The Child with Altered Skin Integrity
McKinney (Chapter 49)
Key Function of Skin
Protection – shield deep tissues from internal injury
Immunity – contains cells that ingest bacteria and other substances.
Thermoregulation – heat regulation through excretion, shivering, and subcutaneous insulation
Communication / sensation of touch, pain, heat & cold/ regeneration
Developmental Variances
The neonate’s dermis is thin causing:
Greater fluid loss
Increased permeability to topical agents
Don’t use topical meds without scripts on infants/ toddlers
IgA does not reach adult levels until age 2-5 making young children less resistant to organisms
(What age groups have highest risk of hand-to-mouth infections?)
Infants have fewer melanocytes and increased photosensitivity
Eccrine sweat glands do not function completely until the child is 2 to 3-years-old so infants and young children are less able to regulate own body temperature
Apocrine sweat glands are not fully functional until puberty
Vascular Birth Marks
Port wine stain- "neuvus flammeus"
Affect 3/1000 live births
Caused by malformed capillaries in early fetal development
Large, pinkish red, usually non-raised areas
Darken with age and can bleed easily
Hemangioma
Affect 1 to 2% of neonates
Caused by proliferation of capillaries and endothelium of capillary lining
Typically not present at birth, but appear and darken in first year of life(usually gone by age 6)
Usually just observe but can be indicative of coagulation disorder
May treat (steroid injection/ laser) if on face or obstructs nose, eyes, mouth
Mongolian spots
Affect as many as 80% of African Am/ Asian/ Am Indian neonates but only 10% of Caucasian neonates
Caused by abnormal pigmentation: (usually fade by age 5)
Café au lait Spots- light, brown, flat marks
Significance: > 5 is suggestive of underlying congenital disorder
Salmon patches- “Angel kisses” “Stork bites”
Affect 40% of neonates (most common)
Flat, pink, irregular in shape on bridge of nose, nape of neck, or forehead
Neonatal Dermatology
Newborn Cord Care
EBP guidelines- Clean cord with water as needed and keep it clean and dry is best.
Shortens time of separation
Does not lead to increased infections
Recommend folding diaper back to keep it dry and free from contamination
Should become dark brown or black in 2-3 days and fall off within 7-10 days
Purulent drainage or redness at base indicates infection
Cradle Cap
Most common type of dermatitis among infants
Occurs on the scalp in first 2-3 weeks of life, usually disappears by 12 mos
May progress to other areas
Nonpruritic, oily, yellow scales that block sweat and sebaceous glands
Retained secretions and inflammation in affected areas
Overgrowth of skin bacteria and yeast and may lead to secondary infection
Interventions
If confined to the scalp
Shampoo with mild baby shampoo
May use OTC antiseborrheic shampoo with sulfur/ salicylic acid, selenium (sebulex), tar (Neutrogena, T-gel), or Ketoconazole 2%
May massage with warm mineral oil to loosen scales before shampooing area
Brush with a soft brush to help remove the scales
If affecting eyelids, use warm water compresses and no-tears shampoo to cleanse area
Good hygiene will prevent recurrence!
Lotions and creams aggravate condition and should not be used!
Seborrheic Dermatitis (Dandruff)
Chronic, temporary. Not allergic. Results in scaling and erythema (sound like cradle cap?)
Common in areas high in sebaceious glands
May be pruritic (itchy)
Treatment:
Daily cleansing and scale removal with anti-seborrheic shampoos and gentle brushing of scales
May treat with hydrocortisone cream
No use of lotions or moisturizers (already too oily)
If affecting infant diaper area, may result in secondary yeast infection.
