Introduction:
The skin is the body's largest organ, performing many functions essential to the protection and physiologic functions of the body. It performs as a barrier against the invasion of bacteria and excessive water loss. Through vasoconstriction and vasodilation, the skin responds to changes in internal and external temperature changes. It performs sensory functions of pain, temperature and touch for the client. The aesthetic functions of the skin such as displaying identity and emotions are important to the client and nurses.

I. Anatomy & Physiology: Skin Layers
A. Epidermis: outermost layer of skin; avascular and superficial; composed of outer, dead

cornified portion and deeper, living portion folding into the dermis.

1. Measures 0.05mm to 1 mm

2. Replaced with new cells every 30 days

3. Epidermal cells: melanocytes-in basal layer; secrete melanin providing skin & hair color.

keratinocytes- from basal layer; flatten & die to make stratum corneum;

produce keratin (protective protein); differentiation takes 4 weeks.
 

B. Dermis: inner, supportive layer consisting mainly of collagen; highly vascular; elastin fibers,

nerves, lymphatic vessels, hair follicles, & sebaceous and sweat glands are found in the

dermis.

1. Measures 1mm to 4mm

2. Assists in temperature & blood pressure regulation

3. Two layers: papillary layer- folds into ridges or papillae; forms fingerprints & footprints.

reticular layer- contains collagen, elastin & reticular fibers supporting skin.
 

C. Hypodermis: attaches the skin to underlying tissues & organs; contains loose connective

tissue and fat cells for insulation; not actually part of the skin organ.
 

II. Assessment:
 

A. Subjective data:

1. History of skin disease - hives, allergies, psoriasis, eczema, hx of diabetes

2. Change in mole - size, color, itching

3. Pruritus

4. Excessive bruising

5. Rash or lesion

6. Environmental or occupational hazards

7. Medications
 

B. Objective data:
 

1. Physical examination:

a. Inspection: general color, pigmentation, bruising, lesions, rash. Critical factor is

change.

b. Palpation: temperature, turgor & mobility, moisture, texture.
 

2. Primary skin lesions:

a. Macule:

circumscribed, flat discoloration(brown, blue, red)

Example: freckle, petechiae, first-degree burn

b. Vesicle:

small, circumscribed collection of serous fluid; tense or fluctuant

up to 0.5 cm to less than 1 cm (Bulla is greater than 1 cm)

Example: herpes simplex, chicken pox, impetigo
 

c. Plaque:

circumscribed, elevated, superficial solid lesion

greater than 0.5 cm

often formed by confluent papules

Example: psoriasis
 
 
 

d. Nodule:

circumscribed, elevated solid lesion

greater than 0.5 cm (large nodule = tumor)

Example: wart, gouty tophi
 

e. Papule:

firm, elevated, circumscribed lesion

up to 0.5 cm in size

Example: elevated mole, pimple, senile angioma
 

f. Pustule:

yellow or white vesicle filled with pus

size varies

Example: acne

g. Wheal:

transient, irregularly shaped, faint pink or red elevation

size varies

Example: hive, mosquito bite
 
 
 

3. Secondary skin lesions:
 

a. Scales:

flakes of exfoliated skin

may be fine, sheetlike, coarse, adhered to primary lesion

color may be white, silvery or ashen

Example: dandruff, psoriasis
 

b. Scar:

abnormal formation of connective tissue

color varies from red, pink, silver to white

may be elevated or concave

Example: trauma, surgery, burns
 

c. Erosions:

loss of epidermis, surface is moist but does not bleed

not associated with scarring

Example: rupture of vesicle or bullae
 

d. Ulcers:

deep erosion resulting from loss of epidermis and part of dermis

color may be red or blue

may bleed or scar

Example: decubiti
 

e. Fissure:

linear crack in skin, usually in epidermis or dermis

sharply defined, vertical walls

Example: hand dermatitis, chapped lips
 

f. Atrophy:

thinning of the skin with loss or skin furrows

skin appears depressed, shinier, more translucent

Example: striae, arterial insufficiency

g. Crusts:

dried residue to serous, pus, or blood

color variable (brown, black, honey-colored, yellow, red)

Example: impetigo, herpes simplex
 
 
 
 
 

