Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of atopic dermatitis and eczema
- Describe the diagnostic and laboratory values related to specific diseases of the integumentary system
- Apply nursing concepts and plan associated nursing care for the patient with various integumentary disorders
- Evaluate the efficacy of nursing care for patients with integumentary disorders
- Describe the medical therapies that apply to treating various integumentary disorders
The integumentary system is the body’s largest organ. It comprises the skin, hair, nails, and integumentary (exocrine) glands. The exocrine glands secrete their substances through ducts onto the skin’s epithelial surface, whereas endocrine glands release their substances directly into the bloodstream. Some examples of the skin’s exocrine glands are sweat glands and sebaceous glands, which produce sebum, the oil that keeps the skin moisturized. More information about endocrine glands can be found in Chapter 21 Endocrine System and Endocrine System Disorders.
The main function of the integumentary system is to protect the body from outside organisms such as bacteria and viruses. It also helps regulate the body’s temperature (MedlinePlus, 2023). Integumentary conditions may also be called dermatological conditions, given the layers of the skin being discussed. Nurses and health-care professionals encounter various dermatological conditions throughout their careers, and some conditions are more common than others. It is important to understand the causes behind these conditions, their clinical manifestations, and relevant nursing interventions.
Integumentary Anatomy Overview
The skin comprises three layers: the epidermis, the dermis, and the hypodermis (Figure 14.2). The epidermis is the outermost layer, made of epithelial cells, and is the body’s first defense against organisms. The dermis is the middle layer, just below the epidermis, and is made up of connective tissue that supports the epidermis. Lastly, the hypodermis, commonly referred to as the subcutaneous tissue, is the bottom layer that is made of adipose and areolar tissue that cushions the underlying organs (Kim and Dao, 2023).
The hair shaft comes through the epidermis, from the roots in the dermis. Hair and nails are formed from keratin, a skin protein. Sebaceous glands excrete sebum to keep the skin soft and protect against water loss. The sweat glands excrete salt and water to cool the body when its temperature increases (Kim and Dao, 2023). For more information about the skin breakdown and healing, refer to Chapter 28 Inflammation and Healing.
Atopic Dermatitis (Eczema)
A type of eczema, atopic dermatitis (AD) is a chronic skin condition in which a person has a dysfunctional skin barrier that allows outside substances to penetrate the skin easily, which results in dry and red areas of skin. Because it is the most common type of eczema, the two terms are commonly interchanged. Although this condition is more common in children, it is also common in adults (Nemeth & Evans, 2022). According to the Centers for Disease Control and Prevention, 7.3% of adults and 10.8% of children in the United States have atopic dermatitis (Centers for Disease Control and Prevention, 2023).
Pathophysiology
In AD, the skin is more susceptible to pathogens (e.g., bacteria) and is easily irritated by allergens. The skin is also more susceptible to water loss (Nemeth & Evans, 2022).
There are several risk factors for AD, including genetics or a family history of AD, a compromised immune system, and epidermal dysfunction. The full disease process is not entirely clear, and research is ongoing (Kim et al., 2019). However, the prevailing opinion is that a specific gene is linked to development of AD, causing corneocytes (cells that make up the outer layer of skin) in the skin to not be as tightly packed and creating separation in the skin barrier (Nemeth & Evans, 2022). Looking at immune system dysfunction, there is often an imbalance of T cells, which causes cytokine release and inflammatory response. Epidermal abnormalities of the skin’s epithelial cells also contribute to eczema and its symptoms (Kim et al., 2019).
Clinical Manifestations
The most common clinical manifestation of AD is itching, and the patient’s skin may appear scaly (Figure 14.3), with small areas of excoriation, where the skin is broken from scratching and may bleed or ooze in severe cases. Other symptoms may be red and/or dry patches of skin, skin thickening, and lichenification, where the skin becomes thick and leathery over time in an area that is frequently scratched. Atopic dermatitis can occur anywhere on the body, but it is most commonly found where joints are flexed, such as behind the knees and the antecubital fossa, as well as the wrists, ankles, and elbows (Nemeth & Evans, 2022). An AD flare-up can be triggered by allergens or stress, or with no warning.
