Chapter 28: Skin Disorders

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Chapter 28 Skin Disorders
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Skin Lesions Defined

• Skin pigment - melanin
• Variations may be due to anatomic, physiologic or
  pathophysiologic changes in skin blood flow
• Normal skin appearance
• Altered by external and internal factors
• Cellulitis
• Infectious inflammation of deep skin structures

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Skin Trauma

• Mechanical Forces that Cause Injury
• Friction
• Compression
• Shearing
• Stretching
• Scraping
• Tearing
• Avulsing
• Puncturing

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Friction and Pressure Problems

• Hyperkeratosis of the Hands and Feet
• Etiology
• Friction and pressure over bony protuberances
• Painful when subcutaneous fat becomes inelastic
• Prevention
• Cushioning devices wearing 2 socks
• Lubricants to reduce friction, shaving calluses
• For calluses on hands, special gloves or
  protective gear

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• Sign and Symptoms
• Thickening, of horny layer of skin, ovular,
  elongated and brown
• Painful with pressure
• Management
• Avoid emery boards and pumice as the increase in
  friction will stimulate skin to produce added
  callus
• Use moisturizer
• Pair off callus with scalpel
• Padding

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• Blisters
• Etiology
• Result of a shearing force that produces a raised
  area that accumulates with fluid
• Prevention
• Use of dust or powder or lubricant to reduce
  friction
• Tubular socks, 2 pairs of socks if feet are
  sensitive or perspire excessively
• Appropriate shoes that are broken in
• Padding and lubricants
• Signs and Symptoms
• Hot spot, sharp burning sensation, painful
• Superficial area of skin raised with clear fluid

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• Management (intact blister)
• Leave intact for 24 hours
• Clean with antiseptic
• Cut small incision to drain fluid (large enough
  that it wont re-seal)
• Prevent refilling with a pressure pad
• Clean again with antiseptic
• Use doughnut to prevent irritation
• Monitor for infection, replace wet bandaging
• Debridement can be performed when tenderness is
  gone

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• Management (open/torn blister)
• Keep clean to avoid infection
• Keep skin in place and apply non-adhering sterile
  dressing and padding
• Monitor daily for infection
• Management (denuded blister)
• If blister is torn 1/2 inch or more remove skin
  flap
• Clean and expose area, apply antiseptic with
  occlusive dressing
• Second skin can be applied to raw area

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• Soft Corns and Hard Corns
• Etiology
• Caused by pressure of improperly fitting shoes
  and anatomic abnormalities
• Soft corns are the result of pressure and
  perspiration, also associated with exostosis
• Signs and Symptoms
• Hard corns form on the tops of toes and tend to
  be painful and dry
• Soft corns result in thickening of skin, white
  and sometimes painful (between 4th and 5th toes)
• Prevention
• Wear properly fitting shoes
• Management
• Surgical removal if painful
• Padding maintain clean dry feet wear
  appropriate shoes

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• Excessive Perspiration (hyperhidrosis)
• Etiology
• Syrup-like perspiration, high in sodium chloride
• Increases risk of other skin irritation
• Makes adherence of bandages difficulty
• Management
• Use of astringent such as alcohol or an absorbent
  powder
• Aluminum chloride or electric current can be used
  to treat condition

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• Chafing of Skin
• Etiology
• Occurs particularly in athletes that are obese or
  heavy limbed
• Result of friction and maceration of skin in
  climate of heat and moisture
• Signs and Symptoms
• Separation of keratin from granular layer of skin
• Causes oozing wounds that crust and crack
• Prevention
• Keep skin dry, clean, and friction free
• For the groin, soft, loose, cotton underwear is
  recommended
• Management
• Clean area with soap and water and treat with
  medicated solution and hydrocortisone cream

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• Xerotic (Dry) Skin
• Etiology
• Drying of skin due to exposure of cold, excessive
  bathing, decrease in humidity causing skin to
  lose water
• Signs and Symptoms
• Dry skin w/ variable redness and scaling itching
• Management
• Prevent water loss and replace lost water
• Bathe in tepid water, use moisturizer
• If condition worsens, refer to physician

