Subject: Pathology Topic: Basic Pathology of the Skin Lecturer: Dr.

Cagampan Date of Lecture: July 4, 2011 Transcriptionist: Feisty Pages: 17

Anatomy and histology of skin

Fig. 1. NORMAL Epidermis; note that skin diseases will involve changes in any layers or combination of layers of epidermis, sometimes even involving the dermis. EPIDERMIS Different layers: a. Stratum basale or stratum germinativum o Most basal b. Stratum spinosum o Thickest layer c. Stratum granulosum o Filled with keratohyaline granules o Keratogenous zone o granular layer d. Stratum corneum o anucleated portion o horny layer o keratinoid Stratum malpighii o nucleated portion o s. basale, s. spinosum, s. granulosum Special cells of the epidermis a. Melanocytes o Dispersed in basal layer o Responsible for pigment o Increases when exposed to light o Approximately 1 melanocyte in every 10 basal cells b. Merkel cells o Found in basal layer, oral mucosa, and hair follicle o Touch receptor

SY 2011-2012

c. Langerhans cells o Found in suprabasal epidermis(immediately above the basal layer) o Have Ag presenting capacity (related to monocytes/macrophages) o Has immunologic function o Related to monocytes and macrophages Epidermal appendages a. Hair follicle b. Sebaceous glands c. Eccrine/sweat glands d. Apocrine glands o Found in axilla e. Nails

Fig. 2 prominence of melanocytes(lt), epidermal appendages(rt)

Fig. 3 Layers of the skin, epidermis, dermis and subcutaneous DERMIS Dermal microvascular unit o Vessels o Nerves o Migrant inflammatory cells

Dermal Muscle cells Dermal Fibroblasts Dermal lymphatics Extracellular matrix SUBCUTANEOUS Deepest portion of skin Properties of the skin Aesthetic function Maintains integrity of the body Protects from injurious stimuli Absorbs and excretes liquids Regulates temperature Water proofs Absorbs ultraviolet light Metabolized vitamin D Detects sensory stimuli Provides cosmetic function Acts as barrier against microorganisms Macroscopic Terms Used in Dermatology can occur not only singly but can be a combination of different terms MACULE o Circumscribed lesion <5mm in diameter characterized by flatness and usually distinguished from surrounding skin by coloration o Eg, vitiligo, freckles o Freckles Light brown, small flat coloration of skin

Fig. 4 Macule

Fig. 5 Freckles(lt)

PATCH o Circumscribed lesion >5mm in diameter characterized by flatness and usually distinguished from surrounding skin by its coloration o Basically, a larger macule. IOW, a larger discoloration. o Vitiligo Part of skin that turns white, flat and hypopigmented patch

Fig. 6 Patch: Vitiligo PAPULE o Elevated dome shaped or flat topped lesion < or equal to 5 mm across o Eg, warts, nevi(mole), dermal tumor, acne vulgaris

Fig. 7 Papule. Warts: several coalescent graying white scaly papule NODULE o Elevated lesion with spherical contour >5mm across o Eg, epidermal inclusion cyst, keratoacanthoma (eg, volcano), appendage tumor, Tumor that pop out of the skin papule

nodule Fig. 8 Nodule: multiple papulo-nodular erythematous lesions on the skin(lt); maybe a common tumor of the skin that present as ovoid masses(rt)

Fig. 9 keratoacanthoma(volcano)- tumor of the skin. The crater is filled with keratin. Common in the palm, face. Unusual tumor because it regress after a few weeks without treatment and often confused with malignancy. PLAQUE o Elevated flat topped area lesion, usually >5mm across o Eg, psoriasis, seborrheic keratosis, mycosis fungoides o A plateau, or an elevated patch

Fig. 10 Plaque; seborrheic keratosis (rt)

Fig. 11 Plaque: possibly a diaper rash; coalescent plaque

Fig. 12 Plaque: seborrheic dermatitis caused by fungal infection showing a coalescent erythematous plaque on the scalp VESICLE o Lesion that is fluid filled raised area < or equal to 5mm o Think of chicken pox o Eg, herpes zoster, chicken pox, eczematous dermatitis

