25
Integumentary Problems
Mary M. Cameron
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Pain
Coping Tissue Integrity
Infection
LEARNING OUTCOMES
1. Outline health promotion practices related to 5. Discuss the etiology, clinical manifestations, and
environmental hazards. interprofessional and nursing management of allergic skin
2. Explain the etiology, clinical manifestations, and disorders.
interprofessional and nursing management of skin cancers. 6. Explain the etiology, clinical manifestations, and
3. Relate the etiology, clinical manifestations, and interprofessional and nursing management related to
interprofessional and nursing management of bacterial, benign skin disorders.
viral, and fungal skin infections. 7. Select appropriate nursing interventions to manage the
4. Describe the etiology, clinical manifestations, and patient with a skin problem.
interprofessional and nursing management of infestations 8. Explain the indications and nursing management related to
and insect bites. common cosmetic procedures and skin grafts.
KEY TERMS
acne vulgaris, Table 25.10 impetigo, Table 25.5
actinic keratosis lichenification
basal cell carcinoma (BCC) melanoma
cellulitis, Table 25.5 psoriasis
cryosurgery rosacea, Table 25.10
curettage squamous cell carcinoma (SCC)
dysplastic nevi (DN) sun protection factor (SPF)
herpes zoster, Table 25.6
This chapter discusses common skin problems and skin cancer. ultraviolet (UV) light. There are 2 types of UV light: UVA and
Impaired skin integrity affects many body functions. The skin UVB. Specific wavelengths (Table 25.1) have different effects on
reflects both physical and psychologic well-being. Many skin the skin. UVA light is responsible for tanning, UVB for sun-
problems leave underlying tissues unprotected from infection burn. The damage caused by UV rays is cumulative. It results in
and chemical dangers. Lesions can be painful because the skin degenerative changes in the dermis and premature aging (e.g.,
has many sensory nerve endings. Skin problems are often highly loss of elasticity, thinning, wrinkling). Prolonged and repeated
visible, potentially affecting body image and causing distress. sun exposure increases risk for actinic keratosis (AK), basal and
squamous cell cancers, and melanoma.
Provide teaching on sun protection. People often do not
ENVIRONMENTAL HAZARDS understand the risks of sun exposure. Following sun safety
Sun exposure comes with serious risk and results in perma- guidelines beginning early in life can help avoid the dam-
nent skin damage. Sunlight is made up of visible light and aging effects of the sun and prevent skin cancer later in life.
471
,472 SECTION 5 Problems Related to Altered Sensory Input
TABLE 25.1 Wavelengths of Sun and BOX 25.1 EVIDENCE-BASED PRACTICE
Effects on Skin Tanning Booths and Skin Cancer
Wavelength Effect
You are a nurse working in a dermatology clinic. D.F., a 30-year-old woman
Long (ultraviolet A [UVA]) Can cause elastic tissue damage and with fair skin and blue eyes, is completing her health history before her annual
actinic skin damage skin screening. She says she visits an indoor tanning salon every other week.
Contributes to skin cancer She tells you that being tan makes her feel “healthier and prettier.”
Middle (ultraviolet B [UVB]) Causes sunburn and cumulative effect of
sun damage Making Clinical Decisions
Major factor in developing skin cancer Best Available Evidence
Short (ultraviolet C [UVC]) Blocked by the atmosphere and does not There is a strong link between exposure to UVA from indoor tanning booth use
reach earth and increased risk for all skin cancers. Skin damage starts with the 1st visit.
95% of persons with melanoma who are diagnosed before age 30 report hav-
ing used tanning booths. Melanoma risk increases with the number of years,
Fair-skinned persons and those with light-colored eyes should hours, and sessions of indoor tanning independent of outdoor exposure.
be especially cautious about sun exposure. They have less mela- Clinician Expertise
nin and thus less natural protection. You note that D.F. has several skin cancer risk factors: fair skin, blue eyes,
Teach the patient ways to avoid the damaging effects of the frequent use of tanning booths.
