Dermatology Objectives

1.         Identify the three layers of the skin, and describe their basic structures.

Zen Seeker

Anonymous

Epidermis-most superficial layer, thin layer lacking (devoid) blood vessels.

Dermis-supplies epidermis with Nutrition, well supplied with blood.  Connective tissue, subcutaneous glands and some hair follicles.

Subcutaneous tissue-contains fat, sweat glands, remainder of hair follicles.

Brent K Swartz pg. 124- 125 and Martini.   The three layers of skin are the Epidermis, Dermis, and Subcutaneous tissue or hypodermis.

A.  The epidermis is the thin outermost layer of the skin, composed of several layers of  keratin producing cells called keratinocytes.  The epidermis is divided into five  layers:

a.  Stratum Germinatium or basale  is the deepest epidermal layer.  

This layer of actively dividing basal cells, slowly migrate into the upper epidermal layers where they keratinize, and are ultimately shed from the stratum corneum (the most superficial epidermal layer).  This process takes about 4 weeks.  Also located in the basal layer are Merkel cells, which serve as touch sensors, and melanocytes which produce melanin.  Melanin protects skin from UV radiation and is also responsible for variations of skin color.

b.  Stratum Spinosum is 8 to 10 cell layers thick and just superficial to the stratum basale.  In addition to containing keratinocytes, this layer also contains Langerhans cells.  These cells are responsible for stimulating defense against microorganisms that manage to penetrate the superficial layers of the epidermis and superficial skin cancers.

c.   Stratum Granulosum is superficial to the stratum spinosum.  This layer is noteworthy for its 3-5 layers of keratinocytes which are no longer dividing.  At this point large quantities of keratin are manufactured.  

d.  Stratum Lucidum  is found deep to the stratus corneum.  This flattened, densely packed and keratin filled layer is generally found in thick skin such as the soles of the feet and hands.  

e.  Stratum Corneum is the most superficial layer of the epidermis.  It contains many layers of dead keritinocytes completely filled with keratin, with the outermost layers constantly shedding.  This relatively dry layer makes growth difficult for microorganisms in addition to providing a water-resistant barrier.  

 B.  Just beneath the epidermis is the dermis, which is the dense connective tissue   foundation forming the bulk of the skin.  The dermis consists of branching blood vessels that form a rich capillary bed in the dermal papillae (projections that interlock with ridges in the epidermis).  In addition, this layer contains hair follicles and their associated arrector pili muscles, sweat glands, lymph vessels, and nerve fibers.    

C.       The deepest layer of skin is the hypodermis or subcutaneous tissue layer.  Composed mainly of fatty connective tissue, this adipose layer provides thermo regulation as well as protection for the more superficial skin layers from bone prominences. 

Anonymous

The three layers of the skin are the epidermis, dermis and the subcutaneous tissue.  The epidermis is the outermost, totally cellular layer of the skin.  It is composed of squamous epithelium.  In the outer layer of the skin, these cells are arranged in several layers (strata) and are therefore called stratified squamous epithelium.

The dermis layer, directly below the epidermis is composed of blood and lymph vessels and nerve fibers, as well as the accessory organs of the skin, which are the hair follicles, sweat glands, and sebaceous glands.  The dermis is composed of interwoven elastic and collagen fibers.

The subcutaneous layer of the skin is another connective tissue layer; it specializes in the formation of fat.  Lipocytes are predominant in the subcutaneous layer, and they manufacture and store large quantities of fat.

Mary

Epidermis-layers of stratified squamous epithelium that germinate in a basement membrane and are pushed upward until sloughed off by continuously dividing new cells. Martini, 144/Swartz, 124

Dermis- the middle layer of skin that consists of two layers of connective tissue. The upper, or papillary layer is areolar connective tissue and contains the nerves and capillaries necessary to supply the basement membrane with nutrients for the rapidly dividing epithelial cells. The deeper, or reticular layer is network of dense, interwoven mesh of structural proteins that houses the sweat glands and roots of the hair follicles. (Martini, 150/ Swartz, 124)

Subcutaneous layer- This layer is indistinctly divided from the reticular of the dermis. It consists of areolar and adipose connective tissue that serve to anchor, cushion, and support the skin. Martini, 152

2.         Describe the role of each of the following:

                              keratinocytes (keratocytes in Swartz- Remember keratinocytes!)

                              melanocytes

                              collagen (Dictionary)

                              elastin (Dictionary)

                              insensible perspiration (Dictionary)

Zen Seeker

Anonymous

1. Keratinocytes-a living cell in the epidermis that has not processed into a dead cell yet. Make up keratin to waterproof the skin.

2. Melanocytes-in epidermis, form and contain a black pigment melanin that is transferred to other cells giving color to the skin and absorption of ultraviolet light.

3. Collagen-found in dermis letter, toughen resistant up flexible, hardens as the body ages.  It supports and protects the blood and nerve networks.

4.  Elastin- in the dermis and is interwoven with collagen.  Serve to restore the skins original configuration after stretching.

