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INDIVIDUAL
A.
Adults:
1.
4: DERMATOLOGY GUIDELINES
CONSIDERATIONS
Skin lesions begin to appear in early adulthood.
Encourage the client to monitor lesions over time.
B.
Geriatrics:
1.
Benign lesions are commonly seen in the elderly
population.
B.
Vaginal: thick, white, “cottage-cheese-like” vaginal dis-
charge with or without vaginal itching.
C.
Genital: bright red rash with well-demarcated satellite
lesions advancing to pustules or erosions in the genital or diaper area.
D.
Males: erythemic rash that may advance to erosions seen
on male genitalia, with the scrotum perhaps involved.
BIBLIOGRAPHY
Boer, F. L., ten, Eikelder., G, M. L., Kapiteijn, E. H., Creutzberg, C. L.,
Galaal, K., & van Poelgeest, M. I. E. (2019). Vulvar malignant melanoma: Pathogenesis, clinical behavior and management: Review
of the literature. Cancer Treatment Reviews, 73, 91–103. https://doi.
org/10.1016/j.ctrv.2018.12.005
Broccolo, F., Drago, F., Ciccarese, G., Genoni, A., Porro, A., Parodi, A.,
Chumakov, K., & Toniolo, A. (2019). Possible long-term sequelae
in hand, foot, and mouth disease caused by Coxsackievirus A6.
Journal of the American Academy of Dermatology, 80(3), 804–806.
https://doi.org/10.1016/j.jaad.2018.08.034
CANDIDIASIS
DEFINITION
A.
A fungal infection of the mucous membranes and/or
skin, candidiasis is caused by the Candida albicans fungus
(Figure 4.4).
FIGURE
4.4
Candidiasis (diaper
rash on female
newborn).
Source:
Reproduced from
Kifer, Z. A. (2012). Fast
facts for wound care nursing:
Practical wound management
in a nutshell (p. 264). Springer
Publishing Company.
INCIDENCE
A.
It occurs frequently in females, children, and the elderly
population.
PATHOGENESIS
A.
An overgrowth of C. albicans occurs when the mucous
membranes and/or skin are exposed to moisture, warmth,
and an alteration in the membrane barrier.
PREDISPOSING
A.
Immunosuppression.
B.
Use of antibiotics.
C.
Hyperglycemia.
D.
Chronic use of steroid.
E.
Frequent douching by individuals with a uterus.
F.
Adults wearing dentures.
COMMON
A.
Oral: a persistent white patch on the tongue or roof the
mouth which may be slightly reddened with or without crevices on the tongue.
FACTORS
COMPLAINTS
SUBJECTIVE
A.
Question the client about onset, duration, and location of
DATA
lesions.
B.
Determine whether the client has a history of infections.
C.
Inquire into medical history and current medications.
D.
Rule out the presence of any other current medical
conditions.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Assess skin and mucous membranes for discharge and
lesions.
2.
Observe location and severity of lesions.
B.
Palpate:
1.
Palpate lymph nodes in neck and groin.
DIAGNOSTIC
A.
Vaginal and genital infections need to be evaluated for
TESTS
sexually transmitted infections (STIs), especially if the client is sexually active with multiple partners. Vaginal/genital culture specimen should be sent for gonorrhea/chlamydia
testing.
B.
Other specimens to consider include wet prep/potassium
hydroxide (KOH) 10% solution, Gram stain vaginal culture
for Candida.
DIFFERENTIAL
A.
Oral candidiasis:
1.
Leukoplakia.
2.
Stomatitis.
3.
Formula (for newborns).
B.
Diaper area:
1.
Candidiasis.
2.
Contact dermatitis.
3.
Bacterial infection.
C.
Genital area:
1.
Candidiasis.
2.
Bacterial infection.
3.
Bacterial vaginosis.
4.
Chlamydia.
5.
Gonorrhea.
6.
Trichomoniasis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Treatment can be successful with good hygiene and
medications.
2.
Stress to the client to keep the affected area cool and
dry. Frequent changes of clothing may be necessary to
keep the area cool and dry to avoid damp conditions.
3.
Diaper area will need to be changed more frequently;
suggest using cloth diapers and allowing skin to be
exposed to air for short periods.
B.
Client teaching:
1.
Use medication on the skin to help with symptoms.
2.
Do not scratch. Keep ngernails short.
C.
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Pharmaceutical therapy: Choose one of the following phar-
maceutical therapies:
1.
Oral:
a.
Nystatin (Mycostatin) oral suspension 100,000 U/
mL, 2 mL for infants and 4 to 6 mL for older children
and adults, QID for 7 to 10 days.
b.
Gentian violet aqueous solution, 1% for infants and
2% for adults, one to two times per day.
c.
Lotrimin buccal troches, ve times per day for 2
weeks, only for adults.
2.
Diaper:
a.
Nystatin cream, three to four times per day for 7 to
10 days.
b.
Mycolog II, apply sparingly to skin BID until
resolved.
3.
Vaginal:
a.
Clotrimazole 1% cream, 5 g intravaginally for 7 to 14
days.
b.
Miconazole 2% cream, 5 g intravaginally for 7 days
(over the counter [OTC]).
c.
Terconazole .8% cream, 5 g intravaginally for 3 days.
d.
Terconazole 80mg vaginal suppository, at bedtime
for 3 days.
e.
Fluconazole (Diucan) 150mg, oral tablet one time.
f.
Other preparations available in stronger or weaker
doses.
FOLLOW-UP
A.
None indicated unless not resolved or complications arise.
CONSULTATION/REFERRAL
A.
Consult a physician if not resolved within 2 weeks.
79
CONTACT
CONTACT DERMATITIS
DERMATITIS
DEFINITION
A.
Contact dermatitis is a cutaneous response to direct expo-
sure of the skin to irritants (irritant contact dermatitis) or allergens (allergic contact dermatitis). See Figure 4.5 for examples
of contact dermatitis.
