Management of Patient with

Dermatologic Problems
 Objectives:
No. Objectives Methodology
1. Recognize the types, causes, clinical manifestation, Lecture
diagnostic tests, complication, management & nursing discussion &
intervention of patient with dermatologic disorders
(secretory disorders, Infectious skin disorders: bacterial &
Video show
viral infection, fungal/mycotic infection, parasitic
infection & non-infectious skin disorders)
2. Formulate nursing care plan within the nursing process
framework for care of patient with dermatologic disorders
3. Design a teaching plan for patients with alteration of
integumentary functions
Terminologies
Dermatitis: skin inflammation
Dermatosis: abnormal skin lesion
Bullae: large, fluid filled blister
Furuncle (boil): localized skin infection of single hair follicle
Carbuncle: localized skin infection involving several hair
follicles
Comedones: primary lesion of acne caused by sebum blockage
in hair follicle
Lichenification (scaling): thickening of skin horny layer
(epidermis outer layer)
Pruritus: itching
Tinea: superficial fungal infection
 Skin Disorders
Secretory disorders:
Acne vulgaris
Bacterial skin infection:
Impetigo
Folliculitis, Furuncles
& Carbuncles
Viral skin infection:
Herpes Zoster
Herpes simplex Infectious Dermatoses
Fungal (Mycotic) skin infection
Parasitis infection:
Pediculosis: lice infestation
Scabies

Noninfectious inflammatory dermatoses:

Irritant contact dermatitis
Psoriasis
Secretory disorders: Acne Vulgaris

It affect hair follicles commonly on face, trunk &

neck & upper arms

It is a chronic dermatosis characterized by

comedones (primary acne lesions), both closed
and open, and by papules, pustules, nodules, and
cysts

It can be genetic, hormonal, and bacterial factors

Acne Vulgaris
 Secretory disorders: Acne Vulgaris

Pathophysiology:
During puberty, androgens stimulate sebaceous
glands causing them to enlarge & secrete sebum that
rises to hair follicle top & flow out onto skin surface

Accumulated sebum plugs pilosebaceous ducts &

acne occurs

The sebaceous plugging cause local inflammatory

response
 Secretory disorders: Acne Vulgaris
Clinical manifestations:

Main acne lesions are comedones & can be papule, nodules,

pustule, cyst
Closed comedones (whiteheads) form from impacted lipids or
oils and keratin that plug the dilated follicle
Closed comedones (whiteheads) may evolve into open
comedones (blackheads)
Some closed comedones may rupture resulting in inflammatory
reaction caused by leakage of follicular content that can be
seen as:
Erythematous papules
Inflammatory pustules
Inflammatory cysts
Deeper papules & cysts cause skin scarring
Acne Vulgaris
 Secretory disorders: Acne Vulgaris

Assessment & diagnostic findings:

Acne diagnosis depends on history & physical
examination, evidence of lesions characteristics of
acne & age
Females report flare-ups few days before menses
Presence of comedones with oily skin more in
midfacial area other parts of face are dry
Mild, moderate or sever acne
Biopsy from open lesions
 Secretory disorders: Acne Vulgaris

Medical management:

Aims to:
Reduce bacterial colonies
Decrease sebaceous gland activity
Prevent follicles from becoming plugged
Reduce inflammation & combat secondary infection
Minimize scarring & eliminate predisposing factors

The therapeutic regimen depends on the type of lesion

(e.g., comedones, papule, pustule, cyst)
 Secretory disorders: Acne Vulgaris

Management

Nutritional & hygiene therapy (twice washing with

soap, use oil free cosmetics & creams)

Common treatment types:

Topical: e.g gel
Systemic: e.g oral antibiotics
Surgical: e.g comedones extraction
 Secretory disorders: Acne Vulgaris:
Nutritional & hygiene therapy

Avoid Foods high in refined sugars

Maintenance of good nutrition equips the immune system
for effective action against bacteria and infection.

For mild cases of acne, washing twice each day with a

cleansing soap and use of over-the-counter products that
contain benzoyl peroxide or salicylic acid may be required.

Oil-free cosmetics and creams should be chosen.

Secretory disorders, Acne Vulgaris Pharmacologic
therapy (Topical therapy):

Benzoyl peroxide: reduce inflammatory lesions, depress sebum

production, promote comedo plugs breakdown (enhance its removal) &
has antibacterial effect
Instructed pt to discontinue use of the product if severe irritation occurs

Vit. A acid (Tretinoin): to clear keratin plugs from pilosebaceous ducts.

Avoid sun exposure to prevent sunburn

Topical antibiotic: suppress bacterial growth, reduce superficial fatty

acid level, comedones, papules & putules, has no systemic S.E
(Clindamycine & Erythromycin commonly used)
Topical combination gels include both benzoyl peroxide and an
antibiotic (e.g., benzoyl erythromycin [Benzamycin]) are commonly
prescribed and can be very effective treatment
 Secretory disorders: Acne Vulgaris
Systemic therapy:
Oral antibiotic: effective in treating moderate to sever acne
Tetracycline family contra. In pregnancy as it affect teeth development
(enamel hypoplasia & teeth discoloration) with other S.E e.g
photosensitivity

