Skin Assessment of the School-Aged Child: Infectious vs. Non ...

Commonly Seen Infectious and Non-Infectious Skin Disorders in the School-Aged Child Melinda Rodriguez DNP, APRN, FNP-BC Nursing Education Doctors Hospital at Renaissance Health Systems Disclosures Nothing to disclose Objectives Discuss a brief overview of the anatomy and physiology of the skin Discuss the importance of history collection

Discuss infectious skin disorders affecting the school-aged child Discuss the non-infectious skin disorders affecting the school-aged child Discuss assessment and management of Acanthosis Nigricans (AN) Brief Overview of Integumentary System Provides an elastic, rugged, self-regenerating cover for the body Largest organ of the body Includes: hair and nails Maintains and keeps body structures in place

Anatomy and Physiology Comprised of several layers Protects against microbial and foreign substance invasion Regulates body temperature Provides sensory perception via nerve endings

Produces vitamin D from precursors in skin Contributes to blood pressure regulation Functions of the Skin Complex organs made up of may cell types Largest organ of the body Provides barrier between external and internal environments Provides protection against organisms Skin receptors relay: touch, pressure, temperature and pain to CNS Also provide ability for localization and discrimination McCance & Huether, (2014).

Overview of the Skin Assessment Problems may arise from many mechanisms and inflammatory processes Some causes may be environmental, traumatic and secondary to exposures Evaluation of skin disorders require a in-depth focus history and PE Assess for infectious symptoms: fever, itching Look at the presentation of lesion, configuration and distribution Seidel, Ball, Dains et al., (2015).

External Clues to Internal Problems Persistent pruritus may indicate chronic renal failure, liver disease, diabetes Supernumerary nipples located along mammary ridge, may be associated with renal problems Facial port wine stain may be associated with ocular defects, malformation of meninges Age-Appropriate History

Gather data specific to current skin problems Family, PMH of similar problems Skin care routines Recent changes in skin, hair or nail care Sun-exposure habits; use of sunscreen Medication history

Onset, date of occurrence History of recent travel Rx medications; OTC medications, lotions used History of Present Illness Note recent or past changes in the skin: pruritus, dryness, sores, rashes, lumps Symptoms: pain, exudate, bleeding, color changes Recent drug exposure; chemicals; Generalized symptoms: fever, travel hx Use of topical or oral medications Seidel et al., (2015).

History (contd) Eating habits; allergies to foods Communicable disease exposure Allergic disorders; asthma

Exposure to pets; animals Skin injury; outdoor exposures Nail biting Thinning of hair Seidel et al., (2015). Mechanisms of Self-Defense Bacteria-Derived Chemicals: skin, mucous membranes and GI tract, urethra and vagina have protective microorganisms Common bacteria on the skin: staph and strept C-difficile in the GI tract

Lactobacillus protection of the vaginal tract Inspection of the Skin Performed by inspection and palpation Inspection: lighting is essential

Observe for symmetry Adequate exposure of the skin Inspect skin thickness Assess for color variances Assess for nevi; abnormally shaped; variegated colors Seidel et al., (2015). Palpation of the Skin Palpate for the following:

Moisture Temperature Texture Turgor Mobility Visualdex.com Seidel et al., (2015). Blood supply/nerve innervation

Blood supply to skin limited Include papillary capillaries Dermis facilitates the regulation of body temperature Evaporation of sweat cools body Regulates vasoconstriction McCance & Huether, (2010).

Morphological Criteria Includes: Location of lesion

Distribution Determine whether primary or secondary Shape of lesion Margins/borders/irregularities Pigmentation/color/variations Palpate texture/consistency Wear gloves if open lesions present Seidel et al., (2015). Morphological Characteristics of Lesions

Linear (in a line) Stellate (star shaped) Reticulate (netlike; lacy) Mobilliform (maculopapular; confluent) Irregular borders Border raised above Advancing; spreading beyond borders (cellulitis)

Seidel et al., (2015). Pigmentation Flesh colored Erythematous/pink

Salmon colored (psoriasis) Black Purple Yellow/waxy Pearly Primary Skin Lesions Macule: flat, circumscribed area; changes to color of skin; less than 1cm in diameter (freckle) Papule: elevated firm circumscribed area less than 1cm (wart) Patch: a flat non-palpable irregular shaped macule; more than 1cm (vitiligo)

