DERMATOLOGY

Quinter Wetende
BScN KeMU
REVIEW OF ANATOMY AND PHYSIOLOGY OF SKIN

LAYERS OF THE SKIN

LAYERS OF THE EPIDERMIS
CELLS FOUND IN SKIN TISSUE
FUNCTIONS OF THE SKIN
BROAD OBJECTIVE

 The learner will be able to promote health, prevent

illness, manage and rehabilitate patients suffering from
skin conditions.
PRINCIPALS OF DERMATOLOGICAL
EXAM
 Comprehensive hx taking and through physical exam are
important in diagnosing skin conditions
COMPREHENSIVE HISTORY
 For how long the condition been there.
 The kind of lesion.

 Inquire about any previous condition operation ,injuries ,or any

medication.
 Nutrition history coz some conditions are related to nutrition.

 Exposure to heat and sunlight and exposure to pets.

CT
 Natural light should always be used
 Examine the whole body some lesions might be found
in private parts, breast, anus or genitalia.
 Distribution of the lesion and their pattern e.g. are they
asymmetrical or not. eg in conditions such as herpes
zoster they are symmetrical and in allergic dermatitis
they appear at the point of contact.
CT
 The skin color e.g. yellowish its an indication of pus, reddish
is blood, when cyanosed blood flow is not well.
 Indicate whether the lesions are dry or weeping.

 Configuration of the lesion eg a linear lesion ,angular ,or

bizarre in nature,
 Palpate and determine the degree of infiltration is it thin or
thick, talk about edema ,skin elasticity ,etc,
 determine whether they are primary or secondary lesions
PRIMARY LESIONS AND SECONDARY
LESIONS

 Primary lesions - These are most basic initial lesions

that appear on the skin
 Secondary lesions are complications of primary lesions
PRIMARY LESIONS
 Macue – a non palpable discolouration of the skin.Its
contagious. Mostly associated with poor hygiene.
 Papule - solid palpable elevation of the skin and ranges btn 1-
5 mm in diameter .found in acne
 Nodule – solid palpable deep sited elevation larger than 1cm in
diameter.
 Vesicle – elevation of the skin with a clear fluid and is less than
1cm in diameter.
CT
 Bulla – very big vesicles more than 1cm in diameter.eg in
pemhigus.
 Pustule – a vesicle with pus inside eg.infected acne

 Wheal- transient elevation of the skin caused by edema of the

dermis normally secondary to increased permeability
SECONDARY LESIONS
 scales – heaped up layers of stratum corneum.(dead tissues of
the skin ) in a condition called psoriasis.
 Crusts- dry accumulation of exudate and excretion eg
pus ,blood,and serum.They accumulate in the skin eg in
impetigo.
CT

Maceration
 Excoriations – linear scraps They are traumatized regions.eg
eg some small scratches on the skin.
 Ulcer – a local erosion of the skin the skin that goes deep into
the dermis.
 burrow – linear elevation of the skin at the end.
LAB INVESTIGATIONS
 Swabbing – taken to lab for examination
 Aspirates – aspirating the fluid from a vesicle for lab
examination
 Immunoflourescence

 Patch testing

 Skin biopsy.

 Blood examination - basophiles can be elevated in

allergic conditions. Eg blood for VDRL
 Routine examination urinalysis FGH.HB ESR
PRINCIPALS OF DERMATOLOGICAL
THERAPHY
 Application of wet dressing
 Barrier therapy

 Topical medications

 Systemic medications

 Surgical therapy
IMPETIGO
 It is a superficial infection of the skin caused by staphylococci,
streptococci, or multiple bacteria.
 Bullous impetigo, a more deep-seated infection of the skin
caused by S. aureus, is characterized by the formation of bullae
(ie, large, fluid-filled blisters) from original vesicles.
• The bullae rupture, leaving raw, red areas.
• The exposed areas of the body, face, hands, neck, and
extremities are most frequently involved.
• Impetigo is contagious and may spread to other parts of the
patient’s skin or to other members of the family who touch the
patient or use towels or combs that are soiled with the exudate
of the lesions.
• Although impetigo is seen at all ages, it is particularly common
among children living in poor hygienic conditions.
• It often follows pediculosis capitis (head lice), scabies
(itch mites), herpes simplex, insect bites, poison ivy, or
eczema.
• Chronic health problems, poor hygiene, and malnutrition
may predispose an adult to impetigo.
• Some people have been identified as asymptomatic
carriers of S. aureus, usually in the nasal passages.
CLINICAL MANIFESTATIONS
• The lesions begin as small, red macules, which quickly become
discrete, thin-walled vesicles that soon rupture and become
covered with a loosely adherent honey-yellow crust
• These crusts are easily removed to reveal smooth, red, moist
surfaces on which new crusts soon develop.
• If the scalp is involved, the hair is matted, which distinguishes
the condition from ringworm
MEDICAL MANAGEMENT
• Systemic antibiotic therapy is the usual treatment.
• It reduces contagious spread, treats deep infection, and
prevents acute glomerulonephritis
• (ie, kidney infection)
• This may occur as an aftermath of streptococcal skin diseases.
• In nonbullous impetigo, benzathine penicillin or oral penicillin
may be prescribed.
• Bullous impetigo is treated with a penicillinase-resistant
penicillin (eg, cloxacillin, doxicyclin)
 In penicillin-allergic patients, erythromycin is an effective
alternative.
 Topical antibacterial therapy (eg, mupirocin) may be
prescribed when the disease is limited to a small area.
 However, topical therapy requires that the medication be
applied to the lesions
 Several times daily for a week.
 The treatment regimen may be impossible for some patients or
their caregivers to follow.
 Topical antibiotics generally are not as effective as systemic
therapy in eradicating or preventing the spread of streptococci
from the respiratory tract, thereby increasing the risk for
developing glomerulonephritis
 When topical therapy is prescribed, lesions are soaked or
washed with soap solution to remove the central site of
bacterial growth
 This gives the topical antibiotic an opportunity to reach the
infected site.
 After the crusts are removed, a topical medication (eg,
Polysporin, bacitracin) may be applied.
 Gloves are worn when providing patient care.
 An antiseptic solution, such as povidone-iodine
(Betadine) may be used to clean the skin, reduce
bacterial content in the infected area, and prevent spread
NURSING CARE
• The nurse instructs the patient and family members to bathe at
least once daily with bactericidal soap.
• Cleanliness and good hygiene practices help prevent the spread
of the lesions from one skin area to another and from one
person to another.
• Each person should have a separate towel and washcloth.
• Because impetigo is a contagious disorder, infected people
should avoid contact with other people until the lesions heal.
FOLLICULITIS, FURUNCLES, AND CARBUNCLES

