DERMIS – DERMATOLOGY©

Dermis:

It lies underneath the epidermis. Its thickness varies from area to area. It is very thick
on the back and very thin on the nasal bridge. The thickness is about 1-3 mm. It is
thicker than the epidermis. The area under the epidermis is composed of papillae and
here fibers arranged loosely. This area is called “papillary dermis”. The deeper part
of the dermis, which contains hair follicles, eccrine glands called reticular dermis. So
dermis composed of papillary dermis and reticular dermis. There are projections from
the epidermis called rete pex protrude to the dermis. They are also called “dermal
papillae”. So the superficial layer of the dermis (upper part) is called the papillary
dermis. The advantage of these rete pex and papilli is to give more support between
the dermis and epidermis, so not easily separated.

In case of burns: There is formation of new skin and this pattern makes the
epidermis flat, so any slight trauma lead to separation and then lead to sub epidermal
blisters.

There are 3 types of Fibers in the dermis: Collagen, elastic and reticular fibers.
These fibers are embedded in an amorphous substance without ground substance.

1. Collagen Fibers:- Are the major components of the dermis. It comprises

70% of the dry weight of the skin. Collagen fibers are loose and fine in the
papillary dermis (upper part of the dermis). They are thick and form bundles
in the reticular dermis (lower part of the dermis). These collagen fibers are
composed of bundle and each bundle is 3-15 mm. These fibers are composed
of 3 major amino acids: hydroxy-prolin, hydroxylysin and glycin. They
stained red with routine stain haematoxyline-Eosin stain.

2. Elastic Fibers: They are much thinner than the collagen fibers. They require
special stain. They are coarser and thicker as we go deep into the dermis. The
main function of elastic fibers is that they are responsible for the elasticity of
the skin (resemble rubber) i.e action of re recciling of the skin. While the
collagen fibers are responsible for strength of the skin, so the main function is
pressure resistance.

3. Reticular Fibers: Very fine fibers normally found underneath the dermo
epidermal junction (Basement membrane zone). It is differ from collagen
fibers that it is finer and need special stain to be visualized, which is silver
stain. These fibers are the first fibers appear in the skin during fetal life. So
that they are abundant in the fetal skin but they are found in very small amount
in the normal skin.

Ground substance: Is mucopolysaccaride and need special stain.

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Blood Vessel of the skin:-

The epidermis has no blood vessels. It gets its nutrients from the dermis via the
dermo epidermal junction. In the dermis there are 2 plexus of blood vessels. The first
one is the superficial plexus in the upper part of the dermis just underneath the dermal
papillae and the 2nd plexus, which is the deep plexus around the hair follicle and
eccrine glands. The plexus is composed of arterioles, capillaries and venules. There
is also an intercommunicating plexus in between these 2 plexuses.

The vasculature of the skin is working about 10-30% of its capacity and it work to full
capacity when there is strenuous exercise such as running in which the body wants to
get rid of the excessive heat (so during exercise the vasculature of skin working may
reach 100% of its capacity). And in such instance skin will radiate heat so play a very
important role in the cooling system of the body.

EMBRYOLOGY OF THE SKIN:-

The epidermis and the skin appendages are all ectodermal in origin. The dermis
including collagen fibre, elastic and reticular fibers, and fibroblast and subcutaneous
fat are mesodermal in origin. The melanocyte and nerves are ectodermal (neural
crest) in origin.

In the dermis there are certain cells called “fibroblast” which produce collagen,
reticular, elastic fibers and also produce the ground substance in which these fibers
are embedded. Other cells found in the dermis as :”lymphocytes”, “Macrophages”,
and mast cells.

PIGMENTS WHICH PLAY A ROLE IN THE COLOR OF THE SKIN:-

There are 3 pigments: 1- Haemoglobin (Hb), 2-Melanin, 3-Carotin.

Haemoglobin:- Found in the RBC inside the blood vessels, it gives red color of the
skin. In certain inflammatory conditions in which the blood vessels are dilated the
skin become red in color. While the pale color of the skin which occur in anaemia for
example is due to decrease of lacking of oxy-haemoglobin pigments. The color
becomes blue in cyanosed patients because of increase of deoxy-Hb.

