The skin is the largest organ of the human body, exceeding two square metres in area in the average adult. Whilst it is rarely more than 2 mm in thickness, the skin plus subcutaneous fat may weigh 9 kg — approximately 14% of the body weight. The primary function of skin is to act as a physical barrier between the organism and its external environment, preventing water loss in dry conditions, hydration in humid or aquatic environments, and access to the body by microbes, and screening the harmful effects of ultraviolet rays of the sun. The skin also plays an important role in transmitting signals from the external environment and in regulating body temperature. The structure of skin confers mechanical strength, enabling it to withstand considerable physical insults, and when it is breached, it exhibits an amazing power of regeneration and repair.The epidermis, the outer layer of the skin, is a multi-layered epithelium approximately 0.1 mm thick, although there are great variations, such as on the palms and soles, where it may reach 1.4 mm. (The underlying dermis is about 3 mm thick.) The major cell type of the epidermis is the keratinocyte, so named because of the protein keratin, which it synthesizes in abundance. The epidermis is in a state of constant turnover, with keratinocytes being generated by mitosis (cell division) in a basal layer adjacent to the underlying dermis, and daughter cells passing outward toward the skin surface through successive stages of differentiation, characterized by dramatic changes in shape and size (see figure). After leaving the basal layer, the cells become large and polyhedral (spinous), and are joined to adjacent cells by complex structures called ‘desmosomes’, which are like spot welds. This spinous layer may be several cells thick, with the cells becoming increasingly flattened before they form the granular layer and then ultimately the cornified horny outer layer, in which the cells lose most of their internal structures including their nuclei and essentially become dead packages of compacted keratin coated with lipid. Cell-to-cell adhesive processes degenerate and the dead cells are eventually shed from the skin surface. It takes 26-42 days for a cell to transit from the basal layer to the outer horny layer, and a further 14 days before being shed, so the epidermis can completely replace itself within two months. The rate of epidermal cell turnover is normally strictly controlled, but a number of diseases are characterized by epidermal hyperproliferation. In psoriasis, for example, the rate may be increased twenty-fold.
The keratin proteins within the keratinocytes are fundamental to the protective functioning and integrity of the skin. The mixture of compacted fibrous keratins in the outer horny layer (the word, ‘keratin’ is derived from the Greek keratos, meaning horn) is highly stable, inert, hard, waterproof, and resistant to physical insult, and therefore is ideally suited to act as a protective layer. The dehydrated nature of the horny surface layer together with an acidic environment due to various secretions, makes it an inhospitable environment for microorganisms. That this outer surface of dead, keratin-rich cell layers is important in regulating water loss or skin saturation in humid conditions and infection can be demonstrated by removal of the outer layers by successive stripping with sellotape. The resulting denuded skin surface is highly permeable to water and susceptible to infection by a number of microorganisms. Defects in keratins have now been identified as having a causal role in a number of skin disorders.
Other cell types within the epidermis include melanocytes, Langerhan cells, and Merkel cells. The melanocytes are confined to the basal cell layer, are highly dendritic (i.e. they have many branching extensions, like nerve cells), and synthesize the pigment melanin, which moves into surrounding keratinocytes, via the dendritic processes, in small packages termed melanosomes. The Langerhan cells appear to be involved in immunological monitoring of the skin, while the Merkel cells are associated with sensory perception.

The layers and components of the skin. Right: the full thickness; left, the epidermis only
(Click to enlarge)
The dermisis a dense fibroelastic tissue, of which the major constituents are
collagen, forming a fibrous rope-like network predominantly in a plane parallel to the epidermis, and elastic fibres, which form a fine network in all directions. The collagen fibres confer tensile strength to the tissue, while elastic fibres allow restoration of the normal skin architecture following deformation by external mechanical forces. The space between this fibrillar network is filled with glycosaminoglycans, which are large polysaccharides, and, although they are present in small amounts, they bind vast amounts of water, forming a gel-like matrix which controls the tone and turgor of the tissue and helps to resist compressive forces. The outer region of the dermis is highly uneven, with numerous projections called papillae, which conform tightly to the contours of the epidermis, imparting a resistance to sheer forces upon it. The boundary between the epidermis and dermis is demarcated by a thin membrane and by complex structures which ensure tight anchorage of each to the other. Defects in some of these junctional complexes are associated with certain blistering diseases, such as epidermolysis bullosa, where there there is an abnormality of anchoring fibrils. The dermis contains a number of structures which are derived during development from the epidermal layer, notably sweat and sebaceous glands and
hair follicles.
