7 The Integumentary System Objectives In this chapter we will study ‘© the importance of the integumentary system in @ physica! examination; ‘© terms deseribing the most common skin lesions; ‘© some diagnostic tests for skin disorders; ‘© the rule of nines used to evaluate burn patients ‘© pressure ulcers, allergic contact dermatitis, and infections and infestations ofthe skin and diagnostic signs in the nails; and acne vulgaris. Diagnosing Skin Disorders ‘The skin is the largest, most visible, and most vulnerable of the body organs. Many illnesses cause ‘isiblo changes in the skn-not only disorders ofthe skin itself, but also intemal disorders such as anemia, ting. disease, heart disease, hepatitis, deliydration, ane hormone imbalances that affect the ski, Inspection of the infegumentary system is one of the major cloments of a comprehensive physical examination. Tae clinician notes the condition of the facial skin, studies the patents hands, and palpetes the hair and nails, looking especially for abnormal colors, excessive dryness oF oiliness, temperature, texture turgor (how easily a pinch of skin returns to its normal, flat appearance), and the type end distibution of any lestons that are presmnt, ‘The clinician may bo the first to notice lesions such as skin cancer in areas thatthe patent cannot seo—for example, behind the ears and on the back, When a patient complains of « skin irritation or lesion, the history should inelude information on potentially harmful substances with which the pationt has come in coninct—for example, cleaning solvents or poison ivy. Table 7.1 deseibes many of the most commonly seen kin lesions. ‘The diagnosis of skin disorders is ofen complicated by overlapping or _ nonspecific symptoms such as-itching and pain, Pruritis (tching) may result from such diverse. causes as eczema, infestation with lice, « food allergy, or @ systemie disease such as iro deficiency or thyroid trouble. Pain may result from prurtis and the 40 ‘excessive seratching that it stimulates, or it may arise independently ftom another disease altogether. Specific skin tests, including the following, can help narrow down the diagnosis: ‘+ Patch (serateh) test In this procedure, « known allergen (a substance that causes an allergy) is applied to the skin surface or introduced into the skin by seratch or injection. After 1 or 2 days, the site is examined for inflammation (redness and swelling). If inflammation occurs, it indicates that the patient is allergic to that substance. ‘+ Skin biopsy A sample of skin is taken (by seraping or shaving the surface) and then microscopically examined, An abnormal histological appearance may be diagnostic of the ‘various forms of skin cancer, among other disorders, + Shave biopsy (skin serapings) ‘The surface of the skin” is scraped and ~exat microscopically for fungi, mange mites, and thor pathogens. + Microbial culturing In this procedure, samples of microorganisms are swabbed for the skin surface and used (0 inoculate a cuhure medium, After allowing time for the microbes to multiply, they can be identified by means of biochemical characteristics, nutrient requirements, and microscopic appearance.Table 7.1 Skin Lesions Lesion Deseription Examples Primary Lesions (may develop from previously normals Flat, nonpalpable lesions and changes in color ) Macule Small (< 1 em dit) aren diferent in Freckles, measles, petechine colar from surrounding skin Patch Larger than a macule © 1 ¢m din), Vitiligo, portewine sain Srregutar in shape “Telangiectasis Thin, irregular red fines produced by capillary dilation Rosacea Palpable, elevated solid masses Papule ‘Small, firm, elevated area (ap to 5 mm dia.) ‘Wart, elevated mole Prague Piet, elevated, cough lesion oer 5 mim Psoriasis, seborrcie keratosis in diameter; may result from coalescence of papules Nedile Elevated lesion over $ mm fa sine, Lipoma ‘often deeper and firmer than « papule Tumor Large & 26mm dia), decper nodule Neoplas, tipoma Wheal Elevated, irregular area of temporary Insect bites, hives ‘cutaneous eema Superficial elevaed lesions with fluid-filled covites Bolla Blovated vesicle over S mm in diameter Blister, pesophigus vulgaris filed with serous fuid os Blevated, encapsulata lesion in dermis or Acne, sebaceous eyst subeuiancous tissue, filled with quid or semisolid metier Pustale Blevated, superficial, pusflled lesion Acne, impetigo Vesicle Elevated, supefilal lesion up to $ mm Shingles, chickenpox in diameter; fied with serous fd Secondary Lesions (develop from changes in primary lesions) as of surfce tissue Brasion Loss of epidermis, usually following rupture ‘Ruptured blister or chickenpox of vesicle; mois: and glistening but net bleeding vesiele leer ecper lass of epidermis