Common Pathologies of the Integumentary System

Common Pathologies of the Integumentary System
©Irene Mueller, EdD, RHIA Montana Hospital Association June 20, 2012

Objectives Review Integumentary System Pathologies for ICD-10-CM/PCS Coding ICD-10-CM Chapter 12 (L00-L99) – Diseases of Skin & SubQ Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes Chapter 2 (C00-D49) – Malignant Neoplasms ICD-10-PCS 0 - Medical & Surgical Section H – Skin and Breast J – SubQ tissue and fascia

Skin Chapter vs Other Chapters
Certain Skin Conditions in Other ICD-10 Chapters Complications of Preg, Childbirth, Puerperium Congenital Infectious Neoplasms Parasitic Perinatal Systemic connective tissue disorders

Outline Abnormal Skin Pigmentations General Skin Lesions Inflammations
Pressure Ulcers, Ulcers Scalded Skin Syndrome Hair Pathologies Alopecia Folliculitis Nail Pathologies Paronychia Tumors B9, Malignant Injuries Burns, Wounds General Skin Lesions Inflammations Infections Abscess Cellulitis Furuncles/Carbuncles Impetigo Pilonidal cyst/sinus Warts Lesions Bullous Cicatrix Corns/Calluses Other

General Skin lesions Papule Petechia Plaque Purpura Pustule Scale
Scleroma Telangiectasia Ulcer Vesicle Wheal Bulla Burrow Comedo Comedone Crust Cyst Ecchymosis Erosion Eschar Excoriation Fissure Freckle Induration Keloid Lichenification Macule Mole Nodule WOW: Check a good medical dictionary for pictures of these; Should know differences between them

Patterns & Distribution of Lesions
Annular Discrete Clustered Confluent Dermatomal, Zosteriform Eczematoid Follicular Guttate Iris/Target Koebner Phenomenon, Isomorphic response Linear Lesions Morbilliform Multiform Reticular Satellite lesions Scarlatiniform Serpiginous Strawberry tongue Universalis

Skin Conditions and Stress
Many conditions Aggravated by stress Cause of stress

Infections of Skin/SQ (L00-L08)
Abscess/Furuncle/Carbuncle Scalded Skin Syndrome Impetigo Cellulitis and Acute Lymphangitis Acute Lymphadenitis

Bullous Disorders (L10-L14)
Bulla = blister, bleb Latin bulla (pl. bullae), "bubble" Circumscribed elevation of skin 0.5 cm+ diameter containing a liquid Vesicle = <0.5 cm in diameter Acantholytic disorders Pemphigoid Pemphigus

Acantholytic Disorders
Gk akantha, thorn or prickle, & lysis, loosening Primary disorder of skin (sometimes mucous membranes) characterized by loss of cohesion between epidermal cells, resulting in intraepidermal clefts, vesicles, and bullae Inflammatory, viral & autoimmune skin diseases, particularly pemphigus complex

Dermatitis (L20-L30) Inflammation of skin Many types/forms Acute
Subacute Chronic Manifestations Pruritus, Erythema Cutaneous Lesions Most common Atopic (Eczema) Contact Seborrheic

Papulosquamous Disorders (L40-45)
Skin eruption Both papular (pimple-like) AND scaly Psoriasis Parapsoriasis Pityriasis rosea Lichen planus

Urticaria and Erythema (L50-L54)
Many types Erythema Multiforme Marginatum Many other types

Radiation-Related Disorders (L55-59)
Actinic keratosis AKA Solar keratosis Radiodermatitis AKA radiation dermatitis Sunburn 1st 2nd 3rd

Disorders of Skin Appendages (L60-L75)
Nail Disorders Ingrowing Nail Onycholysis Hair Disorders Acne Rosacea Sweat Gland Disorders

Hair Pathologies Follicular cysts Alopecia areata
Eccrine sweat disorders Apocrine sweat disorders Alopecia areata Androgenic alopecia Nonscarring hair loss Cicatricial alopecia Hair color/shaft abnormalities Hypertrichosis Acne Rosacea

Nail Pathologies Ingrowing nail Onychia/Paraonychia - Gk, onyx, nail
Onycholysis Onychogryphosis Psoriasis

Intraop/Postop Complications of Skin (L76)
Hemorrhage/hematoma of skin Accidental puncture/laceration of skin Postprocedural hemorrhage/hematoma Other information Dermatologic procedure vs other procedure

Other Disorders of Skin/SQ (L80-L99)
Vitiligo Pigmentation Disorders Seborrheic keratosis Pressure Ulcers Atopic Disorders of skin Hypertrophic Disorders of skin Lupus erythematosus Vasculitis limited to skin Non-pressure chronic ulcers Keloid Corns & Calluses

Abscess/Furuncle/Carbuncle
Abscess - collection of pus & infected material in or on skin – anywhere on body Furuncle (Boil) Abscess involving hair follicle and Subq tissue Carbuncle Very large boil OR multiple furuncles joined by many drainage canals Carbunculosis Many carbuncles

Acantholytic Disorders
Transient acantholytic dermatosis Etiology – Unknown Itchy red spots on trunk Usu. older men Usu. Lasts 6-8 mos, can be much longer AKA Grover disease Tx: Cortisone cream, Accutane, Tetracycline, Phototx, antifungals, Cortisone Injections Acquired keratosis follicularis NOT congenital NOT Darier Disease

