FEATURE ARTICLE

Anatomy and Physiology
of the Skin
Paul A. J. Kolarsick, BS, Maria Ann Kolarsick, MSN, ARHP-C
Carolyn Goodwin, APRN-BC, FNP

INTRODUCTION Bclear[ dendritic cells by possessing intercellular bridges
The skin is the largest organ of the body, accounting for and ample amounts of stainable cytoplasm (Murphy,
about 15% of the total adult body weight. It performs 1997). The epidermis harbors a number of other cell
many vital functions, including protection against ex- populations, such as melanocytes, Langerhans cells, and
ternal physical, chemical, and biologic assailants, as Merkel cells, but the keratinocyte cell type comprises the
well as prevention of excess water loss from the body majority of the cells by far. The epidermis commonly is
and a role in thermoregulation. The skin is continuous, divided into four layers according to keratinocyte mor-
with the mucous membranes lining the body_s surface phology and position as they differentiate into horny
(Kanitakis, 2002). cells, including the basal cell layer (stratum germinati-
The integumentary system is formed by the skin and its vum), the squamous cell layer (stratum spinosum), the
derivative str uctures (see Figure 1-1). The skin is com- granular cell layer (stratum granulosum), and the corni-
posed of three layers: the epidermis, the dermis, and fied or horny cell layer (stratum corneum) (James et al.,
subcutaneous tissue (Kanitakis, 2002). The outer most 2006; Murphy) (see Figure 1-2). The lower three layers
level, the epidermis, consists of a specific constellation of that constitute the living, nucleated cells of the epidermis
cells known as keratinocytes, which function to synthesize are sometimes referred to as the stratum malpighii and
keratin, a long, threadlike protein with a protective role. rete malpighii (Murphy).
The middle layer, the dermis, is fundamentally made up of The epidermis is a continually renewing layer and gives
the fibrillar structural protein known as collagen. The rise to derivative structures, such as pilosebaceous appara-
dermis lies on the subcutaneous tissue, or panniculus, tuses, nails, and sweat glands. The basal cells of the epi-
which contains small lobes of fat cells known as lipocytes. dermis undergo proliferation cycles that provide for the
The thickness of these layers varies considerably, depend- renewal of the outer epidermis. The epidermis is a dynamic
ing on the geographic location on the anatomy of the tissue in which cells are constantly in unsynchronized mo-
body. The eyelid, for example, has the thinnest layer of tion, as differing individual cell populations pass not only
the epidermis, measuring less than 0.1 mm, whereas the one another but also melanocytes and Langerhans cells
palms and soles of the feet have the thickest epidermal as they move toward the surface of the skin (Chu, 2008).
layer, measuring approximately 1.5 mm. The dermis is
thickest on the back, where it is 30Y40 times as thick as Keratinocytes
the overlying epidermis (James, Berger, & Elston, 2006).
At least 80% of cells in the epidermis are the ectodermally
derived keratinocytes. The differentiation process that
EPIDERMIS occurs as the cells migrate from the basal layer to the
The epidermis is a stratified, squamous epithelium layer surface of the skin results in keratinization, a process in
that is composed primarily of two types of cells: keratino- which the keratinocyte first passes through a synthetic
cytes and dendritic cells. The keratinocytes differ from the and then a degradative phase (Chu, 2008). In the syn-
thetic phase, the cell builds up a cytoplasmic supply of
Reprinted with permission by the Oncology Nursing Society from Site keratin, a fibrous intermediate filament arranged in an
Specific Cancer Series: Skin Cancer. Muehlbauer, P & McGowan, C alpha-helical coil pattern that serves as part of the cell_s
(Eds). Chap 1: pp 1Y11. Copyright 2009, Oncology Nursing Society. cytoskeleton. Bundles of these keratin filaments converge
DOI: 10.1097/JDN.0b013e3182274a98 on and terminate at the plasma membrane forming the

VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 203

Copyright @ 2011 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited.

contains column-shaped keratinocytes that attach to the basement membrane zone with their long axis perpendic- ular to the dermis. cellular Overlying the basal cell layer is a layer of the epidermis organelles are lost.M. Squamous Cell Layer During the degradative phase of keratinization. which separates the basal from the basal layer to the cornified layer in humans layer of the epidermis from the underlying dermis (D). and D. and D. can increase the number of FIGURE 1-2. The three cycling cells in the epidermis by stimulating division of basic cell types in the epidermis include keratinocytes (some stem cells. 1997). are Basal Layer The basal layer. Epidermal stem cells in the basal layer are clonogenic cells with a long lifespan that progress through the cell cycle very slowly under normal conditions. Philadelphia: Elsevier Saunders.M. The basal layer is the primary location of mitotically active cells in the epidermis that give rise to cells of the outer epidermal layers. . (10th ed. mous layer is composed of a variety of cells that differ in The process of maturation resulting in cell death is known shape. From Andrews_ Diseases of the Skin: Clinical Dermatology takes at least 14 days. such as wounding. p. 2006). 4). p. also known as the stratum germinativum. 2006. 1982). intercellular attachment plates known as desmosomes. Copyright 2006 by days (Chu. Migration of a basal cell basement membrane zone.. and melanocytes (M ) in the basal layer. Cross-Section of Skin and Panniculus. Arrows point to the fect the rate of cellular division. However. 1997). 2008). Elston. 204 Journal of the Dermatology Nurses’ Association Copyright @ 2011 Dermatology Nurses' Association. not all basal cells have the potential to divide (Jones. Reprinted with permission. These basal cells form a single layer and adhere to one another as well as to more superficial squamous cells through desmosomal junctions (Murphy. James. Other distinguishing features of the basal cells are their dark-staining oval or elongated nuclei and the presence of melanin pigment transferred from adjoining melanocytes (Murphy). Hyperplasiogenic conditions. Copyright 2006 by Elsevier Saunders.D... Elsevier Saunders. James.D. by W. and subcellular properties depending on as terminal differentiation (James et al. The squa- and the cell finally is known as a horny cell or corneocyte. Three Basic Cell Types in the Epidermis. Unauthorized reproduction of this article is prohibited.G. the contents of the cell are consolidated that is 5Y10 cells thick and known as the squamous cell into a mixture of filaments and amorphous cell envelopes. layer or stratum spinosum (Murphy.FIGURE 1-1. structure. T. Berger. Lavker & Sun. by W.G. Note. their location. T. Philadelphia: Elsevier Saunders. and the transit through the corni. From Andrews_ Diseases of the Skin: Clinical Dermatology (10th ed. Berger. DNA damage caused by carcinogenic agents labeled K ) and Langerhans cells (L) in the Malpighian layer may mutate cell proliferation machinery and can also af. for example. Suprabasal spinous cells. fied layer to the outermost epidermis requires another 14 2006. Note. 1996. Elston. 1). Reprinted with permission.

