Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of various dermatologic conditions
- Describe the diagnostic tests used and laboratory values observed in dermatologic conditions
- Apply nursing concepts and plan associated nursing care for the patient with varying dermatologic conditions
- Evaluate the efficacy of nursing care for patients with various dermatologic conditions
- Describe the medical therapies that apply to treating various dermatologic conditions
Over the span of their careers, nurses will encounter various dermatologic disorders and conditions. Dermatologic disorders often only involve the skin and its layers, whereas integumentary disorders can involve the skin and its accessories, like hair, nails, and glands. As a nurse, it is important to be able to differentiate and understand the treatment of common skin conditions to provide quality patient care. For any slight changes in the patient’s condition, the nurse should think about the most likely cause or condition. The nurse will also educate patients on risk factors, prevention, treatment, and follow-up care.
Contact Dermatitis
Inflammation or irritation of the skin is called dermatitis. There are several different types of dermatitis, including contact, seborrheic, and generalized exfoliative dermatitis. Each has different signs and symptoms.
Inflammation of the skin caused by direct contact with an irritant or allergens is called contact dermatitis. Allergic contact dermatitis occurs in approximately one in five people, making it a very common skin disorder. Some common agents causing contact dermatitis are latex, poison ivy, metals, and certain plants (Adler & DeLeo, 2021).
Pathophysiology
When a patient’s skin is exposed to irritants, cytokines are released, causing an inflammatory response and skin barrier disruption. In allergic contact dermatitis, exposure to an allergen causes the skin’s T cells to activate and the skin to react (Litchman et al., 2023). The allergic reaction is discussed in greater detail in Chapter 24 Management of Patients with Allergic Disorders.
Clinical Manifestations
Clinical manifestations of contact dermatitis include itching, stinging, and pain at the site where the contact occurred. Contact dermatitis commonly occurs on the hands but can occur anywhere on the body if an irritant is exposed to the skin. Depending on the stage of exposure (i.e., acute, subacute, chronic), contact dermatitis may appear differently (Figure 14.10). In the acute phase, the skin will be erythematous and have vesicles, or blisters, which are small, thin-walled sacs with filled with clear fluid. In the subacute phase, crusts may have formed over the acute lesions. During the chronic phase, lichenification (thick and leathery appearance of the skin) occurs (Litchman et al., 2023).
Assessment and Diagnostics
Depending on the stage of the contact dermatitis, the patient’s skin will look different. The nurse can determine the stage based on the assessment.
Diagnosis of contact dermatitis is often made by presenting symptoms and a thorough history. Usually, the patient will state they have a new exposure to a certain allergen or irritant. To fully diagnose contact allergic dermatitis, patch testing is the gold standard. Patients have several patches applied to their back with common or possible irritants and, after 48 hours, the patches are removed. The health-care provider or allergist then determines the allergy based on the skin test results (Litchman et al., 2023).
Nursing Care of the Patient with Contact Dermatitis
When caring for a patient with contact dermatitis, it is important to obtain a thorough history because this often points to an irritant or allergen. After the patient is diagnosed with contact dermatitis by the health-care provider, the nurse will provide pharmacological and nonpharmacological interventions. Some interventions are identifying the allergen, alleviating itching, and applying topical creams for inflammation and itching.
Recognizing and Analyzing Cues
When recognizing cues, the patient may report recent exposure to a new chemical, irritant, or allergen (e.g., dermatitis develops after wearing latex gloves for the first time). The nurse may look at the affected area and note erythematous and swollen skin. There may also be vesicles or pustules present, and the patient may complain of itching (Litchman et al., 2023). When analyzing these cues and reviewing the patient’s history, the nurse may find that the patient had a new exposure to a known or unknown irritant.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Typically, the priority nursing hypothesis for contact dermatitis is impaired skin integrity. The nurse will generate solutions related to impaired skin integrity, starting with eliminating the known or suspected irritant or allergen. The nurse would also apply prescribed topical corticosteroids to the affected area(s). To help with itching, the nurse may administer antihistamines, like cetirizine. If the contact dermatitis is from an allergen, the nurse would anticipate patch testing and potentially apply or assist with applying the patches. The nurse would also instruct the patient to avoid any friction to prevent further irritation to the area and to wear clothing to cover the affected area (Litchman et al., 2023).
Evaluation of Nursing Care for the Patient with Contact Dermatitis
After the nurse has implemented their actions, they will evaluate the effectiveness of the interventions. An expected outcome would be for the irritant to be identified and the patient’s skin to begin to heal and appear less irritated.
Evaluating Outcomes
When evaluating outcomes, the nurse would expect the patient’s skin to appear nonerythematous, with no swelling or itching present. The vesicles or pustules should be resolved or in various stages of healing. The nurse should also anticipate the irritant to be identified and the patient to discontinue use of or contact with the known substance.
Medical Therapies and Related Care
Once the irritant or allergen is removed and treatment is initiated, the patient’s symptoms will resolve and no further referral is needed. However, if an allergen is suspected, the patient may need to be referred to an allergist for testing. Depending on the severity of the rash, the patient may need a referral to a dermatologist.
