ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA

POSTGRADUATE DIPLOMA IN
FAMILY MEDICINE

MODULE 13
Dermatology & STI

2nd Edition

Author:

Assoc. Prof. Dr. Chandran Rajagopal

MBBS, FCGP, FRSH,MAMS (Vienna), DRM ,Dip Ven,Dip STD&AIDS,
Diploma in Dermatology, Diplomate in Restorative & Aesthetic Medicine(Miami,
USA), Certified Master trainer AARAM USA,
Fellow American Academy of Dermatology
Fellow American Academy of Restorative & Aesthetic Medicine
Fellow American Academy Aesthetic and Restorative Surgery
Member Academy of Family Physicians of Malaysia
Fellow Indian Academy Medical Specialists(Family Medicine)
Certified Trainer,Teaching of Family Medicine (AFPM)
Certified Physican in management of Estrogen deficiency ,menopause and HRT ,
College of Physicians and Surgeons, University of Columbia,New York

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Chapter 1: Microanatomy of the skin

Body organs aren't all internal like the brain or the heart. There's one we wear on the outside. Skin is our
largest organ—adults carry some 8 pounds (3.6 kilograms) and 22 square feet (2 square meters) of it. This
fleshy covering does a lot more than make us look presentable. In fact, without it, we'd literally evaporate.
Skin acts as a waterproof, insulating shield, guarding the body against extremes of temperature, damaging
sunlight, and harmful chemicals. It also exudes antibacterial substances that prevent infection and
manufactures vitamin D for converting calcium into healthy bones. Skin additionally is a huge sensor packed
with nerves for keeping the brain in touch with the outside world. At the same time, skin allows us free
movement, proving itself an amazingly versatile organ.
Skin is made up of three layers. The outermost is the epidermis. This consists mainly of cells called
keratinocytes, made from the tough protein keratin (also the material in hair and nails). Keratinocytes form
several layers that constantly grow outwards as the exterior cells die and flake off. It takes roughly five weeks
for newly created cells to work their way to the surface. This covering of dead skin is known as the stratum
corneum, or horny layer, and its thickness varies considerably, being more than ten times thicker on the soles
of the feet than around the eyes. The epidermis harbors defensive Langerhans cells, which alert the body's
immune system to viruses and other infectious agents.there is no way that you can study about the skin
without knowing the foundations ie the microanatomy of the skin and its various functions.

Functions of the skin

1. Helps regulate body temperature

2. Provides a surface for grip

3. Acts as a sensory organ

4. Acts as an outpost for immune surveillance

5. Plays a role in Vitamin D production

6. Has a cosmetic association

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Sebum

It is an oily secretion produced by sebaceous glands, tiny ducts adjacent to hair follicles.

Sebum is secreted into the follicle, from which it spreads over the hair and skin. The main role of sebum is to
waterproof the skin and hair.

Both excess and lack of sebum are undesirable. Excess sebum is associated with oily skin and acne. It is
particularly common in adolescents as the increased levels of sex hormones stimulate sebum production. Lack
of sebum, which is common in middle and older age, leads to skin dryness and accelerates wrinkle formation It
is really a big ask to learn about dermatology and sexually transmitted diseases in 80’hours.However in real
time the family physician is usually the first one to treat a patients skin disease. As a matter of fact 25% of a
family physicians practice is “Dermatologic”. As such it is necessary for the primary care physician to be
fairly well versed skin diseases.

Skin structure and functions of the skin

Skin Functions

Protection against

Water loss - Stratum Corneum

Water gain - Straum Corneum
Toxic substance penetration - Stratum Corneum
Microbial attack - Stratum Corneum
Mechanical injury - Stratum Corneum

Thermal regulation

Via heat loss

Sweat evaporation via eccrine glands

Vasomotor regulation – Vasculature

Via heat conservation

Body hair and insulation provided by body heat

Sensory functions by free nerve endings and end organs

Secondary sexual characteristics

Immune functions protect against foreign antigens from epidermal antigen presenting cells.
Metabolic Vit D synthesis

Radiation (UV) protection

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Skin Microscopy

Thickness ranges from (0-04 mm eye lids) to 0.16 (palms and soles)

Turn over – 28to 40 days required to move from stratum basale to stratum corneum, 52 days for full epithelial
cycling.

Layers of the skin

Stratum basale - multiplying columnar cells

Stratum Spinosum - 5 – 12 layers, polyhedral cells.intrcellular

Bridges and dermasomes present.

