Nyoman Suryawati Putu Gede Sudira · 2018. 5. 8. · Study Guide Basic Clinical Skills Block Skin...

Nyoman Suryawati

Putu Gede Sudira

Study Guide Basic Clinical Skills Block Skin and Hearing Systems and Disorders

Department of Medical Education - Faculty of Medicine – Universitas Udayana, 2017

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BASIC CLINICAL SKILL OF THE SKIN AND

HEARING SYSTEMS AND DISORDERS

FIRST EDITION

Editor

Nyoman Suryawati

Putu Gede Sudira

Publisher:

Eka Print

In collaboration with

Department of Medical Education Medicine Programme, Faculty of Medicine, Udayana

University

Denpasar 2017



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BASIC CLINICAL SKILL OF THE SKIN AND HEARING SYSTEMS AND DISORDERS

Planners

Nyoman Suryawati

Ni Made Linawati

Andi Dwi Saputra

IA Alit Widhiartini

Herman Saputra

I Made Krisna Dinata

Putu Gede Sudira

Contributors

Nyoman Suryawati

Ni Made Linawati

IGAA Praharsini

Luh Mas Rusyati

IGAA Dwi Karmila

NLP Ratih V. Karna

Ni Made Dwi Puspawati

Made Wardhana

IGN Dharma Putra

Herman Saputra

Andi Dwi Saputra

IA Alit Widhiartini

Sucindra Dewi

IG Kamasan Arijana


Editors

Nyoman Suryawati Putu Gede Sudira

Layout

Yuliwaty

I Gde Nengah Adhilaksman S. W.

21,6 cm X 27,9 cm

xi, 65 pages

ISBN : 9 786022 942856

First Edition: Desember 2017

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or

transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or

otherwise without prior written permission of the publisher.

Published by Eka Print in collaboration with Department of Medical Education Medicine

Programme, Faculty of Medicine, Universitas Udayana.



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CONTENT

CONTENT ....................................................................................................................................... 4

PREFACE ....................................................................................................................................... 6

GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND DISORDERS ......... 7

LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN

STANDARD OF DOCTOR COMPETENCY 2012) ........................................................................ 8

LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN

STANDARD OF DOCTOR COMPETENCY 2012) ........................................................................ 9

LABORATORY AND BASIC CLINICAL SKILLS TIMETABLE .................................................... 10

BASIC CLINICAL SKILLS............................................................................................................. 11

BCS 1: Efflorescence .................................................................................................................... 12

Primary Lesions ........................................................................................................................ 12

Secondary Lesions ................................................................................................................... 16

Diagnostic Details of Lesions ................................................................................................... 18

Distribution of The Lesions ....................................................................................................... 19

Skin Examination ...................................................................................................................... 19

Examination of Hair, Nail, and Mucosa .................................................................................... 20

BCS 2: KOH Preparation as Investigation of Superficial Mycosis ............................................... 21

BCS 3: Diagnosis of Scabies by Skin Scraping Examination ...................................................... 22

BCS 4: Tzanck Smear as a Diagnostic Tool in Dermatology ...................................................... 24

BCS 5: Wound Care ..................................................................................................................... 26

BCS 6: Basal Cell Carcinoma, Squamous Cell Carcinoma, Nevus Pigmentosus, Cutaneous

Melanoma, Abcess Incision and Drainage, Enucleation, Elliptical or Fusiform Excision, and Nail

Avulsion ......................................................................................................................................... 30

6.1 Basal Cell Carcinoma (BCC) .............................................................................................. 30

6.2 Squamous Cell Carcinoma (SCC) ...................................................................................... 32

6.3 Nevus Pigmentosus ............................................................................................................ 34

6.4 Cutaneous Melanoma......................................................................................................... 37

6.5 Abcess Incision and Drainage ............................................................................................ 40

6.6 Enucleation ......................................................................................................................... 41

6.7 Elliptical or Fusiform Excision ............................................................................................. 41

6.8 Nail Avulsion ....................................................................................................................... 43

BCS 7: Valsalva Maneuver, Cleaning of MAE, Foreign bodies, and Cerumen Extraction ......... 47

7.1 Valsava Maneuver .............................................................................................................. 47

7.2 Foreign Body In Canalis Auditorius Externa (CAE) ........................................................... 49



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LABORATORY GUIDELINE ......................................................................................................... 53

Histology: Skin and Hearing Structure ......................................................................................... 54

Anatomy Pathology: Skin and Hearing Systems Disorders ......................................................... 55

Pharmacology & Pharmacy: Rational Therapy of Topical Preparations in Dermatology ............ 56

Physiology: Hearing ...................................................................................................................... 58

REFERENCES ............................................................................................................................. 64



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PREFACE

The medical curriculum has become increasingly vertically integrated, with stronger basic

concept and support by clinical examples and cases to help in the understanding of the relevance

of the underlying basic science. Basic science concepts may help in the understanding of the

pathophysiology and treatment of diseases. Skin and hearing systems and disorders block have

been written to take account of this trend and to integrate core aspects of basic science,

pathophysiology, and treatment into a single, easy to use revision aid.

The skin and hearing systems and disorders block will refresh the basic anatomy, histology,

physiology of skin and hearing systems, varies dermatology cases (papulo-erythrosquamosa,

Morbus Hansen, viral infection, insect bite and infestation, dermatophytosis, drug eruption,

pigmentary, and sebaceous gland disorders, bacterial infection, dermatitis), rational topical

treatment in dermatology, dermatopharmacology, an example of the otic drug, and varies cases

in hearing systems including hearing loss.

This study guide is developed by the academic staffs from various departments: Anatomy,

Physiology, Histology, Pharmacology, Pharmacy, Anatomy Pathology, Dermato-venereology, Ear

Nose and Throat Department.

The learning process will be carried out for 3 weeks (16 working days) and 1 week for Basic

Clinical Skills starts from December 12th, 2017 as shown in the timetable. The final examination

will be conducted on January 17th, 2018 in the form of Multiple Choice Questions (MCQ).

Assessment methods are a final exam (MCQ), small group discussion, and a student project. The

learning situations include lectures, individual learning, small group discussion, student project,

plenary session, practice, and clinical skills.

Most of the learning material should be learned independently and discuss in Small Group

Discussion by the students with the help of a facilitator. Lectures are given to emphasize the most

important thing of the material. In a small group discussion, the students gave learning task to

lead their discussion.

This study guide needs more revision in the future so that the planners kindly invite readers

to give any comments and critics for its completion. Thank you.

Planners



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GENERAL CURRICULUM OF THE SKIN AND HEARING SYSTEMS AND

DISORDERS

Aims:

Manage common skin disorders knowledge in the context of primary health care settings.

Identify skin disorders which may require a referral.

Learning outcomes:

Describe the functional structure of the skin and its appendices and hearing systems.

Identify typical skin manifestation related to skin disorders.

Identify the risks and compatibility of topical treatment in dermatology.

Diagnose and manage common skin and hearing systems disorders.

Refer patient to life/disability threatening, refractory, and unidentified skin and hearing systems

disorders.

Educate the patient and their family about skin health.

Curriculum contents:

The functional structure of the skin and its appendices and hearing systems.

Common pathological bases of skin disorders.

Primary skin manifestation in common skin disorders.

Risks and compatibility of topical treatment in dermatology.

Secondary skin manifestations.

Symptoms and sign of common skin disorders, clinical diagnose of common skin disorders,

management of common skin disorders: papulo-erythrosquamosa, Morbus Hansen, viral

infection, insect bite and infestation, dermatophytosis, drug eruption, pigmentary and sebaceous

gland disorders, bacterial infection, dermatitis

Symptoms and sign, clinical diagnosis, and management of common hearing systems disorders:

hearing loss in children, Meniere, sudden hearing loss, presbycusis, perichondritis, myringitis,

otitis media, labyrinthitis, ear trauma/othematoma, barotrauma, motion sickness, PGPKT.

Referal of a patient with life/disability threatening, refractory, or unidentified skin and hearing

systems disorders.

General principles of skin and hearing systems health.

Education and prevention of common and contagious skin and hearing systems diseases.