Generalized Exfoliative Dermatitis (Erythroderma)
Inflammation of the skin causing erythema and scaling covering 90% of the body’s surface area is called generalized exfoliative dermatitis, or erythroderma. When severe enough, this condition is life-threatening. Although rare, this skin condition can be caused by many factors, including underlying skin disorders, infection, medications, or malignancy (Austad & Athalye, 2023).
Pathophysiology
The exact pathophysiology of exfoliative dermatitis is not known. Underlying skin conditions, such as psoriasis, atopic dermatitis, and contact dermatitis, seem to be major contributing factors to the development of this disorder. Generalized exfoliative dermatitis is thought to be an inflammatory-mediated response, resulting in rapid epithelial cell turnover (Harper-Kirksey, 2018).
Clinical Manifestations
Clinical manifestations of erythroderma are red patches that appear on the skin, covering 90% of the body. After they appear, the skin starts to scale and flake off. Because this condition affects a large portion of the body skin, it is considered life-threatening, and the patient’s condition should be managed in a hospital setting. The patient will also complain of itching and may have a fever, along with an enlarged spleen, liver, and lymph nodes. In some cases, patients lose their hair, and their nails will shed and become ridged (Austad & Athalye, 2023).
Assessment and Diagnostics
When assessing a patient, the nurse will notice diffuse erythematous skin with scaling and peeling. The nurse will obtain a thorough patient history, including information about when the symptoms started. Information about the patient’s medications, allergies, present skin conditions, and other related information may be helpful in determining the underlying cause (Harper-Kirksey, 2018). The nurse will also complete any diagnostic tests ordered by the health-care provider, such as a CBC, CMP, ESR, and C-reactive protein (CRP) level.
After completing a thorough history, the nurse can expect the health-care provider to order several diagnostic and laboratory tests. The provider may order a skin biopsy, histology, blood cultures, CBC, CMP, and imaging to help identify the underlying cause. Depending on the underlying condition, the patient may have an elevated WBC count, CRP level, and ESR. The laboratory tests may also show anemia, eosinophilia (excess eosinophils), or other abnormal values. Skin biopsy samples may show mites or other organisms. Imaging, like a chest x-ray, may show malignancies or sarcoidosis, an inflammatory disease in which the immune system overreacts. Blood cultures may reveal infections or viruses (Harper-Kirksey, 2018).
Nursing Care of the Patient with Generalized Exfoliative Dermatitis
When caring for a patient with generalized exfoliative dermatitis, it is important to complete a thorough history of the patient. The nurse must also be aware that this condition is potentially life-threatening and interventions must be provided as ordered.
Recognizing and Analyzing Cues
The patient may report skin itching and may reveal underlying skin conditions like psoriasis or eczema, malignancy, or new medications. The nurse will notice a bright red rash, covering almost the entire body. The patient’s skin will flake and peel, even on the palms of the hands and soles of the feet, and they may have hair loss or brittle and ridged nails. When examining the patient’s abdomen, the nurse may palpate an enlarged liver or spleen. The nurse may also note lymphadenopathy. When analyzing these cues, the nurse will help the health-care provider by assessing the patient’s skin and then narrow down potential diagnoses based on the laboratory results (Austad & Athalye, 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority nursing hypothesis for the nurse is potential hemodynamic stability, because the patient’s skin barrier is almost completely absent. The nurse will generate solutions related to maintaining hemodynamic stability and prevent fluid loss. The nurse will provide adequate hydration through IV fluid replacement and replace electrolytes (e.g., potassium, magnesium, calcium) when indicated. The nurse will monitor the patient’s hemodynamic status, ensuring the patient’s blood pressure and heart rate are within normal limits, and monitor the patient’s temperature, providing cooling or warming measures when needed (Harper-Kirksey, 2018).
Another nursing hypothesis related to generalized exfoliative dermatitis is impaired skin integrity. The nurse will provide oral antihistamines (e.g., diphenhydramine) and topical corticosteroids for any itching. The nurse may provide an oatmeal bath and wound care, as needed. Blood cultures may also be needed for identifying bacterial or fungal skin-infection organisms, and nurses can administer antibiotics or antivirals, as ordered, to prevent skin infections (Harper-Kirksey, 2018).
Evaluation of Nursing Care for the Patient with Generalized Exfoliative Dermatitis
After the nurse has generated solutions and taken action related to the nursing hypotheses, they will evaluate outcomes. An expected outcome for a patient with erythroderma is to maintain hemodynamic stability and for the patient’s skin disorder to resolve.
Evaluating Outcomes
When evaluating hemodynamic stability and impaired skin integrity, the nurse would expect the patient’s vital signs to be within normal limits, without fluid imbalance or electrolyte disturbances, and for the patient’s skin to begin healing, with decreased peeling and itching, and eventually heal entirely. The time frame for resolution of symptoms will vary depending on when the underlying cause and any complications. The nurse would also expect the patient’s skin to not have any signs of infection and return to a normal appearance (Harper-Kirksey, 2018).
