CHAPTER 7

Nursing Care of Children with Disorders of Skin

INTRODUCTION

• The skin is the largest organ in the body, covering its entire exterior.
• It has three layers—the epidermis, dermis, and hypodermis—with different anatomical structures and functions.
• The back, with its thick epidermis, has the thickest skin of all three regions.

• Layers of skin

Meaning of Important Terminologies

• Flat Lesions
• Macule
• Patch

• Raised Lesions
• Papule
• Nodule

• Depressed Lesions
• Erosion
• Excoriation

• Fluid-Filled Lesions
• Bulla (plural = bullae)
• Vesicle

• Vascular Lesions
• Ecchymosis (plural = ecchymoses)
• Telangiectasia

Various skin lesions

Various skin lesions

Various skin lesions

Common skin lesions

Common skin lesions

COLLODION BABY (CB)

• CB is a congenital condition characterized by an adhesive, supple, parchment, or cellophane-like membrane covering the entire body.

Etiology

• The exact cause of the CB syndrome is unknown.
• Usually, an autosomal recessive inheritance pattern is observed and associated with consanguineous marriages.

Types of collodion defect

Classification

• The most common types of ichthyosis found in CBs are given as follows:
• Autosomal recessive congenital ichthyosis (ARCI)
• Lamellar ichthyosis (LI)
• Harlequin ichthyosis
• Nonbullous congenital ichthyosiform erythroderma (NBCIE).

Pathophysiology of Collodion Baby (CB)

Clinical Manifestations

• Skin
• Extremities
• Others: Anal fissures, signs of fluid and electrolyte imbalance, and hypothermia or hypothermia.

(A) Collodion baby at birth and (B) the same baby during infancy after shedding of skin layer

Colloid baby at birth (note the contracture of the limbs; “eclabium” means the turning outward of the lip)

Diagnostic Evaluation

• The diagnosis is made based on the clinical presentation at birth.
• Skin punch biopsy reveals the thickness of the stratum corneum, based on which the disease is classified.

Complications

• Fissures, ischemia, and edema of limbs due to membrane compression.
• Irregular body temperature.

Medical Management

• Management of this condition requires the combined effort of a dermatologist, neonatologist, and, in some cases, ophthalmologist and ear, nose, and throat (ENT) specialist.

Nursing Management of Colloid Baby

• During Hospital Stay

• Maintain standard precautions to prevent infection to the child.
• Monitor and record the vital signs of the neonate, as these babies are prone to hypothermia.

IMPETIGO

• Impetigo is the most common bacterial skin infection in children between the ages of 2 and 5 years.

Impetigo

Types

• Nonbullous (70% of Cases)

• Nonbullous impetigo, or impetigo contagiosa, is caused by S. aureus or Streptococcus pyogenes and is characterized by honey-colored crusts on the face and extremities.

• Bullous (30% of Cases)

• Bullous impetigo is caused by S. aureus only.

Etiology

• The most common causative organisms are S. aureus, group A beta-hemolytic S. pyogenes, a combination of the two, or less commonly, anaerobic bacteria, Haemophilus influenzae.

Risk Factors

• Trauma to skin
• Hot, humid climates
• Poor personal hygiene

Clinical Manifestations

• Nonbullous impetigo starts as a maculopapular rash that transforms into rapidly rupturing thin-walled vesicles, leaving superficial, sometimes pruritic, or painful erosions covered by the classic honey-colored crusts.

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• Large, fragile, flaccid bullae characterize bullous impetigo typically found on the trunk, axilla, and extremities and in intertriginous (diaper) areas.

• Once the bullae are ruptured, a thin, brown crust occurs on the remaining erosions on its periphery, leaving a typical scale.

Bullous impetigo

Brown crust appearing after bullae rupture in a child with impetigo

Diagnostic Evaluation

• The diagnosis of nonbullous and bullous impetigo is based on clinical evaluation.
• Culture and susceptibility of the pus or bullous fluid.

