SKIN AND SUBCUTANEOUS TISSUE. I. Introduction A. Function 1. Protection 2. Thermoregulation 3. Sensory.

SKIN AND SKIN AND SUBCUTANEOUS TISSUESUBCUTANEOUS TISSUE

I. IntroductionI. Introduction

A. FunctionA. Function

1. Protection1. Protection

2. Thermoregulation2. Thermoregulation

3. Sensory3. Sensory

B. AnatomyB. Anatomy1. Epidermis – most cellular layer1. Epidermis – most cellular layer

a. keratinocytes – most numerousa. keratinocytes – most numerousand forms a mechanical barrierand forms a mechanical barrier

b.Langerhan’s – immunologic b.Langerhan’s – immunologic functionfunction

c. Melanocytes – pigmentc. Melanocytes – pigment

2. Dermis – supporting layer, mostly 2. Dermis – supporting layer, mostly fibroblast which produce collagenfibroblast which produce collagen

3. Basement layer – dermal 3. Basement layer – dermal epidermal epidermal junctionjunction

- first layer where blood vessel and - first layer where blood vessel and lymphatics are presentlymphatics are present

- if lesion has not crossed this layer, it - if lesion has not crossed this layer, it is is called an “in-situ” lesioncalled an “in-situ” lesion

II. PathologyII. Pathology

A. TraumaA. Trauma

1. Dirty and infected wounds – 1. Dirty and infected wounds – debridement and closed by debridement and closed by secondary secondary intentionintention

2. Lacerations – closed primarily2. Lacerations – closed primarily

LACERATIONSLACERATIONS

B. Decubitus Ulcer or Pressure UlcerB. Decubitus Ulcer or Pressure Ulcer

- excessive, unrelieved pressure (60 - excessive, unrelieved pressure (60 cm Hg applied for 1 hour)cm Hg applied for 1 hour)

- muscle more sensitive than skin to - muscle more sensitive than skin to ischemiaischemia

- Tx. – debridement and grafting- Tx. – debridement and grafting

DECUBITUS ULCERDECUBITUS ULCER

C. Keloid and Hypetrophic Scar C. Keloid and Hypetrophic Scar - over abundance of deposition of collagen- over abundance of deposition of collagen

1. Hypertrophic scar – nodularity 1. Hypertrophic scar – nodularity remains remains within the within the incisionincision

- no treatment necessary- no treatment necessary

2. Keloid – nodularity goes beyond the 2. Keloid – nodularity goes beyond the incisionincision- seen more in children and across sternum- seen more in children and across sternum- treated with triamcinolone- treated with triamcinolone

KELOIDKELOID

D. InfectionsD. Infections1. Folliculitis – infected 1. Folliculitis – infected hair hair folliclefollicle- caused by Staph. sp.- caused by Staph. sp.- leads to furuncle - leads to furuncle carbunclecarbuncle- Tx. – incision and - Tx. – incision and drainage drainage and and antibioticsantibiotics

2. Hidradenitis suppuritiva2. Hidradenitis suppuritiva- plugged apocrine gland - plugged apocrine gland in in axilla and inguinal axilla and inguinal areaarea- Tx. – warm compress, - Tx. – warm compress, hygiene, discontinuation hygiene, discontinuation of of deodorants, open deodorants, open drainage if drainage if recurrentrecurrent

3. Pilonidal disease – infected 3. Pilonidal disease – infected pilosebaceous cysts in the pilosebaceous cysts in the saccrococygeal area, lined by saccrococygeal area, lined by granulation tissuegranulation tissue

- Tx. – drainage, currete- Tx. – drainage, currete

4. Staphyloccocal Scalded Skin Syndrome4. Staphyloccocal Scalded Skin Syndrome- erythema, bullae formation, loss of - erythema, bullae formation, loss of

epidermisepidermis- caused by exotoxin from staphyloccocal - caused by exotoxin from staphyloccocal infectioninfection- similar to partial thickness burn- similar to partial thickness burn-cleavage is in the granular layer-cleavage is in the granular layer- Tx. – replace fluid, electrolytes, skin - Tx. – replace fluid, electrolytes, skin

care,care,antibioticsantibiotics

STAPHYLOCOCCAL SCALDED STAPHYLOCOCCAL SCALDED SKIN SYNDROMESKIN SYNDROME

5. Toxic Epidermal Necrolysis5. Toxic Epidermal Necrolysis- Immunologic reaction to - Immunologic reaction to

certain drugs certain drugs such such as as sulfonamides, phenytoin, sulfonamides, phenytoin, barbituates, barbituates, and tetracyclineand tetracycline

- Tx. – same as SSSS- Tx. – same as SSSS

6. Viral – verruca vulgaris, 6. Viral – verruca vulgaris, associated with pappiloma associated with pappiloma virusvirus- associated with squamous - associated with squamous

cell cell caca- Tx. – chemical, - Tx. – chemical,

electrocautery, electrocautery, surgerysurgery

E. Benign TumorsE. Benign TumorsCystsCysts1. epidermal – 1. epidermal – sebaceous sebaceous cysts, cysts, most commonmost common

