The Integumentary System
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What are the functions of skin?
- fuid balance
- temp control
- abdorption of UV
- metabolize vit D
How many people who consult a physician have a skin disorder?
One in four
What can cause birthmarks?
an overgrowth of blood vessels (strawberry hemangioma), pigment cells (cafe au lait spot), epidermal cells (nevus sebaceus), or connective tissue (collagenoma).
What are hemangiomas?
A collection of extra blood vessels.
Skin changes associated with aging?
- gray hair
- increased facial hair
- dereased elasticity of skin and blood vessels
What is wrinkling the result of?
loss of elastin fibers, weakened collagen and decreased subcutaneous fat
What happens to the thickness of skin as we age?
skin becomes translucent and paper-thin do to diminished stratum corneum (outermost layer of epidermis)
Why is immunological function decreased in the aging adult?
because of weakening of defensive shield
What does decreased ability to produce vit D through sunlight exposure lead to?
altered calcium metabolism which leads to increased osteoporosis
Therapist implications for aging/fragile skin?
Use care with modalities (circulation, adipose, meabolism are altered), poor dissipation of heat/cold, change in resistance to electrical current.
Signs and symptoms of skin disease?
- 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
how do you document skin lesions?
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)
When does atopic dermatitis occur?
occurs in 10% of children in the 1st year of life.
What is atopic dermatitis?
rash that itches, red, oozing, crusty ras (acute), brown-gray skin color (chronic), Xerosis and pruritis caused by a bacterial infection.
Treatment for atopic dermatitis?
hygiene, moisturizing, topical agents (antibiotics, anthihistamine, corticosteroids)
What is contact dermatitis?
in pattern of contact with allergen, can be chamical, mechanical, physical or biological.
Common causes of contact dermatitis?
- nickel (jewelry)
- chromates (tanning leathers)
- rubber additives (latex)
- topical antibiotics or anesthetics (neomycin, lidocaine)
What is stasis dermatitis?
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)
Stasis dermatitis mechnism?
increased venous pressure, slowed microcirculation, margination of white blood cells
Where does stasis dermatitis present?
distal leg involved with edema and erythema, later hyperpigmentation and sclerosis
Treatment of stasis dermatitis?
alleviate edema, use support hose, topical steroids, emollients. Ambulation with pressure support garments. LE elevation with support garmets
stasis dermatitis wound care?
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)
What is rosacea?
chronic disorder of middle aged and of the aging adult (facial) related to acne (large vascular component).
What is rosacea linked to?
GI disturbances (same bacterium)
Presentation of rosacea?
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.
When is rosacea the worst?
in the summer (sun, heat, humidity)
Treatment of rosacea?
topical or systemic
Four main types of skin infections?
What is Impetigo?
Highly contagious superficial infaction from staphylococci or streptococci
Incidence of impetigo?
<5 years old or older adults
Presentation of impetigo?
- small macules develop into small blisters (pu-filled)
- vesicle breaks and forms thick yellow crust. Causes pain, erythema, itching, cellulitis
- scratching spreads infection
Management of impetigo?
Burow's solution (aluminum acetate in water) and oral antibiotics
what is the #1 fastest growing cancer?
What is celluitis?
inflammation of dermis and subcutaneous tissue spread widely through tissues - often bacterial infection of staphylococci or streptococci
Incidence of cellulitis?
aging adult and those with a decreased immune reaction: diabetes mellitus, malnutrition, steroids, wounds/ulcers, edema and lymph obstruction.
Presentation of cellulitis?
erythema, edema, tender, nodular tissue
Management of cellulitis?
intravenous antibiotics, may require debridement
What is Herpes zoster (shingles)?
reactivation of the virus that causes chicken pox (varicella zoster)
Peak incidence age of herpes zoster?
What is herpes zoster brought on by?
- an immunocompromised state (age, malignancy, organ transpant, AIDS)
- virus lies dormant in ganglia of nerves (posterior spinal nerve root or cranial nerve root )
Clinical presentation of Herpes zoster?
- 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
Management of Herpes zoster?
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)
What are verrucae/warts?
common benign infection of skin and adjacent mucous membranes. Caused by human papilloma viruses.
Incidence of warts?
greater in children and young adults. transmitted by direct contact or autoinoculation
Presentation of warts?
single or multiple lesions with thick white surfaces. Most common type (verruca vulgaris) has rough elevated round surface, mostly seen on extremities.
Medical management of warts?
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)
What is tinea corporis?
Ringworm, ring-shaped pigmented patches covered with vesicles or scales, often itchy. Diagnosed by lab analysis.
