Dermatology and Venereology

DERMATOLOGY & VENEREOLOGYDERMATOLOGY & VENEREOLOGY

dr. Sugastiasri Sumaryo, SpKKdr. Sugastiasri Sumaryo, SpKKDepartment of Dermatology & VenereologyFaculty of Medicine Diponegoro University

IntroductionIntroduction What is dermatology ? Dermatology may be defined as “the study of the skin and its diseases”

or as “the branch of science of the skin”

What is venereology ? Venereology may be defined as “the study of the genital and its diseases”

The skin is of major importance in our “body-image”. The psychological disturbance induced by skin problems. Skin diseases not only cause stress or depression, but in

addition, psychological stress from other cause can exacerbate many skin diseases.

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Structure and Function of SkinStructure and Function of Skin

Structure of skin• The skin is composed of two distinct

components, from the surface downward:

Epidermis

Dermis

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Structure and Function of Structure and Function of SkinSkin

Structure of skin (continuation)

• The epidermis is the thinnest component, varying in thickness from 0.04 mm on the eyelid to 1,6 mm on the palms; the average thickness of epidermis for most of its expanse is 0,1 mm.

• Thus on simple morphological grounds the epidermis can be divides into 4 distinct layers: Stratum basale

( or Stratum germinativum ) Stratum spinosum Stratum granulosum Stratum corneum The term Malpighian layer includes both the basal

and spinous. Other cells resident within the epidermis include melanocytes, Langerhans cells and Merkel cells.

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Structure of skin Structure of skin (continuation)

• The Dermis is bounded distally by its junction with the epidermis and proximally by the subcutaneous fat, contributes 15 – 20 % of the total weight of the human body. It varies in thickness from 1 mm on the face to 4 mm on the back and thigh. The dermis is 15-40 times thicker than the epidermis, depending on the anatomic site.

Dermis pars papilare

Dermis pars reticulare

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Structure of skin Structure of skin (continuation)

• The dermo-epidermal junction is one of the largest ephithelio-mesenchymal junction in the body.

It is a highly specialized attachment between the epidermis and the papilay dermis.

Three different types of epidermal cells: Basal keratinocyt Melanocyt Merkel cells

• Human skin are derived from either: Ectoderm: epidermis, folliculo sebaceus apocrine

unit, eccrine unit, nail. Mesoderm: melanocyt, nerves, sensory receptor, the

other elements in the skin i.e. Langerhans, macrophage, mast cell, fibrocytes, blood v, lymph v, muscle, adipocytes.

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Structure and Function of SkinStructure and Function of Skin (continuation)

Function of skin• The most obvious function of the skin are to protect the

body by preventing the lost of fluid and the penetration of undesirable substances or radiation, and by cushioning it against mechanical shocks.

• Equal importance, is the immunological response. • A number of sensations – touch, pressure, warmth, cold and

pain are perceived by the skin.• Vitamin D3 is essential for skeletal development. It is

syntesized in the skin as a result of exposure to ultraviolet B (UVB) radiation. Vitamin D3 is formed, principally in the stratum spinosum and the stratum basale, from the precursor 7 – dehydrocholesterol.

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Function of skin Function of skin (continuation)(continuation)

• The tissues of the skin are the target for a wide range of chemical messengers. For example, hair follicles and sebaceous glands are the targets for androgenic steroids secreted by gonads and the adrenal cortex, and melanocytes are directly influence by polypeptide hormones of the pituitary (MSH).

• Melanocytes are dendritic cells that synthezie and secrete melanin-containing organelles called melanosome. In human, there are 2 major classes of integumentary melanin:EumelaninsPheomelanins

• The nerves of the skin are part of two major systems:Somatic sensoryAutonomic motor

These melanins protected skin from UV

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The somatic sensory system mediates the sensation of pain, itch, temperature, light touch, pressure, vibration and discriminative sensations of touch.

The autonomic motor nerves control cutaneous vascular tone, pilomotor responses.

• Subcutaneuos fatSubcutaneuos fat Typically, the subcutaneous fat in adult shows

differences between the sexes in its gross distribution and microscopic characteristics.

The gynoid distribution of fat in women causes prominent curvature of breast, buttocks, hips, anterior thighs, inner aspect of knees, lower abdomen, and pubic region.

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• Subcutaneuos fatSubcutaneuos fat (continuation)

In contrast, the android distribution of fat in men leads to deposition of adipocytes in the nape of the neck and the deltoyid and epigastric regions.

In both sexes, certain anatomic sites have relatively little fat, e.g. the eyelids, ear lobes, scalp, nostrils, scrotum, penis, clitoris, and dorsa of hands and feet.

