Integumentary

Integumentary Issues

Bacterial Infection: Impetigo

Types of Impetigo

  • Bullous Impetigo (think Blistery)

    • Forms bullae that rupture and crust.

    • Commonly found on trunk, face, buttocks, perineum, limbs.

  • Non-bullous Impetigo

    • Small vesicles develop into plaques with honey-crust.

    • Typically occurs around the nose and mouth.

  • Common causes: staph aureus, staph pyogenes, group A strep

  • It is an epidermal skin infection that spreads person to person. Age 2-6 is most common. Summer months

  • Self-limiting but topical abx speed healing & decrease spread.

    • Severe case or immunocompromised may require systemic oral rx

  • Risks: secondary infections from scratching & spread

Nursing Considerations/Education

  • Emphasize hand hygiene with antibacterial soap for all family members.

  • Avoid sharing personal items (towels, washcloths, toys).

  • Topical antibiotics: Remove honey crusts 1st with warm water and antibacterial soap. Contagious until 48 hrs on abx

  • Oral antibiotics: Complete the full course of meds! Strep incompletely treated can cause other issues. Not contagious once on abx for 24 hrs

  • In hospital: place on contact precautions.

Acne

Bacterial Process

  • Propionibacterium acnes: (gram positive)

    • Normally present on skin, can cause inflammation leading to acne.

    • Acne can also lead to secondary skin infections

    • Common sites: face, neck, back, trunk.

    • Self-limiting, not life-threatening but can lead to body image issues, depression, permanent skin pitting & scarring

    • Manifests as: blackheads, whiteheads, pustules, papules, nodules and/or cysts

Risk Factors

  • Genetic component, male gender, hormonal flares in females, cosmetics with lanolin or petroleum, exposure to cooking grease (fast food workers), high glycemic index foods, and dairy products

  • Treatment: gentle cleansing- avoid abrading skin. ~topical or oral medication~

Treatment Options

  • Topical Treatments

    • Tretinoin: Vitamin A derivative, anti-inflammatory, helps prevent acne. Irritating to skin. Avoid sun exposure or SPF

    • Benzoyl Peroxide: Kills acne-causing bacteria.

    • Topical Antibiotics: Monitor for allergic reactions and watch for photosensitivity. Using every other day helps lessen skin irritation

  • Oral Agents

    • Antibiotics: Tetracycline, doxycycline, erythromycin, minocycline.

      • Watch for allergies and photosensitivity/SPF

    • Oral contraceptives: Can help females by decreasing androgen levels (which cause acne)

      • Takes 4-5 months for efficacy

    • Isotretinoin: For cystic acne or unresponsive to other treatments.

      • Only dermatologist can prescribe

      • Teratogenic!! IPLEDGE form:

        • Females agree to 2 forms of contraception starting 1 month before until 1 month after final dose

      • Cannot donate blood until 30 days after final dose

      • Can cause depression or violent behavior- monthly monitoring

      • Can cause transient elevation in cholesterol & triglycerides

Viral: Human Papilloma Virus (HPV): Warts

  • Anywhere on skin

    • Single or in clusters

    • Elevated, rough, firm papules

  • Plantar- foot

    • Flatter with hyperkeratosis of sole of foot (hardened skin)

    • Once hyperkeratotic area removed, wart with black pinpoint areas present

Treatment

  • Individualized destructive treatments: Cryotherapy, laser, electrocautery, surgery, topical caustics.

  • Padding for painful plantar warts (with holes around wart help)

  • Competent immune systems can eventually heal infection. Above tx can “jump start” immune system ability to heal warts, wart clusters

HPV Vaccine- HPV related cancers, genital warts

  • Gardasil 9: (covers 9 HPV types) given at age 9-14 years. CDC has two dosing schedules depending on when series is started (2 or 3 doses)

  • 15-45 years (3 doses). Recommended before age 26 years but have expanded to people up to 45 years

  • Reason to give: Protects against HPV related cancers (cervical, penile, anal, mouth, throat) & genital warts (HPV 6&11)

  • Vaccine (o.5 mL IM) can cause fainting

    • Observe for 15 minutes after injection- any vax can cause a vasovagal fear response

Fungal Infection: Tinea (Ringworm)

  • Fungal pathogen- trichophytons, microsporums, epidermophytons

Types of Tinea

  • Tinea Capitus: Scalp, may cause hair loss around area

  • Tinea Corporis: Body.

  • Tinea Cruris: Thigh and scrotum (jock itch).

  • Tinea Pedis: Foot (athlete’s foot).

