Commonly Seen Infectious and Non-Infectious Skin Disorders in the School-Aged Child - PowerPoint Presentation

Slide1

Commonly Seen Infectious and Non-Infectious Skin Disorders in the School-Aged Child

Melinda Rodriguez DNP, APRN, FNP-BC

Nursing Education Doctor’s Hospital at Renaissance Health Systems

Slide2

Disclosures

Nothing to disclose

Slide3

Objectives

Discuss a brief overview of the anatomy and physiology of the skin

Discuss the importance of history collection

Discuss infectious skin disorders affecting the school-aged child

Discuss the non-infectious skin disorders affecting the school-aged child

Discuss assessment and management of Acanthosis Nigricans (AN)

Slide4

Brief Overview of Integumentary System

Provides an elastic, rugged, self-regenerating cover for the body

Largest organ of the body

Includes: hair and nails

Maintains and keeps body structures in place

Slide5

Anatomy and Physiology

Comprised of several layers

Protects against microbial and foreign substance invasion

Regulates body temperature

Provides sensory perception via nerve endings

Produces vitamin D from precursors in skin

Contributes to blood pressure regulation

Slide6

Functions of the Skin

Complex organs made up of may cell typesLargest organ of the bodyProvides barrier between external and internal environmentsProvides protection against organismsSkin receptors relay: touch, pressure, temperature and pain to CNSAlso provide ability for localization and discrimination

McCance & Huether, (2014).

Slide7

Overview of the Skin Assessment

Problems may arise from many mechanisms and inflammatory processesSome causes may be environmental, traumatic and secondary to exposuresEvaluation of skin disorders require a in-depth focus history and PEAssess for infectious symptoms: fever, itchingLook at the presentation of lesion, configuration and distribution

Seidel, Ball, Dains et al., (2015).

Slide8

External Clues to Internal Problems

Persistent pruritus may indicate chronic renal failure, liver disease, diabetes

Supernumerary nipples located along mammary ridge, may be associated with renal problems

Facial port wine stain may be associated with ocular defects, malformation of meninges

Slide9

Age-Appropriate History

Gather data specific to current skin problems

Family, PMH of similar problems

Skin care routines

Recent changes in skin, hair or nail care

Sun-exposure habits; use of sunscreen

Medication history

Onset, date of occurrence

History of recent travel

Rx medications; OTC medications, lotions used

Slide10

History of Present Illness

Note recent or past changes in the skin: pruritus, dryness, sores, rashes, lumpsSymptoms: pain, exudate, bleeding, color changesRecent drug exposure; chemicals; Generalized symptoms: fever, travel hxUse of topical or oral medications

Seidel et al., (2015).

Slide11

History (cont’d)

Eating habits; allergies to foodsCommunicable disease exposureAllergic disorders; asthmaExposure to pets; animalsSkin injury; outdoor exposuresNail bitingThinning of hair

Seidel et al., (2015).

Slide12

Mechanisms of Self-Defense

Bacteria-Derived Chemicals

:

skin, mucous membranes and GI tract, urethra and vagina have protective microorganisms

Common bacteria on the skin: staph and strept

C-difficile in the GI tract

Lactobacillus protection of the vaginal tract

Slide13

Inspection of the Skin

Performed by inspection and palpationInspection: lighting is essentialObserve for symmetryAdequate exposure of the skinInspect skin thicknessAssess for color variancesAssess for nevi; abnormally shaped; variegated colors

Seidel et al., (2015).

Slide14

Palpation of the Skin

Palpate for the following:MoistureTemperatureTextureTurgorMobility

Visualdex.com

Seidel et al., (2015).

Slide15

Blood supply/nerve innervation

Blood supply to skin limitedInclude papillary capillariesDermis facilitates the regulation of body temperatureEvaporation of sweat cools bodyRegulates vasoconstriction

McCance & Huether, (2010).

Slide16

Morphological Criteria

Includes:Location of lesionDistributionDetermine whether primary or secondaryShape of lesionMargins/borders/irregularitiesPigmentation/color/variationsPalpate texture/consistencyWear gloves if open lesions present

Seidel et al., (2015).

