Disorders of the Skin and Subcutaneous Tissues
Disorders of the Skin and Subcutaneous Tissues Aug. 26, 20091.BasicsText: Harrison’s: Chapter 52OBJECTIVES:The student should be able to:Describe the structure and function of the skin.Protection against microorganismsUV raysFluid lossMechanical stressSensoryTemperature regulationVit D production2.Skin LesionsOBJECTIVES:The student should be able to:Recognize and differentiate the morphology of the following primary skin lesions:Macule- flat lesion that is typified by change in color example: freckle (ephelid)Papule- raised lesion <5mm (solid) example: white headPlaque- raised w/ flat plateau like surface example: psoriasisNodule- round lesion >5mm (larger papule)Nodular Tumor MassSolid raised >5cmConvalescence of many nodules Pustule- raised lesion that has puss- not necessarily infection5229225236855Vesicle- raised lesion that has fluid, <5mm- NOT PUSS---example: allergic contact dermatitis (poision ivy)Wheal- redish, edematous papule or plaque- normally short lived vasodilatation or penetrability—changes quickly, last only 24-48 ina defined area.Bulla- raised lesion that has fluid, >5mm (big vesicle)Cyst- Soft, raised, encapsulated lesion filled with semisolid or liquid contentsSebacaeous CystBlockage of follicular canal with sebumCan see a hole where the canal should is Test- white puss can be squeezed outTumor- Telangiectasia- dilated superficial blood vessel—Test- blanch when tested with diascopyRecognize and differentiate the morphology of secondary skin lesions:Scale- Excessive build up of stratum corniumErosion- loss of epidermis, no harm to dermisUlcer- loss of epidermis and dermis, results in a scarFissure- crack in skin or ulcer in mucous membraneCrust- Dried exudate of body fluid (yellow= serous, red=blood)Erythema- Excoriation- linear or angular lesion caused by scratchingAtrophy- An acquired loss of substance. In the skin, this may appear as a depression with intact epidermis or as sites of shiny, delicate, wrinkled lesions (epidermal atrophy) Scar- change in skin secondary to traumaEdema- fluid buildup under skinHyperpigmentationHypopigmentationDepigmentationLichenification- thickening of the skin, makes well defined skin wrinklesHyperkeratosis- Hypertrophy of the horny layer of the skin, usually associated with hypertrophy of the granular and prickle-cell layers Identify information that should be obtained in all dermatological histories.3. Dermatologic TherapyText: OBJECTIVES:The student should be able to:Utilize eight guidelines that should be considered when selecting therapy for patientsKISSHave pt. RepeatGive written instructionsTopicals, how often, where & how muchPrescribe enoughIf chronic, refillsPregnant?Warn of adverse reactions“if its dry wet it, if its wet, dry it”.Identify indications for each of the following:Lotions and Creams (for dryness)Restore water and lipids to epidermisCreams more lubricatingCreams most useful for intertriginous (areas that rub together) area (groin, rectal area, axilla) and scalpApply to wet skinPreparations that contain urea (Carmol), or lactic acid are most effectiveMenthol and phenol added to keep itching (purities) downGelsAre greaseless mixtures of propylene glycol and water, some contain alcoholUseful for acute exudative inflammation (poison ivy, scalp areas) Ointments (dry lesions)Penetration better than creamsGrease with little waterWet dressingsBest for exudative inflammatory diseasesWet compresses suppress inflammation and debride crust and serumRepeated cycles of wetting and drying make lesion dryOnce lesion is dry, switch to emollient creams and lotions Identify indications for topical, intralesional and systemic ICALPsoriasis, hand eczema Group 1* Not on face, axilla, groin, under breastLimit use to 14 day Atopic dermatitis (adult) Group 2 &3Not on face, axilla, groin or under breastLimit use to 21 daysAtopic dermatitis (children) Groups 4&5Limit use to 7-21days and intertriginous areasEyelid and diaper dermatitis Groups 6&7Reevaluate if no response in 28days INTRALESIONALIndicated for