Skin disease with pirates diagnosis. Diagnosis of skin diseases

At first glance, it seems that diagnosing a skin disease is as easy as pie, because it is the most accessible organ for research. But in reality 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 skin-related problems are primarily examined with the eyes, the diagnosis of skin diseases is primarily based on examination of the skin and mucous membranes. Well, of course, in addition to the examination, the doctor must have logical thinking. If the doctor is based only on one examination, then this is unlikely to lead to a correct diagnosis.

The first step in making a diagnosis is taking an anamnesis. The doctor must thoroughly question the patient about how the disease began, what symptoms are inherent in it, etc. By collecting anamnesis, the doctor will be able to find out what causes a particular disease. Well, for example, one skin disease can be caused by a disorder of the immune system, and another due to the fact that a person often comes into contact with harmful substances.

In most cases, anamnesis is taken before the examination begins.

What should the medical history include?

• All complaints related to the disease that the patient has.
• The dermatologist must clarify the following information:
• Has the patient had any previous cases of this disease?
• How does the disease develop? Were there any relapses?
• How exactly does the skin change and how long does it take for this to happen?

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

If the doctor suspects the allergic nature of the disease (and even if not), he should ask the patient about what medications he has taken recently. In most cases, the patient remembers that he once took this or that drug only when the dermatologist asks him about it.

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

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

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

In conclusion, I would also like to say that if you find yourself with any rashes and it doesn’t matter whether they bother you or not, be sure to go through. Only a specialist can accurately diagnose and prescribe the correct treatment.

Before treatment for a dermatological disease begins, it is necessary to diagnose and make an accurate diagnosis. Each patient has the right to count on increased attention to himself and the provision of truly worthy medical care. A thorough examination is mandatory, since skin diseases are caused by internal disorders in the human body.

Due to the fact that the causes of the development of diseases turn out to be truly different, a full examination is required, which is the basis for a correct, reliable diagnosis. Modern medical centers can use modern equipment, which is sure to be truly useful for carrying out diagnostic measures and determining further actions.

To make an accurate diagnosis, it is necessary to use various diagnostic methods: laboratory, general clinical, instrumental, histological, microbiological, biochemical. It is important to note that dermatoscopy is commonly used to diagnose skin cancer.

What should a full examination program include?

1. Examination of the patient by a dermatologist.

2. Collecting anamnesis, which involves conducting a survey to find out about previous diseases and medications taken. At this stage, the characteristics of the sick person’s life and his state of health, including mental health, are taken into account.

3. Blood and urine analysis.

4. Scrapings that are required for histological as well as histochemical analysis.

5. Blood test for HIV and syphilis.

7. Dermatoscopy of moles and neoplasms. This technique also allows for timely detection of melanoma.

9. Endoscopic examination, which involves the use of optical instruments.

10. Consultations. In some cases, a neurologist, rheumatologist, endocrinologist, gastroenterologist, and allergist may be involved.

Modern methods of treating dermatological diseases

Modern dermatology has managed to please the emergence of numerous techniques that make it possible to successfully treat even complex dermatological diseases. After a correctly established diagnosis and the correct treatment method, it becomes possible to note decent dynamics and achieve recovery.

EHF therapy can be used for acne, and photochemotherapy can be used to treat skin cancer, which immediately suggests the possibility of successful treatment of even the most complex diseases. To remove skin lesions, a special liquid nitrogen-based procedure called cryodestruction is often used. Immunotherapy can be used to strengthen a person's immune system.

Treatment with one's own stem cells has been successfully used to treat complex pathologies. So, as you have already understood, modern medicine makes it possible to successfully treat serious dermatological diseases.

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, the clinical picture of 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 include 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, increased body temperature, etc.

Complaints. Contact between a doctor and a patient begins with 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 the individual characteristics of the patient, the reactivity of his nervous system. Some patients react very painfully to minor manifestations of the disease, others may present minor complaints when the skin pathology is severe. This especially applies to 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 hundred

The value of the free edge of the fingernails 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 prurigo, neurodermatitis, lichen planus, almost all forms of eczema), others occur without itching or it is mild (psoriasis, pityriasis rosea, pyoderma, acne vulgaris and rosacea, etc.) . In some dermatoses, itching is usually accompanied by scratching (scabies, lice, prurigo, etc.), while in others, despite severe itching, scratching is not observed (urticaria, lichen planus, etc.). In addition, in patients with pruritic dermatoses, the itching usually intensifies 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 patient’s illness and life. A correctly and carefully collected anamnesis 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 anamnesis often facilitates diagnosis, so it is necessary to ask the patient a number of clarifying questions. To what does the patient attribute the occurrence of his disease? When did it first arise (congenital - acquired)? With the consumption of certain products (chocolate, citrus fruits, nuts - often of an allergic nature; shrimp, squid and many other various products - food toxicdermia; bread and everything containing gluten - Dühring's dermatitis herpetiformis)? Is there a connection with taking medications (drug toxicity)? Are the rashes localized only on open areas (photodermatoses? phototoxic reactions to drugs with photosensitizing properties?) or on closed areas too (another dermatosis? photoallergy to drugs?)? (If rashes on open areas of the skin occur a few minutes after sun exposure - solar urticaria; after 24-48 hours - polymorphic photodermatosis (solar prurigo or solar eczema)). Rash around the mouth (perioral dermatitis? allergic reaction to fluoride in toothpaste?).

If you suspect an occupational skin disease, it is important to find out the characteristics of the patient’s work: erysipeloid occurs in workers

sneezing in slaughterhouses, canneries processing raw meat (usually pork), fish, milkmaids' knots - from milkmaids, anthrax - from butchers, tanners, glanders - from veterinarians, grooms and other persons serving animals with glanders. Toxic melasma is observed in individuals who frequently come into contact with hydrocarbons (oil distillation products, gas, etc.). If skin leishmaniasis, leprosy, phlebotoderma and a number of other dermatoses are suspected, it is necessary to find out whether the patient, even for a short time, was in those areas where these diseases occur, for example, if leishmaniasis is suspected - in Central Asia or the Caucasus, with suspected 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 duration of casual sexual contact may be important for establishing a diagnosis.