The dermis has a copious blood supply, with capillaries extending right up into the dermal papillae projections; these are the nearest vessels to the epidermis, which is itself avascular. Constriction or dilation of the blood vessels alters the temperature of the skin, plays an important role in whole body
temperature regulation, and may be observed as pallor or flushing. The skin also has a rich sensory nerve supply, particularly abundant on the face, hands, and genitalia. Some nerve endings lie in the epidermis adjacent to Merkel cells, where they can detect pain, temperature changes, and itch. Nerves of the sympathetic system are associated with blood vessels, sweat glands, and the arrector pili muscles of hairs, which allow hairs to ‘stand on end’.
Hair While in most animals hair and fur plays an important role in heat conservation, in humans its primary function is in sexual attraction. The keratinous hairs cover the whole body surface except the palms and soles, and are present as either ‘terminal’ hair characterized by that of the scalp, or ‘vellus’ hair such as the very fine short body hairs. Hair fibres arise as a result of cell division within the hair follicles, which go through a cyclical pattern of active growth, regression, and a resting phase. The rate of hair growth varies depending upon body site: eyebrow hair, for example, grows much faster than the scalp hair rate of about 0.33 mm per day. Loss of hair in males (male pattern baldness) is essentially inherited and androgen-dependent: from the second decade, following multiple growth cycles, the terminal hairs gradually convert to fine vellus hairs. Other types of baldness (alopecia) may occur due to infection or immunological disorders.
Sebaceous glands are sac-like structures that arise from an epithelial outgrowth of the hair follicle outer root sheath, and are composed of a single cell type, the sebocyte. The gland produces an oily ‘sebum’ secretion, of unknown function. The glands remain immature until puberty, and it is the secretion of sebum that is associated with pubertal acne. This is a chronic inflammation of the hair follicle and sebaceous gland (pilosebaceous unit) characterized by pustules, comedones (blackheads), cysts, and scars, and it affects most adolescents. Treatments may include anti-androgens, retinoids, or antibiotics.
Sweat glands are of two types. Eccrine sweat glands are distributed over almost all of the body surface (2-4 million in total), but they are particularly numerous on the palms, soles, axillae, and forehead. The eccrine sweat gland is a simple unbranched tube which runs from the epidermal surface deep into the dermis, where it develops into a coiled structure. These glands are responsible for the secretion of large amounts of sweat, particularly during strenuous exercise or heat stress, when up to 10 litres a day may be produced; evaporation of the sweat cools the body. Elevated sweat production may also be stimulated by emotion or the consumption of spicy food. Apocrine sweat glands differ from the eccrine in that the gland ducts discharge into the lumen of a hair follicle; also they are confined mainly to the underarms, and the genital area in women. Their secretion is probably of limited functional significance, but as a result of bacterial action it is responsible for body odour.
Wound healing
Skin has an amazing ability to heal wounds, but the rate of healing is dependent upon the severity of the wound. Superficial wounds may be repaired rapidly by simple migration of keratinocytes over the defect. Deeper wounds involve blood coagulation, inflammation, re-epithelialization, wound contraction, and new tissue synthesis and remodelling. These processes have been optimized for rapid wound closure, thus preventing fluid loss and infection, but usually at the expense of subsequent function and cosmetic appearance by the formation of scar tissue. Some large wounds, such as severe burns, may be assisted in their healing response by grafts, or by the use of keratinocyte sheets — grown in the laboratory from keratinocytes derived from biopsies of the patient's own skin. Much research effort is currently devoted to accelerating wound healing and reducing scar formation.
