BASIC SCIENCE
Structure and function of
skin, hair and nails
Joey E Lai-Cheong
John A McGrath
Abstract
The skin is the largest organ of the human body. It is a complex epithelial
and mesenchymal tissue comprising a multilayered stratified epidermis,
adnexal structures such as hair follicles, sweat glands and sebaceous
glands, a dermis containing collagen and elastic fibres, and underlying
subcutaneous fat. More than 1000 disease entities involving the skin
have been described and up to 20% of all patient referrals to general
practitioners involve skin pathology. Diseases such as psoriasis, eczema,
urticaria and skin cancer impose a considerable burden on healthcare re-
sources and impact significantly on patients’ quality of life. Knowledge of
the structure and function of the skin and its appendages is paramount to
understanding the biology of healthy skin and the pathophysiology of
skin diseases.
Keywords dermis; epidermis; hair follicles; keratinocytes; melanocytes;
nail apparatus; subcutaneous fat
Structure of the skin
The skin accounts for about 15% of the total body weight of an
adult and has a surface area of about 2 m2. In a 70-kg adult, the
skin weighs about 13 kg, making it the largest organ in the
human body. Skin consists of three main zones (Figure 1a):
 epidermis
 dermis
 subcutis.
Skin diseases can affect each region of the skin.
Epidermis
The epidermis is the outermost layer of the skin. The principal
cell is the keratinocyte (95% of cells). Melanocytes, Langerhans
cells and Merkel cells account for the remaining 5%. The
epidermis is divided into four main layers depending on the state
of keratinocyte differentiation (Figure 1b).
The basal layer consists of a single layer of keratinocytes.
These cells proliferate and commit daughter cells to terminal
differentiation, which ends in the formation of the stratum cor-
neum.1 This process normally takes about 40 days but is shorter
Joey E Lai-Cheong BMedSci(Hons) MBBS PhD MRCP is a Consultant
Dermatologist at King Edward VII Hospital, Windsor, UK. Competing
interests: none declared.
John A McGrath MD FRCP FMedSci is Professor of Molecular Dermatology at
St John’s Institute of Dermatology, King’s College London, UK.
Competing interests: none declared.
MEDICINE 41:6
in diseases such as psoriasis. Melanocytes, which are dendritic
cells derived from the neural crest, also sit in the basal layer.
Melanocytes synthesize melanin, which is packaged in subcel-
lular organelles (melanosomes) and then transported to the
neighbouring basal keratinocytes. The melanosomes form a
‘melanin cap’ that protects basal keratinocyte nuclei from
harmful ultraviolet radiation. There is little racial variation in the
number of melanocytes. Skin colour is determined by the num-
ber and size of the melanosomes and the nature of the melanin
(eumelanin versus pheomelanin).2 The outermost stratum cor-
neum (cornified layer) is composed of about 10 layers of flat-
tened corneocytes, although it is thicker on the palms and soles.
These cells are embedded within a hydrophobic extracellular
matrix derived from lipid precursors and lipid hydrolases, which
are both secreted by lamellar bodies present within the subjacent
granular layer.3 These hydrolases cleave the lipid precursors
resulting in the formation of fatty acids, cholesterol and at least
10 ceramides. These lipid components then organize themselves
into lamellar bilayers that integrate between the corneocytes,
provide a watertight seal and maintain epidermal barrier
integrity.4
Langerhans cells are bone marrow-derived, antigen-present-
ing dendritic cells and may be found throughout the epidermis.
Merkel cells within the epidermis transmit sensory information
from the skin to sensory nerves.
Dermaleepidermal junction
The epidermis is separated from the dermis by the cutaneous
basement membrane zone (BMZ) (Figure 2). Although less than
200 nm across, this region of skin is composed of an intricate
network of macromolecules that link the keratin intermediate fil-
aments of basal keratinocytes with collagen fibres in the superfi-
cial dermis. The main function of the proteins and glycoproteins
within the BMZ is to provide adhesion between the epidermis and
the dermis. Defects in these molecules result in skin blistering.5,6
Dermis
The dermis is 0.5e5 mm thick, depending on body site: a thin
dermis is found on the eyelid and a thick dermis is present on
back skin. It is subdivided into two main layers:
 papillary dermis, which is in contact with the BMZ and is
richly supplied by blood vessels and sensory nerve
endings.
 reticular dermis, which is the principal part of the dermis
that is in contact with the subcutis.
The dermis is composed of interstitial (collagen fibres, elastic
tissue and ground substance) and cellular (fibroblast, mast cell,
plasma cell, lymphocytes, dermal dendritic cell and histiocyte)
components. It also contains blood vessels (superficial and deep
plexi), lymphatic channels and sensory nerves (free nerve end-
ings and end corpuscles, which include Pacinian corpuscles that
sense vibration, and Meissner corpuscles, which are responsible
for tactile and pressure sensations).
About 70% of the dry weight of the dermis is made up of
collagens,7 of which the predominant types are types I and III.8
Elastic fibres are less tough than collagen fibres but impart
extensible properties to the skin. They account for about 5% of
the dry weight of the dermis and consist of elastin and elastic
microfibrils (e.g. fibrillin).
317 Ó 2013 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

