Anatomy and Human movement Lec5 Dr.

Israa Al Hawani

SKIN AND ITS APPENDAGES

Introduction
The skin is a tough, pliable waterproof covering of the body, blending with
the more delicate lining membranes of the body at the mouth, nose, eyelids,
urogenital and anal openings. It is the largest single organ in the body. Not
only does it provide a surface covering, it is also a sensory organ endowed
with a host of nerve endings which provide sensitivity to touch and
pressure, changes in temperature and painful stimuli. As far as general
sensations are concerned, the skin is their principal source. The
waterproofing function of the skin is essentially concerned with the
prevention of fluid loss from the body. To this end, fatty secretions from
sebaceous glands help to maintain this waterproofing, as well as being
acted upon to produce vitamin D. However, the efficient waterproofing
mechanism does not prevent the skin having an absorptive function when
certain drugs, vitamins and hormones are applied to it in a suitable form.
Nor does it prevent the excretion of certain crystalloids through sweating;
if sweating is copious as much as 1g of non-protein nitrogen may be
eliminated in an hour. Because human beings are warm-blooded, body
temperature must be kept within relatively narrow limits despite enormous
variations in environmental temperature. Reduction of body temperature is
a special function of the skin; because of the variability in its blood supply
and the presence of sweat glands heat is lost through radiation, convection
and evaporation. Together with the lungs, the skin accounts for over 90%
of total heat loss from the body. As well as the ability of the blood vessels
to ‘open up’ to promote heat loss, they can also be ‘closed down’ in an
attempt to conserve body heat in cool environments.
The metabolic functions of the skin require a large sur face area for
effective functioning. In adults, the area is approximately 1.8 m2, being
seven times greater than at birth. Skin thickness also varies, not only with
age but also from region to region. It is thinnest over the eyelids (0.5 mm)
and thickest over the back of the neck and upper trunk, the palm of the
hand and the sole of the foot. It generally tends to be thicker over posterior
and extensor sur faces than over anterior and flexor surfaces, usually being
between 1 and 2 mm thick.
The total thickness of the skin depends on the thickness of both the
epidermis and the dermis. On the palms of the hands and soles of the feet
the epidermis is responsible for the thickness of the skin, the dermis being

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

relatively thin. This arrangement provides protection for the underlying

dermis, as the palms and soles are regions of great wear and tear. The
character of flexor and extensor skin differs in more respects than just
thickness. The extensor skin of the limbs tends to be hairier than the flexor
skin, while the flexor skin is usually far more sensitive as it has a rich nerve
supply.
The skin is loosely applied to underlying tissues so that it is easily
displaced. However, in some regions it may be firmly attached to the
underlying structures, e.g. the cartilage of the ear and nose, the
subcutaneous periosteal surface of the tibia, and the deep fascia
surrounding joints. In response to continued friction, skin reacts by
increasing the thickness of its superficial layers. When wounded it
responds by increased growth and repair. 22 Skin and its appendages.
The skin of young individuals is extremely elastic, rapidly returning to its
original shape and position. However, this elasticity is increasingly lost
with increasing age so that unless it is firmly attached to the underlying
tissues it stretches. The stretching tends to occur in one direction because
of the orientation of the collagen fibres in the dee per layers, which runs
predominantly at right angles to the direction of stretch, therefore being
parallel to the communicating grooves present on the skin surface. In some
places the skin is bound down to the underlying deep fascia to allow
freedom of movement without interference from subcutaneous fat and
otherwise highly mobile skin. For example, at flexion creases of joints the
skin is bound down to the underlying fibrous tissue. Where the skin has to
be pulled around a joint when it is flexed, it is bound down in loose folds
which are taken up in flexion: the joints of the fingers clearly show this
arrangement.
In adjusting to allow movement, the skin follows the contours of the body.
Although this is enabled by its intrinsic elasticity the skin is nevertheless
subjected to internal stresses, which vary from region to region. These
stress lines are often referred to as Langer’s lines or cleavage lines (Fig.
1.19). They are important because incisions along these lines heal with a
minimum of scarring, whereas in wounds across them the scar may become
thicker, with the possible risk of scar contraction, because the wound edges
are being pulled apart by the internal stresses of the skin. Langer’s lines do
not always correspond with the stress lines of life; they merely reflect the
stresses within the skin at rest.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Skin colour depends on the presence of pigment (melanin) and the

