Mennonite College of Nursing

Illinois State University

Family Nurse Practitioner III 475

Skin Problems

Statistics

· About 4 percent of all physician visits are made to dermatologists (approximately 25 million per year)

· 58% females

· 32% between ages of 25 and 44, 16% between ages 15 and 24

o This has changed…in 1975-76, patients under 25 years of age accounted for 40% of the visits

· 91% of visits were made by white patients

· Visit rate was highest for patients 65 years of age and older (17 visits per 100 persons)

· Major expected sources of payment were “self-payment” (37%) and “Blue Cross/Blue Shield” (16%)

· Reasons for visits

o Acne/pimples (16.6%)

o Skin rash (11.8%)

o Skin lesion (6.7%)

o Warts (6.0%)

o Discoloration or pigmentation (5.5%)

o Other symptoms referable to skin (4.6%)

o Moles (4.2%)

o Hair/scalp (3.3%)

o Cancer (2.6%)

o Psoriasis (2.4%)

o Eczema and dermatitis (1.8%)

· When medications prescribed, most common were dermatologics (such as steroids) (55.5%) and antimicrobial agents (16.5%)

· Length of visits

o 1-5 minutes (17.1%)

o 6-10 minutes (37.6%)

o 11-15 minutes (26.5%)

o 16-30 minutes (15.6%)

o 31-60 minutes (2.5%)

o More than 60 minutes (0.1%)

Primary and Secondary Skin Lesions

Primary Skin Lesions
Definition/Term/		Size/Description	Example
Flat, nonpalpable changes in skin color with circumscribed borders:
· Macule		< 1 cm	Freckle, petechiae, flat moles (nevi)
· Patch		> 1 cm	Vitiligo
Palpable elevated solid masses:
· Papule		< 0.5 cm	Elevated nevi, warts
· Plaque		> 0.5 cm (flat, elevated; may be formed by clustering of papules, feels like “thick” skin)	Psoriasis, actinic keratosis
· Nodule		0.5-2 cm (has circumscribed border; extends deeper into the dermis layer than a papule)	Lipoma
· Tumor		> 1-2 cm (may not have well- defined borders)	Large lipoma, carcinoma
· Wheal		Irregular, transient, superficial area of edema	Insect bite, urticaria (hives)
Circumscribed elevated area containing fluid:
· Vesicle		< 0.5 cm (filled with serous fluid)	Herpes simplex, herpes zoster (shingles), poison ivy
· Bulla			Blisters from second-degree burn, Pemphigus vulgaris
· Pustule		Size varies (filled with pus)	Acne, impetigo, carbuncle
Secondary Skin Lesions
Term	Description
Fissure	A crack in the epidermis (as seen with chapped lips)
Erosion	Superficial loss of epidermis; scarring unlikely; often accompanies vesicles, bullae, or pustules
Ulcer	Deep erosion through epidermis extending into the dermis; scarring may result (as with a pressure ulcer)
Scale	Accumulation of dead epithelium; usually seen in papules and plaques (such as the silvery scale seen with psoriasis)
Crust	Accumulation of dried serum and debris over a damaged epidermis; usually seen in vesicles, bullae, and pustules (as with herpes simplex, herpes zoster)
Excoriation	Linear erosion caused by scratching
Lichenification	Thickened skin caused by chronic rubbing and scratching (as seen with eczema)
Atrophy	Thinning of the skin (as seen in older adults)
Scar	Connective tissue that replaces injured tissue (red/purple in color at first, later turns white)
Keloid	Scar tissue that appears hypertrophied from excessive collagen formation during healing

Dermatologic concepts

Lotion

· suspension of powder in water (i.e. calamine)

· used in acute and subacute pruritic and inflammatory dermatitides where cooling and drying are still desirable, but where less evaporative effect is needed compared to that provided by wet dressings

· should not be used frequently with oozing lesions because residues of the powder can produce hard, thick concretions that can be abrasive to the skin and can form a shield that encourages bacterial growth underneath

