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Pediatric Integumentary Disorders

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					_______________________________________Pediatric Integumentary Disorders                                      1


Pediatric Integumentary Disorders
Key Concepts
    •   Like most body systems, the integumentary system isn't mature at birth.
    •   Therefore, it provides a less effective barrier to physical elements or microorganisms during birth
        and infancy than during childhood.
    •   This helps to explain why infants and young children are more prone to infection.
    •   The skin of infants and young children appears smoother than that of adults.
    •   A child's skin has less terminal hair and hasn't been subjected to long-term exposure to
        environmental elements.
    •   Infants have poorly developed subcutaneous fat, predisposing them to hypothermia.
    •   Exocrine sweat glands don't begin to function until the first month of life, which also inhibits the
        infant's ability to control body temperature.
    •   With the onset of adolescence, apocrine glands enlarge and become active.
    •   This activity leads to axillary sweating and characteristic body odor.
    •   The sebaceous glands begin to produce sebum in response to hormone activity, which predisposes
        the adolescent to acne.
    •   Along with the skin glands becoming active, coarse terminal hair grows in the axillae and pubic
        areas of both sexes and on the faces of males.
    •   Skin performs many vital functions. These include:
            - protecting against trauma
            - regulating body temperature
            - serving as an organ of excretion and sensation
            - synthesizing vitamin D in the presence of ultraviolet light.
    •   A child's skin differs from an adult's in two important ways:
            - The child has thinner and more sensitive skin than the adult.
            - Birthmarks in the neonate can result from the sensitivity of the neonate's skin, the
                 incomplete migration of skin cells, or clogged pores.

Diagnostic tests
   • Diascopy
            – a lesion is covered with a microscope slide or piece of clear plastic. The area is observed
                 to determine whether dilated capillaries or extravasated blood is causing the redness of a
                 lesion.

    •   Sidelighting
            – shows minor elevations or depressions in lesions; it also helps determine the
                configuration and degree of eruption.

    •   Subdued lighting
           – another test, highlights the difference between normal skin and circumscribed lesions that
               are hypopigmented or hyperpigmented.

    •   Immunofluorescence
           – identifies immunoglobulins and elastic tissue in detecting skin manifestations of
              immunologically mediated disease.

    •   Gram stains and exudate cultures
           – help identify organisms responsible for underlying infections.
           –

________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                                  2

   •   Patch tests
           – identify contact sensitivity (usually with dermatitis).

   •   Skin biopsy
           – is used to determine the histology of cells. It can be used to diagnose or confirm a
               disorder.
           – Nursing actions
                   • Before the procedure
                          • Explain the procedure to the child and parents.
                          • Make sure that written, informed consent has been obtained.
                   • After the procedure
                          • Tell the parents that the child should avoid wool or rough clothing.
                          • Prevent secondary infections by cutting the child's nails and applying
                              mittens and elbow restraints.
                          • Suggest the child wear light, loose, nonirritating clothing.

Acne Vulgaris
   •   An inflammatory disease of the sebaceous follicles,
   •   acne vulgaris primarily affects adolescents, although lesions can appear as early a age 8.
   •   Although acne strikes boys more often and more severely, it usually occurs in girls I an earlier
       age and tends to last longer, sometimes into adulthood.
   •   The prognosis is good with treatment.

   •   CAUSES
         - Androgen-stimulated sebum production
         - Follicular occlusion
         - No longer attributed to dietary influences (such theories appear to be groundless)
         - Propionibacterium acnes, a normal skin flora

   •   Predisposing factors
          - Androgen stimulation
          - Certain drugs,
                  • including corticosteroids, corticotropin, androgens, iodides, bromides,
                       trimethadione, phenytoin, isoniazid, lithium, and halothane; cobalt irradiation; or
                       total parenteral nutrition
          - Cosmetics
          - Exposure to heavy oils, greases, or tars
          - Heredity
          - Oral contraceptives
                  • (many females experience acne flare-ups during their first few menses after
                       starting or discontinuing oral contraceptives)
          - Trauma or rubbing from tight clothing
          - Unfavorable climate

   •   ASSESSMENT FINDINGS
          - Closed comedo, or whitehead (acne plug not protruding from the follicle and covered by
            the epidermis)
          - Open comedo, or blackhead (acne plug protruding and not covered by the epidermis)
          - Inflammation and characteristic acne pustules, Papules or, in severe forms, acne cysts or
            abscesses (caused by rupture or leakage of an enlarged plug into the dermis)
          - Acne scars from chronic, recurring lesions
________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                                 3


   •   DIAGNOSTIC TEST RESULTS
          – Diagnostic testing isn't necessary. The appearance of characteristic acne lesions,
            especially in an adolescent patient, confirms the presence of acne vulgaris.

