SECTION J: INTEGUMENTARY DISORDERS

COMMON/DISORDER SYNONYMS

• Contact dermatitis

• Seborrheic dermatitis

• Atopic dermatitis (AD)

ICD-9-CM CODES

• 692.0 Contact dermatitis and other eczema due to detergents

• 692.1 Contact dermatitis and other eczema due to oils and greases

• 692.2 Contact dermatitis and other eczema due to solvents

• 692.3 Contact dermatitis and other eczema due to drugs and medicines in contact with skin

• 692.4 Contact dermatitis and other eczema due to other chemical products

• 692.5 Contact dermatitis and other eczema due to food in contact with skin

• 692.6 Contact dermatitis and other eczema due to plants [except food]

• 692.7 Contact dermatitis and other eczema due to solar radiation

• 692.8 Contact dermatitis and other eczema due to other specified agents

• 692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander

• 692.89 Contact dermatitis and other eczema due to other specified agents

• 692.9 Contact dermatitis and other eczema, unspecified cause

ICD-10-CM CODE

• L20–L30 Dermatitis and eczema

PREFERRED PRACTICE PATTERN¹

• 7B: Impaired Integumentary Integrity Associated with Superficial Skin Involvement²

KEY FEATURES

Description

• Dermatitis is an inflammation of the skin.

• Dermatitis is a common condition that usually is not life threatening or contagious.

• It embraces a range of ailments that in most cases are characterized by red, itchy skin.

• Common types of dermatitis include

  • Contact dermatitis: Inflammation that occurs when substances touching the skin cause irritation or an allergic reaction.

  • AD or eczema: Chronic, relapsing, and inflammatory condition that results in itchy, inflamed, irritated skin.

    • These diseases often have an inherited tendency to develop alongside other allergic conditions such as asthma and hay fever.

  • Seborrheic dermatitis: Common skin disorder occurring in areas rich in sebaceous glands such as the scalp, ears, eyebrows, and chest, causing scaly, itchy red skin, and stubborn dandruff.

Essentials of Diagnosis

• Diagnosis is generally based on medical history and examination of the skin.

• Contact dermatitis: Diagnosis is based on medical history, the appearance of the skin, and a history of exposure to irritants or allergens.

• Seborrheic dermatitis: Diagnosis is based on history, appearance of the skin, physical, and skin biopsy.

• AD (eczema): Diagnosis is based on history and appearance of the skin.

• Skin lesion biopsies or skin cultures may be used to rule out other causes.

General Considerations

• Individuals in certain outdoor and manufacturing occupations are at higher risk for exposure to allergens and irritants that may cause dermatitis.

• Treatment is similar for most types of skin irritation and inflammation.

• Individuals often have an inherited tendency to develop other allergic conditions such as asthma and hay fever.

Demographics

• Dermatitis occurs in about 3% to 5% of the general population and affects all races as well as males and females equally.

• Contact dermatitis accounts for 90% of occupational skin disorders.

CLINICAL FINDINGS

Functional Implications

• Inability to tolerate stress; cold, dry air; or allergens without rash, itching, and dry skin

• Limitation of the use of some modalities

Possible Contributing Causes

• Skin lesions

• Circulation impairment

• Edema

• The following make symptoms worse:

  • Allergies to pollen, mold, dust mites, or animals

  • Colds or the flu

  • Diet

  • Contact with rough materials

  • Dry skin

  • Exposure to environmental irritants

  • Exposure to water

  • Feeling too hot or too cold

  • Fragrances or dyes added to skin lotions or soaps

  • Stress

• Contact dermatitis: Results from either repeated contact with irritants or contact with allergy-producing substances such as poison ivy, poison oak, flowers, herbs, fruits, and vegetables

Differential Diagnosis

• Dermatophytid

• Fungal infection

• Impetigo

• Pompholyx

• Psoriasis

• Scabies

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Scraping of the lesion and examination under the microscope

• Skin biopsy

• Skin patch tests

• Immunological testing

• Elevated total immunoglobulin (IgE) denotes an underlying allergy

FINDINGS AND INTERPRETATION

• Skin biopsy (when eczema does not respond to treatment)

• Skin patch tests: May be used to isolate the allergens causing the skin reaction

TREATMENT

Medication

• Corticosteroid creams or ointments³

• Calcineurin inhibitors (Tacrolimus and Pimecrolimus)³

• Coal tar³

• Antihistamines and steroids

• Oral or injected corticosteroids³

• Immunomodulators

• Antibiotics

• Tricyclic antidepressants

• Wet dressings and soothing anti-itch (antipruritic) or drying lotions may be recommended to reduce other symptoms