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LIST OF COMPETENCY CLINICAL SKILLS OF INTEGUMENT SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

PEMERIKSAAN FISIK

1 Kulit, inspeksi dengan kaca pembesar 4A

2 Inspeksi membran mukosa 4A

3 Inspeksi daerah perianal 4A

4 Inspeksi kulit dan kuku ekstremitas 4A

5 Kulit, inspeksi dengan sinar UVA (Wood’s lamp) 4A

6 Dermografisme 4A

7 Palpasi kulit 4A

8 Deskripsi lesi kulit dengan perubahan primer dan sekunder,

seperti ukuran, distribusi, penyebaran dan konfigurasi

4A

9 Pemeriksaan rambut (inspeksi, pull test) 4A

PEMERIKSAAN TAMBAHAN

10 Pemeriksaan laboratorium: ZN, KOH, Giemsa, Gram 4A

11 Punch biopsy 2

12 Patch test 2

13 Prick test 2

TERAPI

14 Desinfeksi 4A

15 Kulit, insisi/drainase abses, bursa/ ganglion 4A

16 Kulit, eksisi tumor 4A

17 Warts, cryotherapy 1

18 Jerawat, terapi komedo 4A

19 Perawatan luka (pemasangan dressing, bandage) 4A

20 Varicose veins, compressive sclerotherapy 2

21 Varicose veins, compressive bandage therapy 4A

22 Phototherapy 1

23 Ekstraksi kuku 4A

24 Rozerplasty 4A

PENCEGAHAN

25 Pencarian kontak 4A



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LIST OF COMPETENCY CLINICAL SKILLS OF HEARING SYSTEMS (INDONESIAN STANDARD OF DOCTOR COMPETENCY 2012)

Indra Pendengaran dan Keseimbangan

1 Inspeksi aurikula, posisi telinga dan mastoid 4A

2 Pemeriksaan meatus auditorius externus dengan otoskop 4A

3 Pemeriksaan membran timpani dengan otoskop 4A

4 Menggunakan cermin kepala 4A

5 Menggunakan lampu kepala 4A

6 Tes pendengaran, pemeriksaan garpu tala (Weber, Rinne,

Schwabach)

4A

7 Tes pendengaran, tes berbisik 4A

8 Intepretasi hasil Audiometri – tone & speech audiometry 3

9 Pemeriksaan pendengaran pada anak-anak 4A

10 Otoscopy pneumatic (Siegle) 2

11 Melakukan dan menginterpretasikan timpanometri 2

12 Pemeriksaan vestibular 2

13 Tes Ewing 2

Indra Pembau

14 Inspeksi bentuk hidung dan lubang hidung 4A

15 Penilaian obstruksi hidung 4A

16 Uji pembauan 4A

17 Rinoskopi anterior 4A

18 Transluminasi sinus frontalis & maksila 4A

19 Nasofaringoskopi 2

20 USG sinus 1

21 Radiologi sinus 2

22 Interpretasi radiologi sinus 3

Indra Pengecap

23 Penilaian pengecapan 4A

THT

24 Manuver Politzer 2

25 Manuver Valsalva 4A

26 Pembersihan meatus auditorius eksternus dengan usapan 4A

27 Pengambilan serumen menggunakan kait atau kuret 4A

28 Pengambilan benda asing di telinga 4A

29 Parasentesis 2

30 Insersi grommet tube 1

31 Menyesuaikan alat bantu dengar 2

32 Menghentikan perdarahan hidung 4A

33 Pengambilan benda asing dari hidung 4A

34 Bilas sinus/ sinus lavage /pungsi sinus 2

35 Antroskopi 1

36 Trakeostomi 2

37 Krikotiroidektomi 2



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LABORATORY AND BASIC CLINICAL SKILLS TIMETABLE

13-12-2017

Classroom

08-01-2018

Classroom

09-01-2018

Classroom

10-01-2018

Classroom

11-01-2018

Classroom

Skin, Nail, Mucous, Hair Effloresence,

Dermographism

(Praharsini/ Dwi Puspawati)

Laboratory Investigation

(KOH, Giemsa, wood lamp)

(Suryawati, Dwi

Karmila)

Wound Care, Open Dressing,

Compression Pressure of

Varicose Vein

(Luh Mas Rusyati, Ratih)

BCC,SCC, Nevus pigmentosus,

Malignant melanoma, Abscess Incision, Enucleation, Nail Extraction, Nevus

Excision

(Wardhana/ Dharma Putra)

Valsalva Maneuver, Cleaning of

MAE, Foreign bodies, and Cerumen Extraction

(Andi S)

08.00 – 09.00 A, B A, B A, B A, B A, B

09.00 – 10.00 A, B A, B A, B A, B A, B

10.00 – 11.00 C, D C, D C, D C, D C, D

11.00 – 12.00 C, D C, D C, D C, D C, D

Histology lab Histology lab Physiology & Pharmacy Lab

Physiology/ Pharmacy Lab

Physiology Lab

Histology Practicum skin

and hearing organ

(Linawati/ Arijana)

Anatomy PathologyPracti

cum skin and hearing systems

(Herman)

Topical Prepa ration in skin and

Otic drug

( IA Alit W)

Pharmacology practicum in Skin and

hearing

(Sucindra Dewi)

Physiology practicum

(Krisna)

08.00-09.00 C C C C C

09.00-10.00 D D D D D

10.00-11.00 A A A A A 11.00-12.00 B B B B B

Group A: SGD A1, A2, A3, A4, A5. Group B: SGD A6, A7, A8, A9, A10. Group C: SGD B1, B2, B3, B4, B5. Group D: SGD B6, B7, B8, B9, B10.



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BASIC CLINICAL SKILLS



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BCS 1: Efflorescence

Praharsini & Dwi Puspawati

Most skin diseases produce or present with lesions that have more or less distinct characteristics.

They may be uniform or vary in size, shape, and color, and perhaps occur in different stages of

evolution or involution. In some cases, the appearance of skin lesion may be so distinctive so

then the diagnosis is easy to be made. In other cases, subjective symptoms and clinical sign in

themselves are inadequate, and a complete history and laboratory examinations, including

biopsy, are essential to conclude a diagnosis.

The same disease may show variations under different conditions and in different individuals. The

appearance of the lesions may have been modified by previous treatment or obscured by external

influences, such as scratching or secondary infection. Subjective symptoms may be the only

evidence of a disease, as in pruritus, and the skin appearance may be generally unremarkable.

Although history is important, the diagnosis in dermatology is most frequently made based on the

objective physical characteristic and location or distribution of one or more lesions that can be

seen or felt. Therefore, careful physical examination of the skin is crucial in making a dermatology

diagnosis.

The original lesions are known as the primary lesions, and identification of such lesions is the

most important aspect of dermatologic physical examination. They may continue until fully

developed or be modified by regression, trauma, or another external factor, producing secondary

lesions. Dermatology has a vocabulary that is quite distinct from other medical specialties and it

is necessary to describe skin disorder.

Primary Lesions

These are the following form of primary lesions such as macules, papules, plaques, nodules,

tumors, wheals, vesicles, bullae, pustules and telangiectasia.

Macule. A small, circular, flat spot less than 2 cm in diameter. The color of a macule is not the

same as that of nearby skin. Macules come in a variety of shapes and are usually brown, white,

or red. Examples of macules include freckles and flat moles. A macule more than 2 cm in diameter

is called a patch.



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Figure 1. Macula depigmentation in vitiligo patient

Papule. A solid raised lesion less than 0,5 cm across. A grouped papules more than 2 cm across

is called a plaque. Papules and plaques can be rough in texture and red, pink, or brown in color.

Papules are associated with such conditions as warts, syphilis, psoriasis, seborrheic and actinic

keratoses, lichen planus, and skin cancer.

Figure 2. Typical violaceous papules of lichen planus at the wrist



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Nodule. A solid lesion that has distinct edges and that is usually more deeply rooted than a

papule. Doctors often describe a nodule as "palpable," because when we palpate, it can be felt

as a hard mass distinct from the tissue surrounding it. A nodule more than 2 cm in diameter is

called a tumor. Nodules are associated with, among other conditions, keratinous cysts, lipomas,

fibromas, and some types of lymphomas.

Figure 3. Nodule

Wheal (Urtica). A skin elevation caused by swelling that can be itchy and usually disappears

soon after erupting. Wheals are generally associated with an allergic reaction, such as to a drug

or an insect bite.

Figure 4. Multiple wheal and dermatographism



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Vesicle. A raised lesion less than 1 cm across and filled with a clear fluid. Vesicles which diameter

more than 1 cm across are called bullae or blisters. These lesions may be the result of sunburns,

insect bites, chemical irritation, or certain viral infections, such as herpes.

Figure 5. Vesicles, bullae, and erosions

Pustule. A raised lesion filled with pus. A pustule usually results from an infection, such as acne,

impetigo, or boils.

