The Integumentary System

Sehreen Ashraf
 Definition
• The integumentary system is an
organ system consisting of the skin, hair,
nails, and exocrine glands.

• protects the body's internal living tissues and

organs, protects against invasion by infectious
organism, and protects the body from
dehydration.
 Skin
• The skin is only a few
millimeters thick yet is by
far the largest organ in the
body
• constituting 15% to 20%
of the body weight
• The average
person's skin weighs 10
pounds and has a surface
area of almost 20 square
feet.
 Functions
• Primary function of the skin is to protect underlying
structures from external injury and harmful substances
• The skin is primarily an insulator
• Holding the organs together
• Sensory perception
• Contributing to fluid balance,
• Controlling temperature
• Absorbing ultraviolet (UV) radiation
• Metabolizing vitamin D
• And synthesizing epidermal lipids
 SKIN LESIONS
• Any skin area that has different characteristics
from the surrounding skin, including color,
shape, size, and texture
• Often appear as a result of a localized damage
to the skin, like sunburns or contact dermatitis
 Primary lesion
• The is the first lesion to appear on the skin
and has a visually recognizable structure (e.g.,
macule, papule, plaque, nodule, tumor, wheal,
vesicle, pustule)
• When changes occur in the primary lesion, it
becomes a secondary lesion (e.g., scale,
crust,, ulcer, scar, fissure, atrophy).
• Macules are flat, well-circumcised lesions up to 1 cm (0.39
inches) in diameter,
• While patches are similar but are larger than 1 cm.
• Papules are raised bumps that are up to 1 cm in diameter;
• Plaques are similar, though larger than 1 cm.
• A smooth papule or plaque that is transient (meaning that it
occasionally appears and disappears) is called a wheal.
• Vesicles (such as with herpes simplex infections) are up to 1 cm in
diameter and look like clear, fluid-filled blisters,
• While bullae are larger than 1 cm
• Pustules (such as pimples or acne) are pus-filled, elevated lesions up
to 1 cm in diameter.
• Finally, scales are accumulations of thickened stratum corneum (the
outermost layer of the skin, consisting of dead skin cells) that become
dry and flaky and sometimes peel off;
• while crusts are dry exudates like sebum, pus, or blood.
 Birthmarks
• Commonly caused by a nevus (pl., Nevi)
• Nevus (plural: nevi) is the medical term for a
mole.
• May involve an overgrowth of one or more of
any of the normal components of skin
• Such as pigment cells
• Blood vessels
• And lymph vessels
• Birthmarks may be classified as pigment cell
(e.G., Mongolian spot, café au lait spot), vascular
(e.G., Port-wine stain, strawberry hemangioma),
epidermal (e.G., Epidermal nevus, nevus
sebaceus), or connective tissue (e.G., Juvenile
elastoma, collagenoma) birthmarks
• Most birthmarks do not require treatment.
• Vascular birthmarks may be removed with laser
therapy for cosmetic
 Interesting fact
• The presence of six
or more café au lait
spots over 5 cm in
length requires
medical
investigation,
because these may
be diagnostic of
neurofibromatosis
or Albright
syndrome.
SIGNS AND SYMPTOMS OF SKIN
DISEASE
 Pruritus (itching)
• is one of the most common manifestations of
dermatologic disease
• Xerosis (excessively dry skin )is the most
common cause of pruritus
• when the skin loses more moisture than it
retains
• The skin contains sebaceous glands, small glands
that create your skin's natural oilsebum
• These substances include ceramides, hyaluronic
acid, lactic acid, urea, and amino acids.natural
moisture factor (NMF).
• Many systemic disorders may cause pruritus,
most commonly diabetes mellitus, drug
hypersensitivity, and hyperthyroidism
 Xeroderma
• is a mild form of ichthyosis or excessive
dryness of the skin
• characterized by dry, rough, discolored skin
• with the formation of scaly desquamation
(shedding of the epithelium in small sheets)
• This problem is accentuated by the use of
drying skin cleansers, soaps, disinfectants, and
solvents, and by dry climates.
 Urticaria (hives)
• Is a vascular reaction of the skin
marked by the appearance of smooth,
slightly elevated patches (wheals).
• These are redder or paler than the
surrounding skin and are often
accompanied by severe itching
• An allergic response to drugs or
infection
• And rarely last longer than 2 days,
• There is approximately a 50%
reduction in numbers of mast cells
responsible for urticaria in intrinsically
aged skin.
 Rash
• is a generalized term for an
eruption accompanied by
itching
• Rashes typically occur as a
secondary response to
some primary agent, such
as exposure to the sun,
allergens, irritants, or
medications or in
association with systemic
disease
 Blisters (vesicle or bulla)
• Are fluid-containing elevated lesions of
the skin with clear watery or bloody
contents
• Blisters may be primarily associated with
diseases of a genetic or autoimmune
origin
• Or may be secondary to viral or bacterial
infections of the skin (e.G., Herpes
simplex, impetigo)
• Local injury to the skin (e.G., Burns,
ischemia, pressure, dermatitis)
• Or drug induced (e.G., Penicillamine,
captopril)
• neoplasm, called paraneoplastic
pemphigus, may be the first sign of
 Other symptoms
• Unusual spots, moles, nodules, cysts
• • Edema
• • Changes in appearance of nails
• • Changes in skin pigmentation, turgor,
texture
Why should you consider these skin lesions

