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Braun C, Coutier L, Bégin P, Nosbaum A. Skin-centered strategies in food allergy prevention. Pediatr Allergy Immunol 2024; 35:e14130. [PMID: 38693814 DOI: 10.1111/pai.14130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/19/2024] [Accepted: 04/03/2024] [Indexed: 05/03/2024]
Abstract
While the early introduction of food allergens in the infant diet has been shown to be effective at preventing the development of food allergy (FA), its implementation in real life has been associated with various challenges. Interventions aimed at correcting skin barrier dysfunction have been explored in recent decades as a distinct or complementary mean to prevent allergic sensitization through the skin and subsequent development of FA. Studies assessing the application of emollient from birth have yielded conflicting results, and meta-analyses have demonstrated either no effect or only a slight positive effect on FA prevention. However, a careful review of the clinical trials reveals that different emollients were used, which may have explained some of the discrepancies between study results. Emollient application protocols also varied widely between studies. While firm conclusions cannot be drawn with regard to their overall efficacy at preventing FA, the available data provide valuable insight into the characteristics that could be associated with a more effective intervention. Namely, successful trials tended to use emollients with an acidic pH of 5.5, applied over the entire body, and combined with topical corticosteroids in affected areas. Consensus on the optimal strategy to restore skin barrier function could help improve the homogeneity and clinical relevance of future trials on this topic. In the meantime, clinicians should avoid products associated with worse outcomes.
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Affiliation(s)
- Camille Braun
- Section of Allergy and Clinical Immunology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Pneumology, Allergy, Cystic Fibrosis, Hôpital Femme Mère Enfant, Bron, France
- Centre International de Recherche en Infectiologie, INSERM U1111, CNRS UMR 5308, Université Lyon 1, Lyon, France
| | - Laurianne Coutier
- Department of Pediatrics, Pneumology, Allergy, Cystic Fibrosis, Hôpital Femme Mère Enfant, Bron, France
- INSERM U1028 CNRS UMR 5292, Université Lyon 1, Lyon, France
| | - Philippe Bégin
- Section of Allergy and Clinical Immunology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
- Department of Medicine, Section of Allergy and Clinical Immunology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Audrey Nosbaum
- Centre International de Recherche en Infectiologie, INSERM U1111, CNRS UMR 5308, Université Lyon 1, Lyon, France
- Department of Allergy and Clinical Immunology, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
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van den Bogaard EH, Elias PM, Goleva E, Berdyshev E, Smits JPH, Danby SG, Cork MJ, Leung DYM. Targeting Skin Barrier Function in Atopic Dermatitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1335-1346. [PMID: 36805053 DOI: 10.1016/j.jaip.2023.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/22/2023]
Abstract
Atopic dermatitis (AD) is the most common chronic inflammatory skin disease in the general population. Skin barrier dysfunction is the central abnormality leading to AD. The cause of skin barrier dysfunction is complex and rooted in genetic mutations, interactions between the immune pathway activation and epithelial cells, altered host defense mechanisms, as well as environmental influences that cause epithelial cell activation and release of alarmins (such as thymic stromal lymphopoietin) that can activate the type 2 immune pathway, including generation of interleukins 4 and 13, which induces defects in the skin barrier and increased allergic inflammation. These inflammatory pathways are further influenced by environmental factors including the microbiome (especially Staphylococcus aureus), air pollution, stress, and other factors. As such, AD is a syndrome involving multiple phenotypes, all of which have in common skin barrier dysfunction as a key contributing factor. Understanding mechanisms leading to skin barrier dysfunction in AD is pointing to the development of new topical and systemic treatments in AD that helps keep skin borders secure and effectively treat the disease.
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Affiliation(s)
- Ellen H van den Bogaard
- Department of Dermatology, Radboud Institute for Molecular Life Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter M Elias
- Department of Dermatology, University of California San Francisco and VA Medical Center, San Francisco, Calif
| | - Elena Goleva
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, National Jewish Health, Denver, Colo
| | - Evgeny Berdyshev
- Department of Pulmonology, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colo
| | - Jos P H Smits
- Department of Dermatology, Radboud Institute for Molecular Life Science, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon G Danby
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School at The University of Sheffield, Beech Hill Road, Sheffield, UK
| | - Michael J Cork
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School at The University of Sheffield, Beech Hill Road, Sheffield, UK
| | - Donald Y M Leung
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, National Jewish Health, Denver, Colo.
