Professional Documents
Culture Documents
2 2 Dermatology
2 2 Dermatology
Introduction
In this lesson we'll review the assessment of the
skin, hair, nails, and mucous membranes, which
can provide clues to systemic disease,
cutaneous infection or injury, bites or stings,
parasite infestation, and skin cancer. We'll cover
the following topics:
History
Physical examination
Common screening and diagnostic tests
Health-promotion behaviors related to the
dermatologic system
Incidence
Problems of the skin account for 4% or 5% of
visits to primary-care providers
Nearly 20% of patients seen have signs and
symptoms related to dermatology
Skin cancer is now at epidemic proportions,
affecting about one in 88 people
Most skin cancer is nonmelanoma skin cancer
(NMSC)
The increase in the incidence of skin cancer rate
is associated with cumulative skin exposure to
ultraviolet light from the sun or tanning beds
History
Current complaint
Constitutional signs and symptoms
Signs and symptoms of problem with the skin,
hair, nails, or mucous membranes
Onset and progression of problem over time
Location
Pattern of spread
Change in individual lesions
Change in contact
Details of prodromal period, including
relationship of symptoms to provocative factors
Relieving factors, including previous treatment
Risk factors for skin cancer
History
Medical history
Allergic response produced by exposure to medications,
foods, or other substances
Contraceptive method
Serious illnesses or injuries
Hospitalizations
Radiation
Previous skin problems or skin cancer
Immunosuppression
Chronic illness, including diabetes mellitus and
hypertension
Tetanus prophylaxis status
Atopic history (e.g., asthma, hay fever, eczema)
History
Family history
Skin cancer
Psoriasis
Atopy
Tuberous sclerosis
Melanoma
Xanthomas
Genetic conditions
Medication history
Over-the-counter (OTC), prescription, or
complementary therapies related to the chief
complaint (including topical steroids) and
reasons for use
History
Psychosocial history
Occupation and leisure activities
Drug, alcohol, and tobacco use
Sunbathing and use of tanning beds
Use of sunscreen
Exposures
Travel
Sexual abuse, particularly that involving
exposure to pediculosis pubis
Risk factors for human immunodeficiency virus
(HIV) infection
Physical Examination
Conduct a comprehensive physical examination, paying special attention to particular areas not
usually exposed during an exam.
Examination
Prepare the appropriate tools and environment for the examination
Assess the patient's general appearance, including whether he or she seems well or appears
uncomfortable
Assess vital signs
Inspect the skin (with patient disrobed and draped appropriately) for color, texture, and
hydration status
Remember that skin characteristics vary with age
Pay particular attention to lesions that are consistent with skin cancer: NMSC, including basalcell carcinoma and squamous-cell carcinoma; premalignant lesions such as dysplastic nevi and
actinic keratoses; and malignant melanoma (use the mnemonic ABCDE to help you remember
the signs of malignant melanoma)
Note the configuration of any lesions and assess for epidermal, pigment, or dermal involvement
Assess rashes for dermal or epidermal involvement
Note the pattern of distribution of lesions
Note the structure of the lesion, including whether it is primary or secondary; its dimensions;
whether it is elevated or depressed; its palpable or visible features, such as atrophy or
lichenification; and its color and other physical characteristics
Palpate skin surfaces, noting moisture, mobility, turgor, texture, and temperature
Palpate the lesion for consistency, temperature, mobility, and tenderness
Inspect the mucous membranes
Inspect the hair, scalp, eyelashes, eyebrows, and body hair
Inspect and palpate the nails and note the presence of lesions
Physical Examination
Diagnostic procedures
Examine skin material (scrapings, scales, crusts,
exudates, tissue) under a microscope to detect yeast
and fungus, bacteria, virus, spirochetes, or parasites
Use a Wood light to help diagnose certain fungal and
bacterial diseases and disorders of pigmentation
Perform diascopy to differentiate erythema from purpura
or petechiae (erythema blanches with pressure, whereas
purpura and petechiae do not)
Perform laboratory tests (if indicated)
Use dermoscopy for noninvasive inspection of deeper
layers of the skin
Perform an incisional (punch or shave) or excisional
biopsy as indicated
Education
Provide the patient or caregiver with guidelines for safe
sun exposure and explain how to treat sunburn
Encourage the patient to avoid tanning beds
Stress caution in high altitudes or in the presence of
reflecting snow, sand, water, or concrete, all of which
increase penetration of harmful rays
Teach the patient how to perform self-examination of the
skin in accordance with
American Academy of Dermatology guidelines
Tell the patient to make an appointment for a clinical
examination if his or her self-examination reveals certain
findings
Caution patients against using public hot tubs because of
the potential for folliculitis
Provide guidelines for safe body piercing, tattoo art, and
application of artificial nails
Introduction
In this lesson we'll review the presentation,
diagnosis, and treatment of acne vulgaris and
acne rosacea, disorders of the sebaceous and
apocrine glands. Acne vulgaris is a multifactorial
disease of the pilosebaceous unit in men and
women in Westernized societies who are near
puberty; in most cases, the condition becomes
less active as adolescence ends. Acne rosacea,
a chronic skin eruption with flushing and dilation
of small blood vessels in the face, is most
common in midlife. Both disorders are often
seen by the family nurse practitioner.
