allergic skin manifestations: drug reactions, insect bites and fungal infections

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n 1974 an estimated 15 percent of I the American people were said to have some form of allergic disease.’ Likewise, the numbers of children evaluated and treated for allergic reactions, both acute and chronic, on an inpatient and outpatient ba- sis, have increased. With this rise, there has been a greater demand for current treatment protocols and an increased awareness on the part of nurses to become more knowledgea- ble in respect to diseases of the skin.

It is the nurse who has contact with a patient over the greatest span of time. It is this health care provi- der who is placed in the position to observe, assess, implement treat- ments ordered, and provide for the continuity of care established for pa- tients and their families-as well as educate the public. An ongoing assessment of the patient’s physical and emotional status is crucial to the treatment regimen and to its duration. Nurses, therefore, have the ultimate responsibility to keep up- to-date in their knowledge of the patterns of allergic responses in order to more effectively provide total patient care.

In considering the types of allergic responses that precipitate dermatologic manifestations, it is extremely important to review some common hypersensitive reactions. Being familiar with the clinical symptoms, progression of the disease, and the various treatment protocols can be beneficial in promot- ing interventions, thereby reducing the severity of an acute episode as well as facilitating more effective management of chronic reactions. This chapter will focus on drug reactions, insect bites, and fungal in-

fections which affect children and adolescents.

DRUG REACTIONS Hypersensitivity to a drug is the result of an immune response resulting in the formation of specific antibod- ies and/or of sensitized lymphocytes. Therefore, the drug which induces an allergic reaction must be either antigen (protein) or hapatene (certain chemicals which combine with serum protein and become anti- gens).’

A variety of factors, both physio- logical and environmental, influ- ence or precipitate the development of a drug reaction. Each of the following variables mentioned must be given equal consideration in the evolution of drug allergies (most are interdependent).

Children on the whole present with fewer drug eruptions than adults because adults have had a greater exposure to a wider variety of drugs and their tendency to develop allergies to them has increased. The exceptions to this tenet are found in the chronic or acutely ill child or the child who is frequently hospitalized and receiving a number of different drugs; therefore, the correlation between the number of drugs one receives and the development of an associated reaction is extremely high. Similarly, both an abnormal accumulation of a drug (or drugs) and adverse interactions of drugs may result in toxic effects which are evident as hypersensitive responses. Likewise, further investi- gation reveals that illnesses affecting the renal filtration may reduce the urinary excretion time and subse2 quently result in the toxic accumulation of a drug.

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14 ISSUES IN COMPREHENSIVE PEDIA TRIG NURSING

A universal variable to be consid- ered as a causal factor in allergy development is that of individual dif- ferences. It is important to recall both physiologic and environmental variations which affect individual responses. For instance, the meta- bolic rates of one individual cause responses that are unique to him or her. Therefore, response to a medication and whether or not a hypersensitivity develops is dependent upon and reflective of the inherent biochemical deviations as well as their effect on the rate at which he or she is able to effectively metabol- ize the medication. Also, sunlight in combination with some oral medications may, at times, produce an inflammatory reaction on exposed skin surfaces.

Additional factors to keep in mind when attempting to discover a predisposition to allergic response to medications include the following: allergic individuals who have a greater risk of developing drug reactions, the route of administration (p. 0. is less sensitizing than I.V.), re- peated exposure to a drug or drugs which increases the occurrence of reactions, the sensitizing capacity of specific drugs varies.

These variables are important considerations when obtaining the history, and doing an initial assessment in addition to that point in time when guidelines for management are being established.

Drug reactions range from the minimum one lesion to that of life threatening generalized epidermal necrosis. The prognosis depends upon identifying and eradicating the causative agent, the extent of in- volvement, and the adequacy of treatment.

