Chapter 30

The Child with a skin condition

Chapter 30

Skin Development and Function

1. Main function is protection
2. Acts as body’s first line of defense against disease
3. Prevents passage of harmful physical and chemical agents
4. Prevents loss of water and electrolytes
5. Can regenerate and repair itself
6. Along with the central nervous system, there are four basic skin sensations
1. Pain
2. Temperature
3. Touch
4. Pressure
7. Secretes sebum
8. Surface of skin is acidic
1. Protects from pathological microorganisms

Skin Disorders and Variations

Skin condition may be a manifestation of a systemic disease; others may be congenital

• Skin color is an important diagnostic criterion in certain diseases
• Skin tests can be used to diagnose allergies
• Hair is inspected for color, texture, quality, distribution, and elasticity
• Condition of hair can change based on nutrition or disease status
• Hair can change because of medications or medical treatments
• Managing itching is a key component in preventing secondary infection caused by scratching
• Applying skin creams and ointments as prescribed is important, not only in the treatment of skin conditions but also in the prevention of infections

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The nurse should describe the lesions with regard to:

Port Wine Nevus

Strawberry Nevus

• Common hemangioma
• Consists of dilated capillaries in the dermal space
• Usually disappears without treatment
• May not be apparent until a few weeks after birth
• Begins flat but becomes raised, bright red, elevated, and sharply demarcated

• Present at birth
• Caused by dilated dermal capillaries
• Lesions are flat, sharply demarcated, and purple to pink
• Different from strawberry nevus in that the lesion darkens as child gets older, it does not disappear

• Size
• Color
• Configuration
• Presence of pain or itching
• Distribution
• Generalized or localized
• Condition of skin around lesions

Skin Manifestations of Illness

Butterfly Rash

Hypopigmented macules

Café au lait macules

• Over nose and cheeks
• Associated with photosensitivity
• May be associated with systemic lupus erythematous (SLE)

• Whitish oval or leaf shaped
• Multiple macules associated with tuberous sclerosis

• Light brown, oval patches
• Multiple macules are associated with neurofibromatosis (a chromosomal abnormality) and tuberous sclerosis

Skin Manifestations of Illness

Scaling Skin Eruption

Vascular Birthmark

Stye

• Around mouth in a horseshoe-shaped distribution
• Also seen on chin, cheeks, or as a perianal rash
• Has papules and scales
• Associated with zinc deficiency in infants, as well as diarrhea and failure to thrive

• Resembles a bruise that changes in appearance over the years
• Hemangiomas around the chin may be associated with airway problems
• Those appearing around the lumbar region may be associated with spinal problems

• A stye, or hordeolum, is an inflammation of the sebaceous gland of the eyelid commonly seen in infants and children

Skin Infections

• Miliaria
• Intertrigo
• Seborrheic dermatitis
• Diaper dermatitis
• Acne Vulgaris
• Herpes simplex, type I

Infantile Eczema

Atopic dermatitis is an inflammation of genetically hypersensitive skin

• Spongiosis or breakdown of dermal cells and formation of intradermal vesicles
• Rarely seen in breastfed infants until they begin to eat additional food
• It is a symptom rather than a disorder
• Infant is oversensitive to certain substances
• Worse in winter
• Lesions are easily infected by bacterial or viral agents
• Infants and children with eczema should not be exposed to adults with cold sores because they may develop a systemic reaction with high fever and multiple vesicles on the eczematous skin
• May flare up after immunizations
• Lab studies show increased IgE and eosinophil levels.

Parent Teaching

Ointments should be completely washed off between applications

Elbow restraints can prevent an infant from scratching while allowing freedom of movement

Best absorbed after a warm bath

Applied by stroking in direction of hair growth

Cortisone creams should be avoided because they do not resolve the underlying cause

Topical steroids should not be used when a viral infection is present

Staphylococcal Infection

• Primary infection may develop in a newborn in the umbilicus or circumcision wound.
• May occur while in hospital or after discharge
• Infection may enter bloodstream, leading to septicemia.
• Small pustules on a newborn must be reported immediately.
• Antibiotic ointments are used in some situations; in others, intravenous antibiotics are required.
• If an infant has MRSA, the child is placed in contact isolation if hospitalized.