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• Ingrown Toenails
• Etiology
• Generally occurs in great toe
• Nail grows laterally into skin
• Result of lateral pressure from shoes, poor nail
  trimming, and repeated trauma

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• Signs and Symptoms
• Pain and swelling
• Penetrated skin becomes inflamed and purulent
  with lateral nail fold swollen and irritated
• Prevention
• Properly fitting shoes and socks are essential
• Weekly toenail trimming (cut straight across)
• Leave nail long enough to clear skin
• Management
• Conservative management includes soaking the
  inflamed toe in warm water (20 minutes)
• Place cotton under edge of nail to clear from
  skin
• If chronic, remove wedge of nail and apply
  antiseptic compress until inflammation resides

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Wounds

• Abrasions
• Scraping of skin against rough surface (top
  surface of skin is worn away)
• Increased probability of infection due to
  exposure of dirt and foreign material
• Clean and debride
• Punctures
• Direct penetration of skin with pointed object
• Must be referred to physician

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• Lacerations
• Object tears tissue, giving wound appearance of
  jagged edge (sometimes result of blunt trauma)
• Presents environment susceptible to infection
• Skin Incision
• Smooth cut in skin - not jagged
• Skin Avulsion
• Skin torn away from body (should be placed in
  moist gauze w/in a plastic bag that is then
  immersed in cold water)
• Transport to hospital with athlete for possible
  reattachment

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• Skin Bruises
• Result of blunt trauma causes disruption of
  superficial blood vessels and results in black
  and blue discoloration
• Treatment requires RICE to control hemorrhaging

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Wound Management

• All wounds must be assumed contaminated
• Pay close attention to all universal precautions
• Clean all wounds with soap and water to minimize
  infection
• Apply a dressing with antiseptic (unless
  physician examination is necessary)
• Lacerations and punctures should be treated by a
  physician
• Use of occlusive dressings
• Minimizes scab formation, perceived pain from
  exposed nerves, cost and time effective, provide
  adequate barrier
• Antibiotic ointment used to prevent secondary
  infection (SEE TABLE 28-4 for added instruction)

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Athletic Training Room Practice in Wound Care

• Use clean and sterile instruments
• Clean hands thoroughly and use gloves
• Clean in and around skin lesion
• Use a non-medicated covering if athlete is to be
  sent for medical attention
• Avoid touching any part of sterile dressings that
  will contact the wound
• Place medication on pad
• Secure the dressing in place

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Bacterial Infections

• Bacteria are single celled micro-organisms
• Spherical, doublets, and spirochetes
• Staphylococcus
• Gram positive bacteria that appears in clumps in
  skin and upper respiratory tract
• Streptococcus
• Chain bacteria often associated with systemic
  disease and skin infections
• Bacillus
• Spore forming, aerobic, and occasionally mobile
• Can cause systemic damage

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• Impetigo Contagiosa
• Etiology
• Caused by A-beta-hemolytic streptococci, S aureus
  or combination of these bacteria
• Spread through close contact
• Signs and Symptoms
• Mild itching and soreness followed by eruption of
  small vesicles and pustules that rupture and
  crust
• Generally develops in body folds that are subject
  to friction
• Management
• Cleansing and topical antibacterial agents
• Systemic antibiotics

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• Furunculosis (Boils)
• Etiology
• Infection of hair follicle that results in
  pustule formation
• Generally the result of a staphy. infection

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• Signs and Symptoms
• Pustule that becomes reddened and enlarged as
  well as hard from internal pressure
• Pain and tenderness increase with pressure
• Most will mature and rupture
• Management
• Care involves protection from additional
  irritation
• Referral to physician for antibiotics
• Keep athlete from contact with other team members
  while boil is draining