A
B
DC
4.5 (A, B, C) Examples of contact
FIGURE
dermatitis and (D) facial contact dermatitis.
Reproduced from Lyons, F., & Ousley, L. (2015).
Source:
Dermatology for the advanced practice nurse. Springer Publishing
Company, Figures III.15, III.16.
1.
Irritant contact dermatitis is a nonimmunologic
response of the epidermis.
2.
Allergic contact dermatitis is an immunologic response
after one or more exposures to a particular agent.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Most effective medications for those who are pregnant
are clotrimazole, miconazole, and terconazole.
2.
Recommend a full 7-day course of treatment during
pregnancy.
B.
Adults:
1.
Consider immunosuppression in all adults with oral
candidiasis (HIV, diabetes, chemotherapy, leukemia).
2.
Adults with oral lesions need to be assessed for leuko-
plakia, especially if the client has a history of smoking or
chewing tobacco.
BIBLIOGRAPHY
Hillier, S., Gould, V., Beamer, M., Kaiser, J., & Juul, J. (2019). Diagnostic
accuracy of clinical criteria for bacterial vaginosis, vulvovaginal candidiasis and BV/VVC co-infections. American Journal of
Obstetrics & Gynecology, 221(6), 671–672. https://doi-org.proxy.library
.vanderbilt.edu/10.1016/j.ajog.2019.10.085
Latti, P., Ramanarayanan, S., & Prashant, G. M. (2019). Antifungal
efcacy of spice extracts against Candida albicans: An in vitro study.
Indian Journal of Community Medicine, 44, S77–S80. https://doi-org.pro
xy.library.vanderbilt.edu/10.4103/ijcm.IJCM_140_19
Pappas, P. G., Kauffman, C. A. Andes., R, D., Clancy, C. J., Marr, K. A.,
Ostrosky-Zeichner, L., Reboli, A. C., Schuster, M. G., Vazquez, J. A.,
Walsh, T. J., Zaoutis, T. E., & Sobel, J. D. (2016). Clinical practice guideline for the management of candidiasis: 2016 Update by the infectious
diseases society of America. Clinical Infectious Diseases, 62, e1. https://
doi.org/10.1093/cid/civ933
INCIDENCE
A.
Contact dermatitis occurs in all ages. People who work
with chemicals daily and wash their hands numerous times a
day have a higher incidence of irritant dermatitis. Irritant contact dermatitis is seen in the elderly due to their dry skin.
PATHOGENESIS
A.
Irritant contact dermatitis is caused by an alteration
of the outer layer of the dermis due to exposure to chemicals, lotions, cold and dry air, soaps, detergents, or organic
solvents.
B.
Allergic contact dermatitis is caused by an alteration in the
epidermis where after exposure to an allergen the immune
system responds by producing inammation of the cutaneous tissue. Common allergens include poison ivy, poison oak,
sumac, nickel jewelry, hair dye, rubber and leather chemicals
(latex gloves), cleaning supplies, harsh soaps, detergents, and
topical medicines.
PREDISPOSING
A.
Occupation (hairdresser, nurse, housecleaner, food han-
FACTORS
dlers, mechanical industry workers, etc.).
B.
Jewelry.
C.
Activities in yard or woods.
COMMON
A.
COMPLAINTS
Irritation of the skin, ranging from redness to pruritic
inammation, with possible progression of blisters.
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1.
4: DERMATOLOGY GUIDELINES
Poison oak, ivy, and sumac induce classic presentation:
Lesions (vesicles) and papules on an erythemic base present in a linear fashion with sharp margins.
2.
Diffuse pattern with erythema may be seen when oleo-
resin is contacted with pets or smoke from burning re.
B.
Exposure to some type of irritant known to the client.
Round or annular lesions may have an internal cause, such as
a drug reaction.
OTHER
SIGNS AND SYMPTOMS
A.
Chronic:
1.
Erythema with thickening.
2.
Scaling.
3.
Fissures.
4.
Inammation; with chronic dermatitis, lichenication
may occur with scales and ssures.
5.
Lichenication which may occur with scales and
ssures.
B.
Diaper dermatitis:
1.
Prominent red, shiny rash on the buttocks and genitalia.
C.
Candidiasis diaper rash:
1.
Bright red rash with satellite lesions at margins.
2.
Inammation and excoriations present.
3.
Creases may be involved.
SUBJECTIVE
A.
Ask the client when irritation began and how it has
DATA
progressed.
B.
Elicit history of exposure to allergens.
C.
Question the client regarding activity and skin contact
with irritants before outbreak (cleaning agents, walking in
woods, hobbies, change in soap/laundry detergent, shaving
cream, lotions, etc.).
D.
List occupation and family history of allergens.
E.
Review medication list, including prescription, OTC, and
herbal medicines, to evaluate an interaction.
F.
List medications and OTC remedies used to relieve symp-
toms and results.
PHYSICAL
A.
Check temperature (if indicated).
B.
Inspect:
EXAMINATION
1.
Inspect the skin, noting type and location of lesions.
Note the pattern of inammation. The shape of irritation may mimic the shape of the irritant, such as the skin
under a ring or watch.
2.
Determine progression of lesions.
3.
Differentiate between primary and secondary lesions.
DIAGNOSTIC
A.
Consider none if source is known.
B.
Wet mount (potassium hydroxide [KOH], saline) to rule
TESTS
out fungal infection if Candida is suspected.
C.
Culture/sensitivity of pustules.
D.
Patch test to rule out allergic contact dermatitis.
DIFFERENTIAL
A.
Irritant contact dermatitis.
B.
Allergic contact dermatitis.
C.
Diaper dermatitis.
D.
Candida.
E.
Tinea pedis, corporis, and cruris.
F.
Drug reactions.
G.
Pityriasis rosea.
H.
Scabies.
DIAGNOSES
PLAN
A.
General interventions:
1.
Irritant contact dermatitis: Remove the irritating agent.
a.
