SUBCUTANEOUS TISSUE

EXAMINATION

SUBCUTANEOUS TISSUE
HYPODERMIS HYPODERM SUBCUTIS ADIPOSE TISSUE

the lowermost layer of the skin, of variable thickness

contains:

loose CONNECTIVE fibers (elastic, fibrous bands)

lobules of FAT

HAIR FOLLICLE roots

The glandular part of some SEBACEOUS GLANDS

Blood vessels, Lymphatic vessels, Nerves

BURSAE, in the space overlying joints in order

Fine, flat sheets of MUSCLE (the scalp, face, hand, nipple, and scrotum)

its main role: FAT storage

SUBCUTANEOUS TISSUE
Any lump/swelling should be access by these characteristics
1.

Position, location

2.

Size and Shape

3.

Surface, Edge

4.

Consistency

5.

Attachments

6.

Adjacent skin signs of inflammation

redness (erythema)
tenderness
heat

7.

Thrills, bruits and noises

SUBCUTANEOUS TISSUE
LIPOMA
= benign tumor of adipose tissue where adipocytes have
increased size and number
well defined mass with smooth edge,
of variable dimensions and locations
painless
consistency can be:
soft,
fluctuant
hard (FIBROLIPOMA) with ossifications
movable on superficial and profound layers

SUBCUTANEOUS TISSUE
LIPOMA can be:
CAPSULATED
DIFUSSE

= fatty tissue mass occupying a region of variable dimensions, seldom

symmetrically: shoulders, neck, thorax

UNIQUE
MULTIPLE (LIPOMATOSIS)
MULTIPLE FAMILIAL LIPOMATOSIS
ADIPOSIS DOLOROSA (DERCUMs disease)
= multiple painful lipomas located on the trunk and limbs
affects mostly postmenopausal women

SYMMETRICAL LIPOMATOSIS

SUBCUTANEOUS TISSUE
LIPODYSTROPHIES
= group of diseases characterized by:
abnormalities of fat distribution

associated with metabolic, autoimmune or renal disorders

CONGENITAL lipodystrophies

generalized/partial (the residual fat undergoes compensatory hypertrophy)

appears from birth total or partial absence of fat tissue
associated with insulin resistance and diabetes, hypertriglyceridemia

ACQUIRED lipodystrophies

Acquired partial lipodystrophy (BARRAQUERSIMONS syndrome)

Acquired generalized lipodystrophy
HIV-associated lipodystrophy
Localized lipodystrophy (LIPOATROPHY):
insulin injection sites, buffalo hump

INFLAMMATORY LESIONS IN THE ADIPOSE TISSUE

PANNICULITIS
= tender skin nodules weight loss fever
unique or multiple nodules,
of variable sizes,
tender spontaneously or when palpated,
of firm consistency then fluctuant,
discoloration of adjacent skin: reddening-brownish-darker
pigmentation

due to the fat necrosis

evolution: resorbtion (lipoatrophy) or suppuration (oily fluid)
examples:
posttraumatic, cold exposure
WEBER-CHRISTIAN disease
associated with connective tissue disorders (SLE, scleroderma)
ERYTHEMA NODOSUM

WEBER CHRISTIAN disease

ERYTHEMA NODOSUM

INFLAMMATORY LESIONS IN THE ADIPOSE TISSUE

CELLULITIS
= regional, diffuse, severe inflammation of the skin and
subcutaneous tissues due to acute bacterial infection
(streptococci or staphylococci)
clinical findings:
- unilateral redness, swelling, increased warmth, tenderness
- usually with indistinct borders, except in ERYSIPELAS
(a type of cellulitis with sharply demarcated margins)

- lymphangitis and regional lymphadenopathy

- systemic manifestations (fever, chills, hypotension, tachycardia)
- evolution: blistering, abscesses, ulceration, erosion or
after successful treatment, the skin may flake or peel off as it heals
- complication: septicaemia, necrotising fasciitis, endocarditis
- differential diagnosis: DEEP VENOUS THROMBOSIS

Differentiating Cellulitis and Deep Venous Thrombosis (DVT)

