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