1

SIGNS &
DISEASE DEFINITION CAUSES NURSING INTERVENTION
SYMPTOMS
DIABETER MELLITUS  also known as juvenile diabetes
or insulin-dependent diabetes
 Genetics
 exposure to viruses
 increased thirst
 frquent urination
Medical management:
 Insulin therapy
TYPE-1  chronic condition in which the and other  bed wetting in children  Diet - high in carbohydrates and fiber, and low in fat.
body produces little or no insulin environmental factors who previously didn't wet  Activity
due to autoimmune destruction of the bed during the night  continuous glucose monitoring
the beta cellls in the pancreas Risk factors:  extreme hunger
 family history  unintended weight loss Pharmacologic management:
 genetics  irritability or mood  Insulin - insulin taken orally to lower blood sugar may
 geography - increases changes be broken down by the stomach enzymes
as you travel away  fatigue or weakness  High blood pressure medications -
from the equator  blurred vision angiotensin-converting enzymes (ACE) inhibitors or
 age - children angiotension II receptor blockers (ARBs) to help keep
between 4 and 7 kidneys healthy; recommended for patients with BP
years old; above 140/90mmHG
children between  Aspirin - may be recommended by the physician to
10 to 14 years old take regularly to protect the heart.
 Cholesterol-lowering drugs *DUE TO THE RISK OF
HEART DISEASE
 LDL below 100mg/dL (2.6 mmol/L)
 HDL women: over 50 mg/dL (1.3 mmol/L)
 men: over 40 mg/dL (1 mmol/L)
 TRIGLYCERIDES less than 150mg/dL (1.7 mmol/L)

Nursing management
 dietary management
 physical activity
 insulin regimen / oral antidiabetic agents
 *care may also be complex as some of the patients
may suffer from other long-term conditions, such as
coronary artery disease
 ensure adequate and appropriate nutrition
 prevent skin breakdown
 prevent skin infection
 regulate glucose levels
 provide child and family teaching in the management
of hypoglycemia and hyperglycemia

