Skin Disorders

Shaheen

Objectives
Explain the structure and function of the skin and identify the lesions that result from skin abnormalities. Describe in detail how skin trauma occurs, how it may be prevented, and how it may be managed. Identify bacterial skin infections that are potentially contagious Describe the correct hygiene practices to use to avoid fungal infections Identify potentially threatening viral infections Contrast allergic, thermal, and chemical reactions of the skin Identify infestations and insect bites and contrast them with other skin infections

Objective

Explain the structure and function of the skin and identify the lesions that result from skin abnormalities. Describe in detail how skin trauma occurs, how it may be prevented, and how it may be managed.

I. Skin Lesions Defined

A. Skin pigment - melanin 1. Variations may be due to anatomic, physiologic or pathophysiologic changes in skin blood flow 2. Normal skin appearance a. Altered by external and internal factors b. Cellulitis- Infectious inflammation of deep skin structures

B. Skin Trauma 1. Mechanical Forces that Cause Injury a. Friction b. Compression c. Shearing d. Stretching e. Scraping f.Tearing g. Avulsing h. Puncturing

Scenario
A basketball player wearing new shoes during a game sustains a blister on the back of his heel. How should this condition be managed during and after the game?

-If denuded, skin flap should be completely removed. -The area should be washed with soap, water, and antiseptic then covered with an occlusive dressing After the game a scond-skin dressing should be applied to the raw area

II. . Friction and Pressure Problems

A. Hyperkeratosis of the Hands and Feet 1. Etiology a. Friction and pressure over bony protuberances b. Painful when subcutaneous fat becomes inelastic 2. Prevention a. Cushioning devices; wearing 2 socks b. Lubricants to reduce friction, shaving calluses c. For calluses on hands, special gloves or protective gear

3. Sign and Symptoms a. Thickening, of horny layer of skin, ovular, elongated and brown b. Painful with pressure 4. Management a. Avoid emery boards and pumice as the increase in friction will stimulate skin to produce added callus b. Use moisturizer c. Pair off callus with scalpel d. Padding

B. Blisters 1. Etiology a. Result of a shearing force that produces a raised area that accumulates with fluid 2. Prevention a. Use of dust or powder or lubricant to reduce friction b. Tubular socks, 2 pairs of socks if feet are sensitive or perspire excessively c. Appropriate shoes that are broken in d. Padding and lubricants

3. Signs and Symptoms a. Hot spot, sharp burning sensation, painful b. Superficial area of skin raised with clear fluid

4. Management (intact blister) a. Leave intact for 24 hours b. Clean with antiseptic c. Cut small incision to drain fluid (large enough that it wont re-seal) d. Prevent refilling with a pressure pad e. Clean again with antiseptic f. Use doughnut to prevent irritation g. Monitor for infection, replace wet bandaging h. Debridement can be performed when tenderness is gone

5. Management (open/torn blister) a. Keep clean to avoid infection b. Keep skin in place and apply nonadhering sterile dressing and padding c. Monitor daily for infection

6. Management (denuded blister) a. If blister is torn 1/2 inch or more remove skin flap b. Clean and expose area, apply antiseptic with occlusive dressing c. Second skin can be applied to raw area

C. Soft Corns and Hard Corns 1. Etiology a. Caused by pressure of improperly fitting shoes and anatomic abnormalities b. Soft corns are the result of pressure and perspiration, also associated with exostosis

2. Signs and Symptoms a. Hard corns form on the tops of toes and tend to be painful and dry b. Soft corns result in thickening of skin, white and sometimes painful (between 4th and 5th toes)

3. Prevention a. Wear properly fitting shoes 4. Management a. Surgical removal if painful b. Padding; maintain clean dry feet; wear appropriate shoes