and cerns, Pressure ulcer, sypltic hancre sometimes with bleeding and searing Fissure Linear erack in the skin 7 Attte’s foot Accumalsied moterial on skin surface Crust Drei blood, serum, or pas on skin npetigo Seale Flake of exfotitod epidermal ells Dandrul, psoriasis Other Lesions Excoriation Abrasion or srateh Scraps, veratches, seabies Keleid| let iro sn tat progress beyond Possurgical keloids eeu of original injury Lichenification ‘Thickening and roughening with exaggerated Chenie dermatitis silty of normal skin furtows, resulting froin persistent scratching, rubbing, or iitation Sear Fibrous tissue replacing injure skin, not ‘Honled wounds and surgical extending beyond the injury incisions 41Common Skin Disorders Skin disorders ave a wide variety of causes, inchuding trauma, infection, allergy, and cancer. This seetion also describes pressure ulers, contact, dermatitis, and infection with viruses, bacteria, fungi, ‘and parasites, Bums and the Rule of Nines ‘The skin is more exposed to trauma than any other ‘organ, and burns are the most serious and common rauma of the skin as well as the leading cause of accidental death, The treatment of a burn and the Prognosis for recovery depend on the extent of the bum. Extent is commonly estimated by means of the rrle of nines, in which the body surface area (BSA) is divided into regions that are each a fraction (one-half) ‘or a multiple of 9. For adults, the head is about 9% of the BSA, each upper limb is 9%, the wunk is 18%, each lawer limb is 18%, and the perineum is 1%, For the head, trunk, and limbs, the percentage is divided evenly between the anterior and posterior surfaces ‘These values differ for children and are often stated using a table with data atranged according, to the child's age. Burns of irregular shape and distribution can be estimated by comparing them to ‘the palm of the patient's hand, which is about 1% af tho body surface aren, repardlass af age, According, to the rule of nines, if an adult were burned over the face and the anterior surface of the trunk and upper limbs, the burn would cover roughly 22.5% of the body. A burn affecting 20% or more of the body surfice is considered a major burn; Burns affecting two-thirds or more of the body are usually fatal Pressure Ulcers Pressure ulcers ure skin lesions caused by isehemla (lack of blood flow) and the resulting necrosis (tissue Geath) in areas of skin subjected to persistent pressure, They ure also known a5 bedsores and decubitus ulcers, among other names. Pressure ulcers commonly occur in people who are confined to @ bed for whesichair and are unable to change pasion for long periods, Pressure ulcers occur especially in areas ‘where bone comes close to the Surfice and the skin is compressed between the bone and the surface on which the patient rests. Thus, they are often seen in the areas of the caceyx (“tailbono”), hips, ankles, and heels, Unrelieved pressure ean lead to necrosis and lammation, ‘The necrotic lesion may extend well 2 beyond the skin, exposing underlying muscle and bone. Pressure ulcers are more common in elderly patients than in younger ones snd more frequectly seen in whites than in other people. They are also common in people who suffer decreased sensation and are tus unaware of the pressure and growing lesion; therefors, spinal cord injuries and diabetes malitus are sk factors for pressure uleers ‘An important goal in patient care is to prevent pressure ulcers fom forming. This is accomplished by changing the patent's positon frequently, ensuring adequate nutrient and fluid intako, and using beds and wheelchairs that have pressure-educing surfoss. If pressure ulcers develop, treatment is based on tic soveity, Superficial ulcers affecting only the upper layer ofthe skin ae treated by covering te uler with a flat dressing that will not wrinkle and Keeping the tloer moist. Large pressure ulcers that effet deoper layers ofthe skin and underying tissues may roquire debridement (ettng or scraping away necrotic tissue) and opening the Ision to allow drainage. The wound may be closed with a skin graft or, more commonly, & ryocutancous flap (created ftom the patients own skin, muscle, and underiying blood vessels near the ret ofthe ulcer). Allergic Contact Dermatitis ‘One of the many inflammatory dscases of the sk allergic contact dermatitis, seen in sllersies to ivy and cosmetics, for example. Whon an allergon contacts tho skin, it may bind toa carier protein and form a sensitizing allergen, Dendritic calls ofthe skin process the allergen and alert the immune system, ‘hich than mounts an immune response to the allergen. An allergic response isnot usually seen unt the second exposure to an antigen, Symptoms include erythema, pruritis, swolling, and