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2.
4: DERMATOLOGY GUIDELINES
Biopsy any suspicious lesions. Excise lesion with nar-
row margins, making sure to include all margins. If biopsy
results of specimen are inadequate for accurate histologic
diagnosis or staging, repeat biopsy. Include all clinical history information on the pathology report with the specimen when sending to pathology.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Skin Care Assessment.”
1.
Educate the clients regarding the importance of early
identication of lesions and monthly assessment of skin.
The U.S. Preventive Services Task Force (USPSTF) recommends counseling adolescents and young adults less
than 24 years of age regarding reducing the amount of
UV radiation exposure, especially between the hours of
10 a.m. and 3 p.m. In adults older than 24 years of age,
the USPSTF did not nd sufcient evidence to determine
the effects of counseling these clients regarding the use of
sun protection.
2.
Instruct the client on monthly skin evaluation. Teach
the “ABCD” method of exam for changes in lesions:
Asymmetry, Border, Color, and Diameter. A body map may
be used to mark skin changes and monitor progress. Mark
the site of the lesion on the body map, including measurements and date found. A body map can be accessed at www.
skincancer.org/skin-cancer-information/early-detection/
body-map.
C.
Pharmaceutical therapy:
1.
None indicated.
FOLLOW-UP
A.
When a diagnosis is made, follow up according to diagno-
sis. Differentiate between benign skin lesions and malignant
melanoma. Follow-up/treatment depends on the diagnosis (nonsurgical vs. surgical removal for diagnosis). Surgical
removal is recommended for recurrent and suspicious lesions.
Dermatology, 80(4), 970–978. https://doi.org/10.1016/j.jaad.2018.09.0
44
PSORIASIS
DEFINITION
A.
A common benign, chronic, inammatory skin disorder,
psoriasis is characterized by whitish scaly patches commonly
seen on the scalp, knees, and elbows (Figure 4.18).
FIGURE 4.18 Psoriasis.
Source: Reproduced from Kifer, Z.
A. (2012). Fast facts for wound
care nursing: Practical wound
management in a nutshell (p. 252).
Springer Publishing Company.
INCIDENCE
A.
Psoriasis occurs in about 1% to 3% of the world population.
B.
Psoriasis affects 7.5 million people in the United States.
Approximately 80% of these clients have plaque psoriasis.
C.
It occurs at any age:
1.
Peak of onset seen in adolescence.
2.
Seen in young adults (16–22 years old).
3.
Occurs in adults 50 to 60 years old.
CONSULTATION/REFERRAL
A.
Refer all clients to a dermatologist if skin cancer is
suspected.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Teach parents to use sun protection factor 30 or greater
on pediatric clients exposed to the sun.
B.
Geriatrics:
1.
The elderly are at higher risk of skin cancer due to
their decreased immune system as they age, as well as
their cumulative chronic disease risk factors. Educate
these clients regarding their risk factors and teach them
how to assess the skin for lesions. Encourage frequent
skin assessment and early diagnosis for improved
outcomes.
BIBLIOGRAPHY
Jansen, M. H. E., Kessels, J. P. H. M., Nelemans, P. J., Kouloubis, N.,
Arits, A. H. M. M., van Pelt, H. P. A., Quaedvlieg, P. J. F., Essers, B.
A. B., Steijlen, P. M., & Kelleners-Smeets, N. W. J.& Mosterd, K.
(2019). Randomized trial of four treatment approaches for actinic
keratosis. New England Journal of Medicine, 380(10), 935–946. https://
doi.org/10.1056/NEJMoa1811850
Wei, E. X., Li, X., & Nan, H. (2019). Extremity nevus count is an inde-
pendent risk factor for basal cell carcinoma and melanoma, but
not squamous cell carcinoma. Journal of the American Academy of
PATHOGENESIS
A.
Etiology is unknown; this is a multifactorial disease with a
denite genetic component. Hyperproliferation of the epidermis and inammation of the epidermis and dermis are seen,
with epidermal transit time rapidly increased (six- to ninefold). A T-lymphocyte-mediated dermal immune response
may occur due to the microbial antigen or autoimmune
process.
PREDISPOSING
A.
Family history.
B.
Drugs that exacerbate the condition:
1.
Lithium.
2.
Beta-blockers.
3.
Nonsteroidal anti-inammatory drugs (NSAIDs).
4.
Antimalarial.
5.
Sudden withdrawal of systemic or potent topical
FACTORS
corticosteroids.
C.
Stress (common triggering factor).
D.
Local trauma or irritation.
E.
Recent streptococcal infection.
F.
Alcohol use.
G.
Tobacco use.
H.
HIV association; suspected if onset is abrupt.
COMMON
A.
COMPLAINT
Dry scaly rash.
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OTHER
SIGNS AND SYMPTOMS
A.
Pruritic and/or painful lesions.
B.
Silvery scales on discrete erythematous plaques.
1.
Onset commonly occurs as a guttate form with small,
scattered, teardrop-shaped papules and plaques after a
streptococcal infection in a child or young adult.
2.
Larger, chronic plaques occur later in life.
C.
Lesions commonly seen on the scalp, elbows, and knees,
but may involve any area of the body.
D.
Glossitis or geographic tongue: small pits or yellow-brown
spots (oil spots).
E.
Positive Auspitz sign: punctate bleeding points with
removal of scale.
F.
Onycholysis.
G.
Stippled nails and pitting; approximately 50% of clients
have nail involvement.
H.
Periarticular swelling of small joints of ngers and toes.
Joint pain and involvement signal psoriatic arthritis.
I.
Pustular variant with predominant involvement of hands
and/or feet, including nails.
SUBJECTIVE
A.
Question the client regarding any predisposing factors
DATA
listed earlier to identify risk factors.
B.
Ask the client if there have been changes in the course of
symptoms.
C.
Ascertain whether the symptoms worsen in winter and
improve in summer.
D.
Determine the site of the lesion and whether the onset is
sudden and/or painful.
E.