5. Insensible perspiration-perspiration that is evaporated before it is perceived as moisture on the body.  Cools the body down.  We loose 500-600cc a day

Brent K Taber’s medical dictionary   

1. Keratinocytes are keratin producing cells that provide the skin with its protective properties.  

2. Melanocytes are located in the stratum basale and manufacture melanin.  Melanin is eventually transferred into the keratinocytes and protects the epidermis and dermis from UV radiation.  Melanin is also responsible for variances in skin color.  

3. Collagen is a fibrous insoluble protein found in connective tissue such as skin, bone, ligaments and cartilage.

4. Elastin is an extracellular connective tissue protein that is the principal component of elastic fiber.  

5. Insensible perspiration is water from interstitial fluids that slowly penetrates the surface of the stratum corneum and evaporates into the surrounding air (about 500ml qd).

Anonymous

a. Keratinocytes-Most epidermal cells are keratinocytes.  Its role is to produce keratin, a fibrous protein that helps give the epidermis its protective properties. Waterproof the skin. Pp. 149, Marieb.
b. Melanocytes-in epidermis, form and contain a black pigment melanin that is transferred to other cells giving color to the skin and absorption of ultraviolet light. Also see pp150 of Marieb
c. Collagen-found in dermis letter, toughen resistant up flexible, hardens as the body ages. It supports and protects the blood and nerve networks. Collagen molecules are secreted into the extracellular space, where they are assembled into cross-linked fibers. Marieb 126
d. Elastin- in the dermis and is interwoven with collagen. Serve to restore the skins original configuration after stretching. A rubberlike protein that allows them to stretch and recoil. Marieb 126
e. Insensible perspiration-perspiration that is evaporated before it is perceived as moisture on the body. Cools the body down. We loose 500-600cc a day. Basal level of body heat loss due to the continuous evaporation of water from the lungs, mucosa of mouth, and through the skin. Marieb 993-994

Mary

Keratinocytes- proliferating epidermal cells which produce keratin and resemble the melanocytes of the basal membrane. Swartz, 168/Pathology, 508

Melanocytes- pigment producing cells of the basal membrane in the epidermis. Path, 508

Collagen- insoluble protein found in connective tissue of the dermis. Taber’s

Elastin- connective tissue protein that is the main component of the middle layer of the arteries. It has the ability to stretch and then return to its former shape. Martini, 120

Insensible perspiration- process by which water from interstitial space evaporates through the stratum corneum. Martini, 147

3.         Describe the protective, barrier, and heat regulatory functions of the skin.

(The Electronic Textbook of Dermatology)

Anonymous

Protection: Stratum corneum is dry low pH, which is inhospitable to pathogenic microorganisms.

-melanocytes act as a trap to soak up UV radiation.

-stratum corneum is resistant to many corrosive chemicals.

Barrier: stratum corneum prevents water loss

-also acts to absorb water (prune effect)

Heat Regulation: through blood vessels; vessels dilate to send blood to the skin for radiant heat loss or constriction when needed for heat conservation.

     -through sweating eccrine sweat glands is what allow us to adapt in wide ranges of climates. Capable of delivering large amounts of water to the skin in time of heat to cool the skin.

Brent K The Electronic Textbook of Dermatology. The skin has 3 types of protective barriers:  chemical, physical, and biological.  

a.      Chemical barriers include skin secretions and melanin.  Despite bacteria covering the skin’s surface, the low pH (acid mantle) of its secretions retard bacterial multiplication.  Additionally bacteria can be killed outright by bactericidal substances in sebum and by the secretion of a natural antibiotic called human defensin.

b.     Physical barriers are provided by continuity of skin and the hardness of its keratinized cells.  The water-resistance of the epidermis blocks the diffusion of water and water-soluble substances, both, exiting and entering.  This doesn’t apply to lipid and fat soluble substances, oleoresins (oils found in poison ivy and oak), organic solvents, salts of heavy metals (lead, nickel, and mercury), and certain drug agents.

c.      Biological barriers include Langerhan’s cells of the epidermis and macrophages in the dermis.  Macrophages dispose of viruses and bacteria that have managed to penetrate the epidermis.

Temperature regulation is controlled by the anterior hypothalamus.  As long as the external temperature is lower than body temperature, the skin surface will continue to lose heat.  Providing the environmental temperature is below 88-90 degrees F., sweat glands continuously secrete unnoticeable amounts of sweat.  When body temperature rises, the dermal blood vessels dilate and the sweat glands are stimulated into vigorous secretory activity.  In a cold environment vessels constrict causing warm blood to bypass the skin in order to conserve body heat.  Exposure to extreme cold reduces the rate of blood flow to very low values, so that nutritive function may sometimes suffer.  Conversely, heating the skin until maximal vasodilatation occurs, increases the cutaneous blood flow 7 times the normal value.  This diminishes the peripheral resistance and increases the cardiac output, which may lead to the decompensation of the heart in borderline-heart-failure subjects exposed to hot weather. 

Anonymous

           First, as a protective membrane over the entire body, the skin guards the deeper tissues of the body against excessive loss of water, salts, and heat and against invasion of pathogens and their toxins.

