DERMATOLOGY & VENEREOLOGY

dr. Sugastiasri Sumaryo, SpKK

Department of Dermatology & Venereology
Faculty of Medicine Diponegoro University

Introduction

What is dermatology ?
Dermatology may be defined as
the study of the skin and its diseases
or as the branch of science of the skin

What is venereology ?
Venereology may be defined as
the study of the genital and its diseases

The skin is of major importance in our body-image.

The psychological disturbance induced by skin problems.
Skin diseases not only cause stress or depression, but in
addition, psychological stress from other cause can
exacerbate many skin diseases.

Structure and Function of Skin

Structure of skin
The skin is composed of two distinct
components, from the surface downward:

Epidermis

Dermis

Structure and Function of

Skin

Structure of skin (continuation)

The epidermis is the thinnest component, varying in
thickness from 0.04 mm on the eyelid to 1,6 mm on
the palms; the average thickness of epidermis for most
of its expanse is 0,1 mm.
Thus on simple morphological grounds the epidermis
can be divides into 4 distinct layers:

Stratum basale
( or Stratum germinativum )
Stratum spinosum
Stratum granulosum
Stratum corneum
The term Malpighian layer includes both the basal
and spinous. Other cells resident within the
epidermis include melanocytes, Langerhans cells
and Merkel cells.

Structure of skin

(continuation)

The Dermis is bounded distally by its junction with the epidermis

and proximally by the subcutaneous fat, contributes 15 20 % of
the total weight of the human body. It varies in thickness from 1 mm
on the face to 4 mm on the back and thigh. The dermis is 15-40
times thicker than the epidermis, depending on the anatomic site.

Dermis pars papilare

Dermis pars reticulare

Structure of skin

(continuation)

The dermo-epidermal junction is one of the largest

ephithelio-mesenchymal junction in the body.
It is a highly specialized attachment between the
epidermis and the papilay dermis.
Three different types of epidermal cells:
Basal keratinocyt
Melanocyt
Merkel cells

Human skin are derived from either:

Ectoderm: epidermis, folliculo sebaceus apocrine unit,

eccrine unit, nail.
Mesoderm: melanocyt, nerves, sensory receptor, the
other elements in the skin i.e. Langerhans,
macrophage, mast cell, fibrocytes, blood v, lymph v,
muscle, adipocytes.

Structure and Function of Skin

(continuation)

Function of skin
The most obvious function of the skin are to protect the body
by preventing the lost of fluid and the penetration of
undesirable substances or radiation, and by cushioning it
against mechanical shocks.
Equal importance, is the immunological response.
A number of sensations touch, pressure, warmth, cold and
pain are perceived by the skin.
Vitamin D3 is essential for skeletal development. It is
syntesized in the skin as a result of exposure to ultraviolet B
(UVB) radiation. Vitamin D3 is formed, principally in the
stratum spinosum and the stratum basale, from the precursor
7 dehydrocholesterol.

Function of skin

(continuation)

The tissues of the skin are the target for a wide range of
chemical messengers. For example, hair follicles and
sebaceous glands are the targets for androgenic steroids
secreted by gonads and the adrenal cortex, and
melanocytes are directly influence by polypeptide hormones
of the pituitary (MSH).
Melanocytes are dendritic cells that synthezie and secrete
melanin-containing organelles called melanosome. In
human, there are 2 major classes of integumentary melanin:
Eumelanins
Pheomelanins

These melanins protected skin from UV

The nerves of the skin are part of two major systems:

Somatic

sensory
Autonomic motor

Function of skin

(continuation)

The somatic sensory system mediates the sensation of

pain, itch, temperature, light touch, pressure, vibration
and discriminative sensations of touch.
The autonomic motor nerves control cutaneous
vascular tone, pilomotor responses.

Subcutaneuos fat

Typically, the subcutaneous fat in adult shows

differences between the sexes in its gross distribution
and microscopic characteristics.
The gynoid distribution of fat in women causes
prominent curvature of breast, buttocks, hips, anterior
thighs, inner aspect of knees, lower abdomen, and
pubic region.

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Function of skin
Subcutaneuos fat

(continuation)
(continuation)

In contrast, the android distribution of fat in men leads to

deposition of adipocytes in the nape of the neck and the
deltoyid and epigastric regions.
In both sexes, certain anatomic sites have relatively little
fat, e.g. the eyelids, ear lobes, scalp, nostrils, scrotum,
penis, clitoris, and dorsa of hands and feet.
Subcutaneous fat has several functions:
deposits of fat act as shock absorbers
Protecting and supporting vital organs
Facilities
mobility of skin over structures that
underlie it.
A cosmetic role is contributed by the accentuated
distribution of fat in the sexes.

