1. Anatomy, histology, physiology of the skin
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: Functions of the 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. SKIN… the heaviest single organ of the body!
Skin is the largest organ of the body, it constitutes about 16% of body weight.

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

6. Pic: Epidermal Layers

8. Dermis is organized into two distinct areas:
Papillary dermis (the superficial zone).
Reticular dermis
(the deeper zone - it composes the bulk of the dermis).

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

10. 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.

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

12. 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)
Eccrine are distributed throughout the body except: lip margins, eardrums, nail beds, innner surface of the prepuce, glans penis. Apocrine glands are fewer and different in Asians/ native americans causing no odor. Sebaceous glands; sex hormones primariliary testosterone and secretory activity varies throughout the lifespan. 12

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

14. 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.

15. 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.

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

17. Objective investigation
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.

18. Objective investigation (continued)
Palpation ( to diagnose):
Skin elastic.
Skin moistness.
Subcutaneous fat.
Lymphatic nodes: ( size, consistency, movable or immovable etc.).

19. Dermatological status:
Inspection.
Palpation.
Scraping.
Dermoscopy.
Laboratory end special methods.

20. Inspection: Skin texture Lesions: type: primary and secondary;
color: red, brawn, white;
shape: round, oval, annular;
arrangement: grouped (herpetiform, zoster form), disseminated (erythrodermic psoriasis).

21. Examination of Lesions
Configuration
Annular (rings)
Grouped
Linear
Diffuse

22. DISTRIBUTION
Distribution The term "distribution" refers to the clinical arrangement of skin lesions on the integument.
localized: grouped into specific areas
generalized: dispersed all over
symmetric: no pattern
asymmetric: pattern lacking randomness
discrete: separate
grouped: clustered
.confluent (coalescing): smaller into larger
cleavage plane: arranged along lines of skin tension 22

23. CONFIGURATION
Configuration The term "configuration" refers to the shape of lesions.
margination: sharp?can be traced with tip of a pencil, ill-defined?
circinate: round, circular >
arciform: partial circle
annular: round or circular with CENTRAL CLEARING
iris or target: bull's eye lesions, annular with central internal activity zone
serpiginous: meandering
gyrate: connecting arcs
linear: straight
zosteriform: dermatomal
Miscellaneous Helpful Modifiers
verrucous: wart-like ,telangiectasia: a conditional dilated capillary blood
blanching: press out ,eczematoid: dermatitis-
hyperkeratotic: thick ,sessile: attached directly by the
pedunculated:
Color: pink, red, purple (purpuric lesions do not blanch), white, tan, brown, black, grey, yellow, can be uniform or variegated
Sunexposed, sites of pressure, skin folds, follicular localization
purpura: a condition characterized by extravasated blood in the skin noted on examination as non-blanchable reddish pigment     23

24. 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.

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

26. Macula and Patch Description Circumscribed Flat Discoloration
Smaller than 0.5 cm-macula
Larger that 0.5 cm- patch
May be brown, blue, red.

27. 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

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

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

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

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

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

33. Lipoma: nodule/tumor: circumscribed depth implied solid lesion > 1 cm Circumscribed, elevated, deeper and firm than a papule large nodules are called tumors
Lipomas are single or multip, soft, round, movable against the overlying skin. Occur especially on trunk, neck , extremities, but can occur anywhere. Lipomas are composed of fat cells and a connective tissue framework.
Benign, slow growing, subcutaneous skin growth. In this case, the lipoma is rather large and located in the neck region. On palpation, these are soft, nontender, and freely mobile
LIPOMA BENIGN TUMOR 33

34. 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.

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

36. Primary lesions with cavity:
Vesicles
Bulla
Pustules
Cyst

37. Vesicle Description Herpes zoster
Circumscribed collection of free fluid
Up to 0.5 cm in diameter
Herpes zoster

38. A circumscribed collection
Bulla formed due to 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

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

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

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

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

43. 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.

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

45. FISSURE Description Examples
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.

46. 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.

47. Scar Description Examples
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.

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

49. 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

50. LICHENIFICATION Chronic lichenified atopic dermatitis
Atopic dermatitis tx with topical steroids, varying potencies, oral H1 blockers to induce fatigue and therefore less scratching by patient 50

51. Scales Description The may be
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

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

53. 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

54. 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.

55. 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.

56. no inflammatory types of lesions
In 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. In some vascular lesions with a convoluted vessel structure, however, blunt pressure from a flat surface will not empty the vessels and the corner of a glass slide needs to be gently placed on the lesion. Even then, it will not always blanch completely. Therefore, success in blanching is a more useful physical sign than failure to blanch. When pressed on to some granulomatous lesions a glass slide reveals an appearance commonly referred to as 'apple jelly nodule'.
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

57. 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.

58. MYCOLOGY SAMPLES
Coetaneous scale, nail clippings and plucked hairs can be examined by light microscopy when mounted in 20% potassium hydroxide.
The keratin is dissolved, allowing fungal hyphae to be identified.

59. SWABS
Bacterial swabs in an appropriate culture medium are sometimes useful.

60. PRICK TESTS
Prick tests are a way of detecting coetaneous type I (immediate)
hypersensitivity to various antigens such as pollen, house dust mite or dander.
The 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
due to a local increase in capillary permeability and the flare a result of activation of the axon reflex.

61. IMMUNOFLUORESCENCE
A portion of the skin biopsy can be frozen in liquid nitrogen for direct immunofluorescence (IF). This involves visualising antigens that are present in skin by identifying them with fluorescein-labelled antibodies. Similarly, indirect immunofluorescence can identify circulating antibodies in the serum by an additional step of adding the serum to a section of normal skin or other substrate. Immunofluorescence plays a major role in the diagnosis of the autoimmune bullous disorders.

62. ELECTRON MICROSCOPY
This investigation has played an important role in the diagnosis of some of the rare blistering disorders such as epidermolysis bullosa, although the availability of a range of antibodies to basement membrane zone antigens has in part replaced it.
PHOTOTESTING
Phototesting involves exposing skin (often on the back) to a graded series of doses of ultraviolet radiation (UVR) of known wavelength, either on one occasion or repeatedly.

63. Laboratory and special methods
General laboratory investigation:
general blood analysis;
general urine analysis;
stool test for parasites;
examination of blood for sugar;
Wasserman reaction.

64. Thank you for your attention !