1 Efren N. Aquino M.D. Jan. 6, 2009 May 19, 2009

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Efren N. Aquino M.D.Jan. 6, 2009

May 19, 2009

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Fungal infections are caused by microscopic organisms (fungi) that can live on the skin. They can live on the dead tissues of the hair, nails, and outer skin layers.

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Fungal Infections of the Fungal Infections of the SkinSkin

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Superficial fungal infections are known as dermatophytoses.

The most common are:tinea capitis, tinea corporis, tinea cruris, and tinea pedis.

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Tinea refers to the common disorder known as “ringworm.”

The name comes from its characteristic ring-shaped lesion and the location of infection.

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Dermatophytoses Etiology/pathophysiology

Microsporum audouinii major fungal pathogen

Tinea capitis - Ringworm of the scalp

Tinea corporis - Ringworm of the body

Tinea cruris - Jock itchTinea pedis (most common) - Athlete’s foot

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Clinical Clinical manifestations/assessmentmanifestations/assessmentTinea capitis

Erythematous around lesion with pustules around the edges and alopecia at the site

The hair can break off at the scalp, and hair loss is typically not permanent.

8Tinea capitis.

(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)

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Dermatophytoses Dermatophytoses (cont..)(cont..)Clinical manifestations/assessment Tinea corporisTinea corporis refers to ringworm of the body.

Flat lesions—clear center with red border, scaliness, and pruritus

Outbreaks are typically in hairless areas.

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Tinea Corporis

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Dermatophytoses Dermatophytoses (cont..)(cont..)Clinical manifestations/assessment Tinea crurisTinea crurisBrownish-red lesions in groin area, severe pruritus with skin excoriation due to intense scratching

These lesions migrate outward from the groin region.

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Dermatophytoses Dermatophytoses (cont..)(cont..)

Tinea cruris, also known informally as crotch itch or jock itch in American English and dhobi itch or scrot rot in British English, is a dermatophyte fungal infection of the groin region in either sex, though more often seen in males.

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Dermatophytoses Dermatophytoses (cont..)(cont..) The type of fungus that most

commonly causes tinea cruris is called Trichophyton rubrum. Some other contributing fungi are

Candida albicans, Trichophyton mentagrophytes and

Epidermophyton floccosum.

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Dermatophytoses Dermatophytoses (cont..)(cont..)Clinical manifestations/assessment

Tinea pedisFissures and vesicles around and below toes

Tinea pedis is also known as “athlete’s foot.”

This infection is associated with more skin maceration than the other types of tinea.

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Diagnostic tests Visual inspection Ultraviolet light for tinea capitisInfected hair becomes fluorescent (blue-green) under the light

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Medical management Griseofulvin—oral Antifungal soaps and shampoos Tinactin or Desenex Burrow’s solution (tinea pedis)

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Nursing Interventions The feet should be cleaned and dried thoroughly, paying special attention to the toes.

Proper application of medications and warm compresses

Excellent foot care is stressed. Wearing sandal-type shoes or going barefoot helps decrease foot moisture.

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Inflammatory Disorders of Inflammatory Disorders of the Skinthe Skin

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Superficial inflammation of the skin is known as dermatitis.

It can be caused by numerous agents, such as drugs, plants, chemicals, metals, and food.

The nurse first observes erythema and edema, followed by the eruption of vesicles that rupture and encrust.

Pruritus is always present, which promotes further skin excoriation.

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1. Contact dermatitis2. Dermatitis venenata, exfoliative dermatitis,

anddermatitis medicamentosa

3. Urticaria4. Angioedema5. Eczema (atopic dermtitis)6. Acne vulgaris7. Psoriasis8. Systemic lupus erythematosus

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Contact dermatitis – The epidermis is inflammed and damagedEtiology/pathophysiology

Direct contact with agents of hypersensitivityDetergents, soaps, industrial chemicals, plants

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Contact dermatitisContact dermatitis Clinical manifestations/assessment

BurningPainPruritusEdemaPapules and vesicles

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Contact dermatitisContact dermatitis Diagnostic tests

Health history – (1) tried a new soap, (2) been traveling and using different personal items, or

(3) been working with plants or flowers

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Contact dermatitisContact dermatitis Diagnostic tests

Intradermal skin testing Elimination diets Elevated serum IgE levels and eosinophilla support the diagnosis.

