SKIN

Our skin is the largest organ of the human body. The integument or skin makes up 15% to 20%
of the body’s weight. Intact skin is the body’s primary defense system. It protects us from
invasion by organisms, helps to regulate body temperature, manufactures vitamins and provides
our external appearance. Skin has three primary layers (i.e., epidermis or outer layer; the dermis
or inner layer and the hypodermis or subcutaneous layer) as well as epidermal appendages (i.e.
Eccrine glands, apocrine glands, sebaceous glands, hair follicles and nails).

The skin is the most prominent organ containing epithelium, which is composed of cells that
provide a continuous barrier between the body contents and the outside the environment.
Epithelial cells also cover the Gastrointestinal tract, pulmonary airways and alveoli, renal tubules
and the urinary system, and the ducts that empty onto the surface of the skin of the GI and
respiratory systems. Epithelial cells allow the selective transport of ions, nutrients, and metabolic
wastes and have a permeability to water that is partially regulated.

STRUCTURE OF INTEGUMENTARY SYSTEM

EPIDERMIS

The epidermis is composed of keratinized,

stratified squamous epithelium. It is made
of four or five layers of epithelial cells,
depending on its location in the body. It
does not have any blood vessels within it
(i.e., it is avascular). Skin that has four
layers of cells is referred to as “thin skin.”
From deep to superficial, these layers are
the stratum basale, stratum spinosum,
stratum granulosum, and stratum corneum.
Most of the skin can be classified as thin
skin. “Thick skin” is found only on the
palms of the hands and the soles of the feet.
It has a fifth layer, called the stratum
lucidum, located between the stratum
corneum and the stratum granulosum.

Layers of Epidermis

The layers of the epidermis include the stratum basale (the deepest portion of the epidermis),
stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum (the most
superficial portion of the epidermis).

Stratum basale, also known as stratum germinativum, is the deepest layer, separated from the
dermis by the basement membrane (basal lamina) and attached to the basement membrane by
hemidesmosomes. The cells found in this layer are cuboidal to columnar mitotically active stem
cells that are constantly producing keratinocytes. This layer also contains melanocytes.

Stratum spinosum, 8-10 cell layers, also known as the prickle cell layer contains irregular,
polyhedral cells with cytoplasmic processes, sometimes called “spines”, that extend outward and
contact neighboring cells by desmosomes. Dendritic cells can be found in this layer.

Stratum granulosum, 3-5 cell layers, contains diamond shaped cells with keratohyalin granules
and lamellar granules. Keratohyalin granules contain keratin precursors that eventually
aggregate, crosslink, and form bundles. The lamellar granules contain the glycolipids that get
secreted to the surface of the cells and function as a glue, keeping the cells stuck together.
Stratum lucidum, 2-3 cell layers, present in thicker skin found in the palms and soles, is a thin
clear layer consisting of eleidin which is a transformation product of keratohyalin.

Stratum corneum, 20-30 cell layers, is the uppermost layer, made up of keratin and horny
scales made up of dead keratinocytes, known as anucleate squamous cells. This is the layer
which varies most in thickness, especially in callused skin. Within this layer, the dead
keratinocytes secrete defensins which are part of our first immune defense

DERMIS

The dermis, a dense layer of tissue beneath the epidermis, gives the skin most of its
substance and structure. The dermis contains fibroblasts, macrophages, mast cells and
lymphocytes. The skin’s lymphatic, vascular, and nerve supplies, which maintain equilibrium in
the skin, are in the dermis.

The dermis is divided into two parts: papillary and reticular. The papillary dermis, which
contains increased amounts of collagen, blood vessels, sweat glands, and elastin, is in contact
with the epidermis. The reticular dermis also contains collagen but with increased amounts of
mature elastic tissue. The dermis houses many specialized cells, blood vessels, and nerves.

Dermis - Specialized Structures

 Nerve endings
 Blood vessels
 Sweat glands
 Oil glands - keep skin waterproof, usually discharges around hair shafts
 Hair follicles - produce hair from hair root or papilla

Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and cause
goose flesh

HYPODERMIS

The subcutaneous layer is a specialized layer of connective tissue. It is sometimes called

the adipose layer because of its fat content. This layer is absent in some sites, such as eyelids,
scrotum, areola and tibia. Subcutaneous fat is generally thickest on the back and buttocks, giving
shape and contour over the bone. This layer functions as insulation from extremes of hot and
cold, as a cushion to trauma, and as a source of energy and hormone metabolism.
FUNCTION OF THE INTEGUMENTARY SYSTEM

PROTECTION

The skin protects the rest of the body from the basic elements of nature such as wind,
water, and UV sunlight. It acts as a protective barrier against water loss, due to the presence of
layers of keratin and glycolipids in the stratum corneum. It also is the first line of defense against
abrasive activity due to contact with grit, microbes, or harmful chemicals. Sweat excreted from
sweat glands deters microbes from over-colonizing the skin surface by generating dermicidin,
which has antibiotic properties.

HOMEASTASIS

Skin forms a barrier that prevents excessive loss of water and electrolytes from the
internal environment and also prevents the subcutaneous tissues from drying out. The
effectiveness of this impermeable membrane is readily recognized when one observes the
extreme loss of fluids that occurs with damage to the skin, as with burns and other injuries.
Insensible loss of water and electrolytes occurs only though pores in this effective barrier.

THERMOREGULATION

Body temperature represents the balance between heat regeneration and heat loss
processes. The skin, with its ability to alter the rate of heat loss, is the major point of regulation
of body temperature. The rate of heat loss depends primarily on the surface temperature of the
skin, which is in turn a function of the skin’s blood flow.

