The Integumentary System

• insulation
• sensation
• fuid balance
• temp control
• abdorption of UV
• metabolize vit D

One in four

an overgrowth of blood vessels (strawberry hemangioma), pigment cells (cafe au lait spot), epidermal cells (nevus sebaceus), or connective tissue (collagenoma).

A collection of extra blood vessels.

• gray hair
• balding
• increased facial hair
• dereased elasticity of skin and blood vessels
• wrinkling

loss of elastin fibers, weakened collagen and decreased subcutaneous fat

skin becomes translucent and paper-thin do to diminished stratum corneum (outermost layer of epidermis)

because of weakening of defensive shield

altered calcium metabolism which leads to increased osteoporosis

Use care with modalities (circulation, adipose, meabolism are altered), poor dissipation of heat/cold, change in resistance to electrical current.

• pruitis (itching)
• uricaria (hives often resulting from an allergic response)
• wheals (smooth, elevated patches)
• rash (eruption with itching)
• blisters (fluid containing lesions)
• ichthyosis (excessive dryness)
• Xeroderma (mild dryness, rough, discoloration
• spots that have recently appeared or changed since initial appearance

size, shape, color, pain/tenderness, itching, texture, mobility/turgor, elevation/depression, location (universal, regional, pattern), pattern(ringed, grouped, linear, diffuse), exudate (color, odor, consistency, amount)

occurs in 10% of children in the 1st year of life.

rash that itches, red, oozing, crusty ras (acute), brown-gray skin color (chronic), Xerosis and pruritis caused by a bacterial infection.

hygiene, moisturizing, topical agents (antibiotics, anthihistamine, corticosteroids)

in pattern of contact with allergen, can be chamical, mechanical, physical or biological.

• nickel (jewelry)
• chromates (tanning leathers)
• rubber additives (latex)
• topical antibiotics or anesthetics (neomycin, lidocaine)

very dry, thin skin of lower extremities with shallow ulcers. (history of varicose veins and DTVs. Significant lower extremity edema due to venous insufficiency. tissue necrosis from hypoxic blood supply (ulcers, open sores, weepy skin)

increased venous pressure, slowed microcirculation, margination of white blood cells

distal leg involved with edema and erythema, later hyperpigmentation and sclerosis

alleviate edema, use support hose, topical steroids, emollients. Ambulation with pressure support garments. LE elevation with support garmets

UNNA boot (gauze impregnated with zinc oxide, gelatin, calamine, glycerin) applied distal to proximal in upward spiral and allowed to dry. Left on for average of 3-4 days (up to 7)

chronic disorder of middle aged and of the aging adult (facial) related to acne (large vascular component).

GI disturbances (same bacterium)

cheeks, nose, chin or entire face presents with a rosy appearance. Can be very inflammatory with papules and pustules. Complaint of burning or stinging with flushing.

in the summer (sun, heat, humidity)

topical or systemic

• bacterial
• viral
• fungal
• parasitic

Highly contagious superficial infaction from staphylococci or streptococci

<5 years old or older adults

• small macules develop into small blisters (pu-filled)
• vesicle breaks and forms thick yellow crust. Causes pain, erythema, itching, cellulitis
• scratching spreads infection 

Burow's solution (aluminum acetate in water) and oral antibiotics

skin cancer

inflammation of dermis and subcutaneous tissue spread widely through tissues - often bacterial infection of staphylococci or streptococci

aging adult and those with a decreased immune reaction: diabetes mellitus, malnutrition, steroids, wounds/ulcers, edema and lymph obstruction.

erythema, edema, tender, nodular tissue

intravenous antibiotics, may require debridement

reactivation of the virus that causes chicken pox (varicella zoster)

ages 50-70

• an immunocompromised state (age, malignancy, organ transpant, AIDS)
• virus lies dormant in ganglia of nerves (posterior spinal nerve root or cranial nerve root )

• unilateral distribution of red papules along dermatome usually trunk or cranial nerves
• pain, nuralgia, itching
• papules develop into vesicles withing 5 days. they dry and resolve in 2-4 weeks
• post-herpetic neuralgia in people > age 60 

relief of itching and neuralgic pain. Corticosteroids early may abort the attack. several other drugs slow progression of rash. Isolation room (when in hospital) if you have not had chicken pox or have not been vaccinated you should not come in contact with individuals exhibiting shingles. There is a vaccine available (Zovirax; for use post exposure)

common benign infection of skin and adjacent mucous membranes. Caused by human papilloma viruses.

greater in children and young adults. transmitted by direct contact or autoinoculation

single or multiple lesions with thick white surfaces. Most common type (verruca vulgaris) has rough elevated round surface, mostly seen on extremities.

differentiation from callus/corns - plantar warts are painful, obliterate skin lines, red or black capillary dots. treatment depends on size, number, and type (salicyclic acid, cryotherapy, electrodesiccation with currettage)

Ringworm, ring-shaped pigmented patches covered with vesicles or scales, often itchy. Diagnosed by lab analysis.