The following clinical criteria can be helpful in identifying an allergic drug reaction:

1. Small amounts of the drug can induce an allergic reaction.

2. Reaction differs from the ex- pected pharmacologic action.

3. Sensitization to the drug is necessary (the allergic reaction appears after 5-7 days).

4. Symptoms are allergic in type: rash, urticaria, asthma, serum sickness, anaphylactic reaction.

5. Symptoms can be reproduced by the same drug on different occasions or sometimes by cross-reacting drugs3

In identifying and classifying the type of drug reaction present, a thorough description of the specific skin lesions is imperative. Recogniz- ing characteristic eruptions can help to pinpoint the medication and dic- tate a treatment regimen. This is especially important if the drug is un- known-a situation which arises in an emergency room or on a home visit.

The most common drug eruption is the appearance of urticaria or wheals. They are evanescent or transitory lesions which appear rapidly and subside slowly. Beginning with a localized pruritis or numb- ness, there is a progression to the development of erythematous, edema- tous oval lesions with sharp, demarcated edges of varying sizes. Characteristically they are white or pink lesions surrounded by pink ar- eolae. If the lesions involve the lips, mucosa or eyelids, diffuse swelling may be apparent rather than specific recognizable lesions. The distribution of wheals varies, as does the duration. Frequently urticaria1 reactions can be seen in response to

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THE INTEGUMENTARY SYSTEM 15

antibiotics, barbiturates, salicylates, radiopaque media, insulin, chloral hydrate, antepar, atabrine, and vac- cines (rabies, diphtheria-tetanus toxoids, and poliomyelitis). For example, a penicillin allergy results in a rapid, diffuse urticaria within 2 to 24 hours after administration. A late urticaria may begin to appear 2 to 3 weeks after exposure to the drug, with a diffuse erythema, fever, ar- thralgia, proteinuria, and lympha- denopathy.

Another commonly observed dermatologic drug response is that of a fixed eruption which occurs as a de- layed response to a medication ap- pearing in the same location each time. Usually it is a single lesion characteristically described as a purplish red, round, or oval plaque with sharp borders and pruritic in nature. The lesion is most often lo- cated on an extremity; however, it may be observed elsewhere. Drugs most commonly associated with this type of response are phenolpthalein, barbiturates, salicylates, sulfonamides, and tetracyclines.

There are many other morpho- logic patterns of skin lesions indica- tive of an allergy. Most of them are observed in hospital settings. They include purpuric eruptions, a characteristic allergic response to sulfon- amide, quinidine, penicillin, and thiazide therapy. Still others result in photosensitization and chlorpro- mazine, tetracycline, sulfonamides, griseofulvin (fungicidal agent), and methotrexate are examples. Perhaps methotrexate is the most significant since the numbers of children receiving this chemotheraputic agent are rapidly increasing.

There are several issues to be con- sidered when one reviews these clin-

ical manifestations: I . The dosage ordered and wheth-

er this is a “first” experience with this medication.

2. The length of time the child has been on this and other protocols.

3. The route of administration. 4. The inherent individual differ-

ences. 5. All the other variables influ-

encing the development of drug allergies.

Obviously the greater the popula- tion being treated, the greater the number of observed adverse reactions. Its significance is incredible to nurses who dispense medications.

There are two other drug-related skin eruptions which need to be dis- cussed-erythema multiforme-like and Stevens-Johnson syndrome, (the latter is a severe form of the former). In general these lesions restrict themselves to those children 4 years of age and older. Erythema multiforme clinically results in macular and erythematous eruptions which are irregularly distributed over the body surface, more frequently on the back of hands, forearms, and sides of the neck. There is a rapid progression from a rash to papular and vesicular phases with polymorp- hous lesions. These eruptions may appear singularly or in crops and may persist over a 2 to 4 week peri- od. Other symptoms that can pre- cede or be observed in conjunction with the dermatologic manifestations are fever, joint pains, malaise, and nausea. Drugs capable of producing this form of reaction are: penicillin, antipyrine, sulfonamides, bromides, idodides, and salicylates.

Stevens-Johnson syndrome which is seen more frequently in males is

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16 ISSUES IN COMPREHENSIVE PEDIA TRIC NURSING

the result of severe allergic response to sulfonamides or barbiturates and it can be described in the following manner:

1. Lesions on mucous membranes (usually faucial or buccal).

2. Erythematous, papular skin eruptions with peripheral spread, developing into con- fluent and widespread vesicular bulbous lesions.

