Skin

1. Skin and subcutaneous tissues
DR VIJAY JAGANATHAN
MS MRCS DNB surgery MCh DNB plastic surgery
fellow in hand and reconstructive microsurgery
PROFESSOR
,Dept of Plastic surgery

2. Epidermis:
• -5% of the skin
• five layers - strata:basalis (deep), spinosum,
granulosum, lucidum & corneum (superficial).
• keratinised, stratified squamous epithelium;
• -Keratinocytes grow and are replaced by mitoses in
stratum granulosum
• -strata lucidum; granulosum and spinosum: :Thick in
glabrous skin and absent in eyelid skin.

3. Melanocytes :
• dendritic cells / neural crest origin,
• located in basal epidermis.
• Melanin - transferred via membrane processes
• transferred to keratinocytes in the strata
granulosum and spinosum.
• Ethnic diff in skin colour --By distribution of
melanin in keratinocytes, not by number of it

4. Sweat glands
Eccrine glands
• distributed throughout the entire body surface
• except in lips.
• secrete sweat in response to emotion or during
thermoregulation.

5. Apocrine glands
• secretion. in response to emotion and hormone/ become
active at puberty.
• found in the axillae and groins
• secretion,- malodourous after bacterial degradation,
Sweat glands

7. angiosomes
• 3d segments of tissue -with arterial & venous supply
• Blood flows b/w neighbouring angiosomes by choke vessel
• ‘choke’ vessels, - situated within muscles
 Blood supply to the skin anastomoses in
 subfascial,
 fascial,
 subdermal,
 dermal and
 subepidermal plexi.

8. • Epidermis has no blood vessels/ cells nourish by
diffusion.
• venous drainage is via both valved and unvalved
veins.
• Unvalved veins allow oscillating flow in the
subdermal plexus
angiosomes

9. • Neurofibromatosis
• Schwann cells form tumours
• 70% -autosomal dominant /30% sporadic mutations.
• Chromosomes 17 gene mutation
Gardner’s syndrome
• autosomal dominant disease
• variant of familial adenomatous polyposis (FAP)
• abnormal gene on Ch. 5.
• multiple epidermoid cysts and lipomata.

10. Naevoid basal cell carcinoma (Gorlin’s) syndrome
• autosomal dominant
• abnormal tumour suppressor gene on Ch. 9q 22-31
coding - ‘patched’ protein.
• c/f multiple basal cell carcinomas (BCCs).
• Head - over-developed supraorbital ridges; broad
nasal roots; hyperteliorism; molar odontogeniccysts.
• Trunk - bifid ribs; scoliosis;
• Hand - brachymetacarpalism; palmar pits

11. Hyperhydrosis
• excessive eccrine sweating
• palms, soles of the feet, axillae and groins,
treated
• -antiperspirants
• -local injections with botulinum toxin A.
• - laparoscopic cervical sympathectomy.

12. Lipodystrophy
• a localised or generalised loss of fatty tissue,
• complication of long-term administration of
insulin,
• treatment with protease inhibitors in hiv
• transplant recipients.
treated by
• by autologous fat grafting,
• injections of poly-L-lactic acid
• free tissue transfer.

13. HIDRADENITIS SUPPURATIVA (HS
• four women for every man
• apocrine glands,
• MC IN axillae and groins;
• but also the scalp, breast, chest and perineum
• genetic predisposition with variable penetrance,
• associated with obesity and smoking.

14. Treatment
• stop smoking
• lose excess weight
• antiseptic soaps
• tea tree oil
• non-compressive and aerated underwear.
• antibiotics
• antiandrogen drug
• require radical excision & Reconstruction
HIDRADENITIS SUPPURATIVA (HS

15. PYODERMA GANGRENOSUM (PG)
• cutaneous ulceration with purple undermined edges,
• secondary to IBD , RA, non-Hodgkin’s lymphoma or
Wegener’s granulomatosis
• respond to steroids
• surgery may exacerbate the condition.

16. Necrotising fasciitis
• Meleney’s synergistic gangrene and Fournier’s gangrene are
variants
• synergistic, polymicrobial infection
• MC streptococcal species (Group A β-haemolytic)
C/F :
• oedema beyond skin erythema;
• & woody-hard texture OF SC tissues;
• cant distinguish fascial plane & muscle;
• disproportionate pain N skin vesicles & soft tissue crepitus
• Lymphangitis - absent.

