GCC Clinical Context — Skin Assessment
In the GCC population, darker skin types (Fitzpatrick IV–VI) predominate among South Asian and Arab populations. Erythema may appear darker/purplish rather than red. Post-inflammatory hyperpigmentation (PIH) is more common and clinically significant. Standard assessment tools may underdetect early pressure injuries in darker skin — rely on palpation (warmth, oedema, induration) alongside visual assessment.
Skin Structure — Epidermis
5 Layers (Superficial → Deep)
- Stratum Corneum — outermost; dead keratinocytes; barrier function; 15–20 cell layers
- Stratum Lucidum — only in thick skin (palms/soles); clear layer of dead cells
- Stratum Granulosum — keratohyalin granules; waterproofing begins
- Stratum Spinosum — Langerhans cells (immune); desmosomes for cell cohesion
- Stratum Basale — deepest; single layer; mitosis occurs; melanocytes located here
Key Cells
- Keratinocytes — 90% of epidermis; produce keratin
- Melanocytes — basale layer; produce melanin; UV protection
- Langerhans cells — antigen-presenting immune cells
- Merkel cells — mechanoreception / light touch
Dermis & Hypodermis
Dermis — 2 Layers
- Papillary dermis — thin; loose connective tissue; dermal papillae; capillary loops supplying epidermis
- Reticular dermis — thick; dense irregular connective tissue; collagen (type I) for strength; elastin fibres for recoil; fibroblasts; mast cells
Dermis contains: hair follicles, sebaceous glands, eccrine/apocrine sweat glands, nerve fibres (free endings, Meissner's, Pacinian corpuscles), lymphatics, blood vessels.
Hypodermis (Subcutaneous Layer)
- Adipose tissue and loose connective tissue
- Functions: insulation, energy storage, cushioning, anchors skin to fascia
- Site of subcutaneous injections
Skin Functions
Barrier
Prevents water loss (TEWL), blocks pathogens, resists chemical/mechanical injury. Compromised by wounds, eczema, ageing.
Thermoregulation
Eccrine sweating (cooling), cutaneous vasodilation/vasoconstriction, subcutaneous fat (insulation). Critical in GCC extreme heat.
Sensation
Touch (Meissner's), pressure/vibration (Pacinian), pain/temperature (free nerve endings), proprioception.
Immune Defence
Langerhans cells present antigens; antimicrobial peptides (defensins); acidic pH (4.5–5.5) inhibits pathogens.
Vitamin D Synthesis
UVB converts 7-dehydrocholesterol → previtamin D3 → Vitamin D3. Darker skin requires longer UV exposure. Deficiency common in fully covered GCC women.
Other
Excretion of sweat/salts, absorption of topical medications, cosmetic/identity function.
Systematic Skin Assessment
Inspection
- Colour — erythema, pallor, cyanosis, jaundice, pigmentation changes. In darker skin: erythema may be purplish, use palpation.
- Texture — smooth vs rough, lichenification, atrophy
- Moisture — dry, moist, oily, diaphoretic
- Turgor — tent test (delayed return suggests dehydration; unreliable in elderly)
- Temperature — dorsum of hand; localised warmth suggests inflammation/infection
- Lesion distribution — localised, generalised, photo-distributed, dermatomal, flexural
Palpation of Lesions
- Blanchability — diascopy (glass slide pressure): blanches = vascular; non-blanching = extravasated blood / pressure injury Stage 1
- Consistency — soft, firm, hard, fluctuant (fluid), rubbery
- Mobility — attached, mobile, tethered to underlying structures
- Tenderness — level of pain on palpation; surrounding induration
Lesion Description — SCAM Framework
S — Size Measure in millimetres (length × width). Use ruler in photographs.
C — Colour Describe using standard terms: erythematous, hyperpigmented, hypopigmented, violaceous, flesh-coloured.
A — Arrangement Discrete, grouped/herpetiform, linear, annular, zosteriform, reticulate, confluent.
M — Morphology Primary lesion type + any secondary changes. Distribution (anatomical site, symmetry, photo-distribution).
Lesion Terminology
Primary Lesions
Macule
Flat colour change <1 cm. Non-palpable. E.g. freckle, petechiae.
Patch
Flat colour change >1 cm. E.g. vitiligo, port-wine stain.
Papule
Raised solid <1 cm. Palpable. E.g. wart, acne.
Plaque
Raised flat-topped >1 cm. E.g. psoriasis, lichen planus.
Vesicle
Fluid-filled <1 cm. Clear fluid. E.g. herpes simplex, chickenpox.
Bulla
Fluid-filled >1 cm. E.g. bullous pemphigoid, burns.
Pustule
Pus-filled. E.g. acne pustule, folliculitis, impetigo.
Nodule
Solid, palpable, 1–2 cm, extends into dermis/subcutis. E.g. dermatofibroma.
Wheal
Transient oedematous raised lesion. E.g. urticaria. Resolves <24h.
Telangiectasia
Dilated superficial blood vessels. E.g. rosacea, liver disease.
Secondary Lesions (result from primary lesion evolution)
Scale
Flaking stratum corneum. E.g. psoriasis (silvery), tinea (fine).
Crust
Dried exudate (serum/blood/pus). E.g. impetigo (honey-coloured).