           Second, the skin contains two types of glands that produce important secretions. These glands under the skin are the sebaceous (produce oily secretion) and the sweat glands (produce watery secretion).

            Third, nerve fibers located under the skin act as receptors for sensations such as pain, temperature, pressure, and touch.

            Fourth, several different tissues in the skin aid in maintaining thermoregulation. Nerve fibers by carrying messages to and from the heat centers in the brain, and then impulses causing vasodilatation, and sweat glands assisting in heat elimination by evaporation.

Mary Martini, 157

The skin, when unbroken, provides a slightly acidic barrier that is microbial resistant, and serves to cover and cushion the underlying organs. The skin is also instrumental in the thermoregulatory process of the body by housing the sweat glands which release water to the skin as a coolant: sensible perspiration.

4.         Describe the significance of each of the following in a dermatologic history:

                              a.   details of onset

                              b.   evolution of symptoms

                              c.   previous diagnosis and treatment

                              d.   PMH of skin disease

                              e.   PMH of allergies

                              f.    PMH of chronic disease

                              g.   environmental/occupational history

                              h.   family history of skin disease (distinguish between inherited and acquired disease in the family)

                              i.    medications

                              j.    other medical problems

                              k.   sexual history

Anonymous

a.        details of onset: Make every effort to obtain information in detail regarding the onset (appearance of initial lesions, location, potential, environment exposures.

b.       Evolution o symptoms: What has been the course of evolution?

1.                    specific lesions and or symptoms

2.                    the skin problem in general (spreading, healing, occurring in different places.

c.        previous diagnosis and treatment: PMH of this condition, any treatment used so far?

1.                    past evaluations, dx, or procedures

2.                    what tx has been used if any? How effective was it?

d.       PMH of skin disease?  (ex, eczema, psoriasis ect)

e.        PMH of allergies?

1.                    Systemic (anaphylaxis)

2.                    Localized reaction (rash)

f.         PMH of chronic disease? (diabetes, asthma)

g.       Environmental/ occupational history (work, hobbies, household)

h.       Family history of skin diseases (distinguish between inherited and acquired disease in the family

1.                    Inherited: any FH of skin disease

Any FH of allergies

2.                    Acquired: Does anyone else in the household have any of the same symptoms?

i.         Medications: Current of recent medicines for any other problems?

j.         Other medical problems: Other “active” problems for the pt are under the care of a practitioner.

k.        Sexual history: That pertains

 Brent K Swartz 127 (vague info)

1. Details of onset are helpful in diagnosing types of skin disorders.  Certain disorders occur within certain age groups or during different seasons.  

b.     Evolution of symptoms help to determine whether the lesion is primary or secondary.

c.      Previous diagnosis and treatment are helpful for further treatments. By determining if previous treatments were successful or otherwise, helps to streamline treatment and diagnosis

d.     Past medical history of skin diseases is significant in that many disorders have no cure.  It helps to determine if lesion is new or the return of the previous chronic skin disorder.  What was the previous treatment?  Did it help?

e.      The significance of PMH of allergies is that many disorders can be attributed to the immune response such as contact dermatitis.  Knowing  a pt’s allergies may be helpful in narrowing diagnosis.  

f.       The PMH of chronic diseases is important because many diseases cause skin disorders.  A few examples include Lindsay’s nails, secondary to chronic renal failure, spider angiomas found more commonly in pregnant women, pt’s with liver disease or vitamin B deficiencies, and Kaposi’s Sarcoma most frequently occurring in AIDS pt’s.

g.      Environmental and occupational history is important in determining whether a skin disorder can be attributed to chemical exposure or similar agents.  This info is important regardless of how long the pt. has been exposed to the same chemicals.  Manufactures often change constituents.  Also, it can take years for a person to become sensitized to a substance.

h.      Family history is useful in the prevention and diagnosis of skin disorders.  Many skin disorders are inherited.  Making the provider aware of acquired diseases in the family such as malignant melanomas, raises a flag to the provider and pt. to be vigilant in the detection of early lesions.  In addition, it gives the opportunity for pt. education on prevention.  

i.        Fitzpatrick, Johnson, Wolff p546. Medication history is important due to the frequency of adverse drug reactions.  Complications of drug therapy are the most common adverse event for hospitalized individuals.  Reactions in ambulatory settings are also common.  

j.       Any other medical problems gives the practitioner helpful clues to possible etiologies of a skin disorder.

Sexual history is significant for determining pt. risk factors of STD’s.  A pt. that has multiple partners and/or practices unsafe sex is more at risk for disorders of the genitalia.  Sexual history allows the practitioner a direction to focus for diagnosis.

Anonymous

Describe the significance of each of the following in a dermatologic history:

- family history of skin disease (distinguish between inherited and acquired disease in the family)

Inherited: -any FH of skin disease (psoriasis, eczema, etc)

-any FH of allergies (atopic diseases: asthma, eczema, hay fever.

