Epidemiology of skin diseases

Skin disease is common. Approximately 20% of the UK population have a skin disorder meriting medical management. The type, incidence and prevalence of skin disorders depend on social, economic, geographical, racial and cultural factors (Gawkrodger 2008). Internal and external factors contribute to skin disorders (Table 12.1). The economic implications of skin disease can be considerable for individuals, families and employers. Skin diseases are the most common group of occupational health problems leading to absence from work. Work-induced dermatoses (skin disease) leads to lost working time and often to compensation claims.

Table 12.1 External and internal factors causing skin disease

Age is an important factor in diagnosing disorders, some conditions being exclusive to a particular age group, and others persisting throughout life. Atopic eczema, for example, is most common in infancy, while acne develops in adolescence and normally wanes by the late 30s. Older people show expected degenerative skin changes, with 27% having malignant skin lesions. Psoriasis and eczema occur in all age groups and can be cyclical in nature throughout life.

Malignant melanoma, the deadliest form of skin cancer, is the second most common cancer in young adults (aged 15–34) (Cancer Research UK 2009a). It is largely preventable and may be curable if diagnosed and treated early (All Party Parliamentary Group [APPG] 2008). Non-melanoma skin cancer is also increasing with estimates suggesting doubling of rates every 10–20 years (APPG 2008). Current UK campaigns aim to change behaviour in relation to sunlight exposure and to UVL during sunbed use by educating people that a suntan is a sign of damaged skin rather than a desirable fashion statement. People should be alert for specific changes, a vital factor in early detection of melanoma.

Genetic or hereditary factors can be relevant to the diagnosis, and a family history should be part of the assessment. Psychological stress (exams, divorce, etc.) is common as a trigger, but most skin disorders are stressful conditions in their own right. Certain skin disorders are recognised as being entirely of psychogenic origin, e.g. trichotillomania (breaking of hair).

Social factors impact on skin disorders, and improvements in standards of living, personal hygiene and nutrition have reduced the rate of certain skin disorders (Gawkrodger 2008). The current rise in the number of patients with asthma and eczema appears to be associated with environment changes of the home, e.g. central heating, carpeting, etc. Unemployment and low wages restrict job mobility and people with industrial skin diseases may have difficulty in changing jobs to alleviate the condition. Homelessness and poor housing create problems in maintaining skin care, the former often resulting in limited access to medical care.

The nurse’s role

Patients with skin disorders and support groups have asserted their right to access specialist staff and be nursed in specialist areas (Department of Health [DH] 2004). If nurses can spend time talking with the patient, educating and demonstrating skin care techniques, it increases their confidence and potentially the patient becomes the ‘expert’ and the burden of skin care can be alleviated by supported self management (Dermatology Workforce Group 2007), a strategy that fits with Government position on long-term conditions (DH 2006).

Cure is not a word widely used in dermatology given the cyclical nature of many conditions, so nurses involved often forge long-term relationships with patients. Nurses with experience of chronic skin disease can help patients who require empathy and guidance from specialist practitioners who have the time, knowledge and willingness to share clinical skills with this motivated client group. Kurwa & Finlay (1995) reported inpatient management as improving QoL for dermatology patients, while peer group interaction between patients in dermatology wards is recognised as beneficial.

It is important to share this specialist knowledge with primary care nurses as ‘care moves closer to the patient’ with dermatology being one of the specialisms moving into the community from secondary care (DH 2006). The supportive role of nurses in primary care is vital. Only a small minority of patients are referred to dermatologists. Self-medication, OTC therapies and nurse prescribing mean that, for many, pharmacists and community teams are the first contact for most patients. The dermatology nurse specialist/practitioner/liaison uses educational input to support the primary care team in providing information and therapies that are valid, accurate and up-to-date and, in an advisory and consultative capacity, helps sustain continuity of care (Stone 1997). Dermatology nurse practitioners/specialists have introduced initiatives in many areas of practice such as nurse-led clinics for chronic disease management (eczema, psoriasis, acne) utilising non-medical prescribing and managing patients with skin cancer. Nurses are therefore an important group within the dermatology team, playing a vital role in the provision of direct specialised care.

Structure of the skin

The skin is composed of two layers: epidermis and dermis. Beneath these layers, a layer of subcutaneous fat protects and insulates the underlying structures.

Epidermis

The epidermis is composed of stratified epithelium and varies in thickness between different parts of the body; skin on the palms and soles is thicker than that on the face or back. The epidermis is avascular, the cells being nourished by means of diffusion of materials. Structures passing through the epidermis include hair follicles and sebaceous and sweat glands (Figure 12.1A). The epidermis has several layers, its health depending on three factors:

• regular division and migration of epidermal cells to the skin surface

• gradual keratinisation of these cells

• desquamation or rubbing away of these cells.

Figure 12.1 A. The structure of the skin. B. The layers of the epidermis.

The layers of the epidermis are (Figure 12.1B):

Basal layer (stratum basale)

The cells lying nearest the dermis form the germinative layer where cell division occurs. Cells migrate upwards from this layer, becoming keratinised over a period of 21–28 days before being shed.

Prickle cell layer (stratum spinosum)

Cells in this layer have intercellular connections that protect against shearing forces or trauma to the skin.

