Chapter 11 :: Cellular Components of the
2
Cutaneous Immune System
:: Johann E. Gudjonsson &
Robert L. Modlin
AT-A-GLANCE
■ Human immune system consists broadly of innate
vs adaptive immune responses.
■ Innate immune system has multiple different
cellular subsets that have in common rapid
response to infection and injury but are
restricted in their ability to recognize and
respond to all pathogens, instead relying on
germline encoded pattern recognition receptors
and danger signals.
■ Adaptive immune system is a slower but
more adaptive arm of the immune system that
can respond to near limitless range of
pathogens.
■ Recently identified immune cells, such as innate
lymphoid cells and unconventional T cells, span
the spectrum between the innate and the adaptive
immune system.
INTRODUCTION
Apart from being one of the largest organs in the human
body, the skin acts as a protective barrier between the
internal and external environments. Although the epi-
dermis acts as a physical and physiologic barrier to
the entry of commensals and pathogens, the near con-
stant exposure to an array of both benign and harm-
ful microorganisms and other stressors in the skin has
promoted the evolution of a complex cellular immune
network, involving both the innate and adaptive
parts of the immune system. This ensures adequate
responses against pathogens as well as mechanisms
to promote homeostasis and control excessive inflam-
matory response. This network in the skin has been
named the skin immune system and consists of a large
number of specialized skin-resident immune cells as
well as circulating lymphocytes constantly recirculat-
ing between the skin, skin-draining lymph nodes, and
the peripheral circulation.1 The cellular constituents of
the skin immune system involve multiple cell types,
subtypes of immune cells, and often involve partici-
pation of parenchymal cells including keratinocytes,
endothelial cells and fibroblasts (Fig. 11-1). The interac-
tions between these are highly complex, with each cell
type often having both specific and redundant roles in
immune responses.
INNATE AND ADAPTIVE
IMMUNE SYSTEM
Chapter 11 :: Cellular Components of the Cutaneous Immune System
The skin immune system includes components of
both the innate and adaptive immune components
(Fig. 11-2). The innate immune system recognizes
specific motifs, such as proteins, lipids, nucleotides,
and other metabolites, associated with broad classes of
pathogens, and with the receptors for these encoded
in germline DNA. In contrast, the adaptive immune
system is based on the generation of near limit-
less antigen receptor or antibody diversity through
somatic recombination, which in turn provides the
foundation for immunologic memory through dif-
ferentiation, expansion, and persistence of long-lived
antigen-specific lymphocytes.2 This expansion and
persistence of antigen-specific lymphocytes in turn
allow a more rapid and robust response in the event
of subsequent immunologic challenge. In recent years,
this distinction has been somewhat challenged as it has
become clear that many immune cells have properties
of both the innate and adaptive immune systems, and
that the innate immune system can adapt to repeated
challenges. Such innate immune memory response has
been termed “trained immunity” and provides protec-
tion against reinfection in a T- and B-cell–independent
manner.3
Whereas T and B cells are the primary cells of the
adaptive immune system, dendritic cells and macro-
phages with their prominent expression of pattern-
associated receptors are the key players of the innate
immune system, in terms of either directly dealing
with microbial infection and/or instructing the adap-
tive immune response. Other cell types that partici-
pate in innate immune responses include mast cells,
neutrophils, and resident tissue cells such as kerati-
nocytes, endothelial cells and fibroblasts. Several cell
types have dual characteristics of the innate and adap-
tive immune system, including innate lymphoid cells
(ILCs), and innate-like T cells, as discussed in greater
detail later in this chapter.
The primary function of the innate immune system
is to provide a rapid first line of defense against micro-
bial pathogens to contain them, while the much slower
but more powerful adaptive part of the immune sys-
tem is being activated. The activation of the innate
immune system promotes activation of the adaptive
immune system and dictates what type of adaptive
immune response is mounted against the invading
pathogen. Therefore, these 2 systems act in synergy
2 Cellular components of the immune system in healthy skin

Stratum corneum

Granular layer

Spinous layer

CD8+ LC
Basal layer LC (TRM
Part 2

Dermis
Macrophage Dermal DC ILCs Mast cell CD4+
::
Structure and Function of Skin

γδ
Fibroblasts Lymphatic Plasmacytoid Blood T cell
vessel DC vessel

Figure 11-1 Components of the cellular immune system in healthy skin. Multiple different immune cell populations
are present in healthy skin. Langerhans cells and resident memory T cells, primarily CD8+, reside in the epidermal layer,
whereas CD4+ and γδ T cells are found in the upper dermis. Innate lymphoid cells (ILCs) are found in proximity to the
dermal-epidermal junction, whereas mast cells are often in proximity to dermal blood vessels. Dermal dendritic cells and
macrophages are found in the dermis. Other cells may contribute to immune responses in skin such as fibroblasts, lym-
phatic blood vessels, nerves (not shown), and melanocytes (not shown).

