Lecture 1

 Regional variation
o Epidermis: Thickest on palms & soles 1.5 mm. Thinnest on eyelids 0.1 mm
o Dermis: thickest on back
 Epidermis has 4 layers: Stratum corneum, stratum granulosum, stratum spinosum, stratum basale
o 30 days for keratinocytes to move thru skin cells
 Epidermis has 4 cell types
o Keratinocytes = Lamellar Ichthyosis, Ichythosis vulgaris, Harlequin Fetus, Epidermolysis Bullosa Simplex
o Melanocytes: Vitiligo, piebaldism, albinism
o Langerhans cells: BM derived. 3-5% of cells in epidermis. Birbeck granules (intra CP organelles) on EM. Chief APC in
epidermis. Not routinely seen on H&E: Langerhans Cell Histiocytosis, ACD
o Merkel cells
 DEJ: Bullous Pemphigoid, Epidermolysis Bullosa
 Hair follicle
o Phases of growth:
 90% Anagen – hockey stick shaped, hair growing phase. Occurs for ~ 2-6 yr.
 3% Catagen –matrix cells stop dividing
 10% Telogen resting phase – rounded shape (will be shed). Occurs for ~ 100d
o Total number of hair follicles 100,000. 100-200 Shed how many hairs per day

Describing skin lesions

 Primary lesion:
o Macule/patch- Ex is café au lait spots-tan patches
o Papule/plaque/nodule  these are all raised- Example is warts that are papules
o Vesicle/bullae- Example of vesicle is HSV.
o Wheal: annular ring or solid, raised, d/t dermal edema
o Eczematous patch = scaly patch. Scaly Patch in Antecubial region-atopic dermatitis
o Papulosquamous = scaly plaque. Ex: silver scale plaque is psoriasis
o Nodule = ex is cyst on guys back
 Secondary changes:
o Erosion/ulcer = loss of skin. Ex gun metal gray border is pyogenc gangranosum
o Fissure
o Lichenification = leathery
o Atrophy = loss of skin, discoid lupus may have this (sometimes will be de-pigmtd patches)
 Configurations and special lesions:
o Targetoid = erythema multiforme
o Reticular = Livedo reticularis, net like, pink color
o Annular and scaly = subacute cutaneous lupus (SCLE), somewhat photo-distributed
o Burrow = web space. Ex: scabies
o Petechial/purpura= TENS/SJS;

