Text Book of Dermatology EDITOR-N-CHIEF Xu jinhua Department of dermatology Huashan Hospita Fudan University
Text Book of Dermatology EDITOR-IN-CHIEF Xu Jinhua Department of Dermatology Huashan Hospital Fudan University
CONTENTS hapterl Structure and function of human skin Chapter 2 Diagnosis of skin Disease Chapter 3 Therapy in Dermatology and venereology Chapter4 Fungal Diseases Chapter 5 Common viral diseases of skin Chapter 7 Sexually transmitted diseases Chapter 8 Contact Dermatitis Chapter 9 Neurodermatitis Chapter 10 ecz Chapter ll Urticaria Chapter 12 drug eruption Chapter 13 Papulosquamous dermatoses Chapter 14 Lupus Erythematosus Chapter 15 Bullous Dermatoses Chapter 16 vitiligo Chapter 17 Acne
CONTENTS Chapter1 Structure and function of human skin Chapter 2 Diagnosis of Skin Disease Chapter 3 Therapy in Dermatology and Venereology Chapter 4 Fungal Diseases Chapter 5 Common viral diseases of skin Chapter 6 Scabies Chapter 7 Sexually Transmitted Diseases Chapter 8 Contact Dermatitis Chapter 9 Neurodermatitis Chapter 10 Eczema Chapter 11 Urticaria Chapter 12 Drug Eruption Chapter 13 Papulosquamous dermatoses Chapter 14 Lupus Erythematosus Chapter 15 Bullous Dermatoses Chapter 16 Vitiligo Chapter 17 Acne
Chapter 1 Structure and function of human skin Introduction of skin structure Human skin is a uniquely engineered organ covering the body Being the largest organ, the skin provides around 16% of the body mass of an average person, and it covers average area of 1.5 m2. The average thickness is 0. 5-4 mm (not includ ing subcutaneous fat tissue). The skin is thickest on the palms and soles. It is very thin on the eyelid performs many vital roles as both a barrier and a regulating influence between the outside world and the controlled environment within our bodies Skin color differs by race, age, gender and location. It is darker around external enitalia, anus, and areola The skin is composed of epidermis, dermis, subcutaneous tissue and skin appendag including hair follicles, sebaceous glands, ecrrine glands and apocrine glands, nmailsges on its surface by continuously alternating ridges and sulci, in individually unique roved There is no hair on the palms and soles, so called glabrous skin. Glabrous skin is configurations known as dermatoglyphics. It is characterized by the presence of glands. Hair-bearing skin, on the other hand, has both hair follicles and sebaceous gland h encapsulated sense organs within the dermis, and by a lack of hair follicles and sebaceou but lacks encapsulated sense organs Histology of the skin lEpidermis The epidermis is the outmost tissue in human beings. Derived from ectoderm, it can be classified as stratified squamous epithelium. Keratinocyte is the major cell, making up 95% of the total. Other cells include melanocytes, Langerhans cells and merkel cells D)Keratinocyte es move progressively from attachment to the epidermal basement membrane towards the skin surface, forming several well-defined layers. The differentiation process is called cornification The epidermis contains five histologically distinct layers from the inside to the outside stratum basale, stratum spinosum, stratum granulosum, stratum lucidum and stratum corneum a.The stratum basale(basal cell layer) is a continuous layer that is generally described as only one cell thick, but may be two to three cells thick in glabrous skin and hyperproliferative epidermis. The cells of the basal layer are similar to those of other tissues within the body they contain the typical organelles such as mitochondria and ribosomes, and the cells are metabolically active. The keratinocytes of the stratum basale are attached to the basement membrane by hemidesmosomes, which act rather like proteinaceous anchors for these lowest layer cells. Within the stratum basale and the adjacent cell layer, the stratum spinosum, keratinocytes are connected througl desmosomes, again highly specialised proteinaceous cellular bridges b The stratum spinosum(also known as the spinous layer or prickle cell layer) is found on top of the basal layer, and together these two layers are termed the Malpighian layer This spinous layer consists of two to six rows of keratinocytes that change morphology from columnar to polygonal cells. Within this layer the keratinocytes begin to differentiate and synthesise keratins that aggregate to form tonofilaments
Chapter 1 Structure and function of human skin Introduction of skin structure Human skin is a uniquely engineered organ covering the body. Being the largest organ, the skin provides around 16% of the body mass of an average person, and it covers an average area of 1.5 m2 . The average thickness is 0.5-4 mm (not including subcutaneous fat tissue). The skin is thickest on the palms and soles. It is very thin on the eyelid. It performs many vital roles as both a barrier and a regulating influence between the outside world and the controlled environment within our bodies. Skin color differs by race, age, gender and location. It is darker around external genitalia, anus, and areola. The skin is composed of epidermis, dermis, subcutaneous tissue and skin appendages including hair follicles, sebaceous glands, ecrrine glands and apocrine glands, nails. There is no hair on the palms and soles, so called glabrous skin. Glabrous skin is grooved on its surface by continuously alternating ridges and sulci, in individually unique configurations known as dermatoglyphics. It is characterized by the presence of encapsulated sense organs within the dermis, and by a lack of hair follicles and sebaceous glands. Hair-bearing skin, on the other hand, has both hair follicles and sebaceous glands but lacks encapsulated sense organs. Histology of the skin 1.Epidermis The epidermis is the outmost tissue in human beings. Derived from ectoderm, it can be classified as stratified squamous epithelium. Keratinocyte is the major cell, making up 95% of the total. Other cells include melanocytes, Langerhan’s cells and Merkel cells. 