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BACKGROUND
Skin
Protective barrier
Bodys primary thermoregulatory organ
Melanin Production
Genetically activate factors
UV
o UV A (315 to 400 nm) majority of skin
damage
o UV B (240 to 315 nm) sunburn injury &
melanoma development
Hormones estrogen, ACTH, MSH
EPIDERMIS
Functions
Semipermeable barrier to chemical absorption
Prevents fluid loss
Protects against penetration of solar radiation
Rebuffs infectious agents
Composition
Very little ECM
Keratinocytes
o Transit time: 40-56 days
Layers of epidermis
Stratum germinatum
o Basal cells mitotically active, single layer of
least differentiated keratinocytes
Stratum spinosium
o Keratinocytes linked together Keratin
Keratin intermediate filaments, flexible
scaffolding resist external stress
Keratin 5 & 14
o Point mutations blistering
diseases (Epidermolysis bullosa)
o No mitotic activity
Stratum granulosum
o Cells accumulate keratohyalin granules
Stratum lucidum
Stratum corneum horny layer
o Keratinocytes age, lose intercellular connections
& shed
DERMIS
resist physical forces
soft tissue durability
Blood Supply: Vertical vascular channels interconnect
2 horizontal plexuses papillary dermis & dermalsubcutaneous junction
Glomus bodies tortuous arteriovenous shunts that
allow a substancial increase in superficial blood flow
when stimulated to open
Meissners, Ruffinis & Pacinis corpuscles transmit
info on local pressur, vibration & touch
Free nerve endings temperature, touch, pain & itch
sensations
Composition
ECM collection of fibrous proteins & associated
glycoproteins embedded in glycosaminoglycans &
proteoglycans
o architectural framework mechanical support
(nerves, vasculature and adnexal structures) &
viscoelasticity
o regulate neighboring cells (migration,
proliferation & survival)
Collagen main functional protein within
o 70% of dermal dry weight
o Remarkable tensible strength
o Tropocollagen collagen precursor
3 polypeptide chains: hydroxyproline,
hydroxylysine & glycine wrapped in
helix
o Type I collagen skin
Bite wounds
Etiology: Viridans streptococci, S. aureus, Eikenella
corrodens, H. influenza & -lactamase producing
bacteria
Dog bites most frequent animal related wound
o Pasteurella multocida, Staphylococcus species,
-hemolytic streptococci, E. corrodens,
Actinomyces, Fusobacterium
Contaminated wounds
Treatments: drainage, copious irrigation,
debridement of necrotic material, antibiotic therapy,
extremity immobilization & elevation
EXPOSURE TO CAUSTIC SUBSTANCES
Acidic Agents deep tissue coagulative injury
nerves, blood vessels, tendons & bone injury
Initial treatment: copious irrigation with water or
normal saline for 15-30 mins
Hydroflouric Acid cardiac arrhythmia
o Topical calcium carbonate gel
Alkaline agents fat saponifications tissue
penetration tissue damage
Liquifactive injury
Treatment: Immediate irrigation with continuous
flow of water for > 2 hours
IVF extravasation leakage of injectable fluids into
interstitial space --- Chemical burn
Produces injury via chemical toxicity, osmotic
toxicity or pressure effects in a closed environment
Associated Substances
o Cationic solutions K, Ca, HCO3
o Osmotically active chemicals TPN,
o Antibiotics or cytotoxic drugs
Dorsum of the hand most common site
Risk Factors
o undergoing chemotherapy
o newborn fragility, small caliber veins, poor
ability to verbalize pain, frequent use of
pressurized IVF
high concentration dextrose solutions,
calcium, bicarbonate, parenteral nutrition
o adults
chemotherapeutic agents: doxorubicin &
paclitaxel
Treatment: conservative
o
o
HYPER/HYPOTHERMIC INJURY
