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Assisting in Dermatology
Chapter 38
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
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Define, spell, and pronounce the terms listed
in the vocabulary.
Apply critical thinking skills in performing
patient assessment and care.
Explain the major functions of the skin.
Diagram the anatomic structures of the skin.
Compare various skin lesions, and give
examples of each.
Describe typical integumentary system
infections.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives
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Differentiate among various inflammatory and
autoimmune integumentary disorders.
Recognize thermal injuries to the skin.
Compare the characteristics of benign and
malignant neoplasms.
Define grading and staging of malignant tumors.
Conduct patient education on the warning signs
of cancer.
Describe skin malignancies and their treatment.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives
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Define the ABCD rule for identifying a
malignant melanoma.
Summarize allergy testing procedures.
Explain dermatologic procedures conducted
in the ambulatory care setting.
Accurately obtain an exudate sample from a
wound for laboratory analysis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
The Skin
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Acts as a barrier to protect vital internal organs
against infection and injury
Helps dissipate heat and regulate body
temperature
Synthesizes vitamin D when exposed to
ultraviolet light
Responds to sensations such as heat, cold,
pain, and pressure
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
5
Anatomy and Physiology
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The skin is made up of three layers:
 Epidermis
• Keratinocytes in basal cell layer
• Melanocytes
 Dermis
• Contains collagen and elastin fibers; blood and lymph
vessels; muscles; hair follicles; sebaceous and sweat
glands
• Resident vs. transient flora
 Subcutaneous
layer—adipose tissue; thins
with aging
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Layers of Skin
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Skin Lesions
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Caused by systemic problem (allergic reaction
or liver disease) or localized response
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The diagnosis of skin lesions is based on:
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color, level of elevation, and texture of the lesion
 presence of pruritus, excoriation, pain, or drainage
 whether the lesion is a primary or secondary growth
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Types of Skin Lesions
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Bacterial Infections
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Impetigo—caused by Streptococcus or
Staphylococcus
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Small vesicles around nose and mouth rupture with
exudate
Spreads by direct contact
From Marks J, Miller J: Lookingbill’s principles of
dermatology, ed 4, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Critical Thinking Application
Mrs. Allio calls the office with concerns about
her family because of exposure to a child in the
neighborhood who was diagnosed with
impetigo. She tells Melissa that her 3-year-old
son woke up this morning with blisters around
his mouth. Dr. Lee prescribes polymyxinbacitracin-neomycin (neosporin) ointment to be
applied three times daily to the affected areas.
What should Melissa tell Mrs. Allio about
preventing the spread of the infection to her
other children?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
11
Bacterial Infections
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Acne vulgaris—disorder of hair follicle and
sebaceous gland unit; comedones
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Treatment—antibacterial creams, Retin-A, oral
tetracycline, Accutane
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
12
Bacterial Infections
From Poller A, Mancini A: Hurwitz
clinical pediatric dermatology: a
textbook of skin disorders in
childhood and adolescence, ed 3,
Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
13
Bacterial Infections
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Furuncles and carbuncles—boil and
collection of boils
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Treatment—antibiotics, antibiotic ung, I&D
Cellulitis—erysipelas—acute infection by
Streptococcus or Staphylococcus
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Originates in a small area and spreads regionally
Treatment to prevent systemic infection; antibiotics,
warm compresses
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
14
Rosacea
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Chronic disease that is seen most frequently in
women between the ages of 30 and 60 years
Inflammation and pustule formation
Originates as a frequent flushing across the
nose, forehead, cheeks, and chin
Treatment:
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topical antibiotics and oral antibiotics such as
tetracycline, erythromycin, or doxycycline
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
15
Rhinophyma
From du Vivier A: Atlas of
clinical dermatology, ed
2, London, 1993, Gower
Medical Publishing.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Fungal Infections
