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IN THE NAME OWNER OF BEAUTY 1 The Integumentary System Instructor: Shahnaz Pouladi Assisstant Proffesor in Nursing of Medical Bushehr University Sciences 2 1394 Three Layers of skin: Epidermis: Stratified squamous epithelium; outer layer is "keratinized" or "cornified" Dermis: Dense irregular connective tissue Hypodermis: Adipose connective tissue (technically not 3 part of system) Epidermis: Avascular. Depends on blood vessels in underlying dermis for its nutrition Cells formed by mitosis in deepest, or basal layer, then get pushed into more superficial layers or "strata" 4 (Epidermis) Stratum Basale = Single row of dividing cells Stratum Spinosum = Three or four layers of cells; Some cell division Stratum Granulosum = Three or four layers of cells; Actively synthesizing protein keratin Stratum Lucidum = One or two layers of dying cells Stratum Corneum = Many layers of flat, dead, scale-like cells full of keratin 5 Primary cell type in epidermis = keratinocytes which produce large amounts of protein keratin Other cell types: Langerhans cells (really macrophages) clean up debris Merkel cells detect touch and pressure; transfer this information to sensory receptors in the dermis Melanocytes produce pigment melanin & transfer it to keratinocytes 6 Dermis: Dense irregular connective tissue Separated from epidermis (stratified squamous epithelium) by basement membrane Highly vascular Highly innervated Two Layers: Papillary layer just below epidermis Reticular layer forms deep 80% 7 Dermis = Dense irregular connective tissue. Thus: Cells = Fibroblasts / Fibrocytes Macrophages Mast cells Lymphocytes etc. Fibers = Collagen (therefore strong, flexible) Elastic (therefore stretchable) Weight gain tears collagen fibers producing striae (stretch marks) 8 Hypoderm (Subcutaneous Tissue) • Primarily is adipose tissue • Provides a cushion 9 Appendages of the skin 10 Appendages of the skin Hair follicles and hair Sweat glands Sebaceous (oil) glands Nails on fingers and toes 11 Hair - Distribuled over all skin except: - palms of hands soles of feet nipples glans of penis & clitoris minor labia Formed in follicles located deep in dermis - Consists of layers of dead, highly keratinized keratinocytes 12 Shaft Root Bulb 13 Each hair is associated with: One or more sebacious (oil) glands An arrector pili muscle A plexus of nerves around the root 14 Hair • • • • • • 15 The rate of growth varies Hair loss Hair growth by sex hormone Different functions of hairs Hair color Hair quantity and distribution Nails 16 Nails: - Tips of fingers and toes - Thick layer of densely packed keratinocytes - Produced by nail matrix at proximal end, hidden under eponychium or cuticle Average growth: 0.5 mm per week 17 18 GLANDS OF THE SKIN 19 Sebaceous (oil) glands: - Branched tubular glands - Duct opens into opening of hair follicle - Secretes sebum, consisting of lipids, proteins, carbohydrates, 20 Sweat Glands - 2 to 3 million - Two types: Merocrine: Distributed over all skin except nipples (Eccrine) Simple coiled glands in dermis Duct leads to sweat pore on surface Secreted watery sweat for cooling Apocrine: Located only in axillary, pubic, anal regions Larger than eccrine glands Duct opens into opening of hair follicle Secretes thicker sweat, high content of proteins and fats. 21 Sweat is usually 99% water with a pH between 4 and 6 Sweat glands produce 500ml of insensible perspiration (no noticable wetness)daily Two specially modified sweat glands: Ceruminous—found in the external ear canal. Secretion combines with sebum and dead epidermal cells to form earwax (keeps eardrum pliable, canal waterproof and has a bactericidal effect) Mammary --milk producing glands found in the female breast (modified apocrine glands) 22 Function of the Skin 23 Functions of the skin • 1. Protection – First line of defense – Keratin: protects body from water loss, barrier for environmental factors (stratum corneum) – Melanin: keeps UV rays from penetrating – Surface film: sweat, oil, etc – Basal layer: composed of collagen(tissue organization and