• Folliculitis is an infection of bacterial or fungal origin

that arises within the hair follicles.
• Lesions may be superficial or deep.
• Single or multiple papules or pustules appear close to the
hair follicles.
• Folliculitis commonly affects the beard area of men who
shave and women’s legs.
• Other areas include the axillae, trunk, and buttocks.
• Pseudofolliculitis barbae (i.e, shaving bumps) are an
inflammatory reaction that occurs predominately on the faces
of African American and other curly-haired men as a result of
shaving.
• The sharp ingrowing hairs have a curved root that grows at a
more acute angle and pierces the skin, provoking an irritative
reaction.
• The only entirely effective treatment is to avoid shaving.
• Other treatments include using special lotions or antibiotics or
using a hand brush to dislodge the hairs mechanically.
A FURUNCLE (IE, BOIL)
• It is an acute inflammation arising deep in one or more hair
follicles and spreading into the surrounding dermis.
• It is a deeper form of folliculitis.
• Furunculosis refers to multiple or recurrent lesions.
• Furuncles may occur anywhere on the body but are more
prevalent in areas subjected to irritation, pressure, friction, and
excessive perspiration, such as the back of the neck, the
axillae, and the buttocks.
• A furuncle may start as a small, red, raised, painful pimple.
• Frequently, the infection progresses and involves the skin and
subcutaneous fatty tissue, causing tenderness, pain, and
surrounding cellulitis.
• The area of redness and induration represents an effort of the
body to keep the infection localized.
• The bacteria (usually staphylococci) produce necrosis of the
invaded tissue.
• The characteristic pointing of a boil follows in a few days.
• When this occurs, the center becomes yellow or black,
and the boil is said to have “come to a head.”
• A carbuncle is an abscess of the skin and subcutaneous
tissue
• It represents an extension of a furuncle that has invaded
several follicles and is large and deep seated.
• It is usually caused by a staphylococcal infection.
• Carbuncles appear most commonly in areas where the
skin is thick and inelastic.
• The back of the neck and the buttocks are common sites.
• In carbuncles, the extensive inflammation frequently prevents a
complete walling off of the infection;
• Absorption may occur, resulting in high fever, pain,
leukocytosis and even extension of the infection to the
bloodstream.
 Furuncles and carbuncles are more likely to occur in
patients with underlying systemic diseases, such as
diabetes or hematologic malignancies, and in those
receiving immunosuppressive therapy for other diseases.
 Both are more prevalent in hot climates, especially on
skin beneath occlusive clothing.
MEDICAL MANAGEMENT
• In treating staphylococcal infections, it is important not to
rupture or destroy the protective wall of induration that
localizes the infection.
• The boil or pimple should never be squeezed.
• Follicular disorders, including folliculitis, furuncles, and
carbuncles, are usually caused by staphylococci
• If the immune system is impaired, the causative organisms may
be gram-negative bacilli..
• Systemic antibiotic therapy, selected by sensitivity study, is
generally indicated.
• Oral cloxacillin, dicloxacillin, and flucloxacillin are first-line
medications.
• Cephalosporins and erythromycin are also effective.
• Bed rest is advised for patients who have boils on the perineum
or in the anal region
• Systemic antibiotic therapy is indicated to prevent the spread
of the infection.
 When the pus has localized and is fluctuant, a small incision
with a scalpel can speed resolution by relieving the tension
 This ensures direct evacuation of the pus and slough.

 The patient is instructed to keep the draining lesion covered

with a dressing
NURSING MANAGEMENT
 Intravenous fluids
 fever reduction

 Other supportive treatments

 Warm, moist compresses increase vascularization and hasten

resolution of the furuncle or carbuncle.
 The surrounding skin may be cleaned gently with antibacterial
soap, and an antibacterial ointment may be applied.
 Soiled dressings are handled according to standard
precautions.
 Nursing personnel should carefully follow isolation
precautions to avoid becoming carriers
ACNE VULGARIS
 Is a common follicular disorder affecting susceptible hair
follicles, most commonly found on the face, neck and
upper trunk

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 Characterized by camedones (primary acne lesions),
both open and closed
 Most common in adolescents and young adults between
12 – 35 years. Both gender affected equally but with
early onset in girls

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CAUSES/ RISK FACTORS
 Hormonal: Hormonal activity, such as menstrual cycles
and puberty, may contribute to the formation of acne.

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During puberty, an increase in male sex hormones called
androgens cause the follicular glands to grow larger and
make more sebum. Acne becomes more marked at this
stage because the androgen is functioning at peak activity

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 Genetic: The tendency to develop acne runs in families.
A family history of acne is associated with an earlier
occurrence of acne.

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 Psychological: scientific research indicates that
increased acne severity is significantly associated with
increased stress levels.

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 Infection: Propionibacterium acnes (P. acnes) is the
anaerobic bacterium species that is widely concluded to
cause acne, though Staphylococcus epidermidis has been

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universally discovered to play some role since normal
pores appear colonized only by P.acnes.

 Diet: A high glycemic load diet is associated with

worsening acne. There is also a positive association
between the consumption of milk and a glycemic food.

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CLINICAL MANIFESTATIONS
 Closed comedones (whiteheads ): Obstructive lesions
formed from impacted lipids or oils and keratin that plug
the dilated follicle

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 Open comedones (blackheads): Contents of duct are
open, the black color resulting from lipid, bacterial and
epithelial debris
 Papules (pinheads), and Pustules (pimples),

 Scarring

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NUTRITION AND HYGIENE THERAPY

 Elimination of specific food or food products associated

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with fare – up of acne e.g. chocolate, cola, fried foods
and milk products
 Maintenance of good nutrition to equip the immune
system for effective action against bacteria and infection
 Washing twice a day with a cleansing soap for mild
cases
 Positive assurance, listening attentively and being
sensitive to patient’s feeling
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PHARMACOTHERAPY
 a) Topical Therapy
 1. Benzoyl peroxide:

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 Produce a rapid and sustained reduction of inflammatory
lesions;
 They depress sebum production and promote breakdown
of comedo plugs;
 Produce antibacterial effect by suppressing P. acnes.

