Anatomy, Skin (Integument)

Article Author:
Wilfredo Lopez-Ojeda
Amarendra Pandey
Mandy Alhajj

Article Editor:
Amanda Oakley

Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma

Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon

9/21/2019 1:35:16 PM


The skin is the largest and primary protective organ in the body, covering the body's entire external surface and serving as a first-order physical barrier against the environment. Its functions include protection against ultraviolet (UV) light, temperature regulation, trauma, protection from pathogens, microorganism and toxins. The skin also plays a role in immunologic surveillance, sensory perception, control of insensible fluid loss, and homeostasis in general. The skin is also highly adaptive with different thicknesses and specialized functions in body parts like the palms, soles, elbows, knees. This article will discuss the anatomy of the skin, including its structure, function, embryology, blood, lymphatic, and nerve supply, surgical and clinical significance. [1][2]

Structure and Function

The skin is primarily made up of three layers. The upper layer is the epidermis, the layer below it is dermis, and the third and deepest layer is the subcutaneous tissue. 

  • The epidermis, the outermost layer of skin, provides a waterproof barrier and contributes to our skin tone.
  • The dermis, found beneath the epidermis, contains tough connective tissue, hair follicles, blood vessels, lymphatic vessels, and sweat glands.
  • The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The epidermis is further divided into 5 layers in thick skin like the palms and soles: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. While in other places the epidermis has 4 layers lacking the stratum lucidum.

The dermis is further divided into two layers known as the papillary dermis (the upper layer) and the reticular dermis (the lower layer) which contains the blood vessels and capillaries the supply to the skin.

The functions of the skin include:

  • Protection against microorganisms, dehydration, ultraviolet light, and mechanical damage. Skin is the first physical barrier that the human body has against the external environment.
  • Sensation to pain, temperature, touch, and deep pressure.
  • Mobility allowing smooth movement of the body.
  • Endocrine activity. The skin initiates the biochemical processes involved in Vitamin D production, which is essential for calcium absorption and normal bone metabolism.
  • Exocrine activity by the release of water, urea, and ammonia. Skin secretes products like sebum, sweat, and pheromones, but also exerts important immunologic functions by the secretions of bioactive substances such as cytokines.
  • Immunity development against pathogens.

Regulation of  Temperature. Skin participates in thermal regulation by the conservation or release of heat and helps to maintain the body’s water and homeostatic balance. [1][2]


Embryologically, the epidermis originates from the surface ectoderm. It is infiltrated with pigment-producing cells known as melanocytes, which originate from the neural crest. Other cell types present in the epidermis include keratinocytes, antigen processing Langerhans cells, and Merkel cells, tactile receptors that sense pressure changes at the bottom of the epidermis.

The dermis is embryologically derived from the mesoderm and contains connective tissue macromolecular components and cells. It includes elastic fibers, collagen, nerves, blood vessels, adipocytes (fat cells), and fibroblasts.  [1][2]

Blood Supply and Lymphatics

The skin is highly vascularized and is supplied by plexuses found between the reticular and papillary layers of the dermis. The blood supply originates from an extensive network of larger blood vessels and capillaries that extend from regional branches of the systemic circulation to local sites throughout subcutaneous tissue and dermis, respectively.

Also, there is an extensive lymphatic framework that runs alongside many of the skin’s blood vessels, particularly those attached to the venous end of the capillary networks. [3]


Several skin receptors play specific roles in our ability to physically perceive the changes in the external environment.

  • Meissner receptors detect light touch.
  • Pacinian corpuscles perceive deep pressure and vibrational changes.
  • Ruffini endings detect deep pressure and stretching of the skin’s collagen fibers.
  • Free nerve endings located in the epidermis respond to pain, light touch, and temperature variations.
  • Merkel receptors associated with the Merkel cells respond to sustained light touch induction over the skin.

Dermatomes are in an area of skin that is mainly supplied by a single spinal nerve. There are 8 cervical nerves, except for C1, contributing to the dermatomes,12 thoracic nerves, 5 lumbar nerves, and 5 sacral nerves. Each of these nerves relays sensation (including pain) from a particular region of the skin to the brain.[4]


In all areas of the skin that contain hair follicles, arrector pili muscles, the smallest skeletal muscles of the body, are found. These tiny muscular structures control the positioning of hairs and the activity of certain glands in response to environmental induction, such as heat and abrasion. The arrector pili muscles contract and raise the hairs under conditions of stress when the sympathetic nervous system is activated such as during the fight or flight response. [1][2]

Physiologic Variants

The multiple layers of the skin are dynamic, shedding and replacing old inner layers. Although the thickness of skin varies based on its location, there are additional factors such as age, gender, and health that affect the skin’s density or thickness. The varying thickness is due to changes in the dermis and epidermis. Thick skin is found in the palms and soles where there is marked keratinization and the stratum lucidum layer. Thinner skin is found in other areas of the body, especially on the mucosal surfaces exposed to the external environment such as oral mucosa, vaginal canal, and other selected internal body surfaces.