Skin exposed to temperature extremes
Hyperthermic Burns
Factors Affecting Degree of Tissue Injury
Temperature
Period
Method of exposure
RADIATION EXPOSURE
UV radiation
o UV A 400 to 315 nm
o UV B 315 to 290 nm
Acute sunburns, chronic skin damage
malignant degeneration
o UV C 290 to 200 nm
Absorbed by ozone layer
iatrogenic management
industrial/occupational applications
Management
Prompt Recognition
Broad spectrum IV antibiotics
Aggressive surgical debridement
ICU support
Aggressive fluid replacement - offset acute RF
Treatment
Excision
o Remove the entirety of cyst wall after resolution
of inflammation
Infected incision & drainage
KERATOSES (SEBORRHEIC, SOLAR)
Seborrheic Keratoses sun-exposed areas of the
body: face, forearms, back of hands
o Old age groups most notableon the chest, back
and abdomen
o Light brown/yellow lesions, velvety, grease
texture
o Premalignant lesions SCC
sudden eruption of multiple lesions
o Histological Findings: lesions contain atypical
appearing- keratinocytes & evidence of solar
damage
o Treatment:
Lesion destruction
Topical 5-FU
Surgical excision
Electrodessication
Dermabrasion
NEVI (ACQUIRED & CONGENITAL)
Acquired Melanocytic Nevi
Junctional nevus cells accumulate in the
epidermis
Compound mature nevus cells migrate partially
into the dermis
Dermal finally rest in dermal tissues
most undergo involution
Congenital Nevi rare
larger lesions with hair
Giant congenital lesions (giant hairy nevi) swim
trunk distribution, chest or back
May develop to malignant melanoma
Treatment
Total excision
Serial excisions with local tissue
expansion/advancement
VASCULAR TUMORS OF THE SKIN &
SUBCUTANEOUS TISSUES
Hemangiomas benign
Initially undergo rapid cellular proliferation over 1st
year of life & slowly involute throughout
Key Factors
exposure to UV radiation
Melanin
Chemicals carcinogens: tar, arsenic & nitrogen
mustard
Radiation therapy
HPV
Chronic irritation/Nonhealing areas burnscars,
sites of repeated bullous skin sloughing, decubitus
ulcers
Systemic immunologic dysfunction on
chemotherapy, with advanced HIV/AIDS,Transplant
patients
BASAL CELL CARCINOMA most common type of
skin cancer
Subtypes
Nodulocystic or noduloucerative waxy&
frequently cream colored
o Rolled pearly borderssurrounding a central ulcer
Superficial basal cell cancers red scaling lesion
on trunk
Micronodular
Infiltrative
Pigmented tan to black
Morpheaform flat, plaquelike lesion
o Relatively aggressive prompt excision
Basosquamous metastasize similar to SCC
slow growing
extremely rare metastasis
can cause local destruction
Treatment:
Small areas of cumulative damage excision
Small lesions curettage & electrodissection
Recommended: surgical excision with 1-cm margin
& histologic confirmation that margins are tumor
free
Tumors with aesthetic value Mohs Surgery
Palpable nodes Regional lymph nodes excision
Lesions arising in chronic wounds prophylactic
lymphadenectomy
Treatment:
o Radiation therapy
o Topical 5-FU
o Mohs micrographic surgery
o intralesional interferon injection
o retinoids + interferon
Nodular 15 to 20 % of melanomas
o Vertical growth phase during diagnosis
o Darker & raised
o aggressive lesion but similar prognosis with
superficial spreading
Lentigo maligna 4 to 15% of melanomas
o Common site: neck, face and back of hands of
elderly
o tend to become large but best prognosis because
invasive growth occurs late
Acral lentiginous type rare
o Most common sites: palms, soles
Subungual regions (great toe or thumb)
blue-black discooration of posterior nail fold
Diagnosis: Hutchinsons sign
pigmentation in the proximal or lateral
nail folds
o
o
Radiation therapy
Imatinib(?)