 Initially causes redness and peeling hence patient should

be informed

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 The gel should be applied once a day and at night,
 Improvement may take 8 to 12 weeks

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 2. Topical Retinoid
 Vitamin A acid (tretinoin) is applied to clear keratin
plugs from pilosebaceous ducts.
 It speeds cellular turnover

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 3. Topical Antibiotics
 Include tetracycline, clindamycin and erythromycin

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 Suppress growth of P. acnes
 Reduce superficial free fatty acid levels
 Decrease comedones, papules and pustules

 b) Systemic Therapy
 Systemic Antibiotics
 Oral antibiotics like tetracycline, minocycline and doxycycline
are used in small doses over a long period of time (months to
years) 46

 Effective in moderate and severe acne

 2. Oral Retinoid/ Vit. A

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 Reduces sebaceous gland size and inhibits sebum
production

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 3. Hormone Therapy

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 Estrogen therapy suppresses sebum production and
reduces skin oiliness

 Reserved for women when acne begins somewhat later

than usual and tends to flare up at certain times during
the menstrual cycle

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NURSING MANAGEMENT
 Largely aimed at monitoring and managing potential
skin complications

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 Patients should be warned against discontinuing the
drugs because this can exacerbate acne, lead to more
flare – ups and increase the chances of scarring

 Discourage manipulation of comedones, papules and

pustules because it increases the potential of scarring

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 Advice clients on long – term antibiotics like tetracycline
especially women to watch out for side – effects like oral
and genital candidiasis

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 Teach patient on the need to wash the face with mild
soaps and water at least twice a day to remove surface
oils and prevent obstruction of oil glands

 Caution patients against scrubbing the face because it

worsens the acne.
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 Advice the patient against all forms of trauma including
propping the hands against the face, rubbing the face and
wearing tight collars and helmets

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 Instruct patients to avoid manipulating the pimples or
blackheads. Squeezing merely worsens the acne

 Cosmetics, shaving and lotions can aggravate acne, these

substances are best avoided unless otherwise

 Encourage the patient to eat a nutritious diet to help 51

maintain a strong immunity

ECZEMA

 Also called dermatitis

 Eczema is a skin disease characterised by inflammation
and irritation
TYPE OF ECZEMA

1. A topic Dermatitis
 Is the most severe and chronic ( long –lasting) kind of
eczema
 It typically affects the insides of the elbows: backs of the
knees and the face
 Its symptoms are dry: itchy , scaly skin cracks behind
the ears and rashes on the cheeks arms and legs
2. CONTACT DERMATITIS

 Is reaction that can occur when the skin come into

contact with certain substances which can cause skin
inflammation eg chemical s detergents, fumes woollen
fabrics
 Often seen around the hands

 There are two kinds of contact dermatitis

1 Irritant contact dermatitis

2 Allergic contact dermatitis
3. SEBORRHEIC DERMATITIS

 Affect the upper chest and have round, red areas in

addition to slight scaling
 Symptoms –

a) Redness
b) Itching
c) Dry and Flushed skin
CAUSES / PREDISPOSING FACTORS
overactive response by body’s immune system when:-
A Contact with rough or coarse materials may cause skin to
become itchy, eg wooL.
B Household products like soap or detergent eg dettol
C Coming into contact with animal dung may may cause an
outbreak
D Upper respiratory infection or colds may also trigger
E Person engaged in wet works eg baby sitting,g food handlers

 NB :Eczema is commonly found in families with history of

other allergies or asthma.
CLINICAL MANIFESTATIONS

 Itching start before rash appears: rash appear on

face ,back, wrist, hands or feet.
 Affected areas appear dry thickened or scally.

 Reddish patches and then turn brown with time

 In infants the itchy rash can produce oozing, crusting

condition that mainly on face and scalp but patches may
appear anywhere.
 The oozing papules become crusty and eventually form
scars.
DIAGNOSIS
 Physical examination
 History taking

 Patch test is also done( A test of skin sensitivity in which a

number of possible allergens are applied to the skin. Causal
agent of allergy will produce an inflammation.)
 Swab from oozing fluids to R/O other secondary infection
MANAGEMENT
 Put the patient on local antibiotics to prevent or treat secondary
infections
 Give topical applicants : emulsifying ointments or aqueous
creams to treat the crust if the skin is too dry
 Particular type of bathing soaps may be prescribed eg Dove
soap.
 Give antihistamine eg piriton to ease itching
 Nurse the patient in a cool environment with plenty of cool air.
 Advise the patient to avoid scratchy material such as wool.
 Crust and scales are not removed but allowed to drop naturally.
RISK FACTORS

 Trauma/ Injury to the skin often as minor as a scratch or

an insect bite
 Poor nutrition,

 poor hygiene and intestinal parasites

 Neuropathy

 Arterial diseases
SEBORRHOEA
 This refers to a secretory disorder of the skin which is
characterized by excessive production of sebum in areas
where sebum glands are found.
 It affects any hairy bearing area in the body such as the face,
scalp, eyebrows, eyelids, sides of the nose, ears, axillae, chest,
breasts and gluteal crease of the buttocks
 Sebum is a secretion of the sebaceous gland.
PATHOPHYSIOLOGY OF SEBORRHEIC
DERMATITIS

 This condition occurs as a result of increased production

of sebum which accumulates on the surface of the scalp
blocking the pores of the skin on the scalp.
 This leads to crusting which is due to lack of skin
moistures, hence the formation of the powdery flakes
which fall off as dandruff.
ASSESSMENT AND DIAGNOSTIC FINDINGS:

 Complete history taking and Physical

examination
 Skin biopsy to rule out other causes
CLINICAL MANIFESTATION
There are two forms of serrboheic dermatitis
 Oil form serrboheic dermatitis

 Dry form serrboheic dermatitis

INCIDENCE

 It may affect infants from two months to twelve months

of age: this is referred to as cradle cap, and may continue
to adulthood.
 Generally, this condition affects more men than women

 It is a common skin condition in infants, Adolescents and

Adult.
SIGNS OF OILY FORM SERRBOBEIC
DERMATITIS

 Moist or greasy patches of sallow greasy appearing skin

with or without scales
 Slight erythema ( redness of the affected area)
 Small pustules or papulopastules on the trunk resembling
acne.
SIGNS OF DRY FIRM SERRBOHEIC DERMATITIS

