Introduction

&
Basic Science of
the Skin
Aklilu Melaku Gebremariam,MD
Dermatologist,
Dermatopathologist
Outline
 Introduction to dermatology
 Basic science of the skin
 Functions of normal skin
 Structure of normal skin and the skin
appendages
INTRODUCTION TO DERMATOLOGY
Dermatology
 Dermatology is the field of medicine
that deals with the macroscopic study of
skin, adjacent mucosa (oral and genital)
and cutaneous adnexa, while
dermatopathology deals with the
microscopic study of the same
structures. ( Bolognia J , Dermatology-3rd
ed)
Classification of Skin
Diseases

 Many ways to classify

 Virchow’s classification of diseases
 7 broad categories: Name!
Examples by
category
 Infectious
Cutaneous diseases
Bacterial infections

 Impetigo
 SSSS
 Folliculitis
 Cellulitis/Erysipelas
 Leprosy
 CTB
 Etc.
 Fungal Infections
 Superficial  Deep
 Dermatophytes
 Chromoblastomy
 T. Capitis
 T. Corporis cosis
 T. pedis
 Sporotrichosis
 Etc.
 Yeast
 Mycetoma
 T. Versicolor  Etc.
 Candidiasis
 Etc.
 Systemic
 Onychomycosis  Coccidiomycosis
 Viral Infections
 HPV
 MC
 HSV
 HZ
 HIV
 Etc.
 Protozoal infections

 Leishmaniasis
 Ameboid protozoa
 Trypanosomiasis
 Etc.
Worms( Helminths)
 Onchocerciasis
 Cutaneous larva migrans
 Filariasis
 Etc.
Infestations

 Scabies
 Pediculosis
 Tungiasis
 Myiasis
 STIs
 Gonorrhea
 Chlamydia
 Trichomonas vaginalis
 Syphilis
 Chancroid
 HSV
 LGV
 Donovanosis
 Etc.
Noninfectious
diseases
 Papulosquamous and

Eczematous
Eczemas
 Atopic Dermatitis
 Papulosquam
 Allergic Contact
Dermatitis,Irritant ous
contact dermatitis  Psoriasis
 Seborrheic Dermatitis  PLEVA, PLC
 Nummular eczema  P. Rosae
 Stasis dermatitis  PRP
 Dyshidrotic eczema  LP
 Id reaction  Etc.
(Autoeczematisation)
 LSC, prurigo nodularis
 etc
Erythemas and Urticarias
 Urticaria and Angioedema
 EM,SJS and TEN
 Drug reactions
 Purpuras and Cutaneous vasculitis
 Etc.
Autoimmune Bullous Diseases
 BP
 PV
 PF
 DH
 LAD/CBDC
 CP
 Paraneoplastic Pemphigus
 Bullous LE
 Etc.
Autoimmune connective tissue diseases

 Lupus Erythematosus(DLE,SLE)
 Dermatomyositis
 Rheumatoid arthritis
 Scleroderma
 Antiphospholipid Antibodies syndrome
 Etc.
Disorders of the PSU

 Acne
 Rosacea
 HS
 Fox Fordyce
 Miliaria
 Hyperhydrosis
 Etc.
 Genodermatoses
 Neurofibromatosis  Heritable disorders
 Tuberous sclerosis
of Connective
 Gen0photodermatoses(XP
,Cockayne tissue (Cutis
Syndrome,Bloom Laxa,PXE ,Ehlers-
Syndrome,etc.) Danlos syndrome)
 Ichthyoses  Porphyrias
 Keratodermas  Enzyme deficiency
 Darier Disease and
Hailey-Hailey Disease diseases
 Epidermolysis
 Albinism
 Primary bullosa
immunodeficiencies
Pigmentary disorders
 Hyper-

 Hypo-
Hair,Nails and Mucous membranes
diseases
Disorders of Subcutaneous Fat

 Panniculitides

 Lipodystrophies
Atrophies and D/os of Dermal connective
tissues

 EDS, PXE, Cutis laxa

 Dermal hypertrophies
 Atrophies
Vascular Disorders
 Infantile Hemangiomas
 Vascular Malformations
 Other vascular disorders
Photodermatoses
Disorders due to other physical agents

