Integumentary System


Anatomy

JC Kennetth Jacinto, MD
The Skin
 View histology slides
>Study Area>

Five layers of the Epidermis Keratinocytes

Stratum corneum
Most superficial layer; 20–30 layers of dead
cells, essentially flat membranous sacs filled
with keratin. Glycolipids in extracellular space.

Stratum granulosum
Typically one to five layers of flattened cells,
organelles deteriorating; cytoplasm full of
lamellar granules (release lipids) and
keratohyaline granules.
Stratum spinosum
Several layers of keratinocytes unified by
desmosomes. Cells contain thick bundles of
intermediate filaments made of pre-keratin.

Stratum basale
Deepest epidermal layer; one row of actively
mitotic stem cells; some newly formed cells
become part of the more superficial layers.
See occasional melanocytes and dendritic Dermis
cells.

(a) Dermis Melanin Sensory Tactile

granule nerve (Merkel)

Californians Like Girls in String Bikinis

ending cell
Figure 5.2 Epidermal cells and layers of the epidermis.
(a) Photomicrograph of the four major epidermal layers in thin skin (200×). Desmosomes Melanocyte Dendritic cell
(b) Diagram showing these four layers and the distribution of different cell types.
(b)
The stratum lucidum, present in thick skin, is not illustrated here.
Epidermis: 4 or 5 layers (strata)
1.  Stratum basale: simple cuboidal epithelial tissue
•  Actively divides to make new epidermis
•  Deepest layer of the epidermis
2.  Stratum spinosum & granulosum: superficial to the basale
3.  Stratum lucidum: found only in thick skin
4.  Stratum corneum: composed of dead, keratin-filled cells that flake
off (exfoliate)
 CHAPTER 5 FVR;]cRUd\R]cMahEhbcR\ 133

Stratum corneum

Epidermis

Melanized cells
of stratum basale

Dermis

(a) Dark skin (b) Light skin

Figure 5.3 HMaWMcW^]b W] EYW] BWU\R]cMcW^]͙

impart less color to the cells, and it breaks down more rapidly. Melanin is a bar-
the surface unsuitable for the growth of many microorganisms. Maintenance the epidermis covering the general body surface (Figure 4.4c).

Figure 4.4 Thin and Thick Skin. The epidermis is a stratified squamous epithelium that varies in
thickness.

Stratum
corneum

Basal
Epidermis
lamina
Stratum
Epidermal lucidum
ridge
Dermis
Dermal Dermal
papilla papilla
Epidermal
Dermis ridge
LM × 240 LM × 240

a The basic organization of the epidermis. b Thin skin covers most of the exposed c Thick skin covers the surfaces
The thickness of the epidermis, especially body surface. (During sectioning the of the palms and soles.
the stratum corneum, changes depending stratum corneum has pulled away
on the location sampled. from the rest of the epidermis.)

90 The Integumentary System

TABLE 5.4 Comparison of Thin and Thick Skin

FEATURE THIN SKIN THICK SKIN

Distribution All parts of body except areas such as palms, Areas such as palms, palmar surface of digits,
palmar surface of digits, and soles. and soles.
Epidermal thickness 0.10–0.15 mm (0.004–0.006 in.). 0.6–4.5 mm (0.024–0.18 in.), due mostly to a
thicker stratum corneum.
Epidermal strata Stratum lucidum essentially lacking; thinner Stratum lucidum present; thicker strata
strata spinosum and corneum. spinosum and corneum.
Epidermal ridges Lacking due to poorly developed, fewer, and Present due to well-developed and more
less-well-organized dermal papillae. numerous dermal papillae organized in
parallel rows.
Hair follicles and arrector Present. Absent.
pili muscles
Sebaceous glands Present. Absent.
Sudoriferous glands Fewer. More numerous.
Sensory receptors Sparser. Denser.
Dermis
•  Referred to as "true skin."
•  The dermis contains:
•  Papillae
•  Fibers
•  Nerve endings
•  Cutaneous glands
•  Hair follicles
•  Blood vessels
Dermis
•  Papillae
•  Conelike projec-ons of dermis that fit into recesses of epidermis
•  Possess blood vessels, touch receptors
•  Form fingerprints and toe prints
Dermis
•  Fibers
•  Composed of fibrous connec-ve -ssue made by fibroblasts
•  Collagen: strength and toughness
•  Elas-c fibers: extensibility and elas-city
Dermis
•  Nutri-on
•  Vitamin A and vitamin C are important for healthy skin because they are
necessary for collagen produc-on.
•  Vitamin A
•  Green and yellow vegetables, dairy products, and liver