vesielar lesions at the ste of contact. Patch testing is mest often used to tify the antigen. Removal of the antigen and revention of further contact are required to stop the inflammatory response an allow for Ussue repair, Severe inflammation may require either topical or systemic. treatment. with © corticosteroid such as hhydrovortisone, Latex allergy is of ineceasing concern in health cate because clinicians are expose to such «wide variety of products made of latex, including eather, tubing, elastic, and gloves. used for surgery, cxamitations, and cleaningViral Infections ‘Many difforent virusos cause skin diseases. Examples include cold sores, warts, shingles, and chickenpox. Chickenpox is 2 common disease of early childhood caused by the varicella-zoster virus. The virus is spread through sirbome dropkis and by close personal contac. The virus causes a fever accompanied by a vesicular rash that usually begins ‘on the scalp, face, and trunk and then spreads to the limbs. Vesicles, papules, and macules appear for upto 5 deys. The patient is infectious to others from 24 tours before the rash develops to as Tong as 6 days after. In time, the vesicles rupture and become encrusted. ‘Treatment methods include baths, wet dressings, and antihistamines to relowe_ itching Seratching the rash can lead to a secondary infetion, hie then may require antibiotic treatm. After the chickenpox clears up, the virus may remain domeant in the nervous system and erupt much later in life (usually after age $0) as @ long-lasting, sometimes very painful skin disorder called shingles (herpes mster). Bacterial Infections ‘Most bacterial infections of the skin are caused by Staphylococcus aureus (“staph infections”). Examples include: + folliculitis, infection ofthe hair follicle; + furuncles or boils, folliculitis that has spread to the surrounding dermis; es, aggregates of infected hair follicles; ‘© cellulitis, infection ofthe domis and subcutaneous tissuc. Such conditions are usually treated by cleaning the area with soap and water and applying, topical antibiotics. Furuncles and carbuncles are often ‘teated with warm compresses to promote drainage. If the infection persists or spreads to other body systems, ‘oral antibiotics are prescribed Fungal infections (Tinea) Fungi often feed on the protein keratin and therefore infoct the hair, nails, and epidermis. ‘Tinea, or fungal infection, is classified by location: tines capitis, on the scalp; tinea cruris, the groin; tinea pes, the fet, tinea manus, the hands; tinea unguium, the nails; end tinea corporis, the skin excluding the scalp, feo hands, fect, and gonitals. ‘Tinea corporis often as a ringlike border and was therefore named ringworm in the fifteenth century, although we now recognize that itis not a worm. Symptoms of tinea vary depending con the body region affected, but itehing and scales are ‘common to all types. Diagnosis is usually made by ‘examining skin scrapings and identifying the microbes in culture, Treatment typically involves topical and systemic antifungal drugs. Keeping the infected area clean and dry also helps inhibit fungal growth. Parasitic Infestations Parasites are organisms that live in contact with nother organism, called the ost, and usually cause some pathology. Although the aforementioned bacteria and fungi can be considered parasites in the broad sense, the word parasite more often denotes ‘organisms such as protozoans, worms, and arthropods that live on and at the expense of a host. The presence of skin parasites is called an infestation, as opposed oan infection, which is the multiplication of pathogens within the body. Some skin pathogens can be classified either way, such as a fungus that is not confined to the skin surface but also pensirates deeply into the skin. Some parasitic animals invade the human body accidentally. For example, if « cat with hookwormns (genus Ancylostoma) buries its feces in a child's sandbox, worm larvae hatch from eugs in the feoes ‘and may burrow into the skin of children playing in the sandbox. ‘These larvae cause an infestation called creeping eruption (cutaneous larva migrans). The ‘worms become disoriented in this unnatural host, crawl about in the skin, and soon die there. As they burrow through the skin, they create undulating trails that become inflamed, itehy, and crusty. Dogs also ‘arty Ancylastoma. When allowed to roam on beaches and defecate in the sand, they set the stage for ‘creeping eruption in people who later sit or fe on that spot even after tho fecal pile has disappeared. Creeping eruption itself is not dangerous, but scratching the itchy lesions can lead to more serious secondary bucterial infections. Lice are small, parasitic, blood-sucking