Pathophysiology - 02 Integumentary Disorders

o PATHOPHYSIOLOGY LECTURE 2 - INTEGUMENTARY SYSTEM PATHOLOGY: SKIN COLOR AND DISEASE • Color of skin can indicate disease o Yellow skin (jaundice) - may indicate liver disease ▪ In liver disease, body can’t break down bilirubin ▪ Buildup of bilirubin gives skin yellow color ▪ Yellowish color may be seen in whites of eyes o Bronze color - indicate adrenal gland disease; malfunctioning adrenal glands can cause skin to produce excessive melanin o Bruised skin - indicate skin, blood, or circulatory problems o Plantar warts ▪ Found on sole of foot ▪ Tend to grow inward • Have smooth appearance on surface • Can cause pain when walking • Treatment - removal by surgery or freezing Genital warts ▪ Sexually transmitted, and highly contagious ▪ Some types of HPV have been associated with cervical cancer ▪ Recently developed vaccine may help prevent cervical cancer associated with certain types of HPV HERPES FUNGAL INFECTIONS • • • • • • Lifelong viral infection that produces clusters of small fluidfilled sacs (vesicles/blisters) Signs and symptoms - usually come and go; stress and other diseases can temporarily decrease immunity, and lead to symptom flare Herpes varicella o Also known as chickenpox o Can be spread by airborne particles or direct contact o Vesicles can be found on face, trunk, and extremities o Vesicles associated with intense itching Herpes zoster o Also known as shingles o Develops when dormant chickenpox virus re-activates o Causes extremely painful blisters/rashes that follow course of a sensory nerve o Symptoms develop when stress, disease, trauma, or aging prevent immune system from keeping virus in check Herpes simplex type 1 o Causes “cold sores” or “fever blisters” around mouth or nose o Commonly develops after common cold or fever Herpes simplex type 2 o Causes genital herpes o Spread by direct contact o Most contagious when in active stage; however, can be spread during remission • BACTERIAL INFECTIONS • HUMAN PAPILLOMA VIRUS (HPV) • Causes warts (verruca); hypertrophy of keratin cells in skin; types of warts o Common warts ▪ Usually found on children’s hands and fingers ▪ Spread by scratching and direct contact ▪ Often disappear on their own Tinea o General term for fungal skin infections o Usually located in warm, moist regions of body o Signs and symptoms - cracking, weeping, itchy skin o Tinea Pedis (athlete’s foot) ▪ Fungal infection of foot ▪ Spread by direct contact with contaminated surfaces (like locker room floors) ▪ Most commonly develops in warm, moist area between toes o Tinea cruris (jock itch) ▪ Fungal infection of groin and scrotal areas ▪ Mainly affects men ▪ Aggravated by increased perspiration, and tight fitting shorts/pants/undergarments o Tinea corporis (ringworm) ▪ Fungal infection of smooth skin on arms, legs and body ▪ Appearance - red, ring-shaped structure w/ pale center ▪ There is no actual worm involved o Tinea unguium ▪ Fungal infection under finger or toenails ▪ If untreated, results overgrown and thick nails with white/brittle appearance • Cellulitis o Infection of skin and subcutaneous tissue o Caused by Staphylococcus o Source of infection often wound of some kind Lyme disease o Bacterial infection spread by deer tick bites o Signs and symptoms ▪ “Bull’s eye” rash - red circle w/ lighter center; often very first presenting sign of infection; appears few days to several wks following tick bite ▪ Flu-like symptoms, fever, and chills ▪ Malaise ▪ Joint inflammation o o If untreated, can lead to neurological, cardiovascular problems, arthritis Diagnosis: blood test can confirm presence of infection • HOW SKIN HEALS • • • Everyone has skin injuries from time to time If skin is punctured and wound damages blood vessels, wound fills with blood; blood contains substances that cause clotting; top part of clot exposed to air hardens to form scab, nature’s band-aid, forming barrier and preventing pathogens from entering White blood cells enter & destroy any pathogens, while fibroblasts come & begin pulling edges of wound together; basale layer hyper-produces cells for repair of wound If wound is deep, scar, composed of collagen fibers, develops; scars don’t contain any accessory organs or nerve endings; stitches, adhesive strips (butterflies), or special glue reduce scarring Note, wound ideally starts to heal from inside out; this aids in preventing pathogens from becoming trapped between healed surface and deeper