Plaque: elevated, firm, rough with flat top surface; greater than 1cm in diameter ( psoriasis) Vesicle: elevated, circumscribed superficial; does not extend to dermis, filled with serous fluid less than 1cm McCance & Huether, (2014). Primary Skin Lesions Macule/Papule Secondary Lesions (contd) Scale: heaped up keratinized flaky skin; thick or thin, dry variation in size (seborrheic dermatitis)

Lichenification: rough, thickened epidermis secondary to persistent rubbing, itching of skin; flexor surfaces of skin (chronic dermatitis) Scar: thin to thick fibrous tissue; replaces normal skin following injury (healed wound) Keloid: irregular-shaped, elevated progressively enlarging, goes beyond boundaries of the wound; excessive collagen formation McCance & Huether, (2014). Secondary Lesions Keloid

Scar medicinenet.com Vascular Skin Lesions Spider angioma; red central body with spider-like legs; blanches with pressure Purpura; is red purple in color; non-blanchable; greater than 0.5cm in diameter Petechiae; red-purple in color, non-blanchable; less than 0.5cm in diameter Telangiectasia; fine, irregular red lines

Venous star; bluish spider; irregular shape does not blanch with pressure Vascular Lesions Telangiectasias Pigment Disorders of the Skin Skin reflects emotional states Warmth and other responses are given/received Pigmentary skin disorder: vitiligo affects people of all races, sudden appearances of white patches; vary in size, hereditary and genetic cause

Albinism: genetic disorder absence of pigment in skin, hair, eyes; found in all races Melasma: darkened macules on face; OC use; exacerbated by sun exposure McCance & Huether, (2010). Assessment of the Adolescent Increased oiliness or perspiration may be evident Increased axillary perspiration related to maturity of the apocrine glands Hair on extremities becomes coarser and darker Pubic hair develops; secondary sex characteristics

Infectious and Non-Infectious Conditions of the Skin Management and Treatment Common Skin Disorders Seen in the Schools

Impetigo Varicella Scabies/Pediculosis Herpes simplex Contact dermatitis/eczema Molluscum Contagiosum Hand, Foot and Mouth Disease Fifths Disease (erythema infectiosum)

Rubeola /Measles Stept Infection (Scarletina) Infectious vs. Non-Infectious History of present illness is very important

Events that preceded the skin condition Need to rule out trauma Medication history Previous outbreak Fever and any other systemic symptoms Allergies Eczema Characterized by : acute inflammation, erythema, edema and vesiculation Itching is often severe Multiple causes; allergic contact Common culprits: personal care products,

fragrances, detergents Often sudden in onset Habif, (2011). Prognosis/Management Avoid provoking factors; eruption improves in 7-10 days Excoriation secondary to itching/scratching could develop bacterial infection Topical steroids (used sparingly and as directed) Oral antihistamines (Benadryl) Treatment often based on elimination of causing

factor Habif, (2011). Allergic Contact Dermatitis Common T-cell mediated or delayed hypersensitivity

Allergens: chemicals, foreign proteins, poison ivy Erythema, swelling with itching Vesicular lesions are where contact is made Removal is necessary to help with tissue repair Systemic steroids are one form of treatment Atopic dermatitis: more common in infancy and childhood, usually associated with asthma, allergic rhinitis McCance & Huether, (2014). Allergic Contact Dermatitis

Delayed type hypersensitivity reaction Caused by skin contact with an allergen Results in eczematous dermatitis Common causes include: Metals (nickel) Rubber Shoes Preservatives in lotions, creams, cosmetics Habif, (2011).

Allergic Contact Dermatitis Pathologyoutlines.com Mayoclinic.org Management/ Treatment

Avoidance of the allergenic substance Identification of allergen (patch testing) Topical treatment (topical corticosteroids) Choice of topical corticosteroids depends on body site affected (use sparingly on pediatric population) 3-week tapering course of oral corticosteroids Education of patient/caregiver Habif, (2011). Pediatric Considerations Allergies can develop after years of exposure to products/medications

Consider patch testing Re-assessment of recent exposures Assess the integrity of the skin Be alert for S/S of infection Habif, (2011). Bacterial Infections of the Skin

Can result from primary skin lesions Any break in the integrity of the skin May result in erythema, edema, pain, pus May result in systemic symptoms such as: Fever Malaise Myalgias Nausea and vomiting Impetigo

Highly contagious superficial skin infection Caused by strept or staph 80% of cases caused by staph aureus Occurs after minor skin injury, insect bite Bacteria may colonize in the nasal passages Warm climates and poor hygiene contribute to it Lesions may be localized or wide spread; common on face