regeneration, selective permeability, physical barrier, bind) 24 Functions of the skin • 2. Sensation – Pressure, touch, temp, pain, etc – Two specialized receptors: • Meissner corpuscle – detects light pressure • Pacinian corpuscle – detects deep pressure 25 Functions of the skin • 3. Fluid balance • The stratum corneum has the capacity to absorb water • Skin damage (burn) • The skin is not completely impermeable to water. (evaporation) 600cc/day 26 Functions of the skin • 4. Body temperature – Body produces heat (metabolism of foods) – Body releases 80% of heat through skin – Three major physical processes for loss of heat [radiation, conduction (evaporation), convection]. – On a hot day the skin releases almost 3000 calories of body heat (enough to boil five gallons of water) – Heat loss is controlled by negative feedback loop – Skin blood flow 27 Functions of the skin • 3. Produces Vitamin D – Uv rays combine with skin to make cholecalciferol – Cholecalciferol is transported to the liver and kidneys where it is changed to vit D – Vitamin D is essential for preventing osteoprosis 28 Functions of the skin • Immune response function • Langerhans cells facilitate the uptake of IgEassociated allergens • Plays a pivotal role in the pathogenesis of atopic dermatitis and other allergic disease 29 Skin and Aging Process 30 Assessment of the Skin 31 Preparation • • • • • • • • 32 Equipment Well-lit Room Comfortable Environment Hand washing Appropriate use of Gloves Privacy/Draping Organized Assessment Explanations PHYSICAL ASSESSMENT 33 Physical Assessment • Inspection – Color – Bleeding – Ecchymosis – Vascularity – Lesions 34 Physical Assessment • Palpation – Moisture – Temperature – Texture – Turgor – Edema 35 • Color – Normal=Uniformed whitish pink or brown – Abnormal • • • • • 36 Cyanosis Jaundice Carotenemia Albinism Vitiligo Cyanosis 37 Jaundice 38 Carotenemia 39 Albinism 40 Vitiligo 41 Physical Assessment • Bleeding, Ecchymosis, Vascularity – Normal=No areas – Abnormal • • • • • 42 Spontaneous Bleeding Petechiae Ecchymosis Venous Star Necrosis Petechiae 43 Ecchymosis 44 Venous Star 45 Necrosis 46 Lesions • Lesions – Normal=No lesions except freckles, birthmarks, nevi (flat moles) – Abnormal • Rashes • Pressure Ulcers • Burns 47 SKIN LESIONS 48 Kind of lesions in dermatology 1- Primary Skin Lesions 2-Secondary Skin Lesions 49 PRIMARY LESIONS 50 macule • Flat, circumscribed skin discoloration that lacks surface elevation or depression • Lesser than 1cm • Vitiligo 51 Patch • Flat, circumscribed skin discoloration, a very large macule • Vitiligo 52 Papule • Elevated, solid lesion <0.5 cm in diameter • B.C.C • Intradermal Nevi 53 Plaque • Elevated, solid”confluence of papule”>0.5 cm in diameter that lacks a deep component • Psoriasis 54 Nodule • Elevated, solid lesion>0.5 cm in diameter, a largerdeeper papule • Lipoma • Rheumatoid nudule 55 Vesicle • Plaque that contains clear fluid ,a blister • Lesser than .5 cm • Herpes simplex • Herpes zoster • Contact dermatitis 56 Bulla • Localized fluid collection>0.5 cm in diameter, a large vesicle • Pemphigus vulgaris • Bullous impetigo 57 Pustule • Vesicle or bulla that contains purulent material • • • • 58 Folliculitis Impetigo Acne Pustular psoriasis Wheal (Hive) • Firm,edematous,plaque that is evanescent and pruritic • Urticaria 59 Cyst • Nodule that contains fluid semisolidmaterial • Sebaceous cyst • Epidermal cysts 60 SECONDARY LESIONS 61 Crust • A collection of cellular debris ,dried serum, and blood • Impetigo • Herpes, eczema 62 Erosion • A partial focal loss of epidermis, heals without scarring • Ruptured vesicles • Scratch marks 63 Scale • Thick stratum corneum that results from hyperproliferation or increased cohesion of keratinocytes • dandruff • Psoriasis • Dry skin 64 Ulcer • A full-thickness, focal loss of dermis, heals with scarring • Bed sore • Syphlis 65 Fissure • Vertical loss of epidermis and dermis with sharply defined walls, crack in skin • Chapped lips or hands 66 Scar • A collection of new connective tissue, may be hypertrophic or atrohic scar • Burn • Acne 67 Atrophy • Thinning of the