Disorders of the Skin Lecture Notes

General Assessment of the Integumentary System

• Initial Contact and Examination: A general assessment of the skin begins at the initial contact with the patient and continues throughout the entire physical examination.
• Documentation: Nurses must record a general statement regarding the physical condition of the skin as part of the formal medical record.

Subjective Data and Functional Health Patterns

• Past Health History: Identifies previous trauma, surgery, or prior diseases involving the skin. Nurses should note any history of chronic or unprotected exposure to UV light, including the use of tanning beds and previous radiation treatments.
• Medications:     * Query the patient about skin-related issues resulting from prescription or over-the-counter (OTC) medications.     * Document medications used for primary skin problems (e.g., acne) or secondary symptoms (e.g., itching/pruritus).
• Surgery and Treatments: Determine if surgical procedures, including cosmetic surgery, have been performed. Note treatments like phototherapy, radiation therapy, laser resurfacing, or cosmetic "peels."
• Functional Health Patterns:     * Health Perception-Health Management: Focuses on daily hygiene habits, sun protection practices, and use of personal care products.     * Nutritional-Metabolic: Assess skin, hair, nails, and mucous membranes for changes related to diet or food allergies. For obese patients, check intertriginous areas (where skin surfaces overlap) for chafing or rashes. Inquire about delayed wound healing.     * Elimination: Assess for dehydration, edema, and pruritus, which may indicate fluid balance alterations. Check anal and perineal skin if incontinence is present.     * Activity-Exercise: Identify environmental hazards in hobbies or recreation, such as exposure to carcinogens, chemical irritants, or allergens.     * Sleep-Rest: Pruritus can severely disturb sleep. Tiredness may manifest as dark circles under the eyes and decreased facial skin firmness.     * Cognitive-Perceptual: Assess perception of heat, cold, pain, and touch. Neuropathy may manifest as numbness, tingling, or crawling sensations.     * Self-Perception-Self-Concept: Evaluate feelings related to the skin condition, such as anxiety, sadness, despair, or altered body image.     * Role-Relationship: Assess how the skin condition affects family, peer, and work relationships, as well as occupational exposure to irritants.     * Sexuality-Reproductive: Tactfully assess the impact of skin conditions on sexual activity.     * Coping-Stress Tolerance: Stress can create or exacerbate certain skin conditions.     * Value-Belief: Cultural or religious beliefs may influence self-image or limit treatment choices.

Objective Data and Physical Examination Techniques

• Examination Environment:     * The room should be private with a moderate temperature.     * Good lighting is essential; exposure to daylight is preferred.     * The patient should be in a dressing gown allowing easy access to all skin areas.
• Systematic Approach:     * Perform a head-to-toe general inspection before focusing on problem areas.     * Compare symmetric body parts.     * Use the metric system for all measurements.     * Use appropriate terminology and nomenclature in documentation.
• Inspection Elements:     * Color and Pigmentation: Check for general color, vascularity, and bruising.     * Change: The critical factor in assessment is identifying change in the skin.     * Body Art: Note piercings and tattoos.     * Lesions: Record color, size, distribution, location, and shape.     * Odors: Note any unusual odors during the systemic inspection.     * Hair and Nails: Inspect all body hair. For nails, examine shape, thickness, curvature, and surface.
• Palpation Elements:     * Temperature: Best assessed using the back (dorsum) of the hand; skin should be warm.     * Turgor: Refers to elasticity. Assessed by gently pinching the skin under the clavicle or on the back of the hand.     * Moisture: Dampness or dryness; should be intact without flaking, scaling, or cracking.     * Texture: Refers to fineness or coarseness; should be smooth and firm.

