1. Chapter 28: Skin Disorders

3. Skin Lesions Defined Skin pigment - melanin Normal skin appearance
Variations may be due to anatomic, physiologic or pathophysiologic changes in skin blood flow
Normal skin appearance
Altered by external and internal factors
Cellulitis
Infectious inflammation of deep skin structures

6. Mechanical Forces that Cause Injury
Skin Trauma
Mechanical Forces that Cause Injury
Friction
Compression
Shearing
Stretching
Scraping
Tearing
Avulsing
Puncturing

7. Friction and Pressure Problems
Hyperkeratosis of the Hands and Feet
Etiology
Friction and pressure over bony protuberances
Painful when subcutaneous fat becomes inelastic
Prevention
Cushioning devices; wearing 2 socks
Lubricants to reduce friction, shaving calluses
For calluses on hands, special gloves or protective gear

8. Sign and Symptoms Management
Thickening, of horny layer of skin, ovular, elongated and brown
Painful with pressure
Management
Avoid emery boards and pumice as the increase in friction will stimulate skin to produce added callus
Use moisturizer
Pair off callus with scalpel
Padding

9. Blisters Etiology Prevention Signs and Symptoms
Result of a shearing force that produces a raised area that accumulates with fluid
Prevention
Use of dust or powder or lubricant to reduce friction
Tubular socks, 2 pairs of socks if feet are sensitive or perspire excessively
Appropriate shoes that are broken in
Padding and lubricants
Signs and Symptoms
Hot spot, sharp burning sensation, painful
Superficial area of skin raised with clear fluid

10. Management (intact blister)
Leave intact for 24 hours
Clean with antiseptic
Cut small incision to drain fluid (large enough that it won’t re-seal)
Prevent refilling with a pressure pad
Clean again with antiseptic
Use doughnut to prevent irritation
Monitor for infection, replace wet bandaging
Debridement can be performed when tenderness is gone

11. Management (open/torn blister)
Keep clean to avoid infection
Keep skin in place and apply non-adhering sterile dressing and padding
Monitor daily for infection
Management (denuded blister)
If blister is torn 1/2 inch or more remove skin flap
Clean and expose area, apply antiseptic with occlusive dressing
Second skin can be applied to raw area

12. Soft Corns and Hard Corns
Etiology
Caused by pressure of improperly fitting shoes and anatomic abnormalities
Soft corns are the result of pressure and perspiration, also associated with exostosis
Signs and Symptoms
Hard corns form on the tops of toes and tend to be painful and dry
Soft corns result in thickening of skin, white and sometimes painful (between 4th and 5th toes)
Prevention
Wear properly fitting shoes
Management
Surgical removal if painful
Padding; maintain clean dry feet; wear appropriate shoes

13. Excessive Perspiration (hyperhidrosis)
Etiology
Syrup-like perspiration, high in sodium chloride
Increases risk of other skin irritation
Makes adherence of bandages difficulty
Management
Use of astringent such as alcohol or an absorbent powder
Aluminum chloride or electric current can be used to treat condition

14. Chafing of Skin Etiology Signs and Symptoms Prevention Management
Occurs particularly in athletes that are obese or heavy limbed
Result of friction and maceration of skin in climate of heat and moisture
Signs and Symptoms
Separation of keratin from granular layer of skin
Causes oozing wounds that crust and crack
Prevention
Keep skin dry, clean, and friction free
For the groin, soft, loose, cotton underwear is recommended
Management
Clean area with soap and water and treat with medicated solution and hydrocortisone cream

15. Xerotic (Dry) Skin Etiology Signs and Symptoms Management
Drying of skin due to exposure of cold, excessive bathing, decrease in humidity causing skin to lose water
Signs and Symptoms
Dry skin w/ variable redness and scaling; itching
Management
Prevent water loss and replace lost water
Bathe in tepid water, use moisturizer
If condition worsens, refer to physician

16. Ingrown Toenails Etiology Generally occurs in great toe
Nail grows laterally into skin
Result of lateral pressure from shoes, poor nail trimming, and repeated trauma

17. Signs and Symptoms Prevention Management Pain and swelling
Penetrated skin becomes inflamed and purulent with lateral nail fold swollen and irritated
Prevention
Properly fitting shoes and socks are essential
Weekly toenail trimming (cut straight across)
Leave nail long enough to clear skin
Management
Conservative management includes soaking the inflamed toe in warm water (20 minutes)
Place cotton under edge of nail to clear from skin
If chronic, remove wedge of nail and apply antiseptic compress until inflammation resides