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Wen S, Elias PM, Wakefield JS, Mauro TM, Man MQ. The link between cutaneous inflammation and cognitive impairment. J Eur Acad Dermatol Venereol 2022; 36:1705-1712. [PMID: 35748522 PMCID: PMC9481668 DOI: 10.1111/jdv.18360] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/30/2022] [Indexed: 12/01/2022]
Abstract
Cognitive impairment is a symptom of neurological disorders, including dementia and Alzheimer's disease; and mild cognitive impairment can be a precursor of both disorders. Aged humans and animal models with other systemic disorders, such as cardiovascular diseases and diabetes, display a higher incidence of cognitive decline. Epidemiological studies have shown that the incidence of cognitive impairment also is higher in subjects with certain inflammatory skin disorders, including psoriasis and chronic eczematous dermatitis. Chronologically aged individuals exhibit increased cutaneous inflammation and elevated circulating cytokine levels, linked to alterations in epidermal function, which itself can induce cutaneous inflammation. Conversely, strategies that improve epidermal function can lower cytokine levels in both the skin and circulation. Thus, it seems likely that epidermal dysfunction could contribute, at least in part, to the development of chronic low-grade inflammation, also termed 'inflammaging', in the elderly. The evidence of cognitive impairment in patients with inflammatory dermatoses suggests a link between cutaneous inflammation and cognitive impairment. Because of the pathogenic role of epidermal dysfunction in ageing-associated cutaneous inflammation, improvements in epidermal function could be an alternative approach for mitigation of the ageing-associated decline in cognitive function.
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Affiliation(s)
- S Wen
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - P M Elias
- Dermatology Service, Veterans Affairs Medical Center San Francisco, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - J S Wakefield
- Dermatology Service, Veterans Affairs Medical Center San Francisco, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - T M Mauro
- Dermatology Service, Veterans Affairs Medical Center San Francisco, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
| | - M-Q Man
- Dermatology Hospital, Southern Medical University, Guangdong, China
- Dermatology Service, Veterans Affairs Medical Center San Francisco, San Francisco, California, USA
- Department of Dermatology, University of California San Francisco, San Francisco, California, USA
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Wang H, Zhou S, Fan X, Wang Z. Effect of multifunctional laser photoelectricity platform combined with hydroxychloroquine treatment sensitive facial skin. Dermatol Ther 2022; 35:e15795. [PMID: 36038516 DOI: 10.1111/dth.15795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/30/2022] [Accepted: 08/14/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To observe the clinical efficacy of a multifunctional laser photoelectric platform combined with hydroxychloroquine in the treatment of l sensitive facia skin. METHODS A total of 226 patients with sensitive facial skin treated from March 2019 to November 2021 were randomly divided into two groups.Both groups were given an external moisturizer (shumin moisturizer) once in the morning and once in the evening as basic skin care treatment for the disease. The control group received hydroxychloroquine sulfate tablets (0.2 g), twice a day; The observation group was treated with multifunctional laser photoelectric platform combined with hydroxychloroquine orally, and the clinical effects of the two groups were compared. RESULTS The effective rates of the observation group were 48.67%, 73.45% and 93.80% at the first, second and fourth weekend of treatment respectively, which were significantly higher than those of the control group (15.93%, 30.97% and 38.93%, respectively), with statistical significance (P<0.05). CONCLUSION On the basis of skin care with an external moisturizer, using a multifunctional laser photoelectric platform combined with hydroxychloroquine can significantly improve the clinical efficacy of facial sensitive skin, superior to hydroxychloroquine alone, with high safety and worthy of clinical application. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hongyan Wang
- The First Affiliated Hospital of Anhui Medical University
| | - Shuo Zhou
- Skin Source Sensitive Skin repair center,Anhui Hefei, China
| | - Xing Fan
- The First Affiliated Hospital of Anhui Medical University
| | - Zaixing Wang
- The First Affiliated Hospital of Anhui Medical University
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Ryczaj K, Dumycz K, Spiewak R, Feleszko W. Contact allergens in moisturizers in preventative emollient therapy – A systematic review. Clin Transl Allergy 2022; 12:e12150. [PMID: 35677673 PMCID: PMC9168229 DOI: 10.1002/clt2.12150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Results of preventative emollient therapy on atopic dermatitis and food allergy trials are inconsistent. In addition to the ingredients considered beneficial, the moisturizers may contain potentially harmful haptens. This study aimed to assess the prevalence of haptens in moisturizers used in studies to prevent atopic dermatitis or food allergy and assess their correlations to the trial results. Methods A systematic search of studies investigating the role of emollient usage in preventing atopic dermatitis or food allergy in infants was performed from inception to December 2020. Haptens were identified based on the nine common patch test series (European, American, and Australian). Results 12 clinical trial studies were included in the review. In total, 16 different emollients were applied as an intervention. The vast majority (75%) of preparations contained at least one hapten from which several substances pose high allergic or irritant potential. Quantitative data synthesis of the findings regarding food allergy and atopic dermatitis prevention was not possible due to the significant heterogeneity of preparations used. Conclusions Careful selection of emollient should consider the absence of potentially harmful ingredients, particularly when used in youngest children. Chronic skin exposure to haptens promotes the development of allergic contact dermatitis and moreover, via deterioration of the skin barrier and subclinical inflammation, may facilitate epicutaneous sensitization and promote atopic dermatitis; however further research is needed to validate our suppositions.
