Adult Care - Chapter 9 - Skin

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First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care

The content of this chapter has been reviewed July 2009

On this page:

• Assessment of the Integumentary System
  • History of Present Illness and Review of Systems
  • Physical Examination
    
    
• Common Problems of the Skin
  • Cellulitis
  • Chronic Wounds
  • Cutaneous Infections (Uncomplicated) (Folliculitis, Furuncle and Carbuncles)
  • Cutaneous Infections (Complicated)
  • Eczema (Atopic Dermatitis)
  • Impetigo
  • Methicillin-Resistant Staphylococcus Aureus
    • Hospital-Acquired MRSA
    • Community-Acquired MRSA(CA-MRSA)
  • Pediculosis (Lice Infestation)
  • Ringworm (Tinea)
  • Scabies
  • Stasis Dermatitis
  • Urticaria (Hives)
  • Warts (Verrucae)
    
    
• Dermatological Emergencies
  • Burns
  • Frostbite
  • Skin Wounds of traumatic origin
    
    
• Appendix A - Decisional Tools in the Ongoing Management of Wounds
• Sources

Assessment of the Integumentary System

History of Present Illness and Review of Systems^{Footnote 1}

The following characteristics of each symptom should be elicited and explored:

• Onset (sudden or gradual) and duration
• Chronology
• Relationship to season, travel history, heat, cold, previous treatment, drug ingestion, occupation, hobbies and pregnancy
• Current situation (improving or deteriorating)
• Location
• Quality
• Timing (frequency, duration)
• Time of day when symptoms are most severe
• Severity
• Precipitating and aggravating factors
• Relieving factors
• Associated symptoms
• Effects on daily activities
• Previous diagnosis of similar episodes
• Efficacy of previous treatments

Cardinal Symptoms

In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited, as described below. When skin changes are the chief complaint, it may be necessary to perform a complete investigation for multisystem disease which includes the history and physical exam, basic laboratory studies and may require a biopsy, immunofluorescence and imaging. Skin symptoms may include pruritus, pain or paresthesia.^{Footnote 2}

Skin

• Changes in texture or colour
• Unusual dryness or moisture
• Itching, burning, pain, numbness
• Rash
• Bruises, petechiae
• Changes in pigmentation
• Lesions, blisters, crust
• Changes in moles or birthmarks

Hair

• Changes in amount, texture, distribution

Nails

• Changes in texture, structure

Other Associated Symptoms

• Site of onset, spreading
• Date(s) and site(s) of recurrence(s)
• Intermittent or continuous
• Influence of environmental or occupational factors
• Others at home with similar symptoms

Medical History (Specific to Integumentary System)

• Allergic manifestation (for example, asthma, hay fever, urticaria)
• Recent or current viral illness
• Recent or current bacterial illness
• Fever, malaise, arthralgias
• Allergies to drugs, foods, other chemical substances
• Medications (for example, steroids, OCPs [oral contraceptive pills], antibiotics, OTCs [over-the-counter drugs])
• Immunosuppression from health condition or medication use (for example, HIV/AIDS or glucocorticoids)
• Seborrheic dermatitis
• Psoriasis
• Diabetes mellitus
• Photosensitivity

Family History (Specific to Integumentary System)

• Allergies (for example, seasonal, to food)
• Seborrheic dermatitis
• Others at home with similar symptoms (for example, rash)
• Psoriasis

Personal and Social History (Specific to Integumentary System)

• Obesity
• Poor hygiene
• Hot or humid environment, poor environmental sanitation
• Stress (may precipitate flares of chronic skin problem such as psoriasis)
• Exposure to new chemicals (for example, soaps), foods, pets, plants
• Emotional disturbance
• History of sensitive skin
• Others at home, work or school with similar symptoms
• Recent travel

Physical Examination

• Apparent state of health
• Appearance of comfort or distress
• Colour (for example, flushed, pale)
• Nutritional status (obese or emaciated)
• State of hydration
• Match between appearance and stated age
• Vital signs (temperature may be elevated)

Inspection and Palpation of the Skin

• Colour
• Temperature, texture, turgor
• Dryness or moisture
• Scaling
• Pigmentation
• Vascularity (erythema, abnormal veins)
• Bruises, petechiae
• Edema (dependent, facial)
• Induration
• Blanching
• Individual lesions (colour, type, general shape, texture, arrangement, margination, pattern of distribution, character of edge [whether raised or flat])^{Footnote 3}
• Hair (amount, texture, distribution)
• Nails (shape, texture, discoloration, grooving)
• Mucous membranes
• Flexural folds

Other Aspects

• Examine lymph nodes
• Examine area distal to enlarged lymph nodes

Major Types of Skin Lesions

The major types and characteristics of skin lesions are given in Table 1, "Major Types of Skin Lesions."

Jaundice, spider angiomata, palmar erythema or a necklace of telangiectasia may indicate alcoholic liver disease. Petechiae or purpura suggest a coagulation problem.

Table 1: Major Types of Skin Lesions^{Footnote 4 ,Footnote 5}

Type of Lesion	Characteristics
Basic lesions
Atrophy (also can be sequential)	Skin thin and wrinkled
Bulla	Circumscribed, elevated lesion > 5 mm in diameter containing fluid
Excoriation	Linear or hollowed-out crusted area, caused by scratching, rubbing or picking
Macule	Flat, circumscribed, discoloured spot; size and shape variable (for example, freckle, mole, port-wine stain)
Nodule	Palpable, solid lesion that may or may not be elevated (keratinous cyst, small lipoma, fibroma)
Papule	Solid elevated lesion (for example, wart, psoriasis, pigmented mole)
Plaque	Well defined plateau-like elevation that occupies a relatively large surface compared to its height above the skin (for example eczema, psoriasis)
Pustule	Superficial elevated lesion containing pus (impetigo, acne, furuncle, carbuncle)
Purpura	Ecchymosis or small hemorrhages in the skin, mucous membranes or serosal surfaces between blue and red in colour
Ulcer (also sequential)	Loss of epidermis and at least part of the dermis; may go deeper depending on grade of ulcer
Telangiectasia	Fine, often irregular red line produced by dilatation of a normally invisible capillary
Vesicle	Circumscribed, elevated lesion < 5 mm in diameter containing fluid (for example, insect bite, allergic contact dermatitis, sunburn)
Wheal	Transient, irregularly shaped, elevated, indurated, changeable lesion caused by local edema (for example, allergic reaction to a drug, a bite, sunlight)
Sequential lesions
Erosion	Loss of part or all of the epidermis
Exudation: dry (crust or scab)	Dried serum, blood or pus
Exudation: wet (weeping)	Drainage of serum, blood or pus
Lichenification	Skin thickened, skin markings accentuated (for example, atopic dermatitis)
Scales	Heaping-up of the horny epithelium (for example, psoriasis, seborrheic dermatitis, fungal infection, chronic dermatitis)
Scar	Various skin manifestations of healed process (for example keloid or acne cicatrisation)

Common Problems of the Skin

Cellulitis

Acute, diffuse, spreading infection of the skin, involving the deeper layers of the skin and the subcutaneous tissue.

Causes

• Bacteria: most commonly Staphylococcus or Streptococcus
• Predisposing factors: local trauma, furuncle, carbuncle, underlying skin ulcer
• Increase risk in clients with venous or lymphatic compromise, diabetes mellitus and prior skin lesion or trauma 

If a bite was the original trauma, different organisms are involved. See Skin Wounds of traumatic origin.

History

• Localized pain
• Redness
• Swelling
• Area increasingly red, warm to touch, painful
• Area around skin lesion also tender
• Fever and headache may be present, note onset
• Any trauma, rash

Physical Findings

• Temperature may be elevated
• Heart rate may be elevated
• Redness, swelling
• Advancing edge of lesion diffuse, not sharply demarcated
• Small amount of purulent discharge may be present
• Skin surrounding lesion red and swollen, may be tense
• Edema
• Tenderness
• Induration (firm to touch)
• Regional lymph nodes may be enlarged, tender

Differential Diagnosis

• Folliculitis
• Foreign body
• Abscess
• Necrotizing fasciitis

Complications

• Progression of infection
• Abscess
• Sepsis
• Thrombophlebitis
• Deep vein thrombosis (more likely to be seen in elderly with lower extremity cellulitis)^{Footnote 6}
• Osteomyelitis

Diagnostic Tests

• Swab any wound discharge for culture and sensitivity (consider MRSA)
• Consider blood cultures if fever present

Management

If the condition is mild, physician consultation and referral are not usually required, and the client can be treated on an outpatient basis. If the condition is moderate to severe, IV therapy and referral are necessary.

Goals of Treatment

• Control infection
• Identify formation of abscess

Appropriate Consultation

Mild Cellulitis

Consultation not usually required.

Moderate-to-Severe Cellulitis

Consult physician if any of the following conditions pertain:

• Cellulitis is moderate to severe (for example, large area is involved)
• Cellulitis is progressing rapidly, which may indicate an invasive streptococcal infection
• Cellulitis involves hands, feet, face or a joint
• Client is immunocompromised (for example, has diabetes mellitus)
• Client is febrile, appears acutely ill or shows signs of sepsis
• Foreign body is suspected

Nonpharmacologic Interventions

Mild Cellulitis

• Apply warm saline compresses to affected areas qid
• Elevate, rest and gently splint the affected limb
• Counsel client about appropriate use of medications (dose, frequency, compliance)
• Encourage proper hygiene of all skin wounds to prevent future infection
• Stress importance of close follow-up

Adjuvant Therapy

Mild Cellulitis

If original lesion caused by trauma, check for tetanus vaccination; if not up to date, administer tetanus vaccine.

Moderate-to-Severe Cellulitis

• Start IV therapy with normal saline to keep vein open; adjust rate according to state of hydration and age
• If original lesion caused by trauma, check tetanus vaccination record; if not up to date, administer tetanus vaccine

Pharmacologic Interventions

Mild Cellulitis

Oral antibiotics:

cephalexin (Keflex), 500 mg PO qid for 10 days
or
cloxacillin, 500 mg PO qid for 10 days

For clients with allergy to penicillin:

azithromycin (Zithromax), 500 mg on day 1 followed by 250 mg PO daily for 4 days

Antipyretics and analgesia:

acetaminophen (Tylenol), 325 mg, 1-2 tabs PO q4-6h prn

Moderate-to-Severe Cellulitis (non-facial)

Administer IV antibiotics only as directed by a physician. Often, the following is used:

cefazolin (Ancef), 1 g IV/IM q8h or

cefazolin (Ancef) 2 g IV q24h
+ probenecid 1 g po once daily given 30 minutes prior to cefazolin*
*avoid concomitant use of probenecid with ketorolac

For clients with allergy to penicillin:

clindamycin 600 mg IV/IM q8h

Antipyretics and analgesia:

acetaminophen (Tylenol), 325 mg, 1-2 tabs PO q4-6h prn

Monitoring and Follow-Up

Mild Cellulitis

• Follow up daily to ensure that infection is controlled
• Instruct client to return for reassessment immediately if lesion becomes fluctuant, if pain increases or if fever develops

Moderate-to-Severe Cellulitis

Monitor vital signs and affected area frequently for progression.

Referral

Moderate-to-Severe Cellulitis

May need medevac for IV antibiotic therapy.

