ASCSG’s Newsletter Volume I no. 1
Winter 2008

What’s new in Dermatology?

New targeted therapeutic strategies for a common and problematic skin ailment.

During the past few years, two new products (Protopic™ ointment and Elidel™ cream) have been launched for the treatment of atopic dermatitis (eczema), both of which are non-steroidal agents (as opposed to topical steroid or cortisone creams). These products have a targeted effect on specific immune reactions of the skin which function abnormally in patients suffering with atopic dermatitis (eczema).

These new “Topical ImmunoModulators” (or T.I.M.s) are a revolutionary change in the therapy of this condition, and will soon become a part of the armamentarium in treating a number of inflammatory skin diseases: not only eczema but certainly psoriasis and potentially others as well. The emergence of these agents represents a new dawn. Through our increased understanding of the immune mechanisms involved in these diseases, we can now more accurately target therapies against more specific abnormal or adverse events taking place in the disease process. This means effective therapies without unnecessary side effects.

Aesthetic Services Corner:

• As always, you are entitled to a complimentary skin care consultation by one of our licensed aestheticians.

Our quarterly article:

Skin Moisturizers: What They Do and How to Choose and Use Them

When we were babies, our skin had more natural moisture than it will ever have at any other time in our lives. As we get older, keeping skin well-hydrated is probably the single most important thing we can do to keep it looking young and healthy. Unfortunately, chronic ultraviolet irradiation and chronic sun damage ( photoaging and photodamage), environmental factors (such as exposure to water, detergents, solvents, etc.), genetic factors and various skin disorders, all serve to rob the skin of needed moisture. In fact, the basic and necessary act of routine cleansing is, in itself, a major contributor to dry skin. Your best defense is adequate sun protection, good health practices and the use of a moisturizer.

If you think water is a moisturizer . . . you’re right

Water is a moisturizer, but only when it is stopped from evaporating off of the surface of the skin. Applying a skin moisturizer can do that. Simply put, a moisturizer is a product designed to restore and maintain optimum hydration of the stratum corneum, the outermost layer of compacted dead skin cells (called corneocytes) which are continually replenished by the outer layer of cells that comprise living skin, called the epidermis.

Basically, there are only two ways in which a moisturizer can optimally hydrate the stratum corneum:

1. By increasing the water-holding capacity of the stratum corneum through the topical application of ingredients known as humectants. These serve to replace – and in some cases replenish - compounds such as lactic acid, urea, various salts and amino acids derived from the degradation of the skin protein called filaggrin, which naturally, collectively form a mixture, in conjunction with these flattened corneocytes on the skin’s surface. (Interestingly, some of the most well-known humectants are in fact these very molecules just mentioned, such as lactic acid and urea.)

2. The second way is to trap water in the stratum corneum by depositing an impermeable layer of water-insoluble material on the skin surface (such as Vaseline™ or other oily petroleum-based products - also known as occlusives. These mimic the effect of the natural lipid layers of the skin surface, which restrict evaporation of water from the surface and seal in the natural humectants.

Emollients are similar to occlusives, but because they are derived mainly from vegetable and animal oils, as well as from lipids other than petrolatum, they are less greasy and therefore more appealing. Unfortunately, they are also less effective in sealing the stratum corneum. (Oils and lipids are used interchangeably in the cosmetic manufacturing business. The words “Oil and “emollient” are most commonly used on product packaging, as opposed to “fat” and “lipid” which purely from a consumer marketing standpoint, carry a more negative connotation.) Moisturizing products generally combine oils and lipids with water. This mixture is then stabilized through the addition of emulsifiers (similar to keeping a salad dressing – which has both oil and water soluble components – mixed). The further addition of humectants to such an emulsion can enhance the effectiveness of the moisturizer.

In summary, moisturizers create a film-like barrier between your skin and the air, thus slowing the evaporation process and keeping the epidermis hydrated and slightly thickened or plumped up, relative to its dehydrated state. Consistently using a good quality emollient moisturizer helps skin retain water within the epidermis making the skin more “plump” which results in the appearance of fewer fine lines and creases.

Moisture and sun exposure

Skin loses moisture and also elasticity from many factors, most notably chronic sun exposure. Dermatologists estimate that 90% of wrinkles, fine lines and age spots are in fact evidence of the sun’s damaging effects. Skin can become dehydrated and additionally damaged by sun exposure from everyday walking or driving down the street as well as from deliberate tanning. A broad-spectrum sunscreen with a minimum SPF of 15 and a built-in moisturizer (or a moisturizer with a built-in broad-spectrum sunscreen) protects skin from ultraviolet light A and B (UVA/UVB) and helps it retain moisture at the same time. Finding a daily moisturizer for the face with this dual action is the ideal approach to protecting one’s skin.

The vitamin connection
Vitamins are now seen more commonly as additives to moisturizers. Some of the more notable ones are briefly discussed below but this list will continue to grow as more and more nutritional additives are found to have potential beneficial effects on the skin.

