Download Primary and Secondary Skin Lesions

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Mennonite College of Nursing
At
Illinois State University
Family Nurse Practitioner III 475
Skin Problems
Statistics
 About 4 percent of all physician visits are made to dermatologists (approximately 25
million per year)
 58% females
 32% between ages of 25 and 44, 16% between ages 15 and 24
o This has changed…in 1975-76, patients under 25 years of age accounted for
40% of the visits
 91% of visits were made by white patients
 Visit rate was highest for patients 65 years of age and older (17 visits per 100 persons)
 Major expected sources of payment were “self-payment” (37%) and “Blue Cross/
Blue Shield” (16%)
 Reasons for visits
o Acne/pimples (16.6%)
o Skin rash (11.8%)
o Skin lesion (6.7%)
o Warts (6.0%)
o Discoloration or pigmentation (5.5%)
o Other symptoms referable to skin (4.6%)
o Moles (4.2%)
o Hair/scalp (3.3%)
o Cancer (2.6%)
o Psoriasis (2.4%)
o Eczema and dermatitis (1.8%)
 When medications prescribed, most common were dermatologics (such as steroids)
(55.5%) and antimicrobial agents (16.5%)
 Length of visits
o 1-5 minutes (17.1%)
o 6-10 minutes (37.6%)
o 11-15 minutes (26.5%)
o 16-30 minutes (15.6%)
o 31-60 minutes (2.5%)
o More than 60 minutes (0.1%)
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Primary and Secondary Skin Lesions
Primary Skin Lesions
Definition/Term/
Flat, nonpalpable changes in skin
color with circumscribed borders:
 Macule
Size/Description
Example
< 1 cm
Freckle, petechiae, flat moles (nevi)
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> 1 cm
Vitiligo
< 0.5 cm
Elevated nevi, warts
> 0.5 cm (flat, elevated; may be
formed by clustering of
papules, feels like “thick” skin)
0.5-2 cm (has circumscribed
border; extends deeper into the
dermis layer than a papule)
> 1-2 cm (may not have welldefined borders)
Irregular, transient, superficial
area of edema
Psoriasis, actinic keratosis
< 0.5 cm (filled with serous
fluid)
Herpes simplex, herpes
zoster (shingles), poison ivy
Blisters from second-degree burn,
Pemphigus vulgaris
Acne, impetigo, carbuncle
Patch
Palpable elevated solid masses:
 Papule
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Plaque
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Nodule
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Tumor
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Wheal
Circumscribed elevated area
containing fluid:
 Vesicle
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Bulla
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Pustule
Term
Fissure
Erosion
Ulcer
Scale
Crust
Excoriation
Lichenification
Atrophy
Scar
Keloid
Size varies (filled with pus)
Lipoma
Large lipoma, carcinoma
Insect bite, urticaria (hives)
Secondary Skin Lesions
Description
A crack in the epidermis (as seen with chapped lips)
Superficial loss of epidermis; scarring unlikely; often
accompanies vesicles, bullae, or pustules
Deep erosion through epidermis extending into the dermis;
scarring may result (as with a pressure ulcer)
Accumulation of dead epithelium; usually seen in papules and
plaques (such as the silvery scale seen with psoriasis)
Accumulation of dried serum and debris over a damaged
epidermis; usually seen in vesicles, bullae, and pustules (as
with herpes simplex, herpes zoster)
Linear erosion caused by scratching
Thickened skin caused by chronic rubbing and scratching (as
seen with eczema)
Thinning of the skin (as seen in older adults)
Connective tissue that replaces injured tissue (red/purple in
color at first, later turns white)
Scar tissue that appears hypertrophied from excessive
collagen formation during healing
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Dermatologic concepts
Lotion
 suspension of powder in water (i.e. calamine)
 used in acute and subacute pruritic and inflammatory dermatitides where cooling and drying
are still desirable, but where less evaporative effect is needed compared to that provided by
wet dressings
 should not be used frequently with oozing lesions because residues of the powder can
produce hard, thick concretions that can be abrasive to the skin and can form a shield that
encourages bacterial growth underneath
Gels
 bridge between the largely water, liquid lotions and the largely oil, semisolid ointments
 Despite their viscosity, gels spread nicely, disappear when warmed by the skin, and have a
drying effect
 Avoid gels containing alcohol (it stings!) for acute dermatitis
Liniments
 Essentially lotions with oil added (ex: Phenol)
Creams
 Can be rubbed in so does not show
 Contains water; promotes evaporation
 Good for oozing/crusting
Ointments
 Can be rubbed in
 Occlusive, little water, not good cosmetically
 Contains medication and oil
 Oleagionous ointments, such as petrolatum, contain no water and are greasy (used for dry,
scaly, chronic conditions
Pastes
 Oleaginous ointments that contain a substantial amount of powder
 More viscous
Special Note regarding topical corticosteroids:
Skin penetration and thus potency is enhanced by the vehicle the steroid is in. In decreasing
order of effectiveness are ointments, gels, creams, and lotions.