Cellular players in innate and adaptive immune responses in skin

Innate immune cells

Mast cell Adaptive

immune cells

Dendritic cells
T cells
Interstitial
lymphoid cells

Macrophage

B cells

Neutrophils
Fibroblasts Innate-like
T cells
Resident
tissue cellls
(keratinocytes, endothelial cells,
fibroblasts)

144 Figure 11-2 Innate and adaptive cells. Interstitial lymphoid cells and innate-like T cells have both innate and adaptive
immune functions.
 The immune response
Foreign
Innate response
pathogen
Rapid response
Pattern recognition receptors-
germ-line encoded
- CD14, mannose and scavenger
Cytokines, costimulatory
molecules-instructive role for
adaptive response
Direct response for host defense
- Phagocytosis
- Antimicrobial activity
Figure 11-3 The immune system of higher vertebrates uses both innate and adaptive immune responses. These immune
responses differ in the way they recognize foreign antigens and the speed with which they respond, yet they complement
each other in eradicating foreign pathogens.
to defend the host, but abnormal activation of these
systems can frequently lead to various inflammatory
conditions and diseases (Fig. 11-3).
CELLULAR COMPONENTS
OF THE IMMUNE SYSTEM
T CELLS
T cells are derived from multipotent hematopoietic
stem cells in the bone marrow. Progenitor T cells migrate
through the blood to the thymus, where they mature.
This is the reason for the naming of these cells, where
the “T” in T cells stands for “thymus-dependent.” The
majority of human T cells rearrange their alpha and
beta chains on the T-cell receptor in the thymus and are
termed αβ T cells, whereas a small minority of T cells
in the thymus have γδ T-cell receptors. The γδ receptors
have limited diversity and are considered to be part of
the innate immune system. These two, αβ and γδ, are
the key lineages of T cells.
T cells that have completed their primary develop-
ment in the thymus, and have not yet encountered
their specific antigen, are known as naïve T cells and
circulate through the bloodstream to secondary lym-
phoid organs including lymph nodes and the spleen.
Once a naïve T cell meets its specific antigen, presented
to it as a peptide MHC complex on the surface of an
antigen-presenting cell in secondary lymphoid organs,
it is able to develop into an effector T cell and a longer-
lived central memory T cells. In contrast to naïve
T cells, effector T cells are able to mount a response
to antigens. T cells can be either CD4+ or CD8+. Naive
CD8+ T cells recognize peptide antigens in the bind-
ing pocket of MHC class I molecules such as HLA-A,
2
Adaptive response
Slow response
Recognition - initially low affinity
receptors
Gene rearrangement
Clonal expansion
Chapter 11 :: Cellular Components of the Cutaneous Immune System
Response - T and B cells with
receptors encoded by fully
rearranged genes
Memory
HLA-B, or HLA-C, and differentiate into cytotoxic
effector T cells, which recognize and kill infected cells.
Some αβ CD8+ T cells with limited TCR diversity are
able to respond to lipid antigens by MHC class I–like
antigen-presenting molecules, including the CD1 fam-
ily of proteins. CD8+ effector T cells are often defined
by the major cytokine that they produce, including
IFN-γ, IL-4, and IL-17, as T-cytotoxic (TC)1, TC2, and
TC17s, respectively. Naïve CD4+ T cells recognize pep-
tide antigens in the binding pocket of MHC class II
molecules such as HLA-DR, HLA-DQ, and HLA-DP
on antigen-presenting cells and differentiate into effec-
tor subsets that have broader and different immuno-
logic functions. This includes the main CD4+ T-cell
subsets, T helper 1 (TH1), TH2, TH17, and T follicular-
helper (TFH), and T regulatory cells (Tregs) (Fig. 11-4).
T HELPER 1 (TH1) CELLS
TH1 cells are characterized by the production of the
cytokines IL-2, IFN-γ, and TNF-α. TH1 cells are the main
mediators of cell-mediated immunity. These cells are
characterized by the expression of the T-box transcrip-
tion factor T-bet, which induces both transcriptional
activation of the IFN-γ gene locus and responsiveness
to the TH1-polarizing cytokine IL-12. TH1 cells, primar-
ily by the release of IFN-γ, activate macrophages to kill
or inhibit the growth of pathogens and trigger cyto-
toxic T-cell responses.
T HELPER 2 (TH2) CELLS
TH2 cells are characterized by the production of the
cytokines IL-4, IL-5, and IL-13. The zinc-finger tran-
scription factor GATA-3 is critical for inducing the 145
TH2 program in these cells. In contrast to TH1 cells,
2 T-cell differentiation

