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1、Introduction,The etiology, symptom and diagnosis of skin disorders,Section one The etiology The causes of cutaneous disorders,Skin diseases are an immense subject, yet two thirds of skin diseases are due to fewer than ten conditions.Psychological factors, genetic factors, internal disease, drugs, in
2、fections;sunshine, heat and cold, chemicals, infections, trauma friction (allergens or irritants),General etiological factors,AgeSexjob or professionseason and weatherrace of peoplepersonal hygienesocial factors,1Extrinsic factors,Physical factorsChemical factorsBiological factors,2Intrinsic factors
3、,（1）heredityichthyosis、alphosis、epidermolysis bullosa、xeroderma pigmentosum（2）food：urticaria（3）dysmetabolismXanthoma, skin amyloidosis,Intrinsic factors,（4）endocrine disturbance：Acne, melasma（5）nerve injury factors dystrophia ulcer（6）psychological factorsAlopecia, polyidrosis, cholinergic urticaria,
4、Intrinsic factors,（7）accompany with some viscera disordersdiabetic patient with prutitusViscera malignancy with dermatomyosis or acanthosis nigrans,Pathogenesis of Skin Disease,Section twoThe menifestation of skin disaeses,Symptoms of skin diseasesPruritus：moderate or severe，long or short time， loca
5、l or generalizedPain： infection（bacteria，virusZoster）， Sweets syn., Angioleiomyoma, DermatomyositisNumbness：Leprosy with superficial sensory disturbance, hypoesthesia in temperature,pain and touch.Systematic symptoms,The signs of skin diseases-The lesions,The signs Lesions can be seen or palpable Th
6、e primary lesionsLesions with diagnostic value and produced by the pathological changes of skinThe secondary lesionslesions follow primary eruptions with scratching, therapy, infection or the process of recovery,Individual skin lesions are analogous to the letters of the alphabet, and groups of lesi
7、ons can be analogous to words or phrases.,Primary lesions,Primary lesions is the original lesions is the most important aspect of the dermatologic physical examinationMacules (patches)Papules (plaques)Nodules (mass or tumor)WhealsBullae and vesiclesPustulesCystes,Macule. A macule is a circumscribed,
8、 flat lesion that differs from surrounding skin because of its color. Macules may have any size or shape. A. They may be the result of hyperpigmentation (A), hypopigmentation, dermal pigmentation (B), vascular abnormalities, capillary dilatation (erythema) (C), or purpura (D). Macules with very fine
9、 scaling are called maculosquamous, as in tinea versicolor. B. The clinical appearance of an eruption that consists of multiple, well-defined red macules of varying size that blanch upon pressure (diascopy) and are thus due to inflammatory vasodilatation. This eruption represents a drug reaction.,Ma
10、cule,erythema,The macule of hyperpigmentation,The macule of hypopigmentation,The patch of depigmentation,Patches A patch is a large macule, 1cm or greater in diameter, as may be seen nevus lammeus or vitiligo,Papule. A papule is a small, solid, elevated lesion. Papules are smaller than 1 cm in diame
11、ter, and the major portion of a papule projects above the plane of the surrounding skin. A. Papules may result, for example, from metabolic deposits in the dermis,Papule,Papule,(A), from localized dermal cellular infiltrates (B), and from localized hyperplasia of cellular elements in the dermis or e
12、pidermis (vegetation) in: B. Two well-defined and dome-shaped papules of firm consistency and brownish color, which are dermal melanocytic nevi;(C). Papules with scaling are referred to as papulosquamous lesions, as in psoriasis. Clinical examples of papules are shown C. multiple, well-defined, and
13、coalescing papules of varying size are seen. Their violaceous color, glistening surface, and flat tops are characteristic of lichen planus.,Plaque,Plaque,Plaque. A plaque, shown in the drawing (A), is a mesa-like elevation that occupies a relatively large surface area in comparison with its height a
14、bove the skin surface. Well-defined, reddish, scaling plaques that coalesce to cover large areas of the back and buttocks are seen in (B). There is some regression in the center, as is typical for psoriasis. Lichenification (C) represents thickening of skin and accentuation of skin markings. The pro
15、cess results from repeated rubbing and frequently develops in persons with atopy; it can occur in eczematous dermatitis or other conditions associated with pruritus. Lesions of lichenification are not as well defined as most plaques are and often show signs of scratching, such as excoriations and cr
16、usts.,(A),(B),(C),plaque,Nodule. A nodule is a palpable, solid, round or ellipsoidal lesion. Depth of involvement and/or substantive palpability rather than diameter differentiate a nodule from a papule,Nodule,Nodule,A. Nodules may be located in the epidermis (B) or extend into the dermis or subcuta
17、neous tissue (A). (B). This photograph shows a well-defined, firm nodule with a smooth and glistening surface through which telangiectasia (dilated capillaries) can be seen; there is central crusting indicating tissue breakdown and thus incipient ulceration (nodular basal cell carcinoma). (C). Multi
18、ple nodules of varying size can be seen (melanoma metastases),(A),(B),(C),nodule,Wheal,Wheal,Wheal. A wheal (A) is a rounded or flat-topped papule or plaque that is characteristically evanescent, disappearing within hours. Wheals may be tiny papules 3 to 4 mm in diameter, as in cholinergic urticaria
