Skin Disorders Guide

INTEGUMENTARY DISORDERS
By Habtamu A.(RN, BSc, MSc in Adult
Health Nursing, PhD student)
HA(MSN) 1

Anatomy of the skin
• The skin consists of 3 layers:
–Epidermis- non vascular outermost layer,
continuously dividing cells
–Dermis- takes the largest portion of the skin
and provides strength and structure. It
consists of glands (sebaceous, sweat), hair
follicle, blood vessels, and nerve endings
–Subcutaneous tissue (hypodermis)- the
inner most layer. contains major vascular
networks, fat, nerves, and lymphatics
HA(MSN) 2

Function of the skin
• Protection- protection of underlying structures from
invasion by bacteria, noxious chemicals and foreign
matter.
• Sensory perception- transmits pain, touch, pressure,
temperature, itching, etc
• Fluid balance (excretion)- absorption of fluids and
evaporation of excess.
• Temperature regulation- produced heat released
through skin by radiation, conduction, and convection
• Vitamin synthesis- skin exposed to ultra violet light
can convert substances necessary for synthesizing
vitamin D3 (cholecalciferol).
• Aesthetic- provides beautiness and appearance
HA(MSN) 5

Factors influencing skin integrity
• Immoblity is the major factor leading to
pressure sore development .
• The pt who is confined to bed & unable to
change position is at greatest risk .
• Trauma most likely occur
– over the prominent areas
– weight bearing areas
HA(MSN) 6

• Prolonged pressure impairs blood flow to
tissue & resulfs in ischemia & inferction
• The extent of pressure necessary to cause
tisue damage depnds on the tolerance of the
pt's skin & supporting stuctures .
HA(MSN) 7

• Tolerance to pressurs trauma is influenced by
the following factors:
– Duration of pressure
– Magnitude of pressure
– Body position
– Friction
– Impaired moblity
– Malnutrition
– Dehy dration
HA(MSN) 8

COMMON DERMATOLOGIC TERMS
• Lichenification: distinictive thickening of skin
• Crust: dried exudate of body fliuds
• Erusion: epithelial deficiet
• Ulcer: epithelial deficiet (disruption of deep
skin integrity)
• Atrophy: an acquired loss of substance
• Scar:change in the skin secondery to trumas
or inflammation
HA(MSN) 9

Description of skin lesion
(primary lession)
I. circumscribed , flat , nonpalpable changes in
skin color
• Macule = small upto 1 cm, eg. petechia
• Patch = larger than 1 cm , eg vitilligo
HA(MSN) 10

Description of skin lesion...
II. Palpable elevated solid masses
– Papule: up to 0.5cm eg. elevated nevus
– Plaque: elevated surface > 0.5 cm
– Nodule: deeper & firmer than papule
=> 0.5 -1-2cm eg tumor
– Wheal: irregular, superficial area of localized
skin edema
HA(MSN) 11

Description of skin lesion...
III. Superficial elevation of skin formed by free
fluid in a cavity in the skin layer.
• Vesicle: up to 0.5 cm
=> filled c serous fluid,eg herps simplex
• Bulla: > 0.5 cm, Filled of serous fluid, eg 2nd
degree burn ( blister)
• Pustule: filled pus, eg impetiao, acne
HA(MSN) 12

Secondery lesion
IV. Loss of skin surface
• Erusion => loss of superficial epidermis
• Ulcer => deep loss of skin surface
=> May bleed & scar, eg. sphilic chancre
• Fissure => linear creak in the skin
eg.A thlet's foot
HA(MSN) 13

Secondery lesion....
On skin surface:
• curst = dried residue of serum ,pus or blood,
eg Impetigo
• Scale = a thin flake of exfoliative epiderms
eg.dandruff, Dry skin, Psoriasis
HA(MSN) 14

Vascular skin lesions
• a lesion that originated from a blood vessel
– Petechia/Purpura
– Ecchymosis
– venous star
HA(MSN) 15

Skin lesion configuration
• Linear- in line
• Annular and arciform –circular or arcing
• Zosteriform- linear along a nerve route.
• Grouped -clustered lesion
• Discrete -separate and distinict
• Confluent- lesions that run together or join
• Generalized- widespread eruption
• Localized- lesions on distinct area
HA(MSN) 16

Assessing the skin
• Assessment includes a thorough
- history taking,
-inspection and
-palpation of the skin.
HA(MSN) 17

Herpes vircilla virus
HA(MSN) 20

Adverse effect of topical corticosteriods
HA(MSN) 23

Assessing the general appearance of
the skin
• The general appearance of the skin is
assessed by observing (Inspection) color,
skin lesions, and vascularity.
• On palpation skin turgor and mobility,
possible edema, temperature, moisture,
dryness, oiliness, tenderness, and skin
texture (rough and smooth).
HA(MSN) 25

Color change: can be hyperpigmentation,
hypopigmentation or depigmentation
1. Redness- fever, alcohol intake, local
inflammation due to increased blood flow to
the skin.
2. Bluish color (cyanosis) - decreased oxygen
supply due to chronic heart and lung disease,
exposure to cold, and anxiety
HA(MSN) 26

Cont’ed…
3. Yellowish color (jaundice) - increased serum bilirubin
concentration due to liver disease or red blood cell
haemolysis
- Uremia- renal failure
4. Brown-tan- Addison’s disease: cortisol deficiency
stimulates increased melanin production
- Birth mark, chloasma of pregnancy (face patches), and
sun exposure
5. Pale: Albunism- total absence of pigment melanin
• Vitiligo- destruction of the melanocytes in
circumscribed areas of the skin
HA(MSN) 27

Benign skin condition-vitiligo
HA(MSN) 28

Diagnostics test
• Skin biopsy: removal of a piece of skin by
shave, punch, or excision technique for a
microscopic study of the skin to determine the
histology of cells to rule out malignancy and to
establish an exact diagnosis.
• Patch testing: performed to identify
substances to which the patient has developed
an allergy.
• Potassium hydroxide test (KOH): helps to
identify fungal skin infection
HA(MSN) 33

Diagnostics test…
• Gram stain and culture with sensitivity test:
helps to identify the organism responsible for
an underlying infection with the effective drug
identification
• Slit Skin Smear (SSS): to identify the
causative agent of leprosy (mycobacterium
leprea)
HA(MSN) 34

