Management of PatientsWith Dermatologic

Disorders

LEARNING OBJECTIVES

On completion of this chapter, the learner will be able to:

1. Discuss the management and nursing care of the patient with
infections of the skin and parasitic skin diseases.
2. Identify the management and nursing care of the patient with psoriasis.
3. Identify the management and nursing care of patients undergoing
plastic and cosmetic procedures.

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Dermatologic disorders are encountered frequently by nurses across many
practice settings. The nurse can educating the patients how to care for their
skin. The objectives of nursing interventions are to prevent additional skin
damage, prevent secondary infection, reverse the inflammatory process,
and relieve the symptoms.

SECRETORY DISORDERS
Acne Vulgaris
it is a common disorder affecting susceptible hair follicles, most
commonly on the face, back, chest, and upper arms. It is a chronic
dermatosis characterized by closed and open comedones and papules,
pustules, nodules, and cysts.
Pathophysiology
During puberty, androgens stimulate the sebaceous glands, causing them
to enlarge and secrete a natural oil (sebum) that rises to the top of the hair
follicle and flows out onto the skin surface.
Clinical Manifestations
The main lesions of acne are comedones. Closed comedones (whiteheads)
and open comedones (blackheads). The resultant inflammation is seen
clinically as erythematous papules, inflammatory pustules, and
inflammatory cysts.
Assessment and Diagnostic Findings
The diagnosis of acne is based on the history and physical examination,
evidence of lesions characteristic of acne, and age.
Medical Management
The goals of management are to reduce bacterial colonies, decrease
sebaceous gland activity, prevent the follicles from becoming plugged,
reduce inflammation, combat secondary infection, minimize scarring, and
eliminate factors that predispose the person to acne. The therapeutic
regimen depends on the type of lesion (e.g., comedones, papule, pustule,
cyst).
Nutrition and Hygiene Therapy
maintenance of good nutrition equips the immune system for effective
action against bacteria and infection.

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Pharmacologic Therapy:
Topical and Systemic Therapy
Surgical Management
Treatment includes comedo extraction; injections of corticosteroids into
the inflamed lesions; and incision and drainage of large, fluctuant nodular
cystic lesions.
Nursing Management
Nursing care of patients with acne includes monitoring and managing
potential complications of skin treatments.
Major nursing activities include providing patient education, particularly
in proper skin care techniques, and managing potential problems related
to the skin disorder or therapy.
Providing positive reassurance, listening attentively, and being sensitive to
the feelings of the patient with acne are essential to the patient’s
psychological well-being and understanding of the disease and treatment
plan. In particular, women with acne frequently report diminished quality
of life, more anxiety, and depression .
Preventing Scarring
Prevention of scarring is the ultimate goal of therapy. The chance of
scarring increases with the severity of the grade of acne.

INFECTIOUS DERMATOSES

Viral Skin Infections

Herpes Zoster
Herpes zoster, also called shingles, is an infection caused by the varicella-
zoster virus (VZV.
Clinical Manifestations
Manifestations typically occur in three phases, including the preeruptive,
acute eruptive, and postherpetic neuralgia (PHN) phases.
During the preeruptive phase, the patient will typically complain of pain, or
sometimes pruritus or paresthesias, over the sensory region that follows that
dermatome. This phase lasts from 1 to 10 days.
The acute eruptive phase there are unilateral patchy erythematous, vesicles and
severe and unrelenting pain . This phase typically lasts between 10 and 15 days .
The last phase—PHN—is variable in terms of both duration and manifestations.
The pain is typically localized to the dermatomal area that was affected.

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Medical Management
Herpes zoster infection can be arrested if oral antiviral agents such as
acyclovir or famciclovir (Famvir) are given within 24 hours of the initial
eruption.
Figure 61-3 • Herpes zoster
(shingles).

The goals of herpes zoster management are to relieve the pain and to
reduce or avoid complications, which include infection, scarring, and PHN
and eye complications. Pain is controlled with analgesic agents
Nursing Management
The nurse assesses the patient’s discomfort and response to medication.
The patient is educated about how to apply dressings or medication to the
lesions and to follow proper hand hygiene techniques to avoid spreading
the virus.

Parasitic Skin Infestations

Scabies
Scabies is an infestation of the skin by the itch mite Sarcoptes scabei. The
disease is most commonly found in people living in substandard hygienic
conditions and in people who are sexually active.
Clinical Manifestations
It takes approximately 4 weeks from the time of contact for the patient’s
symptoms to appear. One classic sign of scabies is the increased itching
that occurs during the evening hours. If the infection has spread, other
members of the family and close friends also complain of pruritus about 1
month later. Secondary lesions include vesicles, papules, excoriations, and
crusts.

