Skin disease with pirates diagnosis. Fundamentals of Diagnosis of Skin Diseases

At first glance, it seems that diagnosing a skin disease is as easy as shelling pears, because it is the most accessible organ for research. But in fact, this is absolutely not the case. The thing is that there are so many different dermatoses that a dermatologist sometimes has to make a lot of attempts to recognize skin changes.

Due to the fact that all problems associated with the skin, first of all, are examined by the eyes of diagnostics. skin diseases is primarily based on the examination skin and mucous membranes. Well, of course, in addition to the examination, the doctor must have logical thinking. If the doctor will be based on only one examination, then this is unlikely to lead to the correct diagnosis.

The first step in making a diagnosis is the history taking. The doctor must thoroughly ask the patient about how the disease began, what symptoms are inherent in it, etc. through the collection of anamnesis, the doctor will be able to find out what causes this or that disease. Well, for example, one skin disease can be caused by a violation immune system, and the other is due to the fact that a person often comes into contact with harmful substances.

In most cases, anamnesis is taken before the start of the examination.

What should be included in the anamnesis?

• All complaints related to the disease that the patient only has.
• A dermatologist must necessarily clarify such information as:
• Has the patient had previous cases of this disease?
• How does the disease develop? Have there been relapses?
• How exactly does the skin cover change and for how long does this happen?

In addition to all of the above, the doctor must establish whether the patient is worried about his existing disease. Often, skin diseases occur with such unpleasant symptoms as itching, burning, redness of the skin, etc. that is why the patient should be asked about his worries. Very often, patients with skin diseases complain of severe itching. But sometimes it happens that rashes do not bother a person at all. For example, with syphilis, a rash appears on the skin, which is just there and that's it.

If the doctor has suspicions about the allergic nature of the disease (yes, if not, too), he should ask the patient about what medications he has been taking lately. In most cases, the fact that the patient once took this or that drug, he remembers only when he is asked about it by a dermatologist.

It is very important that the diagnosis of skin diseases is also based on a very important point - as an anamnesis of the patient's life. Well, for example, a person who comes to the doctor with a problem with a skin disease can work as a painter at a construction site. This information is extremely important. the cause of dermatosis may lie precisely in the profession of the patient. This means that a person with a skin disease due to prolonged contact with paints has earned himself a skin disease.

After the dermatologist receives all the necessary information, he can begin to examine the skin.

• Inspection should begin with the affected area, but, nevertheless, the entire body of the patient should be examined.
• Inspection must be carried out in diffused daylight. It will also be just great if the doctor has a magnifying glass and an additional side light source.

In conclusion, I also want to say that if you find any rashes in yourself and whether they interfere with you or not, go through without fail. Only a specialist can accurately diagnose and prescribe the right treatment.

Few people know that the human skin is the largest organ in the body. The skin area on the body is about two square meters. Based on this, it is quite logical to assume that the number of skin diseases includes a considerable list.

In addition to the fact that the human skin performs protective and immune function body, it also regulates temperature, water balance and many sensations. That is why it is so important to protect the skin from the effects of various diseases. This task is the most important in terms of prevention.

Below you can find out which of the most common skin diseases can occur in a person and see their photos. Here you can get acquainted with the description of diseases, as well as with the symptoms and causes of the disease. You should immediately pay attention to the fact that many skin diseases can be cured without much difficulty.

What are skin diseases in humans?

Skin diseases can be of various origins. All of them differ in their appearance, symptoms and cause of formation.

Dermatitis is a rash in the form of bubbles, peeling, discomfort, itching, burning, and so on. The reasons may be different, depending on which several varieties of dermatitis are distinguished, for example, infectious, allergic, atopic, food, etc.

The cream contains exclusively natural ingredients, including bee products and plant extracts. High efficiency, practically no contraindications and minimal risks side effects. The amazing results of treatment with this drug appear already in the first weeks of use. I recommend.

Photos and names of skin diseases in humans

Now it’s worth considering a photo of the main diseases of the skin, and below get acquainted with their symptoms, causes and description.

The most common skin diseases:

1. Papilloma

The disease is called sebaceous glands, which is characterized by clogging and the formation of inflammation of the follicles. People often call this skin disease acne.

The main causes of acne:

Acne symptoms:

• The formation of comedones in the form of black or white acne.
• Formation of deep acne: papules and pustules.
• The defeat of the chest, face, back and shoulders.
• The formation of redness and tuberosity.
• The appearance of purulent acne.

Dermatitis is any inflammation of the skin. There are several types of dermatitis. The most common types of dermatitis are: contact, diaper, seborrheic, atopic.

Despite this, dermatitis has some main causes:

Symptoms of skin dermatitis:

• The appearance of burning and itching.
• Formation of blisters on the skin.
• The presence of swelling.
• The formation of redness at the site of inflammation.
• Formation of scales and dry crusts.

Here you can learn in detail about the features and treatment of inflammation, as well as see.

Such a skin disease as lichen includes a number of several varieties. Each of these species is distinguished by its pathogen, type of rash, localization and infectivity.

Detailed information about the types of this disease can be found on the website.

The main causes of lichen on the human skin:

Symptoms of lichen disease:

• The formation of colored and flaky spots.
• The formation of spots on any part of the body, depending on the type of disease.
• Some species are accompanied by an increase in temperature.

Herpes is a very common skin disease. Most of the world's population at least once faced with this disease.

This disease is accompanied by thickening and keratinization of human skin. With the development of keratosis, pain and bleeding wounds may appear.

The main causes of keratosis:

Symptoms of the manifestation of keratosis:

• Roughness and unevenness of the skin in the first stage of the disease.
• The formation of hard brown or red spots.
• Peeling of the skin around the formations.
• The presence of itching.

Carcinoma is considered one of the signs of the development of skin cancer.

The disease can form on any part of the skin. A sharp increase in the number of moles on the body should already be alarming.

The main symptoms of carcinoma:

• The formation of pearly or shiny cones.
• Ulcer formation.
• Formation of pink convex spots.

hemangioma called a benign formation on the skin due to a vascular defect, which is most often manifested in children. Externally, the disease is a bumpy spots of a red hue.

Causes of hemangioma:

Symptoms of a hemangioma:

• At the initial stage, the formation is a faint spot in the face or neck of the child.
• Spot redness.
• The stain becomes burgundy.

Melanoma is another sign of skin cancer. At the first sign of melanoma, you should consult a doctor.

The main symptoms of melanoma:

Papilloma

papilloma called a tumor benign, which appears on the surface of the skin in the form of a small growth.

Causes of papilloma:

The main symptoms of papilloma:

• The formation of a pink or bodily growth.
• The size of the formation can reach several centimeters.
• The formation of a common wart.

It is customary to call a group of fungal diseases of the skin. As a rule, this disease occurs in 20% of the inhabitants of the planet. The main cause of dermatomycosis in humans is the ingress of fungi on the skin or mucous area of ​​a person.

Symptoms of ringworm:

• The formation of red spots, which are covered with scales.
• The presence of itching.
• Hair loss and breakage.
• Delamination of nails.

Treatment

As a rule, skin diseases are treated in the following ways:

• Compliance with the diet and proper diet, the use of the necessary vitamins.
• Treatment medicines to boost the immune system.
• The use of antibiotics if the skin disease has become severe.
• External treatment with ointments and creams.

It is important to note that any treatment should begin only after the establishment of the disease itself and its causes by a specialist. So do not neglect to visit a doctor at the first symptoms of a skin disease.

Conclusion

You should also not forget that the best treatment skin diseases is prevention. Elementary preventive methods are: personal hygiene, diet and precautions during outdoor recreation.

Methods for diagnosing dermatological diseases are no less diverse and complex than skin diseases themselves. Sometimes a visual inspection is enough, and sometimes a comprehensive study of the whole organism is necessary. Skin diseases sometimes they affect the general condition of a person, and vice versa - diseases of other systems affect the condition of the skin. When a person complains to a dermatologist, it is important to understand whether skin manifestations are the cause or effect of the disease.

It would seem that the skin is the largest organ in terms of area and the most accessible organ for diagnosis. human body. But it is the skin that serves as the first protective barrier against all kinds of harmful environmental influences; in addition, skin diseases are so diverse that their diagnosis is sometimes more difficult than the analysis of the condition internal organs.

Accuracy in making a dermatological diagnosis is largely determined by the "human factor": the doctor's attentiveness and experience, his ability to logically analyze and synthesize. Diagnosis of any dermatological disease includes several stages.

The first stage of a dermatological examination is the collection of an anamnesis, which involves an external examination and a conversation with the patient, and sometimes with his relatives. Need to find out possible reasons and the presence of factors contributing to the occurrence of skin diseases, the presence of comorbid (comorbid or background) diseases, information about heredity, lifestyle, nutrition, psychological state medications taken. Sometimes, with the same observed symptoms, the presence or absence of itching, the persistence of skin rashes, the frequency and area of ​​\u200b\u200btheir appearance can be very important.

2. Examination of the patient

When answers to the main questions are received, a skin examination is performed, which begins with the affected area and necessarily covers the entire body. The most objective results are obtained by examining the skin in diffused daylight. Often a magnifying glass is used. In many diseases, lesions on the skin have a certain, “recognizable” shape, structure and color.