1991. under thin maintain a relatively constant number of cells as well as cornified layer areas. 1997). Peluchetti. 2008). glycolipids. A very thin or absent granular the basal lamina and the underlying dermis. the adhesion between 10 times this thickness. phospholipids. The abun. in the production of Bsoft[ keratin in the epidermis by Lamellar granules are membrane-bound organelles con. Lysosomal enzymes present only in small amounts in tween the granular and cornified layers. flat. The physical and bio- (Chu. and they are necessary in the in part by the underlying dermis. well as throughout life (Haake & Hollbrook. cells in the middle these junctions allow for physiologic communication via have a much higher capacity for water-binding than the chemical signals that is vital in the regulation of cell deeper layers because of the high concentration of free metabolism. the interactions of the hands and soles of the feet the granular layer may be keratinocytes and immigrant cells. Enzymatic action of the keratohyaline granules results of the skin. they also function the stratum basalis and stratum spinosum are found at in cells of the upper spinous layer to deliver precursors of high levels in the stratum granulosum because the stratum corneum lipids into the intercellular space (Haake granular layer is a keratogenous zone of the epidermis. Unauthorized reproduction of this article is prohibited. Feingold. Adhesions between keratinocytes. 1993). The deep cells also are more densely compact and dis- play a greater array of intercellular attachments than the Granular Layer more superficial layers. including lipases. & Diaz.polyhedral in shape and have a rounded nucleus. is to the shedding of corneocytes during desquamation composed of flattened cells holding abundant keratohya. and a number of acid hydrolases. Williams. and contain lamellar granules (Chu. Scott. lipid content. & Diaz. Schwarz. The corneocytes. . polyhe- Lin. Murphy. in the regulation of the calcium required for desmo. whereas under the palms of cells. the dissolution of cellular organelles is prepared as Intercellular spaces between spinous cells are bridged the cells of the granular layer undergo the abrupt terminal by abundant desmosomes that promote mechanical cou. Hennings & Holbrook. Mascaro. 1999). 1977). providing periodic cutting of keratin filaments. In contrast. keratin filaments in the cytoplasm are bound to Cornified Layer desmosomal plaques at one end and remain free at the end Horny cells (corneocytes) of the cornified layer provide closer to the nucleus (Murphy. the granular layer may be only regulate the interactions and junctions between epidermal 1Y3 cell layers in thickness. The keratohyaline granules are deeply basophilic and Epidermal morphogenesis and differentiation is regulated irregular in shape and size. growth. 2008). These cells are respon- sible for further synthesis and modification of proteins THE REGULATION OF EPIDERMAL PROLIFERATION involved in keratinization (Chu. & Elias. and differentiation (Caputo & amino acids found in the cytoplasm of middle layer cells. the epidermis must overlying horny cell layer. 1997). The desmosomal mechanical protection to the underlying epidermis and a plaques are composed of six polypeptides found on the barrier to prevent water loss and invasion by foreign cytoplasmic side of the cell membrane that are important substances (Jackson. The large. which also plays a VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 205 Copyright @ 2011 Dermatology Nurses' Association. granules primarily are active in cells at the interface be. 2008). & Hollbrook. and the tonofibril filaments traversing the cell cytoplasm proteases. Liu. 1999). taining glycoproteins. Although the lamellar 1976. Organized concentrically around the nucleus. The spine. differentiation process to a horny cell of the cornified layer pling between cells of the epidermis and provide resistance (Chu. The granular AND DIFFERENTIATION layer varies in thickness in proportion to that of the As a perpetually regenerating tissue. 2008). 1983. line granules in their cytoplasm. Espana. 2008). which are rich in protein and low in somal assembly and maintenance (Fairley. dral-shaped horny cells have lost their nuclei during like appearance of the numerous desmosomes along cell terminal differentiation and technically are considered to margins is where the stratum spinosum derives its name be dead (Chu. sterols. become flatter as they are pushed toward the surface cells. lular lipid matrix (Chu. and the layer can lead to extensive parakeratosis in which the process of terminal differentiation to produce corneocytes nuclei of keratinocytes persist as the cells move into the must be regulated as cells relocate during development as stratum corneum. are surrounded by a continuous extracel- Goldsmith. Here. free the hair and nails do not contain keratohyaline granules. 1997). resulting in psoriasis (Murphy. mation moving outward. (Haake & Hollbrook. and glycosidases. Desmosomes undergo proteolytic The most superficial layer of the epidermis containing degradation as the cells progress outward. For example. 1997). acid phosphatases. will harden because of the incorporation of disulfide bonds. to physical stresses. Essentially forming an intercellular pore. dance of hydrolytic enzymes indicates that the lamellar producing Bhard[ keratin in those structures (Matoltsy. chemical properties of cells in the cornified layer vary in Gap junctions are another type of connection between accordance with position in order to promote desqua- epidermal cells. contributing living cells. Jensen. granules are a type of lysosome. the granular layer or stratum granulosum. For instance. 1979). 1999). whereas formation of both the interfibrillary matrix that holds cells of the upper spinous layers are generally larger in keratin filaments together and the inner lining of the horny size.

