Disorders of the
Integumentary System
Compiled by Sr. Venina
Navuta
17/1/2017
Integumentary System Consists of
• Skin
• Hair,
• Nails
• Glands
First line of defense.
Functions of Skin
• Surface barrier
• Provides sensory perception
• Fluid & electrolyte balance (insensible)
• Temperature regulation
• Role in body image and expression
Skin Assessment
• Visual inspection
• Palpation
• Olfactory senses
• Adequate lighting
• Remove necessary clothing while
providing respect and privacy
• Appropriate client positions
Visual inspection
Skin color:
• Palor
• Cyanosis
• Jaundice
• Erythema
• Hyperpigmentation
• Hypopigmentation – vitiligo
Visible changes if the Skin
• Changes in skin color texture
• Eczema, infections
• Assess the vascularity & hydration of skin
• Edema – swelling, pitting edema
1+ 2 mm
3+ 6 mm
2+ 4 mm
4+ 8 mm
Nails – configuration, consistency, color
• Hair – color and distribution, aloplecia,
location
Assessment of Lesions
• Vary in size, shape and cause
• Primary vs. Secondary
• Eruptions: cysts, wheals, bullous,
pustules, psoriasis, eczyma,
vesicles, bullae, nodules, papules
• Discoloration: macules
Dermatological
Manifestations & Conditions
• Result of systemic conditions.e.g
endocrine(increased sweating, warm skin
with persistent flush, thin nails, vitiligo,
alopecia, fine soft hair
• Psychological stress of illness, personal or
family problems
• Maybe a first sign of a disorder and could
be a reason why a person would seek
medical assistance.
Common Diagnostic Tests
• Skin Biopsy: punch,
excisional, incisional, shave
• Microscopic tests: potassium
hydroxide(KOH),Tzanck test, culture,
mineral oil slides, immunofluorescent
studies
• Other tests: Wood’s lamp, Patch
test,curettage, cryosurgery
Common Medications:
Integumentary System
• Antibiotics: oral(systemic), topical
• Antifungals:
topical(nystatin),oral(griseofulvin)
• Corticosteroids: topical, systemic,
intralesional
• Antihistamine: oral
Cont’d
• Phototherapy: UV lights in specific
wavelengths
• Herbal: insect bites, skin excoriation
• Antimetabolites: methotrexate
• Non-steroidal:
immunomodulators.e.g.
tacrolimusm, imiquimod
Nursing Care Includes
• Administering topical & systemic
medication
• Managing wet dressings and other
specialised dressings
• Providing therapeutic baths
Nursing Process
- To be done at the clinical lab
Four major objectives of therapy
• Protect skin
• Prevent additional damage &
secondary infections
• Reverse the inflammatory
process
• Relieve symptoms
Advances in Wound Treatment
• Growth factors: cytokines or proteins that
have potent mitogenic activity (Vaneau et
al., 2007).
• Regranex gel: contains becaplermin, a
recombinant human platelet-derived
growth factor, promotes chemotactic
recruitment and proliferation of the cells
involved in wound healing (Fonder et al.,
2008).
cont’d
• Bioengineered skin substitutes:
cultures of keratinocytes delivered
on a petrolatum gauze.eg.
AlloDerm, Apligraf, Dermagraf,
Epicel and Laserskin.
• Oral Medications e.g.
Pentoxifylline (Trental)
Healing of Chronic Wounds
• Mechanical debridement is
contraindicated
• Recommend use of commercial cleansing
agent
• Initial selection of dressing type-crucial
• Documenting presence of bacteria is
important before appropriate antibiotic
is prescribed
Format for Discussion of Disorders
• Definition & pathophysiology: review
A&P, description of disease process
• Epidemiology/Causes: trend in disease
• Clinical manifestations: reasons for
occurrences of ~
• Assessment & Diagnostic Tests: review
of physical assessment & use of
appropriate DTs
• Treatment: conservative, surgery
• Medication/therapies
• Nursing Management/Medical
Management
• Complications
• Patient Education
• Special needs of nursing staff: provision
of knowledge, support and care
Pruritis
• Common symptom of skin
problems/disease
• Scratching the pruritic area causes
the inflamed cells and nerve endings
to release histamine, which produces
more pruritus, generating a vicious
itch–scratch cycle.
• Responds to an itch by scratching, can
alter integrity of the skin,
• and excoriation, redness, raised areas
(i.e. wheals), infection, or changes in
pigmentation may result.
• Pruritus usually, more severe at night
→there are less distractions and less
frequently reported during waking hours,
probably because the person is distracted
by daily activities.