Incidence
Acne vulgaris
An estimated 80% of people between the ages
of 11 and 30 years experience an acne outbreak
at some point
Acne vulgaris affects between 40 million and 50
million individuals a year in the United States
alone
Nearly 12% of women and 3% of men will
continue to have clinical acne until age 44
White boys and men have been shown to have
more severe nodulocystic acne than black boys
and men
Incidence
Acne rosacea
Acne rosacea is most common in those with
Celtic and Northern European ancestry (fair skin
makes it more apparent) and least common in
black patients (darker skin may hide the
condition)
More women than men are affected by acne
rosacea, but men have more severe forms
Rosacea mainly affects adults older than age 30
years
More than 14 million in the United States are
affected
Pathophysiology
Acne vulgaris
Increased size and activity of sebaceous
glands
Altered growth of follicles and abnormal
differentiation of follicular kerotinocytes,
leading to the formation of follicular plugs
Proliferation of Propionibacterium acnes in
follicles
Inflammatory and immune responses
Pathophysiology
Acne rosacea
Although the cause of acne rosacea is unknown,
theories exist
Pathologic findings include inflammation surrounding
hypertrophied sebaceous glands contributing to papules,
pustules, and cysts; vascular dilation and infiltrates of
lymphocytes; and no comedones or blocked ducts
The condition is associated with blepharitis, keratitis, and
conjunctivitis; the lesions are prominent on the convex
areas of the face: forehead, nose, cheeks, and chin
Rosacea is classified into four subtypes:
erythematotelangiectatic, papulopustular, phymatous,
and ocular
History
Current complaint
Duration of symptoms
Location
Seasonal variation
Premenstrual flare-up
Thinning of scalp hair or increase of androgendependent hair such as facial hair (women)
Secondary features of acne rosacea
History
Medical history
Endocrine disorders
Drug allergies
Menstrual history and pregnancy status
Hormone tests
Family history
Other skin disorders
Atopy (irritation to topical acne treatment)
Hydradenitis suppurativa
History
Medication history
Current and past treatment (topical and
systemic) of acne
Current and past treatment of other diseases
Failure of previous therapies
Oral contraceptives or birth control method used
and effect on acne
Psychosocial history
Aggravation by stress
Disfigurement
Occupational disability
Cosmetics and moisturizer products used
Physical Examination
Examination
Inspect and palpate the skin
Determine the number and location of the
lesions and whether the lesions are
noninflammatory or inflammatory
For each predominant type of lesion in each
location, note the severity
Look for complications such as rhinophyma
(acne rosacea) and scarring
Note the presence of associated conditions
Physical Examination
Diagnostic procedures
In most cases, no screening or diagnostic tests are
needed in the assessment and diagnosis of acne
Hormone assessments are conducted in women with
suspected hyperandrogenemia
Serum and urine pregnancy tests are conducted to rule
out pregnancy before the initiation of treatment with a
potentially hazardous drug
Complete blood count with differential and renal, liver,
and lipid profile are performed initially and every 4 weeks
for patients treated with isotretinoin (Accutane)
The diagnosis of acne vulgaris is based on the presence
of comedones
The diagnosis of acne rosacea requires evidence of one
or more primary features in a central distribution on the
face
Physical Examination
Differential diagnosis: acne vulgaris
Rosacea
Steroid acne
Molluscum contagiosum
Folliculitis
Differential diagnosis: acne rosacea
Acne vulgaris
Steroid abuse with rosacea
Fungal infection
Cutaneous features of lupus erythematosus
Drug eruptions (especially iodides and bromides)
Treatment
Nonpharmacologic: acne vulgaris
Stress reduction
Gentle skin care with soap products for sensitive skin
Avoidance of oil-based cosmetics, moisturizers, and
sunscreens
Avoidance of greasy hair products near the face
Nonpharmacologic: acne rosacea
Avoidance of oily cosmetics
Use of camouflage makeup as appropriate
Reassurance
Stress reduction
Minimizing sun exposure
Avoiding known triggers
Avoiding certain medications, if possible, by informing
prescribers of an acne or rosacea diagnosis
Laser therapy for telangiectasia and ablative therapy for
rhinophyma
Treatment
Pharmacologic: acne vulgaris
Treatment is based on whether acne is
mild or moderate to severe
Pharmacologic: acne rosacea
Topical antibiotics
Oral antibiotics for cases involving
papulopustular (subtype 2)
Low-dose isotretinoin or topical retinoids
Education
Acne vulgaris
Explain the origins of the disease and reassure the patient
that the condition is not his or her fault
Stress that treatment success depends heavily on the
patient's compliance with prescribed therapies
Acknowledge the social and psychological impact of
having acne and offer appropriate support, counseling,
and referral, if needed
Encourage the patient to use adequate sun protection and
gentle skin care while taking topical and oral medications
Explain that acne treatment is a long-term process and tell
the patient that initial worsening is possible as the
medication brings out the acne waiting to emerge onto the
skin
Explain that it may take 12 to 16 weeks to reach maximum
reduction in the number of lesions
Education
Acne rosacea
Suggest the use of camouflage makeup, if
appropriate
Tell the patient to avoid unnecessary sun
exposure and to use sunscreen when sun
avoidance is not possible
Encourage the patient to avoid triggers that
worsen the condition
Tell the patient to notify prescribing health-care
providers of the disorder in an effort to avoid
vasodilator therapy if at all possible
Offer additional resources for information, such
as the National Rosacea Society
Follow-Up
Schedule three follow-up visits over 12 to 16
weeks to establish an effective plan of care
See patients at 4 to 6 weeks to assess
compliance and response to and tolerance of
prescribed regimen, then follow up at 1-month
intervals to further assess response and
compliance and make therapeutic changes as
indicated
See the patient taking long-term antibiotics
regularly with the plan of weaning him or her off
the drugs as other treatments (e.g., topical
retinoids, hormonal treatment) allow
Referral
Consult as needed with specialists (dermatologists,
gynecologists) to plan a safe, effective treatment for the
patient with acne
Refer the patient to a dermatologist if acne does not
respond to an adequate trial of initial treatments or if
isotretinoin (Accutane) is indicated
If endocrine disease is suspected, refer patient to an
endocrinologist
Refer the patient with acne rosacea who desires
electrodessication or sclerosis of permanently dilated
vessels in the face to a dermatologist
Refer the patient with rhinophyma to a surgeon for
surgical correction, if appropriate
Refer the patient with ocular effects of rosacea to an
ophthalmologist
Introduction
Atopic dermatitis (eczema) is a chronic, cyclic,
relapsing, inflammatory, intensely pruritic skin
disease with multiple clinical presentations.
Contact dermatitis is an eruption of the skin
related to contact with an irritating substance or
allergen. Seborrheic dermatitis is a chronic skin
condition affecting the scalp, face, central chest,
and intertriginous areas.
In this lesson we'll review the assessment,
diagnosis, and treatment of these common skin
conditions.