Assessment and Diagnostics
The nurse will most likely notice small areas on the skin with abnormal redness. The nurse should ask the patient about a familial or personal history of AD and ask if the patient has any specific triggers that cause symptoms. The nurse should also ask about symptom onset, location, duration, and rash characteristics, as well as about alleviating or aggravating factors as well as timing and severity of symptoms.
Usually, a diagnosis of AD is based on the patient’s symptoms and clinical presentation. Laboratory testing is not indicated unless allergens are suspected to be the cause (Nemeth & Evans, 2022). The health-care provider may ask about steroid use or environmental triggers, like cigarette smoke, soaps, or detergents. If a diagnosis is still not clear, the health-care provider may order a skin biopsy of the rash (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2022). If allergies are suspected, the health-care provider may order a scratch test for allergies. If health-care provider suspects immune system problems, tests for immunoglobins, an antinuclear antibody test, or other bloodwork may be helpful. The nurse can look for these results in the patient’s chart.
Nursing Care of the Patient with AD
When caring for a patient with AD, it is important to understand the patient’s past medical history. Be sure to ask the patient if they have a family history of atopic dermatitis, because the condition can be linked to a specific inheritable gene. The nurse can provide both pharmacological and nonpharmacological interventions, with a health-care provider’s order, to assist with symptom relief and treating AD. Pharmacological interventions include topical emollients or antibiotics and oral antihistamines for itching. Nonpharmacological interventions include removing possible triggers and promoting hydration and skin integrity.
Recognizing and Analyzing Cues
The nurse may notice the patient is itchy and has areas of dry skin. Some areas may appear erythematous (abnormally red) and with mild to moderate excoriation. If the patient is scratching the areas frequently, the nurse may recognize skin thickening, oozing, weeping, or bleeding. The nurse should ask the patient the following questions:
- When did the symptoms start?
- Does anything aggravate the symptoms?
- Have you tried any treatments, and have they worked?
- Do you have any known environmental allergies?
- Does anyone in your family have similar symptoms or been diagnosed with eczema?
The patient may mention a specific trigger that causes their skin to break out, such as certain detergents or animal dander; however, there is not always a specific trigger. All the mentioned clinical manifestations can indicate AD, psoriasis, hives, skin allergies, or other skin disorders (Nemeth & Evans, 2022).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority nursing hypothesis related to AD is typically impaired skin integrity. If specific environmental allergens have been identified, the nurse should educate the patient to avoid these. If the triggers cannot be removed or the patient is experiencing itching, the nurse can request an order from the health-care provider for bedtime oral antihistamines. Oral antihistamines are preferred to be administered at bedtime because they act more as a sedative than itch relief; if administered during the daytime, they can cause unwanted drowsiness.
Because AD causes water loss from the skin, hydration is key. The nurse promotes a daily skin-moisturizing routine with oil-based ointments and lotions instead of water-based lotions. Water-based lotions do not hold the skin’s moisture as long as oil-based ointment. Lotions should be fragrance-free because fragrances can sometimes be a trigger to AD. A daily moisturizing regimen may not be enough to help the patient’s skin condition from worsening. Therefore, the nurse would discuss this with the provider and request an order for a topical anti-inflammatory or steroid (Kim, 2023).
Because AD is caused by dysfunction of the skin barrier, the patient is more likely to develop secondary fungal or bacterial infections, such as with Staphylococcus aureus (Nemeth & Evans, 2022). The nurse should frequently examine the patient’s skin for signs and symptoms of infection. Signs and symptoms to look for include increased redness, swelling, and pus or unusual colored discharge from the areas; sometimes, yellow crusts will form over the areas of excoriation (MedlinePlus, 2023). If the nurse notes signs of infection, they should alert the health-care provider, and a topical and/or oral medication may be prescribed to treat for secondary infection. Topical mupirocin is commonly prescribed for bacterial infections and ketoconazole for fungal infections (Nemeth & Evans, 2022).
Evaluation of Nursing Care for the Patient with AD
After the nurse has implemented interventions, they must evaluate their effectiveness. The nurse observes for signs of improvement to the patient’s skin, including no new impairment of skin integrity.
