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Anatomy, histology, physiology of the skin. Anatomy, histology, physiology of the skin. Methods of examination of patients with skin Methods of examination of patients with skin
diseases.diseases. Morphology of primary and secondary Morphology of primary and secondary
skin lesionsskin lesions..
Lector: Shkilna M.
ContentContent
Anatomy of skin:Anatomy of skin:o EpidermisEpidermiso DermisDermiso SubcutisSubcutiso Skin appendages .Skin appendages .
Functions of the skin.Functions of the skin.Methods of examination of patients with skin diseases:Methods of examination of patients with skin diseases:o Patient’s passport.Patient’s passport.o Patient’s complaints.Patient’s complaints.o History of present illness.History of present illness.o Life history (past history).Life history (past history).o Objective investigation (Objective investigation (morphology of primary and secondary skin lesions).morphology of primary and secondary skin lesions).
Investigations.Investigations.
SKIN… the heaviest single organ of SKIN… the heaviest single organ of the body!the body!
Skin is the largest organ of the body, it constitutes about 16% of body weight.Skin is the largest organ of the body, it constitutes about 16% of body weight.
Anatomy of skinAnatomy of skin
EpidermisEpidermis
DermisDermis
Hypodermis or Hypodermis or subcutaneous tissuesubcutaneous tissue
Appendages (hair, Appendages (hair, nails, sebaceous and nails, sebaceous and sweat glands).sweat glands).
Pic: Epidermal LayersPic: Epidermal Layers
Dermis is organized into two Dermis is organized into two distinct areas:distinct areas:
Papillary dermisPapillary dermis (the superficial zone).(the superficial zone).Reticular dermisReticular dermis (the deeper zone - it composes the bulk of the dermis).(the deeper zone - it composes the bulk of the dermis).
Components of the dermis:Components of the dermis:
collagencollagen (70-80%) – (70-80%) –
for resiliency;for resiliency;
elastin elastin (1-3%) –(1-3%) –
for elasticity;for elasticity;
proteoglycansproteoglycans – –
to maintain water within the dermis.to maintain water within the dermis.
Subcutis or subcutaneous fatSubcutis or subcutaneous fat : :
is arranged into distinct is arranged into distinct fat lobules which are fat lobules which are divided by fibrous divided by fibrous septae blood vessels, septae blood vessels, nerves, and lymphatics nerves, and lymphatics are also found in the are also found in the fibrous septae.fibrous septae.
Superficial netSuperficial net (in (in granular cell granular cell
layerlayer).).
Deep plexusDeep plexus (in subcutaneous (in subcutaneous
fat).fat).
Skin vessels:Skin vessels: Skin nerves:Skin nerves:
AppendagesAppendages
Eccrine sweat glandsEccrine sweat glands (open (open directly onto surface of skin directly onto surface of skin and regulate body temp)and regulate body temp)Apocrine glandsApocrine glands (axillae, (axillae, nipples, areolae, anogenital nipples, areolae, anogenital area, eyelids and external area, eyelids and external ears) respond to emotional ears) respond to emotional stimuli, bacteria causes body stimuli, bacteria causes body odor.odor.Sebaceous glandsSebaceous glands (secrete (secrete sebum, keep skin/hair from sebum, keep skin/hair from drying out) stimulated by drying out) stimulated by hormoneshormonesHaiHairr (Vellus and Terminal)(Vellus and Terminal)NailsNails (protect distal ends of (protect distal ends of fingers/toes)fingers/toes)
Functions of the skin:Functions of the skin:
Barrier. Barrier.
Metabolic. Metabolic.
Temperature regulation.Temperature regulation.
Secretion.Secretion.
Immune surveillance.Immune surveillance.
Coetaneous sensation.Coetaneous sensation.
Methods ofMethods of examination of patients examination of patients with skin with skin diseasesdiseases
1. Patient’s passport.1. Patient’s passport.2. Patient’s complaints:2. Patient’s complaints:a) skin rashesa) skin rashesb) subjective sensation, which are connected with b) subjective sensation, which are connected with
skin rashes: skin rashes: – itch of the skin;itch of the skin;– burning;burning;– pain;pain;– skin weeping;skin weeping;– dryness of the skin;dryness of the skin;– feeling of a tense skin;feeling of a tense skin;– weakness, weight loss, fever etc.weakness, weight loss, fever etc.
