2. Out lines
Anatomy & physiology Overview
Common terms
Description of skin lesion
Assessment of skin
Diagnostic tests
Disorder of skin
Burn
29-Feb-24 AW 2
3. Anatomy over view
The skin consists of 3 layers:
–Epidermis- non vascular outermost layer,
continuously dividing cells
–Dermis- takes the largest portion of the skin
and provides strength and structure. It
consists of glands (sebaceous, sweat), hair
follicle, blood vessels, and nerve endings
–Subcutaneous tissue (hypodermis)- the
inner most layer. contains major vascular
networks, fat, nerves, and lymphatics
29-Feb-24 AW 3
6. Function of the skin
• Protection- protection of underlying structures from
invasion by bacteria, noxious chemicals and foreign
matter.
• Sensory perception- transmits pain, touch, pressure,
temperature, itching, etc
• Fluid balance (excretion)- absorption of fluids and
evaporation of excess.
• Temperature regulation- produced heat released
through skin by radiation, conduction, and convection
• Vitamin synthesis- skin exposed to ultra violet light
can convert substances necessary for synthesizing
vitamin D3 (cholecalciferol).
• Aesthetic- provides beautiness and appearance
29-Feb-24 AW 6
7. Factors influencing skin integrity
• Immoblity is the major factor leading to
pressure sore development .
• The pt who is confined to bed & unable to
change position is at greatest risk .
• Trauma most likely occur
– over the prominent areas
– weight bearing areas
29-Feb-24 AW 7
8. Factors influencing Cont ..d
•Prolonged pressure impairs blood flow to
tissue & results in ischemia & infarction
• The extent of pressure necessary to cause
tissue damage depnds on the tolerance of
the pt's skin & supporting structures .
29-Feb-24 AW 8
9. Tolerance to pressurs trauma is
influenced by the following factors:
–Duration of pressure
–Magnitude of pressure
–Body position
–Friction
–Impaired mobility
–Malnutrition
–Dehydration
29-Feb-24 AW 9
10. COMMON DERMATOLOGIC TERMS
• Lichenification: distinictive thickening of
skin
• Crust: dried exudate of body fliuds
• Erusion: epithelial deficiet
• Ulcer: epithelial deficiet (disruption of deep
skin integrity)
• Atrophy: an acquired loss of substance
• Scar:change in the skin secondery to
trumas or inflammation
29-Feb-24 AW 10
11. Description of skin lesion
• primary lession
I. circumscribed , flat , nonpalpable
changes in
skin color
• Macule = small upto 1 cm, eg. petechia
• Patch = larger than 1 cm , eg vitilligo
29-Feb-24 AW 11
12. Description of skin lesion Cont …d
• II. Palpable elevated solid masses
–Papule: up to 0.5cm eg. elevated nevus
–Plaque: elevated surface > 0.5 cm
–Nodule: deeper & firmer than papule
=> 0.5 -1-2cm eg tumor
–Wheal: irregular, superficial area of
localized
skin edema
29-Feb-24 AW 12
13. Description of skin lesion Cont …d
• III. Superficial elevation of skin formed by
free
fluid in a cavity in the skin layer.
• Vesicle: up to 0.5 cm
=> filled c serous fluid,eg herps simplex
• Bulla: > 0.5 cm, Filled of serous fluid, eg
2nd
degree burn ( blister)
• Pustule: filled pus, eg impetiao, acne
29-Feb-24 AW 13
14. Description of skin lesion Cont …d
Secondary lesion
I. Loss of skin surface
• Erusion => loss of superficial epidermis
• Ulcer => deep loss of skin surface
=> May bleed & scar, eg. sphilic chancre
• Fissure => linear creak in the skin
eg.A thlet's foot
29-Feb-24 AW 14
15. Description of skin lesion Cont …d
Secondary lesion Cont …d
On skin surface:
• curst = dried residue of serum ,pus or blood,
eg Impetigo
• Scale = a thin flake of exfoliative epiderms
eg.dandruff, Dry skin, Psoriasis
29-Feb-24 AW 15
16. Vascular skin lesions
• a lesion that originated from a blood vessel
–Petechia/Purpura
–Ecchymosis
–venous star
29-Feb-24 AW 16
17. Skin lesion configuration
• Linear- in line
• Annular and arciform –circular or arcing
• Zosteriform- linear along a nerve route.
• Grouped -clustered lesion
• Discrete -separate and distinict
• Confluent- lesions that run together or join
• Generalized- widespread eruption
• Localized- lesions on distinct area
29-Feb-24 AW 17
18. Assessing the skin
• Assessment includes a thorough
- history taking,
-inspection and
-palpation of the skin.
29-Feb-24 AW 18
24. Assessing the general appearance of
the skin
• The general appearance of the skin is assessed
by observing (Inspection) color, skin lesions, and
vascularity.
• On palpation skin turgor and mobility, possible
edema, temperature, moisture, dryness,
oiliness, tenderness, and skin texture (rough and
smooth).
29-Feb-24 AW 24
25. Color change
Can be hyperpigmentation,
hypopigmentation or depigmentation
1. Redness- fever, alcohol intake, local
inflammation due to increased blood flow to the
skin.
2. Bluish color (cyanosis) - decreased oxygen
supply due to chronic heart and lung disease,
exposure to cold, and anxiety
29-Feb-24 AW 25
26. Cont …d
3. Yellowish color (jaundice) - increased serum
bilirubin
concentration due to liver disease or red blood cell
haemolysis
- Uremia- renal failure
4. Brown-tan- Addison’s disease: cortisol deficiency
stimulates increased melanin production
- Birth mark, chloasma of pregnancy (face patches),
and sun exposure
5. Pale: Albinism- total absence of pigment melanin
• Vitiligo- destruction of the melanocytes in
circumscribed areas of the skin
29-Feb-24 AW 26
30. Diagnostics test
Skin biopsy: removal of a piece of skin by
shave, punch, or excision technique for a
microscopic study of the skin to determine the
histology of cells to rule out malignancy and to
establish an exact diagnosis.
Patch testing: performed to identify substances
to which the patient has developed an allergy.
Potassium hydroxide test (KOH): helps to
identify fungal skin infection
29-Feb-24 AW 30
31. Cont …d
Gram stain and culture with sensitivity test:
helps to identify the organism responsible for
an underlying infection with the effective drug
identification
Slit Skin Smear (SSS): to identify the causative
agent of leprosy (mycobacterium leprea)
29-Feb-24 AW 31
32. Disorder of the skin
I . Inflammatory and allargic skin disorders
– Acne
– Psoriasis
– Atopic dermatitis (eczema)
– Contact dermatitis
II. Bacterial infections
– Impetigo – Boil (furuncle) – Carbancle – Cellilitis
29-Feb-24 AW 32
33. Disorder of the skin…
III. fungal infections
Candidiasis
Tinea captis
Tinea corporis
Tinea pedis (atlet's foot)
29-Feb-24 AW 33
34. Disorder of the skin…
IV. Viral infections
Herpes simplex (cold - sore)
Herpes zoster (shingles)
Warts
29-Feb-24 AW 34
35. Inflammatory and allergic condition
A. Eczema/Dermatitis - It is a chronic pruritic
inflammatory disorder affecting the epidermis, and
dermis commencing in infancy, often persisting
throughout child hood but eventually remitting
and some times recurring in adult life.
They are a non-infectious inflammation of the
skin and it can be acute, sub-acute or chronic.
