24.2: Skin Integrity

Learning Objectives

By the end of this section, you will be able to:

• Identify risk factors for impaired skin integrity
• Examine common skin disorders that cause impaired skin integrity
• Describe health promotion behaviors related to skin integrity

Skin integrity refers to the overall health of the skin. Factors that influence healthy skin are patient specific. These factors include age, genetics, and overall health. For example, the skin color of a patient of Asian descent will appear different from that of a patient of Eastern European descent. In addition, skin changes as people age, so the nurse must consider age when assessing a patient’s skin. It is crucial that nurses obtain the patient’s health history and perform an assessment to identify risk factors for impaired skin integrity to effectively implement nursing interventions and provide education to patients and families. The nurse must be aware of common skin disorders that can lead to impaired skin integrity as well as health promotion behaviors related to skin integrity.

Risk Factors for Impaired Skin Integrity

When the skin is healthy and unbroken, the skin is able to efficiently carry out its functions. Resistance of the skin and mucous membranes to injury varies among patients and is dependent on factors including age and medical conditions. Patients with adequate nutrition are also more resistant to injury or disease. Adequate perfusion is vital in maintaining cell life. When skin integrity is impaired, cells do not get the nourishment they need and cannot eliminate wastes effectively. To identify risks for impaired skin integrity, the nurse must examine lifestyle and behavioral factors as well as genetic and state of health factors.

Lifestyle and Behavioral Factors

Lifestyle and behavioral factors that affect skin integrity include a patient’s nutrition, activity levels, sexuality, medications used, illicit drug use, body piercings, tattoos, and substances that come in contact with the skin like soaps, detergents, and lotions. Nutrition plays an important role in the health of a patient’s skin. Inadequate nutrition may lead to skin breakdown, delayed wound healing, premature aging of the skin, inflammation, dryness, and changes in hair. A patient’s exposure to the sun or other UV light may place them at risk of skin cancer as a result of prolonged exposure.

The use of certain types of hygiene products may also place a patient at risk of impaired skin integrity. Certain types of soaps, lotions, and detergents may be too harsh for a person’s skin based on their age, health condition, and genetics. Some detergents and soaps increase the pH levels of the stratum corneum, and those products may cause rashes, inflammation, dermatitis, and acne breakouts. Older people who do not use emollients (ingredients that soothe dryness) are at risk of impaired skin integrity because their skin is dry and more susceptible to cracking.

State of Health and Genetic Factors

State of health and genetic factors may affect the skin. Nutrition can adversely or positively affect the health of the skin. Some people experience dehydration and malnourishment caused by an illness versus a lifestyle choice. Dehydration and malnourishment result in a deficiency in fluids, protein, and vitamin C. This causes the skin to lose its elasticity and become more susceptible to breakdown.

Side effects of certain medications may also affect skin. For example, localized pruritis (itching) is common with hydrocodone, and patients may scratch themselves in an attempt to relieve the itching. Corticosteroids cause thinning of the skin making it more susceptible to injury, and certain antibiotics increase sensitivity to sunlight causing an individual to burn easily. Patients who experience incontinence or have issues with diarrhea are at risk of skin breakdown as a result of the excess moisture. Patients with jaundice are at risk of lesions and infections from scratching because of dry, itchy skin. There are also numerous conditions that cause secondary disruptions to the integumentary system. For example, patients undergoing radiation treatment for cancer are at risk of erythema (reddening of the skin), pruritus, or loss of skin integrity (Figure 24.8).

Figure 24.8 Erythema (i.e., reddening of the skin) has multiple causes—in this case, heat rash. (credit: “16850” by Dr. Lester Cordes/CDC, Public Domain)

Common Skin Disorders

There are various skin disorders that the nurse should be aware of to effectively care for their patients. Common skin disorder classifications include bacterial infections, viral infections, fungal infections, inflammatory reactions, and skin cancers. It is crucial for the nurse to be able to identify and describe skin disorders as well as their underlying cause and treatment.

Bacterial Infections

Bacteria naturally reside on the skin. An infection can occur, however, when the skin is not intact allowing bacteria to enter through hair follicles or breaks in the skin (e.g., scrapes, surgical incisions, bites). Some bacterial infections are localized and involve just the skin or the soft tissues under the skin, or they can become systemic involving multiple body systems. Common bacterial infections of the skin include impetigo, folliculitis, carbuncles, and cellulitis (Table 24.1).

Disorder	Description	Example
Impetigo	Contagious superficial skin infection	(CC BY 4.0; Rice University & OpenStax)
Folliculitis	Infection of the hair follicle	(CC BY 4.0; Rice University & OpenStax)
Carbuncle	Clusters of deep skin abscesses	(credit: “Cutaneous abscess caused by MRSA on the hip” by CDC, Public Domain)
Cellulitis	Localized infection and inflammation	(credit: “Cellulitis toes (44699139982)” by John Campbell/Wikimedia Commons, Public Domain)

Table 24.1 Common Bacterial Skin Disorders

Impetigo

A highly contagious superficial skin infection called impetigo is most commonly found in children. Patients with impetigo can spread it to other areas of their own body as well as to other people they come in contact with. Although it can occur anywhere on the body, it primarily occurs on the arms, legs, and face. Impetigo is either bullous or nonbullous in nature. Caused by Staphylococcus aureus, bullous impetigo is usually sporadic and develops on intact skin. Flaccid bullae generally grow in size to form larger blisters filled with clear yellow to dark turbid fluid and burst to expose raw skin that becomes covered with a thin brown crust. The most common kind of impetigo, nonbullous impetigo, usually occurs after injury to the skin or as a secondary bacterial infection of another skin disorder like atopic dermatitis. Nonbullous impetigo presents as clusters of pustules that rapidly break down and form thick adherent honey-colored crusts on the face and extremities. Other risk factors for impetigo include poor hygiene and a moist environment. Treatment for impetigo may include topical or oral antibiotics.

