SKIN AND

SUBCUTANEOUS
TISSUES
KATHLEEN GONZALES, MD, DPBU, FPUA
 SKIN
• Largest human organ
• Accounts for approximately
15% total body weight
• Epidermis - semipermeable
layer
• barrier to chemical
absorption
• prevents fluid loss
• protects against penetration
of solar radiation
• rebuffs infectious agents
 SKIN

• Skin’s ability to regulate body

heat makes it the body’s
primary thermoregulatory
organ
 LAYERS OF THE SKIN

• Epidermis
• Dermis
• Subcutaneous
tissue (hypodermis)
• EPIDERMIS
• Consists primarily of
continually regenerating
keratinocytes
• Stratified, forming 4-5
histologically distinct
layers
• Lacks any vascular
structures; obtains
nutrients from dermal
vasculature
Pacinian – for pressure and vib
( rem : pleasure & vib )
 Merkel- light
touch

The different layers represent layers of

keratinocytes at differing stages of their
approximately 30-day life cycle
 EPIDERMAL COMPONENTS
KERATINOCYTES
• Make up about 90% of the
cells of epidermis
• Have 4-5 distinct stages in
life cycle
• Stratum basale : germinative
layer, single layer of
asynchronous continuously
replicating cuboidal to
columnar epithelial cells
• Beginning of the life
cycle of keratinocytes
• Stratum spinosum: “spiny”
layer; named due to
appearance of the
intercellular desmosomal
attachments under light
microscopy
• As keratinocytes migrate
superficially, they flatten
and develop keratohyalin
granules; and lose cellular
structures except for
keratin filaments and
proteins (granulosum)
• In palms and soles, there is
a layer of flat translucent
keratinocytes (lucidum)
• Stratum corneum: cornified
layer; keratinocytes are
flatten, anucleated, protein-
rich and surrounded with
lipid-rich matrix – protects
tissue from mechanical,
chemical and bacterial
disruption
• LANGERHANS CELLS
• 3-6% of the cells in
epidermis; immune cells
• Typically found within stratum
spinosum
• Mobile, dendritic cells that
interdigitate between
keratinocytes sampling any
antigen that attempt to pass
thru the cutaneous tissue
• Contain Birbeck granules for
presentation of antigen to T-
cells
• Functionally impaired by UV
radiation (UVB)
• MELANOCYTES
• Found within stratum basale
• Responsible for production of
pigment melanin
• Neural-crest derived cells with a
ratio of 4-10 keratinocytes per
melanocyte
• Differences in skin pigmentation
are based on melanocyte activity
and not the count
• It is the rate of melanin production,
transfer to keratinocytes and
melanosome degradation that
determine degree of skin
pigmentation
• UV radiation, estrogen, ACTH,
melanocyte-stimulating hormone –
• MERKEL CELLS
• Slow-adapting
mechanoreceptors essential
for light touch sensation
• Typically aggregate among
basal keratinocytes in digits,
lips and bases of some hair
follicles
• Joined to keratinocytes by
desmosomes
• Merkel cell carcinoma – a rare,
but difficult-to-treat malignancy
• LYMPHOCYTES
• Less than 1% of the cells in epidermis
• Found primarily within basal layer of keratinocytes
• Express an effector memory T-cell phenotype
• TOKER CELLS
• Found in the epidermis of the
nipple in 10% of both males
and females
• Immunochemical studies
have implicated them as a
possible source of Paget’s
disease of the nipple
 EPIDERMAL APPENDAGES