Actinic Keratosis (L57.0) Small, rough, raised area found on skin
In sun for long period of time – can become SCC RF: Fair skin, Blue/green eyes, Blond or red hair Kidney or other transplant Take medicines to suppress immune system Lot of time each day in sun Many, severe sunburns early in life Older

Actinic Keratosis Face, scalp, back of hands, chest, or other sun-exposed areas Flat, scaly areas Color -gray, pink, red, or same color as skin Often, white/yellow crusty "scale" on top Later – develops hard & wart-like or gritty, rough, surface May be easier to feel than see

Acne vulagis L aknas, misreading of Gk. akmas, "points, dots” L. vulgaris “common” Inflammatory disease of sebaceous glands & hair follicles Overproduction of sebum, faster shedding of skin cells = plug and growth of bacteria in follicles Papules, putules, comedones, nodules, possible scars Face, neck, shoulders, chest, back

Acne vulgaris Unknown etiology Hormonal changes Hereditary tendencies
Any age, most common in Adolescents 14-17 Girls Late teens Boys Precipitating factors Food allergies, carbonated drinks, endocrine disorders, psychological factors, fatigue, steroid drugs

Acute Lymphangitis Bacterial infection in lymphatic vessels
Streptococcus pyogenes most often; Staph “Flesh-eating” bacterium Characterized by painful, red streaks below skin Potentially serious/fatal infection Can rapidly spread to bloodstream Cut, scratch, insect bite, surgical wound, other skin injury

Acute Lymphadenitis Inflammation of lymph node
Neck, arms, or legs; chest or abdomen Often complication of bacterial wound infection Hemolytic Streptococci or Staphylococci Caused by viruses/other disease agents also Viruses, protozoa, rickettsiae, fungi, tuberculosis Generalized: number of lymph nodes Localized: limited to few nodes in infection area Sometimes accompanied by lymphangitis

Alopecia Loss of hair 2 main types
Alopecia areata = body's immune system mistakenly attacks hair follicles Androgenetic alopecia = inherited Head hair thins & falls out Men = male pattern hair loss Women = female diffuse hair loss

Carbuncle (L02) Usu. caused by Staphylococcus aureus
Contagious Back, Nape of Neck, Anywhere Friction from clothing, shaving More common in Men than Women Composed of several skin boils (furuncles) Infected mass filled w/ fluid, pus, & dead tissue – up to golf ball size May or may not drain RF: DM, dermatitis, weak immune system

Cellulitis (L03) Acute, diffuse, bacterial infection Signs
Infection spreads over 2 days Deep Skin and SubQ Lower extremities most often, anywhere Signs Erythema, pitting edema Skin is tender and hot Red lines/streaks PROXIMAL Along lymph vessels to lymph glands

Cellulitis Streptococcus or Staphylococcus Can lead to
Small cut/lesion Enzymes from bacteria Break down skin cells Prevent body responses Can lead to Abscesses Bacteremia Tx: Antibiotics (IV)

Corns & Calluses (L84) Localized, hyperplastic areas
Stratum Corneum of Epidermis Calluses AKA Tylosis Larger (up to 1 inch) Ball of foot, palms Corns AKA Clavus Smaller, on toes Glassy core More painful Pressure/friction Shoes Orthopedic deformity Faulty weight-bearing Repeated trauma (Musicians) Impaired Circulation Foot Peripheral Neuropathy DM

Dermatitis, Atopic (Eczema) (L24)
Inflammation of skin Patients w/ family hx of allergic conditions Vesicular eruptions Exudative in children Dry, Leathery in adults Characteristic pattern Face, neck, elbows & knees, upper trunk Pruritis Idiopathic Allergic connection assumed

Dermatitis, Atopic (Eczema) Gk, ekzein, to boil over
Infants Sensitivity to milk, OJ, other foods Flare-up Triggered by Stress, anxiety, conflict Wool clothing, blankets Frequent bathing/handwashing May improve in summer Tends to improve with time

Dermatitis, Contact (L23-24)
Acute inflammation of skin Irritants on surface Allergic reaction Erythema, edema, small vesicles, itching, stinging Causes: Poison Ivy, Oak, Sumac; Dyes, Latex, Furs, Preservatives, Drugs, Detergents, Cleaners, Cosmetics, Chemicals, Acids, Metals, Sunshine, Tanning Beds (ICD-10-CM specific codes)

Dematitis, Seborrheic (L21)
One of most common skin conditions Inflammation of Oil glands in skin Areas with greatest # of glands Scalp, eyebrows, eyelids, sides of nose, behind ears, middle of chest Skin is reddened, covered with scales (yellowish, greasy-looking) May be itching, usu. mild

Dermatitis, Seborrheic
Any age; most common during infancy Cradle cap Clears w/in 8-12 months (no tx) Adults w/ CNS disorders (ex. Parkinson) Adults w/ stress AMI, long LOS in hospital/nursing home Immune system disorders (AIDS) Psoriasis Idiopathic; heredity predisposition Tx: Corticosteroids; dandruff shampoos

Furuncle (L02) Usu. caused by Staphylococcus aureus
Other bacteria or fungi found on skin surface Face, neck, armpit, buttocks, thighs, anywhere One OR many boils

