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3/11/2014

INTEGUMENTARY SYSTEM

ANATOMY OF SKIN
Epidermis
dead cells protect cells underneath; replaced q34 weeks; contains keratin
keratin outer barrier, repel pathogens, prevent excessive fluid loss Insensible water loss400-600mL No blood vessels or nerves

SUBLAYERS OF EPIDERMIS
stratum basale rapid cell division q19 days replenish the regular loss of skin 25% of the cells are melanocytes melanin - pigmentation of skin and hair production melanocyte-stimulating hormone hypothalamus

Abnormality in the epidermis


Albinism- recessive trait- lacks melanin- white skin, no pigment in the iris of eye Vitiligo- areas of hypopigmentation Melasma/ chloasma- patches of dark skin

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DERMIS
largest portion of skin blood vessels and sensory nerve endings fibroblasts collagen and elastin collagen main structural component skins strength elastin elasticity and flexibility

SUBCUTANEOUS TISSUE
hypodermis contains half the bodys stored fat amount and location vary age, sex, diet cushion between skin layers, muscles, bones skin mobility molds body contours Insulation

HAIR
slender, threadlike outgrowths of the epidermis hair scalp growth rate - 1 mm q3 days arrector pili ANS; contracts - stand on end

HAIR

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NAILS
hard, transparent plate of keratin nail growth continuous renewal: fingernail 170 days toenail 12-18 months

GLANDS OF THE SKIN


sweat gland concentrated: palms & soles 10 liters (2.6 gallons) of fluid per day evaporates and cools the body

eccrine gland sweat basal coiled portion; water, salt content of blood plasma - SNS
apocrine gland
axillae,scalp, face, anal region, scrotum, labia majora active puberty milky sweat (organic subs.) broken down by bacteria BODY ODOR! ceruminous gland external ear cerumen (wax)

GLANDS OF THE SKIN


sebaceous gland connected duct hair follicle sebum present in each hair lubricate hair render skin soft and pliable

FUNCTIONS OF SKIN
PROTECTION against invasion bacteria, foreign subs. Sebum- acidic Resident flora SENSATION

FUNCTIONS OF SKIN
FLUID BALANCE absorb water prevent excessive loss insensible perspiration 600 ml daily TEMPERATURE REGULATION heat from metabolism of food conduction evaporation convection

receptor endings of nerves sense temperature, pain, light touch, pressure (heavy touch) more concentrated in some areas (fingertips)

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SKIN RELATED TO AGING


Factors: excessive sun exposure, systemic diseases, poor nutrition, medications major changes: Dermis thinner and SQ diminished Decreased sensory receptors dryness wrinkling uneven pigmentation proliferative lesions

SKIN RELATED TO AGING


other changes: cherry angiomas bright red moles diminished hair scalp, pubic area Skin tags- small projections of the skin solar lentigo (liver spots) brown patch melasma (dark discoloration) lentigines (freckles) wrinkles xerosis (dryness) Thinning of the skin

ASSESSMENT

Skin Lesions
Color cyanotic, black (eschar), bruise

Dermatosis abnormal skin condition

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Distribution of lesions

Primary Skin Lesions


Macule, patch = flat Papule, plaque (scale like) Nodule, Tumor Wheal

annular

linear

Primary Skin Lesions


Vesicle, Bulla Pustule

Primary Skin Lesions


Cyst

Secondary skin lesions


Lichenification Erosion Ulcer

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Secondary skin lesions


Fissure Scales Crust

Secondary skin lesions


Scar Keloid Atrophy

Vascularity and Hydration


Petechiae Ecchymoses Telangiectasis

Vascularity and Hydration


Angiomas Venous stars Skin turgor

Diagnostic Evaluation
Paronychia
Skin biopsy by scalpel incision or skin punch instrument Immunofluorescence

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Diagnostic Evaluation
Patch testing - allergy Skin scrapings UV rays (fungal infection) Tzanck smear Woods light examination Clinical photographs

Secretory Disorders
Dandruff!!! ACNE!!!

Seborrheic Dermatitis
A chronic inflammatory disease Exact cause is unknown Overproduction of sebum May be bacterial or fungal in nature

Commonly called dandruff in adults and cradle cap in infants Commonly occurs in babies below 3 months of age and adults of 30-60 years of age More common in men than women

Clinical Manifestations
Oily Form
Affected site may be moist or greasy Slight erythema May be with or without scaling

Dry Form
Flaky desquamation of the scalp Mild forms may be asymptomatic Accompanied by pruritus

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Management
Depends on the age and affected part!

