Pathalogy of the Integumentary system. This is avery brieft presentation on the topic The Integumentary System Pathalogy.

1. THE INTEGUMENTARY SYSTEM
Dr Aman Ud Din Khan
Consultant Physiotherapist

2. Skin Lesions
• Approximately one in every four people who consult a physician has a
skin disorder
• Lesions of the skin or skin manifestations of systemic disorders can be
classified as primary or secondary lesions.
• The primary lesion is the first lesion to appear on the skin and has a
visually recognizable structure (e.g., macule, papule, plaque, nodule,
tumor, wheal, vesicle, pustule).
• When changes occur in the primary lesion, it becomes a secondary
lesion (e.g., scale, crust, thickening, erosion, ulcer, scar, excoriation,
fissure, atrophy).
• These changes may result from many factors, including scratching,
rubbing, medication, natural disease progression, or processes of
healing

4. SIGNS AND SYMPTOMS OF SKIN DISEASE

5. Pruritus & Xerosis:
Pruritus (itching) is one of the most common manifestations of
dermatologic disease and can be a symptom of underlying systemic
disease in people with generalized itching, especially among the
chronically ill and older populations.
Xerosis is the most common cause of pruritus. It can lead to damage if
scratching injures the skin’s protective barrier, possibly resulting in
increased inflammation, infection, and scarring. Many systemic
disorders may cause pruritus, most commonly diabetes mellitus, drug
hypersensitivity, and hyperthyroidism

6. Urticaria:
• Urticaria, more commonly known as hives, is a vascular reaction of
the skin marked by the appearance of smooth, slightly elevated
patches
• Rash is a generalized term for an eruption on the skin, most often on
the face, trunk, axilla, and groin, and is often accompanied by itching
• Rashes typically occur as a secondary response to some primary
agent, such as exposure to the sun, allergens, irritants, or medications
or in association with systemic disease.

7. Blisters:
• Blisters (vesicle or bulla) are fluid-containing elevated lesions of the
skin with clear watery or bloody contents. They can occur as a
manifestation of a wide variety of diseases. Blisters may be primarily
associated with diseases of a genetic or autoimmune origin or may be
secondary to viral or bacterial infections of the skin

8. Aging and the Integumentary System
• The skin undergoes numerous changes that can be seen and felt
throughout the life span.
• The most obvious change occur first during puberty and again during
older adulthood.
• Hormone changes during puberty stimulate the maturation of hair
follicles, sebaceous glands, and apocrine and eccrine units in certain
body areas.
• Mild acne, perspiration and body odor, freckles (promoted by sun
exposure), and pigmented nevi (moles) are common occurrences.

9. • The skin exhibits changes that denote the onset of senescence (the process
or condition of growing old).
• These changes may be due to the aging process itself (intrinsic aging), to
the cumulative effects of exposure to sunlight (photoaging), or to
environmental factors (extrinsic aging).
• Other common age-related integumentary changes include lax skin,
vascular changes (e.g., decreased elasticity of blood vessel walls; a
• Many other benign changes may occur, including seborrheic keratoses
(brown or black, wart-like growths), lentigines (liver spots, unrelated to the
liver but rather secondary to sun exposure), and skin tags (small, flesh-
colored papules).ngiomas) , dermal or epidermal degenerative changes,
and wrinkling

10. Common Skin Disorders
Atopic Dermatitis
• Atopic dermatitis (AD) is a chronic
inflammatory skin disease. It is the most
common type of eczema
• The word atopic (from atopy) refers to a
group of three associated allergic
disorders: asthma, allergic rhinitis (hay
fever), and AD.
• There is usually a personal or family
history of allergic disorders present, and
AD is often associated with food allergies
as well.

11. Etiologic and Risk Factors and Pathogenesis
• The exact cause of AD is unknown, but it is thought to be a result of
dry, irritable skin with a malfunction of the body’s immune system.
• Genetics may play a part, but this has not been proved.
• Stress and emotional problems can worsen AD but do not cause it.
• AD is often associated with increased levels of serum immunoglobulin
E and with sensitization to food allergens
• Compared with normal skin, the dry skin of AD has a reduced water-
binding capacity, a higher trans epidermal water loss, and a decreased
water content.
• Rubbing and scratching of itchy skin are responsible for many of the
clinical changes seen in the skin.