Acquired (contagious)

-"Does anyone else in the household (or playmates, or sexual partners) have similar symptoms?" (e.g. scabies, ringworm, impetigo)

- medications

The patient could be allergic to the medication

- other medical problems

Other Ôactive" problems for which patient is seeing another practitioner.  There might be some drug interactions that a patient might be allergic to

- sexual history-contact dermatitis, scabies, etc

Anonymous

a.        Details of onset.

To help diagnose, it is important to find out, in detail, the onset of the lesion. It is also important to find out the location of the lesion and potential environmental factors which may have contributed or caused the lesion.

b.       Evolution of symptoms.

It is important to get details of the current symptoms to help in diagnosis. For example: Is the lesion itching, burning, scaling, crusting, blistering, weeping? Ect…

c.        Previous Diagnosis and treatment:

It is important to find out 1) past evaluations, diagnosis, or procedures for this problem. 2) What treatment has been used if any,  and how effective was it?  This will help establish if it is a reoccurring problem, or something new.   

d.       PMH of skin disease:

Establish any PMH of skin disease, such as eczema, psoriasis, dermatitis, acne, ect… The current problem could be related to, or a result of any PMH of skin disease.  

e.        PMH of allergies:

Establish allergies and type of reaction, is it systematic (anaphylaxis, drug rash, skin eruption) or localized reaction (contact dermatitis). PMH of allergies could be a cause of the current skin condition.   

f.         PMH of chronic disease:

A PMH of chronic disease is also important to help in diagnosis. Inquire about diabetes, asthma, hayfever, ect… The current skin problem could be a symptom of a PMH of chronic disease.

Dawn

a.        details of onset:  rashes or lesions can change over time so need to know what it was originally.  Also time of onset can give clues to what the rash or lesion may be.    

b.       evolution of symptoms:  gives a pattern or further clues to make a diagnosis

c.        previous diagnosis and treatment:  trying to find out if anything worked or if the skin problem was exacerbated

d.       PMH of skin disease:  higher risk for malignancies.  Information provided may help in diagnosis/treatment.  

e.        PMH of allergies:  higher risk for dermatologic symptoms and may assist in diagnosis/treatment

f.         PMH of chronic disease:  dermatologic symptoms can be manifested from chronic illnesses.  Information provided may assist in diagnosis/treatment.

g.       Environmental/occupational history:  for chemical exposure or other similar agents.  Manufacturers frequently change the basic constituents without notifying the consumer.  It may also take years for a patient to become sensitized to a substance.  

h.       Family history of skin disease (distinguish between inherited and acquired disease in the family):  Inherited:  important for knowing if an individual is predisposed to developing certain skin disorders.  Acquired:  need to know if their skin disorder is from their environment or from a somatic mutation (a sudden change in the chromosomal material in somatic cell nuclei affecting derived cells but not offspring – Moby’s medical dictionary)

i.         Medications:  patients can suddenly develop a reaction to medications even if they have been taking the medication for years.  Also, did they use any medications that may have changed the nature of the skin disorder?  

j.         Other medical problems:  skin disorders can be manifested by acute or chronic diseases.  

k.        Sexual history:  STD’s can have associated skin disorders.  

p. 127-128 Swartz (Most of this information relates to general history taking. Even though it is the skin, you still have the same reasons for asking these questions.)

5.         Describe the physical exam of a patient with a dermatologic problem.

Anonymous

A.      Temperature

B.       General inspection of the skin

1.        Color

2.        Skin temp

3.        Moisture

4.        Texture and thickness

5.        Turgor and mobility

6.        Lesion unrelated to the present complaint

C.       Inspection of specific lesion

1.        Color

2.        Number of lesions

3.        Location and distribution of lesion BE SPACIFIC!

4.        Grouping and configuration of lesions

5.        Size of lesion in mms. or cms.

6.        Shape and borders

7.        Surface

8.        Consistency

9.        Tenderness

10.     Mobility

11.     Special characteristics  

Brent K Swartz 129. Examination of the skin should be done in a well lighted room with inspection and palpation of all skin surfaces.  Palpation with gloved hands of lesions also must be performed.  Palpation helps define the lesions characteristics: texture, consistency, fluid, edema in the adjacent area, tenderness, and blanching.  While evaluating the skin, take note of the color, moisture, turgor, and texture.  

      *While pt. is sitting up:  

     -inspect the hair and scalp, look for lesions, distribution and texture of hair.  

           Nail bed changes are usually indicative for a specific disease.  

-inspect nails for shape, size, color, brittleness, hemorrhages under the nail, transverse lines or grooves in the nail or nail bed, and an increased white area on the nail bed.  

       *Inspection of face and neck:

            -evaluate eyelids, forehead, ears, nose, and lips carefully.  

            -evaluate the mucous membranes of the mouth and nose for ulceration, bleeding,           

             or telangiectasis.

        *Evaluate back for lesions.

        *While pt. is lying down:

 - inspect skin, chest, and abdomen with particular attention being paid to the inguinal and genital area.  