• Extreme caution is also necessary whenever

using electrical or thermal modalities (heat or
cold) with older people
• Decreased circulation, reduced subcutaneous
adipose tissue
• and altered metabolism create a situation
where initial skin resistance to electricity or
poor dissipation of heat or cold can lead to
tissue damage
 Laboratory values
• Such as prealbumin levels to indicate
nutritional status
• And glucose levels, hemoglobin, and
hematocrit to monitor wound healing,
• Provide the therapist with necessary
information when setting up and carrying out
an appropriate intervention plan.
AGING AND THE INTEGUMENTARY
SYSTEM
 Intro
• The skin exhibits changes that denote the onset of
senescence (the process or condition of growing old)
• These changes may be due to the aging process itself
(intrinsic aging)
• to the cumulative effects of exposure to sunlight
(photoaging)
• or to environmental factors (extrinsic aging)
• As aging occurs, both structural and functional changes
occur in the skin resulting clinically in diminished pain
perception, increased vulnerability to injury, decreased
vascularity, and a weakened inflammatory response
 Visible indications of skin changes
• Grey hair, balding and loss of secondary sexual
hair, and increased facial hair
• For women, excessive facial hair may occur
along the upperlip and around the chin
• Women may also experience balding after
menopause
• Men frequently develop increased facial hair in
the nares(nostrils), eyebrows, and helix of the
ear.
 Cont……
• lax skin
• vascular changes (e.g., decreased
elasticity of blood vessel walls;
angiomas)
• dermal or epidermal
degenerative changes, and
wrinkling
• Wrinkling signifies loss of elastin
fibers, weakened collagen, and
decreased subcutaneous fat
 Cont…..
• Blood vessels within the reticular dermis are
reduced in number, and the walls are thinned
• This compromises blood flow
• And appears physiologically as pale skin
• And an impaired capacity to thermoregulate
• Seborrheic keratoses (brown or black, wart-
like growths), lentigines (liver spots, unrelated
to the liver but rather secondary to sun
exposure), and skin tags (small, flesh-colored
papules).
• A primary factor in the loss of protective
functions of the skin is the diminished barrier
function of the stratum corneum (outermost
layer of the epidermis)
• There are fewer melanocytes, with decreased
protection against UV radiation.
 A significant decrease in the number of
Langerhans cells
• occurs, so that by the time a person reaches
70 years of age
• there is only half the number of Langerhans
cells compared to the number in early
adulthood
• A reduction in Langerhans cell counts
represents a loss of immune surveillance and
an increased risk of skin cancer
 The epidermis
• Is also one of the body’s principal suppliers of
vitamin D
• Which is produced when a hormone, 7-
dehydrocholesterol, is exposed to sunlight
• At 65 years of age, the levels of that hormone
are only about 25% of what they were in
youth, contributing to vitamin D deficiency
• Because vitamin D plays a vital role in building
bone, to osteoporosis as well.
 oxidative damage
• It is generally agreed that one of the major
and important contributions to skin aging, skin
disorders, and skin diseases is the oxidative
damage that occurs to the skin as a result of
environmental exposures and endogenous
(within the skin itself) factors.
 oxidation process
• The skin is rich in lipids, proteins, and
deoxyribonucleic acid (DNA), all of which are
extremely sensitive to the oxidation process
• Scientists are developing methods of
decreasing protein crosslinking and
accelerating increased collagen to slow
down/aide in reversing the oxidation process
 Hormonal abnormalities
• Hormone changes during puberty stimulate
the maturation of hair follicles, sebaceous
glands, and apocrine and eccrine units in
certain body areas
• Mild acne, perspiration and body odor,
freckles (promoted by sun exposure), and
pigmented nevi (moles) are common
occurrences
 Cont….
• During adolescence and adulthood, the use of birth
control pills or pregnancy may result in temporary
changes in hair growth patterns or hyperpigmentation
of the cheeks and forehead known as melasma or
pregnancy mask
• Other hormonal abnormalities may result in excessive
facial and body hair in women (androgen-related)
• Hormonal and genetic changes also produce male-
pattern baldness (alopecia)
• Smoking is an independent causative factor of facial
wrinkles
SPECIAL IMPLICATIONS FOR THE THERAPIST

• The therapist must remain alert to all skin changes, because

age-associated blunting of vascular and immune responses
may make skin findings more subtle in older adults
compared to younger clients with similar disorders.
• Vascular changes affecting thermoregulation and wound
healing require careful consideration when planning therapy
intervention.
• Likewise, loss of collagen increases susceptibility to shearing
force trauma, increasing the risk for pressure ulcers.
• Wound healing is impaired in intrinsically aged as compared
to young skin in that the rate of healing is appreciably
slower, but paradoxically the resultant scar is usually more
cosmetically acceptable.
COMMON SKIN DISORDERS
 Atopic Dermatitis
• (AD) is a chronic inflammatory skin
disease
• Most common type of eczema
• Affecting more than 10% of children
• The word atopic (from atopy) refers
to a group of three associated
allergic disorders:
• Asthma, allergic rhinitis (hay fever),
and AD. There is usually a personal
or family history of allergic
disorders present
• And AD is often associated with
food allergies as well.
 Causes
• The exact cause of AD is unknown
• But it is thought to be a result of dry, irritable
skin
• With a malfunction of the body’s immune
system.
• Genetics may play a part, but this has not been
proved
• Stress and emotional problems can worsen AD
but do not cause it.
• AD is often associated with increased levels of
serum immunoglobulin E
• And with sensitization to food allergens
• Some foods may be responsible for
exacerbations of skin inflammation, but their
pathogenic role must be clinically assessed
• Xerosis (abnormal dryness) associated with AD is
usually worse during periods of low humidity and
over the winter
• Compared with normal skin, the dry skin of AD has a
reduced water-binding capacity
• A higher transepidermal water loss
• And a decreased water content
• Rubbing and scratching of itchy skin are responsible
for many of the clinical changes seen in the skin
 Clinical Manifestations
• AD begins in many people during infancy in
the form of a red, oozing, crusting rash
classified as acute dermatitis
• As the child grows, the chronic form of
dermatitis results in skin that is dry, thickened,
and brownish-grey in color
• The rash tends to become localized to the
large folds of the extremities as the person
becomes older.
 Treatment
• Although no cure exists, AD often resolves
spontaneously
• Personal hygiene, moisturizing the skin,
avoidance of irritants, topical pharmacology,
and systemic medications (e.g., antibiotics,
antihistamines, and rarely, systemic
corticosteroids) are treatment techniques
currently availabl
 Adjuvant therapy
• Includes UV irradiation preferably with UVA1
wavelength or UVB 311 nm
• Dietary recommendations should be specific
and given only in diagnosed individual food
allergy
• Allergen-specific immunotherapy to
aeroallergens may be useful in selected cases.
SPECIAL IMPLICATIONS FOR THE THERAPIST

