INFLAMMATORY DISORDERS

Objectives Explain dermatitis and psoriasis Discuss the education plan for a client with inflammatory disorders List drugs used for treatment of inflammatory disorders Identify foods causing allergies Identify topical drugs used for the client with disorders of the skin Discuss components of a client education plan for the self-use of topical medications

DERMATITIS Contact dermatitis from tape. Poison ivy dermatitis.

CONTACT DERMATITIS PATHOPHYSIOLOGY: -direct contact with agents in the environment that a person is hypersensitive to -epidermis becomes inflamed and damaged by the repeated contact -soaps, industrial chemicals, plants ,etc.

POISON OAK

SIGNS AND SYMPTOMS -lesions at the point of contact. -burning, pain, itching, and swelling. -red with papules -small, raised , solid skin lesions less than 1 cm. in diameter

ASSESSMENT SUBJECTIVE DATA -history of the pt.’s activities -ask for a log of the past 48 hours before the s/s developed.

ASSESSMENT SUBJECTIVE DATA -tried a new soap. -traveling and using different personal items. -working with plants or flowers. -severe itching. -difficulty moving the affected area.

ASSESSMENT OBJECTIVE DATA: -erythema. -papules /vesicles that generally ooze and weep a clear fluid. -scratch marks. -edema of the area.

DIAGNOSTIC TESTS -health history to identify the agent. -intra-dermal skin testing. -elimination diets are used to identify food allergies. -elevated serum IgE levels and eosinopilia.

NURSING DIAGNOSES Impaired skin integrity, related to scratching Pain, related to pruritis

TREATMENT MEDICAL MANAGEMENT -identify the cause of the hypersensitive reaction. -treat symptomatically -swelling, itching, discomfort. -oral antihistamines -corticosteroids topically. -prophylactic treatment for asthma

NURSING INTERVENTIONS -protect the inflamed area from further harm. -rest the affected area. -wet dressings (Burrow’s solution) -use medical aseptic technique when applying the corticosteroids to the open lesions. -provide a cool environment with humidity. -cold compresses -deceases the circulation and cause vasoconstriction -this relieves the pruritis

NURSING INTERVENTIONS, CONT. -daily baths with an application of oil. -cut the fingertips -decreases excoriation from scratching - wear mittens or gloves). -clothing should be lightweight and loose.

TEACHING -keep a history of possible predisposing offensive agents. -avoid the causative agent once it has been identified. -avoid any rubbing of the area -any excessive heat -any soaps -these can all cause itching which could easily re-open the wound

PROGNOSIS -removal of the offensive agent results in full recovery -if there is a recurrence, then the pt. may need to be desensitized.

DERMATITIS VENENATA, EXFOLIATIVE DERMATITIS, AND DERMATITIS MEDICAMENTOSA

Inflammatory Disorders of the Skin Dermatitis venenata, exfoliative dermatitis, and dermatitis medicamentosa Etiology/pathophysiology Dermatitis venenata: -Contact with certain plants Exfoliative dermatitis: -Ingestation of heavy metals, antibiotics, aspirin, codeine, gold, or iodine Dermatitis medicamentosa: -Hypersensitivity to a medication

DERMATITIS VENENATA -Contact with certain plants - poison oak /poison ivy. -Mild-severe erythema with pruritis -Body undergoes a sensitizing antigen formation on first exposure -Lymphocytes to release irritating chemicals - inflammation - edema - vesiculation

EXFOLIATIVE DERMATITIS -Ingestation of heavy metals, or by antibiotics, - - aspirin, codeine, arsenic, mercury gold or iodine. -Skin sloughs off -swollen/reddened -severe pruritis -fever -Patients are hospitalized -Treatment is individualized.

EXFOLIATIVE DERMATITIS -Cause should be removed and treated -Prevent secondary infections -Avoid further irritation. -Maintain fluid balance.

DERMATITIS MEDICAMENTOSA -Medication causes a hypersensitive reaction -Any drug can cause a reaction -penicillin, codeine, and iron.

