10. Integumentary and Lymphatic Pathologies Flashcards
Papule
A small, firm, elevated lesion
•Circumscribed, solid elevation of skin with no visible fluid.
•Can be either brown, purple, pink or red in colour.
•Can see “maculopapular rash” like in measles.
Pustule
Small, elevated, erythematous lesion containing pus
•Purulent material usually consists of necrotic inflammatory cells.
•These can be white or red.
Macule
Small, flat, circumscribed lesion of a different colour to normal skin
•A change in surface colour, without elevation or depression (non-palpable).
Nodule
- Morphologically similar to a papule, but is bigger & deeper e.g. Rheumatoid Arthritis.
- May be filled withinflamed tissue or fluid.
Crust
- Collection of dried bodyfluid (blood plasma & exudate) & dead skin cells (ascab).
- Exudate: any fluid that filters from the blood.
Lichenification
Thick, dry, rough plaques of thickened skin
•Visible thickeningof epidermis, with accentuated skin markings/pronounced lines.
•“Bark like” appearance.
•The hallmark of chronic eczema/dermatitis or excessive scratching.
Erosion
Shallow, moist cavity in the epidermis
•Wearing away with loss of superficial epidermis (from chemicals, friction or pressure).
•‘Ulcer’ in diabetes.
Keloid
Raised, irregular mass of collagen due to scar tissue formation
•Abnormal scar tissue that grows beyond the skin boundary.
•Strong genetic links. Vaccination site, scratching, burns.
Comedone (Acne)
Blackheads, whiteheads or red bumps due to excess sebum, keratin and debris forming a plug in the sebaceous duct of a hair follicle.
•Hormones such as testosterone can cause more and thicker oil secretions that block pores.
•Open comedo: Blackhead (acne vulgaris) -if oil is open to air it will oxidise> turns dark
•Closed comedo: Whitehead
If skin has grown over oily material it remains white.
Eczema/Dermatitis
- The terms “eczema” and “dermatitis” are interchangeable.
* A very common chronic, pruritic, inflammatory skin condition.
Eczemea/Dermatitis
- Flaky, dry, oedematous.
* Erythematous, pruritic (itchy), crusty, weepy lesions mostly on flexor surfaces of joints.
Eczema/Dermatitis: Complications
• Secondary bacterial infections.
Contact Dermatitis
- An acute inflammation of the skin caused by direct contact with an agent.
- Divided into Irritant (80%) and Allergen (20%) contact dermatitis:
Irritant contact dermatitis (ICD)
- Non-specific inflammatory reaction to a substance contacting skin.
- Abrasive chemicals can corrode the epidermis causing cutaneous ulceration.
- Hands are vulnerable due to frequent occupational exposure to soap (that can abrade the lipids in skin).
- A type called phototoxic dermatitis in which topical (e.g. perfumes) or ingested irritants are activated by exposure to UV rays.
Allergen Contact Dermatitis (ACD)
- A Type IV delayed hypersensitivity reaction.
- Sensitisation occurs on first exposure.
- Pruritic, erythematous rash develops at the site on subsequent exposures.
- Can occur with various chemicals, rubber, plants, metals.
- Multiple allergens cause ACD and cross-sensitisation among agents is common.
- A variant called photoallergic contact dermatitis in which a substance becomes allergenic only after it undergoes structural change triggered by UV light. e.g. sunscreens.
Contact Dermatitis: Signs and Symptoms
- Location of symptoms can give a clue to the irritant/allergen.
- Pruritic rash, often burning, stinging, eroded, blistered skin.
- Irritant contact dermatitis = ulceration, burning, prickling, soreness and quicker onset of symptoms.
- Allergen contact dermatitis= pruritis is significant, but slower onset of symptoms.
Contact Dermatitis: Treatment
Remove allergen. Steroids & anti-histamines
Atopic Dermatitis/Eczema
- An immune-mediated inflammation of the skin due to the interaction between genetic & environmental factors.
- Pruritus is the primary symptom.
- Usually occurs in infancy/childhood.
- Primarily affects children in urban areas or developed countries, and prevalence has increased over the last 30 years
Atopic Dermatitis/Eczema: Allergens
- Foods (milk, eggs, soy, wheat, peanuts, fish).
* Airborne (dust mites, moulds, pollen).
Atopic Dermatitis/Eczema: Causes
- Family history of atopic disorders in 2/3 of cases: asthma or allergic rhinitis.
- Genetic weaknesses in epidermal barrier function.
- Some patients have a mutation in the filaggrin gene: a structural protein in the stratum corneum.
- Loss of filaggrin may result in impaired skin’s barrier function leading to entry of foreign environmentalsubstances that may trigger immune responses.
- The skin may be deficient in ‘ceramides’ (fatty acids) increasing transepidermalwater loss.
