8/10/2019 5_skin#1E77

1/34

EXAMINATION

OF THE

SKIN AND MUCOSAE

Dr. Sorin Stamate

8/10/2019 5_skin#1E77

2/34

GENERALITIES

TEGUMENTUM = WHAT COVERS

= is the outer covering of living tissue,

with complexes functions:

sensation

adaptive immune system

heat regulation

storage and synthesisexcretion

= semiological map

8/10/2019 5_skin#1E77

3/34

GENERALITIES

Thickness= 0,2 - 0,5mm (at the level of the eyelids)

4 - 8mm (at the level of the heels)

Surface =1,5 - 2 m2, with:

folds:

coarsely (inframammary, intergluteal, inguinal)

more discreet (the flexion face of joints)

fine (fingerprints)

palmary and plantar foldsmark the limits of

papillary crests

infundibular depressions (popularly - pores)

correspond to the openings of

sudoriferous glands channels or to

sebaceous follicles

8/10/2019 5_skin#1E77

4/34

GENERALITIES

3 layers:

The epidermis:

Superficial, no blood vessels Layers of cells melanocytes produce melanin

The dermis:

Connective tissue (collagenic, elastic and reticular

fibers, fibroblasts, mast cells) Nerves, blood vessels, lymphatic vessels, muscles,

Sebaceous glands, the channels of sebaceous glands

Role: derm is nutr i t ion, skin analyzer

The hypodermis: Adipose lobules separated by fibrous tracts,

Nerves, receptors, blood and lymphatic vessels,

Sudoriferous glands, the deeper portion of bulb of hair

Role: tegum ent support

8/10/2019 5_skin#1E77

5/34

SKIN GLANDS

Sudoriferous glands:

= merocrine glandsproduce sweat: water, chloride,

sodium, potassium, lactic acid, urea, fat acids,

mucopolysaccharides, glycoproteins, hydrosoluble

vitamins

Sebaceous glands

= holocrine glands

Open at the level of hair follicle produce sebum (oxycholesterin, cholesterin, unsaturated fat acids, soaps)

androgens increase secretion

estrogens decrease secretion

8/10/2019 5_skin#1E77

6/34

hair 1:

1hair shaft

2sebaceous gland

3epidermis

4dermis

5hair follicle

6hair bulb

7papill

8/10/2019 5_skin#1E77

7/34

HAIRS AND NAILS

= Annexa of skin

- visible from the outsideNAILS

= corneous thin sheets on the surface of the

distal phalangessource: nail matrix

the lunula is a part of the nail matrix

HAIR

the enlarged basal part of a hair within the skin =

ROOT

the part of a hair projecting beyond the skin =

SHAFT

8/10/2019 5_skin#1E77

8/34

CUTANEOUS SYMPTOMS:

PRURITUS

pruritus (latin) = itch

= cutaneous symptom produced by subliminal irritation of

nervous terminations by the mediators (histamine,

acetylcholine) which determines an attenuated pain

In producing pruritus, interfere:

Genetic factors

Psychological factorsemotional pruritus

Secondary lesions:

excoriations

lichenification

cutaneous infections

local pigmentations

degraded nails

8/10/2019 5_skin#1E77

9/34

Pruritus Prurigo(Prurigo =

papulous, pruriginous lesions, determining local pruritus)

PRURITUS

SECONDARY(Determined by cutaneous affections)

PRIMITIVE(SINE MATERIA)

GENERALIZE

LOCAL

8/10/2019 5_skin#1E77

10/34

SYSTEMIC PRURITUS

Appears in:

Jaundice syndromes(billiary salts retention;appears in pre-jaundice phase

Neoplasia; increases in night or in heat conditions)

Paraneoplasic pruritus(lymphoma, lymphosarcoma, carcinoma)

Diabetes mellitus(! Early signs)

Uremia(calcium deposits in the tegument irritation of nervousterminations)

Gout(teenagers)

8/10/2019 5_skin#1E77

11/34

SYSTEMIC PRURITUS

Appears in:

Parasitic infections

Hyperthyroid, hypothyroid, Cushing syndrome,

acromegaly, menopauses)

Senile (elasticity changes; + capillary fragility)

Drugs allergy

(usually along with urticarian eruption)

Scabies - intensive (specially during the night), +

grattage lesions

Other causes: psychological, gastric hypoacidity,

feriprive anemia/pernicious, avitaminose

8/10/2019 5_skin#1E77

12/34

LOCAL PRURITUS

Has preferential localization in several affections:

