ANATOMY OF SKIN

Epidermis
dead cells protect

cells underneath;
replaced q3-4 weeks;
contains keratin
keratin outer barrier,

repel pathogens,
prevent excessive fluid
loss
Insensible water loss-

400-600mL

DERMIS
largest portion of skin
blood vessels and sensory nerve endings
strength and structure of skin
fibroblasts collagen and elastin
collagen main structural component skins

strength
elastin elasticity

SUBCUTANEOUS TISSUE
hypodermis
contains half the bodys stored fat
amount and location vary age, sex, diet
cushion between skin layers, muscles, bones
skin mobility
molds body contours
Insulation

HAIR
slender, threadlike outgrowths of the epidermis
interstitial air bubbles that give the hair a silvery

color

hair shaft above the skin

cortex
Medulla

hair follicle tubular cavity; for tissue repair

hair bulb - contains cells keratinocytes
blood

vessels from papillae provide

nourishment

HAIR
X - palms, soles, lips, nipples, distal

segments of fingers and toes

keratin packed dead keratinocytes

hair scalp growth rate - 1 mm (0.04 in)

q3 days
arrector pili ANS; contracts - stand on

end

HAIR

NAILS
hard, transparent plate of keratin
nail growth continuous; 0.1 mm daily
renewal:
fingernail 170 days
toenail 12-18 months

GLANDS OF THE SKIN

sweat gland
concentrated:

palms & soles

10 liters (2.6

gallons) of fluid per

day
evaporates and

cools the body

eccrine gland
sweat basal

coiled portion;
water, salt
content of blood
plasma - SNS

apocrine gland

axillae, anal region,

scrotum, labia
majora
active puberty
milky sweat
(organic subs.)
broken down by
bacteria BODY
ODOR!
ceruminous gland
external ear
cerumen (wax)

GLANDS OF THE SKIN

sebaceous gland
connected duct

hair follicle
sebum
present in each
hair
lubricate hair
render skin soft
and pliable

FUNCTIONS OF SKIN
PROTECTION
against invasion

bacteria, foreign subs.

SENSATION
receptor endings of
nerves
sense temperature, pain,
light touch, pressure
(heavy touch)
more concentrated in
some areas (fingertips)

FUNCTIONS OF SKIN
FLUID BALANCE
absorb water prevent

excessive loss
insensible perspiration
600 ml daily
TEMPERATURE

REGULATION
heat from metabolism
of food
radiation
conduction
evaporation
convection

HEALTH HISTORY & CLINICAL

MANIFESTATIONS

family and personal hx of skin allergies

allergic reactions to food, meds, chemicals
previous skin problems
skin cancer
name of cosmetics, soaps, shampoos, etc. obtained
note:
onset
signs & symptoms
location
duration of any pain
itching
rash

PHYSICAL ASSESSMENT
inspect/observe:
color
temperature
moisture or dryness
skin texture
lesions
vascularity
mobility
condition of hair and nails

palpate:
skin turgor
edema
Elasticity

fever, sunburn, inflammation

pink to reddish
pallor - skin color
cyanosis bluish hypoxia
extremities, nail beds, lips
jaundice yellowish
serum bilirubin sclerae

PHYSICAL ASSESSMENT
cyanosis

erythema

bluish discoloration

redness of skin

lack of oxygen blood

congestion of

lips, fingertips, nail

capillaries
palpated for increased
warmth & smoothness
or hardness
rash
indicate areas - itching
borders palpable
pxs temp
lymph nodes palpated

beds
if dark-skinned:
around mouth and
lips
over cheekbones &
earlobes

PHYSICAL ASSESSMENT
color changes
hypopigmentation - melanin; fungal infection, eczema,

vitiligo (destruction of melanocytes white patches)

hyperpigmentation - melanin; occur after disease or
injury, sun injury, aging
dark skin:

melanin faster rate of production, larger

quantities
buccal mucosa, lips, tongue, nails pink
lesions black, purple, gray
postinflammatory hyperpgimentation
less likely to have skin cancer