Patient Preferences and Values
sun. This includes wearing protective clothing, including sun-
After listening, D.F. tells you that she will consider reducing the frequency of
glasses, a large-brimmed hat, and a darker colored, long-sleeved
her visits—going only when she has an important event to attend.
shirt of a tightly woven fabric or carrying an umbrella. The
greatest risk is with midday sun, between the hours of 10:00 Implications for Nursing Practice
a.m. and 2:00 p.m., regardless of the latitude. This is when 80% 1. How would you respond to D.F., given the information that she shared with you?
of UV rays occur. Even on overcast days, serious sunburn can 2. What resources can help address her view that a “tan looks healthy?”
occur because up to 80% of the sun’s UV rays can penetrate the 3. What sun safety guidelines should she follow to prevent skin cancer?
clouds. Warn people of the dangers of tanning booths and sun
Reference for Evidence
lamps, which emit UVA. Tanning booths increase the risk for
Alberg AJ, LoConte NK, Foxhall L, et al.: American Society of Clinical Oncology policy state-
sunburn, cataracts, and skin cancer (Box 25.1).1 ment on skin cancer prevention, JCO Oncology Practice 16:490, 2020.
Sunscreens can filter both UVA and UVB wavelengths. The 2
types of topical sunscreens are chemical and physical. Chemical
sunscreens absorb into the skin. There they absorb or filter UV TABLE 25.2 Drug Therapy
light, resulting in decreased UV light penetration. Physical sun-
screens sit on top of the skin. They reflect UV radiation away from Drugs That May Cause Photosensitivity
the skin. Regular sunscreen use decreases the risk for melanoma. Categories Examples
The US Food and Drug Administration (FDA) rates sun- Antidepressants fluoxetine, paroxetine, venlafaxine
screen products on their sun protection factor (SPF). The Antidysrhythmics amiodarone (Cordarone), quinidine
SPF measures the effectiveness of a sunscreen in filtering and Antihistamines cetirizine (Zyrtec), chlorpheniramine, cle-
absorbing UV radiation. All sunscreen labels in the United mastine, diphenhydramine, loratadine
States must say which rays they protect against. Products labeled Antimicrobials tetracycline, azithromycin (Zithromax),
ciprofloxacin, sulfonamides
with “broad spectrum” block both UVA and UVB.2 Sunscreens
Antifungals griseofulvin, ketoconazole
with broad spectrum labeling must have an SPF of at least 15. Antipsychotics chlorpromazine, haloperidol
Sunscreens with an SPF of 15 or more filter 92% of the UVB rays Cholesterol-lowering agents atorvastatin, simvastatin
and make sunburn unlikely when applied appropriately. Diuretics furosemide (Lasix), thiazides
People need to select the right sunscreen for their needs. The Hypoglycemics glipizide, glyburide
general suggestion is that everyone should use daily sunscreen with Nonsteroidal antiinflammatory diclofenac (Voltaren), ibuprofen,
a minimum SPF of 15. Teach patients to look for the term broad drugs naproxen, piroxicam (Feldene),
spectrum on sunscreen packaging. People with a history of skin
cancer or problems with sun sensitivity should use a product with manifestations of drug-induced photosensitivity (Fig. 25.1) are
an SPF of at least 30. Sunscreens should be applied 20 to 30 min- like those of a sunburn. These include swelling, redness, vesicles,
utes before going outdoors, even in cloudy weather. The SPF value and papular, plaque-like lesions. Assess the photosensitivity of
of all sunscreens decreases with time. Sunscreen should be reap- each drug. Teach patients who are taking these drugs about
plied every 2 hours. You should apply 1 ounce per total body appli- their photosensitizing effect and the need to protect the skin
cation. The ears, toes, and lips also need sunscreen. Sunscreens are from photosensitivity reactions by using sunscreen products.
not “waterproof ” and must be reapplied after swimming. Teach patients to assess their skin monthly. They should
Some drugs potentiate the sun’s effects, even with brief expo- have a periodic professional assessment of areas that are hard
sure. The chemicals in these drugs absorb light when exposed to to see. The cornerstone of skin assessment is the ABCDE rule.
natural sunlight and release energy that harms cells and tissues. Assess lesions for Asymmetry, Border irregularity, Color change
Common photosensitizing drugs are shown in Table 25.2. The and variation, Diameter of 6 mm or more, and Evolving in
, CHAPTER 25 Integumentary Problems 473
lesions are so visible increases the chance of early detection and
diagnosis. This often leads to a highly favorable prognosis.