Figure 6. Multiple pustules on erythematous macule



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Telangiectasia. Small, dilated blood vessels that appear close to the surface of the skin.

Telangiectasia is often a symptom of such diseases as rosacea or scleroderma.

Secondary Lesions

The major types of secondary skin lesions are an ulcer, fissure, scale, crust, erosion, excoriation,

scar, lichenification, and atrophy.

Ulcer. Lesion with a loss of the upper portion of the skin (epidermis) and part of the lower portion

(dermis). Ulcers can result from acute conditions such as bacterial infection or trauma, or from

chronic conditions, such as scleroderma or disorders involving peripheral veins and arteries. An

ulcer that appears as a deep crack that extends to the dermis is called a fissure.

Figure 7. Ulcer

Scale. Lesion with a dry, composed of dead skin cells that often flakes off the surface of the skin.

The body ordinarily is constantly shedding imperceptible tiny, thin fragments of stratum corneum.

When the formation of epidermal cells is rapid or the process of normal keratinization is interfered

or as a result of pathologic exfoliation, can produce scale. Diseases that promote scale include

fungal infections, psoriasis, and seborrheic dermatitis.

Figure 8. Thick scale in Psoriasis Vulgaris



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Crust. A dried collection of blood, serum, or pus. Also called a scab, a crust is often part of the

normal healing process of many infectious lesions.

Figure 9. Multiple brown crusts in herpes zoster patient

Erosion. Lose of all or portions of the epidermis alone, as in impetigo or herpes zoster after

vesicles rupture produces an erosion. It may or may not become crusted, but it heals without a

scar formation.

Figure 10. Erosion

Excoriation. An excoration is a punctate or linear abrasion produced by mechanical factors

including scratching or picking at a primary lesion. This lesion usually involving the epidermis only

and not reaching the papillary layer of the dermis.



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Scar. Discolored, fibrous tissue that permanently replaces normal skin after the destruction of the

dermis. A very thick and raised scar is called a keloid.

Lichenification. Rough, thick epidermis with exaggerated skin lines. This is often a characteristic

of scratch dermatitis and atopic dermatitis.

Figure 11. Grossly lichenified

Atrophy. An area of skin that has become very thin and wrinkled. Normally seen in older

individuals and people who are using very potent topical corticosteroid medication.

Diagnostic Details of Lesions

1. Characteristic or Morphology of The Lesions

Individual lesion described with the help of a magnifying glass. To find out the early primary lesion

and to inspect it closely. Note the shape (geometric shape, oval), color (salmon-pink,

erythematous, skin color, yellow), size, margin (sharpness of edge, well-defined, ill-defined), the

surface characteristics (dome-shaped, umbilicated, spike-like), temperature and smell.

2. Configuration of The Lesions

The certain term is used to describe the configuration that an eruption assumes either primarily

or by enlargement or coalescence. Lesion in a line are called linear, and they may be confluent

or discrete. Lesions may form a complete circle (annular) or a portion of a circle (arcuate or gyrate)

or may be composed of several intersecting portions of circles (polycyclic). If the eruption that not

linear nor parts of a circle, it may be serpiginous.



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Figure 12. Grouped lesion : cluster Figure 13. Serpiginous lesion

Distribution of The Lesions

Distribution of the lesions can be: symmetrical, asymmetrical, exposed area, sun-exposed area,

scalp region, hand, extensor aspect, flexor aspect.

Figure 14. Distribution lesion following

Blasckho lines

Figure 15. Distribution lesion in extensor aspect

Skin Examination

The examination should be conducted in a well-lit room. Natural sunlight is the ideal illumination.

A magnifying has a value in examining small lesions. It may be necessary to palpate the lesion

for firmness and fluctuation. The entire eruption must be seen to evaluate configuration and

distribution. This examination can optimally be done by having the patient completely undress.

It is very important to have a thorough examination of the whole body especially for a new

consultation and for the elderly. Sometimes, examination of the back and buttock of the elderly

may reveal unexpected lesions, even the patient himself or herself may not notice them e.g.

persistent chronic annular erythematous rash in the buttock found in a case of tuberculoid leprosy.



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Examination of Hair, Nail, and Mucosa

Involvement of hair-bearing areas by certain skin disorders caused characteristic lesions. For

example, discoid lupus can cause scarring alopecia with characteristic dys-pigmentation.

Sometimes on the skin lesions may be much less characteristic. Diffuse hair loss may be seen in

certain conditions such as acrodermatitis-enteropathica and maybe a clue to the diagnosis. In

addition, loss of hair within a skin lesion may be suggestive of the correct diagnosis, e.g. the

alopecia seen in the tumid plaques of follicular mucinosis.

Some skin disorders cause characteristic changes of the nail, even when the periungual tissue is

not involved. The pitting nail can be seen in psoriasis and alopecia areata, and this finding may

be useful in confirming these diagnoses when other findings are not characteristic. In addition,

the nails and adjacent structures may be the important site of pathology, as in candidal

paronychia.

Figure 16. Nail involvement in psoriasis: pitting (left) and subungual hyperkeratosis with

onycholysis (right)

The complete skin examinations include an examination of the mucosa. Oral lesions are

characteristically found in viral syndrome, lichen planus, HIV associated Kaposi sarcoma and

autoimmune bullous diseases.



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BCS 2: KOH Preparation as Investigation of Superficial Mycosis

Dwi Karmila

The KOH test also known as a potassium hydroxide preparation or KOH preparation is a quick,

inexpensive fungal test to differentiate superficial mycosis symptoms from other skin disorders

like psoriasis and eczema. Potassium hydroxide (KOH) preparation is used for the rapid detection

of fungal elements in a clinical specimen, as it clears the specimen making fungal elements more

visible during the direct microscopic examination.

KOH is a strong alkali. When specimen such as skin, hair, nails or sputum is mixed with 20% w/v

KOH, it softens, digests and clears the tissues (e.g., keratin present in skins) surrounding the

fungi so that the hyphae and conidia (spores) of fungi can be seen under a microscope.

The procedure of KOH Preparation:

1. Place a drop of KOH solution on a slide.

2. Transfer the specimen (small pieces) to the drop of KOH, and cover with glass. Place the

slide in a petri dish, or another container with a lid, together with a damp piece of filter paper

or cotton wool to prevent the preparation from drying out.

3. As soon as the specimen has cleared, examine it microscopically using the 10X and 40X

objectives with the condenser iris diaphragm closed sufficiently to give a good contrast.



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BCS 3: Diagnosis of Scabies by Skin Scraping Examination

Suryawati

The standard technique for the diagnosis of scabies consists of the identification of the mite, eggs,

or feces by microscopic examination of scales obtained by a skin scraping. Repeated tests in

different areas are often needed for a conclusive diagnosis because the sensitivity is low. Other

diagnostic procedures include the burrow ink test, the adhesive tape test, and the polymerase

chain reaction (PCR)-based method for detecting S. scabiei DNA in skin scrapings.

Equipment

1. Gloves

2. Magnifying glass

3. Light source

4. Alcohol Swabs

5. #15 scalpel blades

6. Glass slide and coverslips

7. Mineral oil or immersion oil

8. Laboratorium requisition forms

9. Sharps container

10. Microscope

Procedure

1. The highest yield in identifying a mite is in typical burrows on the finger webs, flexor aspect

of the wrist and penis.

2. Use a magnifying glass to identify recent burrows or papules. A bright light and magnifying

glass will assist in visualizing the mite (tiny dark speck ) at the end of the burrow

3. Explain the procedure to the patient and perform hand hygiene

4. Using an alcohol swab scrub the area to be scraped for 30 seconds and allow to air dry

5. Apply a single drop of mineral oil over un-excoriated burrow

6. Scrape in excoriated, noninflamed areas (Burrows) with a #15 scalpel blade. The mineral

oil will emulsify the scrapings

7. Using the blade put the emulsified scrapings on a slide; cover the slide with a coverslip

8. Send covered slide with a completed requisition to the laboratory for diagnostic purposes



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Microscopic finding

Three findings are diagnostic of scabies: S. scabiei mites, their eggs and their fecal pellets or

scybala (figure below).

Figure 17. Microscopic Finding of Scabies



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BCS 4: Tzanck Smear as a Diagnostic Tool in Dermatology

Suryawati

Tzanck smear is a very simple, rapid, cheap and reliable cytodiagnostic tool in dermatology.