Granular layer (stratum granulosum)

This layer contains keratohyalin, a precursor of keratin, which gradually replaces the cytoplasm of the cells.

Clear cell layer (stratum lucidum)

Present only where the skin is thickened, e.g. the soles of feet. The cells exhibit nuclear degeneration and contain large amounts of keratin. Skin injury or friction increases cell production, resulting in a callus or corn.

Cornified, horny layer (stratum corneum)

Comprises thin, flat, non-nucleated cells, the cytoplasm of which has been totally replaced by keratin.

The epidermal/dermal junction is convoluted into dips and ridges which help to prevent damage to the skin from shearing forces. The configuration of these ridges is visible at the epidermal surface as corresponding characteristic, individualised patterns, e.g. at the fingertips.

Glands

Functions of the skin

Intact skin is vital to health and well-being. As the largest organ in the body, weighing approximately 4 kg, and having a surface area of 2 m², the skin has many vital functions (Hughes 2001):

History taking

The history should reveal the person’s description and understanding of the disorder as well as their perception of living with it. It can often be a symptom of systemic disease or a condition in its own right, e.g. pruritus may indicate liver disease/low ferritin or dry skin. An effective assessment should determine the impact of the skin disorder on those around the patient. Skin disease, with all its social implications, has a major cultural impact that varies within a multicultural society. Cultural beliefs need to be identified if treatment programmes are to be adapted to acknowledge such issues. It is important to ask patients what they have already used to treat their skin disorder. Many OTC preparations or treatments, borrowed from well-meaning friends, can exacerbate an existing skin condition. When examining skin, the nurse must have knowledge of ‘normal’ skin to be able to identify the abnormal at any age.

Physical examination

The entire skin surface is examined to determine the extent of the disorder. Touch is very important – lightly run the tips of the fingers over the skin surface. Palpation of skin lesions will determine changes in skin texture with associated crusting or scaling. In skin disorders, the term ‘lesion’ describes a small area of disease, while an ‘eruption’ or ‘rash’ describes widespread skin involvement.

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Skin assessment includes routine examination of the hair and nails as changes can aid diagnosis, e.g. nail changes in psoriasis or fungal infection. The distribution of lesions can vary. Psoriasis tends to localise on the outer aspects of elbows and knees, while eczema is most common in the skin flexures.

During assessment, the nurse should recognise that skin changes can be a manifestation of systemic disorders, e.g. liver disease. Peters (2001) reminds the nurse to recognise the wide diversity of skin colour and pigmentation in society. The pathophysiology of the disorder will be unchanged, but skin pigmentation can influence skin changes during illness.

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Communication with patients is important for accurate assessment, as a patient’s description of symptoms is relevant to diagnosis and management. Initial nursing management involves alleviation of distressing symptoms while awaiting diagnosis.

The nurse should also recognise that the effect of the physical appearance of a skin disorder on quality of life is often viewed by the patient as being of greater importance than the discomfort of having abnormal skin (Lewis-Jones 1999).

Investigations

Investigations assist with the process of elimination or act as supporting evidence to develop a working diagnosis. Interpretation of the result is important, while identifying the relevance to the current clinical picture and the patient.

Common investigations include:

Topical therapies

Topical therapies are usually known as first-line treatments and are applied directly on the skin which is the target organ and readily accessible. Various classes of topical preparations are used (Box 12.2).

Ongoing commitment is needed to maintain treatment as topical therapies can be messy, time-consuming and smelly (Box 12.3). Treatment programmes often have to be customised because therapeutic responses can differ with each patient.

Regular nursing assessment will identify improvements or deterioration and allow treatment to be amended appropriately. A maintenance programme is needed as well as the treatment response for a flare. The patient needs to have the therapies at home so they can also use them immediately a flare occurs – step-up step-down. In order to achieve the desired outcome, the skilled practitioner needs a sound knowledge of dermatology therapies balanced with abilities to educate, support and motivate the patient to complete lengthy treatment programmes.

A fire hazard is associated with the use of paraffin-based skin products (National Patient Safety Agency 2007) and nurses must alert patients to this danger.

Systemic therapies

A range of oral medication, from antibiotics to immunosuppressant to biological drugs, is used to treat long-term inflammatory conditions as well as acute inflammatory or bullous conditions. Monitoring of patients on oral medication is often undertaken by dermatology nurses who work as non-medical prescribers: they interpret blood results and alter doses or initiate alternative therapies used in conjunction with topical therapies (see Useful websites, e.g. The British Association of Dermatologists). Nurses must know the potential side-effects of topical and systemic therapies in order to provide safe care and when necessary be able to adjust therapy accordingly.

Complementary therapies

The increasing interest in complementary therapies to treat skin disorders reflects a rise in public awareness of non-traditional approaches to treatment, perhaps stimulated by the failure of orthodox medicine to provide ‘cures’. The nurse is ideally placed to discuss both the orthodox and complementary options available. Discussion should focus on the safe use of complementary therapies initiated by referral to a practitioner who has undergone accredited training and is a licensed practitioner with insurance. Complementary therapy should be considered as an adjunct and not as an alternative to routine therapies.