18. Wounds Abrasions Punctures
Scraping of skin against rough surface (top surface of skin is worn away)
Increased probability of infection due to exposure of dirt and foreign material
Clean and debride
Punctures
Direct penetration of skin with pointed object
Must be referred to physician

20. Lacerations Skin Incision Skin Avulsion
Object tears tissue, giving wound appearance of jagged edge (sometimes result of blunt trauma)
Presents environment susceptible to infection
Skin Incision
Smooth cut in skin - not jagged
Skin Avulsion
Skin torn away from body (should be placed in moist gauze w/in a plastic bag that is then immersed in cold water)
Transport to hospital with athlete for possible reattachment

22. Skin Bruises
Result of blunt trauma; causes disruption of superficial blood vessels and results in black and blue discoloration
Treatment requires RICE to control hemorrhaging

23. Wound Management All wounds must be assumed contaminated
Pay close attention to all universal precautions
Clean all wounds with soap and water to minimize infection
Apply a dressing with antiseptic (unless physician examination is necessary)
Lacerations and punctures should be treated by a physician
Use of occlusive dressings
Minimizes scab formation, perceived pain from exposed nerves, cost and time effective, provide adequate barrier
Antibiotic ointment used to prevent secondary infection (SEE TABLE 28-4 for added instruction)

24. Athletic Training Room Practice in Wound Care
Use clean and sterile instruments
Clean hands thoroughly and use gloves
Clean in and around skin lesion
Use a non-medicated covering if athlete is to be sent for medical attention
Avoid touching any part of sterile dressings that will contact the wound
Place medication on pad
Secure the dressing in place

25. Bacterial Infections Bacteria are single celled micro-organisms
Spherical, doublets, and spirochetes
Staphylococcus
Gram positive bacteria that appears in clumps in skin and upper respiratory tract
Streptococcus
Chain bacteria often associated with systemic disease and skin infections
Bacillus
Spore forming, aerobic, and occasionally mobile
Can cause systemic damage

26. Impetigo Contagiosa Etiology Signs and Symptoms Management
Caused by A-beta-hemolytic streptococci, S aureus or combination of these bacteria
Spread through close contact
Signs and Symptoms
Mild itching and soreness followed by eruption of small vesicles and pustules that rupture and crust
Generally develops in body folds that are subject to friction
Management
Cleansing and topical antibacterial agents
Systemic antibiotics

28. Furunculosis (Boils) Etiology
Infection of hair follicle that results in pustule formation
Generally the result of a staphy. infection

29. Signs and Symptoms Management
Pustule that becomes reddened and enlarged as well as hard from internal pressure
Pain and tenderness increase with pressure
Most will mature and rupture
Management
Care involves protection from additional irritation
Referral to physician for antibiotics
Keep athlete from contact with other team members while boil is draining

30. Carbuncles Etiology Signs and Symptoms Management
Similar in terms of early stage development as furuncles
Signs and Symptoms
Larger and deeper than furuncle and has several openings in the skin
May produce fever and elevation of WBC count
Starts hard and red and over a few days emerges into a lesion that discharges yellowish pus
Management
Surgical drainage combined with the administration of antibiotics
Warm compress is applied to promote circulation

31. Folliculitis Etiology Inflammation of hair follicle
Caused by non-infectious or infectious agents
Moist warm environment and mechanical occlusion contribute to condition
Psuedofolliculitis (PFB)

32. Signs and Symptoms Management
Redness around follicle that is followed by development of papule or pustule at the hair follicle
Followed by development of crust that sloughs off with the hair
Deeper infection may cause scarring and alopecia in that area
Management
Management is much like impetigo
Moist heat is used to increase circulation
Antibiotics can also be used depending on the condition

33. Hidradenitis Suppurativa
Etiology
Primary inflammation event of the hair follicle resulting in secondary blockage of the apocrine gland
Signs and Symptoms
Begins as small papule that can develop into deep dermal inflammation
Management
Avoid use of antiperspirants, deodorants and shaving creams
Use medicated soaps and systemic antibiotics