vascularity of the dermis. When hot the skin appears reddened due to the
reflection of large quantities of blood through the epidermis. Similarly,
when cold the skin appears paler due to the reduction of blood flow to it.
The degree of oxygenation of the blood also influences skin colour;
anaemic individuals generally appear pale. Individual and racial variations
in skin colour are dependent upon the presence of melanin in the deepest
layers of the epidermis. In darker skinned races, the melanin is distributed
throughout the layers of the epidermis. In response to sunlight and heat the
skin increases its degree of pigmentation, thereby making it appear darker.
This physiological increase in pigment formation, i.e. tanning from
exposure to sunlight, is widely sought after in white populations. Some
areas of the body show a constant deeper pigmentation, these being the
external genital and perianal regions, the axilla and the areola of the breast.
On the pads of the fingers and toes, and extending over the palm of the
hand and sole of the foot, are a series of alternating ridges and depressions.
The arrangement of these ridges and depressions is highly individual, so
much so that even identical twins have different patterns. It is this
patterning which forms the basis for identification through finger prints.
They are due to the specific arrangement of the large dermal papillae under
the epidermis and act to improve the grip and prevent slippage. Along the
summits of these ridges sweat glands open; sebaceous glands and hair are
absent on these surfaces.
The skin and subcutaneous tissues camouflage the deeper structures of the
body. Nevertheless, itis often necessary to identify and manipulate these
deeper structures through the skin, and also to test their function,
effectiveness and efficiency. To do this the examiner relies heavily on
sensor information provided by their own skin, particularly that of the
digits and hands. Indeed, the skin of this region is so richly endowed with
sensory nerve endings that it allows objects to be identified by touch alone,
culminating in the ability of the blind to read with their fingers.
As well as the functions of the skin referred to above, nails, hair, sebaceous
and sweat glands are all derived from the epidermis. The delicate creases
extending in all directions across the skin form irregular diamond-shaped
regions. It is at the intersections of these creases that hairs typically emerge.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Structure
The skin consists of a superficial layer of ectodermal origin known as the
epidermis, and a deeper mesodermal-derived layer known as the dermis
(Fig. 1.20A).
Epidermis The epidermis is a layer of stratified squamous epithelium of
varying thickness (0.3–1.0 mm), being composed of many layers of cells.
The deeper cells are living and actively proliferating, with the cells
produced gradually passing toward the surface; as they do so they become
cornified (keratinized). They are ultimately shed as the skin rubs against
the clothing and other surfaces. The epidermis is avascular but is penetrated
by sensory nerve endings. Its deep surface is firmly locked to the
underlying dermis by projections into it known as epidermal pegs, with the
reciprocal projections from the dermis being known as dermal papillae
(Fig. 1.20A).
It is convenient to consider the epidermis as being divided into a number
of layers, particularly in the so-called thick skin of the palm or sole of the
foot. These layers are from within outwards the stratum basale, stratum
spinosum, stratum granulosum, stratum lucidum and finally the stratum
corneum (Fig. 1.20A).

