Chapter 1. GENERAL INFORMATION ABOUT THE SKIN AND ITS ADDITIONS. ELEMENTS OF SKIN RASH, THEIR PATHOHISTOLOGY

Chapter 1. GENERAL INFORMATION ABOUT THE SKIN AND ITS ADDITIONS. ELEMENTS OF SKIN RASH, THEIR PATHOHISTOLOGY

1.1. STRUCTURE OF THE SKIN AND ITS ADDITIVES

The skin is a multifunctional organ that covers the human body and serves as a boundary separating it from the external environment, closely interconnected with all other organs and systems. In this regard, various physiological and pathological processes are to a certain extent reflected in the skin or proceed with its participation.

The skin covers the entire surface of the body. In the area of ​​​​natural openings (mouth, nose, urethra, vagina and anus), the skin passes into the mucous membrane. The total skin area in an adult is from 1.5 to 1.8 m 2, in a child it depends on age.

In the process of ontogenesis, the skin develops from 2 germ layers - the outer (ectoderm) and middle (mesoderm), and consists of 2 types of tissue - epidermal and connective, which are closely related.

Skin layers

There are 3 sections of the skin (Fig. 1-1):

Epidermis (epidermis);

Dermis (derma);

. subcutaneous adipose tissue (subcutis), or hypodermis (hypodermis).

Epidermis

The epidermis and its appendages (hair, nails, sweat and sebaceous glands) develop from the ectoderm. At the 2nd week of embryogenesis, melanocytes penetrate into the basal layer of the epidermis from the neural crest.

Rice. 1-1. Skin structure

The epidermis is represented by a stratified squamous keratinized epithelium, the thickness of which in the most delicate places (eyelids) is 0.04 mm, in the rough ones (palms, soles) - up to 1.6 mm.

There are 3 types of cells in the epidermis:

Keratinocytes (epidermocytes) are presented in various evolutionary forms and constitute the main cell mass of the epidermis;

pigment cells (melanocytes);

Immune cells (intraepidermal macrophages).

Merkel cells are also found in the epidermis, but they are neuroreceptor structures and are associated with nerve endings penetrating from the dermis.

In the epidermis, 5 layers are distinguished (Fig. 1-2):

Horny (stratum corneum);

. brilliant (stratum lucidum);

. grainy (stratum granulosum);

. prickly (stratum spinosum);

. basal (stratum basele).

Basal layer

The basal layer consists of 1 row of cylindrical cells (basal keratinocytes), with mitotic activity. The keratinocytes of the basal layer are interconnected by desmosomes, and attached to the basement membrane by hemidesmosomes. Hemidesmosomes are microscopic cytoplasmic outgrowths of cells that penetrate the basement membrane, they cause a strong connection of the epidermis with the basement membrane and dermis.

There are 2 subpopulations of keratinocytes: one of them is constantly proliferating, the second is at rest (reserve). The main function of keratinocytes in the basal layer is the constant proliferation and regeneration of epidermal defects.

Rice. 1-2.The structure of the epidermis

Melanocytes - large process pigment cells lie on the basement membrane and form the basal layer of the epidermis. Melanocytes are even in the mucous membrane. The exception is the thick epidermis of the palms and soles, where these cells are absent. In an adult, the number of melanocytes is approximately 10% of all epidermal cells (in newborns - 3.7%, and in children - 7%). The number of melanocytic cells does not depend on race or gender. Melanocytes synthesize pigment melanin, protecting the skin from the harmful effects of ultraviolet (UV) rays. Melanocytes produce melanin from tyrosine with the participation of the enzyme tyrosinase.

Spiny layer

The spiny layer located above the basal layer consists of 3-8 rows of cells with "spikes". Spiny keratinocytes contain a large number of outgrowths (desmosomes) that penetrate into the recesses of neighboring cells and connect them according to the zipper principle with the formation of Bizzocero's nodules. All this gives the epidermis strength and elasticity.

Langerhans cells(intraepidermal macrophages) are also located in the spinous layer and are cells with long processes reaching the basement membrane and the granular layer. In inflammatory processes, they can migrate to the dermis and lymph nodes. Distinguishes Langerhans cells from other macrophages by the presence in them of special racket-like Birbeck granules containing kalon, a substance that suppresses the proliferation of keratinocytes. Langerhans cells make up 2 to 7% of all epidermal cells and are of mesodermal origin.

The main functions of Langerhans cells:

Regulation of the population size of keratinocytes;

Antigen presentation on T-helpers of lymphocytes, secretion of interleukins (IL) 1, IL-4, interferon (IFN), tumor necrosis factor (TNF), etc., and also participate in immunopathological processes of the skin.

Greenstein cells outwardly resemble Langerhans cells, but without Birbeck's granules. The number of cells is 1-3% of all epidermal cells. They act as antigen-presenting cells for T-suppressor lymphocytes.

The basal and spiny layers are collectively referred to as the malpighian, or germ layer of the epidermis.

Granular layer

The granular layer consists of 1-2 rows of cells (2-4 rows on the palms and soles) in the form of an elongated rhombus - granular keratinocytes. Feature cells of this series - the presence in the cytoplasm of many keratohyalin granules and Orland granules, lamellar bodies with lipid vesicles (keratinos). In the future, these substances form bilipid layers between the horny scales. Highly specialized epidermal lipids include ceramides, cholesterol, fatty acids, phospholipids, and other lipid compounds.

glitter layer

The shiny (eleidine) layer looks like a shiny, narrow, structureless strip that separates the granular layer from the stratum corneum (available on the palms and soles).

stratum corneum

stratum corneum - end product of keratinocyte evolution. The stratum corneum consists of many tiled scales (corneocytes), which are dead, keratin-filled remnants of keratinocytes. Corneocytes adhere tightly to each other, but on the surface in contact with the external environment, they lose strength and are easily separated - physiological peeling, imperceptible to the eye. The thickness of the stratum corneum in different parts of the skin varies significantly (the largest is on the soles and palms, in the area of ​​​​corns).

Corneocytes and lipid layers from the keratinosomes of the granular layer form multilayer lipid structures in the stratum corneum and form epidermal lipid barrier, protecting the skin from transepidermal water loss and providing watertightness of the epidermis. The epidermal lipid barrier also plays the role of a special intercellular cementing substance, which ensures the adhesion of the structures of the stratum corneum and preserves the integrity of the skin. Epidermal ceramides not only retain water in the skin, but also regulate the rate of desquamation, affecting the differentiation of keratinocytes, and also have a pronounced antimicrobial effect.

Development cycle epitheliocytes (from the cells of the basal layer to the torn off horny plates) is normally 28 days.

The epidermis separates from the dermis basement membrane, which is a specialized extracellular matrix. Electron microscopy reveals a light and dense layer in the basement membrane.

plates and plasmalemma. Numerous pinocytic vesicles are revealed in the plasmolemma, which indicates the active participation of the basement membrane in the exchange processes between the epidermis and the dermis. Due to the absence of blood vessels in the epidermis, its nutrition is carried out by the diffusion of nutrients through the basement membrane from the dermis.

Features of the structure of the epidermis in children

In children, the epidermis is thin, it contains mainly the basal, spiny and stratum corneum. The stratum corneum in children is thin and loose. Up to the very top rows, cells contain nuclei. The processes of exfoliation of the stratum corneum in young children occur 4-5 times faster than in adults. Due to the absence of a granular layer in the epidermis of young children, ceramides are practically not synthesized in the skin and a failure of the epidermal lipid barrier occurs. Due to these structural features, the skin of a child, especially a younger one, is easily vulnerable to the slightest adverse effects (violations of hygiene, frequent bathing and the use of soap, tight swaddling) and is prone to the development of macerations.

In the skin of children, the processes of mitotic division are more intense than in adults. Mitoses occur not only in the cells of the basal layer, but also partially in the spinous layer, which contributes to faster reparative processes (epithelialization) when the epidermis is damaged.

An important feature of the skin in children is the fragile connection of the keratinocytes of the basal layer with each other, as well as with the basement membrane, associated with a small number of desmosomes and half-desmosomes in these cells. As a result, in children more often than in adults, epidermolytic processes occur, leading to disruption of the dermal-epidermal junction and clinically manifested by bullous dermatoses (pemphigus of the newborn, Ritter's exfoliative dermatitis, bullous impetigo, etc.).

In the skin of children, the number of melanocytes is reduced compared to the skin of adults, and up to 6 months of age, melanocyte cells are functionally inactive and contain a small amount of melanin granules, which determines the increased sensitivity of children's skin to UV irradiation (UVR).

The skin of newborns differs from that of adults in its pH response. In adults, the pH of the skin is slightly acidic, in newborns it has

there is a neutral reaction, and in seborrheic zones and folds (due to caseous lubrication) - alkaline. Only by the 2-4th week of a child's life does the skin reaction begin to shift to an acidic environment. This feature causes more frequent development of pyoderma and candidal infection in young children.

Dermis

The dermis consists of 2 layers: papillary and reticular. The papillary layer is formed by loose connective tissue and a capillary network, and the reticular layer is formed by dense, fibrous, unformed connective tissue. Both layers consist of 3 components: cells, ground substance and fibers. The dermis also contains blood, lymphatic vessels and nerve endings.

Dermal cells

Fibroblasts are the main cells of the dermis. They provide the synthesis of collagen, elastic and reticulin fibers, as well as the main substance.

Mast cells (mastocytes, tissue basophils) are classified as descendants of blood stem cells and tissue analogues of basophilic blood leukocytes. The cytoplasm of mast cells contains specific granules with biologically active substances: histamine, heparin, serotonin, hyaluronic acid. These substances have a regulatory effect on the permeability of skin vessels, differentiation of various cells, participate in the development of inflammatory and immune reactions, etc. They have a high migration ability.

Histiocytes (tissue macrophages) carry out phagocytosis. Their cytoplasm has lysosomes, containing hydrolytic lysosomal enzymes (collagenase, elastase, lysozyme etc.), due to which the destruction of phagocytosed particles is carried out. Histiocytes secrete mediators: IL-1, IFN-α , TNF etc., which activate and suppress the functions and division of connective tissue cells and immunocompetent cells.

T-lymphocytes - blood cells located around the blood and lymphatic vessels. If necessary, they are able to quickly migrate to the lower parts of the epidermis along the dermal tissue. There are 3 types of T-lymphocytes: T-helpers, T-suppressors, T-killers. T-helpers activate the production of antibodies of B-lymphocytes. T-suppressors inhibit the incorporation of B-lymphocytes into

differentiation and delay the production of antibodies. T-killers - lymphocytes that independently carry out the lysis of foreign cells.

. Plasma cells (plasmocytes) are rarely found in the dermis under normal conditions, as a rule, only around the vessels. The function of plasma cells is the secretion of antibodies (immunoglobulins - IgA, IgM, IgG, etc.).

fibers

. Collagen fibers - the main fibers of the dermis, are built from type 1 protein - collagen, which provides the mechanical strength of the dermis.

. Elastic fibers form an extensive thin network in the dermis, contain the protein elastin, the distinctive properties of which are extensibility and contractility.

. Reticular fibers are located directly under the epidermis, have a pronounced extensibility. There are especially many of them around the skin appendages (hair follicles, sweat glands), where they act as a frame.

Connective tissue fibers of the dermis are located in a strictly defined direction, they are linear and form Langer lines(Fig. 1-3). The skin is more strongly stretched in the direction perpendicular to the course of the fibers and, therefore, the least noticeable scar after a skin incision is obtained when a wound is applied along the course of the fibers, which must be taken into account during surgical interventions, during massage.

Base substance

The main (amorphous) substance is a gel containing glycosaminoglycans, proteoglycans, hyaluronic acid, glycoproteins, fats,

Rice. 1-3. Langer lines

inorganic substances. All these substances promote the absorption and retention of water in tissues, ensure cellular reactions, biochemical processes, and also give strength to the basic substance of the connective tissue.

Vessels of the dermis

The boundary of the papillary and reticular layers is considered to be the branching of the surface network circulatory vessels forming horizontal networks: superficial and deep. run parallel to the arteries veins. The superficial plexus is represented by small-caliber vessels (capillaries, arterioles, venules) located in the papillary dermis. The capillaries extend vertically into the papillae, where they form the finest ramifications in the form of loops and are responsible for microcirculation in the skin. The deep network is located on the border of the dermis with subcutaneous fatty tissue. The deep plexus is formed by a network of vessels of a larger diameter in the reticular layer of the dermis and subcutaneous adipose tissue. There are anastomoses between the superficial and deep plexuses.

In close topographical and functional relationships with blood vessels are lymphatic vessels, also forming superficial and deep network.

The structure of the dermis in children

In newborns and children infancy the dermis is much thinner than in adults, and different in structure. The boundary zone between the epidermis and the dermis is smoothed and differs in the small size of the dermal papillae (with the exception of the skin of the palms and soles). The dermis is dominated by poorly differentiated connective tissue cells and thin collagen fibers.

