Inlammatory skin conditions may be either acute or chronic. Acute hypersensitivity reactions may cause dia- per dermatitis, contact dermatitis, erythema multiforme, and urticaria. Atopic dermatitis is a chronic hypersensitiv- ity disorder. Seborrhea and psoriasis are chronic inlam- matory skin disorders that do not occur as a result of hypersensitivity.
Diaper Dermatitis
Dermatitis refers to an inlammatory reaction of the skin. Diaper dermatitis refers to an inlammatory reac- tion of the skin in the area covered by a diaper. It is a nonimmunologic response to a skin irritant that results in skin cell hydration disturbance. Prolonged exposure to urine and feces may lead to skin breakdown (Fig. 46.10).
Diaper wearing increases the skin’s pH, activating fecal enzymes that further contribute to skin maceration.
EVIDENCE-BASED PRACTICE 46.1 EFFECTIVENESS OF VARIOUS SYSTEMIC ANTIFUNGAL DRUGS IN TREATING TINEA CAPITIS IN CHILDREN
STUDY
Tinea capitis (fungal infection of the scalp) affects a large number of children. Traditionally, a 6- to 8-week course of oral griseofulvin was required to eradicate the infection.
The authors evaluated 21 randomized controlled studies that included a total of 1,812 participants. The studies determined the effectiveness of terbinaine, itraconazole, luconazole, and griseofulvin at eradicating dermatophytes in tinea capitis.
Findings
The authors found that shorter courses (2 to 4 weeks) with terbinaine, itraconazole, or luconazole were as effective
at treating tinea capitis as the traditional longer course with griseofulvin.
Nursing Implications
Shorter courses of treatment will improve compliance, although the drugs may be more expensive. Educate families that the shorter course will be simpler to complete and result in fewer side effects and decreased need for laboratory evaluation of their child. Assist families with any paperwork needed to encourage insurance coverage for these drugs if needed.
Adapted from González, U., Seaton, T., Bergus, G., Jacobson, J., & Martínez-Monzón, C. (2007). Systemic antifungal therapy for tinea capitis in children. The Cochrane Library 2007, 4. Indianapolis, IN: John Wiley & Sons.
FIGURE 46.10 Diaper dermatitis.
The sensation of itchiness comes irst, and then the rash becomes apparent. The scratching causes the rash to appear. Sweating causes atopic dermatitis to worsen, as does excessively humid or dry environments.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1674. Assessment indings pertinent to atopic dermatitis are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Wiggling or scratching
• Dry skin
• Scratch marks noticed by the parents
• Disrupted sleep
• Irritability
Explore the child’s current and past medical history for risk factors such as:
• Family history of atopic dermatitis, allergic rhinitis, or asthma
• Child’s history of asthma or allergic rhinitis
• Food or environmental allergies
Determine the onset of the rash; its location, pro- gression, and severity; and response to treatments used so far. Note medications used to treat the rash, as well as other medications the child may be taking.
Physical Examination
Physical examination consists of inspection and observa- tion and auscultation.
INSPECTION AND OBSERVATION
Observe whether the infant is wiggling or the child is actively scratching. Carefully inspect the skin. Document dry, scaly, or laky skin, as well as hypertrophy and licheniication (Fig. 46.11). If lesions are present they may be dry lesions or weepy papules or vesicles (luid- illed lesions). In children younger than 2 years old, the rash is most likely to occur on the face, scalp, wrists, and extensor surfaces of the arms or legs. In older chil- dren it may occur anywhere on the skin, but is found more commonly on the lexor areas. Note erythema or warmth, which may indicate associated secondary bac- terial infection. Document areas of hyperpigmentation or hypopigmentation, which may have resulted from a prior exacerbation of atopic dermatitis or its treatment.
Inspect the eyes, nose, and throat for symptoms of allergic rhinitis.
