Basal Cell Carcinoma

Change in basal cells; no maturation or normal keratinization;

continuing division of basal cells and formation of enlarging mass;

related to excessive sun exposure, genetic skin type, x-ray radiation,

scars, and some types of nevi

Nodular and ulcerative:

Fig. 24-2

Superficial

Surgical excision, chemosurgery, electrosurgery, cryosurgery; 90% cure rate; slow-growing tumor that invades local tissue; metastasis rare; 5-FU and imiquimod (Aldara) for superficial lesions, photodynamic therapy for small lesions

Squamous Cell Carcinoma

Frequent occurrence on previously damaged skin (e.g., from sun, radiation, scar);

malignant tumor of squamous cell of epidermis;

invasion of dermis, surrounding skin

Superficial

Early

Late

Fig. 24-3

Surgical excision, cryosurgery, radiation therapy, chemotherapy, electrodesiccation and curettage;

untreated lesion possibly metastasizes to regional lymph nodes and distant organs; high cure rate with early detection and treatment

Malignant Melanoma

Neoplastic growth of melanocytes anywhere on skin, eyes, or mucous membranes; classification according to major histologic mode of spread; potential invasion and widespread metastases

Irregular color, surface, and border; variegation of color

including red, white, blue, black, gray, brown; flat or elevated;

eroded or ulcerated; often under 1 cm in size; most common sites in males are back, then chest; in females are legs, then back (see Fig. 24-4)

Surgical excision and possible sentinel lymph node evaluation depending on the depth;

correlation of survival rate with depth of invasion;

poor prognosis unless diagnosed and treated early; spreading by local extension, regional lymphatic vessels, and bloodstream;

adjuvant therapy after surgery may be indicated if lesion greater than 1.5 mm in depth

Cellulitis

Inflammation of subcutaneous tissues; possibly secondary complication or primary infection; often following break in skin; Staphylococcus aureus and streptococci usual causative agents; deep inflammation of subcutaneous tissue from enzymes produced by bacteria

Hot, tender, erythematous, and edematous area with diffuse borders;

chills, malaise and fever (Fig. 24-7)

Moist heat, immobilization and elevation, systemic antibiotic therapy,

hospitalization if severe; progression to gangrene possible if untreated

Candidiasis

Caused by Candida albicans; also known as moniliasis; 50% of adults symptom-free carriers;

presenting in warm, moist areas such as groin area, oral mucosa, and submammary folds; HIV infection, chemotherapy, radiation,

and organ transplantation related to depression of cell-mediated immunity that allows yeast to become pathogenic

Mouth:

Vagina:

Skin:

Fig. 24-11

Microscopic examination and culture; azole antifungals (e.g., fluconazole, ketoconazole) or other specific medication such as vaginal suppository or oral lozenge;

 sexual abstinence or use of condom; skin hygiene to keep area clean and dry;

powder is effective on nonmucosal surfaces of skin to prevent recurrence

Tinea Corporis

Various dermatophytes, commonly referred to as ringworm

Typical annular (ringlike) scaly appearance, well-defined margins; erythematous

Cool compresses; topical antifungals for isolated patches;

creams or solutions of miconazole (Monistat),

ketoconazole, clotrimazole (Lotrimin), and butenafine (Mentax)

Tinea Pedis

Various dermatophytes, commonly referred to as athlete's foot

Interdigital scaling and maceration;

scaly plantar surfaces sometimes with erythema and blistering;

may be pruritic; possibly painful

Topical antifungal cream, gel, solution, spray, or powder

Tinea Unguium (Onychomycosis)

Various dermatophytes; incidence increases with age

Only few nails on one hand may be affected;

toenails more commonly affected; scaliness under distal nail plate; brittle, thickened,

broken/crumbling nails with yellowish discoloration (see Fig. 24-12)

Oral antifungal (terbinafine [Lamisil], itraconazole [Sporanox]);

topical antifungal cream or solution (minimal effectiveness) if unable to tolerate systemic treatment;

thinning of toenails if needed; nail avulsion (removal) is an option

Allergic Contact Dermatitis

Manifestation of delayed hypersensitivity, absorbed agent acting as antigen,

 sensitization after one or more exposures,

appearance of lesions 2-7 days after contact with allergen

Red papules and plaques; sharply circumscribed with occasional vesicles; usually pruritic;

area of dermatitis frequently takes shape of causative agent (e.g., metal allergy and band-like dermatitis on ring finger) (see Fig. 14-11)

circumscribed with occasional vesicles; usually pruritic; area of dermatitis frequently takes shape of causative agent

(e.g., metal allergy and band-like dermatitis on ring finger) (see Fig. 14-11)

Topical or oral corticosteroids, antihistamines; skin lubrication;

elimination of contact allergen; avoidance of irritating affected area; systemic corticosteroids if sensitivity severe

Psoriasis

Autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells; family predisposition; usually develops before age 40

Sharply demarcated silvery scaling plaques on reddish colored skin commonly on the scalp, elbows, knees;

palms, soles, and fingernails; itching, burning, pain; localized or general, intermittent or continuous; symptoms vary in intensity from mild to severe (see Fig. 24-14)

Goal is to reduce inflammation and suppress rapid turnover of epidermal cells; topical treatments: corticosteroids, tar, calcipotriene, anthralin;

intralesional injection of corticosteroids for chronic plaques; systemic treatments; natural or artificial UVB;