Oral retinoids (e.g., isotretinoin [Claravis]) are used in patients with

nodular cystic acne unresponsive to conventional therapy.
It prevent scarring that can result from cyst formation, reduce sebaceous
gland size and inhibit sebum production, cause the epidermis to shed
(epidermal desquamation), thereby unseating and expelling existing
comedones.
Most common side effect is cheilitis (inflammation of the lips). Dry and
chafed skin and mucous membranes
Effective contraceptive measures for women of childbearing age are
mandatory during treatment and for about 4 to 8 weeks thereafter
To avoid additive toxic effects, patients should avoid taking vitamin A
supplements while taking retinoids
 Secretory disorders: Acne Vulgaris
Estrogen therapy: to suppress sebum production & reduced
skin oilness

Synthetic vit. A compound e.g Isotretinoin: reduce sebaceous

gland size & inhibits sebum production &epidermal shed

Surgical Management
Comedone extraction
Corticosteroids injection into inflamed lesions
I&D
Phototherapy (red or blue light)
Dermabrasion for deep scars to remove epidermis & some
superficial demise
 Secretory disorders: Acne Vulgaris

Nursing management: Aims to prevent scarring

Monitoring & managing potential complications
Educate patient about proper skin care & managing potential
skin problems
Educate to wash face & other affected part with mild soap &
water twice/day, mild abrasive soaps & drying agents given to
eliminate oily feeling
Discouraged & disheartend pt by body image to be treated with
sensitivity & encourage them to express their feeling
Provide positive reassurance, listening attentively & be sensitive
to patient’s feelings
Encourage pt to adhere to treatment & explaine about disease
& treatment plan (meds. Application)
 Secretory disorders: Acne Vulgaris
Nursing management (preventing scarring & educating pt about
self-care):

Instruct about the importance of adherence to treatment as it may lead

to flare-ups & increase chance of deep scarring
To avoid manipulation of comedone, papule & pustules as it increases
chance of scarring

In extraction of deep-seated comedones or inflamed lesions extraction

I&D, results in scarring, hypo/hyperpigmentation may affect tissue, this
to be explained for patient

Educate patient about self-care (adherance to med., wash face & other
affected areas with mild soap & water BID, avoid all forms of friction &
trauma, cosmieics, shaving creams & lotions. Avoid manipulation &
squeezing, propping hands against face, rubbing face, wearing tight
collars & helmets..)
Infectious Dermatoses: Bacterial skin
infection
Pyodermas: pus-forming bacterial infections of skin
(primary or secondary)

Primary skin infection: originate in normal skin &

usually caused by single organism
Secondary skin infection: arise from preexisting skin
disorder or from disruption of skin integrity from
injury or surgery

Common bacterial infections: Impetigo, Folliculitis

Folliculitis may lead to furuncles or carbuncles.
 Bacterial skin infection: Impetigo

Superficial skin infection caused by strepto-

/staphylo-cocci or multiple bacteria e.g MRSA.

Bullous impetigo: more deep seated skin infection by

S. aureus, presence of bullae from original vesicles
Nonbullous impetigo: affect skin been disrupted by
cuts, abrasions, bites, trauma, S.aureus

Impetigo is seen in people of all races and ages

It is contagious
 Bacterial skin infection: Impetigo

Etiology
Sharing personal items
Poor hygienic conditions
Malnutrition
Warm humid climate

Clinical manifestations:
Lesions on face & extremities begin as small red macules, then become
discrete/separated, thin walled vesicles that ruptured & covered with
honey-yellow crust

Crust easily removed revealing smooth, red moist surface where new
crust develop soon
Impetigo
 Bacterial skin infection: Impetigo

Medical management:

Topical antibacterial therapy (Bactroban, Altabax): for small area (given

5-7 days) & instruct the pt/staff to:
Wear gloves, lesions are soaked or washed with soap solution to remove
central site of bacterial growth to give the antibiotic opportunity to
reach infected site, then the cream is applied

Systemic antibiotic agent: to treat infections that are widespread or in

cases where there are systemic manifestations e.g fever, to reduce
contagious spread, treating deep infection, preventing acute
glomerulonephritis which occur due to strepto. Skin infection.
(Augmentin, Cloxacillin or Dicloxacillin)

For MRSA: Antibiotic e.g Clindamycin, levofloxacin, ciprofloxacin

 Bacterial skin infection: Impetigo
Nursing management:
Educate pt & family about the following:
Daily bath with bactericidal soap
Cleanliness & good hygiene to prevent lesions spread to another skin
areas & from one person to another
Hand hygiene after touching lesions & importance of wearing gloves
Each person should use his own personal things e.g towel & wash
cloth
Avoid contact with others until lesions healed
Correct use of topical antibiotics: wash lesions with soap & water to
remove central site crust of bacterial growth, so antibiotic can reach
infected site, after removing crusts to apply antibiotic

If patient hospitalized use PPE to provide pt care

 Bacterial skin infection: Folliculitis,
Furuncles & Carbuncles

Folliculitis: inflammatory condition of cells within the wall & ostia of hair
follicles can be bacterial, viral, fungal or parasitic

Superficial or deep, single or multiple papules or pustules close to hair

follicles
Commonly affect men’s beard & women’s leg after shaving

Pseudofolliculitis barbae (shaving bumps). Sharp ingrowing hairs have a

curved root that grows at a more acute angle and pierces the skin,
provoking an irritative reaction
The effective treatment is to avoid shaving, other treatment antibiotics
or speacial lotions or using hand brush to dislodge hairs mechanically
If pt must remove facial hair, depilatory cream & using electric razor
Folliculitis
 Bacterial skin infection: Folliculitis,
Furuncles & Carbuncles
Furuncles (boil): acute inflammation arising deep In one or more hair
follicles & spreading into surrounding dermis

