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Skin Examination

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Examination Of Skin

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Skin Examination

  1. 1. Examination of the Skin (L.CUTIS) Dr. Sudeesh Shetty Final Year P.G Scholar Dept of Roganidana GAMC Banglore.
  2. 2. OUTLINE ANATOMY and PHYSIOLOGY  HISTORY  EXAMINATION  drsudeeshshetty@gmail.com 2
  3. 3. Skin Anatomy drsudeeshshetty@gmail.com 3
  4. 4. drsudeeshshetty@gmail.com 4
  5. 5. 1.Epidermis     The epidermis is composed of 4 or 5 layers depending on the region of skin being considered The epidermis is the topmost layer, and consists primarily of keratinocytes. The epidermis is separated from the dermis, its underlying tissue, by a basement membrane. The epidermis is avascular, nourished by diffusion from the dermis, constituted at 95% of keratinocytes but also containing melanocytes, Langerhans cells, Merkel cells, and inflammatory cells. Epidermis is divided into the following 5 sublayers or strata:  Stratum corneum  Stratum lucidum  Stratum granulosum  Stratum spinosum  Stratum germinativum (also called "stratum basale"). drsudeeshshetty@gmail.com 5
  6. 6. drsudeeshshetty@gmail.com 6
  7. 7. Stratum corneum Stratum lucidum Stratum granulosum (granular cell layer) Stratum spinosum (spiny layer) Stratum besale drsudeeshshetty@gmail.com 7
  8. 8.          Those layers in descending order are cornified layer (stratum corneum) Composed of 10 to 30 layers of polyhedral, anucleated corneocytes (final step of keratinocyte differentiation), with the palms and soles having the most layers. Corneocytes are surrounded by a protein envelope (cornified envelope proteins), filled with water retaining keratin proteins, attached together through corneodesmosomes and surrounded in the extracellular space by stacked layers of lipids. Most of the barrier functions of the epidermis localize to this layer.[10]clear/translucent layer (stratum lucidum, only in palms and soles) The skin found in the palms and soles is known as "thick skin" because it has 5 epidermal layers instead of 4.granular layer (stratum granulosum) Keratinocytes lose their nuclei and their cytoplasm appears granular. Lipids, contained into those keratinocytes within lamellar bodies, are released into the extracellular space through exocytosis to form a lipid barrier. Those polar lipids are then converted into nonpolar lipids and arranged parallel to the cell surface. For example glycosphingolipids become ceramides and phospholipids become free fatty acids.[spinous layer (stratum spinosum) Keratinocytes become connected through desmosomes and start produce lamellar bodies, from within the Golgi, enriched in polar lipids,glycosphingolipids, free sterols, phospholipids and catabolic enzymes.[4] Langerhans cells, immunologically active cells, are located in the middle of this layer.[9]basal/germinal layer (stratum basale/germinativum). Composed mainly of proliferating and non-proliferating keratinocytes, attached to the basement membrane by hemidesmosomes. Melanocytes are present, connected to numerouskeratinocytes in this and other strata through dendrites. Merkel cells are also found in the stratum basale with large numbers in touch-sensitive sites such as the fingertips and lips. They are closely associated with cutaneous nerves and seem to be involved in light touch sensation.The term Malpighian layer (stratum malpighi) is usually defined as both the stratum basale and stratum spinosum. drsudeeshshetty@gmail.com 8
  9. 9. 2.Dermis  The dermis lies below the epidermis, and consists primarily of fibroblasts, collagen, and elastic fibers  The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. .  The dermis is tightly connected to the epidermis by a basement membrane.  The dermis is structurally divided into two areas: a superficial area adjacent to the epidermis, called the papillary region, and a deep thicker area known as the reticular region  It also harbors many nerve endings that provide the sense of touch and heat. drsudeeshshetty@gmail.com 9
  10. 10.  It is between 1-4 mm thick (depending on age and body location), making it much thicker than the epidermis.  It contains the hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels and blood vessels. The blood vessels in the dermis provide nourishment and waste removal from its own cells as well as from the Stratum basale of the epidermis. drsudeeshshetty@gmail.com 10
  11. 11. Papillary dermis Reticular dermis drsudeeshshetty@gmail.com 11
  12. 12. 3.Hypodermis  Below the dermis lies fat, also called subcutis, panniculus, or hypodermis.  Blood capillaries are found beneath the epidermis, and are linked to an arteriole and a venule.  Arterial shunt vessels may bypass the network in ears, the nose and fingertips. drsudeeshshetty@gmail.com 12
  13. 13. Skin Function          Coloring/Complexion Protective barrier Mechanical barrier Temperature regulator Sensor Vitamin D producer Repairer Excreter Expresser drsudeeshshetty@gmail.com 13
  14. 14. Review Chart drsudeeshshetty@gmail.com 14
  15. 15. Pigments There are at least five different pigments that determine the color of the skin. These pigments are present at different levels and places. 1. Melanin: It is brown in color and present in the germinative zone of the epidermis. 2. Melanoid: It resembles melanin but is present diffusely throughout the epidermis. 3. Carotene: This pigment is yellow to orange in color. It is present in the stratum corneum and fat cells of dermis and superficial fascia. 4. Hemoglobin (also spelled haemoglobin): It is found in blood and is not a pigment of the skin but develops a purple color. 5. Oxyhemoglobin: It is also found in blood and is not a 15 drsudeeshshetty@gmail.com pigment of the skin. It develops a red color.
