This document provides information on assessing and managing disorders of the integumentary system in children. It discusses the objectives of the lecture, the functions of skin, and techniques for assessing the skin, hair and nails through history taking and physical examination. Specific assessment methods are outlined, including inspection of skin color and lesions, palpation of temperature, texture and edema. Common skin disorders and burns in children are also reviewed. The goal is to equip students to properly examine the integumentary system and identify any disorders, as well as understand their treatment and nursing care.

1. Assessment and disorders of the
integumentary system
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2. Session Objectives:
By the end of this lecture, the student will be able to:
• Apply different assessment techniques of integumentary
system
• Identify disorders of integumentary system
• Identify different pharmacological management for patients
with integumentary system disorders
• Provide appropriate nursing intervention for patients with
integumentary system disorders
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3. What is the 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
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4. What is the Function of the skin?
• Temperature regulation – produced heat released
through skin by radiation and convection
• Vitamin synthesis – skin exposed to ultra violet light
can convert substances necessary for synthesizing
vitamin D3 ( cholecalciferol )
• Aesthetic – provides beautiness and appearance
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5. Introduction
• Although many skin disorders are easily recognized by
simple inspection
• The history and physical examination are often necessary
for accurate assessment.
▫ The entire body surface, all mucous membranes,
conjunctiva, hair, and nails should always be examined
thoroughly under adequate illumination.
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6. Introduction…
• Many communicable infectious diseases or infestations
common to childhood have characteristic skin rashes as a
manifestation of the illness.
• Disorders of the skin, hair, and nails can be acute or chronic,
localized, or caused by a systemic problem.
• Assessment of the skin in children also yields crucial
information about a child’s nutritional, cardiovascular, and
hydration status.
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7. HISTORY…
 Chief complaints
 History of present illness
 Past medical history
 Current medication
 Immunization status
 History of allergies
 Family history of skin disorders or allergies
 Social history
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8. History of Present Illness
• Most pediatric integumentary complaints are related to
contagious skin infections, infestations, or communicable
diseases.
• Other complaints include skin dryness, bruising, swelling,
increased pigmentation, rashes, hair loss, and a change in
the condition of the nails.
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9. 9
SUBJECTIVE OR
OBJECTIVE DATA
KEY QUESTIONS
Date of onset of rash or lesions Sudden or gradual?
Evolution of rash or lesions Intermittent or continuous? Has the rash or lesion changed
since its onset (e.g., varicella begins as erythematous
macules then progresses to papules, then vesicles, then
crusts)?
Location of rash or lesions Is the rash or lesion localized or has it spread? Where is the
rash located?
Quantity of rash or lesions Are there single or multiple lesions
Associated symptoms Is there a history of a recent fever, malaise, systemic illness,
or weight loss or gain?
All of these can indicate viral or bacterial illness.
Aggravating factors What makes the rash worse?
Alleviating factors Are any treatments (e.g., prescription or over-the-counter
medications, heat, cold, creams, lotions, home remedies)
currently being used? If so, what are their effects?
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10. Past Medical History
▫ Used to establish a baseline dermatologic assessment
▫ illnesses, infections, injuries involving the skin
Immunization status
 Is it possible that immunizations for communicable
diseases have caused integumentary manifestations.?
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11. Current Medications
• Side effects or allergic reactions to medications often
manifest as skin rashes.
• Ask the parent what, if any, treatment was used for itching
or discomfort, noting the effectiveness of the treatment.
• The most obvious integumentary manifestation of steroid
use is the development of acne in adolescents.
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12. History of allergies
• Ask the parents if their child has any allergies and type of
reaction the child experiences after exposure to the allergen
(e.g., itching, rashes, urticaria).
• History of allergies related to the following: medications,
foods, chemicals, insect bites, animals, plants, and
environmental allergens.
• Any treatments for these allergies.
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13. Family History
• A family history is important to obtain, focusing on
hereditary skin disorders, such as atopic dermatitis
(eczema), seborrheic dermatitis, psoriasis.
• Ask if any family members have been ill recently,
currently have a rash
• A family history of skin cancer should be noted.
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14. Social History
• Certain aspects of the child’s social situation and
lifestyle can influence the condition of his or her skin,
hair, and nails.
• Sun exposure and use of sunscreen
• Personal hygiene
• Hot or humid environment; extreme cold temperature
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15. PHYSICAL EXAMINATION
• Assessment of the integumentary system involves
inspection and palpation of the skin, hair and nails.
• Palpation also aids in assessing elevated skin lesions.
▫ Always wear gloves
▫ Room with good light
▫ Natural daylight is the best
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16. PHYSICAL EXAMINATION…
• Helpful tools that assist the provider during inspection of the
skin include a penlight, a magnifying glass to enlarge small
areas of the skin for closer inspection, and a centimeter ruler
to measure any lesions.
• To assess and diagnose any dermatologic conditions accurately
in children, the provider must be familiar with the correct
terminology used to describe dermatologic lesions
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17. PHYSICAL EXAMINATION…
• To assess the skin accurately, the child should remove all
clothes and wear an age- appropriate patient gown.
• Privacy must be ensured.
• Infants can remain in a diaper, which can be removed easily
when the diaper area is inspected.
• For the exam, infants can lie on the exam table or be held on
the parent’s lap.
• Older children and adolescents should sit on the exam table.
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18. Inspection
• Should be done in a head-to-toe fashion.
• Evaluate the skin’s color and look for edema, rashes, and
lesions.
• Normal skin color varies from pink, yellow, brown to dark
brown or black, depending on the child’s race.
• The color of the nailbeds, earlobes, sclerae, conjunctivae, lips,
and mucous membranes.
• When describing skin color, concrete, specific descriptions are
important.
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19. Abnormal Skin Color Findings in Children
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20. Morphology of the lesions
• Primary lesions develop from previously normal skin.
• Secondary lesions evolve from primary lesions and are
usually because of the child scratching the primary
lesions.
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21. 21
Primary lesion: Macule
 macula, “spot”)
 A macule is flat; if you
can feel it, then it is not
a macule.
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22. 22
Examples of Macules
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23. 23
Primary lesion: Patch
 Patches are flat but
larger than macules
 If it’s flat and larger
than 1 cm, it is a
patch
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24. 24
Examples of Patches
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25. 25
Primary lesion: Papule
 (L. papula, “pimple”)
 Papules are raised
lesions less than 1 cm
 It is caused by a
proliferation of cells in
epidermis or superficial
dermis
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26. 26
Examples of Papules
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27. 27
Primary lesions: Plaque
 Plaques > 1 cm
• You can feel them
• They cast a shadow with
side lighting
 It is also caused by a
proliferation of cells in
epidermis or superficial
dermis
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28. 28
Examples of Plaques
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29. 29
Nodule
 (L. nodulus, “small
knot”)
 It is caused by a
proliferation of cells into
the mid-deep dermis
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30. 30
Examples of Nodules
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31. 31
Primary lesion: Vesicle
 Vesicle is fluid-filled
papules (small
blisters)
 A large (> 1cm)
blister is called a
bulla
vesicle bulla
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32. 32
32
Examples of Vesicles