Antigen

Dendritic cell

Naive T cell

IFN-γ IFNs, IL-12 IL-6, IL-21

IL-2
Th1 TFH IL-21
T-bet Bcl-6 IL-17
LY-α
IL-2, IL-4 TGF-β, IL-2
TGF-β TNF-α
IL-4 Th2 IL-4 IL-1-β IL-23 IL-6 Treg TGF-β
IL-5 GATA-3 TGF-β IL-6 FoxP3 IL-10
Part 2

IL-6 ? IL-35
IL-13 Th9 Th22
IL-9 Th17 IL-22
::

IL-10 RORf t
Structure and Function of Skin

IL-17A IL-22
IL-17F IL-26

Figure 11-4 Schematic view of events governing and occurring in T-cell differentiation. Depending on the type and acti-
vation status of the antigen-presenting dendritic cells (DCs) and on the type and amounts of cytokines secreted by these
and/or other cells, naïve T cells will expand and differentiate into various subsets, that is, TH1, TH2, TH9, TH17, TH22, Treg, and
TFH. They exhibit different types of transcription factors and secrete different types of cytokines.

TH2 cells facilitate humoral (antibody) responses and
inhibit some cell-mediated immune responses. There
is significant crossregulation between those 2 arms
of the immune system. Thus, the TH1 cytokine IFN-γ
downregulates TH2 responses, and conversely, IL-4
downregulates both Th1 responses and macrophage
function.
T HELPER 9 (TH9) CELLS
IL-9 is produced by a population of T cells, which is
distinguished from other T-cell lineages such as TH1,
TH2, and TH17 cells. These TH9 cells coproduce TNF-
α, but unlike mouse TH9 cells, do not produce IL-10.
TH9 cells are found primarily among the skin homing
(cutaneous leukocyte antigen [CLA] positive) T-cell
population and are present in healthy human skin.
IL-9 promotes upregulation of other proinflammatory
cytokines including IFN-γ, IL-13, and IL-17, suggest-
ing that TH9 activation can initiate inflammatory reac-
tions and amplify activation and cytokine production
of other TH subsets.4
T HELPER 17 (TH17) CELLS
TH17 cells are characterized by the production of the
cytokines IL-17A, IL-17F, IL-21, IL-22, and recently
IL-26.5 They depend on IL-23 for their survival and
expansion,6 and are regulated by the transcription fac-
tor RORyt. TH17 cells are involved in antigen responses
against extracellular pathogens including both bacte-
146 ria and fungi. These cells have been implicated as key
players in the pathogenesis of psoriasis.
T REGULATORY CELLS (TREGS)
Tregs play a key role in maintaining tolerance to self-
antigens in the periphery. Loss of Tregs, as happens
in IPEX (immune dysregulation, polyendocrinopa-
thy, enteropathy, and X-linked) syndrome, results in
multiorgan autoimmune disease. Tregs function by
suppressing the activation, cytokine production, and
proliferation of other T cells.7 They are characterized
by expression of the transcription factor FOXP3, the
genetic cause of IPEX syndrome. About 5% to 10% of
the T cells resident in normal human skin are FOXP3+
T regs.8 Other populations of Tregs have been reported
in humans, including IL-10 producing FOXP3-negative
cells, and have been implicated in systemic lupus
erythematosus.
T FOLLICULAR HELPER CELLS (TFH)
TFH represent a distinct subset of CD4+ T cells primarily
found in B-cell areas of lymph nodes, spleen, and Payer
patches. TFH trigger the formation and maintenance of
germinal centers in lymph nodes and spleen through
the expression of CD40 ligand (CD40L) and the secre-
tion of IL-21 and IL-4. These cells play a crucial role
in orchestrating selection and survival of B cells that
go on to differentiate into either antibody-producing
plasma cells or memory B cells.
SKIN HOMING
To gain entry into the skin, T cells need to express the
right surface molecules and receptors. This includes
the cutaneous lymphocyte antigen (CLA),9 and expres-
sion of specific chemokine receptors including CCR4
and CCR10.10 CLA is an inducible carbohydrate modi-
fication of P-selecting glycoprotein ligand-1 (PSGL-1),
a known surface glycoprotein that is expressed con-
stitutively on all human peripheral-blood T cells.
This modification enables it to bind E-selectin, which
is highly expressed on skin endothelial cells.9 CCR4
binds to the chemokines CCL17 and CCL22, whereas
CCR10 binds to the chemokine CCL27. CCR4 is present
on essentially all skin-homing cells, whereas CCR10 is
only present on a subset of skin-homing T cells.10 This
specific and highly controlled trafficking of T cells
to the skin explains the greater than 100-fold enrich-
ment of antigen-reactive T cells at the site of cutaneous
inflammation compared with blood.
TISSUE RESIDENT (TRM), EFFECTOR
(TEM), AND CENTRAL MEMORY
(TCM) T CELLS
Healthy human skin contains about twice as many
T cells as are present in the entire blood volume, or about
20 billion. Of skin-tropic (CLA+) memory T cells, 98%
are located in human skin under non-inflamed condi-
tions and only 2% are present in the circulation.11 These
findings radically changed the long-held assumption
that memory T cells continuously recirculate between
peripheral organs via the blood and secondary lym-
