Nyoman Suryawati Putu Gede Sudira

Study Guide Basic Clinical Skills Block Skin and Hearing Systems and Disorders

BASIC CLINICAL SKILL OF THE SKIN AND HEARING SYSTEMS AND DISORDERS

FIRST EDITION

Editor Nyoman Suryawati Putu Gede Sudira

Publisher:

Eka Print

In collaboration with

Department of Medical Education Medicine Programme, Faculty of Medicine, Udayana University

Denpasar 2017

Department of Medical Education - Faculty of Medicine – Universitas Udayana, 2017 2 Study Guide Basic Clinical Skills Block Skin and Hearing Systems and Disorders

BASIC CLINICAL SKILL OF THE SKIN AND HEARING SYSTEMS AND DISORDERS

Planners Nyoman Suryawati Herman Saputra Ni Made Linawati I Made Krisna Dinata Andi Dwi Saputra Putu Gede Sudira IA Alit Widhiartini

Contributors Nyoman Suryawati IGN Dharma Putra Ni Made Linawati Herman Saputra IGAA Praharsini Andi Dwi Saputra Luh Mas Rusyati IA Alit Widhiartini IGAA Dwi Karmila Sucindra Dewi NLP Ratih V. Karna IG Kamasan Arijana Ni Made Dwi Puspawati I Made Krisna Dinata Made Wardhana

Editors Nyoman Suryawati Putu Gede Sudira

Layout Yuliwaty I Gde Nengah Adhilaksman S. W.

21,6 cm X 27,9 cm xi, 65 pages

ISBN : 9 786022 942856 First Edition: Desember 2017

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior written permission of the publisher. Published by Eka Print in collaboration with Department of Medical Education Medicine Programme, Faculty of Medicine, Universitas Udayana.

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CONTENT

CONTENT ...... 4 PREFACE ...... 6 GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND DISORDERS ...... 7 LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) ...... 8 LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) ...... 9 LABORATORY AND BASIC CLINICAL SKILLS TIMETABLE ...... 10 BASIC CLINICAL SKILLS...... 11 BCS 1: Efflorescence ...... 12 Primary Lesions ...... 12 Secondary Lesions ...... 16 Diagnostic Details of Lesions ...... 18 Distribution of The Lesions ...... 19 Skin Examination ...... 19 Examination of Hair, Nail, and Mucosa ...... 20 BCS 2: KOH Preparation as Investigation of Superficial Mycosis ...... 21 BCS 3: Diagnosis of Scabies by Skin Scraping Examination ...... 22 BCS 4: Tzanck Smear as a Diagnostic Tool in Dermatology ...... 24 BCS 5: Wound Care ...... 26 BCS 6: Basal Cell Carcinoma, Squamous Cell Carcinoma, Nevus Pigmentosus, Cutaneous Melanoma, Abcess Incision and Drainage, Enucleation, Elliptical or Fusiform Excision, and Nail Avulsion ...... 30 6.1 Basal Cell Carcinoma (BCC) ...... 30 6.2 Squamous Cell Carcinoma (SCC) ...... 32 6.3 Nevus Pigmentosus ...... 34 6.4 Cutaneous Melanoma...... 37 6.5 Abcess Incision and Drainage ...... 40 6.6 Enucleation ...... 41 6.7 Elliptical or Fusiform Excision ...... 41 6.8 Nail Avulsion ...... 43 BCS 7: Valsalva Maneuver, Cleaning of MAE, Foreign bodies, and Cerumen Extraction ...... 47 7.1 Valsava Maneuver ...... 47 7.2 Foreign Body In Canalis Auditorius Externa (CAE) ...... 49

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LABORATORY GUIDELINE ...... 53 Histology: Skin and Hearing Structure ...... 54 Anatomy Pathology: Skin and Hearing Systems Disorders ...... 55 Pharmacology & Pharmacy: Rational Therapy of Topical Preparations in Dermatology ...... 56 Physiology: Hearing ...... 58 REFERENCES ...... 64

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PREFACE

The medical curriculum has become increasingly vertically integrated, with stronger basic concept and support by clinical examples and cases to help in the understanding of the relevance of the underlying basic science. Basic science concepts may help in the understanding of the pathophysiology and treatment of diseases. Skin and hearing systems and disorders block have been written to take account of this trend and to integrate core aspects of basic science, pathophysiology, and treatment into a single, easy to use revision aid. The skin and hearing systems and disorders block will refresh the basic anatomy, histology, physiology of skin and hearing systems, varies dermatology cases (papulo-erythrosquamosa, Morbus Hansen, viral infection, insect bite and infestation, dermatophytosis, drug eruption, pigmentary, and sebaceous gland disorders, bacterial infection, dermatitis), rational topical treatment in dermatology, dermatopharmacology, an example of the otic drug, and varies cases in hearing systems including hearing loss. This study guide is developed by the academic staffs from various departments: Anatomy, Physiology, Histology, Pharmacology, Pharmacy, Anatomy Pathology, Dermato-venereology, Ear Nose and Throat Department. The learning process will be carried out for 3 weeks (16 working days) and 1 week for Basic Clinical Skills starts from December 12th, 2017 as shown in the timetable. The final examination will be conducted on January 17th, 2018 in the form of Multiple Choice Questions (MCQ). Assessment methods are a final exam (MCQ), small group discussion, and a student project. The learning situations include lectures, individual learning, small group discussion, student project, plenary session, practice, and clinical skills. Most of the learning material should be learned independently and discuss in Small Group Discussion by the students with the help of a facilitator. Lectures are given to emphasize the most important thing of the material. In a small group discussion, the students gave learning task to lead their discussion. This study guide needs more revision in the future so that the planners kindly invite readers to give any comments and critics for its completion. Thank you.

Planners

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GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND DISORDERS

Aims:  Manage common skin disorders knowledge in the context of primary health care settings.  Identify skin disorders which may require a referral.

Learning outcomes:  Describe the functional structure of the skin and its appendices and hearing systems.  Identify typical skin manifestation related to skin disorders.  Identify the risks and compatibility of topical treatment in dermatology.  Diagnose and manage common skin and hearing systems disorders.  Refer patient to life/disability threatening, refractory, and unidentified skin and hearing systems disorders.  Educate the patient and their family about skin health.

Curriculum contents:  The functional structure of the skin and its appendices and hearing systems.  Common pathological bases of skin disorders.  Primary skin manifestation in common skin disorders.  Risks and compatibility of topical treatment in dermatology.  Secondary skin manifestations.  Symptoms and sign of common skin disorders, clinical diagnose of common skin disorders, management of common skin disorders: papulo-erythrosquamosa, Morbus Hansen, viral infection, insect bite and infestation, dermatophytosis, drug eruption, pigmentary and sebaceous gland disorders, bacterial infection, dermatitis  Symptoms and sign, clinical diagnosis, and management of common hearing systems disorders: hearing loss in children, Meniere, sudden hearing loss, presbycusis, perichondritis, myringitis, otitis media, labyrinthitis, ear trauma/othematoma, barotrauma, motion sickness, PGPKT.  Referal of a patient with life/disability threatening, refractory, or unidentified skin and hearing systems disorders.  General principles of skin and hearing systems health.  Education and prevention of common and contagious skin and hearing systems diseases.