2. Trichilemmal – 2. Trichilemmal – occurs occurs more more commonly in commonly in femalesfemales

3. Dermoid – 3. Dermoid – results results from from epithelium epithelium trapped during trapped during midline closure in midline closure in

fetal fetal developmentdevelopment

- Tx. - excision- Tx. - excision

F. NeviF. Nevi

1. Acquired1. Acquired

a. Junctional – epidermisa. Junctional – epidermis

b. Compound – migrates partiallyb. Compound – migrates partially

down to the dermisdown to the dermis

c. Dermal – cells at dermal layerc. Dermal – cells at dermal layer

- involutes- involutes

ACQUIRED NEVIACQUIRED NEVI

2. Congenital – rare2. Congenital – rare

- large and may contain hair- large and may contain hair

- occurs in bathing trunks - occurs in bathing trunks distributiondistribution

- Tx. - excision- Tx. - excision

CONGENITAL NEVICONGENITAL NEVI

G. VascularG. Vascular1. Hemangioma1. Hemangioma

a. capillary a. capillary (strawberry) (strawberry) - compressible, - compressible,

vascular vascular lesion with lesion with sharp borderssharp borders

- located mostly in - located mostly in the the face, scalp, and face, scalp, and shoulder shoulder - observe, 90% - observe, 90% involuteinvolute

b. Cavernousb. Cavernous- bright red or purple, with spongy - bright red or purple, with spongy

consistencyconsistency- Tx. – excision- Tx. – excision

2. Vascular malformation2. Vascular malformation- enlarged vascular spaces lined with non - enlarged vascular spaces lined with non

proliferating endothelial cellsproliferating endothelial cellsa. portwine stain – capillary malformationa. portwine stain – capillary malformation- Tx. – embolization- Tx. – embolization

b. glomus tumor – painful blue –gray nodulesb. glomus tumor – painful blue –gray nodules- arises from the glomus body or Sucquet-- arises from the glomus body or Sucquet-Hoyer canal found in the dermis and Hoyer canal found in the dermis and contributes to thermal regulationcontributes to thermal regulation- may lead to glomangiosarcoma- may lead to glomangiosarcoma- Tx. - excision- Tx. - excision

GLOMUS TUMORGLOMUS TUMOR

H. Soft Tissue Tumors H. Soft Tissue Tumors ( achrocordons, lipomas, ( achrocordons, lipomas, dermatofibromas)dermatofibromas)- Tx. – excision- Tx. – excision

I. NeuralI. Neural- Neurofibromas (café-- Neurofibromas (café-au-lait spots)au-lait spots)- associated with von - associated with von Reklinghausen’s diseaseReklinghausen’s disease

J. Malignant TumorsJ. Malignant Tumors

1. Epidemiology1. Epidemiology

a. malignant radiationa. malignant radiation

b. chemicalsb. chemicals

c. viral c. viral

d. chronic irritationd. chronic irritation

e. immunosuppresione. immunosuppresion

2. Types2. Types

a. basal cell carcinomaa. basal cell carcinoma

- most common- most common

- slow growing, rare - slow growing, rare metastasesmetastases

- excision with 2-4 mm margin- excision with 2-4 mm margin

BASAL CELL CARCINOMBASAL CELL CARCINOM

b. squamous cell carcinomab. squamous cell carcinoma- metastasizes faster- metastasizes faster- Bowen’s disease – ca-in-situ- Bowen’s disease – ca-in-situ- Erythroplasia of Queyrat – ca of - Erythroplasia of Queyrat – ca of

the penisthe penis- lesion more than 1 cm has - lesion more than 1 cm has

50% 50% chance of metastasischance of metastasis- Tx. – excision with 1 cm margin- Tx. – excision with 1 cm margin- Moh’s technique – serial - Moh’s technique – serial

excision to excision to preserve skinpreserve skin

SQUAMOUS CELL SQUAMOUS CELL CARCINOMACARCINOMA

ERYTHROPLASI OF QUEYRATERYTHROPLASI OF QUEYRAT

c. malignant melanomac. malignant melanoma

- arises from dysplastic - arises from dysplastic melanocytesmelanocytes

i. superficial spreadingi. superficial spreading

- most common (70%)- most common (70%)

- flat with areas of regression- flat with areas of regression

ii. nodular – 15-20%ii. nodular – 15-20%- dark, slightly raised- dark, slightly raised- growth more vertical than - growth more vertical than

radialradial

iii. lentigo malignant 5-10%iii. lentigo malignant 5-10%- best prognosis- best prognosis- occurs in areas of high - occurs in areas of high

solar solar degenerationdegeneration

MELANOMAMELANOMA

b. prognosticationb. prognosticationi. Clarki. Clarkii. Breslowii. Breslowiii other factorsiii other factors- anatomic location – - anatomic location – extremities better than extremities better than

trunk trunk or faceor face- ulceration- ulceration

- inflammatory infitrates- inflammatory infitrates- sex- sex- histologic type- histologic type

c. treatmentc. treatment- still primarily surgical- still primarily surgical

i. in-situ - .5 to 1 cm margini. in-situ - .5 to 1 cm marginii. T1 (smaller than .76 mm) ii. T1 (smaller than .76 mm) - 1-2 cm- 1-2 cmiii. thicker lesion – 3 cm marginiii. thicker lesion – 3 cm margin- excision is up to the deep fascia- excision is up to the deep fascia

- chemotherapy- chemotherapy- palpable nodes are removed by regional - palpable nodes are removed by regional dissectiondissection