Slide17

Morphological Characteristics of Lesions

Linear (in a line)Stellate (star shaped)Reticulate (netlike; lacy)Mobilliform (maculopapular; confluent)Irregular bordersBorder raised above Advancing; spreading beyond borders (cellulitis)

Seidel et al., (2015).

Slide18

Pigmentation

Flesh colored

Erythematous/pink

Salmon colored (psoriasis)

Black

Purple

Yellow/waxy

Pearly

Slide19

Primary Skin Lesions

Macule: flat, circumscribed area; changes to color of skin; less than 1cm in diameter (freckle)Papule: elevated firm circumscribed area less than 1cm (wart)Patch: a flat non-palpable irregular shaped macule; more than 1cm (vitiligo)Plaque: elevated, firm, rough with flat top surface; greater than 1cm in diameter ( psoriasis)Vesicle: elevated, circumscribed superficial; does not extend to dermis, filled with serous fluid less than 1cm

McCance & Huether, (

2014).

Slide20

Primary Skin Lesions

Macule/Papule

Slide21

Secondary Lesions (cont’d)

Scale: heaped up keratinized flaky skin; thick or thin, dry variation in size (seborrheic dermatitis)Lichenification: rough, thickened epidermis secondary to persistent rubbing, itching of skin; flexor surfaces of skin (chronic dermatitis)Scar: thin to thick fibrous tissue; replaces normal skin following injury (healed wound)Keloid: irregular-shaped, elevated progressively enlarging, goes beyond boundaries of the wound; excessive collagen formation

McCance & Huether, (

2014).

Slide22

Secondary Lesions

Keloid

Scar

m

edicinenet.com

Slide23

Vascular Skin Lesions

Spider angioma

; red central body with spider-like legs; blanches with pressure

Purpura

;

is red purple in color; non-

blanchable

; greater than 0.5cm in diameter

Petechiae

; red-purple in color, non-

blanchable

; less than 0.5cm in diameter

Telangiectasia

; fine, irregular red lines

Venous star;

bluish spider; irregular shape does not blanch with pressure

Slide24

Vascular Lesions

Telangiectasias

Slide25

Pigment Disorders of the Skin

Skin reflects emotional statesWarmth and other responses are given/receivedPigmentary skin disorder: vitiligo affects people of all races, sudden appearances of white patches; vary in size, hereditary and genetic causeAlbinism: genetic disorder absence of pigment in skin, hair, eyes; found in all racesMelasma: darkened macules on face; OC use; exacerbated by sun exposure

McCance & Huether, (2010).

Slide26

Assessment of the Adolescent

Increased oiliness or perspiration may be evident

Increased axillary perspiration related to maturity of the apocrine glands

Hair on extremities becomes coarser and darker

Pubic hair develops; secondary sex characteristics

Slide27

Infectious and Non-Infectious Conditions of the Skin

Management and Treatment

Slide28

Common Skin Disorders Seen in the Schools

Impetigo

Varicella

Scabies/Pediculosis

Herpes simplex

Contact dermatitis/eczema

Molluscum Contagiosum

Hand, Foot and Mouth Disease

Fifth’s Disease (erythema infectiosum)

Rubeola /Measles

Stept Infection (Scarletina)

Slide29

Infectious vs. Non-Infectious

History of present illness is very important

Events that preceded the skin condition

Need to rule out trauma

Medication history

Previous outbreak

Fever and any other systemic symptoms

Allergies

Slide30

Eczema

Characterized by : acute inflammation, erythema, edema and vesiculationItching is often severeMultiple causes; allergic contact Common culprits: personal care products, fragrances, detergentsOften sudden in onset

Habif, (2011).

Slide31

Prognosis/Management

Avoid provoking factors; eruption improves in 7-10 daysExcoriation secondary to itching/scratching could develop bacterial infectionTopical steroids (used sparingly and as directed)Oral antihistamines (Benadryl)Treatment often based on elimination of causing factor

Habif, (2011).