29-Feb-24 AW 35
37. Cont ….d
Causes
The exact cause is unknown
Imbalance of the immune system with an
increase in the immunoglobulin “E” activity and
deficient of cell mediated delayed
hypersensitivity.
Can be exacerbated by infection, bites, pollen,
wool, silk, fur, ointments, detergents, perfume,
certain foods, temperature extremes, humidity,
sweating and stress
29-Feb-24 AW 37
38. Sign and symptom
An acute stage eczema shows redness, swelling,
papules, blisters, oozing and crusts.
In the sub-acute stage the skin is still red but
becomes drier and scalier and may show
pigment change.
In the chronic stage -lichenification, -
excoriation, -scaling and cracks are seen
29-Feb-24 AW 38
39. Types of eczema
Atopic eczema - is a chronic relapsing skin disorder
that usually begins in infancy and is characterized
principally by dry skin and pruritis, consequent
rubbing and scratching lead to lichenification
This patient has a genetic predisposition for
hypersensitivity reactions such as asthma,
allergic rhinitis, and chronic urticaria.
The eczema comes and goes
The eczema triggered by dryness of the skin,
infections, heat, sweating, contact with allergens
or irritants and emotional stress.
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40. Eczema Cont …d
Mostly affected sites are elbow and knee
folds, wrists, ankles, face, and neck; in some
cases it can be generalized
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41. Seborrhoic eczema
- is a very common chronic dermatitis
characterized by redness and scaling that
occurs in regions where the sebaceous glands are
most active, such as:
Scalp, border of forehead/scalp
Behind ears, above and in between eyebrows
In nasolabial folds,
Sternum –In between the shoulder blades,
in axillae –Groin ,
Perianal area
29-Feb-24 AW 41
42. Seborrhoic eczema
Under the breast , umbilicus and in body folds
Pts often complains of oily skin
The eczema comes and goes
In HIV patients, the eczema can become very
widespread and easily super infected
29-Feb-24 AW 42
43. Infective eczema
• which occurs as a response to an oozing skin
infection.
• Common sites are the foot, and ankle region
• Causative organisms are usually staphylococci/
streptococci
• Vaseline use aggravates this condition
29-Feb-24 AW 43
44. Contact eczema
• is caused by contact of the skin with an irritant or
an allergen.
• Vaseline commonly causes: Vaseline dermatitis.
• Common causes of irritant contact eczema on
hands, arms and legs are excessive use of soap
(especially if not washed off properly)
• detergents, chemicals, sunlight, jewellery,
• dyes, bleaches, perfume, nail polish/remover, etc
29-Feb-24 AW 44
45. Sign and symptom of eczema/
dermatitis
Itching
Redness, dry skin, lichenification,
excoriation, scaling skin
Papules, blisters, oozing and crusts
Color change
29-Feb-24 AW 45
46. Management (general)
Stop the use of irritants (contact eczema)
Mild topical steroid such as
hydrocortisone 1% cream twice daily until
lesions clear.
In severe itching use antihistamines E.g.:
promethazine 25mg at night,
chlorphenaramine 4mg at day time/night
29-Feb-24 AW 46
47. Management Cont …d
In bacterial super infection use KMNO4
solution, Betadine solution, antibiotics
Explain to the Patient, and Parents that
not serious and will disappear in time.
Keep finger nails short and covered at
night
Use non greasy or non moisturizers
(seborrhoic eczema)
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48. Management Cont …d
An imidazole cream twice daily/ketaconazole
200 mg/d 1-3 weeks (seborrhoic eczema)
The vicious circle of itch – scratch –
lichenification – itch needs to be broken , (atopic
eczema)- conscious effort to stop scratching
In photo allergies – sun protection by wide rim
sun hat, long sleeves, high collar, sunglasses, stay
indoor, sunscreen, umbrella, etc
Keep the site clean
29-Feb-24 AW 48
49. Acne
- Is a common disorder of the sebaceous gland
associated with excess production of sebum
and blockage of the duct resulting in a
variety of inflammatory manifestations.
Common in puberty and usually regresses in
early adult hood
Patient complain of oiliness of the skin.
- Occurs on the face, upper trunk and Shoulders
- Appears to be multiple inflammatory papules,
pustules and nodules
29-Feb-24 AW 49
50. Acne Cont ….d
It can be very mild to be very severe: - they
blend together to form large inflammatory
areas with cysts and scar formation.
Cause-genetic, hormone and bacteria play a
role
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51. Acne Cont ….d
Sign and symptom
Red nodules, cyst , red papules, scars, pustules,
keloids
There may be mild soreness, pain or itching
Inflammatory papules, pustules, pores acne
cyst, scarring
Diagnosis
Clinical – Cyst formation, slow resolution,
scarring
Common at puberty and common of all skin
conditions
29-Feb-24 AW 51
52. Management
Stop the use of vaseline, oil, ointment,
greasy cosmetics which further blocks
sebaceous ducts.
Benzoyl per oxide 5-10% gel or tretinoin
0.01- 0.1% cream or gel apply at night.
Salicylic acid 1-10% in alcoholic solution for
removal of excess sebum.
For pustular/inflammatory lesions use
topical clindamycin 1% solution,
erythromycin 2% lotion
29-Feb-24 AW 52
53. Management Cont …d
In severe cases use systemic long term
antibiotics like doxycycline 100mg twice
daily until substantial improvement
followed by 100mg once daily until
acceptable.
Surgical treatment – extraction of
comedones, incision and drainage of large
fluctuant, nodulocystic lesions
29-Feb-24 AW 53
54. Psoriasis
Is a chronic recurrent, hereditary, non
infectious disease of the skin caused by
abnormally fast turn over of the epidermis
The turn over may be up to 40 times than
normal and as a result the epidermis is not able
to develop normally, therefore it doesn’t allow
formation of the normal protective layer of the
skin.
29-Feb-24 AW 54
55. Psoriasis Cont …d
• Skin become red, inflamed, and the scales are
thicker than normal
• It produces a so called candle-wax phenomenon,
when you scratch such a patch it becomes silvery
white.
• Sites can be extensor areas of extremities
especially elbow, knees, buttocks, shoulder and
scalp
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58. Psoriasis Cont …d
• Cure is there but it reoccurs
• Occurs at any age but 10-35 years is common
mostly.
• Periods of emotional stress and anxiety
aggravate the condition.
Sign and symptom.
• May itch severely in body folds covered with
silvery scales
• Finger and toenails may show pitting and
thickening
• Associated arthritis
29-Feb-24 AW 58
59. Management
Explain to the Pt the recurrent nature of the
disease.
Salicylic acid 2-10% ointment twice daily to
reduce scaling
Moisturizers (Vaseline, paraffin oil, or cream)
Treat any super infection with KMNO4 , or
antibiotics if necessary
Psoriatic arthritis NSAIDS E.g: Ibuprofen,
Indomethacin, and ASA
Methotrexates as a last option in sever cases.
29-Feb-24 AW 59
60. Infection of the skin(pyoderma)
1. Cellulitis
Is a diffuse, acute streptococcal or staphylococcal
infection of the skin and subcutaneous tissue
Cause
Caused by bacteria’s like
streptococcus/staphylococcus aureus
Results from break in skin
Infection rapidly spread through lymphatic
system
29-Feb-24 AW 60
61. Infection of the skin
1. Cellulitis
Sign and symptom
• Tender, red, hot, indurated and swollen area that
is well demarcated
• Possible fluctuant abscess or purulent drainage
• Fever, chills, and malaise
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66. 2. Furunclosis
Is an acute painful infection of perifollicular
abscess (boils)
Is an acute, localized, deep seated, red, hot,
very tender, inflammatory perifollicular
abscess.