34. Acne Vulgaris Etiology Signs and Symptoms Management
Inflammatory disease of the hair follicle and the sebaceous glands
Sex hormones may contribute
Signs and Symptoms
Present with whiteheads, blackheads, flesh or red colored papules, pustules or cysts
If chronic and deep = may scar
Psychological impact
Management
Topical and systemic agents used to treat acne
Mild soaps are recommended

35. Paronychia and Onychia
Etiology
Caused by staph, strep and or fungal organisms that accompany contamination of open wounds or hangnails
Damage to cuticle puts finger at risk
Signs and Symptoms
Rapid onset; painful with bright red swelling of proximal and lateral fold of nail
Accumulation of purulent material w/in nail fold
Management
Soak finger or toe in hot solution of Epsom salt 3 times daily
Topical antibiotics, systemic antibiotics if severe
May require pus removal through skin incision

36. Tetanus Infection (lockjaw)
Etiology
Acute infection of the CNS caused by tetanus bacillus
Bacteria enters through the blood and open wounds
Signs and Symptoms
Stiffness of the jaw and muscles of the neck
Muscles of facial expression produce contortion and become painful
Fever may become markedly elevated
Management
Treat in intensive care unit
Childhood immunization

37. Fungal Infections
Group of organisms that include yeast and molds which are usually not pathogenic
Grow best in unsanitary conditions with warmth, moisture and darkness
Infections generally occur in keratinized tissue found in hair, nails and stratum corneum
Dermatophytes (Ringworm fungi)
Cause of most skin, nail and hair fungal infections

38. Tinea of the Scalp (tinea capitis)
Signs and Symptoms
Ringworm of the scalp begins as a small papule that spreads peripherally
Appears as small grayish scales resulting in scattered balding
Easily spread through close physical contact
Management
Topical creams and shampoos are ineffective in treating fungus in hair shaft
Systemic antifungal agents are replacing older agents due to increased resistance
Some topical agents are used in conjunction

39. Tinea of the Body (tinea corporis)
Signs and Symptoms
Commonly involve extremities and trunk
Itchy red-brown scaling annular plaque that expands peripherally
Management
Topical antifungal cream

40. Tinea of the Nail (tinea unguium/ onchomycosis)
Signs and Symptoms
Fungal infection of the nail -- found commonly in those engaged in water sports or who have chronic athlete’s foot
Nail becomes thick, brittle and separated from its bed
Management
Some topical antifungal agents have proved useful
Systemic medications are most effective
Surgical removal of nail may be necessary if extremely infected

41. Tinea of the Groin (tinea cruris)
Etiology
Symmetric red-brown scaling plaque with snake-like border
Signs and Symptoms
Mild to moderate itching

42. Management Treat until cured
Will respond to many of the non-prescription medications
Medications that mask symptoms should be avoided
Failure to respond to normal management may suggest a non-fungal problem (such as bacteria) and should be referred to a physician
May require additional topical medications and oral prescriptions

43. Athlete’s Foot (tinea pedis)
Etiology
Most common form of superficial fungal infection
Tricophyton species are most common cause of athlete’s foot
Webs of toes may become infected by a combination of yeast and dermatophytes
Signs and Symptoms
Extreme itching on soles of feet, between and on top of toes
Appears as dry scaling patch or inflammatory scaling red papules forming larger plaques
May develop secondary infection from itching and bacteria
Management
Topical antifungal agents and good foot hygiene

45. Candidiasis (Moniliasis)
Etiology
Yeast-like fungus that can produce skin, mucous membrane and internal infections
Ideal environment includes hot humid weather, tight clothing, and poor hygiene
Signs and Symptom
Infections w/in body folds
Presents as beefy red patches and possible satellite pustules
White, macerated border may surround the red area; deep painful fissures may develop at skin creases
Management
Maintain dry area
Use antifungal agents to clear infection

46. Tinea Versicolor Etiology Signs and Symptoms Management
Caused by a yeast
Appears commonly in areas in which sebaceous glands actively secrete body oils
Signs and Symptoms
Fungus produces multiple, small, circular macules that are pink, brown, or white
Commonly occur on chest, abdomen, and neck
Do not tan when exposed to sun and usually are asymptomatic
Management
Straightforward treatment - recurrences are common
Use selenium shampoo (Selsun) and topical econazole nitrate (or something similar)
When microorganism has been eradicated, re-pigmentation of the area will occur

47. Viral Infections
Ultramicroscopic organisms that require host cells to complete their life cycle
May stimulate cell chemically to produce more virus until host cell dies
Lies within bud-like structure that does not damage cell or virus, w/out causing infection
A number of skin infections are caused by viruses