1) Keratinocyte Keratinocytes move progressively from attachment to the epidermal basement membrane towards the skin surface, forming several well-defined layers. The differentiation process is called cornification. The epidermis contains five histologically distinct layers from the inside to the outside: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum and stratum corneum: a.The stratum basale (basal cell layer) is a continuous layer that is generally described as only one cell thick, but may be two to three cells thick in glabrous skin and hyperproliferative epidermis. The cells of the basal layer are similar to those of other tissues within the body; they contain the typical organelles such as mitochondria and ribosomes, and the cells are metabolically active. The keratinocytes of the stratum basale are attached to the basement membrane by hemidesmosomes, which act rather like proteinaceous anchors for these lowest layer cells. Within the stratum basale and the adjacent cell layer, the stratum spinosum, keratinocytes are connected through desmosomes, again highly specialised proteinaceous cellular bridges. b.The stratum spinosum (also known as the spinous layer or prickle cell layer) is found on top of the basal layer, and together these two layers are termed the Malpighian layer. This spinous layer consists of two to six rows of keratinocytes that change morphology from columnar to polygonal cells. Within this layer the keratinocytes begin to differentiate and synthesise keratins that aggregate to form tonofilaments
C The stratum granulosum(or granular layer)is only one to three cell layers thick, the stratum granulosum contains enzymes that begin degradation of the viable cell components such as the nuclei and organelles. The granular cells are so called because they acquire granular structures. Keratohyalin granules mature the keratins within the d The stratum lucidum is the layer in which the cell nucleus disintegrates. There is an increase in keratinisation of the cells concomitant with further morphological changes such as cell flattening. The stratum lucidum can be found in soles and palms e The stratum corneum(or horny layer )is the final product of epidermal cell differentiation. Typically, the stratum corneum comprises only 10 to 15 cell layers and is around 10 um thick when dry. This thin layer consists of dead, anucleate, keratinised cells embedded in a lipid matrix. The stratum corneum serves to regulate water loss from the body whilst preventing the entry of harmful materials, includ ing microorganisms Typically, it takes 14 days for a cell from the stratum basale to differentiate into a stratum corneum cell, and the stratum corneum cells are typically retained for a further 14 days prior to shedding 2)Melanocyte The melanocyte is a dendritic, pigment-synthesizing cell derived from neural crest that is confined mainly to the basal layer. Differentiation of the melanocyte correlates with the acquisition of its primary functions: melanogenesis, arborization, and transfer of pigment to keratinocytes. There are important organizational relationships and functional interactions between keratinocytes and melanocytes that the melanocyte depends on for differentiation and function. Approximately 36 basal and suprabasal keratinocytes ar thought to coexist functionally with each melanocyte in an epidermal melanin unit 3) The langerhan’scll Langerhans cells are bone marrow-derived, antigen-processing and-presenting cells that are involved in a variety of T cell responses. Langerhans cells are dendritic and do not form junctions with any of the cells. They are distributed in the basal, spinous, and granular layers, showing a preference for a suprabasal position Langerhans cells migrate from the bone marrow to the circulation into the en s ife ly in embryonic development and continue to repopulate the epidermis throug a number of the markers expressed by the Langerhans cell are characteristic for other cells of the monocyte-macrophage lineage and provide some insight into their function Langerhans cells are the primary cells in the epidermis responsible for the recognition uptake, processing, and presentation of soluble antigen and haptens to sensitized T lymphocytes, and are implicated in the pathologic mechanisms underlying cutaneous immunological disorders pidermal appendage Pilosebaceous units, eccrine and apocrine glands and nails constitute epidermal appendages. Embryologically, they are ectodermal in origin I) Hair follicle Hair can be found in varying densities of growth over the entire surface of the bod ceptions being on the palms, soles and glans penis. Follicles are most dense on the scalp and face Each hair follicle is lined by germinative cells, which produce keratin; and by melanocytes, which synthesize pigment. The hair shaft consists of an outer cuticle, a