nodulocystic (cystic acne) and large pustular lesions, alopecia areata, keloids May be given at full strength or mixed with saline or xylocaine (more painful)May cause atrophy*, local reactions, systemic absorption, hypopigmentations, telangiectasia, and sterile abscess Identify contraindications and complications to systemic Produces antiinflammatory responseIndicated when topical are unsuccessfulAdverse effects include suppression of hypothalamic-pituitary-adrenal axis (HPA) and Cushing’s syndrome4.Diagnostic Procedures Text:OBJECTIVESThe student should be able to:Describe indications and positive findings associated with the following diagnostic procedures:Potassium Hydroxide Prep (KOH)Consider when scaling fungal lesion is suspectedDissolves keratin allowing visualization of fungal elements: hyphae, budding yeastFungal Culture4714875124460Indicated for hair and nail infectionsUtilize cotton swab technique* Scabies TestTouch lesion with blue or black felt-tip pinWait a few minutes for ink to dryWipe of ink with alcohol padBurrow are highlighted as a dark lineScrape away with a curved #15 scapel blade and transferred to glass microscope slide-619125131445Tzanck SmearFor herpesvirus or varicella zoster virus infections5505450340360Base of vesicular lesion is scraped and placed on slide, air-dried, and stained with Giemsa or Wright’s stain+ multinucleated epithelia giant cellsWood’s Lamp ExaminationPerform in a dark roomErythrasma-coral pink (corynebacterium m.)Pseudomonas-pale blueTinea capitis secondary to dermatophytes-pale green to yellow Curettage and ElectrodesiccationShave BiopsyPunch BiopsySnip ExcisionCryosurgeryAug 28, 20095.Tumors of the Skin Text: Harrison’s Chapter 83A. Benign NeoplasmOBJECTIVES:Regarding the following, the student should be able to:1.Describe and identify.2.Establish a diagnosis.3.Indicate the prognosis.4.Establish a treatment plan.a.Acrochordon (Skin Tag)b.Callus/Chavusc.Cherry angiomasd.Nevuse.Seborrheic Keratosisf.Solar LentigoB.Premalignant and Malignant NeoplasmsOBJECTIVES:The student should be able to:1.Describe and identify the following.2.Recognize the diagnostic and therapeutic challenges associated with each.a.Actinic Keratosisb.Keratoacanthomac.Melanomad.Basal Cell CarcinomaSquamous Cell Carcinoma3.The student should relate risk factors as genetic influence and the inherent dangers of sun exposure and tanning booths.Aug.31, 20097. Infections of the SkinText: Harrison’s Chapter 53A.Viral Diseases OBJECTIVESRegarding the following, the student should be able to:Recognize and define the pathogenesis.Establish the diagnosis.Assess and individualize the treatment.-504825159385Erythema Infectiosum/5ths disease/ slapped cheekRed FlagsProdrome of flu-like symptoms followed by “slapped cheek” appearance 2 days later. Few days later reticulated erythematous rash on trunk, lasting about 1 week.Can recur for weeks to monthsEtiologyParvo B-19Peaks at ages 5-14DiagnosisPV B19 IgG, IgM, clinical appearanceTreatmentSymptomaticADULTpruitus, arthopathy, fever, rash and adenopathy hydrops fetalis RBC aplastic crisis-504825130810HerpanginaRed FlagsGray/White Papulovesicles with erythematous ring that ulcerate. Commonly on tonsillar fauces, palate.EtiologyCoxsackievirus, Enteroviruses, echovirusDiagnosisAssociated with fever, HA, cervical LAD, sore throat49530007620Treatmentsymptomatic, usually lasts 4 – 6 days HAND FOOT AND MOUTH DISEASE- coxsackie Herpes Simplex (type 1)Red Flags-63817579375HSV 1 “cold sore” “fever blister”Primary gingivostomatitis Children and young adults (only seen about 1%)Fever, sore throat, painful (burning) vesicles in oral mucosaSeropositive 85 – 90%; 1/3 symptomatic Recurrent Herpes Labialis Grouped vesicles on an erythematous baseVirus dormant in trigeminal ganglia until reactivatedLifetime infection-58102517780EtiologyHSV 1DiagnosisAPPEARANCETzanck smearsIgG antibody titercultureTreatmentSymptomaticOral meds:Acyclovir - 200 mgm 7-10 dayValacyclovir – 1 Gm BID x 10 daysFamcyclovir – 250 mgm TID x 5 daysTopical: Denavir as effectiveHerpes Zoster- Shingles-676275106680Red