Ask the client to describe the skin, whether it is itchy or
painful.
F.
Assess lesions for any associated discharge (blood or pus).
G.
Ask if the client is using any new soaps, creams, or lotions.
H.
Rule out any exposure to industrial or domestic toxins.
I.
Ask the client about any possible contact with venereal
disease (sexually transmitted diseases [STDs]).
J.
Review whether there has been any close physical contact
with others with skin disorders.
K.
Elicit information regarding any preceding systemic symp-
toms (fever, sore throat, and anorexia).
PHYSICAL
A.
Check temperature (if indicated).
B.
Inspect:
EXAMINATION
1.
Inspect skin, noting type and distribution of lesion.
Assess the oral mucosa, nails, and nail beds.
2.
Assess joints for erythema and/or synovitis (inam-
mation of the synovial membrane).
C.
Palpate:
1.
Palpate the joints for tenderness and synovitis.
DIAGNOSTIC
A.
Skin biopsy may be performed if the diagnosis remains
TESTS
uncertain.
B.
None indicated unless HIV infection is suspected; if so,
order HIV test.
C.
If joint inammation is present, consider rheumatoid fac-
tor, erythrocyte sedimentation rate, and uric acid.
D.
If there is a history of streptococcal infection, order anti-
streptolysin O titer.
DIFFERENTIAL
A.
Psoriasis.
DIAGNOSES
PSORIASIS
B.
Scalp: seborrheic dermatitis.
C.
Body folds: candidiasis.
D.
Trunk: pityriasis rosea andtinea corporis.
E.
Hand dermatitis.
F.
Squamous cell carcinoma (SCC).
G.
Cutaneous lupus erythematosus.
H.
Eczema.
PLAN
A.
General interventions:
1.
This is a chronic disorder that requires long-term treat-
ment, a high degree of client involvement, and therapy
that is simple and inexpensive.
2.
Aim of treatment is control, not cure.
3.
Exposure to sunlight may be benecial. However,
symptoms worsen in a small percentage of clients with
exposure to sunlight.
4.
Sequence of agents for involvement of less than 20%
body surface is as follows:
a.
Emollients (Eucerin cream or Aquaphor cream).
b.
Keratolytic agents (salicylic acid gel or ointment).
c.
Topical corticosteroids: use lowest potency to con-
trol disease.
d.
Calcipotriene ointment: vitamin D analogue (calci-
potriene ointment 0.005%).
e.
Anthralin: use as short-contact therapy 1% to 3%.
f.
Coal tar (Estar, PsoriGel): use in conjunction with
topical steroids or anthralin; may apply at bedtime or
in the morning for 15 minutes and then shower off.
g.
Medicated shampoos: useful for scalp psoriasis, in
conjunction with topical steroids and other treatments.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Psoriasis.”
1.
Help the client understand the chronic nature of this
disease characterized by ares and remission. Teach stress
monitoring and control. Assist with coping techniques.
2.
A trial of a gluten-free diet may be tried to help symp-
toms. See Appendix B: “Gluten-Free Diet.”
3.
Encourage the client to reach out to the National
Psoriasis Foundation for education and resources for the
client and the family.
C.
Pharmaceutical therapy:
1.
If the disease is not controlled with the rst agent, then
an alternative agent may be tried.
2.
Mild to moderate disease: Topical steroids are a
rst-line therapy.
3.
Use emollients to start treatment (e.g., Eucerin Plus
lotion or cream, Lubriderm Moisture Plus, Moisture).
4.
Scalp: Use coal tar shampoo (Zetar, T/Gel, Pentrax) in
place of regular shampoo two times per week.
a.
Apply lather to scalp, allow to soak for 5 minutes,
and then rinse.
b.
If plaques are very thick, use P and S Liquid (over
the counter). Massage in at night and wash out in the
morning.
5.
For additional treatment as needed, apply triamcino-
lone acetonide 0.1% (Kenalog 0.1%) lotion or equivalent to
scaly, stubborn areas once or twice daily until controlled.
Avoid the face.
6.
Dovonex Scalp Solution: Apply on dry scalp as
directed.
7.
Face and skin folds: Use hydrocortisone cream 1%, apply
sparingly up to 4 weeks, preferably no more than 2 weeks.
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4: DERMATOLOGY GUIDELINES
If lesions are unresponsive, consider increasing to 2.5% and
taper quickly with improvement.
8.
Body, arms, and legs: Use triamcinolone acetonide
0.025% (Aristocort A) cream BID up to 2 weeks. Avoid nor-
9.
For thick plaques, try Keralyt Gel (6% salicylic acid),
then corticosteroids.
10.
Use coal tar (Estar Gel) once or twice daily in combina-
tion with corticosteroids.
11.
Anthralin (Dritho-Creme) is benecial as an alternate
to steroid lotion for scalp psoriasis. Avoid sunlight.
12.
Vitamin D
analogue (calcipotriol), BID up to 8 weeks,
3
is comparable with midpotency corticosteroids. Avoid
face and skin folds.
13.
Systemic agents for moderate to severe psoriasis may
be used if other measures fail. Systemic agents should
be prescribed by a dermatology specialist; these medications include retinoids, methotrexate, cyclosporine,
and apremilast. These medications should be monitored
closely for liver/kidney function changes.
FOLLOW-UP
A.
See the client in 2 to 3 weeks to evaluate treatment.
B.
Follow up in 2 months to monitor side effects.
C.
Follow-up must be individualized for each client.
BIBLIOGRAPHY
Frampton, J. E. (2019). Tildrakizumab: A review in moderate-to-severe
plaque psoriasis. American Journal of Clinical Dermatology, 20(2), 295–
306. https://doi.org/10.1007/s40257-019-00435-9
Menter, A., Strober, B. E., Kaplan, D. H., Kivelevitch, D., Prater, E. F.,
Stoff, B., Armstrong, A. W., Connor, C., Cordoro, K. M., Davis, D.