Chronic Wounds

Foot ulcers, diabetic leg ulcers, peripheral vascular disease ulcers and pressure ulcers are not specifically covered in these guidelines. However, the general principals in the ongoing management of wounds include the need for debridement, control of the bacterial burden and control of the moisture balance.^{Footnote 7}

A number of Best Practice Guidelines from the Registered Nurses Association of Ontario address common wound care issues. Of interest are the guidelines on:

•  Assessment and Management of Foot Ulcers for People with Diabetes
•  Assessment & Management of Stage I to IV Pressure Ulcers
•  Assessment and Management of Venous Leg Ulcers
•  Risk Assessment and Prevention of Pressure Ulcers

A selection of decisional tools in the management of wounds can be found in Appendix A.

Cutaneous Infections (Uncomplicated)

Folliculitis: superficial infection of a hair follicle; acute lesion consists of dome-shaped pustule at the mouth of a hair follicle; pustule ruptures to form a crust; primary sites include scalp, shoulders, anterior chest, upper back and other hair-bearing areas.

Furuncle: red, hot inflammatory nodule(s) involving subcutaneous tissue that arise from a hair follicle; primary sites include thigh, neck, face, axillae, perineum and buttocks.

Carbuncles: deep-seated abscess formed by multiple coalescing furuncles; lesions drain through multiple points to the surface.

Causes

• Infection with Staphylococcus aureus (most common), anaerobes, other microorganisms
• Predisposing factors: obesity, diabetes mellitus, poor hygiene, excessive friction or perspiration, seborrhea, local trauma (for example, from plucking hairs), use of immunosuppressive drugs (for example, systemic steroids)

History

• Pain, swelling, redness at infected site
• Fever may be present

Physical Findings

• Localized redness, swelling
• Lesion may be draining, crusted
• Localized induration
• Tenderness
• Fluctuance (may be difficult to palpate if abscess is deep)
• Regional lymph nodes may be enlarged and tender
• Temperature may be elevated
• Heart rate may be elevated

Differential Diagnosis

• Cellulitis
• Abscess

Complications

• Scarring
• Spread of infection (for example, lymphangitis, lymphadenitis)
• Abscess
• Recurrence
• Sepsis 

Diagnostic Tests

• Swab discharge for culture and sensitivity (consider MRSA)
• Determine blood glucose level if infection is recurrent or if symptoms suggestive of diabetes mellitus are present

Management

Goals of Treatment

• Control infection
• Prevent complication
• Identify predisposing underlying conditions (for example, diabetes mellitus)

Appropriate Consultation

Consult a physician if client is febrile or appears acutely ill; if extensive cellulitis, lymphangitis or adenopathy is present; or if infection is suspected or detected in a critical region (for example, perirectal area) or in an immunocompromised client (for example, diabetic person).

Nonpharmacologic Interventions

• Apply warm saline compresses to soften and soak away crusts qid and prn
• Cleanse with antiseptic antimicrobial agent to decrease bacterial growth
• Incise and drain localized large furuncles or carbuncles to relieve pain and pressure
• Counsel client about appropriate use of medications (dose, frequency, compliance) and if on antibiotics, reinforce the need to complete a course despite feeling better within days
• Recommend proper hygiene (that is, daily washing with prescribed soap)
• Counsel client about prevention of future episodes 

Pharmacologic Interventions

Apply topical antibiotic preparation:

mupirocin (Bactroban) ointment, tid for 10 days

Oral antibiotics may be necessary if client is febrile or there are multiple lesions that appear infected:

cephalexin (Keflex), 500 mg PO qid for 10 days
or
cloxacillin 500 mg PO qid for 10 days

For clients with allergy to penicillin:

azithromycin (Zithromax), 500 mg on day 1 followed by 250 mg PO daily for 4 days

Antipyretics and analgesia:

acetaminophen (Tylenol), 325 mg, 1-2 tabs PO q4-6h prn

Monitoring and Follow-Up

Follow up daily until infection resolves.

Referral

Referral usually not required.

Cutaneous Infections (Complicated)

Appropriate Consultation

Consult a physician if client is febrile or appears acutely ill; if extensive cellulitis, lymphangitis or adenopathy is present; or if infection is suspected or detected in a critical region (for example, perirectal area, face, feet, decubitus ulcers) or in an immunocompromised client (for example, diabetic person).

Adjuvant Therapy

Start IV therapy with normal saline; adjust rate according to state of hydration and age.

Pharmacologic Interventions

If ordered by a physician,IV antibiotics such as the following may be considered before transfer:

cefazolin (Ancef), 1-2 g IV/IM q8h

If abscess is in the perirectal area:

cefazolin (Ancef), 1-2 g IV/IM q8h
and
metronidazole (Flagyl), 500 mg IV q8h

The physician may also add gentamicin to this combination for more polymicrobial coverage.

Referral

Medevac as soon as possible, for continued IV drug therapy and possible surgical drainage.

Eczema (Atopic Dermatitis)

Chronic, itchy, inflammatory condition of the skin.

Causes

• Largely unknown
• Inherited skin sensitivity
• Allergy

History

• Typically begins in infancy
• May last throughout entire life
• Pattern in adulthood differs from that in infancy and childhood
• Periods of remission and exacerbation
• Family history of eczema, allergies and asthma common
• Characterized chiefly by itching and scaling
• Eruptions of small groups of vesicles may occur
• Scratching leads to rupture of vesicles
• Clear serous fluid oozes from vesicles, leading to development of rash
• Vicious cycle of itch, scratch, rash, itch
• Usually affects face, neck, upper arms and back, flexural folds, feet
• May be more generalized
• Secondary bacterial infection common
• Specific irritating agents can be identified
• Wool, solvents, perfumed creams, lotions, soaps bothersome
• Allergies, hay fever, asthma, contact dermatitis often present
• Hot humid or cold dry weather and emotional stress may aggravate symptoms

Physical Findings

• Skin scaly, dry, thickened (lichenified)
• Fissures may be present
• Excoriations
• Mild redness and edema often present
• Vesicles may be present in some areas
• Lesions may be weeping
• Pustular or crusted lesions may be present
• Some areas of skin usually show chronic changes (thin skin, scarring, lichenification)

Differential Diagnosis

• Seborrheic dermatitis
• Dry skin (winter itch)
• Allergic contact dermatitis
• Psoriasis
• Scabies

Complications

• Scarring
• Secondary bacterial infection
• Chronic irritation of skin
• Side effects of medication (for example, steroid preparations)

Diagnostic Tests

• None

Management

Goals of Treatment

• Relieve symptoms
• Prevent secondary infection

Appropriate Consultation

Consult a physician if no response to therapy after 1 week.

Nonpharmacologic Interventions

• Offer support to client, as it can be difficult to live with this irritating and cosmetically unattractive condition
• Advise client to stop using steroid preparations once acute lesions have healed, since steroids do not have any preventive benefit and may further irritate and damage skin
• Assist client to identify precipitating and aggravating factors, and encourage avoidance
• If lesions are wet, promote drying and cooling with compresses qid prn (aluminum acetate [Burow's solution] or normal saline)
• If lesions are dry, promote lubrication with Glaxal base or petroleum jelly (Vaseline) bid, after bathing and prn

Client Education

• Counsel client about appropriate use of medications (dose, frequency, application)
• Encourage proper hygiene to prevent secondary bacterial infection
• Recommend loose-fitting cotton clothing
• Recommend avoidance of coarse materials and wool
• Recommend avoidance of overheating (hot showers)
• Recommend avoidance of irritants at work and at home
• Recommend use of a soap substitute (for example, Aveeno) and avoidance of soaps
• Suggest that cotton gloves be worn inside rubber gloves when client works with liquids
• Suggest that greasy lubricants (such as Lubriderm) be applied within minutes of leaving shower or bath to "lock in" moisture

Pharmacologic Interventions

Reduce inflammation if itch moderate or severe:

hydrocortisone 1% cream (Topicort), bid-tid for 1-2 weeks

Gels and creams are used for acute, weeping eruptions. Ointments are used for dry or lichenified lesions. Lotions are used for hairy areas.

Pruritus associated with eczema is not mediated by histamine, so histamine blockade is generally ineffective. Hydroxyzine (Atarax) may provide some relief through central sedation.^{Footnote 8} Sedative effect of hydroxyzine is useful to break the itch-scratch cycle.

hydroxyzine (Atarax), 10-25 mg PO bid and hs prn

Start with 10 mg if client is small, elderly or taking anxiolytics.

Monitoring and Follow-Up

Follow up in 1-2 weeks to assess response. If no response, discuss use of a more potent topical steroids with physician. Advise client to return sooner if signs of infection develop.

Referral

Arrange elective follow-up with a physician if there is no response to treatment.

Impetigo

Highly contagious superficial bacterial infection of skin.

Causes

• Streptococcus, Staphylococcus or a mixture of both
• Predisposing factors: local trauma, insect bites, skin lesions from other disorders (for example, eczema, scabies, pediculosis)

History

• More common on face, scalp and hands, but may occur anywhere
• Involved area is usually exposed
• May complicate chickenpox, eczema and other skin disorders marked by open lesions^{Footnote 9}
• New lesions usually due to auto-inoculation
• Rash begins as red spots, which may be itchy
• Lesions become small blisters and pustules, which rupture and drain
• Discharge dries to form characteristic golden yellow crusts
• Lesions painless
• Fever and systemic symptoms rare
• Mild fever may be present in more generalized infections

Physical Findings

• Thick, golden yellow, crusted lesion on a red base
• Numerous skin lesions at various stages present (vesicles, pustules, crusts, serous or pustular drainage, healing lesions, bullae may be present)
• Lesions and surrounding skin may feel warm to touch
• Regional lymph nodes may be enlarged, tender

Differential Diagnosis

• Infected eczema, contact dermatitis, scabies
• Herpes simplex infection with blisters or crusts
• Chickenpox infection with blisters or crusts
• Shingles (herpes zoster) with blisters or crusts
• Bullous insect bites

Complications

• Localized or widespread cellulitis
• Post-streptococcal glomerulonephritis (uncommon in adults)

Diagnostic Tests

• None
• Consider swabbing if MRSA is known in community or if there is no response to initial treatment

Management

Goals of Treatment

• Control infection
• Prevent auto-inoculation
• Prevent spread to other household members

Appropriate Consultation

Consult a physician if there is failure to respond to therapy.

Nonpharmacologic Interventions

• Apply warm saline compresses to soften and soak away crusts qid and prn
• Cleanse with antiseptic antimicrobial agent to decrease bacterial growth
• Counsel client about appropriate use of medications (dose, frequency, compliance)
• Recommend proper hygiene (that is, daily washing with prescribed soap)
• Counsel client about prevention of future episodes
• Suggest strategies to prevent spread to other household members (for example, proper hand-washing, use of separate towels)

Pharmacologic Interventions

Apply topical antibiotic preparation:

mupirocin (Bactroban) ointment, tid for 7 to 10 days

Oral antibiotics may be necessary if there are multiple lesions that appear infected:

cloxacillin, 500 mg PO qid for 7 to 10 days
or
cephalexin (Keflex), 500 mg PO qid for 7 to 10 days

For clients with allergy to penicillin:

erythromycin, 1 g/day divided bid, tid or qid for 7 to 10 days

Monitoring and Follow-Up

• Follow up in 2-3 days to assess response to treatment
• Instruct client to return for reassessment if fever develops or infection spreads despite therapy

Referral

Not usually necessary unless complications develop.