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

The stratum basale consists of a single layer of cells adjacent to the dermis.
Itis in this layer, as well as in the stratum spinosum that new cells are
produced to replace those lost from the surface. The stratum spinosum
itself consists of several layers of irregularly shaped cells, which become
flattened as they approach the stratum granulosum. The stratum basale and
stratum spinosum together are often referred to as the germinal zone,
because of their role in new cell production.
Collectively, the remaining layers of the epidermis (granulosum, lucidum
and corneum) are often referred to as the horny layer. In the stratum
granulosum the cells become increasingly flattened and the process of
keratinization begins: the cells in this layer are in the process of dying. A
relatively thin transparent layer (the stratum lucidum) lies between the
granulosum and the superficial stratum corneum. It is from the stratum
corneum that the cells are shed: it is also mainly responsible for the
thickness of the skin.
The epidermal melanocytes, which are responsible for the pigmentation of
the skin, lie within the deepest layers of the epidermis.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Dermis
The dermis is the deeper interlacing feltwork of collagen and elastic fibres,
which generally comprises the greater part of total skin thickness. It can be
divided into a superficial finely-textured papillary layer, which, although
clearly separated from it, interdigitates with the epidermis, and a deeper
coarser reticular layer, which gradually blends into the underlying
subcutaneous connective tissue.
The projecting dermal papillae usually contain capillary networks which
bring the blood into close association with the epidermis (Fig. 1.20A). The
ability to open up or close down these networks is responsible for the
regulation of heat loss through the skin, as well as causing individuals to
blush in moments of embarrassment. Some papillae contain tactile
receptors, which are obviously more numerous in regions of high tactile
sensitivity (e.g. fingers, lips) and less so in other regions (e.g. back).
The reticular layer of dermis consists of a dense mass of interweaving
collagen and elastic connective tissue fibres. It is this layer which gives the
skin its toughness and strength. The fibres run in all directions, but are
generally tangential to the surface. However, there is a predominant
orientation of fibre bundles, with respect to the skin surface, which varies
in different regions of the body. It is this orientation which gives rise to the
cleavage lines of the skin (Fig. 1.19).
The dermis contains numerous blood vessels and lymphatic channels,
nerves and sensory nerve endings as well as a small amount of fat. In
addition, it also contains hair follicles, sweat and sebaceous glands, and
smooth muscle (arrector pili). The deep surface of the dermis is invaginated
by projections of subcutaneous connective tissue, which serve partly for
the entrance of the nerves and blood vessels into the skin (Fig. 1.20B).
Subcutaneous connective tissue
This is a layer of loosely arranged connective tissue containing fat and
some elastic fibres. The amount of subcutaneous fat varies in different parts
of the body, being completely absent in only a few regions (eyelid,
scrotum, penis, nipple and areola). The distribution of subcutaneous fat
also differs between Menand women, constituting a secondary sexual
characteristic in women, e.g. the breast as well as the rounded contour of
the hips. The subcutaneous connective tissue contains blood and lymph
vessels, the roots of hair follicles, the secretory parts of sweat glands,
cutaneous nerves, and sensory endings (particularly Pacinian (pressure)

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

corpuscles) (Figs. 1.20B and 1.21). In the subcutaneous tissue overlying

joints, subcutaneous bursae exist, which contain a small amount of fluid
thereby facilitating movement of the skin in these regions.
Cutaneous sensory receptors
The nerve endings in skin vary in structure from simple to complex
formations. Simple nerve endings are those in which the axon terminates
without undergoing any branching or other elaboration. Complex endings
are those in which the axons undergo any of a variety of changes, such as
forming expansions, assuming a tangled appearance, or becoming
surrounded by additional specialized tissue. When an axon terminates by
losing its myelin sheath ending as a naked axon, it is known as a free nerve
ending. The types of nerve endings in skin are shown in Fig.1.21.
Simple, free nerve endings occur within the epidermis and the dermis. In
the epidermis they run as naked axons between the epidermal cells and may
undergo branching; they are generally orientated perpendicular to the skin
surface. In contrast, in the dermis free nerve endings run parallel to the skin
surface. Free nerve endings are thought to detect stimuli that generate the
sensations of pain and temperature, but many are also capable of
responding to mechanical stimuli like touch and pressure which deform the
skin. Free nerve endings are also found surrounding the roots of hairs.
These endings are stimulated by deformation of the hair, and are involved
in detecting coarse stimuli causing the hairs on the skin to bend.
Merkel’s discs are complex endings formed when a free nerve ending
terminates as a disc-like expansion under a specialized cell in the epidermis
called a Merkel cell or a tactile cell. They are found in hairless skin,
particularly in the fingertips, and are thought to mediate the sensation of
touch.
Meissner’s corpuscles are complex encapsulated receptors formed by a
spiralling axon surrounded by flattened Schwann cells in turn surrounded
by fibrous tissue continuous with the endoneurium of the axon. Meissner’s
corpuscles are believed to be involved in the sensation of touch.
Krause’s end bulbs consist of an axon that forms a cluster of multiple short
branches surrounded by a fibrous capsule. Simpler varieties occur in which
the axon does not undergo branching, forming only a bulbous ending sur
rounded by a poorly developed capsule. The function of these nerve
endings is unclear, but they occur in the dermis and are believed to respond
to mechanical stimulation of the skin.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Ruffini corpuscles consist of an axon that forms a flattened tangle of

branches embedded in a bundle of collagen fibres. These nerve endings
occur in the dermis and respond to stretching of the collagen fibres when
the skin is deformed by pressure.
Pacinian corpuscles are the most complex of sensory nerve endings and
consist of a single axon surrounded by several concentric laminae of
modified Schwann cells all enclosed in a fibrous capsule. These structures
are located in the dermis and are designed to respond to pressure stimuli.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Appendages of the skin

