Chapter 29. Learning Objectives. Learning Objectives (Cont d) 9/10/2012. Cutaneous Disorders

Transcription

1 Chapter 29 Cutaneous Disorders Learning Objectives Describe the three layers of skin, and their composition and functions Describe the morphology of primary skin lesions Describe the morphology of secondary skin lesions 2 Learning Objectives (Cont d) Describe the recognition and treatment of skin cancer Describe the recognition of malignant melanoma and how it is best recognized Recognize and treat decubitus ulcers Recognize and treat atopic dermatitis 3 1

2 Learning Objectives (Cont d) Recognize and treat contact dermatitis Recognize and treat psoriasis Recognize and treat impetigo Recognize and treat folliculitis 4 Learning Objectives (Cont d) Recognize and treat furuncles and carbuncles Recognize and treat cellulitis Recognize and treat fungal infections Recognize and treat Candida species infections 5 Learning Objectives (Cont d) Recognize and treat pediculosis Recognize and treat scabies Recognize and treat common warts Recognize and treat Varicella species infections 6 2

3 Learning Objectives (Cont d) Recognize and treat herpes simplex Recognize and treat herpes zoster Recognize and treat urticaria Recognize and treat erythema multiforme 7 Anatomy and Physiology of the Skin Largest organ Protection Temperature regulation Storage Sensation 8 Anatomy and Physiology of the Skin (Cont d) Epidermis Top layer Keratinocytes Protects from environmental conditions Prevents desiccation Immune surveillance 9 3

4 Anatomy and Physiology of the Skin (Cont d) Dermis Collagen Hair follicles Glands 10 Anatomy and Physiology of the Skin (Cont d) Subcutaneous layer Nerves Large blood vessels Adipose tissue 11 Anatomy and Physiology of the Skin (Cont d) Skin lesion description Size: millimeters Color: pigmentation Type: primary, secondary, special Arrangement: grouped lesions Distribution: generalized, truncal Shape: round, irregular Moisture: moist, dry Elevation: flat, elevated 12 4

5 Primary Skin Lesions Macule Flat, circumscribed discolored 13 Primary Skin Lesions (Cont d) Papule Elevated solid lesion Arise from epidermis, dermis 14 Primary Skin Lesions (Cont d) Plaque Elevated solid lesion Lacks deep component Formed by coalescence of papules 15 5

6 Primary Skin Lesions (Cont d) Patch Flat, circumscribed, discolored lesion >1 cm Large macule Mongolian spot 16 Primary Skin Lesions (Cont d) Patch 17 Primary Skin Lesions (Cont d) Nodule Elevated solid lesion Deep skin, subcutaneous tissues Larger, deeper than papules 18 6

7 Primary Skin Lesions (Cont d) Wheal Firm, rounded, flattopped elevation of skin Evanescent Pruritic 19 Primary Skin Lesions (Cont d) Vesicle Elevated lesion Contains clear fluid 20 Primary Skin Lesions (Cont d) Bulla Localized, fluidfilled lesion 21 7

8 Primary Skin Lesions (Cont d) Pustule Contains purulent material 22 Primary Skin Lesions (Cont d) Cyst Elevated, circumscribed, walled cavity Contains fluid/purulent material 23 Primary Skin Lesions (Cont d) Cyst 24 8

9 Secondary Skin Lesions Crust Collection of cellular debris/dried blood 25 Secondary Skin Lesions (Cont d) Erosion Partial focal epidermis loss Depressed, moist, does not bleed 26 Secondary Skin Lesions (Cont d) Ulcer Full-thickness crater Involves dermis, epidermis with surface epithelium loss Depressed, may bleed 27 9

10 Secondary Skin Lesions (Cont d) Fissure Epidermis, dermis vertical loss, sharply defined walls Crack 28 Secondary Skin Lesions (Cont d) Excoriation Linear erosion from scratching Hollowed-out area, sometimes crusted 29 Secondary Skin Lesions (Cont d) Scar Collection of new connective tissue Hypertrophic/atrophic Implies dermoepidermal damage 30 10

11 Secondary Skin Lesions (Cont d) Scale Thick stratum corneum Hyperproliferation/ increased cohesion of keratinocytes 31 Description, definition, etiology Most common malignancy Cells grow out of control, take over healthy cells Nonmelanoma Basal cell carcinoma Skin Cancers 32 Skin Cancers (Cont d) Description, definition, etiology Malignant melanoma 33 11

