Background
Managing Skin Trauma
Hygiene
Patient Education
Direction of Examination
Skin Eruptions and Rashes
Surface Sensitivity
Itching
Infection
Etiology
Antibiotics
Wet Dressings
COMMENTARY
Trauma-associated Skin Disorders
Contusions
Abrasions
Blisters
Troublesome Callosities
Corns
Surfer's Nodes
Lacerations
Nummular Eczema
Frostbite
Burns and Scalds
Sunburn
Bites and Stings
Acute Traumatic Gangrene
Trauma of the Nails and Fingertips
Disorders Often Related to Skin Trauma in Athletics or Physical Labor
Tetanus
Erysipelas
Stomatitis
Sensitivity Eczema (Atopic or Allergic Derma-
titis)
Stasic Eczema
Decubitus Ulcers
Verrucae
Plantar Warts
Keloid
Effects of Certain Skin Residues
PERSPIRATION RELATED DISORDERS
The Role of General Hygiene
Hyperhidrosis
Bromhidrosis
Miliaria
Hidradenitis
Pruritus Ani
A few dermatologic conditions are seen in posttraumatic care as primary disorders, many as secondary states. Infections, rashes, torn nails, and various eruptions are often encountered. In this final paper of this series, we limit our concern to the management of skin problems especially related to skin trauma associated with the musculoskeletal injuries. Descriptions of some types of skin trauma such as bites, burns, infestations, and toxic eruptions are brief or omitted because they do not fall within the general scope of this paper. Several types of ski8n infection have their highest incidence in a warm moist locker room environment.
A papule is a rounded or oval hard elevation of the skin, varying in size from a pinhead to a pea. Early, it has a feeling similar to that of fine shot beneath the skin. It is usually reddish when fully developed. Warts and pimples are examples. Papules are the characteristic eruption in the first stage of variola.
Vesicles
A vesicle is a slight circumscribed elevation of the skin containing a clear or opaque fluid or serum. It usually follows the papular stage of an eruption and is found in allergic contact dermatitis, herpes, and the second stage of smallpox.
Pustules
A pustule is an elevation of the skin containing pus, about the size of a vesicle. It often follows the vesicular stage in an eruption. A pustule is produced by suppuration of serum contained in a vesicle, giving it a smoky or cloudy appearance. It is found in impetigo, boils, acne, deep fungus infections, and the third stage of smallpox.
Herpes
A herpic eruption consists of a series of minute vesicles situated upon a red hard base attended by a burning or smarting pain. When occurring on the lips, it is called herpes labialis. When occurring on the nose, it is called herpes nasi; around the ribs, herpes zoster (shingles); and in the genital area, it is known as herpes progenitalis.
Blebs (bullae)
These blister-like eruptions are large elevations of the skin containing a clear or opaque fluid. The large vesicles vary in size from a pea to a goose egg.
Wheals
Wheals (pomphi) are circumscribed areas of cutaneous or subcutaneous edema of a temporary character. They are common in allergic reactions from drugs, insect bites, or an environmental irritant such as sunlight, pressure, heat or cold.
Macules
A macule is an area of discoloration without elevation or depression. It may be any color, shape, or size. Macules that occur in the eruptive fevers are red and slightly elevated above the skin level due to hyperemia. They measure 2--4 mm in diameter, may appear upon any skin surface, and may be distributed sparsely or densely. They are characteristic of measles, freckles, and flat moles.
Nodules
Nodules are solid, usually elevated, lesions of the skin of deep origin which vary in size from a pea to a cherry. A nodule is essentially a small tumor.
Petechiae and
ecchymoses
Cutaneous or subcutaneous hemorrhages may occur as small spots called petechiae or in large areas called ecchymoses. They occur as an eruptive sign in cerebrospinal meningitis and dengue and are also commonly found in scurvy, purpura, and hemophilia. They are produced from a lack of motor function being expressed in the minute muscular fibers forming the blood vessel walls, permitting them to relax, fibers to separate, and blood to ooze between the minute fibers.
Erythema and
exanthem
This is an evenly distributed redness of the skin due to a cutaneous hyperemia such as seen in erysipelas and the exanthemata. The eruption presents an uneven redness.
Telangiectasia
This condition is the result of dilated superficial blood vessels. Most lesions are of unknown cause, but they may be associated with certain systemic disorders (eg, iatrogenic).