  16. 16. Nutrition for healthy skin 1. Vitamin A, also known as retinoids, benefits the skin by normalizing keratinization, downregulating sebum production which contributes to acne, and reversing and treating photodamage, striae, and cellulite. 2. Vitamin D and analogs are used to downregulate the cutaneous immune system and epithelial proliferation while promoting differentiation. 3. Vitamin C is an antioxidant that regulates collagen synthesis, forms barrier lipids, regenerates vitamin E, and provides photoprotection. 4. Vitamin E is a membrane antioxidant that protects against oxidative damage and also provides protection against harmful UV rays. 16 drsudeeshshetty@gmail.com
  17. 17. Skin Appendages drsudeeshshetty@gmail.com 17
  18. 18. Hair drsudeeshshetty@gmail.com 18
  19. 19. Nails drsudeeshshetty@gmail.com 19
  20. 20. The Skin: History •Chief complaint •History of present illness (HPI) •Past medical history (PMH)-previous problems and systemic disease,Medications,Allergies •Family history-skin CA, psoriasis, allergy, infestations and infections •Psychosocial-personal habits,exposures,Health-related behaviors •Social history•Review of systemsdrsudeeshshetty@gmail.com 20
  21. 21. HPI: • • • • • • • • When did it start? Does it itch, burn, or hurt? Associated symptoms Is this the first episode? Where on the body did it start?-Location How has it spread (pattern of spread)? How have individual lesions changed (evolution)? Provoking/Alleviating/aggravating exacerbating factors? • Previous treatments and response? o Timing of Attacks o Occupation o Topical agents o Drug history o Season of year drsudeeshshetty@gmail.com o Environment 21
  22. 22.  The Total Body Skin Exam (TBSE) includes inspection of the entire skin surface, including: • the scalp, hair, and nails • the mucous membranes of the mouth, eyes, anus, and genitals drsudeeshshetty@gmail.com 22
  23. 23. History-Hair Timing Associated symptoms Nutrition Alleviating/aggravating Treatment(s) Exposures drsudeeshshetty@gmail.com 23
  24. 24. History-Nails  Timing  Associated symptoms  Nutrition  Alleviating/aggravating  Treatment(s)  Exposures drsudeeshshetty@gmail.com 24
  25. 25. Examination aides/Diagnostic aids/Essential elements for the skin exam: Ruler  Lighting  Penlight  Gloves  Magnifying glass  Woods lamp      Adequate lighting Undressed patient, in a gown • Preferably without makeup, watches, jew elry Privacy An open mind about what you are seeing drsudeeshshetty@gmail.com 25
  26. 26.  Accurately records the size of a lesion on successive examinations  Measure in the longest axis first, then in the perpendicular axis • e.g., this papule is 6x4 mm drsudeeshshetty@gmail.com 26
  27. 27.  Dermatoscopes --Magnify the lesions with a hand lens or using epiluminescence microscopy (using a hand lens with magnification and lighting built in to better visualize lesions)  Inexpensive magnifying glasses may help detect fine details • Avoid LED lights, which cast a blue hue drsudeeshshetty@gmail.com 27
  28. 28.    A penlight is used for side lighting Detects atrophy and fine wrinkling Distinguishes • Flat from raised lesions • Whether lesions are solid or fluid-filled  Also helps look inside the mouth drsudeeshshetty@gmail.com 28
  29. 29.  Use diascopy (press a transparent, firm object such as a glass slide against a lesion) to determine if an erythematous lesion blanches. drsudeeshshetty@gmail.com 29
  30. 30.  Use a wood’s lamp (long wavelength ultraviolet light) to examine if a lesion is hypo or depigmented or to see if a fungal infection fluoresces. drsudeeshshetty@gmail.com 30
  31. 31. Examination (exposure!)  Inspection – – – – –  Palpation – – – – – Color Uniformity Thickness Hygiene Lesions  Moisture Temperature Texture Turgor Mobility Sequence – Regional – System drsudeeshshetty@gmail.com 31
  32. 32. Colour Skin- or flesh-colored Hypopigmented vs hyperpigmented White Brown Grey Black Red Blue Violaceous Dark purple (purpura) Yellow Orange drsudeeshshetty@gmail.com Green 32
  33. 33. Lesion Description         Size, Shape, Color Edges Texture Elevated or depressed Exudates Configuration Location&Distribution PICTURE!! Three categories of observation : 1.Anatomic distribution of the lesion 2.Configuration of groups of lesions 3.The morphology of the individual lesions drsudeeshshetty@gmail.com 33
  34. 34. Distribution means location on the body  Configuration means how the lesions are arranged or relate to each other  drsudeeshshetty@gmail.com 34
  35. 35. Distribution drsudeeshshetty@gmail.com 35
  36. 36. Configuration drsudeeshshetty@gmail.com 36
  37. 37. Primary skin lesion: 1 Macule 7 Bulla 13 Ecchymosis 2 Papule 8 Postule 14 Hemotoma 3 Plaque 9 Wheal 15 Poikiloderma 4 Nodule 10 Telangictasia 16 Erythema 5 Papilloma 11 Petechiae 17 Burrow 6 Vesicle 12 Purpura 18 Comedo drsudeeshshetty@gmail.com 37
  38. 38. drsudeeshshetty@gmail.com 38