Risk Factors
Risk factors for skin cancer include (1) having fair skin, blond
or red hair with blue eye color; (2) history of outdoor sunbath-
ing; (3) living near the equator or at high altitudes; (4) family or
personal history of skin cancer; (5) having an outdoor occupa-
tion; (6) spending a lot of time in outdoor recreation activities;
and (7) indoor tanning.3 The Fitzpatrick Classification of Skin
Type can help you determine a person’s skin complexion and
their risk for skin cancer (Table 25.3). Patients treated with oral
methoxsalen (psoralen) and psoralen plus ultraviolet A radia-
Fig. 25.1 Photosensitivity reaction in a patient taking methotrexate. tion (PUVA) have a higher risk.
(From Valeyrie-Allanore L, Obeid O, Revuz J: Dermatology, ed 4, St. Dark-skinned persons are less susceptible to skin cancer
Louis, 2018, Elsevier.) because of their increased melanin, which acts like a sunscreen
(Box 25.2). However, there is still a risk, and they need to wear
sunscreen. They often have melanomas on areas with less melanin,
such as the palms, soles, mucous membranes, and under the nails.
Since it is common for people with dark skin to have pigmented,
longitudinal bands on their nails, assess for nail discoloration.
A B NONMELANOMA SKIN CANCER
Nonmelanoma skin cancers (basal cell and squamous cell
cancers) are the most common forms of skin cancer. More
than 5.4 million new cases are diagnosed each year.3 Nonmel-
anoma skin cancers do not develop from melanocytes. They
develop in the basement membrane of the skin. Although
C D
there are few deaths from nonmelanoma skin cancer, they
Fig. 25.2 The ABCDEs of melanoma. (A) Asymmetry: one half unlike have the potential for severe local destruction, disfigurement,
the other half. (B) Border irregularity: edges are ragged, notched, or
and disability.
blurred. (C) Color: varied pigmentation; shades of tan, brown, and black.
(D) Diameter: greater than 6 mm (diameter of a pencil eraser). (E, not Nonmelanoma skin cancers usually develop in sun-exposed
pictured) Evolving; changing appearance (change in shape, size, color, areas, such as the face, head, neck, back of the hands, and arms.
or other characteristic noted over time). (From The Skin Cancer Foun- The most common causative factor is sun exposure. There are
dation, New York, NY.) some differences between basal and squamous cell cancers.
Squamous cell cancers usually occur on the head and neck, where
appearance (Fig. 25.2). Emphasize that a persistent lesion that there is the highest degree of UV radiation. Basal cell cancers do
does not heal and lesions once flat and now raised, once small not follow that pattern and may occur in sun-protected areas.
and recently growing, or changing in appearance are warning
signs. Patients should consult their HCP at once if any lesions Actinic Keratosis
or moles show any clinical signs (ABCDEs). Actinic keratosis (AK), or solar keratosis, is the most common
precancerous skin lesion. They affect most of the older White
population. Sun exposure is a key factor. AKs appear most often
SKIN CANCER on skin that has been exposed to the sun or to artificial UV light.
Skin cancer is the most commonly diagnosed cancer.3 Skin can- They may spontaneously resolve if a person reduces exposure
cers are either nonmelanoma or melanoma. The fact that skin to sunlight.