Use topical soaks with saline or Burow solution
(1:40 dilution) for weeping areas.
b.
Suggest lukewarm baths (not hot) or oatmeal
(Aveeno) baths, as needed.
c.
For dry erythematous skin, recommend Eucerin or
Aquaphor ointments to rehydrate skin.
d.
Remind the client to avoid scratching skin and to
keep nails short.
e.
Suggest use of mild soaps and cleansers.
2.
Allergic contact dermatitis:
a.
Instruct the client to avoid contact with the caus-
ative agent.
b.
Have the client wash the affected area with cool
water immediately after exposure.
c.
Recommend lukewarm baths with oatmeal (Aveeno)
three to four times per day.
d.
Tell the client to apply calamine lotion after baths.
3.
Diaper dermatitis:
a.
Instruct the caretaker to change the client’s diaper
frequently, cleaning with water only, and allow skin
to air-dry 15 to 30 minutes four times a day. Tell the
parent not to use lotions or powders, but to apply zinc
oxide (Desitin ointment or powder, or Happy Hiney)
with each diaper change.
B.
For treatment of candidiasis diaper rash, refer to the
“Candidiasis” section in this chapter.
C.
Client teaching: See Client Teaching Guide for this chapter,
“Dermatitis.”
D.
Pharmaceutical therapy:
1.
Irritant contact dermatitis:
a.
Hydrocortisone 2.5% ointment three to four times
per day for 2 weeks.
2.
Allergic contact dermatitis:
a.
Low-dose topical steroids: hydrocortisone 2.5%
ointment three to four times per day for 1 to 2 weeks
after blistering stage; triamcinolone acetonide 0.025%
(Kenalog) ointment/cream BID.
b.
Intermediate-dose topical steroids: triamcino lone
acetonide 0.1% (Kenalog) cream BID; cream/ointment
should not be used longer than 2 weeks at a time.
c.
High-potent topical steroids: uocinonide 0.05%
(Lidex) ointment three to four times per day; not to be
used on face or skin folds; cream/ointment should not
be used longer than 2 weeks at a time.
d.
Hydroxyzine 25 to 50mg QID and diphenhydramine
HCl (Benadryl) 25 to 50mg QID; for children, 0.5 mg/
kg/dose TID as needed.
e.
If the rash is severe (face, eyes, genitalia, mucous
membranes), consider prednisone 60 to 80 mg/d to
start and taper over 10 to 14 days.
f.
Triamcinolone acetonide (Kenalog) 40 to 60mg by
intramuscular injection.
3.
Secondary bacterial infections:
a.
Erythromycin 250 mg QID or amoxicillin/
clavulanic acid (Augmentin) 875mg BID for 10 days.
4.
Secondary candidiasis infections:
a.
Use miconazole nitrate 2% cream, miconazole pow-
der, or nystatin cream.
b.
Use clotrimazole (Lotrimin) or ketoconazole
(Nizoral) cream three to four times per day for 10 days.
c.
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If inammation is present along with yeast, use
Mycolog II.
d.
If secondary bacterial infection is present, use mupiro-
cin (Bactroban) ointment TID for 7 to 10 days.
FOLLOW-UP
A.
None required if case is mild.
B.
See the client again in 2 to 3 days for severe cases, or phone
to assess progress.
CONSULTATION/REFERRAL
A.
Consult with a physician when steroid treatment is necessary
or if worsening symptoms develop despite adequate therapy.
ECZEMA OR ATOPIC DERMATITIS
81
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
If medications are necessary during pregnancy, con-
sider the gestational age of the fetus and the category of
medication.
B.
Pediatrics:
1.
For infants and children, consider hydroxyzine (Atarax)
.5 mg/kg/dose TID as needed for severe pruritus.
C.
Elderly:
1.
Clients may only exhibit scaling as the prominent irri-
tation rather than erythema and inammation. Topical
medications (neomycin, vitamin E, lanolin) and acrylate
adhesives are common causes of contact dermatitis.
2.
Pruritus that persists ≥6 weeks in the elderly population
65 years old and older is considered a chronic dermatitis
condition. Studies indicate that the aging epidermal barrier,
nervous system, and immune system predispose geriatrics
to a sensation of “itchiness.” Topical medications are considered rst-line treatment for geriatrics; however, systemic
treatments might be considered after evaluation of the client’s comorbid diseases.
BIBLIOGRAPHY
Schadler, E. D., & Kamat, D. (2019). Common annular lesions in the
pedia-tric population: Part 2. Pediatric Annals, 48(3), e135–e138. https:/
/doi.org/10.3928/19382359-20190222-01
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
ECZEMA
OR ATOPIC DERMATITIS
DEFINITION
A.
This pattern of skin inammation has clinical features of
erythema, itching, scaling, lichenication, papules, and vesicles in various combinations. Currently, the term eczema is used
interchangeably with dermatitis. The most common variants are
atopic dermatitis (Figure 4.6) and atopic eczema. Classication
is done by cause, either endogenous or exogenous.
INCIDENCE
A.
The overall prevalence of all forms of eczema is about 18 in
1,000 in the United States.
B.
With atopic dermatitis, 60% of those affected become
aficted between infancy and 12 years of age. It is more common in boys. Approximately 20% of children and 3% of adults
are affected.
PATHOGENESIS
A.
Eczema is characterized by a lymphohistiocytic inltra-
tion around the upper dermal vessels. Epidermal spongiosis
or intercellular epidermal edema and inammation are seen.
FIGURE
4.6 Atopic dermatitis.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for
wound care nursing: Practical wound management in a
nutshell (p. 264). Springer Publishing Company.
PREDISPOSING
A.
Family history of atopic triad: dermatitis, asthma, and
FACTORS
allergic rhinitis
B.
Exposure to allergens:
1.
Common foods: cow’s milk, nuts, wheat, soy, and sh.
2.
Common environmental allergens: dust, mold, cat
dander, and low humidity (dry air).
C.
