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Assessing the patient with a skin condition

Author(s)

S Lawton
Dermatology Liaison Sister
Queen's Medical Centre
Nottingham, UK

Contents
Published: May 2002
Last updated: May 2002
Revision: 1.0

Keywords: skin assessment; dermatology patient; skin lesions; pigmented skin; nurses' role.

Abstract

Skin diseases affect 20-30% of the population at any one time, seriously interfering with activities in 10%. Skin conditions are, by their vary nature, visible. As a result, those with a skin condition receive the same reaction from society as anyone who looks 'different'. They can be subjected to stares, whispered comments, antagonism, insult or exclusion from normal social activity. Those with a skin condition have the needs of all other patients, but in addition, the impact upon their lives of a skin condition, its treatment and the ways in which others perceive them, makes their situation unique. Many nurses, however, will have little or no experience of patients with skin conditions. They need therefore to be aware of the wide-ranging effects a skin disease can have on individuals and their families. It is important that nurses understand the basic principles of skin disease and care, but are also aware of their limitations, seeking further advice as necessary. This article will guide the nurse in assessing patients with a skin condition.


Introduction

Skin diseases affect 20-33% of the population at any one time, seriously interfering with activities in 10%. Epidemiological evidence suggests that many cases of skin disease do not reach the general practitioner (GP) or even the local pharmacist; nevertheless, each year about 15% of the population consult their GPs about skin complaints. Five percent of these are referred on for specialist advice and typically GPs spend at least 10% of their working time dealing with skin diseases [1].

Skin conditions are, by their vary nature, visible. As a result, those with a skin condition receive the same reaction from society as anyone who looks 'different'. They can be subjected to stares, whispered comments, antagonism, insult or exclusion from normal social activity. Those with a skin condition have the needs of all other patients, but in addition, the impact upon their lives of a skin condition, its treatment and the ways in which others perceive them, makes their situation unique. It may be argued that such feelings may be experienced by all patients, whatever their condition, but what makes dermatology patients different is that these feelings have been developed, compounded and reinforced by their experiences over a number of years. In addition, the stark reality is that for many dermatological conditions there is no cure. Life will be characterised by periods of remission and exacerbation. Many healthcare professionals will see patients during different stages of the disease process, often when things are at their worst and with their needs changing. Further, because a dermatological condition may be life-long, needs will change with age. Dermatology patients need acceptance, support and to be treated as equal, valued, complete human beings [2].

Nursing assessment

Assessment of the dermatology patient includes obtaining a detailed dermatological history as this may provide clues to diagnosis, management and nursing care of the existing problem, with careful observation and meticulous description and should cover the following areas:

.

History of the patient's skin condition

  1. How long has the condition been present?

  2. How often does it occur or recur?

  3. Are there any seasonal variations?

  4. Is there a family history of skin disease?

  5. What are the patient's occupation and hobbies?

  6. What medication is the patient taking?

  7. Are there any known allergies?

  8. Previous and present treatments and their effectiveness?

  9. Are there any treatments, actions or behavioural changes which influence the condition?

General assessment

The skin conveys a wealth of information about the person inside it, indeed it frequently mirrors health status - simple examples of this are 'ill', flushed', 'pale' or 'peaky' appearances, recognised by those not trained in physical assessment. A great deal can be observed in a person's face, which may give insight to his or her state of mind, self-caring abilities, and the existence of adequate support and back-up systems [4].

Physical skin assessment

Make a point of touching your patients. This will give you clinical information about skin texture and temperature whilst also breaking down the physical barrier, which many dermatology patients experience. Most people are unused to exposing their body to 'strangers'. Other factors such as religion, culture and upbringing should be considered before a physical examination begins [4]. This physical examination needs to take place in a warm environment with privacy. Explanation needs to be given as to why you may be undressing them when the rash is only on one part of their body. The skin tells a story so it may need to be examined thoroughly, looking at the distribution, character and shape of the lesions (Table 1). This needs to be done, preferably, in good natural light, which will not change the colour of what is seen.
Table 1: The lesions
Character Is there redness (erythema), scaling, crusting, exudate? Are there excoriations, blisters, erosions, pustules, papules? Are the lesions all the same (monomorphic), e.g. drug rash or variable (polymorphic) e.g. chickenpox?
Shape Are the lesions small, large, annular (ring shaped), linear?
Distribution Is it acral (hands, feet), extremities of ears and nose, in light exposed areas or mainly confined to the trunk?

Findings should be documented using appropriate terminology or descriptions on a body plan. Other findings such as scars following surgery, amputation of digits or limbs and wounds found should be documented and dated [3].

Terminology for describing skin lesions

Primary lesions

Primary lesions are those present at the initial onset of the disease:

  1. Macule - a flat mark; circumscribed area of colour change: brown, red, white or tan. Example: vitiligo

  2. Papule - elevated 'spot'; palpable, firm, circumscribed lesion generally less than 5 mm in diameter. Example: scabies/insect bites

  3. Nodule - elevated; firm; circumscribed; palpable; can involve all layers of the skin; larger than 5 mm in diameter. Example: erythema nodosum

  4. Plaque - elevated, flat topped, firm, rough, superficial papule greater than 2 cm in diameter. Papules can coalesce to form plaques. Example: psoriasis

  5. Wheal - elevated, irregular-shaped area of cutaneous oedema; solid, transient, changing, variable diameter; red, pale pink or white in colour. Example: urticaria

  6. Vesicle - elevated, circumscribed, superficial fluid filled blister less than 5 mm in diameter. Example: herpes simplex/pompholyx

  7. Bulla - vesicle greater than 5 mm in diameter. Example: bullous pemphigoid

  8. Pustule - elevated, superficial, similar to vesicle but filled with pus. Example: impetigo

Secondary lesions

Secondary lesions are the result of changes over time caused by disease progression, manipulation (scratching, rubbing, picking) or treatments.

