Identify the disorders of the skin.
Identify drug therapy for the treatment of acne vulgaris and drug therapy for other skin disorders.
Identify the prototype and describe the action, use, adverse effects, contraindications, and nursing implications for the retinoids.
Implement the nursing process in the care of the patient with disorders of the skin.
Clinical Application Case Study
Gerard Aylward is a 16-year-old high school sophomore who has a history of asthma. As a child, he received allergy shots on a weekly basis. He now has a severe case of acne vulgaris. He has been taking tetracycline hydrochloride 500 mg orally every 12 hours. His acne remains severe, and his dermatologist has decided to discontinue the tetracycline and start isotretinoin 35 mg orally two times per day for 15 weeks.
KEY TERMS
Acne vulgaris: common disorder characterized by excessive production of sebum and obstruction of hair follicles, which normally carry sebum to the skin surface
Dermatitis: general term denoting an inflammatory response of the skin to injuries, irritants, allergens, or trauma; also referred to as eczema
Emollient: lubricant used to relieve pruritus and dryness of the skin
Erythema: redness of the skin
Pruritus: itching
Psoriasis: scaling, dry, erythematous skin eruptions on the elbows, knees, scalp, and trunk
Rosacea: chronic disease characterized by erythema, telangiectases (fine, red, superficial blood vessels), and acne-like lesions of facial skin
Tinea pedis: common type of ringworm infection; also called athlete’s foot
Urticaria: inflammatory response characterized by a skin lesion called a wheal, a raised edematous area with a pale center and red border, which itches intensely; also known as hives
Introduction
This chapter discusses the disorders of the skin. In addition, it introduces acne vulgaris and the drugs administered for their treatment.
Disorders of the Skin
Dermatologic disorders may be primary (i.e., originate in the skin or mucous membranes) or secondary (i.e., result from a systemic condition, such as measles or adverse drug reactions).
Inflammatory Disorders
Dermatitis
Dermatitis, also called eczema, is a general term denoting an inflammatory response of the skin to injuries from irritants, allergens, or trauma. Whatever the cause, dermatitis is usually characterized by erythema (redness), pruritus (itching), and skin lesions. It may be acute or chronic.
Atopic dermatitis is a common disorder characterized by dry skin, pruritus, and lesions that vary according to the extent of inflammation, stages of healing, and scratching. Scratching damages the skin and increases the risk of secondary infection. Acute lesions are reddened skin areas containing papules and vesicles; chronic lesions are often thick, fibrotic, and nodular. The cause is uncertain but may involve allergic, hereditary, or psychological elements. Exposure to possible causes or exacerbating factors such as allergens, irritating chemicals, foods, and emotional stress are factors to consider.
Contact dermatitis results from direct contact with irritants (e.g., soaps, detergents) or allergens (e.g., clothing materials or dyes, jewelry, cosmetics) that stimulate inflammation. Irritants cause tissue damage and dermatitis in anyone with sufficient contact or exposure. Allergens cause dermatitis only in sensitized or hypersensitive people. The location of the dermatitis may indicate the cause (e.g., facial dermatitis may indicate an allergy to cosmetics).
Seborrheic dermatitis is a disease of the sebaceous glands characterized by excessive production of sebum. It may occur on the scalp, face, or trunk. A simple form involving the scalp is dandruff, which is characterized by flaking and itching of the skin. More severe forms are characterized by greasy, yellow scales or crusts with variable amounts of erythema and itching.
Drug-induced skin reactions can occur with virtually any drug and can resemble the signs and symptoms of virtually any skin disorder. Topical drugs usually cause a localized, contact dermatitis-type of reaction and systemic drugs cause generalized skin lesions. Skin manifestations of serious drug reactions include erythema, facial edema, pain, blisters, necrosis, and urticaria. Systemic manifestations may include fever, enlarged lymph nodes, joint pain or inflammation, shortness of breath, hypotension, and leukocytosis. Drug-related reactions usually occur within the 1st or 2nd week of drug administration and subside when the drug is discontinued.