Fibroblasts are derived from the mesenchyme. The dermis

Rete ridges Melanocytes also contains histiocytes, antigen-presenting cells that
a
Hair follicle Dermal phagocytose and degrade foreign substances and present
blood antigens to T cells. Mast cells are distributed near dermal
b vessels blood vessels and are responsible for the secretion of che-
motransmitters such as histamines during an allergic reac-
tion. Within the dermis there are 1.5e4  106 sweat glands,
which are subdivided into eccrine and apocrine glands. Most
thermoregulatory sweating and sweat fluid comes from
eccrine glands.

Subcutis
The subcutis is the innermost layer of the skin and is composed
of lipocytes. The lipocytes are arranged into fat lobules, which
are separated from one another by fibrous septae. Bundles of
fibres originating from the dermis into the subcutis strengthen
Sweat glands the connection between these two compartments. In non-obese
Arrector pili subjects, about 80% of all body fat is located within the
subcutis.

Structure of hair
(a) Haematoxylin and eosin staining of normal skin (chest) shows the three
layers of the skin, namely the epidermis, dermis and subcutis. Adnexal Humans have up to 5 million hairs. There are three types of hair:
structures such as hair follicles, arrector pili muscle and sweat glands are
clearly seen. (b) Higher magnification of normal skin shows the four principal  lanugo hair, which is shed soon after birth
layers of the epidermis. Melanocytes are scattered within the basal layer of  vellus hair, which is fine hair distributed mostly over the
the epidermis (bar = 50 µm).
body
 terminal hair, which is longer and coarser.
Figure 1 Fewer than 2% of men and 45% of women go through life with a
full head of hair.
Collagen and elastic fibres are bathed in a gelatinous sub- The hair follicle is a complex epithelial structure (Figure 3).
stance called ground substance, which is composed of pro- It is surrounded by an outer hair root sheath, which helps
teoglycans and glycoproteins. protect the growing hair, and an inner hair root sheath, which
The fibroblast is the predominant cell type in the dermis. follows the hair shaft up to the opening of the sebaceous gland.
It secretes collagens, elastic fibres and ground substance. The base of the hair follicle consists of the dermal papilla,
which is richly supplied by blood vessels and sensory nerves.
Within the hair papilla resides the hair bulb, which is the site
Dermal–epidermal junction where the growing hair originates. An important structure
Hemidesmosomes
within the hair follicle is the hair bulge, which has been
shown to harbour both epithelial and melanocytic stem cell
Keratin intermediate
populations (the former generate hair follicles, sebaceous
filaments
glands and, during wound healing, the interfollicular epithe-
lium). The hair bulb is the site of insertion of the arrector pili
muscle. Contraction of the arrector pili muscle leads to
‘goosebumps’.
Hair consists of three concentric areas:
 the cuticle, which is the outer covering of the hair
 the cortex, which is the largest portion of the hair and
imparts strength to the hair shaft
 the medulla, which is the central area of the hair and is not
200 nm always present.
Hair typically grows 10e15 mm per month. Its growth is dynamic
and consists of three phases:
 an anagen phase during which the hair is actively growing;
Lamina densa about 84% of hairs are in the anagen phase, which lasts
Anchoring fibrils 3e10 years
Ultrastructure of the cutaneous basement membrane zone by transmission  a catagen phase during which the hair stops growing but
electron microscopy. cellular activity still continues within the germinal centre
of the hair follicle; about 1% of hairs are in the catagen
Figure 2 phase, which lasts 2e3 weeks

MEDICINE 41:6 318 Ó 2013 Elsevier Ltd. All rights reserved.