Impetigo (L01) Superficial skin infection Vesicular/Pustular lesions,
Staphylococcus aureus or Streptococcus Insect bites, scabies, poor hygiene, anemia, malnutrition, eczema (loss of skin integrity) Highly contagious, Warm weather Face, arms/legs, anywhere Vesicular/Pustular lesions, Rupture -Form thick, yellow crusts Children, 2 – 6 yo MedlinePlus

Ingrowing nail (L60.0) Edge of nail grows down/into skin of toe
Can be pain, redness, and swelling around nail Cause: usu. Poorly fitting shoes & improperly trimmed nails Dangerous for DM

Lupus erythematosus (L93.0)
AKA Local, Discoid, Chronic Cutaneous Lupus (CCLE), Discoid Lupus (DLE) Chronic skin disease Primarily women 20 – 40 Characterized by eruption of red lesions over cheeks & bridge of nose Scarring w/ altered pigmentation Exacerbated by trauma & sunlight Tx: Sunscreen, Topical Corticosteroids Systemic Agents

Onychia/Paraonychia (L03.0)
AKA onychitis Inflammation of finger/toenail matrix; may lose Paraonychia Superficial infection of epithelium lateral to nail plate Acute More painful (usu. Bacterial) Chronic (often several nails) (usu. Fungal) Culture of exudate to determine etiology RF – Hands in water for long periods

Onycholysis (L60.1) Spontaneous separation of nail plate Etiology
Starting at distal free margin & progressing proximally Beginning at proximal nail & extending to free Most often in psoriasis of nails (onychomadesis) Just at lateral borders (Rare) Etiology Endogenous, exogenous, hereditary, &idiopathic Contact irritants, trauma, & moisture Associated with many other diseases Tx: Depends on Cause

Onychogryphosis (L60.2) Gk, onyx + gryphein, to curve
Abnormal hypertrophy & curving of nails Gives a claw-like appearance

Parapsoriasis (L41) 2 general forms Small plaque type, usu. B9
Tx: emollients, topical tar, steroids, phototx Large plaque type, precursor of cutaneous T-cell lymphoma (CTCL). Tx: phototherapy or topical corticosteroids

Parapsoriasis (L41.x) No uniform, accepted definition
Group of skin diseases characterized by Scaly patches OR Slightly elevated papules and/or plaques Resemblance to psoriasis BUT includes several inflammatory cutaneous diseases unrelated in pathogenesis, histopathology, & tx response

Pemphigoid vs Pemphigus
Separate autoimmune diseases Both have sub types Both cause burn-like blisters Both very rare; can’t be cured PemphigoiD = Deep PemphiguS = Superficial Pemphigoid more common, less dangerous Tends to affect older people, usually 60+

Pemphigoid (12.9) Gk pemphix, blister Autoantibodies –
Against basement membrane of epidermis Not against epidermal cell junctions Intact, tense bullae up to 3 cm Trunk, arms, & legs Rare in mouth

Pemphigus (L10) Group of disorders caused by auto-antibodies against some part of epidermis Including Oral mucosa Lead to disruption of intercellular junctions and blisters Ruptured bullae covered with scabs Tx: Immunosuppressive agents Prognosis is variable Many patients - higher than normal mortality rate

Pemphigus Risk Factors
Possible triggers Non-steroidal anti-inflammatory drugs such as ibuprofen Drugs derived from penicillamine Herpes simplex virus Exposure to sunlight Long-term stress

Pilonodal Cyst/Sinus Latin - pilus (hair); nidus (nest) nest
Abnormal pocket in skin, usu. contains hair, skin debris & other abnormal tissue Almost always located near tailbone at top of buttocks cleft (small pit) Affect men more often; most commonly in young adults When becomes infected (abscess) causes pains, inflammation & usu. drainage of fluids

Pilonidal Cyst (L05) Risk Factors
Obesity, Inactive lifestyle Occupation or sports requiring prolonged sitting Excess body hair; Stiff or coarse hair Poor hygiene; Excess sweating When chronically infected pilonidal cyst isn't treated properly Increased risk of developing squamous cell carcinoma.

Pilonidal Sinus Hair may protrude from tract below skin’s surface that connects infected pilonidal cyst to opening on skin's surface More than one sinus tract may form Tx: I&D, currettage May be left open to heal MedlinePlus

Psoriasis, Gk - itch Non-infective
Thick, flaky, various-sized red patches Covered with white, silvery scales Scales progress to plaques, sometimes pustules Chronic condition, most common bet yo Scalp, outer arms/legs, trunk, palms/soles, nail beds (nails thicken, crumble) Genetic basis Maybe autoimmune Whites - more common

Psoriasis, Arthropathic (L40.50)
Several different forms Small distal joints, fingers & toes Joints on one side of body only Bilateral larger joints Back and spine psoriatic arthritis mutilans (rare) - joints & bones destroyed (gnarled,club-like hands & feet) (L40.52) Symptoms of psoriasis usu. Precede arthritis Clue to possible joint disease is pitting and other changes in fingernails

Psoriasis (L40) Precipitating factors Remissions and Exacerabations
Hormonal changes, climate changes, emotional stress, poor health Remissions and Exacerabations Guttate psoriasis – Rare form Frequently follows Strep infection L, drop MedlinePlus