Erosion
Superficial loss of epidermis. Heals without scar.
Ulcer
Full-thickness skin loss into dermis/beyond. Heals with scar.
Fissure
Linear crack through epidermis ± dermis. E.g. angular cheilitis, heel fissures.
Lichenification
Thickened skin with accentuated markings from chronic rubbing. E.g. atopic eczema.
Scar
Fibrous tissue replacing dermis. Hypertrophic (raised, confined) or keloid (extends beyond).
Excoriation
Scratch marks — linear abrasions. Suggests pruritus.
Fitzpatrick Skin Phototype Scale
Classifies skin response to UV exposure. Important for photoprotection counselling and skin cancer risk in GCC context.
Type I
Always burns, never tans
Always burns, never tans
Type II
Burns easily, tans minimally
Burns easily, tans minimally
Type III
Burns moderately, tans gradually
Burns moderately, tans gradually
Type IV
Burns minimally, tans well
Burns minimally, tans well
Type V
Rarely burns, tans deeply
Rarely burns, tans deeply
Type VI
Never burns, deeply pigmented
Never burns, deeply pigmented
Dermoscopy Principles
- Handheld dermoscope uses polarised/immersion light to visualise subsurface structures (dermal-epidermal junction)
- Key structures: pigment network, dots/globules, streaks, regression, vascular patterns
- ABCD rule of dermoscopy: Asymmetry, Border irregularity, Colour (≥3 colours), Differential structures
- Requires training — refer to dermatology if uncertain about pigmented lesions
GCC Dermatology Patterns
The GCC climate (extreme heat, high humidity, dust) drives specific dermatological presentations: tinea versicolor and pityriasis alba are very prevalent due to sweating and sun exposure. Scabies outbreaks occur in labour camps (overcrowding). Contact dermatitis is common among domestic workers using harsh detergents. Acne frequently flares during hot, humid summers. Vitamin D deficiency is paradoxically common despite abundant sun (due to covered clothing, indoor lifestyle).
Eczema / Atopic Dermatitis
Clinical Features
- Xerosis (dry skin) — fundamental feature; impaired skin barrier (filaggrin mutations)
- Pruritus — severe, worse at night; itch-scratch cycle
- Lichenification — thickened leathery skin from chronic rubbing
- Flexural distribution — antecubital fossa, popliteal fossa, wrists, neck
- In infants: cheeks, scalp, extensor surfaces
- In darker skin: follicular pattern, grey/violaceous discolouration common
Step-Up Treatment Ladder
- Emollients (base of all treatment) — apply liberally, multiple times daily; use as soap substitute
- Topical corticosteroids — potency matched to severity/site; fingertip unit (FTU) dosing
- Topical calcineurin inhibitors (tacrolimus/pimecrolimus) — steroid-sparing, safe for face/skin folds
- Systemic therapy — ciclosporin, methotrexate, azathioprine
- Dupilumab (IL-4/IL-13 antagonist) — targeted biologic for moderate-severe disease; available in GCC
Nursing: Steroid Ladder
Mild (hydrocortisone 1%) → Moderate (betamethasone valerate 0.025%) → Potent (mometasone, betamethasone 0.1%) → Very potent (clobetasol) — avoid potent steroids on face/skin folds/under occlusion.
Psoriasis
Clinical Features
- Plaques — well-demarcated, erythematous with silvery-white scale; chronic inflammatory
- Auspitz sign — pinpoint bleeding on scale removal (Koebner-susceptible)
- Koebner phenomenon — new psoriasis at sites of trauma/injury
- Nail changes — pitting, onycholysis, oil-drop sign, subungual hyperkeratosis
- Psoriatic arthritis — 30% of patients; asymmetric oligoarthritis; DIP joint involvement
- Sites — scalp, extensor surfaces (elbows, knees), lower back, nails
PASI Score
Psoriasis Area and Severity Index — assesses Area × Erythema + Induration + Scale across 4 body regions. PASI ≥10 = moderate-severe. Used for biologic eligibility.
Treatment
- Topical — corticosteroids + Vitamin D analogues (calcipotriol); combination product (Dovobet) first-line for mild-moderate
- Phototherapy — narrowband UVB (NB-UVB); PUVA; 3×/week sessions
- Conventional systemic — methotrexate (hepatotoxic monitoring), ciclosporin, acitretin
- Biologics — TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab, ixekizumab), IL-23 inhibitors (guselkumab, risankizumab)
Nursing Monitoring: Methotrexate
FBC, LFTs, renal function — baseline then 2-4 weekly. Folic acid 5mg weekly (except day of methotrexate). Counsel: avoid alcohol, pregnancy contraindication.
Contact Dermatitis
| Irritant CD | Allergic CD | |
|---|---|---|
| Mechanism | Direct chemical damage | Type IV hypersensitivity (delayed) |
| Onset | Rapid (minutes–hours) | 48–72 hours after re-exposure |
| Distribution | Contact site only; sharp margins | May spread beyond contact site |
| GCC triggers | Detergents, bleach (domestic workers), cement | Nickel (jewellery), fragrances, henna (PPD) |
| Diagnosis | Clinical history | Patch testing (48h + 96h readings) |
| Treatment | Remove irritant; barrier cream; emollients | Identify + avoid allergen; topical steroids; antihistamines for itch |
GCC Note — Black Henna / PPD
Para-phenylenediamine (PPD) in black henna is a potent allergen causing severe ACD. Common in GCC tourist settings. Can sensitise to sulfonamides/thiazide diuretics.