SWEAT GLANDS
• Derived from the
embryologic ectoderm,
but bulk resides within
the dermis
• Tubular-shaped
exocrine gland and
excretory duct
ECCRINE SWEAT GLANDS
• Majority of sweat glands
• Important in
thermoregulation via
evaporative heat loss
• Solutes are released in the
gland via exocytosis
• Present in greatest
number on the palms,
soles, axillae, and
forehead
• Produces 10L/d in an adult
APOCRINE SWEAT GLANDS
• Found around axilla, anus,
areola, eyelid, external
auditory canal
• Undergo excretion process
via decapitation of part of
the cell
• Typically activated by sex
hormones
• Secretion is initially
odorless, but bacteria may
cause an odor to develop
APOECCRINE SWEAT
GLANDS
• Similar to an apocrine gland
but opens directly to the skin
surface
• PILOSEBACEOUS UNITS
• Made up of a hair follicle,
sebaceous gland, an erector
pili muscle and a sensory
organ
• Responsible for the production
of hair and sebum; present in
the entire body sparing the
palms, soles and mucosa
• Present in great number on
face and scalp
• Sebaceous glands secrete
sebum into the follicle and skin
via a duct
• NAIL
• Keratinaceous structures
overlying the distal
phalanges of the fingers and
toes
• Protects the distal digits; and
augment function of the digit
for counter-pressure
• 3 main parts:
• Nail root – continuous with
the germinal nail matrix;
adherence point of the nail
• Nail plate – lies on top of the
nail bed
• Free edge – overlies a
thickened portion of
 DERMIS
• Mesoderm-derived tissue that protects and supports
the epidermis while anchoring it to the
subcutaneous tissue
• Mostly composed of structural proteins and cellular
components
• Collagen – main functional protein within the
dermis; 70% of dermal dry weight and responsible
for its tensile strength
• Skin primarily contains type 1 collagen
• Fetal dermis contains mostly type III (reticulin fibers)
collagen
• FIBROBLASTS
• Found in the loose papillary
layer; fundamental cells of the
dermis
• Responsible for producing all
dermal fibers and the ground
substance
• The workhorse of wound
healing, while macrophages
are the orchestrators
• DERMAL
DENDROCYTES
• Comprised of a variety of
mesenchymal dendritic
cells
• Responsible for antigen
uptake and processing for
presentation to immune
cells
• Typically found in the
papillary dermis
• MAST CELLS
• Effector secretory cells
of the immune system
• Responsible for
immediate type I
hypersensitivity
reactions
• When primed with IgE
antibodies, causes the
release of histamine and
cytokines leading to
vasodilation and
dermatitis during allergic
reactions
• Blood supply – intricate
network of blood vessels;
interconnecting
horizontal plexuses, one
in the papillary dermis
and the other at the
dermal-subcutaneous
junction
• Glomus bodies –
tortuous arteriovenous
shunts that allow a
substantial increase in
superficial blood flow
• Cutaneous sensation
– via dermal
autonomic fibers
synapsed to sweat
glands, erector pili and
vasculature control
points
• Meissner’s, Ruffini’s,
Pacini’s corpuscles –
transmit information
on local pressure,
vibration and touch
 INJURIES TO SKIN AND SUBCUTANEOUS
TISSUES

