Chapter 6 :: Skin Glands: Sebaceous, Eccrine, and Apocrine Glands

:: Christos C. Zouboulis

INTRODUCTION

The human skin has several types of exocrine glands (Latin, glandulae cutis), which
release their biochemi- cal products onto the skin surface. All skin glands consist
by a secretory compartment, the gland or coil (tubulus), and an excretory part, the
duct (ductus). Skin gland cells are of epithelial origin, but their secretory
compartments are located at different depths in the dermis.

Three major types of skin glands are recognized according to their product, the
excretory function, and the location, where the excretory ducts release their
products (diseases of these glands are listed in Table 6-1). Regarding their product,
skin glands are classified into glands secreting sebum (sebaceous glands) and sweat
(sweat glands). Concerning their secretory function, skin glands are classified into
holocrine glands, whose fully differentiated secretory cells burst and release both
the cytoplasmic content and the cell membranes into their ducts, and mero- crine
glands, which excrete their product via exo- cytosis from secretory cells. Regarding
the location where their ducts release their product, the ducts of sebaceous glands,
in most cases, and apocrine sweat glands excrete their products into the hair follicle
canal, and the eccrine sweat glands excrete directly onto the skin surface. Sebaceous
glands are holocrine glands, and sweat glands (both eccrine and apocrine ones) are
merocrine glands.

SEBACEOUS GLANDS

AT-A-GLANCE

 Sebaceous glands are multilobular structures that consist of acini connected

to a common excretory duct and are usually associated with a hair follicle.
  Sebaceous glands vary considerably in size, even in the same individual and
in the same anatomic area.
 The sebaceous glands excrete lipids by disintegration of entire cells, a
process known as holocrine secretion.
 Human sebum, as it leaves the sebaceous gland, contains squalene,
cholesterol, cholesterol esters, wax esters, and triglycerides.
 Sebaceous glands are regulated by several molecules, among them
androgens and retinoids.

ANATOMY OF THE SEBACEOUS GLANDS

HISTOLOGY

Human sebaceous glands are multilobular structures of epithelial origin that consist
of acini connected to a common excretory duct, the sebaceous duct (ductus
seboglandularis) (Fig. 6-1). Sebaceous glands are com- posed of sebocytes, which
are lipid-producing uniquely differentiated epithelial cells.1,2 On the other hand,
the sebaceous duct is lined by undifferentiated kerati- nocytes and is usually
associated with a hair follicle which is composed of stratified squamous epithelium.
The periphery of the sebaceous gland is a basal cell layer composed of small,
cuboidal, nucleated, highly mitotic sebocytes.1,3 Cells progress toward the middle
of the gland and accumulate lipid droplets (LDs) as they transform into terminally
differentiated cells, full of lipids.3 The latter lack all other cellular organ- elles,
burst, and die, excreting their entire contents to the duct in a holocrine manner (Fig.
6-2). Surrounding the glands are connective tissue capsules composed of collagen
fibers that provide physical support.4

LOCATION

Sebaceous glands are associated with hair follicles all over the body. A sebaceous
gland associated with a hair follicle is termed a pilosebaceous unit (see Fig. 6-1).
The glands may also be found in certain nonhairy sites, including the eyelids
(Meibomian glands, tar- sal glands), the nipples (Montgomery glands, areolar
glands), around the genitals (Tyson glands), and the mucosa (lips, gums and inner
cheeks, and genitals; Fordyce spots).1 Fordyce spots open and release their content
directly to the epithelial surface. The latter are visible to the unaided eye because
of their large size (up to 2 to 3 mm) and the transparency of the oral epi- thelium
(Fig. 6-3). Only the palms and soles, which have no hair follicles, are totally devoid
of sebaceous glands. In addition, the dorsal surfaces of the hand and foot have
sparse sebaceous glands.5 Sebaceous glands vary considerably in size, even within
the same individual and within the same anatomic area. On the external body
surface, most glands are only a fraction of a millimeter in size. The largest glands
and greatest density of glands are located on the nose (1600 glands/cm2) followed
by the face and scalp (up to 400 to 900 glands/cm2).4 The hairs associated with
these large glands are often tiny, and the total structure is more specifically termed
sebaceous follicles, being a pilosebaceous unit variant, the other two being the
terminal hair follicle and the vellus hair follicle.

EMBRYOGENESIS AND MORPHOGENESIS

The development of the sebaceous glands is closely related to the differentiation of

hair follicles and epidermis.6-8 At the 10th to 12th weeks of fetal life, a stra- tum
intermedium becomes apparent, and at about the same time, developing hair germs
are quite distinct. In the following weeks, the follicles extend downward into the
dermis, and the rudiments of the sebaceous glands appear on the posterior surfaces
of the hair pegs. By

13 to 16 weeks, the glands are clearly distinguishable, arising in a cephalocaudal

sequence from bulges (epi- thelial placodes) of the hair follicles. The latter contain
the epidermal stem cells that generate multiple cell lin- eages, including epidermal
and follicular keratinocytes, as well as sebaceous glands. As daughter cells migrate
from the bulge region, changes in the expression pat- terns of numerous
transcription factors determine their final cell lineage. Despite continuous
differentiation of its cells, the sebaceous gland can be regenerated by the reservoir
of stem cells in the hair follicle bulge. How- ever, retroviral lineage marking has
provided strong evidence that the sebaceous gland might arise and be maintained
independently of the hair follicle bulge.9

Wnt or wingless (Wnt) and Sonic hedgehog (Shh) signaling pathways are
intricately involved in embry- onic patterning and cell fate decisions. Cells destined
to become sebocytes have increased Shh and Myc signaling and decreased Wnt
signaling (Fig. 6-4A).10,11 In human SZ95 sebocyte and transgenic mouse models,
whereas intact Wnt signaling promotes hair follicle differentia- tion, inhibition of
Wnt signaling by preventing the Lef1– B-catenin interaction leads to sebocyte
differentiation.11,12 Loss of function and gain of function in both models
demonstrated that blocking Shh signaling inhibited normal sebocyte differentiation,
and constitutively acti- vating Shh signaling increased the number and size of
human sebocytes and mouse sebaceous glands in skin.

Several important molecular aspects of sebaceous gland development have been

identified, mostly with the aid of genetically modified cell lines. The earliest known
signal necessary for sebaceous gland development is SOX9, which is in fact
essential for the specification of early hair follicle stem cells and there- fore for the
morphogenesis of both structures (Fig. 6-5).9 Further studies indicate that later in
embryonic devel- opment, a subpopulation of these stem cells expressing PRDM1
(formerly known as BLIMP1) is established near the entrance of the sebaceous
gland. PRDM1 (BLIMP-1) acts as a marker of terminal epithelial cell
differentiation.13,14 Loss of PRDM1 (BLIMP-1) results in increased gene
expression of c-myc, an essential player in sebaceous gland homeostasis.15
Overexpression of c-myc in transgenic mice results in enlarged and more numerous
sebaceous gland at the expense of the hair follicle lineage. Moreover, skin-specific
deletion of c-myc negatively affects sebaceous gland develop- ment. In skin, c-myc
and β-catenin exert opposing effects on sebocyte differentiation (see Fig. 6-4).
Antag- onizing Wnt–β-catenin signaling constitutes an impor- tant prerequisite for
normal sebaceous differentiation in postnatal skin tissue. Stem cells expressing
LRIG1, which has been suggested to be multipotent stem cells giving rise to
epidermal lineages, can act under homeostatic conditions as sebocyte progenitor
cells.16