epidermis, dermis or fat that cause depression in the skin surface • Aged skin 68 Lichenification • Focal area of thickened skin produced by chronic scratching or rubbing • Contact Dermatitis 69 Keloid • Hypertrophied scar tissue, elevated, irregular, • Surgical incision 70 Moisture 71 Moisture • Moisture – Normal=Dry with minimum of Perspiration – Abnormal • Xerosis • Diaphoresis 72 Temperature 73 Temperature • Temperature – Normal= warm; hands & feet slightly cooler – Abnormal • Hypothermia • Hyperthermia 74 Texture 75 Texture • Texture – Normal=smooth, firm – Abnormal • Roughness • Soft 76 Turgor 77 Turgor • Turgor – Normal=when skin is released, it should return to original contour rapidly – Abnormal • Dehydration 78 Edema • Edema – Normal=No edema present – Abnormal • Pitting edema is rated on 4 point scale • 1+ is if the pitting lasts 0 to 15 sec 2+ is if the pitting lasts 16 to 30sec 3+ is if the pitting lasts 31 to 60sec 4+ is if the pitting lasts >60sec 79 ASSESSING THE NAILS 80 81 • Bacterial Nail diseases – Paronychia infections of the nail fold can be caused by bacteria, fungi and some viruses. The proximal and lateral nail folds act as a barrier, or seal, between the nail plate and the surrounding tissue. If a tear or a break occurs in this seal, the bacterium can easily enter. this type of infection is characterized by pain, redness and swelling of the nail folds. People who have their hands in water for extended periods may develop this condition, and it is highly contagious. 82 • Beau's Lines are nails that are characterized by horizontal lines of darkened cells and linear depressions. This disorder may be caused by trauma, illness, malnutrition or any major metabolic condition, chemotherapy or other damaging event, and is the result of any interruption in the protein formation of the nail plate. Seek a physicians diagnosis. • Koilonychia is usually caused through iron deficiency anemia. these nails show raised ridges and are thin and concave. Seek a physicians advice and treatment. 83 84 Onychorrhexis Onychorrhexis • Presence of longitudinal striations or ridges • A sign of advanced age but it can also occur with the following: –Rheumatoid arthritis –Peripheral vascular disease 85 ASSESSING THE HAIR 86 • Color and texture • Distribution (cyclophosphamide) • Hair loss 87 Androgenetic Alopecia - Male 88 Androgenetic Alopecia - Male 89 Androgenetic Alopecia - Female 90 Alopecia Areata 91 SKIN CONSEQUENCES OF SELECTED SYSTEMATIC DISEASE 92 93 Figs 24,25. Legs of two patients with diabetes mellitus. The patient on the left is a teenage girl with insulin dependent diabetes. The patient on the right is an adult onset diabetic. Both have multiple atrophic hyperpigmented macules, so-called diabetic dermopathy. Stasis Dermatitis - Early • Large vessels are damaged • The skin suffers from lack of nutrients • Very dry and fragile 94 Skin Infections • Bacterial infections (around hair follicles) • Fungal infections (areas that remain moist all the time) • Candida infections (around the border of the area) • Dermatophyte infections (around the toenails and feet) 95 Leg and Foot Ulcers • Cause : Change in peripheral nerves in diabetic cases 96 DIAGNOSTIC EVALUATION 97 Diagnostic Evaluation • • • • • • • 98 Skin biopsy Immunoflurescence test Identify the site of an immune reaction Direct Immunoflurescence test Indirect Immunoflurescence test Patch testing Skin scraping Tzanck smear Wood’s light examination Clinical photographs Skin biopsy • Performed to obtain tissue for microscopic examination by scalpel excision or by a skin punch instrument • Biopsy from skin nodules, plaque, blisters for rule out of malignancy 99 Immunofluorescence • Designed to identify the site of an immune reaction • An antigen or antibody with a flurochrome dye combine • Antibodies can be made fluorescent • Direct immunofluorescence • Indirect immunofluorescence 100 Patch testing • For detect of allergy • Apply suspected an allergen to normal skin • Evaluation of patient response 101 Skin Scrapings • Tissue sample are scraped from fungal lesions n • Examine microscopically • Infestations such as scabies 102 Tzank Smear • A test used to examine cells from blistering skin conditions • Evaluate microscopically 103 Wood’s Light Examination • Wood’s light is a special lamp that produces long-wave ultraviolet rays, which result in a characteristic dark purple fluorescence • It is possible to differentiate epidermal from dermal lesions and hypopigmented and hyperpigmented from normal skin • Light is not harmful to skin or eyes • Lesions that contain melanin be disappeared under ultraviolet light • Lesions that are devoid of melanin increases in whiteness under ultraviolet light 104 Clinical Photographs • For detecting of the nature and extend of the skin condition and progress or improvement resulting from treatment • Used if the characteristics of the mole are changing 105 Hidradenitis Suppurativa • H.S is a chronic suppurative folliculitis of the perineal, axillary, and genital area or under the bereasts • The cause is unknown but have a genetic basis • Pathophysiology: • Abnormal blockage of the sweat glands • Management • Hot compress and oral antibiotic • Isotretinoin or acitretin drugs • Incision and drainage 106 Hidradenitis suppurativa Pacient č. 1 107 ISOTRETINOIN, ATB, PREDNISON Hidradenitis suppurativa Pacient č. 1 108 Hidradenitis suppurativa Pacient č. 2 109 ATB, ISOTRETINOIN, PREDNISON Hidradenitis suppurativa Pacient č. 2 110 PO CHIRURGICKÉ LÉČBĚ Hidradenitis suppurativa Pacient č. 3 111 ATB, ISOTRETINOIN, PREDNISON Hidradenitis suppurativa Pacient č. 3 112 PO CHIRURGICKÉ LÉČBĚ VPRAVO Hidradenitis suppurativa Pacient č. 3 113 PO CHIRURGICKÉ LÉČBĚ VPRAVO Hidradenitis suppurativa Pacient č. 3 114 BEZ CHIRURGICKÉ LÉČBY VLEVO Hidradenitis suppurativa Pacient č. 3 115 BEZ CHIRURGICKÉ LÉČBY VLEVO SEBORRHEIC DERMATOSIS 116 Seborrheic Dermatosis • • • • - Seborrhea is excessive production of sebum Exist in areas where sebaceous glands Is a chronic inflammatory of the skin Clinical manifestations: Two forms: oily form and dry form Oily form: moist or greasy, patches of yellow, with or without scaling, slight erythema - Forehead, nasolabial fold, scalp, axillae, groin, breasts, 117 Seborrheic Dermatosis • Dry form: - Flaky desquamation of the scalp with a profuse amount of fine, powdery scales (dandruf) - Medical management: - Corticosteroid cream (glaucoma and cataract) - In this disease develop secondary candida infection - Treatment of dandruff: frequent shampooing (containing selenium sulfide suspension, zinc pyrithione, salicylic acid, sulfur compounds) - Nursing management: - Avoid external irritant, exessive heat, perspiration, rubbing 118 Seborrheic Dermatosis 119 Acne Vulgaris • • • • • • • 120 A.V is a common disorder affecting susceptible hair follicles Face, neck, upper trunk 85% adolescents experience it Affects 12-35 year olds Pathophysiology: During puberty, androgens stimulate the sebaceous glands C/M Close and open comedones (impacted of lipids, oils, keratin) A.V is seen as erythematous papules, inflammatory pustule, inflammatory cyst Acne Vulgaris • • • • • • • • 121 M/M Goal: Reduce bacterial colonies Decrease sebaceous gland activity Prevent of plugged Reduce inflammation Combat secondary infection Minimize scarring Acne Vulgaris • • • • • 122 1) Nutrition and Hygiene Therapy Diet is not believed to play a major role Good nutrition for increase of immune system Washing of face two/day Oil free cosmetic and cream Acne Vulgaris • Pharmacologic therapy • 2) Topical Therapy: • Salicylic acid or benzoyl peroxide are effective in removing of plugs (some persons are sensitive) • Use once daily and cause redness and scaling • Benzoyl erythromycin • Benzoyl sulfur • Vitamin A acid (tretinoin) • Avoid of sun •123 Topical antibiotics Acne Vulgaris • Pharmacologic therapy • 3) Systemic Therapy • Oral antibiotics (tetracycline family contraindicate) • Synthetic vitamin A compound(retinoid) such as isotretinoin that reduce sebaceous gland size (side effect: cheilitis, dry and chafed skin) • Isotretinoin is toratogen • Estrogen therapy for female 124 Acne Vulgaris • • • • 4) Surgical Management Comedo extraction