Medical Therapies and Related Care
Because generalized exfoliative dermatitis can be life-threatening, a large interdisciplinary health-care team is needed to properly care for the patient. The nurse can expect collaborative care from a dermatologist (a specialist in skin disorders), an infectious disease specialist, and a pharmacist to help determine underlying etiology. To maintain hemodynamic stability, consultations from a cardiologist and pulmonologist may be indicated. Lastly, if malignancy is found or suspected, an oncologist would collaborate with the health-care team (Austad & Athalye, 2023).
Seborrheic Dermatitis
The skin condition that usually affects the scalp or areas with sebaceous glands, such as the face or areas with skin folds, is called seborrheic dermatitis. This condition mainly affects infants and people in middle age but can affect anyone. The noninflammatory type of seborrheic dermatitis is more commonly called dandruff and occurs in adults. In infants, this condition is known as “cradle cap” (Tucker & Masood, 2023).
Pathophysiology
The exact pathophysiology of seborrheic dermatitis is not entirely known. Some theories state that the skin’s microbiota becomes disturbed or there is an increase in fatty acids on the skin. Other theories point to a weakened immune system that may allow yeasts to overgrow, or a genetic predisposition to the condition (Tucker & Masood, 2023).
Clinical Manifestations
Clinical manifestations of adult seborrheic dermatitis include itching and burning, usually on the scalp or chin, where hair grows. However, this condition can appear anywhere on the body where sebaceous glands are present. There will be small flakes of skin and, when examining the scalp, there will be light-colored papules with greasy crusts and scales. In infants, seborrheic dermatitis will appear as greasy crusts that can be yellow to brown (Tucker & Masood, 2023)
Assessment and Diagnostics
Diagnosis of seborrheic dermatitis is often made clinically on the basis of the patient’s presenting symptoms. In an adult patient, the nurse will note the clinical manifestations, usually the scalp.
Although routine laboratory tests are not typically ordered to diagnose seborrheic dermatitis, the health-care provider may order them in cases of severe or sudden onset symptoms. Some additional tests may include potassium hydroxide (KOH) skin scraping, histology, HIV testing, antinuclear antibody (ANA), ESR, and several others, although they are not commonly needed (Tucker & Masood, 2023). A positive KOH result can mean a fungal infection has developed. Elevated ANA and ESR results could indicate an underlying autoimmune response or condition.
Nursing Care of the Patient with Seborrheic Dermatitis
When caring for a patient with seborrheic dermatitis, the nurse will recognize and analyze patient cues to create a priority nursing hypothesis. Once they generate a priority hypothesis, the nurse will generate solutions, take action, and then evaluate their interventions.
Recognizing and Analyzing Cues
The nurse will begin by recognizing patient cues for seborrheic dermatitis. The patient may report itching to the scalp, beard area, or another area where many sebaceous glands are present. When examining the affected area, the nurse will note the characteristics of seborrheic dermatitis. In infants, the caregiver may be concerned about the child’s scalp and notice yellow to brown crusts.
When analyzing cues, the nurse should ask the patient or caregiver if the patient has any preexisting skin conditions or has had this condition before. The nurse should gather a full medical history for the patient, including any immune disorders like HIV or systemic lupus erythematosus (Tucker & Masood, 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse will prioritize hypotheses based on the patient’s cues, generate solutions, and take action. The priority nursing hypothesis for seborrheic dermatitis is impaired skin integrity. When generating solutions and taking action, the nurse can provide both pharmacological and nonpharmacological interventions.
For both infants and adults, the nurse can promote skin care routines that include moisturizing the skin. The nurse can anticipate the health-care provider ordering topical shampoos or creams that contain antifungals combined with anti-inflammatory and anti-itch components, or these medications alone. Many medications for seborrheic dermatitis can be found over the counter; examples are selenium sulfide, ketoconazole, zinc pyrithione, and salicylic acid plus sulfur in sorbelene cream. With infants, the nurse should gently assist with removing the crusts with forceps or saline-soaked gauze before applying creams. The nurse can educate the parents on removing crusts with a loofah or mildly abrasive sponge. In severe cases, oral antifungals such as fluconazole or terbinafine may be prescribed by the health-care provider (Tucker & Masood, 2023).
Evaluation of Nursing Care for the Patient with Seborrheic Dermatitis
After the nurse has implemented the chosen actions, they can evaluate effectiveness. An expected outcome would be for the affected area to present without flaking or crusts.
Evaluating Outcomes
When evaluating outcomes, the nurse would expect the patient’s skin to show decreased scaling or flaking, and a decrease in the number in the papules. The adult patient would also report decreased or no itching. In infants, greasy crusts are not present, or are resolving.
Medical Therapies and Related Care
Most cases of seborrheic dermatitis are self-limiting; usually, adult patients will have acute flares. In chronic or severe cases, the patient may be referred to a dermatologist for further evaluation or a pharmacist for special shampoo formularies. In addition, if the patient has any new or underlying medical conditions that may be contributing to the seborrheic dermatitis, they will be referred to the appropriate specialist. For example, the health-care provider may refer a patient to an infectious disease specialist if they have an underlying condition, to an immunologist if they have HIV, or to a rheumatologist if they have an autoimmune disorders like systemic lupus erythematous (Tucker & Masood, 2023).