Primary
Secondary

Primary Skin Lesions

Macule, Patch
Papule, Plaque
Nodule, Tumor
Vesicle, Bulla
Wheal
Pustule
Cyst

Primary Skin Lesions

Macule, Patch
Flat, nonpalpable skin color change (color may
be brown, white, tan, purple, red)
Macule: <1 cm, circumscribed border
Patch: >1 cm, may have irregular border

Examples:
Freckles, flat moles, petechia, rubella, vitiligo,
port wine stains,ecchymosis

Papule, Plaque
Elevated, palpable, solid mass
Circumscribed border
Plaque may be coalesced papules with flat top
Papule: <0.5 cm
Plaque: >0.5 cm

Examples:
Papules: Elevated nevi, warts, lichen planus
Plaques: Psoriasis, actinic keratosis

Nodule, Tumor
Elevated, palpable, solid mass
Extends deeper into the dermis than a papule
Nodule: 0.52 cm; circumscribed
Tumor: >12 cm; tumors do not always have sharp
borders

Examples:
Nodules: Lipoma, squamous cell carcinoma,
poorly absorbed injection, dermatofibroma
Tumors: Larger lipoma, carcinoma

Vesicle, Bulla
Circumscribed, elevated, palpable mass
containing serous fluid
Vesicle: <0.5 cm
Bulla: >0.5 cm

Examples:
Vesicles: Herpes simplex/zoster, chickenpox,
poison ivy, second-degree burn (blister)
Bulla: Pemphigus, contact dermatitis, large
burn blisters, poison ivy, bullous impetigo

Wheal
Elevated mass with transient borders
Often irregular
Size and color vary
Caused by movement of serous fluid into the

dermis
Does not contain free fluid in a cavity (as, for
example, a vesicle does)

Examples:
Urticaria (hives), insect bites

Pustule
Pus-filled vesicle or bulla

Examples:
Acne, impetigo, furuncles, carbuncles

Cyst
Encapsulated fluid-filled or semisolid mass
In the subcutaneous tissue or dermis

Examples:
Sebaceous cyst, epidermoid cysts

Secondary Skin Lesions

Erosion
Ulcer
Fissure
Scales
Crust
Scar (Cicatrix)
Keloid
Atrophy
Lichenification

Erosion
Loss of superficial epidermis
Does not extend to dermis
Depressed, moist area

Examples:
Ruptured vesicles, scratch marks

Ulcer
Skin loss extending past epidermis
Necrotic tissue loss
Bleeding and scarring possible

Examples:
Stasis ulcer of venous insufficiency, pressure

ulcer

Fissure
Linear crack in the skin
May extend to dermis

Examples:
Chapped lips or hands, athletes foot

Scales
Flakes secondary to desquamated, dead

epithelium
Flakes may adhere to skin surface
Color varies (silvery, white)
Texture varies (thick, fine)

Examples:
Dandruff, psoriasis, dry skin, pityriasis rosea

Crust
Dried residue of serum, blood, or pus on skin

surface
Large, adherent crust is a scab

Examples:
Residue left after vesicle rupture: impetigo,

herpes, eczema

Scar (Cicatrix)
Skin mark left after healing of a wound or lesion
Represents replacement by connective tissue of
the injured tissue
Young scars: red or purple
Mature scars: white or glistening

Examples:
Healed wound or surgical incision

Keloid
Hypertrophied scar tissue
Secondary to excessive collagen
formation during healing
Elevated, irregular, red
Greater incidence among African Americans

Example:
Keloid of ear piercing or surgical incision

Atrophy
Thin, dry, transparent appearance of epidermis
Loss of surface markings
Secondary to loss of collagen and elastin
Underlying vessels may be visible

Examples:
Aged skin, arterial insufficiency

Lichenification
Thickening and roughening of the skin
Accentuated skin markings
May be secondary to repeated rubbing,

irritation, scratching

Example:
Contact dermatitis

Skin
Lesion
Types
Secondary Lesions:
Are a result of
trauma, chronicity, or
infection of primary
lesion.

