Pediatric Clinical Practice Guidelines for Nurses in Primary Care
Chapter 16 - The Skin
Assessment of the Integumentary System
History of Present Illness and Review of System
General
The following characteristics of each symptom should be elicited and explored:
- Onset (sudden or gradual)
- Skin site involved
- Chronology
- Date(s) and site(s) of recurrence(s)
- Current situation (improving or deteriorating)
- Nature of symptom: intermittent or continuous
- Influence of environmental factors
- Potential causative factors
- Measures taken to relieve symptoms
Cardinal Symptoms
In addition to the general characteristics outlined above, additional characteristics
of specific symptoms should be elicited, as follows.
Skin
- Changes in texture, color, pigmentation
- Unusual dryness or moisture
- Itching
- Rash
- Bruises, petechiae
- Lesions
- Changes in moles or birthmarks
Hair
- Changes in amount, texture, distribution
Nails
- Changes in texture, structure
Medical History (Specific to Integumentary system)
- Allergic manifestation (e.g., asthma, hay fever, urticaria, eczema)
- Recent or current viral or bacterial illness
- Allergies to drugs, foods or other chemical substances
- Sensitivity to sunlight
- Medications: current and past prescription and OTC drugs
- Immunosuppression (e.g., HIV/AIDS)
- Seborrheic dermatitis
- Dermatitis
- Psoriasis
- Diabetes mellitus
Family History (Specific to Integumentary system)
- Allergies (e.g., seasonal hay fever, allergies to foods)
- Asthma
- Seborrheic dermatitis
- Psoriasis
- Others at home with similar symptoms (e.g., rash)
Personal and Social History (Specific to Integumentary system)
- Obesity
- Inadequate personal hygiene
- Hot or humid environment, poor environmental sanitation
- Exposure to new chemicals (e.g., soaps), foods, pets or plants
- Emotional disturbance
- History of sensitive skin
- Others at home, work or school with similar symptoms
- Recent travel
Physical Examination
General Appearance
- Apparent state of health
- Appearance of comfort or distress
- Color (e.g., flushed, pale)
- Nutritional status (obese or emaciated)
- State of hydration
- Vital signs (temperature may be elevated)
Inspection and Palpation of the Skin
- Color
- Temperature, texture, turgor
- Dryness or moisture
- Scaling
- Pigmentation
- Vascularity (erythema, abnormal veins)
- Bruising, petechiae
- Edema (dependent, facial)
- Induration (firm to touch)
- Individual lesions (color, type, texture, general pattern of distribution,
character of edge, whether raised or flat)
- Hair (amount, texture, distribution)
- Nails (shape, texture, discoloration, grooving)
- Mucous membranes (e.g., moisture, lesions)
- Skin folds (e.g., rashes, lesions)
- Joint involvement
Fig. 16-1: Skin Lesions Up to 1 cm in Greatest Dimension
Other Aspects
- Examine lymph nodes
- Examine area distal to enlarged lymph nodes
Types of Lesions
Lesions of the skin and mucous membranes are characterized by their size,
elevation, contents and color (Figs. 16-1 to 16-3).
Fig. 16-2: Skin Lesions Greater than 1 cm in at Least One Dimension
Fig. 16-3: Skin Lesions of Variable Size
Common Problems of the Skin
Scabies
Definition
Infestation of the skin with a mite parasite. Skin eruptions consist variably
of wheals, papules, vesicles, burrows and superimposed eczematous dermatitis.
The lesions are intensely pruritic, especially at night, which leads to marked
excoriation.
In infants, the face, scalp, palms and soles are most commonly involved. In
adolescents, the lesions, which often appear as threadlike burrows, occur in
the interdigital spaces, the groin and genitalia, the umbilicus, and the axillae
and on the wrists, elbows, ankles and buttocks.
Cause
- Itch mite, Sarcoptes scabiei, which burrows under the skin
- Usually transmitted by direct contact and (rarely) fomites (e.g., clothes,
linen)
Risk Factors
- Failure to recognize an infestation
- Faulty application of treatment
- Failure to treat close contacts
- Failure to eradicate mites from clothing and bed linen
- Exposure to someone with scabies
The Aboriginal population in some areas may be at risk from a number of additional
factors, such as the following:
- Crowded housing, shared beds, crowded schools and daycare centers
- High pediatric population
- Lack of running water, which may predispose to poor hygiene and secondary
skin infection
History
- Severe itching
- Itching generally worse at night
- Rash on hands, feet, flexural folds
- Symptoms may take 1-2 months to develop after contact with mite
- Symptoms are due to hypersensitivity to mite and its products
Physical Findings
- Usually affects interdigital web spaces, flexures of wrists and arms, axillae,
belt line, lower folds of buttocks, genitalia, areolae of nipples
- Diffuse red rash
- Primary lesions: papules, vesicles, pustules, burrows
- Secondary lesions: scabs, excoriations, crusts, nodules, secondary
infection
- Lesions in various stages present at the same time
- Secondary lesions may predominate
- Burrows (gray or flesh-colored ridges 5-15 mm long) may be few or many
- Burrows commonly seen on anterior wrist or hand and in interdigital web
spaces
- In infants, burrows are much less common
Differential Diagnosis
- Pediculosis
- Impetigo
- Eczema (atopic dermatitis)
- Contact or irritant dermatitis
- Viral exanthem
- Chickenpox
- Drug reaction
Complications
Diagnostic Tests
None.
Management
Goals of Treatment
- Eradicate infestation
- Control secondary infection
- Relieve symptoms
Appropriate Consultation
Consult physician if you are unsure of the diagnosis.
