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78 Part IV&Skin Care
SKIN PHYSIOLOGY
5. Which cell type is the most important in regulating promotion of growth factors and affecting wound healing?
C. Macrophages.
The macrophage is the most important regulator of growth factors in the wound-healing process. They are
the second in line to arrive on the scene, following neutrophils, in the acute inflammatory response (days
1
1–6).
REFERENCE
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 2014;133:199e
SKIN PHYSIOLOGY
6. A patient is told to stop smoking cigarettes 4 to 6 weeks prior to her upcoming breast augmentation surgery.
By having her stop cigarette use, what primary negative effect on wound healing are you trying to mitigate?
E. Peripheral microvascular vasoconstriction.
Although cigarette use has been shown to have a host of negative effects on wound healing, the primary
mechanism by which it is proposed to affect healing is by having negative effects on the inflammatory
phase of wound healing by causing peripheral microvascular vasoconstriction.
1,2,3,4
REFERENCES
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconstr Surg 2016; 138(3, Suppl):9S–17S
2. Coon D, Tuffaha S, Christensen J, et al. Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications. Plast Reconstr Surg 2013;131(2):385–391
3. Rinker B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg 2013;70
(5):599–605
4. Silverstein P. Smoking and wound healing. Am J Med 1992;93(1A):22S–24S
SKIN PHYSIOLOGY
7. Final scar healing strength will reach a maximum of 80% original strength by approximately __ days.
E. 90.
During the maturation phase (week 3 to 1 year) of wound healing, there is equilibrium between collagen
formation, deposition, and breakdown. Stronger cross-links are formed through increased collagen organization, as type I collagen replaces type III to revert back to the original 4:1 ratio. Finally, healing tensile
strength will begin to plateau, achieving a maximum of 80% of original strength by about 90 days from initiation of wound-healing process.
1,2,3,4,5
REFERENCES
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 2014;133:199e
2. Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith's Plastic
Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997
3. Levenson SM, Geever EF, Crowley, Oates JF 3rd, Berard CW, Rosen H. The healing of rat skin wounds. Ann Surg
1965;161(2):293–308
4. Madden JW, Peacock EE Jr. Studies on the biology of collagen during wound healing. I. Rate of collagen synthesis
and deposition in cutaneous wounds of the rat. Surgery 1968;64(1):288–294
5. Ireton JE, Unger JG, Rohrich RJ. The role of wound healing and its everyday application in plastic surgery: a practical perspective and systematic review. Plast Reconstr Surg Glob Open 2013;1(1):e10–e19
FACTORS AFFECTING WOUND HEALING
8. In which of the following skin conditions can surgical correction be beneficial?
C. Cutis laxa.
Cutis laxa may benefit from surgical correction. This originates from a nonfunctioning elastase inhibitor,
which leads to gradual degeneration of elastic fibers in the skin of those affected. The skin develops a coarse
texture, drooping all over the body. Although the condition slowly worsens over time, surgical correction
may still be indicated and can also be quite beneficial for patients with cutis laxa (unlike A, B, D, and E).
The primary treatment of Stevens-Johnson syndrome is stopping nonessential medications that may be the
Chapter 13&Anatomy, Physiology, and Disorders of the Skin 79
cause, supportive care with fluid management in addition to wound care, and antibiotics to control infection
if needed.
1,2
REFERENCES
1. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 2014;133:199e
2. Glat P, Longaker M. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, et al, eds. Grabb and Smith's Plastic
Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1997
FACTORS AFFECTING WOUND HEALING
9. Which of the following medications is associated with decreasing collagen synthesis?
E. Anti-inflammatory agents.
A thorough history of medication usage (recent past, present) is vital to understanding a patient's
potential for adverse wound healing. Anti-inflammatory drugs in particular have been associated with
decreasing the amount of collagen synthesis significantly, by about 45%. This can have a detrimental
effect on wound-healing properties of skin following aesthetic procedures. Thus, patients should be
counseled well before surgery to abstain for at least 2 weeks prior and after surgery.