3. Conjunctivitis and photosensi- tivity.

4. Symptoms of erythema multiforme.

Recommended treatment usually includes: soothing lotions, such as calamine, to ease local irritation; antihistamines to inhibit and reverse the reaction; peroxide rinses after eating; broad spectrum antibiotics for prophylaxis of infection in the necrotic areas of the skin and mucous membranes; corticosteroids to minimize the inflammatory response; and maintenance of an accurate fluid and electrolyte balance. The prognosis is guarded. A mortal- ity rate of 10 percent during the early phase is significant. In addition, there may be a loss of vision due to corneal ulceration.

There are several implications for the nursing management of dermatologic manifestations due to a drug allergy. Treatment protocols are directed toward eradicating the symptoms (usually accomplished in mild cases with the administration of epinephrine or antihistamines) and prophylaxis. Therefore, it is necessary for a nurse to be familiar with the actions of medications taken by a child to produce the allergic response as well as the action of medications used for treatment. Collect- ing accurate data in a nursing

history and establishing a plan of care based upon those findings is imperative. Only through such efforts can the source of the allergic response be determined.

Such data should serve as the foundation for future nursing interventions. For example, the nurse can determine the focus of health education necessary to prevent future occurrences. Astute observation by a nurse should stimulate the following questions: Is this an allergic response to one medication? Will the elimination of this medication be sufficient? Is it necessary to cau- tion the child and his or her parents against the use of other, similar medications? Should the child wear a bracelet or carry a card stipulat- ing this allergy? Was this an allergy associated with a mixture of anta- gonistic or protagonistic medications? Is the drug causing the reaction isolated? Are treatment protocols reducing the allergic manifestations? Are additional allergic responses developing? Is this child in the hospital for impaired renal func- tioning, which inhibits excretion and causes a toxic level of the drug to develop? Has this child demon- strated sensitivities to radiopaque dye? If the child is a new diabetic and reaction to the insulin occurs, is it related to pork or beef sensitivity and is sensitization necessary? Once the acute episode has passed what long term therapy, if any, will be needed? What is the effect of this reaction and the treatment protocol on the child, both physically and emotionally? Will body image be affected?

The child should be encouraged to verbalize and participate in ther- apeutic play situations. Parents

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should be encouraged to talk, for guilt feelings may be present, whether or not there is merit to them. Concrete suggestions in preventing future episodes should be made and parents should be in- volved in planning long term management. Teaching should focus on the hypersensitive effects of the drug emphasizing the observations the parents should make, as well as early treatment measures they may in- stitute. If the parents were aware of this allergy previously, and the medication was given to the child, then the emphasis should be on re-education. Parents should be thoroughly instructed to observe for a rash, when it was noted, its distribution, and if it was preceded by anything other than the medication.

While all of the above are important, a crucial aspect of nursing in- tervention lies in the area of preven- tative education, especially in relation to increasing the public’s awareness of such occurrences. Pro- phylaxis, keen observation for initial signs, and immediate treatment of acute and chronic allergic responses could have a significant effect on its prevalence. Such a concerted effort to educate could reduce the number of hospital visits and duration of stay, as well as decrease the number of acute reactions or minimize their severity. An educated public is cer- tainly the best form of prophylaxis.

INSECT BITES AND STINGS Another source of allergic skin manifestations in children result from insect bites and stings. These offenders produce disease in the following ways:

1. The venenating arthropods-

centipedes, scorpions, spiders, ticks, mites, bees, wasps, ants and blister beetles-project poisonous venom into the human body.

2. The tissue invaders: the itch mite produces scabies, maggots of flies cause myiasis.

3. Mechanical transmitting agents of disease such as the housefly, lice, ticks, and gnats4

The classification of sensitization to insects was postulated by Benson in 1934.5 There are three primary sources of insect sensitivity derived from :

1. inhalation, contact with, or dust from the wings or body of the insect;

2. an injection of serum through a sting; and

3. the by-product of the instilla- tion of salivary secretions.