VulvarDiabetes mellitus (associated to candidose)

menopause (widow pruritus)

iron deficiency

lack of vitamins uterin/anexial neoplasia

psychogenic

Scrotal/Penian Diabetes mellitus

Prostate carcinoma

urinary tract infections (frequent urethritis)

psychogenic

8/10/2019 5_skin#1E77

13/34

LOCAL PRURITUS

Has preferential localization in several affections:

Abdomen, hips, extremities hepatitis, cirrhosis

Nasal:

asthma allergic rhinitis

lambliase (children)

uremia

morphinomania hyperfoliculinemia

Auricular

diabetes mellitus

8/10/2019 5_skin#1E77

14/34

LOCAL PRURITUS

Has preferential localization in several affections:

Scalp: alcohol abuse

pre-/postmenstrual

Anal:

parasitic infections

hemorrhoids

intestinal diseases

nearby infections

8/10/2019 5_skin#1E77

15/34

SKIN COLOUR CHANGES

Skin color: results from 4 natural pigments other pathologic ones

melanin (brown) oxyhemoglobin (bright red)mainly within arteries/capillaries

deoxyhemoglobin (more bluish)present in venous blood

carotene (yellow)

Special conditions/pathologic ones:

hemosiderin bilirubin

metals

Depends on: skin thickness light (artifical light distorts colours)

!!! The examination of skin color must be done in

sunlight

8/10/2019 5_skin#1E77

16/34

SKIN COLOUR CHANGES

CLASSIFICATION:

PALLOR

CYANOSIS

JAUNDICE

HYPERCAROTENEMIA

CHANGES OF SKIN PIGMENTATION

HYPEREMIA (redness of the skin)

8/10/2019 5_skin#1E77

17/34

PALLOR

= lighter color of the skin and visible mucosae, causes by areduced amount of oxyhemoglobin

Main causes: THICKENING OF THE SKIN (myxedema, edema)

LACK OF DEVELOPPMENT OF DERMAL CAPPILARIES

(hypogonadism in men - Egyptian picture aspect)

VASOCONSTRICTION (strong emotions, acutecirculatory failure)

ANAEMIA

(in association with tiredness and fatigue)

!!! Pallor is best appreciated where the epidermis is

thinnest: the fingernails, the lips, tongue, palpebral

conjunctiva, palmar skin

8/10/2019 5_skin#1E77

18/34

PALLOR

Different colors associated with pallor could be

correlated with the causes of the anemia+ f lavin ic shadehemolytic anemia

+ yel lowish shade - pernicious anemia

+ verd in ic shadeyoung girls chlorosis (green

sickness) = hypchromic anemia

+ l ighter yel low shadegastric neoplasia

+ cafe au lait shadebacterial endocarditis

+ white like paper shadeacute hemorrhagicanemia

8/10/2019 5_skin#1E77

19/34

PALLOR

Pallor is associated with clue signs that could

ascertain the origins of anemia: Koi lonych ia= spoon nails - anemia due to

iron deficiency (the nails are flattened and

have concavities) Hunter gloss i t ispernicious anemia

Inappetence & loss of w eight- neoplasia

Cutaneous hemo rrhagic mani festat ions(petechia, ecchymoses, hematomas)acute

leukemia, loss of blood

C OS S

8/10/2019 5_skin#1E77

20/34

CYANOSIS

= bluish color of the skin and mucosal surfaces due to the

presence in the circulating blood of an increased

quantity of reduced Hb (more than 5g/dl) or a different

type of Hb

- Disappears with digital pressure

CYANOSIS FALSE CYANOSIS

= discoloration of the skin induced by deposition of gold

salts (chrys ias is), silver salts (argyr ia), arsenic or othercompounds

N.B.

False cyanosis doesnt disappear with digital pressure

8/10/2019 5_skin#1E77

21/34

CYANOSIS

Due to abnormal hemoglobin

or rare type of hemoglobin

-Kansas Hb

- Methemoglobin

- Sulphuretted Hb

Due to an increased

quantity of reduced Hb

Increased quantity of reduced

Hb in the arterial blood

CYANOSIS

8/10/2019 5_skin#1E77

22/34

CYANOSIS DUE TO ABNORMAL Hb/rare Hb

Appears in patients without a cardiac and pulmonary

disease. They are rare conditions.METHEMOGLOBINEMIA:

Oxidative substances- intoxication with nitrites, fenacetin,

clorat de potasiu, derivati anilinici

Congenital/genetic- hemoglobin M

IdiopaticMethemoglobinemia nefamiliala

SULPHURETTED HEMOGLOBIN: Hijmans van der Berghtoxic cyanosis

- due to presence of sulphuretted hydrogen in intestine

Administration of drugs like fenacetinor sulphamides

8/10/2019 5_skin#1E77

23/34

CYANOSIS DUE TO AN QUANTITY OF

REDUCED Hb

The bluish color appears when the quantity of reduced

Hb in the arterial blood is more than 5 g/dl (Normally:

8/10/2019 5_skin#1E77

24/34

CYANOSIS

CYANOSIS

LOCALIZED

GENERALIZED

CENTRAL

PERIPHERAL

CARDIAC

/STASIS

PULMONARY

right-left SHUNT

8/10/2019 5_skin#1E77

25/34

PULMONARY CENTRAL CYANOSIS

This is the sign of respiratory insufficiency

Bad oxygenation (low arterial saturation) of arterial bloodin the lungs

Caused by:

Low alveolar oxygen pressure

Disturbances in gas exchange

Ventilation/perfusion mismatch

Characteristics:

Generalized (even the tongue is cyanotic) Warm (hypoxia induces vasodilatation)

Negative Lewis test (rubbing the ear lobe with the fingertips does

not make cyanosis to disappear)

Oxygen supplementation of the inspired air may correct cyanosis

CENTRAL CYANOSIS WITH RIGHT TO

8/10/2019 5_skin#1E77

26/34

CENTRAL CYANOSIS WITH RIGHT-TO-

LEFT SHUNT

It is also called the blue syndrome

Causes:- Congenital heart disease (CHD) with right-to-left

shunt (Fallot tetralogy)

Associated with retarded growth and physical

development, dyspnea on exertion, clubbing of the fingers

and toes

Positionsquatting.

Anoxic episodes (spells).

It is not influenced by oxygen administration

8/10/2019 5_skin#1E77

27/34

CENTRAL CYANOSIS

CENTRAL GENERALIZED PERIPHERAL

8/10/2019 5_skin#1E77

28/34

CENTRAL GENERALIZED PERIPHERAL

CYANOSIS (STASIS)

The sign of right heart failure

Accompanied by gravitational edema

Characters of peripheral cyanosis:

Respects blood peripheral circuits

DOESNT affect the tongue COLD (because of the low velocity of blood: stasis +

vasoconstriction)

Positive Lewis testrubbing the ear lobe with the

fingertips makes cyanosis to disappear becoming red) In CARDIOGENIC SHOCK patient presents pale cyanosis

due to vasoconstriction, marmoreal teguments, which

remain cold and cyanotic when adopting a declive position

LOCALIZED CYANOSIS

8/10/2019 5_skin#1E77

29/34

LOCALIZED CYANOSIS

ERYTHROCYANOSIS

Appears in POLYCYTHEMIA VERA

It is also called red cyanosis

Described by Osler in XIX century, as red like

roses in summer and blue like indigo in winter Color changes are more obvious in the areas

exposed to temperature variations (face and

hands) It is associated with pruritus sine materia which

commonly starts after a bath

LOCALIZED CYANOSIS

8/10/2019 5_skin#1E77

30/34

LOCALIZED CYANOSIS

It is due to an increased tissue oxygen extraction ofarterial blood produced by 2 mechanisms:

Decreased arterial supply

Slowing down of venous-capillary circulation

LOCALIZED

CYANOSIS

ACUTE

CHRONIC

Thrombophlebitis

(Phlegmatia coerulea)Arterial embolus

Peripheral chronic

ischemia syndrome

Acrocyanosis

LOCALIZED CYANOSIS

8/10/2019 5_skin#1E77

31/34

LOCALIZED CYANOSIS

ACROCYANOSIS

= refers to a persistent blue or cyanotic discoloration of thedigits, most commonly occurring in the hands although also

occurring in the face and feet as well

Appears in: cold exposure, phlebitis, chronic venous

failure, Raynaud syndrome

Causes: functional anomalies in capillary circulation

LIVEDO RETICULARIS- a lace-like purplish discoloration

- a particular aspect: RACEMOS LIVEDOpermanent red-violet arborizations??in SLE, PAN

- abdomen: acute pancreatitis

FACE CYANOSIS

venous thrombosis, superior cave vein syndrome

8/10/2019 5_skin#1E77

32/34

ACROCYANOSIS

8/10/2019 5_skin#1E77

33/34

THROMBOPHLEBITIS

8/10/2019 5_skin#1E77

34/34

LIVEDO RETICULARIS