Integumentary Disorders Introduction: Certain disorders occur in children at particular ages due to the growth and development process and the immaturity of the anatomical and physiological aspects of the child’s body. Many of these disorders lend themselves to educating families and the public about treatment and prevent. Skin Differences: Infants: Skin is immature at birth and provides a less effective barrier to physical elements and microorganisms. The skin is thinner and more sensitive. Adolescence: Sebaceous glands become enlarged and active, producing sebum in response to hormones, which predisposes the individual to acne. Assessment: Data collection History of allergies, exposure to any irritants (chemicals, animals, medication, etc.) Exposure to other individuals with similar complaints Observe signs and symptoms o Assess lesions for size, color, shape, distribution, type of lesion (macula, papule, pustule, etc) o Description of how the skin feels- painful or itching. Disorders I. Dermatitis Inflammation of the skin that occurs in response to contact with an allergen or irritant Common Irritants: Soap, fabric softeners, lotions, urine and stool Common Allergens: o Poison ivy, Poison oak o Lanolin o Latex, rubber o Nickel o Fragrances Signs and Symptoms o Erythema o Edema o Pururitus o Vesicles or bullae that rupture, ooze and crust Treatment o Application of a corticosteroid topical agent – remind to continue use for 2-3 weeks after signs of healing o Application of protective barrier ointments o Oatmeal baths, wet dressings o Wash clothes and rinse twice II. Eczema Chronic superficial skin disorder characterized by intense pruritis Etiology: o Activation of T-cell with excessive production of IgE o Tends to occur in children with hereditary allergic tendencies o Have xerosis Signs and Symptoms: o Erythematous patches with vesicles o Pruritus o Exudate and crusts o Drying and scaling o Lichenification (thickening of the skin) Treatment: III. Acne: Etiology and Pathophysiology: Inflammatory disease of the skin involving the sebaceous glands and hair follicles. Contributing factors include: heredity, hormonal influences, and emotional stress. Acne is unrelated to the general cleanliness of the skin. Assessment: Clinical Manifestations: 1. Closed lesions that are slightly palpable, non-erythematous papules commonly called whiteheads. 2. Open lesions called blackheads. Follicles with dilated openings. The black is not dirt, it is a consequence of oxidation of melanin. 3. Inflammed lesions – follicular wall ruptures leaking sebum, and cells into the dermis causing the formation of papules, pustules, nodules and cysts (nodules filled with pus). Diagnosis: 1. Assessment – physical examination Therapeutic Interventions and Nursing Care: Goal to prevent scarring and promote positive self-image. Individualize treatment to gender, age and severity of infection. It takes 4-6 weeks to begin to see improvement, with optimal results in 3-5 months. Medication Therapy o Topical: Benzoyl Peroxide, Tretinoin (RetinA), tetracycline and erythromycin. Topical agents are preferred treatment to systemic antibiotics, however increases in antibiotic resistant bacteria may require use of systemic antibiotics. Benzlyl peroxide and tretinoin should not be used at the same time because may decrease effectiveness of each. o Oral: 1. Antibiotics - Tetracycline, minocycline, erythromycin and clindamycin- used for severe inflammatory acne or resistant to topical medications. 2. Isotretinoin (Accutane)- topical estrogen. Reserved for those with severe inflammatory acne and other treatment has not worked. Side effects include cataracts, cheilitis, dry skin, pruritius, conjunctivitis, nosebleeds and depression. Also a teratogen. Patient Teaching- 1. Do not pick or squeeze! This increases the bacterial count on the surface of the skin and opens lesions to infection that worsens scarring. 2. Remind patients that the treatment will not show improvement until about 4-6 weeks but they must consistently follow the regime set up by the physician. 3. Keep hair clean and off forehead. 4. Females on Isotretinoin should receive counseling on necessity of observing strict contraceptive measures. 5. Emotional support – reinforce positive self-image and self-esteem. IV. Impetigo Etiology and Pathophysiology: Caused by a group A beta-hemolytic strep infection of the skin. Occurs as a secondary infection from another skin lesion. Incubation is 7-10 days after initial contact with the bacteria. This is highly contagious in children 2-5 years of age. Assessment: Begins as a small reddish macular rash commonly seen on face around mouth and nose, may also appear on extremities. Progresses to a papular and vesicular rash that oozes serous fluid Secondary lesions form a moist, thick, honey-colored crust. Causes extreme pruritus of the skin. Diagnosis: 1. Assessment of lesions 2. May do a culture. Be sure to swab under the crusts. Therapeutic Interventions and Nursing Care: Apply moist soaks of Burrow’s solution or warm soapy water to soften lesions, remove crusts, cover to prevent spread through scratching. Trim fingernails Teach thorough hand washing to patient and family members with antimicrobial soap Family should wear gloves when washing and applying ointment. The child should sleep alone and not share towels, combs, eating utensils. Family and community education regarding the transmission, prevention and treatment of impetigo. Include the importance of protecting immuno- compromised individuals. Medication Therapy: - Topical antibiotics TID to lesions after cleansing and removing crusts. Bactroban Baciguent Neosporin - Oral Antibiotics: Cephalexin (Keflex) Erythromycin Dicloxacillin **Be sure child takes all antibiotics. A complication of impetigo and strep infections is glomerulonephritis. Want to prevent this from occurring. V. Candiditis Thrush Etiology and Pathophysiology: Thrush or oral candiditis is caused by an overgrowth of the fungus Candida albicans. Usually acquired through delivery while passing through an infected vagina. Assessment: Clinical Manifestations: 1. White, curd-like plaques on the tongue, gums, and buccal mucosa 2. Distinguished from milk curds by difficulty in removing 3. Difficulty with eating 4. If has candiditis dermatitis – bright red rash in diaper area mainly and may progress to abdomen. Diagnosis: 1. Assessment Therapeutic Interventions and Nursing Care: Medication Therapy 1. Nystatin oral suspension – swab into mucous membranes of mouth every 4 - 6 hours. Treatment should continue for 48 hours after all symptoms have disappeared. Apply after feedings for prolong contact Nursing Care 1. Teach parents to wash pacifer, nipples and bottles 2. Teach good handwashing 3. If mother is breast feeding, breasts will need application of Nystatin. 