Adult Eczema - Clinical Scenario

Front 1

what is the anatomy of the epidermis and dermis

Back 1

Keratinised epidermis is derived from basal cells.

Cells adhere via desmosomes.

Epidermal cells are keratinocytes, melanocytes and Langerhans cells.

Langerhans cells are antigen-presenting cells.

The basement membrane zone is a complex interaction of differing proteins.

Dermis is mainly composed of collagen, also elastin, hyaluronic acid and cells.

Subcutaneous tissue stores fat.

Appendages are hair, nails, sebaceous glands, eccrine and apocrine glands.

Hair and nails are formed from keratinised cells.Phases of the hair cycle are anagen, catagen and telogen.

Skin pH 5.5 is protective against microbial attack.

Skin colour depends on melanin and other pigments.

Front 2

Functions of the skin include

Back 2

barrier function, maintenance of fluid balance, regulation of body temperature, vitamin D synthesis and social communication.

Front 3

the thinnest sites of skin are the

Back 3

eyelids and scrotum

Front 4

the thickest sites of skin are the

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soles and palms

Front 5

Skin is made up of

Back 5

Epidermis

Basement membrane zone

Dermis

Subcutaneous tissue

Appendages: hair, glands, nails.

nb These layers are modified according to the needs of the specific area of the body. For example, the scalp is covered with thick hair, the palms have particularly thick epidermis and the face contains large numbers of sebaceous glands.

Front 6

epidermis is a dynamic structure acting as a

Back 6

semi-permeable barrier

Front 7

epidermis is a dynamic structure acting as a semi-permeable barrier with what layer in the surface (ie outter most layer)

Back 7

layer of flat “dead” (anuclear) cells at the surface (stratum corneum)

Front 8

the surface ie outter most layer, of the epidermis is the

Back 8

stratum corneum

Front 9

The epidermis regenerates in orderly fashion by cell division of

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keratinocytes in the basal layer, with maturing daughter cells becoming increasingly keratinised as they move to the skin surface.

Keratinocytes adhere because of desmosome complexes attached to the cell membranes.

Front 10

langerhan cells are what

Back 10

monocytes within the epidermis that recognise and process small molecules penetrating the skin surface.

These antigen-presenting cells are identified in tissue sections by characteristic surface markers.

Front 11

what cells in the basal layer of the epidermis protect against UV radiation

Back 11

Melanocytes in the basal layer protect the skin from ultraviolet radiation

Front 12

epidermis layers

Back 12

come lets get sun burnt

Stratum aka layer:

Corneum

Lucidum

Granulosum

Spinosum

Basale

between the basale stratum aka the basal layer and the dermis below it is the BASEMENT MEMBRANE

Front 13

the basement membrane is attached to cells in the basal layer aka stratum basale via

Back 13

hemidesmosomes

Front 14

Desmosomes make and break as

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keratinocytes move from basal layer to surface

Front 15

The dermis supports the epidermis by providing it with

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nutrients and toughness

Front 16

the dermis is mainly made up of

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collagen, with elastic fibres, ground substance, nerves, blood vessels and cellular infiltrations.

Front 17

what is the name of the area just below the epidermis basement membrane

Back 17

The papillary dermis is the upper portion beneath the epidermis, characterised by thin haphazardly arranged collagen fibres, thin elastic fibres and ground substance.

The lower portion is the reticular dermis, composed of coarse elastic fibres and thick collagen bundles parallel to the skin surface.

Front 18

below the epidermis and dermis is the

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subcutaneous tissue

Front 19

subcutaneous tissue is made up of

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lobules of adipose cells, which contain fat. These are surrounded by connective tissue, larger blood vessels and nerves.

Front 20

within the skin BVs can be found in the

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dermis and subcutaneous tissue

Front 21

skin appendages include

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Eccrine sweat apparatus

Pilosebaceous structures

Apocrine glands

Nails

Front 22

Eccrine sweat glands produce

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a hypotonic solution of water, sodium chloride, urea, ammonia and uric acid

Front 23

eccrine sweat glands are most on the

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palms, soles, axillae and forehead and are absent on the lips, labia minora, glans penis and prepuce

Front 24

eccrine sweat glands are found in what layer of the skin

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dermis

Front 25

eccrine sweat glands is controlled by

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hypothalamus

Front 26

Sweat is produced in response to

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exercise, high temperature (internal or environmental), spicy food, emotional stress and sometimes spontaneously

It reaches the skin surface via a coiled duct.