• TRAUMATIC INJURIES
• Caused by penetrating, blunt and shear force, and
degloving injuries
• Clean lacerations – may be closed primarily
• Infected wound – healing by secondary intention
• Debridement of nonviable tissue and aggressive
irrigation – guiding principles in complex wounds
• Degloving injuries – treated as third-degree or full-
thickness burns
• Bite wounds – 4.5M injuries annually
• Human bite – Viridans streptococci, Staph aureus,
Eikenella corrodens, H. influenza, beta-lactamase-
producing bacteria
• Dog bites – Pasteurella multocida, Staph species,
alpha-hemolytic streptocci, E. corrodens,
Actinomyces, Fusobacterium
• Drainage, copious irrigation, debridement of
necrotic material, antibiotic therapy, extremity
immobilization and elevation
• EXPOSURE TO CAUSTIC
SUBSTANCES
• Either acidic or alkali solutions
• Acid exposure – deep tissue
coagulative injury damaging
nerves, blood vessels, tendons
and bone
• Tx: copious skin irrigation for 30
min with either saline or water
• Hydrofluoric acid – additional tx
challenge because fluoride ions
absorb the body’s calcium
supply which may cause cardiac
arrythmia
• Tx: topical quaternary
ammonium compounds, topical
• Alkali exposure
• Usually household cleaning
agents
• Causes fat saponification
facilitating tissue penetration
and increased tissue damage
• Liquefactive injury produced by
alkali burns provide a longer,
more sustained period of injury
• Tx: immediate irrigation with
continuous water flow for at
least 2 hrs
• IVF Extravasation
• Leakage of injectable fluids into
interstitial space – considered a
chemical burn
• Deep injury via chemical toxicity,
osmotic toxicity or pressure
effects in a closed environment
• Most common IVF
extravasations causing necrosis
in infant – dextrose solutions,
calcium carbonate, parenteral
nutrition
• In adult – chemodrug
doxorubicin causing cellular
death
• HYPERTHERMIC INJURY
• Zone of coagulation -
central area of injury;
exposed to the most direct
heat and becomes necrotic
• Zone of stasis –
surrounding the zone of
coagulation; has marginal
tissue perfusion and
questionable viability
• Zone of hyperemia –
outermost zone; most
similar to uninjured tissue
but with increased blood
flow as the body’s response
to injury
• Hypothermic Injury (Frostbite)
– results in acute freezing of
tissues depending on duration
of exposure and temperature
gradient at the skin surface
• Direct cellular injury to blood
vessel walls and
microvascular thrombosis
• Skin’s tensile strength
decreases by 20% in cold
envt (12C/53.6F)
• Tx: rapid rewarming, close
observation, elevation and
splinting, daily hydrotherapy
and serial debridement
• PRESSURE INJURY
• Prolonged excessive pressure can result to
pressure ulcer formation
• 1 hour of 60mm Hg pressure can produce
histologically identifiable venous thrombosis,
muscle degeneration and tissue necrosis
• Sitting can produce as
high as 300 mmHg at the
ischial tuberosities
• Sacral pressure can build
to 150mmHg when lying
• Healthy individuals shift
their body weight, but
patients who are unable to
sense pain or are
bedridden may develop
pressure ulcers
• Tx: relief of pressure, wound care, systemic
enhancement such as optimization of nutrition
• Air flotation mattresses and gel seat cushions – to
redistribute pressure
• Surgical mgt: debridement of all necrotic tissues
followed by thorough irrigation
• Shallow wounds may be allowed to close by
secondary intention
• Deeper wounds – surgical debridement and
coverage
• RADIATION EXPOSURE
• Sources : solar exposure (UV),
iatrogenic management,
industrial/occupational
applications
• UVB – responsible for acute
sunburns and chronic skin
damage
• Ionizing radiation – blocks
mitosis in rapidly dividing cells;
mainstay in treatment of various
malignancies
• Acute radiation changes –
erythema, basal epithelial
cellular death
• Chronic changes – loss of
capillaries via thrombosis and
fibrinoid necrosis of vessel walls
INFECTIONS OF THE SKIN AND SQ TISSUES

• Erythema, warmth, tenderness,

edema and cellulitis
• Group A streptococci, Staph aureus
• Folliculitis – infection of hair follicle
• Furuncle (boil) – begins as
folliculitis, eventually progress to a
fluctuant nodule
• Carbuncles ( collection of boils)–
more deep-seated infections
resulting in multiple draining
cutaneous sinuses; require incision
and drainage
• NECROTIZING SOFT TISSUE INFECTION
• Most common sites – external genitalia, perineum,
abdominal wall (Fournier’s gangrene)
• Necrotizing fascitis – rapid extensive infection of the
fascia deep to the adipose tissue
• Necrotizing myositis – involves muscles and
spreads to adjacent tissues
• Risk factors: DM, malnutrition, obesity, chronic
alcoholism, peripheral vascular disease, CLL,
steroid use, renal failure, cirrhosis, autoimmune
deficiency syndrome
• Tx: prompt recognition, broad-spectrum IV
antibiotics, aggressive surgical debridement, ICU
support, aggressive fluid replacement
• HIDRADENITIS
SUPPURATIVA – defect of the
terminal follicular epithelium
resulting to apocrine gland
blockage leading to abscess
formation in affected axillary,
inguinal and perianal regions
• Following rupture, foul-
smelling sinuses form and
repeated infxns create wide
inflammation
• Tx: warm compress, antibiotics
and open drainage
• Wide excision with skin
grafting for chronic hidradenitis
• ACTINOMYCOSIS –
granulomatous suppurative
bacterial disease caused by
Actinomyces causing deep
cutaneous infection
• 40-60% occur in the face or
head
• Usually results after tooth
extraction, odontogenic
infection, facial trauma
• Dx: histologic analysis and
presence of sulfur granules
within purulent specimen
• Tx: Penicillin and sulfonamides
 VIRAL INFECTIONS OF THE SKIN AND SQ
TISSUES