Sebaceous gland cells at first contain glycogen. This lingers at the periphery
of the gland but is quickly lost at the center, where lipid drops are vis- ible at 17
weeks.13,14 The future common excretory duct, around which the acini of the
sebaceous gland attach, begins as a solid cord. The cells composing the cord are
filled with sebum, and eventually they lose their integrity, rupture, and form a
channel that establishes the first pilosebaceous canal, the duct, through which
sebum flows into the follicular canal and subsequently to the skin surface. New
acini result from buds on the peripheral sebaceous duct wall. The cell organization
of the neonatal sebaceous acini con- sists of undifferentiated (basal), differentiating
(early, advanced and fully differentiated), and mature seba- ceous gland cells (see
Fig. 6-2).3,17-19 Undifferentiated cells arranged in a single layer facing the basal
lam- ina, comparable to the epidermal basal layer; they represent the germinative
cells of the gland, flattened or cuboidal in shape, showing round and densely
basophilic nuclei.20 These bear characteristics of stem cells because they give rise
to a continual flux of pro- liferating and differentiating cells. The basal cells of the
peripheral zone form about 40% of the gland. Growing toward the center of the
gland lobules, the basal cells gradually differentiate into an early dif- ferentiated
cell type, an advanced differentiated cell type, a fully differentiated cell type, and
the mature sebocyte.3,21 The maturation zone also represents about 40% of the
sebaceous gland.

PHYSIOLOGY OF THE SEBACEOUS GLAND

HOLOCRINE SECRETION
The sebaceous glands exude lipids by disintegration of entire cells, a process known
as holocrine secretion. Holocrine secretion by sebaceous gland cells does not occur
mechanically via increased cell volume, as considered previously, but rather from
a multistep, cell-specific lysosomal DNase2-mediated mode of programmed cell
death, which differs from apoptosis, necroptosis, and cornification.22

As sebaceous gland cells are displaced into the cen- ter of the gland, they begin to
produce lipids, which accumulate in droplets. With approaching the seba- ceous
duct, they disintegrate and release their content. Only neutral lipids reach the skin
surface. Proteins, nucleic acids, and the membrane phospholipids are digested and
are apparently recycled during the dis- integration of the cells.2 Sebaceous gland
secretion can be enhanced with increased rates of induced terminal sebocyte
differentiation.

LIPID COMPOSITION OF SEBUM

Sebum production is a continuous event. The exact mechanisms underlying its

regulation are not fully defined. Complexity and uniqueness are the two terms that
best characterize sebaceous lipids. ∆6 desatura- tion, wax ester synthesis, and
squalene accumulation are examples that manifest sebaceous lipid biology.22-24
Genetic knockout animal models of lipid synthesis demonstrate dramatic changes
in skin physiology and pathology, resulting from impairment of sebaceous lipid
pathways.25 Human sebum, as it leaves the seba- ceous gland, contains a mixture
of nonpolar (neutral) lipids, mainly triglycerides, wax esters, squalene, and smaller
amounts of cholesterol and cholesterol esters (Fig. 6-6). During passage of sebum
through the hair canal, bacterial enzymes hydrolyze some of the tri- glycerides, so
that the lipid mixture reaching the skin surface contains free fatty acids and small
propor- tions of mono- and diglycerides, in addition to the original components.
Triglycerides, diglycerides, and free fatty acids form 40% to 60% of total skin
surface lipids followed by wax esters (25% to 30%), squalene (12% to 15%),
cholesterol esters (3% to 6%), and cho- lesterol (1.5% to 2.5%).26,27 The wax
esters and squalene distinguish sebum from the lipids of human internal organs,
which contain no wax esters and little squa- lene. However, human sebaceous
glands appear to be unable to transform squalene to sterols, such as cho- lesterol.
The patterns of unsaturation of the fatty acids in the triglycerides, wax esters, and
cholesterol esters also distinguish human sebum from the lipids of other organs.
The “normal” mammalian pathway of desatu- ration involves inserting a double
bond between the 9th and 10th carbons of stearic acid (18:0) to form oleic acid
(18:1∆9). However, in human sebaceous glands, the predominant pattern is the
insertion of a ∆6 double bond into palmitic acid (16:0). The resulting sapienic acid
(16:1∆6) (see Fig. 6-6) is the major fatty acid of adult human sebum. Elongation of
the chain by two carbons and insertion of another double bond gives sebaleic acid
(18:2∆5,8), a fatty acid thought to be unique to human sebum.22-24

Sebaceous fatty acids and alcohols are also distin- guished by chain branching.
Methyl branches can occur on the penultimate carbon of a fatty acid chain (iso
branching), on the third from the last (ante- penultimate) carbon (anteiso
branching), or on any

even-numbered carbon (internal branching). Exam- ples of these unusual

unsaturated and branched- chain moieties are included in the lipid structures in Fig.
6-6.

FUNCTION OF SEBUM

Sebum in humans was initially considered to solely cause acne.28,29 Subsequently,

it has been suggested that sebum reduces water loss from the skin’s surface and
functions to keep skin soft and smooth, although evidence for these claims in
humans is minimal; how- ever, as demonstrated in the sebaceous gland–deficient
(Asebia) mouse model, glycerol derived from triglyc- eride hydrolysis in sebum is
critical for maintaining stratum corneum hydration.30 Sebum has later been shown
to have mild antibacterial action, protecting the skin from infection by bacteria and
fungi because it contains antiinflammatory lipids and immuno- globulin A, which
is secreted from most exocrine glands.31-33 Vitamin E delivery to the upper layers
of the skin protects the skin and its surface lipids from oxidation. Thus, sebum flow
to the surface of the skin may provide the transit mechanism necessary for vitamin
E to function.34 The current concept is that sebum is involved in the multimodal
activities of the sebaceous glands (Table 6-2).

INNATE IMMUNITY

Antimicrobial peptides, including cathelicidin, pso- riasin, β-defensin 1, and β-

defensin 2, are expressed within the sebaceous gland. Functional cathelicidin
peptides have direct antimicrobial activity against Propionibacterium acnes but
also initiate cytokine pro- duction and inflammation in the host organism.35,36 In
addition, free fatty acids in human sebum are bacte- ricidal against gram-positive
organisms as a result of its ability to increase β-defensin 2 expression.31,36 Innate
immune Toll-like receptors 2 and 4 (TLR2, TLR4) as well as CD1d and CD14
molecules are also expressed in sebaceous glands and immortalized human
sebocytes.37 With the expression of innate immune receptors and antibacterial
peptides, the sebaceous gland may play an important role in pathogen recognition
and protection of the skin surface.3

FACTORS REGULATING SEBACEOUS GLAND SIZE AND SEBUM

PRODUCTION

Sebocytes preserve characteristics of stem-like cells despite their programming for

terminal differentia- tion because they present a remarkable potential of bipotential
differentiation.42,43 The sebaceous gland might be maintained by unipotent stem
cells that are replenished by multipotent stem cells in the hair fol- licle bulge.13
However, it is an emerging view that there might be at least three distinct niches
for skin stem cells: the follicle bulge, the base of the sebaceous gland, and the basal
layer of the epidermis.44
The average transit time of sebaceous gland cells from formation to discharge, has
been calculated as 7.4 days in the human gland, with 4 to 7 days in undifferentiated
and 14 to 25 in differentiated lipid- producing cells.1 Within any one glandular unit,
the acini vary in differentiation and maturity. The syn- thesis and discharge of the
lipids contained in the sebaceous cells require more than 1 week. The size of
sebaceous glands increases with age. The mean size rises from 0.2 mm2 ± 0.5 mm2
to 0.4 mm2 ± 2.1 mm2. The sebaceous cells of prepubertal and hypogonadal boys
and men are qualitatively similar to those of normal adults, even though the glands
are smaller.45 In gen- eral, whereas the number of sebaceous glands remains
approximately the same throughout life, their size tends to change with age.46 The
turnover of the seba- ceous glands in older adults is slowed down compared with
young adults.