Clinical findings vary with the method of contact. Reactions seen in individuals sensitized by inhalation include urticaria or atopic eczema. Responses to stings consist of nausea and vomiting, urticaria, edema, vertigo, pallor, and sweating. In more severe reactions to stings dysp- nea, shock, coma, and death can result. Insect bites, on the other hand, are less toxic and generally produce local responses such as skin eruptions (papular urticaria), edema, or generalized symptoms such as nausea and vomiting.

Skin reactions to insect bites result from a hypersensitivity. While a nonsensitive person will have little or no reaction to the bite, a sensitive person may have immediate, de- layed, or a combined response con- sisting of headaches, fever, weak- ness, involuntary muscle spasms, and occasional convulsions.

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18 ISSUES IN COMPREHENSIVE PEDIA TRIC NURSING

A common skin eruption seen in infancy and early childhood and associated with the bite of a common dog or cat flea, bed bugs, or human fleas is a papular urticaria. The lesions are distributed on the arms, legs, and exposed areas of the face and neck. Initially a small papule, a circumscribed, solid elevated lesion without visible fluid appears, varying in size from that of a pinhead to a pea. It may be acuminate, rounded, conical, flat or umbilicated, and ranges in color from white to red to yellow to black. It is pruritic and generally becomes excoriated. Sec- ondary skin infections are common.

Treatment of allergic reactions to insect bites or stings is directed toward the eradication of the symptoms and prevention. The regimen followed for mild reactions consists of a topical application of ammonia and corticosteroids to reduce the pain and inflammation as well as administration of an antihistamine to minimize or counteract the effects of the bite. If available, the application of ice to the site helps to slow down the reaction and reduce swelling and discomfort. If the reaction is progressing rapidly from mild to more severe, epinephrine is the drug of choice, followed by an antihistamine such as Benadryl. Immediate removal of the insect stinger or tick is necessary for recovery. It may become necessary to apply a tourniquet to the affected extremity in order to prevent further progression of the hypersensitive reaction. To counteract the reaction from a black widow spider bite, which produces the most severe effects of any insect bite, an intramuscular injection of antiserum must be given. The ac- companying pain can be reduced to

a degree by the parenteral administration of a 10 percent solution of calcium gluconate. A thorough knowledge of the common insects in a particular region may enhance the speed with which a diagnosis is made and facilitate the treatment instituted.

Long term therapy should be ini- tiated once the acute reaction has passed and the cause has been isolated. Health teaching is the major component of nursing management. The family should be instructed in varying types of prevention as well as emergency measures to be initiat- ed in case of a severe hypersensitivity. Such measures are especially important with the increase in such outdoor activities as camping or hiking.

Methods of prevention include: 1. Desensitization therapy admin-

istered to the child who has ex- perienced a systemic reaction.

2. Avoiding areas known to attract insects (flowers, shrubs, wooded areas).

3. The use of an insect repellent. 4. Wearing light colored clothes

which supposedly attract fewer insects.

5. Wearing appropriate attire (long sleeves, hat, socks, shoes).

6. An emergency kit containing epinephrine, tourniquet, ephedrine, and an antihistamine should be carried on out- ings.

7. Careful inspection and possible fumigation of the home and pets.

FUNGAL INFECTIONS With the “back to nature” focus of our youth, there has been an increase in fungal infections. Such

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THE INTEGC’MENTAR Y SYSTEM 19

problems are fairly common in children. They are highly communica- ble and spread depends on the health habits of a child as well as the frequency with which public showers are used. If the child is of school age (junior high school or high school), the number of contacts increases, thereby increasing her or his risk of developing a fungal infection and also markedly accelerating the potential rate of dissemination to epidemic proportions.

