Integumentary System

Disorders
Dr. A. Campbell et al.
November 11, 2013

Objectives
1. Define terminologies relevant to skin
disorders
2. Describe the shape and configuration of the
various types of lesions
3. Differentiate between the types of lesions
4. Describe the aetiology, pathophysiology,
clinical manifestations and treatment of
selected skin disorders

Integumentary System Disorders - Terms

Macule small, flat spot about 1cm in
diameter
Eg. Freckle, petechiae

Papule elevated superficial lesion about 1cm

in diameter
Nodule solid marble-like lesions; deeper and
firmer than papule, greater than 0.5 cm in
diameter
Vesicle serous fluid-filled sac; vary in
diameter up 1cm.
eg. Herpes simplex

Bullae large fluid filled blisters; 1cm or more

Eg. 2nd degree burns

Integumentary System Disorders

Terms
Pustule small circumscribed elevation of
the skin filled with lymph or pus
Eg. Acne vulgaris and impetigo

Wheal raised, superficial, irregular area of

skin oedema; itchy
Eg. insect bite, hive

Plaque superficial elevated surfaces; 1cm

or more in diameter; formed by coalescence
of papules
Petechiae small, purplish haemorrhagic
spot or red spot from flea bites.

Primary Skin Lesions

Integumentary System Disorders

Terms

Rash temporary skin eruptions.

Eg. Diaper and heat rash
Scale small dry exfoliation shed from upper layer of
skin
Crust a scab; secondary lesion. Outer covering or
coat
Excoriation abrasion of the epidermis for eg. by
trauma

Integumentary System Disorders

Terms
Ulcer defect in which epidermis and papillary layer of
dermis are lost may extend to subcutaneous tissue.
Open sore; seen in pathologically damaged tissue
Lichenification thickened or leathery roughening of
the skin from continued irritation
Keloid scar formation in the skin following trauma or
surgical incision. Raised, firm, thickened scar; may grow
for prolonged period
Scar mark left in the skin by wound, sore, injury due
to replacement of connective tissue

Secondary Skin Lesions

Integumentary System Disorders

Additional Terms (Read)
Callus
- tumour
Corns
- patch (pigment)
Pigmented disorder
Eg. Vitiligo
Pruritis
Dry Skin

Integumentary System Disorders

General Clinical Manifestations
Primary Lesion eg. papule
Secondary lesion eg. Crust
Pigmented skin disorders eg. vitiligo
Pruritis
Dry skin
Inflammatory response
Pain/tenderness
Redness
Heat/warmth
Swelling

Configuration of Skin Lesions

Integumentary System Disorders

Treatment
Microscopy
Culture
Patch testing
Baths & dressings
Skin Biopsy
Aesthetic, aseptic procedures

Integumentary System Disorders

PSORIASIS
A chronic, noninfectious skin inflammation
involving keratin synthesis that results in
psoriatic patches
Psoriasis vulgaris is the most common form

Aetiology
Specific cause unknown
Stress, trauma, infection, and changes in
climate; the use of certain medications
Koebners phenomenon may develop from
psoriatic lesions at a site of injury, eg. a
scratched or sunburned area

Integumentary System Disorders

Pathophysiology
Lesions develop on knees elbows, scalp,
lumbrosacral area, gluteal cleft and penis
Structural disorder of epidermis and dermis due to
accelerated turn over of keratinocytes
(hyperkeratosis), granular layer of epidermis is
thinned out or absent
Production of keratin is abnormal
Thick, poorly adhesive cells appear as silvery
scales
Adaptive increase in vascular growth produces
erythematous base beneath scales
Periods of exacerbations and remissions

PSORIASIS
Clinical Manifestations
Small red pustules
Pruritus
Shedding, silvery, white scales on a
raised, reddened, round plaque that
usually affects the scalp, knees,
elbows, extensor surfaces of arms
and legs, and sacral regions
Yellow discoloration, pitting, and
thickening of nails may occur
Joint inflammation with psoriatic arthritis