A variety of experimental models are used to study the factors involved in

sebaceous gland regulation, including cell culture of isolated human sebaceous
glands, primary sebocytes, immortalized sebocyte cell lines, and three-dimensional
models, as well as mouse and hamster animal models.47-50 Results from these
investigations clearly indicate that sebaceous glands are multifactional (see Table
6-2),51,52 regulated, among others, by ligands of sebaceous gland cell receptors
(Table 6-3), such as androgen and estrogen receptors, peroxisome-proliferator-
activated receptors (PPAR) and liver-X receptor (LXR), neuropeptide receptors,
retinoid, and vitamin D receptors.53-56 The ligand– receptor complexes activate
pathways involving lipogenesis but also cell proliferation, differentiation, hormone
metabolism, and cytokine and chemokine release.57

ANDROGENS

Sebaceous glands require androgenic stimulation to produce significant quantities

of sebum. Individu- als with a genetic deficiency of androgen receptors (complete
androgen insensitivity) have no detectable sebum secretion and do not develop
acne.58 Although the most powerful androgens are testosterone and its end-organ
reduction product, 5α-dihydrotestosterone (DHT), levels of testosterone do not
parallel the pat- terns of sebaceous gland activity. For example, testos- terone levels
are many fold higher in males than in females, with no overlap between the sexes.
However, the average rates of sebum secretion are only slightly higher in males
than in females, with considerable overlap between the sexes. Also, sebum
secretion starts to increase in children during adrenarche, a develop- mental event
that precedes puberty by about 2 years.

The weak adrenal androgen, dehydroepiandros- terone sulfate (DHEAS), is

probably a significant regu- lator of sebaceous gland activity through its conversion
to testosterone and DHT in the sebaceous gland.59 Levels of DHEAS are high in
newborns, very low in 2- to 4-year-old children, and start to rise when sebum
secretion starts to increase. In adulthood, DHEAS levels show considerable
individual variation but are only slightly higher in men than in women on the aver-
age. There is a decline in DHEAS levels in both sexes starting in early adulthood
and continuing throughout life; this decline parallels the decline of sebum secre-
tion. DHEAS is present in the blood in high concentra- tion. The enzymes required
to convert DHEAS to more potent androgens are present in sebaceous glands.60
These include 3β-hydroxysteroid dehydrogenase, 17β-hydroxysteroid
dehydrogenase, and 5α-reductase. Each of these enzymes exists in two or more
isoforms that exhibit tissue-specific differences in their expres- sion. The
predominant isozymes in the sebaceous gland include the type 1 3β-hydroxysteroid
dehydro- genase, the type 2 17β-hydroxysteroid dehydrogenase, and the type 1 5α-
reductase.61,62

RETINOIDS

Isotretinoin (13-cis-retinoic acid, 13-cis-RA) is the most potent pharmacologic

inhibitor of sebum secretion. Significant reductions in sebum production can be
observed as early as 2 weeks after use.63,64 Histologi- cally, sebaceous glands are
markedly reduced in size, and individual sebocytes appear undifferentiated lacking
the characteristic cytoplasmic accumulation of sebaceous lipids.3,65

Isotretinoin does not interact with any of the known retinoid receptors. It may serve
as a prodrug for the synthesis of all-trans-retinoic acid, which interacts with retinoid
receptors expressed in sebaceous gland cells (retinoic acid receptors [RARs;
isotypes α and γ] and ret- inoid X receptors [RXRs; isotypes α, β, γ]).66 However,
it has greater sebosuppressive action than do all-trans- or 9-cis-retinoic acid.67 13-
cis-RA exerts pluripotent effects on human sebaceous gland cells and their
lipogenesis.63 Inhibition of androgen synthesis, cell cycle arrest, and apoptosis by
13-cis-RA may explain the reduction of sebaceous gland size after treatment.

PEROXISOME-PROLIFERATOR-

ACTIVATED RECEPTORS

PPARs are members of the nuclear hormone receptor family and act as
transcriptional regulators of a variety of genes, including those involved in lipid
metabolism in adipose tissue, liver, and skin. PPARs are similar to retinoid
receptors in many ways. Each of these recep- tors forms heterodimers with retinoid
X receptors to regulate the transcription of genes involved in a variety of processes,
including lipid metabolism and cellular proliferation and differentiation. PPARα, δ,
and γ receptor subtypes have been detected in basal sebaceous gland cells.54
PPARγ is also detected within differentiated cells. Pharmacologic PPAR-γ modula-
tion regulates sebogenesis and inflammation in SZ95

human sebaceous gland cells.68 In patients receiving fibrates (PPAR-α ligands) for
hyperlipidemia or thia- zolidinediones (PPAR-γ ligands) for diabetes, sebum
secretion rates are increased.69

PPAR-γ–RXR-α and LXR–RXRα promoter inter- actions are of crucial importance

for the regulation of key genes of lipid metabolism. Although vari- ous fatty acids,
eicosanoids, and prostanoids acti- vate PPARs, oxysterols and intermediate
products of the cholesterol biosynthetic pathway activate LXRs. PPAR-α agonists
and PPAR-γ antagonists may reduce sebaceous lipid synthesis and as such may be
useful in the treatment of acne. On the other hand, whereas PPAR-γ agonists may
be beneficial in aging skin, PPAR-δ agonists may be involved in sebaceous
tumorigenesis.

LXR

LXRs, which are members of the NHR family, play a critical role in cholesterol
homeostasis and lipid metabolism.70 Treatment of SZ95 sebaceous gland cells with
the LXR ligands TO901317 or 22(R)- hydroxycholesterol enhanced accumulation
of LDs in the cells, which could be explained through induction of the expression
of the LXRα receptor and known LXR targets, such as fatty acid synthase and sterol
regula- tory element–binding protein-1 (SREBP-1).54,71

FOXO1

FoxO1 is expressed in most lipid-metabolizing cells, including the prostate, liver,

fat tissue, and skin.72 Human sebaceous gland cells also express FoxO1. Acne and
increased sebaceous lipogenesis are associ- ated with a relative nuclear deficiency
of FoxO1 caused by increased growth hormone–insulin–insulin-like growth factor
1 or fibroblast growth factor 2 signaling.