4. Give small frequent feedings of cool soothing liquids. 5. For the dermatitis – leave area exposed to light and air to reduce the moisture that leads to fungal growth. VI. Tinea Infections Dermatophytosis (Ringworm) Etiology and Pathophysiology: A fungal infection of the stratum corneum, nails and hair (the base of the hair shaft causing hair to break off. Rarely permanent.) Caused by a group of fungi called dermophytes. Tinea Capitis- Ringworm of the scalp/head Transmission: person to person, animal to person, soil to person. (Why do cats have such a bad reputation for spreading ringworm?) Assessment: Clinical Manifestations: Red and scaling of the scalp Circumscribed patches to patchy, gray scaling areas of alopecia. Thick broken hairs close to the scalp Pruritis / itching Generally asymptomatic, but severe, deep inflammatory reaction may appear as boggy, encrusted lesions (kerions). Diagnosis: Potassium hydroxide examination – place hair or scales from lesion on slide with few drops of potassium hydroxide for visualizaton. Therapeutic Interventions and Nursing Care: Medication Therapy - Antifungal- topical on lesions until completely healed (may take 1 to 3 months to heal even with treatment) 1. Oral griseofulvin 2. Lamisil Remove or cleanse items of transmission, clothing, bedding, combs, and animals. Effectiveness of antifungal medication is enhanced by frequent shampoos, clipping hair and keeping fingernails trimmed and hands clean. (It is best if the patient does not scratch the lesions. Why?) The child should not return to school until lesions are dry. VI. Pediculosis Capitis (lice or cooties) Etiology and Pathophysiology: a parasitic skin disorder caused by the louse insect. The lice lay eggs which look like white flecks, attached firmly to the base of a hair shaft. Lice require several meals of human blood each day and will die if they are away from a human host for more than 2 days. Most common among children 3 – 10 years of age. Classroom is thought to be primary source of infection. Assessment: Clinical Manifestations: Itching / pruritis – persistent on the scalp Close examination of the scalp reveals eggs (nits) firmly attached to hair shafts. Eggs that have hatched are white; newly formed nits are brown. Diagnosis: 1. Assessment – identification of louse on scalp / hair. Goal: Focuses on resolution of infection, comfort measures, and teaching Therapeutic Interventions and Nursing Care: Medication Therapy: 1. Pediculocides shampoos such as NIX. 2. Ovicides Kwell (Lindane). – do not use on infants under 2 years of age. *Both of these categories of medications will usually require only one application for cure. Neurotoxicity is a side effect which can occur with misuse of the product. 3. Natural pyrethins RID. May require several applications and still may not be successful. Nursing Care and Patient Teaching: 1. Apply to wet hair to form a lather and rub in for at least recommended time as prescribed. 2. Do not use a cream rinse or combination shampoo / conditioner prior to using the pediculocide. Do not rewash the hair for 1-2 days following treatment. 3. Follow shampooing with a thorough fine-toothed combing to remove any remaining nits. 4. Family/patient teaching regarding the transmission, prevention, and eradication of a lice infestation. (Include when it is approved for the child to return to school or daycare.) 5. Teach that easily transmitted by clothing, towels, bed linens, combs, close contact, and upholstery and how to decrease transmission. Should check household every 2-3 days until all lice and nits are eradicated. Treatment of the environment is essential because lice can live in warm environment and capable of hatching for over a week. 6. Pay close attention to cleansing of hats, caps, bicycle helmets. VII. Scabies: Etiology and Pathophysiology: Caused by the Sarcoptes scabei mite. Females are about 0.3 to 0.4 mm long and 0.23 to 0.35 mm wide. Males are slightly more than half that size. This parasitic skin disorder, (found in the stratum corneum-not living tissue) is caused by the female mite. The mites burrow into the skin depositing eggs and fecal material. Incubation period is 2-6 weeks Assessment: Intense Pruritis which increases at night Red, popular rash Minute grayish-brown threadlike, burrow tracks with a black dot at the end of the burrow. Usually found between the fingers, palms, antecubital spaces, axillae, occasionally on the neck, feet, popliteal areas, and groin. (What do all these areas have in common that makes them a good site for this insect to grow?) Diagnosis: Confirmed by microscopic demonstration from skin scrapings. Therapeutic Interventions and Nursing Care: Medication Therapy: - Topical Scabicide cream, Elimite. Application of scabicide cream: 1. Bathe in tepid water first and dry skin thoroughly. 2. Apply Elimite to the entire body with particular attention to folds, fingernails, etc. It should be left on for a specific number of hours (4 to 14) to kill mite. Best to put on a night. 3. Apply clean clothing. 4. After prescribed hours of treatment, scabicide is removed by bathing. Teaching: 1. How transmitted to prevent spread. Transmitted by clothing, towels, close contact 2. Rash and itch will continue until stratum corneum is replaced (2-3 weeks). 3. All member of the household need to be treated whether or not if they have symptoms. 4. Launder linen and underclothing, wash in hot water and bleach if possible. Dry in hot dryer. 4. Reduce contacts with others until completion of treatment.
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