Ch 52 Nursing Management: Patients w/ Dermatologic Problems

Exfoliative Dermatitis: Clinical Manifestations and Assessment

-Condition starts acutely as patchy or generalized erythematous eruption accompanied by fever, malaise, and occasionally GI symptoms. -Skin color changes from pink to dark red. -After a week, the characteristic exfoliation begins, usually in the form of thin flakes that leave the underlying skin smooth and red, w/ new scales forming as the older ones come off. -Hair loss may accompany this disorder. -Relapses are common. -Systemic effects include high-output heart failure, intestinal disturbances, breast enlargement, elevated levels of uric acid in the blood (ie, hyperuricemia), and temp disturbances.

Noninfectious Inflammatory Dermatoses: Psoriasis

-Considered one of the most common skin diseases, psoriasis affects approx 2% of population, appearing more often in ppl of European ancestry. -It is thought that this chronic, noninfectious, inflammatory disease stems from hereditary defect that causes overproduction of keratin -Onset may occur at any age, but psoriasis is most common in ppl b/w 15 and 35 yrs of age. -Psoriasis has a tendency to improve and then recur periodically throughout life

Surgical Management: Cryosurgery

-Destroys tumor by deep-freezing tissue. -Thermocouple needle apparatus inserted into skin, & liquid nitrogen is directed to center of tumor until tumor base is −40°C to −60°C. -Liquid nitrogen has lowest boiling point of all cryogens, is inexpensive, & is easy to obtain. -Tumor tissue is frozen, allowed to thaw, & then refrozen. -Site thaws naturally and then becomes gelatinous & heals spontaneously. -Swelling and edema follow freezing. -Appearance of lesion varies. -Normal healing, which may take 4 to 6 wks, occurs faster in areas w/ good blood supply.

Surgical Management: Electrosurgery

-Destruction or removal of tissue by electrical energy. -Current converted to heat, which then passes to tissue from a cold electrode. -May be preceded by curettage (excising the skin tumor by scraping surface w curette). -Electrodesiccation then implemented to achieve hemostasis & destroy any viable malignant cells at base of wound or along its edges. -Electrodesiccation useful for lesions smaller than 1 to 2 cm in diameter. -This method takes advantage of fact that the tumor is softer than surrounding skin & therefore can be outlined by a curette, which "feels" the extent of tumor. -Tumor is removed & base cauterized. Process is repeated twice

Noninfectious Inflammatory Dermatoses: Exfoliative Dermatitis

-Exfoliative dermatitis is a serious condition characterized by progressive inflammation in which generalized erythema and scaling occur. -It may be associated with chills, fever, prostration, severe toxicity, and a pruritic scaling of the skin.

Blistering Disorders: Bullous Pemphigoid

-Acquired disease of flaccid blisters appearing on normal or erythematous skin.

Psoriasis: Pathophysiology

-Although primary cause of psoriasis is unknown, a combination of specific genetic makeup & environmental stimuli may trigger onset of disease -Current evidence supports an immunologic basis for disease -Periods of emotional stress & anxiety aggravate condition, and trauma, infections, and seasonal & hormonal changes also trigger factors -Epidermal cells are produced at a rate that is about 6 to 9 times faster than normal. -Cells in basal layer of skin divide too quickly, and newly formed cells move so rapidly to skin surface that they become evident as profuse scales or plaques of epidermal tissue. -Psoriatic epidermal cell may travel from basal cell layer of epidermis to stratum corneum and be cast off in 3 to 4 days, which is in sharp contrast to the normal 26 to 28 days -As a result of increased number of basal cells & rapid cell passage, normal events of cell maturation & growth cannot take place. -This abnormal process does not allow normal protective layers of skin to form

Pharmacologic Therapy: Systemic Agents

-Although systemic corticosteroids may cause rapid improvement of psoriasis, their usual risks & possibility of triggering a severe flare-up on withdrawal limit their use -Systemic cytotoxic preparations, such as methotrexate, have been used in treating extensive psoriasis that fails to respond to other forms of therapy -Methotrexate appears to inhibit DNA synthesis in epidermal cells, thereby reducing turnover time of psoriatic epidermis. However, med can be toxic, esp to liver, kidney, and bone marrow. -Lab studies must be monitored to ensure that hepatic, hematopoietic, and renal systems are functioning adequately. -Pt should avoid drinking alcohol while taking methotrexate, b/c alcohol ingestion increases possibility of liver damage -Med is teratogenic & thus should not be administered to preg women -Hydroxyurea (Hydrea) also inhibits cell replication by affecting DNA synthesis. Pt is monitored for signs & symptoms of bone marrow depression -Cyclosporine A, a cyclic peptide used to prevent rejection of transplanted organs, has shown some success in treating severe, therapy-resistant causes of psoriasis. However, its use is limited by side effects such as hypertension and nephrotoxicity -Oral retinoids modulate growth and differentiation of epithelial tissue -Etretinate is esp useful for severe pustular or erythrodermic psoriasis. -Etretinate is a teratogen w/ very long half-life; cannot be used for women w/ childbearing potential

Psoriasis: Complications

-Asymmetric rheumatoid factor- negative arthritis of multiple joints occurs in about 5% of ppl w/ psoriasis. -Arthritic development can occur before or after skin lesions appear -Relationship b/w arthritis & psoriasis is not understood, although recent studies suggest an interplay b/w genetic, environmental factors, and immune system -Erythrodermic psoriasis, an exfoliative psoriatic state, involves disease progression that affects total body surface. Pt is acutely ill, w/ impaired temp regulation, and fluid & protein loss. -Erythrodermic psoriasis often appears in ppl w/ chronic psoriasis after infections, after exposure to certain meds, or following withdrawal of systemic corticosteroids

Pemphigus: Pathophysiology

-Autoimmune disease involving immunoglobulin G. -Thought that pemphigus antibody is directed against a specific cell-surface antigen in epidermal cells. -Blister forms from the antigen-antibody reaction -Level of serum antibody is predictive of disease severity.

