STRUCTURE OF SKIN

Dr . Basem Khaled Elswerky

• Bachelor of Medicine and Surgery
• Master of Science in Dermatology, Venereology, and Andrology
• Master in Mental Health and Family Counseling
• Clinical Nutrition Professional Diploma
• Hospital Management Professional Diploma
Lecturer College of Medicine and Health Science , University of Palestine
Structure of Skin
 Structure of Skin

The skin is divided into three layers: epidermis, dermis, and subcutaneous tissue. In
addition, there are skin appendages: nails, hair follicles, sebaceous glands, eccrine and
apocrine sweat glands
 epidermis

dermis

subcutaneous
tissue
muscle
 hair
sweat gland

Epidermis
homy cell layer
granular cell —S’
layer
• >1 mast cell
prickle cell layer
• a

basal cell layer dermal

Dermis dendrocyte
papillary layer^ macrophage
►

fibroblast

reticular layer — elastic fiber

collagen fiber

Hypodermis

hair follicle blood vessel nerve

Skin appendages:
/- Eccrine sweat glands:
• They are present on all body sites except very few areas as the labia minora and the
glans penis.
• The gland consists of coiled secretory part deep in the dermis and a duct which
opens separately on the skin surface.
• The secretion of eccrine sweat gland is a clear watery fluid which plays an important
role in the process of heat regulation and has antimicrobial properties as well.
2- Apocrine sweat glands:
• They are present in few areas predominantly in the axilla, anogenital area, female
breast, eyelids and external auditory canal.
• The gland consists of coiled secretory part in the deep dermis and duct which opens
into the upper portion of the hair follicle.
• The glands produce on oily secretion of protein, carbohydrate, ammonia, and lipid.
• Apocrine glands become active at puberty.
 3- Sebaceous glands:
• They are found all over the skin surface except palms and soles.
• It consists of secretory portion and a duct which opens into upper part of a hair
follicle, the hair follicle and associated gland is known as a pilosebaceous unit.
• Sebocytes secrete lipid-rich sebum with emollient as well as antimicrobial
properties.
• Both apocrine sweat glands and sebaceous glands are under control of testosterone
and therefore, become active at puberty.

4- Hair follicle:
• Hairs arc present all over the body except palms, soles, dorsal aspects of the distal
phalanges, labia minora and glans penis.
• The hair follicle comprises pocket of epithelium which is continuous with the
superficial epidermis and a hair shaft which is formed of medulla, cortex and
cuticle.
• There are three types of hair: lanugo, vellus and terminal hair.
• And three types of hair follicles: vellus, terminal and sebaceous hair follicles.
5- Nails
They arc solid translucent plates composed of modified homy cells.
Epidermis
 The Epidermis
The epidermis is the outermost part of the skin. It is stratified squamous
epithelium. It is thin on the eyelids and thick on the palms and soles. Its prime function
is to act as a protective barrier. The main cell of the epidermis is the keratinocyte
which produces the protein keratin. The epidermis is avascular structure and its main
blood supply is through the dermis. The four layers of the epidermis (Fig.2) represent
the stages of maturation of keratin by keratinocytes.
1. Basal cell layer: The innermost layer of the epidermis. It consists of a single row of
columnar cells which are anchored to the basement membrane by adhesion
junctions called hemidesmosomes.
2. Spinous cell layer: forms the great bulk of epidermis. It consists of 5-7 rows of
polygonal cells which arc attached together by desmosomes.
3. Granular cell layer: it consists of 2-3 rows of flattened keratinocytes filled with
deeply basophilic granules.
4. Horny cornified layer: keratinocytes finally die (loose their organelles including
nuclei) as they reach the surface to form the stratum comeum.
• Regeneration of epidermis and hair follicles depends on population of epidermal
stem cells.
• In addition to keratinocytes, there are three types of branched cells in the epidermis:
the melanocyte, which synthesizes pigment (melanin); Langerhans’ cell, which
serves as a frontline element in immune reactions of the skin; and Merkel’s cell, the
function of which is not clearly defined.
 Desquamating c

• ••••
Stratum corneum
•• **9• e
? .••**•*
eratohyaline /o. •• •• •1 >4rx -*g. -
Granular layer
• * *«•
ranule------- ' 0 + ke
L A -F/
k ■ e z* o

