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2.
4: DERMATOLOGY GUIDELINES
Vaseline or other lip ointments may be applied as
needed and lip ointment with sun protection factor 30 or
greater may be applied when exposed to sunlight.
B.
Client teaching:
1.
Educate the client regarding the disease process of
HSV-1.
2.
Instruct the client to wash hands frequently.
3.
Suggest proper care of lips to prevent drying and to
reduce pain.
4.
Educate regarding transmission of virus to others.
5.
Teach the client to expect recurrences at variable times.
C.
Pharmaceutical therapy:
1.
Precautions should be used when administering
medication to clients who are immunocompromised and
who have a history of renal insufciency.
a.
Lidocaine 2% as needed for comfort.
b.
Diphenhydramine (Benadryl) elixir to rinse mouth
as needed.
c.
Acetaminophen (Tylenol) as needed for pain.
d.
Campho-Phenique application as needed.
2.
Initial episode:
a.
Acyclovir 400 mg PO TID for 7 to 10 days or until
resolved.
b.
Valacyclovir 1 g BID for 7 to 10 days.
3.
Recurrent episodes: Begin one of the following when
prodrome begins or within 2 days of onset of lesions to get
maximum effect:
a.
Acyclovir 400mg PO TID for 5 days.
b.
Acyclovir 800mg PO BID for 5 days.
c.
Other alternative antivirals,with dosage depending
on renal function:
i.
Famciclovir (Famvir) 750mg PO x 1 dose.
ii.
Valacyclovir (Valtrex) 2 g PO x 1 dose.
4.
Suppressive therapy:
a.
Acyclovir 400mg PO BID for 1 year.
b.
Valacyclovir 500mg PO once daily.
FOLLOW-UP
A.
None needed if resolved without complications.
HERPES
ZOSTER OR SHINGLES
DEFINITION
Herpes
zoster is a viral infection manifested by painful, vesicular lesions on the skin, limited to one side of the body, following one body dermatome (Figure 4.12).
FIGURE
4.12 Varicella
zoster.
Source: Reproduced from Kifer, Z.
A. (2012). Fast facts for wound care
nursing: Practical wound management
in a nutshell (p. 259). Springer
Publishing Company.
INCIDENCE
A.
Infection may occur at any age; however, it is more com-
mon in older adults and the elderly. It is estimated by the
Centers for Disease Control and Prevention that approximately 30% of persons in the United States will experience
herpes zoster in their lifetime.
PATHOGENESIS
A.
After the primary episode of chickenpox (varicella zoster),
the virus remains dormant in the body. Herpes zoster occurs
when the varicella virus has been stimulated and reactivated
in the dorsal root ganglia, producing the clinical manifestations of herpes zoster as discussed in the following. Duration
of infection usually lasts 14 to 21 days, but may be longer in
the elderly or debilitated clients.
CONSULTATION/REFERRAL
A.
Refer the client to a physician if treatment is unsuccessful
or further complications arise.
INDIVIDUAL
A.
Pediatrics:
1.
B.
Adolescents/Adults:
1.
CONSIDERATIONS
Initial outbreak commonly occurs in childhood.
HSV-1 can also be transmitted sexually through oral
sex. Educate teens/adults regarding transmitting the virus
during sexual contact. Transmission is possible if having
sexual relations with partners; avoid contact when lesions
are present.
2.
Advise using a dental dam during oral sex to prevent
transmission.
3.
Avoid sharing toothbrush and eating utensils.
BIBLIOGRAPHY
Centers for Disease Control and Prevention. (2019). Genital her-
pes—CDC fact sheet. Retrieved from https://www.cdc.gov/std/
herpes/STDFact-Herpes.htm
PREDISPOSING
A.
Adulthood.
B.
Immunocompromised clients.
C.
Spinal cord trauma or injury.
D.
Autoimmune disease.
COMMON
A.
Prodrome: itching, burning, tingling, or painful sensation
FACTORS
COMPLAINTS
at lesion sites.
B.
Active: malaise, fever, headache, or pruritic rash on the
skin.
OTHER
SIGNS AND SYMPTOMS
A.
Lesions: Clusters of vesicles on an erythemic base that
burst and produce crusted lesions. These are most commonly
found on the chest and back area, but may also occur on the
head and neck area or extremities. Distribution of lesions typically appears along a single dermatome.
B.
Motor weakness (may be seen in approximately 5% of
clients).
HERPES ZOSTER OR SHINGLES
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SUBJECTIVE
A.
Determine onset, location, and progression of rash.
B.
Ask the client about prodromal symptoms: burning, itch-
DATA
ing, tingling, or painful sensation at the site before lesions
break out.
C.
Evaluate the client’s status regarding immunosuppressive
agents, diseases, and so forth.
PHYSICAL
A.
Check temperature, pulse, respiration, and blood
EXAMINATION
pressure.
B.
Inspect:
1.
Observe skin for lesions, noting characteristics and
distribution.
2.
Inspect ears, nose, and throat.
C.
Auscultate:
1.
Heart.
2.
Lungs.
DIAGNOSTIC
A.
Usually none.
B.
Culture vesicular lesions.
C.
Consider Tzanck smear.
D.
Consider test for HIV in young clients with herpes zoster.
DIFFERENTIAL
A.
Herpes zoster.
B.
Varicella.
C.
Poison ivy.
D.
Herpes simplex virus.
E.
Contact dermatitis.
F.
Coxsackievirus.
G.
Postherpetic neuralgia.
TESTS
DIAGNOSES
PLAN
A.
General interventions:
1.
Comfort measures. Instruct the client to apply wet
dressings (Burow solution) on the site for 30 to 60 minutes
at least four times a day. Calamine lotions may be used as
needed; oatmeal (Aveeno) bath may be used for comfort;
acetaminophen (Tylenol) is taken as needed for malaise,
temperature, and comfort.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Herpes Zoster or Shingles.”