Vascular Skin Lesions

Petechiae
Ecchymosis
Cherry Angioma
Spider Angioma
Telangiectasia (Venous star)

Pediculosis
Lice infestation- affects

people of all ages

Ectoparasites
Three varieties
1. Pediculosis capitis
2. Pediculosis corporis
3. Pediculosis pubis

Pediculosis Capitis
Infestation of the scalp by the

head louse
Visible slivery, glistening oval
bodies
Attaches to the hair shaft
with a tenacious substance
Found commonly along the back
of the head and behind the
ears
The insect bite causes intense
itching
Transmitted directly or
indirectly

Pediculosis Capitis
Medical Management
Treatment is aimed at
destroying the insect and ova
Lindane-containing shampoo or
pyrethin compounds with
piperonyl butoxide
Fine-toothed comb dipped in
vinegar
Infested clothing, beddings and
towels be washed in hot water
or dry cleaned

Nursing Management
Treatment is started immediately
Warn not to share combs, brushes

and hats
Each family member should be
inspected daily for at least 2 weeks
Inform about lindane

Pediculosis Corporis and Pubis

Infestation of the body louse
Common in people who live in in-close quarters and

do not change clothing

Spread by close contact with infested clothing or
linens or by sexual contact
Pediculosis pubis is usually coexist in people with
sexually transmitted disease
Bites causes characteristic minute hemorrhagic
points
Excoriations as a result of itching and scratching

Clinical Manifestations
Itching is the most

common symptom
Reddish-brown dust in
underclothing
Gray-blue macules on
the trunk, thighs and
axillae

Medical Management
Lindane or 5% permethrin to affected area of

the skin and to hairy areas

Eyelashes: Petrolatum is thickly applied 2x
daily for 8 days, mechanical removal

Nursing Management
Thoroughly clean and dry the skin before

applying the medication

Clothing and beddings should be machine
washed in hot water of dry cleaned
Education about hygiene and methods to
prevent or control infestation
Diagnostic workup for patient and partner
with STD
Reassure patients and significant others that
symptoms are temporary

Scabies
Infestation of the skin by the itch mite

Sarcoptes scabiei
Most often in children and adolescence
Fingernails, popliteal fossae, wrists, axillae,
nipples, umbilicus, lower abdomen, genitalia, and
buttocks are the most common sites
Contracted by skin to skin contact, often by
sexual contact and by use of contaminated towels,
beddings and clothing
4 weeks before symptoms to appear

Scabies
extremely pruritic papular lesions
Inspect for burrows: magnifying

glass and penlight at an oblique angle

to the skin
Red pruritic eruptions between
adjacent skin areas
One characteristic sign is increased
itching at night
Scrape materials under lowpowered microscope in immersion oil

Scabies
Medical Management
Warm soapy bath or shower, dry
thoroughly and allow skin to cool
Anti-histamines or topical Synalar to
improve itching
A Prednisone taper for severe itching
Topical Lindane, Crotamiton or 5%
permethin is applied neck down for 12-24
hours and repeated after a week

Scabies
Nursing Management
Beddings and clothing washed in hot water,
dried in hot dryer cycle or dry-cleaned
Topical corticosteroids for scabicide
irritation
Inform patient that itching may continue,
instruct not to apply more scabicide
Family members with contact should also be
treated

Contact /Atopic Dermatitis

Psoriasis
Exfoliative Dermatitis

Contact Dermatitis
inflammatory reaction of the

skin to physical, chemical, or

biologic agents
Primary irritant type vs.
Allergic
Acute or chronic rash
Predisposing factors: extremes
of heat and cold, frequent
contact with soap and water,
and a preexisting skin disease

Atopic Dermatitis
Chronic rash
Associated with respiratory allergies and

atopic skin diseases

Description
Chronic non-infectious inflammatory
disease of the skin

Epidermal cells produce 3-9 times

faster than normal

Cells of basal layer
scales

s. corneum

NORMAL: 26-28 days

PSORIASIS: 3-4 days

No growth and maturation

Protective layers do not form

Causes
2 Main Theories:
1.Disorder of excessive growth and

reproduction of skin cells

Problem: fault of the epidermis and its

keratinocytes

Excess keratin (component of dead

cells in s. corneum for protection and
prevention of
fluid loss)