insects. ‘Thrce species of lice infest humans: the head louse, Pediculus humarus capitis, which lives on the scalp tnd glues its eggs (nis) to the hair; the body louse, Fediculus Inmanus corporis, which lives in the clothing and glues its eggs to the fabric; and the pubic louse (erabs"), Prhirus pubis, a more stocky, erab- 8shaped louse that lives in the pubic hair. Infestation with lice of any species is called pediculosis. Head lice are especially common among schoo! children. Pubic lice are normslly transmitted by sexual contact. For the most part, all thee species cause itching, Which may be intense enough to imerfere with sieep and schoolwork, but nothing more serious. The body louse, however, spreads bacterial diseases, including, epidemic typhus, which has caused monumental epidemics killing millions of people, ‘The body louse, and thus typhus, spreads from person to person mainly in crowded, unsanitary conditions, such as urban slums, prison camps, fophouses, and crowded ‘mental health institutions, and by sharing beds and clothing with infested people Mies are arachnids, related to ticks and spiders One of the most comunon mite infestations of humans is seabies, caused by the mange mite Sarcoptes scabie!. Like Ancylostoma larvae, Sarcoptes burrows through the skin and causes intensely itchy, crusty kesions. Unlike Ancylastoma, however, the infestation does not disappear on its own, and Sarcoptes is quite at home in humans, where it reproduces on the body. Scabies is treated with topical medications Disorders of the Accessory Organs of the Skin Nails The accessory organs of the skin also are subjct to pathology. Abnormalities of the ails, for example, fa be importa iletors of boll local and systemic diseases. Lung diseases that cause chronic hypoxemia (deficiency of blood oxygen lead to clubbing of the fingertips, ‘The fingertip Becomes bulbous and the rail more convex. Cizthsis ofthe liver and nominsulin- dependent diabetes melts can cause Terry's nals in which the nals ere abnormally white witha distal band of brown. White spas, lines, pits, and grooves in the nails san indicate psoriasis, various systemic illnesses, oF just excessive manicuring. Since many tail markings begin at the nal root und rove toward the fp asthe nail grows, elncians can often estimate the time ofan ins from the position of the marking and the known rate of nal growth (about 0.1 mmny in the fingernsils), For sush reasons, inspection of @ “4 petient’s fingernails is an important part of a physical examination Acne ‘The most common disorder of the cutaneous glands is acne vulgaris (vulgaris means “eommon”). Acne een cccur at any age, but is most common and pronounced fn adolescence, when the body is adapting to the elevated level of testosterone and other sex sterids (Testosterone is secreted in both males and females.) Acne affecis about 85% of people between 12 and 25, years of age. It is equally common in males and females, but often affects males more severely. Acne originates in the sebaceous follicfes—bair follicles with @ small vellus hair, large sebaceous alan, and a dilated canal opening onto the skin as a pore. Acne is triggered by 2 combination of thro factors: (1) hyperkeratosis, the excessive accumulation of dead keratinocytes blocking the follicle; @2) excessive secretion of sebum in response to androgens; and (3) a bacterium, Propianibacterium ‘aenes. Seburn and bacteria accumulate in the blocked follicle until the follicle ruptures, exposing. the ‘contents t0 the dermis and triggering inflammation ‘The bacteria break down the lipids of sebum into froc fatty acids that, combined with enzymes and othor bcterial secretions, intensify the inflammation, ‘The primary lesion of acne is & comedo, a mass of keratinocytes, sebum, and bacteria in a. dilated follicle. A whitehead is a “closed comedo” filed with sebaceous secretion; a blackiead isan “open comedic” that derives its darker color from oxidation of the sebum. When the infected follicle ruptures and inflammation follows, the comedo develops into. a pustule, papule, or cystic nodule, The last two of these are deeper than the frst and may leavern scar. Acne is no longer thought to be caused by chocolate, sugar, or other foods. There is a hereditary influence on susceptibility to acne and its severity Cleanliness of the skin helps minimize the severity. Acne can be treated with topical antibioties and retinoic eid and, in severe cases, oral antibioties, The prescription drug Acutaye reduces sebacoous secretion and can markedly improve nene, but if used inthe first month of pregnancy, it greatly increases the risk of birth defects. Most cases of acne clear up in a person's 20s, but the age at remission varies greatly