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Hair

Function of hair
Provides : - a sexually attractive ornament
- hair screen of nasal passages from irritants
Protects : - the scalp from the suns rays
Shields : - the eyes from sunlight & droplets of sweat
Help
: - to reduce friction in intertriginous areas
Contribute
: - to the perception of tactile stimuli

During the life time, a particular hair follicle may

generate all 3 types of hair:
In the scalp may initially produce a lanugo hair
Later a terminal hair
Finally, in balding, a vellus hair

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Hair
The hair structure

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Hair (continuation)

The growth of hair is cyclical as a consequence of

established cycles of hair follicles. The 3 phases in the
cycles of a follicle are:

Growing (anagen)
Involuting (catagen)
Resting (telogen)

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Sebaceous Unit

Sebaceous glands are most numerous and most

productive on the scalp and face and are largest on
the forehead, nose, and upper part of the back.

With the exception of the palms, soles, and dorsal of

the feet, sebaceous glands of various sizes are
distributes over the entire surface of the body.
Sebaceous
glands

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Apocrine Glands & Eccrine Glands

Apocrine unit in humans are found in the axillae,

areolae, periumbilical region, perineal and
circumanal areas, prepuce, scrotum, mons pubis,
labia minora, external auditory canal, and on the
eyelids.
Bacteria present in follicular infundibula and on
the skin surface act on apocrine secretion to
produce short-chain fatty acids, ammonia, and
other odorifereous subtances. An offensive body
odor may be controlled by deodorants that
contain antibacterial ingredients.
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Apocrine Glands & Eccrine Glands

Apocrine
glands

Eccrine
glands

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Nail
Nail have several functions:

To protect the terminal phalanges

Can be made to do in a cosmetically pleasing way
To participate in the appreciation of fine tactile stimuli
Used as tools with which to scratch the skin
To grasp minute objects

Situated on the dorsal aspect of the distal phalanx of

every finger and toe, a nail (known also a nail plate) as
a hard, convex, rectangular, translucent structure the
measures approximately 0,5 0,7 mm in thickness.
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Nail
The nail structure

Nail plate
Matrix

Lateral
Nail Fold

Lunula
Cuticle

Nail Bed

Proksimal
Nail Fold

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Principle of Clinical Diagnosis

When a patient seeks a dermatological opinion, it is

usually for one of two reasons:
A growth or because of concern malignancy
The second is for a rash, which is usually more
widespread and often pruritic.

In medicine, the traditional approach is to take the

history before doing the physical examination. We find
it most useful to ask questions both before and after
examination:
what is your skin problem?
when did it start?
has it gotten better or worse?
does it bother you?
For skin disorder, the most common and important
symptom is itching . does it itch?
how have you treated it?
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History of Skin Lesion

7 Key Question:

When did it start?

Does it itch, burn, or hurt?
Where on the body did it start?
How has it spread? (pattern of spread).
How have individual lesions changed? (evaluation)
Provocative factor?
Previous treatment(s)?

Family history
A positive family history for atopic diseases (atopic
dermatitis, asthma, hay fever) will help support
the diagnosis. A diagnosis of neurofibromatosis
dominantly inherited disease.

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History of Skin Lesion

Social

History

Porphyria cutanea tarda, a disease sometimes

induced by alcohol.
Neurodermatitis, the physician will want to know
something about the patient stresses.
Contact dermatitis, chronic hand dermatitis, question
about occupational exposure may be important and
should be directed particularly to material and
substances that the patient contacts either by
handling or by immersion.

Review of systems as indicated by clinical situation,

with particular attention to possible connections
between cutaneus signs and diseases of other
organ system (e.g. rheumatic complaints):
myalgias, arthralgias, Raynauds phenomenon

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History of Skin Lesion

Past medical history

- operations
- illnesses
- allergies, especially drug allergies
- medications (present and past)
- habits (smoking, alcohol intake, drug abuse)
- atopic history (asthma, hay fever, eczema)

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Physical Examination

Inspection

The

most important part of the physical

examination is inspection.
For the skin to be adequately inspected, there are
3 essential requirements:
A completely undressed patient, clothed in and

examining gown
Adequate illumination, preferably natural light or
bright overhead fluorescent lighting
An examining physician prepared to see what is
before him/her
Detail

examination of skin, hair, nails, and mucous

membranes.
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Physical Examination

Inspection

Four cardinal features.

1. Type of lesion: macule, papule, nodule, vesicle, etc.
2. Shape of individual lesions: annular, iris, arciform, linear,

round, oval, umbilicated, etc.