STRUCTURAL PROTEINS

During sebogenesis, lipids are stored in LDs. LDs are limited by a membrane
containing phospholipids and numerous proteins and enzymes. The most relevant
membrane proteins are the perilipin (PLIN) family, which possesses structural and
regulatory properties. In particular, PLIN2, the major form expressed during the
differentiation process, regulates the gland size in vivo and regulates sebaceous
lipid accumulation.73 Experimental downmodulation of the PLIN2 expres- sion
significantly modifies the composition of neutral lipids with a significant decrease
in the unsaturated fatty acid component caused by a marked decrease in the
expression of specific lipogenic enzymes. On the other hand, PLIN3 has currently
been shown to modulate specific lipogenic pathways in human seba- ceous gland
cells.74 Another structural protein, angio- poietin-like 4, is strongly induced during
human sebocyte differentiation and regulates sebaceous lipogenesis.75

CONCLUSION

The regulation of sebaceous glands and human sebum production is complex.

Advances are being made in this area, which may lead to alternative therapies for
the reduction of sebum and improve- ments in acne.

SWEAT GLANDS

AT-A-GLANCE

 A human has 2 to 4 million sweat glands (200 to 400/cm2 of skin surface).

 Up to 10 L/day of sweat is produced by acclimatized individuals.
 In humans, sweat glands are generally classified into apocrine and eccrine
types.
 Hypothalamic temperature is the strongest stimulus for sweating.
 Acetylcholine is the major stimulus of eccrine sweat glands secreted by
sympathetic nerves.
 Adrenergic stimulation controls apocrine gland secretion.
 Botulinum toxin inhibits sweating by preventing acetylcholine release.
 Oxidative metabolism of glucose is a major source of eccrine gland
adenosine triphosphate.
 Ductal reabsorption conserves NaCl.
 Bacteria are necessary for apocrine odor.
 Odiferous precursors secretion is controlled by the MRP8 encoded by
ABCC11.
 Eccrine gland sweat allows the body to control its internal temperature in
response to thermal stress. Apocrine gland function is more obscure but likely
includes pheromone production. Although the eccrine and apocrine secretory
portions of sweat glands are clearly morphologically distinctive, their ducts are
histologically indistinguishable if the duct orifice can- not be detected.
Immunohistological distinction can be performed by the stage-specific
embryonic antigen-4 (SSEA-4), which is a marker of ductal cells of eccrine but
not of apocrine sweat glands.76

ECCRINE SWEAT GLANDS

DEVELOPMENT OF THE ECCRINE SWEAT GLANDS

A human has approximately 2 to 4 million sweat glands (200 to 400/cm2 of skin

surface).77 Sweat glands are found over nearly the entire body surface and are
especially dense on the palms, soles, forehead, and upper limbs.78 However, they
are absent at the mar- gins of the lips, the eardrums, and the nailbeds of fingers and
toenails. Anlagen of eccrine sweat glands first appear in 3.5-month-old fetuses on
the palms and soles (see Chap. 4), then develop in the axillary skin in the fifth fetal
month, and finally develop over the entire body by the sixth fetal month.78 The
anlagen of the eccrine sweat gland, which develops from the epi- dermal ridge, is
double layered and develops a lumen between the layers between the fourth and
eighth fetal months. By the eighth fetal month, eccrine secretory cells resemble
those of an adult; by the ninth fetal month, myoepithelial cells form around the
secretory coil and the excretory duct.

ANATOMY AND FUNCTION OF THE ECCRINE SWEAT GLANDS

Two distinct segments, the secretory coil (tubulus) and the duct, form the eccrine
sweat gland. The secretory coil secretes a sterile, dilute electrolyte solution with
pri- mary components of bicarbonate, potassium, sodium chloride (NaCl), and other
minor components such as glucose, pyruvate, lactate, cytokines, immunoglobulins,
antimicrobial peptides (eg, dermcidin,79 β-defensin,80 cathelicidines81). Relative
to the plasma and extracellu- lar fluid, the concentration of Na+ ions is much lower
in sweat (∼40 mM versus ∼150 mM in plasma and extra- cellular fluid). The

eccrine excretion has a high con- centration of Na+ ions. However, Na+ ions are
partially reabsorbed via the epithelial sodium channels (ENaC) that are located on
the apical membrane of the eccrine gland duct cells.82 This reuptake of Na+ ions
reduces the loss of Na+ during the process of perspiration.

Secretory Coil:

The secretory coil contains three distinct cell types: (1) clear (secretory), (2) dark
(mucoid), and (3) myoepithelial.83 The clear and dark cells occur in approximately
equal numbers but differ in their distribution. Although the dark cells border the
apical (luminal) surfaces, the clear cells rest either directly on the basement
membrane or on the on the myoepithelial cells. The clear cells directly access the
lumen by forming intercellular canaliculi (Fig. 6-7). Spindle-shaped contractile
myoepithelial cells lie on the basement membrane and abut the clear cells. An adult
secretory coil is approximately 2- to 5-mm long and approximately 30 to 50 μm in
diameter. Heat accu- mulation results in larger sweat glands and ducts, and their
dimensions in turn correlate with enhanced sweat output.84 Clear cells contain
abundant mitochon- dria and an autofluorescent body, called the lipofuscin granule,
in the cytoplasm. The clear cell plasma mem- brane forms many villi. The clear cell
secretes water and electrolytes. Dark cells have a smooth cell surface and contain
abundant dark cell granules.83 The func- tion of dark cells is unknown.
Myoepithelial cells con- tain actin filaments and are contractile,85,86 producing
pulsatile sweat.

Duct:

The duct of the eccrine sweat gland consists of an outer ring of peripheral or basal
cells and an inner ring of luminal or cuticular cells. It seems that the proximal
(coiled) duct is functionally more active than the distal straight portion in pumping
Na+ for ductal Na+ reabsorption because Na+, K+-adenosine triphosphatase
(ATPase) activity and the number of mitochondria are higher in the proximal
portion (Fig. 6-8).83,85,87,88 In contrast, the luminal ductal cells have fewer
mitochondria, much less Na+, K+-ATPase activity, and a dense layer of
tonofilaments near the luminal membrane, which is often referred to as the cuticular
border. The cuticular border provides struc- tural resilience to the ductal lumen,
which may dilate whenever ductal flow of sweat is blocked. The entire structural
organization of the duct is well designed for the most efficient Na+ absorptive
function. The luminal membrane serves as the absorptive surface by
accommodating both Na+ and Cl− channels, and the basal ductal cells serve in Na+
pumping by pro- viding maximally expanded Na+ pump sites and efficient energy
metabolism. The lumen and the duct contain β-defensin, an antimicrobial, cysteine-
rich, low-molecular-weight peptide.80,81 In the epidermis, the duct spirals tightly
upon itself.