Slide32

Allergic Contact Dermatitis

Common T-cell mediated or delayed hypersensitivityAllergens: chemicals, foreign proteins, poison ivyErythema, swelling with itchingVesicular lesions are where contact is madeRemoval is necessary to help with tissue repairSystemic steroids are one form of treatmentAtopic dermatitis: more common in infancy and childhood, usually associated with asthma, allergic rhinitis

McCance & Huether, (

2014).

Slide33

Allergic Contact Dermatitis

Delayed type hypersensitivity reactionCaused by skin contact with an allergenResults in eczematous dermatitisCommon causes include:Metals (nickel)RubberShoesPreservatives in lotions, creams, cosmetics

Habif, (2011).

Slide34

Allergic Contact Dermatitis

Pathologyoutlines.com

Mayoclinic.org

Slide35

Management/ Treatment

Avoidance of the allergenic substanceIdentification of allergen (patch testing)Topical treatment (topical corticosteroids)Choice of topical corticosteroids depends on body site affected (use sparingly on pediatric population)3-week tapering course of oral corticosteroidsEducation of patient/caregiver

Habif, (2011).

Slide36

Pediatric Considerations

Allergies can develop after years of exposure to products/medicationsConsider “patch” testingRe-assessment of recent exposuresAssess the integrity of the skinBe alert for S/S of infection

Habif, (2011).

Slide37

Bacterial Infections of the Skin

Can result from primary skin lesions

Any break in the integrity of the skin

May result in erythema, edema, pain, pus

May result in systemic symptoms such as:

Fever

Malaise

Myalgias

Nausea and vomiting

Slide38

Impetigo

Highly contagious superficial skin infectionCaused by strept or staph80% of cases caused by staph aureusOccurs after minor skin injury, insect biteBacteria may colonize in the nasal passages Warm climates and poor hygiene contribute to itLesions may be localized or wide spread; common on face

Habif, (2011).

Slide39

Skin Findings

Vesicles/pustules presentRed a moist baseErythematousLesions often coalesceDevelop an adherent crust honey-yellow to white-brown in colorThin-roofed bullae may develop

Habif, (2011).

Slide40

Impetigo

Medicinenet.com

Slide41

Pediatric Considerations

Most common bacterial infection in childrenRarely post-streptococcal glomerulonephritis may follow infectionAntibacterial soaps are recommended to be used twice daily for chronic casesBacterial culture may be indicated for chronic cases

Habif, (2011).

Slide42

Treatment/Management

Disease is self-limiting; could spreadLocalized infections: Mupirocin 2% topicalOral antibiotics: doxycycline, clarithromycin, cephalexin (Keflex) x 10-14 days of treatmentRecurrent impetigo may require topical Mupirocin in the naresGood handwashing

Habif, (2011).

Slide43

Viral Infections

Verucca: warts, common benign papillomas; caused by HPV; transmitted by direct contactHerpes simplex: (HSV) infection of skin and mucous membranes; two types HSV 1 and HSV 2; symptoms begin with burning or tingling; umbilicated vesicles and erythemaHerpes Zoster: shingles; acute localized vesicular eruption distributed along dermatomal segment; prevention via Zostavax vaccine

McCance & Huether, (

2014).

Slide44

Verruca Vulgaris

Also known as “warts”Benign epidermal proliferationsCaused by human papilloma virus (HPV)Over 150 different types of HPVTransmission is by simple contact; often on non-intact skinLocal spread is caused by autoinoculationPeak incidence ages 12-16 yrs

Habif, (2011).

Slide45

Skin Findings

Flesh-colored papules evolve into dome shaped, gray to brown, hyperkeratotic , rough papulesCommon sites:HandsSkinPeriungualKnees, plantar surfaces

Habif, (2011).

Slide46

Management/Treatment

Course is highly variableSpontaneous resolution with time2/3 of warts in children regress within 2 yearsMultiple treatments are availableOTC topical salicylic acid preparationsDuration of treatment is usually 8-12 weeksCryotherapyImiquimod 5% cream (Aldara)

Habif, (2011).