Often called deep impetigo, ecthyma is a skin infection that occurs deep inside the skin characterized by shallow, small ulcers that look punched out and may contain pus. The brown crust that covers the ulcers is thicker than the crust that covers the ulcers of impetigo. Treatment options for impetigo and ecthyma include antibiotic ointments or creams for smaller areas. Larger infected areas or areas that are not responding to the topical antibiotics may require oral antibiotics. The infected areas should be washed gently with soap and water multiple times a day to remove crusts. Individuals who have recurrent infections should have a nasal swab cultured to see if they are a nasal carrier of Staphylococci or Streptococci. People who are nasal carriers will need a topical antibiotic applied to their nasal passages (Rehmus, 2023).

Folliculitis

An infection of the hair follicle that often results from occluded hair follicles is called folliculitis. It may affect a single hair follicle or multiple hair follicles. Common risk factors for folliculitis include poor hygiene, maceration (i.e., occurs when skin is exposed to a moist environment for too long), occlusive emollient products, and contact with contaminated water. Folliculitis often appear as pustules surrounded by erythema where a hair follicle is present. Hair follicles may easily fall out as well. Treatment includes warm compresses after washing with antibacterial soap and water multiple times a day, topical antibiotics, and oral antibiotics.

Carbuncle

Clusters of skin abscesses connected to one another below the surface of the skin, known as carbuncles, often form when one or more hair follicles become infected. If left untreated, the abscesses fill with pus and will rupture, discharging a creamy pink or white fluid. If the abscess is too deep, it may not be able to drain on its own. Bacteria can spread from the abscess and infect surrounding tissues and lymph nodes. Infected individuals may also have a fever, chills, and malaise. Carbuncles are likely to leave a scar. Most carbuncles are caused by Staphylococcus aureus. Risk factors for the development of carbuncles include poor overall health, friction from shaving or clothing, and poor hygiene. Patients with weakened immune systems are more likely to develop Staphylococcus infections that lead to carbuncles. Some skin abscesses may go away on their own with the use of warm compresses. However, some carbuncles may require a provider to open and drain the abscess and then wash out the pocket with a sterile saline solution. Oral antibiotics may also be needed to aid in treating the infection. Individuals with recurrent skin abscesses may be instructed to wash their skin with antiseptic solutions (e.g., iodine) (Rehmus, 2023).

Cellulitis

A localized infection and inflammation of the skin and tissues beneath the skin is called cellulitis. It is most often caused by Streptococcus, Staphylococcus, and methicillin-resistant Staphylococcus aureus. The infection usually occurs when the bacteria enter open wounds, skin abscesses, fungal infections, or other skin conditions. Although cellulitis can occur anywhere on the body, it occurs most often on the legs and affects one side of the body. Bilateral cellulitis is rare, and its presence should warrant assessment of other health conditions (Chuang et al., 2022).

The infection generally presents with redness, tenderness, and pain. The skin also often becomes hot and swollen and may look slightly pitted. Fluid-filled vesicles (small blisters) or bullae (large blisters) may appear on the infected areas. Some patients may experience fever, rapid heart rate, headache, confusion, hypotension, or chills. If the infection spreads to the lymph nodes, the nodes can become tender and swollen, and the vessels can become inflamed. Treatment may include antibiotics, drainage of any abscesses, and treatment of any disorders contributing to the infection (Rehmus, 2023). Compression stockings (i.e., thromboembolic deterrent [TED] hose) may also be effective by reducing edema (swelling caused by excessive buildup of fluid in tissue spaces or a body cavity) and increasing blood flow.

Viral Infections

Viral skin infections are the result of a reaction from a systemic virus within the body or an infection of the skin itself. This type of infection encompasses a variety of conditions such as herpes simplex, herpes zoster, verruca, and human papillomavirus (Table 24.2). Viral skin infections are often contagious, and some may be passed by skin-to-skin contact or through the air when the infected individual coughs or sneezes.

Disorder	Description	Example
Herpes simplex	Infection caused by herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2)	(credit: “Herpes labialis - opryszczka wargowa” by Jojo/Wikimedia Commons, Public Domain)
Shingles	Rash associated with varicella-zoster virus	(credit: modification of “21506” by K.L. Herrmann/CDC, Public Domain)
Verruca	Growths on the skin caused by human papillomavirus	(credit: “Verruca vulgaris” by Abbassyma/Wikimedia Commons, Public Domain)

Table 24.2 Common Viral Skin Disorders

Herpes Simplex

A viral infection that can cause painful blisters or ulcers is called herpes simplex and is categorized into herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2). Most often, HSV-1 spreads by oral contact and causes infections in or around the mouth or lips. This virus presents as ulcers or blisters (cold sores). It can also cause genital herpes if an infected person made contact with another person’s genital mucosa. Herpes simplex virus type 1 is commonly spread through kissing, sharing objects that are in or near the mouth, and any other skin-to-skin contact. On the other hand, HSV-2 is spread by sexual contact and causes genital herpes. This virus usually presents as open sores, blisters, or bumps around the anus or genitals. It may also appear in the sacral area. The virus can also be spread from mother to baby during childbirth if the mother has an active outbreak.

