Integumentary System

A Course Companion

Peter Reuter, M.D., Ph.D.

Valerie Weiss, M.D., M.S.
 Module 5 Integumentary System

5.1 Module Outline

In this module, you will study the structure and function of the integumentary system, including the skin and its related
functions. You will also learn about common disorders and injuries of the integumentary system, as well as diagnostic and
therapeutic procedures.
 Module Objectives
 Key Vocabulary
 Abbreviations, Acronyms, and Symbols
 Anatomy & Physiology
 Epidermis
 Dermis
 Subcutaneous Layer (Hypodermis)
 Sebaceous Glands
 Sweat Glands
 Hair
 Nails
 Pathology
 Common Skin Diseases
 Burns
 Skin Cancer
 Diagnostic and Therapeutic Procedures

5.2 Module Objectives

Upon completion of this module, you will be able to:
 Recognize, spell, and build words related to the integumentary system.
 Identify and describe the structures and functions of the integumentary system.
 Describe and understand pathological conditions, diagnostic and therapeutic procedures related to the integumentary
system.
 Demonstrate your understanding of the content by completing the Test Your Knowledge section at the end of the
module.

5.3 Key Vocabulary

This section introduces major structures, combining forms, suffixes, and prefixes related to the integumentary system. For a
more complete list, check Commonly Used Adjectives, Prefixes, and Suffixes in the Appendix.

Table 5.1 Overview of Major Structures and Combining Forms

Major Structure(s) Primary Function(s) Related Combining Forms
Skin Forms the first line of defense for the cutane(o)-, dermat(o)-, derm(o)-
immune system. It also waterproofs the
body and is a major receptor for sense of
touch.
Sebaceous glands Secrete oil (sebum) to lubricate the skin seb(o)-
and prevent growth of bacteria.
Major Structure(s) Primary Function(s) Related Combining Forms
Sweat glands Secrete sweat to regulate body hidr(o)-
temperature and water content. They
excrete some wastes from metabolism.

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Hair Alerts us to the presence of insects on the pil(i)-, pil(o)-, trich(o)-

skin and prevents us from losing body
heat.
Nails Protect the last bone of each finger and onych(o)-, ungu(o)-
toe.
Combining Form(s) Meaning Example(s)
Alopec(i)- Baldness Alopecia = partial or complete loss of hair
Cry(o)- Cold Cryosurgery = surgery that uses liquid
nitrogen to freeze some skin tissue
Cutane(o)- Skin Subcutaneous = beneath the skin
Dermat(o)-, derm(o)- Skin Dermatologist = physician who specializes
in diagnosing and treating disorders of the
skin
Erythr(o)-, Erythem(o)- Red Erythroderma = widespread redness
accompanied by scaling of the skin
Hidr(o)- Sweat Hyperhidrosis = condition of excessive
sweating
Koil(o)- Hollow, concave Koilonychia = spooning of the nails
Lip(o)- Fat Lipoma = benign, fatty deposit under the
skin
Melan(o)- Black Melanoma = Black tumor of the skin
Myc(o)- Fungus Onychomycosis = fungal infection of the
nail
Onych(o)- Nail Onychophagia = Nail biting
Pil(i)-, Pil(o)- Hair Pilomatricoma = noncancerous (benign)
skin tumor
Scler(o)- Hard, Hardening Scleroderma = condition of hardened skin
Seb(o)- Sebum (oil) Seborrhea = condition in which there is an
overproduction of the sebum
Trich(o)- Hair Trichotillomania = Behavior in which one
has a compulsion for hair pulling
Urtic(o)- Rash, hives Urticaria = hives caused by an allergic
reaction
Xer(o)- Dry Xeroderma = excessive dryness of the
skin

5.4 Abbreviations, Acronyms, and Symbols

Table 5.2 lists a limited number of abbreviations, acronyms, and symbols. For more, see the list of Acronyms, Abbreviations,
and Symbols in the Appendix.