Front 27

Pilosebaceous structures produce

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terminal hair on the scalp and vellus hair on the body surface (short, thin, light coloured).

Front 28

what helps erect hair

Back 28

Smooth muscles (arrector pili) cause erection of the hairs on exposure to cold or fear (goose bumps).

Front 29

hair growth cycle includes

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growth phase (anagen) that lasts several years;

a short involutional phase (catagen);

and a resting phase that lasts for several months (telogen).

Anagen hairs have a pointed tip and telogen hairs have a clubbed or bulbous tip.

Front 30

Hair colour depends on

Back 30

the amount of melanin within the cortex during anagen

dark hair has more eumelanin melanosomes; fair hair fewer with more lamellated phaeomelanin; red hair has erythromelanin; grey/white hair very few melanocytes.

Front 31

Sebaceous glands produce

Back 31

sebum

Front 32

sebaceous glands are most concentrated on

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scalp & face where circulating androgens induce increased secretion at puberty.

Front 33

Sebum is secreted into the hair follicle except it in the labia, prepuce, nipple and areola, where it is secreted directly onto the skin surface.

true/false

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true

Front 34

Apocrine glands are found in

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axillae and perianal regions and become active after puberty

They produce a thick secretion that rapidly becomes colonised by bacteria resulting in characteristic body odour. The ducts open into the pilosebaceous follicle

Front 35

The nail plate is a specialised form of

Back 35

stratum corneum growing from keratinocytes in the matrix.

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Front 37

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Front 38

whats the acid mantle

Back 38

Skin has an average pH value of 5.5, creating the acid mantle

Front 39

the acidity of skin is the result of

Back 39

acidic substances such as amino acids, lactic acid and fatty acids in perspiration, sebum and the hormones

There are resident protective microflora (bacteria and yeasts) but the acid mantle repels pathogenic microorganisms and reduces body odour

Front 40

skin color features

Back 40

varies from ‘white’ (absence of pigmentation) to ‘black’ (densely melanized). The colour depends on the quantity and depth of melanin and other chromophores.

Front 41

skin colors

Back 41

Oxidised haemoglobin: red

Deoxidised haemoglobin: blue

Haemosiderin: red-brown

Carotene: orange-yellow

Bilirubin bound to elastin: green-yellow

Dermal exogenous pigment: Tattoos, makeup, drugs, metallic compounds

Front 42

he thickness and quality of keratinocytes and dermal components may also affect skin colour. e.g.

Back 42

A thick layer of horny cells can appear white (psoriasis), yellow (seborrhoeic dermatitis), dirty-brown (ichthyosis) or black (eschar). Inflammatory infiltrates may result in plaques that are yellow-brown (granulomata), violaceous (lichen planus) or scarlet (psoriasis).

Front 43

melanin features

Back 43

The pigment melanin is formed by the action of tyrosinase on dopamine metabolites in melanosomes.

Melanosomes are specialised pigment granules in the cytoplasm of melanocytes.

Most skins produce eumelanin predominantly, but the melanin in red-headed celts is phaeomelanin.

Front 44

The amount of melanin depends on:

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Genetic factors: ethnicity/phototype.

Active melanogenesis.

Front 45

There are melanocytes in the normal skin of all races. However, dark-skinned people produce more melanin, and it is distributed to keratinocytes throughout the epidermis.

true/false

Back 45

true

Front 46

The more superficial the pigment, the more effective the protection it provides against

Back 46

damage caused by ultraviolet radiation. Albinos have inactive melanocytes.