In the diagnosis of a number of dermatoses, the seasonality of the disease is important. Thus, in autumn and spring, exudative erythema multiforme, pityriasis rosea, erythema nodosum, and herpes zoster more often occur. Patients with photodermatoses, erythematosis, phlebotoderma, meadow dermatitis, epidermophytosis, etc. often consult a doctor for the first time in the spring or summer; patients with chills - in damp and cold seasons.

Sometimes the diagnosis is helped by the tendency of dermatosis to recur (eczema, psoriasis, athlete's foot, exudative erythema, Dühring's dermatitis, herpes simplex, etc.) or, conversely, the absence of a tendency to recur (deep trichophytosis, pityriasis rosea, herpes zoster, etc.).

Anamnesis is of great importance when a drug rash is suspected: the patient indicates that the rashes recur after taking a particular medication, although the patient’s denial of such a connection does not yet exclude a drug rash. Some patients, when carefully collecting anamnesis, indicate that relapses of rashes are associated with the consumption of chocolate, strawberries, crayfish, etc. Information about past and present tuberculosis, syphilis, liver diseases, gastrointestinal tract, blood, etc. also helps in diagnosis. dysfunctions of the nervous system and endocrine glands.

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

its intensity, localization, 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, prurigo nodosum, chronic trichophytosis, systemic scleroderma, erythema nodosum are more common in women, rhinophyma, acne-keloid - in men.

Anamnesis makes it possible to clarify when and in what areas the first manifestations of the disease occurred, how long these manifestations last, what changes occurred in them, i.e. the frequency and duration of relapses and remissions (if any), the relationship of rashes with nutrition and therapy used in the past, the effectiveness of treatment.

Interview with a dermatological patient regarding the life history section (anamnesis vitae), is no different from that in therapeutic clinics.

When 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, cold, taking medications, certain types of food, the effect of chemicals on the skin, 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 what kind and what its effectiveness was. You should pay attention to the effect of water and soap on the skin.

When collecting a life history in order to identify the role of external factors in the pathogenesis of dermatosis, you should pay attention to the patient’s working and living conditions, as well as learn about previous diseases, skin diseases in the patient’s family members and his blood relatives, alcohol consumption and smoking.

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

The patient should be asked to undress completely, even if he complains of isolated rashes. Pay attention to the prevalence of morphological elements, since the process can be universal, affecting the entire skin (erythroderma), the rash can be generalized or local, located symmetrically or asymmetrically. Pay attention to whether the patient has one type of primary elements (monomorphic rash) or different primary elements (polymorphic rash). The location of the elements in relation to each other has important diagnostic significance. Rashes

can be located separately or grouped, forming figures in the form of rings, arcs, lines, etc. When the rashes are located in separate small groups, they are said to be herpetiform. The rash may tend to merge. The boundaries of the lesion may be clear or blurry. Often the localization of the rash has diagnostic significance.

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

An isomorphic reaction (Köbner's symptom) is of important 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 sun rays, etc.).

In some cases resort to special research methods: vitropression(pressure on the affected surface with a watch glass, a glass spatula or a glass slide) to clarify the color of the element, identify caseosis, etc.; layer-by-layer scraping of the element, allowing you to determine peeling. According to 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 resorted to. The material for research is scales, hair, nail plates, the contents of pustules and vesical elements, discharge from erosions and ulcers, blood, etc.

The results of a study of the cellular composition of the vesical fluid, a cytological study of fingerprint smears taken from the surface of erosions to detect acantholytic cells, and data from a general clinical analysis of blood and urine are of important diagnostic significance.

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

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

Furuncle, carbuncle, hidradenitis, ecthyma vulgaris, pityriasis versicolor, erythrasma, athlete's foot, rubrophytosis, scuticular form of favus, vesicular and herpes zoster, erythematosis, scleroderma, eczema, urticaria, lichen planus, lichen planus, chancroid, broad condylomas of the secondary period Syphilis and many other skin and venereal diseases in the “classical” course are easily diagnosed with appropriate length of service and experience. However, in some cases, visual diagnosis is difficult due to the morphological similarity of many dermatoses. Often, in the clinical picture and course of “classical” dermatoses, one or another atypicality is noted. In these cases, a dermatovenerologist, having examined the patient and not being able to establish a diagnosis by the appearance of the rash, and even after using additional examination methods (palpation, diascopy, scraping of rashes, etc.), must clarify the patient’s history and complaints. If necessary, special dermatovenerological studies should be carried out (pathohistological examination of biopsy material, testing for fungi, Treponema pallidum, gonococcus, Mycobacterium tuberculosis, leprosy bacillus, acantholytic cells, serological blood reactions, immunoallergological examination, etc.) in order to establish the final diagnosis of the disease, clarification of its etiology and pathogenesis.

Let us proceed to the presentation of the examination scheme for a dermatological patient.

4.1. Description of the general condition of the body

The general state of health is assessed by mental and physical status, and the correspondence of appearance to age. The examination is carried out according to general rules, so we will present them briefly. The size, density, mobility, and tenderness of the lymph nodes accessible to palpation are examined. The musculoskeletal system is examined and muscle tone is determined. When examining the nose, nasopharynx, percussion and auscultation examination, the condition of the respiratory organs is determined.

They identify complaints about dysfunction of the circulatory system, determine the boundaries of the heart, listen to its sounds, measure blood pressure, and determine the pulse. Then they find out complaints about the functions of the digestive organs, examine the oral cavity, and palpate the abdomen (liver, spleen). When examining 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. The endocrine status and state of the neuropsychic sphere (emotional mobility, performance, sleep, cranial nerve function, skin and tendon reflexes) are determined.

Dermatological status. The study of skin lesions is helped by examining healthy areas of the skin, mucous membranes, and skin appendages. The skin is examined in diffuse 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, muscle turgor 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 not shiny. Changes in skin color may be associated with dysfunction of 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 and folded; the presence or absence of adhesion to underlying tissues is determined by moving the skin.

Of no small importance is dermographism - the reaction of the neurovascular system of the skin to mechanical irritation, indicating the vasomotor innervation of the skin. The appearance of a red stripe after passing a blunt object over the skin (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 diffuse dermographism is observed in eczema, psoriasis, white - in patients with prurigo, exfoliative dermatitis, persistent white or mixed, quickly turning into white - in patients with atopic dermatitis, urticarial (wide swollen, sharply raised stripes of red color after even weak mechanical skin irritations, sometimes disappearing after 40-60 minutes) - in patients with urticaria, prurigo.