It is a deep form of folliculitis

Commonly seen in areas of irritation, pressure, friction & excessive
perspiration

Start as small red raised painful pimple then infection progresses &
involve skin & subcutaneous fatty tissue, causing tenderness, pain &
surrounding cellulitis

The area of redness & induration represents an effort of the body to

keep the infection localized

Staph. Bacteria produces tissue necrosis , then the center becomes

yellow or black & the boil come to a head
Furuncles
 Bacterial skin infection: Folliculitis,
Furuncles & Carbuncles
Carbuncles: abscess of skin & subcutaneous tissue, caused by
Staph. infection

Represents an extension of furuncle which invaded several

follicles & is large & deep seated
Appear on thick inelastic skin (back of neck & buttocks
common)
Purulent material may be absorbed resulting in Fever, pain,
leukocytosis & extension to bloodstream (sepsis)

Furuncles & Carbuncles can occur in pt with systemic disease

e.g DM, Hematologic malignancies & those on
immunosuppressive therapy and its more in hot climates
Carbuncles
 Bacterial skin infection: Folliculitis,
Furuncles & Carbuncles

Medical management:

Treat Staph. Infection:

Don’t destroy or rupture the induration protective wall that localizes
infection
Boil or pimple shouldn't be squeezed
Based on culture & sensitivity systemic antibiotic therapy prescribed
Oral Dicloxacillin & Cephalosporins are 1st line meds.
If MRAS specific antibiotics to be e.g Clindamycin, trimethoprim–
sulfamethoxazole, or minocycline
If pus localized & fluctuant, small incision can spread resolution by
relieving tension & ensuring direct evacuation of pus & debris
Pt instructed to keep draining lesion covered with dressing
Bacterial skin infection: Folliculitis, Furuncles
& Carbuncles
Nursing management/Education:
IV fluids
Monitor vital signs & Fever reduction
Warm, moist compresses speed-up resolution of furuncle & carbuncle
Surrounding skin to be cleaned with antibacterial soap & antibacterial ointment
applied
Soiled dressing handled according to standard precaution
Gloves/PPE worn in patient care
Teach about self-care (to prevent & control stap. Skin infection: hygienic
environment, if lesion draining cover mattress & pillow with plastic material,
wipe daily with disinfectant & change linens , towels & clothing daily to be
laundered after use, use antibacterial soap & shampoo as ordered)

Special precaution in dealing with facial boils as it drains directly into cranial
nervous sinuses. Sinus thrombosis can develop after a boil manipulation . The
infection can travel through sinus tract& penetrate brain cavity causing brain
abcess
 Viral Skin Infections
Herpes Zoster
Herpes Simplex
 Viral Skin Infections: Herpes Zoster

Herpes Zoster (shingles): an infection caused by varicella

zoster virus VZVs. This virus cause both HZ & Chickenpox
(varicella)

Characterized by painful vesicular eruption along area of

distribution of sensory nerves (dermatome) from one or
more posterior ganglia

The VZV responsible for the outbreak inside nerve cells

near brain & spinal cord. Later when these latent viruses
reactivated, they travel by PNS to skin to multiply & create
a red rash of small fluid-filled blisters

Can affects HIV & cancer pt

 Viral Skin Infections: Herpes Zoster

Clinical manifestations occur in 3 phases:

Pre-eruptive: previously dormant/inactive VZV becomes reactivated
within the dorsal root ganglia of spinal cord. Patient C/O pain, pruritus or
paresthesia over sensory region follows dermatome (over 1 – 10 days)

Acute eruptive: appearace of unilateral patchy erythematous (segmental

inflammation) areas in dermatomal area affected with sever pain. Vesicles
develop that appear clear then cloudy & eventually rupture & crust (10 –
15 days)

Post-hereptic neuralgia PHN phase: pt have PHN localized pain in

dermatomal area for 60 or more days

Herpes zoster ophthalmicus HZO is subtype of HZ. Branch of trigeminal

nerve affected causing pain & ocular complication e.g blindness
Herpes Zoster
Herpes zoster ophthalmicus
 Viral Skin Infections: Herpes Zoster
Medical management:
Aims to relive pain & reduce/avoid complications e.g
infection, scarring, PHN & eye complications: blindness

Oral antiviral agent e.g Acyclovir (Zovirax) within 24 Hrs

after initial eruption to be effective in halting disease
progression &reducing pain. IV Acyclovir may be indicated
in immunocompromised pt

Analgesic agent in acute phase control/prevent persistent

pain patterns

Systemic corticosteriods to reduce incidence & duration of

PHN
 Viral Skin Infections: Herpes Zoster

Medical management cont.:

SC injection of anti-inflammatory agent (Triamcinolone)
under painful areas is effective
Urgent ophthalmologist reference for HZO pt
Childhood varicella vaccination

VZV vaccine (Zostavax)

Can decrease incidence of primary varicella
To boost VZV cellular immunity in people >50Y
Recommended as a preventive strategy for adults who are
not immunocompromized
 Viral Skin Infections: Herpes Zoster

