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===Motivation===
===Motivation===
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#The skin is the biggest, thus most important organ  
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1.  The skin is the biggest, thus most important organ  
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#Skin diseases account for 17% of all primary care visits  
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2.  Skin diseases account for 17% of all primary care visits  
===Objectives===
===Objectives===
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===Expectations===
===Expectations===
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*Structure and function of the skin
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*Structure and function of the skin  
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*History and physical examination (learn the vocab)
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*History and physical examination  
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*Recognize the clinical (and histologic) hallmarks of diseases discussed
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*Recognize the clinical (and histologic) hallmarks of diseases discussed  
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*Know how and when to refer a patient
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*Know how and when to refer a patient
===Structure and Function===
===Structure and Function===
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*Three parts: epidermis, dermis, and subcutaneous.
 
*Epidermis:
*Epidermis:
**Has keratinocytes, melanocytes, and langerhans cells
**Has keratinocytes, melanocytes, and langerhans cells
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====Keratinocytes====
====Keratinocytes====
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*Makes up most of the epidermis.
 
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*Keeps in what should be in and out what should be out
 
*Barrier Function: form the stratum corneum
*Barrier Function: form the stratum corneum
*Produce cytokines and inflammatory molecules
*Produce cytokines and inflammatory molecules
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*Produce antimicrobial proteins and lipids; more potent than anything we can prescribe
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*Produce antimicrobial proteins and lipids
*Metabolize drugs
*Metabolize drugs
*Arm skin: http://www.lab.anhb.uwa.edu.au/mb140/corepages/integumentary/Images/skthick0021he.jpg
*Arm skin: http://www.lab.anhb.uwa.edu.au/mb140/corepages/integumentary/Images/skthick0021he.jpg
*Finger skin: http://www.udel.edu/biology/Wags/histopage/colorpage/cin/cinsgdi.GIF
*Finger skin: http://www.udel.edu/biology/Wags/histopage/colorpage/cin/cinsgdi.GIF
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**Has different keratins than has the arm
 
====Melanocytes====
====Melanocytes====
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*Melanocytes determine how much melanin and therefore the pigmentation of the pt
 
*Produce pigment
*Produce pigment
*Pigment protects against ultraviolet radiation
*Pigment protects against ultraviolet radiation
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*Macrophage-like cells in epidermis  
*Macrophage-like cells in epidermis  
*Important for antigen recognition
*Important for antigen recognition
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*About 1/3 of all T cells have been educated in the skin
 
*http://www.technion.ac.il/~mdcourse/274203/slides/Skin/6-Langerhans%20Cells.jpg
*http://www.technion.ac.il/~mdcourse/274203/slides/Skin/6-Langerhans%20Cells.jpg
*http://faculty.une.edu/com/abell/histo/thickskin1w.jpg
*http://faculty.une.edu/com/abell/histo/thickskin1w.jpg
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*Found in the dermis
*Found in the dermis
*Produce collagen and ground substance
*Produce collagen and ground substance
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*Keloid scar is an example of excessive fibroblast activity
 
*http://ouhsc.edu/histology/Glass%20slides/43_06.jpg
*http://ouhsc.edu/histology/Glass%20slides/43_06.jpg
*http://www.nature.com/nrc/journal/v6/n5/images/nrc1877-f1.jpg
*http://www.nature.com/nrc/journal/v6/n5/images/nrc1877-f1.jpg
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====Primary lesions====
====Primary lesions====
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*Basic lesions that defines a disease process
 
=====Macule / Patch=====
=====Macule / Patch=====
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*Macule: Circumcised, flat ('''non-palpable'''), discolored (hence you can see it)
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*Circumcised, flat ('''non-palpable'''), varies in color
**Discoloration: brown, blue, red, hypopigmented
**Discoloration: brown, blue, red, hypopigmented
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**A tattoo is an artificial papule
 
*Large macules (~> 2cm) are called "patches"
*Large macules (~> 2cm) are called "patches"
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**Port-wine stain is an example of a macule
 