PSORIASIS

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

Integumentary System Disorders

Treatment
Topical or systemic
Topical therapy
Coal tar preparations, corticosteroids, Anthralin
Vitamin D preparation, (Calcipotriene, Dovonex)
suppresses epidermopoiesis and cause sloughing of the
rapidly growing epidermal cells

Salicylic Acid; Retinoid compound, tazarotene (Tazorac)

Occlusive dressings may be applied following

application of the corticosteroid to increase its
effectiveness

Integumentary System Disorders

Topical /intralesional Treatment

Administration of injections into highly visible
or isolated patches of psoriasis that are
resistant to other forms of therapy
Triamcinolone acetonide (Aristocort, Kenolog10, Trymex) is injected and care is taken so
that normal skin is not injected with the
medication

Integumentary System Disorders

Systemic therapy
Systemic medications may be prescribed
to treat extensive psoriasis that does not
respond to other forms of therapy
Prescribed medications may include
corticosteroids, methotrexate,
hydroxyurea (Hydrea), and cyclosporine A
(CyA)

Integumentary System Disorders

Photochemotherapy
A combination of psoralens and ultraviolet-A
(PUVA) light therapy (decreases cellular
proliferation)
Clients may take a photosensitizing
medication (8-methoxypsoralen) and is
subsequently exposed to long-wave
ultraviolet light

ULTRAVIOLET LIGHT
TREATMENT

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders. Courtesy of Department of Dermatology,
Baylor College of Medicine, Houston, TX.

STRUCTURE OF THE SKIN

From Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis, 1999, Mosby.

Integumentary System Disorders

Cellulitis
Diffuse, pus-forming skin infection into the
deeper dermis and subcutaneous fat
Legs are common sites

Aetiology
-haemolytic Streptococcus
Staphylococcus Aureus

Integumentary System Disorders

Cellulitis
Pathophysiology
Due to failure of the inflammatory response
to contain infecting organism
Permit further spread
Involves the lymph system which may
result in repeat infection
Impair lymphatic drainage results in
swollen legs
Systemic manifestations of inflammation
may precede skin lesions

Integumentary System Disorders

Clinical Manifestations
Malaise
Fever
Lesion red, raised, warm, tender, plaque,
indefinite border, covering a small to wide
area
Pain
Pruritis/Itching at site
Swelling
Redness and warmth
Bacteraemia may be present

Integumentary System Disorders

Treatment
Systemic antibiotics
Cold compresses
Bedrest
Elevation of affected area

CELLULITIS

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management
for positive outcomes (6th ed.). Philadelphia: W.B. Saunders.

Integumentary System Disorders

Herpes Zoster (Shingles) and Varicella
(Chickenpox)
Acute, localised vesicular eruption
distributed over dermatomal sections of
the body
An acute viral infection of the dorsal
nerve root ganglion
Varicella is the initial childhood infection
Herpes Zoster is recurrence of infection
from activation of dormant virus

Integumentary System Disorders

Aetiology
Varicella-zoster virus
Reactivation of the varicella-zoster virus or
exposure to varicella-zoster, or can occur
during any immunocompromised state
Herpes zoster is contagious to individuals
who have not had chickenpox
Incidence increase with age

Integumentary System Disorders

Pathophysiology
Initial infection produced chickenpox
Skin rash develops
Acute inflammation resolves in a week but virus
remains in body
Persists in dormant state in dorsal root ganglia of
sensory system (thoracic, lumbar or cranial nerves)
Virus remains inactive with help of cell-mediated
immunity
Herpes Zoster once reactivated persists for about 3
weeks
Inflammation, haemorrhage necrosis, neuronal loss
on histology resulting in altered pain impulses

Integumentary System Disorders

Clinical Manifestations
Varicella
Malaise
Fever
Respiratory symptoms
Small erythematous macules and papules
over trunk and face then extremities; develop
into vesicles, rupture, crust over and heal

Integumentary System Disorders

Clinical Manifestations Contd
Herpes Zoster
Unilaterally clustered skin vesicles along
peripheral sensory nerves on the trunk, thorax,
or face
New crops of vesicles erupt for 3 5 days

Oedema
Superficial haemorrhage of skin
Burning and neuralgia
Pruritus
Paresthesias
Sensitivity of the skin to touch

Integumentary System Disorders

Complications
Eye involvement
Postherpetic neuralgia (pain more than 1 3
months after rash resolves)

Treatment
Immunisation (prevention)
Symptomatic and supportive (Varicella)
Antiviral drugs (Acyclovir, famciclovir)

HERPES ZOSTER

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

HERPES ZOSTER

From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.