Methicillin-Resistant Staphylococcus Aureus^{Footnote 10 ,Footnote 11 ,Footnote 12}

Methicillin-resistant Staphylococcus aureus (MRSA) are bacteria that are resistant to partly synthetic penicillins like cloxacillin and methicillin. The bacteria can also be resistant to other antibiotics. It is difficult to treat, as medications used to treat other strains of Staphylococcus aureus may not be of benefit.^{Footnote 13} Staphylococcus aureus is normally found on the skin and in the nares of healthy people. Currently, there are two strains of MRSA that have different molecular and antibiotic resistance profiles.^{Footnote 14}

Hospital-Acquired MRSA

Hospital-acquired MRSA is encountered most often in those who have been in a hospital or health care facility, or had medical procedures done and who have a weakened immune system.^{Footnote 15}

Community-Acquired MRSA (CA-MRSA)

A person is considered to have CA-MRSA if they have not been in the hospital or had a medical procedure done within the past year and they have a positive culture report for MRSA. The infection usually presents on the skin as pimple(s) or boil(s) and is seen in persons that are otherwise healthy.^{Footnote 15} Currently, the CA-MRSA strains are more likely to be susceptible to antibiotic classes, other than beta-lactams, than hospital-acquired MRSA strains.^{Footnote 13}

Primary Care Health Practitioners must become aware of the emergence of CA-MRSA as a cause of infection in Canada, particularly when overcrowding is an issue.

The prevalence of CA-MRSA in Canada is currently thought to be low but rising in Canadian communities. Most cases are skin infections with principal sites of colonization being the skin, nares and perineum.

Causes

• Methicillin-resistant Staphylococcus aureus

Mechanism of Spread

• Skin to skin contact
• Skin to instrument contact
• Cat or dog bite^{Footnote 16} 

Risk Factors for MRSA Carriage

• Crowded housing
• Lack of quality running water
• Antibiotic use
• Hospitalization or recent outpatient attendance
• Chronic illness
• Intravenous drug abuse
• Close contact with an individual with any of these risk factors

History

• Localized pain
• Redness
• Swelling
• Drainage of fluids or pus from lesion may be present
• Fever may be present
• Skin abscess may be present
• Area around skin lesion may be warm
• History of MRSA (hospital or community acquired)
• History of cat or dog bite^{Footnote 16}

For more serious infections chills, fatigue, malaise, headache, muscle aches or shortness of breath may be present.

Suspect Hospital-Acquired MRSA

• If a person has been hospitalized or had a medical procedure done in the past year
• If a person has a weakened immune system

Suspect CA-MRSA

• In communities where it is known that approximately 10% to 15% of community isolates of S. aureus are methicillin resistant, CA-MRSA should be suspected in any patient who presents with a suspected staphylococcal skin infection
• When risk factors for CA-MRSA are present
• When there is a poor response to beta-lactam therapy in individuals with presumed staphylococcal infection
• In severe infections compatible with S. aureus (for example, sepsis, necrotizing fasciitis, necrotizing pneumonia and emphysema)

Physical Findings

• Temperature may be elevated
• Heart rate may be elevated
• Redness, swelling
• Tenderness
• Small or large amount of purulent or serous discharge may be present
• Skin surrounding lesion may be red, swollen, and/or tense
• Edema may be present
• May have induration (firm to touch)
• Regional lymph nodes may be enlarged, tender

Differential Diagnosis

• Cellulitis
• Impetigo
• Folliculitis
• Furuncle or carbuncle
• Foreign body
• Abscess
• Animal bite^{Footnote 16}

Complications

• Progression of infection
• Abscess
• Sepsis
• Endocarditis
• Pneumonia
• Toxic shock syndrome

Diagnostic Tests

Obtain a swab for culture and sensitivity in the following situations:

• Skin lesions are suspect for MRSA
• Recurrent furuncles or abscesses (two or more in six months)
• Any severe presentation of the disease (should include blood cultures)
• An outbreak is suspected (in consultation with public health)
• Prior to beginning antibiotics, from areas of cellulitis for patients who are going to be admitted for inpatient therapy or whose cellulitis progresses once starting treatment

Screening Recommendations

• Routine screening of individuals infected with CA-MRSA or their contacts for colonization of nares or other sites is not recommended
• In communities in which MRSA is known to occur, general efforts to determine carriage rates among asymptomatic household contacts are not recommended
• In selected circumstances, following consultation with public health or a physician, nasal and/or additional site screening may be considered
  
  These selected circumstances include the following:
  
  
  • Individuals with recurrent S. aureus skin infections (two or more in six months), in whom eradication therapy is being considered
  • In a family setting, where recurrent skin infections continue despite repeated review and reinforcement of hygiene measures, and there is not known to be a high prevalence of CA-MRSA in the community
  • To investigate an outbreak in a closed population with continuing new infections despite repeated reinforcement of hygiene practices. When a colonization survey is performed as part of an outbreak investigation, assessing carriage sites other than the nares may be considered, in consultation with public health officials and/or other experts

Management

Goals of Treatment

• Prevention
• Infection control
• Treatment of skin infections

Appropriate Consultation

Consult a physician for all cases of suspected or confirmed MRSA infections.

Nonpharmacologic Interventions

Prevention

The goal of MRSA control is to prevent spread of the bacteria from an infected or colonized individual to other persons.

• Use antibiotics appropriately to reduce or minimize antibiotic resistance
• Optimize the water supply in First Nations communities
• Provide instruction, beginning in early childhood, regarding the method and value of frequent hand washing
• Educate clients about appropriate hygiene practices at all times and in all settings. These include but are not limited to the following: regular hand washing to limit personal contamination and transmission and regular bathing with soap and water
• Families, school and daycare centre personnel and sports teams should be actively encouraged to practice meticulous hand washing, the most important measure to control transmission of MRSA

If skin lesions are present, educate clients to:

• cover lesions with appropriate dressings to contain drainage or exudate
• ensure that appropriate medical care has been received
• not share creams, lotions, soaps, cosmetics and other personal products that are in contact with the skin;
• not share unwashed towels;
• not share personal items that come in contact with the skin lesions - such as razors, toothbrushes, towels, nail files, combs and brushes - without cleaning
• discard contaminated waste, including used dressings, in a safe manner to avoid exposure to other individuals
• wash hands with soap and water after touching any skin lesions and potentially infected materials, such as soiled dressings

Role of Health Care Practitioners

• Health care practitioners should use antibiotics judiciously; overuse of antibiotics continues to contribute to antibiotic resistance
• Patients should be encouraged to complete all courses of antibiotics as prescribed
• Frequent handwashing and decontamination of examination equipment to prevent spread from infected individuals
• Public health officials should be notified if spread occurs beyond a family unit to a localized community group, such as a school or sports team (that is, if an outbreak of the disease is suspected)

Acute Infection

Mild, localized cutaneous infections such as minor abrasions: washing with antibacterial soap and water.

Superficial, localized infections such as impetigo, folliculitis, furuncles, carbuncles and small abscesses without cellulitis: local therapy using warm water soaks and elevation.

Pharmacologic Interventions

Acute Infection

Superficial, localized infections such as impetigo, folliculitis, furuncles, carbuncles and small abscesses without cellulitis, one or more of the following measures may be used:

• topical antiseptics
• topical mupirocin or bacitracin

For the immunocompromised host, antimicrobial therapy is recommended in addition to local measures, incision and drainage.

For empiric therapy of mild to moderate, more generalized infections such as cellulitis (where MRSA is not suspected or confirmed) in addition to local measures, choose one of the following antibiotics:

Start with cloxacillin, or first-generation cephalosporin such as cephalexin or Clavulin (amoxicillin/clavulanic acid)

In a community known to have MRSA: clindamycin or trimethoprim/sulfamethoxazole (note that trimethoprim/sulfamethoxazole does not provide coverage for Group A beta-hemolytic streptococcus).

Severe or life-threatening staphylococcal infection such as necrotizing fasciitis, necrotizing pneumonia: initial coverage may include vancomycin pending physician consult, culture and sensitivity.

Decolonization

Decolonization refers to the process of eradicating or reducing carriage of a particular organism from the skin, nose or other mucosal surfaces. Consult a physician for guidance in decision to attempt decolonization, as success of decolonization is limited.

The available systemic options include rifampin plus another antistaphylococcal antibiotic, such as TMP-SMX, clindamycin, fusidic acid, doxycyline or minocycline.

Eradication from the skin can be attempted using topical agents such as chlorhexidine, whereas nasal decolonization usually requires intranasal mupirocin. Eradication from sites other than the nose usually requires systemic and topical therapy in addition to intranasal therapy.

Monitoring and Follow-Up

Closely monitor clients being treated for suspected or confirmed minor staphylococcal skin infections to ensure response to treatment. Timing of follow-up depends on type and severity of infection at presentation.

Referral

Medevac cases of moderate to severe infections compatible with S. aureus (for example, extensive cellulitis, sepsis, necrotizing fasciitis, necrotizing pneumonia) to hospital for definitive diagnosis and ongoing treatment.

Pediculosis (Lice Infestation)

Infestation with human parasitic lice.

Causes

There are 3 types: head lice, body lice and pubic lice.

Risk Factors

• Crowded housing (for example, shared beds), crowded schools
• High pediatric population
• Failure to recognize an infestation
• Faulty application of treatments
• Failure to treat close contacts simultaneously
• Failure to eradicate lice from linens and clothing at time of treatment
• Lack of running water, which can predispose to poor hygiene and secondary skin infection

History

• Head lice: involve scalp
• Body lice: involve body
• Pubic lice: involve pubic area and may be found in hairs of abdomen, thighs, axillae, eyebrows, eyelashes
• Severe itching of involved area
• Excoriation of skin
• Secondary bacterial infection may occur
• Client may find lice or nits on bedclothes, in seams of clothing

Physical Findings

• Small gray-white nits cemented to base of hair shafts
• Lice may be visualized
• Excoriation of skin

Differential Diagnosis

• Dandruff

Complications

• Recurrent infestation
• Skin infection

Diagnostic Tests

• None

Management

Goals of Treatment

• Eradicate infestation
• Prevent recurrences
• Prevent spread to close contacts

Nonpharmacologic Interventions

• Remove dead lice and nits with tweezers or nit comb
• Avoid irritation of eyes and mucous membranes
• Remove nits on eyelashes with petroleum jelly (nits become coated, and ova die from suffocation)
• Instruct client to place small amount of petroleum jelly on tips of fingers, then close eyes and rub petroleum jelly into lids and brows; repeat two to four times daily for 10 days^{Footnote 17}
• Examine all family members and close personal contacts, including schoolmates and daycare contacts, and treat if infested
• Also treat anyone who shares a bed with the person who has head lice

Client Education

• Counsel client about proper use of medication and side effects
• Recommend that combs, brushes, hats, coats, bedding and clothing of all household members be washed in warm soapy water
• Items that cannot be washed should be sealed in a plastic bag for 3 weeks
• Recommend avoidance of sharing of combs, brushes, hats, etc.
• Suggest that mattresses (which can harbour lice) be vacuumed thoroughly

Pharmacologic Interventions

Insecticide shampoos for head lice:

permethrin (Nix) cream rinse
or
pyrethrin shampoo (R&C shampoo)

Two bottles are often needed for thick or long hair.

Monitoring and Follow-Up

Follow up in 7 days. Ensure treatment is repeated in 7-10 days after original application.^{Footnote 17}

Referral

Usually not necessary.

