Chapter 23 Integ Assessment and Chapter skin cancer

Interigo

Inflammatory condition of the skin folds

Nevus of Ota.

Flat gray to blue pigmentation in the upper trigeminal area, which is more common in dark-skinned individuals.

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Collab Care for Dermatological problems

A careful history is of prime importance in the diagnosis of skin problems. After a careful history and physical examination, inspect individual lesions. Based on the history, physical examination, and appropriate diagnostic tests, either medical, surgical, or combination therapy is planned. Many of the specific therapeutic treatments require specialized equipment and are usually reserved for use by the dermatologist. Many clinicians prescribe drug therapy. The effectiveness of topical therapy can often be related to the base (or vehicle) in which the medication is prepared. Ultraviolet light (UVL) of different wavelengths may be used to treat many dermatologic conditions including psoriasis, cutaneous T-cell lymphoma, atopic dermatitis, vitiligo, and pruritis. One form of phototherapy involves the use of psoralen plus UVA light (PUVA). The photosensitizing drug psoralen is given to patients for a prescribed amount of time before exposure to UVA. Photodynamic therapy is a special type of phototherapy that may be used in the treatment of actinic keratosis and malignant skin tumors. The use of radiation for the treatment of basal and squamous cell carcinomas and malignant melanoma varies greatly according to local practice and availability. Even if radiation therapy is planned, a biopsy must first be performed to obtain a pathologic diagnosis. Radiation to malignant cutaneous lesions may be given to reduce tumor size or in palliative treatment. Laser treatment is expanding rapidly as an efficient surgical tool for many types of dermatologic problems (Table 24-11). Lasers are able to produce measurable, repeatable, consistent zones of tissue damage. Several types of lasers are available in most offices and hospitals. The CO2 laser is the most common treatment..

Atypical/ Dysplastic nevi part 2

An abnormal nevus pattern called dysplastic nevus syndrome identifies an individual at increased risk of melanoma. Approximately 2% to 8% of the white population has moles classified as atypical or dysplastic nevi. Dysplastic nevi (DN), or atypical moles, are nevi that are larger than usual (greater than 5 mm across) with irregular borders and various shades of color (Figure 24-3). These nevi may have the same ABCDE characteristics as melanoma, but they are less pronounced

Cutaneous T-Cell Lymphoma Origination in skin. Localized chronic, slowly progressing disease. Possibly related to environmental toxins and chemical exposure. Mycosis fungoides (MF) is most common form. Sézary syndrome is an advanced form of MF. Prevalence twice as high in men as in women in United States.

Classic presentation involves three stages— patch (early), plaque, and tumor (advanced). History of persistent macular eruption followed by gradual appearance of indurated erythematous plaques on the trunk that appear similar to psoriasis. Pruritus, lymphadenopathy. Treatment usually controls symptoms, not curative. UVB, PUVA, corticosteroids, topical nitrogen mustard, radiation therapy in patch and plaque stage disease. Interferon, systemic chemotherapy, extracorporeal photopheresis, romidepsin (Istodax) for progressive disease. Bexarotene (Targretin), denileukin diftitox (Ontak), and vorinostat (Zolinza) for advanced disease. Disease course is unpredictable, 10% will have progressive disease.

Nursing Management for Dermatologic Problems

Dermatologic conditions are not common reasons for hospitalization. Although it may not be the primary reason for hospitalization, many hospitalized patients will exhibit concurrent skin problems that warrant nursing intervention and patient education. Wet dressings are commonly used when there is oozing from the skin. Oozing usually indicates the presence of an infection and/or inflammation. Salt water or a prescribed solution (i.e., Domeboro powder) is used on the skin by soaking (a foot or hand) or applying compresses to a larger area. Wet dressings are also used to relieve itching, suppress inflammation, and debride a wound. In addition, wet dressings increase penetration of topical medications, promote sleep by relieving discomfort, and enhance removal of scales, crusts, and exudate. Baths are appropriate when large body areas need to be treated. They also have sedative and antipruritic effects. Some agents, such as oilated oatmeal (Aveeno) and sodium bicarbonate, can be added directly to bath water. Topical medications: A thin layer of ointment, cream, lotion or solution, or gel should be applied to clean skin and spread evenly in a downward motion. Thickly applied topical medications waste medication and leave the skin greasy. An alternative method is for you to apply the medication directly onto a dressing.