Fig. 13 Vesicle BULLA o o o o

Fluid filled raised area >5mm If erupted, become plaque Eg, pemphigus vulgaris, burned patients Pemphigus vulgaris Immunologic disease

vesicle

bulla

Dark crusted plaques

Fig. 14 Bulla: blister(lt), multiple vesicles and bulla with some crusted dark plaques(middle) ,bulla of a burned patient(rt) BLISTER o Common term used for vesicle or bulla PUSTULE o Discrete, pus-filled, raised area o Vesicle with pus; less than 5 mm o Eg, impetigo(mamaso in filipino), acne vulgaris o Impetigo Staph infection; theres autoinoculation, when the child scratches, it causes the infection to spread

Fig. 15 Pustule: Impetigo-multiple Coalescent pustule(middle), acne(rt) WHEAL o pantal in filipino o Itchy, transient, elevated areas with variable blanching and erythema formed as a result of dermal edema o Looks the same as plaque but the wheal blanches on pressure(white and then red again), itchy and transient o Usually caused by allergy or insect bite o Eg, urticaria, insect bites, dermatographism o Dermatographism Due to IgE Draw on skin and follows the line of trauma Seen in urticaria

Fig. 16 Wheals

Fig. 17 wheals: multiple wheals(lt), another example of wheal middle. Dermatographism(rt) SCALE o o o o

Dry, horny, platelike excrescenses. Usually on top of plaques Erythematous plaques with scale is usually seen in Psoriasis Psoriasis Epidermal turnover is usually 57 day(from basal to the top) but in psoriasis, its 4x normal(about 7-8 days) Hard to treat, origin is unknown Lift the scale(which are actually stratum corneum) and it will bleed Eg, psoriasis, tinea infection (capitis, corpora)

Fig. 18 Scale: multiple erythematous plaque covered by silvery scale(upper lt), scaly hand from patient with psoriasis(upper rt). Oozing lesion that crusted giving a yellowing scales(lower lt and rt) LICHENIFICATION o Thickened and rough skin characterized by prominent skin markings o Usually a chronic event, happen in skin lesions that are chronically inflammed due to excessive rubbing and dryness o likened to leather o Eg, lichen simplex, eczematous dermatitis

Fig. 19 Lichenification: Erythematous black covered by scales with prominent skin markings(lichenified skin)[upper rt]. Scaling and lichenified plaque [lower rt and lt]

EXCORIATION o Traumatic lesion characterized by breakage of the epidermis o Usually self induced o Usually in epidermis only, once it goes deeper(dermis w/ or w/o subcutaneous involvement) it becomes an ulceration o Eg, body louse infestation, scratches, scabies

Fig. 20 Excoriation ONYCHOLYSIS o Loss of integrity of nail substance o Breakage from nail bed o Psoriasis

Fig. 21 Oncholysis EROSION o Discontinuity of the skin exhibiting incomplete loss of the epidermis

Fig. 22 Erosion

ULCERATION o discontinuity of the skin exhibiting complete loss of the epidermis o e.g. basal cell CA, squamous cell CA o more on this later

Fig. 23 Ulceration Microscopic Terms Used in Dermatopathology HYPERKERATOSIS o Hyperplasia/thickening of the stratum corneum o Normal in palms and soles but in thin skin can be pathologic o Remember the example showed under scale for Psoriasis? Histologically, its described as hyperkeratosis o Eg, psoriasis, squamous cell carcinoma o callus of farmers feet is a form of adaptation for protection, hence this is normal

HYPERKERATOSIS Fig. 24 Hyperkeratosis

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PARAKERATOSIS o Mode of keratinization characterized by retention of the nuclei in the stratum corneum Recall: s. corneum keratin layer is anucleated o Normal in mucous membranes of the oral cavity, aside from this parakeratosis is always pathologic o Eg, psoriasis because skin turnover is fast, not enough time to remove nucleus

Parakeratosis

Fig. 25 Parakeratosis. Notice how both picture show intact nuclei at their stratum corneum.

