Friday, January 14, 2011
Skin disease: Nummular Dermatitis
A pruritic dermatosis, characterized by round tooval (coin-shaped) areas of vesiculation, superficial crusting, andredness. Numberoflesionsvariesfrom few to many. More often this is a symmetrical pattern in young adults. Not related to atopic dermatitis.
Sunday, January 9, 2011
Skin Functions
The skin is a multifunction organ. Its structure is uniquely designed to enable it to undertake each of these functions and cope with a range of environments.
1) Barrier function
The skin is an incredibly effective barrier to the outside world – at its simplest, it keeps the outside world out and the inside in – quite literally it holds the human body together. However, the skin is not just a simple inert envelope; the barrier
it provides is complex and offers physical, chemical and immunological protection.
2) Physical protection
The analogy that is most commonly used to describe the physical barrier properties of the skin is that of a brick wall. In this instance, the layer that really is of interest is the horny layer of the epidermis. Corneocytes form the top layer of skin, these heavily keratinised cells need to be well-hydrated to form a complete barrier – they are the bricks in the wall. These bricks are ‘cemented’ with lipids. As the skin is constantly shedding, it is physically difficult for pathogenic
organisms to take hold.
3) Chemical protection
The surface of the skin is covered in commensal organisms. These ‘friendly’ bacteria and fungi live in harmony with humans and indeed offer a level of protection from pathogenic or disease- causing organisms. The commensals have
evolved to be able to thrive in the slightly acidic environment of the skin surface.
Skin cells are provided with inbuilt protection from UV radiation by melanin. In the upper layers of the epidermis, melanin is scattered throughout the cells providing protection, whilst in the lower layers the protection is specifically
targeted as the melanin granules form ‘umbrellas’ over the nuclei of the basal and spinous cells. Physical and chemical barriers form part of the body’s innate defence system.
1) Barrier function
The skin is an incredibly effective barrier to the outside world – at its simplest, it keeps the outside world out and the inside in – quite literally it holds the human body together. However, the skin is not just a simple inert envelope; the barrier
it provides is complex and offers physical, chemical and immunological protection.
2) Physical protection
The analogy that is most commonly used to describe the physical barrier properties of the skin is that of a brick wall. In this instance, the layer that really is of interest is the horny layer of the epidermis. Corneocytes form the top layer of skin, these heavily keratinised cells need to be well-hydrated to form a complete barrier – they are the bricks in the wall. These bricks are ‘cemented’ with lipids. As the skin is constantly shedding, it is physically difficult for pathogenic
organisms to take hold.
3) Chemical protection
The surface of the skin is covered in commensal organisms. These ‘friendly’ bacteria and fungi live in harmony with humans and indeed offer a level of protection from pathogenic or disease- causing organisms. The commensals have
evolved to be able to thrive in the slightly acidic environment of the skin surface.
Skin cells are provided with inbuilt protection from UV radiation by melanin. In the upper layers of the epidermis, melanin is scattered throughout the cells providing protection, whilst in the lower layers the protection is specifically
targeted as the melanin granules form ‘umbrellas’ over the nuclei of the basal and spinous cells. Physical and chemical barriers form part of the body’s innate defence system.
Saturday, January 8, 2011
Skin care
A considerable amount of data is collected through the process of history taking and examination; however, the key outcome needs to be an informed clinical decision regarding the patient’s need for nursing, medical support and a plan for intervention. Clinical judgements are made not only on information gathering, both
clinical and about the person and their social context, but also account needs to be taken of other factors, such as the patient’s own beliefs and priorities and the resources available to intervene effectively. Here brief reference is made to the knowledge that informs clinical judgements and a brief outline of the key theories that describe and explain how clinical decisions are made. These are intended to raise awareness of the complexity of the decision-making process and what elements need to be considered when trying to formulate effective clinical judgements. Finally, the section briefly highlights issues of prioritisation in dermatology care and which ‘red flag’ skin conditions require a rapid response to minimise patient risk.
clinical and about the person and their social context, but also account needs to be taken of other factors, such as the patient’s own beliefs and priorities and the resources available to intervene effectively. Here brief reference is made to the knowledge that informs clinical judgements and a brief outline of the key theories that describe and explain how clinical decisions are made. These are intended to raise awareness of the complexity of the decision-making process and what elements need to be considered when trying to formulate effective clinical judgements. Finally, the section briefly highlights issues of prioritisation in dermatology care and which ‘red flag’ skin conditions require a rapid response to minimise patient risk.