Slide47

Herpes Simplex

Double-stranded DNA virus; two virus types (types 1 & 2)Type I associated with vesicular, ulcerative oral infectionsType II associated with genital infectionsPrimary infection can be asymptomaticSpread by respiratory droplets, direct contact with active lesionContact with virus containing fluid: saliva, cervical secretions in people with no active diseaseSymptoms occur 3-7 days after contact

Habif, (2011).

Slide48

Herpes Simplex I & II (HSV-1 and HSV2)

Clinicaladvisor.org

Slide49

Primary Infection

Tenderness, pain, mild paresthesias or burning before onset of lesionGrouped vesicles on erythematous base appear; subsequently erodeLesions on the mucus membrane accumulate exudate; on skin may form a crustLesions last 2-6 weeks and heal without scarring

Habif, (2011).

Slide50

Recurrent Infection

Recurrence rate is same as primary infectionLocal skin trauma, systemic changes (fatigue, fever) reactivate the virusTravels down the peripheral nerve to site of initial infectionProdromal symptoms may last 2-24 hoursMany can experience a decrease in outbreaks with time

Habif, (2011).

Slide51

Management and Treatment

Education on how to prevent transmissionAvoid contact with open lesionsInfections can resolve without treatmentChildren should be advised to avoid sharing drinks, eating utensils; kissingTopical agents may be over-the-counter (OTC) or prescribedAntiviral medications

Habif, (2011).

Slide52

Molluscum Contagiosum

Localized, self-limiting viral infectionTransmitted by self inoculation; skin to skin contactCause is DNA virus of the poxvirus familyMay occur at any age: peaks between 3-9yrs and 16-24Tenderness and itching of lesions may occurTransmitted by close contact

Habif, (2011).

Slide53

Skin Findings

Begins as 1-2 shiny, white to flesh-colored dome shaped firm papuleSmall central whitish umbilication (depression)Untreated lesions persist for 6-9 monthsInflammation surrounding the lesion implies host immune response and nearing resolutionChildren have lesions in the upper trunk, extremities and on face

Habif, (2011).

Slide54

Molluscum Contagiosum

Healthline.com

Description: discrete, pink to flesh colored umbilicated dome-shaped lesions. (Habif, 2011).

Slide55

Management and Treatment

Should be kept covered by clothingMinimize transmission of the virusCurettage to remove fairly painless and decreases recurrenceImiquimod 5% cream (Aldara)***** This lesion in young adults could indicate a sexual transmission. If seen in pediatric population in genitalia suspect for sexual abuse.

Habif, (2011).

Slide56

Pediatric Considerations

Autoinoculation around eye is commonLesions will resolve spontaneously with cell-mediated immunityPrimarily a sexually transmitted disease in young adultsLesions will occur in the lower abdomen, genitalia and thighs

Habif, (2011).

Slide57

Varicella

Highly contagious infectionCaused by varicella virusCaused by human herpes virus type 3Transmission is via airborne droplets or vesicular fluidPatients are contagious 2-days prior to outbreak of lesionsProdromal symptoms include:Low-grade feverHeadacheGeneralized vesicular rash

Habif, (2011).

Slide58

Skin Findings

Simultaneous presentation of lesions in various stages of development (vesicles, pustules, crusts)Begin as 2-4mm red papule, then evolve to a thin-walled clear vesicleVesicle becomes umbilicated; fluid can become cloudyLesions eruption ceases within 4 daysCrusts fall within 7 days

Habif, (2011).

Slide59

Management and Treatment

Symptomatic treatment includes use of bland, antipruritic lotions and antihistaminesHydrationTylenol or ibuprofen for feverCut nails short to avoid self-inoculation or skin infection (impetigo)Varicella vaccine is 96% effectiveSeroconversion is 71-91% in healthy childrenChildren immunized with live attenuated virus may have a mild febrile illness; few vesicles 2 weeks after vaccine

Habif, (2011).

Slide60

Hand, Foot and Mouth Disease

Highly contagious viral infectionCauses aphthae-like oral erosionsVesicular lesions on hands and feetSelf limiting Associated with coxsackie virus A-16Incubation period 4-6 daysSpread is by nose and throat dischargeMild symptoms of sore throat and malaise; abdominal pain 1-2 days20% develop cervical lymphadenopathy

Habif, (2011).

