Anatomy of the skin

ANATOMY

Two layers: the epidermis,

made of closely packed
epithelial cells, and the
dermis, made of dense,
irregular connective tissue
that houses blood vessels,
hair follicles, sweat glands,
and other structures.
Hypodermis composed
mainly of loose connective
and fatty tissues.
Epidermis
 

Keratinized, stratified squamous

epithelium
4/ 5 layers
stratum basale,
stratum spinosum,
stratum granulosum,
(stratum lucidum)
stratum corneum
Basale

bond to the dermis via intertwining collagen fibres

Basal cells are precursor of keratinocytes.
As new cells are formed, the existing cells are pushed superficially away
from the stratum basale. 
Merkel cell, which functions as a receptor and is responsible for stimulating
sensory nerves that the brain perceives as touch.
Melanocyte, a cell that produces the pigment melanin. Melanin gives hair
and skin its colour, and also helps protect the DNA in nuclei form UV
damage.
Spinosum

Spiny in appearance due to the protruding cell processes that join the cells
via a structure called a desmosome.
desmosomes interlock with each other and strengthen the bond between
the cells
Langerhans cell, which functions as a macrophage by engulfing bacteria,
foreign particles, and damaged cells that occur in this layer
Keratinocytes in the stratum spinosum begin the synthesis of keratin and
release a water-repelling glycolipid that helps prevent water loss from the
body. Keratin gives hair, nails, and skin their hardness, strength, and water-
resistant properties.
Granulosum

grainy appearance 
The cells become flatter, their cell membranes thicken, and they generate
large amounts of the proteins keratin, which is fibrous, and keratohyalin,
which accumulates as lamellar granules.
The nuclei and other cell organelles disintegrate as the cells die, leaving
behind the keratin, keratohyalin, and cell membranes
Lucidum

found only in the thick skin (palms, soles, and digits)

The keratinocytes that compose the stratum lucidum are dead and
flattened
And packed with eleiden, a clear protein rich in lipids, derived from
keratohyalin, which gives these cells their transparent appearance and
provides a barrier to water.
Corneum

The increased keratinization of the cells in this layer gives it its name. 
15 - 30 layers of cells
prevents the penetration of microbes and the dehydration of underlying
tissues
provides a mechanical protection against abrasion for the more delicate,
underlying layers
replaced during a period of about 4 weeks
Dermis

two layers of connective tissue that

compose an interconnected mesh of
elastin and collagenous fibres
superficial papillary layer serves as an
anchor point for the epidermis
The dermal papillae extending into the
epidermis belong to the papillary layer,
whereas the dense collagen fibre
bundles below belong to the reticular
layer. 
Papillary Layer:
Within the layer fibroblasts, adipocytes, and an abundance of small blood vessels.
contains phagocytes
contains lymphatic capillaries, nerve fibres, and touch receptors called the Meissner
corpuscles.
Reticular Layer:
thicker reticular layer, composed of dense irregular connective tissue which resists forces
in many directions ->flexibility
well vascularized and has a rich sensory and sympathetic nerve supply. 
Elastin fibres provide some elasticity to the skin-> enabling movement
Collagen fibres provide structure and tensile strength. In addition, collagen binds water
to keep the skin hydrated.
Hypodermis

Aka subcutaneous layer

serves to connect the skin to the underlying fascia surrounding the muscles.
The hypodermis consists of well-vascularized, loose, areolar connective
tissue and abundant adipose tissue, which functions as a mode of fat
storage and provides insulation and cushioning for the integument. 
Interesting

Corneum: microdermabrasion, help remove some of the dry, upper layer

and aim to keep the skin looking “fresh” and healthy.
Dermal papillae push up on the epidermis creating unique epidermal ridge
patterns-> Fingerprints
Collagen injections and Retin-A creams help restore skin turgor by either
introducing collagen externally or stimulating blood flow and repair of the
dermis, respectively.
The hypodermis is home to most of the fat that concerns people when
they are trying to keep their weight under control.
Summary

The epidermis provides protection, the dermis provides support and flexibility ,
and the hypodermis provides insulation and padding.
The topmost layer, the stratum corneum, consists of dead cells that shed
periodically and is progressively replaced by cells formed from the basal layer.
The stratum basale also contains melanocytes, cells that produce melanin, the
pigment primarily responsible for giving skin its color. Melanin is transferred to
keratinocytes in the stratum spinosum to protect cells from UV rays.
The dermis connects the epidermis to the hypodermis, and provides strength and
elasticity due to the presence of collagen and elastin fibres. It has only two layers:
the papillary layer with papillae that extend into the epidermis and the lower,
reticular layer composed of loose connective tissue.
The hypodermis, deep to the dermis of skin, is the connective tissue that
connects the dermis to underlying structures; it also harbors adipose tissue for fat
storage and protection.
Eczema