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Micotic infections or dermatophytoses
Treatment—antifungal topical agents
 Lotrimin,
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Nizoral, Spectasole, Mycostatin
Live in dead keratin layer; prefer moist, open
areas
 Tinea
pedis
 Tinea cruris
 Tinea corporis
 Tinea unguium (onychomycosis)
• Treatment—oral Lamisil
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
17
Tinea Corporis
From Callen J, Greer K, Hood A et al: Color atlas of dermatology, ed 2, Philadelphia, 2000, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
18
Viral Infections
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Verrucae (warts)
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Caused by HPV; hyperplasia of epidermis
Herpes simplex (cold sores)
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Caused by HSV-1; painful vesicles; virus dormant in
trigeminal nerve; reoccur from many triggers
Heal in 2 to 3 weeks; treatment with Zovirax or
Denavir
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
19
Viral Infections
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Varicella zoster (shingles)
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Acute inflammation, vesicles following peripheral
dermatome
Chickenpox virus lies dormant in affected dorsal
root ganglia
Treatment: Prednisone, Zovirax, Valtrex, analgesic,
antipruritics
From Callen J, Greer K, Hood A et al: Color atlas of dermatology, ed 2, Philadelphia, 2000, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
20
Vaccines to Prevent Chicken Pox
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Varivax – given to children between ages 12
and 18 months, older children, and adults who
have not had the chicken pox to reduce the risk
and severity of both chicken pox and shingles
Zostavax – varicella-zoster vaccine
recommended for all adults over the age of
60 years whether they have had shingles or
not; does not guarantee protection against
shingles but will reduce the length and severity
of the disease and helps prevent postherpetic
neuralgia
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
21
Parasitic Infections
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Scabies (itch mite)—highly contagious
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Burrow into epidermis; mite can be seen under
microscope
Causes extreme pruritus, excoriation
Therapy—Elimite or Lindane lotion (Kwell) repeated
in 7 to 10 days to kill nits
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
22
Parasitic Infections
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Pediculosis (lice)—highly contagious
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Head, body, or pubic lice; can be seen on hair
follicles
From Callen J, Greer K, Hood A et al: Color atlas of dermatology, ed 2, Philadelphia, 2000, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
CDC Recommendations for Treatment
of Lice
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Apply lice medicine as ordered
After treatment check the hair and use a nit comb to
remove nits and lice every 2–3 days for 2–3 weeks
Retreat in 9–10 days to kill any surviving hatched lice
Steps to avoid reinfestation:
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Machine wash in hot water and dry on high all clothing, bed
linens, and other items worn or used for 2 days before
treatment; dry-clean items that cannot be washed
Soak combs and brushes in hot water
Vacuum floors and furniture
Head lice survive less than 1–2 days; nits die within a
week if they are not on a person
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Critical Thinking Application
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Melissa’s young daughter brought home a
note today warning of a scabies outbreak in
her school. Melissa has a few red marks on
her forearms and the areas are quite itchy.
Dr. Lee does a skin scraping of one of the
areas and views itch mites under the
microscope. How should Melissa and her
family be treated? Should Melissa remain
at work?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Inflammatory Disorders
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Seborrheic dermatitis—dandruff or cradle cap
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Contact dermatitis—acute response from
exposure to an irritant or allergen
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Chronic inflammation of sebaceous glands
Treatment: tar or sulfur shampoos
Seborrheic keratosis—age spots
Erythema, edema, pruritus, vesicles
Wash area ASAP, corticosteroid cream or orally
Eczema (atopic dermatitis)—idiopathic,
associated with allergies
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Vesicular, pruritic, excoriated rash in body creases
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Autoimmune Disorders
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Psoriasis—Chronic disease produces pink
lesions covered with silver scales. Strong
family history. Treatment is palliative—
Soriatane, Neoral, antihistamines, oatmeal
baths.
From Callen J, Greer K, Hood A et al: Color atlas of dermatology, ed 2, Philadelphia, 2000, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
27
Autoimmune Disorders
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Systemic lupus erythematosus (SLE)—Chronic
inflammation of connective tissue. Women nine
times more likely to be affected. Causes changes
in skin (butterfly rash, photosensitivity, arthritis,
damage to kidneys, eyes, heart, and so on).