•  Vitamin C
•  Fruits and green vegetables.
Dermis
•  Nerve Endings
•  Pressure, pain, warm, and cold receptors are in deeper parts of the dermis.
•  Lamellated and tac-le corpuscles are for pressure and touch.
•  Free nerve endings are for pain.
•  Receptor nerve endings may surround a hair follicle.
Accessory Organs of the Skin
Hair
Nails
Sebaceous glands
Sweat glands
 CHAPTER 5 FVR;]cRUd\R]cMahEhbcR\ 137

The hair
Epithelial root
sheath
Hair shaft Hair medulla

Hair cortex
Sebaceous Piloerector Connective
gland muscle tissue
root sheath
Hair receptor
Hair root Hair matrix
Hair bulb
Apocrine
sweat gland Dermal
papilla
Blood
capillaries
in dermal
papilla

(a) (b) 0.5 mm

Figure 5.5EcadPcdaR^SM:MWaM]Q;cb7^ZZWPZR͙
the follicle and respond to hair movements, as when an ant crawls across your arm.
 CHAPTER 6 The Integumentary System 187

Eumelanin

Pheomelanin

Cuticle

Cortex

(c) Red, wavy Air

space
Eumelanin
Pheomelanin

Medulla
(b) Black, straight
(a) Blond, straight (d) Gray, wavy

FIGURE 6.8 The Basis of Hair Color and Texture. Straight hair (a and b) is round in cross section, whereas curly hair (c and d) is flatter.
Blond hair (a) has scanty eumelanin and a moderate amount of pheomelanin. Eumelanin predominates in black and brown hair (b). Red hair
Alopecia
The Nails
Onychomycosis
 Sebaceous Glands
Figure 4.13 Sebaceous Glands and Follicles. The structure of sebaceous glands and sebaceous
follicles in the skin.

Lumen (hair
Sebaceous follicle Sebaceous gland removed)

Wall of hair follicle

4 Basal lamina
Epidermis
Discharge of
sebum
Lumen
Dermis Breakdown of
cell membranes

Mitosis and
growth
Subcutaneous Basal cells
layer
Sebaceous gland LM × 150

Figure 4.14 Sweat Glands.

Myoepithelial cell
Sweat pore
 Mitosis and
growth
Subcutaneous Basal cells
layer
Sebaceous gland LM × 150

Figure 4.14 Sweat Glands. Sweat Glands

Myoepithelial cell
Sweat pore

Connective
tissue of dermis
Duct

Apocrine
gland cells Myoepithelial
cells
Eccrine
gland cells
Duct of
apocrine
sweat gland
Lumen
Lumen
Cross section
of eccrine
sweat gland
Sectional plane LM × 243
through apocrine
LM × 440
sweat gland
b Eccrine sweat glands
a Apocrine sweat glands are found produce a watery fluid
in the axillae (armpits), groin, and called sensible perspiration,
nipples. They produce a thick, or sweat.
foul-smelling fluid.
Dermis
•  Sweat glands
•  Apocrine sweat gland
•  Merocrine sweat gland
•  Ceruminous gland
•  Mammary gland
Dermis
•  Apocrine sweat gland
•  Empty secre-on into hair follicle
•  Located in axillary and genital regions
•  Ac-vate at puberty
•  Milky sweat due to proteins and fats
•  Odorless - body odor due to bacterial decomposi-on
Dermis
•  Merocrine sweat glands
•  Occur all over the body
•  Secrete sweat onto skin surface directly
•  Clear, watery perspira-on
•  Ac-vated with increase in body temperature
•  Func-ons to cool the body through evapora-on
Dermis
•  Ceruminous glands
•  Produce cerumen
•  Found in external auditory canal
•  Keep foreign par-cles and insects out of auditory canal
Dermis
•  Mammary gland
•  In breast -ssue
•  Produces milk
•  Nourishes an infant
Integumentary System

Physiology

JC Kennetth Jacinto, MD
Physiology of the Integumentary System 1

•  The func-ons of the integumentary system include:

•  Protec-on from pathogens and UV light
•  Vitamin D produc-on
•  Temperature regula-on
•  Water reten-on
•  Sensa-on
•  Nonverbal communica-on
Func;ons of the Skin
•  Protec-on from pathogens and UV light
•  Body’s first line of defense
•  Difficult for pathogens to penetrate
•  Dry, acidic surface is unfriendly to bacteria
•  Melanin protects underlying cells from UV light damage.
Func;ons of the Skin
•  Vitamin D produc-on
•  UV light encourages skin to produce vitamin D.
•  Important for the absorp-on of calcium.
Func;ons of the Skin
•  Temperature regula-on
•  Blood vessels in the dermis
•  Constrict to preserve heat for the body’s core

