Integumentary System Effgen Chapter 10 Presented by: Megan Flores, PT, MPT Acknowledgements: Elizabeth Ardolino, PT, PhD Cornelia Lieb-Lundell PT, DPT, PCS, C/NDT

This is a self-paced interactive PowerPoint on the Pediatric Integumentary System Start the PowerPoint from the beginning Answer the embedded questions as you go.

Objectives Provide an overview of pediatric integumentary system issues Name three major categories of pediatric integumentary conditions Discuss general principles for physical therapy management of pediatric integumentary conditions

Normal Skin Epidermis = outer layer, .04mm Dermis = true skin. Highly vascular: aides in regulating body temp

Skin Lesions by Cause Superficial lesions: visible skin eruptions related to infections or growths Inflammatory conditions Rashes: temporary eruptions Growths: permanent eruptions Neurocutaneous: dermatologic manifestations of neurological conditions Mechanical processes: blisters, wounds, etc. resulting from heat, laceration, friction, etc

Inflammations: Bacterial Infections Treatment: generally requires bacterial ointments and/or oral antibiotics Precautions: Cellulitis requires referral Impetigo is contagious, use universal hand washing precautions *Impetigo is one of the most common skin infections among children, usually produces blisters or sores on the face, neck, hands, and diaper area.

Cellulitis Infection of the skin that can affect any area of the body. Begins in an area of broken skin, like a cut or scratch. Bacteria invade and spread, causing inflammation, pain, swelling, warmth, and redness.

Inflammations: Viral Infections Chickenpox Warts Treatment: antiviral agent, antihistamine Precautions: contagious, isolate Warts Treatment: electrocautery, cryotherapy, surgical removal Precautions: irritation will cause to enlarge Warts are contagious

Inflammations: Fungal Infections Occurs in warm, moist climates Treatment: Topical antifungal agents Precautions: Contagious – use hand washing precautions T. corporis (ringworm on arms or legs) transmitted through animals or person to person T. capitis (ring worm on the head) transmitted person to person

Fungal Infections: Ringworm

Rashes: Contact/Allergic Reactions Treatment: Prevent inflammation Keep skin dry Precautions : non specific

Rashes: Diaper Dermatitis Treatment: Topical agents. Do not use baby powder because of risk to respiratory system. Allow baby to go without a diaper when possible. This will allow the rash to dry out and reduce chafing.

Rashes: Eczema The term eczema refers to a number of different skin conditions in which the skin is red and irritated and occasionally results in small, fluid-filled bumps that become moist and ooze. Children with eczema often have family members with hay fever, asthma, or other allergies. About half of children who get eczema will also someday develop hay fever or asthma themselves

Growths Treatment: Become alert to recognize changes!! Refer !!

Growths: Melanomas http://www.nlm.nih.gov/medlineplus/ency/imagepages/3200.htm In the US, approx. 500 children are dx with pediatric melanoma per year, and there is evidence that incidence is on the rise. Melanoma may grow faster in children than in adults. Children may fare better than adults, and if caught early, most do not require treatment beyond surgery. Among children, sun exposure plays less of a role in the development of melanoma. Researchers believe it is a combination of genetic predisposition and other unknown triggers. Children with fair skin, freckles or red or blond hair have a higher risk of melanoma. Previous studies have shown that children who have been treated for melanoma are at an increased risk of recurrence later in life.

Growths: Melanomas http://www.nlm.nih.gov/medlineplus/ency/imagepages/3200.htm Juvenile nevi Classic Melanomas

Test Your Knowledge (click on the symbol next to the answer) Cellulitis is an example of: ◙ Allergic Reaction ◙ Bacterial Infection ◙ Fungal Infection ◙ Viral Infection

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Neurocutaneous Integumentary (Neuro Connection) On gestational day 18: differentiation of the cells form the germ layers, the endoderm, ectoderm, and mesoderm, that will eventually form the nervous system. Neural crest cells that originate from cells dorsolateral to the neural tube will develop into sensory and autonomic neurons. Yang states that the neurologic system is derived from ectoderm.

Neurocutaneous Syndromes (click on each for more info and to see images) Ectodermal Dysplasias Genetic disorder resulting in group of conditions affecting development of skin, teeth, hair, nails, and sweat glands Ataxia Telangiectasia (Louis-Bar Syndrome) Autosomial recessive condition characterized by progressive childhood ataxia Neurofibromatosis Autosomal dominant disorder where the nerves tend to grow tumors Sturge-Weber syndrome Non inherited disorder characterized by vascular malformation(s) of the skin Tuberous sclerosis complex Multi-system genetic disease that causes benign tumors to grow in the brain and other vital organs causing developmental delay

Ectodermal Dysplasias The ectodermal dysplasias comprise a large, heterogeneous group of genetically based inherited disorders of abnormality of skin, hair, nails, teeth, nails (the ectodermal structures) http://www.ectodermaldysplasia.org/whatised.php Click here to return to the presentation

