Skin is made up of three main layers: the epidermis, dermis, and hypodermis. The epidermis is the top layer and contains cells that produce melanin, which determines skin color. The dermis contains blood vessels, hair follicles, and sweat and oil glands. The hypodermis is a subcutaneous fat layer. Common skin disorders discussed include bacterial infections like MRSA and cellulitis, fungal infections, viral infections like chickenpox, and inflammatory conditions like eczema, psoriasis, and rosacea. Special considerations are discussed for assessing and treating skin of elderly patients and those with diabetes or other conditions.

1. Skin Disorders in Sleep Patients

2. Anatomy Derma is the ancient Greek word for skin Skin is made up of two main layers no thicker than 1-2 mm Epidermis Dermis Some refer to the Hypodermis as the third layer of skin. Hypo (under) Dermis (skin)

3. Skin

4. Epidermis The epidermis is approximately .2 mm in thickness. Nonvascular layer of skin Five layers

5. Stratum Corneum (top) Made up of Keratin, which is a protein formed from what is left of the dead skin cells. Stratum Basale (bottom) Melanocytes, which are the cells that produce melanin. Melanin = Pigmentation Note: Melanoma is a type of skin cancer that originates in the melanocytes. The production of melanin is what gives the melanoma a brownish sometimes black color.

6. Dermis (Mesodermal Layer) Blood vessels, capillaries Nerves Hair follicles Sebaceous glands (produce oil) Sweat glands - average person has 2-4 million sweat glands; many are located in the hands, feet armpits and face.

7. Hyperhidrosis Disorder involving excessive sweating Likely to sweat 4-5 times more than the average person Non-life threatening Greater risk for fungal infections

8. Hypodermis – subcutaneous layer Fat cells Connective tissues Larger veins and arteries Larger nerves

9. Fun Facts Skin is the largest organ of the body Shield that helps protect the body against bacteria, chemicals, harmful rays from the sun and other potentially harmful organisms. One of the most vulnerable organs of the body Skin helps regulate body temperature by releasing moisture (sweat)

10. Questions to ask yourself: What type of skin cleanser would be best for this patient? How much pressure should I use while prepping this patient’s skin? Do I need to relocate any electrodes? Should I be using tape? Or should I use gauze?

11. Aging and the Skin Skin becomes more delicate More prone to skin disorders due to decreased elasticity and thickness of the skin Increased dryness and roughness Several reasons for this, include : Exposure to UV rays Smoking or other toxin exposure Previous skin disorders

12. Head Lice - Pediculosis Different from body lice and pubic lice Highly contagious Nuisance, not hazardous to one’s health Lice do NOT jump from head to head

13. Lifecycle of Head Louse

14. Louse and Nits under a microscope

15. Skin irritation from Lice infestation The skin can become itchy due to the bites from the head nymph.

16. Lice Infestation Nits are commonly mistaken as dandruff and vice versa. The easiest way to tell the difference is that dandruff moves and nits stick to the hair shaft.

17. Patient Information on Lice Use OTC shampoos that rid the hair of lice After shampooing check head everyday for the next two weeks. Prescription shampoo is sometimes necessary Buy sprays with lice killing agent to spray pillows and carpets Vacuum carpets every other day for two weeks. (Do Not forget to vacuum the car)

18. Dermatitis Common signs and symptoms, include: Redness Swelling Itching Skin lesions

19. Several Types of Dermatitis Contact dermatitis – a rash resulting from an irritant or allergy-producing substance. Ex.: Poison ivy Seborrheic dermatitis- scalp condition that often causes dandruff Atopic dermatitis- commonly known as eczema, it is a chronic itchy rash that comes and goes. Other types of Dermatitis: Stasis dermatitis, Neurodermatitis, Perioral dermatitis

20. Dandruff (Seborrheic Dermatitis) Excessive flaking of dead skin cells due to rapid skin cell turnover

21. Eczema (Atopic Dermatitis) A rash that is red, patchy, scaly and itchy. Often times blisters and oozing can develop.

22. The exact cause of Eczema is unknown. Genetic predisposition Several forms of eczema Topical ointments and medications can help with the itching and appearance Can lead to bacterial infection Stress can often times aggravate the condition

23. Hives (Urticaria) Raised skin with welt like appearance. Can be itchy. Develops from stress Develops from an allergic reaction - Side effect of medication

24. Poison Ivy or Oak – classified as a contact dermatitis Plant that many people have an allergy to, in which they develop an itchy red rash or blisters. Any drainage from the rash or blisters can be contagious.

