METHODOLOGICAL INSTRUCTIONS
TO PRACTICAL LESSONS FOR 4-nd
COURSE STUDENTS OF
DENTISTRY FACULTY
LESSON N 2 (PRACTICAL-6 HOURS)
Themes: 1. Bullous dermatosis. Pemphigus, its varieties. Herpetiformic dermatitis.
Virus dermatosis. Herpes simplex. Herpes zoster. Warts (human
papillomavirus infections): common warts, flat
warts, plantar warts. Molluscum contagiosum.
2. Urticaria and erythema. Allergic, idiopathic, thermographic, cholinergic urticaria. Angioedema.bullous and non-bullous
erythema multiform. Vasculitis allergic, urticarial, nodule. Henoch-Schonlein purpura.
Aim: To develop skills in methods of skin
assessment, identification of skin lesions, working out plan of general
examination, treatment and prophylaxis of Bullous dermatosis,
urticaria and erythema, parasitogenic
skin diseases, pyoderma.
Professional orientation of
students:
Skin is the largest
organ of the body, it constitutes about 16% of body weight, its total surface
area is about 1.2-2.2 m2. Bullous skin diseases are characterized by the
presence of blisters or erosions of the skin and mucous membranes. Bullous skin
diseases may be acquired or induced or they may be autoimmune in origin. The
autoimmune bullous skin disorders are all characterized by the presence of
autoantibodies that target distinct adhesion molecules of the epidermis and dermoepidermal basement membrane zone. The consequences of
these antibodies are a loss of the targeted protein's adhesive properties,
which leads, in turn, to the appearance of blisters and erosions. Herpes
simplex viruses are ubiquitous, host-adapted pathogens that cause a wide
variety of disease states. Two types exist: herpes simplex virus type 1 (HSV-1)
and type 2 (HSV-2). Both are closely related but differ in epidemiology. HSV-1
is traditionally associated with orofacial disease,
while HSV-2 is traditionally associated with genital disease; however, lesion
location is not necessarily indicative of viral type. Up to 80% of herpes
simplex infections are asymptomatic. Symptomatic infections can be
characterized by significant morbidity and recurrence. In immunocompromised
hosts, infections can cause life-threatening complications. The prevalence of
HSV infection worldwide has increased over the last several decades, making it
a major public health concern. Prompt recognition of herpes simplex infection
and early initiation of therapy are of utmost importance in the management of
the disease.
Pruritus
(itching) and rash are the primary manifestations of urticaria,
and permanent hyperpigmentation or hypopigmentation are rare. Acute urticaria is usually
self-limited and commonly resolves within 24 hours but may last up to 6 weeks. Chronic urticaria lasts more than 6
weeks. Neither acute nor chronic urticaria results in
long-term consequences other than anxiety and depression. The depression can be
severe enough to lead to suicide in rare cases. Also, many of the diseases
associated with chronic urticaria may cause very
significant morbidity and mortality.
Methodology
of Practical Class (900-1200 hour).
Methodic of Student s
Practical Activity:
1. To prepare to communication with a patient and examination
(clean warm hands, cut off nails, if necessary ‑ gloves, spatula, needed
instruments).
2. Greeting and identification (name, level of competence), get the
agreement of patient.
3. At the receiving of agreement of patient to set confidential
mutual relations (a friendly face, respect and concern, soft talk during
conversation).
4. To collect complaints,
anamnesis of illness to explain to the patient the reason of finding out of
separate questions (contact with patient with Bullous
dermatosis , Herpetiformic
dermatitis, virus dermatosis, herpes simplex,
herpes zoster, warts, urticaria and erythema).
5. To explain the results of questioning.
6. To explain to the patient, what examination will be done and its
reasonability, to get an agreement.
7. To notify about the possibility of the occurrence of unpleasant
feelings during examination.
8. To conduct the examination of patient (to estimate the general
state, consciousness status, position of patient in the bed, detail history of
the disease, inspection of unigured skin areas (color
– pale, icteric, cyanotic etc.); dermatological status (inspection; palpation;
scraping; diascopy), skin lesions (type, shape, and arrangement). It is necessary to
reveal features of clinical motion of Bullous dermatosis , Herpetiformic
dermatitis, virus dermatosis, herpes simplex,
herpes zoster, warts, urticaria and erythema
, demonstrating practical skills.
9. To explain the results of examination understandably for
patient.
10. To finish a conversation, thank for communication, wish favorable flow of illness and rapid convalescence.
Practical work 1. To perform Tzanck test.
This is
cytological examination of skin blisters. After rupturing the roof of the blister, the base is scraped with a surgical
blade onto a microscopic slide and fixed. The slides are stained with Giemsa stain, Wright's stain, or toluidine blue and examined under the microscope. Made from floor of the erosion
(after removing the crust) shows acantholytic cells.
Practical work 2. To perform Nikolsky’s sign.
Application of tangential pressure on normal skin results in formation
of anew bulla or if applied to pre-existing bulla
results in the spread of bulla (Nikolsky’s sign).
Break (1200-1230 hour).
1.
Anatomy,
histology, and physiology of the skin – layers of skin, epidermal layers, cell of the epidermis, dermis layers, and cells of the
dermis, hypodermis, functions of the skin, glands of the skin, hair and nails.
2.
Skin
lesions and methods of examination of patients with skin diseases – terms used
to describe skin lesions (type, shape, and arrangement),
investigations.
3.
