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INTRODUCTION
Skin
- largest human organ
- protective barrier, environmental buffer
- functions:
1. creates a semipermeable barrier to chemical absorption
2. prevents fluid loss
3. protects against penetration of solar radiation
4. rebuffs infectious agents
5. dermal durability resists physical forces
6. regulates body heat (body’s primary thermoregulatory organ)
- Extracellular Matrix (ECM): a collection of fibrous proteins and associated glycoproteins embedded in a
hydrated ground substance of glycosaminoglycans and proteoglycans; provides architectural framework
that imparts mechanical support and viscoelasticity; can regulate the neighboring cells, including their
ability to migrate, proliferate and survive injury
THE EPIDERMIS
- composed primarily of keratinocytes
- a dynamic, multilayered composite of maturing cells
- (internal to external): stratum germinatum stratum spinosumstratum granulosumstratum
lucidumstratum corneum
- basal cells: mitotically active, single cell layer of the least differentiated keratinocytes at the base of
epidermal structure; multiply leave the basal laminabegin differentiation and upward migration
- spinous layer: keratinocytes are linked together by tonofibrils = keratin
- entry into the granular layercells accumulate keratohyaline granules
- horny layerkeratinocytes age, lose their intercellular connections shed
- basal layer exitshedding=keratinocyte transit time = approx 40-56 days
- melanocytes and other cellular components w/n the skin deter absorption of harmful radiation
- melanocytes: initially derived from precursor cells of the eural crestextend dendritic processes upward
into epidermal tissues from their position beneath the basal cell layer; 1 melanocyte : 35 keratinocytes;
produce melanin from yrosine and cysteine
- pigment is packaged into melanoomes w/n the melanocyte cell body transported into the epidermis
via dendritic processesapocopation (dendritic processes are sheared off)melanin is transferred to
keratinocytes via phagocytosis
- Despite differences in skin tone, the density of melanocytes is constant among individuals. It is the rate of
melanin production, transfer to keratinocytes, and melanosome degradation that determine the degree of
skin pigmentation
- Genetically activated factors as well as ultraviolet (UV) radiation, hormones such as estrogen,
adrenocorticotropic hormone, and melanocyte-stimulating hormone, increase melanin production.
- Cutamelanocytes – play a critical role in neutralizing the sun’s harmful rays
- Exposure to UV lightdamageaffects the function of tumor suppressor genescell deathneoplastic
formation
- majority of solar radiation that reaches the Earth is UVA (315 to 400 nm)
- majority of skin damage is caused by UVB (240 to 315 nm)
- UVB is the major factor in sunburn injury, and is a known risk factor in the development of melanoma.
Although UVB causes considerable DNA damage in the skin, UVA has only recently has been shown to
damage DNA, proteins, and lipids.
- UV-related damage may be potentiated by ionizing radiation, viruses or chemical carcinogens
- Keratins – maintains cellular integrity; intermediate filaments found w/n the spindle layer; provide flexible
scaffolding (to resist external stress); mitotically active ones mainly express keratins 5 and 14
- Point mutations affecting these genes may result in blistering diseases, such as epidermolysis bullosa,
associated with spontaneous release of dermal-epidermal attachments.
- In addition to its role in resisting radiation, toxin absorption, and deforming forces, the skin is a critically
immunoreactive barrier.
- Following migration into epidermal structure from the bone marrow, Langerhans' cells act as the skin's
macrophages. This specialized cell type expresses class II major histocompatibility antigens, and has
antigen-presenting capabilities.
- In addition to initiating rejection of foreign bodies, Langerhans' cells play a crucial role in
immunosurveillance against viral infections and neoplasms of the skin.
THE DERMIS
- mostly comprised of structural proteins, and to a smaller degree, cellular components.
- Collagen: main functional protein within the dermis (70% of dermal dry weight); responsible for its
remarkable tensile strength.
- Tropocollagen: a collagen precursor, consists of three polypeptide chains (hydroxyproline, hydroxylysine,
- Although pheromone-producing apocrine glands play a distinct role in lower mammalian life, these structures
have not been shown to demonstrate significant activity in human populations.
- Hair follicles are mitotically active germinal centers that produce hair, a cylinder of tightly packed cornified
epithelial cells.
- The hairfollicle
- Production of hair
- Contains a reservoir of pluripotential stem cells critical in epidermal reproductivity
- capable of near limitless expansion to replace lost or injured cells
- restore epidermal continuity after wounding
- For example, in skin graft harvest, residual hair follicles supply new keratinocytes to regenerate the
epidermis and restore skin integrity.
C. HYPER-AND-HYPOTHERMIC INJURY
- skin exposed to extreme temperaturesignificant risk of hypo/hyperthermic injury
- zone of coagulation: central area of injury; exposed to the most direct heat transfernecrosis
- zone of stasis: surrounds the zone of coagulation; has marinal tissue perfusion and questionable viability
- zone of hyperemia: outermost area; most similar to uninjured tissue and demonstrates blood flow due to
the body’s response to injury
- hypothermic injury= (frostbite) results in the acute freezing of tissues and is the product of 2 factors: (a)
duration of exposure, (b) the temperature gradient at the skin surface
- Severe hypothermia primarily exerts its damaging effect by causing direct cellular injury to blood vessel walls
and microvascular thrombosis.