CONTACT DERMATITIS  a type IV delayed hypersensitivity

reaction, is an acute or chronic
 water
 soaps - detergents,
 Bumps and blisters,
sometimes oozing and
Medical management:
 Avoiding the irritant - identify the substance so it can
skin inflammation that results shampoos, other crusting be avoided
from direct skin contact with cleaning agents  Red rash  Phototherapy - some patients need light therapy to
chemicals or allergens.  solvents - turpentine,  Itching, which may be calm their immune system.
 neither contagious nor fuel, kerosene, severe  Medicated baths - prescrivbed for larger areas of
life-threatening, but can be very thinners  Dry, cackled, scaly skin dermatitis.
uncomfortable  extremes of  Swelling, burning, or
2
ALLERGIC DERMATITIS  results from direct contact with
temperature tenderness Pharmacologic management
 Hydrocortisone - a corticosteroid, may be
substances called allergens. Risk factors: prescribed to combat inflamamation in a localized
IRRITANT CONTACT  occupation
 history of atopic
area.
 Antihistamines - prescription antihistamines may be
DERMATITIS dermatitis given if the non-prescription strength is inadequate.
 when skin comes into contact  gender - women  Barrier cream - can provide a productive layer for the
with an irritating substance. are more likely to skin.
PHOTOTOXIC CONTACT develop CD  Antibiotics - either topical or oral may be used to treat
DERMATITS  sun-burn like disorder resulting
because of
jewelry
the use of
and
secondary infection
Nursing intervention
from direct tissue damage fragrances  SKIN CARE. Encourage to bathe in warm water using
PHOTOALLERGIC following the UV light-induced
activation of phototoxic agent.
 age a mild soap, then air dry the skin and gently pat to
dry.
CONTACT DERMATITIS  TOPICAL APPLICATION. Usually applied twice a
day, spread thinly and sparingly.
 delayed-type hypersensitivity  PHOTOTHERAPY PREPARATION. This method
cutaneous reaction in response uses UV A or B light waves to promote healing of the
to a photoantigen applies to the skin.
skin in subjects previously  ACKNOWLEDGE PATIENT'S FEELINGS. Allow
sensitized to the same patient to verbalize feelings regarding their skin
substance. condition.
 PROPER HYGIENE. Encourage the patient to keep
the skin clean, dry, and well lubricated to reduce skin
trauma and risk for infection.
ULCERATIVE  an inflammatory bowel disease
(IBD) that causes inflammation
 exact cause is still
UNKNOWN
 Urgent/frequent need to
have BM
Medical management:
 PROCTOCOLECTOMY - complete removal of the
COLITIS and ulcers (sores) in the digestive  Loss of weight due to colon and rectum; patient will have a permanent
tract. Risk factors constant diarrhea, Low ileostomy.
 it affects the innermost lining of  age RBCs (anemia  ILEONAL ANASTOMOSIS (J-POUCH) - colon and
the large intestine (colon) and  race or ethnicity  Cramps in abdomen rectum removed and a pouch is created that is
rectum  family history (very painful) attached to the ileum to allow stool to pass from small
 Electrolyte imbalance, intestine to anus.
ULCERATIVE  inflammation is confined to the Elevated temperature
PROCTITIS area closest to the anus (rectum);
bleeding may be the only sign
 Rectal bleeding
 Severe diarrhea (pus,
Pharmacologic management
 Anti-inflammatory drugs - 5-aminosalicylates,
of the disease. blood, mucous) corticosteroids.
 Immune system suppressors - azathioprine and
mercaptopurine; cyclosporine; tofacitinib.
PROCTOSIGMOIDITIS  inflammation involves the rectum  Biologics - targets proteins made by the I.S;
and sigmoid colon, which is the infliximab, adalimumab, and golimumab;
lower end of the colon vedolizumab; ustekinumab
 Anti-diarrheal medications
LEFT-SIDED COLITIS  extends from the rectum up
through the sigmoid descending
 Pain relievers
 Antispasmodics
colon  Iron supplements
PANCOLITIS  often affects the entire colon and Nursing intervention
3
causes bouts of bloody diarrhea  Monitor VS, patient's BM (appearance and
that may be severe frequency), and bowel sounds.
 Keep patient hydrated.
 Monitor daily weight.
 Note for signs and symptoms of toxic megacolon and
peritonitis.
 May be NPO with IV hyrdration.
 DIET EDUCATION: Avoid during flare-up: high-fiber
foods, foods hard to digest, allergen type foods, and
spicy, high-fat foods.
 Foods to eat during flare-up: low fiber (easier to
digest), high-protein, and stay hydrated,
 Importance about regular screening of colon cancer.
TRANSPLANT  when there is not immunologic
tolerance to the new organ and
REJECTION the host’s immune system
damages the transplanted tissue.

 The damage is often most

evident in the vessels of the
donated tissue where antigens
lining the endothelium come into
contact with the immune cells
circulating in the hosts blood.

Hyperacute Transplant  Occurs almost immediately and

is often evident while you are still
 It is caused by
accidental ABO Blood
 Vessel Thrombosis

Rejection in surgery.
 type mismatching of the donor
and recipient.
 This means the host has
preformed antibodies against the
donated tissue.

Acute Transplant  the most common type of

rejection and usually has an
 Results in leukocyte
infiltration of the graft
 Vasculitis

Rejection onset between weeks and vessel.

months of the transplant.
 It is a T-Cell mediated response
against foreign Major
Histocompatibility Complex in the
donated organ. Therefore, it is an
example of Type IV
hypersensitivity.
 If identified early Acute Rejection
may be able to be treated with
immunosuppressants and
corticosteroids.
4

Chronic Transplant  Occurs months to years after the  Kidney Injury

Rejection transplant.
 The exact mechanism is not very
 Results in intimal
thickening and fibrosis
(Nephropathy)
 Accelerated
well understood but it probably of graft vessels as arteriosclerosis
involves a combination of Type III well as organ atrophy.  “Vanishing Bile Duct”
and Type IV hypersensitivity Sydrome
directed against the foreign MHC  T-cell Mediated cytokine
molecules which look like production
self-MHC presenting a foreign  Bronchiolitis
antigen.

 Donor T-Cells in the graft  diarrhea, rash and  Immunosuppressants are usually the treatment of
Graft vs. Host proliferate and attack the jaundice. choice
recipient’s tissue.
 This is most commonly seen in
Bone Marrow Transplants,
because the donated tissue has a
large amount of immune cells.
 The immune cells from the graft
spread through the body and
cause systemic symptoms that
are not isolated to the
transplanted organ.