It is thought that both tests relate to abnormalities of T-cell function.

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Contact dermatitisContact dermatitis Medical management/nursing

interventions Remove cause Burrow’s solution Corticosteroids to lesions Cold compresses Antihistamines (Benadryl)

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Contact dermatitisContact dermatitis Nursing Interventions

The primary goal is to identify the offensive agent so as to rest the involved skin and protect it from further damage.

Wet dressings, using Burow’s solution, help promote the healing process.

A cool environment with increased humidity decrease the pruritus. Cold compresses may be applied to

decrease circulation to the area (vasoconstriction).

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Contact dermatitisContact dermatitis Nursing Interventions

Daily baths to cleanse the skin should be taken with an application of oil.

Fingernails should be cut at the level of the fingertips to decrease excoriation from scratching.

Clothing should be lightweight and loose to decrease trauma of the involved area.

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Contact dermatitisContact dermatitis Prognosis

Removal of the offensive agent results in full recovery.

Desensitizing the individual may be necessary if recurrences are frequent.

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Inflammatory Disorders of the Inflammatory Disorders of the SkinSkin

Dermatitis venenata, exfoliative dermatitis, and dermatitis medicamentosa Etiology/pathophysiology

Dermatitis venenata: Contact with certain plants

Exfoliative dermatitis: Infestation of heavy metals, antibiotics, aspirin, codeine, gold, or iodine

Dermatitis medicamentosa: Hypersensitivity to a medication

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Dermatitis venenata, Dermatitis venenata, Exfoliative dermatitis, and Exfoliative dermatitis, and Dermatitis medicamentosaDermatitis medicamentosa

Clinical manifestations/assessment Mild to severe erythema and pruritus

Vesicles Respiratory distress (especially with medicamentosa)

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Exfoliative Exfoliative DermatitisDermatitis

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Medical management/nursing interventions

All dermatitisColloid solution, lotions, and ointmentsCordicosteroids

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Medical management/nursing interventions Dermatitis venenata

Thoroughly wash affected areaCool, wet compressesCalamine lotion

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Medical management/nursing interventions Dermatitis medicamentosa

Discontinue use of drug

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UrticariaUrticaria Etiology/pathophysiology

Presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold.

The wheals (round elevation of the skin; white in the center with a pale red periphery) of urticaria appear suddenly.

Urticaria or hives is caused by the release of histamine in an antigen-antibody reaction.

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UrticariaUrticaria Etiology/pathophysiology

Clinical manifestations/assessment Pruritus Burning pain Wheals

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UrticariaUrticaria Diagnostic tests

Health history Allergy skin test Serum examination for immunoglobulin E (IgE)

Medical management Identify cause and alleviate symptoms

Antihistamine (Benadryl) Epinephrine

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UrticariaUrticaria Nursing Interventions

Identify and alleviate cause Therapeutic bath Teach patient possible causes and prevention

The signs and symptoms of an anaphylactic reaction should be reviewed to include shortness of breath, wheezing, and cyanosis.

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UrticariaUrticaria Prognosis

Patient recover fully when the offensive agent is determined and avoided.

Compliance with the therapeutic treatment regimen influences the outcome.

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AngioedemaAngioedemaEtiology/pathophysiology

Form of urticaria Occurs only in subcutaneous tissue

Same offenders as urticaria Common sites: eyelids, hands, feet, tongue, larynx, GI, genitalia, or lips

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AngioedemaAngioedema

Clinical manifestations/assessment Burning and pruritus Acute pain (GI tract) Respiratory distress (larynx) Edema of an entire area (eyelid, feet, lips, etc.)

