Anatomy of Skin

and Basic Skin

Lesions
Digital Lecture Series
Anatomy of Skin

• Largest organ system

• Measures about 2.12 sqm, weighing 4.2 kg
• Hair, sebaceous and eccrine glands, nails, mucous
membranes make important components with specialized
physiological functions
Embryology of Skin

• All constituents are derived from ectoderm and mesoderm

• Ectoderm and mesoderm begin to proliferate and differentiate
at 4th week of intrauterine life
• The specialized structures of skin, teeth, hair, nails and glands
begin to appear on this time
Layers of Skin

• Epidermis
−Stratum basale
−Stratum spinosum
−Stratum granulosum
−Stratum corneum
• Dermis
−Papillary dermis
−Reticular dermis
• Subcutaneous tissue
Layers of Skin
Epidermis

• Stratum basale (basal cell layer, stratum germinativum,

germinative layer): Cuboidal/columnar cells; large oval
nuclei, dense basophilic cytoplasm, basement membrane
• Stratum spinosum (stratum spinosum, spinous layer,
prickle cell layer): 5-10 layers of polygonal cells with
delicate spinous processes (desmosomes) connecting
adjacent keratinocytes
• Stratum granulosum (granular cell layer): 1-3 layers of
flattened diamond shaped cells filled with coarse basophilic
keratohyalin granules
Epidermis

• Stratum corneum:
−Flattened, anuclear, eosinophilic corneocytes, dead layer
shed during epidermal turnover
• Stratum lucidum*:
−Clear layer found in palms and soles
• Epidermal turnover/transit time:
−Time taken for a cell to pass from basal layer to surface of
skin is 52-75 days (normal skin)
Other Cells in Epidermis

• Melanocytes
• Langerhans cells
• Merkel cells
Melanocytes

• Neural crest derived dendritic cells

• Synthesize and secrete melanin containing organelles called
melanosomes
• Located in basal cell layer; 1:10 ratio
• Epidermal melanin unit: A single melanocyte supplies
melanosomes to 36 keratinocytes (1:36)
• Melanosomes vary in number and size according to skin type
Melanocytes - Melanogenesis

• Melanin formed through mediation of tyrosinase and DOPA

from tyrosine

Phenylalanine Tyrosine DOPA

DOPA quinone

• Controlled by: Pheomelanin Eumelanin

−Genetic factors
−UVR
−Hormones (e.g., MSH)
Melanocytes - Functions

• Melanin:
−Impart color to skin and hair
−Protect the skin from UV radiation
−Biochemical neutralizer of toxic, free radical oxygen
derivatives
Langerhans cells and Merkel Cells

• Langerhans cells
−Dendritic cells
−Type of macrophage
−Role in various immune processes like - allergic contact
dermatitis, immune tolerance, surveillance against viral
infections and neoplasia
• Merkel cell
−Non-dendritic cells lying in or near basal layer or hair follicles
−Neuritic cells
−Fine touch receptors
−Detect mechanical deformities of epidermis
Functions of Epidermis

• Cornification
• Barrier function
• Permeability
• Maintenance of fluid and electrolyte balance
• Thermoregulation
• Pigmentation
• Immune function
• Sensory receptor
• Vitamin D synthesis
Epidermal Appendages

• Hair follicles
• Sebaceous glands
• Sweat glands
−Eccrine glands
−Apocrine glands
−Apo-eccrine glands
Hair

• Found over the entire surface of the body except palms, soles,
glans penis, clitoris, labia minora, mucocutaneous junction
and distal portions of the fingers and toe
• Types of hair
−Lanugo hair: Fine, soft hair in fetus
−Vellus hair: Fine, short, non-medullated hair over most parts
of the body
−Terminal hair: Long, coarse, medullated hair over scalp,
beard and body depending on age and gender
Hair: Anatomy

• Longitudinal section
−Infundibulum
−Isthmus
−Stem
−Bulb
Hair: Anatomy

• Cross section
−Outer sheath
−Inner sheath
• Henle’s layer
• Huxley’s layer
• Cuticle
−Cortex
−Medulla
Hair Growth Cycle

