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EXAMINATION

OF THE
SKIN AND MUCOSAE

Dr. Sorin Stamate

GENERALITIES
TEGUMENTUM = WHAT COVERS
= is the outer covering of living tissue,
with complexes functions:
sensation
adaptive immune system
heat regulation
storage and synthesis

excretion

= semiological map

GENERALITIES
Thickness = 0,2 - 0,5mm (at the level of the eyelids)

4 - 8mm (at the level of the heels)


Surface = 1,5 - 2 m2, with:
folds:
coarsely (inframammary, intergluteal, inguinal)
more discreet (the flexion face of joints)
fine (fingerprints)
palmary and plantar folds mark the limits of
papillary crests
infundibular depressions (popularly - pores)
correspond to the openings of
sudoriferous glands channels or to
sebaceous follicles

GENERALITIES
3 layers:

The epidermis:
Superficial, no blood vessels
Layers of cells melanocytes produce melanin
The dermis:
Connective tissue (collagenic, elastic and reticular
fibers, fibroblasts, mast cells)
Nerves, blood vessels, lymphatic vessels, muscles,
Sebaceous glands, the channels of sebaceous glands
Role: dermis nutrition, skin analyzer

The hypodermis:
Adipose lobules separated by fibrous tracts,
Nerves, receptors, blood and lymphatic vessels,
Sudoriferous glands, the deeper portion of bulb of hair
Role: tegument support

SKIN GLANDS
Sudoriferous glands:
= merocrine glands produce sweat: water, chloride,
sodium, potassium, lactic acid, urea, fat acids,
mucopolysaccharides, glycoproteins, hydrosoluble
vitamins

Sebaceous glands
= holocrine glands

Open at the level of hair follicle


produce sebum (oxycholesterin, cholesterin, unsaturated fat acids, soaps)
androgens increase secretion
estrogens decrease secretion

hair 1:
1 hair shaft
2 sebaceous gland
3 epidermis
4 dermis

5 hair follicle
6 hair bulb
7 papill

HAIRS AND NAILS


= Annexa of skin
- visible from the outside
NAILS
= corneous thin sheets on the surface of the
distal phalanges
source: nail matrix
the lunula is a part of the nail matrix
HAIR

the enlarged basal part of a hair within the skin =


ROOT
the part of a hair projecting beyond the skin =
SHAFT

CUTANEOUS SYMPTOMS:
PRURITUS
pruritus (latin) = itch
= cutaneous symptom produced by subliminal irritation of
nervous terminations by the mediators (histamine,
acetylcholine) which determines an attenuated pain
In producing pruritus, interfere:
Genetic factors
Psychological factors emotional pruritus
Secondary lesions:
excoriations
lichenification
cutaneous infections
local pigmentations
degraded nails

! Pruritus Prurigo
(Prurigo =
papulous, pruriginous lesions, determining local pruritus)

SECONDARY

(Determined by cutaneous affections)

PRURITUS

GENERALIZED

PRIMITIVE

(SINE MATERIA)

LOCAL

SYSTEMIC PRURITUS
Appears in:

Jaundice syndromes (billiary salts retention;


appears in pre-jaundice phase
Neoplasia; increases in night or in heat conditions)
Paraneoplasic pruritus
(lymphoma, lymphosarcoma, carcinoma)
Diabetes mellitus (! Early signs)
Uremia
(calcium deposits in the tegument irritation of nervous
terminations)
Gout (teenagers)

SYSTEMIC PRURITUS
Appears in:

Parasitic infections
Hyperthyroid, hypothyroid, Cushing syndrome,

acromegaly, menopauses)
Senile (elasticity changes; + capillary fragility)
Drugs allergy
(usually along with urticarian eruption)
Scabies - intensive (specially during the night), +
grattage lesions
Other causes: psychological, gastric hypoacidity,

feriprive anemia/pernicious, avitaminose

LOCAL PRURITUS
Has preferential localization in several affections:

Vulvar
Diabetes

mellitus (associated to candidose)


menopause (widow pruritus)
iron deficiency
lack of vitamins
uterin/anexial neoplasia
psychogenic

Scrotal/Penian

Diabetes mellitus
Prostate carcinoma
urinary tract infections (frequent urethritis)
psychogenic

LOCAL PRURITUS
Has preferential localization in several affections:

Abdomen, hips, extremities

hepatitis, cirrhosis

Nasal:

asthma
allergic rhinitis
lambliase (children)
uremia
morphinomania
hyperfoliculinemia

Auricular

diabetes mellitus

LOCAL PRURITUS
Has preferential localization in several affections:

Scalp:

alcohol abuse
pre-/postmenstrual

Anal:

parasitic infections

hemorrhoids

intestinal diseases

nearby infections

SKIN COLOUR CHANGES


Skin color: results from 4 natural pigments other pathologic ones
melanin (brown)

oxyhemoglobin (bright red)mainly within arteries/capillaries


deoxyhemoglobin (more bluish) present in venous blood
carotene (yellow)

Special conditions/pathologic ones:


hemosiderin

bilirubin
metals

Depends on:

skin thickness
light (artifical light distorts colours)
!!! The examination of skin color must be done in

sunlight

SKIN COLOUR CHANGES


CLASSIFICATION:

PALLOR

CYANOSIS

JAUNDICE

HYPERCAROTENEMIA

CHANGES OF SKIN PIGMENTATION

HYPEREMIA (redness of the skin)

PALLOR
= lighter color of the skin and visible mucosae, causes by a
reduced amount of oxyhemoglobin
Main causes:

THICKENING OF THE SKIN (myxedema, edema)


LACK OF DEVELOPPMENT OF DERMAL CAPPILARIES
(hypogonadism in men - Egyptian picture aspect)
VASOCONSTRICTION (strong emotions, acute
circulatory failure)
ANAEMIA
(in association with tiredness and fatigue)

!!! Pallor is best appreciated where the epidermis is


thinnest: the fingernails, the lips, tongue, palpebral
conjunctiva, palmar skin

PALLOR
Different colors associated with pallor could be
correlated with the causes of the anemia
+ flavinic shade hemolytic anemia
+ yellowish shade - pernicious anemia
+ verdinic shade young girls chlorosis (green
sickness) = hypchromic anemia
+ lighter yellow shade gastric neoplasia
+ cafe au lait shade bacterial endocarditis
+ white like paper shade acute hemorrhagic anemia

PALLOR
Pallor is associated with clue signs that could
ascertain the origins of anemia:
spoon nails - anemia due to
iron deficiency (the nails are flattened and
have concavities)

Koilonychia=

Hunter

glossitis pernicious anemia

Inappetence
Cutaneous

&loss of weight - neoplasia

hemorrhagic manifestations
(petechia, ecchymoses, hematomas) acute
leukemia, loss of blood

CYANOSIS
= bluish color of the skin and mucosal surfaces due to the
presence in the circulating blood of an increased
quantity of reduced Hb (more than 5g/dl) or a different
type of Hb
- Disappears with digital pressure

CYANOSIS FALSE CYANOSIS


= discoloration of the skin induced by deposition of gold
salts (chrysiasis), silver salts (argyria), arsenic or other
compounds
N.B.
False cyanosis doesnt disappear with digital pressure

CYANOSIS
Due to abnormal hemoglobin
or rare type of hemoglobin
-Kansas Hb
- Methemoglobin
- Sulphuretted Hb

CYANOSIS

Due to an increased
quantity of reduced Hb
Increased quantity of reduced
Hb in the arterial blood

CYANOSIS DUE TO ABNORMAL Hb/rare Hb


Appears in patients without a cardiac and pulmonary
disease. They are rare conditions.
METHEMOGLOBINEMIA:

Oxidative substances- intoxication with nitrites, fenacetin,


clorat de potasiu, derivati anilinici
Congenital/genetic - hemoglobin M
Idiopatic Methemoglobinemia nefamiliala