48. Herpes Simplex Labialis, Gladiatorum, and Herpes Zoster
Etiology
Highly contagious and is usually transmitted directly through a lesion in the skin or mucous membrane
Resides in sensory nerve neurilemmal sheath following initial outbreak
Recurrent attacks stimulated by sunlight, emotional disturbances, illness, fatigue, or infection
Type I vs. Type II
Signs and Symptoms
Early indication = tingling or hypersensitivity in an infected area 24 hours prior to appearance of lesions
Local swelling followed by outbreak of vesicles
Athlete may feel ill w/ headache, sore throat, swollen lymph glands and pain in area of lesions

50. Signs and Symptoms (continued)
Vesicles generally rupture in 1-3 days spilling serous material
Heal in generally days
If an athlete has an outbreak they should be disqualified from competition due to contagious nature of condition
Management
Herpes simplex lesions are self limiting - reduce pain and promote early healing
Use of antiviral drugs can reduce recurrence and shorten course of outbreak
Complications
Can lead to secondary infection

51. Verruca Virus and Warts
Varied of forms exist
verruca plana (flat wart), verruca plantaris (plantar wart), and condyloma acuminatum (venereal wart)
Different types of human papilloma virus have been identified
Uses epidermal layer of skin to reproduce and growth
Wart enters through lesion in skin

52. Common Wart Signs and Symptoms Management
Small, round, elevated lesion with rough dry surfaces
Painful if pressure is applied
May be subject to secondary bacterial infection
Management
If vulnerable, they should be protected until treated by a physician
Use of electrocautery, topical salicylic acid or liquid nitrogen are common means of managing this condition

53. Plantar Warts Etiology Signs and Symptoms Management
Spread through papilloma virus
Signs and Symptoms
Located on sole of foot, on or adjacent to areas of abnormal weight bearing
Areas of excessive epidermal thickening
Discomfort, point tenderness
Hemorrhagic puncta (black seeds)
Management
While in competition, protect and prevent spreading
Pair away callus and apply keratolytic
Following season, wart can be removed by freezing it or by electrodessication (maintain protection until removal)

54. Molluscum Contagiosum
Etiology
Poxvirus infection which is more contagious than warts (especially during direct body contact)
Signs and Symptoms
Small, flesh or red colored, smooth-domed papules with central umbilication
Management
Physician referral is necessary
Cleansing and destructive procedure (counterirritant such as cantharidin, surgical removal or cryosurgery)

55. Allergic, Thermal, and Chemical Skin Reactions
Allergies are immunologically mediate responses to molecules in dyes and proteins against which the body’s immune system is sensitized
Allergens may be food, drugs, clothing, dusts, pollens, plants, animals, heat, cold, or light
The skin will reflect an allergy in many ways such as reddening and swelling of the tissue, uticaria or hives, burning or itching
ATC’s must recognize gross signs of allergic responses and be prepared to remove allergens and treat topically or systemically with antipruritic agents

56. Contact Dermatitis (allergic and irritant)
Etiology
Plants are the most common cause (poison ivy, poison oak, sumac, ragweed, primrose)
Topical medications
Chemicals found in fragrances and preservatives of soaps, detergents
Signs and Symptoms
Onset may range from 1 day to 1 week
Redness, swelling, formation of vesicles that ooze fluid and form crust, constant itching
May change from redness and blistering to erythematous scaling, lichenified papules and plaques
Management
Avoid allergen
Tap water compresses or soaks, topical corticosteroids

58. Milaria (Prickly Heat)
Etiology
Continued exposure to heat and moisture causing retention of perspiration by sweat glands
Signs and Symptoms
Itching and burning vesicles and pustules
Occurs most often on arms, trunks, and bending areas of the body
Management
Avoidance of overheating, frequent bathing with non-irritating soap, wearing loose-fitting clothing and use of antipruritic lotions

59. Chilblains (pernio) Etiology Signs and Symptoms Management
Caused by excessive exposure to cold
Signs and Symptoms
Tissue does not freeze but reacts with edema, reddening and possibly blistering along with a sensation of burning and itching after exposure to cold
Management
Exercise and gradual warming of the part
Massage and application of heat are contraindicated
Some systemic drugs can be used in severe cases

