ACNE

Acne, the most common skin condition occurring in child- hood (Burch & Morelli, 2011), is a disorder that affects the pilosebaceous unit. It affects males and females, as well as all ethnic groups. Overall, males tend to have more severe disease than females, probably because of the androgen inluence (Burch & Morelli, 2011). Acne that

Thinking About Development

E

mily Wilson is a 15-year-old female with a history of moderate psoriasis. She experiences signiicant scaling along her hairline, forehead, scalp, and arms. Hypopig- mentation and striae are beginning to occur on her arms as a result of topical medication use. She is a talented ballerina but expresses increasing concerns about her skin alterations showing while she is performing.

How does Emily’s developmental stage affect self- care related to her psoriasis?

What is the most appropriate approach for the nurse to take to educate Emily about control of her pso- riasis?

How will the nurse best promote an appropriate body image for Emily?

surface. Androgenous hormones stimulate sebaceous gland proliferation and production of sebum. These hormones exhibit increased activity during the puber- tal years. Abnormal shedding of the outermost layer of the skin (the stratum corneum) occurs at the level of the follicular opening, resulting in a keratin plug that ills the follicle. The sebaceous glands increase sebum production. Bacterial overgrowth of Propionibacterium acnes occurs because the presence of sebum and kera- tin in the follicular canal creates an excellent environ- ment for growth. Inlammation occurs as the follicu- lar wall perforates, allowing the contents to leak into nearby tissue.

Therapeutic Management

Therapeutic management focuses on reducing P. acnes, decreasing sebum production, normalizing skin shed- ding, and eliminating inlammation. Teach the adoles- cent to cleanse the skin gently twice a day. Medication therapy may include a combination of benzoyl peroxide, salicylic acid, retinoids, and topical or oral antibiotics.

Isotretinoin (Accutane) may be used in severe cases.

Drug Guide 46.1 gives further information on these medi- cations. In girls, oral contraceptives may help lessen acne by decreasing the effects of androgens on the sebaceous glands. Diode laser or blue ultraviolet light therapy may also be used. CO₂ lasers and dermabrasion may be used to treat pitted scarring.

Nursing Assessment

Note history of onset of acne lesions, as well as fam- ily history of acne. Determine medication use; certain medications may hasten the onset of acne or worsen it when already present. In particular, note use of cortico- steroids, androgens, lithium, phenytoin, and isoniazid.

Document history of an endocrine disorder, particularly one that results in hyperandrogenism. In girls, note worsening of acne 2 to 7 days before the start of the menstrual period. Inspect the skin for lesions (particu- larly on the face and upper chest and back, which are the areas of highest sebaceous activity). Note presence, distribution, and extent of noninlammatory lesions, such as open and closed comedones, as well as inlam- matory lesions such as papules, pustules, nodules, or cysts (open comedones are commonly referred to as blackheads and closed comedones as whiteheads; see Fig. 46.17). Examine the skin for hypertrophic scarring resulting from inlammatory lesions. Table 46.3 explains the acne classiication. Note oily skin and oily hair, which result from increased sebum production. Deter- mine remedies that have been used and the extent of success of those treatments. Assess the child’s or teen’s feelings about the disorder.

persists past the usual course of time for infantile or ado- lescent acne may be caused by endocrine abnormalities.

It may also occur in response to the use of certain types of drugs such as corticosteroids, androgens, phenytoin, and others. The usual presentation and nursing manage- ment of acne neonatorum and acne vulgaris is presented below.

Acne Neonatorum

Acne neonatorum occurs as a response to the presence of maternal androgens and affects about 20% of new- borns (O’Connor, McLaughlin, & Ham, 2008). It generally appears between 2 and 4 weeks of age and lasts up to 4 to 6 months, sometimes lasting until 2 to 3 years of age (O’Connor et al., 2008). Neonatal acne affects boys more often than girls and tends to be more severe in boys.

Usually no treatment is necessary, but in severe cases there is a risk of scarring, so a topical preparation may be prescribed.

Nursing Assessment

Note oily face or scalp. Examine the face (especially the cheeks), upper chest, and back for inlammatory papules and pustules. Document absence of fever.