NEURAL CONTROL OF ECCRINE SWEATING

The preoptic hypothalamic area plays an essential role in regulating body

temperature: whereas local heating of the preoptic hypothalamic tissue activates
general- ized sweating, vasodilatation, and rapid breathing, local cooling of the
preoptic area causes generalized vasoconstriction and shivering. Whereas the
elevation of hypothalamic temperature associated with an increase in body
temperature provides the strongest stimulus for thermoregulatory sweating
responses, cutaneous temperature exerts a weaker influence on the rate of
sweating.84,89 On a degree-to-degree basis, an increase in internal temperature is
about nine times more efficient than an increase in mean skin tempera- ture in
stimulating the sweat center. The local tempera- ture effect is speculated to be due
to increased release of periglandular neurotransmitters.
The sweating in menopausal “hot flashes” rein- forces the concept of a central
hypothalamic mecha- nism for thermal sweating but also shows that the response
of individuals to the same changes in core temperature can vary. Although
hormonal factors influence sweating during menopause, excessive sweating does
not correlate simply with hormonal levels. Instead, menopausal hot flashes seem to
be caused by a hypersensitive brain response (particu- larly the hypothalamus but
perhaps the insula, ante- rior cingulate, amygdala, and primary somatosensory
cortex as well). In asymptomatic menopausal women and premenopausal women,
the core temperature can change up to 0.4°C (33°F) without eliciting a response. In
symptomatic postmenopausal women, changes as small as 0.1°C (32°F) trigger
peripheral vasodilation and sweating. Why the brain is hypersensitive to small
changes in core temperature is poorly understood, but increased levels of brain
norepinephrine appear to influence the response to small changes in core tem-
perature through their action on α2-adrenergic recep- tors in the brain; higher levels
of the norepinephrine metabolite 3-methoxy-4-hydroxyphenylglycol have also
been found in symptomatic menopausal women compared with asymptomatic
women. Decreased nor- epinephrine release is postulated as the mechanism by
which clonidine relieves hot flashes in symptomatic women. Decreased core
temperature may be the rea- son that women with decreased body mass index tend
to have fewer symptoms even though their estrogen levels probably are lower than
those in women with increased body mass index. Levels of estrogen, lutein- izing
hormone, and β-endorphins also were originally thought to influence hot flashes,
but later studies have suggested no association.90

Innervation:

Efferent nerve fibers originating from the hypothalamic preoptic sweat center
descend through the ipsilateral brainstem and medulla and synapse in the
intermediolateral cell columns of the spinal cord without crossing (although
sympathetic vasomotor fibers may partially cross).91 The myelin- ated axons rising
from the intermediolateral horn of the spinal cord (preganglionic fibers) pass out in
the anterior roots to reach (through white ramus commu- nicans) the sympathetic
chain and synapse. Unmyelin- ated postganglionic sympathetic class C fibers
arising from sympathetic ganglia join the major peripheral nerves and end around
the sweat gland. The supply to the skin of the upper limb is commonly from T2 to
T8. The face and the eyelids are supplied by T1 to T4, so that resection of T2 for
the treatment of palmar hyperhi- drosis is likely to cause Horner syndrome. The
trunk is supplied by T4 to T12 and the lower limbs by T10 to L2. Unlike the sensory
innervation, a significant overlap of innervation occurs in the sympathetic
dermatome because a single preganglionic fiber can synapse with several
postganglionic fibers.

The major neurotransmitter released from the peri- glandular nerve endings is
acetylcholine (Ach), an exception to the general rule of sympathetic inner- vation,
in which noradrenaline is the peripheral neurotransmitter.92 In addition to ACh,
adenosine tri- phosphate (ATP), catecholamine, vasoactive intestinal peptide, atrial
natriuretic peptide, calcitonin gene- related peptide, and galanin have been localized
in the periglandular nerves. The significance of these pep- tides or neurotransmitters
in relation to sweat gland function is not fully understood.

Botulinum toxin interferes with ACh release. Its heavy chain binds the neurotoxin
selectively to the cholinergic terminal, and the light chain acts within the cells to
prevent ACh release. Type A toxin cleaves sensory nerve action potential-25, a 25-
kDa synap- tosomal-associated protein; the type B light chain cleaves vesicle-
associated membrane protein (also called synaptobrevin). Botulinum toxins are
used for symptomatic relief of hyperhidrosis.93 A more detailed description can be
found in Chaps. 81 and 216.

Denervation:

In humans, the sweating response to intradermal injection of nicotine or ACh

disappears within a few weeks after denervation of the postgangli- onic fibers,93,94
and the sweating response to heat ceases immediately after resection of the nerves.
In contrast, after denervation of preganglionic fibers (caused by spinal cord injuries
or neuropathies), pharmacologic responsiveness of the sweat glands is maintained
from several months to 2 years, even though their thermally induced sweating is no
longer present.95

EMOTIONAL SWEATING

Sweating induced by emotional stress (emotional sweating) can occur over the
whole skin surface in some individuals, but it is usually confined to the palms, soles,
axillae, and forehead. Emotional sweat- ing on the palms and soles ceases during
sleep, but thermal sweating occurs even during sleep if the body temperature rises.
Because both types of sweating can be inhibited by atropine, emotional sweating is
cholin- ergically medicated.

PHARMACOLOGY OF THE ECCRINE SWEAT GLAND AND SWEATING

RATE

Sweat glands respond to cholinergic agents, α- and β-adrenergic stimulants, and

other periglandular neu- rotransmitters, such as vasoactive intestinal peptide and
ATP. Periglandular ACh is the major stimulant of sweat secretion, and its
periglandular concentration determines the sweat rate in humans.96 When dissoci-
ated clear cells are stimulated in vitro by cholinergic agents, they lose K + and Cl−,
increase intracellular Ca2+, and shrink, mimicking actions seen in vivo. Striking
individual differences exist in the degree of sweating in response to a given thermal
or physical stress. In general, males perspire more profusely than females. 97 The
sweat rate in a given area of the skin is determined by the number of active glands
and the average sweat rate per gland. The maximal sweat rate per gland var- ies
from 2 to 20 nL/min2. Sweat rate increases during acclimatization, but the
morphologic and pharmaco- logic bases of the individual and regional differences
in sweating rate during acclimatization are still poorly understood (Fig. 6-9). In
thermally induced sweating, the sweat rate can be mathematically related to the
body and skin temperatures in a given subject only in the low sweat rate range.
Cholinergic stimulation yields a 5 to 10 times higher sweating rate than does β-
adrenergic stimulation. α-Adrenergic stimulation (by phenylephrine) is no more
potent than isoproter- enol (ISO) (a β-adrenergic agonist) in humans in vivo.98
Whereas cholinergic sweating begins immediately on intradermal injection, β-
adrenergic sweating requires a latent period of from 1 to 2 minutes, which suggests
that the intracellular mechanism of sweat induction may be different for
methacholine and for ISO. Because the sweat rate in response to adrenergic agents
is rather low, it may be reasonable to surmise that adrenergic stimulation in
periglandular nerves may be involved in the regulation of sweat gland function but
not in the induction of sweat secretion. One consequence of dual cholinergic and
adrenergic innervation is to maximize tissue accumulation of cyclic adenosine
monophos- phate (cAMP), which may be instrumental in stimulat- ing the synthesis
of sweat and glandular hypertrophy of the sweat gland. The possibility that
periglandular catecholamine is directly involved in emotional sweat- ing or
sweating associated with pheochromocytoma99 may be ruled out because these
sweating responses can be blocked by anticholinergic agents.