1
REFERENCE
1. Fairweather M, Heit YI, Buie J, Rosenberg LM, Briggs A, Orgill DP, Bertagnolli MM. Celecoxib inhibits early cutaneous wound healing. J Surg Res 2015;194(2):717–724
SKIN ANALYSIS
10. How does treatment approach differ for static versus dynamic rhytids of the face?
D. Static rhytids can be treated with laser resurfacing, fillers, or surgery.
Static rhytids of the face appear at rest, without requiring facial expression muscle movement to
accentuate. These are best treated by laser resurfacing, filler injection, or (definitively) with surgery.
Dynamic rhytids, on the other hand, are accentuated with animation of facial expression musculature,
and thus respond well to neurotoxin treatment.
1
REFERENCE
1. Baker TJ, Stuzin JM, Baker TM, eds. Facial Skin Resurfacing. New York: Thieme Publishers; 1998
SKIN ANALYSIS
11. In determining aggressiveness of a melanoma, which of the following characteristics is most predictive of
staging and prognosis?
D. Depth >2 mm.
Breslow thickness (measurement of depth of invasion, superficial to deep) is the most important factor
in the staging and prognosis of melanoma-type skin cancer. Best prognosis is given for depth of <0.75
mm; the worst is classif ied by >4 mm of depth. Any depth between these values warrants a sentinel
lymph node biopsy. Although the other factors listed are important in the identification of melanomatype skin cancer, only the depth is used as a prognostic, staging tool.
1
REFERENCE
1. Langley RG, Barnhi llRL, Mihm MC Jr, et al. Neoplasms: cutaneous melanoma. In: Freedberg IM, Eisen AZ, Wolff K,
et al, eds. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York: McGraw-Hill; 2003
PHYSIOLOGY OF COMMON MEDICAL SKIN THERAPIES
12. A retired farmer presents with multiple, small, rough and scaly erythematous plaques on his face. Which of
the following is an appropriate initial course of action in treating this patient?
B. Topical 5-FU.
Actinic keratoses are rough, scaly, erythematous patches or plaques, often appearing on sun-exposed
areas such as the scalp, face, rim of ear, or dorsal upper extremity. They are considered premalignant
80 Part IV&Skin Care
lesions, as approximately 10% will eventually progress to squamous cell carcinoma, and 60% of
squamous cell carcinomas arise within an actinic keratosis. When multiple actinic keratoses are present,
it is often not practical to treat each spot individually. Standard of care includes either topical therapy
with 5-fluorouracil (5-FU) or topical imiquimod. Standard surgical excision in order to prevent
progression to cancer is also an accepted method of treatment. However, this is often reserved for cases
where it is difficult to tell if the lesion is an actinic keratosis or an earlycancer.
1
REFERENCE
1. Marks R, Rennie G, Selwood TS. Malignant transformation of solar keratoses to squamous cell carcinoma. Lancet
1988;1:795
PHYSIOLOGY OF COMMON MEDICAL SKIN THERAPIES
13. Which of the following potentially predisposing factors contributes most to a patient's increased likelihood
of developing malignant melanoma?
C. Family history of melanoma.
Among the options listed, none of the factors predisposes to melanoma development more strongly than
does a positive family history of melanoma. Another notable risk factor is patients with multiple atypical
nevi throughout their life.