1.
Tell the client that the rash usually lasts approximately
2 to 3 weeks.
2.
Instruct the client to monitor for signs/symptoms of
postherpetic neuralgia.
3.
Instruct the client to call if symptoms worsen or do not
improve, or if signs of bacterial infection occur.
4.
Emphasize to the client that the virus is easily transmit-
ted to vulnerable persons.
C.
Pharmaceutical therapy:
1.
Antiviral medications should be initiated within 24 to
48 hours after outbreak.
a.
Acyclovir (Zovirax) 800 mg ve times daily for
7 days.
b.
Famciclovir (Famvir) 500 to 750 mg PO TID for 7
days.
c.
Valacyclovir (Valtrex) 1,000 mg PO TID for 7 days.
2.
Acetaminophen (Tylenol) or ibuprofen may be usedas
needed for pain or discomfort.
3.
Narcotics may be used for severe pain as needed.
4.
Postherpetic neuralgia may be treated with the
following:
a.
Narcotics or other pain-relieving medications.
b.
Long-term medications may be needed for pain
control:
i.
Gabapentin 300 to 600mg TID, titrate dose up
for optimal relief.
ii.
Amitriptyline 10 mg every bedtime or other
low-dose tricyclic antidepressants; may titrate up to
50mg every bedtime if needed to achieve relief.
5.
If secondary bacterial infection of the skin occurs,
apply silver sulfadiazine (Silvadene) topically to the site
until resolved.
6.
Use of steroids is controversial. Corticosteroids may
be used with caution. These may increase the risk of
dissemination.
FOLLOW-UP
A.
Follow up as needed for complications.
B.
Monitor the client for complications: postherpetic neural-
gia, Guillain–Barré syndrome, motor weakness, secondary
infection, meningoencephalitis, ophthalmic and facial palsy,
corneal ulceration, and so forth.
CONSULTATION/REFERRAL
A.
Ramsay Hunt syndrome occurs when a shingles outbreak
affects the facial nerve near one of the ears. This can cause
facial paralysis and hearing loss in the affected ear. Consult a
physician.
B.
Hutchinson sign refers to vesicles in the periorbital region.
These clients require an ophthalmologist referral.
C.
Consult with a physician if secondary infection occurs or if
secondary complications arise.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Acyclovir falls under category C drug classication.
The safety and efcacy of the use of antiviral medications
during pregnancy need to be considered.
2.
Pregnant individuals who are not immune to the virus
need to take precautions to prevent contact with the virus
while pregnant. Complications during pregnancy may
include congenital varicella for the fetus and varicella
pneumonia for the mother.
B.
Pediatrics:
1.
Shingles is rarely seen in children.
C.
Elderly:
1.
Postherpetic neuralgia occurs in approximately 15% of
clients. It is commonly seen in elderly clients.
2.
The Centers for Disease Control and Prevention (CDC)
recommends the shingles vaccine for all clients 50 years of
age and older, irrespective of whether they have had the
chickenpox or shingles infection in the past. There are two
types available: The CDC recommends the recombinant
vaccine (Shingrix) over the live vaccine unless contraindicated. For those who have had a recent shingles outbreak,
it is recommended that resolution of the rash be complete
before administering the vaccination.
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a.
Guidelines for Shingrix—a recombinant zoster
vaccine:
i.
Administration dosing:
1)
Two doses administered intramuscularly:
rst dose given on day 0 and the second dose
administered 2 to 6 months after the rst.
ii.
Indications:
1)
Immunocompetent clients older than 50
years.
2)
Clients who previously received the vari-
cella vaccine and the (live) zoster vaccine. The
CDC recommends waiting 5 years to administer
the Shingrix vaccine if Zostavax was previously
administered.
3)
Clients with comorbid conditions.
iii.
Contraindications:
1)
Clients with known allergy to components
of the vaccine.
3.
The virus is contagious to those who have not had
chickenpox.
BIBLIOGRAPHY
Centers for Disease Control and Prevention. (2020, October 2020). Shingles
(herpes zoster) https://www.cdc.gov/shingles
Chu, L., Daganzo, S., & Aronowitz, P. (2019). Chickenpox in a vaccinated
adult. JGIM: Journal of General Internal Medicine, 34(3), 479–480. https:/
/doi.org/10.1007/s11606-018-4816-9
Jones, G., & Whittle, N. (2019). Understanding the health risks of vari-
cella zoster virus in pregnancy. Primary Health Care, 29(2), 45–50.
https://doi.org/10.7748/phc.2019.e1522
Shafran, S. D. (2019). Prevention of shingles: Better protection and bet-
ter value with recombinant vaccine. Annals of Internal Medicine, 170(6),
416–417. https://doi.org/10.7326/M19-0141
IMPETIGO
DEFINITION
A.
Impetigo is a bacterial infection of the skin, most com-
monly caused by Staphylococcus aureus or Streptococcus pyogenes, or both (Figure 4.13).
INCIDENCE
A.
It occurs equally in males and females and is most com-
monly seen in children, especially in those 2 to 5 years of age.
PATHOGENESIS
A.
An alteration in the skin integrity allows bacterial invasion
into the epidermis, causing an infection. Small, moist vesicles
ranging from red macules to honey- colored crusts or erosions
occur singly or grouped together. The most common organisms are S. aureus and group A beta-hemolytic S. pyogenes.
PREDISPOSING
A.
Poor hygiene.
B.
Warm climate.
C.
Break in the skin.
COMMON
A.
Tender sores around the mouth and nose area in which the
lesions continue to spread and worsen, despite over-the-counter
medication treatment.
