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. Epidermis most cellular layer
• a. keratinocytes most numerous
• and forms a mechanical barrier
• b.Langerhans immunologic function
• c. Melanocytes pigment

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• 2. Dermis supporting layer, mostly
  fibroblast which produce collagen
• 3. Basement layer dermal epidermal junction
• - first layer where blood vessel and
  lymphatics are present
• - if lesion has not crossed this layer, it is
  called an in-situ lesion

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• II. Pathology
• A. Trauma
• 1. Dirty and infected wounds debridement and
  closed by secondary intention
• 2. Lacerations closed primarily

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LACERATIONS
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• B. Decubitus Ulcer or Pressure Ulcer
• - excessive, unrelieved pressure (60 cm Hg
  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 scar nodularity remains
  within the incision
• - no treatment necessary
• 2. Keloid nodularity 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. Folliculitis infected hair follicle
• - caused by Staph. sp.
• - leads to furuncle ? carbuncle
• - Tx. incision and drainage and antibiotics
• 2. Hidradenitis suppuritiva
• - plugged apocrine gland in axilla and
  inguinal area
• - Tx. warm compress, hygiene,
  discontinuation of deodorants, open drainage if
  recurrent

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• 3. Pilonidal disease infected pilosebaceous
  cysts in the saccrococygeal area, lined by
  granulation tissue
• - Tx. drainage, currete

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• 4. Staphyloccocal Scalded Skin Syndrome
• - erythema, bullae formation, loss of
  epidermis
• - caused by exotoxin from staphyloccocal
  infection
• - similar to partial thickness burn
• -cleavage is in the granular layer
• - Tx. replace fluid, electrolytes, skin care,
• antibiotics

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STAPHYLOCOCCAL SCALDED SKIN SYNDROME
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• 5. Toxic Epidermal Necrolysis
• - Immunologic reaction to certain drugs such
  as sulfonamides, phenytoin, barbituates, and
  tetracycline
• - Tx. same as SSSS
• 6. Viral verruca vulgaris, associated with
  pappiloma virus
• - associated with squamous cell ca
• - Tx. chemical, electrocautery, surgery

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• E. Benign Tumors
• Cysts
• 1. epidermal sebaceous cysts, most common
• 2. Trichilemmal occurs more commonly in
  females
• 3. Dermoid results from epithelium
  trapped during midline closure in fetal
  development
• - Tx. - excision

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• F. Nevi
• 1. Acquired
• a. Junctional epidermis
• b. Compound migrates partially
• down to the dermis
• c. Dermal cells at dermal layer
• - involutes

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ACQUIRED NEVI
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• 2. Congenital rare
• - large and may contain hair
• - occurs in bathing trunks distribution
• - Tx. - excision

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CONGENITAL NEVI
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• G. Vascular
• 1. Hemangioma
• a. capillary (strawberry)
• - compressible, vascular lesion with sharp
  borders
• - located mostly in the face, scalp, and
  shoulder - observe, 90 involute

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• b. Cavernous
• - bright red or purple, with spongy
  consistency
• - Tx. excision
• 2. Vascular malformation
• - enlarged vascular spaces lined with non
  proliferating endothelial cells
• a. portwine stain capillary malformation
• - Tx. embolization
• b. glomus tumor painful blue gray nodules
• - arises from the glomus body or
  Sucquet- Hoyer canal found in the dermis and
  contributes 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 (café-au-lait spots)
• - associated with von Reklinghausens disease

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• J. Malignant Tumors
• 1. Epidemiology
• a. malignant radiation
• b. 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 Queyrat ca of the
  penis
• - lesion more than 1 cm has 50 chance of
  metastasis
• - Tx. excision with 1 cm margin
• - Mohs technique serial excision to
  preserve 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. nodular 15-20
• - dark, slightly raised
• - growth more vertical than radial
• iii. lentigo malignant 5-10
• - best prognosis
• - occurs in areas of high solar
  degeneration

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MELANOMA
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• b. prognostication
• i. Clark
• ii. Breslow
• iii other factors
• - anatomic location extremities better
  than trunk or face
• - ulceration

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• - inflammatory infitrates
• - sex
• - histologic type
• c. treatment
• - still primarily surgical
• i. in-situ - .5 to 1 cm margin
• ii. T1 (smaller than .76 mm)
• - 1-2 cm
• iii. thicker lesion 3 cm margin
• - excision is up to the deep fascia
• - chemotherapy
• - palpable nodes are removed by regional
  dissection