Table 5.2 Abbreviations, Acronyms, and Symbols related to the Integumentary System
AA alopecia areata
BCC, BCCA basal cell cancer or carcinoma
caut cauterization
CRYO cryosurgery
debm debridement
Ecz, Ez eczema
LE lupus erythematosus

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 MM, mm malignant melanoma
NF necrotizing fasciitis
PS, ps psoriasis
ST sclerotherapy
SCC squamous cell cancer or carcinoma

5.5 Anatomy & Physiology

The integumentary system is made up of the skin and its related structures, which include glands, hair, and the nails. The skin
is a vital organ of the body. It measures approximately 16-20 square feet and is actually the largest bodily organ. The primary
functions of the skin are:
 Immune defense for blocking entrance of harmful microorganisms (pathogens).
 Barrier for fluid loss and waterproofing of the body.
 Sensation for temperature, touch, and pain.
 Vitamin D production with the help of the sun’s ultraviolet light.

5.5.1 Epidermis Figure 5.1 Layers of the skin and associated structures
The outermost layer of the skin is called the
epidermis (epi- above, dermis skin). It is formed
from flat, scaly cells that we call squamous
epithelial tissue. The epidermis has a basal or
bottom layer with cells that are constantly dividing
to produce new skin cells. These cells migrate
upward until they reach the surface where the cells
are shed and sloughed off.
The epidermis contains a fibrous, water-repellent
protein called keratin. In the epidermis, we have a
soft keratin; in the hair and nails, a hard keratin.
The bottom layer of the epidermis has specialized
cells called melanocytes (melano- black, -cyte
cell). These cells produce a color pigment
(melanin) that ranges from yellow-brown to black.
The type and amount of melanin pigment a person
has determines the color of their skin. Clusters of
melanin produce freckles or moles on the skin.
Carotenes are yellow to orange-colored fat-soluble
pigments that we take in with food, especially fruit and vegetables. They are stored in the skin and contribute a minor amount
to our skin color. These pigments are most visible in areas where we have no melanocytes, such as the palms of the hands
and the soles of the feet.
Another contribution to skin color comes from the hemoglobin inside our red blood cells. When we are hot or flushed, the
increased blood flow colors our skin pink.
Melanin has the vital function of protecting our skin against harmful ultraviolet rays produced by the sun. However, ultraviolet
light also helps to produce an essential nutrient, Vitamin D. Too much sun exposure, however, damages the skin cells and
can lead to skin cancer (see below).

5.5.2 Dermis
The dermis is the thick layer of skin directly below the epidermis. It contains connective tissue with collagen and elastic
fibers, blood and lymph vessels, and nerve endings, along with associated structures such as hair follicles, sebaceous
glands, and sweat glands. Collagen (colla- glue, -gen producing) is the most common protein of the human body. Collagen
fibers are an integral part of bone, cartilage, muscle tendons, ligaments, blood vessel walls, and capsules around organs.
Collagen endows skin with the ability to withstand pulling (tearing) forces, while elastic fibers enable the skin to stretch and

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return to its original size and shape. Sensory nerve endings in the dermis help us to perceive touch, pressure, pain, and
temperature.

5.5.3 Subcutaneous Layer

The subcutaneous layer of the skin lies below the dermis, which is why it is also referred to as the hypodermis (hypo-
below, dermis skin). This layer is mainly made of fat or adipose tissue and connects the skin to the underlying surface
muscles to provide anchoring. In addition, it stores nutrients for our body.

5.5.4 Sebaceous Glands

Sebaceous or oil glands produce sebum, a type of skin oil. Sebum lubricates the skin to make it soft. Oil glands are always
connected to a hair follicle. The sebum is released into the opening of the hair follicle and from there onto the surface of the
skin. Sebum is slightly acidic and, therefore, prevents growth of bacteria on the skin. Loss of sebum due to dry skin or
scrubbing with soap increases the chance of developing bacterial and fungal skin disorders, such as ring worm.

5.5.5 Sweat Glands

Sweat glands are also known as sudoriferous (sudor(i)- sweat, -ferous producing) glands. They are subdivided into two
main types: eccrine (or merocrine) glands are most numerous on the palms of the hands, the soles of the feet, and the
forehead. These glands are responsible for sweating, which is also known as perspiring. Apocrine glands are confined to
the axillary and anogenital areas and their ducts connect to hair follicles. The only become active after puberty.
Sweat (perspiration) is mostly water (99%) with a small amount of salt and metabolic waste products. Hidrosis is the
production and excretion of sweat.