Basal Cell and Squamous Cell Carcinoma: Nursing Management

-B/c many skin cancers removed by excision, pts usually treated in outpatient surgical units. -Role of nurse is to teach pt about prevention of skin cancer & about self-care after treatment.

Basal Cell and Squamous Cell Carcinoma: Clinical Manifestations and Assessment

-BCC is most common type of skin cancer. -Generally appears on sun-exposed areas of body & is more prevalent in regions where the population is subjected to intense & extensive exposure to sun. -Incidence is proportional to age of the pt (average, 60 years) & total amount of sun exposure, and it is inversely proportional to the amount of melanin in the skin. -BCC usually begins as small, waxy nodule w/ rolled, translucent, pearly borders; telangiectatic vessels may be present. -As it grows, it undergoes central ulceration & sometimes crusting -BCC characterized by invasion & erosion of contiguous (adjoining) tissues. -Rarely metastasizes, but recurrence is common. However, neglected lesion can result in loss of nose, ear, or lip. -Other variants of BCC may appear as shiny, flat, gray or yellowish plaques. -SCC is malignant proliferation arising from epidermis. -Although usually appears on sun-damaged skin, may arise from normal skin or from preexisting skin lesions. -Of greater concern than BCC because it is a truly invasive carcinoma, metastasizing by blood or lymphatic system. -Lesions may be primary, arising on skin and mucous membranes, or may develop from a precancerous condition, such as actinic keratosis (lesions occurring in sun-exposed areas), leukoplakia (premalignant lesion of the mucous membrane), or scarred or ulcerated lesions. -SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding -Border of SCC lesion may be wider, more infiltrated, & more inflammatory than that of a BCC lesion. -Secondary infection can occur. Exposed areas, especially of upper extremities & of face, lower lip, ears, nose, & forehead, are common sites. -Incidence of BCC & SCC increased in all immunocompromised people -Tumors have same appearance as in non-HIV-infected ppl; however, in HIV pts, tumors may grow more rapidly & recur more freq. -These tumors are managed same as those for general population. -Freq follow-up (every 4 to 6 months) recommended to monitor forSCC is a malignant proliferation arising from the epidermis. Although it usually appears on sun-damaged skin, it may arise from normal skin or from preexisting skin lesions. It is of greater concern than BCC because it is a truly invasive carcinoma, metastasizing by the blood or lymphatic system. -Metastases account for 75% of deaths from SCC. The lesions may be primary, arising on the skin and mucous membranes, or they may develop from a precancerous condition, such as actinic keratosis (lesions occurring in sun-exposed areas), leukoplakia (premalignant lesion of the mucous membrane), or scarred or ulcerated lesions. -SCC appears as a rough, thickened, scaly tumor that may be asymptomatic or may involve bleeding (see Fig. 52-5). The border of an SCC lesion may be wider, more infiltrated, and more inflammatory than that of a BCC lesion. Secondary infection can occur. -Exposed areas, especially of the upper extremities and of the face, lower lip, ears, nose, and forehead, are common sites. -Incidence of BCC and SCC is increased in all immunocompromised people, including those infected with HIV.

Malignant Melanoma: Clinical Manifestations and Assessment (Box 52-10)

-Biopsy results confirm diagnosis of melanoma -Excisional biopsy specimen provides info on type, level of invasion, & thickness of lesion. -Excisional biopsy specimen that includes a 1-cm margin of normal tissue & a portion of underlying subcutaneous fatty tissue is sufficient for staging a melanoma in situ or an early, noninvasive melanoma. -Incisional biopsy should be performed when suspicious lesion too large to be removed safely w/o extensive scarring. -Biopsy specimens obtained by shaving, curettage, or needle aspiration are not considered reliable histologic proof of disease. -Thorough history & physical exam should include a meticulous skin exam & palpation of regional lymph nodes that drain lesional area. -B/c melanoma occurs in families, positive family history of melanoma is investigated so that first-degree relatives, who may be at high risk for melanoma, can be evaluated for atypical lesions. -After diagnosis of melanoma has been confirmed, a chest X-ray, complete blood cell count, liver function tests, and radionuclide or computed tomography scans are usually performed to stage extent of disease.

Bullous Pemphigoid: Clinical Manifestations and Assessment

-Bullous pemphigoid appears more often on flexor surfaces of arms, legs, axilla, & groin. -Oral lesions, if present, usually transient & minimal. -When blisters break, skin has shallow erosions that heal fairly quickly. -Pruritus can be intense, even before appearance of blisters. -Common in elderly, w/ peak incidence at about 60 yrs of age. -No gender or racial predilection, & disease can be found throughout the world.