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• Carbuncles
• Etiology
• Similar in terms of early stage development as
  furuncles
• Signs and Symptoms
• Larger and deeper than furuncle and has several
  openings in the skin
• May produce fever and elevation of WBC count
• Starts hard and red and over a few days emerges
  into a lesion that discharges yellowish pus
• Management
• Surgical drainage combined with the
  administration of antibiotics
• Warm compress is applied to promote circulation

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• Folliculitis
• Etiology
• Inflammation of hair follicle
• Caused by non-infectious or infectious agents
• Moist warm environment and mechanical occlusion
  contribute to condition
• Psuedofolliculitis (PFB)

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• Signs and Symptoms
• Redness around follicle that is followed by
  development of papule or pustule at the hair
  follicle
• Followed by development of crust that sloughs off
  with the hair
• Deeper infection may cause scarring and alopecia
  in that area
• Management
• Management is much like impetigo
• Moist heat is used to increase circulation
• Antibiotics can also be used depending on the
  condition

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• Hidradenitis Suppurativa
• Etiology
• Primary inflammation event of the hair follicle
  resulting in secondary blockage of the apocrine
  gland
• Signs and Symptoms
• Begins as small papule that can develop into deep
  dermal inflammation
• Management
• Avoid use of antiperspirants, deodorants and
  shaving creams
• Use medicated soaps and systemic antibiotics

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• Acne Vulgaris
• Etiology
• Inflammatory disease of the hair follicle and the
  sebaceous glands
• Sex hormones may contribute
• Signs and Symptoms
• Present with whiteheads, blackheads, flesh or red
  colored papules, pustules or cysts
• If chronic and deep may scar
• Psychological impact
• Management
• Topical and systemic agents used to treat acne
• Mild soaps are recommended

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• Paronychia and Onychia
• Etiology
• Caused by staph, strep and or fungal organisms
  that accompany contamination of open wounds or
  hangnails
• Damage to cuticle puts finger at risk
• Signs and Symptoms
• Rapid onset painful with bright red swelling of
  proximal and lateral fold of nail
• Accumulation of purulent material w/in nail fold
• Management
• Soak finger or toe in hot solution of Epsom salt
  3 times daily
• Topical antibiotics, systemic antibiotics if
  severe
• May require pus removal through skin incision

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• Tetanus Infection (lockjaw)
• Etiology
• Acute infection of the CNS caused by tetanus
  bacillus
• Bacteria enters through the blood and open wounds
• Signs and Symptoms
• Stiffness of the jaw and muscles of the neck
• Muscles of facial expression produce contortion
  and become painful
• Fever may become markedly elevated
• Management
• Treat in intensive care unit
• Childhood immunization

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Fungal Infections

• Group of organisms that include yeast and molds
  which are usually not pathogenic
• Grow best in unsanitary conditions with warmth,
  moisture and darkness
• Infections generally occur in keratinized tissue
  found in hair, nails and stratum corneum
• Dermatophytes (Ringworm fungi)
• Cause of most skin, nail and hair fungal
  infections

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• Tinea of the Scalp (tinea capitis)
• Signs and Symptoms
• Ringworm of the scalp begins as a small papule
  that spreads peripherally
• Appears as small grayish scales resulting in
  scattered balding
• Easily spread through close physical contact
• Management
• Topical creams and shampoos are ineffective in
  treating fungus in hair shaft
• Systemic antifungal agents are replacing older
  agents due to increased resistance
• Some topical agents are used in conjunction

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• Tinea of the Body (tinea corporis)
• Signs and Symptoms
• Commonly involve extremities and trunk
• Itchy red-brown scaling annular plaque that
  expands peripherally
• Management
• Topical antifungal cream

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• Tinea of the Nail (tinea unguium/ onchomycosis)
• Signs and Symptoms
• Fungal infection of the nail -- found commonly in
  those engaged in water sports or who have chronic
  athletes foot
• Nail becomes thick, brittle and separated from
  its bed
• Management
• Some topical antifungal agents have proved useful
  