MULTIPLE SCLEROSIS  a chronic demyelinating disease

that affects the myelin sheath of
 Exact cause is not
known yet


Cerebellar sign:
Nystagmus
 Medical management:

neurons in the CNS  Most theories  Ataxia  NO exact cure

suggest that MS is an  Disarhtria  Aim is to prevent or postpone the long term disability
immunogenetic viral  Dysphagia (often evolves slowly over many years)
disease (with Epstein  Treatment of acute relapses
Barr virus) Motor:  Treatment aimed at disease management
 Weakness or paralysis  Symptomatic treatment
Risk factors: of limbs, trunk or head
 Age(most of the  Diplopia Pharmacologic management
time between 20-40  Scanning speech  ABC (and R) Drugs- the main pharmacologic therapy
years)  Spasticity of muscles for MS
 Sex(more common that are chronically  Interferons beta-1a (Avonex)-IM injection once a
in women) affected week
 Family  Interferons beta-1b (Betaseron)-subcutaneously
history(genetic  Sensory: every other day
susceptibility)  Numbness, tingling  Glatiramer acetate (Copaxone)- Subcutaneous
 Certain  Patchy injection every day
infections(like Epstein blindness(scotomas)  Rebif -subcutaneous injection 3 times a week
Barr virus)  Blurred vision, dizziness *(For the treatment of relapsing MS)
 Climate(usually in  Vertigo, tinnitus,
cold areas) decreased hearing, Nutritional Theraphy:
5
 Certain auto chronic neuropathic  megavitamin therapy (cobalamin/vit. B12 and vit. C)
immune diseases pain, Romberg’s sign  low fat diet
(higher risks with  Radicular (nerve root)  high roughage diet(to relieve constipation)
thyroid disease, pain in lower thoracic
type-1 DM or IBD) abdominal region Other therapies:
 Smoking  Lhermitte’s sign-  Physical and speech therapies
 Stress, fatigue transient sensory  Exercise
 Physical injury symptom described as  Water exercise
 Pregnancy (may an electric shock
be relating to stress to radiating down the spine Surgical management
labour or puerperium) or into limbs with flexion Deep brain stimulation
of neck  if other options have failed then a device is implanted
that stimulates an area of brain. (incase of severe
Elimination tremor in limbs)
 Can’t hold urine; Implantation of a drug catheter or pump
nocturia, overactive  a catheter is placed in lower spinal area to deliver a
bladder constant flow of drug like baclofen.
 Retention
 Constipation, diarrhea, Nursing intervention
can’t hold stool  Promoting physical mobility
 Exercises
Emotional Problems:  Minimizing spasticity and contractures
 Fatigue (associated with  Activity and Rest
energy needs)  Minimizing effects of immobility
 Depression  Preventing Injury
 Deconditioning  Enhancing bladder and bowel control
 Medication side effects  Managing speech and swallowing difficulties
 Uhthoff’s sign- heat  Improving sensory and cognitive function
worsens signs and  Vision
symptoms  Cognition and emotional responses
 Strengthening coping mechanisms
 Improving self-care abilities
 Promoting Sexual Functioning
 Promoting home and community based care
 Teaching patients self-care
 Continuing care

LUPUS  Lupus is an autoimmune disease

in which the immune system
ERYTHEMATOSUS attacks healthy tissue. It affects
the joints, skin, brain, lungs,
kidneys, and blood vessels,
leading to inflammation and
tissue damage in the affected
organs.
6
Lupus dermatitis  Lupus affecting the skin in the
 redness, itching, pain
and eventual scarring
form of a rash

 muscle and joint pain

Drug-induced  This type of lupus occurs as a sometimes with swelling
lupus result of an overreaction to
certain medications such as
 flu-like symptoms of
fatigue and fever
Apresoline (hydralazine) or  Serositis certain
quinidine and Pronestyl laboratory test
(procainamide). It is similar to  abnormalities. of the skin
SLE.

 fatigue, skin rashes, Nursing goals of a client will systemic lupus

Systemic lupus fevers, and pain or erythematosus (SLE) may include relief of pain and
erythematosus  This type of lupus affects the
internal organs and is the
swelling in the joints.
 flares
discomfort, relief of fatigue, maintenance of skin
integrity, compliance with the prescribed medications,
(SLE) mostserious type.  remission and increased knowledge regarding the disease, and
 sun sensitivity, oral absence of complications.
ulcers, arthritis,
Neonatal lupus  lung problems, heart
 Lupus affecting an infant as a problems,
result of passively acquiring  kidney problems,
antibodies from a mother with seizures,
SLE  psychosis, and blood cell
and
 immunological
abnormalities.