Urticaria
Urticaria (hives) is an inflammatory response characterized by a skin lesion called a wheal, a raised edematous area with a pale center and red border, which itches intensely. Histamine, the most common mediator of urticaria, causes vasodilation, increased vascular permeability, and pruritus. Mast cells and basophils release histamine as a result of both allergic (e.g., insect bites, foods, drugs) and nonallergic (e.g., radiocontrast media, opiates, heat, cold, pressure, ultraviolet [UV] light) stimuli. An important difference between allergic and nonallergic reactions is that many allergic reactions require prior exposure to the stimulus, whereas nonallergic reactions can occur with the first exposure.
Psoriasis
Psoriasis is a chronic, inflammatory disorder attributed to activated T lymphocytes, which produce cytokines that stimulate abnormal growth of affected skin cells and blood vessels. The abnormal growth results in excessively rapid turnover of epidermal cells. Instead of 30 days from formation to elimination of normal epidermal cells, epidermal cells involved in psoriasis are abnormal in structure and have a lifespan of about 4 days. Skin lesions of psoriasis are erythematous, dry, and scaling. The lesions may occur anywhere on the body but commonly involve the skin covering bony prominences, such as the elbows and knees. Skin lesions may be tender, but they do not usually cause severe pain or itching. However, the lesions are unsightly and usually cause embarrassment and mental distress.
This skin disease is characterized by remissions and exacerbations. Exacerbating factors include infections, winter weather, some drugs (e.g., beta blockers, lithium), and possibly stress, obesity, and alcoholism.
Rosacea
Rosacea is a chronic disease characterized by erythema, telangiectases (fine, red, superficial blood vessels), and acne-like lesions of facial skin. Hyperplasia of the nose (rhinophyma) eventually develops. The disorder usually occurs in middle-aged and older people, and it is more common in men. The etiology is thought to be excessive production of certain inflammatory proteins. Spicy foods, heat, alcohol, and embarrassment can worsen the condition.
Dermatologic Infections
Bacterial Infections
Bacterial infections of the skin are common; they are most often caused by streptococci or staphylococci.
• Cellulitis is characterized by erythema, tenderness, and edema, which may spread to subcutaneous tissue. Generalized malaise, chills, and fever may occur.
• Folliculitis is an infection of the hair follicles that most often occurs on the scalp or bearded areas of the face.
• Furuncles and carbuncles are infections usually caused by staphylococci. Furuncles (boils) may result from folliculitis and tend to recur. They usually occur in the neck, face, axillae, buttocks, thighs, and perineum. Carbuncles involve many hair follicles and include multiple pustules. Carbuncles may cause fever, malaise, leukocytosis, and bacteremia. Healing of carbuncles often produces scar tissue.
• Impetigo is a superficial skin infection caused by streptococci or staphylococci.
Fungal Infections
Fungal infections of the skin and mucous membranes are most often caused by Candida albicans.
• Oral candidiasis (thrush) involves mucous membranes of the mouth. It often occurs as a superinfection after the use of broad-spectrum systemic antibiotics.
• Candidiasis of the vagina and vulva occurs with systemic antibiotic therapy and in women with diabetes mellitus.
• Intertrigo involves skin folds or areas where two skin surfaces are in contact (e.g., groin, pendulous breasts).
• Tinea infections (ringworm) are caused by fungi (dermatophytes). These infections may involve the scalp (tinea capitis), the body (tinea corporis), the foot (tinea pedis), and other areas of the body. Tinea pedis, commonly called athlete’s foot, is a type of ringworm infection.
Viral Infections
Viral infections of the skin include verrucae (warts) and herpes infections. There are two types of herpes simplex infections: type 1 usually involves the face or neck (e.g., fever blisters or cold sores on the lips) and type 2 involves the genitalia. Other herpes infections include varicella (chickenpox) and herpes zoster (shingles).
Trauma
Trauma refers to a physical injury that disrupts the skin. When the skin is broken, it may not be able to function properly. The major problem associated with skin wounds is infection. Common wounds include lacerations (cuts or tears), abrasions (shearing or scraping of the skin), puncture wounds, surgical incisions, and burns.
Ulcerations
Cutaneous ulcerations are usually caused by trauma and impaired circulation. They may become inflamed or infected.
