Lector: Shkilna M.

1. Anatomy, histology, physiology of the skin. Methods of examination of patients with skin diseases.Morphology of primary and secondary skin lesions. Lector: Shkilna M.

2. Content Anatomy of skin: • Epidermis • Dermis • Subcutis • Skin appendages . Functions of the skin. Methods of examination of patients with skin diseases: • Patient’s passport. • Patient’s complaints. • History of present illness. • Life history (past history). • Objective investigation (morphology of primary and secondary skin lesions). Investigations.

3. Anatomy of skin • Epidermis • Dermis • Hypodermis or subcutaneous tissue • Appendages (hair, nails, sebaceous and sweat glands).

4. Epidermal Layers

6. collagen (70-80%) – for resiliency; elastin (1-3%) – for elasticity; proteoglycans – to maintain water within the dermis. Dermis Components of the dermis: Two distinct areas:

7. Subcutis or subcutaneous fat : is arranged into distinct fat lobules which are divided by fibrous septae blood vessels, nerves, and lymphatics are also found in the fibrous septae.

8. Superficial net (in granular cell layer). Deep plexus (in subcutaneous fat). Skin vessels: Skin nerves:

9. Appendages • Eccrine sweat glands (open directly onto surface of skin and regulate body temp) • Apocrine glands (axillae, nipples, areolae, anogenital area, eyelids and external ears) respond to emotional stimuli, bacteria causes body odor. • Sebaceous glands (secrete sebum, keep skin/hair from drying out) stimulated by hormones • Hair(Vellus and Terminal) • Nails (protect distal ends of fingers/toes)

10. Functions of the skin: • Barrier. • Metabolic. • Temperature regulation. • Secretion. • Immune surveillance. • Coetaneous sensation.

11. Methods of examination of patients with skin diseases 1. Patient’s passport. 2. Patient’s complaints: a) skin rashes b) subjective sensation, which are connected with skin rashes: • itch of the skin; • burning; • pain; • skin weeping; • dryness of the skin; • feeling of a tense skin; • weakness, weight loss, fever etc.

12. History of present illness: • Possible etiology of the disease ( according patient’s mind). • Duration of the disease: Acute ( < 2 month) Chronic ( > 2 month). • Course of a disease. • Previous treatment and effect from it. • Family history: • contagious diseases; • hereditary diseases.

13. Life history (past history): • Past medical history. • Associated inner diseases. • Occupational hazards. • Allergic history. • Harmful habit.

14. General state of the patient ( satisfactory or not, fever etc. ). Systems revive. Assessment of nails, hair, and mucosal surfaces, even if these are recorded as unaffected. Palpation ( to diagnose): Skin elastic. Skin moistness. Subcutaneous fat. Lymphatic nodes: ( size, consistency, movable or immovable etc.). Objective investigation

15. Skin texture Lesions: type: primary and secondary; color: red, brawn, white; shape: round, oval, annular; arrangement: grouped (herpetiform, zoster form), disseminated (erythrodermic psoriasis). Configuration of Lesions Annular (rings) Grouped Linear Diffuse Inspection:

16. DISTRIBUTION

17. CONFIGURATION

18. Morphology of primary and secondary skin lesions Primary skin lesions is the initial lesion that has not been altered by trauma, manipulation (scratching, scrubbing), or natural regression over time. Types: • primary lesions without cavity; • primary lesions with cavity.

19. Primary lesions without cavity: • Macula's • Urtica • Papule • Nodule

20. MACULE • Description • Circumscribed • Flat • Discoloration • Smaller than 0.5 cm-macule • Larger that 0.5 cm- patch • May be brown, blue, red or hypo pigmented • Inflammatory • Noninflammatory TINEA VERSICOLOR

21. BROWN MACULE Becker's nevus. A typical lesion with macular pigmentation and hair. Becker's nevus. This lesion contains no pigmentation.

22. PAPULE • Description • an elevated solid lesionup to 0.5 cm in diameter • Color varies: flesh, yellow , white, brown, red, blue or violet • May become confluent • May form plaques

23. PLAQUE • Description • A circumscribed, elevated, superficial, solid lesion more than 0.5cm in diameter • often formed by the confluence of papules

24. Plaque SECONDARY SYPHYLIS PSORIASIS PLAQUE • Examples of Plaques • Eczema • Pityriasis roseas • Tinea corporis • Psoriasis • Syphilis

25. Nodule • Description • Circumscribed • Often round • Solid lesion • More that 0.5 cm in diameter • Larger nodule is a tumor Metastatic carcinoma of the breast.

26. LIPOMA BENIGN TUMOR

27. WHEAL (HIVE) • Description • Starts as red erythematous macules. • Soon paleoedematous wheals develop • Irregular, asymmetrical • Velvety to touch • Erythematic well defined, fades on pressure • Subside within few hours without leaving any trace • Dermographism positive • Wheals develop along line of scratching or pressure.