  39. 39. MACULE Macule – A flat, colored lesion, <2cm in diameter, not raised above the surface of surrounding skin  Freckle – prototype of pigmented macule  Non-palpable lesion with distinct borders, less than 1 cm in diameter  drsudeeshshetty@gmail.com 39
  40. 40.  Non-palpable change in skin color with distinct borders localized changes in skin color.  Areas may be small or large; occur in many shapes and colors.  Not palpable   may be associated with desquamation or scaling e.g- rubeola, rubella, secondary syphilis, rose spots of typhoid fever, drug eruptions, petechiae, purpura, first degree burns, systemic lupus erythematosus, pityriasis rosea and vitiligo drsudeeshshetty@gmail.com 40
  41. 41. MACULE drsudeeshshetty@gmail.com 41
  42. 42. PATCH Non-palpable lesion with distinct borders, greater than 1 cm in diameter Non-palpable change in skin color with distinct borders drsudeeshshetty@gmail.com 42
  43. 43. PATCH drsudeeshshetty@gmail.com 43
  44. 44. drsudeeshshetty@gmail.com 44
  45. 45. VESICLE  Fluid-containing, superficial, thin-walled cavity less than 1 cm  Small, raised, fluid-filled lesions are called vesicles  e.g-varicella with vesicles and bullae acute eczematous dermatitis, seconddegree burns drsudeeshshetty@gmail.com 45
  46. 46. VESICLE drsudeeshshetty@gmail.com 46
  47. 47. BULLA Fluid-containing ,superficial, cavity greater than 1 cm e.g-bullous pemphigoid, dermatitis, second-degree bullous impetigo drsudeeshshetty@gmail.com thin-walled contact burns, 47
  48. 48. BULLA drsudeeshshetty@gmail.com 48
  49. 49. Pustule *Pus containing, superficial,thin-walled cavity, frequently arise from hair follicles or sweat glands. Pus is made up of leukocytes and a thin fluid called liquor puris (L. “pus liquid”) examples: acne,furuncles,and bromide and iodide eruptions, Inflammatory acne, furuncles, and bromide and iodide eruptions. 49 drsudeeshshetty@gmail.com
  50. 50. Pustule drsudeeshshetty@gmail.com 50
  51. 51. drsudeeshshetty@gmail.com 51
  52. 52. Papule  *Palpable, solid lesion less than 1 cm in diameter  *A small, solid lesion, <0.5 cm in diameter, raised above the surface of surrounding skin & hence palpable  Borders and tops may be in various forms –round or irregular --senile angiomas, eczematous dermatitis, secondary syphilis –pedunculate – neurofibromas Eg: white head in acne, blue nevus drsudeeshshetty@gmail.com 52
  53. 53. Papule drsudeeshshetty@gmail.com 53
  54. 54. NODULES *A large ( 0.5 – 5.0 cm ), firm lesion raised above the surface of surrounding skin. *A raised area in the skin where the overlying epidermis looks and feels normal, but there is a proliferation of cells in deeper tissues is called a nodule. *Differs from papule only in size *Rubbery, Mobile, Non-tender drsudeeshshetty@gmail.com 54
  55. 55. NODULES drsudeeshshetty@gmail.com 55
  56. 56. Tumor *A solid, raised growth >5cm in diameter drsudeeshshetty@gmail.com 56
  57. 57. Plaque Palpable, solid lesion greater than 1 cm in diameter. A large >1cm, flat topped raised lesion, edges may either be distinct ( in psoriasis ) or gradually blend with surrounding skin ( in eczematous dermatitis ) Yellow -- xanthomas brown -- seborrheic warts Red scaling plaques -- psoriasis, pityriasis rosea E.g- Urticaria, psoriasis drsudeeshshetty@gmail.com 57
  58. 58. Plaque drsudeeshshetty@gmail.com 58
  59. 59. WHEAL /Hives A raised, erythematous, edematous, papule / plaque, usually representing short-lived vasodilatation and vasopermeability Eg: urticaria and insect bites drsudeeshshetty@gmail.com 59
  60. 60. WHEAL drsudeeshshetty@gmail.com 60
  61. 61. Telangiectasia A dilated superficial blood vessel. *Angioectasias (also known as spider veins) are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. *They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. *They can also develop on the legs, specifically on the upper thigh, below the knee joint, and around the ankles. *They may be composed of abnormal aggregations of arterioles, capillaries, or venules. *Because telangiectasias are vascular lesions, they blanch when tested withdiascopy. *Telangiectasia is a component of the CREST variant of scleroderma (CREST is an acronym that stands for calcinosis, Raynaud's phenomenon,esophageal dysmotility, sclerodactyly, and telangiectasia.) 61 drsudeeshshetty@gmail.com
  62. 62. Telangiectasias may develop anywhere within the body but can be easily seen in the skin, mucous membranes, and whites of the eyes. Usually, they do not cause symptoms. However, some telangiectasias bleed and cause significant problems. Telangiectasias may also occur in the brain and cause major problems from bleeding. e.g-Cushing's syndrome Venous hypertension varicose and telangiectatic leg veins liver disease. Chronic treatment withuse,Aging,Genetics,Pregnancy,Sun exposure Causes----Alcohol topical corticosteroids Diseases associated with this condition include: Ataxia - telangiectasia Bloom syndrome Cutis marmorata telangiectatica congenita Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) Klippel-Trenaunay-Weber syndrome Nevus flammeus such as port-wine stain Rosacea Spider angioma Sturge-Weber disease drsudeeshshetty@gmail.com Xeroderma pigmentosa 62