Q - Io ~ {O
Spinous layer
L. ***+* o

esmosome zr © -
Basal layer
o
Stratum Dead
corneum keratinocyles
Stratum
luodum

Stratum
granulosum Lameftar granules

Keratinocyte

Langertians cell
Stratum
spmosum

Melanocyte

Stratum Merkel ce«

basale Tactile disc
Sensory neuron
Dermis
 Note :

Proliferation and shedding

• The thickness of the epidermis is regulated by the balance between proliferation of
basal keratinocytes and shedding of cells at the surface (desquamation).
• It takes about 40 days for a keratinocyte to move upwards from the basal layer to the
homy layer.
Dermis
 The Dermis
The dermis varies in thickness from 0.3 mm on the eyelid to 3.0 mm on the back; it
is composed of cellular constituents and three types of connective tissue: collagen,
elastic tissue, and reticular fibers. It acts as a frame work and support for blood
vessels, lymphatic vessels and nerve supply of the skin and skin appendages. The
dermis is divided into two layers: the thin upper layer, called the papillary layer, is
composed of thin, haphazardly arranged collagen fibers; the thicker lower layer,
called the reticular layer, extends from the base of the papillary layer to the
subcutaneous tissue and is composed of thick collagen fibers that are arranged
parallel to the surface of the skin.
The junction of the epidermis and dermis is formed by the basement membrane zone
and is called the dermo-epidermal junction.
 hair
sweat gland

Epidermis
homy cell
granular cell

mast cell
prickle cell

basal cell layer dermal

Dermis dendrocyte
papillary layer macrophage

fibroblast

reticular layer elastic fiber

collagen fiber

Hypodermis

hair follicle blood vessel nerve

Functions
The skin is the
LARGEST organ of the
body, it weighs 1/7 of
body with surface
area of 1.75 m2
Function of the skin

DSS ITP
Vitamin D formation
Sensory function
Sweat excretion
Immunological function & Protection
Temperature control

1490^55^574573
Prevention of water & electrolyte loss
 FUNCTIONS OF THE SKIN
The skin is the largest immunologically active organ in the body, and its relative
accessibility for basic science research has recently allowed much progress in our
understanding of its multiplicity of functions.
When the skin is unable to play its usual role in the maintenance of fluid balance and
temperature regulation, this clinical situation is referred to as “skin failure’* and it
happens in cases of severe bums and some other skin diseases that simulate severe
bums.

Skin functions can be summarized in the following:

1. Prevention of water loss.
2. Immune defence:
• Structural integrity of stratum comcum.
• Acid Ph of sweat.
• Fungistatic activity of sebaceous secretions.
3. Protection against UV damage:
• Melanin synthesized by melanocytes helps to protect kcratinocytc nuclei from the
harmful effects of UV radiation.
 4. Temperature regulation:
• Vasoconstriction and vasodilatation control the flow of bl
to the body surface.
• Evaporation of sweat cools the
5. Synthesis of vitamin D
6. Sensation:
• Free nerve endings detect potentially harmful stimuli (heat, pain).
• Specialized end organs detect pressure, vibration, and touch.
I
Autonomic nerves supply bl ITtli vessels, sweat glands, and arrector pili muscles.
7. Aesthetic: the skin has an important role in social interaction.
FUNGAL INFECTIONS: CANDIDIASIS

Dr . Basem Khaled Elswerky

• Bachelor of Medicine and Surgery
• Master of Science in Dermatology, Venereology, and Andrology
• Master in Mental Health and Family Counseling
• Clinical Nutrition Professional Diploma
• Hospital Management Professional Diploma
• Lecturer College of Medicine and Health Science , University of Palestine
 FUNGAL INFECTIONS OF THE SKIN

Fungal linfections in human is common and mainly due to two main groups of fungi:

A. Dermatophytes
B. Yeasts
 Classification of Fungi

• Dermatophytes(Tinea):
• M ilticell filaments (hyphae)
• Reproduce by spores formation.

• Yeasts(Candida);
• Unicellular forms M
• Replicate 7 ' budding. H
 DERMATOPHYTES : = ring worm = tinea

• Clinical Presentation:
the exact feature depends on the side :
1. Affection of the scalp (Tinea capitis).
2. Affection of the beard (Tinea barbae).
3. Affection of the glabrous skin (Tinea corporis).
4. Affection of the genitocrural area (Tinea cruris).
5. Macerate web space [Tinea pedis (feet) and manum (hand)]
6. Affection of the nails (Onychomycosis).
CUTANEOUS CANDIDAL INFECTIONS:

It is a common condition caused by the yeast Candida albicans .