Slide61

Skin Findings

Oral aphthae-like erosions vary 10 or moreCutaneous lesions occur in 2/3 of patientsBegin as 3-7mm red macules, becoming pale, white oval vesicles with red areolaHealing occurs in approximately 7 days

Habif, (2011).

Slide62

Management and Treatment

Children may be isolated during most contagious period (3-7 days)Fever/pain controlled with TylenolCool fluids; acidic food avoidedNeed to keep child well hydratedAntiviral medication

Habif, (2011).

Slide63

Erythema Infectiosum (Fifth’s Disease)

Also known as “slapped cheek” syndromeViral exanthemOccurs mostly in the winter and springCaused by parvovirus B19Transmitted via respiratory secretions, blood or vertically from mother to fetusPeak age is between 5-14 yearsProdromal symptoms: low grade fever, pruritus, malaise, sore throat

Habif, (2011).

Slide64

Skin Findings

Facial erythema (slapped cheek)Red papules on cheeks that coalesce 2-days after onset of facial rash, lacy, erythema in a “fish-net” pattern on trunk and proximal extremities, buttocksFades within 6-14 daysMay appear 2-3 weeks; factors such as sunlight, hot water and emotional/physical activityAdults may experience myalgias

Habif, (2011).

Slide65

Prognosis/Treatment

Exposed pregnant women should seek serological testing and follow up with PCPChild is not considered infectious once rash develops; may return to schoolMost infections are self-limiting without consequenceNSAIDS can control myalgiasControl fever, hydrationPregnant woman exposed should seek OB/GYN care

Habif, (2011).

Slide66

Erythema Infectiosum

Webmd.com

Slide67

Kawasaki Disease

Also known as mucocutaneous lymph node syndrome

Morbidity and mortality associated with cardiovascular complications

Ages range from 7 weeks to 12 years; adult cases rare

Recurrence is rare

Diagnosis based on having the following:

Fever of unknown origin

Bilateral conjuntiva injection

Cervical lymphadenopathy

Exanthem with vesicles and or crusts

Coronary artery aneurysms

Slide68

Skin Findings

Conjunctival injection

Uveitis

Lips and oral pharynx erythematous, dry fissured, cracked and crusted

Hypertrophic tongue papillae

(strawberry tongue)

Extremities (2-5 days) feet become edematous and tender

Desquamation of the hands and feet; peeling of skin

Rash is polymorphous,

macular, papular, urticarial-like lesions; diaper dermatitis

Slide69

Non-Skin Findings

Fever without chills or seats can last 15-30 days

Fever begins abruptly and spikes dos not respond to antibiotics or antipyretics

Cervical lymphadenopathy, often limited to one

Cardiac involvement; myocarditis, tachycardia and arrhythmias

Coronary artery aneurysms

Acute phase leukocytosis

Slide70

Treatment

I.V. immune globulin (IVIG)

Methylprednisolone an alternative to IVIG

Close monitoring of patient

Hydration

Oral care

Rest; control of fever

Slide71

Kawasaki Disease

Slide72

Streptococcal Infection/Scarletina

Posterior pharynx is erythematous

Enlarged palatine tonsils

Cervical lymphadenopathy

Fever, malaise

Post infection:

Skin develops dry sandpaper appearance

Slide73

Pediculosis (head lice)

Flattened, wingless, insects; infest hair of scalp, body and pubic regionAttach to the skin and feed on human bloodLay eggs (nits) on shaft of hairHighly contagiousDirect contact primary source of transmissionLice live about 30 daysFemales lay 7-10 nits dailyLay nits 1cm from scalp

Habif, (2011).

Slide74

Pediculosis

Slide75

Management and Treatment

Standard is topical with Permethrin rinse 1% OTCPermethrin 5% is administered for treatment failuresHome remedies include:Application of VaselineMayonnaise or pomadesApply shower cap and keep overnightHair clean 1-2-3 kills lice on contactOral prescribed treatments; BactrimOral antibiotics for secondary infectionNit removal (may use vinegar with 50% water)

Habif, (2011).

