 Distinct layers of the skin

INTEGUMENTARY  Stratum basale – deepest; cuboidal & columnar cells,

undergo mitosis every 19 days
SYSTEM o Cells from this stratum take 40-56 days to
reach the surface
Functions of the Integumentary S. (STEP V) o As cells from this layer are pushed, it forms
▪ It consists of the skin, and accessory structures such as the intermediate strata
hair, glands, and nails. o AKA stratum germinativum (germinativum
1. Sensation means growth)
2. Temperature regulation  Stratum corneum – most superficial stratum; dead
3. Excretion squamous cells filled with keratin (structural strength);
4. Protection lipids (prevent fluid loss); joined by desmosomes—
5. Vitamin D production mechanical link that bind adjacent cells together
Callus – “kalyo” thickened area
 Produced when skin is subjected to friction
 ↑in the number of layers of the stratum corneum
Corn – bony prominence, thickened corn shaped structure
 Also, d/t thickening of the stratum corneum
Dandruff
 Excessive stratum cells sloughed from the surface
of the scalp

2. Dermis
 Dense collagenous connective tissue, contains
fibroblasts, adipocytes, macrophages
 Already has supply of blood vessels (vascular)
 Nerves, hair follicles, smooth muscles, glands,
lymphatic vessels extend into the dermis
 Abundant in collagen and elastic fibers
o Collagen (resist stretching) & elastic fibers –
Skin structural strength
1. Epidermis o Collagen start to reduce in production at 40
 Most superficial layer or 60 years of age
Cleavage lines/Tension lines – collagen fibers are oriented in
 Avascular some directions; skin is most resistant to stretch along these
 Stratified squamous epithelium lines
 In deepest layers, mitosis occurs
o New cells are produced by mitosis in its deepest
layers, as these new cells form, older cells are
pushed superficially causing it slough and flake
off

Keratinization – cells change shape and chemical composition;

cells become filed with the protein keratin (becomes hard)
 Epithelial cells die and produce and outer layer of
dead, hard cells that resists abrasion and forms a
barrier