Nursing management:
Instruct patient & family about adherence to prescribed antiviral
agents and importance of follow-up
Assess pt’s discomfort & response to medications & collaborate
with primary provider to adjust meds. regimen
Educate pt how to apply wet dressing or medications to lesions
Teach about proper hand hygiene
Encourage diversionary activities & relaxation techniques for
restful sleep & relieving discomfort
Assist with dressing if indicated
Administer medications as ordered
Provide nourishing meals
Viral Skin Infections: Herpes Simplex

Herpes Simplex HS: characterized by eruption of small blister

HSV type 1(cold sore/fever blisters): affect skin of lips, mouth,

gums or tongue
HSV type 2: occurs in genital area (incubation 2 – 12 days)

Both types can be in both locations through human oral genital

contact & vice versa

Herpes labialis can spread through contaminated razors, towels &

dishes. Activated by overexposure to sunlight or wind, cold
influenza, heavy alcohol use, physical or emotional stress
Herpes Simplex
Herpes Simplex
 Viral Skin Infections: Herpes Simplex

HSV type I Clinical manifestations:

Small blister on skin of lips, mouth, gums or tongue or

around mouth
Early symptoms include burning, itching & increase
sensitivity or tingling/briking/burning sensation
Lesions appear as macules or papules progressing to small
blisters (vesicles) filled with clear yellowish fluid
Lesions are raised red painful can break & ooze
Can extend through epidermis & penetrate into underlying
dermis resulting in partial thickness wound. Eventually
yellow crusts slough to reveal pink healing skin
 Viral Skin Infections: Herpes Simplex

HSV type I Medical management:

Acyclovir & Valacyclovir to minimize symptoms &

length/duration of outbreak
Acetaminophen as analgesia
Topical anesthetics e.g Lidocaine to control
discomfort
Occlusive ointments as Herpecin-L or
Docosanol/Abreva to speed healing process
 Viral Skin Infections: Herpes Simplex

HSV type 2: causes herpetic lesions (blisters) on external

genitalia & occasionally vagina & cervix

STI & may be transmitted asexually from wet surfaces or

self transmission (touching cold sore then genital area)
Asymptomatic or Painful infection lasting over 1 week

Recurrence associated with stress, sunburn, dental work,

inadequate rest, poor nutrition or any situation affect
immune system
 Viral Skin Infections: Herpes Simplex

HSV-2 clinical manifestations:

Itching, pain
Infected area become red & edematous
Infection begins with macules & papules then progress to
vesicles (appear as blisters then ulcerates) & ulcers
Influenza like symptoms may occur 3 – 4 days post lesion
appearance
Inguinal lymphadenopathy, fever, myalgia, headache, dysuria
Lesions lasts 4 – 15 days
Possible complications: spread to other areas due to self-
touching, septic meningitis, neonatal transmission, sever
emotional stress related to diagnosis
 Viral Skin Infections: Herpes Simplex

HSV-2 Medical management:

Treatment aims to relieve symptoms, preventing spread of

infection, making pt comfortable, decrease potential health risks
& initiating counseling and education program

Oral antiviral agent (Acyclovir/Zovirax, Valacyclovir/Valtrex &

Famciclovir/Famvir) suppress symptoms & shorten course of
infection, decrease lesion duration, prevent recurrences

Condom use decrease HS as STI

 Viral Skin Infections: Herpes Simplex

HSV-2 Nursing management:

Instruct patient & family about hygiene, adherence to prescribed

antivirus, follow-up & use barrier method with sexual contact
Lesions should be kept clean, avoid ointments & powders as it prevent
lesion drying
Clothing should be clean, loose, soft & absorbent
Assess pt’s discomfort & response to medications & collaborate with
primary provider to adjust meds.
Instruct pt to contact HCP if dysuria/bladder distension present
Teach about proper hygienic practice/hand hygiene & how to relief
urination discomfort (by pouring warm water over genetalia during
voiding or by sitz bath)
Encourage diversionary activities & relaxation techniques for restful
sleep & decrease discomfort
Psychological support as needed
 Fungal/Mycotic Skin Infection

Common fungal skin infection is Tinea (ringworm):

Tinea capitis (head/hair infection)

Tinea corporis (body)
Tinea cruris (groin)
Tinea pedis (foot)
Tinea unguium (toenails)

For diagnosis: to obtain specimen (lesion cleaned, scalpel or

glass slid used to remove scales from lesion margin, scales
dropped on slid to which K hydroxide added for microscopic
examination)
 Parasitic skin infections:

Pediculosis: Lice Infestation

Scabies: Itch mite
 Parasitic skin infections: Pediculosis

3 varieties of lice infest humans:

Pediculus humanus capitis (head

louse)
Pediculus humanus Corporis
(body louse)
Pediculosis pubis (pubic louse or
crab)
Pediculosis
 Parasitic Skin Infections: Pediculosis:
Lice Infestation

Pediculus humanus capitis (head louse): is a scalp infestation by

head louse
Pediculus humanus Corporis (body louse): infestation of body
by body louse, common in people live in close quarters
Pediculosis pubis (pubic louse or crab): infestation localized in
genital region, transmitted by sexual contact

Lice are called ectoparasites because they live on the outside of

the host’s body.
They depend on the host for their nourishment, feeding on
human blood approximately five times each day.
They inject their digestive juices and excrement into the skin,
which causes severe itching
 Parasitic Skin Infections: Pediculosis: Lice
Infestation

