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INTEGUMENTARY DISORDERS
Structures & Functions of Skin & Appendages

Epi de rmi s

Stratum Corneu m (outer layer of dead keratinized cells) flat scale like
cells called squamous cells

Stratum Germinativum (basal cell layer)– cells migrate from basal layer
upward to corneum and sheds

St ru ctur es & Fu ncti on s of Ski n & App en da ge s

Dermi s

Papillar y layer- upper thin layer

Ret icular layer - deep thick layer

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Fibroblast cells- Primary cell type fround in the dermis

Sub cut an eou s Tis su e (f at) - below the dermis an is not part of the
skin.

Ski n ( epid erm al ) Appe nd ag es – down growths of epidermis into

dermis; develop from epidermis
- Hair & Hair Follicles
- Nails
- Glands:

Sebaceous glands – secret sebum which is emptied into the hair follicles
- prevents skin from drying

Apocr in e Glands - sweat glands secrete milky substance that becomes

odoriferous when altered by skin surface bacteria

Eccrine Gland s- widely distributed over the body, except in a few areas,
such as the lips.
- These glands function to cool the body by evaporation, to
excrete waste products, and moisturize surface cells

Fun ctio n of Ski n:

A. Protection

B. Homeo stasis

C. Thermoregulation

D. Sen sory R eception

E. Aesthe tic functions - include the mirrowring of various emotions such as

anger or embarrassment, as well as displaying te individual
identity of a person.

Eff ect s of A gi ng on th e Ski n

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Adole scenc e – surge of hormones (androgens) lead to maturation of hair

follicles, sebaceous glands, apocrine and eccrine units. Sweat, odor, acne,
Pigmented nevi (freckles)

Adult – male baldness, facial hair on women, sebaceous cysts, skin tags

Older Adulthood – thinner skin; more sensitive to minor changes in humidity,

temperature, wrinkles due to weakened collagen; Lentigines (liver spots – have
nothing to do with liver) black or brown flat lesions can appear anywhere, but on
face and dorsum of hand from prolonged sun exposure. (“Aging” pigment– left
over from broken-down cells)

As se ss me nt of th e In te gum ent ar y S ys tem

A. H istory

B. Ph ysical Exam
Good lighting (natural lighting), privacy, moderate room temp, expose section
at a time, pt comfortable
Syst ematic – proceed head-to-toe; compare symmetrical parts; perform
general inspection then lesion specific exam
Inspect general color & pigmentation, vascularity or bruising, presence of
lesions or discoloration
Vascularity ( angioma, petechiae, purpura)
Lesion – color, size, distribution, location, shape recorded; also configuration
(pattern) and distribution (arrangement); note odor
Refer to Table 22-7 & 22-8, pg. 483
Tattoos, needle-track marks

Le sio n Co nfi gur ati on

Annular - ring-shaped
Gy rate - Ring-Spiral-shaped
Iris lesion s - Concentric rings or “bull’s eyes”
Linear - In a line
Num mular, discoid - Coinlike
Pol ymorphous - Occurring in several forms
Punctuate - Marked by points or dots
Serpig inou s - Snakelike
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Di stri butio n Te rmino lo gy

Asy mmetric - Unilateral distribution

Conflue nt- Merging together
Diffuse- Wide distribution
Discrete- Separate from other lesions
Grouped - Closter of lesions
Solitar y- A single lesion
Symm etric- Bilateral distribution
Zosteriform- Band like distribution along a dermatome area

Hair & sc alp

 Examine body hair distribution, texture & quantity of hair

Examine scalp for lice (Caucasian); nap of neck, behind ears bite
marks, nets- eggs
Nails – shape, thickness, curvature & surface
Palpation – determine temp (use back of hand), turgor, mobility, moisture &
texture

Sk in As se ssm ent
1. Pallor
2. Jaundice
3. Temperature
4. Texture
5. Turgor
6. Edema
7. Tenderness