Nursing Management

Instruct parents to avoid picking or squeezing the pimples;

to do so places the infant at risk for secondary bacterial infection and cellulitis. Teach parents to wash the affected areas daily with clear water. Avoid using fragranced soaps or lotions on the area with acne. Inform the parents that as the newborn’s hormones stabilize over time, the acne usually resolves without additional intervention.

Acne Vulgaris

Acne vulgaris affects 50% to 85% of adolescents between the ages of 12 and 16 years, and endogenous androgens play a role in its development (Burch & Morelli, 2011).

It occurs most frequently on the face, chest, and back.

Risk factors for the development of acne vulgaris include preadolescent or adolescent age, male gender (due to the presence of androgens), an oily complexion, Cush- ing syndrome, or another disease process resulting in increased androgen production.

Pathophysiology

The sebaceous gland produces sebum and is connected by a duct to the follicular canal that opens on the skin’s

to further irritate the condition. Adolescent girls taking isotretinoin (Accutane) who are sexually active must be on a pregnancy prevention program because the drug causes defects in fetal development (Fulton, 2012) (Box 46.2).

Adolescents interested in complementary medicine approaches may try topical use of a tea tree oil prepara- tion. Fewer adverse effects may occur with tea tree oil preparations than with benzoyl peroxide preparations, but local reactions may still occur (Leopold, 2010).

If the acne is severe, depression may occur as a result of body image disturbances. Provide emotional support to adolescents undergoing acne therapy. Refer teens for counseling if necessary.

Take Note!

Chocolate, skim milk, and French fries have not been proven to contribute to the incidence or severity of acne. However, advise teens to wash their hands after eat- ing greasy inger foods to avoid spreading additional oil to the surface of the face (Burch & Morelli, 2011).

Nursing Management

Avoid oil-based cosmetics and hair products, as their use may block pores, contributing to noninlammatory lesions. Look for cosmetic products labeled as noncom- edogenic. Headbands, helmets, and hats may exacer- bate the lesions by causing friction. Dryness and peel- ing may occur with acne treatment, so encourage the child to use a humectant moisturizer. Mild cleansing with soap and water twice daily is appropriate. Avoid excessive scrubbing and harsh chemical or alcohol- based cleansers. Avoid picking or squeezing the lesions.

Using a noncomedogenic sunscreen with an SPF of 30 or higher may reduce the risk of postinlammatory dis- coloration from acne lesions (Burns et al., 2009). Teach adolescents that the prescribed topical medications must be used daily and that it may take 4 to 6 weeks to see results. Avoid the use of over-the-counter prepara- tions because they are irritating and aggravate the dry- ing effect of prescription acne treatments. Instruct boys to shave gently and avoid using dull razors, so as not FIGURE 46.17 Acne vulgaris.

TABLE 46.3 CLASSIFICATION OF ACNE Classification Manifestations

Mild acne Primarily noninlammatory lesions (comedones)

Moderate acne Comedones plus inlammatory lesions such as papules or pustules (localized to face or back)

Severe acne Lesions similar to moderate acne, but more widespread, and/or presence of cysts or nodules.

Associated more frequently with scarring

BOX 46.2

DECREASING RISK OF FETAL EXPOSURE TO ISOTRETINOIN: iPLEDGE

• As of 2006, physicians, pharmacists, and patients are required to register in the iPLEDGE program before they prescribe, dispense, or receive isotret- inoin (Accutane).

• The iPLEDGE program is a central registry requir- ing monthly input as noted below in order to continue isotretinoin treatment.

• Monthly input includes the following:

• Females of childbearing age are using two forms of contraception.

• Pregnancy test results are negative.

• Isotretinoin users do not donate blood during treatment or for 1 month after completion of treatment.

• Additional links are provided on .

