HEALTH AND WELLNESS

INTEGUMENTARY SYSTEM
By Dr M Umer Iqbal
LIFESPAN CHANGES
 The integumentary system contains the largest organ of the
body, the skin.

 This system also includes subcutaneous tissues (responsible for

storing energy and absorbing trauma), the nails, the hair, and the
structures immediately under the superficial skin layer (dermis).

 Barrier against infection and injury, the skin helps to regulate

body temperature, removes waste products from the body,
protects internal structures (to some extent) from ultraviolet
(UV) radiation, and produces vit.D, an essential nutrient for
maintaining normal blood levels of calcium and phosphorus
needed to form and maintain strong bones.
 A healthy full-term baby is born with extra fat and
increased skin elasticity.

 Changes in the skin become more apparent during

puberty when hormones influence sexual changes in hair
and fat distribution and, in some cases, increased
secretion from sebaceous glands.

 With aging and exposure to UV radiation, toxins, and

other damaging agents, the skin tends to lose its
elasticity, its vascularity, its thickness, its strength, and
its thcrmoregulation properties.
 In older adults, the overall function of the skin is
compromised with the graying of hair and the
physiological changes underlying changes in physical
appearance, including tissue dehydration and impaired
wound healing.

 Primary practice includes health education about

maintaining skin hydration as well as avoiding the
various risk factors leading to premature aging and
pathology.
INTEGUMENTARY PATHOLOGY

 Amputation, congestive heart failure, diabetes,

malnutrition, neuromuscular dysfunction, obesity,
peripheral nerve involvement, spinal cord dysfunction,
and vascular disease.

 Any clients with impairments limiting levels of activity,

reducing sensation, or causing edema, inflammation,
pain, or ischemia are at increased risk for integumentary
problems and should be monitored carefully by the
physical therapist.
 Physical therapists are fortunate in their practices to have the
time to complete a comprehensive and thorough examination
of their clients.

 A comprehensive examination and assessment of the patient

includes identification of secondary complications related to
chronic pathology, such as loss of integumentary integrity.

 Suspected risk to integumentary integrity should lead the

physical therapist to three vital areas of skin care education:
risk reduction for skin cancers, avoidance of pressure sores or
wound development, and medication side effects with
integumentary manifestations.
 In 'addition, physical therapists can help clients prevent
losses of skin elasticity and range of motion by
encouraging passive and active movement, a healthy diet
(including adequate hydration), and protection from
irritants and infections affecting the skin's integrity.

 As integumentary conditions become more severe, the

client becomes more vulnerable to complications
resulting from exposure of underlying tissue.

 Physical therapists can play a key role in primary,

secondary, and tertiary preventive care of clients
SKIN CANCER

 One growing concern is the risk of skin cancer. The incidence of skin
cancer is greater than the incidence of breast, lung, prostate, colorectal,
and kidney cancers combined.

 The ABCDE rule of skin cancer helps to identify any abnormal skin
lesions that are suspect and includes the following:
 "A" represents asymmetry in the lesions (ie, one half of the lesions is
unlike other half).
 "B" represents borders that are irregular or poorly circumscribed.

 "C” represents color variation in the lesions (melanomas tend to have

color variations that include tan, brown, black, white, red, and blue).
 "D" represents diameter greater than 6 mm (the size of a pencil eraser)
since cancerous skin lesions tend to grow.
 "E" represents elevation since normal skin lesions tend to be flat and
raised lesions may represent abnormal growth.
 The American Cancer Society recommends a thor­ough
skin exam every 3 years between the ages of 20 and 40,
every year age 40 or older, and monthly skin self-exams,
most easily performed after a bath or shower.

 A thorough screening demands that the entire surface of

the body be palpated and inspected in good light. The
onset and duration of each symptom should be recorded,
together with a description of the lesion and any
subsequent changes.
PRIMARY PREVENTION
 includes educating individuals about monthly checks as
well as the need to use a full-length mirror and brightly
lit room to examine the entire body, including:

 The scalp, inside the mouth, between the toes, and the
bottoms of the feet Individuals at an increased risk for
melanoma are those with fair complexions; excessive
exposure to UV radiation from the sun or tanning booths;
occupational exposure to coal, tar, pitch, creosote,
arsenic compounds, and radium; or human
immunodeficiency virus (HIV).
EXAMINATION
 Skin examination should be performed regularly during
physical therapy visits. Most skin cancers develop mainly on
areas of skin exposed to direct sunlight, including the scalp,
face, lips, ears, neck, chest, arms and hands, and on the legs in
women.
 They can also develop on unexposed , areas, such as the palms,
the spaces between toes, and the genital area. A cancerous skin
lesion can appear suddenly, or it can develop slowly.
 Secondary prevention includes reducing risk factors that can
cause a recurrence of malignant skin lesions, including sun
protection, self examination, and early diagnosis of potential
malignant melanoma, basal cell carcinoma, and squamous cell
carcinoma—common forms of skin cancer.
 Basal cell or squamous cell carcinomas, the most common of
skin cancers, are likely to present in one of the following ways:
as an open sore that bleeds, oozes, or crusts and is present for
more than 3 weeks; as an irritated red patch that may itch or
hurt; as a growth with a rolled border and central indentation; as
a shiny bump or nodule; or as a scarlike area.

 Sudden or continuous enlargement of a lesion; surface changes

such as bleeding, crusting, erosion, oozing, scaling, or
uIteration; changes in the sur­rounding skin such as redness,
swelling, or satellite pigmentation; changes in sensation such as
itching, tenderness, or pain; changes in consistency such as
softening or friability; and the development of a new pigmented
lesion, particularly in clients older than 40 years of age.
BCC AND SCC
PRESSURE SORES

 Physical therapists are vital members of health care

teams when treating clients at risk for skin breakdown,
including clients with periods of immobility, prolonged
pressure on bony prominences, poor nutrition,
incontinence of bowel and/or bladder, lowered mental
alertness, history of pressure sore or open wound, or lack
of sensation.

 Healthy People 2010 defines "persons at risk" as persons

with a disability.
 The Agency for Health Care Policy and Research (AHCPR; now
the Agency for Healthcare Research and Quality) recommended
the Braden Scale and the Norton Scale as appropriate tools for
assessing a patient's risk for pressure ulcers.

 The Braden Scale, presents a risk assessment incorporating six

subscales:
 (1) sensory perception,

 (2) skin moisture,

 (3) activity,

 (4) mobility,

 (5) nutritional status,

 (6) friction and shear factors.

ATTENTION
 Complications such as endocarditis (heart infection),
bone formation in soft tissue ,osteomyelitis (bone
infection), bactcremia (blood infection), fistulas
(abnormal openings between organs), septic arthritis
(infection of inflamed joints), develomement of sinus
tracts or abscess, and systemic complications of topical
treatment, such as iodine toxicity and hearing loss after
topical neomycin and systemic gentamicin, are not
uncommon and can result from poor hygiene and
exposure to infectious agents.
HEALTH EDUCATION FOR SKIN CARE

 keeping nails trimmed, avoiding scratching the skin, and bathing in

nonfragranced warm water, rather than hot water.

 The Lower Extremity Amputation Prevention (LEAP) organization

advo­cates routine and frequent screening of skin for risk factors
associated with diabetes.

 These include prominence of metatarsal heads, dry skin, callus

formation, unable to perceive 10 g force (5.07 Simmes-Weinstein
filament), and finally, decreased thermal and vibration sensation,
which tends to dry the skin.

 Also, avoidance of allergens and skin irritants such as fabric softeners,

perfumed soaps, and household cleansers should be emphasized.
 For those engaged in aquatic activities, bathing is essential
following swimming for removing drying pool chemicals.

 Protection from the sun can be achieved by avoiding peak

sunshine (10:00 am to 4:00 pm) and limiting unnecessary sun
exposure through protective clothing and maintained sunscreen.

 Over-the-counter topical ointments (such as topical steroids)

can be used to manage minor skin irritations and to reduce skin
infections when there is skin injury; however, any client
presenting with chronic skin inflammation, pruritus, or
suspicious skin lesions should be more thoroughly examined by
a dermatologist.
SIDE EFFECTS OF MEDICATIONS
 The most com­mon medications encountered in the
management of many acute conditions include
analgesics, anti-inflammatory agents, and muscle
relaxants.
 Physical therapists should be aware of adverse drug
reactions associated with these medications.
 Cutaneous drug reactions are the most common adverse
responses to drugs, though not the only adverse reaction.
Urticaria (itchy, swollen, red bumps or patches on the skin) is
the most common reaction; however, there are many different
types of drug reactions, and some are life threatening.
 Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can
cause angioedema (swelling beneath the skin) and urticaria.
 NSAIDs can cause common cutaneous reactions, such as
pruritus (itching), nwrbilliform rasli (rash appearing like
measles), urticaria, and photo-sensitivity. Urticaria is most
frequent in salicylate-sensitive patients. Other skin reactions are
unusual, although purpura (bruiselike coloration) and cutaneous
vasculitis (an allergic inflammatory reaction of vessels)