 It consists of flaky desquamation of the scalp with

profuse amount of fine powdery Scales and this is
commonly known as dandruff.
MEDICAL MANAGEMENT

 Since there is no known cure for seborrhoea, the patient

should be explained and know the objective of the
therapy which is to control the disorder and maintain the
health of the skin.
 Applying topic corticsterteroid ointments to inhibit the
inflammatory process of the face, head and affected
areas of the body such as: diprosalic ointment
( betamethasone + salicy acid)
PRECAUTION
 Medications should be applied with care to prevent them from
penetrating to the eyelid as it may lead to glaucoma or
dermatitis.
2. Ensure adequate aeration of the skin and cleaning skin fold
areas thoroughly
3. Use shampoos to wash hair at least three times weekly.
(Leave shampoo to remain in the hair after application for 5-10
minutes before rinsing)
NB
 Alternate shampoos to avoid resistance from developing
by using antiseborrheic creams such as bio selenium
shampoo,, keto plus shampoo and candid TV.
 Then apply antiserrboheic ointments like salicylic or
sulphur compounds eg. white field ointment.
4.Use oral antifungal such as ketoconazole 200mg once
daily for 30 days
NURSING MANAGEMENT

Do not scrub the dry scalp as it lead to secondary

infection which finally results excoriation.
 Avoid scratching or scrubbing the infected scalp near
person as it may be transmitted from one person to
another.
 CT
 Take caution to prevent transmission
 Cut the hair short to increase ventilation of keratin cells

 Daily bathing to keep the hair and skin folds clean to prevent
secondary infection.
 If the patients presents with dandruff, reinforce on treatment by use of
the prescribed medication.
 Patients who becomes discouraged and dishearted by the effect of the
body image should be treated with sensitivity and encouraged to
express their feelings
PEMPHIGUS
 Its an autoimmune disease where IgG antibody is directed
against a specific cell surface antigen in epidermal cells.
 Its characterised by-Appearance of a bullae (blister) of various
sizes on normal skin and mucus membranes.
 The blister form due to antibody antigen reaction. The level of
serum antibody is predictive of disease severity
 Incidence- Jewish and Mediterranean descent, occur in men
and women in middle and late adulthood
CAUSES

 Genetic factors
 Autoimmune disease eg mostly Myasthenia gravis
SIGNS AND SYMPTOMS

 Oral lesions which are irregular , painful ,bleed easily

and heal slowly
 Bullae enlarge, rupture and leave, painful eroded area
accompanied by crusting and oozing.
 Characteristic odour

 Nikolsky’s sign ( blistering or sloughing of uninvolved

skin when minimal pressure is applied)
TYPES OF PEMPHIGUS
Depends on the blister formed
1. PEMPHIGUS VULGARIS
 Is the most common types of disorder

 Starts in the mouth ie mouth blisters

 Can be painful but most do not itch leave scars

 Occurs among people of 40-60 years

2. PEMPHIGUS FOLIACEUS

 Most often start with crusty sores or blisters on the face

and scalps then goes to the chest and back.
 Can cause loose moist scales on the skin

 Most sores are itchy not painful as pemphigus vulgaris

 Does not cause mouth blisters / sores

3. PEMPHIGUS VEGERANS
 Cause sores in region groin and under the arms

4. INTRAEPIDERMAL NEUTROPHILICE IG A
PEMHIGUS
 Least harmful type of pemphigus. blisters look like for
pemphigus foliaceus
 Can also cause small bump with pus inside

 Caused by antibody 1 g A
5. PARANEOPLASTIC PEMPHIGUS
 Is a rare type of pemphigus but more severe types.
it’s a complication of cancer usually lymphoma’ s
and Castleman’s diseases
 Specialist may be needed for diagnosis
 Occurs in people with some types of cancer and can
cause
1 Painful mouth and lip sores
2 Curls and scars on the lining of the eyes and eyelid.
3 Skin blisters
DIAGNOSIS

 History and physical examination

 Biopsy

 Immuno florescent studies, shows intraepidermal

presence of 1 g G
 Blood sample for FHG and serum level
MANAGMENT
Medical
 High doses of corticosteroids

 Immunosuppressive agents eg Azathioprine ( Imuran)

and mycophenolate mofetil ( cellcept). These agents are
administered early in course to control disease and to
avoid high doses of corticosteroids.
 Antibioltics are given to treat infections.

 Liver function test is done to show how epidermal cells

are separated from each other
 Anti – Inflammatory agents
NURSING MANAGEMENT

 Analgesics
 Enhancing skin integrity and discomfort by using cool,
wet dressing .
 Reducing anxiety by listening to the patient worries and
health educate the patient about the disease.
 Monitoring and managing potential complication eg
sepsis.
 Keep patient warm

 Antibiotic may be given prophilatically

COMPLICATIONS
 Secondary infections
 Sepsis

 Genital ulcers

 Septicaemia
PSORIASIS

 Psoriasis is a chronic inflammatory disease of the skin in

which the production of epidermal cell of the basal layer
occur at a rate that is approximately 6-9 times faster than
normal
 The rapid reproduction of cell is accompanied by rapid
transition of cells from the germinative layer of top of the
stratum corneum.
 The transition is reduced from the normal 30-40 days to
around 7 days this occurs anywhere in the body.
 There’s a genetic predisposition to psoriasis but the cause
is ideopathic
CT
 Its has a tendency to improve but keeps on recurring.
some of the factors triggering recurrence include
. Bacterial infection e.g. pharyngitis
 Emotional trauma

 Mechanical trauma

 Drugs e.g. receptor antagonist e.g. propranolol

 Day to day fear and wear

 Seasonal and hormonal changes

 Emotional stress and anxiety

PSORIASIS (DIAGRAM)

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 MAIN TYPES OF PSORIASIS
Plaque psoriasis – Also know as psoriasis vulgaris. Presents with red patches
with white scales on top of the skin. Mainly affects the back of
forearms, shins, belly bottom and scalp. makes 90% of psoriatic attacks.
Pastular psoriasis – Presents with small non – infections pus filled blisters
Inverse psoriasis – Forms red patches in skin folds
Gultate psoriasis- formed by drop –shaped lesions
Erythrodermic psoriasis– Occurs when a rash becomes very widespread.
May affect the finger nails and toe nails which changes nail colour
PATHOPHYSIOLOGY