Malignant Melanoma: Risk Factors

-Cause of malignant melanoma unknown, but ultraviolet rays are strongly suspected, based on indirect evidence such as increased incidence of melanoma in countries near equator and in ppl younger than 30 yrs who used a tanning bed more than 10 times per yr. -Ethnicity is risk factor; in general, 1 in 100 Caucasians acquires melanoma each year. -As many as 10% of pts w/ melanoma are members of melanoma-prone families who have multiple changing moles (dysplastic nevi) that are susceptible to malignant transformation. -Pts w dysplastic nevus syndrome have been found to have unusual moles, larger & more numerous moles, lesions w/ irregular outlines, & pigmentation located all over skin. -Microscopic exam of dysplastic moles shows disordered, faulty growth.

Complications: Fluid & Electrolyte Imbalance

-Extensive denudation of skin leads to fluid & electrolyte imbalance b/c of significant loss of fluids & sodium chloride from skin. -Sodium chloride loss is responsible for many of systemic symptoms associated w/ disease and is treated by IV administration of saline solution. -Large amount of protein & blood is lost from denuded skin areas. -Blood component therapy may be prescribed to maintain blood volume, hemoglobin level, & plasma protein concentration. -Serum albumin, protein, hemoglobin, & hematocrit values monitored. -Pt encouraged to maintain adequate oral fluid intake. -Cool, nonirritating fluids encouraged to maintain hydration. -Small, frequent meals or snacks of high-protein, high-calorie foods help maintain nutritional status. -Parenteral nutrition considered if pt cannot eat an adequate diet.

Medical Management: Radiation Therapy

-Frequently performed for cancer of eyelid, tip of nose, and areas in or near vital structures (eg, facial nerve). -Reserved for older pts, b/c X-ray changes may be seen after 5 to 10 yrs, and malignant changes in scars may be induced by irradiation 15 to 30 yrs later. -Pt should be informed that skin may become red & blistered. -Bland skin ointment prescribed by provider may be applied to relieve discomfort. -Pt should also be cautioned to avoid exposure to sun.

Pemphigus: Risk Factors

-Genetic factors may also have a role in its development, w/ highest incidence among those of Jewish or Mediterranean descent. -Usually occurs in men & women in middle and late adulthood. -Condition may be associated w/ penicillins and captopril and w/ disorder myasthenia gravis.

Psoriasis: Medical and Nursing Management

-Goal of management are to slow rapid turnover of epidermis, to promote resolution of psoriatic lesions, and to control natural cycles of the disease. There is no cure -Therapeutic approach should be one that pt understands; it should be cosmetically acceptable and minimally disruptive of lifestyle -Any precipitating or aggravating factors are addressed -An assessment is made of lifestyle, b/c psoriasis is significantly affected by stress -Pt is informed that treatment of severe psoriasis can be time-consuming, expensive, and aesthetically unappealing at times

Basal Cell and Squamous Cell Carcinoma: Medical Management

-Goal of treatment is to eradicate tumor. -Treatment method depends on tumor location; cell type, location, & depth; cosmetic desires of pt; history of previous treatment; whether tumor is invasive; & whether metastatic nodes present. -Management of BCC & SCC includes surgical excision, Mohs' micrographic surgery, electrosurgery, cryosurgery, & radiation therapy.

Pemphigus: Medical & Nursing Management

-Goals of therapy are to bring disease under control as rapidly as possible, prevent loss of serum & the development of secondary infection, and to promote re-epithelization (renewal of epithelial tissue) -Corticosteroids administered in high doses to control disease & keep skin free of blisters. -High dosage level is maintained until remission is apparent. In some cases, corticosteroid therapy must be maintained for life. -High-dose corticosteroid therapy has serious toxic effects. -Immunosuppressive agents may be prescribed to help control disease & reduce corticosteroid dose. -Plasmapheresis temporarily decreases serum antibody level & has been used w/ variable success, although generally reserved for life-threatening cases.

Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome: Medical and Nursing Management