SULPHURETTED HEMOGLOBIN:

Hijmans van der Bergh toxic cyanosis


- due to presence of sulphuretted hydrogen in intestine
Administration of drugs like fenacetin or sulphamides

CYANOSIS DUE TO AN QUANTITY OF


REDUCED Hb
The bluish color appears when the quantity of reduced

Hb in the arterial blood is more than 5 g/dl (Normally:


<3g/dl)
Cyanosis = indicates a bad oxygenation of arterial

blood (hypoxemia)!!! The degree of cyanosis depends


on quantity of Hb pay attention to the anemic
patients because of the small quantity of Hb, cyanosis
appears when hypoxemia is extremely severe

CYANOSIS
LOCALIZED
PULMONARY
right-left SHUNT

CYANOSIS

CENTRAL
GENERALIZED

PERIPHERAL
CARDIAC
/STASIS

PULMONARY CENTRAL CYANOSIS


This is the sign of respiratory insufficiency

Bad oxygenation (low arterial saturation) of arterial blood


in the lungs
Caused by:
Low alveolar oxygen pressure
Disturbances in gas exchange
Ventilation/perfusion mismatch
Characteristics:

Generalized (even the tongue is cyanotic)


Warm (hypoxia induces vasodilatation)
Negative Lewis test (rubbing the ear lobe with the fingertips does
not make cyanosis to disappear)
Oxygen supplementation of the inspired air may correct cyanosis

CENTRAL CYANOSIS WITH RIGHT-TOLEFT SHUNT


It is also called the blue syndrome
Causes:- Congenital heart disease (CHD) with right-to-left

shunt (Fallot tetralogy)


Associated with retarded growth and physical

development, dyspnea on exertion, clubbing of the fingers


and toes
Position squatting.
Anoxic episodes (spells).
It is not influenced by oxygen administration

CENTRAL CYANOSIS

CENTRAL GENERALIZED PERIPHERAL


CYANOSIS (STASIS)
The sign of right heart failure
Accompanied by gravitational edema
Characters of peripheral cyanosis:

Respects blood peripheral circuits


DOESNT affect the tongue
COLD (because of the low velocity of blood: stasis +
vasoconstriction)
Positive Lewis test rubbing the ear lobe with the
fingertips makes cyanosis to disappear becoming red)

In CARDIOGENIC SHOCK patient presents pale cyanosis

due to vasoconstriction, marmoreal teguments, which


remain cold and cyanotic when adopting a declive position

LOCALIZED CYANOSIS
ERYTHROCYANOSIS
Appears in POLYCYTHEMIA VERA
It is also called red cyanosis
Described by Osler in XIX century, as red like

roses in summer and blue like indigo in winter


Color changes are more obvious in the areas

exposed to temperature variations (face and


hands)
It is associated with pruritus sine materia which

commonly starts after a bath

LOCALIZED CYANOSIS

It is due to an increased tissue oxygen extraction of


arterial blood produced by 2 mechanisms:

Decreased arterial supply


Slowing down of venous-capillary circulation

ACUTE

Thrombophlebitis
(Phlegmatia coerulea)
Arterial embolus

LOCALIZED
CYANOSIS

Peripheral chronic
ischemia syndrome

CHRONIC

Acrocyanosis

LOCALIZED CYANOSIS
ACROCYANOSIS
= refers to a persistent blue or cyanotic discoloration of the
digits, most commonly occurring in the hands although also
occurring in the face and feet as well
Appears in: cold exposure, phlebitis, chronic venous
failure, Raynaud syndrome
Causes: functional anomalies in capillary circulation

LIVEDO RETICULARIS
- a lace-like purplish discoloration
- a particular aspect: RACEMOS LIVEDO permanent redviolet arborizations?? in SLE, PAN
- abdomen: acute pancreatitis

FACE CYANOSIS
venous thrombosis, superior cave vein syndrome

ACROCYANOSIS

THROMBOPHLEBITIS

LIVEDO RETICULARIS