HYPERSENSITIVITY Refers to undesirable immune

reactions produced by the normal
Mediated by sensitized T
cells and macrophages
Allergic Contact Dermatitis
Graft Rejection
DELAYED immune system Caused by inflammation
resulting from cytokines
produced by CD4+ T
Type I ( Anaphylactic) The most severe from of cells and cell killing by
hypersensitivity reaction. It is an CD8+ T cells
immediate reaction beginning within
minutes of exposure to an antigen

Type II (Cytotoxic) Occurs when the system mistakenly

identifies a normal constituent of the
body as foreign.

Type III (Immune involves immune complexes formed

when antigens bind to antibodies.
Complex)
7
Type IV (Delayed type) also known
hypersensitivity.
as cellular

GLUMERULONEPHRITIS  is inflammation of the

 glomeruli, which are structures in
 Medical management
 temporary treatment with an artificial kidney
your kidneys that are machine to remove extra fluid and control high
 made up of tiny blood vessels blood pressure and kidney failure
 Antibiotics are not used for acute
glomerulonephritis, but they are important in
acute Certain illnesses are
known to trigger acute
 puffiness of your face in
the morning blood in
treating other forms of disease related to bacterial
infection.
glumerulonephritis GN, including: your urine (or brown  plasmapheresis. This process removes the fluid
 strep throat urine) urinating less part of your blood, called plasma, and replaces it
 systemic lupus than usual with intravenous fluids or donated plasma that
erythematosus  Shortness of breath and contains no antibodies.
 Goodpasture cough
syndrome Nursing management
 Amyloidosis COMPLICATIONS  Activity. Bed rest should be maintained until acute
 granulomatosis with  acute kidney failure symptoms and gross hematuria disappear.
polyangiitis  chronic kidney disease  Prevent infection. The child must be protected from
 polyarteritis  electrolyte imbalances, chilling and contact with people with infections.
such as high levels of  Monitor intake and output. Fluid intake and urinary
 certain immune sodium or potassium output should be carefully monitored and recorded;
chronic diseasesa  chronic urinary tract special attention is needed to keep the intake within
glumerulonephritis  history
cancerexposure
of
to
infections
 congestive heart failure
prescribed limits.
 Monitor BP. Blood pressure should be monitored
some hydrocarbon due to retained fluid or regularly using the same arm and a properly fitting
solvents fluid overload cuff.
 having the acute form  pulmonary edema due to  Monitor urine characteristics. The urine must be
of GN may make you retained fluid or fluid tested regularly for protein and hematuria using
more likely to overload high blood dipstick tests.
develop chronic GN pressure
later on.  malignant hypertension,
which is rapidly
increasing high blood
pressure
 Increased risk of
infections

ANAPHYLAXIS  serious, life-threatening allergic

reaction and can put your body


Food
medications
 Skin reactions, including
hives and itching and
Medical management
 Remove antigen.
into shock.  insect bites flushed or  Administer medications.
 latex  pale skin.  Cardiopulmonary resuscitation.
 Low blood pressure  Endotracheal intubation.
8
Risk factors  Constriction of your
 Allergies or asthma. airways and a
 Previous anaphylaxis.  swollen tongue or throat,
 Certain other which can cause
conditions wheezing and trouble
breathing.
 A weak and rapid pulse.
 Nausea, vomiting or
diarrhea.
 Dizziness or fainting.
Complication
 Respiratory obstruction
 Systemic vascular
collapse
 intravenous therapy
Pharmacological management
 Epinephrine.
 Diphenhydramine.
 Albuterol
Nursing management
 Monitor client’s airway.
 Monitor the oxygenation status.
 Focus breathing.
 Positioning.
 Activity.
 Hemodynamic parameters.
 Monitor urine output.