Habif, (2011). Skin Findings Vesicles/pustules present Red a moist base Erythematous Lesions often coalesce

Develop an adherent crust honey-yellow to whitebrown in color Thin-roofed bullae may develop Habif, (2011). Impetigo Medicinenet.com Pediatric Considerations Most common bacterial infection in children Rarely post-streptococcal glomerulonephritis may follow infection

Antibacterial soaps are recommended to be used twice daily for chronic cases Bacterial culture may be indicated for chronic cases Habif, (2011). Treatment/Management Disease is self-limiting; could spread Localized infections: Mupirocin 2% topical Oral antibiotics: doxycycline, clarithromycin, cephalexin (Keflex) x 10-14 days of treatment Recurrent impetigo may require topical Mupirocin in the nares

Good handwashing Habif, (2011). Viral Infections Verucca: warts, common benign papillomas; caused by HPV; transmitted by direct contact Herpes simplex: (HSV) infection of skin and mucous membranes; two types HSV 1 and HSV 2; symptoms begin with burning or tingling; umbilicated vesicles and erythema Herpes Zoster: shingles; acute localized vesicular eruption distributed along dermatomal segment; prevention via Zostavax vaccine

McCance & Huether, (2014). Verruca Vulgaris Also known as warts

Benign epidermal proliferations Caused by human papilloma virus (HPV) Over 150 different types of HPV Transmission is by simple contact; often on non-intact skin Local spread is caused by autoinoculation Peak incidence ages 12-16 yrs Habif, (2011). Skin Findings Flesh-colored papules evolve into dome shaped, gray to brown, hyperkeratotic , rough papules Common sites:

Hands Skin Periungual Knees, plantar surfaces Habif, (2011). Management/Treatment

Course is highly variable Spontaneous resolution with time 2/3 of warts in children regress within 2 years Multiple treatments are available OTC topical salicylic acid preparations Duration of treatment is usually 8-12 weeks Cryotherapy Imiquimod 5% cream (Aldara) Habif, (2011). Herpes Simplex

Double-stranded DNA virus; two virus types (types 1 & 2) Type I associated with vesicular, ulcerative oral infections Type II associated with genital infections Primary infection can be asymptomatic Spread by respiratory droplets, direct contact with active lesion Contact with virus containing fluid: saliva, cervical secretions in people with no active disease

Symptoms occur 3-7 days after contact Habif, (2011). Herpes Simplex I & II (HSV-1 and HSV2) Clinicaladvisor.org Primary Infection Tenderness, pain, mild paresthesias or burning before onset of lesion Grouped vesicles on erythematous base appear; subsequently erode

Lesions on the mucus membrane accumulate exudate; on skin may form a crust Lesions last 2-6 weeks and heal without scarring Habif, (2011). Recurrent Infection Recurrence rate is same as primary infection Local skin trauma, systemic changes (fatigue, fever) reactivate the virus Travels down the peripheral nerve to site of initial infection Prodromal symptoms may last 2-24 hours Many can experience a decrease in outbreaks with time

Habif, (2011). Management and Treatment Education on how to prevent transmission Avoid contact with open lesions Infections can resolve without treatment Children should be advised to avoid sharing drinks, eating

utensils; kissing Topical agents may be over-the-counter (OTC) or prescribed Antiviral medications Habif, (2011). Molluscum Contagiosum

Localized, self-limiting viral infection Transmitted by self inoculation; skin to skin contact Cause is DNA virus of the poxvirus family May occur at any age: peaks between 3-9yrs and 16-24 Tenderness and itching of lesions may occur Transmitted by close contact Habif, (2011). Skin Findings Begins as 1-2 shiny, white to flesh-colored dome shaped

firm papule Small central whitish umbilication (depression) Untreated lesions persist for 6-9 months Inflammation surrounding the lesion implies host immune response and nearing resolution Children have lesions in the upper trunk, extremities and on face Habif, (2011). Molluscum Contagiosum Healthline.com

Description: discrete, pink to flesh colored umbilicated dome-shaped lesions. (Habif, 2011). Management and Treatment Should be kept covered by clothing Minimize transmission of the virus Curettage to remove fairly painless and decreases recurrence Imiquimod 5% cream (Aldara) ***** This lesion in young adults could indicate a sexual transmission. If seen in pediatric population in genitalia suspect for sexual abuse.