• HUMAN PAPILLOMA VIRUS (HPV)

• Warts –epidermal growths caused by
HPV
• Common wart (verruca vulgaris) –
fingers and toes, rough and bulbous
• Plantar wart (verruca plantaris) – soles
and palms
• Flat wart (verruca plana) – slightly
raised and flat; face, legs and hands
• Venereal wart (condyloma acuminata)
– grow in moist areas around vulva,
anus and scrotum
• Dx: hyperkeratosis (hypertrophy of horny layer),
acanthosis (hypertrophy of spinous layer) and
papillomatosis
• Tx: removal via chemicals – formalin, podophyllum,
phenol-nitric acid; curettage with electrodessication;
surgical excision for extensive areas
• Recurrences are common because of viral etiology
• HPV types 5,8,10 – assoc with squamous cell
cancers
• HPV type 6 and 11 – causes condyloma acuminata
• HUMAN
IMMUNODEFICIENCY
VIRUS
• Variety of skin
manifestations
• Delayed wound healing is
thought to be secondary to
decreasing T-cell CD4
count, opportunistic
infection, low serum
albumin and poor nutrition
 INFLAMMATORY DISEASES
• PYODERMA GANGRENOSUM
( due to neutrophils fails to get to
site s autoimmune/dec immunity )
• Uncommon destructive cutaneous
lesion
• A rapidly enlarging necrotic lesion
with undermined border and
surrounding erythema
• Commonly assoc with
inflammatory bowel disease,
rheumatoid arthritis, hematologic
malignancy and immunoglobulin A
gammapathy
• Tx: systemic steroids or
cyclosporine, aggressive wound
care and skin graft coverage
• EPIDERMAL NECROLYSIS
(EN)
• Rare mucocutaneous
disorder characterized by
cutaneous destruction at the
dermoepidermal junction
• Commonly referred to as
either SJS or TEN depending
on the extent of skin
involvement
• SJS - <10% of total body
surface area is involved
• TEN - >30% TBSA
• Clinical presentation occurs
within 8 weeks of initiation
of a new drug treatment
(anticonvulsants,
sulfonamides, allopurinol,
oxicams, nevirapine)
• Macular rash in the face
and trunk and progressing
to extremities within hours
to days; bullae formation
that eventually burst
leaving partial thickness
wounds
• Positive nikolsky sign
• EPIDERMAL NECROLYSIS (EN)
• Management:
• Discontinuation of the offending agent
• Maintenance of euvolemia, early enteral feeding,
measures to reduce risk of infection
• Surgical debridement of devitalized tissue, use of
topical antibiotics, dressings
 SOFT TISSUE TUMORS
• Lipomas – most common
subcutaneous neoplasm;
benign Tx: excision
• Acrochordons (skin tags) –
fleshy pedunculated masses
located on the preauricular
area, axillae, trunk and eyelids;
Tx: “tying off”, resection
• Dermatofibromas – solitary, soft
tissue nodules 1-2 cm in
diameter, found on legs and
flanks. Tx: excisional biopsy
 NEURAL TUMORS
• Neurofibromas – arise from
nerve sheath; majority are
assoc with café au lait spots,
Lisch nodules and an
autosomal dominant
inheritance(von
Recklinghausen’s disease)
• Firm, discrete nodules
attached to a nerve
• Neurilemomas – arising from
cells of peripheral nerve sheath;
discrete nodules that may
induce local or radiating pain
along the distribution of nerve
• Tx: operative resection
 BENIGN TUMORS
• HEMANGIOMAS
• Benign vascular tumors that arise
from proliferation of endothelial cells
• Occur in 4% of children by 1 year of
age
• Appears at birth, a period of rapid
growth during 1st year and then
gradual involution over childhood in
>90% of cases
• Surgical resection if the lesion
obstruct the airway, GI tract, vision
and m-s function
• Propanolol – causes cessation of
growth
• Corticosteroids, interferon-alpha
• NEVI
• Areas of melanocytic
hyperplasia or neoplasia
• Exposure to UV radiation is
associated with increased
density of the lesions
• Typically symmetric and small
• Congenital nevi: result of
abnormal development of
melanocytes; <1% of neonates
• Giant congenital nevi: 5%
chance of developing into
malignancy – surgical excision
• CYSTIC LESIONS
• Overgrowth of epidermis
towards the center of the lesion
• Epidermoid cysts: keratin-
plugged pilosebaceous unit
(upper chest and back)
• Most common cutaneous cysts
• Mature epidermis complete with
granular layer
• Trichillemal cyst
• Derived from the outer sheath
of hair follicles; lack a granular
layer
• Almost always found on the
scalp
• Dermoid cyst
• A result of persistent epithelium
within embryonic lines of fusion
• Occur most commonly between
the forehead and nose tip,
eyebrow
• Contain epithelial tissue, hair,
epidermal appendages
• Keratosis
• Actinic Keratosis –
neoplasms of epidermal
keratinocytes from sun
damage to squamous cell
carcinoma
• Typically occur in fair-
skinned elderly in sun-
exposed areas
• UV radiation is the
greatest risk factor
• Erythematous, scaly to
hypertrophic keratinized
lesions
• Can regress
spontaneously; persist
without change; transform
into invasive squamous
cell CA (10%)
• 60-65% of SCCA originate
from actinic keratoses
• Tx: excision, 5-FU,
cautery, dermabrasion
• Keratosis
• Seborrheic Keratosis–
benign lesions of the
epidermis; well-
demarcated “stuck on”
appearing papules or
plaques in elderly
• Clonal expansion of
keratinocytes and
melanocytes
• Carry no malignant
potential
 MALIGNANT TUMORS
• Epidermal tumors – Basal cell CA, SCC, melanoma
• Risk factors:
• increased exposure to UV radiation
• albino individuals of dark-skinned races (melanin
protection)
• chemical carcinogens (tar, arsenic, nitrogen
mustard)
• Certain subtypes of HPV
• Chronically irritated or nonhealing areas
• Immunosuppressed pxs
 BASAL CELL CARCINOMA