Disorder of the skin
I . Inflammatory and allargic skin disorders
– Acne
– Psoriasis
– Atopic dermatitis (eczema)
– Contact dermatitis
II. Bacterial infections
– Impetigo
– Boil (furuncle)
– Carbancle
– Cellilitis
HA(MSN) 35

Disorder of the skin…
III. fungal infections
– Candidiasis
– Tinea captis
– Tinea corporis
– Tinea pedis (atlet's foot)
HA(MSN) 36

Disorder of the skin…
IV. Viral infections
– Herpes simplex (cold - sore)
– Herpes zoster (shingles)
– Warts
HA(MSN) 37

Inflammatory and allergic condition
A. Eczema/Dermatitis
- It is a chronic pruritic inflammatory disorder
affecting the epidermis, and dermis
commencing in infancy, often persisting
throughout child hood but eventually remitting
and some times recurring in adult life.
• They are a non-infectious inflammation of the
skin and it can be acute, sub-acute or chronic.
HA(MSN) 38

Con’ted….
• Causes
– The exact cause is unknown
– Imbalance of the immune system with an increase
in the immunoglobulin “E” activity and deficient
of cell mediated delayed hypersensitivity.
• Can be exacerbated by infection, bites, pollen,
wool, silk, fur, ointments, detergents,
perfume, certain foods, temperature
extremes, humidity, sweating and stress
HA(MSN) 40

Hypersensitivity reactions
HA(MSN) 41

Sign and symptom
• An acute stage eczema shows redness,
swelling, papules, blisters, oozing and crusts.
• In the sub-acute stage the skin is still red but
becomes drier and scalier and may show
pigment change.
• In the chronic stage
-lichenification,
-excoriation,
-scaling and cracks are seen
HA(MSN) 42

Types of eczema
Atopic eczema
- is a chronic relapsing skin disorder that usually
begins in infancy and is characterized principally
by dry skin and pruritis, consequent rubbing and
scratching lead to lichenification
• This patient has a genetic predisposition for
hypersensitivity reactions such as asthma, allergic
rhinitis, and chronic urticaria.
– The eczema comes and goes
– The eczema triggered by dryness of the skin,
infections, heat, sweating, contact with allergens or
irritants and emotional stress.
HA(MSN) 43

Atopic eczema…
• Mostly affected sites are elbow and knee
folds, wrists, ankles, face, and neck; in some
cases it can be generalized
HA(MSN) 44

Seborrhoic eczema
- is a very common chronic dermatitis
characterized by redness and scaling that
occurs in regions where the sebaceous
glands are most active, such as:
–Scalp, border of forehead/scalp
–Behind ears, above and in between
eyebrows
–In nasolabial folds, Sternum
–In between the shoulder blades, in axillae
–Groin , Perianal area
HA(MSN) 47

Seborrhoic eczema…
–Under the breast , umbilicus and in body
folds
–Pts often complains of oily skin
–The eczema comes and goes
–In HIV patients, the eczema can become very
widespread and easily super infected
HA(MSN) 48

Infective eczema
• which occurs as a response to an oozing skin
infection.
• Common sites are the foot, and ankle region
• Causative organisms are usually staphylococci/
streptococci
• Vaseline use aggravates this condition
HA(MSN) 49

Contact eczema:
• is caused by contact of the skin with an
irritant or an allergen.
• Vaseline commonly causes: Vaseline
dermatitis.
• Common causes of irritant contact eczema on
hands, arms and legs are excessive use of H2O,
soap (especially if not washed off properly)
detergents, chemicals, sunlight, jewellery,
dyes, bleaches, perfume, nail polish/remover,
etc
HA(MSN) 50

Sign and symptom of eczema/
dermatitis
(general)
• Itching
• Redness, dry skin, lichenification, excoriation,
scaling skin
• Papules, blisters, oozing and crusts
• Color change
HA(MSN) 52

Management (general)
• Stop the use of irritants (contact eczema)
• Mild topical steroid such as hydrocortisone 1%
cream twice daily until lesions clear.
• In severe itching use antihistamines
E.g.: promethazine 25mg at night,
chlorphenaramine 4mg at day time/night
HA(MSN) 53

Mgt cont…
• In bacterial super infection use KMNO4
solution, Betadine solution, antibiotics
• Explain to the Patient, and Parents that not
serious and will disappear in time.
• Keep finger nails short and covered at night
• Use non greasy or non moisturizers
(seborrhoic eczema)
HA(MSN) 54

Mgt cont…
• An imidazole cream twice daily/ketaconazole
200 mg/d 1-3 weeks (seborrhoic eczema)
• The vicious circle of itch – scratch –
lichenification – itch needs to be broken , (atopic
eczema)- conscious effort to stop scratching
• In photo allergies – sun protection by wide rim
sun hat, long sleeves, high collar, sunglasses, stay
indoor, sunscreen, umbrella, etc
• Keep the site clean
HA(MSN) 55

Acne
- Is a common disorder of the sebaceous gland
associated with excess production of sebum
and blockage of the duct resulting in a
variety of inflammatory manifestations.
• Common in puberty and usually regresses in
early adult hood
• Patient complain of oiliness of the skin.
- Occurs on the face, upper trunk and
shoulders
- Appears to be multiple inflammatory papules,
pustules and nodules
HA(MSN) 56

Acne…
• It can be very mild to be very severe: - they
blend together to form large inflammatory
areas with cysts and scar formation.
Cause-genetic, hormone and bacteria play a role
HA(MSN) 57

Cont..
Sign and symptom
• Red nodules, cyst , red papules, scars,
pustules, keloids
• There may be mild soreness, pain or itching
• Inflammatory papules, pustules, pores acne cyst,
scarring
Diagnosis
• Clinical
– Cyst formation, slow resolution, scarring
– Common at puberty and common of all skin conditions
HA(MSN) 59

Management
• Stop the use of vaseline, oil, ointment, greasy
cosmetics which further blocks sebaceous
ducts.
• Benzoyl per oxide 5-10% gel or tretinoin 0.01-
0.1% cream or gel apply at night.
• Salicylic acid 1-10% in alcoholic solution for
removal of excess sebum.
• For pustular/inflammatory lesions use topical
clindamycin 1% solution, erythromycin 2%
lotion
HA(MSN) 60