• Once a rash has occurred, follow all the prevention tips above and add the following:
• Allow the infant or child to go diaperless for a period of time each day to allow the rash to heal.
• Blow-dry the diaper area/rash area with the dryer set on the warm (not hot) setting for 3 to 5 minutes.
Take Note!
Discourage parents from using any type of baby powder to avoid the risk of aspiration; inhalation of talcum-containing powders may result in pneumonitis (Garlich & Nelson, 2011).
Atopic Dermatitis
Atopic dermatitis (eczema) is one of the disorders in the atopy family (along with asthma and allergic rhini- tis). Atopic dermatitis affects 10% to 20% of U.S. children and up to 90% of children with atopic dermatitis develop symptoms before 5 years of age (Tofte, 2008). About half of the children who have atopic dermatitis will also develop allergic rhinitis and/or asthma (Marino & Fine, 2009; Ogles, 2008).
The chronic itching associated with atopic derma- titis causes a great deal of psychological distress. The child’s self-image may be affected, particularly if the rash is extensive. Dificulty sleeping may occur because of the itching. The child is irritable and has dificulty concen- trating, and family life is disrupted. Parents’ stress related to the child’s condition may increase the child’s anxiety and lead to an increase in itching and scratching. The child may outgrow atopic dermatitis, its severity may decrease as the child approaches adulthood, or the child may continue to have dificulties into the adult years.
Bacterial superinfection may occur as a complication.
Therapeutic management includes good skin hydra- tion, application of topical corticosteroids or immune modulators, oral antihistamines for sedative effects, and antibiotics if secondary infection occurs.
Pathophysiology
Atopic dermatitis is a chronic disorder characterized by extreme itching and inlamed, reddened, and swollen skin. It has a relapsing and remitting nature. The skin reaction occurs in response to speciic allergens, usu- ally food (especially eggs, wheat, milk, and peanuts) or environmental triggers (e.g., molds, dust mites, and cat dander). Other factors, such as high or low ambient tem- peratures, perspiring, scratching, skin irritants, or stress, may contribute to lare-ups. When the child encounters a triggering antigen, antigen-presenting cells stimulate interleukins to begin the inlammatory process. The skin begins to feel pruritic and the child starts to scratch.
• Vaseline
• Crisco
Take Note!
Vaseline or generic petrolatum is an inexpensive, readily available moisturizer.
Apply moisturizer multiple times throughout the day. Avoid clothing made of synthetic fabrics or wool.
Avoid triggers known to exacerbate atopic dermatitis.
Taking evening primrose oil and other essential fatty acids as an oral supplement over a period of at least 6 weeks may produce an improvement in the atopic dermatitis (Senapati, Banerjee, & Gangopadhyay, 2008).
If not initially recommended by the physician or nurse practitioner, the parent should consult with him or her irst before starting these supplements. Headache and nausea are rare adverse effects of these supplements and, if they occur, are usually mild. Chamomile prepara- tions for topical use may also be effective and are gener- ally considered safe.
Maintaining Skin Integrity and Preventing Infection
Cut the child’s ingernails short and keep them clean.
Avoid tight clothing and heat. Use 100% cotton bed sheets and pajamas. In addition to keeping the child’s skin well moisturized, it is extremely important to pre- vent the child from scratching. Scratching causes the rash to appear and further scratching may lead to secondary infection. Antihistamines given at bedtime may sedate the child enough to allow him or her to sleep without awakening because of itching.
During the waking hours, behavior modiication may help to keep the child from scratching. Have the parent keep a diary for 1 week to determine the pattern of scratching. Help the parent to determine speciic strat- egies that may raise the child’s awareness of scratching.
A hand-held clicker or counter may help to identify the scratching episode for the child, thus raising awareness.
The use of diversion, imagination, and play may help to distract the child from scratching. The parent and child may create a game together that results in the child par- ticipating in a behavior rather than scratching. Pressing the skin or clenching the ist may replace scratching. It is important for the child to stay active to distract his or her mind from the itching. It is important for the parent to positively reinforce and reward the desired behaviors.