33. 33
Pustule
 Pus is made up of
leukocytes and a
thin fluid called
liquor puris (L. “pus
liquid”)
 See also furuncle
and abscess
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34. Secondary skin lesions
• Scaling
Is an increase in the dead cells on the surface of the skin
(stratum corneum).
• Exfoliation
Exfoliation is the stratum corneum peeling off, usually occurring
after acute inflammation.
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35. 35
Erosion
 Erosions are loss of part
or all of the epidermis
 They may occur after a
vesicle forms and the top
peels off
 They weep and become
crusted
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36. 36
Ulcer
 (L. ulcus, “sore”)
 Ulcers are complete loss of the
epidermis in addition to part of the
dermis
 They often heal with scarring;
erosions usually do not heal with
scars
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37. Lichenification
• Is caused by chronic
rubbing or Repeated
rubbing of skin results in
thickening and
hyperpigmentation of skin
• The skin markings become
prominent.
• It occurs in chronic eczema
eg. atopic dermatitis.
• Eg:- Lichen simplex
chronicus, Atopic
dermatitis.

38. Secondary skin lesions…
• Erosion
An erosion is caused by loss of the surface of a skin lesion, it is
a shallow moist or crusted lesion. Involve focal loss of the
epidermis, and they heal without scarring
• Ulcers extend into the dermis and tend to heal with scarring.
Ulcerated lesions inflicted by scratching are often linear or
angular in configuration and are called excoriations.
An excoriation is a scratch mark. It may be a linear erosion.
May occur in the absence of a primary dermatosis.
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39. Secondary skin lesions…
• Crusting
Crust occurs when plasma exudes through an eroded
epidermis. It is rough on the surface and is yellow or brown in
color.
• Erythroderma
Erythroderma is a term used to indicate red skin over the entire
body.
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40. Palpation
• The skin should be palpated to assess temperature, texture,
turgor, moisture and edema.
• The skin should feel warm when palpated.
• Skin temperature that is cool to the touch may indicate
▫ hypothermia or poor localized circulation.
▫ Hypothyroidism
▫ Skin that feels hot when palpated may be the result of fever,
hyperthyroidism, infection, or recent sunburn.
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41. Palpation…
• Assess skin moisture by palpation.
• The skin is normally slightly dry.
• Excessive skin dryness may be because of overbathing, poor
nutrition, sunburn, chronic exposure to cold temperatures, or
hypothyroidism.
• Skin that feels moist in a child could simply be the result of
perspiration after physical activity or diaphoresis secondary to
hyperthyroidism or cardiac conditions or shock.
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42. Palpation…
Skin turgor
• Assessment of skin turgor evaluates the elasticity of
the skin.
• Assessment of skin turgor to assess dehydration.
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43. Palpation…
• Skin that has decreased mobility indicates edema.
▫ Edema in children can be generalized, dependent, or periorbital.
▫ Generalized edema is most serious, likely reflecting a cardiac,
hepatic, or renal disorder.
▫ Dependent edema is seen in the lower extremities or buttocks
and is also likely to have a renal or cardiac origin.
▫ Periorbital edema in children could be the result of recent sleep,
crying, allergies, alteration in renal function, or hypothyroidism.
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44. • The provider should also palpate for edema.
• This is done by pressing firmly against the skin.
• If indentations are left after palpation, the edema is
positive for pitting.
• Pitting is graded on a four-point scale to quantify the
extent of the edema.
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45. Grading of Pitting Edema
SCALE DESCRIPTION INDENT
ATION
1+ Slight pitting; slight indentation of skin
pitting disappears quickly after being
compressed.
2 mm
2+ Slightly deeper pitting; indentation
subsides rapidly (10–15 sec).
4 mm
3+ Deep pitting; noticeable swelling;
indentation remains for a short time;
may last for more than 1 min.
6 mm
4+ Very deep pitting; marked swelling;
indentation lasts approximately 2–5 min.
8 mm
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46. Hair
• Assessment of the hair begins by inspecting the hair color
, quality , cleanliness, and amount.
• Scalp hair should be shiny, strong, and elastic.
• Hair that is dry can be the result of poor nutrition,
hypothyroidism, frequent swimming or shampooing.
• Hair tufts noted over the spine, especially in the sacral
area, can indicate spina bifida occulta.
• Any presence of nits (eggs of head lice) on the hair shaft
should be noted.
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47. Nails
• Nail beds should be pink, smooth, flat, or slightly convex
in shape with uniform thickness.
• Nails that appear white or yellow and thickened can
indicate a fungal infection
• Nail changes can also be a sign of systemic illness; for
example, cyanotic nail beds can indicate hypoxia.
• Pale nail beds may indicate anemia.
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48. Inspection…
Normal Early clubbing Advanced
clubbing
Nail clubbing is a sign of chronic hypoxia.
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49. Burn in children
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50. Objective of presentation
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At the end of this presentation ,the students will
be able to:
▫ Define burn
▫ Explain the different causes of burn
▫ Assess burned wound
▫ Know the management measures for burn
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51. 51
Introduction
• Burn is the destruction of tissue by thermal, electrical,
chemical or radio active agent.
• Injury to the skin and deeper tissues caused by hot
liquids, flames, radiant heat, direct contact with hot
solids, caustic chemicals, electricity, or electromagnetic
(nuclear) radiation.
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52. • Worldwide:
▫ Young children- 60-80% scalds
▫ Older children- fire injury more likely
▫ >/= 5 yrs: 56% with flame burns.
• Mortality related to size, depth, and presence of inhalational
injury
• Burns are a 2nd leading cause of unintentional death in children,
second only to motor vehicle crashes.
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53. TYPES OF BURNS
• Thermal: exposure to flame or a hot object
• Chemical: exposure to acid, alkali or organic substances
• Electrical : result from the conversion of electrical energy
into heat.
• Radiation : result from radiant energy being transferred to
the body resulting in production of cellular toxins
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54. • Chemical Burn
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• Electrical Burn

