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Handbook of Dermatology & Venereology HANDBOOK OF DERMATOLOGY & VENEREOLOGY (Social Hygiene Handbook, 2nd Edition) TABLE OF CONTENT DERMATOLOGICAL DISEASES Introduction of Skin Diseases Dr. K.K. LO Pruritus Dr. C.S. LEUNG Eczema Dr. Y.M. TANG, Dr. H.F. HO & Dr. K.H. YEUNG Psoriasis Dr. K.K. LO & Dr. L.Y. HO Acne Vulgaris and Other Acneiform Eruptions Dr. C.Y. LEUNG Urticaria Dr. C.Y. LEUNG Vitiligo Dr. R. SU Cutaneous Vasculitis Dr. R. SU Collagen-vascular Diseases Dr. R. SU & Dr. Y.M. TANG Blistering Diseases Dr. C.N. LOOK Alopecia Dr. C.N. LOOK Nail Diseases Dr. H.F. HO Cutaneous Malignancies Dr. H.F. HO Infection: Bacterial, Viral, Fungal Dr. W.K. FUNG Infestations Dr. T.S. AU Cutaneous Tuberculosis and Atypical Mycobacterial Infection Dr. L.Y. CHONG Leprosy (Hansen's Disease) Dr. N.R. HONEY & Dr. K.K. LO Practical Guidelines for Phototherapy Dr. L.Y. CHONG Health Nursing in Skin Clinics Ms. M. WONG, Mr. W. LEUNG, Mr. E. WAN & Subordinates Health Nursing in Special Skin Clinics Ms. M. WONG, Mr. W. LEUNG & Subordinates Cutaneous Laser Therapy Dr. L.Y. CHONG & Dr. H.H.L. CHAN Cutaneous Manifestation of Internal Disease Dr. H.H.L. CHAN & Dr. W.K. FUNG Cutaneous Drug Eruptions Dr. L.Y. CHONG SEXUALLY TRANSMITTED DISEASES Introduction of STD Dr. L.Y. CHONG Syphilis Dr. L.Y. CHONG Gonorrhoea Dr. K.H. LAU & Dr. H.F. HO Non-Gonococcal Urethritis and Non-Specific Genital Infection Dr. K.T. CHAN Chancroid Dr. Y.M. TANG Lymphogranuloma Venereum Dr. N.M. LUK Genital Warts Dr. C.Y. LEUNG Genital Herpes Dr. C.N. LOOK HIV Infection Dr. L.Y. CHONG Molluscum Contagiosum Dr. S.Y. CHENG Candidiasis Dr. L.Y. CHAN Trichomoniasis Dr. C.S. LEUNG Pediculosis Pubis Dr. W.M. CHEUNG Balanitis, Bacterial Vaginosis and Other Genital Conditions Dr. T.S. AU & Dr. K.H. YEUNG STD in Pregnancy Dr. K.M. HO & Dr. W.S. LAM Health Nursing in Social Hygiene Clinics Mr. W. LEUNG, Mr. S. LEUNG, Mr. T. LAM & Subordinates TOPICAL PREPARATIONS FOR DERMATOLOGICAL & SEXUALLY TRANSMITTED DISEASES Basic Pharmacology and Terminology of Topical Preparations Dr. Y.M. TANG & Dr. R. SU Principles of Prescribing Topical Preparations and Topical Steriods Dr. Y.M. TANG & Dr. R. SU Government Formulary Dr. Y.M. TANG & Dr. R. SU Commercial Dermatological Preparations and Sunscreens Dr. K.M. HO, Dr. R. SU & Dr. Y.M. TANG APPENDIX Dermatology, Social Hygiene and Special Skin Clinics in Hong Kong Medical staff of Social Hygiene Service Publications from/Contributed by Social Hygiene Service Annual Incidence and Trends of Disease Suggested Books for Reading Normal Laboratory Values INTRODUCTION OF SKIN DISEASES Dr. K.K. LO CHAPTER 1 The art of diagnosis in dermatology in the past was particularly emphasized by the visual experience of the skin and the skin lesions. The story of arriving a dermatological diagnosis even when the patient has not the time to sit down is less true nowadays for a careful dermatologist. It is a good way to impress the neophyte dermatologist but it is not the rule. It is true that some skin lesions can be diagnosed on sight with a high degree of confidence but even in such cases a systematic approach is indispensable for a good dermatologist not to miss other important skin lesions. When dermatology first evolved from general internal medicine in the nineteenth century, the principle of diagnosis in medicine still held valid till today even in the highly specialized specialty: dermatology. Hence, detailed systematic history with good physical examination, supplemented by appropriate investigations will be the golden rule for the correct approach in the diagnosis of skin conditions. The old days of when you can recognize the lesion and so the lesion can recognize you will only be true for some senior dermatologists but it will not be seen again in modern dermatology. 1. SKIN FUNCTION AND STRUCTURE OF SKIN 1.1. Skin Function Skin is actually the largest organ in the body. Its wet weight can be as heavy as 4 kg and covers an area of 1.4 to 2 sq metres. It also plays many important functions in the body as summarized in Table I. Table I: Function of the Skin Function Structure Protection from harmful agents of external environment: biological germs, Epidermis ultraviolet light & chemicals Preservation of a balanced internal Epidermis environment Shock absorber Subcutaneous fat Blood vessels & eccrine sweat Temperature regulation glands Insulation Subcutaneous fat Sensation Nerve endings Lubrication Sebaceous glands Protection & grip Nails Calorie reserve Subcutaneous fat Vitamin D synthesis Epidermis Body odour Apocrine sweat glands Psychosocial Hair & Nails 1.2. Structure of Skin Epidermis: Thickness varies from 0.1 mm at the eyelids to nearly 1 mm on the palms and soles. The outermost is the horny layer (stratum corneum) which is made up of flattened dead keratinocytes. It acts as the major physical barrier in the epidermis. The granular layer, spinous layer or prickle cell layer are composed of the living keratinocytes and the basal layer which is the deepest, most active and single layer of the epidermis is the germinative layer for the