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Affiliation(s)
- Klaudia Ryczaj
- Department of Pediatric Pneumonology and Allergy Medical University of Warsaw Warsaw Poland
| | - Karolina Dumycz
- Department of Pediatric Pneumonology and Allergy Medical University of Warsaw Warsaw Poland
- Doctoral School Medical University of Warsaw Warsaw Poland
| | - Radoslaw Spiewak
- Department of Experimental Dermatology and Cosmetology Jagiellonian University Medical College Krakow Poland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy Medical University of Warsaw Warsaw Poland
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6
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Elias PM. Optimizing emollient therapy for skin barrier repair in atopic dermatitis. Ann Allergy Asthma Immunol 2022; 128:505-511. [PMID: 35065300 PMCID: PMC9979622 DOI: 10.1016/j.anai.2022.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We compared the principal characteristics of over-the-counter moisturizers with physiological lipid-based barrier repair therapy (BRT). DATA SOURCES An extended literature reported that moisturizers are considered standard ancillary therapy for anti-inflammatory skin disorders such as atopic dermatitis (AD). Additional studies have found that physiological lipid-based BRT can comprise effective, stand-alone therapy for pediatric AD. RESULTS Not all moisturizers are beneficial-some negatively impact skin function, and in doing so, they risk inducing or exacerbating inflammation in patients with AD. The frequent self-reported occurrences of sensitive skin in patients with AD could reflect the potential toxicity of such formulations. A still unanswered question is whether improper formulations could also prove to be counterproductive in other types of sensitive skin, such as rosacea. In contrast, we found how physiological lipid-based BRT (when comprised of the 3 key stratum corneum lipids in sufficient quantities and at an appropriate molar ratio) can correct the barrier abnormality, thereby reducing inflammation in AD and possibly in other inflammatory dermatoses, such as adult eczemas and possibly even psoriasis. CONCLUSION We provide guidelines for the appropriate dispensation of moisturizers and physiological lipid-based, BRT for the treatment of AD. Both over-the-counter (Atopalm) and prescription (EpiCeram) products are available in the United States with these characteristics.
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Affiliation(s)
- Peter M Elias
- Department of Dermatology, University of California (UC) San Francisco and Veteran Affairs (VA) Medical Center, San Francisco, California.
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Ye L, Wang Z, Kim Y, Elias PM, Li T, Wen S, Song J, Lv C, Yang B, Man MQ. A Topical Emollient Mitigates the Progression of Cognitive Impairment in the Elderly: A Randomized, Open-Label Pilot Trial. J Eur Acad Dermatol Venereol 2022; 36:1382-1388. [PMID: 35442543 DOI: 10.1111/jdv.18162] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/21/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cognitive impairment is common in the elderly. Prior studies suggest a link between chronic inflammation and cognitive dysfunction, while aging-associated epidermal dysfunction has been connected to elevations in circulating cytokines. OBJECTIVE We assessed here whether improvements in epidermal function can mitigate the progression of cognitive impairment. METHODS This randomized, open-label pilot trial was carried out in two cities in northern China. A total of 200 participants aged ≥65 years were randomly assigned to the emollient-treated and untreated groups at 1:1 ratio. Participants in the treated group were treated topically with Atopalm cream® twice-daily from November to the following May each year for three consecutive years, while the untreated subjects served as controls. The Global Deterioration Scale (GDS) was used to assess the severity of cognitive impairment, while epidermal biophysical properties were measured on the forearms and the shins in parallel. RESULTS Over the three-year trial, GDS significantly increased from baseline (p<0.0001) in the controls, while in the treated group, GDS stabilized. While stratum corneum hydration on the forearms did not change significantly in the controls, transepidermal water loss rates (TEWL), significantly increased by the end of the trial compared to baselines in the controls (p<0.0001). On the forearms of the treated group, stratum corneum hydration increased (p<0.0001) while skin surface pH decreased from baseline (p<0.0001). CONCLUSIONS These results suggest that improvements in epidermal function with topical emollient can mitigate the progression of cognitive impairment. However, the sample size was relatively small, and trials in a larger cohort are needed to validate the present results.