Different Strata
Stretch marks (striae) – skin is overstretched, leaving lines
that are visible
 Rapid weight gain and pregnancy may cause this
Dermal papillae – finger-like projections in the upper
part of the dermis which extend toward the
epidermis. It contains blood vessels that supply the
epidermis with nutrients, remove waste products, and
regulate body temperature
 The dermal papillae in the palms of the hands and
soles of the feet are arranged in definite patterns
that form looped ridges in the epidermal surface
(fingerprints and footprints)
 These ridges increase friction and enhance the
grasping or gripping ability of the hands and feet
3. Subcutaneous Tissue/ Hypodermis  Hair follicle – where each hair rises
 Attaches the skin to underlying bones and muscles o Can play an important role in skin repair
o If the surface epidermis is damaged, the
 Also called the hypodermis
epithelial cells within the follicle can divide
 Loose connective tissue and become a source of new cells
o Storage of our body’s fat (padding,  Shaft – above the skin
insulation)  Root – below the skin
o Fat in this layer functions as padding and  Hair bulb – site of hair cell formation; “growth zone”
insulation o Where distribution of melanocytes occurs
 Hair papilla- where hair bulb rests; supplies hair bulb
Skin Color with blood and nourishment needed to produce hair
 Melanin – pigments responsible for skin, hair, eye color  Cortex – hard keratin, covering of the central core
o It is also a protective pigment  Medulla – soft central core
 Melanin pigments – yellow (Caucasian), brown  Cuticle – single layer of overlapping cells that holds
(Asians), black (African) the hair in the hair follicle; heaviest keratinized region
 Melanocytes – produce melanin; irregularly shaped cells; and outermost layer of hairs
found mainly in the stratum basale
Growth Stage
 Melanosomes – vesicles derived from the golgi apparatus  Hair is formed by epithelial cells within the hair bulb
where melanin is produced
 Divide and undergo keratinization
o Packed melanin
 Hair root + shaft = columns of dead keratinized
 Factors of Melanin Production epithelial cells
o Genetic factors
o Exposure to UV light (e.g., exposure to UV light Resting Stage
increases melanin production as a protective  Growth stops
mechanism→ suntanned)  Hair is held in the hair follicle
o Hormones (e.g., estrogen and melanocyte-
stimulating hormone (MSH) results to an increase Next growth stage
production of melanin during pregnancy→  A new hair is formed
chloasma “mask of pregnancy”)  The old hair falls out
 Albinism - recessive genetic trait that causes deficiency / Eyelashes – grow for about 30 days; rest for 105 days
absence of melanin
 Cyanosis - bluish skin color; decreased blood O2 Scalp hairs – grow for 3 years; rest for 1 – 2 years
 Carotene – yellow pigment in plants (squash, carrots); Arrector Pili – smooth muscles associated with every hair follicle;
source of vitamin A contraction = hair to stand more perpendicular to the skin’s
o Lipid-soluble and if taken in excessive amounts, surface; produces goose bumps
the skin may turn yellowish