  1. Scale - heaped-up keratinised cells; flaky exfoliation; irregular; thick or thin; dry or oily; variable size; silver, white or tan in colour. Example: psoriasis

  2. Crust - dried serum, blood or purulent exudate; slightly elevated; size variable. Examples: impetigo discoid pattern atopic eczema

  3. Excoriation - loss of epidermis; linear area usually due to scratching. Example: atopic eczema

  4. Lichenification - rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching. Examples: chronic eczema, lichen simplex

Assessing pigmented skin

Among the members of any population, there are a significant range of skin colours and hair types. It is therefore important that healthcare professionals are able to recognise reactions in patients with deeply pigmented skin in order to diagnose and treat them effectively. Often lesions, which in white skin appear red or brown, would appear black or purple in pigmented skin. Mild degrees of redness (erythema) may be masked completely. Inflammation commonly leads to pigmentary changes - both lighter and darker, which may persist for a long time after the initial dermatosis has finally settled. It may be this post-inflammatory pigmentation that brings the patient to the dermatologist. Pigmented skin shows more of a pigmentary reaction following trauma or inflammation than non-pigmented or lightly pigmented skin. Consequently post-inflammatory hyperpigmentation and hypopigmentation poses particular problems for black patients. In inflammatory skin diseases such as atopic eczema, acne vulgaris and lichen planus, the post-inflammatory hyperpigmentation can persist well after the active disease process has subsided and sometimes indefinitely. Hypopigmentation may also be seen with pityriasis alba, sarcoidosis, leprosy, pityriasis versicolor and may also follow eczema, herpes zoster, cryotherapy and the use of topical corticosteroids. Darker skins may also have an inherent tendency to show particular reaction patterns that are different from those seen in white skin. Follicular, papular and annular patterns are seen more frequently in Afro-Caribbean skin than in white skin. Keloid scarring may also occur more often in people with a black skin [5].

The skin as a sensory organ

It is also important to establish the degree of pain, itching and soreness associated with the skin condition. Itching (pruritus) is the principal symptom of dermatological disease and also occurs in numerous systemic disorders. It can be an extremely distressing complaint and is reported as the prime cause of 2.8% of consultations in general practice. It is vital to attempt to identify and treat the underlying cause of pruritus. The most common cause of itching is a primary skin disease such as eczema, urticaria, lichen planus, psoriasis, dermatitis herpetiformis, insect bites and scabies. Systemic causes of itch include pregnancy, chronic renal failure, cholestasis, thyroid dysfunction, haematological disorders, iron deficiency and internal malignancy [6].

Knowledge and education

The nurse needs to establish patients' level of knowledge about their skin in general, their condition and expectations, how it affects their life and plan the appropriate education and support for them. This must involve patients at every level. Patients with skin disease wish for "a sound diagnosis, clear information, and unambiguous, practical and realistic advice on what can and should be done about it, if anything, forming the basis of a joint decision about therapy"[7]. This need for information, explanation, advice and support is increased by the uncertainty, misunderstanding, prejudice and ignorance surrounding skin disease within the community [7].

Conclusions

Nurses, when assessing the dermatology patient, should try to develop their powers of observation [4]. It is vital to not only listen, but also hear; not only to look, but also see. This will result in increasingly effective prevention and cure of disease and greater success in health promotion with nurses able to:

Many nurses, however, will have no experience of patients with skin conditions. They need therefore to be aware of the wide-ranging effects a skin disease can on individuals and their families. It is important that nurses understand the basic principles of skin disease and care, but are also aware of their limitations, seeking further advice as necessary. Skin disease is more than skin deep!

References

1. All Parliamentary Group on Skin. An investigation into the adequacy of service provision and treatments for patients with skin diseases in the UK. London: The Group, 1997.

2. Lawton S. A quality of life for people with skin disease. London: Skin Care Campaign, 2000.

3. Lawton S. Assessing the skin. Professional Nurse 1998; 13(4).

4. Mairis E. Four senses for a full skin assessment. Professional Nurse 1992; 376-80.

5. Lawton S. Assessing pigmented skin. Nursing Times 2000; 96(27): 14.

6. Fitzgerald D, English J. Itching and scratching: what treatment options are available? Nursing Dialogue 1993; 18: 1-2.

7. Jobling R. Dermatology tomorrow - the patient's viewpoint. Dermatology in Practice 1988; 6: 18-21.

Further Reading

Buchanan P. Dermatology. Nursing Standard 1998; 12(40): 48-54.

Hughes E, Van Onselen J, editors. Dermatology Nursing: a practical guide. Edinburgh: Churchill Livingstone, 2001.




All materials copyright © 1992-Feb 2001 by SMTL, March 2001 et seq by SMTL unless otherwise stated.

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