17. Xray air in sc tissues
Mx :
• surgical – excise till bleeding tissues
• antibiotics
• VAC dressings,
• early skin grafting
Mortality - 30% and 50%
Necrotising fasciitis

18. Milia
• hard, keratin retention cysts
• mc babies and chronic sun exposure, in the elderly
Epidermal cysts/sebaceous cysts
• LINED stratified-squamous epithelium, from hair follicle
infundibuli
• fixed to the skin + central punctum
• excision if uninfected
Meibomian cysts -
epidermal cysts on edge of the eyelid
• Tricholemmal cysts-
from epidermis external root sheath of hair follicle

20. SKIN TUMOURS - Benign lesions
Basal cell papilloma (seborrhoeic keratosis, senile keratosis, verruca senilis)
• warty lesions
• pigmented and hyperkeratotic
• from the basal layer of epidermal cells
• contain melanocytes.
Papillary wart (verruca vulgaris)-
• infection with human papilloma virus (HPV),hpv
• also cause- plantar warts and condylomata acuminata.

21. • Freckle (ephelis)-contains a normal number of
melanocytes,/large number of melanin granules
• Nevus (mole )- non specific medical term for visible
circumscribed lesion of skin or mucosa(cluster of
melanocytes )
• Intradermal naevus- faintly pigmented papules /mc in
adults / cluster of dermal melanocytes
• compound nevus -dermoepidermal junctional proliferation
of naevus cells, with dermis projection / mc in adolescent

22. naevus of Ota
• MC Oriental and African races
• four times MC in women
• dermal, melanocytic hamartoma
• blue or grey macule
• mc site face trigeminal V1 and V2 dermatomes.
naevus of Ito
• dermal melanocytosis
• MC shoulder
• occur simultaneously with naevus of Ota

23. Tricholemmoma (naevus sebaceous of Jadassohn)
• congenital hamartoma
• appearance of a linear verrucous naevus.
• 10% form a BCC
Adenoma sebaceum (tuberous sclerosis, Bourneville
disease)
• facial papules (angiofibromas
• in children before 10 years of age
• MX ;argon or pulse dye lasers or scalpel
Rhinophyma
• end-stage sequela of nasal acne rosacea
• C/F nasal sebaceous gland hypertrophy and hyperplasia
• MC affect elderly men (M:F12:1).
• Occult BCCs exist in 3%.
• Treatment = dermabrasion or laser resurfacing

24. Extramammary Paget’s disease( intraepidermal adenoca)
• Mc site axillae, genital and perianal
• 25% there is in situ or invasive adenocarcinoma.
Giant congenital pigmented naevus or giant hairy naevus
• naevus cells -from epidermis to subdermal muscle.
• precursors of melanoma, 3–5%
• 1 in 3 childhood melanoma arise in GCPN,
• Melanoma presentation in GCPN
 15% at birth;
62% at puberty
 99% by 45 yrs

25. Atypical (dysplastic) naevus
• irregular proliferations of melanocytes at the basal layer
of epidermis
• Diagnostic c/f- 3 of below
• variegated pigmentation
• ill-defined borders;
• undulating irregular surfaces
• measure >5 mm.
• types : sporadic or familial (familial atypical multiple mole-
melanoma (FAMMM) syndrome).
• Melanoma risk in dysplastic naevus
• Sporadic : 6 times greater
• fammm syndrome: 10% risk

26. Basal cell carcinoma
• Malignant tumour of epithelial cells of basal epidermis and
hair follicles;
• MC men than women.
• 95% cases - 40 and 80 yrs
• 33% arise in parts of body not sunexposed
• .Nodular and nodulocystic - 90% of BCC

27. Localized variety
1. nodular;
2. nodulocystic;
3. cystic;
4. pigmented and
5. naevoid
generalised
• superficial: 1.multifocal & 2.superficialspreading
• infiltrative: 1.morphoeic,2. ice pick and 3. cicatrizing
collagenase
Basal cell carcinoma

28. high-risk’
• large (>2 cm);
• near the eye, nose and ear
• Recurrent tumours
• presence of immunosuppression
• micronodular or infiltrating subtypes
Basal cell carcinoma

29. two-stage surgical approach OR
Mohs’ micrographic surgery IF
• margins are ill-defined, or
• tissue at a premium (nose, eyes)
• excision margin between 2 and15 mm, depending on
the macroscopic variant.