SUBJECTIVE
A.
Elicit onset, progression, duration, and location of the
lesions.
B.
Ask the client whether they have had contact with any
other child or person with similar lesions.
FACTORS
COMPLAINTS
DATA
FIGURE
4.13 Impetigo.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for wound
care nursing: Practical wound management in a nutshell (p. 255).
Springer Publishing Company.
C.
Assess whether the client exhibits any other symptoms,
especially systemic symptoms (fever, malaise, etc.).
D.
Elicit what treatment has been tried, if any.
PHYSICAL
A.
Check temperature.
B.
Inspect:
EXAMINATION
1.
Examine skin, noting types of lesions and skin
involvement.
2.
Examine ears, nose, mouth, and throat.
C.
Auscultate:
1.
Lungs.
2.
Heart.
DIAGNOSTIC
A.
None required.
B.
May perform culture if recurrent or resistant to treatment.
DIFFERENTIAL
A.
Impetigo.
B.
Varicella.
C.
Folliculitis.
D.
Erysipelas.
E.
Herpes simplex.
F.
Second-degree burns.
G.
Pharyngitis or tonsillitis: throat erythema, with tonsillar
TESTS
DIAGNOSES
hypertrophy and exudate present; lymph nodes: adenopathy
of anterior cervical chain.
H.
Ecthyma: severe case of impetigo with lymphadenitis.
I.
Insect bites.
J.
Necrotizing fasciitis.
K.
Contact dermatitis.
L.
Scabies.
PLAN
A.
General interventions:
1.
Crusted lesions may be removed with thorough, gentle
washing with mild soap three to four times daily.
2.
Impetigo must be adequately treated and resolved to
prevent postinfection complications such as the following:
a.
Poststreptococcal acute glomerulonephritis, celluli-
tis, ecthyma, and bacteremia.
INSECT BITES AND STINGS
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B.
Client teaching:
1.
Encourage good handwashing and hygiene to reduce
spread of infection.
C.
Pharmaceutical therapy:
1.
If few lesions are noted without involvement of celluli-
tis: topical mupirocin (Bactroban) ointment applied to the
site TID for 5 days; alternative topical ointment: retapamulin applied to the site BID for 5 days.
2.
Systemic antibiotics recommended for several lesions;
oral treatment recommended for 7 days (Table 4.2).
FOLLOW-UP
A.
Schedule appointment in 10 to 14 days to determine reso-
lution of infection.
CONSULTATION/REFERRAL
A.
Consult a physician if complications arise or if resolution
is not complete with antibiotic therapy.
BIBLIOGRAPHY
Galli, L., Venturini, E., Bassi, A., Gattinara, G. C., Chiappini, E., Delippi,
C., Diociaiuti, A., Esposito, S., Garazzino, S., Giannattasio, A.,
Krzysztoak, A., Latorre, S., Vecchio, A. L., Marchisio, P., Montagnani,
C., Nicolini, G., Novelli, A., Rossolini, G. M., & Tersigni, C. (2019).
& Italian Pediatric Infectious Diseases Society; Italian Pediatric
Dermatology Society. Common community-acquired bacterial skin
and soft-tissue infections in children: An intersociety consensus on
impetigo, abscess, and cellulitis treatment. Clinical Therapeutics, 41(3),
532. https://doi.org/10.1016/j.clinthera.2019.01.010
Madden, J., Buck, S., Beachkofsky, T., & Xia, Y. (2018). Diffuse facial rash in
a former collegiate wrestler: The patient described a history of “recurrent impetigo,” which led to an uncommon diagnosis. Journal of Family
Practice, 67(12), 783–785.
May, P. J., Tong, S. Y. C., Steer, A. C., Currie, B. J. Andrews., M, R., Carapetis,
J. R., & Bowen, A. C. (2019). Treatment, prevention and public health
management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: A systematic review. Tropical Medicine &
International Health, 24(3), 280–293. https://doi.org/10.1111/tmi.13198
Rosen, T., Albareda, N., Rosenberg, N., Roth, S., Zsolt, I., & Hebert,
A. A. (2018). Efcacy and safety of ozenoxacin 1% cream, a novel
antibiotic for the topical treatment of impetigo in children and
adults. Journal of the American Academy of Dermatology, AB121.
https://doi.org/10.1016/j.jaad.2018.05.509 79(3)
INSECT
BITES AND STINGS
DEFINITION
A.
Bites and/or stings on the skin come from commonly
encountered insects: bees, hornets, wasps, mosquitoes, chig-
gers, ticks, eas, re ants, and bedbugs.
INCIDENCE
A.
Bites are seen in all age groupsand are more common in
summer months.
PATHOGENESIS
A.
Some bites elicit local tissue inammation and destruction
due to the proteins and enzymes in the poison or venom of the
insect.
B.
Immunoglobulin E (IgE)-mediated allergic reactions
(immediate or delayed) may occur.
C.
Serum-sickness reaction may appear 10 to 14 days after a
sting with venom. Toxic reactions can also occur from multiple stings, yielding large inoculation of poison or venom.
D.
With tick bites, exposure to Rocky Mountain spotted
fever, Lyme disease, ehrlichiosis, and babesiosis disease may
occur.
PREDISPOSING
A.
Exposure to areas of heavy insect infestations.
B.
Warm-weather months.
C.
Outdoor exposure with bare feet and bright clothes.
D.
Use of perfumes and/or colognes.
E.
Previous sensitization.