Complications

• Cellulitis
• Septicemia
• Osteomyelitis and septic arthritis

Medical Management

• Both types usually resolve within 2–3 weeks without scarring, but pharmaceutical management is required in some cases of impetigo.

Topical Antibiotics for Impetigo

• Fusidic acid 2% ointment is applied to affected skin thrice daily for 7–12 days.
• Mupirocin, a 2% cream, is applied to the affected skin of children older than 3 months thrice daily for 7–10 days.

Nursing Management

• Maintain good personal hygiene. Keep the nails short to avoid secondary infections and provide loose fitting cotton clothes.
• Avoid contact with other children during the active outbreak.

BOILS

• Boils are the most common skin disorders of children, affecting 10%–20% of children in India.

Types

• Furuncle (boil)
• Carbuncle (cluster of boils)

Etiology

• The causative organisms are S. aureus (most common), S. pyogenes, and Escherichia coli.

Risk Factors

• Poor hygiene and sanitation
• Skin trauma or injury

Scratching → transfer of S. aureus�↓�Breakdown of skin barrier�↓�Bacterial entry into hair follicle�↓�Bacterial multiplication�↓�Folliculitis → Furuncle → Carbuncle�↓�Inflammatory response�↓�Fever & malaise

Pathophysiology

Graphical presentation of the difference between acne, boil, and carbuncle

Clinical Manifestations

• Red, painful, swollen nodule or pustule.
• Pus or discharge from the site.

Diagnostic Evaluation

• The diagnosis is typically made based on physical examination findings.
• If systemic symptoms are present, a complete blood count may be obtained.

Complications

• Scar
• Septicemia
• Cavernous sinus thrombophlebitis (rare)

Medical Management

• Administration of analgesics is considered for pain management (paracetamol and ibuprofen).
• Application of topical antibiotics: Mupirocin ointment (2%) thrice daily and Neosporin ointment thrice daily.

Nursing Management

• Pain Management

• Apply warm compresses for 5–10 minutes to facilitate drainage.
• Apply topical antibiotics as advised and to continue the course of oral antibiotics.
• Report to a healthcare provider if there is excessive pus drainage or bleeding from the carbuncle.

PEDICULOSIS

• Lice (order: Phthiraptera) are small, wingless insects that spend their entire lives on their host .
• It affects children between 6 and 12 years of age, and the incidence rate is 14%–49%.

Human lice

Etiology

Pediculosis of scalp

Pediculus Humanus Capitis (Head Lice)

• Head lice are obligate ectoparasites that live on the human scalp for food, warmth, moisture, and shelter.
• Generally, head lice feed every 3–6 hours by sucking blood from the scalp.

Pediculus Humanus Corporis (Body Lice)

• Body lice feed one to five times daily and can live up to 60 days.

Pthirus Pubis (Pubic Lice)

• Pthirus pubis (pubic lice) infests mainly pubic hair (inducing phthiriasis pubis).

Risk Factors

• Age
• Gender
• Social and cultural factors

Pathophysiology

Clinical Manifestations

• Most pediculosis symptoms in school children are mild-to-moderate.
• Although rare, heavy and chronic infestations can lead to anemia.

Lice in eyelashes

Diagnostic Evaluation

• Diagnosis is based on visual detection of the adult and nymphal stages.
• Dermoscopy (dermatoscopy or epiluminoscopy) is a safe and confirmatory diagnostic method for body louse.

Complications

• Social embarrassment.
• Loss of skin integrity leading to secondary bacterial infection (impetigo and pyoderma).

Medical Management of Pediculosis Among Children

• Wet Combing for Pediculosis

• It is also known as “bug busting.” This is an adjunct treatment of choice for head lice.

• Dimethicone 4% Lotion

• It suffocates the lice and nits (eggs) as it forms a physical barrier around them, preventing them from moving and feeding.

Permethrin 1% Creme

• Permethrin 1% is a synthetic pyrethroid used widely as a treatment.