Habif, (2011). Pediatric Considerations Autoinoculation around eye is common Lesions will resolve spontaneously with cell-mediated immunity Primarily a sexually transmitted disease in young adults Lesions will occur in the lower abdomen, genitalia and thighs Habif, (2011). Varicella

Highly contagious infection Caused by varicella virus Caused by human herpes virus type 3 Transmission is via airborne droplets or vesicular fluid Patients are contagious 2-days prior to outbreak of lesions Prodromal symptoms include:

Low-grade fever Headache Generalized vesicular rash Habif, (2011). Skin Findings Simultaneous presentation of lesions in various stages of development (vesicles, pustules, crusts) Begin as 2-4mm red papule, then evolve to a thin-walled clear vesicle Vesicle becomes umbilicated; fluid can become cloudy Lesions eruption ceases within 4 days Crusts fall within 7 days

Habif, (2011). Management and Treatment Symptomatic treatment includes use of bland, antipruritic lotions and antihistamines Hydration Tylenol or ibuprofen for fever Cut nails short to avoid self-inoculation or skin infection (impetigo) Varicella vaccine is 96% effective Seroconversion is 71-91% in healthy children Children immunized with live attenuated virus may have a mild

febrile illness; few vesicles 2 weeks after vaccine Habif, (2011). Hand, Foot and Mouth Disease

Highly contagious viral infection Causes aphthae-like oral erosions Vesicular lesions on hands and feet Self limiting Associated with coxsackie virus A-16 Incubation period 4-6 days Spread is by nose and throat discharge Mild symptoms of sore throat and malaise; abdominal pain 1-2 days 20% develop cervical lymphadenopathy Habif, (2011). Skin Findings

Oral aphthae-like erosions vary 10 or more Cutaneous lesions occur in 2/3 of patients Begin as 3-7mm red macules, becoming pale, white oval vesicles with red areola Healing occurs in approximately 7 days Habif, (2011). Management and Treatment Children may be isolated during most contagious period (37 days) Fever/pain controlled with Tylenol Cool fluids; acidic food avoided Need to keep child well hydrated

Antiviral medication Habif, (2011). Erythema Infectiosum (Fifths Disease) Also known as slapped cheek syndrome Viral exanthem

Occurs mostly in the winter and spring Caused by parvovirus B19 Transmitted via respiratory secretions, blood or vertically from mother to fetus Peak age is between 5-14 years Prodromal symptoms: low grade fever, pruritus, malaise, sore throat Habif, (2011). Skin Findings Facial erythema (slapped cheek) Red papules on cheeks that coalesce 2-days after onset of facial rash, lacy, erythema in a fishnet pattern on trunk and proximal extremities, buttocks

Fades within 6-14 days May appear 2-3 weeks; factors such as sunlight, hot water and emotional/physical activity Adults may experience myalgias Habif, (2011). Prognosis/Treatment Exposed pregnant women should seek serological testing and follow up with PCP Child is not considered infectious once rash develops; may return to school Most infections are self-limiting without consequence

NSAIDS can control myalgias Control fever, hydration Pregnant woman exposed should seek OB/GYN care Habif, (2011). Erythema Infectiosum Webmd.com Kawasaki Disease

Also known as mucocutaneous lymph node syndrome Morbidity and mortality associated with cardiovascular complications Ages range from 7 weeks to 12 years; adult cases rare Recurrence is rare Diagnosis based on having the following: Fever of unknown origin Bilateral conjuntiva injection Cervical lymphadenopathy Exanthem with vesicles and or crusts

Coronary artery aneurysms Skin Findings Conjunctival injection Uveitis Lips and oral pharynx erythematous, dry fissured, cracked and crusted Hypertrophic tongue papillae (strawberry tongue) Extremities (2-5 days) feet become edematous and tender Desquamation of the hands and feet; peeling of skin Rash is polymorphous, macular, papular, urticarial-like lesions; diaper dermatitis

Non-Skin Findings Fever without chills or seats can last 15-30 days Fever begins abruptly and spikes dos not respond to antibiotics or antipyretics Cervical lymphadenopathy, often limited to one Cardiac involvement; myocarditis, tachycardia and arrhythmias Coronary artery aneurysms Acute phase leukocytosis Treatment

I.V. immune globulin (IVIG) Methylprednisolone an alternative to IVIG Close monitoring of patient Hydration Oral care Rest; control of fever Kawasaki Disease

Streptococcal Infection/Scarletina Posterior pharynx is erythematous Enlarged palatine tonsils Cervical lymphadenopathy Fever, malaise Post infection:

Skin develops dry sandpaper appearance Pediculosis (head lice) Flattened, wingless, insects; infest hair of scalp, body and pubic region Attach to the skin and feed on human blood Lay eggs (nits) on shaft of hair Highly contagious Direct contact primary source of transmission Lice live about 30 days Females lay 7-10 nits daily Lay nits 1cm from scalp Habif, (2011).