Contact Dermatitis
Contact dermatitis is a cell-mediated response to an antigenic substance exposure. The irst exposure is the sensitization phase. The antigen attaches to cells AUSCULTATION
Auscultate the lungs for wheezing (commonly found in the associated condition of asthma).
Laboratory and Diagnostic Tests
Serum immunoglobulin E (IgE) levels may be elevated in the child with atopic dermatitis. Skin prick allergy testing may determine the food or environmental allergen to which the child is sensitive.
Nursing Management
Nursing management of the child with atopic dermatitis focuses on promoting skin hydration, maintaining skin integrity, and preventing infection.
Promoting Skin Hydration
First and foremost, avoid hot water and any skin or hair product containing perfumes, dyes, or fragrance. Bathe the child twice daily in warm (not hot) water. Use a mild soap to clean only the dirty areas. Recommended mild soaps or cleansing agents include:
• Unscented Dove or Dove for sensitive skin
• Tone
• Caress
• Oil of Olay
• Cetaphil
• Aquanil
Slightly pat the child dry after the bath, but do not rub the skin with the towel. Leave the child moist. Apply prescribed topical ointments or creams to the affected area. Apply fragrance-free moisturizer over the pre- scribed topical medication and all over the child’s body.
Recommended moisturizers include:
• Eucerin, Moisturel, Curel (cream or lotion)
• Aquaphor
FIGURE 46.11 Atopic dermatitis rash is red, dry, and scaly.
Take Note!
Nickel dermatitis may occur from contact with jew- elry, eyeglasses, belts, or clothing snaps. Infants may display a small red circle with scaling at the site of contact with sleeper snaps.
Nursing Management
Contact dermatitis may be prevented by avoiding con- tact with the allergen. When the condition does occur, nursing management focuses on relieving the discomfort associated with the rash. Administer topical or systemic corticosteroids as prescribed and teach the family about use of the medications. Teaching Guidelines 46.2 gives more information about the treatment and prevention of contact dermatitis.
Teaching Guidelines 46.2
PREVENTION AND TREATMENT OF CONTACT DERMATITIS
Prevention
• Wear long sleeves and long pants on outings in the woods.
• Identify and remove offending plants in the yard by using a commercial weed or underbrush killer.
• Vinyl gloves (not rubber or latex) are an effective barrier.
• The plant’s oil residue may be on clothes, pets, gar- den and sports equipment, and toys; wash those well with soap and water.
• If contact occurs, wash vigorously with soap and water within 10 minutes of contact.
that migrate to regional lymph nodes and have contact with T lymphocytes, where recognition of antigen is developed. During the second phase, elicitation, con- tact with the antigen results in T-lymphocyte prolifera- tion and release of inlammatory mediators. An allergic response occurs within 24 to 48 hours after contact with the substance.
Contact dermatitis may occur as a result of allergy to nickel or cobalt found in clothing hardware and dyes, and chemicals found in many hygiene products and cosmetics.
One of the more common causes of contact dermatitis in children results from exposure to highly allergenic plants such as Toxicodendron radicans (poison ivy), Toxicoden- dron quercifolium (Eastern poison oak), Toxicodendron diversilobum (Western poison oak), and Toxicodendron vernix (poison sumac).
Direct or indirect contact with the plant’s oleoresin found in the leaves, stems, and roots results in an allergic reaction. Even contact with dormant plants or plants per- ceived to be dead may cause an allergic response. The rash is extremely pruritic and may last for 2 to 4 weeks;
lesions continue to appear during the illness. Contact dermatitis is not contagious and does not spread either to other parts of the affected child’s skin or to other people. Scratching does not spread the rash, but it may cause skin damage or secondary infection. Complica- tions of contact dermatitis include secondary bacterial skin infections and licheniication or hyperpigmentation, particularly in dark-skinned people.