Among the usual cellular elements of the skin - histiocytes, reticulocytes, fibrocytes, plasmocytes, lymphocytes - there are many mast cells (mastocytes) that secrete biologically active substances and enzymes (histamine, heparin, hyaluronidase, etc.), in connection with which the children have a physiological readiness for the occurrence of common allergic and inflammatory reactions. The gaps between cells and fibers are filled with the basic substance of the connective tissue, in which important role play mucopolysaccharides (hyaluronic and chondriotinsulfuric acids), which have high water-retaining properties. Thanks to these polysaccharides,

The skin of children contains much more water than that of adults. Water maintains a high turgor of children's skin and contributes to a more rapid spread of inflammatory, allergic and intoxication processes.

In children, the vessels of the skin have certain features. An abundant capillary network with undifferentiated endothelium in infants is constantly in a state of dilatation, which causes the presence of physiological hyperemia and a peculiar pink-purple color of the skin. This explains the imperfection of thermoregulation in young children. Skin vessels are highly permeable.

Lymphatic vessels and tubules are dilated and often form lymphatic lakes. Regional lymph nodes in infants are poorly developed, their lymphatic tissue is easily permeable to bacteria and toxins. It should be noted that passive innate immunity against coccal flora (especially staphylococci) in newborns is weakly expressed, since a small amount of antibodies comes from the mother in utero. These features explain the tendency to generalization of infectious skin diseases in children.

Subcutaneous adipose tissue (hypoderm)

The hypodermis is the deepest layer of the skin. Consists of fat cells (adipocytes), connective tissue stroma, blood vessels and nerves. The dermis and hypodermis do not have a clear boundary, since the fibrous tissue of the hypodermis is a continuation of the reticular layer of the dermis. Accumulation of fat cells forms fat lobules (lobuli), separated by connective tissue fibers (trabeculae).

Adipocytes (lipocytes, fat cells)- the main cells of the hypodermis. There are two types of adipocytes: white and brown.

The brown adipocyte is a small cell with few fat vacuoles. In these cells, during the breakdown of fatty acids and glucose in mitochondria, energy is not stored in the form of adenosine triphosphoric acid, but is dissipated in the form of heat, warming a person in the cold.

A white adipocyte is a large cell filled with one large drop of fat. In adults, white adipocytes predominate in the hypodermis.

Connective tissue fibers- collagen strands associated with the underlying fascia - form the cellular structure of the hypodermis.

The thickness of the hypodermis depends on the location, gender and nutrition. Subcutaneous fatty tissue is absent on the eyelids, nail bed, foreskin, labia minora and scrotum. It is weakly expressed in the area of ​​the nose, auricles, red border of the lips. The distribution of subcutaneous fat is regulated by sex hormones.

The function of the hypodermis is to protect the skin from mechanical injuries and ruptures of the underlying tissues of the body. Adipocytes are also involved in the synthesis of a number of hormones and releasing factors in different age periods.

In children, subcutaneous adipose tissue is characterized by friability and an abundance of fat lobules. In newborns, the mass of subcutaneous adipose tissue is 4-5 times greater than in adults. The increase in the mass of adipose tissue in the first year of life occurs due to an increase in the number of adipocytes, so the systematic overfeeding of young children can lead to persistent and severe obesity. The composition of the subcutaneous adipose tissue of infants is close to the composition of human milk fats, which creates the possibility of direct (bypassing digestion) utilization of breast milk fat.

In the hypodermis of young children, especially in the interscapular region, there are a lot of brown adipocytes, the number of which decreases with age. It is brown adipocytes that provide more high level heat production in newborns - the so-called non-shivering thermogenesis.

Connective tissue cells consist of not yet mature collagen fibers, their contours are fuzzy. Fat cells in children under 12 years of age contain a lot of refractory acids (stearic and palmitic), which explains the high turgor and the development of subcutaneous necrosis of adipose tissue in some newborns with trauma.

The distribution and order of reduction of the subcutaneous fat layer during weight loss in children is peculiar. Most fat is deposited on the face (cheeks), buttocks, thighs, abdomen. Subcutaneous fatty tissue disappears first on the abdomen and chest, and lastly on the face.

An abundant capillary network with dilated vessels shines through the thin epidermis and creates "physiological hyperemia" and a peculiar pink-pearl color of the skin of newborns.

Skin muscles

Skin muscles are represented by 2 types of muscle tissue: smooth and striated.

Smooth muscles are built from myocytes - spindle-shaped cells with a rod-shaped nucleus. Myocytes are part of the structure of blood and lymphatic vessels, as well as sweat glands. They form the muscles that lift the hair (m. arrector pili). When contracted, these muscles pull up the lower end of the hair follicle and lift the hair, and also provide squeezing out the secretion of the sebaceous glands.

The striated muscles are located in the skin of the face in the form of delicate fibers woven into the dermis, and are called mimic muscles.

In children, the muscles of the skin are poorly developed, with the exception of the involuntary smooth muscle that lifts the hair. (m. arrector pili).

Skin innervation

The skin has a rich neuro-receptor apparatus. Nerve fibers are represented by branches of cerebrospinal and autonomic nerves. Cerebrospinal nerve fibers belong to the central nervous system (CNS). They are responsible for different types of sensitivity. Vegetative fibers belong to the autonomic nervous system (sympathetic and parasympathetic) and regulate the functioning of the glands, blood vessels and muscles of the skin.

Nerve fibers run parallel to the blood and lymphatic vessels, enter the hypodermis, where they form large plexuses. Thinner branches depart from the plexuses, branching and forming deep dermal plexuses. Small branches from them rise to the epidermis and form superficial plexuses located in the papillary dermis and in the epidermis.

Receptor endings divide by free and not free. Free ones have the form of bare axial cylinders (devoid of auxiliary glial cells) and end in the epidermis, hair follicles and glands. Responsible for pain and temperature sensitivity.

Non-free nerve endings are divided into unencapsulated and encapsulated, commonly referred to as bodies.

Non-encapsulated nerve endings include the end sections of neurons in the form of discs that form synapses with Merkel cells, performing the function of touch. Localized in the epidermis.

Encapsulated nerve endings are diverse and are different types mechanoreceptors (slowly and rapidly adapting receptors):

.Meissner corpuscles located inside the papillae of the dermis, there are many of them in the skin of the palmar-lateral surfaces of the fingers, lips, genitals;

.Krause flasks localized in the dermis, especially a lot of them at the transition of the skin into the mucous membranes in the lips, eyelids, external genitalia;

In the lower part of the dermis and the upper part of the hypodermis are localized Ruffini bodies;

In the deep layers of the dermis and hypodermis, mainly in the area of ​​​​the palms, soles, nipples of the mammary glands, genital organs, bodies of Vater-Pacini;

Genital Dogel bodies are found in the skin of the genital organs, providing increased sensitivity of these zones.

Skin appendages

Skin appendages include sweat and sebaceous glands, hair and nails.

sweat glands

According to the type of secretion, sweat glands are divided into eccrine and apocrine glands.

eccrine glands

Eccrine glands, producing a secret and releasing it into the lumen of the gland, retain unchanged secretory cells. They are found in all parts of the skin, with the exception of the red border of the lips, the glans penis and the foreskin. In adults, eccrine sweat glands resemble thin corkscrew-shaped convoluted tubes, the ends of which lie in the dermis, and the excretory ducts open freely to the surface of the skin and sweat is released from them. Sweat is a slightly acidic liquid of low specific gravity (1.004). It consists of 98% water, and 2% is inorganic compounds, products of protein metabolism (creatinine, urea, ammonia, etc.). In case of poisoning, toxic substances can be released through sweat.

In newborns, the number of eccrine sweat glands is 12 times greater than in adults. After birth, new eccrine sweat glands do not appear, only their atrophy occurs. Secretory

the gland section is represented by 6-12 loops of the epithelial tubule. Unlike adults, the excretory ducts of the sweat glands in infants are straight and dilated, and not corkscrew-shaped, tortuous, as in adults. After 2-3 months after birth, the sweat glands begin to intensively produce sweat, thereby carrying out significant thermoregulation. Increased perspiration appears first on the head, then on the skin of the chest and back. These features of the structure and functioning are prerequisites for the development of such diseases of the sweat glands in children as vesiculopustulosis, Finger's pseudofurunculosis, etc.

Apocrine glands

In the apocrine glands, secretion occurs by destroying the apical part of the secretory cell of the gland, located deep in the dermis.

Apocrine glands are located in armpits ah, in the area of ​​the pubis, inguinal folds, genitals, the circumference of the anus and the nipple of the mammary glands. A variety of apocrine glands is the sulfur glands of the external auditory canal. The sweat glands secrete a secret into the funnel of the hair follicle under the sebaceous gland. Apocrine sweat glands develop especially intensively during puberty and are regulated by sex hormones. In young children, they do not function.

The secret of the glands is a thick liquid with a characteristic individual odor. The sweat of apocrine sweat glands contains more protein compounds and iron than the sweat of eccrine sweat glands, the oxidation of which in air leads to the formation of volatile aromatic substances. (pheromones), which are responsible for the smell of sweat. The smell of sweat is one of the most ancient physiological mechanisms (odorant indication), which largely determines human sexual behavior. The reaction of the secretion of the apocrine glands is weakly alkaline.

Sebaceous glands

Sebaceous glands (glandulae sebaceae) originate from the ectodermal germ layer, are alveolar glands with branched terminal sections. The cells of the main layer of the sebaceous glands correspond to the basal cells of the epidermis. They have the ability to reproduce and renew. The glands are located in the upper third of the dermis, are associated with the hair follicle and secrete into its expanded

part secret. One hair follicle has 1 or 2 sebaceous glands. In some cases, the ducts of the large sebaceous glands open directly to the surface of the skin (on the wings of the nose, the border of the red border of the lips, the head of the penis, the inner leaf of the foreskin, the labia minora, the clitoris, the nipple and the areola of the nipple). Sebaceous glands are absent in the skin of the palms and soles.

The sebaceous glands function holocrine type, i.e. during the formation of a secret, the cells of the gland gradually accumulate lipid drops, degenerate and then completely collapse, and their remains are part of the secret (sebum). Sebum (sebum), standing out on the surface of the epidermis, provides lubrication of the hair and the stratum corneum of the skin, makes them more elastic, and also performs a thermal insulating function. The secretion of sebum includes triglycerides of fatty acids, wax, squalene, free fatty acids, cholesterol, etc. The composition of sebum also includes lysozyme, which has a bactericidal effect, and antioxidants: a-carotene and a-tocopherol, which have photoprotective properties.

The secretion of the sebaceous glands by sex hormones is regulated.

In children sebaceous glands are formed by the 3rd-4th month of intrauterine development and begin to function intensively before the birth of the child, abundantly covering the entire skin of the fetus with skin lubricant (vernix caseosa). The sebaceous glands in newborns are large, there are many of them in the face, perineum, back and scalp, where they form open comedones. During the first year of life, the secretion of the sebaceous glands in children is still stimulated by maternal sex hormones, so newborns may develop gneiss, seborrheic dermatitis, and infantile acne. By the beginning of the second year of life, the function of the sebaceous glands in a child decreases sharply, and even part of them, located on the extensor surfaces of the upper and lower extremities, atrophies. Increased secretion of the sebaceous glands occurs in puberty and leads to the development of adolescent acne in some cases, the appearance of dandruff, seborrheic dermatitis.

The sweat and sebaceous glands are abundantly supplied in their capsules with vessels and nerve endings that regulate their functional activity.

The entire surface of the skin is covered with a continuous thin water-lipid emulsion film - water-lipid mantle. It is formed by the secretions of the sebaceous glands, eccrine sweat glands and ceramides of the stratum corneum of the epidermis. The water-lipid mantle prevents

drying of the skin, regulates the rate of desquamation and differentiation of keratinocytes. The mantle maintains a constant acidity of the skin surface (pH 4.5-5.5) due to the presence of lactic and citric acids in it * and contains lysozyme, due to which it also performs a bactericidal function.

Hair

Hair (pilus)- thin long horny threads synthesized by the hair follicle and covering human skin. In adults, there are up to 2 million hairs on the surface of the body, of which there are up to 100 thousand on the head. The structure of hair is genetically determined and largely depends on race.

hair types

There are 3 types of hair in humans: long, bristly and fluffy.

. Long hair located on the scalp, and after puberty develop from the previous vellus hair in the beard and mustache, armpits, pubis. This hair is thick, long, pigmented. average value long hair head is 60-75 cm, more long hair are rare, mostly in girls under 15 years of age.

. bristly hair also thick and pigmented, but much shorter. Hair of this type is localized on the eyebrows, eyelashes, in the nasal passages and external auditory canals.

. vellus hair- the most numerous, thin, short, poorly pigmented, cover most of the skin. They are of particular importance in the formation of tactile sensitivity, being a kind of sensitive endings, when irritated, contraction of the muscles that lift the hair occurs. Under the influence of sex hormones (androgens) during puberty, as well as with various endocrine diseases, vellus hair can transform into long hair.

