The Skin and

Subcutaneous
Tissue
dr. Aulia Janer
Supervised by :
dr. Benny Raymond Sp.BP-RE

Anatomy and histology

The epidermis and its appendages are of

ectodermal origin
The dermis and hypodermis are of mesodermal
origin

EPIDERMIS
Consist cell layer (from
deep) :
Stratum basale (single layer
cell)
Stratum spinosum (5-15 cells
thick)
Stratum granulare (1-3 cells)
Stratum corneum ( 5-10 cells
In palmoplantar additional layer
: stratum lucidum (between
corneum
and granulare)

Epidermal Component

Keratinocyte
Melanocyte
Langerhans Cell
Merkel Cell
Toker Cell
Epidermal appendages
Sweat glands
Pilosebaceous Follicles
Nails

DERMIS
elastic connective tissue that supports and protects the
epidermis, dermal appendages, and neurovascular plexuses
Consist 2 part :
The papillary (superficial) dermis
The reticular dermis
Dermal Fiber
Cells : Fibroblast &
denritic
Cutaneous
Vasculature
Cutaneous Enervation

HYPODERMIS (Subcutaneous Fat, Panniculus

Adiposus)

The main cells of the hypodermis are the

adipocytes
Important role in thermoregulation, insulation,
storage of energy, and protection from
mechanical injuries.

INFLAMMATORY CONDITIONS
Hidradenitis
Suppurativa
Chronic
inflammatory
Painful
subcutaneous
nodules
Diagnosis is made
characterized :
clinically
multiple abscesses, internetworking sinus tracts, foulsmelling exudate from draining sinuses, inflammation in the
dermis, both atrophic and hypertrophic scars, ulceration,
and infection, which may extend deep into the fascia

Toxic Epidermal Necrolysis and

StevenJohnson Syndrome
An autoimmune reaction
The two principles of TENS
management :
Acute withdrawal offending
Supportive

Treatment
IVIG, Plasmapheresis aimed at
decreasing cytokine and drug load,
cyclosporine, cyclophosphamide, and
antiTNF- antibodies

INJURIES
Radiation-Induced Injuries

UV radiation reaching earth

surface (700-2500 nm)

UVB rays (290320 nm)

radiation low but highly energetic
UVA rays (320400 nm) lower
in energy but 95% of UV rays
reaching the ground
Short-term Erythema and
Pigmentation
Long-term

Irregular
pigmentation
and
hyperpigmented areas, melasma,
postinflammatory pigmentation,
and actinic lentigines (sun spots)
Minor radiation maintaining the
integrity
Severe radiation surgical
excision of damaged tissues

Trauma-Induced Injuries
Mechanical Injury

Result of penetrating, blunt, and shear forces, or a

combination of these Tangential abrasion similar
to burns injury
Management depend on depth of injury
Deeper wound require split-thickness skin grafting

Bite Wounds
May lead to severe deep-tissue infections if
unrecognized and not treated appropriately
Wound management

Irrigation
Pressure irrigation
Closed primarily specially face,
Anti rabies

Caustic Injury
Damage from chemical burns
depend:
Concentration
Duration
Quantity : Acid ? Alkali ?

Acidic injuries superficial burn

result of coagulation necrosis of
the skin combined thermal and
chemical injury
Treatment : neutralization acidic
solutions and 2 hours for alkaline
injurie

Pressure Injury
Tissue pressures that exceed the pressure of the
microcirculation (30 mmHg) result in tissue
ischemia. Frequent or prolonged ischemic insults
will ultimately result in tissue damage

BACTERIAL INFECTIONS OF THE SKIN AND

SUBCUTANEOUS TISSUE
Uncomplicated Skin Infections
limited to the epidermis and less than 75 cm2
Impetigo, cellulitis, erysipelas, folliculitis, furuncles, and
simple abscesses are included in this category
Minor primary infections antibiotic topical
Incision and drainage are sufficient, and antibiotics are
not warranted
Complicated Skin Infections
Deep-tissue infections (below the dermis), extensive
cellulitis, necrotizing fasciitis, and myonecrosis are
considered complicated skin infections

A. Initial presentation of necrotizing soft issue

infection in an obese, diabetic patient.
B. Following operative debridementto muscle layer.

VIRAL INFECTIONS WITH SURGICAL

IMPLICATIONS
Human Papillomavirus Infections
Human papillomaviruses (HPV) are small DNA viruses of the
papovavirus family.
Common warts (verruca vulgaris) are caused by HPV-1, -2
and -4
First-line therapy topical preparations of salicylic acid,
silver nitrate, and glutaraldehyde If these fail,
cryotherapy may be considered

BENIGN TUMOR
Neural Tumors
Arise from the nerve sheath

Dermal neurofibromas benign

Neurilemomas are discrete
nodules consisting of Schwann
cells

Hemangioma
- Benign proliferation of
endothelial cells
- Treatment :
Systemic prednisone and interferon-
Surgical resection

Nevi
- Overgrowth of melanocytic
nevus cells
- Choice treatment is total
excision

Cystic Lesions
- Type : Epidermal, Dermoid,
Trichilemmal
- Epidermis that grows toward the
center of the cyst

Keratosis
Abnormal proliferation of
intraepidermal keratinocytes
Two type: Actinic & Seborrheic
behavior to be malignant
Treatment : excision, fluorouracil,
cautery and destruction, and
dermabrasion
Neural
Tumors
Arise from the nerve sheath are
collectively referred to as neural
tumors
Neurilemomas are discrete Schwann
cells of the peripheral nerve sheath,
often causing pain along the
distribution
Lipoma
& Dermatofibroma
treated with
simple resection

Arise from lipid cell and fibroblast

Excision the best choice

MALIGNANT TUMORS
Basal Cell Carcinoma (BCC)
Arise from nonkeratinocytes
Choice treatment is total excision
Risk Factor :UV exposure,
Immunodeficiency, chemical exposure,
ion radiation
Variation : Nodular and Superficial
Treatment : Mohs microsurgery,
excisional surgery, and cautery and
destruction Cell Carcinoma
Squamous
risk factor is UV exposure, chemical
agents, physical agents, infection,
psoralen, chronic non healing wound
Treatment : cautery and ablation,
cryotherapy, drug therapy including
imiquimod, surgical excision, Mohs
microsurgery, and radiation therapy

Melanoma
risk factor UV radiation personal history
of melanoma, Individuals with
dysplastic nevi, Congenital nevi
starts as a localized then vertical
AJCC : local (I,II), regional (III), metastase
distant (IV)
Technique of sentinel lymph node biopsy for
cutaneous melanoma

Kaposis Sarcoma
proliferation and inflammation of
endothelial-derived spindle cell lesions
five major forms : classic, african, HIV,
Aids associated, immunosuppression
associated
Driven by HHV-8
cryotherapy, photodynamic therapy,
radiation therapy, intralesional
injections, and topical therapy.
surgery is limited

Angiosarcoma
aggressive cancer that arises from
vascular endothelial cells, older than
40 years
Poor prognosis, survival of 18 to 28
months
red patch on the face or scalp, often
with satellite lesions and distant
metastasis
Surgical excision with wide margins is
the treatment of choice for localized
disease, but high recurrence

Extramammary Pagets
Disease
rare adenocarcinoma of apocrine
glands arises in perianal and axillary
regions and in genitalia

Men and woman

erythematous or nonpigmented
plaques with an eczema-like
appearance

THANK YOU