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LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

PEMERIKSAAN FISIK 1 Kulit, inspeksi dengan kaca pembesar 4A 2 Inspeksi membran mukosa 4A 3 Inspeksi daerah perianal 4A 4 Inspeksi kulit dan kuku ekstremitas 4A 5 Kulit, inspeksi dengan sinar UVA (Wood’s lamp) 4A 6 Dermografisme 4A 7 Palpasi kulit 4A 8 Deskripsi lesi kulit dengan perubahan primer dan sekunder, 4A seperti ukuran, distribusi, penyebaran dan konfigurasi 9 Pemeriksaan rambut (inspeksi, pull test) 4A PEMERIKSAAN TAMBAHAN 10 Pemeriksaan laboratorium: ZN, KOH, Giemsa, Gram 4A 11 Punch biopsy 2 12 Patch test 2 13 Prick test 2 TERAPI 14 Desinfeksi 4A 15 Kulit, insisi/drainase abses, bursa/ ganglion 4A 16 Kulit, eksisi tumor 4A 17 Warts, cryotherapy 1 18 Jerawat, terapi komedo 4A 19 Perawatan luka (pemasangan dressing, bandage) 4A 20 Varicose veins, compressive sclerotherapy 2 21 Varicose veins, compressive bandage therapy 4A 22 Phototherapy 1 23 Ekstraksi kuku 4A 24 Rozerplasty 4A PENCEGAHAN 25 Pencarian kontak 4A

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LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012) Indra Pendengaran dan Keseimbangan 1 Inspeksi aurikula, posisi telinga dan mastoid 4A 2 Pemeriksaan meatus auditorius externus dengan otoskop 4A 3 Pemeriksaan membran timpani dengan otoskop 4A 4 Menggunakan cermin kepala 4A 5 Menggunakan lampu kepala 4A 6 Tes pendengaran, pemeriksaan garpu tala (Weber, Rinne, 4A Schwabach) 7 Tes pendengaran, tes berbisik 4A 8 Intepretasi hasil Audiometri – tone & speech audiometry 3 9 Pemeriksaan pendengaran pada anak-anak 4A 10 Otoscopy pneumatic (Siegle) 2 11 Melakukan dan menginterpretasikan timpanometri 2 12 Pemeriksaan vestibular 2 13 Tes Ewing 2 Indra Pembau 14 Inspeksi bentuk hidung dan lubang hidung 4A 15 Penilaian obstruksi hidung 4A 16 Uji pembauan 4A 17 Rinoskopi anterior 4A 18 Transluminasi sinus frontalis & maksila 4A 19 Nasofaringoskopi 2 20 USG sinus 1 21 Radiologi sinus 2 22 Interpretasi radiologi sinus 3 Indra Pengecap 23 Penilaian pengecapan 4A THT 24 Manuver Politzer 2 25 Manuver Valsalva 4A 26 Pembersihan meatus auditorius eksternus dengan usapan 4A 27 Pengambilan serumen menggunakan kait atau kuret 4A 28 Pengambilan benda asing di telinga 4A 29 Parasentesis 2 30 Insersi grommet tube 1 31 Menyesuaikan alat bantu dengar 2 32 Menghentikan perdarahan hidung 4A 33 Pengambilan benda asing dari hidung 4A 34 Bilas sinus/ sinus lavage /pungsi sinus 2 35 Antroskopi 1 36 Trakeostomi 2 37 Krikotiroidektomi 2

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LABORATORY AND BASIC CLINICAL SKILLS TIMETABLE

13-12-2017 08-01-2018 09-01-2018 10-01-2018 11-01-2018

Classroom Classroom Classroom Classroom Classroom Skin, Nail, Laboratory Wound Care, Open BCC,SCC, Nevus Valsalva Mucous, Hair Investigation Dressing, pigmentosus, Maneuver, Effloresence, (KOH, Giemsa, Compression Malignant melanoma, Cleaning of Dermographism wood lamp) Pressure of Abscess Incision, MAE, Foreign Varicose Vein Enucleation, Nail bodies, and (Praharsini/ Dwi (Suryawati, Dwi Extraction, Nevus Cerumen Puspawati) Karmila) (Luh Mas Rusyati, Excision Extraction Ratih) (Wardhana/ Dharma (Andi S) Putra) 08.00 – 09.00 A, B A, B A, B A, B A, B 09.00 – 10.00 A, B A, B A, B A, B A, B 10.00 – 11.00 C, D C, D C, D C, D C, D 11.00 – 12.00 C, D C, D C, D C, D C, D

Histology lab Histology lab Physiology & Physiology/ Pharmacy Physiology Pharmacy Lab Lab Lab Histology Anatomy Topical Prepa Pharmacology Physiology Practicum skin PathologyPracti ration in skin and practicum in Skin and practicum and hearing organ cum skin and Otic drug hearing hearing systems (Krisna) (Linawati/ Arijana) ( IA Alit W) (Sucindra Dewi) (Herman) 08.00-09.00 C C C C C 09.00-10.00 D D D D D 10.00-11.00 A A A A A 11.00-12.00 B B B B B

Group A: SGD A1, A2, A3, A4, A5.

Group B: SGD A6, A7, A8, A9, A10.

Group C: SGD B1, B2, B3, B4, B5.

Group D: SGD B6, B7, B8, B9, B10.

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BASIC CLINICAL SKILLS

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BCS 1: Efflorescence Praharsini & Dwi Puspawati

Most skin diseases produce or present with lesions that have more or less distinct characteristics. They may be uniform or vary in size, shape, and color, and perhaps occur in different stages of evolution or involution. In some cases, the appearance of skin lesion may be so distinctive so then the diagnosis is easy to be made. In other cases, subjective symptoms and clinical sign in themselves are inadequate, and a complete history and laboratory examinations, including biopsy, are essential to conclude a diagnosis. The same disease may show variations under different conditions and in different individuals. The appearance of the lesions may have been modified by previous treatment or obscured by external influences, such as scratching or secondary infection. Subjective symptoms may be the only evidence of a disease, as in pruritus, and the skin appearance may be generally unremarkable. Although history is important, the diagnosis in dermatology is most frequently made based on the objective physical characteristic and location or distribution of one or more lesions that can be seen or felt. Therefore, careful physical examination of the skin is crucial in making a dermatology diagnosis. The original lesions are known as the primary lesions, and identification of such lesions is the most important aspect of dermatologic physical examination. They may continue until fully developed or be modified by regression, trauma, or another external factor, producing secondary lesions. Dermatology has a vocabulary that is quite distinct from other medical specialties and it is necessary to describe skin disorder.

Primary Lesions These are the following form of primary lesions such as macules, papules, plaques, nodules, tumors, wheals, vesicles, bullae, pustules and telangiectasia. Macule. A small, circular, flat spot less than 2 cm in diameter. The color of a macule is not the same as that of nearby skin. Macules come in a variety of shapes and are usually brown, white, or red. Examples of macules include freckles and flat moles. A macule more than 2 cm in diameter is called a patch.

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Figure 1. Macula depigmentation in vitiligo patient Papule. A solid raised lesion less than 0,5 cm across. A grouped papules more than 2 cm across is called a plaque. Papules and plaques can be rough in texture and red, pink, or brown in color. Papules are associated with such conditions as warts, syphilis, psoriasis, seborrheic and actinic keratoses, lichen planus, and skin cancer.

Figure 2. Typical violaceous papules of lichen planus at the wrist

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Nodule. A solid lesion that has distinct edges and that is usually more deeply rooted than a papule. Doctors often describe a nodule as "palpable," because when we palpate, it can be felt as a hard mass distinct from the tissue surrounding it. A nodule more than 2 cm in diameter is called a tumor. Nodules are associated with, among other conditions, keratinous cysts, lipomas, fibromas, and some types of lymphomas.

Figure 3. Nodule Wheal (Urtica). A skin elevation caused by swelling that can be itchy and usually disappears soon after erupting. Wheals are generally associated with an allergic reaction, such as to a drug or an insect bite.

Figure 4. Multiple wheal and dermatographism

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Vesicle. A raised lesion less than 1 cm across and filled with a clear fluid. Vesicles which diameter more than 1 cm across are called bullae or blisters. These lesions may be the result of sunburns, insect bites, chemical irritation, or certain viral infections, such as herpes.

Figure 5. Vesicles, bullae, and erosions Pustule. A raised lesion filled with pus. A pustule usually results from an infection, such as acne, impetigo, or boils.

Figure 6. Multiple pustules on erythematous macule

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Telangiectasia. Small, dilated blood vessels that appear close to the surface of the skin. Telangiectasia is often a symptom of such diseases as rosacea or scleroderma.

Secondary Lesions The major types of secondary skin lesions are an ulcer, fissure, scale, crust, erosion, excoriation, scar, lichenification, and atrophy. Ulcer. Lesion with a loss of the upper portion of the skin (epidermis) and part of the lower portion (dermis). Ulcers can result from acute conditions such as bacterial infection or trauma, or from chronic conditions, such as scleroderma or disorders involving peripheral veins and arteries. An ulcer that appears as a deep crack that extends to the dermis is called a fissure.