Glands
 Birthmarks – congenital disorder of the capillaries in the I. Sebaceous Glands
dermis (dilation of the capillaries e.g., strawberry  Simple, branched acinar glands (sac-like)
hemangiomas)  Connected by a duct to the superficial part of the
hair follicle
Accessory Skin Structure  Sebum – oily, white substance rich in lipids;
Hair released by holocrine secretion; lubricates the
 Columns of dead, keratinized epithelial cells hair/surface of the skin (prevents drying and
protects against bacteria)
 Found everywhere on the skin except on the
 White heads- blockage of the sebaceous glands
palms, soles, lips, nipples, parts of the  Blackheads- accumulated material which
genitalia, and distal parts of the fingers and oxidizes, dries and then darkens
toes  Acne- infection of the sebaceous glands
 Seborrhea or seborrheic dermatitis- “cradle cap”
in infants – it is caused by the overactivity of the
sebaceous glands

II. Sweat Glands

 Sweat- clear secretion (produced by the sweat glands)

that is primarily water, salts, vitamin C and it may
contain traces of metabolic wastes and lactic acid
 Eccrine Sweat Glands
 o Simple, coiled, tubular glands located in 2. Temperature Regulation
almost every part of the skin  Normal body temp. = 36.5oC -37.5oC
 Release sweat by merocrine  Rate of chemical that run within the body can
secretion increased or decreased based on the body temp
 Numerous in the palms and soles  Factors that raise body temperature
 Apocrine Sweat Glands o Exercise
o Simple, coiled, tubular glands o Fever
 Produce a think secretion rich o Increase in environmental temperature
in organic substances  The skin controls heat loss from the body through
 Released primary by dilation and constriction of blood vessels and the
merocrine secretion; some activity of the sweat glands underneath the skin
glands demonstrate holocrine o Heat is lost through vasodilation (↑blood
secretion supply→ activation of sweat glands)
 Larger than merocrine glands o Heat is retained through vasoconstriction
(↓blood supply→ ↓activity of sweat glands)
o Open into hair follicles in armpits and
 Sweat glands produce sweat, which evaporates and
genitalia lowers body temperature
o Become active at puberty and produces  Heat is lost by radiation (infrared energy), convection
body odor (air movement), conduction (direct contact)

III. Other Glands 3. Excretion

 Ceruminous glands – cerumen (earwax)  Skin glands remove water and salt
 Mammary glands – milk  Also removes small amounts of urea, uric acid,
ammonia
Nails 4. Protection
 Dead stratum corneum cells  Reducing water loss
 Contain a very hard type of keratin o Lipids act as a barrier to the diffusion of
water
 Prevents microorganisms from entering the body
 Protects underlying structures against abrasion
 Melanin absorbs UV light and protects underlying
structures from its harmful effects
 Hair on head = heat insulator
 Eyebrows = keep sweat out of the eyes
 Eyelashes = protects the eyes from foreign objects
 Hair in the nose, ears = prevents the entry of dust
 Nails = protect the ends of the fingers, toes from
damage; can be used in defense