3. Arrangement of multiple lesions: isolated, scattered, grouped,
herpetiform, zosteriform, annular, arciform, linear, reticular,
etc. (configuration).
4. Distribution ( be sure to examine scalp, mouth, palms, and
soles).
a.
Extent of involvement: circumscribed, regional,
generalized, universal.
b.
Pattern: symetry, exposed areas, sites of pressure,
intertriginous areas
c.
Characteristic location: fexural, axtensor, intertriginous,
glaborous, palms and soles, dermatomalm trunk, lower
extremities, exposed areas, etc.
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Physical Examination
The
Major
Purpos
es

To reassure our
patient that we are
not afraid to touch
their skin lesions.

Palpation
To assess the
texture and
consistency of the
skin lesions
(softness, firmness,
fluctuate, depth).

To evaluate
whether or not
lesions are tender
(cellulitis,
erythema
nodusum).

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Laboratory Studies
Special procedures
1. Biopsy for histopathologic and other analyses.
2. Grams stain of crusts, scales, or exudate.
3. KOH prep for yeast or fungi.
4. Cytologic preparation (Tzanck smear) in vesicular
and bullous eruptions.
5. Bacteriologic, viral, and fungal cultures as indicated.
6. Woods lamp examination of urine for porphyrins
and of hair and skin for fluorescence, and for
changes in pigmentation.
7. Scrabing for scabies mite.
8. Patch tests.
9. Acetowhitening.
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Laboratory Studies
General:
Hematology, chemistry, urinalysis, serologic tests
(e.g. STS, ANA), stool examination, and imaging
studies.

Final diagnosis
Reexamination over time, and more than one biopsy
may be required for definitive diagnosis.

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Skin diseases predilections

.
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References:
1.
2.
3.

Fitzpatrick, Dermatology in general medicine,

2003
Moschella, Dermatology, 1992
Rook, Text book of Dermatology, 1992

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MAKULA
A. Lesi datar, batas tegas berbeda

dengan kulit sekitar karena

warnanya.
Akibat
B. Akibat
C. Akibat
D. Akibat
A.

hiperpigmentasi
pigmentasi dermal
dilatasi kapiler
purpura

B. Erupsi pada reaksi obat : makula

eritem, batas tegas, multipel

dengan berbagai ukuran akibat
vasodilatasi inflamatori.

Dr. Sugastiasri S, SpKK

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PAPULA
Lesi elevasi padat dengan ukuran kecil
( < 1 cm) di bagian terbesar papul
tampak di atas kulit
A.

Permukaan kulit
A.
B.

C.

Akibat deposit metabolik dermis

Akibat hiperplasia lokalisata elemen
seluler dalam dermis atau epidermis.
Papula dengan skuama pada lesi
papuloskuamosa

Nevus melanositik dermal, papul

multipel ukuran bervariasi warna
kecoklatan.
C. Liken planus,
papul multipel
ukuran bervariasi warna violaseus
permukaan datar, mengkilat.
B.

Dr. Sugastiasri S, SpKK

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KISTA
A. Kista Epidermal
Dibatasi epitel skuamosa
yang menghasilkan bahan
keratin.
B. Kista kenyal kebiruan,
tampak pada:
A.

B. Kista tumor adneksa

(kista hidroadenoma)
berisi bahan
menyerupai mukus.

Dr. Sugastiasri S, SpKK

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URTIKA

A. Papul atau plakat dengan atap mendatar yang tidak menetap

dan segera menghilang dalam beberapa jam

B. Urtikaria kolinergik papul kecil ( 3 4 mm)
C. Urtika besar, bergabung membentuk plakat seperti pada
reaksi alergi penisilin, obat lain dan alergen makanan.
Dr. Sugastiasri S, SpKK

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VESIKEL
Adalah lesi dengan batas tegas
mengandung cairan
Celah dalam epidermis akibat
proses akantolisis
B. Akibat degenerasi balon pada
infeksi virus
A.

Vesikel pada herpes zoster

Dr. Sugastiasri S, SpKK

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VESIKEL SUBEPIDERMAL
VESIKEL BULA
Lesi dengan batas tegas
mengandung cairan
A. Vesikel Subepidermal

B. Pada keadaan lanjut menjadi

bula

Dr. Sugastiasri S, SpKK

bula tegang berisi cairan

serous atau hemorhagi
di atas kulit normal atau
eritem

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VESIKEL SUBKORNEAL
Hasil akumulasi cairan tepat di
bawah stratum korneum
B. Akibat udem inter-seluler
A.

Vesikel subkorneal transparan

yang rapuh pada impetigo
stafilokokus

Dr. Sugastiasri S, SpKK

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PUSTULA
A. Papula berisi eksudat

purulen

B. Pustula non folikel primer

pada psoriasis

Dr. Sugastiasri S, SpKK

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NODUL
A. Lesi bulat / elips, padat dan

palpabel
A.
B.