Monday, December 27, 2010
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Saturday, December 25, 2010
Radiotherapy
Other factors affecting skin breakdown
Malignancy can affect the skin barrier when the pathological process leads to a breakdown in skin integrity, such as a malignant fungating wound, which may include mycosis fungoides, a type of cutaneous T-cell lymphoma. Whilst such problems will require wound care, the effects of cancer treatments can have implications for skin
care. Iatrogenic effects or the effects of medical treatment on the skin such as radiotherapy effects and adverse drug reactions (ADRs) are now examined.
care. Iatrogenic effects or the effects of medical treatment on the skin such as radiotherapy effects and adverse drug reactions (ADRs) are now examined.
The effects of urine and incontinence on the skin
The effects of urinary incontinence on skin vulnerability are another neglected area of nursing investigation. Despite the scale of the problem, the effects and prevention of urine exposure on skin barrier disruption has
received limited research attention. The prevalence of urinary incontinence provides an indication of the potential significance of the problem. It is estimated that 200 million people worldwide have significant
urinary incontinence and many more with mild bladder problems, with a high occurrence among people living in institutional settings. Obesity affects 20% of the population in UK (National Audit Office, 2001). It is
a major health problem in most affluent countries and is likely to lead to skin vulnerability due to the formation of skin folds. Children are another vulnerable group; it is estimated that in the UK 500,000 experiencenocturnal enuresis (persistent bedwetting). Although incontinence may not of coursen accompany older age, an increased incidence of multiple disabilities in this group may contribute to reduced ability to maintain continence, making this group vulnerable to skin damage. The skin of an incontinent person will be
exposed to regular contact with urine, sweat and possibly faeces. As such, the skin is vulnerable to chemical irritation by urine and physical effects caused by wetness of the skin that encourages maceration; these can disrupt the skin barrier and lead to breakdown. The decomposition of urinary urea by microorganisms release ammonia to form the alkali, ammonium hydroxide, thereby disrupting the acid mantle. Chemical irritation of the skin may arise from both the rise in alkalinity and bacterial proliferation. Perineal dermatitis may arise from urine exposure, which is characterised by inflammation of the skin, and may include redness, tissue breakdown, oozing, crusting, itching and pain within the perineal area. Faecal incontinence may present even more risk to skin integrity. It is more common in the general population than is often realised and the survey
cited above suggests 5.7% of women and 6.2% of men over 40 years living in their own homes report some degree of faecal incontinence. Overall, 1.4% of adults reported major faecal incontinence (at least several times a month) and 0.7% had disabling incontinence with a major impact on their quality of life. Excess moisture can increase the friction coefficient, making the skin more vulnerable to breakdown due to friction forces. This, coupled with frequent washing of the incontinent patient’s skin, can disrupt skin barrier function by removal of skin lipids and the acceleration of epidermal water loss (further examination is given later). A number of studies reveal a general association between urinary incontinence and pressure sores, but few demonstrate a causal link. For example, a study of nursing home residents by Schnelle et al. (1997) demonstrated that skin problems tend to occur in areas where there has been consistent excessive skin wetness (hydration) through urine exposure. These findings are consistent with supporting experimental evidence that skin exposed to urine due to infrequent pad change can increase the wetness of the skin; the increase in friction and abrasion predisposing it to breakdown. Prolonged exposure to water alone may cause
hydration dermatitis and prolonged occlusion of the skin (as within a continence product) may reduce skin barrier function and significantly raise microbial counts and pH.
