ANATOMY OF SKIN

LAYERS OF SKIN:

1. Epidermis
- Made of: closesly packed epithelial cells
2. Dermis
- Made of: dense, irregular connective tissue
- Consist of: blood vessels, hair follicles, sweat glands, etc
3. Hypodermis
- Made of: loose connective tissue, fatty tissue

FUNCTION OF SKIN

- Protection
o Abrasion
o Infection
o UV light
o Dehydration
- Thermal regulation
o Insulation (fat keeps us warm)
o Cooling (sweating cools us down)
- Sensory reception
- Vit D production
o Vit D diproduksi di dermis stlh exposure to sunlight
- Communication (raised eyebrow)

HISTOLOGY OF SKIN

EPIDERMIS

 Karakteristik:
o Tebal antara 0,4 – 1,5 mm
 Cells of epidermis:
o Keratinocyte (90%) – waterproof & protect skin, nails, stratum corneum
 Collumnar cells derived from ectoderm
 Produce protein (keratin), lipids, inflammatory cytokines
 Express adhesion molecules & attached to surrounding cells by desmosomes
 Dividing cells dgn 19-day cycle
 Tersusun atas stratum2 itu semuahhh
o Melanocyte (8%) – produksi melanin; lokasi diantara sel keratinocyte
 Dendritic cells with clear cytoplasm & small dark-staining nuclei
 Produksi melanin dgn: oxidation of amino acid tyrosine  polymerization
 Melanogenesis (proses pembentukan melanin): terjadi stlh exposure thd UV radiation
 Fungsi melanin: protect epidermis & dermis from UV radiation
 Granule melanin migrasi & transfer ke keratinocyte (dendritic process allow transfer of melanin to
adjacent keratinocytes by pinocytosis), trs akumulasi diatas keratinocyte nucleus di germinativum dan
spinosum of epidermis cell: akumulasi granule melanin inilah yg akan protect from UV radiation
 3 types:
  Eumelanin (most common) – black brown
 Pheomelanin – red color
 Neuromelanin
o Merkel cells/discs
 slow mechanoreceptors = receptors for light touch
 paling byk di: palms & soles
o Langerhans cells – immunological defense; lokasi diantara sel keratinocyte

 Function: utk protective & defensive function

o Permeability barrier
 Memperlambat water loss dr body from evaporation utk maintain homeostasis
o Mechanical barrier
 Invasi mikroorganisme & toxic chemical yg mau masuk body
o Antimicrobial peptides
 Delivered to the SC intercellular domains via secretion of lamellar body content
o Immunologic function
 Langerhans cells – antigen-presenting cell of the skin
 Participate in contact allergy
o Protection fr UV light
 Via pigment system – melanocyte produce melanosome (pigment granules), contain dark pigment yg provide
skin color
o Skin barrier & pH
 pH 5.4 – 5.9 (acid mantle)
 Guna nya utk: cutaneous antimicrobial defense & a barrier againts permeability
 Layers of Epidermis:
o Stratum corneum
o Stratum lucidum (only in thick skin)
o Stratum granulosum (keratinocyte dgn dark keratohyalline granules)
o Stratum spinosum (keratinocyte, langerhans cells, desmosomes)
o Stratum basale
SG + SS + SB: stratum Malpighi
  Stratum corneum (SC)
o Many sublayer (multi-layer tissue) of flat, keratinocyte mati called: corneocyte or squames
o Tertanam didlm intercellular lipid matrix
o Primary barrier againts pathogen entry
o Regulation of water loss from body
o Protect skin againts abrasion
o Secara terus2an shed & replaced by cells from deeper strata
o Constant friction  callus
o Surrounded by: multiple planar lamellae sheets, (byk bgt) ceramides, cholesterol, free fatty acids (FFA)
 Ceramides:
 Lipid component utk lamellar arangement
 Composed of: polyunsaturated fatty acids and spingosines
 Highly hydrophobic lipids inhibit the outward movement of water
*Desomosome: intercellular junction yg nempelin between cells
o SC desomosome composed by: glycoproteins, sometimes called: corneoesmosomes
o Desomosome joining corneocytes: corneodesmosine
o Korneocyte dari stratum basale  corneum: butuh waktu 14 hari
o Korneocyte lepas dari epidermis (shedding)  14 hari
 Stratum lucidum
o Cuma ada pada bagian kulit yang tebal (kulit di fingertips, palms, soles)
o Composed of: a few rows of corneocyte (dead keratinocyte)
o Protection from UV radiation
 Stratum granulosum
o Consist of: keratinocyte, and
o Tonofilaments, contain:
 Keratohyaline granules (help pembentukan cornified cell envelop/CCE)  memulai program kematian
keratinocyte
 Mengandung: profilagrin (utk kelembapan & saring UV light) & Loricin
 Lamellated granules (contain waterproofing glycolipid)
 Stratum spinosum (spiny layer)
o 8-10 layers of keratinocyte yg berbentuk poligonal; uk keratinocyte SS > uk k SB
o Keratinocyte SS  bentuk lamellar granules (LG)
 Terdiri dari: protein & lipid
 Berperan dalam pembentukan sawar lipid pada stratum korneum
o “spiny” appearance due to thick bundles of intermediate filaments (tonofilament)
o Contain: star-shaped Langerhans cells – berperan menyajikan antigen (penting dalam pertahanan imunologik)
 Stratum basale/Stratum germinativum (deepest layer)
o Cells actively devide, continuous cell division occurs which produces all other layers
o Contain:
 Keratinocyte
 berbentuk toraks berjajar diatas basal membrane zone/BMZ
 bs berdiri kokoh diatas BMZ krn ada hemidesmosom (ptg: BPAg & Integrin)  gangguan pd
hemidesmosom: kulit ga bs nahan trauma mekanik (cth penyakit: pemfigoid bulosa)
 Sel Punca (stem cell)
 Lamat belah diri, aktif saat terjadi kerusakan luas epidermis yg butuh regenerasi cpt
 Transient amplifying cells (TAC) – subpopulasi terbesar
 Aktif mitosis
 Stlh bbrp kali aktif membelah, dia pindah ke lapisan diatas stratum basalis (suprabasal) = sel pasca
mitosis
 Sel pascamitosis (post-mitotic cells)
 Merkel cell (sbg mechanoreceptors: sensory nerve ending)
 Melanocyte (secrete pigmen melanin - yg ngasih warna kulit)