- inspect pubic and perineal area with elevation of the scrotum.  Pretibial areas are evaluated for ulcerations or waxy deposits.  The feet, soles and toes should be carefully examined.  The toes should be spread in order to evaluate the webs thoroughly.  

         *Instruct pt to roll onto the left side.

-inspect skin on the back, gluteal, and perineal areas.

Anonymous

a.        Temperature  (taken if there is a generalized rash or signs of infection)

b.       General inspection of the skin:

• Color  (pale, tanned, sunburned)

• Skin temperature

• Moisture (dry, oily, sweaty)

• Texture and thickness (coarse, vs. fine)

• Turgor and mobility (state of hydration)

• Lesions unrelated to present complaint (e.g., moles, xanthomas, angiomas, etc.)

c.        Inspection of specific lesions:

• Color

• Number of lesions (the actual number, or estimation)

• Location and distribution of lesions – be specific! (e.g., scalp, face and trunk are areas of high sebaceous gland concentration; on extremities, it makes a difference whether lesions are on extensor or flexor surfaces; intertriginous areas foster certain types of infectous rashes, etc.

• Grouping or configuration of lesions (e.g., linear or clustered; in a dermatome, as in herpes zoster)

• Size of leions in mms. or cms.

• Shape and borders (e.g., round, linear, oval, and geographic are shapes; borders can be well-defined, ill-defined, circumscribed, or irregular)

• Surface (e.g., flat or raised; verrucous means wart-like)

• Tenderness (or non-tender)

• Mobility (mobile – moves with the skin; non-mobile or fixed – skin moves over it)

• Special characteristics (e.g., peduculated (on a stalk), exudative. etc.)

Dawn pp. 129-134 Swartz (View pictures and look at examples of what to look for during the exam.  This is a general synopsis of the physical examination.)

The examination of the skin consists of inspection and palpation.  The use of natural light is preferable.  

•         Inspection:

-          evaluate color, moisture (excessive:  normal or seen in fevers, emotions, neoplastic diseases, or hyperthyroidism; dryness:  normal or myxedema, nephritis, and certain drug-induced states), turgor (provides a mechanism for estimating the general state of hydration:  if the skin over the forehead is pulled up and released, it should promptly reassume its normal contour; decreased hydration will show a delayed response), and texture (soft = texture of skin over baby’s abdomen;  “soft” textured skin is seen in hypothyroidism, hypopituitarism, and eunuchoid states; “hard” skin is seen in scleroderma, myxedema, and amyloidosis; “velvety” skin is seen in Ehlers-Danlos syndrome)

-          note any color changes (cyanosis, jaundice, or pigmentary abnormalities

-          look for red vascular lesions (petechiae, purpura, or angiomas)

-          inspect all pigmented lesions for ABCD (asymmetry of shape, border irregularity, color variation, diameter larger than 6 mm)

-          inspect the hair:  alopecia or hirsutism.  Notice distribution and texture.

-          Inspect the nail beds:  shape, size, color, brittleness, hemorrhages

-          Inspect the skin of the face and neck, mucous membranes of the mouth and nose, and the nasolabial fold and mouth (is it normal?).

-          Inspect the skin over the back for lesions

-          Inspect the skin of the chest, abdomen and LE.  Pay particular attention to the skin of the inguinal and genital area.  Inspect the pubic hair.  Elevate the scrotum.  Inspect the perianal area.  Inspect pretibial areas for ulcerations or waxy deposits.

-          Inspect the feet and soles

•         Palpation of any skin lesion to define:  texture, consistency, fluid, edema in the adjacent area, tenderness, and blanching

6.         List the characteristics of skin lesions that can be described on physical exam

Anonymous

1.        Color

2.        Number of lesions

3.        Location and distribution of lesion BE SPACIFIC!

4.        Grouping and configuration of lesions

5.        Size of lesion in mms. or cms.

6.        Shape and borders

7.        Surface

8.        Consistency

9.        Tenderness

10.     Mobility

11.     Special characteristics

Anonymous

color                     surface

number                 consistency

location                tenderness

grouping               mobility               

size                       special characteristics

shape

Sung K, Swartz, p.135

      The three specific criteria for a dermatologic diagnosis are based on:

      a. Morphology – describe its appearance (shape, color, flat vs raised, solid vs fluid filled).

      b. Configuration – describe its arrangement (confluent, grouped, linear, etc, see p.140)

            c. Distribution – note its location 

Dawn

Classify lesions as:

•         Primary:  arise from normal skin.  They result from anatomic changes in the epidermis, dermis, or subcutaneous tissue.  It is the most characteristic lesion of the skin disorder.

•         Secondary:  result from changes in the primary lesion.  They develop during the course of the cutaneous disease.  

Characteristics:

•         Description:  flat or raised and whether it is solid or contains fluid.  Use a penlight to see if it is elevated.  If a penlight is directed to one side of a lesion, a shadow will form according to the height of the lesion.  see fig 7-17 to 7-23 pp.  135-139

•         Location:  distribution of the lesions is crucial.  Inspect the patient’s clothing when contact dermatitis or lice is suspected.  Also, occupational exposure may leave traces of contamination with oils or other materials on clothes.

