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05a April, 2018

INTRODUCTION TO CLINICAL DERMATOLOGY
Dr. Joan Rosal Patricio
Department of Internal Medicine

TOPIC OUTLINE  And stratum basale / is the deepest layer of the epidermis. Other cells
I. What is Dermatology? found in this layer include melanocytes, Langerhans cells (immune
II. Normal Skin cells), and Merkel cells (touch receptors).
III. Approach to Dermatologic Diagnosis  The second layer of the skin is the dermis which is 15 to 40x thicker
a. Morphology than the epidermis. The dermis consists of dense fibrous connective
i. Type of Lesion tissue whose predominant component is collagen. The collagen fibers
- Primary serves as the basis for recognizing the 2 layers of dermis. The/
- Secondary papillary dermis which is the thin zone immediately beneath the
ii. Color epidermis consists of relative small, finely textured collagen fibers
iii. Shape and/ and the reticular dermis/ which is the thick zone that extends
iv. Arrangement beneath the papillary layer to the surface of the subcutaneous fat. The
v. Distribution reticular layer consists of larger, more coarsely textured collagen
b. Complete History fibers.
c. Diagnostic Techniques
APPROACH TO DERMATOLOGIC DIAGNOSIS
Italics = notes in pptx Morphology
 Appearance and structure, irrespective of etiology or
WHAT IS DERMATOLOGY?
pathophysiology
 Field of Medicine that deals with the macroscopic study of the skin,
adjacent mucosa and cutaneous adnexa
 Dermatopathology – deals with the microscopic study of the skin Type of Lesion
 In contrast to other fields of clinical medicine, the lesions are examined Primary Lesions
first before a detailed history is taken. In this regard, diagnostic  Macule
accuracy is higher.

NORMAL SKIN

o Flat, circumscribed
o Hypo- or hyperpigmented
o < 2 cm in diameter
o e.g. Ephelides

 Patch

 We will again reorient ourselves with the normal histology of the skin.
Strictly speaking/ the skin is made up of 2 parts, an outer layer, the
epidermis/ and an inner layer, the dermis which rests on and is o Flat, circumscribed
attached to the hypodermis or subcutaneous fat o Hypo- or hyperpigmented
 The epidermis is the thinnest component of the skin. It is composed of o > 2 cm in diameter
different layers characterized by the keratinocyte changes as they o e.g. Vitiligo
migrate upward toward maturation.
 Starting from the top layer we have the stratum corneum, it is the  Papule
outermost layer of the epidermis, consisting of keratinocytes that lack
nuclei and organelles
 In the palms and soles, we have an additional layer called the stratum
lucidum. it is composed of three to five layers of dead, flattened
keratinocytes.
 The stratum granulosum/ (or granular layer) is a layer formed
when keratonicytes from the underlying stratum spinosum become
granular. These cells contain keratohyalin granules.
o Elevated thus palpable
 The stratum spinosum located above the basal layer is where o Firm
keratinization begins. o < 0.5 cm in diameter
o e.g. Milium

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o Fluid-filled
o Clear or hemorrhagic
 Nodule o > 0.5 cm cm in diameter
o e.g. Bullous pemphigoid

 Pustule

o Palpable, circumscribed
o Greatest mass maybe below skin surface
o 0.5 to 5.0 cm in diameter
o NOT a vesicle
o e.g. Basal cell carcinoma
o Contains purulent material
o < 0.5 cm in diameter
 Tumor
o e.g. Folliculitis

 Wheal

o Palpable, circumscribed
o Benign or malignant o Edematous papule or plaque
o > 5.0 cm in diameter o Evanescent
o e.g. Familial multiple lipomatosis o e.g. Dermatographism

 Plaque  Telangiectasia

o Raised, plateau-like o Superficial dialted blood vessel

o Distinct or indistinct margins o e.g. Spider nevi
o > 1.0 cm in diameter
o e.g. Psoriasis Secondary Lesions
 Crust
 Vesicle

o Dried serum, blood or pus on the surface

o Fluid-filled
o Often translucent - Impetigo contagiosa
o < 0.5 cm cm in diameter - Thin and easily removed
o e.g. Herpes Zoster - Thick and adherent
- Yellow – serum
 Bulla - Dark red, brown or black – blood
- Green, yellow-green - pus