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Affiliation(s)
- L Ye
- Dermatology Hospital, Southern Medical University, Guangdong, 510091, China
| | - Z Wang
- The 7th People's Hospital of Shenyang, Liaoning, 110003, China
| | - Y Kim
- CRID Center, NeoPharm Co., Ltd., Daejeon, 34037, Republic of Korea
| | - P M Elias
- Department of Dermatology, University of California San Francisco and Veterans Affairs Medical Center, San Francisco, CA, 94121, USA
| | - T Li
- The 7th People's Hospital of Shenyang, Liaoning, 110003, China
| | - S Wen
- Dermatology Hospital, Southern Medical University, Guangdong, 510091, China
| | - J Song
- Department of Dermatology, Dalian Skin Disease Hospital, Liaoning, 116021, China
| | - C Lv
- Department of Dermatology, Dalian Skin Disease Hospital, Liaoning, 116021, China
| | - B Yang
- Dermatology Hospital, Southern Medical University, Guangdong, 510091, China
| | - M Q Man
- Dermatology Hospital, Southern Medical University, Guangdong, 510091, China
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Ripszky Totan A, Greabu M, Stanescu-Spinu II, Imre M, Spinu TC, Miricescu D, Ilinca R, Coculescu EC, Badoiu SC, Coculescu BI, Albu C. The Yin and Yang dualistic features of autophagy in thermal burn wound healing. Int J Immunopathol Pharmacol 2022; 36:3946320221125090. [PMID: 36121435 PMCID: PMC9490459 DOI: 10.1177/03946320221125090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Burn healing should be regarded as a dynamic process consisting of two main, interrelated phases: (a) the inflammatory phase when neutrophils and monocytes infiltrate the injury site, through localized vasodilation and fluid extravasation, and (b) the proliferative-remodeling phase, which represents a key event in wound healing. In the skin, both canonical autophagy (induced by starvation, oxidative stress, and environmental aggressions) and non-canonical or selective autophagy have evolved to play a discrete, but, essential, “housekeeping” role, for homeostasis, immune tolerance, and survival. Experimental data supporting the pro-survival roles of autophagy, highlighting its Yang, luminous and positive feature of this complex but insufficient explored molecular pathway, have been reported. Autophagic cell death describes an “excessive” degradation of important cellular components that are necessary for normal cell function. This deadly molecular mechanism brings to light the darker, concealed, Yin feature of autophagy. Autophagy seems to perform dual, conflicting roles in the angiogenesis context, revealing once again, its Yin–Yang features. Autophagy with its Yin–Yang features remains the shadow player, able to decide quietly whether the cell survives or dies.
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Affiliation(s)
- Alexandra Ripszky Totan
- Department of Biochemistry, 367124Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Maria Greabu
- Department of Biochemistry, 367124Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Iulia-Ioana Stanescu-Spinu
- Department of Biochemistry, 367124Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Marina Imre
- Department of Complete Denture, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Tudor-Claudiu Spinu
- Department of Fixed Prosthodontics and Occlusology, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Daniela Miricescu
- Department of Biochemistry, 367124Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Radu Ilinca
- Department of Biophysics, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Elena Claudia Coculescu
- Department of Oral Pathology, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Romania
| | - Silviu Constantin Badoiu
- Department of Anatomy and Embryology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan-Ioan Coculescu
- Cantacuzino National Medico-Military Institute for Research and Development, Bucharest, Romania
| | - Crenguta Albu
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, Faculty of Dental Medicine, Bucharest, Romania
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Bhargava P, Singdia H, Nijhawan S, Mathur DK, Bhargava RK. A study of biophysical profile of inguinal skin: An implication for health and disease. Indian J Sex Transm Dis AIDS 2021; 42:7-13. [PMID: 34765931 PMCID: PMC8579585 DOI: 10.4103/ijstd.ijstd_101_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 07/28/2020] [Accepted: 10/12/2020] [Indexed: 11/08/2022] Open
Abstract
Context: Inguinal skin is prone to various infectious dermatological conditions such as erythrasma, intertrigo, hidradenitis suppurativa, folliculitis, dermatophytic infection, and various sexually transmitted diseases, as compared to the skin elsewhere. Aim: Our study attempts to compare the biophysical profile parameters (BPPs) of the genital skin with that of the rest of the body, while taking skin of the upper back as control. It also attempts to find out if there is a difference in BPPs of the two sites and that how the change in the BPPs, bring about change in microbiome and make inguinal skin more prone to infections. Materials and Methods: This was a hospital-based comparative study conducted over 976 patients (600 males and 376 females) of age group 18–60 years, where BPP parameters such as hydration, skin pH, transepidermal water loss (TEWL), and sebum content were measured over the skin of the upper back and right inguinal region, and the results were summarized and presented as proportions (%). Chi-square test was used to compare abnormal findings. P ≤ 0.05 was taken as statistically significant. MedCalc 16.4 version software was used for all statistical calculations. Results: Significant difference was noted in skin pH and TEWL, where P value came out to be <0.05, which was statistically significant, whereas there was minimal difference in sebum content and skin hydration in both the areas, in males and females. Conclusion: Raised skin pH disturbs organization of lipid bilayers (disturbed barrier), decreases lipid processing (impaired SC cohesion), and increases serine protease activity (reduced AMP). Increased TEWL (defect in physical barrier) and decreased hydration predispose the genital skin to infections. Use of pH buffered solutions (3–4), barrier repair creams containing ceramides, and barrier protective creams with dimethicone can help prevent these inguinal dermatoses.
