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Anatomy, Physiology and Homeostasis of theSkinIThe Concept of Nourishment of the Skin toEnhancethe Functionand Restoration ofDamaged, ImpairedSkin WithClinicalApplicationsJaneFore-Pfliger,MD, CWS,FAPWCA,Lewis-ClarkWound CareClinicLewiston, IDand Clarkston,WA
Introduction
The beginning of a wound is disruption of the stratum corneum of the epidermis; the final healingof a wound is the return of the fully functional stratum corneum. Much has been learned about the
development and maintenance of the epidermis in the last several years. Additionally, research is
revealing ways to enhance and restore the function of impaired skin. Through the use of nourishing
topical agents, such as Olivamine*, the skin can be treated and restored to full function, enabling the
skin to be the very effective barrier it is meant to be. A healthy epidermis is flexible yet strong, able tofight off invading organisms and is able to recover and heal after inflammatory and mechanical insults.
Endermic nourishment of the skin that is exposed to external factors will help to prevent the
development of wounds. Skin that is newly healed is also susceptible to damage and requires treatment
and ongoing maintenance to again attain durability. Conditions that lead to impaired skin include
photo and chronological aging, eczema and other inflammatory dermatoses, arterial insufficiency,
venous stasis, lymphedema, injury to the peri-wound skin, incontinence, fissuring, and cracking.
EpidermisOne purpose of the epidermis is to build a fully functional and capablestratum corneum. Thesefunctions include building a strong, flexible, and mature corneocyte proteins as well as abundant
intracellular lipid layers. The skin is the largest organ of the body and is the primary line of defense
against chemical, environmental, infectious and mechanical stressors. Orderly maturation of the
epidermis is essential for a normal stratum corneum. This visible organ, reflecting the general health
of the person, is metabolically very active with biosensors and responds to many stimuli including
humidity and chemicals. Average turnover rate for the epidermis is 39 days.A fully functional and
mature epithelium is the ultimate defense of our bodies. Compromise to this line of defense is
considered significant in ability to cause damage.
*OlivamineTM Containing Products, RemedyTM,from Medline Industries, Inc. Mundelein, IL
Presented at the Clinical Symposium on Advances in Skin and Wound Care)Phoenix)AZ)September 3~-October 3, 2004
Protective FunctionsOf The Epidermis.Metabolic Functions - Barrier and Lipid
.Mechanical Integrity
. Defense - Chemicals, Drugs, Antigens
. AntioxidantRepair
. Cytokine Signaling- Langerhans, Melanocytes,
Keratinocytes release signals to defend and repair
.Antimicrobial Defense
.Permeability Barrier Hydration - Limits
Transepidermal Water Loss (TEWL) to 2-5 cc/hrl cm2
.Waterproofing/Repellency
. Cohesion/Desquamation
Conditions Associated WithSkin Damage. Flattening and weakening of the dermal - epidermal
junction reducing communication, nutrition, and blood
supply. Along with this, the main source of skin hydration
is significantly reduced. The skin is more fragile and more
prone to skin tears.
.Epidermal turnover rate reduction results in slower healing.
.The intracellular layers are reduced leading to dryness
and cracking.
. Cholesterol and amino acids are reduced leading to adecreased bacterial defense mechanism.
WHAT FACTORS ARE ESSENTIAL TO
HEALTHY SKIN DEVELOPMENT,MAINTENANCE AND REPAIR?
1. Adequate building blocks (nutrients) for productionof the skin
2. Optimal conditions for orderly maturation of the
epidermis
3.A healthy dermis to support the epidermal function
.pH is elevated.
.Dermis is thinned trom loss of collagen, losing elasticity.
. There is decreased perspiration and less sebaceous activity.
.A relative humidity of less than 40% leads to dryness as
the most common cause of pruritus.
.Contact allergy reactions increase due to a poor epidermalbarrier.
.Reduced vitamin D production.
HOW CAN WE NOURISH, REPAIR ANDPOTENTIALLY CREATEMORE
DURABLE SKIN?
Products that are placed on the skin should have a
significant positive impact on the optimal functioning
of the epidermis and dermis. The skin needs topical
support, at all times, particularly in times of distress.
Topical Ingredients to Optimize Cellular Biosynthesisand Repair.Antioxidants - Hydroxytyrosol
.Amino Acids - Must be altered to be bioavailable
.Vitamins - niacinamide, lipoic acid, ascorbic acid
. Lipids- mixtures of ceremides, cholesterol, fatty acids
. Lipidprecursors- phytosphingosine, tetraacetylphyt
osphingosine, omega-hydroxyfatty acids, linoleic acid,
natural oils (saillower, olive, borage)
. Alpha, beta, & polyhydroxyacids - L-lactic, malic, citric,
salicylic, glycolic acid
. Humectants- glycerol, urea
. Proteaseinhibitors- egg white lysozyme,
aminocyclohexanecarboxylic acid
Summary
.Minerals - magnesium, calcium
. Histaminereceptor antagonists- HI and H2 receptor
antagonists
.Peroxisome proliferator receptor agonists - especially
PPAR alpha like linoleic acid, vitamin D, retinoids, some
fatty acids, fibric acid derivatives, petroselinic acid,niacinamide
. Triterpenoids- ursolic acid
. GABA agonists - type A agonists - musimol,
Isoguvacme
. Purinergic receptor- P2Y antagonists
. Glucocorticoid receptor antagonists
Traditionally, we use topical skin care products that have a passive function, leaving the patient susceptible to skin injury and
poor healing. Recently, in our clinical practice, many patients have benefited from the addition of a skin care regime that
included the application of topical nutrients and lipid based products. We have noticed great improvements in general skin
conditions such as diffuse rashes, diabetic skin conditions, scarring, perineal breakdown as well as lower extremities with venous
dermatitis. Several case studies are represented here. By adding an active product that nourishes and enhances metabolic
function to our skin protocols we have seen a dramatic improvement in the overall skin health, strength and durability of the
epidermis and demonstrated more resistance to breakdown. Since the fully functioning and mature epithelium is our ultimate
defense, we have found a way to help reduce any compromise to this important organ.