Cytology is a diagnostic tool used to investigate the characteristics of individual cells. In this

method, materials obtained in a variety of ways are transferred to a glass slide, stained with

various dyes, and then examined under the light microscope. As a method for the diagnosis of

cutaneous disorders, cytology was first used by Arnault Tzanck in 1947.Cytology has been widely

used by dermatologists for diagnosing various cutaneous dermatoses, such as for viral infections

(herpetic infections), immunobullous disease (pemphigus), bacterial infection (Staphylococcal

Scalded Skin Syndrome) or a skin tumor.

Preparation of Tzanck smear

1. Samples should be taken from a fresh vesicle and cleaned with 70% alcohol.

2. The vesicle should be unroofed or the crust removed, and the base scraped with the blunt

edge of a scalpel blade (no 15) or the edge of a spatula.

3. The material is transferred to a glass slide by touching the spatula to the glass slide

repeatedly but gently, air dried.

4. The material obtained stained with Giemsa stain for 20–25 minutes.

5. Then it is washed with water and examined under the microscope.

Cytologic findings

1. The cytological findings are pathognomonic of herpetic infection because of the presence

of tremendously enlarged, multinucleated giant cells (ballooning cells). The cytoplasm is

hyper-basophilic; the nuclei are giant, often have a smoky appearance due to the absence

of the chromatin network, and may contain inclusion bodies due to the presence of

reproducing viral units (figure 18).

2. The cytologic finding from immunobullous disease such as pemphigus is characterized by

numerous acantholytic (or Tzanck) cells (figure 19).

3. A Tzanck smear taken from a fresh bulla from Staphylococcal Scalded Skin Syndrome

(SSSS)shows an abundance of viable keratinocytes (dyskeratotic cells, acantholytic cell)

without inflammatory cells different with Toxic Epidermal Necrolysis (TEN) that presents

scarce necrotic keratinocytes along with fibroblasts and inflammatory cells.



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Fig 18. Paucilesional herpes zoster (a). Ballooning cells at·200 (b) and 1000(c).

Fig 19. A typical acantholytic cell of pemphigus vulgaris.



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BCS 5: Wound Care

Luh Mas Rusyati & Ratih Karna

Skin as barrier protection of the body against external world plays a significant role in the

prevention of infection. Skin that got wounded and not intact will allow the infection to easily

penetrate to the body. Skin and soft tissue infection is still a major problem and is the number four

of most causes of outpatient treatment in Indonesia. This type of infection can be caused by gram-

positive bacteria such as Staphylococcus aureus and Group Aβ-streptococci, or by gram-negative

bacteria such as Pseudomonas and Serratia. After the discovery of antibiotics, most of the

infectious cases could be treated well. But, these days management of infection would be more

challenging and demand more attention with the increase of immunocompromised diseases

including diabetes mellitus. Ulcer itself describes as discontinuity of epidermis and dermis either

caused by a natural history of an underlying disease or by manipulation and trauma. Skin

infections with such situations describe above could prolong the length of stay and the use of

antibiotics.

It needs to be bear in mind that the cause of the wound would not necessarily determine the

management of the wound. It is caused by an event can be different and evolve in the problem

and manifestation. Every medical personnel should be able to assess and manage a wound or

ulcer properly especially in term of wound care, wound toilet, and dressing options. The problem

of wounds including infections, necrotic tissue, and exudates. Infection could be managed by

properly choosing the correct antibiotic accompanied by wound toilet and irrigation. Necrotic

tissue should be managed by debridement with various technical options such as surgery,

autolytic, enzymatic, mechanic and biologic. Exudates now more easily manageable by various

modern dressing that developed with a highly absorbent material such as calcium alginate,

Hydrofiber, or foam.

Before starting doing wound treatment, we have to evaluate the condition of the wound to see if

there are infections or exudates occurred and necrotic tissue was found in the wound. Modern

dressing does not depend on antibiotic or antiseptic because irrigation can be done using

materials that contain silver (Ag) which act against bacteria. While treating the wound, coping

with exudation is a very important step in order to keep the wound moist and it will increase the

re-epithelialization so the healing process will be 50% faster than dry wound. Physiologic Natrium

Chloride (NaCl 0,9%) often used in Dermatology Department to irrigate the wound, especially with

prior dermatitis lesion because NaCl 0,9% is nonirritating. Various options of modern dressing

were available such as calcium alginate, hydrofiberdan foam.



27

In cases of necrotic tissue presence, debridement of the wound is the only choice. Some of the

purpose of debridement are removing necrotic tissue, reducing bacterial contamination, and

promote healing process. Not all debridement procedure was done by surgical measure, even

though it is the fastest and give more complete result. Beside by surgical technique, there is less

invasive nonsurgical debridement that can be an option, such as debridement enzymatic,

debridement autolytic, and debridement biologic. Enzymatic debridement achieved by topical

collagenase ointment that can remove necrotic tissue. Autolytic debridement removes the

remains of necrotic tissue by maintaining the wound in a moist condition. The moist wound will

activate a proteolytic enzyme which also acts to liquefy necrotic tissue. This technique is pain-

free and cheaper. Mechanic debridement was done by wet to dry dressing with sterile gauze by

which the gauze dry, the necrotic tissue will also be removed. The disadvantage of this technique

is discomfort and sometimes disturbing the newly formed epithelial cells. Whereas biologic

debridement using a biological agent such as larva Phaneniceasericata (green blow fly) to remove

the necrotic skins.

Conventional Wound Dressings

1. Sodium Chloride 0,9%. Physiological solutions, safe for dressings especially for the wound

with dermatitis risk.

2. Permanganate Kalikus (1:5.000 – 1:10.000). Antiseptic, pink-purple staining, difficult to

prepare.

Figure 20. Saline-moistened gauze



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Modern Dressings

1. Film transparent self-adhesive sheet. It from polyurethane, gas and water vapor

permeable, impermeable to fluid and bacteria, thin and elastic, easily conforming to

wounds with complex shape and angles, difficult to use as they fold on themselves easily.

Figure 21. Film transparent self-adhesive sheet

2. Foam. Composed of polyurethane or a silicone center, with a semi-occlusive outer layer,

convenient over bony prominences or within exudative cavities. Should be changed as

often becomes soaked with exudate, which may range from daily to once or twice weekly.

Figure 22. Foam



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3. Hydrocolloids. Composed of cross-linked polymer matrices, integrated adhesives, and

starches, such as cellulose, gelatin, pectin, and guar. Available as sheets, pastes, and

powders. Upon contact with wound exudates, hydrocolloids absorb water and form gels.

Figure 23. Hydrocolloids

4. Alginate. Best choice for highly exudative wounds, composed of seaweed or kelp-based

polysaccharides. The gel is highly absorbent. Calcium ions within the dressing exchange

with the sodium ions in wound exudate to form an alginate gel.

Figure 24. Alginate



30

BCS 6: Basal Cell Carcinoma, Squamous Cell Carcinoma, Nevus Pigmentosus,

Cutaneous Melanoma, Abcess Incision and Drainage, Enucleation, Elliptical or

Fusiform Excision, and Nail Avulsion

Dharma Putra & Made Wardhana

6.1 Basal Cell Carcinoma (BCC)

Basal Cell Carcinoma (BCC) is the most common cancer in humans. Basal Cell Carcinoma more

common in the ederly individual. Basal Cell Carcinoma characters develop on sun-exposed skin

in the lighter skinned individual. Basal Cell Carcinoma is rare in the dark skin because of the

inherent photoprotection of melanin and melanosomal dispresion. Risk factors for BCC are

ultraviolet light (UVL) exposure, light hair and eye color, northen european ancestry, and inability

to tan. Pathogenesis of BCC involves exposure to UVL, particulary the ultraviolet B spectrum

(290-320 nm) that induced mutations in p53 tumor suppesor genes.

Clinical Manifestations of BCC may vary for different clinical subtypes, which included nodular,

superficial, morphea-form, pigmented, and fibroepitheloma of Pinkus (FEP).

1. Nodular Basal Cell Carcinoma

The most common clinical subtype of BCC. It occurs most commonly on the sun exposed

area of the head and neck. Appeared as a translucent papule or nodule depending on

duration. There are usually telangiectasis and often rolled border. Large lessions with central

necrosis are reffered by the term rodent ulcer. The differential diagnosis of nodular BCC

included traumatized dermal nevus and amelanotic melanoma.

Figure 25. Nodular Basal Cell Carcinoma Figure 26. Rodent ulcer

2. Pigmented Basal Cell Carcinoma

Appeared as hyperpigmented, translucent papule, which may also be eroded. The

differential diagnosis includes nodular melanoma.