5. Vitamin D Production
 Skin exposed to UV light produces cholecalciferol
(modified in the liver, then in the kidneys to produce
active vitamin D)
 Best sources of Vit. D = fatty fish, vit. D fortified milk
 Small amounts of Vit D = eggs, butter, liver
 Active Vit. D stimulates the small intestine to absorb
calcium and phosphate (normal bone growth, normal
 Nail body – visible part of the nail muscle function)
 Nail root – part of the nail covered by skin 7-dehydrocholesterol + sunlight→ skin photolysis→ 7-
 Cuticle – eponychium; s. corneum that extends dehydrocholesterol in the stratum basale is sent to the liver for
onto the nail body hydroxylation, which transforms to calcidiol→ calcidiol goes to
 Nail matrix – produces the nail the kidneys→ The kidney hydrolyzes the calcidiol into Vitamin D3
 Nail bed – contributes to nail formation
 Lunula – white, crescent-shaped area; part of the Integumentary System as a Diagnostic Aid
nail matrix visible through the nail body  Cyanosis – bluish color to the skin caused by
decreased blood O2 content
Physiology of the Integumentary System (STEP V) o May be cause by impaired circulatory or
respiratory function
1. Sensation  Jaundice – yellowish skin color caused by liver
damage (viral hepatitis)
 Detects pain, heat, cold, pressure, and other stimuli  Rashes & lesions - symptoms of problems elsewhere;
e.g., scarlet fever causes reddish rash, typhoid fever
(rose spots), allergic reaction to food or drugs can
 develop rashes  Development of malignant
 Vitamin A Deficiency – excess keratin production; melanoma
sandpaper texture characteristic o UVB
 Iron Deficiency Anemia – nails become flat or  Most burning of the skin
concave  Development of basal cell and
 Lead Poisoning – high levels of lead in the hair squamous cell carcinoma
Burns
 Burn – injury to a tissue caused by heat, cold, friction, I. Basal cell carcinoma
chemicals, electricity, and radiation  Most frequent type and least malignant
 Begins in the cells of the stratum basale and
I. Partial-thickness Burns extends into the dermis to produce an open ulcer
 S. basale remains viable  Cure; surgical removal or radiation therapy
 Regeneration of the epidermis occurs within the burn  Little danger of cancer to spread,
area metastasize
First-degree burns II. Squamous cell carcinoma
 Epidermis  Develops from cells immediately superficial to the
 Red and painful stratum basale
 Slight edema (swelling)  Cells continue to divide as they produce keratin→
 E.g., sunburns, brief exposure to hot and cold objects nodular, keratinized tumor confined to the epidermis
 Can invade the dermis, metastasize, and cause death
 Heals within a week without scarring
III. Malignant melanoma
Second-degree burns
 Cancer of the melanocytes
 Epidermis, minimal damage to the dermis
 Rare form of skin cancer (5% of skin cancers) that
o Epidermis regenerates from the epithelial
arises from melanocytes; usually from a pre-existing
tissue mole
 Dermal damage is minimal o Mole – an aggregation or nest of
o Redness, pain, edema, blisters melanocytes
o Healing = 2 weeks o Large, flat, spreading lesion or deeply
o Will not produce scars pigmented nodule
 Deep into the dermis  Metastasis is common
o Pink to red in color  Often fatal
o Takes several months to heal  ABCD rule for recognizing melanoma:
o Might scar o A- asymmetry
II. Full-thickness Burns o B- border
 Third-degree burns o C- color
o Epidermis, dermis, and underlying tissues o D- diameter
are completely destroyed
o Recovery occurs from the edges of the burn FX of Aging on the Integumentary S.
wound  Epidermis thins
o Region of the 3rd degree burn is painless  Amount of collagen in the dermis decreases ▪
(sensory receptors have been destroyed) Skin infections are most likely
o White, tan, brown, black, deep  Repair of skin occurs slower
 Cherry red  Decrease no. of elastic fibers in the dermis and loss of
o Take a long time for burn to heal fat (sagging of skin, wrinkles)
o Form scar tissue  Decrease of activity of sweat glands = reduced ability
to regulate body temp.
o Skin grafts are used to prevent  Decrease sebaceous gland activity = skin becomes
complications and to speed healing drier
 Decrease no. of melanocytes
Skin Cancer  Some areas, the no. of melanocytes increase = age
 Most common type of cancer spots
 Exposure to UV light from the sun  Increased melanin production = freckles; also,
 Usually on face, neck, hands gray/white hair
 Most like to have skin cancer = fair skinned or  Skin that is exposed to sunlight = shows signs of
older than 50 aging more rapid
 Limiting exposure to sun, using sunscreen;
reduces the likelihood of developing skin cancer
 Ultraviolet light
o UVA Assessment of the skin, hair,
 Longer wavelength
 Causes most tanning of the skin and nails
 circulation
Skin Assessment o Jaundice- yellowing of the skin
Pediatric Clients Skin Assessment Skin Uniformity
Infants and Children    Should be generally uniform except in areas exposed to the
sun and areas prone to friction (e.g., groin and armpit)
 Have very smooth skin – lack of exposure to environmental  Areas with lighter pigmentation—palms, lips, and nail beds
variables  Deviations (abnormal findings)
 Subcutaneous is poorly developed, thus, predisposing
Hyperpigmentation
infants to hypothermia
 Abnormal distribution of melanin
 Freckles, birthmarks
Vernix Caseosa o Birthmarks are abnormal distribution of melanin
Mongolian blue spots