Herpes Zoster

Chicken pox, or varicella, is caused by the varicella-zoster virus. After the initial illness has ended, the virus remains dormant in the dorsal root ganglia and can reactivate later in the person’s life causing a painful, maculopapular rash called herpes zoster (or shingles). Patients who have received a varicella vaccine are also at risk of developing herpes zoster later. The rash associated with shingles most often appears on the trunk of the body along a thoracic dermatome. The rash primarily stays on one side of the body, follows dermatomes, and does not cross the midline. Although not common, the rash can affect three or more dermatomes and is called disseminated zoster. This type of rash occurs in patients with a weakened or suppressed immune system. The symptoms are often painful, tingly, or itchy and may precede the appearance of the rash. Some patients may also experience headache, malaise (overall weakness) in the prodromal state (period between the appearance of initial symptoms and the full development of an illness), chills, or photophobia (bright light sensitivity). Vesicles develop into clusters, which continue to form over three to five days and gradually dry and crust over. The rash usually heals in two to four weeks and can leave scarring or pigmentation changes behind. Shingles can be prevented by the recombinant zoster vaccine. This virus can spread to others when it is active and can cause varicella in those who have never had varicella or been vaccinated against it. Antiviral medications, like valacyclovir and acyclovir, may also be used to shorten the length and severity of a shingles breakout.

Verruca

Warts, or verruca, are growths on the skin caused by the viral infection, human papillomavirus (HPV). The warts may appear raised or flat and can have a black dot in the middle. Warts are often not painful; although, some people may complain of pain. Warts may develop at any age but are more commonly found in children. Patients with warts may have as few as one or as many as hundreds. Warts are contagious and can spread from one area of the patient’s body to another body part or to another person through prolonged or repeated contact. Only a small break in the skin needs to be present for the virus to spread (Dinulos, 2023c). Genital warts, however, are spread by sexual contact.

Verrucae are classified by their shape and location. A type of wart that grows in clusters is referred to as a mosaic wart. Common warts are firm, round, or irregularly shaped growths with a rough surface. They may be brown, yellow, gray-black, or light gray and are generally less than 1 centimeter across. These warts appear on the face, fingers, elbows, and knees. A wart on the soles of the feet, known as a plantar wart, is usually flat due to the pressure of standing and walking. Warts that appear on the soles of the feet may cause pain when walking or standing. A wart found on the palms of the hand is called a palmar wart. Both palmar and plantar warts tend to be hard and flat with well-defined boundaries and a rough surface. Thick, cauliflower-like growths around the fingers are known as periungual warts. A long, small, narrow growth that appear on the lips, face, or eyelids is called a filiform wart. Typically smooth, flat topped, and either yellow-brown, pink, or flesh colored, flat warts may appear in areas that are shaved or along stretch marks. A wart (condyloma acuminata, venereal warts) occurring on the vagina, vulva, cervix, and penis is called a genital wart and can be either flat, smooth, and irregular or velvety bumpy growths with a cauliflower-like texture (Dinulos, 2023c).

Generally, warts are easily recognizable by appearance. Occasionally, a biopsy may be needed to confirm the diagnosis. Treatment options include applying topical chemicals and burning, cutting, or freezing the wart. A Candida yeast antigen may be injected into the warts causing an immune response to fight against the virus (Dinulos, 2023c). Warts may return even after removal. The human papillomavirus (HPV) vaccine may be used to prevent the spread of the virus. Patients with genital warts should have the warts removed to prevent spreading from person to person. They should also be educated on safe sex and the need to inform their partners of the diagnosis.

Fungal Infections

Fungal skin infections caused by fungus overgrowth most commonly occur in moist areas of the skin, such as between the toes, under the breasts, or in the genital areas. Fungal skin infections are usually caused by yeasts (e.g., Candida albicans) or dermatophytes (e.g., Microsporum). The fungi live on the stratum corneum and typically do not penetrate deeper into the skin. Patients who experience obesity are more likely to have fungal skin infections related to excessive skinfolds. Patients with diabetes are also at risk of fungal infections (Aaron, 2023). Common fungal skin infections include six types of tinea (Table 24.3).

Disorder	Description	Example
Tinea pedis	Also known as athlete’s foot; a fungal infection characterized by a buildup of scale and may be accompanied by redness and itching	(credit: “Athletes foot” by Ellington/Wikimedia Commons, Public Domain)
Tinea barbae	Also known as beard ringworm; generally a superficial infection but may occur deeper	(credit: modification of “4807” by CDC, Public Domain)
Tinea corporis	Also known as body ringworm; a fungal skin infection affecting the face, arms, trunk, and legs	(credit: modification of “Tinea corporis” by Mohammad3021/Wikimedia Commons, Public Domain)
Tinea cruris	Also known as jock itch; a fungal skin infection of the groin	(credit: modification of “21482” by Dr. Lucille K. Georg/CDC, Public Domain)
Tinea capitis	Also known as scalp ringworm; a fungal infection of the scalp	(credit: modification of “Tinea capitis clinical presentation” by Coulibaly O, Kone AK, Niaré-Doumbo S, Goïta S, Gaudart J, Djimdé AA, et al., CC BY 4.0)
Tinea unguium	Also known as onychomycosis; a fungal infection of the toenail or fingernail	(credit: modification of “579” by Dr. Edwin P. Ewing, Jr./CDC, Public Domain)

Table 24.3 Common Fungal Skin Disorders

Tinea

Known as ringworm, tinea may be found on the feet, beard, body, groin, scalp, or toes. Athlete’s foot, or tinea pedis, is characterized by a buildup of scale and may be accompanied by redness and itching. This infection is commonly caused by sweat from the feet accumulating between the toes allowing fungi to grow. This infection can spread to others who share showers, bathrooms, or other areas where infected individuals walk barefoot. Patients who wear tight shoes are also at risk of developing this infection. Fluid-filled blisters may also form with this infection. If the scaling is severe, the skin may crack and can lead to bacterial infections. Athlete’s foot may be treated by topical antifungal ointments or oral antifungals like itraconazole (Sporanox). Prevention measures include wearing sandals or shower shoes in communal bathrooms, wearing breathable shoes, frequently changing socks, minimizing moisture on feet and in footwear, and completely drying feet and in between toes after bathing. Antifungal powders may also be used to aid in keeping the feet dry (Aaron, 2023).

