Skin and Subcutaneous Tissue

THE SKIN AND
SUBCUTANEOUS TISSUE
TOPICS
• Anatomy and Histology
• Inflammatory Conditions
• Injuries
• Bioengineered Skin Substitutes
• Bacterial Infections of the Skin and Subcutaneous Tissue
• Viral Infections with Surgical Implications
• Benign Tumors
• Malignant Tumors
• Conclusion
TOPICS
• Injuries
• Benign Tumors
• Conclusion
Anatomy and Histology
ANATOMY AND HISTOLOGY
Epidermis
• outermost layer of the cutaneous tissue, primarily of continually
regenerating keratinocytes
• thickness: ranging from 75 to 150 µm in thin skin (eyelids) to 0.4 to 1.5

mm in thick skin (palms and soles)
Epidermis (cont..)
• Histologically distinct layers
1. stratum basale - germinative layer; deep, single layer of

asynchronous, continuously replicating cuboidal to columnar
epithelial cells
2. stratum spinosum- spiny layer; 5 to 15 cells in thickness. It has

spinous appearance of the intercellular desmosomal
Epidermis (cont..)
• Histologically distinct layers
• 3. stratum granulosum - basophilic keratohyalin granules. There are

also structures called lamellar granules within these cells that
contain the lipids and glycolipids
• 4. stratum lucidum - layer of flat, translucent keratinocytes
• 5. stratum corneum - cornified layer; protein-rich, flattened

keratinocytes surrounded by a lipid-rich matrix. Protects the tissue
from mechanical, chemical, and bacterial disruption
Epidermal Components
1. Keratinocytes - 90% of the cells of the epidermis
2. Langerhans Cells - typically found within the stratum spinosum. Takes up

antigens for presentation to T-cells
3. Melanocytes - found within the stratum basale. Responsible for

production of the pigment melanin in the skin
Epidermal Components (cont..)
4. Merkel Cells - essential for light touch sensation
5. Lymphocytes - < 1% of the cells in the epidermis and primarily within the
basal layer of keratinocytes. They typically express an effector memory T-cell
phenotype
6. Toker Cells - found in the epidermis of the nipple in 10% of both males
and females. Immunohistochemical studies have implicated them as a
possible source of Paget’s disease of the nipple
Epidermal Appendages
• Sweat Glands - derived from the embryologic ectoderm
1. Exocrine gland - majority of the sweat glands in the body and are extremely
important to the process of thermoregulation
2. Apocrine sweat gland - found around the axilla, anus, areola, eyelid, and
external auditory canal. Activated by sex hormones. Secretions from apocrine
glands is initially odorless, but bacteria in the region may cause an odor to
develop.
3. Apoeccrine - similar to an apocrine gland but opens directly to the skin

surface
Epidermal Appendages (cont..)
• Pilosebaceous Unit
• Made up of a hair follicle, sebaceous gland, an erector pili muscle, and a

sensory organ. Responsible for the production of hair and sebum and are
present almost entirely throughout the body, sparing the palms, soles, and
mucosa
• They are lined by the germinal epithelium of the epidermis
• Sebaceous glands secrete sebum into the follicle and skin via a duct. The lipid-
secreting glands are largely influenced by androgens and become functionally
active during puberty
Epidermal Appendages (cont..)
• Nails - keratinaceous structures overlying the distal phalanges of the fingers and
toes
• 3 main parts:
1. Nail Root - proximal portion of the nail, continuous with the germinal nail matrix
2. Nail Plate - lies on top of the nail bed, the shape of which is determined by the
underlying phalanx
3. Hyponychium - free edge, which overlies a thickened portion of epidermis

Dermal Components
• Architecture:
• Mesoderm-derived tissue that protects and supports the epidermis

while anchoring it to the underlying subcutaneous tissue
• 3 components: a fibrous structure, the ground substance that surrounds

those fibers, and the cell population that is supported by the dermis.
Dermal Components (cont..)
• Architecture:
• 2 Layers: the papillary layer and the reticular layer.
• Papillary layer - is made up of papillae that interdigitate with the rete

ridges of the deep portion of the epidermis. It is characterized by a
greater density of cells
• Reticular layer - made up of a coarse network of fibers and the

ground substance that surrounds it
Dermal Components (cont..)
• Fibers and Ground Substance:
• 98% of the dry weight of the dermis is made up of collagen, typically

