Cutaneous Findings in Systemic Disease

1
Cutaneous Findings in Systemic Disease

• Skin Lesions in Renal Disease and Other Entities
• Elle H. Abel, B.S., R-PAC

2
Function of the Skin

• The skin is the largest organ of the body
• Functions
• Protects the bodys inner structures from
  micro-organisms, drying, trauma
• Regulates Body temperature through evaporation of
  perspiration for cooling and constricting of
  superficial blood vessels to conserve heat
• Excretes water and electrolytes through
  perspiration
• Sensory perception of touch, pressure, and pain

3
Epidermis

• Outer layer of the skin
• Made up of many layers,
• Protects the underlying layers from drying,
  trauma, invasion by micro-organisms
• Deepest layer of the epidermis constantly
  produces new cells
• Pushed to the surface
• Shed
• Replaced by new cells

4
Melanin

• Cells called melanocytes contain the skin pigment
  melanin responsible for skin color
• Dark skinned people have more melanin than light
  skinned people

5

http//www.agen.ufl.edu/chyn/age2062/lect/lect_19
/25_12A.GIF
6
Dermis

• Inner layer of skin, lies beneath the epidermis
• Contains blood vessels, nerves, lymphatics, and
  sebaceous and sweat glands
• Contains cells that promote wound healing.
• Contains major sensory fibers responsible for
  distinguishing pain, touch, heat and cold
• Hair follicles throughout the body (except palms
  and soles of feet) , more numerous in axillae,
  scalp and pubic area

7
Sebaceous and Sweat Glands

• Sebaceous glands produce an oily substance called
  sebum that protects the skin from excessive
  dryness
• Sweat glands concentrated in the axillae,
  forehead, palms of hands and soles of the feet.
• Perspiration aids in
• excretion of water and electrolytes
• temperature regulation
• Cooling the skin by evaporation
• Conservation of body heat/warmth by constriction
  of superficial blood vessels

8
Subcutaneous Tissue

• The subcutaneous tissue is a layer of adipose
  (fat) tissue that interfaces with the lower level
  of the dermis
• Subcutaneous tissue insulates and provides shape
  and contour over the bone structures

9
Psychological, Social, Vocational Impact of Skin
Conditions

• The skin is a visible organ, vulnerable to injury
  and irritation and changes in the internal or
  external environment
• Changes in the internal environment may be
  reflected by presence of external lesions of the
  skin, signaling underlying disease (ie. Systemic
  Lupus Erythematosis)
• Emotional factors can cause skin eruptions
  (localized or systemic)
• Conditions of the skin have an impact on quality
  of life, restrict vocational, social, family,
  leisure, sexual activity

10
Psychosocial Considerations

• Skin disorders can produce major psychological
  impact on the individual experiencing it
• Society places great value on clear, healthy skin
• Skin disorders may be perceived as contagious or
  due to lack of cleanliness
• Disfiguring skin conditions have a negative
  effect on self-image, inter-personal
  relationships, secondary psychological symptoms
  including depression, social phobia, paranoia
  (Psoriasis, Acne)

www.healthopedia.com
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Dermatitis

• Dermatitis is a superficial inflammation of the
  skin
• Atopic Dermatitis (Exzema) is a type of
  dermatitis
• redness (erythema)
• swelling (edema)
• itching (pruritis)
• Treatment of atopic dermatitis includes
• avoiding prolonged contact with hot water,
• avoid drying soaps,
• use moisturizers
• Antihistamines, steroid creams (temporarily) and
  ointments may aid in symptom reduction
• Phototherapy, UV light, chemotherapy

http//www.thirdage.com/healthgate/Images/si1510.j
pg
12
Contact Dermatitis

• Localized inflammation
• Generalized allergic reaction
• Occurs at site of contact
• Remove offending agent

www.healthopedia.com/ pictures/contact-dermati...
13
Allergic Reactions

• Immune Response
• Hypersensitivity reaction
• Urticaria (Hives)
• Local or systemic
• Avoid Contact with offending agent

http//www.lf2.cuni.cz/Projekty/interna/foto/012/p
ic00011.jpg
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Psoriasis