These are nails, hairs, sebaceous, sweat and mammary glands, and are all
derived from the epidermis.
Nails
A nail consists of an approximately rectangular plate of horny tissue found
on the dorsum of the terminal phalanx of the fingers, thumb and the toes
(Fig. 1.22). They are a special modification of the two most superficial
layers of the epidermis, particularly the stratum lucidum. Its transparency
allows the pinkness of the underlying highly vascular nail bed to show
through. The nail is partly surrounded by a fold of skin, the nail wall, which
is firmly adherent to the underlying nail bed with some fibres ending in the
periosteum of the distal phalanx. It is this firm attachment which enables
the nails to be used for scratching and as instruments for prizing open
various objects.
The distal end of the nail is free, while the proximal covered part
constitutes the nail root. There is an abundant supply of sensory nerve
endings and blood vessels to the nail bed. The nails grow at approximately
1mm per week, being faster in summer than in winter.

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

Hairs
Hairs are widely distributed over the body surface, notable exceptions
being the palm of the hand and the sole of the foot. Hairs vary in thickness
and length; most are extremely fine so that the skin may appear hairless.
There is a marked sexual difference in the distribution of coarse hair,
particularly on the face and trunk, and in its loss from the scalp. This coarse
hair tends to become more prominent after puberty, particularly in the
axilla, over the pubes, and on the face in males.
Except for the eyelashes, all hairs emerge obliquely from the skin surface,
with the hairs in any one region doing so in the same direction. The part of
the hair which projects from the skin surface is the shaft and that under the
skin is the root, which is ensheathed in a sleeve of epidermis known as the
follicle extending into the subcutaneous tissue (Fig. 1.20B). The shaft
appears circular in cross-section. Throughout most of its length the hair
consists of the keratinized remains of cells. Hair colour is due to pigment
in the hair cells (melanin and a subtle red pigment), and to air within the
shaft of the hair. The hair of the head has a lifespan of between 2 and 4
years, while that of the eyelashes is only 3–5 months. All hairs are
intermittently shed and replaced.
In the growing hair, the deepest part of the hair follicle expands to form a
cap, known as the bulb of the hair, which almost completely surrounds
some loose, vascular connective tissue, known as the papilla. The cells of
the follicle around the papilla proliferate to form the various layers of the
hair. In the resting hair follicle, the bulb and papilla shrink, with the deepest
part of the follicle being irregular in shape.
Associated with each hair are one or more sebaceous glands, which lie in
the angle between the slanting hair follicle and the skin surface with their
ducts opening into the neck of the follicle. Bundles of smooth muscle fibres
(the arrector pili) attach to the sheath of the hair follicle, deep to the
sebaceous gland, and pass to the papillary layers of the dermis on the side
towards which the hair slopes (Fig. 1.20B). Contraction of the muscle
fibres causes the hair to stand away from the skin, elevating the skin around
the opening of the hair follicles, producing ‘goose flesh’. This action also
compresses the sebaceous glands causing them to empty their secretions
onto the skin surface. Elevation of the hairs traps a layer of air against the
skin surface in an attempt to produce an insulating layer to reduce heat loss,
while the sebaceous secretions are important in ‘water proofing’ the skin

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

surface and in aiding the absorption of fat-soluble substances through the

skin.
Glands
Sebaceous glands
These are associated with all hairs and hair follicles, there being between
one and four associated with each hair. They may also exist where there is
no hair, such as the corner of the mouth and adjacent mucosa, the lips, the
areola and the nipple, opening directly onto the skin surface. How ever,
they are absent from the skin of the palm and sole and the dorsum of the
distal segments of the digits. The glands vary in size between 0.2 and 2.0
mm in diameter. The cells of the glands are continuously destroyed in the
production of the oily secretions, known as sebum. This mode of secretion
production is known as holocrine secretion.
Inflammation and accumulation of secretion within the sebaceous glands
give rise to acne. If plugging of the outlet is permanent, a sebaceous cyst
may be formed in the duct and follicles. These may become so enlarged
that they require surgical removal. Sebaceous glands do not appear to be
under nervous control.
Sweat glands
These have a wide distribution throughout the body (Fig. 1.23), being more
numerous on its exposed parts, especially on the palms, soles and flexor
surfaces of the digits. Here the ducts open onto the summits of the
epidermal ridges. Each gland has a long tube extending into the
subcutaneous tissue, where it becomes coiled, forming the secretory body
of the gland (Fig. 1.20B). The glands produce sweat, which is a clear fluid
without any cellular elements, for secretion (eccrine secretion). The
production of sweat is important in temperature regulation, as its
evaporation from the skin surface promotes heat loss. These eccrine sweat
glands are innervated by sympathetic nerves. Consequently, any
disturbance in the sympathetic nervous system will result in a dry warm
skin (anhydrosis) either locally or extensively.
In the axilla, groin and around the anus there are large modified sweat
glands between 3 and 5 mm in diameter lying deeply in the subcutaneous
layer. Their ducts may be associated with a hair follicle or they may open
directly onto the skin surface. The secretions of the glands include some
disintegration products of the gland cells (apocrine secretions). The odour