Beard ringworm, or tinea barbae, is generally a superficial infection but may occur deeper into the dermis. Tinea barbae is characterized by circular patches or a swollen patch that may ooze pus and can result in scarring or whisker loss. Most beard skin infections are caused by bacteria rather than fungi; however, tinea barbae is a fungal infection. Antifungal medications or corticosteroids are common treatments for beard ringworm (Aaron, 2023).

Body ringworm, or tinea corporis, is a fungal skin infection affecting the face, arms, trunk, and legs. This infection is characterized by round, pink-to-red patches with raised, scaly borders that can be itchy. Clearing in the center may also be present. This infection can spread from one area of an infected person’s body to another or from person-to-person contact. Antifungal medications may be applied topically or taken orally to treat this infection (Aaron, 2023).

Jock itch, known as tinea cruris, is a fungal skin infection of the groin. This is often characterized by a painful, itchy rash with a scaly, pink border. This infection is more common in men and is caused by trapped moisture between the scrotum and thigh. It most often develops in warm weather or when wearing tight or wet clothing. Patients experiencing obesity are at risk as well because of trapped moisture in skinfolds. The infection usually begins in the skinfolds of the genital area and spreads to the upper inner thighs. Antifungal medications may be taken orally or applied topically (Aaron, 2023).

Scalp ringworm, or tinea capitis, is a fungal infection of the scalp. This infection is characterized by a scaly, dry patch, a patch of hair loss, or both. The hair shafts may break at the surface (black dot ringworm) or break above the surface (gray patch ringworm). This infection can also cause dandruff-like flaking. A kerion may also be present. A kerion is a large, inflamed, swollen, and sometimes painful patch that can ooze pus. A culture may be needed to assess the type of fungus, or an ultraviolet light may be used to confirm the diagnosis. Treatment of scalp ringworm includes oral antifungals, antifungal creams, selenium sulfide (Selsun Blue) shampoos, or corticosteroids (Aaron, 2023).

A fungal infection of the toenail or fingernail is called tinea unguium. This infection is characterized by thickened nails that crumble easily and have white or yellow discoloration. The whole nail may become detached in more severe infections. If left untreated, the patient may have pain, balance issues, or a candidal infection. Treatment options include oral antifungals, topical ciclopirox olamine (Penlac) nail lacquer, and topical antifungals. Prevention is similar to that of preventing athlete’s foot.

Parasitic Infections

An organism that lives in or on an organism of a different species (the host), and depends on the host for nutrients is called a parasites. Parasitic skin infections occur when insects or worms burrow into the skin of a patient to lay their eggs or live there. Common parasitic skin infections include scabies and pediculosis (lice) (Table 24.4). Both infections are spread from person to person through physical contact. The parasites can live on physical objects such as brushes, clothing, furniture, and bedding; therefore, the parasites can spread to another person as well when contact is made with infested objects. Parasitic infections are generally treated by removing the source of the infestation as well as topical and oral medications to aid in killing the parasites and relieve any swelling, itching, or skin damage (Campbell & Soman-Faulkner, 2023).

Disorder	Description	Example
Scabies	Mites	(credit: “ScabiesDo3,” by Cixia/Wikimedia Commons, Public Domain)
Pediculosis capitis	Head lice	(credit: “Heavily infested hair with Pediculus humanus capitis (arrow)” by NIH, CC BY)
Pediculosis corporis	Body lice	(credit: Abdoul Karim Sangaré, Ogobara K. Doumbo, Didier Raoult, CC BY 4.0)

Table 24.4 Common Parasitic Skin Disorders

Scabies

Caused by the Sarcoptes scabiei mite, scabies are accompanied by extreme itching no matter how few mites have burrowed into the skin (Dinulos, 2023a). Initially, the burrows are often visible and can be anywhere on the body, except they are less likely on the face. The burrows appear as a thin line and can have a tiny bump where the mite is located. Darker skinned individuals may only display raised, solid areas. Due to the intense scratching, this infestation can often turn into a bacterial infection. Over time, the areas usually become inflamed, making the burrows less visible. Infestations that turn severe may cause areas of crusted, thickened skin that do not itch. Risk factors for attracting scabies are crowded conditions like schools, multifamily homes, and shelters. Hygiene is not a factor with scabies.

Pediculosis

A lice infestation is called pediculosis. Lice are wingless insects that are not easily seen and may infect the body, head, or pubic area. Each type of lice can cause severe itching and bites that range from red (body and head lice) to grayish blue (pubic lice). An infestation with lice may be diagnosed with the presence of lice, nits (eggs), or both. A fine-toothed comb may be needed to assess the hair for lice, and the nits may be easier to see versus the lice itself. Body lice are often found in the seams of clothing and bedding. Pubic lice may require an ultraviolet light or a microscope to be seen. Pubic lice may leave feces on the patient’s skin or underwear, which are characterized by dark brown specks. An infestation with lice will require replacing or thoroughly cleaning and drying linens and clothing. Items that are not able to be laundered can be placed in an airtight bag for two weeks to kill the lice. People who have close contact with an infected patient should also treat themselves, including sexual partners (Dinulos, 2023b).