Louse lays eggs (nits) close to

scalp & firmly attaches
To hair shafts

Young lice hatches in about

10days & reach maturity
in 2 weeks

It is transmitted by
physical contact or indirectly by
infested combs, brushes,
wigs, hats & bedding
 Parasitic Skin Infections: Pediculosis:
Lice Infestation
Clinical manifestations:

Presence of silvery glistening oval eggs

Intense pruritus results in Scratching can lead to bacterial infection e.g impetigo
or furunclosis
body louse lives primarily in the seams of underwear and clothing,
Its bites cause characteristic minute hemorrhagic points.
Widespread excoriation may appear as a result of intense pruritus and
scratching, especially on the trunk and neck.
Among the secondary lesions produced are parallel linear scratches and a slight
degree of eczema.
In long-standing cases, the skin may become thick, dry, and scaly, with dark
pigmented areas
Reddish-brown dust (insects excretions)
Gray-blue macules on trunk, thighs & axillae
Nits cemented to hair
Parasitic Skin Infections: Pediculosis: Lice
Infestation
Pruritus, particularly at night, is the most common symptom of
pediculosis pubis.
Reddish-brown dust (i.e., excretions of the insects) may be
found in the patient’s underclothing.
The pubic area should be examined with a magnifying glass for
lice crawling down a hair shaft or nits cemented to the hair or at
the junction with the skin.
Infestation by pubic lice may coexist with STD. There may also
be infestation of the hairs of the chest, axillae, beard, and
eyelashes.
Gray-blue macules may sometimes be seen on the trunk,
thighs, and axillae as a result of either the reaction of the
insects’ saliva with bilirubin (converting it to biliverdin) or an
excretion produced by the salivary glands of the louse
 Parasitic Skin Infections: Pediculosis: Lice
Infestation

Complications:
Sever pruritus
Pyoderma (impetigo or frunculosis)
Dermatitis
Body lice can transmit epidemic rickettsial disease
(epidemic typhus, relapsing fever & trench fever) to
humans.
The causative organism may be in GI tract of the
insect and may be excreted on the skin surface of the
infested person
Parasitic Skin Infections: Pediculosis: Lice
Infestation
Medical management:
Washing hair with shampoo containing pyrethrin compounds with piperonyl
butoxide (RID or R & C shampoo)
Rinsing hair with permethrin (Nix)
After washing/rinsing, comb hair with fine-toothed comb dipped in vinegar to
remove nits
Pt with body lice to be instructed to bathe with soap & water
Topical medication given for head & pubic lice & not for body lice
Petrolatum applied for Eyelashes lice with mechanical removal of nits
All articles of clothing, towels, and bedding that may have lice or nits should
be washed in hot water—at least 54°C (130°F)—or dry-cleaned to prevent
reinfestation.
As prevention, combs & brushes to be disinfected with shampoo or discarded
furniture, rugs, and floors should be vacuumed frequently
Treat affected family member
Complications e.g sever pruritus, pyoderma & dermatitis treated with
antipruritics, systemic antibiotics & corticosteroids.
 Parasitic Skin Infections: Pediculosis: Lice
Infestation
Nursing management:

informs the patient that head lice may infest anyone and are not a sign of
uncleanliness
Teach pt/family to shampoo scalp & hair according to product directions
After washing/rinsing, comb hair with fine-toothed comb dipped in vinegar to
remove nits
Clothing, towels & bedding having lice or nits should be washed in hot water or
dry cleaned
Furniture, rugs, floors should be vacuumed frequently
Combs & brushes to be disinfected with shampoo or discarded
Instruct to avoid sharing combs, brushes & hats
Educate & encourage about importance of personal hygiene & methods to
prevent infestation
Treatment is necessary for all family members and sexual contacts of patients
with body and/or pubic lice.
The patient and partner must also be scheduled for a diagnostic workup for
coexisting STIs.
 Parasitic Skin Infections: Scabies

Skin infestation by Itch

Mite Sarcoptes Scabiei
Common in substandard
hygienic conditions &
sexually active people
Mites involve fingers &
hand contact can
produce infection
 Parasitic Skin Infections: Scabies

Clinical manifestations: after 4 weeks incubation

Increased itching (evening hours)

Red pruritic eruptions on skin
Presence of small, raised burrows using magnifying glass &
penlight
Burrows can be multiple, Straight or wavy brown or black,
threadlike lesions common on fingers & wrists with other sites
Red, pruritic eruptions usually appear between adjacent skin
areas
Secondary lesions include vesicles, papules, excoriations &
crusts
 Parasitic Skin Infections: Scabies

Gerontologic Considerations:
Susceptible to outbreaks of scabies
May have peripheral sensory deficits, so Less prone
to scratch or may be physically unable to scratch.
Hcp should wear gloves when providing hands-on
care to a patient suspected of having scabies
Treat all residents, staff, and families of patients at
the same time to prevent reinfection
Antiscabicidal medication may be effective to remove
scales that are present with crusted scabies Crusts
May be removed with warm water soaks followed by
application of 5% Salicylic acid in petrolatum cream
 Parasitic Skin Infections: Scabies

Assesment & diagnostic findings:

Sample of superficial epidermis is scraped from

top of burrows or papules placed on microscopic
blade for microscopic examination for presence
of mite
 Parasitic Skin Infections: Scabies