Ab no rmaliti es
Alopecia - loss of hair
Come do - black heads and white heads
Cyanosis - bluish-grey or dark or dark purple discoloration of the skin
Ecch ymo sis - bruise like lesions caused by collection of blood in dermis
Keloid - hypertrophied scar beyond margin of incision or trauma
Mole (nevus) - Benign overgrowth of melanocytes
Petechiae - pinpoint, discrete deposits of blood
Varicosit y - Increased prominence of superficial veins
Vitil igo - cyst depigmentation- congenital or acquired loss of melanin resulting
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in white, depigmented areas

As se ss me nt of D ark Ski n C ol or
 Refer to table 22-6, pg. 483

 Cyano sis – Shen or gray color most easily seen in the conjunctiva of the eye,
mucous membranes and nail beds

Jaundice - Yellowish-green color most obviously seen in sclera of eye (do not
confuse w/ yellow pigmentation, which may be evident in dark-
skinned patients) Palms of hands, and soles of feet

Pallor – Underlying red tone in brown or black skin is absent. Lighted skinned
AA may have yellowish brown skin dark skinned AA may appear
ashen or gray

Asse ss ment of colo r easily mad e where epidermis is thin &

pigmen tation lighter – lips, mucous membrane, palms & nail beds

 Pseudofoll iculitis – bacterial disorder caused by staph aureus characterized

by erythematous papules

 Keloids – Overgrowth of collagenous tissue at site of skin injury

 Mongolian spots – benign bluish-black macules

 Pigme nted nails (bands) pg. 478

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Typ es of Le sio ns
Primary – lesions that develop on previously unaltered skin

 Macule – flat, non-palpable; circumscribed; less than 1 cm in diameter;

called a patch if greater than 1 cm; skin color change (brown, red, purple,
white or tan); due to change in melanocytes or a change in vascularity;
Ex: freckles, petechiae, measles, flat mole (nevus)

 Papu le – elevated, palpable, firm circumscribed solid lesion; less

than 1 cm in diameter; may involve epidermis or dermis or both
Ex: wart (veruca), elevated mole, drug related eruptions (allergic rash)

 Nodule – raised, firm, palpable, solid lesion extending deeper into dermis
and larger and deeper than papule – greater than .5 cm in diameter;
Ex: lipomas, erythema nodosum

 Plaque – raised but flat topped, firm, rough, superficial papule greater
than 1 cm in diameter; formed from merging papules or nodules; larger
than papule but not deeper;
Ex: psoriasis, seborrheic and active keratoses

 Tumor – larger than nodule, elevated firm lesion that may or may not be
easily demarcated; greater than 2 cm in diameter; may or may not vary
from skin color; can be benign or malignant;
Ex: neoplasm

 Wheal – (also called hive, urticaria – due to allergic reaction) vascular

reaction causes vasodilation which leads to erythema in which fluid leaks
out of vessels into tissue causing edema in dermis; firm, edematous,
irregularly shaped area; diameter variable; pale pink with lighter center;
Ex: insect bite, urticaria)

 Vesicle (blister) – elevated sharply defined lesion containing serous

fluid; Contains free fluid; up to .5 cm
Ex: blister, chicken pox, herpes simplex, SMALL

 Bulla (e) – LARGE, elevated, fluid-filled lesion greater than 1 cm

Ex: blister, pemphigus vulgaris, second degree burn
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 Cyst – elevated, thick walled, palpable, encapsulated lesion containing

fluid or semi-solid material; similar to nodule but not solid; material from
sebaceous glands and hair follicles;
Ex. Sebaceous cyst

 Pustule – elevated superficial vesicles filled with purulent fluid (WBCs,

debris, microorganisms, and their products); vary in size;
Ex: acne, impetigo (Im-pe-ti-go), ant bite

 Boils, Furuncle s – pustule larger than 1 cm

 Carbuncle – collection of furuncles; deeper than furuncle; never incise

 Ab scess es – similar to furuncle but usually starts with some trauma

Typ es of Le sio ns
Sec on dar y – lesions that change with time or because of a factor such as

scratching or infection

 Fissure – Linear crack or break from epidermis to dermis; dry or moist;

Ex: athlete's foot, cracks at corner of mouth

 Scale – dried fragments of sloughed epidermal cells, irregular in shape

and size and colors are white, tan, yellow or silver; Due to increased
proliferation of epidermal cells; outer layer does not shed fast enough to
keep up with proliferation, thus scales on top of scales; Ex: dandruff, dry
skin, or psoriasis