-Goals of treatment include control of fluid & electrolyte balance, prevention of sepsis, & prevention of ophthalmic complications. -Supportive care is mainstay of treatment. -All nonessential meds discontinued immediately. -If possible, pt is treated in regional burn center, b/c aggressive treatment similar to that for severe burns is required. -Skin loss may approach 100% of total body surface area. -Surgical débridement or hydrotherapy in a Hubbard tank (large steel tub) may be performed to remove involved skin. -Tissue samples from nasopharynx, eyes, ears, blood, urine, skin, & unruptured blisters obtained for culture to identify pathogenic organisms. -IV fluids prescribed to maintain fluid & electrolyte balance, esp in the pt who has severe mucosal involvement & who cannot easily take oral nourishment. -B/c indwelling IV catheter may be site of infection, fluid replacement is carried out by nasogastric tube & then orally asap. -Initial treatment w/ systemic corticosteroids is controversial. -Some experts argue for early high-dose corticosteroid treatment. However, in most cases, risk of infection, complication of fluid & electrolyte imbalance, delay in healing process, & difficulty in initiating oral corticosteroids early in course of disease outweigh perceived benefits. -In patients w/ TEN thought to result from a med reaction, corticosteroids may be administered; however, the pt should be closely monitored for adverse effects. -Protecting skin w/ topical agents is crucial. Various topical antibacterial & anesthetic agents used to prevent wound sepsis & to assist w/ pain management. -Systemic antibiotic therapy used w/ extreme caution. -Temporary biologic dressings (eg, pigskin) or plastic semipermeable dressings (eg, Vigilon) may be used to reduce pain, decrease evaporation, & prevent secondary infection until epithelium regenerates. -Meticulous oropharyngeal & eye care essential when there is severe involvement of mucous membranes & eyes. -As pt completes acute inpatient stage of illness, focus directed toward rehabilitation & outpatient care or care in a rehab center. -Pt & fam members are involved in care & instructed in procedures, such as wound care and dressing changes that need to be continued at home. -Pt & fam members provided w/ instructions about pain management, nutrition, measures to increase mobility, & prevention of complications, including prevention of infection. -Taught signs and symptoms of complications & instructed when to notify health care provider. -Instructions provided in writing to pt & fam so they can refer to them when necessary at later times. -Interdisciplinary follow-up care is imperative to ensure that pt's progress continues. -Some pts will require care in a rehab center before returning home. Others will require outpatient physical & occupational therapy for an extended period. -When pt returns home, home care nurse coordinates care provided by various members of the health care team -Nurse also monitors pt's progress, provides ongoing assessment to identify complications, & monitors pt's adherence to plan of care. -Pt's adaptation to home care environment & pt's and fam's needs for support & assistance are assessed. -Referrals to community agencies made as appropriate.

Pharmacologic Therapy: Intralesional Agents

-Intralesional injections of corticosteroid triamcinolone acetonide(Aristocort, Kenalog-10, Trymex) can be administered directly into highly visible or isolated patches of psoriasis that are not resistant to other forms of therapy. -Care must be taken to ensure that med is not injected into normal skin

Malignant SKin Tumors: Kaposi's Sarcoma

-Kaposi's sarcoma (KS) is a malignancy of endothelial cells that line small blood vessels. -KS is manifested clinically by lesions of skin, oral cavity, GI tract, and lungs. -Skin lesions consist of reddish-purple to dark-blue macules, plaques, or nodules. -KS is subdivided into three categories: 1. Classic KS occurs predominantly in men of Mediterranean or Jewish ancestry b/w 40 and 70 yrs. Most pts have nodules or plaques on lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal. 2. Endemic (African) KS affects ppl predominantly in eastern half of Africa near equator. Men are affected more often than women, and children can be affected as well. Disease may resemble classic KS, or may infiltrate & progress to lymphadenopathic forms. 3. Immunosuppression-associated KS occurs in transplant recipients and ppl w AIDS. This form of KS is characterized by local skin lesions & disseminated visceral and mucocutaneous diseases. Greater degree of immunosuppression, higher the incidence of KS. Immunosuppression-related KS that results from AIDS is an aggressive tumor that involves multiple body organs. Its presentation resembles that of KS associated w immunosuppressive therapy. Most pts are b/w ages of 20 & 40 yrs.

TEN & SJS Complications: Sepsis

-Major cause of death from TEN is infection, & most common sites of infection are skin & mucosal surfaces, lungs, and blood. -Organisms most often involved are Staphylococcus aureus, Pseudomonas, Klebsiella, Escherichia coli, Serratia, and Candida. -Monitoring vital signs closely and noticing changes in respiratory, renal, & GI function may quickly detect beginning of infection. -Strict asepsis always maintained during routine skin care measures. -Hand hygiene & wearing sterile gloves when carrying out procedures are essential. -When condition involves a large portion of body, pt should be in a private room to prevent possible cross-infection from other pts. -Visitors should wear protective garments & wash hands before & after coming into contact w/ pt. -Ppl w/ any infections or infectious disease should not visit pt until they are no longer a danger to pt

Nursing Management: Teaching Skin Cancer Prevention (Box 52-8) (Box 52-7)

-Studies show that reg daily use of sunscreen w SPF of at least 15 can reduce recurrence of skin cancer by as much as 40% -Sunscreen should be applied to head, neck, arms, and hands every morning at least 30 mins before leaving house & reapplied every 4 hrs if skin perspires. -Intermittent application of sunscreen only when exposure is anticipated has been shown less effective than daily use. -Research has shown that daily use of sunscreen on hands and face reduces total incidence of solar keratoses, which are precursors of SCC, but has no effect on overall incidence of BCC. -These data are inconsistent, but one theory is that ppl have false sense of security when wearing sunscreen & tend to stay out in sun for longer periods. This longer exposure is believed to contribute to increasing incidence of melanoma. -Nurses should discuss issues with pts who are at high risk of skin cancer -Nurses should also encourage skin self-examination

Malignant Skin Tumors: Malignant Melanoma

-Malignant melanoma is a cancerous neoplasm in which atypical melanocytes are present in epidermis & dermis (& sometimes subcutaneous cells). -Most lethal of all skin cancers & is responsible for about 3% of all cancer deaths -Can occur in one of several forms: superficial spreading melanoma, lentigo-maligna melanoma, nodular melanoma, & acral-lentiginous melanoma. -These types have specific clinical & histologic features, as well as different biologic behaviors. -Most melanomas arise from cutaneous epidermal melanocytes, but some appear in preexisting nevi (moles) in skin or develop in uveal tract of eye. -Melanomas occasionally appear simultaneously w/ cancer of other organs. -Worldwide incidence of melanoma doubles every 10 yrs, an increase that is probably related to increased recreational sun exposure, changes in ozone layer, & improved methods of early detection. -Peak incidence occurs b/w ages of 20 and 45. -Incidence of melanoma is increasing faster than that of almost any other cancer, & mortality rate is increasing faster than that of any other cancer except lung cancer.