The first two stages of skin diagnosis, as a rule, allow the dermatologist to make a preliminary diagnosis or suggest several possible ones. In addition, the nature of the disease becomes clear - an acute or chronic condition, hereditary or acquired; it also turns out the stage of development of the disease and the degree of damage to the skin.

3. Laboratory research

Laboratory studies are especially important if skin manifestations are suspected to be due to other, non-dermatological conditions. If this is confirmed, symptomatic treatment is prescribed, and the main measures are focused on treatment. somatic disease. To identify the relationship between skin pathology and other diseases allows:

• general blood analysis;
• general urine analysis;
• biochemical analysis blood;
• stool analysis;
• immunogram.

If necessary, the dermatologist directs the patient for a consultation with other specialists who can prescribe a number of more specific studies.

4. Special diagnostic methods

Actually dermatological diagnostics includes a number of methods and techniques that complement the visual examination of the skin:

• palpation (to assess the elasticity and structure of the skin);
• skin-allergic tests (to determine allergens);
• sowing the affected area (growing microorganisms from the surface of the skin in a special environment);
• microscopy of scrapings (examination of parts of the skin under a microscope);
• scraping (to detect peeling);
• diascopy (assessment of the reaction of the skin when pressed with a glass slide);
• histology (examination for the presence of cancer cells).

Most diagnostic techniques in dermatology are safe and painless. Early detection disease gives a better chance of recovery. Even skin rashes you are not disturbed by pain or itching, but only attract attention as something new on the body - you should not postpone a visit to the doctor.

A dermatological patient seeks medical help when he detects changes on the skin or visible mucous membranes, in some cases accompanied by subjective sensations. However clinical picture skin diseases provides a complex symptom complex. All symptoms of the disease are divided into subjective and objective. Subjective symptoms include manifestations of the disease that the patient feels, objective symptoms - changes that the doctor finds on the skin or visible mucous membranes during examination or palpation. Rashes are often accompanied by general symptoms: malaise, feeling of weakness, general weakness, fever, etc.

Complaints. The doctor's contact with the patient begins with the clarification of complaints. Dermatological patients most often complain of itching, burning, pain, tingling, etc. However, subjective symptoms depend not only and not so much on the severity of the disease, but on individual features patient, his reactivity nervous system. Some patients react very painfully to minor manifestations of the disease, while others may present minor complaints with the severity of skin pathology. This is especially true for itching, the severity of which depends not only on dermatosis, but sometimes to a greater extent on its perception by the patient. Objective signs of itching are multiple excoriations - traces of scratching, as well as

the value of the free edge of the nails of the fingers and the polishing of the nail plates.

The presence or absence of itching has a certain diagnostic value. Some dermatoses are always accompanied by itching (scabies, urticaria, various forms of pruritus, neurodermatitis, lichen planus, almost all forms of eczema), others occur without itching or it is slightly expressed (psoriasis, pink lichen, pyoderma, acne vulgaris and redheads, etc.). In some dermatoses, itching is usually accompanied by scratching (scabies, lice, pruritus, etc.), while in others, despite severe itching, no scratching is observed (urticaria, lichen planus, etc.). In addition, in patients with pruritic dermatoses, itching usually increases or occurs at night when the skin warms up; especially in patients with scabies.

Anamnesis. After clarifying the complaints, they begin to collect an anamnesis of the disease and the life of the patient. A correct and thorough history is often of great importance in establishing the diagnosis of a skin or venereal disease. The circumstances preceding or accompanying the onset and maintenance of the disease are important for identifying etiological and pathogenetic factors, without which it is difficult to hope for successful treatment.

A well-collected history often facilitates diagnosis, so it is necessary to ask the patient a number of clarifying questions. What does the patient associate the occurrence of his disease with? When did it first arise (congenital - acquired)? With the use of certain foods (chocolate, citrus fruits, nuts - more often of an allergic nature; shrimp, squid and many other diverse foods - food toxidermia; bread and everything containing gluten - Dühring's herpetiform dermatitis)? Is there a relationship with medication (drug toxidermia)? Are the rashes localized only in open areas (photodermatosis? phototoxic reactions to drugs with photosensitizing properties?) or also in closed areas (other dermatosis? photoallergy to drugs?)? (If rashes on open areas of the skin occur a few minutes after insolation - solar urticaria; after 24-48 hours - polymorphic photodermatosis (solar pruritus or solar eczema)). Eruptions around the mouth (perioral dermatitis? allergic reaction to fluoride in toothpaste?).

If an occupational skin disease is suspected, it is important to find out the features of the patient's work: erysipeloid occurs in workers

slaughterhouses, canneries processing raw meat (often pork), fish, milkers' knots - from milkmaids, anthrax - from butchers, tanners, glanders - from veterinarians, grooms and other persons serving animals with glanders. Toxic melasma is observed in persons who often come into contact with hydrocarbons (oil distillation products, gas, etc.). If you suspect skin leishmaniasis, leprosy, phlebotoderma and a number of other dermatosis, you need to find out if the patient was, even for a short time, in those areas where these diseases occur, for example, if leishmaniasis is suspected - in Central Asia or the Caucasus, with suspicion of deep mycoses, tropical treponematoses - in hot climates, etc. In cases of complaints of discharge from the urethra, the appearance of erosive or ulcerative elements on the genitals, the prescription of casual sexual contact may be important for establishing the diagnosis.

In the diagnosis of a number of dermatoses, the seasonality of the disease is important. So, in autumn and spring, erythema multiforme exudative, pink lichen, erythema nodosum, herpes zoster occur more often. Patients with photodermatosis, erythematosis, phlebotoderma, meadow dermatitis, epidermophytosis, etc. more often go to the doctor for the first time in spring or summer; patients with chills - in the damp and cold season.

Sometimes the propensity of dermatosis to relapse (eczema, psoriasis, athlete's foot, exudative erythema, Dühring's dermatitis, herpes simplex, etc.) or, conversely, the lack of a tendency to recurrence (deep trichophytosis, pink lichen, herpes zoster, etc.) helps in the diagnosis.

Of great importance is the anamnesis if a drug rash is suspected: the patient indicates that his rashes recur after the use of one or another medication, although the patient's denial of such a connection does not yet exclude a drug rash. Some patients, with a careful history taking, indicate that relapses of rashes are associated with the use of chocolate, strawberries, crayfish, etc. Information about past and present tuberculosis, syphilis, diseases of the liver, gastrointestinal tract, blood, dysfunction of the nervous system, endocrine glands.

Questioning the patient allows you to establish in some cases the family nature of the disease, which helps in the diagnosis of scabies, ringworm, hereditary and congenital dermatoses (some forms of keratoses, Darier's disease, etc.), as well as to find out the presence or absence of itching,

its intensity, localization, the greatest severity at certain hours of the day.

It should be borne in mind that some skin diseases occur predominantly in individuals of a certain gender. For example, pruritus nodosum, chronic trichophytosis, systemic scleroderma, erythema nodosum are more common in women, rhinophyma, acne-keloid - in men.

The anamnesis allows you to clarify when and in what areas the first manifestations of the disease appeared, how long these manifestations exist, what changes occurred with them, i.e. the frequency and duration of relapses and remissions (if any), the relationship of rashes with nutrition and past therapy, the effectiveness of treatment.

Survey of a dermatological patient in the section of life history (anamnesis vitae), is no different from that in clinics of a therapeutic profile.

Finding out the history of a skin disease, it is necessary to determine its duration, as well as the reasons with which the patient himself associates its onset and exacerbation (stress, cooling, taking medicines, certain types of food, effects on the skin chemical substances, insolation, etc.). Then the nature of the course of dermatosis, the tendency to relapse, in particular the seasonality of exacerbations and remissions, and their duration are established. If the patient has already received treatment, then it is necessary to find out which one, and what was its effectiveness. Pay attention to the effect of water, soap on the skin.

Gathering a life history to identify the role external factors in the pathogenesis of dermatosis, one should pay attention to the working and living conditions of the patient, as well as learn about past diseases, skin diseases from family members of the patient and his blood relatives, alcohol consumption and smoking.

Examination of the patient is the most important point in the diagnosis of skin disease.

The patient should be asked to undress completely, even if he complains of single rashes. Pay attention to the prevalence of morphological elements, since the process can be universal, capture the entire skin (erythroderma), the rash can be generalized or local, located symmetrically or asymmetrically. Consideration should be given to whether the patient has one type of primary elements (monomorphic rash) or primary elements are diverse (polymorphic rash). An important diagnostic value is the location of the elements in relation to each other. rashes

can be located in isolation or grouped, forming figures in the form of rings, arcs, lines, etc. When the lesions are located in separate small groups, they are said to be herpetiform. The rash may have a tendency to coalesce. The boundaries of the lesion may be clear or vague. Often, the localization of the rash is of diagnostic value.

When studying morphological elements, it is necessary first of all to determine their color, shape and shape, with the help of palpation to find out whether they rise above the level of the skin or mucous membrane or not. Their consistency (hard or soft), depth of occurrence (surface or deep) should be determined. It is important to clarify the dynamics of the process: the elements exist constantly or periodically disappear, what is their regression (resorption, peeling, ulceration, atrophy, etc.), to determine whether the elements leave a scar and if so, what kind.

An isomorphic reaction (Köbner's symptom) is of great diagnostic importance: the appearance of fresh primary elements characteristic of this disease at the site of irritation of the skin or mucous membrane

any exogenous factor (scratch, friction, burn, including sunlight, etc.).