Ataxia-telangiectasia AKA Louis-Bar Syndrome Rare inherited disease Impairs areas of the cerebellum, causing ataxia Weakens the immune system Characteristic: mall clusters of enlarged blood vessels occur in the eyes and on the surface of the skin (called telangiectases) Click here to return to the presentation

Neurofibromatosis Genetic disorder that disturbs cell growth in the nervous system. High risk of tumor formation, particularly in the brain Can cause growth of non-cancerous tumors on nerve tissue, producing skin and bone abnormalities. Click here to return to the presentation

Sturge-Weber syndrome Congenital disorder of unknown incidence and cause. Characterized by facial birthmark called “port wine stain” and neurological abnormalities. Neurological concerns relate to development of brain angiomas Each case of Sturge-Weber Syndrome is unique and exhibits the characteristic findings to varying degrees. Click here to return to the presentation

Tuberous sclerosis Rare multi-system genetic disease that causes non-malignant tumors to grow in the brain and on other vital organs such as the kidneys, heart, eyes, lungs, and skin. A combination of symptoms may include seizures, intellectual disability, developmental delay, behavioral problems, skin abnormalities, lung and kidney disease. Click here to return to the presentation

Test Your Knowledge (click on the symbol next to the answer) Which neurocutaneous syndrome is characterized by facial birthmark called a “port wine stain”? ◙ Ataxia-telangiectasia ◙ Neurofibromatosis ◙ Sturge-Weber ◙ Tuberous Sclerosis

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Skin Injuries due to Mechanical Processes Thermal injuries Pressure injuries Laceration, abrasion, UV exposure injuries

Thermal Injuries Skin injuries due to heat In infants under age 1 year, the third most common cause of death Between ages 1-9 years, deaths second only to motor vehicle accidents Most common burn mechanism is scalding Most scalding injuries result from beverages or bathing water too hot Highest fatality rate results from fires and this often includes inhalation injuries

Thermal Injuries Superficial Partial Thickness Superficial Deep Full thickness

Burn severity and functional outcomes Size Depth Location Joints Face Hands

Differences in Young Children and Adults Body surfaces differ Skin is thinner Dehydration is a greater problem for the young child Temperature control is more difficult Physiologic differences Higher mortality rate

Pressure injuries Pressure Ulcers Stage I- Non-blanchable erythema of intact skin Stage II Partial-thickness skin loss involving epidermis or dermis, or both Stage III Full thickness skin loss damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage IV Full-thickness skin loss extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures

True or False (click on the symbol next to the answer) A child you are treating was admitted to the hospital with a stage III pressure ulcer. The wound is now covered with intact skin, but is non-blanchable. You would now document this as a stage I pressure ulcer in your notes. ◙ True ◙ False

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Correct! This would be documented as a “healing stage III pressure ulcer” Click here to move to the next slide: ◙

Phases of wound healing Inflammatory phase Hallmarks –color, temperature, swelling, pain Fibroblasts first appear in this phase Proliferative phase Fibroplasia- granulation tissue Wound contraction Epithelization – begins immediately after trauma and continues during proliferation Maturation Collagen/lysis organization Scare Formation

Examination and Evaluation: Systems Review Comorbidities with Integumentary impairments: Musculoskeletal Contractures, diminished sensation or inhibition of mobility can result in skin breakdown Neuromuscular Frequently developmental delay and/or neurological findings Respiratory Results from thermal and inhalation injury Cardiopulmonary Results from inhibition of movement, exercise participation and wound healing Cognitive delays If the child is unable to communicate pain there is a greater risk for skin breakdown

Interventions with Burn Injuries Therapeutic exercise Breathing with chest mobilization Assistive devices/splints Integumentary repair Dressings Range of motion PROM AROM AAROM

Burns: Assistive, Adaptive, Orthotic, Protective and Prosthetic Devices

Burns: Assistive, Adaptive, Orthotic, Protective and Prosthetic Devices

Keys to Cooperation: Pediatric Burn Rehabilitation Serghiou Explain all procedures at age-level of understanding Be honest Pair painful procedures with peak of effectiveness of pain medications Demonstrate on a family member or friend first Incorporate family early in treatment Allow child to make some choices Avoid invading a child’s personal space

Keys to Cooperation: Pediatric Burn Rehabilitation (continued) Serghiou Give the child “breaks Never make a child feel guilty or state “you are bad” for his/her behavior Use age-appropriate activities Make friendly visits at non-therapy times No lab coats! Listen to concerns, do not minimize Arrange for peer meeting(s)

THANK YOU Thank you to the parents and children and educational website sources who participated in the development of this information and graciously allowed the use of their pictures for educational purposes. and Dr. Michael Serghiou OTR http://www.docstoc.com/docs/28896777/Pediatric-Burn-Rehabilitation---PowerPoint Picture material is copyrighted and may not be used without the author’s permission. 2013

You have completed the Integumentary System Interactive PowerPoint *Please refer to Effgen Chapter 10 for more information on the Pediatric Integumentary System