Injection of corticosteroid in lesions Incision and drainage of nodular cystic leasions • Cryosurgery(freezing with liquid nitrogen) • Abrasive therapy (dermabrasion) 125 126 BACTERIAL SKIN INFECTIONS 127 Bacterial Skin Infections • Impetigo • Impetigo is a superfatial infection of the skin caused by staph., strep. • Bullous impetigo • The exposed areas of the skin involved • Is contagious • In all ages is seen but in children with poor hygiene is common • Follows pediculosis capitis, scabies, herpes simplex, insect bites, poison ivy, eczema 128 Bacterial Skin Infections • Impetigo (cont.) • C/M • Red macules • Thin-walled vesicles • Crust • M/M • • • • • • 129 Systemic antibiotic therapy Non bullous impetigo: benzathin penicillin, oral penicillin, Bullous impetigo: penecillinase resistant penicillin (cloxacillin, dicloxacillin Topical antibiotic therapy Mupirocin (in small area) several times daily/week Lesion must soaked before topical antibiotic Impetigo 130 Folliculitis, Furuncles, Carbuncles • Folliculitis is an infection of bacterial or fungal origin that arises within the hair follicles • Lesions may be superficial or deep • Single or multiple papules or pustules appear close to the hair folicle • Beard area in men and women’s leg • Usually caused by staph. • Pseudofolliculitis barbae (shaving bumps) 131 Folliculitis 132 Furuncle • An acute inflammation arising deep in one or more hair follicle and spreading into the surrounding dermis • Furunculosis is multiple or recurrent lesions • Occur anywhere and more in pressure area • Start as a small, red, raised, painful pimple after a few days convert to furuncle (center become yellow or black) 133 Furuncle 134 Carbuncle • An abscess of the skin and subcutaneous tissue that represents an extension of a furuncle that has invaded several follicles and is large and deep seated. • Usually caused by a staph • Appear most commonly in thick skin and inelastic • Result fever, pain, leukocytosis • More likely in pt. with underlying systemic disease (diabetes, hematologic malignancy, in person that use immune suppressive drugs) 135 Carbuncle 136 Medical management • • • • • • 137 Not to rupture protective wall of leasons The boil or pimple should never be squeezed Systematic antibiotic therapy: Oral cloxacillin and dicloxacillin Cephalosporin and erythromycin When the pus has localized small, incision and drainage induced VIRAL INFECTIONS 138 Herpes Zoster • Commonly known as “shingles” • Reactivation of latent VZV in dorsal root or cranial nerve ganglion cells • 10% of patients are > 50 & 50% of patients are > 85 years old • Lesions appear over several days, usually resolve in 1-3 weeks • Disease more severe/longer duration in immunocompromised patients 139 Herpes Zoster • Severe HZ can be first sign of HIV of underlying malignancy (often Hodgkin’s disease) • Average adult has one episode over lifetime • Patients with multiple episodes over a short period of time indicate further investigation 140 HZ – clinical manifestation • Lesions often preceded by pruritis, tenderness and pain and/or neurologic changes • This pain often confused with Sciatica, renal/urinary stones, cholecystitis (gallbladder disease,) and pleural/cardiac disease 141 HZ – clinical manifestation • Lesions appear posteriorly, the progress in anterior direction • Presents as grouped papules, vesicles, pustules and crusts on erythematous base • Lesions spontaneously heal in 1-2 weeks 142 HZ – clinical manifestation • 50% of cases involve thoracic nerves • 15-20% cervical or lumbar nerves • Remainder involve sacral and cranial nerve roots 143 HZ – clinical manifestation • Be wary of lesions presenting on nasal tip as this defines involvement of nasociliary branch of ophthalmic division of trigeminal nerve (CN V1) • ~33% of cases of ophthalmic zoster involve CN V1 • Ophthalmic Zoster can be extremely destructive to eyeball apparatus • Zoster with nasal tip involvement indicates immediate referral to ophthalmology for further investigation! • May need IV antivirals 144 HZ - Diagnosis • Usually a clinical diagnosis based on characteristic prodromal symptoms and appearance • Usually do viral culture for VZV • Can also do skin biopsy for histopathology, Tzanck smear, Antibody studies, etc. 145 HZ - Treatment • Immunization ~80% effective (Zostavax) • Anti viral agents: - Acyclovir (zovirax) -Valacyclovir (valtrex) - Famciclovir (famvir) • Systemic corticostroid for pt.