D. Excessive Perspiration (hyperhidrosis) 1. Etiology a.Syrup-like perspiration, high in sodium chloride b. Increases risk of other skin irritation c. Makes adherence of bandages difficulty 2. Management a. Use of astringent such as alcohol or an absorbent powder b. Aluminum chloride or electric current can be used to treat condition

Scenario
A heavy limbed shotputter complains of skin irritation in his groin region. The area appears red and macerated. Some of the tissue is cracked and there are oozing sores. How could this chafing have been prevented -Keep the skin dry and friction free -The athlete who is prone to this problem should wear loose cotton underwear -Males should wear a supporter

E. Chafing of Skin 1. Etiology a. Occurs particularly in athletes that are obese or heavy limbed b. Result of friction and maceration of skin in climate of heat and moisture

2. Signs and Symptoms a. Separation of keratin from granular layer of skin b. Causes oozing wounds that crust and crack

3. Prevention a. Keep skin dry, clean, and friction free b. For the groin, soft, loose, cotton underwear is recommended 4. Management a. Clean area with soap and water and treat with medicated solution and hydrocortisone cream

F. Xerotic (Dry) Skin 1. Etiology a. Drying of skin due to exposure of cold, excessive bathing, decrease in humidity causing skin to lose water 2. Signs and Symptoms a. Dry skin w/ variable redness and scaling; itching 3. Management a. Prevent water loss and replace lost water b. Bathe in tepid water, use moisturizer c. If condition worsens, refer to physician

G. Ingrown Toenails 1. Etiology a. Generally occurs in great toe b. Nail grows laterally into skin c. Result of lateral pressure from shoes, poor nail trimming, and repeated trauma 2. Signs and Symptoms a. Pain and swelling b. Penetrated skin becomes inflamed and purulent with lateral nail fold swollen and irritated

3. Prevention a. Properly fitting shoes and socks are essential b. Weekly toenail trimming (cut straight across) c. Leave nail long enough to clear skin

4. Management a. Conservative management includes soaking the inflamed toe in warm water (20 minutes) b. Place cotton under edge of nail to clear from skin c. If chronic, remove wedge of nail and apply antiseptic compress until inflammation resides d. Physician may take more aggressive approach

Review Questions
1. Describe the skins anatomy and function 2. Contrast micro-organisms that are related to the skin 3. Relate the mechanical forces of friction, compression, shearing, stretching, scraping, tearing, avulsing, and puncturing to skin injuries. 4. List the steps to take in managing skin trauma

III. Wounds
A. Abrasions 1. Scraping of skin against rough surface (top surface of skin is worn away) 2. Increased probability of infection due to exposure of dirt and foreign material 3. Clean and debride

B. Punctures 1. Direct penetration of skin with pointed object 2. Must be referred to physician C. Lacerations 1. Object tears tissue, giving wound appearance of jagged edge (sometimes result of blunt trauma) 2. Presents environment susceptible to infection

D. Skin Incision 1. Smooth cut in skin - not jagged E. Skin Avulsion 1. Skin torn away from body (should be placed in moist gauze w/in a plastic bag that is then immersed in cold water) 2. Transport to hospital with athlete for possible reattachment

F. Skin Bruises 1. Result of blunt trauma; causes disruption of superficial blood vessels and results in black and blue discoloration 2. Treatment requires RICE to control hemorrhaging

Scenario
A baseball player slides into second base and sustains a serious slide burn on the left side. What are the major concerns with this type of injury and how should it be managed? Major concern is infection. Area should be cleaned with mild soap and water. Debrided with a brush. Covered with antibiotic ointment

G. Wound Management 1. All wounds must be assumed contaminated 2. Pay close attention to all universal precautions 3. Clean all wounds with soap and water to minimize infection 4. Apply a dressing with antiseptic (unless physician examination is necessary) 5. Lacerations and punctures should be treated by a physician

H. Use of occlusive dressings 1. Minimizes scab formation, perceived pain from exposed nerves, cost and time effective, provide adequate barrier 2. Antibiotic ointment used to prevent secondary infection 3. If the wound is discharging serum (fluid) to dressing should be changed regularly