Medical management

Pt instructed to take warm soapy bath to remove

scaling debris from crust, then to pat the skin
dry & allow it to cool
Scabicide & 5% Permethrin prescribed
The medication kept 12 – 24 Hrs then to wash
thoroughly & repeat treatment in 1 week
 Parasitic Skin Infections: Scabies
Nursing management:
Instruct patient to wear clean clothing and sleep between freshly laundered
bed linens
Importance of daily warm soapy bath & wearing clean clothing
All bedding & clothing should be washed in hot water & dried on the hot dryer
cycle
Instruct pt/family about medication use
After treatment completed, pt can apply topical corticosteroid to skin lesions
as scabicide may irritate skin
Pruritus may continue several weeks as manifestation of hypersensitivity, so
instruct pt not to apply more scabicide to prevent further irritation & itching
Instruct pt not to take frequent hot shower as it can dry skin & produce
pruritus
Instead oral antihistamine can control pruritus
If secondary infection present, oral antibiotic to be given
Family & close contact to be treated
If scabies is sexually transmitted, the patient may require treatment for
coexisting STI
 Noninfectious Inflammatory Dermatoses:
Irritant Contact Dermatitis
Irritant contact dermatitis (Eczema):
An inflammatory reaction of skin to physical, chemical or biologic
agents.
Can be primary irritant type (nonallergic reaction results from exposure
to an irritating substance/contact allergens
Caused by exposure to or additive effects of irritants (e.g., soaps,
detergents, organic solvents).
Epidermis damaged by repeated physical & chemical irritations
(exposure to irritant substance)
Causes: soaps, detergents, scouring compounds, industrial chemicals
Predisposing factors:
Extremes cold or heat, frequent contact with soap & water & pre-
existing skin disease
Persons whose occupation required repeated hand washing, repeated
exposure to food & other irritants
 Noninfectious Inflammatory
Dermatoses: Irritant Contact Dermatitis

Clinical manifestations:

1st reaction (acute) phase: Pruritus, Burning & erythema

followed by Edema, Papules, Vesicles, Oozing or weeping

Subacute phase: vesicles changed & alternate with crusting,

drying, fissuring & peeling

If reaction repeated or pt scratch, lichenification & pigmentation

occur

Seconday bacterial invasion may follow.

 Noninfectious Inflammatory
#Dermatoses: Irritant Contact Dermatitis

Assessment & diagnostic findings: to determine

dermatitis condition (allergic or contact)

Determine skin eruption location

History of exposure
Patch testing on affected skin

For more information refer to Textbook Chapter 37

#Contact Dermatitis: Assessment and
Diagnostic Findings
History of exposure, physical examination, and patch
testing needed to determining allergens.
Assessment should include:
The date of onset
Any identifiable relationship to work environment
and skin care products
The location of the lesions, distribution of the
dermatitis,
To verify the diagnosis, patch testing & environmental
history of exposure to contact allergens required.
 Noninfectious Inflammatory
Dermatoses: Irritant Contact Dermatitis

Medical management:

Aimed to sooth & heal involved skin and protect it from further damage
determine dermatitis condition (allergic or irritant contact) by
identifying reaction distribution pattern
Detailed history obtained
Offending irritant removed
Soap to be avoided until healing occurs
Barrier cream contain ceramide used for small erythema patches
Thin layer of corticosteroid cream or ointment can be applied as ordered
Cool wet dressing applied over vesicular dermatitis
Teach pt how to avoid future bouts of irritant dermatitis
Noninfectious Inflammatory: Psoriasis

It is a chronic inflammatory multisystem disorder

of the skin
It may involve oral cavity, eyes and joints.
Characterized by the appearance of silvery
plaques appear on the skin over the elbows,
knees, scalp, lower back, and buttocks at any age.
Have genetic predisposition
Psoriasis is characterized by periods of remission
and exacerbation throughout life
 Noninfectious Inflammatory: Psoriasis
Pathophysiology

Causes:
An autoimmune
Emotional stress, anxiety aggravate the condition
Trauma, Infections, seasonal & hormonal changes
may serve as triggers
 Psoriasis: Clinical Manifestation

Lesions appear as red, raised patches of skin covered with

silvery scales
The scaly patches are formed by the buildup of living & dead
skin
If the scales are scraped away, the dark red base of the lesion
is exposed, producing multiple bleeding points
The patches are not moist and may be pruritic.
May involve Nails, with pitting, discoloration, crumbling
beneath the free edges, and separation of the nail plate
Psoriasis is classified as mild, moderate & sever based on
affected areas (Mild if the plaques involve less than 5% BSA),
moderate 5% - 10% of BSA & severe if more than 10% BSA)
 Psoriasis: Complications

Asymmetric rheumatoid factor-negative arthritis

of multiple joints
Spondyloarthropathies,
Psoriatic arthritis.
Generalized exfoliative dermatitis
(erythroderma)

Refer to chapter 38 for further information

Psoriasis: Assessment and Diagnostic
Findings

The presence of the classic plaque-type lesions

generally confirms the diagnosis of psoriasis
HCP should assess for signs of nail and scalp
involvement and for a positive family history.
Biopsy of the skin is of little diagnostic value.
The presence and extent of plaque should be
assessed carefully, to calculate BSA involvement.
 Psoriasis: Medical Management

The goals of management are:

To slow the rapid turnover of epidermis
To promote resolution of the psoriatic lesions
To control the natural cycles of the disease.

There is no known cure.