FACTORS
TABLE
4.2 RECOMMENDED ANTIBIOTICS FOR IMPETIGO
Adults Children
Cephalexin 250–500mg QID 25–50mg/kg/d in 3–4 divided doses
Dicloxacillin 250–500mg QID 25–50mg/kg/d in 4 divided doses
Alternative for Allergy to Penicillin and Cephalosporin
Erythromycin Base 250mg QID 40mg/kg/d in 3–4 divided doses
Clarithromycin 250mg BID 15mg/kg/d in 2 divided doses
MRSA Suspected or Confirmed
Clindamycin 300–450mg QID 20mg/kg/d in 3 divided doses
OR
Trimethoprim-sulfamethoxazole 1–2 double strength tabs BID 8–12mg/kg/d in 2 divided doses
OR
Doxycycline 100mg BID 2–4 mg/kg/d in 2 divided doses
MRSA,
Methicillin-resistant Staphylococcus aureus.
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4: DERMATOLOGY GUIDELINES
COMMON
A.
COMPLAINTS
Local reaction: pain, swelling, and redness at the site after
insect bite.
B.
Toxic reaction: local reaction plus headache, vertigo, gas-
trointestinal symptoms (nausea, vomiting, diarrhea), syncope,
convulsions, and/or fever.
SUBJECTIVE
A.
Did the client see what bit or stung them?
B.
If the client felt the bite or sting, were they bitten or stung
DATA
once or multiple times?
C.
How long ago did it occur?
D.
Where was the client when the injury occurred
(environment)?
E.
Has the client ever been bitten or stung before? If so, did
they have any reaction then? If so, what was the treatment?
PHYSICAL
A.
Check temperature, pulse, respiration, and blood pressure.
EXAMINATION
Observe overall respiratory status.
B.
Inspect:
1.
Inspect site of injury for local reaction; note erythema,
rash, or edema.
2.
Perform ear, nose, and throat examination.
C.
Auscultate:
1.
Heart.
2.
Lungs.
D.
Palpate:
1.
Palpate injured site.
2.
Assess nodes for lymphadenopathy.
3.
Perform abdominal examination, if appropriate.
DIAGNOSTIC
A.
None required.
B.
Consider taking skin scrapings to evaluate under a
TESTS
microscope.
C.
Consider culture if infection is suspected.
DIFFERENTIAL
A.
Insect bite:
1.
Bees, hornets, wasps, bedbugs: Local pain, redness,
DIAGNOSES
pruritus, and swelling occur at the site. Red papules and
wheals appear, enlarge, and then subside within hours.
Delayed hypersensitivity occurs within 7 days with
enlarged, local reaction, with fever, malaise, headache,
arthralgias, and lymphadenopathy. Toxicity can occur.
Anaphylaxis may be seen with generalized warmth and
urticaria, erythema, angioedema, intestinal cramping,
bronchospasm, laryngospasm, shock, and collapse.
2.
Ticks: Local redness, swelling, and itching, an enlarged
area of redness and swelling may occur.
3.
Mosquitoes and chiggers: Local redness, swelling, and
itching occur. Delayed reaction can include edema and
burning sensation.
4.
Fleas: Local redness, swelling, and itching occur.
Usually, papules are noted in a zigzag pattern, especially
on legs and waist. Note hemorrhagic puncta surrounded
by erythematous and urticarial patches. Flea bites can
transmit diseases.
5.
Body lice: Small noninammatory red spots, intensely
pruritic, are found on waist, shoulders, axilla, and neck.
Note linear scratch marks. Note secondary infection.
6.
Scabies: Pruritus is the dominant symptom. Note
inammation and burrows on skin with papules and vesicles, especially in the webs of the hands and feet.
7.
Fire ants: Papules appear and turn to pustules
within 6 to 24 hours after bite. Watch for localized
necrosis with scarring. Urticaria and angioedema can
occur (Figure 4.14).
FIGURE
4.14 Pustules resulting from fire ant
bites.
B.
Allergic reaction.
PLAN
A.
General interventions:
1.
For anaphylaxis, activate emergency medical services
(EMS) immediately.
2.
With all bites and stings, treat anaphylaxis rst.
3.
Local reactions: Treat with analgesic of choice. Apply
ice packs to the site for approximately 10 minutes. Elevate
the affected extremities.
4.
Delayed reactions: Administer antihistamines as
needed. Consider corticosteroid use.
5.
Routine wound care: Cleanse wound. Remove stinger.
If it is a painful sting, apply a cotton ball soaked in meat
tenderizer or sodium bicarbonate paste.
6.
Debride as necessary.
7.
For embedded insects, apply petroleum jelly, nail pol-
ish, or alcohol over site for 30 minutes and wait for insect
or tick to withdraw.
8.
Referral to allergist-immunologist is recommended
for clients with a severe systemic reaction for skin testing and to evaluate candidacy for venom immunotherapy
treatment.
9.
Hospitalize the client for severe reactions.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Insect Bites and Stings.”
C.
Pharmaceutical therapy:
1.
Antihistamines:
a.
Children:
i.
Younger child (2–6 years): diphenhydra mine
6.25mg every 4 to 6 hours.
ii.
Older child (6–12 years): diphenhydra mine 12.5
to 25mg every 4 to 6 hours.
b.
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Adult: diphenhydramine (Benadryl) 50mg Q6H as
needed.
2.
Mild anaphylaxis:
a.
Epinephrine 1:1,000 (aqueous) administered subcu-
taneously. Usual dose is as follows:
i.
Children: 0.01 mg/kg; may repeat in 4 hours if
needed.
ii.
Adults: 0.3 mg intramuscularly (IM); may
repeat if needed.
b.
Oral antihistamines for the next 24 hours (Atarax):
i.
Children: hydroxyzine hydrochloride (Atarax)
2 to 4 mg/kg/d divided into three doses.
ii.
Adults: hydroxyzine hydrochloride (Atarax) 10
to 25mg QID.
3.
Severe anaphylaxis:
a.
