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Inflammatory and Infectious Disorders of the Skin

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1 Inflammatory and Infectious Disorders of the Skin

2 Objectives 1. Describe and discuss, Dermatitis, Acne Vulgaris , Urticaria, Psoriasis, Seborrheic Keratosis. Scleroderma, Systemic Lupus Erythematous, Shingles,scabies, and impetigo as to definition, etiology, pathophysiology, signs and symptoms, diagnosis, medical and nursing management. 2. Apply the nursing process for clients with inflammatory and infectious disorders of the skin. 3. Recognize systemic disorders with dermatologic symptoms.

3 Dermatitis A general term used to describe inflammation of the skin.
Description Most types of dermatitis are characterized by an itchy pink or red rash Pruritus: itching May be localized or generalized

4 Types of Dematitis Allergic or contact dematitis is an allergic reaction to something that irritates the skin and is manifested by one or more lines of red, swollen, blistered skin that may itch or seep. It usually appears within 48 hours after touching or brushing against a substance to which the skin is sensitive. More common in adults than in children. Etiology: in patients with allergies, sensitized mast cells in the skin release histamine, causing a red rash, itching, and localized swelling

5 Types of Dermatitis Irritant dermatitis is a localized reaction that occurs when the skin comes into contact with a strong chemical such as a detergent Etiology: the caustic quality of the substance damages the protein structure of the skin or eliminates secretions that protect it.

6 Contact dermatitis of the (left) face and (right) wrist

7 Dermatitis

8 Contact dermatitis Vesiculation: blister formation and oozing
Can occur on any part of the body, but it usually affects the hands, feet, and groin. Contact dermatitis usually does not spread from one person to another, nor does it spread beyond the area exposed to the irritant unless affected skin comes into contact with another part of the body.

9 Contact dermatitis Medical Management: Remove the source of irritation
Flushing the skin with cool water Burow’s solution wet dressings Topical lotions such as calamine Antihistamines such as Benadryl (diphenhydramine) Corticosteroids: topically or orally


11 Poison Ivy/Oak

12 Poison Ivy Rash

13 Atopic Dermatitis This form of dermatitis, commonly referred to as eczema, is a chronic condition that causes itchy, inflamed skin. Most often, it occurs in the folds of the elbows, backs of the knees or the front of the neck. It tends to flare periodically and then subside for a time, even up to several years. The exact cause of this skin disorder is unknown, but it may result from a malfunction in the body's immune system.

14 Atopic Dermatitis: Eczema

15 Eczema: Atopic Dermatitis

16 Dermatitis Pathophysiology and Etiology Assessment Findings
Types: Allergic contact; primary irritant Assessment Findings Blood vessel dilation; itching; vesiculation Skin patch test; visual examination

17 Acne of (left) the face and (right) the chest
Acne Vulgaris Acne of (left) the face and (right) the chest

18 Acne Vulgaris Condition which coincides with puberty; believed to be related to hormone levels that occur when secondary sex characteristics are developing. An inflammatory disorder that affects the sebaceous glands and hair follicles Severity of the condition varies from minimal to severe

19 Acne Vulgaris Pathophysiology and Etiology Assessment Findings
Overproduction of sebum Assessment Findings Comedones (blackhead); oily scalp Visual examination Medical Management Gentle facial cleansing; drying agents containing benzoyl peroxide Topical and oral drugs and antibiotics Removal with instruments

20 Acne Develops as a result of blockages in follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen production . The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead). Increased sebum production provides an environment for the overgrowth of Propionibacterium acnes.

21 Acne Severe cases can cause permanent scarring
Medical Management: Gentle facial cleansing and non- prescription agents Drug therapy: Retin-A (tretinoin) topically or Accutane (isotretinoin) orally Antibiotics: tetracycline and erythromycin

22 Acne Vulgaris Surgical Management Nursing Management
Dermabrasion for surface scarring Nursing Management Client teaching Cleanliness: Face and hair Avoid cosmetics, Manipulation of lesions Precautions for pregnant women: Risk associated with systemic oral Retin - A (isotretinoin) for birth defects

23 Rosacea A chronic skin disorder that manifest in a variety of ways
Usually characterized by a rosy appearance Cause is unknown: possible genetics, immunological factors, exposure to UV light, bacterial skin infection with Helicobacter pylori or a mite infestation of the facial hair follicles Over time, continued dilation of facial capillaries and arterioles causing visible streaks on the skin called telangiectases