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AngioedemaAngioedema

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AngioedemaAngioedema Medical management

Antihistamines (Benadryl®) Epinephrine Corticosteroids (Solu-Medrol®) Cold compresses

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AngioedemaAngioedema Nursing interventions

Cold compresses Respiratory assessment, continuous

Medical alert Education and teaching for prevention

PrognosisWith early treatment, the prognosis

is good

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Eczema (atopic dermatitis)Eczema (atopic dermatitis) Etiology/pathophysiology

Allergen causes histamine to be released and an antigen-antibody reaction occurs

Primarily occurs in infants The common allergies are to chocolate, eggs, wheat, and orange juice.

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Eczema (atopic dermatitis)Eczema (atopic dermatitis) Clinical manifestations/assessment

Pruritus Papules and vesicles on scalp, forehead, cheeks, neck, and extremities

The vesicles generally rupture, discharging a yellow, tenacious exudates that dries and encrusts.

the skin may depigment and become shiny with dry scales.

Erythema and dryness of area

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Eczema (atopic dermatitis)Eczema (atopic dermatitis) Eczema (atopic dermatitis)

(continued)Diagnostic tests

Health history (heredity) Diet elimination Skin testing

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Eczema (atopic dermatitis)Eczema (atopic dermatitis) Medical management/nursing

interventionsReduce exposure to allergenHydration of skinTopical steroidsLotions—Eucerin, Alpha-Keri,

Lubriderm, or Curel 3-4 times/day

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Acne vulgarisAcne vulgaris

Etiology/pathophysiology Occluded oil glands

Androgens increase the size of the oil gland

Influencing factors Diet Stress Heredity Overactive hormones

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Acne vulgaris Acne vulgaris (cont..)(cont..) Clinical manifestations/assessment

Tenderness and edema Oily, shiny skin Pustules Comedones (blackheads) Scarring from traumatized lesions

Diagnostic tests Inspection of lesion Blood samples for androgen level

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Comedones with a Comedones with a few inflammatory few inflammatory pustulespustules

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Papulo-pustular acnePapulo-pustular acne

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Acne vulgaris Acne vulgaris (cont..)(cont..) Medical management/nursing

interventions Keep skin clean Keep hands and hair away from area

Wash hair daily Water-based makeup

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Acne vulgaris Acne vulgaris (cont..)(cont..) Medical management/nursing

interventionsTopical therapy

Benzoyl peroxide, vitamin A acids, antibiotics, sulfur-zinc lotions

Systemic therapyTetracycline, isotretinoin (Accutane)

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PsoriasisPsoriasis Etiology/pathophysiology

Noninfectious, hereditary, chronic, proliferative epidermal disorder

Skin cells divide more rapidly than normal

Clinical manifestations/assessment Raised, erythematous, circumscribed, silvery, scaling plaques

Located on scalp, elbows, knees, chin, and trunk

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Psoriasis.Psoriasis.

(Courtesy of the Department of

Dermatology, School of Medicine, University of

Utah.)

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Medical management/nursing Medical management/nursing interventionsinterventions

Objective of treatment: decrease inflammation Reduces shedding of the outer layer of

skin Slow down the proliferation of skin

epithelium Topical steroids

e.g: betamethasone, hydrocortisone decrease inflammation

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Keratolytic agents Tar preparations Salicylic acid Reduces shedding of the outer layer of

skin Photochemotherapy

PUVA ( Oral psoralen + Ultraviolet light)

Methotrexate and vit D reduce epidermal proliferation

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PsoriasisPsoriasis Prognosis:

Psoriasis is a chronic disease. The clinical course is variable, but less

than half of the patients followed for a prolonged period will have a prolonged remission; severity may range from a minimal cosmetic problem to a life-threatening emergency.

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Systemic Lupus Erythematosus Systemic Lupus Erythematosus (SLE)(SLE)

Etiology/pathophysiology Also referred to as systemic red wolf skin Autoimmune disorder Inflammation of almost any body part

Skin, joints, kidneys, and serous membranes

Affects women more than men Chronic, incurable, and multicausal

disease Contributing factors

Immunological, hormonal, genetic, and viral

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Systemic lupus erythematosus Systemic lupus erythematosus (cont..)(cont..)