Subcutaneous fat has several functions: deposits of fat act as shock absorbers Protecting and supporting vital organs Facilities mobility of skin over structures that

underlie it. A cosmetic role is contributed by the accentuated

distribution of fat in the sexes.

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HairHair Function of hair

• Provides : - a sexually attractive ornament - hair screen of nasal passages from irritants

• Protects : - the scalp from the sun’s rays• Shields : - the eyes from sunlight & droplets of sweat• Help : - to reduce friction in intertriginous areas• Contribute : - to the perception of tactile stimuli

During the life time, a particular hair follicle may generate all 3 types of hair:• In the scalp may initially produce a lanugo hair• Later a terminal hair• Finally, in balding, a vellus hair

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HairHairThe hair structure

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Hair Hair (continuation) The growth of hair is cyclical as a consequence of

established cycles of hair follicles. The 3 phases in the cycles of a follicle are:

• Growing (anagen)• Involuting (catagen)• Resting (telogen)

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Sebaceous UnitSebaceous Unit Sebaceous glands are most numerous and most

productive on the scalp and face and are largest on the forehead, nose, and upper part of the back.

With the exception of the palms, soles, and dorsal of the feet, sebaceous glands of various sizes are distributes over the entire surface of the body.

Sebaceous glands

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Apocrine Glands & Eccrine GlandsApocrine Glands & Eccrine Glands Apocrine unit in humans are found in the axillae,

areolae, periumbilical region, perineal and circumanal areas, prepuce, scrotum, mons pubis, labia minora, external auditory canal, and on the eyelids.

Bacteria present in follicular infundibula and on the skin surface act on apocrine secretion to produce short-chain fatty acids, ammonia, and other odorifereous subtances. “An offensive” body odor may be controlled by deodorants that contain antibacterial ingredients.

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Apocrine Glands & Eccrine GlandsApocrine Glands & Eccrine Glands

Apocrine glands

Eccrine glands

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Nail Nail

Nail have several functions:• To protect the terminal phalanges• Can be made to do in a cosmetically pleasing way• To participate in the appreciation of fine tactile stimuli• Used as tools with which to scratch the skin• To grasp minute objects

Situated on the dorsal aspect of the distal phalanx of every finger and toe, a nail (known also a nail plate) as a hard, convex, rectangular, translucent structure the measures approximately 0,5 – 0,7 mm in thickness.

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Nail Nail The nail structure

Nail plate

Cuticle

Lunula

Proksimal Nail Fold

Lateral Nail Fold

Nail Bed

Matrix

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Principle of Clinical DiagnosisPrinciple of Clinical Diagnosis

When a patient seeks a dermatological opinion, it is usually for one of two reasons: A “growth” or because of concern malignancy The second is for a “rash”, which is usually more

widespread and often pruritic.

In medicine, the traditional approach is to take the history before doing the physical examination. We find it most useful to ask questions both before and after examination: “what is your skin problem?” “when did it start?” “has it gotten better or worse?” “does it bother you?” For skin disorder, the most common and important

symptom is itching . “does it itch?” “how have you treated it?”

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History of Skin LesionHistory of Skin Lesion

7 Key Question:7 Key Question: When did it start? Does it itch, burn, or hurt? Where on the body did it start? How has it spread? (pattern of spread). How have individual lesions changed? (evaluation) Provocative factor? Previous treatment(s)?

Family historyFamily history A positive family history for atopic diseases (atopic

dermatitis, asthma, hay fever) will help support the diagnosis. A diagnosis of neurofibromatosis dominantly inherited disease.

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Social HistorySocial History Porphyria cutanea tarda, a disease sometimes

induced by alcohol. Neurodermatitis, the physician will want to know

something about the patient stresses. Contact dermatitis, chronic hand dermatitis,

question about occupational exposure may be important and should be directed particularly to material and substances that the patient contacts either by handling or by immersion.

Review of systems Review of systems as indicated by clinical situation, with particular attention to possible connections between cutaneus signs and diseases of other organ system (e.g. rheumatic complaints): myalgias, arthralgias, Raynaud’s phenomenon

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Past medical historyPast medical history- operations- illnesses- allergies, especially drug allergies

- medications (present and past)- habits (smoking, alcohol intake, drug

abuse)- atopic history (asthma, hay fever, eczema)

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Physical Examination InspectionPhysical Examination Inspection

The most important part of the physical examination is inspection.