55. PATHOPHYSIOLOGY
• Burns are caused by a transfer of energy from the source to
the body through conduction or electromagnetic
radiation
• Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular contents.
• The skin and the mucosa of the upper airways are the
common sites of tissue destruction
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56. PATHOPHYSIOLOGY…
• The impact of a burn can range from a minor local injury to
multisystem involvement when a major burn is sustained.
• Because of cell damage, intracellular fluid loss results in
serious fluid volume and electrolyte shifts.
• The child’s blood pressure will be low level, and the child can
go into shock and die.
• high risk for infection.
• If extensive tissue damage, can result in scarring and
permanent disfigurement.
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57. Systemic Response
• Damaged tissue ->vasoactive mediators
(cytokines, prostaglandins, free radicals)
• Increased capillary permeability-> increased fluid in
surrounding interstitial space
• Capillary leak: 18 to 24 hours
• Large burns: can see myocardial depression hypotension,
edema (burn shock, burn edema)
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58. Metabolic Response
• Hypermetabolic response:
• Increased catecholamines, glucagon, cortisol ->
increased metabolic rate, catabolism
• Decreased growth hormone, insulin-like growth factor
(anabolic hormones)
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59. BURN WOUND ASSESSMENT
• Classified according to depth of injury and extent of body surface
area involved
• The severity of the burn is determined by how deeply the damage
extends into the tissue and the total body surface area involved.
• Burn wounds differentiated depending on the level of dermis and
subcutaneous tissue involved
1. Superficial (first-degree)
2. Deep (second-degree)
3. Full thickness (third-degree)
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60. 1. Superficial-Thickness Burn (First degree)
2. Partial-Thickness Burn (Second degree)
3. Full-Thickness Burn (Third degree)
4. Full-Thickness Burn (Fourth degree)
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61. Superficial burns (first-degree)
• Involve only the epidermis.
• A minor sunburn without blistering is
an example of a superficial burn.
• Red, swollen, and dry areas with
tenderness
• Typically they are somewhat painful for
48 to 72 hours
• heal spontaneously without scarring in
5 to 10 days.
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62. Partial-thickness burns (second degree)
• Partial-thickness burns are divided
into:
• Superficial partial thickness,
involving the epidermis and
superficial dermis.
• Deep partial thickness burns,
involving the epidermis and deeper
dermis.
• Burns blister and are erythematous,
moist, and painful.
• Typically they heal spontaneously
without scarring in 1 to 3 weeks.
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63. Full-thickness burns (third-degree)
• Involve the epidermis and the entire dermis and
can extend into the subcutaneous tissue.
• They can be white, black, or brown.
• These burns do not heal spontaneously
• heal with contraction.
• The eschar that develops has
• a leathery texture and diminished sensation.
• Skin grafting is usually performed on these burns
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64. Calculation of Burned Body Surface Area
Calculation of Burned Body
Surface Area
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65. TOTAL BODY SURFACE AREA (TBSA)?
• Superficial and electrical burns are not involved in the
calculation
• Lund and Browder Chart is the most accurate because
it adjusts for age
• Rule of nines divides the body – adequate for initial
assessment mostly for adult burns
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66. Lund &Browder Chart used for determining BSA
67
Evans, 18.1, 2007)
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67. ABA
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68. Grading System
• Minor: <10% TBSA in adults, <5% in kids or older
adults, <2% full thickness
• Moderate: 10-20% in adults, 5-10% young or old, 2-5%
with full thickness, high voltage injury, suspected
inhalation injury, circumferential burn, underlying
medical condition predisposing to infection.
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69. • Major /sever : >20% TBSA in adults, >10%
young or old,>5% full thickness
▫ High voltage burn
▫ Known inhalation injury
▫ Significant burn to face, eyes, ears, genitalia, or
joints
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70. FLUID IMBALANCES
• Occur as a result of fluid shift and cell damage
• Hypovolemia
• Metabolic acidosis
• Hyperkalemia
• Hyponatremia
• Hemoconcentration (elevated blood osmolarity,
hematocrit/hemoglobin) due to dehydration
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71. Complications
• Infection
• Decreased Peripheral vascular resistance and
hypovolemia
• Acute tubular necrosis - Renal failure …..
• Cardiac arrhythmias
• Cardiac arrest
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72. Pre-Hospital care
• ABC’s, supplemental oxygen
• Intubation if airway burn/inhalation
• Remove burned clothing and jewelry
• Cover area with clean sheet (warmth)
• Establish vascular access if possible- IV fluids, pain
medications
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73. Cooling
• Immediate cooling can be beneficial
• Cool with water 10-20 minutes after burn
• Water temp no less than 8 Celsius
• No ice, no butter
• Watch for and take measures to prevent hypothermia
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74. Diagnostic Studies
• Baseline CBC, electrolytes
• UA may reveal myoglobinuria if muscle injury
• Carbon monoxide levels
• Consider CXR, soft tissue neck films
• Others based on presentation
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75. Management
• Airway:
• Reliable IV access for fluid resuscitation
• Consider bladder catheter to reliably measure I/O
• Tetanus immune globulin if incomplete primary
immunization (less than 3)
• Antibiotic
• Consider surgical consultation
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76. IV Fluids
• Parkland formula: 4 ml/kg per %TBSA in 24 hours in
addition to maintenance fluids.
• Half of fluid given over 1st 8 hours, 2nd 50% given over the
next 16 hours calculated from the time of onset of injury
• The rate of infusion is adjusted according to the patient's
response to therapy.
• Ringer’s lactate often used (LR) in 1st 24 hours.
• Consider colloid/albumin after 24 hours to improve oncotic
pressure 77
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77. IV Fluids
• Pulse and blood pressure should return to normal, and an
adequate urine output (>1 mL/kg/hr in children; 0.5–10
mL/kg/hr in adolescents) should be accomplished by
varying the intravenous infusion rate.
• Vital signs, acid-base balance, and mental status reflect
the adequacy of resuscitation.
• Because of interstitial edema and sequestration of fluid in
muscle cells, patients may gain up to 20% over baseline
pre-burn body weight.
• Patients with burns of 30% of BSA require a large
venous access (central venous line) to deliver the
fluid required over the critical 1st 24 hr.
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78. • During the 2nd 24 hr after the burn, patients begin to
reabsorb edema fluid and to diurese. Half of the 1st day's
fluid requirement is infused as lactated Ringer solution in
5% dextrose.
• The adequacy of resuscitation should be constantly
assessed using vital signs, urine output, blood gases,
hematocrit, and protein levels.
• Oral supplementation may start as early as 48 hr
postburn. Milk formula, artificial feedings, homogenized
milk, or soy-based products can be given by bolus or
constant infusion through a nasogastric or small bowel
feeding tube.
• As oral fluids are tolerated, intravenous fluids are
decreased proportionately in an effort to keep the total
fluid intake constant, particularly if pulmonary
dysfunction is present.
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79. Fluid…
• Use this formula for fluids to replace loss from burns.
• 2 - 4cc x wt in kg x % burn / 24 hrs
• Expected urine output for child: 1 cc / kg /hr and for infant: 2
cc/ kg / hr
• Example
▫ 20 kg child with 30% burn:
▫ 20 (kg) x 30(%) x 2 (cc/kg/) = 1200 cc in 24 hr
▫ Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially
▫ 75 cc / hr for burn loss + normal 60 cc / hr maintenance =135 cc /
hr
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80. Monitoring
• Very close I/O
• <30 kg: UOP 1-2ml/kg/hr
• >30 kg: 0.5-1 ml/kg/hr
• If increased UOP: check for glucose (osmotic diuresis)
• If decreased UOP: increase fluid, evaluate renal function
• Monitor HR and BP
• Pain control
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81. Wound Management
• Clean with mild soap and water
• Avoid disinfectants
• Remove clothing and debris
• Debridement of devitalized tissue with sterile saline soaked
gauze
• Large, painful blisters ruptured should be removed
• Topical antibiotic covered with non adherent dressing, then
covered with tubular net or gauze bandage
• Dressings should be changed frequently- 1-2x/day
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82. Reading assignment for burn clients
• Pain management
• Wound care
• Prevention of impaired mobility
• Nutritional support
• Psychological support.
By:Yohannes B.
84