Exposure to topical medications, most commonly neomy-
cin, lanolin, and topical anesthetics like benzocaine.
D.
Skin irritants: harsh soaps, skin-care products with per-
fumes, chemicals and alcohol, fabrics containing wool, and
tight clothing.
E.
Stress.
COMMON
A.
OTHER
A.
COMPLAINTS
Skin changes:
1.
Itching, impossible to relieve.
2.
Dryness.
3.
Discoloration, lichenication, and scaling.
4.
Skin thickening.
5.
Associated bleeding and oozing skin.
SIGNS AND SYMPTOMS
Primary lesions, papules, and pustules may lead to
excoriation.
B.
Lesions commonly seen on trunk, face, and antecubital
and popliteal fossae in children. Adults will have lesions on
the face, trunk, neck, and genital area.
C.
Other common features include infraorbital fold (Dennie
sign), increased palmar creases, facial erythema, and scaling.
SUBJECTIVE
A.
Determine whether the onset was sudden or gradual.
B.
Ask the client if the skin is itchy or painful.
C.
Assess if there is any associated discharge (blood or pus).
D.
Ask if the client has recently taken any antibiotics, other
DATA
oral drugs, or topical medications.
E.
Ask the client about use of soaps, creams, or lotions.
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F.
Assess for any preceding systemic symptoms (fever, sore
4: DERMATOLOGY GUIDELINES
throat, anorexia, vaginal discharge).
G.
Ask the client about recent travel abroad.
H.
Rule out insect bites.
I.
Rule out any possible exposure to industrial or domestic
toxins.
J.
Elicit what precipitates itching.
K.
Evaluate for increased stress level at home, work, in rela-
tionships, and so forth.
PHYSICAL
A.
Check temperature (if indicated).
B.
Inspect:
EXAMINATION
1.
Inspect skin for lesions.
2.
Recognize bacteria-infected eczema; Staphylococcus
aureus is the most common pathogen. It appears with
acute weeping dermatitis and crusted and small, supercial pustules.
DIAGNOSTIC
A.
Culture skin lesions to determine viral, bacterial, or fungal
TESTS
etiology.
B.
Blood work: Serum immunoglobulin E (IgE) is elevated
with atopic dermatitis.
DIFFERENTIAL
A.
Atopic dermatitis, acute or chronic.
B.
Contact dermatitis, acute or chronic.
C.
Seborrheic dermatitis.
D.
Ichthyosis vulgaris.
E.
Bacterial/fungal infections.
F.
Neoplastic disease.
G.
Immunologic and metabolic disorders.
DIAGNOSES
PLAN
A.
General interventions:
1.
Frequently treat the dry skin with emollients
(Aquaphor, Eucerin).
2.
Pat, do not rub skin.
3.
Children: Only bathe every two to three nights. Avoid
excessive use of soap and water when bathing. Use gentle
cleansers, such as Cetaphil or CeraVe, when bathing.
4.
Avoid wool products and lanolin preparations.
5.
Keep ngernails short to prevent scratching/scarring
skin.
6.
Treatment of secondary bacterial infections may be
neededas appropriate.
7.
Eliminate trigger foods one at a time for 1 month to see
improvement. Begin with eliminating cow’s milk products. Consider soy-based foods instead.
8.
Allergy testing may be considered if symptoms
continue.
9.
Ointments are usually recommended over creams for
moisturizing.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Eczema.”
C.
Pharmaceutical therapy:
1.
Atopic: acute, adult:
a.
Wet dressings with Burow solution changed every 2
to 3 hours.
Potent topical corticosteroid: betamethasone valer-
b.
ate 0.1% two to three times daily for up to 2 to 3 weeks.
c.
Antihistamine of choice: cetirizine HCl (Zyrtec) or
diphenhydramine HCl (Benadryl).
d.
Oral steroid for severe cases: prednisone 1 mg/kg
(40–60mg/d) tapered over 2 to 3 weeks.
2.
Atopic: acute, occurs in infants and children:
a.
Hydrocortisone:
i.
Infants and children: 2.5% ointment BID; 1% on
the face and intertriginous areas.
ii.
Adolescents: triamcinolone acetonide 0.1%
(Aristocort) ointment; apply thinly BID for 2 to
3 weeks. Precautions should be given regarding
possibility of hypopigmentation of skin even with
short-term use of steroids on skin.
b.
Antihistamines for itching:
i.
Infants and children: hydroxyzine (Atarax) 0.5
mg/kg/dose TID as needed or diphenhydramine
HCl (Benadryl); for children 2 to 6 years, 6.25mg
every 4 to 6 hours; for children 6 to 12 years, 12.5 to
25mg every 4 to 6 hours.
ii.
Adolescents: hydroxyzine 25 to 50mg/dose every
4 to 6 hours or diphenhydramine HCl (Benadryl).
3.
Atopic: chronic, adult:
a.
Short course of potent topical corticosteroid beta-
methasone dipropionate (Diprolene) or clobetasol propionate (Temovate) BID for 7 days.
4.
Alternative therapies:
a.
Probiotics have limited benet.
b.
Melatonin has been studied and shown to be useful
in children 6 to 12 years of age, in addition to the usual
treatment of topical corticosteroids and emollients.
5.
Antibacterial treatments for secondary bacterial infec-
tions: S. aureus.
a.
Adults:
i.
Augmentin 875mg PO BID for 10 to 14 days.
ii.
Keex 500mg PO QID for 10 to 14 days.
iii.
Erythromycin 500mg PO QID for 10 to 14 days.
OR
iv.
Dicloxacillin 250mg Q6H for 10 days.
b.
Children:
i.
Augmentin 25 to 45 mg/kg/d PO in two
divided doses for 10 days.
ii.
Erythromycin 30 to 50 mg/kg/d PO in two,
three, or four evenly divided doses for 10 days.
iii.
Cefdinir (Omnicef): not recommended for chil-
dren younger than 6 months; for children6 to 12
months, 7 mg/kg Q12H for 10 days.