Body lice (pediculosis corporis) live on and lay their eggs on bedding and clothing rather than the skin. The lice will migrate to various areas of the body to feed. Patients who live in crowded areas, have poor hygiene, or are of low socioeconomic status are more at risk of acquiring body lice. The lice spread because of sharing contaminated bedding and clothing. This type of lice can also transmit different types of fevers (Dinulos, 2023b). Treatment includes thoroughly cleaning linens and clothing.

Head lice (pediculosis capitis) are found on the hair and scalp. The lice lay eggs that take about one week to hatch and are called nymphs. It takes another seven days for the nymphs to reach their adult stage. The lice require a blood supply to live and will feed off their host several times a day. If the lice are deprived of blood, they will usually die within one to two days. Hygiene and socioeconomic status have no bearing on head lice. Shampoos that contain permethrin (Acticin), piperonyl butoxide (Red Pediculicide), or lindane are effective for treating head lice. Creams that contain malathion (Ovide) or spinosad (Natroba) suspensions may also be effective. Nits need to be removed with a fine-toothed comb. Treatments must be repeated seven to ten days later to kill any potential newly hatched lice. Ivermectin (Stromectol) may also be used if lice are resistant to medicated shampoos or creams (Dinulos, 2023b).

Pubic lice (pediculosis pubis), often referred to as crabs, infest the hairs of the anal and genital areas but can also infest the thigh, chest, and facial hair. This type of lice may be spread by sexual contact or close contact or by physical objects like linens and clothing. The same shampoos and creams used for head lice are effective for treating pubic lice. In addition, petroleum jelly, physostigmine ointment, fluorescein eye drops, petrolatum salve, and oral ivermectin (Stromectol) are effective for the lice that have infested a patient’s eyelashes (Dinulos, 2023b).

Inflammatory Reactions

Inflammatory skin reactions are either chronic or acute and are the result of a hypersensitivity reaction, an autoimmune disorder, or a genetic predisposition. These skin reactions may also recur when the stress factor or environmental trigger that caused the reaction are present. Inflammatory skin reactions include eczema, seborrheic dermatitis, urticaria, acne vulgaris, psoriasis, and systemic lupus erythematosus (SLE) (Table 24.5). These reactions require obtaining a comprehensive health history including family history, medications, diet, hygiene practices, and environmental conditions as well as a full assessment to identify possible triggers or causes.

Disorder	Description	Example
Eczema	Itchy, chronic inflammation of the skin	(credit: “Eczema-arms” by Jambula/Wikimedia Commons, Public Domain)
Seborrheic dermatitis	Inflammatory skin reaction primarily on the scalp and face	(credit: “Seborrhoeic dermatitis2” by Klaus D. Peter/Wikimedia Commons, CC BY 3.0)
Urticaria	Rash characterized by wheals and erythema	(credit: “Urticaria2” by Hyper84/Wikimedia Commons, Public Domain)
Acne vulgaris	Inflammatory skin reaction caused by clogged hair follicles	(credit: “Acne papulopustulosa” by Dr. Thomas Brinkmeier, CC BY 4.0)
Psoriasis	Recurring, chronic condition that causes red patches with silvery scales	(credit: “psoriasis on elbow” by Haley Otman/Wikimedia Commons, CC BY 3.0)
Systemic lupus erythematosus	Chronic, autoimmune inflammatory disorder, often presents with a butterfly rash	(CC BY 4.0; Rice University & OpenStax)

Table 24.5 Common Inflammatory Skin Disorders

Eczema

Atopic dermatitis, known as eczema, is part of the atopy family. Atopy means there is a genetic tendency to develop allergic conditions like asthma, eczema, and allergic rhinitis, and it is associated with a heightened immune response. This rash is characterized by itchy, chronic inflammation of the outer skin layers. In the acute phase, the rash may be red, oozing, and crusted areas with occasional blisters present. The chronic phase may have dry, thickened areas caused by scratching and rubbing. The rash may occur in one or more areas in adult patients and can spread to several areas on infants. The rash can vary in intensity, color, and location but is always itchy and triggers scratching, which can cause the skin to break and bleed. Stress, irritation, and dry air also make the itching more intense. Environmental triggers include harsh soaps, excessive bathing or handwashing, sweating, rough fabrics (e.g., wool), or Staphylococcus aureus present on the skin. Allergens like wheat, dairy, and eggs may also be a trigger. Tears in the skin caused by scratching or rubbing can often lead to bacterial infections.

Prevention includes minimizing triggers and managing stress. Treatments include skin care, ultraviolet light, corticosteroids, and biologic agents. General skin hygiene includes using soap substitutes, applying moisturizers after bathing, using lukewarm water, and patting skin dry. Antihistamines may also be used to relieve itching. Antibiotics may be needed when the reactions escalate to bacterial infections or for patients who are at risk of developing an infection (Ruenger, 2023). This reaction can be disabling and have long-term emotional effects that may require additional assessment and interventions to promote positive coping and body image.

Seborrheic Dermatitis

An inflammatory skin reaction called seborrheic dermatitis affects the scalp and may also be present on the face, around the ears, and occasionally on other areas that have oil glands present. This reaction is more common in infants and adult patients from 30 to 70 years of age. Genetic factors and cold-weather conditions affect the severity and risk of this disorder. The rash is characterized by greasy, yellow scales, pruritis, and dandruff.