30. radiotherapy
• elderly or infirm patients,
• similar recurrence rates to surgery
• risk of generating further malignancy after 1–2 decades.
5-fluorouracil, imquimod
• Biopsy-proven,
• superficial tumours

31. SCC associated with
• chronic inflammation (SCC IN scar -Marjolin’s ulcer.)
• immunosuppression.
• IR
• chemical carcinogens (arsenicals, tar)
• HPV 5 and 16
• current and previous tobacco use

32. SCC is a continuum of lesion of
• actinic (solar) Keratosis (AK), i.e. cutaneous horns
• keratoacanthomas,

33. AKs
• permananent sun damage
• MICRO :dyskeratosis / partial-thickness, cellular atypia, /
subepidermal inflammation / intact basement membrane
• c/f : ‘wax and wane’ AS macular and papular lesion
•
• Can improve after moisturisation
• upto 20% form SCC.
• keratin horn: AK with a height greater than base diameter-
/ 10% has underlying SCC

34. Keratoacanthomas
• self-healing SCCs
• twice as common in men 50–70
• MC face or limbs
• Othe factors : HPV in a hair follicle /smoking
/chemical carcinogen.
• Treatment :Excision not observation

35. Bowen’s disease
• SCC in situ or dysplasia in hypertrophic AKs
• MC -mucocutaneous surface of the body.
• erythroplasia of Queyrat- glans penis bowens disease
• treatment :
• Topical therapy with 5-fluorouracil or imiquimod
• surgical excision with a 4 mm margin,
• Mohs’ micrographic surgery for larger or recurrent
lesions

36. Better Prognosis :
• Depth <2 mm, no metastasis
worse prognosis
• >6 mm, 15% -have metastasised.
• Surface size: lesions >2 cm
• higher the Broder’s grade
• Microscopic invasion of lympho-vascular spaces or nerve
• Scc on lips and ears have higher local recurrence
• Extremities tumors fare worse than those on the trunk.

37. Treatment :
• Surgical excision
• margins for primary excision
• 4 mm clearance for tumor <2 cm across,
• 1-cm clearance margin if >2 cm.
• 95% of local recurrence and regional metastases occur within
5 years

38. Cutaneous malignant melanoma
• 75% - skin malignancy-related deaths.
• MC cancer in young adults (20–39 years)
• 5% of MM second primary melanoma. Develops
• 7% of MM presents as occult metastasis from an unknown
primary

39. People at most risk of developing MM
• genetic syndromes
• past history of MM
• first-degree relatives who have MM;
• more than 30 sun-acquired naevi
• history of five significant sun-burns before the age of 16
• fair-skinned/ red-haired people living close to the equator
• excessive UVR exposure
• anyone with immunosuppression

40. Transformation of nevi to melanoma
• 10–20% of MM form in pre-existing naevi,
• MC naevi to form MM are
atypical naevi,
atypical junctional lenitiginous naevi (usually facial)
giant pigmented congenital naevi.

41. Superficial spreading melanoma (SSM)
• MC (70%)
• usually arising in a pre-existent naevus
• Nodularity within SSM MEANS onset of the vertical growth phase.

42. Nodular melanoma (NM)
• 15% of all MM
• 5% amelanotic.
• more aggressive than SSM,
• MC arise de novo
• MC men
• MC trunk, head or neck
• MC blue/black papules, 1–2 cm in diameter, sharply
demarcated.{lack horizontal growth phase},

43. Lentigo maligna melanoma LMM
• 5% and 10% of MM
• slow-growing,
• MC variegated brown macule
• MC face, neck or hands of the elderly
• MCwomen .
• have less metastatic potential ( long time for
verticalgrowth )

44. Acral lentigious melanoma
• (2–8% of MM)
• MC soles of feet and palms of hands.
• rare in white-skinned individuals
• MC Afro-Caribbean, Hispanic and Asian population
(35–60%).
• MC flat, irregular macule
• 25% are amelanotic

45. Amelanotic melanoma
• Flesh -coloured,
• C/F : mets from unknown skin primary; or
gastrointestinal tract, with obstruction or
intussusception.
Desmoplastic melanoma
• MC head and neck region.
• propensity for perineural infiltration
• amelanotic clinically

46. Management :
excision biopsy
with 2–3 mm margin of skin& a cuff of subdermal fat
Sugical Margins for melanoma wide local excision
• in situ melanoma- 5 mm margin
• melanoma <1 mm deep- 1 cm margin
• deeper lesions- 2 cm only margin
Incision biopsy
large lesions on the face where an excision biopsy of the
whole lesion would be disfiguring

47. ADJUVANT THERAPY
FOR UNRESECTABLE AND METASTATIC MM.
dabrafenib or vemurafenib,
block B-RAF action
Trametinib
different action on the MAPK ( mitogen activated
protein kinase )
ipilimumab or nivolimumab
immune checkpoint inhibitors

48. q
True about epidermis is
• 85% of the skin
• keratinised,non stratified squamous epithelium;
• Keratinocytes grow and are replaced by mitoses in stratum
granulosum
• granulosum and spinosum are Thin in glabrous skin

49. A
• True about epidermis is
• 85% of the skin
• keratinised,non stratified squamous epithelium;
• Keratinocytes grow and are replaced by mitoses in
stratum granulosum
• granulosum and spinosum are Thin in glabrous
skin

50. Q
• True about Melanocytes are
• dendritic cells / neural crest origin,
• located in spinosum epidermis.
• Melanin - transferred by diapedisis
• melanin, is transferred to keratinocytes in the
strata granulosum and spinosum.