Cycles through periods of exacerbation and
remission.
Scleroderma—Chronic progressive disease of
blood vessels and connective tissue. Causes
sclerosis of affected areas. Raynaud’s
phenomenon is first sign; poor prognosis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
28
Thermal Injuries
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Burns are classified as:
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superficial (first-degree)—erythema, no blisters
partial-thickness (second-degree)—vesicles, SC
edema, and pain
full-thickness (third-degree)—destroys all dermal
layers and deeper tissues; may be life-threatening
Treatment for minor burn—cleanse site, debride
dead skin, check tetanus status, apply
sulfadiazine cream, give analgesics.
The most important concern in burn treatment is
the prevention of infection.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
29
Classification of Burns
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
30
Patient Education for Burn Care
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Warning signs of infection include fever,
malaise, inflammation, swelling, increased pain,
odor, and drainage from the burn area
Review care of the wound, including gentle
cleansing and covering the wound with an
antibiotic ointment
Consume a high-calorie, high-protein diet to
maintain weight and promote healing
For partial-thickness burns, new skin
development takes 6 weeks, with complete
healing in 6 to 12 months
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Critical Thinking Application
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Thomas Rangoso, a 66-year-old patient, calls
the office to report a burn to his right hand
and forearm. He fell while passing the stove
and burned himself on the hot surface.
Mr. Rangoso tells you the area is very red
and painful with blisters in the center. He
wants to break the blisters and put butter on
the burn. Should Mr. Rangoso be seen by
Dr. Lee, and what should Melissa tell him
about the care of the burn?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Cold Injuries
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Cold injuries are usually less severe than
burns, but prolonged exposure can result in
infection, gangrene, amputation, and, in severe
situations, death.
Frostbite can be either superficial or deep.
Treatment: immersion in warm water; never
rub exposed area; monitor vital signs
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
33
Benign and Malignant Neoplasms
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Benign masses are encapsulated; although they
may grow, they remain within a confining shell.
Malignant tumors invade and take over the
surrounding tissues.
Local invasion of surrounding tissue occurs when
malignant cells break through the basement
membrane that separates epithelial cells from
connective tissue and invade blood and lymph
vessels, which can then carry the malignant cells
throughout the body.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
34
Grading
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Grading and staging describe the extent of
malignant involvement so the physician can
plan appropriate treatment.
Grading is the histologic, or cellular,
classification of the tumor. The more poorly
differentiated the cells from the tumor, the less
they look like normal cells, and the poorer the
prognosis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Staging
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Staging involves using physical examination and
diagnostic tests (such as bone or liver scans) to
determine the degree of tumor spread.
The size and depth of the primary tumor, the
level of lymph node involvement, and the
presence of metastatic spread determine if the
patient has a carcinoma in situ, a tumor that is
localized to the organ of origin, a direct spread
beyond the primary organ, lymph node
metastasis, or a confirmed secondary tumor
growth at a distant metastasis.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
36
Assisting with a Tissue Biopsy
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Assemble supplies
Prepare patient with proper gowning, draping, and
positioning
Confirm there is informed consent
Prepare the site of the biopsy according to office
protocol
Assist the physician as needed, using appropriate
personal protective equipment
Label the sample container and prepare it for
transport to the testing laboratory
Disinfect and sterilize equipment
Sanitize hands and document the procedure
including patient education on biopsy site care
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
37
Warning Signs of Cancer
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The warning signs of cancer
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Change in bowel or bladder habits
 A sore that does not heal
 Unusual bleeding or discharge
 A thickening or a lump in the breast or elsewhere
 Indigestion or difficulty in swallowing
 An obvious change in a wart or mole
 A nagging cough or hoarseness
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Early Detection
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Any of these warning signs should be reported
to the physician immediately.