Drug Therapy for Dermatological Problems

Drug Therapy Antibiotics are used both topically and systemically to treat dermatologic problems, and are often used in combination. When using topical antibiotics, apply a thin film lightly to clean skin. If there are manifestations of systemic infection, a systemic antibiotic should be used. Systemic antibiotics are useful in the treatment of bacterial infections and acne vulgaris. Corticosteroids are particularly effective in treating a wide variety of dermatologic conditions and can be used topically, intralesionally, or systemically. Topical corticosteroids are used for their local anti-inflammatory action as well as for their antipruritic effects. Intralesional corticosteroids are injected directly into or just beneath the lesion. This method provides a reservoir of medication with an effect lasting several weeks to months, and is commonly used in the treatment of psoriasis, alopecia areata (patchy hair loss), cystic acne, hypertrophic scars, and keloids. Systemic corticosteroids can have remarkable results in the treatment of dermatologic conditions. Oral antihistamines are used to treat conditions that exhibit urticaria, angioedema, and pruritus. Dermatologic problems such as atopic dermatitis, allergic dermatitis, and other allergic cutaneous reactions can be mediated with the use of histamine blockers. Fluorouracil (5-FU) is a topical cytotoxic agent with selective toxicity for sun-damaged cells. 5-FU is available in four strengths (0.5%, 1%, 2%, and 5%) and is used for the treatment of premalignant (especially actinic keratosis) and some malignant skin diseases. Topical immunomodulators, such as pimecrolimus (Elidel) and tacrolimus (Protopic), are medications used to treat atopic dermatitis. They work by suppressing an overreactive immune system.

Nursing Management of derm part 2

Emotional stress can occur for persons who suffer from chronic skin problems such as psoriasis, atopic dermatitis, or acne. The sequelae of chronic skin problems could result in social and employment problems with subsequent financial implications, a poor self-image, problems with sexuality, and increasing and progressive frustration. Help the patient comply with the prescribed regimen. Dermatology patient support groups are listed on the American Academy of Dermatology website (www.aad.org). These groups are extremely helpful for patient support and accurate education materials. Many lesions can be camouflaged with the skillful use of cosmetics. Scarring and lichenification are the results of chronic dermatologic problems. The location of the scar is the determining factor with respect to its cosmetic implications. Facial scars are the most damaging psychologically, because they are so visible.

Malignant Melanoma Neoplastic growth of melanocytes anywhere on skin, eyes, or mucous membranes. Classification according to major histologic mode of spread. Potential invasion and widespread metastases.

Irregular color, surface, and border. Variegated color, including red, white, blue, black, gray, brown. Flat or elevated. Eroded or ulcerated. Often <1 cm in size. Most common sites in males are back, then chest. In females are legs, then back (see Fig. 24-2). Surgical excision and possible sentinel lymph node evaluation depending on the depth. Correlation of survival rate with depth of invasion. Poor prognosis unless diagnosed and treated early. Spreading by local extension, regional lymphatic vessels, and bloodstream. Possible use of adjuvant therapy

Malignant Melonoma

Malignant melanoma is a tumor arising in melanocytes, which are the cells producing melanin. Melanoma causes the majority of deaths due to skin cancer. Melanoma has the ability to metastasize to any organ, including the brain and heart. The death rate of melanoma is 10 times higher in white persons than in African Americans. Although the exact cause of melanoma is unknown, a combination of environmental and genetic factors is involved. The use of immunosuppressive drugs and a history of dysplastic nevi also increase a person's risk. Although UV radiation from the sun is the main cause of melanomas and other skin cancer, artificial sources of UV radiation, such as sunlamps and tanning booths, also play a role. Although anyone can develop melanoma, the risk is greatest for people who have red or blond hair, blue or light-colored eyes, and light-colored skin that freckles easily. A person may be born with a genetic disposition toward getting melanoma. Between 5% and 10% of people who develop melanoma have a first-degree relative (e.g., parent, sibling) who developed melanoma.