12. Clinical Manifestations
• AD begins in many people during infancy in the form of a red, oozing,
crusting rash classified as acute dermatitis
• It is found mainly on flexor surfaces such as the elbows and knees,
neck, sides of the face, eyelids, and the backs of hands and feet.
• Xerosis and pruritus are the major symptoms of AD and cause the
greatest morbidity with severely excoriated lesions, infection, and
scarring. Viral, bacterial, and fungal secondary skin infections may
cause further changes in the skin

13. Treatment
• Personal hygiene, moisturizing the skin, avoidance of irritants, topical
pharmacology, and systemic medications (e.g., antibiotics,
antihistamines, and rarely, systemic corticosteroids) are treatment
techniques currently available
• Dietary recommendations should be specific and given only in
diagnosed individual food allergy

14. Eczema and Dermatitis
Eczema or dermatitis is a superficial inflammation of the skin caused by irritant
exposure, allergic sensitization or genetically determined idiopathic factors.
Eczema or dermatitis has three primary stages. This condition can manifest in
any one of the three stages, or the three stages may coexist.
Acute dermatitis is characterized by extensive erosions with serous exudate or
by intensely pruritic, erythematous papules and vesicles on a background of
erythema.
Subacute dermatitis is characterized by erythematous, excoriated (scratched or
abraded), scaling papules or plaques that are either grouped or scattered over
erythematous skin. Often the scaling is so fine and diffuse the skin acquires a
silvery sheen.
Chronic dermatitis is characterized by thickened skin and increased skin
marking (called lichenification) secondary to rubbing and scratching;
excoriated papules, fibrotic papules, and nodules (prurigo nodularis); and
postinflammatory hyperpigmentation and hypopigmentation.

16. clinical manifestations
• The clinical manifestations include itching, a feeling of heaviness in
the legs, brown-stained skin, and open shallow lesions
• The lesions are very slow to heal because of a lack of oxygenated
blood.
• Gait training is an important part of compression, the gold standard,
in the treatment of stasis dermatitis

17. Skin Infections
• Impetigo (Bisno 2009)
• Definition and Overview.
• Impetigo is a superficial skin infection commonly caused by
staphylococci or streptococci.
• It is most commonly found in infants, young children 2 to 5 years of
age, older people, and occurs most often during hot, humid weather.

18. Clinical Manifestations.
• Small macules (flat spots) rapidly develop into vesicles (small blisters)
that become pustular (pus-filled).
• When the vesicle breaks, a thick yellow crust forms from the exudate,
causing pain, surrounding erythema, regional adenitis (inflammation
of gland), cellulitis (inflammation of tissue), and itching.

19. Viral Infections
• Warts (Verrucae)
• Warts are common, benign viral infections of the skin and adjacent
mucous membranes caused by human papillomaviruses (HPVs).
• Transmission is probably through direct contact, but autoinoculation
is possible.
• The most common wart (verruca vulgaris) is referred to as such and
appears as a rough, elevated, round surface most frequently on the
extremities, especially the hands and fingers.
• Plantar warts are slightly elevated or flat,

20. Fungal Infections (Dermatophytoses)
• Fungal infections such as ringworm are caused by a group of fungi that
invade the stratum corneum, hair, and nails
• Ringworm (Tinea Corporis)
• Tinea corporis, or ringworm, has no association with worms but rather
is marked by the formation of ring-shaped pigmented patches covered
with vesicles or scales that often become itchy
• Transmissioncan occur directly through contact with infected lesions
• Diagnosis can be made through laboratory examination of the affected
skin
• Treatment with the drug griseofulvin may take weeks to months

21. Athlete’s Foot (Tinea Pedis)
• Tinea pedis, or athlete’s foot, causes erythema, skin peeling, and
pruritus between the toes that may spread from the interdigital
spaces to the plantar surface of the foot.
• Severe infection may result in inflammation, with severe itching and
pain on walking. Some individuals develop a strong foot odor as well.
• Clean, dry socks and adequate footwear (well-ventilated, properly
fitting) are important. After washing the feet and drying thoroughly
between the toes, antifungal cream or powder (the latter to absorb
perspiration and prevent excoriation) can be applied.