layer of skin where they could develop into pocket of infection Wound Repair • Decubitus Ulcers • • • BURNS • • • • • Can be caused by heat, chemicals, electricity, or radiation Two factors affect assessments of damage: o Depth o Amount of area damaged Depth of burn relates to layer/s of skin affected by burn First degree burns o Damage only outer layer, or epidermis o Symptoms include redness and pain, but no blister o Pain subsides in 2–3 days; there is no scarring o Complete healing takes about one week Second degree burns o Involve entire depth of epidermis & portion of dermis o Symptoms include redness, pain, and blistering o Extent of blistering dependent on depth of burn o Blistering extends after initial burn o Blisters heal within 10–14 days if there are no complications, with deeper second degree burns taking 1–3½ months o Scarring in second degree burns is common • • • • • • • • • • Third degree burns o Affect all three layers of skin o Surface of burn has leathery feel and will range in color from black, brown, tan, red, or white o Patient feels no pain because pain receptors are destroyed o Also destroyed are sweat and sebaceous glands, hair follicles, and blood vessels Fourth degree burns o Worst burns o Penetrate bone and cause bone damage Rule of nines - used to estimate extent of area damaged by burns Body divided into following regions, each given percentage of body surface area value: o Head and neck: 9% o Each upper limb: 9% (2 x 9 = 18%) o Front of trunk: 18% o Back of trunk and buttocks: 18% o Front of legs: 18% o Back of legs: 18% o Perineum (including anus and urogenital region): 1% Clinical concerns for burn victims relate to functions of skin already discussed, including: o Bacterial infections o Fluid loss o Heat loss Severe burns - require healing steps at intensity level body can’t manage on its own Damaged skin must be removed as soon as possible and skin grafting must be started Autografting - using patient’s own skin Heterografting - required if patient suffered large area of burn and has little healthy skin to graft Grafting - requires many trips to OR because large areas can’t be done all at once and often grafts don’t “take” It is possible to grow sheets of skin tissue in laboratory from patient cells or utilization of synthetic materials o HAIR COLOR AND TEXTURE • Fissure - crack-like slit that extends through epidermis into dermis Alopecia o Term for any type of hair loss; can be acute or chronic o Some forms, such as male pattern baldness, do not represent a disease, but are inherited traits o Hair loss can also be a result of chemotherapy for cancer treatments, hormonal imbalance, scale infections, severe emotional or physical stress, or side effects of other medications LICE • • • • • • • Tiny insect parasites that live on scalp/skin Pediculosis - lice infestation Lice spread by direct contact with infested person or infested objects (hair brushes, etc). Head lice - extremely common; checked for in schools Body lice - result of poor personal hygiene; can carry disease Pubic lice - spread through sexual contact; also known as “crabs” Treatments for lice o Bathing or shampooing with medicated shampoo; shampoo eliminates lice and their eggs (called “nits”) o Thorough cleaning of all bedding, towels, clothing, hats, combs and hairbrushes (alternatively, these items can be discarded) DISEASES OF THE INTEGUMENTARY SYSTEM • SCABIES • • • • • • Tiny mite that burrows into skin to lay eggs Transmitted via direct contact with infected individual Mites typically lodge in folds of skin (wrist, underarms, groin, under breasts, etc) Symptoms: intense itching, vesicles, and pustules Without treatment, cycle develops: o Eggs are laid under skin o Eggs hatch in 3-5 days and young mature in 2-3 wks o Mites mate and start process over again Treatment - specially formulated cream is applied to skin • SKIN LESIONS • • Pathologically altered piece of tissue Types of Lesions: o Macule - discolored spot on skin o Wheal (urticaria) - localized evanescent elevation of skin that is often accompanied by itching o Papule - solid, elevated area on skin o Nodule - larger papule o Vesicle - small fluid filled sac (blister) o Bulla - large vesicle o Pustule - pus-filled lesion o Ulcer - eating or gnawing away of tissue o Crust - dry, serous, brown, yellow red or green exuadation o Scale - thick, dry flack of cornified epithelial cells • Abrasion o Etiology: mechanical removal of skin