51. A
• True about Melanocytes are
• dendritic cells / neural crest origin,
• located in spinosum epidermis.
• Melanin - transferred by diapedisis
• melanin, is transferred to keratinocytes in the strata granulosum
and spinosum.

52. Q
• ECCRINE GLANDS ARE
• SEBACEOUS GLANDS
• distributed throughout the entire body surface,
• Maximum glands are in lips.
• secrete sweat in response to puberty hormones

53. a
• ECCRINE GLANDS ARE
• SEBACEOUS GLANDS
• distributed throughout the entire body surface
• Maximum glands are in lips.
• secrete sweat in response to puberty hormones

54. Q
FALSE STATEMENT IS
• Angiosomes are connected by choke vessels
• Choke vessels are mainly in subdermal plexus
• Oscillating veins are unvalved
• Epidermis nourishes by simple diffusion

55. FALSE STATEMENT IS
• Angiosomes are connected by choke vessels
• Choke vessels are mainly in subdermal plexus
• Oscillating veins are unvalved
• Epidermis nourishes by simple diffusion

56. q
Following are due to abnormality in chromosome 9 except
• Gardeners syndrome
• Ferguson-Smith syndrome
• Xeroderma pigmentosum
• Gorlin’s syndrome

57. a
Following are due to abnormality in chromosome 9 except
• Gardeners syndrome
• Ferguson-Smith syndrome
• Xeroderma pigmentosum
• Gorlin’s syndrome

58. q
• Treatment of hyperhydrosis are all except
• -antiperspirants
• -local injections with botulinum toxin A.
• - laparoscopic cervical sympathectomy.
• Anticholinergic drugs

59. A
• Treatment of hyperhydrosis are all except
• -antiperspirants
• -local injections with botulinum toxin A.
• - laparoscopic cervical sympathectomy.
• Anticholinergic drugs

60. q
All are true about lipodystrophy except
• It’s a complication administration of insulin,
• It’s a complication of hiv
• Seen in transplant recipients.
• treated by by autologous fat grafting,
• treated by injections of poly-L-lactic acid
• treated by free tissue transfer.

61. A
All are true about lipodystrophy except
• It’s a complication administration of insulin,
• It’s a complication of hiv
• Seen in transplant recipients.
• treated by by autologous fat grafting,
• treated by injections of poly-L-lactic acid
• treated by free tissue transfer.

62. Q
IN HIDRADENITIS SUPPURATIVA (HS) true is
• four women for every man affected
• Eccrine glandsaffected
• Never happens in scalp, breast, chest and perineum
• No genetic predisposition with variable penetrance,
• Not associated with obesity and smoking.
• Treatment with non-compressive and aerated
underwear.
• require radical excision & Reconstruction

63. A
IN HIDRADENITIS SUPPURATIVA (HS) true is
• four women for every man affected
• Eccrine glands affected
• Never happens in scalp, breast, chest and perineum
• No genetic predisposition with variable penetrance
• Not associated with obesity and smoking.
• Treatment with non-compressive and aerated underwear.
• require radical excision & Reconstruction

64. Q
ALL EXCEPT ONE HIGHLY ASSOCIATED TO CAUSE PYODERMA
GANGRENOSUM (PG)
• IBD
• RA
• non-Hodgkin’s lymphoma
• Wegener’s granulomatosis
• SLE

65. A
ALL EXCEPT ONE HIGHLY ASSOCIATED TO CAUSE PYODERMA
GANGRENOSUM (PG)
• IBD
• RA
• non-Hodgkin’s lymphoma
• Wegener’s granulomatosis
• SLE

66. q
FALSE ABOUT Necrotising fasciitis IS
• It’s a polymicrobial infection
• MC streptococcal species (Group A β-haemolytic)
• Lymphangitis present
• Xray air in sc tissues
• early skin grafting treatment of choice