CaseStudy 1DO has had IDDM for over 34 years and has suffered for many yearswith fissured, dry, scaly skin over her elbows, fingers, toes and feet and
knees. She uses an insulin pump and there are no other reported chronicconditions.
7-02-04 Crescentshaped fissure, throughthe upper layersof the epidermis with mildinflammationon the largetoe
7-29-04 Continues to progress andappears to be more durable
9-08-04 Closed
7-02-04 Skin appears dry with smallwound present on the elbow
7-29-04 Continuing to improve
9-08-04
CaseStudy 2JS is a 62 year old male with severe venous hypertension, edema, cellulitisand the tendency to dry; scaling skin. He has had ulcers in the inframalleolar
area on his left foot for over seven years. He has been using appropriatecompression stockings.
6-4-04 Introduced the
Olivamine containingproducts, to moisturizeand help make the skinmore durable.
6-28-04 Legs appear tohave better moisturization,and JS reports that hisskin feels better.
8-25-04 Continuingwiththe skin care regime,theskin continuesto improve.
Case Study 3SN is a 52 year old male who has diabetes, severe vasculopathy and
significant neuropathy, hypertension and presents with recurrent fissuringand severe dryness on both feet. He has a callous on his right first toe thatusually needs shaving at each office visit. The rash on his toes appears tohave a fungal component - we started him on an antifungal cream thatalso contained Olivamine.
6-18-04 Right foot, planter surface,note cal-lous on greater toe
7-09-04 After 21 days of this regime, there ismarked improvement.There has also been adecrease in the need for shaving the callous
6-18-04 Planteraspectof the leftfoot, notethefissuringunderthe 5 th digit.Possiblefungalcom-ponent
7-09-04 The planter aspect of the left foot, lesscracking noted
CaseStudy 4BS is a 57 year old female who survived a traumatic gun shot wound, butsuffered a pelvic fracture and was left paralyzed from the waist downseveral years ago. She has had multiple recurrent ulcers in the rightperivaginal perineal area. She is very involved in her care and takes greatmeasures to decrease any further breakdown while transferring. She hasused moisturizers for several years and when the need arises, she uses anantifungal treatment.
6-11-04 Started Olivamine'product for this fragile, scaly,erythematous perinealskin.
~
~
7-09-03 Approximately one month of
therapy, the erythema has decreased
significantly. After approximately one
month, the patient reported dramatic
improvement to her skin.
8-20-04 The perineal arearemains free of wounds andthe skin appears more resist-ant to breakdown.
References:1. Choung CM, NickoloffB], Elias PM, Goldsmith LA, Macher E, Maderson PA, Sundberg]p,Tagami
H, Plonka PM, Thestrup-Pedersen K, Bernard BA, Schroder ]M, Dotto P, Chang CH, Williams ML,
Feingold KR, King LE, Kligman AM, Rees ]L, Christophers F,What is the true 'function' of skin? ExpDermatol 2002: 11: 159-187.
2. Draelos Z, Therapeutic Moisturizers, Dermatologic Clinics Oct 2000:18:4.
3. Elias PM and Feingold KR. Does the tail wag the dog? Role of the barrier in the pathogensis of
inflammatory dermatoses and therapeutic implications. Arch Dermatol. 2001 Aug; 137(8) 1079-1081.
4. Elias PM, The epidermal permeability barrier: from the early days at Harvard to emerging concepts,] Invest Dermatol 204:233:36-39
5. Ganz T, Epithelia: Not just physical barriers, Proc Natl Adad Sci USA, 2002:99:3357-3358.
6. Hachem], Crumrine D, Fluhr ], Brown B, Feingold K, Elias P,pH directly regulates epidermal
permeability barrier homeostasis, and stratum corneum integrity/cohesion,] Invest Dermatol2003:121:345-353.
7. Kanitakis ], Anatomy, histology and immunohistochemisty of normal human skin, European] ofDermatol 2002:Vol 12: 390-401.
8. Madison K, Barrier function of the skin: "La raison d'Etre" of the epidermis,] Invest Dermatol2003:121:231-241..
9. Rawlings AV,Trends in stratum corneum research and the management of dry skin conditions,International] of Cosmetic Science 2003:25: 63-95.
10. Rippke F,Schreiner V, Schwanitz H, The acidic milieu of the horny layer, Am] Clin Dermatol2002:3:261-272.
11. Tagami H, Kobayashi H, Zhen X, Kikuchi K, Environmental effects on the functions of the stratum
corneum,] ofInvest Dermatol Symp Proc 2001:6:87-94.
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