  63. 63. Telangiectasia drsudeeshshetty@gmail.com 63
  64. 64. Petechiae Petechiae – pinhead-sized macules of extravascular blood in the dermis.  Petechiae are flat.  A petechia (Lural petechiae) is a small (1 - 2 mm) red or purple spot on the body, caused by a minor hemorrhage (brokencapillary blood vessels).  "Petechiae" refers to one of the three major classes of purpuric skin conditions.  Purpuric eruptions are classified by size into three broad categories.  Petechiae is generally used to refer to the smallest of the three classes of purpuric skin eruptions, those that 64 drsudeeshshetty@gmail.com measure less than 3 mm. 
  65. 65. Petechiae drsudeeshshetty@gmail.com 65
  66. 66. Purpura The larger ones are referred to as purpura  Purpura (from Latin: purpura, meaning "purple") is the appearance of red or purple discolorations on the skin that do not blanch on applying pressure.  drsudeeshshetty@gmail.com 66
  67. 67.       They are caused by bleeding underneath the skin usually secondary to vasculitis or dietary deficiency of vitamin C (scurvy). Purpura measure 0.3–1 cm (3–10 mm), whereas petechiae measure less than 3 mm, and ecchymoses greater than 1 cm. This is common with typhus and can be present with meningitis caused by meningococcal meningitis or septicaemia. In particular, meningococcus (Neisseria meningitidis), a Gramnegative diplococcus organism, releases endotoxin when it lyses. Endotoxin activates the Hageman factor (clotting factor XII), which causes disseminated intravascular coagulation (DIC). The DIC is what appears as a rash on the affected individual. drsudeeshshetty@gmail.com 67
  68. 68. Purpura drsudeeshshetty@gmail.com 68
  69. 69. Ecchymosis If bleeding involves deeper structures then it is an ecchymosis  a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.  drsudeeshshetty@gmail.com 69
  70. 70.     An ecchymosis is the medical term for a subcutaneouspurpura (extravasation of blood) larger than 1 centimeter or a hematoma, commonly, but erroneously, called a bruise. That is, bruises are caused by trauma whereas ecchymoses, a type of purpura, are not caused by trauma. A broader definition of ecchymosis is the escape of blood into the tissues from ruptured blood vessels. The term also applies to the subcutaneous discoloration resulting from seepage of blood within the contused tissue. drsudeeshshetty@gmail.com 70
  71. 71. Ecchymosis drsudeeshshetty@gmail.com 71
  72. 72. Erythema  Erythema is a skin condition characterized by redness or rash.  Erythema (from the Greek erythros, meaning red) is redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin.  There are many types of erythema, including photosensitivity, erythema multiforme, and erythema nodusum.  It occurs with any skin injury, infection, or inflammation. drsudeeshshetty@gmail.com 72
  73. 73.              Photosensitivity is caused by a reaction to sunlight and tends to occur when something, such as an infection or a medication, increases your sensitivity to ultraviolet radiation. Erythema multiforme is characterized by raised spots or other lesions on the skin. It is usually caused by a reaction to medications, infections (especially herpes simplex virus), or illness. Erythema nodosum is a form of erythema that is accompanied by tender lumps, usually on the legs below the knees, and may be caused by certain medications or diseases. Erythema ab igne Erythema chronicum migrans Erythema induratum Erythema infectiosum (or fifth disease) Erythema marginatum Erythema migrans Erythema multiforme (EM) Erythema nodosum Erythema toxicum Keratolytic winter erythema drsudeeshshetty@gmail.com 73
  74. 74. Erythema drsudeeshshetty@gmail.com 74
  75. 75. Hematoma  A hematoma or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue.  An ecchymosis, commonly called a bruise, is a hematoma of the skin larger than 10mm.  Internal bleeding is generally considered to be a spreading of blood within the abdomen or skull, not within muscle  It is not to be confused with hemangioma which is an abnormal build up of blood vessels in the skin or internal organs. 75 drsudeeshshetty@gmail.com
  76. 76. Types      Subdermal hematoma (under the skin) Head/brain: – Subgaleal hematoma – between the galea aponeurosis and periosteum – Cephalohematoma – between the periosteum and skull. Commonly caused by vacuum delivery and vertex delivery. – Epidural hematoma – between the skull and dura mater – Subdural hematoma – between the dura mater and arachnoid mater – Subarachnoid hematoma – between the arachnoid mater and pia mater (the subarachnoid space) – Othematoma – between the skin and the layers of cartilage of the ear Perichondral hematoma (ear) Perianal hematoma (anus) Subungual hematoma (nail) Degrees    Petechiae – small pinpoint hematomas less than 3 mm in diameter Purpura (purple) – a bruise about 1 cm in diameter, generally round in shape Ecchymosis – subcutaneous extravasation of blood in a thin layer under the skin, i.e. bruising or "black and blue," over 1 cm in diameter drsudeeshshetty@gmail.com 76