• Creams or ointments containing petrolatum may be

used
• And those that contain urea or lactic acid improve
the binding of water in the skin and prevent
evaporation.
• Older clients should be encouraged to bathe with
tepid water using a nondrying, nonfragranced, or
unscented soap or other agent when indicated
• Emollients must be applied to the body within 5
minutes after showering or bathing,
 Avoid
• The use of water, alcohol, or any topical
agents containing alcohol should be avoided
• Topical agents, such as ultrasound gel and
mobilization creams, must be used carefully,
observing for any skin reaction.
CONTACT DERMATITIS
 Intro
• Can be an acute or chronic skin inflammation
caused by exposure to a chemical, mechanical,
physical, or biologic agent
• It is one of the most common environmental
skin diseases occurring at any age
• As people age, they may develop delayed cell-
mediated hypersensitivity to a variety of
substances that come in contact with the skin.
 Common sensitizers
• Include nickel (found in jewelry and many
common foods)
• Chromates (used in tanning leathers)
• Wool fats (particularly lanolin found in
moisturizers and skin creams)
• Rubber additives
• Topical antibiotics (typically neomycin and
bacitracin)
• Topical anesthetics, such as benzocaine
 Clinical Manifestations
• Intense pruritus (itching)
• Erythema (redness)
• And edema (swelling) of the skin occur 1 to 2
days after exposure in previously sensitized
persons
• These conditions may progress to vesiculation,
oozing (watery discharges), crusting, and
scaling
 Treatment
• Acute lesions usually resolve in 3 weeks;
• Chronic lesions persist until the causative agent has been
removed
• Avoid contact with strong soaps, detergents, solvents,
bleaches, and other strong chemicals
• The involved skin should be lubricated frequently with
emollients.
• Topical anesthetics or steroids (topical or sometimes
systemic) or both may be prescribed
• For those people unable to avoid known allergens,
immunosuppressant therapies
 SPECIAL IMPLICATIONS FOR THE
THERAPIST
• The client’s skin always must be examined
before and after intervention for the
appearance of any adverse reactions
• The client should be instructed to report any
discomfort or unusual findings during or after
treatment to the therapist
• The person with contact dermatitis associated with the
use of a silicone sleeve or interface with a prosthetic
device should be cautioned about the use of soaps that
do not include a rinsing agent
• Many antibacterial and antiperspirant soaps leave
particles on the surface of the skin that act as a barrier
on the skin’s surface against bacterial invasion
• A rash or blister may occur in patchy areas
corresponding to pressure points when the friction of
the interface drives the soap particles back into the skin.
• Soap-free cleansing agents or a soft soap
should be used for daily cleansing, and a
petroleumbased ointment can be applied to
the limb before putting on the liner.
 What to Avoid
• Water-based ointments should be avoided
when using urethane liners, because these can
cause the normally tacky urethane to adhere
to the skin so that when the liner is removed,
bits of skin may be pulled off as well.
ECZEMA AND DERMATITIS
 Intro
• Eczema and dermatitis are terms that are
often used interchangeably
• a superficial inflammation of the skin caused
by irritant exposure, allergic sensitization
(delayed hypersensitivity), or genetically
determined idiopathic factors.
 Causes
• By hypoproteinemia
• Venous insufficiency
• Allergens, irritants
• Or underlying malignancy, such as leukemia or
lymphoma
• From drug–drug interaction can occur.
• The normal aging process with the flattened
epidermal–dermal junction and loss of dermis results
in skin fragility, which contributes to the development
of skin tears and dermatitis.
 Types
• Allergic dermatitis
• Irritant dermatitis
• Seborrheic dermatitis
• Nummular eczema
• AD
• Stasis dermatitis
 three primary stages
• Acute dermatitis is characterized by extensive erosions with
serous exudate or by intensely pruritic, erythematous papules and
vesicles on a background of erythema
• Subacute dermatitis is characterized by erythematous, excoriated
(scratched or abraded), scaling papules or plaques that are either
grouped or scattered over erythematous skin. Often the scaling is
so fine and diffuse the skin acquires a silvery sheen
• Chronic dermatitis is characterized by thickened skin and
increased skin marking (called lichenification) secondary to
rubbing and scratching; excoriated papules, fibrotic papules, and
nodules (prurigo nodularis); and postinflammatory
hyperpigmentation and hypopigmentation.
SKIN INFECTIONS
 Bacterial Infections
• Normally the skin harbors a variety of bacterial flora
• including the major pathogenic varieties of
staphylococci and streptococci.
• The degree of their pathogenicity depends on the
invasiveness and toxigenicity of the specific
organisms, the integrity of the skin, the barrier of
the host, and the immune and cellular defenses of
the host
• Organisms usually enter the skin through abrasions
or puncture wounds of the hands.
 Impetigo
• caused by staphylococci or
streptococci
• commonly found in infants,
young children 2 to 5 years of
age, older people
• occurs most often during hot,
humid weather
• Lesions frequently affect the
face, heal slowly, and leave
depigmented areas. Neither
fever nor pain
 Predisposing factors
• Include close contact in schools, overcrowded living
quarters
• Poor skin hygiene, anemia, malnutrition, and minor
skin trauma
• It can be spread by direct contact, environmental
contamination, or an arthropod vector
• Impetigo often occurs as a secondary infection in
conditions characterized by a cutaneous barrier
broken to microbes, such as eczema or herpes
zoster excoriations
 Clinical Manifestations
• Small macules (flat spots) rapidly develop into
vesicles (small blisters) that become pustular
(pus-filled)
• When the vesicle breaks, a thick yellow crust