Hair is absent on the palms, soles, lateral surfaces of the fingers, the red border of the lips, the glans penis, the inner surface of the preputial sac, on the clitoris and labia minora.

hair structure

Anatomically, the hair is divided into 2 parts (Fig. 1-4). The upper part of the hair, located above the surface of the skin, is called rod, and the lower intradermal part - root.

Rice. 1-4. hair structure

The hair root lies deep in the dermis and hypodermis and forms hair follicle, which is surrounded by a connective tissue hair bag. At the top of the hair follicle there is an extension - funnel, where the ducts of the sebaceous, as well as apocrine sweat glands flow (in the places of their localization). Under the funnel area, a muscle that lifts the hair is woven into the hair bag at one end, and the other end of the muscle is located in the papillary dermis. The follicle ends with an expanded and thickened part - hair follicle, into which the connective tissue grows papilla with blood vessels and nerves. Lower part of the bulb (matrix) represented by matrix cells - basal trichocytes, intensive division of which ensures hair growth. The pressure created inside the follicle due to continuous mitosis causes the hair to grow upward. On average, hair growth on the head is 1 cm / month. Basal trichocytes divide much faster than basal keratinocytes, but their mitotic rhythm is directly dependent on the hair growth cycle.

The matrix also contains melanocytes and Langerhans cells. Melanocytes of the matrix synthesize melanin granules, which are captured by trichocytes and enter the cortical substance of the hair. Hair color depends on the activity of melanocytes and is due to 2 pigments: eumelanin, defining black-brown hair color,

and pheomelanin, giving light shades of hair. Red hair is dyed under the influence of a rare combination of pheomelanin and erythromelanin pigments.

The human hair consists of 3 structures: the medulla, the cortex and the cuticle.

.medulla occupies the central part of the hair and is uneven in structure. The medulla is most pronounced in the hair follicle and consists of polymorphic cells that appeared during the differentiation of basal trichocytes in the central region of the matrix. As it moves away from the bulb, the zone of the medulla narrows and disappears at the level of the mouth of the hair follicle, and in the shaft it is filled with mesh air structures.

.cortex is located around the medulla and is formed by elongated keratinizing cells. In humans, the cortex is the main substance in the structure of the hair and gives them elasticity and mechanical strength.

.Cuticle- the outermost part of the hair, consists of 2 types of horny cells: corneocytes the inner sheath of the hair (continuation of the epidermis) and horny cells, derivatives of hair trichocytes. Horn cells - cuticles are arranged in the form of tiled scales, which tightly fit one under the other, establishing a strong, but mobile connection with each other.

Hair growth cycle

Human hair goes through 3 phases of development (Fig. 1-5), smoothly passing from one to another: anagen (growth phase), catagen (phase of regressive changes) and telogen (resting phase). The average duration of anagen is 1000 days (from 2 to 5 years), catagen - 2-3 weeks, telogen - about 100 days.

Phase anagen characterized by activation of matrix trichocytes and elements of the hair papilla. Active hair growth occurs. With age, the duration of the anagen phase decreases.

At the end of the anagen phase, an intermediate phase begins - catagen. During this period, melanin is not formed, the follicle decreases, and its base moves up, separating from the neurovascular hair papilla.

Third - telogen- rest phase. During this period, the hair falls out on its own and begins to grow from the same follicle. new hair. Each follicle gives rise to 20-30 hairs.

Rice. 1-5.Hair development cycle

In humans, the hairline on the head is associated with the identification of personality and gender. Eyebrows and eyelashes are important organs of tactile sensitivity that perform a receptor function. Hair retains odors, including the apocrine glands in the armpits and inguinal regions, thus attracting a potential sexual partner.

Normally, in a healthy person, at least 85% of hair follicles are in the anagen phase, 1% are in the catagen phase, and no more than 14% are in the telogen phase.

Vellus hair does not have a medulla, their growth is slow (0.3-0.5 mm/day), but in spring and summer they grow faster.

Features in children

In children, hair is laid on the 2-3rd month of intrauterine development in the area of ​​the chin, upper lip and eyebrows. The formation of hair rudiments throughout the skin ends at the 4-5th month. Primary delicate vellus hair of the fetus (lanugo) fall out before birth. 1 month before normal delivery, this fluff completely falls out and is replaced by a shorter, but somewhat less tender second coat.

rich fluff (vellus), and on the head even the long and bristly hair with which the child is born. All hair follicles in the fetus are in the anagen phase and at birth synchronously enter the telogen phase. Accordingly, after 2-3 months, physiological hair loss occurs in newborns. In the following months, the hair follicles asynchronously enter the anagen phase and the secondary fluff is replaced by tertiary, permanent hair.

In children, the depth of the hair follicle and hair papilla is more superficial (mainly in the dermis). Children's hair differs from adult hair in greater hydrophilicity, elasticity and the content of a significant amount of soft keratin, which contributes to their more frequent damage than in adults by pathogenic fungi.

Nail

Nail (unquis) begins to form on the 3rd month of intrauterine life. Its growth is very slow, and only shortly before childbirth does the nail plate reach the end of the distal phalanx. By the length of the nail, you can judge the term of the child.

The structure of the nail

The nail (Fig. 1-6) is a dense elastic quadrangular horny plate lying on the epithelium of the terminal phalanges of the fingers and toes. The nail plate is made up of body and root. The body of the nail is its visible part, hidden in the nail groove, the proximal part of the nail is its root. The nail plate on the outside has smooth surface, and from the inside it is covered with scallops and grooves. It consists of dense horny scales, sometimes with remnants of nuclei containing hard keratin. The nail plate lies on nail

Rice. 1-6. The structure of the nail

bed, which is a thick layer of the epidermis without a stratum corneum (the stratum corneum replaces the nail plate).

In the proximal part of the root, the stratum corneum of the epidermis is wrapped, tightly attached to the edge of the plate, forming eponychium.

The growing part of the nail root is called matrix and consists of onychoblasts. Due to the reproduction of onychoblasts, the nail grows in length, and due to the reproduction of cells of the basal layer of the nail bed - in thickness. The matrix also contains melanocytes, Langerhans cells and Merkel cells. The growth rate of the nail on the hands is 3-4 mm / month, on the legs - 1-2 mm. It takes 150-220 days for the full regrowth of the nail plate.

Features in children

In children, nail growth is very slow and only shortly before birth does the nail plate reach the end of the distal phalanx.

For newborns, a slight slowdown in nail growth is characteristic, associated with pronounced thickening of the epidermal cords under the nail bed and, as a result, the blood and lymph circulation changed as a result.

It is noticed that in children with underdeveloped hair on the head, the nails grow more slowly than in children with normal hair growth.

Despite the fact that the structure of the nails in children does not differ from the nails of adults, children aged 2-5 years are characterized by thin dystrophic nails with lateral thickening of the nail plate, especially on the toes. Of the onychodystrophies, the most common onychoshisis, flowing with splitting of the nail plate in the form of leaf-shaped plates at the free edge and a wavy shape of the nail. As a rule, these changes do not require treatment and disappear on their own by 5-7 years.

Physiological functions of the skin

Barrier-protective function

. Mechanical protection carried out by horny scales filled with keratin; epidermal lipid barrier; adhesion of the cells of the basal layer to each other; a strong connection of the epidermis and dermis with the help of a basement membrane, the main substance and fibers of the dermis (collagen and elastin), which provide elasticity and high elasticity of the skin; fatty structures of the hypodermis.

. Biological (antimicrobial) protection provided by tight adhesion of horny scales; active counter growth (for bacteria penetrating deep into the skin) of epidermal cells and physiological peeling of the skin; electrostatic properties of the epidermis, which repel negatively charged bacteria from negatively charged corneocytes; acid mantle.

An important part of the biological protection of the skin - microbial antagonism, caused by saprophytic and conditionally pathogenic flora, permanently living in the stratum corneum of the epidermis and normal skin microflora. To saprophytes include Escherichia coli, diphtheroid bacteria, Proteus, detected on smooth skin, Staphylococcus albus, St. flavus, St. epidermicus and others - in the mouths of hair follicles. Conditionally pathogenic flora are lipophilic pitirosporal flora, micrococci, various variants of corynobacteria, which under normal conditions are in an inactive state. In the process of life, the normal microflora releases various substances - toxins that prevent the reproduction of pathogenic flora.

. UV protection carried out by melanin synthesized by melanocytes and antioxidant substances that are part of sebum, as well as hair, eyebrows and eyelashes. Care must be taken when children are exposed to the sun, since there are not enough melanosome organelles in their skin cells and the activity of the enzyme tyrosinase is weakly expressed.

. Maintaining water balance It is carried out due to the water-lipid mantle and the epidermal lipid barrier, which prevent not only transepidermal water loss, but also excessive water ingress into the skin.

. Regeneration of the damaged skin during injuries is carried out due to mitosis of the basal layer of the epidermis (epithelization) and activation of collagen synthesis by dermal fibroblasts (scarring).

Immune function of the skin

The immune function of the skin is a complex complex system that includes 2 lines of immunological protection: epidermal and dermal.

In the epidermis, immune cells are Langerhans cells and Greenstein cells, as well as keratinocytes that synthesize cytokines and interferons that inhibit protein synthesis in viral cells.

In the dermis, immune cells are tissue basophils, histiocytes, T-lymphocytes.

Tissue basophils (mast cells, mastocytes) are involved in immediate and delayed allergic reactions, various inflammatory processes. Histiocytes (tissue macrophages) provide phagocytosis and destruction of foreign cells that have entered the skin with lysosomal enzymes. T-helpers and T-suppressors are involved in humoral immunity, and T-killers are able to lyse target cells without prior immunization.

Receptor function

The receptor function is carried out by free and non-free endings of somatic and autonomic nerves that perceive the impact of the external environment on the body.

Infants have immaturity and insufficient differentiation of the central formations of the spinal cord and brain. In this regard, nervous excitation is not realized in a clearly conscious and well-localized sensation. The child cannot analyze the abundance of irritating impulses from the external environment, and his central nervous system is often in a state of extreme inhibition. As a result, infants need a long sleep, and children of primary school age are characterized by inadequate irritation reactions.

thermoregulation

The thermoregulatory function ensures that the balance between heat production and heat loss is maintained.

Heat transfer occurs due to the following processes:

Evaporation of water (20%) is carried out by 2 mechanisms: sweating of eccrine sweat glands (perspiratio sensibilis) and imperceptible loss of water (perspiratio insensibilis), which is due to the passage of fluid through the layers of the epidermis and its evaporation. The intensity of this process directly depends on body temperature;

Heat conduction (30%) occurs due to heating of the air adjacent to the skin;

Thermal radiation (50%) is characterized by skin radiation of thermal infrared rays.

Heat production, or thermogenesis, is carried out due to involuntary muscle tremors and lipolysis (the breakdown of fats with the release of energy). Thermogenesis also includes a heat-saving function. It is provided by the thermal insulation properties of the adipose tissue of the hypodermis, the vascular component, which responds to a decrease in temperature with vascular spasm, and also through neuroreceptors that send impulses to the central nervous system about changes in ambient temperature, which makes a person put on warm clothes.

In newborns and young children, thermogenesis is deficient due to the fact that thermoregulatory systems are not yet fully activated until the age of 7-10 years. Heat transfer due to heat radiation and heat conduction predominates. These types of heat transfer and imperceptible sweating in young children, age-related physiological expansion of the lymphatic and blood vessels, increased secretory function of the sweat glands contribute to the development of respiratory diseases.

secretory function

Secretory function is provided by sweat (eccrine and apocrine) and sebaceous glands, which are regulated by the endocrine and nervous systems.

excretory function

The excretory function is associated with the secretory, it is carried out transepidermally and through the appendages of the skin. Thus, metabolic products (urea, uric acid, etc.), medicinal and toxic substances are released onto the surface of the skin.

Due to the fact that the participation of sweat glands in the excretion of metabolic products in children under the age of 3-4 months is insignificant, the excretion of water and minerals directly transepidermally prevails. (perspiratio insersibilis), which is facilitated by the delicate, thin, loose stratum corneum of the skin.

Respiratory function

The respiratory function carries out the transfer of oxygen and the release of carbon dioxide by the skin, which is most significant for the upper layers of the epidermis. Skin respiration accounts for 2% of total gas exchange.

In early childhood, the skin is more permeable to gases and liquids than in adults, which compensates for the morphological and functional insufficiency of the alveolar tissue of the lung apparatus.

Resorption function

The resorption function is characterized by the absorption and entry into the bloodstream of substances that enter the skin. It should be noted that the resorption of water and solids through healthy skin almost never happens. However, substances dissolved in fats are well absorbed through the skin. The degree of absorption depends on the functional activity of the sebaceous hair follicles, the state of the water-lipid mantle, and the strength of the stratum corneum. In the folds of the skin, in the area of ​​the scalp, absorption occurs actively. It increases with hyperemia of the skin, its swelling, maceration, erosion. Under these conditions in children, dosage forms containing tar, salicylic acids, resorcinol and other ingredients that can be absorbed by the skin should be prescribed with caution.