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Affiliation(s)
- Puneet Bhargava
- Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
| | - Heena Singdia
- Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
| | - Shivi Nijhawan
- Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
| | - Deepak K Mathur
- Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
| | - Rishi K Bhargava
- Department of Dermatology, SMS Medical College, Jaipur, Rajasthan, India
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Guo JW, Jee SH. Strategies to Develop a Suitable Formulation for Inflammatory Skin Disease Treatment. Int J Mol Sci 2021; 22:ijms22116078. [PMID: 34199951 PMCID: PMC8200229 DOI: 10.3390/ijms22116078] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 12/16/2022] Open
Abstract
Skin barrier functions, environmental insults, and genetic backgrounds are intricately linked and form the basis of common inflammatory skin disorders, such as atopic dermatitis, psoriasis, and seborrheic dermatitis, which may seriously affect one’s quality of life. Topical therapy is usually the first line of management. It is believed that successful topical treatment requires pharmaceutical formulation from a sufficient dosage to exert therapeutic effects by penetrating the stratum corneum and then diffusing to the target area. However, many factors can affect this process including the physicochemical properties of the active compound, the composition of the formulation base, and the limitations and conditions of the skin barrier, especially in inflammatory skin. This article briefly reviews the available data on these issues and provides opinions on strategies to develop a suitable formulation for inflammatory skin disease treatment.
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Affiliation(s)
- Jiun-Wen Guo
- Department of Medical Research, Cathay General Hospital, Taipei 10630, Taiwan
- Program in Pharmaceutical Biotechnology, College of Medicine, Fu Jen Catholic University, New Taipei City 24205, Taiwan
- Correspondence: ; Tel.: +886-2864-61500 (ext. 2327)
| | - Shiou-Hwa Jee
- Department of Dermatology, Cathay General Hospital, Taipei 10630, Taiwan;
- Department of Dermatology, College of Medicine, National Taiwan University, Taipei 10617, Taiwan
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11
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Chen L, Zheng J. Does sensitive skin represent a skin condition or manifestations of other disorders? J Cosmet Dermatol 2020; 20:2058-2061. [PMID: 33159415 PMCID: PMC8359429 DOI: 10.1111/jocd.13829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/28/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022]
Abstract
Sensitive skin or cutaneous sensory syndrome is defined as a skin condition that is hypersensitive to stimuli, presented with itching, irritant, erythema, and dryness. However, is it associated with more than impairment of epidermal functions, psychological stress and topical medication or products? We think that it can be a skin condition or manifestation of other cutaneous or extracutaneous disorders. In this paper, we brief relation of sensitive skin syndrome with cutaneous and extracutaneous disorders, clinically, and pathophysiologically.
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Affiliation(s)
- Lihong Chen
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Zheng
- Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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12
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Aging-associated alterations in epidermal function and their clinical significance. Aging (Albany NY) 2020; 12:5551-5565. [PMID: 32217811 PMCID: PMC7138575 DOI: 10.18632/aging.102946] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/10/2020] [Indexed: 12/11/2022]
Abstract
Chronologically-aged skin displays multiple functional changes in both the dermis and the epidermis. It appears that epidermal dysfunction, compromised permeability homeostasis, reduced stratum corneum hydration and elevated skin surface pH predispose to the development of aging-associated cutaneous and extracutaneous disorders. Improvements in epidermal function have been shown to be an effective alternative therapy in the prevention and treatment of some aging-associated cutaneous disorders, including eczematous dermatitis, pruritus, and xerosis. Recent studies demonstrated that epidermal dysfunction leads to the development of chronic, low-grade systemic inflammation, termed ‘inflammaging,’ which is linked to the development of aging-associated systemic disorders. Thus, correction of epidermal dysfunction could comprise a novel strategy in the prevention and treatment of aging-associated systemic disorders as well. In this review, we summarize aging-associated alterations in epidermal function, their underlying mechanisms, and their clinical significance. Regimens to improve epidermal function in the elderly are also discussed.
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13
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Liu D, Wen S, Huang LN, Wang X, Gong CY, Li Z, Wang H, Elias PM, Yang B, Man MQ. Comparison of transepidermal water loss rates in subjects with skin patch test positive vs negative to skin care products. J Cosmet Dermatol 2019; 19:2021-2024. [PMID: 31846195 DOI: 10.1111/jocd.13264] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adverse cutaneous reactions to skin care products (SCP) are becoming increasingly common and may be indicative of defective permeability barrier function. AIM To determine the differences in transepidermal water loss rates (TEWL) between skin patch positive vs negative to skin care products in normal Chinese females. METHODS Skin patch test reactions to nine skin care products were assessed in 65 normal Chinese females. Correlations of cutaneous reactions to a panel of nine foreign and domestic SCP with permeability barrier function and stratum corneum (SC) hydration levels were analyzed. RESULTS Out of 65 subjects, 24 (37%) displayed positive reactions to one or more SCP. However, the occurrence of positive reactions to patch tests did not correlate with either transepidermal water loss rates or SC hydration levels. CONCLUSIONS Though a substantial proportion of normal females display adverse reactions to SCP, this problem cannot be attributed to differences in the qualities of their epidermal permeability barriers, and therefore, these reactions more likely reflect the potential adverse events of the SCP themselves. However, further studies in large cohort of both males and females would be helpful to ascertain whether TEWL levels can predict cutaneous reactions to SCP.