There are certain principles of treatment and prevention that are universal to all fungal infections. The initial treatment of an active, acute fungal infection is identical to that of acute dermatitis with the addition of fungicidal agents. The use of such strong irritants should be carefully monitored and restricted only to that amount necessary for treatment. Since moisture serves as a medium for proliferation, the skin, should be kept dry and community showers should be avoided.

There are four common catego- ries of fungal infections classified by the area of the body on which they focus their attention. They are tinea circinata or tinea corporis (body ringworm), tinea cruris (eczema marginaturn, or “jock itch”), tinea of the palms and feet (epidermophytosis, “athlete’s foot”), and tinea capitis (fun‘gus of scalp). Tinea Corporis The first type of fungal infection, tinea corporis or body ringworm, occurs with lesions involving one or more irregular, erythematous, slightly raised, scaly patches which are soon covered with small vesicles. As the lesions spread and clear cen- trally, they leave a characteristic ring-shaped lesion with active le-

sions peripherally surrounding the healed center. Mild itching is associated with these eruptions which generally appear on the face, neck, hands, and forearms. The most common cause is the animal-born microsporum lanosum found in cats and dogs.

If intense inflammation is present, the treatment is directed at local soothing measures such as soaks or lotions, followed by an application of Whitfield’s ointment (Benzoic and salicylic acid ‘/4 strength) three times daily for two weeks. Next, fungicidal measures should be instituted. The medications of choice are (1) local application of Tinactin, 1 percent cream, to all the lesions twice a day for two to four weeks, depending on the response, or (2) griseofulvin (Fulvicin), 20 mg./kg/ day in three doses for 4 to 8 weeks, the duration also dependent on its effectiveness. General measures of treatment and prophylaxis involve instructing the child and his or her parents to avoid contact with infected household pets and to avoid the exchange of clothes without ade- quate laundering. In order to ensure that future infections are either eliminated or reduced, the source of the infection, the house pet, must be treated also. Tmea Cruris This fungal infection, also known as “jock itch,” is commonly seen in ad- olescence. These lesions are sharply circumscribed, red plaques with a tendency to heal in the center. Their clinical appearance, however, may be modified by perspiration and bacterial contamination. The inguinal region is the primary location for tinea cruris. Acute inflammation and maceration often occur.

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20 ISSUES IN COMPREHENSIVE PEDIA TRIC NURSING’

Treatment is directed first toward reducing local symptoms. Wet compresses of potassium permanganate (1:10,000) or an aluminum acetate solution (1:20) applied to second- arily infected or inflamed lesions are particularly effective soothing agents. Sitz baths with the afore- mentioned solutions, in more dilute concentrations, can provide the adolescent with some relief in the pres- ence of perineal lesions.

After treating the infection local- ly, efforts should be directed toward attacking the fungus itself. There are several medications available to a physician and they include: (1) sulfur (34%) and resorcinoe (2%) lotion twice daily, (2) a weak solution of iodine (less than 1% tincture) twice daily, (3) salicylic acid (1%) and sulfur (3%) ointment. If these agents are unsuccessful, griseofulvin, used in treating tinea corporis, may help control this fungal infection.

General instructions given to an adolescent should stress that: pow- der be applied to the affected areas, 2 or 3 times daily; overbathing be avoided (a daily bath is sufficient); rough-textured clothing should be eliminated. Health education focus- ing on personal hygiene is an activi- ty which needs to be done diligently.

Athlete’s Foot Probably the most prevalent fungal infection is epidermophytosis or “athlete’s foot.” While all children are affected, it is seen more frequently in older children and adolescents. Three types of lesions are characteristic:

1. Red, dry, scaly, and fissured eruptions between the toes.

2. Acute, tense papulovesicular and bulbous eruptions on the soles or sides of the feet.

3. Dry, scaly, thickened areas between the toes or on the palms. Pruritis may be present. The primary site of infection is generally isolated to the web spaces between the toes. Secondary sites are usually some distance from the original location. These lesions are symmetrical vesicular formations.

For some time, “athlete’s foot” was thought to be transmitted through public showers, but from re- cent investigations, it appears that an individual has the predisposition to and susceptibility for the infection. Its development is influenced by perspiration, poor foot hygiene, and poor evaporation of moisture.