Adapted from U.S. Food and Drug Administration, Center for Drug Evaluation and Research. (2010). iPledge 2007 update. Retrieved July 7, 2012, from http://www.fda.gov/Drugs/DrugSafety/PostmarketDrug- SafetyInformationforPatientsandProviders/ucm094306.htm

Consider This

P

axton Herman, age 16, comes to the clinic with com- plaints of acne on his face and back. What assessment information should the nurse obtain? What education will be important for Paxton?

nature, children often attempt tasks they are not yet capable of or take risks that an adult would not, often resulting in a fall or other accident. Minor injuries include minor cuts and abrasions, as well as skin pen- etration of foreign bodies such as splinters or glass frag- ments. The break in the skin allows an entry point for bacteria, and the complication of cellulitis may occur.

Treatment is directed at cleaning the wound and pre- venting infection.

Nursing Assessment

Obtain the history from the child or caregiver to deter- mine whether dirt or a foreign object may be present in the wound. Inspect the wound, noting depth of injury, a foreign body, and bleeding.

Nursing Management

Cleanse the wound with mild soap and water or with an antibacterial cleanser. Wet gauze helps to scrub away ine and large sand particles. Remove pieces of loose skin with sterile scissors, foreign particles with sterile for- ceps, and road tar with petrolatum. Small abrasions and minor, well-approximated cuts may be left open to the air. Apply a small amount of antibacterial ointment and cover large abrasions with a loose dressing. Change the dressing 12 hours later and redress after cleaning the wound. Leave it open to air after 24 hours have passed from the time of injury.

Calendula preparations are presumed to be safe for topical use and may speed wound healing. Chamo- mile may help to dry a weeping wound, and allergic reactions to the herb are rare (Ehrlich, 2010). Assess the wound daily for signs of infection, which include purulence, warmth, edema, increasing pain, and erythema that extends past the margin of the cut or abrasion.

Burns

Burns are a common preventable mechanism of injury among children and adolescents. Young children are at highest risk for burns and the mortality rate from burns is highest in children younger than 6 years of age (Bergen, Chen, Warner, & Fingerhut, 2008). Speciically, burns are the third-leading cause of death from unintentional injury in children between 1 and 4 years of age (Ber- gen et al., 2008). Most pediatric burn-related injuries do not result in death, but injuries from burns often cause extreme pain and extensive burns can result in serious disigurement. Children younger than 10 years of age are at highest risk of scald and contact burns (acciden- tal touching or intentional child abuse) and from burns

INJURIES

Children, by their inquisitive natures, developmental immaturity, and skin’s properties, are prone to experi- ence a variety of skin injuries. Pressure ulcers are most likely to occur in hospitalized or otherwise immobile children. Typical healthy, active children are likely to suf- fer cuts, abrasions, foreign body penetration, burns and other thermal injuries, bites, and stings.

Pressure Ulcers

Skin breakdown involves changes in intact skin, which may range from blanchable erythema to deep pressure ulcers. The term “pressure ulcer” refers to damage to the skin resulting in skin loss and development of a crater that may range from mild to deep. The incidence of pressure ulcers in critically ill children is 18% to 27% (Schindler et al., 2011). Pressure ulcers develop from a combination of fac- tors, including immobility or decreased activity, decreased sensory perception, increased moisture, impaired nutri- tional status, inadequate tissue perfusion, and the forces of friction and shear. Common sites of pressure ulcers in hospitalized children include the occiput and toes, while children who require wheelchairs for mobility have pres- sure ulcers in the sacral or hip area more frequently.

Nursing Assessment

Note history of immobility (chronic, related to a condi- tion such as paralysis) or lengthy hospitalization, par- ticularly in intensive care. Inspect the skin for areas of erythema or warmth. Note ulceration of the skin. Use the facility’s wound assessment scale to document the extent of the ulcer. Take a photo of the ulcer if possible.

Nursing Management

Position the child to alleviate pressure on the area of the ulcer. Use specialized beds or mattresses to prevent fur- ther pressure areas from developing. Perform prescribed wound care meticulously, noting the formation of granu- lation tissue as the ulcer begins to heal. Prevent pressure ulcers in the child who is hospitalized for long periods of time by turning the child frequently, assessing the entire surface of the child’s skin at least every shift, using pres- sure-alleviating beds and mattresses, and maintaining the child’s nutritional status.