• Other treatments

  • Phototherapy

  • Wrap therapy, emollient oils during bathing, and wrapping affected areas after bathing

IMPAIRMENTS

• Skin integrity

• Circulation

• Pain

• Sensation

• Gait

• Joint ROM

• Muscle strength

• Functional mobility

• Self-care

• Home management

TESTS AND MEASURES

• Integumentary integrity tests

  • Pigmentation

  • Shape and size of skin involvement

  • Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection

  • Skin temperature

  • Tissue mobility, turgor, texture

• Circulation tests

  • Capillary refill, palpation of pulses

• Volume and girth measurement for edema and effusion

• Pain: Subjective report, visual analog pain (VAS) scale, or verbal report

• Gait

• Sensation

• Joint ROM

• Strength

• Functional mobility

INTERVENTION

• Not typically treated by PT, but PT should be able to recognize the condition and check the skin before and after application of modalities

• Depending on the extent of condition and secondary impairments, the following may apply

  • Dressings (e.g., wound coverings)

  • Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)

  • Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)

  • Hydrotherapy

  • Phototherapy (e.g., ultraviolet)

  • Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments)

  • Orthotic: Protective and supportive devices

  • Electrical muscle stimulation

  • Transcutaneous electrical nerve stimulation (TENS)

  • Functional training

  • ADL/IADL training

FUNCTIONAL GOALS

• PT goals would be consistent with the movement-related problems that occur secondary to the condition.

• Goals related to the condition could include the following:

  • Ability to perform physical tasks is increased.

  • Awareness and use of community resources are improved.

  • Risk of recurrence of condition is reduced.

  • Risk of secondary impairments is reduced.

  • Self-management of symptoms is improved.

  • Pain is decreased.

  • Sense of well-being is improved.

  • Soft tissue swelling, inflammation, or restriction is reduced.

  • Tolerance to positions and activities is increased.

  • Ability to recognize and initiate treatment of a recurrence is improved through increased self-management of symptoms.

  • Deformities are prevented.

  • Wound and soft tissue healing is enhanced.

  • Complications of soft tissue and circulatory disorders are decreased.

PROGNOSIS

• Generalized hypersensitivity reaction (anaphylaxis and angioedema) in hypersensitive individuals is potentially fatal and can occur upon exposure to an allergen.

• Contact dermatitis usually clears up without complications within 2 or 3 weeks but may return if the substance or material that caused it cannot be identified or avoided.

• Seborrheic dermatitis and AD are chronic conditions that are likely to recur after treatment.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Atopic dermatitis (AD)

• Atopic eczema

• Infantile eczema

• Nummular eczema

ICD-9-CM CODES

• 692.0 Contact dermatitis and other eczema due to detergents

• 692.1 Contact dermatitis and other eczema due to oils and greases

• 692.2 Contact dermatitis and other eczema due to solvents

• 692.3 Contact dermatitis and other eczema due to drugs and medicines in contact with skin

• 692.4 Contact dermatitis and other eczema due to other chemical products

• 692.5 Contact dermatitis and other eczema due to food in contact with skin

• 692.6 Contact dermatitis and other eczema due to plants [except food]

• 692.7 Contact dermatitis and other eczema due to solar radiation

• 692.8 Contact dermatitis and other eczema due to other specified agents

• 692.84 Contact dermatitis and other eczema due to animal (cat) (dog) dander

• 692.89 Contact dermatitis and other eczema due to other specified agents

• 692.9 Contact dermatitis and other eczema, unspecified cause

ICD-10-CM CODE

• L20–L30 Dermatitis and eczema

PREFERRED PRACTICE PATTERN¹

• 7B: Impaired Integumentary Integrity Secondary to Superficial Skin Involvement²

KEY FEATURES

Description

• Eczema is a common group of skin conditions

• Form of dermatitis

• A chronic, relapsing, and inflammatory skin condition

• Results in itchy, inflamed, irritated skin

• Often has an inherited tendency to develop other allergic conditions such as asthma and hay fever

Essentials of Diagnosis

• There are no laboratory tests used to diagnose eczema

• Clinical features of the disease are used for diagnosis, including the itchiness and the biology and spread (appearance) of the lesions

• Ruling out other skin diseases like contact dermatitis and seborrheic dermatitis is used to confirm the diagnosis

• Skin lesion biopsies or skin cultures may be used to rule out other causes

General Considerations

• There are three stages of the disease: Infantile, childhood, and adult

  • Often with latent phases in between

  • At each stage, the condition may be diagnosed as acute, ­subacute, or chronic

• Intrinsic

  • Nonallergic with xerosis and occurrence at a younger age

• Extrinsic

  • Generally associated with a medical history (personal or hereditary) of respiratory allergy