22. Other Parasitic Infections
• Scabies
• Definition. Scabies (mites) is a highly contagious skin eruption caused
by a mite, Sarcoptes scabiei
• The female mite burrows into the skin and deposits eggs that hatch
into larvae in a few days.
• Scabies is easily transmitted by skin-to-skin contact or by contact with
contaminated objects, such as linens or shared inanimate objects.

23. • The symptoms include
• intense pruritus (worse at night),
• The mite is usually found in the burrow, commonly in the interdigital
web spaces, flexor aspects of the wrist (volar surface), axillae,
waistline, genitalia in males, and the umbilicus.
• Intense scratching can lead to severe excoriation and secondary
bacterial infection

24. Skin Disorders Associated With Immune Dysfunction
• Psoriasis
• Psoriasis is a chronic, inherited, recurrent inflammatory but noninfectious
dermatosis characterized by welldefined erythematous plaques covered
with a silvery scale
• There are several types of psoriasis, including plaque, guttate,
erythrodermic, and pustular psoriasis
• Etiologic and Risk Factors
• The cause of psoriasis is unknown, but it appears to be hereditary; that is,
the tendency to develop psoriasis is genetically determined
• Although psoriasis is thought to be genetically linked, it may be triggered
by mechanical, UV, and chemical injury; various infections (especially by β-
hemolytic streptococci); prescription drug use; psychologic stress; smoking;
and pregnancy and other endocrine changes

25. Pathogenesis
• The underlying abnormality in psoriasis has not been definitively
identified. It is a disorder of the keratinocytes, which form in the
lower epidermis, flatten with age, and move toward the surface as
new cells
• A second component in the pathogenesis of psoriasis is the immune
system reaction, because T cells appear at the sites of heightened
keratinocyte activity

26. Clinical Manifestations
• Psoriasis appears as erythematous papules and plaques covered with
silvery scales.
• The lesions in ordinary cases have a predilection for the scalp, chest,
nails, elbows, knees, groin, skin folds, lower back, and buttocks
• The most common subjective complaint is itching and,occasionally,
pain from dry, cracked, encrusted lesions.
• In approximately 30% of cases, psoriasis spreads to the fingernails,
producing small indentations and yellow or brown discoloration. In
severe cases, the accumulation of thick, crumbly debris under the nail
causes it to separate from the nail bed (nail dystrophy).
• Approximately 10% of people with psoriasis (usually moderate to
severe) develop arthritic symptoms referred to as psoriatic arthritis

27. Lupus Erythematosus
• Lupus erythematosus is a chronic inflammatory disorder of the
connective tissues.
• It appears in several forms, including cutaneous lupus erythematosus
primarily affecting the skin and systemic lupus erythematosus (SLE),
which affects multiple organ systems (including the skin) with
considerably more morbidity and associated mortality

28. • Clinical Manifestations.
• Discoid lesions (chronic cutaneous LE) can develop from the rash
typically seen in lupus and become raised, red, smooth plaques with
follicular plugging and central atrophy. The raised edges and sunken
centers give them a coin-like appearance
• Hair tends to become brittle, and scalp lesions can cause localized
alopecia
• The most recognized skin manifestation of SLE (acute cutaneous LE) is
the classic butterfly rash over the nose, cheeks, and forehead

29. Polymyositis and Dermatomyositis
• Polymyositis and dermatomyositis are the two most common
idiopathic inflammatory diseases of muscle
• They are diffuse, inflammatory myopathies that produce symmetric
weakness of striated muscle, primarily the proximal muscles of the
shoulder and pelvic girdles, neck, and pharynx.
• These related illnesses belong to the family of rheumatic diseases.
• These diseases often progress slowly, with frequent exacerbations
and remissions.

30. • Clinical Manifestations
• Symmetric proximal muscle weakness is the dominant feature of these
diseases, although it is variable in its onset, progression, and severity. In
some people, symptoms appear suddenly, progress rapidly, and quickly
result in a bedridden state, sometimes requiring ventilator assistance and
tube feeding.
• Cardiac involvement is not uncommon and contributes significantly to
mortality
• Pulmonary disease (progressive pulmonary fibrosis) can result from
weakness of the respiratory muscles, intrinsic lung pathologic conditions,
or aspiration. Swallowing difficulties, And reflux are common, especially in
severe cases.