forms from the exudate, causing pain,
surrounding erythema, regional adenitis
(inflammation of gland), cellulitis
(inflammation of tissue), and itching.
 Cellulitis
• Spreading acute inflammation with infection
of the skin and subcutaneous tissue that
spreads widely through tissue spaces
• Streptococcus pyogenes or staphylococcus is
the usual cause of this infection in adults and
haemophilus influenzae type b in children,
although other pathogens may be responsible
• The skin is erythematous,
edematous, tender, and
sometimes nodular
• It can develop under the skin
anywhere but affects the
extremities most often.
• Erysipelas, a surface cellulitis of
the skin, affects the upper dermis
and is characterized by patches of
skin that are red and painful with
sharply defined borders and that
feel hot to the touch
• Facial cellulitis involves the face, especially
the cheek or periorbital or orbital tissues; the
neck may also be affected
• Pelvic cellulitis involves the tissues
surrounding the uterus and is called
parametritis
VIRAL INFECTIONS
 Intro
• Viruses are intracellular parasites that produce
their effect by using the intracellular
substances of the host cells
• In a viral infection the epidermal cells react
with inflammation and vesiculation (as in
herpes zoster) or by proliferating to form
growths (warts).
 Herpes Zoster
• viral infection that occurs with reactivation of
the varicella-zoster virus
• Symptoms typically start with pain along the
affected dermatome, which is followed in 2-3
days by a vesicular eruption
• Classic physical findings include painful
grouped herpetiform vesicles on an
erythematous base
• Treatment includes antiviral medications
such as acyclovir, famciclovir, and valacyclovir
given within 72 hours of symptom onset.
• Reactivation of varicella-zoster virus (VZV) that
has remained dormant within dorsal root
ganglia, often for decades after the patient’s
initial exposure to the virus in the form of
varicella (chickenpox), results in herpes zoster
(shingles)
• acute cases often lead to postherpetic
neuralgia (PHN)affect nerve fibers and
skin burning pain
 Warts (Verrucae)
• common, benign viral infections of the skin and adjacent mucous
membranes
• caused by human papillomaviruses (HPVs)
• Transmission is probably through direct contact, but autoinoculation
is possible
• may appear singly or as multiple lesions
• with thick white surfaces containing many pointed projections
• .The most common wart (verruca vulgaris) is referred to as such and
appears as a rough, elevated, round surface most frequently on the
extremities, especially the hands and fingers
• Plantar warts are slightly elevated or flat, occurring singly or in large
clusters referred to as mosaic warts, primarily at pressure points of
the feet.
 TREATMENT
• . Some warts respond to simple treatment, and some disappear
spontaneously
• Over-the-counter salicylic acid preparations applied topically may be
used to induce peeling of the skin
• Other methods are cryotherapy and use of acids
• Electrodesiccation
• High-frequency electric current destroys the wart and is followed by
surgical removal of dead tissue at the base with application of an
antibiotic ointment and dressing for 48 hours
• Atrophic scarring may occur
• The use of mechanical (nonthermal) ultrasound has been advocated
by some in the treatment of plantar warts, but this has not been
widely accepted by the medical
FUNGAL INFECTIONS
(DERMATOPHYTOSES)
 Intro
• Fungal infections such as ringworm are caused by a group of
fungi that invade the stratum corneum, hair, and nails
• These are superficial infections by fungi that live on, not in,
the skin and are confined to the dead keratin layers
• Unable to survive in the deeper layers
• Because the keratin is being shed (desquamated) constantly
• The fungus must multiply at a rate that equals the rate of
keratin production to maintain itself
• Fungal infections will spread without treatment
• Antifungal creams are available over the counter, but diagnosis
is required to identify the skin lesion
 Ringworm (Tinea Corporis)
• Dermatophytoses, or fungal infections of the hair, skin,
or nails, are designated by the latin word tinea, with
further designation related to the affected area of the
body
• Tinea corporis, or ringworm, has no association with
worms
• But rather is marked by the formation of ring-shaped
pigmented patches covered with vesicles or scales that
often become itchy
• Transmission can occur directly through contact with
infected lesions
• Diagnosis : through laboratory examination of the affected
skin
• Treatment : requires maintaining clean, dry skin and
applying antifungal powder or topical agent
• Treatment with the drug griseofulvin may take weeks to
months to complete
• Possible side effects of this agent include headache, GI
upset, fatigue, insomnia, and photosensitivity.
• . Occasionally an obese client with tinea corporis is
referred to therapy for wound management secondary to
skin breakdown
 Causes
• Three different types of fungi can cause
ringworm:
• Trichophyton, Microsporum,
and Epidermophyton.
 Athlete’s Foot (Tinea Pedis)
• Causes erythema
• Skin peeling
• And pruritus between the toes that may
spread from the interdigital spaces to the
plantar surface of the foot
• Severe infection may result in inflammation
• with severe itching and pain on walking
• Some individuals develop a strong foot odor
as well
• Clean, dry socks and adequate footwear (well
ventilated, properly fitting) are important
• After washing the feet and drying thoroughly
between the toes,
 Cause
• A history of antibiotic use, yeast infections
(candidiasis, including intestinal yeast)
• And other risk factors for candidiasis may
contribute to athlete’s foot
• The fungus thrives in warm, moist environments
• It’s commonly found in showers, on locker room
floors, and around swimming pools
• keeping your feet wet for long periods of time
• having sweaty feet
 Yeast (Candidiasis)
• frequently a complication of