Management …
• In severe cases use systemic long term
antibiotics like doxycycline 100mg twice daily
until substantial improvement followed by
100mg once daily until acceptable.
• Surgical treatment – extraction of comedones,
incision and drainage of large fluctuant,
nodulocystic lesions
HA(MSN) 61

Psoriasis
• Is a chronic recurrent, hereditary, non infectious
disease of the skin caused by abnormally fast
turn over of the epidermis
• The turn over may be up to 40 times than
normal and as a result the epidermis is not able
to develop normally, therefore it doesn’t allow
formation of the normal protective layer of the
skin.
HA(MSN) 62

Psoriasis…
• Skin become red, inflamed, and the scales are
thicker than normal
• It produces a so called candle-wax
phenomenon, when you scratch such a patch it
becomes silvery white.
• Sites can be extensor areas of extremities
especially elbow, knees, buttocks, shoulder and
scalp
HA(MSN) 63

Generalized psoriasis
HA(MSN) 65

• Cure is there but it reoccurs
• Occurs at any age but 10-35 years is common
mostly.
• Periods of emotional stress and anxiety
aggravate the condition.
Sign and symptom.
• May itch severely in body folds covered with
silvery scales
• Finger and toenails may show pitting and
thickening
• Associated arthritis
HA(MSN) 67

Management
• Explain to the Pt the recurrent nature of the
disease.
• Salicylic acid 2-10% ointment twice daily to
reduce scaling
• Moisturizers (Vaseline, paraffin oil, or cream)
• Treat any super infection with KMNO4 , or
antibiotics if necessary
• Psoriatic arthritis NSAIDS E.g.: Ibuprofen,
Indomethacin, and ASA
• Methotrexates as a last option in sever cases.
HA(MSN) 68

Infection of the skin
1. Cellulitis
• Is a diffuse, acute streptococcal or staphylococcal
infection of the skin and subcutaneous tissue
Cause
• Caused by bacteria’s like streptococcus/staphylococcus
aureus
• Results from break in skin
• Infection rapidly spread through lymphatic system
Sign and symptom
• Tender, red, hot, indurated and swollen area that is well
demarcated
• Possible fluctuant abscess or purulent drainage
• Fever, chills, and malaise
HA(MSN) 69

HA(MSN) 70
Features:
Red
Swollen
Warm to touch
No areas of
pus
Painful
Tender

HA(MSN) 75
The result of “skin popping” -
Multiple injection site abscesses

HA(MSN) 76
Cellulitis with abscess
If rapid spreading beyond this line occurs, this may be
necrotizing , and requires surgery

HA(MSN) 77
Necrotizing fasciitis

Management
• Oral antibiotics
• Parentral/systemic antibiotics for hands, face,
or lymphatic spread
• Surgical drainage and debridement
HA(MSN) 80

2. Furunclosis
• Is an acute painful infection of perifollicular
abscess (boils)
• Is an acute, localized, deep seated, red, hot,
very tender, inflammatory perifollicular abscess.
• Common microorganism: staphylococcus
aureus
• Most common on persons who are carriers of
staphylococcus, contact with oils or grease,
diabetes, poor habits of personal hygiene,
immunosuppression, alcoholism, obese,
malnutrited, etc HA(MSN) 81

Furunclosis…
• The lesion begins in the opening of hair
follicle or sebaceous gland
• Sites can be back of the neck, face, buttocks,
thighs, perineum, breasts, axilla, nose,
genitallia, etc
HA(MSN) 82

Sign and symptom
• Hard nodule initially then fluctuant abscess
with centrally yellow pustule, then ruptures in
to an ulcer.
• It can be isolated single lesion or few multiple
lesion
• Hotness and pain at the site.
Diagnosis
• Gram stain of the pus
• Culture and sensitivity test of blood/pus
HA(MSN) 84

Cont..
Treatment
• Warm compresses -
• Warn patient not to squeeze or incise the
lesion
• Incision and drainage when it is fluctuance.
• Systemic antibiotics (cloxacillin, erythromycin)
• Rest especially for genital areas.
• For the sever pain codien, morphine
HA(MSN) 85

3. Carbuncles
(multiple furuncles)
- Is an aggregation of interconnected furuncles
that drain through multiple openings in the
skin.
• Exposure to grease and oil increase the risk.
• Occurs mostly where the skin is thick
• Microorganism mostly: staph. aureus
Sign and symptom
• Sites are back of the neck, shoulder, buttock,
outer aspect of the thigh and over the hip
joints. HA(MSN) 86

Carbuncles ….
• Develop slowly than furuncle
• They can reach the size of an egg/small
orange.
• Fever, chills, extreme pain, malaise.
• Because of the large size of the lesion and its
delayed drainage the patient is much sicker
HA(MSN) 87

Cont…
Diagnosis
• Gramstain of the pus
• Culture of pus/blood
• Leucocytosis (12,000-20,000 mm3) normal
4,000-10,000mm3
Treatment
• The same as furuncle, plus
• Avoid friction and irritation from tight clothing.
HA(MSN) 89

4. Folliculitis
• Is inflammation of the hair follicle
Sign and symptom
– Single or multiple papules or pustules
– Commonly seen in the beard area of men and
women’s legs from shaving
Management
• Warm compress to relieve pain
• Clean with antibacterial soap
• Topical antibiotic ointment
• Systemic antibiotics for recurrent cases
HA(MSN) 90

5. Impetigo
• Is an acute, contagious, rapidly spreading
cutaneous infection and is a very common
bacterial infection of the superficial skin
• Causative agents are stap. aureus or a B-hemolytic
streptococcus or both
Sign and Symptom
• Superficial pustules or blisters which becomes
oozing with yellow crusts
• Contagious
• Blisters break easily and form golden crusts
Diagnosis
-Clinical
- Culture and sensitivityHA(MSN) 92

Management
• KMNO4 bath or wet dressing-in mild forms
• Prevent spreading by not sharing towels and
ointment, change clothes, towels and sheets
frequently.
• In sever forms give cloxacillin 250-500mg QID daily
for 7-10 days in adults, and 50-100mg/kg/24 hours
divided in to 4 doses for children.
• Erythromycin 250-500mg 4 times daily for 7-10
days in adults, and 25-50mg/kg/24hrs divided in to
4 doses for children
• Cut finger nails short to minimize damage to lesion
and to prevent autoinoculation from scratching
HA(MSN) 95