M. R., Elewski, B. E., Gelfand, J. M., Gordon, K. B., Gottlieb, A. B.,
Kavanaugh, A., Kiselica, M., Korman, N. J., Kroshinsky, D., Lebwohl,
M., & Elmets, C. A, . . (2019). Joint AAD-NPF guidelines of care for the
management and treatment of psoriasis with biologics. Journal of the
American Academy of Dermatology, 80(4), 1029–1072. https://doi.org/1
0.1016/j.jaad.2018.11.057
Sparks, J. A., Lesperance, T., Accortt, N. A., & Solomon, D. H. (2019).
Subsequent cardiovascular events among patients with rheumatoid
arthritis, psoriatic arthritis, or psoriasis: Patterns of disease-modifying
antirheumatic drug treatment. Arthritis Care & Research, 71(4), 512–520.
https://doi.org/10.1002/acr.23609
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
SCABIES
DEFINITION
A.
Scabies is a contagious skin infestation by the mite Sarcoptes
scabiei (Figure 4.19).
CONSULTATION/REFERRAL
A.
Medical management: For involvement greater than 20%
of body, refer the client to a dermatologist for the following:
1.
Light therapy with UVA or ultraviolet B (UVB). UVB
light therapy is often used in conjunction with keratolytic
agents.
2.
Synthetic retinoids: Etretinate or acitretin are options.
3.
Low-dose cyclosporine or Azuldine can be effective.
B.
Refer the client with extensive disease, psoriatic arthri-
tis, or inammatory disease to a rheumatologist. Medications
are used to suppress the immune system’s response, which
include adalimumab (Humira), etanercept (Enbrel), iniximab (Remicade), and ustekinumab (Stelara).
C.
Cases of generalized pustular psoriasis of exfolia-
tive erythroderma should be referred immediately to a
dermatologist.
D.
All systemic therapies should be given under supervision
of a dermatologist or a rheumatologist.
INDIVIDUAL
A.
Geriatrics:
1.
CONSIDERATIONS
First-line therapy for mild to moderate psoriasis in
the elderly population is topical treatments. Systemic steroid therapies place geriatrics at a higher risk of adverse
effects, including atrophy, rebound phenomenon, tachyphylaxis, secondary skin infections, telangiectasia, and
purpura.
2.
If topical treatment is not effective, before considering
other treatments, do an assessment for client adherence
and physical function abilities. Verify the client is using
the medication correctly and consistently.
3.
If the medication is being implemented appropriately,
then consider second-line treatments of systemic medications or UVB phototherapy. Second-line therapies must
have a thorough review of comorbidities, any client needs
for assistance, and an evaluation of functional status before
initiating the systemic/phototherapy.
FIGURE
4.19 Scabies.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for
wound care nursing: Practical wound management in a nutshell
(p. 255). Springer Publishing Company.
INCIDENCE
A.
Scabies occurs mainly in individuals in close contact with
many other individuals, such as schoolchildren or nursing
home residents. It is rare among African Americans.
PATHOGENESIS
A.
Scabies is transmitted through close contact with an indi-
vidual who is infested with the mite S.scabies. Transmission
may occur through sexual contact or contact with mite-infested
clothing or sheets. The fertilized female mite burrows into the
stratum corneum of a host and deposits eggs and fecal pellets.
Larvae hatch, mature, and repeat the cycle.
B.
A hypersensitivity reaction is responsible for the intense
pruritus.
PREDISPOSING
A.
Close contact with large numbers of individuals.
B.
Institutionalized.
C.
Poverty.
D.
Sexual promiscuity.
FACTORS
SCABIES
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101
COMMON
A.
B.
C.
D.
OTHER
A.
COMPLAINTS
Intense itching, worse at night.
Skin excoriation.
Generalized pruritus.
Rash.
SIGNS AND SYMPTOMS
Mites burrow in nger webs, wrists, sides of hands and
feet, axilla, buttocks, and in the penis and scrotum in males.
B.
Discrete vesicles and papules, distributed in linear fashion.
C.
Erythema.
D.
Secondary infections caused by scratching or infection
(pustules and pinpoint erosions).
E.
Nodules in covered areas (buttocks, groin, scrotum, penis,
and axilla), which may have slightly eroded surfaces that persist for months after mites have been eradicated.
F.
Diffuse eruption that spares the face.
SUBJECTIVE
A.
Elicit information regarding housing conditions, close con-
DATA
tact, or sexual contact with potentially infected individuals.
B.
Question the client regarding onset, duration, and location
of itching.
PHYSICAL
A.
Check temperature.
B.
Inspect:
EXAMINATION
1.
Examine all body surfaces with client unclothed.
2.
Use a magnifying lens to identify characteristic bur-
rows in nger webs, wrists, and penis.
3.
Inspect adult pubic area for lesions.
3.
Household members should be treated simultaneously
as a prophylactic measure and to reduce the chance of
reinfection.
4.
The client should be advised that pruritus may con-
tinue for up to a week even with a successful treatment
due to local irritation.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Scabies.”
C.
Pharmaceutical therapy:
1.
First line of therapy, due to its low toxicity, is 5% per-
methrin (Elimite Cream) applied to all body areas from the
neck down and washed off in 8 to 14 hours. One application is highly effective, but some dermatologists recommend retreatment in 1 week.
2.
An oral dose of the anthelmintic agent ivermectin (200
mcg/kg) followed by a repeat dose in 1 to 2 weeks has
been shown to be effective and to rapidly control pruritus
in healthy clients and HIV clients.
3.
Diphenhydramine (Benadryl) 25 to 50 mg may be
given PO every 4 to 6 hours if indicated for pruritus. Other
nonsedating antihistamines may be used. Toxicity is usually a result of client overtreatment (failure to follow prescribed regimen). Advise the client of this danger.
FOLLOW-UP
A.
Follow up in 2 weeks to assess treatment response.
CONSULTATION/REFERRAL
A.
Consult or refer the client to the physician if, at 2-week
follow-up, pharmaceutical therapy has been ineffective.