Common microorganism: staphylococcus
aureus
Most common on persons who are carriers of
staphylococcus, contact with oils or grease,
diabetes, poor habits of personal hygiene,
immunosuppression, alcoholism, obese,
malnourished, etc
29-Feb-24 AW 66
67. 2. Furunclosis
Is an acute painful infection of perifollicular
abscess (boils)
Is an acute, localized, deep seated, red, hot, very
tender, inflammatory perifollicular abscess.
Common microorganism: staphylococcus aureus
Most common on persons who are carriers of
staphylococcus, contact with oils or grease,
diabetes, poor habits of personal hygiene,
immunosuppression, alcoholism, obese,
malnutrited, etc
29-Feb-24 AW 67
68. 2. Furunclosis
The lesion begins in the opening of hair follicle
or sebaceous gland
Sites can be back of the neck, face, buttocks,
thighs, perineum, breasts, axilla, nose, genitallia,
etc
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70. Sign and symptom
• Hard nodule initially then fluctuant abscess
with centrally yellow pustule, then ruptures in
to an ulcer.
• It can be isolated single lesion or few multiple
lesion
• Hotness and pain at the site.
Diagnosis
• Gram stain of the pus
• Culture and sensitivity test of blood/pus
29-Feb-24 AW 70
71. Treatment
• Warm compresses -
• Warn patient not to squeeze or incise the
lesion
• Incision and drainage when it is fluctuance.
• Systemic antibiotics (cloxacillin,
erythromycin)
• Rest especially for genital areas.
• For the sever pain codien, morphine
29-Feb-24 AW 71
72. 3. Carbuncles (multiple furuncles)
- Is an aggregation of interconnected furuncles
that drain through multiple openings in the skin.
• Exposure to grease and oil increase the risk.
• Occurs mostly where the skin is thick
• Microorganism mostly: staph. aureus
Sign and symptom
• Sites are back of the neck, shoulder, buttock,
outer aspect of the thigh and over the hip
joints.
29-Feb-24 AW 72
73. 3.Carbuncles
•Develop slowly than furuncle
• They can reach the size of an egg/small
orange.
• Fever, chills, extreme pain, malaise.
• Because of the large size of the lesion and
its delayed drainage the patient is much
sicker
29-Feb-24 AW 73
75. Diagnosis
• Gram stain Of The Pus
• Culture Of Pus/Blood
• Leucocytosis (12,000-20,000 Mm3)
Normal 4,000-10,000mm3
Treatment
• The Same As Furuncle, Plus
• Avoid Friction And Irritation From Tight
Clothing.
29-Feb-24 AW 75
76. 4. Folliculitis
Is inflammation of the hair follicle
Sign and symptom
Single or multiple papules or pustules
Commonly seen in the beard area of men and
women’s legs from shaving
Pseudofolicullitis barbae(PFB) also known as
Shaving bumps.
Management
Warm compress to relieve pain
Clean with antibacterial soap
Topical antibiotic ointment
Systemic antibiotics for recurrent cases
29-Feb-24 AW 76
78. 5. Impetigo
Is an acute, contagious, rapidly spreading
cutaneous infection and is a very common bacterial
infection of the superficial skin
Causative agents are stap. aureus or
a B-hemolytic streptococcus or both
Sign and Symptom
• Superficial pustules or blisters which becomes oozing
with yellow crusts
• Contagious
• Blisters break easily and form golden crusts
Diagnosis
Clinical
Culture and sensitivity
29-Feb-24 AW 78
80. Management
• KMNO4 bath or wet dressing-in mild forms
• Prevent spreading by not sharing towels and
ointment, change clothes, towels and sheets
frequently.
• In severe forms give cloxacillin 250-500mg QID daily
for 7-10 days in adults, and 50-100mg/kg/24 hours
divided in to 4 doses for children.
• Erythromycin 250-500mg 4 times daily for 7-10 days
in adults, and 25-50mg/kg/24hrs divided in to 4 doses
for children
• Cut finger nails short to minimize damage to lesion
and to prevent autoinoculation from scratching
29-Feb-24 AW 80
81. Fungal skin disorder
1. Dermatophytoses (Mycoses)
• Is a fungal infection of the skin, hair and nails
Types
A. Tinea pedis (Athlete’s foot)
• Is itchy, whitish scaling lesions and inflammation
of the superficial skin of the feet and interdigital
spaces of the toes
• Common between the 4th and 5th toe.
• Often seen in people wearing rubber boots/shoes
29-Feb-24 AW 81
83. Management
• Keep the space in between the toes dry
• wear cotton socks
• Avoid shoe that are too tight/hot
• changing socks daily prevents reinfection.
• Imidazole cream/ whitfield’s ointment twice daily
until symptoms disappear for a total of 4 weeks
• Treat secondary bacterial infection if present
29-Feb-24 AW 83
84. Management Cont …d
B. Tinea corporis (Tinea circinata)
• A fungal infection that affects the trunk, legs,
arms/neck, excluding the beard area, feet, hands
and groin
Is fungal infection of the skin most common on
the exposed surfaces of the body.
Sites are face, arms and shoulders.
Intensive itching is there
Frequent causes of tinea corporis is the presence
of an infected pet in the home
29-Feb-24 AW 84
85. Management Cont …d
• Imidazole cream/whitfield’s ointment twice daily
for a minimum of 4 weeks
• Multiple, widespread lesions may be treated
systematically
• Griseofulvin 500mg once daily for 2-6wks (10-
15mg/kg)
• Ketaconazole 200mg once/twice daily
• When there is sever itching antihistamines /mild
steroids can be added
29-Feb-24 AW 85
87. C. Tinea capitis (ring worm)
• Is a contagious fungal disease of the scalp and
hair shaft
Sign and symptom
• One or more round patches with scaling
• Hair loss (temporarly), alopecia
• Lymphnodes in the neck swell and the patient
may have fever and headache
Diagnosis
Clinical
Microscopy of affected hairs and skin(KOH)
29-Feb-24 AW 87
89. Treatment
Griseofulvin for 6 weeks
Shampoo hair 2 or 3 times with Nizoral or
selenium sulfide shampoo.
29-Feb-24 AW 89
90. D. Tinea unguium
- Is a chronic fungal and some times mixed yeast
infection of the toe/finger nails
• Is commonly occurs in people who frequently
wet the hands such as domestic workers, cleaners,
kitchen and laundary staff
Sign and Symptom
• Nail become thickened, friable (easily
crumbled), lusterless
• Accumulation of debris under the free edge of
the nail
• The nail may be destroyed
29-Feb-24 AW 90
92. Treatment
- use ketaconazole 200mg/d until symptoms
clear. (Itraconazole 200mg/d x 3 months, or
Itraconazole 200mg bid x 1week per month
during 3 months)
• Keep the site dry
29-Feb-24 AW 92
93. E. Tinea versicolor (pityriasis versicolor)
Is a common chronic superficial fungal
infection which is caused by the unicellular
yeast pityrosporum ovale or orbiculare
which is normally present on the trunk as a
commensal.