Fungal skin disorder
1. Dermatophytoses (Mycoses)
• Is a fungal infection of the skin, hair and nails
Types
a. Tinea pedis (Athlete’s foot)
• Is itchy, whitish scaling lesions and inflammation
of the superficial skin of the feet and interdigital
spaces of the toes
• Common between the 4th and 5th toe.
• Often seen in people wearing rubber
boots/shoes
HA(MSN) 96

Cont..
Management
• Keep the space in between the toes dry
• wear cotton socks
• Avoid shoe that are too tight/hot
• changing socks daily prevents reinfection.
• Imidazole cream/ whitfield’s ointment twice daily
until symptoms disappear for a total of 4 weeks
• Treat secondary bacterial infection if present
HA(MSN) 98

b. Tinea corporis (Tinea circinata)
• A fungal infection that affects the trunk, legs,
arms/neck, excluding the beard area, feet,
hands and groin
– Is fungal infection of the skin most common on the
exposed surfaces of the body.
– Sites are face, arms and shoulders.
– Intensive itching is there
• Frequent causes of tinea corporis is the
prescence of an infected pet in the home
HA(MSN) 99

Cont..
Management
• Imidazole cream/whitfield’s ointment twice daily
for aminimum of 4 weeks
• Multiple, widespread lesions may be treated
systematically
• Griseofulvin 500mg once daily for 2-6wks (10-
15mg/kg)
• Ketaconazole 200mg once/twice daily
• When there is sever itching antihistamines /mild
steroids can be added
HA(MSN) 100

c. Tinea capitis (ring worm)
• Is a contagious fungal disease of the scalp and
hair shaft
Sign and symptom
• One or more round patches with scaling
• Hair loss (temporarly), alopecia
• Lymphnodes in the neck swell and the patient
may have fever and headache
Diagnosis
– Clinical
– Microscopy of affected hairs and skin(KOH)
HA(MSN) 102

Cont..
Management
• Greseofulvin 500mg once daily for 8-12 weeks.
(10-15mg/kg for children)
• Add whitfield’s ointment/miconazole twice daily
topically for 4 weeks
• In case of bacterial super infection antiseptics and
/antibiotics are needed
HA(MSN) 104

d. Tinea unguium
- Is a chronic fungal and some times mixed
yeast infection of the toe/finger nails
• Is commonly occurs in people who frequently
wet the hands such as domestic workers,
cleaners, kitchen and laundary staff
Sign and Symptom
• Nail become thickened, friable (easily
crumbled), lusterless
• Accumulation of debris under the free edge of
the nail
• The nail may be destroyed
HA(MSN) 105

Cont..
Management
• Griseofulvin 500gm once daily until the
affected nails have grown out completely
(year/longer) even though it recurres.
• If there is no improvement by griseofulvin in
2-4 months mixed yeast infection
- use ketaconazole 200mg/d until symptoms
clear. (Itraconazole 200mg/d x 3 months, or
Itraconazole 200mg bid x 1week per month
during 3 months)
• Keep the site dry
HA(MSN) 107

e. Tinea versicolor (pityriasis
versicolor)
• Is a common chronic superficial fungal
infection which is caused by the unicellular
yeast pityrosporum ovale or orbiculare which
is normally present on the trunk as a
commensal.
• Often there is cosmetic complaints
HA(MSN) 108

Cont..
Sign and Symptom
• Appears commonly when there is warm and humid
air, pregnancy, and serious underlying disease
• Hypopigmented macule on the trunk
• Disturbance of the pigment of the skin (versicolor)
• Recurrences are common especially after in
adequate treatment or re-infection.
Diagnose
– Clinical
– Microscopy
HA(MSN) 110

Cont…
Management
• Scrubbing the skin with a brush takes away a lot
of the infected scales.
• Imidazole cream twice daily on affected areas for
4 weeks.
• Add selenium sulphide suspension /ketaconazole
2% shampoo twice weekly.
• Selsun shampoo to affected areas overnights as a
lotion or to affected areas and the scalp for 10
minutes daily for 2-4 weeks.
HA(MSN) 111

f. Tinea cruris (Jack itch)
• A fungal infection of the groin, pubic region and thighs
Sign and symptom
• Scaling at the periphery
• A patch that may spread to buttocks
• Starts from groin and advancing down to inner thigh
• Itching and irritation
Diagnosis
• Clinical,KOH
Management
• Treat with topical antifungal or systemic antifungal for
sever cases
• Reduction of moisture in groin
• Wash contaminated under wear in hot water
HA(MSN) 112

g. Tinea barbae
• Is a fungal infection involving the beard
• Affects males only
• More common in farmers
Sign and symptom
• Pruritis
• Tenderness and pain
• Pustular folliculitis around the hair follicle
• Involved hairs are loose and easily removed
Management:Systemic antifungal
HA(MSN) 113

h. Candidiasis /moniliasis/
• Candida albicans is a resident of the mucus
membranes, it becomes pathogenic under
favourable host condition these are:
– When host immunity is decreased, such as HIV,
cancer, steroid use, cytotoxic drugs, radiotherapy,
chronic disease, pregnancy and contraceptive pill use
– Warm and moisture (groins, under breasts, b/n toes)
– Use of broad spectrum antibiotics which kills resident
non pathogenic bacteria
HA(MSN) 115

Sign and Symptom
• On the oral (oral candidiasis/thrush)- white
cheesy adherent plaque that can be painful
• When oral lesions extend to the throat and
esophagus they can cause anorexia, nausea,
dysphagia, and vomiting
• On the vulvovagina (candidia vulvovaginitis)-
vaginal irritation, soreness and a thick creamy
discharge
HA(MSN) 117

Management
• Keep lesions of the skin dry
• Paint mucosal /smaller wet lesions with
Gentian violet daily
• Nystatin cream, oral suspension twice daily for
skin/ oral / miconazol oral gel 4 x /d x 1week
• Imidazole pessaries nightly for 2 weeks for
vaginal candldiasis
• Imidazole cream twice daily for skin infections
• Ketaconazole 200mg twice daily for 1-2weeks
for oesophageal candidiasis
• Itraconazole 100mg/d x 2weeks
• Fluconazole 50-200mg /d x 1-2weeks
HA(MSN) 118