Gels

· bridge between the largely water, liquid lotions and the largely oil, semisolid ointments

· Despite their viscosity, gels spread nicely, disappear when warmed by the skin, and have a drying effect

· Avoid gels containing alcohol (it stings!) for acute dermatitis

Liniments

· Essentially lotions with oil added (ex: Phenol)

Creams

· Can be rubbed in so does not show

· Contains water; promotes evaporation

· Good for oozing/crusting

Ointments

· Can be rubbed in

· Occlusive, little water, not good cosmetically

· Contains medication and oil

· Oleagionous ointments, such as petrolatum, contain no water and are greasy (used for dry, scaly, chronic conditions

Pastes

· Oleaginous ointments that contain a substantial amount of powder

· More viscous

Special Note regarding topical corticosteroids:

Skin penetration and thus potency is enhanced by the vehicle the steroid is in. In decreasing order of effectiveness are ointments, gels, creams, and lotions.

(For example: Group 1 topical corticosteroid is “ultra high potency” and Group 7 is “low potency”. Kenalog 0.10% ointment is Group 4, cream is Group 5)

Geriatric Dermatology

Important for two main reasons:

The proportion of the population over age 65 continues to increase

Because of this expanding population and environmental changes, conditions such as skin tumors have greatly expanded in prevalence and burden of disease.
Premalignant, malignant, and benign skin tumors occur at a rate of almost 1 in 5 in people older than age 65.

Common skin conditions also may be more difficult to diagnose or be more resistant to treatment in elderly patients because they may be:

Institutionalized
Malnourished
Taking multiple medications
Dealing with multiple chronic diseases
More susceptible to medication side effects

Skin changes associated with aging

Thinning of the dermis

Poor wound healing
Increased susceptibility to irritant contact dermatitis
Increased risk of depot of medications in the skin, which are cleared more slowly (e.g., corticosteroids render the skin more prone to atrophy)

More prominent vasculature
Changes in collagen, elastin

Make the skin less stretchable and more lax
Increased susceptibility to trauma, with subsequent tearing

Note: Most of the physical features associated with aging (e.g., pigmentary mottling, leather-like appearance, dermal atrophy) actually are the result of sun exposure and not intrinsic to aging.

Common Geriatric Skin Conditions

· Common dermatoses

o Dermatophytosis (especially onychomycosis), seborrheic dermatitis, stasis dermatitis, contact dermatitis, malignant skin tumors, and , particularly xerotic eczema

· Common benign tumors

o Seborrheic keratosis, acrochordon, cherry hemangiomas, sebaceous hyperplasia, venous lakes, telangiectasia, epidermal inclusion cysts, milia

· Angular cheilitis

o Occurs as maceration at the oral commissures, as a result of loss of alveolar bone and teeth, iron or B complex vitamin deficiency or chronic antibiotic use. Candida may be present in the areas.

o Properly fitting dentures and use of Vytone (combination low-potency steroid and antiyeast agent) or ketoconazole cream to the affected area twice daily may be helpful.

· Generalized pruritus

o Diagnostic workup of pruritus should be thorough if there is no response to therapy after 2-3 weeks, because the incidence of underlying systemic disease is higher in the over 65 age group.

· Drug eruptions

o Elderly patients tend to take more/multiple medications.