Contact Dermatitis
Caused by hundreds of substances:
Rubber products
Clothing dyes
Nickel
Plant oils
Scented or strongly alkaline soaps
Skin lotions
Cosmetics
Wool clothing
Nickel Allergy
Assessment
Occurs in exposed areas of skin:
Face, neck, hands, forearms, legs and feet
Lesions may be well demarcated resembling the shape and size of the offending substance
Interventions
Assess skin: type/ extent of lesions
Identify causative agent: moisture, friction, chemicals
Ask parents about product use, new foods, laundry practices, diapering
Teach hazards of baby oils, baby powder, other products
Cleanse irritants away with water/ mild cleansers and avoid re-exposure
Change diaper for newborns hourly and older infants every 2 hours and expose area to air for extended periods daily
Avoid rubber/ plastic pants, soak washable diapers in hot water and double rinse
Use cool compresses of tap water/ Burow’s solution/ steroid creams
Use barrier creams like zinc oxide / Desitin
Atopic Dermatitis or Eczema
Assessment
Severe pruritis
Erythema
Exudate and crusts or lichenification
Common sites: cheeks, forehead, scalp, extensor surfaces of arms and legs
May have distressing psychosocial effects on child and family
Multidisciplinary Interventions
Frequent re-hydration of the skin with non-alcohol lotions/ moisturizers
Elidel cream
To reduce the inflammation: topical corticosteroids
Control the itching: antihistamine such as dipenhydramine: Benadryl/ loratadine: Claritin
Antiinflammatory corticosteroid creams and ointments and topical steroid creams for flare ups
Topical calcineurin inhibitors
In children older than age 2
Avoid exposure to sun/ heat lamps/ or tanning beds
Allergy testing to identify potential outbreak triggers
Avoid solid foods for first six months
Breastfeeding for first year
Nursing Considerations
Impaired skin integrity
Impaired comfort
Risk for secondary infections
Scratching
Impaired skin integrity
Fatigue/ sleep disturbance
Knowledge deficit
Psychosocial issues
Body image
Self esteem issues
Interventions
Teach regarding use of mild soaps (Neutrogena/ Dove (hypoallergenic)) and prescribed topical medications
What laundry detergents would you advise? Hypo-allergenic, mild detergents. Avoid changing detergents, and remember fabric softeners are usually perfumed- best to avoid
Humidifier during winter months
Strips of cotton sheets moistened with soaks and topical medications make good dressings, soft cleansing cloths
Tepid bathwater to keep skin clean, but avoid overheating and causing dryness and irritation
Fingernails kept clean and short, cotton gloves, mittens
Lightweight long-sleeved tops and one-piece outfits help avoid overheating as well as preventing scratching
Turn underwear inside out to avoid scratching, cut out tags from clothes
Stress reduction techniques and body image considerations
Acne vulgaris
Chronic, inflammatory process of the sebaceous hair follicles.
Can be influenced by heredity, hormones
Some argument regarding whether stress may play a role (text says yes/ other sources say no)
Myths: related to foods/ dirty skin
Occurrence: 85% of teenagers aged 15 to 17 years.
More common in males.
Tends to improve in summer and flare up in winter
Assessment
Reddened, hyperpigmented lesions form pustules close to skin surface
Skin cells “plug” pores causing white heads and blackheads
Lesions usually occur on the face, neck, back, chest and shoulders
Ruptures of pustules deep in dermis can cause cysts and abscesses and may cause scarring
Bacteria deep in the follicles may cause inflammation and disrupt integrity of follicle walls
Interventions
Topical medications
OTC preparations- benzoyl peroxide
Prescription -
1. Topical retinoid preparations (tretinoin)
Use sunscreen to reduce photosensitivity
2. Topical antibiotics may cause bacterial resistance
3. Hormone therapy
4. Accutane (isotretinoin)
Severely teratogenic (2 negative pregnancy tests to start, monthly negative pregnancy test to continue, and a negative test at end)
Treatment goal: to prevent scarring and promote positive self-image in adolescent
Typically several weeks for improvement
May take 2-3 months for prescription management to improve in severe cases
Parasitic Infestations
Lice
Pediculosis capitis (head)
Identified by presence of nits or (eggs) glued to the hair of any of these areas or presence of lice.
Characterized by intense itching (pruritus)
Not a reportable condition but millions of children are affected each year worldwide
Facts
Head lice infestation ranges from 1% to 40% in children.
Most common in ages 5 to 12 (preschool and young school age children)
Affects all socioeconomic groups.
Less common in African American due to the shape of the hair shaft.
Girls are affected twice as often as boys
Transmission by direct contact with infected person, clothing, grooming articles, bedding, or carpeting.
Assessment
Symptoms: itching, whitish colored eggs at shaft of hair, redness at site of itching.