PHARMACOLOGY AND FUNCTION OF ECCRINE MYOEPITHELIUM

The periodicity of sweat secretion in vivo is caused by the periodicity of central

nerve impulse discharges, which occur synchronously with vasomotor tonus waves.
Myoepithelial contraction occurs with choliner- gic stimulation, but neither α- nor
β-adrenergic agents induce tubular contraction.100 Although the myoepi- thelium
may contribute to sweat production via pul- satile contractions, it also seems to
provide structural support for the secretory epithelium, especially under conditions
in which stagnation of sweat flow (caused by ductal blockade) results in an increase
in luminal hydrostatic pressure.86

ENERGY METABOLISM
Sweat secretion is mediated by the energy (ie, ATP)- dependent active transport of
ions, so a continuous supply of metabolic energy is mandatory for sustained sweat
secretion. Endogenous glycogen stored in the clear cells can sustain sweat secretion
for less than 10 minutes; thus, the sweat gland must depend almost exclusively on
exogenous substrates for its energy metabolism. Mannose, lactate, and pyruvate are
used nearly as readily as glucose; other hexoses, fatty acids, ketone bodies,
intermediates of the tricarboxylic acid cycle, and amino acids are either very poorly
used or not used as substrates. The physiologic significance of lactate or pyruvate
utilization by the sweat gland is not yet clear. However, because the plasma level
of glucose (5.5 mM) is much higher than that of lactate (1 to 2 mM) or pyruvate
(<1 mM), glucose may play a major role in sweat secretion. Oxidative metabolism
of glucose is favored as the major route of ATP formation for secretory activity.100

COMPOSITION OF HUMAN ECCRINE SWEAT

Inorganic Ions:

Sweat is formed in two steps: (1) secretion of a primary fluid containing nearly iso-
tonic NaCl concentrations by the secretory coil and (2) reabsorption of NaCl from
the primary fluid by the duct. Although a number of factors affect ductal NaCl
absorption, the sweat rate (and thus the tran- sit time of sweat) has the most
important influence on final NaCl concentration. Sweat NaCl concentra- tion
increases with increasing sweat rate to plateau at around 100 mM (Fig. 6-10).
Potassium (K+) concentra- tion in sweat is relatively constant. It ranges from 5 to
10 mM, which is slightly higher than plasma K+ con- centration. HCO3−
concentration in the primary sweat fluid is approximately 10 mM, but that of final
sweat is less than 1 mM, which indicates that HCO3− is reab- sorbed by the duct,

presumably accompanied by ductal acidification.101 Sweat NaCl concentration is

increased in individuals with cystic fibrosis.102 Aquagenic wrin- kling of the palms
(whitened, wrinkling, and papil- lation of the palms after brief water exposure) is
seen more frequently in carriers and patients with cystic fibrosis (see Chap. 81).
Lactate:

The concentration of lactate in sweat usu- ally depends on the sweat rate. At low
sweat rates, lactate concentration is as high as 30 to 40 mM, but it rapidly drops to
a plateau at around 10 to 15 mM as the sweat rate increases. Whereas
acclimatization is known to lower sweat lactate concentrations, arterial occlusion
rapidly raises sweat NaCl and lactate con- centrations and reduces the sweat
rate.100 Sweat lactate is probably produced by glycolysis of glucose by the
secretory cells.103

Urea:

Urea in sweat is derived mostly from serum urea.104 Sweat urea content is usually
expressed as a sweat–plasma ratio (S/P urea). S/P urea is high (2 to 4) at a low sweat
rate range but approaches a plateau at 1.2 to 1.5 as the sweat rate increases.

Ammonia and Amino Acids:

The ammonia concentration in sweat is 0.5 to 8 mM,105 which is 20 to 50 times

higher than the plasma ammonia level. The concentration of sweat ammonia is
inversely related to the sweat rate and sweat pH. Free amino acids are present in
human sweat,106 although it is not clear what proportion of measured amino acids
derive from epi- dermal contamination.

Proteins Including Proteases:

The concentration of sweat protein in the least contaminated, thermally induced

sweat is approximately 20 mg/dL, with the major portion being low-molecular-
weight proteins (ie, molecular weight <10,000). Because sweat samples collected
by simple scraping (and even those collected with a plastic bag) can be massively
contami- nated with plasma or epidermal proteins, previous reports on the presence
of α- and γ-globulins, transfer- rin, ceruloplasmin, orosomucoid, albumin,106,107
and immunoglobulin E must be carefully reexamined. The sweat samples collected
over an oil barrier placed on the skin (the least-contaminated sweat) contain no or
trace of γ-globulin and a very small amount of albu- min. Yokozeki and
coworkers108 also reported the pres- ence of cysteine proteinases and their
endogenous inhibitors in sweat and the sweat gland. Dermcidin is an antimicrobial
peptide produced and secreted in sweat.79 Other organic compounds reported to be
pres- ent in sweat include histamine,109 prostaglandin,110 and vitamin K–like
substances.111 Sweat also contains traces of pyruvate and glucose. Sweat glucose
increases con- currently with a rise in plasma glucose level. Some orally ingested
drugs, including griseofulvin,112 ketoconazole,113 amphetamines,114 and various
chemo- therapeutic agents,115 are secreted in sweat.

MECHANISMS OF SWEAT SECRETION

Several distinct sequential processes lead to eccrine gland sweat production116: (1)
stimulation of the eccrine sweat gland by ACh via increased intracellular Ca2+; (2)
Ca2+-stimulated loss of cellular K+, Cl−, and H2O, which leads to eccrine gland
cell shrinkage; and (3) volume-activated transcellular plus paracellular fluxes of
Na+, Cl−, and H2O, which leads to net flux of largely isotonic NaCl solution into
the glandular lumen. These processes are illustrated in Fig. 6-11.

Sweating initially is stimulated when ACh is released from periglandular

cholinergic nerve endings in response to thermal or emotional stimuli. ACh binds
to cholinergic receptors on the clear cell plasma mem- brane, stimulating
intracellular Ca2+ release and influx, and increasing cytosolic Ca2+ concentrations.
Increased intracellular Ca2+, in turn, opens Ca2+-sensitive Cl− and K+ channels in
the clear cell basolateral membrane, which allows Cl− and K+ to escape. Because
H2O follows K+ and Cl−, to maintain cell iso-osmolarity, the cell shrinks.116,117
This decrease in cell volume sets off a second cascade of cell signaling events. First,
decreased cell volume stimulates the NKCC1118 class of Na/K/2Cl cotrans-
porters, which carry Na+, K+, and 2Cl− into the cell in an electrically neutral
fashion (ie, two cations and two anions cancel out net charges). The resulting
increase in cytosolic Na+ activates the Na+, K+-ATPase, located in the basolateral
membrane, which recycles Na+ and K+ across the basolateral membrane. The net
movement of the negatively charged Cl− ion across the apical membrane into the
lumen in turn drives the positively charged Na+ ion into the lumen as well, along a
paracellular pathway. Therefore, the final product of glandular secretion is the net
movement of Na+, Cl−, and H2O into the glandular lumen to form the isotonic
NaCl precursor of sweat.

ACh-induced sweating, which constitutes the bulk of sweat production, appears to

be mediated by intra- cellular Ca2+, as detailed earlier. In contrast, adrenergic-
induced sweating appears to be mediated by increased intracellular cAMP. 119

MECHANISM OF DUCTAL REABSORPTION

Because the production of large sweat volumes could lead to dangerous losses of
NaCl, the sweat duct has evolved to reabsorb NaCl, which minimizes electrolyte
loss, even at high sweat volumes (Fig. 6-12).