80% 90% type I collagen and 8% to 12% type III collagen. Collagen
types IV and VII are also found in much smaller quantities in the dermo-
epidermal junction
Cells
• Fibroblasts
• Found in the loose, papillary layer, and are the fundamental cells of the
dermis
• Responsible for producing all dermal fibers and the ground substance
within which those fibers reside
• They are typically spindle- or stellate-shaped and have a well-

developed rough endoplasmic reticulum
Cells (cont..)
• Dermal Dendrocytes
• Comprised of a variety of mesenchymal dendritic cells recognizable

mainly by immunohistochemistry
• Responsible for antigen uptake and processing for presentation to the

immune system, as well as the orchestration of processes involved in
wound healing and tissue remodeling
Cells (cont..)
• Mast Cells
• effector secretory cells of the immune system that are responsible for
immediate type 1 hypersensitivity reactions
Cutaneous Vasculature
• Superficial, subpapillary plexus is located between the papillary and

reticular dermis and provides a vascular loop to every papilla of the
papillary dermis
• Deep dermal plexus is located at the junction of the reticular dermis and
hypodermis, and it derives its blood supply from perforating arteries of
larger vessels below the cutaneous tissues
Cutaneous Innervation
• An afferent component made up of free nerve endings and specialized

corpuscular receptors is responsible for conveying to our brain
information about the environment, while numerous functions of the
cutaneous tissues, such as AV-shunting, piloerection, and sweat
secretion are controlled by the myelinated and unmyelinated fibers of an
efferent component of the CNS
Hypodermis
• Richly vascularized loose connective tissue that separates and attaches

the dermis to the underlying muscle and fascia
• It is made up primarily of pockets of lipid-laden adipocytes separated

by septae that contain cellular components
• Functions: insulation, storage of energy, and protection from

mechanical forces
TOPICS
• Injuries
• Benign Tumors
• Conclusion
INFLAMMATORY CONDITIONS
Hidradenitis Suppurativa
• aka Acne Inversa
• Painful skin condition typically affecting areas of the body bearing

apocrine glands
• It is characterized by tender, deep nodules that can expand, coalesce,

spontaneously drain, and form persistent sinus tracts in some cases
leading to significant scarring and hyperkeratosis
Hidradenitis Suppurativa (cont..)
• Diagnosis of hidradenitis is clinical, and the presentation is most

commonly categorized by the Hurley classification system, divided into
three stages.
Pyoderma gangrenosum
• Development of sterile pustules which progress to painful, ulcerating

lesions with purple borders
• Arises in individuals with a hematologic malignancy or inflammatory

disorder, such as inflammatory bowel disease or rheumatoid arthritis
• Most commonly affected sites are the legs, but lesions can occur
anywhere
Pyoderma gangrenosum (cont..)
• Initial pathology is sterile, it can easily become secondarily infected
• 5 distinct types of pyoderma gangrenosum described: vegetative,

pustular, peristomal, ulcerative, and bullous
Epidermal Necrolysis
• Rare mucocutaneous disorder characterized by cutaneous destruction at

the dermoepidermal junction
• Commonly referred to as either Stevens-Johnson syndrome (SJS) or toxic

epidermal necrolysis (TEN) depending on the extent of skin involvement
present
Epidermal Necrolysis (cont..)
• SJS refers to cases in which <10% of total body surface area is involved,
while cases with >30% involvement are considered TEN, with an SJS-TEN
overlap syndrome referring to all cases in between
• Clinical presentation usually occurs within 8 weeks of initiation of a new

drug treatment and is characterized by a macular rash beginning in the
face and trunk and progressing to the extremities within hours to days
• The macular rashes then begin to blister and coalesce, forming bullae that
eventually burst, leaving partial thickness wounds with exposed dermis
• Mucous membrane involvement is seen in 90% of cases and can involve

the oral, genital, and ocular mucosa, as well as the respiratory and
gastrointestinal tracts
• Drugs most commonly associated with EN include anticonvulsants,

sulfonamides, allopurinol, oxiaromatic cams (nonsteroidal anti-
inflammatory drugs), and nevirapine
• The prognosis of EN is generally related to the surface area affected and

secondary complications of extensive cutaneous damage, like secondary
infections and loss of hemodynamic stability due to increased insensible
losses and third spacing of fluid
• Nikolsky sign = lateral pressure on

the skin causes separation of the
epidermis from the dermis
TOPICS
• Injuries
• Benign Tumors
• Conclusion
INJURIES
Radiation-Induced Injuries
• Result from exposure to electromagnetic radiation from industrial/

occupation applications or, more commonly, from environmental exposure
and medical treatments.
INJURIES
Trauma-Induced Injuries
• Mechanical Injury:
• Physical disruption of the skin can occur via numerous mechanisms
• Treatment of the wound is dependent on the size of the defect left

behind by the insult, any exposed structures that remain in the wound
bed, and the presence of contaminating debris or infection
INJURIES
Trauma-Induced Injuries (cont..)
• Clean, simple lacerations can be irrigated, debrided, and closed

primarily.
• Grossly contaminated or infected wounds should be allowed to heal by

secondary intention or delayed primary closure
• In wounds allowed to heal secondarily, negative pressure wound

therapy can increase the rate of granulation tissue formation.
INJURIES
• Partial thickness injuries with preservation of the regenerative

pilosebaceous units can be allowed to heal on their own while
maintaining a moist, antimicrobial wound environment.
• Full thickness wounds may require reconstruction with split- or full-

thickness skin grafting depending on the size of the defect and the
need for future cosmesis and durability.
INJURIES
• Bite Wounds
• Bites from dogs, humans, and other animals can quickly lead to severe
deep-tissue infections if not properly recognized and treated
• Hand - most common location of bite wounds