Participation in metabolism

Participation in skin metabolism is multifaceted and includes secretory, excretory, respiratory, resorption functions. The metabolism of the skin is in relationship with the whole body through the enzymatic, endocrine and nervous systems: the enzymes contained in the skin catabolize proteins, fats, carbohydrates. However, there are biochemical processes that are unique to the skin, such as the formation of keratin, melanin, and the synthesis of vitamin D.

Under the influence of ultraviolet radiation in the epidermis (basal and spiny layers), the hormone cholecalciferol (vitamin D 3) is synthesized, the metabolites of which carry out effects similar to steroids.

Children's skin, to a greater extent than adults, has the ability to temporarily delay or deposit carbohydrates, residual nitrogen and other protein metabolites, thereby weakening their toxic effect on other organs and tissues. In this regard, for example, the appearance of persistent itching may indicate the emerging pathological processes of liver function, and the appearance of pyogenic elements - the presence of latent diabetes.

endocrine function of the skin

The endocrine function of the skin is largely associated with the adipocytes of the hypodermis, which produce estrogens and are the depot of sex hormones in the body.

It should be noted that many types of metabolic activity of the skin are regulated by hormones. So, the function of the sebaceous and apocrine glands, hair growth are regulated by sex hormones; dystrophic processes in the skin occur with hypercortisolism syndrome, etc.

Healthy human skin is practically impervious to microorganisms. At the same time, in the skin of children, especially infants, due to the friability of the stratum corneum, high humidity and skin temperature, the growth of pathogenic flora occurs. This is also facilitated by the neutral or slightly alkaline environment of the water-lipid mantle, which contains an insufficient amount of low molecular weight free fatty acids. Changing the pH of children's skin to a neutral or slightly alkaline environment (from 4.2-5.6 to 6.12-6.72) affects the redistribution of ions, changes in chemical properties and increases skin permeability. In this regard, especially with maceration and inflammation, it is necessary to carefully prescribe solutions, warming compresses, ointment dressings.

Thus, the skin in children, especially in newborns and infants, differs from the skin of an adult in its anatomical structure and functional features, which explains distinctive features morphological elements: they have a more pronounced nature of inflammation, are prone to dissemination, fusion, erosion.

1.2. GENERAL VIEW ON THE ETIOLOGY AND PATHOGENESIS OF SKIN DISEASES

Under etiology understand the cause that caused the disease, under pathogenesis- the mechanism of occurrence of the development of the disease, as well as the ways of its spread.

Etiology of skin diseases

The development of skin diseases can be caused by many reasons, which are divided into exogenous(external) and endogenous(internal).

Exogenous etiological factors

Mechanical stimuli

Mechanical irritants include pressure, especially prolonged pressure, and friction, and can cause simple dermatitis on the skin. These factors lead to the appearance of corns, abrasions (for example, on the skin of the feet when wearing tight shoes, on the hands when doing physical work), and as a result of friction of the contacting surfaces, maceration develops.

Obese children are characterized by the development intertrigo, or diaper rash arising in the folds as a result of friction of the contacting surfaces.

Physical factors

Numerous physical factors affecting the skin, including temperature, as well as the influence of radiant energy, are the cause of the development of contact dermatitis.

Thermal factors include the effect on the skin of low or high temperatures. Thus, exposure to high temperatures on the skin leads to the development of burns in young children, dermatitis can occur when taking baths with a temperature of more than 40 ° C. The action of low temperatures, leading to tissue damage, is called frostbite. In young children, when the skin is exposed to cold, wind, especially in combination with dampness, a special form of frostbite often occurs - chill.

Most often among the skin irritating factors associated with radiant energy, there is exposure to the skin of sunlight. Of the entire spectrum of sunlight, the occurrence of dermatitis is mainly promoted by short-wave and UV rays, which can lead to the development solar dermatitis. Various types of ionizing radiation (X-rays, α-, β-, γ-rays, etc.) contribute to the development of not only radiation dermatitis, but also lead to severe dystrophic changes with necrosis of skin areas.

Chemical Factors

Chemical factors that can cause contact dermatitis are extremely diverse: these are strong acids, alkalis, metal salts, etc. They can be found in industries (professional

chemical irritants), in everyday life or be presented in the form of various medicinal substances.

In children, chemical dermatitis can occur when the skin is treated with high concentrations of disinfectants.

Biological factors

Biological factors are the cause of the development phytodermatitis, caused by the toxic juice of a number of plants (hogweed, primrose, poison ivy, etc.), as well as a number of dermatitis caused by contact with poisonous insects, corals, jellyfish, animals.

These factors can be attributed to unconditional irritants, since their impact always and in everyone causes a certain reaction of the skin and mucous membranes to the damaging effect of the irritant.

Endogenous etiological factors

Significantly more diverse endogenous etiological factors, including genetic, diseases internal organs, naru-

metabolic disorders, tumors, diseases of the endocrine and nervous systems, hematopoiesis, vascular system, etc.

Diseases of the internal organs

Diseases of the internal organs can cause pathological changes in the skin and oral mucosa as a result of intoxication, metabolic disorders, and also reflexively. The pathology of the internal organs often contributes to the formation of an allergic condition that underlies the pathogenesis of many dermatoses.

Metabolic disorders

Metabolic disorders, especially carbohydrate, lipid, mineral and water, lead to corresponding disorders in the skin. These disorders become the cause or one of the pathogenetic mechanisms for the development of a number of dermatoses. So, for example, hyperglycemia can lead to furunculosis, skin itching; violation of lipid metabolism underlies the occurrence of xanthoma.

Improper nutrition

An important role in the development of skin diseases is played by malnutrition, which, especially in childhood, can lead to the development and exacerbation of allergic dermatosis (atopic dermatitis, strophulus, toxicoderma). Duehring's dermatitis herpetiformis develops with the abuse of iodine-containing products (iodized salt, sea fish, sea kale, etc.). A severe course of acne vulgaris is typical when eating a large amount of saturated fats, etc. Also great importance in the pathogenesis of many skin diseases, they have hypo- and avitaminosis, especially associated with vitamins A, C, PP, P, group B, etc. skin hemorrhages.

Psychogenic factors

In domestic dermatology, the role of psychogenic factors in the occurrence of many skin diseases has been constantly emphasized. Emotional influences lead to the release of acetylcholine, a chemical transmitter (mediator) of nervous excitation at all levels and in all parts of the nervous system and contribute to the development of diseases such as lichen planus, atopic dermatitis, pruritus, urticaria.

Diseases of the nervous system

Organic diseases of the central and peripheral nervous systems can also lead to various skin diseases, such as neurotrophic ulcers when the sciatic and other nerves are damaged.

Endocrinopathy

It is often possible to establish a connection between the occurrence of dermatosis and dysfunction of the endocrine glands - endocrinopathies. Classical examples are late acne in women with gonadal dysfunction, hair loss in patients with thyroid diseases, bronze skin coloration in Addison's disease.

Infectious diseases

Infectious diseases play a significant role in the development of many skin diseases. The presence of foci of chronic infection causes the development of bacterial allergies, intoxication and cellular immunodeficiency. So, chronic streptococcal diseases (tonsillitis, sinusitis, etc.) cause the development of allergic vasculitis, tuberculosis develops erythema nodosum, granuloma annulare (especially in children), recurrent herpes provokes the development of erythema multiforme exudative.

Other diseases

Some dermatoses are based on disturbances in hematopoietic system. Thus, specific and nonspecific changes in the skin and oral mucosa often occur in patients with leukemia and other blood diseases. Also of great importance in dermatology are vascular pathology, leading to the development of allergic vasculitis, trophic ulcers of venous origin, pyoderma gangrenosum, etc.

Skin lesions may develop due to cancer disease, localized either directly in the skin (melanoma, skin lymphoma, basalioma, atheroma, lipoma, etc.), or in other organs, but manifested by changes in the skin in the form of, for example, dermatomyositis, Dühring's herpetiform dermatitis, carcinoid syndrome.

A certain importance in the occurrence of a number of skin diseases belongs to genetic factor. The role of heredity is especially clearly manifested in neurofibromatosis, ichthyosis, epidermolysis bullosa, keratoderma, atopic dermatitis, etc.

In the etiology and pathogenesis of a number of dermatoses, a certain role belongs to immune diseases. This group includes allergic dermatoses and autoimmune diseases.

.Allergodermatoses- skin diseases accompanied by allergic reactions. This group is extensive and includes contact-allergic dermatitis, eczema, atopic dermatitis (AtD), urticaria, pruritus, etc.

.autoimmune consider diseases in which the body immunologically "fights" with its own tissues and cells. In dermatology, such diseases are pemphigus, bullous pemphigoid, dermatomyositis, scleroderma, lupus erythematosus, vitiligo, alopecia areata, etc.

Immune diseases of the skin can also be attributed skin diseases in pregnant women: polymorphic dermatosis of pregnant women, herpes of pregnant women, prurigo of pregnant women, etc. These dermatoses occur in women during pregnancy or immediately after it and develop on allergens that have come transplacentally from the fetus to the mother.

Etiological classification

The etiological factors of skin diseases can be divided into 3 groups.

.1st group constitute diseases and changes in internal organs that directly lead to the occurrence of dermatosis, for example, metabolic disorders that cause calcification or xanthomatosis of the skin; pathology of the hematopoietic organs associated with leukemic rashes, etc.; genetic changes leading to congenital diseases, such as ichthyosis, keratoderma, epidermolysis bullosa, etc.

.2nd group constitute risk factors, i.e. factors (diseases of internal organs, metabolic disorders, genetic factors, chronic infections, hypothermia, and many others) that create a predisposition - a background for the development of the disease. Thus, hyperglycemia in diabetes mellitus creates the prerequisites for the development of furunculosis, hypothermia leads to an exacerbation of recurrent herpes, allergic vasculitis, etc.

The hereditary predisposition of a person to a particular disease, in particular dermatosis, implies that metabolic characteristics are transmitted from parents to children,

intracellular biochemical reactions and other signs that make them more susceptible to the development of these skin diseases. However, this tendency is by no means always realized in the disease and depends on the additional action of irritating factors that aggravate this predisposition. This explains why children and parents do not always suffer from the same diseases. . 3rd group combine the so-called resolving factors, in the 1st place among which stress should be put. Stress is characterized by nervous tension and includes the totality of all nonspecific reactions of the body (vascular, neuroendocrine, immune). These pathophysiological reactions affect all organs and systems in the body and, of course, the skin. Dermatological patients very often associate the onset of psoriasis, alopecia areata, and urticaria with stress. Thus, the etiology and pathogenesis of many dermatosis has not yet been finally established. Skin diseases are often caused by a number of adverse effects, both endogenous and exogenous, which could gradually affect the body for many years, preparing the "soil" for the development of the disease. The same reason, the same etiological factor, depending on the different mechanism of action on the skin, can cause the occurrence of various forms of skin lesions.

The state of the human body largely depends on social living and working conditions, which in adverse situations are a combination of provoking factors and lead to the development professional skin diseases (contact allergic dermatitis, eczema) and social diseases (tuberculosis, scabies, pediculosis, sexually transmitted infections - STIs).

The pathogenesis of skin diseases

The pathogenesis of skin diseases is based on the following processes: inflammation (non-immune and immune), dystrophy and oncological (uncontrolled rampant) growth.

Among skin diseases, diseases with an inflammatory nature of the course predominate.

Schematically, the pathogenesis of many skin diseases is as follows. An inflammatory response develops to skin irritation.

litelny reaction, which, depending on the severity of the irritating factor, can proceed with a predominance of proliferative, exudative or alterative processes.

.Proliferative inflammation characterized by increased mitosis, accumulation of cellular elements and increased collagen synthesis. It develops with a slight and prolonged exposure to irritating factors.

.Exudative inflammation accompanied by the release of biologically active substances, increased vascular permeability, tissue edema. Exudative inflammation develops on strong irritants.

.Alteration develops as an extreme form of inflammation, on very strong provoking factors and consists in damage and subsequent necrosis of tissue structures.

Distinguish between immune and non-immune inflammation.

To non-immune include serous (for example, with contact dermatitis), hemorrhagic (with scurvy), purulent (with pyoderma), perifocal (for example, around a foreign body that has entered the tissues, etc.) inflammation.

play an important role in dermatology immune inflammation, in which immune responses trigger the process of inflammation. Immune reactions are protective and adaptive in nature and are aimed at freeing the body from foreign antigens coming from outside. So, when an antigen enters the body, the following reactions are possible: the development of immunity (i.e., the protection of the body from genetic alienation), the emergence of immunological tolerance, the development of hypersensitivity (allergy). Allergy - pathologically increased specific sensitivity of the body to substances with antigenic properties during the development of immunological reactions.

immunocompetent cells in the skin are: in the epidermis - Langerhans cells and Greenstein cells, in the dermis - lymphocytes, tissue basophils, macrophages, plasma cells, eosinophilic granulocytes.