Ringworm (Tinea)

Superficial fungal infection of skin.

• On feet: tinea pedis (athlete's foot)
• In groin: tinea cruris (jock itch)
• On body: tinea corporis
• On scalp: tinea capitis (see "Tinea Capitis" in the chapter, "Pediatric Skin")

Tinea versicolor, a yeast infection (Pityrosporum ovale) is described in Table 2, "History and Physical Findings for Various Forms of Tinea." The microscopic examination of scales prepared with KOH can differentiate this tinea from other hypopigmented or scaly skin lesions.^{Footnote 19}

Causes

Dermatophytes (fungi) that invade dead tissue, such as the skin's stratum corneum, nails and hair.

History and Physical Findings

The history and physical findings for various forms of tinea are given in Table 2.

Table 2: History and Physical Findings for Various Forms of Tinea^{Footnote 20}

Type	History	Physical Findings
Tinea pedis	Affects feet Itch severe Scaling and redness, mainly between toes Foul odour may be present Area may be moist, whitened, macerated, cracked Skin peels off easily with red, tender area underneath One or several small vesicles may be present Vesicles rupture leaving a "collarette" of scales May involve sole of foot with marked scaling (itch minimal)	Scaling of lateral interdigital areas Moist, whitened, macerated, cracked skin may be present Skin peels off easily with red, raw, tender area underneath One or several small blisters may be present Sole of foot may be involved with marked scaling Fissures may become secondarily infected (cellulitis )
Tinea cruris	Affects groin Common in men Itch mild to severe Begins as erythema of crural fold Spreads outward May spread onto thighs or buttocks Scrotum and penis usually not affected Often spread by infected towel Often associated with tinea pedis Predisposing factors: excessive sweating, diabetes mellitus, friction	Involves crural areas and upper inner thigh Scaly reddish brown lesion Sharply defined margin Central clearing absent Groin, thigh, buttock may be involved May be bilateral or unilateral Scrotum and penis usually not affected
Tinea versicolor (Pityriasis vesicolor)	Yeast infection frequently seen in young adults, less common when sebum production is reduced or absent Predisposing factors: high humidity at skin surface, high rate of sebum production Appears in summertime, fades during cooler months	Chronic superficial hypopigmented macules, sharply marginated or raised scaly lesions Commonly affects upper trunk, proximal limbs, genitalia Varies from light brown to white or pink, with varied intensities and hues
Tinea corporis	Affects any smooth, nonhairy part of body Scaly, circular or oval skin lesions Frequently itchy May be asymptomatic	Lesions variable in size Typically a well-circumscribed circular or oval patch Reddish pink and scaly Central clearing Accentuation of redness at outer border Margins scaly, vesicular or pustular

Differential Diagnosis

• Soft callus
• Wart
• Seborrheic dermatitis
• Candidal infection of foot or groin
• Local chafing or irritation of groin
• Contact, atopic or allergic dermatitis
• Psoriasis

Complications

Secondary bacterial infection (particularly with tinea pedis).

Diagnostic Tests

Take skin scrapings (KOH preparation) for mycologic investigation (fungal culture) and direct microscopy.

Management

Goals of Treatment

• Relieve symptoms
• Eradicate infection

Appropriate Consultation

Consult a physician if there is failure to respond to an adequate trial of antifungal therapy.

Nonpharmacologic Interventions

Apply compresses (Burow's solution) bid or tid to dry and relieve itch (for tinea pedis and tinea cruris only).

Client Education

• Recommend elimination of moisture and heat
• Suggest that client modify socks and footwear
• Recommend avoidance of restrictive clothing, nylon underwear, prolonged wearing of wet bathing suit or work clothes
• Counsel client about appropriate use of medications (dose, frequency, compliance)
• Recommend proper hygiene (client should change socks frequently and avoid wearing rubber shoes)

Pharmacologic Interventions

For tinea pedis and tinea cruris, topical antifungal agent for at least 2 weeks; continue until 1 week after resolution of lesions:

clotrimazole skin cream (Canesten), bid or tid

For tinea corporis, apply a topical antifungal agent such as clotrimazole for 4 weeks.

For tinea versicolor, apply selenium sulfide (2.5%) lotion or shampoo, daily to affected areas for 10-15 minutes, followed by shower, for 7-14 days.^{Footnote 21}

Monitoring and Follow-Up

Follow up in 2 weeks to ensure resolution.

Referral

Refer to physician if fungal infections are recurrent, if they develop in an immunosuppressed or diabetic client, if there is no response to therapy or if the nails become involved.^{Footnote 22}

Scabies^{Footnote 23}

Infestation of the skin by a parasitic mite.

Cause

• Sarcoptes scabiei
• Direct (skin to skin) contact with contaminated articles for up to 48 hours

Risk Factors

• Faulty application of treatment regimens
• Failure to treat close contacts
• Failure to eradicate mites from clothing and bed linen
• Daycare settings

The Aboriginal population is particularly at risk because of a number of additional factors:

• Crowded housing, shared beds, crowded schools and daycare centres
• High pediatric population
• Reduced access to medical or nursing care
• Lack of running water, which may predispose to poor hygiene and secondary skin infection
• Mites can survive much longer than 36 hours in colder conditions with high relative humidity^{Footnote 23}

History

• Severe itching
• Itching generally worse at night or after a hot shower
• Rash of hands, feet, flexural folds
• Transmitted by intimate or sexual contact with infected person
• Transmitted by clothes
• Symptoms may take 6 weeks to develop after initial contact with mite
• Symptoms are due to hypersensitivity to mite and its products

Physical Findings

• Usually affects interdigital web spaces, flexures of wrists and arms, axillae, belt line, lower folds of buttocks, genitalia, areolae of nipples
• Diffuse red rash
• Primary lesions: papules, vesicles, pustules, burrows
• Secondary lesions: scabs, excoriations, crusts, nodules, secondary infection
• Lesions in various stages present at the same time
• Secondary lesions may predominate
• Burrows (gray or flesh-coloured ridges 5-15 mm long) may be few or many
• Burrows commonly seen on anterior wrist or hand and in interdigital web spaces

Differential Diagnosis

• Pediculosis
• Impetigo
• Eczema
• Contact and irritant dermatitis

Complications

• Secondary bacterial infection

Diagnostic Tests

• None

Management

Goals of Treatment

• Eradicate infestation
• Control secondary infection
• Relieve symptoms

Appropriate Consultation

Consult physician if unsure of diagnosis.

Nonpharmacologic Interventions

Client Education

Counsel client about proper use and side effects of medication.

Control Measures

• Prophylactic therapy essential for all household members, since signs of scabies may not appear for 1-2 months after the infection is acquired
• Treat all household members at the same time to prevent re-infection
• All bed linen (sheets, pillow slips) and clothing worn next to the skin (underwear, T-shirts, socks, jeans) should be laundered in a hot soapy wash and dried with a hot drying cycle, as available
• If hot water is not available, place all bed linen and clothing into plastic bags and store away from family for 5-7 days, as the parasite cannot survive beyond 4 days without skin contact
• Children may return to daycare or school the day after treatment is completed
• Health care workers who have had close contact with clients with scabies may themselves require prophylactic treatment
• Community education, aimed at early recognition and awareness of scabies, is important
• In widespread scabies epidemics, prophylactic treatment of a whole community may be optimal management

Pharmacologic Interventions

Scabicide cream or lotion, to be applied to entire body, from chin to toes (emphasize that scabicide must be applied in skin creases, between fingers and toes, between buttocks, under breasts and to external genitalia):

permethrin 5% dermal cream (Nix) (drug of choice)

Leave on skin for 8-14 hours. A single application is usually curative but medication may be reapplied after 1 week if symptoms persist.

The safety of permethrin in pregnant and lactating women has not been established.

Pruritus may be a problem, particularly at night.

hydroxyzine (Atarax), 10-25 mg PO bid and hs prn

Instruct client that itching, nodular skin lesions and dermatitis may persist for weeks or months, even after successful treatment. Mid-potency topical corticosteroids such as betamethasone valerate cream 0.1% may help manage these.^{Footnote 24}

Monitoring and Follow-Up

• Follow up in 1 week to assess response to treatment
• Advise client to return immediately if signs of secondary infection develop

Referral

Rarely necessary if original diagnosis is correct and adequate eradication treatment is followed by the client and his or her contacts.

Stasis Dermatitis^{Footnote 25}

Inflammation of skin caused by pooling of venous blood in lower limb and chronic edema. Characterized by eczema of the legs with edema, hyperpigmentation and persistent inflammation.

Causes

• Impaired circulation resulting in chronic venous insufficiency (venous valvular incompetence)
• Secondary to peripheral vascular diseases affecting legs such as varicose veins, previous deep vein thrombosis

History

• Itchiness
• Itch worsens with use of soaps, drying, bathing
• Swelling of ankles
• Initially, swelling is relieved by elevation; later, swelling may become constant

Physical Findings

• Affects lower leg or sites of trauma or irritation
• Over-distended veins
• Localized swelling
• Tiny petechiae, crusting, exudates
• Dusky red deposits of hemosiderin in skin
• May progress to edema, redness and scaling of large area of legs
• Ulceration may occur

Differential Diagnosis

• Contact dermatitis
• Cellulitis

Complications

• Skin breakdown, ulceration
• Infection
• Deep venous thrombosis

Diagnostic Tests

• None

Management

Goals of Treatment

• Control edema
• Prevent formation of ulcers
• Prevent infection

Appropriate Consultation

Consult physician if condition progresses despite treatment or if there is skin breakdown and ulceration.

Nonpharmacologic Interventions

• Encourage client to elevate legs as much as possible and prevent venous stasis
• Application of compression stockings (30-40 mm Hg) when ambulatory (prescribed by a physician or nurse practitioner)
• Application of cool normal-saline soaks or wet normal-saline dressings in acute phase
• Lubrication of area twice daily with emollient cream
• Advise not to scratch or use irritants (soap, hot water, rough clothes, rubbing)

Pharmacologic Interventions

• None

Monitoring and Follow-Up

• Follow up in 1 week to determine if there is a response to conservative therapy
• Monitor for signs of skin breakdown, infection
• Advise client of the signs of infection and instruct him or her to return to clinic immediately if they occur

Referral

Arrange elective follow-up with physician as necessary. Patient will require a prescription for compression stockings (30-40 mm Hg).

Urticaria (Hives)^{Footnote 26}

Local wheal and erythema of skin.

Causes

• Often unknown
• Chronic idiopathic
• Hypersensitivity to foods, drugs, inhaled allergens, insect bite or sting
• Hormones
• Physical agents (for example, heat, cold, sun)
• Systemic disease (for example, systemic lupus erythematosus)
• Infection (for example, hepatitis, mononucleosis or other viral illness)
• Cholinergic trigger (heat, exercise, stress)

History

• Recent medication intake including vitamins, ASA, NSAIDs, antacids, opioids and progesterone
• Recent exposure to one of above causes
• Itchy white-to-pink patches
• Client may feel unwell

Physical Findings

• May occur anywhere on body
• May be localized or generalized
• Lesions multiple, irregular in shape and size
• Raised white or light rose-pink patches, usually surrounded by red halo
• Peripheral extension and coalescence of patches may occur
• Patches may wax and wane
• Individual wheals rarely persist for > 12-24 hours
• Signs of scratching may be evident
• Anxiety
• May progress to gasping for air, respiratory stridor and hoarseness

Differential Diagnosis

• Vasculitis
• Insect bites
• Erythema multiforme
• Systemic lupus erythematosus

Complications

• Recurrence
• Severe itching
• Systemic allergic response with bronchospasm
• Anaphylaxis

Diagnostic Tests

Referral to a dermatological specialist can be considered in consultation with a physician.  