(For example: Group 1 topical corticosteroid is “ultra high potency” and Group 7 is “low
potency”. Kenalog 0.10% ointment is Group 4, cream is Group 5)
Tips on Topical Corticosteroids
Source: Crosby, J., & Morales, R. (April 15, 2004). A penny pincher’s guide to topical corticosteroids. Consultant.
718-719.
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Prescribe generic products
o The equivalent brand-name products may be more effective, but the increase in
efficacy usually does not justify the added cost
o If your initial choice is not sufficiently effective, change to a higher-strength
generic
For most conditions, use triamcinolone 0.1% as a first-choice agent
o Medium potency available in large sizes as both cream and ointment and one of
the lowest in cost
o For severe cases, it is reasonable to start with a higher strength
Prescribe enough
o Chronic conditions needing long-term treatment require larger quantities. 1-lb jar
is an option!
o For initial trials, however, it may be wise to use a small size
Use ointment preferentially, except on the scalp, on the face, in intertriginous areas, and
on very hairy areas
o An ointment is generally more effective than the cream of equivalent
concentration, but a bit greasy.
o When greasiness is a problem, prescribe ointment for use at bedtime and cream
for daytime use
o Use gels, lotions, or solutions for hairy areas
Don’t use corticosteroids for conditions in which corticosteroids are known to be
ineffective
o These include scabies, tinea, candida infections, herpes, neurotic excoriations, and
dry skin.
o Urticaria, insect bites, and sunburn also frequently respond poorly to
corticosteroids
Don’t use high-potency agents in intertriginous areas, on the face, on the genitals, or
under occlusion.
o This can result in increased skin atrophy or systemic absorption
o Use high-potency agents with caution in children and older patients
Don’t use a high-potency agent for more than 2-3 weeks.
o After this amount of time, give the patient a 2-week break before resuming
treatment
o Limit high-potency agents to a maximum of 50 g/wk for small areas
Application 3 times daily –r less is usually sufficiency.
o Even once-daily application may suffice (e.g., an ointment applied daily at
bedtime)
Instruct patients to apply creams sparingly; they should use quantities that will vanish
when rubbed in lightly
Use pulse doing when treating chronic or resistant conditions with high-potency agents
that are not available in economical large sizes
o Example: Prescribe the high-potency agent for weekend use only and a lowerpotency agent (that is available in larger sizes) for use during the week
Beware of potential for allergy or irritation. Consider stopping treatment for a while if
the condition gets worse or does not respond.
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Geriatric Dermatology
Important for two main reasons:
1. The proportion of the population over age 65 continues to increase
a. Because of this expanding population and environmental changes, conditions such
as skin tumors have greatly expanded in prevalence and burden of disease.
b. Premalignant, malignant, and benign skin tumors occur at a rate of almost 1 in 5
in people older than age 65.