24 Rosacea

25 Rosacea S/S: Flushing of skin, like a persistent sunburn, face appears swollen and baggy, facial pores enlarge, nose becomes enlarged (rhinophyma) Medical Management: Antibiotics, topical medications Laser treatments; pulsed light treatments Nursing management: patient teaching re: reduce sun exposure, gentle cleansing, stress-management

26 Furuncles, Furunculosis and Carbuncles
Furuncle: a boil Furunculosis: multiple furnuculosis Carbuncle: a furuncle which drains pus Causes: skin infections caused by bacteria which normally live harmlessly on the skin Predisposition by: diabetes, poor diet and general health, immunodepression

27 Furuncle - Boil

28 Furuncle - Treatment C&S of pathogen
Hot wet soaks, antibiotics, surgical incision and drainage (I & D) Strict aseptic technique when changing dressings to avoid spreading the infection to other parts of the body

29 Question Is the following statement true or false?
Furuncles, furunculosis, and carbuncles are treated with antibiotic therapy.

30 Answer True. Furuncles, furunculosis, and carbuncles are the result of skin infection or diabetes mellitus. A culture and sensitivity lab result indicates the proper antibiotic to use in treatment.

31 Psoriasis Pathophysiology, Etiology: Likely genetic predisposition; Keratinocytes; Plaque Assessment Findings: Signs and Symptoms Erythema with silvery scales; Lesions Diagnostic Findings: Visual examination; Skin biopsy Medical Management: Symptomatic treatment; Drug therapy; Biologic therapy; Photochemotherapy

32 Psoriasis Named for the Greek word psōra meaning "itch," psoriasis is a chronic, non-contagious disease characterized by inflamed lesions covered with silvery-white scabs of dead skin.

33 Psoriasis                                       

34 Psoriasis Psoriasis on the elbows

35 Psoriasis                                       

36 Pathophysiology Normal skin cells mature and replace dead skin every 28–30 days. Psoriasis causes skin cells to mature in less than a week. Because the body can't shed old skin as rapidly as new cells are rising to the surface, raised patches of dead skin develop on the arms, back, chest, elbows, legs, nails, folds between the buttocks, and scalp.

37 Psoriasis is considered mild if it affects less than 5% of the surface of the body; moderate, if 5–30% of the skin is involved, and severe, if the disease affects more than 30% of the body surface.

38 Nursing Process: The Client With Psoriasis
Assessment Skin integrity; appearance Family history of psoriasis Triggering factors Diagnosis, Planning, and Interventions Impaired skin integrity Disturbed body image

39 Nursing Process: The Client With Psoriasis
Evaluation of Expected Outcomes Improved integrity and appearance of skin Reduced itching; copes effectively with altered appearance

40 Pediculosis DIAGNOSIS
Head and pubic lice infestations are diagnosed by finding lice or viable eggs (nits) on examination. Excoriations and pyoderma (any pus-containing skin infection) also may be present.

41 Pediculosis - Treatment
Topical Agents - Over-the-counter agents approved by the U.S. Food and Drug Administration (FDA) belong to the pyrethrum group of insecticides (pyrethroids). Both 4 percent piperonyl butoxide­0.33 percent pyrethrins (e.g., Rid, Pronto) and 1 percent permethrin (Nix) are safe and effective. Experts consider permethrin as the treatment of choice. Oral Agents. Ivermectin (Stromectol), in an oral dose of 200 mcg per kg, effectively kills nymphs and lice, but not eggs. To kill newly hatched nymphs, a second dose should be given seven to 10 days after the first dose..

42 Scabies Pathophysiology, Etiology: Itch mite; Spread by skin-to-skin contact Assessment Findings: Signs and Symptoms Itching; Excoriation Diagnostic Findings: Visual examination; Ink or mineral oil test Medical Management: Scabicide application; Thorough bathing, clean clothing, avoiding contact with those infected Nursing Management

43 Scabies Mite

44 Scabies

45 Treatment Apply a mite-killer like permethrin (brand name: Elimite).
These creams are applied from the neck down, left on overnight, then washed off. This application is usually repeated in seven days. An alternative treatment is 1 ounce of a 1% lotion or 30 grams of cream of lindane, applied from the neck down and washed off after approximately eight hours. Since lindane can cause seizures when it is absorbed through the skin, it should not be used if skin is significantly irritated or wet, such as with extensive skin disease, rash, or after a bath. As an additional precaution, lindane should not be used in pregnant or nursing women or children younger than 2 years old. Lindane is only recommended if patients cannot tolerate other therapies or if other therapies have not been effective.