61. Sunburns Etiology Signs and Symptoms
Inflammatory response to injury caused by ultraviolet solar radiation
Must be cautious of physical characteristics, chemicals, food and drugs that make individuals more susceptible
Signs and Symptoms
Varies from erythema to severe blistering
May experience shock if severe enough
Can cause malfunctioning of organs w/in the skin
Will appear 2-8 hours following exposure, with symptoms becoming most severe at 12 hours
S&S will dissipate w/in hours

62. Sunburns (continued) Management
Can be prevented through the use of sunscreen (sun protection factor or SPF)
Filters ultraviolet light
Water/sweat resistant sunscreen is recommended
Treat a burn according to the degree of inflammation
Cool water, aloe based solutions
More severe burns may require bathing in a bath of cornstarch or vinegar
Severe burns require physician assistance

63. Psoriasis Etiology Signs and Symptoms
Exact cause is unknown -- genetic factors may play a role in condition
Infection, smoking, some drugs and possible hormonal factors may cause an outbreak
Signs and Symptoms
Lesion begins as reddish papules that progress to plaques
Lesions progress to yellowish white scaly condition that tends to be located on the elbows, knees, trunk, genitalia, and umbilicus

64. Psoriasis (continued)
Management
Teaching patient self management
Glucocorticoids and kerolytic agents can be used in conjunction with each other
Long term oral medications may be necessary
Counseling may be necessary for psychological aspects of condition

65. Infestation and Bites Scabies Etiology Signs and Symptoms Management
Caused by mites which cause extreme nocturnal itching (tunnels and lays eggs)
Signs and Symptoms
Appear as dark lines between fingers and toes, body flexures, nipples and genitalia
Excoriations, pustules and papules caused by itching tends to hide true cause
Skin develops hypersensitivity to the mite
Management
Permethrin 5% is treatment of choice
Washing of bedding and clothes is necessary
Topical corticosteroids may be necessary to treat itching

66. Lice (Pediculosis) Etiology Signs and Symptoms Management
Manifestation by the louse (louse of head, pubic region and body)
Signs and Symptoms
Bites cause itching dermatitis through subsequent scratching -- promotes pustule and excoriations to develop
Management
Cure is rapid with use of any number of agents
Good hygiene is paramount
To prevent re-infestation all clothing and bedding should be washed in hot soapy water or discarded

67. Fleas Etiology Signs and Symptoms Management
Small wingless insects that suck blood
Can transmit systemic diseases
Signs and Symptoms
Great deal of discomfort can be felt if come into contact with a high number of fleas
Concentrate bites on ankles and lower legs
Management
Following a bite, itching must be prevented with antipruritic lotion
Avoid scratching to prevent secondary infection
Insecticides can also be effective

68. Ticks Etiology Signs and Symptoms Management
Parasitic insects that have an affinity for blood
Carriers of a variety of microorganisms that can transmit Rocky Mountain spotted fever and Lyme disease
Signs and Symptoms
Headaches, fever, malaise, myalgia, and rash, perechiae and prupura, enlarging annular red ring w/ or w/out central red papule
Management
Remove tick (mineral oil or fingernail polish)
Grasping head of tick is an acceptable method
Systemic treatment is necessary to prevent morbidity and mortality associated with RMSF and Lyme disease

69. Mosquitoes Etiology Signs and Symptoms Management
Unless carrying a disease, mosquitoes produce bites that cause only mild discomfort
Attracted to lights, dark clothing and warm moist skin
Signs and Symptoms
Small reddish papule with associated itching
Management
Topical medication
Use of repellents can also be used on the skin to prevent contact with mosquitoes

70. Stinging Insects Etiology Signs and Symptoms
Bees, wasps, hornets, yellow jackets -- inflict venomous sting
Hypersensitive individuals may experience an allergic reaction
Signs and Symptoms
If an allergic reaction occurs an increase in heart rate and breathing will occur, along with chest tightness, dizziness, sweating and even LOC

71. Insect Stings (continued)
Management
To prevent, avoid wearing scented lotions or shampoos, brightly colored clothes, jewelry, suede, or leather, and avoid going barefoot.
If an athlete is susceptible to anaphylactic reactions instructions on use of an EpiPen are necessary
If uncomplicated, the stinger should be removed with tweezers or a credit card and soothing medications should be applied
Soap detergent will also lessen symptoms
In cases of anaphylactic reaction immediate physician referral is necessary