• Hair cycle consists of three phases:

−Anagen:
• Phase of growth and activity, lasts for 2-10 years
• About 90% of hair are in anagen at a given time
−Catagen:
• Phase of transition, lasts for 1-3 weeks
• About 1% hair are in catagen
−Telogen:
• Resting phase lasts for about 3 months
• About 10% hair are in telogen
• Telogen hair is shed and anagen hair replaces it
• Average hair loss is = 100/day
Sebaceous Glands

• Lipid producing holocrine, multi-lobed glands

• Arise from the hair follicle at the junction of the infundibulum
and the isthmus
• Distributed all over the body except the palms and soles
• Numerous, large and productive over the face and scalp
• Stimulated by androgens and mature at puberty
Sebaceous Glands

• Consists of lobules of epithelial cells that differentiate toward

lipid producing cells in a centripetal manner
• Enlarged, vacuolated cells in the center of the lobule
disintegrate into an amorphous mass – the sebum
• Major components of sebum: Triglycerides, wax esters,
squalene, cholesterol esters, and cholesterol
• Dermatoses: Acne, rosacea, seborrheic dermatitis
Sweat Glands

• Depending on mode of secretion these are –

−Eccrine sweat glands and apocrine sweat glands
−Apo-eccrine glands have features of both
−All have 2 parts-
• Secretary coil
• Duct
Eccrine Sweat Glands

• These are present all over body except over the lips, external ear
canal and labia minora
• Most are concentrated in the palms, soles and axillae
• The secretary coil lies deep in the dermis that connects with the
surface by a duct
• Major role is in thermoregulation
• Control of sweating
−Innervated by sympathetic cholinergic nerve fibers
−The central control of sweating lies in preoptic hypothalamic
sweat center
−Temperature, emotions, hormones (antidiuretic hormone,
aldosterone), gustatory (hot spicy foods)
Apocrine Sweat Glands

• These are mainly present in axillae, nipples, peri-umbilical

skin, perineum and genitalia
• Modified apocrine glands are ceruminous glands (external ear
canal), Moll’s glands (eyelids) and mammary glands
• The secretary coil lies at junction of dermis and subcutis
• The duct opens into the mid part of hair follicle just above the
entrance of sebaceous gland
• Innervated by adrenergic sympathetic nerve fibers
• Vestigial sexual function and represent scent glands
Dermis

• Constitute 15-20% of body weight

• Papillary dermis - thin zone beneath epidermis
• Reticular dermis - thick zone which extends from base of
papillary dermis to the surface of subcutaneous fat
• The upward projection of dermis, the dermal papillae,
strongly inter digitate with the downward, the rete pegs, of
epidermis to form dermo-epidermal junction
• 3 components: Cells, fibers and ground substance
Dermis- Structure

• Cellular contents
−Fibroblasts, mast cells, histiocytes, Langerhans cells,
lymphocytes and eosinophils
• Non-cellular connective tissue
−Collagen (80%), elastic fibers (2%) and ground substance
(mucopolysaccharides, glycoproteins, chondroitin sulphate)
−Embedded nerves, blood vessels, lymph vessels, muscles
and pilosebaceous, apocrine and eccrine units
Dermis - Variation in Thickness

• Difference of thickness of the skin is dependent largely on

dermal thickness, with the palms and soles being thickest (1.5
mm) and thinnest in the eyelids and post-auricular region
(0.05 mm)
• Males have thicker skin than females
• Children and elderly have thinner skin than adults
Dermo-epidermal Junction (Basement
Membrane Zone)

• Consists of
−Basal lamina
−Lamina lucida
−Lamina densa
−Anchoring filaments
−Anchoring fibrils
−Dermal microfibril bundles
Dermo-epidermal Junction

• Functions
−Attachment of dermis to epidermis
−Mechanical support to epidermis
−Regulation of permeability for nutrients and exogenous
substances
−Influence growth, differentiation and migration of basal
keratinocytes
−Autoantibodies to proteins in the dermo-epidermal junction
responsible for bullous pemphigoid
−Inherited defect in epidermolysis bullosa
Nerves and Innervation