Mostly due to the effects of androgens, adult males typically have thicker skin than females on most areas of the body. Children tend to have thin skin, which gradually thickens until the fourth decade of life, affected by the concentration of sex steroids, general health, and hydration. The skin begins to thin again during the fifth decade of life, primarily due to changes in the dermis with loss of epithelial appendages, elastic fibers, and ground substance, among others. Genetic and environmental factors also affect the skin’s fullness. For example, a person with an occupation requiring much outdoor exposure to the sun and ultraviolet radiation will tend to show premature skin aging signs sooner than a person working indoors. Genetics also influence the natural skin contour; for example, people of African-American descent typically exhibit fuller and more lustrous skin compared to their Anglo-Saxon counterparts.[1][2][3]

Surgical Considerations

Surgical incisions usually are made along the relaxed skin tension lines to improve healing and reduce scarring. These lines are commonly referred to as “cleavage lines,” which closely match the alignment of bundles of collagen fibers within the dermis. Their discovery followed the investigations of the Austrian anatomist Karl Langer, who noticed a consistent pattern of ellipsoidal lines over the skin surface of the studied specimens (cadavers) after repetitively puncturing their skin with a circular tool. His reports referred to the lines as elongated creases following singular ellipsoidal patterns in different directions based on the specific body areas. These lines are known as the “Langer’s lines.” Surgical incisions are best made parallel to the direction of Langer’s lines to reduce scarring and improve healing, especially during cosmetic surgical procedures. Langer’s lines have a completely different functional rationale and anatomical etiology from dermatomal lines.[5][6]

Clinical Significance

The skin has many areas of clinical and cosmetic significance including skin cancers, acne, infections, and wrinkle formation to name a few.

The three most common skin cancers encountered are basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. UV damage, sporadic mutations, and genetics play a role in the abnormal function and growth of the skins cellular components that give rise to skin cancers.

Acne, a skin condition that results from plugging of hair follicles with dead keratinocytes and oil, is common in youth, but can also plague adults. The severity is variable an can range from papules and pustules to nodules and cysts. This difficult but treatable condition is often linked to the gram-positive bacterium, cutibacterium acnes.

Skin infections can include cellulitis, erysipelas, and impetigo caused by staphylococcus and streptococcal species of bacteria.

Lines and creases develop over the bony articulations (joints) and high friction surface areas, such as the knees and elbows. Contraction of the skin causes wrinkles that lie perpendicular to the underneath skeletal muscles which act as vectors of physical tension or stress points. Relaxed skin tension lines form during relaxation and often follow a different direction than those from age and contracting wrinkles. The relaxed skin tension lines are caused by natural tension on the skin from the deeper skin structures. [3][4]

Other Issues

Dermatomes and Referred Pain

In the human body, the sensory fibers carrying pain stimuli are arranged into dermatomes, which are segmentally distributed across the entire body surface (illustration below). Dermatomes develop embryologically, but functionally represent how sensory information (i.e., pain) travels from a particular skin receptor type (i.e., nociceptor) to the corresponding peripheral nerves that, in turn, connect to specific spinal nerves (cervical; C1–C8, thoracic: T1–T12, lumbar: L1–L5 and sacral: S1–S5), reaching the spinal cord where the signals ultimately ascend to the brain.[6][7][8]

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Anatomy, Skin (Integument) - Questions

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A 40-year-old female presents to the dermatology clinic with complaints of hair loss, brittle nails, bilateral nipple discharge, and oily skin. Her past medical history is significant for telogen effluvium and anxiety. Workup and treatment of the epidermal appendages involved are initiated. Which of the following non-epidermal appendage is affected in these patients presenting complaints?

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A 36-year-old male is brought to the emergency department after he fell off from the bike. The patient is not in distress and is oriented to time, place, and person. He has abrasions to his face, scalp, arms, and abdomen. Physical exam reveals a laceration of his right upper eyelid. What is expected in this anatomical site?

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A 20 yea old female wants scar revision surgery on an earlier post-trauma scar made by healing by secondary intention on her left cheek above the zygomatic process, the priority of the dermato-surgeon should be to minimise scar which essentially means removing the earlier scar tissue at the same time leaving behind a very fine suture line, in this case the surgeon needs to know about the lines of Langer and which statement is of paramount importance to him of the following ?

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Anatomy, Skin (Integument) - References


Maranduca MA,Branisteanu D,Serban DN,Branisteanu DC,Stoleriu G,Manolache N,Serban IL, Synthesis and physiological implications of melanic pigments. Oncology letters. 2019 May;     [PubMed]
Someya T,Amagai M, Toward a new generation of smart skins. Nature biotechnology. 2019 Apr;     [PubMed]
Strnadova K,Sandera V,Dvorankova B,Kodet O,Duskova M,Smetana K,Lacina L, Skin aging: the dermal perspective. Clinics in dermatology. 2019 Jul - Aug     [PubMed]


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