Generally ½ to ¼ inch from scalp
Infestation may be most active behind ears or at nape of neck
Can have posterior cervical lymph adenopathy/ secondary scalp infections
Interventions
Assess presence of nits or lice in area of bright light or sunlight by using two tongue depressors to separate hair shafts moving from side to side and front to back
Especially focus on areas of crown, behind ears and at nape of neck
Anti-lice shampoo such as Nix (permethrin based)
Lindane not used under age 2 (has been nominated for elimination)
Being phased out because of environmental effects and risks of use
Washing bedding, towels, anything child’s head may have come in contact with in hot soapy water.
Vacuum all floors and rugs
Do not need to fumigate the house
Should notify school if infected
Some schools have “no nit” policies, but others allow return after 1 day of treatment
Bartonella quintana
Trench fever (associated with head lice infection)
Characterized by fever (single bout or recurrent), headache, rash, and bone pain (shins, neck, and back)
Common among over-crowding conditions in absence of hygiene (consider homeless population)
Dx: Serology/ blood cultures
Treatment is with antibiotics
Other types of lice
Pediculosis corporis
On skin in areas under tight clothing
Nits attach firmly to seams of clothing or bedding
Pediculosis pubis
On pubic hair and facial hair, in axillae and on body surface
If present on eyebrow or eyelashes or prepubescent child, this suggest sexual abuse
Blue spots on thighs and trunk in cases of heavy infestation
May be identified by dark brown spots on underwear and sheets
Insect waste material
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
•Infestation is passed through close personal contact
Assessment
Pruritus especially profound at night or nap time.
Lesions may be generalized but tend to distribute on the palms, soles and axillae
Burrow tracks may be seen
Diagnosis confirmed by skin scrapings and microscopic exam
In infants, head, palms and soles of feet may be affected
In older children: wrists, finger webs, body creases, beltline and genitalia are affected
Interventions
Permethrin cream (Elamite) is drug of choice
May use lindane 1% (Kwell) if permethrin is not effective
Lindane should not be used in children under 2 or in pregnant women due to neurotoxicity
Treat all family members regardless of symptoms
Massage into all dry skin surfaces of body and head (avoiding eyes and mouth) and then from neck to soles of feet -
Leave on for Elamite or permethrin on 8 to 14 hours (bedtime is recommended) and lindane on 4 to 8 hours
May re-apply one week later as recommended
Can use hydrocortisone cream and oral antihistamines for pruritis
Treat Environment
For both head lice and scabies
Wash washable fabrics with hot water
Frequent environmental cleanings, daily checks, and isolating bed linens to prevent spread
Dry in high heat
Tie stuffed animals in plastic bags
Vacuum frequently
Fungal Infections
Candidiasis- “ Oral Thrush” or “Yeast”
Thrives in warm, moist areas
May be associated with antibiotic use
Oral thrush due to dirty nipples/ pacifiers or mom’s breasts
Difficulty eating (Offer cool liquids to soothe
Very red, raised bumps
Diaper area will not clear with zinc oxide/ Desitin
Treatment: Antifungals: Nystatin (oral solutions/ cream) or Lotrimin/ miconazole for diaper area q 6 hours x 3-4 days
Persistent yeast may indicate immunocompromised status
Tinea Infections
Tinea capitis
Tinea corporis
Tinea cruris
Tinea pedis
Treatment: Antifungals such as lotrimin/ miconazole
Griseofulvin Oral x 6 weeks
Take with meal or milk
Causes increased photosensitivity
Must monitor liver function studies
Impetigo
• The most common skin infection in children
•Superficial and often secondary to cold, scratch, bug bite (other condition that causes impaired skin integrity)
•Bacteria invade the superficial skin.
•Causative agent is carried in the nasal area:
•Staph or Group A Strep
•Teach:
•Avoid sharing towels, utensils, touching/ scratching wounds
•Frequent hand washing, light covering of wound, avoid friction
•Be concerned with periorbital edema or blood in urine as may progress to glomerulonephritis and kidney damage
Interventions
Wash hands frequently
Wear gloves when providing treatment
Wash lesion with antibacterial soap and water TID
Topical antibiotics TID:
Mupropicin
Bacitracin
PO antibiotics: Keflex 1st generation cephalosporin if on face or around mouth/ nose
May require IV if severe or extensive infections
No school/ daycare 24 hours after treatment started
Impetigo / cellulitis
Cellulitis
A full-thickness skin infection that has penetrated to subcutaneous layer
involves dermis and underlying connective tissue.
any part of the body can be affected.
may follow break in skin, URI, otitis media, tooth abscess
Cellulitis around the eyes is usually an extension of a sinus infection, otitis media, or tooth abscess
Causative organisms:
Haemophilus influenzae, Staph, or Group A Strep
Presents risk of meningitis, sepsis, or septic arthritis
Diagnostic Tests
WBC count
Blood culture
Culturing organism from lesion aspiration.