Predisposing factors :
• Diabetes
• Obesity
• Moisture and Sweating
• Drugs as corticosteroids , cytotoxics and antibiotics (prolonged intake)
• Conditions associated with Decrease resistance , e.g. anemia, pregnancy,
cushing's syndrome , diabetes mellitus .
• Immunocompromised individuals
It may present as :
A. Oral candidiasis (oral thrush): Clinically, whitish curd-like patches
(pseudomembrane) on tongue and buccal mucosa characterize it. The patches can
be scrubbed and leave erythematous base. Angular stomatitis (perleche) is
commonly associated.
B. Genital candidiasis: It may affect the vagina in females (candidal vaginitis) and the
glans penis in males (candidal balanitis). It is also one of the sexually transmitted
diseases.

C. Candidal intertrigo: It affects the groin, axillae and submammary regions. The
lesion is well defined, moist and erythematous. The edge is festooned and small
satellite lesions (papules & pustules) are seen outside the edge. Also the interdigital
clefts arc involved in wetworkers who do not dry their hands properly.
D. Chronic mucocutaneous candidiasis: It is a rare condition and is due to a state of
immune deficiency against candidal organisms. It is characterized by chronic
paronychia, oral candidiasis, hyperkeratotic lesions on hands and feet and
subungual hyperkeratosis.
E. Candidal paronychia: nail folds
 Oral candidiasis Genital Candidal
(oral thrush) candidiasis intertrigo

SITE • tongue vagina • Groin Paronychia

• buccal mucosa glans penis • Axillae oral candidiasis
• submammary

SHAPE whitish curd-like whitish patches well-defined, All Forms Nail folds
patches with erythema erythematous
patches

SPECIFIC scrubbed> Edge is festooned immune deficiency

erythematous satellite
papules & pustules
DD • Contact dermatitis: young infants+ ill-defined
• Psoriasis: well-defined border
• TINEA CRURIS: Raised active edge
 Investigation

• Wood's light examination

• Direct microscopy (KOH 10%)

• Yeasts

• Culture: Sabouraud's agar

• Macroscopic appearance

• Microscopic appearance
Treatment of candidal infections :
• Avoid humid

• Topical therapy:
Topical antifungal agents e.g. imidazoles .

• Systemic therapy:
• Systemic in severe , extensive and resistant cases .
• Broad spectrum antifungal agents e.g. itraconazole .
DIAGNOSIS OF SKIN DISEASES
Part 1
Dr . Basem Khaled Elswerky
• Bachelor of Medicine and Surgery
• Master of Science in Dermatology, Venereology, and Andrology
• Master in Mental Health and Family Counseling
• Clinical Nutrition Professional Diploma
• Hospital Management Professional Diploma
■ Lecturer College of Medicine and Health Science , University of Palestine
History taking:
Personal history: age, sex, occupation, special habits ...

Present historv:
• Onset, course, and duration of the disease.
• The first site affected.
• Is the condition recurrent or it has any particular occurrence or seasonal
variation?
• Does it itch or bum & if so is it worse at any particular time?
• Does the skin ooze clear fluid, pus or blood?
• What makes the rash better or worse? Does sunlight makes a difference?
Family history: of similar disorders.
Drug history:
• The response of the condition to previous treatment.
• Drug intake to exclude drug reaction.
• History of any topical agents that have been applied to the skin for medical or
cosmetic purposes.
Examination:
• The patient must be examined under good light closer to natural sun light.
• A magnifying lens is of value in examining small lesions.
• Sometimes the patient should be undressed & examined to determine the overall
distribution of the disease.
• Identify the primary lesions & determine the secondary lesions.
• Diagnostic details of the lesions:
- The shape, size, configuration, consistency, content, color, edge & nature of the
surface (if it is dry or wet).
Presence or absence of scales.
Examination of the scalp, hair, nails & mucous membranes.
Absence or presence & character of any enlarged lymph nodes must be assessed.
 LESIONS

(B) Color
(C) Site
2. (A) Itchy
(B) Painful
(C) Burning Sensation

Dermatological Association (mm,Nail,Hair)

Systemic diseases (viral, DM)

 Color
4. Healing Z
Scar

5. Complication
Primary skin Lesions
lesions with which skin diseases begin
They may continue as such
They may undergo modification, passing into the
secondary skin lesions.
 lry Lesion

(A) Color (B) Elevation

□ change in color
> less than 1cm = mac
> more than 1cm = Patch
 (B) Elevation.

