Cutaneous Findings in Systemic Disease

Cutaneous Findings in Systemic Disease Skin Lesions in Renal Disease and Other Entities Elle H. Abel, B.S., R-PAC Function of the Skin • The skin is the largest organ of the body • Functions – Protects the body’s inner structures from micro-organisms, drying, trauma – Regulates Body temperature through evaporation of perspiration for cooling and constricting of superficial blood vessels to conserve heat – Excretes water and electrolytes through perspiration – Sensory perception of touch, pressure, and pain Epidermis • Outer layer of the skin • Made up of many layers, • Protects the underlying layers from drying, trauma, invasion by micro-organisms • Deepest layer of the epidermis constantly produces new cells – Pushed to the surface – Shed – Replaced by new cells Melanin • Cells called melanocytes contain the skin pigment melanin responsible for skin color • Dark skinned people have more melanin than light skinned people • http://www.agen.ufl.edu/~chyn/age2062/lect/lect_19/25_12A.GIF Dermis • Inner layer of skin, lies beneath the epidermis • Contains blood vessels, nerves, lymphatics, and sebaceous and sweat glands • Contains cells that promote wound healing. • Contains major sensory fibers responsible for distinguishing pain, touch, heat and cold • Hair follicles throughout the body (except palms and soles of feet) , more numerous in axillae, scalp and pubic area Sebaceous and Sweat Glands • Sebaceous glands produce an oily substance called sebum that protects the skin from excessive dryness • Sweat glands concentrated in the axillae, forehead, palms of hands and soles of the feet. • Perspiration aids in – excretion of water and electrolytes – temperature regulation • Cooling the skin by evaporation • Conservation of body heat/warmth by constriction of superficial blood vessels Subcutaneous Tissue • The subcutaneous tissue is a layer of adipose (fat) tissue that interfaces with the lower level of the dermis • Subcutaneous tissue insulates and provides shape and contour over the bone structures Psychological, Social, Vocational Impact of Skin Conditions • The skin is a visible organ, vulnerable to injury and irritation and changes in the internal or external environment • Changes in the internal environment may be reflected by presence of external lesions of the skin, signaling underlying disease (ie. Systemic Lupus Erythematosis) • Emotional factors can cause skin eruptions (localized or systemic) • Conditions of the skin have an impact on quality of life, restrict vocational, social, family, leisure, sexual activity Psychosocial Considerations • Skin disorders can produce major psychological impact on the individual experiencing it • Society places great value on clear, healthy skin • Skin disorders may be perceived as contagious or due to lack of cleanliness • Disfiguring skin conditions have a negative effect on selfimage, inter-personal relationships, secondary psychological symptoms including depression, social phobia, paranoia (Psoriasis, Acne) www.healthopedia.com Dermatitis • • Dermatitis is a superficial inflammation of the skin Atopic Dermatitis (Exzema) is a type of dermatitis – redness (erythema) – swelling (edema) – itching (pruritis) • Treatment of atopic dermatitis includes; – avoiding prolonged contact with hot water, – avoid drying soaps, – use moisturizers – Antihistamines, steroid creams (temporarily) and ointments may aid in symptom reduction – Phototherapy, UV light, chemotherapy http://www.thirdage.com/healthgate/Images/si1510.jpg Contact Dermatitis • • • • Localized inflammation Generalized allergic reaction Occurs at site of contact Remove offending agent www.healthopedia.com/ pictures/contact-dermati... Allergic Reactions • Immune Response • Hypersensitivity reaction • Urticaria (Hives) • Local or systemic • Avoid Contact with offending agent http://www.lf2.cuni.cz/Projekty/interna/foto/01 2/pic00011.jpg Psoriasis • Inflammatory Process • Rapidly turning over epidermal cells • Remission • Exacerbation http://www.monpso.net/pso_images/coude_1_big.jpg Treatment of Psoriasis • There is no known cure • Control the condition by suppressing the immunemediated response. • Avoid injury to the skin • Topical steroids, emollients, ultraviolet light, chemotherapy, coal tar derivatives, vitamin D analogs, topical retinoids • Methotrexate, Aceitretin, Cyclosporine may be used in moderate and severe cases Require close monitoring of BP and skin Blood levels for liver function tests, kidney function, blood lipids, bone marrow suppression - Treatment side effects • Atrophy of skin if meds are too strong • Tachyphylaxis- the body becomes immune to the effects of the drug with repeated use • Teratogenic side effects- fetal abnormalities • Irritation of liver, kidney failure, bone marrow suppression • Steroids may cause psychoses, insomnia, GI upset or GI bleed, weight gain, hirsutism, mood swings, fluid retention Infection or Inflammation? • Effective treatment requires that one correctly identify the cause of a skin disorder • Infection with bacterial, fungal, parasitic and viral organisms requires specific