 Heat
 Cold
 Water
 Electricity
 Chemical
 Friction & traumatic
 Sports-related
 Skin signs of abuse
Metabolic and systemic
diseases
 Nutritional
 Mucinoses
 Amyloidosis
 Porphyria
 Other deposition disorders
 GVHD
 Dermatologic manifestations in patients
with systemic diseases
 Cutaneous Manifestations of Systemic
Disease
 Addison Disease
 Amyloidosis
 Thyroid Disease
 Renal Disease
 Gastrointestinal Disease
 Pulmonary
 Cardiac
 Neurological Disease
 DM
 Hyperlipidemias
 Cutaneous Hematology
 Paraneoplastic Diseases
 Cutaneous metastases
 Eosinophilic  Neutroph  Others
 HES ilic  Mastocytoses
 Granuloma  PG  Histiocytoses
faciale  Xanthomas
 Behcet’s
 Non-infectious
 Well Sxx  Sweet’s
granulomas( Sarc
oidosis,GA,NL,etc)
 Pregnancy
dermatosis
 Lymphedema
 Psychodermatose
s
 ……etc.!………
Neoplastic
Epithelial
 Epidermal: benign, malignant

 Adnexal : Follicular, Sebacous, Apocrine,and Eccrine

Non-Epithelial
 Melanocytic: Nevi, melanoma

Mesenchymal
.
.
.
Lymphocytic
Non-lymphocytic
 Emergency Dermatology

 EM, SJS, TEN

 Angioedema /Anaphylaxis
 Erythroderma
 Rashes in the Acutely Ill Febrile Patient
 Necrotizing Fasciitis
 Eczema herpeticum ,etc.
Others
Subspecialties
 Dermatosurgery  Photodermatology
 Dermatopathology  Geriatric
 Cosmetic dermatology
dermatology
 Allergology
 Rheumatologic
 Immunodermatology
Dermatology
 Pediatric dermatology
 Etc.
Objectives

 Diagnosis and Treatment of common

skin diseases
 Refer cases that need the attention
of a dermatologist
 References
• African Dermatology. Kasahun D. Bilcha
et al
• Fitzpatrick’s Color Atlas and synopsis of
Clinical Dermatology
• Anthony du Vivier. Atlas of Clinical
Dermatology,4th ed.
• Common skin diseases in Africa,2 nd
edition, Colette van Hees and Ben Naafs
• Dermatology, 3 rd ed. Bolognia J
• Andrew’s Text Book of Dermatology
• Fitzpatrick’s Dermatology in General
 Basic Science of
The Skin:
Structure and
Function
MEDICAL STUDENT CORE
CURRICULUM IN DERMATOLOGY
Aklilu Melaku Gebremariam,MD
Dermatologist,
Dermatopathologist
 Goals and Objectives
42

 The goal of this module is to introduce medical

students to some of the important basic science
principles necessary in understanding dermatologic
disease.
 By completing the module, the learner will be able
to:
• Gain familiarity with skin functions and how relevant
dysfunction contributes to disease
• Approach dermatologic disease with an
understanding of basic skin structure and
microanatomy
 Module Outline
43

 Functions of the skin

• Skin conditions related to disorder of
skin function
 Basic anatomy of the skin
• Related cutaneous diseases
 Take-home points
Functions of the
skin….Think…
 Functions of the Skin:
Barrier function
45
 The skin provides a physical barrier that
regulates water loss and protects against
mechanical, chemical and microbial insults from
the external environment.
 Dysfunction of the skin barrier leads to injury,
dehydration, infection
• This child has atopic and inflammation.
dermatitis, a chronic
skin condition
associated with
barrier dysfunction.
 Resistance to mechanical force
 Provided by the dermis
 Functions of the skin:
Immunologic function
48
 As an immunologic barrier, the skin both
senses and responds to pathogens.
 Dysfunction of the immunologic barrier
leads to infection, skin cancer,
inflammatory skin conditions and allergy.
• This HIV-positive man has
molluscum contagiosum, a
skin infection caused by a
virus.
 Functions of the skin:
Temperature regulation
49
 The skin helps maintain a constant body temperature
with the insulating properties of fat and hair and
through accelerating heat loss with sweat production
and a dense superficial microvasculature.
 Dysfunction of temperature regulation leads to hyper-
or hypothermia. Another example of thermoregulation
dysfunction is Raynaud phenomenon (chronic
episodic attacks of digital ischemia provoked
by exposure to cold).
 Functions of the skin:
Protection from radiation
50
 The dark pigment melanin in the epidermis protects
cells against ultraviolet radiation.
 Dysfunction of melanin production causes the
patient to be more susceptible to skin cancer.
• This patient with
albinism has a skin
cancer on the back.
 Functions of the skin:
Nerve sensation
51
 Sensory receptors allow the skin to constantly monitor
the environment and mechanoreceptors in the skin are
important for the body’s interactions with physical
objects
 Dysfunction leads to pruritus (itch), dysesthesia
(abnormal sensation), and insensitivity to injury (e.g.
diabetes, leprosy).
• This photo is of a
chronic ulcer on the foot
of a patient with
peripheral neuropathy
related to diabetes.
 Functions of the skin:
Injury repair
52
 The cutaneous wound repair process has four phases:
coagulation, inflammatory phase, proliferative-migratory
phase (tissue formation), and remodeling phase
 Loss of ability to repair injury (e.g. post-radiation
treatment) leads to delayed wound healing .
• This patient has a chronic
ulcer following trauma on
the scalp in a site previously
irradiated as part of
treatment for
squamous cell carcinoma.
 Vitamin D synthesis
 In the presence of UVB
 In the keratinocytes of the basal epidermis
 7-dehydrocholesterol (provitamin D3 ) 
Previtamin D3  Vitamin D3  vitamin D (1,25-
hydroxyvitamin D, calcitriol)
 Functions of the skin:
Appearance, Quality of Life
54
 Skin defects and even physiologic aging can result in
considerable psychological distress, an important clinical
feature of many cutaneous diseases.
• This patient has HIV-
associated lipoatrophy,
characterized by loss of fat
throughout the face.
• Atrophy of buccal fat pads
can be of particular concern
to patients since it gives the
appearance of facial wasting
and can have an impact on
self-esteem.
 Add vitiligo pt here
 Module Outline
56

