Maryville Nurs 623 Exam 1

Basics with skin conditions - - •Alopecia •Rash •Pruritus •Uticaria •Pigmentation change Skin lesion—New vs. Change HPI questions for skin problems - -Duration of symptoms Precipitating factors •Medications •Food •Occupation •Outdoors •Hobbies/Sport participation •Exposure to insects •Jewelry/metals/chemicals •Family history Is it: Local or systemic Pruritus- all day or worse at night Uticaria - duration Pigmented changes Pigmentation/Changes of the skin Diff diagnosis - -Nevi- brown, beige or pink( 5mm) Melanoma Related to pregnancy- melasma (mask of pregnancy) Addison disease Side effect of medication- steroid therapy skin lesions - -Macule - flat, nonpalpable (freckle, petechia) Papule - PALPABLE, solid elevation of skin (elevated nevus) Nodule - elevated solid mass, deeper and firmer than papule (wart) Tumor - solid mass deep in subcutaneous tissue (epithelioma) Wheal - irregularly shaped, elevated area (hive, mosquito bite NURS 623 NURS 623 NURS 623 Vesicle - elevation of skin with serous (clear) fluid Pustule - similar to vesicle but filled with pus (acne) Ulcer - deep loss of skin (venous statis ulcer) Atophy - thinning of skin Bullae-Clear fluid-filled blisters 10 mm in diameter. These may be caused by burns, bites, irritant or allergic contact dermatitis, and drug reactions. primary versus secondary skin lesions - -Primary skin lesions are those which develop as a direct result of the disease process. Secondary lesions are those which evolve from primary lesions or develop as a consequence of the patient's activities. Parasitic Skin Infections - -scabies and lice Scabies - -Highly contagious infestation that occurs mainly in children, young adults, health care workers, and institutionalized persons of all ages. Subjective: Complaints of intense itching that is usually more severe at night. Objective:Earliest physical sign is small 1 to 2 mm red papules located in areas of body most attractive to mites. Itching, excoriation, , crusting, and scaling may be present making it hard to see scabies. Diagnostics:Ink burrow test Scabies treatment - -Permethrin 5% cream (Remember you have 5 fingers)- leave on for 8-14 hours then shower- daily for 7 days. Oral antihistamines for itching, topical steroids for itching. The entire household must be treated. Everything should be washed with hot water/detergent, treat any infection that is present. Starve mites by sealing them in a bag for about 10 days. Lice treatment - -Permethrin 1% leave on for 10 mins then rinse. May repeat in 7 days if needed. Fungal skin infections - -· Candidiasis- bright, beefy red rash treat with topical antifungal, NURS 623 NURS 623 · Dermatophytoses - the tineas (ringworm) · Onychomycosis treat with Terbinafine for 6-12 weeks (only 73-79% effective, educate patient. · Fungal infections survive on keratin, so considered superficial. · Pathogens: Epidermophyton, trichophyton, microsporum. · Those at risk are DM and immunocompromised. · Diagnostics: KOH Tinea corporis (Ringworm of body) - -Hx of erythematous round and elevated pruritic lesion that grows in size & starts to clear in the center Miconazole 2% cream BID x4 weeks, Clotrimazole 1%, Terbafine 1% Tinea capitus (ringworm of head) - -Children common. Painless bald spot, may have kerion that looks like honeycomb, inflammation. Boggy mass containing broken hairs and oozing purulent material from follicular orifices Systemic antifungals - Griseofulvin BID for 2-4 months or 2 weeks after negative cultures. Teratogenic - use 2nd method of contraception. OR terbinafine cream Tinea versicolor (skin, AKA pityriasis versicolor) - -Round or oval lesions of hypo or hyperpigmentation macule, located mainly on back chest, arms, sometimes neck/face. Sometimes very fine scales seen. Agent P oribiculare causes round, pityrosporum ovale causes oval Clotrimazole 1% cream and solution BID up to 4 weeks Bacterial infections of the skin - -· Impetigo · highly contagious Cellulitis · Keflex (1st gen cephalosporine) 