Parasitic skin disorder
a. Scabies
• Is an infection of the skin caused by a parasite
called mite sarcoptes scabiei, a mite which lays its
eggs in burrow in the stratum and induces an
intensively itchy allergic response
Sign and Symptom
• Small blisters and papules
• Sever itching, when warm particularly at night
• Scratch marks and very common secondary
infection with pustules
• Common sites are between fingers, sides of the
hands, sides of the wrists, buttocks
HA(MSN) 119

Cont…
Management
• Treat all close contacts of the patient and
family
• Benzyl benzoate 25% emulsion for adult,
dilute with one part water (1:1) for children,
dilute with 3 parts water (1:3) for infants.
Apply for 3 consecutive nights. Wash off each
morning.
• Sulphur 5-20% ointment twice daily for 1-2
Weeks
HA(MSN) 121

b. Pediculosis
• Is an infestation with a louse which may be found
in the:
• Scalp- Pediculosis capitis
• Body- Pediculosis corporis
• Hair bearing region- Pediculosis pubis (phthiriasis)
Sign and symptom
• Itching (excoriation)
• The presence of lice and nits
• Over crowding, poor personal hygiene, prolonged
wearing of the same cloth
HA(MSN) 122

Cont..
Management
• Improve personal hygiene
• Improve living condition
• Change clothing
• Treat secondary bacterial infection if present
HA(MSN) 124

F. Viral skin disorder
• It is an acute contagious short lived (7-12 days)
infection of the skin or mucus membrane
caused by virus
Types:
a. Herpes simplex
• Is an infection which is caused by herpes
simplex virus that causes vesicular eruption
(cold sore or fever blister) on lip (herpes
labialis), and on genitalia (herpes genitalia)
HA(MSN) 125

Cont….
Sign and Symptom
- Few days of burning sensation at the site
initially and tingling sensation
- Then a group of blisters appear which
quickly break down to form superficial ulcer
- Highly contagious when the lesions are
visible
Diagnose
• Clinical
• smear HA(MSN) 128

Cont…
Management
• Primary infection-since they are painful:
Analgesia
• Lips: Zinc oxide ointment to soothe and
protect from sun light
• Zinc oxide ointment plus castor oil
• Antiseptic mouth wash: Chlorhexidine 3-4
times daily
HA(MSN) 129

Cont….
• TTC skin ointment 3 times daily for secondary
bacterial infection
• Genital: KmNo4 (Betadine) sitz bath 3 times a day
• TTC ointment application 3 times a day
• Zinc oxide and castor oil to soothe
• For severe infections or infections in
immunocompromised patients Acyclovir 200-400
mg five times daily for 5-10 days either topically or
systematically
• Recurrence can be triggered by:
- Exposure to sun light (herpes labialis)
-Oral sex, fever, stress, etc
HA(MSN) 130

b. Herpes zoster (shingles)
• Is an acute unilateral and segmental
inflammation of the dorsal root ganglia of a
nerve by a latent varicella zoster infection in
the partially immune host.
Sign and symptom
• A localized vesicles in cluster form on one side
of the body/unilateral/
• Itching, tenderness and severe pain on the
site
**The thoracic, cervical and ophthalmic nerves
are frequently affected
HA(MSN) 131

b. Herpes zoster…
• After 1-2 weeks crusts begin to fall off with
residual scaring
• Over 10% of patients develop a persistent
burning sensation
• Much more common in HIV patients, old
patients, and malignancy cases
HA(MSN) 132

Management
• Analgesia with NSAIDs
• Antibiotics for secondary infections
• If the eye is involved immediately refer to
ophthalmologist
• For immunocompromised patients
Acyclovir 800mg 5 times daily for 1 week
• Amitryptline 75mg at night
• Night/Carbamazepine 600-800mg/day
HA(MSN) 134

c. Verrucae /Warts/
• Are common benign skin tumors caused by infection
with the Human Papilloma Virus.
Types:
1. Plantar warts- warts on the sole of the foot
2. Plane (flat/Juvenile) warts- warts on the face of
children
3. Genital warts/condylomata acuminate/- warts that
appear on genital organs
4. Molluscum contagiosum- a wart which appear on
small children which has typical characteristics of
central dimple and dome shaped papules
HA(MSN) 135

Sign and symptom
• Found at any age but most common in children and
teenagers
• They can spread by contact
• The infected person immune system clears the warts
with in 2 years in 2/3 cases
Management
• Freeze with liquid nitrogen- Molluscum contagiosum
• Salicylic acid 50% twice daily followed by scraping the
warts –Plantar warts
• Salicylic acid 2-5% ointement twice daily for 4-8 weeks –
Plane warts
• Silver nitrate pencil touch- daily - Plane warts
• Podophyllin 10-25% solution apply weekly by using
match sticks and wash off after 4-6 hours- Genital warts
• Threat partners - Genital warts
HA(MSN) 138

G. Skin cancer
• Cancer is a disease of the cell in which the
normal mechanism of control of growth and
proliferation are disturbed. The malignant cell is
able to invade the surrounding tissue and
regional lymph nodes.
• Metastasis is the secondary growth of the
primary cancer in another organ.
• Skin assessment-20-39 age-every 3 years
• >40 age-annually
HA(MSN) 139

Plastic surgery (Cosmetic surgery)
• Are a type of reconstructive surgery
performed to reconstruct or to alter
congenital or acquired defects or to
restore or improve the body’s appearance
HA(MSN) 140

Purpose of plastic surgery
–To repair defect (reconstruction)
–To restore function (restoration)
–To replace lost part
– For better appearance
–To install prosthetic implants
– For complete change of identity
HA(MSN) 141

Possible complications of plastic
surgery
• Pigment change- chemical peeling
• Infection-surgery
• Milia- chemical peeling
• Scarring- surgery
• Atrophy- surgery
• Sensitivity change- chemical peeling
• Long term (4 to 5 months) erythema or pruritis-
chemical peeling
• Hematoma- surgery
HA(MSN) 142

Skin graft
• Is the technique in which a section of skin is
detached from its own blood supply from the
donor site and transferred as free tissue to a
distant (recipient)
Purpose
• To enhance wound healing
• To repair defects
• To cover wounds in which insufficient skin is
available
• To improve appearance
HA(MSN) 143

Sources of skin graft can be:
• Autograft- use of tissue from self
• Allograft- use of tissue from the same species
• Xenograft- use of tissue from different species
• Isograft- use of tissue from genetically
identical persons
• Engineered- graft sources from combined
biological and synthetic materials
• Synthetic graft- substance from non-biological
source
HA(MSN) 144