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 Scale  Atrophy

o Excessive accumulation of stratum corneum

o Epidermal: thinned epidermis  wrinkled and shiny
o e.g. Psoriasis due to increased proliferation and or delayed
o Dermal: loss collagen  depression
desquamation
o e.g. Aging – cigarette paper wrinkling

 Fissure
 Lichenification

o Thickened epidermis
o Linear cleft in skin o Accentuation of skin markings
o Often painful o e.g. Lichen simplex chronicus
o e.g. Chronic hand dermatitis
 Excoriation
 Erosion

o Linear, angular erosions caused by scratching or packing

o e.g. Atopic dermatitis

 Scar
o Partial loss of epidermis
o Heals without scarring
o e.g. Pemphigus

 Ulcer

o Fibrous tissue replacement secondary to trauma

o Hypertrophic or atrophic
o e.g. Hypertrophic scar

Color
 Erythematous Red – exfoliative dermatitis
 Salmon Pink – psoriasis
 Black – warfarin-induced necrosis
 Gray – amiodarone-induced hyperpigmentation
o Full thickness loss of epidermis, may extend to dermis or
subcutis  Violaceous (Purple) – cutaneous vasculitis
o Heals with scarring  Blue – Mongolian spots
o e.g. Venous ulcer  White – vitiligo (secondary to autoimmune destruction of
o Always occurs in a pathologically altered tissue melanocytes
o Clue to diagnosis are the borders of the lesion (varicosities, stasis  Green – P. aeruginosa (secondary to pyoverdin – fluorescein)
dermatitis, lipodermatosclerosis)  Orange – Pityriasis rubra pilaris
 Yellow – xanthelasma (cutaneous deposition of lipids; patients are
mostly normolipemic
 Copper – secondary syphilis
 Brown – melasma

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Erythematoid Red and Salmon Pink Orange and Yellow

Copper and Brown

Black and Gray

Shape
 Annular – ring-shaped; the edge of the lesion is different from the
center
 Nummular – coin-shaped, uniform morphology from center to edge
 Polycyclic – coalescing circles, rings or incomplete rings; urticaria
 Arcuate – arc-shaped, incomplete formation of annular lesion;
Violaceous and Blue urticaria
 Linear – straight line; lichen nitidus
 Reticular – net-like or lacy; livedo reticularis
 Serpiginous – serpentine or snake-like; cutaneous larva migrans
 Targetoid – target-like; at least 3 distinct zones; erythema
multiforme
 Whorled – marble-like; 2 distinct colors interspersed in a wavy
pattern

Annular and Nummular

White and Green

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Polycylic and Arcuate Herpetiform and Scattered Arrangements

Distribution
 Dermatomal / Zosteriform
Linear and Reticular
o Unilateral and lying the distribution of a single spinal afferent
nerve root
 Blaschkoid
o Following lines of skin cell migration during embryogenesis
 Lymphangitic
o Along the distribution of lymph vessel
 Acral
o Occurring in distal locations
 Sun-protected
 Sun-exposed
 Extensor
o Over dorsal extremities
 Flexor
o Over flexor muscles
Serpiginous and Targetoid o Antecubital and popliteal fossa
 Localized
o Confined to a single body location
 Generalized
o Widespread
 Bilateral Symmetric
o Mirror-image
o Both sides of the body
 Universal
o Entire cutaneous surface

Dermatoform and Blaschkoid

Whorled

Sun-protected and Sun-exposed

Arrangement of Multiple Lesions

 Grouped / Herpetiform
o Lesions clustered together
 Scattered
o Irregularly distributed

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Extensor and Flexor - Atopy (asthma, hay fever, eczema)

8. Family history (atopy, melanoma, psoriasis, acne)
9. Social (occupation, drug abuse) and travel history (endemic
areas)
10. Sexual history (risk factors for HIV: blood transfusion, multiple
partners, STDs)
11. Review of systems