Introduction
Intertrigoinflammation caused by skin-to-skin contact,
generally found in the groin, axilla, or inframammary
foldshas the potential to result in secondary fungal or
bacterial infection when microorganisms invade the body
through broken skin. Left unmanaged, fungal infection
may provide a portal for lymphangitis or cellulitis,
especially in patients whose leg veins have been used
for open-heart surgery; chronic untreated kerions can
result in scarring alopecia, and untreated cutaneous
candidiasis can result in bacterial infection.
In this lesson, we'll cover data collection, diagnosis, and
management of the following fungal disorders that may
result from intertrigo:
Tinea (fungal infections caused by dermatophytes)
Cutaneous candidiasis (diaper rash)
About Tinea
Tinea: Incidence
The estimated cost of treatment of fungal
infections in the United States in 1994 was $400
million
Tinea is manifested most commonly in children
as scalp infections
Tinea capitis is more common in AfricanAmerican children than in children of other races
The incidence of onychomycosis increases with
age
Tinea: Pathophysiology
Tinea: History
Current complaint
Location and duration of occurrence
Associated symptoms, including itching, burning,
pain, or excessive sweating
Current treatments
Contact with infected animals or persons
History of shared combs, towels, or clothing
Recent travel
Use of communal showers or swimming areas
Environmental exposures, such as contact sports
and use of sports facilities or activities such as
swimming and gardening
Tinea: History
Medical history
General medical condition, especially status of hepatic,
renal, and endocrine systems and presence of
immunosuppressive disorders
History of previous occurrence and past treatments
History of other skin disorders or allergies
Medication history
Current medications
Family history
History of tinea infections
History of other skin disorders
Other family members with skin disorders
Psychosocial history
Living conditions
Tinea: Treatment
Pharmacologic
Topical creams are the preferred treatment for all forms of tinea
except tinea capitis, tinea barbae, and onychomycosis, which require
a combination of topical and oral medications
Common adverse effects of oral antifungal medications include
gastrointestinal complaints and headache
Pharmacologic: capitis and barbae
Prescribe 2.5% selenium sulfide shampoo to prevent the spread of
infection
Advise use of 1% Selsun Blue shampoo (can be purchased over the
counter [OTC])
Griseofulvin (Fulvicin) is the only agent approved for tinea capitis;
however, resistant organisms require an increased dosage and
longer duration of treatment
Griseofulvin, terbinafine (Lamisil), ketoconazole (Nizoral), and other
agents differ in their dosages for children and adults
Griseofulvin has the most adverse effects, followed by ketoconazole,
itraconazole, and terbinafine
Prescribe prednisone 1 to 2 mg/kg daily for 5 to 10 days for adults
with inflammatory tinea capitis
Check drug interactions before prescribing
Tinea: Treatment
Pharmacologic: corporis
A topical agent such as miconazole nitrate 1%
(Monistat), clotrimazole 2% (Lotrimin), and econazole
1% (Spectazole) is usually effective
Advise patients to continue applying topical agents twice
daily for 2 weeks after clinical signs and symptoms have
disappeared
Oral agents are for widespread, inflammatory, or
resistant infections
Pharmacologic: versicolor
Topical agents such as selenium sulfide lotion 2.5%
(Selsun), miconazole cream 2.5%, clotrimazole 1%, and
thiosulfate 25% are effective
Advise patients to apply beyond the borders of the
affected areas for 5 to 10 minutes every day for 2 weeks
Oral medications usually are not needed but may be
used in resistant cases or for prophylaxis
Tinea: Treatment
Pharmacologic: pedia and manuum
Clotrimazole, miconazole, tolnaftate, or terbinafine hydrochloride
cream, applied twice daily to the feet, should be continued for 2
weeks after the condition has cleared
Butenafine 1% may also be used daily after bathing for 4 weeks
Talcum powder or antifungal powders (OTC) can be used
In severe cases, Burows solution can help with oozing lesions
Pharmacologic: cruris
Clotrimazole or miconazole topical cream may be applied twice daily
for 3 to 4 weeks
In children, 1% terbinafine may be applied daily for 7 days
Butenafine 1% may be applied daily after bathing for 2 weeks
Oral treatment may be administered in resistant cases
Pharmacologic: onychomycosis
Oral medications are more effective than topical medications
Advise patients to avoid antacids within 2 hours of taking oral
medications
Tinea: Treatment
Nonpharmacologic
The affected child may return to school
after beginning oral therapy
A child in the daycare setting does not
need to be isolated once treatment has
begun
Tinea: Education
Explain that adverse effects and drug interactions are associated with oral
antifungal medications
Teach the patients to avoid sharing brushes, combs, hats, towels, and other
items that can transmit fungal scales and to keep his or her own items clean
Stress the importance of good hygiene and suggest the use of a benzoyl
peroxide wash
Encourage the patient to treat pets that may be infected
Tell the patient to avoid braiding their hair or using oils on the hair or scalp
Suggest the application of creams after bathing and reapplying after
swimming or exercising
Encourage the patient to keep the skin dry and to remove wet swimsuits as
soon as possible
Suggest cotton undergarments and loose-fitting clothes
Advise the patient with fungal disorders of the feet to wear leather or
nonocclusive shoes with cotton socks, to use drying powders on the feet,
and to wear sandals or rubber shoes in communal areas as appropriate
Explain that the recurrence rate is high and that treatment may be needed
each spring before sun exposure, especially to stop the redevelopment of
tinea versicolor
Explain that it may be necessary to order cultures and treat other family
members
Encourage all family members to use selenium sulfide shampoo to prevent
recurrences caused by asymptomatic carriers
Introduction
Skin problems caused by infestations of lice
(body, head, or pubic) and scabies are inevitable
diagnoses faced by the family nurse practitioner
in practice today. Left untreated, infestations can
result in continued infestation, "vagabond's skin"
(lichenified, scaling, hyperpigmented papules,
most commonly on the trunk), and multiple
pyodermas of the scalp, as well as secondary
infection, plus psychosocial discomfort because
of the stigma attached to these disorders.