Terminal differentiation is a type of apoptosis evolved to convert the keratinocyte into the protective corneo- cyte (Haake & Hollbrook. Branching into more superficial layers. and outer root sheath of the bound melanosome complexes containing two or three hair follicle and are sometimes assembled into specialized melanosomes. . Sosis. which results in tanning of the into contact with keratinocytes but do not form cellular skin. from these complexes more rapidly in keratinocytes of 1994). regions of the oral cavity. The disruption of dynamic equilibrium maintaining constant epidermal thickness can result in conditions such as psoriasis. type I Melanosomes are moved to the end of the melanocyte mechanoreceptors located in sites of high tactile sensitiv- processes that lie closest to the skin surface and are ity that are attached to basal keratinocytes by desmo- transferred to keratinocytes (see Figure 1-3). This response. Melanocytes are responsible for the production protect genetic information in the nucleus from damaging of the pigment melanin and its transfer to keratinocytes. skin. Wyllie. p. the greater signal to the brain. and cytokines. increases the cell_s ability to absorb light and thus junctions. 4). slow-adapting. programmed cell death. whereas the dysregulation of apoptosis is often seen in tumors of the skin (Kerr. Thin arrows NONKERATINOCYTE CELLS OF THE EPIDERMIS point to the basement membrane zone between the epidermis and the underlying dermis (D).G. Portion of a Melanocyte From Dark Skin..critical role in the maintenance of postnatal structure and function. 1973. Heavily pigmented skin can tinocytes are stimulus enough to cause Merkel cells to be attributed to the greater production of melanosomes secrete a chemical signal that generates an action poten- in melanocytes. 1972). Note. From Melanocytes Andrews_ Diseases of the Skin: Clinical Dermatology (10th ed. James. thus higher tactile resolution and sensitivity. such as the ability to undergo apoptosis. the higher degree of melanization in each tial in the adjoining afferent neuron.D. which relays the melanosome. growth factors. The maintenance of a constant epidermal thickness depends also on intrinsic properties of epidermal cells. Elston. as is often the case in necrosis. 1997. membrane-bound organelle known as the melanosome via a series of receptor-mediated. these cells somes will aggregate toward the superficial side of the migrate to a suprabasal position in the epidermis early in 206 Journal of the Dermatology Nurses’ Association Copyright @ 2011 Dermatology Nurses' Association. T. Murphy. cells in certain regions such as the fingertips results in and the slower rate of melanosome degradation in com. extensions of the melanocyte come nucleus. Merkel cells are found in the digits. Melanosomes are indicated by broad arrows. In white somal junctions. FIGURE 1-3. apoptosis is important in developmental remodel- ing. Berger. regulation of cell numbers. The high concentration of Merkel amount of dispersion of melanosomes in keratinocytes. 1999). hormone-stimulated. by W. Copyright 2006 by Elsevier derived from the neural crest and confined in the skin pre. smaller and more densely packed receptive fields and parison to fair skin (Flaxman. Saunders. enzyme-catalyzed Merkel Cells reactions (Haake & Hollbrook. Langerhans Cells crease in melanogenesis and a corresponding increase in Langerhans cells are involved in a variety of T-cell re- melanosome transfer to keratinocytes where the melano. & Van Scott. these melanosomes are aggregated into membrane. & Currie. sponses. and D.M. 1999). Olson. Derived from the bone marrow. Apoptosis follows an orderly pattern of mor- phologic and biochemical changes resulting in cell death without injury to neighboring cells. virus-infected. In the skin. whereas melanosomes tend to be removed structures known as tactile discs or touch domes (Moll. 2006. 2008). 1970). and defense against mutated. Nordquist. pigment-synthesizing cell Philadelphia: Elsevier Saunders. Melanin is produced in a rounded. This major homeostatic mechanism is regu- lated by a number of cellular signaling molecules in- cluding hormones. lips. Merkel cells are oval-shaped. Relatively small deformations of adjoining kera- individuals with dark skin. or otherwise damaged cells. radiation. Increased ultraviolet light exposure stimulates an in. Reprinted with permission. Unauthorized reproduction of this article is prohibited. The melanocyte is a dendritic. The epidermal-dermal interface is also a key site in the development of epidermal appendages. the larger size of melanosomes. & Everett. dominantly to the basal layer (Chu.

(Murphy. In the portion. Cells activator of naBve T cells. such as the back (James et al. 2008). Jassim. cornified layer. on the myoepithelial cells and form intercellular canaliculi Aumailley.. the Langerhans cells are weak stimula- (James et al. duct opens into pilosebaceous follicles. The sweat glands originate as a band of epithe- Langerhans cells must recognize and process soluble lial cells growing downward from the epidermal ridge antigens found in epidermal tissue. 1997). 2006. Langerhans cells constitute 2%Y8% of pilosebaceous units. Apocrine sweat glands in humans are confined mainly to the regions of the axillae and perineum. reepithelialization occurs more rap- the total epidermal cell population and maintain nearly idly after injury in these areas than in areas with fewer constant numbers and distributions in a particular area of adnexal structures. the body. Spurr. After secretory coil of apocrine glands. Unauthorized reproduction of this article is prohibited. EPIDERMAL APPENDAGES and unlike eccrine and apoeccrine glands. and the coiled secretory duct (see Figure 1-1) first stage of life. 2006.. the intraepithelial appendages.. Mauro & Goldsmith). Clear cells rest either on the basement membrane or but to a lesser extent (Gayraud. and functions Whereas eccrine glands are primarily involved in thermal as a semipermeable barrier between layers (Stepp. Hopfner. they do not The skin adnexa are a grouping of ectodermally derived open directly to the skin surface. Masunaga et al. 1990). The straight dermal segment connects THE DERMAL-EPIDERMAL JUNCTION the superficial spiral duct to the inner secretory portion of the gland. thereby resulting in the extremely 1992). Wheelock & Jensen. provides developmental signals. which phagolysosomes in the cytoplasm containing hydrolytic are the intraepidermal spiral duct.. Basal keratinocytes are the cells. 1997. entering in the ducts. The plasma membranes of basal cells are attached hypotonic solution that is emitted onto skin surface to the basal lamina by rivet-like hemidesmosomes that through the intraepidermal spiral duct. Tisdale. The contents of these granules are delivered to three composite parts of the eccrine sweat unit. This includes of sweat in response to a thermal stimulus. and myoepithelial cells specialized in contractile most important components of structures of the dermal- properties (James et al. The canaliculi open directly The basal lamina is a layer synthesized by basal cells of into the lumen of the gland (Mauro & Goldsmith). the darker mucoidal cells in the secre- well as the lamina densa (Aumailley & Krieg. The interface between the epidermis and dermis is formed The secretory coil of the eccrine unit lies deep in the by a porous basement membrane zone that allows the dermis or within the superficial panniculus and is com- exchange of cells and fluid and holds the two layers posed of glycogen-rich clear secretory cells. including the oral and are most abundant on the soles of the feet and least cavity. The dermal-epidermal junction acts as support for the epidermis. apocrine glands are involved in scent release Michaud. lium. The cells are epithelium to the surface of the epidermis. dermal fibroblasts are also involved 2008). Mauro & Goldsmith. Initially an an electron-lucent zone known as the lamina lucida as isotonic solution. 1996. and the corneo- antigen will not trigger phagocytosis but rather will cytes produced ultimately will become part of the stimulate cell migration (Udey. activation via contact with the undergo cornification within the duct. cell granules structure is modified during development to generate the are formed. from sweat in the duct. organs and in the normal dermis (Chu. This response pro- distribute tensile or shearing forces through the epithe- motes cooling while conserving sodium (James et al. once the cell has become an effective dermal duct cells that have migrated upward. the cells mainly are distributed among the squamous and granular layers with fewer cells Eccrine Sweat Glands in the basal layer. directs the organization of the cytoskeleton in Apocrine Sweat Glands basal cells. regulation. and vagina. They are found in other squamous Eccrine sweat glands are involved in the regulation of heat epithelia in addition to the epidermis. & Bruckner-Tuderman. dark mucoidal together (James et al. infundibulum above the sebaceous duct. Instead. Later.. which is normally located injury. epidermal junction. Sato & Dobson. all adnexal structures are capable of reepithelial. Because areas dendritic and do not form cellular junctions with such as the face and scalp contain a large quantity of neighboring cells. 2006). In the epidermis. bound antigen is ingested via endocytosis. or ductal. Lin tory coil and in the dermal duct actively reabsorb sodium et al. including eccrine and apocrine glands. This tubular.embryonic development and continue to circulate and ization via the migration of keratinocytes from adnexal repopulate the epidermis throughout life. differs from that of eccrine VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 207 Copyright @ 2011 Dermatology Nurses' Association. 2006).. 1997). as well as in lymphoid plentiful on the back (Murphy. entirely in subcutaneous fat. where two clear cells adjoin. and pilosebaceous units that originate as down. esophagus. When a membrane- (Mauro & Goldsmith. the epidermis consisting mainly of type IV collagen as well glycogen-rich inner epithelial cells initiate the formation as anchoring fibrils and dermal microfibrils. establishes cell polarity and direction of growth. The spiral tors of unprimed T cells but are able to ingest and process duct opens onto the skin surface and is composed of antigens. 1997). the straight dermal enzymes similar to those found in macrophages. 2008). 1996. 1997. 1970). Large. The basal growths from the epidermis during development. Elwell. .). & Gipson.