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HYPERGRANULOSIS o Hyperplasia of the stratum granulosum o Eg, verrucca vulgaris (common viral wart)

Fig. 26 Hypergranulosis, this also shows hyperkeratosis and parakeratosis ACANTHOSIS o Epidermal hyperplasia (whole epidermis is thickened) o Eg, verucca vulgaris

Acanthosis Fig. 27 Acanthosis. Note how all layers of epidermis are hyperplastic

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DYSKERATOSIS o Abnormal, premature keratinization within cells below stratum granulosum o May be premalignant or dysplasia o Dyskeratotic cells are usually intensely eosinophilic and may contain a small, dense, basophilic nuclear remnant o Dyskeratotic cells may also be densely basophilic as seen in Darier's disease o Cells become larger and hyperchromatotic o Seen in any layer of the skin o Eg, actinic keratosis, squamous cell carcinoma

Fig. 28 Dyskeratosis in Squamous cell carcinoma ACANTHOLYSIS o Loss of intercellular connections resulting in loss of cohesion between keratinocytes o Occurs in stratum spinosum o Eg, pemphigus vulgaris (primary), impetigo

Fig. 29 Acantholysis : acantholytic cells (upper lt). Seen in edema(upper rt). Note how all slides show a loss of intercellular cohesion.

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PAPILLOMATOSIS o Hyperplasia of the papillary dermis recall: Papillary dermis- uppermost layer of the dermis, intertwined with the rete ridges of the epidermis, composed of fine and loosely arranged collagen fibers o form a jagged epithelium that looks like a hypeplastic epidermis but it is ACTUALLY the dermis that is changing o Eg, verrucca vulgaris

Fig.30 Papillomatosis, notice the jagged feature of the papillary dermis

acanthosis

papillomatosis

hypergranulosis

Fig. 31 Wart showing papillomatosis, hypergranulosis, and acanthosis LENTIGINOUS o Refers to the linear pattern of melanocyte proliferation within the epidermal basal layer o Eg lentigo simplex

Fig. 32 Lentiginous; notice how the s. basale is lined with melanocytes.

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SPONGIOSIS o Intercellular edema of the epidermis; accumulation of fluid in between cells o Looks like acantholysis but in spongiosis, cohesion is not necessarily destroyed. To distinguish between the two, special immunoflourescence would have to be performed as well as a good clinical history to distinguish the 2. o Eg, acute eczematous dermatitis o Hallmark of eczematous dermatitis

Fig. 33 Spongiosis. Hard to distinguish with acantholysis, so read the patient history and it should give you a clue whether this is a spongiosis or acantholysis. Bottom picture is a severe case of spongiosis causing a formation of vesicle. HYDROPIC SWELLING o Intracellular edema of keratinocytes o Usually involves entire epidermal layer o Often seen in viral infections

Fig. 34 Hydropic Swelling

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EXOCYTOSIS o Infiltration of the epidermis by inflammatory or circulating blood cells o Eg, inflammatory dermatoses, mycosis fungoides

Fig. 35 Exocytosis; all pictures showing infiltration

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ULCERATION o discontinuity of the skin exhibiting complete loss of the epidermis o e.g. basal cell CA, squamous cell CA

Ulceration Fig. 36 Ulceration. Note how the epithelium is now replaced by fibrotic tissue and inflammation(not clearly seen) VACUOLIZATION o Formation of vacuoles within or adjacent to cells o Vacuolization vs hydropic swelling Vacuolization is usually found in dermal-epidermal junction Usually seen in SLE o Eg, koilocytosis in verucca vulgaris, basal cell vacuolization in SLE

Fig. 37 Vacoulization END OF TRANSCRIPTION!!!!!! Thanks Sheila for the recording and for typing most of the tranx contents! Hello to Bibit, Joyce, Shar, JC, and Tin!!!! May bago n akong name for us BULALO,,bwahahaha!! Hello rin sa The susettes!, Group 26 commed, group 36 microbio, mega grp 5 in pharma, my PD and Patho grp mates.. ANG DAMING GROUPINGS!!!!!!!! Sa lahat ng transcribers I HEART YOU ALL!!! PINAY, my new GF, I love you!! Bwahahahaha!!! My krases, Angela and Mai- stay FABULOUS! Sa aking pinaproject na new love team(evil laugh!!).. soon to be revealed! Bwahahaha! For I know the plans I have for you, declares the Lord, plans for wholeness and not for evil, to gove you a future and a hope. Jeremiah 29:11

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