 Sc ar – Abnormal formation of connective tissue that replaces

normal skin Ex: surgical incision, or healed wound

 Crust (natures bandaide)– dried serum, sebum, blood, or pus on skin

surface producing a temporary barrier to the environment; Brown or
honey colored = bacterial; dark = blood; Ex: impetigo, eczema, scab on
abrasion

 Ulcer – loss of epidermis and dermis; crater-like, irregular shape Ex:

pressure ulcer, chancre
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 Atrophy – depression in skin resulting from thinning of epidermis or

dermis; Ex: aged skin, striae

 Exco riation – area in which epidermis is missing exposing the dermis;

Ex: scabies, abrasion or scratch

Diagnostic Tests
Refer to Table 22-10, pg. 485

KOH – (potassium hydroxide) – Hair, scales, or nails examined for superficial

fungal infection
- Specimen is put on a glass slide and 10 %- 20% concentration of
potassium hydroxide added

Culture – Identifies fungal, bacterial, and viaral organisms.

Fu ngi - scraping performed if fungus is systemic involving the skin
Bacteria - material obtained from intact pustules, bvullae, or abscess
Viruses - bullae scarped and exudates taken from center of lesion

Tzanck Test- Fluid and cells from vesicles examined

- Used to diagnose herpes infections
- Specimen put on slide, stained and examined microscopically
- Use sterile technique for collection of fluid

Mineral Oil Slides – To check for infestations, scrapings are placed on slide
with mineral oil

Wood’s lamp (black light) Exam – Examination of skin with long-wave

ultraviolet light causes specific substances to fluorescent (Pseudomonas
organisms, fungal infections, Vitiligo)

Patch te st – Used to determine whether patient is allergic to any testing

material
- Small amount of potentially allergenic material pallied under occlusion,
usually to skin on back
- Instruct pt. to return in 48 hr for removal of allergens and evaluation

Biopsy – Removal of tissue specimen for histologic examination (cellular

assessment under microscope)
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Punch Biopsy – circular instrument cuts down into epidermis, dermis, and
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SC tissues; the opening may need to be closed with sutures

Exc isional B iopsy – done when necessary to be sure to remove entire
lesion; suture needed
Incisional Biops y – elliptical incision made in lesion too large to excise;
does not cause extensive cosmetic defect
Shave Biopsy – tissue obtained by cutting or shaving; goes through
epidermis and upper portion of dermis; no need for sutures; little or no
scarring
* Verif y that consen t form is signed i f ne eded

Su n Ex po sur e
Wear broad spectrum sunscreen with a sun protection factor (SPF) of 15 or
higher
Protection – wear large-brimmed hat, UV-blocking sunglasses, long sleeved

shirt of lightly woven fabric, carry umbrella

Avoid unnecessary sun exposure especially during sun’s peak hour 1000 – 1600

Avoid tanning parlors and artificial tanning devices (sunlamps)

Examine skin had to toe Q monthly

Have professional skin exam annually

Photosensitizing medication – tetracycline, NSAIDS, thiazide diuretics and

tricyclic antidepressants) increases skin’s sensitivity to sun

Acti nic Ke ra to sis (AK) (Sol ar Ke ra to sis )

- is a pre-malignant form of squamous cell carcinoma that affects nearly all of
the older white population
Small crusty, scaly, or crumbly bump or horn arises from skin surface
Color
May itch or produce pricking or tender sensation
Size –eighth – quarter of an inch ( 2-4 mm) or large as an inch; several at a
time
Location
Dangerous – precursor of cancer or a pre-cancer

Actinic K eratosis ( AK)