DIAGNOSTIC
A.
Three ndings are diagnostic of scabies:
1.
2.
3.
B.
Burrow identication: Ink the suspected area with a blue
TESTS
Microscopic identication of S. scabiei mites.
Eggs.
Fecal pellets (scybala).
or black felt-tipped pen, then wipe with an alcohol swab.
The burrow absorbs the ink, while the surface ink is wiped
clean.
C.
A tiny black dot may be seen at the end of a burrow, which
represents the mite, ova, or feces, and can be transferred by
means of a 25-gauge hypodermic needle to immersion oil on a
slide for microscopic identication.
D.
Place a drop of mineral oil on a suspected lesion, scrape
the lesion with a #15 blade, and transfer the shaved material
to a microscope slide for direct examination of the mite under
low power.
DIFFERENTIAL
A.
Atopic dermatitis.
B.
Insect bites.
C.
Pityriasis rosea.
D.
Eczema.
E.
Seborrheic dermatitis.
F.
Syphilis.
G.
Pediculosis.
H.
Allergic or irritant contact dermatitis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Implement comfort measures to reduce pruritus.
2.
Treat secondary infection(s) with antibiotics.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Permethrin is classied as category B by the Food and
Drug Administration. Use is only recommended if the
benets outweigh the risks.
B.
Pediatrics:
1.
Infants and toddlers often have more widespread
involvement, which can include the face and scalp.
2.
Vesicular lesions on thepalms and soles are more com-
monly seen.
3.
Drug of choice is permethrin 5% cream; apply over the
head, neck, and body, avoiding the eyes. The cream should
be removed by bathing within 8 to 14 hours.
4.
Infants and children with underlying cutaneous dis-
ease, malnutrition, prematurity, or a history of seizure disorders should be treated with special caution due to their
increased risk of toxicity.
C.
Partners:
1.
All intimate contacts within the past month and close
household and family members should be treated.
D.
Geriatrics:
1.
The elderly tend to have more severe pruritus despite
fewer lesions.
2.
They are at risk of extensive infections due to
age-related decline in immunity.
3.
The excoriations may become severe and may be com-
plicated by cellulitis.
4.
Avoid rst-generation anticholinergics due to risk of
confusion, dry mouth, constipation, and other anticholinergic effects or toxicity.
5.
Geriatric clients with dementia or declining functional
abilities need a thorough home environment assessment
and an evaluation for any issues of neglect or abuse.
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BIBLIOGRAPHY
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
Workowski, K. A., Bachman, H., Chan, P. A., Johnston, C. M., Muzny, C.
A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually
transmitted infections treatment guidelines, 2021. Morbidity and
Mortality Weekly Report (MMWR), 70, 1.
SEBORRHEIC
DERMATITIS
DEFINITION
A.
A common chronic, erythematous, scaling dermatosis,
seborrheic dermatitis occurs in areas of the most active sebaceous glands, such as the face and scalp, body folds, and presternal region (Figure 4.20).
OTHER
SIGNS AND SYMPTOMS
A.
Variable pruritus, often increasing with perspiration and
in winter.
B.
Oily, aking skin on erythemic base around ears, nose,
eyebrows, and eyelids.
C.
Red, cracking skin in body folds, axilla, groin, or in ano-
genital, submammary, or umbilical areas.
D.
Primary lesions: plaques.
E.
Secondary lesions: erythema, scales, ssures, exudate, and
symmetric eyelid involvement.
F.
Lesions with drainage or crusting may indicate secondary
bacterial infection.
G.
Distribution pattern in infants: scalp and diaper area.
H.
Distribution area in adults: scalp, eyebrows, paranasal
area, nasolabial fold, chin, behind ears, chest, and groin.
I.
Secondary impetigo in children.
SUBJECTIVE
A.
Identify location, onset, and progression of symptoms.
B.
Ask the client to describe symptoms. Ask if the skin is
DATA
itchy or painful.
C.
Assess lesions for any associated discharge (blood or pus).
D.
Elicit information regarding use of topical medications,
soaps, creams, or lotions. Quiz the client regarding any oral
medications being taken.
E.
Determine whether there were any preceding sys-
temic symptoms (fever, sore throat, anorexia, or vaginal
discharge).
F.
Rule out any possible exposure to industrial or domestic
toxins.
G.
Ask the client to identify what improves or worsens this
condition.
FIGURE
4.20 Infantile seborrheic
dermatitis.
INCIDENCE
A.
Seborrheic dermatitis is very common, affecting approxi-
mately 1% to 5% of the general population.
B.
Incidence is higher in HIV-infected individuals, ranging
from 34% to 83%.
PATHOGENESIS
A.
Etiology is unknown. There is a possibility that it is hor-
monally dependent, has a fungal (Pityrosporum ovale or
Candida albicans) component, is neurogenic, or may reect a
nutritional deciency.
B.
Currently, it is identied as an inammatory disorder that
most probably results from a dysfunction of sebaceous glands.
PREDISPOSING
A.
Possible link between infantile and adult forms.
B.
Possible familial trend.
C.
High association with HIV-infected individuals.
COMMON
A.
Infants: “cradle cap.”
B.
Adults: “dandruff,” dry aky scalp.
C.
Rash with “sticky akes.”
no presenting complaints are found on a routine physical
Often
examination.
FACTORS
COMPLAINTS
PHYSICAL
A.
Inspect:
B.
Palpate:
DIAGNOSTIC
A.
None required.
B.
Consider fungal culture in children and adolescents to rule
EXAMINATION
1.
Inspect the skin, noting areas of lesions and distribution.
2.
Assess eyes for blepharitis.
3.
Inspect ears and nose.
1.
Palpate the skin, noting textureand moisture.
TESTS
out a fungal infection.
C.
Consider possible skin biopsy to rule out other conditions.
DIFFERENTIAL
A.
Seborrheic dermatitis.
B.
Atopic dermatitis.
C.
Candidiasis.
D.
Dermatophytosis.