• antifungal powder or ointment, keeping skin clean and dry
• oral medication available (griseofulvin). (may see clients for wound care, when skin breakdown accompanies infection)

athlete's foot, presents as erythema, skin peeling, pruritus with severe inflammation,itching, and pain with walking. Located between toes and on sole of foot.

clean, dry socks and well-ventilated, properly fitting footwear. Washing feet and drying thoroughly between toes. antifungal powder or cream.

Highly contagious eruption cuased by mites. Common worldwide problem. female mite burrows into skin, lays eggs that hatch in a few days. Transmitted skin to skin or contact with contaminated objects (linens, brushes)

intesnse pruritis excoriated skin, linear ridges with cesicles at one end (Eggs)

web spaces, flexor aspect of wrist, axillar, waistline, umbilicus, and breasts and genital areas

lotion or new one dose oral medication (stromectol)

Lice, infestation of common parasite in head, body and genital areas. Transmitted through personal items and skin to skin contact.

school children, overcrowded situcations, poor hygiene situations

severe itching, eczematous changes, excoriations from scratching, eggs attached to hair shafts.

Soap or shampoo w/ permethrin or single oral dose of ivermectin

Chronic, systemic inflammatory disease impacting kin, joints, kidneys, heart, blood forming organs, nervous system, and mucous membranes.

• Discoid: limited to the skin
• Systemic: typically more severe 

infections, sulfa/penicillin antibiotics, uv light exposure, extreme stress, pregnancy.

• women are affected 10-15 times more than men, peak incidence between ages 15-40 yrs.
• africans, native americans, and asians more prone to develop the disease. 

survival rate has improved but death can occur from renal failure, cerebral infarct, and cardiovascular failure - secondary to immune complex deposition.

a combination of anti-inflammatory, immunosuppressive, and chemotherapeutic agents. Mild SLE use NSAIDs, corticosteroids, and hydroxychloroquine; topical steroids (prednisone) for the skin rash.

inflammation and fibrosis of many parts of the body

any individuals but more prevalent in women 25-55 years old

• Limited scleroderma
• diffuse scleroderma 

(cutaneous; CREST) generally a more mild form but can be life-threatening with intestine and pulmonary involvement

wide spread skin thickening and visceral organ involvement

NO cure, treatment centers on the individual reflecting the organ system involved. exercise, jt protection, skin protection, stress management.

30%

immunosuppression, DMARDs (penicillamine), antibiotics (tetracyclines), antiinflammatories

Polymyositis and a rash. A purpilish rash on eyelids that can progress to anterior neck, upper chest, back, shoulders, arms

smooth, or scaly red/violet colored inflammation of digits

Idiopathic inflammatory autoimmune diseases of uscle. symmetric proximal muscle weakness. malaise, fatigue and weight loss precedes weakness. cardiac involvement is common. pulmonary muscle weakness also can occur.

Non-contagious chronic, inherited recurrent inflammatory dermatosis. Disorder of keratinocytes and immune response. 

Common in young adults, mean onset = 27 years

well-defined erythematous plaques covered with a silbery scale. scalp , chest, elbows, knees, lower back, buttocks. Pruritis, pain from dry, cracked, encrusted lesions, spreads to fingernails in 30%, psoriatic arthritis occurs in 10%.

stress and cold weather. flare-ups more common in winter

• topical agents (corticosteroids, retinol, oatmeal baths)
• phototherapy (UVB exposure or PUVA combo of sensitizing agent + UVA)
• antimetabolites (coal tar)
• immunosuppressants

Pressure ulcers caused by unrelieved pressure. Ischemia results in skin and underlying tissue damage

over bony prominences such as the sacrum, heel, ischial tuberosity, and greater trochanter

red, brow/black or yellow. Infection is localized. Often painful if sensation is intact.

centers on wound cleansing, removal of necrotic tissue and infection. Will heal if pressure removed and ulver kept moist with occlusive dressing.

Skin remains intact but with observable local changes in temp, texture, color (red, blue, pruple), or sensation (pain/itching). Persistent erythema.

Partial-thickness skin loss. The ulcer involves the epidermis, dermis, or both and is considered a partial-thickness skin loss. It is superficial and may look like an abrasion, blister, or shallow crater.

Full-thickness skin loss. The ulcer forms a deep crater. The adjacent tissue may be involved. There is damage to or necrosis of the subcutaneous tissue, which may extend down to the underlying fascia. The fascia is not affected.

Full-thickness skin loss accompanied by tissue necrosis oor damage to muscle, bone, or supporting structures, such as tendon or joint capsule. There is extensive tissue destruction; sinus tracts my be present.

an injury from exposure or direct contact with thermal, chemical, electrical, or radiation source

depth, percent or total body surface area (rule of 9's), location, age, health and mechanism of injury

wound debridement, minimize hypertrophic scarring, maintain ROM, prevent contractures.