Integumentary System Disorders

Acne vulgaris
Common, self-limiting, multifactorial
disorder of the pilosebaceous unit
Results in formation of discrete papular
and pustular lesion
May result in scarring
The types of lesions include comedones
(open and closed), pustules, papules, and
nodules

Integumentary System Disorders

Aetiology
Exact cause is unknown
May include androgenic influence on
sebaceous glands, increased sebum
production, and proliferation of
Propionibacterium acne (enzymes reduce
lipids to irritating fatty acids)
Chocolate, nuts, fatty foods, or cosmetics
may not affect acne

Integumentary System Disorders

Aetiology Contd
Exacerbations coincide with the menstrual
cycle from hormonal activity
Heat, humidity, and excessive perspiration
affect acne
Pathophysiology
Acne-prone areas are the face, upper chest, and
back
Pilosebaceous units larger

Obstruction of units multifactorial

Increase amount and viscosity of sebum

Integumentary System Disorders

Pathophysiology Contd
Increased sloughing of follicular cells
Obstructed units are susceptible to bacterial infections
from propionibacterium acnes from normal skin flora
Clinical Manifestations
Closed comedones: whiteheads
Open comedones: blackheads
Pustules and papules
Nodules
Deep scarring
Cysts
Pain
Pruritis

Integumentary System Disorders

Treatment
Requires active treatment for control until
it spontaneously resolves
Topical antimicrobials benzoyl peroxide
Oral antibiotics eg. clindamycin
Topical retinoids eg. Vitamin A
Isotretinoin
Other drugs eg. Azelaic Acid, Salicylic
Acid

ACNE

From Weston WL, Lane AT, Morrelli JG: Color textbook of pediatric dermatology, ed. 2, St.
Louis, 1996, Mosby.

ACNE VULGARIS Additional Notes

IMPLEMENTATION
Instruct the client in the administration (provide
written instructions) of topical or oral antibiotics
as prescribed
Instruct the client in the use of isotretinoin
(Accutane) if prescribed to inhibit sebum
production and reduce sebaceous gland size
Instruct the client about the adverse effects of
isotretinoin (Accutane), which include cheilitis
(lip inflammation), skin dryness, elevated
triglycerides, and eye discomfort

ACNE VULGARIS
IMPLEMENTATION
Instruct the client to stop taking vitamin
A supplements during treatment with
isotretinoin (Accutane)
Inform the client that improvement may
not be apparent for 4 to 6 weeks
Instruct the client in appropriate skincleansing methods, with emphasis on
not scrubbing the face and using only
the agreed-upon topical agents

ACNE VULGARIS
IMPLEMENTATION
Instruct the client not to squeeze, prick,
or pick at lesions
Instruct the client to use products
labeled noncomedogenic and cosmetics
that are water-based, and to avoid
contact with excessive oil-based
products
Instruct the client on the importance of
follow-up treatment

Integumentary System Disorders Read and make notes

Tinea
Eczema/dermatitis
Impetigo
Benign tumors
Keratoses
Warts (Verrucae)
Hemangiomas
Moles (Pigmented nevi)
Keloids

SCABIES
DESCRIPTION
A parasitic skin disorder caused by an
infestation of the Sarcoptes scabiei (itch mite)
Is endemic among school children and
institutionalized populations because of close
personal contact
Risk factors include close personal contact with
an infected person or contaminated article
There is a 1-month delay between the initial
infestation and onset of pruritus in the host

SCABIES
ASSESSMENT
Erythematous papules and pustules
Threadlike, brownish, linear burrows up
to 1 cm long
Secondary lesions consist of vesicles,
crusts, reddish-brown nodules, and
excoriations
Intense pruritus that worsens at night

SCABIES

From Weston WL, Lane AT, Morrelli JG: Color textbook of pediatric dermatology, ed. 2, St.
Louis, 1996, Mosby.