DERMATITIS MEDICAMENTOSA Signs and symptoms -mild to severe erythema -pruritus. -vesicles/eruptions -respiratory distress -especially with medicamentosa

VESICLES

ASSESSMENT SUBJECTIVE: -Complaints of pruritis/burning pain in the involved area OBJECTIVE: -Lesions are white in the center/red on the periphery. -Vesicles -Severe dyspnea caused by respiratory distress

DIAGNOSTIC TESTS Patient history. A laboratory exam for serum IgE and eosinopilia.

NURSING DIAGNOSES Impaired skin integrity, related to crusted, open lesions Risk for infection, related to break in skin Deficient knowledge, related to the cause and spread of the disease

TREATMENT -Therapeutic baths -Administration of corticosteroids. -Treatment is directed at the cause.

NURSING INTERVENTIONS: Dermatitis venenata- -Wash the affected area immediately after contact with the offending allergen -Cool, open, wet dressings to the lesions -Calamine lotion

NURSING INTERVENTIONS -Therapeutic baths with colloid solution, lotions, and ointments - alleviates the itching -Emotional support - the physical appearance is difficult for both the patient/family to accept.

NURSING INTERVENTIONS Dermatitis medicamentosa -center around the causative drug and discontinuation -if the drug cannot be identified -no drugs should be given -lesions will disappear after the medication has been stopped -PCP must be notified for further orders

TEACHING -Wear a medical alert bracelet/necklace showing the name of the allergen -Inspect the lesions daily -exudate, size, and body part. -Fever -have the pt. check his temperature -Medical asepsis/aseptic hand washing technique

TEACHING -Appropriate application of topical meds -Keep the involved areas dry when giving care -Own personal items that are not to be shared – -linens, towels, comb, etc. -Family must be involved with the teaching

PROGNOSIS Full recovery -when the offending agent is gone

Inflammatory Disorders of the Skin Urticaria (Wheals/Hives) Etiology/pathophysiology Allergic reaction -release of histamine in an antigen-antibody reaction -drugs -food -insect bites -inhalants -emotional stress -exposure to heat or cold

Inflammatory Disorders of the Skin Clinical manifestations/assessment Pruritus Burning pain Wheals/ hives - release of histamine - capillaries to dilate - increased permeability

WHEALS OR HIVES

ASSESSMENT SUBJECTIVE: -pruritis -edema -burning pain -shortness of breath .

ASSESSMENT OBJECTIVE DATA: -Wheals of varying shapes and sizes -pale centers/red edges -Intense scratching -Respiratory status may be compromised.

Inflammatory Disorders of the Skin Diagnostic tests -Health history -Allergy skin test -IgE (serum immunoglobulin E) - check for its elevation.

ALLERGY SKIN TESTING

TREATMENT Medical management/nursing interventions -Identify and alleviate cause. -Antihistamine (Benadryl). -Therapeutic bath. -Epinephrine. -Teach patient possible causes. -Teach preventive measures.

TEACHING . Signs and symptoms of a anaphylactic reaction. -shortness of breath -wheezing -cyanosis

PROGNOSIS Full recovery when the obnoxious agent is removed/avoided. Patient must comply with the treatment regimen.

Inflammatory Disorders of the Skin Angioedema Etiology/pathophysiology -form of urticaria -subcutaneous tissue -same offenders as urticaria -eyelids, hands, feet, tongue, larynx, GI, genitalia, or lips -angioedema is a local edema of an entire area rarely occurs in more than a single area at one time

Inflammatory Disorders of the Skin Angioedema Clinical manifestations/assessment -burning /pruritus -lesions that are normal on the outer skin -edema -acute pain -in the GI tract -respiratory distress -in the larynx -edema of an entire area -eyelid, feet, lips, etc.

ANGIOEDEMA

DIAGNOSTIC TESTS -patient history. -history of allergies are more likely to have angioedema.

TREATMENT Medical management/nursing interventions -cold compresses. -antihistamines -epinephrine -corticosteroids -assess respiratory function for s/s of distress.

TEACHING -wear a medical alert bracelet or necklace. -prevent recurrent episodes.