83. INFLAMMATORY AND ALLERGIC
CONDITIONS
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84. Inflammatory and allergic condition
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
• Dermatitis means “inflammation of the skin
• Eczema comes from the Greek ekzein (= boiling) and is
used by some to refer to an acute inflammation with
vesicles and edema
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85. Etiology
• AD is a complex genetic disorder that results in a defective
skin barrier, reduced skin innate immune responses,
• And exaggerated T-cell responses to environmental allergens
and microbes that lead to chronic skin inflammation.
• It affects 10-30% of children worldwide and occurs in
families with other atopic diseases, such as asthma, allergic
rhinitis
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86. Etiology…
• The exact cause is unknown
• Imbalance of the immune system with an increase in
the immunoglobulin “E” activity
▫ Can be exacerbated by infection, bites, pollen, wool,
silk, fur, ointments, detergents, perfume, certain foods,
temperature extremes, humidity, sweating and stress
• Infants with AD are predisposed to development of allergic
rhinitis and/or asthma later in childhood
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87. Sign and symptom
• Acute stage
▫ eczema shows redness, swelling,
papules, blisters, oozing and
crusts.
• Sub-acute stage
▫ the skin is still red but becomes
drier and scalier and may show
pigment change.
• Chronic stage
▫ lichenification, excoriation,
scaling and cracks.
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88. 8/25/2022
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89. Types of dermatitis/eczema
A. Atopic dermatitis
• Is a chronic relapsing skin disorder characterized principally
by dry skin and pruritis, consequent rubbing and scratching
lead to lichenification
• Intense pruritus, especially at night, and cutaneous reactivity
are the cardinal features of AD.
• This patient has a genetic predisposition for hypersensitivity
reactions such as asthma, allergic rhinitis, and chronic urticaria.
▫ The eczema comes and goes
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90. Atopic dermatitis
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91. B. Seborrhoic dermatitis
• 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
▫ Under the breast , umbilicus and in body folds
• Pts often complains of oily skin
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92. C. Infective dermatitis
• 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
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93. D. Contact dermatitis
• 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 H2O, soap (especially if not
washed off properly) detergents, chemicals, sunlight, jewelry,
bleaches, perfume, nail polish/remover, etc
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94. Sign and symptom of eczema/ dermatitis
(general)
• Itching
• Redness, dry skin, lichenification, excoriation,
scaling skin
• Papules, blisters, oozing and crusts
• Color change
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95. Laboratory Findings
• There are no specific laboratory tests to diagnose AD.
• Many patients have peripheral blood eosinophilia and
increased serum IgE levels.
• The diagnosis of clinical allergy to these allergens
requires confirmation by history and environmental
challenges.
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96. Management (general)
• Stop the use of irritants (contact eczema)
A topical steroid preparation is applied two times daily and covered
with wet dressings.
▫ hydrocortisone 1% cream.
▫ Betamethasone valerate (Valisone) 0.1% ointment
▫ Hydrocortisone valerate (Westcort) 0.2%
• In severe itching use antihistamines
E.g.: promethazine 25mg at night, chlorphenaramine 4mg
98
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97. Mgt cont…
• In bacterial super infection use KMNO4 solution and
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)
• Hydration by baths or wet dressings.
99
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98. PSORIASIS
• A chronic recurrent dermatosis characterized by a T
cell-mediated inflammatory reaction and subsequent
epidermal hyper proliferation.
• Is a common, chronic, recurrent inflammatory disease of
the skin characterized by round, circumscribed,
erythematous, covered by silvery white scales
100
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99. What is psoriasis?
101
▫ Inflammatory and hyperplastic disease
of skin
▫ Characterised by erythema and elevated
scaly plaques
▫ Chronic, relapsing condition
▫ Course of disease often unpredictable
1