Sun exposure
Exposure of the skin to non-ionizing ultraviolet emissions of the sun is unavoidable, but the effect of such exposure is dependent upon both skin type and the length of exposure. Skin is classified as a certain type depending upon its susceptibility to burn, ranging from type I for very fair skin which burns easily and never tans, to type VI-black negroid skin. Within the spectrum of sunlight, ultraviolet B (UVB, 290-320 nm wavelength) causes sunburn, while both UVB and UVA (320-400 nm) will induce pigmentation. UVB is predominantly absorbed by the outer horny layer, allowing only about 10% to reach the dermis, while all UVA penetrates the epidermis to reach the dermis. Exposure to UVA (the predominant wavelength used in sunbeds) is therefore likely to be a major contributor to connective tissue damage in the dermis, resulting in the features of aged, wrinkled skin. More seriously, sun exposure is a major cause of skin cancer (see below).
Sun exposure does have some benefits, such as promoting the synthesis of vitamin D3 from its precursor in the skin, while stimulation of tanning has a protective effect from subsequent sun exposure. Many psoriasis patients also exhibit a marked improvement in their disease following sun exposure.
Ageing
Aged sun-protected skin is characterized by a general laxity, thinning, and the presence of numerous fine wrinkles. The skin becomes less elastic, is greatly reduced in its tensile strength, and exhibits a diminished ability to resist various insults such as injury, infection, and irritants. Chronic sun exposure induces substantial photoageing characterized by a coarse leathery texture, loss of elasticity, deep wrinkles, yellowish colouration, and the presence of numerous irregular pigmented lesions including actinic keratoses. While the youth of today may regard a deep tan as attractive, in their later years they will undoubtedly suffer the consequences of their actions. A more sinister consequence of prolonged sun exposure is the greatly increased incidence of both benign and malignant tumours.
Skin diseases
In the UK, skin diseases account for approximately 10% of patient visits to general practitioners and 6% of hospital outpatient referrals, and this, combined with the fact that they are the most prevalent cause of occupational absence, has substantial economic implications. In addition, many skin diseases, such as those that are debilitating or particularly apparent and extensive, can have serious psychological effects. Some of the more common skin complaints include urticaria (an eruption characterized by usually itchy weals and swelling), acne, viral warts, infections (bacterial, viral or fungal such as ringworm and athlete's, foot), eczema/dermatitis, rashes, and psoriasis. Psoriasis affects approximately 2% of the population in Europe and North America, and is characterized by well demarcated, inflammatory red plaques topped by silvery scales; it is a major medical problem, causing anxiety and distress, and can be debilitating in severe cases. Although our knowledge of the disease has progressed greatly in recent years, the primary cause of the excessive epidermal proliferation which underlies psoriasis has eluded major worldwide research efforts.
Tumours
Tumours of the skin may be benign or malignant. Benign epidermal tumours such as ‘seborrheic keratoses’ are extremely common. Malignant skin tumours are much the commonest type of cancer overall. Excess exposure, particularly of pale Caucasian skin to ultraviolet irradiation in the form of sunlight, is currently recognized as the major cause of skin cancers, of which the most frequent are basal cell carcinomas (rodent ulcers), squamous cell carcinomas, and malignant melanoma. Basal cell carcinomas are most frequently found on the faces of middle-aged or elderly patients and do not spread to other parts of the body, whereas squamous cell carcinomas may spread. Both of these tumour types are derived from keratinocytes, and are usually treated by simple excision. Malignant melanomas are derived from epidermal melanocytes, and frequently arise from pre-existing pigmented lesions such as moles. The incidence has increased dramatically over the last two decades and this is the most lethal of all skin cancers, spreading rapidly to other organs. If caught at an early stage, however, the prognosis is good, and, due to public education campaigns, the use of sun screens has become more prevalent, and patients are presenting at the clinic much earlier.
Cosmetics
Cosmetics play an important role in skin protection, either as moisturizers or sunscreens, but many are simply used to promote attractiveness, to mask unwanted smells, or to impart pleasant smells and camouflage skin defects. Many contain so-called active ingredients which may alleviate the damage inflicted by sun exposure such as anti-wrinkle creams, or skin lightening creams, or artificial tanning creams. However, a number of cosmetic preparations may elicit a reaction in some people resulting in either irritant dermatitis or allergic sensitivity and contact urticaria.
— Mike Edward, Rona Mackie
Bibliography
- MacKie, R. M. (1997). Healthy skin — the facts. Oxford University Press, Oxford.
- MacKie, R. M. (1996). Clinical dermatology, 4th ed. Oxford University Press, Oxford
See also body decoration, body odours, hair, sun and the body, sweating; temperature regulation.