Bullous Pemphigoid: Medical and Nursing Management

-Medical treatment includes topical corticosteroids for localized eruptions & systemic corticosteroids for widespread involvement. -Systemic corticosteroids may be continued for months, in alternate-day doses -Pt needs to understand implications of long-term corticosteroid therapy.

Pemphigus: Complications

-Most common complications arise when disease process is widespread. -Before advent of corticosteroid & immunosuppressive therapy, pts were very susceptible to secondary bacterial infection. -Skin bacteria have relatively easy access to bullae as they ooze, rupture, & leave denuded (loss of epidermis) areas exposed to the environment. -Fluid & electrolyte imbalance results from fluid & protein loss as the bullae rupture. -Hypoalbuminemia is common when disease process includes extensive areas of body skin surface & mucous membranes.

Malignant Skin Tumors: Basal Cell and Squamous Cell Carcinoma

-Most common types of skin cancer are basal cell carcinoma (BCC) & squamous cell (epidermoid) carcinoma (SCC) -Skin cancer is diagnosed by biopsy & histologic evaluation.

Medical and Nursing Management: Removal of Scales

-Most important principle of psoriasis is gentle removal of scales. This can be accomplished w/ baths -Oils or coal tar preparations can be added to bath water and soft brush used to scrub psoriatic plaque gently. -After bathing, application of emollient creams containing alphahydroxy acids (e.g., Penederm) or salicylic acids continues to soften scales -Pt & fam should be encourages to establish regular skin care routine that can be maintained even when psoriasis is not in acute stage.

Pemphigus: Clinical Manifestations & Assessment

-Most pts present w/ oral lesions appearing as irregularly shaped erosions that are painful, bleed easily, and heal slowly. -Skin bullae enlarge, rupture, & leave large, painful, eroded areas that are accompanied by crusting and oozing. -Offensive odor emanates from bullae & exuding serum. -There is blistering or sloughing of uninvolved skin when min pressure is applied (Nikolsky's sign). -Eroded skin heals slowly, & large areas of the body eventually are involved. -Bacterial superinfection is common

TEN & SJS Complications: Conjunctival Retraction, Scars, and Corneal Lesions

-Nurse inspects eyes daily for signs of pruritus, burning, & dryness, which may indicate progression to keratoconjunctivitis, the principal eye complication. -Applying a cool, damp cloth over eyes may relieve burning sensations. -Eyes are kept clean & observed for signs of discharge or discomfort, & progression of symptoms documented & reported. -Administering eye lubricant, when prescribed, may alleviate dryness & prevent corneal abrasion. -Using eye patches or reminding pt to blink periodically may counteract dryness. -Pt instructed to avoid rubbing eyes or putting any med into eyes that has not been prescribed or approved by provider.

Exfoliative Dermatitis: Medical and Nursing Management

-Objectives of management are to maintain fluid & electrolyte balance and prevent infection -Treatment is individualized & supportive & should be initiated as soon as condition is diagnosed -Pt may be hospitalized & placed on bed rest. -All medications that may be implicated are discontinued. -Comfortable room temp should be maintained b/c pt does not have normal thermoregulatory control as a result of temp fluctuations caused by vasodilation & evaporative water loss. -Fluid & electrolyte balance must be maintained b/c there is considerable water & protein loss from the skin surface. -Administration of plasma volume expanders may be indicated.

Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome: Risk Factors

-Occur in all ages & both genders. -Incidence increased in older ppl b/c of their use of many meds. -Ppl who are immunosuppressed have a high risk of SJS and TEN. -Although incidence of TEN and SJS in the general population is about 2 to 3 cases per 1 million people in the US, risk associated w/ sulfonamides in HIV-positive individuals may approach 1 case per 1,000. -Most pts w/ TEN have abnormal metabolism of the med; mechanism leading to TEN seems to be a cell-mediated cytotoxic reaction.

Types: Acral-Lentiginous Melanoma

-Occurs in areas not excessively exposed to sunlight & where hair follicles absent. -Found on palms of hands, on soles, in nail beds, & in mucous membranes in dark-skinned ppl. -Appear as irregular, pigmented macules that develop nodules. -May become invasive early.

Types: Superficial Spreading Melanoma

-Superficial spreading melanoma occurs anywhere on body & is most common form of melanoma. -Usually affects middle-aged ppl & occurs most freq on trunk & lower extremities. -Lesion tends to be circular, w/ irregular outer portions. -Margins of lesion may be flat or elevated & palpable -This type of melanoma may appear in a combo of colors, w/ hues of tan, brown, & black mixed w/ gray, blue-black, or white. -Sometimes dull pink rose color can be seen in small area within lesion.