Cultural Context
Skin Tone Variations and Symptom Presentation in Atopic Dermatitis
Atopic dermatitis (AD) can manifest differently depending on the patient’s skin tone. In lighter skin tones, AD typically presents as red, inflamed patches. However, in darker skin tones, these patches may appear darker, greyish, or purplish rather than red. Postinflammatory hyperpigmentation, which leaves dark spots where the eczema was active, is more common in individuals with darker skin tones.
Hair Texture and Scalp Care
Patients with different hair textures may experience atopic dermatitis on the scalp differently. For those with coarser or curly hair, AD symptoms on the scalp might be overlooked due to the density and texture of the hair. Special attention should be given to thoroughly examining the scalp and providing tailored advice on managing scalp dermatitis without causing damage to the hair. This may include recommending specific hair-care routines or products that are gentle on both the skin and hair.
Cultural Practices and Treatment Adherence
Cultural beliefs and practices can influence how patients perceive and manage AD. Some cultures may prefer natural or home remedies versus prescribed medications, which can affect treatment adherence. Nurses should engage in open, respectful conversations to understand the patient’s cultural preferences and integrate culturally acceptable treatment options. Providing education on the effectiveness and safety of prescribed treatments while also respecting traditional practices can enhance adherence and outcomes.
Effect on Nurse-Patient Communication
Effective communication is essential for understanding and addressing cultural differences in managing AD. Nurses should use culturally sensitive language and ask open-ended questions to better understand the patient’s experiences and preferences. Providing educational materials in the patient’s preferred language and considering literacy levels can also improve aid understanding and management of the condition.
Evaluating Outcomes
When evaluating desired outcomes, the nurse should ensure that the patient’s AD is improving. The patient would report decreased itching, and the areas of healing AD would show decreased redness. If the patient had previous signs of infection, the nurse would expect the patient’s skin to improve in appearance, showing decreased redness, swelling, and discharge from the infected areas. The nurse would still encourage a daily moisturizing regimen for the prevention of AD flares (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2022).
Medical Therapies and Related Care
Suppose symptoms do not seem to be improving or are worsening. In that case, the nurse can also recommend that the provider refer the patient to a dermatologist, who is a doctor specializing in treating skin disorders. If an allergy is suspected to be triggering AD flares, the nurse should be aware that the patient may need to see an allergist. Sometimes AD can lead to secondary infections; in those cases, the nurse should ask for help from a wound care or infectious disease provider (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2022). To promote wound healing, the nurse can also seek recommendations from a nutritionist. A high-protein diet can promote wound healing, as can dietary supplements. The nutritionist may also be able to identify foods that are causing skin reactions. Some common foods are wheat, eggs, and dairy products (Bemak, 2018).
Psoriasis
The chronic dermatological disorder characterized by the proliferation of skin cells and chronic inflammation is called psoriasis (Nair & Badri, 2023) (Figure 14.4). It affects more than 7.5 million people in the United States, about 3% of the population (Armstrong et al., 2021).
Pathophysiology
Psoriasis is characterized by the proliferation of skin cells, specifically keratinocytes, which are activated by T cells infiltrating the skin. The proliferation of keratinocytes causes thickened skin or areas of thick plaques to form. A plaque is a raised lesion on the skin. This can lead to epidermal hyperplasia, thickening of the epidermis, and parakeratosis, a condition in which keratinocytes do not fully reach maturity. It also causes a skin inflammatory immune response through the cytokine response (Nair & Badri, 2023).
Psoriasis is an autoimmune disorder. An autoimmune disorder occurs when the body attacks its own cells and natural defenses. Because this condition affects the entire body, people with psoriasis may present not only with skin issues but also joint pain, nail changes, and poor sleep. It has also been linked to several inherited genes (Rendon & Schakel, 2019). The pathogenesis of psoriasis is unclear, although there is some indication that triggers (e.g., allergies, stress, dry skin, injuries) can potentiate a flare (MedlinePlus, 2022).