Diagnostic Techniques
Skin Biopsy
 Simplest, most rewarding diagnostic technique
o Because of the easy accessibility of the skin and the variety of
techniques for study of the specimen (histopathology,
immunopathology, electron microscopy)
 Minor surgical procedure
Localized and Generalized  Local anesthesia: 1% Lidocaine +/- Epinephrine
 Reasons:
o Uncertainty of clinical diagnosis
o Poor response to therapy
o Exclude other conditions
o Investigate symptoms in the absence of clinically recognizable
disease

Shave Biopsy
 Superficial shave biopsy
o To remove benign and exophytic lesions

Bilateral symmetric and Universal

 Deep shave biopsy/ saucerization

o For superficial malignancies
o e.g. BCC, AK

Dermatologic History
1. Chief Complaint
2. Evolution of lesion
- When? (Onset/duration)
- Where? (Site of onset)
- How did it spread? (Pattern, centrifugal measles vs centripetal
Punch Biopsy
rocky mountain spotted fever)
- How did individual lesions change? (Color/shape)  Most common, 3-5 mm punch, twist downward like corkscrew, base
- Provocative factors? (Heat/cold, sun/photosensitivity, cut off with scissors
exercise, drugs, pregnancy)  Suspected pathology is within dermis or subcutis
3. Symptoms associated with the eruption
- Does it itch/hurt/numb? (Symptoms)
- What has relieved the symptoms? (Scratching, cool
environment)
- Time of day when symptoms are most severe? (Night/day)
4. Current/previous treatment (Topical/systemic)
5. Associated systemic symptoms (Prodrome: malaise, fever,
athralgia, weight loss)
6. Ongoing or previous illnesses (Recent hospitalization/operations,
immunizations, TB)
7. History of allergies
- Medications

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Incision (partial) / Excision (whole) Biopsy o Giemsa, Wright’s, methylene blue

 Lesions that require examination of the dermis or subcutaneous  Microscopy:
layer o Multinucleated giant cells (10-20 nuclei)
 In contrast to punch biopsy, require margins
Diascopy

 Pressing a microscopic slide over a skin lesion

 Red colored lesions:
o Blanches on pressure (Erythema)
KOH Preparation
o Does not blanch (Purpura)
o Granulomatous lesions → “Apple-jelly” color
 Erythema – capillary dilatation
 Purpuric – extravasation of blood
 Apple jelly – granulomatous lesion: sarcoidosis, cutaneous TB,
lymphoma, granuloma annulare

Wood’s Light

 Quick and inexpensive

 Detect presence of mycelia
 Specimen:
o Advancing borders (scales)
o Hair (plucked)
o Nail clippings
 KOH 10-20% solution
 Microscopy:
o Long branching hyphae
o Short hyphae and spores
o Pseudohyphae and budding yeasts
 The scale is removed using the dull edge of the scalpel and then  UV long-wave light 360nm (“black light”)
treated with 1-2 drops of potassium hydroxide solution  (+) Flourescence:
 KOH dissolves the keratin and allow easier visualization of the fungal o C. minutissimum – coral pink
elements o M. canis – yellow
 Slightly warming the slide with a low intensity flame accelerates the o Pseudomonas – pale blue
dissolution of the keratin o Vitiligo – white (accentuated)
 Short cigar-butt hyphae and spores – Tinea versicolor Depending on the disease, they will flouresce a certain color:
 Pseudohyphae and budding yeasts – Candida
 Erythrasma caused by C. minutissimum  Coral pink due to
coproporphyrin III
Tzanck Smear
 Tinea capitis (ectothrix) caused by M. canis  Yellow due to
pteridine
 Pseudomonas  Pale blue due to pyocyanin
 Pseudomonas  Yellow-green due to fluorescein
 Pseudomonas  Black due pyomelanin
 “Odor of grapes”  trimethylamine
 Vitiligo  “accentuated” brighter than surrounding normal skin
In the absence of epidermal melanin, which absorbs most of the UVA light,
photons reach the dermis and is absorbed by collagen that flouresces
 Cytologic technique
emitting a bright light.
 Herpesvirus infections
 Specimen:
o Early vesicle (base)
 Stains:

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Patch Test

 Document sensitivity to a specific antigen

 Suspected allergens are applied using Finn chambers
 Left under occlusion for 48 hours
 (+) DTH reaction: papular vesicular lesion

TABLES IN HARRISON’S 19TH ED.

TRANSER’S MESSAGE

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