Therapeutic management is directed toward man- agement of itching and the use of topical corticosteroids.
Moderate-potency topical glucocorticoid cream or oint- ment is used for mild to moderate contact dermatitis, and high-potency preparations are used for more severe cases. Some severe cases of contact dermatitis may require the use of systemic steroids.
Nursing Assessment
Elicit the health history, noting onset, description, loca- tion, and progression of the rash, which may be intensely pruritic and vesicular if caused by allergenic plant expo- sure (see Fig. 46.12). Rashes caused by other allergic exposure may be quite variable in their appearance and intensity of pruritus. Document treatment used thus far, and the child’s response to it. Examine the skin, not- ing rash that may vary from maculopapular in nature to an erythematous papulovesicular rash at the site of contact. Some lesions may be weeping; others may erupt and form a crust. The lesions are often distributed in an asymmetric linear pattern on exposed body parts if caused by allergenic plant exposure. If the child’s shirt came in contact with the plant and then the shirt was removed by pulling it over the head, there may be wide- spread lesions over both sides of the face. Lesions near the eyes often cause signiicant eyelid edema.
FIGURE 46.12 Note vesicular rash in linear formation charac- teristic of poison ivy.
vesicles, and target lesions over a period of days (hence the name multiforme) (Fig. 46.13).
Nursing Management
Discontinue the medication or food if it is identiied as the cause. Ensure that treatment for Mycoplasma is instituted if present. Encourage oral hydration. Adminis- ter analgesics and antihistamines as needed to promote comfort. If oral lesions are present, encourage soothing mouthwashes or use of topic oral anesthetics in the older child or teen. Oral lesions may be débrided with hydro- gen peroxide.
Urticaria
Urticaria, commonly called hives, is a type I hypersensi- tivity reaction caused by an immunologically mediated antigen–antibody response of histamine release from
• Zanfel and Tecnu Oak-N-Ivy Outdoor Skin Cleanser (both soap mixtures) may prevent rash if used to wash the skin soon after exposure.
• Ivy Block (an organoclay) is the only U.S. Food and Drug Administration–approved preventive treatment for contact dermatitis related to poison ivy, oak, or sumac. (Visit for web links that will pro- vide additional information.) It is applied to the skin before possible exposure.
Treatment
• Wash lesions daily with mild soap and water.
• Mildly débride crusted lesions.
• Tepid baths (colloidal oatmeal such as Aveeno) are helpful to decrease itching.
• Avoid hot baths or showers, as they aggravate itch- ing.
• Apply corticosteroid preparations topically as directed (if using high-potency preparations, do not cover with an occlusive dressing).
• Weeping lesions may be wrapped lightly; avoid occlusion.
• Burow or Domeboro solutions with a dressing applied twice daily for 20 minutes may help to dry weepy lesions.
• Over-the-counter preparations such as calamine lotion or Ivy Rest may reduce itching and help the lesions to dry.
• Do not use topical antihistamines, benzocaine, or neomycin because of the potential for sensitization.
Erythema Multiforme
Erythema multiforme, though uncommon in children, is an acute, self-limiting hypersensitivity reaction. It may occur in response to viral infections, such as adenovirus or Epstein-Barr virus; Mycoplasma pneumoniae infec- tion; or a drug (especially sulfa drugs, penicillins, or immunizations) or food reaction. Stevens-Johnson syn- drome is the most severe form of erythema multiforme and most often occurs in response to certain medica- tions or to Mycoplasma infection (Box 46.1). Therapeutic management of erythema multiforme is generally sup- portive because it resolves on its own.
Nursing Assessment
Note history of fever, malaise, and achiness (myalgia).