Ivermectin

• This act on neurotransmitters glutamate or gamma aminobutyric acid (GABA) paralyzes the parasite, resulting in death, and also prevents nits from hatching.
• Antibiotics are needed in case of louse-borne infections.

Nursing Management

• Avoid head-to-head contact with others.
• Avoid sharing personal items such as hair accessories, towels, or pillows.
• Keep long hair tied back.

SCABIES

• Scabies is a highly contagious, pruritic, parasitic skin infection caused by the mite.

Etiology

• Scabies is caused by the itch mite Sarcoptes scabiei (S scabiei) var. hominis.

Scabies mites and their borrows

Pathophysiology

Risk Factors

• This mite can infect any child but is more prevalent in immunosuppressed children and their primary caregivers.

Clinical Manifestations

• Classic Scabies

• Circadian rhythm
• If left untreated, the infestation may last for years and has been called the 7-year itch.

Circle of Hebra

Scabies affecting plantar surface of feet

Scabies over the trunk

Crusted Scabies

• Although rare in children, it is characterized by a severe infestation of millions of mites, resulting in hyperkeratotic plaques or crusted skin.

Diagnostic Evaluation

• Skin scrapings
• The burrow ink
• Adhesive tape stripping

The 2020 International Alliance for the Control of Scabies Consensus Criteria for the diagnosis of scabies

Complications of Scabies

• Acute poststreptococcal glomerulonephritis (APSGN) and acute renal failure (ARF) are associated with chronic renal impairment and chronic rheumatic heart disease.

Management

• Thus, infested persons and their close physical contacts should be treated simultaneously, regardless of whether symptoms are present.

Medical Management

• Topical Treatment

• Permethrin, a 5% cream, is a synthetic pyrethroid and potent insecticide.
• Benzyl benzoate (12.5% for children and 6.25% for infants)

• Oral Treatment

• Oral ivermectin: Oral ivermectin is a safe oral antiparasitic commonly used for complex cases of scabies in children under 15 kg.
• Environmental control

Nursing Management

• If the child is admitted for other medical conditions and is found to have scabies, maintain contact precautions and preferably isolate the child.
• Clean clothing and bedding
• Keep all family members’ skin clean and dry to prevent reinfestation.

DERMATOPHYTOSIS

• Dermatophytes are fungi that invade and multiply within keratinized tissues (skin, hair, and nails), causing infection.

Types

• Trichophyton
• Epidermophyton
• Microsporum

Various forms of tinea infections in different parts of the body

Risk Factors

• The climate’s temperature rise is due to global warming.
• Sharing of fomites with the infected family members or close contacts.

Clinical Manifestations

• Children commonly present with an itchy, red rash typically present on the exposed skin of the neck, trunk, and extremities.

DIAGNOSTIC EVALUATION

• DIRECT MICROSCOPY
• SENSITIVITY TESTING

COMPLICATIONS

• Secondary bacterial infections

MEDICAL MANAGEMENT

• Topical antifungals
• Oral antifungals

NURSING MANAGEMENT

• Apply the medication to the affected area as directed, usually two to three times daily.
• Wash the affected area with soap and water daily.
• Use an antifungal powder or spray on your feet and in your shoes.

ACNE VULGARIS

• Acne vulgaris is a common chronic cutaneous inflammatory disorder of the pilosebaceous unit.

INFANTILE ACNE

Acne among adolescents (back and cheeks)

Etiology

• Causative organisms are Cutibacterium acnes (formerly Propionibacterium acnes) and Staphylococcus epidermidis.

Risk Factors

• Genetic predisposition.
• Excessive emotional stress.
• Environmental factors (humidity).

Pathophysiology

Increased sebum production�↓�Clogging of hair follicles (pores)�↓�Comedone formation�(Blackheads & whiteheads)�↓�Bacterial growth�↓�Inflammation�↓�Papules → Pustules → Nodules�↓�Scarring & hyperpigmentation

Types and Clinical Manifestations

• Acne fulminans or acne maligna: Acne fulminans or acne maligna is a rare skin disorder that presents as an acute, painful, ulcerating, and hemorrhagic clinical form of acne.