Basal Cell Carcinoma Change in basal cells. No maturation or normal keratinization. Continuing division of basal cells and formation of enlarging mass. Related to excessive sun exposure, genetic skin type, x-ray radiation, scars, and some types of nevi.

Nodular and ulcerative: Small, slowly enlarging papule. Borders semitranslucent or"pearly," with overlying telangiectasia. Erosion, ulceration, and depression of center. Normal skin markings lost (see Fig. 24-2). Superficial: Erythematous, pearly, sharply defined, barely elevated plaques. Surgical excision, chemosurgery, electrosurgery, chemotherapy, cryosurgery. 90% cure rate. Slow-growing tumor that invades local tissue. Metastasis rare. 5-FU and imiquimod for superficial lesions, photodynamic therapy for small lesions, vismodegib (Erivedge) for metastatic or recurrent locally invasive lesions.

Atypical or Dysplastic Nevi Morphologically between common acquired nevi and melanoma. May be precursor of malignant melanoma.

Often >5 mm. Irregular border, possibly notched. Variegated color of tan, brown, black, red, or pink within single mole. Presence of at least one flat portion, often at edge of mole. Frequently multiple. Most common site on back, but possible in uncommon mole sites such as scalp or buttocks (Fig. 24-3). Increased risk for melanoma. Careful monitoring of persons suspected of familial tendency to melanoma or dysplastic nevi. Excisional biopsy for suspicious lesions.

Malignant Melonoma diagnosis

Pigmented lesions suspicious for melanoma should not be shave-biopsied, shave-excised, or electrocauterized. Handheld screening devices (e.g., MelaFind) can assist the health care provider to determine whether a lesion without the obvious ABCDE signs should be biopsied. The most important prognostic factor is tumor thickness at the time of diagnosis. Two methods to determine thickness are currently being used. The Breslow measurement indicates the depth of the tumor in millimeters (Figure 24-5), and the Clark level indicates the depth of invasion of the tumor; the higher the number, the deeper the melanoma.

Nursing Management part 2

Pruritus (itching) can be caused by dry skin, almost any physical or chemical stimulus to the skin (such as drugs or insects), and any scaling skin disorder. The itch/scratch cycle must be broken to prevent excoriation and lichenification. Control of pruritus is also important because it is difficult to diagnose a lesion that is excoriated and inflamed. Inform the patient of the various methods that may be helpful in breaking the itch/scratch cycle. A cool environment may cause vasoconstriction and decrease itching. Topically applied menthol, camphor, or phenol can be used to numb the itch receptors. Systemic antihistamines may provide relief while the underlying cause of the patient's pruritus is diagnosed and treated. Wet dressings may also relieve pruritus. Lichenification is a thickening of skin as a result of the proliferation of keratinocytes with accentuation of the normal markings of the skin. Lichenification is caused by chronic scratching or rubbing of the skin and is often associated with atopic dermatoses and pruritic conditions. Treatment of the cause of the itching is the key to prevention of lichenification. Prevention of spread: Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. The most common contagious lesions include impetigo, staphylococcal infections, pyoderma, fungal infections, primary chancre, scabies, and pediculosis. Open lesions on the skin are susceptible to invasion by other viral, bacterial, or fungal organisms. Meticulous hygiene, hand washing, and dressing changes are important to minimize the potential for secondary infections. Warn the patient about scratching the lesions, which can cause excoriations and create a portal of entry for pathogens. Trim the patient's nails short to minimize trauma from scratching. You are often in a position to advise patients regarding care of the skin following simple dermatologic surgical procedures, such as skin biopsy, excision, and cryosurgery. Patient follow-up should be individualized. In general, your instructions should include dressing changes, use of topical antibiotics, and the signs and symptoms of infection.