Urticaria

Hives, or urticaria, is a type I hypersensitivity reaction resulting from an immunologically mediated antigen-antibody response of mast cells releasing histamine. This reaction is characterized by wheals (or hives) and erythema present after vasodilation and increased vascular permeability. The rash is easily identifiable by raised, swollen, flesh-colored or red bumps or welts on the skin. This reaction often begins rapidly and may be accompanied by swelling of the face, lips, throat, or airways (angioedema). The wheals can take several weeks to resolve.

Acne Vulgaris

Acne is a common inflammatory skin reaction causing pimples, papules, pustules, blackheads, whiteheads, cysts, or abscesses on various areas of the skin. These skin abnormalities vary in size, severity, and deepness into the skin layers. Caused by bacteria, dead skin cells, or dried sebum that clogs hair follicles, acne vulgaris prevents sebum from passing up through the pores (Figure 24.9).

Figure 24.9 There are several types of acne. The most common types are whiteheads, blackheads, pustules, papules, cystic acne, and nodules. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Mild acne includes blackheads, whiteheads, pimples, papules, and pustules and generally does not leave scars unless skin injury occurs when popping or squeezing the pimples:

• blackhead: flesh-colored, small bumps with a dark center
• whitehead: flesh-colored small bumps that do not have a dark center
• pimple: a small area of red skin that can be painful or cause discomfort
• pustule: similar to pimples but contain white or yellow pus

Severe acne is when patients have several blackheads, whiteheads, pimples, pustules, nodules, or deep acne (i.e., cystic acne). Lesions called cystic acne are usually larger, red, painful, and pus-filled nodules that merge under the skin and often leave scars.

Acne generally lessens in severity by the midtwenties but may appear to those in their forties. This type of skin reaction can cause emotional stress and may require counseling. General care for acne includes washing daily with a mild soap, using water-based cosmetics, and eating a balanced diet low in processed carbohydrates. Inflammatory foods like gluten or dairy may need to be limited because it can cause acne for some individuals. Blackheads and whiteheads can be removed by comedone extraction. This is the use of a comedone extractor by a healthcare professional to incise the pore and then use gentle pressure around the pore opening with a wire loop.

Psoriasis

A recurring, chronic skin condition called psoriasis causes one or more raised areas of red skin patches with silvery scales and a distinct border. Psoriasis is caused by an abnormally high rate of skin cell growth. This skin condition is immune mediated and often occurs because of a genetic predisposition. It can occur anywhere on the body. Various triggers may exacerbate this skin condition, but it is controllable. Flare-ups of psoriasis may be triggered by burns, colds or infections, stress, certain medications, cold weather, obesity, HIV, smoking, and inflammatory foods like gluten. Therapeutic management includes coal tar topical (Balnetar) shampoos, ultraviolet light, topical steroids, mineral oil, topical anti-inflammatories, emollient creams, immunosuppressants (e.g., methotrexate [Trexall]), and other medications (e.g., acitretin [Soriatane], infliximab [Avsola]). Patients who have identifiable triggers may need to engage in lifestyle modifications, such as limiting cold exposure or eliminating inflammatory foods, such as sugar and high fructose syrups (Das, 2023).

Systemic Lupus Erythematosus

A chronic autoimmune inflammatory disorder called systemic lupus erythematosus (SLE) involves connective tissues of the joints, skin, kidneys, mucous membranes, and blood vessel walls. This skin disorder, also known as lupus, can be diagnosed with blood tests or other diagnostic testing. Sudden fever is often the first symptom of this condition. The rash is characterized by round, raised, and reddened areas that can lead to skin loss, scarring, and hair loss. This skin disorder may also include a butterfly-shaped reddened area across the nose and cheeks. Light-exposed areas (e.g., face, scalp) also have clusters of the rash. The rash may be flat or have psoriasis-like characteristics, and those affected may experience painful joints and fatigue. Migraines, mental disorders, epilepsy, and organ dysfunction may also occur. Patients with SLE may experience lung problems (e.g., pleural effusion), heart problems (e.g., pericarditis), enlarged lymph nodes or spleen, kidney failure, decreased blood cells or platelets, gastrointestinal problems (e.g., nausea, pancreatitis), or pregnancy complications (e.g., miscarriage, stillbirth) (Nevares, 2022). People with SLE often also experience Raynaud syndrome, a condition that causes pale or blue fingers with cold exposure. Flare-ups of lupus may be triggered by infection, pregnancy, surgery, or sun exposure. Early detection is optimal for a better prognosis and limiting the risks of kidney and other organ damage.

Skin Cancer

The most common type of cancer is skin cancer, which has three main types: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma (Figure 24.10). Patients with fair skin and lower melanin production and patients who spend a significant time in the sun are at higher risk of all types of skin cancers. However, patients with darker skin and those who spend minimal time outdoors can still develop skin cancer.

