-}6$ months): Erythema, vesicles, weeping/crusting on cheeks, scalp, elbows, knees.

  • Children ($2\text{-}3$ years): Clusters of red papules on flexural areas (antecubital/popliteal), ankles, wrists; lichenification (leathery skin).

  • Adolescents/Adults: Similar distribution; dry, thick, leathery confluent papules.

  • Management: Hydration, emollients post-bath, cotton clothing, avoiding triggers (bubble baths, perfumes). Medications include Hydroxyzine (for itching) and topical corticosteroids.

• Psoriasis

  • Chronic, inflammatory, multi-system autoimmune disorder that speeds up the growth of immature epidermis cells.

  • Symptoms: Red, raised, silvery plaques; dry skin. Psoriatic Arthritis is a potential complication.

  • Management: Goal is to slow cell growth and remove scales gently (oatmeal baths, coal tar). Treatments include topical corticosteroids, Vitamin D analogs (calcipotriene), Vitamin A (tazarotene), Phototherapy (UVL), and systemic/biologic agents (Methotrexate, Cyclosporine).

Severe Blistering Diseases

• Toxic Epidermal Necrolysis (TEN) & Stevens-Johnson Syndrome (SJS)

  • Severe reactions often triggered by medications: Antibiotics (Sulfonamides), Anticonvulsants, NSAIDs, Allopurinol, Meloxicam.

  • Characteristics: Widespread erythema, macule formation, blisters, epidermal detachment (sloughing), and erosion.

  • SJS: More common in children/adolescents.

  • TEN: Affects all ages; more severe than SJS.

  • Impact: Involves skin, lips, mouth, eyes, and genitals.

• Clinical Management

  • Discontinue the causative factor immediately.

  • Specialized wound care and biologic dressings.

  • Maintenance of IV fluids, electrolyte balance, and thermoregulation.

  • Pain management and nutritional support.

Skin Cancer

• Background

  • Most common cancer type; $1$ in $5$ Americans will develop it by age $70$.

  • Risk Factors: Age (<30 or >50), UV/Sun exposure, family history, indoor tanning, light skin, red/blond hair, blue/green eyes, immunosuppression.

• ABCDEs of Melanoma

  • A - Asymmetry: One half does not match the other.

  • B - Border: Uneven, notched, or blurred edges.

  • C - Color: Variation in shades (two or more shades).

  • D - Diameter: Larger than $1/4\text{ inch}$.

  • E - Evolving: Change in size, shape, or color over time.

Nursing Diagnoses and Goals

• Goals of Care

  • Prevent additional damage.

  • Prevent secondary infection.

  • Reverse the inflammatory process.

  • Relieve symptoms.

• Common Diagnoses

  • Impaired Skin Integrity.

  • Social Isolation.

  • Ineffective Health Maintenance.

  • Altered Body Image.