4. When drainage has stopped = no need for dressing 5. Wound should be cleaned with hydrogen peroxide or Betadine 6. Effective against bacteria and not harmful to fibroblasts 7. Antibacterial ointment should be used to limit bacterial growth and to prevent dressing from adhering to wound 8. Proper care = minimized inflammatory response with quick healing and reduced scarring

Scenario
A baseball player is hit with an elbow just above her eyebrow. There is a laceration with a good deal of bleeding. Upon closer inspection the ATC realizes that despite the large amount of bleeding , the laceration is not that long, but is fairly deep. Should this laceration be closed with steri-strips , butterfly band aid, or sutures?

SUTURES!!!

I. Suturing 1. Dependent on severity 2. Determined by physician 3. Should be put in as soon as possible 4. Within 12 hours following injury 5. Utilize fine suture material and minimal tightening 6. Limits additional damage, inflammation and scarring 7. Large areas or slow healing areas = larger material to be left in longer 8. Occasionally steri-strips or butterfly bandages will suffice

IV. Bacterial Infections

A. Bacteria are single celled microorganisms 1. Spherical, doublets, and spirochetes B. Staphylococcus 1.Gram positive bacteria that appears in clumps in skin and upper respiratory tract

C. Streptococcus 1. Chain bacteria often associated with systemic disease and skin infections D. Bacillus 1. Spore forming, aerobic, and occasionally mobile 2. Can cause systemic damage

E. Impetigo Contagiosa 1. Etiology a. Caused by A-beta-hemolytic streptococci, S aureus or combination of these bacteria b. Spread through close contact 2. Signs and Symptoms a. Mild itching and soreness followed by eruption of small vesicles and pustules that rupture and crust b. Generally develops in body folds that are subject to friction 3. Management a. Cleansing and topical antibacterial agents b. Systemic antibiotics

F. Furunculosis (Boils) 1. Etiology a. Infection of hair follicle that results in pustule formation b. Generally the result of a staph. infection 2. Signs and Symptoms a.Pustule that becomes reddened and enlarged as well as hard from internal pressure b. Pain and tenderness increase with pressure c. Most will mature and rupture

3. Management a. Care involves protection from additional irritation b. Referral to physician for antibiotics c. Keep athlete from contact with other team members while boil is draining

G. Carbuncles 1. Etiology a. Similar in terms of early stage development as furuncles 2. Signs and Symptoms a. Larger and deeper than furuncle and has several openings in the skin b. May produce fever and elevation of WBC count c. Starts hard and red and over a few days emerges into a lesion that discharges yellowish pus

3. Management a. Surgical drainage combined with the administration of antibiotics b. Warm compress is applied to promote circulation

H. Folliculitis 1. Etiology a. Inflammation of hair follicle b. Caused by non-infectious or infectious agents c. Moist warm environment and mechanical occlusion contribute to condition d. Psuedofolliculitis (PFB)

2. Signs and Symptoms a. Redness around follicle that is followed by development of papule or pustule at the hair follicle b. Followed by development of crust that sloughs off with the hair c. Deeper infection may cause scarring and alopecia in that area

3. Management a. Management is much like impetigo b. Moist heat is used to increase circulation c. Antibiotics can also be used depending on the condition

I. Hidradenitis Suppurativa 1. Etiology a. Primary inflammation event of the hair follicle resulting in secondary blockage of the apocrine gland 2. Signs and Symptoms a. Begins as small papule that can develop into deep dermal inflammation

3. Management a. Avoid use of antiperspirants, deodorants and shaving creams b. Use medicated soaps and systemic antibiotics

J. Acne Vulgaris 1. Etiology a. Inflammatory disease of the hair follicle and the sebaceous glands b. Sex hormones may contribute 2. Signs and Symptoms a. Present with whiteheads, blackheads, flesh or red colored papules, pustules or cysts b. If chronic and deep = may scar c. Psychological impact