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

associated with these glands is not from the secretion itself, but is due to
bacterial invasion and contamination from the skin. Pigment granules
associated with axillary glands produce a slight coloration of the secretion.
The apocrine glands vary with sexual development, enlarging at puberty.
In females they show cyclical changes associated with the menstrual cycle.
The glands which open at the margins of the eyelid (ciliary glands) are
modified, uncoiled sweat glands, as are the glands of the external auditory
meatus (ceruminous glands). The cells of the ceruminous glands contain a
yel lowish pigment which colours the wax secretion (cerumen).
Mammary gland (breast)
The mammary glands are modified sweat glands, being accessory to the
reproductive function in females, secreting milk (lactation) for the
nourishment of the infant. In children prior to puberty and in adult males,
the glands are rudimentary and functionless.
Blood supply and lymphatic drainage of the skin
The arterial supply of the skin is derived from vessels in the subcutaneous
connective tissue layer, which form a network at the boundary between the
dermis and subcutaneous tissue (Fig. 1.20B). Branches from the network
supply the fat, sweat glands and deep parts of the hair follicles. Branches
within the dermis form a subpapillary plexus. The epidermis is avascular.
Abundant arteriovenous anastomoses occur within the skin. Lymphatics of
the skin begin in the dermal papillae as networks or blind out growths
which form a dense mesh of lymphatic capillaries in the papillary layer.
Larger lymphatic vessels pass deeply to the boundary between the dermis
and subcutaneous tis sue to accompany the arteries as they pass centrally.
Nerves of the skin
The nerves of the skin are of two types, afferent somatic fibres mediating
pain, touch, pressure, heat and cold (general sensations), and efferent
autonomic (sympathetic) fibres supplying blood vessels, arrector pili and
sweat glands. The sensory (afferent) endings have several forms. Free
nerve endings extend between cells of the basal layer of the epidermis,
terminating around and adjacent to hair follicles. They are receptive to
general tactile sensation as well as painful stimuli. Enclosed tactile
corpuscles lie in the der mal papillae, being sensitive to touch. Pacinian
corpuscles (Figs. 1.20B and 1.21) exist in the subcutaneous tissue, being
particularly plentiful along the sides of the digits, and act as pressure

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Anatomy and Human movement Lec5 Dr. Israa Al Hawani

receptors. Specific endings for heat and cold have been described, although
general agreement as to their identity has not been reached.
Application
The majority of physiotherapy techniques are applied either directly or
indirectly via the patient’s skin. Manual manipulations, such as massage,
and thermal treatments both have an effect on the skin. The skin provides
an extremely important barrier as it restricts the penetration of damaging
electromagnetic radiations in the ultraviolet spectrum. All but the very
longest ultraviolet wavelengths are absorbed by the skin, and if sufficiently
high levels of ultraviolet have been absorbed then the characteristic effects
of erythema, thickening of the epidermis, increased pigmentation and
finally peeling will all be seen.
The general dryness and natural greasiness of the skin surface mean that it
has a high electrical resistance. Consequently, if electrical currents are to
be applied directly to body tissues this resistance must be reduced. This is
usually successfully achieved by the application of moist pads or
conducting gels to the skin below the site of electrode attachment.

Section summary
Skin
• A tough pliable waterproof covering of the body endowed with sensory
receptors for pain, pressure, touch and temperature. • On average it is
between 1 and 2 mm thick, being thicker over posterior and extensor
surfaces.
• Consists of a superficial epidermis (0.3–1.0 mm thick) and an intimately
related deeper dermis overlying a variable amount of subcutaneous
connective tissue.
• Nails are modifications of the two superficial layers of the epidermis. 28
Early embryology • Hairs are widely distributed over the skin, emerging at
an angle from the surface.
• Sebaceous glands release oily secretions onto the skin surface; sweat
glands are important in temperature regulation; the mammary gland
(breast) is a modified sweat gland.

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