INJURIES
• Bite Wounds
• Early presentation bite wounds yield polymicrobial cultures, while

cultures from a late infection will typically exhibit one dominant
pathogen
INJURIES
• Bite Wounds
• Common aerobic bacteria: Pasteurella multocida, Streptococcus,

Staphylococcus, Neisseria, and Corynebacterium
• Common anaerobic organisms: Fusobacterium, Porphyromonas,

Prevotella, Propionibacterium, Bacteroides, and Peptostreptococcus
INJURIES
• Bite Wounds
• Cat bite bacteriology is similar, with slightly higher prevalence of

Pasturella species
INJURIES
• Bite Wounds
• Antibiotic prophylaxis after a human bite is recommended as it has been shown to

significantly decrease the rate of infection
• A course of 3 to 7 days of amoxicillin/clavulanate is typically used. Alternatives are

doxycycline or clindamycin with ciprofloxacin
INJURIES
• Bite Wounds
INJURIES
Caustic Injury
• Chemical burns make up to 10.7% of all burns but account for up to 30%
of all burn-related deaths
• The extent of tissue destruction from a chemical burn is dependent on

type of chemical agent, concentration, volume, and time of exposure,
among other variables
INJURIES
Caustic Injury (cont..)
• Injuries from acidic solutions are typically not as severe as those from
basic solutions
• Acidic injuries typically result in superficial eschar formation because the

coagulative necrosis caused by acids limits tissue penetration
• Basic solution injuries undergo liquefactive necrosis. Common examples

of agents that often cause alkaline chemical burns are sodium hydroxide
(drain decloggers and paint removers) and calcium hydroxide (cement)
INJURIES
• Treatment for acidic or alkaline chemical burns is first and foremost

centered around dilution of the offending agent, typically using distilled
water or saline for 30 minutes for acidic burns and 2 hours for alkaline
injuries
INJURIES
• After removal of the caustic agent, the burn is treated like other burns and
is based on the depth of tissue injury
INJURIES
• Topical antimicrobials and nonadherent dressings are used for partial-

thickness wounds with surgical debridement and reconstruction if needed
for full thickness injuries
• Prophylactic use of antibiotics is generally avoided

INJURIES
INJURIES
Thermal Injury
• Involves the damage or destruction of the soft tissue due to extremes of

temperature, and the extent of injury is dependent on the degree
temperature to which the tissue is exposed and the duration of exposure
INJURIES
Thermal Injury (cont..)
• Zone of Coagulation: focus of thermal injury that has already undergone

necrosis
• Zone of Hyperemia: outside the zone of coagulation, which exhibits signs

of inflammation but will likely remain viable
• Zone of Stasis: In between these two zones with questionable tissue

viability, and it is this area at which proper burn care can salvage viable
tissue and decrease the extent of injury
INJURIES
Thermal Injury (cont..)
INJURIES
Pressure Injury
• Affect the critically ill (22% to 49% of all critically ill patients are affected),
the chronically bed- or wheelchair- bound, patients undergoing surgical
procedures, and those with Foley catheters, artificial airways, or other
medical equipment
INJURIES
Pressure Injury (cont..)
• 4 stages:
• stage 1: nonblanching erythema over intact skin
• stage 2: partial-thickness injury with blistering or exposed dermis
• stage 3: full-thickness injury extending down to, but not including, fascia
and without undermining of adjacent tissue
• stage 4: full-thickness skin injury with destruction or necrosis of muscle,

bone, tendon, or joint capsule
INJURIES
Pressure Injury (cont..)
TOPIC
• Injuries
• Benign Tumors
• Conclusion
BIOENGINEERED SKIN SUBSTITUTES
Typically derived from or designed to imitate dermal tissue, providing a
regenerative matrix or stimulating autogenous dermal regeneration while
protecting the underlying soft tissue and structures
BIOENGINEERED SKIN SUBSTITUTES
• Four types of skin substitutes:
1. autografts - which are taken from the patient and placed over a soft
tissue defect (split-thickness and full-thickness skin grafts)
2. allografts - which are taken from human organ donors
3. xenografts - which are taken from members of other animal species
4. synthetic and semisynthetic biomaterials

TOPICS
• Injuries
• Benign Tumors
• Conclusion
BACTERIAL INFECTIONS OF THE SKIN AND
SUBCUTANEOUS TISSUE
• Staphylococcus aureus - agent most commonly responsible for skin and

soft tissue infections
• Less common isolates include other gram-positive bacteria such as