CT scan of head with peri-orbital cellulitis
If cellulitis in the eye area may spread to brain
Assessment
Characteristic reddened or lilac-colored, swollen skin that pits when pressed with finger
Borders are indistinct
Warm/ tender to touch
Superficial blistering
Fever/ malaise/ or headache
Guarding/ irritability
VS Q 4 hours/ PRN
Interventions
Hospitalization if large area involved or facial cellulitis
IV antibiotics followed by IM/ PO for 10 days
Ceftriaxone Sulfamethoxazole/ Trimethoprim
Cephalosporin Clindamycin
Cloxacillin Vancomycin
Dicloxacillin Linezolid
Tylenol Q 4 H for pain management
Warm moist packs/ compresses to area if ordered
Assess for spread
If peri-orbital test for ocular movement and vision acuity
May require incision/ debridement if community acquired MRSA
Viral Infections (Herpetic)
HSV I
Herpes labialis “fever blister” most common manifestation
Usually occurs before 20 years old
Antibodies against HSV I found in 80% adolescents and 85% are asymptomatic
HSV II
Generally affects anal-genital area causing blisters
Rare before age 14 (consider sexual abuse if occurs)
Types of Herpes infections
H. labialis- fever blister
Prodromal itching/ paresthesia, then outbreak of vesicular clusters 2 days to 2 weeks after exposure
Lesions crust within 7 to 14 days
H. gingivostomatitis- More sever, involves oral cavity
Often children <5 years old, involves cervical node enlargement and vesicles/ ulcerations of throat
Chills, fever, malaise, bad breath, and drooling
H. keratitis- Infection of conjunctiva/ cornea presents with tearing/ photophobia and is caused by rubbing eyes with contaminated fingers
Risk vision loss
H. whitlow- Infection of fingertips with vesicles, pruritis, & pain 3 to 7 days after exposure
Nurses are at risk (no patient care until healed)
Diagnosis of Herpetic Infections
Tzanck smear confirms herpes infection
Positive results cannot differentiate between varicella zoster and HSV I
Negative does not rule out HSV infection
Immunofluorescence assay can detect HSV antigen and polymerase chain reaction can detect HSV I DNA on blood samples
Gold Standard for diagnosis:Tissue culture
Nursing Considerations
Infection Control
Comfort
Dehydration prevention
Inflammatory or Immune-mediated response
Treatment
Symptom management as there is no cure for HSV infection
Oral fluids to prevent dehydration (ice pops, non-citrus juice, non-carbonated drinks) if affecting oral mucosa
Remember- lesions hurt and child may not want to eat or drink.
IV fluids if dehydrated
Medication:
Topical or oral acyclovir (Zovirax) can reduce recovery time
IV acyclovir (Zovirax) for immunocompromised children to decrease severity
Ocular HSV infection is treated by opthamology specialist
Antibiotic ointment for prevention of secondary infection
Corticosteroids are contraindicated (worsen infection)
Analgesia
Oral or rectal acetaminophen
Codeine
Topical anasthetics to numb lesions
Anesthetic mouth rinse
“Magic Mouth Wash”
Equal parts dipenhydramine (Benadryl) elixir + bismuth subsalicylate (Kaopectate) + 2 % viscous Lidocaine to decrease pain and help child eat
Monitor for decreased oral reflex or “gag” reflex in small children to prevent aspiration
Other Considerations
Monitor lesions
Oral care
Rinse mouth frequently with normal saline
Report signs of dehydration
Offer bland, soft foods (reassure parents that a few days without food intake is OK, but stress importance of oral fluids)
Preventing Spread
Contact Precautions if hospitalized
Meticulous hand hygiene
Care with oral care, suctioning, handling bed linens/ belongings
Remember: Scabs don’t form on mucus membranes
Contagious until completely healed
Parents should not share bottles, nipples, toys, eating utensils, or towels (wash items in hot, soapy water or dishwasher)
Teach avoiding hand-to-mouth contact
Comfort and cuddle child frequently
Thank You!
m
McKinney (Chapter 49)
Key Function of Skin
Protection – shield deep tissues from internal injury
Immunity – contains cells that ingest bacteria and other substances.