Psoriasis and Nails Nail changes occur in
Up to 50 % of psoriasis patients Up to 80 % psoriatic arthritis patients Most common Nail problems in psoriasis Pitting—shallow or deep holes in nail Deformation—alterations in normal shape of nail Thickening of nail Onycholysis—separation of nail from nail bed Discoloration—unusual nail coloration, such as yellow-brown

Radiodermatitis (L58) Cutaneous inflammatory reaction
Acute or Chronic Exposure to biologically effective levels of ionizing radiation Most common example of normal tissue damage as a result of radiotherapy About 95% of radiation oncology patients 87% moderate to severe radiodermatitis

Radiodermatitis Includes Late effects (90 days to years after tx)
Localized erythema & edema Grade 1 Skin shedding (desquamation) Hair loss (epilation) Fibrosis Necrosis (ulcers/hemorrhages) Grade 4 Late effects (90 days to years after tx) Result of permanent damage to dermis Atrophy, fibrosis, telangiectasias, & pigmentation changes Tx: Depends on Grade

Rosacea L, rosaceus, rosy
Facial skin redness, where blushing occurs Insidious onset Mistaken for sunburn or acnes Becomes more noticeable /does not go away Dryness, pimples (pustular) Small blood vessels dilate Knobby bumps on nose, looks swollen Usu. Male patients

Rosacea (L71) Unknown etiology Lighter complexions – higher risk
May be inherited Lighter complexions – higher risk Not infectious/contagious Triggers vary from person to person Sunlight, hard exercise, extreme heat/cold, stress, spicy foods, hot drinks, alcohol, hot/cold weather, wind Tx: topical antibiotics, Finacea, laser surgery, sunscreens

Scalded Skin Syndrome (L00)
AKA - Ritter disease; Staphylococcal scalded skin syndrome (SSS) Infection - skin becomes damaged & sheds certain strains of Staphylococcus Toxin causes skin damage Blisters as if skin were scalded Most commonly in infants & children under 5 Tx: IV antibiotics and fluids

Seborrheic Keratosis (L82)
S&S, cont. Located on face, chest, shoulders, back, or other areas Usu. painless, but may irritate & itch Yellow, brown, black, or other colors Slightly raised, flat surface; rough or wart-like texture May be single, but usually many AKA Seborrheic Wart B9 skin tumor Usu. After age 40 Runs in families S&S Often waxy surface Round-to-oval “Pasted-on" appearance

Sunburn (L55) Severity determined by depth of burn 1st 2nd 3rd degree
Damage to epidermis Erythema (Pain, Redness, Swelling) 2nd Damage to Dermis; Erythema, Blisters 3rd degree Damage to Hypodermis & Nerve supply Numbness; then scars Loss of sensation/function possible

Burn Severity

Ulcers L, ulcus, a sore Circumscribed, craterlike lesion of he skin or mucous membrane Resulting from necrosis accompanying some inflammatory, infectious, or malignant processes Produced by sloughing of necrotic inflammatory tissue

Ulcers, Non-Pressure (L97)
Arterial ulcers Venous stasis ulcers Diabetic ulcers Neurotrophic ulcers NOT pressure ulcers

Arterial ulcers Complete or partial arterial blockage
Causes tissue necrosis and/or ulceration of extremity AKA Ischemic ulcer Large/small vessel; toes, ankles, fingers Risk Factors Peripheral vascular disease (PVD) Diabetes mellitus Advanced Age Tx: Surgical or Medical to increase circulation

S&S of Arterial Ulcer No pulse in area of extremity
Painful ulceration Cool or Cold skin Small, punctate ulcers; usually well defined Delayed capillary return time Briefly push on end of toe and release Normal color should return to toe in <3 seconds Atrophic appearing skin (shiny, thin, dry) Loss of digital & pedal hair Frequently on dorsal foot; occur anywhere

Venous stasis ulcers AKA Varicose Ulcers Venous Stasis Location
Cessation or impairment of venous flow AKA phlebostasis, venostasis Location Below knee – usu. Inner part of leg, just above ankle. Can be uni/bilateral Tx: Bed rest, elevation, & pressure bandages Antibiotics if needed for infection

Venous stasis ulcers (I83)
Common in patients w/Hx of leg swelling Varicose veins Hx of blood clots in superficial OR deep leg veins Affect 500, ,000 people in US yearly Account for 80 to 90 % of all leg ulcers

Diabetic ulcers (E08-E11) Most common foot injuries leading to lower extremity amputation Risk of LE amputation times higher in diabetics Early detection/appropriate treatment of diabetic ulcers may prevent up to 85 % of amputations Ulcers almost always form in patients with neuropathy Typically painless

Neurotrophic ulcers Occur primarily in Diabetics – see Diabetic ulcer
% of Diabetics - mild to severe forms of nervous system damage Can affect anyone w/ impaired sensation in feet Predominantly sensory neuropathy, Sensory-motor neuropathy, or Autonomic neuropathy Essential cryoglobulinemic vasculitis

Ulcers, Pressure (L 89) Localized injury to skin and/or underlying tissue Usually over bony prominence Result of pressure, or Pressure in combination w/shear and/or friction 6 stages NPUAP, 2007 Tx: Decrease pressure, friction and shear