   •   NURSING DIAGNOSES
         – Impaired skin integrity
         – Disturbed body image
         – Risk for infection

   •   TREATMENT
          – Exposure to ultraviolet light (but never when a photosensitizing agent, such as tretinoin,
            is being used)

   •   Drug therapy
          – Intralesional corticosteroid injection
          – Oral isotretinoin (Accutane)
                  • limited to those with nodulocystic or recalcitrant acne who don't respond to
                     conventional therapy; contraindicated during pregnancy
          – Systemic therapy:
                  • usually tetracycline (Achromycin) to decrease-bacterial growth;
                  • erythromycin
                  • (tetracycline contraindicated during pregnancy and childhood because it discolors
                     developing teeth)
          – Topical medications:
                  • benzoyl peroxide (Benzac), clindamycin (Cleocin), or erythromycin
                     (Benzamycin) antibacterial agents, alone or in combination with tretinoin
                     (retinoic acid, Retin-A), or a keratolytic
          – • Antiandrogenic agents:
                  • estrogens or spironolactone (Aldactazide)

   •   INTERVENTIONS AND RATIONALES
          – Check the patient's drug history because some medications, such as oral contraceptives,
            may cause acne flareups.
          – Try to identify predisposing factors to determine those that can be eliminated or
            modified.
          – Explain the causes of acne to the patient and family. Make sure that they understand the
            prescribed treatment is more likely to improve acne than a strict diet and fanatic scrub-
            bing with soap and water. Provide written instructions regarding treatment to eliminate
            misconceptions.
          – Instruct the patient receiving tretinoin to apply it at least 30 minutes after washing the
            face and at least 1 hour before bedtime.
                 • Warn against using it around the eyes or lips to prevent damage.
                 • After treatments, the skin should look pink and dry. If it appears red or starts to
                     peel, the preparation may have to be weakened or applied less often.
          – Advise the patient to avoid exposure to sunlight or to use a sunscreen to prevent a photo-
            sensitivity reaction.
          – If the prescribed regimen includes tretinoin and benzoyl peroxide, tell the patient to use
            one preparation in the morning and the other at night to avoid skin irritation.
          – Instruct the patient to take tetracycline on an empty stomach and not to take it with
            antacids or milk because it interacts with their metallic ions and is then poorly absorbed.


________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                               4

           –   Tell the patient who is taking isotretinoin to avoid vitamin A supplements, which can
               worsen adverse effects.
           –   Also discuss how to deal with the dry skin and mucous membranes that usually occur
               during treatment.
           –   Warn the female patient about the severe risk of terato-genesis.
           –   Monitor liver function and lipid levels to avoid toxicity.
           –   Inform the patient that acne takes a long time to clear — possibly even years for complete
               resolution.
           –   Encourage continued local skin care even after acne clears.
           –   Explain the adverse effects of all drugs to promote compliance.
           –   Pay special attention to the patient's perception of his physical appearance, and offer
               emotional support to help the patient cope with the effects of his illness.

   –   Teaching topics
          – Adhering to treatment regimen
          – Avoiding prolonged exposure to sunlight
          – Eliminating misconceptions
          – Eliminating predisposing factors, such as cosmetic use and emotional stress


Contact dermatitis
   •   Contact dermatitis, also known as diaper rash, is a local skin reaction in the areas normally
       covered by a diaper.

   •   CAUSES
         - Body soaps, bubble baths, tight clothes, and wool or rough clothing
         - Clothing dyes or the soaps used to wash diapers
         - Irritation due to acidic urine and stools or the formation of ammonia in the diaper
         - Moist, warm environment contained by a plastic diaper lining

   •   ASSESSMENT FINDINGS
          - Characteristic bright, red, maculopapular rash in the diaper area
          - Irritability because the rash is painful and warm

   •   DIAGNOSTIC TEST RESULTS
          - Diagnostic testing isn't necessary. Diagnosis is based on inspection.