25. Burns A burn occurs when the skin becomes damaged due to exposure from: Radiation - Sunlight - Sound waves - Ionizing radiation - X-rays Chemicals Electricity Wind

26. Radiation Burn/Dermatitis The most common burn is a sunburn caused by UV rays. Radiation therapy used in combination with Chemotherapy can also cause severe burns

27. Bacterial Infections There are several types of bacteria. Listed below are a few examples: Staphylococcus MRSA (Methicillin-Resistant Staphylococcus Aureus) is a strain of staphylococcus. Streptococcus Hemophyllus Influenza HIB vaccine helps to protect against this bacteria

28. Staphylococcus Bacteria can be present without causing an infection Commonly found on the skin and in the nose Infections can affect tissues, bone, bloodstream and can be the cause of pneumonia Different Strains = Level of Severity

29. MRSA (Methicillin- Resistant Staphylococcus Aureus) Since the bacteria does not respond well to many antibiotics (Methicillin, Penicillin, Amoxicillin), infections can become serious. Mild infections can be treated with certain antibiotics and good hygiene. Progression of the infection into the bloodstream or bone can be potentially life-threatening. Topical antibiotics, oral antibiotics and intravenous antibiotics are all options used to treat MRSA infections. Note: MRSA is contagious when a person has an active infection or if somebody is a “carrier” of the bacteria.

30. MRSA Infection

31. CDC Recommendations to avoid MRSA Wash hands with soap and warm water. Alcohol based sanitizers can be just as good. If one has an abrasion, make sure to clean and cover the wound until it has healed. Avoid contact with other’s wounds or bandages Avoid sharing towels and razors

32. Streptococcus Common infections, include: Strep throat Scarlett fever Cellulitis Different Strains = Level of Severity

33. Cellulitis Bacterial infection that spreads through the dermal and subcutaneous tissues. Skin is visibly warm, red, swollen and tender Sensitivity to pressure Hard to culture, unless pus like substance or other drainage is available

34. Common infection areas, include: Legs Around the eyes (Periorbital Cellulitis) Cheeks Treatment options, include: Oral antibiotics Injection antibiotics Intravenous antibiotics

35. Cellulitis Peri-orbital Cellulitis

36. Neuropathy An abnormality of the nervous system. There is a problem with the communication between the brain and the body. Any part of the nerve cell (cell body, axon, or dendrites) can be damaged. The most common place for the damage to occur is in the axon. There are several types of neuropathy, including: Diabetic, Alcoholic, and Chemotherapy Induced Peripheral Neuropathy (CIPN).

37. The three nerve types affected are: Sensory Nerves- controls the sense of touch, pain, temperature, numbness, etc. Motor Nerves-control of voluntary movements Autonomic Nerves - control involuntary functions such as breathing, digestion, blood pressure, etc.

38. If sensory nerves become damaged, the result could be loss of pain sensation replaced with numbness. Numbness of the extremities could cause minor wounds to become infected by bacteria, leading to Ulcers.

39. Neuropathic Ulcer

40. Diabetic patients are prone to skin disorders due to sensory neuropathy and micro-vascular disease. This is why extra caution should be taken when cleansing the skin with a light abrasive solution.

41. Fungal Infections Fungi or fungus is a microscopic organism that can be found on the skin. Fungus does not always cause problems; however, problems occur when it grows out of control, in turn, creating a fungal infection.

42. Fungus grows in moist areas Some people are genetically prone to fungal infections Contagious. Can easily be transferred from one section of skin to another or from person to person. Itchy Medications and anti-fungal ointments can be used to get rid of an infection

43. Fungal infections can occur on the skin and/or nails. There are several names for fungal infections depending on the infected area. Body Ringworm (Tinea Corporis) Athlete’s Foot (Tinea Pedis)- Most common Jock Itch (tinea Cruris) Scalp Ringworm (Tinea Capitis) Nail Ringworm Beard Ringworm

44. Tinea Corporis (Ringworm)

45. Tinea Capitis- Scalp Ringworm Scalp ringworm can cause hair loss in the infected area. Extremely hard to rid the scalp of the fungus

46. Nail Ringworm Nail thickening Yellow Malformation Nail loss Note: Important to disinfect oximeters or use disposable oximeters

47. Sebaceous Gland Disorders Sebaceous glands are located alongside the hair follicles. They produce oils. The most common Sebaceous gland disorders are acne and Rosacea. Some people report discomfort from sebaceous gland disorders.

48. Blackheads Also known as an open comedo. Blackheads are formed at the surface of the skin. Oils (Sebum) and keratin cells are what clog the pore. The black coloring is due to the exposure to the air.

49. Whiteheads and Cystic Acne Whiteheads are closed comedos. Whiteheads develop when oils that are clogging the pore are trapped below the skins surface. Cystic Acne is the most severe form of acne due to its ability to cause scarring. The pressure from dead skin cells builds up causing leakage of bacteria found in the duct to inflame the dermis. If that bacteria cannot drain completely bumps and nodules appear causing cystic acne.

