CH 50: Skin Disorders

Type Clinical Manifestation Management Complications

Bacterial Skin Infection *See Table 50.2* Blood C/S Skin and soft tissue infection
Fever CT Overuse of Abx
Tachycardia CBC Necrotizing soft tissue
Pain Needle bx infection
Disorientation Punch bx SSI
Lethargy Cellulitis
Hypotension Quantitative tissue bx 
Ischemia invasive test, tissue below
Tissue necrosis surface of wound obtained and
Sepsis sent for quantitative gram
Fournier’s. gangrene stain and culture
See table 50.1
Herpes Simplex Primary: first time infected HSV1 or HSV 2 lab analysis Quality of life r/t stress of dx
individual -Virological testing  of GH
Direct contact w/individual mucocutaneous (region of -Pt feel isolated, devastated
who is asymptomatic, in a body where mucosa and embarrassed
prodromal stage of disease or transitions into skin) lesions or -Pregnancy  complication of
has active/genital infections, ulcers disseminated neonatal herpes
secretions or lesions -Cytological tzanck’s smear (C-Sections recommended)
Fever (examines skin scrapings
Malaise smeared onto slide)
Myalgia -Cervical pap smear
Anorexia -Serological type specific
Irritability glycoproteim G-based assay
Cervical/Inguinal Partner w/GH, person
lymphadenopathy presenting for STI testing
Lesions (lip, face, mucous w/hx of multiple sex partners,
membranes of mouth, person w/HIV or homosexual
pharynx, genitals) men
Secondary: recurrent HSV Suppressive therapy: antiviral:
infections occur following acyclovir, valacyclovir,
exogenous or endogenous famciclovir (for GH)
trigger that reactive the
dormant virus
UV light exposure
Febrile illness
Stress
Fungal Infections Dermatophytes (aerobic)  Antifungal agents are primary Proliferate (esp in critically ill
reproduce with spores H&P and immunocompromised) 
Yeast KOH microscopy  hyphae candida
Rashes confirm dx Tx pt at greatest risk
Vesicles Wood’s lamp  UV light w/antifungal medications to
Pustules held close to skin in darkened reduce morbidity from
room, helpful in dx tinea candidemia
versicolor (fluoresces pale -Use of corticosteroids or
yellow to white) immunosuppressive
Fungal culture medications, abx use,
Histological evaluation parenteral nutrition, presence
of invasive CVC
Psoriasis Lifelong inflammatory No lab test specific Risk of developing other
disorder characterized by Dx based on pt’s clinical disease (CA, CV disease,
exacerbation and remissions manifestation Crohn’s, diabetes, metabolic
of raised, scaling, ESR high syndrome, uveitis, liver
erythematous plaques Goal of tx: reduce clinical disease)
Plaques seen on the elbow, manifestations, control -Basal cell carcinoma
knees, legs, palms, soles of disease, improve quality of -Squamous cell carcinoma r/t
feet, scalp, trunk, face life exposure during phototherapy
Pitting (onycholysis lifting See table 50.5 -Systemic infections
 of nail away from nail bed) Topical creams and ointments,
Splinter hemorrhages under UV light therapy, systemic
nail medication
*medications (Li, B-blockers,
indomethacin)
Skin Trauma Edema H&P Risk for infection 
Erythema Immunization hx erythema, increased
Heat *Tetanus temperature surrounding
Pain ABI: ratio of systolic BP tissue, odor, purulent drainage,
Necrotic tissue obtained at the ankle and in increased swelling, increased
*See table 50.6 the arm is sensitive, non- pain, fever
invasive indicator of arterial Depth of injury  damage
perfusion to LE underlying structure of
Nutritional status muscle, tendon, bone and
MUST scale (malnutrition nerve
universal screening tool)
Infection  wound
management (C/S of wound
by swabbing or bx)
Assessment includes overall
health and nutritional status,
skin integrity, mobility,
hydration of status
Debridement methods: see
table 50.9
Pressure Ulcers Occurs in pt w/limited Braden scale Infection
mobility and bed ridden 15-18: mild Swab cultures
Localized injury to skin and/or 13-14: moderate Punch bx w/culture  identify
underlying tissue (over. Bony 10-12: high bacteria in deeper tissues such
prominence) <9: very high risk as muscle and bone
Redness Nutritional assessment: see *Osteomyelitis  evaluate
Blanching table 50.12 w/x-ray, CT, or MRI  bone
Skin breakdown CRP exposed  pt is dx clinically
ESR w/osteomyelitis
Vigilant monitoring (fever, Wounds contaminated w/fecal
increased WBC,) or urine
-Colostomy (temporary
diverting)  once site healed,
r-anastomosed at pt’s request
Skin Cancer See box 50.5 Dependent on size, location, Financial concerns for
Actinic keratosis: recurrence, current health families during tx
precancerous lesions, status Infections
proliferate in epidermis Surgical excision Psychosocial
-No tx  squamous cell Curettage and
carcinoma electrodesiccation
Clinical features: Skin-colored Mohs’ micrographic sx
to reddish brown macules, Photodynamic therapy
papules, or plaques; range Cryotherapy
from a few millimeters up to 2 Radiotherapy
cm; usually occur as multiple Chemotherapy (topical)
lesions
Body distribution: Sun-
exposed areas (particularly
cheeks, temples, forehead,
anterior and posterior neck,
ears, backs of hands, and
forearms)
Clinical course: May begin as
erythematous, scaly plaques
that exfoliate with toweling
off or the rubbing of clothes
 during the day; induration at
the base, cutaneous horn,
ulceration, or pain may
indicate transformation to
squamous cell carcinoma.
Squamous cell carcinoma:
most attributed to exposure to
UVB over extended period of
time
Clinical features: Crusted
papules and plaques that can
become indurated and
ulcerated. Larger lesions can
become painful and bleed.
-Can arise from chronically
open wounds, burn scars, or
leg ulcers because of chronic
inflammation.
Body distribution: Sun-
exposed skin, especially the
top of the head, neck, and lips
Clinical course: Can invade
fatty tissue beneath the dermis
and spread via the lymph
nodes to other parts of the
body (although, this is not that
common); recurrence rate
within 3 years is 18%.
Basal cell carcinoma: arise
from basement membrane of
epidermis (rarely
metastaticSignificantly
damage tissue secondary to
large excision)
Clinical features: Pearly,
translucent, flesh-colored
papules; superficial
telangiectasias (broken blood
vessels) are usually visible;
may have rolled edges or
ulcerations
Body distribution: Sun-
exposed areas, especially
head, neck, and trunk
Clinical course: Usually not
metastatic but can become
locally invasive; recurrence
rate after excision is 44% in 3
years
Malignant melanoma: most
serious, originates from
melanocytes found in
basement membrane of
epidermis
-ABCDE
-ANYWHERE on body, esp
existing moles, upper back,
lower legs, soles of feet, palms
of hands and dark-skinned
individuals
Reconstructive Surgery
ABI Ratio (Systolic BP/BP at ankle or arm)
Braden scale