The muscle-hair reflex (“gooseflesh”) is obtained by lightly passing a cold object over the skin. Normally, it lasts for 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 and Hebra's prurigo. Its increase occurs in patients with atopic dermatitis with functional disorders of the central and autonomic nervous system.

If leprosy, syringomyelia, or pathomimia are suspected, 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 rash is of inflammatory or non-inflammatory origin. Most manifestations of skin and sexually transmitted 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). Next, indicate the localization of the rash with a description of the predominant location of the elements. Many dermatoses have a favorite localization, but this is of auxiliary importance for establishing a diagnosis. So, for example, with scaly lichen, papulonecrotic tuberculosis of the skin, Hebra pruritus, the rashes are located on the extensor surfaces of the limbs; for tuberculous lupus, erythematosis, acne, etc. - on the skin of the face; for microbial and varicose eczema, erythema nodosum and indurated erythema of Bazin, trophic and chronic pyococcal ulcers, etc. - on the skin of the legs; with pemphigus, ulcerative tuberculosis, etc. - in the oral cavity. Next, 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 asymmetrical.

Then the primary and secondary morphological elements are indicated and their features are described: color, boundaries, shape, outline (configuration), surface, consistency, relationships. An experienced dermatologist distinguishes not only the color of the elements, but also its shades, which often has important diagnostic significance. The boundaries of morphological elements can be clear and fuzzy, sharp and blurred. When describing the shape of elements, for example papules, it should be noted that they are flat, cone-shaped or hemispherical.

new, etc. The outlines of the elements can be round, oval, polygonal or polycyclic, small or large scalloped, etc. The consistency of the elements can be woody-dense, densely elastic, soft, doughy. The surface of the elements can be smooth, rough, bumpy, etc. They can be isolated from each other or drained; in the first case, they talk about the focal location of the rash. If the rash resembles circles, semicircles, ovals, arcs, then they speak of the correct grouping of the rash. An incorrectly grouped rash is located in a certain area, but does not form any geometric figure. Systematized is a rash located along the nerve trunks (with herpes zoster), blood vessels, according to the distribution of dermatometamers, etc. When the rash is randomly distributed, there is no pattern 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 of 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 examination methods dermatological and venereological patients include both general (blood, urine, gastric juice, stool tests for worm eggs, X-ray of the chest organs, etc.) and special (serological, microscopic, pathomorphological examination).

Scraping rashes with a glass slide, scalpel, etc. is used mainly when lichen planus and parapsoriasis are suspected. With psoriasis, it is possible to obtain three characteristic symptoms in succession: “stearin spot”, “film” and “blood dew”, or pinpoint bleeding, with guttate parapsoriasis - a symptom of hidden peeling. With erythematosis, scraping of scales with follicular “spines” is accompanied by pain (Besnier's symptom).

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

During diascopy, in other words, vitropressure uses a glass plate (slide or watch glass) to press on an area of ​​skin, bleeding it, which helps study elements whose color is masked by hyperemia from reactive inflammation. This method makes it possible to recognize, for example, elements of tuberculous lupus, which, upon diascopy, acquire a characteristic brownish-yellow tint (the “apple jelly” phenomenon).

In some dermatoses, on apparently healthy skin, in response to its irritation, rashes characteristic of this disease occur. This phenomenon is called an isomorphic stimulation reaction. This reaction can occur spontaneously, in areas exposed to friction, maceration, intense solar irradiation, for example in patients with eczema, neurodermatitis, lichen planus, or can be caused artificially - by irritation in psoriasis (Köbner's symptom), lichen planus in a progressive stage. Urticarial dermographism in urticaria is also an example of an isomorphic reaction. The stratum corneum is cleared with petroleum jelly sometimes in case of lichen ruber to better identify the sign of Wickham’s “mesh”.

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

To confirm the diagnosis of an allergic disease, skin tests (tests) are widely used. There are cutaneous (application), scarification, and intradermal (intradermal) tests. More often, an application test is used using the compress (patchwork) method of Jadassohn, or the drip 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-Collos) is used in patients with tuberculous skin lesions. However, their negative answer does not exclude a specific process. The result is considered positive when a reaction occurs to large dilutions of tuberculin. Intradermal tests with fungal filtrates and vaccines are used for some dermatomycosis, although nonspecific positive results are sometimes observed. Intradermal tests with specific antigens are used for leprosy (with lepromin), inguinal lymphogranulomatosis (Frey's reaction), tularemia (with tularin), glanders (with malein), etc.

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

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

If drug-induced 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 (usually with a sulfonamide drug). Skin tests in cases of allergic drug dermatitis do not always give positive results.

In recent years, the use of skin tests in the diagnosis of allergic diseases has come under criticism. These tests can lead to severe complications with significant general and focal reactions, especially in patients with severe allergic conditions. In addition, skin tests can contribute to increased 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 administration of even minimal amounts (up to 10 IU) can cause anaphylactic shock with a fatal outcome in the patient. They should be replaced by indirect methods for diagnosing an allergic condition. These include increased levels of beta and gamma globulins, etc., as well as serological reactions (Coombs, hemagglutination, Fellner and Beer agglutination, precipitation, complement fixation, immune adhesion, etc.) and cytological phenomena

(Fleck leukocyte agglomeration reaction, Shelley 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 skin manifestations. 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 in the differential diagnosis of pemphigus. In these cases, a cytological examination of the contents of blisters or fingerprint preparations is used (Tzanck test, acantholytic cells of pemphigus), and to diagnose systemic lupus erythematosus, the detection of lupus erythematosus cells (LE cells) in the blood is used.

If syphilis is suspected, a complex of serological reactions is performed (treponema pallidum immobilization reaction, immunofluorescence reaction, passive hemagglutination reaction - RPHA, etc.). Bacterioscopic (for fungi, yeast cells, Treponema pallidum, gonococcus and Trichomonas, scabies mite, etc.) and bacteriological (culture) 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, the pathological material is inoculated into guinea pigs, if blastomycosis is suspected, into rats).

A biopsy of the affected area of ​​skin, mucous membrane or morphological element with pathohistological examination of the obtained material for a number of dermatoses provides an invaluable service in establishing a diagnosis. This especially applies to 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 based on the totality of all data obtained during the examination, including the result of the biopsy.

