VOL: 96, ISSUE: 41, PAGE NO: 33
Rosemary Turnbull, BSc, RSCN, is paediatric and dermatology sister, Chelsea and Westminster Hospital, London
Many different conditions affect the skin and, for this reason, a prompt and accurate diagnosis is necessary so that effective treatment can be started. This is particularly important in children whose skin condition may cause them to be ridiculed by others - which, of course, further affects their body image.
To carry out an accurate and effective skin assessment you need to be able to recognise normal skin function and know how it differs between adults and children.
In structure, a child’s skin is fundamentally the same as that of the adult, although the blood and nerve supplies are still immature. The dermis is thinner, with less collagen and fewer elastic fibres. This means that the skin is fragile and can be more easily damaged through both physical and mechanical trauma.
Sebaceous glands become active during foetal life due to the high level of maternal androgens. This is evident at birth where the normal infant has a greasy covering over the skin, the vernix caseosa, made up of sebum and shed skin. This coating is generally washed off at birth or peels off naturally. Sometimes the sebaceous glands become blocked, which produces milia, or milk spots. These resolve spontaneously and parents should be reassured of this.
Eccrine glands are responsible for sweat production. Because babies are small, the reduced skin surface area in relation to body mass means that these glands are closer together and function irregularly. In an infant they respond at higher temperatures than in adults, due to their immaturity. As a result, the infant has a reduced ability to sweat, and becomes prone to overheating. This may be evident in the form of miliaria, heat rash or prickly heat.
Apocrine glands are modified sweat glands that are attached to hair follicles, located mainly in the axillary, perineal and pubic areas. These glands are smaller and do not fully function until the child reaches puberty.
Because children’s skin produces less melanin than adults’ skin, it appears paler in colour and is also at a higher risk of being damaged by ultraviolet radiation (Tortora and Anagnostakos, 1987).
Healthy skin function
Healthy skin acts as a barrier against irritants, ultraviolet radiation, antigens and micro-organisms. In addition to this it prevents water and electrolyte loss and regulates temperature through the action of sweat glands and blood vessels. The Langerhans’ cells and lymphocytes contribute to its immunological function and the skin provides synthesis of vitamin D.
Obtaining a history
Unlike an adult, a child is unlikely to be able to give a comprehensive history of their skin problem so a structured assessment format is necessary to gain an accurate and detailed history.
For children up to five years of age, ask to see the child health record as this may offer insight into the onset of any problem.The child health record is completed by the health visitor at each visit and may provide details of any occurrence of skin complaints or conditions that the child may have experienced previously. This booklet should be updated following skin assessment to ensure continuity of care and to maintain communication between health care professionals.
The examination room should have adequate lighting and be warm and comfortable so as to encourage the child to cooperate during the examination. A selection of suitable toys and books are useful to distract the child, if necessary, while they are being examined.
A verbal history of the condition should be obtained from the parent or carer and the child should be urged to contribute if they so wish, to describe how they feel the condition is affecting them.
The child’s height and weight should be recorded and dietary intake and requirements ascertained. This is necessary as some skin disorders can develop as a result of dietary deficiencies or imbalances. In some instances parents have been known to change their child’s diet, because they feel certain items may initiate or aggravate skin problems, without professional consultation.
Allergic reactions should be discussed to eliminate the possibility of topical reactions and any family history of skin disorders noted because some conditions, such as psoriasis and eczema, can be genetically inherited. Once the past medical history has been obtained, questions should then focus on the current and presenting problem. Even if the parent reports that the skin problem has cleared or faded by the time of the appointment it is still important to establish a sound history of what made them seek advice and what actually occurred.
Touch is an essential part of any skin assessment and enables the practitioner to assess the texture and turgor of the skin as well as assess the temperature of the child.
All skin lesions should be documented methodically. This should include the distribution of the rash as well as its configuration, colour and texture. Where possible, the nurse should identify both primary and secondary lesions.
The aim of assessment
The assessment of the child should be a continuous process of gathering and evaluating information. By using this process, it is possible to specify and administer the most appropriate treatments and monitor the outcomes.