Nodul meluas ke jaringan

subkutan
Nodul terletak dalam epidermis

B. KSB roduler

Nodul batas tegas

Permukaan halus mengkilat

Teleangiektasis & krusta.

C. Metastase Melanoma

Nodul multipel dengan ukuran

bervariasi

Dr. Sugastiasri S, SpKK

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EROSI
A. Lesi basah dapat sebagai

akibat ter-kelupasnya atap

vesikel atau bula juga
akibat proses epidermal
nekrolisis.
Sembuh tanpa ja-ringan
parut.
B. Erosi pada Toksik epidermis

nekrolisis,

Dr. Sugastiasri S, SpKK

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ATROPI

Penyusutan atau penipisan kulit

Dapat terjadi terbatas di epidermis atau dermis atau secara
simultan pada keduanya

Dr. Sugastiasri S, SpKK

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JARINGAN PARUT
A. Jaringan Parut,

Pergantian
jaringan fibrosa yang timbul
sebagai konsekuensi
penyembuhan luka.
Jaringan parut hipertropi
B. Jaringan parut atropi
A.

B. Jaringan Parut Hipertropi

Dr. Sugastiasri S, SpKK

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DESKUAMASI
Adalah akumulasi stratum korneum
abnormal

Dr. Sugastiasri S, SpKK

A.

Skuamasi parakeratotik pada

hiperplasia epidermal psoriasiform.

B.

Skuama melekat erat dan teraba

kasar pada keratosis aktinik

C.

Skuama melekat erat pada psoriasis.

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BENTUK, SUSUNAN LESI, DISTRIBUSI

A. Lesi linier pada

fenomena Koebner

B. Lesi anular & arciform,

susunan anular &

arciform.

C. Lesi iris merupakan

lesi anular yang

penting, cth. pada
eritema multiforme
Dr. Sugastiasri S, SpKK

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BENTUK, SUSUNAN LESI, DISTRIBUSI

Dr. Sugastiasri S, SpKK

D.

Lesi berkelompok

E.

Herpetiform pada herpes

simpleks atau herpes
zoster

F.

Zosteriform
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KRUSTA
A. Serum, darah atau eksudat

purulen yang mengering

Krusta tipis, lembut & mudah
dilepas
B. Krusta tebal dan melekat.
A.

B. Krusta superficial, warna

seperti madu dengan

permukaan mengkilat pada
impetigo.

Dr. Sugastiasri S, SpKK

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ULKUS
A. Defek yang menetap setelah

sebagian epidermis/dermis
rusak atau hilang
Pada proses penyem-buhan
meninggalkan jaringan parut
B. Ulkus gigantic

Ulkus batas tegas de-ngan

dasar jaringan granulasi
kemerahan.

Dr. Sugastiasri S, SpKK

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KELAINAN
HISTOPATOLOGIK

EPIDERMIS (1)
Hiperkeratosis:

penebalan str.korneum

Parakeratosis:

inti (+)
Ortokeratosis: inti (-)
Hiperplasia:

epidermis yg menjadi lebih

tebal krn sel2nya bertambah
Hipoplasia: epidermis yg menipis krn
sel2nya mengecil dan berkurang
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EPIDERMIS (2)
Hipertrofi:

epidermis yg menebal krn sel 2nya

bertambah besar
Atrofi: penipisan epidermis krn sel 2nya
mengecil dan berkurang
Hipergranulosis: penebalan str. Granulosum
Spongiosis: penimbunan cairan diantara
sel2 epidermis
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EPIDERMIS (3)
Degenerasi

balon: edema di dlm sel

epidermis
Degenerasi hidropik: rongga 2 dibawah atau
diatas membrana basalis
Akantosis: penebalan str. Spinosum
Akantolisis: hilangnya kohesi antar sel 2
epidermis, shg terbentuk celah
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EPIDERMIS (4)
Eksositosis:

sel2 radang yg msk ke dlm

epidermis
Diskeratotik: sel epidermis yg mengalami
keratinisasi lebih awal
Nekrosis: kematian sel atau jaringan
setempat pd organisme yg hidup
Cleft: ruangan tanpa cairan di epidermis
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DERMIS
Papilomatosis:

papil yang memanjang

melampaui batas permukaan kulit

Fibrosis:

kolagen >>, fibroblas >>

Sklerosis:

kolagen >>, fibroblas <<

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SUB KUTIS
Peradangan
Nekrosis
Vaskulitis
Proses

degeneratif
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R2r Prod.

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