•  Dilate to increase blood flow to the skin so that heat can radiate out of the body
Func;ons of the Skin
•  Water reten-on
•  The skin’s epidermis waterproofs the body by keeping water from the environment
out and body fluids in.
Func;ons of the Skin
•  Sensa-on
•  Nerve endings are located in the stratum basale, and dermis respond to s-muli:
•  Temperature
•  Pain
•  Touch
•  Pressure
Func;ons of the Skin
•  Nonverbal communica-on
•  Blushing when embarrassed
•  Pale when frightened
•  Color, texture, silkiness, and other quali-es of the skin and hair can all be indica-ve
of overall health
Effects of Aging on the Integumentary System 1

All parts of the integumentary system are affected by aging

Loss of sebaceous and sweat glands in the dermis
Loss of melanocytes causing uneven tanning and age spots
Dermis thins and the number of collagen and elastic fibers is
reduced
•  This, along with gravity, causes sagging and wrinkling of the skin
Effects of Aging on the Integumentary System 1

Blood vessels become more fragile and are less efficient in

regulating temperature
Bumps that lead to bruises are more frequent because of
thinner dermis
Nail plate and matrix thins
Hair thins and turns gray due to the loss of melanocytes
Integumentary System

Pathology

JC Kennetth Jacinto, MD
Injuries to the Skin
 Wound Healing

Jump to long descrip-on

 Wound Healing

Jump to long descrip-on

Regeneration versus Fibrosis
•  Skin can heal by regeneration or fibrosis.
•  In regeneration, normal function returns.
•  The stratum basale cells reach contact inhibition before the fibroblasts fill
the area with scar tissue.
•  In fibrosis, normal functioning tissue is replaced by scar tissue.
•  Fibroblasts’ collagen fibers produce granulation tissue to fill in the wound’s
clot.
•  Fibroblasts reach contact inhibition before the cells of the stratum basale
cells.
Burns
Common Skin Disorders
 Skin Cancer
Chapter 5 The Integumentary System 185

(a) Basal cell carcinoma (b) Squamous cell carcinoma (c) Melanoma

Figure 5.10 Photographs of skin cancers.

There is no such thing as a “healthy tan,” but the good news is pigment. Most such cancers appear spontaneously, and about
Skin Cancer
•  Skin cancer is the most common cancer, and it is associated with sun
exposure.
•  Basal cell carcinoma is the most common skin cancer, and it tends not to
metastasize.
•  Squamous cell carcinoma results from keratinocytes in the stratum
spinosum. They commonly form on the face, hands, ears, and neck and can
metastasize.
•  Malignant melanoma is the rarest form of skin cancer. It is the most deadly
because it metastasizes easily. Usually begins in a mole.
 Bacterial Infections
CHAPTER
In bullous impetigo, there is cleavage of the upper epidermis, typically
within the granular layer. Acantholysis mimicking pemphigus foliaceus 74
may be observed. Relatively few inflammatory cells are present within

Bacterial Diseases
the blister cavity, and a neutrophilic infiltrate is often found in the
upper dermis. Gram-positive cocci may be evident.

Diagnosis and differential diagnosis

The diagnosis of impetigo is usually made clinically; exudate from
beneath the crust or fluid from intact bullae can be sent for culture to
confirm the diagnosis and determine susceptibility to antibiotics. Leu-
kocytosis is seen in approximately half of patients with impetigo and
regional lymphadenopathy is common. The differential diagnosis of
non-bullous and bullous impetigo is presented in Table 74.2.
Normal
Treatment
For healthy patients with a few superficial lesions and no systemic
symptoms, topical mupirocin, retapamulin, or fusidic acid (not avail-
able in the US) are often equally (if not more) effective than oral anti-
A biotics. However, S. aureus can develop resistance to each of these
A agents3a,4. Treatment should also includeB cleansing the affected area
and removing crusts, which can be facilitated by wet dressings.
The extent of skin involvement, the presence of complications (e.g. Staphylo
cellulitis, lymphangitis, bacteremia), comorbid conditions (e.g. atopic Streptoc
dermatitis, varicella), the patient’s immune status, and local drug-
resistance patterns (e.g. the prevalence of community-associated
methicillin-resistant S. aureus [CA-MRSA]) should be considered when
deciding whether topical, oral, or intravenous therapy is the most appro-
priate treatment (Table 74.3). The risk of developing post-streptococcal
glomerulonephritis following streptococcal impetigo is not affected by
treatment and is greater with certain subtypes of Str. pyogenes (see Table ©Dr. P. Marazzi/Science Source
Skin Infections
•  Skin can be infected by a type of bacteria, a virus, fungus, or parasite.
Bacterial skin infections
•  Impetigo: caused by the bacterium Staphylococcus or Streptococcus.
Appears as a cluster of vesicles that burst and crust over, which may cause
pain and itching.
•  Cellulitis: infection of the skin’s dermis or hypodermis and is frequently
caused by Streptococcus or Staphylococcus bacteria. Commonly occurs on
the face and lower legs, characterized by redness and swelling of an area of
the skin that increases in size rapidly.
 • Buschke–Löwenstein tumor 6, 11
12
Table 80.2 Interaction of herpes simplex viruses (HSV)
Acyclovir with the immuneFamciclovir
Valacyclovir system: host respons