Acne Vulgaris
Pathophysiology
- Sebaceous follicle obstruction → P. acnes colonisation → inflammation
- Comedones (non-inflammatory): open (blackhead), closed (whitehead)
- Inflammatory: papules, pustules, nodules, cysts
- Scars: atrophic (icepick/boxcar/rolling) or hypertrophic/keloid (common in darker skin)
GCC: Acne flares during hot, humid summer months due to increased sebum production and sweating.
Treatment Ladder
- Topical retinoids (tretinoin/adapalene) ± benzoyl peroxide
- Add topical antibiotics (clindamycin) or azelaic acid
- Oral antibiotics (doxycycline, lymecycline) — 3-month course max
- Combined oral contraceptive (females) — co-cyprindiol
- Isotretinoin (oral retinoid) — teratogenic; IPLEDGE monitoring; LFTs/lipids
Fungal Infections (Tinea)
| Type | Site | Features |
|---|---|---|
| Tinea pedis | Feet | Interdigital maceration, scaling, "moccasin" pattern |
| Tinea cruris | Groin | Annular erythema, sharp margin, spares scrotum |
| Tinea corporis | Body | Annular, advancing scaly edge, central clearing |
| Tinea capitis | Scalp | Scaling, alopecia, kerion (inflammatory mass) |
| Tinea versicolor | Trunk | Hypo/hyperpigmented macules; Malassezia; very common in GCC |
| Onychomycosis | Nails | Yellowing, thickening, subungual debris |
Diagnosis & Treatment
- KOH microscopy — scraping in 10–20% KOH; hyphae/pseudohyphae visualised
- Wood's lamp — tinea capitis (M. canis fluoresces green); T. versicolor (yellow-green)
- Topical antifungals: clotrimazole, terbinafine, ketoconazole 2–4 weeks
- Oral therapy: terbinafine (dermatophytes), itraconazole (yeasts/mould), fluconazole
- Tinea capitis always requires systemic therapy (griseofulvin in children)
Scabies
Features
- Caused by Sarcoptes scabiei mite — burrows in stratum corneum
- Burrows — short, linear, slightly scaly tracks; pathognomonic
- Distribution — web spaces, wrists, genitalia, axillae, areolae, waistline; face spared (except infants)
- Pruritus — intense, worse at night (mite activity); Type IV hypersensitivity
- Incubation — 4–6 weeks if first infection; 1–3 days if re-infection
- Norwegian (crusted) scabies — hyperkeratotic plaques; thousands of mites; immunocompromised
Treatment
- Permethrin 5% cream — apply neck to toe, leave 8–12h, repeat at day 7. First-line.
- Ivermectin oral — 200 mcg/kg; 2 doses 2 weeks apart; used when topical impractical
- Treat all household contacts simultaneously — even if asymptomatic
- Wash clothing/bedding 60°C; bag non-washables 72h
- Post-scabetic itch can persist weeks — not treatment failure
GCC Context Scabies outbreaks in labour accommodation (overcrowding). Infection control measures and whole-facility treatment protocols may be required.
Rosacea & Pityriasis Alba
Rosacea
- Chronic inflammatory condition of facial skin; predominant in fair-skinned adults (Fitzpatrick I–III)
- Subtypes: Erythematotelangiectatic (flushing/erythema/telangiectasia), Papulopustular (similar to acne), Phymatous (tissue overgrowth — rhinophyma), Ocular (conjunctivitis/blepharitis)
- Triggers: heat, spicy food, alcohol, UV, emotional stress — especially relevant in GCC outdoor workers
- Treatment: topical metronidazole / azelaic acid; oral doxycycline; laser for telangiectasia; isotretinoin for phymatous
Pityriasis Alba (GCC — Very Common)
- Post-inflammatory hypopigmentation; considered a mild eczema variant
- Features: pale, slightly scaly patches on face/upper arms in children; more noticeable on darker skin (Fitzpatrick IV–VI)
- Associations: atopic tendency, sun exposure, dry climate
- Treatment: reassurance (self-limiting over months–years); emollients; low-potency topical steroids / calcineurin inhibitors if inflamed; sun protection
- Distinguish from vitiligo (complete depigmentation, no scale)
TIMES Framework — Wound Bed Preparation
T — Tissue
- Necrotic (black/brown) — eschar; devitalised; impairs healing; requires debridement
- Sloughy (yellow/grey) — devitalised fibrinous tissue; moisture-retentive dressings
- Granulating (red) — healthy granulation tissue; moist environment needed
- Epithelialising (pink) — new epithelium; delicate; protect and keep moist
I — Infection/Inflammation
- Contamination — organisms present, not proliferating
- Colonisation — organisms proliferating, no host response
- Local infection — host response: NERDS criteria
- Spreading infection — cellulitis, lymphangitis: STONEES
- Systemic infection — SIRS, sepsis
M — Moisture Balance
- Too dry — desiccation; impairs cell migration; use occlusive/moisture-retentive dressings
- Optimal — moist healing environment; promotes autolysis
- Too wet/macerated — periwound skin breakdown; use absorbent dressings, barrier cream
- Exudate types: serous (clear/pale yellow), serosanguinous (pink), sanguinous (red), purulent (thick/opaque/malodorous)
E — Edge of Wound
- Undermining — tissue destruction under intact skin at margins; measure clock positions
- Rolling/epibole — rolled wound edges, epithelium turned inward; debride or ablate
- Callused/hyperkeratotic — often diabetic foot; requires debridement
- Active wound edges — pink/flush with wound bed; healthy healing
S — Surrounding Skin
Erythema, oedema, warmth, induration, maceration, eczema, lipodermatosclerosis, haemosiderin staining. Document distance from wound edge.