Ulcers, Pressure AKA Bed Sore Decubitus ulcer Plaster ulcer
Pressure area Pressure sore Slough [sluf] Layer/mass of dead tissue separated from surrounding living tissue Eschar - hard crust or scab

Pressure Ulcer Stages Suspected Deep Tissue Injury Stage I
Purple or maroon localized area of discolored intact skin or blood-filled blister Due to damage of underlying soft tissue from pressure and/or shear Stage I Intact skin w/ non-blanchable redness of localized area Usu. Over bony prominence Darkly pigmented skin may not visibly blanch Color may differ from surrounding area

Pressure Ulcer Stages Stage II Stage III
Partial-thickness loss of dermis Shallow open ulcer w/ red pink wound bed, w/o slough May also present as an intact or open/ruptured serum-filled blister Stage III Full-thickness tissue loss SQ fat may be visible but bone, tendon or muscle are NOT exposed Slough may be present but does not obscure depth of tissue loss May include undermining and tunneling

Pressure Ulcer Stages Stage IV Unstageable
Full thickness tissue loss w/ exposed bone, tendon or muscle Slough or eschar may be present on some parts of wound bed Often includes undermining & tunneling Unstageable Full thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in wound bed

Risk Factors for Pressure Ulcers
Age Reduced skin cell turnover, drier skin, reduction of collagen & elastin, & reduced vascularity at dermal/epidermal junction cause Skin less resistant to shear forces Increased surface area (potential fluid loss increase) Increased traumatic injury risk (e.g. skin tears) Decreased homeostasis Reduction of barrier function

RF for Pressure Ulcers Thin Body Nutrition & Hydration
More prone to develop pressure ulcers over bony prominences Nutrition & Hydration hypoalbuminemia, weight loss, cachexias, dehydration, and malnutrition commonly reported risk factors predisposing persons to pressure ulcer. Pressure ulcers can generate stress response, which further adds to nutritional needs Lower dietary protein intake

RF for Pressure Ulcers Inability to feed oneself
Particular Medical Conditions Diabetes Malnutrition Altered mental status Spinal cord injury Orthopedic injury Depression Vascular disease Anaerobic waste products believed to accumulate due to pressure-induced occlusion of lymphatic vessels & contribute to tissue necrosis

PU Assessment Tools Braden Scale Norton Scale
Most researched, validated, & nationally recognized tool Comprehensive May not have same predictive value & accuracy in LTC Not readily used in outpatient clinic setting View tool at Norton Scale Short, straightforward, easy to complete Does NOT address nutrition View tool at

Unavoidable Pressure Ulcers
CMS definition in LTC “An unavoidable pressure ulcer occurs when facility staff evaluated resident’s clinical condition and pressure ulcer risk factors, defined and implemented interventions consistent with resident needs, goals, and recognized standards of practice, monitored and evaluated impact of interventions, and revised approaches as appropriate.”

Urticaria L, urtica, nettle
AKA – Hives Severe itching, then redness, then wheal Localized, various sizes Can include GI tract – abdominal colic Pharynx – can cause asphyxiation Deep tissues = angioedema – more serious Usu. Short duration, can become chronic

Urticaria (L50) Dermis Acute hypersensitivity Release of histamine
Local inflammation, vasodilation, edema Allergic reaction Shellfish, strawberries, peanuts, etc. Insect stings Infection, Sunlight, Temperature extremes Tx: epinephrine, prednisone

Skin Injuries & Neoplasms
Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes Chapter 2 (C00-D49) – Malignant Neoplasms

Skin Injuries in ICD-10-CM
Exfoliation Desquamation External Constriction Foreign Body Frostbite Incision Laceration Wound Abrasion Excoriation Avulsion Wound, Open Bite (nonvenomous) Superficial Open Blister (nonthermal) Burn Contusion Corrosion

Abrasion L: abradere, to scrape off
Rubbing away of skin surface by friction against rough surface, usu. Not deeper than epidermis, can bleed Mild abrasion (Graze) does NOT scar Deep abrasion may scar AKA – Scrape, Scratch, Excoriation Types Rope burn, friction burn, road rash, rug burn

Avulsion of Skin L, avulsio, a pulling away
Avulsion injury - removal of all layers of skin Chunk of tissue removed from body Includes all 3 layers of skin at minimum More than simple lacerations; less than amputations Etiology: Animal bites, industrial equipment, or MVAs Skin flap or Degloving Higher Risk of Infection

Bite (Non-venomous) Wound or puncture made by living organism
Superficial = Skin Open = Communicates directly with atmosphere Pets, Humans, Insects, Snakes, etc. Can be heavily contaminated

Blister (Non-thermal)
Friction (New Shoes) Abrasion Blister Electricity Chemicals Radiation from sun Cold Pinched skin (blood blister)

Burn (T20-T25) Electrical heating appliances Electricity Flame
Friction Hot air and hot gases Hot objects Leading cause of injury in US Lightning Radiation Scalds Chemical Burn (Corrosion) NOT Sunburn

Burns 85%–90% caused by heat
10%–15% frostbite, chemical, & electrical damage million burns each year in U.S 60,000 to 80,000 burn victims hospitalized 5,000 people die 35,000 to 50,000 people - temporary or permanent disability 2ndary to burns

