Derma
Derma
Derma
Introduction to
dermatology
(Structures & functions of the skin + the language of dermatology)
Objectives:
● Topical therapy
Color index:
- Main text
- Important
- Dr’s explanation
- Golden notes
- Extra
This lecture was originally done by both 438 & 439 teams.
So great thanks to them
Function, Structure of the skin
The Skin:
● The skin is the largest organ of the body.
● Body surface area of 1.5- 2 m2
● Contributes to 1/6- 1/7 of body weight
● It consists of many cell types called “Keratinocytes”
● Specialized structures like the Basement Membrane
● It serves multiple functions that are crucial to health and survival
● Skin diseases are common
● Skin lesions maybe the presenting feature of an underlying systemic diseases
● Skin disease can have serious psychosocial effects.
● The skin is associated with RA , SLE , Dermatomyositis , Ankylosing spondylitis , Scleroderma.
Skin function:
Immune
● Barrier to harmful exogenous substance & pathogens, Langerhans cells in the skin are part of the
adaptive immune system.
● acts as a barrier from chemical, antimicrobial, heat and radiation damage.
Sensory organ
● Contains a variety of nerve endings that respond to heat, cold, touch, pressure, vibration and pain.
Hence, protects against physical injury.
Thermoregulation
● Regulates body temperature through eccrine glands “sweat glands” and dermal blood vessels.
Important component of immune system.
Other functions
● Psychological & Cosmetic Importance
● Protection: acts as a barrier from chemical, antimicrobial, heat and radiation damage.
● Sensation: it has nerve endings which respond to temperature, pressure, pain, touch & vibration.
● Storage: of fat in the hypodermis Contains 50% of fat (subcutaneous tissue).
● Synthesis: of vitamin D.
Function, Structure of the skin
Hypodermis
Epidermis Dermis
(Subcutaneous tissue)
1-Keratinocytes
2-Melanocytes
- They are found in the stratum basale (Basal layer)
- They produce melanin.
- there are 2 types of melanin: the brownish black (eumelanin) and the reddish yellow (pheomelanin).
- Melanin packed into melanosomes and transported to basal keratinocytes.
- Skin colour is determined by the number and size of the melanosomes (not the number of
melanocytes).
3- Langerhans cells
4-Merkel cells
Stratum - It is only found on the palms and soles below the Stratum Corneum.
lucidum
- Flat cells containing keratohyalin granules which is responsible for the colour of the cells,
making it the darkest layer.
- Diamond shaped granular cell layer & Cytoplasm is filled with Keratohyalin granules..
Stratum
- The thickness of this layer is proportional to that of the stratum corneum (thicker in palms
granulosum
and soles (10 cell layers) than in the face (1-3 cell layers) because the stratum corneum is
thicker there.
- Has a waterproof properties
● Provides nutrition and support to the epidermis and interacts with it during wound repair.
● Gives the skin its strength, elasticity, and softness.
● It contains nerve endings so if you feel pain after stepping on a pin it means that the pin
reached the dermis.
● The range is between 1 and 4 mm in thickness (depending on age and body site). So it’s
thicker than epidermis
● It is divided into two layers:
○ Papillary dermis (Upper layer).
○ Reticular dermis (Lower layer).
● Consists of:
1. Collagen fibers 70-80%:
○ Provides strength to the skin.
○ Thin & loose fibers in papillary dermis.
○ Thick & dense fibers in the reticular
dermis.
2. Elastic fibers 1-3% :
Dermis ○ Provides elasticity.
○ Protects against trauma and shearing forces.
3. Ground substance:
○ E.g. proteoglycans and glycoproteins.
-Functions includes water absorption, shock-absorption and lubrication
between collagen and elastic fibers.
- They are larger than eccrine glands. open to the hair follicle
- They release region-specific secretions that bacteria act on.