Demographics

• Eczema is the most common skin problem for which people seek medical treatment

• Affects about 10% of the U.S. population

CLINICAL FINDINGS

Functional Implications

• Inability to tolerate stress; cold, dry air; allergens without rash, itching, and dry skin

• Limitation of the use of some modalities

Possible Contributing Causes

• Skin lesions

• Celiac disease

• Gluten sensitivity

• Circulation impairment

• Pain

• Edema

• The following can make symptoms worse

  • Allergies to pollen, mold, dust mites, or animals

  • Colds or the flu

  • Diet

  • Contact with rough materials

  • Dry skin

  • Exposure to environmental irritants

  • Exposure to water

  • Feeling too hot or too cold

  • Fragrances or dyes added to skin lotions or soaps

  • Stress

Differential Diagnosis

• Chronic dermatoses

• Measles

• Pityriasis rosea

• Psoriasis

• Scarlet fever

• Squamous cell carcinoma

• Tinea corporis

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Scraping of the lesion and examination under the microscope

• Skin biopsy (when eczema does not respond to treatment)

• Skin patch tests

• Immunological testing

• Elevated total hemoglobin (IgE)

• There are no laboratory tests used to diagnose eczema

FINDINGS AND INTERPRETATION

• Elevated total hemoglobin (IgE) denotes an underlying allergy

TREATMENT

Medication

• Corticosteroid creams or ointments³

• Calcineurin inhibitors (Tacrolimus and Pimecrolimus)³

• Coal tar³

• Antihistamines and steroids

• Oral or injected corticosteroids³

• Immunomodulators

• Antibiotics

• Tricyclic antidepressants

• Other treatments

  • Phototherapy

  • Wrap therapy

    • Emollient oils during bathing and wrapping affected areas after bathing

IMPAIRMENTS

• Skin integrity

• Circulation

• Pain

• Sensation

• Joint ROM

• Muscle strength

• Functional mobility

• Self-care

• Home management

TESTS AND MEASURES

• Integumentary integrity

  • Pigmentation

  • Shape and size of skin involvement

  • Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection

  • Skin temperature

  • Tissue mobility: Turgor, texture

• Circulation

  • Capillary refill, palpation of pulses

• Volume and girth measurement for edema and effusion

• Pain: Subjective report, visual analog pain (VAS) scale, or verbal report

• Sensation

• Joint ROM

• Strength and muscle endurance

• Functional mobility

• Orthotic: Protective and supportive devices

INTERVENTION

• Not typically treated by PT, but PT should be able to recognize the condition and check the skin before and after application of modalities

• Depending on the extent of the condition and secondary impairments, the following may apply:

  • Dressings (e.g., wound coverings)

  • Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)

  • Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)

  • Hydrotherapy

  • Phototherapy (e.g., ultraviolet)

  • Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments)

  • Orthotic: Protective and supportive devices

  • Electrical muscle stimulation

  • Transcutaneous electrical nerve stimulation (TENS)

  • Functional training

  • ADL/IADL training

FUNCTIONAL GOALS

• PT goals would be consistent with the movement-related problems that occur secondary to the condition.

• Goals related to the condition could include the following:

  • Ability to perform physical tasks is increased.

  • Awareness and use of community resources are improved.

  • Risk of recurrence of the condition is reduced.

  • Risk of secondary impairments is reduced.

  • Self-management of symptoms is improved.

  • Pain is decreased.

  • Soft tissue swelling, inflammation, or restriction is reduced.

  • Tolerance to positions and activities is increased.

  • Ability to recognize and initiate treatment of a recurrence is improved through increased self-management of symptoms.

  • Deformities are prevented..

  • Wound and soft tissue healing is enhanced.

  • Complications of soft tissue and circulatory disorders are decreased.

PROGNOSIS

• Chronic condition, but is controllable with treatment.

• With childhood onset, it often resolves in the teens.

• In adults, it is often long term and reoccurring.

• Flare-ups are most likely in the winter when there is dry, cold air.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Superficial pyoderma

• Streptococcal impetigo

• Impetigo contagiosa

ICD-9-CM CODE

• 041.01 Streptococcus infection in conditions classified elsewhere and of unspecified site, Streptococcus, group A

ICD-10-CM CODE

• B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere

PREFERRED PRACTICE PATTERN¹

• 7B: Impaired Integumentary Integrity Secondary to Superficial Skin Involvement

KEY FEATURES

Description

• Streptococcus pyogenes (group A Streptococcus) is responsible for infections in the skin

• Group A infections

  • Cellulitis and erysipelas

  • Impetigo

  • Scarlet fever

  • Severe strep infections

• Highly infectious skin rash, spreads rapidly

• It occurs most often in tropical climates or during the summer months in nontropical climates

• With this infection, the patient is usually afebrile and has no pain

• Lesions are most often on the face and extremities and may become a mild but chronic illness if untreated

• Most common in children, particularly those in unhealthy living conditions

• In adults, it may follow other skin disorders or a recent upper respiratory infection, such as a cold or other virus

• Preceding a streptococcal respiratory infection

Essentials of Diagnosis

• Diagnosis is usually made by considering medical history and signs and symptoms, including the distinctive sores.