Acne fulminans

• Acne excoriée: Acne excoriée is a condition often seen in young women with an underlying psychiatric disorder.

Acne excoriée (compulsively squeezed and scratched acne)

Complications

• Scarring and hyperpigmentation
• Emotional distress

Medical Management

• Topical retinoids, such as tretinoin, tazarotene, adapalene, and tazarotene, are included in the initial management.
• Oral isotretinoin is a retinoid that combats acne vulgaris by counteracting the four pathogenic factors contributing to the disease.

Nursing Management

• Educate them on hygiene and skin care, such as washing their hands before touching their face.
• Use lukewarm water for cleansing and pat dry with a clean towel.
• Encourage a healthy diet of fruits, vegetables, whole grains, and lean proteins. Consider keeping a food diary to identify potential triggers.

DIAPER DERMATITIS

• Diaper dermatitis is an inflammatory reaction to the skin around the diaper area.

Diaper dermatitis

Etiology

• Excessive moisture (e.g., frequent passage of urine and stool among infants).
• Infection is due to poor hygienic practices by the primary caregiver.
• Frequency of diaper changes

Diaper use in infants�↓�↑ Moisture + friction�↓�Skin maceration & barrier breakdown�↓�Urine & fecal accumulation�↓�↑ Skin pH (urea breakdown)�↓�↑ Fecal enzyme activity�↓�Skin damage�↓�Microbial infection�(S. aureus, S. pyogenes, C. albicans)

Pathophysiology

Clinical Manifestations

• Erythema, papules, scaling, and erosions are generally found around the thighs, scrotum, suprapubic area, and buttocks.
• Small papules and pustules to large, fragile blisters of bullous impetigo can be found in S. aureus infection.

Diagnostic Evaluation

• Gram staining from the culture sample obtained can confirm suspected bacterial infection (rarely performed).

Complications

• It superimposed fungal or bacterial infection. It can be flared up in immunocompromised children.

Management

• Medical Management

• Keeping the area dry by using absorbent diapers, changing diapers frequently, and maintaining the baby’s hygiene usually facilitates healing.

Nursing Management

• Ensure good hygiene practices, such as washing hands before and after changing diapers.

ATOPIC DERMATITIS (AD)

• AD is a chronic inflammatory, highly pruritic, relapsing skin disease that typically manifests in early childhood and also precedes the development of other atopic disorders, including asthma, allergic rhinitis, and food allergies

Atopic dermatitis

Atopic dermatitis in an infant

Risk Factors

• Pruritus is precipitated by exposure to sweating, exposure in heat (during summer), emotional stress, pollutants and pollens (during traveling), and even sometimes by certain food particles.

Pathophysiology

Genetic predisposition to atopy�↓�Environmental triggers�↓�Disturbed skin barrier�↓�Altered skin microbiome�↓�Immune dysregulation�↓�Chronic skin inflammation

Clinical Features of AD

refer to book

Table no. 2

Page no. 334

Diagnostic Evaluation

• V-IGA
• Severity Index (EASI)
• Scoring Atopic Dermatitis (SCORAD)

Complications

• Infectious Complications

• Physical complications include sleep disturbances at night, secondary bacterial infection with S. aureus colonization.

Management

• Medical Management

• Hydration and use of occlusive topical moisturizers
• Prevention and treatment of secondary bacterial infection

Nursing Management

• Maintain a consistent skincare routine, moisturizing at least twice a day.
• Avoid triggers such as soaps, detergents, fragrances, and stress.

ALOPECIA

• The pattern and causes of hair loss differ in adults and pediatric age groups.
• The prevalence of pediatric alopecia areata is approximately 20.4% among children.

Types

• Alopecia areata (patchy hair loss)
• Alopecia totalis (total hair loss on the scalp)
• Alopecia universalis (total body hair loss).

Etiology

• Genetic predisposition
• Autoimmune response (no specific organism) is primarily found in alopecia areata.