History of present illness:History of present illness:
Possible etiology of the diseasePossible etiology of the disease
( according patient’s mind).( according patient’s mind).
Duration of the disease:Duration of the disease:
Acute ( < 2 month)Acute ( < 2 month)
Chronic ( > 2 month).Chronic ( > 2 month).
Course of a disease.Course of a disease.
Previous treatment and effect from it.Previous treatment and effect from it.
Family history:Family history:
– contagious diseases;contagious diseases;
– hereditary diseases.hereditary diseases.
Life history (past history):Life history (past history):
Past medical history.Past medical history.Associated inner diseases.Associated inner diseases.Occupational hazards.Occupational hazards.Allergic history.Allergic history.Harmful habit.Harmful habit.
Objective investigationObjective investigation
General state of the patient General state of the patient
( satisfactory or not, fever etc. ).( satisfactory or not, fever etc. ).Systems revive.Systems revive.Assessment of nails, hair, and Assessment of nails, hair, and
mucosal surfaces, even if these mucosal surfaces, even if these are recorded as unaffected.are recorded as unaffected.
Objective investigation (continued)Objective investigation (continued)
Palpation ( to diagnose):Palpation ( to diagnose): Skin elastic.Skin elastic. Skin moistness.Skin moistness. Subcutaneous fat.Subcutaneous fat. Lymphatic nodes: ( size, consistency, Lymphatic nodes: ( size, consistency,
movable or immovable etc.).movable or immovable etc.).
Dermatological status:Dermatological status:
Inspection.Inspection.Palpation.Palpation.Scraping.Scraping.Dermoscopy.Dermoscopy.Laboratory end special methods.Laboratory end special methods.
Inspection:Inspection:
Skin textureSkin texture
Lesions:Lesions: type: primary and secondary;type: primary and secondary; color: red, brawn, white;color: red, brawn, white; shape: round, oval, annular; shape: round, oval, annular; arrangement: grouped (herpetiform, arrangement: grouped (herpetiform,
zoster form), disseminated zoster form), disseminated (erythrodermic psoriasis). (erythrodermic psoriasis).
Examination of LesionsExamination of Lesions
ConfigurationConfigurationAnnular (rings)Annular (rings)GroupedGroupedLinearLinearDiffuse Diffuse
DISTRIBUTION
CONFIGURATION
Morphology of primary and Morphology of primary and secondary skin lesionssecondary skin lesions
Primary skin lesionsPrimary skin lesions
is the initial lesion that has not been altered by is the initial lesion that has not been altered by trauma, manipulation (scratching, scrubbing), trauma, manipulation (scratching, scrubbing), or natural regression over time.or natural regression over time.
Types:Types:
primary lesions without cavity;primary lesions without cavity;
primary lesions with cavity.primary lesions with cavity.
Primary lesions without cavity:Primary lesions without cavity:
Macula'sMacula's
UrticaUrtica
PapulePapule
NoduleNodule
Macula and PatchMacula and Patch
DescriptionDescriptionCircumscribedCircumscribedFlatFlatDiscolorationDiscolorationSmaller than 0.5 cm-maculaSmaller than 0.5 cm-maculaLarger that 0.5 cm- patchLarger that 0.5 cm- patchMay be brown, blue, red.May be brown, blue, red.
MACULEMACULE
DescriptionDescription CircumscribedCircumscribed FlatFlat DiscolorationDiscoloration Smaller than 0.5 cm-Smaller than 0.5 cm-
maculemacule Larger that 0.5 cm- patchLarger that 0.5 cm- patch May be brown, blue, red or May be brown, blue, red or
hypo pigmentedhypo pigmented InflammatoryInflammatory NonNoninflammatoryinflammatory
TINEA VERSICOLOR
Becker's nevus. This lesion contains no pigmentation.
Becker's nevus. A typical lesion with macular pigmentation and hair.