Eczema is an allergic reaction that

manifests as dry, itchy patches of skin
that resemble rashes
It may be accompanied by swelling of
the skin, flaking, and in severe cases,
bleeding.
Symptoms are usually managed with
moisturizers, corticosteroid creams, and
immunosuppressants.
Eczema

Eczema is a chronic inflammatory skin disease that affects about 20% of

children and 3% of adults.
characterized by pruritus, scratching, and eczematous lesions (dry,
 scaling and crusted areas of skin),
and when chronic may be associated with lichenification and pigmentary
changes.
relapsing course with flares at varying frequency and periods of remission. 
Eczema aka atopic eczema, or atopic dermatitis 
Diagnostic criteria

Itchy skin + 3:

visible flexural dermatitis/ or visible dermatitis on the cheeks and/or

extensor areas in children aged <18 m)
PH of flexural dermatitis (or dermatitis on the cheeks and/or extensor
areas in children aged 18 months or under)
dry skin in the last 12 months
personal history of asthma or allergic rhinitis (or history of atopic
disease in a first degree relative of children aged under 4 years)
onset of signs and symptoms under the age of 2 years
Risk factors

Small family size

Increased income and education
Migration from rural to urban environments
Increased use of antibiotics
Pathogenesis
Itching

Inside-out:
Immunological
disturbance causes IgE
Inflammation Scratching
mediated sensitisation,
epithelial barrier
dysfunction is
secondary
Outside-in: Epidermal
barrier dysfunction
allows irritants and
allergens into the skin, Penetration Disturbed
of Allergens/ skin barrier
with immunological irritants function
disturbance secondary
Breaking the cycle

Immune: dysfunction: minimise exposures

Itch: antihistamines
Scratching: physical barrier
Skin barrier: emollients
Inflammation: avoid soap, irritants, treat infection and steroids
Regular desquamation
Intercellular lipid bilayers
Natural Moisturising Factors
Production of antimicrobial
peptides

Genetic defects: Filaggrin

gene mutation in 30% of
eczema patients
Filaggrin involved in
production of natural
moisturising factors which
forms a permeability barrier to
water and inhibits the entry of
microbes, allergens,
and irritants
References

http://library.open.oregonstate.edu/aandp/chapter/5-1-layers-of-the-skin/
https://www.dermnetnz.org/topics/guidelines-for-the-diagnosis-and-
assessment-of-eczema/
https://www.webmd.com/skin-problems-and-treatments/eczema/ss/
slideshow-eczema-overview
https://www.pharmac.govt.nz/assets/ss-eczema-1b-what-is-eczema-dr-
diana-purvis.pdf
Psoriasis

The prevalence about 1.3-2.2% in the UK, with the highest prevalence
being in white people.
Men and women are equally affected.
It can occur at any age; majority of cases first present before the age of 35
Plaque psoriasis accounts for 90% of all people with psoriasis.
 Risk factors
Significant genetic link (shown in monozygotic twin studies)
Environmental factors:
Infection: Streptococcal infection associated with formation of guttate psoriasis
HIV infection and AIDS
Psychological stress is widely believed to play a role but evidence for a causal relationship is lacking.
Postpartum hormonal changes.
Drugs including lithium, antimalarials, B-blocker, ACE, antibiotics, NSAIDs, imiquimod
Smoking and alcohol.
Trauma - psoriasis may be spread to uninvolved skin by various types of trauma.
Pathophysiology

Psoriasis is defined by the abnormal and excessive proliferation of

keratinocytes
Skin is replaced every 3-5 days rather than 28-30 of those not affected
Involves a proinflammatory cascade involving dendritic cells (APC), T cells
(Th1, 17, 22) and crucially cytokines (IL-1, IL-17, IL-23
It is proposed that deficits in T cells and subsequent cytokine production
(including ‘feed forward’) result in the clinical manifestations of psoriasis
References

Psoriasis pathogenesis and the development of novel targeted immune

therapies; hawkes et al. September 2017; journal of allergy clinical
immunology
https://www.jacionline.org/article/S0091-6749(17)31197-1/pdf