epidermis. There is a gradual differentiation from basal layer to the horny layer. Skin appendages: Hair, nail, eccrine sweat glands, apocrine sweat glands, sebaceous glands. Dermo-epidermal junction: At the interface between the epidermis and dermis lies the basement membrane zone. Electron microscopy shows that it can further be divided to basal cell membrane, lamina lucida (20-40 nm), lamina densa (30-60 nm, Type IV collagen) and sublamina densa with anchoring fibrils (Type VII collagen), dermal microfibril bundles and Types I & III collagen fibres. The structures of the dermo-epidermal junction provide good mechanical support, adhesion and growth of the basal layer unless it is diseased. Dermis: It is thickest at the palms, soles and back (3 mm) least at the eyelids (0.3 mm) and penis. There are papillary dermis and deeper reticular dermis. It contains many cells, fibres and amorphous ground substance. Fibroblast for synthesis of collagen, reticulin, elastin, glycosaminoglycans is the major cell in the dermis. The ground substance consists of two glycosaminoglycans: hyaluronic acid and dermatan sulphate. Other structures found in the dermis include: blood vessels, lymphatics, nerves, nerve endings and receptors, dartos muscles in scrotum, appendageal glands and their accessories e.g. arrector pili muscles. Subcutaneous fat: It is absent from the eyelids and the male genitalia. It has abundant blood and lymphatic supplies. 1.3. Cell Types Epidermis: Keratinocytes (85% of cells in epidermis), Langerhans cells (800 per sq mm), Melanocytes (from neural crest, wedged between basal keratinocyte in 1 to 10 ratio; 1 melanocyte supplies pigments to 36 keratinocyte), Merkel Cells. Dermis: Fibroblast, mononuclear phagocytes, lymphocyte, Langerhans cell, Mast cell. 1.4. Kinetics of Skin Epidermis: Cell cycles of keratinocytes: 300 hours (from G1, S, G2 to M phases); keratinocytes need 14 days to move from basal layer to horny layer and another 14 days to slough off from horny layer (i.e. from the basal layer to the environment requires 28 days). Skin appendages: Hair (scalp): growth rate: 0.37 mm/day, 80% in anagen at any one time; anagen phase: 3 years, catagen phase: 3 weeks, telogen phase: 3 months. Nail: fingernail growth rate: 1 cm/3 months (0.1 mm/day), toenail growth 1 cm/9 months 2. HISTORY TAKING IN DERMATOLOGY 2.1. General History Race, geographical factors (especially for immigrants), occupation, sports, hobbies, social background, ethnic tradition (dietary habits) Past medical history: allergy to medication, hay fever, asthma, past major illness or operation. Social & occupational history: travel abroad, hobbies and details of the type of work, substances in contact. 2.2. Special History (Dermatology) History of present illness: duration, date & site of onset, details of spread, evolution of rash & original morphology, symptoms such as itchiness, pain, burning sensation, numbness, precipitating and relieving factors such as climate, sunlight etc., treatment (topical & systemic medication) sought or applied. Past history of skin disorders, history of sunburn. Family history of skin disorders (e.g. skin cancers) and atopic disorders. Drugs: include herbs, topical, systemic, patient initiated or physician prescribed. Patient's own perception on the cause of the problem. 3. PHYSICAL EXAMINATION 3.1. General Examination Good lighting, adequate privacy, light torch, spatula, magnifying glass and transparent glass slide for diascopy. General impression on the patient is very important especially for the general health, pallor, intellectual assessment, queer personality etc. will be picked up by an observant doctor when patient enters the consultation room. 3.2. Examination of Skin Distribution of the rash, arrangement and morphology of individual rash. Distribution of the lesion: symmetrical, asymmetrical, exposed area, sun exposed area, scalp region, hand, extensor aspect, flexor aspect. Arrangement and configuration of the lesion: grouped (as in insect bites, dermatitis herpetiformis, herpes simplex, common warts), annular or arciform (as in granuloma annulare, mycosis fungoides, tinea circinata, erythema annulare centrifugum), linear pattern (as in Koebner phenomenon, Psoriasis, lichen planus, plane wart, molluscum contagiosum; epidermal naevus, sporotrichosis, lichen striatus, lichen simplex, morphoea, lichen sclerosis, phytophotodermatitis). Morphology of lesion: Individual lesion described with the help of magnifying glass. To find out the early primary lesion and to inspect it closely. Note the shape(geometric shape, oval), colour(salmon-pink, erythematous, skin colour, yellow), size, margin (sharpness of edge, well- defined, ill-defined), the surface characteristics (dome-shaped, umbilicated, spike like), temperature and smell. It is a good practice if affordable to have thorough examination of the whole body especially for new consultation and for the elderly. Sometimes, examination of the back and buttock of the elderly may pick up unexpected lesions, even the patient himself or herself may not notice them e.g.
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