c.The stratum granulosum (or granular layer) is only one to three cell layers thick, the stratum granulosum contains enzymes that begin degradation of the viable cell components such as the nuclei and organelles. The granular cells are so called because they acquire granular structures. Keratohyalin granules mature the keratins within the cell. d.The stratum lucidum is the layer in which the cell nucleus disintegrates. There is an increase in keratinisation of the cells concomitant with further morphological changes such as cell flattening. The stratum lucidum can be found in soles and palms. e.The stratum corneum (or horny layer ) is the final product of epidermal cell differentiation. Typically, the stratum corneum comprises only 10 to 15 cell layers and is around 10 µm thick when dry. This thin layer consists of dead, anucleate, keratinised cells embedded in a lipid matrix. The stratum corneum serves to regulate water loss from the body whilst preventing the entry of harmful materials, including microorganisms. Typically, it takes 14 daysfor a cell from the stratum basale to differentiate into a stratum corneum cell, and the stratum corneum cells are typically retained for a further 14 days prior to shedding. 2) Melanocyte The melanocyte is a dendritic, pigment-synthesizing cell derived from neural crest that is confined mainly to the basal layer. Differentiation of the melanocyte correlates with the acquisition of its primary functions: melanogenesis, arborization, and transfer of pigment to keratinocytes. There are important organizational relationships and functional interactions between keratinocytes and melanocytes that the melanocyte depends on for differentiation and function. Approximately 36 basal and suprabasal keratinocytes are thought to coexist functionally with each melanocyte in an epidermal melanin unit. 3) The Langerhan’s cell Langerhans cells are bone marrow–derived, antigen-processing and -presenting cells that are involved in a variety of T cell responses. Langerhans cells are dendritic and do not form junctions with any of the cells. They are distributed in the basal, spinous, and granular layers, showing a preference for a suprabasal position. Langerhans cells migrate from the bone marrow to the circulation into the epidermis early in embryonic development and continue to repopulate the epidermis throughout life. A number of the markers expressed by the Langerhans cell are characteristic for other cells of the monocyte–macrophage lineage and provide some insight into their function. Langerhans cells are the primary cells in the epidermis responsible for the recognition, uptake, processing, and presentation of soluble antigen and haptens to sensitized T lymphocytes, and are implicated in the pathologic mechanisms underlying cutaneous immunological disorders. 2. Epidermal appendages Pilosebaceous units, eccrine and apocrine glands and nails constitute epidermal appendages. Embryologically, they are ectodermal in origin. 1) Hair follicle Hair can be found in varying densities of growth over the entire surface of the body, exceptions being on the palms, soles and glans penis. Follicles are most dense on the scalp and face. Each hair follicle is lined by germinative cells, which produce keratin; and by melanocytes, which synthesize pigment. The hair shaft consists of an outer cuticle, a
cortex of keratinocytes and an inner medulla. The root sheath, which surrounds the hair bulb, is composed of an outer and inner layer. An erector pili muscle is assoc iated with the hair shaft and contracts with cold, fear and emotion to pull the hair erect, giv ing the skin goose bumps During the growing phase or anagen, the cells of the hair bulb actively devide and produce the growing hair. Then hair follicles go into the catagen, or transitional phase of activity, the matrix cells stop dividing. During catagen, the lower protion of the follicle disappears, leav ing behind a thin strand of epithelial cells surrounded by a thick basement membrane zone. During telogen, the ep ithelial strand subsequently shortens to the level of the arrector pili muscle 2) Sebaceous gland Sebaceous glands are derived from epidermal cells and are closely associated with hair follicles. Sebaceous glands are found in greatest abundance on the face and scalp, though they are distributed throughout all skin sites except the palms and soles. They are small in children, enlarging and becoming active at puberty, being sensitive to androgens. They produce an oily sebum by holocrine secretion in which the cells break down and release their lipid cytoplasm 3)Sweat glands Sweat glands are thought to be over 2.5 million on the skin surface and they are present over the majority of the body They are located within the dermis and are composed of coiled tubes, which secrete a watery substance They are classified into two different types: eccrine and apocrin a. Eccrine glands are found all over the skin especially on the palms, soles, axillae forehead. They are under psychological and thermal control. Sympathetic(choliner nerve fibres innervate eccrine glands. The watery fluid they secrete contains chloride, lactic acid, fatty acids, urea, glycoproteins and mucopolysaccharides b. apocrine glands are larger, the ducts of which empty out into the hair follicles. They are present in the axillae, anogenital region and areolae and are under thermal control They become active at puberty, producing a protein-rich secretion which when acted upon by skin bacteria gives out a characteristic odour. These glands are under the control f sympathetic( energi ic)nerve fibr 4)Nails Nails consist of a dense plate of hardened keratin between 0.3 and 0. 5mm thick The nail is made up of a nail bed, nail matrix and a nail plate. The nail matrix is composed of dividing keratinocytes, which mature and keratinise into the nail plate. Underneath the nail plate lies the nail bed. The nail plate appears pink due to adjacent dermal capillaries and the white lunula at the base of the plate. The thickened epidermis which underlies the free margin of the nail at the proximal end is called the hyponychium. Fingernails grow at 0. 1 mm per day; the toenails more slowly 2. Dermis The dermis derives from mesoderm, and is typically 3-5 mm thick and is the major component of human skin. It is composed of a network of connective tissue, predominantly collagen fibrils providing support and elastic tissue providing flexibility The dermis has numerous structures embedded within it: blood and lymphatic vessels nerve endings, pilosebaceous units and sweat glands(eccrine and apocrine). The extensive vasculature of the skin is essential for regulation of body temperature whilst
