IN THE NAME OF LORD THE MOST GRACIOUS THE MOST MERCIFUL The Skin: Basic Structure and Function

Q.1 Components of skin Epidermis: the major protective layer Dermis: the major support layer Skin appendages Subcutaneous tissue (fat) Q.2 Cell types seen in the epidermis Keratinocytes: principal cell of the epidermis, originate from ectodermic, has the specialized function of producing keratin, plays imp role in immune function of skin. Melanocytes: found in the basal cell layer, the pigment-producing cell Langerhans cells: An important immunological competent cell Merkel cell Q.3 Layers of the epidermis Basal layer (basal cell layer): innermost layer of epidermis, only keratinocytes in normal epidermis which undergo cell division. Prickle cell layer (stratum spinosum): above basal cell layer, keratinization begins here. granular layer (stratum granulosum): contain distinctive dark granules that are composed of keratohyalin Horny layer (cornified layer, stratum corneum): outer non-nucleated barrier layer, The cells in the stratum corneum are dead and are large, flat, polyhedral, plate-like envelops filled with keratin Q.4 Skin Appendages include: Eccrine sweat glands- distributed over the entire body surface, are most abundant on the palms, soles, forehead, and axillae, help regulate temperature by excreting sweet onto the surface of the skin Apocrine sweet glands- are generally confined to the following sites like axillae, areolae , the anogenital region. do not begin to function until puberty. responsible for body odor, bacterial action on apocrine sweet causes body odor Hair follicle- are distributed over the entire body surface except for the palms and soles. Types of hair include- a) vellus hairs (short, fine, light colored) b) terminal hairs (long, thick, dark colored). Sebaceaous Glands- are part of the pilosebaceous unit and so are found wherever hair follicles are located and produce an oily substance termed sebum, which may be useful as a skin moisturizer. Nails- Nails are made of keratin produced in the matrix and Nails facilitate fine grasping and pinching maneuvers. Q.5 basement membrane zone it is the anchoring complex joining the epidermis and derms of the skin anchoring complex is composed of the hemidesmosomes, anchoring filaments, and anchoring fibrils

Cutaneous Symptoms, Signs, and Diagnosis Q.6 Macules (Spots) Macules are variously sized, circumscribed changes in skin color, without elevation or depression. They may be circular, oval or irregular, and may be distinct in outline or fade into the surrounding skin. Q.7 Papules Papules are circumscribed, solid elevations with no visible fluid, varying in size from a pinhead to 1 cm. They may be acuminate, rounded, conical, flat-topped, or umbilicated They may appear white (as in milium),red(as in scabies), yellowish(as in xanthoma), reddish brown ( as in lupus vulgaris), or black(as in melanoma) If capped by scales, they are known as squamous papules, and the eruption is called papulosquamous Q.8 Nodules Nodules are morphologically similar to papules More than 1 cm in diameter Centered in dermis or the subcutaneous fat Deeper than plaques It can be seen or not ,but it is surely can be touched Q.9 Wheals Wheals are evanescent (vanish quickly), edematous, plateau like (flat) elevations of various sizes They are usually oval or irregular in shape Pink to red, and surrounded by a pink areola They may be discrete or may coalesce The lesions often develop quickly Wheal is the prototypic lesion of urticaria Q.10 Lichenification Lichenification is a circumscribed hypertrophy of skin where rubbed or scratched constantly The skin becomes thickened and leathery The normal marking of the skin become exaggerated. It is often seen in pruritus diseases Diseases Resulting from Fungi and Yeasts Q.11 Clinical types Tinea capitis r: Its a ringworm. n its clinical types r: Tinea alba: often noninflammatory lesions Tinea nigra: often noninflammatory, or light inflammatory lesions Tinea favosa: inflammatory lesions Kerion: inflammatory lesions, may cause scarring