Management

Goals of Treatment

• Relieve symptoms
• Identify precipitating factor
• Prevent recurrence
• Desensitization to the trigger antigen may be possible

Appropriate Consultation

Contact physician if any of the following pertain:

• Symptoms are severe
• Complications are present
• Client is pregnant or lactating
• Condition recurs

If shortness of breath, wheezing or swelling of tongue or mouth occurs, see "Anaphylaxis" in the chapter, "General Emergencies and Major Trauma."

Nonpharmacologic Interventions

• Application of cool compresses to reduce itching
• Avoidance of overheating
• Temporary avoidance of hot, spicy food

Client Education

• Counsel client about appropriate use of medications (dose, frequency, side effects)
• Recommend proper skin hygiene to prevent infection
• Recommend avoidance of scratching; client should keep fingernails short and clean
• Assist client in identifying causative agent (including any recent changes in food or brands, as different food companies put different additives into their products)
• Reassure client that episodes are self-limited

Pharmacologic Interventions

Apply topical antipruritic agents:

calamine lotion qid prn

Oral antihistamine to relieve itch and suppress formation of new lesions:

diphenhydramine (Benadryl), 25-50 mg PO q6-8h for 2-7 days
or
hydroxyzine (Atarax), 25-50 mg PO q6-8h for 2-7 days
or a second generation antihistamine
cetirizine (Reactine), 10 mg PO od

Monitoring and Follow-Up

• Follow up in 2-7 days
• Instruct client to return for reassessment if lesions progress despite therapy
• Instruct client to return to clinic immediately if shortness of breath, wheezing or swelling of tongue or mouth occurs; in this situation, see "Anaphylaxis" in the chapter, "General Emergencies and Major Trauma."

Referral

Refer to a physician for evaluation if lesions are recurrent (to rule out allergies or an underlying organic pathology).

Warts (Verrucae)^{Footnote 27}

Common, benign epithelial hyperkeratotic tumours categorized by location and appearance. Viral transmission is through direct contact but auto-inoculation is possible.

Causes

• Human papillomavirus

History

• Occur most commonly in children
• Single or multiple lesions
• Risk factors: break in skin, nail biting

Physical Findings

• Usually occur on hands, fingers, feet and face
• May be small or large
• May be single or in clusters
• Raised tumours with thickened, rough surface
• White, gray, yellow or brown
• Black dots (thrombosed capillaries) may be seen within wart
• Well-defined round or irregular margin
• Surface may be flat (flat wart)
• Firm, rough
• Lesions bleed from central capillaries when pared

Differential Diagnosis

• Corns
• Molloscum contagiosum

Complications

• Unacceptable cosmetic appearance
• Recurrence, enlargement or spread of warts
• Formation of keloid

Diagnostic Tests

• None

Management

Goals of Treatment

• Eradication of lesion
• Control of spread

Appropriate Consultation

Do not treat facial warts; do not treat any warts if client is pregnant. In both of these situations, arrange consultation with physician.

Nonpharmacologic Interventions

• Give the client support and encouragement to persevere, as the treatment is long and tedious
• Before each application of medication: soak affected area in warm water to soften wart; use a pumice stone to remove dead tissue, or pare away dead skin with scalpel

Client Education

• Counsel client about appropriate use of medications (dose, frequency, application, protection of surrounding skin)
• Suggest strategies to avoid spread to other areas of body and to other persons

Pharmacologic Interventions

Explain to client how to apply topical treatment to warts:

salicylic and lactic acid (Duo Film) liquid, od for up to 3 months

Remind client to protect normal surrounding skin with Vaseline petroleum jelly.

Monitoring and Follow-Up

Follow up every 2 weeks to assess response and adherence to treatment regimen.

Referral

Refer electively to a physician if no response after 12 weeks of therapy.

Dermatological Emergencies

Burns

Tissue injury caused by thermal contact.

Types of Burns^{Footnote 28,Footnote 29}

First-Degree (Superficial)

Involves epidermal layer of skin only.

Second-Degree (Partial thickness)

• Superficial: Involves epidermis and superficial portions of the dermis
• Deep: Extends to deeper dermis, damaging hair follicles and glandular tissue. Differentiation from full thickness burns is often difficult. Deep partial thickness burns can easily convert to full-thickness burn if secondary infection, mechanical trauma or progressive thrombosis occurs

Third-Degree (Full thickness)

Extends through and destroys dermis. Involves every body system and organ and extends to subcutaneous tissue, damaging muscle, bones and interstitial tissue.

Causes

Thermal

• Flame; tends to cause full-thickness burn, especially if clothing burns
• Molten metal, tars or melted synthetics lead to prolonged skin contact

Electrical

• Similar to crush injuries: muscle necrosis, rhabdomyolysis, myoglobinuria occur
• Require special consideration as these burns are often more serious than they appear; always assume that an electrical burn is severe

Chemical

• Strong acids are quickly neutralized or quickly absorbed
• Alkalis cause liquefaction necrosis and can penetrate deeply, leading to progressive necrosis up to several hours after contact

Radiation

• Initially appear hyperemic; may later resemble third-degree burns
• Damage can extend deep into the tissue
• Sunburns are of this type and involve moderate superficial pain

History

Defer history until airway, breathing and circulation (ABC) have been assessed and stabilized.

• Obtain accurate description of exact mechanism of injury and onset
• Inquire about any treatment given at home (for example, cooling, application of oils)
• Obtain medical history (when time permits)
• Determine medications (when time permits)
• Determine allergies (when time permits)
• Determine tetanus vaccination status

Physical Findings

• Assess ABC
• Look for singed nasal hair, hypoxia, soot-stained sputum persistent cough and/or respiratory obstruction to indicate inhalational injury^{Footnote 30}
• Temperature may be elevated if inflammation and infection is developing
• Heart rate may be elevated
• Blood pressure may be low if client is in shock
• Determine depth (see Table 3, "Burn Depth") and extent (see Table 4, "Assessing Extent of a Burn [Rule of Nines]" and chart) of the burn

Table 3: Burn Depth^{Footnote 31}

Depth	Cause	Appearance	Sensation	Healing time
Superficial (First-Degree)	Ultraviolet exposure Very short flash	Dry, red Blanches with pressure	Painful	3-6 days
Superficial partial-thickness (Second-Degree)	Scald (spill or splash) Short flash	Blisters Moist, red, weeping Blanches with pressure	Painful to temperature and air	7-20 days
Deep partial-thickness (Second-Degree)	Scald (spill) Flame Oil Grease	Blisters (easily unroofed) Wet or waxy dry Variable color (patchy to cheesy white to red) Does not blanch with pressure	Perceptive of pressure only	> 21 days
Full-thickness (Third-Degree)	Scald (immersion) Flame Steam Oil Grease Chemical Electrical	Waxy white to leathery gray to charred and black Dry and inelastic No blanching with pressure	Deep pressure only	Never (if > 2 percent total body surface area)

Table 4: Assessing Extent of a Burn (Rule of Nines)

Body Part Surface Area	Percentage of Body
Head	9
Both arms	18
Anterior trunk	18
Posterior trunk	18
Both legs	36
Palm of hands	1
Total	100

Adult Rule of Nines

Source of illustration: Firefighter Nation WebChief (2008)  Determining Depth and Percentage of Burn Injuries.

Table 5: Classification of Burns by Severity (Surface Area Involved)^{Footnote 32}

Adapted from: Joffe MD. (2009, May).  Emergency care of moderate and severe thermal burns in children. UpToDate Online 17.2.

Differential Diagnosis

• Small areas of deep burning (full-thickness - 3rd degree) within superficial burn (partial-thickness - 2nd degree)
• Toxic epidermal necrolysis  

Complications

• Increasing depth of burn
• Shock
• Secondary infection
• Sepsis
• Renal failure

Diagnostic Tests

• None

Management

Management is based on the depth of the burns and an accurate estimate of total body surface area (see Table 4, "Assessing Extent of a Burn (Rule of Nines)" and Table 5, "Classification of Burns by Severity [Surface Area Involved]").

Goals of Treatment

• Promote healing and restoration of tissue
• Prevent complications

Adjuvant Therapy^{Footnote 32}

Check whether tetanus vaccination is up to date; give tetanus vaccine as needed (refer to the most recent Canadian Immunization Guide).

Nonpharmacologic Interventions

The first step is general first aid, cleansing and cooling the affected area.

• Thermal burn: Rapidly remove clothing or jewellery and any obvious debris in contact with the area to decrease contact time and allow accurate assessment. Immerse in cool water or apply cool compresses to reduce heat and prevent extension of burn (see "Nonpharmacologic Interventions," "Second-Degree Burns"). Exercise caution if cooling burns of > 10% and < 20% in size. Severe burns should not be immersed or be cooled if core body temperature is below 35 degrees Celsius. Use warm intravenous fluids to maintain core temperature^{Footnote 33}
• Chemical burn: Irrigate. If dry powder is still visible on the skin, brush it away before irrigating the skin with water. Irrigate with copious amounts of water for at least 15 (preferably 30) minutes after powders have been removed. This process should be started at the accident scene if possible. Alkali burns should be irrigated for 1-2 hours after injury. Call poison control centre for specific instructions. Chemical burn depth is difficult to assess until tissue begins to slough days later. All chemical burns should be considered deep partial-thickness or full thickness until proven otherwise^{Footnote 34}
• Tar burn: Cool, clean gently and apply a petrolatum-based antibacterial ointment (for example, Polysporin) or other petroleum-based product. Do not attempt to scrape tar off the skin surface, as this can cause further damage. Avoid chemical solvents, which may cause additional burns. After 24 hours the tar can be washed away and the injury treated as a thermal burn
• Electrical burn: Be cautious and observe the client closely. Watch for cardiac arrhythmias, fractures secondary to muscle contraction and compartment syndromes.32 Cardiac monitoring for 24 hours is essential if there was significant exposure to electrical current. Apply a cervical collar. An electrical burn may cause thrombosis of any vessel in the body. Clean and dress as for a thermal burn

Treatment of Minor Burns

Appropriate Consultation

Consult a physician if there are any concerns about the burn or client (for example infection, age, pain).

