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Skin & Subcutaneous Tissue

Skin & Subcutaneous Tissue


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Published by sarguss14
Lecture on Diseases of the Skin and Subcutaneous Tissue
Lecture on Diseases of the Skin and Subcutaneous Tissue

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Published by: sarguss14 on Aug 14, 2008
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This session will provide the students with a quick overview of skin anatomy/histology, physiology, common skin tumors, skin cancer, melanoma We’ll cover what is skin cancer, what causes it, how to spot it early if it occurs, some treatment options, and what can be done to prevent it. That this will serve as a challenge for students to seek more knowledge

Learning Objectives
 

Review Anatomy/Histology/Physiology of the skin Identify and be able to differentiate common skin lesions and benign tumors Identify clinical characteristics of
– Precancerous lesions – Common skin cancers

 

Define risk factors for development of skin cancer Choose appropriate methods for diagnosis and treatment

A Look at Normal Skin

A Look at Normal Skin
Skin is composed of two primary layers
•Epidermis - ectodermally derived outer layer composed of
keratinized stratified squamous epithelium. •Dermis - mesodermally derived layer of dense irregular collagenous connective tissue that underlies and interdigitates with the epidermis. Hypodermis is a loose connective tissue containing varying amounts of adipose that underlies and supports the skin; it is the superficial fascia that covers the entire body.


  

Serves as a barrier to physical, biological, and chemical agents and to radiation Regulates body temperature (thermoregulation) by evaporative cooling (perspiration), heat radiation at the surface of the body (blood circulation), and serves as insulation (a minor function in humans) Site of excretion through sweat glands Photochemical production of vitamin D Serves as a sensory organ

Injuries to the Skin & Subcutaneous Tissue
    

Traumatic Injuries Caustic Injuries Extremes of Temperature Radiation Injuries Pressure Ulcers

Decubitus Ulcer (Pressure sores)

Bacterial Infections


Bacterial Infections


Bacterial Infection

A carbuncle is a deep-seated infection of the skin and underlying tissue that typically forms in closely placed hair follicles.

Bacterial Infection


Staphylococcal Scalding Skin Syndrome (SSSS)

Toxic Epidermal Necrolysis (TEN)

Pyoderma gangrenosum

Fournier’s Gangrene


Meleney’s Gangrene

Evidence of early recurrence following ‘primary’ closure.

Hidradenitis suppurativa ‘severe’ group.


Pilonidal Disease

Actinomycosis w/ sulphur granules



Hypertrophic Scar


Port Wine Stains

Glomus Tumor

Symptoms usually consist of a triad •severe paroxysmal pain--the pain can be excruciating and is described as a burning or bursting •localized tenderness •extreme cold sensitivity

Vascular Malformations


. Expressing the lipoma.

Sebaceous cyst

Neurofibromatosi s

Ganglion Cyst

Popliteal Cyst

Seborrheic keratoses


Why is skin cancer important?

 

It’s the most common type of cancer in the United States; about 40 to 50 percent of Americans who live to age 65 will be diagnosed with it, at least once; it’s found in more than 1 million Americans each year; it will kill nearly 8,000 people; …. and it is largely preventable.

Is skin cancer deadly?

… it depends on the type of skin cancer, and how or if it’s treated, as we’ll discuss in this session.

Skin Cancer

The major factor in skin cancer formation is sun exposure Skin type is also important in dictating how the skin reacts to the sun
Pale Celtic skin is most at risk Dark afrocaribean skin is least at risk

What causes skin cancer?
 

 

Ftq`Ì xqwÌ`yhtqdw vHIu Ì`ch` whts may be the main cause of skin cancer. Artificially-produced UV radiation, such as from sunlamps and tanning booths, also can cause skin cancer. Predisposition (genetics) Skin type is also important in dictating how the skin reacts to the sun
 Pale Celtic skin is most at risk  Dark afrocaribean skin is least at risk

Chemicals (e.g., trivalent inorganic arsenic).

Who is at risk for skin cancer?
    