•         Configuration:  arrangement of the lesion will often lead the examiner to a group of related disease states with similar presenting dermatologic signs.   p. 140 – Swartz  

7.         Define the following terms: 

                              macule                                       ulcer                                    crust

                              patch                                          comedo                                lichenification

                              papule                                        milia                                    excoriation

                              plaque                                        telangiectasia                     erosion

                              nodule                                        petechiae                            fissure

                              tumor                                         purpura (ecchymosis)

                              wheal                                          spider angioma

                              vesicle                                        wart

                              bulla                                           scar

                              pustule                                       keloid

                              cyst                                            burrows

                              scale

Zen Seeker

Name		Definition	Examples
Primary skin lesions – nonpalpable, flat
Macule		< 1 cm	freckles, moles
Patch		> 1cm	vitiligo, café au lait spots
Primary skin lesions – palpable solid mass
Papule		< 1cm	nevus, wart
Plaque		flat, elevated, superficial papule w/ surface area > height	psoriasis, seborrheic keratosis
Nodule		1-2 cm	erythema nodosum
Tumor		> 2cm	neoplasms
Wheal		supeficial area of cutaneous edema	hives, insect bite
Wart		a flesh-colored growth characterized by circumscribed hypertrophy of the papillae of the corium, with thickening of the malpighian, granular, and keratin layers of the epidermis, caused by human papilloma virus	from Stedman’s Medical Dictionary
Primary skin lesions – palpable, fluid filled
Vesicle		< 1 cm; filled w/ serous fluid	blister, herpes simplex
Bulla		> 1cm; filled w/ serous fluid	blister, pemphigus vulgaris
Pustule		similar to vesicle but filled w/ pus
Special primary skin lesions
Comedo		plugged opening of sebaceous gland	blackhead
Cyst		palpable lesion filled w/ semiliquid material or fluid	sebaceous cyst
Burrow		< 10mm, raised tunnel	scabies
Milia		tiny, keratin-filled cysts, representing an accumulation of keratin in the distal portion of the sweat gland
Secondary skin lesions – below the skin plane
Atrophy		reduction of skin thickening ocurring at any skin layer	striae, aged skin
Erosion		loss of part or all of the epidermis; moist surface	rupture of a vesicle
Ulcer		loss of epidermis and dermis; may bleed	stasis ulcer, chancre
Fissure		linear crack from epidermis into dermis	cheilitis, athlete’s foot
Excoriation		a superficial linear, or “dugout”, traumatized area, usually self-induced	abrasion, scratch mark
Secondary skin lesions – above the skin plane
Scale		heaped-up keratinized cells; exfoliated epidermis	dandruff, psoriasis
Crust		dried residue of pus, serum, or blood	scabs, impetigo
Vascular skin lesions
Petechiae		reddish-purple; nonblanching; < 0.5 cm	intravascular defects
Purpura		reddish-purple; nonblanching; > 0.5 cm	intravascular defects
Ecchymosis		reddish-purple; nonblanching; variable size	trauma, vasculitis
Telangiectasia		fine, irregular dilated blood vessels that blanch w/ pressure	dilatation of capillaries
Spider angioma		central red body w/ radiating spider-like arms that blanch w/ pressure to the central area	liver disease, estrogens
Miscellaneous skin lesions
Scar		replacement of destroyed dermis by fibrous tissue; may be atrophic or hyperplastic	healed wound
Keloid		elevated, enlarging scar growing beyond boundaries of wound	burn scars
Lichenification		roughening and thickening of epidermis; accentuated skin markings	atopic dermatitis

Anonymous

a.        Macule-discolored flat lesion, small spot. (Example: freckles, flat mole)

b.       Patch-larger than macule.  Example vitiligo.

c.        Papule-up to 0.5 centimeters, salad elevation of skin.  Example elevated nevus.

d.       Plaque-if flat elevated surface larger than 0.5 cm often coalescence of papules.

e.        Nodule-larger then 0.5 cm; often deeper and firmer than that papule.

f.         Tumor- it large nodule.

g.       Wheal-a somewhat in regular, a relatively transient, superficial area of localized skin edema.  Example mosquito bite, hives.

h.       Vesicle-up to 0.5 cm fill with serous fluid.  Example herpes simplex.

i.         Bulla- greater than 0.5 cm; filled with serous fluid.  Example second-degree burns.

j.         Pustule-filled with puss.  Example acne, impetigo.

k.        Ulcer- open sore or erosion.  Example decubitus ulcer.

l.         Comedones- (blackhead) sebum plug partially blocking the pore.

m.      Milia- small white head closed to air at the top.

n.       Telangiectasia-dilation of the previously existing small or terminal vessels of the part.

o.       Petechia-a small pinpoint and rich, smaller version of ecchymoses. (black and blue mark)

p.       Purpura-(ecchymoses)-merging ecchymoses and petechia over any part of the body. (black and blue mark)

q.       Spider angioma-fiery red up to 2 cm central body, sometimes raised, surrounded by erythema and radiating legs.