Assessment –
Cause – chronic sun exposure; artificial sources (tanning devices)
Greatest Risk –
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Tr eatme nt
 Cryosurger y – Liquid nitrogen applied to growth with spray device or
cotton-tipped applicator to freeze them; crusted & fall off; minimal side
effect – redness, swelling, dark skinned individual may be loss of pigment
 Curettage & Desicccation – lesions suspected to be early cancer –
biopsy specimen taken by shaving of top of lesion with a scalpel or
scraping of with curette, then curette used to remove base of lesion;
bleeding stopped with electrocautery needle; wound care afterward
 Topical
 5- fluo rouracil (5- FU) - creates a therapeutic inflammatory
response that causes erythema, vesicles, erosion, ulcerations,
necrosis and finally epithelialization; Pin meds and topical
corticosteroids may be used to enable to withstand process.
* Teach client it w ill get wo rse before it gets
bett er & avoid sun du ring t x
 Imiquimod cream
 Gel with hyaluronic acid & anti-inflammatory drug diclofenac
 Chemical Peeling
 Laser Surgery
 Photodynamic Therapy (PDT)

Bas al Cel l Ca rci nom a

#1 most common skin cancer, least deadly

Malignant epithelial tumor of skin arising from basal cells of epidermis; basal
layer of skin
SSx
Small fleshy bump or nodule – dome shaped papule with well –defined

borders; flesh –colored “pearly” or shiny appearance – dose not keratinize

Painless

Slow growing

Rarely metastasizes, but can invade and destroy local tissue; invade
bone and brain
Treatm ent
- Multiple treatment modalities are used depending on the tumor location and
histologic type, history of recurrence, and partient characteristics
- Electrodessication, curettage, excision, cryosurgery, radiation therapy, Mohs’
micrographic surgery, topical chemo, and intralesional alph-interferon.
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Squam ou s C el l Ca rc in oma

- Second most common skin cancer among fair-skinned persons (rarely found in
dark-skinned persons)
- Malignant tumor of epidermal keratinocytes found in areas of sun exposure –
long term exposure; outer layer of skin (the epithelium)
SSX
- Early- firm nodules with indistinct border w/ scaling and ulceration;
opaque
- Late- Covering of lesion with scale or horn form keratinization; most
common on sun exposed areas such as face and hands
Treatm ent
- Surgical removal, cryosurgery, radiation, chemo, Mohs’ procedure or
microscopically controlled excision, electrodessication, and curettage; untreated
lesion possible metastasizes to regional lymph nodes; high cure rate with early
detection and Tx

Mali gn ant Me la no ma

Tumor in melanocytes (cells producing melanin)

Deadliest form of skin cancer but least common
Linked to excessive sun exposure; most often found in whites, Dark brown or
black skin is not a guarantee against melanoma
SSx
Scaling, oozing, and /or bleeding nevus (mole) or other pigmented lesion
ABCD s of Melano ma

 A symmetry – one side does not look like the other side

 B order Irregularity – edges are ragged or uneven

C olor – more than one color present- streaks of tan, brown, black, red, blue,
white

 D iameter – larger than size of a pencil eraser (6 mm) or has changed shape

Treatmen t
Intial treatment is surgery.

Pru ritus
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Itching
Caused by any physical or chemical stimulus to the skin – drugs, insects, dry
skin
Itch-scratch cycle must be broken (protective barrier) to prevent excoriation
Keep fingernails short
Mitten or gloves especially at bedtime
Heat or rubbing (causes vasodilation) avoided
Dryness of skin lowers the itch threshold & increases itch sensation
Emollients – moisten and lubricate skin – apply to moist skin
Pat dry & not totally dry

Eczematou s Disorders/Der matitis

Acute or Chronic
Erythema
Papules
Vesicles
Pustules
Scales
Crust
Scars
Dry or Wet
Varying degrees itching /burning

Medication Vehicles
Powders
Lotions
Creams
Ointments
Emollients

TOPICAL MEDICAT IONS

Lotion s – suspension; powder in water require shaking (calamine); applied

directly to skin, may use dressing soaked in the lotion
Powders – have a talc, zinc , bentonine or cornstarch base ; dusted on skin
with shaker or cotton sponge
Creams – suspensions or oil in water or emulsions of water in oil (may cause
contact dermatitis); rubbed into skin by hand; moisturizing & emollient effects
Gels – semisolid emulsions become liquid when applied to skin or scalp

Paste s – mixtures of powders & ointments used to protect the skin; applied
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thickly with a tongue blade or a gloved hand