2. Immune-mediated Disorder
excessive reproduction of skin cells is secondary to
factors produced by the immune system
T cells (which normally help protect the body against
infection) become active, migrate to the dermis and
trigger the release of cytokines (tumor necrosis
factor-alpha TNF) which cause inflammation and the
rapid production of skin cells
not known what initiates the activation of the T cells

The immune-mediated model of psoriasis

has been supported

observation that immunosuppressant

medications can clear psoriasis plaques

idiosyncratic disease may worsen or

improve for no apparent reason

stress (physical and mental), skin injury, and

streptococcal infection
worsening of the disease include infections,
stress, and changes in season and climate

Assessment & Diagnosis

Dx: appearance of the skin (plaque-type

lesions)
no special blood tests
skin biopsy, or scraping has little value
Nail and scalp involvement
Family history

Clinical Manifestations
Lesions (red, raised patches of skin covered

with silvery scales)

Scaly patches: build-up of living and dead skin
from fast growth and turnover
Bleeding points: when the scales are scraped
away (Auspitz sign)
Patches: not moist and are pruritic
Koebners phenomenon

Koebners phenomenon

Most common sites:

Scalp
Extensor surface of the elbows and knees
Lower back
Genitalia
Nails (pitting, discoloration, crumbling

beneath free edges, separation of nail plate)

Palms
Soles
Bilateral symmetry is a feature of psoriasis

Effect on Quality of Life

Depend on severity and location
Itching and pain: self-care, walking, and sleep
On hands and feet: certain occupations,

some sports, and caring for family

members or at home
medical care is costly and can interfere
with an employment or school schedule.

self-conscious about their appearance

poor self-image: fear of public rejection and

psychosexual concerns
Psychological distress can lead to depression and
social isolation

Treatment
Topical treatment
Phototherapy
Photochemotherapy
Systemic treatment
Alternative therapy

Topical treatment
Bath solutions and moisturizers
sooth affected skin and reduce the dryness
which accompanies the build-up of skin on
psoriatic plaques
Medicated creams and ointments applied

to psoriatic plaques

reduce inflammation, remove built-up

scale, reduce skin turn over, and clear

affected skin of plaques

Disadvantages
irritate normal skin
time consuming
awkward to apply
not for long use
stain clothing
strong odour
Abrupt withdrawal (corticosteroids)

rebound

Phototherapy
daily, short, non-burning exposure to

sunlight helped to clear or improve

psoriasis
Types:

UVA (380315 nm)

UVB (315280 nm)
UVC (< 280 nm)

UVB: absorbed by the epidermis and has a

beneficial effect on psoriasis

Narrowband UVB (311 to 312 nm): most helpful
Exposure to UVB several times per week,
over several weeks can help people attain
a remission from psoriasis

Photochemotherapy
Psoralen and PUVA combines oral or topical

administration of psoralen with exposure to (UVA)

light
mechanism of action probably involves activation
of psoralen by UVA light which inhibits the
abnormally rapid production of the cells in
psoriatic skin

Nursing Considerations
Dark glasses during PUVA tx: risk of

cataracts from exposure to sunlight

PUVA is associated with nausea, HA,
fatigue, burning, and itching
Long-term tx: squamous-cell & melanoma skin CA

Systemic treatment
resistant to topical treatment and phototherapy is

treated by medications (pill or injection)

blood and liver function tests (toxicity of the
medication)
Pregnancy must be avoided (majority)
Alcohol (liver damage)

3 Main Immunosupressant Drugs

Methotrexate
Ciclosporin
Retinoids
Topical steroids
Coal tar products
Medicated shampoos

Care of the Patient with

Psoriasis
Follow the basics of good health

balanced diet, drinking plenty of water, and

getting enough sleep (avoid feeling tired and
overstressed, and fight off infections that can
aggravate the skin)

Learn the triggers

certain infections, some medications,
skin injury, stress, winter weather,
and smoking
Avoid scratching
can

puncture the skin, allowing bacteria to

enter and cause an infection, and bleed
and worsens psoriasis

Apply a cold compress

reduce inflammation and lessen the desire to

scratch

Apply a menthol-based ointment or

topical steroid
manage the itch until the psoriasis clears

Bathe in warm, not hot water

short, warm showers and use fragrance-free

cleansers

Never pick at lesions

can cause bleeding, infection, and a

worsening of the psoriasis

Pat your skin dry; rubbing can irritate

it
lesions to form
gently patting your skin dry

Wear cotton clothing next to your skin

Cotton is less likely than other fabrics to irritate
the skin or cause overheating