E.
Histiocytosis X.
F.
Psoriasis vulgaris.
G.
Rosacea.
H.
Systemic lupus erythematosus.
I.
Tinea capitis.
J.
Tinea versicolor.
K.
Vitamin deciency.
L.
Impetigo.
M.
Eczema.
N.
Secondary syphilis.
DIAGNOSES
TINEA
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PLAN
A.
General interventions:
1.
Shampooing is the foundation of treatment.
a.
Infants:
i.
Rub petroleum jelly into the scalp to soften
crusts 20 to 30 minutes before shampooing.
ii.
Shampoo daily with baby shampoo using a soft
brush.
b.
Toddlers or adolescents:
i.
Shampoo every other day with antiseborrheic
shampoo (Selsun Blue, Exsel, or Nizoral).
2.
If the skin does not clear after 1 to 2 weeks of treatment,
it is appropriate to use ketoconazole 2% cream.
3.
Seborrheic blepharitis:
a.
Hot compress plus gentle debridement with
cotton-tipped applicator and baby shampoo twice a
day.
b.
For secondary bacterial infection, sulfacetamide
sodium 10% (ophthalmic Sodium Sulamyd).
4.
Continue treatment for several days after lesions
disappear.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Seborrheic Dermatitis.”
C.
Pharmaceutical therapy:
1.
Most shampoos should be used two times per week.
Those with coal tar can be used three times per week.
2.
Medicated shampoos:
a.
Coal tar (Denorex, T/Gel, Pentrax, Tegrin) sham-
poo, apply as directed.
b.
Salicylic acid (Ionil Plus, P and S) shampoo, apply as
directed.
c.
Selenium sulde (Exsel, Selsun Blue) shampoo, use
daily.
d.
Ketoconazole 2% (Nizoral) cream, apply to affected
area BID for 4 to 6 weeks.
e.
Combination shampoos: coal tar and salicylic acid
(T/Sal); salicylic acid and sulfur (Sebulex). These
shampoos may be used one to two times a week,
alternating with other shampoos during the week.
Always apply corticosteroids in a thin layer only;
avoid the eyes.
3.
Topical corticosteroid lotions or solutions: Use in com-
bination with medicated shampoo if 2 to 3 weeks of treatment with shampoo alone fails.
4.
Adults: scalp:
a.
Start with medium potency, for example, betameth-
asone valerate 0.1% lotion 20 to 60mL BID.
b.
If treatment is not effective in 2 weeks, increase
potency, for example, uocinonide 0.05% solution 20 to
60mL BID, or uocinolone acetonide 0.01% oil 120mL
nightly with shower cap.
c.
As dermatitis is controlled, decrease to mild potency,
for example, hydrocortisone 1% to 2.5% lotion 20 to
60mL once or BID.
5.
Adults: face or groin:
a.
Low-potency agents, for example, hydrocortisone
1% cream or desonide 0.05% cream once or BID.
b.
Consider lotion for eyebrows for easier application.
c.
Metronidazole 1% gel on face once or twice daily.
6.
Recalcitrant disease:
a.
Add ketoconazole 2% cream (15, 30, or 60 g) every
day.
b.
Use sulfacetamide sodium 10%, with sulfur 5%,
lotion 25 g once or twice daily.
FOLLOW-UP
A.
Advise the client to call the ofce in 5 to 6 days to report
progress.
B.
The client should return to the ofce if no improvement is
seen.
CONSULTATION/REFERRAL
A.
Refer the client to a dermatologist if the condition does not
clear in 10 to 14 days.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Pediatrics:
1.
2.
3.
CONSIDERATIONS
Ketoconazole is not recommended.
Avoid using tar preparations on infants.
Use baby shampoo only.
If lesions are inammatory, use topical steroids no
stronger than hydrocortisone 0.5% to 1.0% BID.
4.
Betamethasone valerate (Valisone) lotion may be used
daily for scalp only if other treatments fail.
5.
Be aware of potential for emotional distress in
adolescents.
6.
Treat with antiseborrheic shampoo every other day for
adolescents.
C.
Geriatrics:
1.
Seborrheic dermatitis is one of the most common
inammatory skin disorders in the elderly population.
Clients with light dry skin are at the greater risk of an
occurrence, especially during the winter.
BIBLIOGRAPHY
Barak-Shinar, D., & Green, L. J. (2018). Scalp seborrheic dermatitis and
dandruff therapy using an herbal and zinc pyrithione-based therapy of shampoo and scalp lotion. Journal of Clinical & Aesthetic
Dermatology, 11(1), 26–31. http://search.ebscohost.com.proxy.libr
ary.vanderbilt.edu/login.aspx?direct=true&AuthType=ip,uid,cp
id&custid=s9007717&db=ccm&AN=127294010&site=ehost-live
Friedmann, D. P., Mishra, V., & Batty, T. (2018). Progressive facial pap-
ules in an African-American patient: An atypical presentation of
seborrheic dermatitis. Journal of Clinical & Aesthetic Dermatology,
11(7), 44–45. http://search.ebscohost.com.proxy.library.vanderbilt.
edu/login.aspx?direct=true&AuthType=ip,uid,cpid&custid=s9
007717&db=ccm&AN=130845905&site=ehost-live
TINEA
DEFINITION
A.
Tinea corporis (ringworm) is a fungal infection of the skin
tissue (keratin) commonly seen on the trunk and extremities
(Figure 4.21).
B.
Tinea capitis is a fungal infection of scalp hair.
C.
Tinea cruris is a fungal infection of the groin.
D.
Tinea pedis is a fungal infection of the foot.
E.
Tinea unguium (dermatophyte onychomycosis) is a fungal
infection of the nail.
INCIDENCE
A.
Ringworm is a fairly common fungal infection seen in
adults and children.
PATHOGENESIS
A.
The causative fungal species varies, depending on the
location of the infection. Three common organisms are
Epidermophyton, Microsporum, and Trichophyton.
B.