Inflamm and infectious skin dzs

 Psoriasis
o Classical presentation: red plaques w/ silver scale on elbows knees, scalp, or gluteal cleft
o Types:
 Plaque vs guttate. Guttate: smaller than plaques
 Inverse = found in creases, so no scaly but very red
 Pustular= less plaque-like with pus
 Erythrodermic: ?
 Rosacea
o Occurs on the face as flushing, persistent erythema, telangiectasias, and papules or pustules
o No comedones & older age of onset. Ocular involvement
o Erythematotelangiectatic- picture, sparing of NL folds.
o Papulopustular = looks like acne but older person
o Could poss be confused w/ Lupus but a person w/ Rosacea will have a Hx otherwise nl. A person w/ lupus will have a
Hx of systemic dz most likely a problem w/ kidneys.
 Eczematous dermatitis
o Pruritic, poorly demarcated, red, scaly, crusted, can have vesicles, weep, often w/ erosions/excoriations
o Hallmark of any chronic dermatitis is lichenifications
o Allergic contact dermatitis – belt = rash
o Nummular dermatitis – usu on legs & arms, may look like psoriasis but its not an elbow or knee or scalp
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 o Stasis dermatitis – lower leg, cayenne pepper discoloration
 Pityriasis rosea
o Starts w/ a herald patch. Salmon-colored macules and papules. Christmas tree distribution
 Tinea versicolor: Same distribution, but malasezzia furfur causes it. Also, no herald patch.
 Scabies
o Burrows, vesicles, or papules on the hands, inter-digits, wrists, elbows, axillae, lower abd, genitals, buttocks and upper
thighs
o V itchy esp at night time. V contagious
Drug eruptions and skin findings of system dz
 Morbilliform drug rash: Usually viral causes
 Erythema multiforme
o Target lesion, central dusky papules or patches w/ two or more concentric red rings
o Usually symmetric, on palms, back, neck & arms. Caused by HSV, mycoplasma or drugs
 SJS and TEN
o Prodrome of an URI- fever and painful skin
o Two or more mucosal surfaces involved w/ vesicles, bullae, erosions and hemorrhagic crusts, conjunctiva, oral mucosa
and genitalia
o SJS <10% of BSA. TEN > 30% BSA
o Almost always d/t drugs, NSAIDS, abx and anti-epileptics
 Lupus erythematousus – variants (3 types)
o Acute –usually assoc w/ systemic dz and will have ds DNA abs, usually ANA +
o Sub acute cutaneous – associated w/ anti Ro ab, no systemic involvement,
o Discoid not ANA +, inflammation, significant scarring
 Dermatomyositis
o Classic lesions: Heliotrope rash, shawl sign. Gottron’s papules on knuckles. Polikioderma (patches of hypo or
hyperpigemntation w/ telangestasia & epidermal atrophy) is characteristic. Periungula telangiectasias (ragged cuticles)
o Prox muscles weakness may preceded, come with DM or be absent. Hx: poss trouble walking up stairs
 Pyoderma gangrenosum
o Uncommon painful ulcers of uncertain etiol. Dx of exclusion
o Most commonly occurs on the legs
o Associated dz – Chrons’ ulcerative colitis, Arthritis including RA, monoclonal gammopathy IgA
o Lesions starts as papulopustule – looks like folliculitis, which progresses to a deep ulceration w/ a violet border, gun
metal gray that overhangs the ulcer bed
Benign and malignant skin lesions
 Congenital melanocytic nevus
o Know the sizes! They are measured based on adult size
 Small <1.5 cm
 Medium 1.5 - 20 cm
 Large or giant >20 cm
o Giant nevus- Risk of melanoma is btwn 5-7% and usually before age 20
 Basal cell carcinoma
o Most common cancer in humans, most common skin cancer overall
o Pearly shiny yellow nodules with rolled edge
o May have ulcer and telangiectasias
o Usually on face or scalp
 SCC
o Crusted or ulcerated pink papules or nodules
o Commonly located on face, dorsal Forearm, hand, lower lip, & genitals
o Look very similar but no overlying telangiectasias & BCC is usually not on lower lip or genitals
 Melanoma
o ABCDEs: Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving
o 1/3 of melanomas develop in a pre-existing nevus
o Prognosis: 10 determined by the depth of tumor from the granular layer – breslow thickness
o Worse Px: Ulceration, Older, ♂, trunk, head, and neck, LNs involved, visceral metastases
o Don’t measure stratum corneum in the epidermis for breslow thickness, measure from the granulosum layers!

Pediatric dermatology
 Acne
o Pathogenesis
 Abnl differentiation of keratin
 Androgen stim of sebaceous glands
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  Propionibacterium acnes (nl flora, can overgrow)
 Inflammation (neutrophil chemotaxis)
o Types: Comedonal acne: Open and closed. Inflamm acne, papules & pustules. Nodulocystic
 Molluscum contagiosum: Smooth shiny dome shaped umbilicated papules, 2-5 mm. DNA pox virus
 Atopic dermatitis
o If it’s not itchy its not eczema. Seen in kids
o Dry, scaling, red, & excoriated patches predilection of eyes & check, neck , AC & popliteal fossa
o Young infant – may have reverse pattern, but look at AC fossa
 When is atopic dermatitis life threatening? Eczema Herpeticum
o Super-infxn w/ herpes simples
o Punched out erosions on top of eczematous areas = know pic of guy’s face & baby’s trunk & head
Lec 7 Photobio & photodermatoses
 Rays
o UV 100 - 400 nm
o UVC 100 - 290 nm. Germicidal, kills TB, causes DNA damage. blocked by ozone
o UVB 290 – 320. Causes: sunburn, photoaging, photosensitivity, Vit D syn. Blocked by clear glass
o UVA 320-400: UVA2 320 to 340. UVA1 340-400. Causes immediate pigment darkening, photo sensitivity. Passes thru
clear glass
 Sunscreens:
o Absorbers go on 30 min before exposure, protect against free radicals
o Reflectors all broad spectrum, zinc oxide, z-cote, titanium oxide
 Polymorphous light eruption: Mostly ♀, springtime, lesions present w/in hr & last a few ds, gets better thru hardening, as summer
progresses
 Solar urticarial lesions: Arise w/in min of sun exp & lasts less < 24 hr