This lesson focuses on recognizing, managing,
and preventing the spread of such infestations.
Lice: Incidence
Pedicular infestation of the skin or hair is caused by a species of
blood-sucking lice capable of living as external parasites on the
human host
Three types of lice that inhabit the human host are Pediculus
humanus corporis, Pediculus humanus capitis, and Phthirus pubis
Between 6 million and 12 million cases occur each year in the United
States and hundreds of millions of cases exist worldwide
Most cases of lice infestation (50% to 75%) occur in children younger
than 12 years old
Lice can be epidemic in daycare centers, kindergartens, and schools
Lice infestation occurs in all ages and socioeconomic groups and in
all geographic regions
Infestations are less common in blacks than in whites
Infestations may occur in any season but are most common August
through November
Lice are generally transmitted by way of contact with bedding or other
human beings, but each type of infestation has a specific incidence
Lice: Pathophysiology
Lice are ectoparasites that, when spread by way of direct
or fomite contact, pierce the skin to feed (shown here)
When the louse bites, it first infuses saliva to prevent
clotting and then probes for a vessel
The female louse lays 100 to 300 eggs (nits) during its
lifetime
The louse cannot live away from a human host for more
than 50 to 55 hours
The saliva of the louse provokes symptoms through a
histamine response
Secondary skin lesions are common because of
scratching; lymphadenopathy and irritation at the
scratched sites may indicate infection
Certain factors increase susceptibility to pediculosis
capitis, pediculosis corporis, and pediculosis pubis
Lice: History
Current complaint
Known exposure to lice
Intense itching (the hallmark of louse infestation),
often worse at night, particularly on the back and
at the side of the scalp and, in pediculosis capitis,
at the occipital hairline and in the postauricular
area
Sleeplessness
Irritability
Difficulty concentrating in school because of
itching and fatigue resulting from interrupted
sleep
Lice: History
Family history
Infestation in any family member or close associate
Psychosocial history
Enrollment in daycare, kindergarten, school, or camp
Sharing of clothing or hairbrushes, combs, barrettes, wigs, hats, and
other hair-care items
Participation in sports in which equipment is shared
Homelessness, residence in a crowded environment, or other factor
preventing regular bathing, shampooing, and laundering of clothing
Sharing of clothing, pillows, or bedding
Whether the patient wears clothing from yard sales or thrift shops
and whether he or she launders these items before use
Number of sexual partners
Possibility of sexual abuse in a child
Perceptions of the problem (infestation carries a stigma, and many
misconceptions about lice infestation exist)
Lice: Treatment
Nonpharmacologic
Commercial preparations such as
GenDerm's Step 2 ease nit removal
A solution of one part white vinegar to one
part water may also be used to loosen nits
A nit comb (metal works best) helps
remove all nits from the hair
Petrolatum applied twice a day for 10 days
aids in the treatment of infested eyelashes
Lice: Treatment
Pharmacologic
A pediculicide such as a pyrethrin, permethrin,
lindane, ivermectin, or malathion is required to kill
lice and nits
During application of a pediculicide, the patient's
eyes must be covered and shut
Most pediculicides are contraindicated in children
younger than 2 years, in pregnant women and in
lactating women
Treat secondary infections with antibiotics such
as erythromycin, dicloxicillin, or cephalosporin
Treat eyelash infestations on the basis of the age
of the patient
Lice: Education
Reassure the patient and family that pediculosis is curable,
does not cause long-term effects, and is a common problem in
all socioeconomic groups
Because lice are transmitted from person to person, educate
children and parents about transmission and preventive
measures
Teach the patient or caregiver how to disinfect the personal
articles of the infested individual and how to clean the
environment
Recommend that all family members and close contacts be
examined for infestation and undergo treatment at the same
time as the patient (in the case of pediculosis pubis, this
includes sexual partners)
Advise parents to inform school authorities about any child with
lice infestation
Reinforce the importance of exposing all lice and nits to
pediculicide and destroying or removing all nits from infested
hair
Lice: Follow-Up
During louse season, have the parent
check the child's hair every 3 days
Several days after treatment, have a
family member reexamine the child
Ensure that pediculicide is reapplied 7 to
10 days after the initial treatment
For pediculosis pubis, ensure that all of
the patient's sexual contacts during the
previous month undergo treatment
Lice: Referral
Refer children younger than 2 years to a
physician
Refer a pregnant or lactating woman to a
physician
Referral is indicated if treatment fails
Any patient with a coexisting dermatologic
condition should be referred to a physician
Pediculosis pubis in a child should cause the
nurse practitioner to suspect sexual abuse; the
appropriate authorities should be notified in such
cases
Scabies: Incidence
Scabies (Sarcoptes scabiei) exists in two
variants: nodular and crusted (Norwegian)
Scabies is most common in children, young
adults, institutionalized persons of all ages, and
persons with acquired immune deficiency
syndrome
Incidence is persistently high in developing
countries and in overcrowded housing
elsewhere
Norwegian scabies is more common than the
nodular variant among the immunodeficient and
those with mental or physical disabilities such as
Down syndrome, neurologic disease, or
malnutrition
Scabies: Pathophysiology
The mite that causes scabies infestation is an obligate parasitethe human skin itch
