1. Pediatric Integumentary System (illustration  illustration)

General

1. Pediatric difference: thinner skin
   1. Newborn's skin thinner, more easily hurt by endotoxins and infection, shearing and tearing forces
   2. Child's body absorbs more of topical products
   3. Harder to regulate body temperature
2. Factors in skin condition
   1. Age
   2. Hydration and nutrition
   3. Soap, laundry detergents, and topical products
   4. Medications
   5. Infectious processes (viral, bacterial, fungal)
   6. Mechanical forces (tearing, friction, shearing) & vascular damage
   7. Tape and adhesive products
   8. Allergy
   9. IV infiltration
   10. Temperature
   11. Bodily secretions: urine, stool, ostomy drainage, fistula
       
3. Wounds, wound healing, modes of skin care
   1. Assessment
      1. acute or chronic: etiology of pressure, shearing, trauma
      2. measurements: depth, size, location, "tunneling", open, closed
      3. staging: partial or full thickness, complex (involving muscle, bone)
   2. Factors impacting wound healing (illustration)
      1. perfusion, oxygenation
      2. nutrition
      3. infection
      4. underlying systemic condition
      5. topical products utilized
   3. Principles of successful wound management
      1. remove or eliminate causative factors
      2. provide appropriate systemic support: fluids, nutrition
      3. apply appropriate topical products: encourage moist wound healing and process of occlusion.
   4. Evaluation of successful wound healing
      1. type: primary, secondary or tertiary wound closure
      2. measurement: decreasing size, viable tissue, decreased exudate, color
   5. Modes of caring for skin disorders
      1. non-surgical: skin care products, nutrition, healthy lifestyle
      2. surgical: debridement, skin grafts and flaps
         

Noninfectious Skin Conditions

4. Atopic dermatitis (eczema) (illustration)
   1. Etiology: genetic tendency, multifactorial with family history of allergies or asthma; exacerbated by stress and certain foods
   2. Pathophysiology: trigger- increased histamine release with inflammatory response - itching and findings of exacerbation
   3. Findings
      1. dry skin, itching, erythema
      2. macule, papule, pustuleand even vesiclespossible
      3. acute weeping areas with excoriated red plaques
   4. Diagnostics
      1. family history
      2. physical exam
      3. lab tests (eosinophils, IgE)
   5. Management
      1. goals: control itching, moisturize, remove irritants and allergens, and prevent secondary problems (infections)
      2. products: wet compresses, occlusive dressings, creams/ointments, hydrocortisone cream, mild detergents
      3. medications: antihistamines
      4. elimination diet
      5. other: remove allergens, short fingernails, clothe lightly to decrease sweating
         
5. Seborrheic dermatitis (in infants: cradle cap)
   1. Recurrent inflammatory reaction of skin
   2. Etiology: probable dysfunction of sebaceous glands
   3. Findings: usually nonpruritic oily scales on scalp, forehead and eyebrows or behind ears
   4. Management: scalp hygiene with mild baby shampoos, hydration creams, baby oil
      
6. Diaper dermatitis ("diaper rash") (illustration)
   1. Etiology
      1. ammonia in urine, fecal enzymes, detergents, moisture, heat
      2. can lead to secondary fungal infection (especially candida albicans)
   2. Pathophysiology
      1. prolonged contact with irritant (especially urine ammonia, which is formed by urea breakdown from fecal bacteria); inflammation
      2. excoriation, with macules/papules and erosion
      3. concern: secondary infection.
   3. Findings: red, excoriated, macules/papules, maceration
   4. Management
      1. cleaning and frequent diaper changes
      2. skin protectants/moisture barriers to keep skin dry
      3. topical antifungals and steroids
      4. if diarrhea, treat underlying cause
7. Contact dermatitis (illustration)
   1. Etiology: multiple factors and irritants foods, solutions, allergens, plants
   2. Findings: irritant and allergic types
      1. irritant: causes dry, inflamed, pruritic lesions where irritant touched
      2. allergic: blisters after weeping, pruritic, lesions
   3. Management: topical (antiinflammatory, antipruritic) cold compresses, supportive care
      
8. Acne vulgaris
   1. Etiology: multifactorial (heredity, hormones, emotions)
   2. Pathophysiology
      1. puberty - increased androgens
      2. increased sebaceous glands secrete more sebum
      3. pores become plugged and dilated
      4. fatty acids are oxidized on skin and form blackheads OR
      5. internal fatty acids form whiteheads
      6. rupture causes local inflammation, sometimes with pustules
   3. Findings: whiteheads (closed comedomes), blackheads (open comedomes), papules, pustules, nodules, red and excoriated skin
   4. Management
      1. general: good cleansing, nutrition, no squeezing or picking
      2. topicals: vitamin A, topical antibiotics, topical benzoyl peroxide
      3. oral: antibiotics, possible estrogen for girls
   5. Concerns: scarring, bacterial invasions, body image, education needed on myths and realities of causative agents and treatment modalities, compliance

Infectious Disorders - Bacterial Infections of Skin

9. Impetigo contagiosa
   1. Etiology: staphylococcus aureus, group A beta-hemolytic streptococcus
   2. Pathophysiology: starts in area of broken skin - highly contagious for seven to ten days
   3. Findings
      1. primary: macules-vesicles of bulla that rupture (illustration)
      2. secondary: honey-colored crusts, superficial erosion, easily bleeds, pruritic
   4. Management
      1. careful removal of crusts/debris with warm soapy solution or Burow's solution
      2. topical antibiotics for early small lesions
      3. treatment of choice: systemic antibiotics
      4. short fingernails
   5. Concerns: highly contagious (good hand washing, no sharing towels or eating utensils)
      
10. Cellulitis: infection of dermis and/or subcutaneous tissue
    1. Etiology: strep, S. aureus, Haemophilus influenza
    2. Pathophysiology
       1. starts in area of broken skin
       2. highly contagious for days
       3. can occur on any part of the body
    3. Findings
       1. affected area (red, edema, tender, occasional discoloration)
       2. enlarged lymph nodes, "streaking" frequently seen, fever, malaise, headache
    4. Diagnostics: CBC, cultures, possible skin culture, CT
    5. Management: oral or parenteral antibiotics, warm moist compresses, possible incision and drainage, rest
    6. Concerns: secondary infection, alteration in skin integrity
       
11. Herpes simplex type one (oral herpes, cold sore, fever blister) (illustration 1  illustration 2)
    1. Etiology: HSV-1 or HSV-2, cytomegalovirus (CMV), Epstein Barr (infectious mononucleosis), Varicella zoster
    2. Pathophysiology: virus infects body fluids, which then come in contact with breaks in the skin or mucous membranes:
       1. HSV-1 affects areas above the waist; "cold sore"
       2. HSV-2: affects areas below the waist; genital
       3. virus dormant within nerve cells; then reactivated by fever, stress, trauma, sun exposure, menstruation
    3. Findings
       1. often depend on location in body
       2. prodromal period common
       3. vesicles, pain, pruritis, paresthesias, increased skin sensitivity at site
    4. Diagnostics: history, physical exam, smears, tissue cultures
    5. Management - symptomatic: fluids; possible antiviral or antibiotic if secondary infection; analgesics
    6. Concerns: highly contagious, secondary infection, pain, body image; HSV-2 is sexually transmitted