 

Light skin color, hair color, eye color. Family history of skin cancer. Personal history of skin cancer. Certain types and a large number of moles. Freckles, which indicate sun sensitivity and sun damage. Chronic exposure to the sun. History of sunburns early in life.

The Sun and Man
Effects on the skin are acute and chronic  Acute - protective
- Skin tanning - Epidermal thickening - Sun burn

- Photocarcinogenesis - Photoaging

Ultraviolet Spectrum




X rays 100-280 280-210 310-400


UVC UVB UVA 100-280 280-315 315-400

Visible Light 400-700

Stratosphere - Ozone Layer

Dead Sea Level

Sea Level

Ultraviolet radiation

UVB rays (290-320 nm) are more likely than UVA rays (400-320 nm) to cause sunburn. But, UVA rays pass deeper into the skin. UVB radiation is thought to be the cause of melanoma and other types of skin cancer. UVA radiation may cause skin damage that can lead to skin cancer and cause premature aging of the skin.

 

Primary types
-Actinic keratosis - Leukoplakia - Bowen’s Disease

-Basal cell carcinoma -Squamous cell carcinoma -Melanoma -Others (of the specialized structures of the skin)

Actinic keratosis

A pre-cancerous condition of thick, scaly patches of sun-damaged skin. Also referred to as solar or senile keratosis.

Actinic (Solar)Keratosis(AK)
• 20 % give rise to squamous cell carcinoma • Appear on sun-exposed areas • Often multiple

Actinic keratoses

Hypertrophic AK’s

Actinic cheilitis

Treatment of AK’s

Liquid nitrogen cryotherapy Topical therapies – 5-FU (Efudex) – Imiquimod (Aldara)

Electrodessication and Curettage for hypertrophic lesions

Liquid nitrogen Cryotherapy

Residual hypopigmentation

Blister formation

Topical therapies
Efudex or Aldara

* 3-5 times per week * 6-8 weeks


•Found on mucous membrane (mouth, vulva, rectum) •Theraphy – cryotherapy or excision, cessation of predisposing faactors (i.e., chewing of tobacco)

Bowens Disease – squamous cell carcinoma in situ

Erythematous, sharp, irregular outline with crusting canter; multiple lesion often present When seen on penis vulva or oral cavity – termed Erythroplasia of Queyrat

Approximately 5% become invasive carcinoma Excision is most widely accepted treatment

Bowen’s Disease

Basal cell carcinoma (BCC)

Basal Cell Carcinoma

Skin cancer that arises from the basal cells, small round cells found in the lower part (or base) of the epidermis, the outer layer of the skin.

Basal Cell Carcinoma

Basal cell carcinoma accounts for more than 90 percent of all skin cancers in the United States. It is a slow-growing cancer that seldom spreads to other parts of the body, and generally is readily treatable. May erode into surrounding structures if not treated.

Basal Cell Carcinoma

BCC is the most frequent skin cancer (80%)  BCC is 4x more frequent than SCC

Metastases are rare (<1% of cases)  Local destruction of tissue

BCC- clinical types

Pigmented Infiltrative

Superficial Morpheaform

Nodular BCC

Chronic lesion Easy bleeding Pearly border Surface telangiectasias Head and neck, trunk, and extremities

Pigmented BCC

Similar to nodular but with black discoloration  Melanin deposits

Pigmented races Face, trunk, and scalp

Superficial BCC

Erythematous scaly plaque Slow growth Asymptomatic Trunk, extremities, face

Morpheaform BCC

Resembles scar Asymptomatic and slow growing Ill-defined margins Marked subclinical extension

Squamous Cell Carcinoma (SCC)

Squamous Cell Carcinoma
 

Cancer that begins in squamous cells, which are thin, flat cells that look like fish scales. Squamous cells are found in the tissue that forms the surface of the skin. Also found on other internal and external body surfaces.

Squamous Cell Carcinoma

More than 250,000 new cases of squamous cell carcinoma diagnosed each year. Often develop from sun damaged areas called solar or actinic keratosis. Look similar to basal cell carcinoma, and even actinic keratosis.

Squamous Cell Carcinoma

Similar in appearance to actinic keratosis and basal cell carcinoma.