• Inflammatory Process
• Rapidly turning over epidermal cells
• Remission
• Exacerbation

http//www.monpso.net/pso_images/coude_1_big.jpg
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Treatment of Psoriasis

• There is no known cure
• Control the condition by suppressing the
  immune-mediated response.
• Avoid injury to the skin
• Topical steroids, emollients, ultraviolet light,
  chemotherapy, coal tar derivatives, vitamin D
  analogs, topical retinoids
• Methotrexate, Aceitretin, Cyclosporine may be
  used in moderate and severe cases -Require
  close monitoring of BP and skin -Blood levels
  for liver function tests, kidney function,
  blood lipids, bone marrow suppression

16
Treatment side effects

• Atrophy of skin if meds are too strong
• Tachyphylaxis- the body becomes immune to the
  effects of the drug with repeated use
• Teratogenic side effects- fetal abnormalities
• Irritation of liver, kidney failure, bone marrow
  suppression
• Steroids may cause psychoses, insomnia, GI upset
  or GI bleed, weight gain, hirsutism, mood swings,
  fluid retention

17
Infection or Inflammation?

• Effective treatment requires that one correctly
  identify the cause of a skin disorder
• Infection with bacterial, fungal, parasitic and
  viral organisms requires specific treatments

18
Acne

• Most commonly encountered skin condition due to
  interaction of bacteria of the skin, excess oils,
  hormones
• Face, neck and trunk most commonly affected
• Adolescence, reaction to a drug (steroid,
  chemotherapy)
• May be disfiguring and disabling
• Goal to reduce inflammation and scarring, prevent
  clogging of hair follicles, prevent infection
• Treatment includes topical or systemic medication
  or dermabrasion

19
http//llorente.com/hyperbaric/EV_IMAGES/images/HR
20after20220proteus.jpg, http//www.eyeambeauti
ful.com/images/bna-acne-b.jpg, http//www.medic8.c
om/healthguide/articles/acne.html,
library.thinkquest.org/ C004510F/acne.htm
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Herpes Zoster (Shingles)

• Reactivated Chicken Pox (Varicella Zoster)
• Weakened immune system, aging, medical conditions
  causing decreased immune response will increase
  risk of H. Zoster
• Vesicles erupt along a peripheral sensory nerve
  root causing water filled blisters, itching and
  pain
• Reactivated virus is contagious- persons who have
  never had chicken pox or been vaccinated should
  avoid contact
• Treatment requires prompt antiviral therapy and
  symptomatic support with analgesia, oral and
  topical

21
Skin LesionsLocalSystemic Disease
22
http//www.thachers.org/images/Zoster.JPG,
www.surviveoutdoors.com/. ../herpes_zoster.asp
http//www.neuro24.de/bilder1/zoster.jpg
23
Skin Cancers

• Occur more than any other kind of cancer
• Basal Cell cancer is highly visible and treated
  early has high cure rate
• Malignant Melanoma originates in melanocytes-
  more dangerous than Basal cell cancer, spreads
  rapidly into deeper skin layers and metastasizes
  to other organs
• Treatment of malignant melanoma is surgical
  removal of the lesion with wide excision
• Avoid sun exposure, use protective sunscreens,
  avoid artificial tanning

24
Basal Cell Cancer Malignant Melanoma
http//dermatlas.med.jhmi.edu/derm/IndexDisplay.cf
m?ImageID-382739824
25
Diagnosis of Skin Lesions

• Biopsy
• Skin Scrapings
• Cultures
• Smears for exudate (pus, drainage from a wound)
• Patch tests for Allergic reactions
• History (pressure sores-decubitus ulcers)

26
Burns

• Any tissue injury as a result of direct heat,
  chemicals, radiation, or electrical current
• Treatment and Prognosis depends on severity of
  the burn, cause or type of burn, depth of burn
  and amount of body surface area involved

27
Burns
http//dermatlas.med.jhmi.edu/derm/
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Thermal and Chemical Burns

• Most common type of burn caused by fire, hot
  liquids, direct injury are thermal burns
• Chemical burns result from strong acids (sulfuric
  acid, lye) and extent of injury depends on
  duration of contact
• Radiation Burns from UV light (and sun!),
  ionizing radiation, large doses of local
  radiation