Flags- Red rash w./ papules on dermatome. Doesn’t break midline (normally)EtiologyHerpesvirus varicellae (reactivated in system)Diagnosisclinical, PCR, Biopsy, Culture, Tzanck smearTreatmentantiviralsHerepes Simplex (Type 2)Red Flags- cold sore on the ex organs Etiology-628650-590550Diagnosis: clinical, PCR, Biopsy, Culture, Tzanck smearTreatment: Antiviral: Valtrex, acyclovir, famcylcovir TreatmentAntiviral: Valtrex, acyclovir, famcylcovir -628650199390Roseola Infantum (6ths disease, 3 day fever)Red Flags- 3day of high fevers then as fever falls get morbilliform rash6 – 36 month old child)EtiologyHHV-6DiagnosisclinicalTreatmentSymptomatic, antipyretics Varicella- chicken poxRed Flags- -73342595885“Dew on a red rose petal” (red patche with raised vesicle in center…several)pruritus, fever, HA, malaiseEtiologyHerpesvirus varicellaeDiagnosislesions at different stages spreads centripetally, culture, Tzanck smearTreatmentAcyclovir for adults or immunocomprised, cool compresses, Sarna lotionVerrucaRed Flags-628650167640Hyperkeratotic papules with black dotsEtiologySpread: by touch, sites of trauma Human Papillomavirus, HPVVerruca Vulgaris – common warts HPV-2Verruca Plantaris – Plantar warts HPV-1Verruca Plana – Flat wars HPV-3Condyloma Acuminata – HPV 6, 11, 16, 18DiagnosisClinical or biopsyTreatmentCryotherapy, Salicylic acid, excision, lasers, podophyllin, cantharidin, Candida antigen, praying, aldara etc.Viral exanthemaRed Flags- non specific viral rashEtiologyDiagnosisTreatmentB. Bacterial DiseasesText:OBJECTIVESRegarding the following, the student should be able to:Recognize and define the pathogenesis.Establish the diagnosis.Identify genetic factorsAssess and individualize the treatment.ImpetigoRed Flags-Contagious, acute, purulent (honey colored drainage) infection of the skin.EtiologyNon-bullous (crusted) - Group A Beta-hemolytic Strep +/- Staph442912589535Bullous - Staph aureus DiagnosisAppearance: vesicles > pustules > crustingCulture: not recommendedTreatmentSystemic- Dicloxicillin or cephalosporinTopical - (Bactroban)Soaks- for debridementErysipelasRed FlagsSharply demarcated erythema possible plaques and edema, usually on face or extremities4295775-876300EtiologyGroup A Beta Hemolytic Strep.Diagnosisappearance, poss culture: group A strepTreatmentantibiotics, oral or IV Folliculitis, etcRed Flagsinfection of the hair follicles- mistaken for spider bitesPustule Furuncleacute tender fluctuant deep seated noduleCarbunclemultiple coalescent furuncles with multiple draining sinusesCommon on buttocks, back of neck, beard, back and chest-76200049530Etiology- Staphylococcus aureus Predisposing Factors-topical steroids, injury, abrasion or surgical woundDiagnosisCulture/apperanceTreatmentIncision and Drainage + antibiotics, culture, warm compressesAcne vulgarisRed Flags- acne-yeahEtiologyProliferation of propionbacterium acnes (P. acnes) in follicles-76200061595Hypertrophy of sebaceous gland and increased sebum (androgen) blocks the pilosebaceous units causing inflammation and rupture of the follicleDiagnosisMild: papules few, more pustules, no nodulesModerate: many papules and pustules, few nodulesSevere: several papules, pustules and nodules TreatmentTopical benzoyl peroxide, 5-10%, dailyTopical tretinoin - reverses the abnormal keratinization, 2-3 weeksTopical antibiotics - Erythromycin or Clindamycin Accutane - systemic Vit A C. Superficial Fungal DiseasesText: OBJECTIVESRegarding the following, the student should be able to:1.Recognize and define the pathogenesis.2.Establish the diagnosis.3.Assess and individualize the treatment.a.Tinea –RING WORMTinea capitis – scalpTinea corporis – bodyTinea cruris – groinTinea manus – handTinea pedis – feetTinea unguium Onychomycosis – nailCapitisRed Flags- Alopecia with “black dots”. Erythema and scaling in an annular configurationEtiology 3 main types of fungusTrichophyton Microsporum Epidermophyton Can be transmitted by direct contact, animal exposures, and fomites 405765095250DiagnosisKOH of hairWood’s lamp (20%)Culture (Sabouraud’s medium)Treatment