Erythema, mild to severe, skin blanches with pressure

Large, thick-walled blisters over extensive area, edema, mottled red base, broken epidermis, wet weeping, shiny surface, painful

black, white, red, brown, dry surface, fat exposed, edema, tissue disruption, painless/insensate

Skin cancer, the most rapidly increasing form of cancer

UVB exposure, protection during the 1st and 2nd decades significantly decreases the risk

benign, premalignant, and malignant (melanoma and non-melanoma)

Begnign proliferation of basal cells occuring after middle age. Senile warts, multiple lesions on back, chest, and face.

waxy, smooth, or raised. Vary in color: yellow, flesh tones, dark brown/balck. small to large wart like plaques

Left untreated unless itch or pain occurs, then cryotherapy with liquid nitrogen

benign pigmented or non-pigmented lesions that form from aggregations of melanocytes. 

brown, black, or flesh colored. Size and thickness varies, occur singly or in groups.

nevi, particularly those that are irritated. report any changes in size, color, texture and if bleeding or excessive itching occurs.

Precancerous skin disease, results from many years of exposure to UV radiation.

Occurs in chronically sun exposed areas. Affects older caucasian population (face, ears, lowerlip, bald scalp, dorsum of hand)

actinic keratosis

squamous cell carcinoma.

Well-defined, crusty or sanpaper-like patch or bump. Dry and rough. light or dark, tan, pink, red, combo. May itch or have pricking or tender sensation.

not all need to be removed. Topical antimetabolites, cryosurgery, electrodessication, laser resurfacing, chemical peels, photodynamic treatment (topical application followed by blue light)

• Basal cell carcinoma
• Squamous cell carcinoma
• malignant melanoma 

Derived from undifferentiated basal cells of the epidermis. slow growing, surface epithelial tumor.

Causes significant local destruction. Rarely metastasized beyond skin. Does not invade blood or lymph vessels.

Nodular Basal Cell carcinoma

Generally age > 40 fair-skinned males but tanning booths changed that

Pearly or ivory appearance, rolled edges, elevated above skin surface slightly, usually painless, size increase is slow, may ulcerate centrally

65% on head and neck, also on trunk (upper back and chest). If not detected early, may invade deep tissues. Once one occurs, more likely to have others.

Squamous cell carcinoma, caused by sun damaged skin.

Tumor of epidermal keritinocytes (top layer of epidermis)

• in situ
• invasive

rim of eat, face, lips, mouth, dorsum of hand. 80% occur on head or neck.

Fair skinned most often, men > women and average age = 60

a flat reddish area with a crusty surface that doesn't clear up. It may develop into a firm, growing lump that may ulcerate (become an open sore).

presentation varies. Poorly defined margins. Ulcer, flat red area, cutaneous horn, indurated plaque or nodule, may also be crusted. Red - flesh colored, surrounded by scaly tissue.

don't usually metastasize but when they do they metastasize early (to lymph), begin with inflammation and induration. systemic symptoms: pain, malaise, fatigue, weakness, anorexia.

malignant melanoma readily metastatic

from melanocytes (pigment cells). most often on skin but can have in any lined cavity. 

5% of all cancers. 1 in 75 people in their lifetime (1:1500 chance in 1930's)

• 40-60 years
• women > men (but men have greater mortality from tumor)
• lighter skinned
• associated with intensity rather than duration of exposure to UV (present in head and neck in men and legs in women, 70% from preexisting nevus) 

• 1.) superficial spreading
• 2.) nodular melanoma
• 3.) Lentigo malignant melanoma
• 4.) Acral lentiginos melanoma 

• from preexisting mole
• brown or black raised patch with irregular border
• variable pigmentation
• asymptomatic unless advanced (itch, bleeding)

12% of malignant melanomas. Men aged 20-60.

Small, suddenly appearing, quickly enlarging, uniformally and dark pigmented papule, may be grayish, any change in mole needs to be checked, early recognition is key.

because the prognosis of melanoma worsens with the thickness of the lesion, and this variety of melanoma seems to grow in thickness rather than diameter

present 50-80 years of age. less common: 6-10% of melanomas. 1/3 develop into malignant melanoma.

Large, flat freckle, irregular border, varied pigmentation in single lesion - brown, blue, black, red, white.

common in lower pigmented areas, without hair: palms of hands, soles of feet, nail beds, mucous membranes

Flat dark brown portions, raised bumpy areas that are brown- black or blue-black

people with dark skin

5% of cutaneous melanomas

• surgical excision or chemotherapy or radiation (cryo and electrodessication typically not used)
• sprea ds quickly and insidiously and is life-treatening at early stages. Is 100% curable if detected early. Monthly screenings are suggested. Use the ABCD program.

• Asymmetry: one half is not like the other half
• Border: irregular, scalloped or poorly circumscribed
• Color: Varied, changes from one area to another within lesion 
• Diameter: larger than the head of a pencil eraser (6mm)