Nonpharmacologic Interventions
Client Education
- Counsel parents or caregiver (and child, if old enough) about proper use
of medication and its side effects
Control Measures
- Prophylactic therapy is essential for all household members, since signs
of scabies may not appear for 1-2 months after the infection is acquired
- Treat all household members at the same time to prevent re-infection
- All bed linen (sheets, pillow slips) and clothing worn next to the skin
(underwear, T-shirts, socks, jeans) should be laundered in a hot soapy wash
and dried with a hot drying cycle, as available
- If hot water is not available, place all bed linen and clothing into plastic
bags and store away from the family for 5-7 days, as the parasite cannot
survive beyond 4 days without skin contact
- Placing bedding outside in the cold or in ultraviolet light will also help
- Children may return to daycare or school the day after treatment is completed
- Healthcare workers who have had close contact with people who have scabies
may themselves require prophylactic treatment
- Community education, aimed at early recognition and awareness of scabies,
is important
- In widespread scabies epidemics, prophylactic treatment of a whole community
may constitute optimal management
Pharmacologic Interventions
Scabicide cream or lotion, applied to entire body, from chin to toes. Emphasize
that scabicide must be applied in skin creases, between fingers and toes, between
buttocks, under breasts and to external genitalia.
permethrin 5% dermal cream (Nix) (A class drug) (drug of
choice)
Leave on skin for 8-14 hours. A single application is usually curative, but
medication may be re-applied after 1 week if symptoms persist.
The safety of permethrin for infants <3 months
old has not been established.
Pruritus may be a problem, particularly at night. Advise the child and the
parents or caregiver that itching will persist for up to 2 weeks. To manage
itching:
diphenhydramine hydrochloride (Benadryl) (A class drug)
(as 2.5 mg/mL elixir), 1.25 mg/kg PO q4-6h prn, maximum dose 300 mg/day (over
6 doses)
Children <2 years old: 2-3 mL
Children 2-4 years old: 5 mL
Children 5-11 years old: 5-10 mL
Children ≥12 years old: 10-20 mL or 25-50 mg in capsule form
Topical steroids may be useful after antiscabietic treatment, because the
rash and itching may persist for several days:
hydrocortisone 0.5% (Unicort) (A class drug), applied od
or bid
Monitoring and Follow-Up
- Follow up in 1 week to assess response to treatment
- Advise parents or caregiver to bring child back to the clinic immediately
if signs of secondary infection develop
Referral
Rarely necessary if original diagnosis is correct and adequate eradication
treatment is adhered to by the child and his or her contacts.
Impetigo
Definition
Highly contagious, superficial bacterial infection of the skin.
Causes
- Streptococcus, Staphylococcus or both
- Predisposing factors: local trauma, insect bites, skin lesions from other
disorders (e.g., eczema, scabies, pediculosis)
History
- More common on face, scalp and hands, but may occur anywhere
- Involved area is usually exposed
- Usually occurs during summer
- New lesions usually due to auto-inoculation
- Rash begins as red spots, which may be itchy
- Lesions become small blisters and pustules, which rupture and drain
- Discharge dries to form characteristic golden yellow crusts
- Lesions painless
- Fever and systemic symptoms rare
- Mild fever may be present in more generalized infections
Physical Findings
- Thick, golden yellow, crusted lesion on a red base
- Numerous skin lesions at various stages present (vesicles, pustules, crusts,
serous or pustular drainage, healing lesions)
- Bullae may be present
- Lesions and surrounding skin may feel warm to touch
- Local lymph nodes may be enlarged, tender
Differential Diagnosis
- Infection associated with eczema, contact dermatitis or scabies
- Herpes simplex infection with blisters or crusts
- Chickenpox infection with blisters or crusts
- Shingles (herpes zoster) with blisters or crusts
- Insect bites
Complications
- Localized or widespread cellulitis
- Post-streptococcal glomerulonephritis
- Invasive group A streptococcal disease (invasive GAS)
Diagnostic Tests
- Wound swab for culture and sensitivity (may be confirmatory)
Management
Goals of Treatment
- Control infection
- Prevent auto-inoculation
- Prevent spread to other household members
Appropriate Consultation
Consult a physician if there is no response to therapy.
Nonpharmacologic Interventions
- Warm saline compresses to soften and soak away crusts qid and prn
- Cleanse with an antiseptic antimicrobial agent to decrease bacterial growth
Client Education
- Counsel parents or caregiver about appropriate use of medications (including
dose, frequency and compliance)
- Offer recommendations about hygiene as necessary
- Cut fingernails to prevent scratching
- Counsel parents or caregiver about prevention of future episodes
- Suggest strategies to prevent spread to other household members (e.g.,
proper hand-washing, use of separate towels)
Pharmacologic Interventions
Apply topical antibiotic preparation after each soaking:
mupirocin ointment (Bactroban) (A class drug), qid for 7-10
days
or
fusidic acid (Fusidin) (A class drug) qid for 7-10 days
Oral antibiotics may be necessary if there are multiple lesions that appear
infected:
cloxacillin (Orbenin) (A class drug), 25-50 mg/kg per day,
divided q6h, PO
or
erythromycin (E-Mycin tabs or EES suspension) (A class drug),
40 mg/kg per day, divided q6h, PO
Topical antibiotics such as mupirocin (Bactroban)
may be used alone for small areas or in conjunction with oral antibiotics
for larger areas.
Monitoring and Follow-Up
- Follow up in 3 to 5 days to assess response to treatment
- Instruct parents or caregiver to bring the child back for reassessment
if fever develops or infection spreads despite therapy
Referral
Not usually necessary unless complications develop.
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