- IgE involved in 70 to 80% of cases “true allergy”.
- Predominance of pathogenic staphylococcus aureus in the skin flora of 90% of patients.
Atopic Dermatitis/Eczema: Signs and Symptoms
- Red scaly lesions on flexor surfacesand cheeks. Very itchy.
- Broken skin on scratching ->lichenification.
- Infection on skin (very inflamed and with pus).
Atopic Dermatitis/Eczema: Treatment
Corticosteroids, soap substitutes.
Urticaria (Hives)
- An itchy (pruritic), red (erythematous), blotchy and raised rash resulting from swelling of the superficial skin.
- Can develop in the pharyngeal mucosa causing swelling in the throat and obstruction of the airways.
- Occurs due to therelease of histamine from mast cells (causing vasodilation and capillary leakage).
- Causes: medications, food allergies, stings, stress.
Urticaria (Hives): Treatment
Anti-histamines
Psoriasis
- Psoriasis is a chronic, autoimmune, inflammatory skin disease.
- In psoriasis, the stratum basale is dividing too quickly making abnormal keratin, thus the stratum corneum renewal is as little as 7 days rather than 40 days.
- There is reduced shedding and an accumulation of the stratum corneum, causing silvery scales and flakes on the skin surface.
Psoriasis: Causes
- Autoimmune -T-Lymphocyte mediated hyperproliferation of keratinocytes.
- Environmental, genetic and immunologic factors.
- Genetic defect in mitotic control.
- Susceptibility may be due to genetic defects in detoxification enzymes.
Psoriasis: Triggers
Infection, chemicals, alcohol, stress, anti-malarials, beta-blockers.
Psoriasis: Signs and Symptoms
- Red scaly plaques covered with overlapping silvery shiny scales that may bleed.
- Characteristically involves extensor surfaces (wrists, elbows, knees) and scalp.
- Possibly tiny dents in finger/toenails.
- Arthritis(14% ->autoimmune).
Psoriasis: Treatment
Corticosteroids, UV light therapy, methotrexate (immunosuppressant!)
Acne Vulgaris
- Blockage of sebaceous/hair follicle duct.
- It is more common in males and the onset is typically at puberty.
- In acne, oil that normally drains to the skin surface, gets blocked by excess skin cells inside the follicle. This provides an ideal location for bacteria to grow.
- Acne tends to affect the face & to a lesser extent, the back.
Acne Vulgaris: Causes
- There is a high prevalence of acne in western populations. Some non-westernised populations have a complete absence of acne, which strongly points to environmental factors including diet.
- Foods that are high in glucose & elevate insulin levels promote oil production & excess skin cell production in follicles. They also cause the testes (& ovaries) to produce testosterone. Dairy will do the same! This is a typical western diet.
- Linked to excess testosterone (hence puberty).
- Premenstrual hormonal imbalances.
- Oily creams & some drugs (anabolic).
Acne Vulgaris: Types
- Closed comedomes(white heads): when the trapped sebum and bacteria stay below the skin surface.
- Open comedomes(black heads): Oxidised lipids causes dark colour.
- ‘Inflammatory acne’ can occur which begins as closed comedomes. Distension of the follicle occurs causing inflammation (red papules).
- Cystscan occur when follicles rupture resulting in a pustule/nodule.
- Large, deep pustules can break down adjacent tissue & cause scarring.
Acne: Treatment
- Roaccutane–often effective but many side effects including teratogenicity. Antibiotics.
- Facial cleansers, contraceptive pill.
Acne Rosacea
- Chronic Inflammation of the skin associated with vascular changes, which results in flushing.
- Often accompanied by seborrhoea(excessive discharge of sebum) but is notan inflammation of the follicles.
- Suspected that other organs are affected too, such as the stomach & intestines.
- More common in women.
Acne Rosacea: Signs and Symptoms
• Facial flushing -redness across nose & cheeks, seborrhoea (oily skin) with papules, pustules.
Acne Rosacea: Causes
- Exaggerated vasodilatory response to hyperthermia.
- High incidence of gastric ‘Helicobacter pylori’ found in rosacea patients (88%). Flushing reaction may be caused by gastrin (gastrin = H pylorigrowth).
- Other causes include environmental (oil, chlorine, UV), cosmetics (e.g. paraffin), medications. stress.
Acne Rosacea: Treatment
Mild local treatment with NSAIDs and antibiotics.
Warts and Verruca
Benign proliferation of the skin and mucosa caused by infection with the Human Papilloma Virus (2 and 4).
Warts and Verruca: Signs and Symptoms
Papularlesions with a coarse roughened surface. Usually with a red margin.
Warts and Verruca: Treatment
Laser or freezing(suppression, not a cure!).
Skin Tags
- Small growths attached to skin by stalk.
- Often neck, axilla, groin, eye lid, anus. Generally occurs in areas where skin rubs.