r.         Venous star-a small, red nodule formed by dilating vein in the skin.

s.        Scar-replacement of destroyed tissue by fibrous tissue.

t.         Keloid-hypertrophied, thicken scar occurs after trauma or surgical incision.  (occurs because of excessive collagen formation)

u.       Crest-calcinosis, Raynaud phenomenon (spasm of the digital arteries, with blanching and numbness of fingers

v.       Lichenification-leathery indurations and thickening of the skin with hyperkeratosis.  Caused by scratching.

w.      Excoriation-an abrasion or scratch mark.  May be linear or rounded.  Example scratched insect bite.

x.        Erosion-loss of superficial up dermis.  Surface is moist but does not bleed.  Example rupture of a vessel as in chicken pox.

y.       Fisher-a linear crack in the skin.  Example athlete's foot.

z.        Cyst-A thickened Wall, closed sacs or pouch containing a fluid or semisolid material.  Example pilonidal cyst.

aa.     Scale-a thin flake of exfoliated epidermis.  Example dandruff, dry skin.

bb.    Borrows-is a minute, slightly raise tunnel in the epidermis.  Commonly found on finger webs and the side of finger.  Example borrows of scabies.

Anonymous

ref. Bates chap 6;

McCance, the integumentary system

MACULE- A circumscibed discoloured (often reddened) flat lesion, LESS than 1cm diam..  ex. freckles, flat moles, petechiae, measles, scarlet fever

ECHYMOSIS - Bluish-black macule. Black and blue mark, bruise. caused by hemorrhages into the skin from injury or spontaneous bleeding into the tissues

PETECHIAE - Small pinpoint hemorrhage. Does not blanch when pressure applied. Smaller version of petechiae.

PURPURA - Merging ecchymoses andpetechiae over any part of the body.

PATCH -   A flat, nonpalpable, irregular shaped macule MORE than 1cm in diameter. ex. vitiligo, port wine stains, mongolian spots, cafe au lait spot

PAPULE - An elevated, firm, circumscribed area less than 1 cm diameter. ex. wart, elevated moles, lichen plannus

PLAQUE - Elevated, firm, and rough lesion w/ flat top surface greater tham 1 cm in diam. ex. psoriasis, seborrheic and actinic keratoses

WHEAL - Elevated, irregular-shaped area of cutaneous edema; solid, transient; variable diameter. ex insect bites uticaria, allergic reaction

NODULE - Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1-2cm in diam. ex erythema nodosum, lipomas

TUMOR - Elevated, solid lesions; may be clearly demarcated; deeper in dermis; greater than 2 cm in diam. ex neoplasms, benign tumor, lipoma, hemangioma

VESICLE - Elevated, circumscribed, superficial. not into dermis; filled w/ serous fluid; less than 1 cm in diam. ex varicella (chicken pox) herpes zoster (shingles)

BULLA - Vesicle greater than 1 cm in diam. ex blister, pemphigus vulgaris

PUSTULE - Elevated, superficial lesion; similar to a vesicle but filled w/ purulent fluid ex impetigo, acne

CYST - Elevated, circumscribed, encapsulated lesion in dermis or subcutaneous layer; filled w/ liquid or semi-solid material. ex sebaceous cyst, cystic acne

TELANGIECTASIA - Fine irregular red lines produced by capillary dilation

SCALE-  Heaped up keratinized cells; flaky skin; irregular;thick or thin; dry or oily; varies in size.  

LICHENIFICATION - Rough thickened matitis secondary to persistent rubbing, itching or skin irritation; often involves flexor surface of extremity.  Chronic dermatitis

SCAR - Thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis. ex healed wound or surgical scar.

KELOID - Irregular-shaped elevated, progressively enlarging scar; grows beyond boundaries of the wound; caused by excessive collagen formation during healing.  Darker skinned people at higher risk for keloid formation.

EXCORIATION - Loss of the epidermis; linear; hollowed out, crusted area. ex abrasion, scrath, scabies

FISSURE -  Linear crack from the epidermis to the dermis; may be moist or dry. ex athlete's foot, cracks in ombissure

EROSION - Loss of part of the epidermis; depressed; moist; glistening; follows rupture of bulla or vesicle

ULCER - Loss of epidermis and dermis; concave, varies in size. ex Decubiti, stasis ulcers

SPIDER ANGIOMA - Fiery red w/ central body, sometimes raised surrounding by erythema and radiating legs. Almost always found above the waist. sig for liver dz, pregnancy, vit B deficiency

VENOUS STAR - ??

COMEDONE - a blackhead, sebum plug partially blocking a pore

MILIA - Smooth pinhead-sized, white, raised areas w/o surrounding erythema on nose chin and forehead, caused by sebum blockage in sebaceous glands. Common on infants.

BURROWS - A minute slightly raised tunnel in the4 epidermis. a short line that may end in a vesicle, caused by the burrowing activities of the scabies mite.

CREST - ??

Sung K, Swartz, p.135-9

8. Describe the proper evaluation of pigmented lesions and describe the danger signs for melanoma (A,B,C,D).

Zen Seeker

A
Asymmetry--one half unlike the other half.

