Dermatology/Wound Care

Inquiring Minds Want to Know

Dermatology/Wound Care

By Audrey Kirchner, CHDS

We know from the Book of Style that dermatology (integumentary system) is the specialty focused on identification, treatment, and management of diseases or disorders involving skin and connective tissues.

Dermatology covers a wide range of conditions and diseases from congenital defects (such as moles or port wine stain birthmarks) to viral or bacterial infections (such as herpes zoster or MRSA) to malignancies (such as melanomas or basal or squamous cell
carcinomas). Linked closely are allergic and immunologic responses to conditions occurring on the skin or in connective tissues. Because of the close association between dermatology and immunology, testing for many skin conditions involves evaluation
of the immune system.

Some of the conditions dermatologists treat are acne, dermatitis, and eczema. They also treat scar revisions, perform cosmetic surgery, and treat skin cancers and wounds. Psoriasis (which is an immune system disorder causing scaly, itchy and painful plaques)
would also be treated by a dermatologist.

Much of dermatology and wound care is done in an outpatient setting though surgical procedures and/or acute care settings most often occur when there is a malignancy involved, an emergent situation such as a severe allergic reaction, or infection that
may be present due to a nonhealing wound or infection. Cosmetic procedures such as facelifts or breast reconstructions may also be part of acute care transcription, though many of these procedures are performed in the outpatient setting today.

Allergy testing most often is done through skin tests such as scratch or prick testing as well as patch testing to monitor for allergic responses to a specific allergen or agent. There are other ways to test for allergies such as the RAST test (a blood
test) and a challenge test (where an allergen can be inhaled or taken through other routes).

Burns are classified as 1st through 4th degree dependent upon burn depth. Burns are also assessed by a system called the Rule of Nines. This is a formula based upon multiples of 9, which is then used to determine the percentage of the total body surface
area that has been burned. It is important to note that the Rule of Nines is handled differently for babies and children because a child’s head is large in comparison to an adult’s head and legs are much shorter compared to an adult’s. Thus, the formula
must be adjusted for children. According to the Rule of Nines, the head and each arm is scored as 9% burn area while the individual leg, anterior trunk and posterior trunk is scored at 18% for each. The perineum is scored as 1%. Dependent upon the
location and degree of burn, treatment is given from topical to surgical excision and skin-regenerative modalities.

Similar to burns, decubitus ulcers are treated by wound care specialists and/or dermatologists. They are classified according to their depth and severity from stage I decubitus (nonblanching redness but intact skin) through stage IV (full-thickness skin
loss with extensive tissue destruction to include deep to bone). If burns or decubitus ulcers are severe enough or nonresponsive to treatment, amputation may be the only effective treatment to stop tissue necrosis and/or infection.

Dermatology and wound care specialties also deal with treatment of skin cancers.

The ABCDs of skin cancer detection are the following:

A – Asymmetry – one-half of a mole or lesion does not match the other.

B – Border (regularity) – the edges are notched or irregular.

C – Color (variations) – the color is not symmetric or may be partly brown or black.

D – Diameter – the lesion is greater than 6 mm across (the size of a pencil eraser).

In terms of melanomas, we also add the category below:
E – Evolving – a lesion present begins to change in character, size, or color.

Skin cancers such as melanomas or basal cell carcinomas are treated by dermatologists. The level of invasion of a primary malignant melanoma will be assessed by a Clark level. This measures invasion of the skin from the epidermis. A Clark level I is invasive
to the papillary dermis where a Clark level IV is invasive to the subcutaneous fat.

Melanomas are often classified with a Clark level as well as a Breslow thickness level. This measurement is used to describe the relationship between a tumor’s depth, its invasion level, and the 5-year survival rate after surgical removal of the tumor.
It is determined on a scale of millimeters, with the best outcome level being less than 0.76 mm to the most worrisome outcome measurement being more than 8.0 mm.

A Mohs surgical procedure for basal cell or squamous cell carcinomas is one in which a patient undergoes surgical excision until the specimen no longer contains cancerous cells. An excisional biopsy of the lesion in question is done, and it is then examined
under a microscope for malignant cells. If there are malignant cells in the specimen, further tissue is removed, examined again under the microscope and if free of malignant cells, the procedure is terminated. If malignant cells are still present,
the excision continues with re-exam under the microscope until the specimen is free of malignant cells. If much tissue is removed, sometimes the patient will have to undergo a flap reconstruction to cover the defect.

Wound care is a subspecialty of dermatology that deals primarily with treating and healing wounds. Wounds can be incurred from many sources such as lacerations, amputations, bedsores, bacterial or viral infections, or dog bites and other traumas. Wounds
may be treated topically with various dressings and applications of wound-healing agents. Wounds may require surgical debridement and/or revision. Still other wounds may require the addition of nutritional supplements (in the event that the patient
is malnourished or has deficiencies of some kind). Some may require hyperbaric oxygen treatment. In hyperbaric wound treatment, the patient is exposed to 100% oxygen, which helps to heal wounds quicker. Wound care can be short-term or may require
multiple debridements and redressings per week, all dependent upon the type of wound, its underlying cause and prognosis for healing.

(See Chapter 20 in the Book of Style for more information.)