29
Electrical Burns

• Electric Current or Lightening
• May cause local tissue damage, sudden death,
  cardiac arrest, nerve damage
• Despite lack of external signs extensive internal
  damage may result as current travels through the
  body damaging nerves, blood vessels, and major
  organs

30
Burn Severity

• Burn Depth
• 1st Degree Burn- Superficial, affects only
  the epidermis Red skin, blisters pose a risk for
  infection serving as a portal of entry
• 2nd Degree Burn- a partial thickness burn
  affecting dermis and epidermis
• 3rd Degree burn- full- thickness burn
• 4th Degree Burn extends to underlying
  subcutaneous fat, muscle or bone

31
Rule of Nines

• Head 9
• Front 18
• Back 18
• Arm 9
• Leg 18
• Perineum/groin 1

www.moondragon.org/ health/disorders/burns.html
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Treatment of Burns

• Depends on the severity of the burn
• Depends on associated injuries
• Debride eschar to avoid infection or sepsis
• Tubbing, brushing, dressing of skin
• Application of silver sulfadiazene or other
  topical med
• Monitor pain needs, nutritional needs, daily
  hygeine

33
Psychosocial issues Identity
alteredBody imagePTSDAnxietyGuiltHostility
and AngerGrafted skin is sensitivePressure
garments are restrictiveDiseases of the skin
lead to isolationStress reduction is important
34
Vocational issues

• Return to work ability dependent on the vocation,
  site, and extent of burns
• If work related injury guilt and distress between
  co-workers and injured may exist
• Emotional stress could prevent re-entry to work

35
Skin lesions as Signs of Systemic Disease

• Rashes
• Nodules
• Lymph Nodes
• Tumor or Mass lesion
• Skin color and skin changes
• Skin temperature

36
Pressure Sores

• Decubitus Ulcers
• common in bed ridden patients
• common in paraplegic, quadraplegic
• any person with prolonged pressure to a site or
  sensory nerve loss
• ARE REVERSIBLE OR AVOIDABLE WITH SKIN CARE
  PRECAUTIONS

37
Hair, Scalp, Nails

• Alopecia
• Auto-Immune, thyroid disease
• Iatrogenic (chemotherapy, radiation therapy)
• Psychiatric Disorders and self-abuse
• Hirsutism-
• Endocrine Conditions
• Medications
• Nail Disorders

38
AlopeciaTrichotillomania
http//dermatlas.med.jhmi.edu/derm/index.cfm
39
Renal Disease and Case Study

• A 61 year old female has had a nine year history
  of renal failure requiring dialysis
• Kidney biopsy was inconclusive
• Several Medical problems co-exist with renal
  disease (Hypertension, Rheumatoid arthritis,
  Sjogren Syndrome, COPD requiring oxygen therapy
  and History of Pulmonary Hemorrhage due to
  vasculitis)

40
Wegeners GranulomatosisDiagnosed by lung
biopsy and specialized lab tests
41
Kidney Anatomy
http//health.allrefer.com/health/renal-cell-carci
noma-kidney-anatomy.html
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Pics
www.nature.com/.../ n4/fig_tab/4810434f1.html
http//www.emedicine.com/derm/images/401stasis1.jp
g http//www.skina.org/atlas/20dermatitis/images/s
tasis20dermatitis03.jpg
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Silent Invisible Disease

• Vague or absent symptoms
• Slow progressive onset
• May be perceived as anxious or attention-seeking
• Unreliable or negative tests

44
Function of the Renal System and Urinary Tract

• Rid the body of by-products of metabolism
• Bladder is a storage area for urine
• Maintain homeostasis (internal chemical balance)
• Regulate water content and electrolytes
• Excrete Urea, Uric acid, creatinine

45
Secrete Hormones

• Vitamin D
• regulates calcium production
• Erythropoieten-
• influences red blood cell production
• Renin
• Influences blood pressure, sodium and potassium
  balance
• Stimulates a hormone (angiotensin) that
  stimulates the adrenal cortex to secrete
  aldosterone (affecting Na and K balance)

46
Causes of Renal Disease

• Infection
• Inflammation
• Auto-Immune diseases (Systemic Lupus, Wegeners
  Granulomatosis, Diabetes)
• Adverse Drug Reactions
• Trauma or injury
• Toxic injury
• Cancer, Multiple Myeloma
• Idiopathic and Iatrogenic causes