To diagnose 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 increased sensitivity to various allergens, skin tests (tests) are performed, as well as in vitro tests: basophil degranulation reactions, blast transformation of lymphocytes, etc.

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

The change in social formation that has occurred in our country has introduced new aspects into the relationship between doctor and patient. Along with state medical institutions, private offices and clinics appeared, and the previously non-existent concept of selling medical services arose. In 1992, the “Law on the Protection of Consumer Rights”, “Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens’ Health”, and federal laws on health care were adopted. Additions were made to the Criminal and Civil Codes of 1996 regarding the liability of medical workers for causing harm to health when providing medical care (services). Moral damage (physical and moral suffering) caused by an 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 inhumane treatment of the patient.

However, not all doctors evaluate the medico-legal aspects of their activities. Ignorance of the legal foundations of medical practice does not relieve the doctor from responsibility for possible harm that he may cause to the patient. When prescribing treatment, the doctor must make sure that these medications will not cause complications in the patient. We had to provide emergency care to a patient with a history of an allergic reaction to pentrexil, which she warned the doctor about. However, the doctor prescribed the same drug to the patient under a different commercial name (ampicillin), which caused a serious complication in the form of Stevens-Johnson syndrome, which required hospitalization of the patient. The doctor's actions were qualified as inadequate quality of medical care.

The work of medical institutions and medical personnel is regulated by orders and regulatory documents of higher medical organizations, but in practice, doctors, especially young ones, do not know the contents of these documents. To date, acquaintance with them has not been provided for in the educational program in medical higher educational institutions. At the same time, ignorance of legal issues does not relieve the doctor of responsibility for mistakes.

The relationship between a doctor and a patient includes 3 main stages: collecting anamnesis, listening to the patient’s complaints, examining the patient and making 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 to correctly diagnose the disease, the doctor must allow the patient to state his complaints. Haste and 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.

The examination of the patient and the diagnosis must be fully reflected in the medical history. This is an important diagnostic, treatment and legal document that can be used in investigative and judicial proceedings. Careless registration of a 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 inadequate quality of medical care, diagnostic errors, choice of erroneous treatment tactics, and deficiencies in maintaining primary medical records.

Legislative regulations are aimed at protecting the rights of patients, while the rights of doctors remain essentially unprotected. Most lawsuits against dermatovenerologists are resolved in favor of patients. In such a situation, the doctor can only rely on complete and correctly completed medical documentation and his legal literacy. Corrections, stickers, and insertions into the text of medical documents are classified 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 the state of their health (v. 31). The patient does not have special medical knowledge, therefore the doctor is obliged to provide the patient with information about his disease, recommended treatment tactics, and possible complications in a form accessible to the patient. Without the patient’s consent to the entire list of services, the actions of a medical worker are not legal. The patient thus consciously participates in the treatment process. Proper information allows you to establish trust

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

Currently, a number of medical institutions have introduced the practice of obtaining informed consent from the patient to carry out a particular intervention. Such consent must be obtained for both the planned examination and the proposed treatment.

The doctor evaluates the result of the treatment as “clinical recovery” or “clinical improvement.” These concepts are subjective and can be challenged by a patient who does not receive 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 objective condition of the patient.

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

include recommended regimens that provide the best balance between treatment effectiveness and proven drug safety. Alternative regimens provide acceptable treatment results in the absence of the possibility of using recommended regimens in the 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, which occurs under the influence of a variety of external and internal stimuli, is conventionally distinguished. 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 a given person, the reactivity of the body and other factors.

In the microscopic picture of each inflammation, alteration, exudation and proliferation are distinguished to varying degrees of severity. Under alteration understand the manifestations of tissue damage (dystrophy and necrosis of tissue elements), under exudation- release of fluid and formed elements from the vessels 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 mild. In terms of the intensity of inflammatory reactions, subacute inflammation occupies a middle place between acute and chronic inflammation.

Pathological processes in the epidermis occur in a unique 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. The core is deformed and often has all the signs

pyknosis. 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 vesicle filled with liquid, in which the nucleolus is sometimes preserved. Vacuolar degeneration is observed in lichen planus, lupus erythematosus, lichen sclerosus, and vascular atrophic poikiloderma;

in the form of spongiosis, or intercellular edema, in which edematous fluid pushes apart the intercellular spaces of the Malpighian layer, breaks intercellular bridges, which leads to loss of communication between 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 voting 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 mutual communication and float freely in the serous-fibrinous contents of the vesicle, taking on a spherical shape. Such changes are observed in viral diseases, for example, herpes. In skin diseases accompanied by inflammation, combinations of serous edema are more common.

In acute inflammation, the infiltrate is dominated by polymorphonuclear leukocytes (neutrophils, eosinophils); in chronic inflammation, the infiltrate contains predominantly lymphocytes located diffusely or around the vessels. The infiltrates contain many histiocytes.

Plasma cells have a well-developed basophilic cytoplasm, the nucleus is located eccentrically, and they are larger in size than lymphocytes. Epithelioid cells have an elongated shape, a large round or oval nucleus and abundant cytoplasm. Large multinucleate round or oval cells 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- increase in the number of rows of cells of the spinous layer of the epidermis. A distinction is made between simple acanthosis - a uniform and moderate increase in the rows of cells of the spinous layer above and between the papillae of the dermis (juvenile warts); interpapillary acanthosis - mainly between the papillae of the dermis (psoriasis); infiltrating acanthosis is a pronounced proliferation of cells of the spinous layer, in which

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

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

Hyperkeratosis - excessive thickening of the stratum corneum without structural changes in cells, parakeratosis - disruption of the keratinization process(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 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 the eruptive elements and their location allows one 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 ones are more common. Non-inflammatory manifestations include pigment spots, tumors, atrophies, hyperkeratosis, etc.

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

In an acute inflammatory reaction, the classic signs of inflammation are clearly expressed: intense redness, juicy, with unclear boundaries of the lesions as a result of the severity of the exudative reaction, often leading to the appearance of cavitary formations (serous or purulent). Itching or burning, local fever, sometimes pain in the affected area. All this can lead to dysfunction.

In non-acute inflammatory or chronic reactions, the symptoms of inflammation are less pronounced, stagnant shades of the lesions predominate (cyanosis, fluidity, brownishness) with clear boundaries.