 Psoriasis: Medical Management
Treatment involves the commitment of time and effort by the patient and
possibly the family.
An assessment is made of lifestyle because psoriasis is significantly affected by
stress to address aggravating factors
Management of emotional factors should be addressed as part of the overall
treatment of psoriasis.
The patient is informed that treatment of severe psoriasis can be time-
consuming, expensive, and aesthetically unappealing at times.

Gentle removal of scales is an important principle of psoriasis treatment. This

can be accomplished by:
Taking baths with added oils (e.g., olive oil, mineral oil), colloidal oatmeal
preparations, or coal tar preparations.
A soft brush may be used to gently scrub the psoriatic plaques.
After bathing, the application of emollient creams containing alpha-hydroxy acids
(e.g., Lac- Hydrin, Penederm) or salicylic acid can soften thick scales.

The patient and family should be encouraged to establish a regular skin care
routine that can be maintained even when the psoriasis is not in an acute stage
 Psoriasis: Medical Management:

Pharmacologic Therapy
Three types of therapy are commonly indicated:
topical, phototherapy, and systemic.
Topical agents with phototherapy, are
recommended for mild disease.
Patients with moderate or severe disease should
receive topical agents, phototherapy & systemic
treatment
 Psoriasis: Pharmacologic Therapy

Topical Agents: used to slow the overactive epidermis

Topical corticosteroids may be applied for their anti-inflammatory
effects
Choose the correct strength & effective vehicle base of
corticosteroid for the involved site
High-potency topical corticosteroids should not be used on the
face and intertriginous areas. For other areas shouldn’t exceed 4
weeks (BID)
For long-term therapy, moderate potency corticosteroids are used
On the face and intertriginous areas, only low-potency
corticosteroids are appropriate for long-term use

Occlusive dressings may be applied to increase the effectiveness

of the corticosteroid e.g large plastic bags, large rolls of tubular
plastic & a vinyl jogging suit
 Psoriasis: Pharmacologic Therapy
Occlusive dressings should not remain in place longer than 8 hours

The skin should be inspected carefully for side effects of corticosteroids

(the appearance of atrophy, hypopigmentation, striae, and
telangiectasias)
Potent corticosteroids applied on large areas of the body, have the
potential to cause adrenal suppression through percutaneous absorption
of the medication

If psoriasis involves large areas of the body, other treatment modalities

(e.g., nonsteroidal topical medications, ultraviolet light) may be used
instead or in combination to decrease the need for corticosteroids

Treatment with topical nonsteroidal agents, such as calcipotriene

(Dovonex) and tazarotene (Tazorac), can suppress epidermopoiesis
(i.e.development of epidermal cells) and cause sloughing of the rapidly
growing epidermal cells.
Calcipotriene 0.05% is a derivative of vitamin D2. It works by decreasing
the mitotic turnover of the psoriatic plaques.
 Psoriasis: Pharmacologic Therapy

The intertriginous areas and face should be avoided when using

Calcipotriene & monitored for hypercalcemia
Calcipotriene is available as a cream for use on the body and a solution
for the scalp. It is not recommended for use by older adult patients
because of their more fragile skin or by pregnant or lactating women

Tazarotene, a retinoid, causes sloughing of the scales covering psoriatic

plaques, increasing sensitivity to sunlight by loss of the outermost layer
of skin, so the patient should be cautioned to use an effective sunscreen
and avoid other photosensitizers
Pregnancy test should be done before initiating Tazarotene, and an
effective contraceptive should be continued during treatment.

Intralesional injections of the corticosteroid triamcinolone (Aristocort)

can be given directly into highly visible or isolated patches of psoriasis
that are resistant to other forms of therapy
 Psoriasis: Pharmacologic Therapy

Phototherapy: using UVB therapy may be effective as a single-

therapy modality

Phototherapy is more effective when it is given as UVA in

conjunction with a photosensitizing oral medication (PUVA).
The patient takes a photosensitizing medication (i.E., Psoralen)
in a standard dose & exposed to long-wave ultraviolet light
When Psoralen-treated skin is exposed to UVA light, the
psoralen binds with DNA & decreases epidermal cellular
proliferation.
PUVA has been associated with long-term risks of skin cancer,
cataracts, and premature aging of the skin
 Psoriasis: Pharmacologic Therapy

An interim period of 48 hours between treatments is

necessary to allow any burns resulting from PUVA
therapy to become evident.

After the psoriasis clears, the patient begins a

maintenance program.

Once little or no disease is active, less potent

therapies are used to keep minor flare-ups under
control
 Psoriasis: Pharmacologic Therapy

Systemic Agents:
systemic corticosteroids may cause rapid improvement of psoriasis, but
severe flare-up may occur on withdrawal.

Methotrexate, a systemic cytotoxic agent, is the first-line drug for

treating moderate to severe psoriasis
Methotrexate inhibit DNA synthesis in epidermal cells, thereby reducing
the turnover time of the psoriatic epidermis.
It can be toxic to the liver, kidneys, and bone marrow. Laboratory studies
must be monitored to ensure that the hepatic, hematopoietic, and renal
systems are functioning adequately.
The patient should avoid drinking alcohol while taking methotrexate.
It is teratogenic and thus shouldn’t be given to pregnant women.
 Psoriasis: Pharmacologic Therapy

Cyclosporine (Neoral), a cyclic peptide immunosuppressive agent used

for severe refractory psoriasis

Only indicated for short-term use, generally no longer than 3 to 6 months

due to its side effects e.g hypertension and nephrotoxicity

Biologic agents: Another line of treatments for psoriasis because of their

derivation from immunomodulators and bioengineered proteins (such as
antibodies or recombinant cytokines) and their targeted action directly
on the T cells.