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Affiliation(s)
- Dan Liu
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Si Wen
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Li-Ning Huang
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Xiaohua Wang
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Can-Yi Gong
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Zhiping Li
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Hui Wang
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Peter M Elias
- Dermatology Services, Veterans Affairs Medical Center and University of California San Francisco, San Francisco, CA, USA
| | - Bin Yang
- Dermatology Hospital, Southern Medical University, Guangdong, China
| | - Mao-Qiang Man
- Dermatology Hospital, Southern Medical University, Guangdong, China
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14
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Lee YB, Ahn SK, Ahn GY, Bak H, Hong SP, Go EJ, Park CO, Lee SE, Lee WJ, Ko HC, Lee JB, Kim HJ, Park K, Lee SH, Song DH, Choi SY, Sung YO, Kim TH, Goo JW. Baumann Skin Type in the Korean Male Population. Ann Dermatol 2019; 31:621-630. [PMID: 33911661 PMCID: PMC7992607 DOI: 10.5021/ad.2019.31.6.621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/09/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Background Research into the Baumann skin type (BST) has recently expanded, with growing interest in the development of an efficient and effective skin type classification system for better understanding of this skin condition. Objective We aimed to identify male-specific skin type characteristics with investigation into the distribution of BST by age and region in the Korean male population and to determine the intrinsic and extrinsic factors related to skin type. Methods A questionnaire was administered to collect information about age, region, working behavior, drinking behavior, smoking behavior, usual habit of sun protection, medical history, and the BST which consisted of four parameters; oily (O) or dry (D), sensitive (S) or resistant (R), pigmented (P) or non-pigmented (N), and wrinkled (W) or tight (T). Results We surveyed 1,000 Korean males aged between 20 and 60 years who were divided equally by age and region. Of the total respondents, OSNW type accounted for the largest percentage and ORPW type the lowest. In terms of Baumann parameters, O type was 53.5%, S type was 56.1%, N type was 84.4% and W type was 57.5%. Several behavioral factors were found to have various relationships with the skin type. Conclusion The predominant skin type in the Korean male respondents was OSNW type, and the distribution of skin types with regards to age and region was reported to be distinct. Therefore, skin care should be customized based on detailed skin types considering the various environmental factors.
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Affiliation(s)
- Young Bin Lee
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Ku Ahn
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Gun Young Ahn
- Chungdam Gowoonsesang, Dr. G Dermatology Clinic, Seoul, Korea
| | - Hana Bak
- Chungdam Hana Dermatolgic Clinic, Seoul, Korea
| | - Seung Phil Hong
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eun Jung Go
- Department of Dermatology, National Police Hospital, Seoul, Korea
| | - Chang Ook Park
- Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Dermatology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Weon Ju Lee
- Department of Dermatology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
| | - Jee-Bum Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | | | - Kun Park
- Department of Dermatology, Wonkwang University School of Medicine, Iksan, Korea
| | - Sang-Hoon Lee
- Department of Dermatology, Soonchunhyang University College of Medicine, Seoul, Korea
| | | | - Sun Young Choi
- Deparment of Dermatology, Inje University Seoul Paik Hospital, Seoul, Korea
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15
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Assessment of Skin Physiology Change and Safety After Intradermal Injections With Botulinum Toxin: A Randomized, Double-Blind, Placebo-Controlled, Split-Face Pilot Study in Rosacea Patients With Facial Erythema. Dermatol Surg 2019; 45:1155-1162. [DOI: 10.1097/dss.0000000000001819] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Ding DM, Tu Y, Man MQ, Wu WJ, Lu FY, Li X, Li Y, Yang JT, Jin YM, Yang CY, He L. Association between lactic acid sting test scores, self-assessed sensitive skin scores and biophysical properties in Chinese females. Int J Cosmet Sci 2019; 41:398-404. [PMID: 31194883 PMCID: PMC6851893 DOI: 10.1111/ics.12550] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
Abstract
Background Lactic acid sting test (LAST) is a classical method to identify sensitive skin. However, some subjects with self‐perceived sensitive skin are negative for LAST. Objective To determine whether LAST scores are associated with specific phenotype of sensitive skin. Methods A total of 292 subjects with self‐perceived sensitive skin were enrolled in this study. The Sensitive Scale was used to evaluate the severity of burning, stinging, itching, tautness, erythema and scaling based on 0–10 scale scores. In addition to the assessment of LAST scores, epidermal biophysical properties were measured using an MPA system. Results The Sensitive Scale scores of stinging, itching, tautness and scaling were significantly different between the LAST‐positive and ‐negative groups. However, burning and erythema scores did not differ between the LAST‐positive and ‐negative groups. LAST scores were positively correlated with the Sensitive Scale scores for stinging, itching, tautness and scaling, but not for burning and erythema scores. Moreover, LAST scores negatively correlated with stratum corneum hydration, but positively with transepidermal water loss (TEWL) rates. Conclusions Lactic acid sting test scores positively correlated with TEWL rates. LAST scores could be used to identify subjects with sensitive skin characterized mainly by stinging and itching, but not those mainly by burning and erythema.