19、 shown in the clinical photograph (B). They may be large, coalescing plaques, as in allergic reactions to penicillin, other drugs, or alimentary allergens, as shown in (C). An eruption consisting of wheals is termed urticaria and usually itches.,(A),(B),(C),Wheal,Vesicles and bullae are the technica
20、l terms for blisters. A vesicle is a circumscribed lesion that contains fluid.,(A), subcorneal vesicles (A) result from fluid accumulation just below the stratum corneum. Spongiotic vesicles (B) result from intercellular edema. A bulla is a vesicle larger than 0.5 cm. The clinical photograph (B) sho
21、ws multiple translucent subcorneal vesicles that are extremely fragile, collapse easily, and thus lead to crusting (arrows).,Vesicles,Vesicles,Vesicles,Vesicle. Shown in the drawing (A), acantholytic vesicles (A) result from cleavage within the epidermis due to loss of intercellular attachments. Bal
22、loon degeneration of epidermal cells leads to the formation of vesicles in certain viral infections (B), such as varicella-zoster. Vesicles characteristic of herpes zoster are shown in (B). They appear in crops and are grouped. Central umbilication can be seen in some of them,Vesicle. Subepidermal v
23、esicles, as shown in the drawing (A), occur as a consequence of pathologic changes in the region of the dermal-epidermal junction. Subepidermal vesicles and bullae are seen in bullous erythema multiforme, porphyria cutanea tarda, epidermolysis bullosa, dermatitis herpetiformis, and bullous pemphigoi
24、d.,papulovesicle,bullae,bullae,Pustule. A pustule is a papule that contains purulent exudate (A). Primary, nonfollicular pustules occur in pustular psoriasis (B). These very superficial, subcorneal pustules may coalesce to form lakes of pus.,Pustule,Pustule,pustule,Cyst. A cyst is a sac that contain
25、s liquid or semisolid material (fluid, cells, cell products). A spherical or oval nodule or papule may clinically be suspected of being a cyst if, on palpation, it is resilient; the eyeball, for example, feels like a cyst. The most common cysts, shown in the drawing (A), are epidermal cysts (A), whi
26、ch are lined with squamous epithelium and produce keratinous material. Cysts of pilar origin that are lined with multilayered epithelium, which does not mature through a granular layer, are pilar cysts (B). The bluish, resilient cyst, shown in (B), represents a cystic adnexal tumor (cystic hidradeno
27、ma), which is filled with a mucus-like material.,Cyst,Cyst,Secondary lesions,The primary lesions may be modified by regression, trauma, or other extraneous factors, producing Secondary lesions, such as:ScalesCrustsMaceration and ErosionsUlcersFissuresExcoriationScarsAtropyLichenification,Desquamatio
28、n(Scales) Abnormal shedding or accumulation of stratum corneum in perceptible flakes is called scaling and is shown in the drawing,Scales,scale,scale,(A). Parakeratotic scale (with retained nuclei) may be seen surmounting psoriasiform epidermal hyperplasia (A). Densely adherent scale with a gritty f
29、eel from a localized increase in the stratum corneum is seen in actinic keratoses (B). Typical psoriatic scaling is shown in the photograph (B). Scales that adhere tightly to the underlying epidermis may build up to form an asbestos-like layer that obscures the underlying lesion, as in the psoriatic
30、 plaque shown in (C).,Crusts (encrusted exudates, scabs) The dried serum, pus, or blood, usually mixed with epithelial and sometimes bacterial Crusts may be thick and adherent (B) Crusts are yellow when formed from dried serum, green or yellow-green when formed from purulent exudate, or brown or dar
31、k red when formed from blood. Superficial crusts that occur as honey-colored, delicate, glistening particulates on the surface are typical of impetigo and are illustrated in the photograph (B).,Crusts,maceration,Maceration: keratinocytes absorb more water for skin in the moist circumstance, then ski
32、n becomes soft, white and crinkled.,erosion,Loss of all or portions of the epidermis alone, may become crusted, but it heals without a scar.,Loss of al or portions fo the epidermis alone, as in impetigo or heres zoster or simplex after veesicles rupture, produces an erosionIt may or may not become c
33、rusted, but it heals without a scarAn erosion, as shown in the drawing (A), is a moist, circumscribed, usually depressed lesion that results from loss of all or a portion of the viable epidermis. Erosions remain after the roofs of vesicles and bullae become detached. Erosions also develop after epid
34、ermal necrosis as in toxic epidermal necrolysis, shown in the photograph (B).,Erosion,Ulcer. An ulcer, shown in (A), is the hole or defect that remains after an area of epidermis and at least part of the dermis have been destroyed or removed. Because the dermis is involved, ulcers heal with scarring
35、. The clinical photograph (B) shows a gigantic ulcer with a red, granulating base and well-defined, punched-out borders.,Ulcer.,ulcer,Ulcer,Fissure is a linear cleft through the epidermis or into the dermis caused by chronic inflammation asteaosis cutis,fissure,Excoriation,An excoriation is a puncta
36、te or linear abrasion produced by mechanical means, usually involving only the epidermis but not uncommonly reaching the papillary layer of the dermis,Scar. A scar is the fibrous tissue replacement that develops as a consequence of healing at the site of a prior ulcer or wound. A scar may be hypertr
37、ophic (A) or atrophic (B), as shown in the drawing (A). A typical clinical example of a hypertrophic scar is shown in the photograph (B).,Scar,Scar.,Atrophy. Atrophy refers to a diminution or thinning of the skin. It may be limited to the epidermis or the dermis or may occur simultaneously in both.