Pruritus
Itching, or pruritus, can occur due to a variety of reasons or underlying medical conditions. Many skin disorders, like atopic dermatitis and psoriasis, present with symptoms of itching. Other diseases, like chronic kidney disease or substance use disorders, can cause pruritus as well (Fazio & Yosipovitch, 2022).
Pathophysiology
Generalized pruritus is a symptom more common in patients over age 65 years, and the pathophysiology is generally unknown. Underlying conditions may contribute to pruritus in the older adult, such as skin disorders like psoriasis or AD, or neurological disorders, like postherpetic neuralgia. Systemic diseases, like Hodgkin’s lymphoma, thyroid imbalances, and anemias can also contribute to pruritus. Sometimes dehydration or liver problems can also cause pruritus (Chung et al., 2021).
Clinical Manifestations
The patient will report generalized itching. The nurse may also note reddened or dry and scaly skin. If there are underlying skin conditions present, the nurse may also notice skin lesions indicative of that particular skin disorder (Fazio & Yosipovitch, 2022).
Assessment and Diagnostics
After initial assessment of the skin, the health-care provider will initially order CBC, CMP, ESR, CRP, liver, and thyroid function tests to help determine an underlying cause. The provider may also look for anemias and allergies, or perform HIV testing if there is a suspicion of any of these conditions (Roh et al., 2022). The health-care provider will also complete a thorough medical history and review the patient’s list of medications.
Depending on the patient’s underlying condition, laboratory values will be different. For instance, if the patient has underlying hypothyroidism, their thyroid function tests would be abnormal, whereas if the patient has iron-deficiency anemia, their blood counts would be abnormal and iron levels would be low.
Nursing Care of the Patient with Pruritus
When caring for a patient with pruritus, it is important to understand the underlying cause. After the patient is diagnosed by the health-care provider, the nurse will provide pharmacological and nonpharmacological interventions.
Recognizing and Analyzing Cues
When recognizing cues, the nurse will assist the health-care provider. The patient will report itching and the nurse may notice the skin is dry, scaling, and red (Fazio & Yosipovitch, 2022). If the nurse recognizes the patient has these symptoms, they may ask the following questions:
- Do you have any known allergies?
- Does anything aggravate the symptoms?
- Have you tried any treatments?
- What is your medical history, or do you have any health conditions?
- What medications are you taking?
- When did the symptoms start?
Prioritizing Hypotheses, Generating Solutions, and Taking Action
When prioritizing hypotheses for pruritus, treating the underlying cause usually takes priority. For example, if the underlying medical condition is hypothyroidism, the nurse would expect the patient to be prescribed levothyroxine. Another priority hypothesis is to impaired skin integrity. The nurse’s goal or expected outcome would be to help keep the patient’s skin intact.
When generating solutions and taking action, the nurse would promote the use of emollients and moisturizers to help relieve dry skin. The health-care provider may also prescribe topical steroids or oral antihistamines, like diphenhydramine or fexofenadine, to help relieve itching. In patients with chronic kidney disease, ultraviolet light therapy may be ordered. Selective serotonin reuptake inhibitors, like sertraline or fluoxetine, may help with generalized pruritus. The nurse would administer these as indicated or collaborate with other members of the health-care team (Chung et al., 2021).
Evaluation of Nursing Care for the Patient with Pruritus
After the nurse has implemented interventions, they will evaluate effectiveness. An expected outcome is to keep the patient’s skin intact. The nurse can assist the health-care provider identify the underlying health condition by collecting specimens for the ordered diagnostic tests.
Evaluating Outcomes
When evaluating the outcome for skin integrity, the nurse would expect the patient’s skin to be moist and intact without areas of excoriation, lesions, or signs of infection.
Medical Therapies and Related Care
Depending on the underlying cause, the patient may require care from a collaborative health-care team and internal medicine. If the patient’s underlying condition is neurological, the nurse would collaborate with the neurology department. Other specialties might include oncology, pharmacy, infectious disease, nephrology, and psychiatry (Chung et al., 2021).
Acne
Pustules or nodules on the face, neck, and sometimes upper back and arms is called acne. It is a very common skin disorder that frequently occurs during the adolescent years from bacteria in the genus Cutibacterium (formerly, Propionibacterium); however, it can occur at any age. Acne can be caused by medications such as anticonvulsants or steroids, or by endocrine problems such as polycystic ovarian syndrome (PCOS). Genetics and puberty are factors in developing acne as well (Sutaria et al., 2023).
Pathophysiology
Any hormonal changes can contribute to acne. An increase in androgen levels leads to more sebum production in the skin. Acne can also be caused by increased keratinocyte production leading to an increase in sebum. In addition, colonization with the bacteria C acnes promotes an inflammatory response of the skin, causing acne to appear. Some foods and cosmetics can trigger acne as well (Sutaria et al., 2023).