FEATURE

CELLULITIS

DVT

Skin temperature

Hot

Normal or cool

Skin color

Red

Normal or cyanotic

Skin surface

Orange skin

Smooth

++

Lymphangitis
Regional Lymphadenopathy

CELLULITIS

ERYSIPELAS

ERYSIPELAS

SUBCUTANEOUS TISSUE - ASSESSMENT OF HYDRATION

in adults water comprises 60-65% of body mass:
2/3: intracellular AND 1/3: interstitial fluid (2/3) + volemia (1/3)

assessing the hydration state:

detailed history of the nature and the quantity of fluid loss
(vomiting, diarrhoea, sweating, burns and polyuria, raised ambient temperature)

check the SKIN TURGOR

examine the patient TONGUE and MOUTH MUCOSAE
look for WEIGHT LOSS (if previous weight is known)
check the PULSE and BLOOD PRESSURE (supine and erect)]
check for EDEMA
examine the JUGULAR VENOUS PULSE

SKIN TURGOR gently pinch o fold of skin on the neck or the subclavicular area,
hold it for a few seconds then release it
NORMAL SKIN TURGOR: well-hydrated skin springs back into position immediately
DECREASED TURGOR: abnormally slow skin turgor seen in dehydration

SUBCUTANEOUS TISSUE - OEDEMA

swelling of soft tissues due to an increase in interstitial fluid

predominantly sodium and water, but also protein and cell-rich fluid

LOCALIZED or GENERALIZED

a sign or a syndrome

results from:
increased movement of fluid from the intravascular interstitial space or
decreased movement of water from the interstitium capillaries/lymphatics

mechanisms involved:
capillary hydrostatic pressure
plasma oncotic pressure
capillary permeability
Obstruction of the lymphatic system

SUBCUTANEOUS TISSUE - OEDEMA

CLINICAL FEATURES

ONSET: ABRUPTLY or INSIDIOUSLY

EVOLUTION in TIME
INSPECTION

normal anatomical profile disappears swelling of the affected area

examine the EXTENT
SYMMETRY: generalized edema
ADJACENT SKIN:
initially, UNDER TENSION and SHINY
in resolution, fine longitudinal folds + thickening of the teguments
COLOR: NORMAL or CYANOTIC (cardiac, venous obstruction)
WHITE (renal edema)
RED (inflammatory or allergic)
OTHER SKIN LESIONS or DISCOLORATIONS
HAIR/NAILS CHANGES

SUBCUTANEOUS TISSUE - OEDEMA

CLINICAL FEATURES

PALPATION
SKIN TEMPERATURE:
NORMAL: hypoproteinemia, venous/lymphatic obstruction
COLD: CARDIAC edema
WARM: inflammatory, allergic
SENSIBILITY:
only INFLAMMATORY edema is PAINFUL
CONSISTENCY: PRESENCE and THE DEGREE of PITTING
SOFT, EASY PITTING: hypoproteinemia
NO PITTING or MILD DEPRESSIONS: inflammatory, venous
NO PITTING: myxedema and lymphedema
SEVERITY of edema is graded on a 4-point scale, from slight to very marked

ASSOCIATED SYMPTOMS and SIGNS

Where to look for edema ?

behind each medial malleolus:

by aplying digital pressure on the area until a pit is formed.

over the dorsum of each foot

on the ANTERIOR part of THE CALF
Over the knee articulation.
Anterior abdominal wall:

when you fold the skin pits and orange like surface appear.
Sacral region - bed imobilised patients.

Breast edema - inferoexternal aspect.

Upper limbs: inferior, internal and posterior aspect, over the elbow.
Face edema: compare the aspect with a recent photo.

SUBCUTANEOUS TISSUE - OEDEMA

GENERALIZED OEDEMA

causes: hypoPROTEINEMIA and FLUID OVERLOAD

etiology:

HEART failure, LIVER failure, KIDNEY disorders

starvation, chronic pancreatitis, malabsorbtion sd.
iatrogenic: excessive fluid replacement, repeated removal of ascites

small hidrosaline retention weight gain

symmetrical, usually dependent (fluid overload) or nondependent in

areas with lax conjunctive tissue (eyelid, face, scrotum) - hypoproteinemia

ANASARCA
= generalized massive edema + fluid accumulation in the serous cavities
(hydrothorax, ascites, hydropericardium)
- usually the fluid is a transudate