  77. 77. Hematoma drsudeeshshetty@gmail.com 77
  78. 78. Morphology drsudeeshshetty@gmail.com 78
  79. 79. Comedones          A plug of keratin and sebum wedged in dilated pilosebaceous orifice. Comedones are the skin-coloured, small bumps (papules) frequently found on the forehead and chin of those with acne. Open comedones are blackheads; black because of surface pigment (melanin) rather than dirt Closed comedones are whiteheads; the follicle is completely blocked Macrocomedones are facial closed comedones that are larger than 2-3 mm in diameter Solar comedones are found on the cheeks and chin of older people, and are thought to be due to sun damage. Larger and deeper uninflamed bumps are called nodules. They are more common on the trunk than on the face The cells lining the sebaceous duct proliferate excessively in acne (cornification) and may block the sebaceous duct forming a comedone. These may be so small that they are not visible to the naked eye 79 (microcomedones). drsudeeshshetty@gmail.com
  80. 80. • A comedo is a clogged hair follicle (pore) in the skin.[1] Keratin (skin debris) combines with oil to block the follicle. • A comedo can be open (blackhead) or closed by skin (whitehead), and occur with or without acne. • The word comedo comes from Latin to suggest the worm-like look of a blackhead that has been secreted. • The plural of comedo is comedones. • The chronic inflammatory condition that usually includes both comedones and inflamed papules and pustules (pimples) is called acne.[2][4] Infection causes inflammation and the development of pus. • Whether or not a skin condition classifies as acne depends on the amount of comedones and infection. • Comedo-type ductal carcinoma in situ (DCIS) is not related to the skin conditions discussed here. • DCIS is a non-invasive form of breast cancer, but comedo-type DCIS may be more aggressive and so may be more likely to become invasive. drsudeeshshetty@gmail.com 80
  81. 81. open Comedones drsudeeshshetty@gmail.com closed 81
  82. 82. Burrow  A linear or cuvillinear papule, caused by burrowing scabies mite  Burrows are linear lesions produced by infestation of the skin and formation of tunnels (e.g., with infestation by the scabitic mite or by cutaneous larva migrans)  Linear or serpiginous (wavy, serpent-like borders) tunnels within the epidermis. The small and short tunnels ofscabies are an example. drsudeeshshetty@gmail.com 82
  83. 83.  Microscopic examination of a skin biopsy or the skin scrapings done at time of clinical examination. The outer layers of eggs ( called ‘egg casings) and mites appear eosinophilic (pink) and scybala (feces) appear brown. These are present in the stratum corneum. The dermal inflammation contains eosinophils, as a response to the parasitic infection. drsudeeshshetty@gmail.com 83
  84. 84. Burrow drsudeeshshetty@gmail.com 84
  85. 85. CYST  A cyst is a closed tumorous lesion covered by a membranous lining, which does not always elevate above the skin.  examples: sebaceous and epidermal cysts drsudeeshshetty@gmail.com 85
  86. 86. The covering consists of epithelial tissue or connective tissue containing keratinous substances (observed in epidermal cysts, for example) or fluid components (e.g., in eccrine and apocrine hydrocystomas) elevated lesions containing fluid or viscous material appear as papules or nodules  distinction is made by puncturing to examine their contents and depth  drsudeeshshetty@gmail.com 86
  87. 87. CYST drsudeeshshetty@gmail.com 87
  88. 88. Abscess Thick-walled cavity containing pus  The organisms or foreign materials kill the local cells, resulting in the release of cytokines.  The cytokines trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.  drsudeeshshetty@gmail.com 88
  89. 89.  An abscess (Latin: abscessus) is a collection of pus (neutrophils) that has accumulated within a tissue because of an inflammatory process in response to either an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.  The organisms or foreign materials kill the local cells, resulting in the release of cytokines. The cytokines trigger an inflammatory response, which draws large numbers of white blood cells to the area and increases the regional blood flow.  The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.  Abscesses must be differentiated from empyemas, which are accumulations of pus in a preexisting rather than a newly formed 89 drsudeeshshetty@gmail.com anatomical cavity.