5.5.6 Hair
The major function of hair is to alert the body to the presence of insects on the skin. Moreover, hair guards against physical
trauma, heat loss, and excess sunlight. Hair is found on most body surfaces except for the palms of the hand, soles of the
feet, lips, and nipples. Hair consists of dead cells that contain hard keratin, which is more durable than the soft keratin of the
skin. Different pigments (melanins) produced by the hair melanocytes give hair its color, which depends on our genetic
makeup. Hair follicles are sacs that hold the root of the hair. The arrector pili are tiny muscle fibers attached to the hair
follicles that respond to cold or fright by giving us goose bumps.

5.5.7 Nails
Nails protect the last bone of each finger or toe. Just like hair, nails are made of hard keratin. As they grow, nails slide over
the nail bed until they form the free or cutting edge of the nail. The lunula (lunula = little moon) is a half-moon shaped
area of the nail over the nail root, where the nail is formed.
Figure 5.2 Hair structure Figure 5.3 Nail structure

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5.6 Pathology
The skin is damaged more often than any other system in our body, because it serves as our protection from the outside
environment and the first line of defense against invaders, such as bacteria, fungi, viruses, and parasites. Cuts, bruises, and
other physical damage, including burns (see below), occur on an almost daily basis but hardly ever prompt medical attention.
Many autoimmune diseases and infections cause skin changes such as rashes, redness, or various other signs of
inflammation. A skin disease may only be the visible part of a generalized disorder that may affect a number of internal
organs and lead to disability or death.
The skin is further helpful in revealing general health conditions. For example, in liver disease, the skin turns yellow or
becomes jaundiced.

5.6.1 Common Skin Diseases

Dermatitis (dermat(o)- skin, -itis inflammation) refers to any inflammation of the skin. Typically, a condition with dermatitis
will include redness, swelling, and itching. Another word for itching is pruritus (prurit- itching, -us singular noun ending).
Erythema (erythem- flushed, -a noun ending), a redness of the skin, is a sign seen in many skin disorders, including the
common sunburn. Regardless of the skin condition, erythema results from the dilation and leaking of the smallest blood
vessels (capillaries), resulting in red skin.
The skin can be infected by bacteria, viruses, fungi, or parasites. Bacterial infections can be treated with antibiotics; viral
infections with antiviral medications, fungal infections with antifungal medications, and parasitic infections with the
appropriate parasite-killing medications.

Table 5.3 Common Skin Disorders

Callus Thickening of part of the skin on the hands and feet because of repeated
rubbing.
Cicatrix Normal scar resulting from the healing of a wound.
Keloid Abnormally raised or thickened scar that expands beyond the boundaries of
the incision. Keloids are more common among people with darker skin. There
is an inherited tendency to form these raised scars or keloids.
Ulcer Tissue loss seen in an open lesion of the skin or the mucous membranes.
Typically, they are painful. There are many different causes of ulcers, including
prolonged pressure on an area, like from being bed ridden. Ulcers that
develop from immobility are called bedsores or decubitus ulcers.
Contact dermatitis Localized irritation of the skin caused by an irritant (for example, diaper rash)
or an allergic reaction (for example, latex gloves).
Hives also known as urticaria Itchy welts causes by an allergic reaction.
Eczema also known as atopic A form of persistent dermatitis. It is common and affects many infants and
dermatitis young children. Eczema almost always causes pruritus and is most common
in the creases of joints, such as the back of the knees and inner surface of the
elbows.
Ichthyosis Group of inherited skin disorders that are characterized by dry, thickened, and
scaly skin (ichthy(o)- dry, scaly, -osis abnormal condition or disease).
Bleeding into the Skin
Contusion General term for a bruise.
Ecchymosis Irregular, purplish discolored bruise. There is a large accumulation of blood
underneath the skin, but the skin does not swell.
Petechiae Small, pinpoint bleedings (hemorrhages) that are smaller than one tenth of an
inch in diameter. Petechiae may result from high fevers.
Hematoma Swelling of clotted blood that is trapped in the tissue.
Birthmarks
Port-wine stain Large, flat, purple-reddish discoloration of the face or neck at birth. This
birthmark will not resolve without laser treatment.

