1.

02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS

TISSUE (PART2)
Dr. DULNUAN || 2-23-23 SURGERY 2
Transcribers: TABUNIAR,JAM/AFAN, MONICA
Editors: GAYODAN,KLYN

OUTLINE will form an abscess. It is always important to drain the

abscess.

I. INTRODUCTION
II. BACTERIAL INFECTION
III. VIRAL INFECTIONS
IV. NEOPLASM
V. REFERENCE

Impetigo Erysipelas
Legend:
Remember Lecturer Book
  🕮

I. INTRODUCTION
• divided into what kind of infections
• mostly bacterial infections, some are viral and
surgical implications

II. BACTERIAL INFECTIONS Cellulitis

2. Complicated skin infections
What do you think the most common bacterial o Surface area >75cm2
infections of the skin? o Deeper infections extending below the
- Staphylococcus Aureus (44%) dermis

• Most common isolate:

o Staphylococcus aureus (44%) A. EXTENSIVE CELLULITIS
o Enterococcus -Similar to treatment of simple cellulitis
o Beta hemolytic
anything with history of DM, Trauma, and other
o Immunocompromised host:
comorbid condition(cirrhosis). Also arise in Bites. from the
▪ Pseudomonas
past lecture, we mention that the hand is common
▪ E. coli
location for animal bites, that will lead to cellulitis.
▪ Enterobacter
▪ Klebsiella o Initial antibiotics will need coverage for
Management guide: beta hemolytic streptococci
o MRSA coverage if no improvement in
1. Uncomplicated skin infections symptoms:
• Surface area <75cm2 ✓ Vancomycin (first line)
• Common uncomplicated skin infections are: ✓ Clindamycin -> increasing resistance
o Impetigo rates to antibiotic
o Erysipelas ✓ Linezolid, Daptomycin, Tigecycline,
o Cellulitis Telavancin
o Folliculitis
Impetigo are very distinct because anything that has B. NECROTIZING SOFT TISSUE INFECTIONS (NSTI)
honey colored rusting can be impetigo.
Erysipelas is a reddish diffused infection on the sun
exposed area of the face.
Cellulitis is a diffused infection that goes up to the
dermis to the subcutaneous tissue. Red and tender to
touch.
Folliculitis inflammation of the hair follicles and can
affect any place where there is a hair follicle.
Complicated version of folliculitis is the CARBUNCLE
when they coalesce, and when they progress(worsen) it • Clinical presentation
- necrotic tissue with dead muscle,
thrombosed vessels, dishwater fluid
Page 1 of 6
[SURGERY 2] 1.02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS TISSUE (PART2)– Dr. DULNUAN
- (+) finger test o Epidermodysplasia verruciformis - HPV 5,
8 (autosomal recessive, high rate of
Para silang zombie, naghihiwalay yung mga skin nila malignant transformation)
at mabilis ang progression. Treatment :
o Regress spontaneously in the
• Risk Factors
immunocompetent patient
- Diabetes mellitus
Do not operate on cutaneous viral infection
- IV drug abuse
because there are other treatment to do.
- Obesity Alcohol abuse
- Immune suppression
- Malnutrition 2. MUCOSAL
o Mucosal (Condyloma acuminata)
3 Types (pathogenic isolates)
o Low risk - HPV 6, 11
• Gram positive, Gram negative, Anaerobic
o High risk - HPV 16, 18, 31, 33
bacteria (Clostridium perfringens, C. septicum)
o Treatment
• Beta-hemolytic Streptococcus or Staphylococcus
▪ Cryotherapy
species (trauma history, toxic shocks)
▪ Salicyclic acid, silver nitrate
• V. vulnificus (skin exposed from a of a body of salt
water)  Malignancy for Condyloma acuminata is cervical
Principles of Management of NSTI
III. NEOPLASM
• Source control with wide surgical debridement
• Broad spectrum antibiotics
• Supportive care and rescucitation

Need to diagnosed NSTI very early in order to

remove all damage tissue. (wide debridma)

