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MINISTRY OF HEALTH
UZBEKISTAN
TASHKENT MEDICAL ACADEMY
medical Faculty
Medical-Pedagogical faculty
Department of Skin and Venereal Diseases
Lecture, Skin and Venereal Diseases
for 4th year students
Tashkent 2013-2014 y
Lecture number 1
Anatomy, histology, pathology and PATOGISTOLOGIYA GENERAL SKIN framework for the diagnosis of
skin diseases, the factors contributing DISEASES
The drafters:
Musaeva N.Sh., Azizov B.S., Allaeva M.J.
Plan and organizational structure of the lecture
Opening remarks, oparedelenie source of knowledge, the explanation of problems lectures
1. Structure of the skin, histology, patogistologiya skin
2. drivers of dermatoses.
3. Survey methodology dermatological patients
4. Primary and secondary elements
5. Questions for learning styles lecture.
Lecture number 1
SUBJECT: anatomy, histology, pathology GENERAL PATHOLOGY AND SKIN basis of diagnosis of skin
diseases, the factors of the disease.
The main tasks of the science of dermatology and clinical discipline is the study of the function and
structure of the skin in health and disease, the relationship with the pathology of skin diseases of the
internal organs and body systems, identify the causes and pathogenesis of various diseases of the skin
(dermatitis). Development of diagnostics, treatment and prevention of diseases of the skin.
The skin is one of the most important organs involved in homeostasis of man. As a unique
multifunctional membrane formation, it is a sensory and defense mechanisms provides human contact
with the outside world, reflects the quality of the functioning of the internal organs. Endokrinnyoy and
nervous systems. In the course of ontogeny in human skin has developed a highly immune system,
which is the first barrier to entry into the body of infection and other pathological substances. Minor
violations of the body are often accompanied by skin manifestations, signals the presence of visceral
diseases or disorders of the nervous system.
As a result of exogenous and endogenous factors on the skin it can develop pathological processes:
Exogenous factors that can cause pathological conditions in the skin: - Physical: friction, pressure, high
and low temperature, radiation, energy, and others - chemical, infectious: Bacteria , viruses, pathogenic
fungi, protozoa.
Endogenous factors which might be the cause of skin diseases: are - an imbalance of vitamins A, C and
B complex - metabolic (carbohydrate, lipid, mineral) - Chronic Gastrointestinal Disease Markers,
dysfunction of the endocrine glands - sensitization of the organism to the various agents of the
environment - genetic predisposition, immunodeficiency and autoimmunity - organic and functional
disorders of the nervous system.
The following structures are distinguished in morphofunctional unity in the skin: - the epidermis - dermis
- hypodermis - skin appendages. Formation of the epidermis is the ectoderm, dermis and hypodermis from the mesoderm. Epidermis, dermis and hypodermis consist of: the epidermis - epithelial - dermis connective - hypodermis - fat and connective.
The epidermis contains 5 layers - basal, prickly - grainy - shining; horny.
Features of the basal layer: - basal layer consists of one series of prismatic and cylindrical cells were
located on the basement membrane, the cells of the basal layer are mitotically active in the cytoplasm
of the plasma is a large amount of DNA - RNA - containing structures, ribosomes and mitochondria,
thereby ensured formation of structures overlying epidermis cells of the basal layer spologayutsya
melanocytes from white-rostchatyeepidermotsitov (Langerhans cells), sensory cells (Merkel cells).
Basement membrane: is formed by processes kornepodobnyh lower surface of the basal cells is fuzzy
contours, relief repeats of epidermal strands penetrating into the dermis, epidermis provides a strong
bond with the dermis, a barrier function - is involved in the exchange processes between the epidermis
and dermis.
Prickly layer consists of 3-8 layers of cells, the presence of many different
cytoplasmic outgrowths (spikes or acanthus), consisting of compacted cell walls (desmosomal
structures. thorny layer to provide a strong connection with the formation of cells between channels
with circulating intercellular fluid. in the thorny layer are also white otrostchatyepidermotsity
(Langerhans cells). Granular compacted layer has a diamond shape and consists of 1-3 rows - in the
nuclei of the granular layer decreased RNA and DNA - in the cytoplasm of cells of the granular layer
formed inclusion - keratohyalin grains, which inhibits mitotic division. Malpighi in germ layer idermisa
includes basal - ribbed - grainy. shiny layer is well marked on the skin of the palms and soles, contain
eleidin - substance strongly prelomyayuschee light - limited permeability of water and electrolytes of
the epidermis, plays an important role in maintaining constant pH of the epidermis. features of the
stratum corneum is the following: it is the most yavletsya thick layer of the epidermis, is made up of
dead cells lacking nuclei and contains a special ingredient - keratin. Keratin different high density and
resistance to various substances, the surface cells of the stratum corneum is constantly rejected by
desquamation of the horny cover (physiological peeling) and the dermis is made up of cellular elements
of the following structures: a fibrous substance interstitial substance.