 In this disease, the cells in the basal layer of the skin

divides too quickly and newly formed cells move so
rapidly to the skin surface that they become evident as
profuse or plague of epidermal tissues. As a result of the
increased number of basal cells passage, the normal
event of cell maturation and growth cannot occur, which
prevent formation of the normal protective layers of the
skin.
CLINICAL FEATURES
 Pruritus
 Lesion appear as red raised patches on skin covered with silver
scales
 If scales are scooped away, a dark red base of the lesion is
exposed producing multiple bleeding points.
 Parts mainly affected include the scalp, flex oral of areas of
back and genitalia
 Bilateral symmetry affecting both sides of the body is a
feature of psoriasis
 In about ¼ of all the effected, the nails are affected and they
present with pitting, discolouration, crumbling beneath the
free edges, dubbing and separation of the nail plate
 Pastular lesion may occur. if it occurs on the palms and soles
DIAGNOSIS

 Based on clinical findings

 rule out fungal infection
MANAGEMENT
Goal is :

To control the rapid turnover of epidermis, to promote resolution

of the psoriatic lesion, and control the natural cycles of the
disease.
 Remove all the aggravating factors

 There is no known cure

 Gentle removal of scales this can be accomplished by baths

 Oils such as olive oil, minera oil or areeno oil, oatmeal bath or
coal tar preparations ( balnetar ) can be added to water and a
soft brush used to scrub the psoriatic plagues gently
CT
 After bathing the application of emollient creams containing
alpha hydroxyl acids or salicylic acid will continue to soften
thick scales cover the skin with tar or antralin
 Three types of therapy are standard , topical, systemic and intra
lesional
 use of topical steroids eg betamethason covered with a heavy
dressing to reduce the multiplication of cells.
 Photo chemotherapy / ultra –violet radiation eg 8-
methoxypsolaren
 Use of systemic cytotoxic drugs eg methotrexate
NURSING MANAGEMENT
 Assessment through carefully concentrating on the areas prone
for psoriasis eg elbow, knees ,scalp
 Promoting understanding by health promotion and assurance of
controlling the disease, adherence to treatment regimen,
avoiding use of unprescribed drugs such as indomethacine,
beta blockers which may exacerbate mild psoriasis.
 Increasing skin integrity by application of emollient cream and
bathing oil to prevent fissures on the skin.
 Monitoring and managing potential complications such as
psoriatic arthritis
COMPLICATION

 The patient may develop exfoliate psoriasis a condition

in which the disease spreads entire body . this is also
known as Erythrodermic psoriasis.
 Asymmetrical rheumatic factor, Associated with arthritis
of multiple joints causing a crippling disability, the cause
of this phenomenon is rarely understood.
 URTICARIA
 An allergic reaction of the skin caused by cold, some foods, stress and
pressure .
 It is characterized by sudden appearance of pinkish oedematous
elevations that vary in size shape and sometimes they itch. They
remain for few minutes to several hours before disappearing.If the
sequence continues longer than 6wks it is called chronic urticaria
 It can be a vertical line irregular round , single or multiple depending
on scratch pattern.
 It is type I hypersensitivity involving, immunoglubin E due to altered
immune system.
CAUSES
 Environment factors- pollen, dust particles, fungi change in
temperature, extreme cold, heat pressure.
 Cholinergic factors- exercise, pressure, changes, in temperature
of body after sweating affecting nerve ending of skin.
 Drugs- NSAIDS like aspirin and penicillin m ay become
sensitive with the skin
CT
 Emotional factors – Stress may act as exciting, Aggravating or
maintaining cause especially under prolonged stress, anxiety
sadness or insecurity such will alter immunological functions
and lead to hypersensitity
 Autoimmune cause - presence of antibodies against
immunglobin E. which releases histamine and inturn affects
basophils which are responsible for allergic reaction leading to
chronic urticaria.
 Water-causes constriction of blood vessels the bringing an
allergic reaction
CLINICAL MANIFESTATION

 Appearance of hives[urticaria] of the skin

 Fever as there is inflammation thermo receptor cells are
interfered
 Lesions are raised and erythromatous

 Tend to concentrate on the trunk and upper extremities

 Itching and burning

 Swelling and redness

 Palpitations
DIAGNOSIS
 Physical examination of skin eruption
 Clinical manifestation

 Systemic history taking to rule out endocrine allergy and

hormone disorder
MEDICAL MANAGEMENT

 Give epinephrine to dilate bronchial muscles since in

allergic reaction there are palpitations also to activate
heart muscles
 Give antihistamines eg. certrizine to inhibit production
of histamines by I g E
 Give corticosteroids eg hydrocortisone as they are
immune suppressants though discouraged for long
periods
NURSING MANAGEMENT

 Monitor patient symptoms

 Administering prescribed medication

 Evaluation patient response to medication

 Health education to the patient on avoidance of

allergens.
DERMATOPHYTES
 Dermatophytes are a group of fungi that cause skin, nail
and hair infections and require keratin for growth.

sam
 TINEA PEDIS: ATHLETE’S FOOT

 Most common fungal infection

 Occurs on the soles of feet or between the toes. May also

affect finger nails

 Clinical Manifestations
 Erythematous, inflamed, and vesicular lesions of feet.

 Itching and irritation

105
 Management
 Topical antifungal agents e.g. miconazole and

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clotrimazole. Should be continued for several weeks
because of high rate of recurrence
 Soaking feet in potassium permanganate solutions to
remove crusts, scales and debris and to reduce
inflammation
 Instruct patient to keep the feet as dry as possible and
especially between the toes.
 Small pieces of cotton can be put between toes at night
to absorb moisture
106
 Soaks should be made from cotton since it is a good

sam
absorber of perspiration
 Encourage use of open shoes or canvas sneakers
especially for people who perspire excessively and
avoidance of tight shoes or plastic or rubber-soled shoes
or boots.
 Application of talcum powder or antifungal powder
twice daily helps keep feet dry
 Several pairs of shoes should be alternated so that they
can dry completely before being worn again
107
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108
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109
 TINEA CORPORIS (RINGWORM OF THE BODY)
 The typical ringed lesions appear on the face, neck, trunk

sam
and extremities

 Clinical Manifestations
 Begin as a macule which spreads to form ring like
papules or vesicles with central clearing
 Lesions are found in clusters, and very pruritic