Fluid Solid
Fluid collection (only) Pus
I
pustules

> Less than 0,5 cm = Vesicle * less than 0,5cm = Papule

> more than 0,5 cm = bulla * more than 0,5cm = nodule

* laque
 How describe the lesion?
i. Flat or elevated?

2. Small(<lcm) or large(>l cm)?

3. Solid or has a cavity?

4. Clear fluid filled or non-clear fluid

filled?
 1 .Macule

□ Change of skin
color.
□ Flat.
□ <lcm in diameter.
□ Diseases: drug
eruption, acne,
vitiligo, T. versicolor
melanoma.
 2.Patch
□ Change of skin
color.
Patch
□ Flat.
□ >lcm.
□ Diseases: vitiligo,
neurofibromatosis,
pityriasis rosea,
melasma.
M a c u le
 3.vesicle

□ Elevated
□ <1 cm. Vesicles
□ Cavity filled with clear
fluid.
□ Diseases: herpes
simplex, herpes zoster,
Pemphigus vulgaris,
bollous impetigo, chicken
pox
 4.Bulla
□ Elevated
□ >1 cm.
Bulla
□ Cavity filled
clear fluid.
□ Types:
1. Tense,
2. Flacced
□ Diseases: Pemphigus
vulgaris, bollous impetigo,
epidermlysis bollousa, burn.
 5.papule
□ Elevated
a Solid
□ < 1 cm in diameter.
□ Shape:
1. domed
2. flat-topped
3. umbilicated
a Diseases: acne, lichen
planus, warts,
psoriasis, eczema.
 6.Nodule
□ Elevated
□ Solid
□ > 1 cm.
□ Location:
1. Epidermal.
2. Dermal.
3. Subcutaneous tissue.
□ Diseases: erythema
nodosum, angiofibroma^
pyogenic granuloma,
neurofibromatosis.
 7.Plaque

□ Solid.
□ Raised.
a Flat-topped .
a >1 cm. in diameter.
□ Diseases: psoriasis,
seborrheic
keratosis,discoid LE,
eczema, seborrheic
dermatitis.
Papule

Plaque
 8.Pustule
□ Elevated
□ < 1 cm
□ Contain purulent
exudate:
1. White
2. Yellow
3. Greenish-yellow
4. Hemorrhagic
□ Diseases: Furuncle, acne,
folliculitis, pustular psoriasis,
 SPECIFIC
I. Wheal (hive):
A firm edematous plaque resulting from infiltration of the dermis with
fluid. Wheals are itchy evanescent lesions that may last only a few hours,
it is the characteristic primary lesion of urticaria .

I. Burrow:
An elevated channel in the superficial epidermis produced by sarcoptes
scabiei.
III. Comedone: dilated pilocebaceous duct filled with sebum
and hyperkeratosis leading to obstruction of the pathway
of sebum. Comedones are the primary lesions of acne and
they are either open (blackheads) or closed (whiteheads).

III. Target (iris) lesions :

They are the hallmark of erythema multiforme, characterized

by circular erythematous lesions with a vesicle or papule in
the center.
 9.wheal

a Localized transient
edema.
a Edema in papillary
dermis.
□ Rapidly change in
size and shape .
a Diseases: urticaria,
angioedema, insect
bite.
Review and Exercises
mac
patch
-
 J

»✓

O TM Cokx An»« of FamOy Modcwto

End of part
DIAGNOSIS OF SKIN DISEASES

Part 2
Dr.Basem khaled Elswerky
 SECONDARY LESIONS

Secondary lesions develop during the evolutionary' process of skin disease or are
created by scratching or infection. They may be the only type of lesion present, in which
case the primary' disease process must be inferred. The differential diagnoses of
secondary lesions are as follows