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Strawberry hemangioma Raised purple-reddish birthmark. This birthmark is a harmless tumor made of
blood vessels. Often, these birthmarks lesson and may even disappear by the
age of 5 without treatment.
Skin Infections
Cellulitis Bacterial infection just below the skin. It is characterized by erythema,
swelling, warmth, and pain. It can spread rapidly and be dangerous if not
treated.
Impetigo Bacterial skin infection characterized by pustules that become crusted and
rupture
Gangrene Death of skin tissue caused by lack of blood flow to a certain area of the body.
It can be fatal if bacteria invade the body and the infection spreads. The tissue
will have a foul-smell of decay (putrefication).
Cold sores or fever blisters Herpes simplex virus causes ulcers or sores in the mouth or genital area.
The sores are painful and will remain dormant (asleep) and then reactivate,
based on stress, fatigue, or general illness.
Herpes zoster also known as shingles Acute viral infection characterized by painful skin eruptions that follow the
underlying inflamed nerve. This nerve inflammation occurs when the chicken
pox virus (Varicella zoster virus), is reactivated later in life. There are now
vaccines to prevent both chicken pox and shingles from occurring.
Verrucae (Verrucae vulgaris) also Firm nodules on the surface of the skin. The human papillomavirus (HPV)
known as warts infects the cells of the skin (keratinocytes) and causes hypertrophy (hyper-
excessive, -trophy development) of the skin, which creates a wart. Warts are
extremely common and can be seen on the hands, feet, or genitals. They are
spread easily by contact. Many warts disappear on their own with time.
Tinea also known as ringworm Fungal infection that spreads out in a ring-like fashion leaving normal-looking
skin in the middle of the circle. This fungus can infect many areas of the body
so it is named based on where it is found. Tinea capitis is found on the scalp,
tinea corporis on the body. Tinea cruris is found on the genitals; it is
commonly known as jock itch. Tinea pedis is an infection between the toes
of the foot; it is better known as athlete’s foot.
Pediculosis also known as lice The lice lay eggs and reproduce. They can live in the skin, most commonly on
the head (pediculosis capitis).
Figure 5.5 Impetigo (left), Herpes simplex (fever blisters, center), and Herpes zoster (shingles, right)

Autoimmune Diseases that can Affect the Skin

Lupus erythematosus also known as Affects many of the tissues of the body, especially the joints and kidneys. In
lupus the skin, a butterfly-shaped rash is often seen on the cheeks and nose.
Psoriasis Characterized by raised, red plaques covered with thick, silvery scales. Often
affects the elbows, knees, or the scalp.
Scleroderma Causes the connective tissue of the body to harden. The skin becomes hard
and tight in patients with scleroderma (scler(o)- hard, derma- skin).
Pathologies of the Sebaceous Glands

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Acne vulgaris also known as acne Very common, especially during puberty with the increase in sex hormone
levels. Acne is caused by an overproduction of sebum and characterized by
pustular breakouts in the sebaceous (oil) glands.
Sebaceous cyst Closed sac-like structure or cyst associated with an oil gland
Seborrheic dermatitis Also known as dandruff if found in the scalp (or cradle cap in infants). It is an
inflammation that causes scaling and itching, most often in the scalp.
Figure 5.6 Lupus erythematosus (left), Psoriasis vulgaris (center), and Ringworm (right)