phoid structures and are rapidly recruited to the site of
infection when needed. Instead, a substantial number
of T cells are static and reside in the skin, where they
can provide rapid defense against invading patho-
gens. This also explains observations made from the
xenotransplant model of human skin inflammation. In
these studies, healthy-appearing skin of patients with
psoriasis was grafted onto immunodeficient mice.
After few weeks, the uninvolved skin spontaneously
developed psoriasis, whereas no changes were seen
for skin from nonpsoriatic healthy controls. These
elegant studies demonstrated that T cells that reside
in noninflamed human skin are sufficient to create an
inflammatory pathology in the absence of recirculat-
ing lymphocytes.12 These observations and others led
to the naming of these T cells as “resident memory
T cells,” or TRM.
TRM cells are nonrecirculating memory T cells that
are found in epithelial barrier tissues, including the
GI tract, lung, skin, and reproductive tract.13 The
physiologic role of this is to provide these epithe-
lial sites with highly protective T cells specific for
the pathogens most commonly encountered through
these tissues, and at the sites where they are read-
ily available when needed13 (Fig. 11-5). Evidence
for this function of TRM cells derives from vaccina-
tion studies with the live vaccinia virus through
skin scarification, in which keratinocytes become
infected. Vaccination via scarification generated
long-term T cell–mediated immunity—characterized
by increased number of skin resident memory CD8+
cells—that was 100,000 times more effective than
subcutaneous, intradermal, and intramuscular vacci-
nation in protecting against reinfection of the skin.14
2
Although illustrative of the function of TRM cells, this
study also questions the value of traditional routes
of vaccination, particularly against pathogens that
primarily infect the skin.14
TRM cells have been suggested to exist as 2 phe-
notypically and functionally distinct populations.
Both of these populations express the TRM marker
CD69 and are distinguished by the expression of the
surface marker CD103. CD69+CD103+ TRM cells are
enriched in the epidermis, are predominantly CD8+,
and have a tendency for increased effector cytokine
production, whereas CD103– TRM cells are more fre-
Chapter 11 :: Cellular Components of the Cutaneous Immune System
quently encountered in the dermis and have slightly
lower but still potent effector functions when com-
pared with recirculating T cells.15 In contrast, CD103+
TRM cells have more limited proliferative capacity
compared with CD103– TRM cells. CD103 expression
was enhanced by keratinocyte contact and is TGF-β
dependent,15 and through its binding to E-cadherin in
the epidermis is responsible for retaining these cells
within the epidermis.
Human skin also contains populations of recircu-
lating memory T cells. These cells coexpress both the
skin homing receptor CLA and CCR4 and the central
memory markers CCR7/L-selectin (CD62L). Based on
variable expression of L-selectin, these cells have been
named migratory memory T cells (TMM) (L-selectin
negative) in contrast to central memory T cells (TCM,
L-selectin+).15 TCM have higher sensitivity to antigenic
stimulation and are less dependent on costimulation
compared to naïve T cells. Following TCR triggering,
TCM produce mainly IL-2, but after proliferation they
differentiate into effector T cells (TEM), which are char-
acterized by rapid effector function and are capable of
producing large amounts of effector cytokines includ-
ing IFN-γ, IL-4, and IL-17, as well as perforin in the
case of CD8+ TEM.
Importantly, the biology of these T-cell subsets can
help explain many of the clinical characteristics of vari-
ous skin diseases. As TRM do not migrate or recirculate,
inflammatory lesions caused by these cells tend to be
sharply demarcated, with abrupt cut-off from normal
skin, a classic feature of skin lesions in diseases such as
psoriasis. It also explains why lesions tend to persist
long-term in a particular location, and often recur in the
same location on discontinuation of effective therapy.
Furthermore, as these cells are already on-site, they can
respond to repeated antigen challenges extremely rap-
idly, often within hours of exposure—such as that seen
in fixed drug eruptions. Finally, the biology of the TRM
cells can also help explain differences between types of
cutaneous lymphomas, such as mycosis fungoides and
Sezary syndrome, with the former being mediated by
TRM cells and the latter by circulating central memory
T cells (TCM).15 Finally, as TRM cells have a tendency
to progressively accumulate in tissues with repeated
antigen exposure, TRM-mediated inflammatory dis-
eases tend to worsen over time, with an increasingly
rapid onset of inflammation and increasing severity of 147
inflammation with each exposure.13
2 Contributions of memory cells to skin immunity