Medical and Nursing Management: Photochemotherapy

-One treatment for severely debilitating psoriasis is a psoralen (photo toxic) med combined w/ ultraviolet-A (PUVA) light therapy -In this treatment, pt takes a photosensitizing med (usually 8-methoxypsoralen) in standard dose & is subsequently exposed to long-wave ultraviolet light as med plasma levels peak -Although mechanism of action is not completely understood, it is thought that when psoralen-treated skin is exposed to ultraviolent-A light, the psoralen binds w/ DNA and decreases cellular proliferation -PUVA has been associated w/ long-term risks of skin cancer, cataracts, and premature aging of skin -PUVA unit consists of a chamber that contains high-output black-light lamps & an external reflectance system -Exposure time is calibrated according for specific unit in use and anticipated tolerance of pt's skin. -Pt usually treated 2 to 3 times each week until psoriasis clears. Interim period of 48 hrs b/w treatments is necessary; it takes long time for any burns resulting from PUVA therapy to become evident -After psoriasis clears, pt begins maintenance program. Once little or not disease is active, less potent therapies are used to keep minor flare-ups under control -Ultraviolet-B (UVB) light therapy also used to treat generalized plaques. -UVB light ranges from 270 to 350 nm, although research has shown that narrow range, 310 to 312 nm, is action spectrum. Used alone or combined w/ topical coal tar -If access to light treatment not feasible, pt can expose him/herself to sunlight -Risks of all light treatments are similar and include acute sunburn reaction; exacerbation of photosensitive disorders such as lupous, rosacea, and polymorphic light eruption; as well as other skin changes such as increased wrinkles, thickening, & increased risk for skin cancer

Blistering Disorders: Pemphigus

-Pemphigus is group of serious diseases of skin characterized by appearance of bullae (blisters) of various sizes of apparently normal skin & mucous membranes

Medical Management: Surgical Management

-Primary goal is to remove tumor entirely. -Best way to maintain cosmetic appearance is to place incision properly along natural skin tension lines & natural anatomic body lines. -Size of incision depends on tumor size & location but usually involves a length-to-width ratio of 3:1. -Adequacy of surgical excision is verified by microscopic evaluation of sections of specimen. -When tumor is large, reconstructive surgery w/ use of skin flap or skin grafting may be required. -Incision is closed in layers to enhance cosmetic effect. -Pressure dressing applied over wound provides support. -Infection after simple excision is uncommon if proper surgical asepsis maintained.

Complications: Infection & Sepsis

-Pt susceptible to infection b/c barrier function of skin is compromised. -Bullae also susceptible to infection, & sepsis may follow. -Skin is cleaned to remove debris & dead skin and to prevent infection. -Secondary infection may be accompanied by an unpleasant odor from skin or oral lesions. -Candida albicans of the mouth (ie, thrush) commonly affects pts receiving high-dose corticosteroid therapy. -Oral cavity is inspected daily, & any changes reported. Oral lesions are slow to heal. -Infection is leading cause of death in pts w blistering diseases. -Particular attention given to assessment for signs & symptoms of local and systemic infection. -Seemingly trivial complaints or minimal changes investigated, b/c corticosteroids can mask or alter typical signs & symptoms of infection. -Vital signs monitored, & temp fluctuations documented. -Pt observed for chills, & all secretions and excretions are monitored for changes suggesting infection. -Results of culture & sensitivity tests are monitored. -Antimicrobial agents administered as prescribed, & response to treatment is assessed. -Health care personnel must perform effective hand hygiene & wear gloves. -In hospitalized pts, environmental contamination reduced as much as possible. Protective isolation measures & standard precautions are warranted.

Malignant Skin Tumors (Box 52-6)

-Skin cancer is most common cancer in United States. -If incidence continues at present rate, an estimated one of eight fair-skinned Americans will eventually develop skin cancer, esp basal cell carcinoma. -B/c skin is easily inspected, skin cancer is readily seen & detected & is most successfully treated type of cancer. -Exposure to sun is leading cause of skin cancer; incidence is related to total amount of exposure to sun. -Sun damage is cumulative, & harmful effects may be severe by 20 yrs of age. -Increase in skin cancer probably reflects changing lifestyles & emphasis on sunbathing & related activities in light of changes in environment -Changes in ozone layer from effects of worldwide industrial air pollutants, such as chlorofluorocarbons, have prompted concern that incidence of skin cancers, esp malignant melanoma, will increase. -Scientists believe that ozone layer helps protect earth from effects of solar ultraviolet radiation. Proponents of this theory predict an increase in skin cancers as consequence of changes in ozone layer. -Protective measures should be used throughout life, & nurses should inform pts about risk factors associated w/ skin cancer.

Malignant Skin Tumors: Metastatic Skin Tumors

-Skin is an important, although not a common, site of metastatic cancer. -All types of cancer may metastasize to skin, but carcinoma of breast is primary source of cutaneous metastases in women. -Other sources include cancer of large intestine, ovaries, and lungs. -In men, most common primary sites are lungs, large intestine, oral cavity, kidneys, or stomach. -Skin metastases from melanomas are found in both genders. -Clinical appearance of metastatic skin lesions is not distinctive, except perhaps in some cases of breast cancer in which diffuse, brawny hardening of the skin of the involved breast is seen. -In most instances, metastatic lesions occur as multiple cutaneous or subcutaneous nodules of various sizes that may be skin-colored or diff shades of red.