47
Cystitis

• A condition where bacteria has entered the
  sterile environment of the bladder causing
  infection and inflammation
• Symptoms include pain, discomfort with voiding,
  bloody or sedimentous urine
• Risk factors include immobility, use of urinary
  catheter, structural problems of bladder or
  urethra

48
Pyelonephritis

• Infection of the kidney
• Can be a complication of Cystitis or caused by
  stasis, spread of infection from other parts of
  the body or obstructions
• Symptoms include fever, chills, rigors, flank or
  abdominal pain, nausea or vomiting
• May be acute or chronic
• Chronic pyelonephritis can cause renal failure

49
Urinary or Renal Calculi

• Kidney stones
• Nephrolithiasis
• Urolithiasis
• Stones cause severe pain and may lead to
  obstruction and infection
• Radiographic intravenous pyelogram (IVP) will
  show stones and obstruction
• Stones severely obstructing the kidneys will
  cause back up of urine causing pressure on the
  kidney (Hydronephrosis)

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Treatments for Stones

• Hydration for small stones and supportive
  measures
• Lithotomy
• Lithotripsy
• Etiology of stones and composition

51
Glomerulonephritis

• Symptoms may be mild and undetected or severe
  causing pain, blood in urine, dark colored urine
  (tea or amber colored urine) or foamy urine from
  increased proteins
• Glomerulonephritis is an immunologic response to
  bacteria, viruses or auto-immune mediated
• Causes include Streptococcal infections, Lupus,
  auto-immune diseases

52
Nephrectomy

• Trauma, stones, tumors, chronic infections, and
  symptomatic non-functioning kidneys can be
  treated by removal of the kidney by nephrectomy
• Polycystic kidney Dx (Brights Disease) is a
  hereditary condition of slow progressive kidney
  disease and renal failure due to cysts on the
  kidney
• ESRD- End stage renal disease

53
Acute Renal Failure

• Sudden Onset
• Medical Condition, Surgery
• Trauma
• Hypovolemia due to Hemorrhage
• Severe dehydration, low blood pressure
• Septicemia, obstruction, nephrotoxins

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Treatment

• Remove /reverse the cause
• Prevent damage to the kidney
• Supportive measures

55
Chronic Renal Failure(ESRD)

• Due to Acute renal failure
• Irreversible damage
• Glomerulonephritis
• Polycystic kidney disease
• Pyelonephritis
• Idiopathic/Iatrogenic

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Symptoms and Signs in ESRD

• Asymptomatic
• Malnourished due to anorexia
• Oliguric or anuric
• Anemia causing dyspnea
• Impaired sexual function
• Intellectual impairment

57
Treatment for ESRDBecause there is no cure,
treatment is directed at control of the disease
and maintenance of the work of the kidney

• Peritoneal Dialysis
• Hemodialysis
• Kidney Transplant
• Medications
• Diet

58
Peritoneal dialysis
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if
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Psychosocial issues and Physiologic changes
inESRD

• Emotional Reaction to ESRD
• Mourning loss of bodily function
• Loss of control
• Feelings of disconnectdness
• Anger
• Uncertainty of treatment choices
• Cognitive changes
• impaired judgment, memory loss,difficulty
  concentrating

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Lifestyle Issues in ESRD

• During the acute phase
• After treatment few limitations exist
• For ESRD consumers lifestyle changes are profound
• stringent dietary restrictions, freedom
  restricted due to treatment, demanding medical
  regimen with or without transplant, decreased
  endurance and physical tolerance, decreased sex
  drive, depression and mood disorder, insomnia

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Vocational Issues in ESRD

• Depends on severity of kidney disease and
• vocation
• previous work history
• concommitant medical problems
• treatment requirements
• cognitive abilities
• Flexible work schedule

62
Thank You !

• References
• Falvo, Donna Medical and Psychosocial Aspects of
  Disability 3rd Edition Chapters 13 and 15
• http//dermatlas.med.jhmi.edu/derm/
• Ames, Warwick A. Management of the Major Burn
  http//www.nda.ox.ac.uk/wfsa/html/u10/u1010p01.htm