4. Pre-malignant and Malignant skin conditions:
 

a. Actinic keratosis:

pre-malignant form of squamous cell carcinoma (1% incidence)

affects nearly all elderly, white population

irregularly shaped, flat, hyperkeratotic, multiple, rough scale on red base

caused by sun damage

Treatment: cryotherapy, **5-FU(fluorouracil)

b. Dysplastic nevus syndrome:

precursor of malignant melanoma

irregular shape, varied color, larger than 5 mm

Treatment: excisional biopsy
 

c. Basal cell carcinoma:

locally invasive malignancy arising from epidermal basal cells

borders semitranslucent or "pearly"

erosion, ulceration and depression of center

related to sun-exposure, genetic skin type, radiation

Treatment: excisional surgery, cryosurgery, 95% cure rate, metastasis rare
 

d. Squamous cell carcinoma:

malignant tumor of squamous cells of epidermis with invasion of dermis

related to sun damage, radiation

Early: firm nodules with indistinct borders, ulceration

Late: lesion covered with scale

Most common on face and hands

Treatment: surgical removal, cryosurgery, radiation therapy, high cure rate with

early diagnosis and treatment; metastasis possible
 

e. Malignant melanoma:

neoplastic growth of melanocytes with potential for invasion and metastasis

most deadly skin cancer and increasing worldwide faster than any other cancer

Risk factors: sun exposure; radiation; skin sensitivity; genetic, hormonal and

immunologic factors

A, B, C, D

Most important prognostic factor is tumor thickness at time of diagnosis

Treatment: wide surgical excision with margin of normal skin; chemotherapy,

radiation depending on stage of tumor; gene therapy being investigated

f. Kaposis sarcoma:

neoplasms occurring in predominantly in homosexual men

multiple vascular nodules in skin, mucous membranes, and viscera

small, red to purple nodules ranging from few mm to several cm

causes lymphedema, disfigurement, organ involvement = dyspnea

Diagnosis: biopsy of lesion

Treatment: depends on patient's immune status; chemotherapy, radiation
 
 
 

5. Non-malignant skin conditions:

a. Bacterial Infections:

1. Impetigo:

caused by group A beta-hemolytic streptococci or staphylococci

associated with poor hygiene, very contagious (*wear clean gloves)

honey-colored vesicles, crusty, erythematous, pruritic

most commonly found on face (especially in pediatric patients)

Treatment: systemic: PCN or erythromycin

local: warm saline soaks followed by soap&water removal of

crusts; topical antibiotic cream; meticulous hygiene

Prognosis: resulting glomerulonephritis with no treatment
 

2. Folliculitis:

Usually caused by staph in areas subject to friction, moisture, oil

"shavers rash"

small pustule at hair follicle; crusting; tender; found on scalp, beard
 

3. Furuncle:

Deep infection with staph around hair follicle

associated with severe acne or seborrheic dermatitis

drains pus; tender; core of necrotic debris on rupture

Treatment: incision and drainage; warm, moist compresses
 

4. Carbuncle:

Multiple interconnecting furuncles

heals with slow scar formation

Treatment: incision and drainage
 

5. Cellulitis:

Inflammation of subcutaneous tissue

can be primary infection or secondary complication

staph aureus and strep usual causative agents

hot, tender, erythematous, diffuse borders, malaise, fever

Treatment: moist heat, immobilization & elevation; hospitalization

if severe; can lead to gangrene
 

b. Viral Infections:

1. Herpes simplex virus type I:

Generally oral lesions; virus remains in nerve root & returns to skin with

exacerbation by sunlight, trauma, stress

contagious to those not previously infected; increase in severity with age

grouped vesicles on erythematous base

Treatment: moist compresses; antiviral agents (acyclovir)

2. Herpes simplex virus type II:

Generally genital lesions; frequent recurrence

clinical manifestations and treatment same as HSV I
 

3. Herpes zoster:

Activation of varicella-zoster virus; commonly called "shingles"

linear patches along dermatome of grouped vesicles

unilateral, burning, pain, and neuralgia preceding & during outbreak

Treatment: antiviral agents; wet compresses, white petrolatum to lesions;

systemic corticosteriods; scarring & post-herpetic neuralgia
 

4. Verruca vulgaris:

Caused by human papilloma virus (HPV)

circumscribed, hypertrophic flesh-colored papule; painful on compression

Treatment: spontaneous disappearance in 1-2 years possible; removal with

scissors and curette; liquid nitrogen; CO2 laser surgery
 

c. Fungal Infections:
 