3. Management a. Topical and systemic agents used to treat acne b. Sometimes the use endogenous hormones is required c. Mild soaps are recommended

K. Paronychia and Onychia 1. Etiology a. Caused by staph, strep and or fungal organisms that accompany contamination of open wounds or hangnails b. Damage to cuticle puts finger at risk

2. Signs and Symptoms a. Rapid onset; painful with bright red swelling of proximal and lateral fold of nail b. Accumulation of purulent material w/in nail fold 3. Management a. Soak finger or toe in hot solution of Epsom salt 3 times daily b. Topical antibiotics, systemic antibiotics if severe c. May require pus removal through skin incision

L. Tetanus Infection (lockjaw) 1. Etiology a. Acute infection of the CNS caused by tetanus bacillus b. Bacteria enters through the blood and open wounds 2. Signs and Symptoms a. Stiffness of the jaw and muscles of the neck b. Muscles of facial expression produce contortion and become painful c. Fever may become markedly elevated 3. Management a. Treat in intensive care unit b. Childhood immunization

V. Fungal Infections
A. Group of organisms that include yeast and molds which are usually not pathogenic 1. Grow best in unsanitary conditions with warmth, moisture and darkness 2. Infections generally occur in keratinized tissue found in hair, nails and stratum corneum

B. Dermatophytes (Ringworm fungi) 1. Cause of most skin, nail and hair fungal infections C. Tinea of the Scalp (tinea capitis) 1. Signs and Symptoms a. Ringworm of the scalp begins as a small papule that spreads peripherally b. Appears as small grayish scales resulting in scattered balding c. Easily spread through close physical contact

2. Management a. Topical creams and shampoos are ineffective in treating fungus in hair shaft b. Systemic antifungal agents are replacing older agents due to increased resistance c. Some topical agents are used in conjunction

D. Tinea of the Body (tinea corporis) 1. Signs and Symptoms a. Commonly involve extremities and trunk b. Itchy red-brown scaling annular plaque that expands peripherally 2. Management a. Topical antifungal cream

E. Tinea of the Nail (tinea unguium/ onchomycosis) 1. Signs and Symptoms a. Fungal infection of the nail -found commonly in those engaged in water sports or who have chronic athletes foot b. Nail becomes thick, brittle and separated from its bed

2. Management a. Some topical antifungal agents have proved useful b. Systemic medications are most effective c. Surgical removal of nail may be necessary if extremely infected

F. Tinea of the Groin (tinea cruris) 1. Etiology a. Symmetric red-brown scaling plaque with snake-like border 2. Signs and Symptoms b. Mild to moderate itching

3. Management a. Treat until cured b. Will respond to many of the nonprescription medications c. Medications that mask symptoms should be avoided d. Failure to respond to normal management may suggest a non-fungal problem (such as bacteria) and should be referred to a physician e. May require additional topical medications and oral prescriptions

G. Athletes Foot (tinea pedis) 1. Etiology a. Most common form of superficial fungal infection b. Tricophyton species are most common cause of athletes foot c. Webs of toes may become infected by a combination of yeast and dermatophytes

2. Signs and Symptoms a. Extreme itching on soles of feet, between and on top of toes b. Appears as dry scaling patch or inflammatory scaling red papules forming larger plaques c. May develop secondary infection from itching and bacteria 3. Management a. Topical antifungal agents and good foot hygiene

H. Candidiasis (Moniliasis) 1. Etiology a. Yeast-like fungus that can produce skin, mucous membrane and internal infections b. Ideal environment includes hot humid weather, tight clothing, and poor hygiene

2. Signs and Symptom a. Infections w/in body folds b. Presents as beefy red patches and possible satellite pustules c. White, macerated border may surround the red area; deep painful fissures may develop at skin creases 3. Management a. Maintain dry area b. Use antifungal agents to clear infection