FOLLOW-UP
A.
See client in ofce in 1 to 2 weeks and then every month
until condition is stabilized.
B.
Monitor the client for superimposed staphylococcal infec-
tion; may use oral erythromycin or dicloxacillin.
C.
Client may be seen every 3 to 6 months thereafter for client
education updates.
CONSULTATION/REFERRAL
A.
Eczema herpeticum (herpes simplex type 1) may progress
rapidly. Refer the client to a dermatologist.
B.
Refer the client to a dermatologist if skin eruptions are
severe or fail to respond to conservative treatment.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Children:
CONSIDERATIONS
Avoid oral steroids.
1.
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Teach clients to apply emollients when they have an
itch rather than scratching. The goal is to control the rash
and symptoms.
C.
Young adults and elderly:
1.
Nummular eczema is commonly seen, characterized
by coin-shaped vesicles and papules seen on the extremities and/or trunk.
BIBLIOGRAPHY
Nutten, S. (2015). Atopic dermatitis: Global epidemiology and risk
factors. Annals of Nutrition & Metabolism, 8–16. https://doi.org/
10.1159/000370220 66(Suppl. 1)
Shi, K., & Lio, P. A. (2019). Alternative treatments for atopic dermatitis:
An update. American Journal of Clinical Dermatology, 20(2), 251–266.
https://doi.org/10.1007/s40257-018-0412-3
Tanei, R., & Hasegawa, Y. (2016). Atopic dermatitis in older adults: A view-
point from geriatric dermatology. Geriatrics & Gerontology International,
16(1), 75–86. https://doi.org/10.1111/ggi.12771
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
Vandiver, A., & Cohe, B. A. (2016). Vesicular rash in an infant with eczema.
Contemporary Pediatrics, 33(6), 38–40.
Voelker, R. (2019). Older adults may fuel an upturn in eczema cases.
JAMA: Journal of the American Medical Association, 321(11), 1038–1039.
https://doi.org/10.1001/jama.2019.0384
ERYTHEMA
MULTIFORME
DEFINITION
A.
This dermal and epidermal inammatory process is charac-
terized by symmetric eruption of erythematous, iris-shaped papules (“target” lesions) and vesiculobullous lesions (Figure 4.7).
ERYTHEMA MULTIFORME
83
PATHOGENESIS
A.
The disorder is thought to be an immunologic reaction on
the skin, possibly triggered by circulating immune complexes.
PREDISPOSING
A.
Infections: recurrent HSV, mycoplasma infections, and
FACTORS
adenoviral infections.
B.
Drugs: sulfonamides, phenytoin, barbiturates, phenylbu-
tazone, and penicillin.
C.
Idiopathic: greater than 50%; consider occult malignancy.
COMMON
A.
B.
C.
D.
OTHER
A.
B.
COMPLAINTS
Rash with intense pruritus.
Nonspecic upper respiratory infection followed by rash.
General malaise, body aches, and joint pain.
Fever.
SIGNS AND SYMPTOMS
Primary: macules, papules, and plaques.
Secondary: erythema, dull red, target-like lesions blanch
to pressure; distribution is symmetric, primarily on exor
surfaces. Classic target lesions develop abruptly and sym-
metrically and are heaviest peripherally; they often involve
palms and soles.
C.
Swelling of hands and feet.
D.
Painful oral lesions.
E.
Eye discomfort (redness, itching, burning, pain, visual
changes).
SUBJECTIVE
A.
Ask if the client has ever been diagnosed with erythema
DATA
multiforme.
B.
Determine whether the onset of symptoms was sudden or
gradual.
C.
Assess for any associated discharge (blood or pus).
D.
Identify the location of the symptoms.
E.
Complete a drug history. Has the client recently taken any
antibiotics or other drugs? Question the client regarding use
of any topical medications.
F.
Determine the presence of any preceding systemic symp-
toms (fever, sore throat, anorexia, or vaginal discharge).
G.
Rule out any possible exposure to industrial or domestic
toxins.
H.
Question the client concerning any possible contact with
venereal disease.
I.
Ask the client about any close physical contact with others
with skin disorders.
J.
Elicit information concerning any possible exposure to HIV.
K.
Rule out sources of chronic infection, neoplasia, or connec-
tive tissue disease.
FIGURE
4.7 Erythema multiforme.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts
for wound care nursing: Practical wound management
in a nutshell (p. 262). Springer Publishing Company.
INCIDENCE
A.
Erythema multiforme accounts for up to 1% of dermatol-
ogy outpatient visits.
B.
Children younger than 3 years and adults older than 50
years are rarely affected.
C.
It may occur in seasonal epidemics.
D.
Approximately 90% of cases of erythema multiforme
minor follow a recent outbreak of herpes simplex virus
(HSV)-1 or mycoplasma infection.
PHYSICAL
A.
Check temperature, pulse, respirations, and blood pressure.
B.
Inspect:
C.
Palpate:
D.
Auscultate:
E.
Perform neurologic examination.
EXAMINATION
1.
Skin for lesions.
2.
Mouth and mucous membranes for lesions.
1.
Abdomen for masses and tenderness.
1.
Heart.
2.
Lungs.
3.
Abdomen.
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4: DERMATOLOGY GUIDELINES
DIAGNOSTIC
A.
Punch biopsy of skin.
B.
Complete blood count (CBC).
C.
Urinalysis.
DIFFERENTIAL
A.
Erythema multiforme:
1.
TESTS
DIAGNOSES
Erythema multiforme minor: pruritus, swelling of
hands and feet, and painful oral lesions.
2.
Erythema multiforme major: fever, arthralgias, myal-
gias, cough, and oral erosions with severe pain.
B.
Urticaria.
C.
Viral exanthems.
D.
Stevens–Johnson syndrome (SJS): a severe, life-
threatening, systemic reaction with fever, malaise, cough, sore
throat, chest pain, vomiting, diarrhea, myalgia, arthralgia, and
severe skin manifestations, with painful bullous lesions on
mucous membranes (Figure 4.8).