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Figure 27. Pigmented Basal Cell Carcinoma

3. Superficial Basal Cell Carcinoma

Appeared as an erythematous patch (often well dermacated) that resembles eczema.

Figure 28. Superficial Basal Cell Carcinoma

4. Morpheaform (Sclerosing) Basal Cell Carcinoma

Aggresive growth variant of BCC, have an ivory-white appearance and may resemble a scar

or small lesion of morphea.



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Figure 29. Morpheaform Basal Cell Carcinoma

5. Fibroepitheloma of Pinkus (FEP)

Fibroepitheloma of Pinkus clasically presents as a pink papule usually on the lower back. It

may be difficult to distinguish form an acrocordon and skin tag.

Figure 30. Fibroepitheloma of Pinkus

The biologic behavior of BCC can have a local invasion. BCC is a slow-growing tumor that

invades locally rather than metastasizes. If untreated, the tumor will progress to invade

subcutaneous tissue, muscle, and bone. Perineural invasion and metastasis are rare in BCC.

BCC treatments include standard surgical exicions, Mohs Micrographic Surgery (MMS),

destruction with various modalitied (curretage and desiccation, cryosurgery), topical

chemoterapy (imiquimod 5% cream, 5-fluorouracil, hedgehog inhibitor), photodynamic

therapy (PDT), and radiation therapy.

6.2 Squamous Cell Carcinoma (SCC)

Cutaneous squamous cell carcinomas (SCCs) are malignant neoplasms derived from suprabasal

epidermal keratinocytes. Together with basal cell carcinoma, both represent the most common

malignancy in humans. In most cases, this malignancy evolves from precursor lesions of actinic

keratosis and Bowen disease (SCC in situ). Cutaneous SCC represents a broad spectrum of

disease ranging from easily managed, superficially invasive cancers to highly infiltrative,

metastasizing tumors that can result in death. The clinical presentation can be variable despite

the existence of easily identified typical lesions. There are a number of factors, including both,

acquired and genetic skin conditions that may predispose to SCC: precursor lesions, UV/ radiation

exposure, environmental carcinogens, immunosuppressions, scars, burns, chronic scarring, HPV

infection, genodermatoses (albinism, xeroderma pigmentosum, porokeratosis, epidermolysis

bullosa). The majority of SCCs arise on sun-exposed areas such as the head, neck, and dorsal

hands. SCC typically presents in solitary fashion, with the exception is in immunosuppressed



33

patients, who may manifest eruptive SCCs. The most common morphology is a firm, flesh-colored

or erythematous, keratotic papule or plaque. Other presentations include as an ulcer, a smooth

nodule, or a thick cutaneous horn. SCC may also be verrucous or present as an abscess,

particularly if in a periungual location. The margins may be indistinct. With enlargement, there is

usually increased firmness, elevation, and fixation to underlying tissues. Enlarged lymph node

nearby that is firm and nontender may indicate tumor metastasis.

Fig 31. Ulcerative squamous cell carcinomas of the jaw.

The diagnosis of SCC is always made by skin biopsy. Histologic hallmark of invasive SCC is the

extension of atypical keratinocytes beyond the basement membrane into the dermis, with varying

proportions of normal-appearing and atypical squamous cells.The tumor may appear as single

cells, small groups or nests of cells, or a single mass. Squamous differentiation is seen as foci of

keratinization in concentric rings of squamous cells called horn pearls. In every case, it is

important to note clues that may indicate a precursor lesion or particular etiology. The grade,

depth of penetration, tumor thickness, and hair follicle involvement should also be reported. Low-

grade tumors are comprised of uniform cells, resembling mature keratinocytes, with intracellular

bridges and keratin production. By contrast, high-grade SCCs are characterized by atypical cells,

loss of intracellular bridges, minimal or absent keratin production, and a less distinct demarcation

between malignant cells and adjacent normal stroma.

Fig 32. Atypical keratinocytes and foci of keratinization

Treatment of SCC includes the surgical excision, Mohs micrographic surgery, topical therapy (in



34

situ disease only), and radiation therapy. Conventional surgical excision is viewed by many as

the treatment of choice for small primary SCCs. Recommended margins are 4 mm for low-risk

lesions or SCCs with a depth of less than 2 mm; for lesions with a depth of more than 6 mm or a

diameter larger than 1 cm, Mohs micrographic surgery is recommended. Mohs micrographic

surgery is also recommended in specific circumstances when the highest cure rate and minimal

tissue destruction are desired. Radiation can be used to treat superficially invasive to moderate-

risk lesions and serves as an important adjuvant to excisional surgery in treating residual

microscopic disease and providing prophylaxis against metastatic disease. Radiation therapy is

not advised for verrucous carcinoma, in which there is an associated low rate of anaplastic

transformation.

After a diagnosis of SCC, all patients should be considered at high risk for developing additional

lesions of SCC as well as BCC. They should be seen at regular intervals, ranging from 3 months

to 12 months, depending on the degree of risk of prior lesions, the status of precursor lesions,

and individual patient compliance. Some preventative measures are likely to reduce the risk of

recurrences, such as sun protection, treatment of any precursor lesions and HPV infection,

decreased alcohol consumption and smoking cessation.

6.3 Nevus Pigmentosus

Nevus pigmentosus or nevomelanocytic neoplasias is used to describe the presence of a

melanocytic cell in epidermis, dermis, or in other tissue. Nevus pigmentosum can occur because

of mutasions N-RAS, GNAQ, and B-RAF genes that disrupt normal melanocytic development and

result in acumulation of the melanocytic cell. This alteration can induce by UVL. Based on clinical

features the nevus pigmentosum include:

1. Congenital Nevomelanocytic Nevi (CNN)

Present at birth or shorthly thereafter. Divided based on size criteria, small CNN (<1.5 cm),

medium (1,5-19,9 cm), and large or giant (>20 cm). The countour of CNN may smooth, pebbly,

rugose, verrucous, cerebriform, or grossly lobular surface. Have regular and sharply

demarcated. Some CNN has coarse, long, and darkly pigmented hair.

2. Common Acquired Nevomelanocytic Nevus Figure 34. Medium CNN Figure 33. Small CNN Figure 35. Giant CNN



35

The majority appear to develop during the second and third decade of life. Clinically the

lession tend to be uniform in appearance and relatively small in size. The lession have had a

homogenous surface and coloration pattern (skin-colored, pink, or brown) round, oval, dome-

shaped, pendiculated or flat-topped with regular outlines and sharp borders. The surface of

nevi may reveal hair that is less or equal to surrounding skin.

Figure 36. Common Acquired Nevomelanocytic Nevus 3. Nevus Spilus

The lession appeared as a hyperpigmented patch background (1 cm to greater than 10 cm)

with scattered darker flat or raised element macular or papular pigmented. The lession

becomes during infancy or early childhood. Lession have been noted primary on the torso and

extremities.

Figure 37. Nevus Spilus

4. Blue Nevus

Lession appears as a blue, blue-gray, or blue-black papules, nodule, or plaque. Lession is

generally acquired but may be congenital.

Figure 38. Blue Nevus

5. Pigmented Spindel Cell Nevus



36

The pigmented spindle cell nevus presents as a jet black lession often with “starburst”

appearance. The lession usually have uniform darkly pigmented with a sharp border.

Appeared during the third decade of life. Lession have been noted primarily in the lower

extremities and back.

Figure 39. Pigmented Spindel Cell Nevus

6. Splitz Nevus

Lession appears as a dome-shaped papule, the color pink or red, hairless, firm, and dome-

shaped. Some spliz nevus may resemble keloid.

Figure 40. Splitz Nevus

The spectrum of nevomelanocytic neoplasmas often subcategorized based on the location of the

melanocytic cell, into junctional, dermal, and compound on histopathology examination.

1. Junctional nevus pigmentosus

A melanocytic cell in the epidermis. The nevus lession usually flatter and darker.

2. Dermal nevus pigmentosus

A melanocytic cell in the dermis. The nevus lession usually elevated and less pigmented.

3. Compound nevus pigmentosus

A melanocytic cell in both areas epidermis and dermis.



37

Management approach of nevus pigmentosum is the compelete removal of nevus with exisicion

with safety margin 3-5 mm. Exicision should be included subcutaneous fat to ensure complete

removal of the deep dermal melanocytic cell. After exision, the nevus tissue continues with

histopathology examnination. If the size of nevus pigmentosum large and difficult to do exision,

the other modalities of treatment are curretage, dermabration, chemical peel, cryotherapy,

electrosurgery, ablative laser, and also pigmented laser.