 Functions of the skin

• Skin conditions related to disorder
of skin function
 Basic anatomy of the skin
• Related cutaneous diseases
 Take-home points
 Layers of the skin
57

 Skin is composed of three layers:

• Epidermis
• Dermis
• Subcutis
 Epidermis
 The outermost part of the skin
 Major protective layer derived from the fetal ectoderm
 Thickness vary from 0.1 to 1.5 mm
 Has no nerves, vessels or connective tissue
 Kinds:
 Glabrous skin – no hair follicles and sebaceous glands, thick
epidermis, encapsulated sense organs
 Hair bearing skin
 Can you name the layers of the skin indicated
below?
60

b
 Layers of the skin
61
 The epidermis is the topmost layer, and
consists primarily of keratinocytes.
 The dermis lies below the epidermis, and
consists primarily of fibroblasts, collagen,
and elastic fibers.

Epidermis

Dermis
 Layers of the skin
62

Below the Epidermis

dermis lies Dermis

fat, also
called
subcutis,
panniculus, or Subcutis

hypodermis.
 Outline: basic anatomy of skin
63

 Layers of the skin

• Epidermis: layers, cell types, and
function
• Dermis: layers, cell types, and
function
• Subcutis
 Adnexal structures
 Can you name the four major layers of the
epidermis?
64

d
 Can you name the four major layers of the
epidermis?
65

Stratum corneum

Stratum
granulosum
(granular cell
Stratum
layer)
spinosum
(spiny layer)
Stratum basale
(basal cell
layer)
 Functions of the layers of the epidermis
66

We will review the layers from bottom up, since that is the
order in which epidermal cells mature over their two-week life
cycle from the basal cell layer to the stratum corneum.
They are then shed two weeks after reaching the stratum
corneum (for a 28-day cycle). The cells differentiate as they
move upwards through the layers.
1. Basal layer
• The basal layer is the source
of epidermal stem cells. Cell
division occurs here.
• Keratinocytes start in the
basal layer and move
upwards.
 Functions of the layers of the epidermis
67

2. Spinous layer
• Center of epidermis.
Has a “spiny”
appearance due to
desmosomal junctions
(see slide 32), which
hold the keratinocytes
together.
1. Basal layer
 Functions of the layers of the epidermis
68

3. Granular cell layer

• Lipids produced by the
keratinocytes in the
granular cell layer and
secreted into the
extracellular space
between the
keratinocyte forms a
water barrier that
keeps water in the skin
2. Spinous layer
1. Basal layer
 Functions of the layers of the epidermis
69

4. Stratum corneum
• Made up of
desquamating
keratinocytes. Thick
outer layers of flattened
keratinized non-
nucleated cells provide a
barrier against trauma
and infection.
3. Granular cell layer
2. Spinous layer
1. Basal layer
 The Stratum Corneum
70
 You can think of the stratum corneum as a
wall of bricks and mortar
• Bricks: flattened keratinocytes filled with
keratin and filaggrin
• Mortar: lipid mixture, which surrounds the
keratinocytes and provides the water barrier