 Clusters of pustules may be seen around the borders

110
 Management
 Topical antifungal to be used on small areas. Should be

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used continuously for 4 weeks even if lesions disappear
 Oral antifungal to be used in extensive cases e.g.
fluconazole
 Note: Side effects of oral antifungals include:
photosensitivity, skin rashes, headache and nausea
 Instruct patient to use a clean towel and to wash clothes
daily. Clean cotton clothes be dressed next to the body
daily
 Instruct patient to keep all skin areas and folds that 111
retain moisture dry
 sam
112
 TINEA CAPITIS (RINGWORM OF SCALP)
 Contagious fungal infection of the hair shafts and a common

sam
cause loss of hair in children
 Any child with scaling on the scalp should be considered to
have tinea capitis until proven otherwise

 Clinical Manifestations
 Starts as one or several round, erythematous scaling patches
 Small pustules or papules may be seen at the edges of such
patches
 Hairs in affected area become brittle and break off at or near
the scalp. Since in most cases tinea capitis heals without 113

scarring, the hair loss is temporary

 Management

sam
 Systemic antifungal agents e.g. griseofulvin and
ketoconazole
 Topical agents do not provide an effective cure because
the infection occurs within the hair shaft and below the
surface of scalp. However, they can be used to inactivate
the organisms already in the hair, minimizing contagion
and eliminating the need to clip the hair
 Hair should be washed with shampoo two or three times
a week
114
 Improve on hygiene
 Each member of the family should have his/her own

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comb and brush. Should also avoid exchanging hats and
other headgear

 All family members and pets should be examined and

treated

115
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116
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117
 TINEA CRURIS (RINGWORM OF GROIN)
 Ringworm infection of groin, which may spread to inner

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areas of thighs and buttock area
 Common in obese people and those who wear tight
clothing
 Incidence high in people with diabetes

 Management
 Topical antifungals for mild cases e.g. miconazole,
clotrimazole for 3 to 4 weeks to ensure eradication of
infection 118
 Oral antifungals for severe cases

sam
 Instruct patient to avoid excessive heat and humidity and
to avoid wearing nylon underwear and tight – fitting
clothing

 Groin area should cleaned thoroughly, dried well and

dusted with a topical antifungal agent as a preventive
measure to prevent recurrence

119
 TINEA UNGUIUM (ONYCHOMYCOSIS)
 Also called ringworm of nails

sam
 Chronic infection of toe nails or, less commonly finger
nails
 Associated with long – standing fungal infection of the
feet
 The nails become thickened, friable (easily crumbled)
and lusterless, and eventually the nail plate separates
 Since infection is chronic, the entire nail may be
destroyed
120
 Management
 Oral antifungal for 6 weeks if the fingernails are involved

sam
and 12 weeks if the toenails are involved
 Encourage patient to comply with lengthy treatment, as
fungal infections of the nail are difficult to treat.
 Examine patient for other areas of tinea infection (feet,
groin), encourage treatment, and teach patient that
infection may be spread from fingernails by scratching.
 After nail removal, advise patient to keep hand or foot
elevated for several hours, and change dressing daily by
applying gauze and antibiotic ointment or other prescribed
medication until nail bed is free of exudate or blood. 121
 sam
122
PEDICULOSIS (LICE INFESTATION)
 Affects all age groups

sam
 Lice are ectoparasites since they live outside the body

 Depend on their host for nourishment, feeding on human

blood approximately 5 times a day

 They inject their digestive juices and excrement into the

skin which causes severe itching

123
 PEDICULUS HUMANUS CAPITIS (HEAD LOUSE)

sam
 Is an infestation of scalp by head louse

 Female louse lay eggs (nits) close to the scalp. The nits
become firmly attached to hair shafts with a sticky
substance

 The young lice hatch in a about 10 days and reach

maturity in 2 weeks 124
 Clinical Manifestations

sam
 Lice found most commonly along the back of the head
and behind the ears
 Eggs appear silvery glistening white oval bodies difficult
to remove from the hair
 Severe itching as a result of bites of the lice, scratching
results to secondary bacterial infection
 Transmitted directly by physical contact or indirectly by
infested combs, brushes, hats, wigs and beddings
125
 PEDICULOSIS CORPORIS AND PUBIS
 Pediculosis corporis is infestation of body by body louse

sam
 Pediculosis pubis is the infestation of the genital region
and is transmitted chiefly by sexual contact

 Clinical Manifestations
 Intense itching as a result of bites, scratching then results
to skin excoriation
 Skin may become dark, dry and scaly, with dark
pigmented areas
126
 Reddish brown dust (excretion of lice) may be found on
the patient’s underclothing

sam
 Macules may be seen on trunk, axillae and thighs as a
result of reaction of the lice’s saliva with bilirubin

 Note: Pubis infestation by lice may coexist with some

STIs like gonorrhea, syphilis and herpes

127
 Management
 Bathing with soap and applying lindane (antiparasitic

sam
agent)
 If eyelashes are involved petroleum may be applied to
eyelashes, then lice and nits removed
 Antipruritus, antibiotics and corticosteroids for
complications e.g. pruritus, pyoderma and dermatitis
 Advise patient that pediculosis pubis is considered a
sexually transmitted disease; partners must be examined
and treated
128
 Urge patient to wash all clothing, towels, linens, combs,
and hair items by soaking in hot water for 10 minutes.
Alternatively, clothes may be dry-cleaned or ironed,

sam
paying close attention to the seams.

 Items that cannot be washed or dry-cleaned can be stored

for 30 days without use.

 Advise patient not to use antiparasitic preparations more

frequently than recommended.
129
SCABIES
 Is an infestation of the skin by the itch mite – Sarcoptes
scabiei

sam
 May be found in people living in substandard hygienic
conditions but is also common in very clean people

 Is highly contagious

 Transmitted by close personal contact

130
CLINICAL MANIFESTATIONS
 Itching, more intense at night because the increased
warmth of the skin has stimulating effect on the parasite.

sam
 Small erythematous papules and short, wavy burrows are
seen on skin surface.

 Frequently seen between fingers and on the wrist. Other

sites are the groin area, around the nipples, extensor
surfaces of the elbows, the knees, the edges of feet and
axillary folds .
131
 Spares head and scalp except in children under age 1.

sam
 Atypical scabies may be found in immune compromised
people and may be resistant to standard treatment

 Secondary lesions include vesicles, papules, excoriation

and crusts

 Bacterial superinfection may result from excoriation of

burrows and papules
132
MEDICAL MANAGEMENT
 Patient instructed to take a warm soapy bath or shower to
remove the scaling debris from the crusts and then dry
well

sam
 Treated with antiparasitic, such as lindane (kwell),
permethrin (Nix)

 Topical or systemic steroids may be needed to treat

symptoms of allergic reaction to mites.