6.4 Cutaneous Melanoma

Cutaneous melanoma is the one of the skin cancer in humans. Risk factor cutaneous melanoma

included the history of sunburn or heavy sun exposure, blue or green eyes, blonde or red hair,

fair complexion, have > 100 typical nevi, any typical nevi, prior personal or family history of

melanoma, or p16 mutation. Mean age at diagnosis is 53 years. Most common location is the

back of men and lower extremities followed by trunk for women but can occur anywhere on the

skin surface.

Based on the clinical finding, melanoma can be divided into:

1. Superficial Spreading Melanoma (SSM)

SSM is the most common subtypes melanoma. The lesions have irregular borders, irregular

pigmentation, or it may present a discrete focal area of darkening within preexisting nevus.

The lesions slowly changing over months to years.

Figure 41. Superficial Spreading Melanoma

2. Nodular Melanoma (NM)

Nodular Melanoma is the second most common subtypes melanoma. The trunk is the most

common site. Nodular Melanoma have rapid evolution, over several weeks to years. Nodular

Melanoma typically appeared as dark blue-black our bluish-red raised lession, but 5% cases

are amelanotic.



38

Figure 42. Nodular Melanoma

3. Lentigo Maligna (LM) and Lentigo Maligna Melanoma (LMM)

Lentigo Maligna is a subtype of melanoma in situ with a prolonged radial growth phase that

may progress to invasive LMM with time. The most common location is on the chronically sun-

exposed face, cheeks, nose, neck, scalp, and ear. Lentigo Maligna is flat, slowly enlaging

brown, freckle like macule with irregularly shaped and differing shades of brown and tan.

Lentigo Maligna Melanoma is frequently larger than LM. Both LM and LMM have ill-defined

borders.

Figure 43. Lentigo Maligna Figure 44. Lentigo Maligna Melanoma

4. Acral Lentiginous Melanoma (ALM)

Acral Lentiginous Melanoma is a subtype of melanoma in the darker-pigmented individual.

The most common site ALM is the sole, palm, and subungual. The clinical appearance ALM

can be brown, black, tan, or red with variegations on color and irregular bordees, however,

the most common color is brown-black. Subungual ALM, arised from nail matrix, most

commonly on great toe or thumb. It appeared as a brown to black discoloration or growth in

the nail bed.



39

Figure 45. Acral Lentiginous Melanoma

Diagnosis cutaneous melanoma can be made by using ABCD rule, 7 point check list using

dermoscopy examination. The gold standard for diagnosis melanoma is based on a

histopathologic evaluation of the specimen. Sentinel Lymph Node Biopsy (SLNB) can be used for

evaluation of regional metastasis melanoma on the lymph node. For evaluation distant metastasis

can be used imaging modalities such as CT-scan, MRI, PET, Chest X-ray, and hematologic test

Lactate Dehydrogenase (LDH).

Figure 46. ABCD Rule Figure 47. Seven points check list



40

Treatment of primary cutaneous melanoma is exsicion, the current recomended margin for exicion

based on Breslow depth from histopatoly examnination. Treatment for regional metastatis

cutaneous melanoma on lymph node is complete node dissection, give chemotherapy agent use

isolated lymp perfusion or isolated lymp infusion method. Treatment for distant metastasis

cutaneous melanoma is systemic chemotherapy and immunotherapies like decarbazine (DTIC),

Temozolomide (TMZ), or high doses interleukin-2 (IL-2).

6.5 Abcess Incision and Drainage

AIM: Once an abscess has formed an antibiotic cannot penetrate the avascular slough lining

the cavity. It is only after the abscess has been incised and the slough scraped away that the

antibiotic as well as the body’s own cellular and humoral defenses gain access to the cavity and

eradicate the infection.

EQUIPMENT:

1. Steril gloves

2. Sterile gauze.

3. Skin antiseptic agent

4. Local anesthetic (1% lidocaine)

5. Syringe with 25-gauge needle for anesthetic administration

6. No. 11 blade scalpel

7. Hemostat

8. Syringe and saline for irrigation

9. Dressing supplies.

PROCEDURE (Modified Hilton’s Method):

1. Put on sterile gloves.

2. Carry out draping and isolation of surgical site.

3. Clean the surgical site with an antiseptic agent.

4. Infiltration of the local anesthetic agent.

5. Incision with a scalpel blade (No. 11) over the most prominent part, parallel to Langer’s lines.

6. As far as possible, keep incision in the most dependant part.

7. Introduce hemostat. After introducing, open the blades and rotate to widen the tract and break

the septa. If required, the gloved finger should be introduced to break the septa.

8. Take pus for culture and sensitivity.



41

9. Irrigate cavity with an antiseptic (povidone iodine, hydrogen peroxide), followed by irrigation

with saline.

10. Pack the cavity with roller gauze (bleeding due to congested vessels and granulation tissue

in the wall is controlled by tight packing).

11. Apply a sterile dressing and secure with adhesive tape.

POST-PROCEDURE:

1. Give broad spectrum antibiotics until culture and sensitivity report available

2. After that, give specific antibiotics according to the report

3. Analgesics

4. Anti-inflammatory

5. Instruct the patient to not disturb the dressing until the first follow-up visit.

6.6 Enucleation

AIM: Enucleation technique can be used to remove the molluscum body in molluscum

contagiosum, which is a common skin infection caused by a pox virus ussualy present as raised

nodule with an umbilicated centre. The cellular material within the central umblication is extracted

manually using a needle.

EQUIPMENT:

1. Sterile needle 16 to 18 gauge

2. Alcohol swab.

PROCEDURE:

1. Swab the affected skin area with an alcohol swab.

2. Using a sterile needle, cut across the body of the molluscum lesion with the needle.

3. Remove the contents of the papule with an alcohol swab.

POST-PROCEDURE:

Minimal care is needed which includes keeping the wound dry and applying an antibiotic ointment

and simple daily dressing.

6.7 Elliptical or Fusiform Excision



42

AIM: The design and execution of a fusiform ellipse are fundamental skills of skin surgery. The

purpose of this procedure is to remove a skin specimen and in the process produce a cosmetically

acceptable linear scar. Although the nomenclature for the procedure may vary depending upon

the design (eg, elliptical, fusiform, tangent-to-circle), the purpose remains the same.

EQUIPMENT:

1. Surgical marking pen

2. Lidocaine 1-2% with or without epinephrine

3. Syringes, 5 to 10 mL

4. Needles, 27 to 30 gauge for injection

5. Sterile gloves

6. Electrosurgical instrument for hemostasis (optional to have one for cutting)

7. No. 15 scalpel or No. 15c and blade handle

8. Adson forceps (with and without teeth)

9. Iris scissors (optional to have another scissor for undermining)

10. Webster needle holder (consider gold-handled holder with carbide inserts)

11. Mosquito hemostats

12. Skin hooks (single, sharp prong)

13. Cotton-tipped applicators (CTAs) and gauze

14. Skin preparation solution (chlorhexidine or povidone-iodine)

15. Sterile drapes and a single fenestrated drape

16. Suture materials

17. Specimen container with formalin and label

18. Dressings: 2 × 2 gauzes, 4 × 4 gauzes, adhesive tape

PROCEDURE:

1. The fusiform excision is designed with a 3 to 1 length-to-width ratio, oriented in the direction

of the lines of least skin tension. The excision lines can be marked on the skin using a skin-

marking pen.

2. The skin is prepped with chlorhexidine or povidone-iodine solution and anesthetized with 1%

or 2% lidocaine with or without epinephrine. The hemostatic benefit of epinephrine is added

for most procedures, except when the surgery is performed on the digits or the tip of the nose.

The anesthetic can be administered with a 10-mL syringe and a 30-gauge needle for

enhanced patient comfort.

3. Following administration of the anesthetic, sterile gloves can be applied, the skin can be

reprepped with povidone-iodine solution, and a sterile fenestrated paper drape placed over



43

the surgical field. Sterile bandages can be used at the edge of the fenestration to keep the

drape from shifting and prevent unprepped skin from appearing through the drape hole.

4. The incision is made with a no.15 scalpel blade held vertical to the skin. Inward beveling, or

“wedging,” is discouraged. The first pass of the scalpel on each wound edge should be smooth

and continuous to prevent notching of the skin. A second pass of the blade may be needed to

extend these incisions down to the level of the fat. Some 4x4 gauze can be used to wipe the

surgical field clear of blood.