C. ACTINOMYCOSIS
• Inhabit the oropharynx, GI tract, female genital
tract
• Clinical presentation: pyogenic infection of the
submandibular or paramandibular area
• Treatment: High dose penicillin therapy
rescucitation
A. BENIGN NEOPLASM

1. HEMANGIOMA

● Arise from proliferation of endothelial cells

● Present at birth (rapid growth)— gradual
involution (90%)
II. VIRAL INFECTIONS
● GLUT-1 glucose transporter protein puts
A. HPV them at risk of consumptive
coagulopathy
● Treatment:
1. CUTANEOUS ○ Propranolol
o Verruca vulgaris - HPV 1, 2, 4 ○ Laser therapy
o Plantar and Palmar warts - HPV 1, 4 ○ Selective embolization then
o Plane warts - HPV 3, 10 surgical debulking

Page 2 of 6
[SURGERY 2] 1.02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS TISSUE (PART2)– Dr. DULNUAN
Because the hemangiomas are large they consume a 4. SOFT TISSUE TUMORS
lot of cardiac output and can lead to heart failure and
consumptive coagulopathy. Usually it is indication for • Acrochordons (Skin tags)
resection with 90 % involute at 5 years of age, if does not
involute, treat it with propranolol and need to operate.
Hemangioma can also affect the airway. They can’t
breath and we use tracheostomy and surgery to treat.
There is high risk of recurrence.
The glut 1, weirdly present and greater risk with
consumptive coagulopathy.
The bigger – surgical debulking and selective
embolization. Small- lazer therapy.
Embolization within 48 hrs for it to work.
• Pedunculated lesions made of epidermal
Any complications on hemagioma: major blood loss
keratinocytes surrounding a collagenous core
Collagen is the primary component of dermis.
2. NEVI

Types:
1. Dermatofibromas
o Pink to brown papules that pucker in the
center when the lesion is pinched
o Usually present in females, lower
extremities

● Areas of melanocytic hyperplasia

(different area)
● Typically symmetric and small
○ Epidermis: junctional
○ Partially on the dermis:
compound
○ Dermis: dermal Appearance: Hollow in the center
● Treatment: Recommendation is excision
○ Serial Excision
2. Lipoma (fats)
3. CYSTIC LESIONS o Most common subcutaneous neoplasm
● Epidermoid cysts o Painless, slow growing mobile mass of
○ Proliferation of epidermis resulting subcutaneous tissue
in keratin-plugged Well circumscribed and well demarcated and
pilosebaceous units (basic unit of asymptomatic because they grow in the
sweat glands) subcutaneous tissue. Low malignant potential.
○ Upper chest and neck (hole sa Simple primary incision.
gitna)
● Trichilemmal cyst 5. NEURAL TUMORS
○ Derived from outer sheath of hair • Neuromas
follicles o Disordered growth of Schwann cells and
○ On PE, more firm consistency nerve axons, typically arise from previous
○ Found in scalp in women usually. surgical scar lines
● Dermoid cysts ● Schwannomas
○ Persistent epithelium within ○ Proliferation of Schwann cells of
embryonic lines of fusion the peripheral nerve sheath
○ Anything midline location- fused ○ Related to Type 2
embryologically. (eyebrow, Neurofibromatosis
forehead, nosetip) ● Neurofibromas
Treatment: excision ○ Proliferation of nerve elements
○ Type 1 Neurofibromatosis (café
ole)
Page 3 of 6
[SURGERY 2] 1.02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS TISSUE (PART2)– Dr. DULNUAN
○ No schwann cells involve. ○ Ionizing radiation
○ HPV 16, 18
B. MALIGNANT NEOPLASM ○ Immunosuppression
○ Smoking
1. BASAL CELL CARCINOMA ○ Chronic wounds
• M>F, 60+ ○ Burn scars
• Risk factor ● Clinical presentation
o UVB>UVA during adolescence ○ Scaly or ulcerated papule or
o Immune suppression plaque
o Chemical exposure ○ Bleeding with minimal trauma is
o Ionizing radiation not uncommon
• Deficiency in the p53 tumor suppressor gene ● Marjolin’s ulcer: SCC arising from chronic
(50%) wounds or burn scars
Mostly seen on the nose or tip of the nose, ● Treatment
upper lip. ○ Wide surgical excision