12 Skin Cancers (Cont d) History and physical findings History, full examination Duration, evolution of lesion Color Morphology Distribution 34 Skin Cancers (Cont d) Therapeutic interventions Excision Radiation therapy Electrosurgery Photodynamic therapy Topical treatments Melanoma, staging and complete surgical removal 35 Skin Cancers (Cont d) Patient and family education Avoid sun exposure Sunscreen Appropriate clothing, hats Early detection Melanoma recognition 36 12

13 Skin Cancers (Cont d) Description, definition, etiology Pressure ulcers Localized areas of tissue damage Develop when soft tissue is compressed between bony prominence and firm external surface Factors Skin integrity breaks Pressure-induced changes, ischemia 37 Decubitus Ulcers History and physical findings Lesion over bony prominence Sacrum, heels most common Findings Localized soft tissue involvement Warmth Erythema Tenderness Purulent discharge Foul odor 38 Decubitus Ulcers (Cont d) History and physical findings Stage I Intact skin Warm Tender Inflamed Thickened Red skin, blanches under pressure Continued pressure, tissue destruction Skin white, ischemia 39 13

14 Decubitus Ulcers (Cont d) History and physical findings Stage II Epidermis loss Abrasion, blister, superficial ulceration 40 Decubitus Ulcers (Cont d) History and physical findings Stage III Loss of all skin layers Subcutaneous tissue involvement Crater, with/without adjacent tissue undermining 41 Decubitus Ulcers (Cont d) History and physical findings Stage IV Loss of all skin layers, subcutaneous tissue Underlying structures Muscle Bone Tendon Joint capsules 42 14

15 Decubitus Ulcers (Cont d) Therapeutic interventions Local wound care Necrotic tissue debridement Wound dressing Nutritional support Pressure relief 43 Decubitus Ulcers (Cont d) Decubitus Ulcer 44 Atopic Dermatitis (Eczema) Description, definition, etiology Chronic inflammatory skin disease Familial with allergies Genetic disposition 45 15

16 Atopic Dermatitis (Eczema) (Cont d) History and physical findings Itch that rashes Requirements (3 of 4) Pruritus Typical morphology, distribution Chronic/relapsing course Personal/family history of asthma, allergic rhinitis, atopic dermatitis 46 Atopic Dermatitis (Eczema) (Cont d) History and physical findings Children Pruritic patches with papules, scaling on face, scalp, extremities, trunk Adults Neck Antecubital fossae Popliteal fossae 47 Atopic Dermatitis (Eczema) (Cont d) Differential diagnosis Eczematous disorders Therapeutic interventions Topical antiinflammatory preparations Skin lubrication 48 16

17 Atopic Dermatitis (Eczema) (Cont d) Atopic Dermatitis 49 Contact Dermatitis Description, definition, etiology Direct skin exposure to substance Erythematous and edematous, covered with small vesicles 50 Contact Dermatitis (Cont d) History and physical findings Pruritic rash 2 week exposure before rash Differential diagnosis Identical to other eczematous-type rashes No laboratory tests 51 17

18 Contact Dermatitis (Cont d) Therapeutic interventions Prevention Tapered systemic steroids Astringent dressings 52 Contact Dermatitis (Cont d) Contact Dermatitis 53 Psoriasis Description, definition, etiology Erythematous papules, plaques with silver scale Genetic predisposition, 40% 54 18

19 Psoriasis (Cont d) History and physical findings Red, discrete, flat-topped persistent plaques, papules with thick, silvery scales Physical examination 55 Psoriasis (Cont d) Differential diagnosis Silvery scale not present, mistaken for fungal infections Therapeutic interventions Decrease epidermal/dermal inflammation Based on severity, patient preference, response 56 Psoriasis (Cont d) Psoriasis 57 19

20 Bacterial Skin Infections Bacterial infections Staphylococcus aureus Colonizes skin Entry through damaged skin, hair follicle A beta-hemolytic streptococci Entry through damaged skin 58 Bacterial Skin Infections (Cont d) Impetigo Epidemiology Vesicopustular skin infection Face, extremities from scratching infected lesions Skin-to-skin contact contagion 59 Bacterial Skin Infections (Cont d) Impetigo History and physical findings Begins at traumatized skin region Vesicles, pustules develop, rupture, crust Thick, golden/honey-like appearance Burning, pruritis 60 20