Clinical manifestations/assessment Erythema butterfly rash over nose and

cheeks Alopecia Photosensitivity Oral ulcers Polyarthralgias and polyarthritis Pleuritic pain, pleural effusion, pericarditis,

and vasculitis Renal disorders Neurological signs (seizures) Hematological disorders

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Systemic Lupus Erythematosus (SLE) – The

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Systemic Lupus Erythematosus Systemic Lupus Erythematosus (cont..)(cont..)

Diagnostic tests Antinuclear antibody DNA antibody Complement CBC Erythrocyte

sedimentation rate Coagulation profile Rheumatoid factor

Rapid plasma reagin

• Skin and renal biopsy• C-reactive protein• Coomb’s test• LE cell prep• Urinalysis• Chest x-ray

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MedicationsNonsteroidal antiinflammatory agentsIbuprofen, ASA

antimalarial drugs - hydroxychloroquine (Plaquenil®) or chloroquine

Corticosteroids - methylprednisoloneantineoplastic drugs – azathioprine (Imuran)

antiinfective agents - CiprofloxacinAnalgesics diuretics

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No cure treat symptoms induce remission aleviate exacerbations Avoid direct sunlight Balance rest and exercise Balanced diet

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PrognosisPrognosis There is no known cure for SLE. There is no known cure for SLE. Management of the disease depends on Management of the disease depends on

the nature and severity of the the nature and severity of the manifestations and the organs affected. manifestations and the organs affected.

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Parasitic Diseases of the Parasitic Diseases of the SkinSkin

1. Pediculosis1. Pediculosis2. Scabies2. Scabies

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PediculosisPediculosis Etiology/pathophysiology

Lice infestation Three types of lice

Head lice (capitis)Attaches to hair shaft and lays eggs

Body lice (corporis)Found around the neck, waist, and thighsFound in seams of clothing

Pubic lice (crabs)Looks like crab with pincersFound in pubic area

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Pediculosis Pediculosis (cont..)(cont..)

Clinical manifestations/assessment Nits and/or lice on involved area Pinpoint raised, red macules Pinpoint hemorrhages Severe pruritus Excoriation

Diagnostic tests Physical exam

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Eggs of Pediculus attached to shafts of hair.

(From Baran R., Dawber, R.R., & Levene, G.M. [1991]. Color atlas of the hair, scalp, and nails. St. Louis: Mosby.)

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Lindane (Kwell); pyrethrins (RID) Cool compresses Corticosteroid ointment Assess all contacts Wash bed linens and clothes in hot

water Properly clean furniture or

nonwashable materials

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ScabiesScabies Etiology/pathophysiology

Sarcoptes scabiei (itch mite) Mite lays eggs under the skin Transmitted by prolonged contact with

infected area Clinical manifestations/assessment

Wavy, brown, threadlike lines on the body

Pruritus Excoriation

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ScabiesScabies Diagnostic tests

Microscopic examination of infected skin

Medical management/nursing interventions

Lindane (Kwell), pyrethrins (RID), crotamiton (Eurax), 4-8% solution of sulfur in petrolatum

Treat all family members Wash linens and clothing in hot water

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Tumors of the SkinTumors of the Skin

Keloids Angiomas Verruca (wart) Nevi (moles) Basal cell carcinoma Squamous cell carcinoma Malignant melanoma

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Tumors of the SkinTumors of the Skin Keloids

Overgrowth of collagenous scar tissue; raised, hard, and shiny

May be surgically removed, but may recur Steroids and radiation may be used

Angiomas A group of blood vessels dilate and form a

tumor-like mass Port-wine birthmark Treatment: electrolysis; radiation

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(From Zitelli, B.J., Davis, H.W. [2002]. Atlas of pediatric physical diagnosis. [4th ed.]. St. Louis: Mosby.)