Often there is cosmetic complaints
29-Feb-24 AW 93
95. Sign and Symptom
• Appears commonly when there is warm and
humid air, pregnancy, and serious underlying
disease
• Hypopigmented macule on the trunk
• Disturbance of the pigment of the skin
(versicolor)
• Recurrences are common especially after in
adequate treatment or re-infection.
Diagnose
Clinical
Microscopy
29-Feb-24 AW 95
96. Management
• Scrubbing the skin with a brush takes away a lot
of the infected scales.
• Imidazole cream twice daily on affected areas
for 4 weeks.
• Add selenium sulphide suspension /ketaconazole
2% shampoo twice weekly.
• Selsun shampoo to affected areas overnights as a
lotion or to affected areas and the scalp for 10
minutes daily for 2-4 weeks.
29-Feb-24 AW 96
97. F. Tinea cruris (Jack itch)
• A fungal infection of the groin, pubic region and thighs
Sign and symptom
• Scaling at the periphery
• A patch that may spread to buttocks
• Starts from groin and advancing down to inner thigh •
Itching and irritation
Diagnosis
• Clinical,
KOH
Management
• Treat with topical antifungal or systemic antifungal for
sever cases
• Reduction of moisture in groin
• Wash contaminated under wear in hot water
29-Feb-24 AW 97
98. G. Tinea barbae
• Is a fungal infection involving the beard
• Affects males only
• More common in farmers
Sign and symptom
• Pruritis
• Tenderness and pain
• Pustular folliculitis around the hair follicle
• Involved hairs are loose and easily removed
Management:
Systemic antifungal
29-Feb-24 AW 98
100. H. Candidiasis /moniliasis/
• Candida albicans is a resident of the mucus
membranes, it becomes pathogenic under
favourable host condition these are:
When host immunity is decreased, such as HIV,
cancer, steroid use, cytotoxic drugs, radiotherapy,
chronic disease, pregnancy and contraceptive pill
use
Warm and moisture (groins, under breasts, b/n
toes)
Use of broad spectrum antibiotics which kills
resident non pathogenic bacteria
29-Feb-24 AW 100
101. Sign and Symptom
On the oral (oral candidiasis/thrush)- white
cheesy adherent plaque that can be painful
When oral lesions extend to the throat and
esophagus they can cause anorexia, nausea,
dysphagia, and vomiting
On the vulvovagina (candidia vulvovaginitis)
vaginal irritation, soreness and a thick creamy
discharge
29-Feb-24 AW 101
102. Management
• Keep lesions of the skin dry
• Paint mucosal /smaller wet lesions with Gentian
violet daily
• Nystatin cream, oral suspension twice daily for skin/
oral / miconazol oral gel 4 x /d x 1week
• Imidazole pessaries nightly for 2 weeks for vaginal
candldiasis
• Imidazole cream twice daily for skin infections
• Ketaconazole 200mg twice daily for 1-2weeks for
oesophageal candidiasis
• Itraconazole 100mg/d x 2weeks
• Fluconazole 50-200mg /d x 1-2weeks
29-Feb-24 AW 102
103. Parasitic skin disorder
A. Scabies
Is an infection of the skin caused by a parasite called
mite sarcoptes scabiei, a mite which lays its eggs in
burrow in the stratum and induces an intensively
itchy allergic response
Sign and Symptom
• Small blisters and papules
• Sever itching, when warm particularly at night
• Scratch marks and very common secondary
infection with pustules
• Common sites are between fingers, sides of the
hands, sides of the wrists, buttocks
29-Feb-24 AW 103
104. Parasitic skin Cont …d
Management
• Treat all close contacts of the patient and family
Benzyl benzoate 25% emulsion for adult, dilute
with one part water (1:1) for children, dilute with 3
parts water (1:3) for infants.
Apply for 3 consecutive nights. Wash off each
morning.
• Sulphur 5-20% ointment twice daily for 1-2
Weeks
29-Feb-24 AW 104
105. B. Pediculosis
• Is an infestation with a louse which may be
found in the:
• Scalp- Pediculosis capitis
• Body- Pediculosis corporis
• Hair bearing region- Pediculosis pubis
(phthiriasis)
Sign and symptom
• Itching (excoriation)
• The presence of lice and nits
• Over crowding, poor personal hygiene, prolonged
wearing of the same cloth
29-Feb-24 AW 105
106. B. Pediculosis
Management
• Improve personal hygiene
• Improve living condition
• Change clothing
• Treat secondary bacterial infection if
present
All articles, clothing, towels, and bedding
that may have lice or nits should be washed
in hot water—at least 54°C (130°F)
29-Feb-24 AW 106
107. B. Pediculosis
Management
The patient is instructed to shampoo the
scalp and hair according to the product
directions.
After the hair is rinsed thoroughly, it is
combed with a fine-toothed comb dipped
in vinegar to remove any remaining nits or
nit shells freed from the hair shafts.
29-Feb-24 AW 107
108. F. Viral skin disorder
It is an acute contagious short lived (7-12
days) infection of the skin or mucus
membrane caused by virus
Types:
A. Herpes simplex
• Is an infection which is caused by herpes
simplex virus that causes vesicular eruption
(cold sore or fever blister) on lip (herpes
labialis), and on genitalia (herpes genitalia)
29-Feb-24 AW 108
109. A. Herpes Simplex Cont …d
Herpes simplex is a common skin infection.
There are two types of the causative virus,
which are identified by viral typing.
Generally, herpes simplex type 1 occurs on
the mouth and type 2 in the genital area,
but both viral types can be found in both
locations.
29-Feb-24 AW 109
111. Sign & symptoms
Few days of burning sensation at the site initially
and tingling sensation
- Then a group of blisters appear which quickly
break down to form superficial ulcer
- Highly contagious when the lesions are visible
Diagnose
• Clinical
• smear
29-Feb-24 AW 111
112. Management
• Primary infection-since they are painful:
Analgesia
• Lips: Zinc oxide ointment to soothe and
protect from sun light
• Zinc oxide ointment plus castor oil
• Antiseptic mouth wash: Chlorhexidine 3-4
times daily
29-Feb-24 AW 112
113. Management
• TTC skin ointment 3 times daily for secondary
bacterial infection
• Genital: KmNo4 (Betadine) sitz bath 3 times a day
• TTC ointment application 3 times a day
• Zinc oxide and castor oil to soothe
• For severe infections or infections in
immunocompromised patients Acyclovir 200-400 mg
five times daily for 5-10 days either topically or
systematically
• Recurrence can be triggered by:
- Exposure to sun light (herpes labialis)
-Oral sex, fever, stress, etc
29-Feb-24 AW 113
114. B. Herpes zoster (shingles)
• Is an acute unilateral and segmental
inflammation of the dorsal root ganglia of a nerve
by a latent varicella zoster infection in the partially
immune host.
Herpes zoster, also called shingles;
The viruses causing chickenpox and herpes zoster
are indistinguishable, hence the name varicella-
zoster virus.
29-Feb-24 AW 114
115. B. Herpes zoster (shingles) Cont ..d
Herpes zoster represents a reactivation of latent
varicella virus infection and reflects lowered
immunity.
Much more common in HIV patients, old
patients, and malignancy cases
29-Feb-24 AW 115
116. B. Herpes zoster (shingles) Cont …d
Sign and symptom
The eruption is usually accompanied or preceded by
pain.
The early vesicles, which contain serum, later may
become purulent, rupture, and form crusts.
