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Chapter 37
Dermatologic Disorders
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Anatomy and Physiology

Epidermis – thin outer layer
➢ Five layers of stratified squamous epithelium
➢ Keratinocytes comprise most epidermal cells
➢ Melanin produced in basal layer

Dermis – thick middle layer
➢ Regulates heat loss
➢ Provides host defenses
➢ Aids in nutrition/regulatory functions

Subcutaneous layer
➢ Primarily adipose tissue
➢ Contains arteries/arterioles for thermoregulation
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2
Anatomy and Physiology

Skin appendages – hair, nails, sweat and
sebaceous glands
➢ Terminal hair – scalp, axillae, pubis
➢ Vellus hair – on remainder of body
➢ Nails – keratin – grow continually
➢ Three types of sweat glands
• Eccrine – entire body; maintain fluids/lytes/temperature
• Ceruminous – external ear canal
• Apocrine – axillary, genital, periumbilical – body odor
➢ Sebaceous glands – secrete sebum/prevent
excessive evaporation, minimize heat loss, lubricate
skin
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3
Pathophysiology and Defense
Mechanisms

Disruption of skin/subcutaneous tissue
➢ Bacterial, fungal, viral infections
➢ Allergic and inflammatory reactions
➢ Infestations
➢ Vascular reactions
➢ Papulosquamous and bullous eruptions
➢ Congenital lesions
➢ Hair and nail disorders
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4
Pathophysiology and Defense
Mechanisms

Three cutaneous reactions to trauma, infection,
inflammation
➢ Pigment lability – postinflammatory hypo- or
hyperpigmentation; may be temporary or permanent
➢ Follicular response – prominent papule and follicle
formation
➢ Mesenchymal response – scarring, keloids
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5
Special Considerations in Children with
Dark Skin

Preventive care
➢ Immunize for varicella to prevent scarring
➢ Use insect repellants
➢ Treat pruritic/inflammatory conditions early
➢ Reduce causes of traction alopecia
➢ Use moisturizing agents/eliminate soaps if dry skin
➢ Use oral antipruritics for dry, itchy skin
➢ Caution about use of topical medications
➢ Avoid trauma/procedures that induce keloids
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6
Special Considerations in Children with
Dark Skin

Cutaneous reaction patterns
➢ Pigment lability common
➢ Keloids/hypertrophic scars frequent
➢ Lichenification, vesicular/bullous reactions occur

Normal variations and common problems
➢ Color/texture may vary from one part of body to another
➢ Pigmentation of mucosa/nails correlates with cutaneous
pigmentation
➢ Increased melanin in thicker-skinned areas
➢ Line of differentiation between hyperpigmented dorsal/extensor
surfaces and less-pigmented ventral surfaces
➢ Mongolian spots/café au lait spots
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7
Special Considerations in Children with
Dark Skin

Normal variations and common problems (Cont.)
➢ Normal exfoliation produces gray scales
➢ Color alterations difficult to assess
➢ Erythema may appear as purple tinge
➢ Tightly curled hair tangles when dry/mats when wet
➢ Atopic dermatitis with pityriasis alba and
postinflammatory hypopigmentation
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8
Special Considerations in Children with
Dark Skin

Cultural/ethnic practices with skin sequelae
➢ Hair pomade – acne
➢ Bleaching creams – discoloration, erythematous
nodules
➢ Chemical/thermal hair straighteners – alopecia
➢ Tightly braided hair – traction folliculitis
➢ Henna – orange discoloration of skin
➢ Decorative practices – scars
➢ Coining/cupping – ecchymoses
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9
Assessment of the Skin and
Subcutaneous Tissue

History
➢ Onset, duration
➢ Original appearance of lesions/treatments
➢ Associated symptoms
➢ Exposures, medications, allergies

Physical examination
➢ Examination of entire body
➢ Good light/Wood’s lamp
➢ Location, type, color, pattern, distribution

Diagnostic studies
➢ Scrapings of skin for microscopic examination
➢ Microbial cultures
➢ Biopsies/patch testing
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10
MANAGEMENT STRATEGIES
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11
Hydration and Lubrication
Bathing – lukewarm water long enough for skin
to become moistened; pat skin dry
 Environmental considerations – humidity;
greater than 90% can macerate skin. Water
consumption helps hydrate skin
 Skin care agents

➢ Soaps, oils, colloids – non-allergic, mild best
➢ Moisturizers and lubricants – retain water in skin
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12
Hydration and Lubrication

Wet dressings
➢ Moisturize skin, decrease itching, remove crusts
➢ Should be moderately wet/lukewarm water
➢ Apply 10-20 minutes 2-4×/day
➢ Saline, Burow solution used
➢ Apply creams/ointments after wet dressings

Occlusive dressings
➢ Decrease water evaporation
➢ Enhance hydration and absorption of medications

Other considerations
➢ Avoid irritants – wool, sweat, saliva
➢ Milk, eggs, wheat, tomatoes, citrus, chocolate, fish, nuts most
common food allergens
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13
Sunscreens and Sunblocks
Protect skin from UV light
 Daily application of sunscreen with SPF of 30
 Chemical-containing sunscreens applied 30
minutes before exposure to allow binding to
stratum corneum
 Reapply after swimming, perspiring, washing
 Never a substitute for sun protection

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14
Medications

General considerations
➢ Usually topical medications
➢ Restore hydration, alleviate symptoms, reduce inflammation,
protect skin, reduce scale/debris, clean, eradicate organisms
➢ Must consider preparation – stabilizers, preservatives, perfumes
➢ Acute inflammation – wet dressings, powders, suspension
lotions, alcohol- or water-based lotions, aerosols
➢ Chronic inflammation – creams, oil-based lotions/gels, ointments
➢ Patient’s tolerance for/willingness to use
➢ Dry or humid environment
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Medications

Antibacterial agents
➢ Soap, antibacterial soap, topical antiseptics
➢ Avoid neomycin – contact sensitization
➢ Oral antibiotics for more severe infections
➢ Culture/sensitivity if MRSA suspected

Antifungal agents
➢ Many topical antifungal agents are OTC
➢ Oral agents – hair, nail, refractory skin infections
➢ Use oral agents with caution in children
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16
Medications

Antiviral agents
➢ Topical antivirals – cutaneous herpes
➢ Oral antivirals – shorten course; treat recurrent
➢ Wart therapy agents – destroy keratinocytes

Anti-acne agents
➢ Topical keratolytics – relieve follicular obstruction
• First-line – benzoyl peroxide/retinoic acid
• Combine with other agents for moderate to severe
➢ Topical antibiotics
➢ Systemic antibiotics
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Medications

Anti-inflammatory agents
➢ Topical glucocorticoids (Table 37-1)
• High potency
• Moderate potency
• Low potency
• Nonfluorinated are less potent/fewer side effects
➢ Key to use – be familiar with a few low-, medium-,
and high-potency steroids/use consistently
➢ Potency: ointments > creams > lotions
➢ Rare use of high-potency recommended
➢ Only low-potency on face, buttocks, groin, axillae
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18
Medications

Anti-pruritic agents
➢ Antihistamines for sedation/to relieve itching
➢ Avoid topical antihistamines – contact sensitization

Topical calcineurin inhibitors
➢ Immunosuppressive, nonsteroidal
➢ Expensive; do not use in children
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