1
REFERENCE
1. Langley RG, Barnhi llRL, Mihm MC, Jr, et al. Neoplasms: cutaneous melanoma. In: Freedberg IM, Eisen AZ,
Wolff K, et al, eds. Fitzpatrick's Dermatology in General Medicine. 6th ed. New York: McGraw-Hill; 2003
14. Cosmeceuticals and Other Office Products
Sammy Sinno, Michael E. Nissan
See Essentials of Aesthetic Surger y, pp. 191–196
CLEANSERS
1. Which of the following is true regarding high detergent surfactants?
A. They are most appropriate for patients with dry skin.
B. They may lead to barrier damage and inability of skin to hold water.
C. Compared with other cleansers, high detergent surfactants remove less skin surface sebum.
D. Cleansers based on sodium cocoyl isethionate are high detergent.
E. Synthetic moisturizers, such as syndets, are considered high detergent surfactants.
MOISTURIZERS
2. Which of the following moisturizers acts by drawing water from deeper skin layers to the dehydrated stratum
corneum?
A. Petrolatum.
B. Lanolin.
C. Mineral oil.
D. Dimethicone.
E. Glycerin.
MOISTURIZERS
3. A patient is seen in clinic for an itchy, erythematous perioral rash. He says that the rash appeared the day
after he began applying a new balm for increasingly chapped lips. Which of the following agents is the most
likely cause of this reaction?
A. Petrolatum.
B. Lanolin.
C. Mineral oil.
D. Dimethicone.
E. Glycerin.
ALPHA-HYDROXY ACIDS
4. Which of the following is an advantage of alpha-hydroxy acids such as glycolic acid and lactic acid?
A. Stimulates collagen synthesis.
B. Inhibits elastase.
C. Exerts antioxidant effects by preventing lipid oxidation, protecting the cellular membrane from free radicals.
D. Enhances exfoliation of the stratum corneum.
E. Regulates epithelial cell growth and differentiation.
SUNSCREENS
5. Which of the following is true regarding sunscreens?
A. UVA radiation causes sunburn.
B. Inorganic filters should be used with organic filters to prevent skin whitening.
C. Sunscreens prevent photoaging and reverse existing damage.
D. Paraaminobenzoic acid, salicylates, and cinnamates can be applied to prevent photoaging.
E. Zinc oxide and titanium dioxide are examples of organic filters.
82 Part IV&Skin Care
BOTANICALS
6. Which of the following compounds acts as a topical antioxidant that can improve photodamaged skin?
A. Soy.
B. Silymarin.
C. Retinol.
D. Curcumin.
E. Grape seed extract.
TREATMENT OF PIGMENTED SKIN
7. Regimens to treat pigmented skin should include a cleanser (such as glycolic acid) followed by a serum that
inhibits which of the following enzymes?
A. Tyrosinase.
B. Phenylalanine hydroxylase.
C. Homogentisate oxidase.
D. Tyrosine hydroxylase.
E. DOPA decarboxylase.
Chapter 14&Cosmeceuticals and Other Office Products 83
Answers
CLEANSERS
1. Which of the following is true regarding high detergent surfactants?
B. They may lead to barrier damage and inability of skin to hold water.
The active ingredients of cleansers are surfactants. Compared with low detergent surfactants that remove
less skin surface sebum, high detergent surfactants may remove skin surface sebum and intracellular lipids,
leading to barrier damage and dry skin. For this reason, patients with dry skin benefit from surfactants that
remove less skin surface sebum, such as cleansers based on sodium cocoyl isethionate. Synthetic
moisturizers would be considered low detergent surfactants as they remove less sebum; therefore, E is
incorrect.
REFERENCE
1. Draelos ZD. Active agents in common skin care products. Plast Reconstr Surg 2010;125:719
MOISTURIZERS
2. Which of the following moisturizers acts by drawing water from deeper skin layers to the dehydrated stratum
corneum?
E. Glycerin.
Glycerin is a humectant, a class of moisturizer that hydrates the stratum corneum by drawing water from the
dermis and epidermis below. Its action is mediated by regulation of aquaporin channels in the skin.
Petrolatum, lanolin, oils, and dimethicone are occlusive agents that act as barriers, physically reducing
transepidermal water loss.