Melanin:- The dark skin is due to increase of melanin pigment while in the light or
fair skin there is decrease amount of melanin pigment. The same thing occurs in case
of color of the hair but here there is a special type of melanin pig. As follows:-

Red color: caused by erythromelanin- Black color caused by eumelanin.

Yellow color: caused by pheomelanin.
While in case of grey or white color there is no melanin.

Carotin: It is the precurser of vitamin A. it is deposited in the subcutaneous tissue

and so give the yellow color of the subcutaneous fat and play a role in the color of the
skin.

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If someone eat a lot of carrot, which is rich in carotin and the skin color, may turn
yellow (caraotinaemia). This case resembling jaundice but the sclera is white in case
of carotinaemia and yellow in jaundice.

EXAMINATION OF PATIENT IN DERMATOLOGY:-

Unlike other branches of medicine, we depend in the DX on the history taking and
examination. There is no ECG, no CT scan, no stethoscope is used, no
sphygmomanometer. Example of importance of history taking: patient which rash it
could be viral in origin or unknown aetiology or due to drug eruption. If the patient
said that he is taking ampicillin e.g. then think about drug eruption.

Lacnnee Law:- The patient is giving you the DX.

HISTORY:- Ask about:

 Duration of the illness,
 Site of the disease,
 Nature of the disease, symptom either itchy, painful, .. etc.,
 Drug history. Medical history e.g. diabetes mellitus.
 Occupational history is important as in eczema in housewives because of the
detergent or other example is cement dermatitis.
 Family history: is an important because some disease runs in families as
heredity.
Examination:-

Undressed the patient completely if it is possible because some lesion is not the true
one and there is another original lesion in other site. So examine the whole body skin.
We need source of light (good source of illumination) and you may use torch
sometimes and also you need magnifying lens for tiny lesions (to see them more
clearly). Examine the whole body skin regarding nails, hair and mucus membranes.

Dermatological Terminology:-

“ I ” PRIMARY LESIONS:-

1. Macule:- Well demarcated lesion, flat with change in the color of the skin. It
is less than 1 cm in diameter.

2. Papule:- Well demarcated slightly raised skin lesions and it is less than 0.5
cm in diameter.

3. Patch:- Large macule so it is defined as follow: well demarcated lesion, flat

characterized by change in the color of the skin and it is more than 1 cm in
diameter.

4. Plaque: Flat, well-demarcated lesion. It is slightly raised and its diameter is

more than 0.5 cm. E.g. of papule is viral wart. Example of plaque is Psoriatic
plaque. Example of macule and patch is pigmentory disorder of skin as
vetiligo.

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 5. Nodule: Hard lesion well-demarcated lesion, raised and larger than papule.
The majority is deep (i.e dermal or subcutaneous in position). In other words,
they lie deeper and are more infiltrative.

6. Vesicle: Papule which containing fluid. It is less than 0.5 cm in diameter.

7. Bulla:- is a large vesicle. So defined as papule-containing fluid larger than

0.5 cm in diameter.
Example of vesicle: Herpes simplex or herpes zoster vesicle.
Example of bulla : Blistering disorders.

Both vesicle and bullae are called blisters.

8. Pustule: a vesicle containing pus.

9. “Weal, or wheal” : Red or slight pink raised oedematous lesion. It is due to
extravasation of the fluid intravascular to the extravascular lie to the
surrounding tissues of the skin. It is characteristic feature of “Urticaria”.
- If oedema affect the skin, it will lead to weal.
- If oedema involve the subcutaneous tissue, it will lead to angio
oedema.

10. Cyst: Palpable mass, it is an epithelial-lined cavity containing fluid, semisolid

or solid material. E.g. is the epidermoid cyst (which is sometimes regards as a
sebaceous cyst but this is a common mistake because this cyst has no thing
with the sebaceous gland and it originate from the epidermis and thus it is
called the epidermoid cyst).
The entire above-mentioned lesions are primary lesions ie.the first
manifestation of the skin.

II SECONDARY LESIONS:

1. Crust : Dry exadate and epithelial debris. The exadate could be serum, blood
or pus.

2. Scale: Collection of fragments of stratum cornium, it could be fine or large

fragments called flects. Normally stratum cornium shed continuously but each
cell shed individually but if this occurs in collection then it will lead to
scaling. So it is loss of stratum cornium as collection of fragment not
individually as cells. E.g psoriasis.