Thermoregulation – heat regulation through excretion, shivering, and subcutaneous insulation
Communication / sensation of touch, pain, heat & cold/ regeneration
Developmental Variances
The neonate’s dermis is thin causing:
Greater fluid loss
Increased permeability to topical agents
Don’t use topical meds without scripts on infants/ toddlers
IgA does not reach adult levels until age 2-5 making young children less resistant to organisms
(What age groups have highest risk of hand-to-mouth infections?)
Infants have fewer melanocytes and increased photosensitivity
Eccrine sweat glands do not function completely until the child is 2 to 3-years-old so infants and young children are less able to regulate own body temperature
Apocrine sweat glands are not fully functional until puberty
Vascular Birth Marks
Port wine stain- "neuvus flammeus"
Affect 3/1000 live births
Caused by malformed capillaries in early fetal development
Large, pinkish red, usually non-raised areas
Darken with age and can bleed easily
Hemangioma
Affect 1 to 2% of neonates
Caused by proliferation of capillaries and endothelium of capillary lining
Typically not present at birth, but appear and darken in first year of life(usually gone by age 6)
Usually just observe but can be indicative of coagulation disorder
May treat (steroid injection/ laser) if on face or obstructs nose, eyes, mouth
Mongolian spots
Affect as many as 80% of African Am/ Asian/ Am Indian neonates but only 10% of Caucasian neonates
Caused by abnormal pigmentation: (usually fade by age 5)
Café au lait Spots- light, brown, flat marks
Significance: > 5 is suggestive of underlying congenital disorder
Salmon patches- “Angel kisses” “Stork bites”
Affect 40% of neonates (most common)
Flat, pink, irregular in shape on bridge of nose, nape of neck, or forehead
Neonatal Dermatology
Newborn Cord Care
EBP guidelines- Clean cord with water as needed and keep it clean and dry is best.
Shortens time of separation
Does not lead to increased infections
Recommend folding diaper back to keep it dry and free from contamination
Should become dark brown or black in 2-3 days and fall off within 7-10 days
Purulent drainage or redness at base indicates infection
Cradle Cap
Most common type of dermatitis among infants
Occurs on the scalp in first 2-3 weeks of life, usually disappears by 12 mos
May progress to other areas
Nonpruritic, oily, yellow scales that block sweat and sebaceous glands
Retained secretions and inflammation in affected areas
Overgrowth of skin bacteria and yeast and may lead to secondary infection
Interventions
If confined to the scalp
Shampoo with mild baby shampoo
May use OTC antiseborrheic shampoo with sulfur/ salicylic acid, selenium (sebulex), tar (Neutrogena, T-gel), or Ketoconazole 2%
May massage with warm mineral oil to loosen scales before shampooing area
Brush with a soft brush to help remove the scales
If affecting eyelids, use warm water compresses and no-tears shampoo to cleanse area
Good hygiene will prevent recurrence!
Lotions and creams aggravate condition and should not be used!
Seborrheic Dermatitis (Dandruff)
Chronic, temporary. Not allergic. Results in scaling and erythema (sound like cradle cap?)
Common in areas high in sebaceious glands
May be pruritic (itchy)
Treatment:
Daily cleansing and scale removal with anti-seborrheic shampoos and gentle brushing of scales
May treat with hydrocortisone cream
No use of lotions or moisturizers (already too oily)
If affecting infant diaper area, may result in secondary yeast infection.