The infection can be obtained from other people, animals
(puppies, kittens), and the soil.
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FIGURE
4.21 Tinea corporis.
Source:
Reproduced from Kifer, Z. A. (2012). Fast facts for
wound care nursing: Practical wound management in a
nutshell (p. 258). Springer Publishing Company.
PREDISPOSING
A.
Exposure to person or facilities (e.g., locker rooms) infected
FACTORS
with the fungus.
B.
Poor nutrition.
C.
Poor health.
D.
Poor hygiene.
E.
Warm climates.
F.
Immunosuppression.
COMMON
A.
B.
C.
COMPLAINTS
Scaly, itchy patch of skin.
When circular in shape, usually tinea corporis (ringworm).
When nails are thickened and yellow, usually tinea
unguium.
OTHER
SIGNS AND SYMPTOMS
A.
Tinea capitis: erythema, scaling of scalp, with hair loss at
site.
B.
Tinea corporis: circular, erythematous, well-demarcated
lesion on the skin with hypopigmentation at the center of
lesion; usually pruritic.
C.
Tinea cruris: well-demarcated scaling lesions on the groin
(not scrotum) or thigh; usually pruritic.
D.
Tinea pedis: scaly, erythemic vesicles on feet, between toes,
and in arch, with extreme pruritus.
E.
Tinea unguium (onychomycosis): thickening and yellow-
ing of the toenail or ngernail, often with other fungal infection or alone.
PHYSICAL
A.
Check temperature (if indicated).
B.
Inspect:
DIAGNOSTIC
A.
Obtain scrapings of the border of the lesion for evaluation.
DIFFERENTIAL
A.
Tinea corporis.
B.
Dermatitis.
C.
Alopecia areata.
D.
Psoriasis.
E.
Contact dermatitis.
F.
Atopic eczema.
G.
Subacute cutaneous lupus erythematosus.
H.
Pityriasis rosea.
EXAMINATION
1.
Examine all areas of skin.
2.
Note type of lesions present.
TESTS
1.
Potassium hydroxide (KOH).
2.
Wet prep.
3.
Fungal cultures.
DIAGNOSES
PLAN
A.
General interventions:
1.
Identify type of lesion.
2.
Identify other infected family members or sexual part-
ners for treatment.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Ringworm (Tinea).”
1.
Reinforce medication regimen for a 4- to 8-week period
for resolution.
C.
Pharmaceutical therapy:
1.
Tinea capitis:
a.
Adults: griseofulvin 500 mg PO per day for 4 to 6
weeks.
b.
Children: griseofulvin 10 to 20mg/kg/d for 4 to 8
weeks. Griseofulvin is best absorbed with high-fat
foods.
2.
Tinea corporis, pedis, and cruris:
a.
Use wet dressings with Burow solution along with
one of the following:
i.
Clotrimazole 1% (Lotrimin) cream, or econazole
nitrate 1% cream, BID for 14 to 28 days.
ii.
Terbinane 1% cream (Lamisil), topical, apply
once or twice daily for 1 to 4 weeks. Not recommended for children.
3.
Onychomycosis: Successful treatment is difcult.
a.
Itraconazole (Sporanox) 100mg, two tablets PO BID
for 7 days. Repeat in 1 month, then repeat again in 1
more month.
SUBJECTIVE
A.
Ask the client about onset, duration, and progression of
DATA
the patch or rash on the skin.
B.
Assess other areas of skin involvement.
C.
Ask if the lesion is pruritic.
D.
Inquire as to the client’s exposure to anyone with similar
symptoms.
E.
Determine whether the client has a history of similar
lesions.
F.
Query the client regarding predisposing factors.
G.
Review with the client what remedies were used and with
what results.
Monitor
liver function tests (LFTs) at 6 weeks after starting medication.
b.
Terbinane:
i.
Fingernail: 250mg once daily for 6 weeks.
ii.
Toenail: 250mg daily for 12 weeks.
c.
Home cure: Apply Vicks VapoRub on toenail bed
and cover with a sock every night at bedtime for
approximately 4 to 6 months or until resolved. This
treatment offers a safe, cost-effective alternative to oral
medications.
FOLLOW-UP
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A.
A 2- to 4-week follow-up is recommended to evaluate
progress.
B.
When using Sporanox, monitor liver function tests (LFTs)
at 6 weeks. If the medication is continued, monitoring LFTs
every 6 to 8 weeks is recommended.
CONSULTATION/REFERRAL
A.
Consult a physician if the infection has not improved.
TINEA VERSICOLOR
105
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Oral antifungal medications are not recommended
during pregnancy.
B.
Pediatrics:
1.
Tinea capitis is common in children 2 to 10 years old.
When hair has been lost, regrowth takes time.
2.
Tinea pedis is common in adolescents.
3.
Tinea unguium is common in adolescents, but rare in
children.
C.
Adults:
1.
Tinea capitis is rare in adults.
2.
Tinea cruris is more common in obese males, but rare
in females.
3.
Tinea pedis is common in adults.
4.
Tinea unguium is seen in adults.
5.
Transient and/or permanent hearing loss has been
documented in some clients with use of itraconazole.
These cases were reported when itraconazole was used
with quinidine, which is contraindicated.
D.
Elderly:
1.
Itraconazole should be used cautiously in the elderly
client.
2.
Recommendation for tinea treatment with the elderly
population is terbinane due to its decreased risk for cardiac complications and drug interactions.
BIBLIOGRAPHY
Hudson, A., Sturgeon, A., & Peiris, A. (2018). Tinea versicolor. JAMA:
Journal of the American Medical Association, 320(13). https://doi.org/
10.1001/jama.2018.12429 1396
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
Shear, N. H., Gupta, A. K., Piguet, V., Versteeg, S. G., Tosti, A., & Piraccini,
B. M. (2019). A practical guide to curing onychomycosis: How to maximize cure at the patient, organism, treatment, and environmental
level. American Journal of Clinical Dermatology, 20(1), 123–133. https://
doi.org/10.1007/s40257-018-0403-4
Trayes, K. P., Savage, K., & Studdiford, J. S. (2018). Annular lesions:
Diagnosis and treatment. American Family Physician, 98(5), 283–291.