Enterococcus species (9%), β-hemolytic streptococci (4%), and
coagulase-negative staphylococci (3%)
• Gram-negative species like Pseudomonas aeruginosa (11%), Escherichia

coli (7.2%), Enterobacter (5%), Klebsiella (4%), and Serratia (2%)
SUBCUTANEOUS TISSUE
Uncomplicated Skin Infections
• Impetigo - is a superficial infection, typically of the face, that occurs most

frequently in infants or children, resulting in honey-colored crusting.
• Erysipelas - is a cutaneous infection localized to the upper layers of the

dermis
SUBCUTANEOUS TISSUE
Uncomplicated Skin Infections (cont..)
• Cellulitis - is a deeper infection, affecting the deeper dermis and

subcutaneous tissue
• Folliculitis - describes inflammation of the hair follicle

SUBCUTANEOUS TISSUE
• Furuncle - describes a follicle with swelling and a collection of purulent

material. These lesions can sometimes coalesce into a carbuncle, an
abscess with multiple different draining sinus tracts.
SUBCUTANEOUS TISSUE
• Treatment:
• Topical antimicrobials like 2% mupirocin
• Furuncles, carbuncles and other simple abscesses can be incised,

drained, and packed, typically without the use of systemic antibiotics
SUBCUTANEOUS TISSUE
• Treatment:
• Systemic antibiotics after incision and drainage of abscess should be

made based upon presence or absence of systemic inflammatory
response syndrome (SIRS) criteria.
• For nonpurulent, uncomplicated cellulitis in which there is no drainable

collection, systemic antibiotic coverage for β-hemolytic streptococcus
is recommended
SUBCUTANEOUS TISSUE
• Treatment:
• Antibiotic coverage for streptococcus is generally accomplished with β-

lactam antibiotics like penicillins or first-generation cephalosporins
• MRSA coverage is accomplished with clindamycin, trimethoprim-

sulfamethoxazole, linezolid, and tetracyclines. Clindamycin,
trimethoprim-sulfamethoxazole, linezolid, or tetracycline combined with
a β-lactam can all be used for dual coverage of streptococcus and
MRSA
SUBCUTANEOUS TISSUE
Complicated Skin Infections
• Superficial cellulitis with large surface area (>75 cm2) or deeper infections
extending below the dermis
SUBCUTANEOUS TISSUE
Complicated Skin Infections (cont..)
• Necrotizing soft tissue infections (NSTI) - Necrotizing fasciitis
• Initial treatment consists of intravenous antibiotics that cover β-

hemolytic streptococcus, such as cephalosporins, with the addition of
MRSA coverage if there is no improvement in symptoms.
• Vancomycin is typically the first choice for MRSA coverage
• Surgical exploration and debridement

SUBCUTANEOUS TISSUE
Complicated Skin Infections (cont..)
• Necrotizing soft tissue infections (NSTI) - Necrotizing fasciitis
• NSTIs commonly originate at the genitalia, perineum (Fournier’s

gangrene), and abdominal wall. Subcutaneous tissue, fascia and
muscle can all be affected. Necrotizing fasciitis involves infection of the
fascia, and the infection can quickly travel along the easily separable,
avascular planes.
SUBCUTANEOUS TISSUE
Actinomycosis
• Actinomycetes - gram positive rods that inhabit the oropharynx,

gastrointestinal tract, and female genital tract
• Cervicofacial form of Actinomycetes infection is the most common

presentation (55% of cases), and typically presenting as an acute
pyogenic infection in the submandibular or paramandibular area
SUBCUTANEOUS TISSUE
Actinomycosis (cont..)
• Diagnosis: demonstration of gram-positive filamentous organisms and

sulfur granules on histological examination
• Treatment:
• High doses of intravenous followed by oral penicillin therapy
• Surgery - (+) extensive necrotic tissue, poor response to antibiotics, or

the need for tissue biopsy to rule out malignancy.
TOPICS
• Injuries
• Benign Tumors
• Conclusion
VIRAL INFECTIONS WITH SURGICAL
IMPLICATIONS
Human Papillomavirus Infections
• Transmitted via cutaneous contact with individuals who have clinical or

subclinical infection and occur more frequently in immunocompromised
individuals
• Histology: nonspecific findings of hyperkeratosis, papillomatosis, and

acanthosis, as well as the hallmark koilocytes (clear halo around
nucleus)
• Slow-growing papules on the skin or mucosal surfaces

IMPLICATIONS
Human Papillomavirus Infections (cont..)
• Subtypes: Cutaneous or Mucosal
• Cutaneous types - hands and fingers.
• Verruca vulgaris, or common warts - caused by HPV types 1, 2, and 4
• Plantar and palmar warts - (HPV-1 and -4) typically occur at points of
pressure and are characterized by a keratotic plug surrounded by a
hyperkeratotic ring with black dots (thrombosed capillaries) on the
surface.
IMPLICATIONS
• Subtypes: Cutaneous Type
• Plane warts occur on the face, dorsum of hands, and shins. They are
caused by HPV-3 and -10 and tend to be multiple, flat-topped lesions
with a smooth surface and light brown color. Cutaneous warts
typically regress spontaneously in the immunocompetent patient
IMPLICATIONS
• Subtypes: Cutaneous Type
• Epidermodysplasia verruci formis is a rare, autosomal recessive