  90. 90. Abscess drsudeeshshetty@gmail.com 90
  91. 91. Papilloma o Papilloma is a general medical term for a tumor of the skin or mucous membrane with finger-like projections. o Papillomas are also known as neoplasms. o While the vast majority of papillomas are benign (noncancerous), they can occasionally be dysplastic (precancerous) or malignant (cancerous). drsudeeshshetty@gmail.com 91
  92. 92. o Papillomas can occur in areas throughout the body. o Papillomas on the skin (cutaneous papillomas) are commonly referred to as warts. o They occur on areas such as the hands, feet and knees. Papillomas can also occur in the nose, brain, genitals, conjunctiva of the eye, and female breast ducts. o Papilloma in the throat, windpipe and lungs is a rare disease called recurrent respiratory papillomatosis (RRP). o Most papillomas are caused by a virus. o The human papillomaviruses (HPVs) are a group of more than 150 viruses that can cause papillomas. HPVs can cause papillomas of the skin, genitals, mouth, eyes and throat. Certain HPVs can cause cervical cancer in women. o Some types of papilloma have other, nonviral, causes. o For example, nasal papilloma may be caused by a tissue injury. In addition, there are types of papillomas that do not have known causes. These include intraductal (breast duct) papilloma and choroid plexus papilloma (a rare benign brain 92 drsudeeshshetty@gmail.com tumor most often seen in young children).
  93. 93. A benign papillomatous tumor derived from epithelium. Cauliflowerlike projections that arise from the mucosal surface. It may appear white or normal colored. It may be pedunculated or sessile. The average size is less than 2.0 cm. No strong sex preference. The most common site was the palate-uvula area followed by tongue and lips. The durations ranged from weeks to 10 years. There is no evidence that papillomas are premalignant.  Papilloma (plural papillomas or papillomata) refers to a benign epithelial tumor growing exophytically (outwardly projecting) in nipple-like and often finger-like fronds.  In this context papilla refers to the projection created by the tumor, not a tumor on an already existing papilla (such as the nipple).  When used without context, it frequently refers to infections (squamous cell papilloma) caused by human papillomavirus (HPV), such as warts.  There are, however, a number of other conditions that cause papilloma, as well as many cases in which there is no known cause.Human papillomavirus infection is a major cause of cervical cancer, although most HPV infections do not cause cancer. drsudeeshshetty@gmail.com 93
  94. 94. Papilloma drsudeeshshetty@gmail.com 94
  95. 95. Poikiloderma  Poikiloderma is a skin condition that consists of areas of hypopigmentation, hyperpigmentation, telangiec tasias and atrophy.  Poikiloderma is most frequently seen on the chest or the neck, characterized by red colored pigment on the skin that is commonly associated with sun damage. e.g--Poikiloderma vasculare , atrophicans Poikiloderma of Civatte, Hereditary sclerosing poikiloderma drsudeeshshetty@gmail.com 95
  96. 96.                  The exact cause of poikiloderma is unknown; however, extended sun exposure, namely the ultraviolet light emitted by the sun, is the primary factor Causes Congenital Rothmund-Thompson Syndrome Dyskeratosis Congenita Mendes da Costa Syndrome Other Heriditary Causes Hereditary Sclerosing Poikiloderma of Weary Weary-Kindler Syndrome Kindler Syndrome Diffuse and Macular Atrophic Dermatosis Degos-Touraine Syndrome Acquired Injury to cold, heat, ionizing radiation, exposure to sensitizing chemicals Lichen Planus Dermatomyositis Lupus Erythematosus Systemic Sclerosis Cutaneous T Cell Lymphomas 96 drsudeeshshetty@gmail.com
  97. 97. Poikiloderma drsudeeshshetty@gmail.com 97
  98. 98. Secondary skin lesion: Changes in skin which are superimposed or are the consequence of the primary process 1 Scale 7 Ulcer 2 Crust 8 Sinus 3 Excoriation 9 Scar 4 Lichenification 10 Keloid 5 Fissure 11 Atrophy 6 Erosion 12 Stria drsudeeshshetty@gmail.com 98
  99. 99. drsudeeshshetty@gmail.com 99
  100. 100. SCALINING  Scaling is the abnormal thickening of the skin surface and formation of scaly white lamellae from the accumulation of horny cell layers.  Detachment of scales from the skin surface is called desquamation. Since the normal horny cell layers exfoliate individually, individual desquamation lamellae cannot be seen by the naked eye.  Scales are observed when multiple horny cell layers pathologically exfoliate in diseases such as psoriasis e.g-desquamating psoriasis layers of stratum drsudeeshshetty@gmail.com corneum in 100
  101. 101. SCALINING drsudeeshshetty@gmail.com 101