• Rich network of nerves with 2 types of sensory endings – ‘The

corpuscles (mechano-receptors)’ and ‘free nerve endings
(nociceptors)’
• Mechano-receptors
−Light touch: Merkel cells of the epidermis, Meissner’s
corpuscles in dermal papillae
−Pressure: Pacinian corpuscles in deep dermis or
subcutaneous tissue
Nerves and Innervation

• Nociceptors
−Pain and itch: Transmitted through naked fine free nerve
endings located in the basal layer of the epidermis close to
the derma-epidermal junction
−Temperature:
• Krause bulbs detect cold, Ruffini end organs detect heat
• Heat, cold and proprioception also located in the
superficial dermis
−Adjacent dermatomes often overlap (important for local
anesthesia)
Blood & Lymphatic Supply

• Extensive subdermal and dermal plexuses

• Dermal plexus: 2 horizontal plexuses connected by vertical
communicating vessels–
−Superficial horizontal plexus lies in the papillary dermis,
feeding arterioles/capillary loops in dermal papillae
−Deep horizontal plexus lies deep just above the
subcutis, supplies to sweat gland and hair follicles
• Cutaneous vasculature important in thermoregulation
• Cutaneous lymphatics parallels the blood supply
Basic Skin Lesions
Classification

• Primary lesions
• Secondary lesions
• Special lesions
Classification

Primary Secondary
Special lesions
lesions lesions
• Macule • Scales • Wheal
• Papule • Crust • Burrow
• Nodule • Erosion • Comedone
• Plaque • Ulcer • Milium
• Vesicle • Excoriation • Purpura
• Bulla • Fissure • Telangectasia
• Pustule • Sinus • Sclerosis
• Cyst • Scar • Poikiloderma
• Lichenification • Target lesions
• Atrophy
Macule

• Definition: Circumscribed alteration in the colour of the skin of

any size or shape that is non-palpable and without depression
and has no alteration in the skin texture or scaling within the
lesion
−Macule >1-2 cms in diameter is “large macule”
−Macule >2 cms in diameter is “area”
−Margins can be well defined or ill defined
−Shape can be circular, oval or irregular
• Color of macule – Erythematous, hypopigmented (e.g., nevus
hypochromic), hyperpigmented (e.g., melasma), depigmented
(e.g., vitiligo)
Depigmented and Hypopigmented
Macules

Vitiligo
Hyperpigmented Macules

Melas Nev
ma us
Papule

• Definition: Small, solid, elevated, palpable lesion up to 0.5

cm in size formed either by localized proliferation of tissue
cells or infiltration with inflammatory cells
• Papules sized 1-2 mms are called “micropapules”
• Shape: Sessile, pedunculated, dome-shaped, flat-topped,
filiform, acuminate, umbilicated
Papule

• Colour: Varies-
−Brownish: Verruca vulgaris
−Yellowish orange: Xanthoma
−Violaceous purple: Lichen planus
−Pearly white: Molluscum contagiosum
−Blue-black: Malignant melanoma
• Surface: Rough or smooth surfaced
• Examples: Warts (rough surface), Lichen nitidus
(micropapules), Molluscum contagiosum (umbilicated)
Nodule

• Definition: Solid, elevated, palpable lesion >0.5 to 1 cm in size formed

either by localized proliferation of tissue cells or infiltration with
inflammatory cells
• A nodule sized >1.0 cm is better be called a “large nodule”
• Shape: Ellipsoid or globular, pedunculated or sessile
• Surface: Smooth, keratotic, ulcerated or fungating
• Types: Depending anatomical component involved-
−Epidermal, epidermal-dermal, dermal, dermal-subdermal or
subcutaneous
• Other features: Depending on underlying pathology-
−Warm, hard, soft, fluctuant, tender, movable or fixed
• Examples: Neurofibroma, leprosy, erythema nodosum
Papules and nodules Shiny, pearly
of varied morphology umbilicated papules
and size in in molluscum
neurofibromatosis contagiosum
Plaque