  • Highly transmissible through person-to-person contact, pool surfaces, showers, sports equipment, clothing, combs, moist soil

  • Trichophytons can come from pet cats. May need to treat pet as well- keep reinfecting owners

Tinea Treatment: Topical or oral

  • Tinea capitus: selenium sulfide shampoos, oral griseofulvin, oral ketoconazole

  • Tinea capitus, pedis or cruris: topical antifungals or oral griseofulvin, clotrimazole or ciclopirox

  • When dressing child/getting dressed: put socks on first if tinea pedis present~ lessens chance of spread to other parts of body

  • Treatment can take 2 weeks to 3 months depending on severity & immunity status

Pediculosis Capitus (Head Lice)

Overview

  • Most eggs (nits) found around the scalp, nape of neck, and ears.

  • Spread through direct contact or shared items.

Treatment Options

  • Treat with permethrin 1% shampoo (kills lice but not nits).

    • Combing out the nits with a fine-tooth metal comb (nitpicking!). Then repeat shampoo in 7 days.•

  • If lice resistance to permethrin, use malathion 0.5%

  • Wash bedding and clothes in hot water and detergent.

  • Use treatment shampoo on combs and brushes for 1 hour or boil for 10 minutes.•

  • Items which can’t be washed, seal in a plastic bag for 14 days to kill lice.

  • Non-chemical treatments:

    • Lice resistant to permethrin shampoos exist•

    • Tea tree oil and lavender oils

    • Olive oil and nit picking (can take a month)

    • Heated air treatments ($$) but kill both lice and eggs

Infestations Pediculosis Capitus

  • Spreads: Direct “head-to-head” or “hair-to-hair” contact w. infected person, objects (combs, brushes, hats), or bedding

  • Lice can live up for 48 hours w/o human host; live 1 month w/ host

  • Risks: Daycare, crowded conditions, schools, sharing combs, brushes, hats. ~ Developmental: dress-up, sharing masks, hats, crowns, bows

  • Appearance: lice are small, gray/tan, no wings. Nits look like dandruff on hair shaft BUT firmly attached (won’t flake off)

  • Symptoms: itchy!!

Prevention and Management

  • Wash bedding and clothes in hot water, seal non-washable items in plastic bags.

Lyme Disease

Overview

  • Nearly 476,000 cases/year in the U.S. CDC: 30,000

  • Caused by Borrelia burgdorferi bacteria spread by ticks. (deer & mice)

  • Vaccine: not currently avail- phase 3 trials

    • Vaccine works by introducing antibody formation, so if a human is bitten by a tick, when it drinks our blood, the antibodies neutralize the bacteria in the tick so it can’t transmit it

  • Highest incidence in 5-9 year-old age group and those outdoors in wooded areas frequently.•

  • Tick needs to be attached for 36-48 hours for infection to transmit.•

  • Incubation up to 32 days after an infected tick bite… symptoms can appear a month later

  • It is not contagious human to human but is considered a communicable disease with the TICK being the VECTOR from animal to human.

  • Often: Bull’s eye rash

    • Erythema migrans

Not always a perfect bull’s eye*

Where ticks like to hang out ~ will fall off themselves when full

Stages of Lyme Disease- 3

  • Localized Disease: (LD)

    • Erythema migrans (bull's eye rash)- painless annular (ring shaped) red rash (70-80% of cases)

    • Fever, chills, flu-like symptoms, swollen lymph nodes

  • Early Disseminated Disease: (EDD)

    • Multiple smaller erythema migrans

    • Generalized lymphadenopathy

    • Fatigue

    • Meningitis

    • Facial nerve palsy

    • Joint pain

    • Carditis

  • Late Disseminated Disease: (LDD) (2-12 months)

  • Lyme arthritis

    • large joints~ knee; most common in kids

  • carditis

  • encephalitis

  • meningitis

Treatment Options

  • Localized: 10-21 days of antibiotics~ amoxicillin, cefuroxime, or doxycycline

  • Early Disseminated Disease: 21-28 days of antibiotics

  • Late Disseminated Disease: up to 28 days of antibiotics

**IV antibiotics may be used for persistent arthritis, carditis, meningitis, encephalitis

Nursing Considerations

  • Teach: Full body check for ticks after outings in woods/tick areas (people & pets)•

  • Teach parents how to remove ticks–

    • Grasp tick firmly with tweezers where mouth is attached to skin and pull gently until the tick releases, then cleanse with soap and water– Do not burn ticks off!

    • Educate parents on completing antibiotics: adherence to full regimen is an issue!

    • Avoid sun exposure with doxycycline

    • Promote rest

Pediatric Skin Assessment Instruments

  • Braden-Q:

  • Braden Q-D

    • Assess risk for pressure injuries

    • Address risks associated with medical devices.

    • Use tubing ties to the top of the crib to alleviate pressure

  • Risk for pressure injuries from medical devices must be addressed