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

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

The rashes that appear on the skin and mucous membranes consist of individual elements, which are divided into primary and secondary. Primary elements are rashes that appear on unchanged skin, the red border of the lips or the oral mucosa, i.e. The disease begins with them, they are not a transformation of already existing rashes. Secondary elements are rashes that develop 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 secondary. For example, the dry form of ex-foliative cheilitis begins with scales, which are secondary elements; erosions in the erosive-ulcerative form of lichen planus are not a consequence of blisters, etc.

Knowledge of the elements of the rash allows one to navigate the extensive and variable pathology of the skin, mucous membrane of the mouth and lips, and correctly diagnose the disease.

4.5. Primary morphological elements

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

Spot (macula) represents a limited change in color of the skin or mucous membrane. Usually the spot is located at the same level as 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 clinically manifest as limited redness of the skin as a result of vasodilatation of the superficial vascular

plexus. They are divided into inflammatory and non-inflammatory. Inflammatory vascular spots are 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 you press on the spots that appear as a result of the dilation of the skin vessels, they disappear and after the pressure stops they appear again 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 can be acutely inflammatory - bright pink in color, with unclear boundaries, a tendency to merge and peel, often with swelling and itching, and non-acute inflammatory - pale pink color with a brownish tint, not itchy, usually not merging. Acute inflammatory roseola appears as a primary element in patients with measles, scarlet fever, eczema, dermatitis, and pityriasis rosea; not acutely inflammatory - in patients with secondary (rarely tertiary) syphilis, erythrasma, pityriasis versicolor.

Rice. 2. Spot (macula)

Rice. 3. Dychromic spot

Rice. 4. Vascular spot

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

With emotional excitement and neurotic reactions, large confluent non-inflammatory spots appear (short-term dilatation of the vessels of the superficial choroid plexus) without itching and peeling, called “erythema of embarrassment” (anger or shyness).

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

also temporarily disappear when pressure is applied and appear when the pressure stops. Telangiectasia can exist independently and be part of the clinical picture of rosacea, scarring erythematosis and some other skin diseases. Congenital ones include non-inflammatory vascular birthmarks (nevi).

When the permeability of the vascular walls increases, hemorrhage into the skin can occur, resulting in the formation of so-called hemorrhagic spots, not disappearing under pressure. Depending on the time that has passed since 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 shape - ecchymoses; in cases of massive hemorrhages with swelling of the skin and its elevation above the level of surrounding areas, they speak of hematoma. Hemorrhagic spots occur with allergic vasculitis of the skin, scorbutus (hypovitaminosis C), and some infectious diseases (typhoid, rubella, scarlet fever, etc.).

When the content of melanin pigment in the skin increases or decreases, dyschromic spots, which There are hyperpigmented (increased pigment) and depigmented (decreased pigment). Pigment spots can be congenital (moles, lens-tigo) and acquired (freckles, chloasma, vitiligo).

Hyperpigmented spots include freckles (small areas of light brown, brown color, formed under the influence of

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

Small depigmented spots are called leucoderma. True leukoderma occurs in patients with secondary recurrent syphilis (depigmented spots form on a hyperpigmented background). False, or secondary, leukoderma (pseudo-leukoderma) is observed in place of former morphological elements (usually spotty-flaky) in a number of dermatoses (pityriasis versicolor, psoriasis, etc.), when the surrounding areas of healthy skin have been exposed to ultraviolet irradiation (tanning). With 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 papula - a cavityless, more or less dense element, rising above the level of the skin and resolving without the formation of a scar or cicatricial atrophy (Fig. 5). Sometimes papules leave behind unstable marks - pigmentation or depigmentation. Papules located predominantly in the epidermis are called epidermal(for example, flat wart), in dermis - dermal(with secondary syphilis). Most often, papules have an epidermal location(for example, with lichen planus, lichen planus, neurodermatitis).

Papules are divided into inflammatory and non-inflammatory. The former are much more common: with lichen planus, eczema, secondary syphilis, lichen planus and acuminate, neurodermatitis, etc. With them, the formation of an inflammatory infiltrate in the papillary layer of the dermis, vasodilation and limited swelling are noted. Pressing on the papule causes it to turn pale, but its color does not disappear completely. For non-inflammatory papules growth of the epidermis is noted (wart) or deposition of pathological metabolic products in the dermis

Rice. 5. Nodule (papula)

(xanthoma) or proliferation of dermal tissue (papilloma). Some dermatologists identify acute inflammatory papules (exudative papules in patients with eczema, dermatitis), which are formed as a result of the accumulation of exudate in the papillary layer of the dermis with acute dilation and increased permeability of the vessels of the superficial capillary network.

Papules come in various sizes: from 1 mm and larger. Papules measuring 1 mm are called miliary (milium- millet grain), or lichen (for lichen planus, for lichen scrofulous), size from 0.5 to 1 cm - lenticular (lenticula- lentils), they occur with psoriasis, secondary syphilis, etc., size from 1 to 2 cm - nummular (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 clear boundaries, but different shapes (round, oval, flat, polygonal, pointed with an umbilical depression, dome-shaped) with a smooth or rough surface. The consistency of the nodules can also be varied (soft, doughy, densely elastic, dense, hard) and their color (the color of normal skin, yellow, pink, red, purple, purple, brown, etc.).

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

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

Tuberculum - an infiltrative, cavity-free, non-acute inflammatory element, rising above the skin level, often ulcerating and ending in scarring or cicatricial atrophy (Fig. 6). In appearance, especially at the initial stage, it is difficult to distinguish from a nodule. Thus, the size, shape, surface, color and consistency of the tubercle and nodule may be similar. The inflammatory cellular 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

followed by scar 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, the mosaic nature of the scar in syphilis, bridges in tuberculous lupus, etc.).

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

In various diseases, the tubercles have distinctive features of histological structure. For example, a tubercle in skin tuberculosis consists predominantly of epithelioid cells and varying numbers of giant Langhans cells (Mycobacterium tuberculosis is rarely found in the center; lymphocytes are usually present at the periphery); the tubercle in syphilis consists of plasma cells, lymphocytes, epithelioid cells and fibroblasts(treponemas are not found in the tubercle; there may be a small number of giant cells).