Topical Vitamin C, or ascorbic acid, is becoming an increasingly popular moisturizer ingredient. Vitamin C acts as an antioxidant and is considered essential in wound healing because it helps maintain the elasticity and the integrity of the extracellular matrix (that’s substances called glycosaminoglycans and mucopolysaccharides which are the “mortar essentially “bricks” that closely associate with the “mortar”. Topically applied, Vitamin C can firm the skin, as well as reduce fine lines and wrinkles. It may also lessen the severity of sunburns because of it’s anti-inflammatory properties that degrade and eliminate histamine. Current research indicates that vitamin E, another antioxidant, may have anti-inflammatory effects on the skin when topically applied. Panthenol, the alcohol form of vitamin B5 that has long been used topically in shampoos is now being tested for efficacy on the skin. Vitamin A derivatives are a family of natural and synthetic derivatives collectively known as retinoids, that when applied topically, can reduce skin wrinkling and roughness. They can also decrease the blotchy pigmentation and appearance of atypical cells in the epidermis that results from chronic sun exposure. Retinoids have also demonstrated effects in the deeper layers of the skin, the dermis, by stimulating new collagen formation and increasing new blood vessel formation.

Choosing an appropriate moisturizer
People with oily skin and/or acne should avoid using moisturizers that can clog pores (follicular plugging) causing white heads and black heads (comedogenesis). Many emollients (e.g., octyl stearate, isocetyl stearate ) occlusives ( e.g., mineral oil, petrolatum, various vegetable oils such as sesame or jojaba oil, cocoa butter ) detergents (e.g., sodium lauryl sulfate) and some emulsifiers can exacerbate such problems, but remember: just because a product is not labeled non-comedogenic doesn’t necessarily mean it will result in the production of comedones in a particular patient. That is, by way of example some patients can use products containing cocoa butter and never experience such a problem. However, those patients who are prone to acne should be aware of the potential of such comedogenic substances to cause such problems and to be prepared for some trial and error before settling on an appropriate product. Similarly, people with tendencies to develop acne should likewise be cautious when using cleansers and certain moisturizing soaps, which may leave an oily film. Though the phrase “oil-free” on a label usually means the product doesn’t contain oil, it may contain other ingredients that act like oils and are equally likely to encourage breakouts. You should be aware that some products labeled oil-free actually contain silicone oils. Moisturizers claiming to be “Oil-controlling” often contain talc and clay, which absorb sebum and natural oils on the skin surface, in addition to other ingredients that moisturize.

Some moisturizing products may actually be acnegenic as opposed to comedogenic. These appear to cause acne papules and pustules, as opposed to whiteheads and blackheads, as a result of follicular irritation rather than follicular plugging. Substances that are acnegenic are not necessarily comedogenic, and vice versa. Unfortunately, listing substances that are acnegenic is fruitless since it appears that it is the interaction of these substances, as well as their concentration, that is critical in the production of follicular irritation. In general, moisturizers are less likely culprits in acnegenicity, as opposed to cosmetics, which are the most common cause. Still, overall, the cosmetic industry has minimized this risk for most users of cosmetics and the incidence of comedogenicity and acnegenicity in both moisturizers and cosmetics is rare.

Oily skin often responds well to moisturizers containing an alpha- or beta-hydroxy acid (AHA or BHA) that exfoliate the dead skin cells and increase cellular turnover. The exfoliation caused by AHAs and BHAs also increase the penetration ability of moisturizers. In acne-prone skin, this exfoliating action also dislodges comedones and prevents their formation. Since the advent of AHA-containing moisturizing creams and lotions in 1992, no other cosmetic ingredient has produced the overwhelming consumer response and the clinical evidence seen with glycolic acid; studies have shown a reduction in fine lines, wrinkles, enlarged pores, uneven pigmentation and an improvement in skin texture and luminosity (radiance). All AHA and BHA moisturizers should be kept away from the eyes and used in combination with a sunscreen, as exfoliating the dead outer cells makes skin more vulnerable to UV rays.

For dry skin, humectants or moisturizers with more oil than water are recommended. The higher the concentration of humectants and emollient oils in a given product, the more effective is the moisturizer, in general. However, the marketplace has now responded to a demand for more light, elegant and esthetically pleasing products, which, in general, contain lower concentrations of these substances. Remember: the greater the concentration of humectants and emollients, the more effective the moisturizer is.

As already mentioned, other ingredients effective in treating treat dry skin are alpha-hydroxy acids (glycolic acid, lactic acid, etc.), urea, mineral oil, stearic acid, propylene glycol and glycerin. Those with dry skin should avoid using deodorant or antibacterial soaps because they can worsen dryness. Soaps that are mildly moisturizing are best for general use as they do an adequate job of cleansing without stripping the skin of its natural oils. Whatever kind of soap is used must be completely rinsed off or the resulting residue can dry the skin and attract dirt.

Moisturizing safely
There are certain instances and medical conditions that contraindicate using moisturizers, at least without a physician’s approval. A skin infection or irritation, with particular emphasis on those associated with diabetes or poor circulation, are situations that call for physician review prior to purchasing and using a moisturizer. In addition, moisturizers should never be ingested or applied to infected or lacerated skin.

For related information see our article on Xerosis (Dry Skin) in our Newsletter:

“Tis the season of dry skin”

The information in this article should not be used as a substitute for medical diagnosis, advice or treatment. For specific situations, consult with your doctor or health care professional.