Nonpharmacologic Interventions^{Footnote 29,Footnote 33}

First-Degree Burns

• Cleanse with normal saline or sterile water
• Dressings: Cover area lightly with sterile, dry gauze, hydrogel sheet (for example, 2nd Skin^TM) or a non-adherent mesh gauze dressing (for example, Jelonet^TM, Adaptic^TM dressings)

Second-Degree Burns

• Remove any attached clothing and debris
• Cleanse with sterile water or normal saline
• If using silver-coated dressing, cleanse with sterile water only
• In small and moderate size burns, cooling of the burn area using cool water or saline-soaked gauze can minimize the zone of injury. Saline-soaked gauze at 12 degrees Celsius applied for 15-30 minutes for the first several hours after injury, effectively decreases burn pain. Monitor core temperature while cooling especially if > 10% burns are involved. Discontinue cooling if body temperature is below 35 degrees Celsius. Use warm intravenous fluids to maintain core temperature
• Gently débride using sterile technique
• Ruptured blisters should be removed but the management of clean, intact blisters is controversial. Never attempt needle aspiration of a blister as this increases the risk of infection. Unroofing blisters with cloudy fluid or if rupture is imminent, such as over a joint, can be recommended. Blisters present for several weeks without resorption may indicate an underlying deep partial or full thickness burn which will necessitate a referral
• Dressings: Silver-coated, low-adherent dressing (for example Acticoat^TM) can be used as an antimicrobial barrier layer for partial and full-thickness wounds. Use sterile water for cleansing and soaking of the dressing prior to application, if using this class of dressing. Refer to Appendix A for additional decisional tools for the ongoing management of wounds
• There is some evidence for the use of topical antibiotics (for example, Bactracin or antibiotic-impregnated dressings such as Sofratulle^TM) in the management of superficial partial-thickness burns. However there is no clear evidence demonstrating improved outcomes in minor burns using such treatments
• The application of non-adherent porous mesh gauze dressing to superficial partial-thickness burns can also be considered
• There is no role for steroids in the treatment of minor burns

Client Education

• Counsel client about appropriate use of medications (dose, frequency)
• Suggest that analgesics be taken 1 hour before dressing changes
• Recommend that dressing be kept clean and dry until area healed

Pharmacologic Interventions

Analgesia:

ibuprofen (Motrin), 200 mg, 1-2 tabs PO q6h prn
or
acetaminophen (Tylenol), 325 mg, 1-2 tabs, q4h prn
or
acetaminophen with codeine (Tylenol #3), 1-2 tabs q4-6h prn (maximum 12 tabs/day)

Regular dosing may be necessary rather than prn.

Larger, more severe deep partial-thickness burns require topical antibiotic ointment or impregnated dressings (ointments can make evaluation of drainage difficult). Apply:

framycetin sulfate (Sofratulle) dressing od
or
silver sulfadiazine (Flamazine), od

Absolute contraindication to silver sulfadiazine: term pregnancy.

Relative contraindication to silver sulfadiazine: possible cross-sensitivity to other sulfonamides, pregnancy.

Prophylactic antibiotics should rarely be required but may be considered for:

• immunocompromised clients
• clients at high risk of endocarditis
• clients with artificial joints

Broad-spectrum coverage with first-generation cephalosporin or with a penicillinase-resistant penicillin plus an aminoglycoside may be used if necessary.

Discuss choice with a physician.

Monitoring and Follow-Up

• Follow up in 24 hours and daily until the burn is healed
• Re-evaluate depth and extent of injury
• Monitor for healing and development of infection
• Cleanse and débride prn; tub soaks can help loosen coagulum and speed separation of necrotic debris
• Reapply Sofratulle dressing or silver sulfadiazine and dry sterile dressing

Absolute sterility is not mandatory during dressing changes; however, cleanliness and thorough cleaning of hands, sinks, tubs and any instruments used is emphasized.

Treatment of Moderate and Severe Burns

Always watch for renal failure from rhabdomyolysis and sepsis in clients with severe burns.

Appropriate Consultation

Consult a physician as soon as the client's condition is stabilized.

Adjuvant Therapy^{Footnote 34,Footnote 35}

Perform Primary Survey

• Stabilize ABC
• Establish airway and assist ventilation as required
• Administer oxygen at 6-10 L/min or more; keep oxygen saturation > 97% to 98%
• Start IV therapy with Ringer's lactate or normal saline
• Replace fluid losses:
  • Initiate fluids if > 15% to 20% of body surface area
  • Infuse warm Normal saline or Ringer's lactate
  • In adults: 2-4 mL X body weight in kilograms X % of Total Body Surface Area (TBSA) burned
  • Administer one half of fluid in the first 8 hours from time of burn injury; remainder of fluid is administered over the next 16 hours
  • Maintain hourly urine output at 0.5 to 1 mL/kg in adults. If output exceeds that rate, test for glucose
  • Clinical signs of volume status, such as heart rate, blood pressure, pulse pressure, distal pulses, capillary refill and color and turgor of uninjured skin are monitored every hour for the first 24 hours. Inadequate fluid resuscitation is the most common cause of diminished distal pulses in the newly burned patient
• Moderate burn areas (see Table 5, "Classification of Burns by Severity (Surface Area Involved") can be cooled using cool water or saline soaked gauze, which can also minimize the zone of injury. Saline-soaked gauze at 12 degrees Celsius can be applied for 15-30 minutes for the first several hours after injury. Monitor core temperature while cooling especially if > 10% burns are involved. Discontinue cooling if body temperature is below 35 degrees Celsius. Use warm intravenous fluids to maintain core temperature.

Burn shock usually takes hours to develop. If shock is evident on initial presentation, look for other causes of volume loss such as a major injury elsewhere in the body. Refer to "Shock" in the chapter, "General Emergencies and Major Trauma."

Special Considerations for Resuscitation

• Restlessness may be secondary to hypoxia
• Assume smoke inhalation (see "Inhalation of Toxic Materials" in the chapter "General Emergencies and Major Trauma.")
• Monitor for respiratory distress or respiratory failure

Perform Secondary Survey and Identify Associated Injuries

• Insert urinary catheter if appropriate
• Insert nasogastric tube if appropriate
• Assess peripheral circulation if client has circumferential burn on extremities
• Monitor colour, capillary refilling, paresthesia and deep tissue pain

Nonpharmacologic Interventions

Wound Care

• Cover burns with sterile, dry dressings
• See "Nonpharmacologic Interventions," "Second Degree Burns") for the management of blisters
• Do not immerse or apply cold water to severe burns (see Table 5, "Classification of Burns by Severity [Surface Area Involved]")

Pharmacologic Interventions

For analgesia, consult a physician first, if possible; otherwise give:

morphine 5-10 mg IM or SC, or morphine 2.5-5 mg IV stat

Monitoring and Follow-Up

• Monitor ABC and vital signs frequently
• Watch for signs of shock (it usually takes hours for burn shock to develop)
• In circumferential burns, extensive extremity burns or electrical burns, watch for vascular or neurologic compromise, which indicates a developing compartment syndrome; immediate escharotomy is required
• Elevate extremities to minimize swelling

Referral

Medevac as soon as possible (using criteria in Table 6, "Criteria for Transfer of Burn Patient").

Table 6: Criteria for Transfer of Burn Patient^{Footnote 35}

Frostbite^{Footnote 36,Footnote 37}

Thermal injury to tissue caused by cold. Injury may occur without (see Table 7, "Types of Cold Injury Without Frostbite") or with (see Table 8, "Classification of Frostbite") freezing of the tissue. Freezing of the tissu

Table 7: Types of Cold Injury Without Frostbite

Type of Injury	Cause	Clinical Observations	Treatment
Chilblain (peripheral cold injury without freezing of tissue)	Prolonged dry exposure at temperatures above freezing	Affected areas are pruritic, reddish blue; may be swollen; may have blisters or superficial ulcerations; areas may be more temperature sensitive in future; no permanent injury	Rewarm as for frostbite (see Nonpharmacologic Interventions); pain medication should be provided
Trench foot and immersion injury	Prolonged wet exposure at temperatures above freezing	May have tissue destruction resembling partial-hickness burns, including blisters, pain, hypersensitivity to cold; temperature sensitivity may be permanent	Rewarm as for frostbite (see Nonpharmacologic Interventions)

e is defined by the formation of ice crystals.

Table 8: Classification of Frostbite^{Footnote 38,Footnote 39}

1st degree injury (frostnip)	2nd degree injury	3rd degree injury	4th degree injury
Gross appearance of the injured area
Superficial, skin changes reversible White to yellow firm plaque, numb; loss of sensation Comparable to superficial (first-degree) hot thermal burn	Superficial blisters containing clear or milky fluid with or without erythema and edema in surrounding tissue Blisters appear in 24-48 hours; fluid reabsorbs; hard, blackened eschar may develop; remains sensitive to heat and cold Treat conservatively; generally resolves without surgical intervention in 3-4 weeks	Deeper blisters containing red or purple fluid, OR darkly discoloured skin without blisters Tissue feels woody under skin; affects muscles, tendons, etc. Hemorrhagic blisters and loss of distal function; may take several months to determine extent of injury Frozen tissue will eventually slough	Extensive dark and cyanotic skin without blisters or edema
Outcome
Central pale area surrounded by erythema with no tissue lost but pain may be present	Limited superficial skin loss with blisters surrounded by erythema and edema	Hemorrhagic blisters and eschar formation leading to various outcomes depending on depth of injury.	Necrosis and tissue lost. Gangrene can occur within a few hours

Adapted from: Hoyt KS, Selfridge-Thomas J, editors. Emergency nursing core curriculum. 6th ed. Emergency Nurses Association and Saunders-Elsevier; 2007 and Robson MC, Smith DJ Jr. Cold injuries. In: McCarthy JG (Ed.). Plastic surgery. WB Saunders Company; 1990. p. 849-66.

Cause

Exposure to cold.

History

Ninety percent of frostbite cases involve the hand and feet, while cheeks, nose, ears and penis are commonly affected.^{Footnote 40}

Frostnip

• Initially cold, burning pain
• Area becomes blanched
• With rewarming, area becomes reddened

Frostbite

• Cold burning pain progresses to tingling
• Later, numbness or heavy sensation
• Area becomes pale or white
• Rewarming causes pain, throbbing or burning sensation
• Evaluate for hypothermia
• Contributing factors: alcohol intoxication, homelessness, inappropriate clothing for weather

Physical Findings

• Variable
• Temperature may be reduced if there is associated hypothermia or elevated if there is infection
• Client in mild-to-acute distress
• Affected area may be reddened, blue or white
• Edema may be present
• Blisters may be present
• Infection may be evident if client presents later
• Area is initially cold and hard to touch
• Sensation reduced
• If rewarming has occurred, area will be warm and tender
• Excessive sweating
• May be necrosis present

See also Table 7, "Types of Cold Injury Without Frostbite" and Table 8, "Classification of Frostbite."

Differential Diagnosis

• Superficial versus deep frostbite

Complications

• Infection
• Hypothermia
• Tissue loss
• Hypersensitivity to cold in affected area may last several years or be permanent

Management

Goals of Treatment

• Identify associated hypothermia and/or dehydration
• Rewarm parts
• Control pain (active rewarming is very painful)
• Address wound care
• Prevent infection

Treat frostnip and superficial frostbite as you would a superficial first-degree thermal burn. See "Nonpharmacologic Interventions," "First-Degree Burns."

Appropriate Consultation

Consult a physician for all but first-degree (frostnip) injury.

Adjuvant Therapy

Check whether tetanus vaccination is up to date; give tetanus vaccine as needed (refer to the most recent Canadian Immunization Guide).