• Definition: Solid, elevated, palpable lesion >1 cm in diameter with a

flat plateau like surface
−Formed by extension of coalescence of papules or nodules
• Plaque sized >2 cms are “large plaques”
• Shape: Round, oval, discoid (uniformly thickened) or annular with
regular or irregular borders
• Types: Depending on anatomical component involved-
−Epidermal, epidermal-dermal, dermal, dermal-subdermal or
subcutaneous
• Surface changes: Depending on underlying pathology-
−Scaling, necrosis, erosion, ulceration, crusting, eschcar formation
• Examples: Psoriasis, leprosy, granuloma annulare
Plaque

Well-defined,
erythematous, scaly Annular plaques in
large plaques of leprosy
psoriasis vulgaris
Vesicle & Bulla (Blister)

• Definitions:
• Examples: Herpes simplex,
−Vesicle: An elevated fluid-filled lesion
sized <0.5 cm pemphigus, scalds, bullous
−Bulla: Fluid filled lesion sized >0.5 cm pemphigoid
• Formation: Vesicles or bullae arise from
the cleavage at either intraepidermal or
sub epidermal level by-
a. Formation of cavity
b. Collection of fluid
−In bulla, the fluid in the cavity exerts
equal pressure in all directions giving
spherical shape
−Contents of vesicle: Clear, serous,
turbid, hemorrhagic
Pustule

• Definition: A circumscribed raised pus-

filled lesion
− Pustules may vary in size and in
certain conditions like pustular
psoriasis they may coalesce to give
“lake of pus” appearance
• Purulent exudate contain either
cellular debris, leukocytes, or bacteria or
may be sterile
− They can be located at the opening of
hair follicles as in folliculitis
− Pustules are superficial- heal without
scarring
• Examples: Bacterial (folliculitis), pustular
Pustules in pustular
psoriasis psoriasis
Cyst & Abscess

Cyst Abscess
• Definition: A closed cavity or • Definition:

sac (normal or abnormal) that −It is localized accumulation of

has an epithelial, endothelial pus deep in dermis or sub cutis

−Usually not visible on the
or membranous lining and
surface of skin
contain fluid or semisolid
• It is erythematous, warm, tender,
material
fluctuant nodule
• Examples: Sebaceous cyst,
• From staphylococcal,
epidermal cyst (milia), pilar streptococcal infections
cyst
Secondary Lesions

Primary Secondary
Special lesions
lesions lesions
• Macule • Scales • Wheal
• Papule • Crust • Burrow
• Nodule • Erosion • Comedone
• Plaque • Ulcer • Milium
• Vesicle • Excoriation • Purpura
• Bulla • Fissure • Telangectasia
• Pustule • Sinus • Sclerosis
• Cyst • Scar • Poikiloderma
• Lichenification • Target lesions
• Atrophy
Scale

• Scale
−It is visible exfoliation of flake of
stratum corneum
−Morphology varies with type of
skin disease
−Examples-
• Silvery, loose scales-
Psoriasis
• Fine powdery scales-
Pityriasis versicolor
• Fish-like scales – Ichthyosis
• Collarette scales - Pityriasis
rosea, seborrheic dermatitis
Ichthyotic scales
Crust

• Crust
−Crust is dried up exudates
(blood, serum, pus)
−Removal of crusts leave moist
surface/erosion beneath
−Colour of crust varies with nature
of exudate:
• Yellow-brown– dried serous
secretions
• Turbid yellow-green-
purulent secretion
• Reddish black- hemorrhagic
Hemorrhagic crusts
secretion
Erosion

• Erosion
−Raw, moist lesion left from a
complete or partial loss of
epidermis or mucosal
epithelium
−Results from trauma, rupture
of vesicles or bullae, or
epidermal necrosis
−Heal without scar unless
secondarily infected
−Examples: in pemphigus, SJS- Erosions, hemorrhagic
crusts in a pemphigus
TEN
patient
Ulcer