PROGNOSIS -With treatment ,the prognosis is excellent

ECZEMA

Inflammatory Disorders of the Skin Eczema (atopic dermatitis) Etiology/pathophysiology -Allergen causes histamine to be released -antigen-antibody reaction -Primarily occurs in infants. -chocolate, orange juice, eggs, wheat.

ALLERGENS

ASSESSMENT -Papules/vesicles -edged with redness -ruptures -discharges a yellow, thick exudate -dries, becomes crusted -infected -skin becomes shiny, de-pigmented -dry scales.

ASSESSMENT SUBJECTIVE: -pruritis -scratching -children are more fussy/irritable -anorexic. -skin is tender to the touch. -family history of allergies -asthma is often associated with children who have eczema.

ASSESSMENT -Papules and vesicles -scalp, forehead, cheeks, neck, and extremities. -Erythematic/dryness of area. -Pruritis.

Inflammatory Disorders of the Skin Eczema (atopic dermatitis) Diagnostic tests Health history (heredity is a primary factor). Diet elimination. Skin testing and IgE serum tests. Medical management/nursing interventions Reduce exposure to allergen Hydration of skin Topical steroids Lotions—Eucerin, Alpha-Keri, Lubriderm, or Curel 3-4 times/day

ECZEMA (atopic dermatitis)

NURSING DIAGNOSES Impaired skin integrity, related to open lesions Risk for situational low self-esteem, related to change in body image Risk for infection, related to open lesions

NURSING INTERVENTIONS -therapeutic baths -occlusive preparations -wet dressings -maximizes the hydration of the skin -topical steroids -lesions healed-lotions are used -Eucerin, Alpha Keri, Lubriderm, Curel - apply 3-4 times/day.

NURSING INTERVENTIONS -monitor emotions -anger, depression anxiety, embarrassment, guilt, etc. -encourage the pt. to verbalize his feelings -use effective listening skills -open-ended questions.

WET DRESSING, OCCLUSIVE DRESSING

Inflammatory Disorders of the Skin Acne vulgaris Etiology/pathophysiology -Occluded oil glands (the sebaceous glands) -The cause is unknown -Androgens increase the size of the oil gland -It primarily occurs in adolescents -Influencing factors -Diet -Stress -Heredity -Overactive hormones

Inflammatory Disorders of the Skin Acne vulgaris Clinical manifestations/assessment -Tenderness and edema -Oily, shiny skin -Pustules -Comedones -blackheads - the effect of oxygen on sebum, not dirt -Scarring from traumatized lesions

COMEDONES

ASSESSSMENT SUBJECTIVE DATA: -how is the acne affects his/her lifestyle. -face and chin. -lesions increase with emotional upsets/ stress

ASSESSMENT OBJECTIVE: Note the presence of edema in the involved area.

DIAGNOSTIC TESTS Blood samples for androgen level Health history Inspection of lesion

NURSING DIAGNOSES Impaired skin integrity, related to occluded oil glands Situational low self-esteem, related to physical appearance Social isolation, related to decreased self-esteem

Inflammatory Disorders of the Skin Acne vulgaris Medical management/nursing interventions Keep skin clean Keep hands and hair away from area Wash hair daily Water-based makeup Topical therapy Benzoyl peroxide, vitamin A acids, antibiotics, sulfur- zinc lotions Systemic therapy Tetracycline, isotretinoin (Accutane)

ACUTANE

ORAL MEDICATION, WATER-BASED MAKE-UP

TOPICAL MEDICATIONS

NURSING INTERVENTIONS -Adolescents may not comply with long-term treatment regimens. -Evaluate the pt.’s understanding/reaction to his acne disorder. -What does acne mean to the pt.? -Focus on: -skin care -compliance -emotional support

NURSING INTERVENTIONS -Prevention -identification of factors that directly increase acne -Cleanliness decreases infection/promotes healing. -The skin should be washed 2-3 times/ day with a medicated soap -Improvement is slow so compliance is hard.