FIGURE
4.8 Stevens–Johnson syndrome.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for wound
care nursing: Practical wound management in a nutshell (p. 253).
Springer Publishing Company.
E.
Pemphigus vulgaris.
F.
Bullous pemphigoid.
G.
Other bullous diseases.
H.
Staphylococcal scalded skin syndrome.
I.
Vasculitis.
PLAN
A.
General interventions:
1.
Identify and treat precipitating causes or triggers.
2.
Burow solution or warm compress may be used for
mild cases as needed.
3.
Oral lesions may be treated with saline solution, warm
saltwater, and/or Mary’s mouthwash (Benadryl, lidocaine, and Kaopectate).
4.
Discontinue any medications suspected of precipitat-
ing symptoms.
5.
Provide adequate pain relief if skin or oral lesions are
painful. Lesions remain xed at least 7 days.
6.
Maintain nutrition and uid replacement for this
hypercatabolic state.
7.
Consider chronic viral suppression therapy for recur-
rent herpes simplex viral infections.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Erythema Multiforme.”
C.
Pharmaceutical therapy:
1.
Antihistamines, such as Benadryl or Claritin, may be
used for itching.
2.
Acetaminophen may be used to reduce fever and for
general discomfort/pain.
3.
Potent topical corticosteroids: Apply betamethasone
dipropionate 0.05% or clobetasol propionate 0.05% BID for
up to 2 weeks. Avoid use on face and groin.
4.
Open lesions should be treated like open burn wounds.
Stop offending medications that may cause blistering of
wounds and treat with steroids.
5.
Oral antibiotics may be needed to control secondary
bacterial skin infection.
6.
Oral steroids may be used for severe oral mucosal
lesions: oral prednisone 40 to 60mg/d tapering over 2 to 4
weeks.
7.
Hospitalization may be needed for severe cases.
Intravenous immunoglobulins may also be needed.
FOLLOW-UP
A.
See the client in the ofce in 1 to 2 days to evaluate initial
treatment.
CONSULTATION/REFERRAL
A.
If the client has recurrent or chronic infection, refer them to
a physician.
B.
Immediate consultation and/or hospital admission is criti-
cal if SJS is suspected.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Systemic corticosteroids may increase the risk of infec-
tion and prolong healing. Use low- to mid-potency topical
corticosteroids.
B.
Adults/Pediatrics:
1.
Eye involvement can lead to keratitis, scarring, or vision
loss. Referral to an ophthalmologist is recommended.
BIBLIOGRAPHY
dall’Oglio, F., Lacarrubba, F., Luca, M., Boscaglia, S., & Micali, G. (2018).
Clinical and erythema-directed instrumental evaluation of papulopustular rosacea treated with topical ivermectin. Journal of the
American Academy of Dermatology, 79, AB75. https://doi.org/
10.1016/j.jaad.2018.05.335
Hashemi, D. A., Carlos, C., & Rosenbach, M. (2019). Herpes-associated
erythema multiforme. JAMA Dermatology, 155(1), 108. https://doi.org
/10.1001/jamadermatol.2018.3973
Kaplan, D. L. (2018). What is the cause of these papules? Consultant, 1–4.
(00107069), 58(7)
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
FOLLICULITIS
DEFINITION
A.
Folliculitis is inammation of the supercial or deep por-
tion of the hair follicle causing an infection. This can be caused
by bacteria, fungi, viral or parasitic processes.
INCIDENCE
A.
A very common disorder, folliculitis occurs in all ages and
is seen more frequently in males.
B.
Malassezia folliculitis is commonly seen in clients with
immunosuppression, diabetes, and antibiotic use.
PATHOGENESIS
A.
Bacterial organisms (most commonly Saureus) invade the
follicle wall and cause an infectious process.
B.
Fungal organisms, Malassezia folliculitis, also known as
Pityrosporum, invade the follicle wall and cause an infectious
process (Figure 4.9).
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Inspect:
1.
Assess skin for lesions and describe.
C.
Palpate:
1.
Palpate lesions and associated lymph nodes.
FOLLICULITIS
85
FIGURE
4.9 Folliculitis.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for wound care
nursing: Practical wound management in a nutshell (p. 260). Springer
Publishing Company.
PREDISPOSING
A.
Break in the skin tissue.
B.
Use of razors on skin.
C.
Poor hygiene.
D.
Diabetes.
E.
Long-term oral antibiotic therapy for acne.
F.
Exposure to hot tubs or heated swimming pools.
G.
Immunosuppression.
COMMON
A.
Outbreak of pustules on the face, scalp, or extremities that
FACTORS
COMPLAINT
does not resolve despite proper hygiene and care.
OTHER
SIGNS AND SYMPTOMS
A.
Tenderness and itching at the site.
B.
Furuncle (abscess): a deep pustule, tender, rm or uctu-
ant, found in groin, axilla, waistline, or buttocks.
C.
Carbuncle: a group of follicles coalescing into one larger,
painful, infected area; fever and chills possible.
D.
Excoriated folliculitis: chronic thickened, excoriated pap-
ules or nodules.
SUBJECTIVE
A.
Elicit the initial outbreak of lesions, as well as onset and
DATA
progression.
B.
Identify what makes the lesions better or worse.
C.
Ask the client what medications, soaps, or lotions have
been used on the lesions.
D.
Complete a medical history. Ask if the client has had a sim-
ilar outbreak before.
E.
Describe systemic symptoms if they have occurred (fever,
chills, etc.).
F.
Does the client have a beard, shave their face, or use a
razor frequently?
G.
Is there a recent history of use of a hot tub? (Commonly seen
1–4 days after use of hot tub, whirlpool, or swimming pool.)
H.
Does the client wear tight pants/jeans or use oils that clog
pores in the groin area?
I.