  102. 102. CRUSTING  Crust is solidified keratin and exudate that forms on an erosion or on ulcerous skin.  A crust of clotted blood is called a bloody crust (commonly called a scab).  Crusts are a sign of pyogenic infection e.g-Impetigo with honey colored crust drsudeeshshetty@gmail.com 102
  103. 103. CRUSTING Dried serum, blood or purulent exudate Impetigo with honey colored crust drsudeeshshetty@gmail.com 103
  104. 104. Morphology drsudeeshshetty@gmail.com 104
  105. 105. Erosion         Erosions are loss of the epidermis They may occur after a vesicle forms and the top peels off A skin defect where there has been loss of the epidermis only e.g-toxic epidermal necrolysis A skin defect where there has been loss of the epidermis only They weep and become crusted This is an example of a secondary change or characteristic Area of skin denuded by complete or partial loss of epidermis. 105 drsudeeshshetty@gmail.com No associated loss of dermis
  106. 106. Erosion Toxic epidermal necrolysis drsudeeshshetty@gmail.com 106
  107. 107. Ulcer If an erosion involves the dermis, it is called an…ulcer.  An area of skin from which the whole of epidermis & atleast the upper part of dermis has been lost  A skin defect where there has been loss of the epidermis and dermis  e.gPyoderma gangrenosum traumatic ulcers, burns, and stasis ulcers  drsudeeshshetty@gmail.com 107
  108. 108. (L. ulcus, “sore”)  Ulcers often heal with scarring; erosions usually do not  Erosions and ulcers are secondary lesions  Secondary lesions (or changes) may evolve from primary lesions, or may be caused by external forces such as scratching, trauma, infection, or the healing process.  Gangrene---extensive destruction of the skin -- may leave many dead cells that become blackened drsudeeshshetty@gmail.com 108
  109. 109. Ulcer Pyoderma gangrenosum drsudeeshshetty@gmail.com 109
  110. 110. EXCORIATION Linear, angular erosions that may be covered by crust and are caused by scratching.  Superficial excavation of the epidermis that results from scratching  E.g- Linear excoriations in a patient with atopic dermatitis  drsudeeshshetty@gmail.com 110
  111. 111. EXCORIATION drsudeeshshetty@gmail.com 111
  112. 112. FISSURE o A slit- shaped deep ulcer o In anatomy,a fissure (Latin fissura, plural fissurae ) is a groove, natural division, deep furrow, elongated cleft, or tear in various parts of the body. Eg: Irritant dermatitis of hands/foot. drsudeeshshetty@gmail.com 112
  113. 113.  A skin fissure is a cutaneous condition in which there is a linear-like cleavage of skin, sometimes defined as extending into the dermis.  It is smaller than a skin laceration. A skin area on which there are many skin fissures is called cracked skin, and is most commonly a result of skin dryness.  Ichthyosis is a genetic disorder where there is often severe skin cracking. drsudeeshshetty@gmail.com 113
  114. 114. FISSURE drsudeeshshetty@gmail.com 114
  115. 115. ATROPHY  A accquired loss of substance .  In skin,this may appear as a depression with intact epidermis ( loss of dermal /subdermal tissues ) Or appear as sites of shiny, delicate, wrinkled lesions (epidermal atrophy )  Epidermal atrophy results from a decrease in the number of epidermal cell layers.  Dermal atrophy results from a decrease in the dermal connective tissue. e.g-Steroid Induced Atrophy:Many years of inappropriate application of topical steroids have led to local changes and atrophy. 115 drsudeeshshetty@gmail.com
  116. 116. ATROPHY drsudeeshshetty@gmail.com 116
  117. 117. LICHENIFICATION   A distinctive thickening of skin that is characterized by accenuated skin-fold markings. Lichenification – skin thickening that is the result of chronic rubbing leading to accentuation of normal skin lines. drsudeeshshetty@gmail.com 117
  118. 118. LICHENIFICATION Atopic dermatitis with lichenification drsudeeshshetty@gmail.com 118
  119. 119. Scar  A change in the skin secondary to trauma or inflammation  Sites may be erythematous,hypopigmented or hyperpigmented depending upon their age /character.  Scar- a lesion formed as a result of dermal damage. drsudeeshshetty@gmail.com 119
  120. 120. Scar HYPERTROPHIC SCAR drsudeeshshetty@gmail.com 120
  121. 121. KELOID Keloid is a benign overgrowth of the connective tissue of the skin consequent to an abnormal healing process of the skin in predisposed individuals. Keloid can cause serious aesthetic and occasionally functional disabilities. Keloid occur in all races but it is most common and severe in the black race. drsudeeshshetty@gmail.com 121
