Altered Integument Concept Maps Gary Schofield, RN

Clinical Manifestations of Skin Dysfunction Infections Bacterial: Folliculitis, Foruncle, Carbuncles, Cellulitis, Erysipelas Viral: Herpes (Simplex,Zoster, Varicella), Warts Fungal: Tinea, Candidiasis INFLAMATORY Eczema, Atopic, Dermatitis-Contact (Allergic, Irritant), Stasis, Seborrheic DISORDERS OF THE SKIN Vesiculobullous (Vesicle Formation) Pemphigus (Vulgaris,Vegetans, Foliaceus, Erythematous) Bullous Phemphoid Erythema Multiforme: (Steven-Johnson Syndrome & Toxic Epidermal Necrolysis) Papulosquamos Inflamatory process associated with papules, scales, plaques, & erythema Psoriasis, Pityriasis Rosea, Lichen Planus, Acne (Vulgarius, Rosacea), Lupus Erythematous [Dicoid (DLE) Systemic (SLE)] Vascular (Commonly assoc. with skin disease) Cutaneous vasculitis Urticaria Scleroderma Insect Bites Ticks (Rocky Mt Spotted Fever, Lyme Disease) Mosquitoes (Malaria, Yellow Fever) Flies Frost Bite Affects fingers, ears, toes, & cheeks Cancer Basal Cell (Surface epithelial -Most Common) Squamous Cell -Epidermis Malignan Melanoma –originates in melanocytes Kaposi Sarcoma –vascular malignancy Benign Tumors Seborrheic Keratosis Keratocanthoma Actinic Keratosis Nevi (moles) Clinical Manifestations of Skin Dysfunction Lesions, Keloids, Pressure Ulcers, Pruritis, Disorders of the Hair Alopecia (Male pattern, Female pattern) Areata – usually temporary baldness Hirsutism – could indicate polycystic ovaries, adrenal hyperplasia, or adrenal tumor Disorders of the Nail Paronychia – acute or chronic infection of the cuticle Onychomycosis – fungal or dermatophyte infectionof the nail plate

Microscopic Immunofluorescense Skin Biopsy Tzanck Microscopic Immunofluorescense Diascopy Gram Stain Skin Diagnostic Procedures Side Lighting Culture Skin Scrapings Wood Lamp Exam Patch & Scratch Tests

Primary Secondary Special Lesions Skin Lesions Macule – ↓ 1cm, flat, change in color Scale – heaped-up, keratinized cells, flaky skin Papule – ↓ 1 cm, elevated and firm Lichenification – rough, thickened epidermis, flexor surface of extremity Patch – Flat, nonpalpable, ↑ 1 cm Keloid – irregular-shaped, elevated, enlarging scar, beyond boundaries of the wound, excessive collagen formation during healing Plaque – elevated, firm, rough, ↑ 1cm Wheal – elevated, irregular shape, solid, transient Scar – thin-thick fibrous tissue that replaces normal skin, to the dermis Nodule – elevated, firm, circumscribed, deeper in dermis 1-2 cm Excoriation – loss of the epidermis, linear, hollowed-out, crusted area Tumor – elevated, solid, clearly demarkated, deeper in dermis ↑ 2 cm Fissure – linear crack or break from the epidermis to dermis, may be moist or dry Vesicle – elevated circumscribed, superficial, filled with serous fluid ↓ 1cm Ulceration – loss of epidermis and dermis, concave, varies in size Bulla - vesicle ↑ 1 cm Atrophy – thinning of the skin surface, loss of skin markings Pustule – elevated, superficial, filled with purulent fluid Cyst – elevated, circumscribed, encapsulated, dermis/ subcutaneous layer, liquid filled or semisolid Telangiectasa – fine, irregular red lines, capillary dilation Special Lesions Comedone – a plug of sebaceous and keratin material lodged in a hair follicle (Blackhead Burrow – narrow, raised, irregular cannel caused by parasite Petechiae – circumscribed area of blood less than 0.5 cm in diameter Purpura – circumscribed area of blood greater than 0.5 cm in diameter Skin Lesions