5. The scalpel is turned parallel to the skin surface to undermine the central fusiform island of

skin. The central island of skin is lifted with Adson forceps with teeth as the scalpel is moved

in the level of the upper fat. Once the central island of skin is removed, it is immediately placed

in formalin and retained for histologic evaluation.

6. Bleeding sites in the wound base can be controlled by applying hemostats or suture ligation.

The lateral tissues are elevated with a non disposable skin hook or a disposable hook. The

lateral skin edges are not lifted with Adson forceps because the forceps may cause tissue

necrosis. The lateral skin edges are undermined with a horizontally held scalpel or scissors in

the level of the upper fat; 3 cm of lateral undermining is required for every 1 cm of skin edge

relaxation.

7. Interrupted, deep-buried sutures are placed to eliminate dead space at the wound base,

promote healing, reduce tension on the skin sutures, and improve the final cosmetic

appearance of the scar.

8. Once the suturing is completed, the wound should be squeezed gently to remove any residual

blood from beneath the wound that will interfere with healing. Direct pressure can be applied

with gauze by the patient for 10 minutes or more to assist with hemostasis. The assistant then

cleans the site with saline solution, applies antibiotic ointment, and places a pressure dressing

(elastic bandage over gauze).

POST-PROCEDURE:

1. Broad spectrum antibiotics

2. Analgesics

3. Anti-inflammatory

4. Instruct the patient to not disturb the dressing until the first follow-up visit

6.8 Nail Avulsion

The removal of the nail plate can be carried out using distal or proximal approaches. In both

techniques, inserting the blunt instrument back and forth between the horny layer of the proximal

nail fold and the nail plate loosens the proximal nail fold adherence.



44

Figure 48. A). Distal nail avulsion; B). Proximal nail avulsion

In the more commonly used distal approach, a Freer septum elevator or a dental spatula is

inserted between the nail plate and nail bed (fig 1). The nail is separated from its nail bed

attachment using proximal force applied in anterior-posterior movements so as not to injure the

longitudinal ridges of the nail bed. The detachment is completed by firmly pushing the instrument

into the posterolateral corners of the nail plate. Then, one of the lateral edges is grasped with a

sturdy hemostat, and extracted with an upward and circular movement to accomplish the removal

of the nail plate. The proximal approach for nail avulsion is advisable when the subungual distal

area adheres strongly to the nail plate and when the hyponychium may be injured by the

subungual introduction of the spatula. The proximal nail fold is freed as described in Distal

Approach. The spatula is then used to reflect the proximal nail fold, and is delicately inserted

under the base of the nail plate where adherence is normally weak. The instrument is advanced

distally following the natural cleavage plane, and this operation is repeated on the entire width of

the subungual region. After the last attachments are freed, the nail plate is easily pulled out.



45

Total surgical removal should be discouraged, however, because the distal nail bed may shrink

and become dislocated dorsally. In addition, the loss of counter pressure produced by the removal

of the nail plate allows expansion of the distal soft tissue, and the distal edge of the regrowing nail

then embeds itself. In patients at high risk, nonsurgical removal of the nail plate should be

considered when necessary. This can be accomplished by applying 40% urea paste directly to

the nail after protecting the surrounding skin. Urea acts on the bond between nail keratin and

diseased nail plate, sparing only the normal nail tissue.

PARTIAL NAIL AVULSION

Partial distal avulsion requires only separation of the nail from the distal nail bed. This procedure

can be performed under local anesthesia, when, for instance, a fungal infection is of limited extent.

An affected portion of the nail plate may be removed in one session, even when the disease has

reached the deeper regions of the subungual tissue beneath the proximal nail fold. Commonly,

an English anvil nail splitter or a double-action bone rongeur is used for this procedure.

Partial surgical section of the lateral and/or medial segment of the nail plate may be sufficient for

the treatment of distal lateral subungual onychomycosis. In the toe, this procedure leaves enough

normal nail to counteract the upward forces exerted on the distal soft tissue when walking, and

this will prevent the appearance of a distal nail wall.

Figure 49. A and B. Technique of removal the base of nail plate

In proximal subungual onychomycosis, removal of the nonadjacent base of the nail plate, cut



46

transversely, leaves the distal portion of the nail in place (Fig 2), which decreases discomfort.

Similarly, an acute paronychia that does not respond to appropriate antibiotics within 48 hours

should be treated surgically by removing the base of the nail plate.

TRAP DOOR NAIL AVULSION

This technique minimizes trauma in nail surgery when accessing the nail bed and matrix. Trap

door nail plate avulsion entails the separation of all periungual attachments except for that

between the dorsum of the nail and the ventral aspect of the proximal nail fold. Both are then

reflected in the bloc in the manner of a trap door, utilizing the same oblique incisions normally

made for resection of the PNF alone.



47

BCS 7: Valsalva Maneuver, Cleaning of MAE, Foreign bodies, and Cerumen

Extraction

Andi Dwi Saputra

7.1 Valsava Maneuver

When a person has a feeling of fullness in his or her ears, it is usually the person will attempt to

spontaneously relieve the discomfort by equating the pressure between the middle ear and the

environment through accelerating air circulation through the Eustachian tube by moving the jaw,

swallowing and advocating equalizer technique/ pressure balancing between the outer ear and

middle ear with Toynbee and Valsava maneuver. Toynbee maneuver is done by closing/ punching

the nose with the fingers and then shut up and swallowing saliva, while Valsava maneuver done

by closing/ punching the nose with the fingers, shut the mouth and then blowing with the closed

mouth.

The Valsava maneuver comes from the name of the Italian anatomist Antonio Maria Valsalva

(1666-1723), who first described this procedure by covering both sides of the nose and mouth

and blowing on the cheek with forced expiration. This causes an increase in air pressure in the

posterior space of the nose and into the Eustachian tubes, inflating the middle ear cavity and

producing prominent movements of the tympanic membrane. This movement is most visible in

the superior-posterior quadrant of the eardrum and can be easily seen through the ear canal.

Figure 50. Valsava Maneuver



48





49

7.2 Foreign Body In Canalis Auditorius Externa (CAE)

Any foreign body that entering to CAE must be removed. Handling must certainly remember and

know the anatomy of the outer ear. The ear canal as part of the outer ear has a unique structure

where the outer 1/3 contains thick connective tissue and cartilage while the inner 2/3 is thinner

and directly attached to the periosteum.

The outside of the ear canal also contains glands that produce cerumen where it also functions

as a protection of ear canal from foreign body and infections. Basically, cerumen do not need to

be cleaned actively because the ear canal has a cleansing mechanism. The use of tools to clean

the cerumen will actually push the cerumen more in and make the skin layer damaged.

Cerumen is cleaned when it caused complaints such as a full sense of the ear and hearing loss.

Some methods to clean cerumen include irrigation with warm and sterile water, using a hook,

cotton applicator, or forceps.

Figure 53. Foreign body in Canalis Auditorius Externus



50

Figure 54. Cerumen extraction



51

The various foreign body can enter into the ear canal both living things such as insects and

inanimate objects such as mote. Usually more often happened in children because the habit of

inserting objects into the ear. Management of foreign body should be done carefully and according

to ability. Visualization should be clear into the ear canal because it is not infrequently

accompanied by swelling of the ear canal. The method of taking a foreign body in the ear canal

can also be done by using a hook for a round object, forceps for paper or easily clamped objects,

irrigation when a foreign body is small and close to the tympanic membrane.

Small insects that entering the ear canal must be killed first by using water, coconut oil, or non-

irritating alcohol in the ear canal.

Complications that can be experienced when removing foreign bodies include skin excoriation of

the ear canal, bleeding, post-action infections, and rupture of the tympanic membrane. To avoid

such things must be done carefully, using appropriate tools, and keep the child's peace.




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53

LABORATORY GUIDELINE



54

Histology: Skin and Hearing Structure

Thick Skin, Thin Skin, and Skin Appendages

Aim : To increase understanding of thick, thin skin, and skin appendages structure.