I. Tinea Versicolor 1. Etiology a. Caused by a yeast b. Appears commonly in areas in which sebaceous glands actively secrete body oils 2. Signs and Symptoms a. Fungus produces multiple, small, circular macules that are pink, brown, or white b. Commonly occur on chest, abdomen, and neck c. Do not tan when exposed to sun and usually are asymptomatic

3. Management a. Straightforward treatment recurrences are common b. Use selenium shampoo (Selsun) and topical econazole nitrate (or something similar) c. When microorganism has been eradicated, re-pigmentation of the area will occur

Review Questions
1. How can wounds be managed to avoid serious skin infection? 2. What common bacterial infections are commonly seen in patients 3. Name the body parts in which tinea may be found. 4. Why is candidiasis considered one of the most serious fungal infections?

Scenario
A tennis player complains to the athletic trainer that she has a sharp pain in the ball of her right foot. She says that it feels as though she stepped on a piece of glass. On inspection, the athletic trainer observes excessive callus formation on the ball of the foot that is dotted with a cluster of black specks. What is this condition and how should it be managed?

Plantar's wart Callus should be pared down 40% salicylic acid should be applied

VI. Viral Infections

A. Ultramicroscopic organisms that require host cells to complete their life cycle 1. May stimulate cell chemically to produce more virus until host cell dies 2. Lies within bud-like structure that does not damage cell or virus, w/out causing infection 3. A number of skin infections are caused by viruses

B. Herpes Simplex Labialis, Gladiatorum, and Herpes Zoster 1. Etiology a. Highly contagious and is usually transmitted directly through a lesion in the skin or mucous membrane b. Resides in sensory nerve neurilemmal sheath following initial outbreak c. Recurrent attacks stimulated by sunlight, emotional disturbances, illness, fatigue, or infection d. Type I vs. Type II

2. Signs and Symptoms a. Early indication = tingling or hypersensitivity in an infected area 24 hours prior to appearance of lesions b. Local swelling followed by outbreak of vesicles c. Athlete may feel ill w/ headache, sore throat, swollen lymph glands and pain in area of lesions

d. Vesicles generally rupture in 1-3 days spilling serous material e.Heal in generally 10-14 days f. If an athlete has an outbreak they should be disqualified from competition due to contagious nature of condition

3. Management a. Herpes simplex lesions are self limiting - reduce pain and promote early healing b. Use of antiviral drugs can reduce recurrence and shorten course of outbreak 4. Complications a. Can lead to secondary infection

VII. Verruca Virus and Warts

A. Variety of forms exist 1. verruca plana (flat wart), verruca plantaris (plantar wart), and condyloma acuminatum (venereal wart) 2. Different types of human papilloma virus have been identified 3. Uses epidermal layer of skin to reproduce and grow 4. Wart enters through lesion in skin

B. Common Wart 1. Signs and Symptoms a. Small, round, elevated lesion with rough dry surfaces b. Painful if pressure is applied c. May be subject to secondary bacterial infection 2. Management a. If vulnerable, they should be protected until treated by a physician b. Use of electrocautery, topical salicylic acid or liquid nitrogen are common means of managing this condition

C. Plantar Warts 1. Etiology a. Spread through papilloma virus 2. Signs and Symptoms a. Located on sole of foot, or adjacent to areas of abnormal weight bearing b. Areas of excessive epidermal thickening c. Discomfort, point tenderness d. Hemorrhagic puncta (black seeds)

3. Management a. While in competition, protect and prevent spreading b. Pair away callus and apply keratolytic c. Following season, wart can be removed by freezing it or by electrodessication (maintain protection until removal)

D. Molluscum Contagiosum 1. Etiology a. Poxvirus infection which is more contagious than warts (especially during direct body contact) 2. Signs and Symptoms a. Small, flesh or red colored, smooth-domed papules with central umbilication