67. a
FALSE ABOUT Necrotising fasciitis IS
• It’s a polymicrobial infection
• MC streptococcal species (Group A β-haemolytic)
• Lymphangitis present
• Xray air in sc tissues
• early skin grafting treatment of choice

68. Q
False statement are
• Milia are hard, keratin retention cysts &mc babies
• sebaceous cysts lined with true, stratified-squamous
epithelium, from external root sheath of hair follicle
• Meibomian cysts - epidermal cysts on edge of the
eyelid
• Tricholemmal cysts- from epidermis of hair follicle
infundibuli

69. A
False statement are
• Milia are hard, keratin retention cysts &mc babies
• sebaceous cysts lined with true, stratified-squamous
epithelium, from external root sheath of hair follicle
• Meibomian cysts - epidermal cysts on edge of the
eyelid
• Tricholemmal cysts- from epidermis of hair follicle
infundibuli

70. Q
False statement in this is
• Papillary wart (verruca vulgaris)- HPV associated
• Basal cell papilloma (seborrhoeic keratosis)- contain
melanocytes
• Freckle (ephelis)- normal number of melanocytes,/large
number of melanin granules
• Intradermal naevus -cluster of dermal melanocytes
• compound nevus -Subcutaneous proliferation of naevus
cells, with dermis projection

71. A
False statement in this is
• Papillary wart (verruca vulgaris)- HPV associated
• Basal cell papilloma (seborrhoeic keratosis)- contain
melanocytes
• Freckle (ephelis)- normal number of melanocytes,/large
number of melanin granules
• Intradermal naevus -cluster of dermal melanocytes
• compound nevus -Subcutaneous proliferation of naevus
cells, with dermis projection

72. q
• True statement are
• naevus of Ota MC shoulder
• naevus of Ito is hamartoma
• Naevus of ito cant occur simultaneously with naevus of Ota
• naevus of Ota mc site face trigeminal V1 and V2 dermatomes.

73. a
• True statement are
• naevus of Ota MC shoulder
• naevus of Ito is hamartoma
• Naevus of ito cant occur simultaneously with naevus of Ota
• naevus of Ota mc site face trigeminal V1 and V2
dermatomes.

74. Q
• False statement among premalignant conditions
• Adenoca exists insitu in exramammary pagets
disease
• Dysplastic nevi is only sporadic
• Giant hairy navi 99 % after 45 years have
melanoma
• Famm is associated with dysplastic nevi

75. A
• False statement among premalignant conditions
• Adenoca exists insitu in exramammary pagets disease
• Dysplastic nevi is only sporadic
• Giant hairy navi 99 % after 45 years have melanoma
• Famm is associated with dysplastic nevi

76. q
• Treatment of bcc are all except
• 5-fluorouracil,
• imquimod
• radiotherapy
• Mohs’ micrographic surgery
• Surgery with margin b/w 10 and15 mm always

77. A
• Treatment of bcc are all except
• 5-fluorouracil,
• imquimod
• radiotherapy
• Mohs’ micrographic surgery
• Surgery with margin b/w 10 and15 mm always

78. Q
• FOLLOWING STATEMENTS ARE WRONG ABOUT SCC
• expresses cytokeratins 1 and 10.
• HPV 5 and 16 can cause them
• Keratoacanthomas is a self healing scc
• In keratin horn 10% has underlying SCC
• Bowen’s disease treated with 4 mm marginexcision
• >6 mm depth invasion -50 % -have metastasised.

79. a
• FOLLOWING STATEMENTS ARE WRONG ABOUT SCC
• expresses cytokeratins 1 and 10.
• HPV 5 and 16 can cause them
• Keratoacanthomas is a self healing scc
• In keratin horn 10% has underlying SCC
• Bowen’s disease treated with 4 mm marginexcision
• >6 mm depth invasion -50 % -have metastasised.

80. q
• True statements about cutaneous malignant melanoma
are
• 10%- skin malignancy-related deaths.
• MC cancer in young adults (20–39 years)
• 50%of MM second primary melanoma
• 70% of MM presents as occult metastasis from an
unknown primary

81. a
• True statements about cutaneous malignant melanoma are
• 10%- skin malignancy-related deaths.
• MC cancer in young adults (20–39 years)
• 50%of MM second primary melanoma
• 70% of MM presents as occult metastasis from an unknown primary

82. q
• Propensity for perineural infiltration is for
• Desmoplastic melanoma
• Amelanotic melanoma
• Nodular melanoma (NM)
• Acral lentigious melanoma

83. a
• Propensity for perineural infiltration is for
• Desmoplastic melanoma
• Amelanotic melanoma
• Nodular melanoma (NM)
• Acral lentigious melanoma