1
1,2
REFERENCES
1. Friberg SE, Ma Z. Stratum corneum lipids, petrolatum and white oils. Cosmet Toilet 1993;107:55
2. Spencer TS. Dry skin and skin moisturizers. Clin Dermatol 1988;6:24
MOISTURIZERS
3. A patient is seen in clinic for an itchy, erythematous perioral rash. He says that the rash appeared the day
after he began applying a new balm for increasingly chapped lips. Which of the following agents is the most
likely cause of this reaction?
B. Lanolin.
Based on the location of the rash and the patient's history of application of a new skin product, allergic
contact dermatitis is the most likely diagnosis. The etiology is a delayed-type hypersensitivity reaction to
an antigen in the balm the patient applied to the lips. Although any product may potentially cause such a
reaction, lanolin, a derivative of sheep sebaceous secretions, is particularly associated with allergic contact
dermatitis.
1,2
REFERENCES
1. Friberg SE, Ma Z. Stratum corneum lipids, petrolatum and white oils. Cosmet Toilet 1993;107:55
2. Spencer TS. Dry skin and skin moisturizers. Clin Dermatol 1988;6:24
ALPHA-HYDROXY ACIDS
4. Which of the following is an advantage of alpha-hydroxy acids such as glycolic acid and lactic acid?
D. Enhances exfoliation of the stratum corneum.
Alpha-hydroxy acids comprise a wide variety of products, including glycolic acid, lactic acid, malic acid, citric
acid, and tartaric acid. Preparations are available for over-the-counter use or for in-office peel treatments.
They exert their effect by enhancing exfoliation of the stratum corneum, the keratinous outermost layer of
84 Part IV&Skin Care
the epidermis. Common applications include treatment of photodamage, hyperpigmentation, melasma, dry
skin, acne, and rosacea.
1
REFERENCE
1. Sinno S, Lee DS, Khachemoune A. Vitamins and cutaneous wound healing. J Wound Care 2011;20:287
SUNSCREENS
5. Which of the following is true regarding sunscreens?
B. Inorganic filters should be used with organic filters to prevent skin whitening.
Sunscreens are designed to absorb or reflect UVA and UVB radiation.
photoaging, while UVB radiation is responsible for sunburn. Examples of UVB filters include paraaminobenzoic acid, salicylates, and cinnamates—application of these agents aids in preventing UVB-induced
sunburn, but not photoaging, which is a sequela of UVA exposure. Although it is true that some sunscreens can prevent photoaging, they cannot reverse existing damage. Zinc oxide and titanium dioxide are
examples of inorganic filters, which should be used with organic filters to prevent skin whitening.
1
UVA radiation is responsible for
1,2,3
REFERENCES
1. Chatterjee L, Agarwal R, Mukhtar H. Ultraviolet B radiation-induced DNA lesions in mouse epidermis: an assessment using a novel 32P-postlabeling technique. Biochem Biophys Res Commun 1996;229:590
2. Duell EA, Derguini F, Kang S, et al. Extraction of human epidermis treated with retinol yields retro-retinoids in
addition to free retinol and retinyl esters. J Invest Dermatol 1996;107:178
3. Torras H. Retinoids in aging. Clin Dermatol 1996;14:207
BOTANICALS
6. Which of the following compounds acts as a topical antioxidant that can improve photodamaged skin?
C. Retinol.
Retinol is the naturally occurring form of vitamin A, and it acts as an antioxidant when applied to the
skin. On the skin, it is converted to retinoic acid, which improves photodamage. Soy increases collagen
synthesis, silymarin decreases the formation of DNA-damaging pyrimidine dimers, and curcumin acts as
a moisturizer. Although grape seed extract does act as a free radical scavenger, it has not been shown to
improve photodamaged skin.