• Subtypes 3. MELANOMA
o Nodular
▪ Raised, pink papules with
telangiectasias and depressed
tumor center, “rodent ulcer”
appearance
o Micronodular
o Superficial spreading
o Infiltrative
o Morpheaform (Aggressive)

• Treatment
o Depends on the size, location, high or low
risk
o Small, primary BCC: 4mm margins
• Arise from melanocytes at the epidermal-dermal
o Large BCC: 10mm margins
junction but may also originate from mucosal
ALWAYS EXCISION in surgery
surfaces
• Risk factor
o Exposure to UV radiation
o Childhood sunburns
o Family history

 Practice pearls (ABCDE)

A Asymmetric

B Borders (irregular)

C Color variations

2. SQUAMOUS CELL CARCINOMA D Diameter greater than 6 mm

E Evolution or change

• Clinical presentation
o Often start as localized, radial growth
followed by a more aggressive, vertical
growth phase
• Types
o Superficial spreading: arise from precursor
● Second most common skin cancer melanocytic nervous (COMMON)
● Risk factors o Nodular: arise de novo, M>F, trunk (LESS
○ UV radiation exposure COMMON)
○ Fitzpatrick skin type I or II
Page 4 of 6
[SURGERY 2] 1.02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS TISSUE (PART2)– Dr. DULNUAN

o Lentigo maligna: sun exposed areas

5. KAPOSI’S SARCOMA
• STAGING • Epidermoid cysts
o Breslow tumor thickness (indicators for o Proliferation of epidermis resulting in
worse prognosis) keratin-plugged pilosebaceous units
▪ Tumor ulceration • Trichilemmal cyst
▪ Mitotic rate > 1 per mm2 o Derived from outer sheath of hair follicles
▪ Metastasis • Dermoid cysts
Staging for the depth of the tumor. o Persistent epithelium within embryonic
lines of fusion

6. DERMATOFIBROSARCOMA PROTRUBERANS

● Rare, low grade sarcoma of fibroblast

• Treatment
origin
o Wide excision with 10mm margins
● Low metastatic potential
o Completion lymphadenectomy is an
● Presents as a slow growing violaceous
option
mass
o Most common sites of metastasis are the
● Treatment is wide surgical excision with
lungs and liver
30mm mar
o Prophylactic lymph node dissection.

4. MERKEL CELL CARCINOMA

7. MALIGNANT FIBROUS HISTIOCYTOMA (rare)

● Soft tissue sarcomas seen in the head
and neck of elderly patients
● Surgery is the treatment of choice
Other name is Undifferentiated
• Neuroendocrine tumor of the skin
pleomorphic sarcoma/ mixofibrous sarcoma.
• Treatment entails wide surgical excision with
Treatment of choice: biopsy /surgery
peripheral deep-margin assessment
• Wide surgical excision, deep margin assessment.

Page 5 of 6
[SURGERY 2] 1.02 SUGICAL CONDITIONS OF THE SKIN AND SUBCUTANEOUS TISSUE (PART2)– Dr. DULNUAN

8. ANGIOSARCOMA
● Arise from vascular endothelial cells
● Usually presents as a red patch on the
face
● Cancer of vessel, rare.

9. EXTRAMAMMARY PAGET’S DISEASE

● Adenocarcinoma of the apocrine glands
○ May rise from the axillary,
perinatal and genital regions
● High incidence of concomitant
malignancies.

 IMPORTANT DIAGNOSTICS OF THIS CASES:

• Biopsy for its certainty
• CT-scan/MRI
• If skin is involved: do biopsy
• Melanoma: sentinel biopsy
o Inject die, radioactive for it to trace the
surrounding lymph nodes, green if
positive(lymphadenectomy)

 REMEMBER ALL THE TREATMENT PER CONDITIONS.

IV. REFERRENCE
• PPT of doc Dulnuan

Philippians 4:6,7
“Don't worry about anything; instead, pray about everything. Tell
God what you need, and thank him for all he has done.”

Page 6 of 6