Figure 7. Ulcer Scale. Lesion with a dry, composed of dead skin cells that often flakes off the surface of the skin. The body ordinarily is constantly shedding imperceptible tiny, thin fragments of stratum corneum. When the formation of epidermal cells is rapid or the process of normal keratinization is interfered or as a result of pathologic exfoliation, can produce scale. Diseases that promote scale include fungal infections, psoriasis, and seborrheic dermatitis.

Figure 8. Thick scale in Psoriasis Vulgaris

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Crust. A dried collection of blood, serum, or pus. Also called a scab, a crust is often part of the normal healing process of many infectious lesions.

Figure 9. Multiple brown crusts in herpes zoster patient Erosion. Lose of all or portions of the epidermis alone, as in impetigo or herpes zoster after vesicles rupture produces an erosion. It may or may not become crusted, but it heals without a scar formation.

Figure 10. Erosion Excoriation. An excoration is a punctate or linear abrasion produced by mechanical factors including scratching or picking at a primary lesion. This lesion usually involving the epidermis only and not reaching the papillary layer of the dermis.

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Scar. Discolored, fibrous tissue that permanently replaces normal skin after the destruction of the dermis. A very thick and raised scar is called a keloid. Lichenification. Rough, thick epidermis with exaggerated skin lines. This is often a characteristic of scratch dermatitis and atopic dermatitis.

Figure 11. Grossly lichenified Atrophy. An area of skin that has become very thin and wrinkled. Normally seen in older individuals and people who are using very potent topical corticosteroid medication.

Diagnostic Details of Lesions 1. Characteristic or Morphology of The Lesions Individual lesion described with the help of a magnifying glass. To find out the early primary lesion and to inspect it closely. Note the shape (geometric shape, oval), color (salmon-pink, erythematous, skin color, yellow), size, margin (sharpness of edge, well-defined, ill-defined), the surface characteristics (dome-shaped, umbilicated, spike-like), temperature and smell. 2. Configuration of The Lesions The certain term is used to describe the configuration that an eruption assumes either primarily or by enlargement or coalescence. Lesion in a line are called linear, and they may be confluent or discrete. Lesions may form a complete circle (annular) or a portion of a circle (arcuate or gyrate) or may be composed of several intersecting portions of circles (polycyclic). If the eruption that not linear nor parts of a circle, it may be serpiginous.

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Figure 12. Grouped lesion : cluster Figure 13. Serpiginous lesion

Distribution of The Lesions Distribution of the lesions can be: symmetrical, asymmetrical, exposed area, sun-exposed area, scalp region, hand, extensor aspect, flexor aspect.

Figure 14. Distribution lesion following Figure 15. Distribution lesion in extensor aspect Blasckho lines

Skin Examination The examination should be conducted in a well-lit room. Natural sunlight is the ideal illumination. A magnifying has a value in examining small lesions. It may be necessary to palpate the lesion for firmness and fluctuation. The entire eruption must be seen to evaluate configuration and distribution. This examination can optimally be done by having the patient completely undress. It is very important to have a thorough examination of the whole body especially for a new consultation and for the elderly. Sometimes, examination of the back and buttock of the elderly may reveal unexpected lesions, even the patient himself or herself may not notice them e.g. persistent chronic annular erythematous rash in the buttock found in a case of tuberculoid leprosy.

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Examination of Hair, Nail, and Mucosa Involvement of hair-bearing areas by certain skin disorders caused characteristic lesions. For example, discoid lupus can cause scarring alopecia with characteristic dys-pigmentation. Sometimes on the skin lesions may be much less characteristic. Diffuse hair loss may be seen in certain conditions such as acrodermatitis-enteropathica and maybe a clue to the diagnosis. In addition, loss of hair within a skin lesion may be suggestive of the correct diagnosis, e.g. the alopecia seen in the tumid plaques of follicular mucinosis. Some skin disorders cause characteristic changes of the nail, even when the periungual tissue is not involved. The pitting nail can be seen in psoriasis and alopecia areata, and this finding may be useful in confirming these diagnoses when other findings are not characteristic. In addition, the nails and adjacent structures may be the important site of pathology, as in candidal paronychia.

Figure 16. Nail involvement in psoriasis: pitting (left) and subungual hyperkeratosis with onycholysis (right) The complete skin examinations include an examination of the mucosa. Oral lesions are characteristically found in viral syndrome, lichen planus, HIV associated Kaposi sarcoma and autoimmune bullous diseases.

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BCS 2: KOH Preparation as Investigation of Superficial Mycosis Dwi Karmila

The KOH test also known as a potassium hydroxide preparation or KOH preparation is a quick, inexpensive fungal test to differentiate superficial mycosis symptoms from other skin disorders like psoriasis and eczema. Potassium hydroxide (KOH) preparation is used for the rapid detection of fungal elements in a clinical specimen, as it clears the specimen making fungal elements more visible during the direct microscopic examination. KOH is a strong alkali. When specimen such as skin, hair, nails or sputum is mixed with 20% w/v KOH, it softens, digests and clears the tissues (e.g., keratin present in skins) surrounding the fungi so that the hyphae and conidia (spores) of fungi can be seen under a microscope.

The procedure of KOH Preparation: 1. Place a drop of KOH solution on a slide. 2. Transfer the specimen (small pieces) to the drop of KOH, and cover with glass. Place the slide in a petri dish, or another container with a lid, together with a damp piece of filter paper or cotton wool to prevent the preparation from drying out. 3. As soon as the specimen has cleared, examine it microscopically using the 10X and 40X objectives with the condenser iris diaphragm closed sufficiently to give a good contrast.

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BCS 3: Diagnosis of Scabies by Skin Scraping Examination Suryawati

The standard technique for the diagnosis of scabies consists of the identification of the mite, eggs, or feces by microscopic examination of scales obtained by a skin scraping. Repeated tests in different areas are often needed for a conclusive diagnosis because the sensitivity is low. Other diagnostic procedures include the burrow ink test, the adhesive tape test, and the polymerase chain reaction (PCR)-based method for detecting S. scabiei DNA in skin scrapings.

Equipment 1. Gloves 2. Magnifying glass 3. Light source 4. Alcohol Swabs 5. #15 scalpel blades 6. Glass slide and coverslips 7. Mineral oil or immersion oil 8. Laboratorium requisition forms 9. Sharps container 10. Microscope

Procedure 1. The highest yield in identifying a mite is in typical burrows on the finger webs, flexor aspect of the wrist and penis. 2. Use a magnifying glass to identify recent burrows or papules. A bright light and magnifying glass will assist in visualizing the mite (tiny dark speck ) at the end of the burrow 3. Explain the procedure to the patient and perform hand hygiene 4. Using an alcohol swab scrub the area to be scraped for 30 seconds and allow to air dry 5. Apply a single drop of mineral oil over un-excoriated burrow 6. Scrape in excoriated, noninflamed areas (Burrows) with a #15 scalpel blade. The mineral oil will emulsify the scrapings 7. Using the blade put the emulsified scrapings on a slide; cover the slide with a coverslip 8. Send covered slide with a completed requisition to the laboratory for diagnostic purposes

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Microscopic finding Three findings are diagnostic of scabies: S. scabiei mites, their eggs and their fecal pellets or scybala (figure below).

Figure 17. Microscopic Finding of Scabies

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BCS 4: Tzanck Smear as a Diagnostic Tool in Dermatology Suryawati

Tzanck smear is a very simple, rapid, cheap and reliable cytodiagnostic tool in dermatology. Cytology is a diagnostic tool used to investigate the characteristics of individual cells. In this method, materials obtained in a variety of ways are transferred to a glass slide, stained with various dyes, and then examined under the light microscope. As a method for the diagnosis of cutaneous disorders, cytology was first used by Arnault Tzanck in 1947.Cytology has been widely used by dermatologists for diagnosing various cutaneous dermatoses, such as for viral infections (herpetic infections), immunobullous disease (pemphigus), bacterial infection (Staphylococcal Scalded Skin Syndrome) or a skin tumor.