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Tumors of the SkinTumors of the Skin Verruca (wart)

Benign, viral warty skin lesion Common locations: hands, arms, and

fingers Treatment: cauterization, solid carbon

dioxide, liquid nitrogen, salicylic acid Nevi (moles)

Congenital skin blemish Usually benign, but may become malignant Assess for any change in color, size, or

texture Assess for bleeding or pruritus

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Basal cell carcinomaSkin cancerCaused by frequent contact with

chemicals, overexposure to the sun, radiation treatment

Most common on face and upper trunk

Favorable outcome with early detection and removal

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Squamous cell carcinomaFirm, nodular lesion; ulceration and

indurated marginsRapid invasion with metastasis via

lymphatic systemSun-exposed areas; sites of chronic

irritationEarly detection and treatment are

important

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(From Belcher, A. E. [1992]. Cancer nursing. St. Louis: Mosby.)

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Squamous cell carcinoma. (Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)

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Malignant melanomaMalignant melanoma Cancerous neoplasm

Melanocytes invade the epidermis, dermis, and subcutaneous tissue

Greatest risk Fair complexion, blue eyes, red or

blond hair, and freckles Treatment

Surgical excision Chemotherapy

Cisplatin, methotrexate, dacarbazine

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Figure 43-18

The ABCDs of melanoma.

(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)

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Prevention of Skin CancerPrevention of Skin Cancer The American Academy of Dermatology

(AAD) has recommended these three preventive steps for prevention of skin cancer: Wear protective clothing, including a hat

with a 4-inch brim. Apply sunscreen all over the body and

avoid sun from 10 am to 3 pm. Regularly use a broad-spectrum

sunscreen with a skin protection factor (SPF) of 15 or higher, even on cloudy days.

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Prevention of Skin CancerPrevention of Skin CancerThe following six steps have been The following six steps have been

recommended by the AAD and the Skin recommended by the AAD and the Skin Cancer Foundation to help reduce the risk Cancer Foundation to help reduce the risk of sunburn and skin cancer:of sunburn and skin cancer:

1.1. Minimize exposure to the sun at midday-Minimize exposure to the sun at midday-

between 10 AM and 3 PM.between 10 AM and 3 PM.

2. Apply sunscreen, with at least an SPF 15 or 2. Apply sunscreen, with at least an SPF 15 or

higher that protects against both ultraviolet A higher that protects against both ultraviolet A

(UVA) and ultraviolet B (UVB) rays, to all areas (UVA) and ultraviolet B (UVB) rays, to all areas

of the body that are exposed to the sun.of the body that are exposed to the sun.

3. Reapply sunscreen every 2 hours, even on 3. Reapply sunscreen every 2 hours, even on

cloudy days. Reapply after swimming or cloudy days. Reapply after swimming or

perspiring.perspiring.

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Prevention of Skin CancerPrevention of Skin Cancer

4. 4. Wear clothing that covers the body and Wear clothing that covers the body and

shades the face. shades the face.

Hats should provide shade for both the Hats should provide shade for both the

face and back of the neck. face and back of the neck.

Wearing sunglasses reduces the amount of Wearing sunglasses reduces the amount of

rays reaching the eyes by filtering as much rays reaching the eyes by filtering as much

as 80% of the rays, and protecting the as 80% of the rays, and protecting the

eyelids as well as the lenses.eyelids as well as the lenses.

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Prevention of Skin CancerPrevention of Skin Cancer

5. Avoid exposure to UV radiation from 5. Avoid exposure to UV radiation from

sunlamps and tanning parlors.sunlamps and tanning parlors.

6. Protect children. Keep them from 6. Protect children. Keep them from

excessive sun exposure when the sun is excessive sun exposure when the sun is

stronger (10 AM to 3 PM), and apply stronger (10 AM to 3 PM), and apply

sunscreen liberally and frequently to sunscreen liberally and frequently to

children ages 6 months and older.children ages 6 months and older.

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• END END • DONE DONE

Documents

1 Efren N. Aquino M.D. Jan. 6, 2009 May 19, 2009