In the papillary dermis distinguish, mesh layers. papillary layer papillary dermis: an upper layer of the
dermis, educated "papillae" lie between ridges ribbed epithelial cells - the fibrous substance of the
dermis more represented nezhnovoloknistoy connective tissue - in the papilla are vessels nourishing the
epidermis, dermis and nerve endings. Features reticular dermis: - mesh layer is more compact and is a
major part of the dermis - stroma mesh layer more compounds represented by coarse-fibered fabric
light sensitivity, strength of the skin depends largely on the structure of the mesh layer.
Hypodermis consists of bundles of connective tissue, which is a large number of spherical fat cells and
in subcutaneous fat are: blood vessels, nerve endings, sweat glands, hair follicles. Hair, nails, sweat
glands, sebaceous glands are appendages of the skin. Anatomical parts differing in your hair shaft above the surface of the skin part of the hair root - hair department intradermally - funnel - a deepening
of the output shaft to the surface of the skin - onion - distal part of the root, Volosyan follicle, hair root is
surrounded by a shell.
Hair is made of-brain - the cortical layer, the cuticle. In appearance distinguish-vellus hair, bristly
(eyebrows, eyelashes, beard, mustache and hair in the genital area), long (scalp). There are simple sweat
glands "or ekkrinnyemerokrinovye" - the apocrine sweat glands. Especially many siting simple sweat
glands on the palms, soles and face. No sweat glands: - at the head of the penis, the outer surface of the
labia minora, the inner layer of the foreskin. Features of apocrine sweat glands - have a tubular
structure, larger in size than simple sweat glands were located deeper ducts associated with their
sebaceous hair follicles start to function only at puberty. Apocrine sweat glands are located around the
hair follicles on the skin of the genitals, anus, the areolas nipples, armpits.
The physiological functions of the skin: immune, protective, secretory and excretory,
thermoregulatory, metabolic, receptor.
Immune function is provided by a complex system of immunoreactive epidermal Lerma and
subcutaneous tissue, preventing the introduction and spread of foreign antigens in the body. This
function is carried out 1) keratinocytes (morphologically and functionally similar to the epithelial cells of
the thymus), expressed on the surface histocompatibility antigens, provide contact with Langerhans
cells and Greenstein (intraepidermal macrophages) that provide information to T-lymphocytes.
Contribute to the maturation of T-cells directly vzapmodeystvuyut T-lymphocytes produce a number of
immune response mediators (cytokines, interleukins). Include vospaliteltnyh chain reaction
(prostaglandins, leukotrienes, etc.). T-lymphocytes, 90% is located in the epidermis and upper dermis
(mainly around blood vessels). Ratio of T-suppressor T-helperovk = 0,93-0,96.3) B cells are in the middle
and deep layers of the dermis (antibody production) .4) endothelial cells of postcapillaryvenules of the
upper vascular plexus 5) fibroblatsy-macrophage system, histiocytes, dendritic cells with receptors for C
and
Fragment of mast cells, immediate hypersensitivity reaction cell aliens reacting T cells with nonspecific protective factors, basal membrane prevents penetration into the epidermis of the CEC,
antibodies, antibodies and other biologically active mediators.
Pathology of the skin
At the heart of the formation of various skin eruptions are various pathological processes in the
epidermis, dermis, hypodermis, the totality of which may be specific to a particular dermatosis and
often considered in the diagnosis of disease and nredko is an important study to diagnose. Distinguish
histopathological processes observed in the epidermis and dermis.
By the nature of the process in the epidermis histopathological release processes associated with
changes in epidermal kinetics (hyperkeratosis, granulosis, acanthosis), breach of differentiation of the
cells of the epidermis (parkeratoz, dyskeratosis), breach of epidermal connections (acantholysis,
ballooning and vacuolar degeneration, spongiosis)
Hyperkeratosis - thickening of the horny layer of the epidermis, which is a consequence of excessive
keratin content. Retentive distinguish proliferative and hyperkeratosis. Proliferative hy-z-formed as a
result of increased functional activity of the cells of the epidermis, proceeding against the thickening of
the granular layer and the thorny and is observed at CPL, neurodermatitisit.d. Retentive type is formed
as a result of slowing the exfoliation of cells of the stratum corneum, which is due to higher content of
the stratum corneumglikozoaminoglikanov playing cementing role and impedes separation horn cells
and their physiological rejection. Granular layer is thin or absent. .
