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Chapter 28: Skin Disorders Skin Lesions Defined Skin pigmen

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Title: Chapter 28: Skin Disorders Skin Lesions Defined Skin pigmen


1
Chapter 28 Skin Disorders
2
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3
Skin Lesions Defined
  • Skin pigment - melanin
  • Variations may be due to anatomic, physiologic or
    pathophysiologic changes in skin blood flow
  • Normal skin appearance
  • Altered by external and internal factors
  • Cellulitis
  • Infectious inflammation of deep skin structures

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6
Skin Trauma
  • Mechanical Forces that Cause Injury
  • Friction
  • Compression
  • Shearing
  • Stretching
  • Scraping
  • Tearing
  • Avulsing
  • Puncturing

7
Friction and Pressure Problems
  • Hyperkeratosis of the Hands and Feet
  • Etiology
  • Friction and pressure over bony protuberances
  • Painful when subcutaneous fat becomes inelastic
  • Prevention
  • Cushioning devices wearing 2 socks
  • Lubricants to reduce friction, shaving calluses
  • For calluses on hands, special gloves or
    protective gear

8
  • Sign and Symptoms
  • Thickening, of horny layer of skin, ovular,
    elongated and brown
  • Painful with pressure
  • Management
  • Avoid emery boards and pumice as the increase in
    friction will stimulate skin to produce added
    callus
  • Use moisturizer
  • Pair off callus with scalpel
  • Padding

9
  • Blisters
  • Etiology
  • Result of a shearing force that produces a raised
    area that accumulates with fluid
  • Prevention
  • Use of dust or powder or lubricant to reduce
    friction
  • Tubular socks, 2 pairs of socks if feet are
    sensitive or perspire excessively
  • Appropriate shoes that are broken in
  • Padding and lubricants
  • Signs and Symptoms
  • Hot spot, sharp burning sensation, painful
  • Superficial area of skin raised with clear fluid

10
  • Management (intact blister)
  • Leave intact for 24 hours
  • Clean with antiseptic
  • Cut small incision to drain fluid (large enough
    that it wont re-seal)
  • Prevent refilling with a pressure pad
  • Clean again with antiseptic
  • Use doughnut to prevent irritation
  • Monitor for infection, replace wet bandaging
  • Debridement can be performed when tenderness is
    gone

11
  • Management (open/torn blister)
  • Keep clean to avoid infection
  • Keep skin in place and apply non-adhering sterile
    dressing and padding
  • Monitor daily for infection
  • Management (denuded blister)
  • If blister is torn 1/2 inch or more remove skin
    flap
  • Clean and expose area, apply antiseptic with
    occlusive dressing
  • Second skin can be applied to raw area

12
  • Soft Corns and Hard Corns
  • Etiology
  • Caused by pressure of improperly fitting shoes
    and anatomic abnormalities
  • Soft corns are the result of pressure and
    perspiration, also associated with exostosis
  • Signs and Symptoms
  • Hard corns form on the tops of toes and tend to
    be painful and dry
  • Soft corns result in thickening of skin, white
    and sometimes painful (between 4th and 5th toes)
  • Prevention
  • Wear properly fitting shoes
  • Management
  • Surgical removal if painful
  • Padding maintain clean dry feet wear
    appropriate shoes

13
  • Excessive Perspiration (hyperhidrosis)
  • Etiology
  • Syrup-like perspiration, high in sodium chloride
  • Increases risk of other skin irritation
  • Makes adherence of bandages difficulty
  • Management
  • Use of astringent such as alcohol or an absorbent
    powder
  • Aluminum chloride or electric current can be used
    to treat condition

14
  • Chafing of Skin
  • Etiology
  • Occurs particularly in athletes that are obese or
    heavy limbed
  • Result of friction and maceration of skin in
    climate of heat and moisture
  • Signs and Symptoms
  • Separation of keratin from granular layer of skin
  • Causes oozing wounds that crust and crack
  • Prevention
  • Keep skin dry, clean, and friction free
  • For the groin, soft, loose, cotton underwear is
    recommended
  • Management
  • Clean area with soap and water and treat with
    medicated solution and hydrocortisone cream