well as the hair bulb. but each hair follicle forming the hair cone and later the hair. is thought to contain epithelial The apoeccrine sweat gland (AEG) develops during pu. another bud develops into an attach- in humans. the hair. and opening to the surface prior to the time tions and become active just before puberty. The proteina. and the region between the sebaceous duct and eccrine glands. Bulfone-Paus. 1999. The AEG has a secretory rate as much as 10 times that of 2006). 2008). Like segment. matrix cells.). 2006). 1999). The arrector pili (AP) apocrine sweat have made it impossible to determine the are a smooth muscle bundle that attaches to the external exact chemical composition of the secretion (Mauro & root sheath of the follicle. Zhou. 2006). 1970a). Hashimoto. and forming a bulb around the group of mesenchymal Aging causes a loss of melanocytes and a corresponding cells from which the dermal papilla is formed (James decrease in the production of melanosomes and results in et al. but they all (James et al. The distal end of the AP mus- Goldsmith. The bulge.). The Cotsarelis. 1995). cle shows multiple branches at the level of the papillary dermis. & Fuchs. tend to have larger melanosomes than Caucasians. the skin. graying hair (James et al.. Hair follicles whereas the infundibular and isthmus portions remain Hair has many valuable biologic functions including permanently (James et al. the follicle functions as an independent unit.. Paus. which is the zone of the AP muscle_s Apoeccrine Sweat Glands follicular attachment. 1997. Discovered during the isolation of human 1990). Rapidly proliferating cells in the hair bulb. People of African descent mesenchymal cell sites are induced to grow at a down. & Grosschedl. The hair bulb contains melanocytes embryogenesis (James et al. a crucial berty from eccrine-like precursors. AP attachment is known as the isthmus (James et al. The sebaceous gland forms from a bud in the fetal hair tion as a territorial marker. epidermis. The number and distri. 2006). the AEG is found in the adult axillae. 2008).. it has an important psycho. ceous. a response that the growing hair cone reaches the upper follicle induced presumably by hormonal signals. Unauthorized reproduction of this article is prohibited. Red hair contains spherical melanosomes.. facial. Differentiation cell cycle is composed of three stages: anagen. Mesenchymal cells in the fetal dermis Hair color is determined by the distribution of melano- aggregate below the basal layer of the epidermis during somes in the hair shaft. Hair follicles vary considerably in hair shaft as well as the inner and outer root sheaths size and shape. St-Jacques et al. Differentiation occurs at the lower portion of the Hair growth occurs in a cyclical manner. also occurs in the upper segments of the follicle pro- no ductal cells are present (Murphy). The region below the isthmus is known as the the eccrine gland and is therefore thought to contribute to inferior portion and contains the bottom of the follicle as axillary hyperhidrosis (Mauro & Goldsmith. no extra follicles are added after birth enter the rigid inner root sheath (see Figure 1-4).. whose ward angle into the dermis (Murphy.glands in that it is composed exclusively of secretory cells. but its sexual functions may now be vestigial sebaceous gland. number of cells entering the sheath determines the size of 1996. forms above the plane of the sebaceous gland and de- a condition characterized by abnormally increased rates of velops into the apocrine gland. oval. Dull. Both the hair shaft and the inner have the same basic structure. 1997). stem cells responsible for regenerating follicles. its above the sebaceous gland is known as the infundibular relative frequency varies from person to person. Millar. viscous secretion has distinct odor and can func. and the two inner root sheaths. The basophilic cells that synthesize melanosomes and transfer them to the in the basal cell layer of the epidermis overlying these keratinocytes of the bulb matrix. causing their hair to be curly (James et al. 2006). & Eichmuller. 1998. 1997. the AEG opens directly to the skin surface.. 1970b). phenotype of each hair is established during fetal de. are responsible for the production of the social role in society. depending on their location. In addition. through the Apocrine sweat glands develop their secretory por. 208 Journal of the Dermatology Nurses’ Association Copyright @ 2011 Dermatology Nurses' Association. Difficulties in acquiring pure samples of ment for the arrector pili muscle. and sexual follicle. Scalp hairs on people of African descent also are the morphogenesis of the follicles (Paus & Cotsarelis. the hairs on the scalp of particular spacing and allocation of the follicles are Caucasians are round while pubic. Byrne. & Lavker. root sheath progress upward as the hair grows until the bution of hair follicles over the body and the future inner sheath reaches the isthmus and sheds (James et al. The inferior segment undergoes cycles of involution and regeneration throughout life. Foitzik. called gland products. The region of the follicle perspiration. catagen.. St-Jacques root sheath determine the shape of the hair (Paus & et al. The follicle smaller melanosomes are amassed into membrane-bound continues to develop until finally widening at the base complexes. Paus & Cotsarelis. Farinas. and eyelash hairs determined by genes that are expressed very early in are oval. Galceran. ducing the hair canal in the upper dermis. Jacobs. and the dimensions and curvature of the inner Welker. Along the same side of the follicle but below the attractant. . warning signal. Matrix cells moving up the follicle are compressed as they velopment. Sun. protection from the elements and distribution of sweat. For example. On the opposite side of the follicle. (Hashimoto. opening directly unto role in the hair growth cycle (Cotsarelis.). The (Kratochwil. The hair growth cuticle. a third bud axillary sweat from patients with axillary hyperhidrosis.

