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Integumentary Function
in the center) on the buccal mucosa, and mild to severe
photosensitivity. The person commonly has coldlike
symptoms, general malaise, and myalgia. In severe cases,
the macules may hemorrhage into the skin tissue or onto
the outer body surface. This form is called
hemorrhagic
measles
. The course of measles is more severe in infants,
adults, and malnourished children. The World Health
Organization recommends vitamin A treatment for
measles in developing countries to reduce morbidity and
mortality. There may be severe complications, includ-
ing otitis media, pneumonia, and encephalitis. Antibody
titers are determined for a conclusive diagnosis of rube-
ola. Measles is a disease preventable by vaccine, and
immunization is required by law in the United States.
Varicella.
Varicella (chickenpox) is a common commu-
nicable childhood disease. It is caused by the varicella-
zoster virus, which also is the agent in herpes zoster
(shingles). The characteristic skin lesion occurs in three
stages: macule, vesicle, and granular scab. The macu-
lar stage is characterized by development within hours
of macules over the trunk, spreading to the limbs, buc-
cal mucosa, scalp, axillae, upper respiratory tract, and
conjunctiva (Fig. 46-28). During the second stage, the
macules form vesicles with depressed centers. The vesi-
cles break open and a scab forms during the third stage.
Crops of lesions occur successively, so that all three
forms of the lesion usually are visible by the 3rd day of
the illness.
Mild to extreme pruritus accompanies the lesions,
which can lead to scratching and subsequent develop-
ment of secondary bacterial infections. Chickenpox also
is accompanied by coldlike symptoms, including cough,
coryza, and sometimes photosensitivity. Mild febrile
states usually occur, typically beginning 24 hours before
lesion outbreak. Side effects, such as pneumonia, septic
complications, and encephalitis, are rare.
Varicella in adults may be more severe, with a pro-
longed recovery rate and greater chances for devel-
opment of varicella pneumonitis or encephalitis.
Immunocompromised persons may experience a
chronic, painful form of the infection.
Despite breakthrough cases and lower efficacy rates
overall than in other vaccines, live attenuated varicella
vaccine has been demonstrated to have dramatically
decreased varicella morbidity and mortality since 1995,
when the vaccine was introduced in the United States.
72
The vaccine is most effective in children under 10 years
of age.
72
One dose of the vaccine is required by law in
the United States; however, a second dose is now rec-
ommended to address what is called
primary vaccine
failure
. It is believed that a single dose of varicella vac-
cine may only prime the host response, without induc-
ing protective immunity. Outbreaks of mild cases of
varicella, called
breakthrough varicella,
have occurred
in vaccinated populations. The breakthrough infection
is difficult to diagnose because the maculopapular rash
does not have the classic sign of vesicles.
Skin Manifestations and Disorders
in the Elderly
Elderly persons experience a variety of age-related skin
disorders and exacerbations of earlier skin problems.
Aging skin is believed to involve a complex process of
actinic (solar) damage, normal aging, and hormonal
influences. Actinic changes primarily involve increased
occurrence of lesions on sun-exposed surfaces of the
body.
Normal Age-Related Changes
Normal skin changes associated with aging are seen on
areas of the body that have not been exposed to the sun.
They include thinning of the dermis and the epidermis,
diminution in subcutaneous tissue, a decrease and thick-
ening of blood vessels, and a decrease in the number
of melanocytes, Langerhans cells, and Merkel cells. The
keratinocytes shrink, but the number of dead keratin-
ized cells at the surface increases. This results in less pad-
ding and thinner skin, with color and elasticity changes.
The skin also loses its resistance to environmental and
mechanical trauma. Tissue repair takes longer.
With aging, there is also less hair and nail growth, and
there is permanent hair pigment loss. Hormonally, there
is less sebaceous gland activity, although the glands in
the facial skin may increase in size. Hair growth reduc-
tion also may be hormonally influenced. Although the
reason is poorly understood, the skin in most elderly
persons older than 70 years of age becomes dry, rough,
scaly, and itchy. When there is no underlying pathologic
process, it is called
senile pruritus
. Itching and dryness
become worse during the winter, when the need for
home heating lowers the humidity.
The aging of skin, however, is not just a manifesta-
tion of age itself. Most skin changes associated with the
elderly are the result of cumulative actinic or environ-
mental damage. For example, the wrinkled, leathery
look of aged skin, as well as odd scars and ecchymotic
spots, are due to solar elastotic degenerative change.
FIGURE 46-28.
Blisterlike lesions of varicella (i.e., chickenpox)
on the face of a young child. (From the Centers for Disease
Control and Prevention Public Health Image Library. No. 10486.
Courtesy of John Noble, Jr.)