Contact Dermatitis
Caused by hundreds of substances:
Rubber products
Clothing dyes
Nickel
Plant oils
Scented or strongly alkaline soaps
Skin lotions
Cosmetics
Wool clothing
Nickel Allergy
Assessment
Occurs in exposed areas of skin:
Face, neck, hands, forearms, legs and feet
Lesions may be well demarcated resembling the shape and size of the offending substance
Interventions
Assess skin: type/ extent of lesions
Identify causative agent: moisture, friction, chemicals
Ask parents about product use, new foods, laundry practices, diapering
Teach hazards of baby oils, baby powder, other products
Cleanse irritants away with water/ mild cleansers and avoid re-exposure
Change diaper for newborns hourly and older infants every 2 hours and expose area to air for extended periods daily
Avoid rubber/ plastic pants, soak washable diapers in hot water and double rinse
Use cool compresses of tap water/ Burow’s solution/ steroid creams
Use barrier creams like zinc oxide / Desitin
Atopic Dermatitis or Eczema
Assessment
Severe pruritis
Erythema
Exudate and crusts or lichenification
Common sites: cheeks, forehead, scalp, extensor surfaces of arms and legs
May have distressing psychosocial effects on child and family
Multidisciplinary Interventions
Frequent re-hydration of the skin with non-alcohol lotions/ moisturizers
Elidel cream
To reduce the inflammation: topical corticosteroids
Control the itching: antihistamine such as dipenhydramine: Benadryl/ loratadine: Claritin
Antiinflammatory corticosteroid creams and ointments and topical steroid creams for flare ups
Topical calcineurin inhibitors
In children older than age 2
Avoid exposure to sun/ heat lamps/ or tanning beds
Allergy testing to identify potential outbreak triggers
Avoid solid foods for first six months
Breastfeeding for first year
Nursing Considerations
Impaired skin integrity
Impaired comfort
Risk for secondary infections
Scratching
Impaired skin integrity
Fatigue/ sleep disturbance
Knowledge deficit
Psychosocial issues
Body image
Self esteem issues
Interventions
Teach regarding use of mild soaps (Neutrogena/ Dove (hypoallergenic)) and prescribed topical medications
What laundry detergents would you advise? Hypo-allergenic, mild detergents. Avoid changing detergents, and remember fabric softeners are usually perfumed- best to avoid
Humidifier during winter months
Strips of cotton sheets moistened with soaks and topical medications make good dressings, soft cleansing cloths
Tepid bathwater to keep skin clean, but avoid overheating and causing dryness and irritation
Fingernails kept clean and short, cotton gloves, mittens
Lightweight long-sleeved tops and one-piece outfits help avoid overheating as well as preventing scratching
Turn underwear inside out to avoid scratching, cut out tags from clothes
Stress reduction techniques and body image considerations
Acne vulgaris
Chronic, inflammatory process of the sebaceous hair follicles.
Can be influenced by heredity, hormones
Some argument regarding whether stress may play a role (text says yes/ other sources say no)
Myths: related to foods/ dirty skin
Occurrence: 85% of teenagers aged 15 to 17 years.
More common in males.
Tends to improve in summer and flare up in winter
Assessment
Reddened, hyperpigmented lesions form pustules close to skin surface
Skin cells “plug” pores causing white heads and blackheads
Lesions usually occur on the face, neck, back, chest and shoulders
Ruptures of pustules deep in dermis can cause cysts and abscesses and may cause scarring
Bacteria deep in the follicles may cause inflammation and disrupt integrity of follicle walls
Interventions
Topical medications
OTC preparations- benzoyl peroxide
Prescription -
1. Topical retinoid preparations (tretinoin)
Use sunscreen to reduce photosensitivity
2. Topical antibiotics may cause bacterial resistance
3. Hormone therapy
4. Accutane (isotretinoin)
Severely teratogenic (2 negative pregnancy tests to start, monthly negative pregnancy test to continue, and a negative test at end)
Treatment goal: to prevent scarring and promote positive self-image in adolescent
Typically several weeks for improvement
May take 2-3 months for prescription management to improve in severe cases
Parasitic Infestations
Lice
Pediculosis capitis (head)
Identified by presence of nits or (eggs) glued to the hair of any of these areas or presence of lice.
Characterized by intense itching (pruritus)
Not a reportable condition but millions of children are affected each year worldwide
Facts
Head lice infestation ranges from 1% to 40% in children.
Most common in ages 5 to 12 (preschool and young school age children)
Affects all socioeconomic groups.
Less common in African American due to the shape of the hair shaft.
Girls are affected twice as often as boys
Transmission by direct contact with infected person, clothing, grooming articles, bedding, or carpeting.
Assessment
Symptoms: itching, whitish colored eggs at shaft of hair, redness at site of itching.