In some cases resort to special research methods: vitropressure(pressure on the affected surface with a watch glass, glass spatula or glass slide) to clarify the color of the element, detect caseosis, etc.; layer-by-layer scraping of the element, allowing to determine peeling. According to the indications, increased fragility of the capillaries of the papillary layer, etc. is determined.

If an infectious etiology of dermatosis is suspected, bacterioscopic and, in some cases, bacteriological diagnostics are used. The material for the study is scales, hair, nail plates, the contents of pustules and bladder elements, discharge of erosions and ulcers, blood, etc.

Of great diagnostic importance are the results of a study of the cellular composition of the cystic fluid, a cytological study of smears-imprints taken from the surface of erosions to detect acantholytic cells, general data clinical analysis blood and urine.

According to the primary and secondary morphological elements, one can read the diagnosis on the patient's skin. The more competent the dermatovenereologist, the richer his clinical experience, the better his visual memory is developed, the more often the type of rash (the nature of the morphological elements, their

prevalence, localization, shape, outlines, boundaries, surface, their mutual relationship, consistency) he can diagnose the disease. Here it is not possible to list all the clinical forms of dermatoses that can occur typically. Let us indicate as examples only a few skin and venereal diseases that may have manifestations that make it relatively easy to establish a clinical diagnosis.

Furuncle, carbuncle, hydradenitis, ecthyma vulgaris, pityriasis versicolor, erythrasma, epidermophytosis of the feet, rubrophytosis, scutular form of the favus, vesicular and herpes zoster, erythematosis, scleroderma, eczema, urticaria, scaly lichen, lichen planus, chancre, wide condylomas of the secondary period of syphilis and many other skin and venereal diseases in the "classic » The course is easily diagnosed with appropriate experience and experience. However, in some cases, visual diagnosis is difficult due to the morphological similarity of many dermatoses. Often in the clinical picture and the course of "classic" dermatoses, one or another atypicality is noted. In these cases, the dermatovenereologist, having examined the patient and not being able to establish a diagnosis by the appearance of the rash, and even after using additional methods examinations (palpation, diascopy, scraping of rashes, etc.), should clarify the history and complaints of the patient. In necessary cases, special dermatovenereological studies should be carried out (pathohistological examination of biopsy material, examination for fungi, pale treponema, gonococcus, Mycobacterium tuberculosis, leprosy bacillus, acantholytic cells, serological blood tests, immunoallergological examination, etc.) in order to establish the final diagnosis of the disease, clarification of its etiology and pathogenesis.

We turn to the presentation of the scheme of examination of a dermatological patient.

4.1. Description general condition organism

The general state of health is assessed by mental and physical status, age-appropriate appearance. The survey is carried out according to the general rules, so we will outline them briefly. Examine the size, density, mobility, soreness available for palpation lymph nodes. Examine the musculoskeletal system and determine muscle tone. When examining the nose, nasopharynx, percussion and auscultatory examination, the state of the respiratory organs is determined.

Complaints about the violation of the functions of the circulatory organs are detected, the boundaries of the heart are determined, its tones are heard, blood pressure is measured, and the pulse is determined. Then they find out complaints about the functions of the digestive organs, examine the oral cavity, palpate the abdomen (liver, spleen). In the study of the genitourinary system, Pasternatsky's symptom is determined, attention is paid to the frequency of urination, the type of urine, the development of the genital organs, the nature and frequency of menstruation. Determine the endocrine status and the state of the neuropsychic sphere (emotional mobility, performance, sleep, function cranial nerves, skin and tendon reflexes).

Dermatological status. Examination of healthy areas of the skin, mucous membranes, and appendages of the skin helps to study skin lesions. The skin is examined in diffused daylight or good electric lighting, including fluorescent lamps. It is necessary to determine the color of the skin and visible mucous membranes, the elasticity and extensibility of healthy skin, the turgor of muscles and subcutaneous fat, as well as the condition of the sebaceous and sweat glands, nails and hair, pigmentation, the presence of scars, nevoid formations, etc. Healthy skin has a matte surface and does not shine. A change in skin color may be associated with dysfunctions of the organs and systems of the body (for example, with Addison's disease, toxic melasma, the skin is dark, with Botkin's disease - yellow, with congestion - bluish). To determine the extensibility and elasticity of the skin, it is felt, collected in a fold; the presence or absence of cohesion with the underlying tissues is determined by shifting the skin.

Of no small importance is dermographism - the reaction of the neurovascular apparatus of the skin to mechanical irritation, indicating the vasomotor innervation of the skin. The appearance of a red stripe after passing over the skin with a blunt object (the edge of a wooden spatula, the handle of a neurological hammer), which disappears without a trace after 2-3 minutes, is considered normal dermographism. Red spilled dermographism is observed in eczema, psoriasis, white - in patients with pruritus, exfoliative dermatitis, persistent white or mixed, quickly turning into white - in patients with atopic dermatitis, urticaria (wide edematous, sharply rising bands of red color after even a weak mechanical skin irritations, sometimes disappearing after 40-60 minutes) - in patients with urticaria, pruritus.

Muscle-hair reflex ("goosebumps") is obtained by lightly passing a cold object over the skin. Normally, it lasts 5-10 seconds and then disappears without a trace. The absence of this reflex indicates a disorder of sympathetic innervation and is observed in patients with ichthyosis, Hebra's pruritus. Its increase occurs in patients with atopic dermatitis with functional disorders of the central and autonomic nervous system.

In case of suspected leprosy, syringomyelia, pathomymia, the study of tactile, pain and temperature sensitivity of the skin is often of decisive diagnostic importance.

Damage to the skin and mucous membranes (status localis) it is recommended to describe sequentially, adhering to a certain scheme. First, it is advisable to indicate whether the rashes are of inflammatory or non-inflammatory origin. Most manifestations of skin and venereal diseases are associated with inflammation. Then the rashes should be classified as acute inflammatory (with a predominance of the exudative component of inflammation) or non-acute inflammatory (with a predominance of the proliferative component of inflammation). Further, the localization of the rashes is indicated with a description of the predominant location of the elements. Many dermatoses have a favorite localization, but this is of secondary importance for establishing a diagnosis. So, for example, with scaly lichen, papulonecrotic tuberculosis of the skin, Hebra's pruritus, rashes are located on the extensor surfaces of the limbs; with lupus erythematosus, erythematosus, acne and others - on the skin of the face; with microbial and varicose eczema, erythema nodosum and Bazin's erythema indurated, trophic and chronic pyococcal ulcers, etc. - on the skin of the legs; with pemphigus, ulcerative tuberculosis, etc. - in the oral cavity. Further, attention is paid to the prevalence of the lesion, which can be limited, disseminated, generalized, universal in the form of erythroderma, as well as symmetrical and asymmetric.

Then the primary and secondary morphological elements are indicated and their features are described: color, borders, shape, outlines (configuration), surface, consistency, relationships. An experienced dermatologist distinguishes not only the color of the elements, but also its shades, which often has an important diagnostic value. The boundaries of morphological elements can be clear and fuzzy, sharp and unsharp. When describing the shape of elements, such as papules, it should be noted that they are flat, conical or hemispherical.

nye, etc. The outlines of the elements are rounded, oval, polygonal or polycyclic, small or large scalloped, etc. According to the consistency, the elements can be woody-dense, densely elastic, soft, doughy. The surface of the elements can be smooth, rough, bumpy, etc. They are isolated from each other or drain; in the first case, they talk about the focal location of the rash. If the rash resembles circles, semicircles, ovals, arcs, then they talk about the correct grouping of the rash. An irregularly grouped rash is located in a certain area, but does not form any geometric figure. A systematized rash is called a rash located along the nerve trunks (with herpes zoster), blood vessels, according to the distribution of dermatometamers, etc. With a disorderly arrangement of the rash, there is no regularity in the placement of morphological elements.

Primary and secondary morphological elements and their clinical features are the basis of dermatological diagnosis. However, it is often necessary to use special methods clinical and laboratory research.

4.2. Special dermatological and laboratory tests

Special dermatological research methods are non-invasive and invasive: scraping, palpation, diascopy, determination of isomorphic reaction, dermographism, muscle-hair reflex, skin tests, dermatoscopy, dermatography, histological and histochemical examination of skin biopsy from the lesion.

To laboratory methods surveys dermatological and venereal disease patients include both general (blood, urine, gastric juice, feces for worm eggs, chest X-ray, etc.) and special (serological, microscopic, pathomorphological examination).

Scraping of rashes with a glass slide, scalpel, etc. is used mainly for suspected scaly lichen and parapsoriasis. With psoriasis, it is possible to get three consecutive characteristic symptom: "stearin stain", "film" and "blood dew", or point bleeding, with drop-shaped parapsoriasis - a symptom of hidden peeling. With erythematosis, scraping of scales with follicular "spikes" is accompanied by soreness (Besnier's symptom).

The consistency of the elements is determined by palpation; if the extreme states of consistency are relatively easy to assess, then its transitional forms require an appropriate skill.

On diascopy, in other words, vitropressure, a glass plate (a glass slide or a watch glass) is pressed on a skin area, bleeding it, which helps to study the elements, the color of which is masked by hyperemia from reactive inflammation. This method makes it possible to recognize, for example, elements of lupus erythematosus, which acquire a characteristic brownish-yellow hue during diascopy (apple jelly phenomenon).