1. Candidiasis:

Caused by candida albicans; also called moniliasis

presents in warm, moist areas such as crural areas, oral area, submammary

Mouth: white patches leaving erosions when removed

Vagina: vaginitis; red, edematous, painful vaginal wall

Skin: diffuse papular erythematous rash

Treatment: nystatin powder, cream or suppository
 

2. Tinea corporis:

Caused by dermatophytes; commonly called "ringworm"

annular, well-defined margins, erythematous

Treatment: antifungals (Monistat or Lotrimin)
 

3. Tinea cruris:

Caused by dermatophytes; commonly called "jock itch"

Well-defined border in groin area

Treatment: topical antifungal cream or solution
 

4. Tinea unguium:

Caused by dermatophytes; "toenail fungus"

Thick, brittle, white to yellow nails

Treatment: nail avulsion or antifungal oral meds
 

5. Tinea pedis:

Caused by dermatophytes: commonly called "athletes foot"

Interdigital scaling and maceration; pruritus
 

d. Infestations & Insect Bites:
 

1. Bees & wasps:

Intense burning, local pain; swelling, itching; possible anaphylaxis

Treatment: cool compress; antipruritic or antihistamine lotion
 

2. Pediculosis: head, body, & pubic lice

Caused by blood-sucking parasites; excrement & eggs left on skin; live in

hair and clothing

Treatment: application of pyrethrins
 

3. Scabies:

Caused by parasite; eggs, feces & mite parts cause severe pruritus

Presence of burrows, redness, swelling

Treatment: benzene hexachloride or benzyl benzoate
 

4. Ticks:

Can cause Lyme disease - spreading ringlike rash 3-4 weeks after bite;

flu-like symptoms; itchy or painful rash; cardiac, arthritic or neuro

manifestations

5. Spiders:
 
 
 

e. Allergic conditions:
 

1. Contact dermatitis:

Manifestation of delayed hypersensitivity

Red, hivelike papules & plaques; circumscribed; vesicles; pruritus possible

Treatment: topical corticosteroid; antihistamines; avoidance of allergen
 

2. Urticaria:

Allergic manifestation; edema in upper dermis; localized histamine release

Multiple, rounded elevations

Treatment: antihistamines; removal of source
 

3. Drug reaction:

Caused by any drug that acts and an antigen

Rash of any morphology; red, macular, papular, semiconfluent;abrupt onset

Treatment: withdrawal of drug; systemic corticosteroid
 

4. Atopic dermatitis:

Exact cause unknown but possibly related to genetic allergy tendencies

Scaly, red to brown circumscribed lesions; pruritic

Treatment: topical corticosteroid; phototherapy; coal tar therapy
 

f. Benign skin conditions:
 

1. Acne:

Inflammation of sebaceous glands

Common in adolescents

Comedones (blackheads) & closed comedones(whiteheads)

Non-inflammatory & inflammatory papules & pustules

Commonly located on face, back, neck

Treatment: mechanical removal, benzoyl peroxide, antibacterial soap

2. Moles:

Developed from melanocyte precursor cells, heredity possible

Hyperpigmented areas that vary in size & color

Treatment: none
 

3. Psoriasis:

Excessively rapid turnover of epidermal cells

Scaling, silvery plaques on scalp, elbows & knees, nails, palms & soles

Treatment: corticosteroid, tar, ultraviolet light
 

4. Seborrheic keratosis:

Benign, genetically determined growths; increases with age

No association with sun exposure

Round, flat, papules or plaques, often warty

Treatment: removal for cosmetic reasons

5. Skin tags:

Small, skin-colored, pedunculated

Treatment: removal for cosmetic reasons
 

6. Lipoma:

Benign tumor of adipose tissue; encapsulated

Rubbery, compressible, vary in size

Treatment: none except biopsy

7. Vitiligo:

Absence of melanocytes; unknown cause

Usually symmetric and permanent

Treatment: repigmentation with UVA light
 

8. Lentigo:

Increased number of melanocytes; "liver spots"

Related to aging and sun exposure

Hyperpigmented, brown, black, flat, lesions

Treatment: liquid nitrogen for cosmetic reasons
 
 

Jarvis, C. (1996). Physical examination and health assessment. Philadelphia: Saunders.
 

Lewis, S., Heitkemper, M., Dirksen, S. (2000). Medical-surgical nursing: Assessment and management of clincial problems. St. Louis: Mosby.
 

Smyth, P. (2000). Clinical assessment of pediatric patients. Unpublished manuscript.