For the skin to be adequately inspected, there are 3 essential requirements: A completely undressed patient, clothed in and

examining gown Adequate illumination, preferably natural light or

bright overhead fluorescent lighting An examining physician prepared to see what is

before him/her Detail examination of skin, hair, nails, and mucous

membranes.

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Physical Examination InspectionPhysical Examination Inspection

Four cardinal features.1. Type of lesion: macule, papule, nodule, vesicle, etc.2. Shape of individual lesions: annular, iris, arciform, linear,

round, oval, umbilicated, etc.3. Arrangement of multiple lesions: isolated, scattered, grouped,

herpetiform, zosteriform, annular, arciform, linear, reticular, etc. (configuration).

4. Distribution ( be sure to examine scalp, mouth, palms, and soles).

a. Extent of involvement: circumscribed, regional, generalized, universal.

b. Pattern: symetry, exposed areas, sites of pressure, intertriginous areas

c. Characteristic location: fexural, axtensor, intertriginous, glaborous, palms and soles, dermatomalm trunk, lower extremities, exposed areas, etc.

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Physical Examination PalpationPhysical Examination Palpation

The Major

Purposes

To assess the texture and

consistency of the skin lesions

(softness, firmness, fluctuate, depth).

To evaluate whether or not

lesions are tender (cellulitis, erythema nodusum).

To reassure our patient that we are not afraid to touch their skin lesions.

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Laboratory StudiesLaboratory Studies

Special procedures1. Biopsy for histopathologic and other analyses.2. Gram’s stain of crusts, scales, or exudate.3. KOH prep for yeast or fungi.4. Cytologic preparation (Tzanck smear) in vesicular

and bullous eruptions.5. Bacteriologic, viral, and fungal cultures as

indicated.6. Wood’s lamp examination of urine for porphyrins

and of hair and skin for fluorescence, and for changes in pigmentation.

7. Scrabing for scabies mite. 8. Patch tests.9. Acetowhitening.

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Laboratory StudiesLaboratory Studies

Reexamination over time, and more than one biopsy may be required for definitive diagnosis.

General:Hematology, chemistry, urinalysis, serologic tests (e.g. STS, ANA), stool examination, and imaging studies.

Final diagnosis Final diagnosis

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Skin diseases predilectionsSkin diseases predilections

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References:References:

1. Fitzpatrick, Dermatology in general medicine, 2003

2. Moschella, Dermatology, 19923. Rook, Text book of Dermatology, 1992

31Dr. Sugastiasri S, SpKK

MAKULAMAKULA

A. Lesi datar, batas tegas berbeda dengan kulit sekitar karena warnanya.A. Akibat hiperpigmentasiB. Akibat pigmentasi dermalC. Akibat dilatasi kapilerD. Akibat purpura

B. Erupsi pada reaksi obat : makula eritem, batas tegas, multipel dengan berbagai ukuran akibat vasodilatasi inflamatori.


PAPULAPAPULA

Lesi elevasi padat dengan ukuran kecil (Ø < 1 cm) di bagian terbesar papul tampak di atas kulitA. Permukaan kulit

A. Akibat deposit metabolik dermis B. Akibat hiperplasia lokalisata elemen

seluler dalam dermis atau epidermis.C. Papula dengan skuama pada lesi

papuloskuamosa

B. Nevus melanositik dermal, papul multipel ukuran bervariasi warna kecoklatan.

C. Liken planus, papul multipel ukuran bervariasi warna violaseus permukaan datar, mengkilat.


KISTAKISTA

A. Kista EpidermalA. Dibatasi epitel skuamosa

yang menghasilkan bahan keratin.

B. Kista kenyal kebiruan, tampak pada:

B. Kista tumor adneksa (kista hidroadenoma) berisi bahan menyerupai mukus.


URTIKAURTIKA

A. Papul atau plakat dengan atap mendatar yang tidak menetap dan segera menghilang dalam beberapa jam

B. Urtikaria kolinergik papul kecil (Ø 3 – 4 mm)C. Urtika besar, bergabung membentuk plakat seperti pada

reaksi alergi penisilin, obat lain dan alergen makanan.