Slide76

Scabies

Parasitic infection caused by mite Sarcoptes scabieiComplaints are of intense itching, unremittingCommon presentation in one member of the familyCan be seen in familiesSkin findings: curved burrow, can be linear and S-shaped; slightly elevated vesicle or papule 1-2mm in sizeCan be found in intertriginous areas, webs of fingers, wrists, sides of hands, feet, lateral fingers and toes. genitalia

Habif, (2011).

Slide77

Management and Treatment

Permethrin or lindane applied to entire skin surface from the neck downPatient should bathe after 12 hours of applicationAvoid eyes and mouthBenzyl benzoate bath and lotionAll clothes must be washed; bed linenPost treatment pruritus can occur Assessment for areas of topical infection from scratching

Habif, (2011).

Slide78

Lyme Disease

Tick-borne disease; Borrelia burgdorferi Evolves through 3 stages; affects almost all organ systemsCutaneous eruption of Lyme disease is called erythema migransOnset of disease is 3-28 days after tick bite3 Stages:Stage I: expanding target like patch; flu like symptomsStage II: cardiac and neurological problemsStage III: arthritis and continuous neuro problems persist

Habif, (2011).

Slide79

Skin Findings

Initial tick bite, inflamed bite reactionTick must stay attached for at least 24 hoursSkin changes (erythema migrans)Begins with a small papule with slowly enlarging ring of erythema20-50% of people have multiple rings

Habif, (2011).

Slide80

Management and Treatment

Prevention of tick bites/exposureWearing protective garmentsFrequent assessment of skinN-diethyl-meta-tolumide on skin/permethrin on clothes (need to check with PCP for safety)Early symptoms of disease treated with 21 days of treatment with Doxycycline, or Ceftin, or AmoxicillinSeek PCP care ASAP

Habif, (2011).

Slide81

Acanthosis Nigricans

Elevated, velvety hyperpigmentation of the flexural skin, neck, axillae and groinCommonly associated with obesity, diabetes, endocrinopathiesPatients complain about an asymptomatic dirty appearance to skin folds; not removed by vigorous washingMay be a family hx of eruption

Habif, (2011).

Slide82

Skin/Non-Skin Findings

AN is a cutaneous marker of tissue insulin resistancePatients without DM have increased levels of circulating insulinGlucose levels may be elevatedImpaired response to exogenous insulinCan be caused by estrogens and nicotinic acidLess common: tumors of the lung, prostate, breast and ovary

Habif, (2011).

Slide83

Acanthosis Nigricans

Nape of Neck

Axilla

Trunk/Axillae

Slide84

Management and Treatment

Skin eruption does not cause require treatmentTreatment is necessary for obesityEvaluation for the presence of diabetesEvaluation of blood pressure, measurement of body mass index (BMI)Goal of therapy is to correct underlying disease processCorrection of hyperinsulemia (metabolic syndrome)Weight reduction

Habif, (2011).

Slide85

Summary

Proper assessment of skin disorder

Assess for system involvement; fever, malaise

Educate children and families on the importance of:

Proper hygiene

Early evaluation by PCP and follow-up

Referral and reporting of communicable diseases

Refer to communicable disease reference chart

Slide86

References

American Diabetes Association (2017).

Standards of medical care in diabetes-2017

.

Diabetes Care: The Journal of Clinical and Applied Research and Education. 40(1),

pgs. 1-142.

Habif, T.P., Campbell, J.L., Chapman, M.S., Dinulos, J.G.H, & Zug, K.A. (2011).

Skin

disease: Diagnosis & Treatment

,

3

rd

Ed. Saunders Elsevier, New York, NY

McCance, K.L., Huether, S.E., Brashers, V.L, & Rote,N.S. (2014).

Pathophysiology:

The biological basis for disease in adults and children

. 7

th

Ed. St. Louis, Missouri.

National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]. (2017).

Retrieved from: http://www.niddk.nih.gov.health-information/diabetes/overview/

Seidel, H.M., Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W.

(2015). Mosby’s Guide to Physical Examination, 8

th

Ed., Elsevier, St. Louis, Missouri.