• Systemic medications are most effective
• Surgical removal of nail may be necessary if
  extremely infected

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• Tinea of the Groin (tinea cruris)
• Etiology
• Symmetric red-brown scaling plaque with
  snake-like border
• Signs and Symptoms
• Mild to moderate itching

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• Management
• Treat until cured
• Will respond to many of the non-prescription
  medications
• Medications that mask symptoms should be avoided
• Failure to respond to normal management may
  suggest a non-fungal problem (such as bacteria)
  and should be referred to a physician
• May require additional topical medications and
  oral prescriptions

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• Athletes Foot (tinea pedis)
• Etiology
• Most common form of superficial fungal infection
• Tricophyton species are most common cause of
  athletes foot
• Webs of toes may become infected by a combination
  of yeast and dermatophytes
• Signs and Symptoms
• Extreme itching on soles of feet, between and on
  top of toes
• Appears as dry scaling patch or inflammatory
  scaling red papules forming larger plaques
• May develop secondary infection from itching and
  bacteria
• Management
• Topical antifungal agents and good foot hygiene

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• Candidiasis (Moniliasis)
• Etiology
• Yeast-like fungus that can produce skin, mucous
  membrane and internal infections
• Ideal environment includes hot humid weather,
  tight clothing, and poor hygiene
• Signs and Symptom
• Infections w/in body folds
• Presents as beefy red patches and possible
  satellite pustules
• White, macerated border may surround the red
  area deep painful fissures may develop at skin
  creases
• Management
• Maintain dry area
• Use antifungal agents to clear infection

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• Tinea Versicolor
• Etiology
• Caused by a yeast
• Appears commonly in areas in which sebaceous
  glands actively secrete body oils
• Signs and Symptoms
• Fungus produces multiple, small, circular macules
  that are pink, brown, or white
• Commonly occur on chest, abdomen, and neck
• Do not tan when exposed to sun and usually are
  asymptomatic
• Management
• Straightforward treatment - recurrences are
  common
• Use selenium shampoo (Selsun) and topical
  econazole nitrate (or something similar)
• When microorganism has been eradicated,
  re-pigmentation of the area will occur

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Viral Infections

• Ultramicroscopic organisms that require host
  cells to complete their life cycle
• May stimulate cell chemically to produce more
  virus until host cell dies
• Lies within bud-like structure that does not
  damage cell or virus, w/out causing infection
• A number of skin infections are caused by viruses

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• Herpes Simplex Labialis, Gladiatorum, and Herpes
  Zoster
• Etiology
• Highly contagious and is usually transmitted
  directly through a lesion in the skin or mucous
  membrane
• Resides in sensory nerve neurilemmal sheath
  following initial outbreak
• Recurrent attacks stimulated by sunlight,
  emotional disturbances, illness, fatigue, or
  infection
• Type I vs. Type II
• Signs and Symptoms
• Early indication tingling or hypersensitivity
  in an infected area 24 hours prior to appearance
  of lesions
• Local swelling followed by outbreak of vesicles
• Athlete may feel ill w/ headache, sore throat,
  swollen lymph glands and pain in area of lesions

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• Signs and Symptoms (continued)
• Vesicles generally rupture in 1-3 days spilling
  serous material
• Heal in generally 10-14 days
• If an athlete has an outbreak they should be
  disqualified from competition due to contagious
  nature of condition
• Management
• Herpes simplex lesions are self limiting - reduce
  pain and promote early healing
• Use of antiviral drugs can reduce recurrence and
  shorten course of outbreak
• Complications
• Can lead to secondary infection

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Verruca Virus and Warts

• Varied of forms exist
• verruca plana (flat wart), verruca plantaris
  (plantar wart), and condyloma acuminatum
  (venereal wart)
• Different types of human papilloma virus have
  been identified
• Uses epidermal layer of skin to reproduce and
  growth
• Wart enters through lesion in skin