Stratum granulosum - Flat fusiform cells(1to3),

Keratinohyaline granules present

Stratum corneum - Enucleated flattened cells

Cells Origin Function

Keratinocyte Ectodermal,move upwards Synthesises tonofilaments

stratum basalis upwards which is the precursor keratin

keratinocytes mature to form cornified cells

Melanocytes(ratio of ) Neural crest These are dendritic

cells containing melanosomes

to melanocytes is 4:1 to 10:1

Langerhan cells Mesenchymal Dendritic cells

with intracytoplasmic granules.

Role in graft rejection,

Delayed hyper sensitivity immune reaction

Merkel cells Neural Crest Dendritic cells with

intracytoplasmic ,neurosecretory granules

Functions as slow adapting touch receptors

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Prickle Cell Layer (stratum spinosum)

Daughter basal cells migrate upwards and differentiate into polyhedral cells in this layer. Desmosomes
interconnect these polyhedral cells and give rise to the "prickles/spines" seen at light microscope level. Keratin
tonofibrils form the cytoplasmic supportive network. Langerhans cells are mostly found in this layer.They are
dendritic, immunologically active cells that play a role in antigen presentation.

KERATINISATION

The progressive maturation of a keratinocyte is charcterized by the accumulation of keratin, called

keratinization. The cells of the stratum granulosum (SGR) accumlate dense basophilic keratohyalin granules
(seen on the close-up view).

These granules contain lipids, which along with the desmosomal connections, help to form a waterproof
barrier that functions to prevent fluid loss from the body

GRANULAR CELL LAYER (stratum granulosum)

In this layer, cells become flattened and lose their nuclei. In the cytoplasm, there are keratohyalin granules as
well as membrane-coating granules which expel their lipid contents into the intercellular spaces (lamella
granules a.k.a Odland bodies). The keratohyalin granule merges to form the tonofilaments.

HORNY LAYER (stratum corneum)

This layer is composed of sheets of overlapping polyhedral cornified cells with no nuclei called corneocytes.
This layer is thickest on the palms and soles. The flattened corneocyte develops a thickened cell envelope. Its
cytoplasm is replaced by keratin tonofibrils in a matrix formed from keratohyalin granules.Whereas, the
membrane-coating granules produce lipid glue that keeps the cells stuck together. This forms the hydrophobic
barrier membrane that protects the skin, and prevents water loss.

Epidermopoiesis

The epidermis is a multilayered structure (stratified epithelium) which renews itself continuously by cell
division in its deepest layer, the basal. The principal cell type, the epidermal cell, is most commonly referred to
as a keratinocyte. The cells produced by cell division in the basal layer constitute the prickle cell layer and as
they ascend towards the surface they undergo a process known as keratinization which involves the synthesis
of the fibrous protein keratin. The total epidermal renewal time is 52-75 days.

The cells on the surface of the skin, forming the horny layer (stratum corneum), are fully keratinized dead cells
which are gradually abraded by day to day wear and tear from the environment.This is the principle of
chemical peels

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Non-Keratinocyte Cells of the Epidermis

Three cells essential for the function of the mature epidermis are not keratinocytes. (Ie Melanocyte, Langerhan
cells, Merkle cells.

Two of them are derived from extracutaneous sources and migrate from their tissue of origin into the
epidermis (Melanocyte & Langerhan cells.

The third (Merkle cell) probably derives from the keratinocyte but is so extensively modified by differentiation
that it bears no resemblance

Melanocytes

Melanocytes are pigment-producing dendritic cells in mature epidermis. They are derived from the neural crest
and migrate into the epidermis in the 6th week of embryonic life.

They are functionally immature during their migration. There are about 36 keratinocytes for each melanocyte
they synthesize and secrete melanin containing organelles called melanosomes and transfer these to
keratinocytes.

The process of transfer is called apocaption where the tips of the dendrites are phagocytosed by the
keratinocytes.

Melanin: Types, Synthesis and Hormonal Regulation

Fair skinned person synthesized a light brown type of melanin , Pheomelanin – which are distributed in small
amounts to the surrounding keratinocytes .
Dark coloured persons produce a dark form of melanin Eumelanin – are distributed in large amounts to the
neighbouring keratinocytes.
All other skin colours are due to an admixture of light brown pheomelanin and dark brown eumelanin.

Functions of the Skin

 barrier to physical agents

 protects against mechanical injury

 prevents dehydration of body through fluid loss

 reduces the penetration of UV Radiation

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SWEAT

It is a salty, watery solution produced by sweat glands, numerous microscopic channels opening onto the skin
surface. As sebum and sweat mix up on the skin surface, they form a protective layer often referred to as the
acid mantle .Acid mantle has a particular level of acidity characterized by pH from about 4 to 5.5. A pH of 7 is
considered neutral, above 7 is alkaline, and below is acidic.

