Skin – Immune Disorders

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Skin Immune Disorders

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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Key Function of Skin

• Protection shield from internal injury.
• Immunity contains cells that ingest bacteria
  and other substances.
• Thermoregulation heat regulation through
  sweating, shivering, and subcutaneous insulation
• Communication / sensation / regeneration

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Developmental Variances

• Sweat glands function by the time the child is
  3-years-old.
• The visco-elastic property of the dermis becomes
  completely functional at about 2 years.
• The neonates dermis is thin and very hydrated,
  thus is at greater risk for fluid loss and serves
  as an ineffective barrier.

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Diagnostic Tests

• Cultures
• Scraping
• Skin biopsy
• Skin testing
• Woods lamp

Woods Lamp
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Neonatal skin lesions

• Vascular birth marks hemangioma
• Port wine stain
• Abnormal pigmentation Mongolian spots
• Neonatal acne small red papules and pustules
  appear on face trunk.
• Milia white or yellow, 1-2mm papules appearing
  on cheeks, nose, chin, and forehead

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Inflammatory Skin Disorders

• Diaper dermatitis
• Contact dermatitis
• Atopic dermatitis or eczema

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Diaper Dermatitis
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Diaper Dermatitis

• Identify causative agent
• Cleanse with mild cleaner
• Apply barrier
• Expose to air
• Teach hazards of baby powder

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Cradle Cap

• Rash that occurs on the scalp.
• It may cause scaling and redness of the scalp.
• It may progress to other areas.

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Treatment

• If confined to the scalp
• Wash area with mild baby shampoo and brush with a
  soft brush to help remove the scales.
• Do not apply baby oil or mineral oil to the area
  - this will only allow for more build up of the
  scales.

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Cradle Cap
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Baby Care
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Atopic dermatitis or Eczema

• Chronic, relapsing inflammation of the dermis and
  epidermis characterized by itching, edema,
  papules, erythema, excoriation, serous discharge
  and crusting.
• Patients have a heightened reaction to a variety
  of allergens.

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Dermatitis
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Dermatitis
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Assessment

• History of asthma, allergic rhinitis
• Lesions generally occur in creases.
• Management
• Control the itching OTC Benadryl
• Reduce inflammation topical corticosteroids
• Hydrate the skin
• Elidel Cream
• Preventing infection

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Acne Vulgaris

• A chronic, inflammatory process of the
  pilosebaceous follicles.
• Occurrence 85 of teenager aged 15 to 17 years.
• More common in females than males.

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Acne

• Over activity of oil glands at the base of hair
  follicles
• Hormone activity
• Skin cell plug pores causing white heads and
  blackheads.
• No cure

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Acne

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Management of Acne

• Topical medications
• OTC preparations
• Prescription - Topical retinoid preparations
• Prescription - Topical antibiotics
• Systemic medication
• Antibiotics
• Hormonal therapy birth control pills
• Accutane use with extreme caution when all else
  fails

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Pediculosis

• Head lice infestation ranges from 1 to 40 in
  children.
• Most common in ages 5 to 12.
• Less common in African American due to the shape
  of the hair shaft.
• Transmission by direct contact with infected
  person, clothing, grooming articles, bedding, or
  carpeting.

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Pediculosis

• Head lice
• Pubic lice
• Body lice

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Signs and Symptoms

• Symptoms itching, whitish colored eggs at shaft
  of hair, redness at site of itching.

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Nits
Empty nit case
Viable nit
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Interventions

• Anti-lice shampoo
• Removal of nits
• Washing bedding, towels, anything childs head
  may have come in contact with in hot soapy water.
• Vacuum all floors and rugs
• Do not need to fumigate the house
• Child can return to school after 1 day of
  treatment

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Scabies

• A contagious skin condition caused by the human
  skin mite.
• Tiny, eight-legged creature burrows within the
  skin and penetrate the epidermis and lays eggs
• Allergic reaction occurs
• Severe itching

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Assessment

• Pruritus especially profound at night or nap
  time.
• Lesions may be generalized but tend to distribute
  on the palms, soles and axillae
• In older children finger webs, body creases,
  beltline and genitalia

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Management

• Permethrin cream is drug of choice
• Massage into all skin surfaces neck to soles of
  feet - leave on for 8 to 14 hours.
• Clothing bedding and other contact items need to
  be washed in hot soapy water.
• Vacuum upholstered furniture - rugs

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Scabies
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Scabies
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Impetigo

• The most common skin infection in children.
• Causative agent is carried in the nasal area.
• Bacteria invade the superficial skin.

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Causative agent

• Group A beta-hemolytic streptococcal (GABHS)
• Staph aureus

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Impetigo

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Spread

• Highly contagious skin infection.
• Most common among children.
• Spread through physical contact.
• Clothes, bedding, towels and other objects.

