THE INTEGUMENTARY SYSTEM

INTRODUCTION
• Integumentary system protects body from environmental
damage

• Skin forms protective barrier, shielding body from elements and

pathogens, as well as performing several other vital functions

• Skin is essential to well-being, helps to regulate body

temperature, and contains many accessory organs such as nail,
hair, and glands
System Overview
• Integumentary system performs several vital functions:
• Protection from pathogens
• Balances fluid levels
• Stores fatty tissue for energy supply
• Produces vitamin D (with help from sun)
• Provides sensory input
• Helps to regulate body temperature
LAYERS OF SKIN
Epidermis
• Layer of skin we see on the outside; made up of five or
six even smaller layers of tissue

• There are no blood vessels or nerve endings in this layer

• Cells on surface are constantly shedding, being replaced

with new cells that grow and arise from deeper region
called stratum basale every 2–4 weeks
Epidermis
• Outermost layer is layer of dead cells, called stratum corneum,
which are flat, scaly, keratinized epithelial cells

• You slough off 500 million cells every day, or about 1½ pounds
of dead skin a year, allowing for rapid repair in case of injuries
Dermis
• Layer below, or inferior, to epidermis is thicker dermis layer
• Contains the following:
• Capillaries
• Collagenous/elastic fibers
• Involuntary muscles
• Nerve endings
• Lymph vessels
• Hair follicles
• Sudoriferous glands (sweat)
• Sebaceous glands (oil)
Dermis
• Nerve fibers allow you to sense what is happening in your
environment

• Collagen and elastic fibers allow for elasticity of skin,

preventing tearing with movement; allow skin to return to
normal shape during periods of rest; older people lose some
elasticity, leading to wrinkles
Hypodermis/Subcutaneous Fascia
• Innermost layer of skin is subcutaneous fascia, or hypodermis

• Composed of elastic and fibrous connective tissue and fatty

tissue

• Lipocytes, or fat cells, produce fat needed to provide padding

to protect deeper tissues of body and act as insulation for
temperature regulation

• Fascia attaches to muscles of body

Pathology Connection: Skin Color and Disease
• Color of skin can indicate disease

• Yellow skin (jaundice) may indicate liver disease

• In liver disease, body can’t break down bilirubin

• Buildup of bilirubin gives skin yellow color

• Yellowish color may also be seen in whites of eyes

• Bronze color may indicate adrenal gland disease; malfunctioning adrenal

glands can cause skin to produce excessive melanin

• Bruised skin could indicate skin, blood, or circulatory problems

 IMPORTANT TERMINOLOGIES IN
DERMATOPATHOLOGY
• MACROSCOPIC TERMS

• MICROSCOPIC TERMS
 Macroscopic Terms
• Bulla: Elevated fluid-filled lesion more than 5 mm
• Vesicle: Elevated fluid-filled lesion 5 mm or less
• Pustule: Discrete, pus-filled raised lesion
• Macule: A circumscribed, flat area of discoloration <1cm

• Patch: A circumscribed, flat area of discoloration >1cm

• Papule: Elevated lesion <1cm

• Nodule: Elevated dome-shaped lesion >1cm

• Plaque: Elevated flat-topped lesion >1cm

• Scale: Dry, plate-like excrescence

• Wheal: Pruritic, elevated, erythematous lesion secondary to

dermal edema
 Microscopic Terms:
• Acantholysis: Loss of intercellular keratinocyte connections

• Acanthosis: Epidermal hyperplasia

• Hyperkeratosis: Stratum corneum thickening

• Parakeratosis: Stratum corneum with retained nuclei

• Dyskeratosis: Abnormal keratinization below the stratum granulosum

• Hydropic swelling (ballooning): Intracellular keratinocyte edema
• Spongiosis: Epidermal intercellular edema

Hydropic swelling Spongiosis

• Papillomatosis: Surface elevation due to dermal
papillae hyperplasia

Papillomatosis
 SKIN DISEASES
1. Acute inflammatory diseases: 4. Blistering diseases:
• Urticaria • Pemphigus
• Acute Eczema 5. Neoplastic
2. Chronic inflammatory diseases:
Benign:
• Psoriasis
• Nevi
• Lichen planus
• Actinic keratosis
• Lichen simplex chronicus
3. Infections: • Seborrheic keratosis

• Viral (warts) Malignant:

• Bacterial (Impetigo) • Basal cell carcinoma
• Fungal (Tinea) • Squamous cell carcinoma
• Melanoma
 ACUTE INFLAMMATORY DISORDERS
Urticaria
• A rash of round, red welts on the skin that itch intensely, sometimes
with dangerous swelling, caused by an allergic reaction, typically to
specific foods.
• Angioedema  pale pink swelling occurs especially on face affecting
eyelids and lips. Also associated with swelling of tongue, larynx and
pharynx.
Morphology
• Lesion begins as erythematous macules, which rapidly evolve into pale
pink edematous wheal.
• Number and size of wheals are variable.
Clinical features:
Urticaria may also be associated with systemic symptoms in form of
• Malaise
• Fever
• Headache
• Abdominal pain
• Diarrhea
• Vomiting
• Arthralgia
• Dizziness
• Syncope
 Acute Eczematous Dermatitis
Eczematous dermatitis is subdivided based on the initiating factors:

• Allergic contact dermatitis (e.g., poison ivy)

• Atopic dermatitis

• Drug-related eczematous dermatitis

• Photo eczematous dermatitis

• Primary irritant dermatitis

MORPHOLOGY:

Acute lesions: Spongiosis  forming intra-epidermal vesicles, papillary

dermal edema.