The tubercles, as a rule, appear 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 cavityless infiltrative non-acute inflammatory element located in the subcutaneous fatty tissue, large in size - up to 2-3 cm or more (Fig. 7). Initially node

Rice. 6. Tubercle (tuberculum)

Rice. 7. Knot (nodus)

Rice. 8. 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 ranges from soft (with collivative tuberculosis) to densely elastic (with leprosy and tertiary syphilis). The uniqueness of nodes in a number of diseases (appearance, color, shape, surface,

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

Vesicula (Fig. 8) - the primary cavity exudative element, contains fluid and slightly rises above the skin level. In the vesicle there is a cavity filled with serous, less often serous-hemorrhagic contents, a tire and a bottom. 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 septa). The bubble size is from 1 to 3-4 mm. The contents of the vesicle can be transparent, serous, less often bloody; often becomes cloudy and purulent. This occurs when a vesicle (vesicle) transforms into an abscess (pustule). The liquid of the bubble dries into a crust or its tire bursts, an eroded surface is formed and weeping occurs, as with eczema in the acute stage. Blisters can be located on unchanged skin, but more often have an inflammatory erythematous base. On the oral mucosa and on the contacting surfaces of the skin, the bubbles quickly open, revealing eroded surfaces; in places with thicker tires (for example, on the palms with dyshidrosis), they last longer. The blisters pass without a trace or leave behind temporary pigmentation, as, for example, with Dühring's dermatosis herpetiformis.

When vesicles form, spongiosis (eczema, dermatitis), ballooning degeneration (simple vesicle) are observed histologically.

herpes zoster, chickenpox), intracellular vacuolization (dyshidrotic eczema, athlete's foot).

Bubble (Fig. 9) - an exudative cavity element measuring 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 bubble is called subcorneal, in the thickness of the spinous 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 cloudy or hemorrhagic. The fluid of the blisters contains leukocytes, eosinophils, and epithelial cells. For the diagnosis of some dermatoses, cytological examination of imprint smears or scrapings from the bottom of the bladder is important, since in a number of dermatoses the cellular composition has features.

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

Blisters occur with pemphigus vulgaris, congenital pemphigus, exudative erythema multiforme, burns, drug-induced 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 unchanged 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. In case of burns, serous exudate lifts the necrotic area of ​​the epidermis. The formation of intraepidermal blisters is often promoted by various endogenous factors; in this case, disruption of intercellular connections (acantholysis) and degenerative changes in epidermal cells are observed. If the structure of the basement membrane is disrupted, edematous fluid or exudate protruding from the vessels peels off

Rice. 9. Bubble (bulla)

the entire epidermis (epidermolysis) and subepidermal blisters appear, 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 appear both on apparently unchanged skin or mucous membrane, and against the background of inflammation. The mechanism of bubble formation is different. Intraepidermal blisters usually form as a result of acantholysis.

The essence of the process is the melting of intercellular connections (acanthus), the spinous cells are separated and exudate-filled cracks appear between them, which then turn into blisters. In this case, the spiny cells become rounded, become slightly smaller, and their nuclei become larger than those of ordinary cells. They line the bottom of the bubble. These acantholytic cells (Tzanck cells) have important diagnostic value; they confirm the diagnosis of pemphigus. Subepidermal blisters form between the layers of the basement membrane or directly above or below it and are a consequence 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 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 deep in the epidermis and prone to crust formation is called impetigo. After the crust falls off, temporary pigmentation of the affected area remains. Pustules located around hair follicles are called folliculitis. If pus penetrates into the mouth of the hair funnel, the center of the abscess penetrates the hair, forms ostio-folliculitis.

Folliculitis can be superficial, leaving no traces behind, or deep (the process involves 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. A deep non-follicular abscess, involving the dermis, is called ecthyma. When it resolves, an ulcer forms and heals with a scar. Ecthyma is caused by streptococcus. Streptococcal superficial pustule (flaccid, flat) is called conflict.

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

Blister (urtica) (Fig. 11) - ex-sudative cavity-free element, formed as a result of limited acute inflammatory edema of the papillary layer of the skin. The blister is a dense pillow-shaped elevation of a round or, less commonly, oval shape and is accompanied by severe itching. A blister is an ephemeral formation; it usually disappears quickly (from several tens of minutes to several hours) and disappears without a trace. The size of the blisters ranges from 1 to 10-12 cm. Due to the vasodilation 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 mosquito bites, mosquitoes and other insects, from heat, cold, when touching stinging nettle (external factors), from intoxication and sensitization (internal factors). Urticaria on the skin occurs with drug, food and infectious allergies (urticaria, angioneurotic 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, large, long-lasting blisters arise from mechanical irritation of the skin. (urticaria factitia, or dermografismus urticaris).

Despite the severe itching that accompanies the blistering rash, signs of scratching on the skin of patients are usually not found.

Rice. 10. Pustule (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 pigment spots, scales, crusts, superficial and deep cracks, abrasions, erosions, ulcers, scars, lichenification and vegetation.

Pigmentation (Fig. 12). Primary pigmentations include freckles, chloasma, pigmented birthmarks, etc., secondary pigmentations include hyperpigmentations formed as a result of increased deposition of melanin pigment after the resolution of primary (nodules, tubercles, vesicles, blisters, pustules) and secondary (erosions, ulcers) elements, and also due to the deposition of blood pigment - hemosiderin in so-called hemosiderosis of the skin. Secondary hypo-pigmentation (Fig. 13) is associated with a decrease in melanin content in certain areas of the skin and is called secondary leukoderma. Secondary pigment spots repeat the size and outline of the elements in the place of which they were formed.

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

To diagnose processes with the formation of scales, their thickness, color, size, consistency (dry, oily, brittle, hard), and tightness are important. Scales that fit tightly to the underlying tissues are formed as a result of hyperkeratosis, while scales that are easily torn off are formed as a result of parakeratosis. Scales can also develop primarily: parakeratotic with dandruff, soft leukoplakia, exfoliative cheilitis, hyperkeratotic with ichthyosis, etc.