Abscesses
An abscess is a collection of pus circumscribed by a pyogenic membrane and located in the subcutaneous tissue. Abscesses of the skin usually develop suddenly and are small in size except when on the scalp. They form round swellings that are hard or firm at first, but soon become soft and fluctuate under pressure. When opened, they give off a thick pus. They are most common on the scalp with eczema, on the face and neck with acne, and on the extremities with scabies. They may disappear by absorption or open of their own accord. There is but slight pain and discomfort in cutaneous abscesses. They differ from a boil in that they are not raised and pointed, do not have a central core, and are less firm. They differ from carbuncles by the absence of constitutional symptoms, brawny infiltration, intense inflammation, and cubiform mode of opening. An abscess differs from syphilitic gumma in that a gumma has no pain, is dark red in color, grows slowly, is usually multiple, and when cut, it gives off little bloody fluid.
Furuncles
Boils may be classed as a form of cutaneous eruption. They are circumscribed areas of suppuration in the subcutaneous tissue and usually involve one or more sebaceous glands. At the onset, they are red; but as soon as suppuration has occurred, they become yellowish-white.
Tumors
Tumors are atypical growths of various size, shape, and consistency located in the deep layers of the skin.
Table 2. Types of Secondary Skin Eruptions
Cicatrix
This is a scar or a similar effect of nature to heal skin damage by means of connective tissue. It occurs only where the papillary layer of the skin is destroyed.
Lichenification
This term refers to a thickening of the skin associated with accentuated skin markings.
Crust (Scab)
A scab is a dried secretion or exudate (eg, blood, pus, serum) upon the skin which follows vesicles, pustules, weeping eczema, other inflammatory and infectious diseases, cuts and abrasions.
Scale
This is a circumscribed, light in color, thin layer of epidermal cells that has become detached and is about to shed. Scales are common in psoriasis, superficial fungus infections, and chronic dermatitis.
Excoriation
Excoriation refers to a scratch mark or a superficial denudation of the skin.
Fissure
A fissure is a crack in the skin extending down to the corium and usually located in the folds of the skin over the joints.
Erosion
The term erosion refers to a loss of epidermal tissue such as seen in herpes infection.
Ulcer
An ulcer is a deep erosion where epidermal tissue and at least part of the dermal tissue is lost. Ulcers often result from acute bacterial infection, physical trauma, peripheral vascular disease, and chronic fungal infections.
A history or appearance of a rash is often the first clue of a primary dermatologic disease, of a serious systemic disease, of a common infectious process, or of a serious drug reaction. The word "rash" is a vague term. When a rash is a part of the clinical profile, questions should probe onset, first location and changes, initial appearance and changes, relationship to clothing or environmental exposure, relationship to known allergies, family history, personal habits, relationship to cosmetics, prescribed drugs, and proprietary medications. Associated symptoms such as tenderness, deep pain, fever, malaise, joint complaints, itching, oozing, or the formation of hives, blisters, and blebs should be questioned.
Surface Sensitivity
Tenderness is often the result of inflammation and edema. The lack of pain or its diminished perception is also an important clue. Both diseases of cutaneous nerve proper and diseases involving neurovascular bundles in the skin can produce anesthesia. In evaluating the pathophysiology involved, remember that the peripheral paths are involved in the transmission of pain, touch, hot, cold, baragnosis, vibration, and itching.
Itching
Pruritus is a disagreeable cutaneous dysesthesia that demands attempted relief through arbitrary or compulsive scratching. Itching is a type of pain associated only with the skin caused by such a variety of conditions that its presence has little diagnostic value in itself. When severe and continual for weeks on end, it can preoccupy the mind and torment the soul. Both depression and anxiety states may be a contributing cause or an effect. When pruritus is a complaint, note if the itching disturbs sleep, if scratching can be controlled, or what situations appear to aggravate or ease the itching such as certain clothing, events, temperatures, soaps, environments, etc. Very hot showers remove skin oils, encourage microcracks, and enhance itching.
Pruritus can be related to a systemic disease, a primary skin disease, or neither. It may be generalized with or without skin eruptions, or it may be localized with or without evident pathology. Intense itching is associated with poison ivy and oak, and a large variety of allergic, inflammatory, and idiopathic skin conditions. It is also a major feature of obstructive hepatobiliary disease.
Isolated pruritus associated without evident local pathology is characteristic of dry skin, a parasitic infestation, a fungus or mold, a contact sensitivity, a systemic condition, or of psychogenic origin. A severe generalized pruritus may be the result of disease and (1) occur without skin lesions from dry or dirty skin, contact sensitivity, allergies to foods or drugs or soaps, psychogenic factors, metabolic disorders, and malignant conditions; or (2) occur with skin eruption such as with urticaria, contact dermatitis, atopic dermatitis, neurodermatitis, dermatitis herpetiformis, scabies, and lichen planus.