38、As shown in the drawing (A), epidermal atrophy (B) is manifested by a thin, almost transparent epidermis. Atrophic epidermis may or may not retain the normal skin lines. Dermal atrophy (A) results from a decrease in the papillary or reticular dermal connective tissue and is manifested as a depressio
39、n in the skin. Atrophy of subcutaneous tissue may also lead to depressions in the skin surface. Marked dermal and epidermal atrophy is shown in the photograph (B). Loss of normal skin texture, thinning, and wrinkling are present.,Atrophy,Atrophy of subcutaneuse tissue,Lichenification,Represents thic
40、kening of skin and accentuation of skin markings. The process results fromrepeated rubbing Frequently develops in persons with atopy; It can occur in eczematous dermatitis or other conditions associated with pruritus.,lichenification,Shape and arrangement of lesions,nodule,cyste,vesicle,bulla,plaque
41、,wheal,macules,patch,papule,fissure,erosion,ulcer,Pemphigus vulgaris. The bulla has been extended by applying pressure with the finger (Nikolskys sign).,Types of Skin Lesions,attention ：,1.Basic lesions can evolve (development)2.Primary to secondary lesions3. Primary and secondary lesions are not un
42、changeable. Such as pustules and pigmention,Section three The diagnosis of skin disorders,History takenPhysical examinationThe ditrbution and location of the lesionsThe kind of lesionThe character of lesions,The general medical history should include:,Identifying data: age, sex, and race. History of
43、 present illness, with particular regard to onset, evolution, and precipitating factors. Past medical history: illnesses, operations, hospital admissions, pregnancies, allergies (especially drug sensitivities), hazardous exposures, habits, and diet. In all cases, the presence or history of atopic di
44、sorders (asthma, hay fever, allergic rhinitis, atopic eczema) should be specifically asked about and recorded.,The general medical history,Present or recent medications (prescription and nonprescription); illicit drug use. Social history: birthplace, residence, travel, employment, hobbies, emotional
45、 status, pets. Sexual history, with particular attention to risk factors for sexually transmitted diseases.,The general medical history,Family history: skin diseases, allergies, atopic disorders diabetes, hypertension, bleeding disorders, anemia, and neurologic, muscular, intellectual, or emotional
46、disturbances. In pruritic patients, it is especially helpful to determine whether anyone at home, or with whom the patient has close physical contact, is also itching.,The general medical history,Review of systems: constitutional symptoms (fever, sweats, chills, headache, nausea, vomiting, etc.) may
47、 point to an “acute illness syndrome.” Fatigue, anorexia, weight loss, malaise, etc. may point to a “chronic illness syndrome.” Myalgias, arthralgias, arthritis, and Raynauds phenomenon may provide important clues to diagnosis. A careful review of those systems or organs in which pathologic changes
48、often occur simultaneously with skin changes should also be performedeyes, respiratory tract, cardiovascular system, gastrointestinal tract, genitourinary system, endocrine system, musculoskeletal system, lymph nodes, and nervous system, including psychiatric status.,The general medical history,The
49、history of a skin eruption should include an exact description of the onset, a careful description of the first lesions, the details of the development and extension of the lesions. In obtaining the history, careful questioning by the examiner is necessary to elucidate the relationship of the onset
50、of the initial eruption or of recurrences,The general medical history,(1) the patients occupation, (2) treatment obtained from a previous physician or self-administered, (3) the diagnosis such treatment was based on and how it was established,(4) the patients experience with prescription and nonpres