Clinical Manifestations
There are many types of psoriasis; the most common is plaque psoriasis. When observing plaque psoriasis, there are often well-defined thick patches of reddened skin with a silverly scale appearance. Common areas where plaque psoriasis is found are the elbows and knees, but it can be found anywhere on the body, like the scalp and soles of the feet (MedlinePlus, 2022). Other types of psoriasis will present with varying signs (e.g., itching, dry or scaly skin, joint achiness, thickened nails), depending on the type of psoriasis (Nair & Badri, 2023). These are summarized in Table 14.1.
| Type | Clinical Manifestation | Common Location(s) | Image |
|---|---|---|---|
| Plaque psoriasis | Dry, itchy, raised skin plaques Varies in number Varies in color |
Elbows, knees, lower back, scalp |
(credit: CDC/ Dr. N.J. Fiumara/Public Health Image Library, Public Domain)
|
| Nail psoriasis | Nail pitting Abnormal nail growth Nail discoloration Nail separation from nail bed (onycholysis) Crumbling nails |
Fingernails, toenails |
(credit: “Psoriasis fingernail” by “Fluzwup”/Wikipedia, Public Domain)
|
| Guttate psoriasis | Small, drop-shaped scaling spots | Trunk, arms, legs |
(credit: modification of “Figure 1 Small, red, drop-like lesions of Guttate psoriasis located at the hand (A)” by Theocharis Koufakis and Ioannis Gabranis/National Library of Medicine, CC BY 2.0)
|
| Inverse psoriasis | Inflamed, smooth patches | Groin, buttocks, breasts |
(credit: CDC/ Dr. Gavin Hart/Public Health Image Library, Public Domain)
|
| Pustular psoriasis | Pus-filled blisters Varies in patch size |
Palms, soles |
(credit: Roland Tanglao/Flickr, CC BY 2.0)
|
| Erythrodermic psoriasis | Peeling rash Itchy or burning Short or long-term |
Entire body |
(credit: CDC/ Public Health Image Library, Public Domain)
|
Assessment and Diagnostics
While assessing the skin, the nurse can recognize psoriasis by identifying well-defined thick patches of reddened skin with a silvery scale appearance. Because psoriasis has a genetic component, the nurse should ask the patient about any familial history of psoriasis or skin conditions. The nurse asks if anything triggers the patches to appear or itch and if the patient has any autoimmune disorders. Some laboratory tests the health-care provider may have already ordered are a complete blood cell count (CBC), rheumatoid factors, erythrocyte sedimentation rate (ESR), and uric acid level. The nurse can look for previous results in the patient’s chart.
Typically, a diagnosis of psoriasis is based on the patient’s symptoms, clinical presentation, and how the skin condition appears, such as whether it is macular or popular. A skin biopsy may be taken for an accurate diagnosis, because psoriasis can resemble other skin conditions. The health-care provider can order additional blood tests to help determine the cause or exact etiology; these tests may include renal and liver function panels, a pregnancy test, and hepatitis serology (Nair & Badri, 2023). Elevated rheumatoid factor level, uric acid levels, and ESR can indicate psoriasis.
Nursing Care of the Patient with Psoriasis
When caring for patients with psoriasis, the nurse recognizes and analyzes patient cues and implements nursing interventions. Nursing care for patients with psoriasis involves recognizing and analyzing various patient cues, including skin assessment, symptom severity, and psychosocial effects. Interventions focus on skin care management with moisturizers and topical treatments, systemic and phototherapy monitoring, and symptom-relief strategies for itching and pain. Nurses also provide education on trigger avoidance and healthy lifestyle modifications, and offer psychosocial support through counseling and support groups. By coordinating with interdisciplinary teams and advocating for patients, nurses ensure comprehensive care that improves patient outcomes and quality of life.
Link to Learning
Health-care providers often use the Psoriasis Area and Severity Index (PASI) tool to determine the severity of a patient’s psoriasis when prescribing medication and appropriate treatment. This helps determine and guide the appropriate treatment. Nurses can use this also use this tool as a reference to help guide their nursing interventions and expected outcomes. They can look through the health-care providers notes to determine the patient’s PASI score.
Recognizing and Analyzing Cues
The patient may report itchy and dry skin. The nurse should assess the patient for psoriatic plaques on the elbows, knees, or other areas of the body and ask the patient about their family history of skin disorders. The nurse can ask the patient when the symptoms started, if they are reoccurring, and if there are any specific triggers. They can also ask what treatments the patient has tried and if they helped (Nair & Badri, 2023). If the patient reports a familial history of psoriasis and the nurse notices the silvery patches of skin, this may indicate the patient has a form of psoriasis.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority nursing hypothesis for psoriasis is impaired skin integrity. Both pharmacological and nonpharmacological interventions are aimed at providing symptom relief and treatment. The nurse promotes a daily skin moisturizing routine with oil-based emollients and moisturizers to create a skin barrier and aid skin healing. Topical treatments, such as ointments or creams, are used in mild cases of psoriasis. Some examples include cortisone creams, coal tar, retinoids, or dithranol. Coal tar is a medicine used to help with skin itching and dryness by slowing skin cell growth (Nair & Badri, 2023).