2. Common skin conditions also may be more difficult to diagnose or be more resistant to
treatment in elderly patients because they may be:
a. Institutionalized
b. Malnourished
c. Taking multiple medications
d. Dealing with multiple chronic diseases
e. More susceptible to medication side effects
Skin changes associated with aging
 Thinning of the dermis
o Poor wound healing
o Increased susceptibility to irritant contact dermatitis
o Increased risk of depot of medications in the skin, which are cleared more slowly
(e.g., corticosteroids render the skin more prone to atrophy)
 More prominent vasculature
 Changes in collagen, elastin
o Make the skin less stretchable and more lax
o Increased susceptibility to trauma, with subsequent tearing
Note: Most of the physical features associated with aging (e.g., pigmentary mottling,
leather-like appearance, dermal atrophy) actually are the result of sun exposure and
not intrinsic to aging.
Common Geriatric Skin Conditions
 Common dermatoses
o Dermatophytosis (especially onychomycosis), seborrheic dermatitis, stasis
dermatitis, contact dermatitis, malignant skin tumors, and , particularly xerotic
eczema
 Common benign tumors
o Seborrheic keratosis, acrochordon, cherry hemangiomas, sebaceous hyperplasia,
venous lakes, telangiectasia, epidermal inclusion cysts, milia
 Angular cheilitis
o Occurs as maceration at the oral commissures, as a result of loss of alveolar bone
and teeth, iron or B complex vitamin deficiency or chronic antibiotic use. Candida
may be present in the areas.
o Properly fitting dentures and use of Vytone (combination low-potency steroid and
antiyeast agent) or ketoconazole cream to the affected area twice daily may be helpful.
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Generalized pruritus
o Diagnostic workup of pruritus should be thorough if there is no response to therapy
after 2-3 weeks, because the incidence of underlying systemic disease is higher in
the over 65 age group.
Drug eruptions
o Elderly patients tend to take more/multiple medications.
Common Skin Lesions in Old Age, Their Color and Type
Lesion
Color
*N = Nonmalignant
M = Malignant
P = Premalignant
Actinic keratoses
Yellow, skin colored, or brown
P
Basal cell carcinoma
Skin colored
M
Blue nevus
Blue
N
Cherry hemangiomas
Red
N
Compound nevus (Biopsy if suspicious)
Brown
N
Cysts (inflamed or infected)
Red
N
Dermal nevi
Skin colored
N
Dermatofibroma
Brown
N
Dysplastic nevus
Brown
P
Epidermoid (sebaceous) cyst
Skin colored
N
Erythema nodosum
Red
N
Erythema ab igne
Red
N
Freckles
Brown
N
Hypersensitivity reactions (Erythema,
Red
N
urticaria, erythema multiforme, toxic
epidermal necrolysis, vasculitis
Insect bites
Red
N
Junctional nevus
Brown
N
Kaposi’s sarcoma
Blue, red, or brown
M
Keratoacanthoma
Skin colored
N
Lentigines
Brown
N
Lipomas
Skin colored
N
Melanoma
Brown or multicolored
M
Milia
White
N
Molluscum contagiosum
Skin colored
N
Nodular malignant melanoma
Blue
M
Pityriasis alba
White
N
Postinflammatory hypopigmentation
White
N
Sebaceous hyperplasia
Yellow
N
Seborrheic dermatitis
Red
N
Seborrheic keratoses
Brown or skin colored
N
Skin tags
Skin colored
N
Squamous cell carcinoma
Skin colored
M
Tinea versicolor
White
N
Venous lakes
Bluish-red
N
Vitiligo
White
N
Warts
Skin colored
N
Xanthomas
Yellow
N
Type*
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Benign Dermatoses
 Solar lentigines (“brown spots”)
o Circumscribed, pigmented, nonmalignant macules
o Approximately 0.5 cm in diameter
o Induced by natured or artificial sources of UV radiation
o In rare cases, and over a period of many years, dark brown areas develop into a
melanoma (lentigo-maligna melanoma)…usually larger (3-6 cm) and irregularly
pigmented and shaped.
 If not treated adequately, 50% chance that it will become invasive
malignant melanoma and 10% chance that it will metastasize.