10-14 days, or dicloxacillin, · PCN allergy use Erythromycin. · non purulent assume staph aureus Purulent cellulitis · I&D first line · NO 1st gen cephalosporine · Consider MRSA- Bactrim, Cleocin, Doxycycline Impetigo - -Honey crusted plaques, usually on face Bullous: begin as small vesicles that rupture easily with serous fluid turning into crust NURS 623 NURS 623 Nonbullous, vesticulopustular: thick, adherent lesions, dirty yellow-colored crust with erythematous margins Treatment: Clean lesions. Bactroban TID x 7 days. Antibiotic (Keflex, Augmentin, Cloxacillin). With no treatment, it is self-limiting 2-3 wks follilculitis - -Staphylococcus. Multiple small papules on erythematous base, can be large yellow white tender pustules in adults. Common in places hair is present, widespread is characteristic, bumpy rash, no itching. Treatment: Only if becomes infected. Large lesions cleansed with weak soap solution, followed by soaking with saline or aluminum subacetate BID. TAO can be used BID for 5 days. Oral ABT 1st gen cephalo. if resistant Localized cellulitis - -The typical lesion of cellulitis is wide, diffuse area of erythematous skin that is warm and tender to palpation. Infection is occasionally accompanied by severe edema. Systemic symptoms such as fever, chills, and malaise may also be present. CAUSES- Diabetic patient or other immunocompromised patients. Any break in the skin. Skin breaks from surgical incisions, skin tears, wounds, trauma, insect bites or stings, and animal or human bites. PREEXISTING conditions- stasis ulcers, dermatitides, viral skin infections, superficial bacterial infections, and bolus disease all have the risk for secondary infections. Subjective- tender, warm, erythematous areas of skin usually on face, neck, and extremities. Usually report an insect bite or some form of skin break. If recurrent cellulitis may deny any trauma or injury. Objective- Lower leg most common site of infection .If lower extremity cellulites should look for SS of tinea pedis (Athletes foot) infection can be point of entry for bacteria. In children and occasionally adults the checks and periorbital area are more common sites of involvement. Red and warm appearance to the skin will be noted. Red boarders are flat and diffused. Localized cellulitis treatment - -Diagnostic testing- most cases are diagnosed by history and PE . Usually no discharge or obvious wound therefore unable to obtain a culture. If open wound or purulent discharge present a culture and gram stain should be obtained. For patients with fever a CBC should be done . If periorbital cellulitis EOM should be done and test of cranial nerves. Management- Take into consideration severity of infection, site of infection, underlying disease, and virulence of the pathogen. NURS 623 NURS 623 For those who have cellulitis not related to human or animal bites takes DICLOXACILLIN or CEPHALEXIN for 10-14 days. Patients with penicillin allergy get Erythromycin. Infected human and animal bites are treated with Augmentin for at least 2 weeks. LE's cellulitis requires bedrest and elevation of the leg. Need to consider comorbid conditions and consider referral of treatment. Hemophilus influenza can e treated with Ceftin If gram neg microorganism treat with fluoroquinolones such as levofloxacin can be used. Diabetic are typically treated with Augmentin purulent cellulitis treatment - -· I&D first line · NO 1st gen cephalosporine · Consider MRSA- Bactrim, Cleocin, Doxycycline Viral Skin Infections - -chicken pox, shingles, measles, warts, herpes Herpes Zoster (shingles) - -Unexplained pain along dermatome. Unilateral vesicular rash along dermatome lasting 3-5 days, up to 30. Treatment Famcyclovir, Acyclovir, Valacyclovir. Prednisone taper. Vaccine. herpes simplex - -Oral or genital, can be asymptomatic. Tenderness, pain, mild paresthesia's, or burning before onset. Prodrome can include headache, fever, muscle ache, lymphadenopathy, local pain. Grouped vesicles on erythematous base. No cure. Oral: lip ointment Blistex. OTC Abreva. Denavir for extensive lesions. Genital: Valacyclovir and famciclovir better choices acne vulgaris - -Located on face, chest, back, and upper outer arms. · Mild = total lesions 30, noninflammatory. Comedones with small papules. · Moderate = total lesions 30-125, inflammation. Papules & pustules with yellow/green tops. · Severe = lesions 125, nodulocystic acne. NURS 623 NURS 623 Treatments: Tretinoin, topical vs. systemic antibiotics, Isotretinoin Rosacea - -Chronic, central face, persistent erythema telangiectasia, erythematous papules. Treatment : Avoid triggers, topical flagyl (may take 6-8 wks), PO tetracycline, minocycline, or doxycycline Atopic Dermatitis (eczema) - -o A chronic inflammatory skin disorder with a complex pathogenesis involving genetic susceptibility, immunologic and epidermal barrier dysfunction, and environmental factors. o Pruritus is the primary symptom; skin lesions range from mild erythema to severe lichenification. o Presents as red patches with white scales on top o Chronic and recurring. Atopic dermatitis treatment - -o Moisturizers o Avoidance of allergic and irritant triggers- avoid frequent bathing with hot water •Burrow's solution, silver nitrate solutions (to dry out lesions) •Topical steroids for inflammation •Petrolatum/emollients to maintain hydration Contact Dermatitis - -o a rash that occurs at the site of exposure to a substance capable of producing an allergic or irritant skin response. Cause: o Noxious, irritating substances or substances to which the patient has developed a skin allergy. o Direct exposure to substance that triggers an immune response (T-cell mediated response) o May be allergic or irritant induced Ex: poison ivy Contact dermatitis treatment - -o Treated topically with evaporative measures. · the application of repeated cycles of cool water compresses followed by drying. o Once the weeping and oozing have stopped, application of: ·-potent topical steroids two times a day to the affected areas for two to three weeks. o It may be necessary to treat with oral steroids for two to three weeks- if more than 10% of the body It will usually take one to three weeks for the allergen to be entirely removed from the skin so that the rash resolves entirely. NURS 623 NURS 623 Seborrheic Dermatitis - -o Common in Parkinson's patients and patients with HIV. Severe cases should prompt you to look for risk factors of HIV o Caused by Increased production of sebum o Scaly, greasy rash- affected skin is pink, edematous, and cover with yellow to brown scales and crusts. o Usually seen on scalp, forehead, eyebrows, and area surrounding the nose/ears. o Common in infancy and called "cradle cap" Subjective- pink scaling rash located on face and scalp, typically male . May itch Objective- scaly patches that may be slightly papular. Each patch is surrounded by erythema. Greasy and appear yellow. Seborrheic Dermatitis treatment - -OTC dandruff shampoo, leave on 5-7 mins to be effective. Resistant seborrhea dermatitis may require a prescription shampoo 2.5 selenium sulfide shampoo, a ketoconazole shampoo (Nizoral shampoo) and a detoconazole shampoo are available. Keratolytic or oil based lotions are used to soften heavy crust. If significant erythema is present may need topical corticosteroid Hydrocortisone cream. For a superinfection of gram positive skin infection Cephalexin 7-10 days is required. Asteatotic Dermatitis - -Common in elderly •Secondary to aging, dehydrated skin, and malnutrition Pruritus, cracked, erythematous patches •usually shins or extensor surface of arms •Seasonal potentially •Men women Prevention •Humidifier •Moisturizers Treatment •Avoid hot water showers/baths •Hydrophilic petrolatum or urea 10% cream immediately after shower/bath •Avoid rubbing skin with towel •Class 4 topical steroid ointment bid for 2-3 weeks to break itch cycle (i.e. 0.1% triamcinolone acetonide) Bullous Phephigoid - -Average onset 65y -Primary lesions, tense vesicles or bulla filled with se