 Cheese-like substance (sebum)

o Avoids maceration of the skin
o Has antimicrobial and moisturizing qualities
o Also aids as heat insulator d/t immaturity of the  Bluish purple spots observed in the gluteal area of an infant
adipose tissue  Melanin has not reached the upper part of the skin resulting
o From the sebaceous glands and desquamated to this discoloration
fetal skin  Disappears at age 1
Cutis Marmorata
 Appears 20 wks AOG
Lanugo

 Skin has a pinkish blue mottled or marbled appearance

 Seen abundantly in the shoulders and back of the baby when subjected to cold temperatures
 Fine, downy hair that will disappear in 10-15 days after  Returns to normal once infant is rewarmed
Senile Lentigines
birth
 Preterm- abundant lanugo
 Post term- absent lanugo
Merocrine 
 Begins to function about 4 weeks  
Eccrine Glands 
 Perspiration – present after 1 hour (after birth)

Inspection
 Brown spots that start to appear when a person age
Skin Color
 May be a result of sun exposure (UV radiation from the
 Should be the first to be observed
sun)
 Depends on the nationality of the person, may range from Freckles
pinkish tan, rudy dark red, yellow, or brown
 Indication of sun damage, hypothyroidism
 Deviations o Hypothyroidism can trigger melasma
o Erythema- reddening of the skin
o Changes in hormones if (+) hypothyroidism→
o Cyanosis- bluish discoloration of the skin
effects on inflammatory cytokines→ stimulation
o Pallor- whitish color of the skin d/t ↓blood of melanocytes
  ↑production of melanin when skin is exposed to UV rays Palpation
 Light brown spots observed in the face, neck, and/or Temperature
shoulders  Use the dorsum of the hands when assessing temperature
 More prominent in Caucasians o Skin is thinner, thus, more sensitive to heat and
Addison’s disease cold
 Causes bronze pigmentation of the skin  Temperature should be warm to touch and bilaterally
o Accumulation of ACTH (adrenal glands may be to similar on both extremities
damaged to react to ACTH) → act directly on the o Unless exposed to a cold environment, skin may
melanocytes→ increase in melanogenesis be cold
 Changes the distribution of body hair  Hypothermia
Hypopigmentation o Generalized or localized coolness
Vitiligo o May occur when an extremity is immobilized
 Destruction or lack of the melanocytes (cast)
 Most prominent in Africans  Hyperthermia
 May occur at any age and remains for life o Increase in the normal temperature (N: 36.5oC -
 May be caused by autoimmunity 37.5oC)
 White patches on the skin o Fever, infections
Albinism Skin turgor
 A congenital disorder that causes complete or partial lack  Ability of the skin to change shape and return to normal
of melanin after it has been pinched
 Causes the skin to appear light throughout the body  N: <3 seconds
(except in the case of partial albinism)  Assess fluid loss or dehydration (>3 seconds)
 Associated with a number of problems such as o D/t vomiting or diarrhea
photophobia, nystagmus, amblyopia  Skin turgor is longer in older people
o Lack of pigment in the iris does not permit Edema
filtering of light entering the eyes  Swelling
 More prone to skin cancer  Abnormal accumulation of fluids in the interstitial space in
Physiologic Jaundice certain areas of the body
 Jaundice is normal after the first 24 hours of life up to o Leakage of fluids from the capillaries
seven days  Anasarca- generalized edema
 Jaundice within the first 24 hours is abnormal→ early  Periorbital edema- swelling around the eyes
hemolysis of the RBCs  Pitting edema
 Maximum intensity at the 3rd to 4th day of life Inspection and Palpation
Lesions
 Assess color, elevation, size, and location
Patters/Distribution of lesions
Annular lesions
 “Annulus”
means ringed
 Lesions
appear circular
or ovoid macules
and/or patches
with erythematous
periphery and
central
clearing

Confluent Lesions
  Lesions that merge together (joining or running
together)
Linear Lesions

 Lesions arranged in a line

Pedunculated lesions Primary Lesions

 Macule
o Flat, cannot be palpated, color may range from
brown, white, tan, purple, and red
o Less than 1 cm with a circumscribed border
o Café au lait
 Papule
o Small and elevated
o Containing solid mass
 Benign tumors usually less than 1 cm and has its own o Circumscribed border and are less than 0.5 cm
blood vessels
 Plaque
o Slightly elevated, scale-like lesion
Size
o >0.5 cm to 1cm in diameter
 Measure in centimeters using a ruler
o Psoriasis
Location and distribution
 Pustule
 Note the area, region, extremity it is found
o Puss-filled (purulent) vesicle or bulla
 Note for exudates (color)
o Erythema toxicum neonatorum and acne
 Gently scape a scale on a lesion to see if it comes off or
bleeds, if it comes to perform the lesion blanching test  Nodule
o May feels like large pea under the skin
Tumbler Test o Circumscribed, elevated solid lesion with depth
 To check if a lesion is blanchable or not up to 0.5-2 cm e.g., cyst
o Meningitis and herpes zoster/ shingles are non-  Cyst
blanchable lesions o Non-cancerous, closed pockets of tissue that can
be filled with fluid, pus, or other material that may
extend to the subcutaneous layer
o Can develop as a result of infection, clogging of
sebaceous glands, or around foreign bodies such
as earrings
 Tumor
o Common as people get older
o Larger than a nodule
o Seborrheic keratosis is an example of common
 Herpes zoster lesions never cross the midline because the benign tumors
spinal nerves are not connected
o Lies dormant in the dorsal root ganglia
 A non-blanchable erythema may be indicative of pressure
ulcer or bed sores