MEDICATED SOAP

NURSING INTERVENTIONS -Often it takes 3 weeks of treatment -Family support -Primary cause for low self-esteem -Not comparing oneself with others -Give positive reinforcement -Focus on his strengths

TEACHING -Both the physical and emotional needs of the pt. -Diet, hygiene, stress reduction, makeup, and medications. -Coping skills. -Adolescent should talk about his feelings -decreases any long-term effects that acne may have on his personality.

PROGNOSIS Prognosis is good. Lasting psychological effects can occur from the scarring that may result. In rare cases, eczema may develop from taking med: for acne, such as isotretinoin.

Psoriasis

Psoriasis Etiology/pathophysiology Noninfectious. Skin cells divide more rapidly than normal -normal– skin replaced every 28 days -psoriasis-skin replaced every 7 days. -occur at any age. -hereditary. -at the epidermis. -no known predisposing factors. -severe scaling is the result of the rapid cell division.

ASSESSMENT SUBJECTIVE: -pruritis. -feelings of depression, frustration, loneliness. -people may stare at them.

ASSESSMENT Clinical manifestations/assessment -raised, erythematous, circumscribed, silvery, scaling plaques -scalp, elbows, knees, chin, and trunk -primary lesion is papular.

DIAGNOSTIC TESTS -no special tests. -observation of the patient/symptoms.

TREATMENT Goal-slow the proliferation of the epithelial layers of the skin. Topical steroids Keratolytic agents -occlusive wet dressings to decrease inflammation Tar preparations Salicylic acid Reduces shedding of the outer layer of skin Photochemotherapy PUVA Oral psoralen Ultraviolet light

NURSING DIAGNOSES Impaired skin integrity, related to proliferation of epithelial cells Situational low self-esteem, related to appearance Social isolation, related to decreased self-esteem

NURSING INTERVENTIONS -Administration of the treatment modality. -Rest -Promote psychological well-being -counseling, exercise, etc. -Focus on positive attributes. -Medical asepsis. -Conceal obvious lesions.

TEACHING -Nature of the disease -Treatments -Compliance with medical care. -Disease is not CURABLE -Patient needs to understand this.

PROGNOSIS -Chronic disease. -Clinical course is variable -less than 50% will have a prolonged remission. -Severity: -cosmetic problem to a life-threatening emergency

Systemic Lupus Erythematosus (SLE) Etiology/pathophysiology Autoimmune disorder - antibodies against its own cells Inflammation of almost any body part. Skin, joints, kidneys, and serous membranes Affects women more than men -9 times more women than men Contributing factors Immunological, hormonal, genetic, and viral. Origin still remains a mystery.

SLE -Disease of exacerbations and remissions -triggered by contributing factors. -Inflammatory lesions -affect several organ systems -skin, joints, kidneys, and serous membranes. -T-suppressor cells decrease

SLE Clinical manifestations/assessment Erythema butterfly rash over nose and cheeks Alopecia Butterfly rash - occurs in 10-50% of patients Photosensitivity Organic brain syndrome

SLE Polyarthralgias and polyarthritis -90-95% of patients Pleuritic pain Pleural effusion Pericarditis Vasculitis Oral ulcers Anemia -most common.

SLE Neurological signs (seizures) Renal disorders Hematological disorders

Systemic lupus erythematosus (SLE) flare. Figure 3-11 (From Habif, T.P., et al. [2005]. Skin disease: diagnosis and treatment. [2nd ed.]. St. Louis: Mosby.) Systemic lupus erythematosus (SLE) flare.

SLE Diagnostic Tests Antinuclear antibody (ANA) DNA antibody Complement CBC Erythrocyte sedimentation rate (ESR) Coagulation profile Rheumatoid factor

DIAGNOSTIC TESTS Rapid plasma reagin Skin and renal biopsy C-reactive protein (CRP) Coomb’s test LE cell prep (lupus erythematosus) Urinalysis Chest x-ray

NURSING DIAGNOSES Impaired skin integrity, related to skin rash, hair loss, skin atrophy, discoid lesions involving other parts of the body.