Use sunscreen
using retinoids should apply sunscreen 15 to
20 minutes before going outdoors and wear
protective clothing
sunburn, which can trigger psoriasis

Exfoliative Dermatitis
Progressive inflammation in which

erythema and scaling occur in a more

or less generalized distribution
Profound loss of s. corneum (capillary
leakage, hypoproteinemia, and negative
nitrogen balance)

Epidemiology
Any race
Male-to-female ratio is 2-4:1
older than 40 years, except when the condition

results from atopic dermatitis, seborrheic

dermatitis, staphylococcal-scalded skin
syndrome, or a hereditary ichthyosis (related to
etiology)

Assessment & Diagnosis

elimination of known causes, such as certain

drugs (i.e., penicillin and barbiturates)

other skin conditions (atopic dermatitis,
lymphoma)
physical examination
medical history
Skin samples to laboratories

Clinical Manifestations
Patchy or generalized erythematous eruptions
Fever
Malaise
GI symptoms
Color change (pink to dark red)
Exfoliation (scaling)

Exfoliation as thin flakes

& red
Hair loss
Relapse

skin smooth
new scales

Management
Antibiotics for infection (C & S)
Antihistamines for severe itch
Topical meds for acute dermatitis
Oral or parenteral corticosteroids

(uncontrolled)
Avoid irritants
Tx of specific cause

Care of the Patient with

Exfoliative Dermatitis

Comfortable room temp. (no normal

thermoregulatory control temp. fluctuations

due to vasodilation and evaporative water loss)
Maintain skin moisture with wet dressings,
emollients and mild topical steroids

Definition

Greek pemphix, meaning bubble or blister.

an autoimmune disorder
body's defenses mistake its own tissues as foreign,

and attack the cells >>antigen-antibody reaction

>> binding of antibodies to the surface of the cells
of the outer layer of the skin, the epidermis

Immunoglobulin G
epidermal acantholysis-destruction of the

"cement" that holds cells together

Highest incidence: Jewish or Mediterranean
Usually occurs in middle and late adulthood

Causes
Hereditary
Benign Familial Pemphigus (Hailey-Hailey disease)

Exposure to chemicals , dyes, trauma,

surgery, x-ray and infections

Carpet Shampoo - well known to trigger the

blistering in Kawasaki disease

Pemphigus Foliaceus- may be triggered by a

substance transmitted through the bite of

blackflies
Adverse reaction to penicillins and captopril
such as d-penicillamine or rifampin

Manifestations
Bullae, blistering and raw sores on skin and

mucous membranes

Painful, bleed easily, heal slowly

characteristic offensive odor

Nikolskys sign blistering or sloughing of

uninvolved skin when minimal pressure is

applied
location and type of blisters vary according to
the type of Pemphigus
Mostly misdiagnosed as Herpes

TREATMENT
Topical Corticosteroids (Prednisone)
Analgesics
Immunosuppressive agents

Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Gold
Plasmapheresis (plasma exchange)
Antibiotics or creams-infection and relieve inflamm.
Silver sulfadiazine cream also may be used

TEN and SJS

most severe form of erythema multiforme
both triggered by
reaction to medications

Antibiotics, antiseizure agents, butazones, and

sulfonamides

from a viral infection

Occur in all ages and most genders

Increased risk
older people
immunocompromised

Clinical Manifestations
Initial
conjunctival burning

or itching
Cutaneous tenderness
Fever
Cough
Sore throat
Headaches
Extreme malaise
myalgias

Subsequent
rapid onset of erythema

skin surface
mucous membranes:
including the oral mucosa,
conjunctiva, and genitalia

Ulcerations

larynx, bronchi, esophagus

large sheets of epidermis

are shed
excruciatingly tender skin
weeping surface =
scalded skin syndrome

Complications
Sepsis
Keratoconjunctivitis

Assessment and
Diagnostic Findings

History of ingestion of medications

Histologic studies
Cytodiagnosis
Immunofluorescent studies

Medical Management
Supportive care = mainstay of treatment
Goals of treatment
control of fluid and electrolyte balance
prevention of sepsis
prevention of ophthalmic complications

Discontinue all nonessential medications!