Pathologies of the Sweat Glands

Diaphoresis Profuse sweating that can be brought on by heat or illness.
Sleep hyperhidrosis or night sweats Excessive sweating during sleep may be due to a variety of causes, including
menopause, medications, and diseases like cancer or tuberculosis.
Pathologies of the Hair
Folliculitis Inflammation of the hair follicle(s). This condition is especially common in the
beard area of men.
Hirsutism The presence of excessive hair in women, usually occurring in a male pattern,
such as hair growth on the chest. Typically, it is caused by a hormonal
imbalance.
Alopecia also known as baldness It can be a partial or complete loss of hair. There are many causes of alopecia,
such as cancer treatment or other medications, autoimmune disorders, or
genetic factors (as in male pattern baldness, in which hair is lost from the top
of the head but remains in the back and at the temples).
Figure 5.7 Albinism (left), Vitiligo (center), and Acne (right)

Pathologies of the Nails

Koilonychia also known as spoon nail A malformation of the nail in which the nail is scooped out or concave.
Onychomycosis Fungal infection of either the fingernails or toenails.
Onychophagia Refers to the very common biting of the nail(s).
Pathologies of Skin Pigmentation

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Albinism A genetic condition in which the melanocytes do not produce enough melanin.
Thus, there is a lack of pigment in the skin, hair, and colored portion of the eye
(the iris).
Vitiligo Skin condition marked by the destruction of the pigment-forming melanocytes.
The cause is unknown, although it is associated with a family history and
autoimmune diseases. Vitiligo is characterized by irregular white patches of the
skin that can gradually grow larger.

5.6.2 Burns
A burn is tissue damage to the skin inflicted by intense heat, electricity, radiation, or chemicals. Burns are classified
according to their severity and how deep from the surface the burn damages skin tissue.
 First degree burn (superficial burn) is damage to the upper most layer (epidermis) only. It is characterized by local
redness, edema (swelling), and pain. First degree burns are painful, but will heal without problems. Having a sunburn is
a good example of a first degree burn. As a result of the irritation of pigment-forming melanocytes, first degree burns
cause a discoloration of the affected area, for example, a tan after a sunburn.
 Second degree burn (partial thickness burn) is damage only to the epidermis and the upper part of the dermis.
Second degree burns blister and are red. They are painful but usually heal without complication unless the blisters get
popped and the area becomes infected.
 Third degree burn (full thickness burn) is damage to the epidermis, the entire dermis, the hypodermis, and often the
tissues below (including muscle or bone). The skin will look charred and black-brown. Because the nerve fibers are
damaged, third degree burns are not painful. Skin grafting will be required. Dehydration with electrolyte imbalance
(including shock) is an immediate threat that requires treatment.
Figure 5.8 Rule of Nines
The Rule of Nines is used to help medical care providers estimate the amount of
fluid loss in second and third degree burns of adults. The body surface is
subdivided into 11 areas of 9% each.
 The head counts as one area of 9%.
 Each upper limb (arm) counts for 9% as well.
 The front and back of the trunk count for 18% each, for a total of 36%.
 The area over the front of the chest counts for 9% as does the area over
the abdomen.
 On the back, the upper and lower back count for 9% each,
 The anogenital area makes up the remaining 1%
 Each lower limb (leg) is counted as two times 9% (9% for the front of the leg
and 9% for the back), giving them a total of 18% each.
Each severely burned area (second or third degree burn) is added together to
estimate the total body area damaged.
 For example, second degree burn injuries to the front and the back of both
legs would add up to an estimated burn damage of 36%.
Burn injuries are considered critical in adults if more than 25% of the skin is damaged by second degree burns or 10% by
third degree burns. Young children and older people are more at risk, because they may not be able to cope with the fluid
loss and their immune system may not be strong enough to fight off infection of the damaged areas.

Table 5.4 Classification of Burns

Type of Burn Common Name Layers of Skin Involved
First degree Superficial burn Upper epidermis only
Type of Burn Common Name Layers of Skin Involved
Second degree Partial thickness burn Epidermis and part of dermis

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 Third degree Full thickness burn Epidermis, dermis, and hypodermis (may
damage muscle and bone below)