BROWN MACULE
PAPULEPAPULE
DescriptionDescription– an elevated solid lesionan elevated solid lesion
up to 0.5 cm in diameterup to 0.5 cm in diameter
– Color varies: flesh, Color varies: flesh, yellow , white, brown, yellow , white, brown, red, blue or violetred, blue or violet
– May become confluentMay become confluent
– May form plaquesMay form plaques
PLAQUE
A circumscribed, elevated, superficial, solid lesion more than 0.5cm in diameter often formed by the confluence of papules
DescriptionDescription
PlaquePlaque
Examples of PlaquesExamples of Plaques EczemaEczema
Pityriasis roseasPityriasis roseas Tinea corporisTinea corporis
PsoriasisPsoriasis SyphilisSyphilis
PSORIASIS PLAQUE SECONDARY SYPHYLIS
NoduleNodule
DescriptionDescription– CircumscribedCircumscribed– Often roundOften round– Solid lesionSolid lesion– More that 0.5 cm in More that 0.5 cm in
diameterdiameter– Larger nodule is a Larger nodule is a
tumortumor
Metastatic carcinoma of the breast.
LIPOMA BENIGN TUMOR
WHEAL (HIVE)WHEAL (HIVE)
DescriptionDescription
Starts as red erythematous macules.Soon paleoedematous wheals develop Irregular, asymmetricalVelvety to touchErythematic well defined, fades on pressureSubside within few hours without leaving any traceDermographism positiveWheals develop along line of scratching or pressure.
Physical urticariaPhysical urticaria
Cold urticariaurticaria : Reaction to cold, such as ice, cold air or water - worse with sudden change in temperature
Primary lesions with cavity:Primary lesions with cavity:
VesiclesVesicles
BullaBulla
PustulesPustules
CystCyst
Vesicle Vesicle
DescriptionDescription
Circumscribed Circumscribed collection of free collection of free fluidfluid
Up to 0.5 cm in Up to 0.5 cm in diameterdiameter
Herpes zoster
Bulla formed dueBulla formed due to fluid in the skin and fluid to fluid in the skin and fluid collection occurs at sites where the cohesion on the skin collection occurs at sites where the cohesion on the skin
is weak:is weak:
SubcornealSubcorneal
Intra – epidermal,Intra – epidermal, due to due to individual keratinocytesindividual keratinocytes
Dermo –Dermo – epidermalepidermal junctionjunction
A circumscribed collection of free fluid more than
0,5 sm in diameter
PUSTULEPUSTULE
DescriptionDescriptionCircumscribed Circumscribed
collection of collection of leukocytesleukocytes
Free fluidFree fluidVaries in sizeVaries in size
Staphylococcal folliculitis
CYSTCYST
A circumscribed A circumscribed lesion with a wall lesion with a wall and a lumen, it and a lumen, it may contain fluid may contain fluid or solid matteror solid matter
Secondary skin lesionsSecondary skin lesions
Types:Types:
Scale.Scale.
Crusts.Crusts.
ErosionsErosions..
EROSIONEROSION
DescriptionDescription
A focal loss of epidermis;
erosions do not penetrate
below the dermoepidermal
junction; and therefore heal
without scarring Toxic epidermal necrolysis
CRUSTCRUST
DescriptionDescription
Is a collection of dried serum and cellular debris- a scabIs a collection of dried serum and cellular debris- a scab
ExamplesExamples
– Acute eczematous inflammation, Atopic on the face, Impetigo- golden Acute eczematous inflammation, Atopic on the face, Impetigo- golden or honey colored, Tinea capitis.or honey colored, Tinea capitis.
Impetigo. A thick, honey-yellow adherent crust covers the entire eroded surface.
UlcerUlcer A focal loss of A focal loss of epidermis and dermis, epidermis and dermis, and heal with scarringand heal with scarring
ExamplesExamples– DecubitusDecubitus
– IschemicIschemic
– Stasis ulcersStasis ulcers
– Neoplasm's Neoplasm's
FISSUREFISSURE
DescriptionDescriptionA linear loss of epidermis A linear loss of epidermis
and dermis with sharply and dermis with sharply defined nearly vertical defined nearly vertical wallswalls
ExamplesExamples– Chapping – hands and Chapping – hands and
feetfeet
– Eczema on the finger Eczema on the finger tiptip
Asteatotic eczema. Excessive washing produced this advanced case with cracking and fissures.
ATROPHYATROPHY
DescriptionDescription
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.