Preparation of Tzanck smear 1. Samples should be taken from a fresh vesicle and cleaned with 70% alcohol. 2. The vesicle should be unroofed or the crust removed, and the base scraped with the blunt edge of a scalpel blade (no 15) or the edge of a spatula. 3. The material is transferred to a glass slide by touching the spatula to the glass slide repeatedly but gently, air dried. 4. The material obtained stained with Giemsa stain for 20–25 minutes. 5. Then it is washed with water and examined under the microscope.

Cytologic findings 1. The cytological findings are pathognomonic of herpetic infection because of the presence of tremendously enlarged, multinucleated giant cells (ballooning cells). The cytoplasm is hyper-basophilic; the nuclei are giant, often have a smoky appearance due to the absence of the chromatin network, and may contain inclusion bodies due to the presence of reproducing viral units (figure 18). 2. The cytologic finding from immunobullous disease such as pemphigus is characterized by numerous acantholytic (or Tzanck) cells (figure 19). 3. A Tzanck smear taken from a fresh bulla from Staphylococcal Scalded Skin Syndrome (SSSS)shows an abundance of viable keratinocytes (dyskeratotic cells, acantholytic cell) without inflammatory cells different with Toxic Epidermal Necrolysis (TEN) that presents scarce necrotic keratinocytes along with fibroblasts and inflammatory cells.

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Fig 18. Paucilesional herpes zoster (a). Ballooning cells at·200 (b) and 1000(c).

Fig 19. A typical acantholytic cell of pemphigus vulgaris.

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BCS 5: Wound Care Luh Mas Rusyati & Ratih Karna

Skin as barrier protection of the body against external world plays a significant role in the prevention of infection. Skin that got wounded and not intact will allow the infection to easily penetrate to the body. Skin and soft tissue infection is still a major problem and is the number four of most causes of outpatient treatment in Indonesia. This type of infection can be caused by gram- positive bacteria such as Staphylococcus aureus and Group Aβ-streptococci, or by gram-negative bacteria such as Pseudomonas and Serratia. After the discovery of antibiotics, most of the infectious cases could be treated well. But, these days management of infection would be more challenging and demand more attention with the increase of immunocompromised diseases including diabetes mellitus. Ulcer itself describes as discontinuity of epidermis and dermis either caused by a natural history of an underlying disease or by manipulation and trauma. Skin infections with such situations describe above could prolong the length of stay and the use of antibiotics. It needs to be bear in mind that the cause of the wound would not necessarily determine the management of the wound. It is caused by an event can be different and evolve in the problem and manifestation. Every medical personnel should be able to assess and manage a wound or ulcer properly especially in term of wound care, wound toilet, and dressing options. The problem of wounds including infections, necrotic tissue, and exudates. Infection could be managed by properly choosing the correct antibiotic accompanied by wound toilet and irrigation. Necrotic tissue should be managed by debridement with various technical options such as surgery, autolytic, enzymatic, mechanic and biologic. Exudates now more easily manageable by various modern dressing that developed with a highly absorbent material such as calcium alginate, Hydrofiber, or foam. Before starting doing wound treatment, we have to evaluate the condition of the wound to see if there are infections or exudates occurred and necrotic tissue was found in the wound. Modern dressing does not depend on antibiotic or antiseptic because irrigation can be done using materials that contain silver (Ag) which act against bacteria. While treating the wound, coping with exudation is a very important step in order to keep the wound moist and it will increase the re-epithelialization so the healing process will be 50% faster than dry wound. Physiologic Natrium Chloride (NaCl 0,9%) often used in Dermatology Department to irrigate the wound, especially with prior dermatitis lesion because NaCl 0,9% is nonirritating. Various options of modern dressing were available such as calcium alginate, hydrofiberdan foam.

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In cases of necrotic tissue presence, debridement of the wound is the only choice. Some of the purpose of debridement are removing necrotic tissue, reducing bacterial contamination, and promote healing process. Not all debridement procedure was done by surgical measure, even though it is the fastest and give more complete result. Beside by surgical technique, there is less invasive nonsurgical debridement that can be an option, such as debridement enzymatic, debridement autolytic, and debridement biologic. Enzymatic debridement achieved by topical collagenase ointment that can remove necrotic tissue. Autolytic debridement removes the remains of necrotic tissue by maintaining the wound in a moist condition. The moist wound will activate a proteolytic enzyme which also acts to liquefy necrotic tissue. This technique is pain- free and cheaper. Mechanic debridement was done by wet to dry dressing with sterile gauze by which the gauze dry, the necrotic tissue will also be removed. The disadvantage of this technique is discomfort and sometimes disturbing the newly formed epithelial cells. Whereas biologic debridement using a biological agent such as larva Phaneniceasericata (green blow fly) to remove the necrotic skins.

Conventional Wound Dressings 1. Sodium Chloride 0,9%. Physiological solutions, safe for dressings especially for the wound with dermatitis risk. 2. Permanganate Kalikus (1:5.000 – 1:10.000). Antiseptic, pink-purple staining, difficult to prepare.

Figure 20. Saline-moistened gauze

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Modern Dressings 1. Film transparent self-adhesive sheet. It from polyurethane, gas and water vapor permeable, impermeable to fluid and bacteria, thin and elastic, easily conforming to wounds with complex shape and angles, difficult to use as they fold on themselves easily.

Figure 21. Film transparent self-adhesive sheet

2. Foam. Composed of polyurethane or a silicone center, with a semi-occlusive outer layer, convenient over bony prominences or within exudative cavities. Should be changed as often becomes soaked with exudate, which may range from daily to once or twice weekly.

Figure 22. Foam

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3. Hydrocolloids. Composed of cross-linked polymer matrices, integrated adhesives, and starches, such as cellulose, gelatin, pectin, and guar. Available as sheets, pastes, and powders. Upon contact with wound exudates, hydrocolloids absorb water and form gels.

Figure 23. Hydrocolloids 4. Alginate. Best choice for highly exudative wounds, composed of seaweed or kelp-based polysaccharides. The gel is highly absorbent. Calcium ions within the dressing exchange with the sodium ions in wound exudate to form an alginate gel.

Figure 24. Alginate

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BCS 6: Basal Cell Carcinoma, Squamous Cell Carcinoma, Nevus Pigmentosus, Cutaneous Melanoma, Abcess Incision and Drainage, Enucleation, Elliptical or Fusiform Excision, and Nail Avulsion Dharma Putra & Made Wardhana

6.1 Basal Cell Carcinoma (BCC) Basal Cell Carcinoma (BCC) is the most common cancer in humans. Basal Cell Carcinoma more common in the ederly individual. Basal Cell Carcinoma characters develop on sun-exposed skin in the lighter skinned individual. Basal Cell Carcinoma is rare in the dark skin because of the inherent photoprotection of melanin and melanosomal dispresion. Risk factors for BCC are ultraviolet light (UVL) exposure, light hair and eye color, northen european ancestry, and inability to tan. Pathogenesis of BCC involves exposure to UVL, particulary the ultraviolet B spectrum (290-320 nm) that induced mutations in p53 tumor suppesor genes. Clinical Manifestations of BCC may vary for different clinical subtypes, which included nodular, superficial, morphea-form, pigmented, and fibroepitheloma of Pinkus (FEP). 1. Nodular Basal Cell Carcinoma The most common clinical subtype of BCC. It occurs most commonly on the sun exposed area of the head and neck. Appeared as a translucent papule or nodule depending on duration. There are usually telangiectasis and often rolled border. Large lessions with central necrosis are reffered by the term rodent ulcer. The differential diagnosis of nodular BCC included traumatized dermal nevus and amelanotic melanoma.

Figure 25. Nodular Basal Cell Carcinoma Figure 26. Rodent ulcer

2. Pigmented Basal Cell Carcinoma Appeared as hyperpigmented, translucent papule, which may also be eroded. The differential diagnosis includes nodular melanoma.

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Figure 27. Pigmented Basal Cell Carcinoma

3. Superficial Basal Cell Carcinoma Appeared as an erythematous patch (often well dermacated) that resembles eczema.

Figure 28. Superficial Basal Cell Carcinoma

4. Morpheaform (Sclerosing) Basal Cell Carcinoma Aggresive growth variant of BCC, have an ivory-white appearance and may resemble a scar or small lesion of morphea.