Wound Measurement & Documentation
Measurement Methods
- Linear measurement — length (head-to-foot axis) × width (perpendicular) × depth (mm) using sterile probe
- Wound tracing — acetate tracing of wound margins; calculate area (planimetry)
- Photography — standardised: same angle (90°), same distance (30cm), ruler in frame, lighting consistent; document at each dressing change
- Undermining — clock-face positions (e.g., 3cm at 6 o'clock)
- Volume — length × width × depth (cm³) approximation or saline fill method
Documentation Standard
- Date, time, nurse name/designation
- Wound location, dimensions, tissue type (%)
- Exudate: amount + type + colour + odour
- Periwound skin status
- Dressing applied (product, size, frequency)
- Patient response/pain at dressing change
Infection Assessment — NERDS & STONEES
NERDS — Local Wound Infection (surface biofilm)
N Non-healing despite optimal management
E Exudate increase (quantity or change in character)
R Red friable granulation tissue (bleeds easily)
D Debris — slough, dead tissue, foreign material in wound bed
S Smell — new or increased malodour
≥3 NERDS criteria → topical antimicrobial dressings (silver, iodine, PHMB)
STONEES — Spreading/Deep Infection
S Size increasing despite treatment
T Temperature elevation (periwound or systemic fever)
O Os (bone) — probe-to-bone test, osteomyelitis risk
N New satellite areas or breakdown
E Erythema/oedema spreading >2cm from wound edge
E Exudate purulent or increased
S Smell offensive
≥3 STONEES criteria → systemic antibiotics; urgent medical review; consider swab/biopsy
Wound Swabs & Healability Assessment
Wound Swabbing Technique
- Z-technique (Levine method) — preferred: rotate swab over 1cm² area, sufficient pressure to express fluid from wound tissue; 10-point Z across wound surface
- Fluid swab — absorb wound fluid; less representative of wound tissue organisms
- Wound biopsy — gold standard; tissue cultures most accurate; surgical or punch biopsy
- Clean wound before swabbing (irrigate with saline) — reduces surface contaminants
- Do not swab slough or necrotic tissue directly
- Send for M,C&S with clinical context (temperature, antibiotics)
Healability Framework
H
Healable Wound — cause treatable; adequate blood supply (ABI ≥0.6); patient optimised (nutrition/glucose control/offloading). Goal: active healing protocols.
M
Maintenance Wound — patient factors limit healing (poor compliance, ongoing ischaemia, unavoidable pressure). Goal: prevent deterioration, manage symptoms.
N
Non-Healable / Palliative Wound — end-of-life, malignant wounds, critical limb ischaemia not for revascularisation. Goal: comfort, odour control, dignity.
GCC Quality & Safety Context
Pressure injury rates are a key performance indicator for CBAHI (Saudi Arabia) and JCI accreditation. Hospitals must track hospital-acquired pressure injury (HAPI) incidence, conduct root cause analysis for Stage 3+ injuries, and demonstrate prevention bundle compliance. Duty of candour obligations apply when patients develop new pressure injuries.
NPIAP/EPUAP Pressure Injury Classification
1
Stage 1 — Non-blanchable Erythema, Intact Skin. Localised non-blanchable erythema over a bony prominence. In darker skin: may appear purple/maroon — palpate for warmth, oedema, firmness. Intact epidermis.
2
Stage 2 — Partial Thickness Skin Loss. Exposed dermis; wound bed pink/red, moist. May present as intact/ruptured serum-filled blister. No slough/eschar. Adipose tissue not visible.
3
Stage 3 — Full Thickness Skin Loss. Adipose tissue visible. Slough/eschar may be present. Undermining/tunnelling common. Bone, tendon, fascia NOT exposed/palpable. Depth varies by anatomy (nose/ear = shallow; obese areas = deep).
4
Stage 4 — Full Thickness Tissue Loss. Exposed or directly palpable bone, tendon, muscle. Slough/eschar often present. High osteomyelitis risk. Probe-to-bone test positive. Undermining/tunnelling common.
U
Unstageable — Obscured Full Thickness. Full thickness skin loss; base covered by slough (yellow/tan/grey/green) or eschar (tan/brown/black). Cannot confirm true stage until base is visible. If stable dry eschar on heel — do NOT debride (natural protection).
DTI
Deep Tissue Pressure Injury (DTI). Intact or non-intact skin with localised area of persistent non-blanchable deep red, maroon, or purple discolouration, or blood-filled blister. Results from intense/prolonged pressure+shear at bone-muscle interface. May evolve rapidly to expose tissue loss.