Skin Disorders in Children Insect Bites/ Paracites Acne Vulgaris Most common skin disease; affects 85% population ages 12-25. Severe acne runs in families; Causes unknown Skin Disorders in Children Vascular Disorders Strawberry Hemangioms – raised vascular lesions Cavernous Hemangioma –larger more mature vessels than above Salmon Patches – macular, pink lesions fade with age Port-Wine stains – congenital malformations of dermal capillaries; does not fade with age Minor to Severe Localized or General Dermatitis Atopic – most common cause of eczema in children Diaper – most common skin disorder of infancy/early childhood Insect Bites/ Paracites Scabies – contagious; caused by itch mite Pediculosis -lice Fleas Bedbugs Other Milaria –dematosis common in infants Erythema Toxicum Neonatorum Toxic Epidermal Necrolysis – hypersensitive reactions to drugs usual cause; treat like burn; must differientiate with biopsy Infections Viral Molluscum Contagiosum – highly contagious Rubella- German Measles Rubeola – highly contagious Roseola – 6mos – 2 y/o Chicken Pox/ Herpes Zoster - Varicella Bacterial Impetigo – Bullous (Staph aureus), Vesicular (Group A Strep), Staphyloccal Scalded-Skin Syndrome [(SSSS)- usually seen in infants and children <5 years] Fungal Tina Capitis- involves scalp; most common fungal infection 2-10 yrs Tina Corporis- superficial dermatophyte Thrush – Candida in mucous membranes of month

Rad Theapy, Surgery, Electrodisiccation, Cryosurgery No metastasizes beyond the skin Less common in dark-skinned people Melanin- Protective Factor Slow Growth Rate Results of a defect that prevents shedding of cells by normal keratinization process Lack of normal keratin proteins Start as a nodule Exposure (Sunlight) = Ultraviolet Radiation Strongest 10:00am – 3:00pm Protection during 1st 10-20 yrs ↓ risk 3 Stages of Growth - Initiation - Progression - Metastasis Affects epidermis Significantly more malignant than basal cell if untreated 75% of cases located on neck and head Countries with high arsenic in drinking water have ↑ predonminance Outdoor Workers = ↑ incident Basal Cell Carcinoma Treatment Rad Theapy, Surgery, Electrodisiccation, Cryosurgery Mutation of p53 tumor Suppressor Gene Squamous Cell Carcinoma Malignant tumor of the skin Originates in melanocytes Incidence is increasing Young-Middle Age Adults ↑ risk Malignant Melanoma Biopsy - Color and/or size change - Irregular notched margin - Itching, Bleeding, Oozing, Nodularity - Scab formation or Ulceration Nevus Types ● Junctional ● Compound ● Intradermal Nevus (mole) – aggregation of melanocytes Most are not suspicious Suspect = Removal

Exposure to UV Light Solar and Artificial Risk Factors Malignant Melanoma Malignant Degeneration of Melanocytes Steroid Hormone Activity Light Skin Easy to Sunburn Genetic Predisposition Basal Layer of Epidermis Benign Melanocvtic Nevus Facial Hair Freckles 10-15% of cutaneous menanoma 50-80 yrs old at diagnosis Location: Head, Neck, Dorsum of Hands Pigmentation According to Thickness ● <1.5 mm (Level I,II) Tan & Brown ● >1.5mm (Level III) Tan, Brown Blue-Black ● >1.5mm (Level IV,V) Nodule Lentigo Malignant Melanoma (LMM) 70% of Cutaneous Melanoma Location: Legs of Females & ↑ Back Both Genders Superficial Spreading Melanoma (SSM) Clinical Varieties of Cutaneous Melanoma 20-60 yrs at diagnosis Primary Nodular Melanoma (PNM) 12% of Cutaneous Melanoma No Specific Site Preference >1.5 mm (Level III) small nodule, any hue >1.5 (Level IV,V) large nodule, any hue Acral-Lentiginous Melanoma 2-8% Whites, 75% Blacks, Hispanic, Asian 20-60 yrs old Palms, Soles of Feet, Mucous Membranes Affected Blue-Black in hue

References: Corwin, E. J. (2000). Handbook of Pathophysiology (2nd ed.). Philadelphia, PA: Lippincott. Nicol, N. H. & Huether, S. E. (2006). Alterations of the integument in children. In K. L. McCance & S. Huether (Eds.), Pathophsiology: The Biologic Basis for Disease in Adults & Children (pp.1609- 1623). St Louis, MO: ElSevier Mosby. Nicol, N. H., Huether, S. E. & Weber, R. (2006). Structure, function, and disorders of the integument. In K. L. McCance & S. Huether (Eds.), Pathophsiology: The Biologic Basis for Disease in Adults & Children (pp.1573-1607). St Louis, MO: ElSevier Mosby.