The inflammation is usually unilateral, involving the
thoracic, cervical, or cranial nerves in a bandlike
configuration (it follows the dermatome).
The blisters are usually confined to a narrow region
of the face or trunk
The clinical course varies from 1 to 3 weeks.
If an ophthalmic nerve is involved, the patient may
have eye pain.
29-Feb-24 AW 116
117. B. Herpes zoster (shingles) Cont …d
Medical Management
The goals of herpes zoster management are to
relieve the pain and to reduce or avoid
complications, which include infection, scarring,
and postherpetic neuralgia and eye
complications.
Pain is controlled with analgesics, because
adequate pain control during the acute phase
helps prevent persistent pain patterns.
29-Feb-24 AW 117
118. B. Herpes zoster (shingles) Cont …d
Medical Management
Systemic corticosteroids may be prescribed for
patients older than age 50 years to reduce the
incidence and duration of postherpetic neuralgia
(ie, persistent pain of the affected nerve after
healing).
Analgesia with NSAIDs
Antibiotics for secondary infections
If the eye is involved immediately refer to
ophthalmologist
For immunocompromised patients Acyclovir 800mg
5 times daily for 1 week
Amitryptline 75mg at night Night/Carbamazepine
600-800mg/day
29-Feb-24 AW 118
119. B. Herpes zoster (shingles) Cont …d
Medical Management
Over 10% of patients develop a persistent
burning sensation.
29-Feb-24 AW 119
120. C. Verrucae /Warts/
• Are common benign skin tumors caused by infection
with the Human Papilloma Virus.
Types:
1. Plantar warts- warts on the sole of the foot
2. Plane (flat/Juvenile) warts- warts on the face of
children
3. Genital warts/condylomata acuminate/- warts that
appear on genital organs
4. Molluscum contagiosum- a wart which appear on
small children which has typical characteristics of
central dimple and dome shaped papules
29-Feb-24 AW 120
121. Sign and symptom
• Found at any age but most common in children and teenagers
• They can spread by contact
• The infected person immune system clears the warts with in 2
years in 2/3 cases
Management
• Freeze with liquid nitrogen - Molluscum contagiosum
• Salicylic acid 50% twice daily followed by scraping the
warts –Plantar warts
• Salicylic acid 2-5% ointement twice daily for 4-8 weeks
– Plane warts
• Silver nitrate pencil touch- daily - Plane warts
• Podophyllin 10-25% solution apply weekly by using match
sticks and wash off after 4-6 hours- Genital warts
• Threat partners - Genital warts
29-Feb-24 AW 121
122. TOXIC EPIDERMAL NECROLYSIS
AND STEVENS-JOHNSON SYNDROME
Toxic epidermal necrolysis (TEN) and Stevens-
Johnson syndrome (SJS) are potentially fatal skin
disorders and the most severe form
of erythema multiforme.
The mortality rate from TEN approaches 30%.
Both conditions are triggered by a reaction to
medications or result from a viral infection.
Antibiotics, antiseizure agents, butazones, and
sulfonamides are the most frequent medications
implicated in TEN and SJS
29-Feb-24 AW 122
123. Clinical Manifestations
TEN and SJS are characterized initially by
conjunctival burning or itching, cutaneous
tenderness, fever, cough, sore throat, headache,
extreme malaise, and myalgias.
These signs are followed by a rapid onset of
erythema involving much of the skin surface and
mucous membranes;
including the oral mucosa, conjunctiva, and
genitalia.
In severe cases of mucosal involvement, there may
be danger of damage to the larynx, bronchi, and
esophagus from ulcerations.
Large, flaccid bullae develop in some areas;
29-Feb-24 AW 123
124. Clinical Manifestations
In other areas, large sheets of epidermis are
shed, exposing the underlying dermis.
Fingernails, toenails, eyebrows, and eyelashes
may be shed along with the surrounding
epidermis.
29-Feb-24 AW 124
125. Medical Management
The goals of treatment include control of fluid
and electrolyte balance, prevention of sepsis,
and prevention of ophthalmic complications.
Supportive care is the mainstay of treatment.
All nonessential medications are discontinued
immediately.
Iv fluids, may be at regional burn center.
Corticosteroids may be administered.
Various topical antibacterial and anesthetic
agents
29-Feb-24 AW 125
126. CYSTS
Cysts of the skin are epithelium-lined cavities
that contain fluid or solid material.
Epidermal cysts (ie, epidermoid cysts) occur
frequently and may be described as slow-
growing, firm, elevated tumors found most
frequently on the face, neck, upper chest, and
back.
Removal of the cysts provides a cure.
29-Feb-24 AW 126
127. KELOIDS
Keloids are benign overgrowths of fibrous tissue
at the site of a scar or trauma.
They appear to be more common among
darkskinned people.
Keloids are asymptomatic but may cause
disfigurement and cosmetic concern.
The treatment, which is not always satisfactory,
consists of surgical excision, intralesional
corticosteroid therapy, and radiation.
29-Feb-24 AW 127
128. Skin cancer
Exposure to the sun is the leading cause of skin
cancer;
incidence is related to the total amount of
exposure to the sun.
Sun damage is cumulative, and harmful effects
may be severe by age 20 years.
Skin assessment-20-39 age-every 3 years
>40 age -annually
29-Feb-24 AW 128
129. Risk factors for Skin cancer
Changes in the ozone layer from the effects of
worldwide industrial air pollutants, such as
chlorofluorocarbons
Exposure to chemical pollutants (industrial workers
in arsenic, nitrates, coal, tar and pitch, oils and
paraffins)
Sun-damaged skin (elderly people)
History of x-ray therapy for acne or benign lesions
Scars from severe burns
Chronic skin irritations
Immunosuppression
Genetic factors
29-Feb-24 AW 129
130. BASAL CELL AND SQUAMOUS
CELL CARCINOMA
The most common types of skin cancer are
basal cell carcinoma (BCC) and squamous
cell (epidermoid) carcinoma (SCC).
The third most common type, malignant
melanoma,
Skin cancer is diagnosed by biopsy and
histologic evaluation.
29-Feb-24 AW 130
131. C/M
BCC is the most common type of skin cancer. It
generally appears on sun-exposed areas of the
body
The incidence is proportional to the age of the
patient (average age of 60 years) and the total
amount of sun exposure, and it is inversely
proportional to the amount of melanin in the
skin.
29-Feb-24 AW 131
132. C/M cont …d
The tumors appear most frequently on the face.
BCC is characterized by invasion and erosion of
contiguous (adjoining) tissues.
It rarely metastasizes, but recurrence is common.
29-Feb-24 AW 132
133. C/M Cont …d
SCC is a malignant proliferation arising from the
epidermis.
Although it usually appears on sun-damaged
skin, it may arise from normal skin or from
preexisting skin lesions.
It is of greater concern than BCC because it is a
truly invasive carcinoma, metastasizing by the
blood or lymphatic system.
Metastases account for 75% of deaths from SCC.
29-Feb-24 AW 133
134. C/M Cont …d
The lesions may be primary, arising on the
skin and mucous membranes, or
They may develop from a precancerous
condition, such as actinic keratosis (ie,
lesions occurring in sun-exposed areas),
leukoplakia (ie, premalignant lesion of the
mucous membrane), or scarred or
ulcerated lesions.
29-Feb-24 AW 134
135. Prognosis
The prognosis for BCC is usually good,
tumors remain localized,
SCC depends on the incidence of
metastases, which is related to
the histologic type and the level or depth of
invasion.
