III.

Clinical Discussion
A. Anatomy and Physiology

INTEGUMENTARY SYSTEM
ANATOMY OF THE SKIN, HAIR AND GLANDS OF THE SKIN The skin is composed of three layers: epidermis, dermis, and subcutaneous tissue. The epidermis is an outermost layer of stratified epithelial cells and composed predominantly of keratinocytes. It ranges in thickness from about 0.1 mm on the eyelids to about 1 mm on the palms of the hands and soles of the feet. Four distinct layers compose the epidermis, from innermost to outermost: stratum germinativum, stratum granulosum, stratum lucidum, and stratum corneum.

Epidermis is contiguous with the mucous membranes and the lining of the ear canals, consists of live, continuously dividing cells covered on the surface by dead cells that were originally deeper in the dermis but were pushed upward by the newly developing, more differentiated cells underneath. This external layer is almost completely replaced every 3 to 4 weeks. The dead cells contain large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin and has the capacity to repel pathogens and prevent excessive fluid loss from the body.

Melanocytes are the special cells of the epidermis that are primarily involved in producing the pigment melanin, which colors the skin and hair. The more melanin in the tissue, the darker is the color. Normal skin color depends on race and varies from pale; almost ivory, to deep brown, almost pure black. Systemic disease affects skin color as well. Production of melanin is controlled by a hormone secreted from the hypothalamus of the brain called melanocyte-stimulating hormone. It is believed that melanin can absorb ultraviolet light in sunlight. Dermis The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular. The papillary dermis lies directly beneath the epidermis and is composed primarily of fibroblast cells capable of producing one form of collagen, a component of connective tissue. The reticular layer lies beneath the papillary layer and also produces collagen and elastic bundles. The dermis is also made up of blood and lymph vessels, nerves, sweat and sebaceous glands, and hair roots. The dermis is often referred to as the true skin. Subcutaneous Tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones. It promotes skin mobility, molds body contours, and insulates the body. Fat is deposited and distributed according to the persons gender and in part accounts for the difference in body shape between men and women. Overeating results in increased deposition of fat beneath the skin. The subcutaneous tissues and amount of fat deposited are important factors in body temperature regulation. Hair An outgrowth of the skin, hair is present over the entire body except for the palms and soles. The hair consists of a root formed in the dermis and a hair shaft that projects beyond the skin. It grows in a cavity called a hair follicle. Proliferation of cells in the bulb of the hair causes the hair to form. Hair follicles undergo cycles of growth and rest. Glands of the Skin There are two types of skin glands: sebaceous glands and sweat glands. The sebaceous glands are associated with hair follicles. The ducts of the sebaceous glands empty sebum (ie, oily secretion) onto the space between the hair follicle and the hair shaft. For each hair there is a sebaceous gland, the secretions of which lubricate the hair and render the skin soft and pliable. Sweat glands are found in the skin over most of the body surface. They are heavily concentrated in the palms of the hands and soles of the feet. Sweat glands are subclassified into two categories: eccrine and apocrine.

The eccrine sweat glands are found in all areas of the skin. Their ducts open directly onto the skin surface. The thin, watery secretion called sweat is produced in the basal coiled portion of the eccrine gland and is released into its narrow duct. Sweat is composed of predominantly water and contains about one half of the salt content of the blood plasma. Sweat is released from eccrine glands in response to elevated ambient temperature and elevated body temperature. The rate of sweat secretion is under the control of the sympathetic nervous system. Excessive sweating of the palms and soles, axillae, forehead, and other areas may occur in response to pain and stress. The apocrine sweat glands are larger, and unlike eccrine glands, their secretion contains parts of the secretory cells. They are located in the axillae, anal region, scrotum, and labia majora. Their ducts generally open onto hair follicles. The apocrine glands become active at puberty. Apocrine glands produce a milky sweat that is sometimes broken down by bacteria to produce the characteristic underarm odor. FUNCTIONS OF THE SKIN Protection The skin covering most of the body is no more than 1 mm thick, but it provides very effective protection against invasion by bacteria and other foreign matter. The thickened skin of the palms and soles protects against the effects of the constant trauma that occurs in these areas.

Sensation The receptor endings of nerves in the skin allow the body to constantly monitor the conditions of the immediate environment. The primary functions of the receptors in the skin are to sense temperature, pain, light touch, and pressure (or heavy touch). Different nerve endings respond to each of the different stimuli. Although the nerve endings are distributed over the entire body, they are more concentrated in some areas than in others. For example, the fingertips are more densely innervated than the skin on the back. Fluid Balance The stratum corneum (ie, outermost layer of the epidermis) has the capacity to absorb water, thereby preventing an excessive loss of water and electrolytes from the internal body and retaining moisture in the subcutaneous tissues. When skin is damaged, as occurs with a severe burn, large quantities of fluids and electrolytes may be lost rapidly, possibly leading to circulatory collapse, shock, and death. The skin is not completely impermeable to water. Small

amounts of water continuously evaporate from the skin surface. This evaporation, called insensible perspiration, amounts to approximately 600 mL daily in a normal adult. Insensible water loss varies with the body and ambient temperature. Temperature Regulation The body continuously produces heat as a result of the metabolism of food, which produces energy. This heat is dissipated primarily through the skin. Three major physical processes are involved in loss of heat from the body to the environment.

The first process, radiation, is the transfer of heat to another object of lower temperature situated at a distance. The second process, conduction, is the transfer of heat from the body to a cooler object in contact with it. Heat transferred by conduction to the air surrounding the body is removed by the third process, convection, which consists of movement of warm air molecules away from the body. Vitamin Production Skin exposed to ultraviolet light can convert substances necessaryfor synthesizing vitamin D (cholecalciferol) which is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

Immune Response Function Research findings (Demis, 1998) indicate that several dermal cells (ie, Langerhans cells, interleukin-1producing keratinocytes, and subsets of T lymphocytes) and three varieties of human leukocyte antigen (ie, protein marker on white blood cells indicating the type of cell) are important components of the immune system. Ongoing research is expected to more clearly define the role of these dermal cells in immune function.