Notes
Definition
- Contact dermatitis is an inflammatory reaction of the skin to physical, chemical, or biologic agents.
- It may be of the primary irritant type, or it may be allergic.
- The epidermis is damaged by repeated physical and chemical irritation.
- Common causes of irritant dermatitis are soaps, detergents, scouring compounds, and industrial chemicals.
- Predisposing factors include extremes of heat and cold, frequent use of soap and water, and a preexisting skin disease.
Other types of dermatitis
- Contact dermatitis is caused by an allergen or an irritating substance. Irritant contact dermatitis accounts for 80% of all cases of contact dermatitis.
- Atopic dermatitis is very common worldwide and increasing in prevalence. It affects males and females equally and accounts for 10%–20% of all referrals to dermatologists. Individuals who live in urban areas with low humidity are more prone to develop this type of dermatitis.
- Dermatitis herpetiformis appears as a result of a gastrointestinal condition, known as celiac disease.
- Seborrheic dermatitis is more common in infants and in individuals between 30 and 70 years old. It appears to affect primarily men and it occurs in 85% of people suffering from AIDS.
- Nummular dermatitis is a less common type of dermatitis, with no known cause and which tends to appear more frequently in middle-age people.
- Stasis dermatitis is an inflammation on the lower legs which is caused by buildups of blood and fluid and it is more likely to occur in people with varicose.
- Perioral dermatitis is somewhat similar to rosacea; it appears more often in women between 20 and 60 years old.
- Infective dermatitis is dermatitis secondary to a skin infection
Clinical Manifestations
- Eruptions when the causative agent contacts the skin.
- Itching, burning, and erythema are followed by edema, papules, vesicles, and oozing or weeping as first reactions.
- In the subacute phase, the vesicular changes are less marked and alternate with crusting, drying, fissuring, and peeling.
- If repeated reactions occur or the patient continually scratches the skin, lichenification and pigmentation occur; secondary bacterial invasion may follow.
Medical Management
- Soothe and heal the involved skin and protect it from further damage.
- Determine the distribution pattern of the reaction to differentiate between allergic type and irritant type.
- Identify and remove the offending irritant; soap is generally not used on site until healed.
- Use bland, unmedicated lotions for small patches of erythema; apply cool wet dressings over small areas of vesicular dermatitis; a corticosteroid ointment may be used.
- Medicated baths at room temperature are prescribed for larger areas of dermatitis.
- In severe, widespread conditions, a short course of systemic steroids may be prescribed.
Nursing Management
Instruct patient to adhere to the following instructions for at least 4 months, until the skin appears completely healed:
- Find out the cause of the problem.
- Avoid contact with the irritants, or wash skin thoroughly immediately after exposure to the irritants.
- Avoid heat, soap, and rubbing the skin.
- Choose bath soaps, detergents, and cosmetics that do not contain fragrance; avoid using a fabric softener dryer sheet.
- Avoid topical medications, lotions, or ointments, except when prescribed.
- Make sure gloves are cotton-lined; do not wear for more than 15 to 20 minutes at a time.
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Exam
Nursing Care Plan
Nursing Diagnosis
Impaired Skin Integrity
Common Related Factors
- Contact with irritants or allergens
Defining Characteristics
- Inflammation
- Dry, flaky skin
- Erosions, excoriations, fissures
- Pruritus, pain, blisters
Expected Outcomes
- Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin.
Nursing Interventions
Ongoing Assessment
- Assess skin, noting color, moisture, texture, temperature; note erythema, edema, tenderness.
- Rationale: Specific types of dermatitis may have characteristic patterns of skin changes and lesions.
- Assess the skin systematically. Look for areas of irritant and allergic contact.
- Rationale: Flexural areas (elbows, neck, posterior knees) are common areas affected in atopic dermatitis.
- Assess skin for lesions. Note presence of excoriations, erosions, fissures, or thickening.
- Rationale: Open skin lesions increase the patient’s risk for infection. Thickening occurs in response to chronic scratching (lichenification).
- Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.
- Rationale: Patients may develop dermatitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to dermatitis.
- Identify signs of itching and scratching.
- Rationale: The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification
- Identify any scarring that may have occurred.
- Rationale: Long-term scarring may result in body image disturbances.
Therapeutic Actions
- Encourage the patient to adopt skin care routines to decrease skin irritation:
- Rationale: One of the first steps in the management of dermatitis is promoting healthy skin and healing of skin lesions.
- Bathe or shower using lukewarm water and mild soap or nonsoap cleansers.
- Rationale: Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
- After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk drying.
- Rationale: Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
- Apply topical lubricants immediately after bathing.
- Rationale: Lubrication with fragrance-free creams or ointments serves as a barrier to prevent further drying of the skin through evaporation. Moisturizing is the cornerstone of treatment. Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea. Lotions are lighter and less emollient than creams. If more moisturizing is required than a lotion can provide, a cream is recommended. These include Keri cream, Cetaphil cream, Eucerin cream, and Neutrogena Norwegian formula. Ointments are the most emollient. Vaseline Pyre Petroleum Jelly or Aquaphor Natural Healing Ointment may be beneficial.
- Apply topical steroid creams or ointments.
- Rationale: These drugs reduce inflammation and promote healing of the skin. The patient may begin using over-the-counter hydrocortisone preparations. If these are not effective, the physician may include prescription corticosteroids for topical use. Usual application is twice daily, thinly and sparingly. Do not use with an occlusive dressing, because this potentiates the action and systemic absorption of the steroid. Usual duration of use of topical steroids is up to 14 days in adults.