Determine onset and progression of rash, and presence of pruritus (itchiness) and burning. Document the child’s temperature upon assessment. Inspect the skin for lesions, which most commonly occur over the hands and feet and extensor surfaces of the extremities, with spread to the trunk. Lesions progress from erythema-
tous macules (lat reddened areas) to papules, plaques, FIGURE 46.13 Erythema multiforme.
BOX 46.1
STEVENS-JOHNSON SYNDROME
• 1- to 14-day history of fever, malaise, headache, generalized aching, emesis, and diarrhea
• Sudden onset of high fever with rash appearing
• Rash is characteristic of erythema multiforme with the addition of inlammatory bullae on at least two types of mucosa (lips, oral mucosa, bulbar conjunctivae, or anogenital region).
• Mortality rate of 10% (Marino & Fine, 2009), particularly when the genitourinary, gastrointestinal, and respiratory tracts are involved
• Treatment: hospitalization, isolation, luid and electrolyte support, treatment of secondary infection of the lesions
• Ophthalmologic consult to determine if corneal ulcer- ation, keratitis, uveitis, or panophthalmitis is present
Take Note!
In an emergency situation when airway and breathing are compromised, subcutaneous epinephrine followed by intravenous (IV) diphenhydramine and corticosteroids is necessary.
Seborrhea
Seborrhea is a chronic inlammatory dermatitis that may occur on the skin or scalp. In infants it occurs most often on the scalp and is commonly referred to as cradle cap.
Infants may also manifest seborrhea on the nose or eye- brows, behind the ears, or in the diaper area. It usually resolves over a period of weeks to months (Shelov &
Altman, 2009). Adolescents manifest seborrhea on the scalp (dandruff) and on the eyebrows and eyelashes, behind the ears, and between the shoulder blades.
It is thought that seborrhea is an inlammatory reac- tion to the fungus Pityrosporum ovale and is worsened by sebaceous involvement related to maternal hormones in the infant and androgens in the adolescent.
Therapeutic management includes treating the skin lesions with corticosteroid creams or lotions. Antidan- druff shampoos containing selenium sulide, ketocon- azole, or tar are used to treat the scalp.
Nursing Assessment
Elicit the health history, determining onset and progres- sion of skin and scalp changes. Note response to treat- ment used so far. In the infant, inspect the scalp and fore- head, behind the ears, and the neck, trunk, and diaper area for thick or laky greasy yellow scales (Fig. 46.15).
mast cells. Vasodilation and increased vascular perme- ability result, and erythema and wheals then occur. Urti- caria usually begins rapidly and may disappear in a few days or may take up to 6 to 8 weeks to resolve. The most common causes of this reaction are foods, drugs, animal stings, infections, environmental stimuli (e.g., heat, cold, sun, tight clothes), and stress. Therapeutic management focuses on identifying and removing the cause as well as providing antihistamines or steroids.
Nursing Assessment
Obtain a detailed history of new foods, medications, symptoms of a recent infection, changes in environment, or unusual stress. Inspect the skin, noting raised, edema- tous hives anywhere on the body or mucous membranes (Fig. 46.14). The hives are pruritic, blanch when pressed, and may migrate. Angioedema may also be present and is identiiable as subcutaneous edema and warmth, occur- ring most frequently on the extremities, face, or genitalia.
Carefully assess airway and breathing, as hypersensitivity reactions may affect respiratory status.
Nursing Management
Identify and remove the offending trigger. Discontinue antibiotics. Administer antihistamines, corticosteroids, and topical antipruritics as prescribed. Inform the child and family that the episode should resolve within a few days. If it lasts up to 6 weeks, the child should be reevaluated (Burns et al., 2009). Advise the family to obtain a medical alert bracelet for the child if the reac- tion is severe.
FIGURE 46.14 Ill-appearing child with urticaria. (Used with permis- sion from Fleisher GR, Ludwig S, Baskin MN. Atlas of pediatric emergency medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2004:88).
FIGURE 46.15 Severe cradle cap (yellow, greasy-appearing plaques).