SCC types

 

In-situ Bowen’s disease Erythroplasia of Queyrat Invasive SCC Keratoacanthoma

Bowen’s disease

In-situ SCC

Arsenic, HPV 16, radiation

Erythroplasia of Queyrat

In-situ SCC Uncircumcised men May progress to invasive SCC

Invasive SCC

Erythematous nodule Indurated lesion Sun-exposed skin  Men > women Slow growth

Invasive SCC


Low grade SCC Rapid growth over weeks Trauma, sun exposure, HPV 11 and 16 May progress to invasive SCC

SCC is locally invasive and destructive Metastases in 1-3% of cases  To lymph nodes – 50-73% survival  Distant sites (lungs) – Incurable

Treatment of SCC
 Efudex or aldara    Liquid nitrogen cryotherapy  Radiation therapy  Curettage electrodessication (ED/C)  Surgical excision

Bowen’s disease Erythroplasia of Queyrat

Invasive squamous cell carcinoma

Surgical excision Traditional Mohs surgery Radiation therapy

Malignant Melanoma (MM)


A form of skin cancer that arises in melanocytes, the cells that produce pigment and also are found in the epidermis. Melanomas usually begin in a mole, which is a benign cluster of melanocytes and other tissue.
Normal moles:

May be found when a pre-existing mole changes:
Early changes - forming a new black area - newly formed fine scales - itching in a mole More advanced changes - texture changes (becomes hard or lumpy) - itch, ooze, or bleed - usually do not cause pain

Risk factors- MM

Fair skin, red hair, and blue eyes Intermittent sun exposure
Sunburns Tanning beds

Freckles and melanocytic nevi Family history of melanoma

Clinical types- MM

Superficial spreading melanoma Lentigo maligna melanoma

Acral lentiginous melanoma

Nodular melanoma

Melanoma (the A-B-C and Ds)
Asymmetry -- The shape of one half does not
match the other.

Melanoma (the A-B-C and Ds)
Border -- The edges are often ragged, notched,
blurred, or irregular in outline; the pigment may spread into the surrounding skin.

Melanoma (the A-B-C and Ds) Color -- The color is uneven. Shades of black,
brown, and tan may be present. Areas of white, grey, red, pink, or blue also may be seen.

Melanoma (the A-B-C and Ds) Diameter -- There is a change in size, usually an
increase. Melanomas are usually larger than the eraser of a pencil (5 mm or 1/4 inch).

Stage 0 Melanoma
 Known as “cancer in situ,” meaning the lesion

contains cancer cells in only the outer layer of skin
 Also called noninvasive cancer

Stage IA Melanoma
 Size is less than 1.0

mm or smaller
 Has no ulceration  Is Clark’s level II or


Stage IB Melanoma
 Size is less than 1.0

mm or smaller and has ulceration or Clark’s level IV or V invasion
 Or, the size is

between 1.0 mm and

Stage IIA Melanoma
 Size is between 1.0

mm and 2.0 mm and has ulceration
 Or, the size is

between 2.0 mm and 4.0 mm and has no ulceration

Stage IIB Melanoma
 Size is between 2.0

mm and 4.0 mm and has ulceration
 Or, the size is larger

than 4.0 mm and has no ulceration

Stage IIC Melanoma

 Size is larger

than 4.0 mm and has ulceration

Stage III Melanoma

Any tumor size The cancer has spread to nearby lymph nodes and/or there is in-transit or satellite involvement Has not spread to other parts of the body

Stage IV Melanoma
Any tumor size The cancer has

spread to other parts of the body beyond the regional lymph nodes

Prognostic features- MM

Good prognosis  Breslow < 1mm Intermediate prognosis  Breslow 1-4mm Bad prognosis  Breslow >4mm

How is Melanoma Treated?
     

