Issues in Dermatology. Rhonda Lesniak, PhD, ARNP, FNP-BC, NCSN

Issues in Dermatology Rhonda Lesniak, PhD, ARNP, FNP-BC, NCSN

Anatomy of the Skin

Functions Protect Fluid balance Absorption Synthesis of Vitamin D Sensation/communication with external environment Thermoregulation Immunity Excretion

Physical Assessment Approach: head-to-toe, anterior, posterior, and lateral; or by region as you assess other systems Techniques: inspection and palpation Maintain universal precautions General survey with vital signs and head-to-toe scan

Inspection of the Skin Color Moisture Temperature Texture Mobility/turgor Lesions

Palpation of the Skin Moisture Temperature Texture Mobility and Turgor Surface characteristics of any lesions

Descriptions of Lesions Anatomical location Size Color Type of lesion ( papule, macule, vesicle) Blanching or pulsation of vascular lesions Surface characteristics, exudate Arrangement, configuration, and distribution

History How and when did the rash/lesion occur? Is it a single lesion or multiple lesions? Where is rash located? Describe it? Use of OTC agents? PMH of this problem before? Has this child been exposed to any contagious illness? Relationship of skin lesion to season, heat, cold, drugs, occupation, chemicals? Any new soaps, detergents, perfumes, or lotions? Exposure to plants, shrubs, ivy? Any associated symptoms? Cold, flu, fever? Acute ( headache, chills, fever) or Chronic (fatigue, weakness, anorexia)? Are the child s immunizations up to date?

Types of Skin Lesions Macule- flat discoloration (freckle) >1cm=patch (vitiligo) Papule- elevated solid lesion (nevus) >1cm= plaque (psoriasis) Wheal- circumscribed area of skin edema (hive) Nodule- solid lesion that can be level, elevated, or beneath skin Vesicle- elevation of the skin containing serous fluid (varicella) Bullae- fluid filled >1cm (blister) Pustule- vesicle like with purulent content (impetigo, acne) Fissure- linear crack into epidermis (athletes foot) Ulcer- deeper loss of epidermis and dermis (pressure soar) Scale- thin flake of epidermis (dandruff, psoriasis) Lichenification- thickening and roughing of skin (chronic scratching)

Glossary of Terms Diameter < 1 cm Description Diameter > 1 cm Macule- flat circumscribed discoloration of the skin- Patch Papule- elevated circumscribed solid lesion- Plaque Nodule- solid lesion that can be level with, above, Tumor or beneath the skin Vesicle- circumscribed elevation of the skin Bullae containing serous fluid Petechiae circumscribed skin deposit of blood Purpura or heme-pigments

Primary Lesions May arise from previously normal skin Macules, patch, papule, plaque, nodule, wheal, vesicle, bulla, pustule

Macules Flat, circumscribed, nonpalpable Small-up to 1 cm Freckle Petechia Patch Flat spot 1 cm or larger

Patch Flat Nonpalpable >1 cm Examples- Birthmark Café-au-lait spot Mongolian spot Port wine stain Tinea versicolor Vitiligo

Papules Palpable elevated solid mass Up to 1 cm Examples: Elevated nevus Basal call carcinoma Seborrheic keratosis

Plaque Elevated superficial lesion 1 cm or larger Coalesced papules Examples: Eczema Psoriasis

Nodule Marble like lesion Larger than.5 cm Deeper and firmer than papule Examples: Lipoma Cyst

Wheal Irregular Transient Superficial Example: Hives

Vesicle Circumscribed superficial elevation of the skin formed by free fluid Up to 1 cm Filled with serous fluid Examples: Herpes simplex Blister

Bulla Larger lesion > 1 cm Circumscribed, elevated Filled with serous fluid Examples: Blister 2 nd degree burn

Pustule Circumscribed, elevated Filled with fluid Examples: Acne Impetigo

Secondary Lesions Result from changes in primary lesions Erosions, crust, ulcer, scale, fissure

Atopic Dermatitis

Skin Lichenification

Excoriation

SHAPE Round Oval Polygonal Annular Iris Serpiginous Umbilicated

ARRANGEMENT Annular- in a ring (lyme disease) Confluent or coalescent- multiple lesions blending together (multiple skin conditions) Reticular- netlike cluster (multiple) Dermatomal- along a neurocutaneous dermatome (herpes zoster) Linear- in streaks (poison ivy)

DISTRIBUTION Extent- isolated, localized, regional, generalized, universal Pattern- symmetrical, exposed areas, sites of pressure, follicular localization, random

Round or oval

Discrete

Grouped

Linear

confluent

Distribution of lesions Diffuse/generalized Scattered Localized Regional Extensor surfaces (psoriasis) Flexor surfaces (intertrigo) Dermatome (herpes zoster) Hair areas (herpes type, pediculosis pubis) Intertriginous areas (folds of skin-diaper rash) Sun exposed areas

Inspection of Hair Color Quantity Distribution Texture Condition of scalp Lesions or pediculosis

Inspection of Nails Color Condition Angle of attachment Abnormalities

Palpation of Hair & Nails Scalp mobility Scalp tenderness, masses Texture of hair & nails Capillary refill