VESIKEL VESIKEL

Adalah lesi dengan batas tegas mengandung cairanA. Celah dalam epidermis akibat

proses akantolisis B. Akibat degenerasi balon pada

infeksi virus

Vesikel pada herpes zoster


VESIKEL SUBEPIDERMALVESIKEL SUBEPIDERMAL

VESIKEL – BULA Lesi dengan batas tegas

mengandung cairan

A. Vesikel Subepidermal

B. Pada keadaan lanjut menjadi bula • bula tegang berisi cairan

serous atau hemorhagi• di atas kulit normal atau

eritem


VESIKEL SUBKORNEALVESIKEL SUBKORNEAL

A. Hasil akumulasi cairan tepat di bawah stratum korneum

B. Akibat udem inter-seluler

Vesikel subkorneal transparan yang rapuh pada impetigo stafilokokus


PUSTULAPUSTULA

A. Papula berisi eksudat purulen

B. Pustula non folikel primer pada psoriasis


NODULNODUL

A. Lesi bulat / elips, padat dan palpabelA. Nodul meluas ke jaringan

subkutanB. Nodul terletak dalam epidermis

B. KSB roduler• Nodul batas tegas• Permukaan halus mengkilat• Teleangiektasis & krusta.

C. Metastase Melanoma Nodul multipel dengan ukuran

bervariasi


EROSIEROSI

A. Lesi basah dapat sebagai akibat ter-kelupasnya atap vesikel atau bula juga akibat proses epidermal nekrolisis.

Sembuh tanpa ja-ringan parut.

B. Erosi pada Toksik epidermis nekrolisis,


ATROPIATROPI

Penyusutan atau penipisan kulit Dapat terjadi terbatas di epidermis atau dermis atau secara simultan pada keduanya


JARINGAN PARUTJARINGAN PARUT

A. Jaringan Parut, Pergantian jaringan fibrosa yang timbul sebagai konsekuensi penyembuhan luka.A. Jaringan parut hipertropiB. Jaringan parut atropi

B. Jaringan Parut Hipertropi


DESKUAMASIDESKUAMASI

Adalah akumulasi stratum korneum abnormalA. Skuamasi parakeratotik pada

hiperplasia epidermal psoriasiform.

B. Skuama melekat erat dan teraba kasar pada keratosis aktinik

C. Skuama melekat erat pada psoriasis.


BENTUK, SUSUNAN LESI, DISTRIBUSIBENTUK, SUSUNAN LESI, DISTRIBUSI

A. Lesi linier pada fenomena Koebner

B. Lesi anular & arciform, susunan anular & arciform.

C. Lesi iris merupakan lesi anular yang penting, cth. pada eritema multiforme


BENTUK, SUSUNAN LESI, DISTRIBUSIBENTUK, SUSUNAN LESI, DISTRIBUSI

D. Lesi berkelompok

E. Herpetiform pada herpes simpleks atau herpes zoster

F. Zosteriform


KRUSTAKRUSTA

A. Serum, darah atau eksudat purulen yang mengeringA. Krusta tipis, lembut & mudah

dilepasB. Krusta tebal dan melekat.

B. Krusta superficial, warna seperti madu dengan permukaan mengkilat pada impetigo.


ULKUSULKUS

A. Defek yang menetap setelah sebagian epidermis/dermis rusak atau hilang

Pada proses penyem-buhan meninggalkan jaringan parut

B. Ulkus “gigantic’ Ulkus batas tegas de-ngan

dasar jaringan granulasi kemerahan.

KELAINAN HISTOPATOLOGIK

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Hiperkeratosis: penebalan str.korneumParakeratosis: inti (+)Ortokeratosis: inti (-)

Hiperplasia: epidermis yg menjadi lebih tebal krn sel2nya bertambah

Hipoplasia: epidermis yg menipis krn sel2nya mengecil dan berkurang

EPIDERMIS (1)

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Hipertrofi: epidermis yg menebal krn sel2nya bertambah besar

Atrofi: penipisan epidermis krn sel2nya mengecil dan berkurang

Hipergranulosis: penebalan str. GranulosumSpongiosis: penimbunan cairan diantara

sel2 epidermis

EPIDERMIS (2)

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Degenerasi balon: edema di dlm sel epidermis

Degenerasi hidropik: rongga2 dibawah atau diatas membrana basalis

Akantosis: penebalan str. SpinosumAkantolisis: hilangnya kohesi antar sel2

epidermis, shg terbentuk celah

EPIDERMIS (3)

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Eksositosis: sel2 radang yg msk ke dlm epidermis

Diskeratotik: sel epidermis yg mengalami keratinisasi lebih awal

Nekrosis: kematian sel atau jaringan setempat pd organisme yg hidup

Cleft: ruangan tanpa cairan di epidermis

EPIDERMIS (4)

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DERMIS

Papilomatosis: papil yang memanjang melampaui batas permukaan kulit

Fibrosis: kolagen >>, fibroblas >>

Sklerosis: kolagen >>, fibroblas <<

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SUB KUTIS

Peradangan

Nekrosis

Vaskulitis

Proses degeneratif

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R2r Prod.

Dermatology and Venereology

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