Ductal Na+ reabsorption is accomplished through the coordinated activities of

intracellular enzymes and plasma membrane ion channels, pumps, and exchangers.
These mechanisms not only reabsorb electrolytes but also acidify the sweat, which
results in a final sweat product that is hypotonic and acidic. Na+ reenters the duct
cells through the apical membrane via amiloride-sensitive120 epithelial Na+
channels (ENaC)5 and is transported across the basolateral mem- brane by ouabain-
sensitive88 Na+, K+-ATPase pumps. Cl− transport appears to be both transcellular
and paracellular, with the cystic fibrosis transmembrane regulator (CFTR) Cl−
channels playing an important role in transcellular fluxes.118 In cystic fibrosis,
CFTR Cl− channels are mutated, and eccrine duct Cl− reab- sorption is defective
but not completely abolished.27 Na+ is increased in the duct and the sweat at the
skin surface.121 Unlike in the lung, CFTR mutations do not lead to increased
ENaC-mediated Na+ influx, which suggests that the CFTR–ENaC interactions seen
in other tissues differ from that in the eccrine duct. Sweat acidification appears to
be mediated via the enzyme carbonic anhydrase, the HCO3−/Cl and Na+/H+

exchangers, and the V-type H+ ATPase. The intracellu- lar enzyme carbonic
anhydrase catalyzes HCO3− and H+ production. Whereas intracellular HCO3− is

cleared via the HCO3−/Cl antiporter, H+ is pumped into the luminal sweat by the

V-type H+ ATPase.122 The Na+/H+ antiporter NHE1 (Na+/H+ exchanger isoform

1),123,124 found in the basolateral membrane, is important in intracellular pH
regulation.

The transfer of sweat to the skin surface without leakage is important for the
homeostatic regulation of skin and is impaired in atopic dermatitis; lesional skin
presents a decreased claudin-3 expression in sweat glands, which is accompanied
by sweat leakage.122

Several drugs are known to modify ductal NaCl reab- sorption. When aldosterone
is injected systemically or locally, the Na/K ratio in sweat begins to decrease within
6 hours, reaching a nadir at 24 hours and returning to the preinjection level in 48 to
72 hours.121 Na+ deprivation stimulates both renin and aldoste- rone secretion, but
high thermal stress per se (a single 1-hour exposure of humans to a temperature of
40°C [104°F]) is a potent stimulator of renin and aldosterone secretion in either the
presence or absence of sodium deprivation. In an in vitro sweat gland preparation,
neither acetazolamide (a carbonic anhydrase inhibitor) nor antidiuretic hormone
changed ductal or secretory function. However, more potent carbonic anhydrase
inhibitors, such as topiramate,125 have been reported to induce oligohidrosis
APOCRINE SWEAT GLANDS

Apocrine sweat glands are found in humans, largely confined to the regions of the
axillae, the perineum, and the areolae of the breast.126 Differentiated apo- crine
sweat glands are present at the external audi- tory canal (ceruminous glands).
Apocrine sweat glands do not become functional until just before puberty; thus, it
is assumed that their develop- ment is associated with the hormonal changes at
puberty, although the exact hormones have not been identified.

ANATOMY

Apocrine glands are coiled and localized in the sub- cutaneous fat near the dermis.
The gland consists of a single layer of cuboidal or columnar cells. These secre- tory
cells rest on a layer of myoepithelial cells.127 The duct is composed of a double
layer of cuboidal cells and empties into hair follicle infundibulum. Sweat and
sebum are mixed in the hair follicle and arrive mixed at the epidermal surface. The
apocrine sweat is cloudy, viscous, initially odorless, and at a pH of 6 to 7.5.

The sweat of apocrine sweat glands only attains its characteristic odor upon being
degraded by bacteria, which releases volatile odor molecules. More bacte- ria
(especially corynebacteria) leads to stronger odor. The presence of axillary hair also
makes the odor even more pungent because secretions, debris, keratin, and bacteria
accumulate on the hair.

Like the eccrine gland, the myoepithelium fulfills dual functions in both providing
structural support and pumping out preformed sweat.

β-Adrenergic receptors and purinergic receptors have been identified on apocrine

glands.94 However, nerve fibers and muscarinic receptors have not been identified,
suggesting that any cholinergic stimulation acts humorally.128

FUNCTIONS
A number of functions have been attributed to the apocrine glands, including roles
as odoriferous sexual attractants, territorial markers, and warning signals. These
glands play a role in increasing frictional resis- tance and tactile sensibility as well
as in increasing evaporative heat loss in some species. The production of
pheromones by the apocrine glands of many species is well established.129

Because the apocrine glands of humans do not begin to function until puberty and
are odor producing, it is attractive to speculate that they have some sexual function,
which may now be vestigial. There are high levels of 15-lipoxygenase-2 in the
secretory cells of the apocrine gland. Its product, 15-hydroxyeicosatet- raenoic, a
ligand for the nuclear receptor PPARγ, may function as a signaling molecule and
in secretion or differentiation.128

COMPOSITION OF SECRETION

When it is first secreted, the apocrine sweat of humans is milky, viscid, and without
odor. Apocrine sweat contains three types of precursors: fatty acids, sulfanyl
alkanols, and odiferous steroids, which are converted by bacteria on axillary skin,
particularly corynebacte- rium striatum, into odiferous substances. Secretion of
amino acid and steroid precursors is controlled by an ATP-dependent efflux pump
multidrug resistance pro- tein 8 (MRP8), encoded by the gene ABCC11, which is
expressed in apocrine sweat glands. Axillary odor is significantly reduced in Asian
populations that carry a single nucleotide polymorphism in this gene, which also
affects earwax characteristics.130

MODE OF SECRETION

Despite previous reports for apocrine (decapitation), holocrine, and merocrine types
of secretion in apocrine glands, current data indicate that the secretion of apo- crine
glands is merocrine. Cannulation of the duct of the human apocrine sweat gland has
shown that secre- tion is pulsatile, and it is assumed that contractions of the
myoepithelial cells surrounding the secretory cells are responsible for these
pulsations.131

CONTROL OF SECRETION

The apocrine sweat glands of humans respond to emo- tive stimuli only after
puberty. They can be stimulated by either epinephrine or norepinephrine given
locally or systemically. Studies have shown that the apocrine glands are controlled
mainly by adrenergic agonists,132 although some cholinergic control also has been
reported.128,133 This is in contrast to the eccrine glands, which are under
cholinergic control.

Although an intact nerve supply is a functional requirement of apocrine sweating,

the demonstration of nerve endings or varicosities in close proximity to the glands
has been difficult.128,133 Local capillary circu- lation likely assists in conveying
transmitter substance to the sweat gland cells, a form of neurohumoral transmission.