mite, known as Sarcoptes scabieian oval, gray, or translucent parasite 0.3 to 0.5
mm long
Close contact is necessary for transmission
The impregnated female mite Burows into the skin, using chemical factors in the
saliva to dissolve keratin on the skin's surface
Once in the Burow, the female remains there her entire life (approximately 30 days),
laying two or three eggs per day
The eggs hatch in 3 or 4 days and the mites reach maturity in approximately 4 days,
after which they migrate to the surface, mate, and repeat the cycle
A person infested with classic (nodular) scabies who bathes frequently may have
more than 50 mites in the skin; with the Norwegian type, thousands of mites may be
involved
Symptoms, which occur 4 to 6 weeks after the first infestation, are the result of a
hypersensitivity reaction caused by mite saliva and feces (scybala) deposited in the
skin
People who are infested with scabies more than once experience symptoms in 24 to
48 hours after succeeding exposures
In rare cases transmission occurs by way of fomites such as towels and linens; the
mite can live for as long as 5 days away from the human host
Diagnosis is sometimes difficult because the scratching provoked by intense itching
obscures the classic signs
The distribution of lesions and multiple individuals affected in the same residential
setting should increase the index of suspicion for scabies infestation
Scabies: History
Current complaint
Generalized pruritic rash, particularly on the
hands, flexor portion of the wrists, elbows,
axillary folds, buttocks, breasts, abdomen, and
genitals
Intense intermittent itching, especially nocturnal,
intensifying with increased warmth of skin and
persisting for weeks after treatment; itching may
not be noted, however, by an
immunosuppressed patient
Sleeplessness resulting from intense pruritus
Scabies: History
Medical history
Previous infestation
Previous episodes of itching
Family history
Similar symptoms in family members or close
contacts, especially those living with the patient
Psychosocial history
Multiple sexual partners
Daycare, school, or camp attendance
Institutionalization
Residence in a nursing home
Scabies: Treatment
Nonpharmacologic
All bed linens and clothing that have been used
or worn in the preceding 3 days should be
washed in hot water with detergent and dried in
a hot dryer or dry cleaned
Bed linens should be washed in hot water daily
until the course of treatment is finished
Because the mite cannot survive off the host for
more than 3 days, items that are not washable
can be sealed in a plastic bag for 7 days to kill
the mites
Scabies: Treatment
Pharmacologic
Oral antihistamines and mild topical corticosteroid agents may be
needed after treatment to help control pruritus
Permethrin 5% (Elimite) is the preferred treatment because of its low
toxicity and high efficacy
Lindane 1% (Kwell) lotion is considered an alternative treatment
because of organism resistance and its neurotoxic effects in infants
Crotamiton 10% (Eurax) cream or lotion is less effective than
permethrin but is considered safe for infants and pregnant and
nursing women
A sulfur preparation (precipitated sulfur 5% to 10%) is the preferred
treatment for infants younger than 2 months, pregnant or nursing
women, and people who cannot afford other treatments
Ivermectin can also be used as an alternative treatment, but its
safety and efficacy have not been established in children weighing
less than 15 kg
Secondary bacterial infections should be treated as well
Scabies: Education
Introduction
In this lesson we'll review several skin
conditions seen in primary-care practice:
Paronychia
Pityriasis rosea
Erythema multiforme
Stevens-Johnson syndrome
Paronychia: History
Current complaint
Pain or throbbing in the affected finger or
toe
Swelling and redness around the nail
Changes in the nail plate
Onset and progression of symptoms
Relieving and aggravating factors
Treatment strategies attempted
Associated symptoms
Trauma of the affected area
Paronychia: History
Medical history
Chronic illness, particularly diabetes
mellitus
Allergies
Medication history
Any prescription or nonprescription drugs
taken
Psychosocial history
Employment or leisure activities that
require immersion of hands for long
periods
Paronychia: Treatment
Nonpharmacologic
Elevation of the affected digit to relieve throbbing pain
Warm compresses or vinegar soaks in the acute form
Keep the digits dry in the chronic form
Incision and drainage if an abscess forms
Partial or complete removal of an ingrown toenail to
promote healing
Pharmacologic
Antibiotics for acute condition in patients with diabetes,
in cases involving suppuration, and in severe cases
Topical or systemic treatment for chronic paronychia of
bacterial or fungal origin
Paronychia: Education
Teach bartenders, nurses, dishwashers, and other
patients whose work involves prolonged immersion of
the hands to keep the hands dry and encourage the use
of lined rubber gloves when possible
Educate the parents or caregiver of a thumb- or fingersucking child about the condition and encourage the
child to quit
Teach the proper procedure for cutting the nails to help
prevent ingrown nails
Discuss ways to minimize the risk of trauma to the
fingers or toes
Encourage patients with diabetes to maintain good
control of the disease
Explain that complications include abscess and chronic
changes to the nail and, possibly, nail loss
Stevens-Johnson Syndrome:
Pathophysiology
The causative agent is sometimes
unknown, but drug intolerance accounts
for 80% of cases
Infections, especially Mycoplasma, are a
less common cause
Some drugs are associated with SJS, and
some vaccines are considered
precipitators
The syndrome often begins with a flulike
prodrome
Introduction
Psoriasis is a chronic disorder that results
from a polygenic predisposition combined
with such triggering factors as trauma,
infections, and medications. In this lesson,
we'll review the presentation, diagnosis,
and management of this disorder.