Almost all types of immunopathological processes and immune inflammation are realized in the skin. The most significant skin-allergic reactions of immediate and delayed types, cytotoxic reactions, immunocomplex skin reactions.

. Skin-allergic reactions of immediate (anaphylactic) type develop when antigens (allergens) coming from outside interact with IgE antibodies fixed on the surface of mast cells and basophils. When the antigen and antibody interact, degranulation of mast cells and the release of biologically active substances occur. This type of immune inflammation is characteristic of urticaria, drug erythema, etc.

. Cytotoxic reactions(reactions of cytolysis). These reactions involve antibodies of the IgG or IgM type (also called cytotoxic), the action of which is aimed at destroying cell membranes. In dermatology, these reactions are found in pemphigus, pemphigoid, Lyell's syndrome. In their pathogenesis, the leading role is played by autoimmune processes, and autoantibodies are formed to desmogleins of desmosomes of cells of the prickly layer of the epidermis.

. Immunocomplex reactions occur with the participation of antibodies such as IgG or IgM, antigen and complement. Complex antigen-antibody-complement complexes are deposited on the walls of blood vessels, damaging them. An example of immunocomplex diseases is erythema multiforme exudative, systemic connective tissue diseases, Schonlein-Genoch purpura and other allergic vasculitis.

. Skin-allergic reactions of the delayed type. The development of these reactions does not depend on antibodies. The main participants in delayed-type reactions are activated T-lymphocytes, which can directly kill foreign cells or produce special substances - lymphokines that regulate the action of other immunocompetent cells. The development of reactions is slow, they appear after a few hours, and reach a maximum after 48 hours. In dermatology, these reactions are very common and occur in atopic dermatitis, lichen planus, contact allergic dermatitis, eczema.

Skin-allergic reactions of immediate and delayed action underlie allergic dermatoses. The very fact of the frequent development of al-

Allergic diseases in the skin are explained by its constant contact with various physical, chemical and biological irritants. In bound form, allergens remain on the skin for a long time and change the reactivity of immune cells.

Allergic diseases include idiosyncrasy- congenital hypersensitivity to certain foods, drugs. For example, during the treatment of the mother during pregnancy, the fetus developed a sensitization to penicillin, which the woman took for pneumonia. When prescribing this drug to a newborn, the development of drug toxicoderma is possible.

Also matters paraallergy, when sensitization arose on one antigen, and another, similar in antigenic structure, was the resolving factor. An example is the development of sensitization to the epidermophyton fungus, and penicillin, which has common antigens with the fungus, could be resolving.

plays a certain role autoallergy- increased sensitivity of the body to allergens of its own tissues (typical for the development of connective tissue diseases - lupus erythematosus, etc.).

Immunological protection in children

After birth, the child immediately encounters pathogenic and opportunistic flora, in front of which newborns and especially premature babies are practically defenseless. This is due both to the state of immunity (specific protection), and to the structural features and functional immaturity of immunocompetent organs and tissues (skin, mucous membranes, gastrointestinal tract - gastrointestinal tract, lymph nodes, etc.).

Among the nonspecific factors of body defense, the main role is occupied by phagocytosis, carried out by macrophages and neutrophils. This function begins to be carried out from the first months of intrauterine development, gradually improving. By the time of birth, the absorptive capacity of macrophages is more mature, and the final phase of phagocytosis is at a low level and becomes more developed in the second half of life.

Has some antiviral protection interferon, synthesized by leukocytes. Its production begins in newborns, increasing with age.

Specific protection in the first months of life is carried out mainly by immunoglobulins (antibodies), which the child received

during fetal development from the mother through the placenta. However, the placental barrier is passed only for IgG, while IgM and IgA are not transmitted to the child.

Individual components of the immune system can function from 20 weeks of fetal development. So, in a fetus with infection of the mother with syphilis, rubella and other diseases, own IgM is determined in the blood.

The antibodies received from the mother are gradually destroyed by the end of the 6-8th month of the child's life, and the production of own immunoglobulins is still insufficient - it develops transient hypogammaglobulinemia in newborns. That is why the infant is susceptible to such infectious diseases that are less characteristic of children of later periods of life. And structural features and immaturity of protective mechanisms contribute to the development of generalized forms, such as pemphigus of newborns, Kaposi's herpetic eczema, Leiner-Moussou's erythroderma, etc. The gradual increase in antibody production reaches a maximum by 14-16 years of age.

If infants are characterized by infectious diseases (bacterial, viral, fungal), then after the first year of life, allergic dermatoses (atopic dermatitis, urticaria, etc.) associated with the development of sensitization and allergies are increasingly occurring. At the age of up to 2 years, allergens that come with food are of the greatest importance, i.e. prevails alimentary phase of allergic reactions. Breastfeeding is an ideal option if a child has a nutritional allergy. The diet of a breastfeeding mother should be adjusted.

1.3. GENERAL SKIN PATHOHISTOLOGY

Histological examination of the skin is a valuable method for diagnosing skin diseases. For this study a biopsy is needed. Biopsy - in vivo taking of tissues, organs or cell suspensions for subsequent microscopic examination. The importance of biopsy is especially great in oncodermatology, where it is the only method of tumor verification.

Can be used for biopsy different ways taking material.

. incisional biopsy produced with a scalpel, the method allows you to get quite large fragments of the skin. Requires suturing on the resulting skin incision.

. Needle biopsy produced using a special tubular knife, which is used to cut a column of tissue material.

. Shaving biopsy are rarely used and are used in cases where the pathological skin process is localized within the epidermis.

The biopsy technique is simple and can be easily performed on an outpatient basis. The rules for taking a biopsy from dermatological patients are as follows.

. A biopsy is performed under local anesthesia using a 1% solution of procaine or lidocaine. If necessary, stitches are applied to the formed defect.

. The most informative biopsy material includes all layers of the skin (epidermis, dermis and hypodermis).

. The biopsy should include primary morphological elements. Eccentrically growing lesions should be biopsied in the marginal zone. Cavity rashes should be taken fresh.

After the biopsy, the skin tissue is fixed in formalin or alcohol, sectioned, and stained.

The main pathohistological changes in the epidermis:

. hyperkeratosis- thickening of the stratum corneum (excessive formation or delay in the exfoliation of stratum corneum);

. parakeratosis- incomplete keratinization, characterized by the presence of nuclei in the stratum corneum (accompanied by underdevelopment or absence of the granular layer);

. granulosis- thickening of the granular layer;

. acanthosis- an increase in the number of rows of cells of the spinous layer;

. dyskeratosis- premature keratinization of individual keratinocytes;

. intracellular edema(vacuolization) is characterized by the appearance of vacuoles in the protoplasm of epidermocytes, deformation of the nucleus, pycnosis;

. spongiosis(intercellular edema of the epidermis) is characterized by the accumulation of exudate between cells, stretching and rupture of intercellular bridges, may result in the formation of an intraepidermal vesicle;

. ballooning dystrophy- necrobiotic process leading to rupture of intercellular bridges; cells or groups of cells that have lost contact with each other float freely in expanded

intercellular spaces in the form of swollen spherical formations (cylinders);

. acantholysis- loss of communication between epidermal cells due to damage to their desmosomal contacts, leading to the formation of intraepidermal cavities;

. epidermolysis- loss of communication between the epidermis and the dermis in the area of ​​the basement membrane due to damage to the hemidesmosomes, leading to the formation of subepidermal cavities.

The main pathohistological changes in the dermis and hypodermis:

. papillomatosis- elongation, branching of the papillae of the dermis, unevenly raising the epidermis;

. granulomatosis - inflammation leading to the formation of granulomas. Granuloma is characterized by the presence of a focal chronic inflammatory response to tissue damage. By the nature of the cellular composition of granulomas, one can judge the nature of inflammation: acute purulent - neutrophilic leukocytes; syphilis, tuberculosis - histiocytes, epithelioid cells; chronic inflammation - plasma cells, etc.;

. granulation tissue - immature connective tissue, consisting of fibroblasts, young collagen fibers, capillaries;

. subpapillary- swelling of the papillary layer of the skin;

. sclerosis- an increase and thickening of collagen fibers in the dermis, leading to the formation of a scar;

. mucoid swelling of the connective tissue - edema and swelling of the fibers occur in the connective tissue, as well as the accumulation of uncharacteristic glycosaminoglycans;

. fibrinoid swelling of the connective tissue- destruction of collagen fibers and accumulation of fibrinoid in the connective tissue. Histologically, the connective tissue appears homogeneous;

. elastosis- disorganization, gluing, thickening of elastic fibers;

. elastolysis - destruction of elastic fibers;

. hyalinosis - connective tissue dystrophy with deposition of hyaline in it;

. amyloidosis- degeneration of connective tissue with the deposition of amyloid glycoprotein in it;

. microabscesses - small focal accumulations of cells in the epidermis or dermis. Munro microabscesses - accumulation of neutrons

filov in the stratum corneum of the epidermis in psoriasis, microabscesses Potrier - accumulation in the epidermis of immature lymphocytes in lymphomas;

. metachromasia- the phenomenon of staining tissues and cells in a color other than the color of the dye, is detected in the presence of acid mucopolysaccharides and amyloid;

. atrophy- reduction in the number of skin layers or its volume. It can refer to both individual layers of the skin, and to the skin as a whole;

. necrobiosis- the process of tissue dying, accompanied by cheesy and fibrinoid necrosis.

1.4. MORPHOLOGICAL ELEMENTS OF SKIN RASHES

To give a correct assessment of the pathological skin process, it is necessary to be able to distinguish between the elements that make up the skin rash. So, when describing a dermatological disease (status localis) use special terms called in dermatology morphological elements. There are primary and secondary morphological elements.

. occur on unchanged skin and characterize the onset of the disease; in turn, they are divided into cavitary (infiltrative) and cavitary (exudative).

. develop in the process of evolution of primary elements and indicates the duration of the skin process.

To make a diagnosis, it is important to recognize the type of primary element of the rash. This can be difficult to do with the rapid evolution of primary elements into secondary ones. In such cases, knowing the main patterns and features of the evolution of primary eruptions, it is possible to determine the previous element from the secondary ones.

General characteristics of the primary morphological elements and their evolution are shown in Table. 1-1.

The characteristics of secondary morphological elements are presented in Table. 1-2.

Table 1-1. Primary elements and their dynamics

Table 1-2. Secondary morphological elements and their definition

When studying the morphological elements in a patient, attention should be paid to their relative position, the monomorphic or polymorphic nature of the rash, the characteristics of individual elements: size, color, shape, consistency, surface, content, etc., as well as their dynamics.

. Monomorphic a rash consisting of primary elements of the 1st type is called, for example, with secondary syphilis - roseolous rash, with acute urticaria - blisters.

. Polymorphic rash are called conditions in which different morphological elements appear on the skin. Distinguish between true and false polymorphism:

Under true polymorphism understand the presence on the patient's skin of 2 or more primary morphological elements (papule, vesicle, etc.). For example, with neurofibromatosis, the skin appears dark spots and neurofibroma nodes;

-false polymorphism occurs during the evolution of primary morphological elements into secondary ones (pustule - crust erosion) and is characterized by a "variegated" pattern of rashes. False polymorphism is common, especially in chronic inflammatory dermatoses (eczema, atopic dermatitis, scabies, etc.).

Primary morphological elementsCavityless Primary Elements

Spot

Spot (macula)- limited change in skin color without disturbing its relief and consistency. Spots on the skin are called the term "exanthema", on the mucous membrane - "enanthema".

According to the mechanism of occurrence, vascular, pigmented and artificial spots are distinguished (Fig. 1-7).

. Vascular spots have different shades of red. Changes in blood vessels lie in the pathogenesis of the formation of vascular spots. So, among the vascular spots, inflammatory, telangiectatic, hemorrhagic and spots caused by the growth of blood vessels are distinguished.

-Inflammatory vascular spots occur during an inflammatory skin process due to vasodilation. With vitropressure, the spots of this type turn pale.

Small inflammatory spots ranging in size from 2-3 mm to 2 cm are called roseola. Acute inflammatory roseola of bright pink color, edematous, prone to fusion and peeling, usually occurs in children with allergic dermatitis, eczema, pink lichen, childhood infectious diseases (measles, rubella, scarlet fever). Neo-inflammatory roseola is hardly noticeable, has a pale pink color, clear outlines, and is not prone to fusion and peeling. Such

Rice. 1-7. Spot: a - pigmented, b - vascular, c - hemorrhagic, d - artificial

roseola, as a primary element, occurs in patients with secondary syphilis, pityriasis versicolor, leprosy.