Systemic antifungals CorporisRed Flags- . Annular with central clearing and well defined borders.446722591440Etiology Same as capitisDiagnosis KOH - hyphae, cultureTreatment Topical (2-3 weeks) Oral (2-4 weeks)ONYCHOMYCOSIS Red Flags Fungi toenailsEtiology3943350116840Same as capitisDiagnosis Need to make prior to treatmentKOHTreatment Treatment (oral)Griseofulvin Sporanox Lamisil ManusRed Flags- 4414520270510Usually unilateral with bilateral feet involvement (‘two feet one hand disease’) Appearance: hyperkeratotic EtiologySame as capitisDiagnosisKOH, CxTreatment may require months if nails involved PedísRed Flags- Appearance - Subclinical to severe secondary infection. Varies with species.2933699-266700 EtiologySame as capitisDiagnosis AppearanceKOHCulture Treatment TopicalOral if secondary infectedBurrow’s solution if maceratedCotton socks, sandals, powdersb.Tinea versicolor-83820083185Red Flags- patches of skin that don’t tan (SUNSPOTS)Usually on central upper trunkEtiologyYeast (superficial Malassezia)DiagnosisKOH shows spaghetti and meatballs look (budding yeast and hyphae)TreatmentSelsun blueTopical and oral Candidiasis “yeast infection”-59182034925Red FlagsErythematous papules and plaques with satellite pustules, can involve scrotumdiaper area in infantsintertrigenous (rub together spots) areas in adultsThrush- yeast infection of mucous membranes of mouthParonychia- occurs around the nails EtiologyCandida (type of yeast) -67627564770DiagnosisKOH/culture, pseudohyphaeTreatmentlocal treatment to keep area dry and topical/oral antifungalsSeptember 02, 20088. Miscellaneous Skin DisordersText:A.ArthropodsOBJECTIVES: For the following, the student should be able to:Describe the associated skin problems.Identify the etiologic agent and establish the diagnosis.Outline treatment and patient management.ScabiesRed Flags-7810505715intense pruritus worse at nightLocation - finger webs, flexor surf, genitalsEtiology Sarcoptes Scabiei (mites)DiagnosisAppearance of burrow (felt pen)scrapings with KOHOnce they start scratching hard to see burrowSecondary to scratching pin point red dots TreatmentEurax daily x 5 days, repeat 1 wkContinued pruritus after treatmentPediculosis- lice-695325130810head (capitus) - children (hats, combs, etc.)body (corporis)- unclean setting, seams of clothinggenitals (pubis) – aka crabs is sexually transmittedRed FlagsItches w/o rashEtiologylice (pediculus humanus)Diagnosisappearance, nits (eggs) , Wood’s lampTreatmentApply Nix(permethrin)cream rinse x 10 min to dry clean hair“nit comb”Repeat 1 wkTick bitesTicks are ectoparasites that act as vectors for -71437538100spirochetal, bacterial, rickettsial, parasitic infections- Lyme, RMSP, TularemiaRed Flagspresence of tick, FB reaction, macules and papulesEtiologySee aboveDiagnosispresence of tick, FB reaction, macules and papulesTreatmentremove tick< 48 hr. decrease risk prevention with tick sprayLyme Disease-8191505715NE, Wisconsin, Minnesota, CAerythema migrans- large red area, inside gets clear- “bulls eye” flu-like symptomsSerology, ElisaMost of the time this is false positive…if you suspect just treat Rx: doxycycline Can be given prophlatically if bite suspected Fire ant bites428625036195Red Flags- really itchy, pustules, inflammation Etiology- um, really, you don’t know this?DiagnosisappearanceTreatmentSteroid for bad inflammationAntihistamines for itchingSpider bitesBlack WidowRed Flags small local reactionhours later cramps due to neurotoxinEtiologyVenom of black widowDiagnosisAppearance, symptoms, and hx of exposureTreatmentIV opiods plus benzodiazepines, antivenom antiserum,PO muscle relaxant, Ice Tet tox Brown recluseRed Flags -100012599060 severe local reaction, rare systemic symptoms fever, n/v, weakness and myalgia HemolysisNecrotic ulcersEtiology BR venomDiagnosis Appearance, exposureTreatment RICE, Antihistamines, Dapsone Monitor CBC for severe bitesFlea bites-82867519685Red FlagsAround ankles usuallyMacular to bolus in apperenceitchyEtiologyAgain, really?DiagnosisAppearance and presence of pets or indignant circumstancesTreatmentRelieve