Pathophysiology of burn
• Tissue destruction results from:
- coagulation
- protein denaturation, or
-ionization of cellular contents.
• Disruption of the skin can lead to:
- increased fluid loss,
-infection, hypothermia, scarring,
-compromised immunity, and
-changes in function, appearance, and body image.
• The depth of the injury depends on:
- the temperature of the burning agent and
-the duration of contact with the agent.
HA(MSN) 147

Assessment of burn injury depends on:
1. cause and temperature of the burning
agent.
2. location
3. duration of contact with the agent
HA(MSN) 148

Classification of burn
• Burn injuries are described according to:
- the depth of the injury,
-extent of body surface area injured,
-location and age..
A. By depth
1. First degree burn (superficial burn)
• epidermis is involved
• Redness and pain on the area
• Healing takes place rapidly within a week.
HA(MSN) 149

CONT…
2. Second degree burn (partial thickness burn)
• epidermis and part of the dermis
• Blister formation, pain, moist, mottled
appearance of skin, and swelling.
• Hair follicles and sebaceous glands may be
partly destroyed.
• Superimposed infection can interfere with
healing
• Small burns (1-2% BSA) of this type can be
treated through self care
HA(MSN) 151

Deep partial thickness
HA(MSN) 153

Cont’d..
• infection by gram +ve bacteria
(staphylococcus, streptococcus) occurs during
the first day.
• After the third day, gram –ve bacteria (mainly
pseudomonas) predominate and can convert a
second degree burn to third degree.
• Topical therapy with silver sulfadiazines,
silver nitrate or antibiotics is essential
HA(MSN) 155

3. Third degree burn (full thickness burn)
• The skin, with all of its epithelial structures, hair
follicle, sebaceous gland and subcutaneous
tissue destroyed.
• Dry, pale white, leathery, or charred, broken
skin with fat exposed is seen.
• Symptoms of shock and haematuria can be
present.
• Scarring and loss of function is inevitable.
• Needs skin graft for healing
HA(MSN) 156

Fourth degree burn (as char burn)
• May damage bones, tendons, muscles, blood
vessels and peripheral nerves.
• Necrosis of muscles and bones can happen.
*The following factors are considered in
determining the depth of burn:
– How the injury occurred
– Causative agent
– Temperature of the burning agent
– Duration of contact with the agent
– Thickness of the skin
HA(MSN) 159

RXs
1. Superficial burn treatment
• Skin is intact so there is a low chance of
infection.
• Topical “exudates” as physical protection can be
used.
• Dressings or films that are self adhesive, water
proof and semi-permeable.
• Skin protectants
• Cold compresses, external anesthetics, topical
corticosteroids and oral pain relievers.
HA(MSN) 161

2. Superficial partial thickness burn
• Unbroken skin
Do not disturb blisters!!! They are protective
of the skin below the blister.
• If broken/debrided: May become infected so
cleanse 1-2x’s/day to remove dead skin. Do not
pull on skin!
• Cleanse with bland soaps or surfactants and
water 1-2xs/day
• First aid antiseptics or antibiotics sufficient
• Dressing and skin protectant should be used
HA(MSN) 162

B. By extent
• TBSA
-Rule of nine,
- Lund and Browder method, and
- Palm method.
1. Estimate of body surface area using rule of nine
• It assigns percentages in multiples of nine to
major body surfaces
• It is the most common, simple, and quick method
HA(MSN) 163

Adult Infant (child)
• Head 9% 18%
• Abdomen and Thorax
- Front 18% 18%
- Back 18% 18%
• Genitalia 1% -
• Hands
- Right 9% 9%
- Left 9% 9%
• Leg
-Right 18% 14%
-Left 18% 14%
Total 100% 100%
HA(MSN) 164

2. Estimate of body surface area using the Lund
and Browder method
• Is the more precise method of estimating the
extent of burn, because it recognizes the
various anatomic parts, especially the head and
legs
• Head----------------------- 7%
• Neck----------------------- 2%
• Anterior trunk---------- 13%
• Posterior trunk--------- 13%
• Right buttock------------ 2 ½ %
• Left buttock-------------- 2 ½ %
HA(MSN) 167

• Genitalia------------------ 1%
• Right upper arm--------- 4%
• Left upper arm----------- 4%
• Right lower arm---------- 3%
• Left lower arm------------ 3%
• Right hand----------------- 2 ½ %
• Left hand------------------- 2 ½%
• Right thigh---------------- 9 ½%
• Left thigh------------------ 9 ½%
• Right leg------------------- 7%
• Left leg--------------------- 7%
• Right foot----------------- 3 ½%
• Left foot------------------- 3 ½%
100%
HA(MSN)
168

3. Palm method
• Used in patients with scattered burns
• The size of the patient’s palm is approximately
1% of TBSA
• In general an adult who suffered burns of 25%
and an infant (child) of 15% wherever the
location requires Hospitalization
HA(MSN) 169

C. By location
• Burns of the
-face,
-neck and
-circumferential burns of the chest may inhibit
respiration
• Burns of the hands, feet, joints, and eyes are of
concern because they make self care impossible
and jeopardize later function
• Hands and feet are difficult to manage
medically because of superficial vascular and
nerve supply systems
HA(MSN) 170

Cont…
• The ears and nose, composed mainly of
cartilage, are susceptible to infection because of
poor blood supply to the cartilage
• Burns of the buttock or genitalia are susceptible
to infection
• circumferential burns of the extremities can
cause circulatory compromise distal to the burn
with subsequent neurologic impairment of the
affected extremity
HA(MSN) 171

D. By age
• an infant is less able to cope with burn injuries
because of:
- an immature immune system and
- generally poor host defense mechanisms,
• The older adult heals more slowly and has more
difficulty with rehabilitation than a child or
younger adult
• Infection of the burn wound and pneumonia are
common complications in the older patient
HA(MSN) 172

Fluid type and fluid replacement formulas
for burn patients
Fluids can be:
• Colloids are whole blood, plasma, plasma
expanders, and dextran, etc
• Crystalloid (Electrolytes) are sodium chloride,
ringers lactate, etc
Fluid replacement formulas are:
• Consensus formula
• Evans formula
• Brooke Army formula
• Parkland/Baxter formula
HA(MSN) 173