*http://www.websters-dictionary-online.net/images/wiki/wikipedia/commons/thumb/c/c3/Macule.svg/300px-Macule.svg.png
*http://www.websters-dictionary-online.net/images/wiki/wikipedia/commons/thumb/c/c3/Macule.svg/300px-Macule.svg.png
*http://courses.washington.edu/hubio567/lang/odlnd038.gif
*http://courses.washington.edu/hubio567/lang/odlnd038.gif
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=====Papule / Plaque=====
=====Papule / Plaque=====
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*'''Elevated''', solid, 0.5-1 cm diameter
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*Elevated, solid, 0.5-1 cm diameter
*Larger is a plaque
*Larger is a plaque
*Confluent papules are called "plaques"
*Confluent papules are called "plaques"
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=====Wheal=====
=====Wheal=====
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*Firm, edematous plaque resulting because of infiltration of the dermis with fluid
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*Firm, edematous plaque
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**Example is urticaria (hives) or a TB test
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*From infiltration of the dermis with fluid
*Wheals are transient, may only last hours
*Wheals are transient, may only last hours
*http://www.skincareguide.ca/images/glossary/wheal.jpg
*http://www.skincareguide.ca/images/glossary/wheal.jpg
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=====Vesicle / Bulla=====
=====Vesicle / Bulla=====
*Circumscribed collection of free fluid up to 0.5 cm diameter
*Circumscribed collection of free fluid up to 0.5 cm diameter
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**In contrast to a pustule, contents are clear
 
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**Varicella zoster makes vesicles
 
*Bulla is over 0.5 cm diamter
*Bulla is over 0.5 cm diamter
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**Look differently depending on where the fluid resides: under the stratum corneum or under the whole epidermis
 
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====Secondary Lesions====
====Secondary Lesions====
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*Lesions that evolve from pt interaction with a disease process: scratching, picking, et cetera
 
=====Scales=====
=====Scales=====
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*http://www.steadyhealth.com/2996/Image/copy-of-psoriasis.jpg
*http://www.steadyhealth.com/2996/Image/copy-of-psoriasis.jpg
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=====Crusts (scab) / Erosions=====
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=====Crusts / Erosions=====
*Crust: collection of dried serum and cellular debris (a scab)
*Crust: collection of dried serum and cellular debris (a scab)
**http://www.dermweb.com/morphology/graphics/morph061.jpg
**http://www.dermweb.com/morphology/graphics/morph061.jpg
**http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=wolf6_c011f019t.jpg
**http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=wolf6_c011f019t.jpg
-
 
-
 
*Erosion: focal loss of epidermis
*Erosion: focal loss of epidermis
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**Any scratch that doesn't scar
 
**Do not penetrate below the dermal-epidermal junction and thus do not scar
**Do not penetrate below the dermal-epidermal junction and thus do not scar
**http://www.accessmedicine.ca/loadBinary.aspx?name=wolf7&filename=wolf7_c004f010t.jpg
**http://www.accessmedicine.ca/loadBinary.aspx?name=wolf7&filename=wolf7_c004f010t.jpg
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=====Ulcers=====
=====Ulcers=====
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*A focal loss of epidermis '''and dermis'''
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*A focal loss of epidermis AND DERMIS
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*Ulcers heal with scarring
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*Ulcers heal with scarring.
*http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Skin_Ulcer-2.jpg
*http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Skin_Ulcer-2.jpg
*http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Skin_Ulcer-3.jpg
*http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Skin_Ulcer-3.jpg
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=====Fissure=====
=====Fissure=====
*Linear loss of epidermis and dermis with sharply defined, vertical walls
*Linear loss of epidermis and dermis with sharply defined, vertical walls
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**Chapped lips, for example
 
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**Think of corners of mouth
 
*http://www.infoderm.com/infoderm/images/las/lesions/Fissure.jpg
*http://www.infoderm.com/infoderm/images/las/lesions/Fissure.jpg
*http://faculty.washington.edu/alexbert/MEDEX/Derm/fisure.gif
*http://faculty.washington.edu/alexbert/MEDEX/Derm/fisure.gif
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=====Atrophy=====
=====Atrophy=====
*Depression in the skin from thinning of the epidermis or dermis
*Depression in the skin from thinning of the epidermis or dermis
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**feels like cigarette paper
 
-
**morvea: localized scleroderma
 
*http://mizzouderm.com/uploads/4/4/2/3/4423869/4212698_orig.jpg?214
*http://mizzouderm.com/uploads/4/4/2/3/4423869/4212698_orig.jpg?214
*http://dermimages.med.jhmi.edu/images/Steroid_Atrophy_1_030303.jpg
*http://dermimages.med.jhmi.edu/images/Steroid_Atrophy_1_030303.jpg
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=====Scar=====
=====Scar=====
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*Abnormal form of connective tissue '''implying dermal damage'''.
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*Abnormal form of connective tissue implying dermal damage.
*After an injury scars are initially thick and pink and become white and atrophic with time.
*After an injury scars are initially thick and pink and become white and atrophic with time.
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*To scar, one must get to the dermal papillary level, to the erector pili muscle.
 