TABLE 25.3 Fitzpatrick Classification of Skin Type
Skin Type Skin Color Characteristics
I White, freckles, very fair. Red or blond hair. Blue eyes Always burns, never tans
II White, fair. Red or blond hair. Blue, hazel, or green eyes Usually burns, tans with difficulty
III Cream white, fair. Any eye or hair color Sometimes mild burn, gradually tan
IV Brown, typical Mediterranean skin Rarely burns, tans with ease
V Deep brown, Middle Eastern skin types Very rarely burns, tans very easily
VI Black Never burns, tans very easily
Integumentary Problems
Mary M. Cameron
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Cellular Regulation Pain
Coping Tissue Integrity
Infection
LEARNING OUTCOMES
1. Outline health promotion practices related to 5. Discuss the etiology, clinical manifestations, and
environmental hazards. interprofessional and nursing management of allergic skin
2. Explain the etiology, clinical manifestations, and disorders.
interprofessional and nursing management of skin cancers. 6. Explain the etiology, clinical manifestations, and
3. Relate the etiology, clinical manifestations, and interprofessional and nursing management related to
interprofessional and nursing management of bacterial, benign skin disorders.
viral, and fungal skin infections. 7. Select appropriate nursing interventions to manage the
4. Describe the etiology, clinical manifestations, and patient with a skin problem.
interprofessional and nursing management of infestations 8. Explain the indications and nursing management related to
and insect bites. common cosmetic procedures and skin grafts.
KEY TERMS
acne vulgaris, Table 25.10 impetigo, Table 25.5
actinic keratosis lichenification
basal cell carcinoma (BCC) melanoma
cellulitis, Table 25.5 psoriasis
cryosurgery rosacea, Table 25.10
curettage squamous cell carcinoma (SCC)
dysplastic nevi (DN) sun protection factor (SPF)
herpes zoster, Table 25.6
This chapter discusses common skin problems and skin cancer. ultraviolet (UV) light. There are 2 types of UV light: UVA and
Impaired skin integrity affects many body functions. The skin UVB. Specific wavelengths (Table 25.1) have different effects on
reflects both physical and psychologic well-being. Many skin the skin. UVA light is responsible for tanning, UVB for sun-
problems leave underlying tissues unprotected from infection burn. The damage caused by UV rays is cumulative. It results in
and chemical dangers. Lesions can be painful because the skin degenerative changes in the dermis and premature aging (e.g.,
has many sensory nerve endings. Skin problems are often highly loss of elasticity, thinning, wrinkling). Prolonged and repeated
visible, potentially affecting body image and causing distress. sun exposure increases risk for actinic keratosis (AK), basal and
squamous cell cancers, and melanoma.
Provide teaching on sun protection. People often do not
ENVIRONMENTAL HAZARDS understand the risks of sun exposure. Following sun safety
Sun exposure comes with serious risk and results in perma- guidelines beginning early in life can help avoid the dam-
nent skin damage. Sunlight is made up of visible light and aging effects of the sun and prevent skin cancer later in life.
471
,472 SECTION 5 Problems Related to Altered Sensory Input
TABLE 25.1 Wavelengths of Sun and BOX 25.1 EVIDENCE-BASED PRACTICE
Effects on Skin Tanning Booths and Skin Cancer
Wavelength Effect
You are a nurse working in a dermatology clinic. D.F., a 30-year-old woman
Long (ultraviolet A [UVA]) Can cause elastic tissue damage and with fair skin and blue eyes, is completing her health history before her annual
actinic skin damage skin screening. She says she visits an indoor tanning salon every other week.
Contributes to skin cancer She tells you that being tan makes her feel “healthier and prettier.”
Middle (ultraviolet B [UVB]) Causes sunburn and cumulative effect of
sun damage Making Clinical Decisions
Major factor in developing skin cancer Best Available Evidence
Short (ultraviolet C [UVC]) Blocked by the atmosphere and does not There is a strong link between exposure to UVA from indoor tanning booth use
reach earth and increased risk for all skin cancers. Skin damage starts with the 1st visit.
95% of persons with melanoma who are diagnosed before age 30 report hav-
ing used tanning booths. Melanoma risk increases with the number of years,
Fair-skinned persons and those with light-colored eyes should hours, and sessions of indoor tanning independent of outdoor exposure.
be especially cautious about sun exposure. They have less mela- Clinician Expertise
nin and thus less natural protection. You note that D.F. has several skin cancer risk factors: fair skin, blue eyes,
Teach the patient ways to avoid the damaging effects of the frequent use of tanning booths.