15
  • Xerotic (Dry) Skin
  • Etiology
  • Drying of skin due to exposure of cold, excessive
    bathing, decrease in humidity causing skin to
    lose water
  • Signs and Symptoms
  • Dry skin w/ variable redness and scaling itching
  • Management
  • Prevent water loss and replace lost water
  • Bathe in tepid water, use moisturizer
  • If condition worsens, refer to physician

16
  • Ingrown Toenails
  • Etiology
  • Generally occurs in great toe
  • Nail grows laterally into skin
  • Result of lateral pressure from shoes, poor nail
    trimming, and repeated trauma

17
  • Signs and Symptoms
  • Pain and swelling
  • Penetrated skin becomes inflamed and purulent
    with lateral nail fold swollen and irritated
  • Prevention
  • Properly fitting shoes and socks are essential
  • Weekly toenail trimming (cut straight across)
  • Leave nail long enough to clear skin
  • Management
  • Conservative management includes soaking the
    inflamed toe in warm water (20 minutes)
  • Place cotton under edge of nail to clear from
    skin
  • If chronic, remove wedge of nail and apply
    antiseptic compress until inflammation resides

18
Wounds
  • Abrasions
  • Scraping of skin against rough surface (top
    surface of skin is worn away)
  • Increased probability of infection due to
    exposure of dirt and foreign material
  • Clean and debride
  • Punctures
  • Direct penetration of skin with pointed object
  • Must be referred to physician

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  • Lacerations
  • Object tears tissue, giving wound appearance of
    jagged edge (sometimes result of blunt trauma)
  • Presents environment susceptible to infection
  • Skin Incision
  • Smooth cut in skin - not jagged
  • Skin Avulsion
  • Skin torn away from body (should be placed in
    moist gauze w/in a plastic bag that is then
    immersed in cold water)
  • Transport to hospital with athlete for possible
    reattachment

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  • Skin Bruises
  • Result of blunt trauma causes disruption of
    superficial blood vessels and results in black
    and blue discoloration
  • Treatment requires RICE to control hemorrhaging

23
Wound Management
  • All wounds must be assumed contaminated
  • Pay close attention to all universal precautions
  • Clean all wounds with soap and water to minimize
    infection
  • Apply a dressing with antiseptic (unless
    physician examination is necessary)
  • Lacerations and punctures should be treated by a
    physician
  • Use of occlusive dressings
  • Minimizes scab formation, perceived pain from
    exposed nerves, cost and time effective, provide
    adequate barrier
  • Antibiotic ointment used to prevent secondary
    infection (SEE TABLE 28-4 for added instruction)

24
Athletic Training Room Practice in Wound Care
  • Use clean and sterile instruments
  • Clean hands thoroughly and use gloves
  • Clean in and around skin lesion
  • Use a non-medicated covering if athlete is to be
    sent for medical attention
  • Avoid touching any part of sterile dressings that
    will contact the wound
  • Place medication on pad
  • Secure the dressing in place

25
Bacterial Infections
  • Bacteria are single celled micro-organisms
  • Spherical, doublets, and spirochetes
  • Staphylococcus
  • Gram positive bacteria that appears in clumps in
    skin and upper respiratory tract
  • Streptococcus
  • Chain bacteria often associated with systemic
    disease and skin infections
  • Bacillus
  • Spore forming, aerobic, and occasionally mobile
  • Can cause systemic damage

26
  • Impetigo Contagiosa
  • Etiology
  • Caused by A-beta-hemolytic streptococci, S aureus
    or combination of these bacteria
  • Spread through close contact
  • Signs and Symptoms
  • Mild itching and soreness followed by eruption of
    small vesicles and pustules that rupture and
    crust
  • Generally develops in body folds that are subject
    to friction
  • Management
  • Cleansing and topical antibacterial agents
  • Systemic antibiotics

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  • Furunculosis (Boils)
  • Etiology
  • Infection of hair follicle that results in
    pustule formation
  • Generally the result of a staphy. infection

29
  • Signs and Symptoms
  • Pustule that becomes reddened and enlarged as
    well as hard from internal pressure
  • Pain and tenderness increase with pressure
  • Most will mature and rupture
  • Management
  • Care involves protection from additional
    irritation
  • Referral to physician for antibiotics
  • Keep athlete from contact with other team members
    while boil is draining