Management
Surgical debridment/hydrotherapy hubbard

tank
Culture and sensitivity
Systemic corticosteroids
Immunoglobulin (IVIG)
Topical antibacterials and anesthetics
Biologic dressings
Plastic semi permeable dressing (ex Vigilon)

Oropharyngeal and eye care

Nursing Management
Maintaining Skin Integrity
Attaining Fluid Balance
Preventing Hypothermia
Relieving Pain
Reducing Anxiety
Monitoring and managing potential

complications
Sepsis
conjunctival retraction, scars, and corneal lesions

Sun exposure leading cause

Types

- Basal Cell Carcinoma

- Squamous Cell Carcinoma
- Malignant Melanoma

Basal Cell Carcinoma

Most common type of skin cancer
Extensive exposure to the sun
Greater incidence in older people
Inversely proportional to melanin content of skin
Usually begins as small waxy nodules with rolled,

translucent, pearly borders

Other variants shiny, flat, gray or yellowish plaques

Undergoes central ulceration and sometimes

crusting
Common on face
Rare metastasis
Recurrence common
Good prognosis

Clinical Manifestations
Squamous Cell Carcinoma
malignant proliferation arising from the epidermis
appears on sun-damaged skin
truly invasive carcinoma
Types
Primary
From precancerous condition actinic keratosis,
leukoplakia or scarred or ulcerated lesions

appears as a rough, thickened, scaly tumor

may be asymptomatic or may involve bleeding
Prognosis depends on metastasis

Management
Surgical excision
Mohs Micrographic Surgery
Electrosurgery
Cryosurgery
Radiation Therapy

 Prevention
Sunscreen use at least SPF 15
Reduces skin CA risk by 40%
Head, neck and arms- 30 mins before leaving the
house and reapplied every 4 hours if the skin
perspires.

Malignant Melanoma
Most lethal of all skin cancers (20% of CA deaths)
Atypical melanocytes in the Epidermis and Dermis
Can appear spontaneously with other CA of other

organs

Forms
Superficial Spreading Melanoma
Lentigo-Maligna Melanoma
Nodular Melanoma
Acral-Lentiginous Melanoma

Malignant Melanoma
Superficial Spreading Melanoma
Most common
occurs anywhere on the body
circular, with irregular outer portions

Malignant Melanoma
Lentigo Maligna

Melanoma
slowly evolving
Pigmented lesions
Occur on exposed areas
dorsum of the hand,
the head and the neck in
elderly people

Malignant Melanoma
Nodular Melanoma
Spherical, blueberry like

nodule with a smooth

and blue black color
Px description as a
blood blister that did not
resolve
Invades directly into the
dermis poor prognosis

Malignant Melanoma
Acral-Lentiginous Melanoma
areas where there is no excessive exposure to

sunlight, hair follicles are absent

Palm of hands, on the soles, in the nail beds,
and in mucous membrane in dark skinned
people

Malignant Melanoma
Assessment and Diagnostic Findings
Biopsy- confirmative
Palpation of regional lymph nodes
Screening in family up to first degree

relatives
After biopsy chest xray, CBC, liver
function tests, radionuclide, or
computed tomography

Malignant Melanoma
Prognosis
1.5mm poor
thin skin lesion, no lymph involvement = 3%

chance of metastis, and 95% for long term

survival
With regional lymph nodes 20-50% chance
of surviving for 5 years

Malignant Melanoma
Medical Management
Surgical excision
Immunotherapy
Chemotherapy
Nursing Management
Relieving pain and discomfort
Reducing anxiety and depression
Monitoring and managing vital complications
metastasis

Kaposis Sarcoma
Associated with HIV and AIDS resulting in more

aggressive form
3 categories
Classic KS
African (endemic KS)
KS associated with immunosuppressive therapy