Diagnostic and Surgical Care for Dermatologic Problems

Skin scraping is done to obtain a sample of surface cells (stratum corneum) for microscopic inspection and diagnosis. The most common tests of skin scrapings are potassium hydroxide (KOH) for fungus and mineral oil examination for scabies. Electrodesiccation is destruction of tissue by burning through conversion of electrical energy into heat. The major uses of this type of therapy are coagulation of bleeding vessels to obtain hemostasis and destruction of small telangiectasias (dilation of groups of superficial capillaries and venules). It usually involves more superficial destruction, and a monopolar electrode is used. Electrocoagulation has a deeper effect, with better hemostasis and an increased possibility of scarring. A dipolar electrode is used. Curettage is the removal and scooping away of tissue using an instrument with a circular cutting edge attached to a handle. Punch biopsy is a common dermatologic procedure used to obtain a tissue sample for histologic study or to remove small lesions (Figure 24-12). It is generally reserved for lesions smaller than 0.5 cm. Cryosurgery is the use of subfreezing temperatures to destroy epidermal lesions. Cryosurgery is a useful treatment for common benign, precancerous conditions including common and genital warts, cutaneous tags, thin seborrheic keratoses, lentigines, actinic keratoses, and nonmelanoma skin cancers. Topical liquid nitrogen (−196° F) is the agent most commonly used for cryosurgery. Excision should be considered if the lesion to be removed involves the dermis. Complete closure of the excised area usually results in a good cosmetic result. A specific type of excision is Mohs surgery, which is a microscopically controlled removal of a cutaneous malignancy. This procedure sections the surgical specimen horizontally, so that 100% of the surgical margin can be examined. Tissue is removed in thin layers, and all margins of the specimen are mapped to determine whether any malignant cells remain (Figure 24-13).

Squamous Cell Carcinoma Frequent occurrence on previously damaged skin (e.g., from sun, radiation, scar). Malignant tumor of squamous cell of epidermis. Invasion of dermis, surrounding skin.

Superficial: Thin, scaly erythematous plaque without invasion into the dermis. Early: Firm nodules with indistinct borders, scaling and ulceration (see eFig. 24-1). Late: Covering of lesion with scale or horn from keratinization, ulceration. Most common on sun-exposed areas such as face and hands. Surgical excision, cryosurgery, radiation therapy, chemotherapy, electrodesiccation and curettage. Untreated lesion may metastasize to regional lymph nodes and distant organs. High cure rate with early detection and treatment.

Malignant skin neoplasms patient education

Teach patients to self-examine their skin at least on a monthly basis. ABCDE Rule: The examination of skin lesions for Asymmetry, Border irregularity, Color change/variation, Diameter of 6 mm or more, and Evolving in appearance is simple to teach patients and easy to remember (Figure 24-2).

Inte diagnostic studies

The main diagnostic techniques related to skin problems are inspection of an individual lesion and a careful history related to the problem. Dermatoscopy is examination of the skin through a lighted instrument with optical magnification. Biopsy is one of the most common diagnostic tests used in the evaluation of a skin lesion. Techniques include punch, incisional, excisional, and shave biopsies. Stains and cultures are used to test for fungal, bacterial, and viral infections. Patch testing and photopatch testing may be used in the evaluation of allergic dermatitis and photoallergic reactions.

Ger considerations for skin

The rate of age-related skin changes is influenced by heredity, personal history of sun exposure, hygiene practices, nutrition, and general state of health. Skin changes related to aging include decreased turgor, thinning, drying, wrinkling, vascular lesions, increased skin fragility, and benign neoplasms. Decrease subcutaneous fat leads to an increased risk of traumatic injury, hypothermia, and skin shearing, which may lead to pressure ulcers. With aging, the apocrine and eccrine glands atrophy, causing dry skin and decreased body odor. The growth rate of hair and nails decreases as a result of atrophy of the involved structures. Hormonal and vitamin deficiencies can cause dry, thin hair and alopecia (partial or complete lack of hair).

Malignant Melonoma collab care

Treatment depends on the site of the original tumor, the stage of the cancer, and the patient's age and general health. Initial treatment of malignant melanoma is surgical excision, which may require a skin graft to close (discussed later in the chapter). Melanoma that has spread to the lymph nodes or nearby sites usually requires additional (adjuvant) therapy such as chemotherapy, biologic therapy (e.g., α-interferon, interleukin-2), and/or radiation therapy.