cortex of keratinocytes and an inner medulla. The root sheath, which surrounds the hair bulb, is composed of an outer and inner layer. An erector pili muscle is associated with the hair shaft and contracts with cold, fear and emotion to pull the hair erect, giving the skin `goose bumps'. During the growing phase or anagen, the cells of the hair bulb actively devide and produce the growing hair. Then hair follicles go into the catagen, or transitional phase of activity, the matrix cells stop dividing. During catagen, the lower protion of the follicle disappears, leaving behind a thin strand of epithelial cells surrounded by a thick basement membrane zone. During telogen, the epithelial strand subsequently shortens to the level of the arrector pili muscle. 2) Sebaceous gland Sebaceous glands are derived from epidermal cells and are closely associated with hair follicles. Sebaceous glands are found in greatest abundance on the face and scalp, though they are distributed throughout all skin sites except the palms and soles. They are small in children, enlarging and becoming active at puberty, being sensitive to androgens. They produce an oily sebum by holocrine secretion in which the cells break down and release their lipid cytoplasm. 3) Sweat glands Sweat glands are thought to be over 2.5 million on the skin surface and they are present over the majority of the body. They are located within the dermis and are composed of coiled tubes, which secrete a watery substance. They are classified into two different types: eccrine and apocrine. a. Eccrine glands are found all over the skin especially on the palms, soles, axillae and forehead. They are under psychological and thermal control. Sympathetic (cholinergic) nerve fibres innervate eccrine glands. The watery fluid they secrete contains chloride, lactic acid, fatty acids, urea, glycoproteins and mucopolysaccharides. b. Apocrine glands are larger, the ducts of which empty out into the hair follicles. They are present in the axillae, anogenital region and areolae and are under thermal control. They become active at puberty, producing a protein-rich secretion which when acted upon by skin bacteria gives out a characteristic odour. These glands are under the control of sympathetic (adrenergic) nerve fibres. 4) Nails Nails consist of a dense plate of hardened keratin between 0.3 and 0.5mm thick. The nail is made up of a nail bed, nail matrix and a nail plate. The nail matrix is composed of dividing keratinocytes, which mature and keratinise into the nail plate. Underneath the nail plate lies the nail bed. The nail plate appears pink due to adjacent dermal capillaries and the white lunula at the base of the plate. The thickened epidermis which underlies the free margin of the nail at the proximal end is called the hyponychium. Fingernails grow at 0.1 mm per day; the toenails more slowly. 2. Dermis The dermis derives from mesoderm, and is typically 3–5 mm thick and is the major component of human skin. It is composed of a network of connective tissue, predominantly collagen fibrils providing support and elastic tissue providing flexibility. The dermis has numerous structures embedded within it: blood and lymphatic vessels, nerve endings, pilosebaceous units and sweat glands (eccrine and apocrine). The extensive vasculature of the skin is essential for regulation of body temperature whilst
also delivering oxygen and nutrients to the tissue and removing toxins and waste The size and arrangement of the collagen fibers distinguishes two main regions in the dermis, papillary and reticular dermis. The thin, superficial papillary dermis interdigitates with the epidermis, from which it is separated by a basement membrane; the underlying nine-tenths is called the reticular dermis it blends with the subcutaneous fat Fibroblasts are the most numerous of the cells found in loose connective tissue Fibroblasts are developed from the mesenchyme. Fibroblasts are responsible for the manufacture of all the dermal connective tissue elements or their precursors a Dermis consists of collagen fibers, reticular fibers, elastic fibers and ground subst round substances are composed of proteoglycans Proteoglycans are families of modified core proteins to which are attached polymers of unbranched disaccharides 3. Subcutaneous tissue The subcutaneous fat layer locates between the overlying dermis and the underlying body constituents. This layer of adipose tissue principally serves to insulate the body and to provide mechanical protection against physical shock. The subcutaneous fatty layer can also provide a read ily available supply of high-energy molecules, whilst the principal blood vessels and nerves are carried to the skin in this layer Function of the skin The most obvious functions of the skin are to provide a protective barrier for the body The barrier is largely situated in the epidermis, isolated epidermis being as impermeable as whole skin, whereas once the epidermis is removed the dermis is almost completely permeable. The epidermal barrier is localized to the stratum corneum. An intact stratum corneum prevents invasion of the skin by normal skin flora or pathogenic microorganisms. The skin has two barriers to UV radiation: a melanin barrier in the epidermis, and a protein barrier, concentrated in the stratum corneum. Both function by absorbing radiation, thereby minimizing absorption by dna and other cellular constituents The skin plays a major role in thermoregulation of the human body Heat can be lost through the skin surface by radiation, convection, conduction and evaporation. In high environmental temperatures, eccrine sweating can enhance the process of evaporation The skin is the largest immunologically active organ in the body Cells residing in the skin(keratinocytes, Langerhans' cells) are important immunological cells. or passing through(T lymphocytes)the epidermis Nerves in the skin direct the sensations of touch(including vibration and pressure), pain, warmth, cold and itch. Nerve end ings either exist freely in the skin or are encapsulated as specialized sensory receptors, such as Meissner's or Pacinian corpuscles The skin plays an important role in social and sexual communication in humans Cosmetics are used to enhance the appearance and sexual attraction. Skin lesions and discoloration may cause tremendous stress on humans (Yan Chunlin)