Classification of Primary and Secondary Skin Lesions

• Primary Skin Lesions: Develop on previously unaltered skin.     * Macule: A circumscribed, flat area with color change $<0.5\,cm$. Examples: freckles, petechiae, measles, vitiligo. If $>0.5\,cm$, it is a Patch.     * Papule: An elevated, solid lesion $<0.5\,cm$. Examples: warts, elevated moles, basal cell carcinoma. If $>0.5\,cm$, it is a Nodule.     * Vesicle: A circumscribed collection of serous fluid $<0.5\,cm$. Examples: chickenpox (varicella), shingles (herpes zoster), second-degree burns.     * Plaque: A circumscribed, elevated, superficial, solid lesion $>0.5\,cm$. Examples: psoriasis, seborrheic keratosis.     * Wheal: Firm, edematous, irregularly shaped area with variable diameter. Examples: insect bites, urticaria.     * Pustule: Elevated, superficial lesion filled with purulent fluid. Examples: acne, impetigo.
• Secondary Skin Lesions: Lesions that change over time or result from factors like scratching or infection.     * Fissure: A linear crack from the epidermis to the dermis (e.g., athlete’s foot).     * Scale: Excess dead epidermal cells from abnormal keratinization (e.g., flaking after sunburn).     * Scar: Abnormal connective tissue replacing normal skin (e.g., surgical incision).     * Ulcer: Irregularly shaped loss of epidermis extending into the dermis (e.g., pressure ulcer).     * Atrophy: Depression resulting from thinning of the epidermis or dermis (e.g., aged skin, striae).     * Excoriation: Area where the epidermis is missing, exposing the dermis (e.g., abrasion, scratch).

Lesion Distribution Terminology

• Annular: Circular, starts in center and spreads to periphery (e.g., ringworm).
• Asymmetric: Unilateral distribution.
• Confluent: Lesions merging together (e.g., hives).
• Discrete: Distinct individual lesions that remain separate (e.g., acne).
• Gyrate: Twisted, coiled, spiral, or snakelike.
• Grouped: Clusters of lesions (e.g., contact dermatitis).
• Localized: Limited, clearly defined area.
• Polycyclic: Annular lesions that grow together (e.g., psoriasis).
• Solitary: A single lesion.
• Symmetric: Bilateral distribution.
• Zosteriform: Linear arrangement along a dermatome (e.g., herpes zoster).

Assessment Variations in Light and Dark Skin

• Assessment Sites: Best assessed where the epidermis is thinnest and least influenced by the sun (lips, mucous membranes, nail beds, buttocks).
• Cyanosis: In light skin, appears as grayish-blue; in dark skin, ashen or gray color in the conjunctiva or mucous membranes.
• Ecchymosis: In light skin, red/purple/yellow/green; in dark skin, purple to brownish-black.
• Erythema: In dark skin, look for a deeper brown or purple tone and palpate for increased skin temperature.
• Jaundice: Most obvious in the sclera (do not confuse with normal yellow eye pigmentation in dark-skinned patients).
• Pallor: In dark skin, appears as a lack of underlying red tone, or as yellowish-brown/ashen gray skin.
• Petechiae: Hard to see in dark skin; check the buccal mucosa or conjunctiva.
• Conditions Predisposing Dark Skin:     * Keloid: Overgrowth of collagenous tissue at a site of injury.     * Vitiligo: Total loss of pigment in an area.     * Dermatosis papulosa nigra: Small, pigmented wart-like papules on the face.     * Nevus of Ota: Slate-gray or blue-gray birthmark around the eye.     * Traction Alopecia: Hair loss from legal trauma (hair rollers or tight braiding).     * Pseudofolliculitis: Inflammatory response to ingrown hairs from shaving.

Diagnostic Studies

• Curettage: Scooping away tissue using a sharp, spoon-like instrument.
• Patch Testing:     * Used for allergic dermatitis. Allergens are applied for $48\,hr$.     * Nursing Responsibility: Patients must not wash the area, play vigorous sports (to keep tape on), or expose the site to UV light during the $48\,hr$ period.
• Biopsy Types:     * Excisional: Removal of the entire lesion for cosmetic results and diagnosis; closed with sutures.     * Incisional: Wedge-shaped incision in a large lesion.     * Punch: Uses a special instrument to remove a circle of tissue including dermis and fat.     * Shave: Thin specimen taken using a razor blade for superficial lesions.