Common Skin Lesions in Old Age, Their Color and Type

Lesion	Color	Type
Actinic keratoses	Yellow, skin colored, or brown	P
Basal cell carcinoma	Skin colored	M
Blue nevus	Blue	N
Cherry hemangiomas	Red	N
Compound nevus (Biopsy if suspicious)	Brown	N
Cysts (inflamed or infected)	Red	N
Dermal nevi	Skin colored	N
Dermatofibroma	Brown	N
Dysplastic nevus	Brown	P
Epidermoid (sebaceous) cyst	Skin colored	N
Erythema nodosum	Red	N
Erythema ab igne	Red	N
Freckles	Brown	N
Hypersensitivity reactions	Red	N
Erythema	Red	N
Urticaria	Red	N
Erythema multiforme	Red	N
Toxic epidermal necrolysis	Red	N
Vasculitis	Red	N
Insect bites	Red	N
Junctional nevus	Brown	N
Kaposi’s sarcoma	Blue, red, or brown	M
Keratoacanthoma	Skin colored	N
Lentigines	Brown	N
Lipomas	Skin colored	N
Melanoma	Brown or multicolored	M
Milia	White	N
Molluscum contagiosum	Skin colored	N
Nodular malignant melanoma	Blue	M
Pityriasis alba	White	N
Postinflammatory hypopigmentation	White	N
Sebaceous hyperplasia	Yellow	N
Seborrheic dermatitis	Red	N
Seborrheic keratoses	Brown or skin colored	N
Skin tags	Skin colored	N
Squamous cell carcinoma	Skin colored	M
Tinea versicolor	White	N
Venous lakes	Bluish-red	N
Vitiligo	White	N
Warts	Skin colored	N
Xanthomas	Yellow	N

N = Nonmalignant M = Malignant P = Premalignant

Benign Dermatoses

Solar lentigines (“brown spots”)

Circumscribed, pigmented, nonmalignant macules
Approximately 0.5 cm in diameter
Induced by natured or artificial sources of UV radiation
In rare cases, and over a period of many years, dark brown areas develop into a melanoma (lentigo-maligna melanoma)…usually larger (3-6 cm) and irregularly pigmented and shaped.

If not treated adequately, 50% chance that it will become invasive malignant melanoma and 10% chance that it will metastasize.

Sebaceous hyperplasia

Look like yellow nodules that may have a central pore
The number of sebaceous glands remains constant as a person ages, but they increase in size and become more visible, particularly in chronically sun-exposed skin.

Paradoxically, sebum production decreases over time, contributing to the dry skin seen in normally aged as well as photo-aged skin

Important to distinguish sebaceous hyperplasia from nodular basal cell cancer

In contrast to basal cell cancer, the sebaceous gland is not translucent and does not have telangiectatic blood vessels.
If in doubt, it is always best to perform a biopsy.

Milia

Tiny, 1 mm, white, epidermal cysts frequently seen on sun-damaged skin
Not malignant
Can be removed with a comedone or needle extractor for cosmetic reasons

Acrochordons

Flesh-colored skin tags
More commonly seen on the neck and axillae of the elderly, especially the obese
Always benign (composed of normal skin)
If irritating or if patient wants them removed for cosmetic reasons, scissors excision or electrodesiccation can be performed.

Seborrheic keratosis

Brown-black, stuck-on lesions resembling barnacles
Common in the elderly
Can appear anywhere on the body

Occur most frequently in the seborrheic areas (e.g., the back, chest, face, and inframammary areas)

Hereditary predisposition; not related to sun exposure
Superficial removal of the lesions can be accomplished by the use of a razor blade held parallel to the skin surface (all specimens should be submitted for pathological diagnosis)

Seborrheic dermatitis

Often seen in the nursing home population in general and particularly in patients with Parkinson’s disease
Redness and scaling can be observed on the scalp, around the ears and the nose, in the eyebrows and on the anterior chest
Treatment with topical ketoconazole (Nizoral) is usually effective

Purpura

With aging, thinning of the dermis leads to increased fragility of the dermal capillaries, and blood vessels rupture.
The resultant extravasation of blood into the surrounding tissue, commonly seen on the dorsal forearm and hands, is referred to as purpura, or ecchymosis.
If a skin tear occurs, nonadherent dressings secured with tubular retention bandages should be used to prevent trauma to the surrounding skin.