In some dermatoses, on apparently healthy skin, in response to its irritation, rashes occur, which are characteristic this disease. This phenomenon is called an isomorphic irritation reaction. This reaction can occur spontaneously, in places subjected to friction, maceration, intense solar radiation, for example, in patients with eczema, neurodermatitis, lichen planus, or it can be artificially caused by irritation in psoriasis (Köbner's symptom), lichen planus in an advanced stage. Urticarial dermographism in urticaria is also an example of an isomorphic reaction. The stratum corneum is clarified with vaseline oil, sometimes with lichen erythematosus, to better identify the sign of Wickham's "grid".

Non-invasive also include modern methods research - dermatoscopy and dermatography. With dermatoscopy using a 20x magnification through a layer of liquid oil, skin elements can be clearly seen, especially in the differential diagnosis of pigmented rashes. Dermatography is based on ultrasonic (20 Mhz) examination of skin layers and subcutaneous tissue. Using this method, one can judge the depth of the primary and secondary elements, the effectiveness of the therapy, the water content in the skin, and many other parameters.

In order to confirm the diagnosis allergic disease widely used skin tests (tests). There are skin (application), scarifying, and intradermal (intradermal) tests. More often, an application test is used using the Yadasson compress (patchwork) method, or a drop test proposed by V.V. Ivanov and N.S. Vedrov. In some cases, scarification and compress (scarification-application) methods are combined.

Skin and intradermal reactions with tuberculin (Pirk, Mantoux, Nathan-Kollos) is used in patients with tuberculous skin lesions. However, their negative answer does not rule out a specific process. The result is considered positive if a reaction occurs to large dilutions of tuberculin. Intradermal tests with fungal filtrates and vaccines are used in some ringworms, although non-specific positive results are sometimes observed. Intradermal tests with specific antigens are used for leprosy (with lepromine), inguinal lymphogranulomatosis (Frey reaction), tularemia (with tularin), glanders (with malein), etc.

Skin tests with possible food allergens (for eczema, atopic dermatitis, etc.) are rarely used in dermatological practice. Usually, clinical observation of the patient is carried out with the exclusion from food of certain products suspected of being causally significant. The same is true for pyrethrum and some flowers.

In patients with occupational dermatoses, skin tests with various chemicals are used to confirm their association with chemical agents.

If drug dermatitis is suspected, after its resolution, sometimes for the purpose of prevention they resort (with the consent of the patient) to an oral or parenteral test with very small doses of the suspected allergen (often with a sulfanilamide drug). Skin tests in cases of allergic medicinal dermatitis do not always give positive results.

AT last years The use of skin tests in the diagnosis of allergic diseases has been criticized. These tests can lead to severe complications with significant general and focal reactions, especially in patients with a severe allergic condition. In addition, skin tests can enhance sensitization and progression of the process due to the release of biologically active substances. It should be remembered that in case of sensitization to antibiotics, the introduction of even its minimum amounts (up to 10 IU) can cause anaphylactic shock with a fatal outcome in a patient. They should be replaced by indirect methods for diagnosing an allergic condition. These include an increased content of beta and gamma globulins, etc., as well as serological reactions (Coombs, hemagglutination, Felner and Beer agglutinations, precipitation, complement fixation, immune adhesion, etc.) and cytological phenomena

(Fleck's leukocyte agglomeration test, Shelley's basophil degranulation test, leukocytolysis reaction, leukopenic test, thrombocytopenic index).

The results of a clinical blood test play a decisive role in leukemic diseases accompanied by manifestations on the skin. If Dühring's dermatitis herpetiformis is suspected, the diagnosis is confirmed by eosinophilia in the blood and in the contents of the blisters, which is especially important when differential diagnosis with bubble. In these cases, a cytological examination of the contents of the blisters or imprint preparations (Tzank test, pemphigus acantholytic cells) is used, and for the diagnosis of systemic lupus erythematosus, the detection of lupus erythematosus cells (LE-cells) in the blood.

If syphilis is suspected, a complex is made serological reactions(treponema pallidum immobilization reaction, immunofluorescence reaction, passive hemagglutination reaction - RPHA, etc.). Bacterioscopic (for fungi, yeast cells, pale treponema, gonococcus and Trichomonas, scabies mite, etc.) and bacteriological (crops) studies are widely used. Sometimes, in order to clarify the etiology of the disease, it is necessary to infect animals with pathological material taken from the patient (for example, if skin tuberculosis is suspected, pathological material is grafted guinea pigs, if blastomycosis is suspected - to rats).

A biopsy of the affected area of ​​the skin, mucous membrane or morphological element with pathohistological examination of the obtained material in a number of dermatoses provides an invaluable service in establishing a diagnosis. This is especially true for those diseases in which the histological picture is quite characteristic: lichen planus, granuloma annulare, leprosy, urticaria pigmentosa, skin neoplasms, etc. In some cases, the pathological picture may be similar (tuberculosis, syphilis, etc.) and the diagnosis of the disease put on the basis of all the data obtained during the examination, including the result of a biopsy.

For the diagnosis of dermatoses, in the pathogenesis of which autoimmune mechanisms play a certain role, immunological research methods are used, for example, indirect and direct immunofluorescence. The first detects circulating antibodies of classes A, M, G, the second - immune complexes fixed in tissues containing the same classes of immunoglobulins, complement fractions, fibrin.

To identify hypersensitivity various allergens are subjected to skin tests (tests), as well as in vitro tests: reactions of degranulation of basophils, blast transformation of lymphocytes, etc.

4.3. Medico-legal relations in the work of a dermatovenereologist

The change in the social formation that has taken place in our country has introduced new aspects into the relationship between the doctor and the patient. Along with state medical institutions, private offices and clinics appeared, the concept of sale that did not exist before medical services. In 1992, the "Law on the Protection of Consumer Rights", "Fundamentals of the Russian Federation Legislation on the Protection of the Health of Citizens", federal laws on health care were adopted. Amendments were made to the Criminal and Civil Code of 1996 regarding liability medical workers for causing harm to health while providing medical care(services). Moral damage (physical and moral suffering) caused by action (inaction) is subject to compensation. This definition also includes those cases when, during the provision of medical care, no harm was caused to health as such, but the doctor showed disrespect or an inhumane attitude towards the patient.

However, not all doctors evaluate the medical and legal aspects of their activities. Ignorance of the legal foundations of medical activity does not relieve the doctor from responsibility for possible harm which it can cause to the patient. When prescribing treatment, the doctor must make sure that these drugs will not cause complications in this patient. We had to provide urgent assistance to a patient with a history of allergic reaction to Pentrexil, about which she warned the doctor. However, the doctor prescribed the patient the same drug under a different commercial name (ampicillin), which caused a severe complication in the form of Stevens-Johnson syndrome, which required hospitalization of the patient. The actions of the doctor were qualified as inadequate quality of medical care.

Work medical institutions and medical personnel is regulated by orders and normative documents higher medical organizations, but in practice doctors, especially young ones, do not know the content of these documents. Acquaintance with them has not yet been provided for by the educational program in medical higher educational institutions. At the same time, ignorance of legal issues does not relieve the doctor of responsibility for errors.

The relationship between the doctor and the patient includes 3 main stages: taking an anamnesis, listening to the patient's complaints, examining the patient and establishing a diagnosis, and treating the patient.

The doctor's ability to listen carefully to the patient largely determines the establishment of contact with the patient. Even if one glance at the patient is enough for the correct diagnosis of the disease, the doctor must allow the patient to state his complaints. Haste, lack of attentiveness of the doctor can cause a denial reaction in the patient, which does not contribute to successful treatment. Such patients go from one doctor to another, cultivating a skeptical attitude about the possibility of their recovery. The pathological psychosomatic state of the patient, which underlies many dermatoses, deepens.

Examination of the patient and the establishment of a diagnosis should be fully reflected in the medical history. This is an important medical diagnostic and legal document that can be used in investigative and judicial proceedings. Careless registration of the medical history testifies against the doctor in a conflict case and leads to various sanctions, including judicial ones. The main causes of conflict situations are the inadequate quality of medical care, diagnostic errors, the choice of erroneous treatment tactics, shortcomings in maintaining primary medical records.

Legislative regulations aim to protect the rights of patients, while the rights of physicians remain essentially unprotected. Most lawsuits against dermatovenereologists are resolved in favor of patients. In such a situation, the doctor can rely only on complete and correctly executed medical documentation and on his legal literacy. Corrections, stickers, insertions into the text of medical documents are qualified as made retroactively.

"Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" define the right of citizens to informed voluntary consent to medical intervention (Article 32), to refuse medical intervention (Article 33), to confidentiality (Article 30), to information about their health status (Article 31). The patient does not have special medical knowledge, therefore the doctor is obliged to provide the patient with information about his disease, about the recommended treatment tactics, about possible complications in a form accessible to the patient. Without the consent of the patient for the entire list of services, the actions of a medical worker are not lawful. The patient thus consciously participates in the healing process. Correct information allows you to establish trust

relationship between doctor and patient. The signature of the patient confirms his consent to the proposed examination and treatment.

Currently, a number of medical institutions have introduced the practice of obtaining the informed consent of the patient to conduct this or that intervention. Such consent must be obtained both for the planned examination and for the proposed treatment.