Degrees of Burns Newer terminology Older Terminology
Superficial partial thickness; epidermis and upper part of dermis injured Deep partial thickness; epidermis & large upper portion of dermis injured Full thickness; all layers destroyed Older Terminology 1st degree; outer layers of epidermis injured, erythema, but no blistering 2nd degree; epidermis into dermis but basal layer remains, blistering 3rd degree; all epidermis & dermis destroyed; only white eschar remains 4th degree; muscle, nerve and bone damaged

Degrees of Burns 4th degree burns extend to tissue
5th degree extends to bone 6th degree burns are through bone Old classification system

Rule of Nines for Burn Extent
Total Body Surface Area (BSA) (Adults) Age Infants, children, & elderly survival Total Body Surface Area greater area of involvement ~ prognosis Depth of Burn— More Total BSA ~ full thickness, prognosis Other Injuries - Prognosis as concurrent injuries increase

Burn Treatment Determined by Degree and Extent of Burns
Table of Treatment Modalities by Burn Degree Rehabilitation of Burn Injuries

Contusion L, contundere, to bruise AKA Bruise
Injury that does not disrupt integrity of skin Caused by blow to body Characterized by swelling, discoloration, & pain

Corrosion (T20-T25) L, corrodere, to gnaw away
Tissue damage due to exposure to strong alkali or acid Main types of irritant and/or corrosive Acids, bases, oxidizers, solvents, reducing agents and alkylants Types of chemical weapons Vesicants or Urticants

External Constriction
Classified as superficial injury Ex: Hair tourniquet syndrome AKA hair strangulation External constriction of finger, toe, or external genitalia by hair OR thread, ring, rubber band, other object that can go around a body part Relatively common in infants Can be emergency situation Object NOT removed; infection or amputation

Foreign Body Any object or substance found in organ or tissue in which it does NOT belong under normal circumstances Superficial Open Wound w/FB

Foreign Body Accidental/unintentional Iatrogenic Intentional
From abrasions & open wounds in various accidents or GSWs, May elicit FB-type granuloma formationr Intentional Introduced in context of sexual deviancy Anorectum or vagina - vibrators, bottles, light bulbs, eggs, etc. Iatrogenic Sutures, sponges, instruments left during surgery Metals & plastics replacing/enhancing failing/non-functioning body parts

Frostbite Superficial RF: IF blood vessels NOT damaged
Damage to skin caused by extreme cold Red, painful, Blisters, Gangrene Hands, feet, nose, & ears most common areas RF: Beta-blockers Peripheral vascular disease Smoke, Diabetes Raynaud phenomenon IF blood vessels NOT damaged Complete Recovery Possible

Incision Neat, Clean cut Surgery Sharp instrument, such as knife

Wound Laceration Puncture wound W/Without FB Dull, Blunt instrument
Jagged, irregular wound Some tearing, breaking of tissue Puncture wound Sharp, pointed object pierces skin Can be deep; look insignificant Anaerobic infection risk W/Without FB

Lacerations From shallow cuts to deep gashes penetrating thru muscle to internal organs/bone Superficial laceration involves only skin Deeper laceration may penetrate veins or arteries Blood vessel may require repair Causes - include accidents at home & work, motor vehicle crashes, & violence

Open Wound vs Superficial
Open wounds Animal bites, avulsions, cuts, lacerations, puncture wounds, traumatic amputations Superficial injuries Animal bites that do NOT break all skin layers Abrasions or contusions Skin tears (Elderly, etc.)

Gunshot wounds Skin Damage = external, surface wounds caused by a bullet Usually, entrance wound smaller/tidier than exit site Amount of injury at entrance/exit (if present) sites related to Caliber of bullet Angle at which bullet traverses tissues Distance from gun Type of bullet

Integumentary System Neoplasms
Benign usu. Need ONLY cosmetic tx Most common cancers in US C43-44 Melanoma and Other malignant Neoplasms of Skin BCC SCC Melanoma Merkel Cell Ca C50 Malignant Neoplasm of Breast C ndary Malignant Neoplasm of Skin C84.0 Cutaneous Lymphoma

Benign Neoplasms of Skin
Acrochordon Skin tag Cherry angioma Dermatofibroma Dermatosis papulosa nigra Ephilides Freckles Epidermal inclusion cyst Lentigines Liver spots Lipoma Milium Nevus Mole Pyogenic granuloma Sebaceous hyperplasia Seborrheic keratosis

Keratinocyte cancers Most common non-melanoma skin cancers
Cells share some features of keratinocytes Most abundant cell type of normal skin Most common types of keratinocyte cancer Basal cell carcinoma Squamous cell carcinoma

Other Skin Cancers Other non-melanoma skin cancers include
Merkel cell carcinoma Kaposi sarcoma Cutaneous (skin) lymphoma Skin adnexal tumors Various types of sarcomas

Basal Cell Carcinoma About 80% of skin cancers
Sun-exposed areas, especially head & neck Slow growing, seldom spread BUT IF left untxed; can invade & metastasize Can recur at same place Increases chance of getting BCC elsewhere Up to 50% of people will get new BCC w/in 5 years