moistureassociated skin damage (MASD)
• due to chronic wetness from wound
exudate, urine, stool, and/or perspiration
• It can be found periwound, peristoma, in
skin folds
• Usually appearing as a bright red rash
with tiny macules and papules, it also can
appear scaly
SPECIAL IMPLICATIONS FOR THE
THERAPIST
• Affected persons should not share hair care products
(e.g., combs, brushes, headgear), clothes, or
• Affected persons must use their own towels and linens
• Because fungal infections are superficial (living on
the skin), the therapist and all health care personnel are
required by the Centers for Medicare and Medicaid
Services (CMS) to cut body hair rather than
shave it, for the application of electrodes or other
adhesives and with wound management
• Cutting the hair closely will avoid providing
microscopic nicks that can give entrance for the
transmission of surface pathogens
• Athlete’s foot, often observed by the therapist (see
previous description), should be discussed with the client.
• it can be an entry point for bacterial infections, especially in
older adults. Keeping athlete’s foot under control is an
important way to prevent cellulitis, a bacterial
infection in the legs, and is especially important in the
presence of diabetes
• Yeast People who take immunosuppressive medications or
have immune system disorders such as diabetes or cancer are
at higher risk for developing yeast infections due to MASD
•
OTHER PARASITIC INFECTIONS
 Intro
• caused by insect and animal contacts
• Contact with insects that puncture the skin for the
purpose of sucking blood, injecting venom, or
laying their eggs is relatively common
• Substances deposited by insects are considered
foreign to the host and may create an allergic
sensitivity in that individual and produce pruritus,
urticaria, or systemic reactions of a greater or lesser
degree, depending on the individual’s sensitivity.
 Scabies
• Scabies (mites) is a highly contagious skin eruption
• caused by a mite, Sarcoptes scabiei
• The female mite burrows into the skin and deposits eggs that hatch into larvae in a few
days
• Scabies is easily transmitted by skin-to-skin contact or by contact with contaminated
objects, such as linens or shared inanimate objects
• Infections with human T-cell leukemia/lymphoma virus 1 (HTLV-1) and HIV are associated
with scabies
• Mites can spread rapidly between members of the same household, nursing home, or
institution
• but the inflammatory response and itching do not occur until approximately 30 to 60 days
after initial contact.
 Clinical Manifestations
• The symptoms :intense pruritus (worse at
night), usually excoriated skin, and the
burrow, which is a linear ridge with a vesicle
at one end
• The mite is usually found in the burrow,
commonly in the interdigital web spaces,
flexor aspects of the wrist (volar surface),
axillae, waistline, nipples in females,
genitalia in males, and the umbilicus
• Intense scratching can lead to severe
excoriation and secondary bacterial infection
• Itching can become generalized secondary to
sensitization.
SPECIAL IMPLICATIONS FOR THE
THERAPIST
• If a hospitalized person has scabies, prevent transmission to
self and others
• by practicing good handwashing technique
• and by wearing gloves when touching the affected person
• and a gown when in close contact.
• Gas-autoclave blood pressure cuffs or other equipment
used with the affected person before using them on other
people
• All linens and toweling used must be isolated after use
until the person is noninfectious
• If the person is treated anywhere outside the hospital
room (e.g., on a plinth or treatment mat), the area must be
thoroughly disinfected after each session
 Pediculosis (Lousiness)
• Infestation by pediculus humanus
• A very common parasite infecting the head,
body, and genital area
• Transmission is from one person to another,
usually on shared personal items, such as
combs, lockers, clothes, or furniture
• Lice are not carried or transmitted by pets
• Pediculus humanus var. capitis, the head louse, is transmitted through
personal contact or through shared hairbrushes or shared head wear
• Severe itching accompanied by secondary eczematous changes develops
• and small greyish or white nits (eggs) are usually seen attached to the base of
the hair shafts
• Pediculus corporis, the body or clothes louse, produces intense itching, which
in turn results in severe excoriations from scratching and possible secondary
bacterial infections
• The lice or nits are generally found in the seams of the affected individual’s
clothing
• Pediculus pubis (Phthirus pubis), the pubic or crab louse, is usually
transmitted by sexual contact but can be transferred on clothing or towels
• The lice and nits are usually found at the base of the pubic hairs
• Sometimes dark brown particles (louse excreta) may be seen on underclothes.
SPECIAL IMPLICATIONS FOR THE
THERAPIST
• Wear gloves while carefully inspecting the head of
any adult or child who scratches excessively
• All combs and brushes should be soaked in the
cleaning agent, and clothing must be boiled,
drycleaned, or washed in a machine (hot cycle)
• The seams of the clothing should be pressed with a
hot iron
• . Any item that cannot be cleaned can be stored in a
sealed plastic bag for 2 to 3 weeks until all lice have
been killed
SKIN CANCER
 Intro
• Skin cancers are the most prevalent form of cancer
• Eventually affecting nearly all white people older than 65 years of age.
• Tsolar radiation (exposure to midrange-wavelength ultraviolet b [uvb]
radiation) causes most skin cancers
• And protection from the sun during the first two decades of life
significantly reduces the risk of skin cancer
• The melanoma rate is rising most rapidly in persons younger than 40
years of age
• And is now the most common cancer in women between the ages of
25 and 29 years
• And second only to breast cancer in the age group from 30 to 34
years
 Three broad categories
• seborrheic keratosis and nevi