B
Border irregular--scalloped or poorly circumscribed border.

C
Color varied from one area to another; shades of tan and brown; black; sometimes white, red or blue.

D
Diameter larger than 6mm as a rule (diameter of a pencil eraser).

The ABCDs of Melanoma

Sung K, Swartz, p.130

      Check the following for any pigmented lesion (shape, border, color, diameter). If positive for any of these may be signs of melanoma.

      Asymmetry of shape – half the lesion appears different from the other half

      Border irregularity – scalloped or poorly circumscribed contour

      Color variation – may show shades of tan and brown, black, and sometimes white, red, or blue

Diameter larger than 6 mm – considered a danger sign for melanoma (about size of a pencil eraser)

Mike

Swartz pg 135-140

a.     Macule-discolored flat lesion, small spot. (Example: freckles, flat mole)

b.     Patch-larger than macule.  Example vitiligo.

c.     Papule-up to 0.5 centimeters, salad elevation of skin.  Example elevated nevus.

d.     Plaque-if flat elevated surface larger than 0.5 cm often coalescence of papules.

e.     Nodule-larger then 0.5 cm; often deeper and firmer than that papule.

f.      Tumor- it large nodule.

g.     Wheal-a somewhat in regular, a relatively transient, superficial area of localized skin edema.  Example mosquito bite, hives.

h.     Vesicle-up to 0.5 cm fill with serous fluid.  Example herpes simplex.

i.      Bulla- greater than 0.5 cm; filled with serous fluid.  Example second-degree burns.

j.      Pustule-filled with puss.  Example acne, impetigo.

k.     Ulcer- open sore or erosion.  Example decubitus ulcer.

l.      Comedones- (blackhead) sebum plug partially blocking the pore.

m.   Milia- small white head closed to air at the top.

n.     Telangiectasia-dilation of the previously existing small or terminal vessels of the part.

o.     Petechia-a small pinpoint and rich, smaller version of ecchymoses. (black and blue mark)

p.    Purpura-(ecchymoses)-merging ecchymoses and petechia over any part of the body. (black and blue mark)

q.     Spider angioma-fiery red up to 2 cm central body, sometimes raised, surrounded by erythema and radiating legs.

r.      Venous star-a small, red nodule formed by dilating vein in the skin.

s.     Scar-replacement of destroyed tissue by fibrous tissue.

t.      Keloid-hypertrophied, thicken scar occurs after trauma or surgical incision.  (occurs because of excessive collagen formation)

u.     Crest-calcinosis, Raynaud phenomenon (spasm of the digital arteries, with blanching and numbness of fingers

v.     Lichenification-leathery indurations and thickening of the skin with hyperkeratosis.  Caused by scratching.

w.   Excoriation-an abrasion or scratch mark.  May be linear or rounded.  Example scratched insect bite.

x.     Erosion-loss of superficial up dermis.  Surface is moist but does not bleed.  Example rupture of a vessel as in chicken pox.

y.    Fisher-a linear crack in the skin.  Example athlete's foot.

z.     Cyst-A thickened Wall, closed sacs or pouch containing a fluid or semisolid material.  Example pilonidal cyst.

aa.   Scale-a thin flake of exfoliated epidermis.  Example dandruff, dry skin.

bb.  Borrows-is a minute, slightly raise tunnel in the epidermis.  Commonly found on finger webs and the side of finger.  Example borrows of scabies.

Mike

Swartz, p.130

Check the following for any pigmented lesion (shape, border, color, diameter). If positive for any of these may be signs of melanoma.

     Asymmetry of shape – half the lesion appears different from the other half

     Border irregularity – scalloped or poorly circumscribed contour

     Color variation – may show shades of tan and brown, black, and sometimes   white,    red, or blue

     Diameter larger than 6 mm – considered a danger sign for melanoma (about size of a pencil eraser)

9. Given a patient with a rash be able to describe the lesion(s) accurately and completely.

Sung K, Henry’s Handout, p.2-3

      a. Morphology

          -  color

          -  number of lesions (actual number or general estimate)

          -  size of lesions in mm or cm

      -  shape and borders (round, linear, oval, geographic; borders can be well-defined, ill-defined,

   circumscribed, or irregular)

-  surface (flat or raised, verrucous meaning wart-like)

-  consistency (soft, fluctuant, firm, or hard)

-  tenderness

-  mobility (mobile – moves with the skin; non-mobile or fixed – skin moves over it)

b.   Configuration or grouping of lesions – linear or clustered; in a dermatome, as in herpes zoster

c.                        Distribution and location of lesions – be specific (scalp, face and trunk are areas of high sebaceous gland concentration; on extremities, it makes a difference whether lesions are on extensor or flexor surfaces; intertriginous (between skinfolds) areas foster certain types of infectious rashes, etc...) 

10. Be able to identify all the lesions in #7 given a patient or a picture demonstrating the lesion.

 Sung K, Swartz, p.142-78

See pictures in Swartz and online derm atlas on healthlinks