Early detection and self-examination are
crucial to cancer survival.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
Neoplasms of the Skin
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Basal cell carcinoma is very slow growing;
most frequently seen form of skin cancer
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small, pearly, dome-shaped nodule with small
visible blood vessels called telaniectasis; may also
appear as a persistent sore that does not heal with
a reddish, irritated appearance
Modified from Damjanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Neoplasms of the Skin
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Squamous cell carcinoma—grows rapidly;
tends to metastasize
 Firm,
red nodule with scales; may ulcerate
Modified from Damjanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41
Neoplasms of the Skin
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Malignant melanoma—change in mole;
increased risk with sunburns, congenital nevi,
dysplastic nevi, red hair, fair skin, family history
Courtesy National Cancer Institute, Bethesda, Md.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
42
ABCDE for Melanoma
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The ABCDE rule for early detection of a
malignant melanoma:
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Asymmetry
 Irregular border
 Change in color; variety of colors
 Increase in diameter—size of pencil eraser
 Elevation
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If a mole displays any of these characteristics,
a dermatologist should check it immediately.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
43
Treatment of Skin Cancer
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Surgery, eradicate the tumor with
cryosurgery, electrodesiccation, or
chemotherapeutic agents
Mohs micrographic surgery – removal of
basal and squamous cell carcinomas
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Physician uses a microscope to systematically
trace the cancerous lesion down to its roots and
remove the tumor layer by layer to minimize the
chance of regrowth and decrease scar formation
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
44
National Cancer Institute
Recommendations
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Prevent skin cancer by protecting yourself from the
sun.
Stay out of the midday sun
Protect yourself from UV rays
Use protective clothing and a wide-brimmed hat
when in the sun, and protect eyes with sunglasses
Use a sunscreen that filters both UVB and UVA rays
with a sun protection factor (SPF) of at least 15
Do not use artificial lamps and tanning beds
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
45
Assisting with Dermal Examination
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Diascope – glass plate held against skin to
observe changes from pressure
Palpation used to check for elasticity, turgor,
edema
Terms
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Cyanosis erythema
Leukoderma jaundice
Vitiligo petechiae
Ecchymoses
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
46
Allergy Skin Testing
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Guidelines—stop antihistamines 3 days before; test
sites are anterior forearm and back; label allergen
sites; only performed with physician on site and
emergency medications available; may cause mild
systemic allergic responses
Positive reaction—wheal forms; reaction graded
2 to 4
Scratch test
Intradermal
Patch test—reaction read in 1 to 4 days
RAST—laboratory test; identifies specific allergens
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
47
Guidelines for Skin Testing
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Stop taking antihistamines 3 to 10 days before
testing
Use anterior forearm, upper arm, and back
Specifically label allergen sites, space 11/2 to
2 inches apart
Notify physician immediately of signs of
anaphylaxis; prepare emergency supplies;
perform allergy testing only when the physician is
on-site
Skin testing may cause a mild systemic allergic
response such as rhinitis, wheezing, and
sneezing; patient should contact the physician if
a more severe reaction occurs
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
48
Treatment of Allergies
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Antihistamines—Zyrtec and Allegra or OTCs
Immunotherapy—weekly or bimonthly injections
over a period of years of minute doses of
identified allergens to desensitize the immune
system and develop resistance to allergen
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Administer each allergen in a separate site
 Take extreme care in drawing up accurate dose
 Document amount of each allergen, site; monitor
patient for reaction for 20 to 30 minutes and
document any localized or systemic reaction
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
49
Wound Culture
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Sterile procedure; swab wound; may need more than
one swab unit to obtain exudate from entire wound;
label each container
Ordered if wound inflamed, wound draining, patient
febrile
Aerobic cultures—detect microbes that grow in the
presence of oxygen and are found on superficial
wound surfaces
Anaerobic cultures—detect microbes that require little
or no oxygen; in deeper wounds or areas that have
poor blood supply
Culture results determine correct antibiotic treatment
(C&S)
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50
Procedures for Appearance
Modification
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Chemical peel (chemexfoliation)
Dermabrasion
Laser resurfacing (photothermolysis)
Botox injections
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
51
Patient Education
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Consult the dermatologist you work for and get
approval of skin care products that the office
can recommend to patients.
Educate patients on the dangers of sun
exposure and tanning beds and the warning
signs of cancer.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
52