tissue o Signs and symptoms: loss of skin surface integrity, redness, swelling, inflammation o Diagnostic tests: visual examination o Treatment: proper cleansing technique, removal of any foreign matter, antiseptic, bandage if necessary Acne o Etiology: metabolic condition, allergies, various drugs or endocrine disorders are possible causative agents o Signs and symptoms: inflammation of hair follicles/sebaceous glands especially on face, neck, chest, upper back/shoulders; can form blackheads, cysts, nodules, pustules, and pimples o Diagnostic tests: visual examination o Treatment: ▪ Mild: proper cleansing techniques and OTC treatments ▪ Severe: proper cleansing techniques including prescribed medications, antibiotics, steroids and/or all-trans retinoic acid (tretinoin) Decubitus ulcer (pressure ulcers; bedsores) o Etiology: tissue injury resultant of unrelieved pressure placed upon a specific area o Signs and symptoms: red, inflamed, crater-like lesion usually located over bony prominence o • • • • • • Diagnostic tests: visual inspection, culturing of site for infection o Treatment: preventative measures such as turning and padding important; treat infection of the sore Boil (furuncle) o Etiology: staphylococcus bacteria o Signs and symptoms: inflammation, localized encapsulated pus filled lesion, painful affected site; carbuncles are a large abscess composed of several furuncles o Diagnostic tests: visual examination, site culture o Treatment: proper antiseptic cleansing techniques, antibiotics, application of warm moist heat, depending on severity, may require draining Burns (thermal) o Etiology: heat or radiation or varying intensities & duration o Signs and symptoms: depending on intensity and duration: reddening of affected surface, penetrating additional skin layers as 2nd Degree Burn severity increases. Color is dependent on severity w/ a deepening red, to black o Diagnostic tests: visual examination o Treatment: dependent upon severity Cellulitis o Etiology: bacteria (streptococcus & staphylococcus) o Signs and symptoms: inflammation of skin and subcutaneous tissue, red and swollen, painful o Diagnostic tests: visual examination, site culture o Treatment: antibiotics (oral or intravenously, dependant on the severity) Contusion (bruise) o Etiology: blunt force or some form of skin injury without the skin surface breaking o Signs and symptoms: pain, swelling, discoloration o Diagnostic tests: visual inspection; imaging may be needed to check for more severe injury o Treatment: cold applications, firm bandage to impede swelling, elevation when possible, heat application, massage Dermatitis (contact) o Etiology: contact with allergen (extreme range of potential agents including, soaps, cosmetics, metals, drugs, plastics, etc.) o Signs and symptoms: small, reddish lesions to larger vesicles, weepy crusted areas, itching possible o Diagnostic tests: visual examination o Treatment: avoidance of causative agent; medication to decrease inflammatory process Eczema o Etiology: genetic predisposition to allergies (in infants it may include reaction to milk/dairy products, other foods), stress o Signs and symptoms: skin inflammation, redness, vesicles, scales, crusting, pustules o Diagnostic tests: visual examination, history o Treatment, no true cure: treat symptoms; eliminate offending food, reduce stress, topical cortiosteroidal creams, skin moisturizers, antihistamines • • • • • Folliculitis o Etiology: bacteria (usually staphylococcus) o Signs and symptoms: small pustules that form around base of hair follicle o Diagnostic tests: visual examination, site culture o Treatment: proper daily cleansing with antiseptic cleanser, oral antibiotics (chronic or severe cases) Herpes o Etiology: Herpes family of viruses o Signs and symptoms: clusters of fluid filled vesicles in patterns specific to condition, skin inflammation, rash, pain related to Herpes Simplex involved sensory nerve; remains dormant until immunosupression o Diagnostic tests: visual examination, site culture o Treatment: antiviral drugs, usually self-limiting Hives (urticaria) o Etiology: allergic reaction to external agent such as bee stings, plants, temperature extremes, sunlight, or internal agents such as foods, food additives, medication, antibiotics, or specific disease conditions o Signs and symptoms: itchy wheals surrounded by red inflamed area; can cover most of body o Diagnostic tests: visual examination, patient history o