DERMIS

 Karakteristik:
o Terbentuk dari connective tissue, containing collagen & elastic fibers
o Structure provides strength, extensibility (kemampuan utk stretch), elasticity (kemampuan kulit utk balik ke bentuk
semula)
o Many capillaries & many nerve endings (major blood vessels: at hypodermis)
 Contain 2 layers:
o The thin outer papillary region/layer
 consist of:
 Areolar connective tissue, containing: thin collagen & elastic fiber
  Dermal papillae: small projection of blood vessel ke epidermis (utk kasih supply ke epidermis); also
form fingerprints
 Corpuscles of touch and free nerve endings
 Function:
 Provide nutrients for epidermis utk produce keratinocyte
o Nutrient supply & temp regulation occur krn ada blood vessels in this layer: sekalian utk
remove cellular waste products (melalui ginjal) & kill skin cells contain waste products
 Pink tint of the skin: due to dilation of this blood vessels
o The deeper thick reticular region/layer, consist of:
 Dense irregular connective tissue, containing: collagen & elastic fibers adipose cells (utk strengthen the skin &
elasticity)
 Hair follicles
 Nerves
 Sebaceous (oil) gland
 Secrete sebum: bantu utk lubrikasi & mencegah kulit jadi terlalu kering
 Sudoriferous (sweat) gland
*Striae (stretch marks) – bs appear kalo skin stretched too much

 Somatic (sensory) receptor in dermis, dibagi 2:

o Free/unencapsulated nerve endings
o Encapsulated nerve endings – consist of 1/more neural and fibers enclosed in connective tissue

HYPODERMIS/SUBKUTIS

 Lapisan yg paling dalam

 Contain:
o lamellated (pacinian) corpuscles (detects external pressure applied to skin)
o many collagen
o adipose tissue/fat
 utk attach dermis ke underlying tissue
 prevensi tubuh kt spy ga kedinginan
 sbg energy source

EFLORESENSI KULIT (LESI KULIT)

DIBAGI MENJADI:

- PRIMER : lesi kulit awal

- SEKUNDER : lesi kulit yg sudah mengalami perubahan krn wktu/faktor eksternal
- KHUSUS : specific utk skin dz
JENIS LESI:

1. MENINGKAT (RAISED)

Papula Solid, kecil, nonjol, < 0.5 cm, colour varies.