Skin Care Enviormental hazards

Years of exposure to the sun are cumulative and damaging. The ultraviolet (UV) rays of the sun cause degenerative changes in the dermis, resulting in premature aging. Prolonged and repeated sun exposure is a major factor in precancerous and cancerous lesions. Actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma are dermatologic problems that are associated with direct or indirect sun exposure. Patients should recognize that sun safety guidelines include sun avoidance (especially during the midday hours), protective clothing, and sunscreen. Other factors that increase the possibility of sunburn include being at high altitude; being in snow, which reflects 80% of the sun's rays; or being in or near water. Sunscreens can filter both UVA and UVB wavelengths. Patients can seek treatment for irritant or allergic dermatitis, which are two types of contact dermatitis. Irritant contact dermatitis is produced by direct chemical injury to the skin. Allergic contact dermatitis is an antigen-specific, type IV delayed hypersensitivity response. X-rays are valuable in both diagnosis and therapy but can cause serious side effects to the skin, including erythema, dry and moist desquamation, edema, and hypopigmentation and hyperpigmentation. Sleep is restorative to the skin, as well as to the rest of the body. Pruritic skin diseases often interfere with sleep. Adequate rest increases the patient's ability to tolerate itching, thereby decreasing skin damage from the resultant scratching. Exercise increases circulation and dilates the blood vessels. In addition to the healthy glow produced by exercise, the psychologic effects can also improve one's appearance and mental outlook. Hygienic practices are influenced by the skin type, lifestyle, and culture of the patient. The use of mild, moisturizing soaps (e.g., Ivory) and lipid-free cleansers, as well as avoiding hot water and vigorous scrubbing, can noticeably decrease local skin irritation and inflammation. A well-balanced diet adequate in all food groups can produce healthy skin, hair, and nails. Important elements include Vitamins A, B complex, C, D3, and K; protein and unsaturated fats.

Sunscreen

benzophenones block both UVA and UVB rays. The general recommendation is that everyone should use a sunscreen with a minimum SPF of 15 daily. Teach patients to look for the term broad spectrum on sunscreen packaging. Sunscreens with an SPF of 15 or more filter 92% of the UVB rays that are responsible for erythema, and make sunburn unlikely when applied appropriately. Patients who have a history of skin cancer or problems with sun sensitivity should use a product with an SPF of at least 30. Sunscreens should be applied 20 to 30 minutes before going outdoors, even in cloudy weather. The SPF value of all sunscreens decreases with time after application, and therefore sunscreen should be reapplied every 2 hours in a sufficient amount. One ounce per total body application is recommended. The ears, toes, and lips also need sunscreen. Sunscreens are not "waterproof " and should be reapplied immediately after swimming. Regular sunscreen use decreases the rate of developing melanoma.

Actinic keratosis, also known as solar keratosis,

consists of hyperkeratotic papules and plaques occurring on sun-exposed areas. Actinic keratoses are premalignant skin lesions that affect nearly all of the older white population. The clinical appearance of actinic keratoses can be highly varied. The typical lesion is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn Cryosurgery, chemical peels, laser resurfacing, topical application of 5-FU over entire area for 14-28 days or topical application of imiquimod (Aldara) for 16 wk, photodynamic therapy followed by light irradiation. Recurrence possible even with adequate treatment.

Nonmelanoma skin cancers

develop in the epidermis. The most common sites for the development of nonmelanoma skin cancer are in sun-exposed areas and include the face, head, neck, back of the hands, and arms.

Squamous cell carcinoma (SCC) part 2

is a malignant neoplasm of keratinizing epidermal cells. It frequently occurs on sun-exposed skin at the base of an actinic keratosis or another lesion. SCC is less common than BCC. SCC can be highly aggressive, has the potential to metastasize, and may lead to death if not treated early and correctly. Pipe, cigar, and cigarette smoking contribute to the formation of SCC on the mouth and lips.