Figure 24.10 The three main types of skin cancer include (a) basal cell carcinoma, (b) squamous cell carcinoma, and (c) melanoma. (credit a: “Basal cell carcinoma” by John Hendrix/Wikimedia Commons, Public Domain; credit b: “skin cancer, squamous cell carcinoma, face” by Kelly Nelson/National Cancer Institute, Public Domain; credit c: “Melanoma” by National Cancer Institute, Public Domain)

Basal Cell Carcinoma

The most common type of skin cancer, basal cell carcinoma, is generally found on the head or neck. This type of skin cancer rarely metastasizes to other parts of the body but does invade and gradually destroy surrounding tissues. Basal cell carcinomas grow slowly and can go unnoticed because of the gradual change. These tumors can grow near the eyes, mouth, nose, or ears. They can be serious but are not usually fatal. Most tumors generally grow into the skin. The lesions are small, shiny bumps that may break open, form a scab, and sometimes bleed or flatten and look like scarring. Although a healthcare provider can easily identify this type of lesion, a biopsy should be performed to confirm the type of cancer. Treatment options include removal of the tumor by curettage and electrodesiccation, cutting it out, or cryosurgery. Topical chemotherapy medications may be applied to the skin. Using lasers and chemicals on the skin, known as photodynamic therapy, and radiation therapy are also options. Larger areas of basal cell carcinoma may require the Mohs procedure, where layers of the skin are removed and examined for cancer cells until no signs of cancer remain. The healthcare provider (often a dermatologist) may use sutures, skin flaps, or skin grafts to replace the removed skin or refer the patient to a plastic surgeon for closure (Nambudiri, 2024).

Squamous Cell Carcinoma

The second most common type of skin cancer, squamous cell carcinoma, generally develops on sun-exposed areas but can grow where sun exposure is limited. Squamous cell carcinoma is the cancer of squamous cells, keratinocytes, the main epidermal structural cells. This type of skin cancer is more likely with patients who have precancerous growths like actinic keratoses, scarred skin, and chronic mucus membrane or skin sores. This skin cancer generally starts as a red area with a crusted, scaly surface that may turn into a raised, firm, wartlike surface. This lesion can become an open sore and grow into the underlying tissues. Biopsy is also best for diagnosing this type of cancer. The prognosis is generally excellent with early intervention. This type of cancer can metastasize and become fatal if not treated in time. Treatment options are similar to basal cell carcinoma but also include using an immune checkpoint inhibitor (e.g., PD-1 inhibitor [cemiplimab]). For patients who have large lesions that have metastasized or spread to the tissues underneath or cannot have surgery, PD-1 inhibitors help the body’s immune system annihilate the cancer (Nambudiri, 2024).

Malignant Melanoma

The most dangerous of the skin cancers, malignant melanoma, originates in the melanocytes. As sunlight increases melanin production, the risk of skin cancer increases. Melanoma metastasizes to distant parts of the body and can often go undetected, making it fatal. Those with undetected melanoma may not be diagnosed until affected organs of the body start displaying symptoms.

Melanoma may begin as a small, pigmented growth in a sun-exposed area or develop in a preexisting mole but can also occur in the mouth, on the genitals or rectal areas, in the brain, in nail beds, or in or around the eyes. Risk factors for melanoma include those mentioned for other skin cancers but also include those with previous history of skin cancer, large number of moles, weakened immune system, fair skin, freckles, family history of melanoma, advanced age, and large congenital melanocytic nevus.

Melanomas usually are identifiable by an atypical mole with irregular borders and inconsistent colors. Some may be flat, irregular brown patches with small black spots or can be raised brown patches with blue, black, red, or white spots. Melanoma can also be red, black, gray, and firm. A biopsy is needed for diagnosis. Nurses should understand the ABCDEs of melanoma and help educate patients on these warning signs (Table 24.6).

Letter	Meaning	Examples
A	Asymmetry = two halves of a mole are not equal	(credit: “Skin Cancer, Melanoma, Red And Brown Lesion 2” by Laurence Meyer/National Cancer Institute, Public Domain)
B	Borders = borders are irregular and seem to blend in or are not oval or round	(credit: “Skin Cancer, Melanoma, Brown Lesion” by Laurence Meyer/National Cancer Institute, Public Domain)
C	Color = existing mole changes color or moles that have drastically different colors than other moles present on the body	(credit: “Skin Cancer, Melanoma, Red And Brown Lesion 1” by Laurence Meyer/National Cancer Institute, Public Domain)
D	Diameter = more than ¼ inch (0.6 cm) wide	(credit: “Skin Cancer, Melanoma, Foot” by Kelly Nelson/National Cancer Institute, Public Domain)
E	Evolution = mole that changes (bleeds, enlarges, becomes tender, itches) or development of a new mole after the age of 30 years	(credit a: “Common Mole” by National Cancer Institute, Public Domain; credit b: “Melanoma” by National Cancer Institute, Public Domain)

Table 24.6 The ABCDEs of Melanoma

Everyone should be screened regularly for skin cancer by a healthcare provider or dermatologist. Nurses should take any opportunity to educate people about sun exposure and ways to help prevent skin cancer. Key points to educate patients include how to observe changes or unusual skin markings that they should report to their healthcare provider. Additionally, nurses should educate patients about avoiding the sun or seeking shaded areas, especially when the sun’s rays are the strongest (between 10 a.m. and 4 p.m.), wearing sunscreen with a sun protection factor (SPF) of at least thirty or greater, wearing protective clothing (e.g., hats, sunglasses, long sleeves), and avoiding the use of tanning beds (Nambudiri, 2024).

Patient Conversations

Tanning Beds and Cancer Risks

Scenario: A nurse is performing an annual checkup on a patient who subsequently states they have been an avid tanning bed user for more than thirty years.

Nurse: Hi. My name is Susie, and I will be your nurse today. May I have your name and date of birth?

Patient: Yes. Hi, my name is Tiffany Ball, date of birth is May 12, 1975.

Nurse: What medications are you currently taking?

Patient: None.

Nurse: Any known medication allergies?

Patient: No.

Nurse: The last time we saw you, your surgical history included a cesarean section. Is that correct? Any other surgeries?