  122. 122. • • • • • • A keloid (also keloidal scar) is the formation that a type of scar which, depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1. Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to fleshcoloured or red to dark brown in colour. A keloid scar is benign and not contagious, but sometimes accompanied by severe itchiness, pain,[2] and changes in texture. In severe cases, it can affect movement of skin. Keloids should not be confused with hypertrophic scars, which are raised scars that do not grow beyond the boundaries of the original wound. 122 drsudeeshshetty@gmail.com
  123. 123. KELOID drsudeeshshetty@gmail.com 123
  124. 124. Sinus A cavity or channel that permits the escape of pus or fluid e.g-Pilonidal sinus, preauricular sinus, sinus caused by dental absces…. drsudeeshshetty@gmail.com 124
  125. 125. Sinus drsudeeshshetty@gmail.com 125
  126. 126. Striae A streak like, linear , atrophic, pink, purple or white lesion d/t changes in connective tissue Eg: cushings syndrome, pregnancy induced drsudeeshshetty@gmail.com 126
  127. 127.  Stretch marks or striae (singular stria), as they are called in dermatology, are a form of scarring on the skin with an offcolor hue.  They are caused by tearing of the dermis, which over time may diminish, but will not disappear completely.  Stretch marks are often the result of the rapid stretching of the skin associated with rapid growth or rapid weight changes.  Stretch marks may also be influenced by hormonal changes associated with puberty, pregnancy, bodybuilding, hormone replacement therapy, etc.[1]  Medical terminology for these kinds of markings includes striae atrophicae, vergetures, stria distensae, striae cutis distensae, lineae atrophicae, linea albicante, or simply striae.  Stretch marks formed during pregnancy, usually during the last trimester, and usually on the belly, but also commonly occurring on the breasts, thighs, hips, lower back and buttocks, are known as striae gravidarum. drsudeeshshetty@gmail.com 127
  128. 128. Striae drsudeeshshetty@gmail.com 128
  129. 129. Sclerosis *(Greek. Sklerosis - a hardening) Sclerosis is an induration or hardening of the skin. It is often due to fibrosis. *Sclerosis or sclerotizis (also spelled sclerosus in the names of a few disorders) is a hardening of tissue and other anatomical features *In medicine, sclerosis refers to the stiffening of a structure, usually caused by a replacement of the normal organ-specific tissue with connective tissue. drsudeeshshetty@gmail.com 129
  130. 130. Amyotrophic lateral sclerosis, sometimes known as motor neuron disease or Lou Gehrig's disease, a progressive, incurable, usually fatal disease of motor neurons. Atherosclerosis, a deposit of fatty materials, such as cholesterol, in the arteries which causes hardening. Focal Segmental Glomerulosclerosis is a disease that attacks the kidney's filtering system (glomeruli) causing serious scarring and thus a cause of nephrotic syndrome in children and adolescents,[1] as well as an important cause of kidney failure in adults.[2] Hippocampal sclerosis, a brain damage often seen in individuals with temporal lobe epilepsy. Lichen sclerosus, a disease that hardens the connective tissues of the vagina of women and the penis of men. An autoimmune disorder. Liver sclerosis is a common misspelling of cirrhosis of the liver. Multiple sclerosis, or Focal Sclerosis,[3] is a central nervous system disease which affects coordination. Osteosclerosis, a condition where the bone density is significantly increased. Otosclerosis, a disease of the ears. Systemic sclerosis (progressive systemic scleroderma), a rare, chronic disease which affects the skin, and in some cases also blood vessels and internal organs. Tuberous sclerosis, a rare genetic disease which affects multiple systems. Primary sclerosing cholangitis, a hardening of the bile duct by scarring and repeated inflammation. Primary lateral sclerosis, progressive muscle weakness in the voluntary muscles. drsudeeshshetty@gmail.com 130
  131. 131. Sclerosis drsudeeshshetty@gmail.com 131
  132. 132. Primary and Secondary Lesions Raised Flat Depresse d Fluidfilled Vascular Papule Macule Erosion Vesicle Plaque Patch Ulcer Bulla Telangiecta sia Petechiae Nodule Atrophy Pustule Tumor Sinus Furuncle Wheal Stria Abscess Ecchymosi s Burrow Scar drsudeeshshetty@gmail.com 132
  133. 133. EXAMINATION NAILS drsudeeshshetty@gmail.com 133
  134. 134. EXAMINATION NAILS Spooning - kiolonychia drsudeeshshetty@gmail.com 134
  135. 135. EXAMINATION NAILS drsudeeshshetty@gmail.com 135
  136. 136. Example Documentation  No abnormalities - General Statement about overall skin assessment: – Skin is warm, smooth and well hydrated. Full hair distribution on scalp, axilla, and genitalia. Nails are neatly trimmed and without deformity. No discrete lesions noted. drsudeeshshetty@gmail.com 136
  137. 137. drsudeeshshetty@gmail.com 137

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