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Figure 29. Morpheaform Basal Cell Carcinoma

5. Fibroepitheloma of Pinkus (FEP) Fibroepitheloma of Pinkus clasically presents as a pink papule usually on the lower back. It may be difficult to distinguish form an acrocordon and skin tag.

Figure 30. Fibroepitheloma of Pinkus The biologic behavior of BCC can have a local invasion. BCC is a slow-growing tumor that invades locally rather than metastasizes. If untreated, the tumor will progress to invade subcutaneous tissue, muscle, and bone. Perineural invasion and metastasis are rare in BCC. BCC treatments include standard surgical exicions, Mohs Micrographic Surgery (MMS), destruction with various modalitied (curretage and desiccation, cryosurgery), topical chemoterapy (imiquimod 5% cream, 5-fluorouracil, hedgehog inhibitor), photodynamic therapy (PDT), and radiation therapy.

6.2 Squamous Cell Carcinoma (SCC) Cutaneous squamous cell carcinomas (SCCs) are malignant neoplasms derived from suprabasal epidermal keratinocytes. Together with basal cell carcinoma, both represent the most common malignancy in humans. In most cases, this malignancy evolves from precursor lesions of actinic keratosis and Bowen disease (SCC in situ). Cutaneous SCC represents a broad spectrum of disease ranging from easily managed, superficially invasive cancers to highly infiltrative, metastasizing tumors that can result in death. The clinical presentation can be variable despite the existence of easily identified typical lesions. There are a number of factors, including both, acquired and genetic skin conditions that may predispose to SCC: precursor lesions, UV/ radiation exposure, environmental carcinogens, immunosuppressions, scars, burns, chronic scarring, HPV infection, genodermatoses (albinism, xeroderma pigmentosum, porokeratosis, epidermolysis bullosa). The majority of SCCs arise on sun-exposed areas such as the head, neck, and dorsal hands. SCC typically presents in solitary fashion, with the exception is in immunosuppressed

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patients, who may manifest eruptive SCCs. The most common morphology is a firm, flesh-colored or erythematous, keratotic papule or plaque. Other presentations include as an ulcer, a smooth nodule, or a thick cutaneous horn. SCC may also be verrucous or present as an abscess, particularly if in a periungual location. The margins may be indistinct. With enlargement, there is usually increased firmness, elevation, and fixation to underlying tissues. Enlarged lymph node nearby that is firm and nontender may indicate tumor metastasis.

Fig 31. Ulcerative squamous cell carcinomas of the jaw.

The diagnosis of SCC is always made by skin biopsy. Histologic hallmark of invasive SCC is the extension of atypical keratinocytes beyond the basement membrane into the dermis, with varying proportions of normal-appearing and atypical squamous cells.The tumor may appear as single cells, small groups or nests of cells, or a single mass. Squamous differentiation is seen as foci of keratinization in concentric rings of squamous cells called horn pearls. In every case, it is important to note clues that may indicate a precursor lesion or particular etiology. The grade, depth of penetration, tumor thickness, and hair follicle involvement should also be reported. Low- grade tumors are comprised of uniform cells, resembling mature keratinocytes, with intracellular bridges and keratin production. By contrast, high-grade SCCs are characterized by atypical cells, loss of intracellular bridges, minimal or absent keratin production, and a less distinct demarcation between malignant cells and adjacent normal stroma.

Fig 32. Atypical keratinocytes and foci of keratinization Treatment of SCC includes the surgical excision, Mohs micrographic surgery, topical therapy (in

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situ disease only), and radiation therapy. Conventional surgical excision is viewed by many as the treatment of choice for small primary SCCs. Recommended margins are 4 mm for low-risk lesions or SCCs with a depth of less than 2 mm; for lesions with a depth of more than 6 mm or a diameter larger than 1 cm, Mohs micrographic surgery is recommended. Mohs micrographic surgery is also recommended in specific circumstances when the highest cure rate and minimal tissue destruction are desired. Radiation can be used to treat superficially invasive to moderate- risk lesions and serves as an important adjuvant to excisional surgery in treating residual microscopic disease and providing prophylaxis against metastatic disease. Radiation therapy is not advised for verrucous carcinoma, in which there is an associated low rate of anaplastic transformation. After a diagnosis of SCC, all patients should be considered at high risk for developing additional lesions of SCC as well as BCC. They should be seen at regular intervals, ranging from 3 months to 12 months, depending on the degree of risk of prior lesions, the status of precursor lesions, and individual patient compliance. Some preventative measures are likely to reduce the risk of recurrences, such as sun protection, treatment of any precursor lesions and HPV infection, decreased alcohol consumption and smoking cessation.

6.3 Nevus Pigmentosus Nevus pigmentosus or nevomelanocytic neoplasias is used to describe the presence of a melanocytic cell in epidermis, dermis, or in other tissue. Nevus pigmentosum can occur because of mutasions N-RAS, GNAQ, and B-RAF genes that disrupt normal melanocytic development and result in acumulation of the melanocytic cell. This alteration can induce by UVL. Based on clinical features the nevus pigmentosum include: 1. Congenital Nevomelanocytic Nevi (CNN) Present at birth or shorthly thereafter. Divided based on size criteria, small CNN (<1.5 cm), medium (1,5-19,9 cm), and large or giant (>20 cm). The countour of CNN may smooth, pebbly, rugose, verrucous, cerebriform, or grossly lobular surface. Have regular and sharply demarcated. Some CNN has coarse, long, and darkly pigmented hair.

2. CommonFigure 33. Acquired Small CNN Nevomelanocytic Figure 34. Nevus Medium CNN Figure 35. Giant CNN

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The majority appear to develop during the second and third decade of life. Clinically the lession tend to be uniform in appearance and relatively small in size. The lession have had a homogenous surface and coloration pattern (skin-colored, pink, or brown) round, oval, dome- shaped, pendiculated or flat-topped with regular outlines and sharp borders. The surface of nevi may reveal hair that is less or equal to surrounding skin.

Figure 36. Common Acquired Nevomelanocytic Nevus 3. Nevus Spilus The lession appeared as a hyperpigmented patch background (1 cm to greater than 10 cm) with scattered darker flat or raised element macular or papular pigmented. The lession becomes during infancy or early childhood. Lession have been noted primary on the torso and extremities.

Figure 37. Nevus Spilus 4. Blue Nevus Lession appears as a blue, blue-gray, or blue-black papules, nodule, or plaque. Lession is generally acquired but may be congenital.

Figure 38. Blue Nevus 5. Pigmented Spindel Cell Nevus

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The pigmented spindle cell nevus presents as a jet black lession often with “starburst” appearance. The lession usually have uniform darkly pigmented with a sharp border. Appeared during the third decade of life. Lession have been noted primarily in the lower extremities and back.

Figure 39. Pigmented Spindel Cell Nevus

6. Splitz Nevus Lession appears as a dome-shaped papule, the color pink or red, hairless, firm, and dome- shaped. Some spliz nevus may resemble keloid.

Figure 40. Splitz Nevus

The spectrum of nevomelanocytic neoplasmas often subcategorized based on the location of the melanocytic cell, into junctional, dermal, and compound on histopathology examination. 1. Junctional nevus pigmentosus A melanocytic cell in the epidermis. The nevus lession usually flatter and darker. 2. Dermal nevus pigmentosus A melanocytic cell in the dermis. The nevus lession usually elevated and less pigmented. 3. Compound nevus pigmentosus A melanocytic cell in both areas epidermis and dermis.

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Management approach of nevus pigmentosum is the compelete removal of nevus with exisicion with safety margin 3-5 mm. Exicision should be included subcutaneous fat to ensure complete removal of the deep dermal melanocytic cell. After exision, the nevus tissue continues with histopathology examnination. If the size of nevus pigmentosum large and difficult to do exision, the other modalities of treatment are curretage, dermabration, chemical peel, cryotherapy, electrosurgery, ablative laser, and also pigmented laser.