also delivering oxygen and nutrients to the tissue and removing toxins and waste products. The size and arrangement of the collagen fibers distinguishes two main regions in the dermis, papillary and reticular dermis. The thin, superficial papillary dermis interdigitates with the epidermis, from which it is separated by a basement membrane; the underlying nine-tenths is called the reticular dermis, it blends with the subcutaneous fat. Fibroblasts are the most numerous of the cells found in loose connective tissue. Fibroblasts are developed from the mesenchyme. Fibroblasts are responsible for the manufacture of all the dermal connective tissue elements or their precursors. Dermis consists of collagen fibers, reticular fibers, elastic fibers and ground substances. Ground substances are composed of proteoglycans. Proteoglycans are families of modified core proteins to which are attached polymers of unbranched disaccharides. 3. Subcutaneous tissue The subcutaneous fat layer locates between the overlying dermis and the underlying body constituents. This layer of adipose tissue principally serves to insulate the body and to provide mechanical protection against physical shock. The subcutaneous fatty layer can also provide a readily available supply of high-energy molecules, whilst the principal blood vessels and nerves are carried to the skin in this layer. Function of the skin The most obvious functions of the skin are to provide a protective barrier for the body, The barrier is largely situated in the epidermis, isolated epidermis being as impermeable as whole skin, whereas once the epidermis is removed the dermis is almost completely permeable. The epidermal barrier is localized to the stratum corneum. An intact stratum corneum prevents invasion of the skin by normal skin flora or pathogenic microorganisms. The skin has two barriers to UV radiation: a melanin barrier in the epidermis; and a protein barrier, concentrated in the stratum corneum. Both function by absorbing radiation, thereby minimizing absorption by DNA and other cellular constituents. The skin plays a major role in thermoregulation of the human body. Heat can be lost through the skin surface by radiation, convection, conduction and evaporation. In high environmental temperatures, eccrine sweating can enhance the process of evaporation. The skin is the largest immunologically active organ in the body. Cells residing in the skin (keratinocytes, Langerhans' cells) are important immunological cells. or passing through (T lymphocytes) the epidermis. Nerves in the skin direct the sensations of touch (including vibration and pressure), pain, warmth, cold and itch. Nerve endings either exist freely in the skin or are encapsulated as specialized sensory receptors, such as Meissner's or Pacinian corpuscles. The skin plays an important role in social and sexual communication in humans. Cosmetics are used to enhance the appearance and sexual attraction. Skin lesions and discoloration may cause tremendous stress on humans. (Yan Chunlin)
Chapter 2 Diagnosis of Skin Disease Diagnosis of skin diseases is a conclusion to the diseases, characters and pathogenesises, which is according to medical histories, symptoms, course of diseases and necessary check-ups of laboratory. The sufferers can get a proper way of treatment and prevention after having an exact diagnosis. Diagnosis of skin diseases mainly include med ical history, physical method examination, and check-up of laboratory Medical History 1. Gerneral Medical History Includes personal history (especially the one which may be related to the current symptoms), family history(whether the other members of the family have a similar disease or infective d isease, and whether consanguineous marriage exists in the family, etc), past history, living environment, occupation and habit, which may be related to the skin d iseases 2. Special Medical History It includes the time when the disease occurs, skin lesions, position, property and progressive state, subjective symptoms and therapeutical effect, etc Physical Examination Skin disease is usually a reflection of a generalized disease, so it is essential to make a complete physical examination. Examination iterms can be selected according to different 1)Observation In order to observe the skin lesions clearly, it is better to exam the sufferers in the natural sunlight. Make a complete examination to skin, mucosa, hairs, nails, and so on, so as to get all the characters Property It is needed to distinguish primary lesions or secondary lesions, in the same time it is needed to make out how many kinds of lesions exist in the skin diseases Size and Number Size can be measured actually or it can be compared with needlepoint, millet, soybean, walnut, egg, plam or other Colour It may be normal, or other colour, it is needed to assure whether it will involute after removing pressure Edge It may be topical, diffuse, infiltrative, clear, blurry, ridgy, umbilicate or other Shape It may be circular, elliptic, polygonal, irregularly shaped or other Surface t may be smooth, rough, flat, ridgy, hemispherical, mastoid uliflowerlike, umbilicate, erosive, ulcerative, exud ative, bloody, mattery, lepid scabbed or othe Fundus It may be wide, narrow, pedicel or other Content It may be clear, thick, serous, hemic, purulent, sebaceous, foreign matter Distribution It may be unilateral, bilateral, disseminated, general, extensive porad ic confluent, isolated, teeming, along blood vessels and nerves or other Position of the Skin Lesions It may be in the front, back, intertrigo part or other. The Change of hairs and nails 2)Palpation Palpate skin lesions to assure the consistency, height, thickness, topical temperature