100. Etiology
• The etiology is unknown; the suggested causes are:
• Genetic predisposition; family history is common.
• Immunological abnormalities.
• Infection; streptococcal infection precedes psoriasis.
• Trauma , Sunlight
• Pathogenesis:
▫ Abnormal differentiation of keratinocytes and inflammatory
cell infiltration of the epidermis and dermis secondary to a
primary T-cell abnormality
▫ Rapid proliferation of the epidermal cells with no enough
time for maturation results in parakeratosis and scale
formation 102
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101. Clinical presentation: classic psoriasis
103
▫ Well-defined and sharply demarcated
▫ irregular Round/oval-shaped lesions
▫ Usually symmetrical
▫ Erythematous, raised plaques
▫ Covered by white, silvery scales

102. Common sites affected by psoriasis
104
• Can affect any part of
the body typically
scalp, elbow, knees
and sacrum
• Extent of disease
varies

103. Types of psoriasis
• Chronic plaque
• Erythrodermic
• Guttate
• Pustular
▫ Localised and generalised
• Local forms
▫ Palmoplantar
▫ Scalp
▫ Nail
105
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104. Chronic plaque psoriasis
106
• Most common type – affects
approximately 85%
• Features pink, well-defined plaques with
silvery scale
• Lesions may be single or numerous
• Plaques may involve large areas of skin

105. Guttate psoriasis
107
• Occurs predominantly in children, is
characterized by an explosive
eruption of profuse, small, oval or
round lesions
• Sites are the trunk, face, and
proximal portions of the limbs.
• The onset frequently follows a
streptococcal infection;

106. Erythrodermic psoriasis
108
▫ Generalised erythema covering
entire skin surface
▫ May evolve slowly from chronic
plaque psoriasis or appear as eruptive
phenomenon.
▫ Patients may become febrile,
hypo/hyperthermic and dehydrated
▫ Relatively uncommon