The doctor assesses the result of the treatment as “clinical recovery” or “clinical improvement”. These concepts are subjective and can be challenged by a patient who has not received the expected effect. Detailed records in the medical history (outpatient card), reflecting the dynamics of the clinical picture of the disease, serve as protected medical documentation. In foreign dermatological clinics, patients are photographed before and after treatment. The availability of digital devices, the simplicity and speed of obtaining prints on plain paper make it easy to document the patient's objective condition.

One of the development trends modern medicine- the use of medical and diagnostic standards in the practice of a doctor. The standards are designed to provide the best balance between clinical efficacy, safety and cost of therapeutic and diagnostic interventions. They guarantee the relief of the patient's suffering and at the same time are an important element of the doctor's legal protection. Description of medicines included in the treatment and diagnostic standards are based on evidence-based medicine: indications for use and side effects are ranked according to the level of reliability depending on the number and quality of the conducted clinical research. Treatment standards

include recommended regimens that provide the best balance between treatment efficacy and proven drug safety. Alternative regimens provide acceptable treatment results in the absence of the possibility of using the recommended regimens in case of age restrictions, individual intolerance, pregnancy, lactation, etc.

4.4. Histomorphological changes in the skin

Many skin diseases are inflammatory in nature. Depending on the severity and duration of the reaction, acute, subacute and chronic inflammation is conditionally distinguished, which occurs under the influence of various external and internal stimuli. The reaction of the body and skin to the action of the stimulus depends on the state of the receptor apparatus, higher nervous activity in this person, reactivity of the organism and other factors.

In the microscopic picture of each inflammation, alteration, exudation and proliferation of varying severity are distinguished. Under alteration understand the manifestations of tissue damage (dystrophy and necrosis of tissue elements), under exudation- exit from the vessels of fluid and formed elements due to increased permeability of the vascular wall, under proliferation- reproduction of tissue elements. In cases of acute inflammation, vascular-exudative phenomena predominate, and the inflammatory process is more intense. In cases of chronic inflammation, proliferative phenomena predominate, the vascular-exudative component is much less pronounced, and the inflammatory process is not bright. According to the intensity of inflammatory reactions, subacute inflammation occupies a middle place between acute and chronic inflammation.

Pathological processes in the epidermis proceed in a peculiar way due to anatomical features. Inflammatory changes in the epidermis can manifest themselves:

in the form of intracellular edema, or vacuolar degeneration, in which vacuoles are formed in the protoplasm of the cells of the Malpighian layer, located near or around the nucleus and pushing the nucleus to the periphery. In this case, the core is deformed and often has all the signs

pycnosis. The edematous fluid gradually dissolves the cell, leading to its death. If vacuoles are localized in the cell nucleus, then it swells and turns into a round vial filled with liquid, in which the nucleolus is sometimes preserved. Vacuole degeneration is observed in lichen planus, lupus erythematosus, scleroatrophic lichen, and vascular atrophic poikiloderma;

in the form of spongiosis, or intercellular edema, in which the edematous fluid pushes the intercellular spaces of the Malpighian layer, breaks the intercellular bridges, which leads to a loss of communication between the cells, swelling of the cells themselves and the beginning of the formation of epithelial vesicles. Spongiosis is characteristic of eczema and dermatitis;

in the form of balloting degeneration, arising from necrobiotic, degenerative changes in the cells of the Malpighian layer. In addition to profound changes in epithelial cells, the destruction of intercellular bridges leads to the fact that the cells lose their mutual connection and freely float in the serous-fibrinous contents of the vesicle, taking a spherical shape. Such changes are noted in viral diseases, for example, with herpes. In skin diseases accompanied by inflammation, combinations of variants of serous edema are more common.

At acute inflammation in the infiltrate, polymorphonuclear leukocytes (neutrophils, eosinophils) predominate; in chronic infiltrate, it contains mainly lymphocytes located diffusely or around the vessels. The infiltrates contain numerous histiocytes.

Plasma cells have a well-developed basophilic cytoplasm, the nucleus is located eccentrically, and they are larger than lymphocytes. Epithelioid cells have an elongated shape, a large round or oval nucleus and abundant cytoplasm. Large multinucleated cells of a round or oval shape with uneven contours are called giant cells.

In addition to the phenomena of serous inflammation, a number of special pathological changes can be noted in the epidermis.

Acanthosis- an increase in the number of rows of cells of the prickly layer of the epidermis. There are simple acanthosis - a uniform and moderate increase in the rows of cells of the prickly layer above and between the papillae of the dermis (juvenile warts); interpapillary acanthosis - mainly between the papillae of the dermis (psoriasis); infiltrating acanthosis - a pronounced proliferation of cells of the spiny layer, in which

processes of the epidermis penetrate the dermis to a considerable depth (warty tuberculosis).

Acantholysis - melting of intercellular epithelial bridges, disruption of communication between epithelial cells, as a result, the cells are easily separated and form more or less significant layers of exfoliating epidermis. This process is observed with pemphigus, Darier's disease, with viral dermatoses.

Hyperkeratosis (hyperkeratosis) - excessive thickening of the stratum corneum without structural changes in cells, parakeratosis - violation of the process of keratinization(the granular and eleidine layers are absent) in the stratum corneum of the epidermis.

Granulosis - thickening of the granular layer of the epidermis.

The ability to distinguish between the elements that make up a skin rash allows you to correctly assess the pathological process and approach the diagnosis of dermatosis. In many cases, the clinical picture, "written on the skin" by eruptive elements and their location, makes it possible to establish a diagnosis and begin therapy; in some cases, diagnosis requires additional examination methods (including laboratory ones). These data are presented in a special section of the textbook devoted to individual nosological forms of dermatoses.

Skin rashes can be inflammatory or non-inflammatory, inflammatory are more common. Non-inflammatory manifestations include dark spots, tumors, atrophies, hyperkeratosis, etc.

The inflammatory process has 5 classic symptoms: redness (ruber), swelling (tumor) soreness (dolor), temperature rise (calor) and dysfunction (functio laesa). However, the severity of these symptoms varies depending on the degree of the inflammatory response, which can be acutely inflammatory or non-acutely inflammatory.

With an acute inflammatory reaction, the classic signs of inflammation are clearly expressed: redness is intense, juicy, with indistinct boundaries of the lesions as a result of the severity of the exudative reaction, often leading to the appearance of cavity formations (serous or purulent). Itching or burning, local fever, sometimes soreness in the lesion. All this can lead to dysfunction.

With a non-inflammatory, or chronic, reaction, the symptoms of inflammation are less pronounced, congestive shades of lesions predominate (cyanosis, liquidity, brownishness) with clear grains.

nitsy, expressed infiltrative component of inflammation with proliferation of cellular elements. In such patients, pain and burning are absent, and itching is sometimes quite severe.

In accordance with the histomorphological difference between acute and non-acute inflammation, the primary elements are divided into exudative and infiltrative. Infiltrative elements include a spot, nodule, tubercle and node, exudative elements include a vesicle, bladder, abscess and blister.

Eruptions arising on the skin, mucous membranes consist of separate elements, which are divided into primary and secondary. The primary elements are rashes that occur on intact skin, the red border of the lips or the mucous membrane of the mouth, i.e. the disease begins with them, they are not a transformation of already existing rashes. Secondary elements are rashes that have developed as a result of transformation or damage to existing elements.

However, the division of elements into primary and secondary is largely arbitrary. There are diseases that begin with elements that are considered to be secondary. For example, the dry form of exfoliative cheilitis begins with scales, which are secondary elements; erosion with erosive-ulcerative form of red lichen planus are not a consequence of bubbles, etc.

Knowledge of the elements of the rash allows you to navigate the extensive and variable pathology of the skin, oral mucosa and lips, and correctly diagnose the disease.

4.5. Primary morphological elements

The primary elements of the rash include a spot, a blister, a blister, a vesicle, an abscess, a nodule, a tubercle, and a nodule, while the secondary elements include pigmentation disorders, scales, erosion, excoriation (abrasions, traumatic erosion), an ulcer, a fissure, a crust, a scar, and cicatricial atrophy. , vegetation, lichenization (lichenification).

Spot (macula) is a limited discoloration of the skin or mucous membrane. Usually the spot is located on the same level with the surrounding skin, does not differ from it in consistency and is not felt during palpation (Fig. 2).

Spots are divided into vascular, including hemorrhagic, and dyschromic(Fig. 3).

Vascular spots are clinically manifested by limited reddening of the skin as a result of vasodilation of the superficial vascular

plexus. They are divided into inflammatory and non-inflammatory. Inflammatory vascular spots are called limited redness of the skin of various sizes, caused by external or internal irritating factors (Fig. 4). Depending on the degree of filling of the blood vessels, the spots have a red, pink or purple (bluish, stagnant) color.

When pressing on the spots resulting from the expansion of the skin vessels, they disappear and after the cessation of pressure they reappear in the same form.

Small pink inflammatory spots, less than 1 cm in diameter, are called roseola. Roseola occurs with secondary syphilis, measles, scarlet fever, typhoid fever, drug rashes, etc. It is acutely inflammatory - bright pink in color, with indistinct boundaries, a tendency to merge and peel, often with swelling and itching, and not acutely inflammatory - pale pink color with a brownish tint, not itchy, as a rule, not merging. Acute inflammatory roseola appears as a primary element in patients with measles, scarlet fever, eczema, dermatitis, pink lichen; not acute inflammatory - in patients with secondary (rarely tertiary) syphilis, erythrasma, pityriasis versicolor.