The skin is mildly acidic. In addition to helping protect skin from "the elements" (such as wind or pollutants),
acid mantle also inhibits the growth of harmful bacteria and fungi. If acid mantle is disrupted or loses its
acidity, the skin becomes more prone to damage and infection.The loss of acid mantle is one of the side-effects
of washing the skin with soaps or detergents of moderate or high strength.

The skin has several layers & appendages

Epidermis

Dermis

Subcutaneous Layer

Hair

Nails

Sweat Glands

Sebaceous Glands

Nerves

Vessel

HAIR

Hair can be found in greatest concentration in the facial area and is present over our entire body with the
exception of the glabrous skin of the palms, the soles of our feet, the glans penis and the vulval introitus.
The hair follicle originates from the epidermis and the dermis. The epidermis is responsible for the matrix and
hair cells.The dermis gives rise to the papilla which is composed of many blood vessels and nerves. Hair can
be classified in one of three ways. Hairs that are long and fine and formed in the fetus at 20 weeks of birth are
referred to as Lanugo hairs. These are normally shed before birth, but may remain on premature babies. Vellus
hairs cover most of the surface area of our bodies and are colorful, short and fine. At puberty, the Vellus hairs
are stimulated by androgens to form Terminal hairs. Terminal hairs are the longer, darker, thicker hairs found
on the eyebrows, eyelashes, scalp, pubic and axillary region.

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HAIR CYCLE

The most important feature of hair follicles is that their activity is intermittent (cyclical). the hair reaches a
definitive length, it is shed to be replaced by a new hair.

Thus a hair follicle will pass into three stages: an active (anagen) stage, a resting (catagen) stage, and a telogen
stage where the hair stops growing to be finally shed.

In human scalp hair, the anagen stage takes about three years, the catagen stage takes three weeks, and the
telogen phase takes three months. The hair cycle occurs in different hair follicles asynchronously, i.e., at a
given time, each individual hair follicle is at a different stage of the hair cycle.

Skin Appendages cells derived from both ectoderm and mesoderm:

1. Eccrine Sweat Gland

2. Apocrine Sweat Gland

3. Sebaceous Gland

4. Hair Follicle

5. Nails

SUBCUTANEOUS TISSUE

The subcutaneous layer is the interior skin and temperature regulation is its main task. Thus, another major
function of the skin is temperature regulation.

Through widening or narrowing of the blood vessels in the skin and by secretion of liquids over the skin's
glands, the skin has an influence on the body temperature.

The skin has a barrier function.

The pH-value of intact skin is 4.5. This is due to endogenous acid substances in sweat, sebaceous and horny
cells.

The significance of this acid property of the skin's surface becomes obvious by the so-called "acid protection
layer".

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Dermis

Dermis is a tough supportive connective tissue matrix containing numerous specialized structures. The dermal
thickness varies being thinnest (0.6 mm) on the eyelids and thickest (3 mm or more) on the back, palms, and
soles.

The dermis is intimately connected with the epidermis. The papillary dermis - the thin upper layer - of the
dermis - lies directly below and interdigitates with the epidermal rete ridges. The papillary dermis is
composed of loosely interwoven collagen. Found deeper is the thicker reticular dermis.

Dermal Structures

Collagen fibers make up 70% of the dermis and give structural toughness and strength. Elastin fibers are
loosely arranged in all directions and give elasticity to the skin. They are most prevalent near hair follicles and
sweat glands and less so in the papillary dermis. The dermal ground substance consists of a semi-solid matrix
of glycosaminoglycans (GAG) which impart movement to some dermal structures. In addition, the dermis
contains: fibroblasts which synthesize collagen, elastin, other connective tissue and GAG; dermal dendrocytes
which are dendritic cells with immune function; mast cells; macrophages; and lymphocytes.

Important Collagen

The most abundant types of collagen in the skin are I and III; their fibrils form the mesh largely responsible for
the skin's mechanical properties.

Other types of collagen in the skin are V, VI, and XII.

They are found in small amounts & their role is supportive.

Cellular Skin Changes Caused by UV Radiation

Sunlight has a profound effect on the skin causing premature skin aging, skin cancer, and a host of skin
changes.

Exposure to ultraviolet light, UVA or UVB, from sunlight accounts for 90% of the symptoms of premature
skin aging.

Many skin changes that were commonly believed to be due to aging, such as easy bruising, are actually a result
of prolonged exposure to UV radiation

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MUSCLES OF FACIAL EXPRESSION

a) -move skin of face, close eyes, open/close mouth

b) -convey emotions by gestures (ex. sneering, contempt) - most originate – from bones;

c) -inserted – to skin;

- Many are named for their action in Latin/Greek

- movements elicited in test for facial Nerve function

d) Profound knowledge in the muscles of the face and arterial and nerve supply are vital for those
interested in aesthetic medicine or cosmetic dermatology.

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