TYPES of TINEA Ringworm Tinea capitis- scalp. Can have alopecia. Topical does not work, must use systemic therapy- Grisactin Tinea pedis- most common, interdigital. Athletes foot Tinea Corpris- ringworm of body- annular lesions with scaly border Tinea Cruris- fan shaped, red scaly patches on groin, jock itch Tinea Unguium- onychomycosis, nails. Need lengthy systemic drug. Difficult to treat topically. Tinea Manuum- hand Tinea Versicolor- fine scales on lesions, usually hypopigmented skin. Treatment- Selsun Blue or Head and Shoulders- apply for 20 mins/day for two weeks and wash off. Ketoconazole 400mg BIDx1 day

Tinea Corporis

Tinea Pedis

Tinea Cruris

Tinea Capitis

Tinea Versicolor

Tinea Incognito

Tinea Unguinum

Vitiligo

SKIN INFESTATIONS Scabies- tend to burrow in areas of warmth. excoriated papules on the interdigital area, axillary folds, the belt line, areolae, the scrotum, and the penis Close personal contact with an infected person is usually needed to contract this communicable disease. Prescribing Elimite (preferred treatment) requires pt teaching that the itching often persists for a few weeks after successful treatment. Must be applied from the neck down overnight (left on 8-14 hours to be effective).

Scabies

SCABIES

Cutaneous Larva Migrans

Pediculosis

Cat Scratch Fever

Impetigo

Cellulitis Inflammation Infection of the skin and soft tissues Most common organism is group A beta-hemolytic streptococci and S. aureus At risk= diabetes, circulatory problems, liver disease, skin disorders with break in skin such as psoriasis Inflammation causes swelling, red, warmth, and pain. May also cause streaking and/or drainage of clear fluid or pus Treatment includes elevate to relieve pain, cool, wet compresses, and PCN resistant antibiotic such as Cephalexin Return for treatment if not improved by 2-3 days of antibiotic therapy

Cellulitis

Viral Infections Herpes simplex- Type I is above waist; Type II is below. Resides latent in nerve roots. Reactivated by sun, trauma, infections, fever or stress. Lesions are grouped vesicles on a red base, painful, lasts 7-10 days. Type I lesions are on lips, face, mouth or throat. Type II are on penis, vulva, or anus with headache, fever, fatigue. Treatment no cure. Acyclovir or Valtrex are most often used

Herpes Simplex Type I

Viral Infections Varicella- chicken pox, highly contagious, airborne droplets or fluid. Contagious two days prior to lesion formation. Vaccine available. Treat with oral antivirals for 5days. Considered safe once all vesicles are crusted over. Herpes Zoster- shingles, grouped linear vesicles on one side. Can not get zoster from someone else with zoster. Can get chicken pox if never had it. Runs course in 4 weeks. Treatment is symptomatic for pain and itching, hot soaks and calamine lotion. May prescribe antivirals.

Chickenpox (Varicella)

Herpes Zoster (Shingles)

Herpes Zoster

Smallpox

Coxsackie Virus - Hand, Foot, & Mouth Disease

Erythema Infectiosum

Viral Exanthems First disease Measles virus Rubeola, Measles, Hard measles, 14-day measles, Morbilli Second disease Streptococcus pyogenes Scarlet Fever, Scarlatina Third disease Rubella virus Rubella, German measles, 3-day measle Fourth disease possibly Staphylococcus aureus Filatow-Dukes' Disease, Staphylococcal Scalded Skin Syndrome, Ritter's disease Fifth disease Erythrovirus (Parvovirus) B19 Erythema infectiosum Sixth disease Human Herpes Virus 6B or Human Herpes Virus 7 Exanthem subitum, Roseola infantum, "Sudden Rash", rose rash of infants, 3- day fever

Fifth Disease

Pityriasis Rosea

Roseola

Roseola Infantum

Rubeola - Measles

Rubella German Measles

Molluscum Contagiosum

Scarlet Fever

DERMATITIS Atopic dermatitis or eczema is a type one hypersensitivity reaction. Most common sites for the adult is flexor surfaces; Infant is the face Diagnosis includes presence of itching and scratching Most important type of skin care is application of lubricants, minimizing skin dryness by limiting soap and water exposure, and avoiding offending agents Common trigger agent for contact dermatitis is nickel

Contact Dermatitis Poison Ivy

ECZEMA

Eczema

URTICARIA Condition in which eruptions of wheals or hives occur most often in response to an allergen Most common cause is a Type I hypersensitivity reactioneosinophilia Most effective treatment is avoidance of the offending agent, as well as antihistamines and steroids

SUSPICIOUS MOLES The American Cancer Society has proposed the mnemonic ABCD Asymmetry Border irregularity Color variation Diameter greater than 6mm Evolution can be added. The history of a changing mole is the single most important historical reason for close evaluation and possible referral

ACNE ROSACEA More common in middle age to older adult Causes changes in skin color, enlarged pores, and thickening of the soft tissue of the nose Skin lesion classified as pustular

Rosacea

Rosacea Granulomatous

Rosacea

Rosacea Steroid