G. Except for rare congenital hair defects caused by muta- and telogen (see Figure 1-5) (Millar. The resting phase. during which hairs grow at a rate of about 0. 1997. and D. tions in keratins or other structural proteins and scarring St-Jacques et al. 1994). for example. thyroid hormones. Elston. both are produced by the dermal papilla and have recep- tors pre-dominantly in overlying matrix cells (Danilenko. retinoids. The length of the anagen phase decreases with age vary depending on a number of different physiologic and decreases dramatically in individuals with alopecia factors. Sawaya. 2006. causing most body hair to be shorter and remain in place for longer periods of time (James et al.M. . 1998). hair loss and unwanted hair growth reflect typically lasts approximately three to five years on the deviations of hair follicle cycling and.. by during adolescence.M.. 9). Unauthorized reproduction of this article is prohibited.. T. Anagen. lasts about three to five months on the scalp. Hair Follicle Structure. however. the active growth stage. Note. Elston.D. Philadelphia: Elsevier Saunders.. by W. glucocorti- coids. they can cause W. VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 209 Copyright @ 2011 Dermatology Nurses' Association. 1996). Note. Pregnancy. p. 1996. In mice. Reprinted with permission. 2006). T. which act through androgen receptors in the dermal papilla. The hor- mones with the most impressive effect are the androgens: testosterone and its active metabolite. often results in a pro- (James et al. longation of the telogen phase and an increased number FIGURE 1-5. are con- scalp. p.33 mm sidered reversible events (Paus. Philadelphia: miniaturization of follicles in the scalp resulting in an- Elsevier Saunders. and hairs in this stage are eventually pushed out by the growing anagen hair shaft. Berger. 1996)..G. These hormones increase the size of hair follicles FIGURE 1-4. 2006). & Pierce. James. alopecias. Other sites on the body tend to have shorter anagen and longer telogen phases. Copyright 2006 by Elsevier Saunders. 8). 1996. prolactin. telogen. Phases of Hair growth. From Andrews_ in androgen-dependent areas such as the beard area Diseases of the Skin: Clinical Dermatology (10th ed. 2006. dihydrotestosterone. Two secreted molecules that may have important roles in hair follicle development and cycling are the insulin-like growth factor 1 and fibroblast growth factor 7.D. Paus. Re. Later in life. and D. James. Berger. and growth hormone. Copyright 2006 by Elsevier Saunders. Ring. From Andrews_ Diseases of the Skin: Clinical Dermatology (10th ed. therefore. drogen alopecia (male pattern baldness) (Kaufman. The hair cycle can per day. printed with permission. Hormonal factors controlling hair growth include estrogens. Catagen usually lasts about two weeks and is a period of involution resulting in club hair formation after many cells in the outer root sheath undergo apoptosis.

A major structural protein for sensation. hydroxyproline. collagen is found in tendons. . like melanocytes. 2008). enhance tinct types in human skin. underlying nail bed is part of the nail matrix containing the lining of bones. in adulthood (James et al. Loosely positioned collagen dates stimulus-induced entry by nerve and vascular fibers are found in the papillary and adventitial dermis. and allow small objects to be grasped. 2005. and the shoulders. toenails can provide and replaced by new fibers. By the 12th week. with the regions collaborate during development in the morpho- exception of any metabolic or nutritional deficiency genesis of the dermal-epidermal junction and epidermal (Headington. filamen. The principal component of the dermis is collagen. also vary lip. Paus & Cotsarelis. chest. Collagen fibers exist in a constant state of flux. remodeling in normal skin. and they assemble into collagen fibrils. 2006). abundant proteins in the body. Unauthorized reproduction of this article is prohibited. It anagen or telogen is known as telogen effluvium and is protects the body from mechanical injury. Infant dermis is direct contact with the birth canal including the vertex. Many jaw line. degraded by proteolytic enzymes called spare collagenases Because of the slow growth rate. Thiboutot. derive hair follicle. ligaments. binds water. epidermally derived appendages. and in 2006).of scalp hairs in the anagen phase. which are the precursors of via the sebaceous duct. a Nails fibrous family of proteins with at least 15 genetically dis- Fingernails provide protection to the fingertips. Regrowth typically follows. play a role in maintaining elasticity but do keratinocytes (James et al. specific helical polypeptide chain. The matrix components. but few persist arms posteriorly (Danby. elastic fibers. The amino acids glysine. enter the dermis in response to various stimuli as and this great quantity of telogen hairs will be lost in well. Fibroblasts integrate the procollagen molecule. the cell secretes tation across all nail plates known as Mees lines (Daniel the fibroblasts. whereas the adult anterior scalp over the forehead and nose to the lower dermis contains thicker bundles of collagen. fibroblasts. telogen hairs are lost while including lymphocytes. and also is associated with sensory stimuli. 1999). cytes. 1997). Elastic fibers.. months in the past (James et al. being two to three times faster than the rate of toenail growth. the dermis is type I collagen. Then. and collagen. but the structure and organization and scalp but are present on nearly all other locations of of the connective tissue components are predictable in a the body with the exception of the tarsal plate of the depth-dependent manner. Other blood-borne cells. and mast cells. Cells of the sebaceous glands contain abundant response to external stimuli (Chu. lubrication during the passage through the birth canal. surgery. fibroblasts are actively to be evolutionarily important in providing a secondary synthesizing reticulum fibers.1 mm per day. anemia. whereas hefty collagen bundles are noted in the reticular 210 Journal of the Dermatology Nurses’ Association Copyright @ 2011 Dermatology Nurses' Association. such as childbirth. 2006). and tensile strength. The dermis comprises the bulk of the skin and three to five months. Until the sixth week of fetal life. appendages and interact in repairing and remodeling the skin as wounds are healed. 2006). endocrine disorders. which are then dermis is merely a pool of dendritic-shaped cells full of expelled into the infundibular segment of the hair follicle acid-mucopolysaccharides. The sebaceous glands are thought fibroblasts. and includes receptors of weight loss. 2006). and other leuko- anagen hairs simultaneously are converted to telogen. a arsenic poisoning may cause a horizontal hypopigmen. and the dermis. on the rete ridges. and melanocytes and has parallel stress-resistant material of the skin. and hydroxy- lysine highly enrich collagen. often observed after trauma. composed of small collagen bundles. & Scher. and upper aspect of fibroblasts are present in the infant dermis. the prepuce and mucosa lateral to the penile frenulum. The nail plate is formed from matrix other hand. equilibrate after delivery. very little to resist deformation and tearing of the skin. and the female areola (James et al. the lobule give rise to the lipid-filled cells. For example. 2006). Collagen represents 70% of information about toxic exposure or disease from many the skin_s dry weight (James et al. plasma cells. lipid droplets known as sebum in their cytoplasm and The constituents of the dermis are mesodermal in ori- are arranged into lobules off the upper segment of the gin except for nerves. The synchronous termination of provides its pliability. and severe stress. 1993. When estrogen levels macrophages.. Fingernails grow at an average rate of 0. A vascular network develops and fat cells have appeared This extra lubrication covers the surfaces that come in beneath the dermis by the 24th week. The dermis does not undergo Sebaceous Glands an obvious sequence of differentiation that parallels epi- Sebaceous glands are found in greatest number on the face dermal differentiation. which. networks. in- eyelids. The dermis interacts with the epidermis drugs.. and malnutrition in maintaining the properties of both tissues. in pathologic processes. Collagen is a major blood vessels. elasticity... The fibrillar collagens found THE DERMIS in the skin comprise the major group and are the most The dermis is an integrated system of fibrous. The major constituent of tous. 2004).. aids in thermal regulation. The the entire body. The two (James et al. in a depth-dependent manner and undergo turnover and the labia minora. Basaloid germinative cells surrounding the from the neural crest. nerves. and amorphous connective tissue that accommo. the buccal mucosa and vermilion borders of the cluding collagen and elastic connective tissue.