Initial treatment is directed at eliminating the symptoms and lesions. It is interesting to note that treatment of the primary site will clear the secondary sites without local therapy to the secondary sites. Acute lesions (1-10 days) seem to respond well to normal saline soaks for 20 minutes twice daily if mild and potassium permanganate 1 : 10, 000 compresses if a secondary infection exists. For subacute lesions, an application of Whitfield’s ointment ( l/k- ‘/2 strength) is recommended at bedtime. Chronic lesions respond to a daily application of iodine or Ti- nactin. solution twice daily. If the above are unsuccessful in containing the fungus and producing a remis- sion, griseofulvin 250 mg. p.0. 4 times daily for 4 weeks should produce the desired response.

Following resolution of the acute episode, preventing a recurrence is contingent upon the knowledge of the patient and her or his family and whether or not they follow the prescribed treatment regimen. The importance of personal hygiene and

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foot care should be emphasized. They should be instructed to: (1) dry the web spaces between the toes carefully, (2) wear rubber or wood- en sandals in public showers, (3) wear well ventilated shoes, (4) change socks frequently, (5) use drying powders frequently, and (6) use foot soaks in 1 percent sodium hypochlorite solution before and after bathing in public areas. Tinea Capitus The fourth type of fungal infection, tinea capitus or fungus of the scalp, is usually transmitted by an animal such as a dog or cat. (Another less common form of this fungus, the microsporum audouimi, is transmitted by a human source and is highly infectious from child to child.) It occurs most often in boys 5 to 12 years old. The lesion or lesions begin as small, rounded, slightly reddened, scaly patches on any part of the scalp. Hairs in the area are brittle, lack lustre, and often broken off close to the scalp, so the affected area appears bald. Occasionally, boggy encrusted lesions (kerions) may be present or develop in response to therapy. A Wood’s lamp is often used to identify the infected hairs.

Treatment begins by clipping the hair close to and around the lesions. The scalp should be scrubbed with a synthetic, nonfat soap nightly and one of the following agents should be applied for about one week:

1. Mild tincture of iodine (2%) nightly after scrubbing.

2. Ointment salicylanilide (5%) in carbowax twice daily.

3. One-half strength Whitfield’s ointment twice daily.

The drug of choice to achieve a systemic effect is griseofulvin (Fulvi- cin) 20 mg./kg daily in 3 doses for 4

to 8 weeks depending on the response. Leukopenia is an indication to completely stop the medication. A careful assessment of the effectiveness of treatment instituted needs to be done regularly. Pets should be in- spected and treated if infected. The child and family should carefully avoid the exchange of hats, combs, and brushes in order to prevent the spread of the infection. Interesting- ly, if it is not cured earlier, practi- cally all cases clear spontaneously at puberty. Apparently this phenome- non is due to a change in the ph of the skin which occurs at that time.

A variety of skin lesions appear as hypersensitive reactions to medication, insect bites, and fungi. Primary treatment of lesions and an eradication of the source results in a “cure.” A knowledge of protocols and astute observations on the part of a nurse dealing with such problems is essen- tial. Increasing the public’s awareness through health education can have a direct effect on frequency, duration, but, most importantly, on prevention.

REFERENCES 1.

2. 3. 4.

5 .

Wasserman, Edward, Law- rence Slobody: Survey of Clinical Pediatrics, New York: McGraw- Hill, 1974, p. 671. Ibid., p. 683. Ibid., p. 683. Marvin, Janet A., Inez L. King Teefy, Judith M. Johnson: The Integumentary System, in Gla- dys M. Scipien et a1 (eds.), Comprehensive Pediatric Nursing, New York: McGraw-Hill, 1975, p. 838. Vaughn, Warren T., J. Harvey Black: Practice of Allergy, 3rd Edition, St. Louis: C.V. Mosby, 1954, p. 805.

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allergic skin manifestations: drug reactions, insect bites and fungal infections

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