Is the client currently being treated with antibiotics for
acne? (Flare of gram-negative folliculitis may be seen with
chronic use of antibiotics.)
PHYSICAL
A.
Check temperature, pulse, respirations, and blood
EXAMINATION
pressure.
DIAGNOSTIC
A.
Culture and sensitivity to verify appropriate antibiotic
TESTS
coverage.
B.
Gram stain.
C.
Potassium hydroxide (KOH)/wet prep.
D.
Fungal culture of the hair if fungi suspected (tinea of
scalp).
E.
Skin biopsy for diagnosis of Malassezia folliculitis.
DIFFERENTIAL
A.
Folliculitis.
B.
Acne vulgaris.
C.
Ingrown hair follicle.
D.
Keratosis pilaris.
E.
Contact dermatitis.
F.
Papulopustular rosacea.
G.
Hidradenitis suppurativa.
DIAGNOSES
PLAN
A.
General interventions:
1.
Apply warm, moist compress to site for comfort.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Folliculitis.”
1.
If razors are used on the area, have the client use clean,
sharp razors, throw old razors away, and not share razors.
Avoid use of irritating creams or lotions on affected area.
2.
Encourage proper hygiene, with frequent washing of
hands and skin with an antibacterial soap.
3.
Warm compress three to four times a day is encour-
aged at the site for 15 to 20 minutes.
4.
Bleach bath (0.5–1 cup of bleach to 20-L water) reduces
spread of Staphylococcus infection.
C.
Pharmaceutical therapy:
1.
Mild cases: Topical antibiotics are recommended before
oral antibiotics. Apply mupirocin (Bactroban) ointment to
theaffected area TID until resolved.
2.
S. aureus:
a.
Dicloxacillin (Dynapen) 250 to 500 mg PO QID for
10 to 14 days.
b.
Erythromycin 250 to 500 mg PO QID for 10 to
14days.
c.
Cephalexin (Keex) 500mg PO for 10 to 14 days.
3.
Pseudomonas aeruginosa:
a.
Ciprooxacin (Cipro) 500 to 750mg PO BID for 10
days.
b.
Ooxacin 400mg PO BID for 10 days.
4.
Antistaphylococcal antibiotics:
a.
Cephalexin 250 to 500mg QID (children: 25–50mg/
kg/d given in two divided doses).
b.
Clindamycin 150 to 300mg QID (children: 8–16mg/
kg/d in three to four doses per day).
c.
Dicloxacillin 125 to 500mg QID (children: 12.5mg/
kg/d QID).
d.
Erythromycin 250 to 500 mg QID (children:
30–50mg/kg/d QID).
5.
Bacterial infections caused by organisms other than
Staphylococcus may be treated for an extended period, 4 to
8 weeks. These areas may include the axilla, chest, back,
beard, and groin.
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6.
4: DERMATOLOGY GUIDELINES
Methicillin-resistant S. aureus (MRSA):
a.
Bactrim DS 160/800 BID (children: 8–10 mg/kg/d
divide and give Q12H).
b.
Doxycycline 100mg BID (children: 2.2 mg/kg BID
for 1 day and then for the remainder of the duration
once a day).
7.
Severe cases may be treated with oral antibiotics with
topical permethrin Q12H every other night for a 6-week
period, or itraconazole 400mg daily and isotretinoin 0.5
mg/kg/d for up to 4 to 5 months with UVB light therapy.
Consider dermatology referral for severe cases.
8.
Treatment for Malassezia folliculitis is as follows:
a.
Antifungal treatment: Oral antifungal medications
(itraconazole, uconazole, or ketoconazole) should be
prescribed for at least 4 weeks for treatment.
FOLLOW-UP
A.
If not resolved in 2 weeks, further evaluation is needed.
B.
Severe cases, in which carbuncles are not improved with
antibiotic therapy, warrant incision and drainage and referral
to dermatology.
C.
Continue to follow every 2 weeks until resolved.
D.
Test for diabetes mellitus in severe cases.
CONSULTATION/REFERRAL
A.
Refer the client to a physician for testing for immunode-
ciency if severe cases occur or if resistance is seen.
B.
Refer the client to dermatology.
BIBLIOGRAPHY
Rambhia, P. H., Conic, R. R. Z., Murad, A., Atanaskova-Mesinkovska,
N., Piliang, M., & Bergfeld, W. (2019). Updates in therapeutics for folliculitis decalvans: A systematic review withevidence-based analysis.
Journal of the American Academy of Dermatology, 80(3), 794. https://doi.
org/10.1016/j.jaad.2018.07.050
HAND,
FOOT, AND MOUTH SYNDROME
DEFINITION
A.
This is a viral infection caused by coxsackievirus A16, with
vesicular lesions present on the hands, feet, and oral mucosa
(Figure 4.10).
INCIDENCE
A.
Hand, foot, and mouth syndrome is most commonly seen
in preschool children.
PATHOGENESIS
A.
Enteroviruses invade the intestinal tract of humans and are
spread to others by fecal–oral and/or oral–oral (respiratory)
routes. The incubation period is approximately 4 to 6 days.
PREDISPOSING
A.
Childhood.
B.
Conned households or day-care centers and camps.
C.
Seasonal: summer and fall most common.
COMMON
A.
Generalized rash, with lesions on the tongue, gums, and
FACTORS
COMPLAINTS
roof of the mouth.
B.
Lesions (vesicles) also present on the hands, feet, and
buttocks.
OTHER
SIGNS AND SYMPTOMS
A.
Fever.
B.
Sore throat.
C.
Some enteroviruses have been associated with severe con-
sequences such as meningitis, encephalitis, and others. The
family should monitor symptoms carefully.
SUBJECTIVE
A.
Question the client regarding onset, duration, and pro-
DATA
gression of symptoms and lesions.
B.
Determine whether any family member or other contact
person had similar symptoms.
C.
Identify areas where the child comes in contact with numer-
ous children (childcare facility, nurseries at church, school, etc.).