PUVA (UVA with topical or systemic photosensitizer (psoralen); antimetabolite (methotrexate), retinoid (acitretin), immunosuppressant (cyclosporine), biologic therapy (adalimumab [Humira], alefacept [Amevive], etanercept [Enbrel], infliximab [Remicade], ustekinumab [Stelara]) for moderate to severe plaque disease; no cure, but control is possible

HYPERNATREMIA (Na⁺ >145 mEq/L [mmol/L])

causes

IV fluids: hypertonic NaCl, excessive isotonic NaCl, IV sodium bicarbonate

Hypertonic tube feedings without water supplements

Near-drowning in salt water

Diabetes insipidus, primary hyperaldosteronism, Cushing syndrome, uncontrolled diabetes mellitus

hypernatremia with decreased ECF volume

Restlessness, agitation, twitching, seizures, coma

Intense thirst; dry, swollen tongue, sticky mucous membranes

Postural hypotension, ↓ CVP, weight loss

Weakness, lethargy

hypernatremia with normal increased ECF volume

Restlessness, agitation, twitching, seizures, coma

Intense thirst, flushed skin

Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP

HYPONATREMIA (Na⁺ <135 mEq/L [mmol/L])

GI losses: diarrhea, vomiting, fistulas, NG suction

Renal losses: diuretics, adrenal insufficiency, Na⁺ wasting renal disease

Skin losses: burns, wound drainage

SIADH, heart failure, primary hypoaldosteronism

hyponatremia with decreased ECF volume

Irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma

Dry mucous membranes

Postural hypotension, ↓ CVP, ↓ jugular venous filling, tachycardia, thready pulse

Cold and clammy skin

hyponatremia with normal/increased ECF volume

Headache, apathy, confusion, muscle spasms, seizures, coma

Nausea, vomiting, diarrhea, abdominal cramps

Weight gain, ↑ BP, ↑ CVP

HYPERKALEMIA (K⁺ >5.0 mEq/L [mmol/L])

intake issues:Excessive or rapid parenteral administration

Potassium-containing drugs (e.g., potassium-penicillin)

Potassium-containing salt substitute

shift of K out of cell

Acidosis

Tissue catabolism (e.g., fever, sepsis, burns)

Crush injury

Tumor lysis syndrome

failure to eliminate K

Renal disease

Potassium-sparing diuretics

Adrenal insufficiency

ACE inhibitors

clinical manifestations

Irritability

Anxiety

Abdominal cramping, diarrhea

Weakness of lower extremities

Paresthesias

Irregular pulse

Cardiac arrest if hyperkalemia sudden or severe

HYPOKALEMIA (K⁺ <3.5 mEq/L [mmol/L])

K losses: GI losses: diarrhea, vomiting, fistulas, NG suction

Renal losses: diuretics, hyperaldosteronism, magnesium depletion

Skin losses: diaphoresis

Dialysis

shift of K into cells

Increased insulin (e.g., IV dextrose load)

Alkalosis

Tissue repair

↑ Epinephrine (e.g., stress)

lack of K intake

Starvation

Diet low in potassium

Failure to include potassium in parenteral fluids if NPO

manifestations

Fatigue

Muscle weakness, leg cramps

Nausea, vomiting, paralytic ileus

Soft, flabby muscles

Paresthesias, decreased reflexes

Weak, irregular pulse

Polyuria

Hyperglycemia

HYPERCALCEMIA (Ca²⁺ >10.2 mg/dL [2.55 mmol/L])

increased total calcium 

Multiple myeloma

Malignancies with bone metastasis

Prolonged immobilization

Hyperparathyroidism

Vitamin D overdose

Thiazide diuretics

Milk-alkali syndrome

increased ionized calcium

acidosis

manifestations

Lethargy, weakness

Depressed reflexes

Decreased memory

Confusion, personality changes, psychosis

Anorexia, nausea, vomiting

Bone pain, fractures

Polyuria, dehydration

Nephrolithiasis

Stupor, coma

HYPOCALCEMIA (Ca²⁺ <8.6 mg/dL [2.15 mmol/L])

decreased total calcium 

Chronic kidney disease

Elevated phosphorus

Primary hypoparathyroidism

Vitamin D deficiency

Magnesium deficiency

Acute pancreatitis

Loop diuretics (e.g., furosemide [Lasix])

Chronic alcoholism

Diarrhea

↓ Serum albumin (patient is usually asymptomatic due to normal ionized calcium level)

decreased ionized calcium

Alkalosis

Excess administration of citrated blood

manifestations

Easy fatigability

Depression, anxiety, confusion

Numbness and tingling in extremities and region around mouth

Hyperreflexia, muscle cramps

Chvostek's sign

Trousseau's sign

Laryngeal spasm

Tetany, seizures

hypomagnesium

Diarrhea

Vomiting

Chronic alcoholism

Impaired GI absorption

Malabsorption syndrome

Prolonged malnutrition

Large urine output

NG suction

Poorly controlled diabetes mellitus

Hyperaldosteronism

HYPERMAGNESEMIA

Renal failure (especially if patient is given magnesium products)

Excessive administration of magnesium for treatment of eclampsia

Adrenal insufficiency