>50 years • Triamcinolone injection under painful area as anti inflammation 146 PHN – Post Herpetic Neuralgia • Syndrome defined by pain and/or other neurologic symptoms • Can last months to years beyond the illness itself 147 Herpes Zoster 148 Herpes Simplex Virus (HSV) • Two Strains of HSV: HSV 1 and HSV 2 • HSV 1 generally face/lips and HSV 2 generally genitals/anal area. • Virus doesn’t follow any rules: HSV 1 can appear on genital and HSV 2 can appear on face 149 Herpes Simplex Virus (HSV) • On lips, also known as herpes labialis, cold sore or “fever blister” • On fingers, called herpetic whitlow • On wrestlers and other athletes, called herpes gladiatorum • Inside mouth, called herpes gingivostomatitis • Remember, can occur anywhere! 150 Herpes Simplex Virus (HSV) • HSV is a recurrent disease, which after initial exposure and infection, ascends peripheral sensory nerves to the nerve ganglion, where it then resides in a latent fashion • Virus contagious skin-to-skin contact or exposure to fluid from active blisters. 151 HSV – Clinical Presentation • +/- malaise, fever, fatigue, headache • burning/tingling • 12-24 hours later, erythematous macules/patches appear, soon followed by rapid development of painful, yellow, fluid-filled vesicles • Vesicles rupture 24-48 hours later leaving painful, crusted ulcerations and erosions. 152 HSV – Clinical Presentation • Can present as pruritic red macules and patches, or red papules mimicking acne vulgaris. • Majority of patients with HSV are asymptomatic carriers • Trigger factors for eruption: Physical/emotional stress, sunburn, trauma, fever, menstruation 153 Complications • Eczema herpeticum (managed with oral IV acyclovir) • Herpetic whitlow • Intra uterine neonatal infection 154 HSV - Diagnosis • Often a clinical diagnosis • Viral Culture for HSV 1/HSV 2 • Tzanck Smear 155 HSV – Treatment • Topicals: Acyclovir 5% ointment, Penciclovir 1% cream • Oral meds: Acyclovir, valcyclovir (valtrex), famciclovir (famvir) • For severe, disseminated infections: IV acyclovir, foscarnet 156 Herpes Simplex Virus (HSV) 157 FUNGAL SKIN INFECTIONS 158 Fungal Skin Infections • • • • In some cases affect only the skin and its appendages In other cases internal organs are involved Secondary infection appear with bacteria or candida The most common fungal skin infection is tinea that is called ringworm • Tinea infections affect the head, body, groin, feet, nails • For diagnosis the scales are dropped onto a slide and added potassium hydroxide • Wood’s light be helpful 159 Parasitic skin infections • • • • Pediculosis (lice) and Scabies (itch mite) Pediculosis Affects all ages Three varieties of lice: – Pediculus humanus capitis – Pediculus humanus corporis – Phthirus pubis – Feeding of human blood – Causes itching 160 Pediculus humanus capitis • Eggs close the scalp • The young lice hatch in about 10 days and reach maturity in 2 weeks • Transmitted direct or indirect 161 Pediculus corporis and pubis • An infestation of the body • Appear in unwashed people or who live in close sites • Pediculosis pubis is more common 162 Clinical manifestation • Head lice are found most in back of the head and behind the ears • The eggs look like silvery , oval bodies • Cause intense pruritus and lead to bacterial infections such as impetigo and frunculosis • Body lice lives in seams of cloths • Pubic lice may coexist with STD such as gonorrhea, herpes,or syphilis 163 Medical Management • Washing the hair with shampoo lindane or pyrethrin compounds with piperonyl butoxide • Comb hair with a fine-toothed comb dipped in vinegar • All articles should wish in hot water • The room should be vacuumed frequently • All family members have to treat • Complication such as sever pruritus, pyoderma, dermatitis treated