Nursing Management
• Reinforces therapeutic treatment
prescribed by the doctor
• Counsels on specific care to be
undertaken
• Avoid situations that cause pruritis
- Drinking alcohol
- Exposure to overly warm
environments
- Hot foods/liquids
• Wear cotton material clothes and
not synthetic ones – especially at
night
• Nails to be kept short
Medications Used in Treatment
• Topical corticosteroids
• Oral antihistamines
• Diphenhydramine (Benadryl) or
hydroxyzine (Atarax), nocte,is often
effective in producing a restful and
comfortable sleep.
• Non-sedating antihistamine
medications.e.g.fexofenadine
(Allegra) are more appropriate to
relieve daytime pruritus.
• Tricyclic antidepressants.e.g.doxepin
(Sinequan), may be prescribed for
pruritus of neuropsychogenic origin.
• If pruritus continues, further
investigation of a systemic problem is
advised
Perineal & Perianal Pruritis
• Genital and anal regions: caused by
small particles of faecal material
lodged in the perianal crevices or
attached to anal hairs.
• Can result from perianal skin damage
caused by scratching, moisture and
decreased skin resistance as a result
of corticosteroid or antibiotic therapy
Other Causes
•
•
•
•
•
scabies and lice
local lesions such as haemorrhoids
fungal or yeast infections
pinworm infestation.
Conditions such as diabetes mellitus,
anaemia, hyperthyroidism and
pregnancy may also result in pruritus.
Nursing Management
• Proper hygiene
• Discourage home & OTC remedies
• Perineal and perianal area should be
washed with lukewarm water and pat
dry
- Use pre-moistened tissue to wipe area
after defecation
• No bubble baths, sodium
bicarbonate, detergent soaps
• Encourage wearing of cotton
underwear instead of synthetic ones
Secretory Disorders
• Hydradenitis suppurativa:chronic
suppurative folliculitis of the
perianal, axillary and genital areas
or under the breasts.
• develops after puberty, can
produce abscesses or sinuses with
scarring.
• cause is unknown
Pathophysiology
• Abnormal blockage of the sweat
glands causes recurring
inflammation, nodules and
draining sinus tracts.
• hypertrophic bands of scar tissue
form in the area of the sweat
glands.
Clinical manifestations
• Lesions appears in axilla, inguinal
folds, mons pubis and buttocks
• Restlessness and uncomfortable,
irritable
- sleeplessness
Management
• Hot compresses and oral
antibiotics.e.g.Isotretinoin (Accutane,
Sotret) or acitretin (Soriatane)
• I&D of large suppurating areas
• Excision- removing the scar tissue and
any infection. This surgery is drastic and
performed only as a last resort
Seborrhoeic dermatoses
• excessive production of sebum
(secretion of sebaceous glands) in
areas where sebaceous glands are
normally found in large numbers, such
as the face, scalp, eyebrows, eyelids,
sides of the nose and upper lip, malar
regions (cheeks), ears, axillae, under
the breasts, groin and gluteal crease
of the buttocks.
Clinical Manifestations
• 2 forms of seborrhoeic dermatoses: an oily
form and a dry form.
• may start in childhood and continue
throughout life.
• oily form appears moist or greasy.
• patches of shallow, greasy skin, with or
without scaling, and slight erythema,
• mainly on the forehead, beard area, scalp and
the axillae, groin and breasts.
• Small pustules or papulopustules
resembling acne may appear on the
trunk.
 Dry form: consists of flaky
desquamation of the scalp with a
profuse amount of fine, powdery
scales, commonly called dandruff.
 scaling occurs, often accompanied by
pruritus, may lead to scratching,
secondary infections and excoriation.
 Seborrhoeic dermatitis has a genetic
predisposition.
Nursing Management
• avoid external irritants, excessive
heat and perspiration; rubbing and
scratching prolong the disorder.
• the nurse should be sensitive to
these differences when teaching the
patient about home care
- Not everyone use shampoo
Acne Vulgaris
• common disorder affecting susceptible
hair follicles, most commonly on the face,
neck and upper trunk.
• Propionibacterium acnes is the major
cause of this disorder.
• characterised by comedones (primary
acne lesions), both closed and open, and
by papules, pustules, nodules and cysts.
Pathophysiology
• acne occurs when accumulated
sebum plugs the pilosebaceous
ducts.
Clinical Manifesations
• Closed comedones (whiteheads)
form from impacted lipids or oils and
keratin that plug the dilated follicle.
• Closed comedones may evolve into
open comedones, in which the
contents of the ducts are in open
communication with the external
environment
Bacterial Infections &
Infestations
• Causes: staphylococcus aureus &
group A β-hemolytic streptococci are
major bacteria responsible for
primary & secondary skin infections
• Pathophysiology: occurs when there
is an alteration in the balance
between host & microrganism
• Usually start at hair follicle
- folliculitis:small pustule in hair follicle
opening;
- usually staphylococci and present in areas
subjected to friction,
moisture, rubbing or oil.