SCABIES
IMPLEMENTATION
Administer antihistamines or topical
steroids to relieve itching as prescribed
Apply topical antiscabies creams or
lotions such as lindane (Kwell, Scabene),
crotamiton (Eurax), or permethrin 5%
(Elimite) as prescribed
Lindane should not be used in children
younger than age 2 because of the risk
of neurotoxicity and seizures

SCABIES
IMPLEMENTATION
Instruct the client to apply the
antiscabies preparation thinly to the
entire skin from the neck down (face
and scalp are not affected in scabies)
and to leave on for 12 to 24 hours, as
prescribed
Instruct the client to apply antiscabies
preparations to dry skin, because moist
skin increases absorption and the
potential for central nervous system
side effects, such as seizures

SCABIES
IMPLEMENTATION
Following treatment with antiscabies
preparations, instruct the client to remove the
medication by thoroughly washing with soap
and water
All family members and close contacts should
be treated simultaneously
Instruct the client that all bedding and
clothing should be washed in very hot water
and dried on the hot dryer cycle or drycleaned (mites can survive up to 36 hours on
linen)

DECUBITUS
DESCRIPTION
An impairment of skin integrity
Localized areas of necrosis of the skin and
subcutaneous tissue due to pressure; also
known as a pressure ulcer

RISK FACTORS
Malnutrition
Incontinence
Immobility
Skin-shearing
Decreased sensory perception

SHEARING FORCES

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

STAGES OF DECUBITI
STAGE I
A reddened area that returns to normal
skin color after 15 to 20 minutes of
pressure relief, such as turning the client
to another position
The skin is intact
Area is red and does not blanch with
external pressure

STAGE I PRESSURE ULCER

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

STAGES OF DECUBITI
STAGE II
Area in which the top layer of skin is
missing
The ulcer usually is shallow with a pink
to red base; and a white or yellow
eschar may be present

STAGE II PRESSURE ULCER

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

STAGES OF DECUBITI
STAGE III
Deep ulcers that extend into the dermis
and subcutaneous tissues
White, gray, or yellow eschar usually is
present at the bottom of the ulcer, and
the ulcer crater may have a lip or edge;
Purulent drainage is common

STAGE III PRESSURE ULCER

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

STAGES OF DECUBITI
STAGE IV
Deep ulcers that extend into muscle
and bone
Foul-smelling
Brown or black eschar
Purulent drainage is common

STAGE IV PRESSURE ULCER

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for
collaborative care, ed 4, Philadelphia: W.B. Saunders.

DECUBITUS
IMPLEMENTATION
Institute measures to prevent decubiti
Assess the nutritional status of the client
and provide adequate nutritional intake
to promote tissue integrity
Monitor for an alteration in skin integrity
Relieve or remove pressure on the skin
Turn and reposition the immobile client
every 2 hours, or more frequently if
necessary
Ambulate the client

ASSESSMENT OF PRESSURE
RELIEF

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management
for positive outcomes, ed 6, Philadelphia: W.B. Saunders. Modified from Gaymar Industries,
Inc., Orchard Park, NY.

DECUBITUS
IMPLEMENTATION
Provide active and passive exercises every 8
hours
Keep the skin clean and dry and the sheets
wrinkle-free
Apply moisture barrier as prescribed to protect
the skin
Use assistive devices to prevent pressure such
as alternating air pressure mattress or
sheepskin padding
Apply medications or dressings to the wound
as prescribed

REFERENCES
Hansen, M. (1998). Pathophysiology:
Foundations of disease and clinical
intervention. USA, Philadephia: W. B.
Saunders Company.
Mattson Porth, C. (2011).
Pathophysiology: Concepts of altered
health state. USA, Philadelphia:
Lippincott Williams & Wilkins.
Tabers Cyclopedic Medical Dictionary 1993