Anatomical Sites (by frequency)
Sacrum (most common), heels, ischial tuberosities, greater trochanters, elbows, occiput, medial malleoli. Medical device-related PI (MDRPI): under oxygen mask, cervical collar, NG tube, cast edges.
Braden Scale — Risk Assessment
| Domain | 1 (most impaired) | 2 | 3 | 4 (no impairment) |
|---|---|---|---|---|
| Sensory Perception | Completely limited | Very limited | Slightly limited | No impairment |
| Moisture | Constantly moist | Very moist | Occasionally moist | Rarely moist |
| Activity | Bedfast | Chairfast | Walks occasionally | Walks frequently |
| Mobility | Completely immobile | Very limited | Slightly limited | No limitations |
| Nutrition | Very poor | Probably inadequate | Adequate | Excellent |
| Friction + Shear | Problem | Potential problem | No apparent problem | — |
Score ≤9 — Very High Risk
Score 10–12 — High Risk
Score 13–14 — Moderate Risk Intervention required
Score ≤18 = at risk and requires pressure injury prevention bundle. Maximum score = 23 (no risk). Reassess on admission, change in condition, and at minimum every 24-48h.
Pressure Injury Prevention Bundle
Pressure Redistribution
- Repositioning — 2-hourly in bed (30° tilt, not full lateral); 1-hourly if chairfast; use turning clock/chart; document in nursing notes
- Pressure-relieving mattresses:
- Foam (standard) — low risk patients
- Reactive foam (high specification) — at-risk; conform to body shape
- Alternating pressure (dynamic) — high risk; air cells inflate/deflate cyclically
- Low air loss — moisture management + pressure relief
- Heel protection — float heels off bed using foam wedge or heel-protector boots; do NOT use doughnut-type devices
- 30° semi-Fowler maximum to reduce shear; minimise HOB elevation
Skin Care
- Moisturisers to all at-risk skin at least daily
- Barrier cream/film for incontinence-associated dermatitis (IAD)
- Absorbent pads/continence management to reduce moisture exposure
- Gentle cleansing — pH-balanced; no vigorous rubbing
- Inspect skin at every repositioning; document findings
Nutrition
- Protein: 1.2–1.5g/kg/day for pressure injury prevention; 1.5–2g/kg/day for active healing
- Micronutrients: Vitamin C, Zinc, Arginine-enriched supplements (e.g. Cubison, Juven)
- Nutrition screening on admission (MUST score); refer to dietitian if malnourished
- Adequate hydration (urine output >0.5mL/kg/hr)
Wound Care by Stage & Reporting
Dressing Selection by Stage
- Stage 1 — no dressing required; transparent film or thin foam as protection; address causative factors immediately
- Stage 2 — moisture-retentive dressings: hydrocolloid, thin foam, silicone foam, transparent film; protect periwound skin
- Stage 3/4 — debridement (sharp, enzymatic, autolytic, biological/larval), cavity filling (alginates, hydrofibre, foam), NPWT (negative pressure wound therapy) for large wounds; silver/antimicrobial if infected; regular surgical review
- DTI — protect, offload, close monitoring for evolution; do not aggressively debride until tissue declared necrotic
- Unstageable — maintain moist environment, avoid dry eschar disruption; debride if clinically appropriate
Incident Reporting & Quality
- Duty of candour — inform patient/family of any hospital-acquired pressure injury; document conversation
- Incident reporting — any Stage 2+ HAPI requires incident report in hospital risk management system (DATIX or equivalent)
- Stage 3/4 HAPI — serious safety event; root cause analysis (RCA) within 45 days; corrective action plan
- KPI tracking — HAPI rate per 1,000 patient days (benchmark: <1.0 for JCI/CBAHI)
- Wound care rounds, documentation audits, bundle compliance monitoring
- Multidisciplinary: tissue viability nurse (TVN), physiotherapist, dietitian, medical team
NPWT Indications
Stage 3/4 pressure injuries, surgical wounds, diabetic foot ulcers, dehisced wounds, skin grafts. Contraindicated: active bleeding, malignancy in wound, unexplored fistulae, dry/necrotic eschar.
GCC Skin Cancer Context
The GCC has very high UV exposure year-round (UV index often 10–12+ in summer). Historically, lighter-skinned expat populations had limited awareness of photoprotection, leading to rising basal cell carcinoma and squamous cell carcinoma rates. Melanoma incidence is relatively lower in Arab/South Asian populations due to protective melanin, but delayed presentation due to reduced surveillance means poorer outcomes. Nurses play a critical role in skin cancer education and early referral.
Melanoma
ABCDE Criteria for Suspicious Pigmented Lesions
A — Asymmetry One half does not mirror the other
B — Border Irregular, ragged, notched, or blurred edges
C — Colour Multiple colours (tan, brown, black, red, white, blue) within single lesion
D — Diameter >6mm (size of pencil eraser); however any size can be melanoma
E — Evolution Any change in size, shape, colour, or new symptom (bleed/itch/ulcerate)
Staging & Prognosis
- Breslow thickness — depth of invasion (mm) from granular layer to deepest tumour cell; primary prognostic factor
- Clark levels — anatomical depth (I–V); superseded by Breslow in AJCC 8th ed.