21 Bacterial Skin Infections (Cont d) Impetigo Differential diagnosis Contact dermatitis Lesions present with crusted surface Depth Therapeutic interventions Topical antibiotic treatment, minimal lesions Oral antibiotics, more severe cases 61 Bacterial Skin Infections (Cont d) Impetigo Patient and family education Withhold children from daycare for first 24 hours after treatment Frequent handwashing, soap Avoid sharing personal items Avoid contaminated linen 62 Bacterial Skin Infections (Cont d) Impetigo 63 21

22 Bacterial Skin Infections (Cont d) Folliculitis Epidemiology and etiology Caused by S. aureus/pseudomonas aeruginosa 64 Bacterial Skin Infections (Cont d) Folliculitis History and physical findings Multiple lesions <5 mm Erythematous Pruritic Central pustule on top of raised lesion, with central hair Clusters, drain Resolve without scarring 65 Bacterial Skin Infections (Cont d) Folliculitis Differential diagnosis Acne Therapeutic interventions Warm salt water compresses Topical antibiotic ointments Sometimes draining needed 66 22

23 Bacterial Skin Infections (Cont d) Folliculitis 67 Bacterial Skin Infections (Cont d) Furuncles and carbuncles Description, definition, etiology Furuncles Inflammatory nodule, involves hair follicle Carbuncles Abscesses in subcutaneous tissues, drain through hair follicles 68 Bacterial Skin Infections (Cont d) Furuncles and carbuncles History and physical findings Furuncles, painful, drain pus Carbuncles, interconnected furuncles, drain through skin openings Differential diagnosis Skin abscess 69 23

24 Bacterial Skin Infections (Cont d) Furuncles and carbuncles Therapeutic interventions Warm compresses Incision Drainage Antibiotics when systemic infection 70 Bacterial Skin Infections (Cont d) Furuncle Carbuncle 71 Bacterial Skin Infections (Cont d) Cellulitis History and physical findings Swollen, red area of skin Hot, tender Spreads rapidly Face, lower leg skin Superficial initially Subcutaneous, spread to lymph nodes, bloodstream 72 24

25 Bacterial Skin Infections (Cont d) Cellulitis Differential diagnosis Clot deep in veins Therapeutic interventions Oral antibiotic Fever, IV antibiotics 73 Bacterial Skin Infections (Cont d) Cellulitis 74 Fungal Skin Infections Dermatophyte infections Description, definition, etiology Superficial Dermatophytes Tinea + location of lesion History and physical findings Varies by type Scaly rash, itching 75 25

26 Fungal Skin Infections (Cont d) Tinea Capitus 76 Fungal Skin Infections (Cont d) Tinea Cruris 77 Fungal Skin Infections (Cont d) Tinea Pedis 78 26

27 Fungal Skin Infections (Cont d) Tinea Manus 79 Fungal Skin Infections (Cont d) Tinea Versicolor 80 Fungal Skin Infections (Cont d) Dermatophyte infections Differential diagnosis Varies by type KOH preparation differentiates dermatophyte from candidal infection Therapeutic interventions Topical antifungal agents 81 27

28 Fungal Skin Infections (Cont d) Candida infections Description, definition, etiology Inflammatory reactions in epidermis Infection with Candida albicans Bloodstream in immunocompromised Oral cavity, thrush Yeast infections 82 Fungal Skin Infections (Cont d) Candida infections History and physical findings Itching, burning of skin Moist environments Bright-red erythema of affected skin, surrounded by satellite pustules, papules Recent antibiotics 83 Fungal Skin Infections (Cont d) Candida infections Differential diagnosis Other forms of dermatitis Therapeutic interventions Topical antifungal preparations Widespread infection, systemic therapy, fluconazole 84 28