Clinical Manifestations
Acne can come in different forms. It may be open or closed, or it can consist of comedones, red papules, pustules, or nodules and cysts (Figure 14.11). A comedone is a small bump on the skin that may be flesh-colored, white, or dark. A papule is a small, raised bump that is well defined. A pustule is a larger acne lesion that contains pus. A nodule or cyst is a bump that forms below the epidermal layer of the skin; it is filled with keratin and typically lined with squamous epithelium. Patients may report mild pain, swelling, and tenderness at the sites where acne is present.
Assessment and Diagnostics
Typically, acne is diagnosed by its clinical presentation. The nurse may note comedones, red papules, pustules, or nodules and cysts on the patient’s skin. If the health-care provider suspects an underlying contributor, like PCOS or other hormonal disorder, they may order additional laboratory testing, including for follicle-stimulating hormone (FSH), luteinizing hormone (LH), and dehydroepiandrosterone levels (Sutaria et al., 2023). These labs are further discussed in the chapter on reproductive systems.
A diagnosis of acne is often made based on presenting symptoms. In cases of patients with PCOS, the nurse may note an increase in LH and a decline in FSH levels. There may be an increase in androgen levels contributing to acne (Sutaria et al., 2023).
Nursing Care of the Patient with Acne
When caring for a patient with acne, the nurse can provide pharmacological and nonpharmacological interventions, as ordered. Acne is treated on an outpatient basis and usually resolves with treatment.
Recognizing and Analyzing Cues
When recognizing cues, the patient will report areas of redness and tenderness to the face, neck, chest, or upper back. The nurse will observe either comedones, pustules, cysts, or erythematous papules on the patient’s skin. When analyzing these cues, the nurse may ask the patient if they have any skin or medical conditions. The nurse should also consider the patient’s age and onset of the condition, because hormonal changes can lead to acne, especially in adolescents (Sutaria et al., 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority nursing hypothesis for acne is impaired skin integrity, for which the nurse will generate solutions and take action. With acne, the health-care provider may prescribe topical retinoid (e.g., retinoic acid, tretinoin) or topical gels and lotions (e.g., clindamycin, benzoyl peroxide, azelaic acid) depending on the type of acne. In addition, health-care providers may prescribe oral medications (e.g., doxycycline, spironolactone, isotretinoin) to help control the patient’s acne. Oral contraceptives may also be prescribed to address acne in a female patient. The nurse should help administer these medications and teach the patient the importance of daily use and the importance of washing their face. The nurse may also reinforce education about diet changes, like avoiding fatty foods that can trigger acne.
Patients who are prescribed spironolactone need monitoring of their potassium levels because this medication can cause them to increase. The nurse should educate the patient about this requirement, if necessary. The nurse should also teach all patients about medication side effects and when to report them, especially with isotretinoin, because it can lead to serious complications, including birth defects, vision loss, or diabetes (Sutaria et al., 2023).
Evaluation of Nursing Care for the Patient with Acne
After the nurse has implemented their actions, they will evaluate the effectiveness of the interventions. An expected outcome of treatment would be improved appearance of the patient’s skin, with less irritation and without signs of acne.
Evaluating Outcomes
When evaluating outcomes, the nurse would expect the patient’s skin to appear less irritated and red. Comedones, pustules, cysts, and erythematous papules would be absent or healing. Additionally, the patient would understand the education about face washing, diet, and medication side effects or laboratory values that would need to be monitored.
Medical Therapies and Related Care
Usually, once treatment is initiated the patient’s symptoms will resolve and no referral is needed. However, if symptoms continue or worsen, the patient may need a referral to dermatology. If the patient is being treated with isotretinoin, they will need to be closed monitored by a health-care provider for complications, like diabetes or vision loss.
Bacterial Skin Infections
Bacterial skin infections are common. They are usually caused by bacteria that live on the skin, like Staphylococcus and Streptococcus. Depending on the type and location of the bacterial infection, symptoms may look a little different (Rehmus, 2023). Two common bacterial infections the nurse will encounter are impetigo and folliculitis.
Impetigo
A bacterial skin infection commonly caused by gram-positive bacteria is called impetigo. There are two types of impetigo: bullous impetigo and nonbullous impetigo (Figure 14.12). Bullous impetigo begins with a small vesicle, which then leaks clear to dark fluid. Nonbullous impetigo, the more common type, starts with a small vesicle or pustule that forms and ruptures, causing a honey-colored crust to form. The nurse may provide treatment as ordered by the health-care provider, which usually includes applying topical antibiotics (e.g., mupirocin). Before applying the antibiotic, the nurse should remove the crust and wash the area with soap and water. If the infection worsens, the nurse will alert the health-care provider, and the provider may prescribe an oral antibiotic (e.g., cephalexin, amoxicillin-clavulanate). For children, the nurse would also educate caregivers on the importance of personal hygiene and avoiding contact with other children during treatment, because the infection can easily spread (Nardi & Schaefer, 2022).