- SLNB — sentinel lymph node biopsy for staging; Breslow >1mm or high-risk features
- Wide local excision margins — in-situ: 5mm; <1mm: 1cm; 1–2mm: 1–2cm; >2mm: 2–3cm
- Subtypes: Superficial spreading (most common), nodular (aggressive, fast-growing), lentigo maligna (UV-related, elderly), acral lentiginous (palms/soles — commoner in darker skin)
Non-Melanoma Skin Cancers
Basal Cell Carcinoma (BCC) — Most Common Skin Cancer
- Arises from basal keratinocytes; locally invasive; rarely metastasises
- Classic features: pearly/translucent nodule; rolled (telangiectatic) edge; central ulceration (rodent ulcer)
- Subtypes: Nodular (most common), superficial, morphoeic/sclerosing (most aggressive, ill-defined), pigmented
- Treatment: Mohs micrographic surgery (highest cure rate; tissue-sparing for face); standard excision 3–4mm margins; radiotherapy; topical imiquimod/PDT for superficial
- Sun-exposed sites: nose, forehead, periorbital area, ears
Squamous Cell Carcinoma (SCC)
- Arises from keratinocytes; can metastasise (5–10%, higher if immunosuppressed)
- Features: scaly, ulcerating, indurated plaque or nodule; may be hyperkeratotic or crusted
- Precursors: Actinic keratosis (sun-damaged skin), Bowen's disease (SCC in-situ)
- Risk factors: chronic UV exposure, immunosuppression (transplant/HIV), HPV (genital/periungual), chronic wounds, radiation, xeroderma pigmentosum
- High-risk features: >2cm, >4mm depth, perineural invasion, ear/lip/scar location
- Treatment: excision (4–6mm margins); Mohs for high-risk; RT for inoperable/adjuvant
Photoprotection Counselling — GCC Essential
Sun Protection Factor (SPF)
- SPF ≥30 — minimum recommendation; SPF 50+ for fair skin, history of skin cancer, photosensitive conditions
- Broad spectrum — must cover both UVA (ageing, melanoma risk) and UVB (burning, SCC risk)
- Application — 2mg/cm² (most people apply 20–50% of recommended amount); ¼ teaspoon for face; 6 teaspoons for body
- Reapplication — every 2 hours; after swimming/sweating (water-resistant ≠ waterproof)
- SPF >50 offers marginally better protection — SPF 50 blocks 98%, SPF 100 blocks 99%
Behavioural Measures
- Peak UV hours — 10am–4pm; UV index highest in GCC summer 11am–2pm
- Protective clothing — UPF 50+ fabrics; long sleeves; wide-brim hats; UV-blocking sunglasses
- Seek shade — umbrellas reduce UV but reflected UV from sand/water still significant
- Vitamin D paradox — adequate sun exposure needed for synthesis; supplement if covered; do not advise sun exposure for vitamin D in skin cancer patients
- Children: extra vigilance; no sunscreen under 6 months; shade and clothing preferred
Urticaria & Angioedema
Urticaria (Hives)
- Acute (<6 weeks) — allergic (IgE-mediated: food, drugs, latex, insect venom) or non-allergic (infection, physical triggers)
- Chronic spontaneous urticaria (>6 weeks) — often autoimmune; anti-FcεRI or anti-IgE antibodies; investigations: FBC, CRP, TFTs, ANA; UAS7 activity score
- Features: wheals (superficial oedema, pruritic) ± angioedema; individual wheals resolve <24h; dermographism in physical urticaria
- Treatment: non-sedating H1 antihistamines (cetirizine, loratadine) up to 4× standard dose; omalizumab (anti-IgE) for refractory CSU; short-course steroids for severe acute
Angioedema — AIRWAY RISK
Emergency Assessment Angioedema of tongue/larynx/pharynx = potential airway emergency. Assess: hoarseness, stridor, drooling, dysphagia. Have adrenaline (epinephrine) 0.5mg IM available. Hereditary angioedema (C1 inhibitor deficiency) does NOT respond to antihistamines/adrenaline — requires C1-INH concentrate or icatibant.
Lichen Sclerosus
- Chronic inflammatory dermatosis; white atrophic patches; lymphocytic infiltrate
- Site: vulval (most common — 90%), perianal, penile (balanitis xerotica obliterans)
- Symptoms: intense pruritus, soreness, dyspareunia, dysuria; structural changes (labial fusion, clitoral phimosis, introital stenosis)
- Appearance: ivory-white, crinkled "cigarette paper" skin; purpura/ecchymoses from fragile skin; figure-of-eight pattern vulva and perianal
- Cancer risk: 4–5% lifetime SCC risk in vulval LS; regular surveillance essential
- Treatment: ultrapotent topical corticosteroid (clobetasol propionate 0.05%) — initial intensive (daily × 4 weeks, alternate days × 4 weeks, twice weekly × 4 weeks) then maintenance; tacrolimus alternative; surgery for scarring/stenosis
- Nursing role: self-examination education, emollient use, gentle hygiene, psychological support
GCC-Specific Dermatology Conditions
High-Prevalence Conditions in GCC
- Tinea versicolor — Malassezia furfur; hot, humid climate + sweating; hypopigmented or hyperpigmented macules on trunk; Wood's lamp (yellow-green); topical ketoconazole/selenium sulphide; recurrence very common
- Pityriasis alba — post-inflammatory hypopigmentation; common in children; reassurance + emollients; more visible on darker skin tones; not a true depigmentation
- Atopic eczema — high prevalence in South Asian expat population; xerosis worsened by dry A/C environments; molluscum contagiosum as complication in immunosuppressed eczema patients
- Keloid/hypertrophic scarring — significantly higher incidence in Fitzpatrick IV–VI; ear piercing (common in GCC); management: intralesional triamcinolone, silicone gel, pressure therapy, laser
Vitiligo — Psychosocial Impact in GCC
Clinical Complete melanocyte destruction → chalk-white macules/patches; Koebner phenomenon; perioral, periorbital, genital, acrofacial patterns common; Wood's lamp enhances visibility.