30
  • Carbuncles
  • Etiology
  • Similar in terms of early stage development as
    furuncles
  • Signs and Symptoms
  • Larger and deeper than furuncle and has several
    openings in the skin
  • May produce fever and elevation of WBC count
  • Starts hard and red and over a few days emerges
    into a lesion that discharges yellowish pus
  • Management
  • Surgical drainage combined with the
    administration of antibiotics
  • Warm compress is applied to promote circulation

31
  • Folliculitis
  • Etiology
  • Inflammation of hair follicle
  • Caused by non-infectious or infectious agents
  • Moist warm environment and mechanical occlusion
    contribute to condition
  • Psuedofolliculitis (PFB)

32
  • Signs and Symptoms
  • Redness around follicle that is followed by
    development of papule or pustule at the hair
    follicle
  • Followed by development of crust that sloughs off
    with the hair
  • Deeper infection may cause scarring and alopecia
    in that area
  • Management
  • Management is much like impetigo
  • Moist heat is used to increase circulation
  • Antibiotics can also be used depending on the
    condition

33
  • Hidradenitis Suppurativa
  • Etiology
  • Primary inflammation event of the hair follicle
    resulting in secondary blockage of the apocrine
    gland
  • Signs and Symptoms
  • Begins as small papule that can develop into deep
    dermal inflammation
  • Management
  • Avoid use of antiperspirants, deodorants and
    shaving creams
  • Use medicated soaps and systemic antibiotics

34
  • Acne Vulgaris
  • Etiology
  • Inflammatory disease of the hair follicle and the
    sebaceous glands
  • Sex hormones may contribute
  • Signs and Symptoms
  • Present with whiteheads, blackheads, flesh or red
    colored papules, pustules or cysts
  • If chronic and deep may scar
  • Psychological impact
  • Management
  • Topical and systemic agents used to treat acne
  • Mild soaps are recommended

35
  • Paronychia and Onychia
  • Etiology
  • Caused by staph, strep and or fungal organisms
    that accompany contamination of open wounds or
    hangnails
  • Damage to cuticle puts finger at risk
  • Signs and Symptoms
  • Rapid onset painful with bright red swelling of
    proximal and lateral fold of nail
  • Accumulation of purulent material w/in nail fold
  • Management
  • Soak finger or toe in hot solution of Epsom salt
    3 times daily
  • Topical antibiotics, systemic antibiotics if
    severe
  • May require pus removal through skin incision

36
  • Tetanus Infection (lockjaw)
  • Etiology
  • Acute infection of the CNS caused by tetanus
    bacillus
  • Bacteria enters through the blood and open wounds
  • Signs and Symptoms
  • Stiffness of the jaw and muscles of the neck
  • Muscles of facial expression produce contortion
    and become painful
  • Fever may become markedly elevated
  • Management
  • Treat in intensive care unit
  • Childhood immunization

37
Fungal Infections
  • Group of organisms that include yeast and molds
    which are usually not pathogenic
  • Grow best in unsanitary conditions with warmth,
    moisture and darkness
  • Infections generally occur in keratinized tissue
    found in hair, nails and stratum corneum
  • Dermatophytes (Ringworm fungi)
  • Cause of most skin, nail and hair fungal
    infections

38
  • Tinea of the Scalp (tinea capitis)
  • Signs and Symptoms
  • Ringworm of the scalp begins as a small papule
    that spreads peripherally
  • Appears as small grayish scales resulting in
    scattered balding
  • Easily spread through close physical contact
  • Management
  • Topical creams and shampoos are ineffective in
    treating fungus in hair shaft
  • Systemic antifungal agents are replacing older
    agents due to increased resistance
  • Some topical agents are used in conjunction

39
  • Tinea of the Body (tinea corporis)
  • Signs and Symptoms
  • Commonly involve extremities and trunk
  • Itchy red-brown scaling annular plaque that
    expands peripherally
  • Management
  • Topical antifungal cream