As vasodilation commonly aggravates itching, a patient may report that heat increases (eg, hot shower) and cold decreases pruritus. This effect of vasodilation, however, may be hidden by the sedation effect of warmth.
In mild cases, applications of sesame seed oil are beneficial. It readily absorbs and has mild antibacterial and antifungal properties. Cortisone ointments and lotions are antipruritic but no better than sesame seed oil.
Infection
Before infection takes place: (1) The invading organisms must be pathogenic. (2) They must be present in large numbers. (3) They must possess a sufficient degree of virulence. (4) They must enter the body by a path or avenue adapted to their requirements. (5) They must find an environment suitable to their nutritional requirements. (6) There must be inadequate tissue resistance.
Etiology.
The presence of pathogens in the body does not constitute infection, nor does it indicate the existence of an infectious disease. Various types of bacteria are found in many organs of the body in perfectly healthy people. For example, colon bacilli are found in the intestines; streptococci, staphylococci, and pneumococci are commonly found in the mouth and throat without the existence of symptoms. Pernicious viruses are frequently demonstrated in the stools of the healthy.
Pathogens multiply where they find a suitable environment for growth and development. When there is interference with nerve transmission or circulation, there is disturbed metabolism in the tissue supplied. This reduces cellular activity and permits the accumulation of metabolic waste, furnishing an adequate environment for the propagation.
Bacteria assimilate, reproduce, and excrete. Exotoxin is discharged as excreta from the organism into the culture medium. When the bacterium dies and undergoes disintegration, it gives off poisonous endotoxin. These toxins are injurious to the host and become an etiologic factor in disease, not because their purpose is to cause disease, but because inadequate tissue resistance has permitted the bacteria to establish a domicile in the body.
Antibiotics
Antibiotics frequently reduce the severity and effects of many bacterial disease processes, yet they have distinct disadvantages and many limitations. As life saving as they may be in some cases, they are far from the panacea once claimed. Their widespread use tends to develop new resistant strains of bacteria, to destroy normal intestinal bacteria, and to encourage inactive intestinal fungi to become active. Antibiotics have no effect on viral illnesses such as hepatitis, influenza, or the common cold. They commonly result in side effects, producing symptoms of dizziness, rash, and iatrogenic allergies. Indiscriminate use frequently creates a sensitivity that prohibits the person from later use that might be beneficial.
Wet Dressings
Moist dressings are commonly used in aid stations. They are helpful in maintaining constant lesion drainage, cleansing skin injuries, maintaining a constant site temperature, softening and removing crusts, opening blisters without lancing, and allowing medications to penetrate deeper into infected areas. Room-temperature wet packs tend to produce a soothing anesthetic effect.
Application. Cleanse irritated skin by washing with a cleansing spray, but avoid vigorous applications of green soap. The typical dressing is made from cheesecloth as absorbent cotton hardens when wet, dries quickly, and becomes an irritant. An antibacterial jelly should be applied to the skin near the area being treated to prevent maceration of allied tissues. The dressing is dipped in distilled water or a medicinal solution, wrung, and then applied to the skin when still wet but not dripping. Any tap water used in a wet dressing should be first boiled or be distilled. Necessary ointments should be applied abundantly.
The wet dressing is overlaid with plastic sheeting to retard evaporation and then covered with a light elastic bandage for security. For an ambulatory patient, warm clothing should be worn over the bandage to prevent chilling. The dressing should never be allowed to become dry. Trying to add water to the ends of the pack will never suffice. The dressing must be completely reapplied periodically. If topical medications are used, the site must be carefully watched the first 24 hours to monitor reaction. This may require a wet pack without a secured protective covering.
Contraindications. Wet dressings are contraindicated in any condition where circulation is seriously impaired or where the skin becomes drawn or begins to crack. They are usually contraindicated in the elderly because of potential circulatory insufficiences. Classic adhesive tape should never be applied near a moist lesion, area of infection, or suppurative lesion as later removal will insult the lesion. The newer tapes are a blessing. Care must be taken when the dressing is secured that no "tourniquet" effect results. A penicillin ointment should never be applied unless it is known beforehand that the patient in nonallergic. Tar preparations (eg, ichthtol, pragmatar) are contraindicated in skin areas exhibiting heavy hair growth as they tend to produce pustules.
Commentary
If not given quality treatment initially, even minor bruises can cause considerable problems (eg, bleeding, swelling, a portal for infection). Unmanaged infections unrelated to primary dermatitis frequently cause a dermatitis because of secondary infection (eg, ringworm infection progressing into dermatitis).