Pathophysiology

• Autoimmune response against hair follicles causes inflammation and hair loss.

Clinical Manifestations

• Redness
• Itching
• Burning

Diagnostic Evaluation

• Based on clinical examination, diagnosis is made.

Complications

• Psychological issues related to disfigurement.

Medical Management

• Topical or oral administration of corticosteroids
• Minoxidil (2% or 5% solution)
• Anthralin (1% cream)

Nursing Management

• Educate on stress management
• Encourage healthy diet
• Advice to wear a wig or use a hairpiece.

PREMATURE GRAYING OF HAIR (PGH)

• Healthy hair is a sign of general well-being and youth.
• It acts as an esthetic tool and means of nonverbal communication for humans.

Etiology

• Genetic predisposition
• Autoimmune disorders
• Nutritional deficiencies (e.g., vitamin B12, copper).

Pathophysiology

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Increased oxidative stress�↓�↑ Hydrogen peroxide accumulation�↓�Damage to hair follicle pigment cells�↓�↓ Melanin production�↓�Premature graying of hair

Clinical Manifestations

• Patchy or diffuse graying or whitening of hair.
• These hairs are typically coarse and difficult to manage.

Diagnostic Evaluation

• serum vitamin B12
• folic acid
• thyroid profile

Complications

• Poor self-esteem and social isolation in school children.

Management

• Improvement in dietary sources of vitamin B12 and iron is emphasized.
• Thyroid supplementation and vitamin supplements are given based on laboratory values.

Nursing Management

• Educate on stress management

• Encourage healthy diet

• Support self-esteem by dying hair.

HERPES ZOSTER

• Herpes zoster, or shingles, is caused by the reactivation of the latent varicella zoster virus (VZV) in a dorsal root ganglion (DRG).

Herpes zoster infection of skin

Risk Factors

• Previous exposure
• Compromised immunity

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• Painful unilateral vesicular rash along a dermatome, with pain preceding rash.
• Fever, headache, fatigue, and lymphadenopathy may occur.
• Dermatome-specific involvement, including possible eye involvement.

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Clinical Manifestations

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Primary infection�↓�Virus becomes latent in DRG�↓�Latency maintained by:�• LATs (inhibit replication)�• Favorable neuronal environment�• Epigenetic silencing�• Immune evasion�↓�Reactivation of virus�↓�Nerve cell inflammation & damage

Pathophysiology

Diagnostic Evaluation

• Based on the distinctive clinical appearance. Laboratory tests usually are not necessary.
• A Tzanck smear, performed by scraping the base of the lesion, can demonstrate giant cells.

Complications

• Secondary bacterial infection
• Depigmentation and scarring
• Postherpetic neuralgia (uncommon)

Medical Management

• Acyclovir (80 mg/kg/day, in four divided doses; maximum 800 mg/dose for 7–10 days) is the treatment for herpes zoster infection.

Nursing Management

• Keep the child comfortable and hydrated. Provide loose-fitting cotton clothes.
• Avoid close contact with others until the rash has crusted over (usually 5–7 days).

PSORIASIS

• Psoriasis is a chronic, immune-mediated inflammatory skin disease characterized by thickened, scaly, red plaques (Figure 30). Its prevalence is 1%–3%.

Etiology

• Psoriasis is caused by genetic, environmental, and immune system factors.

Types

• Plaque psoriasis (most common)
• Guttate psoriasis (small, droplet-shaped lesions)
• Pustular psoriasis (rare, characterized by pus-filled blisters).

Pathophysiology

• Psoriasis involves an abnormal immune response, leading to excessive skin cell growth and inflammation.

Clinical Manifestations

• Red, scaly patches or plaques
• Silvery scales
• Dry skin

Diagnostic Evaluation

• A skin biopsy (rarely needed) can also confirm the diagnosis.