Q.12 Clinical types of Onychomycosis It is Dermatophyte infections of the nails of hands and/or feet Clinical types: Distal Subungual Onychomycosis, (DSO) Proximal Subungual Onychomycosis, (PSO) White Superficial Onychomycosis , (WSO) Total Dystrophic Onychomycosis, (TDO Bacterial Infections Q.13 Clinical types of Impetigo Impetigo contagious is a superficial cutaneous infection caused by either staphylococci, streptococci, or combined infections and is characterized by discrete ,thin-walled vesicles, pustules and crust. Clinical types: Impetigo contagiosa Bullous impetigo Ecthyma Viral Diseases, Insect biting Q.14 Ramsey-hunt syndrome A herpes virus infection of the geniculate nerve ganglion that causes paralysis of the facial muscles on the same side of the face as the infection. The geniculate ganglion is a sensory ganglion associated with the VIIth cranial nerve . Associated with a rash -- vesicles or tiny water- filled bumps -- in or around the ear and sometimes also on the roof of the mouth. Treatment with steroids and antiviral agents. Eczema Q.15 Eczema Eczema is an inflammatory skin reaction characterized histologically by spongiosis with varying degrees of acanthosis, and a superficial perivascular lympho-histiocytic infiltrate Q.16 diagnostic criteria of atopic eczema Child should have an itchy skin condition (or parental report of scratching or rubbing in a child) Plus three or more of the following1. Onset below age 2 years (not used if child is under 4 years 2. History of skin crease involvement (including cheeks in children under 10 years) 3. History of a generally dry skin 4. Personal history of other atopic disease (or history of any atopic disease in a first degree relative in children under 4 years) 5. Visible flexural dermatitis (or dermatitis of cheeks/forehead and outer limbs in children under 4 years Q17. Common clinical features of eczema Vesicles and serous scabs in red and blotchy skin locations itchiness

 Xerosis Recurrent skin damage may cause post-inflammatory hyper (too much), hypo (not enough) or depigmentation (loss) of the skin color. Severe skin lacerations which are extremely pruritic (itchy) erythematous papules (red bumps) and thin plaques (crusty skin patches) with secondary skin peeling Urticaria Q18. Clinical features of urticaria They develop quickly and disappear quickly too. evanescent wheals last for < 12 h, the whole duration is within 6 weeks The wheals may occur in any area of the body. Mucosal surfaces can also be involved, with related symptoms including respiratory distress, abdominal pain and hoarseness. it is serious when occurring on the larynx. urticarial lesions are usually pruritic and stinging Drug Eruption Q19. Category of Drug Eruptions 1. Simple drug Eruptions Exanthems (morbilliform/scarlatiniform) 46% Urticaria/angioedema 26% Fixed drug Eruption 10% Erythema multiforme minor 5% 2. Complex drug Eruptions Erythema multiforme major 4% Exfoliate dermatitis 4% Toxic epidermal necrolysis 1.3% 3. Other uncommon forms of drug Eruption 3.7% Skin cancer Q20. ABCD criterion for diagnosis of superficial spreading melanoma? ANS- A- asymmetry. B- border irregularity. C- Color variegation. D- diameter is more than 6mm. Contact Dermatitis Q.21 Differences between direct irritant and allergic contact Direct irritant Allergic contact 1. Prevalence Very common Much less common 2. Prior exposure to Not required Essential substance 3. Affected sites Sites of direct contact with Sites of contact and distant little extension sites 4. Susceptibility Everyone susceptible Only some patients susceptible 5. Timing Rapid onset 4~12 hours Onset generally 24 h or after contact Lesions longer after exposure No develop at first exposure lesions on first exposure Psoriasis Q.22 Psoriasis

Psoriasis is a common, genetically determined, inflammatory and proliferative disease of the skin, the most characteristic lesions consisting of chronic, sharply demarcated, dullred, scaly plaques, particularly on the extensor prominences and in the scalp.