Large vascular spots that tend to merge and occupy large areas of the skin are called erythema. Erythema is always an acute inflammatory spot and is associated with skin edema and intense itching. Erythema as a primary morphological element occurs in patients with allergic and contact dermatitis, eczema, toxidermia, and erythema multiforme exudative.

A kind of inflammatory vascular spots is a “stress” erythema that occurs with strong emotional experiences (anger, shame, shyness). In the pathogenesis of this condition, the main role is played by unstable vasodilation caused by neuroreflex mechanisms.

This group of spots can also include erythema caused by venous stasis due to the expansion of venous capillaries and venules, which is called cyanosis. For young children, diffuse cyanosis of the mesh type is characteristic - marble skin.

- Hemorrhagic spots occur on the skin during hemorrhage and are caused by the release of erythrocytes from the blood vessels into the surrounding tissues due to injury or with an increase in the permeability of the vascular wall. Hemorrhagic spots are rashes of complex origin, as they can

be both inflammatory and non-inflammatory, characterized by hemorrhages in the epidermis or papillary dermis. With an inflammatory hemorrhagic lesion, necrosis or increased permeability occurs in the vascular endothelium. Non-inflammatory damage to the integrity of blood vessels occurs as a result of bruises, toxic or mechanical effects. When blood enters the surrounding tissue, the outlines and size of hemorrhagic spots are different.

Point, single small (up to 1 cm in diameter) hemorrhages are called petechiae, larger, irregular outlines in the form of stripes - vibices, large areas of hemorrhage in the form of a "platform" - ecchymosis, and large bruises - hematomas. Hemorrhagic spots differ from inflammatory ones in the presence of a rusty tint due to the coloring of the skin with hemosiderin, as well as the absence of blanching when pressed.

A disease or syndrome characterized by a rash of hemorrhagic spots (regardless of their size and shape) is called purple. Purpura occurs in patients with vasculitis, toxidermia, scurvy, infectious diseases (typhoid and typhoid fever).

- Telangiectatic spots- spots caused by persistent expansion (dilatation) of blood vessels and (or) vascular neoplasms (hemangiomas). Vascular spots, consisting of clearly visible small blood vessels, sometimes branching tree-like, are called telangiectasias. They are formed as a result of persistent paralytic vasodilatation under the influence of the irritating effect of climatic factors, as a result of vegetative neurosis in rosacea; as a side effect of the use of external glucocorticoid drugs, for example, on the face of young children with atopic dermatitis. In newborns, telangiectatic vascular spots are often found, which are localized on the back of the head (Unna's spot, "stork's bite"), in the region of the eyelids, and the bridge of the nose. These telangiectasias resolve on their own by the age of 1-2 years.

- Spots caused by vascular neoplasms, also called hemangiomas. Hemangiomas are capillary, cavernous, venous and are the cause of congenital vascular nevi: flaming nevus, port-wine stains.

. Dark spots associated with a change in the amount of melanin pigment in the skin and can be congenital or acquired. With a decrease in the content of pigment in the skin, there are depigmented spots, and with an increase - hyperpigmented spots of various shades of brown.

Depending on the size of the spots and the mechanism of their occurrence, acquired hyperpigmented spots are divided into freckles, chloasma, melasma.

-Freckles- small foci of hyperpigmentation on the face, back, upper limbs, appearing under the influence of intense UV radiation, are often genetically inherited.

-Chloasma- large yellowish or dark brown spots that occur more often in women during pregnancy or liver disease after UVI.

-Melasma- hyperchromia of a common nature, for example, with Addison's disease, sunburn.

-Lentigo- a small congenital pigment spot caused by the accumulation of melanocytes in the epidermis. Congenital hyperpigmented spots include lentigo, congenital melanocytic nevi, Mongolian spots, etc.

Depigmented, or hypopigmented, congenital macules may be a manifestation of widespread or limited form of albinism.

With a limited form - piebaldism areas of depigmentation appear on the scalp in the form of white strands, on the face. Acquired hypopigmented spots are characteristic of vitiligo, leukoderma.

True primary leukoderma characterized by the appearance of small depigmented spots and is formed with insufficient synthesis of melanin due to intoxication in patients with secondary syphilis, typhus and typhoid fever.

-Vitiligo - an autoimmune disease characterized by the appearance of depigmented spots of various sizes.

Primary leukoderma must be distinguished from secondary leukoderma, or pseudoleukoderma, which is characterized by the appearance of white spots with the resolution of primary elements in psoriasis, eczema, pityriasis versicolor and is caused by secondary pigment deficiency against the background of inflammation.

. artificial stains occur when colored foreign substances are deposited in the skin. The outlines and color of the spots depend on the substance itself and the method of its administration. Tattoo- a pattern on the skin obtained by artificially introducing dyes into the skin.

Nodule, or papule

Nodule, or papule (papula) - a cavityless element that rises above the surface of the skin and resolves without a trace. According to the depth of occurrence (Fig. 1-8), the nodules that form in the epidermis are called epidermal, and formed in the dermis - dermal. Usually, during the inflammatory process, proliferation occurs both in the epidermis and in the dermis, therefore such papules are called epidermal-dermal. Based on the presence of inflammation, non-inflammatory papules (papillomas, xanthomas) and inflammatory(with psoriasis, eczema, etc.).

According to the size of the papules are:

. miliary, the size of a millet grain (1-3 mm) for Devergie's disease, psoriasis;

. lenticular, the size of a lentil (0.5-0.7 cm) with psoriasis, lichen planus;

. nummular, the size of a coin (1-3 cm) for eczema;

. plaques are fused papules of different sizes, characteristic of psoriasis, lymphoma.

The color of the papules varies from red, red-brown (in the presence of inflammation) to grayish-yellow or normal skin with absence

Rice. 1-8. Papule: a - epidermal, b - epidermal-dermal, c - dermal

inflammatory response. The surface of the nodules can be smooth, shiny, and can be covered with a copious amount of scales.

The outlines of papules are different - polygonal, rounded, irregular. Nodules are distinguished by shape flat(for lichen planus) hemispherical(with strofulus) and pointed(for Devergie's disease).

Papules can have a different consistency: dense, densely elastic, doughy, soft. Also, papules are characterized by the presence of a leg (papillomas, genital warts).

The surface of the papule is not initially changed, it is involved in the pathological process for the second time. If a bubble appears on the surface of the papule, then such papules are called seropapules, or papulovesicles, which are found in scabies, strophulus.

tubercle

tubercle (tuberculum)- a cavityless element, rising above the surface of the skin, is resolved by a scar or cicatricial atrophy (Fig. 1-9). Occurs as a result of limited foci of productive

inflammation of the type of infectious granuloma with the phenomena of necrosis, ulceration and scarring. The tubercles have different sizes - from millet grain (diameter 1 mm) to hazelnut. Tubercles are formed in limited areas of the skin. Sometimes the tubercles are grouped and located close to each other, gradually merge, forming

complete infiltrate. In various dermatoses, tubercles have a number of characteristic clinical features. In patients with tuberculosis, the tubercles are soft, flat, easily wounded, often confluent, yellowish-brown in color, and in patients with tertiary syphilis, they are dense, hilly, red-cyanotic or raspberry-brown in color, arranged in a group and not prone to merging. Tubercles are also the primary element in patients with leprosy, leishmaniasis, late congenital syphilis.

Rice. 1-9. tubercle

Knot

Knot (nodus)(Fig. 1-10) - a large infiltrative dense element of a spherical or ovoid shape, located in the deep layers of the dermis

Rice. 1-10. Knot

we and subcutaneous adipose tissue. The knot ranges in size from a pea to a walnut or more. At the beginning of the formation of the element, the knot does not rise above the skin. Then the infiltrate of the node gradually increases, grows into the dermis and epidermis, rising above the surface of the skin. The nodes are mobile or soldered to the skin.

Nodules can be the result of limited non-specific inflammation (erythema nodosum, paniculitis), specific inflammatory reactions, in which infectious granulomas with necrotic decay in the center are formed (tertiary syphilis, tuberculosis) or a tumor process, both benign (fibroma, lipoma) and malignant. (sarcoma). The outcome of the nodes is due to the nature of the disease and can be without a trace, with scarring, with cicatricial atrophy.

The consistency of the node varies: from soft, fluctuating in tuberculosis, to densely elastic in patients with tertiary syphilis and leprosy. Most often, the nodes have a red-brown or red-cyanotic color. Features of nodes in various dermatoses served as the basis for a specific name different types deep infiltrative elements. So, with tertiary syphilis, the node is called gumma, in patients with tuberculosis scrofuloderma, with leprosy - leprosy.

Blister

Blister (urtica)(Fig. 1-11) - an acute inflammatory, cavityless element, rising above the surface of the skin, based on

there is swelling of the upper layers of the dermis. It is distinguished by density, pink-red, and sometimes pearly white color and intense itching. The size of the blister varies widely - from the size of a poppy seed to the palm of your hand and more. Elements tend to merge with the formation of large areas with a significant amount

Rice. 1-11. Blister

due to excoriations. This element of the rash is characterized by ephemeral nature, i.e. a quick, almost instantaneous appearance and the same short-term existence, a quick disappearance without a trace. Urticarial rash occurs with hives, insect bites, and also with anaphylactic reactions.

Hollow primary elements

bubble

bubble (vesicula)(Fig. 1-12) - a cavity surface element filled with serous transparent contents, the size of a poppy seed, a pinhead or small lentils; dimensions

can reach 1 cm. It is formed in the malpighian layer of the epidermis due to intercellular edema (spongiosis) in patients with eczema or intracellular edema in dermatitis or due to balloon dystrophy in herpetic dermatoses. In the vesicle, a cavity filled with serous, serous-hemorrhagic or hemorrhagic contents is distinguished, the bottom

and a cover. With a large number of clustered bubbles, large multi-chamber elements can be formed due to their close arrangement.

Rice. 1-12. bubble

Bubble

Bubble (bulla)(Fig. 1-13) - a large cavity element of a round or oval shape with transparent, cloudy or hemorrhagic contents. The size of the bubble can be significant (from the size of a pea to the palm of your hand or more). The bladder cover is tense or flabby, easily opened and forming erosive weeping surfaces. Depending on the nature of the etiological or pathogenetic factor, the depth of the bladder is different. Subcorneal the bladder is located under the stratum corneum of the epidermis and is characteristic of pemphigus foliaceus. intraepidermal vesicle within the spinous layer is characteristic of pemphigus vulgaris, subepidermal vesicle with damage to the basement membrane is formed with Dühring's dermatitis herpetiformis, epidermolysis bullosa. Most often the bubble

Rice. 1-13.Bladder: a - intraepidermal, b - subcorneal, c - subepidermal

appears against the background of an edematous erythematous spot, but can also occur on visually unchanged skin (pemphigus vulgaris).

abscess

abscess (pustula)(Fig. 1-14) - a cavity element filled with purulent or purulent-hemorrhagic contents, surrounded by an inflammation halo. The abscess cavity is formed in the epidermis as a result of necrosis of epithelial cells under the influence of various pyogenic microorganisms. As a result of the action of pyogenic cocci and their toxins, superficial, located within the epidermis, and deep pustules located in the dermis, hypodermis appear. . Impetigo- a superficial abscess, usually small in size (ranging from a millet grain to a pea), bordered by an edematous, hyperemic border, with rapidly drying contents and resolving with temporary pigmentation.

Rice. 1-14.Abscess: a - follicular pustule, b - conflict

With the connection of the inflammatory process with the hair follicle and the form of the pustular element depending on this, follicular (conical) and non-follicular (flat) pustules are distinguished.

Follicular pustules.

Pustules that affect the hair follicle are called folliculitis.

If the purulent process is localized superficially, only at the mouth of the follicle, it is osteofolliculitis.

A furuncle is a deep folliculitis that proceeds rapidly, acutely, with the involvement of surrounding tissues in the process and the formation of necrosis in the center.

Non-follicular superficial pustules of small sizes (ranging from a millet grain to a pea), bordered by an edematous hyperemic border, with rapidly drying contents and resolving temporary pigmentation, are called conflict.

With the progression of the process, inflammation spreads to the underlying tissues with the formation of a deep flat pustule - ecthyma, ulcerative and often penetrating into deeper tissues.

Secondary morphological elementsSkin dyschromia

Skin dyschromia (dyschromia)- pigmentation disorders that occur at the site of resolved primary morphological elements (papules, vesicles, pustules, inflammatory spots) or secondary elements (erosive-ulcerative). There are secondary hyperpigmentations and depigmentations.

Hyperpigmentation develops as a result of many inflammatory skin diseases (lichen planus, psoriasis, pyoderma) and is associated with increased melanin deposition.

Depigmentation develops with pigment deficiency and is called secondary leukoderma. Secondary leukoderma often develops as an outcome of a superficial inflammatory process in pityriasis versicolor, superficial streptoderma, and atopic dermatitis.