Folliculitis
Infection and inflammation of a hair follicle are called folliculitis (Figure 14.13). It is most commonly caused by bacteria (Staphylococcus) but can also be caused by fungi and viruses (e.g., herpes) (Rehmus, 2023). Patients with bacterial folliculitis often present with itching and a mildly erythematous rash. The nurse may also note small pimples or pustules surrounding the hair follicles. Bacterial folliculitis usually resolves on its own without treatment. However, if it worsens, the first-line treatment is topical antibiotics, like clindamycin or mupirocin. If the nurse notes increased redness, swelling, or discharge, the health-care provider may prescribe oral cephalexin or another antibiotic (Winters & Mitchell, 2022).
Viral Skin Infections
Viruses can cause viral skin infections. Some examples of viruses that can cause skin infections are herpes zoster, COVID-19, human papillomavirus (HPV), and herpes simplex (MedlinePlus, 2023). A nurse must be able to recognize these skin infections and provide appropriate treatment as prescribed by the health-care provider.
Herpes Zoster
Reactivation of the chicken pox virus (varicella zoster) causes a disorder called herpes zoster or shingles. Although it can affect anyone at any age, it more commonly affects older adults who likely contracted varicella zoster in childhood, before vaccination was an option. However, chicken pox during childhood is less common now, due to the introduction of the vaccine (Centers for Disease Control and Prevention, 2024). With herpes zoster, patients will typically present with a viral prodrome or feeling unwell and will often have symptoms like fever and a burning sensation where a rash will appear several days later. Once the skin rash develops, it will have a vesicular appearance, follow a dermatome (i.e., areas of skin innervated by a spinal root), and will be unilateral, never crossing the midline (Figure 14.14). Patients will complain of itching and a burning sensation, and pain is often moderate to severe.
Once the patient is diagnosed with herpes zoster, the nurse can expect the health-care provider to prescribe oral antivirals (e.g., acyclovir, valacyclovir). The provider may also prescribe antibiotic ointments to prevent the development of secondary infections. If the nurse notes any lesions on the patient’s face, especially near the eye or ear, they should inform the health-care provider immediately. This is because herpes zoster follows the dermatomes and can affect the patient’s hearing and eyesight (Nair & Patel, 2023).
Herpes Simplex
There are two types of herpes simplex viruses. The first, herpes simplex virus type 1 (HSV-1), causes vesicular rashes on the skin and face, near the mouth and lips, but it can also occur on the genitalia. The second, herpes simplex virus type 2 (HSV-2) is the most common cause of genital herpes (Kaye, 2021).
Patients with HSV-1 or HSV-2 will usually complain of itching and a tingling sensation in the affected area before a vesicular rash appears. When the rash erupts, it appears as small vesicles with an erythematous base. The health-care provider will usually prescribe oral antivirals like valacyclovir or acyclovir for treatment. A viral culture may also be ordered, which the nurse would collect by removing the top portion of the vesicle and swabbing the clear fluid, to determine if the cause is herpes simplex or another virus. Lesions that are near or affect the eye can cause a condition known as keratitis, and the patient should be referred to an ophthalmologist for treatment (Kaye, 2021).
COVID- 19
Although COVID-19 usually causes respiratory symptoms in patients, it can also cause skin manifestations. The most common rash that develops with a COVID-19 skin infection is usually itchy and maculopapular; however, urticarial rashes (e.g., hives), petechiae, and vesicular rashes may also develop on the body. Another prominent manifestation is “COVID toes,” which are also known as chilblain lesions. This condition causes the patient’s toe(s) to become discolored and inflamed. If a patient who is diagnosed with COVID-19 develops a rash, the nurse should inform the health-care provider so the provider may evaluate the patient. Most skin eruptions associated with COVID-19 are self-limiting and resolve on their own. However, in some cases, the health-care provider may order topical steroids or antibiotics to help open lesions heal or manage symptoms (Singh et al., 2020).
Fungal Skin Infections
Fungal skin infections are caused by fungus, yeasts, or dermatophytes. Common organisms are Candida, Microsporum, and Epidermophyton. Fungal infections do not penetrate past the epidermis and usually occur in moist areas, like the feet and genital area. Usually, patients with fungal infections (e.g., candidiasis) will have itching and mild swelling around the affected area. A patient with athlete’s foot, or tinea pedis, the patient may present with itchiness and scaling of the skin. In cases of ringworm, the nurse may notice round patches with a raised border that is scaly and central clearing (Aaron, 2021).
Fungal infections may have slightly different presentations, but treatment is often the same. Treatment usually involves topical or oral antifungals, such as ketoconazole or fluconazole. However, the health-care provider may also order a skin scraping to confirm the diagnosis, and the nurse may need to collect the sample.
Parasitic Skin Infections
Parasitic skin infections are caused by parasites, like protozoa or helminths. Although parasites flourish in areas with inadequate sanitation, they can survive anywhere and usually enter the body through the skin or mouth (Marie & Petri, Jr., 2023). Some examples of common parasitic skin infections that a nurse may encounter are pediculosis and scabies.