29 Parasitic Infestations Pediculosis Description, definition, etiology Lice Person-to-person spread Combs, clothing, hats, blankets, linens 85 Parasitic Infestations (Cont d) Pediculosis Epidemiology and demographics Pubic louse, pincerlike claws resembling sea crabs Lay 10 eggs/day, 1 month, dies Attach to hair shaft Hatch in 6-10 days Survive 10 days away from human host 6-12 million annually Body lice in clothes, seams Pubic lice, short body hairs 86 Parasitic Infestations (Cont d) Pediculosis History and physical findings Asymptomatic Itching ID of louse, residual nits 87 29

30 Parasitic Infestations (Cont d) Pediculosis Therapeutic interventions Fine-toothed comb Soaking hair, equal parts water and white vinegar Wrap in wet towel for minutes Shampoo solutions 88 Parasitic Infestations (Cont d) Pediculosis Patient and family education All household members examined, treated at same time 90% cure rate Treatments repeated Wash all bedding, towels, clothing in hot water and soap Pubic lice in children, sexual abuse 89 Parasitic Infestations (Cont d) Body Louse 90 30

31 Parasitic Infestations (Cont d) Scabies Description, definition, etiology Contagious skin disease of the epidermis Itching Small, raised, red spots caused by itch mite 91 Parasitic Infestations (Cont d) Scabies History and physical findings Pruritis, severe, worse at night Small, red Nondescript papules, excoriated with blood S-shaped burrow on skin Fingers, sides of hands, wrists, elbows, axillae, groin, breasts, feet 92 Parasitic Infestations (Cont d) Scabies Therapeutic interventions Topical medication 100% cure Benzoate, crotamiton, lindane, permethrin Benadryl Patient and family education All family members should be treated at the same time Clothes, bedding washed in hot, soapy water 93 31

32 Parasitic Infestations (Cont d) Scabies 94 Viral Skin Infections Common cause of skin infection Direct inoculation into epidermal cells of skin Papova Warts, human papillomavirus Pox Molluscum contagiosum virus Herpes Herpes simplex virus, varicella-zoster virus 95 Viral Skin Infections (Cont d) Warts and papillomavirus History and physical findings Benign lesions caused by papillomavirus Hands, fingernails Plantar warts, feet Venereal warts, rectum, perineal area, inguinal folds, external genitalia 96 32

33 Viral Skin Infections (Cont d) Warts and papillomavirus Therapeutic interventions Destruction, painful Cryotherapy with liquid nitrogen Electrodesiccation and curettage Surgical excision Laser therapy 97 Viral Skin Infections (Cont d) Warts Human Papillomavirus 98 Viral Skin Infections (Cont d) Varicella (chickenpox) and variola (smallpox) Description, definition, etiology Contagious vesicular skin eruption Caused by varicella-zoster virus Usually <10 years 99 33

34 Viral Skin Infections (Cont d) Varicella (chickenpox) and variola (smallpox) Epidemiology and demographics million/year Peaks in March to May Person-to-person spread through airborne droplets 100 Viral Skin Infections (Cont d) Varicella (chickenpox) & variola (smallpox) History and physical findings Pruritic vesicular rash Trunk, head, mucous membranes Macules, progresses to papules, vesicles, crusting lesions 101 Viral Skin Infections (Cont d) Varicella (chickenpox) and variola (smallpox) Therapeutic interventions Symptomatic Relieve symptoms Antihistamines Topical creams Antiviral drugs

35 Viral Skin Infections (Cont d) Varicella 103 Viral Skin Infections (Cont d) Herpes simplex Description, definition, etiology HSV-1, oral HSV-2, genital Recurrent 104 Viral Skin Infections (Cont d) Herpes simplex History and physical findings Begin painful, indurated erythema Grouped vesicles become pustules, rupture, drain Sometimes necrotic

36 Viral Skin Infections (Cont d) Herpes simplex Differential diagnosis Impetigo Contact/atopic dermatitis Fungal infections Culture 106 Viral Skin Infections (Cont d) Herpes simplex Therapeutic interventions Topical, oral Reduce outbreak incidence, do not cure Patient and family education Spread by direct contact with infected person Asymptomatic, shedding virus 107 Viral Skin Infections (Cont d) Herpes Simplex

37 Viral Skin Infections (Cont d) Herpes zoster (shingles) Description, definition, etiology Shingles Follows particular nerve distribution Varicella-zoster past history Can lay dormant for decades Stress-induced, weakened immune system 109 Viral Skin Infections (Cont d) Herpes zoster (shingles) History and physical findings Fever Malaise Numbness, pruritis, burning Headache Scattered vesicles Trunk, head, face 110 Viral Skin Infections (Cont d) Herpes zoster (shingles) Therapeutic interventions Analgesics Astringent compresses Acyclovir Steroids