Treatment of tinea corporis?
- antifungal powder or ointment, keeping skin clean and dry
- oral medication available (griseofulvin). (may see clients for wound care, when skin breakdown accompanies infection)
What is Tinea pedis?
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.
Treatment of tinea pedis?
clean, dry socks and well-ventilated, properly fitting footwear. Washing feet and drying thoroughly between toes. antifungal powder or cream.
What is scabies?
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)
Presentation of scabies?
intesnse pruritis excoriated skin, linear ridges with cesicles at one end (Eggs)
Locations of scabies?
web spaces, flexor aspect of wrist, axillar, waistline, umbilicus, and breasts and genital areas
Treatment of scabies?
lotion or new one dose oral medication (stromectol)
What is pediculosis?
Lice, infestation of common parasite in head, body and genital areas. Transmitted through personal items and skin to skin contact.
Incidence of Pediculosis?
school children, overcrowded situcations, poor hygiene situations
Manifestation of pediculosis?
severe itching, eczematous changes, excoriations from scratching, eggs attached to hair shafts.
Treatment of pediculosis?
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 vs. systemic lupus?
- Discoid: limited to the skin
- Systemic: typically more severe
Environmental factors that may trigger systemic lupus erythematosus?
infections, sulfa/penicillin antibiotics, uv light exposure, extreme stress, pregnancy.
Demographics of lupus patients?
- 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.
What does drug treatment of lupus include?
a combination of anti-inflammatory, immunosuppressive, and chemotherapeutic agents. Mild SLE use NSAIDs, corticosteroids, and hydroxychloroquine; topical steroids (prednisone) for the skin rash.
What is scleroderma characterized by?
inflammation and fibrosis of many parts of the body
Who does sclerodema typically occur in?
any individuals but more prevalent in women 25-55 years old
What are the two subsets of scleroderma?
- Limited scleroderma
- diffuse scleroderma
What is limited scleroderma?
(cutaneous; CREST) generally a more mild form but can be life-threatening with intestine and pulmonary involvement
What is diffues scleroderma?
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.
What percent of clients with systemic sclerosis die within 5 years?
immunosuppression, DMARDs (penicillamine), antibiotics (tetracyclines), antiinflammatories
what is dermatomyositis?
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
What is polymyositis?
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.
What is psoriasis?
Non-contagious chronic, inherited recurrent inflammatory dermatosis. Disorder of keratinocytes and immune response.
Who is psoriasis common in?
Common in young adults, mean onset = 27 years
Presentation of psoriasis?
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%.
What triggers psoriasis?
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)
What are decubiti?
Pressure ulcers caused by unrelieved pressure. Ischemia results in skin and underlying tissue damage
where do decubiti occur?
over bony prominences such as the sacrum, heel, ischial tuberosity, and greater trochanter
What do decubiti generally look like?
red, brow/black or yellow. Infection is localized. Often painful if sensation is intact.
What is treatment of decubiti?
centers on wound cleansing, removal of necrotic tissue and infection. Will heal if pressure removed and ulver kept moist with occlusive dressing.
Stage one of decubiti formation?
Skin remains intact but with observable local changes in temp, texture, color (red, blue, pruple), or sensation (pain/itching). Persistent erythema.
Stage two of decubiti formation?
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.
Stage three of decubiti formation?
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.
Stage four of decubiti formation?
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.
What is a burn?
an injury from exposure or direct contact with thermal, chemical, electrical, or radiation source
What is the severity of a burn based on?
depth, percent or total body surface area (rule of 9's), location, age, health and mechanism of injury
PTs role in burn management?
wound debridement, minimize hypertrophic scarring, maintain ROM, prevent contractures.
Characteristics of a 1st degree (superficial) burn?
Erythema, mild to severe, skin blanches with pressure
Characteristics of a 2nd degree (partial thickness) burn?
Large, thick-walled blisters over extensive area, edema, mottled red base, broken epidermis, wet weeping, shiny surface, painful
Characteristics of a 3rd degree (full thickness) burn?
black, white, red, brown, dry surface, fat exposed, edema, tissue disruption, painless/insensate
What is the most prevalent form of cancer?
Skin cancer, the most rapidly increasing form of cancer
What causes most types of skin cancer?
UVB exposure, protection during the 1st and 2nd decades significantly decreases the risk
Three broad categories of skin cancer?
benign, premalignant, and malignant (melanoma and non-melanoma)
What is seborrheic keratosis?
Begnign proliferation of basal cells occuring after middle age. Senile warts, multiple lesions on back, chest, and face.