29-Feb-24 AW 135
136. Medical Management
The goal of treatment is to eradicate the
tumor.
The treatment method depends on:
the tumor location;
the cell type,
location,and depth;
the cosmetic desires of the patient;
the history of previous treatment;
29-Feb-24 AW 136
137. Medical Management
The management of BCC and SCC
includes:
surgical excision,
Mohs’ micrographic surgery,
electrosurgery,
cryosurgery, and
radiation therapy.
29-Feb-24 AW 137
138. MALIGNANT MELANOMA
A malignant melanoma is a cancerous
neoplasm in which atypical melanocytes (ie,
pigment cells) are present in the epidermis
and the dermis (and sometimes the
subcutaneous cells).
It is the most lethal of all the skin cancers
and is responsible for about 2% of all
cancer deaths
29-Feb-24 AW 138
139. MALIGNANT MELANOMA
It can occur in one of several forms:
superficial spreading melanoma, lentigo-
maligna melanoma, nodular melanoma,
and acral-lentiginous melanoma.
These types have specific clinical and
histologic features as well as different
biologic behaviors.
29-Feb-24 AW 139
140. MALIGNANT MELANOMA
Lentigo-maligna melanomas are slowly
evolving, pigmented lesions that occur on
exposed skin areas, especially the dorsum
of the hand, the head, and the neck in
elderly people.
They first appear as tan, flat lesions, but in
time, they undergo changes in size and
color.
29-Feb-24 AW 140
141. MALIGNANT MELANOMA
Nodular melanoma is a spherical, blueberry-like
nodule with a
relatively smooth surface and a relatively
uniform, blue-black color (see Fig. 56-7).
It may be dome shaped with a smooth surface.
It may have other shadings of red, gray, or
purple.
Sometimes, nodular melanomas appear as
irregularly shaped plaques.
The patient may describe this as a blood blister
that fails to resolve.
29-Feb-24 AW 141
142. MALIGNANT MELANOMA
Acral-lentiginous melanoma occurs in areas
not excessively exposed to sunlight and
where hair follicles are absent.
It is found on the palms of the hands, on
the soles, in the nail beds, and in the
mucous membranes in dark-skinned
people.
These melanomas appear as irregular,
pigmented macules that develop nodules.
They may become invasive early.
29-Feb-24 AW 142
143. Prognosis
The prognosis for long-term (5-year)
survival is considered poor when the lesion
is more than 1.5 mm thick or there is
regional lymph node involvement.
29-Feb-24 AW 143
144. Other Malignancies of the Skin
KAPOSI’S SARCOMA
First described by Moritz Kaposi in 1872,
Kaposi’s sarcoma (KS) has received renewed
attention since its association with HIV
infection and AIDS.
Its occurrence with AIDS involves a more
varied and aggressive form of KS than was
seen previously.
29-Feb-24 AW 144
145. Other Malignancies of the Skin
KAPOSI’S SARCOMA
Before the AIDS epidemic, KS was
considered a rare malignancy.
It was subdivided into three categories:
classic KS,
African (endemic) KS, and
KS associated with immunosuppressant
therapy.
29-Feb-24 AW 145
146. Other Malignancies of the Skin
Classic KS:
Most patients have nodules or plaques
on the lower extremities that rarely
metastasize beyond the lower
extremities.
This KS is chronic, relatively benign, and
rarely fatal.
29-Feb-24 AW 146
147. Other Malignancies of the Skin
African (endemic) KS :
Men are affected more often than
women, and children can be affected as
well.
The disease may resemble classic KS, or it
may infiltrate and progress to
lymphadenopathic forms.
29-Feb-24 AW 147
148. Other Malignancies of the Skin
KS associated with immunosuppressant
therapy:
is characterized by local skin lesions and
disseminated visceral and mucocutaneous
diseases.
The greater the degree of
immunosuppression, the higher is the
incidence of KS.
29-Feb-24 AW 148
149. Medical Mgt
Dermatologic and Plastic Reconstructive
Surgery
The word plastic comes from a Greek word
meaning to form.
Plastic or reconstructive surgery is
performed to reconstruct or alter
congenital or acquired defects to restore or
improve the body’s form and function.
29-Feb-24 AW 149
150. Purpose of plastic surgery
To repair defect (reconstruction)
To restore function (restoration)
To replace lost part
For better appearance
To install prosthetic implants
For complete change of identity
29-Feb-24 AW 150
151. WOUND COVERAGE: GRAFTS AND
FLAPS
Skin Grafts
Skin grafting is a technique in which a
section of skin is detached from its own
blood supply and transferred as free tissue
to a distant (recipient) site.
29-Feb-24 AW 151
152. WOUND COVERAGE: GRAFTS AND
FLAPS
Flaps:
A flap is a segment of tissue that remains
attached at one end (ie, a base or pedicle) while
the other end is moved to a recipient area.
Its survival depends on functioning arterial and
venous blood supplies and lymphatic drainage
in its pedicle or base.
A flap differs from a graft in that a portion of
the tissue is attached to its original site and
retains its blood supply. An exception is the free
flap,
29-Feb-24 AW 152
153. WOUND COVERAGE: GRAFTS AND
FLAPS
Free Flaps
A striking advance in reconstructive surgery is
the use of free flaps or free-tissue transfer
achieved by microvascular techniques.
A free flap is completely severed from the body
and transferred to another site.
A free flap receives early vascular supply from
microvascular anastomosis (ie, attachment)
with vessels at the recipient site.
29-Feb-24 AW 153
154. Possible complications of plastic surgery
Pigment change- chemical peeling
Infection-surgery
Milia- chemical peeling
Scarring- surgery
Atrophy- surgery
Sensitivity change- chemical peeling
Long term (4 to 5 months) erythema or
pruritis-
chemical peeling
Hematoma- surgery
29-Feb-24 AW 154
155. Sources of skin graft can be
Autograft- use of tissue from self
Allograft- use of tissue from the same
species
Xenograft- use of tissue from different
species
Isograft- use of tissue from genetically
identical persons
Engineered (Cloning)- graft sources from
combined biological and synthetic
materials
Synthetic graft- substance from non-
biological source
29-Feb-24 AW 155
157. Pathophysiology of burn
Tissue destruction results from:
coagulation
protein denaturation, or
ionization of cellular contents.
Disruption of the skin can lead to:
increased fluid loss,
infection, hypothermia, scarring,
compromised immunity, and
changes in function, appearance, and body image.
The depth of the injury depends on:
the temperature of the burning agent and
the duration of contact with the agent.
29-Feb-24 AW 157
158. BURN
Burns are caused by a transfer of energy from a
heat source to the body.
Heat may be transferred through conduction or
electromagnetic radiation.
Burns are categorized as thermal (which includes
electrical burns), radiation, or chemical.
29-Feb-24 AW 158
159. BURN
For example, in the case of scald burns in adults,
1 second of contact with hot tap water at 68.9°C
(156°F) may result in a burn that destroys both
the epidermis and the dermis, causing a
fullthickness (third-degree) injury.
Fifteen seconds of exposure to hot water at
56.1°C (133°F) results in a similar full-thickness
injury.
Temperatures less than 111°F are tolerated for
long periods without injury.
29-Feb-24 AW 159
160. Assessment of burn injury depends on:
1. cause and temperature of the burning
agent.
