Apoptosis: the skin from a new perspective.

In this review we present skin biology from the perspective of apoptosis. We stress that apoptosis acts as an important homeostatic and defence mechanism in the developing and mature epidermis. Programmed cell death functions in establishing the architecture of the human epidermis and its appendages during development by deletion of stage-specific cells and in the adult epidermis by elimination of excess and abnormal cells. Arguments are presented to support the hypothesis that known regulators of keratinocyte growth may act as survival factors which suppress the cell death pathway. Surviving cells continue to divide until they encounter anti-proliferative factors. Then, unless cells are severely injured and die of necrosis, they will terminally differentiate to death or will die by apoptosis. The mechanisms controlling keratinocyte maturation are co-ordinated with cell position within the epidermal strata. Inappropriate regulatory signals or response of a cell inappropriate to its state will activate apoptosis. Parallels between terminally differentiating keratinocytes and apoptotic cells imply that terminal differentiation and apoptosis proceed along the same death pathway. For terminally differentiating cells, however, this pathway is more elaborate because it allows expression of tissue- and differentiation-specific genes. A model is presented that integrates apoptosis and keratinocyte growth and differentiation.