dr. Elida Ilyas, SpRM

INTRODUCTION Skin is a complex organ whose basic function is holocrine secretion for it selfBeing composed of epidermis and dermis Its 20.000 cm square of surface in an adult and its average thickness 2,5 cmRegulated decease produces the cornified layer and replace by mitosis of basal layer cells

AnatomySkin consist of epidermis, dermis, subdermis

Epidermis : consist 5 layers :1. Stratum corneum 2. Stratum lucidum3. Stratum granulosum4. Stratum spinosum 5. Stratum germinativum/basal layer

− Dermis : consist of :• Major cellular type like fibroblast, histiocyles,

chromaffin cell and mast cell• Collagen, elastin and reticuler fiber • Fibroblast will lay down this system of fibers in

a matrix containing sulfated mucopoly sacharide

- Skin appendages are :• Sweat glands• Sebaceous glands • M. erector pilorum• Plexus capillary • Free nerve ending

Skin function :

Water retaining Body thermo regulation Protection the inside structure of the body Keeping out particulate foreign bodies Keeping out pathogen organsKeeping out chemical Keeping out radiation Letting in sunlight Letting in sensation Letting out heat

Self Replication :The epidermis cells are in the process of constant self replication There are being added from the basal layer by mitosis activity : and while being lost from the horny layer

Respons to injury Non penetrating trauma

In the form of pressure that cause direct and indirect vascular reaction Direct response : vasocontriction vascular reaction manifest by

white line effect Indirect response : alteration in capillary permeability manifest

by erythematous effect

Non penetrating trauma with cell loss

Stripping of the epidermal surface (excoriasis)

Burst of mitosis activity in the basal layer

Reconstitution of epidermal and stratum corneum (skin healing by replication)

Skin healing by :Replication occurs it the injury in the epidermal Substitution of scar tissue occurs if the epidermal structure are lost and injury penetrate into the dermis

Penetrating injury

In the form of the incised skin woundThe end of healing process is substitution of scan tissue

Wound healing processConsist :

1. Inflamatory respons phase 2. Fibroplastic repair phase3. Maturation – remodelling phase

1. Inflamatory respons phaseVascular reaction involve :

Vascular constriction Blood coagulation Growth of fibrous tissue

Chemical mediator Histamin release : vasodilatation and increation permeability swellingLeucotaxin release : supplying leucocytes to the injured areaNecrosin release : responsible for phagocytic activity

Cellular respons : Leucocyt and phago cytic cells delivery to injury tissue, to dispose of injury by product (e.g damage cell, blood) through phagocytosis

2. Fibroblastic repair phaseFibroblastic periode : proliterative activity leading to scar formationLack of oxygen stimulated growth of capillary called granulation tissue, that consist : fibroblast, collagen and capillary Fibroblastic cell begin to synthesize extra cellular matrix collagen fibers Collagen fibers tensile strength tensile strength fibroblast

3. Maturation – remodelling phase

This phase featuring remodelling of the collagen fiber that make up the scar tissue according to the tensile forces A firm, strong, contracted scar exist approximately 3 weeks

The role of therapeutic modalities in medical rehabilitation program to facilitate wound healing

Modalities to facilitate wound healing Cold and superficial hotUltra sound LaserUltra violet light Electrical stimulation

Cold modalities/cryotherapie

Produce vasocontriction, it is effective in reduce fluid filtration and reduce the potential for oedema developVarious type of cold modalities are : ice bag, cold packs, ice massage Used during the inflamatory phase

Heat modalities Induces vasodilatation ; provides :

Increased blood supply Improved tissue oxygenation Stimulation of fibroblast Improved phagocytic activity

Used during inflamatory and fibroblastic phase Various type of heat modalities are :

Hot pack Infra red lampUltra sound Diatermis

Hydrotherapy Delivering superficial heat or cold to facilitate wound healing by immersing the affected limb in hydrotherapy tank filled warm or cold water Effect :

Removes necrotic tissue Soften the eschar Chauging local circulation Reduction patient perception of pain

Used during inflamatory phase

Ultra violet light Light of shorter wave length (180 – 250 nm) named ultra violet light C (UVC) is the type of ultra violet light most commonly used in facilitate wound healing Effect :

Politeration cell Release chemical mediators Stimulated local blood flow Bacteri cidal effect for :

• Methicillen Resistant Staphylococus Aureus (MRSA)• Vancomycin Resistant Entercocus Faecalis

Reduce carcinogenic effect of UVA – UVBUsed during inflamatory phase

Laser Effect therapi :

Leucoyte proliferatif Phagocytosis Increased collagen deposition Release inflamatory mediator (histamin)

Using in inflamatory and fibroblast repair phase

Ultrasound Effect therapy :

Stimulation phagocytic activity cells such as macrophay, neurtrophils Stimulating fibroblast

Using in inflamatory and fibroblast repair phase

Electrostimulation Effect :

Induce cell migration to the site of injury Release chemical mediators Induce inflamatory cell proliferative Reduce oedema Improved fibroblast and collagen deposition Activated epidermal cellImproved granulation tissue