Epinephrine 1:1,000 (aqueous), given subcutane-
ously (see mild anaphylaxis, mentioned earlier).
b.
Oxygen 2 to 4 L as needed.
c.
Albuterol (Ventolin) 5 mg/mL per dose by nebulizer:
i.
Children: 0.1 to 0.15mg/kg in 2 mL of saline.
ii.
Adults: 2.5 mg (0.5 mL of 0.5% solution) in 2 mL
of saline.
4.
Self-treatment for anaphylaxis (emergency treatment
kits):
a.
Ana-Kit contains a preloaded syringe.
b.
EpiPen and EpiPen Junior Auto-Injectors are
spring-loaded automatic injectors.
i.
Children: 0.01 mg/kg IM on the thigh.
ii.
Adults: 0.3 mg IM on the thigh.
FOLLOW-UP
A.
Follow up in 2 weeks to evaluate effectiveness of treat-
ment. If symptoms worsen before this, reevaluation is needed.
CONSULTATION/REFERRAL
A.
Consult with a physician when anaphylaxis occurs.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Children are at a higher risk for complications of a
reaction than adults.
B.
Geriatrics:
1.
Elderly adults are at high risk for complications of
reactions.
BIBLIOGRAPHY
Abrams, E., & Chan, E. (2018). Stinging insect hypersensitivity: Evaluation
and management in children and youth. Pediatrics & Child Health, 557.
https://doi.org/10.1093/pch/pxy140 (1205–7088), 23(8)
Schub, T., & Cabrera, G. (2018). Bites: Head lice. CINAHL Nursing Guide.
LICE (PEDICULOSIS)
C.
P. pubis infestation is more common in adults.
D.
Lice affect all demographics; all social, racial, and eco-
93
nomic groups get lice.
PATHOGENESIS
A.
Head and body lice are transmitted by direct contact from
person to person, that is, through sharing hats, combs, brushes,
and so forth. The parasite hatches from an egg or nit. Once
hatched, the lice live on humans by sucking blood through
the skin. The average adult louse lives 9 to 10 days. The nits
appear as small white eggs on the hair shaft. Nits are very difcult to remove and survive up to 3 weeks after removal from
the host. Body lice lay nits in the seams of clothing.
B.
Pubic lice are found at the base of the hair shaft, where
they lay nits. Pubic lice are transmitted through sexual
contact.
PREDISPOSING
A.
Head and body lice: exposure to crowded public areas,
FACTORS
such as schools; inability to clean and launder clothing, bed
linens, and so forth.
B.
Pubic lice: sexual contact with infected people.
C.
Poor hygiene.
COMMON
A.
COMPLAINTS
Head lice: severe itching and scratching of the head, neck
area, and commonly behind the ears.
B.
Body lice: severe itching on the body, which may lead to
secondary infections of the skin.
C.
Pubic lice: severe itching of genital area.
OTHER
SIGNS AND SYMPTOMS
A.
Excoriated skin from intense scratching.
B.
Visible lice or nits in hair, body, or clothing.
C.
Papules with an erythemic base may develop on the geni-
tal area, axilla, chest, beard, or eyelashes.
D.
P. pubis or nits or lice are found on eyelashes of children.
SUBJECTIVE
A.
Inquire as to exposure to anyone known to have lice.
B.
Identify whether the client attends a crowded environ-
DATA
ment, such as school, day care, and so forth.
C.
Ask if lice and nits have been seen by the client or guardian.
D.
Determine onset, duration, and course of symptoms. Ask:
When were lice or nits rst discovered?
E.
Assess whether the client has been symptomatic (itching,
scratching).
F.
Inquire about social habits of cleaning, laundry, and so
forth.
LICE
(PEDICULOSIS)
DEFINITION
A.
Pediculosis (lice) is an infestation of the louse on human
beings in one of three areas:
1.
Head (Pediculosis capitis).
2.
Pubic area (Pthirus pubis).
3.
Body (Pediculosis corporis).
INCIDENCE
A.
Pediculosis capitis is most common in children. It is esti-
mated that head lice infestations occur in the school systems
anywhere from 10% to 40% of the time.
B.
They are more commonly found in girls than boys.
PHYSICAL
A.
Check temperature to rule out any secondary infection.
B.
Inspect:
EXAMINATION
1.
Inspect hair, body, pubic area, and clothing seams for
nits or lice.
2.
Note excoriation of skin.
3.
Examine eyelashes of children.
4.
Examine skin for secondary bacterial infection.
DIAGNOSTIC
A.
None.
B.
Culture excoriated area if secondary bacterial infection is
TESTS
suspected.
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4: DERMATOLOGY GUIDELINES
DIFFERENTIAL
A.
Lice.
B.
Scabies.
DIAGNOSES
PLAN
A.
General interventions:
1.
Treat immediately with appropriate pediculicides (see
Pharmaceutical therapy).
2.
After treatment, it is imperative to remove each nit and
louse; use ne-tooth comb for nit removal.
3.
Evaluate entire family for lice.
4.
Treat secondary bacterial infection as needed.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Lice (Pediculosis).”
1.
Specic instructions need to be given to the client on
how to get rid of lice and nits.
2.
Reinforce good hygiene; teach children not to share
combs, brushes, hats, and hair accessories.
C.
Pharmaceutical therapy:
1.
Malathion lotion 0.5% (Ovide): pediculicidal and par-
tially ovicidal.
2.
Permethrin lotion 1% (Nix): pediculicidal only.
Available over the counter (OTC) for treatment.
3.
Synergized pyrethrin (Rid 0.3%; available OTC).
4.
Apply, repeat in 24 hours, and then again in 1 week.
5.