Benign
• Actinic keratosis and Boven disease

Premalignant
• Basal cell carcinoma
• Sqamous cell carcinoma

Malignant •
•
Malignant Malinoma
Kaposi sarcoma
• Malignant lesions of the skin are considered as either melanoma or
nonmelanoma. Kaposi sarcoma, which occurs in the skin, is not
included in these categories and is discussed separately in this chapter
• Benign skin lesions, such as seborrheic keratosis or nevi (moles), do
not usually undergo transition to malignant melanoma and do not
usually require treatment
• Although most moles remain benign skin lesions, when malignant
melanoma does occur, it often arises from a preexisting mole, derived
from pigment cells (melanocytes) of the skin
• Keratoacanthomas do require treatment.
• Precancerous lesions, such as actinic keratosis or bowen disease, may
progress to malignancy and must be carefully evaluated. The most
common types of (nonmelanoma) malignant
BENIGN TUMORS
 Seborrheic Keratosis
• Hereditary benign proliferation of basal cells after middle age
• Presenting as multiple lesions on the chest, back, and face.
• The lesions also often appear following hormonal therapy or
inflammatory dermatoses
• The areas are waxy, smooth, or raised lesions
• That vary in color from yellow to flesh tones to dark brown or
black
• Their size varies from barely palpable to large verrucous (wart-
like) plaques
• These tumors are usually left untreated unless they itch or
cause pain
• Otherwise, cryotherapy with liquid nitrogen is an effective
treatment
 Nevi (Moles)
• Pigmented or nonpigmented lesions
• That form from aggregations of melanocytes beginning early in life
• Most moles are brown, black, or flesh-colored
• And may appear on any part of the skin
• Vary in size and thickness
• Occurring in groups or singly
• Nevi seldom undergo transition to malignant melanoma, but as previously
mentioned
• When malignant melanoma does occur, it often arises from a preexisting
mole
• The chances of cancerous transformation are increased as a result of constant
irritation
• Any change in size, color, or texture of a mole
• Bleeding; or any excessive itching should be reported to a physician
PRECANCEROUS CONDITIONS
ACTINIC KERATOSIS AND BOWEN DISEASE.
 Actinic Keratosis
• (Also known as solar keratosis
• Resulting from many years of exposure to the sun’s UV rays.
• The damage caused by overexposure to sunlight
• Results in abnormal cell growth, causing a well-defined, crusty, or sandpaper-
like patch or bump
• That appears on chronically sun-exposed areas of the body (e.G., Face, ears,
lower lip, bald scalp, dorsa of hands and forearms)
• The base may be light or dark, tan, pink, red, or a combination of these, or it
may be the same color as the skin
• The scale or crust is horny, dry, and rough;
• T is often recognized by touch rather than sight
• Ccasionally it itches or produces a pricking or tender sensation
• Reach a size that is most often 3 to 6 mm
• It may disappear only to reappear later.
• Often there are several actinic keratoses
present at one time
• The number of lesions that develops is directly
related to heredity and lifetime exposure to
the sun
• There is a known risk of malignant
degeneration and subsequent metastatic
potential in neglected lesions.
• Almost half of the estimated 5 million current cases
of skin cancer began as actinic keratosis lesions
• often difficult to distinguish a large or hypertrophic
actinic keratosis from a squamous cell carcinoma
• A biopsy may be indicated
• Not all keratoses need to be removed
• The decision about treatment protocol is based on
the nature of the lesion, the number of lesions, and
the age and health of the affected person.
 Treatment
• may be with 5-fluorouracil (Efudex)
• a topical antimetabolite that inhibits cell division
• or masoprocol cream
• cryosurgery using liquid nitrogen
• or curettage by electrodesiccation (superficial tissue
destruction through the use of bursts of electrical current)
• These clients should be advised to avoid sun exposure and
use a high-potency (sun protection factor [SPF] 15)
sunscreen 30 to 60 minutes before going outside. SPF 30 is
recommended for people of fair complexion.
• Sunscreens are not recommended for infants
under 6 months of age.
• Fabric with a tight weave, such as cotton, is
suggested
• such as laser resurfacing (outer layers of the
skin are vaporized)
• or chemical peels (outer layers are burned off
via chemical solution
 Bowen Disease

• Can occur anywhere on the skin (exposed and unexposed

areas)
• Or mucous membranes (especially the glans penis in
uncircumcised males)
• It presents as a persistent, brown to reddish brown, scaly
plaque with well-defined margins
• Often the person has a history of arsenic exposure in youth
• Multiple lesions have been associated with an increased
number of internal malignancies
• Treatment is with surgical excision and topical 5-fluorouracil.
MALIGNANT NEOPLASM
 Basal Cell Carcinoma
• Slowgrowing surface epithelial skin tumor
• Originating from undifferentiated basal cells contained in
the epidermis
• This type of carcinoma rarely metastasizes beyond the skin
and does not invade blood or lymph vessels but can cause
significant local destruction.
• Rarely appeared before age 40 years
• And was more prevalent in blond, fair-skinned males
• In the age group under 30 years, more women than men
develop skin cancer associated with the use of indoor
tanning devices with concentrated doses of UV radiation
• The nodule is usually painless
• And slowly increases in size and may ulcerate
centrally
• More than 65% of basal cell carcinomas are
found on the head and neck
• Other locations are the trunk, especially the
upper back and chest.
 Etiologic and Risk Factors
• Prolonged sun exposure and intermittent sun exposure
• but immunosuppression (e.g., organ transplant recipients, individuals who are
HIV positive)
• genetic predisposition with defects in DNA replication and repair (xeroderma
pigmentosum)
• and rarely, the site of vaccinations are other possible causes.
• Immunosuppressed organ transplant recipients are more likely to develop
squamous cell carcinoma
• whereas HIV-infected adults are far more likely to have basal cell carcinoma
• Dark-skinned people are rarely affected because their basal cells contain the
pigment melanin, a protective factor against sun exposure
• Anyone who has had one basal cell carcinoma is at increased risk of developing
others
• Recurrences of previously treated lesions are possible, usually within the first 2
years after initial treatment.
 Pathogenesis.
• is considered biologically unusual
• It is a stable growth
• characterized by monotonous structure (the
same in small as well as large tumors)
• the absence of progression to metastasis
• and a small amount of chromosomal damage
• seldom seen in animals and not found in
laboratory rodents at al
 Theory
• These tumors arise as a result of a defect
• That prevents the cells from being shed by the normal
keratinization process
• The process of epidermal cell maturation is called
keratinization
• Because the cells synthesize a fibrous protein called keratin
• Basal cells that lack the normal keratin proteins
form basal cell tumors
• Another hypothesis is that undifferentiated basal cells
become carcinomatous instead of differentiating into
sweat glands, sebum, and hair.
 DIAGNOSIS AND TREATMENT.
• clinical examination of appearance must be
confirmed via biopsy and histologic study
• curettage and electrodesiccation,
chemotherapy, surgical excision, and
irradiation.
 Squamous Cell Carcinoma
• Is the second most common skin cancer in
whites/lightskinned individuals
• Usually arising in sun-damaged skin
• Such as the rim of the ear, the face, the lips
and mouth, and the dorsa of the hands
• it is a tumor of the epidermal
keratinocytes
• And rarely occurs in darkskinned people
 Two types
• (Confined to the site
.
of origin)
In situ