- the skin's tensile strength by 20% in a cold environment
- tx protocol for frostbite rapid rewarming, close observation, elevation and splinting, daily hydrotherapy,
and serial debridements
D. PRESSURE INJURY
- presure = pressure ulcer formation
- pressure applied to overlying tissues cutaneous vascular flowischemia of local tissues
- ≥1 hour of 60mmHg = histologically identifiable venous thrombosis, muscle degeneration, tissue necrosis
- normal arteriole (32mmHg), capillary (20mmHg), venule pressures (12mmHg)
- sitting can produce pressures as high as 300mmHg at the ischial tuberosities
- sacral pressure (150mmHg) when lying on a standard hospital mattress
- Patients unable to sense pain or shift their body weight (paraplegics or bedridden individuals) prolonged
elevated tissue pressures local necrosis
- Because muscle tissue is more sensitive to ischemia than skin, necrosis usually extends to a deeper area
than that apparent on superficial inspection.
- Tx:
- elements of pressure sore tx: relief of pressure, wound care, and systemic enhancement, such as
optimization of nutrition.
- Air flotation mattresses and gel seat cushions redistribute pressure = incidence of pressure ulcers=
cost-effective in the care of px at high risk
- nutritional support services to facilitate proper dietary intake
- Surgical management should include debridement of all necrotic tissue followed by thorough irrigation.
- Shallow ulcers may be allowed to close by secondary intention, but deeper wounds with involvement of
the underlying bone require surgical debridement and coverage
D. ACTINOMYCOSIS
- a granulomatous suppurative bacterial disease caused by Actinomyces
- In addition to Nocardia, Actinomadura, and Streptomyces, Actinomyces infections may produce deep
cutaneous infections that present as nodules and spread to form draining tracts within surrounding soft
tissue.
- 40-60% of the actinomycotic infections occur within the face or head
- Actinomycotic infection usually results following tooth extraction, odontogenic infection, or facial trauma
- Accurate diagnosis depends on careful histologic analysis, and the presence of sulfur granules within purulent
specimen is pathognomonic.
- Tx: Penicillin and sulfonamides; areas of deep-seated infection, abscess, or chronic scarring may require
surgical therapy
***Although effective, these techniques destroy any potential tissue sample for confirmatory pathology diagnosis
and tumor margin analysis.
- Surgical excision may be used to both effect complete tumor removal as well as allow proper laboratory
evaluation.
- Basal cell tumors located at areas of great aesthetic value, such as the cheek, nose, or lip, may be best
approached with Mohs' surgery.
- specialized dermatology surgeons: Mohs' surgery uses minimal tissue resection and immediate
microscopic analysis to confirm appropriate resection.
- Large tumors, those that invade surrounding structures, and aggressive histologic types (morpheaform,
infiltrative, and basosquamous) are best treated by surgical excision with 0.5-cm to 1-cm margins
Historically, the vertical thickness of the primary tumor (Breslow thickness) and the anatomic depth of
invasion (Clark level) have represented the dominant factors in the T classification.
- Tx of melanoma may range from simple excision to more complex lymphadenectomy or immunotherapy
- surgical excision is the management of choice: Lesions 1 mm or less in thickness can be treated with a 1-cm
margin. For lesions 1 mm to 4 mm thick, a 2-cm margin is recommended. Lesions of greater than 4 mm
may be treated with 3-cm margins.The surrounding tissue should be removed down to the fascia to
remove all lymphatic channels. If the deep fascia is not involved by the tumor, removing it does not affect
recurrence or survival rates, so the fascia is left intact.
- With lesions deeper than 4 mm, it is highly likely that the tumor cells already have spread to the regional
LNs and distant sites. Removal of the melanomatous LNs has no effect on survival. Most of these patients
die of metastatic disease before developing problems in regional nodes.
- Others:
1. prophylactic dissection – intermediate thickness tumors (T2 and T3, 1-4.0mm); no clinical evidence of
B. KAPOSI’S SARCOMA
- KS: appears as rubbery bluish nodules that occur primarily on the extremities but may appear anywhere on
the skin and viscera
- Usually multifocal rather than metastatic.
- Histo: lesions are composed of capillaries lined by atypical endothelial cells
- Early lesions may resemble hemangiomas, while older lesions contain more spindle cells and resemble
sarcomas.
- Classically, KS is seen in people of Eastern Europe or sub-Saharan Africa.
- locally aggressive but undergo periods of remission
- (+) AIDS or with immunosuppression from chemotherapy - occurs primarily in male homosexuals and not in
IV drug abusers or hemophiliacs. In this form of the disease, the lesions spread rapidly to the nodesGI
and respiratory tract often are involved.
- AIDS-related KS is associated with concurrent infection with a herpes-like virus.
- Tx for all types of KS consists of radiation to the lesions. Combination chemotherapy is effective in
controlling the disease, although most patients develop an opportunistic infection during or shortly after
treatment.
- Surgical treatment is reserved for lesions that interfere with vital functions, such as bowel obstruction or
airway compromise
D. ANGIOSARCOMA
- may arise spontaneously
- mostly on scalp, face, neck
- usually appear as a bruise that spontaneously bleeds or enlarges w/o trauma
- Stewart-Treves syndrome – tumors may also arise in areas of prior radiation therapy/in the setting of
chronic lymphedema of the arm (such as mastectomy)
- Tumor consists of anaplastic endothelial cells surrounding vascular channels
- Tx: total excision (occasional cure); for palliation: chemotherapy and radiation therapy
- Prognosis: usually poor; 5-yr survival rates = <20%
F. FIBROSARCOMA
- hard, irregular masses found in the subcutaneous fat
- fibroblasts appear markedy anaplastic w disorganized growth
- if not excised metastasis
- 5 yr survival rate after excision = 60%
G. LIPOSARCOMA
- arise in the deep muscle planes (and rarely from the subcutaneous tissue)
- occur most commonly on the thigh
- enlarging lipoma: excised and inspected to distinguish it from liposarcoma
- TOC: wide excision (radiation therapy reserved for metastatic disease)