PRINCIPLE OF DERMATOLOGY

By : dr. Nanda Earlia, Sp.KK

Introduction

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Key point Many out patien visits are for dermatologic complaints The patienss chief complaint can be devided into two diagnostic skin disease: growths and rashes

Structure & Function of skin

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Key Points The major function of the skin is as a barrier to maintain internal homeostasis The epidermis s major barrier of the skin

Component of the skin

Epidermis Dermis Skin appendages Subcutaneous fat

Epidermis
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Key point Layer in ascending order: Basal cell, stratum spinosum, stratum granulosum, statum corneum Basal cells are undifferentiated, proliferating cells Stratum spinosum contains keratinocytes connected by desmosomes Keratohyalin granules are seen in stratum granulosum Stratum corneum is major physical barrier The number and size of melanosomes, not melanocytes, determine skin color Langerhans cells are derived from bone marrow and are the skins first line immunologic defense The basement membrane zone is substrate for attachment of epidermis to the dermis The four major ultrastructural regions include the hemidesmosomal plaque of the basal keratinocyte, lamina lucida, lamina densa, and anchoring fibrils located in the sublamina densa the region of the papillary dermis.

2. 3. 4. 5. 6.

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Cell division occurs in the basal cell layer

Skin function
Function
Barrier: Physical Light Immunologic Though flexible foundation Temperature regulation Sensation Grasp Decorative Unknown Insulation form cold and trauma Calorie reservoir

Responsible structure
Epidermis Stratum corneum Melanocytes Langerhans cells Dermis Blood vessels Eccrine sweat glands Nerves Nails Hair Sebaceous glands Subcutaneous fat Subcutaneous fat

Structure
Keratization begins in stratum spinosum Granular cells contain keratohyalin lamellar granular The stratum corneum is the major physical barrier Langerhans cells are the first line of immunologic defense in the skin

Dermis

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Keypoint Provides structural intregity and is biologically and active The primary components of the dermal matrix are collagen, elastin, and extrafibliar matrix

Structural components of the dermis

Colagen Elastic fibers Extrafibliar matrix

Free nerve endings are the most important sensory receptors

Functions of blood vessels:

To supply nutrition To regulate tempearture

Skin appendages

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Key point Eccrine glands help to regulate body temperature Apocrien sweat glands depend on androgen for their development The stem cells of the hair follicle reconstitute the nonpermanent portion of the cycling hair follicle Sebaceous glands are under androgen control

Eccrine and apocrine glands

Eccrine sweat glands help to regulate temperature Bacterial action on apocrine sweat causes body odor

Types of hair
Vellus (light and fine) Terminal (dark and thick)

Hair growth cycles through (anergen), transitional (catagen), and resting (telogen) phases. Normally, 25 to 100 hairs are shed from the scalp each day

Sebaceous glands

Sebaceous glands are androgen dependent

Nails

Nail is made of keratin produced in the matrix

Subcutaneus fat
1. 2. 3.

Insulates Absorbs trauma Is a reserve energy source

Principle of diagnosis
History Physical examination Terminology of skins lession Clinicopathologic of skins lesions Configuration of skin lesions Distribution of skin lesions

Key points 1. Morphologic appearance is critical in making the diagnosis 2. Skin diseases can be divided into growths and rashes

Steps in dermatologic diagnosis

History Physical- identify the morphology of basic lesion Consider Clinicopathologic correlations Configuration of distribution of lesions (when applicable) Laboratory test

Dermatologic diagnosis depends on the examiners skill in skin inspection

History
Key points Let the patient talk uninterruptedly in the beginning Clarify duration, symptoms, distribution, and treatment Expand the history based on the differential diagnosis

Preliminary history
The initial history can be abbrivated by asking three general questions: 1. How long ? 2. Does it itch ? 3. How have you treated it ? Presistence is often required in eliciting a complete medication history

Drugs can cause all types of skin rash

Follow up History
For persistent skin infections, consider the possibility of AIDS. A complete skin exposure history is required whenever contact dermatitis is suspected

Physical examination

Key points Complete skin examination is recommended at the first visit Good lighting is critical Describe the morphology of the eruption

The entire skin surface is examined for

Lesion that may accompany the presenting complaint Unrelated but important incidental findings

Side sighting helps to detect subtle elevations

The scalp, mouthm and nails should not be overload

Palpation helps to:

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Assess texture and consistency Evaluate tenderness Reassure patients that they are not contagious

The most important task in the physical examination is to Characterize the morphology of the basic lesion

Terminology of skin lesion

Key points Primary lesion include muscle, patch, papule, plaque, nodule, cyste, vesicle, pustule, ulcer, wheal, telangiectasia, burrow, and comedo Secondary lesion include scale, crust, oozing, lichenification, induration, fissure and atrophy

Clinicopathologic corellation

Determine which of the skin components are involved in clinical lesion Growth are hyperplastic lesions; rashes are inflamatory

Key points. Envisioning the gross and microscopic morphology together helps to make the diagnosis Rash or growth ? Epidermal, dermal, or subcutaneous ?