• Arise from the basal layer of the epidermis

• Most common type of skin cancer
• Tends to occur on sun-exposed areas most
commonly the nose and other parts of the face,
upper lip, eyelid
• “rodent ulcer” appearance – raised papules with a
depressed tumor center with raised borders
 BASAL CELL CARCINOMA

• Divided into:
• Nodular
• Superifical spreading
• Micronodular
• Infiltrative
• Pigmented
• Morpheaform
 BASAL CELL CARCINOMA
NODULOCYSTIC OR
NODULOULCERATIVE
• Accounts for 70% of BCC
tumors
• Waxy and frequently
cream colored
• Rolled pearly borders
surrounding a central ulcer
PIGMENTED
• Tan to black in color
MORPHEAFORM
• Flat, plaque-like lesion
 BASAL CELL CARCINOMA
• Slow growing
• Metastasis is extremely rare
• Small (less than 2mm) –
treated with curettage,
electrodessication, laser
vaporization
• Mohs surgery – uses
minimal tissue resection
and immediate microscopic
analysis to confirm
appropriate margins
• Large tumors- surgical
excision with 0.5-1.0 cm
margins
 SQUAMOUS CELL CARCINOMA

• Arise from epidermal

keratinocytes
• Less common than BCC
• More devastating due to
increased invasiveness
and tendency to
metastasize
• Scaly red patches, open
sores, elevated growth
with central depression
that may crust or bleed
 SQUAMOUS CELL CARCINOMA

• In situ SCC lesions –

Bowen’s disease
• In situ lesions in penis –
Erythroplasis of Queyrat
• Tumor recurrence more Bowen’s lesion at mid-thigh
prevalent once SCC
tumors grow more than
4mm in thickness
• Lesions that
metastasize are typically
at least 10mm in
diameter
 SQUAMOUS CELL CARCINOMA