ScarScar
DescriptionDescriptionAn abnormal formation of An abnormal formation of
connective tissue, implying connective tissue, implying dermal damage, after injurydermal damage, after injury
Are initially thick and pink, but Are initially thick and pink, but become white and atrophicbecome white and atrophic
ExamplesExamples– Post surg.Post surg.– BurnsBurns– KeloidKeloid– Post any herpesPost any herpes Keloids on the chest and extremities are
raised with a flat surface. The base is wider than the top.
EXCORIATIONEXCORIATION
An erosion caused by scratching;
excoriations are often linear.
LICHENIFICATIONLICHENIFICATION
DescriptionDescription
An area of thickened An area of thickened epidermis induced by epidermis induced by scratchingscratchingSkin lines are accentuated Skin lines are accentuated so it looks like a so it looks like a washboardwashboardExamplesExamples– Atopic dermatitis, Atopic dermatitis,
chronic eczematous chronic eczematous dermatitisdermatitis
LICHENIFICATION
ScalesScales
DescriptionDescriptionExcess dead epidermal
cells that are produced by abnormal keratinization and shedding.
The may beThe may be fine, as in pityriasis;fine, as in pityriasis;
white and silvery, as in white and silvery, as in psoriasis; psoriasis;
or large and fish-like, as or large and fish-like, as in ichthyosisin ichthyosis
Dominant ichthyosis vulgaris
INVESTIGATIONSINVESTIGATIONS
General laboratory investigationGeneral laboratory investigation::General blood analysis.General blood analysis.General urine analysis.General urine analysis.Stool test for parasites.Stool test for parasites.Examination of blood for sugar.Examination of blood for sugar.Wasserman reaction.Wasserman reaction.
INVESTIGATIONSINVESTIGATIONS
Diagnostic TestsDiagnostic TestsSkin Biopsy Skin Biopsy Culture and sensitivity (viral, bacteria, fungi)Culture and sensitivity (viral, bacteria, fungi)ImmunofluorescenceImmunofluorescenceAllergy TestsAllergy Tests Skin ScrapingsSkin ScrapingsTzanck SmearTzanck SmearWood’s Light ExaminationWood’s Light ExaminationClinical PhotographsClinical PhotographsDiascopyDiascopy
EPILUMINESCENCE MICROSCOPY EPILUMINESCENCE MICROSCOPY (DERMATOSCOPY, DERMOSCOPY) (DERMATOSCOPY, DERMOSCOPY)
This refers to surface This refers to surface microscopy using an microscopy using an illuminated lens with oil illuminated lens with oil immersion directly on to the immersion directly on to the skin's surface. The presence skin's surface. The presence of oil reduces specular of oil reduces specular reflection and reduces reflection and reduces 'errors' due to the different 'errors' due to the different refractive indexes of the refractive indexes of the various superficial layers of various superficial layers of skinskin. .
SCRAPINGSCRAPING
Hidden scaling of the Hidden scaling of the skin.skin.
Psoriatic phenomenonts.Psoriatic phenomenonts. Purpura symptom.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
glisteningwhite, adherent membrane appears.
Step C: On removing the membrane, punctate bleeding
points become visible.
DIASCOPYDIASCOPY
A glass slide is pressed firmly on A glass slide is pressed firmly on the skin lesion. If a red lesion the skin lesion. If a red lesion blanches, it implies that the red blanches, it implies that the red colour is secondary to blood within colour is secondary to blood within the vessels. By contrast, blood the vessels. By contrast, blood outside the vessels, such as that outside the vessels, such as that from a bruise or from vasculitis, from a bruise or from vasculitis, will not blanch. will not blanch.
Success in blanching is a more Success in blanching is a more useful physical sign than failure to useful physical sign than failure to blanch. blanch.
Granulomatous lesions a glass slide Granulomatous lesions a glass slide reveals an appearance commonly reveals an appearance commonly referred to as 'apple jelly nodule'. referred to as 'apple jelly nodule'.
Inflammatory or Inflammatory or
no inflammatory types of no inflammatory types of lesionslesions
WOOD'S LIGHTWOOD'S LIGHT
This involves irradiation with a UV light This involves irradiation with a UV light source that causes normal skin, particularly source that causes normal skin, particularly dermis, to fluoresce (in the visible light dermis, to fluoresce (in the visible light range). range).