Do not use a shampoo/conditioner or conditioner
before using head lice treatments. Do not wash hair for 1
to 2 days after using lice treatment regimen.
6.
P. pubis: Permethrin (Nix): apply to pubic area as
directed.
7.
Eyelash manifestation: After removing nits, apply petro-
leum jelly to lashes three to four times a day for 8 to 10 days.
Eyelashes should never be treated with pediculicides.
FOLLOW-UP
A.
None recommended.
B.
Some schools and institutions require follow-up to eval-
uate whether infestation has resolved before admitting the
child back into the classroom.
CONSULTATION/REFERRAL
A.
If lice are a repeated problem, contact social services or
the health department to have a visiting nurse or aide visit
the home to evaluate home conditions and to teach the family
how to prevent infestations.
BIBLIOGRAPHY
Sanchezruiz, W. L., Nuzum, D. S., & Kouzi, S. A. (2018). Oral ivermectin for
the treatment of head lice infestation. American Journal of Health-System
Pharmacy, 75(13), 937–943. https://doi.org/10.2146/ajhp170464
Schub, T., & Cabrera, G. (2018). Bites: Head lice. CINAHL Nursing Guide.
LICHEN
PLANUS
DEFINITION
A.
Lichen planus is a relatively common acute or chronic
inammatory dermatosis. It affects skin and mucous membranes with characteristic at-topped, shiny, violaceous (purplish color), pruritic papules with lacy lines on the skin and
milky-white papules in the mouth.
INCIDENCE
A.
Lichen planus accounts for 0.1% to 1.2% of ofce visits to
dermatologists.
B.
It exhibits no racial preference.
PATHOGENESIS
A.
Etiology is unknown, although it is possibly a
cell-mediated immune response. Most cases remit within 7
years. Lesions may heal with signicant postinammatory
hyperpigmentation.
PREDISPOSING
A.
Severe emotional stress.
B.
Drugs may induce lichenoid plaques.
COMMON
A.
Rash with or without pruritus.
B.
Primary lesions: small, at-topped papules that are polyg-
FACTORS
COMPLAINTS
onal, lightly scaly, and violaceous.
C.
Secondary lesions: erythema, scales, and erosions.
OTHER
SIGNS AND SYMPTOMS
A.
Distribution: volar aspect of wrists, ankles, mouth, genita-
lia, and lumbar region.
B.
Wickham striae (white, lacelike pattern on surface).
C.
Scalp: atrophic skin with alopecia.
D.
Nails: destruction of the nail fold and bed, especially in the
large toe.
E.
Lesions of glans penis.
F.
Erosive lesions of labia and vulva.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Pediatrics:
1.
2.
CONSIDERATIONS
Lindane (Kwell) is contraindicated during pregnancy.
Head lice are commonly seen in school-age children.
Lindane (Kwell) should not be used in infants. The
American Academy of Pediatrics does not recommend lindane as a rst-line treatment for head lice in children secondary to the toxic effects on the brain and central nervous system.
C.
Geriatrics:
1.
For adult/elderly clients with a diagnosis of lice, con-
sider self-neglect, unsuitable living conditions, cognitive/
psychiatric impairments, and/or abuse/neglect of the
elderly.
2.
Consider a home visit for evaluation of the client.
SUBJECTIVE
A.
Determine whether the onset was sudden or gradual.
B.
Ask the client to describe if the skin is itchy or painful.
C.
Assess lesions for any associated discharge (blood or pus).
D.
Identify the location(s) of the problem.
E.
Complete a drug history. Ask the client if they have
DATA
recently taken any antibiotics or other drugs. Ask if they have
used any topical medications, lotions, or other creams.
F.
Determine the presence of any preceding systemic symp-
toms (fever, sore throat, anorexia, or vaginal discharge).
G.
Rule out insect bites.
H.
Identify any possible exposure to industrial toxins, domes-
tic toxins, or color-lm-developing chemicals.
I.
Ask if the client has had any possible sexual contact with
persons with HIV or sexually transmitted infections (STIs).
J.
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Ask if the client has had close physical contact with others
with skin disorders.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Inspect skin and note lesion distribution.
2.
Inspect mucous membranes: buccal mucosa, tongue,
and lips.
3.
Examine hair and nails.
4.
Observe genitalia.
DIAGNOSTIC
A.
A drop of mineral oil accentuates the papule.
B.
If necessary to conrm diagnosis, perform deep shave or
TESTS
punch biopsy of developed lesions.
C.
HIV or STI testing if indicated.
D.
Hepatitis testing should be completed to assess for hepati-
tis C as lichen planus has been shown to have a correlation.
DIFFERENTIAL
A.
Lichenoid drug eruptions.
B.
Leukoplakia.
C.
Chronic graft versus host disease.
D.
Candidiasis (thrush).
E.
Lupus erythematosus.
F.
Contact dermatitis.
G.
Bite trauma.
H.
Secondary syphilis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Discontinue any suspected drug agent.
B.
Client teaching: See Client Teaching Guide for this chapter,
"Lichen Planus".
1.
Instruct the client that the disease may be chronic; most
cases resolve spontaneously.
2.
Encourage the client to avoid severe emotional stress.
3.
Encourage the client to avoid scratching and prevent
secondary infection.
4.
Reassure the client that lichen planus is not contagious.
C.
Pharmaceutical therapy:
1.
Oral antihistamines: hydroxyzine hydrochloride 10
to 50 mg QID as needed for pruritus, or cetirizine HCl
(Zyrtec) 10mg daily.
2.
Medium- to high-potency topical cortico steroids:
a.
Mouth lesions: uocinonide 0.05%, ointment or gel,
two or three times daily.
b.