2. location
3. duration of contact with the agent
29-Feb-24 AW 160
161. Classification of burn
Burn injuries are described according to:
A. The depth of the injury,
B. Extent of body surface area injured,
C. Location and, D. Age.
A. By depth
1. First degree burn (superficial partial
thickness burn)
Epidermis is involved
Redness and pain on the area
Healing takes place rapidly within a week.
29-Feb-24 AW 161
162. 2. Second degree burn (Deep partial
thickness burn)
epidermis and part of the dermis
Blister formation, pain, moist, mottled
appearance of skin, and swelling.
Hair follicles and sebaceous glands may
be partly destroyed.
Superimposed infection can interfere with
healing
Small burns (1-2% BSA) of this type can be
treated through self care
29-Feb-24 AW 162
165. Deep Partial thickness
infection by gram +ve bacteria
(staphylococcus, streptococcus) occurs
during the first day.
After the third day, gram –ve bacteria
(mainly pseudomonas) predominate and
can convert a second degree burn to
third degree.
Topical therapy with silver
sulfadiazines, silver nitrate or
antibiotics is essential
29-Feb-24 AW 165
166. 3. Third degree burn (full thickness
burn
The skin, with all of its epithelial structures,
hair follicle, sebaceous gland and
subcutaneous tissue destroyed.
May involve connective tissue, muscle &
bone.
Dry, pale white, leathery, or charred, broken
skin with fat exposed is seen.
Symptoms of shock and haematuria can be
present.
Scarring and loss of function is inevitable.
Needs skin graft for healing
29-Feb-24 AW 166
167. 3. Third degree burn (full thickness
burn
Wound color ranges widely from
white to red, brown, or black.
Scarring and loss of function is
inevitable.
Is painless because nerve fibers are
destroyed.
The wound appears leathery; hair
follicles and sweat glands are
destroyed
Needs skin graft for healing
29-Feb-24 AW 167
169. B. Extent of body surface area injured,
29-Feb-24
AW
169
Various methods are used to estimate the
TBSA affected by burns;
Among them are:
1. The rule of nines,
2. The Lund and Browder method, and
3. The palm method.
170. 29-Feb-24
AW
170
1. Rule of Nines
An estimation of the
TBSA involved in a
burn is simplified by
using the rule of
nines
171. 2. Estimate of body surface area using
the Lundand Browder method
Is the more precise method of estimating the
extent of burn, because it recognizes the
various anatomic parts, especially the head
and legs
•Head----------------------- 7%
•Neck----------------------- 2%
Anterior trunk----------13%
Posterior trunk---------13%
Right buttock------------ 2 &1/2 %
Left buttck ---------------2 &1/2%
29-Feb-24 AW 171
172. 2. Estimate of body surface area using
the Lund and Browder method
Genitalia------------------ 1%
Right upper arm---------4%
Left upper arm-----------4%
Right lower arm----------3%
Left lower arm------------ 3%
Right hand----------------- 2 ½ %
Left hand------------------- 2 ½%
Right thigh---------------- 9 ½%
Left thigh------------------ 9 ½%
Right leg------------------- 7%
Left leg--------------------- 7%
Right foot-----------------3 ½%
Left foot-------------------3 ½
100%
29-Feb-24 AW 172
173. 3. Palm method
• Used in patients with scattered burns
• The size of the patient ’s palm is approximately
1% of TBSA
• In general an adult who suffered burns of
25% and an infant (child) of 15% wherever the
location requires Hospitalization
29-Feb-24 AW 173
174. C. By location
• Burns of the
face,
neck and
circumferential burns of the chest may inhibit
respiration
• Burns of the hands, feet, joints, and eyes are of
concern because they make self care impossible
and jeopardize later function
• Hands and feet are difficult to manage
medically because of superficial vascular and
nerve supply systems
29-Feb-24 AW 174
175. C. By location Cont …d
• The ears and nose, composed mainly of
• cartilage, are susceptible to infection because
of poor blood supply to the cartilage
• Burns of the buttock or genitalia are
susceptible to infection
• circumferential burns of the extremities can
cause circulatory compromise distal to the burn
with subsequent neurologic impairment of the
affected extremity
29-Feb-24 AW 175
176. D. By age
• An infant is less able to cope with burn injuries
because of:
An immature immune system and generally
poor host defense mechanisms,
The older adult heals more slowly and has
more difficulty with rehabilitation than a child
or younger adult
Infection of the burn wound and pneumonia
are common complications in the older
patient
29-Feb-24 AW 176
177. Fluid type and fluid replacement
formulas
For burn patients Fluids can be:
Colloids are whole blood, plasma, plasma
expanders, and dextran, etc
Crystalloid (Electrolytes) are sodium chloride,
ringers lactate, etc
Fluid replacement formulas are:
Consensus formula
Evans formula
Brooke Army formula
Parkland/Baxter formula
29-Feb-24 AW 177
178. fluid replacement formulas
Consensus Formula
Lactated Ringer’s solution (or other balanced
saline solution): 2–4 mL × kg body weight × %
total body surface area (TBSA) burned.
Half to be given in first 8 hours; remaining half
to be given over next 16 hours.
29-Feb-24 AW 178
179. fluid replacement formulas
Evans Formula
1. Colloids: 1 mL × kg body weight × % TBSA burned
2. Electrolytes (saline): 1 mL × body weight × % TBSA
burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half
over next 16 hours
Day 2: Half of previous day’s colloids and electrolytes;
all of insensible fluid replacement
Maximum of 10,000 mL over 24 hours.
Second- and third-degree (partial- and full-thickness)
burns exceeding 50% TBSA are calculated on the basis
of 50% TBSA.
29-Feb-24 AW 179
180. fluid replacement formulas
Brooke Army Formula
1. Colloids: 0.5 mL × kg body weight × % TBSA burned
2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg
body weight × % TBSA burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half
over next 16 hours
Day 2: Half of colloids; half of electrolytes; all of
insensible fluid replacement.
Second- and third-degree (partial- and full-thickness)
burns exceeding 50% TBSA are calculated on the basis
of 50% TBSA.
29-Feb-24 AW 180
181. fluid replacement formulas
Parkland/Baxter Formula
Lactated Ringer’s solution: 4 mL × kg body weight ×
% TBSA burned
Day 1: Half to be given in first 8 hours; half to be
given over next 16 hours
Day 2: Varies. Colloid is added.
29-Feb-24 AW 181
182. fluid replacement formulas
Hypertonic Saline Solution
Concentrated solutions of sodium chloride (NaCl)
and lactate with concentration of 250–300 mEq
of sodium per liter, administered at
a rate sufficient to maintain a desired volume of
urinary output.
Do not increase the infusion rate during the first
8 postburn hours. Serum sodium levels must be
monitored closely.
Goal: Increase serum sodium level and
osmolality to reduce edema and prevent
pulmonary complications.
29-Feb-24 AW 182
183. Exercise
Using the Consensus formula, do the ff.
(2-4ml X kg X % TBSA burned for 24 hours)
• E.g. Ato Galgalo, 38 years old factory worker,
70kg body weight, sustained a burn injury
of a 50% of TBSA came to surgical
emergency OPD where you are working.
• Calculate the fluid to be administered for Ato
Galgalo Using the Consensus formula?
Eg. 2ml X 70kg X 50%=7000ml/24 hours
How many ml in the 1st 8 hrs? how many
drops/min.?