1. Consensus formula (In the first 24 hours)- the
most commonly used method
2-4ml X kg X % TBSA burned for 24 hours
• E.g.: Ato Chane, 38 years old factory worker,
60kg body weight, sustained a burn injury
with a 30% body surface burn came to surgical
emergency OPD where you are working.
• How are you going to calculate the fluid to be
replaced for Ato Chane?
– Using the Consensus formula
– 2ml X 60kg X 30%=3600ml/24 hours
HA(MSN) 174

Plan of fluid administration
• Half of the calculated fluid in the above case
1800ml should be given over the first 8 hours and
the remaining half that is 1800ml over the next
16 hours.
For example
• Our casualty has a burn to his legs approximating
18% of body surface: 18
• He weighs approximately 100 Kilograms: 100
• Therefore 100 x 4 = 400, 400 x 18 = 7200
• 7200 CCs of fluid are needed.
HA(MSN) 175

cont’d
• Standard IV drip sets for Prehospital cases are
usually called Macrodrip sets...they deliver
1ml Q 10 drop, 1ML= 1CC
• In order to deliver 3600 CCs of fluid in eight
hours we would set the drip rate at 75 drops per
minute, or 7.5 CCs per minute.
• 7.5 CCs x 480 minutes (8 hours) = 3600 CCs or
3.6 Litres (1000 CCs per Litre)
HA(MSN) 176

2. Evans formula
• Colloids-
1ml X Kg X % TBSA burned
• Electrolyte(normal saline)-
1ml X Kg X % TBSA burned
• Day 1: Half to be given in first 8 hours;
remaining half over the next 16 hours
• Day 2: Half of previous day’s colloids and
electrolytes
HA(MSN) 177

3. Brooke Army formula
• Colloids
0.5 ml X Kg X % TBSA burned
• Electrolyte(Ringer’s lactate)-
1.5 ml X Kg X % TBSA burned
• Day 2: Half of colloids; half of electrolytes
HA(MSN) 178

4. Porkland/Baxter formula
• Ringer’s lactate-
4 ml X Kg X % TBSA burned
• Day 2: Varies. Colloid is added
HA(MSN) 179

Systemic effects of burn
• Metabolic - client is in a hypermetabolic stage
• Endocrine
– increased catecholamines, ADH, aldosterone, and
cortisol increase metabolism
– O2 and calorie needs are increased
– the body is under stress response catabolism
increases
calorie requirements may be double or
triple the usual amount needed
HA(MSN) 180

Respiratory
Major cause of morbidity/ mortality
– inhalation injury r/t contact to steam, toxic
fumes, or smoke
– may be r/t treatmentlarge amount of fluid
volume infused may cause edema
– increase in alveolar capillary permeability
– constriction of chest r/t circumferential burn
– injury can occur from edema from irritants
which cause edema and blockage of trachea
HA(MSN) 181

Respiratory…
– decreased movement of the normal cilia in the
trachea may allow foreign bacteria and particles
to enter into the lungs
– lining of the trachea may slough off and become
lodged in the bronchus
– damage to the alveoli and the capillary membrane
may lead to infection and respiratory failure
HA(MSN) 182

Cardiac
• cardiac output is the most effected by the
loss of fluid
• early the rate increases to compensate
for the loss of volume
• cardiac output remains decreased in spite
of the increase rate
– may be decreased for 36 hrs
– when fluid is replaced goes back to normal
function
HA(MSN) 183

GASTROINTESTIONAL
- Effects occur due to the shift of blood volume
to vital organs
- Epinephrine and NE inhibit gastric motility
and decrease blood flow to the GI tract
- Decreased periostalis occurs
- H+ ion production increases
- Develop ulcers (Curling’s ulcer within 24
hours)
- Use H2 blockers
HA(MSN) 184

Immune response
• Widespread impairment of the immune
system
• Skin is barrier to invading organisms
• Changes in the WBC’s occur,
• Susceptibility to infection increases
HA(MSN) 185

Renal response
• Blood flow to the kidneys is decreased and
renal ischemia occurs
• Unless flow is improved renal failure occurs
• With full thickness electrical burns myoglobin
and hemoglobin are released in the blood
and can occlude the renal tubles
With adequate diuretics and fluid the
problem can be corrected
HA(MSN) 186

• Renal function may be altered as a result of
decreased blood volume.
– Destruction of RBC at the injury site results in
free haemoglobin in the urine.
– If muscle damage occurs, myoglobin is released
from the muscle cells and excreted by the
kidney.
– If there is in adequate blood flow through the
kidneys, the hemoglobin and myoglobin
occlude the renal tubules resulting in acute
tubular necrosis and renal failure.
HA(MSN) 187

Etiologies of burn
• Many causes cause affects the outcome
Dry heat-open flame house fire and
explosionsŸ
Moist heat=scald older adults most
common=spills and splatters
Contact burns hot metal/tar/grease
(industrial, home and restaurants)
usually deep because liquid is extremely hot
Chemical injury
-occurs in home and industry (drain cleaner,
acids used in industry or chemicals in industry )
**Severity depends on the length of contact
and amount of tissue exposed
HA(MSN) 188

Management of the patient with a burn injury
• Burn care must be planned according to the
burn depth, local response, the extent of
the injury, and the presence of a systematic
response.
• Burn care then proceeds through 3 phases
HA(MSN) 189

Emergent/ resuscitative phase
• Duration is from onset of injury to completion
of fluid resuscitation.
• The priorities are  ABC of first aid
– Prevention of shock
– Prevention of respiratory distress
– Detection and treatment of concomitant injuries
– Wound assessment and initial care
HA(MSN) 190

Emergent/ resuscitative phase…
• The goal of fluid replacement therapy should
be out put totals of 30 to 50ml/ hour, in
addition systolic blood pressure exceeding 100
mmHg and pulse rate less than 110/minute.
• Oral resuscitation can be successful in adults
with less than 20% TBSA and children with less
than 10% to 15 % TBSA
HA(MSN) 191

2. Acute/ intermediate phase
• Duration is from the beginning of
diuresis to near completion of wound
closure.
• The priorities are- wound care and
closure
–Prevention and treatment of
complications, including infection.
–Nutritional support
HA(MSN) 192

3. Rehabilitation phase
»Duration is from major wound closure to
return to individual’s optimal level of
physical and psychosocial adjustment.
»The priorities are- Prevention of scars
and contractures.
• Physical, occupational and vocational
rehabilitation
• Functional and cosmetic
reconstruction .
• Psycho-social counseling
HA(MSN) 193