Body lesions: betamethasone dipropionate
(Diprolene) 0.05%, triamcinolone (Kenalog), clobetasol (Temovate, Cormax) 0.05%, or other class 1 cream
or ointment BID for 2 to 3 weeks and then stop use.
Caution the client about steroid atrophy.
c.
Genital lesions: desonide cream 0.05% BID initially,
although higher potency creams may be necessary;
topical corticosteroids should be used on genitalia in
short bursts only.
d.
Hypertrophic lesions: Intralesional injections, such
as injecting triamcinolone 5 to 10 mg/mL, 0.5 to 1
mL per 2-cm lesion, are helpful for pruritus relief.
Use cautiously in clients with dark skin due to risk of
hypopigmentation.
3.
Oral prednisone is rarely used, but if necessary use
with a short course only and taper.
FOLLOW-UP
A.
See the client in 1 week for evaluation of treatment.
PITYRIASIS ROSEA
95
CONSULTATION/REFERRAL
A.
Refer the client to a dermatologist if there is no response to
initial treatment.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Pediatrics:
1.
C.
Geriatrics:
1.
CONSIDERATIONS
Use caution with medications prescribed.
For severe itching, consider oral antihistamine.
Avoid rst-generation anticholinergics due to risk of
confusion, dry mouth, constipation, and other anticholinergic effects or toxicity.
BIBLIOGRAPHY
Leung, A. K. C., Barankin, B., & Leong, K. F. (2018). What is the cause
of this boy’s asymptomatic papular rash? Consultant, 1–7. (00107069),
58(1)
Plensdorf, S., Livieratos, M., & Dada, N. (2017). Pigmentation disorders:
Diagnosis and management. American Family Physician, 96(12),
797–804.
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
PITYRIASIS
ROSEA
DEFINITION
A.
Pityriasis rosea is an acute, self-limiting, benign skin erup-
tion characterized by a preceding “herald patch” that is followed by widespread papulosquamous lesions (Figure 4.15).
Herald patch
FIGURE
4.15 Pityriasis rosea.
Source:
From the Centers for Disease Control and Prevention.
INCIDENCE
A.
Pityriasis rosea is relatively common, with more than 75%
of cases in individuals from 10 to 35 years of age.
B.
Incidence is slightly higher in females than in males.
C.
Incidence is higher during the spring and autumn.
PATHOGENESIS
A.
Disease is idiopathic; some evidence exists to support a
viral origin or an autoimmune disorder.
PREDISPOSING
A.
Recent acute infection.
COMMON
A.
Rash: salmon, pink, or tawny-colored lesions, which are
FACTOR
COMPLAINTS
generally concentrated on the trunk, but may develop on
arms, legs, and rarely on the face.
B.
Mild pruritus.
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OTHER
A.
Earliest lesions may be papular but may progress to 1- to
4: DERMATOLOGY GUIDELINES
SIGNS AND SYMPTOMS
2-cm oval plaques.
B.
Long axes of oval lesions run parallel to each other, hence
the term “Christmas tree distribution.”
C.
Preceding herald patch (2–10 cm with central clearing)
closely resembles ringworm; usually appears abruptly a few
days to several weeks before the generalized eruptive phase.
SUBJECTIVE
A.
Elicit information about occurrence of initial, single, 2- to
DATA
10-cm round to oval lesion.
B.
Question the client as to known contact with similar
symptoms. Small epidemics have been identied in fraternity
houses and military bases.
PHYSICAL
A.
Check temperature to rule out any infection.
B.
Inspect:
EXAMINATION
1.
Examine all body surfaces with the client unclothed.
2.
Look for characteristic lesions and distribution.
3.
Check the mucous surfaces, palms, and soles, which
are usually spared by pityriasis rosea.
DIAGNOSTIC
A.
Generally, none required, but potassium hydroxide wet
TESTS
preparation may be useful to distinguish a herald patch from
tinea corporis.
B.
Serology to rule out syphilis, if applicable.
C.
If unable to identify herald patch, a serologic test for syph-
ilis should be ordered because syphilis may be clinically indistinguishable from pityriasis rosea.
D.
White blood count (WBC) normal; no specic laboratory
markers for pityriasis rosea.
DIFFERENTIAL
A.
Pityriasis rosea.
B.
Nummular eczema.
C.
Tinea corporis.
D.
Tinea versicolor.
E.
Viral exanthems.
F.
Drug eruptions:
1.
Captopril.
2.
Bismuth.
3.
Barbiturates.
4.
Clonidine.
5.
Metronidazole.
G.
Secondary syphilis.
H.
Lichen planus.
I.
Psoriasis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Direct sunlight to the point of minimal erythema has-
tens the disappearance of lesions and reduces itching.
Ultraviolet B light in ve consecutive daily exposures can
reduce pruritus and shorten rash, particularly if administered within the rst week of eruption.
2.
It has not been proven to be contagious and is rela-
tively harmless, so isolation is not required.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Pityriasis Rosea.”
1.
Advise the client that the disease is self-limiting and
clears spontaneously in 1 to 3 months.
C.
Pharmaceutical therapy:
1.
Generally, none required, but for itching the following
recommendations exist:
a.
Group V topical steroids and oral antihistamines as
per usual dosing.
b.
Prednisone 20mg BID for 1 to 2 weeks in rare cases
of intense itching.
FOLLOW-UP
A.
None required unless secondary infection (impetigo)
develops. Disease may recur in approximately 2% of clients.
CONSULTATION/REFERRAL
A.
Consult or refer the client to a physician when disease per-
sists beyond 3 months.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Pediatrics:
1.
2.
C.
Geriatrics:
1.
CONSIDERATIONS
Disease has not been shown to affect fetus.
Rash more frequently affects face and distal extre mities.
Impetigo may result from scratching or poor hygiene.