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Assessment and Diagnostic Findings
A sample of superficial epidermis is scraped from the top of the burrows
or papules with a small scalpel blade. The scrapings are placed on a
microscope slide and examined through a microscope at low power to
demonstrate evidence of the mite.
Medical Management
The patient is instructed to take a warm, soapy bath or shower to remove
the scaling debris from the crusts and then to pat the skin dry thoroughly
and allow it to cool. A prescription scabicide, 5% permethrin, is
considered the medication of choice. Oral antihistamines such as
diphenhydramine orhydroxyzine can help control the pruritus
Nursing Management
The patient should wear clean clothing and sleep in freshly laundered bed
linens.
All bedding and clothing should be washed in hot water and dried on the
hot dryer cycle. After treatment is completed, the patient may apply an
ointment, such as a topical corticosteroid, to skin lesions because the
scabicide may irritate the skin. All family members and close contacts
should be treated simultaneously to eliminate the mites

NONINFECTIOUS INFLAMMATORY DERMATOSES

Psoriasis
Psoriasis is a chronic inflammatory multisystem disorder of the skin .
Psoriasis is characterized by periods of remission and exacerbation
throughout life.
Pathophysiology
Current evidence supports an autoimmune basis for psoriasis.
Clinical Manifestations: Lesions that appear as red, raised patches of skin
covered with silvery scales.

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Assessment and Diagnostic Findings
The presence of the classic plaque-type lesions generally confirms the
diagnosis of psoriasis.
Medical Management
The goals of management are to slow the rapid turnover of epidermis, to
promote resolution of the psoriatic lesions, and to control the natural
cycles of the disease. There is no known cure.
Pharmacologic Therapy
Three types of therapy are commonly indicated: topical, phototherapy, and
systemic.
Phototherapy: For patients who do not respond well to topical treatments,
phototherapy using narrow-band ultraviolet-B (UVB) therapy may be
effective as asingle-therapy modality.
Nursing Management
Psoriasis may cause despair and frustration for the patient. The nurse
assesses the impact of the disease on the patient and the coping strategies
used for conducting normal activities and interactions with family and
friends.

PLASTIC, RECONSTRUCTIVE, AND COSMETIC PROCEDURES

Plastic or reconstructive procedures are performed to reconstruct or alter
congenital or acquired defects to restore or improve the body’s form and
function. This type of surgery includes closure of wounds, removal of skin
tumors, repair of soft tissue injuries or burns, correction of deformities, and
repair of cosmetic defects.
Wound Coverage: Grafts and Flaps
Various surgical techniques, including skin grafts and flaps, are used to
cover skin wounds.
Skin Grafts: Skin grafts are commonly used to repair surgical defects such
as those that result from excision of skin tumors, to cover areas denuded of
skin (e.g., burns), and to cover wounds in which insufficient skin is
available topermit wound closure.

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Nursing Management
The nurse must ensure that both the surgical and the donor sites receive
proper postoperative care. Prevention of infection is essential, as it is with
all surgical sites. Both sites can be kept soft and pliable with cream (e.g.,
lanolin).

Quality and Safety Nursing Alert

Both the donor site and the grafted area must be protected from
exposure to extremes in temperature, external trauma, and sunlight
because these areas are sensitive, especially to thermal injuries.

Cosmetic Procedures
Chemical Face Peeling
involves application of a chemical mixture to the face for superficial
destruction of the epidermis and the upper layers of the dermis to treat fine
wrinkles, keratoses, and pigment problems. It is especially useful for
wrinkles at the upper and lower lip, forehead, and periorbital areas. The
most common complications include discoloration of the skin, infection of
the burned area, persistent sensory changes or itching, and occasionally
permanent scarring of the skin.
Dermabrasion
Dermabrasion is a form of skin abrasion used to treat acne scarring, aging,
and sun-damaged skin. The epidermis and some superficial dermis are
removed while the dermis is preserved to allow re-epithelization of
the treated areas. Results are best in the face because it is rich in
intradermal epithelial elements. tretinoin cream (Renova) may be
prescribed with instructions to apply it 2 to 3 weeks preoperatively; this is
associated with accelerating re-epithelialization post dermabrasion.
Facial Reconstructive Surgery
They are performed to repair deformities or restore normal function. They
may vary from closure of small defects to complicated procedures
involving implantation of prosthetic devices to conceal a large defect or
reconstruct a lost part of the face (e.g., nose, ear, jaw).

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Each surgical procedure is customized and involves a variety of incisions,
flaps, and grafts. Multiple surgical procedures may be required.
Nursing Management
The majority of dermatologic and reconstructive procedures are performed
in the physician’s office or in an outpatient surgical department; therefore,
The nurse must prepare both the patient and family for what to expect
during the postoperative recovery time. Table 61-6 lists a few of the
nursing considerations that must be reviewed in educating the patient and
family.
wTABLE 61-6 Nursing Considerations in Cosmetic Procedures

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