Patient: Nope. Just that one so far.

Nurse: Thank you. Have you noticed any new spots on your skin or anything that may concern you?

Patient: I have not noticed anything.

Nurse: Okay, well if you are ready, I will let the provider know you are ready for the skin check.

[The provider comes in and, while performing the annual examination, notices a suspicious mole on the patient’s upper back. The provider removes it with the patient’s permission and sends it off to pathology for a biopsy. The provider leaves the room.]

Patient: Wow. So, what causes skin cancer? I hardly go outside.

Nurse: Do you have a family history of skin cancer? Do you use tanning beds?

Patient: I think my dad had a spot removed a few years ago. I have been tanning in a tanning bed since high school, so maybe thirty years or so. I was told a tanning bed was safer.

Nurse: Tanning beds do increase your risk of developing skin cancer due to the ultraviolet (UV) rays (e.g., UV-A, UV-B) that may be used.

Patient: Oh, so since I already have a spot anyway, I can still tan, right?

Nurse: Your results will come back from the laboratory, and then we can confirm whether or not it is cancerous. It is best to minimize your risks for skin cancer. Just because you have one potential spot does not mean you could not have another. The risks for skin cancer include family history and sun exposure especially between 10 a.m. and 4 p.m. If you are going to be in the sun, use sunscreen with an SPF of at least thirty, find shade often, and wear protective clothing like long sleeves, pants, and wide-brimmed hats.

Patient: So, what are you saying about using tanning beds?

Nurse: Tanning beds do not offer a safe alternative to sunlight. Unfortunately, they also increase the risk for skin cancers, including melanoma, the deadliest form of skin cancer.

Health Promotion and Behavioral Considerations

Health promotion as it relates to skin integrity includes lifestyle choices and behaviors that promote healthy skin. Those with impaired skin integrity should be careful with their hygiene practices and behaviors to avoid further aggravating their skin conditions. Some behaviors that help protect the skin include the following:

• using pH-balanced or mild soaps when bathing
• patting dry versus rubbing, which makes skin more prone to friction tears or other skin damage
• using emollients that moisturize and soften the skin
• avoiding the use of detergents that contain fragrance
• avoiding the use of deodorant soaps
• eliminating triggers

Any possible infectious skin lesions should be observed for signs of improvement or worsening. Drainage is a possibility from skin lesions; therefore, nurses should follow standard and transmission-based precautions when assessing the skin or changing dressings. Standard precautions may include wearing gloves, gowns, masks, or face shields as needed and disposing of them properly after use. Any contaminated dressings should also be disposed of according to organizational policies. Patients who have lesions may need to be educated on proper at-home wound care.

Nurses should educate patients and families on adequate hygiene and proper skin care for prevention of impaired skin integrity. Other behaviors that promote adequate skin integrity should also include understanding the importance of routine skin checks, minimizing sun exposure during the time of day when the ultraviolet rays are the strongest, wearing protective clothing while in the sun, and using sunscreen. Age-related and cultural considerations should be taken into consideration when providing education on health promotion behaviors for impaired skin integrity.

Age-Related Considerations

Newborns have thinner skin that is more sensitive and susceptible to rashes (e.g., contact dermatitis), newborn acne, and seborrheic dermatitis. Newborns cannot care for themselves; therefore, caregivers should be educated on the need to keep the newborn and caregiver nails trimmed to avoid scratching the baby. They should also be educated on signs and symptoms of common skin irritations as well as prevention actions and treatment options.

Toddlers and preschoolers are more prone to accidents because of their high activity levels and difficulties with mobility. They may fall or run into inanimate objects that may lead to lacerations, burns, or other abrasions. Caregivers should be educated to implement safety precautions to prevent injuries. For example, padding sharp corners may prevent accidents.

Head lice, impetigo, scabies, and rashes are more common in school-age children and adolescents. Acne vulgaris generally starts during adolescence and can lead to an impaired body image, which may require counseling. This age group typically wants to be more independent, so education may be needed to ensure proper skin care.

Skin changes as people age (see 24.1 Structures and Function of the Skin). Older adults should focus on adequate nutrition and hydration, especially ensuring adequate protein intake to promote wound healing. Older adults may have impaired mobility, making adequate hygiene difficult or impossible for this age group to perform. Therefore, it is important that the nurse or caregiver promote appropriate skin care, prevention, and intervention with impaired skin integrity. Some skin changes are benign, such as cherry angiomas, seborrheic keratoses, spider angiomas, wrinkles, dryness (xerosis), neurodermatitis, liver spots, melasma, telangiectasia (red marks on the skin caused by widening of shallow blood vessels), and hair loss.

Culturally Related Considerations

Nurses should remember that cultural considerations regarding skin conditions are common but may be different among various cultures and ethnic groups (see 24.1 Structures and Function of the Skin). Patients with fair skin produce less melanin and are more at risk of skin cancers than darker skinned individuals. However, patients with darker skin are more susceptible to post-inflammatory hyperpigmentation, dermatosis papulose nigra, keloids, hair loss, pityriasis, vitiligo, and dry skin. Other considerations include cultures that may not believe in medical interventions. For example, people who follow the Amish religion may not believe in accepting outside medical care or interventions. The nurse should not make assumptions but should assess beliefs and preferences as well as provide education to the patient and their family members regarding the skin disorder, treatment options, and risks of not being treated. The patient should be allowed to decide what interventions they do or do not want to receive without bias from the nurse. The nurse should also analyze a patient’s cultural preferences when developing a plan of care to promote healing and improve skin integrity.