Minor Injuries

Children suffer minor injuries very frequently. Because of their developmental immaturity and inquisitive

(Quilty, 2010). Supericial burns involve only epidermal injury and usually heal without scarring or other sequelae within 4 to 5 days. In partial-thickness burns, injury occurs not only to the epidermis but also to portions of the dermis. These burns usually heal within about 2 weeks and carry a minimal risk of scar formation. Deep partial-thickness burns take longer to heal, may scar, and result in changes in nail and hair appearance as well as sebaceous gland function in the affected area. They may require surgical intervention. Full-thickness burns result in signiicant tissue damage as they extend through the epidermis, dermis, and hypodermis. Extensive scarring results, as hair follicles and sweat glands are destroyed.

Full-thickness burns require a signiicant time to heal. If underlying tendons and/or bone are involved, the burn may be termed fourth degree. Contractures and limited function may occur as a complication of full-thickness burns. Skin grafting is usually necessary. Full or partially circumferential burns may result in ischemia from loss of blood low related to progressive swelling of the area.

Pathophysiology

Burned tissue begins to coagulate after the injury, and direct coagulation and microvascular reactions in the adjacent dermis may extend the burn. The blood vessels demonstrate increased capillary permeability, resulting in vasodilatation. This leads to increased hydrostatic pressure in the capillaries, causing water, electrolytes, and protein to leak out of the vascula- ture and result in signiicant edema. Edema forms very rapidly in the irst 18 hours after the burn, peaking at around 48 hours. Capillary permeability then returns to normal between 48 and 72 hours after the burn and the lymphatics can reabsorb the edema luid. Diuresis occurs, ridding the body of the excess luid. Fluid loss from burned skin occurs at an amount that is 5 to 10 times greater than that from undamaged skin, and this luid loss continues until the damaged surface is healed or grafted.

Initially, the severely burned child experiences a decrease in cardiac output, with a subsequent hyper- metabolic response during which cardiac output increases dramatically. During this heightened meta- bolic state, the child is at risk for insulin resistance and increased protein catabolism. Children who are burned during an indoor or chemical ire are at an increased risk of respiratory injury. Children who have aspirated hot liquids are particularly at risk for airway- altering edema.

Therapeutic Management

Therapeutic management of burns focuses on luid resuscitation, wound care, prevention of infection, and related to ire (Quilty, 2010). Children 10-to-18 years of

age often suffer scald burns when cooking or ire-related burns due to lack of judgment based on developmental level (Quilty, 2010). Carbon monoxide poisoning often occurs in conjunction with burns as a result of smoke inhalation, and infants and children are at greater risk for carbon monoxide poisoning than adults. See Healthy People 2020.

H E A LT H Y P E O P L E 2020

Objective Nursing Significance Reduce residential

ire deaths. Increase functioning residential smoke alarms.

• Question all families about smoke detectors and if they are working.

• Provide families with resources related to ire prevention.

Healthy People Objectives based on data from http://www .healthypeople.gov.

Great advances have been made in the care of chil- dren with serious burns. As a result of improved burn care, children who in the past would have died as a result of burns over large body surface areas have a much greater chance of survival (Quilty, 2010).

Conventional wisdom is that children with severe burns should be transferred to a specialized burn unit.

The Committee on Trauma of the American College of Surgeons has developed the following criteria for referral of burned persons to a burn unit:

• Partial thickness burns greater than 10% of total body surface area

• Burns that involve the face

• Burns that involve the hands and feet, genitalia, perineum, or major joints

• Electrical burns, including lightning injury

• Chemical burns

• Inhalation injury

• Burn injury in children who have preexisting condi- tions that might affect their care

• Persons with burns and traumatic injuries

• Persons who will require special social, emotional, or long-term rehabilitative care

• Burned children in a hospital without qualiied per- sonnel or equipment for the care of children (Gamelli, 2007)

The old terms used to describe the depth of burns as irst, second, and third degree have been replaced by contemporary terminology. Burns are now classiied according to the extent of injury and the terminology used to describe each type includes supericial, par- tial thickness, deep partial thickness, and full thickness

burned child. Inspect the child’s skin, noting erythema, blistering, weeping, or eschar (charred skin).