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• Common Wart
• Signs and Symptoms
• Small, round, elevated lesion
  with rough dry surfaces
• Painful if pressure is applied
• May be subject to secondary
  bacterial infection
• Management
• If vulnerable, they should be protected until
  treated by a physician
• Use of electrocautery, topical salicylic acid or
  liquid nitrogen are common means of managing this
  condition

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• Plantar Warts
• Etiology
• Spread through papilloma virus
• Signs and Symptoms
• Located on sole of foot, on or adjacent to areas
  of abnormal weight bearing
• Areas of excessive epidermal thickening
• Discomfort, point tenderness
• Hemorrhagic puncta (black seeds)
• Management
• While in competition, protect and prevent
  spreading
• Pair away callus and apply keratolytic
• Following season, wart can be removed by freezing
  it or by electrodessication (maintain protection
  until removal)

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• Molluscum Contagiosum
• Etiology
• Poxvirus infection which is more contagious than
  warts (especially during direct body contact)
• Signs and Symptoms
• Small, flesh or red colored, smooth-domed papules
  with central umbilication
• Management
• Physician referral is necessary
• Cleansing and destructive procedure
  (counterirritant such as cantharidin, surgical
  removal or cryosurgery)

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Allergic, Thermal, and Chemical Skin Reactions

• Allergies are immunologically mediate responses
  to molecules in dyes and proteins against which
  the bodys immune system is sensitized
• Allergens may be food, drugs, clothing, dusts,
  pollens, plants, animals, heat, cold, or light
• The skin will reflect an allergy in many ways
  such as reddening and swelling of the tissue,
  uticaria or hives, burning or itching
• ATCs must recognize gross signs of allergic
  responses and be prepared to remove allergens and
  treat topically or systemically with antipruritic
  agents

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• Contact Dermatitis (allergic and irritant)
• Etiology
• Plants are the most common cause (poison ivy,
  poison oak, sumac, ragweed, primrose)
• Topical medications
• Chemicals found in fragrances and preservatives
  of soaps, detergents
• Signs and Symptoms
• Onset may range from 1 day to 1 week
• Redness, swelling, formation of vesicles that
  ooze fluid and form crust, constant itching
• May change from redness and blistering to
  erythematous scaling, lichenified papules and
  plaques
• Management
• Avoid allergen
• Tap water compresses or soaks, topical
  corticosteroids

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• Milaria (Prickly Heat)
• Etiology
• Continued exposure to heat and moisture causing
  retention of perspiration by sweat glands
• Signs and Symptoms
• Itching and burning vesicles and pustules
• Occurs most often on arms, trunks, and bending
  areas of the body
• Management
• Avoidance of overheating, frequent bathing with
  non-irritating soap, wearing loose-fitting
  clothing and use of antipruritic lotions

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• Chilblains (pernio)
• Etiology
• Caused by excessive exposure to cold
• Signs and Symptoms
• Tissue does not freeze but reacts with edema,
  reddening and possibly blistering along with a
  sensation of burning and itching after exposure
  to cold
• Management
• Exercise and gradual warming of the part
• Massage and application of heat are
  contraindicated
• Some systemic drugs can be used in severe cases

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• Sunburns
• Etiology
• Inflammatory response to injury caused by
  ultraviolet solar radiation
• Must be cautious of physical characteristics,
  chemicals, food and drugs that make individuals
  more susceptible
• Signs and Symptoms
• Varies from erythema to severe blistering
• May experience shock if severe enough
• Can cause malfunctioning of organs w/in the skin
• Will appear 2-8 hours following exposure, with
  symptoms becoming most severe at 12 hours
• SS will dissipate w/in 72-96 hours

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• Sunburns (continued)
• Management
• Can be prevented through the use of sunscreen
  (sun protection factor or SPF)
• Filters ultraviolet light
• Water/sweat resistant sunscreen is recommended
• Treat a burn according to the degree of
  inflammation
• Cool water, aloe based solutions
• More severe burns may require bathing in a bath
  of cornstarch or vinegar
• Severe burns require physician assistance