Pediculosis Management and Treatment Standard is topical with Permethrin rinse 1% OTC Permethrin 5% is administered for treatment failures Home remedies include: Application of Vaseline Mayonnaise or pomades Apply shower cap and keep overnight Hair clean 1-2-3 kills lice on contact Oral prescribed treatments; Bactrim Oral antibiotics for secondary infection

Nit removal (may use vinegar with 50% water) Habif, (2011). Scabies Parasitic infection caused by mite Sarcoptes scabiei Complaints are of intense itching, unremitting Common presentation in one member of the family

Can be seen in families Skin findings: curved burrow, can be linear and S-shaped; slightly elevated vesicle or papule 1-2mm in size Can be found in intertriginous areas, webs of fingers, wrists, sides of hands, feet, lateral fingers and toes. genitalia Habif, (2011). Management and Treatment Permethrin or lindane applied to entire skin surface from the neck down Patient should bathe after 12 hours of application

Avoid eyes and mouth Benzyl benzoate bath and lotion All clothes must be washed; bed linen Post treatment pruritus can occur Assessment for areas of topical infection from scratching Habif, (2011). Lyme Disease Tick-borne disease; Borrelia burgdorferi Evolves through 3 stages; affects almost all organ systems Cutaneous eruption of Lyme disease is called erythema migrans

Onset of disease is 3-28 days after tick bite 3 Stages: Stage I: expanding target like patch; flu like symptoms Stage II: cardiac and neurological problems Stage III: arthritis and continuous neuro problems persist Habif, (2011). Skin Findings

Initial tick bite, inflamed bite reaction Tick must stay attached for at least 24 hours Skin changes (erythema migrans) Begins with a small papule with slowly enlarging ring of erythema 20-50% of people have multiple rings Habif, (2011). Management and Treatment

Prevention of tick bites/exposure Wearing protective garments Frequent assessment of skin N-diethyl-meta-tolumide on skin/permethrin on clothes (need to check with PCP for safety) Early symptoms of disease treated with 21 days of treatment with Doxycycline, or Ceftin, or Amoxicillin Seek PCP care ASAP Habif, (2011).

Acanthosis Nigricans Elevated, velvety hyperpigmentation of the flexural skin, neck, axillae and groin Commonly associated with obesity, diabetes, endocrinopathies Patients complain about an asymptomatic dirty appearance to skin folds; not removed by vigorous washing May be a family hx of eruption Habif, (2011). Skin/Non-Skin Findings AN is a cutaneous marker of tissue insulin resistance

Patients without DM have increased levels of circulating insulin Glucose levels may be elevated Impaired response to exogenous insulin Can be caused by estrogens and nicotinic acid Less common: tumors of the lung, prostate, breast and ovary Habif, (2011). Acanthosis Nigricans Nape of Neck

Axilla Trunk/Axillae Management and Treatment Skin eruption does not cause require treatment Treatment is necessary for obesity

Evaluation for the presence of diabetes Evaluation of blood pressure, measurement of body mass index (BMI) Goal of therapy is to correct underlying disease process Correction of hyperinsulemia (metabolic syndrome) Weight reduction Habif, (2011). Summary Proper assessment of skin disorder Assess for system involvement; fever, malaise Educate children and families on the importance of:

Proper hygiene Early evaluation by PCP and follow-up Referral and reporting of communicable diseases Refer to communicable disease reference chart References American Diabetes Association (2017). Standards of medical care in diabetes-2017. Diabetes Care: The Journal of Clinical and Applied Research and Education. 40(1), pgs. 1-142. Habif, T.P., Campbell, J.L., Chapman, M.S., Dinulos, J.G.H, & Zug, K.A. (2011). Skin disease: Diagnosis & Treatment, 3rd Ed. Saunders Elsevier, New York, NY McCance, K.L., Huether, S.E., Brashers, V.L, & Rote,N.S. (2014). Pathophysiology: The biological basis for disease in adults and children. 7th Ed. St. Louis, Missouri.

National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK]. (2017). Retrieved from: http://www.niddk.nih.gov.health-information/diabetes/overview/ Seidel, H.M., Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2015). Mosbys Guide to Physical Examination, 8th Ed., Elsevier, St. Louis, Missouri.