Q.23 4 types of psoriasis 1. psoriasis vulgaris 2. pustular psoriasis 3. psoriatic arthropathy and 4. erythrodermic psoriasis. Q.24 Clinical presentation of psoriasis vulgaris Plaque psoriasis is the typical presentation of psoriasis vulgris. The lesions often involve the elbows, knees, scalp hair margin, sacrum. The plaques vary in diameter from one to several centimetres and are oval or irregular in shape. There may be any number of lesions or only a single one, and, when multiple, may be symmetrically distributed. The red plaques are often surmounted by the very characteristic silvery white scaling. The removal of psoriatic scales usually reveals an underlying smooth, glossy, red membrane with small bleeding points where the thin suprapapillary epithelium is torn off (Auspitz sign). Q.25 Kbner phenomenon Kbner phenomenon is that various types of trauma may elicit the disease in previously uninvolved skin. The reported incidence has varied between 38 and 76% of patients with psoriasis. The Kbner reaction is often thought to be more frequent in actively spreading severe psoriasis. The Kbner phenomenon usually occurs 7-14 days after injury. Gonorrhea, Nongonococcal Urethritis Q26.The pathogen of gonorrhea and NGU pathogen of gonorrhea is Neisseria gonorrhoeae - a gram-negative, aerobic diplococcus pathogen of NGU: Ureaplasma urealyticum - Causes 20% to 40% of cases Chlamydia trachomatis - Causes 23% to 55% of cases of NGU Q.27 Differential Diagnosis NGU Incubation period 7~28 days Onset Gradual Dysuria Smarting feeling Discharge Mucoid or purulent Gram stain of Polymorphonuclear discharge leukocytes Condyloma Acuminata, Genital Herpes Q.28 Clinical feature of condyloma acuminate 1. Incubation time - 1~6monthsaverage 3months 2. Predilection sites Genital areas malebalanusurethral orifice gonococcal urethritis 3~5 days Abrupt Burning Purulent Gram-negative intracellular diplococci

femalelabia major and minor cervical canal Anal areas: anus, perineum Other sitesin mouthbreast 3. Skin lesion- Early stage: Small, soft, slight red rough,spiny papules Characteristic lesion - Have verrucous surface- Papillose, cauliflower like - slow growing Giant CA: very rare

Syphilis 29. The Stages of Syphilis Acquired Syphilis Early acquired Primary syphilis syphilis Secondary (Duration 2 syphilis years) Early latent syphilis Late acquired syphilis (Duration >2 years) Benign tertiary syphilis Late cardiovascular syphilis Late neurosyphilis Late latent syphilis

Congenital Syphilis Chancre Early secondary syphilis Relapsing Secondary syphilis Early congenital syphilis (Age 2 years old) Late congenital syphilis (Age>2 years old) Benign congenital syphilis Late cardiovascular syphilis Late neurosyphilis Latent congenital syphilis

EXTRA QUESTIONS IMPETIGO Impetigo contagious- is a superficial cutaneous infection caused by either staphylococci , streptococci ,or combined infections. Its characterized by discrete ,thinwalled vesicles, pustules and crust. CLINICAL TYPES OF IMPETIGO - Impetigo contagiosa ,Bullous impetigo ,Ecthyma CLINICAL FEATURES OF BULLOUS IPETIGO- This variety of impetigo occurs characteristically in new-born infants . - In most cases the disease begins between the fourth and tenth days of life - The neonatal type is highly contagious and can spread in nurseries - The sites are any parts of the body, early sites are the face and hands, the lesions are bullae - Constitutional symptoms are at first absent, later weakness and fever may be present in the New-born infants. bacteremia ,pneumonia, may develop rapidly ,with fatal termination Ecthyma- is an ulcerative staphylococcal or streptococcal pyodema , nearly always of the shins or dorsal feet .

FURUNCLE Definition - It is an acute, round, tender, circumscribed, perifollicular staphylococcal abscess. Sites of predilection are the nape, axillae, and buttocks, but it may occur anywhere Skin lesions- papule of hair follicle , red nodule ,Commonly single ,but it can recurrent ,this is known as Furunculosis. Symptom - topical pain, headache, fever are not present Erysipelas - IT is an acute beta-hemolytic group A streptococcal infection of the skin involving the superficial dermallymphatics.It is characterized by local redness, heat ,swelling, and a highly characteristic raised, indurated border. TREATMENT Systemic treatment Penicillin is rapidly effective Erythromycin is also efficacious It should be continued for at least 10 days

Topical treatment

Ice bags and cold compresses may be used Topical therapy is unnecessary in some cases Topical steroids should not be used.