38 Viral Skin Infections (Cont d) Herpes Zoster 112 Specialized Erythema Urticaria (hives) Description, definition, etiology Hives Wheal forms edema Reaction to drug, contact with substance causing hypersensitivity 113 Specialized Erythema (Cont d) Urticaria (hives) History and physical findings Drug use Exposures to allergens, chemicals, foods Edematous plaques Scattered, clustered Pruritis

39 Specialized Erythema (Cont d) Urticaria (hives) Therapeutic interventions Suspicious medication discontinued Antihistamines 115 Specialized Erythema (Cont d) Urticaria 116 Specialized Erythema (Cont d) Erythema multiforme Description, definition, etiology Internal reaction in skin

40 Specialized Erythema (Cont d) Erythema multiforme History and physical findings History of drug use Three color zones 118 Specialized Erythema (Cont d) Erythema multiforme Therapeutic interventions Treatment of precipitating cause Patient and family education Serious condition Lasts 2-3 weeks, up to 6 weeks 119 Specialized Erythema (Cont d) Purpura

41 Chapter Summary PPE is extremely important Primary skin lesion; lesion is not altered by scratching, rubbing, scrubbing, or other types of trauma 121 Chapter Summary (Cont d) Secondary skin lesion is lesion altered by scratching, scrubbing, and other types of trauma Describe the skin lesions by using the names of primary or secondary lesions enables the clearest communication between paramedic and medical director and makes documentation of skin lesions most accurate 122 Chapter Summary (Cont d) Learn ABCDE rule to distinguish melanoma from less-harmful lesions Decubitus ulcers/pressure ulcers are localized areas of tissue damage that develop when soft tissue is compressed between bony prominence and a firm external surface for a prolonged period

42 Chapter Summary (Cont d) Atopic dermatitis is a chronic inflammatory skin disease considered familial with allergic features; the term eczema is often incorrectly used interchangeably Contact dermatitis, dermatitis arising from direct skin exposure to a substance; cause may be allergic, irritant induced 124 Chapter Summary (Cont d) Psoriasis is a common chronic skin disorder characterized by erythematous papules and plaques with silvery scale Impetigo is a superficial vesicopustular skin infection that primarily occurs on exposed areas of the face and extremities from scratching infected lesions 125 Chapter Summary (Cont d) Folliculitis is localized to hair follicles; it is more common in immunocompromised patients Furuncles (boils) are inflammatory nodules that involve the hair follicle (many times it follows an episode of folliculitis); a carbuncle is a series of abscesses in subcutaneous tissues that drain through hair follicles

43 Chapter Summary (Cont d) Cellulitis may appear as a swollen, red area of skin; it feels hot and tender and may spread rapidly Untreated, the spreading bacterial infection can rapidly turn into a life-threatening condition Most fungal infections are superficial and are identified by the word tinea, followed by a term that denotes the location of the lesion Most commonly result from a group of fungal infections called dermatophytes 127 Chapter Summary (Cont d) Most common symptom of candidiasis is itching, burning of skin Candida infections in the oral cavity are called thrush Lice, ectoparasites that live on body Human infestation with lice is pediculosis Scabies is a contagious skin disease of the epidermis marked by itching, small, raised, red spots caused by itch mite 128 Chapter Summary (Cont d) Warts are benign lesions caused by the papillomavirus Varicella (chickenpox) is an acute contagious vesicular skin eruption caused by the varicella-zoster virus; it can be distinguished from smallpox by clinical presentation

44 Chapter Summary (Cont d) Herpes simplex is a skin eruption caused by herpes simplex virus; it is divided into two types: HSV-1 causes oral infections and HSV-2 causes genital infections Herpes zoster, shingles, skin eruption follows a particular nerve distribution called a dermatome 130 Chapter Summary (Cont d) Urticaria, hives, is a condition of wheal on the skin resulting from edema Erythema multiforme is known for its target lesions with three zones of color, which makes the diagnosis Epidermis may be normal or blistered; dermis may be erythematous 131 Questions?