1. Scales: Excess dead epidermal cells (homy layer) that are produced by abnormal
keratinizalion and shedding. They may be dry' or greasy, large or small.
2. Crust: a collection of dried secretions.
3. Erosion: a focal loss of epidermis. Erosions do not penetrate below the
dermoepidermal junction and therefore heal without scarring.
4. Ulcer: a focal loss of epidermis and dermis. Ulcers heal with scarring.
5. Fissure: a linear loss of epidermis and dermis with sharply defined nearly vertical
walls.
6. Atrophy: a depression in the skin resulting from thinning of the epidermis or
dermis.
7. Scar: an abnormal formation of connective tissue implying dermal damage, afrer
injury or surgery. Scars arc initially thick and pink but with time become white and
atrophic. It is the fibrous tissue replacement of the skin substance destroyed by
injury or disease.
8. Lichenification: it is a change in the skin which results from prolonged and
repeated irritation. The skin is thickened with accentuation of skin markings and is
usually hyperpigmented.
 1.Scale
Flakes of stratum
corneum.
Varying in size:
Large (like
membranes).
Tiny (like dust).
Dandruff.
Diseases: psoriasis,
parapsoriasis, eczema
mycosis fungoidis,
seborheic dermatitis,
pityriasis rosea, T.
versicolor, ichthyosis.
 2.Crust
Dry serum, blood, or
purulent exudate .
Thick and adherent .
Diseases: Impetigo,
herpes zoster,
chicken pox,
pyoderma, atopic
dermatitis, eczema.
 3.Erosion ion

j Superficial defect
involving only
epidermis.
j Partially loose of the
epidermis.
Diseases: ullous
pemphigoid,
Pemphigus vulgaris,
Impetigo, Candidiasis,
Tinea pedis.
 4.Ulcer

Necrosis of the
epidermis, dermis, or
subcutaneous tissue.
Ulcers always heal
with scar formation.
Diseases: leg ulcer,
Syphilitic chancre,
aphthous ulcers
squamous cell
carcinoma.
 5.Fissure Lire

u linear cleavage into

the dermis.
Fissu re
_j Diseases: Cheilitis,
Chronic eczematous
dermatitis,
Psoriasis, athlete's foot ,
keratoderma.
Loss of tissue from the
epidermis, dermis or
subcutaneous tissues.
Loss of skin texture
and cigarette paper­
like wrinkling.
Location:
Dermal or epidermal.
Diseases: leg ulcer,
wounds, leprosy
poikiloderma, LE.
Fibrous tissue
replacement.
Types:
Hypertrophic and
hard.
Atrophic and soft.
Diseases: burn, healed
wound, necrobiosis
lipoidica,
Pseudoporphyria.
Thickening of the
epidermis seen with
exaggeration of normal
skin lines.

Due to chronic rubbing or

scratching of an area.

Diseases: Atopic
dermatitis, Lichen simplex
chronicus, Eczematous
Dermatitis.
 Color in Dermatology 3 to logy
Pink: caused by increase in blood flow or interstitial fluid.
Red: caused by increased blood or dilated blood vessels.
Purple: caused by increased blood or dilated blood vessels.
Violaceous: lavender, bluish pink.
Depigmented: complete loss of pigment.
Hypopigmented: partial loss of pigment.
Brown: increase in melanin in epidermis.
Gray/blue: increase in melanin in dermis or subcutaneous tissue.
Black: intensely concentrated melanin.
Yellow: associated with lipids or sebaceous glands.
 HISTOPATHOLOGICAL TERMS
Hyperkeratosis: Increase thickness of the cornified layer
Orthokeratosis: Normal cornification (cells have cornified completely without
retained nuclei).
Parakeratosis: Pyknotic nuclei are retained in cells of homy layer with
reduction in granular cell layer.
Acanthosis: Increase m the thickness of stratum malpighii.
Papillomatosis: Accentuation of dermal papillae.
0
I
End Of Part
HY IS A DENTAL STUDENT STUDYING DERMATOLOGY? y

Dr.Basem Khaled Elswerkv

Gain an understanding of common dermatologic
conditions and treatments, many of which can be noticed
by dentists
• Recognize the three major types of skin cancer and
current management of them
Understand skin conditions that can have oral findings
Optimize co-management of patients between dentists
and dermatologists
dentists often see patients more than they see their
dermatologist. Many patients walk around with skin
pathology that they are unaware of.
the major types of skin cancer and their current
management strategies, as many cases occur on the
head/neck and can be diagnosed at early stages by
dentists.
Some skin diseases have oral manifestation
the most common skin lesions a dentist should be aware
of are squamous cell carcinoma, basal cell carcinoma, and
melanoma.