 Sebaceous hyperplasia
o Look like yellow nodules that may have a central pore
o The number of sebaceous glands remains constant as a person ages, but they
increase in size and become more visible, particularly in chronically sun-exposed
skin.
 Paradoxically, sebum production decreases over time, contributing to the
dry skin seen in normally aged as well as photo-aged skin
o Important to distinguish sebaceous hyperplasia from nodular basal cell
cancer
 In contrast to basal cell cancer, the sebaceous gland is not translucent and
does not have telangiectatic blood vessels.
 If in doubt, it is always best to perform a biopsy.
 Milia
o Tiny, 1 mm, white, epidermal cysts frequently seen on sun-damaged skin
o Not malignant
o Can be removed with a comedone or needle extractor for cosmetic reasons
 Acrochordons
o Flesh-colored skin tags
o More commonly seen on the neck and axillae of the elderly, especially the obese
o Always benign (composed of normal skin)
o If irritating or if patient wants them removed for cosmetic reasons, scissors
excision or electrodesiccation can be performed.
 Seborrheic keratosis
o Brown-black, stuck-on lesions resembling barnacles
o Common in the elderly
o Can appear anywhere on the body
 Occur most frequently in the seborrheic areas (e.g., the back, chest, face,
and inframammary areas)
o Hereditary predisposition; not related to sun exposure
o Superficial removal of the lesions can be accomplished by the use of a razor blade
held parallel to the skin surface (all specimens should be submitted for
pathological diagnosis)
 Seborrheic dermatitis
o Often seen in the nursing home population in general and particularly in patients
with Parkinson’s disease
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o Redness and scaling can be observed on the scalp, around the ears and the nose, in
the eyebrows and on the anterior chest
o Treatment with topical ketoconazole (Nizoral) is usually effective
Purpura
o With aging, thinning of the dermis leads to increased fragility of the dermal
capillaries, and blood vessels rupture.
o The resultant extravasation of blood into the surrounding tissue, commonly seen
on the dorsal forearm and hands, is referred to as purpura, or ecchymosis.
o If a skin tear occurs, nonadherent dressings secured with tubular retention
bandages should be used to prevent trauma to the surrounding skin.
Cherry hemangiomas
o Bright red, 1-5 mm papules
o Often increase in number with advancing age
o Most commonly seen on the trunk
o Pathogenesis is unknown; no treatment needed unless for cosmetic reasons
Venous lakes
o Benign venous angiomas
o Occur most often on the lower lips or on the ears of older persons
o Soft, compressible, flat, approximately 4-6 mm in size, bluish red
o Treatment usually unnecessary; however, if the lesion cannot be clinically
differentiated from a melanoma, it should be removed for histological
examination
Pruritus and pruritus with xerosis
o The most common cause of pruritus, a symptom that evokes scratching, is dry
skin or xerosis.
o Common in the elderly
o Skin looks dry, rough, and scaly
o Changes are most pronounced over the anterior legs, extensor aspects of the arms
and forearms, and dorsum of the hands.
o Chronic rubbing and scratching cause thickening of the skin.
o Usually more severe in the winter because low humidity, cold and windy
weather, dry heat, and excessive bathing aggravate the condition.
o Severe cases can result in superinfection and cellulitis.
o Before treatment of the dry skin is begun, it is important to rule out other potential
causes of itching, such as contact allergy, medication or food allergies, scabies,
metabolic diseases, diseases of the liver or pillary ducts, neoplasia, and
psychogenic causes.
o Treatment includes:
 Use of a humidifier
 Bathe less frequently, use warm instead of hot water, use mild
moisturizing soaps only (Aveeno moisturizing soap, Basis, or Dove)
 After bath or shower, the skin should be lightly patted dry and a
moisturized (e.g., hydrophilic ointment, Vaseline, Eucerin, or Moisturel)
applied
 Do not use bath oil since it makes the tub/shower slippery and
hazardous
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If the above does not reduce skin dryness and alleviate the pruritus, LacHydrin 5% (OTC) or prescription strength Lac-Hydrin 12% moisturizers
have been found to be effective.