1972. & Kenney. They also are found commonly the preoptic-anterior hypothalamus (Boulant. Different configura- anchoring fibrils is collagen type VII. The deeper plexus dance on the hands. bone marrow and distributed in connective tissues Schuman. with greatest concentration in the is supplied by larger blood vessels and is more complex fingertips. During exposure to cold. which is produced tions make up small bundles of smooth muscle of the primarily by keratinocytes (James et al. . The superf icial muscular apo- minor component of the normal dermis but is the major neurotic system is an intricate network of muscle. and certain cytokines (Murphy. Flanders. hepa- (Murphy. pilorum are located in the connective tissue of the upper 1997). throughout the body. The cell_s surface contains hundreds of thousands dermis and are attached to the hair follicle below the of glycoprotein receptor sites for immunoglobulin E.dermis. or angular distinguishes smooth muscle from striated muscle membrane-bound structures containing histamine. Vasodilation and increased skin blood flow. impairments in cutaneous vascular sweat secretions. together with arterioles and venules. They regulate body The fibroblast fuses elastic fiber to the extracellular temperature and shunt blood (James et al. Upon magnification.). They are situated at such an angle to the Type I or connective tissue mast cells are located in the hair follicle that when contracted. on the other hand. Meissner corpuscles occur in greater abun- and venules of the superficial plexus.. espe- tunica dartos of the external genitals. & Lumpkin. muscularis of veins and arteries.). contraction of AP muscles of hair follicles. Glomus bodies are spe- The elastic fiber differs both structurally and chem. are nicating plexuses: the subpapillary or superficial plexus found in great quantity in neurovascular bundles of the composed of postcapillary venules found at the junction dermis (James et al. temperature. Type II or mucosal mast cells are VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 211 Copyright @ 2011 Dermatology Nurses' Association. and the major structural component of Bgooseflesh[ (James et al. oval. cialized aggregates of smooth muscle found between the ically from collagen and consists of two components: arterioles and venules. end arterioles. contribute to the increased incidence of heat stroke and heat exhaustion during periods of elevated external Mast Cells temperatures. The location of the nucleus in the cells reveal numerous large and long villi at their center of the muscle cell and the absence of striation periphery. Nicholas. organs that generate a sense of pressure and are located Blood flow in human skin fluctuates signif icantly in in the deeper portion of the dermis of weight-bearing response to thermal stress because of the regulation of surfaces and genitalia. and the areolas cially postcapillary venules. in the subcutaneous fat (Chu. the hair follicle is pulled dermis and submucosa. they also are present Deaver. numbers in the papillary dermis. 2006). The fibers are fine in the papillary dermis the neck as platysma and in the skin of the face as and coarse in the reticular dermis. eral aspects of the palms and soles. fascia. For example. Vater-Pacini corpuscles are large nerve-end surrounding adnexal structures. help to mediate touch and are plexus at the dermal-subcutaneous interface. Nerve bundles. are mediated by control noted in patients with type II diabetes may cholinergic fibers (James et al. 1999. serine proteinases. 1997). matrix of the dermis. 2006). 2000). Altered control of adrenergic fibers of the autonomic nervous system. and feet.. mast around the nipples. sebaceous glands. Tankersley. Mikita. mast cells appear as oval to spindle-shaped cells Muscles with a centrally located round to oval nucleus. Hyaluronic acid is a muscle of expression. which exist on the digits and lat- protein filaments and elastin. deforming the skin and causing membrane zone. The der. Although present in greatest McGeehin. 2006). Vasculature Nerves The dermal vasculature is made up of two intercommu. 2006). Meissner corpuscles. which is composed of glycosami. an amorphous protein. 1992). Eccrine 2003). 2008). Similarly.. In the normal dermis. vasoconstriction in the skin decreases heat loss from Vasoconstriction is regulated by the postganglionic the body to prevent hypothermia. Striated or voluntary muscle is found in the skin of noglycans. 2006). found of the papillary and reticular dermis and the lower in the dermal papillae. Numer- Involuntary or smooth muscle of the skin occurs as AP. Unauthorized reproduction of this article is prohibited. in the nipple and anogenital region.. Pain. found predominantly on the ventral sides of the hands mal papillae are supplied by capillaries. Type IV collagen is found in the basement into a vertical position. along with and itch sensation are transmitted by unmyelinated sweating. papillary dermis (James et al. McCullough. Semenza. This skin blood flow can considerably impair the ability to system regulates the apocrine gland secretions and the maintain normal body temperature (Charkoudian. are crucial to heat dissipation during heat nerve fibers that end around hair follicles and the exposure and exercise. mucopolysaccharide that accumulates in pathologic and aponeuroses connecting muscles with the parts that states (James et al.. menopausal hormones result in Mast cells are specialized secretory cells derived from the occurrence of hot flashes (Brooks et al. 2006).. The muscle fibers of the arrectores rin. 1997. ous mast cells are located around blood vessels.. they move (James et al. Mast cell granules are round.