TINEA
VERSICOLOR
DEFINITION
A.
Tinea versicolor is a fungal infection of the skin which may
be chronic in nature (Figure 4.22). It is most commonly seen on
the upper trunk, but may also spread to the extremities.
INCIDENCE
A.
Tinea versicolor is seen most frequently in adolescents and
young adults.
FIGURE
4.22 Example of tinea versicolor.
Source:
Reproduced from Lyons, F., & Ousley, L. (2015).
Dermatology for the advanced practice nurse. Springer
Publishing Company, Figure III.55.
PATHOGENESIS
A.
Tinea versicolor is a fungal infection of the skin caused by
an overgrowth of Pityrosporum orbiculare, part of the normal
skin ora.
B.
Discoloration of the skin is seen, forming round or oval
maculae, which may become conuent.
C.
Maculae range from 1 cm to very large, greater than 30cm.
PREDISPOSING
A.
Immunosuppressed.
B.
Pregnancy.
C.
Warm temperatures.
D.
Corticosteroid therapy.
E.
Genetic predisposition.
COMMON
A.
Scaly rash on the upper trunk with occasional mild itching.
OTHER
SIGNS AND SYMPTOMS
A.
Annular maculae with mild scaling.
B.
Asymptomatic or pruritic.
C.
Pink-, white-, or brown-colored rash.
SUBJECTIVE
A.
Ascertain when and where the rash began.
B.
Have the client describe how the rash has changed.
C.
Assess the client for any associated symptoms with the
FACTORS
COMPLAINT
DATA
rash, such as itching and burning.
D.
Identify what products the client has used on the skin to
treat rash and with what results.
E.
Elicit information regarding a history of similar rashes.
F.
Query the client regarding current medications.
G.
Review any medical history for comorbid conditions.
PHYSICAL
A.
Inspect:
DIAGNOSTIC
A.
Wet prep/potassium hydroxide (KOH).
B.
Wood lamp: Wood lamp is useful in examining skin to
EXAMINATION
1.
Inspect skin and note type of lesion.
2.
Examine other areas of skin for similar lesions.
TESTS
determine the extent of infection. Inspection of ne scales
with Wood lamp reveals scales with a pale yellow-green uorescence that contains the fungus.
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https://t.me/med1917
4: DERMATOLOGY GUIDELINES
C.
Culture lesion: When obtaining a sample scraping, obtain
the sample from the edge of the lesion for the best sample of
hyphae. (Hyphae and spores have a “spaghetti and meatball”
appearance.)
DIFFERENTIAL
A.
Tinea versicolor.
B.
Tinea corporis.
C.
Pityriasis alba.
D.
Pityriasis rosea: a herald patch is clue to diagnosis.
E.
Seborrheic dermatitis.
F.
Vitiligo.
G.
Secondary syphilis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Apply medication as directed.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Tinea Versicolor.”
1.
These causative species are a normal inhabitant of skin
ora; recurrence is possible.
2.
Skin pigmentation returns after infection has cleared
up. This may take several months to resolve.
C.
Pharmaceutical therapy:
1.
Selenium sulde 2.5% (Selsun Blue):
a.
Advise client to shower at bedtime. Then apply sele-
nium sulde 2.5% cream to skin, covering entire body
from chin down to toes. Leave treatment on skin for 8
to 10 hours. Shower off in the morning.
b.
A second treatment option includes applying the
selenium sulde 2.5% cream to skin lesions daily for
12 days. Leave treatment on skin for 30 minutes, then
shower off.
c.
Treatment may be needed monthly until desired
results are obtained. Encourage use of Selsun Blue on
the entire body surface except on face and head.
2.
Other medications used:
a.
Clotrimazole 1% cream BID for 4 weeks.
b.
Ketoconazole 2%(Nizoral) cream daily for 14 days.
c.
Fluconazole 300mg once weekly for 2 weeks. When
using uconazole as treatment, caution the client
regarding liver damage with toxicity.
FOLLOW-UP
A.
None required if resolution occurs.
B.
Monitor liver function tests every 6 weeks while on oral
medications.
CONSULTATION/REFERRAL
A.
Consult with a physician if current treatment is
unsuccessful.
INDIVIDUAL
A.
Pediatrics:
1.
B.
Adults:
1.
CONSIDERATIONS
Commonly seen in adolescents.
Commonly seen in young adults.
BIBLIOGRAPHY
Lipner, S. R., & Scher, R. K. (2019). Onychomycosis: Clinical overview and
diagnosis. Journal of the American Academy of Dermatology, 80(4), 835–
851. https://doi.org/10.1016/j.jaad.2018.03.062
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
Plensdorf, S., Livieratos, M., & Dada, N. (2017). Pigmentation disor-
ders: Diagnosis and management. American Family Physician, 96(12),
797–804.
Shear, N. H., Gupta, A. K., Piguet, V., Versteeg, S. G., Tosti, A., & Piraccini,
B. M. (2019). A practical guide to curing onychomycosis: How to maximize cure at the patient, organism, treatment, and environmental
level. American Journal of Clinical Dermatology, 20(1), 123–133. https://
doi.org/10.1007/s40257-018-0403-4
WARTS
DEFINITION
A.
A wart is an elevation of the epidermal layer of the skin (skin
tumor). Warts are caused by the human papillomavirus (HPV).
INCIDENCE
A.
Warts occur in people of all ages, more common in chil-
dren and during early adulthood.
B.
By adulthood, 90% of all people have positive antibodies
to the virus.
C.
Warts are seen more frequently in females than in males.
PATHOGENESIS
A.
A circumscribed mass develops on the skin that is limited
to the epidermal layer. The virus, papillomavirus, is located
within the nucleus of the cell.
B.
The virus may be transmitted by touch and is commonly
seen on the hands and feet.