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Interventions

• Good general hygiene wash hands
• Wash lesions with soap and water
• Topical antibiotic therapy (Bactroban)
• Keflex PO 2nd generation cephalosporin
• New antibacterial Altabax (2007)

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Outcomes

• Self-limiting
• No scarring or pox marks post infection.
• Super-infection especially in the neonate.

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Impetigo / cellulitis
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Cellulitis

• A full-thickness skin infection involving dermis
  and underlying connective tissue.
• Any part of the body can be affected.
• Cellulitis around the eyes is usually an
  extension of a sinus infection or otitis media.

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Assessment

• History and physical exam
• WBC count
• Blood culture
• Culturing organism from lesion aspiration.
• CT scan with peri-orbital cellulitis

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Clinical Manifestations

• Characteristic reddened or lilac-colored, swollen
  skin that pits when pressed with finger.
• Borders are indistinct.
• Warm to touch.
• Superficial blistering.

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Cellulitis
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Cellulitis
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Interventions

• Hospitalization if large area involved or facial
  cellulitis.
• IV antibiotics.
• Tylenol for pain management.
• Warm moist packs to area if ordered.
• Assess for spread
• If peri-orbital test for ocular movement and
  vision acuity

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Poison Oak, Ivy and Sumac

• Three potent antigens that characteristically
  produce an intense dermatologic inflammatory
  reaction when contact is made between the skin
  and the allergens contained in the plant.

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Poison Ivy
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Poison Oak
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Interventions

• Prevention
• Wear long pants when hiking or playing in the
  brush.
• Wash with soap and water to remove sticky sap.
• Cleanse under finger nails.
• Sap on fur, clothing or shoes can last up to 1
  week if not cleansed properly.
• Topical cortisone to lesions.

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Systemic Response
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Burns in Children

• Young children who have been severely burned have
  a higher mortality rate than adults.
• Shorter exposure to chemicals or temperature can
  injure child sooner.
• Increased risk for for fluid and heat loss due to
  larger body surface area.

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Burns in Children

• Burns involving more that 10 of TBSA require
  fluid resuscitation.
• Infants and children are at increased risk for
  protein and calorie deficiency due to decreased
  muscle mass and poor eating habits.
• Scarring in more severe.

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Burns in Children

• Immature immune system can lead to increased risk
  of infection.
• Delay in growth may follow extensive burns.

Bowden text Chart 15 28
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Management of Burns

• Ascertain adequacy of airway, oxygen, intubation
• Large bore needle to deliver sufficient fluids at
  a rapid rate.
• Remove clothing and jewelry and examine.

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Alert

• The most common cause of unconsciousness in the
  flame burn patient is hypoxia due to smoke
  inhalation.
• Look for ash and soot around nares.

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Management of Burns

• Admission weight.
• Nasogastric tube to maintain gastric
  decompression.
• Foley catheter for urine specimen and monitor
  output.
• Evaluate burn area and determine the extent and
  depth of injury.

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Flame Burn
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Management

• NG tube in place.
• Catheter for fluid replacement.
• Ambulation to prevent problems
• associated with immobilization

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Percentage of Areas Affected
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Depth of Burns
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First Degree Burn

• Involves only the epidermis and part of the
  underlying skin layers.
• Area is hot, red, and painful, but without
  swelling or blistering.
• Sunburn is usually a first-degree burn.

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Second Degree Burn

• Involves the epidermis and part of the underlying
  skin layers.
• Pain is severe.
• Area is pink or red or mottled.
• Area is moist and seeping, swollen, with blisters.

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Third Degree or Full-thickness

• Involves injury to all layers of skin.
• Destroys the nerve and blood vessels
• No pain at first
• Area may be white, yellow, black or cherry red.
• Skin may appear dry and leathery.

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Wound Management
Gauze with ointment is applied to burn wound.
Dead skin and debris are Carefully trimmed.
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Wound Management
Bowden, Dickey, Greenberg text Children and Their
Families
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Wound Management

• Hydrotherapy is used to cleanse the wound. Gauze
  pads are used
• To debride the wound by removing exudates and
  previous applied
• Medication.

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Skin Grafts
Healed donor site
Removal of split-thickness Skin graft with
dermatone.
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Compartment Syndrome
Escharotomy / fasciotomy in a severely burned arm.
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Burn Wound Covering
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Therapy to Prevent Complications
Elasticized garment and air-plane splints.
Physical therapy to prevent contracture deformity.
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Burns
Ball Bender
Electrical burn caused by biting of electrical
cord.
Flash burn from gasoline.
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Keep Kids Safe
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Infants Immune System

• No active immune response at birth
• Passive immunity from mother
• Potential for immune response is present / active
  response is lacking

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Immune Response

• IgG is received from mother trans-placental and
  in breast milk
• 6 to 9 months infants start to produce IgG
• Immune system starts to assume defensive role
• Active immunity begins after exposure to antigens

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Neonatal Sepsis

• Can be caused by bacterial, fugal, parasitic or
  viral pathogens.
• Etiology complex interaction of maternal-fetal
  colonization, transplacental immunity and
  physical and cellular defenses of the fetus and
  mother.