Another treatment the provider might prescribe is phototherapy, which is ultraviolet light exposure to the skin. The nurse would ensure the patient receives this treatment by coordinating with the health-care team for phototherapy scheduling. For more severe cases of psoriasis, a systemic medication (e.g., methotrexate) may be prescribed by the provider to suppress the patient’s immune system. Because psoriasis is an autoimmune condition, suppressing an inflammatory response with medications can help resolve symptoms. Some providers may also prescribe biologics, like infliximab or adalimumab (MedlinePlus, 2022). If the patient is prescribed any systemic medications, the nurse would administer these as prescribed and monitor the patient’s liver and renal function, because these medications can increase values of biomarkers (e.g., alanine aminotransferase [ALT] levels, ESR). If the patient’s immune system is impaired, infections are more likely to develop (Nair & Badri, 2023). Therefore, the nurse would also monitor for serious infections like tuberculosis and hepatitis.
Link to Learning
Read this article to learn more about biologics and their role in treating psoriasis.
If the patient has identified specific triggers such as cold and dry conditions, drinking excessive amounts of alcohol, or stress, the nurse should educate the patient to avoid these. The nurse should educate the patient on stress-reducing techniques that can reduce psoriasis flares (MedlinePlus, 2022). The nurse should also educate the patient about worsening symptoms (e.g., redness, swelling, unusual discharge) to monitor that might indicate infection due to impaired skin integrity. If the patient or nurse notices any of these issues, the nurse should alert the health-care provider, who may prescribe topical antibiotics, such as mupirocin (Nair & Badri, 2023).
Evaluation of Nursing Care for the Patient with Psoriasis
Once the nurse has implemented pharmacological and nonpharmacological interventions, they must evaluate the effectiveness of the interventions. The nurse observes signs of improvement to the patient’s skin and symptoms and assesses for no new or worsening signs of impaired skin integrity.
Evaluating Outcomes
Psoriasis is a chronic disease, meaning the patient will have periods of remission, when they have little to no symptoms. The nurse should see a desired outcome of treatment, including skin healing, improvement of patchy areas, and decreased skin thickness, redness, and scaly appearance. The patient’s skin should also not show any signs or symptoms of infection, impaired skin integrity, or inflammation. If the patient was prescribed any medications, the nurse should reinforce medication compliance by educating the patient on the importance of continuing the treatment regimen. If the patient is taking systemic medications, the nurse would expect the patient’s renal and liver function test results to be within normal limits. Renal function tests might include glomerular filtration rate (GFR) or creatinine level. Liver function tests include measuring ALT, aspartate aminotransferase (AST), and alkaline phosphatase (ALP) levels to make sure liver function is not impaired while the patient is receiving biologic medications. In addition, the patient would not show any signs of serious infection, like tuberculosis or hepatitis (Nair & Badri, 2023).
If additional areas of psoriasis form or worsening of symptoms or erythema are noted, the nurse should alert the health-care provider and suggest additional treatment, like adding systemic medication, if not already prescribed. The nurse would also evaluate the effectiveness of their education, ensuring the patient understands the importance of adhering to medications and avoiding triggers (Nair & Badri, 2023).
Medical Therapies and Related Care
Treatment of psoriasis often involves a dermatologist; if the patient has not already been referred to one, the nurse may suggest a referral. Psoriasis can cause secondary infections that may require assistance from a wound care nurse or infectious disease specialist, especially if the patient takes biologics or systemic medications. If an allergy is a suspected trigger, the nurse sends a referral to an allergist from the health-care provider. Depending on the area and type of psoriasis, additional referrals to a rheumatologist for autoimmune causes, and nephrologist, for kidney causes, may be warranted. If the patient’s psoriasis is around or near the eyes, a referral to an ophthalmologist is needed (Nair & Badri, 2023).