NURSING DIAGNOSES Disturbed body image, related to baldness, skin pattern pathologies

TREATMENT GOALS: -Relief /managaement of symptoms. -Inducement of remission. -Prevention of complications. -Suppression of inflammation.

SLE Medical management/nursing interventions No cure -treat symptoms, induce remission, alleviate exacerbation. Medications Nonsteroidal ant-inflammatory agents. anti-malarial drugs (hydroxychloroquine). corticosteroids ( prednisone) -Peak amounts of steroids help to achieve remission Anti-neoplastic agents ( Imuran, Cytoxan). Topical corticosteroid creams are used for the rash.

MEDICATIONS Anti-infective drugs -treat/prevent infections -specific agent depends on the infection site -Cipro for a UTI. Dialysis for pts. with renal involvement. Lab Tests -assess renal function (BUN/serum creatinine) Analgesics -pain Diuretics -fluid retention

TREATMENT Balance rest and exercise Balanced diet Avoid direct sunlight

NURSING INTERVENTIONS -Thorough assessment -multi-systemic disease. -Skin care -avoiding direct sunlight -protective clothing -sunscreen. -Balance rest and activity. -Recognize s/s of exacerbation -fever, rash, cough

NURSING INTERVENTIONS -Recognize the s/s of infection. -Reduce stress. -Balanced diet -Reduction of sodium intake.

NURSING INTERVENTIONS -emotional, psychosocial, and spiritual support. -activity level -prevention of infection -potential complications -information on living a normal life.

Pharmacology for the treatment of inflammatory skin disorders Corticosteroids Emollients Antipsoriatics

Corticosteroids -local inflammatory disorders -Topical administration -avoids systemic adverse effects -the inflammatory site must be localized and accessible -effective and relatively safe form of therapy -prescription and non-prescription products

NURSING INTERVENTIONS -Monitor site for healing- -increased use of topical steroids decreases vasoconstriction -decreases the absorption of the steroid -requires a higher amount/more frequent usage -Monitor for increased facial redness when decreasing the amount of topical steroid secondary to tolerance. -Skin atrophy, striae (stretch marks), steroid allergies or skin infections -Fungal infections will not resolve with the use of topical steroids

Emollients -Dry skin -infections, excessive bathing or strong soaps/detergents -pruritus, cracking, and predisposition to skin disorders -prevent the loss of additional skin moisture be forming a occlusive barrier on the skin surface -waxes, fats and/or oils -urea-enhances the skin’s ability to hold moisture -Oils, creams, lotions, bath oils -daily after showering of bathing -do not apply to skin lesions that are moist/exudative

Antipsoriatics Alefacept- -first antibiological therapy for moderate to severe chronic plague psoriasis -provides longer remissions the other treatments -adverse effects- serious infection Efalizumab- -immunosuppressive recombinant monoclonal antibody -stimulates the bodies immune system’s ability to fight disease -adverse effects- thrombocytopenia, hypersensitivity,, headache, fever, chills, nausea and myalgia

Food Allergies Definition: -Ingestion of food that the person’s immune system incorrectly identifies as harmful - 4% of adults have food allergies -6-8% of children age 4 years of younger

-Immune system creates food specific antibodies. -Antigens which are foreign substances (food) -produces the immune response -antibodies start destroying the antigens -immune system discharges large amounts of histamine and chemicals -cause the allergic reaction

Allergic Reaction Respiratory -Tongue swelling, dyspnea Gastrointestinal -Nausea, abdominal pain, diarrhea Skin -Hives, rash Cardiovascular -Tachycardia, hypotension Neurological -Anxiety, loss of consciousness

Anaphylaxis -Severe reaction to allergen -Swelling of the lips, tongue, throat -blocks the upper airway resulting in suffocation -Emergency situation

Common allergy foods: -Eggs, peanuts, tree nuts, fish, shellfish, wheat, soy -Peanuts and tree nuts- severe reactions! -0.6% of Americans are allergic to peanuts -young children -allergic to eggs, milk, peanuts, tree nuts and soy. -outgrow their allergies -usually be allergic to peanuts and tree nuts for the rest of their life.