Generally ½ to ¼ inch from scalp
Infestation may be most active behind ears or at nape of neck
Can have posterior cervical lymph adenopathy/ secondary scalp infections
Interventions
Assess presence of nits or lice in area of bright light or sunlight by using two tongue depressors to separate hair shafts moving from side to side and front to back
Especially focus on areas of crown, behind ears and at nape of neck
Anti-lice shampoo such as Nix (permethrin based)
Lindane not used under age 2 (has been nominated for elimination)
Being phased out because of environmental effects and risks of use
Washing bedding, towels, anything child’s head may have come in contact with in hot soapy water.
Vacuum all floors and rugs
Do not need to fumigate the house
Should notify school if infected
Some schools have “no nit” policies, but others allow return after 1 day of treatment
Bartonella quintana
Trench fever (associated with head lice infection)
Characterized by fever (single bout or recurrent), headache, rash, and bone pain (shins, neck, and back)
Common among over-crowding conditions in absence of hygiene (consider homeless population)
Dx: Serology/ blood cultures
Treatment is with antibiotics
Other types of lice
Pediculosis corporis
On skin in areas under tight clothing
Nits attach firmly to seams of clothing or bedding
Pediculosis pubis
On pubic hair and facial hair, in axillae and on body surface
If present on eyebrow or eyelashes or prepubescent child, this suggest sexual abuse
Blue spots on thighs and trunk in cases of heavy infestation
May be identified by dark brown spots on underwear and sheets
Insect waste material
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
•Infestation is passed through close personal contact
Assessment
Pruritus especially profound at night or nap time.
Lesions may be generalized but tend to distribute on the palms, soles and axillae
Burrow tracks may be seen
Diagnosis confirmed by skin scrapings and microscopic exam
In infants, head, palms and soles of feet may be affected
In older children: wrists, finger webs, body creases, beltline and genitalia are affected
Interventions
Permethrin cream (Elamite) is drug of choice
May use lindane 1% (Kwell) if permethrin is not effective
Lindane should not be used in children under 2 or in pregnant women due to neurotoxicity
Treat all family members regardless of symptoms
Massage into all dry skin surfaces of body and head (avoiding eyes and mouth) and then from neck to soles of feet -
Leave on for Elamite or permethrin on 8 to 14 hours (bedtime is recommended) and lindane on 4 to 8 hours
May re-apply one week later as recommended
Can use hydrocortisone cream and oral antihistamines for pruritis
Treat Environment
For both head lice and scabies
Wash washable fabrics with hot water
Frequent environmental cleanings, daily checks, and isolating bed linens to prevent spread
Dry in high heat
Tie stuffed animals in plastic bags
Vacuum frequently
Fungal Infections
Candidiasis- “ Oral Thrush” or “Yeast”
Thrives in warm, moist areas
May be associated with antibiotic use
Oral thrush due to dirty nipples/ pacifiers or mom’s breasts
Difficulty eating (Offer cool liquids to soothe
Very red, raised bumps
Diaper area will not clear with zinc oxide/ Desitin
Treatment: Antifungals: Nystatin (oral solutions/ cream) or Lotrimin/ miconazole for diaper area q 6 hours x 3-4 days
Persistent yeast may indicate immunocompromised status
Tinea Infections
Tinea capitis
Tinea corporis
Tinea cruris
Tinea pedis
Treatment: Antifungals such as lotrimin/ miconazole
Griseofulvin Oral x 6 weeks
Take with meal or milk
Causes increased photosensitivity
Must monitor liver function studies
Impetigo
• The most common skin infection in children
•Superficial and often secondary to cold, scratch, bug bite (other condition that causes impaired skin integrity)
•Bacteria invade the superficial skin.
•Causative agent is carried in the nasal area:
•Staph or Group A Strep
•Teach:
•Avoid sharing towels, utensils, touching/ scratching wounds
•Frequent hand washing, light covering of wound, avoid friction
•Be concerned with periorbital edema or blood in urine as may progress to glomerulonephritis and kidney damage
Interventions
Wash hands frequently
Wear gloves when providing treatment
Wash lesion with antibacterial soap and water TID
Topical antibiotics TID:
Mupropicin
Bacitracin
PO antibiotics: Keflex 1st generation cephalosporin if on face or around mouth/ nose
May require IV if severe or extensive infections
No school/ daycare 24 hours after treatment started
Impetigo / cellulitis
Cellulitis
A full-thickness skin infection that has penetrated to subcutaneous layer
involves dermis and underlying connective tissue.
any part of the body can be affected.
may follow break in skin, URI, otitis media, tooth abscess
Cellulitis around the eyes is usually an extension of a sinus infection, otitis media, or tooth abscess
Causative organisms:
Haemophilus influenzae, Staph, or Group A Strep
Presents risk of meningitis, sepsis, or septic arthritis
Diagnostic Tests
WBC count
Blood culture
Culturing organism from lesion aspiration.