- Skin coloured or darker and can bleed when knocked. They often drop off.
- Associated with hyperinsulinaemia (common in type 2 diabetes).
Vitiligo
- The skin loses its pigmentation due to the loss of Melanocytes.
- Onset at any age, 50% under 25 years.
- Not contagious.
- Noticeable in races with darker skin
Vitiligo: Causes
- May be a genetic susceptibility.
- Autoimmune link: Increased number of ‘Langerhan cells’ ->hypothesised these cells may inhibit the proliferation of melanocytes.
Burns
Injury to the skin or tissues caused by heat, cold (frostbite), electricity, radiation, chemicals (strong acid/bases).
Burns: Signs and Symptoms
- Damage of the skin withnecrosispain.
* Electrical burns injuries may extend beyond tissue damage (cardiac arrhythmia/fibrillation) etc.
Burns: Treatment
Skin grafting for deep burns, fluid & electrolyte replacement, pain management.
Burn Classification
- 1st degree: affects the epidermis.
- 2nd degree: all of epidermis and some dermis.
- 3rd degree: extends into subcutaneous tissue.
- 4th degree: extends into muscles and tendons.
Burn Complications
- Dehydration–due to loss of water and plasma through damaged skin surface.
- Hypothermia –due to impaired thermoregulation and heat loss.
- Hypovolaemic shock.
- Infection.
- Renal failure –if the kidneys cannot filter waste from broken down red blood cells and damaged tissue.
- Contractures–scar tissue contracts distorting skin and impairing movement.
Lymphangitis
- Inflammation of the lymph vessel.
* Bacterial infection -usually Streptococcus.
Lymphangitis
- Swelling, painful red lines below skin surface along the lymph vessel course.
- Fever, malaise, muscle ache, low appetite.
Lymphangitis: Complications
• Infection may spread to the blood -> septicaemia (hence a medical emergency)
Lymphodema
- Localised lymphatic fluid retention associated with a compromised lymphatic system so reduced lymphatic return.
- Obstruction of lymph vessels causes an increase in protein accumulation in the interstitial fluid.
- increase of protein = water retention, swelling of soft tissue [stage 1 –pitting oedema].
- increase of protein = inflammation and activation of fibroblasts [stage 2 –fibrosis of vessels].
Lymphodema: Causes
- Primary: Congenital,poorly developed lymphatics e.g. vessels.
- Secondary: Damage to the lymphatic system caused by radiotherapy or lymph node removal. Infections e.g. cellulitis.
Lymphodema: Signs and Symptoms
- Severe fatigue of affected area.
- Heavy, painful, swollen limb/area (‘pitting oedema’).
- Discolouration of the skin overlying the lymphoedema.
- Recurring skin infections in the effected limb which may lead to thickening & hardening of the overlying skin.
Lymphodema: Complications
• Recurrent infection, cellulitis, lymphangitis, septicaemia.
Lymphodema: Treatment
• Lymphatic drainage, treat the cause, skin brushing, herbs, diet, compression bandages, exercise.
Lymphadenitis
- Lymphadenitis describes inflammation of lymph nodes.
* Usually a bacterial infection.
Lymphadenitis: Signs and Symptoms
- Often following upper respiratory infection (i.e. Sore throat).
- Enlarged lymph nodes that are often painful on palpation.
Lymphadenitis: Complication
• Lymphangitis.
Lymphadenitis: Treatment
Antibiotics
Splenomegaly
• Enlargement of the spleen due to increased workload; associated with many diseases.
Spenomegaly: Causes
- Viral or bacterial infectionse.g. infectious mononucleosis (glandular fever), malaria.
- Liver diseasessuch as cirrhosis leading to portal vein hypertension.
- Haemolytic anaemiase.g. Thalassemia, Sickle cell anaemia.
- Blood/lymphatic malignancies:Leukaemia & Hodgkin’s lymphoma.
Splenomegaly: Signs and Symptoms
- Abdominal pain.
- Early satiety (due to splenic encroachment).
- Symptoms of haemolytic anaemia due to accompanying cytopenia.
- Palpable left upper quadrant abdominal mass.
Splenomegaly: Complications
- Anaemia, increased bleeding, frequent infections.
* Ruptured spleen.
Optimising Lymphatic Health
- Exercise is essential –lymphatic vessels rely on exercise to ‘pump’ lymph through the body.
- High anti-inflammatory and anti-oxidant diet: green leafy vegetables, berries, omega-3 foods, nuts & seeds, turmeric, ginger.
- Reducing oxidative stress: 7-9 hours of good quality sleep, reducing stress, healthy diet.
- Remove common allergens from the diet to reduce the stress on the digestive and immune systems (e.g. dairy, gluten, nightshades).
- Dry brushing and refer for lymphatic drainage.