• Ulcer forms from breach and

destruction of skin (epidermis,
dermis with basal layer,
adnexal structures) or mucosa
• Heals with scarring
• May be superficial or deep
• Margins of ulcer:
−Overhanging- tubercular
−Punched out– gumma
• Light pink granulation tissue
at floor- healing Ulcer
Excoriations

• Linear or circumscribed
erosions formed from surface
excavations of epidermis due
to scratching
• Frequent finding in patients
having disorders with
pruritus

Linear and punctate

excoriations on the back
induced by scratching
Fissure

• It is a linear, triangular crack in

the skin/mucosa
• Results from excessive tension or
decreased elasticity of the
involved tissue
• Can be superficial or deep
• Deep fissures are painful
• Common over palms and soles
due to thick stratum corneum
• Examples: In palmoplantar
psoriasis, keratodermas, irritant
CD Fissures of heels
Sinus

• It is a tract connecting a
deep cavity to the surface of
the skin
• Contents of the deep cavity
are usually pus, epithelial
debris
• These contents drain to the
surface when such a channel
exits

Multiple sinuses in
nocardiosis
Scar

• It is the proliferation of fibrous

tissue that replaces the normal
collagen after the ulcer involving
the reticular dermis heals
• Epidermis is thinned and wrinkled,
and adnexa like hair are destroyed
• Hypertrophic scars: Typically
take form of plaques or nodules
−It does not grow beyond the
limit of original lesion
• Keloid: Exceeds the limit of
original lesion Keloid
Lichenification

• Definition: Thickening of skin

due to repeated and prolonged
rubbing/scratching of skin
characterized by:
−Thickening of
epidermis/dermis
−Accentuated of skin markings
−Hyperpigmentation
• Examples: Lichen simplex
chronicus (LSC), lichenified
chronic (atopic) dermatitis
Lichenification
(LSC)
Atrophy

• Definition: A loss of cutaneous

mass from diminution in size of
any of the components of skin
• Epidermal atrophy: Glossy,
transparent, cigarette-paper like
thinning and wrinkling, loss of
normal skin lines
• Dermal atrophy: Circumscribed
area of depressed skin, normal in
colour and surface
• Subcutaneous atrophy:
Substantial depression of skin Epidermal
atrophy
Special Lesions

Primary Secondary
Special lesions
lesions lesions
• Macule • Scales • Wheal
• Papule • Crust • Burrow
• Nodule • Erosion • Comedone
• Plaque • Ulcer • Milium
• Vesicle • Excoriation • Purpura
• Bulla • Fissure • Telangectasia
• Pustule • Sinus • Sclerosis
• Cyst • Scar • Poikiloderma
• Lichenification • Target lesions
• Atrophy
Erythema

• Localized or diffuse "redness

of the skin" blanched on
pressure
• Due to vascular congestion
or increased skin perfusion
• Rosacea, viral exanthem and
SLE
Wheal (Hives, Urticaria) & Angioedema

• Definition: An evanescent
(lasting 48-72 hrs) erythematous,
elevated lesion due to oedema of
dermis (wheal) frequently with
central pallor, or dermo-
hypodermis with loose dermal
tissue e.g., lips, eyelids, scrotum
(angioedema)
• Results due to vasodilatation and
increased permeability of dermal
capillaries leading to oedema
• Specific of urticaria
Burrow

• Definition: It is wavy,
thread like tunnel excavated
in the stratum corneum by
scabies mite
• It measures only few mms in
length
• Characteristic of scabies
and particularly seen over
palms and soles, wrists and
genitalia in infants and very
young children
Comedo (Pl. Comedones)

• Definition: A dilated
pilosebaceous orifice plugged by
keratin and sebum
• Open comedo: Pilosebaceous
opening is open to the surface of
skin by black keratinous plug
• Closed comedo: Closed
pilosebaceous opening is
unapparent, accumulates the
whitish keratin
• Characteristic and primary
lesion of acne
Milium