Complications

• Psoriatic arthritis
• Eye problems (e.g., conjunctivitis, uveitis)

Medical Management

• Excessive dryness predisposes to psoriasis; thus, ample emollients should be applied.
• Topical corticosteroids (e.g., triamcinolone 0.1% cream, applied twice daily).

Nursing Management

• Keep the skin moisturized to reduce scaling and itching.
• Use gentle, fragrance-free cleansers and avoid harsh soaps or exfoliants.

VITILIGO

• Vitiligo is a chronic autoimmune skin disease characterized by the loss of pigment-producing cells (melanocytes), leading to white patches on the skin .

Vitiligo in a child

Etiology

• Genetic predisposition
• Autoimmune response
• Epigenetic factors

Types

• Nonsegmental vitiligo (most common)
• Segmental vitiligo (affects one area of the body)
• Mixed vitiligo (combination of nonsegmental and segmental).

Pathophysiology

• Vitiligo involves an abnormal immune response, leading to the destruction of melanocytes.

Clinical Manifestations

• White patches on the skin (often symmetrical)
• Premature graying of hair

Diagnostic Evaluation

• Skin biopsy (rarely needed).
• Autoantibody tests

Complications

• Emotional and psychological distress
• Autoimmune diseases
• Segmental vitiligo

Medical Management

• Administration of topical drugs
• Phototherapy (e.g., narrowband UVB, two to three times a week for 6–12 months).

Nursing Management

• Educate patients and families about vitiligo and treatment.
• Encourage adherence to treatment plans.
• Monitor for side effects and complications such as emotional distress and signs of secondary infection.

SKIN TUBERCULOSIS

• Cutaneous tuberculosis (skin tuberculosis) in children is a significant health problem in India.

Causative Organisms

• The causative organisms are Mycobacterium tuberculosis and Mycobacterium bovis (rarely).

Risk Factors

• Direct contact with an infected person or contaminated surface
• Weakened immune system

Types

• Lupus vulgaris
• Scrofuloderma
• Tuberculous chancre

Clinical Manifestations

• Swollen lymph nodes
• Fever, weight loss, and fatigue.

Pathophysiology

Exposure to infected adult�↓�Primary infection�(lungs ± skin/mucosa)�↓�Regional lymphadenopathy�↓�Spread via lymphatics / bloodstream (sometimes)�↓�Latent infection (dormant bacilli)�↓�Favorable conditions�↓�Reactivation�↓�Cell-mediated immune response�↓�Granuloma formation

Management

• Antitubercular Therapy

• Isoniazid (10–20 mg/kg/day)

Nursing Management

• Encourage healthy lifestyle habits.
• Support self-esteem.

Complications

• Resistance to antitubercular drugs
• Psychological issues due to social isolation.

PEDIATRIC SKIN TUMORS

• These skin conditions are relatively rare, affecting only 1%–2% of all tumors.

Types

• Benign tumors
• Malignant tumors

Etiology

• viral infections (e.g., HPV)
• UV radiation exposure.

Clinical Manifestations

• Abnormal skin growths or lesions
• Changes in skin color, texture, or size of any site

Complications

• Metastasis to other organs
• Recurrence

Management

• Surgical excision
• Chemotherapy

Nursing Management

• Educate on sun protection and skin care.
• Manage pain and discomfort. Monitor for side effects and complications

SKIN CANCER

• Skin cancer is relatively rare among children and is characterized by essential distinguishers from adult disease.

Risk Factors

• BCC develops through radiation dose, exposed skin surface area, and use of chemotherapeutic agents.
• Chronic exposure to chemicals

Types and Clinical Manifestations

• Melanoma
• Basal cell carcinoma
• Squamous cell carcinoma (SCC)

Pathophysiology

Genetic predisposition�↓�Exposure to environmental irritants�↓�Cellular damage & mutations�↓�Abnormal cell proliferation�↓�Cancer development

Complications

• Emotional distress
• Metastasis

Management

• Cryotherapy.
• Touch electrodesiccation.

Nursing Management

• Dress the child in protective clothing, including a hat and sunglasses.
• Keep the affected area clean and dry.

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