Patient Preferences and Values
sun. This includes wearing protective clothing, including sun-
After listening, D.F. tells you that she will consider reducing the frequency of
glasses, a large-brimmed hat, and a darker colored, long-sleeved
her visits—going only when she has an important event to attend.
shirt of a tightly woven fabric or carrying an umbrella. The
greatest risk is with midday sun, between the hours of 10:00 Implications for Nursing Practice
a.m. and 2:00 p.m., regardless of the latitude. This is when 80% 1. How would you respond to D.F., given the information that she shared with you?
of UV rays occur. Even on overcast days, serious sunburn can 2. What resources can help address her view that a “tan looks healthy?”
occur because up to 80% of the sun’s UV rays can penetrate the 3. What sun safety guidelines should she follow to prevent skin cancer?
clouds. Warn people of the dangers of tanning booths and sun
Reference for Evidence
lamps, which emit UVA. Tanning booths increase the risk for
Alberg AJ, LoConte NK, Foxhall L, et al.: American Society of Clinical Oncology policy state-
sunburn, cataracts, and skin cancer (Box 25.1).1 ment on skin cancer prevention, JCO Oncology Practice 16:490, 2020.
Sunscreens can filter both UVA and UVB wavelengths. The 2
types of topical sunscreens are chemical and physical. Chemical
sunscreens absorb into the skin. There they absorb or filter UV TABLE 25.2 Drug Therapy
light, resulting in decreased UV light penetration. Physical sun-
screens sit on top of the skin. They reflect UV radiation away from Drugs That May Cause Photosensitivity
the skin. Regular sunscreen use decreases the risk for melanoma. Categories Examples
The US Food and Drug Administration (FDA) rates sun- Antidepressants fluoxetine, paroxetine, venlafaxine
screen products on their sun protection factor (SPF). The Antidysrhythmics amiodarone (Cordarone), quinidine
SPF measures the effectiveness of a sunscreen in filtering and Antihistamines cetirizine (Zyrtec), chlorpheniramine, cle-
absorbing UV radiation. All sunscreen labels in the United mastine, diphenhydramine, loratadine
States must say which rays they protect against. Products labeled Antimicrobials tetracycline, azithromycin (Zithromax),
ciprofloxacin, sulfonamides
with “broad spectrum” block both UVA and UVB.2 Sunscreens
Antifungals griseofulvin, ketoconazole
with broad spectrum labeling must have an SPF of at least 15. Antipsychotics chlorpromazine, haloperidol
Sunscreens with an SPF of 15 or more filter 92% of the UVB rays Cholesterol-lowering agents atorvastatin, simvastatin
and make sunburn unlikely when applied appropriately. Diuretics furosemide (Lasix), thiazides
People need to select the right sunscreen for their needs. The Hypoglycemics glipizide, glyburide
general suggestion is that everyone should use daily sunscreen with Nonsteroidal antiinflammatory diclofenac (Voltaren), ibuprofen,
a minimum SPF of 15. Teach patients to look for the term broad drugs naproxen, piroxicam (Feldene),
spectrum on sunscreen packaging. People with a history of skin
cancer or problems with sun sensitivity should use a product with manifestations of drug-induced photosensitivity (Fig. 25.1) are
an SPF of at least 30. Sunscreens should be applied 20 to 30 min- like those of a sunburn. These include swelling, redness, vesicles,
utes before going outdoors, even in cloudy weather. The SPF value and papular, plaque-like lesions. Assess the photosensitivity of
of all sunscreens decreases with time. Sunscreen should be reap- each drug. Teach patients who are taking these drugs about
plied every 2 hours. You should apply 1 ounce per total body appli- their photosensitizing effect and the need to protect the skin
cation. The ears, toes, and lips also need sunscreen. Sunscreens are from photosensitivity reactions by using sunscreen products.
not “waterproof ” and must be reapplied after swimming. Teach patients to assess their skin monthly. They should
Some drugs potentiate the sun’s effects, even with brief expo- have a periodic professional assessment of areas that are hard
sure. The chemicals in these drugs absorb light when exposed to to see. The cornerstone of skin assessment is the ABCDE rule.
natural sunlight and release energy that harms cells and tissues. Assess lesions for Asymmetry, Border irregularity, Color change
Common photosensitizing drugs are shown in Table 25.2. The and variation, Diameter of 6 mm or more, and Evolving in
, CHAPTER 25 Integumentary Problems 473
lesions are so visible increases the chance of early detection and
diagnosis. This often leads to a highly favorable prognosis.