• Small lesions can be

treated with curettage and
electrodessication
• Surgical excision with a 1-
cm margin is the
recommended tx
• Moh’s surgery – aesthetic
locations
• Regional LN dissection for
clinically palpable nodes
• Metastatic disease has
only 13% 10-year survival
 MALIGNANT MELANOMA
• Most life-threatening and
aggressive skin cancer
• May arise from
transformed melanocytes
anywhere that these cells
have migrated during
normal embryogenesis
• Dysplastic nevi contain
identifiable focus of
atypical melanocytes –
intermediate stage
between benign nevus
and true malignant
melanoma
 MALIGNANT MELANOMA

4 types of melanona
(in decreasing
frequency)
• Superficial
spreading – 70%
• Nodular
• Lentigo maligna
• Acral lentiginous
The ABCDE-rule for
melanoma
A- Assymetry
B- Border
C – Color
D- Diameter
E - Evolution
Staging
• Traditionally uses
Breslow thickness –
vertical thickness of
the primary tumor
• And Clark level –
anatomic depth of
invasion
• Both were
incorporated in the
AJCC staging
system
• Diagnosis is
made by
excisional
biopsy
• Based on
tumor depth,
appropriate
margins may
be planned
• SENTINEL LYMPH
NODE BIOPSY (SLNB)
• Identifies the first
draining lymph node
from the primary lesion
• Performed at the same
time of initial wide
excision
• Involved preoperative
lymphoscintigraphy
with intradermal
injections of Te-S
colloid to delineate
lymphatic drainage
• For metastatic melanoma – median survival is 7-8
months; 5-year survival rate less than 5%
• Locally recurrent, lymphatic-invading or tumors
unamenable to surgical excision is currently treated
with hyperthermic regional perfusion with melphalan
• Radiation therapy – previously believed to be
ineffective for melanoma, is now under investigation
for symptomatic multiple brain metastases
• Immunologic manipulation – also part of recent
studies; interferon alpha-2b for AJCC stage IIB/III
melanoma
 MERKEL CELL CARCINOMA

• An aggressive neuroendocrine
tumor of the skin
• 5-year survival 46%
• Confirmed by cytokeratin-20
staining
• Presents as rapidly growing flesh
colored to purple plaque
• 30% have lymph node involvement
• 50% develop systemic disease
• Wide excision, SLNB
 KAPOSI’S SARCOMA
• Proliferation and inflammation of
endothelial-derived spindle cell
lesions
• Driven by the human
herpesvirus (HHV-8)
• Diagnosed after 5 th
decade of
life; affects
immunocompromised
individuals
• Appears as multifocal, rubbery
blue-red nodules
• Tx: Antiviral therapy
 DERMATOFIBROSARCOMA
PROTUBERANS
• Rare, low-grade sarcoma of
fibroblast origin
• Low distant metastatic potential
but behaves aggressively locally
with finger-like extensions
• Tumor-depth – prognostic factor
• Slow-growing, violaceous plaque
in the trunk, head, neck or
extremities
• Tx: wide local excision, Mohs
surgery
 MALIGNANT FIBROUS
HISTIOCYTOMA

• Uncommon, cutaneous, spindle-

cell soft tissue sarcoma in
extremities, head, and neck
• Solitary, soft to firm, skin-colored
subcutaneous nodules
• Tx: surgical resection, adjuvant
radiotherapy
 ANGIOSARCOMA
• Uncommon, aggressive cancer
that arises from vascular
endothelial cells
• 5-year survival 15%
• Head and neck variant
• Lymphedema-associated
(Stewart-Treves) sarcoma
• Radiation-induced angiosarcoma
• Epitheloid variant
• Tx: surgical excision with wide
margin
 EXTRAMAMMARY PAGET’S
DISEASE
• Rare adenocarcinoma of apocrine
glands
• Arises in axillary, perianal, and
genital regions
• Erythematous or nonpigmented
plaques with an eczema-like
appearance
• High incidence of concomitant
other malignancies - 40% assoc
with GI and GU malignancies
• Tx: surgical resection
 THANK YOU
KATHLEEN R. GONZALES, MD, FPUA