inherited genetic skin disorder, widespread verrucae that carry a
higher risk of malignant transformation (30%–50% risk of squamous
cell carcinoma), especially when caused by HPV types 5 and 8
IMPLICATIONS
• Subtypes: Mucosal HPV Type
• Mucosal HPV types - cause lesions in the mucosal or genital areas
• Most common mucosal types are HPV-6, -11, -16, -18, -31 and -33
IMPLICATIONS
• Subtypes: Mucosal HPV Type
• Present as condylomata acuminata, genital or veneral warts, papules

that occur on the perineum, external genitalia, anus, and can extend
into the mucosal surfaces of the vagina, urethra and rectum.
• Malignant transformation: Low risk - Types 6 and 11; High Risk -

types 16, 18, 31 and 33
IMPLICATIONS
Cutaneous Manifestations of Human Immunodeficiency Virus
• Acute retroviral syndrome - presents as acute viral exanthem
• This is usually a morbilliform rash affecting the face, trunk, and upper
extremities
TOPICS
• Injuries
• Benign Tumors
• Conclusion
BENIGN TUMORS
Hemangioma
• Benign vascular tumors that arise from the proliferation of endothelial cells
that surround blood-filled cavities.
• Occur in about 4% of children by 1 year of age

BENIGN TUMORS
Hemangioma (cont..)
• Generally managed nonsurgically prior to involution, except during rapid

growth phase that causes obstruction, surgical resection is indicated
• Systemic corticosteroids and interferon-α can impede tumor progression,

and laser therapy has been used as well
• When surgical resection or debulking is considered, upfront selective

embolization can help with planned resection
BENIGN TUMORS
Nevi
• Melanocytic hyperplasia or neoplasia
• Found in the epidermis (junctional), partially in the dermis (compound), or

completely within the dermis (dermal)
BENIGN TUMORS
Nevi (cont..)
• Typically symmetric and small
• Congenital nevi are the result of abnormal development of melanocytes
• Has 5% chance of developing into a malignant melanoma, treatment,

therefore, consists of surgical excision of the lesion as early as is feasible
BENIGN TUMORS
Cystic Lesions
• Characterized by overgrowth of epidermis towards the center of the

lesion, resulting in keratin accumulation
• Epidermoid cysts - (often mistakenly referred to as sebaceous cysts)

are classically the result of keratin-plugged pilosebaceous units
• Presents as a dermal or subcutaneous cyst with a single, keratin-

plugged punctum at the skin surface, often at or above the upper
chest and back
• Histology: mature epidermis complete with granular layer

BENIGN TUMORS
Cystic Lesions (cont..)
• Trichilemmal cyst - derived from the outer sheath of hair follicles
• Almost always found on the scalp and more commonly in women
• Cutaneous cyst - is a dermoid cyst. Congenital variants that occur as

the result of persistent epithelium within embryonic lines of fusion.
• They occur most commonly between the forehead and nose tip,
and the most frequent site is the eyebrow
BENIGN TUMORS
Keratosis
• Actinic Keratosis
• Neoplasms of epidermal keratinocytes that represent a range in a

spectrum of disease from sun damage to squamous cell carcinoma.
• Typically occur in fair-skinned, elderly individuals in primarily sun-

exposed areas
BENIGN TUMORS
Keratosis (cont..)
• UV radiation exposure - greatest risk factor
• Present as erythematous and scaly to hypertrophic, keratinized lesions
• They can become symptomatic, causing bleeding, pruritis and pain

BENIGN TUMORS
Keratosis (cont..)
• Regress spontaneously, persist without change, and transform into

invasive squamous cell carcinoma (approximately 10% of actinic
keratoses)
• Presence of actinic keratoses also serves as a predictor of development

of other squamous cell and basal cell carcinomas
BENIGN TUMORS
Keratosis (cont..)
• Treatment: excision, fluorouracil, cautery and destruction, and

dermabrasion
BENIGN TUMORS
Keratosis (cont..)
• Seborrheic Keratosis
• benign lesions of the epidermis that typically present as well-

demarcated, “stuck on” appearing papules or plaques over elderly
individuals
BENIGN TUMORS
Keratosis (cont..)
• Seborrheic Keratosis
• Clonal expansion of keratinocytes and melanocytes make up the

substance of these lesions
• No malignant potential and treatment is primarily for cosmetic

purposes.
BENIGN TUMORS
Soft Tissue Tumors
• Acrochordons - aka skin tags, are benign, pedunculated lesions on the

skin made up of epidermal keratinocytes surrounding a collagenous core
BENIGN TUMORS
Soft Tissue Tumors (cont..)
• Dermatofibromas - benign cutaneous proliferations that appear most

commonly on the lower extremities of women. Appear as pink to brown
papules that pucker or dimple in the center when the lesion is pinched. In
rare cases, a basal cell carcinoma may develop within a dermatofibroma
BENIGN TUMORS
Soft Tissue Tumors (cont..)
• Lipomas - most common subcutaneous neoplasm and have no malignant