1,2
REFERENCES
1. Duell EA, Derguini F, Kang S, et al. Extraction of human epidermis treated with retinol yields retro-retinoids in
addition to free retinol and retinyl esters. J Invest Dermatol 1996;107:178
2. Torras H. Retinoids in aging. Clin Dermatol 1996;14:207
TREATMENT OF PIGMENTED SKIN
7. Regimens to treat pigmented skin should include a cleanser (such as glycolic acid) followed by a serum that
inhibits which of the following enzymes?
A. Tyrosinase.
Treatment of pigmented skin is twofold; both a cleanser such as glycolic acid and a tyrosinase-inhibiting
serum/moisturizer such as kojic acid or hydroquinone are required. Tyrosinase inhibition hinders
pigmentation, as tyrosinase is the rate-limiting enzyme controlling the production of melanin.
1,2,3
REFERENCES
1. Friberg SE, Ma Z. Stratum corneum lipids, petrolatum and white oils. Cosmet Toilet 1993;107:55
2. Spencer TS. Dry skin and skin moisturizers. Clin Dermatol 1988;6:24
3. Aston SJ, Steinbrech DS, Walden JL. Aesthetic Plastic Surgery. Philadelphia: Saunders Elsevier; 2010
15. Ethnic Skin Care
Sammy Sinno, Michael E. Nissan
See Essentials of Aesthetic Surger y, pp. 197–201
ETHNIC SKIN
1. Which of the following characteristics is more applicable to ethnic skin rather than white skin?
A. Ethnic skin contains a higher concentration of melanocytes.
B. Ethnic skin contains more cell layers in the stratum corneum.
C. Ethnic skin has decreased lipid content.
D. Ethnic skin has decreased desquamation.
E. Darker skin provides increased photoprotection and low response to dermal injury.
FITZPATRICK SCALE
2. A patient is seen in clinic after returning from a tropical vacation. Her sun-exposed skin is visibly sunburnt,
and she states that though she is sometimes able to tan, she usually burns when she is exposed to sunlight.
Her skin is fair and white without freckles. Which of the following is the patient's Fitzpatrick skin type?
A. Type I.
B. Type II.
C. Type III.
D. Type IV.
E. Type V.
HYDRATION
3. Which of the following is characteristic of dry skin in ethnic populations?
A. Darker skin is associated with higher transepidermal water loss.
B. Dryness of skin layers confers lower predisposition for acne development.
C. Pigmented skin is more likely to camouflage the observable signs of dryness.
D. Pigmented skin has lower rates of stratum corneum shedding.
E. Dry skin is characterized by lower rates of inflammation, irritation, and hyperpigmentation.
HYPOPIGMENTATION
4. A 28-year-old woman is seen in clinic for a concerning new patch of depigmented skin on the left cheek. The
lesion is flat, 5 cm in diameter, and sharply demarcated. Other than autoimmune thyroid disease requiring
her to take exogenous thyroid hormone, she is healthy. Which of the following is the most appropriate
response to the patient regarding management of this lesion?
A. Excision with wide margins is necessary.
B. There are no interventions that can be taken at this time.
C. A biopsy of the lesion is necessary.
D. Referral for Mohs surgery.
E. Manage with phototherapy, immunomodulators, and topical steroids.
PIGMENTATION INHIBITORS
5. Which of the following pigmentation inhibitors acts by suppressing the formation of melanocytes?
A. Hydroquinone.
B. Kojic acid.
C. Lactic acid.
D. Retinoids.
E. Lanolin.
86 Part IV&Skin Care
ACNE
6. Which of the following is the most effective strategy for preventing postinflammatory hyperpigmentation in
darker-skinned individuals?
A. Topical clindamycin.
B. Topical retinoids.
C. Doxycycline therapy.
D. Initiating combination therapy only if signs of postinflammatory hyperpigmentation are identified.
E. Immediate treatment with topical clindamycin, topical retinoid, and benzoyl peroxide.
SUNSCREEN
7. A female patient of Northern European heritage who has a history of rosacea would like to know which is the
most appropriate sunscreen she should use and why?
