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SKIN AND SUBCUTANEOUS TISSUE. I. Introduction A. Function 1. Protection 2. Thermoregulation 3. Sensory. B. Anatomy 1. Epidermis – most cellular layer a. keratinocytes – most numerous and forms a mechanical barrier b.Langerhan’s – immunologic function

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I. Introduction

A. Function

1. Protection

2. Thermoregulation

3. Sensory


B. Anatomy

1. Epidermis – most cellular layer

a. keratinocytes – most numerous

and forms a mechanical barrier

b.Langerhan’s – immunologic function

c. Melanocytes – pigment


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


II. Pathology produce collagen

A. Trauma

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

2. Lacerations – closed primarily


Lacerations
LACERATIONS produce collagen


B. Decubitus Ulcer or Pressure Ulcer produce collagen

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

- muscle more sensitive than skin to ischemia

- Tx. – debridement and grafting


Decubitus ulcer
DECUBITUS ULCER produce collagen


C. Keloid and Hypetrophic Scar produce collagen

- 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


Keloid
KELOID produce collagen


D. Infections produce collagen

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


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

- Tx. – drainage, currete


4. Staphyloccocal Scalded Skin Syndrome the saccrococygeal area, lined by granulation tissue

- 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


Staphylococcal scalded skin syndrome
STAPHYLOCOCCAL SCALDED SKIN SYNDROME the saccrococygeal area, lined by granulation tissue


5. Toxic Epidermal Necrolysis the saccrococygeal area, lined by granulation tissue

- 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


E. Benign Tumors the saccrococygeal area, lined by granulation tissue

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


F. Nevi the saccrococygeal area, lined by granulation tissue

1. Acquired

a. Junctional – epidermis

b. Compound – migrates partially

down to the dermis

c. Dermal – cells at dermal layer

- involutes


Acquired nevi
ACQUIRED NEVI the saccrococygeal area, lined by granulation tissue


2. Congenital – rare the saccrococygeal area, lined by granulation tissue

- large and may contain hair

- occurs in bathing trunks distribution

- Tx. - excision


Congenital nevi
CONGENITAL NEVI the saccrococygeal area, lined by granulation tissue


G. Vascular the saccrococygeal area, lined by granulation tissue

1. Hemangioma

a. capillary (strawberry)

- compressible, vascular lesion with sharp borders

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


b. Cavernous the saccrococygeal area, lined by granulation tissue

- 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


Glomus tumor
GLOMUS TUMOR the saccrococygeal area, lined by granulation tissue


H. Soft Tissue Tumors ( achrocordons, lipomas, dermatofibromas)

- Tx. – excision

I. Neural

- Neurofibromas (café-au-lait spots)

- associated with von Reklinghausen’s disease


J. Malignant Tumors dermatofibromas)

1. Epidemiology

a. malignant radiation

b. chemicals

c. viral

d. chronic irritation

e. immunosuppresion


2. Types dermatofibromas)

a. basal cell carcinoma

- most common

- slow growing, rare metastases

- excision with 2-4 mm margin


Basal cell carcinom
BASAL CELL CARCINOM dermatofibromas)


b. squamous cell carcinoma dermatofibromas)

- metastasizes faster

- Bowen’s 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

- Moh’s technique – serial excision to preserve skin


Squamous cell carcinoma
SQUAMOUS CELL CARCINOMA dermatofibromas)


Erythroplasi of queyrat
ERYTHROPLASI OF QUEYRAT dermatofibromas)


c. malignant melanoma dermatofibromas)

- arises from dysplastic melanocytes

i. superficial spreading

- most common (70%)

- flat with areas of regression


ii. nodular – 15-20% dermatofibromas)

- dark, slightly raised

- growth more vertical than radial

iii. lentigo malignant 5-10%

- best prognosis

- occurs in areas of high solar degeneration


Melanoma
MELANOMA dermatofibromas)


b. prognostication dermatofibromas)

i. Clark

ii. Breslow

iii other factors

- anatomic location – extremities better than trunk or face

- ulceration


- inflammatory infitrates dermatofibromas)

- 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


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