potential. Present as a painless, slow-growing, mobile mass of the
subcutaneous tissue.
• Liposarcoma is a malignant fatty tumor that can mimic a lipoma, but is

often deep-seated, rapidly growing, painful, and invasive. In these
cases, cross-sectional imaging is recommended prior to any surgical
resection.
BENIGN TUMORS
Neural Tumors
• Neuromas - disordered growth of Schwann cells and nerve axons, often at

the site of previous trauma. They can present within surgical scar lines or
at the site of previous trauma as flesh-colored papules or nodules and are
typically painful
BENIGN TUMORS
Neural Tumors (cont..)
• Schwannomas - benign proliferation of the Schwann cells of the

peripheral nerve sheath, and can arise sporadically or in association with
type 2 neurofibromatosis. It contains no axons, but may displace the
affected nerve and cause pain along the distribution of the nerve
BENIGN TUMORS
Neural Tumors (cont..)
• Neurofibromas - are benign proliferations that are made up of all nerve

elements, and arise as fleshy and nontender, sessile or pedunculated
masses on the skin
TOPICS
• Injuries
• Benign Tumors
• Conclusion
MALIGNANT TUMORS
Basal Cell Carcinoma (BCC)
• 75% of non-melanoma skin cancers and 25% of all cancers
• seen slightly more commonly in males and individuals over the age of
60
• Primary risk factor - sun exposure (UVB rays more than UVA rays)
MALIGNANT TUMORS
Basal Cell Carcinoma (BCC) (cont..)
• Occurs on sun-exposed areas of the skin, most commonly the nose

and other parts of the face.
• A malignant lesion on the upper lip is almost always BCC, and BCC is
the most common malignant eyelid tumor.
MALIGNANT TUMORS
• Multiple variants of BCC: nodular (most common) and micronodular,

superficial spreading, and infiltrative
• Morpheaform subtype - 2% to 3% of all BCC and is the most

aggressive subtype. It usually presents as an indurated macule or
papule with the appearance of an enlarging scar. The clinical margins
are often indistinct, and the rate of positive margins after excision is
high
MALIGNANT TUMORS
• Treatment of BCC varies according to size, location, type, and high- or

low-risk.
• Includes surgical excision, medical, or destructive therapies

MALIGNANT TUMORS
• Surgical excision - 4 mm margins for small, primary BCC on cosmetically

sensitive areas, and 10 mm margins otherwise
• Mohs microsurgical excision

MALIGNANT TUMORS
• Low risk lesions - cautery and destruction. Other destructive techniques

include cryosurgery and laser ablation.
• Radiation therapy can be used as adjuvant therapy following surgery, or

as primary therapy in poor surgical candidates with low-risk lesions
• Topical imiquimod or 5-fluorouracil

MALIGNANT TUMORS
MALIGNANT TUMORS
Squamous Cell Carcinoma (SCC)
• 2nd most common skin cancer
• Primary risk factor for the development of SCC is UV radiation exposure.
• Other risks include light Fitzpatrick skin type (I or II), environmental factors
such as chemical agents, physical agents (ionizing radiation), psoralen,
HPV-16 and -18 infections, immunosuppression, smoking, chronic
wounds, burn scars, and chronic dermatoses.
MALIGNANT TUMORS
Squamous Cell Carcinoma (SCC) (cont..)
• Heritable risk factors include xeroderma pigmentosum, epidermolysis

bullosa, and oculocutaneous albinism.
• Appears as a scaly or ulcerated papule or plaque, and bleeding of the

lesion with minimal trauma is not uncommon, but pain is rare
• Variants: Actinic Keratosis and Bowen disease

MALIGNANT TUMORS
• Characterized by invasion through the basement membrane into the

dermis of the skin
• Clinical risk factors for recurrence include presentation with neurologic

symptoms, immunosuppression, tumor with poorly defined borders, and
tumor that arises at a site of prior radiation
MALIGNANT TUMORS
• Perineural involvement also has a poorer survival with increased local

recurrence and lymph node metastasis
• Large (>2 cm) lesions, depth of invasion >4 mm, rapid growth, and
location on the ear, lips, nose, scalp, or genitals are all also indicators of
worse prognosis.
MALIGNANT TUMORS
• Treatment: wide surgical excision including subcutaneous fat is the

treatment of choice for SCC. Margins of 4 mm (low risk lesion) and 6 mm
(high-risk lesions)
• Mohs microsurgical excision
• Lymphadenectomy
MALIGNANT TUMOR
MALIGNANT TUMORS
MALIGNANT TUMORS
Melanoma
• Clinical Presentation - Starts as a localized, radial growth phase followed

by a more aggressive, vertical growth phase
• Arise from a pre-existing melanocytic nevus

MALIGNANT TUMORS
Melanoma (cont..)
• Melanoma is characterized according to the American Joint Committee on