Variegated picture of skin lesions with the presence of mesh pigmentation, depigmented atrophic spots, small erythematous

spots and telangiectasias are called poikiloderma(poikilos - motley).

Scales

Scales (squamae)(Fig. 1-15) - loosened, torn off horny plates that have lost contact with the underlying cells. Visually noticeable separation of scales is called peeling (desquamatio). Depending on the size of the scales, fine-lamellar, lamellar and large-lamellar peeling is distinguished.

.fine-lamellar pityriasis peeling (pityriasis) characterized by very small scales, in appearance resembling flour or bran and found in erythrasma, versicolor.

If larger scales are formed during the peeling process, they are called lamellar. Abundant peeling occurs in patients with psoriasis, eczema, etc.

.large plate peeling is characteristic of acute inflammatory diseases: toxicoderma, scarlet fever, pemphigus foliaceus, etc.

Scales on the surface of the elements can be located loosely, easily removed, or fit tightly, as a result of which, when trying to scrape, pain is noted. (symptom of Meshchersky-Besnier) as in discoid lupus erythematosus.

Crust

Crust (crusta)(Fig. 1-16) is a shriveled exudate of the contents of vesicles, blisters, decay of skin tissues, discharge of erosions and ulcers. The color of the crusts depends on the type of exudate to be separated: serous,

Rice. 1-15. Flake

Rice. 1-16. Crust

hemorrhagic or purulent. The color, size and shape of the crusts largely repeat the nature of the primary elements that preceded them.

Thick, flaky, massive crusts are called rupees. They are formed by continuous peripheral growth due to ongoing inflammation underneath and resemble the shell of an oyster. Rupees are detected in syphilis, Norwegian scabies, rupioid psoriasis.

Abrasion

Abrasion (excoriatio)(Fig. 1-17, a), or excoriation, is a skin defect resulting from mechanical damage to the skin (bruise, scratches, scratches). Depending on the depth of damage, abrasions are superficial(within the epidermis) or deep(in the dermis). Superficial excoriations heal without a trace, while deep excoriations leave a scar. Often, abrasions become infected, which leads to the development of pyoderma. Abrasions arising from scratches and scratches are linear in shape and are characteristic of itchy dermatoses (scabies, eczema, atopic dermatitis, lymphoma).

Crack

Crack (rhagas, fissura)(Fig. 1-17, b) - a skin defect resulting from its linear rupture during prolonged inflammatory infiltration, dryness and loss of skin elasticity. More often, cracks occur in places of natural folds (corners of the mouth, perianal region, interdigital folds of the hands and feet), as well as in the joints

Rice. 1-17. Secondary morphological elements: a - abrasion; b - deep crack

(wrist joint, elbow bend, for example, with atopic dermatitis, chronic eczema). A feature of the formation of cracks is the formation of a skin linear defect located perpendicular to the vector of skin stretching.

Surface cracks (fissure) are located only in the epidermis and therefore do not leave scars or atrophy.

deep cracks (rhagas) bleed and heal with scarring. For example, in congenital syphilis, deep radial fissures around the mouth are possible, followed by the formation of Robinson-Fournier scars.

Erosion

Erosion (erosio)(Fig. 1-18, a) - a superficial defect of the epidermis, which is formed after the opening of exudative primary elements (vesicle, bladder, abscess). The sizes and outlines of erosion correspond to the previous primary elements. After the opening of the bubbles, erosion is small, often with a drop of serous fluid on the surface. After opening the blisters along the edge of erosion, fragments of the epidermis can be found, which are the remains of the bladder cover.

Erosion can also be primary, resulting from mechanical trauma (abrasion) and maceration. Erosions heal without scarring and atrophy.

Ulcer

Ulcer (ulcus)(Fig. 1-18, b) - a deep skin defect within the dermis and hypodermis. Unlike wounds, ulcers are the result of pathological changes that have caused necrosis of the deep layers of the dermis. ulcers

Rice. 1-18. Secondary morphological elements: a - erosion; b - ulcer

can be formed as a result of necrotic decay of the infiltrate of primary elements - tubercles, nodes, deep pustules. Ulcers can also occur as a result of primary necrosis of apparently healthy tissues due to impaired trophism (trophic ulcers, ulcerative necrotic form of vasculitis).

When describing an ulcerative defect, the edges, bottom and discharge are necessarily characterized. The edges of the ulcer are undermined, sheer, saucer-shaped, and in consistency - soft, dense, callused. The bottom of the ulcer may be smooth or uneven. In most cases, the bottom of the ulcer is covered with a serous, purulent or hemorrhagic discharge, which gives the ulcer one color or another. The discharge from the wound may be copious or scanty.

Ulcers formed from acute inflammatory exudative elements have edematous, brightly hyperemic edges with a stagnant shade and purulent or purulent-hemorrhagic discharge (at the opening of boils, carbuncles). Ulcers arising from the opening of proliferative formations (tubercles and nodes) are surrounded by a dense infiltrative towering shaft of a brown-red hue. Their discharge is meager, with various diseases it has a certain character. So, in patients with tertiary syphilis, the gummous rod at the bottom of the ulcer is covered with a small amount of yellow transparent sticky discharge resembling glue (gum arabic), in connection with which the node was named gumma.

An ulcer always heals with a scar, the nature of which can sometimes be used to judge a previously transferred pathological process.

Scar

Scar (cicatrix)(Fig. 1-19) - a newly formed skin tissue that occurs in places of its deep damage when this defect is replaced by coarse fibrous connective tissue. The scar contains no hair, sebaceous, sweat glands, blood vessels and elastic fibers; it is formed from collagen fibers. The appearance of the scar is distinguished by the absence of the natural diamond pattern of the skin and skin appendages. Telangiectasias may be noted on the surface of the skin, and some sheen of scar tissue in transmitted light. As a result of the loss of elasticity, the skin in the area of ​​the scar does not gather into a fold, its texture is usually dense.

The scar is formed during the healing of ulcerative defects that occur after the collapse of tubercles, nodes, boils, hydradenitis, ecthymia,

as well as in the healing of deep burns and wounds. Fresh scars are pink and red in color, while old scars are usually depigmented, sometimes hyperpigmented. Clinically distinguish (see Fig. 1-19): flat scars, located on the same level with the skin, hypertrophic scars, raised above the surface of the skin atrophic scars, with a thinned surface, located below the surface of normal skin. Hypertrophic scars of considerable thickness, caused by excessive neoplasm of connective tissue and extending beyond the boundaries of the previous lesion, are called keloid scars.

Rice. 1-19. Scar: a - atrophic; b - normotrophic; c - hypertrophic

The scars formed at the site of infiltrative rashes (nodes, tubercles) correspond in size and shape to the previous element. So, the syphilitic gum is scarred with the formation of stellate deep elongated scars; tuberculous node (scrofuloderma) and ulcers in pyoderma gangrenosum form bridging, retracted, irregularly shaped scars. Tuberculous elements of papulonecrotic tuberculosis leave stamped, sharply defined scars, and syphilitic tubercles of the Tertiary period end in the formation of variegated, mosaic, grouped scars of scalloped outlines.

If the inflammatory infiltrate resolves without violating the integrity of the epidermis (without ulceration) and is replaced by a delicate fibrous substance, then cicatricial atrophy(Fig. 1-20). The affected tissue becomes sharply thinner, the skin pattern disappears, hair follicles, sebaceous and sweat glands undergo atrophy,

a characteristic luster is released, and the skin easily gathers into a fold like tissue paper (Pospelov's symptom). Such changes are detected in patients with discoid lupus erythematosus, scleroderma, leprosy, skin tuberculosis, leishmaniasis and tertiary syphilis.

Rice. 1-20. cicatricial atrophy

Lichenification

Lichenification (lishenificatio)(Fig. 1-21, a) is a thickening of the skin due to various inflammatory infiltrates. Clinically, the focus of lichenification has the appearance of compacted skin with an accentuated diamond-shaped pattern, rough, dry and hyperpigmented (shagreen skin). Lichenification may occur primarily as a result of prolonged mechanical irritation of the skin during itching (for example, psychogenic genesis), secondarily, on the basis of a chronic inflammatory infiltrate, it is formed when itching papular rashes merge in patients with atopic dermatitis, eczema, and lichen planus. With secondary lichenifications, symptoms characteristic of the papular elements of these dermatoses persist.

Rice. 1-21. Secondary morphological elements: a - lichinification; b - vegetation

vegetation

vegetation (vegetation)(Fig. 1-21, b) are villous formations resulting from hypertrophy of the Malpighian layer of the epidermis and papillae of the dermis in places of a prolonged inflammatory process on the surface of papules and erosions. The surface of the vegetation can be dry, hyperkeratotic, grayish in color (vulgar warts) or, conversely, eroded, weeping, pink or red in color, bleeding easily, with serous-purulent discharge (with vegetative pemphigus). When vegetations are localized in the perineal region, they often become infected and are accompanied by an acute inflammatory infiltrate, serous or serous-purulent discharge.

Analysis of primary and secondary morphological elements in patients allows the doctor to assess the nature of the inflammatory response and diagnose the disease.

Dermatovenereology: a textbook for higher students educational institutions/ V. V. Chebotarev, O. B. Tamrazova, N. V. Chebotareva, A. V. Odinets. -2013. - 584 p. : ill.

Skin appendages include sweat and sebaceous glands, hair and nails.

Sweat glands (glandulae suderiferae) (Fig. 294) are tubular glands in shape, located in the end sections, forming glomeruli, in the deepest layers of the dermis. They are located in the subcutaneous base and on the border of the subcutaneous base and the dermis almost throughout the body, except for the red border of the lips and the glans penis. Especially a lot of them on the palms and soles. The excretory duct of the sweat gland (ductus sudoriferus) (Fig. 294) spirally penetrates all layers of the skin, and in the epidermis area it opens on its surface with a sweat pore (porus sudoriferus) (Fig. 294). All sweat glands secrete a liquid secret, resulting in the process of thermoregulation of the body and the removal of harmful metabolic products from it. The secret secreted by the glands located in the armpits, inguinal folds, pubis and pectoral nipples has a characteristic odor.

Sebaceous glands (glandulae sebaseae) (Fig. 294) - simple branched alveolar glands in shape, located on the entire surface of the body, except for the palms and feet. The excretory ducts of the sebaceous glands open into the hair follicle - the follicle - and on the surface of the skin in those places where there is no hairline: on the palms, feet, red border of the lips, breast nipples, on the inner surface of the anus, etc. From 1 to 3 excretory ducts are suitable for each follicle. The sebaceous glands secrete sebum, which prevents the skin and hair from drying out, providing them with fatty lubrication.

Hair (pili) is a derivative of the epidermis and is an elastic horny thread. They cover the entire body, except for the palms, lateral surfaces of the fingers, soles, red border of the lips, labia minora, glans penis and inner sheet of the foreskin.

Hair is divided into primary, which is a delicate infant fluff, secondary - thicker vellus body hair, head hair, eyebrows and eyelashes, and tertiary, appearing during puberty: facial hair (beard and mustache), pubic hair, armpit hair, nostril hair and external auditory canal.

The hair itself consists of a medulla that is absent in vellus hair, a cortical substance that makes up the bulk of the hair and contains the pigment that determines its color, as well as the cuticle that covers the outer surface of the hair.

Hair is divided into a hair shaft (scapus pili) (Fig. 294), located above the surface of the skin, and a hair root (radix pili) (Fig. 294), which lies in the thickness of the skin. The root is located at an angle to the skin and ends with a small seal, called the hair follicle (bulbus pili) (Fig. 294). From below, the papilla of the hair (papilla pili) grows into it (Fig. 294). The root itself is located in the root sheath, formed by the germ layer of the epidermis. The root sheath, in turn, is located in the follicle, or hair bag (follicula pili) (Fig. 294).

Hair growth is provided by producing cells that cover the hair papilla. When the supply of these cells is stopped, new ones are no longer formed, the bulb dies, separates from the papilla, and the hair falls out.

Nails (unguis), like hair, are derivatives of the epidermis, which are dense horny plates. They have a convex shape and are located on the back of the distal phalanges of the fingers and toes. The plates are formed by horny scales tightly adjacent to each other.

The nail is located in the nail bed (matrix unguis), formed by the connective tissue of the dermis and the growth layer of the epidermis and limited at the edges and behind the groove of the bed (sulcus matricis unguis). Above the groove is the nail roller (vallum). The surface of the nail bed consists of rows of longitudinal scallops of the bed (cristae matricis unguis).

In the nail itself, the body of the nail (corpus unguis), the edges of the nail and the root of the nail (radix unguis) are isolated. The latter is located in the posterior groove of the bed, which is much deeper than the lateral grooves. There are four edges of the nail: a free edge (margo liber), protruding above the end of the distal phalanx, a hidden edge (margo occultus), located next to the root of the nail, and two lateral edges (margines laterales).