Lipid
Keratin and
intercellular
filaggrin-filled
matrix
corneocyte
 Filaggrin - an important protein in barrier
function
71
 Filaggrin is a protein found in the granular
cell layer of the epidermis.
 Filaggrin retains water within keratinocytes
 Mutations in filaggrin cause
atopic dermatitis and other
atopic diseases, such as
asthma
• This child has atopic dermatitis.
Notice the dry, erythematous,
plaques on the lower leg
 Diseases related to dysfunction of the
epidermal layers
72
 Certain diseases cause loss of adhesion:
• Bullous pemphigoid: an autoimmune blistering disease,
typically affects older patients. Autoantibodies form to
antigens directly beneath the basal layer of the epidermis.
Clinically, presents as tense bullae on an erythematous base
on the skin (mucous membranes may also be affected)
 Diseases related to dysfunction of the
epidermal layers
73

 In psoriasis, the rate of

epidermal turnover is increased
(thickening).
 The accelerated rate of
movement through the
epidermis doesn’t allow
adequate time for differentiation,
which is recognized as scale.
74

In the next pathology slide, see

if you can identify this common
skin cancer based on what you
have learned about the layers
of the skin

74
 Can you name the type of skin cancer?
(Hint: The cells composing this growth resemble what layer of the
epidermis?)
75
 Basal Cell Carcinoma
76

 Most common form of skin

cancer.
 Composed of cells that
resemble basal
keratinocytes.
 Most commonly presents
as pearly, erythematous
papules or plaques with
rolled borders and
telangectasias in sun-
exposed areas.
 Epidermis: Types of Cells
78

 Three main types of cells make up the

epidermis:
• Keratinocytes
• Melanocytes
• Langerhans cells
 Keratinocytes
79

 Keratinocytes make up the

majority of cells.
 Keratinocytes are held together
by macromolecular structures
that look like stripes (or spines)
between cells, called
desmosomes (primarily visible in
the spinous layer).
 “Clear cells”: Melanocytes
80

 The second type of cell which

makes up the epidermis is the
melanocyte.
 Melanocytes are staggered
along the basal layer at around
one in every 10 keratinocytes.
 They are the pigment-producing
cells, and transfer their pigment,
called melanin, to the
keratinocytes in the basal cell
layer.
 Nevi and Melanoma
81

 Melanocytic nevi, or moles, are benign

collections of melanocytes.
 Melanoma, shown below, is a malignancy of
melanocytes.
 “Clear Cells”: Langerhans Cells
82
 Langerhans cells are the third type of epidermal cells
 They are dendritic cells found in the mid-epidermis
 Their main function is in the afferent limb of the immune
response by providing for the recognition, uptake,
processing, and presentation of antigens to sensitized T-
lymphocytes, and are important in the induction of
delayed-type hypersensitivity.
• A common skin disease in
which Langerhans cells play
a prominent role is allergic
contact dermatitis, such as
poison oak

82
 Langerhans Cells
83
 Outline: basic anatomy of skin
85

 Layers of the skin

• Epidermis: layers, cell types, and
function
• Dermis: layers, cell types, and
function
• Subcutis
 Adnexal structures
 The two layers of the dermis
86

Papillary
dermis

Reticular
dermis
 The Dermis
88

 The dermis provides a flexible but tough support structure.

 It is between 1-4 mm thick (depending on age and body
location), making it much thicker than the epidermis.
 Structural componenets: collagen type I (strength),elastic
fibres (elasticity),and extracellular matrix (gelatinous GAGs
that bind water)
 Contains the blood and lymphatic vessels and nerves which
supply the skin,
 Adnexal structures of the dermis: apocrine & eccrine sweat
glands, sebaceous glands and hair follicles.
 Cells of the dermis: fibroblasts, macrophages & mast cells
 What is in the dermis?
90
 This is a biopsy from the scalp
to show the follicles and
sebaceous (oil) glands, found
in the dermis.
 Note the many hair follicles
(yellow arrow) running through
the dermis.
 Each follicle has associated
sebaceous or oil glands (blue
arrow).
 Red arrow – epidermis
 Green arrow – reticular dermis
 Cells of the dermis
91
 Fibroblasts and mast cells reside in the dermis
 Fibroblasts are responsible for the synthesis and
degradation of connective tissue proteins
 They are instrumental in wound healing and
scaring
• Keloids (abnormal scars)
result from uncontrolled
synthesis and excessive
deposition of collagen at sites
of prior dermal injury and
wound repair
 Cells of the dermis
92

 Mast cells are specialized cells that are

responsible for immediate-type
hypersensitivity reactions in the skin
• The mast cell is the major
effector cell in urticaria,
which is a vascular
reaction of the skin
characterized by wheals
surrounded by a red halo
or flare.
Mast Cells