SUBCUTANEOUS TISSUE - OEDEMA

CARDIAC EDEMA

Symmetric, dependent, painless, pitting edema

Cyanotic and cold edema (stasis cyanosis) due to low cardiac output

Untreated edema develops in a cranial direction anasarca

associated with DYSPNOEA and other signs of HEART FAILURE

more frequent in RIGHT HEART FAILURE

SUBCUTANEOUS TISSUE - OEDEMA

RENAL EDEMA

Symmetric, non-dependent, painless, soft, easy pitting edema

white and of normal temperature

Face, eyelids, dorsal aspect of the feet, external genitalia

mechanisms: hypoproteinemia (NEPHROTIC syndrome) or

fluid overload (NEPHRITIC syndrome)

SUBCUTANEOUS TISSUE - OEDEMA

PREGNANCY EDEMA

Symmetric, dependent, painless, soft, easy pitting edema

white and of normal temperature
on the dorsum of the feet and on the anckles
of moderate severity

pathological edema:
often 3+ or more pretibially;
it also affects the hands and face

Generalised edema after the 20th pregnancy week + hypertension +

proteinuria = preeclampsia eclampsia = seizures, coma, death

SUBCUTANEOUS TISSUE - OEDEMA

CATAMENIAL or CYCLE EDEMA

discreet and moderate edema of the legs

appears predominantly in the second half of the menstrual period.

due to secondary hyperaldosteronism

MYXEDEMA

Appears in severe hypothyroidism.

due to infiltration of the subcutaneous tissue with

mucopolyzaccharides.

periorbital edema that does NOT PIT with pressure

the hair and eyebrows are dry, coarse, and thinned.

the skin is dry and thickened

MYXEDEMA

SUBCUTANEOUS TISSUE - OEDEMA

LOCALIZED OEDEMA

causes:

VENOUS OBSTRUCTION
tumour, thrombosis, or valvular incompetence
hemiparesis, forced immobility
increase venous pressure by impairing venous return
INFLAMMATORY (infection, injury or ischemia)
ALLERGIC
LYMPHATIC OBSTRUCTION
intraluminal obstruction: filarial worms
extraluminal obstruction
congenital hypoplasia of the lymph vessels of the legs
recurrent lymphangitis (resulting in lymphatic fibrosis)
post radical mastectomy and/or irradiation for breast cancer

localized to a single area/extremity/part of an extremity

asymmetrical

SUBCUTANEOUS TISSUE - OEDEMA

ACUTE VENOUS EDEMA

Acute, non-pitting edema in a single, usually lower extremity,

usually with pain; sometimes Homan's sign

Redness, warmth, and tenderness, less marked than in cellulitis

Sometimes a predisposing factor (eg, recent surgery, trauma,

immobilization, hormone replacement, cancer)

CHRONIC VENOUS INSUFFICIENCY

Soft, pits on pressure; later may become brawny (hard)

skin thickening especially near ankle.

occasionally bilaterally and NON PAINFULL

associated with brown pigmentation, varicose veins, ulcerations

due to chronic obstruction or

valvular incompetence of the deep veins

ACUTE VENOUS EDEMA

CHRONIC VENOUS EDEMA

SUBCUTANEOUS TISSUE - OEDEMA

INFLAMMATORY EDEMA

localized edema accompanied by the other features of inflammation

- redness, heat and pain avoid testing for pitting on pressure
due to capillary leak syndrome

ALLERGIC EDEMA

affected area is RED and ITCHY but NOT PAINFUL

ANGIOEDEMA
affects the face, lips and mouth
diffuse, nonpitting, tense, pink or skin-colored swelling
DOES NOT ITCH
develops rapidly typically disappears over subsequent hours/days
may be life-threatening if glottic edema appears

ANGIOEDEMA

SUBCUTANEOUS TISSUE - OEDEMA

LYMPHEDEMA

The legs, external genitalia, the female breast most frequently

involved

Soft swelling in early stages indurated, hard, nonpitting

normal skin in early stages rough and thick = ELEPHANTIASIS

unilateral or bilateral

of normal color, no brown pigmentation of the skin

LYMPHEDEMA

LYMPHEDEMA

ELEPHANTIASIS