   •   NURSING DIAGNOSES
         - Risk for infection
         - Chronic pain
         - Impaired skin integrity

   •   TREATMENT
          - Cleaning the affected area with mild soap and water
          - Leaving the affected area open to air

   •   Drug therapy
          - Vitamin A and D skin cream or zinc oxide ointment to help the skin heal
          - Antibiotics if secondary infection occurs

   •   INTERVENTIONS AND RATIONALES
________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                                 5

            -   Keep the diaper area clean and dry to maintain skin integrity.
            -   Change the diaper immediately after the child voids or defecates to prevent skin
                breakdown.
            -   Wash the area with mild soap and water to promote healing.
            -   Keep the area open to the air without plastic bed linings, if possible, to promote
                circulation and comfort.
            -   Avoid using commercially prepared diaper wipes on broken skin; the chemicals and
                alcohol in commercially prepared wipes may be irritating.

   •   Teaching topics
          - Preventing diaper rash
          - Administering medication


Head lice
   •   Head lice (pediculosis capitis) is a contagious infestation in which lice eggs (look like white
       flecks) are firmly attached near the base of hair shafts.
   •   The cause of this disorder isn't related to the hygiene of a child or family members; however,
       head lice is easily transmitted among children and family members.

   •   CAUSES
         - Sharing of clothing and combs; close physical contact with peers, for example, in gym
            class (common in schoolage children)

   •   ASSESSMENT FINDINGS
          - Pruritus of the scalp
          - White flecks attached to hair shafts

   •   DIAGNOSTIC TEST RESULTS
          - Examination reveals lice eggs, which look like white flecks, firmly attached near the base
            of hair shafts.

   •   NURSING DIAGNOSES
         - Disturbed body image
         - Impaired skin integrity
         - Social isolation

   •   TREATMENT
          - Removal of lice and eggs using fine-toothed comb

   •   Drug therapy
          - Pyrethrins (RID) or permethrin (Elmite) shampoos; lindane (Kwellada) in resistant cases
          - Preventive drug therapy for other family members and classmates

   •   INTERVENTIONS AND RATIONALES
          - Carefully follow the manufacturer's directions when applying medicated shampoo to
            avoid neurotoxicity.
          - Repeat treatment in 7 to 12 days to ensure that all the eggs have been killed.

   •   Teaching topics

________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                                   6

           -   Washing bed linens, hats, combs, brushes, and anything else that came in contact with the
               hair to prevent reinfestation
           -   Assessing for reinfestation
           -   Refraining from exchanging combs, brushes, headgear, or clothing with other children

Impetigo
   •   Impetigo is a highly contagious superficial infection of the skin, marked by patches of tiny
       blisters that erupt.
   •   It's common in children ages 2 to 5. Infection is spread by direct contact; incubation period is 2 to
       10 days after contact.

   •   CAUSES
         - Group A beta-hemolytic streptococci
         - Staphylococci

   •   ASSESSMENT FINDINGS
          - Commonly seen on the face and extremities but may spread to other parts of the body by
            scratching
          - Macular rash progressing to a papular and vesicular rash, which oozes and forms a moist,
            honey-colored crust
          - Pruritus

   •   DIAGNOSTIC TEST RESULTS
          - Diagnostic testing isn't necessary. Diagnosis is based on inspection.

   •   NURSING DIAGNOSES
         - Bathing or hygiene self-care deficit
         - Impaired skin integrity
         - Risk for infection

   •   TREATMENT
          - Washing area with disinfectant soap

   •   Drug therapy
          - Systemic antibiotics (in severe cases)
          - Topical antibiotic ointment

   •   INTERVENTIONS AND RATIONALES
          - Apply antibiotic ointment to eradicate the infection.
          - Wash the area three times daily with antiseptic soap to promote skin healing.
          - Cover the child's hands, if necessary, to prevent secondary infection; cut the child's nails.
          - Cover the lesions to prevent their spread.

   •   Teaching topics
          - Preventing recurrence


Rashes
   •   A rash is a temporary skin eruption.
   •   Three types of rashes

________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                               7

          – Papular
          – Pustular
          – vesicular
   •   Papular rash
          – may erupt anywhere on the body in various configurations and may be acute or chronic.
          – characterize many cutaneous disorders; they may also result from allergy or infectious,
               neoplastic, or systemic disorders.


           –   Common causes of papular rashes in children
                  • infectious diseases, such as molluscum and scarlet fever; scabies; insect bites;
                    allergies or drug reactions; and miliaria.