Chapter 2 Diagnosis of Skin Disease Diagnosis of skin diseases is a conclusion to the diseases, characters and pathogenesises, which is according to medical histories, symptoms, course of diseases and necessary check-ups of laboratory. The sufferers can get a proper way of treatment and prevention after having an exact diagnosis. Diagnosis of skin diseases mainly include medical history, physical method examination, and check-up of laboratory. Medical History 1. Gerneral Medical History It includes personal history(especially the one which may be related to the current symptoms), family history(whether the other members of the family have a similar disease or infective disease, and whether consanguineous marriage exists in the family,etc),past history, living environment, occupation and habit, which may be related to the skin diseases. 2. Special Medical History It includes the time when the disease occurs, skin lesions, position, property and progressive state, subjective symptoms and therapeutical effect, etc. Physical Examination Skin disease is usually a reflection of a generalized disease, so it is essential to make a complete physical examination. Examination iterms can be selected according to different diseases. 1) Observation In order to observe the skin lesions clearly, it is better to exam the sufferers in the natural sunlight. Make a complete examination to skin, mucosa, hairs, nails, and so on, so as to get all the characters. Property It is needed to distinguish primary lesions or secondary lesions, in the same time, it is needed to make out how many kinds of lesions exist in the skin diseases. Size and Number Size can be measured actually or it can be compared with needlepoint, millet, soybean, walnut, egg, plam or other. Colour It may be normal,or other colour, it is needed to assure whether it will involute after removing pressure. Edge It may be topical, diffuse,infiltrative, clear, blurry, ridgy, umbilicate or other. Shape It may be circular, elliptic, polygonal, irregularly shaped or other. Surface It may be smooth, rough, flat, ridgy, hemispherical, mastoid, cauliflowerlike, umbilicate, erosive, ulcerative, exudative, bloody, mattery, lepidic, scabbed or other. Fundus It may be wide, narrow, pedicel or other. Content It may be clear, thick, serous, hemic, purulent, sebaceous, foreign matter or other. Distribution It may be unilateral, bilateral, disseminated, general, extensive, sporadic, confluent, isolated, teeming, along blood vessels and nerves or other. Position of the Skin Lesions It may be in the front, back, intertrigo part or other. The Change of Hairs and Nails 2) Palpation Palpate skin lesions to assure the consistency, height, thickness, topical temperature
relationship with the peripheral tissue, topical sensation, elasticity of the skin, hidrotic and sebaceous cond itions or other 3)Commonly Encountered Diseases of Different Positions Different skin positions have their own commonly encountered diseases because of the different anatomy and tissue characters or different environment influence Head There are dermatitis seborrheica, tinea capitis, psoriasis, alopecia or other There are ance, flat wart, dermatitis, seborrheica, freckle, chloasma, lupus vulgaris, rosacea, contact dermatisis, lupus erythematosus, solarius keratoma or other Labial part There are herpes simplex, fixed drug eruption, lichen planus or Tongue There are geographic tongue, ariboflavinosis, lichen planus, cancer or Neck There are neurodermatitis. furuncle scrofuloderma or other Trunk There are tinea versicolor, psoriasis, pityriasis rosea, herpes zoster, urticaria Breast There are intertrigo. eczema. eczematoid carcinoma or other Axillary fossa There are bromidrosis, hidradenitis suppurativa or other Inguinal region There are tinea cruris, intertrigo or other Pudendal region There are eczema, pruritus ani or other Hand and arm There are eczema, erythema multiforme, sporotrichosis, chilblain tinea infection, contact dermatitis, rhagades, pompholyx, scabies, verruca or other Foot and lower limb There are eczema, erythema nodosum, erythema induratum callus. wart. tinea of feet. rhagades or other Physicl Examination 1. Diascopic examination Press the skin lesions with a microslide, if the colour is clear up, they are usually caused by dermohemia and inflammation, if not, they are usually composed of petechia ecchymosises, and pigmentations. When the papules of lupus vulgaris is blanched by diascopic pressure, it will have an apple-jelly"colour 2. Demographic test Draw on the skin by a blunt body to observe whether it appears a dropsical line, which is called dermographia. It can usually be seen in dermatographism, urticaria and urticaria pigmentosa 3. Wood s light examination rrad iate the skin lesions with a high-voltage mercury lamp containing a filter composed of nickel oxide and silicate rock, which can illuminate 360 nm wavelength ultraviolet radiation. They will appear special colours or fluorescence. For example, it will be brill iant green in tinea alba, sap green in favus, red in erythrasma, Ight red or orange in porphyria, vermeil in squamous cell carc inoma, but it will be negative in basal 4. Skin test Patch test This test is used to exam contact anaphylactogen and exam whether the skin is allergic to any chemical substance. It should be carried out in the standard cond itions and observed in 48-72 hours. It can provide the references to the diagnosi Scratch test This test is used to exam whether anaphy lactogens will cause type I