(seen better)*
Kalo ada yg bersisik (scaling): Papulla
squamous lesion
Plak (plaque) Nonjol, berisi infiltrat, luas, bersisik, diameter
≥ 2 cm
(bercak timbul/beruntus yg bergabung)*

Nodul Dilapisi epidermis, solid round, biasanya > 1

cm diameter (felt better)*
Kalo < 1cm: Nodulus

Kista Dilapisi fibrous tissue (kapsul), solid round,

berisi cairan

Urtika (Wheal) Ekstravasasi plasma/pembuluh darah,

muncul hanya 1-2mnt to hours (depend).
(kyk digigit nyamuk gitu)*

Sikatriks (Scar/bekas Hyper/hypopigmentation; atrofi/hypertrofi

luka/jaringan parut) (e.g keloid)
(kyk daging lbh)*

Komedo Open (hitam), close (raised)

Why? Folikel rambut  lubang membesar 
lemak teroksidasi o/ udara  kelenjar jd
wrna hitam

Horn Lesi hiperkeratotik/hiperkeratosis

(epidermis menebal/mengeras)

Calcinosis Lesi berwarna putih krn penumpukan

kalsium berlebih

2. MENURUN (DEPRESSED)

Erosi (lecet) Lesi kulit sebatas epidermis

Loss of epidermis superficial
(part/all), tidak melebihi stratum
basalis

Ekskoriasi Lesi kulit sebatas dermis/mencapai

stratum papilare, menimbulkan bintik
kemerahan, mengeluarkan serum +
darah
 Ulkus (borok) Lesi kulit lbh dlm dr dermis

Atrofi Sel-sel nya mengecil

(kyk kulit mengkerut)*

Poikiloderma Gabungan dari: Atrofi, telangiektasia

(muncul blood vessels halus),
pigmentary change

Sinus Deep supurative/ bolong yg

disambung bolong (kyk terowongan)
Burrow (terowongan) Terowongan tp buntu (e.g scabies 
tunnel excavated by parasites)

Striae Perubahan struktur kolagen

mendadak (kyk org mendadak
obesitas/hamil)
(stretch mark)*

Sklerosis Pengerasan dermis/dermal fibrosis

3. DATAR (FLAT)

Makula (bercak) Perubahan warna tok, biasa dilapisi

sisik (macula squamosa), < 0.5 cm

Patch (bercak) Perubahan warna kulit

Macula > 0.5 cm (e.g vitiligo)
Erythema Kemerahan kulit krn kapiler
(reversible)  kalo diteken hilang

Erythroderma Erythema yg bnr2 luas sampe 1 badan

Purpura Kemerahan  kalo diteken ga hilang

4. SURFACE CHANGES

Skuama (scale) Scaling of skin/bersisik

Stratum korneum yg terlepas
Krusta (crust/keropeng) Cairan tubuh yg mengering (hardened
deposit)
Fissura (kulit pecah2) Keretakan kulit krn tarikan jaringan
disekitarnya
Likenifikasi Penebalan kulit disertai relief kulit
yang makin jelas menyerupai kulit
pohon; perubahan kolagen pd dermis
superficial krn garukan berulang
Keratoderma Penebalan yg biasa di telapak
kaki/tangan, biasa warna kuning
Eschar Warna hitam (skin necrosis)
(e.g Anthrax)
 5. FLUID-FILLED (TERISI CAIRAN)

Vesikel <0.5 cm, berisi pus/darah/serum

Bula (blister) >0.5 cm, berisi pus/darah/serum
Pustul Circumscribed lesion isinya pus
Furuncle Peradangan & nekrosis di folikel
Carbuncle Furuncle yg banyak (>1)
Abses Kantong yg isi pus/pustule yg besar

6. VASCULAR

Purpura Ekstravasasi RBC ke cutaneous vessel

Infarct Pembuluh darah mati
Telangiektasia Persistent dilatation of kapiler
(irreversible)

BENTUK LESI:

1. ANULAR : pinggiran meradang, tengahnya mereda (central healing) – e.g Tinea

2. DISKOID : bulet merah merata
3. ASINAR : crescent shaped
4. POLISIKLIK : kyk anular tp bergabung
5. HERPETIFORMIS : bulet2 menyerupai pulau2 (grouped)
6. LINEAR : lesi garis lurus
7. RETIKULAR : kyk jala ikan
8. SERPIGINOSA : lesi kulit spt ular – e.g cutaneous larva migrans