5.6.3 Skin Cancer

Skin cancer is extremely common; one in every five Americans will develop skin cancer. The biggest risk factor in developing
skin cancer is exposure to UV radiation from the sun. Frequent irritation of the skin is an additional risk factor for developing
skin cancer.
Most skin tumors, such as moles, are not cancerous!
 A nevus (or mole) is a small, often raised, dark skin growth that develops from melanocytes in the skin. Moles are
benign and very common. They are chronic and do not change over time, even with sunlight exposure. Other names
for nevus include birthmark or beauty mark, because they are present at birth. In contrast, a freckle is a small, flat
patch of pigment that often becomes more pronounced with sun exposure.
 A dysplastic nevus (dys- bad, -plasia formation) is an atypical mole that can develop into skin cancer. One example of
a precancerous skin lesion is an actinic (solar) keratosis. Precancerous describes a growth that is not yet
cancerous; however, if not treated, it is likely to become malignant (mal- evil). An actinic keratosis appears as a small,
scaly spot on sun-damaged skin. Dysplastic growths should always be removed because of their ability to develop into
skin cancer.
 Basal cell carcinoma is the least malignant of the skin cancers and also the most common type of skin cancer. It
develops from the bottom-most cells of the epidermis or basal layer. It can be cured 99% of the time by a surgical
excision.
 Squamous cell carcinoma, the second most common skin cancer, tends to grow rapidly and can potentially spread if
not removed. This tumor develops from the flat, squamous cells of the epidermis. Squamous cell carcinoma lesions
tend to look like crusty sores that won’t heal. This cancer is most commonly found on the scalp, ears, lower lip, and
hands. It has a good prognosis if treated early by radiation therapy and surgical excision.
Figure 5.9 Moles (left) and dysplastic nevi (right)

 Malignant melanoma is the least common type of skin cancer, but the most dangerous due to the risk of spread. It is
highly metastatic and resistant to treatment. It can spread even at a small size into internal organs and the brain or
spinal cord. This tumor develops from the melanocytes of the epidermis (black skin cancer).
Melanomas are treated with a wide, deep surgical excision along with immunotherapy. Immunotherapy works with our
own immune system to help detect and treat cancer.
ABCDE is a mnemonic to help us remember the risk factors for recognizing melanoma. It stands for:
 Asymmetry
 Border irregular, not smooth
 Color much darker than other moles or unusual color
 Diameter greater than the size of a pencil eraser
 Evolving mole

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Table 5.5 Classification of Skin Cancers

Type of Cancer Prevalence Degree of Malignancy
Basal cell carcinoma Most common Least malignant
Squamous cell carcinoma Second most common Second most malignant
Malignant melanoma Least common Most malignant

If a mole develops asymmetry, an irregular scalloped border, dark or unusual color, a diameter larger than a pencil eraser,
and/or changes over time, a dermatologist should examine it!

Figure 5.10 Basal cell carcinoma (left), Squamous cell carcinoma (center), and Malignant melanoma (right)

5.7 Diagnostic and Therapeutic Procedures

Many skin disorders are diagnosed when a dermatologist (dermat(o)- skin, -ologist specialist) performs a biopsy (bi(o)- life,
-opsy view of).
 A biopsy refers to the removal of a small piece of living tissue. A pathologist (patho- disease, -ologist specialist)
examines the tissue under the microscope to make a diagnosis.
A dermatologist often gives a topical medication for treatment of a skin condition.
 Topical medications include creams, gels, and ointments that are applied to the surface of the skin. Steroids (in the
form of cortisone) are anti-inflammatory medications that can be given topically or orally. Cortisone cream/ointment
is an example of a topical medication that relieves itching and speeds healing. Topical steroids are safe and effective,
and can be used in many skin conditions such as eczema and dermatitis.
 Laser treatment of the skin is a technique in which a laser tube emits light at a specific wavelength capable of
destroying some or all skin tissue or color. Laser treatment can be used for a variety of skin conditions, including some
cancers and growths as well as birthmarks and other discolorations of the skin.
 Mohs surgery is a technique used to treat skin cancer. It involves surgically removing skin cancer layer by layer and
examining the tissue under a microscope until healthy, cancer-free tissue around the tumor is reached (called clear
margins). Mohs surgery has a very high success rate and minimizes the amount of scar tissue formed, thus having a
favorable cosmetic outcome.

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