Chronic lesions: progressive acanthosis and hyperkeratosis.

 CHRONIC INFLAMMATORY DISORDERS
Psoriasis
Definition:

• Is a chronic non-infectious, inflammatory disease of the skin in which epidermal cells are
produced at a rate that is about six to nine times faster than normal.

Morphology:

 Well demarkated, pink salmon colour plaque covered by loosely adherent silver white scale.

 Loss of stratum granulosum

 Thinning of epidermal cell lines

 Auspitz sign are produced when vessels bleed readily when the scale is removed, giving rise
to multiple punctuate bleeding points
Pathophysiology
Etiologic factors
The skin in the patches of psoriasis is growing much
faster than normal skin.

↓
Rapid production of cells which does not allow the cells
to manufacture a keratin that gives its hard surface

Flaking and patches of skin

Clinical manifestations of Psoriasis
• Elbows, knees, scalp, ears, lumbosacral areas,
intergluteal cleft and umbilicus are the
common sites of psoriatic lesions

• Nail changes on fingers and toes

• Can wide spread and severe

Lichen Planus
• Self-limited disease  resolves after 1 to 2 years
• Mucosal lesions  persist longer and occasionally become malignant.
Morphology
Pruritic, purple, polygonal papules  may coalesce into plaques;
lesions are often highlighted by white dots or lines called Wickham
striae.
on the wrists and elbows
oral mucosal lesions are generally white and netlike.
Chronic changes include acanthosis and hyperkeratosis.
Lichen Simplex Chronicus
• Manifest as roughening of skin

• Response of local repetitive trauma such as continual rubbing or

scratching

• Prurigo nodularis (hard, extremely itchy bumps))

Pathogenesis:

• Trauma induces epithelial hyperplasia and eventual dermal scarring

 SKIN INFECTIONS
1. Viral (Viral warts)
2. Bacterial (Impetigo)
3. Fungal (Tinea)
VIRAL WARTS/ VERRUCAE
• Common, spontaneously regressing (i.e., 6 months to 2 years)
lesions, typically seen in children and adolescents.

• Etiology: Human papillomaviruses (HPV), transmitted by direct

contact.

• Higher incidence in those with impaired immunity.

Types
1. Verruca vulgaris: > common, typically found on the hand dorsum

2. Verruca plana (flat wart): usually present on the face or hand

dorsum

3. Verruca plantaris (soles) or palmaris (palms): are rough, scaly 1 to 2

cm lesions; these can coalesce and be confused with calluses.

4. Condyloma acuminatum: are soft, tan, cauliflower-like masses

measuring up to many centimeters in diameter.
Clinical features

• Rough, elevated, rounded surfaces

• Most frequently on extremities (especially hands & fingers)

• Mostly seen in children and young adults

MICROSCOPY:
• Papillomatosis (papillary folds)

• Acanthosis

• Hyperkeratosis and Parakeratosis

PATHOGENESIS:

• > 150 types of HPV have been identified, many capable of causing
lesions; the clinical variants of warts are often associated with specific
HPV subtypes.

• HPV 2, 6, 10 and 11 associated with warts

• HPV 16, 18 associated with dysplasia and in situ squamous cell

carcinoma.
Management
Investigation:
• Cytological study
• Application of 5% of acetic acid turns warts whitish if they are
papillomas.
Treatment:
• Electrodesiccation and curettage (Scraping or burning-off skin growths)
• Cryotherapy  (uses extreme cold [liquid nitrogen] to freeze and
destroy tissue)
• Acid therapy  plaster patches impregnated with salicylic acid
• CO2 laser therapy (remove thin layer of skin)
• Antiviral drugs
Impetigo (Bacterial Infection)
Common and highly contagious skin infection that mainly affects infants and young
children
Morphology:
• Commonly presents as erythematous plaques with a yellow crust and may be itchy
or painful.
• Commonly caused by gram-positive bacteria
• Bacterial cocci demonstrated by Gram stain
Clinical features:
• Most common bacterial infection in children
• Staphylococcus aureus
• Streptococcus pyogenes (less common)
• Small macule on extrimities, face, near nose or mouth
Fungal Infections
• Fungal infections can be superficial (stratum corneum, hair and nails) and
deep (dermis or subcutis)
• Superficial due to Tenia or Candida
• Aspergillus cause deep and life threatening infections
Morphology:
• Superficial infections associated with neutrophil (Atopic dermatitis)
• Deep cause greater tissue damage
Clinical Manifestations:
• Erythematous macule with superficial scale that can be pruritic
• Nodular erythematous in immunocompromised persons due to
Aspergillus.
 BLISTERING (BULLOUS) DISEASES
• Primary blistering disorders.