relationship with the peripheral tissue, topical sensation, elasticity of the skin, hidrotic and sebaceous conditions or other. 3) Commonly Encountered Diseases of Different Positions Different skin positions have their own commonly encountered diseases because of the different anatomy and tissue characters or different environment influence. Head There are dermatitis seborrheica, tinea capitis, psoriasis, alopecia or other. Face There are ance, flat wart, dermatisis, seborrheica, freckle, chloasma, lupus vulgaris, rosacea, contact dermatisis, lupus erythematosus, solarius keratoma or other. Labial part There are herpes simplex, fixed drug eruption, lichen planus or other. Tongue There are geographic tongue, ariboflavinosis, lichen planus,cancer or other. Neck There are neurodermatitis, furuncle, scrofuloderma or other. Trunk There are tinea versicolor, psoriasis, pityriasis rosea, herpes zoster, urticaria. Breast There are intertrigo, eczema, eczematoid carcinoma or other. Axillary fossa There are bromidrosis, hidradenitis suppurativa or other. Inguinal region There are tinea cruris, intertrigo or other. Pudendal region There are eczema,pruritus ani or other. Hand and arm There are eczema, erythema multiforme, sporotrichosis, chilblain, tinea infection, contact dermatitis,,rhagades, pompholyx, scabies, verruca or other. Foot and lower limb There are eczema, erythema nodosum, erythema induratum, callus, wart, tinea of feet, rhagades or other. Physicl Examination 1. Diascopic examination Press the skin lesions with a microslide, if the colour is clear up, they are usually caused by dermohemia and inflammation, if not, they are usually composed of petechias, ecchymosises, and pigmentations. When the papules of lupus vulgaris is blanched by diascopic pressure, it will have an “apple-jelly” colour. 2. Dermographic test Draw on the skin by a blunt body to observe whether it appears a dropsical line, which is called dermographia. It can usually be seen in dermatographism, urticaria and urticaria pigmentosa. 3. Wood’ s light examination Irradiate the skin lesions with a high-voltage mercury lamp containing a filter composed of nickel oxide and silicate rock, which can illuminate 360 nm wavelength ultraviolet radiation.. They will appear special colours or fluorescence. For example, it will be brilliant green in tinea alba, sap green in favus, red in erythrasma, lght red or orange in porphyria, vermeil in squamous cell carcinoma, but it will be negative in basal cell carcinoma. 4. Skin test Patch test This test is used to exam contact anaphylactogens and exam whether the skin is allergic to any chemical substance. It should be carried out in the standard conditions and observed in 48~72 hours. It can provide the references to the diagnosis. Scratch test This test is used to exam whether anaphylactogens will cause type Ι
hypersensitivity. The result should be observed in 15-30 minutes Intracutaneous test It can be devided into immed iate reaction and delayed reaction The former is used to exam reaginic antibod ies combined with cells. It is usually applied to the skin d iseases like atopic dermatitis. The reaction often occurs in about 15 minutes The latter one is usually used to exam sufferers type IV hypersensitivity to the antigens of bacterias and funguses, such as tuberculin reaction, lepromin test and so on Check-up of laboratory It includes blood, microorganism, parasite examinations or other. Blood examination includes blood routine examination, routine urine examination, liver function test, kidney function test, blood serum electrolyte test, pathological examination, tissue examination of electron microscope, immuno logic test such as the test of"ANa"and"dsDNA",and so on. However, all of the examinations should be selected according to different diseases Diagonis of skin diseases should be assured in reference to clinicand laboratory survey Sometimes, in order to get an exact diagnosis and a proper treatment, it needs a follow- urvey in a long term (Wu Yueshen)
hypersensitivity. The result should be observed in 15~30 minutes. Intracutaneous test It can be devided into immediate reaction and delayed reaction. The former is used to exam reaginic antibodies combined with cells. It is usually applied to the skin diseases like atopic dermatitis. The reaction often occurs in about 15 minutes. The latter one is usually used to exam sufferers, type Ⅳ hypersensitivity to the antigens of bacterias and funguses, such as tuberculin reaction, lepromin test and so on. Check-up of Laboratory It includes blood, microorganism, parasite examinations or other. Blood examination includes blood routine examination, routine urine examination, liver function test, kidney function test, blood serum electrolyte test, pathological examination, tissue examination of electron microscope, immunologic test such as the test of “ANA” and “dsDNA”, and so on. However, all of the examinations should be selected according to different diseases. Diagonis of skin diseases should be assured in reference to clinicand laboratory survey. Sometimes ,in order to get an exact diagnosis and a proper treatment,it needs a follow-up survey in a long term. (Wu Yueshen)