Treatment: antihistamines, allergen avoidance Keloid o Etiology: tissue trauma or surgical incision o Signs and symptoms: overproduction of collagen during tissue repair often creating larger structure than original scar/traumatized area o Diagnostic tests: visual inspection o Treatment: surgical removal, but there is a great potential for keloids to grow back Lyme disease o Etiology: tick bite containing specific spirochetal bacterium o Signs and symptoms: “Bull’s eye” macule/papule at site of tick bite, flu-like symptoms, stiff neck, swollen lymph node(s), joint aches, fever, headache, persistent sore throat, dry cough; possible neurologic, cardiac, and arthritic complications if left undiagnosed/untreated o Diagnostic tests: visual examination, blood test, patient history o Treatment: vaccine, antibiotics, treat secondary conditions; repeat infection is possibility • • • • • • • Malignant melanoma o Etiology: occurs in melanocytes, excessive exposure to the sun o Signs and symptoms: brown or black irregular patch that appears suddenly. A color or size change in a prexisiting wart or mole may also be an indication o Diagnostic tests: biopsy o Treatment: surgical removal and the surrounding area; chemotherapy Pediculosis (lice) o Etiology: lice infestation o Signs and symptoms: lice and nits (egg deposits) o Diagnostic tests: visual inspection o Treatment: proper cleansing techniques with medicated soap/shampoo, cleaning of all clothing, bedding, towels, combs, etc. to remove infestation Psoriasis o Etiology: possible genetic basis with attacks triggered by emotional stress, illness, sunlight, or skin damage o Signs and symptoms: red skin with silvery patches, rapid replacement of epidermal cells, dry cracking skin with crusting, can be painful; common to have periods of remission then exacerbation; may be arthritic component o Diagnostic tests: visual examination, patient history o Treatment: supportive, skin applications to deal with symptoms; medications: steroids, ultraviolet light Scabies o Etiology: mites o Signs and symptoms: elevated, grayish-white lines (burrows), vesicle and pustule formation (due to bite, feces, ova of offending mite), intense itching o Diagnostic tests: visual inspection o Treatment: proper cleaning technique, application of medicated cream, all infected individuals must be treated to prevent re-infection Seborrheic keratosis o Etiology: unknown agent(s) causing benign overgrowth of epithelial cells o Signs and symptoms: well defined, warty-scaled lesion that can present in variety of colors from yellow to brown o Diagnostic tests: visual inspection, laboratory examination o Treatment: scraping (curettage), or freezing Tinea, types o Tinea barbae (barber’s itch, affects face) o Tinea capitis (affects scalp) o Tinea corporis (ringworm, affects body) o Tinea cruris (jock itch, affects groin) o Tinea pedis (athlete’s foot, affects feet) o Tinea unguium (affects nails) Ringworm o Etiology: fungi o Signs and symptoms: case dependent; red ringshaped patches (mimicking worm), red inflamed skin, cracked and weeping area(s), itch, discoloration of affected nails o Diagnostic tests: visual examination, microscopic examination, site culture o • • Treatment: maintain clean dry condition of affected area, antifungal medication (topical or systemic) Warts (common, plantar, genital) o Etiology: viruses o Signs and symptoms: raised, rubbery, scaly growths of varying sizes and colors o Diagnostic tests: visual examination o Treatment: chemical or physical removal Erythema infectiosum (fifth disease) PHARMACOLOGY CORNER • • • Transdermal patches o Placed on skin in morning and left in place for 24 hours (or more) o Allows medication to be slowly absorbed over time o Examples of common transdermal patches ▪ Nicotine (for smoking cessation) ▪ Nitroglycerine (a heart medication) ▪ Birth control Topical creams o For skin irritation - mild preparations stop itching; more powerful preparations containing corticosteroids work as local anti-inflammatory agents; because cream is not fully absorbed into bloodstream, systemic side effects are minimal o Antifungal - treat fungal infections like ring worm and athlete’s foot o Anti-viral - used to treat herpes and other viral skin conditions o Antibiotic - used to treat bacterial infection; can also be used to prevent wound from becoming infected Medicated shampoos - useful in treating lice and dandruff (excessive dry scalp with sloughing skin)