46 2. An oral medication, ivermectin, is an effective scabicide that does not require creams to be applied. 3. Antihistamines, such as diphenhydramine (Benadryl) can be useful in helping provide relief from itching Wash linens and bedclothes in hot water. Because mites don't live long away from the body, it is not necessary to dry-clean the whole wardrobe, spray furniture and rugs, and so forth Treat sexual contacts or relevant family members (who either have either symptoms or have the kind of relationship that makes transmission likely).

47 Dermatophytoses Dermatophytose: Tinea: Caused by a parasitic fungi; which invade skin, scalp, and nails Ringworm; Athlete’s foot; Jock itch Assessment Findings: Rings of papules or vesicles; Sore skin Medical Management: Oral, topical antifungal agents Burow’s solution, Micatin (miconazole) Nursing Management: keeping skin day, avoid excessive heat and humidity, dry socks, don’t go barefoot in locker rooms

48 Ringworm - fungus (tinea corporis)

49 Ringworm - fungus

50 Athelete’s foot - fungus (tinea pedis)

51 Dermatophytoses Tinea named after the location on the body
Tinea pedis - foot Tinea capitis - head Tinea corporis - body Tinea cruris - groin

52 Shingles - Viral infection
Also called Herpes Zoster: Varicella-zoster virus; Inflammation in dermatome Virus remains dormant in the nerve roots More common in older adults and people who are immunocompromised Assessment Findings: Signs and Symptoms Fever; Headache; Vesicles; Itching, pain Medical Management: Oral or topical Zoviraz (acyclovir); Corticosteroids Nursing Management : warm soaks, avoid contact with immunocompromised patients

53 Shingles - Herpes Zoster

54 Shingles Patient is placed on AIRBORNE PRECAUTIONS: (particles are less than 5 mcg) Private room or cohort room; Masks, gowns and gloves for all patient care Door to room should remain closed Should be negative air pressure room Pregnant health care personnel who have not had chickenpox probably should not care for the patient

55 Shingles

56 Herpes Simplex - A recurrent viral disease caused by the herpes simplex virus
a. type one - marked by the eruption of fluid-containing vesicles on the mouth, lips, or face. b. type two - marked by the eruption of fluid-containing vesicles on the genitals Treatment Acyclovir (Zovirax) is the drug of choice for herpes infection and can be given intravenously or taken by mouth or ointment but is not very useful in this form. A liquid form for children is also available.

57 Herpes Simplex

58 Urticaria A vascular reaction pattern of the skin marked by the transient appearance of smooth, slightly elevated patches that are more red or more pale than the surrounding skin and are accompanied by severe itching. Also called hives.

59 Non-allergic urticaria
Mechanisms other than allergen-antibody interactions are known to cause histamine release from mast cells. For instance, a diverse group of signaling substances called neuropeptides have been found to be involved in emotionally induced urticaria.

60 Urticaria

61 Uticaria - Hives

62 Urticaria An acute or chronic condition characterized by the appearance of itchy weals on the skin. The cause may be an allergy to certain foods , drugs, emotional stress, or local skin irritation resulting from contact with certain plants. Athletes sometimes develop hives while exercising (exercise-induced urticaria). The hives are small and seem to develop in response to the release of histamines associated with the increase in body temperature produced by exercise.

63 Urticaria

64 Treatment & Management
Most treatment plans for urticaria involve being aware of one's triggers. If one's triggers can be identified then outbreaks can often be managed by limiting one's exposure to these situations.

65 Drug treatment Typically in the form of Antihistamines such as diphenhydramine, hydroxyzine, cetirizine and other H1 receptor antagonists. These are taken on a regular basis to protective effect, lessening or halting attacks. For some people, H2-receptor antagonists such as cimetidine (Tagamet) and ranitidine (Zantac) can also help control symptoms either protectively or by lessening symptoms when an attack occurs. When taken in combination with a H1 antagonist it has been shown to have a synergistic effect which is more effective than either treatment alone.

66 Seborrheic Keratosis A superficial, benign, verrucose lesion consisting of proliferating epidermal cells enclosing horn cysts, usually appearing on the face, trunk, or extremities in adulthood.

67 Seborrheic Keratosis

68 Sign And Symptoms The growths resemble flattened or raised warts, but have no viral origins and may exhibit a variety of colors, from pink or yellow through brown and black. Because only the top layers of the epidermis are involved, seborrheic keratoses are often described as having a "pasted-on" appearance.

69 Etiology A mutation of a gene coding for a growth factor receptor (FGFR3), has been associated with seborrheic keratosis.