A. An organic sunscreen is most appropriate, as it does not cause skin whitening.
B. An organic sunscreen is most appropriate, as it is less likely to exacerbate preexisting skin conditions such as
rosacea.
C. An inorganic sunscreen is most appropriate, as it does not cause skin whitening.
D. An inorganic sunscreen is most appropriate, as it is less likely to exacerbate preexisting skin conditions such
as rosacea.
E. Patients with rosacea should avoid using sunscreen.
HAIR REMOVERS
8. Which of the following is true regarding use of chemical depilatories?
A. Frequency of use of chemical depilatories is similar across ethnic groups.
B. Chemical depilatories are an alternative to shaving that do not cause irritation or postinflammatory
hyperpigmentation.
C. Chemical depilatories work by degrading disulfide bonds in the hair shaft.
D. Any active ingredient can effectively be used regardless of coarseness of hair.
E. Calcium thioglycolate and sodium thioglycolate are the most effective ingredients for removal of coarse hair.
Chapter 15&Ethnic Skin Care 87
Answers
ETHNIC SKIN
1. Which of the following characteristics is more applicable to ethnic skin rather than white skin?
B. Ethnic skin contains more cell layers in the stratum corneum.
Darkerpigmentationin ethnicskinisprovided by an increasedrateofmelaninproduction comparedwithwhite
skin. However, melanocyte concentration does not differ between skin types. The increased melanin does provide photoprotection;however,darkerskinis characterized by increasedreactiontotissueinjury,
hypertrophic scars and keloids. Ethnic skin is further characterized by increased lipid content, more cell
layers in the stratum corneum (22 layers in black skin versus 17 in white skin),2and a resultant increased
rate of desquamation.
REFERENCES
1. Reed JT, Ghadially R, Elias PM. Skin type, but neither race nor gender, influence epidermal permeability barrier
function. Arch Dermatol 1995;131:1134
2. Andersen KE, Maibach HI. Black and white human skin differences. J Am Acad Dermatol 1979;1:276
FITZPATRICK SCALE
2. A patient is seen in clinic after returning from a tropical vacation. Her sun-exposed skin is visibly sunburnt,
and she states that though she is sometimes able to tan, she usually burns when she is exposed to sunlight.
Her skin is fair and white without freckles. Which of the following is the patient's Fitzpatrick skin type?
B. Type II.
The Fitzpatrick scale was developed to classify skin by responses to UV light.
sition to sunburn, limited ability to tan, and lack of freckles, her skin is classified as Fitzpatrick skin type
II (Table 15.1).
1
Given this patient's predispo-
1
particularly
Table 15.1 Fitzpatrick Skin Type Classification
Skin Type Characteristics Sun Exposure History
I Pale white, freckles, blue eyes, blond or red hair Always burns, never tans
II Fair white, blue/green/hazel eyes, blond or red hair Usually burns, minimally tans
III Cream white, any hair or eye color Sometimes burns, tans uniformly
IV Moderate brown (Mediterranean) Rarely burns, always tans well
V Dark brown (Middle Eastern) Rarely burns, tans easily
VI Dark brown to black Never burns, tans easily
(Source: Data from Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol
124:869, 1988.)
REFERENCE
1. Odunze M, Cohn A, Few JW. Restylane and people of color. Plast Reconst Surg 2007;120:2011
HYDRATION
3. Which of the following is characteristic of dry skin in ethnic populations?
A. Darker skin is associated with higher transepidermal water loss.
Dryness in ethnic skin is partially attributable to increased transepidermal water loss. The resultant dry
skin is prone to cracks, which predispose the patient to develop acne. Another cosmetic concern related
to dryness in pigmented skin is stratum corneum shedding, which produces an ashy-appearing scale that
is difficult to camouflage on a pigmented backdrop. Additionally, there are higher rates of inf lammation,
irritation, and hyperpigmentation due to impaired barrier function.
1