The basis for this is that in the ultraviolet The basis for this is that in the ultraviolet A wavebands used by Wood's light, A wavebands used by Wood's light, pigmentation has a greater degree of pigmentation has a greater degree of absorption than at longer wavebands, absorption than at longer wavebands, resulting in a greater degree of difference resulting in a greater degree of difference in fluorescence between pigmented and in fluorescence between pigmented and depigmented skin. depigmented skin.
Wood's light also enhances the Wood's light also enhances the examination of cutaneous pigmentary examination of cutaneous pigmentary abnormalities such as in patients with abnormalities such as in patients with vitiligo, where areas of subtle vitiligo, where areas of subtle
depigmentation are more easily seen.depigmentation are more easily seen.
MYCOLOGY SAMPLESMYCOLOGY SAMPLES
Coetaneous scale, nail clippings and plucked hairs can be Coetaneous scale, nail clippings and plucked hairs can be examined by light microscopy when mounted in 20% examined by light microscopy when mounted in 20% potassium hydroxide. potassium hydroxide.
The keratin is dissolved, allowing fungal hyphae to be The keratin is dissolved, allowing fungal hyphae to be identified.identified.
SWABSSWABS
Bacterial swabs in an appropriate culture medium are sometimes Bacterial swabs in an appropriate culture medium are sometimes useful. useful.
PRICK TESTSPRICK TESTS
Prick tests are a way of detecting coetaneous type I (immediate)Prick tests are a way of detecting coetaneous type I (immediate) hypersensitivity to various antigens such as pollen, house dust mite or dander.hypersensitivity to various antigens such as pollen, house dust mite or dander. The skin is pricked with a dilution of the appropriate antigen solution. AfterThe skin is pricked with a dilution of the appropriate antigen solution. After 10 minutes a positive response is indicated by a weal and a flare. The weal is 10 minutes a positive response is indicated by a weal and a flare. The weal is due to a local increase in capillary permeability and the flare a result of due to a local increase in capillary permeability and the flare a result of
activation of the axon reflex. activation of the axon reflex.
IMMUNOFLUORESCENCEIMMUNOFLUORESCENCE
A portion of the skin biopsy can be frozen in liquid A portion of the skin biopsy can be frozen in liquid nitrogen for direct immunofluorescence (IF). This nitrogen for direct immunofluorescence (IF). This involves visualising antigens that are present in skin involves visualising antigens that are present in skin by identifying them with fluorescein-labelled by identifying them with fluorescein-labelled antibodies. Similarly, indirect immunofluorescence antibodies. Similarly, indirect immunofluorescence can identify circulating antibodies in the serum by an can identify circulating antibodies in the serum by an additional step of adding the serum to a section of additional step of adding the serum to a section of normal skin or other substrate. Immunofluorescence normal skin or other substrate. Immunofluorescence plays a major role in the diagnosis of the autoimmune plays a major role in the diagnosis of the autoimmune bullous disorders.bullous disorders.
ELECTRON MICROSCOPYELECTRON MICROSCOPY
This investigation has played an important role in the This investigation has played an important role in the diagnosis of some of the rare blistering disorders such as diagnosis of some of the rare blistering disorders such as epidermolysis bullosa, although the availability of a range epidermolysis bullosa, although the availability of a range of antibodies to basement membrane zone antigens has in of antibodies to basement membrane zone antigens has in part replaced it.part replaced it.
PHOTOTESTINGPHOTOTESTING
Phototesting involves exposing skin (often on the back) to a Phototesting involves exposing skin (often on the back) to a graded series of doses of ultraviolet radiation (UVR) of graded series of doses of ultraviolet radiation (UVR) of known wavelength, either on one occasion or repeatedly.known wavelength, either on one occasion or repeatedly.
Laboratory and special methodsLaboratory and special methods
General laboratory investigation:General laboratory investigation:general blood analysis;general blood analysis;general urine analysis;general urine analysis;stool test for parasites;stool test for parasites;examination of blood for sugar;examination of blood for sugar;Wasserman reaction.Wasserman reaction.
Thank you for your attention !