• Definition: A tiny white

superficial cyst with
epidermal lining containing
lamellated keratin
• Sometimes arise on blistered
or damaged skin e.g., after
dystrophic epidermolysis
bullosa, porphyria,
dermabrasion
Erythema/Purpura

• Erythema: Blanches redness of skin,

and is due to vascular congestion or
increased perfusion e.g., facial erythema
in rosacea
• Purpura: Non-blanching reddish to
purple discolouration of skin due to
extravasation of RBCs in dermis e.g.,
vasculitis, bleeding disorders
• Petechiae: 1-2 mm small pupuric
lesions, Occur in crops e.g., clotting
disorders
• Ecchymosis: Larger purpuric lesions
from extravasation of blood
• Diascopy: Differentiates erythema from
purpura
Telangiectasias

• Definition: Visible and

persistent dilatations of small
capillaries in the superficial
dermis that appear as fine,
bright non-pulsatile, net like
pattern on the skin
• May or may not disappear with
diascopy
• Types: Mat-like, punctate, linear
• Examples: In-rosacea, collagen
vascular diseases
Sclerosis

• Definition: A diffuse
induration and hardening of
skin due to dermal fibrosis
• The skin feels firm board like,
immobile and difficult to pick
up
• Examples: Morphea,
systemic sclerosis

Morph
ea
Poikiloderma

• Definition: A dappled
appearance of skin from
combination of atrophy,
telangiectasia and pigment
changes (hypo or
hyperpigmentation)
• Example: Rothmund
thomson syndrome,
xeroderma pigmentosa
Poikiloderma in
xeroderma
pigmentosa
Target Lesions

• Definition: These have 3

zones:
• Central: dusky, blistered or
purpuric zone
• Middle: pale zone of oedema
• Outer: Erythematous zone
with well defined edge
• Example: Erythema
multiforme
Further Description

• Shape of lesions: The shape of each lesion – dome-shaped, flat

topped, umbilicated, acuminate, pedunculated, verrucous
• Distribution of lesions: The overall distribution of lesions –
scattered, disseminated, widespread, confluent, symmetrical
or asymmetrical, acral
• Pattern of lesions: The arrangement of individual lesions -
annular, arcuate, linear, grouped, discoid, reticulate, gyrate
• Colour of skin and of lesions: e.g., purplish (LP), yellowish
(xanthoma), etc.
Further Description

• Arrangement: Linear, grouped, dermatomal, serpiginous

• Zosteriform: Grouped vesicles arranged in a dermatome
• Corymbiform: Grouped arrangement with a central cluster of
lesions beyond which are scattered individual lesions (verruca
vulgaris)
• Un-patterned grouped lesions: As in verruca plana, lichen
planus, urticaria, insect bites(often in groups of three)
• Spared areas: As in photodermatitis
Thank You
MCQs
Q1: One keratinocyte-melanin unit
comprises-

A. One melanocyte and 10 keratinocytes

B. One melanocyte and 36 keratinocytes
C. One melanocyte and 40 keratinocytes
D. None of the above
E. Answer “A” and “B” above are correct
Q2: Langerhans cells-

A. Are non-dendritic cells

B. Are a fine touch receptors
C. Are involved in skin immune surveillance
D. Are neuritic cells
E. Detect mechanical deformities of epidermis
Q3: Average hair loss is?

A. About 200 per day

B. About 100 per day
C. No hair are shed normally
D. All are true
E. None is true
Q4: Eccrine sweat gland are most
concentrated over

A. Trunk
B. Extremities
C. Scalp
D. Palms, sole and axillae
E. Groins
Q5: Downward projections of epidermis
are called?

A. Reticular dermis
B. Papillae
C. Rete pegs
D. Stratum spinosum
E. Stratum corneum
Q6: Well circumscribed alteration in
the colour without alteration in
texture of the skin is a -
A. Plaque
B. Macule
C. Poikiloderma
D. Erosion
E. Wheal
Q7: Identify the lesion over forehead of
the child in image below
Q8:Identify the type of lesion in the
image below
Q9: Identify the type of lesion in the
image below
Q10: Identify the lesions below
Thank You