Acne Vulgaris
An inflammatory disease of the sebaceous glands Limited to the parts of the body were there is an abundant supply of sebaceous glands Face Neck Chest Upper back Upper arms

Adults with dandruff Shampoo that contains salicylic acid Prescripition medicine such as: selenium sulfide pyrithione zinc

Adults with

seborrheic dermatitis on skin creases


Steroid lotions

Factors related to acne


Role of androgens Propionibacterium acnes Sebum production Follicle growth

Androgens
Stimulates the growth of sebaceous glands Enhance production of sebum Males: risk

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G R A M -N E G A T I V E

Myths about acne


Fatty foods could contribute to the severity of acne Frequent washing of the face using water or soap could cure acne Acne is caused by excessive dirt

Exfoliation
Salicylic and glycolic acid are the common chemical exfoliants Topical and Oral ATB, Oral and External retinoids Normal diet Wash face 2x a day

BACTERIAL SKIN INFECTION

IMPETIGO

Superficial infection of the skin; contagious 80% Staphylococcus areus; 20% streptococcus (GABHS) face, hands, necks and extremities

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children, malnourished, poor hygienic practices


B U L L O U S

- primary skin lesion: pustule - tzanck smear


Manifestations: small vesicles: yellow-honey-colored crust smooth red moist surfaces crusts again Pruritus

P A T H O P H Y S I O L

P A T H O P H Y S I O L

O
G Y

O
G Y

Prevention and Control


proper handwashing proper handling of soiled materials do not scratch: to avoid re-infection to other body parts no sharing of articles avoid contact with other people systemic and topical antibiotic

FOLLICULITIS, FURUNCLES, CARBUNCLES

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FOLLICULITIS
Bacterial or fungal infection that arises from the hair follicles beard area of men, legs of shaving women, axilla, trunk or buttocks Staphylococcus aureus; Streptococcus pyogenes shaving men and women, unhygienic use of razor , those who use straight razor instead of electric

P A T H O P H

Prevention and Control


use of depilatory cream or electric razor rather than straight razor use of special lotions antibiotics

Y
S I O L O G Y

Furuncle (Boils)
Acute inflammation deep in one or more hair follicles and spreads into the surrounding dermis similar with folliculitis but deeper in form and may be multiple and recurrent anywhere in the body but more prevalent in areas subjected to frequent irritation, pressure, friction and excessive perspiration

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P A T H O

sensitive lump under the skin

P
A T H O P H Y S I O L O G Y

core, softens and liquefies as pus forms

P
H Y S I O L

O
G Y

P A T H O P H Y S I O L O G Y

yellowish tip, or head

Clinical manifestations
small, red painful pimple

necrosis of surrounding tissue center or head is yellowish or blackish and is said that the boil has come to a head

Carbuncle
Abscess of the skin and the subcutaneous tissue large and deep seated. two or more confluent furuncles with separate heads nape and buttocks

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P
A T H O P H Y S I O L O G Y

P
A T H O P H Y S I O L O G Y

Nursing Mgt.
hot compresses Antibiotics Do not rupture!!! Do not squeeze!!! Bed rest: boils on perineum Incision and evacuation (wound care & dressing)

Herpes Zoster Shingles

Herpes Zoster
Causative agent
Varicella-zoster virus

Clinical Manifestations
An eruption preceded by pain, which may radiate over the entire region supplied by the affected nerves (nerve pathway) Pain: burning, paresthesia Clinical course: 1-3 weeks Post-herpetic neuralgia- older adults

Characterized by a painful vesicular eruption along the area of distribution of the sensory nerves Usually affects one Cranial nerve or spinal nerve on one side of the body

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Medical Management
Medications:
Analgesics Systemic corticosteroids Anti-viral (Acyclovir)

Herpes zoster

Herpes Simplex

Herpes Simplex

Herpes Simplex 1 (orolabial) Herpes Simplex 2 (genital) Prevalence 85% of adults are seropositive for Herpes simplex 1 Herpes simplex 2 has a lower prevalence >>> sexual activity

Orolabial Herpes
Herpes simplex 1 Fever blisters or cold sores Painful clusters of vesicles on the lips Triggering factors for recurrence Sunlight exposure Increased stress Heals in 2-3weeks

Herpes simplex 1 (orolabial)

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Genital herpes
Herpes simplex 2 Grouped red vesicles initially involving the vagina, rectum or penis
7 to 14 days Symmetric lesions >>>regional lymphadenopathy

Herpes simplex 2 (genital)

*fever *flu-like symptoms

Complications

Medical management
Use of sunscreen liberally on the face and lips Anti-viral administered 5 times a day for 5 days

Tinea Infections
TINEA INFECTIONS? ALIPUNGA???