40
  • Tinea of the Nail (tinea unguium/ onchomycosis)
  • Signs and Symptoms
  • Fungal infection of the nail -- found commonly in
    those engaged in water sports or who have chronic
    athletes foot
  • Nail becomes thick, brittle and separated from
    its bed
  • Management
  • Some topical antifungal agents have proved useful
  • Systemic medications are most effective
  • Surgical removal of nail may be necessary if
    extremely infected

41
  • Tinea of the Groin (tinea cruris)
  • Etiology
  • Symmetric red-brown scaling plaque with
    snake-like border
  • Signs and Symptoms
  • Mild to moderate itching

42
  • Management
  • Treat until cured
  • Will respond to many of the non-prescription
    medications
  • Medications that mask symptoms should be avoided
  • Failure to respond to normal management may
    suggest a non-fungal problem (such as bacteria)
    and should be referred to a physician
  • May require additional topical medications and
    oral prescriptions

43
  • Athletes Foot (tinea pedis)
  • Etiology
  • Most common form of superficial fungal infection
  • Tricophyton species are most common cause of
    athletes foot
  • Webs of toes may become infected by a combination
    of yeast and dermatophytes
  • Signs and Symptoms
  • Extreme itching on soles of feet, between and on
    top of toes
  • Appears as dry scaling patch or inflammatory
    scaling red papules forming larger plaques
  • May develop secondary infection from itching and
    bacteria
  • Management
  • Topical antifungal agents and good foot hygiene

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  • Candidiasis (Moniliasis)
  • Etiology
  • Yeast-like fungus that can produce skin, mucous
    membrane and internal infections
  • Ideal environment includes hot humid weather,
    tight clothing, and poor hygiene
  • Signs and Symptom
  • Infections w/in body folds
  • Presents as beefy red patches and possible
    satellite pustules
  • White, macerated border may surround the red
    area deep painful fissures may develop at skin
    creases
  • Management
  • Maintain dry area
  • Use antifungal agents to clear infection

46
  • Tinea Versicolor
  • Etiology
  • Caused by a yeast
  • Appears commonly in areas in which sebaceous
    glands actively secrete body oils
  • Signs and Symptoms
  • Fungus produces multiple, small, circular macules
    that are pink, brown, or white
  • Commonly occur on chest, abdomen, and neck
  • Do not tan when exposed to sun and usually are
    asymptomatic
  • Management
  • Straightforward treatment - recurrences are
    common
  • Use selenium shampoo (Selsun) and topical
    econazole nitrate (or something similar)
  • When microorganism has been eradicated,
    re-pigmentation of the area will occur

47
Viral Infections
  • Ultramicroscopic organisms that require host
    cells to complete their life cycle
  • May stimulate cell chemically to produce more
    virus until host cell dies
  • Lies within bud-like structure that does not
    damage cell or virus, w/out causing infection
  • A number of skin infections are caused by viruses

48
  • Herpes Simplex Labialis, Gladiatorum, and Herpes
    Zoster
  • Etiology
  • Highly contagious and is usually transmitted
    directly through a lesion in the skin or mucous
    membrane
  • Resides in sensory nerve neurilemmal sheath
    following initial outbreak
  • Recurrent attacks stimulated by sunlight,
    emotional disturbances, illness, fatigue, or
    infection
  • Type I vs. Type II
  • Signs and Symptoms
  • Early indication tingling or hypersensitivity
    in an infected area 24 hours prior to appearance
    of lesions
  • Local swelling followed by outbreak of vesicles
  • Athlete may feel ill w/ headache, sore throat,
    swollen lymph glands and pain in area of lesions

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  • Signs and Symptoms (continued)
  • Vesicles generally rupture in 1-3 days spilling
    serous material
  • Heal in generally 10-14 days
  • If an athlete has an outbreak they should be
    disqualified from competition due to contagious
    nature of condition
  • Management
  • Herpes simplex lesions are self limiting - reduce
    pain and promote early healing
  • Use of antiviral drugs can reduce recurrence and
    shorten course of outbreak
  • Complications
  • Can lead to secondary infection

51
Verruca Virus and Warts
  • Varied of forms exist
  • verruca plana (flat wart), verruca plantaris
    (plantar wart), and condyloma acuminatum
    (venereal wart)
  • Different types of human papilloma virus have
    been identified
  • Uses epidermal layer of skin to reproduce and
    growth
  • Wart enters through lesion in skin