ADDISON DISEASE  is a disorder in which theadrenal

glands – which sit ontop of the
PRIMARY
INSUFFICIENCY
ADRENAL 

muscle weakness
fatigue and tiredness
Medical management
 Prescription of hormones similar to those made by
kidneys  prolonged  darkening in skin color the
 Do not produce enough of the administration  weight loss or decreased  adrenal glands; (HORMONE REPLACEMENT
hormones cortisol and  of glucocorticoids appetite THERAPHY)
aldosterone.  infections in your body  a decrease in heart rate  for instance, hydrocortisone pills to replace cortisol.
 cancer and abnormal or BP  aldosterone, you may receive fludrocortisone
growths  low blood sugar levels  acetate pills.
 tumors  fainting spells  Treatment focuses on corticosteroid replacement
 certain blood thinners  sores in the mouth therapy,
used to control  cravings for salt  usually in the form of tablets once or twice daily.
clotting in the blood  nausea  If you are taking fludrocortisone, your doctor might tell
 Vomiting you to increase your salt intake, especially in hot
SECONDARY  Irritability and humid weather and after vigorous exercise.
ADRENAL  Depression or other  In emergencies and during surgery, the medicine is
INSUFFICIENCY behavioral symptoms given
 tumors  Body hair loss or sexual
 medications dysfunction in women Nursing management
 genetics  Monitor for fluid deficits and hypernatremia
 traumatic brain injury  Monitor and treat hyperkalemia
 Obtain serum potassium and ECG
OTHER:  Administer sodium polystyrene
 Injury to the adrenal sulfonate(Kayexalate), insulin, calcium, glucose,
glands and sodium bicarbonate
 Infection, including  Monitor and treat hypoglycemia
tuberculosis,  Perform frequent neurologic checks, monitor for S/S
HIV/AIDS-related of hypoglycemia, and check serum glucose
infections, and  Administer food and/or supplemental glucose
fungal infections  Maintain a safe environment
 Cancer cells from  Provide assistance ambulating, raise side rails and
another part of the prevent falls by keeping floors clear
body that have
9
GOODPASTURE’S  Is a rare condition characterized
by glomerulonephritis and
SYNDROME hemorrhaging of the lungs
 usually reserved for the
autoimmune disease triggered
when the patient’s immune
system attacks Goodpasture
antigen (a type II hypersensitivity
reaction), which is found in the
kidney and lung, and in time,
causing damage to these organs
SCLERODERMA 

Calcinosis
Raynaud's syndrome
 Esophageal dysmotility
 Sclerodactyly
 Telangiectasia
 Is a systemic inflammatory
rheumatic disease and usually
results in more pathologies than
the five symptoms above
 Mainly affects the hands, arms
LIMITED CUTANEOUS and face, although pulmonary
SCLERODERMA hypertension is frequent
 Also known as morphea
DIFFUSE CUTANEOUS  Also known as systemic sclerosis
invaded the adrenal
glands
 Bleeding into the
adrenal glands
 Surgical removal of
the adrenal glands
 Amyloidosis
 Inherited component;  cough up blood or feel a  Corticosteroids and Immunosuppressants.
 Exposure to certain burning sensation when  Dialysis
chemicals, including urinating  Renal transplant
hydrocarbon solvents  first signs may be vague,  The concentration of anti-GBM antibodies in the
and the weed killer such as fatigue, nausea, blood may be reduced by apheresis to remove blood
Paraquat, and viral difficulty breathing, or plasma and replace a portion of the plasma with an
infections paleness isotonic salt and protein solution. This course of
 Autoimmune treatment usually lasts between three and six months
Lung disease
 dry cough and minor
breathlessness
 lung damage
Kidney disease
 loss of appetite and
malaise at first and then,
when the damage is
more advanced,
breathlessness, high
blood pressure and
edema
 nephritic syndrome,
Acute renal failure and
hematuria
 Pulmonary artery
hypertension which can
 There is no cure for this disease as there is no cure
for scleroderma in general. It slowly progresses and
result in heart failure. should be examined and treated as soon as it has
 Blood vessel thrombosis been diagnosed with immunosuppressives and other
and arteriosclerosis has medications
also led to the necessity
of amputation of fingers.
 Open leg sores can
result from burst blood
vessels and thin skin,
leading to chronic
infections.
 exhaustion, weakness,
difficulty of breathing,
dizziness and delayed
10
SCLERODERMA  Is rapidly progressing and affects
a large area of the skin and one
healing of wounds.

or more internal organs,

frequently the kidneys,
esophagus, heart and lungs, and
can be fatal. There are no
treatments for scleroderma itself,
but individual organ system
complications are treated
CALCINOSIS  Is the formation of calcium
deposits in any soft tissue

Dystrophic calcification  occur as a response to any soft

tissue damage, including that
involved in implantation of
medical devices

Metastatic calcification  involves a systemic calcium

excess imbalance, which can be
caused by hypercalcemia, renal
failure, milk-alkali syndrome, lack
or excess of other minerals, or
other causes.