29-Feb-24 AW 183
184. Classification of Extent of Burn Injury
1. Minor Burn Injury
Second-degree burn of less than 15% total body
surface area (TBSA) in adults or less than 10%
TBSA in children
Third-degree burn of less than 2% TBSA not
involving special care areas (eyes, ears, face,
hands, feet, perineum, joints)
Excludes all patients with electrical injury,
inhalation injury, or concurrent trauma and all at-
risk patients (i.e., extremes of age, intercurrent
disease)
29-Feb-24 AW 184
185. Classification of Extent of Cont …d
2. Moderate, Uncomplicated Burn Injury
Second-degree burns of 15–25% TBSA in adults
or 10–20% in children.
Third-degree burns of less than 10% TBSA not
involving special care areas
Excludes all patients with electrical injury,
inhalation injury, or concurrent trauma; all at-risk
patients (i.e., extremes of age, intercurrent
disease)
29-Feb-24 AW 185
186. Classification of Extent of Cont …d
3. Major Burn Injury
Second-degree burns of at least 25% TBSA in
adults or at least 20% in children.
All third-degree burns 10% or more TBSA.
All burns involving eyes, ears, face, hands, feet,
perineum, joints.
All patients with inhalation injury, electrical
injury, or concurrent trauma; all at-risk patients.
29-Feb-24 AW 186
187. Classification of Extent of Cont …d
Burns that exceed 20% TBSA may produce a local
and a systemic response and are considered
major burn injuries.
The incidence and significance of
pathophysiologic changes are proportional to the
extent of burn injury, with a maximal response
seen in burns covering 60% or more TBSA
29-Feb-24 AW 187
188. Classification of Extent of Cont …d
Additionally, burns of 60% TBSA cause depressed
myocardial contractility;
this, in combination with the loss of circulating
plasma volume, hemoconcentration, and
massive edema formation (Latenser, 2015),
Results in both distributive and hypovolemic
shock.
29-Feb-24 AW 188
189. Classification of Extent of Cont …d
Fluid volume loss is greatest in the first 6 to 8
hours;
capillary integrity returns toward normal by
36 to 48 hours after the burn (Demling,
2015).
These patients are best served when
transferred to a verified burn center as they
are candidates for the occurrence of burn
shock.
29-Feb-24 AW 189
191. Systemic effects of burn
• Metabolic - client is in a hypermetabolic stage
• Endocrine
– increased catecholamines, ADH, aldosterone,
and cortisol increase metabolism
– O2 and calorie needs are increased
– the body is under stress response
catabolism increases calorie requirements
may be double or triple the usual amount
needed
29-Feb-24 AW 191
192. Respiratory
• Major cause of morbidity/ mortality
– inhalation injury r/t contact to steam, toxic
fumes, or smoke
– may be r/t treatment
large amount of fluid volume infused may
cause edema – increase in alveolar capillary
permeability – constriction of chest r/t
circumferential burn – injury can occur from
edema from irritants which cause edema and
blockage of trachea
29-Feb-24 AW 192
193. Respiratory
– decreased movement of the normal cilia in the
trachea may allow foreign bacteria and particles
to enter into the lungs
– lining of the trachea may slough off and
become lodged in the bronchus
– damage to the alveoli and the capillary
membrane may lead to infection and
respiratory failure
29-Feb-24 AW 193
194. Cardiac
• cardiac output is the most effected by the
loss of fluid
• early the rate increases to compensate
for the loss of volume
• cardiac output remains decreased in spite
of the increase rate
– may be decreased for 36 hrs
– when fluid is replaced goes back to normal
function
29-Feb-24 AW 194
195. Gastrointestional
- Effects occur due to the shift of blood volume
to vital organs
- Epinephrine and NE inhibit gastric motility
and decrease blood flow to the GI tract
- Decreased periostalis occurs
- H+ ion production increases
- Develop ulcers (Curling ’s ulcer within 24
hours)
- Use H2 blockers
29-Feb-24 AW 195
196. Immune response
• Widespread impairment of the immune
system
• Skin is barrier to invading organisms
• Changes in the WBC ’s occur,
• Susceptibility to infection increases
29-Feb-24 AW 196
197. Renal response
• Blood flow to the kidneys is decreased and
renal ischemia occurs
• Unless flow is improved renal failure occurs
• With full thickness electrical burns myoglobin
and hemoglobin are released in the blood and
can occlude the renal tubles
With adequate diuretics and fluid the
problem can be corrected
29-Feb-24 AW 197
198. Renal response
Renal function may be altered as a result of
decreased blood volume.
– Destruction of RBC at the injury site results in
free haemoglobin in the urine.
– If muscle damage occurs, myoglobin is released
from the muscle cells and excreted by the kidney.
– If there is in adequate blood flow through the
kidneys, the hemoglobin and myoglobin occlude
the renal tubules resulting in acute tubular necrosis
and renal failure.
29-Feb-24 AW 198
199. In general, the greatest volume of fluid leak
occurs in the first 24 to 36 hours after the
burn.
29-Feb-24 AW 199
200. Etiologies of burn
• Many causes --- cause affects the outcome
Dry heat-open flame --- house fire and
explosions
Moist heat=scald --- older adults most
common=spills and splatters
Contact burns ---- hot metal/tar/grease
(industrial, home and restaurants)
usually deep because liquid is extremely hot
Chemical injury
-occurs in home and industry (drain cleaner,
acids used in industry or chemicals in industry )
**Severity depends on the length of contact and amount
of tissue exposed
29-Feb-24 AW 200
201. Management of the patient with a
burn injury
• Burn care must be planned according to the
burn depth, local response, the extent of
the injury, and the presence of a systematic
response.
• Burn care then proceeds through 3 phases
29-Feb-24 AW 201
202. Phases of Burn Care
• Burn care must be planned according to the
burn depth, local response, the extent of
the injury, and the presence of a systematic
response.
• Burn care then proceeds through 3 phases.
3 phases are:
1. Emergent/ resuscitative phase.
2. Acute
3. Rehabilitative
29-Feb-24 AW 202
203. It is important to remember the CABD
(circulation, airway, breathing, disability) steps
(formerly called ABCs [Airway, Breathing, and
Circulation]) of all trauma care during the early
post-burn period.
29-Feb-24 AW 203
1. Emergent/Resuscitative Phase
Immediate Care
204. 1. Emergent Phase Cont …d
AIRWAY, BREATHING, CIRCULATION
Although the local effects of a burn are the most
evident, the systemic effects pose a greater
threat to life in the emergent/ resuscitative
phase.
Therefore, it is important to remember the ABCs
of all trauma care during the early postburn
period:
29-Feb-24 AW 204
205. Emergency Procedures at the Burn Scene
Extinguish the flames
Cool the burn
Remove restrictive objects
Cover the wound
Irrigate chemical burns
29-Feb-24 AW 205
1. Emergent Phase Cont …d
207. 2. Acute/ intermediate phase
• Duration is from the beginning of
diuresis to near completion of wound closure.
• The priorities are- wound care and closure
–Prevention and treatment of complications,
including infection.
–Nutritional support
29-Feb-24 AW 207
208. 3. Rehabilitation phase
»Duration is from major wound closure to
return to individual’s optimal level of physical
and psychosocial adjustment.
»The priorities are- Prevention of scars and
contractures.
• Physical, occupational and vocational
rehabilitation
• Functional and cosmetic reconstruction .
• Psycho-social counseling
29-Feb-24 AW 208