The flow of blood to the skin is derived in two processes. Direct perfusion is from
capillary beds entering in lateral directions. Skin is also perfused vertically from vessels that
enter from the muscle and fascia supporting it.

In general, the vessels dilate during warm temperatures and constrict during cold. The
hypothalamus is partly responsible for regulating skin blood flow, particularly to the extremities,
the face, ears, and the tip of the nose. Maintenance of the thermal balance allows the internal
temperature of the body to remain at approximately 37 degree Celsius.

SENSORY PERCEPTION

Apart from sight and hearing, the major human sensory apparatus is in the skin. Sensory
fibers responsible for pain, touch and temperature form a complex network in the dermis. The
skin contains specialized receptors to detect discriminative touch and pressure. Touch is sensed
by Meissner’s corpuscles; pressure by Merkel cells and Ruffini endings; vibration by Pacinian
corpuscles; and hair movement by hair follicle endings.
A second grouping of nerves communicates information about temperature and pain to the
somatosensory cortex via the anterolateral pathways. Temperature is sensed by specific
thermoreceptors in the epidermis, and pain is sensed by free nerve endings throughout the
epidermal, dermal, and hypodermal layers.

VITAMIN D REPRODUCTION

The epidermis is involved in synthesis of vitamin D. In the presence of sunlight or ultraviolet

radiation, a sterol found on the Malpighian cells is converted to form cholecalciferol (Vitamin
D3). It assists in the absorption of calcium and phosphate from ingested foods.

PROCESSING OF ANTIGENIC SUBSTANCES

Langerhans cells are scattered among the keratinocytes located primarily in the epidermis;
however, they can also be seen in the dermis. These cells originate in the bone marrow and
migrate to the epidermis. Langerhans cells play a role in the cell-mediated immune responses of
the skin through antigen presentation. Cells in both the epidermis and dermis of the skin are
important in the immune function. Skin is now recognized not only as a physical barrier but also
as a participant in immunologically mediated defense against various antigens.

Di

Classification of Burns:

First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the
epidermis. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example.
Long-term tissue damage is rare and often consists of an increase or decrease in the skin color.

Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part
of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and
painful.

Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis.
They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look
white or blackened and charred.
Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying
tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the
area since the nerve endings are destroyed.

The first step in assessing a burn and planning resuscitation involves a careful examination of all
body surfaces. A standard Lund-Browder chart is readily available in most emergency
departments for a quick assessment of total body surface area burns. If this is not available, the
"rule of nines" is fairly accurate in adult patients.

See the rule of nines as follows. Note that a patient's palm is approximately 1% TBSA and can
be used for estimating patchy areas.

Head/neck - 9% TBSA

Each arm - 9% TBSA

Anterior thorax - 18% TBSA

Posterior thorax - 18% TBSA

Each leg - 18% TBSA

Perineum - 1% TBSA

With pediatric patients, the head is a proportionally larger contributor to body surface area
(BSA), while the upper legs contribute less. This difference is reflected in the slight differences
noted in the pediatric Lund- Browder diagram. A useful tool for estimating BSA of spotty burns
is the close approximation of just less than 1% BSA to the patient’s palm size. Only second-
degree burns or greater should be included in the TBSA determination for burn fluid
calculations.
Thermal burns. These burns are due to heat sources which raise the temperature of the skin and
tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames,
when coming into contact with the skin, can cause thermal burns.

Radiation burns. These burns are due to prolonged exposure to ultraviolet rays of the sun, or to
other sources of radiation such as X-ray.

Chemical burns. These burns are due to strong acids, alkalies, detergents, or solvents coming into
contact with the skin or eyes.

Electrical burns. These burns are from electrical current, either alternating current (AC) or direct
current (DC).

Hypovolaemic shock – from blood loss or excessive fluid loss (eg: major burns or D&V)

Cardiogenic shock – the heart is unable to circulate enough blood volume to maintain adequate
tissue perfusion. This can happen after a heart attack or during an acute episode of heart failure.

Obstructive shock – can be caused by an obstruction in the cardiovascular system. Examples

include a pulmonary embolism (blood clot in the lung) and pneumothorax (collapsed lung).

Distributive shock – occurs as a result of poor distribution of blood to the tissues, leading to
inadequate tissue perfusion. This type of shock is seen in spinal, septic, and anaphylactic shock.
This is also known as relative hypovolaemia.
Hypovolemic shock is caused by severe blood and fluid loss, such as from traumatic bodily
injury, which makes the heart unable to pump enough blood to the body, or severe anemia where
there is not enough blood to carry oxygen through the body.

- Hypovolemic shock treated with fluids (saline) in minor cases, but may require multiple
blood transfusions in severe cases. The underlying cause of the bleeding must also be
identified and corrected.

Neurogenic shock is a life-threatening condition caused by irregular blood circulation in the

body. Trauma or injury to the spine can cause this disruption. Neurogenic shock is extremely
dangerous because it can cause your blood pressure to drop drastically and suddenly, and can
leave irreversible damage to your body tissues. If left untreated, neurogenic shock can be fatal.

Septic shock is treated with prompt administration of antibiotics depending on the source and
type of underlying infection. These patients are often dehydrated and require large amounts of
fluids to increase and maintain blood pressure.

Many different things can cause shock. They can be grouped by type.

Hypovolaemic shock – shock caused by a large loss of blood or body fluids, such as from a
serious accident, major surgery, a burn or a medical condition that causes severe vomiting and
diarrhoea.

Cardiogenic shock – shock due to heart muscle damage, which can happen during a heart attack
or when the heart muscle has a severe infection.

Septic shock – shock caused by severe bacterial infection.

Anaphylactic shock – shock caused by a severe allergic reaction.

Neurogenic or spinal shock – shock caused by damage to the nervous system (brain or spinal
cord).