INFECTIONS, INFESTATIONS, AND BITES INFECTIONS, INFESTATIONS, AND BITES

• Recurrent respiratory 6, 11
papillomatosis, conjunctival ICP, infected cell polypeptide; Creatinine
IFN, interferon;
clearance
IL, interleukin;
Creatinine
clearance
MCP-1, monocyte
clearance
chemotactic peptid
Creatinine
papillomas
TAP, transporter
Indication associated with antigen
(ml/min) processing;
Adjusted dose TRAF3, tumor
(ml/min) necrosis(ml/min)
Adjusted dose factor (TNF) receptor-
Adjusted dose
• Heck disease (focal epithelial 13, 32
B
Primary genital herpes simplex <10 200 mg po BID 10–29 1 g daily 20–39 125 mg BID
hyperplasia)
<10 500 mg daily <20 125 mg daily
*Probably carcinogenic
33
.
Recurrent genital herpes simplex <30 500 mg daily 40–59 500 mg BID × 1 day
Table 79.1 Clinical manifestations and associated human papillomavirus Fig. 79.6 Verrucae 20–39 500 mg once

Viral skin infec;ons

(HPV) types. HPV types in the genus β are in bold. plantares (plantar
warts). The photo was <20 250 mg once
SECTION
taken after shaving<30
of
12
Chronic suppression of herpes 500 mg q48 h or 20–39 125 mg BID
simplex the hyperkeratotic daily
<20 125 mg daily
surface; the black dots
Recurrent orolabial herpes simplex <10 200represent *
mg po BIDhemorrhage
30–49 1 g BID × 1 day 40–59 750 mg once

•  Verruca (warts) into the stratum 10–29

corneum. <10
500 mg BID × 1 day
500 mg once
20–39
<20
500 mg once
250 mg once
Herpes zoster 10–25 800 mg po TID 30–49 1 g BID 40–59 500 mg BID
<10 800 mg po BID 10–29 1 g daily 20–39 500 mg daily

•  Herpes simplex Immunocompromised patients with 25–50 5–10 mg/kg iv q12 h

<10 500 mg daily <20 250 mg daily

mucocutaneous herpes simplex; for iv

10–24 5–10 mg/kg iv q24 h 10–29 1 g daily* 20–39 500 mg daily*
acyclovir, also herpes encephalitis and

•  Varicella (chickenpox) disseminated zoster

*Not specifically FDA-approved for this indication.

<10 2.5–5 mg/kg iv q24 h <10 500 mg daily* <20 250 mg daily*

Table 80.5 Dose reductions for acyclovir, valacyclovir and famciclovir in patients with renal disease. In hemodialysis patients, the medication should be
Fig. 79.4 Verrucae vulgares (common warts). Courtesy, A Geusau, MD. administered after dialysis. BID, twice daily; h, hours; iv, intravenously; po, orally; q, every; TID, three times daily.