- Apply topical immunomodulators (TIMs): Tacrolimus (Protopic) & Pimecrolimus (Elidel)
- Rationale: Tacrolimus (Protopic) has recently been approved for the treatment of atopic dermatitis. TIMs alter the reactivity of cell-surface immunological responsiveness to relieve redness and itching. In 2005, the Food and Drug Administration advised a potential cancer risk with long-term use of pimecrolimus and tacrolimus based on animal studies.
- Prepare the patient for phototherapy or photochemotherapy.
- Rationale: This treatment modality uses ultraviolet A or B light waves to promote healing of the skin. The addition of psoralen, which increases the skin’s sensitivity to light, may benefit patients who do not respond to phototherapy alone.
- Encourage the patient to avoid aggravating factors.
- Rationale: Some change in lifestyle may be indicated to reduce triggers.
Nursing Diagnosis
Disturbed Body Image
Defining Characteristics
- Visible skin lesions
Common Related Factor
- Verbalizes feelings about change in body appearance
- Verbalizes negative feelings about skin condition
- Fear of rejection or reactions of others
Common Expected Outcome
- Patient verbalizes feeling about lesions and continues daily activities and social interactions.
Nursing Interventions
Ongoing Assessment
- Assess the patient’s perception of changed appearance.
- Rationale: The nurse needs to understand the patient’s attitude about visible changes in the appearance of the skin that occur with dermatitis.
- Assess the patient’s behavior related to appearance.
- Rationale: Patients with body image issues may try to hide or camouflage their lesions. Their socialization may decrease based on anxiety or fear about the reactions of others.
Therapeutic Interventions
- Assist the patient in articulating responses to questions from others regarding lesions and contagion.
- Rationale: Patients may need guidance in determining what to say to people who comment about the appearance of their skin. Dermatitis is not a contagious skin condition.
- Allow patients to verbalize feelings regarding their skin condition.
- Rationale: Through talking, the patient can be guided to separate physical appearance from feelings of personal worth.
- Assist patients in identifying ways to enhance their appearance.
- Rationale: Clothing, cosmetics, and accessories may direct attention away from the skin lesions. The patient may need help in selecting methods that do not aggravate the skin lesions.
Nursing Diagnosis
Risk for Infection
Risk Factors
- Impaired skin integrity
- Severe inflammation
- Excoriation
Desired Outcome
- Patient remains free of secondary infection.
Nursing Interventions
Ongoing Assessment
- Assess skin for severity of skin integrity compromise.
- Rationale: The skin is the body’s first line of defense against infection. Disruption of the integrity of skin increases the patient’s risk of developing an infection or of scarring.
- Assess for signs of infection.
- Rationale: Patients with dermatitis are at highest risk for developing skin infections caused byStaphylococcus aureus. Purulent drainage from skin lesions indicates infection. With severe infections, the patient may have an elevated temperature.
Therapeutic Interventions
- Apply topical antibiotics.
- Rationale: Topical antibiotics may be used to treat infections that occur with dermatitis.
- Administer oral antibiotics.
- Rationale: Oral antibiotics may be more effective in treating infections on the skin.
- Encourage the patient to use appropriate hygiene methods.
- Rationale: Keeping the skin clean, dry, and well lubricated reduces skin trauma and risk of infection.
Nursing Diagnosis
Risk for Impaired Skin Integrity
Risk Factors
- Severe pruritus
- Scratches skin frequently
- Dry skin
Desired Outcome
- Patient reports increased comfort level and skin remains intact.
Nursing Interventions
Ongoing Assessment
- Assess severity of pruritus.
- Rationale: Patients with dermatitis may develop an itch-scratch cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itching. Many patients report the itching to be worse at night, thus disrupting their sleep.
- Assess skin for excoriations and lichenification.
- Rationale: Scratching and rubbing the skin in response to the itching increases the irritation of the skin. When papules are scratched, they may break open, causing excoriations that become crusty and infected. Over time, constant rubbing and scratching cause the skin to become thick and leathery (lichenification).
Therapeutic Interventions
- Encourage the patient to avoid triggering factors.
- Rationale: Contact with factors that stimulate histamine release will increase itching. Because irritants vary from one patient to another, each patient needs to determine substances and situations that aggravate the dermatitis.
- Maintain hydration of stratum corneum.
- Rationale: Application of lubricating creams and ointments serve as a barrier to water evaporation from the skin. Moist skin is less likely to experience pruritus.
- Use cool compresses on pruritic areas of the skin.
- Rationale: Cool, moist compresses help relieve pruritus and itching. Additionally, cool baths with colloidal oatmeal (e.g., Aveeno) can provide relief.
- Encourage the patient to keep fingernails trimmed short.
- Rationale: Long fingernails used for scratching are more likely to cause skin trauma and aggravate itching.
- Administer antihistamine drugs.
- Rationale: Antihistamines such as hydroxyzine will help relieve itching and promote comfort. These drugs can be taken at bedtime. Their sedative effect may also help promote sleep. During the daytime, nonsedating antihistamines may increase the efficacy of pruritus control. Loratadine is an over-the-counter medication.
- Apply topical antipruritic agents if indicated.
- Rationale: These may be used alone or combined with oral antihistamines. Over-the-counter products include Sarna lotion, Prax lotion, and Itch-X gel. Prescription Cetaphil with menthol may also help.
- Apply topical steroid creams if indicated.
- Rationale: Do not apply on the face. Use thinly and sparingly, up to a maximum of 14 days. Do not use with occlusive dressings.
- Administer oral steroids.
- Rationale: Short-term low-dose oral steroids may be ordered for severe cases. Oral steroids are not indicated for long-term use despite their efficacy