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Affiliation(s)
- D-M Ding
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - Y Tu
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - M-Q Man
- Dermatology Service, Veterans Affairs Medical Center, San Francisco, CA, 94121, USA.,Department of Dermatology, University of California, San Francisco, CA, 94121, USA
| | - W-J Wu
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - F-Y Lu
- Qujing Affiliated Hospital of Kunming Medical University, Qujing, 655000, China.,Department of Dermatology, The First People's Hospital of Qujing, Qujing, 655000, China
| | - X Li
- Department of Dermatology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, 675000, China
| | - Y Li
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - J-T Yang
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - Y-M Jin
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - C-Y Yang
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - L He
- Department of Dermatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
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17
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Huang LN, Zhong YP, Liu D, Wang XH, Gong CY, Wen S, Elias PM, Yang B, Man MQ. Adverse cutaneous reactions to skin care products on the face vary with age, but not with sex. Contact Dermatitis 2018; 79:365-369. [PMID: 30206954 PMCID: PMC6234074 DOI: 10.1111/cod.13102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/20/2018] [Accepted: 07/22/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adverse skin reactions to skin care products have been increasing in recent years. However, to date, these reactions have not been well characterized. OBJECTIVE To describe the symptoms, clinical signs and frequency of adverse cutaneous reactions to skin care products on the face in males vs females of various ages. PATIENTS AND METHODS All outpatients diagnosed with adverse cutaneous reactions to skin care products on the face examined by dermatologists at the Dermatology Hospital of South Medical University between November 1, 2016 and October 31, 2017, employing a questionnaire and an interview, were eligible. The associations of adverse cutaneous reactions with age and sex were analysed. RESULTS A total of 433 outpatients, accounting for 0.12% of all outpatients, were assessed. Of these, 223 patients, including 204 females and 19 males, aged 4 to 75 years, were eventually diagnosed with adverse reactions to skin care products on the face. Eighty-two per cent of patients experienced pruritus, 80% showed erythema, and 48% showed visible swelling. The incidence rates of both xerosis and oedema correlated positively with age, whereas acne-like lesions were negatively associated with age, but not with sex. CONCLUSIONS Our results indicate that pruritus, xerosis and erythema are common adverse cutaneous reactions to facial skin care products. These reactions vary with age, but not with sex. Vigorous safety testing should precede the marketing of skin care products.
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Affiliation(s)
- Li-ning Huang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Yi-ping Zhong
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Dan Liu
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Xiao-hua Wang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Can-yi Gong
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Si Wen
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Peter M. Elias
- Dermatology Services, Veterans Affairs Medical Center and University of California San Francisco, California
| | - Bin Yang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Mao-Qiang Man
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
- Dermatology Services, Veterans Affairs Medical Center and University of California San Francisco, California
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18
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Elias PM, Wakefield JS, Man MQ. Moisturizers versus Current and Next-Generation Barrier Repair Therapy for the Management of Atopic Dermatitis. Skin Pharmacol Physiol 2018; 32:1-7. [PMID: 30336483 DOI: 10.1159/000493641] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/10/2018] [Indexed: 11/19/2022]
Abstract
We compare here the principal characteristics of over-the-counter moisturizers with physiologic lipid-based barrier repair therapy. Moisturizers are standard ancillary therapy for anti-inflammatory skin disorders, like atopic dermatitis (AD), and can attenuate the emergence of AD, the initial step in the "atopic march." But not all moisturizers are beneficial; some can make skin function worse, and can even induce inflammation, possibly accounting for the frequent occurrence of "sensitive skin" in women. In contrast, physiologic lipid-based barrier repair therapy, if comprised of the 3 key stratum corneum lipids, in sufficient quantities and at an appropriate molar ratio, can correct the barrier abnormality and reduce inflammation in AD, and perhaps in other inflammatory dermatoses.