treatments Acne • Most commonly encountered skin condition due to interaction of bacteria of the skin, excess oils, hormones • Face, neck and trunk most commonly affected • Adolescence, reaction to a drug (steroid, chemotherapy) • May be disfiguring and disabling • Goal to reduce inflammation and scarring, prevent clogging of hair follicles, prevent infection • Treatment includes topical or systemic medication or dermabrasion http://llorente.com/hyperbaric/EV_IMAGES/ima ges/HR%20after%202%20proteus.jpg, http://www.eyeambeautiful.com/images/bnaacne-b.jpg, http://www.medic8.com/healthguide/articles/acn e.html, library.thinkquest.org/ C004510F/acne.htm Herpes Zoster (Shingles) • Reactivated Chicken Pox (Varicella Zoster) • Weakened immune system, aging, medical conditions causing decreased immune response will increase risk of H. Zoster • Vesicles erupt along a peripheral sensory nerve root causing water filled blisters, itching and pain • Reactivated virus is contagious- persons who have never had chicken pox or been vaccinated should avoid contact • Treatment requires prompt antiviral therapy and symptomatic support with analgesia, oral and topical Skin Lesions Local Systemic Disease http://www.thachers.org/images/Zoster.JPG, www.surviveoutdoors.com/. ../herpes_zoster.asp http://www.neuro24.de/bilder1/zoster.jpg Skin Cancers • Occur more than any other kind of cancer • Basal Cell cancer is highly visible and treated early has high cure rate • Malignant Melanoma originates in melanocytes- more dangerous than Basal cell cancer, spreads rapidly into deeper skin layers and metastasizes to other organs • Treatment of malignant melanoma is surgical removal of the lesion with wide excision • Avoid sun exposure, use protective sunscreens, avoid artificial tanning Basal Cell Cancer Malignant Melanoma http://dermatlas.med.jhmi.edu/derm/IndexD isplay.cfm?ImageID=-382739824 Diagnosis of Skin Lesions • • • • Biopsy Skin Scrapings Cultures Smears for exudate (pus, drainage from a wound) • Patch tests for Allergic reactions • History (pressure sores-decubitus ulcers) Burns • Any tissue injury as a result of direct heat, chemicals, radiation, or electrical current • Treatment and Prognosis depends on severity of the burn, cause or type of burn, depth of burn and amount of body surface area involved Burns http://dermatlas.med.jhmi.edu/derm/ Thermal and Chemical Burns • Most common type of burn caused by fire, hot liquids, direct injury are thermal burns • Chemical burns result from strong acids (sulfuric acid, lye) and extent of injury depends on duration of contact • Radiation Burns from UV light (and sun!), ionizing radiation, large doses of local radiation Electrical Burns • Electric Current or Lightening • May cause local tissue damage, sudden death, cardiac arrest, nerve damage • Despite lack of external signs extensive internal damage may result as current travels through the body damaging nerves, blood vessels, and major organs Burn Severity • Burn Depth • 1st Degree BurnSuperficial, affects only the epidermis Red skin, blisters pose a risk for infection serving as a portal of entry • 2nd Degree Burn- a partial thickness burn affecting dermis and epidermis • 3rd Degree burn- full- thickness burn • 4th Degree Burn extends to underlying subcutaneous fat, muscle or bone Rule of Nines • • • • • • Head 9% Front 18% Back 18% Arm 9% Leg 18% Perineum/groin 1% www.moondragon.org/ health/disorders/burns.html Treatment of Burns • • • • • • Depends on the severity of the burn Depends on associated injuries Debride eschar to avoid infection or sepsis Tubbing, brushing, dressing of skin Application of silver sulfadiazene or other topical med Monitor pain needs, nutritional needs*, daily hygeine Psychosocial issues Identity altered Body image PTSD Anxiety Guilt Hostility and Anger Grafted skin is sensitive Pressure garments are restrictive Diseases of the skin lead to isolation Stress reduction is important Vocational issues • Return to work ability dependent on the vocation, site, and extent of burns • If work related injury guilt and distress between co-workers and injured may exist • Emotional stress could prevent re-entry to work Skin lesions as Signs of Systemic Disease • • • • • • Rashes Nodules Lymph Nodes Tumor or Mass lesion Skin color and skin changes Skin temperature Pressure Sores • Decubitus Ulcers – common in bed ridden patients – common in paraplegic, quadraplegic – any person with prolonged pressure to a site or sensory nerve loss – ARE REVERSIBLE OR AVOIDABLE WITH SKIN CARE PRECAUTIONS Hair, Scalp, Nails • Alopecia – Auto-Immune, thyroid disease – Iatrogenic (chemotherapy, radiation therapy) – Psychiatric Disorders and self-abuse • Hirsutism– Endocrine Conditions – Medications • Nail Disorders Alopecia Trichotillomania http://dermatlas.med.jhmi.edu/derm/index.cfm Renal Disease and Case Study • A 61 year old female has had a nine year history of renal failure requiring dialysis • Kidney biopsy was inconclusive • Several Medical problems co-exist with renal disease (Hypertension, Rheumatoid arthritis, Sjogren Syndrome, COPD requiring oxygen therapy and History of Pulmonary