itching B.Papulosquamous and Other Miscellaneous DisordersOBJECTIVES:In regards to the following, the student should be able to:Identify in terms of configuration and distribution and describe the pathophysiology.4657725-200025Establish a diagnosis.Recognize genetic risksIdentify treatment and outline a treatment plan.Atopic DermatitisRed Flagspruritic skin disorder lichenificationEtiologyUnknown, strongly familialPossibly co morbid with chronic staph DiagnosisAppearance4410075139700Family or personal historyTreatmentPimecrolimus cream Topical steroidsAntibioticsTacrolimus ointmentAntihistaminesPsychologicalOtherfamily or personal hx of hay fever, asthma, dry skin, eczemaOnset - early infancy, childhood or adolescence Contact Dermatitis Red Flags-81915040640pruritic, reactionary skin disorderIrritant nonallergic, results from chronic exposure.dryness, scaling, fissuring, and mild inflammation Allergicrequires sensitization, thus previous exposures.1 - 4 days after exposure - presentation varies, redness, bulla, pruritus, vesiculation, oozing, crusting, lichenification EtiologyExposure to irritant or allergenLong line caused by scratchingDiagnosis history, itching, localityTreatmentremovalsymptomatic - antihistamines, soothing lotions4705350-666750steroids-63817512065treat with p.o. meds in by eyesOtherExthanmatous drug eruption: ampicillin Photosensitivity drug-induced (not pictured)Bacterium, ampicillin, etcPosion Ivy LINEAR VESICLESDoes not spread by fluid in vesiclesSpreads by resin on hands, clothes, and pets 4810124125730Seborrheic Dermatitis Red FlagsGREASY, SCALY PLAQUEScommon, chronic, scaling, erythematous, eruptionEtiologyPityrosporum ovale (yeast), -8001005715Genetic environmental factorsDiagnosisAppearanceKOH…remember it can be yeastTreatment Medicated shampoos frequently (Head and Shoulders)Steroid lotions or solutionsKetoconazole cream or shampoo if resistantIF PUSTLES TREAT FOR STAPHOtherLocation - cradle cap (infants), dandruff, scalp, face, upper chest, extent varies.All ages but usually adultsPityriasis Rosea Red Flagslines of cleavage in Christmas tree distribution, 2-10 wks durationpreceded by a short lived salmon colored oval “Herald patch”481012530480311467530480EtiologyUnknown, may be viralDiagnosisChristmas tree apperanceNEGATIVE yeast on KOH TreatmentControl itching Possibly use steroids UVB photo therapyPsoriasis Red Flagschronic, recurrent, hyper proliferative disease of skin495300027940early - red macules covered with dry silvery scales-819150116204later - may coalesceEtiologyunknown - 1/3 have family history, freq follows strep pharyngitis infection in childrenDiagnosisAppearanceFamily and Personal HistoryTreatmentkeep skin moist and lubricated< 20% - topical steroid, Dovonex, coal tar preparations>20% - light therapy, antimetabolites, retinoids, stress management Avoid b-blockers, lithium and systemic steroidsOtherPresentation - joints, ext surfaces, lower back and buttocksCourse - remissions and exacerbations, freq preceded by trauma or strept inf - STRESS! Stasis DermatitisRed FlagsEarly - hyperpigmentation Late - Plaques, vesicles, bullae, cellulitis Later – Ulceration, fibrotic skinEtiologychronic venous insufficiencyPredisposing conditions: DM, obesity, familial, topical allergies4533900161925DiagnosisAppearance and history TreatmentMildElevatesupport hoseExerciseSteroid creamUlcerationDuoderm (bandage to protect wounds)unna boot (ace wrap with calamine and other healing lotions)Avoid steroid creams applied to ulcerUlcers have long healing time OtherLocation: medial malleolus VitiligoRed FlagsAcquired skin depigmentation due to lack of melanocytes 491490078105Patches of depigmented skinEtiologyUnknown, Autoimmune? Genetic?Diagnosisclinical, Woods lightTreatmentSun protection Look for assoc. diseasesAddisons DiseaseDiabetes etc dermatologistOther1% of populationGeneralized (symmetrical) and segmental (nonsymmetrical) Erythema MultiformeRed Flagstarget lesions that begin as macules and develop vesicles in the center with cyanotic centermay have fever, malaise, or