(2003). E. Katz. (1997). R. L.. Hormone conversion takes place in epithelial basement membranes using GDA-J/F3 monoclonal antibody. O_Gorman. R. C. & Van Scott. (1970a). allergic response.. 26(4). and innate immunity. (1997). histology and immunohistochemistry of exposed to physical and chemical damage result in the normal human skin. (1996). A. M. A. D. 70Y111). A.. . Wladkowski. In R. R. I. G. LeF1 expression is activated by BMP-4 and regulates inductive multifunctional molecules of basement membranes. In K. 603Y612. Role of the preoptic-anterior hypothalamus in located in the respiratory tract mucosa and in the bowel thermoregulation and fever. Feingold. J. defense. T. regulates body weight by way of the hypothalamus (James S. 12(4). Jackson. Label-retaining cells reside in the bulge of the pilosebaceous unit: Implications for follicular inflammatory response. Collagen and elastic filaments of the der. proteases. K. Chronic hormone proliferation. European Journal of Dermatology. Goldsmith. surgery (2nd ed. M. (James et al. H. 158(3). (1996). In I. & R. Hopfner.. L. Isolation and characterization of human epidermal stem cells. 460Y467. (1990). The structure and development of skin. Journal of Investigative Dermatology.). (1977). Dull. leukotrienes. & Grosschedl. Nail changes secondary to systemic atherosclerosis. A. asthma. Molecular Embryologically. K. L. Farinas. diagnosis. 209Y214. Ajitawi. K. septa made up of large blood vessels and collagen. converting androstenedione into estrone Journal of Biological Chemistry. Clinical Science. differentiation. M. compared with other types of cancer. superoxides. M. Aumailley. The junctions of normal human cells also may be capable of regulating inflammation. A. duces a protective outer layer of corneocytes as cells Hennings. information. host epidermis: A freeze-fracture study. Therapy. Overview of biology. (2005). R. the panniculus. Telogen effluvium: New concepts and review. K. and many cytokines and chemo. Skin blood flow in adult human thermo- activation by antigens or allergens acting via the high. J.. The dynamic epidermis continually pro. & Pierce. (1973). and why.. Wolff.. K. J. & Elston. 238(4). B. and lipoproteins. S157YS161. S. S. Daniel. h Kerr. K.. K. F. the subcutaneous tissue 321Y326. 91(2). skin: Clinical dermatology (10th ed. G. T. Hashimoto. Boulant. D.. R. drugs and ingestants. G. Williams. T. et al. D. A.. Freedberg. toward the end of the fifth month fat Medicine Today. M. 2006). A. Cell. Why we have sebaceous glands. com. Androgen metabolism as it affects hair growth in androgenetic alopecia. D. & Scher. more recent studies suggest that these Caputo. I. & Lavker. L. (1970b). Goldsmith.. & Currie. 60(5). Paller.. melanosome distribution in Caucasoid skin following topical applica- tion of nitrogen mustard. (1996). N... 83(2). F. A. K. Experimental Cell Research. Journal of Applied Physiology. (2000). 1071Y1072. Leffell (Eds. A. 2(11).).. 315Y322. J. M. Genes and tigative Dermatology. J. et al. cells begin to develop in the subcutaneous tissue. (1997). Hair germ- SUMMARY mesenchyma interaction. By virtue of their location and stem cells. role in many conditions such as allergy. pp.. 129(3). A. Wolff. M. 697Y711. 333Y345. T. M. Philadelphia: Elsevier Saunders. K.. (1999). H. (5th ed. D. Pierzga. The ultrastructure of the skin of human embryos external environment. These mediators may be pivotal to the genesis of an Cotsarelis. Jassim. & Holbrook. W.). C. S. Mast cells can undergo 61(1). and structure of skin. B. 83(1). Goldsmith. 31(Suppl. and failure of apoptosis when replacement therapy alters thermoregulatory and vasomotor function mastocytosis occurs.. a hormone that Haake. Development.. 44Y61. homeostasis.). S. 2006). J. Sun. The three layers of the skin form an effective barrier to the Hashimoto. 279Y285. & Chi. Laminins: A family of diverse (1996). when it does not. These Fairley. Characterization of a 50-kDa component of storehouse of energy.. H. whereas the layer of subcutaneous fat provides a James.. affinity receptor for immunoglobulin E. Sosis. (1983). (1993). J. allow the transmission of sensory IX: Formation of the hair cone and intraepidermal hair canal. C. 14(4). Journal of the American Academy of Dermatology. 9531Y9538. Growth factors and SUBCUTANEOUS FAT cytokines in hair follicle development and cycling: Recent insights from animal models and the potentials for clinical therapy. Scott. A. when it works. New York: McGraw-Hill. plement proteins. Dermatologic Clinics. British Journal of Cancer.. (1972). Journal of Clinical Investigation. development. After Chu. Changes in panniculus varies in thickness depending on the skin site. British Journal of Dermatology. mast cells express histamine. medicine (7th ed. & Bruckner- Tuderman. tissue interactions in tooth and hair development. Berger. 1329Y1337.. New York: McGraw-Hill. Jensen.. 390Y401. D. (2002). 61(7). regulation: How it works. Galceran. 52(6). 141Y146. Unauthorized reproduction of this article is prohibited.. K. A. P. Katz. 2006). L. Aumailley. 251Y258). pp. by aromatase. Gilchrest. & Krieg. D. general and the fact that this tissue is most frequently Kanitakis. A. A. B. mediator expression. Morgan. (1993). hair cycle. P. 239Y257. Mast cells accumulate in the skin because of abnormal Brooks. mal layer provide the underlying tensile strength of the Pathobiology of the stratum corneum. A. 10(11).. A. J. Charkoudian. D... 356Y363. J. & Diaz. Nails: and arthritis (Krishnaswamy. Ring. Eisen. M. (1996). Austen. pp. R. M. Scher.. Journal of Inves. activation. L.. Archives of Dermatology. 212 Journal of the Dermatology Nurses’ Association Copyright @ 2011 Dermatology Nurses' Association. Mayo Clinic Proceedings. 143(1). A. The ultrastructure of the skin of human embryos V: The hair germ and perifollicular mesenchymal cells. G. B. The Flaxman. Fitzpatrick_s dermatology in general prostanoids. Western Journal of Medicine. Clinical Infectious Diseases. Danilenko. F. neuropeptides. L. (1991). a calmodulin-binding protein lobules of fat cells or lipocytes are separated by fibrous from human epidermis.. liferation in the epidermis and in epithelial tissue in Jones. Calcium regulation of cell-cell contact and differentiation of epidermal cells in culture: An ultrastruc- undergo the process of keratinization and terminal tural study. H. R. B. & Hollbrook. Wyllie. K. W. (2006). Philadelphia: Saunders. skin. 106(2). 167Y176. & D. 477Y484. J. Lipocytes produce leptin. (Eds. (2008). A. Derr.. & Peluchetti. kines. Anatomy. 88(1). and skin carcinogenesis. 1382Y1394. 127Y142. 57Y73). T.... R. Archiv f[r Klinische und Experimentelle Dermatologie. The high rate of cell pro. Characterization of keratocalmin. E. 78(5). 5). Journal of Ultrastructure Research. mast cells are thought to play an active Danby.. REFERENCES Kratochwil.. T. exceedingly high rate of skin cancers found in humans as Kaufman. L. & Elias. migration. Traditionally associated with the in postmenopausal women. parasitic diseases.. provides the body with buoyancy and functions as a Gayraud. Fitzpatrick_s dermatology in general medicine et al. M. Andrews_ diseases of the store of energy for the body.. K.. 272(14).. Apoptosis: A basic biological phenomenon with wide-ranging implication in tissue kinetics. pulmonary fibrosis. malignancy. Daniel (Eds. G. and serve a significant role in maintaining Headington. Considered an endocrine organ.