Breast Cancer 2 main types Ductal carcinoma Lobular carcinoma
Begins in tubes (ducts) that move milk from breast to nipple Most breast cancers Lobular carcinoma Begins in lobules that produce milk Rarely, can begin in other breast areas

Breast Cancer Invasive Noninvasive
Spread from milk duct or lobule to other breast tissues Noninvasive NOT yet invaded other breast tissue “In situ“ Women - 1 in 8 will be DX w/breast cancer Men - <1% of all cancers in men < 1% of all diagnosed breast cancers

Breast Ca Risk Factors Age and gender Family Hx of breast cancer
50 + Women times more likely to get than men Family Hx of breast cancer Close relative had breast, uterine, ovarian, or colon cancer % of women w/ breast cancer have family hx Genes BRCA1 and BRCA2 genes Menstrual cycle Early periods (before age 12) Menopause late (after age 55)

Breast Ca Risk Factors Alcohol use DES – Childbirth HRT – Obesity –
1 - 2 glasses + daily Childbirth NO children or after age 30 Being pregnant 2+ times reduces risk Pregnancy at early age reduces risk Dense Breast tissue Being White DES – Increased risk of breast cancer after age 40 HRT – Estrogen for several years Obesity – Link is controversial Radiation Tx Child or young adult Treat ca of chest area

Breast Cancer Tx Six types of standard treatment
Surgery Sentinel lymph node biopsy followed by surgery Adjuvant Tx Radiation therapy Chemotherapy Hormone therapy Targeted therapy Various combinations based on Pt and Stage

Breast Cancer Surgery Breast-conserving surgery
Remove cancer but not breast Lumpectomy: Surgery to remove a tumor (lump) & small amount of normal surrounding tissue Partial mastectomy: Remove part of breast w/cancer & some normal tissue Lining over chest muscles below cancer may be removed AKA segmental mastectomy Lymph Node Dissection (separate incision)

Breast Ca Surgery Total (Simple) Mastectomy
All breast tissues Modified Radical Mastectomy Whole breast, many of lymph nodes, lining over chest muscles; sometimes, part of chest wall muscles Breast Reconstruction At same time OR later

Radiation for Breast Ca
External radiation therapy Machine outside body sends radiation to cancer Internal radiation therapy Radioactive substance sealed in needles, seeds, wires, or catheters Placed directly into or near cancer

Chemotx for Breast Cancer
Systemic chemotherapy Chemotherapy taken by mouth or injected into vein or muscle Drugs enter bloodstream, & can reach cancer cells throughout body Regional chemotherapy Chemotherapy placed directly into CSF, organ, body cavity (such as abdomen) Drugs mainly affect cancer cells in those areas

Hormone Tx for Breast Ca
Hormone therapy Removes hormones OR blocks action Stops cancer cells from growing Some hormones can cause certain Ca When tests show cancer cells have hormone receptors Drugs, surgery, or radiation tx used to reduce production of hormones or block them from working

Targeted Tx for Breast Ca
Uses drugs or other substances ID & attack specific cancer cells without harming normal cells Monoclonal antibodies and Tyrosine kinase Used to treat Breast Ca

Cutaneous (skin) lymphoma
Cancers of lymphocytes (white blood cells) Primarily involving skin Classification is based on lymphocyte type B-lymphocytes (B-cell) T-lymphocytes (T-cell) (CTCL) Most common Red, scaly patches or thickened plaques of skin Often mimic eczema or chronic dermatitis More common in men; after age 50

CTCL Most common type of Skin Lymphoma Treatment Two most common types
Red, scaly patches or thickened plaques of skin Often mimics eczema or chronic dermatitis More common in men; after age 50 Two most common types Mycosis fungoides & Sezary syndrome Treatment Topical Corticosteroids, Topical Chemo, Retinoids Systemic IV Steroids IV Retinoids IV/ Oral Chemo Light Therapy Immunotherapy Radiation Therapy

Melanoma Less than 5% of skin cancer cases
BUT causes large majority of skin ca deaths About 76,250 new melanomas dx 44,250 men & 32,000 women Incidence rates for melanoma rising for 30+ yrs 9,180 are expected to die of melanoma 6,060 men & 3,120 women 2004 to Death rate in whites Dropped those < 50 Stable in women Rising in men > 50

Melanoma Lifetime risk Risk increase with age 2% (1 in 50) for whites
0.1% (1 in 1,000) for blacks 0.5% (1 in 200) for Hispanics Risk increase with age One of more common cas in young adults

Melanoma Risk Factors Ultraviolet (UV) light exposure
Sun and Tanning beds Dysplastic nevi Congenital melanocytic nevi Fair skin, freckling, & light hair Personal Hx of melanoma Immune suppression Age Gender (Male) Xeroderma pigmentosum

S&S of Melanoma ABCDE rule
Asymmetry One half of mole or birthmark does not match other half Border Edges irregular, ragged, notched, or blurred Color NOT same all over & may include shades of brown/black, sometimes patches of pink, red, white, or blue. Diameter Spot >6 mms across– size of pencil eraser, BUT melanomas can be smaller Evolution Any changes in skin lesions, new skin lesions, or growths that look different from moles

S&S of Melanoma Other warning signs Sore doesn’t heal
Pigment spreads from border of spot to surrounding skin Redness or new swelling beyond border Change in sensation itchiness, tenderness, or pain Change in surface of a mole scaliness, oozing, bleeding, or bump/nodule appears