• (Infiltrate
surrounding tissue)
Invasive
 In situ squamous
• cell carcinoma is usually confined to the
epidermis but may extend into the dermis
• Common premalignant skin lesions associated
with in situ carcinomas are actinic keratosis
and Bowen disease
 Invasive squamous cell carcinoma
• Can arise from premalignant lesions of the skin
• Including sun-damaged skin
• Actinic dermatitis
• Scars
• Whitish discolored areas (leukoplakia)
• Radiation-induced keratosis
• Tar and oil keratosis
• And chronic ulcers and sinuses
 Etiologic and Risk Factors.
• Cumulative overexposure to UV radiation (e.G., Outdoor
employment or residence in a warm, sunny climate)
• Burns
• Presence of premalignant lesions such as actinic keratosis or
bowen disease
• Radiation therapy,
• Ingestion of herbicides containing arsenic
• Chronic skin irritation and inflammation, exposure to local
carcinogens eg. Tar
• Hereditary disease such as xeroderma pigmentosum and
albinism
• Organ transplant recipients who are chronically
immunosuppressed are at risk
 Pathogenesis
• UV radiation continues to be one of the most important causes of skin cancer
• because the sun’s UV rays damage the DNA inside the nuclei of the epidermal
cells, triggering enzymes to repair the damage
• UV-damaged cells are usually removed by apoptosis (programmed cell death)
in a process involving the p53 protein
• In non-melanoma skin cancer, the p53 tumor-suppressor gene is often
damaged by UVB irradiation
• We also differ in our ability to produce repair enzymes, which may explain our
differences in tanning ability as well as susceptibility to skin cancer
• Not all DNA lesions are properly repaired, increasing the risk of skin cancer
• Fas ligand (apoptosis) is a critical defense against the accumulation of
mutations caused by sunlight exposure. Its absence or inactivation may be key
to the development of skin cancer.
 Clinical Manifestations
• more difficult to characterize than basal cell tumors
• has poorly defined margins, because the edge blends into the
surrounding sun-damaged skin.
• This type of carcinoma can present as an ulcer, a flat red area, a
cutaneous horn, an indurated plaque, or a nodule
• It may be red to flesh-colored and surrounded by scaly tissue
• More than 80% of squamous cell carcinomas occur in the head
and neck region.
• Malignant transformation of any chronic wound can occur
• Marjolin ulcer is the term given to aggressive epidermoid tumors
that arise from areas of chronic injury and form squamous cell
carcinomas.
 DIAGNOSIS
• . An excisional biopsy provides definitive
diagnosis and staging of squamous cell
carcinoma.
• Other laboratory tests may be appropriate
depending on the presence of systemic
symptoms
 Malignant Melanoma
• Neoplasm of the skin originating from
melanocytes or cells that synthesize the
pigment melanin
• The melanomas occur most frequently in the
skin
• But can also be found in the oral cavity,
esophagus, anal canal, vagina, or meninges or
within the eye.
 The clinical varieties of cutaneous
melanoma are classified into four types