TINEA PEDIS
Athletes foot Most common fungal infection Prevalent in those who use communal showers or swimming pools Appears in hands and feet Scaling and mild redness with macerations in toe webs Clusters of clear vesicles Toenail may also be involved

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Tinea Pedis
Medical Management Potassium permanganate to remove crusts, scales and to reduce inflammation Topical anti-fungal agents for several weeks

TINEA PEDIS

TINEA CORPORIS
Ringworm of the body Appears on the face, neck, trunk and extremities May spread to the hair, scalp or nails

TINEA CORPORIS

Tinea Capitis Ringworm of the scalp Shows as patchy hair loss More common in children Contagious infection of the hair scalp

Tinea Capitis
Medical Management Oral anti-fungal agent Shampoo hair with Nizoral or selenium sulfide shampoo 2-3 times weekly and apply topical anti-fungal preparation

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TINEA CAPITIS

TINEA CRURIS
Jock itch Ringworm infection of the groin Heat, friction and maceration are predisposing factors Most frequently in obese people and those who wear tight underclothing Very pruritic

TINEA CRURIS

TINEA UNGUM
Chronic fungal infection of the toenails or fingernails Usually associated with long-standing fungal infection of the feet Nails become thickened and friable Entire nail may be destroyed

TINEA UNGUM
Medical Management

TINEA UNGUM

Finger nails: Oral anti-fungal for 6 weeks Toenails: 12 weeks

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Nursing Management
Keep feet as dry as possible, including the areas between the toes Small pieces of cotton can be placed between the toes at night Instruct to use a clean towel or wash cloth daily Dry skin thoroughly after bathing especially in the axillae, toe webs and between the breasts

Parasitic Infections
Pediculosis: Lice Three varieties 1. Pediculosis capitis 2. Pediculosis corporis 3. Pediculosis pubis

Pediculosis Capitis
Infestation of the scalp by the head louse Visible slivery, glistening oval bodies (egg: nit) Attaches to the hair shaft with a tenacious substance Found commonly along the back of the head and behind the ears The insect bite causes intense itching Transmitted directly or indirectly

Pediculosis Capitis
Medical Management Treatment is aimed at destroying the insect and ova Lindane shampoo Fine-toothed comb dipped in vinegar Infested clothing, beddings and towels be washed in hot water or dry cleaned

Pediculosis Corporis and Pubis


Infestation of the body louse Spread by close contact with infested clothing or linens or by sexual contact Bites causes characteristic minute hemorrhagic points Excoriations as a result of itching and scratching

Scabies
Infestation of the skin by the itch mite Sarcoptes scabiei

Fingernails, wrists, axillae, nipples, umbilicus, lower abdomen, genitalia, and buttocks are the most common sites
4 weeks before symptoms to appear

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Scabies
extremely pruritic papular lesions Inspect for burrows: magnifying glass and penlight at an oblique angle to the skin One characteristic sign is increased itching at night

Scabies

Scabies
Medical Management Warm soapy bath or shower, dry thoroughly and allow skin to cool Anti-histamines to improve itching Topical Lindane is applied neck down for 12-24 hours and repeated after a week

Noninfectious Inflammatory Dermatoses

Psoriasis
Chronic non-infectious inflammatory disease of the skin Epidermal cells produce 3-9 times faster than normal Cells of basal layer s. corneum scales NORMAL: 26-28 days PSORIASIS: 3-4 days No growth and maturation Protective layers do not form Autoimmune

Psoriasis

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Assessment & Diagnosis


Dx: appearance of the skin (plaquetype lesions) no special blood tests skin biopsy, or scraping has little value Family history

Clinical Manifestations
Lesions (red, raised patches of skin covered with silvery scales) Scaly patches: build-up of living and dead skin from fast growth and turnover Bleeding points: when the scales are scraped away (Auspitz sign) Patches: not moist and are pruritic Most common sites: Scalp Extensor surface of the elbows and knees Lower back Genitalia Nails Palms Soles

Elbow Lower back Arm

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Scalp

Knees

Back

Skin Folds

Feet

Generalized

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Treatment
Topical treatment Phototherapy Photochemotherapy Systemic treatment

Phototherapy
daily, short, non-burning exposure to sunlight helped to clear or improve psoriasis

Types: UVA (380315 nm) UVB (315280 nm) UVC (< 280 nm)

Photochemotherapy
UVB: absorbed by the epidermis and has a beneficial effect on psoriasis Narrowband UVB (311 to 312 nm): most helpful Exposure to UVB several times per week, over several weeks can help people attain a remission from psoriasis Psoralen and PUVA combines oral or topical administration of psoralen with exposure to (UVA) light

Description

Exfoliative Dermatitis

Progressive inflammation in which erythema and scaling occur in a more or less generalized distribution Profound loss of s. corneum (capillary leakage, hypoproteinemia, and negative nitrogen balance)