3. Management a. Physician referral is necessary b. Cleansing and destructive procedure (counterirritant such as cantharidin, surgical removal or cryosurgery)

VIII. Allergic, Thermal, and Chemical Skin Reactions

A. Allergies are immunologically mediate responses to molecules in dyes and proteins against which the bodys immune system is sensitized 1. Allergens may be food, drugs, clothing, dusts, pollens, plants, animals, heat, cold, or light 2. The skin will reflect an allergy in many ways such as reddening and swelling of the tissue, uticaria or hives, burning or itching

B. Contact Dermatitis (allergic and irritant) 1. Etiology a. Plants are the most common cause (poison ivy, poison oak, sumac, ragweed, primrose) b. Topical medications c. Chemicals found in fragrances and preservatives of soaps, detergents

2. Signs and Symptoms a. Onset may range from 1 day to 1 week b. Redness, swelling, formation of vesicles that ooze fluid and form crust, constant itching c. May change from redness and blistering to erythematous scaling, lichenified papules and plaques

3. Management a. Avoid allergen b. Tap water compresses or soaks, topical corticosteroids

C. Milaria (Prickly Heat) 1. Etiology a. Continued exposure to heat and moisture causing retention of perspiration by sweat glands 2. Signs and Symptoms a. Itching and burning vesicles and pustules b. Occurs most often on arms, trunks, and bending areas of the body

3. Management a. Avoidance of overheating, frequent bathing with non-irritating soap, wearing loose-fitting clothing and use of antipruritic lotions

D. Chilblains (pernio) 1. Etiology a. Caused by excessive exposure to cold 2. Signs and Symptoms a. Tissue does not freeze but reacts with edema, reddening and possibly blistering along with a sensation of burning and itching after exposure to cold

3. Management a.Exercise and gradual warming of the part b. Massage and application of heat are contraindicated c. Some systemic drugs can be used in severe cases

E. Sunburns 1. Etiology a. Inflammatory response to injury caused by ultraviolet solar radiation b. Must be cautious of physical characteristics, chemicals, food and drugs that make individuals more susceptible

2. Signs and Symptoms a. Varies from erythema to severe blistering b. May experience shock if severe enough c. Can cause malfunctioning of organs w/in the skin d. Will appear 2-8 hours following exposure, with symptoms becoming most severe at 12 hours e. S&S will dissipate w/in 72-96 hours

3. Management a. Can be prevented through the use of sunscreen (sun protection factor or SPF) b. Filters ultraviolet light c. Water/sweat resistant sunscreen is recommended d. Treat a burn according to the degree of inflammation e. Cool water, aloe based solutions f. More severe burns may require bathing in a bath of cornstarch or vinegar g. Severe burns require physician assistance

F. Psoriasis 1. Etiology a. Exact cause is unknown -- genetic factors may play a role in condition b. Infection, smoking, some drugs and possible hormonal factors may cause an outbreak

2. Signs and Symptoms a. Lesion begins as reddish papules that progress to plaques b. Lesions progress to yellowish white scaly condition that tends to be located on the elbows, knees, trunk, genitalia, and umbilicus

3. Management a. Teaching patient self management b. Glucocorticoids and kerolytic agents can be used in conjunction with each other c. Long term oral medications may be necessary d. Counseling may be necessary for psychological aspects of condition

IX. Infestation and Bites

A. Scabies 1. Etiology a. Caused by mites which cause extreme nocturnal itching (tunnels and lays eggs)

2. Signs and Symptoms a. Appear as dark lines between fingers and toes, body flexures, nipples and genitalia b. Excoriations, pustules and papules caused by itching tends to hide true cause c. Skin develops hypersensitivity to the mite

3. Management a. Permethrin 5% is treatment of choice b. Washing of bedding and clothes is necessary c. Topical corticosteroids may be necessary to treat itching

