Chapter 28: Skin Disorders

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

Skin Trauma

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

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

– 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

• 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

– Management (intact blister) • Leave intact for 24 hours • Clean with antiseptic • Cut small incision to drain fluid (large enough that it won’t 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

– 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

• 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

• 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

• 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

• 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

• 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

– 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

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

• 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

• 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

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)

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

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

• 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

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

– 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

• 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

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

– 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

• 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

• 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

• 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

• 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

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

• 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

• 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

• 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 athlete’s 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

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

– 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

• Athlete’s Foot (tinea pedis) – Etiology • Most common form of superficial fungal infection • Tricophyton species are most common cause of athlete’s 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

• 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

• 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

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

• 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

– 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

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

• 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

• 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)

• 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)

Allergic, Thermal, and Chemical Skin Reactions

• Allergies are immunologically mediate responses to molecules in dyes and proteins against which the body’s 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 • ATC’s must recognize gross signs of allergic responses and be prepared to remove allergens and treat topically or systemically with antipruritic agents

• 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

• 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

• 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

• 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 • S&S will dissipate w/in 72-96 hours

• 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

• 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

• 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

• Scabies

Infestation and Bites

– 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

• 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

• 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

• 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

• 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

• 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

• 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