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Sepsis

• Laboratory confirmed blood stream infection

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Neonatal sepsis

• Mortality rate 50
• 1 to 8 cases per 1000 live births
• Meningitis occurs in 1/3

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Major Risk Factors

• Maternal prolonged rupture of membranes gt 24
  hours
• Intra-partum maternal fever gt 38C
• Prematurity
• Sustained fetal tachycardia gt 160

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Minor Risk Factors

• Twin gestation
• Premature infant
• Low APGAR
• Maternal Group B Streptococcus
• Foul lochia

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Etiology

• Group B beta-hemolytic Streptococcus
• Escherichia coli
• Haemophilus Influenza

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Diagnostic Tests

• C-Reactive Protein earliest indicator of
  infectious / inflammatory process
• CBC with differential
• WBC
• Blood Culture rule out blood borne bacteria
  sepsis (take 3 days for final culture results)
• Lumbar Puncture rule out meningitis
• Urine Culture rule out UTI

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Clinical Manifestations

• Respiratory distress
• Tachypnea / apnea / hypoxia
• Temperature instability
• gt 99.6 (37 C) or lt 97 (36 C)
• Gastrointestinal symptoms
• Vomiting, diarrhea, poor feeding
• Decreased activity lethargic / not eating

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Blood Test

• C-Reactive Protein
• Protein appears within 6 hours or exposure
• Blood culture to identify causative agent

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Medical Management

• Ampicillin
• Gentamicin
• Cefotaxime
• Acyclovir herpes

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Nursing Interventions

• Administer IV antibiotics
• Monitor therapeutic levels
• Monitor VS, temperature, O2 saturation
• Activity level
• Sucking
• Infant parent bonding

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Outcomes

• Newborn will achieve normalization of body
  function
• Parents will participate in care
• Newborn will demonstrate no signs of CV,
  neurological or respiratory compromise
• Newborn will experience no hearing loss as a
  result of antibiotic therapy

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SCIDS

• Severe Combined Immunodeficiency Disease
• Hereditary disease
• Absence of both humoral and cell mediated immunity

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Clinical Manifestations

• Susceptibility to infection
• Frequent infection
• Failure of infection to respond to antibiotic
  treatment

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Treatment

• Manage infection
• Bone marrow transplant

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Acquired Immunodeficiency Syndrome / AIDS

• Human immunodeficiency virus type 1
• is a retro virus that attacks the immune
• system by destroying T lymphocytes.

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AIDS

• T lymphocytes are critical to fighting infection
  and developing immunity.
• HIV renders the immune system useless and the
  child is unable to fight infection.

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Killer T-cells
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Blood Testing in Infants

• Babies born to HIV-positive mothers initially
  test positive for HIV antibodies.
• Only 13 to 39 of these infants are actually
  infected.
• Infants who are not infected with HIV may remain
  positive until they are about 18- months-old.

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Treating Infants in Utero

• Routinely offer HIV testing to all pregnant
  women.
• Administration of zidovudine (AZT) can decrease
  the likelihood of perinatal transmission from 25
  to 8.

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Modes of Transmission

• Three chief modes of transmission
• Sexual contact (both homosexual and
  heterosexual).
• Exposure to needles or other sharp instruments
  contaminated with blood or bloody body fluids.
• Mother-to-infant transmission before or around
  the time of birth.

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Symptoms in Children

• An infant who is HIV positive will generally
  exhibit symptoms between 9 months to 3 years.
• Failure to thrive
• Pneumonia, chronic diarrhea, opportunistic
  infections
• Encephalopathy leading to developmental delay,
  or loss of previously obtained milestones.

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Interdisciplinary Interventions

• Maternal treatment during pregnancy.
• Newborn receives zidovudine for 6 weeks after
  birth.
• Prophylaxis with Septra or Bactrim when CD4 level
  starts to drop.

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Interventions

• Age-appropriate immunizations except those
  containing live attenuated viruses. Can be given
  when T-Cell count is adequate
• Chicken pox - Varicella
• MMR measles, mumps, rubella

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Community Interventions

• Education and prevention are the best ways to
  manage AIDS.
• Safe sexual practices
• Monogamous relationship
• Avoidance of substances such as alcohol and drugs
  that can cloud judgment.

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Changes in HIV

• Number of infected newborns has dropped due to
  treatment of HIV infected mothers.
• HIV has become a chronic disease in children
• Team approach
• Emphasis on community teaching