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

Knowing the form of peeling and the type of scales helps in diagnosing a number of dermatoses. Thus, silver-white scales are found in psoriasis, dark ones - in some forms of ichthyosis, yellow scales - in oily seborrhea, loose, easily removable - in psoriasis. Removing the scales is sometimes painful due to the spike-like horny projections on the lower surface of the scales that penetrate the follicular openings of the skin (in lupus erythematosus). With rosacea, the so-called corrugated and pleated scales, with syphilitic papules they are located collar-shaped (“collar” Bi-etta), with parapsoriasis they 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 serous exudate, pus or blood drying on the skin

Rice. 12. Pigmentation (pigmentation)

Rice. 13. Hypopigmentation (hypopigmentation)

Rice. 14. Flake (squama)

vi, sometimes with an admixture of particles of used medications. There are serous, purulent, serous-purulent, purulent-hemorrhagic crusts, etc. They are formed when vesicles, blisters, pustules dry out, with ulceration of tubercles, nodes, with necrosis and purulent melting of deep pustules. Layered massive oyster-shaped crusts are called rupee (rupiah); in this case, 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 were formed: with serous discharge, the crusts are transparent or yellowish, with purulent discharge - yellow or greenish-yellow, with bloody discharge - red or brownish. When the discharge is mixed, the color of the crusts changes accordingly.

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

Mixed layers on the skin, consisting of scales and crusts, are called squamous crusts; they occur with seborrhea, in some cases of exudative psoriasis.

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

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

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

Abrasion, or excoriation (excoriatio) (Fig. 17) - a skin defect caused by scratching or any other traumatic injury. Scratching can lead to disruption of the integrity of not only the epidermis, but also the papillary layer of the dermis; in these cases, no scar is formed.

With a deeper location of the abrasion, after its healing, a scar, pigmentation or depigmentation remains. Excoriation is an objective sign of intense itching. The location and shape of scratching sometimes helps in diagnosis (for example, with scabies).

Erosion (erosio) (Fig. 18) - a superficial skin defect within the epidermis. Erosion occurs after the opening of vesicles, blisters, pustules and in size and shape they repeat the primary cavitary morphological elements that were in these areas. Most often, erosions are pink or red in color and have a damp, weeping surface. Large eroded surfaces of the skin and mucous membranes occur with pemphigus. Minor erosions occur when vesicles are opened in patients with eczema, vesicular and herpes zoster, dyshidrosis, and dyshidrotic athlete's foot. In the oral cavity, on the contacting surfaces of the skin, eroded syphilitic papules often appear; chancre can also be in the form of erosion. The erosion heals without scar formation.

If erosion persists for a long time on the oral mucosa, its edges may swell and even infiltrate. In this case, it is difficult to distinguish erosion from ulceration. Sometimes this issue is resolved after

Rice. 15. Crust (crusta)

Rice. 16. Surface crack (fissura)

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 form without a preceding bubble, for example, erosive papules in syphilis, the erosive-ulcerative form of lichen planus and lupus erythematosus. The formation of such erosions is actually a consequence of trauma to the easily vulnerable inflamed mucous membrane or skin. As a result of injury, the integrity of the edematous, often macerated epithelium is disrupted.

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

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

Tripe (cicatrix) (Fig. 20) is formed at the sites of deep skin defects as a result of their replacement with coarse, fibrous connective tissue. In this case, the skin papillae are smoothed, and the interpapillary epithelial outgrowths disappear; in this regard, the boundary between the epidermis and dermis appears as a straight horizontal line. There is no skin pattern, follicular or sweat openings on the scar. There is also no hair, sebaceous, sweat glands, blood vessels or elastic fibers in scar tissue. The scar is formed either at the site of deep burns, cuts, ulceration of tubercles, nodes, deep pustules, or by the so-called dry route, without previous ulceration, for example, with papulonecrotic tuberculosis of the skin or in some cases of tertiary tubercular syphilis.

Fresh scars are red or pink, while older ones are hyperpigmented or depigmented. The scar may be smooth or uneven. If an excessive amount of dense material is formed

fibrous tissue, hypertrophic scars appear that rise above the skin level; they are called keloids.

More delicate connective tissue and in smaller quantities than with a scar is formed during the so-called scar atrophy. In this case, the skin in the area of ​​the affected area is significantly thinned, mostly lacks a normal pattern, and often sinks, i.e. is located below the level of the surrounding skin (Fig. 21). Atrophy develops, as a rule, without previous ulceration of the lesion, those. “dry way” (for lupus erythematosus, scleroderma). When squeezed between your fingers, such skin gathers into thin folds like tissue paper.

In diagnosing a previous pathological process in a patient, the localization, shape, number, size and color of scars often help. Thus, syphilitic gumma leaves behind a deep retracted stellate scar, colliculative skin tuberculosis - retracted, uneven, irregularly shaped bridge-shaped scars in the area of ​​the lymph nodes. The same scars on other areas 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. 18. Erosion (erosio)

Rice. 19. Ulcer (ulcus)

Rice. 20. Scar (cicatrix)

Rice. 21. Atrophy (atrophia)

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

Rice. 23. Vegetation (vegetatio)

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

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

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

growths of the spinous layer of the epidermis and have the appearance of villi, papillae of the dermis. The surface of the vegetation is uneven, lumpy, reminiscent of 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 often happens due to friction in the lesions, then they are soft, juicy, pink-red or red in color, bleed easily, and separate serous or serous-bloody fluid. When a secondary infection occurs, pain, a rim of hyperemia along the periphery, and serous-purulent discharge appear.

The optimal conditions for examining a patient are the following:

Room temperature not lower than plus 18 degrees C

The inspection is carried out in diffused daylight, avoiding direct sunlight.

During the examination, the healthcare worker sits with his back to a source of natural light.

The entire skin and visible mucous membranes should be examined, regardless of the location of the lesions.

In the lesions, begin examining and describing the primary morphological elements, and then secondary skin changes.

Description of apparently healthy skin:

Color: flesh-colored, matte, pale, bluish, yellow, earthy, tan.

Turgor and elasticity (reduced, increased, preserved).

Humidity (moderately humid, humid, dry).

Skin pattern and relief (smoothness of skin grooves, increased relief).

It is necessary to pay attention to the nature of sebum secretion (dry, oily skin), to traces of previous diseases (hyperpigment spots, scars), to the condition of the skin appendages. Examine hair (thickness, color, fragility, loss), nails (color, shine, striations, thickening), pigmented, vascular, hypertrophic, linear nevi).