Treatment depends on the stage of melanoma More than one treatment may be used Surgery Immunotherapy Chemotherapy Radiation therapy

Cancer Treatment: Surgery
 

Surgery is standard treatment Removal of the tumor and surrounding skin tissue Lymphatic mapping and sentinel lymph node biopsy may be performed to see if the melanoma has spread to nearby lymph nodes If melanoma has spread to lymph nodes, the lymph nodes are removed Occasionally, a skin graft is done

Cancer Treatment: Surgery

Surgical excision
– In situ = 5 mm margin – Invasive= 1-3 cm depending on Breslow’s depth

Sentinel lymph node biopsy- MM

Recommended for MM with Breslow 1-4mm  Lymphadenectomy for positive nodes

Powerful prognostic feature for disseminated disease

It does not affect survival of patients

Uses materials made by the body or in a laboratory to boost patients’ natural defense against cancer Often effective against melanoma, particularity in reducing risk of recurrence Used in combination with surgery and/or chemotherapy or as part of a clinical trial Most commonly used are interferon alpha-2b and interleukin-2 Side effects may include fatigue, chills, fever, headache, and memory difficulties; sometimes treatment affects blood pressure and causes increased lung fluid

Cancer Treatment: Immunotherapy

 

Cancer Treatment: Chemotherapy
 

If melanoma has not spread beyond a limb (arm or leg), localized chemotherapy techniques may be used Systemic treatment is usually used when there is a high risk that the melanoma may spread or to control advanced disease Combinations of medications are being tested in clinical trials

Cancer Treatment: Radiation Therapy
 

Used most often to relieve symptoms caused by melanoma that has spread May also be used when surgery for a larger melanoma is limited by tumor location, after lymph node removal, or in combination with chemotherapy Can cause skin irritation, nausea, and fatigue

How can it be prevented?
Pick your parents very carefully!

While genetics isn’t the primary factor, having your parents keep you from getting sunburns as a child is important. Too late for that? Keep your kids from getting sunburns. Too late even for that? (Try to) keep their kids from getting sunburns. And, limit further overexposure and damage to your own skin.

 

Because ongoing, excess UV light is harmful even for adults:
 Probably leads to more skin cancer, plus….  Skin damage  Cataracts and other eye disorders  Immune system suppression

Skin Damage
  

Actinic keratosis Hyperplasia (thickening), leathery skin Solar degeneration, such as…
Wrinkles Atrophy (thinning skin) Pigmented and non-pigmented spots Elastin breakdown (sagging skin)

Cataracts and other eye disorders
UV radiation increases the likelihood of:
 Cataracts  Pterygium (i.e., tissue growth that can block vision)  Skin cancer around the eyes  Degeneration of the macula

Immune System Suppression

Overexposure to UV radiation may suppress proper functioning of the body's immune system and the skin's natural defenses

Methods of Preventing Long Term Skin Damage
  

Avoid sun Avoid midday sun Use photo-protective clothing, hats etc Use sunblocks

Avoid Sun
 

Almost impossible Society worships the bronzed body beautiful Even on a cloudy day, UV will get through to the earth’s surface Sunlight is tricky - it will reflect off water, sand and other structures and can get to you even in the shade

SEA Sand

Avoid the Mid-day Sun
 

Simple physics At mid-day the sun is directly above you and the amount of stratosphere it need to penetrate to get to you is less so more gets through Avoid sun exposure for an hour or two either side of mid-day

UV Radiation path lengths for differing Solar Elevation
Sun Directly Overhead








How to limit sun damage to skin?

 

Avoid exposure to the midday sun (10 a.m. to 2 p.m. standard time, or 11 a.m. to 3 p.m. daylight saving time) Wear protective clothing (sun hats, long sleeves, long pants) Apply and renew sunscreens (those with an SPF of 15 to 30 block most of the sun's harmful rays) Use UVA- and UVB-blocking sunglasses Watch the UV Index for your area

 

UV Protective Clothing

  

The finer the weave, the greater the protection Silk is best Nylon stockings have an SPF of about 2 Panama hats give poor protection - holes let light through Cotton cricket hat is better


Reflectant - reflect UVB and to a lesser extent UVA Absorbent - absorb principally UVB into specific chemicals and re-emit as insignificant quantities of heat

Sun Protection Factor

Indication of the amount of time it is safe to spend in the sun without burning ie an SPF of 10 would allow an exposure ten times greater than normal


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