• Pressure ulcers (also called decubitus ulcers) may occur anywhere on the body when external pressure decreases blood flow. Older adults often have thin, dry skin and are at risk of pressure ulcers. Pressure ulcers are most likely to develop in patients who are immobilized, incontinent, malnourished, and debilitated. Common sites include the sacrum, trochanters, ankles, and heels. In addition, abraded skin is susceptible to infection and ulcer formation.
• Venous stasis ulcers, which usually occur on the legs, result from impaired venous circulation. Other signs of venous insufficiency include edema, varicose veins, stasis dermatitis, and brown skin pigmentation. Bacterial infection may occur in the ulcer.
Anorectal Disorders
Hemorrhoids and anal fissures are common anorectal disorders characterized by pruritus, bleeding, and pain. Inflammation and infection may occur.
Acne
Acne is a common disorder characterized by excessive production of sebum and obstruction of hair follicles, which normally carry sebum to the skin surface. As a result, hair follicles expand and form comedones (blackheads and whiteheads). Acne lesions vary from small comedones to acne vulgaris, the most severe form, in which follicles become infected and irritating secretions leak into surrounding tissues to form inflammatory pustules, cysts, and abscesses. Most patients have a variety of lesion types at one time. At least four pathologic events take place within acne-infected hair follicles: (1) androgen-mediated stimulation of sebaceous gland activity, (2) abnormal keratinization leading to follicular plugging (comedone formation), (3) proliferation of the bacterium Propionibacterium acnes within the follicle, and (4) inflammation.
Acne occurs most often on the face, upper back, and chest because there are large numbers of sebaceous glands in these areas. One etiologic factor is increased secretion of male hormones (androgens), which occurs at puberty in both sexes. This leads to increased production of sebum and proliferation of P. acnes, which depend on sebum for survival. P. acnes bacteria contain lipase enzymes that break down free fatty acids and produce inflammation in acne lesions. Other causative factors may include medications (e.g., phenytoin, corticosteroids) and stress (i.e., the stress mechanism may involve stimulation of androgen secretion). There is no evidence that certain foods (e.g., chocolate) or lack of cleanliness causes acne.
NCLEX Success
1. What role do androgens play in the development of acne vulgaris?
A. increased production of testosterone
B. increased production of estrogen
C. increased production of sebum
D. increased production of facial oil
2. A patient is taking dexamethasone for increased pain and inflammation in her right heel. She states that she has developed acne. What is the best response to this patient’s statement?
A. Dexamethasone should decrease acne, not cause it.
B. Dexamethasone may cause acne.
C. Dexamethasone has no effect on acne or contact dermatitis.
D. Dexamethasone should be combined with tetracycline to prevent acne.
3. A 30-year-old man has been asthmatic since age 2 years. Which of the following dermatological disorders is this man prone to developing?
A. rosacea
B. atopic dermatitis
C. external otitis media
D. impetigo
4. Which of the following foods contributes to the development of rosacea?
A. milk
B. high-protein foods
C. alcohol
D. ice creams
Drug Therapy
Many different drugs are used to prevent or treat dermatologic disorders. General treatment goals for many skin disorders are to relieve symptoms (e.g., dryness, pruritus, inflammation, infection), eradicate or improve lesions, promote healing and repair, restore skin integrity, and prevent recurrence. Specific goals often depend on the condition being treated. With acne, for example, goals are to reduce the number of lesions.
Topical drugs are used primarily for local effects of skin and mucous membranes, and systemic absorption is undesirable. Major factors that increase systemic absorption of topical medications include damaged or inflamed skin; high concentrations of drug; and application of drug to the face or mucous membranes, to large areas of the body, or for prolonged periods. With topical medications, cautious use is recommended with infants and young children due to the fact they have more permeable skin and are more likely to absorb the topical drugs. Box 60.1 presents general patient teaching information for topical medications for skin disorders.
BOX 60.1 
Patient Teaching Guidelines for Topical Medications for Skin Disorders
General Considerations
Promote healthy skin by a balanced diet, personal hygiene measures, avoiding excessive exposure to sunlight, avoiding skin injuries, and lubricating dry skin. Healthy skin is less susceptible to inflammation, infections, and other disorders. It also heals more rapidly when disorders or injuries occur.