Ointm ents – retard water loss and lubricate and protect skin; apply to clean

skin and spread evenly in a downward motion small amount on affected area;
ensure even distribution

Atopic Derma titis (Eczema)

Patho – associated with allergic conditions, elevation of IgE levels common,

genetically determined, often family hx; decrease itch threshold, stress, &
increased water contact (hand washing)
SSx – scaly, red to red-brown, circumscribed lesions; accetntuation of skin
markings; pruritic; symmetric eruptions common in antecubital and popliteal
space in adults
Treatm ent – Hydration (water) & Lubrication; soak in tipid water 3-4 x day;
Aveno in bath for itching; pat dry, don’t rub & scrub;

Contac t Dermatitis

Ir ritant contact dermatitis – perfumes

Allergic contact der matitis – delayed hypersensitivity reaction (type IV);
occurs when skin is exposed to substances that easily penetrate the skin and
combine with epidermal proteins, the substance becomes antigenic ( nickel,
mercury, rubber, catchols in poison ivy, poison oak, cosmetics)
SS x - Red, hive like papules and plaques; sharply circumscribed with
occasional vesicles; exposed areas more common; usually pruritic; relation of
area of dermatitis to causative agent.
Treatmen t- Topical corticosteroids, antihistamines; skin lubrication;
elimination of contact allergen; avoidance of irritating affected area; systemic
corticosteroids if sensitivity severe

Stasis Derma titis

Patho – Impaired venous circulation/insufficiency to lower extremities, inability
to get circulation
SSx –

Treatment
1.
2.

3.

4. Comparison of Compression Therapy

Put the squeeze of venous ulcers – compression is the cornerstone

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4. Unna’ s Boot – a fixed protective dressing; stimulates granulation tissue and
epithelial growth. Protects and enhances venous circulation like TED hose.
Dressing soaked with zinc oxide, glycerin and gelatin – after application it
hardens into a cast-like substance. Start at top of foot and work up to just
below knee. Remove weekly to assess and reapply. Must teach pt and family to
watch for pain, drainage, fever, warmth, swelling (all could mean infection); they
should return ASAP with these findings and not wait until next appointment
5. Skin g rafts may be nece ssary

Other Wound Ca re P rinci ples

Assess & treat underlying problems as part of wound management protocol
(obesity, CV disease, DVT, family hx of varicose veins) - impair healing –
expertise of other team members
Clean wound regularly & prepare pt for aggressive debridement if indicated
Wound characteristics – size, presence or absence of infection and
characteristics of surrounding skin
Wounds heal best in moist environment
Moisture-retentive dressing (hydrocolloid, transparent film & certain foams)

– wounds with light to moderate drainage

Absorbent dressing (foams, alginates & specialty absorptive dressings –

moderate to heavy exudate

In te rt ri go
Patho – surfaces rubbing against each other - skin breakdown, large areas,
under breast, pendulous abdomen, rolls of skin tissue; moisture, obesity, Monilia
infection (yeast)
SSx – Dermatitis of overlying surfaces of skin
Treatment –

Psoriasis
Patho – Inflammatory disorder- certain immune cells become overactive and
release proteins called cytokines which cause proliferation of keratinocytes
(skin cells) and the growth of small blood vessels that supply blood and nutrients
to the affected area; skin cells grow much faster than they should
SSx –
Treatment

Comm on Bact eri al Inf ecti on s (Py od erma s)

Ce llu litis
 Patho – infection in skin; inflammation of subcutaneous tissue; not clearly
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demarcated; staph aureus, strep; Local

SSx –

Treatm ent – Moist heat, immobilization (bedrest) and elevation, ABX,

Er ysip el as
Patho – Superficial cellulitis involving the dermis; group A β-hemolytic strip
SSx – Red, hot sharply demarcated plaque, indurated & painful, fever,

Leukoctyosis WBC
Treatm ent – Same as cellulites – PCN

Imp etig o - Peds

Vir al I nf ec tio ns of Sk in

 Her pe s Zos te r (Shing le s)

Patho – Same virus as chicken pox (varicella-zoster) dormant; ends up


along nerve root in body from chicken pox years ago. Occurs in
immunocompromised pt – chronically ill, transplant, older adults
SS x –