70 Treatment Because the tumors are rarely painful, treatment is not often necessary. If a growth becomes excessively itchy, or if it is irritated by clothing or jewelry, cryosurgery has been found to be highly effective in their removal. With resemblance to malignant melanomas, which has sometimes led to a misdiagnosis of the cancerous lesions. If there is any doubt, a skin biopsy will allow a physician to make a correct diagnosis.

71 Scleroderma Scleroderma is a progressive disease that affects the skin and connective tissue (including cartilage, bone, fat, and the tissue that supports the nerves and blood vessels throughout the body). There are two major forms of the disorder. Localized scleroderma mainly affects the skin. Systemic scleroderma, which is also called systemic sclerosis, affects the smaller blood vessels and internal organs of the body.

72 Scleroderma


74 Scleroderma Is an autoimmune disorder, which means that the body's immune system turns against itself. In scleroderma, there is an overproduction of abnormal collagen (a type of protein fiber present in connective tissue). This collagen accumulates throughout the body, causing hardening (sclerosis), scarring (fibrosis), and other damage.

75 Therapy There is no cure for every patient with scleroderma, though there is treatment for some of the symptoms, including drugs that soften the skin and reduce inflammation. Some patients may benefit from exposure to heat. A range of NSAIDs (nonsteroidal anti-inflammatory drugs) can be used to ease symptoms, such as naproxen. If there is esophageal dysmotility .Care must be taken with NSAIDs as they are gastric irritants, and so a proton pump inhibitor (PPI) such as omeprazole can be given in conjunction.

76 Treatment Immunosuppressant drugs, such as mycophenolate mofetil (Cellcept®) or cyclophosphamide are sometimes used to slow the progress. Digital ulcerations and pulmonary hypertension can be helped by prostacyclin (iloprost) infusion. Iloprost increases blood flow by relaxing the arterial wall.

77 Sytemic Lupus Erythematous
Lupus is a condition characterized by chronic inflammation of body tissues caused by autoimmune disease. Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system.

78 SLE - NECK                  

79 Systemic Lupus Erythematosus
Medical Management: Producing remission; Prevent/Treat exacerbations; Medications Renal, Cardiac, GI, CNS symptomatic treatment Nursing Management

80 Systemic Lupus Erythematosus (SLE)
Pathophysiology, Etiology: Unknown triggering mechanism; Destruction of diffuse connective tissues; Affects multiple body systems; Autoimmune; Great imitator Assessment Findings: Signs and Symptoms Clinical signs; Facial rash; Behavioral disturbances; Fluid retention; Proteinuria; Hematuria; Many others Diagnostic Findings: Presenting symptoms; Blood tests; Renal biopsy; Urinalysis

81 Etiology The precise reason for the abnormal autoimmunity that causes lupus is not known. Inherited genes, viruses, ultraviolet light, and drugs may all play some role.

82 What is drug-induced lupus?
Dozens of medications have been reported to trigger SLE; however, more than 90% of this "drug-induced lupus" occurs as a side effect of one of the following six drugs: hydralazine (used for high blood pressure), quinidine and procainamide (used for abnormal heart rhythm), phenytoin (used for epilepsy), isoniazid ( used for tuberculosis), d-penicillamine (used for rheumatoid arthritis). These drugs are known to stimulate the immune system and cause SLE.

83 Criteria used for diagnosing SLE:
Molar rash (over the cheeks of face) “butterfly rash Discoid skin rash: patchy redness that can cause scarring Photosensitivity: skin rash in reaction to sunlight exposure Mucus membrane ulcers: ulcers of the lining of the mouth, nose or throat Arthritis: two or more swollen, tender joints of the extremities

84 Kidney abnormalities: abnormal amounts of urine protein or clumps of cellular elements called casts
Pleuritis/pericarditis: inflammation of the lining tissue around the Heart or lungs, usually associated with chest pain with breathing Brain irritation: manifested by seizures (convulsions) and/or psychosis Blood count abnormalities: low counts of white or red blood cells, or platelets Immunologic disorder: abnormal immune tests include anti-DNA or anti-Sm (Smith) antibodies, falsely positive blood test for syphilis, anticardiolipin antibodies, lupus anticoagulant, or positive LE prep test Antinuclear antibody: positive ANA antibody testing

85 Treatment There is no permanent cure for SLE.
The goal of treatment is to relieve symptoms and protect organs by decreasing inflammation and/or the level of autoimmune activity in the body. Many patients with mild symptoms may need no treatment or only intermittent courses of anti - inflammatory medications. Damage to internal organ(s) may require high doses of corticosteroids in combination with other medications that suppress the body's immune system.