Rice. 2. Spot (macula)

Rice. 3. dyschromic spot

Rice. four. vascular spot

Large vascular spots (10 cm or more) are called erythema. They are edematous, with irregular outlines, bright red, accompanied by itching and occur, as a rule, as a result of acute inflammatory vasodilation in patients with eczema, dermatitis, with first-degree burns, erysipelas, exudative erythema multiforme.

With emotional arousal, neurotic reactions, large confluent non-inflammatory spots appear (short-term expansion of the vessels of the superficial vascular plexus) without itching and peeling, which are called "erythema of embarrassment" (anger or shame).

Spots caused by persistent non-inflammatory expansion of the superficial vessels (capillaries) of the skin are called telangiectasias. They are

also temporarily disappear with pressure and appear when the pressure is stopped. Telangiectasias can exist independently and be included in the clinical picture of rosacea, scarring erythematosis, and some other skin diseases. Congenital include non-inflammatory vascular birthmarks(nevi).

With an increase in permeability vascular walls hemorrhage into the skin may occur, resulting in the formation of so-called hemorrhagic spots, not disappearing under pressure. Depending on the time elapsed after the hemorrhage, the color of such spots can be red, bluish-red, purple, green, yellow (as hemoglobin is converted into hemosiderin and hematoidin). These spots are distinguished by size: pinpoint hemorrhages are called petechiae, small round and usually multiple hemorrhages up to 1 cm - purple, large hemorrhages of irregular outlines - ecchymosis; in cases of massive hemorrhages with swelling of the skin and its elevation above the level of the surrounding areas, they speak of hematoma. Hemorrhagic spots occur with allergic skin vasculitis, scurbut (hypovitaminosis C), some infectious diseases(typhoid, rubella, scarlet fever, etc.).

With an increase or decrease in the content of melanin pigment in the skin, dyschromic spots, which are hyperpigmented (increased pigment) and depigmented (reduced pigment). Age spots can be congenital (moles, lentigo) and acquired (freckles, chloasma, vitiligo).

Freckles are classified as hyperpigmented spots (small areas of light brown, brown color, formed under the influence of

I eat ultraviolet rays), lentigo (foci of hyperpigmentation with symptoms of hyperkeratosis), chloasma (large areas of hyperpigmentation resulting from Addison's disease, hyperthyroidism, pregnancy, etc.).

Small depigmented patches are called leukoderma. True leukoderma occurs in patients with secondary recurrent syphilis (depigmented spots form on a hyperpigmented background). False, or secondary, leukoderma (pseudo-leukoderma) is observed at the site of former morphological elements (often spotty-scaly) in a number of dermatoses (pityriasis versicolor, psoriasis, etc.), when the surrounding areas of healthy skin have been exposed to ultraviolet radiation (tanning). In vitiligo, areas of various sizes are devoid of pigment, which is associated with neuroendocrine disorders and enzymatic dysfunction.

With a congenital absence of pigment in the skin with insufficient coloring of the eyebrows, eyelashes and hair on the head, they speak of albinism.

Nodule, or papule (papula) - a cavityless, more or less dense element, rising above the level of the skin and resolving without scarring or cicatricial atrophy (Fig. 5). Sometimes papules leave behind unstable marks - pigmentation or depigmentation. Papules that occur predominantly in the epidermis are called epidermal(for example, flat wart), in dermis - dermal(with secondary syphilis). Most often, papules have an epidermodermal location.(for example, with lichen planus, lichen scaly, neurodermatitis).

Papules are divided into inflammatory and non-inflammatory. The former are much more common: with lichen scaly, eczema, secondary syphilis, lichen planus and acute lichen, neurodermatitis, etc. With them, the formation of an inflammatory infiltrate in the papillary dermis, vasodilation and limited edema are noted. Pressure on the papule leads to its blanching, but its color does not completely disappear. For non-inflammatory papules growth of the epidermis (wart) or deposition in the dermis of pathological metabolic products

Rice. 5. knot (papula)

(xanthoma) or proliferation of dermal tissue (papilloma). Some dermatologists distinguish acute inflammatory papules (exudative papules in patients with eczema, dermatitis), resulting from the accumulation of exudate in the papillary dermis during acute expansion and increased permeability of the vessels of the superficial capillary network.

Papules come in various sizes: from 1 mm and larger. Papules with a size of 1 mm are called miliary (milium- millet grain), or lichen-nom (with lichen planus, with scrofulous lichen), size from 0.5 to 1 cm - lenticular (lenticula- lentils), they are with psoriasis, secondary syphilis, etc., size from 1 to 2 cm - nummulary (nummus- coin). Larger papules (hypertrophic papules) are found mainly in secondary recurrent syphilis (condylomas lata). Merged papules form plaques up to 10 cm in diameter. Papules usually have well-defined borders, but different shape(rounded, oval, flat, polygonal, pointed with an umbilical depression, domed) with a smooth or rough surface. The consistency of nodules (soft, doughy, densely elastic, dense, hard) and their color (normal skin color, yellow, pink, red, purple, prominent, brown, etc.) can also be varied.

On the contact surfaces of the skin due to friction, on the mucous membranes due to the irritating effect of saliva, secrets, foods, etc., the surface of the papules can be eroded (eroded papules), and the papules themselves can increase in size, hypertrophy. Nodules with a villous surface are called papillomas.

Histologically, with papules in the epidermis, there are phenomena of hyperkeratosis, granulosis, acanthosis, parakeratosis, in the papillary layer of the dermis - the deposition of various infiltrates.

Tubercle (tuberculum) - an infiltrative non-cavitary neo-inflammatory element, rising above the level of the skin, often ulcerating and ending in scarring or cicatricial atrophy (Fig. 6). By appearance, especially at the initial stage, it is difficult to distinguish from a nodule. So, the size, shape, surface, color and consistency of the tubercle and nodule may be similar. The inflammatory cell infiltrate of the tubercles lies not only in the papillary, but mainly in the reticular layer of the dermis and histologically represents an infectious granuloma, which either ulcerates with subsequent scar formation, or undergoes resorption, leaving

after cicatricial atrophy. This is the main clinical difference between tubercles and nodules, which allows many years after the end of the process to differentiate, for example, tubercles in tertiary syphilis or tuberculous lupus (not only the existence of scars or atrophy is taken into account, but also their location, for example, mosaic scar in syphilis, bridges in tuberculous lupus, etc.).

In some cases, the tubercles have a rather characteristic color: red-brown with tertiary syphilis, red-yellow with tuberculous lupus, brownish-rusty with leprosy.

In various diseases, tubercles have distinctive features of the histological structure. So, for example, a tubercle in skin tuberculosis consists mainly of epithelioid cells and a different number of giant cells - Langhans (rarely, Mycobacterium tuberculosis is found in the center; there are usually lymphocytes along the periphery); tubercle in syphilis consists of plasma cells, lymphocytes, epithelioid cells and fibroblasts(Treponemes are not found in the tubercle; there may be a small number of giant cells).

Tubercles, as a rule, occur in limited areas of the skin and either group or merge, forming a continuous infiltrate, much less often they are scattered, disseminated.

Node - primary morphological noncavitary infiltrative neoinflammatory element located in the subcutaneous adipose tissue, large in size - up to 2-3 cm or more (Fig. 7). Node originally

Rice. 6. tubercle (tuberculum)

Rice. 7. Knot (nodus)

Rice. eight. bubble (vesicula)

may not rise above the level of the skin (then it is determined by palpation), and then, as it grows, it begins to rise (often significantly) above the level of the skin. The nodes ulcerate and then scar. The consistency of the nodes is from soft (with collicative tuberculosis) to densely elastic (with leprosy and tertiary syphilis). The peculiarity of nodes in a number of diseases (appearance, color, shape, surface,

consistency, detachable) made it possible to adopt special names for them: scrofuloderma- with collicative tuberculosis, gumma- with tertiary syphilis.

Vesicle (Fig. 8) - the primary cavity exudative element, contains liquid and slightly rises above the level of the skin. In the vesicle, a cavity filled with serous, less often serous-hemorrhagic contents, a tire and a bottom are distinguished. Bubbles can be located under the stratum corneum, in the middle of the epidermis and between the epidermis and dermis; they can be single-chamber and sometimes multi-chamber (in this case, it seems that the patient has a bladder, but it does not have partitions). The bubble size is from 1 to 3-4 mm. The contents of the bubble can be transparent, serous, rarely bloody; often cloudy, becomes purulent. This occurs when the vesicle (vesicle) transforms into an abscess (pustule). The liquid of the bubble dries up into a crust or its cover bursts, an eroded surface is formed and weeping occurs, as with eczema in the acute stage. Vesicles may be located on intact skin, but more often have an inflammatory erythematous base. On the oral mucosa, on the contact surfaces of the skin, the bubbles quickly open, exposing the eroded surfaces; in places with a thicker tire (for example, on the palms with dyshidrosis), they last longer. The vesicles pass without a trace or leave behind temporary pigmentation, as, for example, in Dühring's herpetiform dermatosis.

When bubbles form, histologically observed spongiosis (eczema, dermatitis), ballooning degeneration (simple bubble

vy and shingles, chicken pox), intracellular vacuolization (dyshidrotic eczema, epidermophytosis).