Observed with vulgar ichthyosis.
Granulosa-thickening of the granular layer, in which instead of 1-2 layers of cells have 5 or more.
Characteristic of the CPL
Acanthosis, thickening thorny layer by increasing the rate of keratinocyte proliferation of basal and
suprabasal layers of the epidermis with an increase in their energy metabolism and mitotic activity.
Parakeratosis - a violation of keratinization with the loss of the ability to produce keratohyalin epidermal
cells, resulting in an incomplete keratinization of epidermal cells. The basis is a violation of parakeratosis
relationship between proliferative and differentiation of epidermal cells in relation to the violation of
tissue homeostasis. In the formation of this pathology is an important role for chalones actuating the
epidermal cAMP-cGMPsystem.fall restraint elevated levels of cAMP and cGMP in keratinocytes leads to
stimulation of cell proliferation and delay differentiation.
Dyskeratosis-autonomous premature keratinization of individual keratinocytes, which become larger
with intensely stained nuclei and basophilic, slightly granular cytoplasm. At the heart of the complex is a
violation of dyskeratosistonofilaments - desmosomes with the dissolution of the contact layer of the
latter and their aggregation around the nucleus. Observed at senile keratosis, molluscumcontagiosum,
skin cancer.
Acantholysis, the loss of communication between keratinocytes thorny layer due to damage to their
desmosomno-tonofilamentnyh contacts. This leads to the formation of intraepidermal cavities filled
with extracellular fluid.
Spongiosis, intercellular edema as a result of the penetration of serous fluid from the blood vessels in
the papillary layer of the epidermis.Prietom cells apart, their intercellular connections tighten and tear
in limited areas, why some cells die iobrazuyutsyamicrocavity-spongioticheskie bubbles. Spongiosis
characteristic of eczema, atopic dermatitis.
Vacuolar hydropic degeneration - is characterized by intracellular edema of keratinocytes to form
vacuoles in the cytoplasm, which leads to cell death. Observed in viral skin lesions., Lupus
erythematosus.
Ballooning degeneration - is characterized by a pronounced swelling of the epidermis, having both
extracellular and intracellular nature, resulting in swollen keratinocytes in large rounded dystrophic cells
modified type spherical formations swim freely in the serous-filled cavities and fibrous exudate
resemble cylinders filled with liquid. Observed in viral dermatoses.
Papillomatosis-elongation, often branching dermal papillae, irregularly raised above an epidermis. Is the
morphological basis of secondary cutaneous eleienta - vegetation.
Microcirculatory disorders of the skin is one of the most common phenomena that accompany any
inflammatory reaction in the skin
Elements of the rash
The variety of exogenous and endogenous causes and precipitating factors cause skin rashes
polymorphism (response of an organism), which have the characteristic clinical features.
All kinds of rashes on the skin conventionally divided: the primary elements - the rash appearing on
the same skin, secondary eruptions - developing as a result of transformation (evolution) of existing
lesions. Distinguish primary morphological elements in nature inflammation: - exudative - infiltrative.
The primary morphological elements include spot papule (knot) - bump, knot, bubble, bubble, blister,
pustule. The primary elements include exudative - bubble - bubble - abscess - blister (suspended). The
primary pnfiltrativnym elements include a knot, bump, knot.
Spot: a primary morphological element, show limited changes in skin color, without changing its
topography. The following types of spots: vascular, bleeding, liver, congenital and acquired.
Inflammatory spots are due to expansion of blood vessels, bleeding due to rupture of blood vessels,
vascular permeability disorders, liver due uvelichenyai or reduction of pigment. Species of vascular
spots: roseola, sizes up to 3 penny, erythema - larger spots, telangiectasias - Vascular stains resulting
from stand-th expansion of surface vessels. Distinguished by size dot - petechiae - small round purple
hemorrhage - ecchymosis - big krovoizliyaniya.Vibitsess - linear hemorrhage.
. Blister: this is a limited item bespolostnoeostrovospalitelnogo character plotnovatoy consistency
cushion rising above the skin surface, no clinical varieties resulting from edema (intracellular
th) papillary dermis, slightly raised above the skin and the formation of sharply delineated, testovatoy
consistency, accompanied by itching, is ephemeral (quickly appears and disappears without a trace) is
characteristic of allergic diseases of immediate type.