Features
of clinical motion of Bullous dermatosis , Herpetiformic dermatitis, virus dermatosis, herpes simplex, herpes zoster, warts, urticaria and erythema .
Seminar discussion of theoretical questions and
practical work (1230 – 1400 hour).
Break (1400-1415 hour).
Individual students work (1415-1500 hour) is checked by
solving situational tasks for each topic, answers in test evaluations and
constructive questions (the instructor has tests & situational tasks).
Test evaluation and
situational tasks.
1) Acantholytic epidermal cells are
characterized for:
A.
Pemphigus
vulgaris
B.
Psoriasis
C.
Pioderma
D.
Lichen
planus
E.
Tinea
2) Drugs of choice for patient with
Pemphigus erythematosus are:
A.
Antibiotics
B.
Antifungal drugs
C.
Corticosteroids
D.
None is right
E.
Antiviral drugs
3) Clinical features of pemphigus vulgaris are all, except:
A.
Tense
of flaccid bulla appear on normal skin
B.
On
rupturing, form painful erosions
C.
The
eruption is usually symmetrical
D.
They
are usually irregular in shape
E.
Nikolsky’s sign is negative
4)
Exfoliating
scales are characterized for such types of pemphigus:
A.
Pemphigus
foliaceus
B.
Pemphigus
vulgaris
C.
Pemphigus
vegetans
D.
Pempgigus erythematosus
E.
All is
correct
5)
Acantholytic epidermal cells are characterized for
:
A.
Pemphigus
vulgaris
B.
Psoriasis
C.
Pioderma
D.
Lichen
planus
E.
Tinea
6) Senear-Usher syndrome is synonym of:
A.
Pemphigus
foliaceus
B.
Pemphigus
vulgaris
C.
Pemphigus
vegetans
D.
Pempgigus erythematosus
E.
Phemhigoid
Students should know:
1. Anatomy of human
skin.
2. Histology of human
skin.
3. Physiology of human
skin.
4. History taking of
patients with skin diseases.
5. Methods of
examination of patients with skin diseases
6. Characteristics of
skin lesions:
1)
Primary:
·
Primary
lesions without cavity (macules, urtica, papule, nodule);
·
Primary
lesions with cavity (vesicle, bulla, ppustule, cyst).
2)
Secondary
(scale, crust, erosion, burrow, ulcer, lichenification).
7. Pathogenesis,
clinic, treatment and preventive of: Bullous dermatosis , Herpetiformic
dermatitis, virus dermatosis, herpes simplex,
herpes zoster, warts, urticaria and erythema
Students should be able to:
1.
To
describe skin lesions.
2.
To assess nails, hair,
and mucosal surfaces, even if these are recorded as unaffected.
3.
To
perform diascopy, to investigate dermographism.
4.
To
work out plan of review; appropriate treatment and preventive of Bullous dermatosis , Herpetiformic dermatitis, virus dermatosis, herpes simplex, herpes zoster, warts, urticaria and erythema
3. Answers to the
Self-assessment:
1) Pemphigus vulgaris.
2) Corticosteroids.
3) Nikolsky’s sign is negative.
4) Pemphigus foliaceus.
5) Pemphigus vulgaris.
6) Pempgigus erythematosus
References.
Basic:
1. Savchak V., Kovalchuk M. Skin diseases in the family doctor practice. –
Ternopil, Ukrmedknyha, 2005.-397p.
2. M. Kovalchuk. Skin diseases. Color atlas. – Ternopil, Ukrmedknyha, 2007.-210 p.
3. Savchak V., Halnykina S. Sexually transmitted diseases. – Ternopil, Ukrmedknyha, 2001.-506 p.
4. Patient’s photo, phototests ¹173 – 199; ¹221 – 225, 229 – 241, 208 – 209.
5. Materials
for practical class 2
6. Materials
for preparing for lecture 4
Additional:
1. Color atlas of and Synopsis
of clinical dermatology (Thomas B. Fitzpatrick at al,
1988, p. 1-5.
2. Thomas P.Habif.
Clinical Dermatology. Mosby, 2004.
– 1004 p.
3. P.N. Behl, A. Aggarwal.
Practice
of dermatology (tenth edition). Bangalore, 2005. – 500
p.
4. Alan B. Fleischer Dermatology. Common problems.
New York, 2000. – 303 p.
5. Virendra N Sehgal.
Clinical Dermatology. New Delhi,
2004. – 305 p.
Internet links:
1.
Pemphigus Vulgaris. http://emedicine.medscape.com/article/1064187-overview.
Nikolsky’s
sign. Video. http://www.youtube.com/watch?feature=player_detailpage&v=3bjhVZ_ZyyU
5. Bernard HU, Burk RD, Chen Z, van Doorslaer
K, Hausen Hz, de Villiers EM. Classification of
papillomaviruses (PVs) based on 189 PV types and proposal of taxonomic
amendments. Virology. May 25 2010;401(1):70-9. [Full Text].
6. Chaturvedi AK, Katki HA, Hildesheim
A, Rodríguez AC, Quint W, Schiffman M, et al. Human
papillomavirus infection with multiple types: pattern of coinfection
and risk of cervical disease. J Infect Dis. Apr 1 2011;203(7):910-20. [Full Text].
7. Hives and urticaria. Video.
http://www.youtube.com/watch?feature=player_detailpage&v=hxJIPmDeOoA
The methodical instruction has
been worked out by: by ass. Shkilna M.I.
Methodical instruction was
discussed and adopted at the Department sitting
14/06/2013 Minute N 10.