CT scan of head with peri-orbital cellulitis
If cellulitis in the eye area may spread to brain
Assessment
Characteristic reddened or lilac-colored, swollen skin that pits when pressed with finger
Borders are indistinct
Warm/ tender to touch
Superficial blistering
Fever/ malaise/ or headache
Guarding/ irritability
VS Q 4 hours/ PRN
Interventions
Hospitalization if large area involved or facial cellulitis
IV antibiotics followed by IM/ PO for 10 days
Ceftriaxone Sulfamethoxazole/ Trimethoprim
Cephalosporin Clindamycin
Cloxacillin Vancomycin
Dicloxacillin Linezolid
Tylenol Q 4 H for pain management
Warm moist packs/ compresses to area if ordered
Assess for spread
If peri-orbital test for ocular movement and vision acuity
May require incision/ debridement if community acquired MRSA
Viral Infections (Herpetic)
HSV I
Herpes labialis “fever blister” most common manifestation
Usually occurs before 20 years old
Antibodies against HSV I found in 80% adolescents and 85% are asymptomatic
HSV II
Generally affects anal-genital area causing blisters
Rare before age 14 (consider sexual abuse if occurs)
Types of Herpes infections
H. labialis- fever blister
Prodromal itching/ paresthesia, then outbreak of vesicular clusters 2 days to 2 weeks after exposure
Lesions crust within 7 to 14 days
H. gingivostomatitis- More sever, involves oral cavity
Often children <5 years old, involves cervical node enlargement and vesicles/ ulcerations of throat
Chills, fever, malaise, bad breath, and drooling
H. keratitis- Infection of conjunctiva/ cornea presents with tearing/ photophobia and is caused by rubbing eyes with contaminated fingers
Risk vision loss
H. whitlow- Infection of fingertips with vesicles, pruritis, & pain 3 to 7 days after exposure
Nurses are at risk (no patient care until healed)
Diagnosis of Herpetic Infections
Tzanck smear confirms herpes infection
Positive results cannot differentiate between varicella zoster and HSV I
Negative does not rule out HSV infection
Immunofluorescence assay can detect HSV antigen and polymerase chain reaction can detect HSV I DNA on blood samples
Gold Standard for diagnosis:Tissue culture
Nursing Considerations
Infection Control
Comfort
Dehydration prevention
Inflammatory or Immune-mediated response
Treatment
Symptom management as there is no cure for HSV infection
Oral fluids to prevent dehydration (ice pops, non-citrus juice, non-carbonated drinks) if affecting oral mucosa
Remember- lesions hurt and child may not want to eat or drink.
IV fluids if dehydrated
Medication:
Topical or oral acyclovir (Zovirax) can reduce recovery time
IV acyclovir (Zovirax) for immunocompromised children to decrease severity
Ocular HSV infection is treated by opthamology specialist
Antibiotic ointment for prevention of secondary infection
Corticosteroids are contraindicated (worsen infection)
Analgesia
Oral or rectal acetaminophen
Codeine
Topical anasthetics to numb lesions
Anesthetic mouth rinse
“Magic Mouth Wash”
Equal parts dipenhydramine (Benadryl) elixir + bismuth subsalicylate (Kaopectate) + 2 % viscous Lidocaine to decrease pain and help child eat
Monitor for decreased oral reflex or “gag” reflex in small children to prevent aspiration
Other Considerations
Monitor lesions
Oral care
Rinse mouth frequently with normal saline
Report signs of dehydration
Offer bland, soft foods (reassure parents that a few days without food intake is OK, but stress importance of oral fluids)
Preventing Spread
Contact Precautions if hospitalized
Meticulous hand hygiene
Care with oral care, suctioning, handling bed linens/ belongings
Remember: Scabs don’t form on mucus membranes
Contagious until completely healed
Parents should not share bottles, nipples, toys, eating utensils, or towels (wash items in hot, soapy water or dishwasher)
Teach avoiding hand-to-mouth contact
Comfort and cuddle child frequently
Thank You!
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