Incidence
Pathophysiology
Both systemic and local factors are involved in the
pathogenesis of psoriasis
The abnormality in psoriasis is an alteration of the cell
kinetics of kerotinocytes
The cell cycle shortens from 311 to 36 hours, resulting in
28 times the normal production of epidermal cells
The epidermis and dermis react as an integrated system:
Cell production changes in the germinative layer of the
epidermis, and inflammatory changes in the dermis
trigger the epidermal changes
Psoriasis is a T-celldriven disease; many T-cells are
present in psoriatic lesions surrounding the upper dermal
blood vessels, and the cytokine spectrum is that of a Th1
response
Maintenance of psoriatic lesions is considered an
ongoing autoreactive immune response
History
Current complaint
Pruritus (particularly of the scalp and anogenital areas)
Pustules, papules, and red plaques
Lesions
Arthritis (resembles rheumatoid arthritis)
Fever
Symptoms of strep throat
Acute illness
Stripping, pitting, fraying or separation of the distal margin of
the nail and thickening discoloration and debris under the nail
plate
Associated symptoms such as joint pain (psoriatic arthritis);
weakness, chills, and fever (von Zumbusch syndrome);
hypothermia in older patients; and hemodynamic changes
such as shunting of blood to the skin
Duration and location of symptoms and whether onset was
sudden
History
Family history
Skin disorders
Medication history
Corticosteroids
Lithium
Chloroquine
-Blockers or interferon-
Psychosocial history
Patient's view of disorder (stigma of having a visible skin
disorder)
Stressors
Alcohol consumption
Dietary history (for calorie count, especially in older
patients, who have an increased metabolic rate)
Physical Examination
Examination
Have the patient completely undress and put on a gown
for privacy
Note the patient's general appearance, ranging from well
to uncomfortable to toxic, based on the extent of
involvement of the psoriasis
Record vital signs: height and weight, blood pressure,
temperature, pulse, and respirations
Examine the skin and scalp systematically to determine
the extent, distribution, type, and shape of the lesions
Check the fingernails for pitting or other changes
Examine the mucous membranes and tongue
Examine all areas of flexure, including the groin and
buttocks
Check the lesions for the Auspitz sign (bleeding when a
scale is removed)
Estimate the body surface area (BSA) involved
Physical Examination
Diagnostic procedures
Throat culture for group A -hemolytic
Streptococcus infection
Determination of human immunodeficiency virus
serostatus in at-risk individuals with sudden
onset of psoriasis
Rheumatoid factor determination, erythrocytesedimentation rate, and uric acid level testing if
joint inflammation is present
Skin biopsy, read by a dermatopathologist if any
doubt exists about the diagnosis of psoriasis
Potassium hydroxide prep to rule out tinea of the
skin or nails
Physical Examination
Differential diagnosis
Guttate psoriasis: drug eruption, pityriasis rosea, or
secondary syphilis
Small scaling plaques: seborrheic dermatitis, lichen
simplex chronicus, psoriaform drug eruption, tinea
corporis, or mycosis fungoides
Large geographic plaques: tinea corporis, or mycosis
fungoides
Scalp psoriasis: seborrheic dermatitis or tinea capitis
Inverse psoriasis: tinea, candidiasis (see image),
intertrigo, extramammary Paget disease, glucagonoma
syndrome, Langerhans-cell histiocytosis, or Hailey-Hailey
disease
Nail involvement: onychomycosis
Treatment
The aim of treatment is to bring the psoriasis into remission
or an inactive state. Pharmacologic therapy may be
topical, photo, or systemic, depending on the type and
extent of disease. Treatment may be stopped when
lesions can no longer be felt as raised, even if residual
erythema, brown hyperpigmentation, or
hypopigmentation persists.
Nonpharmacologic
Stress-reduction techniques
Limited sun exposure
Weight-loss counseling
Smoking cessation
Emotional and psychological support
Good skin care, with an emphasis on keeping the skin
well hydrated and lubricated
Treatment
Pharmacologic: topical therapy
Most patients with localized plaques on the trunk and extremities can
be treated with the use of topical therapy alone
Therapy consists of topical fluorinated glucocorticoids in an ointment
base, applied once scales have been removed after soaking in water
Treatment for small lesions consists of intradermal injections with
triamcinolone suspension
Vitamin D analogues and Tazaroten (topical retinoid) are other
alternatives
Pharmacologic: phototherapy
Narrow-band UVB and psoralen and long-wave UV radiation (PUVA,
also called photochemotherapy) are used
Treatment consists of two or three sessions per week
Most patients respond to treatment after 19 to 25 sessions
Pharmacologic: systemic therapy
Oral retinoids are most effective when combined with
photochemotherapy
Methotrexate is not used in young patients because of its liver toxicity
Cyclosporine, which is nephrotoxic, is only used in patients without risk
factors
Monoclonal antibodies and fusion proteins, under development, are
used only by dermatologists at this time
Education
Explain that psoriasis is a chronic condition that can be
controlled but not cured
Reassure the patient that the disease is not contagious
Because most patients feel that psoriasis adversely
affects their quality of life, give them the opportunity to
discuss these feelings
Offer encouragement and assistance in smoking
cessation, weight loss, and development of an exercise
regimen
Teach stress-reduction techniques and help the patient
identify stressors
Advise the patient to avoid trauma to the skin that may
cause psoriasis to "Koebnerize" to areas injured during
invasive activities such as shaving
Explain the complications of misuse of topical
corticosteroids
Follow-Up
Follow up 2 to 3 weeks after therapy is initiated,
then see the patient to check for side effects
every 2 to 3 months
Reinforce the need for compliance with
prescribed treatment regimens
Because this is a chronic, recurrent disorder,
offer patients practical counseling at each visit
on ways to deal with the disorder
If you are not concerned that a patient will
overuse or misuse topical medications, provide
ample refills so the patient can control the
condition on his or her own
Referral
Refer patients whose psoriasis is difficult to
manage or unresponsive to treatment after 2 to
4 weeks to a dermatologist for management
Refer all pediatric patients and adult patients
with psoriatic involvement of more than 15% of
the BSA or with moderate to severe disease to a
dermatologist for management; many are
candidates for phototherapy or systemic therapy
Consider referring the patient to such sources of
patient information as the
National Psoriasis Foundation and eMedicine's
Skin, Hair, and Nails Center
Introduction
Alopecia is the loss of hair from any part of
the body where hair normally grows. The
condition can be extremely distressing to
the affected person, so careful, sensitive
assessment and management are
important.
In this lesson, we'll cover the presentation,
diagnosis, and management of the
nonscarring forms of this condition.
Incidence
Hair occurs everywhere on the body except for the lips, palms, and
soles. There are approximately 120,000 hairs on the scalp and 5
million fine vellus hairs all over the body.