GCC Cultural Context Vitiligo carries significant social stigma in some GCC communities. Can affect marriage prospects, employment, and social integration. Psychological support, patient education, and referral to dermatology support groups essential. Nurses must address psychosocial impact as part of holistic care.
Treatment: topical tacrolimus/corticosteroids for limited disease; NB-UVB phototherapy (best evidence); systemic JAK inhibitors (ruxolitinib cream); camouflage cosmetics; psychological support.
Behçet's Disease — Middle East / GCC Corridor
Higher prevalence in Turkey, Iran, Middle East ("Silk Road disease") — autoimmune vasculitis affecting multiple systems.
- Diagnostic criteria (ISG): Recurrent oral ulcers (≥3×/year) + 2 of: genital ulcers, eye lesions (uveitis/retinal vasculitis), skin lesions (erythema nodosum, pseudofolliculitis, acneiform), pathergy test positive
- Skin manifestations: painful oral aphthae (virtually universal), genital aphthae, erythema nodosum (legs), pseudofolliculitis
- Pathergy test: intradermal saline injection → papule/pustule at 48h (positive in Behçet's)
- Serious complications: posterior uveitis (blindness risk), CNS involvement, large vessel vasculitis (aneurysm), bowel perforation
- Treatment: colchicine (mucocutaneous), corticosteroids, azathioprine, anti-TNF (adalimumab/infliximab) for severe
DHA / DOH / SCFHS — Exam High-Yield Points
Must-Know Facts
- Braden score ≤18 = at risk for pressure injury
- Stage 1 PI: non-blanchable erythema, intact skin; Stage 4: bone/tendon exposed
- NERDS = local wound infection; STONEES = spreading/systemic
- Permethrin 5% first-line for scabies; treat ALL household contacts
- Dupilumab blocks IL-4 and IL-13 — used for atopic dermatitis
- Tinea capitis always needs systemic treatment (topical inadequate)
- KOH microscopy: hyphae confirm dermatophyte infection
- Melanoma: ABCDE rule; Breslow thickness = primary prognostic factor
- BCC: most common skin cancer; rarely metastasises; Mohs surgery
- Auspitz sign and Koebner phenomenon: psoriasis
Common Exam Traps
- Vesicle (<1cm fluid) vs Bulla (>1cm) vs Pustule (pus-filled — not just size)
- Tinea versicolor = Malassezia (yeast), NOT a dermatophyte
- Post-scabetic itch is NOT treatment failure — can persist weeks
- Stable dry eschar on heel = do NOT debride (protective, NPIAP guidance)
- DTI may present with intact skin — not always an open wound
- Patch testing = diagnosis of allergic contact dermatitis (not irritant CD)
- Isotretinoin is teratogenic — contraception essential for female patients
- Fitzpatrick Type I: always burns, never tans (highest skin cancer risk)
- Angioedema of tongue/larynx = airway emergency; hereditary type does NOT respond to antihistamines
- Vitiligo = white patches; pityriasis alba = hypopigmented patches (not fully depigmented)
Practice MCQs — Skin Assessment & Dermatology
1. A 45-year-old patient with dark skin (Fitzpatrick Type V) is on bed rest post-surgery. On inspection, the nurse notices a purple discolouration over the sacrum that does not blanch on diascopy. The skin is intact but feels warmer and firmer than surrounding tissue. What is the correct classification?
- A) Stage 1 pressure injury
- B) Deep Tissue Pressure Injury (DTI)
- C) Stage 2 pressure injury
- D) Unstageable pressure injury
Answer: B. DTI presents as persistent non-blanchable purple/maroon discolouration with intact or non-intact skin. In darker skin, Stage 1 may also appear purple — DTI is distinguished by the deep, poorly defined nature, warmth, and firmness indicating deep tissue involvement. May evolve rapidly.
2. A patient presents with an intensely itchy rash in web spaces of fingers, wrists, and genitalia. The pruritus is worst at night. On close inspection, short linear tracks are visible between fingers. What is the most appropriate first-line treatment?
- A) Oral antihistamines and topical hydrocortisone
- B) Clotrimazole 1% cream for 2 weeks
- C) Permethrin 5% cream applied neck to toe, repeated at day 7, with simultaneous treatment of all household contacts
- D) Oral fluconazole single dose
Answer: C. Classical scabies presentation. Permethrin 5% is first-line. Whole household treatment is essential as asymptomatic contacts may be infested. Oral ivermectin is an alternative if topical therapy is impractical.