If the skin is cracking or inflamed, topical corticosteroids may be used.
Bullous Disorders
 Bullous pemphigoid
o A blistering disease characterized by the presence of tense bullae with strawcolored fluid arising from normal or red skin
o Usually first appear on the distal extremities, followed by the groin and axillae;
eventually are generalized and may include mucous membranes
o Result of an autoimmune reaction to the epidermal basement membrane
o May have severe itching
o Diagnosis made by biopsy with routine and direct immunofluorescence.
o Disease is self-limited, but if untreated, may last from a few months to several
years with periodic remissions and exacerbations
o Mortality is low, but patient is uncomfortable
o Treatment: oral corticosteroids (40-60 mg/day) usually effective
 For mild disease, dapsone or tetracycline may be prescribed.
 Allergic contact dermatitis
o Vesicles and bullae occurring in the area of exposure to an allergen (e.g., poison
ivy on the forearm)
o Usually there is a pattern suggestive of external causation such as lines from
wearing a cap, ring, or necklace.
o If widespread, can be effectively treated with high-dose steroids (e.g. 40-60 mg
for 5-10 days)
o When symptoms are less sever, topical corticosteroids and lubrication are
adequate.
 Herpes zoster
o Self-limiting infection caused by the varicella virus
o Typically presents as a grouped band of inflammatory vesicles and bullae, in a
pattern following a dermatome.
o Can occur anywhere in the skin
o Severe pain and a tingling sensation often precede the eruption
o Treatment with acyclovir, etc.—may reduce the incidence of postherpetic
neuralgia
o If the ophthalmic branch of the trigeminal nerve is involved *e.g., lesions on the
tip of the nose), watch for uveitis and corneal ulceration.
Skin Cancer
 Actinic keratoses
o Usually appear as multiple, flat or slightly elevated, rough, scaly macules or
papules on a hyperemic base., 0.2-1.5 cm in diameter
o Occur on the sun-exposed areas of patients who are already genetically
predisposed; hence they are most commonly seen in fair-skinned individuals
o For a limited number of lesions: curettage or application of liquid nitrogen
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o If multiple lesions are present, treatment of choice is fluorouracil cream
 1% to more delicate areas (face)
 2% or 5% cream for less delicate areas (forearms and dorsum of the
hands)
o Approximately 5-10% of actinic keratoses progress to squamous cell carcinoma
(SCC)
 Basal cell carcinomas (BCCs)
o Most common skin cancers (ratio of basal cell to squamous cell is 4:1)
o Most common BCCs are classified as nodular or ulcerative
o Starts as a small papule. While the BCC slowly enlarges, a central depression,
ringed by a pearly or waxy border with overlying telangiectatic vessels, is formed.
o Most often found on sun-exposed areas of the body, especially the face and neck
o Slow growing and rarely metastasize
o Removal by knife/scalpel excision to allow for biopsy
 Squamous cell carcinoma (SCC)
o Clinical appearance varies, but most appear a s solitary, keratotic nodules with
nondistinct borders on an erythematous base
o Can occur anywhere on the skin, including mucous membranes, but are most
commonly found on sun-damaged skin and arise from actinic keratoses
o Can also develop in burn scars, radiation-damaged skin, and chronic wounds such
as ulcers
o Usually slow growing but can, although rarely, metastasize to the regional lymph
nodes.
o Removal by knife/scalpel excision to allow for biopsy
 Malignant melanoma
o Check for ABCDs of melanoma:
 A – Asymmetry of the lesion
 B – Border irregularity
 C – Color variation
 D – Diameter >/= 0.6 cm
 E – Elevation
o An originally flat lesion that becomes elevated should arouse suspicion
o Only 20% of malignant melanomas arise on sun-exposed areas, so it is important
to examine the entire body.