Apocrine - They are mainly found in the axilla and genital skin.
sweat - Under adrenergic stimuli.
glands - Modified sweat glands that present in the: External ear canal, Eyelids (moll’s glands) and
Areola.
- Under adrenergic stimuli.
Consist of:
○ Nail plate (Formed of hard keratin)
○ Nail bed, (under the plate)
○ Matrix (The lunula is the visible part of the matrix),
○ Proximal and lateral nail folds (Proximal nail fold
morphology can be altered in connective tissue
disease)
Nails ○ Hyponychium.
● Family history:
○ Does anyone in the family have a similar problem?,
○ Does anyone in the family have a disorder of the skin?
○ N.B. Some skin conditions:
e.g. (neurofibromatosis, have a strong genetic basis).
● Psychological history:
○ People with severe, chronic skin disease may suffer from anxiety, depression and social isolation
(e.g: patients with psoriasis).
○ The psychological problem may be the cause of the skin disease, e.g dermatitis artefacta.
● Social history:
○ Occupation (e.g. occupational dermatitis) and hobbies.
○ History of contact with other affected individuals.
○ Recent travel (abroad): it is important to be aware of endemic diseases in other parts of the world.
○ Sun exposure: tanning.. etc.
○ Smoking habits: some conditions are related directly to smoking such as psoriasis, hidradenitis
suppurativa and palmoplantar pustulosis.
● Systemic review
Examination:
● Wash your hands, Introduce yourself, Confirm identity of the patient, Take permission (consent and explain
examination), Privacy, Exposure.
● Use good light, Don't forget to examine: Hair, Nails and Mucous membrane. Look for the patient as a whole,
even if he came with a local lesion!
● General appearance of patient: is he/she well? scratching or displaying other signs of distress.
● Inspection:
Is it symmetrical or asymmetrical?, Does it involve particular sites? (e.g. extensor or flexor, sun-exposed or
covered), Do lesions adopt any particular pattern? (e.g. diffuse, linear, grouped or scattered).
both sides are the same or Such as sacrum, buttocks, ankles, heels.
Symmetrical Pressure areas
similar.
affecting one side of the body Affecting sun-exposed areas such as face,
Photo
Unilateral only. neck and back of hands. Ex: subacute
-sensitive
lupus, nonmelanoma skin cancer
Examination (cont’):
● Configuration: shape or outline of the skin lesion
- Anullar
- Nummular “Discoid”
- Grouped
- Reticular
- Linear
- Target.
basic lesion
VS Develop during evolution of skin
disease or created by scratching
or infection
Descriptive Terms and morphology of Skin lesions
Primary
Description
skin lesion
- Flat lesion. If you close your eyes, your won’t know it’s
there
- Change in skin colour.
Macula
- less than 1 cm in size.
- It Lacks surface elevation or depression.
(not palpable) e.g. freckle.
- Flat lesion.
- Change in skin colour. Pale or dark doesn’t matter
Patch - More than 1 Cm .
- it Lacks surface elevation or depression.
e.g Vitiligo, melasma.
- Raised lesion.
- solid lesion.
- less than 1 cm in size.
Papula - Examine for color and surface changes eg. Umbilicated (mulloscum
contagiosum), Keratotic (like warts), Papillomatous,
Flat topped (lichen planus)
- Raised lesion.
- Contains pus.
- less than 1 cm in size.
Pustule
- Just like a papule but it contains pus.
- it is filled with neutrophils, and may be white, or yellow.
- Not all pustules are infected
- Raised lesion.
- lacks a deep component.
- more than 1 cm in size.
- Confluence (group) of papules leads to the development
Plaque
of larger, usually flat-topped, circumscribed, plateau-like
elevations known as Plaques e.g. Plaque psoriasis.
- Opposite of Papules in term of of size
- Opposite of Patches in term of elevation
- Raised lesion.
- with deep component.
Nodule
- more than 1 cm in size.
- e.g. hidradenitis.