- High incidence in
diabetic patients
• Impetigo:
- Grp A β-hemolytic streptococci,
staphylococci or combination of both
- associated with
poor hygiene &
low socio-economic
status
- contagious
• Furuncle: staphylococci, deep infection
around hair follicle;
• associated with severe acne &
seborrhoeic dermatitis
• Furunculosis: associated with
obese patients, diabetics, those
who are exposed to moisture,
irritation & pressure regularly, those
who are chronically ill
• Carbuncle: multiple
interconnecting
furuncles
• Cellulitis: inflammation of
subcutaneous tissue from enzymes
produced by bacteria. Caused by
staphylococcus aureus & streptococci
• Erysipelas: superficial cellulitis &
involves the dermis. Caused by group
A β-hemolytic streptococci
Collaborative Management
• Systemic antibiotic therapy
prescribed
• IV therapy for acutely ill patients
• Boil/pimple not to be squeezed
• Immediate area surrounding lesion
to be cleaned
• Self care to be promoted
Viral Skin Infections
• Herpes Zoster (shingles) is an infection
caused by the varicella-zoster virus (VZV)
members of a DNA virus group.
S/S
• Pruritis & tenderness over
affected area
• Pain preceding lesions
• Malaise & GI disturbances precede
• Patches of grouped vesicles appear on
red & swollen skin.
• Vesicles can develop into purulent
lesions
• inflammation is usually unilateral,
involving the thoracic, cervical or
cranial nerves in a band-like
configuration.
Collaborative Management
• Antiviral agents
prescibed.e.g.aciclovir – orql/IV
• Systemic corticosteroids
• Diversionary activities to encouraged
with relaxation techniques to
promote sleep & rest
Other conditions
• Herpes Simplex: has two types
- Orolabial herpes
- Genital herpes
Fungal Skin Infections
• Candidiasis
• Most common: tinea
i. Tinea pedis: tinea of the foot
ii. Tinea corporis: ringworm of the body
iii. Tines capitis: tinea of the head
iv. Tinea cruris:Jock itch(groin)
Pediculosis
• Pediculosis capitis: head louse causes
infection
• Pediculosis corporis(body) and
cruris(groin): infection caused
by body louse.
Collaborative Management
• Head louse: shampoo containing lindane
to be applied.
• Clothing to be washed in hot water.
• Complications
- severe pruritus,
- pyoderma and
- dermatitis are treated with
antipruritics, systemic antibiotics and
topical corticosteroids.
Non-Infectious Inflammatory Dermatosis
PSORIASIS
• Psoriasis affects approximately 2%
of the population
• appearing more often in people of European
ancestry.
• It is thought that this chronic disease stems from
a hereditary defect that causes overproduction
of keratin.
• Onset may occur at any age, but psoriasis is most
common in people between 15 and 35 years of
age
Pathophysiology
• Cells in the basal layer of the skin divide too
quickly
• newly formed cells move so rapidly to the skin
surface that they become evident as profuse
scales or plaques of epidermal tissue.
• As a result of the increased number of basal
cells and rapid cell passage, the cell
maturation and growth cannot occur, which
prevents the normal protective layers of the
skin to form.
Clinical Manifestations
• Lesions appear as red, raised
patches of skin covered with silvery
scales
• patches may be pruritic.
• nails -pitting, discoloration,
crumbling beneath the free edges
and separation of the nail plate.
• Bilateral symmetry is a feature of
psoriasis. Particular sites of the body
affected most by this condition
include the scalp, the extensor
surface of the elbows and knees, the
lower part of the back, the genitalia
and the nails.
Collaborative Management
• Goals Of Management are to
- slow the rapid turnover of epidermis,
- to promote resolution of the
psoriatic lesions, and to control the
natural cycles of the disease
Blistering Diseases
• Pemphigus
• Bullous Pemphigoid
• Deramatitis Herpetiformis
Ulcerations
• -Superficial loss of surface tissue
as a result of death of cells
Benign Skin Tumors
•
•
•
•
•
Cysts
Seborrhoeic & actinic keratoses
Verrucae: Warts
Pigmentd naevi: moles
Dermatoma fibroma
Malignant Skin Tumors
• Basal cell and Squamous cell
carcinoma
• Malignant melanoma
• Kaposi’s sarcoma
BURNS
• An injury to the tissues of the
body caused by heat, electrical
current or radiation
• Gravity of effects depends on
- Temperature of burning agent,
duration of contact time, type of
tissue injured
Burns
- Injuries mostly due to
accidents → preventable
* Health promotional activities
done by nurses for first aid
treatment, fire drills (home &
community), community
awareness
References
• Brown, D., & Edwards, H (2012).
Lewis’s Medical-Surgical Nursing:
Assessment and Management of
Clinical Problems (3rd ed.).Sydney.
Elservier