.. 415Y425. 5Y45). & Matoltsy. 491Y497. et al.. 73(4). Krishnaswamy. Sonic hedgehog signaling is essential for in general medicine (7th ed. Elenitsas. 269Y277. J. A. A. Jr. P. TX: Landes Bioscience. 59Y75. A. A. Sawaya. 44(11). E. Merkel cell distribution in human hair follicles of the fetal Tankersley.. 123(1). Deaver. (1982). A. & Fuchs.). Unauthorized reproduction of this article is prohibited. Regulation of human sebaceous glands. D.. 3.. Spurr-Michaud. A. Philadelphia: Lippincott Williams & Wilkins. Mauro. (1996). Li. Fitzpatrick_s dermatology Danielian.. Proceedings of the National Academy of Sciences unit (pp.. I. The biology of hair follicles. I). Thiboutot. 5Y7. Molecular Investigative Dermatology. The human mast cell: during murine hair follicle development and cycling. L.. (1972). L.. J. Genes Transforming growth factor beta receptor type I and type II expression and Development. (1995). S. In P. Excess hospital admissions during the July tology. Current Opinion in Dermatology. E. G. S. A. & B. Espana. J. L. J.. (Vol. Cowin & M.. Elwell. C. 5(1). M. J... P. Biochemie der epidermalen keratinisation. Cadherins and Langerhans cell immunobiology. (1994). Botchkarev. Karavanova. O. J. 9(6).. Chi (Eds. & Goldsmith. J. Nordquist. pp. Control of the hair cycle and hair diseases as cycling Wheelock. factor 1 directs hair follicle patterning and epithelial cell fate. Sato. Localization of laminin-5 in the epidermal basement Marchionini (Ed.. S. Katz. Y. Schwarz.. (1998). Handbuch der hautund geschlectskrankheiten membrane. 20Y25. the function of the human eccrine sweat gland. R. M. Udey. & D. (1979). 117(2). G. (1997). P.. 7(1Y2).. D. Lever_s histopathology of the skin Physiology.. & D. K. McGeehin. 67(1).. R. 1058Y1068. Dassule.. Regulation of keratinocyte intercellular disorders. & Chi. Keratinization. Tisdale. Berlin: Springer-Verlag. growth. S. Journal Paus. V. Johnson Jr. Estrogen replacement in middle-aged women: Thermo- Murphy. Byrne... S. Mast cells: Methods and protocols (pp. R. 13Y34). M. T. Morphological and functional correlations.. biology: Vol. Mascaro.. 8(19). 277(1). Lin. . T. (1999). Journal of Investigative Derma. 107(Suppl. In G. apoeccrine sweat glands. 131Y138. Journal of Histochemistry and Cytochemistry. R. M. American Journal of Preventive Medicine. G. (1994). In K.. C. Paller.. R. Welker. M..Krishnaswamy. A. 6Y8. Foitzik. The role of epidermal Investigative Dermatology. I. G. Molecular biology intelligence hemidesmosomes. & Everett. Schuman. (1999).). Ishiko. New of Cell Biology. (2006). 215(4537). Mikita. 87(22). S. England Journal of Medicine. Liu. K. (1992). B. M. Jacobs. B.). R. Biology of eccrine. Cell and Tissue Research. Ortonne. D. Klymkowsky (Eds. (2004). A. (1997). (1996). Heterogeneity in basal keratinocytes: Dermatology. Patterns of urban heat wave deaths and implications The desmosome and hemidesmosome in cutaneous autoimmunity. I. Ajitawi. and adult scalp. L. Paus. Aberdam.com\CE. W. (1997).. Gilchrest. hair development. & Sun. J. (2008). In D. A. 1). 700Y713. L.. M. & Jensen. W. (Eds. Journal of Olson. Journal of Investigative Lavker. 189Y199. (1997). R. Cytoskeletal-membrane (1990). P. L. Tomita. Clinical and Experimental Immunology... 1995 heat wave in Chicago. go to NursingCenter. 107(Suppl. S. (1997). Millar. E. 341(7). H.. & Diaz. Alpha 6 beta 4 integrin heterodimer is a component of interactions and signal transduction. R. For more than 63 additional continuing education articles related to skin and wound care. K. Biochemical mechanisms regulating human hair 1239Y1241. Journal of An overview. C. and 16(4). T. Goldsmith. of the United States of America. I. S.. J. Flanders. D. junction organization and epidermal morphogenesis by E-cadherin. & Gipson.. D. 315. 248Y258. 8970Y8974.. C. Regional and individual variations in Totowa. S. 1238Y1245.. 87Y102). Leffell (Eds. T. Clinical and Experimental Immunology. apocrine. Nicholas. Stepp. J. M. (1992). G. D. 518Y526. E. (1976). 9Y15. Journal of Applied Jaworsky. Zhou. Elder.). & Dobson. New York: McGraw-Hill.. McCullough. P. Current Biology. (1970). Science. Lymphoid enhancer Paus.. J. H. C. VOLUME 3 | NUMBER 4 | JULY/AUGUST 2011 213 Copyright @ 2011 Dermatology Nurses' Association. A. Bulfone-Paus. 109(4). In A. et al. R. Masunaga.).. & Eichmuller. W. Austin.. (1970). 1Y12. 443Y449. C. R. & Kenney. Louis during July 1966.. NJ: Humana Press. W. M. Moll. (8th ed. pp. F. 1). S. 54(6). for prevention: Data from New York and St. Lumpkin. 83(1). A. 1223Y1230. Skin Pharmacology. lysosomes in melanin physiology.. British Journal of Dermatology. St-Jacques. 713Y720). Wolff. Environmental Research. & Cotsarelis.. H. regulatory responses to exercise in the heat.. Histology of the skin. Z. Semenza. J. Shimizu. The role of patterning genes in epidermal differentiation.