107. Pustular psoriasis
109
Two forms:
 Localised
 More common
 Presents as deep-seated lesions with multiple
small pustules on palms and soles
 Generalised
 Uncommon
 Associated with fever and widespread pustules
across inflamed body surface

108. Palmoplantar psoriasis
110
▫ Can be hyperkeratotic or pustular
▫ May mimic dermatitis – look for
psoriatic manifestations elsewhere
to aid diagnosis
▫ Possibly aggravated by trauma

109. Scalp psoriasis
111
▫ Varies from minor scaling
with erythema to thick
hyperkeratotic plaques
▫ May extend beyond hairline
▫ Patient scratching may
produce asymmetric plaques

110. Nail psoriasis
112
▫ May be present in patients with any
type of psoriasis
▫ Discrete, well-circumscribed
depressions on nail surface
▫ Silvery white crusting under free edge of
nail with some thickening of nail plate

111. Psoriatic arthritis
113
▫ Approximately 5–20%
have associated arthritis
 Distal interphalangeal
involvement
 Symmetrical polyarthritis

112. Diagnosing psoriasis
• Other dermatological disorders can resemble psoriasis
• Diagnosed clinically according to appearance,
distribution, history of lesions and family history
• Important to consider non-cutaneous complications
114

113. Managing psoriasis
• Goals of management
▫ The management is individual and address both medical
and psychological aspects.
▫ Improve quality of life
▫ Achieve long-term remission and disease control
▫ Minimise drug toxicity
▫ Evaluate and monitor efficacy and suitability of individual
treatments
▫ Remain flexible and respond to changing needs
115

114. Treatment options for psoriasis
• Stepwise approach is advised
• Treatments include
▫ General measures and topical therapy
▫ Phototherapy
▫ Systemic and biological therapies
• Combination therapies may
reduce toxicity and improve outcomes
116

115. A- Topical therapy
• Corticosteroids. It is the most frequent therapy, used with
occlusion is more effective. Intra-lesional injection of steroids is
very useful in small lesions.
• Tars. Crude coal tar 2-5%.
• Salicylic acid. 3-5%.
• Ultraviolet light. Artificial UVB, sunlight or narrowband UVB.
117
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116. B. Systemic therapy
• It is used only for the severe forms of the disease as
erythrodermic, pustular and arthropathic psoriasis:
• Corticosteroids.
• Methotrexate
• Retinoids (analogues of vitamin A).
• Cyclosporine A (immunosuppressive drug).
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117. C. Phototherapy
• For psoriasis resistant to topical therapy and covering > 10%
of body surface area
• Immunomodulatory and anti-inflammatory effects
▫ PUVA (administration of psoralen before UVA exposure)
• Treatment usually administered 2–3 times/week
119

118. 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
120
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119. Pathogenesis
Many different factors play a role:
• Altered hormonal status with increased androgens in men and
increased androgenic properties of progesterone in women
• Hyperkeratotic plugs form in follicle opening
• Hyperplasia of sebaceous glands with increased sebum production,
secondary to hormonal changes
• Colonization of follicles by Propionibacterium acnes, which
produces lipases splitting free fatty acids and releasing inflammatory
mediators 121
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120. Clinical features
• Acne vulgaris: divided into two overlapping
subcategories:
• Acne comedonica: Primarily open comedones
(blackheads) and closed comedones (whiteheads).
• Black color is melanin from follicle, not dirt
• Acne papulopustulosa: Follicular pustules or
inflammatory papules; comedones rupture, neutrophils
are attracted 122
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121. 123
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122. Treatment
• General measures: Always discuss the following points
with patients and parents (if patient agrees)
▫ Diet is not a major factor. Patients should eat what they enjoy
▫ Lack of cleanliness is not the crucial issue.
▫ Gentle mild cleansing twice daily is completely adequate.
▫ There is no reason to buy expensive cleansers
▫ Abrasive cleansers can be too irritating
124
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123. Treatment..
Topical therapy
• Topical retinoids: Far and away the best treatment for comedones.
▫ Tretinoin comes in various concentrations as a cream and gel.
▫ It must cause a bit of irritation to be effective.
▫ It should be used in the evening because it is slightly photosensitizing
• Benzoyl peroxide 5–10%: Also comes as wash, cream, water-
based gel, or alcoholic gel; b.i.d. or mornings in combination with
topical retinoids
125
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124. Treatment..
• Topical antibiotics: Antibiotics are used to inhibit
Propionibacterium acnes and reduce the lipolytic acne,
decreasing follicular irritation
▫ Topical antibiotics like erythromycin and clindamycin
• Systemic therapy:
▫ Antibiotics: Usual choice is tetracyclines, generally
minocycline 50–100mg daily
▫ Alternatives include erythromycin and other macrolides
126
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125. Treatment..
• Hormones: Both estrogens and anti-androgens can play a
positive role in female patients
• Isotretinoin inhibits comedo formation and has
immunomodulatory actions
• It is indicated for severe acne, but highly effective in all forms
• N.B. Isotretinoin is teratogenic.
127
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126. Bacterial Infection of Skin
• Direct infection of skin and adjacent tissues
▫ Cellulitis
▫ Furunculosis
▫ Carbuncle
▫ Folliculitis
▫ Impetigo
▫ Ecthyma
128
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127. Folliculitis
• Folliculitis is a bacterial infection/ inflammation of the
hair follicle
• The most common forms are caused by staphylococci, but
other bacteria, viruses, and fungi may also be responsible.
• The lesions are typically small, discrete, pustules with an
erythematous base, located at the ostium of the
pilosebaceous canals
129
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128. 130
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129. • Hair growth is unimpaired, and the lesions heal without
scarring.
• Favored sites include the scalp, buttocks, and
extremities. Poor hygiene, drainage from wounds and
abscesses, and shaving of the legs can be provocative
factors
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130. Sign and symptom
▫ Single or multiple papules or pustules
▫ Commonly seen in the beard area of men and
women’s legs from shaving
Management
• Warm compress to relieve pain
• Clean with antibacterial soap
• Topical antibiotic ointment
• Systemic antibiotics for recurrent cases
132
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131. Furunclosis
• Is an acute painful infection of perifollicular abscess (boils)
• Is an acute, localized, deep seated, red, hot, very tender,
inflammatory perifollicular abscess.
• Common microrganism: 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
133
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132. 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
134
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133. 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
135
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134. Treatment
• Warm compresses to soothing and hasten maturation and
drainage of the lesion.
• 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
136
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135. Carbuncles (multiple furuncles)
▫ Is an aggregation of interconnected furuncles that
drain through multiple openings in the skin.
▫ Occurs mostly where the skin is thick
▫ Microorganism mostly: staph. aureus
▫ Sites are back of the neck, shoulder, buttock, outer
aspect of the thigh and over the hip joints.
137
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136. Sign and symptom
• They are smaller and more superficial than
subcutaneous abscesses
• 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
138
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137. 139
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138. Cont…
Diagnosis
• Gramstain 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.
140
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139. Cellulitis
• Cellulitis is acute bacterial infection
of the skin and subcutaneous tissue
• In cellulitis, an inflammatory
infectious process involves
subcutaneous tissue but does not
destroy it.
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141