- Raised lesion.
- Contains clear fluid.
- less than 1 cm in size.
Vesicle
- e.g. Dermatitis Herpetiformis.
- Vesicle is a smaller bulla.
Descriptive Terms and morphology of Skin lesions
Primary skin
Description
lesion
- Raised lesion.
- Contains clear fluid.
Bulla - more than 1 cm in size.
- bulla is A large vesicle.
- e.g. Bullous Pemphigoid.
Burrow
- Linear tunnel in the epidermis induced by scabies mite.
Secondary Skin
Description
lesion
Important Signs
Description
In Dermatology
Investigations:
Wood’s lamp
● Produces long wave UVL (360 nm).
● Useful in:
○ Vitiligo (Milky white).
○ Erythrasma (coral red).
○ Tinea Versicolor (orange).
○ Pseudomonas (green).
○ Tinea Capitis - (yellow green) fluorescence in M.canis, M. audouini
KOH preparation
Prick test
ﯾﺗم ﺣﻘن اﻟﻣﺎدة ﺗﺣت اﻟﺟﻠد
● food allergy, drug allergy
● Method:
○ Put a drop of allergen containing solution.
○ A nonbleeding prick is made through the drop.
○ After 15-20 minutes the antigen is washed, and the reaction is recorded.
● A positive test shows urticarial reaction, erythema, wheels at site of prick.
● Detects immediate-type IgE mediated reaction (type 1 hypersensitivity)
● Emergency therapeutic measures should be available in case of anaphylaxis.
Important signs and investigation
Investigations cont:
Patch test
● allergic contact dermatitis.
● Method:
○ Select the most probable substances causing dermatitis.
○ Apply the test material over the back.
○ Read after 48 & 72 hr (type 4 hypersensitivity) and look for
(erythema, edema, vesiculation).
● Positive patch test showing erythema and edema.
● In severe positive reaction vesicles may be seen.
Tzanck smear
● Important in diagnosing:
Herpes simplex or VZV (multinucleated giant cells).
● Pemphigus Vulgaris (acantholytic cells; which are floating cells in blistering disorders due to antibodies
against desmosomes)
● Method:
○ Select a fresh vesicle.
○ De-roof and scrape base of the vesicle.
○ Smear onto a slide.
○ Fix with 95% alcohol.
○ Stain with Giemsa stain.
○ Examine under microscope.
Skin biopsy
Very important
● To diagnose or R\O some skin diseases.
○ Shave biopsy: we shave a thin layer from the lesion.
○ Punch biopsy: we use an instrument called “punch”
to remove a circular section through all layers of the lesion.
○ Excisional biopsy: we use a scalpel to take off the entire lesion.
○ Method:
■ Clean skin with alcohol.
■ Infiltrate with 1-2 % xylocaine with adrenaline.
■ Rotate 2-6 mm diameter punch into the lesions.
■ Lift specimen and cut at base of lesion.
■ Fix in 10% formalin
■ For Immunofluorescence put in normal saline.
■ Suture if 5 mm punch is used.
Topical therapy
Topical therapy:
● Applied directly to the skin
● Advantage: less side effects and toxicity.
● Disadvantage: can be time-consuming to apply, messy or uncomfortable!
● Tropical steroids:
○ They act as anti-inflammatory, anti-mitotic, and immunosuppressive agent.
○ Many topical steroids available, from mild (Hydrocortisone) to very potent (Clobetasol).
○ Successful treatment depends on an accurate diagnosis and consideration of the steroid's delivery
vehicle, potency, frequency of application, duration of treatment and side effects.
A) Plaque C) Wheal
B) Papule D) Ulcer
A) Patch C) Papule
B) Plaque D) Macule
Answers:
1:D, 2:D, 3:D, 4:C, 5:D, 6:C, 7:A
Thanks!!
This lecture was updated by: 441 Academic Leader Bassam Al Hubaysh