These agents act by inhibiting activation and migration, eliminating the T

cells completely, slowing postsecretory cytokines or inducing immune
deviation.
 Psoriasis: Pharmacologic Therapy
Infliximab (Remicade) is a monoclonal antibody that binds to
tumor necrosis factor-alpha (TNF-α) and can only be given by IV
infusion.

Ustekinumab (Stelara) is a monoclonal antibody that specifically

interferes with the effect of interleukins (ILs), particularly IL-12
and IL- 23.
Etanercept (Enbrel) is a fusion protein that binds to soluble TNF-
α and blocks its interaction with cell surface receptors.
Alefacept (Amevive) is a fusion protein that inhibits T-cell
proliferation.
Adalimumab (Humira) is a recombinant human IgG1
monoclonal antibody against TNF-α.
These biologic agents have significant side effects, making close
monitoring essential
 Psoriasis: Nursing Management

Psoriasis can eventually exhaust the patient’s resources, interfere with

their job, and negatively affect many aspects of life.
The nurse assesses the impact of the disease on the patient
Assess the coping strategies used for conducting normal activities and
interactions with family and friends
Reassure the pt that the condition is not infectious, not a reflection of
poor personal hygiene, and not skin cancer.
Create an environment in which the patient feels comfortable to discuss
his/her psychosocial and physical response to this chronic illness.
explains with sensitivity that although there is no cure for psoriasis and
lifetime management is necessary, the condition can usually be
controlled.
 Psoriasis: Nursing Management

Explain about disease condition {pathophysiology, factors

that provoke it—irritation or injury to the skin (e.g., cut,
abrasion, sunburn), current illness (e.g., pharyngeal
streptococcal infection), and emotional stress}.
It is emphasized that repeated trauma to the skin and an
unfavorable environment (e.g., cold) may exacerbate
psoriasis.
The patient is cautioned about taking any nonprescription
medications because some may aggravate mild psoriasis.
Advised the patient to seek treatment from the same
primary provider for any acute illnesses or chronic
conditions
 Psoriasis: Nursing Management

Explain the treatment regimen to ensure patient

adherence to the therapeutic regimen.
If the patient has a mild condition confined to
localized areas, application of an emollient to
maintain softness and minimize scaling is required.
Individualized comprehensive plan of care based
on pt’s condition
Patient education materials that are helpful with
face-to-face discussions of the treatment plan.
 Psoriasis: Nursing Management
To avoid injuring the skin, the patient is advised not
to pick at or scratch the affected areas.
Measures to prevent dry skin are encouraged
because dry skin worsens psoriasis.
Emollients have a moisturizing effect, providing an
occlusive film on the skin surface so that normal
water loss through the skin is halted and allowing the
trapped water to hydrate the stratum corneum.
A bath oil or emollient cleansing agent can comfort
sore and scaling skin. Softening the skin can prevent
fissures.
 Psoriasis: Nursing Management

Too-frequent washing produces more soreness and scaling.

Water should be warm, not hot, and the skin should be dried by
patting with a towel rather than by rubbing.

A therapeutic relationship between HCP and the patient with

psoriasis includes education and support.

Introducing the patient to successful coping strategies used by

others with psoriasis and making suggestions for reducing or
coping with stressful situations at home, school, and work can
facilitate a more positive outlook and acceptance of the
chronicity of the disease
 Psoriasis:Promoting Home, Community-
Based, and Transitional Care
Educating Patients About Self-Care
Printed patient education materials to be provided to reinforce face-toface
discussions about treatment guidelines and other considerations.
Patients using topical corticosteroid preparations repeatedly on the face and
around the eyes should be aware that cataract development is possible.
Strict guidelines for applying these medications should be emphasized, because
overuse can result in skin atrophy, striae, and medication resistance.
PUVA, which is reserved for moderate to severe psoriasis, produces
photosensitization.
If exposure to the sun is unavoidable, the skin must be protected with sunscreen
and clothing.
Gray- or green-tinted wraparound sunglasses should be worn to protect the
eyes during and after treatment
ophthalmologic examinations should be performed on a regular basis
Ensure referral to a mental health professional who can help to ease emotional
strain and give support.
Belonging to a support group may also help patients recognize that they are not
alone in experiencing life adjustments in response to a visible, chronic disease.
NCP for Dermatologic Problems Patients

Common nursing diagnosis:

Acute pain related to related skin lesions

Impaired skin integrity related to ruptured bullae……..
Disturbed body image related to appearance of skin…
Anxiety related to skin appearance
Deficient knowledge related to skin disorder & its progress
with management
Risk for infection related to loss of protective barrier of
skin/mucous membranes
 Nursing Care Plan for Dermatologic
Problems Patients

Goals & Nursing interventions:

Relieving pain & discomfort

Enhancing skin integrity & relieving discomfort
Promoting positive body image
Reducing anxiety
Increasing patient’s knowledge
Prevention of infection
References:
Hinkle, JL. And Cheever, KH. 2014. Medical
surgical nursing. 14th ed. Philadelphia:
Lippincott Williams & Wilkins.