Scalded Skin Syndrome

Caused by Staphylococcus aureus

• Lesions begin with a mild erythema with a sandpaper texture
• Vesicles appear, and rupture and peeling occur, exposing a bright-red surface
• Skin appears scalded, and child abuse is often suspected
• Generally heals without scarring

Impetigo

• Caused by staphylococci or group A beta-hemolytic streptococci
• Bullous form seen in infants usually staphylococcal
• Nonbullous form seen in children and young adults
• Newborns susceptible because resistance to skin bacteria is low
• Very contagious
• Treatment is either oral or parenteral antibiotics

Fungal Infections

• Invade stratum corneum, hair, and nails
• Fungi are larger than bacteria
• Tinea capitis—alopecia
• Tinea corporis—oval scaly inflamed ring with clear center
• Tinea pedis—lesions are between toes, on instep and soles; pruritic
• Tinea cruris—“jock itch”

Pediculosis

Hair Thining-Traction Alopecia

Scabies

• Parasitic
• Caused by female mite
• Burrows under skin and lays eggs, especially between fingers
• Burrows contain eggs and feces
• Itching is intense, especially at night
• Thrives in moist body folds
• Spread by close personal contact
• Treatment is the application of permethrin
• All family members and the home and car require treatment

Three types

1. Pediculosis capitis—head lice
2. Pediculosis corporis—body lice
3. Pediculosis pubis—pubic lice, known as crabs

Survival of lice depends on blood extracted from infected person

• Hairstyle trends contribute to traction alopecia
• When gel, pomades, or oils are used, hair follicles can be blocked causing inflammation resulting in scarring & loss

Trichotillomania

• Hair loss caused by compulsive hair pulling & twisting for purpose of relieving tension

Burns

Thermal

Chemical

Electrical

Caused by fire or scalding vapor or liquid

Caused by corrosive powder or liquid

Caused by electrical current passing through the body

• Child should be assessed for entry and exit lesions
• Indicates path of electricity through the body
• Muscle damage can occur

Children’s Response to Burns

1. Skin is thinner, leading to more serious depth of burn with lower temperatures and shorter exposures.
2. Immature response systems in young children can cause shock and heart failure.
3. Large body surface area of child results in greater fluid, electrolyte, and heat loss.
4. Increased BMR results in increased protein and calorie needs
5. Smaller muscle and fat content in the body results in protein and caloric deficiencies when oral intake is limited.
6. Skin more elastic, causing pulling on the scarring areas and resulting in formation of a larger scar.
7. Immature immune system predisposes child to developing infections that complicate burn treatment.
8. Prolonged immobilization and treatment are required for burns adversely affects growth and development.

Types of Burns

Both types are considered open wounds that have the added danger of infection

Moderate

• Partial-thickness burns involving 15% to 30% of body surface
• Full-thickness burns involving less than 10% of body surface

Major

• Partial-thickness involving 30% or more of body surface
• Full-thickness burns involving 10% or more of body surface

The 6 Cs of Burn Care

1. Clothing
2. Cooling
3. Cleaning
4. Chemoprophylaxis
5. Covering
6. Comforting (pain relief)

Emergency Care

• Establish an airway
• Cyanosis, singed nasal hair, charred lips, and stridor are indications that flames may have been inhaled
• An endotracheal tube may be inserted to protect the airway
• Establish an intravenous line
• Obtain blood and other body fluids for laboratory testing
• A nasogastric tube may be inserted to empty stomach and prevent complications

Wound Care

• Can be painful; pain medications should be given in advance of the treatments to ensure adequate pain control is achieved.
• Cleansing and débridement
• Loss of skin increases threat of infection and fluid loss caused by evaporation can be significant

Nursing Care

1. Immediately report signs of infections
2. Observe for fluid overload
3. Burn victims have an increased demand on metabolism and require high-protein diet; additional vitamins and minerals may also be required
4. Prevention of contractures is important
5. Providing emotional support to the child and family is essential

1. Protective isolation is instituted
2. All instruments are sterile
3. Ointments are applied with a sterile gloved hand or sterile tongue depressor
4. Care must be taken to avoid injury to granulating tissue

1. Exercise of the unaffected parts
2. Proper positioning to avoid contractures
3. Change position every 2-4 hours
4. Regular physical therapy

Sunburn

Common skin injury caused by overexposure to sun

• Can be minor epidermal burn to serious partial-thickness burn with blisters
• Goal of treatment
• Stop exposure
• Treat inflammation
• Rehydrate skin

Sunscreen and Sunblock

Sunscreen

• Topical partially absorbs UV light
• Have an SPF rating to evaluate effectiveness in blocking sun rays

Sunblock

• Reflects sunlight
• Zinc oxide and titanium dioxide are effective

Frostbite

Results from freezing of a body part

• Chilblain: a cold injury with erythema and formation of vesicles and ulcerative lesions that occur as a result of vasoconstriction
• In exposure to extreme cold, warmth is lost in the periphery of the body before the core temperature drops
• In extreme cases, the head and torso should be warmed before the extremities to ensure survival
• A deep purple flush appears with the return of sensation, which is accompanied by extreme pain
• Can result in necrosis and may require amputation of the affected extremity