Prevent actinic keratosis and skin cancer by minimizing sun exposure, wearing sun-protective clothing, and using sunscreen. Such measures should begin in early childhood.
Common symptoms of skin disorders are inflammation, infection, and itching, and the goal of most drug therapy is to relieve these symptoms and promote healing. Systemic medications (e.g., oral antihistamines, antibiotics, and corticosteroids) may be used for severe disorders, at least initially, but most medications are applied directly to the skin. There is a wide array of topical products, both prescription and over-the-counter.
It is important to use the correct topical medication and the correct amount for the condition being treated. Topical corticosteroids, for example, come in many vehicles (e.g., creams, lotions, ointments) that cannot be used interchangeably. In addition, they should not be covered with occlusive dressings unless instructed to do so.
Adverse effects of topical medications may involve the skin (e.g., irritation, infection) where the drug is applied or the entire body, when the drug is absorbed into the bloodstream. Systemic absorption is increased when the drug is highly potent; applied to inflamed skin, over a large surface area, or frequently; or covered with an occlusive dressing (e.g., plastic wrap). Systemic absorption is of most concern with corticosteroid preparations.
Some ways to prevent or decrease skin disorders include the following:
Identifying and avoiding, when possible, substances that cause skin irritation and inflammation (e.g., harsh cleaning products, latex gloves, cosmetics, pet dander)
Bathing in warm water with a mild cleanser (e.g., Cetaphil), patting skin dry, and applying lotions or oils (e.g., Eucerin, mineral oil) to lubricate skin and decrease dryness
Avoiding scratching, squeezing, or rubbing skin lesions. These behaviors cause additional skin damage and increase risks of infection. Fingernails should be cut short; cotton gloves can be worn at night.
Maintaining a cool environment; preventing sweating
Applying cold compresses to inflamed, itchy skin
Using baking soda or colloidal oatmeal (Aveeno) in bath water to relieve itching
If you are taking an oral antihistamine to relieve itching, take it on a regular schedule, around the clock, for greater effectiveness.
Unavoidable skin lesions or scars can often be hidden or rendered less noticeable with makeup or clothing.
Women can wear cosmetics over most topical medications. If unclear, ask a health care provider whether makeup is permissible. With acne, use noncomedogenic makeup, moisturizers, and sunscreens.
Self-Administration
Use topical medications only as prescribed or according to the manufacturer’s instructions (for over-the-counter products). Use the correct preparation for the intended area of application (i.e., skin, ear, vagina).
For topical application to skin lesions, cleanse the skin and remove previously applied medication to promote drug contact with the affected area of the skin.
Wash the skin and pat it dry.
Apply a small amount of the drug preparation and rub it in well. A thin layer of medication is effective and decreases the incidence and severity of adverse effects. With acne and rosacea, preventing skin lesions is easier than eliminating lesions that are already present. As a result, topical medications should be applied to the general area of involvement rather than individual lesions.
Wash hands before and after application. Wash before to avoid infection; wash afterward to avoid transferring the drug to the face or eyes and causing adverse reactions.
With azelaic acid (Azelex) for acne, use for the full prescribed period, do not use occlusive dressings or wrappings, and keep away from mouth, eyes, and other mucous membranes (if it gets into eyes, wash eyes with a large amount of water).
With benzoyl peroxide for acne:
With cleansing solutions, wash affected areas once or twice daily. Wet skin areas to be treated before applying the cleanser. Rinse thoroughly and pat dry. Reduce use if excessive drying or peeling occurs.
With other dosage forms, apply once daily initially and gradually increase to two or three times daily if needed. Cleanse skin, let dry completely, and apply a small amount over the affected area. Reduce dosage if excessive drying, redness, or discomfort occurs. If excessive stinging or burning occurs after any single application, remove with mild soap and water and resume use the next day. Keep away from eyes, mouth, and inside of nose. Rinse with water if contact occurs with these areas. Avoid other sources of skin irritation (e.g., sunlight, sunlamps, other topical acne medications).