Description of pathologically changed skin.

Localization of primary elements.

Prevalence of the rash (focal, widespread, universal).

Relative arrangement of elements (drain, separate).

Symmetrical lesions. When located on both sides of the body (hands, feet, legs, thighs, upper limbs, side surfaces of the body), they speak of a symmetrical rash. Otherwise about asymmetrical.

The boundaries of the lesion: clear and vague.

Description of the immediate morphological elements of the rash, first primary, then secondary. They establish the size of the element, shape, color, consistency, boundaries, and surface condition. Rashes may be monomorphic(represented by primary elements of the same type) and polymorphic(represented by various morphological elements).

Side-light inspection method used to determine the elevation of an element. The surface of the element can be smooth, rough, bumpy, etc. Consistency – woody-dense, densely elastic, soft, doughy. The relative position of the elements among themselves is isolated, confluent, there can be a tendency to grouping, the formation of arcs, rings, semi-rings, the rash can be located along the nerve trunks and blood vessels. If there is no pattern in the arrangement of elements, the rash is said to be randomly distributed.

Special skin examination methods:

Palpation– used to determine the condition of the element’s surface, its consistency and depth. It is carried out by stroking and squeezing the element with your fingers or using a button probe.

Diascopy (vitropression)) is carried out by pressing on the element with a glass slide and makes it possible to differentiate an inflammatory spot from a hemorrhagic one (the inflammatory one turns pale during diascopy, and the hemorrhagic one almost does not change). In addition, the method is informative for the diagnosis of tuberculous lupus: on diascopy, the tubercles acquire a yellowish-brown color (the “apple jelly” symptom).

Scraping used to diagnose scaly dermatoses. Scraping is carried out with a scalpel, glass slide or dermatological curette. With psoriasis, it is possible to obtain three characteristic symptoms: “stearin spot”, “terminal film”, “blood dew”. With lupus erythematosus, scraping of scales with follicular spines is accompanied by pain (Besnier-Meshchersky symptom).

Dermographism is a vascular response of the skin to mechanical irritation caused by linear pressure on the skin with a blunt object (wooden spatula). Normal Dermographism is characterized by the formation of a wide pink-red stripe that disappears after 1-3 minutes. With red dermographism, the resulting stripe is wide, elevated, lasts up to 15-20 minutes, and is accompanied by mild itching (eczema, psoriasis). At white dermographism after 15-20 seconds. a white stripe appears, which disappears after 5-10 minutes (neurodermatitis, pruritus). At mixed dermographism red stripe changing to white. Urticarial Dermographism manifests itself in the form of sharply raised, swollen, wide, persistent (up to 30-40 minutes) red stripes (observed with urticaria).

In addition, it is being investigated temperature, tactile and pain sensitivity skin, use drip, application and scarification methods determination of body sensitization (allergic skin tests). Also for the diagnosis of dermatoses, various samples(Balzer, Jadasson), reproduction of phenomena (Koebner phenomenon, Wickham grid, probe failure, apple jelly, Auschpitz phenomenon, Nikolsky and Asbo-Hansen phenomenon). To clarify the diagnosis, carry out microscopic analysis for mushrooms, scabies, demodex, bacteriological analysis(culture), if necessary, with determination of the sensitivity of microflora to antibiotics, histological analysis of skin biopsies, etc.

Few people know that the human skin is the largest organ in the body. The area of ​​skin 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 the protective and immune function of the body, it also regulates temperature, water balance and many sensations. This is why it is so important to protect your skin from the effects of various diseases. This task is the most important regarding prevention.

Below you can find out which of the most common skin diseases a person can experience and see their photos. Here you can find a description of the diseases, as well as 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 the types of skin diseases in humans?

Skin diseases can have different origins. They all differ in their appearance, symptoms and cause of formation.

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

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Photos and names of skin diseases in humans

Now it’s worth looking at photos of the main skin diseases, and below you can read their symptoms, causes and descriptions.

The most common skin diseases:

1. Papilloma

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

The main causes of acne:

Symptoms of acne formation:

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

Dermatitis is any inflammation of the skin. The disease dermatitis has several types. The most common types of dermatitis: 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.
• Presence of swelling.
• Formation of redness at sites of inflammation.
• Formation of scales and dry crusts.

Here you can learn in detail about the characteristics and treatment of inflammation, and also look.

A skin disease such as lichen includes a number of several varieties. Each of these types differs in its pathogen, type of rash, localization and infectiousness.

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:

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

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

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

The main causes of keratosis:

Symptoms of keratosis:

• Roughness and unevenness of the skin at the first stage of the disease.
• Formation of hard brown or red spots.
• Peeling of the skin around the formations.
• 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.

Main symptoms of carcinoma:

• Formation of pearlescent or shiny bumps.
• Formation of ulcers.
• Formation of pink raised spots.

Hemangioma is a benign formation on the skin due to a vascular defect, which most often occurs in children. Externally, the disease appears as bumpy red spots.

Causes of hemangioma:

Symptoms of hemangioma:

• At the initial stage, the formation of a barely noticeable spot in the area of ​​the child’s face or neck.
• Redness of the spot.
• The spot becomes burgundy.

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

Main symptoms of melanoma:

Papilloma

Papilloma is a benign tumor that appears on the surface of the skin in the form of a small growth.

Causes of papilloma:

Main symptoms of papilloma:

• Formation of a pink or flesh-colored growth.
• The size of the formation can reach several centimeters.
• Formation of a common wart.

It is commonly called a group of fungal diseases of the skin. As a rule, this disease occurs in 20% of the world's inhabitants. The main cause of dermatomycosis in humans is the contact of fungi on the skin or mucous area of ​​a person.

Symptoms of dermatomycosis:

• The formation of red spots that are covered with scales.
• Presence of itching.
• Hair loss and breakage.
• Peeling of nails.

Treatment

Typically, skin diseases are treated in the following ways:

• Following a diet and proper nutrition, taking the necessary vitamins.
• Treatment with medications to boost the immune system.
• 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 disease itself and its causes have been established by a specialist. So do not neglect visiting a doctor at the first symptoms of a skin disease.

Conclusion

We should also not forget that The best treatment for skin diseases is prevention. Elementary preventive methods are: compliance with personal hygiene rules, diet and precautions during outdoor recreation.