Melanoma Staging The American Joint Committee on Cancer (AJCC) TNM system T ~ Tumor 0-4 a, b N ~ Node 0-3 a, b, c M ~ Metastasis Tx: Based on Stage Surgery Chemotherapy Immunotherapy Radiation therapy

Melanoma Survival Rates
Stage IA 5-year ~ 97% 10-year ~ 95% Stage IB 5-year ~ 92% 10-year ~ 86% Stage IIA 5-year ~ 81% 10-year ~ 67% Stage IIB 5-year ~ 70% 10-year ~ 57% Stage IIC 5-year ~ 53% 10-year ~ 40% Stage IIIA 5-year ~ 78% 10-year ~ 68% Stage IIIB 5-year ~ 59% 10-year ~ 43% Stage IIIC 5-year ~ 40% 10-year ~ 24% Stage IV 5-year ~ 15%-20% 10-year ~ 10%-15%

Merkel Cell Ca Rare skin ca, but incidence increasing world-wide
Metastasizes quickly Merkel cells at base of epidermis Nodule flesh-colored OR bluish-red, shiny, painless Usu. on face, head, neck; also on limbs or trunk Risk Factors Age, sun exposure, weak immune system, other skin ca, light skin 80% of 10 Merkel cell cas are thought to be related to MCV (Merkel Cell Polyomavirus) AKA Neuroendocrine carcinoma of skin

Merkel Cell Ca Metastasis Prognosis Diagnosis Tx
Liver, Bones, Lungs, Brain Prognosis 33% fatality rate Diagnosis PE, Bx, Sentinel Node Bx, x-rays, CT, PET, octreotide scan Tx Surgery (Mohs), Radiation, Chemo

Squamous Cell Carcinoma
About 20% of skin cas are SCC Sun-exposed areas of body Face, ears, neck, lips, & backs of hands Scars or skin ulcers elsewhere Sometimes begin in actinic keratoses Genital area skin

Squamous Cell Ca More aggressive than BCC
More likely to invade fatty tissues just under skin More likely to spread to lymph nodes and/or metastasize Squamous cell carcinoma in situ AKA Bowen disease Still w/in the epidermis

2ndary Skin Cancers Cancer cells can grow in skin
NOT skin cancer, melanoma, or cutaneous T cell lymphoma Secondary cancer may start to grow On/ near operation scar where primary cancer was removed In other parts of body Secondary skin cancer looks like a pink/red raised lump These nodules can be treated

Questions from Last Session
ICD-10-CM/PCS Implementation date Proposed Rule – Federal Register on April 17, Proposed rule available for comment for 30 days Announcement in June?

Questions from Last Session
Timeline for Required ICD-10-CM/PCS CEs? “CCHIIM will send out a communiqué within 30 days of final decision by HHS on ICD-10 implementation date to address ICD-10 CEU requirements and launch date for ICD-10 compliant exams. Certified professionals are still encouraged to obtain their ICD-10 required CEU’s for submission by December 31, 2013.” Please be aware that delay is not finalized until official notice is send out from HHS Linda DeViller, AHIMA 6/18/2012

Query Example Liposuction of lipomas ICD-10-CM ICD-10-PCS
Location of lipomas ICD-10-PCS INTENT of Root operation Medical reason ~ Extraction Cosmetic reason ~ Alteration What is missing from above statement? What would we need to query for?

Homework Pressure Ulcer Online Training. The National Database of Nursing Quality Indicators® Four Modules Pressure Ulcers and Staging Other Wound Types and Skin Injuries Pressure Ulcer Survey Guide Community vs. Hospital/Unit Acquired Pressure Ulcers CE certificate when all completed w/tests CEs

General Resources Cohen, B. A., Lehmann, C. U. Dermatology Image Atlas. Johns Hopkins University, Dermatology A to Z. AAD. MedlinePlus Swanson, J. R. & Melton, J. L. Dermatology Atlas. Chicago: Loyola University Dermatology Medical Education Website

Resources About Cutaneous Lymphoma. Cutaneous Lymphoma Foundation.
Acute Lymphangitis. Medical Dictionary Article. Armstrong, D. G. & Lavery. L. A. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. AAFP.

Resources Breast Cancer Treatment (PDQ®). National Cancer Institute.
Characteristics of Arterial Ulcers. Wound Educators. YouTube. Common Benign Growths. Dermatology. Cleveland Clinic.

Resources Cutaneous Lupus Erythematosus. Family Practice Notebook.
Evaluation of an Acute Wound. Chapter 6. Gunshot Wounds. Chapter 7.

Resources Lymphadenitis. Medical Dictionary Article.
Gun Shot Wounds. Wheeless' Textbook of Orthopaedics. Duke Orthopedics. Lymphadenitis. Medical Dictionary Article. Practical Plastic Surgery.

Resources Peripheral Neuropathy Fact Sheet. NINDS.
Rashes: MedlinePlus Medical Encyclopedia.

Resources Rose, L. C. Recognizing Neoplastic Skin Lesions: A Photo Guide. Am Fam Physician Sep 15: 58 (4): Skin Lesions. Article. Medical Dictionary. ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002

Questions ? ? ? Thank You !

Common Pathologies of the Integumentary System

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