Cherry hemangiomas

Bright red, 1-5 mm papules
Often increase in number with advancing age
Most commonly seen on the trunk
Pathogenesis is unknown; no treatment needed unless for cosmetic reasons

Venous lakes

Benign venous angiomas
Occur most often on the lower lips or on the ears of older persons
Soft, compressible, flat, approximately 4-6 mm in size, bluish red
Treatment usually unnecessary; however, if the lesion cannot be clinically differentiated from a melanoma, it should be removed for histological examination

Pruritus and pruritus with xerosis

The most common cause of pruritus, a symptom that evokes scratching, is dry skin or xerosis.
Common in the elderly
Skin looks dry, rough, and scaly
Changes are most pronounced over the anterior legs, extensor aspects of the arms and forearms, and dorsum of the hands.
Chronic rubbing and scratching cause thickening of the skin.
Usually more severe in the winter because low humidity, cold and windy weather, dry heat, and excessive bathing aggravate the condition.
Severe cases can result in superinfection and cellulitis.
Before treatment of the dry skin is begun, it is important to rule out other potential causes of itching, such as contact allergy, medication or food allergies, scabies, metabolic diseases, diseases of the liver or pillary ducts, neoplasia, and psychogenic causes.
Treatment includes:

Use of a humidifier
Bathe less frequently, use warm instead of hot water, use mild moisturizing soaps only (Aveeno moisturizing soap, Basis, or Dove)
After bath or shower, the skin should be lightly patted dry and a moisturized (e.g., hydrophilic ointment, Vaseline, Eucerin, or Moisturel) applied

Do not use bath oil since it makes the tub/shower slippery and hazardous

If the above does not reduce skin dryness and alleviate the pruritus, Lac-Hydrin 5% (OTC) or prescription strength Lac-Hydrin 12% moisturizers have been found to be effective.
If the skin is cracking or inflamed, topical corticosteroids may be used.

Bullous Disorders

Bullous pemphigoid

A blistering disease characterized by the presence of tense bullae with straw-colored fluid arising from normal or red skin
Usually first appear on the distal extremities, followed by the groin and axillae; eventually are generalized and may include mucous membranes
Result of an autoimmune reaction to the epidermal basement membrane
May have severe itching
Diagnosis made by biopsy with routine and direct immunofluorescence.
Disease is self-limited, but if untreated, may last from a few months to several years with periodic remissions and exacerbations
Mortality is low, but patient is uncomfortable
Treatment: oral corticosteroids (40-60 mg/day) usually effective

For mild disease, dapsone or tetracycline may be prescribed.

Allergic contact dermatitis

Vesicles and bullae occurring in the area of exposure to an allergen (e.g., poison ivy on the forearm)
Usually there is a pattern suggestive of external causation such as lines from wearing a cap, ring, or necklace.
If widespread, can be effectively treated with high-dose steroids (e.g. 40-60 mg for 5-10 days)
When symptoms are less sever, topical corticosteroids and lubrication are adequate.

Herpes zoster

Self-limiting infection caused by the varicella virus
Typically presents as a grouped band of inflammatory vesicles and bullae, in a pattern following a dermatome.
Can occur anywhere in the skin
Severe pain and a tingling sensation often precede the eruption
Treatment with acyclovir, etc.—may reduce the incidence of postherpetic neuralgia
If the ophthalmic branch of the trigeminal nerve is involved *e.g., lesions on the tip of the nose), watch for uveitis and corneal ulceration.

Skin Cancer

Actinic keratoses

Usually appear as multiple, flat or slightly elevated, rough, scaly macules or papules on a hyperemic base., 0.2-1.5 cm in diameter
Occur on the sun-exposed areas of patients who are already genetically predisposed; hence they are most commonly seen in fair-skinned individuals
For a limited number of lesions: curettage or application of liquid nitrogen
If multiple lesions are present, treatment of choice is fluorouracil cream

1% to more delicate areas (face)
2% or 5% cream for less delicate areas (forearms and dorsum of the hands)

Approximately 5-10% of actinic keratoses progress to squamous cell carcinoma (SCC)

Basal cell carcinomas (BCCs)

Most common skin cancers (ratio of basal cell to squamous cell is 4:1)
Most common BCCs are classified as nodular or ulcerative
Starts as a small papule. While the BCC slowly enlarges, a central depression, ringed by a pearly or waxy border with overlying telangiectatic vessels, is formed.
Most often found on sun-exposed areas of the body, especially the face and neck
Slow growing and rarely metastasize
Removal by knife/scalpel excision to allow for biopsy