 Oral antihistamines can be used to relieve itching 133

NURSING MANAGEMENT
 Teach proper use of medication: Apply thin layer from
neck downward, with particular attention to hands, feet;
every inch of skin must be treated because mites are

sam
migratory. Apply to dry skin. (Wet skin allows more
penetration and the possibility of toxicity.) Leave
medication on for 8-12 hours but not longer, as doing so
will irritate the skin. Wash thoroughly.

 Advise patient to avoid close contact for 24 hours after

treatment to prevent transmission.

134
 Encourage treatment of all family members and close
contacts simultaneously to eliminate the parasite.

sam


 Tell patient that itching may persist for days to weeks

following treatment due to an allergic reaction to mites;
retreatment is not necessary.

 Advise patient to wash all beddings and clothing in hot

water and dried

135
CONTACT DERMATITIS
 Inflammatory condition caused by exposure to irritating
or allergenic substances, such as plants, cosmetics,
cleaning products, soaps and detergents, hair dyes,

sam
metals, and rubber

 There are four basic types:

 Allergic contact dermatitis

 Irritant contact dermatitis

 Photoallergic contact dermatitis

 Phototoxic contact dermatitis

136
 1. Allergic Contact Dermatitis

sam
 Result from contact of skin with an allergen. There is
immunologic involvement

 2. Irritant Contact Dermatitis

 Contact with substances that chemically or physically
damage the skin. There is no immunologic involvement

137
 3. Phototoxic Contact Dermatitis
 Refers so skin damage that result from combination of

sam
sun and chemicals

 4. Photoallergic Contact Dermatitis

 Is of allergic type but is primarily as a result light
exposure

138
CLINICAL MANIFESTATIONS

 Allergic dermatitis is usually widespread trigger actually

sam
touched the skin, whereas irritant dermatitis is confined
to the area on the skin.

 Symptoms of both forms include the following:

 Red rash: This is the usual reaction. The rash appears

immediately in irritant contact dermatitis; in allergic
contact dermatitis, the rash sometimes does not appear
until 24–72 hours after exposure to the allergen. 139
 Blisters or wheals and urticaria (hives): Often form in a

sam
pattern where skin was directly exposed to the allergen
or irritant

 Itchy, burning skin: Irritant contact dermatitis tends to be

more painful than itchy, while allergic contact dermatitis
often itches.

140
 While either form of contact dermatitis can affect any
part of the body, irritant contact dermatitis often affects
the hands, which have been exposed by resting in or

sam
dipping into a container containing the irritant.

 Progresses to weeping, crusting, drying, fissuring, and

peeling.

 Lichenification (thickening of skin) and pigmentation

changes may occur with chronicity
141
MEDICAL MANAGEMENT
 Topical or oral steroids, depending on severity. Oral
steroids usually given in tapered doses (start with high
dose and gradually decrease) to provide greatest anti-

sam
inflammatory effect without adrenal suppression.

 Removal or avoidance of causative agent.

 Antipruritics, systemic or topical antihistamines or

topical calamine preparations.

142
NURSING MANAGEMENT
 Take thorough history to determine causative agent or
contributing factors

sam
 Advise patient to rest the involved skin and protect it
from further damage
 Cool and wet dressings applied over areas of vesicular
dermatitis
 Teach patient to use allergen-free products, wear gloves
and protective clothing, wash and rinse skin thoroughly,
and wash clothing after contact with potential irritants

143
BENIGN SKIN TUMORS
 1. Keloids
 Benign overgrowths of connective tissue expanding
beyond the site of scar or trauma in predisposed
individuals.
 More prevalent among dark-skinned individuals.

 Usually asymptomatic but may cause disfigurement and

sam
cosmetic concern.
 Management though not satisfactory is by intralesional
therapy, corticosteroid therapy, surgical removal and
radiation
145
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146
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147
 2. Verrucae (Warts)

 Common, benign skin tumors caused by human

papilloma virus.

sam
 Often disappear spontaneously, so may not need
treatment.

 Treatment options:
148
 Freezing with liquid nitrogen (destroys wart and spares
rest of skin).

 Area may be treated surgically with curettage

sam
 Application of salicylic acid, topical fluorouracil, topical
vitamin A acid, or other irritants may be helpful,
especially for flat warts.

149
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150
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151
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152

Vaginal Genital HPV

 sam
153
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154
 3. Hemangiomas

 Hemangiomas are benign tumors of the capillaries,

which presents shortly after birth.

sam
 They grow rapidly for 6 to 18 months, followed by
stabilization and subsequent regression. Most
hemangiomas resolve by age 9.

 Surgery is reserved for complicated hemangiomas that 155

may be obstructing the airway.

 Hemangiomas blocking the visual axis or compressing
against the eye are treated with high doses of
corticosteroids or interferon.

 For hemangiomas that do not threaten vision or life, no

intervention is preferred.

sam
 Lasers can be used for ulcerated hemangiomas.

156
 4. Pigmented Nevi (Moles)

 Common skin tumors of various sizes and shapes,

ranging from yellowish to brown to black; may be flat,
macular lesions, elevated papules, or nodules that
occasionally contain hair.

sam
 Most pigmented nevi are harmless; however, in rare
cases, malignant changes supervene and a melanoma
develops at the site of the nevus.
157
 Nevi at sites subject to repeated irritation from clothing
or jewelry can be removed for comfort.

 Nevi that show change in size, shape, or color, become

symptomatic (itch or bleed), or develop notched borders

sam
should be removed to determine if malignant changes
have occurred. This is especially true for nevi with
irregular borders or variations of red, blue, and blue-
black
158
MALIGNANT TUMORS OF THE SKIN
(SKIN CANCERS)
 Most common cancer in the US

 Basal cell carcinomas (BCCs) are the most common but

easily curable because of early diagnosis and slow
progression. They are locally invasive and tend not to
metastasize.

sam
 Squamous cell carcinomas (SCCs) are less common
than BCCs and have an increased potential for metastasis

159
 Malignant melanomas are least common and have a higher
risk of metastasize.

 Most basal and squamous cell carcinomas are located on

sun-exposed areas and are directly related to ultraviolet
radiation. Sun damage is cumulative – the harmful effects

sam
may be severe by age of 20 years.