• A culture may be used to confirm the diagnosis or to rule out another cause.

General Considerations

• Highly contagious and can be spread through close contact or sharing items.

• Scratching can spread the sores to other parts of the body.

• It can be difficult to distinguish clinically between skin infection caused by streptococci and other bacteria such as Staphylococcus

Demographics

• Highest prevalence in children 2 to 5 years of age

• Can be seen in adults, but is more prevalent in children

CLINICAL FINDINGS

Functional Implications

• Very contagious, limiting contact and social status

Possible Contributing Causes

• Skin lesions

• Circulation impairment

• Pain

• Edema

• Contact with someone with the skin infection

Differential Diagnosis

• Erysipelas

• Follicular mucinosis

• Folliculitis

• Herpetic impetigo

• Insect bites

• Lymphadenitis

• Lymphadenopathy

• Pemphigus foliaceus

• Pemphigus vulgaris

• Pseudomonas folliculitis

• Staphylococcus aureus infection

• Tinea

MEANS OF CONFIRMATION OR DIAGNOSIS

Laboratory Tests

• Culture of the skin or lesion

• Blood cultures: Leukocytosis tests

FINDINGS AND INTERPRETATION

• Streptozyme screening test to detect antibodies

• Antistreptolysin O titer (ASO), increased levels are seen

TREATMENT

Medication

• Parental antibiotics

  • Penicillin

  • Cefazolin

IMPAIRMENTS

• Skin integrity

• Circulation

• Pain

• Sensation

• Joint ROM

• Muscle strength

• Functional mobility

• Self-care

• Home management

TESTS AND MEASURES

• Integumentary integrity

  • Pigmentation

  • Shape and size of skin involvement

  • Presence of rash, fungi, blistering, ecchymosis, hair growth, signs of infection

  • Skin temperature

  • Tissue mobility: Turgor, texture

• Circulation

  • Capillary refill, palpation of pulses

• Volume and girth measurement for edema and effusion

• Pain: Subjective report, Visual Analog Scale (VAS) or verbal report

• Sensation

• Joint ROM

• Strength and muscle endurance

• Functional mobility

• Orthotic: Protective and supportive devices

INTERVENTION

• Not typically treated by PT, but PT should be able to recognize the condition and understand that the condition is highly contagious.

• Precautions should be taken to prevent the spread of the disease to healthcare professionals and other patients.

• Depending on the extent of the condition and secondary impairments, the following may apply:

  • Dressings (e.g., wound coverings)

  • Topical agents (e.g., ointments, moisturizers, creams, cleansers, sealants)

  • Athermal modalities (e.g., pulsed ultrasound, pulsed electromagnetic fields)

  • Hydrotherapy

  • Phototherapy (e.g., ultraviolet)

  • Compression therapies (e.g., vasopneumatic compression devices, compression bandaging, compression garments

  • Orthotic: Protective and supportive devices

  • Electrical muscle stimulation

  • Transcutaneous electrical nerve stimulation (TENS)

  • Functional training

  • ADL/IADL training

FUNCTIONAL GOALS

• PT goals would be consistent with the movement-related problems that occur secondary to the condition.

• Goals related to the condition could include the following:

  • Ability to perform physical tasks is increased.

  • Awareness and use of community resources are improved.

  • Risk of recurrence of the condition is reduced.

  • Risk of secondary impairments is reduced.

  • Self-management of symptoms is improved.

  • Sense of well-being is improved.

  • Soft tissue swelling, inflammation, or restriction is reduced.

  • Tolerance to positions and activities is increased.

  • Ability to recognize and initiate treatment of a recurrence is improved through increased self-management of symptoms.

  • Wound and soft tissue healing is enhanced

  • Complications of soft tissue and circulatory disorders are decreased.

  • Pain is decreased.

PROGNOSIS

• With treatment, usually heals within 2 to 3 weeks.

• Lesions usually resolve after 7 to 10 days.

• Cellulitis, lymphangitis, and suppurative lymphadenitis occur in about 10% of patients.

REFERENCE

ADDITIONAL REFERENCES