Tumoral Calcinosis  generally characterized by large,

globular calcifications near joints
RAYNAUD’S  Is a vasospastic disorder causing
discoloration of the fingers, toes,
PHENOMENON and occasionally other
extremities.
 This condition can also cause
nails to become brittle with
longitudinal ridges.
 Is an exaggeration of vasomotor
responses to cold or emotional
stress. More specifically, it is a
hyperactivation of the
sympathetic system causing
extreme vasoconstriction of the
peripheral blood vessels, leading
to tissue hypoxia.
 "being allergic to coldness".
Primary Raynaud’s  thought to be at least partly
hereditary, although specific
genes have not yet been
identified.
 Sufferers are more likely to have
 Pain within the affected
extremities, discoloration
General care
 Avoid environmental triggers
(paleness) and  Keep your hands, feet and head warm
sensations of cold and/or  Quit smoking
numbness  Avoid caffeine and other stimulants and
vasoconstrictors
The symptoms include
several cyclic color Emergency Measures:
changes:  If (Raynaud's) occurs unexpectedly and a source of
 When exposed to cold warm water is available, allow slightly warm water
temperatures, the blood to run over the affected digits while you gently
supply to the fingers or massage the area.
toes, and in some cases  If triggered by exposure in a cold environment, and
the nose or earlobes, is no warm water is available, place the affected digits
markedly reduced; the in a warm body cavity. Keep the affected area warm
skin turns pale or white
 Smoking worsens (called pallor), and Drug Therapy
frequency and becomes cold and  Calcium channel blockers (nifedipine)
intensity of attacks, numb.  Angiotensin II receptor antagonists
and there is a  When the oxygen supply  Alpha-1 adrenergic blockers
hormonal component. is depleted, the skin  Sildenafil (Viagra) improved both microcirculation and
 Caffeine also worsens colour turns blue (called symptoms in patients with secondary Raynaud's
11
migraine and angina the attacks. cyanosis).
 These events are
Secondary Raynaud’s Occurs secondary to a wide variety episodic, and when the
of other conditions: episode subsides or the
 Connective tissue disorders area is warmed, the
 Eating disorders blood flow returns and
 Obstructive disorders the skin colour first turns
 Drugs red (rubor), and then
 Occupation back to normal, often
 Other accompanied by
swelling and tingling.
 Chronic, recurrent cases
of Raynaud
phenomenon can result
in atrophy of the skin,
subcutaneous tissues,
and muscle. It can also
rarely cause ulceration
and ischemic gangrene
phenomenon resistant to vasodilatory therapy
 Fluoxetine, a selective serotonin reuptake inhibitor,
and other antidepressant medications may reduce
the frequency and severity of episodes if caused
mainly due to psychological stressors.
Surgical Intervention
 In severe cases, a sympathectomy procedure can be
performed- the nerves that signal the blood vessels of
the fingertips to constrict are surgically cut
 Microvascular surgery of the affected areas is
another possible therapy.
 Infusions of prostaglandins, e.g. prostacyclin, may be
tried, with amputation in exceptionally severe cases

ESOPHAGEAL  A medical disorder causing

difficulty in swallowing,
MOTILITY DISORDER regurgitation of food and a
spasm-type pain which can be
brought on by an allergic reaction
to certain foods

SCLERODACTYLY  Localized thickening and

tightness of the skin of the fingers
or toes
 Commonly accompanied by
atrophy of the underlying soft
tissues

TELANGIECTASIAS  Are small dilated blood vessels

near the surface of the skin or
 They can also develop
on the legs, specifically
mucous membranes, measuring on the upper thigh,
between 0.5 and 1 millimeter in below the knee joint, and
diameter. around the ankles.
 They can develop anywhere on
the body but are commonly seen
on the face around the nose,
cheeks, and chin.