PathoParm Exam 4: Skin Disorders

The layers of skin are: (3)

1. epidermis

2. dermis

3. subcutaneous tissue layer

The epidermis includes _____ and _____.

- keratinocytes- protein in layers of squamous epithelial cells

- melanocytes

The dermis includes _____ and ______. It also contains the _____.

- sweat glands and hair follicles

- Extra-cellular matrix (ECM)

The extra cellular matrix is located in the dermis and contains _____ that are important for tissue growth and wound healing. They are _____ and _____.

- protiens

- collagen and elastin fibers

The subcutaneous tissue layer contains ____ cells.

fat cells (adipose)

The three types of wound healing are:

1. primary intention

2. secondary intention

3. tertiary intention

Primary intention wound healing typically occurs in wounds with _____ tissue damage. Explain the healing process.

minimal

- not infected or in surgical closure

- healing is through repair and regeneration/formation of new cells; re-epithelialization

- normal tissue structure and function with minimal scarring

Secondary intention wound healing occurs in wounds with ____ _____ where there was ____ closure attempt.

- full-thickness

- no closure attempt

Explain the type of wounds seen in secondary intention wound healing and how they heal.

- wound types: larger wounds, wounds with irregular edges, large amount of exudate, bleeding, or infection

- Healing process: formation of more connective tissue that forms larger amount of granulation tissue = more scarring

Tertiary intention wound healing occurs when wound closure is ______.

delayed with INTENTION

Explain why wound closure is intentionally delayed in tertiary intention wound healing. Explain the healing process.

- Occurs when wounds are infected and need to be left open for drainage and cleaning out the infection before closing

- Center fills with granulation tissue, degree of scarring varies (wide scar)

The layer of skin that is avascular is the _____ which receives its oxygen and nutrients from ______.

- epidermis

- diffusion from the basement membrane

The three phases of wound healing are _____, _____, and _____. These phases _____.

- inflammatory phase, proliferation phase, and remodeling phase

- phases overlap

The first step in the inflammatory phase of wound healing is _____.

hemostasis

Hemostasis is....

What does it control and what happens?

What wound healing phase is this found in?

- formation of a platelet plug or fibrin-based clot

- controls hemorrhage and causes immediate vasoconstriction to prevent bleeding

- found in the first phase of wound healing: inflammatory phase

Which phase of wound healing involves hemostasis and the acute inflammatory response?

the first phase: inflammatory phase

The acute inflammatory response is found in the _____ phase of wound healing.

What happens in the acute inflammatory response?

- inflammatory phase

- recruits neutrophils and macrophages for phagocytosis (ingest bacteria) to minimize tissue damage and prevent infection

The proliferation phase of wound healing is the ______ phase.

second

What are the four things that occur in the proliferation phase?

1. proliferation of new cells

2. granulation of tissue (mass of new connective tissue forms)

3. formation of capillaries (angiogenesis)- brings oxygen/nutrients needed for repair

4. collagen is deposited- produced by fibroblasts

The _____ phase is the final phase of wound healing.

remodeling

What are the two things that occur in the remodeling phase of wound healing?

1. restore structural and functional integrity of tissue

2. granulation tissue is replaced with collagen (may not be the same of normal tissue)

What are the five factors that IMPEDE wound healing?

1. hypoxia/decreased blood flow to wound

2. wound infection

3. poor nutrition

4. medications

5. Diabetes mellitus

What is one of the most important factors that impedes wound healing? What does this lead to...

hypoxia/decreased flow of blood to wound

- leads to infection because there is decreased delivery of WBCs, immune cells, oxygen, and nutrients to the area

Wound infection prevents _____ depositing and prevents _______ in the healing process.

- prevents collagen depositing

- re-epithelialization in the healing process

Vitamin A deficiency ______ deposition of _____ and re-epithelialization.

- decreases deposition of collagen

Vitamin C deficiency _____ an adequate inflammatory process and inhibits _____ secretion by fibroblasts.