Treatmen t – Symptomatic, antiviral agents – acyclovir, Zovorax; wet

compresses, analgesia, mild sedation at HS, systemic steroids;

TX: for post therapeutic neuralgia (PHN) – gabapentin (Neurontin) & tricyclic
antidepressants (TCAs) amitriptyline (elavil or nortryptyline (Pamelor);
extended-dose opioid pain meds – oxycodone (OxyContin) or fentanyl
(Duragesic Patch)

He rp es Z ost er (Shin gl es ) – Interventions

Rx TCAs and opioids – stay well hydrated, select high-fiber foods; use fiber
laxative or stool softener to avoid constipation; carefully assess for suicidal
ideation & promptly refer for tx if needed
Sh ingle s itself no t contagious – close exposure can pass varicella virus to
others, causing initial episode of chickenpox; pts with open lesions educate to
reduce exposing others (unvaccinated, immunocompromised or pregnant
individuals who never had chickenpox
Profound itching – discouraged scratching; measures to protect skin and
reduce risk from bacterial infection important
Soothing oatmeal baths, painted-on topical lotions (calamine or Benadryl;

application of washcloths with cool water; Domeboro astringent and gel from
aloe vera plant relieve itching & pain
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Fun ga l Sk in In fe cti on s

 Ca ndi dia sis

Patho – caused by Candida Albican (moniliasis); present in warm, moist
areas such as crural (leg or thigh, femoral area), oral mucosa, and sub
mammary folds; depression of cell mediated immunity allows yeast to become
pathogenic
SSx –

Treatment – Antifungals, nystatin or other specific meds for vaginal

suppository, oral lozenge; keep skin clean and dry, Mycostatin powder

Tin ea – Fu ng al Inf ec tio n

Patho– Also called ringworm because of characteristic appearance of ring or

rounded tunnel under skin

Typ es of tine a inf ecti on

Tinea Co rporis – dermtophytes; ringworm on body; red macular/papular;
annular appearance, well-defined margins; active border with clearing center
Tinea Ca pitis – ringworm scalp; patchy loss of hair

Tinea C ruris – jock itch, well defined border in groin area; itchy, painful,

red, raw
Tinea P edis – athlete's foot; interdigital scaling, and maceration, erythema

and pruritus, painful

Tr eatme nt of T in ea Inf ecti on s

Pa ras itic Ski n In fe st atio ns

Ped icul os is (Head lice, Body lice, Pubic lice

Patho – parasites suck blood, leave excrement and eggs on skin, live in
seams of clothing (body lice) and in hair as nits; transmission of pubic lice
often by sexual contact
SS x – minute red non inflammatory; points flush with skin; progression of

wheal-like lesions, pruritus, secondary excoriation (parallel linear

Sc abie s
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Patho – infestation of skin with itch mite Sarcoptes scabie, penetrates stratum
corneum; deposits eggs, allergic reaction resulting from presence of eggs, feces,
mite parts; transmission by direct physical contact
SS x

Treatmen t

Nu rs in g Ma na gem en t

 Wet Dr ess in g – used when skin is weeping from infection or inflammation

(water, NS); also used to relieve itching, suppress inflammation and debride a
wound; left in place 10-30 mins, 2-3 x’s/day; avoid maceration (softened) skin;
protect for discomfort and chilling by using linen & bedclothes with pads or
plastic

 Baths (ba ln eoth er apy) – used when large body area need to be Tx;
sedative antipruritic effects; tub full enough to cover effected area; soak
15-20 mins 4 x’s/day; stress importance that skin should not be rubbed
dry with a towel but gently patted to prevent irritation and inflammation; oils
make tub slippery, safety

Nu rs in g Ca re Pl an ( Ch ro ni c S ki n l esio ns )

Refer to NCP 23-1, pg. 504

Risk for infection
Impaired skin integrity
Situational low self-esteem
Psycholog ical impact – psychic pain it can cause “They glance at me and
glance away, pained. My hands and my face mark me. The name of the
disease, spiritually speaking is Humiliation”( Lead to social isolation,
situational low self esteem) novelist John Updike developed condition as child
(psoriasis)
Ineffective health maintenance
Social isolation