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*One year until the scar looks like it's final product
 
*http://www.smartex-balkan.com/wp-content/uploads/2010/09/Keloid-Scar.png
*http://www.smartex-balkan.com/wp-content/uploads/2010/09/Keloid-Scar.png
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=====Comedone=====
=====Comedone=====
*Plug of subaceous and keratinaceous debris lodged in the opening of an hair follicle.
*Plug of subaceous and keratinaceous debris lodged in the opening of an hair follicle.
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**The follicle opening may be '''widened (blackhead)''' or '''narrowed (whitehead)'''.
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*The follicle opening may be widened (blackhead) or narrowed (whitehead).
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**A type of acne.
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*http://acner.org/img/care_and_prevention/blackheads-on-the-neck_3_3552.jpg
*http://acner.org/img/care_and_prevention/blackheads-on-the-neck_3_3552.jpg
*http://www.dartmouth.edu/~thabif/weeklyClinic110600/20GiantComedone.jpg
*http://www.dartmouth.edu/~thabif/weeklyClinic110600/20GiantComedone.jpg
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=====Lichenifcation=====
=====Lichenifcation=====
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*Area of thickened epidermis induced by scratching.
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*Area of thickened epidermis induced by scratching
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**These pts did it to themselves.
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*Skin lines are accentuated so that the surface looks like a washboard
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*Skin lines are accentuated so that the surface looks like a '''washboard'''
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-
*How many times do you have to scratch yourself to induce lichenification: 200k scratches / rubs to get this response!
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*http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Clinical%20Images/Lichenification-101.jpg
*http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology%20Glossary/Glossary%20Clinical%20Images/Lichenification-101.jpg
*http://www.skincareguide.ca/images/glossary/lichen_simplex_chronicus.jpg
*http://www.skincareguide.ca/images/glossary/lichen_simplex_chronicus.jpg
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=====Burrow=====
=====Burrow=====
*Narrow, elevated tortuous channel in the skin, created by a parasite
*Narrow, elevated tortuous channel in the skin, created by a parasite
-
*Scabies most common
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*Scabies
*http://i.quizlet.net/i/U7z1SI38X8HldKGXBPWjIQ_m.jpg
*http://i.quizlet.net/i/U7z1SI38X8HldKGXBPWjIQ_m.jpg
=====Milia=====
=====Milia=====
*Small cysts under the skin; have walls containing epidermis
*Small cysts under the skin; have walls containing epidermis
-
*Associated with scarring; when skin is scarring from injury, skin may form milia
+
*Associated with scarring
-
*Porphyria can occur secondary to hepatitis C; makes skin of hands fragile, thus producing milia
+
*http://dermnetnz.org/doctors/lesions/images/milia1.jpg
*http://dermnetnz.org/doctors/lesions/images/milia1.jpg
*http://www.riversideonline.com/source/images/image_popup/fl7_milia.jpg
*http://www.riversideonline.com/source/images/image_popup/fl7_milia.jpg
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=====Cyst=====
=====Cyst=====
*Circumscribed with wall and lumen; may contain solid matter or fluid
*Circumscribed with wall and lumen; may contain solid matter or fluid
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**A larger milia
 
*http://meded.ucsd.edu/clinicalimg/upper_inclusion_cyst.jpg
*http://meded.ucsd.edu/clinicalimg/upper_inclusion_cyst.jpg
*http://www.primehealthchannel.com/wp-content/uploads/2010/09/Cyst_Profile2.jpg
*http://www.primehealthchannel.com/wp-content/uploads/2010/09/Cyst_Profile2.jpg
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=====Telangiectasia=====
=====Telangiectasia=====
*Dilated superficial blood vessels
*Dilated superficial blood vessels
-
**Can indicate liver disease
+
*Also called spinder angiomas
-
*Also called spider angiomas is a form of telangiectasias with a lesion
+
*http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/cyst2.jpg
*http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/cyst2.jpg
*http://www.michmoleremoval.com/sitebuildercontent/sitebuilderpictures/telangiectasia-s.jpg
*http://www.michmoleremoval.com/sitebuildercontent/sitebuilderpictures/telangiectasia-s.jpg
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**http://dermnetnz.org/site-age-specific/img/purpura-s.jpg
**http://dermnetnz.org/site-age-specific/img/purpura-s.jpg
**http://www.skinsite.com/images/batemans%20purpura.gif
**http://www.skinsite.com/images/batemans%20purpura.gif
-
 
-
===Examples===
 
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*Vitiligo: white macule at the nasal bridge, right edge of the nose, and inferior medial border of the right eye
 
-
*Port-wine stain: red macule across the distributuion of trigeminal V2
 
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*Lichen planus: collection of papules forming a plaque on the right hand and wrist, linear in distribution
 
-
*Deep hemangioma: 2 cm tumor at the lateral, inferior border of the left eye, lacks ulceration, telangeictasia, or eruption
 

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