Nursing management by using the
nursing process
1. Assessment
• Vital signs- especially respiration rate and pulse
• Respiratory functions
• Monitor fluid intake and out put
• Urine out put hourly
• Maximum requirements of fluid replacement
• Body weight
• History of allergy
HA(MSN) 194

• Tetanus immunization
• Past medical and surgical problems
• Current illness and use of medication
• Patient with facial burns- eye examination
• Depth of the wound
• Time of injury
• Burn occurrence in closed space
• Related trauma
• Level of consciousness
• Excessive fluid volume loss
HA(MSN) 195

2. Nursing diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Complication of Burn/Most severe ones are:
• Air way obstruction
• Hypovolemic shock
• Secondary infection
• Contracture
HA(MSN) 196

Wound
I. Based on cleanness
• Clean wound- has a discharge that may be
fresh blood/ serum.
• Septic wound- has discharge like pus,
exudates, and dead tissues.
II. Based on opening
• 1. Closed wound- involves injury to the
underlying tissues with out a break to the skin
or mucus membrane
• 2. Open wound- is a break in the skin or mucus
membrane
HA(MSN) 197

Cont’d
III. Based on tissue damage
1. Abrasion/Graze/wound
– The outer layer/superficial layer of the protective skin is
scrapped off
2. Incised wound/cut/
– When body tissue is cut by a sharp edged material
3. Lacerated wound
• It is an irregular tearing of soft tissue
4. Puncture/stab/wound
5. Avulsion wound
6. Contusion wound/bruise/ wound
• A closed wound that results in tissue damage and ruptured blood
vessels
• If internal organs are contused serious effect may result
HA(MSN) 198

Types of wound healing
1. Primary intention
• The wound is clean and no tissue loss
• The wound closes rapidly because there are no gaps in the tissue
• Edges can be approximated with suture/staples (clip)/ wound closure
strips
• Risk of infection is low
• Fine scar will remain
• E.g.: surgical incision
2. Secondary intention
• Loss of tissue
• Irregular edge, large wound with blood clot
• Edge can not be approximated
• Greater risk of infection
• Longer healing time
• Granulation tissue fills in wound
• Visible scar formation
• E.g.: wounds from trauma, ulceration and infection
HA(MSN) 199

Cont’d…
3. Tertiary intention
• Large area of tissue loss
• Contaminated wound
• Delayed closure even with suture that breaks
down and re-sutured latter
• Results in deeper and wider scar
• E.g.: primary wound which was infected
HA(MSN) 200

Phases of wound healing
Inflammatory phase
• Occurs immediately after an injury and lasts 4-6
days
• Small blood vessels become more permeable
• Presence of edema
• Pain and tenderness occurs
• Phagocytosis occurs
• The client shows elevated temperature,
leukocytosis and generalized malaise
HA(MSN) 201

2. Proliferative or granulation phase
– Begins between 1 and 4 days after the injury and
ends 14-21 days later
– Rapid growth of epithelial cells
– Rebuilding of vascular capillary network and
collagen tissue
– Collagen fibers fill in the gap and form the scar
– Wound scar tissue is very fragile and susceptible
to re-injury
– The color is red because of increased blood flow
HA(MSN) 202

cont’d…
3. Maturation or wound remodeling phase
• Wound contraction begins between 14-21
days, after the injury and lasts up to 2 years
• Scar shrinks and become flat
• Less red as the capillary regress
HA(MSN) 203

Factors that delay wound healing
Age
• Nutrition- adequate nutrition that includes essential amino
acids, vitamin A, C, and zinc is essential for normal wound repairs
• Infection-
• Hormonal influences- the therapeutic administration of adrenal
corticosteroids can make:
• Impairs phagocytosis
• Inhibit fibroblast proliferation and function
• Depresses the formation of granulation tissue
• Inhibit wound contraction
• Mask presence of infection by impairing normal inflammatory
response
• Blood supply-
• Poor blood flow may occur as result of swelling, arterial and
venous pathology
HA(MSN) 204

• Wound separation
• Presence of foreign bodies-
• Smoking- vasoconstriction caused by smoking,
decreases blood supply to the wound, the
carbon in smoke binds with hemoglobin and
further diminishes oxygenation
• Obesity- the bulk and weight of adipose tissue
causes poor vascularity
• Fluid and electrolyte balance-
• Immuno-suppression-
• Radiation therapy- the blood supply in
irradiated tissue is decreased
HA(MSN) 205

• Handling of tissue- rough handling causes injury
and delayed healing
• Edema- reduces blood supply by exerting pressure
on blood vessels
• Medications
-Anti-inflammatory- decrease epithelization and
wound contraction
-Corticosteroids- may mask presence of infection
by impairing normal inflammatory response
-Anticoagulants- may cause hemorrhage
• Patient over activity- prevents approximation of
wound edges
HA(MSN) 206

Cont’d
• Wound stressors- like vomiting, coughing heavily,
and straining produces tension on wounds and
destroys granulation tissue that prevents
apposition of wound edges
• Poor general health- alters cellular function
• Duration of surgical procedure- the longer the
time the higher the delay of wound healing
• Drainage accumulation- accumulation of
drainages favors bacterial growth
• Bleeding (hemorrhage)- bleeding sites becomes a
growth media for microorganisms
HA(MSN) 207

Complications of wound healing
• Hypertrophic scar and keloids- due to excess
production of collagen tissue
• Contracture- shortening of muscle or scar tissue
• Delviscence
• Separation and disruption of previously joined
wound edge
• It can be due to infection, inflammation, weak
granulation tissue.
• Evisceration- excess growth of tissue protrudes
above the surface of the healing wound.
• Adhesions- binding two surfaces or structures that
normally are separate
HA(MSN) 208

Cont’d…
• Major organ dysfunction-
• Herination- the surface layer remains intact but the
deep layers separate permitting the underlying
muscles/organs bulge
• Fistula- draining tunnel may form between two
organs
• Sinus tract- an abscess may form in deeper tissues
and form a tunnel to the out side of the body
• Hematoma- collections of blood or serum in wound
(seroma)
• Infection-
• Hemorrhage-
HA(MSN) 209

• Thanks but still to go!!!!!!
HA(MSN) 210

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