C.
Most warts resolve without treatment within 12 to
24months.
PREDISPOSING
A.
Skin trauma.
B.
Immunosuppression.
C.
Exposure to public showers, pools, locker rooms, and so
forth.
COMMON
A.
Bump on the skin or specic area of the body (hands, feet,
arms, and legs).
B.
Usually painless unless present on the bottom of the foot.
OTHER
SIGNS AND SYMPTOMS
A.
Common wart (verruca vulgaris): esh-colored, irregular
lesion with rough surface; black dots at the center of lesion
occasionally seen, which is thrombosed capillaries; can occur
on any body part.
B.
Filiform wart (verruca liformis): thin, threadlike, pro-
jected papule on face, lips, nose, or eyelids.
C.
Flat wart (verruca plana): at-topped, esh-colored pap-
ule, 1 to 3 mm in diameter, with smooth surface; seen in clusters or in a line, on face and extremities.
D.
Plantar wart (verruca plantaris): rm papule, 2 to 3 cm in
diameter, indented into skin with verrucous surface; painful
with ambulation, when placed on the ball or heel of the foot.
E.
Genital warts: See Chapter 15, “Sexually Transmitted
Infections Guidelines.”
SUBJECTIVE
A.
Determine onset, location, and duration of tumor.
B.
Elicit information regarding a history of warts.
C.
Identify with the client what treatment has been used in the
past and what the results were. Question the client regarding
FACTORS
COMPLAINTS
DATA
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length of time over-the-counter medications were used, and
how aggressive they were with the treatment.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Assess skin for lesions, noting location, appearance,
size, and surface texture of tumor.
2.
Examine the entire body for other lesions.
DIAGNOSTIC
A.
None indicated.
DIFFERENTIAL
A.
Wart:
1.
2.
3.
4.
B.
Seborrheic keratosis.
C.
Callus.
D.
Molluscum contagiosum: These are esh-colored group of
TEST
DIAGNOSES
Verruca vulgaris.
Verruca liformis.
Verruca plana.
Verruca plantaris.
rm papules found on the face, trunk, and/or extremities (Figure
4.23). A white core may be expressed from the lesion. Lesion may
be successfully removed by curettage or cryotherapy.
WOUND CARE: LOWER EXTREMITY ULCER
iii.
Apply cryotherapy with liquid nitrogen to site.
Repeat every 3 to 4 weeks until resolved. Apply
adhesive tape over site and keep covered.
2.
Flat wart:
a.
Retinoic acid: Apply to site BID for 4 to 6 weeks.
b.
Imiquimod (Aldara) 5% cream may be applied by
the client at home. Although the labeled use is for genital warts, the client may consider off-label use at bedtime and wash off after 6 to 8 hours every other day
until resolved. Precautions should be stressed regarding the caustic nature of the cream to healthy skin.
3.
Plantar wart:
a.
Salicylic acid 40% (Mediplast): Apply over the wart.
Remove in 24 to 48 hours and remove dead skin with
a pumice stone or by scraping or using a nail le.
Educate the client to throw away the emery board nail
le after each use. If using a nail le, after each use,
cleanse with alcohol. Repeat every 24 to 48 hours until
wart is removed. This may take up to 6 to 8 weeks.
4.
Filiform wart:
a.
Apply cryotherapy with liquid nitrogen to site.
Repeat every 3 to 4 weeks until resolved. Apply adhesive tape over the site and keep it covered.
b.
For surgical removal, refer to a dermatologist.
107
FIGURE
4.23 Molluscum contagiosum.
Source: Reproduced from Kifer, Z. A. (2012). Fast facts for wound care
nursing: Practical wound management in a nutshell (p. 250). New York,
NY: Springer Publishing Company.
E.
Corn.
F.
Skin cancer.
PLAN
A.
General interventions:
1.
Identify the type of wart.
2.
Conservative treatment is recommended for children.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Warts.”
C.
Pharmaceutical therapy:
1.
Common wart:
a.
After soaking and ling wart with a nail le, apply
one of the following:
i.
Salicylic acid 17% (Compound W) gel BID for
up to 12 weeks, if needed. Keep site covered with
adhesive.
Apply duct tape to site after treatment. Repeat
ii.
this treatment every night for up to 12 weeks or
until resolved.
FOLLOW-UP
A.
Follow the client every 4 to 6 weeks until resolved.
CONSULTATION/REFERRAL
A.
If the diagnosis is unclear, refer the client to a dermatolo-
gist for surgical excision and biopsy.
INDIVIDUAL
A.
Pediatrics:
1.
B.
Geriatrics:
1.
CONSIDERATIONS
Warts are commonly seen in young school-age children.
Use caution if client elects cryotherapy to treat a wart
secondary to thinness of aging skin. Always assess if the
client is taking aspirin or anticoagulant therapy prior to
incisional removal or cryotherapy.
BIBLIOGRAPHY
Efcacy and safety of hydrogen peroxide topical solution, 45%
(w/w) for treatment of common warts: 8-Week results from the
phase 2 WART-203 trial. (2019). Journal of the American Academy of
Dermatology, 81, AB53. https://doi-org.proxy.library.vanderbilt.edu/
10.1016/j.jaad.2019.06.223
Long-term efcacy and safety of hydrogen peroxide topical solution,
45% (w/w) in patients with common warts: Posttreatment results
from the phase 2 WART 203 trial. (2019). Journal of the American
Academy of Dermatology, 81, AB89. https://doi-org.proxy.library.
vanderbilt.edu/10.1016/j.jaad.2019.06.345
WOUND
CARE: LOWER EXTREMITY ULCER
DEFINITION
A.
Vascular ulcer:
1.
Arterial/ischemic ulcer:
a.
Skin ulcers usually found on the medial or lateral
foot or ankle; ulcers are nonhealing due to inadequate
arterial ow.
2.
Venous ulcer:
a.
Chronic skin and subcutaneous lesions are usually
found on the lower extremity between the ankle and
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