Pediculosis
A parasitic skin infection of lice, called pediculosis, can affect anywhere there is body hair, including the pubic region. This condition is caused by a tiny insect, a louse, and is extremely transmissible through close contact. In all cases of pediculosis, the patient will present with itching. Upon examination, the nurse may note adult lice or baby lice (nits) on the affected area. For treatment of head lice, the health-care provider will usually order oral ivermectin or topical shampoos like lindane 1%. After shampooing, a fine-toothed comb is used to remove the nits. Pubic lice are typically treated with creams and shampoos, like permethrin or lindane. When lice affect the eyelashes, fluorescein drops are given, or oral ivermectin.
The nurse also should educate the patient to inform any sexual partners or those with whom they have had in close contact; these people would need to be treated as well. The nurse also instructs the patient to clean towels and bedding in hot water and to not share any personal items like hairbrushes or towels until they are sanitized and clean (Dinulos, 2021).
Scabies
The parasitic skin infection caused by a mite that usually affects the spaces between the fingers, wrists, axillae, and abdomen along the belt line is called scabies. Patients with scabies will report intense itching that is usually worse at night. When examining the patient with the health-care provider, the nurse may notice erythematous papules with small scaly lines or burrows. For treatment, the health-care provider will order topical treatments like permethrin or may prescribe oral ivermectin. When caring for the patient, the nurse should follow contact precautions and wear proper personal protective equipment because scabies can be easily transmitted (Dinulos, 2021).
Benign Tumors
Benign tumors are those that are noncancerous and can grow anywhere on the skin. Common types of benign tumors are cysts, angiomas, keloids, moles, warts, and dermatofibromas. As a nurse, you will encounter many benign tumors; it is important to recognize their appearance, symptoms, and recommended treatment options from the health-care provider.
Cysts
Cysts can appear anywhere on the body. If a patient has a cyst, the nurse may note a small mass or nodule that is hard and nonfluctuant. Rarely, cysts can become infected, and the nurse would note redness, swelling, and potential discharge around the site. If the cyst is large enough or bothersome to the patient, the provider can surgically remove it. Depending on its appearance, the provider may order a biopsy to determine the exact etiology. After the cyst is removed, the nurse would educate the patient on signs and symptoms of infection at the incision site and to avoid strenuous activity for 7 to 10 days after the procedure to prevent infection and maximize skin healing (Zito & Scharf, 2023).
Angiomas
Another type of benign tumor is an angioma, which is a small collection of blood vessels or lymphatic tissue. There are different types of angiomas (e.g., cherry hemangiomas), and they can occur anywhere on the body. In patients with cherry angiomas, the nurse may note a red, dome-shaped area (Figure 14.16). Trauma to an angioma typically causes it to bleed. To determine the depth of larger angiomas, the health-care provider may order imaging, like tomography, before determining if the angioma can be removed. Removal can be done by electrocauterization, cryotherapy, or laser treatment (Qadeer et al., 2023).
Keloids
A keloid is a firm and rubbery area of skin that can appear flesh-colored or hyperpigmented. It can appear as a response to skin inflammation that causes abnormal wound healing and increased skin cell proliferation or hypertrophy. Treatment methods include topical corticosteroids and compression devices to reduce keloid development while wounds are healing. Some patients require more extensive care to remove keloids, including cryotherapy, surgical excision, and laser treatment; the nurse can help coordinate care for these procedures (McGinty & Siddiqui, 2022).
Pigmented Nevi (Moles)
A pigmented nevus or melanocytic nevus, also called a mole, is a macule or papule on the skin. Moles can range in color from the patient’s skin tone to a deep brown. Because moles can resemble skin cancer (specifically, melanoma), the provider will assess the mole for asymmetry, irregular borders, color, diameter, and changes to determine if the area is concerning. If any issues are present, the nurse would anticipate the provider to order a skin biopsy. The provider may also remove the mole completely for histology or for cosmetic reasons (Aaron, 2022).
Verrucae (Warts)
A verruca, or a wart, is a lesion caused by the human papillomavirus (HPV) that is generally flesh-colored, raised, with an irregular surface and can occur anywhere on the skin, including the soles of the feet and palms of the hands. Human papillomavirus causes warts, and warts do not generally cause any symptoms. However, plantar warts that occur on the bottom of the feet can become painful due to friction.
After diagnosis, treatment depends on the size of the warts. Methods might include observation (many warts resolve on their own within 24 months), topical salicylic acid, retinoic acid, or cryotherapy. Verrucae are sometimes biopsied to determine the exact etiology, and the nurse may anticipate the provider ordering a biopsy procedure (Al Aboud & Nigam, 2023).
Dermatofibroma
A dermatofibroma, also called a benign fibrous histiocytoma, is a small, benign papule made of fibroblastic tissue (the skin’s connective tissue) and can range in color from red to brown. Patients may complain about itching in the area, but this is not common. Because dermatofibromas can resemble forms of skin cancer, biopsies are often performed by the health-care provider to confirm diagnosis. For treatment, the nurse can expect the provider recommend surgical excision or cryotherapy (Aaron, 2022).
Malignant Tumors
Malignant tumors are cancerous and can form anywhere on the skin. Common types of malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. As a nurse, you may encounter malignant tumors; it is important to recognize their appearance and be knowledgeable about recommended treatment options from the health-care provider.
