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

2. 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.

3. 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

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

5. 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

6. 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.

7. 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.

8. 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

9. 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

10. Fungal Infections: Ringworm

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

12. 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.

13. 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

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

15. Growths: Melanomas
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.

16. Growths: Melanomas
Juvenile nevi
Classic
Melanomas

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

18. Sorry … incorrect
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19. Correct! Great Work!
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20. 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.

21. 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

22. 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)
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23. 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)
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24. 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.
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25. 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.
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26. 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.
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27. 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

28. Sorry … incorrect
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29. Correct! Great Work!
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30. Skin Injuries due to Mechanical Processes
Thermal injuries
Pressure injuries
Laceration, abrasion, UV exposure injuries

31. 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

32. Thermal Injuries Superficial Partial Thickness Superficial Deep
Full thickness

33. Burn severity and functional outcomes
Size
Depth
Location
Joints
Face
Hands

34. 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

35. 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

36. 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

37. Sorry … incorrect
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38. Correct!
This would be documented as a “healing stage III pressure ulcer”
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39. 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

40. 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

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

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

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

44. 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

45. 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)

46. 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
Picture material is copyrighted and may not be used without the author’s permission. 2013

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