- inhibits

- collagen

______ is needed for wound healing to rebuild and repair. (poor nutrition)

Proteins

Medications that impede wound healing are ______ and ________. This leads to a higher risk for ______.

- corticosteroids and immunosuppresants (chemo)

- leads to a higher chance of infection because they suppress adequate inflammatory and immune response

Wound dehiscence occurs when....

a sutured wound separates

- high risk for infection

pressure injuries

localized ischemic lesion of the skin and underlying tissue, usually over a bony prominence caused by external pressure that impairs blood flow to the area (ischemia)

Risks factors for pressure injuries include: (3)

immobility, decreased sensation, skin status

- patients in hospitals, long term care facilities, the elderly, and quadriplegics

Explain the four stages of pressure injuries.

1. presents as erythema (redness, not blanchable)

2. partial thickness skin loss, presents as a shallow open ulcer (pink/moist wound)

3. full thickness skin loss invading subcutaneous tissue and presents as a deep crater

4. exposure of muscles, ligament, and tendons

- extensive tissue damage and necrosis

Which of the following are at risk for poor wound healing? (select all that apply)

a. 78 year old diabetic hospitalized for hip replacement

b. 48 year old receiving chemotherapy for breast cancer

c. 30 year old with a large wound from a boating accident who lay in a lake for hours before being rescued

d. malnourished 82 year old with emphysema placed on a corticosteroid

a, b, and d

What are the risk factors for skin cancer? (4)

- UV light exposure

- light or fair colored skin

- elderly

- history of skin cancer

Where does basal cell carcinoma originate?

- bottom layer of the epidermis

How does basal cell carcinoma occur?

sun exposure causes mutation to tumor suppressor genes that control skin growth

What are the clinical manifestations of basal cell carcinoma?

- sun exposed areas

- blue, brown, or black (flat, pale areas, or small, red/pink raised)

- shiny bumps that bleed easily

How does squamous cell carcinoma occur?

mutation to tumor suppressor genes that control skin cell growth (keratinocytes located in squamous cells in epidermis)

What are the clinical manifestations of squamous cell carcinoma?

- sun exposed area and non-exposed areas

- firm, can be smooth or more like a plaque, with an ulcer in the center

(non-healing sore that bleeds easily)

Where does melanoma originate?

melanocytes in the epidermis

What are the clinical manifestations of melanoma?

- sun exposed areas, but more commonly non-exposed areas (trunk and legs)

What does melanoma look like?

- moles, brown or black

- watch for changes in moles

What are the sign changes to existing moles? (ABCDE)

- A: asymmetry

- B: irregular Borders

- C: color changes/multi-colored mole

- D: diameter greater than 1/4 inch

- E: evolving moles

What is the difference between Herpes Simplex Type I vs. Type II?

Type I is infection of the lips and type II is infection of the genitals, perineum, and anus (sexually transmitted commonly)

What are the clinical manifestations of herpes? (5)

1. preliminary period when symptoms of eruption are coming: flu, fever, tingling, itching, and burning

2. eruption of painful vesicles (fluid-filled blisters)

3. skin and mucous membranes become red, swollen

4. vesicles open- painful ulcerations

5. ulcerations crust over and heal

Additional for Type II: dysuria (painful urination)

Psoriasis is a _______ inflammatory skin disease.

chronic

- due to immune trigger

In psoriasis, there is hyper proliferation of _____ and decreased cell turnover in the _____. The epidermis _____.

- keratinocytes

- dermis

- the epidermis thickens

What are the clinical manifestations of psoriasis?

- lesions (red and covered with silvery scales)

- occurs on elbows, knees, scalp, buttox, and trunk

- painful, itch, burn

40% of people with psoriasis will develop psoriatic _____ within 5-10 years of onset.

arthritis

(inflammation of the joints, esp, hands and feet)

What is the treatment for psoriasis?

- corticosteroids

- moderate oral corticosteroids

- vitamin D analogs to decrease keratinocyte hyperproliferation