The growth of horny scales occurs due to the growth layer of the epithelium of the nail bed. It is most strongly developed at the root of the nail and even shines through the nail plate. This area is called the lunula (lunula).

epithelial cells form not only the surface layer of the skin - the epidermis, but also the appendages of the skin. These include sweat and sebaceous glands, hair and nails. They all perform important features necessary for the normal functioning of the body.

sweat glands

sweat glands - microscopic formations embedded in the skin and producing a special fluid - sweat. Despite the small size, secretion of sweat glands plays a huge role in human life, one of the main participants in the regulation of water-salt balance in the body, constant body temperature. They are unevenly distributed in the skin. Especially a large number of sweat glands in the face, palms, feet, in the axillary and inguinal regions, in the folds under the mammary glands, in the sternum, back. The excretory duct of the secretory part of the gland comes to the surface of the skin and ends with a flat fossa, which is called the sweat pore.

Sweating plays an important role in the body's thermoregulation. . The separation of sweat and evaporation of moisture from the surface of the skin occurs continuously at any temperature. Every day, under normal conditions, a person loses from 400 to 600 milliliters of sweat. If the ambient air temperature is equal to or higher than body temperature, the amount of sweat produced increases significantly. For example , in hot countries, a person emits up to 4.5 liters of sweat per day. Similarly, when performing physical work, sweating increases to a significant size - 6-9 liters.

The process of sweating is affected by air humidity : the drier the air, the more sweat the human body produces. Together with sweat, the body loses a lot of salt. Therefore, during long hikes in the hot season, when working in

hot shops add up to 0.5% salt to drinking water. It quenches thirst and improves well-being.

Despite the importance of the function of the sweat glands - sweating, very often a person experiences discomfort.

When excited, in unusual situations, sweat profusely appears on the palms and soles of the feet, where there are especially many sweat glands - up to 500 per 1 cm2 of skin.

With an increase in body temperature excess sweat appears on the entire surface of the skin. Frequent sweating can cause swelling (maceration) of the skin, such as between the toes. As a result, cracks and diaper rash appear on the skin.

Sebaceous glands

Sebaceous glands , and a person has more than 250,000 of them, are located mainly in areas covered with hair. Each hair follicle has several sebaceous glands. Their ducts open into the upper expanded part of the hair follicle - a funnel-shaped bowl. But there are sebaceous glands, which, through their excretory duct, secrete fat directly onto the surface of the skin.

There are no sebaceous glands on the soles and palms .

When a muscle contracts straightening hair, the sebaceous gland is compressed, which contributes to the release of fat outward. Most of the fat stands out on the wings of the nose, chin, on the forehead, in the auricles. It serves to lubricate the skin and protects it from cracks and dryness. However, excessive secretion of fat, for example, on the scalp, may be one of the factors contributing to the development of skin disease - seborrhea.

Sebaceous glands secrete fat, fatty acids, cholesterol and other products.

Violation of the function of the sebaceous glands leads to various diseases, in particular to the formation of tumors, keratinization of the skin.

Hair

Hair is an appendage of the skin. The development of hair covering the human body begins in the prenatal period. Primary hair at the end of fetal life or shortly after the birth of a child falls out and is replaced by permanent, or secondary, hair.

On the body, arms and legs, the hair is delicate, thin, the so-called vellus. On the scalp, eyebrows, eyelids, the hair is long - bristly.

On the head, hair growth is most intense in the period of life from 15 to 30 years. With age, and especially after 50 years, hair grows more slowly. Eyebrow hair grows throughout life.

Hair condition depends on the general health of the person. All acute colds, infectious diseases, as well as chronic diseases, physiological restructuring of the body associated with puberty, pregnancy,

menopause, affect the condition of the hair. During these periods, dryness, thinning, brittleness, and hair loss may appear.

The hair is made up of two parts. - rod and root. The stem is located above the skin, the root is located deep in the skin and ends with the bulb. The visible part of the hair - the shaft consists of three layers: the inner, or cerebral, middle - cortical and outer shell - the cuticle.

Depending on the content of cylindrical cells with pigment in the cortical layer of the hair, as well as air bubbles located in the inner and cortical layers, the hair is of different colors. Hair not only decorates a person, it protects the scalp from adverse external influences. Hair does not conduct heat, so winter time they protect the head from hypothermia, and in hot weather - from overheating.

The hair on the arms and legs is sparse; short, protective functions are not performed.

Nails

Nails are also considered appendages of the skin. They are formed from horny cells and appear in the third month of fetal life in the form of a flat thickening on the back surface of the terminal phalanges of the fingers. Gradually, on the sides and behind this thickening, nail folds form in the form of a slight rise in the skin, and then the nail matrix develops, from the multiplying epithelial cells of which the nail plate grows and gradually hardens.

The anatomical concept of "nail" includes (Fig. 11) nail plate 1, nail matrix 4, nail bed 5, nail ridges (posterior 3 and lateral), nail skin 2, subungual gap.

The nail plate consists of translucent keratinized cells, has a convex shape, is firmly connected to the nail bed. It protects the soft tissue of the fingertip, protects the nail bed from mechanical damage, and is resistant to weak acids and alkalis. The nail plate with its posterior and lateral edges is recessed into the nail folds, which are small skin folds.

Rice. 11. The structure of the nail:

1 - nail plate, 2 - nail skin, 3 - posterior nail roller,

4 - nail matrix, 5 - nail bed, b - subungual gap

A healthy nail plate has a shiny surface. Translucent capillaries of the nail bed give it a pink color. The underside of the plate is covered with longitudinal ridges alternating with longitudinal grooves. The scallops are recessed into the surface of the nail bed. In some people with thin nails, the scallops show through in the form of light longitudinal stripes.

Rice. 12. The structure of the nail plate:

1 - body of the nail, 2 - free edge, 3 - hole, 4 - nail folds

At the nail plate (Fig. 12), the body of the nail (central part) 1, the free edge 2 (protrudes above the fingertip), the hole 3 (the rear part of the nail is matte white) are distinguished. The moon is clearly visible on thumbs, less or not at all visible on the other fingers.

Under the free edge of the grayish-white nail plate is the subungual fissure.

The root part of the nail consists of the root of the nail and the matrix. The root has a jagged edge hidden under the skin.

The nail plates on the right hand are slightly wider than on the left. Nail length 10-15 mm, width 10-17 mm, thickness 0.3-0.4 mm.

Nail growth proceeds continuously from matrix cells with the participation of nail bed cells. An adult's nail lengthens by 0.11 mm per day , in a child - by 0.04-0.06 mm. Full renewal of the nail plate occurs in 105 days . On the feet, the nails grow more slowly than on the hands, and the growth rate is not the same on different fingers. In the warm season, nails grow faster. The nail plate is covered on three sides by skin folds - nail folds. The rear roller covers the root of the nail, the edge of the roller forms a narrow and thin nail skin, tightly adjacent to the surface of the nail.

Damage to the nail skin during manicure can lead to infection under the nail fold and nail disease.

The matrix and the nail bed are well supplied with blood through a dense network of capillaries. There are lymphatic vessels and nerve endings in the bed and nail folds. In chemical composition the nail plate includes the protein substance keratin, rich in amino acids, water (about 14%), lipids that give elasticity to the nail (with a lack of lipids, the plate becomes brittle), calcium, phosphorus, zinc, etc.

Hand care

Beautiful hands - business card women

Hands can say a lot about a woman. Hands often give out the age of a woman. They are exposed to active mechanical, thermal and chemical irritants more often than other parts of the body. The skin of the hands dries out early, becomes thinner, loses its elasticity, and age spots and wrinkles appear on it. But well-groomed soft hands- this is what attracts, creates an impression about a person. In ancient times, when knights could only dream of a beautiful lady, their most cherished desire was to touch the hand of their beloved. And the ladies carefully monitored the condition of their hands, so that the gentleman once again admired the velvety and tenderness of the skin.

Now our women are constantly working, their hands either wash the dishes, or clean the vegetables, or do the cleaning - which means that they must be constantly protected. Women's hands are almost always in sight. Women are usually emotional, they like to gesticulate when talking, they like to tap their nails on the table, they will not fail to offer their hand for a kiss if the opportunity presents itself. Especially women like to show their hands if they are beautiful. detergents and cleaning agents, washing powder, the soil when working in the garden has a bad effect on the condition of the skin of the hands. Without special care, their skin becomes dry, rough, cracked, flaky.

The skin on the back of the hands contains very few sebaceous glands, and on the palms they are absent altogether. Therefore, the hydrolipid film of the skin, which provides it with natural protection, is very weakly expressed in the area of ​​the hands. In addition, the epidermis of this zone contains little water - 4-5 times less than the skin of the face. As a result, the skin of the hands is very often dehydrated.

Beautiful hands demand permanent care, one has only to be too lazy and abandon them for at least one day, as the hands will immediately remind themselves of themselves with dryness, tightness of the skin, and if you do not take care of your hands for a longer time, then problems cannot be avoided. Therefore we offer comprehensive program skin and nail care.

Morning care.

Hands are washed with warm water or room temperature water and soap. Ideally, soap should not contain alkali, now there is a large selection of liquid soaps on the market that do not injure the skin of the hands. Washing hands in very cold in hot water also degreases the skin and makes it rough.

Be sure to dry your hands after washing. If moisture remains on them, then on the street the skin of the hands becomes weathered, coarsens, often even cracks appear on it.

Before going outside, hands should be lubricated with hand cream. In winter, do not forget about warm mittens.

Day care.

Hands are washed before eating and, as they get dirty, with warm water and soap or rubbed with lotion. Cleansing wipes can be used to care for and cleanse the skin of the hands, but this does not apply to washing hands before dinner. In summer, if your hands sweat, wipe them more often. To nourish the skin, rub the cream into it several times during the day.

Evening care.

Hand skin care in the evening is more complete and thorough.

Hands are washed with warm water and neutral soap. For better cleansing of the skin, baths are made: warm with a solution acetic acid or lemon juice, saline. After washing and bathing, dry your hands with a towel.

To preserve the beauty of the hands, massages and creams are required. The cream is rubbed with movements similar to those when putting on gloves, that is, from the end of the fingers to their base and beyond? with the whole palm, then with one hand, then with the other. After rubbing the cream, the skin is massaged with similar movements. During the massage, stroking, rubbing, kneading and patting the skin are sequentially performed. In the evening, more oily creams are used to lubricate the skin of the hands. At the same time, during rubbing, it is recommended to do some simple gymnastic exercises for the hands.

In order for the fingers and all joints of the hands to be flexible, mobile, and less tired from work, it is necessary to do hand exercises daily for 3-6 minutes, consisting of the following simple exercises:

Gymnastics for hands

1. Squeezing and unclenching the brushes.

2. Sit down at a table and imitate playing the piano, making sure that all fingers move separately. Raise your fingers as high as possible.

3. Rotate the brush first in one direction, then in the other. Repeat this exercise several times on each side.

4. Stretch your arms forward. Rotate the brushes 10 times clockwise and 10 times counterclockwise.

5. Put your palms together and push them hard towards each other.

6. Rotate your arms above your head.

7. Raise your arms up and down sharply, waving them like a bird's wings before taking off. Repeat 10 times.

8. Hold your hands palms down, interlace your fingers, slowly, in a circular motion, turn your hands palms up, at the same time opening your fingers. Repeat the action in reverse order.

9. Put your hands down and shake them vigorously? at first only with brushes, then to the elbow and, finally, with the whole arm.

Hand exercises are best done when the hands are warm. Do the exercises have to be done very carefully? never let the joints stiffen and become too tense. To strengthen your fingers, try clenching your fists with spools of thread in them. After exercising, rinse your hands with cold water.

Hand massage

improvement of blood circulation, blood supply, accelerates skin regeneration, improves its appearance, having a beneficial effect not only on the condition of the skin, but also on general well-being, improves tone and calms the nerves, since a large number of nerve endings are concentrated here.

Cold hands - this is proof that the peripheral circulatory system does not provide the needs of the body.

Subsequence:

1. lubricate hands nourishing cream or vegetable (preferably olive) oil, we begin to massage from the left hand.

2. In a spiral motion, massage the fingers first first and fifth fingers, then second and fourth and finally the third and first.

direction from the nail to the base, continuing to move along the back of the hand to the wrist.

3. Slowly knead each finger from tip to base.

4. We rotate the fingers, while holding them by the tips, first in one direction, then in the other direction.

5. Place the massaged hand on the elbow, raise the fingers up. Place the palm of your right hand on the back of your left, and the first finger? into her palm. Go down to the middle of the palm, fixing lightly with the first finger. Move down to the wrist. Now go to the side of the palm and move up to the elbow.

6. intensively tug 3-4 times, as if vibrating, fingers, holding each by its tip.

7. Put your hand on the table, and with the palm of the other, smoothly slide over it from the fingertips to the base of the hand, as if stroking it.

8. Turn the hand over with the palm and phalanges of half-bent fingers of the other hand, perform 3-4 rubbing rotational movements.

9. Finish the massage with stroking.