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Clinical Manifestations
Patchy or generalized erythematous eruptions Fever Color change (pink to dark red) Exfoliation (scaling) Exfoliation as thin flakes skin smooth & red new scales Hair loss Relapse

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PEMPHIGUS
Antibiotics for infection (C & S) Antihistamines for severe itch Topical meds for acute dermatitis Oral or parenteral corticosteroids (uncontrolled) Avoid irritants Tx of specific cause

Definition
Greek pemphix, meaning bubble or blister. an autoimmune disorder Immunoglobulin G epidermal acantholysis-destruction of the "cement" that holds cells together Hereditary Benign Familial Pemphigus (Hailey-Hailey disease) exposure to chemicals , dyes Carpet Shampoo - well known to trigger the blistering in Kawasaki disease.

Manifestations
Bullae, blistering and raw sores on skin and mucous membranes.
Painful, bleed easily, heal slowly

with characteristic offensive odor Nikolskys sign blistering or sloughing of uninvolved skin when minimal pressure is applied

TREATMENT
Topical Corticosteroids (Prednisone) Analgesics Immunosuppressive agents Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Gold Plasmapheresis (plasma exchange) Antibiotics or creams-infection and relieve inflamm. Silver sulfadiazine cream also may be used

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Toxic Epidermal Necrolysis and Steven Johnson Syndrome

Toxic Epidermal Necrolysis and Steven Johnson Syndrome

Toxic Epidermal Necrolysis and Steven Johnson Syndrome

- Occurs in all ages and most genders - Increased risk older people immunocompromised Possible causes Cell mediated cytotoxic reaction - Non Drug - Drugs Antibiotics Viral infections Sulphonamides Bacterial infections Penicillins Malignant tumors Macrolides Vaccinations Quinolones idiopathic Allopurinol Nonsteroidal anti-inflammatory drugs (NSAIDs) Anticonvulsants (antiepileptic medicines)

Clinical Manifestations Erythema skin surface, mucous membranes Large bullae Shedding of epidermis- may include fingernails, toenails, eyebrows, and eyelashes Weeping surface of skin (similar to total body, partial thickness burns) Skin loss may approach 100%

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Medical Management

Skin Cancer Sun exposure leading cause Types - Basal Cell Carcinoma - Squamous Cell Carcinoma - Malignant Melanoma

Control of fluid and electrolyte balance Prevention of sepsis Surgical debridement/hydrotherapy hubbard tank Culture and sensitivity Systemic corticosteroids Immunoglobulin (IVIG) Topical antibacterials and anesthetics

Skin Cancer
Clinical Manifestations BCC Most common type of skin cancer Extensive exposure to the sun Usually begins as small waxy nodules with translucent, pearly borders. Other variants shiny, flat, gray or yellowish plaques Tumors- on face Rare metastasis Recurrence common

Skin Cancer
Clinical Manifestations
SCC Arising from the epidermis Appears on sun damaged skin
Metastasis 75% of deaths Primary precancerous condition actinic keratosis, leukoplakia, scarred or ulcerated tumors.

Rough, thickened, scaly tumor may be asymptomatic or may involve bleeding Border may be wider, more infiltrated, and more inflammatory than BCC lesion

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Skin Cancer Prognosis BCC Tumors remain localized Risk for death is low SCC Depends on metastasis

Skin Cancer Medical Management surgical excision Electrosurgery Cryosurgery Radiation Therapy

Management
Watch for excessive bleeding and tight dressings Lesion in perioral area- drink from straw, limit talking and facial movements. Dental work should be avoided until fully healed Sunscreen Follow up examinations every 3 mos. for a year. Incl. palpation of adjacent lymph nodes Suspicious moles Prevention Sunscreen use at least SPF 15 Reduces skin CA risk by 40% Head, neck and arms- 30 mins before leaving the house and reapplied every 4 hours if the skin perspires.

Malignant Melanoma
Most lethal of all skin cancers (20% of CA deaths) Arises from melanocytes

Malignant Melanoma
Assessment and Diagnostic Findings Biopsy- confirmative Palpation of regional lymph nodes Screening in family up to first degree relatives

Present in the Epidermis and Dermis


Can appear spontaneously with other CA of other organs Easily metastasize to regional lymph nodes then other organs

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Malignant Melanoma
Prognosis 1.5mm poor thin skin lesion, no lymph involvement = 3% chance of metastis, and 95% for long term survival With regional lymph nodes 20-50% chance of surviving for 5 years

Malignant Melanoma
Medical Management Surgical excision Immunotherapy Chemotherapy

Kaposis Sarcoma
Associated with HIV and AIDS resulting in more aggressive form 3 categories Classic KS African (endemic KS) KS associated with immunosuppressive therapy Purplish macules- face, scalp, oral mucosa, lower extremities

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