   •   Pustular rash
           – made up of crops of pustules that fill with purulent exudate.
           – These lesions vary greatly in size and shape and can be generalized or localized to the
               hair follicles or sweat glands.
           – appear in skin and systemic disorders, with use of certain drugs, and with exposure to
               skin irritants.
           – Disorders that produce pustular rash in children include
                   • varicella,
                   • erythema toxicum neonatorum,
                   • Candidiasis
                   • impetigo.
                   • Pustules typify the inflammatory lesions of acne vulgaris, common in
                        adolescents.

   •   Vesicular rash
          – scattered or linear distribution of vesicles.
          – A vesicular rash may be mild or severe and temporary or permanent.
          – It may result from infection, inflammation, or allergic reactions.
          – Vesicular rashes in children are caused
                   • staphylococcal infections,
                   •  varicella,
                   • hand-foot-mouth disease

   •   ASSESSMENT FINDINGS
          – Papular rash:
                • raised solid lesions with color changes in circumscribed areas
          – Pustular rash:
                • vesicles and bullae that fill with purulent exudate
          – Vesicular rash:
                • small, raised, circumscribed lesions filled with clear fluid

   •   DIAGNOSTIC TEST RESULTS
          – Aspirate from lesions may reveal cause.
          – Patch test may identify cause.

   •   NURSING DIAGNOSES
         – Impaired skin integrity
         – Risk for infection
         – Disturbed body image
________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                               8


   •   TREATMENT
          – Antibacterial, antifungal, or antiviral agent (depending on cause)
          – Antihistamines if the rash is from an allergy

   •   INTERVENTIONS AND RATIONALES
          – Keep the area cool. Heat aggravates most skin rashes and increases pruritus; coolness
            decreases pruritus.
          – Keep the affected area clean and pat it dry to promote healing.
          – Don't apply powder or cornstarch because these agents encourage bacterial growth.
          – Maintain standard precautions to prevent the spread of infection.
          – Keep weeping lesions covered to prevent transmission.

   •   Teaching topics
          – Understanding sanitary techniques
          – Avoiding sharing combs or hats
          – Avoiding scratching


Scabies
   •   Scabies is a parasitic skin disorder that causes severe itching.
   •   Scabies develops when microscopic itch mites enter a child's skin and provoke a sensitivity
       reaction.
   •   Mites can live their entire lives inside human skin, causing chronic infection.
   •   The female mite burrows into the skin to lay her eggs, from which larvae emerge to copulate and
       then reburrow under the skin.
   •   Scabies is transmitted through the skin or through sexual contact.

   •   CAUSES
         – Female mite that burrows into the skin and deposits eggs in areas that are thin and moist

   •   ASSESSMENT FINDINGS
          – Linear black burrows between fingers and toes and in palms, axillae, and groin
          – Severe itching
          –
   •   DIAGNOSTIC TEST RESULTS
          – Drop of mineral oil placed over the burrow, followed by superficial scraping and
            examination of expressed material under a microscope may reveal ova or mite feces.

   •   NURSING DIAGNOSES
         – Disturbed body image
         – Impaired skin integrity
         – Social isolation

   •   TREATMENT
          – Treatment for all members of the family (as well as close contacts of the child)

   •   Drug therapy
          – Application of lindane (Kwellada) lotion or permethrin (Elmite)

   •   INTERVENTIONS AND RATIONALES
          – Wash the area thoroughly with soap and water to promote healing.
________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28
_______________________________________Pediatric Integumentary Disorders                                    9

           –   Teach the child and parents to apply lindane or permethrin from the neck down covering
               the entire body, wait 15 minutes before dressing, and avoid bathing for 8 to 12 hours to
               ensure effectiveness of therapy.
           –   Don't apply lindane cream if skin is raw or inflamed to avoid irritating the skin.
           –   Explain to the child and parents that if skin irritation or an allergic reaction develops, they
               should notify the doctor immediately, stop using the cream, and wash it off thoroughly to
               avoid risk of an anaphylactic reaction.

   •   Teaching topics
          – Understanding that pruritus may persist for several weeks after treatment
          – Practicing proper hygiene measures
          – Changing bed linens, towels, and clothing after bathing and lotion application
          – Understanding the need to treat family members and close contacts because the parasite
              is transmitted by close personal contact and through clothes and linens




________________________________________________________________________                          “And
we know all things work together for good for those who love God, to those who called according to His
purpose.” Romans 8:28