Types: Lentigo-Malingna Melanoma

-Slowly evolving, pigmented lesion that occurs on exposed skin areas, esp dorsum of hand, head, & neck in elderly ppl. -Often, lesion is present for many yrs before examined by a provider. -First appears as tan, flat lesion, but in time undergoes changes in size & color.

Types: Nodular Melanoma

-Spherical, blueberry-like nodule w/ relatively smooth surface & relatively uniform, blue-black color -May be dome-shaped w/ smooth surface. -May have other shadings of red, gray, or purple. -Sometimes, nodular melanomas appear as irregularly shaped plaques. -Pt may describe as a blood blister that fails to resolve. -Invades directly into adjacent dermis & therefore has poorer prognosis.

Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome: Clinical Manifestations and Assessment

-TEN & SJS are characterized initially by conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise, and myalgias (aches and pains). -These signs are followed by a rapid onset of erythema involving much of the skin surface & mucous membranes, including oral mucosa, conjunctiva, & genitalia. -In severe cases of mucosal involvement, may be danger of damage to larynx, bronchi, & esophagus form ulcerations. -Large, flaccid bullae develop in some areas; in other areas, large sheets of epidermis are shed, exposing underlying dermis. -Fingernails, toenails, eyebrows, & eyelashes may be shed along with surrounding epidermis. -Skin is excruciatingly tender, & loss of skin leaves a weeping surface similar to that of a total-body, partial-thickness burn; hence the condition is also referred to as "scalded skin syndrome." -Histologic studies of frozen skin cells from a fresh lesion & cytodiagnosis of collections of cellular material from a freshly denuded area are conducted. -A history of use of meds known to precipitate TEN or SJS may confirm med reaction as underlying cause. -Immunofluorescent studies may be performed to detect atypical epidermal autoantibodies -Genetic predisposition to erythema multiforme has been suggested but has not been confirmed in all cases.

Surgical Management: Mohs' Micrographic Surgery

-Technique that is most accurate & best conserves normal tissue. -Procedure removes tumor layer by layer. First layer excised includes all evident tumor & small margin of normal-appearing tissue. -Specimen is frozen & analyzed by section to determine if all tumor has been removed. If not, additional layers of tissue shaved & examined until all tissue margins are tumor-free. -In this manner, only tumor & a safe, normal-tissue margin removed. -Mohs' surgery is recommended tissue-sparing procedure, w extremely high cure rates for BCC & SCC. -Treatment of choice and most effective for tumors around eyes, nose, upper lip, & auricular and periauricular areas.

Exfoliative Dermatitis: Pathophysiology

-There is a profound loss of stratum corneum which causes capillary leakage, hypoproteinemia, and negative nitrogen balance. -B/c of widespread dilation of cutaneous vessels, large amounts of body heat are lost, & exfoliative dermatitis has a marked effect on the entire body. -Has a variety of causes. -Considered to be a secondary or reactive process to an underlying skin or systemic disease. -It may appear as a part of the lymphoma group of diseases and may precede the clinical manifestations of lymphoma.

Pharmacologic Therapy: Topical Agents

-Topically applied agents are use to slow overactive epidermis w/o affecting other tissues. -These agents include lotions, ointments, pastes, creams, and shampoos -Topical corticosteroids may be applied for their anti-inflammatory effect. -Choosing correct strength of corticosteroids may for involved site and choosing most effective vehicle base are important aspects of topical treatment. 2-wk break should be taken before repeating treatment w/ high-potency corticosteroids. -For long-term therapy, moderate-potency corticosteroids are used. On face & intertriginous areas, only low-potency corticosteroids are appropriate for long-term use. -Occlusive dressings may be applied to increase effectiveness of corticosteroid. Large rolls of tubular plastic can be used to cover arms & legs. -Another option is a vinyl jogging suit. Med applied, and suit it put on over it. -Hands can be wrapped in gloves, feet in plastic bags, and head in shower cap -Occlusive dressing should not remain in place longer than 8 hrs -Skin should be inspect carefully for appearance of atrophy, hypopigmentation, striae, & telangiectasias, all side effects of corticosteroids -When psoriasis involves large area of body, topical corticosteroid treatment can expensive & invoke some systemic risk. -The more potent corticosteroids, when applied to large areas of body, have potential to cause adrenal suppression through percutaneous absorption of med. In this event, other treatment modalities (nonsteroidal topical meds) may be used instead, or in combo to decrease need for corticosteroids. -Treatment with calcipotriene (Dovonex) & tazarotene (Tazorac) tend to suppress epidermopoiesis (i.e., development of epidermal cells) & cause sloughing of rapidly growing epidermal cells. -Calcipotriene works by decreasing mitotic turnover of psoriatic plaques. Most common side effect is local irritation. Intertriginous area & face should be avoided when using this med. Pt should be monitored for symptoms of hypercalcemia -Calcipotriene is available as a cream for use of body and solution for scalp. Not recommended for use be elderly b/c their more fragile skin or by pregnant/lactating women -Tazarotene, a retinoid, causes sloughing of scales covering psoriatic plaques. Causes increased sensitivity to sunlight by loss of outermost layer of skin, so pt should be cautioned to use effective sunblock & avoid other photosensitizes. -Tazarotene is category X drug. Negative pregnancy test should be obtained before initiating med and effective contraception should be continued during treatment. Side effect include burning, erythema, or irritation at site of application & worsening of psoriasis

Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome

-Toxic epidermal necrolysis (TEN) & Stevens-Johnson syndrome (SJS) are potentially fatal skin disorders & the most severe forms of erythema multiform. -These diseases are mucocutaneous reactions that constitute a spectrum of reactions, w/ TEN being most severe. -TEN & SJS are triggered by reaction to meds. -Antibiotics, esp sulfonamides, antiseizure agents, nonsteroidal anti-inflammatory drugs, & sulfonamides most frequent meds implicated

Malignant Melanoma: Medical and Nursing Management

-Treatment depends on level of invasion and depth of lesion. -Surgical excision is treatment of choice for small, superficial lesions. -Deeper lesions require wide local excision, after which skin grafting may be necessary. -Regional lymph node dissection is commonly performed to rule out metastasis, although new surgical approaches call for only sentinel node biopsy. -Sentinel lymph node is first node by which cancer is likely to spread from primary tumor before spreading to other lymph nodes. This technique used to sample nodes nearest the tumor and spare pt long-term sequelae of extensive removal of lymph nodes if sample nodes are negative. -Immunotherapy modifies immune function and other biologic responses to cancer. -Several forms of immunotherapy offer encouraging results. -Some investigational therapies include biologic response modifiers, adaptive immunotherapy, and monoclonal antibodies directed at melanoma antigens. -One of these, aldesleukin (Proleukin), shows promise in preventing recurrence of melanoma. -Several studies are attempting to develop and test autologous immunization against specific tumor cells. -These studies are in experimental stage but show promise for future development of vaccine against melanoma. -Current treatments for metastatic melanoma rarely if ever produce a satisfactory outcome. -Further surgical intervention may be performed to debulk tumor or to remove part of the organ involved. However, rationale for more extensive surgery is for relief of symptoms, not for cure. -Chemotherapy for metastatic melanoma may be used; however, only a few agents (eg, dacarbazine, nitrosoureas, cisplatin) have been effective in controlling the disease. -When melanoma is located in extremity, regional perfusion may be used; chemotherapeutic agent is perfused directly into area that contains melanoma. -This approach delivers high concentration of cytotoxic agents while avoiding systemic, toxic side effects. -Limb is perfused for 1 hr w high concentrations of medication at temperatures of 39°C to 40°C w a perfusion pump. -Inducing hyperthermia enhances effect of the chemotherapy so that smaller total dose can be used. -Goal of regional perfusion is control of metastasis, esp if used in combo w surgical excision of the primary lesion and w regional lymph node dissection.

Nursing Management: Teaching Self-Care

-Wound usually covered w dressing to protect site from physical trauma, external irritants, and contaminants. -Nurse instructs pt about when to report for a dressing change or provides written & verbal info on how to change dressings, including type of dressing to purchase, how to remove dressings & apply fresh ones, and importance of hand hygiene before and after procedure. -Pt watches for excessive bleeding & tight dressings that compromise circulation. -If lesion is in perioral area, the pt is instructed to drink liquids through a straw & limit talking and facial movement. Dental work should be avoided until area is completely healed. -After sutures are removed, emollient cream may be used to help reduce dryness -Applying sunscreen over wound is advised to prevent postoperative hyperpigmentation if the pt spends time outdoors. -Follow-up exams should be at reg intervals, usually every 3 months for a yr, & should include palpation of adjacent lymph nodes. -Nurse instructs pt to seek treatment for any moles subject to repeated friction & irritation, and to watch for indications of potential malignancy in moles as described previously. -Importance of life-long follow-up evaluations emphasized.

Psoriasis: Clinical Manifestation and Assessment

Lesions appear as red, raised patches of skin covered w/ silvery scales -Scaly patches are formed by buildup of living & dead skin resulting from vast increase in rate of skin cell growth & turnover -If scales are scraped away, dark-red base of lesion is exposed, producing multiple bleeding points. -Patches are not moist & may be pruritic -One variation of this condition is call guttate (in shape of a drop) psoriasis b/c lesions remain about 1 cm wide & are scattered like raindrops over body -Variation is believed to be associated w/ recent streptococcal throat infection. -May range in severity from a cosmetic source of annoyance to a physically disabling & disfiguring disorder -Particular sites of body tend to be affected most by this condition;they include scalp, extensor surface of elbows & knees, lower part of back, and genitalia. -Bilateral symmetry is a feature of psoriasis -In approx 1/4 to 1/2 of pts, the nails are involved, w/ pitting, discoloration, crumbling beneath free edges, and separation of nail plate -Psoriasis occurs on palms & soles, it can cause pustular lesions called palmer pustular psoriasis -B/c lesions tend to change histologically as they progress from early to chronic plaques, biopsy of skin is of little diagnostic value -There are no specific blood tests for diagnosing the condition -When in doubt, health card provider should assess for signs of nail & scalp involvement & for positive family history

Benign Skin Tumors

Table 52-7 provides descriptions of and treatments for common benign skin lesions