PANCE Blueprint Dermatology (5%)

Skin integrity (Pearls)

The NCCPA™ PANCE Dermatology Content Blueprint covers four disorders under the category of skin integrity

Burns

Patient will present as → a 35-year-old male who was throwing some paint thinner on fire to get it going a little better when it splashed on him and caught his R arm and his R hip area on fire. He did not have pain right away and was not going to go to the hospital. He washed off the burnt areas because he had grease and oil on his hands and lower arm. The pain then started to get bad enough for him to have his wife take him to the ER.

Body percentage:

  • Rule of 9’s: Head 9%, Each arm 9%, Chest 9%, Abdomen 9%, Each anterior leg 9%, Each posterior leg 9%, Upper back 9%, Lower back 9%, Genitals 1%
  • Palmar method: Patient’s palm equates to 1%

Degree involvement:

Treatment: Monitor ABCs, fluid replacement, sulfadiazine. Children with > 10% total body surface area and adults with > 15% total body surface area burns need formal fluid resuscitation

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Lacerations

Patient will present as → a 27-year old male who arrives at your clinic after sustaining a laceration to his right thumb while cutting a bagel. He was able to stop the bleeding after about 2 minutes with gentle pressure. Physical exam reveals a 2 cm laceration on the finger pad of the right first digit that approximates easily with gentle pressure.

Suture removal — The timing of suture removal varies with the anatomic site

  • Eyelids – Three days
  • Neck – Three to four days
  • Face – Five days
  • Scalp – 7 to 14 days
  • Trunk and upper extremities – Seven days
  • Lower extremities – 8 to 10 days

Follow-up visits — Most clean wounds do not need to be seen prior to removal unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 48 to 72 hours. It is imperative that clear discharge instructions are given to every patient regarding signs of wound infection.

Nonabsorbable sutures
Suture material Knot security Wound tensile strength Tissue reactivity Workability Anatomic site
Nylon (Ethilon) Good Good Minimal Good Skin closure anywhere
Polybutester (Novafil) Good Good Minimal Good Skin closure anywhere
Polypropylene (Prolene) Least Best Least Fair Skin closure anywhere. Blue dyed suture useful in dark-skinned individuals.
Silk Best Least Most Best Rarely used
Absorbable sutures
Suture material Knot security Wound tensile strength Security (days)* Tissue reactivity Anatomic site
Fast-absorbing gut Poor Least 4 to 6 Most Face
Vicryl Rapide Good Fair 5 to 7 Minimal Face, scalp, undercast/splint
Surgical gut Poor Fair 5 to 7 Most Face (rarely used)
Poliglecaprone 25 (Monocryl) Good Fair 7 to 10 Minimal Face, consider in contaminated wounds needing deep closure
Chromic gut Fair Fair 10 to 14 Most Mouth, tongue, nailbed
Polyglactin (Vicryl) Good Good 30 Minimal Deep closure, nailbed, mouth
Polyglycolic acid (Dexon) Best Good 30 Minimal Deep closure
Polydioxanone (PDS) Fair Best 45 to 60 Least Deep closure
Polyglyconate (Maxon) Fair Best 45 to 60 Least Deep closure
* Retention of 50 percent of tensile strength.

Most wounds should be covered with an antibiotic ointment and a nonadhesive dressing immediately after laceration repair

  • The dressing should be left in place for 24 hours, after which time most wounds can be opened to air.

Prophylactic antibiotics may decrease the risk of infection in some animal and human bites, intraoral lacerations, open fractures, and wounds that extend into cartilage, joints or tendons 

  • Allow animal bites especially in non-cosmetic areas such as the hand and foot to heal by secondary intention

Pressure ulcers

Patient will present as → an 80-year-old bed-bound woman with a temperature of 104°F who you are called to see in the nursing home. The patient is disoriented and confused. On physical examination, the patient’s blood pressure is 110/ 80 mm Hg, and her pulse is 72 beats/ minute and regular. There is an 8 × 5-cm pressure ulcer over her sacrum. Also, there is a purulent, foul-smelling discharge coming from the ulcer.

Sacrum and hip most often affected, reposition every 2 hours

  • Stage 1: erythema of localized area, usually non-blanching over the bony surface
  • Stage 2: partial loss of dermal layer, resulting in pink ulceration
  • Stage 3: full dermal loss often exposing subcutaneous tissue and fat
  • Stage 4: full-thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present

Wound management by stage of the ulcer

  • Stage I: aggressive preventive measures, thin-film dressings for protection
  • Stage II: occlusive dressing to maintain healing, transparent films, hydrocolloids
  • Stages III-IV: Débridement of necrotic tissue. Exudative ulcers will benefit from absorptive dressings such as calcium alginates, foams, hydrofibers. Dry ulcers require occlusive dressing to maintain moisture, including hydrocolloids, and hydrogels.

Risk factors: age >65, impaired circulation, immobilization, undernutrition, incontinence

DX: based on observation and staged according to classification

TX: debridement ⇒ depends on the extent of necrosis; surgical closure may be necessary; vacuum-assisted closure uses negative pressure to reduce wound edema and remove debris/reduce bacterial load

Pressure ulcer staging. (A) Stage I, erythema; (B) Stage II, breakdown of the dermis; (C) Stage III, full thickness skin breakdown; (D) Stage IV, bone, muscle, and supporting tissue involved.

Pressure ulcer staging. (A) Stage I, erythema; (B) Stage II, breakdown of the dermis; (C) Stage III, full-thickness skin breakdown; (D) Stage IV, bone, muscle, and supporting tissue involved.

Stasis dermatitis

Patient will present as → a 75-year-old female with a history of varicose veins. She reports that she has had these for a few months now and hopes to improve their appearance. She also states that her legs often feel restless and heavy and that she often has nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thrombosis after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles.

Stasis dermatitis is caused by fluid buildup due to varicose veins, poor circulation, or heart disease

  • Skin discoloration of the ankles or shins, itching, thickened skin, and open sores (ulcers) are symptoms

Treatments may include compression stockings and corticosteroid creams as well as treating the underlying condition

  • Systemic antibiotics for patients with more extensive infection and signs of cellulitis

Increased scaling, peripheral edema, erosions, crusts, and secondary bacterial infection on the lower third of the leg in a patient with subacute stasis dermatitis.

Vitiligo (ReelDx) (Prev Lesson)
(Next Lesson) Burns (ReelDx)
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