Bubble (Fig. 9) - an exudative cavity element with a size of 1 cm or more. Like the vesicle, it consists of a tire, a cavity filled with serous contents, and a base. When the cavity is located under the stratum corneum, the bladder is called subcorneal, in the thickness of the spiny layer - intraepidermal, between the epidermis and dermis - subepidermal. The shape of the bubbles is round, hemispherical or oval; the contents are transparent, yellowish, less often hazy or hemorrhagic. The blisters contain leukocytes, eosinophils, epithelial cells. For the diagnosis of some dermatoses, a cytological examination of imprint smears or scrapings from the bottom of the bladder is important, since in a number of dermatoses cellular composition has features.

On the contacting surfaces of the skin, as well as on the mucous membranes, the blisters quickly open, forming erosive surfaces with a side of scraps (border) of the blisters.

Blisters occur with pemphigus vulgaris, congenital pemphigus, erythema multiforme exudative, burns, drug toxicoderma and some other skin diseases.

More often the bubble appears against the background of an erythematous spot, but it can also exist on apparently unaltered skin (in patients with pemphigus vulgaris).

With exogenous penetration of microorganisms into the skin, blisters can form due to damage to the epidermis by an infectious agent (for example, streptococci) or their toxins. With burns, serous exudate lifts the necrotic area of ​​the epidermis. The formation of intraepidermal blisters is often promoted by various endogenous factors; at the same time, there is a violation of intercellular connections (acantholysis) and degenerative changes epidermal cells. In case of violation of the structure of the basement membrane, edematous fluid or exudate protruding from the vessels exfoliate

Rice. 9. Bubble (bulla)

the entire epidermis (epidermolysis) and subepidermal blisters occur, for example, with polymorphic exudative erythema. In pemphigus, the location of the blisters is intraepidermal (in the spinous layer), there are single or clustered acantholytic cells.

Bubbles can occur both on externally unaltered skin or mucous membranes, and against the background of inflammation. The mechanism of bubble formation is different. Intraepidermal blisters are usually formed as a result of acantholysis.

The essence of the process is the melting of intercellular bonds (acanthus), spiny cells are separated and gaps filled with exudate appear between them, which then turn into bubbles. At the same time, spiny cells are rounded, slightly reduced, their nuclei become larger than those of ordinary cells. They line the bottom of the bubble. These acantholytic cells (Tzank cells) are of great diagnostic value and confirm the diagnosis of pemphigus. Subepidermal blisters form between the layers of the basement membrane or directly above or below it and are the result of a violation of the strength of the connection of the fibers that form it, which is also possible as a result of immune changes.

Pustule, or pustule (pustula) (Fig. 10) - an exudative cavity element protruding above the level of the surrounding skin, containing pus. Under the influence of waste products of microorganisms (mainly staphylococci), necrosis of epithelial cells occurs, as a result of which an abscess cavity is formed in the epidermis. An abscess lying in the thickness of the epidermis and prone to crusting is called impetigo. After the crust falls off, temporary pigmentation of the affected area remains. Pustules located around the hair follicles are called folliculitis. If a pus penetrates into the mouth of the hair funnel, the center of the abscess penetrates the hair, is formed osteofolliculitis.

Folliculitis can be superficial, leaving no traces behind, and deep (the process captures the part of the follicle lying deep in the dermis), followed by the formation of a scar. The most common causative agent of folliculitis is staphylococcus aureus. A deep non-follicular abscess that also involves the dermis is called ecthyma. When it resolves, an ulcer is formed that heals with a scar. Streptococcus causes ecthyma. A streptococcal superficial pustule (flaccid, flat) is called conflict.

Pustules are always surrounded by a pink halo of inflammation. Sometimes pustules arise secondarily from vesicles and blisters when a secondary pyococcal infection occurs.

Blister (urtica) (Fig. 11) - exudative asexual element, formed as a result of limited acute inflammatory edema of the papillary layer of the skin. The blister is a dense, cushion-like, round or, less commonly, oval-shaped elevation and is accompanied by intense itching. A blister is an ephemeral formation, it usually quickly (from several tens of minutes to several hours) and disappears without a trace. The sizes of the blisters range from 1 to 10-12 cm. Due to the expansion of the vessels that occurs simultaneously with the swelling of the papillae, the color of the blisters is pale pink. With a sharp increase in edema, the vessels are compressed and then the blisters become paler than the skin.

Blisters can occur at the sites of bites of mosquitoes, mosquitoes and other insects, from the action of heat, cold, when touching stinging nettles (external factors), with intoxication and sensitization ( internal factors). Urticaria on the skin it happens with drug, food and infectious allergies (urticaria, angioedema angioedema, serum sickness); it can be caused by mechanical irritation of the affected areas of the skin, for example, with urticaria pigmentosa. In some cases, mechanical irritation of the skin causes large long-existing blisters. (urticaria factitia, or dermografismus urticaris).

Despite the intense itching that accompanies the rash of blisters, traces of scratching on the skin are usually not found in patients.

Rice. ten. abscess (pustula)

Rice. eleven. Blister (urtica)

4.6. Secondary morphological elements

Secondary morphological elements arise in the process of evolution of primary morphological elements. These include age spots, scales, crusts, superficial and deep cracks, abrasions, erosions, ulcers, scars, lichenification and vegetation.

Pigmentation (Fig. 12). Primary pigmentation includes freckles, chloasma, pigmented birthmarks, etc., secondary pigmentations include hyperpigmentation resulting from increased deposition of melanin pigment after resolution of primary (nodules, tubercles, vesicles, blisters, pustules) and secondary (erosions, ulcers) elements, and also due to the deposition of a blood pigment - hemo-siderin in the so-called hemosiderosis of the skin. Secondary hypopigmentations (Fig. 13) are associated with a decrease in the content of melanin in certain areas of the skin and are called secondary leukoderma. Secondary pigment spots repeat the size and shape of the elements in the place of which they formed.

Scale (squama) (Fig. 14) represents torn off horny plates. Under physiological conditions, there is a constant imperceptible rejection of the plates of the stratum corneum; the plates are removed by washing and rubbing with clothing. With a number pathological conditions skin forms scales visible to the naked eye (pathological peeling). If, during peeling, small, tender scales appear, resembling flour or bran, then they are called bran-like, and peeling small plate; such peeling is observed, for example, with pityriasis versicolor. Larger scales are called lamellar, and peeling desquamatio lamelosa; such peeling occurs, for example, in psoriasis. In some skin diseases, for example, with erythroderma, in cases of scarlet fever-like dermatitis, the stratum corneum is rejected in large layers. For a number of dermatoses, such as ichthyosis, scales are one of the permanent objective symptoms.

For the diagnosis of processes with the formation of scales, their thickness, color, size, consistency (dry, oily, brittle, hard), and tightness are important. Scales that are tightly adjacent to the underlying tissues are formed as a result of hyperkeratosis, easily rejected scales - as a result of parakeratosis. Scales can also develop initially: parakeratotic with dandruff, mild leukoplakia, exfoliative cheilitis, hyperkeratotic with ichthyosis, etc.

Scales are formed, as a rule, due to parakeratosis (impaired horn formation), when there is no granular layer in the epidermis, and there are remnants of nuclei in the horny plates. Less often, peeling occurs as a result of hyperkeratosis, i.e. excessive development of ordinary horny cells or keratosis (layering of dense dry horny masses, for example, with corns).

Knowledge of the form of peeling and the type of scales helps in the diagnosis of a number of dermatoses. So, silvery-white scales are found in psoriasis, dark - in some forms of ichthyosis, yellow - in oily seborrhea, loose, easily removable - in psoriasis. Removal of the scales is sometimes painful due to the spike-like horny protrusions on the undersurface of the scales penetrating into the follicular openings of the skin (with lupus erythematosus). With pink lichen, the so-called corrugated and pleated scales, with syphilitic papules, they are collar-nose-shaped ("collar" Bietta), with parapsoriasis look like "wafers"(central peeling), with a number of fungal diseases occurs peripheral peeling etc.

Crust (crusta) (Fig. 15) is formed as a result of drying on the skin of serous exudate, pus or blood

Rice. 12. Pigmentation (pigmentation)

Rice. 13. Hypopigmentation (hypopigmentatio)

Rice. fourteen. Flake (squama)

vi, sometimes with an admixture of particles of used drugs. There are serous, purulent, serous-purulent, purulent-hemorrhagic, etc. crusts. They are formed when vesicles, blisters, pustules dry out, with ulceration of tubercles, nodes, with necrosis and purulent fusion of deep pustules. Layered massive oyster-like crusts are called rupee (rupiah); while the upper part of the crust is the oldest and at the same time the smallest.

The color of the crusts depends on the discharge from which they are formed: with serous discharge, the crusts are transparent or yellowish, with purulent discharge - yellow or greenish-yellow, with bloody discharge - red or brownish. With a mixed discharge, the color of the crusts also changes accordingly.

Crusts often form on the red border of the lips (with pemphigus, exudative erythema multiforme, vesicular lichen, with various cheilitis, etc.). On the skin, crusts occur with scabies, mycoses, pyo-dermatitis, eczema, neurodermatitis, with various syphilides, etc.

Mixed layers on the skin, consisting of scales and crusts, are called scale-crusts; they are found in seborrhea, in some cases of exudative psoriasis.

Surface crack (fissura) is formed only within the epidermis and heals without leaving traces (Fig. 16).