140. Cause
• Caused by bacteria’s like streptococcus/staphylococcus aureus
• Results from break in skin
• Cellulitis is also more common in individuals with lymphatic
stasis, diabetes mellitus, or immunosuppression.
Sign and symptom
• Cellulitis manifests clinically as an area of edema, warmth,
erythema, and tenderness that is well demarcated
• Possible fluctuant abscess or purulent drainage
• Fever, chills, and malaise
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141. 143
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142. Therapy
• Fever, lymphadenopathy, and other constitutional signs are absent
(white blood cell count < 15,000),
• Oral antibiotics
If present
• Parentral/systemic antibiotics
• Culture-directed systemic antibiotic therapy
• Surgical drainage and debridement may also be needed
• Immobilization and elevation of the affected area help reduce
edema; cool, wet dressings relieve local discomfort
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143. 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
More common under poor hygienic conditions
Complications:
• Glomerulonephritis is very common
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144. Sign and Symptom
• Superficial pustules or blisters
which becomes oozing with
yellow crusts
• Blisters break easily and form
golden crusts
Diagnosis
-Clinical
- Culture and sensitivity
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145. Non-bullous impetigo is a
superficial skin infection that
manifests as clusters of vesicles or
pustules that rupture and develop a
honey-colored crust.
Bullous impetigo is a superficial skin
infection that manifests as clusters of
vesicles or pustules that enlarge rapidly to
form bullae. The bullae burst and expose
larger bases, which become covered with
honey-colored crust.
Impetigo (Bullous)
Impetigo (Non-Bullous)
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146. Therapy
• Crusts should be softened with warm compresses and
removed.
• Prevent spreading by not sharing towels and ointment, change
clothes, towels and sheets frequently.
• Cut finger nails short to minimize damage to lesion and to
prevent autoinoculation from scratching
• In sever forms give cloxacillin 50-100mg/kg/24 hours divided
in to 4 doses.
• Erythromycin 25-50mg/kg/24hrs divided in to 4 doses
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147. Ecthyma
• Ecthyma is an ulcerative form of impetigo.
• Ulcerative infection usually caused by group A streptococci.
• Predisposing factors include the presence of pruritic lesions,
such as insect bites, scabies, or pediculosis, that are subject
to frequent scratching; poor hygiene; and malnutrition.
Clinical features
• Ulcers, usually on legs, presumably at sites of minor trauma
• Healing is slow and with scarring.
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148. • Ecthyma gangrenosa is a necrotic ulcer
covered with a gray-black eschar.
• It is usually occurs in immunosuppressed patients
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149. Ecthyma…
Therapy
• Address predisposing factors; compression therapy may
be needed.
• Blood and skin biopsy specimens for culture should be
obtained
• Empirical broad-spectrum, systemic therapy or
• Culture-directed systemic antibiotics.
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150. Cutaneous Fungal Infections
152
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151. Cutaneous Fungal Infections…
• Dermatophytosis - "ringworm" disease of the nails,
hair, and/or stratum corneum of the skin caused by
fungi called dermatophytes.
• Dermatomycosis - more general name for any skin
disease caused by a fungus.
• Etiological agents are called dermatophytes - "skin
plants".
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152. • Three important anamorphic genera, (i.e., Trichophyton,
Microsporum, and Epidermophyton), are involved in
ringworm.
• Dermatophytes are keratinophilic - "keratin loving".
• Keratin is a major protein found in horns, nails, hair, and
skin.
• Ringworm - disease called ‘herpes' by the Greeks, and by the
Romans ‘tinea' (which means small insect larvae).
154
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153. Severity of ringworm disease depends on
▫ Strains or species of fungus involved
▫ Sensitivity of the host to a particular pathogenic fungus.
• More severe reactions occur when a dermatophyte crosses non-
host lines (e.g., from an animal species to man).
• Disease tends to be more severe in individuals with diabetes
mellitus, lymphoid malignancies, immunosuppression, and
states with high plasma cortisol levels,
155
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154. Diagnosis
• Note the symptoms.
• Microscopic examination of slides of skin scrapings, nail
scrapings, and hair.
• Often tissue suspended in 10 % KOH solution to help
clear tissue. Isolation of the fungus from infected tissue.
• Proper treatment is dependent on diagnosis
156
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155. Case study
• An 8-year-old boy demonstrated an annular scaly plaque
on the neck extending into the scalp with broken hairs
and a prominent right occipital lymph node.
1. What is the rash?
2. What causes it?
3. How do you treat it?
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156. Tinea capitis (ring worm )
• Is a contagious fungal diseases of the scalp and hair shaft
• It is particularly common in black children age 4-14 years.
• Anthropophilic species acquired most often by contact with
infected hairs and epithelial cells that are on such surfaces
seats, hats, and combs.
 Dermatophyte spores may also be airborne within the
immediate environment
158
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157. Sing and symptom
• Characterized initially by many small circular patches of
alopecia
• Lymphadenopathy is common
• A severe inflammatory response produces elevated, boggy
granulomatous masses (kerions).
• Fever, pain and permanent scarring and alopecia
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158. Tinea capitis
annular scaly plaque with occipital
adenopathy
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160