31. Thermal Injuries
• Cold Injuries
• Cold injuries result from overexposure to cold air or water and occur
in two major forms: localized injuries (e.g., frostbite) and systemic
injuries (e.g., hypothermia).
• Untreated or improperly treated frostbite can lead to gangrene and
may necessitate amputation requiring therapy and rehabilitation.

32. Pathogenesis and Clinical Manifestations
• Cold-induced injuries can be local or systemic. Severe cold affects all
organ systems and especially the central nervous and cardiovascular
systems.
• Many biologic reactions and pathways become distorted or slowed at
low body core temperatures.
• Low body shell temperature can interfere with athletic ability by
weakening and slowing muscle contractions, by delaying nerve
conduction time, and by facilitating injury.
• Frostbite may be deep or superficial. Superficial frostbite affects the
skin and subcutaneous tissue, especially of the face, ears, extremities,
and other exposed body areas.
• Deep frostbite extends beyond subcutaneous tissue and usually
affects the hands or feet.

33. Miscellaneous Integumentary Disorders.
• Integumentary Ulcers
• Integumentary ulcers can be caused by a variety of underlying
disorders, including neuropathy, vascular insufficiency, radiation, SSc,
vasculitis, and prolonged pressure.

34. Pressure Ulcers
• A pressure ulcer (formerly called bed sore, decubitus ulcer) is a lesion
caused by unrelieved pressure resulting in damage to underlying
tissue. Pressure ulcers usually occur over bony prominences, such as
the heels, sacrum, ischial tuberosities, greater trochanters, elbows,
and scapula, and are staged to classify the degree of tissue damage
observed

35. Pathogenesis
• Pressure is the external factor causing ischemia and tissue necrosis.
Continuous pressure on soft tissues between bony prominences and hard
or unyielding surfaces compresses capillaries and occludes blood flow.
• Normal capillary blood pressure at the arterial end of the vascular bed
averages 32 mm Hg.
• When tissues are externally compressed, that pressure may be exceeded,
reducing blood supply to, and lymphatic drainage of, the affected area.
Shearing
• when the skin layers move in opposite directions) is the intrinsic factor that
contributes to ripping or tearing of blood vessels, further damaging the
integument.

36. Clinical Manifestations
• Irregular patterns indicate additional shearing forces or other
contributing factors.
• Sacral ulcers are often large, undermined, and deep to the bone
because the tissue mass over the sacrum is thin and erodes easily to
the deep tissues.
• Trauma to the tissues produces an acute inflammatory response with
hyperemia, fever, and increased white blood cell count

37. • TREATMENT. Prevention and removing the causative factor are the
first step in the treatment intervention for pressure ulcers
• Topical antimicrobials (e.g., Iodosorb, Iodoflex, silver dressings) can
be effective on local infections without systemic involvement to
control bacterial concentration,

38. Pigmentary Disorders
• Definition and Overview
• Skin color or pigmentation is determined by the deposition of
melanin, a dark polymer found in the skin, as well as in the hair, ciliary
body, choroid of the eye, pigment layer of the retina, and certain
nerve cells.
• Pigmentary disorders (either hyperpigmentation or
hypopigmentation) may be primary or secondary. Secondary
pigmentary changes occur as a result of damage to the skin, such as
irritation, allergy, infection, excoriation, burns, or dermatologic
therapy, such as curettage, dermabrasion, chemical peels, or freezing
with liquid nitrogen.

39. Clinical Manifestations
• Hyperpigmentation.
• Hypopigmentation and Depigmentation

40. Blistering Diseases
• Blisters occur on skin and mucous membranes in a condition called
pemphigus, which is an uncommon intraepidermal blistering disease
in which the epidermal cells separate from one another.
• This disease occurs almost exclusively in middle-aged or older adults
of all races and ethnic groups.

41. Clinical Manifestations
• Blistering diseases are characterized by the formation of flaccid
bullae, or blisters.
• These bullae appear spontaneously, often on the oral mucous
membranes or scalp, and are relatively asymptomatic.
• Erosions and crusts may develop over the blisters, causing toxemia
and a mousy odor
• Disturbances of electrolyte balance are also common because of fluid
losses through the involved skin in severe cases.