Consideration also needs to be given to the effects of drying practices related to washing practices. An excessively dry stratum corneum can develop cracks and fissures and can be as ineffective a barrier as an over-hydrated one (Tsai and Maibach, 1999). Dry and scaling skin contributes to the risk of pressure ulcer
development, although only limited evidence has been found. Those with dry or scaling skin have been found to be at least 2.5 times more likely to develop wounds from skin breakdown compared
to a matched control group, based on one of the largest studies (n 5, 193) examining predictors of pressure sores in the community (55–75 years). As a risk factor, dry skin is not reflected in pressure risk scales,
which focus on the key role of moisture. Aside to dry and over-hydrated skin, some patients also develop sore skin in which there is erythema due to inflammatory effects and a damaged skin barrier. Again, the issue of sore skin is another area given scant attention in the literature.
received limited research attention. The prevalence of urinary incontinence provides an indication of the potential significance of the problem. It is estimated that 200 million people worldwide have significant
urinary incontinence and many more with mild bladder problems, with a high occurrence among people living in institutional settings. Obesity affects 20% of the population in UK (National Audit Office, 2001). It is
a major health problem in most affluent countries and is likely to lead to skin vulnerability due to the formation of skin folds. Children are another vulnerable group; it is estimated that in the UK 500,000 experiencenocturnal enuresis (persistent bedwetting). Although incontinence may not of coursen accompany older age, an increased incidence of multiple disabilities in this group may contribute to reduced ability to maintain continence, making this group vulnerable to skin damage. The skin of an incontinent person will be
exposed to regular contact with urine, sweat and possibly faeces. As such, the skin is vulnerable to chemical irritation by urine and physical effects caused by wetness of the skin that encourages maceration; these can disrupt the skin barrier and lead to breakdown. The decomposition of urinary urea by microorganisms release ammonia to form the alkali, ammonium hydroxide, thereby disrupting the acid mantle. Chemical irritation of the skin may arise from both the rise in alkalinity and bacterial proliferation. Perineal dermatitis may arise from urine exposure, which is characterised by inflammation of the skin, and may include redness, tissue breakdown, oozing, crusting, itching and pain within the perineal area. Faecal incontinence may present even more risk to skin integrity. It is more common in the general population than is often realised and the survey
cited above suggests 5.7% of women and 6.2% of men over 40 years living in their own homes report some degree of faecal incontinence. Overall, 1.4% of adults reported major faecal incontinence (at least several times a month) and 0.7% had disabling incontinence with a major impact on their quality of life. Excess moisture can increase the friction coefficient, making the skin more vulnerable to breakdown due to friction forces. This, coupled with frequent washing of the incontinent patient’s skin, can disrupt skin barrier function by removal of skin lipids and the acceleration of epidermal water loss (further examination is given later). A number of studies reveal a general association between urinary incontinence and pressure sores, but few demonstrate a causal link. For example, a study of nursing home residents by Schnelle et al. (1997) demonstrated that skin problems tend to occur in areas where there has been consistent excessive skin wetness (hydration) through urine exposure. These findings are consistent with supporting experimental evidence that skin exposed to urine due to infrequent pad change can increase the wetness of the skin; the increase in friction and abrasion predisposing it to breakdown. Prolonged exposure to water alone may cause
hydration dermatitis and prolonged occlusion of the skin (as within a continence product) may reduce skin barrier function and significantly raise microbial counts and pH.
Consideration also needs to be given to the effects of drying practices related to washing practices. An excessively dry stratum corneum can develop cracks and fissures and can be as ineffective a barrier as an over-hydrated one (Tsai and Maibach, 1999). Dry and scaling skin contributes to the risk of pressure ulcer
development, although only limited evidence has been found. Those with dry or scaling skin have been found to be at least 2.5 times more likely to develop wounds from skin breakdown compared
to a matched control group, based on one of the largest studies (n 5, 193) examining predictors of pressure sores in the community (55–75 years). As a risk factor, dry skin is not reflected in pressure risk scales,
which focus on the key role of moisture. Aside to dry and over-hydrated skin, some patients also develop sore skin in which there is erythema due to inflammatory effects and a damaged skin barrier. Again, the issue of sore skin is another area given scant attention in the literature.
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