Front 47

Melanin is found in the dermis in some melanocytic naevi (moles) and as a result of inflammation affecting the level of the basement membrane (postinflammatory pigmentation).

true/false

Back 47

true

Front 48

Melanin pigmentation is promoted by:

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Ultraviolet radiation

Hormones (MSH, ACTH, androgens, oestrogens, progesterones)

Inflammation

Friction

It may be reduced by

Melatonin

Corticosteroids.

Front 49

hx taking for derm. key aspects

Back 49

Site or sites affected by the dermatosis.

Its time course.

Symptoms and functional problems.

Exacerbating and relieving factors.

Other health concerns and medications

e.g. age, job, mhx, meds, gender, enviro influences,

PCOMPLAINT = single/multiple/generalised; site, what bothers the px; sxs

mhx = atopic conditions; diabetes; HTN; dyslipidemia (may impact tx)

fhx = eczema, psoriasis, skin caner, autimmune skin probs and CTDs

meds, allergies, shx

Front 50

characterising a skin lesion

Back 50

• Site & size of a skin lesion.
  
• Distribution of skin eruption.
  
• Configuration (shape) of skin lesions.
• Morphology of primary skin lesion.
• Secondary changes.
  

Front 51

skin lesion distributions are many e.g.

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acral

dermatomal

extensor

flexural

follicular

morbilliform

koebnerised

photosensitive

pressure areas

symmetrical

truncal

unilateral

Front 52

what does acral distribution for a skin lesion look like

Back 52

affects distal portions of limbs (hand, foot) and head (ears, nose)

Front 53

acral distribution photo

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Front 54

dermatomal skin lesions have what sort of distribution

Back 54

corresponding with a nerve root distribution

Front 55

dermatomal skin lesion

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Front 56

extensor distribution effects the extensor areas of the limbs

Back 56

Front 57

flexural distributions involve what part of the skin

Back 57

skin flexures (body folds) aka intertriginous

Front 58

flexure distribution

Back 58

Front 59

follicular distribution arise from

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hair FOLLICLES

these may be grouped into confluent plaques

Front 60

mobilliform distribution refers to

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generalised universal distribution

may be mild/severe, scattered/diffuse

Front 61

morbilliform distribution

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Front 62

koebnerised distribution refers to

Back 62

arising in a wound or scar

the koebner phenomenon refers to the tendency of several skin conditions to affect areas subjected to injury esp psoriasis, lichen planus and vitiligo

Front 63

koebnerised distribution

Back 63

Front 64

photosensitive distribution

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Favouring sun exposed areas.

Does not affect skin that is always covered by clothing.

Head & neck: spares eyelids, depth of wrinkles & furrows, areas shadowed by hair, nose & chin. Typically involves "v" of neck.

Backs of hands: spares finger webs. More severe on proximal than distal phalanges.

Forearms: extensor rather than flexor.

Feet: dorsal surface, sparing areas covered by footwear.

Lower legs: may affect extensor and/or flexor surfaces.

Trunk: rarely affected

Front 65

photosensitive distribution

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Front 66

Pressure areas affects

Back 66

areas regularly prone to injury from pressure at rest.

Tops of the ears when sleeping.

Buttocks when sitting.Heels when lying

Front 67

pressure area distribution

Back 67

Front 68

symmetrical distribution of a skin lesion affects the same side on both sides of the body

Back 68

Front 69

truncal distribution of a skin lesion favours the trunk and rarely affects the limbs

Back 69

Front 70

unilateral distribution of a skin lesions tend to affect wholly/predominantly one side of the body

Back 70

Front 71

skin lesions are often grouped together. The pattern or shape may help in diagnosis as many skin conditions have characteristic configuration.

e.g.

Back 71

annular

discoid

gyrate

linear

reticulated

target lesion

Front 72

annular skin lesion are grouped in a circle. multiple rings are polycyclic

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Front 73

discoid skin lesions are round (coin-shaped) lesions. aka nummular

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Front 74

a gyrate rash appears to whirling in a circle or spiral

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Front 75

a linear rash is like a straight line rash like in a scratch true/false

Back 75

true

Front 76

reticulated rash resembles a

Back 76

net

Front 77

target lesions have what

Back 77

concentric rings like a dartboard aka IRIS lesion

Front 78

target lesion

Back 78