52
  • Common Wart
  • Signs and Symptoms
  • Small, round, elevated lesion
    with rough dry surfaces
  • Painful if pressure is applied
  • May be subject to secondary
    bacterial infection
  • Management
  • If vulnerable, they should be protected until
    treated by a physician
  • Use of electrocautery, topical salicylic acid or
    liquid nitrogen are common means of managing this
    condition

53
  • Plantar Warts
  • Etiology
  • Spread through papilloma virus
  • Signs and Symptoms
  • Located on sole of foot, on or adjacent to areas
    of abnormal weight bearing
  • Areas of excessive epidermal thickening
  • Discomfort, point tenderness
  • Hemorrhagic puncta (black seeds)
  • Management
  • While in competition, protect and prevent
    spreading
  • Pair away callus and apply keratolytic
  • Following season, wart can be removed by freezing
    it or by electrodessication (maintain protection
    until removal)

54
  • Molluscum Contagiosum
  • Etiology
  • Poxvirus infection which is more contagious than
    warts (especially during direct body contact)
  • Signs and Symptoms
  • Small, flesh or red colored, smooth-domed papules
    with central umbilication
  • Management
  • Physician referral is necessary
  • Cleansing and destructive procedure
    (counterirritant such as cantharidin, surgical
    removal or cryosurgery)

55
Allergic, Thermal, and Chemical Skin Reactions
  • Allergies are immunologically mediate responses
    to molecules in dyes and proteins against which
    the bodys immune system is sensitized
  • Allergens may be food, drugs, clothing, dusts,
    pollens, plants, animals, heat, cold, or light
  • The skin will reflect an allergy in many ways
    such as reddening and swelling of the tissue,
    uticaria or hives, burning or itching
  • ATCs must recognize gross signs of allergic
    responses and be prepared to remove allergens and
    treat topically or systemically with antipruritic
    agents

56
  • Contact Dermatitis (allergic and irritant)
  • Etiology
  • Plants are the most common cause (poison ivy,
    poison oak, sumac, ragweed, primrose)
  • Topical medications
  • Chemicals found in fragrances and preservatives
    of soaps, detergents
  • Signs and Symptoms
  • Onset may range from 1 day to 1 week
  • Redness, swelling, formation of vesicles that
    ooze fluid and form crust, constant itching
  • May change from redness and blistering to
    erythematous scaling, lichenified papules and
    plaques
  • Management
  • Avoid allergen
  • Tap water compresses or soaks, topical
    corticosteroids

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  • Milaria (Prickly Heat)
  • Etiology
  • Continued exposure to heat and moisture causing
    retention of perspiration by sweat glands
  • Signs and Symptoms
  • Itching and burning vesicles and pustules
  • Occurs most often on arms, trunks, and bending
    areas of the body
  • Management
  • Avoidance of overheating, frequent bathing with
    non-irritating soap, wearing loose-fitting
    clothing and use of antipruritic lotions

59
  • Chilblains (pernio)
  • Etiology
  • Caused by excessive exposure to cold
  • Signs and Symptoms
  • Tissue does not freeze but reacts with edema,
    reddening and possibly blistering along with a
    sensation of burning and itching after exposure
    to cold
  • Management
  • Exercise and gradual warming of the part
  • Massage and application of heat are
    contraindicated
  • Some systemic drugs can be used in severe cases

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61
  • Sunburns
  • Etiology
  • Inflammatory response to injury caused by
    ultraviolet solar radiation
  • Must be cautious of physical characteristics,
    chemicals, food and drugs that make individuals
    more susceptible
  • Signs and Symptoms
  • Varies from erythema to severe blistering
  • May experience shock if severe enough
  • Can cause malfunctioning of organs w/in the skin
  • Will appear 2-8 hours following exposure, with
    symptoms becoming most severe at 12 hours
  • SS will dissipate w/in 72-96 hours

62
  • Sunburns (continued)
  • Management
  • Can be prevented through the use of sunscreen
    (sun protection factor or SPF)
  • Filters ultraviolet light
  • Water/sweat resistant sunscreen is recommended
  • Treat a burn according to the degree of
    inflammation
  • Cool water, aloe based solutions
  • More severe burns may require bathing in a bath
    of cornstarch or vinegar
  • Severe burns require physician assistance