93
 Outline: basic anatomy of skin
94

 Layers of the skin

• Epidermis: layers, cell types, and
function
• Dermis: layers, cell types, and
function
• Subcutis (fat)
 Adnexal structures
 The pilosebaceous (hair/oil gland) unit
95

 Adnexal structures include the

pilosebaceous unit and eccrine
gland
 Pilosebaceous unit consists of:
1. A hair follicle
2. Sebaceous (oil) glands
3. Apocrine* sweat glands
4. An arrector pili muscle (when these
contract you get goosebumps)

Apocrine glands are found in the axillary and

anogenital areas, which is why we do not see them
on this biopsy of the scalp. These glands open
directly in to the hair follicle.
 Adnexal structures of the demis: Disorder of
pilosebaceous unit
98
 Acne vulgaris is a disorder of the
pilosebaceous unit.
 It is caused by 4 factors:
• Plugging of the hair follicle as a result of
abnormal keratinization of the upper
portion (gives rise to comedones)
• P. acnes (bacteria) in the hair follicle (lives
on the oil and breaks it down to free fatty
acids which cause inflammation)
• Presence of hormones (androgens)
• Sebaceous gland activity (increased in
presence of androgens)
 Eccrine Glands
99

 In contrast to apocrine glands,

eccrine sweat glands do not
involve the hair follicle. They
open directly onto the skin
surface and are present
throughout the body.
 Eccrine glands help regulate body
temperature by excreting sweat
onto the skin surface, where
cooling evaporation takes place.
 Eccrine glands are sometimes
genetically absent, which will
predispose a patient to
hyperthermia.
 Picture : Hyperhidrosis wich is due
to cholinergic hyperstimulation of
the eccrine sweat glands, which
are innervated by the
sympathetic nervous system
 Outline: basic anatomy of skin
100

 Layers of the skin

• Epidermis: layers, cell types, and
function
• Dermis: layers, cell types, and
function
• Subcutis
 Adnexal structures
 The Subcutis
101

 The subcutis is the fat layer which separates the dermis from
deeper underlying structures such as fascia and muscles
 Made of adipocytes and the connective tissue septa
 Important for supporting blood vessels, nerves &
lymphatics to the dermis
 Shock Absorber and involved in thermoregulation

 The subcutis insulates the body, serves as an energy supply,

cushions and protects the skin, and allows for its mobility over
underlying structures
 Disorder of the subcutis
102

 Erythema nodosum is an
example of panniculitis
(inflammation of the subcutis)
• Clinically appears as deep-
seated erythematous
nodules, typically on the
shins
• Erythema nodosum may be
idiopathic or a reaction to
infections, medication, or an
underlying autoimmune
disease (e.g. Crohn’s
disease)
Embryology : in brief
 Epithelial structures are from ectoderm
 Epidermis
 Folliculo-sebaceous-apocrine units
 Eccrine units
 Nail units
 Neuroectoderm
 Melanocytes
 Nerves
 Specialized sensory receptors
 Mesoderm
 Lanagerhans’ cells
 Macrophages, mast cells and fibrocytes
 Blood vessels, muscles and adipocytes
 Module Outline
104

 Functions of the skin

• Skin conditions related to disorder
of skin function
 Basic anatomy of the skin
• Related cutaneous diseases
 Take-home points
 Skin Appendages & MMs
 Hair
 Nails
 Mucosa
 Hair
 Three types of hair:
 Lanugo (fine long hair in fetus)
 Vellus (fine short hair on all body surfaces)
 Terminal (coarse long hair on the scalp, eyebrows, eyelashes
& pubic areas)
 Cycles
 Anagen phase (Growth phase) lasts 3 years
 Catagen phase (Transition phase/involution) 3 weeks
 Telogen phase (Resting stage) 3 months
 Scalp Hair
 Growth rate is 0.37 mm/day
 80 to 90% of follicles are growing (anagen)
 5 to 10 % are resting (telogen)
 1 to 3 % are undergoing involution (catagen)
 Nails
 Grows out from the nail matrix and rests
on the underlying nail bed
 Nail

 Growth:
 Finger nails is 1 cm/3 months (fully 6
month)
 Toenail growth 1 cm/9 months (fully 6-18
months)
 Therapy of the diseased nails requires both
time and patience
 Nails may be come involved in a
Acknowledgements

 Dr Tirsit Retta
 American Academy of Dermatology’s
Medical Student Core Curriculum
Workgroup from 2008- 2012
Thank you