-are hereditary -a child having allergies increases when both parents have allergies -allergic to the common foods eaten in their countries -rice allergies are common in Japan

Diagnosis -family history of allergies -food diary -scratch test -RAST (radioallergosorbant test) -measures the presence f food-specific IgE in the blood -elimination of food from the diet -food challenge -capsules of different foods and a placebo -ingested and then followed to see if an allergic reaction occurs (rarely done)

Treatment- -avoid foods that cause allergies Prognosis -not curable but manageable -multiple medications being researched

Nursing Considerations -Carefully reading food labels -Inquire of the food ingredients when eating out. -Counseling by a dietician on the foods that their children need to avoid -Medical alert bracelet with the name of food allergy

Epinephrine injection -carried at all times - person, parents of children - severe/ anaphylactic reaction to foods or medications Epi-pen auto injection -pre-measured epinephrine injection - costs $50 Along with a Epi-pen the person should carry: -food allergies -3 emergency contacts -Physicians name and telephone number -description of how to treat the reaction

Pharmacology of skin disorders Topical antiseptics/germicides Topical Anti-Infectives Topical Cortico-steroids Topical Local Anesthetics Topical Enzymes Keratolytics

Topical Antiseptics and Germicides Long history of usage -spices, vegetable oils and extracts of trees/plants -1800’s Pastuer, Koch -substances that slowed or destroyed pathogenic organisms Definition: -an agent that kills or inhibits the growth of microorganisms that is applied to living tissue

Types- -Hibiclens -Alcohol -Phisohex -Hydrogen -Peroxide -Iodine -Mercurochrome -Betadine -Silver Nitrate -Silvadene -Dakin’s Solution -Septi-Soft

Nursing implications- -Specific to the type of antiseptic -Observe for hypersensitivity -Skin staining/bleaching

Topical Anti-infectives -Prevent infection-minor skin abrasions -treat superficial skin infections -Several antibiotics are combined in a single product -produces a broad spectrum coverage for multiple organisms

Types- -Bacitracin -Polymyoxin -Neomycin -Gentamycin -Tetracycline -Erythromycin

Nursing Considerations -hypersensitivity -systemic absorption if applying to a extensively damaged skin -Neomycin -observe for changes in renal function: -decreased urine output -elevated Creatine and BUN - changes in hearing.

Topical Local Anesthetics Inhibits the conduction of nerve impulses from sensory nerves - reduces pain/pruritis -insect bites, burns and plant allergies -patches, ointments, creams, sprays, liquids of jelly form -Types- “caine” -Lidocaine -Benzocaine -Tetracaine -Cocaine

Nursing Considerations -absorbed systemically through damaged or diseased skin -local or systemic adverse effects -if the medication is applied to a large area of skin -systemic hypersensitivity -CNS stimulant -hypotension -slow heart rate -possible cardiac arrest -avoid in clients -hypersensitivity to “caine” medications -severely traumatized skin

Topical Enzymes Remove dead tissue -enhances the formation of new tissue - promotes wound healing Selectively digest dead tissue Specifically digest protein of dead tissue Destroys components of the necrotic tissue mass.

Types- Collagenase (Santyl) -digests collagen that 75% of skin tissue Fibrinolysin/Desoxyribonuclease (Elase) -dissolves the fibrin structure of blood clots/ DNA strands - make up necrotic tissue.

Nursing considerations Santyl- The wound must be free of antiseptic/ antibacterial medications Compatible with triple antibiotic medication Apply Burrows solution to stop the enzymatic action Elase- Observe for hypersenitivity/allergic reaction

Keratolytics Remove excess keratin layer of skin -acne, warts, psoriasis, corns calluses and fungal infections Breaks down the protein structure of the keratin layer -easier removal of the compacted cellular material Types- Salicylic Acid, Lactic acid

Nursing Considerations -Apply after bathing -Soaked in water for several minutes -Occlude with a dressing/plastic wrap after applying medication -Apply overnight and remove in the morning -Repeated applications will probably control the hyperkeratinic skin growth -occasional reapplications may be needed for reoccurrence