• The level within the skin  important for diagnosis.

PEMPHIGUS

• Uncommon and potentially life-threatening autoimmune disorder

• >30 to 60 years old

Types:

• Pemphigus vulgaris

• Pemphigus vegetans

• Pemphigus foliaceus

• Pemphigus erythematosus
Microscopically:

• Pemphigus vulgaris  acantholysis (intraepithelial blisters)

• Pemphigus vegetans  epidermal hyperplasia

• Pemphigus foliaceus  stratum granulosum is involved

• Pemphigus erythematosus  erythematous, scaly plaques

 DISORDERS OF PIGMENTATION AND
MELANOCYTES
• Non neoplastic: Freckles
• Neoplastic:
-Benign  Nevi/ Moles
-Malignant Melanoma
 BENIGN AND PREMALIGNANT TUMORS
Seborrheic Keratosis
Benign and Premalignant Epithelial Lesions

• Benign epithelial neoplasms are common and present in adult and

elderly patients.

• These tumours grow to a limited size and generally do not undergo

malignant transformation.
Seborrheic Keratosis
• A seborrheic keratosis is a common noncancerous (benign) skin growth
occur most frequently in middle-aged or older persons.

• They arise spontaneously and are particularly numerous on the trunk,

although the extremities, head, and neck also may be sites of involvement.

• Seborrheic keratosis are usually round or oval and range in color from light
tan to black.

• Varied size, from very small to more than 1 inch (2.5 cm) across.

• They can develop as a single growth or in clusters.

Actinic Keratosis
• Actinic Keratosis is malignancy of the epidermis (squamous cell
carcinoma) may be preceded by a series of progressive dysplastic
changes.

• Because such lesions usually are the result of chronic exposure to

sunlight and are associated with hyperkeratosis, they are called actinic
(sun-related) keratoses.

• A high fraction of these lesions are associated with mutations caused by

UV light–induced DNA damage.
• Actinic keratoses usually are less than 1 cm in diameter, tan brown or red
in color, and rough (sandpaper-like) to the touch.

• Microscopically, lower portions of the epidermis show cytologic atypia,

often associated with hyperplasia of basal cells.

• The stratum corneum is thickened with retained nuclei (parakeratosis).

FRECKLES (EPHELIS)

• Common pigmented lesions of

childhood

• 1 to 10 mm, tan-red to brown macules,

fading and recurring with sun exposure.

Morphology:

Hyperpigmentation  focal melanin over-

production.
LENTIGO SIMPLEX (PLURAL, LENTIGINES)

• Benign, hyper-pigmented macule (5 to 10 mm)

• > infancy and childhood (any age)

• Do not darken with sun exposure.

Morphology:

• They result from a mild increase in the number of

normal melanocytes (hyperplasia) in the
epidermis producing increased amounts of
melanin.
MELANOCYTIC NEVUS/ (PIGMENTED NEVUS, MOLE)
• Congenital or acquired benign melanocyte neoplasms
• Well-demarcated, uniformly tan-brown papules
Morphology
• Rounded cells exhibiting uniform nuclei and inconspicuous nucleoli; nevi mature
through characteristic stages:
a. Junctional nevi (i.e., nests of nevus cells at the dermo-epidermal junction) 
Earliest lesions.
b. Compound nevi  nests or cords of melanocytes into the dermis.
c. Dermal nevi No epidermal component. As nevus cells enter the dermis they
undergo maturation, becoming smaller and non-pigmented.
MELANOMA

• Malignant melanocytic neoplasm

• Involves skin, also in oral mucosal surfaces, esophagus, meninges, eye

& viscera.

• Incidence is increasing, especially in West.

ABCDE
Morphology:

• Melanomas progress from radial to vertical growth patterns:

• Radial growth  Horizontal spread within the epidermis and superficial dermis; No
metastases. Lesions include:

1. Lentigo maligna: An indolent lesion on the face that may not progress for decades.

2. Superficial spreading: The most common form of melanoma, usually involving sun-
exposed skin.

3. Acral/mucosal lentiginous: Melanoma unrelated to sun exposure.

• Vertical growth  Dermal invasion of an expanding clonal mass of cells, lacking

cellular maturation, capacity to metastasize.
Pathogenesis:

• Sun exposure

• Severe sunburns.

• 10% to 15%  familial

SQUAMOUS CELL CARCINOMA
• Second most common tumor of sun-exposed skin of older individuals

• >> men than in women

• Less than 5% of lesions metastasize to regional nodes.

Morphology:

• Squamous cell carcinomas  well-demarcated, red, scaling plaques

• Invasive lesions  nodular, variably hyperkeratotic, +/-ulceration.

BASAL CELL CARCINOMA
• Most common invasive human cancer

• Slow growing and rarely metastasize

• UV exposure, Immunosuppression and defects in DNA repair.

Morphology

• Pearly papules, +/- telangiectatic vessels; some are pigmented.

• Advanced lesions  ulcerate & extensive local invasion (rodent ulcer)