DISTRIBUSI & LOKALISASI LESI:

1. DERMATOMAL : segaris dermatom

2. INTERTRIGINOSA : skin folds
3. UNIVERSAL : seluruh badan >50%-90%
4. GENERALIS : seluruh badan <50%
5. UNILATERAL
6. BILATERAL
7. REGIONAL : mengenai bbrp regio (e.g muka + tangan)
8. LOKALIS : terbatas pada 1 regio (e.g hidung saja)
9. KONFLUENS : ≥2 lesi bergabung
10. DISKRET : terpisah

UKURAN LESI:

1. Miliar : kepala jarum pentul

2. Lentikular : biji jagung
3. Numular : uang logam
4. Plakat : >dari numular

STATUS DERMATOLOGI

Jumlah: soliter/multiple

Penyebaran

Bentuk: reguler/ireguler

Ukuran:

Batas: sirkumskrip/difus

Elevasi: timbul/tdk timbul

Sifat: basah/kering

ANAMNESIS DERMATOLOGY

- Past history: general, past skin problems, allergic history

- Fam history: infectious, genetic
 - Occupational & hobbies
- Therpy, skin care, cosmetic used

HAND & FOOT ECZEMA (DYSHIDROTIC ECZEMA)

DEFINISI: blisters develop di telapak kaki/tangan, biasanya gatal, terisi cairan, last 2-4 weeks, may be related to seasonal allergies/stress

CAUSES: unknown, may be related to seasonal allergies, such as hay fever

DIANOSIS: PF, Skin biopsy, Allergy skin testing

TREAT:

- corticosteroid cream/ointment (mild outbreak)

- topical steroid/steroid injection (severe outbreak)
- kompres air dingin 15 min a time, 2-4x/day  reduce discomfort and itchy
- apply moisturizer
- dont scratch

PATCH TEST o Vesicles

o Bullous/ulcerative reaction
- Test utk cari tau penyebab alergi pd kulit, biasanya
- ++: Strong positive reaction
dermatitis kontak alergik
o Erythema
- Test dilakukan ketika keadaan kulit sudah tenang,
o Papule
pasien bebas obat antihistamine, kortikosteroid
o Infiltration
oral dan topikal >2 minggu
o Discrete vesicles
- Uji kulit: pake berbagai macam alergen trs pake fin
- +: Weak positive reaction
chamber (tmpt utk hold alergen nempel ke
o Erythema
kulitnya), ditempelin di punggung dan ditutup dgn
o Papule
plester  dibuka dan dibaca hasilnya pd jam 24,
48, 72 dan 96 o Irritation
- ?+: Doubtful reaction
Interpretation: (Reading plate for IQ Ultra/IQ Ultimate) o Faint macular
o Homogenous erythema
- IR: Irritant reaction
o No infiltration
o Descrete patchy erythema w/o infiltration
- +++: Extreme positive reaction