6.4 Cutaneous Melanoma Cutaneous melanoma is the one of the skin cancer in humans. Risk factor cutaneous melanoma included the history of sunburn or heavy sun exposure, blue or green eyes, blonde or red hair, fair complexion, have > 100 typical nevi, any typical nevi, prior personal or family history of melanoma, or p16 mutation. Mean age at diagnosis is 53 years. Most common location is the back of men and lower extremities followed by trunk for women but can occur anywhere on the skin surface. Based on the clinical finding, melanoma can be divided into: 1. Superficial Spreading Melanoma (SSM) SSM is the most common subtypes melanoma. The lesions have irregular borders, irregular pigmentation, or it may present a discrete focal area of darkening within preexisting nevus. The lesions slowly changing over months to years.

Figure 41. Superficial Spreading Melanoma

2. Nodular Melanoma (NM) Nodular Melanoma is the second most common subtypes melanoma. The trunk is the most common site. Nodular Melanoma have rapid evolution, over several weeks to years. Nodular Melanoma typically appeared as dark blue-black our bluish-red raised lession, but 5% cases are amelanotic.

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Figure 42. Nodular Melanoma

3. Lentigo Maligna (LM) and Lentigo Maligna Melanoma (LMM) Lentigo Maligna is a subtype of melanoma in situ with a prolonged radial growth phase that may progress to invasive LMM with time. The most common location is on the chronically sun- exposed face, cheeks, nose, neck, scalp, and ear. Lentigo Maligna is flat, slowly enlaging brown, freckle like macule with irregularly shaped and differing shades of brown and tan. Lentigo Maligna Melanoma is frequently larger than LM. Both LM and LMM have ill-defined borders.

Figure 43. Lentigo Maligna Figure 44. Lentigo Maligna Melanoma

4. Acral Lentiginous Melanoma (ALM) Acral Lentiginous Melanoma is a subtype of melanoma in the darker-pigmented individual. The most common site ALM is the sole, palm, and subungual. The clinical appearance ALM can be brown, black, tan, or red with variegations on color and irregular bordees, however, the most common color is brown-black. Subungual ALM, arised from nail matrix, most commonly on great toe or thumb. It appeared as a brown to black discoloration or growth in the nail bed.

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Figure 45. Acral Lentiginous Melanoma

Diagnosis cutaneous melanoma can be made by using ABCD rule, 7 point check list using dermoscopy examination. The gold standard for diagnosis melanoma is based on a histopathologic evaluation of the specimen. Sentinel Lymph Node Biopsy (SLNB) can be used for evaluation of regional metastasis melanoma on the lymph node. For evaluation distant metastasis can be used imaging modalities such as CT-scan, MRI, PET, Chest X-ray, and hematologic test Lactate Dehydrogenase (LDH).

Figure 46. ABCD Rule Figure 47. Seven points check list

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Treatment of primary cutaneous melanoma is exsicion, the current recomended margin for exicion based on Breslow depth from histopatoly examnination. Treatment for regional metastatis cutaneous melanoma on lymph node is complete node dissection, give chemotherapy agent use isolated lymp perfusion or isolated lymp infusion method. Treatment for distant metastasis cutaneous melanoma is systemic chemotherapy and immunotherapies like decarbazine (DTIC), Temozolomide (TMZ), or high doses interleukin-2 (IL-2).

6.5 Abcess Incision and Drainage AIM: Once an abscess has formed an antibiotic cannot penetrate the avascular slough lining the cavity. It is only after the abscess has been incised and the slough scraped away that the antibiotic as well as the body’s own cellular and humoral defenses gain access to the cavity and eradicate the infection.

EQUIPMENT: 1. Steril gloves 2. Sterile gauze. 3. Skin antiseptic agent 4. Local anesthetic (1% lidocaine) 5. Syringe with 25-gauge needle for anesthetic administration 6. No. 11 blade scalpel 7. Hemostat 8. Syringe and saline for irrigation 9. Dressing supplies.

PROCEDURE (Modified Hilton’s Method): 1. Put on sterile gloves. 2. Carry out draping and isolation of surgical site. 3. Clean the surgical site with an antiseptic agent. 4. Infiltration of the local anesthetic agent. 5. Incision with a scalpel blade (No. 11) over the most prominent part, parallel to Langer’s lines. 6. As far as possible, keep incision in the most dependant part. 7. Introduce hemostat. After introducing, open the blades and rotate to widen the tract and break the septa. If required, the gloved finger should be introduced to break the septa. 8. Take pus for culture and sensitivity.

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9. Irrigate cavity with an antiseptic (povidone iodine, hydrogen peroxide), followed by irrigation with saline. 10. Pack the cavity with roller gauze (bleeding due to congested vessels and granulation tissue in the wall is controlled by tight packing). 11. Apply a sterile dressing and secure with adhesive tape.

POST-PROCEDURE: 1. Give broad spectrum antibiotics until culture and sensitivity report available 2. After that, give specific antibiotics according to the report 3. Analgesics 4. Anti-inflammatory 5. Instruct the patient to not disturb the dressing until the first follow-up visit.

6.6 Enucleation AIM: Enucleation technique can be used to remove the molluscum body in molluscum contagiosum, which is a common skin infection caused by a pox virus ussualy present as raised nodule with an umbilicated centre. The cellular material within the central umblication is extracted manually using a needle.

EQUIPMENT: 1. Sterile needle 16 to 18 gauge 2. Alcohol swab.

PROCEDURE: 1. Swab the affected skin area with an alcohol swab. 2. Using a sterile needle, cut across the body of the molluscum lesion with the needle. 3. Remove the contents of the papule with an alcohol swab.

POST-PROCEDURE: Minimal care is needed which includes keeping the wound dry and applying an antibiotic ointment and simple daily dressing.

6.7 Elliptical or Fusiform Excision

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AIM: The design and execution of a fusiform ellipse are fundamental skills of skin surgery. The purpose of this procedure is to remove a skin specimen and in the process produce a cosmetically acceptable linear scar. Although the nomenclature for the procedure may vary depending upon the design (eg, elliptical, fusiform, tangent-to-circle), the purpose remains the same. EQUIPMENT: 1. Surgical marking pen 2. Lidocaine 1-2% with or without epinephrine 3. Syringes, 5 to 10 mL 4. Needles, 27 to 30 gauge for injection 5. Sterile gloves 6. Electrosurgical instrument for hemostasis (optional to have one for cutting) 7. No. 15 scalpel or No. 15c and blade handle 8. Adson forceps (with and without teeth) 9. Iris scissors (optional to have another scissor for undermining) 10. Webster needle holder (consider gold-handled holder with carbide inserts) 11. Mosquito hemostats 12. Skin hooks (single, sharp prong) 13. Cotton-tipped applicators (CTAs) and gauze 14. Skin preparation solution (chlorhexidine or povidone-iodine) 15. Sterile drapes and a single fenestrated drape 16. Suture materials 17. Specimen container with formalin and label 18. Dressings: 2 × 2 gauzes, 4 × 4 gauzes, adhesive tape PROCEDURE: 1. The fusiform excision is designed with a 3 to 1 length-to-width ratio, oriented in the direction of the lines of least skin tension. The excision lines can be marked on the skin using a skin- marking pen. 2. The skin is prepped with chlorhexidine or povidone-iodine solution and anesthetized with 1% or 2% lidocaine with or without epinephrine. The hemostatic benefit of epinephrine is added for most procedures, except when the surgery is performed on the digits or the tip of the nose. The anesthetic can be administered with a 10-mL syringe and a 30-gauge needle for enhanced patient comfort. 3. Following administration of the anesthetic, sterile gloves can be applied, the skin can be reprepped with povidone-iodine solution, and a sterile fenestrated paper drape placed over