3. Using the NERDS framework, which set of findings best indicates local wound infection requiring topical antimicrobial dressings?
- A) Spreading cellulitis, fever 38.5°C, elevated WBC
- B) Non-healing wound despite optimal care, increased exudate, red friable granulation tissue, sloughy debris, and new malodour
- C) Wound with clean granulation tissue, low exudate, healing edges
- D) Probe-to-bone positive, erythema extending 4cm from wound edge
Answer: B. NERDS criteria (Non-healing, Exudate increase, Red friable tissue, Debris, Smell) indicate critical colonisation/local infection — treat with topical antimicrobials. Option A/D describe spreading infection (STONEES) requiring systemic antibiotics.
4. A 7-year-old child from South Asia presents to the GCC paediatric clinic with pale, slightly scaly patches on the cheeks and upper arms, more noticeable after sun exposure. The child has a history of mild eczema. The patches do not fluoresce on Wood's lamp. What is the most likely diagnosis?
- A) Vitiligo
- B) Tinea versicolor
- C) Pityriasis alba
- D) Leprosy
Answer: C. Pityriasis alba is post-inflammatory hypopigmentation, common in atopic children, more visible on darker skin. Unlike vitiligo (complete depigmentation, chalk-white, no scale), PA patches have fine scale and partial pigment loss. Management: emollients, reassurance.
5. A patient is prescribed oral methotrexate for chronic plaque psoriasis. Which nursing instruction is most important to include in patient education?
- A) Apply SPF 15 sunscreen daily
- B) Take methotrexate daily with meals
- C) Take folic acid 5mg weekly (on a different day to methotrexate) and avoid alcohol completely
- D) Discontinue all other topical treatments once oral therapy starts
Answer: C. Folic acid supplementation reduces methotrexate side effects (mucositis, folate depletion) without reducing efficacy. Alcohol is absolutely contraindicated due to hepatotoxicity risk. Methotrexate is taken ONCE WEEKLY (not daily) — a common, potentially fatal dosing error.
6. A 65-year-old fair-skinned expat presents with a slow-growing, pearly nodule on the nose with a rolled, telangiectatic edge and central crusting. What is the most likely diagnosis and initial investigation?
- A) Squamous cell carcinoma; punch biopsy
- B) Basal cell carcinoma; incisional or punch biopsy for histological confirmation
- C) Melanoma; excision biopsy with 2mm margins
- D) Keratoacanthoma; observe for 3 months
Answer: B. Classic nodular BCC features (pearly, rolled edge, telangiectasia, central ulceration). Biopsy confirms histological subtype before definitive treatment. Mohs surgery preferred for facial BCC to preserve tissue. BCC rarely metastasises but is locally invasive.
7. What is the recommended protein intake for a patient with an active, healing Stage 3 pressure injury?
- A) 0.8g/kg/day (standard RDA)
- B) 1.0–1.2g/kg/day
- C) 1.5–2.0g/kg/day
- D) 3.0g/kg/day
Answer: C. Active pressure injury healing requires 1.5–2.0g/kg/day protein (prevention: 1.2–1.5g/kg/day). Refer to dietitian. Arginine-enriched supplements (e.g., Juven) support wound healing. Ensure adequate hydration and micronutrients (Vit C, Zinc).
8. Which clinical sign is pathognomonic (diagnostic) of psoriasis when scales are removed from a plaque?
- A) Wickham's striae
- B) Nikolsky sign
- C) Auspitz sign (pinpoint bleeding)
- D) Darier's sign
Answer: C. Auspitz sign — pinpoint bleeding on removal of psoriatic scale — results from thin suprapapillary epidermis and dilated capillaries in dermal papillae. Wickham's striae = lichen planus. Nikolsky sign = pemphigus/TEN. Darier's sign = mastocytoma (urtication on rubbing).
9. A patient develops acute tongue swelling and throat tightness after starting a new ACE inhibitor. What is the most important immediate nursing action?
- A) Administer oral antihistamine and observe
- B) Apply ice pack to face and neck
- C) Call the emergency team immediately; assess airway; prepare adrenaline (epinephrine) 0.5mg IM
- D) Apply topical hydrocortisone cream to neck
Answer: C. ACE inhibitor-induced angioedema (bradykinin-mediated) is a life-threatening emergency. Tongue/laryngeal oedema can rapidly cause airway obstruction. Adrenaline IM, airway management, and emergency team are priorities. Note: this type does NOT reliably respond to antihistamines — it is not IgE-mediated.
10. A 28-year-old Middle Eastern male presents with recurrent painful oral ulcers (4 episodes in 12 months), genital ulcers, and a history of bilateral uveitis. Pathergy test is positive. Which condition should be considered, and what is its geographic significance in GCC?
- A) Herpes simplex — common globally
- B) Crohn's disease with metastatic lesions
- C) Behçet's disease — higher prevalence along the historical Silk Road (Turkey/Iran/Middle East/GCC corridor)
- D) Reactive arthritis (Reiter's syndrome)
Answer: C. Behçet's disease: recurrent oral ulcers + genital ulcers + ocular involvement + positive pathergy test fulfils International Study Group criteria. Significantly higher prevalence in Middle East/Turkey/Iran. Serious complications include uveitis (blindness), CNS involvement, vascular aneurysm. Refer to rheumatology/dermatology.