Basal Cell and Squamous Cell Carcinoma
The most common form of skin cancer, basal cell carcinoma, arises from the lowest layer (basal) of the epidermis. The condition may appear as patches of shiny pink skin to clear bumps that sometimes break open and form a scab. The nurse can expect the health-care provider to order a biopsy of the lesion to confirm the diagnosis of basal cell carcinoma. Treatment involves removal by cauterization, cryosurgery, excision, or Mohs surgery. During Mohs surgery, the provider removes small portions of the lesion and views them under a microscope to determine if the borders have been completely removed (Wells, 2022).
Another form of skin cancer, squamous cell carcinoma originates from the squamous layer of skin and may be preceded by actinic keratosis. When inspecting the patient’s skin, the nurse may notice irregular, scaly, and thickened growths that do not heal. As with basal cell carcinoma, the nurse would anticipate a skin biopsy to be ordered to confirm the diagnosis. The lesion will then be removed using the same techniques as for basal cell carcinoma. After the carcinoma is removed, the nurse can reinforce prevention measures, like avoiding sunlight, using sunscreen, and wearing long-sleeved clothes while outdoors (Wells, 2022).
Melanoma
Another form of skin cancer, melanoma arises from melanocytes and can appear flat or raised and vary in color, including red, brown, black, or blue (Figure 14.16). Lesions often appear in areas where the skin is exposed to sunlight. The main treatment is removal; the health-care provider will biopsy the lesion to confirm the diagnosis. Because melanoma is an aggressive form of skin cancer and can spread to other parts of the body, adjunct therapies like cryotherapy, radiation, and immunotherapy may also be ordered.
Nurses should also reinforce education by instructing patients about skin cancer prevention and the ABCDEs of melanoma. The ABDCEs of melanoma or any skin cancer are:
- A = Asymmetry: Is the lesion asymmetrical?
- B = Borders: Are the borders irregular?
- C = Color: Are there changes in skin color or has the skin become significantly darker?
- D = Diameter: Is the lesion greater than one-quarter of an inch?
- E = Evolution: Has the mole changed?
Answering yes to any of these ABCDEs may indicate the patient potentially has a form of skin cancer (Wells, 2022).
Cutaneous Procedures and Treatment
Benign and malignant skin lesions and tumors are often removed via cutaneous procedures or treatment. Some common cutaneous treatments are laser treatment, cosmetic procedures, and wound flaps or grafts.
Laser Treatment of Lesions
Laser treatment of skin lesions involves using laser light therapy. The skin absorbs laser light, and the affected skin cells repair and heal themselves. Laser treatments are used most commonly on pigmented skin or nevi but can also be used on vascular abnormalities, angiomas, granulomas, and other skin conditions. During this procedure, patients and anyone on the health-care team must wear safety goggles and eye shields to protect themselves from the laser light. The patient should also receive local anesthesia to the area through topical agents like 4% lidocaine. After the laser treatment, the nurse should provide skin-cooling measures (e.g., ice packs) to the treatment area. The nurse should also instruct the patient to avoid sunlight exposure to the area for a certain amount of time (Gaffey & Johnson, 2022).
Cosmetic Procedures
Depending on the type of skin lesion or tumor, the health-care provider may order cosmetic procedures like facial reconstruction or dermabrasion. Facial reconstruction is plastic surgery on the face that is often performed after skin cancer lesions removal or after Mohs surgery. After facial reconstruction, the nurse would administer pain medications and provide wound care as ordered. The nurse may also apply topical antibiotics to the surgical incision to promote wound healing (Cottrell & Raggio, 2023).
Dermabrasion is resurfacing the skin; it promotes remodeling and wound healing by using abrasive materials. This process is often used to treat actinic keratosis and acne scars but can also be used for scar revisions and after Mohs surgery. During the procedure, the nurse may apply local anesthesia ointments (e.g., lidocaine) to help relieve pain and may assist the health-care provider with holding the skin taught. After the procedure, the health-care provider may order saline-soaked gauze or an occlusive ointment, like petroleum, to promote skin healing (Bedford & Daveluy, 2023).
Wound Coverage with Flaps and Grafts
Skin flaps and skin grafts are two common types of skin closure and wound coverage techniques. A skin flap is created when healthy skin is only partially detached to cover a nearby wound, whereas a skin graft involves transferring skin and related blood vessels from one area of the body to another and is used to cover larger wounds. Skin flaps are often the preferred closure technique because the flaps have an adequate vascular supply.
Skin flaps and grafts are often used to close areas where skin cancers or large tumors have been removed, often after surgical excision or Mohs surgery (Prohaska et al., 2022). After a skin flap or graft procedure is performed, the nurse would perform wound care as ordered and assess the site for signs and symptoms of infection. They would also administer pain medication as needed. The nurse can also reinforce postprocedure patient education, such as limiting contact with water at the site of the procedure or avoiding strenuous activity, because it can cause the wound to stretch. Wash your hands thoroughly before changing a dressing, to prevent possible spread of bacteria. If the patient has a vacuum dressing, make sure the tubing is attached and correct pressure is set, because this promotes wound healing and removes excess moisture from the wound bed (Hoss, 2022).