Health Promotion and Environmental Hazards

• Nutrition:     * Vitamin A: Maintenance of epithelial cells and wound healing. Deficiency causes dryness.     * Vitamin B Complex: Metabolic functions. Deficiency (B6/niacin) causes erythema and seborrhea.     * Vitamin C: Collagen formation. Deficiency causes scurvy (petechiae, bleeding gums).     * Vitamin D3: Produced via cutaneous photosynthesis; essential for bone health.     * Vitamin K: Synthesizes clotting factors.     * Protein: Essential for cell growth and wound healing.
• Obesity: Risk factor for poor wound healing, type 2 diabetes, and intertriginous infections (Candidiasis, Intertrigo, Erythrasma).
• Sun Exposure:     * UVA: Responsible for tanning and photoaging.     * UVB: Responsible for sunburn.     * SPF (Sun Protection Factor): Should be at least $15$ (filters $92\%$ of UVB). Reapply every $2\,hr$ and after swimming.

Skin Cancer Types and Manifestations

• Actinic Keratosis (AK): Premalignant skin lesions common in older whites. Flat or elevated, dry, hyperkeratotic scaly papules. Treated with cryosurgery, 5-FU, or chemical peels.
• Basal Cell Carcinoma (BCC): Most common and least deadly; locally invasive but rarely metastasizes. Appearance is a small papule with "pearly" borders and telangiectasia.
• Squamous Cell Carcinoma (SCC): Malignant neoplasm of keratinizing cells. Potential to metastasize. Risk factors include smoking (mouth/lips) and immunosuppression.
• Dysplastic Nevi (DN): Atypical moles $>5\,mm$ with irregular borders and multiple shades. Precursor to melanoma.
• Malignant Melanoma: Most deadly skin cancer; arises in melanocytes.     * ABCDE Rule: Asymmetry, Border irregularity, Color change, Diameter $>6\,mm$, Evolving appearance.     * Prognostic Factors: Tumor thickness is the most important.         * Breslow Measurement: Depth in millimeters.         * Clark Level: Depth of invasion (higher = deeper).

Infections and Infestations

• Bacterial:     * Folliculitis: Staphylococcal infection of hair follicles.     * Cellulitis: Deep inflammation of subcutaneous tissue (Staph/Strep). Symptoms: heat, erythema, edema, fever. In severe cases, treat with IV Vancomycin or Linezolid (Zyvox).
• Viral:     * Herpes Simplex (HSV) 1 & 2: Recurrent lifelong infections. Treated with Acyclovir (Zovirax).     * Herpes Zoster (Shingles): Activation of varicella-zoster virus. Linear distribution along a dermatome. Treated with antivirals and Gabapentin (Neurontin) for postherpetic neuralgia.

Pharmacological Treatments

• Acyclovir (Zovirax): Agent of choice for HSV/VZV. Adverse effects include phlebitis (IV), reversible nephrotoxicity, and neurotoxicity (delirium).
• Topical Glucocorticoids: Use to relieve itching/inflammation. Side effects include skin atrophy, striae, and adrenal suppression. Do not use occlusive bandages.
• Fluorouracil (5-FU): Cytotoxic for sun-damaged cells. Used for AK. Patient will look worse (redness, erosion) before they look better. Avoid sunlight.
• Acne Medications:     * Benzoyl Peroxide: Antibiotic and keratolytic.     * Tretinoin (Retin-A): Vitamin A derivative. Classified as a NIOSH hazardous drug; requires special handling.     * Isotretinoin (Accutane): For severe acne. Highly teratogenic. Requires iPLEDGE program registration. Monitor liver function and triglycerides.     * Spironolactone (Aldactone): Blocks androgen receptors in females to treat acne.
• Sunscreens:     * Organic (Chemical): Absorb UV radiation.     * Inorganic (Physical): Scatter UV radiation (Titanium oxide, Zinc oxide).