50. Rosacea Early Symptoms Progression of Disease Rosacea is a poorly understood disease affecting the face. The cause of Rosacea is unknown. There is no cure; however, symptoms can be controlled with medications. Commonly reported symptoms, include: burning, stinging, and itching.

51. Other symptoms of Rosacea, include: Redness on the cheeks, nose, chin and forehead Small visible blood vessels Bumps or pimples Watery or irritated eyes

52. Varicella (Chickenpox) Rash and flulike symptoms caused by the herpes zoster virus that typically affect children, but can be seen in adults as well. Chickenpox is extremely contagious from two days before the rash appears until the sores have scabbed over.

53. Shingles Shingles is another disorder caused by the herpes zoster virus. Up to 20% of people that have had chickenpox or the varicella vaccine are at risk for getting shingles later in life.

54. The herpes virus lies dormant in the nerves located alongside the spinal cord. A weakened immune system or stress can cause the virus to reactivate. Many times only one nerve is effected, so the shingles rash appears on one side, in one area.

55. Tingling, itchy blisters and rash Treatment includes steroids, pain medication and anti-viral medications Vaccines for people older than 60 years to help prevent a shingles occurrence.

56. Shingles is not contagious to those who have had chickenpox. Shingles is only contagious to those who have not had chickenpox. Note: The person can NOT get shingles, but can contract chickenpox. Shingles is only contagious before the blisters have crusted over. Important for the infected area to be covered

57. Autoimmune Disorders Autoimmune means the body’s immune system wants to attack itself. The immune system creates antibodies to protect against outside bacteria, viruses and antigens, but these antibodies, for reasons not fully understood, can sometimes attack the body leaving it vulnerable to infections.

58. Lupus According to www.lupus.org , approximately 1.5 million Americans and 5 million people worldwide are believed to be living with Lupus. Lupus can be an acute or chronic inflammatory disease of bodily tissues, which effect various parts of the body, including: the skin, heart, lungs, kidneys, liver, joints, nervous system, blood, etc. The cause of Lupus is unknown. Although, there is not a cure for Lupus, medications can help alleviate or reduce the severity that the disease has on the body. Lupus is a disease known for its flare-ups.

59. There are different forms of Lupus. The two most commonly discussed types are: SLE (Systemic Lupus Erythematosus) Cutaneous Lupus Erythematosus Others include: Drug-induced Lupus Erythematosus Neonatal Lupus

60. SLE (Systemic Lupus Erythematosus) SLE is the most notable form of Lupus, effecting internal organs Can be fatal, although more recent medical advances suggest that 80-90% of people with SLE will live a normal life span Most common reason for fatalities are due to infection or kidney failure

61. Cutaneous Lupus Erythematosus Cutaneous Lupus, also referred to as Discoid Lupus, effects the skin. The most common rash resulting from cutaneous lupus is the discoid rash. The rash appears red, raised and often times scaly. The disc like lesions that develop are where the name Discoid Lupus originated. The malar rash or butterfly rash is another example of cutaneous lupus. The malar rash develops on the cheeks, nose, and eyelids. Approximately 10% of people with Cutaneous Lupus will develop SLE (Lupus Foundation of America, 2008).

62. Many times the areas of the body exposed to sunlight or fluorescent lights are affected more so than areas that are covered (Lupus Foundation of America, 2008).

63. Psoriasis Psoriasis is a chronic skin condition originating in the stratum corneum and other layers of the epidermis. It is characterized by inflamed, itchy, red, scaly areas that often develop on the scalp, elbows, knees, and lower back. Psoriasis affects between 5-7 million people in the U.S. ( http://www.healthline.com , Psoriasis, 10/07)

64. Skin Cancer There are different types of skin cancer. All originate in the five layers of the epidermis. Some include: Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma Kaposi’s Sarcoma Paget’s Disease Cutaneous T-Cell Lymphoma

65. Basal Cell Carcinoma Most common form of skin cancer accounting for approximately 80% of all cases. Originates in the basal cells located at the bottom of the epidermis. Commonly found on the face, neck, scalp, shoulders, and back.

66. Melanoma Melanoma is known as the deadliest form of skin cancer, due to it’s ability to metastasize. Begins in the melanocytes.

67. Many of these disorders present in similar ways. Be familiar with some of the more common skin disorders if mentioned in a patients chart Be able to recognize what some of the skin disorders look like. Know when to use alternative methods for cleansing the skin and electrode placement. Ensure patients are comfortable COMMUNICATION

68. Helpful Websites www.cdc.gov www.cancer.gov www.healthline.com www.lupus.org www.nlm.nih.gov www.rosacea.org www.webmd.com http://www.mayoclinic.com http://www.merck.com

69. Questions,Concerns,Feedback Should you have any questions or feedback regarding this presentation please feel free to contact our program director, Jennifer Brickner-York, at [email_address] . Thank You.