The bubble is the primary element and pleural fluid contains, can be formed within or podepidermalno
(surface element) - the size of the bubble more goroshiny.V result of a bubble is formed erosion, which
can be covered by a crust, which remains after the falling away from the bubble secondary
pigmentatsiya.Puzyrek: different size - 0.5 cm Meni bubble, bubble over - the mechanism of formation,
the bubbles can be formed by spongiosis, vacuolar and ballooning degeneration, and bubbles as a result
of acantholysis
Abscess - a cavitary, above the level of the skin up to the formation of a pea, and more filled with pus
nymsodderzhimym.Razlichayut impetigo - follicular pustules folliculitis) - conflict - superficial pustule ecthyma and rupee - deep types pustules.
Typical signs nodule: bespolostnoe, infiltrative education, raised above the surface of the skin and
clearly distinguished, infiltration is not lower than the upper half of the dermis - behind a knot leaves no
scarring and atrophy, and only secondary pigmentation and scaling. Nodule: results from hyperkeratosis, acanthosis, granulosis, papillomatosis, parakeratozaPapuly vary in size: - miliary - the
size of a pinhead - lenticular - about the size of a lentil - nummulyarnye - plaque.
The characteristic features of tubercle and host: - are bespolostnoe infiltrative cells; different: - size (in
most cases greater tubercle node) - the depth of the (nodes located in the hypodermis and may extend
into the underlying tissues.) Element of the corresponding histopathological changes: - spot vasodilatation of the skin, hemorrhage, pigmentation disorders - abscess - purulent inflammation;
- Knot - acanthosis, hyperkeratosis, parakeratosis, granulosa, papillomatosis, blister - swelling in the
papillary dermis (intracellular) - Bubble - acantholysis - bubble - spongiosis, ballooning degeneration bump and assembly - the formation of infectious granulomas, Langhans cluster of cells.
Methods of examination and diagnosis
examination of the skin and the lesion with a magnifying glass, palpation, poskablivanii (grattazh),
symptom vitropressii (diascopy) is used to determine vascular pyaten.Pri pressing the cover glass on the
vascular spot, stain fades caused by compression of blood vessels, and appears again after cessation of
pressure
Also uses special laboratory methods for diagnosis. , Histological analysis, identification of allergic
reactions with skin tests, specific blood tests it.d, immunodiagnostics.
, Monomorphic lesions are composed of elements of the same kind on the skin at the time of inspection;
Polymorphism rash means there are several types of primary or secondary cells in the skin at the time
osmotra.Razlichayut: true polymorphism (required the presence of two or more types of primary cells)
and false polymorphism (primary element there is only one species, and the remaining elements are the
result of the evolution of the primary element.)
Examples of true and false polymorphism: - true polymorphism - spot papule, blister, bubble,
bubble, erosion, crust, secondary spots (with Duhring dermatitis) - false polymorphism: blisters,
erosions, crusts, secondary spots (with pemphigus)
Primary elements in the evolution can be converted to the following: spot - leaves no trace; bubble erosion, crusts (serous), secondary pigmentation (unstable) bubble - the same thing; abscess - erosion or
ulcer, purulent crust, secondary pigmentation or superficial scar, blister - leaves no trace; knot - peeling,
secondary pigmentation, bump and assembly - ulcer, scar atrophy, scarring.
Secondary cells and their characteristics
Chromatosis violation skin pigmentation after resolution previchnyh elements 0papuly, bubbles,
bubbles, gnoynichkiit.d.).Species-and hypo-pigmentation or depigmentation.Cheschuyka-rejects horny
cells epidermisarazlichnogo color (blestyashego, whitish, brownish-yellow, gray and black). Distinguish
pityriasis, krupnoplastinchatye, as layers, asbestovidnye, as a collar, folded, with the presence of
plotnosidyachie spines.
Cork-product drying fluid. Distinguish serous, purulent, bloody, thin, flat, thick layered Crack-linear skin
defect due to loss of its elasticity or inflammation. Often formed in areas of maximum rstyazheniya skin.
Distinguish surface-within the epidermis, deep within the dermis.
Excoriation excoriation = violation of skin integrity as a result of mechanical damage, scratching or
artificial exposure with various objects, patomimiya Distinguish superficial and deep, circular, linear,
strip-shaped.
Erosion, defective skin within the epidermis or partially papillary dermis. Repeats the shape and size of
the previous item
Ulcer-deep skin defect, affecting the epidermis, dermis, and nerdko and underlying tissues.Heals scar.
Coarse-fibered connective scar-proliferation, the replacement of deep defects of the skin, no hair
follicles, sebaceous and sweat glands vessels, elastic fibers. Vegetation-vorsinchatopodobnye or
keratoticheskieobrpzovaniya, delved resulting proliferation of papillae of the skin, thickening of the
epidermis thorny.
Lichenification, thickening, thickening of the skin with increased her figure, a rough surface (view
shagreen) through prolonged raschesyvayaniya favorite sites