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19
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Elias PM, Sugarman J. Does moisturizing the skin equate with barrier repair therapy? Ann Allergy Asthma Immunol 2018; 121:653-656.e2. [PMID: 30009880 DOI: 10.1016/j.anai.2018.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/02/2018] [Accepted: 07/04/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Peter M Elias
- Department of Dermatology, UC San Francisco and VA Medical Center, San Francisco, California.
| | - Jeffrey Sugarman
- Associate Clinical Professor, Dermatology and Family Medicine, UC San Francisco, California
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20
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Sil P, Wong SW, Martinez J. More Than Skin Deep: Autophagy Is Vital for Skin Barrier Function. Front Immunol 2018; 9:1376. [PMID: 29988591 PMCID: PMC6026682 DOI: 10.3389/fimmu.2018.01376] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/04/2018] [Indexed: 12/30/2022] Open
Abstract
The skin is a highly organized first line of defense that stretches up to 1.8 m2 and is home to more than a million commensal bacteria. The microenvironment of skin is driven by factors such as pH, temperature, moisture, sebum level, oxidative stress, diet, resident immune cells, and infectious exposure. The skin has a high turnover of cells as it continually bares itself to environmental stresses. Notwithstanding these limitations, it has devised strategies to adapt as a nutrient-scarce site. To perform its protective function efficiently, it relies on mechanisms to continuously remove dead cells without alarming the immune system, actively purging the dying/senescent cells by immunotolerant efferocytosis. Both canonical (starvation-induced, reactive oxygen species, stress, and environmental insults) and non-canonical (selective) autophagy in the skin have evolved to perform astute due-diligence and housekeeping in a quiescent fashion for survival, cellular functioning, homeostasis, and immune tolerance. The autophagic “homeostatic rheostat” works tirelessly to uphold the delicate balance in immunoregulation and tolerance. If this equilibrium is upset, the immune system can wreak havoc and initiate pathogenesis. Out of all the organs, the skin remains under-studied in the context of autophagy. Here, we touch upon some of the salient features of autophagy active in the skin.
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Affiliation(s)
- Payel Sil
- Immunity, Inflammation, and Disease Laboratory, National Institute of Environmental Health Sciences, Durham, NC, United States
| | - Sing-Wai Wong
- Immunity, Inflammation, and Disease Laboratory, National Institute of Environmental Health Sciences, Durham, NC, United States.,Oral and Craniofacial Biomedicine Curriculum, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jennifer Martinez
- Immunity, Inflammation, and Disease Laboratory, National Institute of Environmental Health Sciences, Durham, NC, United States
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21
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Chen SY, Yin J, Wang XM, Liu YQ, Gao YR, Liu XP. A new discussion of the cutaneous vascular reactivity in sensitive skin: A sub-group of SS? Skin Res Technol 2018; 24:432-439. [PMID: 29396896 DOI: 10.1111/srt.12446] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sensitive skin (SS) seems not to be a one-dimensional condition and many scholars concentrate on skin barrier disruption or sensorineural change, but few focus on its increased vascular reactivity. This study explored the possibility of using the different selection methods and measurement methods to verify a high vascular reactivity in SS without an impaired cutaneous barrier function. METHODS Sixty "self-perceived sensitive skin" volunteers were enlisted and each one completed three kinds of screening tests: assess cutaneous sensory using questionnaire survey and Lactic Acid Sting Test (LAST); assess barrier function using Sodium lauryl sulphate (SLS) skin irritation test and assess cutaneous vascular reactivity using 98% DMSO test and non-invasive measurement. Volunteers were divided into different groups based on response to SLS. The DMSO clinical score and the biophysical parameters obtained by non-invasive measurement were subsequently analysed. RESULTS (1) The positive correlations could be seen between sum LAST score and sum DMSO score regardless of the observation time; (2) The biological parameters (CBF、a*values and L* values) are all keeping with DMSO score; (3) If the participants were divided into SLS reactors and non-reactors, a composition ratio of DMSO score was significant difference in these two groups and in SLS non-reactors, there were still seven participants showed high reaction to DMSO. CONCLUSIONS There is a sub-group of SS for characteristics of a high vascular reactivity without an impaired cutaneous barrier function. The DMSO test and novel non-invasive measurements which are conducive to assess cutaneous vascular reactivity, combined with SLS skin irritation test could help us to screen this kind of SS.
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Affiliation(s)
- S Y Chen
- Dermatology Department, ChengFei Hospital, Chengdu, China
| | - J Yin
- Nephrology Department, The third people's Hospital of Chenddu, The Affiliated Hospital of Xinan Jiaotong University, Chengdu, China
| | - X M Wang
- Skin & Cosmetic Research Department, Shanghai Skin Disease Hospital, Shanghai, China
| | - Y Q Liu
- Dermatology Department, The Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Y R Gao
- Skin & Cosmetic Research Department, Shanghai Skin Disease Hospital, Shanghai, China
| | - X P Liu
- Skin & Cosmetic Research Department, Shanghai Skin Disease Hospital, Shanghai, China
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