POTENCY TOPICAL STEROID

CLASS DRUG

I Betamethasone dipropionate 0.05% ointment

Clobetasol propionate 0.05% cream or ointment or foam

 Diflorasone diacetate 0.05% ointment

Halobetasol propionate 0.05% cream or ointment

II Amcinonide 0.1% ointment

Betamethasone dipropionate 0.05% cream

Betamethasone dipropionate 0.05% ointment

Desoximetasone 0.25% cream, 0.05% gel, 0.25% ointment

Diflorasone diacetate 0.05% ointment

Fluocinonide 0.05% cream, gel, ointment, or solution

Halcinonide 0.1% cream

Mometasone furoate 0.1% ointment

III Amcinonide 0.1% cream or lotion

Betamethasone dipropionate 0.05% cream

Betamethasone dipropionate 0.05% lotion

Betamethasone valerate 0.1% ointment

Desoximetasone 0.05% cream

Diflorasone diacetate 0.05% cream

Fluocinonide cream 0.05%

Fluticasone propionate 0.005% ointment

Halcinonide 0.1% ointment or solution

Triamcinolone acetonide 0.1% ointment

IV Fluocinolone acetonide 0.025% ointment

Flurandrenolide 0.05% ointment

Mometasone furoate 0.1% cream or lotion

Triamcinolone acetonide 0.1% cream or ointment

V Betamethasone valerate 0.1% cream

Desonide 0.05% ointment

Fluocinolone acetonide 0.025% cream

Flurandrenolide 0.05% cream
 Fluticasone propionate 0.05% cream

Hydrocortisone butyrate 0.1% cream, ointment, or solution

Hydrocortisone valerate 0.2% cream or ointment

Triamcinolone acetonide 0.1% lotion or 0.025% ointment

VI Alclometasone dipropionate 0.05% cream or ointment

Betamethasone valerate 0.1% lotion

Desonide 0.05% cream

Flumethasone pivalate 0.03% cream

Fluocinolone acetonide 0.01% cream or solution

Triamcinolone acetonide 0.1% cream

Triamcinolone acetonide 0.025% cream or lotion

VII Hydrocortisone 1% or 2.5% cream, 1% or 2.5% lotion, 1% or 2.5% ointment

Hydrocortisone acetate (1% or 2.5% cream, 1% or 2.5% lotion, 1% or 2.5% ointment) and pramoxine hydrochloride 1%

*Class I is the most potent, and class VII is the least potent. Potency depends on many factors, including the drug’s characteristics and
concentration and the base in which it is used.

PRINSIP DERMATOTERAPI

1. Cleansing agent
- Sabun, detergen, solvents, water
- Remove: crust dan scales (pada psoriasis, eczema, other dermatitis)
2. Anti-infective agent/Anti-microbials
- Antibiotic
o Clindamycin, erythromycin – primary treat utk acne vulgaris (kalo gamau oral)
o Topical metronidazole, topical sulfacetamide, clindamycin, erythromycin – rosacea
o Mupirocin – staphylococcus aureus, streptococci, impetigo
- Antifungal
o To treat candidiasis, dermatophytoses, other fungal infections
- Insecticide
o E.g permethrin, malathion
o To treat lice/kutu
- Non-specific antiseptic agents
o E.g iodine solutions (e.g povidon iodine, clioquinol)  indicated for presurgical skin preparation
o gentian violet  stable antiseptic/antimicrobial
o silver preparation (e.g silver nitrate, silver sulfadiazine)  treat burns, ulcers, strong antimicrobial properties
3. Anti-inflammatory agent (topical)
- Corticosteroid
o Treatment utk non-infectious inflammatory dermatoses
o Lotion  daerah intertriginous (daerah lipetan yg sering ada friction); muka
o Gels  scalp; contact dermatitis
o Creams  daerah intertriginous; muka; inflammatory dermatoses
o Ointments  dry scaly areas
o Corticosteroid-impregnated tape  to protect area from excoriation; increase corticosteroid absorbtion
Durasi pemakaian: biasanya applied 2-3x/day (kalo high potency – 1x/day)
Komplikasi:
 o skin atrophy, striae, acneiform eruptions, fungal growth (jika pemakaian >1 bulan) – face, axilla, genitals lbh
problematic.
o High-potency may cause adrenal suppresion when used in children
- Non-corticosteroid
o Consist of: Tar  indicated for psoriasis
o Side effect: iritasi, folliculitis, staining of clothes & furniture, photosensitization
o Kontraindikasi: infected skin
4. Astringents
- Drying agents that precipitate protein & shrink & contract the skin
- E.g aluminium acetate (burrow solution)
- Used to treat: eczema, exudative skin lesion, ulcers
5. Drying agent & super-absorbent powders
- Utk prevent skin terlalu moist  krn bs iritasi dan luka
- To reduce friction by absorbing moisture
- Contain/use: cornstarch, talc in babypowder
6. Moisturizing agents
- Restore water and oils to the skin – help maintain skin hydration
- Contain: glycerin, mineral oil, petrolium
- Available in: lotions, creams, ointments, bath oil
- Most effective applied to skin yg udh moistened (e.g abis mandi)
7. Keratolytics
- Soften dan exfoliation of epidermal cells
- E.g 3-6% salicylic acid & urea (utk: plantar keratoderma, ichthyosis)
- Used to treat: psoriasis, seborrhoic dermatitis, acne, warts
- Side effect: burning, systemic toxicity (large areas covered)
- Harus dihindari dari children dan infants
8. Antipruritics
- E.g doxepin (utk: atopic dermatitis, nummular dermatitis, michen simplex chronicus dermatitis)
- Prefered topical antipruritics drpd systemic drugs/oral – kalo yg kena small surface

ATOPIC DERMATITIS CRITERIA