Nonpharmacologic Interventions

• Rapidly rewarm affected part by immersing it in 40° C water (slow rewarming is not good)
• Continue rewarming until skin is warm, soft, pliable and flushed red
• Rest affected limb; avoid irritation to skin
• Be careful; do not rub and do not use hot water bottles
• Prevent refreezing; if in the field, do not thaw extremity until it is certain that it will not refreeze
• Elevate limb once it is rewarmed; leave exposed if possible
• Do not break blisters unless they interfere with range of motion in a limb
• Separate toes and fingers with dry cotton gauze
• Wrap client loosely in bulky soft material and protect from injury and exposure during transport
• Give warm fluids to drink
• Forbid smoking; nicotine narrows small arteries reducing blood flow

Prevention Education

• Dress in layers with appropriate cold-weather gear
• Cover all exposed skin areas
• Prepare properly for trips in cold climates

Pharmacologic Interventions

Mild Frostbite

Analgesia for pain:

ibuprofen (Motrin), 200 mg, 2 tabs PO q4h prn (preferred choice)
or
acetaminophen (Tylenol), 325 mg, 1-2 tabs PO q4h prn

Moderate to Severe Frostbite

For analgesia, as pain may be severe during rewarming, consult a physician first, if possible; otherwise give:

morphine 5-10 mg IM or SC, or morphine 2.5-5mg IV stat

Upon physician consult, continue with pain control as appropriate, for example:

morphine 2-4 mg, IV or IM or SC q3-4h prn titrating to effect

Be alert for respiratory depression with opioids.

Monitoring and Follow-up

Mild Frostbite

Reassess and re-dress wound daily for 4-7 days, until the wound is healing well. Monitor for signs of infection.

Referral

Medevac anyone with moderate-to-severe frostbite to hospital as soon as possible.

Skin Wounds of Traumatic Origin

Breach in the integrity of the external surface of the body

Causes

• Blunt trauma: split- or crush-type injuries will swell more and tend to have more devitalized tissue and a higher risk of infection
• Sharp trauma: clean edges, low cellular injury and low risk of infection
• Bite injury: animal or human bites have a high risk of infection

Types of Traumatic Wound^{Footnote 41}

Wounds that result from trauma can be categorized by type.

Table 9: Classification of Wound Type

Wound type	Definition
Laceration	Open wound that results from blunt or sharp trauma to the skin
Abrasion	Skin lesion caused by tangential trauma to the dermis and epidermis, similar to a burn
Avulsion	Full thickness tissue loss that prevents the approximation of the edges of the wound. Commonly seen in fingertip, tip of nose, ear lobe or loss of permanent teeth injuries A severe form of avulsion is "degloving" where the full thickness of the skin is peeled away form a finger, hand, foot or an area of limb, causing devascularization of the skin and damage to underlying tissues
Puncture wound	Tissue penetration by a blunt or sharp object
Foreign body	Any object (for example, wood or metal splinter, body jewellery, glass, fishhook, fragment from gunshot, needles) that becomes embedded in any part of the body. Vegetative foreign bodies (for example, thorns or wood) are highly reactive, lead to infection and should be removed as soon as possible
Missile or velocity wound	Skin lesions caused by an object entering the body at a high speed
Bites	Skin lesion self-inflicted (human) or as a result of a person-to-person (human) or animal contact are at increased risk of infection

History

• Mechanism of injury, risk of foreign body
• Contaminants: wound contact with manure, rust, dirt, etc., will increase risk of infection
• Wounds sustained in barnyards or stables should be considered contaminated (Clostridium tetani is indigenous in manure)
• Time of injury (after 3 hours, the bacterial count in a wound increases dramatically)
• Amount of blood lost
• Loss of function in nearby tendons, ligaments, nerves (sensation)
• Medical illnesses, conditions, treatments (for example, diabetes mellitus, chemotherapy, steroids, peripheral vascular disease and malnutrition may delay wound-healing and increase the risk of infection)
• Allergies (to drugs, dressings, local anesthetics)
• Medications currently used (especially steroids, anticoagulants)
• Status of tetanus vaccination

Physical Examination

• Temperature
• Heart rate, blood pressure (if significant blood loss from wound)
• Dimensions of wound, including depth

Assess for infection:

• Redness
• Heat
• Tenderness
• Discharge
• Fever
• Local lymphadenopathy

Assess integrity of underlying structures (nerves, ligaments, tendons, blood vessels):

• Vascular injury: Capillary refill should be checked distally
• Neurologic injury: Check distal muscle strength, movement distal to wound and sensation. Always check sensation before administering anesthesia. For hand and finger lacerations check two-point discrimination, which should be < 1 cm at the fingertips
• Tendons: Can be evaluated by inspection, but individual muscles must also be tested for full range of motion and full strength. Assess range of motion of all body parts surrounding the wound site
• Bones: Check for open fracture or associated fractures
• Foreign bodies: Inspect the area

Complications

• Infection
• Poor healing
• Laceration of nerve
• Compartment syndrome: loss of sensation may be the first sign; pain severe, out of proportion to injury
• Crush injury may decrease two-point discrimination, and it may take several months to recover
• Injury to major vascular structures (for example, artery)
• Injury to tendon
• MRSA from animal bites^{Footnote 16}
• Rabies infection

Diagnostic Tests

• Usually none
• If there is strong clinical suspicion of foreign body, x-ray or ultrasound may be necessary

Management

Goals of Treatment

• Restore function
• Minimize risk of infection
• Repair injured tissue integrity

Appropriate Consultation

Consult a physician if any of the following pertain:

• Wound is extensive, deep or infected
• Muscle, tendon, nerve or vascular compromise is present or suspected
• Significant tissue deficit is present
• Wound is more than 12 hours old
• The wound is a result of a bite

Adjuvant Therapy

Check whether tetanus vaccination is up to date; give tetanus vaccine as needed (refer to the most recent Canadian Immunization Guide).

Nonpharmacologic Interventions

Wound Repair: General Principles

• Most wounds may be closed with tissue adhesive or sutures up to 12 hours after the injury. Refer to the Pediatric Procedures chapter for indications and contraindications to the use of tissue adhesives. Use clinical judgement when choosing which wounds to close and by which method
• Do not suture or glue wounds that are infected or inflamed, dirty wounds, human or animal bites, puncture wounds, neglected wounds or severe crush wounds
• Do not suture diabetic or steroid-dependent patients with dissolvable sutures
• Wounds on the face that are up to 24 hours old may be closed after thorough cleaning. The blood supply in this area is much better and the risk of infection therefore much lower
• Do not clamp vascular structures until it is determined if the vessel is a significant one needing repair

Homeostasis

Direct pressure is the first choice for controlling bleeding. If a fracture is involved, immobilization will help control bleeding.

Skin Preparation

• Débridement:Using aseptic technique, remove devitalized tissue; avoid taking healthy tissue. High-pressure irrigation is the most effective means of cleansing a wound. Use normal saline in a 60 mL syringe with an 18- or 19-gauge needle or IV catheter attached
  
  Scrubbing does not cleanse the wound as well, and using any disinfectant in the wound damages healthy cells needed for healing.
• Skin disinfection: Can be performed with povidone-iodine solution. Avoid getting the solution in the wound, because it will impede healing. Hair can be clipped in the area if necessary. Shaving hair is not recommended.

Never shave eyebrows. They are needed for alignment of the wound and may not grow back.

Open Wound Care

• To keep the wound open, pack it with bulky, wet saline gauze dressings daily. This will keep the tissue moist and help débride
• Avoid iodine dressings because they damage healthy tissue and slow granulation
• When clean granulation tissue is apparent, secondary closure may be considered; alternatively, the dressing can be changed to dry, sterile, packing material

Wound Closure

• Steri-Strips: If the wound is small and shallow and falls together naturally along lines where there is no tension, it may only need to be reinforced with steri-strips. Dress the wound with dry sterile gauze. Instruct client to keep wound clean and dry for 48 hours
• If a laceration is above the fascia and measures 5 centimeters (cm) or less in length and 0.5 cm or less in width, and if edges can be approximated easily, with no or minimal tension, tissue adhesives may be considered. Refer to the Pediatric Procedures chapter for contraindications to the use of TA
• Suturing: Larger wounds need suturing (see Table 10, "Types of Suture Material for Particular Sites"). Close in layers as necessary using simple interrupted sutures

Table 10: Types of Suture Material for Particular Sites

	Type of Suture	Size	Body Area
Non-absorbable	Nylon-Dermalon, Ethilon	#3-0, 4-0 #5-0, 6-0 #3-0, 4-0, 5-0 #3-0, 4-0, 5-0 #3-0, 4-0, 5-0	Scalp Forehead Back Torso Limbs
	Nylon coated with polypropylene glycol (Prolene)	#5-0, 6-0	Face
Absorbable	Polygalactin (Vicryl, Dexon) Monofilament (Monocryl)	#4-0, 5-0	Subcutaneous tissue Muscle

Types of Suture Needles

• Precision-point cutting needles and small sutures (#5-0 or #6-0) should be chosen when a cosmetic closure is important (for example, on the face)
• Conventional cutting needles with #4-0 or #3-0 nylon sutures are used for routine skin closure

Local Anesthetic for Suturing

Lidocaine (1% is the most frequently used local anesthetic [onset 2-5 minutes, duration 30-60 minutes]):

lidocaine (Xylocaine), 1% without epinephrine, 4.5 mg/kg (maximum 30 mL)

Nurses should use 1% lidocaine without epinephrine as the first choice when suturing a wound as epinephrine prolongs the anesthetic effect and is contraindicated for areas with end arteries or poor circulation (digits, nasal tip, ears, penis).^{Footnote 42} Although rare, an allergic reaction to lidocaine is possible; ensure access to an anaphylaxis kit.

Never use lidocaine with epinephrine on the ears, nose, fingers, toes or penis.

• Use a 27- or 30-gauge needle to inject the lidocaine
• Infiltrate the anesthetic slowly through the open wound edge, avoiding the intact skin
• Always pull back on plunger to ensure the needle is not in a blood vessel
• Administer subsequent injections into an area that has already been anesthetized
• It may be of value to dribble a small amount of lidocaine onto the wound before infiltration to provide some initial anesthesia
• Give anesthetic 5 minutes to be effective
• If extensive suturing is required, it may be necessary to anesthetize and suture a small area at a time to prevent the anesthetic from wearing off before suturing is complete
• Toxic effects of lidocaine: Observed if anesthetic is injected into a blood vessel inadvertently; symptoms include dizziness, tinnitus, nystagmus, seizures, coma, respiratory depression, arrhythmias and seizures (all symptoms are usually self limiting)

Ongoing Management of Wounds

The general principals in the ongoing management of wounds include the need for debridement, control of the bacterial burden and control of the moisture balance.⁷ A number of Best Practice Guidelines from the Registered Nurses Association of Ontario address common wound care issues. Refer to the "Chronic Wounds" section for the list of guidelines available. A selection of decisional tools in the management of wounds can be found in Appendix A.

Pharmacologic Interventions

Antibiotic Prophylaxis

There is no medical indication for prophylactic antibiotics in routine, uncontaminated skin wounds. However, consider prophylactic antibiotic use for clients prone to endocarditis, clients with hip prostheses or lymphedema, diabetic clients with a contaminated foot wound, or other clients with peripheral vascular disease or immunocompromise:

cloxacillin, 500 mg PO qid for 7 days

For clients with allergy to penicillin:

erythromycin, 1g PO daily divided bid, tid or qid

Topical Antibiotics

Consider topical antibiotic ointment for wounds on face and torso:

bacitracin/polymyxin B (Polysporin) ointment, tid or qid for 5 days

Alternatives include the use of antibiotic-impregnated dressings such as Sofratulle^TM or silver-coated low-adherent dressing (for example, Acticoat^TM) which act as an antimicrobial barrier.

Antibiotic ointment should not be left on wounds of the distal extremities for more than 24-48 hours because it may lead to maceration and could delay wound-healing.