As would be expected, drugs that affect adrenergic systems also have an effect on
apocrine sweat glands. Adrenergic neuron-blocking agents inhibit sweating, as do
drugs that deplete the stores of transmitter sub- stance in adrenergic neurons. Drugs
that block spe- cific adrenergic receptors also inhibit sweating, but the types of
receptors that must be blocked differ in various species. The type of receptor that
mediates the response of the apocrine glands of humans has not been elucidated.
Figure 6-1 Cross-section of a pilosebaceous unit: a mul- tiacinar sebaceous gkland associated with
a hair follicle (HF). AP, arrector pili muscle (×20); SD, sebaceous duct, Sebum, sebum and keratin.
(Modified with permission from: Zouboulis CC, Tsatsou F. Anatomy of the sebaceous gland. In:
Zouboulis CC, Katsambas AD, Kligman AM, eds. Pathogenesis and Treatment of Acne and
Rosacea. Berlin: Springer; 2014:27-31. Copyright © 2014.)

Figure 6-2 A, Hematoxylin and eosin–stained section of the human sebaceous gland showing the
different stages of sebocyte differentiation. Cells progress toward the middle of the gland, lose their
nuclei, and organelles, and accumulate lipid droplets. B, Differentiation stages of human sebocytes
in tissue (left)19 and in vitro (right)3 according to Tosti17 and McEwan Jenkinson and coworkers.18
Undifferentiated sebocytes are small cells with a high nucleocytoplasmic ratio. Early differentiated
sebocytes are larger cells with a decreased nucleocyloplasmic ratio compared with the
undifferentiated sebocytes and a few lipid droplets arranged in the perinuclear area. Advanced
differentiated sebocytes are cells with further increases in size and decreases of the
nucleocytoplasmic ratio. Multiple cytoplasmic lipid droplets are distributed inside the cytoplasm.
Fully differentiated sebocytes are cells with abundant, partially large, cytoplasmic lipid droplets.
Mature sebocytes are disorganized large cell with denatured nucelei; the lack of cytoplasmic lipids
is caused by lysis of the cell blood cell membrane.

Figure 6-3 Fordyce spots at the upper lip mucosa.

Figure 6-4 Simplified signaling pathways and transcription factors that are involved in cell lineage
determinations.9-11 As daughter cells migrate from the bulge region, changes in the expression
patterns of numerous transcription fac- tors determine their final cell lineage. Additional path- ways
and transcription factors play a significant role in determining each cell lineage. Lef1, lymphoid
enhancer binding factor 1; Myc, myelocytomatosis oncogene; Shh, Sonic hedgehog; Tcf3,
transcription factor 3; Wnt, wingless (wg)/int.

Figure 6-5 Genes and their proteins/lipids reported to be involved in sebaceous differentiation and
maturation.9 PPAR, peroxisome-proliferator-activated receptor.

Figure 6-6 Human sebaceous gland lipids. The struc- tures of the cholesterol ester, wax ester, and
triglyceride are representative of the many species that are present. Two sebaceous-type unsaturated
fatty acid moieties are shown: sapienic acid (16:1∆6) (in the wax ester structure) and sebaleic acid
(18:2∆5,8) (in the triglyceride structure). Anteiso branching is shown in the alcohol moiety of the
wax ester, and iso branching is shown in the triglyceride.

Figure 6-7 Electron micrograph of the secretory coil of a human eccrine sweat gland. B with arrow,
basal lamina; CC, clear cell; DC, dark cell; ICC, intercellular canaliculi; Lu, lumen; MC,
myoepithelial cell.

Figure 6-8 The ultrastructure of the eccrine duct and secretory coil and the localization of Na +, K+-
adenosine tri- phosphatase (ATPase). The thick lines indicate the localiza- tion of Na+, K+-ATPase.
BM, basement membrane; C, clear cell; D, dark cells; IC, intercellular canaliculi; M, myoepithe-
lial cell; Mc, mitochondria.

Figure 6-9 Individual variation in the size of the sweat gland in four male adults, aged 22 to 28 years.
Sweat glands were isolated from skin biopsy specimens obtained from the upper back behind the
axilla. Whereas subject 1 is a sedentary man who does not exercise regularly, sub- ject 4 is a well-
acclimatized athletic individual.
Figure 6-10 Relationship between the concentration of sweat ingredients and the sweat rate in
thermally induced human sweat in normal individuals and in persons with cystic fibrosis (CF).

Figure 6-11 Modified Na/K/2Cl cotransport model for the ionic mechanism of cholinergic eccrine
sweat secretion. Periglandular neurotransmitters, such as acetylcholine (ACh), bind to receptors on
the basolateral membrane, which leads to increased intracellular Ca 2+; this in turn acti- vates K+
and Cl− channels, mediating K+, Cl–, and H2O efflux from the cell. The resulting cell shrinkage
activates the basolateral Na+/K+/2Cl antiporter, which leads to Na+, K+, and Cl− influx. The Na+
and K+ fluxes are recycled across the basolateral membrane by the Na +, K+-adenosine triphos-
phatase. In contrast, Cl− fluxes flow unopposed into the lumen, causing an electrical gradient that
drives Na+ exit from the tissue into the lumen via a paracellular pathway. Net fluxes: H2O, Cl–, and
Na+ (isotonic) flow into the lumen. pH of the secreted fluid is neutral. Paracellular Na+ fluxes across
the cell junction are indicated with an arrow at the bottom of the figure. B, basolateral membrane;
L, luminal or apical membrane.

Figure 6-12 Illustration of ion reabsorption in the sweat duct. Na+ enters the apical (luminal)
membrane through epithelial Na+ channels (ENaC) and is transported across the basolateral
membrane by Na+, K+-adenosine triphosphatase (ATPase). Cl− enters the cell through the cystic
fibrosis transmembrane regulator Cl− channel (CFTR) and is transported across the lumen via a
paracellular pathway. H+ generated by the enzyme carbonic anhydrase (CA) is pumped into the
lumen by a V-type H+ ATPase (H+ V-ATPase). Intracellular pH homeostasis is maintained by
parallel HCO3–/H+ and Na+/H+ (NHE1) exchangers. The activity of these enzymes, transporters,
and channels results in H+ secretion and Na+ and Cl− reabsorption, which produces a final sweat
that is hypotonic and acidic. Paracellular Cl− fluxes across the cell junction are indicated with an
arrow at the bottom of the figure. B, basolateral membrane; L, luminal or apical membrane.

Diseases of the Sebaceous Glands

Increased activity/volume
Acne vulgaris
Rosacea
(Hyper)seborrhea
Periorificial dermatitis
Hair follicle naevus
Congenital sebaceous gland hyperplasia Senile sebaceous gland hyperplasia Sebaceoma
(sebaceous gland epithelioma) Sebaceous carcinoma

Muir-Torre Syndrome
Decreased activity/volume
Senile xerosis cutis
Psoriasis
Lichen planopilaris
Pseudopelade Brocq
Hidradenitis suppurativa
Linear morphea
Chlor- /dioxin-induced acne Chemotherapy-induced diffuse alopecia Zouboulis syndrome
Diseases of the Eccrine Glands
Increased activity
Hyperhidrosis (primary and secondary)
Eccrine carcinoma
Decreased activity
Hypohidrosis/Anhidrosis
Abnormal activity/Obstruction of the eccrine duct Neutrophilic eccrine hidradenitis
Coma bullae
Erythema multiforme
Cystic fibrosis
Miliaria (crystallina, rubra, and profunda) Syringosquamous metaplasia)