86 Scalp and Hair Disorders: Seborrhea, Seborrheic Dermatitis, Dandruff
Pathophysiology, Etiology: Pityrosporum ovale Assessment Findings: Signs and Symptoms Oily hair; Red or scaly patches on scalp; White flakes from hair; Itching Diagnostic Findings: Laboratory blood work; Skin biopsy Medical Management: Medicated shampoos; Corticosteroids Nursing Management

87 Alopecia Pathophysiology, Etiology: Alopecia areata; Androgenetic alopecia (male pattern baldness) Assessment Findings: Signs and Symptoms Thinning hair Diagnostic Findings: Determined by suspected physical disorder Medical, Surgical Management: Treating the underlying medical disorder; Drug therapy; Hair replacement surgery; Hair grafting; Scalp reduction; Skin flap transfer Nursing Management

88 Patterns of Hair loss

89 Head Lice Pathophysiology, Etiology: Transmitted through direct contact Assessment Findings: Signs and Symptoms Itching of scalp; Small, yellowish-white ovals (nits) attached to hair shafts; Small grey nymphs; Silvery eggs (nits) attached to hair shafts Diagnostic Findings: Scalp, hair inspection Medical Management: Pediculicides; Mechanical removal Nursing Management

90 Head Lice

91 Head Lice

92 Head Lice


94 Nail Disorders: Onychomycosis
Pathophysiology, Etiology: Fungal infection Assessment Findings: Signs and Symptoms Thick, distorted; Yellow, friable nails Diagnostic Findings: Visual inspection; Microscopic examination Medical, Surgical Management: Prolonged systemic drug therapy; Nail removal; Surgery Nursing Management

95 Onychomycosis - fungal infection of toenails

96 Onychocryptosis - Ingrown toenail
Pathophysiology, Etiology: Inherited trait; Fungal nail infections Assessment Findings: Signs and Symptoms Swelling; Pain; Purulent drainage; Odor Diagnostic Findings: Physical examination Medical, Surgical Management: Local, systemic antibiotic therapy; Surgery Nursing Management

97 Onychocryptosis

98 Onychomycosis and Onychocryptosis
Both conditions usually treated by a podiatrist May require surgery Nursing Management: foot-soaks, wear wide shoes and loose socks; keep feet clean and dry

Bacteria, viruses, fungi, or parasites can cause infectious disorders of the skin. Treatment includes topical and systemic medications. Preventing the spread of infection to others is important.

100 Impetigo

101 Bacterial Infection- Impetigo
Impetigo : caused by the bacteria Staphylococcus aureus, (staph), and less frequently, by group A beta-hemolytic streptococci, (strep) Highly contagious. Spreads quickly from one part of the body to another through scratching. It can also be spread to other people if they touch the infected sores or if they have contact with the soiled clothing, diapers, bed sheets, or toys of an infected person. Such factors as heat, humidity, crowded conditions, and poor hygiene increase the chance that impetigo will spread rapidly among large groups.

102 Diagnosis Observation of the appearance, location and pattern of sores is the usual method of diagnosis. Fluid from the vesicles can be cultured and examined to identify the causative bacteria.

103 Treatment Uncomplicated impetigo is usually treated with a topical antibiotic cream such as mupirocin (Bactroban). Oral antibiotics are also commonly prescribed. Patients are advised to wash the affected areas with an antibacterial soap and water several times per day, and to otherwise keep the skin dry. Scratching is discouraged, and the suggestion is that nails be cut or that mittens be worn—especiallly with young children. Ecthyma is treated in the same manner, but at times may require surgical debridement, or removal of the affected area.

104 Exfoliative Dermatitis
Exfoliative dermatitis is widespread scaling of the skin, often with itching (pruritus), skin redness (erythroderma), and hair loss. It may occur in severe cases of many common skin conditions, including eczema, psoriasis, and allergic reactions. A person with erythroderma or exfoliative dermatitis often needs hospital care or admission to an intensive-care burn unit.

Localized symptoms include erythema, severe pruritis, extensive scaling, skin sloughing. Affects the entire body. Chills, fever, and malaise. Treatment includes fluids, corticosteroids, antibiotics, medicated baths, analgesia.

106 Exfoliative Dermatitis

107 Exfoliative Dermatitis

108 Stevens Johnson Syndrome

109 Stevens Johnson Syndrome
A severe, occasionally fatal, inflammatory disease of children and young adults A form of toxic epidermal necrolysis in which the epidermis separates from the dermis, leaving the client with a skin loss similar to a second degree burn Characterized by fever, bullae of the skin, and ulcers of the mucous membranes of the nose, mouth, eyes, and genitalia. May occur from a hypersensitivity reaction to drugs

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