Hair loss is a common and distressing symptom that affects men
and women of all ages
Androgenetic alopecia (common balding) is the most common
cause of hair loss, typically beginning anytime after puberty, when
androgens are synthesized
In the United States, about half of all men and women show some
expression of androgenetic alopecia by age 40
Alopecia areata (patchy balding; see image) is found in 1.7% of the
population
The first patch appears in 60% of patients with alopecia areata
before age 20
Familial incidence of alopecia areata is 37% in patients who had
their first patch by age 30 and 7.1% in those whose first patch
appeared after age 30
Women commonly experience postpartum hair loss (telogen
effluvium)
One third to one half of all cases of alopecia areata start by age 20
Pathophysiology
Hair is composed of keratin, the same material that makes up the fingernails and
toenails
With baldness, hairs are not actually lost; instead, they become vellus
Each hair follicle perpetually goes through three stages in the growth cycle:
catagen (transitional phase), telogen (resting phase) and anagen (growing phase)
Alopecia is classified on the basis of distribution (generalized versus localized)
and scarring potential (scarring, or cicatricial, versus nonscarring, or
noncicatricial)
Nonscarring hair loss appears to be caused by injury resulting from a physical or
physiologic agent or immunologically mediated inflammation. In the section of the
hair follicle known as the bulge, where stem celllike activity controls follicle
regeneration and cycling; if this area is permanently injured, hair will not regrow
Most localized, nonscarring hair loss is hereditary and is caused by androgens
present in both men and women (see image)
The immune system can also cause hair loss
Hair loss resulting from certain causes can be reversible when those causes are
eliminated
Localized, nonscarring alopecia usually results from changes in follicle cycling
Types of generalized, nonscarring alopecia include telogen effluvium and anagen
effluvium
Scarring alopecias have other causes (e.g., discoid lupus, lichen planopilaris,
folliculitis decalvans)
Hair loss that occurs rapidly can be a sign of serious disease
History
Current complaint
Onset, duration, and severity of symptoms
Rate and timing of hair loss
Local or generalized hair loss
Other scalp symptoms (e.g., itching, tingling, burning)
Medical history
Ask about crash diets, post-pregnancy status, trauma,
infection, tinea capitis, collagen vascular disease,
neoplasms, and thyroid disease
Assess drug allergies
Menstrual and reproductive history
Current birth-control method
Recent physical trauma
Recent weight loss or gain
Recent febrile illness
History
Family history
Male- or female-pattern baldness
Arthritis
Medication history
Prescription or over-the-counter (OTC) medications,
vitamins, or herbal supplements, some of which can
cause alopecia
Psychosocial history
Dieting
Increased stress
Use of curlers, hair dyes, straightening agents, or hot
combs
Impact of disease on patient and family with respect to
issues of disfigurement, occupational disability, and
psychosocial impact
Physical Examination
Examination
Note the presence of scars, erythema, scaling, inflammation,
follicular plugging, folliculitis, bogginess, or induration
Observe the density and distribution of hair-focal, diffuse, and malepattern and female-pattern loss
Examine the hair shaft for caliber, length, shape, and fragility (in the
image shown here, a normal hair fiber under polarizing microscopy,
the medulla is blue, the cortex is pink-red, and the cuticle is yellow)
Look for a well-circumscribed oval or circular nonscaly patch of
nonscarring hair loss with proximally tapering exclamation-point
peripheral hairs (alopecia areata)
Palpate the thyroid to assess size, nodularity, and vascularity
Use the "pull test" technique for hair loss
Determine whether eyebrow, eyelash, axillary, or body hair is
affected and examine hair density in other areas (e.g., face,
extremities)
Examine the fingernails
Conduct a complete physical examination, if one is indicated on the
basis of the history and findings of the scalp examination
Physical Examination
Diagnostic procedures
After ruling out other causes of hair loss, consider
laboratory tests for secondary conditions
For female alopecia with symptoms of
hyperandrogenism, check total testosterone, free
testosterone, dehydroepiandrosterone sulfate
(DHEA-S), or prolactin levels
For male and female alopecia without symptoms
of hyperandrogenism, consider other tests to rule
out thyroid disease, syphilis, anemia,
autoimmune disease, fungal or other infection,
tinea capitis (see image), and neoplasm or
inflammatory process
Physical Examination
Differential diagnosis
Nonscarring local alopecia: androgenetic
or alopecia areata
Generalized nonscarring alopecia: telogen
and anagen effluvium caused by
medications, illness, or pregnancy
Trichotillomania or traction alopecia (see
image; caused by tight braiding)
Scarring alopecia (discoid lupus or
folliculitis decalvans)
Treatment
Nonpharmacologic
Cosmetic measures (e.g., changes in hairstyle, wigs, extensions,
hairpieces, and scarves)
Ceasing to wear tight braids, buns, or hairpins
In chemical/allergic causes, avoidance of the identified sources
Laser therapy is showing some promise
Pharmacologic
In secondary causes of alopecia, treat the underlying medical
condition
For trichotillomania, consider behavioral therapy, antianxiety or
antidepressant medication, or a combination, preferably under the
supervision of a mental-health professional
Treat alopecia areata with steroid intralesional scalp injections,
topical steroids, or anthralin or systemic corticosteroids
Consider a hair-growth stimulant such as minoxidil (Rogaine) or
finasteride (Propecia)
Also consider monotherapy or synergistic use, such as adding
estrogen to any therapy (women) or adding tretinoin (Retin-A)
topical as an adjunct toor synergistically withminoxidil (men and
women)
Education
Educate the patient about cause and treatment of hair loss, if known
Discuss the use of medication for regrowth in nonscarring alopecia
Explain the costs and side effects of drug therapies
Make patient aware of transplants (more effective in men) under the
appropriate conditions
Give advice on wigs and hairpieces
Tell the patient to avoid caustic agents in the hair and to avoid
alkaline shampoos
Instruct the patients to comb his or her hair and avoid excessive
brushing
Warn the patient against excessive dieting
For the patient with positive findings of the hair-pull test, provide
anticipatory guidance during the period of extensive hair loss as the
cycle reestablishes itself and regrowth begins; explain that changes
take time and encourage the patient to stick with the regimen for 3 to
6 months
Help the patient and family come to terms with hair loss
Help the patients evaluate his or her therapy, including willingness to
adhere to the treatment regimen and awareness of quality of life and
satisfaction with results
Introduction
In this lesson we'll review three common
skin cancers: basal-cell carcinoma,
squamous-cell carcinoma, andthe most
seriousmalignant melanoma. The family
nurse practitioner plays a key role in
minimizing the risks of skin cancer through
patient education, early recognition of
cancer, and timely referral to a
dermatologist for management.