63
  • Psoriasis
  • Etiology
  • Exact cause is unknown -- genetic factors may
    play a role in condition
  • Infection, smoking, some drugs and possible
    hormonal factors may cause an outbreak
  • Signs and Symptoms
  • Lesion begins as reddish papules that progress to
    plaques
  • Lesions progress to yellowish white scaly
    condition that tends to be located on the elbows,
    knees, trunk, genitalia, and umbilicus

64
  • Psoriasis (continued)
  • Management
  • Teaching patient self management
  • Glucocorticoids and kerolytic agents can be used
    in conjunction with each other
  • Long term oral medications may be necessary
  • Counseling may be necessary for psychological
    aspects of condition

65
Infestation and Bites
  • Scabies
  • Etiology
  • Caused by mites which cause extreme nocturnal
    itching (tunnels and lays eggs)
  • Signs and Symptoms
  • Appear as dark lines between fingers and toes,
    body flexures, nipples and genitalia
  • Excoriations, pustules and papules caused by
    itching tends to hide true cause
  • Skin develops hypersensitivity to the mite
  • Management
  • Permethrin 5 is treatment of choice
  • Washing of bedding and clothes is necessary
  • Topical corticosteroids may be necessary to treat
    itching

66
  • Lice (Pediculosis)
  • Etiology
  • Manifestation by the louse (louse of head, pubic
    region and body)
  • Signs and Symptoms
  • Bites cause itching dermatitis through subsequent
    scratching -- promotes pustule and excoriations
    to develop
  • Management
  • Cure is rapid with use of any number of agents
  • Good hygiene is paramount
  • To prevent re-infestation all clothing and
    bedding should be washed in hot soapy water or
    discarded

67
  • Fleas
  • Etiology
  • Small wingless insects that suck blood
  • Can transmit systemic diseases
  • Signs and Symptoms
  • Great deal of discomfort can be felt if come into
    contact with a high number of fleas
  • Concentrate bites on ankles and lower legs
  • Management
  • Following a bite, itching must be prevented with
    antipruritic lotion
  • Avoid scratching to prevent secondary infection
  • Insecticides can also be effective

68
  • Ticks
  • Etiology
  • Parasitic insects that have an affinity for blood
  • Carriers of a variety of microorganisms that can
    transmit Rocky Mountain spotted fever and Lyme
    disease
  • Signs and Symptoms
  • Headaches, fever, malaise, myalgia, and rash,
    perechiae and prupura, enlarging annular red ring
    w/ or w/out central red papule
  • Management
  • Remove tick (mineral oil or fingernail polish)
  • Grasping head of tick is an acceptable method
  • Systemic treatment is necessary to prevent
    morbidity and mortality associated with RMSF and
    Lyme disease

69
  • Mosquitoes
  • Etiology
  • Unless carrying a disease, mosquitoes produce
    bites that cause only mild discomfort
  • Attracted to lights, dark clothing and warm moist
    skin
  • Signs and Symptoms
  • Small reddish papule with associated itching
  • Management
  • Topical medication
  • Use of repellents can also be used on the skin to
    prevent contact with mosquitoes

70
  • Stinging Insects
  • Etiology
  • Bees, wasps, hornets, yellow jackets -- inflict
    venomous sting
  • Hypersensitive individuals may experience an
    allergic reaction
  • Signs and Symptoms
  • If an allergic reaction occurs an increase in
    heart rate and breathing will occur, along with
    chest tightness, dizziness, sweating and even LOC

71
  • Insect Stings (continued)
  • Management
  • To prevent, avoid wearing scented lotions or
    shampoos, brightly colored clothes, jewelry,
    suede, or leather, and avoid going barefoot.
  • If an athlete is susceptible to anaphylactic
    reactions instructions on use of an EpiPen are
    necessary
  • If uncomplicated, the stinger should be removed
    with tweezers or a credit card and soothing
    medications should be applied
  • Soap detergent will also lessen symptoms
  • In cases of anaphylactic reaction immediate
    physician referral is necessary
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