159. Tinea capitis
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161

160. reaction / autoeczematization / Tinea capitis
patches of scale and erythema over
neck and trunk with pruritic pustules
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162

161. Management
• Oral griseofulvin (20 mg/kg/24 hr) is the recommended
for all forms of tinea capitis.
▫ It may be necessary for 8-12 wk and should be terminated
only after fungal culture results are negative.
• Itraconazole is given for 4-6 wk at a dosage of 3-5
mg/kg/24 hr with food.
• Treatment for 1 month after a negative culture result
minimizes the risk of recurrence.
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162. Management
• Terbinafine is also effective at a dosage of 3-6 mg/kg/24 hr
for 4-6 wk
▫ Vigorous shampooing with a 2.5% selenium sulfide or
ketoconazole shampoo is helpful.
▫ In case of bacterial super infection antiseptics and / antibiotics
are needed
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163. Tinea pedis (Athlete’s foot)
• Is infection of the toe webs and soles of the feet, is
uncommon in young children but occurs with some
frequency in preadolescent and adolescent males.
• Most commonly, the lateral toe webs (3rd to 4th and 4th to
5th interdigital spaces)
• And the subdigital fissured and peeling of the surrounding
skin
• Severe tenderness, itching, and a persistent foul odor are
characteristic.
165
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164. 166
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165. Management
• Careful drying between the toes after bathing expose to
air and wear cotton socks,
• Don’t wear shoe that are too tight/hot , changing socks
daily prevents reinfection
• Topical therapy with an imidazole is curative Several
weeks of therapy may be necessary
• In refractory cases, oral griseofulvin therapy may effect
a cure
• Treat secondary bacterial infection if present
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166. Tinea Corporis
• Defined as infection of the glabrous skin, excluding the
palms, soles, and groin
• Tinea corporis can be acquired by direct contact with
infected persons or by contact with infected scales or
hairs deposited on environmental surfaces.
• Infections are usually acquired from infected pets.
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167. Tinea corporis….
• Clinical lesion begins as a dry, mildly erythematous,
elevated, scaly papule or plaque that spreads
centrifugally and clears centrally.
• lesions are round and scaling at the periphery with a
tendency to central healing
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169

168. 170
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169. Management
• Tinea corporis usually responds to treatment with one of the
topical antifungal agents (e.g., imidazoles, terbinafine,
naftifine) twice daily for 2-4 wk.
• In severe or extensive disease, a course of therapy with oral
griseofulvin may be required for 4 wk.
• Itraconazole has produced excellent results in many cases with
a 1- to 2-wk
• When there is sever itching antihistamines may be added
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170. Parasitic skin disorder
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
• Burrowing and release of toxic or antigenic substances
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171. • The most important factor that determines spread of
scabies is the extent and duration of physical contact
with an affected individual
• The burden of disease is greatest among individuals
living in areas of poor sanitation, overcrowding,
and social disruption cases.
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172. Sign and Symptom
• Threadlike burrows are the classic lesion of scabies
• 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
• Diagnosis of scabies can often be made clinically but is
confirmed by microscopic identification of mites
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173. 8/25/2022
175

174. Management
• The treatment of choice for scabies is permethrin 5%
cream applied to the entire
▫ The medication is left on the skin for 8-12 hr. If necessary,
it may be reapplied in 1 wk for another 8hrs
▫ Pruritus may persist for a number of days and may be
alleviated by a topical corticosteroid preparation.
176
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175. Management
• 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.
• The entire family should be treated, as should caretakers of
the infested child. Clothing, bed linens, and towels should
be thoroughly laundered.
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176. Reading assignment
• diaper dermatitis
• Mucocutaneous Lishmaniasis
• pediculosis
• Viral skin infections
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177. END !!
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