Urticaria
 A common condition characterized by pruritic transient hives or wheals as a result of
vasodilation and subsequent fluid leakage into the dermis; intense itching
 Can occur as a result of circulating antigens (e.g., drugs, inhalants) or, rarely, immune
complexes that result in release of histamine or alterations in the arachidonic pathway
(e.g., NSAIDs). Other causes include physical or environmental exposure, such as in
cold urticaria, which occurs on exposure to rewarming, or in pressure urticaria, which
occurs 3-6 hours after sustained pressure to a body part
 Lesions last less than 24 hours and can occur in any distribution
 The underlying cause is identifiable in < 25-50% of cases
o In some people, stress may precipitate urticaria.
 Acute urticaria = lesions that are present for less than 6 weeks
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Chronic urticaria = lesions that last longer than 6 weeks
Angioedema = involvement of deeper tissues, with predilection for those involving the
mucous membranes, including the larynx and GI tract
o Extensive generalized urticaria may be life-threatening, with involvement of
major organ systems, including cardiovascular collapse.
Treatment
o Discontinue precipitating agents (even long-standing medications may be the
cause)
o Acute urticaria
 Histamine-1 blockers
 Non-sedating preferred: Zyrtec, Claritin, Allegra
 Sedating alternative: Atarax, Chlor-Trimeton, Benadryl, Periactin,
Tavist)
 Histamine-2 blockers may be useful in recalcitrant cases, in addition to the
Histamine-1 blockers: cimetidine 300 mg qid, ranitidine 150 mg bid,
famotidine 20 mg once a day, or nizatidine 150 mg bid
 Prednisone: useful in cases that are unresponsive to antihistamines
 0.5-1.0 mg/kg/day, tapered over 10-15 days
 NOT indicated in the control of chronic urticaria
o Chronic urticaria
 A general screen is indicated for underlying abnormalities, reserving more
specialized tests as symptoms indicate
 General: CBC with diff, sed rate, UA, chem. Profile, liver profile
 Symptom-directed: thyroid tests, complement levels, antinuclear
antibodies, cryoglobulins, stool for O & P, dental or sinus
radiographs, CXR, hepatitis profile
 Use antihistamines for symptoms relief
 For refractory chronic urticaria, consider doxepin 10-100 mg as a single
dose at hs
 Consider an elimination diet.
 In patients with aspirin sensitivity, use a tartrazine-free (a dye used
to color food, drugs, etc.) diet.
 Be suspicious of a particular food that produces symptoms within 2
hours of ingestion.
 May need referral to dermatologist or an allergist
Dermatologic Medication Use in the Elderly
1.
Use lower-strength corticosteroids because of decreased metabolism, decreased
cellular turnover and increased susceptibility to depot effects, with subsequent skin
atrophy.
2.
Use sedating antihistamines with caution, and use lower strengths when possible
(e.g., hydroxyzine 10 mg rather than 25 mg)
3.
Use prednisone with caution because patients may be hypertensive or susceptible to
mild changes in body fluid regulation.
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Diagnosing Common Rashes
See algorithm (distributed in class)
See “Management of Common Skin Diseases” (to be distributed)
Contact dermatitis: Review article “Diagnosis and Management of Contact Dermatitis”
available at http://www.aafp.org/afp/2010/0801/p249.pdf
Atopic dermatitis: Review article “Atopic Dermatitis: An Overview” available at
http://www.aafp.org/afp/2012/0701/p35.pdf
Infections:
Bacterial (cellulitis, MRSA): Review article “Skin and Soft Tissue Infections in
Immunocompetent Patients” available at http://www.aafp.org/afp/2010/0401/p893.pdf
Viral: Review article “Nongenital Herpes Simplex Virus” available at
http://www.aafp.org/afp/2010/1101/p1075.pdf
Fungal: Review article “Diagnosis and Management of Tinea Infections” available at
http://www.aafp.org/afp/2014/1115/p702.pdf
Pigmentation disorders: Review article “Common Pigmentation Disorders” available at
http://www.aafp.org/afp/2009/0115/p109.pdf
Wound Care:
See: “Comparison of Chronic Wound Care Products” (to be distributed)