Antibiotics for Bites

Human Bites

Antibiotics should be given prophylactically for all human bites:

amoxicillin/clavulanate (Clavulin), 875 mg PO bid for 3-5 days^{Footnote 43}

Antibiotics for an infection that is already present, the drug of choice for all human bites:

amoxicillin/clavulanate (Clavulin), 875mg PO bid for 7-10 days^{Footnote 44}

Cefuroxime axetil or doxycycline (for those > 8 years of age) are acceptable alternatives.^{Footnote 43}

Consider IV antibiotics if infection has already occurred, especially for a bite on the hand.

Cat Bites

Antibiotics should be given prophylactically for all cat bites:

amoxicillin/clavulanate (Clavulin), 875 mg PO bid for 3-5 days^{Footnote 45}

Antibiotics for an infection that is already present, the drug of choice for all cat bites:

amoxicillin/clavulanate (Clavulin), 875 mg PO bid for 7-10 days^{Footnote 44}

Cefuroxime axetil or doxycycline (for those > 8 years of age) are alternatives.^{Footnote 45}

Dog Bites

About 20% of dog bites become infected^{Footnote 45} and prophylaxis is only recommended under certain circumstances: moderate/severe bites; crush injury/edema; age > 50 years; puncture wounds; bone/joint involvement; injuries to hand, foot, face, genitalia; splenectomized patients; immunocompromised.^{Footnote 45} These should be discussed with a physician. If there is a need to treat, amoxicillin/clavulanate is the drug of choice (as for other types of bites). Consider need for rabies prophylaxis (see the most recent  Canadian Immunization Guide for details).

Monitoring and Follow-up

• Risk of infection highest in the first 48 hours, so all wounds should be rechecked daily until it is clear that infection is not developing
• After that, follow up when it is time to remove sutures
• Instruct client to return for reassessment if redness, swelling, discharge, pain or fever develops

General Guidelines for Removing Sutures

• Wound appears clean and healed
• Wound appears dry; no drainage evident
• For larger wounds it is advisable to initially remove alternate sutures to ensure that wound edges stay approximated
• Sutures should be removed according to the recommendations in Table 11, "Timing of Removal of Sutures"

Table 11: Timing of Removal of Sutures^{Footnote 47}

Wound location	Removal time
Face	3-5 days; steri-strip reinforcement after suture removal
Scalp	5-8 days
Neck	3-5 days
Chest	7-10 days
Abdomen	7-10 days
Back	10-12 days
Upper extremity
Nonjoint surface	7-10 days
Joint surface	10-12 days (consider splinting)
Lower extremity
Thigh	7-10 days
Knee	12-14 days
Lower leg	7-10 days
Foot	7-10 days

Increase time before removal of sutures in diabetic or steroid-dependent clients in whom healing may take several weeks. The use a heavier type of suture (for example, #3-0) and close monitoring for signs of infection may be required.

Referral

Consider consulting a physician: 

• When there is suspicion of injury to major structures (for example, tendons, ligaments, nerves, vessels). They may require plastic surgery repair
• For lacerations involving eyelid or ear cartilage, that cross vermillion border of lip, and that are complex or very irregularly shaped
• Open fracture is an indication for surgical débridement and repair (except in the case of fracture of a distal phalanx, where copious irrigation and oral antibiotics are acceptable treatment if the injury can be monitored carefully for infection and the bone is aligned)

Appendix A - Decisional Tools in the Ongoing Management of Wounds

The following tables were reproduced with permission from the Registered Nurses Association of Ontario (RNAO) Best Practice Guideline titled:  Assessment & Management of Stage I to IV Pressure ulcers Revised March 2007.

Key Factors in Deciding Method of Debridement

	Surgical	Enzymatic	Autolytic	Biologic	Mechanical
Speed	1	3	5	2	4
Tissue selectivity	3	1	4	2	5
Painful wound	5	2	1	3	4
Exudate	1	4	3	5	2
Infection	1	4	5	2	3
Cost	5	2	1	3	4

Where 1 is most desirable and 5 is least desirable.

Clinical Signs and Symptoms of Wound Infection

Superficial, Increased Bacterial Burden (Critically Colonized)	Deep Wound Infection	Systemic Infection
Non-healing Bright red granulation tissue Friable and exuberant granulation New areas of breakdown or necrosis on the wound surface (slough) Increased exudates that may be translucent or clear before becoming purulent Foul odor	Pain Swelling, induration Erythema Increased temperature Wound breakdown Increased size or satellite areas Undermining Probing to bone	Fever Rigors Chills Hypotension Multiple organ failure

Cleansing Solutions

Agent	Effects
Sodium hypochlorite solution	High pH causes irritation to skin. Dakins Solution and Eusol (buffered preparation) can select out gram-negative micro-organisms.
Hydrogen peroxide	De-sloughing agent while effervescing. Can harm healthy granulation tissue and may form air emboli if packed in deep tissue.
Mercuric chloride, crystal violet, Proflavine	Bacteriostatic agents active against Gram-positive species only. May be mutagens and can have systemic toxicity.
Cetrimide (quarternary ammonium)	Good detergent, active against Gram-positive and -negative organisms, but high toxicity to tissue.
Chlorhexidine	Active against gram-positive and -negative organisms, with small effect on tissue.
Acetic acid (0.5% to 5%)	Low pH, effective against Pseudomonas species, may select out S. aureus.
Povidone iodine	Broad spectrum of activity, although decreased in the presence of pus or exudates. Toxic with prolonged use or over large areas.

Topical Antimicrobials Useful in Wounds with Overt and Covert Infection

Agent	S. Aureus	MRSA	Streptococcus	Pseudomonas	Anaerobes	Comments	Summary
Where "" indicates the infection(s) to which the agent is useful.
Cadexomer Iodine						Also debrides. Low potential for resistance. Caution with thyroid disease.	Low risk and effective
Silver						Do not use with saline. Low potential for resistance.
Silver Sulfadiazine						Caution with sulphonamide sensitivity
Polymycin B Sulphate/Bacitracin Zinc						Bacitracin in the ointment is an allergen; the cream formulation contains the less-sensitizing gramicidin.	Use selectively
Mupirocin						Reserve for MRSA and other resistant Gram+ species
Metrondiazole						Reserve for anaerobes and odour control. Low or no resistance of anaerobes despite systemic use.
Benzoyl peroxide	Weak	Weak	Weak		Weak	Large wounds. Can cause irritation and allergy.
Gentamicin						Reserve for oral/IV use-topical use may encourage resistance.	Use with caution
Fusidin ointment						Contains lanolin (except in the cream).
Polymyxin B sulphate/Bacitracin zinc neomycin						Neomycin component causes allergies, and possibly cross-sensitizes to aminoglycosides.

Modern Classes of Dressing

Generic Categories		Local Wound Care			Care Considerations
Class	Description	Tissue Debridement	Infection	Moisture Balance	Indications/Contraindications
Use with caution if critical colonization is suspected. Dressing is appropriate to address tissue debridement, infection and/or moisture balance. Dressing is very appropriate to address tissue debridement, infection and/or moisture balance. Dressing is most appropriate to address tissue debridement, infection and/or moisture balance. Dressing not considered beneficial May or may not be an appropriate dressing
1. Films/Membranes	Semi-permeable adhesive sheet. Impermeable to H2O molecules and bacteria				Moisture vapour transmission rate varies from film to film. Should not be used on draining or infected wounds. Create occlusive barrier against infection.
2. Non-adherent	Sheets of low adherence to tissue. Non-medicated tulles.				Allow drainage to seep through pores to secondary dressing. Facilitate application of topicals.
3. Hydrogels	Polymers with high H2O content. Available in gels, solid sheets or impregnated gauze.				Should not be used on draining wounds. Solid sheets should not be used on infected wounds.
4. Hydrocolloids	May contain gelatin, sodium cabozymethylcellulose, polysaccharides and/or pectin. Sheet dressings are occlusive with polyurethane film outer layer				Should be used with care on fragile skin. Should not be used on heavily draining or infected wounds. Create occlusive barrier to protect the wound from outside contamination. Characteristic odour may accompany dressing change and should not be confused with infection.
5. Calcium alginates	Sheets or fibrous ropes of calcium sodium alginate (seaweed derivative). Have hemostatic capabilities.				Should not be used on dry wounds. Low tensile strength - avoid packing into narrow deep sinuses. Bioreabsorbable.
6. Composite dressings	Multilayered, combination dressings to increase absorbency and autolysis.				Use on wounds where dressing may stay in place for several days.
7. Foams	Non-adhesive or adhesive polyurethane foam. May have occlusive backing. Sheets or cavity packing. Some have fluid lock.				Use on moderate to heavily draining wounds. Occlusive foams should not be used on heavily draining or infected wounds.
8. Charcoal	Contains odour-adsorbent charcoal within product.				Some charcoal products are inactivated by moisture. Ensure that dressing edges are sealed.
9. Hypertonic	Sheet, ribbon or gel impregnated with sodium concentrate.				Gauze ribbon should not be used on dry wounds. May be painful on sensitive tissue. Gel may be used on dry wounds.
10. Hydrophilic fibres	Sheet or packing strip of sodium carboxymethylcellulose. Converts to a solid gel when activated by moisture (fluid lock).				Best for moderate amount of exudate. Should not be used on dry wounds. Low tensile strength - avoid packing into narrow deep sinuses.
11. Antimicrobials	Silver or cadexomer iodine with vehicle for delivery: sheets, gels, alginates, foams or paste.				Broad spectrum against bacteria. Not to be used on patients with known hypersensitivities to any product components.
12. Other devices	Negative pressure wound therapy (NPWT) applies localized negative pressure to the surface and margins of the wound. Dressings consist of polyurethane or polyvinyl alcohol materials.				This pressure-distributing wound dressing actively removes fluid from the wound and promotes wound edge approximation. Advanced skill required for patient selection for this therapy.
13. Biologics	Living human fibroblasts provided in sheets at ambient or frozen temperatures. Extracellular matrix. Collagen-containing preparations. Hyaluronic acid. Platelet derived growth factor.				Should not be used on wounds with infection, sinus tracts, excessive exudate, or on patients known to have hypersensitivity to any of the product components. Cultural issues related to source. Advanced skill required for patient selection for this therapy.

Sources

Bayoumi IM, Buchanan M. Say, what? The info on leg ulcers.  The Canadian Journal of CME 2004;Aug;83-85. (http://www.stacommunications.com/journals/cme/2004/August/pdf/083.pdf)

Bickley LS. Bates' guide to physical examination and history taking. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.

Biem J, Koehncke N, Classen D, Dosman J.Out of the cold: management of hypothermia and frostbite.  CMAJ 2003:168(3):305-11. (http://www.cmaj.ca/cgi/content/full/168/3/305)

Cohen J, Powderly WG. Infectious diseases. 2nd ed. New York, NY: Elsevier; 2004.

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Ferri FF. Ferri's clinical advisor: Instant diagnosis and treatment. St. Louis, MO: Mosby; 2004.

Fitzpatrick TB, Allen R, Johnson K, et al. Color atlas and synopsis of clinical dermatology. 4th ed. McGraw-Hill; 2001.

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CunliffeT, Carmichael A.  Dermatology guidelines. Produced in collaboration with the Directorate of Dermatology, James Cook University Hospital, London, England; April 2004.

Gibbs S, Harvey I. (2006, May 24).  Topical treatments for cutaneous warts. (http://www.cochrane.org/reviews/en/ab001781.html)

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