Incidence
Pathophysiology
It is not known exactly what triggers the conversion of a
precancerous lesion to a cancerous one, but a variety of
factors increase the likelihood of skin cancer:
History of sunburn or intense, intermittent sun exposure
Living or spending extended periods at high altitude (the
atmosphere provides less protection) or near the equator,
where the sun is more intense
Smoking
Immunosuppression
Exposure to industrial carcinogens
Light hair (red or blond) and blue eyes
White race
Inability to tan (more likely to sunburn or freckle)
Age
Radiation treatment and radiograph exposure
History
Current complaint
Duration of lesions
Changes in lesions over time, especially those that are
quick or aggressive
Systemic symptoms (e.g., fatigue, weight loss)
Signs or symptoms of suspected noncancerous and
cancerous lesions
Patient's coloration
Medical history
Chronic illness
Immunosuppression
Previous skin cancers or precancerous lesions (and their
treatment)
History
Medication history
Corticosteroids
Medicines containing arsenic
Family history
Melanoma
Familial atypical mole and melanoma syndrome
(FAMMS), which puts the patient at a lifetime risk
nearing 100% for the development of melanoma
Psychosocial history
Occupation involving exposure to the sun, radiation, or
industrial chemicals
Outdoor leisure activities and hobbies
Sunbathing or use of a tanning parlor
Use of sunscreens
Physical Examination
Examination
Have the patient undress; provide draping for maximum privacy
Ask the patient to remove concealing cosmetics for good observation
of a lesion, if necessary
Inspect the entire body for lesions
Look for characteristics of BSC, SCC, lentigo maligna melanoma,
superficial spreading melanoma, acral lentiginous melanoma,
amelanotic melanoma, seborrheic keratosis, actinic keratosis, and
nevi
Use the ABCDE approach to skin inspection; positive findings should
inspire a high index of suspicion for malignant melanoma
If lesions were photographed during previous evaluations, compare
and contrast those images with the current findings
Note atypical nevi and the existence of more than 50 moles larger
than 2 mm in diameter
Check the scalp, mucous membranes, and the lymph nodes draining
the area of any lesions found
Use an epiluminescence microscope to magnify and illuminate
lesions
Physical Examination
Diagnostic procedures
Skin biopsy (usually performed by a
dermatologist), particularly when certain signs
are present
Differential diagnosis
Seborrheic keratosis
Traumatized nevus
Lentigo
BSC
SCC
Malignant melanoma
Hemangioma
Pigmented actinic keratosis
Treatment
Nonpharmacologic
Remove noncancerous lesions with the use of
electrocautery or liquid nitrogen
Before referring a patient with a cancerous lesion or one
suspected of being malignant for removal, photograph all
lesions and record the location, name, and size of each
lesion, along with the date, in the patient's record
Excisional biopsy and staging may be based on tumor
thickness in millimeters to the deepest penetration of the
tumor (Breslow measurement) or histologic microstaging
(Clark's level); the depth and margins of the surgical
excision are based on these two assessments
Removal of sentinel lymph nodes is also common
Treatment
Pharmacologic
Imiquimod 5% cream (Aldara) has been
shown in early trials to be an effective and
relatively safe nonsurgical alternative in
the treatment of superficial BSC
The use of interferon is controversial
Chemotherapy may be prescribed for
melanoma
Education
Explain that after lesions have been removed,
the patient may note hypopigmentation in the
area where they were
Tell the patient to perform a skin selfexamination every month and report changes to
the health-care provider; encourage family
members to assist in the inspection
Stress the importance of contacting the healthcare provider if certain signs are noticed
Provide guidelines for protection from sun
exposure
Warn women with melanoma lesions larger than
1 mm in diameter to avoid becoming pregnant
for 2 years; the risk of recurrence is greater
during that period
Introduction
In this lesson, we'll cover the following
viral skin disorders commonly seen in the
primary-care setting:
Molluscum contagiosum
Warts
Herpes simplex
Herpes zoster
Warts: Incidence
Warts are benign tumors of the skin
caused by the DNA human papillomavirus
(HPV). They are painless and appear on
hands or feet as a well-circumscribed
thickened lesion.
More common in children (7%-10% of the
population) between the ages of 12 and
16 years
More common in female patients than in
males
Warts: Pathophysiology
Various types of warts exist, including the common wart,
the flat wart, and the plantar wart
Susceptibility is increased in people taking
immunosuppressant agents, those who spend time in
locker rooms, and in those with atopic dermatitis
Butchers, meatpackers, and fish handlers are susceptible
to warts on their hands and forearms that seem to be
related to prolonged immersion in water and microtrauma
associated with the processing of meats and fish
Health-care professionals may be exposed to HPV in a
plume of smoke during laser or electrosurgical
procedures
Heredity by way of autosomal recessive inheritance
pattern is a factor in epidermodysplasia verrucifomis
(EDV)
Warts: History
Current complaint
Location of warts
Onset of symptoms
Primary or recurrent
Prodromal symptoms
Pain associated with secondary infection of
lesions
Symptoms associated with the onset of lesions
Relieving and exacerbating factors
Exposure to people infected with HPV
Signs and symptoms of gingivostomatitis
Warts: History
Medical history
Skin problems (and treatments)
Immunocompromise
Chronic illness
Allergies
Varicella
Family history
EDV
Varicella
Psychosocial history
Concern about appearance
Warts: Treatment
Nonpharmacologic
Watchful waiting, unless warts cause pain
Cryotherapy
Removal with the use of electrocautery, laser ablation, or
curettage
Occlusion with duct or waterproof tape
Foot soaks to help soften and ease removal of plantar
warts
Pharmacologic
Salicylic acid, daily transdermal delivery for 6 weeks
Trichloroacetic acid
Topical retinoids (for flat warts)
Imiquimod cream
Warts: Education
Explain that warts in epidermodysplasia may become
malignant
Reassure the patient that complete resolution is
expected with or without treatment
Teach the patient to cover a wart being subjected to
cryotherapy to prevent the escape of fluid from the
wound
Tell the patient that he or she can help prevent warts by
using personal shower shoes in locker rooms
Explain that autoinoculation and scarring are possible,
that injury to a nail with warts may result in nail deformity,
and that plantar warts that scar may cause chronic
discomfort when weight is being borne by the foot