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the surgical field. Sterile bandages can be used at the edge of the fenestration to keep the drape from shifting and prevent unprepped skin from appearing through the drape hole. 4. The incision is made with a no.15 scalpel blade held vertical to the skin. Inward beveling, or “wedging,” is discouraged. The first pass of the scalpel on each wound edge should be smooth and continuous to prevent notching of the skin. A second pass of the blade may be needed to extend these incisions down to the level of the fat. Some 4x4 gauze can be used to wipe the surgical field clear of blood. 5. The scalpel is turned parallel to the skin surface to undermine the central fusiform island of skin. The central island of skin is lifted with Adson forceps with teeth as the scalpel is moved in the level of the upper fat. Once the central island of skin is removed, it is immediately placed in formalin and retained for histologic evaluation. 6. Bleeding sites in the wound base can be controlled by applying hemostats or suture ligation. The lateral tissues are elevated with a non disposable skin hook or a disposable hook. The lateral skin edges are not lifted with Adson forceps because the forceps may cause tissue necrosis. The lateral skin edges are undermined with a horizontally held scalpel or scissors in the level of the upper fat; 3 cm of lateral undermining is required for every 1 cm of skin edge relaxation. 7. Interrupted, deep-buried sutures are placed to eliminate dead space at the wound base, promote healing, reduce tension on the skin sutures, and improve the final cosmetic appearance of the scar. 8. Once the suturing is completed, the wound should be squeezed gently to remove any residual blood from beneath the wound that will interfere with healing. Direct pressure can be applied with gauze by the patient for 10 minutes or more to assist with hemostasis. The assistant then cleans the site with saline solution, applies antibiotic ointment, and places a pressure dressing (elastic bandage over gauze). POST-PROCEDURE: 1. Broad spectrum antibiotics 2. Analgesics 3. Anti-inflammatory 4. Instruct the patient to not disturb the dressing until the first follow-up visit 6.8 Nail Avulsion The removal of the nail plate can be carried out using distal or proximal approaches. In both techniques, inserting the blunt instrument back and forth between the horny layer of the proximal nail fold and the nail plate loosens the proximal nail fold adherence.

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Figure 48. A). Distal nail avulsion; B). Proximal nail avulsion

In the more commonly used distal approach, a Freer septum elevator or a dental spatula is inserted between the nail plate and nail bed (fig 1). The nail is separated from its nail bed attachment using proximal force applied in anterior-posterior movements so as not to injure the longitudinal ridges of the nail bed. The detachment is completed by firmly pushing the instrument into the posterolateral corners of the nail plate. Then, one of the lateral edges is grasped with a sturdy hemostat, and extracted with an upward and circular movement to accomplish the removal of the nail plate. The proximal approach for nail avulsion is advisable when the subungual distal area adheres strongly to the nail plate and when the hyponychium may be injured by the subungual introduction of the spatula. The proximal nail fold is freed as described in Distal Approach. The spatula is then used to reflect the proximal nail fold, and is delicately inserted under the base of the nail plate where adherence is normally weak. The instrument is advanced distally following the natural cleavage plane, and this operation is repeated on the entire width of the subungual region. After the last attachments are freed, the nail plate is easily pulled out.

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Total surgical removal should be discouraged, however, because the distal nail bed may shrink and become dislocated dorsally. In addition, the loss of counter pressure produced by the removal of the nail plate allows expansion of the distal soft tissue, and the distal edge of the regrowing nail then embeds itself. In patients at high risk, nonsurgical removal of the nail plate should be considered when necessary. This can be accomplished by applying 40% urea paste directly to the nail after protecting the surrounding skin. Urea acts on the bond between nail keratin and diseased nail plate, sparing only the normal nail tissue.

PARTIAL NAIL AVULSION Partial distal avulsion requires only separation of the nail from the distal nail bed. This procedure can be performed under local anesthesia, when, for instance, a fungal infection is of limited extent. An affected portion of the nail plate may be removed in one session, even when the disease has reached the deeper regions of the subungual tissue beneath the proximal nail fold. Commonly, an English anvil nail splitter or a double-action bone rongeur is used for this procedure. Partial surgical section of the lateral and/or medial segment of the nail plate may be sufficient for the treatment of distal lateral subungual onychomycosis. In the toe, this procedure leaves enough normal nail to counteract the upward forces exerted on the distal soft tissue when walking, and this will prevent the appearance of a distal nail wall.

Figure 49. A and B. Technique of removal the base of nail plate

In proximal subungual onychomycosis, removal of the nonadjacent base of the nail plate, cut

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transversely, leaves the distal portion of the nail in place (Fig 2), which decreases discomfort. Similarly, an acute paronychia that does not respond to appropriate antibiotics within 48 hours should be treated surgically by removing the base of the nail plate. TRAP DOOR NAIL AVULSION This technique minimizes trauma in nail surgery when accessing the nail bed and matrix. Trap door nail plate avulsion entails the separation of all periungual attachments except for that between the dorsum of the nail and the ventral aspect of the proximal nail fold. Both are then reflected in the bloc in the manner of a trap door, utilizing the same oblique incisions normally made for resection of the PNF alone.

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BCS 7: Valsalva Maneuver, Cleaning of MAE, Foreign bodies, and Cerumen Extraction Andi Dwi Saputra

7.1 Valsava Maneuver When a person has a feeling of fullness in his or her ears, it is usually the person will attempt to spontaneously relieve the discomfort by equating the pressure between the middle ear and the environment through accelerating air circulation through the Eustachian tube by moving the jaw, swallowing and advocating equalizer technique/ pressure balancing between the outer ear and middle ear with Toynbee and Valsava maneuver. Toynbee maneuver is done by closing/ punching the nose with the fingers and then shut up and swallowing saliva, while Valsava maneuver done by closing/ punching the nose with the fingers, shut the mouth and then blowing with the closed mouth. The Valsava maneuver comes from the name of the Italian anatomist Antonio Maria Valsalva (1666-1723), who first described this procedure by covering both sides of the nose and mouth and blowing on the cheek with forced expiration. This causes an increase in air pressure in the posterior space of the nose and into the Eustachian tubes, inflating the middle ear cavity and producing prominent movements of the tympanic membrane. This movement is most visible in the superior-posterior quadrant of the eardrum and can be easily seen through the ear canal.

Figure 50. Valsava Maneuver

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Figure 51. Valsava Maneuver

Figure 52. Valsava Maneuver

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7.2 Foreign Body In Canalis Auditorius Externa (CAE)

Any foreign body that entering to CAE must be removed. Handling must certainly remember and know the anatomy of the outer ear. The ear canal as part of the outer ear has a unique structure where the outer 1/3 contains thick connective tissue and cartilage while the inner 2/3 is thinner and directly attached to the periosteum. The outside of the ear canal also contains glands that produce cerumen where it also functions as a protection of ear canal from foreign body and infections. Basically, cerumen do not need to be cleaned actively because the ear canal has a cleansing mechanism. The use of tools to clean the cerumen will actually push the cerumen more in and make the skin layer damaged. Cerumen is cleaned when it caused complaints such as a full sense of the ear and hearing loss. Some methods to clean cerumen include irrigation with warm and sterile water, using a hook, cotton applicator, or forceps.

Figure 53. Foreign body in Canalis Auditorius Externus

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Figure 54. Cerumen extraction

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The various foreign body can enter into the ear canal both living things such as insects and inanimate objects such as mote. Usually more often happened in children because the habit of inserting objects into the ear. Management of foreign body should be done carefully and according to ability. Visualization should be clear into the ear canal because it is not infrequently accompanied by swelling of the ear canal. The method of taking a foreign body in the ear canal can also be done by using a hook for a round object, forceps for paper or easily clamped objects, irrigation when a foreign body is small and close to the tympanic membrane. Small insects that entering the ear canal must be killed first by using water, coconut oil, or non- irritating alcohol in the ear canal. Complications that can be experienced when removing foreign bodies include skin excoriation of the ear canal, bleeding, post-action infections, and rupture of the tympanic membrane. To avoid such things must be done carefully, using appropriate tools, and keep the child's peace.

Figure 55. Foreign body in Canalis Auditorius Externus

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Figure 56. Foreign body in Canalis Auditorius Externus

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LABORATORY GUIDELINE

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Histology: Skin and Hearing Structure Thick Skin, Thin Skin, and Skin Appendages

Aim : To increase understanding of thick, thin skin, and skin appendages structure.