Date & place : see schedule

Conveyer : Dr. dr. Ni Made Linawati, M.Si;

dr. IGK. Arijana, M.Si Med

Material : Microscope

Histological preparations (thick, thin skin and skin appendages)

a. Thick Skin:

Epidermis, dermis

b. Thin Skin (eyelid, lip, scalp, etc)

Epidermis, dermis

c. Skin appendages (in the thick and thin skin):

Hair, sweat gland, sebaceous gland



55

Anatomy Pathology: Skin and Hearing Systems Disorders

Herman Saputra

List and describe the descriptive term of microscopic features in dermatopathology bellow:

1. Hyperkeratosis

2. Parakeratosis

3. Hypergranulosis

4. Acanthosis

5. Papillomatosis

6. Dyskeratosis

7. Acantholysis

8. Spongiosis

9. Hydropic swelling

10. Exocytosis

11. Erosion

12. Ulceration

13. Vacuolization

14. Lentiginous



56

Pharmacology & Pharmacy: Rational Therapy of Topical Preparations in Dermatology

Alit Widhiartini & Sucindra Dewi

Please make a summary of P drugs of dermatological problem complete with topical

recommended treatment. Use the table below. You can use textbook or journal as references and

compared to Buku Panduan Praktek Klinis bagi Dokter di Fasilitas Pelayanan (Permenkes no 5

Tahun 2014).

Table 1. P drugs

Diagnosis Recommended Treatment

Drug Dosage form Frequency per day, duration



57

Aim : To understand the principles of rational drug therapies for topical preparations in

dermatology diseases

The process of the rationale drug therapies:

Step 1: What is the problem/s?

Step 2: What is the aim of the therapy

Step 3: Is the Personalized therapy (P-therapy) suitable for your patient (efficacy, safety,

suitability, cost)

Step 4: Start treatment

Step 5: Giving the information about the therapy, how to apply and adverse effect

Step 6: Monitoring and stop the treatment

Case:

Herpes zoster,

Pediculosis,

Pyoderma (impetigo)



58

Physiology: Hearing


Aim : To study the auditory examination with tuning forks.

Tools and Materials : Tuning forks 256 Hz, 512 Hz, and 100 Hz

Figure 57. Tuning Forks

Working Procedure :

Hearing Test:

1. Rinne test :

a. Vibrate the 256 Hz tuning fork by hitting on the palm of the hand (never on hard objects).

b. Press the rod of the vibrating tuning forks on the mastoid process of one of the ears.

c. When the patient can no longer feel/hear the vibration, the tuning fork is held in front of

the ear.

d. The patient should once more be able to hear a ringing sound (Rinne-positive).

e. If they cannot, there is a conductive hearing loss in that ear (Rinne-negative).

f. Repeat the experiment with the other ear.



59

Figure 58. Rinne Test

2. Weber test:

a. Vibrate the 512 Hz tuning fork by hitting on the palm of the hand (never on hard objects).

b. Placed tuning fork on the patient forehead.

c. The patient is then asked if the sound is localized in the center of the head or whether it

is louder in either ear.

d. If hearing equally well in both ears is called no lateralization. When the sound is heard

stronger in one ear, then called there is lateralization to the ear that hears the stronger

sound.

e. If there is a conductive hearing loss, it is likely to be louder in the affected ear; if there is

a sensorineural hearing loss, it will be quieter in the affected ear.

f. in this experiment, If not lateralization, in an attempt to obtain artificial lateralization, then

close one ear with cotton, and repeat the above experiment.



60

Figure 59. Weber Test

3. Schwabach:

a. Vibrate the 100 Hz tuning fork by hitting on the palm of the hand (never on hard objects)

b. Press the rod of the vibrating tuning forks on the mastoid process of one of the ears.

c. ask the patient to raise his hand when the sound disappears, and at that moment the

examiner moves the tuning fork on his own mastoid process.

d. If the sound is still audible by the examiner, it is called a shortened Schwabach.

e. If the examiner does not hear that sound, then repeat the above experiment, only the

sequence is reversed. The examiner first listens, when no longer heard is transferred to

the patient. When the patient still hears the sound it was called Schwabach elongated.

f. When patient not to hear again, then it says no Schwabach elongated or shortened.

Figure 60 Schwabach Test



61

Physiology: Somesthetic Sensation


Aim : To see how the exteroceptor works.

Tools and Materials : Pencils and Geometric compass tools

Figure 61. Pencils

Figure 62. Geometric compass tools

Working Procedure :

Perception of touch:

a. Put a pencil behind the ear between head and earlobe.

b. Let the pencil in place, while you do other work.

c. What do you feel when the pencil is lifted? Why?



62

Figure 63. Pencil behind the ear

Placement of pressure:

The placement of pressure that must be distinguished from the ability to recognize the basic touch.

a. The examiner emphasizes the pencil tip firmly at a point on the skin.

b. Patients whose eyes are closed is asked to show the pencil tip as close as possible to the

point that was stimulated.

c. The examiner measures the distance between the two points.

d. Do this experiment five times each on the finger, palm, inside of the upper arm and the

back of the neck. Calculate the average for each region.

Tactile discrimination:

a. Specify with the equipment (geometric compass tool), the threshold of distinguishing two

points from the skin of the back of your hand. Measure how many mm/ cm the distance.

b. Do the same on the tips of fingers, nape, lips, and cheeks.

c. All experiments should be done twice, from a large distance between two ends of the

equipment and vice versa, until the threshold is obtained.

d. Try again this experiment, where both ends of the equipment are not touched at the same

time but in a row. Are the results the same? Explain!



63

Figure 64. Measure from a large distance

Figure 65. Measure until the threshold is obtained

Figure 66. Measure the distance



64

REFERENCES

1. Craft N, et al. Superficial Cutaneous Infections and Pyodermas. In: Wolff K, Goldsmith LA,

Katz SI, Gilchrist BA, Paller AS, Leffell DJ, eds. Fitzpatrick’s Dermatology In General

Medicine, 7thed, 2008. USA: McGraw-Hill Company;; p:1694-1719.

2. Departemen Kesehatan Republik Indonesia. Profil Kesehatan Indonesia 2007. 2008.

Jakarta: Departemen Kesehatan RI.

3. Durdu M, Baba M, Seckin MD. The value of Tzanck smear test in the diagnosis of erosive,

vesicular, bullous, and pustular skin lesions. J Am AcadDermatol 2008;59:958-64

4. Eryılmaz A, Durdu M, Baba M, Yıldırım FE. Diagnostic reliability of the Tzanck smear in

dermatologic Diseases. Int J Dermatol 2014; 53: 178–186

5. Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D. Scabies in Color Atlas and synopsis of

clinical dermatology 4th ed. 2001. McGraw-Hill Medical Publishing Division. P834-43

6. Gupta LK, Singhi MK. Tzanck smear: A useful diagnostic tool. Indian J

DermatolVenereolLeprol 2005;71:295-9.

7. Hay RJ, Adrians BM. Bacterial Infections. In: Burns T, Breathach S, Cox N, Griffiths C,

eds. Rook’s Textbook of Dermatology, 7th ed. 2004. USA: Blackwell Science Publishing

Company, p: 27.1-27.85.

8. Leung V, Miller M. Detection of scabies: A systematic review of diagnostic methods. Can

J Infect Dis Med Microbiol 2011; 22:143-6

9. Micali G, Lacarrubba F, Verzì AE, Chosidow O, Schwartz RA. Scabies: Advances in

Noninvasive Diagnosis. PLOS Neglected Tropical Diseases, 2016

10. Nugroho AS. Pemeriksaan penunjang diagnosis mikosis superfisialis. In: Bramono. K.,

Suyoso. S., Indriatmi. W., Ramali. L.M., Widaty. S., Ervianti E., eds.

DermatomikosisSuperfisialis. 2nd ed. 2013. Jakarta: Badan Penerbit FKUI..p.154-163.

11. Perdanakusuma, DS, Hariani L. Modern Wound Management: Indication and Application,

2015. Surabaya: PT Revka Petra Media; 1-65.

12. Rovee TD, Maibach HI. Epidermal Repaired the Chronic Wound. In: Dermatology: Clinical

and Basic Science Series The Epidermis in Wound Healing. 1st ed. London: Library of

Congres Cataloging-in-Publication Data. 2004; pp 25-58

13. Ruocco E, Brunetti G, Vecchio MD, Ruocco V. The practical use of cytology for diagnosis

in Dermatology. JEADV 2011; 25:125–129

14. Ruocco V, Ruocco E. Tzanck smear, an old test for the new millennium: when and how.

Int J Dermatol 1999; 38: 830–834



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15. Schieke S.M., Garg A. Superficial Fungal Infection. In: Goldsmith LA., Katz SI., Gilchrest

BA., Paller AS., Leffell DJ., eds. Fitzpatrick’s Dermatology In General Medicine. 8thed.

2012. New York: McGraw Hill..p. 2277-97.



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