Disease is rarely seen in geriatric clients. Strongly
consider other differential diagnoses, particularly drug
reactions.
2.
Avoid rst-generation anticholinergics due to risk of
confusion, dry mouth, constipation, and other anticholinergic effects or toxicity.
BIBLIOGRAPHY
Kim, H. S., Kim, H., & Lee, J. D. (2017). An annular plaque on the back.
American Family Physician, 96(4), 255–256.
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
Villalon-Gomez, J. M. (2018). Pityriasis rosea: Diagnosis and treatment.
American Family Physician, 97(1), 38–44.
PRECANCEROUS
OR CANCEROUS SKIN LESIONS
DEFINITION
A.
Skin lesions are skin cell changes that occur in the body
that may be precancerous or cancerous.
INCIDENCE
A.
Actinic keratosis is the most common precancerous skin
disorder that occurs in approximately 58 million Americans,
which is an estimate because it is not commonly reported
and/or often occurs without diagnosis.
B.
Basal cell carcinoma (BCC) is the most common form of
skin cancer, with approximately 400,000 new cases per year in
the United States (Figure 4.16). It is often seen in the sixth or
seventh decade of life. It is commonly seen in Caucasians and
noted to be 30% higher in males than in females. The occurrence of BCC is greater in people living in the states that are
closer to the equator than those in the Midwest, thought to be
related to increased exposure to ultraviolet (UV) light.
C.
Squamous cell carcinoma (SCC) is the second leading type
of skin cancer and accounts for 20% of all skin cancers. It is
most often seen in the middle-aged and elderly populations.
D.
Malignant melanoma is the fth leading cause of cancer in
males and females and accounts for less than 5% of all skin cancers (Figure 4.17). The median age at diagnosis is 61 years of age.
PATHOGENESIS
A.
Actinic keratosis: A precancerous skin lesion commonly
caused by damage to the skin as a result of exposure to UV
PRECANCEROUS OR CANCEROUS SKIN LESIONS
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F.
Skin damaged by burns and/or chronic inammation.
G.
History of blistering sunburns before 18 years of age
increases risk.
97
FIGURE
4.16 Basal cell carcinoma.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for
wound care nursing: Practical wound management in a nutshell
(p. 252). Springer Publishing Company.
FIGURE
4.17 Example of malignant
melanoma.
Source:
From the National Cancer Institute.
rays or tanning beds. If not treated, these skin lesions may
turn into a form of skin cancer, such as SCC.
B.
BCC: Abnormal cells of the basal layer of the epidermis
expand. The surrounding stroma supports the basal cell
growth. UV rays (sunlight) are the major contributor to BCC.
BCC is a slow-growing tumor that rarely metastasizes.
C.
SCC: Abnormal cells of the epidermis penetrate the base-
ment membrane of the epidermis and move into the dermis,
producing SCC. This often begins as actinic keratosis that
undergoes malignant change.
D.
Malignant melanoma: Abnormal cells proliferate from
the melanocyte system. Initially, the cells grow supercially
and laterally into the epidermis and papillary dermis. After
a period, the cells begin growing up into the reticular dermis
and subcutaneous fat. Malignant tumors occur because of
the inability of the damaged cells to protect themselves from
long-term exposure to UV rays.
PREDISPOSING
A.
Advanced age (older than 50 years of age).
B.
Median age of 40 years for malignant melanoma.
C.
Exposure to UV light (sun exposure).
D.
Fair complexion (blonde or red hair; blue, green, or gray eyes).
E.
Smokers (damaged lips).
FACTORS
COMMON
A.
B.
OTHER
A.
COMPLAINTS
New lesions found on the skin.
Ulcer that does not heal.
SIGNS AND SYMPTOMS
Actinic keratosis (solar keratosis): scaly, crusted lesions
commonly found on sun-exposed skin areas such as the face,
ears, scalp, lips, and hands that are usually rough in texture
and appearance.
B.
BCC: tumors arising from the basal cell layer of the epi-
dermis; may be seen on face and neck; may appear as an open
sore, pink growth, or nodule that is greater than 1 cm and
which appears shiny, pearly in color with telangiectasia; center may cave in.
C.
SCC: skin lesions seen in sun-exposed areas of the skin,
or skin damaged by burns or chronic inammation; lower lip
lesions common; rm, irregular papules with scaly, bleeding,
friable surface like sandpaper; grows rapidly.
D.
Malignant melanoma: asymmetrical tumor of skin with
irregular border, variation in color, greater than 6 mm in diameter; can metastasize to any organ.
E.
Bowen disease (SCC in situ): chronic, nonhealing erythe-
mic patch with sharp, irregular borders; occurs on skin and/
or the mucocutaneous tissue; resembles eczema but does not
respond to steroids.
SUBJECTIVE
A.
Have the client identify when lesion was rst noted.
B.
Ask the client to describe any changes in size, color, or
DATA
shape of the lesion.
C.
Determine whether the client has noted any new lesions.
D.
Ascertain any family history of malignant melanoma.
E.
Determine the client’s history of skin exposure to the sun
or any other UV rays.
F.
Ask the client about smoking history. If the client smokes,
ask how many packs per day.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Perform full-body exam of the skin for lesions.
2.
Note surface, size, shape, border, color, and diameter of
the lesion.
3.
Examine scalp and ears for lesions.
DIAGNOSTIC
A.
Biopsy suspicious lesions.
DIFFERENTIAL
A.
Actinic keratosis.
B.
BCC.
C.
SCC.
D.
Malignant melanoma.
E.
Solar lentigo.
F.
Seborrheic keratosis.
G.
Common nevus.
H.
Leukoplakia.
TEST
DIAGNOSES
PLAN
A.
General interventions:
1.
Monitor progress/change of lesions detected.
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