Chapter 3 Therapy in Dermatology and venereology Drugs in dermatology There are various kinds of drugs used for both dermatologic and venereolog ic problems The most frequently prescribed will be introduced in this chapter 1. Antihistamines Antihistamines can be classified into 2 categories: HI and H2 receptor antagonists, the former being more important D)HI receptor antagonist Of similar chemical structure with that of histamine, antihistamine compete with histamine for binding with certain receptors, thereby inhibiting such effects of hista as vessel dilation, increased vessel permeability, smooth muscle contraction, secretion of respiratory tract, hypotension, erythema and wheal etc. More or less, some antihistamines also have anti-cholinergic and anti-5-HT effect a. first generation First generation of HI receptor antagonists include chlorpheniramine(4mg tid PO) In ad diton to antihistamine effect, they also have sedative, anticholinergic, anaesthetic etc doxepine(25mg qd PO), cyprophetad ine(2-4mg tid PO), and ketotifen(Img bid PO) and anti-vomiting effects. After these drugs are absorbed via gastrointestinal tract, the initial effect is usually seen 30 minutes later, and the maximal effect can be reached 1-2 hours later. The duration of drug effect is ranged from 4 to 6 hours. metabolized by hepatic P450 system, they will be excreted in urine within 24 hours Indications of first generation of antihistamines include urticaria, drug eruption eczema, dermatitis, lichen planus and pruritus etc Side effects are obvious since these drugs can cross the blood-brain barrier and dilation can be seen in those who take the medicine Therefore, drivers aloft wor bo antagonize cholinergic effects as well. Fatigue, drowsiness, dryness, dysuria and pupil personnel, glaucoma patients, prostatic hypertrophy patients are contraindications or relative contraind ications b. Second generation Second generation antihistamines have much less sedative and anti-cholinergic effects than first generation, since they cannot cross the blood-brain barrier and thus have minimal effect on central nervous system. Moreover, effects of these grugs last longer Therefore, second generation antihistamines are much safer for drivers and patients with chronic disease, and have been more and more widely used. Typical examples of second generation antihistamines are loratad ine(10mg qd PO), cetirizine(10mg qd PO), mequitazine(5mg bid PO), mizolastine(10mg ad PO)etc 2)H2 receptor antagonists indue ing high affinity for H2 receptors, H2 receptor antagonists will suppress histamine d vessel dilation, hypotension and gastric secretion. Absorbed via small intestine, they reach the peak blood concentration 1-1. 5 hous later, and 2/3 of them are excreted in urine. The half life of these drugs is about 2 hours H2 receptor antagonists include cimitidine(0.2 qid, PO), ranitidine(150mg bid, PO) and famotidine(20mg bid, PO), and can be used in combination with HI receptor antagonists for the treatment of chronic urticaria. Side effects include headache d izziness
Chapter 3 Therapy in Dermatology and Venereology Drugs in dermatology There are various kinds of drugs used for both dermatologic and venereologic problems. The most frequently prescribed will be introduced in this chapter. 1. Antihistamines Antihistamines can be classified into 2 categories: H1 and H2 receptor antagonists, the former being more important. 1) H1 receptor antagonist Of similar chemical structure with that of histamine, antihistamine compete with histamine for binding with certain receptors, thereby inhibiting such effects of histamine as vessel dilation, increased vessel permeability,smooth muscle contraction, secretion of respiratory tract, hypotension, erythema and wheal etc. More or less, some antihistamines also have anti-cholinergic and anti-5-HT effect. a. First generation First generation of H1 receptor antagonists include chlorpheniramine (4mg tid PO), doxepine (25mg qd PO), cyprophetadine (2-4mg tid PO), and ketotifen (1mg bid PO) etc.. In additon to antihistamine effect, they also have sedative, anticholinergic, anaesthetic and anti-vomiting effects. After these drugs are absorbed via gastrointestinal tract, the initial effect is usually seen 30 minutes later, and the maximal effect can be reached 1-2 hours later. The duration of drug effect is ranged from 4 to 6 hours. Metabolized by hepatic P450 system, they will be excreted in urine within 24 hours. Indications of first generation of anitihistamines include urticaria, drug eruption, eczema, dermatitis, lichen planus and pruritus etc. Side effects are obvious since these drugs can cross the blood-brain barrier and antagonize cholinergic effects as well. Fatigue, drowsiness, dryness, dysuria and pupil dilation can be seen in those who take the medicine. Therefore, drivers, aloft work personnel, glaucoma patients, prostatic hypertrophy patients are contraindications or relative contraindications. b. Second generation Second generation antihistamines have much less sedative and anti-cholinergic effects than first generation, since they cannot cross the blood-brain barrier and thus have minimal effect on central nervous system. Moreover, effects of these grugs last longer. Therefore, second generation antihistamines are much safer for drivers and patients with chronic disease, and have been more and more widely used. Typical examples of second generation antihistamines are loratadine (10mg qd PO), cetirizine (10mg qd PO), mequitazine(5mg bid PO), mizolastine (10mg qd PO) etc.. 2) H2 receptor antagonists Having high affinity for H2 receptors, H2 receptor antagonists will suppress histamine induced vessel dilation, hypotension and gastric secretion. Absorbed via small intestine, they reach the peak blood concentration 1-1.5 hous later, and 2/3 of them are excreted in urine. The half life of these drugs is about 2 hours. H2 receptor antagonists include cimitidine (0.2 qid, PO), ranitidine (150mg bid, PO) and famotidine (20mg bid, PO), and can be used in combination with H1 receptor antagonists for the treatment of chronic urticaria. Side effects include headache, dizziness