 Exposure to the sun is a leading cause of skin cancer;

incidence is related to the total amount of exposure to the
sun
160

 Diagnosed by skin biopsy and histologic evaluation

RISK FACTORS

 Fair complexion (skin, hair), blue eyes; particularly

those with insufficient skin pigmentation to protect
underlying tissues

 Working outdoors (farmers, fishermen, construction

sam
workers)

 Older people with sun-damaged skin.

161
 Exposure to certain chemical agents (nitrates, tar, oils,
and paraffin).

 Burn scars, damaged skin in areas of chronic

osteomyelitis, fistulae openings.

sam
 Long-term immunosuppressive therapy.

 Genetic susceptibility.

162
 Multiple dysplastic nevi (moles that are larger, irregular,
more numerous, or variable colors) or family history of
dysplastic nevi.

 Congenital nevi that are large (more than 20 cm in size)

sam
 History of X-ray treatment of skin conditions for acne or
benign lesions

163
BASAL CELL CARCINOMA
 Is the most common type of skin cancer, rarely
metastasizes

 Generally appears on the sun exposed areas of the skin

sam
 More prevalent in regions where the population is
subjected to intense and extensive exposure to the sun

 Incidence is proportional to the age of the patient

(average age of 60 years) and the total amount of sun
exposure and it is inversely proportional to the amount 164

of melanin in the skin

PATHOPHYSIOLOGY
 Over exposure to sun leads to the formation of thymine
dimers, a form of DNA damage.

 While DNA repair removes most UV-induced damage,

not all crosslinks are excised. There is, therefore,
cumulative DNA damage leading to mutations.

sam
 Apart from the mutagenesis, over exposure to sunlight
depresses the local immune system, possibly decreasing
immune surveillance for new tumor cells.
165
CLINICAL MANIFESTATIONS
 Begin as small nodules with a rolled, pearly, translucent
border
 Telangiectasia may be present

 Crusting, and occasionally ulceration occur as it grows

 Appear most frequently on sun-exposed skin, frequently

on face between hairline and upper lip.

sam
 If neglected, may cause local destruction, hemorrhage,
and infection of adjacent tissues, producing severe
functional and cosmetic disabilities.

166
SQUAMOUS CELL CARCINOMA
 Is a malignant proliferation arising from the epidermis

 Usually appear on a sun – damaged skin but may als0

arise from normal skin or from preexisting skin
condition

sam
 Is a truly invasive carcinoma, metastasizing by blood or
lymphatic system

167
CLINICAL MANIFESTATIONS
 Appears as reddish rough, thickened, scaly lesion with
bleeding and soreness

 May be asymptomatic; border may be wider, more

indurated, and more inflammatory than BCC

sam
 May be preceded by leukoplakia (premalignant lesion of
mucous membrane) of the mouth or tongue, actinic
keratoses, scarred or ulcerated lesions.

 Seen most commonly on lower lip, rims of ears, head, 168

neck, and backs of the hands.

PROGNOSIS
 Because skin is easily inspected, skin cancer is readily
seen and detected and is the most successfully treated
type of cancer

 Prognosis for BCC is usually good. Tumors remain

localized, and although some require wide excision with

sam
resultant disfigurement, the risk for death from BCC is
low

 The prognosis of SCC depends on the incidence of

metastasis, which is related to the histologic type and the
169
level or depth of invasion
 sam
170
Basal Cell Carcinoma Squamous Cell Carcinoma
MEDICAL MANAGEMENT
 Method of treatment depends on tumor location, cell
type (location and depth), history of previous treatment,
and whether it is invasive, or if metastasis has occurred.

 Curettage followed by electrodessication (usually done

on small tumors of basal or squamous cell type – less

sam
than 1 cm).

 Surgical excision for larger lesions or for those in areas

more likely to recur (around nose, eyes, ears, lips); may
be followed by simple closure, flap, or graft.
171
 Mohs' surgery, a microscopically controlled excision,
with immediate examination of frozen or chemically
fixed sections for evidence of cancer cells. Layers are
removed until a reasonable cancer-free margin is
achieved.
 Radiation therapy can be done for cancer of eyelid, tip of

sam
nose, in or near vital structures, such as facial nerve or
where tissue sparing is difficult with other forms of
treatment; also used for extensive malignancies where
goal is palliation, or when other medical conditions
contraindicate other forms of therapy.
 Other therapeutic regimen include: topical interferon, 172

retinoids, photoradiation.
NURSING MANAGEMENT
 1. Increasing Knowledge and Awareness
 Encourage follow-up skin examinations and instruct the
patient to examine skin monthly as follows:
 Use a full-length mirror and a small hand mirror to aid in
examination.
 Learn where moles/birthmarks are located.

sam
 Inspect all moles and other pigmented lesions; report any
change in color, size, elevation, thickness, or development of
itching or bleeding.

173
 Teach the patient to use a sunscreen routinely and to
avoid becoming sunburned by:
 Avoiding unnecessary exposure to the sun, especially during
times when ultraviolet radiation is most intense (10 A.M. to 3
P.M.).
 Wearing protective clothing (long sleeves, broad-brimmed

sam
hat, high collar, long pants). However, clothing does not
provide complete protection; up to 50% of sun's damaging
rays can penetrate clothes.

174
 2. Reducing Anxiety
 Provide dressing changes and wound care while teaching
patient to take control, as directed after surgical
intervention.
 Administer chemotherapy with attention to possible
adverse effects, as directed.

sam
 Allow patient to express feelings about the seriousness
of diagnosis.
 Answer questions, clarify information, and correct
misconceptions.
 Emphasize use of positive coping skills and support
175
system.
 3. Patient Education and Health Maintenance
 Encourage lifelong follow-up appointments with
dermatologist or primary care provider with
examinations every 6 months.
 Encourage all individuals to have moles removed that
are accessible to repeated friction and irritation,

sam
congenital, or suspicious in any way.
 Teach all individuals the importance of sun-avoidance
measures
 Teach proper use of sunscreen

176
ASSIGNMENT
 Read and make notes on Malignant Melanomas
 Risk Factors

 Clinical Manifestations

 Medical Management

 Nursing Management

sam
177