B. Lice (Pediculosis) 1. Etiology a. Manifestation by the louse (louse of head, pubic region and body) 2. Signs and Symptoms a. Bites cause itching dermatitis through subsequent scratching -promotes pustule and excoriations to develop

3. Management a. Cure is rapid with use of any number of agents b. Good hygiene is paramount c. To prevent re-infestation all clothing and bedding should be washed in hot soapy water or discarded

C. Fleas 1. Etiology a .Small wingless insects that suck blood b. Can transmit systemic diseases 2. Signs and Symptoms a. Great deal of discomfort can be felt if come into contact with a high number of fleas b. Concentrate bites on ankles and lower legs

3. Management a. Following a bite, itching must be prevented with antipruritic lotion b. Avoid scratching to prevent secondary infection c. Insecticides can also be effective

D. Ticks 1. Etiology a. Parasitic insects that have an affinity for blood b. Carriers of a variety of microorganisms that can transmit Rocky Mountain spotted fever and Lyme disease

2. Signs and Symptoms a. Headaches, fever, malaise, myalgia, and rash, perechiae and prupura, enlarging annular red ring w/ or w/out central red papule 3. Management a. Remove tick (mineral oil or fingernail polish) b. Grasping head of tick is an acceptable method c. Systemic treatment is necessary to prevent morbidity and mortality associated with RMSF and Lyme disease d. Lyme Disease

E. Mosquitoes 1. Etiology a. Unless carrying a disease, mosquitoes produce bites that cause only mild discomfort b. Attracted to lights, dark clothing and warm moist skin 2. Signs and Symptoms a. Small reddish papule with associated itching

3. Management a. Topical medication b. Use of repellents can also be used on the skin to prevent contact with mosquitoes

F. Stinging Insects 1. Etiology a. Bees, wasps, hornets, yellow jackets -- inflict venomous sting b. Hypersensitive individuals may experience an allergic reaction 2. Signs and Symptoms a, If an allergic reaction occurs an increase in heart rate and breathing will occur, along with chest tightness, dizziness, sweating and even LOC

3. Management a. To prevent, avoid wearing scented lotions or shampoos, brightly colored clothes, jewelry, suede, or leather, and avoid going barefoot. b. If an athlete is susceptible to anaphylactic reactions instructions on use of an EpiPen are necessary

c. If uncomplicated, the stinger should be removed with tweezers or a credit card and soothing medications should be applied d. Soap detergent will also lessen symptoms e. In cases of anaphylactic reaction immediate physician referral is necessary

G. Spider Bites 1. Etiology a. Typically not dangerous to humans b. Rarely bite more than once c. Must be concerned with black widow and brown recluse

2. Signs and Symptoms a. Pain, small puncture wounds, redness, itching and swelling that lasts a couple days b. Present with center blister, a red ring and then a white ring c. Bite from venomous spider may result in muscle pain and cramps, weakness, sweating, headache, anxiety, nausea, vomiting, difficulty breathing and increased blood pressure

3. Management a. Washing the wound and applying antibiotic ointment b. Seek medical attention if infection presents, ulcer does not heal, nausea, vomiting, fever or rash occur c. If muscle cramping occurs the patient should go to the nearest emergency facility

X. Other Skin Conditions

A. Pityriasis Rosea 1. Etiology a. Acute inflammatory skin rash of unknown origin b. Occurs between the ages of 10-35 c. May be the result of a virus d. Can be spread to other individuals but usually only occurs once in a lifetime

2. Signs and Symptoms a. Single pinkish-red patch (herald patch) on the chest or back b. Within 2 days-3 weeks a secondary macular eruption occurs on chest or upper extremities c. Red and scaly with a clearing in the center

3. Management a. Typically doesnt require treatment b. Gradually disappears over 2-10 week period c. Antipruretics may help with itching d. Anti-inflammatories may be used to reduce itching and rash