•  Herpes zoster (shingles)

79.8). Plantar warts that coalesce into large plaques are referred to as Fig. 80.13 Varicella. A–C Lesions in
mosaic warts (see Fig. 79.8). Extensive chronic verrucosis that is notori- different stages of evolution,
including vesicles, pustules, and
ously resistant to therapy has been observed in immunocompromised
individuals and, at times, in patients with no apparent immune dys-
79.10). They are usually caused by HPV-3 or -10, and less often by
and tends to decrease over the next several years. The time interval
HPV-28 and -29. Other Cl hemorrhagic crusts. Vesicles often
develop central umbilication. D Oral
lesions can also occur (arrow). A,B,
function (Fig. 79.9). Inclusion warts of the sole are plantar cysts from Butcher’s warts, which earn their name from their occurrence in
which HPV types 4, 60, 63, and 65 have been isolated34. In studies between recurrences varies greatly, with individuals having an average
meat- (or fish-) processing professionals, appear as extensive verrucous HSV infecti
Courtesy, Robert Hartman, MD; C, Courtesy, Julie
V Schaffer, MD; D, Courtesy, Judit Stenn, MD.
from Europe, HPV-1 and the closely related types HPV-2, -27, and -57
caused the majority of palmoplantar warts, and they occurred most
of four to seven outbreaks annually. Surprisingly, although the majority
papules or cauliflower-like lesions on the dorsal, palmar, or periungual
aspects of the hands and fingers. These warts are associated with The clinical
commonly in patients 6–10 years of age35,36. Although a higher inci- of individuals with HSV-2 seropositivity report no history of genital
HPV-7 not animal papillomaviruses. cutaneous p
dence of HPV-2-related warts was reported in atopic children, other Epidermodysplasia verruciformis (EV), first described in 1922 by
1402
investigators have failed to find such an association. herpes infection, symptomatic infection is eventually diagnosed in 50%
Lewandowski and Lutz, is a rare genetic disease. It is characterized by compromise
Flat warts are skin-colored or pinkish to brown, relatively smooth- of this group of patients.
a particular susceptibility to cutaneous infections with HPV types in 80.3 (Figs 8
surfaced, slightly elevated, flat-topped papules that are most commonly the genus β (see above), which do not produce clinical lesions in immu- 1387
located on the dorsal hands, arms or face, often in a linear array (Fig. nocompetent individuals37. The disease usually manifests in childhood

©Dr. P. Marazzi/Science Source

 Tinea (fungal infec;ons)
SECTION

12
•  Contact with an infected person,
damp surfaces
INFECTIONS, INFESTATIONS, AND BITES

•  Includes ringworm, athlete’s foot, and

jock itch.
•  a circular rash that clears from the
center, giving it a ringlike appearance

©Dr. P. Marazzi/Science Source

 digital webs (see Fig. 178-1), sides of fingers, volar
aspects of the wrists and lateral palms (Fig. 178-2), less-effective scratchers
elbows, axillae, scrotum, penis (Fig. 178-3), labia, palms and soles as we
and areolae in women. The head and neck are usu- the trunk. Identificatio
ally spared in healthy adults, but in infants, elderly, tated by rubbing a bl
and immunocompromised individuals, all skin sur- affected area. After the
faces are susceptible. Indurated, crusted nodules an alcohol pad, the bu

Scabies
can be seen in infants and young children on inter- surrounding skin becau
triginous areas as well as on the trunk. In crusted burrow.

•  Caused by an infestation of mites

(Sarcoptes scabiei var. hominis)
•  Causes small red bumps on the skin
that itch severely

Figure 178-4 A dermosc

wing jet” sign of dense sc
relatively translucent scab
Figure 178-2 Scabies. Several thread-like burrows are bies eggs (short red arrow
present in the web spaces of the fingers and on the knuck- Heine Delta 20× dermato
les, a common location for these lesions in scabies. Longi- camera. (From Fox G. Diag
tudinal scraping of a burrow will often reveal the mite or BMJ Case Rep. 2009;2009.
mite products under microscopic examination. BMJ Publishing Group Ltd

©Dr. P. Marazzi/Science Source

Atopic derma;;s
•  Atopic derma--s (AD) is a chronically
relapsing skin disease that occurs most
commonly during early infancy and
childhood.
•  It is frequently associated with
abnormali-es in skin barrier func-on,
allergen sensi-za-on, and recurrent skin
infec-ons.

©Dr. P. Marazzi/Science Source

Ur;caria (hives)
•  It is a skin reaction that can be caused by
insect bites or by contact with substances
that can cause an allergic reaction, such as
certain foods or drugs.
•  The symptoms include raised areas of the
skin, redness, and itching.

©Dr. P. Marazzi/Science Source

 Scleroderma
•  It involves the accumulation of excess
connective tissue in the skin and various
organs.
•  The excess collagen causes hardening of
the skin and organs, with decrease
elasticity; this leads to a decrease in
function.
•  It can be caused by exposure to certain
chemicals or can be associated with
autoimmune diseases such as lupus.

©Dr. P. Marazzi/Science Source

THANK YOU!