Cancer (AJCC) as localized disease (stage I and II), regional disease (stage
III), or distant metastatic disease (stage IV)
MALIGNANT TUMORS
Melanoma (cont..)
• Superficial Spreading - most common sub-type of melanoma (50-70%)
• Nodular subtype accounts for 15% to 30%
• Lentigo maligna represents 10% of melanoma cases
• Acral lentiginous melanoma accounts for 29% to 72% of melanomas

MALIGNANT TUMORS
Melanoma (cont..)
• Clinical characteristics: ABCDE
• Asymmetric with irregular Borders, Color variations, a Diameter greater

than 6 mm, and are undergoing some sort of Evolution or change
MALIGNANT TUMORS
Melanoma (cont..)
• Diagnosis and Staging
• History and Physical Examination
• Excisional biopsy with 1- to 3-mm margins, Incisional Biopsy or Punch

Biopsy
MALIGNANT TUMORS
Melanoma (cont..)
• Tissue specimen should include full thickness of the lesion and a small
section of normal adjacent
• FNA - for clinically suspicious lymph nodes

MALIGNANT TUMORS
Melanoma (cont..)
• The Breslow tumor thickness replaced the Clark’s level as the most
important prognostic indicator for melanoma staging
• Tumor ulceration, mitotic rate ≥1 per mm2, and metastasis = worse

prognosis
MALIGNANT TUMORS
Melanoma (cont..)
• Imaging - for High risk for distant metastasis for baseline staging. CT of
the chest, abdomen, and pelvis; whole-body positron emission
tomography (PET)-CT; or brain magnetic resonance imaging (MRI)
• SLNB is a standard staging procedure to evaluate the regional nodes for

patients with clinically node negative malignant melanoma
MALIGNANT TUMORS
Melanoma (cont..)
MALIGNANT TUMORS
Merkel Cell Carcinoma (MCC)
• Aggressive neuroendocrine tumor
• MCC typically presents as a rapidly growing, flesh-colored to red or purple

papule or plaque
• Regional nodes are involved in 30% of patients at diagnosis, and 50% will
develop systemic disease (skin, lymph nodes, liver, lung, bone, and brain)
MALIGNANT TUMORS
Merkel Cell Carcinoma (MCC) (cont..)
• No standardized diagnostic imaging studies for staging, but CT of the

chest, abdomen, pelvis and octreotide scans may provide useful
information when clinically indicated
• Treatment should begin by evaluating nodal basins

MALIGNANT TUMORS
Merkel Cell Carcinoma (MCC) (cont..)
• Clinically negative node: SLNB prior to wide local excision. Elective lymph
node dissection may decrease regional nodal recurrence and in-transit
metastases
• Clinically positive nodes: FNA to confirm disease
• Positive - metastatic staging workup
• Negative - treatment of the primary and nodal basin

MALIGNANT TUMORS
Kaposi’s Sarcoma
• Characterized by the proliferation and inflammation of endothelial-derived

spindle cell lesions.
• Caused by human herpesvirus (HHV-8)

MALIGNANT TUMORS
Kaposi’s Sarcoma (cont..)
• Major forms:
• Classic (Mediterranean)
• African endemic
• HIV-negative men having sex with men (MSM)-associated
• Immunosuppression-associated
MALIGNANT TUMORS
Kaposi’s Sarcoma (cont..)
• Clinically: appears as multifocal, rubbery blue-red nodules
• Treatment: antiviral therapy, cryotherapy, photodynamic therapy, radiation

therapy, intralesional injections, and topical therapy. Surgical biopsy is
important for disease diagnosis. Surgery is limited and generally should
not be pursued except for palliation.
MALIGNANT TUMORS
Dermatofibrosarcoma Protuberans
• Low-grade sarcoma of fibroblast origin
• Low distant metastatic potential
• Tumor depth is the most important prognostic variable

MALIGNANT TUMORS
Dermatofibrosarcoma Protuberans (cont..)
• Clinically: slow-growing, asymptomatic, violaceous plaque involving the

trunk, head, neck, or extremities
• Positive for CD34 and negative for factor XIIIa
• Treatment: wide local excision with 3-cm margins down to deep

underlying fascia or Mohs microsurgery. No nodal dissection.
MALIGNANT TUMORS
Malignant Fibrous Histiocytoma (Undifferentiated Pleomorphic Sarcoma
and Myxofibrosarcoma)
• Uncommon, cutaneous, spindle-cell, soft tissue sarcoma occurs in the

extremities, head, and neck of elderly patients
• They present as solitary, soft to firm, skin-colored subcutaneous nodules
• Treatment: Complete surgical resection and adjuvant radiation therapy