Deep crack (rhagas), in addition to the epidermis, it captures part of the dermis, and sometimes more deeply lying tissues, leaving behind a scar.

Cracks - linear skin defects - are formed when the skin loses its elasticity as a result of inflammatory infiltration on places subject to stretching (for example, at the corners of the mouth, in the interdigital folds, over the joints, in the area anus etc.), with chronic eczema, intertriginous epidermophytosis of the feet, pyodermic or yeast lesions of the corners of the mouth (jam), diaper rash, etc., as well as from stretching the skin with dryness of its stratum corneum. Deep cracks can be observed in early congenital syphilis. They are located around natural openings and bleed easily. Depending on the depth of occurrence, a serous or serous-bloody fluid is released from the cracks, which can dry out into crusts corresponding to the shape of the cracks.

Abrasion, or excoriation (excoriatio) (Fig. 17) - a skin defect resulting from scratching or any other traumatic injury. Scratching can lead to a violation of the integrity of not only the epidermis, but also the papillary layer of the dermis; in these cases, the scar is not formed.

With a deeper location of the abrasion, after its healing, a scar, pigmentation or depigmentation remains. Excoriations are an objective sign of intense itching. The location and shape of the scratches are sometimes helpful in diagnosis (for example, in scabies).

erosion (Fig. 18) - a superficial skin defect within the epidermis. Erosions occur after the opening of vesicles, blisters, pustules, and in size and shape repeat the primary cavity morphological elements that were in these areas. Most often, erosions are pink or red and have a moist, weeping surface. Large eroded surfaces of the skin and mucous membranes occur with pemphigus. Small erosions occur when the vesicles open in patients with eczema, vesicular and herpes zoster, dyshidrosis, dyshidrotic epidermophytosis of the feet. In the oral cavity, on the contact surfaces of the skin, eroded syphilitic papules often appear; hard chancre can also be in the form of erosion. Erosion heals without scarring.

With prolonged existence of erosion on the mucous membrane of the mouth, its edges can swell and even infiltrate. In this case, it is difficult to distinguish erosion from an ulcer. Sometimes this issue is resolved after

Rice. fifteen. Crust (crusta)

Rice. 16. surface crack (fissure)

Rice. 17. Excoriation (excoriatio)

resolution of the element, since a scar always remains at the site of the ulcer. On the mucous membrane of the mouth and lips, less often on the skin, in some pathological processes, erosive surfaces are formed without a previous bubble, for example, erosive papules in syphilis, erosive-ulcerative form of lichen planus and lupus erythematosus. The formation of such erosions is actually the result of traumatization of an easily vulnerable inflamed mucous membrane or skin. As a result of injury, the integrity of the edematous, often macerated epithelium is disrupted.

Ulcer (Fig. 19) - a skin defect with damage to the epidermis, dermis, and sometimes deeper tissues. Ulcers develop from tubercles, nodes, when opening deep pustules. Only the so-called trophic ulcers are formed as a result of primary necrosis of apparently healthy tissues due to a violation of their trophism. Ulcers are round, oval, irregular shape. The color of the surface of the ulcer is from bright red to bluish-congestive. The bottom can be smooth and uneven, covered with serous, purulent, bloody discharge, with scanty or lush granulations. The edges are smooth, undermined and corroded, flat and elevated, dense and soft.

With a purulent inflammatory process, the edges of the ulcer are edematous, soft, abundant purulent discharge and diffuse hyperemia around the ulcer are noted; with the decay of infectious granulomas (for example, gumma with syphilis), there is a dense limited infiltrate around the ulcer and congestive hyperemia along the periphery. With a dense infiltrate around the ulcer without inflammation, a neoplasm should be assumed.

Scar (cicatrix) (Fig. 20) is formed at the sites of deep skin defects as a result of their replacement with coarse, fibrous connective tissue. At the same time, the papillae of the skin are smoothed out, and the interpapillary epithelial outgrowths disappear; in this regard, the border between the epidermis and the dermis is represented as a straight line horizontal line. Skin pattern, follicular and sweat holes on the scar are absent. There are also no hair, sebaceous, sweat glands, blood vessels and elastic fibers in the scar tissue. The scar is formed either at the site of deep burns, cuts, ulceration of tubercles, nodes, deep pustules, or the so-called dry path, without previous ulceration, for example, with papulonecrotic tuberculosis of the skin or in some cases of tertiary tuberculous syphilis.

Fresh scars are red or pink, older ones are hyperpigmented or depigmented. The scar may be smooth or uneven. When an excessive amount of dense

fibrous tissue, hypertrophic scars appear, rising above the level of the skin; they bear the name keloid.

More tender connective tissue and in a smaller amount than with a scar is formed during the so-called cicatricial atrophy. In this case, the skin in the area of ​​the affected area is significantly thinned, mostly devoid of a normal pattern, often sinks, i.e. is below the level of the surrounding skin (Fig. 21). Atrophy develops, as a rule, without previous ulceration of the lesion, those. "dry way" (with lupus erythematosus, scleroderma). Such skin, when squeezed between the fingers, gathers into thin folds like tissue paper.

In the diagnosis of a previously pathological process in a patient, the localization, shape, number, size and color of scars often help. So, syphilitic gumma leaves behind a deep retracted stellate scar, collicative tuberculosis of the skin - retracted uneven, irregularly shaped bridge-like scars in the region of the lymph nodes. The same scars on other parts of the skin can be caused not only by tuberculosis, but also by chronic deep pyoderma. Papulonecrotic tuberculosis of the skin leaves clearly defined, as if stamped

Rice. eighteen. Erosion (erosio)

Rice. 19. Ulcer (ulcus)

Rice. twenty. Scar (cicatrix)

Rice. 21. Atrophy (atrophy)

Rice. 22. Lichenification or lichenification (lichenisatio, lichenificatio)

Rice. 23. vegetation (vegetation)

bath superficial scars, tuberculous syphilis of the tertiary period of syphilis - variegated mosaic scars with scalloped outlines; in place of resolved rashes in lupus erythematosus, a smooth, thin and shiny atrophy of the skin remains.

Lichenization, or lichenification (lichenisatio, lichenificatio) (Fig. 22) is a thickening, thickening of the skin with an increase in its normal pattern, hyperpigmentation, dryness, roughness, shagreenness. Lichenification develops either primarily, due to prolonged skin irritation during scratching (for example, in patients with neurodermatitis), or secondarily, when papular elements merge (for example, papules in psoriasis, lichen planus, chronic eczema, neurodermatitis - diffuse papular infiltration). With lichenification, hypertrophy of the spinous layer of the epidermis is observed with a significant increase in the interpapillary epithelial processes that penetrate deep into the dermis (acanthosis phenomenon), as well as chronic inflammatory infiltration of the upper dermis in combination with elongation of the papillae.

Vegetations (vegetatio) (Fig. 23) are formed in the area of ​​a long-term inflammatory process as a result of increased

growths of the prickly layer of the epidermis and look like villi, papillae of the dermis. The vegetation surface is uneven, bumpy, resembling cockscombs. If the surface of the vegetation is covered with a thickened stratum corneum, then they are dry, hard and gray in color. If the vegetations are eroded, which is often the case with friction in the lesions, then they are soft, juicy, pink-red or red, bleed easily, separate serous or serous-bloody fluid. When a secondary infection is attached, soreness, a rim of hyperemia along the periphery, and a serous-purulent discharge appear.

Diagnostics and treatment of skin diseases includes work in several key areas. So, there are clinical sections for certain types of pathologies: fungi - mycology, diseases of the scalp and hair - trichology. Dermatology is closely related to venereology, cosmetology, and allergology.

The skin not only hurts itself, but also signals damage to internal organs or systems. Often a dermatological disorder is a consequence of unhealthy habits, lifestyle. Features of the structure and functions of the skin are taken into account when determining and treating numerous dermatoses.

When diagnosing and treating skin diseases, the doctor needs to determine the cause of the symptoms. The impact of external factors is varied.

Internal factors in the development of skin diseases:

• violations of the functions of internal organs,
• chronic infections,
• violations metabolism,
• hypovitaminosis,
• damage to the nervous system.

Internal causes lead to changes in the skin and mucous membranes: pigmentation, hemorrhages.

Itching, burning, soreness, changes in skin color or texture, rash are reasons to see a specialist. Come to the appointment of a dermatologist in Maryino at the Euromed S clinic. An experienced doctor will examine you, collect an anamnesis and make a preliminary diagnosis already at the first appointment. If a fungal or infectious lesion is suspected, tests are indicated. Our clinic conducts laboratory diagnostics so get tested the same day to start therapy sooner. Also used are instrumental radiological methods diagnostics, skin tests.

The elimination of any dermatological pathologies requires patience and strict adherence to prescriptions from the patient. Great importance have:

• meticulous hygiene, especially for affected skin, with the use of antiseptics and other drugs,
• dieting - there are a number of products that complicate the course of skin diseases, slow down treatment; dietary changes are essential for allergic skin lesions,
• use of medicines.

In the absence of a response to conservative treatment the following ways are possible:

• surgical intervention,
• assistance of narrow profile specialists: neurologists, endocrinologists and others.

After a thorough diagnosis, treatment of skin diseases is carried out using several methods.

Many diseases, such as psoriasis, are chronic relapsing. In this case, the task of the doctor and the patient is to achieve a stable remission and maintain it.