• Superficial spreading melanoma

• Nodular melanoma
• Lentigo maligna melanoma
• Acral lentiginous melanoma
 Incidence
• Malignant melanoma accounts for up to 5% of all
cancers
• with a lifetime probability of developing melanoma
at 1 in 36 for men and 1 in 55 for women
• Epidemiologists, who report that the incidence of
melanoma is more than doubling every 10 to 20
years, call this a melanoma epidemic
• The incidence is rising in younger age groups, but
the disorder remains rare in children before
adolescence.
 Etiologic and Risk Factors
• Most people who develop melanoma have blond or red hair, fair skin, and blue
eyes
• are prone to sunburn
• These risk factors are thought to be linked to variations in a gene called MC1R
that assists in producing melanin pigment to help protect the skin against UV
rays.
• Not all UVB radiation (280-320 nm) but all UVA radiation (320-400 nm), the
type produced by sun lamps, may promote skin cancer
• For these reasons, the use of tanning devices is considered a significant risk
factor for the development of skin cancer.
• Melanoma occurs more often within families and among people who have
dysplastic nevus syndrome, also known as the atypical mole syndrome
• Other risk factors include excessive exposure to UV radiation through sunlight
or tanning devices, especially intense intermittent exposure, and immune
suppression from chemotherapy.
• There are some reports that airline pilots and flight crews exposed to ionizing
radiation of cosmic origin have increased rates of malignant melanoma
 Clinical Manifestations
• Melanoma can appear anywhere on the body,
not just on sun-exposed area
• Common sites are the head and neck in men,
the legs in women, and the backs of people
exposed to excessive UV radiation
• Up to 70% arise from a preexisting nevus
 MEDICAL MANAGEMEN
• A skin biopsy with histologic examination can distinguish
malignant melanoma from other lesions, determine tumor
thickness, and provide staging
• There are several techniques for staging skin cancer. The
Breslow method measures the thickness of the melanoma;
• the thinner the melanoma, the better the prognosis
• Generally, melanomas less than 1 mm in depth have a very
small chance of spreading
• A second system (Clark levels) used to determine the
appropriate stage evaluates the layers of skin that are
invaded by the melanoma
• A third method of staging, TNM, combines
both previously described methods
• Depending on the depth of the tumor invasion
and metastatic spread, other testing
procedures may be used, including baseline
laboratory studies, a bone scan for metastasis,
or computed tomographic (CT) scan for
metastasis to the chest, abdomen, central
nervous system, and brain
 TREATMENT
• Neither cryosurgery with liquid nitrogen nor electrodesiccation is used to treat
melanoma
• although they are among the acceptable procedures for squamous cell and basal
cell tumors.
• The treatment of choice for melanoma without evidence of distant metastatic
spread is surgical excision
• Surgery is combined with postoperative adjuvant radiation therapy and/or
chemotherapy when there is evidence of regional spread
• Surgery is not usually recommended for tumors that have metastasized to
distant sites
• Previously, surgical excision of the primary lesion site may have been
accompanied by removal of regional lymph nodes
• Radiation therapy is used for metastatic disease to reduce tumor size and
provide palliative relief from painful symptoms; it does not prolong survival time
 PROGNOSIS
• Malignant melanoma is a more serious
problem than other skin cancers
• because it can spread quickly and insidiously
• becoming life-threatening at an earlier stage
of development
• However, it is essentially 100% curable if
detected early
• The more superficial or thin the tumor, the better the
prognosis.
• For example, melanoma lesions less than 0.76 mm deep
have an excellent prognosis (5-year survival rate is 90%)
• whereas deeper lesions (more than 0.76 mm) carry the
risk for metastasis (5-year survival rate is 65% with local
metastasis 30%-35% when distant metastases are
present)
• Metastatic melanoma has a very poor prognosis with a
median survival of less than 8 months and a 5-year
survival rate of less than 5%.
 Cancer Foundation advocates the use of the
ABCD method of early detection of melanoma
and dysplastic (abnormal in size or shape) moles
 Kaposi Sarcoma
• Is a malignancy of vascular tissue that
presents as a skin disorder
• Directly related to Aids-associated
immunodeficiency, and the incidence has
risen dramatically along with the incidence of
AIDS (epidemic KS)
• KS may also occur in kidney transplant
recipients taking immunosuppressive drugs
 Pathogenesis
• angioproliferative tumor
• It is suspected that endogenous substances
produced by HIV-infected cells and/or a viral-
induced tumorigenesis may promote angiogenesis
• Studies have demonstrated the role of vascular
endothelial growth factor A (VEGF-A) and its
receptors in the pathogenesis
• VEGF was also increased in cells from lesions as a
result of organ transplants and even more so in
normal cells around the KS lesion
 Clinical Manifestations
• This neoplasm involves the skin and mucous membranes
• as well as other organs and can lead to tumor-associated edema
and ulcerations
• Classic KS occurs commonly on the lower extremities
• and the affected areas are red, purple, or dark-blue macules
• that slowly enlarge to become nodules or ulcers
• Itching and pain in the lesions that impinge on nerves or organs
may occur
• and as the sarcoma progresses, causing lymphatic obstruction, the
legs become edematous
• The lesions may spread by metastasis through the upper body to
the face and oral mucos
 MEDICAL MANAGEMENT
• Diagnosis is by skin biopsy using a highly sensitive and
specific test for this neoplasm
• A CT scan may be performed to detect and evaluate possible
metastasis
• NEW ANTIRETROVIRAL THERAPIES, in particular the
protease inhibitors, appear to be changing the clinical course
of AIDS KS.
• CHEMOTHERAPY remains an integral part of treatment,
• Experimental therapies being evaluated in ongoing clinical
trials include angiogenesis inhibitors, pregnancy hormone
(human chorionic gonadotropin), photodynamic therapy,
isotretinoin, antiviral medications ganciclovir and foscarnet,
retinoic acid derivatives, and immune modulators, such as
interleukin-12
SPECIAL IMPLICATIONS FOR THE
THERAPIST
• Prevention of skin breakdown and wound
management is the usual focus of intervention
• Clients receiving radiation therapy must keep
the irradiated skin dry to avoid possible
breakdown and subsequent infection
 AWARE
Teach everyone to decrease their risk of skin cancer using the AWARE
acronym:

A Avoid unprotected exposure to sunlight; avoid peak hours of sunlight (10

am to 4 pm); seek shade; never use tanning devices
W Wear close-woven protective clothing, including long-sleeve shirts,
pants, wide-brimmed hat and approved sun-protective (sun) glasses every
day of the year
A Apply sunscreen of SPF 15 (if no risks and no previous problems) or 30
or greater (when there are risk factors or a previous history of skin cancer)
20 min before going outdoors to all exposed skin; reapply every two hours,
especially if exposed to wind, water, or perspiration
R Routinely examine your skin and have a health care provider evaluate any
skin changes
E Educate family and community children about these guidelines; protect
babies from day 1 and begin education early with young children