D.
If not noted in the presenting symptoms, ask the client
about their upper respiratory symptoms (sore throat, fever,
headache, runny nose, cough, etc.).
PHYSICAL
A.
Check temperature, pulse, respirations, and blood pressure.
B.
Inspect:
C.
Palpate:
D.
Auscultate:
DIAGNOSTIC
A.
Usually none, but consider cultures of oral lesions if sec-
EXAMINATION
1.
Skin, ears, nose, and oral cavity for lesions.
1.
Palpate the abdomen and lymph nodes in neck.
2.
Assess for meningism.
1.
Lungs.
2.
Heart.
TESTS
ondary bacterial infection is suspected.
FIGURE
4.10 Hand, foot, and mouth syndrome.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for wound care
nursing: Practical wound management in a nutshell (p. 252). Springer
Publishing Company.
DIFFERENTIAL
A.
Hand, foot, and mouth syndrome.
B.
Pharyngitis.
C.
Pneumonia.
D.
Meningitis.
E.
Meningococcemia: exanthem, petechial rash.
DIAGNOSES
PLAN
A.
General interventions:
1.
Supportive treatment includes warm saline gargles,
acetaminophen (Tylenol) as needed for discomfort, and
increased uids. Popsicles are useful to soothe oral lesions,
especially for small children.
B.
Client teaching:
1.
Reinforce good oral and body hygiene. The virus may
be harbored in the gastrointestinal tract for long periods.
C.
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Pharmaceutical therapy:
1.
None recommended.
2.
Acetaminophen (Tylenol) as needed for fever and
malaise.
FOLLOW-UP
A.
None recommended unless symptoms worsen or do not
resolve in 7 to 10 days.
CONSULTATION/REFERRAL
A.
Refer to a physician for any symptoms related to meningi-
tis or encephalitis.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Seen primarily in the pediatric population.
HERPES SIMPLEX VIRUS TYPE 1
B.
There are approximately 776,000 new cases of herpes diag-
87
nosed annually in the United States.
PATHOGENESIS
A.
Viral infection can be transmitted by direct contactfrom
a vesicular lesion or uid (saliva) containing the virus to the
skin or mucosa of another person, with an incubation period
of 2 to 14 days. Trigeminal ganglia are the host of the oral virus.
The virus can be reactivated, whereupon it travels along the
affected nerve route and produces recurrent lesions. Common
sites of infection are the lips, face, buccal mucosa, and throat.
PREDISPOSING
A.
Immunocompromised clients.
B.
Prior HSV infections.
C.
Exposure to virus.
FACTORS
BIBLIOGRAPHY
Bian, L., Gao, F., Mao, Q., Sun, S., Wu, X., Liu, S., Yang, X., & Liang, Z.
(2019). Hand, foot, and mouth disease associated with coxsackievirus
A10: More serious than it seems. Expert Review of Anti-Infective Therapy,
17(4), 233–242. https://doi.org/10.1080/14787210.2019.1585242
Broccolo, F., Drago, F., Ciccarese, G., Genoni, A., Porro, A., Parodi, A.,
Chumakov, K., & Toniolo, A. (2019). Possible long-term sequelae in
hand, foot, and mouth disease caused by Coxsackievirus A6. Journal of
the American Academy of Dermatology, 80(3), 804–806.
Shayegan, L. H., Antonov, N. K., Morel, K. D., & Garzon, M. C. (2019).
Casting new light on hand-foot-and-mouth disease. Journal of
Pediatrics, 207, 259. https://doi.org/10.1016/j.jpeds.2018.11.032
HERPES
SIMPLEX VIRUS TYPE 1
DEFINITION
A.
Herpes simplex virus type 1 (HSV-1) viral infection of the
cutaneous tissue manifests itself by vesicular lesions on the
mucous membranes and skin. HSV-1 is most often associated
with oral lesions (mouth and lips; Figure 4.11), while HSV-2
is associated with genital lesions. The virus appears in three
stages:
COMMON
A.
OTHER
A.
COMPLAINTS
Painful lips, gums, and oral mucosa.
SIGNS AND SYMPTOMS
Primary lesion: fever, blisters on lips, malaise, and tender
gums.
B.
Recurrent episodes: fever blisters with prodrome of itch-
ing, burning, and tingling sensation at the site before vesicles
appear.
SUBJECTIVE
A.
Ask questions regarding location, onset, and duration of
DATA
lesions.
B.
Elicit description of prodromal symptoms.
C.
Ask the client if systemic symptoms occur with vesicular
outbreak.
D.
Determine when the initial outbreak of lesions occurred
(commonly seen in childhood).
E.
Inquire whether the client has been exposed to anyone
with similar lesions.
F.
If the lesion(s) is recurrent, ask the client if stress, skin
trauma, or sun exposure stimulates an outbreak of fever blisters.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Skin, noting the location, appearance, and stage of
vesicles.
B.
Palpate:
1.
Lymph nodes for lymphadenopathy.
FIGURE
4.11 Herpes simplex virus type 1.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for wound
care nursing: Practical wound management in a nutshell (p. 259).
Springer Publishing Company.
1.
Primary.
2.
Latent.
3.
Recurrent infections.
INCIDENCE
A.
HSV-1 is seen in clients of all ages and in equal numbers of
males and females.
DIAGNOSTIC
A.
Viral cultures.
DIFFERENTIAL
A.
Impetigo: appears as amber-colored vesicular lesions with
TESTS
DIAGNOSES
crusting.
B.
Stomatitis: appears as erythemic or erosion lesions in the
mouth and lips.
C.
Herpes zoster: causes vesicles that run along a single
dermatome.
D.
Stevens–Johnson syndrome (SJS).
E.
Herpangina: vesicles can be noted on the soft palate, ton-
sillar area, and uvula area; usually caused by coxsackievirus.
PLAN
A.
General interventions:
1.
Comfort measures. Ice may be used to reduce swelling
as needed.
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