 BASIC SCIENCE

Structure of hair and associated adnexal components External architecture of the nail

Free edge of nail

Yellow line of Pinkus
Epidermal layers
Distal pink zone
Onychocorneal band
Basal layer
Accentuation of
Infundibulum nail bed erythema
Nail wall
Outer root sheath Sebaceous Proximal pink zone
gland
Lunula

Cuticle
Inner root sheath Hair follicle stem cells
Proximal nail fold

Hair shaft

Figure 4

 the nail bed e this is found at the base of the nail plate on
Dermal Hair follicle
which the latter rests. It is tightly connected to the nail
papilla matrix
plate and is continually keratinized to maintain adhesion.
Fingernails grow by about 3 mm/month, whilst toenails grow
more slowly.
Lineages derived from bulge stem cells
Differentiation pathways supplied by bulge stem cells Function of skin, hair and nails

This figure also defines the major source of stem cells within the follicular
bulge. These cells can give rise to hair follicles, sebaceous glands and
interfollicular epidermis.
Figure 3
 a telogen phase, which is the final stage during which there
is no growth of hair or activity at the hair bulb; about 15 %
of hairs are in the telogen phase, which lasts 3e4 months.
In humans, these three phases occur simultaneously in different
hairs. Every human hair typically undergoes 10e20 complete
cycles of anagenecatagenetelogeneanagen during an average
lifetime.
Structure of nail
Like hair, the nail is a keratinized epithelial structure (Figure 4)
and consists of:
 the nail plate e this is a rectangular convex plate of ker-
atinized cells (onychocytes), which develops from the nail
matrix outwards
 the nail matrix e this is a wedge-shaped structure that
contains a highly specialized epithelium consisting of
keratinocytes, and which generates the nail plate
 the nail folds e these consist of a proximal and a lateral
nail fold, which covers the sides of the nail plate and the
nail bed
 Skin provides a physical barrier against the external
environment and helps reduce water loss by means of the
water-impermeable stratum corneum. The stratum cor-
neum also helps against the penetration of irritants and
other allergens that can cause skin inflammation, such as
in dermatitis.
 Skin contributes to innate and adaptive immunity.
Keratinocyte-derived endogenous anti-microbial peptides
such as defensins and cathelicidins are active against a
variety of bacteria, viruses and fungi.9 The sweat-derived
dermcidin has been shown to have potent anti-microbial
activity against Staphylococcus aureus, Escherichia coli
and Candida. The skin has a network of Langerhans cells,
which act as sentinel cells to initiate immune responses
against microbial threats.
 The skin is important for thermoregulation. Regulation of
heat loss is achieved by vasodilatation and vasoconstric-
tion of both cutaneous superficial and deep vascular plexi.
Thermoregulation is also achieved by sweating produced
by eccrine sweat glands.
 The skin is important for sensory perception due to its rich
supply of free nerve endings and end corpuscles.
 Skin is important for the synthesis of vitamin D and
thereby contributes to bone formation, calcium meta-
bolism, and aspects of immune regulation.
 The subcutaneous fat is important in cushioning trauma,
providing insulation and is an important energy reserve. It
also has an endocrine function.

MEDICINE 41:6 319 Ó 2013 Elsevier Ltd. All rights reserved.

 BASIC SCIENCE
 Nails protect the digits as well as participating in sensory
perception.
Conclusions
The skin is a complex self-regenerating epithelial and mesen-
chymal tissue. Knowledge of the structure of the skin and its
appendages is essential in order to appreciate and understand the
wide variety of skin diseases faced by medical practitioners. A
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MEDICINE 41:6
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Acknowledgements
Figures courtesy of St John’s Institute of Dermatology (King’s
College London).
320 Ó 2013 Elsevier Ltd. All rights reserved.