itching and burning…SELF LIMITINGEtiology384810047625hypersensitivity reactiondrugs infectionsphysical agents pregnancy malignanciesDiagnosisClinically and historyTreatment1-3 wks of prednisone 40-80mg/doral acyclovir for HSV assoc. EMOtherLocation: Backs of hands, palms, soles, extensor limbs, generalized. Occur in crops for 2-3 wksStevens-Johnson SyndromeRed Flagsvesicobullous, mucosa affecting skin, mouth, eyes, and genitals-676275111760trunk, palms, solesPreced by cough, fever, and patchy changes on chest Xray Etiology504825022860severe hypersensitivity reaction following drug reactionphenytoin, phenobarbital, sulfonamides, PCNMay be variant of Erythema MultiformeDiagnosisclinical, skin biopsyTreatmentsystemic steroids?, antihistamines for itching, wet cool compresses, topical steroids for plagues and papules, antibiotics for infectionsOtherMost often in children and young adults391795062865 Urticaria- hivesRed FlagsPruritis Angioedema Lumps and bumpsEtiologyhistamine releaseImmunologic and non-immunologicalPhysical stimulationSkin contactSmall vessel vasculitis DiagnosisTreatment487680094615H1 blockers (histamine blocker)H2 blockers (histamine blocker)Doxepin SteroidsOther-35242568580DermatographiaScratching skin causes red raised line Can write name on skin Acute uticaria /angioedema Erythema Nodosum Red FlagsNodular erythematous eruption limited to extensor side of extremtitiesEtiologyHypersensitivity reaction to antigenic stimuli associated with several diseases -81915063500Infections*, immunopathies, malignancies, and drug therapiesDiagnosisHistory and clinicallyTreatmentSelf limitingHelp symptomsAntinflammatoryCool compresselevation OtherFever, malaise, arthralgia (joint pain) URI (upper respiratory tract infection) precede eruption by 1-3 wks55% are idiopathicFamilial formFemales> males6.Burns Text:3952875183515OBJECTIVE:Define first, second and third-degree burns.Superficial=1stEpidermal layer onlyDon’t blisterRed, dry, painful, blanches with pressureCause: UV, short flashHeal: 3-6 dSuperficial Partial Thickness= 2ndepidermis and the superficial (papillary layer) dermis are injuredBlisters, appear moist, red weeping, blanches with pressure2847975116839Painful to temp and airDeep Partial Thickness= 2nd drgree4295775209550All epidermal and dermal structures are destroyed including hair follicles and glandular tissueBlisters, wet or waxy dry with variable colorDoesn’t blanchPain with pressure only Full Thickness= 3rd degree burns-72390049530Extend through and destroy the dermisPainless, usuallySkin appearance is waxy white to leathery gray to charred and blackDoesn’t blanchEstimate degree of burn using (Rule of 9’s)Recognize systemic effects of burns.1. Burn shock w/in 24-48 hrs for major burnsMyocardial depressionIncreased capillary permeabilityIntravascular volume depletionTreatment: IV crystalloids such as Ringer’s lactate (LR)2. Smoke inhalationNote cough, singed hair, deep facial burn or blistering of oral pharynx, hypoxia3. Infection4. Mesenteric vasoconstrictionSeptember 04, 2009, 1:00pmOffice Dermatology Macule -> Patch (same thing just bigger >5mm)(problem is in dermal/ epidermal junction)Papule -> Plaque (cluster of papules)(problem is in dermis)Vesicle -> Bulla (same thing just bigger >5mm) Pustule (same as vesicle just filled with puss- yellowish, etc.)(Fluid in epidermis)Random TidbitsA cluster of vesicles on the face is Herpes SimplexLinear Vesicles= Poison Ivy/OakDon’t call it a vesicle until you have popped one and gotten fluid out.Always do KOH on borders of rash where fungus is still freshScaring occurs at the junction point of dermis/epidermis…SO if they have an erosion (loss of dermis) they won’t scar. If they have an ulcer (loss of derm and epiderm) they will.Panniculus= subcutaneous Crust= scabSquamous= scalePimples on chest= possible steroid reactionAsk about steroid useLichenification comes from rubbingStria= stretch marksRed are early stages and can be correctedWhite are late stages and can’t be fixed ................
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