28. Physical urticaria • Cold urticaria: Reaction to cold, such as ice, cold air or water - worse with sudden change in temperature

29. Primary lesions with cavity: • Vesicles • Bulla • Pustules • Cyst

30. Vesicle • Description • Circumscribed collection of free fluid • Up to 0.5 cm in diameter Herpeszoster

31. Bulla formed dueto fluid in the skin and fluid collection occurs at sites where the cohesion on the skin is weak: • Subcorneal • Intra – epidermal, due to individual keratinocytes • Dermo –epidermal junction A circumscribed collection of free fluid more than 0,5 sm in diameter

32. PUSTULE • Description • Circumscribed collection of leukocytes • Free fluid • Varies in size Staphylococcal folliculitis

33. CYST • A circumscribed lesion with a wall and a lumen, it may contain fluid or solid matter

34. Secondary skin lesions Types: Scale. Crusts. Erosions.

35. EROSION • Description • A focal loss of epidermis; • erosions do not penetrate below the dermoepidermal junction; • and therefore heal without scarring Toxic epidermal necrolysis

36. CRUST Impetigo. A thick, honey-yellow adherent crust covers the entire eroded surface. • Description Is a collection of dried serum and cellular debris- a scab • Examples • Acute eczematous inflammation, Atopic on the face, Impetigo- golden or honey colored, Tinea capitis.

37. Ulcer • A focal loss of epidermis and dermis, and heal with scarring • Examples • Decubitus • Ischemic • Stasis ulcers • Neoplasm's

38. FISSURE • Description A linear loss of epidermis and dermis with sharply defined nearly vertical walls Examples • Chapping – hands and feet • Eczema on the finger tip Asteatotic eczema. Excessive washing produced this advanced case with cracking and fissures.

39. ATROPHY • Description A depression in the skin resulting from thinning of the epidermis or dermis Lichen sclerosus et atrophicus. The epidermis is thin and atrophic and gives the appearance of wrinkled tissue paper when compressed.

40. Scar • Description An abnormal formation of connective tissue, implying dermal damage, after injury Are initially thick and pink, but become white and atrophic • Examples • Post surg. • Burns • Keloid • Post any herpes Keloids on the chest and extremities are raised with a flat surface. The base is wider than the top.

41. EXCORIATION • An erosion caused by scratching; • excoriations are often linear.

42. LICHENIFICATION • Description • An area of thickened epidermis induced by scratching • Skin lines are accentuated so it looks like a washboard • Examples • Atopic dermatitis, chronic eczematous dermatitis

43. LICHENIFICATION

44. Scales • Description Excess dead epidermal cells that are produced by abnormal keratinization and shedding. The may be • fine, as in pityriasis; • white and silvery, as in psoriasis; • or large and fish-like, as in ichthyosis Dominant ichthyosis vulgaris

45. INVESTIGATIONS • General laboratory investigation: • General blood analysis. • General urine analysis. • Stool test for parasites. • Examination of blood for sugar. • Wasserman reaction.

46. INVESTIGATIONS Diagnostic Tests • Skin Biopsy • Culture and sensitivity (viral, bacteria, fungi) • Immunofluorescence • Allergy Tests • Skin Scrapings • Tzanck Smear • Wood’s Light Examination • Clinical Photographs • Diascopy

47. EPILUMINESCENCE MICROSCOPY (DERMATOSCOPY, DERMOSCOPY) • This refers to surface microscopy using an illuminated lens with oil immersion directly on to the skin's surface. The presence of oil reduces specular reflection and reduces 'errors' due to the different refractive indexes of the various superficial layers of skin.

48. SCRAPING • Hidden scaling of the skin. • Psoriatic phenomenonts. • Purpura symptom. Step A:Gently scrape the lesion with a glass slide. This accentuates the silvery scales (Grattage test positive). Scrape off all the scales. Step B: As you continue to scrape the lesion, a glistening white, adherent membrane appears. Step C: On removing the membrane, punctate bleeding points become visible.

49. DIASCOPY • A glass slide is pressed firmly on the skin lesion. If a red lesion blanches, it implies that the red colour is secondary to blood within the vessels. By contrast, blood outside the vessels, such as that from a bruise or from vasculitis, will not blanch. • Success in blanching is a more useful physical sign than failure to blanch. • Granulomatous lesions a glass slide reveals an appearance commonly referred to as 'apple jelly nodule'. Inflammatory or no inflammatory types of lesions

50. WOOD'S LIGHT • This involves irradiation with a UV light source that causes normal skin, particularly dermis, to fluoresce (in the visible light range). • The basis for this is that in the ultraviolet A wavebands used by Wood's light, pigmentation has a greater degree of absorption than at longer wavebands, resulting in a greater degree of difference in fluorescence between pigmented and depigmented skin. • Wood's light also enhances the examination of cutaneous pigmentary abnormalities such as in patients with vitiligo, where areas of subtle depigmentation are more easily seen.