with antipruritics, systemic antibiotics, topical corticosteroids 164 SCABIES • An infestation of the skin by the itch mite sarcoptes scabiei • Appear In who with substandard hygieine • + or – with sexual activity • Involve the fingers and hand contact may produce infection 165 Clinical Manifestation • • • • • Appear symptoms after 4 weeks Pt. complain of sever itching Ask from of the pt. about site of sever itching Use of magnifying glass and penlight Other site: elbows, knees, the edge of the feet, the point of the elbows, around the nipples, axillary fold, under breasts, the groin or gluteal fold, penis or scrotum • One classic sign is itching at night • Secondary lesions appear such as vesicle, papule, excoriation, crust 166 Assessment and Diagnostic Findings • Confirm with Sarcoptes. scabiei or the mite’s hyproducts from the skin • M/M • Instruction for take a warm, soapy shower and after dry and cooling of the skin prescribe of scabicides • Prescription of scabicide such as: lindane, crotamiton, or 5% permetrin from the neck down for 12 to 24 hours • One application may be enough 167 Scabies 168 CONTACT DERMATITIS 169 Contac Dermatitis • An inflammatory reaction of the skin to physical, chemical, or biologic agents • Common causes of irritant dermatitis are soap, detergents, scouring compounds, industrial chemicals • C/M • Pruritis, burning, erythema, edema, papules, vesicles, oozing, secondary bacterial infections • M/M • Soap is not used until healing • Cool, wet dressing • Corticosteroid 170 NONINFECTIOUS INFLAMMATORY DERMATOSIS 171 Psoriasis • The most common skin disease • 2% of population • A chronic disease stem from a hereditary defect that cause overproduction of keratin • Most common in 15-35 years • Pathophysiology - Immunologic basis • Trigger factors - Emotional stress, trauma, infections, seasonal and hormonal changes - The cell in the basal layer of the skin divide too quickly and 172 the normal events of cell maturation and growth cannot occur Psoriasis • C/M • Red lesions with raised patches of skin covered with silvery scales that are pruritic • Involve the nails in one half of the pt. with pitting, discoloration, beneath the free edges, and separation of the nail plate • Bilateral symmetry of lesions • Most in scalp, elbow, knee, back, genitalia, nail • Arthritis 173 Psoriasis • Assessment and diagnostic finding - Presence of the classic plaque-type lesions - Sign of nail and scalp - Skin biopsy has little diagnostic value 174 Psoriasis • - 175 M/M Control of stress Pharmacologic therapy: Topical agents: topical corticosteroids and covering skin with occlusive dressing, nonsteroidal treatments are calcipotriene ( a synthetic derivative of calcitriol or vitamin D) and tazarotene ( topical retinoid) Systemic agents: Infliximab (a monoclonal antibody against tumour necrosis factor alpha (TNF-α) used to treat autoimmune diseases) Etanercept (a TNF inhibitor) Efalizumb ( monoclonal antibody) Alefacept ( immunosuppressive drug) Adalimumab (the third TNF inhibitor) M/M in Psoriasis - Oral agents: methotrexate, cyclosporine A (an immunosuppressant drug )oral retinoids (Etretinate) - Photochemotherapy: photosensitizing oral medication with exposure to ultraviolet-A light (PUVA). - Photosensitizing medication (8methoxypsoralen) - Phototherapy in the ultraviolet-B (UVB) 176 Psoriasis 177 BLISTERING DISEASE 178 Pemphigus • Pemphigus is a group of serious disease of the skin characterized by the appearance of bullae. • An autoimmune disease involving IgG • A blister forms from the antigen-antibody • Highest incidence in Jewish or Mediterranean • Associated with penicillins and captopril and myasthenia gravis • C/M • Oral lesions that are painful, bleed easily and oozing, Nikolsky’s sign • Complications : secondary bacterial infection, fluid and electrolyte imbalance, hypoalbuminemia 179 Pemphigus • M/M • Goals : prevent loss of serum and the development of secondary infection and to promote reepithelization • Corticosteroid priscription • Immunosuppressive agents : azathioprine, cyclophosphamide, gold • plasmapheresis 180 Pemphigus 181