Presentation of seborrheic keratosis?
waxy, smooth, or raised. Vary in color: yellow, flesh tones, dark brown/balck. small to large wart like plaques
Treatment of seborrheic keratosis?
Left untreated unless itch or pain occurs, then cryotherapy with liquid nitrogen
what is nevi?
benign pigmented or non-pigmented lesions that form from aggregations of melanocytes.
Presentation of nevi?
brown, black, or flesh colored. Size and thickness varies, occur singly or in groups.
What do most malignany melanomas arise from?
nevi, particularly those that are irritated. report any changes in size, color, texture and if bleeding or excessive itching occurs.
What is actinic keratosis?
Precancerous skin disease, results from many years of exposure to UV radiation.
Where does actinic keratosis typically occur?
Occurs in chronically sun exposed areas. Affects older caucasian population (face, ears, lowerlip, bald scalp, dorsum of hand)
What do half of current skin cancers start as?
what can Actinic Keratosis be confused with?
squamous cell carcinoma.
Presentation of Actinic Keratosis?
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.
Treatment of Actinic Keratosis?
not all need to be removed. Topical antimetabolites, cryosurgery, electrodessication, laser resurfacing, chemical peels, photodynamic treatment (topical application followed by blue light)
Three types of malignant neoplasms?
- Basal cell carcinoma
- Squamous cell carcinoma
- malignant melanoma
What is basal cell carcinoma derived from?
Derived from undifferentiated basal cells of the epidermis. slow growing, surface epithelial tumor.
What does basal cell carcinoma cause?
Causes significant local destruction. Rarely metastasized beyond skin. Does not invade blood or lymph vessels.
What is the most common malignant tumor in caucasians?
Nodular Basal Cell carcinoma
Incidence of basal cell carcinoma?
Generally age > 40 fair-skinned males but tanning booths changed that
Presentation of basal cell carcinoma?
Pearly or ivory appearance, rolled edges, elevated above skin surface slightly, usually painless, size increase is slow, may ulcerate centrally
Where do most basal cell carcinomas appear?
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.
What is the second most common skin cancer in caucasians?
Squamous cell carcinoma, caused by sun damaged skin.
What is Squamous cell carcinoma?
Tumor of epidermal keritinocytes (top layer of epidermis)
Two types of Squamous cell carcinoma?
What area does Squamous cell carcinoma affect?
rim of eat, face, lips, mouth, dorsum of hand. 80% occur on head or neck.
Incidence of squamous cell carcinoma?
Fair skinned most often, men > women and average age = 60
What does a squamous cell tumor often appear as?
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 of squamous cell carcinoma?
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.
metastasizeation of squamous cell carcinoma?
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.
What is the most serious form of skin cancer?
malignant melanoma readily metastatic
Where do malignant melanoma neoplasms originate from?
from melanocytes (pigment cells). most often on skin but can have in any lined cavity.
What percent of all cancers are malignant melanoma readily metastatic?
5% of all cancers. 1 in 75 people in their lifetime (1:1500 chance in 1930's)
Peak incidence of malignant melanoma?
- 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)
What are the 4 presentations of malignant melanoma?
- 1.) superficial spreading
- 2.) nodular melanoma
- 3.) Lentigo malignant melanoma
- 4.) Acral lentiginos melanoma
What is superficial spreading type of malignant melanoma?
- from preexisting mole
- brown or black raised patch with irregular border
- variable pigmentation
- asymptomatic unless advanced (itch, bleeding)
What is nodular melanoma type of malignant melanoma?
12% of malignant melanomas. Men aged 20-60.
Presentation of nodular melanoma type of malignant melanoma?
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.
Why do patients more often develop metastatic disease with nodular lesions?
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
What is lentigo malignant melanoma?
present 50-80 years of age. less common: 6-10% of melanomas. 1/3 develop into malignant melanoma.
Presentation of lentigo malignant melanoma?
Large, flat freckle, irregular border, varied pigmentation in single lesion - brown, blue, black, red, white.
Where is acral lentiginos melanoma commonly located?
common in lower pigmented areas, without hair: palms of hands, soles of feet, nail beds, mucous membranes
Presentation of acral lentiginos melanoma?
Flat dark brown portions, raised bumpy areas that are brown- black or blue-black
Who is acral lentiginos melanoma most common in?
people with dark skin
What percent of cutaneous melanomas is acral lentiginos melanoma?
5% of cutaneous melanomas
Treatment of malignant melanoma?
- 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.
What are the ABCDs?
- 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)
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