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• Psoriasis
• Etiology
• Exact cause is unknown -- genetic factors may
  play a role in condition
• Infection, smoking, some drugs and possible
  hormonal factors may cause an outbreak
• Signs and Symptoms
• Lesion begins as reddish papules that progress to
  plaques
• Lesions progress to yellowish white scaly
  condition that tends to be located on the elbows,
  knees, trunk, genitalia, and umbilicus

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• Psoriasis (continued)
• Management
• Teaching patient self management
• Glucocorticoids and kerolytic agents can be used
  in conjunction with each other
• Long term oral medications may be necessary
• Counseling may be necessary for psychological
  aspects of condition

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Infestation and Bites

• Scabies
• Etiology
• Caused by mites which cause extreme nocturnal
  itching (tunnels and lays eggs)
• Signs and Symptoms
• Appear as dark lines between fingers and toes,
  body flexures, nipples and genitalia
• Excoriations, pustules and papules caused by
  itching tends to hide true cause
• Skin develops hypersensitivity to the mite
• Management
• Permethrin 5 is treatment of choice
• Washing of bedding and clothes is necessary
• Topical corticosteroids may be necessary to treat
  itching

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• Lice (Pediculosis)
• Etiology
• Manifestation by the louse (louse of head, pubic
  region and body)
• Signs and Symptoms
• Bites cause itching dermatitis through subsequent
  scratching -- promotes pustule and excoriations
  to develop
• Management
• Cure is rapid with use of any number of agents
• Good hygiene is paramount
• To prevent re-infestation all clothing and
  bedding should be washed in hot soapy water or
  discarded

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• Fleas
• Etiology
• Small wingless insects that suck blood
• Can transmit systemic diseases
• Signs and Symptoms
• Great deal of discomfort can be felt if come into
  contact with a high number of fleas
• Concentrate bites on ankles and lower legs
• Management
• Following a bite, itching must be prevented with
  antipruritic lotion
• Avoid scratching to prevent secondary infection
• Insecticides can also be effective

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• Ticks
• Etiology
• Parasitic insects that have an affinity for blood
• Carriers of a variety of microorganisms that can
  transmit Rocky Mountain spotted fever and Lyme
  disease
• Signs and Symptoms
• Headaches, fever, malaise, myalgia, and rash,
  perechiae and prupura, enlarging annular red ring
  w/ or w/out central red papule
• Management
• Remove tick (mineral oil or fingernail polish)
• Grasping head of tick is an acceptable method
• Systemic treatment is necessary to prevent
  morbidity and mortality associated with RMSF and
  Lyme disease

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• Mosquitoes
• Etiology
• Unless carrying a disease, mosquitoes produce
  bites that cause only mild discomfort
• Attracted to lights, dark clothing and warm moist
  skin
• Signs and Symptoms
• Small reddish papule with associated itching
• Management
• Topical medication
• Use of repellents can also be used on the skin to
  prevent contact with mosquitoes

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• Stinging Insects
• Etiology
• Bees, wasps, hornets, yellow jackets -- inflict
  venomous sting
• Hypersensitive individuals may experience an
  allergic reaction
• Signs and Symptoms
• If an allergic reaction occurs an increase in
  heart rate and breathing will occur, along with
  chest tightness, dizziness, sweating and even LOC

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• Insect Stings (continued)
• Management
• To prevent, avoid wearing scented lotions or
  shampoos, brightly colored clothes, jewelry,
  suede, or leather, and avoid going barefoot.
• If an athlete is susceptible to anaphylactic
  reactions instructions on use of an EpiPen are
  necessary
• If uncomplicated, the stinger should be removed
  with tweezers or a credit card and soothing
  medications should be applied
• Soap detergent will also lessen symptoms
• In cases of anaphylactic reaction immediate
  physician referral is necessary