Bacterial pathogen

Pathogen clearance

Dendritic cell endocytosis

and activation via TLRs
Long-lived sessile
Part 2

skin-resident T cells
::

TEM that migrate to gut,

Structure and Function of Skin

Skin draining lung, & other tissues

lymph node Effector memory
Naïve T cell T cells (TEM)
Peptide-MHC
TCR
CLA
CCR4

L-selectin
CCR7
T cell activation
Central memory
& polarization Effector memory
T cells (TCM)
T cells (TEM)

Non-cutaneous
lymph nodes
Blood vessel

Figure 11-5 Contributions of T effector memory, central memory, and resident memory cells to skin immunity. After expo-
sure to bacterial pathogens, resident dendritic cells in the skin become activated (ie, through activation of toll-like recep-
tors (TLR)) and migrate to skin-draining lymph nodes. Naïve T cells recognizing bacterial peptide antigens on the surface
of dendritic cells differentiate and polarize into skin homing effector memory T cells (TEM) and central memory T cells (TCM).
Skin homing TEM enter all areas of the skin but in highest number at the site of pathogen exposure. These cells will contrib-
ute to pathogen clearance, and some will become long-lived tissue-resident memory T cells (TRM). T cells are also released
from the skin draining lymph nodes and migrate to secondary lymphoid tissue including noncutaneous lymph nodes, giv-
ing rise to new populations of TEM that home to other nonskin peripheral tissues such as the gut and lungs. (Adapted from
Clark RA. J Invest Dermatol. 2010;130(2):362-370, with permission. Copyright © The Society for Investigative Dermatology.)

spleen, peripheral lymph nodes, and gut-associated

B CELLS
B cells form the humoral arm of the immune system,
which is characterized by antibody production. Anti-
bodies produced by B cells have various functions,
they can bind to and neutralize pathogens by prevent-
ing their ability to enter and infect cells, and simi-
larly they may bind and neutralize bacterial toxins.
Antibodies also facilitate the uptake of pathogens by
phagocytes in a process called opsonization that facili-
tates binding to the cell surface Fc receptor. Lastly anti-
bodies bound to pathogens can activate proteins of the
classical pathway of the complement system. As evi-
dent from the description above, the humoral immune
response mainly protects extracellular spaces, blocks
infection of all cells but permits uptake by phagocytes
with the capacity to destroy the pathogen. B cells emi-
148 grate from the bone marrow, following which cells
migrate to secondary lymphoid organs such as the
lymphoid tissue (Payer patches and mesenteric lymph
nodes). B-cell activation usually requires help from
TFH cells. Activated B cells differentiate into either
memory B cells or antibody-secreting plasma cells.
Cytokines made by TFH cells direct the choice of
the antibody isotype in human: that is, IL-4 pro-
motes immunoglobulin G1, G4, and E responses;
IFN-γ induces immunoglobulin G3; whereas TGF-β
induces immunoglobulin A responses. They also have
antibody-independent roles, acting as antigen-present-
ing cells, and producing cytokines with potent effects
on both localized and systemic immunity.
B cells are infrequently found in normal skin under
homeostatic conditions and the role of B cells in cuta-
neous immunity remains poorly defined. For the lim-
ited number of B cells found in skin, it is unclear if
they represent a specific skin-resident population or
whether they are derived from circulation populations
of B cells. Of note, B cells have been observed in chronic