Classify the burn according to its severity. Superi- cial burns are painful, red, dry, and possibly edematous (Fig. 46.18). Partial-thickness and deep partial-thickness burns are very painful and edematous and have a wet appearance or blisters (Fig. 46.19). Full-thickness burns may be very painful or numb or pain-free in some areas.

They appear red, edematous, leathery, dry, or waxy and may display peeling or charred skin (Fig. 46.20). Note whether the burn is circumferential (encircling a body part) or partially circumferential.

Take Note!

Due to overlying blistering, it is difficult to accurately distinguish between partial- and full-thickness burns.

In addition, in the case of third-degree burns, it is difficult to estimate burn depth during the initial evaluation.

Laboratory and Diagnostic Tests

In the child with more extensive burns, electrolytes and complete blood count are used to measure luid and electrolyte balance and to determine the possibility of infection, respectively. If wound infection is suspected, culture of the drainage will determine the particular bac- teria. Nutritional indices such as albumin, transferrin, carotene, retinol, copper, cholesterol, calcium, thiamine, ribolavin, pyridoxine, and iron may be evaluated when restoration of function. Burn infections are treated with

antibiotics speciic to the causative organism. If inva- sive burn damage occurs, surgery may be necessary.

Nursing Assessment

For a full description of the assessment phase of the nursing process, refer to page 1674. Upon arrival, evalu- ate the child with burns to determine if he or she will require intensive management. Remove any smoldering clothing. Obtain a brief history of the burn circumstances while you are assessing the child and providing care.

Health History

If the burn is severe or there is a potential for respira- tory compromise, obtain a brief history while simulta- neously evaluating the child and providing emergency care. If the burn does not appear to pose an immedi- ate life-threatening risk, obtain an in-depth history. Elicit a description of how the burn occurred, noting date, time, and cause. Determine if smoke inhalation or an associated fall may have occurred. Document treatment that the parent or caregiver has provided to the child’s burn so far. Note the child’s recent health status, current medications, recent or chronic illness, and immunization status, in particular noting the date of the most recent tetanus vaccination.

Determine whether the history being given sounds consistent with the type of burn injury that has occurred.

Inquire about what caused the burn and if the event was witnessed by anyone. Spatter-type burns resulting from the child pulling a source of hot luid onto himself or herself usually yield a nonuniform, asymmetric dis- tribution of injury. In contrast, intentional scald injuries usually yield a uniform “stocking” or “glove” distribution when the child’s extremity is held under very hot water as punishment (Giardino & Giardino, 2012). It is impor- tant for the nurse to pick up on clues in the health his- tory that may indicate that the burn is a result of child abuse, rather than an accident (Box 46.3). Children are also burned by curling irons, gasoline, ireworks, room heaters, ovens, and ranges. Obtain a detailed history about the circumstances surrounding these types of burns. Ask the parent what the home hot water heater temperature is.

Physical Examination

Emergency examination of the burned child consists of a primary survey followed by a secondary survey. The primary survey includes evaluation of the child’s airway, breathing, and circulation. The secondary survey focuses on evaluation of the burns and other injuries. Box 46.4 gives information about emergency assessment of the

BOX 46.3

SIGNS OF CHILD ABUSE–INDUCED BURNS

• Inconsistent history given when caregivers are inter- viewed separately

• Delay in seeking treatment by caregiver

• Uniform appearance of the burn, with clear delinea- tion of burned and nonburned area (as with a hot object applied to the skin)

• In the case of a scald-induced burn, lack of spatter- ing of water but evidence of so-called “porcelain- contact sparing,” where the portion of the child’s skin that was in contact with the tub or sink is not burned (commonly seen with a forced immersion in extremely hot water used as punishment)

• Flexor-sparing burns or burns that involve the dor- sum of the hand

• A stocking/glove pattern on the hands or feet (cir- cumferential ring appearing around the extremity, resulting from a caregiver forcefully holding the child under extremely hot water)

Adapted from Giardino, A. P., & Giardino, E. R. (2012). Physical child abuse clinical presentation. Retrieved July 7, 2012, from http://

emedicine. medscape.com/article/915664-overview