Types of Lesions
 Vesicles
o Small, fluid-filled sacs
o Fluid inside may be clear, white, yellow, or mixed
with blood
o Less than 0.5 cm in diameter
 o Herpes simplex  Ecchymosis
 Bulla o Larger than petechiae
o Fluid-filled elevated sac that appears when fluids o Hemorrhagic blotching d/t pooling of blood under
are trapped under a think layer of the skin the skin or mucous membrane
o A type of blister  Hematoma
o Largen than 0.5 cm in diameter o Elevated ecchymosis
o Bullous impetigo  Cherry angioma
o Red moles usually found in the trunk and
extremities
o Papular, round, and may be blanched;
o Usually seen in people aged 10 and older
o Collection of small blood vessels inside a cherry
angioma gives it the reddish appearance
 Spider angioma
o D/t increased levels of estrogen
Secondary Lesions
Other Lesions
 Acne
o Clogging of follicles with oil and dead skin cells
o May be seen in girls 14-16 years old and 16-19 in
boys
 Folliculitis
o Inflammation of the hair follicles d/t bacterial or
fungal infections
 Wheals/ hives
o Elevated mass with transient borders that are
often irregular
o Size and color may vary
o E.g., allergies, urticaria, and insect bites
 Urticaria

 Fissure
o Linear crack extending to the dermis
 Ulcer
o May arise d/t poor blood circulation
o Common in bony prominences
o Affects the epidermis and may extend up to the o Elevated, reddened lesions that results from skin
bones and muscles reactions
 Erosion o E.g., allergies
o Superficial and does not extend to the dermis  Comedone
o Depressed moist area
Vascular Skin Lesions
 Petechiae
o Small red or purple macular spots
o 1-2 mm in diameter
o Tiny, circular, non-raised patches that may
appear on the skin or in mucous or serous
membranes
o Occurs as a result of bleeding under the skin d/t o Increased sebaceous gland activity
abnormality of the thrombocytes o Common skin problem of the adolescent
o Pinkish petechiae may be seen at the third day of o May be seen in girls ages 14-16 and 16-19 in
rubella boys
 Purpura  Acrochordons
o Purplish spots d/t rupture of blood vessels o Skin tags
o Slightly larger than petechiae o Common in areas where there is skin friction
o E.g., meningitis, snakebites o Neck, axillar, cheeks, and trunk
  Alopecia areata
o Common in autoimmune disorders
o May also occur during chemotherapy
o Hair follicles are attacked
 Seborrheic ketosis
o Warty or crusty pigmented lesions
 Mole
o Flat or raised, tanned/brownish, up to 6 mm wide
 Cutaneous tags o Spoon-shaped nails (concave nails)
o Raised papules with a depressed center o May be a sign of iron deficiency anemia or
Hair and Nails Assessment hemochromatosis
General Guidelines  Yellow nails syndrome
o Thickened yellow nails
 Hair assessment
o Check for color and texture o Can be seen with AIDS
o Assess the distribution of hair  Paronychia
o Hair should be shiny in young people, may be a
little course or dry in the elderly
o Oiliness is natural but should not be excessive
o Note for lesions in the scalp
o Note for presence of infestations
 Nail assessment
o Inspect nail color, shape, curvature
o Note for integrity of nails
Assessing the nails
 Normal color is pink d/t blood vessels under
o Local infection around the fingernails or toenails
 Lunula should be present
o Crescent-shaped area found at the base of the o Affects skin at the base and/ or up to the side of
nails the nails
o Its absence will indicate absence of proteins
 Nails should be convex (160-degree angle)
o >180-degree indicates clubbing this is d/t the
dilation of capillaries as compensation for
decreased oxygen going to the nails
Assessment of hair and nails of the aged population
 Drier skin and less perspiration 
 Thinning of the epidermis 
 Greying of hair 
 Nail growth slows down 
 The toenails; thicker, hard, brittle and yellowing
appearance

Deviations (Abnormal Findings)

 Half-and-half nails
o Half of the nail is white
o May be seen in chronic renal disease d/t
electrolyte imbalance
 Pitting
o Depressions and grooves on the nails may be
seen in psoriasis
 Koilonychia