Squamous cell carcinoma (SCC)

Clinical appearance varies, but most appear a s solitary, keratotic nodules with nondistinct borders on an erythematous base
Can occur anywhere on the skin, including mucous membranes, but are most commonly found on sun-damaged skin and arise from actinic keratoses
Can also develop in burn scars, radiation-damaged skin, and chronic wounds such as ulcers
Usually slow growing but can, although rarely, metastasize to the regional lymph nodes.
Removal by knife/scalpel excision to allow for biopsy

Malignant melanoma

Check for ABCDs of melanoma:

A – Asymmetry of the lesion
B – Border irregularity
C – Color variation
D – Diameter >/= 0.6 cm
E – Elevation

An originally flat lesion that becomes elevated should arouse suspicion
Only 20% of malignant melanomas arise on sun-exposed areas, so it is important to examine the entire body.

Urticaria

A common condition characterized by pruritic transient hives or wheals as a result of vasodilation and subsequent fluid leakage into the dermis; intense itching
Can occur as a result of circulating antigens (e.g., drugs, inhalants) or, rarely, immune complexes that result in release of histamine or alterations in the arachidonic pathway (e.g., NSAIDs). Other causes include physical or environmental exposure, such as in cold urticaria, which occurs on exposure to rewarming, or in pressure urticaria, which occurs 3-6 hours after sustained pressure to a body part
Lesions last less than 24 hours and can occur in any distribution
The underlying cause is identifiable in < 25-50% of cases

In some people, stress may precipitate urticaria.

Acute urticaria = lesions that are present for less than 6 weeks
Chronic urticaria = lesions that last longer than 6 weeks
Angioedema = involvement of deeper tissues, with predilection for those involving the mucous membranes, including the larynx and GI tract

Extensive generalized urticaria may be life-threatening, with involvement of major organ systems, including cardiovascular collapse.

Treatment

Discontinue precipitating agents (even long-standing medications may be the cause)
Acute urticaria

Histamine-1 blockers

Non-sedating preferred: Zyrtec, Claritin, Allegra
Sedating alternative: Atarax, Chlor-Trimeton, Benadryl, Periactin, Tavist)

Histamine-2 blockers may be useful in recalcitrant cases, in addition to the Histamine-1 blockers: cimetidine 300 mg qid, ranitidine 150 mg bid, famotidine 20 mg once a day, or nizatidine 150 mg bid
Prednisone: useful in cases that are unresponsive to antihistamines

0.5-1.0 mg/kg/day, tapered over 10-15 days
NOT indicated in the control of chronic urticaria

Chronic urticaria

A general screen is indicated for underlying abnormalities, reserving more specialized tests as symptoms indicate

General: CBC with diff, sed rate, UA, chem. Profile, liver profile
Symptom-directed: thyroid tests, complement levels, antinuclear antibodies, cryoglobulins, stool for O & P, dental or sinus radiographs, CXR, hepatitis profile

Use antihistamines for symptoms relief
For refractory chronic urticaria, consider doxepin 10-100 mg as a single dose at hs
Consider an elimination diet.

In patients with aspirin sensitivity, use a tartrazine-free (a dye used to color food, drugs, etc.) diet.
Be suspicious of a particular food that produces symptoms within 2 hours of ingestion.

May need referral to dermatologist or an allergist

Dermatologic Medication Use in the Elderly

1. Use lower-strength corticosteroids because of decreased metabolism, decreased cellular turnover and increased susceptibility to depot effects, with subsequent skin atrophy.

2. Use sedating antihistamines with caution, and use lower strengths when possible (e.g., hydroxyzine 10 mg rather than 25 mg)

3. Use prednisone with caution because patients may be hypertensive or susceptible to mild changes in body fluid regulation.

Primary Skin Lesions

Secondary Skin Lesions

Term

Description