Neurological Conditions Connected with Skin Issues
Everyone is familiar with secondary complications of neurological injury especially the high risk of pressure injury from decreased sensation. After an injury, the skin loses strength from decreased collagen, decreased blood supply, and muscle size, with an increase in fat. These changes are due to lack of mobility and nerve miscommunication. There are more unusual skin conditions that can occur years after injury to the nervous system. These occur more commonly but are not exclusive to those who have a neurological disease. These conditions are skin infections, seborrheic dermatitis, ingrown toenails, dry skin, and neurogenic skin.
Skin infections are caused by bacteria, viruses, funguses, or parasites that are directly on or in the skin. They can develop in anyone with or without neurological injury or disease. Bacterial skin infections may appear as a pimple, abscess, impetigo, or cellulitis (infection of skin cells). Viral skin infections include a wart, measles, chickenpox, shingles, and hand, foot and mouth disease. Fungal infections may include athlete’s foot, ringworm, nail fungus, mouth thrush, diaper rash, or yeast infection. Skin infections from parasites include lice, bedbugs, or scabies.
The skin is the body’s external defense against any invader from entering. However, infections can slip into an opening in the skin or even just burrow in through healthy skin tissue.
Typically, the body will mount a defense against an invader of the skin. The immune system will detect an invader causing a message to be sent to the brain. The brain then will respond by sending naturally occurring antibodies to eliminate the invader. However, with a neurological disease or injury, the autonomic nervous system (ANS) may not detect the invader, may not send a message to the brain quickly or fully, and may not relay the message to destroy the invader effectively, or any combination of these actions. This allows the invader to multiply. At first, the skin infection may not be detected in other ways by not being seen or felt which allows more time for the invader to multiply.
Treatment for skin infections depends on the bacteria, virus, fungus, or parasite causing the issue. Typically, prescription antibiotic ointments, antiviral creams, antifungals, or antiparasitic medication are needed. Keeping the areas clean and thorough drying is needed. Providing air and light to dark body parts by use of positioning can assist in resolving the area requiring treatment. Remember, bacteria love warm, dark, moist body parts such as armpits, groin, under breasts, and skin folds.
Seborrheic dermatitis looks a lot like dandruff but is more serious. In children, it is seen as a ‘cradle cap’. It is a reaction to normal substances on the surface of the skin which allows Malassezia yeast to overgrow causing the immune system to overreact. This becomes a circular process of flair-ups and clearing. The condition looks like redness, greasy scales, and slight swelling predominantly in the areas of the nose, eyebrows, chest, and upper back, and can occur in the groin and armpits. It may appear on the head in adults and especially in children. It can be confused with diaper rash.
Connections of seborrheic dermatitis occur in neurological conditions such as stroke, head injury, spinal cord injury, Parkinson’s Disease, and epilepsy, among many others. Stress and hormonal changes due to extreme illness as well as depression and alcoholism can trigger the condition.
Treatment is to keep seborrheic dermatitis under control by using a 2% zinc pyrithione cleanser and a moisturizer. A medicated shampoo, antifungal cream, or over-the-counter dandruff product may be prescribed. For cradle cap petroleum jelly or dandruff shampoo may be all that is needed to loosen and remove scales.
Toenails and fingernails are considered part of the skin. In neurological injury, an ingrown nail especially a toenail occurs from the nail growing into the skin or the nail being cut to taper around the shape of the nail which allows the skin to grow over the nail. The symptoms are nail redness, swelling, warmth in the area, pain, and pus. You may not feel the symptoms, but your body will still react to them. Ingrown toenails often trigger episodes of autonomic dysreflexia (AD).
Risks for ingrown nails, of the toes or fingers, include not cutting the nail straight across. Many individuals like to shape the nail around the toe, but this allows the nail to grow into the skin or the skin to cover the nail. Other issues are shoes that are too tight, poorly fitting, or rub with movement such as walking or with tone (spasms). Hitting or bumping your toe or finger can create damage to the nail and swollen tissue around the nail leading to an ingrown nail. Other risk factors are decreased sensation from poor nerve function and diabetes. In children, shoes that are outgrown are a cause.
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A podiatrist should perform a treatment if the issue is in your toe or a healthcare professional if in your finger, especially if you have decreased sensation. Attempting to correct the ingrown nail yourself can lead to more damage and infection. You might be requested to soak your toe in warm water at home. Be sure to dry your toes carefully and thoroughly. The health professional will lift the nail and place gauze to keep it lifted or they may remove part or all of the nail. If an infection is present, antibiotics will be provided.
You can take action to prevent an ingrown nail. Wear roomy shoes. Be sure and check your shoe size because even as adults, foot size changes or edema can create a need for a larger shoe. If you cannot go to the shoe store for measurement, trace your foot when it is hanging down from your body (not when laying) and at the point of the day when you have the most edema. Take the traced cut out to the shoe store to measure it or try it in shoes. Always check your shoes by pressing or having someone press on the shoe to make sure your foot fits well inside the shoe. To prevent an ingrown nail, cut your nails straight across.
Dry skin is from the decreased function of sebaceous (oil glands) and sweat glands of the skin. With a neurological injury, your body may not sweat or produce oils in the area of injury or disease. Skin glands can also be affected by diuretic medication as well as dry air. This condition is more severe than just plain dry skin. It can appear as sores or openings of the skin, especially on the legs, patches of rough texture, or crusty dry scales. It is usually very itchy, which can trigger episodes of AD.
Treatment is to use moisture after bathing. If you have excessively dry skin, moisturizers with lactic acid or refined almond oil work well. You will need to see a healthcare professional or dermatologist for treatment with anti-inflammatory cream, lipids, or in very severe cases steroid cream. Prevention of extremely dry skin includes skin hydration with moisturizer and humidified air. Triggers may include skin irritants such as shaving, fragrances in soaps and lotions, harsh body soaps, dish soap, and scratchy fabric such as wool. Bathe in warm but not hot water. Keep bathing times short.
Neurogenic skin (neurodermatitis) is a condition where sensory nerves in the skin lead to inflammation due to overexpression of mast cells. Mast cells are in connective tissue in the body. They contain histamine which is released in injury, allergies, and inflammatory reactions. They are a part of the immune and neuroimmune systems. This is often seen in issues such as rosacea.
The sensory nerves of the body are extensively connected to the skin to provide information about sensation, temperature, pain, invaders, and other irritants. A disruption of the nervous system, stress, and itching can lead to neurogenic skin. Miscommunication of the sensory nerves in the skin can lead to combinations of all the issues listed above as well as redness and swelling in the affected area. Treatment depends on the type of issue the condition produces.
Maintenance of the skin is critical to the protection of the body. General hygiene, moisturizing, and nail care are essential with neurological injury or disease of any type. Being aware of skin issues can help you protect yourself. Examining your skin for pressure injury is essential but while looking, check for anything abnormal or changes so you can begin early intervention.
Pediatric Consideration:
Pediatric issues with skin are slightly different and often the same with or without neurological injury. Many of the subtle differences between adult and children’s issues are mentioned above.
Prevention is important. Early detection is necessary. Check your child’s skin with pressure injury checks. Being prepared is essential to maintaining overall health.