Hemorrhage due to vasculitis) Wegener’s Granulomatosis Diagnosed by lung biopsy and specialized lab tests Kidney Anatomy http://health.allrefer.com/health/renal-cell-carcinoma-kidney-anatomy.html Pics www.nature.com/.../ n4/fig_tab/4810434f1.html http://www.emedicine.com/derm/images/401stasis1.jpg http://www.skina.org/atlas/20dermatitis/images/stasis%20dermati tis03.jpg Silent Invisible Disease • Vague or absent symptoms • Slow progressive onset • May be perceived as anxious or attentionseeking • Unreliable or negative tests Function of the Renal System and Urinary Tract • • • • • Rid the body of by-products of metabolism Bladder is a storage area for urine Maintain homeostasis (internal chemical balance) Regulate water content and electrolytes Excrete Urea, Uric acid, creatinine Secrete Hormones • Vitamin D – regulates calcium production • Erythropoieten– influences red blood cell production • Renin – Influences blood pressure, sodium and potassium balance – Stimulates a hormone (angiotensin) that stimulates the adrenal cortex to secrete aldosterone (affecting Na and K+ balance) Causes of Renal Disease • Infection • Inflammation • Auto-Immune diseases (Systemic Lupus, Wegener’s Granulomatosis, Diabetes) • Adverse Drug Reactions • Trauma or injury • Toxic injury • Cancer, Multiple Myeloma • Idiopathic and Iatrogenic causes Cystitis • A condition where bacteria has entered the sterile environment of the bladder causing infection and inflammation • Symptoms include pain, discomfort with voiding, bloody or sedimentous urine • Risk factors include immobility, use of urinary catheter, structural problems of bladder or urethra Pyelonephritis • Infection of the kidney • Can be a complication of Cystitis or caused by stasis, spread of infection from other parts of the body or obstructions • Symptoms include fever, chills, rigors, flank or abdominal pain, nausea or vomiting • May be acute or chronic • Chronic pyelonephritis can cause renal failure Urinary or Renal Calculi • • • • Kidney stones Nephrolithiasis Urolithiasis Stones cause severe pain and may lead to obstruction and infection • Radiographic intravenous pyelogram (IVP) will show stones and obstruction • Stones severely obstructing the kidneys will cause back up of urine causing pressure on the kidney (Hydronephrosis) Treatments for Stones • Hydration for small stones and supportive measures • Lithotomy • Lithotripsy • Etiology of stones and composition Glomerulonephritis • Symptoms may be mild and undetected or severe causing pain, blood in urine, dark colored urine (tea or amber colored urine) or foamy urine from increased proteins • Glomerulonephritis is an immunologic response to bacteria, viruses or auto-immune mediated • Causes include Streptococcal infections, Lupus, auto-immune diseases Nephrectomy • Trauma, stones, tumors, chronic infections, and symptomatic non-functioning kidneys can be treated by removal of the kidney by nephrectomy • Polycystic kidney Dx (Bright’s Disease) is a hereditary condition of slow progressive kidney disease and renal failure due to cysts on the kidney • ESRD- End stage renal disease Acute Renal Failure • • • • • • Sudden Onset Medical Condition, Surgery Trauma Hypovolemia due to Hemorrhage Severe dehydration, low blood pressure Septicemia, obstruction, nephrotoxins Treatment • Remove /reverse the cause • Prevent damage to the kidney • Supportive measures Chronic Renal Failure (ESRD) • • • • • • Due to Acute renal failure Irreversible damage Glomerulonephritis Polycystic kidney disease Pyelonephritis Idiopathic/Iatrogenic Symptoms and Signs in ESRD • • • • • • Asymptomatic Malnourished due to anorexia Oliguric or anuric Anemia causing dyspnea Impaired sexual function Intellectual impairment Treatment for ESRD Because there is no cure, treatment is directed at control of the disease and maintenance of the work of the kidney • • • • • Peritoneal Dialysis Hemodialysis Kidney Transplant Medications Diet Peritoneal dialysis http://www.merck.com/media/mmhe2/figures/fg143_1.gif Psychosocial issues and Physiologic changes inESRD • • • • • • • Emotional Reaction to ESRD Mourning loss of bodily function Loss of control Feelings of disconnectdness Anger Uncertainty of treatment choices Cognitive changes – impaired judgment, memory loss,difficulty concentrating Lifestyle Issues in ESRD • During the acute phase • After treatment few limitations exist • For ESRD consumers lifestyle changes are profound – stringent dietary restrictions, freedom restricted due to treatment, demanding medical regimen with or without transplant, decreased endurance and physical tolerance, decreased sex drive, depression and mood disorder, insomnia Vocational Issues in ESRD • Depends on severity of kidney disease and – – – – – – vocation previous work history concommitant medical problems treatment requirements cognitive abilities Flexible work schedule Thank You ! • References: – Falvo, Donna Medical and Psychosocial Aspects of Disability 3rd Edition Chapters 13 and 15 – http://dermatlas.med.jhmi.edu/derm/ – Ames, Warwick A. Management of the Major Burn http://www.nda.ox.ac.uk/wfsa/html/u10/u1010p01.htm