Clinicopathologic corellation
Skin component Epidermis Stratum corneum Subcorneal epedermis Pathologic alteration Hyperkeratosis Hyperplasia Hyperplasia Disruptive inflammatory changes Dried serum Clinical manifestation Scale Lichenification Papules, plaques and nodule Vesicle, bullae and pustule crsust

Dermis Blood vessels

Hyperplasia or inflammation Vasodilatation Hemorrhage Vasodilatation with edema

Hyperplasia

Macule, papules,and nodules Erythema Purpura wheals

Papules, nodules

Nerves

Clinicopathologic corellation (Part 2)

Skin component Connective tissue Pathologic alteration Hyperplasia Loss of epidermis and dermis Hyperplasia Atrophy Hyperplasia or inflammation Hypersecration Hyperplasia or inflammation Hyperplasia or inflammation Clinical manifestation Induration, papules, nodules, and plaques ulceration

Dermal appendages Pilosebaceous units

Hirsutism Alopecia Comedones, papules, nodules and cyst Hyperhidrosis Vesicle, papules, pustules and cyst Induration and nodules

Sweat glands

Subcutaneous fat

Schematic for diagnosis of skin diseases

Schematic for diagnosis of skin diseases

Eczematous Scaling vesicluar Rashes With epidermal involvement

papular
pustular papular Hypopigmented

Schematic for diagnosis of skin diseases

Genneralized Localized

Blanchable

Eritema

Speciallized

Rashes

Without epidermal involvement

notblanchable

Purpura

Macular

papular

Indurated

Schematic for diagnosis of skin diseases

Epidermal

Hair disorder
Miscellaneous Nail disorder

Mucous membrane disorder

Growths
Growth are subdivided into one three categories 1. Epidermal 2. Pigmented 3. Derma or subcutaneous Scale and hyperkeratosis are both terms for excess stratum corneum Malignant epidermal growths usually feel indurated A skin biopsy is often required for diagnosis of a dermal nodule

Rashes
Licheification is the hallmark of chronic eczematous dermatitis Epidermal rashes: 1. Eczematous 2. Scaling 3. Vesicular 4. Papular 5. Pustular 6. Hypopigmented Scale must be distinguished from crust

Vesicle and bullae are important and diagnostic findings Pustules often (but always) indicates infection Hypopigmentary changes are accentuated with woods light examination

Macular purpura is usually a sign of bleeding disorder ; papular purpura indicates a necrotizing vasculitis, often systemic

Miscellaneous conditions
Chronic skin ulcers should be undergo biopsy to rule out malignancy For alopecia, first determine whether it is scarring or non scarring.

Configuration of skin lesion

Key points 1. Configuration cal help make the diagnosis 2. Morphology is more important than configuration

Some examples of configuration

Configuration Linear Morphology Vesicles Papules Diseases Contact dermatitis Psoriasis Lichen planus Flat warts Herpes (Simplex & Zoster) Insect bites Tinea corporis Secondary syphilis Subacute cutaneous lupus erythematosus Granuloma annulare Urticaria Mycosis fungoides

Grouped Annular

Vesicles Papules Scaling

Dermal plaque geographic Wheals Plaques

Mucous membrane disorder

Erosions and ulcerations White lesions

Distribution of skin lesions

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Key points The distribution of skin lesion and the region affected can help to suggest or confirm a diagnosis

REGIONAL DIAGNOSE

Growth

Rashes Scalp

Nevus Seborrheic keratosis

Pilar cyst

Seborrheic dermtitis (dandruff) Psoriasis

Tinea Folliculitis Face

Nevus Lentigo Actinic keratosis Seborrheic keratosis Sebaceous hyperplasia Basal cell carcinoma Squamous cell carcinoma Flat ward Nevus flammeus

Acne Acne rosasea Seborrheic dermatitis Contact dermatitis (cosmetics) Herpes simplex Impetigo Pityriasis alba Atopic dermatitis Lupus erythematosus

Growth Nevus Skin tag Cherry carcinoma Seborrheic keratosis

Rashes Trunk Acne Tinea versicolor Psoriasis Pityrisis rosea

Epidermal inclusion cyst

Lipoma Basal cell carcinoma Keloid neurofibroma Wart (condyloma acuminata)

Scabies
Drug eruption Vricella Mycosis fungoides Secondary syphillis Genitalia Herpes simplex

Molluscum contagiosum
Seborrheic keratosis

Scabies
Psoriasis Lichen planus Syphillis (chncre)

Growth

Rashes Groin (inguinal)

Skin tag Wart

Molluscum contagiosum

Intertrigo Tinea cruris

Candidiasis Pediculosis pubis Hidradenitis suppurtiva Psoriasis Seborrheic dermatitis Extremities

Nevus Dermatofibroma Wart Seborrheic keratosis Actinic keratosis xanthoma

Atopic dermatitis Contact dermatitis Psoriasis Insect bites Erythema multiform Lichen planus (wrists and angkles)

Growth

Rashes Extremities Actinic purpura (arms) Stasis dermatitis (legs) Vasculitis (legs) Erythema nodosum (legs) Hands (Palmar)

wart

Nonspecific dermatitis Atopic dermatitis Psoriasis Tinea manuum Erythema multiform Secondary syphillis

Growth Wart Feet (plantar) Wart (plantar) Corn

Rashes Feet (dorsal) Contact dermatitis (shoe) Contact dermatitis (shoe) Tinea pedis

Nevus

Nonspecific dermatitis
Psoriasis Atopic dermatitis