Risk Factors
Risk factors for skin cancer include (1) having fair skin, blond
or red hair with blue eye color; (2) history of outdoor sunbath-
ing; (3) living near the equator or at high altitudes; (4) family or
personal history of skin cancer; (5) having an outdoor occupa-
tion; (6) spending a lot of time in outdoor recreation activities;
and (7) indoor tanning.3 The Fitzpatrick Classification of Skin
Type can help you determine a person’s skin complexion and
their risk for skin cancer (Table 25.3). Patients treated with oral
methoxsalen (psoralen) and psoralen plus ultraviolet A radia-
Fig. 25.1 Photosensitivity reaction in a patient taking methotrexate. tion (PUVA) have a higher risk.
(From Valeyrie-Allanore L, Obeid O, Revuz J: Dermatology, ed 4, St. Dark-skinned persons are less susceptible to skin cancer
Louis, 2018, Elsevier.) because of their increased melanin, which acts like a sunscreen
(Box 25.2). However, there is still a risk, and they need to wear
sunscreen. They often have melanomas on areas with less melanin,
such as the palms, soles, mucous membranes, and under the nails.
Since it is common for people with dark skin to have pigmented,
longitudinal bands on their nails, assess for nail discoloration.
A B NONMELANOMA SKIN CANCER
Nonmelanoma skin cancers (basal cell and squamous cell
cancers) are the most common forms of skin cancer. More
than 5.4 million new cases are diagnosed each year.3 Nonmel-
anoma skin cancers do not develop from melanocytes. They
develop in the basement membrane of the skin. Although
C D
there are few deaths from nonmelanoma skin cancer, they
Fig. 25.2 The ABCDEs of melanoma. (A) Asymmetry: one half unlike have the potential for severe local destruction, disfigurement,
the other half. (B) Border irregularity: edges are ragged, notched, or
and disability.
blurred. (C) Color: varied pigmentation; shades of tan, brown, and black.
(D) Diameter: greater than 6 mm (diameter of a pencil eraser). (E, not Nonmelanoma skin cancers usually develop in sun-exposed
pictured) Evolving; changing appearance (change in shape, size, color, areas, such as the face, head, neck, back of the hands, and arms.
or other characteristic noted over time). (From The Skin Cancer Foun- The most common causative factor is sun exposure. There are
dation, New York, NY.) some differences between basal and squamous cell cancers.
Squamous cell cancers usually occur on the head and neck, where
appearance (Fig. 25.2). Emphasize that a persistent lesion that there is the highest degree of UV radiation. Basal cell cancers do
does not heal and lesions once flat and now raised, once small not follow that pattern and may occur in sun-protected areas.
and recently growing, or changing in appearance are warning
signs. Patients should consult their HCP at once if any lesions Actinic Keratosis
or moles show any clinical signs (ABCDEs). Actinic keratosis (AK), or solar keratosis, is the most common
precancerous skin lesion. They affect most of the older White
population. Sun exposure is a key factor. AKs appear most often
SKIN CANCER on skin that has been exposed to the sun or to artificial UV light.
Skin cancer is the most commonly diagnosed cancer.3 Skin can- They may spontaneously resolve if a person reduces exposure
cers are either nonmelanoma or melanoma. The fact that skin to sunlight.
TABLE 25.3 Fitzpatrick Classification of Skin Type
Skin Type Skin Color Characteristics
I White, freckles, very fair. Red or blond hair. Blue eyes Always burns, never tans
II White, fair. Red or blond hair. Blue, hazel, or green eyes Usually burns, tans with difficulty
III Cream white, fair. Any eye or hair color Sometimes mild burn, gradually tan
IV Brown, typical Mediterranean skin Rarely burns, tans with ease
V Deep brown, Middle Eastern skin types Very rarely burns, tans very easily
VI Black Never burns, tans very easily
