Download - Lecture Ix Skin and Subcutaneous Tissue
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SKIN AND SUBCUTANEOUS
TISSUE
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I. Introduction
A. Function
1. Protection
2. Thermoregulation
3. Sensory
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B. Anatomy
1. Epidermismost cellular layer
a. keratinocytesmost numerousand forms a mechanical barrier
b.Langerhans immunologic
function
c. Melanocytespigment
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2. Dermissupporting layer, mostlyfibroblast which produce collagen
3. Basement layerdermal epidermaljunction
- first layer where blood vessel and
lymphatics are present- if lesion has not crossed this layer, it iscalled an in-situ lesion
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II. Pathology
A. Trauma
1. Dirty and infected woundsdebridement and closed by secondaryintention
2. Lacerationsclosed primarily
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LACERATIONS
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B. Decubitus Ulcer or Pressure Ulcer
- excessive, unrelieved pressure (60 cmHg applied for 1 hour)
- muscle more sensitive than skin to
ischemia- Tx.debridement and grafting
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DECUBITUS ULCER
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C. Keloid and Hypetrophic Scar
- over abundance of deposition of collagen
1. Hypertrophic scarnodularity remains within theincision
- no treatment necessary
2. Keloidnodularity goes beyond the incision- seen more in children and across sternum
- treated with triamcinolone
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KELOID
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D. Infections
1. Folliculitisinfectedhair follicle- caused by Staph. sp.
- leads to furuncle carbuncle
- Tx.incision and
drainage andantibiotics
2. Hidradenitis suppuritiva
- plugged apocrine gland
in axilla and inguinalarea
- Tx.warm compress,hygiene, discontinuationof deodorants, opendrainage if recurrent
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3. Pilonidal diseaseinfected
pilosebaceous cysts in thesaccrococygeal area, lined bygranulation tissue
- Tx.drainage, currete
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4. Staphyloccocal Scalded Skin Syndrome
- erythema, bullae formation, loss ofepidermis
- caused by exotoxin from staphyloccocalinfection
- similar to partial thickness burn
-cleavage is in the granular layer- Tx.replace fluid, electrolytes, skin care,
antibiotics
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STAPHYLOCOCCAL SCALDED SKINSYNDROME
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5. Toxic Epidermal Necrolysis- Immunologic reaction to
certain drugs such assulfonamides, phenytoin,
barbituates, and tetracycline- Tx.same as SSSS
6. Viralverruca vulgaris,
associated with pappiloma virus- associated with squamous cellca- Tx.chemical, electrocautery,surgery
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E. Benign TumorsCysts
1. epidermalsebaceous cysts,most common
2. Trichilemmal
occurs morecommonly in females
3. Dermoidresultsfrom epithelium
trapped duringmidline closure infetal development- Tx. - excision
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F. Nevi
1. Acquired
a. Junctionalepidermis
b. Compoundmigrates partially
down to the dermis
c. Dermalcells at dermal layer
- involutes
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ACQUIRED NEVI
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2. Congenitalrare
- large and may contain hair
- occurs in bathing trunks distribution
- Tx. - excision
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CONGENITAL NEVI
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G. Vascular1. Hemangioma
a. capillary(strawberry)
- compressible, vascularlesion with sharp borders
- located mostly in theface, scalp, and shoulder- observe, 90% involute
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b. Cavernous- bright red or purple, with spongyconsistency
- Tx.excision
2. Vascular malformation- enlarged vascular spaces lined with nonproliferating endothelial cells
a. portwine staincapillary malformation- Tx.embolization
b. glomus tumorpainful bluegray nodules
- arises from the glomus body or Sucquet- Hoyer canal found in the dermis andcontributes to thermal regulation- may lead to glomangiosarcoma- Tx. - excision
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GLOMUS TUMOR
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H. Soft Tissue Tumors( achrocordons,lipomas,dermatofibromas)
- Tx.excision
I. Neural
- Neurofibromas
(caf-au-lait spots)- associated with vonReklinghausensdisease
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J. Malignant Tumors
1. Epidemiology
a. malignant radiationb. chemicals
c. viral
d. chronic irritation
e. immunosuppresion
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2. Types
a. basal cell carcinoma- most common
- slow growing, rare metastases
- excision with 2-4 mm margin
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BASAL CELL CARCINOM
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b. squamous cell carcinoma- metastasizes faster- Bowens disease ca-in-situ
- Erythroplasia of Queyratca ofthe penis- lesion more than 1 cm has 50%chance of metastasis
- Tx.excision with 1 cm margin- Mohs technique serial excision topreserve skin
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SQUAMOUS CELL CARCINOMA
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ERYTHROPLASI OF QUEYRAT
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c. malignant melanoma
- arises from dysplastic
melanocytes
i. superficial spreading
- most common (70%)
- flat with areas of regression
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ii. nodular15-20%
- dark, slightly raised
- growth more vertical thanradial
iii. lentigo malignant 5-10%
- best prognosis- occurs in areas of high solardegeneration
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MELANOMA
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b. prognostication
i. Clark
ii. Breslowiii other factors
- anatomic location
extremities better than trunkor face
- ulceration
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- inflammatory infitrates- sex
- histologic type
c. treatment- still primarily surgical
i. in-situ - .5 to 1 cm marginii. T1 (smaller than .76 mm)- 1-2 cmiii. thicker lesion3 cm margin- excision is up to the deep fascia
- chemotherapy- palpable nodes are removed by regionaldissection