Date & place : see schedule

Conveyer : Dr. dr. Ni Made Linawati, M.Si; dr. IGK. Arijana, M.Si Med

Material : Microscope Histological preparations (thick, thin skin and skin appendages) a. Thick Skin:  Epidermis, dermis b. Thin Skin (eyelid, lip, scalp, etc)  Epidermis, dermis c. Skin appendages (in the thick and thin skin):  Hair, sweat gland, sebaceous gland

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Anatomy Pathology: Skin and Hearing Systems Disorders Herman Saputra

List and describe the descriptive term of microscopic features in dermatopathology bellow: 1. Hyperkeratosis 2. Parakeratosis 3. Hypergranulosis 4. Acanthosis 5. Papillomatosis 6. Dyskeratosis 7. Acantholysis 8. Spongiosis 9. Hydropic swelling 10. Exocytosis 11. Erosion 12. Ulceration 13. Vacuolization 14. Lentiginous

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Pharmacology & Pharmacy: Rational Therapy of Topical Preparations in Dermatology Alit Widhiartini & Sucindra Dewi

Please make a summary of P drugs of dermatological problem complete with topical recommended treatment. Use the table below. You can use textbook or journal as references and compared to Buku Panduan Praktek Klinis bagi Dokter di Fasilitas Pelayanan (Permenkes no 5 Tahun 2014).

Table 1. P drugs Diagnosis Recommended Treatment Drug Dosage form Frequency per day, duration

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Aim : To understand the principles of rational drug therapies for topical preparations in dermatology diseases

The process of the rationale drug therapies: Step 1: What is the problem/s? Step 2: What is the aim of the therapy Step 3: Is the Personalized therapy (P-therapy) suitable for your patient (efficacy, safety, suitability, cost) Step 4: Start treatment Step 5: Giving the information about the therapy, how to apply and adverse effect Step 6: Monitoring and stop the treatment

Case: Herpes zoster, Pediculosis, Pyoderma (impetigo)

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Physiology: Hearing I Made Krisna Dinata

Aim : To study the auditory examination with tuning forks.

Tools and Materials : Tuning forks 256 Hz, 512 Hz, and 100 Hz

Figure 57. Tuning Forks

Working Procedure : Hearing Test: 1. Rinne test : a. Vibrate the 256 Hz tuning fork by hitting on the palm of the hand (never on hard objects). b. Press the rod of the vibrating tuning forks on the mastoid process of one of the ears. c. When the patient can no longer feel/hear the vibration, the tuning fork is held in front of the ear. d. The patient should once more be able to hear a ringing sound (Rinne-positive). e. If they cannot, there is a conductive hearing loss in that ear (Rinne-negative). f. Repeat the experiment with the other ear.

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Figure 58. Rinne Test 2. Weber test: a. Vibrate the 512 Hz tuning fork by hitting on the palm of the hand (never on hard objects). b. Placed tuning fork on the patient forehead. c. The patient is then asked if the sound is localized in the center of the head or whether it is louder in either ear. d. If hearing equally well in both ears is called no lateralization. When the sound is heard stronger in one ear, then called there is lateralization to the ear that hears the stronger sound. e. If there is a conductive hearing loss, it is likely to be louder in the affected ear; if there is a sensorineural hearing loss, it will be quieter in the affected ear. f. in this experiment, If not lateralization, in an attempt to obtain artificial lateralization, then close one ear with cotton, and repeat the above experiment.

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Figure 59. Weber Test

3. Schwabach: a. Vibrate the 100 Hz tuning fork by hitting on the palm of the hand (never on hard objects) b. Press the rod of the vibrating tuning forks on the mastoid process of one of the ears. c. ask the patient to raise his hand when the sound disappears, and at that moment the examiner moves the tuning fork on his own mastoid process. d. If the sound is still audible by the examiner, it is called a shortened Schwabach. e. If the examiner does not hear that sound, then repeat the above experiment, only the sequence is reversed. The examiner first listens, when no longer heard is transferred to the patient. When the patient still hears the sound it was called Schwabach elongated. f. When patient not to hear again, then it says no Schwabach elongated or shortened.

Figure 60 Schwabach Test

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Physiology: Somesthetic Sensation I Made Krisna Dinata

Aim : To see how the exteroceptor works.

Tools and Materials : Pencils and Geometric compass tools

Figure 61. Pencils

Figure 62. Geometric compass tools

Working Procedure : Perception of touch: a. Put a pencil behind the ear between head and earlobe. b. Let the pencil in place, while you do other work. c. What do you feel when the pencil is lifted? Why?

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Figure 63. Pencil behind the ear

Placement of pressure: The placement of pressure that must be distinguished from the ability to recognize the basic touch. a. The examiner emphasizes the pencil tip firmly at a point on the skin. b. Patients whose eyes are closed is asked to show the pencil tip as close as possible to the point that was stimulated. c. The examiner measures the distance between the two points. d. Do this experiment five times each on the finger, palm, inside of the upper arm and the back of the neck. Calculate the average for each region.

Tactile discrimination: a. Specify with the equipment (geometric compass tool), the threshold of distinguishing two points from the skin of the back of your hand. Measure how many mm/ cm the distance. b. Do the same on the tips of fingers, nape, lips, and cheeks. c. All experiments should be done twice, from a large distance between two ends of the equipment and vice versa, until the threshold is obtained. d. Try again this experiment, where both ends of the equipment are not touched at the same time but in a row. Are the results the same? Explain!

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Figure 64. Measure from a large distance

Figure 65. Measure until the threshold is obtained

Figure 66. Measure the distance

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REFERENCES

1. Craft N, et al. Superficial Cutaneous Infections and Pyodermas. In: Wolff K, Goldsmith LA, Katz SI, Gilchrist BA, Paller AS, Leffell DJ, eds. Fitzpatrick’s Dermatology In General Medicine, 7thed, 2008. USA: McGraw-Hill Company;; p:1694-1719. 2. Departemen Kesehatan Republik Indonesia. Profil Kesehatan Indonesia 2007. 2008. Jakarta: Departemen Kesehatan RI. 3. Durdu M, Baba M, Seckin MD. The value of Tzanck smear test in the diagnosis of erosive, vesicular, bullous, and pustular skin lesions. J Am AcadDermatol 2008;59:958-64 4. Eryılmaz A, Durdu M, Baba M, Yıldırım FE. Diagnostic reliability of the Tzanck smear in dermatologic Diseases. Int J Dermatol 2014; 53: 178–186 5. Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D. Scabies in Color Atlas and synopsis of clinical dermatology 4th ed. 2001. McGraw-Hill Medical Publishing Division. P834-43 6. Gupta LK, Singhi MK. Tzanck smear: A useful diagnostic tool. Indian J DermatolVenereolLeprol 2005;71:295-9. 7. Hay RJ, Adrians BM. Bacterial Infections. In: Burns T, Breathach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology, 7th ed. 2004. USA: Blackwell Science Publishing Company, p: 27.1-27.85. 8. Leung V, Miller M. Detection of scabies: A systematic review of diagnostic methods. Can J Infect Dis Med Microbiol 2011; 22:143-6 9. Micali G, Lacarrubba F, Verzì AE, Chosidow O, Schwartz RA. Scabies: Advances in Noninvasive Diagnosis. PLOS Neglected Tropical Diseases, 2016 10. Nugroho AS. Pemeriksaan penunjang diagnosis mikosis superfisialis. In: Bramono. K., Suyoso. S., Indriatmi. W., Ramali. L.M., Widaty. S., Ervianti E., eds. DermatomikosisSuperfisialis. 2nd ed. 2013. Jakarta: Badan Penerbit FKUI..p.154-163. 11. Perdanakusuma, DS, Hariani L. Modern Wound Management: Indication and Application, 2015. Surabaya: PT Revka Petra Media; 1-65. 12. Rovee TD, Maibach HI. Epidermal Repaired the Chronic Wound. In: Dermatology: Clinical and Basic Science Series The Epidermis in Wound Healing. 1st ed. London: Library of Congres Cataloging-in-Publication Data. 2004; pp 25-58 13. Ruocco E, Brunetti G, Vecchio MD, Ruocco V. The practical use of cytology for diagnosis in Dermatology. JEADV 2011; 25:125–129 14. Ruocco V, Ruocco E. Tzanck smear, an old test for the new millennium: when and how. Int J Dermatol 1999; 38: 830–834

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15. Schieke S.M., Garg A. Superficial Fungal Infection. In: Goldsmith LA., Katz SI., Gilchrest BA., Paller AS., Leffell DJ., eds. Fitzpatrick’s Dermatology In General Medicine. 8thed. 2012. New York: McGraw Hill..p. 2277-97.

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