3. Excoriation: Scratch marks or superficial erosions due to itching. Occur

especially in female with long, sharp nail lead to loss of the skin (superficial
erosion and even deep ulcer may occur). This is called scratches or
excoriation and it is caused by the patient.

4. Fissure: Linear breach in the skin (cracks) surrounded by an abrapt margins.

It is a feature of dry skin for example dry type of eczema.

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 5. Scar: Connective tissue replacement of loss of the skin, which occur due to
injury to the skin. It is not occur in superficial lesion but in deep lesion e.g.
1st degree burn heal without scar formation (superficial lesion). While 3rd
degree burn heals with scar formation because it is a deep lesion.

There are 2 types of scar:

 Atrophic scar: It is flat or slightly depressed scar. E.g is Acne scar.

Atrophic scar lead to a type of skin called pitted skin. Unfortunately,
there is no treatment for such type of scars.

 Hypertrophic scar: it is elevated or raised so called hypertrophic. If

the scar extends from the margin of injury, it is called keloid. Keloid
and hypertrophic scar can be treated with steroids that flattened these
types of scars.

6. Sinus: Fistula or track leading to the skin surface.

7. Ulcer: Loss of skin tissue. It could be superficial or deep. It has margins. It
may be regular or irregular.
8. Lichenification: Epidermal thickening with accentuation of skin markings
due to continuous rabbing as in case of allergic dermatitis lead to thickening
and exaggerations of skin markings. It becomes prominent as a feature of
pruritic condition.

CHANGES ENCOUNTERED IN THE SKIN:-

 Depigmentation : Couplete loss of skin pigments.

 Alopecia : hair loss.

 Petechae : Small purpura.

 Ecchymosis: Extravasation of RBC in the dermis, if small called petechae(as

we said), if large called ecchymosis and all full under the term of purpura. It
is all (i.e petechae and Ecchymosis) differentiated from other erythematous
conditions of the skin by pressing on the lesion. Ecchymosis and petechae do
not blanch with pressing them.

 Erythema: Red discoloration of the skin due to dilatation of blood vessels. It

black on pressure.

 Haemosiderosis: Red or brown pigment due to haemosiderin deposition in the

skin.

 Hyperpigmentation(Melanosis): Darkening of the skin due to high melanin

pigment.

 Hypopigmentation: Partial loss of skin pigments.

 Infiltration: Lesion involving deep parts of the skin.

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  Oedema: 2 types intracellular oedema of epidermis and extracellular oedema.
It is collection of fluid in the skin eg. Urticaria.

 Telangiectasia:- Permanent dilatation of blood vessels (not blanch on

pressure).

HISTOPATHOLOGICAL TERMS (MICROSCOPICAL CHANGES)

 Hyperkeratosis: .. In the thickness of stratum cornium e.g psoriasis.

 Parakeratosis: Retention of nuclei in the horny cells in stratum cornium

which is a feature of psoriasis and chronic eczeme. Normally no nuclei
present in stratum cornium cells.

 Dyskeratosis: Abn.keratinization of the dermis then it is not seen in upper

part of the epidermis as keratinization normally occur but seen in the middle
part of the epidermis. It is a feature of carcinoma in situ. As in case of solar
keratosis.

 Acanthosis: Increase in thickness of epidermis (normally 5-10 cell thickness).

E.g chronic eczeme.

 Acantholysis: Loss of adhesion between keratinocyte lead to become

separated. Normally these cells (keratinocytes) are connected by intercellular
bridges) lead to then the cell become dissociated from each other lead to
round, floating cells inside the epidermis and thus lead to formation of intra-
epidermal blisters. Best example is pemphigus vulgaris or pemphigus in
general.

 Spongiosis: Intercellular oedema (surround the cells) of the skin. (malpaghian

layer). Example: atopic dermatitis.

 Ballon degeneration: Intracellular oedema of skin (prickle cells). It is

characterized feature of herpes infection. (H.zoster or H.simplex).

 Atrophy: Thinning of nepidermis.

 Note: In the dermis we may have cellular infiltrate e.g. neutrophil, eosinophil,
mast cell. Depend on the pathological condition.

 Histiocyte … aggregation lead to granuloma (pathological cells) formation.