MALIGNANT TUMORS
Angiosarcoma
• Uncommon, aggressive cancer that arises from vascular endothelial cells
• Lymphedema-associated angiosarcoma (Stewart-Treves) develops on an

extremity ipsilateral to an axillary lymphadenectomy
MALIGNANT TUMORS
Angiosarcoma (cont..)
• Radiation-induced angiosarcoma occurs 4 to 25 years after radiation

therapy for benign and malignant conditions
• Epithelioid variant of angiosarcoma involves the lower extremities and also

has a poor prognosis
MALIGNANT TUMORS
Angiosarcoma (cont..)
• Treatment: Surgical excision with wide margins and adjuvant radiation

therapy. Cases of extremity disease can be considered for amputation.
Chemotherapy and Radiation may provide palliation, but these modalities
do not prolong overall survival
MALIGNANT TUMORS
Extramammary Paget’s Disease
• Rare adenocarcinoma of apocrine glands arises in axillary, perianal, and

genital regions
• Clinically: erythematous or nonpigmented plaques with an eczema-like

appearance that often persist after failed treatment from other therapies
• Treatment: surgical resection with negative microscopic margins, and

adjuvant radiation may provide additional locoregional control.
TOPICS
• Injuries
• Benign Tumors
• Conclusion
CONCLUSION
Skin is the largest organ in the human body
Recognition and management of cutaneous and subcutaneous diseases

require an astute clinician to optimize clinical outcomes
Improvements in drugs, therapies, and healthcare practices have helped

recovery from skin injuries
CONCLUSION
Skin and subcutaneous diseases are often managed medically, although
surgery frequently complements treatment
Benign tumors are surgical diseases, while malignant tumors are primarily
treated surgically, and additional modalities including chemotherapy and
radiation therapy are sometimes required
The advent of new drug therapies will redefine the role of surgery in this
disease in the coming years.
Thank You

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THE SKIN AND

• Bioengineered Skin Substitutes

• Bacterial Infections of the Skin and Subcutaneous Tissue

• Viral Infections with Surgical Implications

• Bioengineered Skin Substitutes

• Bacterial Infections of the Skin and Subcutaneous Tissue

• Viral Infections with Surgical Implications

• thickness: ranging from 75 to 150 µm in thin skin (eyelids) to 0.4 to 1.5

1. stratum basale - germinative layer; deep, single layer of

2. stratum spinosum- spiny layer; 5 to 15 cells in thickness. It has

• 3. stratum granulosum - basophilic keratohyalin granules. There are

• 4. stratum lucidum - layer of flat, translucent keratinocytes

• 5. stratum corneum - cornified layer; protein-rich, flattened

1. Keratinocytes - 90% of the cells of the epidermis

2. Langerhans Cells - typically found within the stratum spinosum. Takes up

3. Melanocytes - found within the stratum basale. Responsible for

4. Merkel Cells - essential for light touch sensation

• Sweat Glands - derived from the embryologic ectoderm

3. Apoeccrine - similar to an apocrine gland but opens directly to the skin

• Made up of a hair follicle, sebaceous gland, an erector pili muscle, and a

• They are lined by the germinal epithelium of the epidermis

3. Hyponychium - free edge, which overlies a thickened portion of epidermis

• Mesoderm-derived tissue that protects and supports the epidermis

• 3 components: a fibrous structure, the ground substance that surrounds

• 2 Layers: the papillary layer and the reticular layer.

• Papillary layer - is made up of papillae that interdigitate with the rete

• Reticular layer - made up of a coarse network of fibers and the

• Fibers and Ground Substance:

• 98% of the dry weight of the dermis is made up of collagen, typically

• They are typically spindle- or stellate-shaped and have a well-

• Comprised of a variety of mesenchymal dendritic cells recognizable

• Responsible for antigen uptake and processing for presentation to the

• Superficial, subpapillary plexus is located between the papillary and

• An aﬀerent component made up of free nerve endings and specialized

• Richly vascularized loose connective tissue that separates and attaches

• It is made up primarily of pockets of lipid-laden adipocytes separated

• Functions: insulation, storage of energy, and protection from

• Bioengineered Skin Substitutes

• Bacterial Infections of the Skin and Subcutaneous Tissue

• Viral Infections with Surgical Implications

• aka Acne Inversa

• Painful skin condition typically aﬀecting areas of the body bearing

• It is characterized by tender, deep nodules that can expand, coalesce,

• Diagnosis of hidradenitis is clinical, and the presentation is most

• Development of sterile pustules which progress to painful, ulcerating

• Arises in individuals with a hematologic malignancy or inflammatory

• Initial pathology is sterile, it can easily become secondarily infected

• 5 distinct types of pyoderma gangrenosum described: vegetative,

• Rare mucocutaneous disorder characterized by cutaneous destruction at

• Commonly referred to as either Stevens-Johnson syndrome (SJS) or toxic

• Clinical presentation usually occurs within 8 weeks of initiation of a new

• Mucous membrane involvement is seen in 90% of cases and can involve

• Drugs most commonly associated with EN include anticonvulsants,

• The prognosis of EN is generally related to the surface area aﬀected and

• Nikolsky sign = lateral pressure on

• Bioengineered Skin Substitutes

• Bacterial Infections of the Skin and Subcutaneous Tissue