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 Skin Care Revisited

 The Basic Function of Skin

The skin is our protective barrier against the outside world. As the largest organ in the body, the skin is also a signal of our overall health. This organ represents a highly complex system of regulation and protection. It serves to protect our body's systems from microorganisms and chemicals, yet it maintains a flexible network of gateways to transfer wastes and essential nutrients. The skin is composed of two distinct layers: the epidermis and the dermis.

The epidermis is the outermost layer of skin, comprised of sublayers called strata. The epidermis does not contain blood vessels, as its primary responsibilities are protection and regulation of temperature. The stratum corneum comprises the topmost layer of skin and is composed primarily of dead cells. These dead cells provide living tissue with a measure of UV protection. In the interior epidermis, living cells grow in organized layers, eventually flattening and pushing up to the top. The epidermis produces new tissue at a very fast rate, regenerating itself completely approximately every four weeks. Of the cells produced in the epidermis, there are three main types: keratinocytes, melanocytes, and Langerhans cells.

•  Keratinocytes contain protein, which can then provide structure and protection to the skin.
•  Melanocytes produce pigment (melanin) when stimulated by external elements such as sunlight (UV rays).
•  Langerhans cells stimulate immune response and healing, providing the first line of detection for injury and infection.

The dermis contains blood vessels, nerves, hair follicles, sweat glands, oil glands, and structural tissue (elastin and collagen). The dermal layer is the more active layer, responsive to various forms of external stimuli, such as temperature. Key biologic functions such as cellular regeneration and tissue repair take place in the dermis before transfering to the epidermis. Medications and agents that can penetrate the epidermis are absorbed in the dermal layer. The glands and follicles present in the dermis extend to the epidermis through pores. This connection forms the acid mantle, essential for proper functioning of the protective barrier.

A structural matrix composed of protein (collagen and elastin) provides volume, flexibility, and cushioning for skin tissue. This underlying structure in the skin helps to support a person's unique facial features as they evolve with maturity. Collagen and elastin are continuously maintained by the body and are also present in large quantities in cartilage, joints, and other connective tissue. Because the skin is the largest and outmost organ of the body, deficiencies in nutrients and biologic factors can rapidly affect structural maintenance, and such deficiencies can then be compounded by the progressive effects of the environment on the skin. A weakened or impaired structural matrix can affect the skin's texture and tone resulting in wrinkles, folds, improperly healed scar tissue, and areas of sagging or loose skin.

The Hydrolipidic Layer, or Acid Mantle
Sweat and oil (sebum) produced in the dermis combine to form a protective barrier on the surface of the skin, called the acid mantle, or hydrolipidic layer. The acid mantle is maintained at a pH between 4.5 and 5.5 to combat and neutralize the effects of alkaline substances that may invade through the skin to cause infection (environmental agents are typically alkaline in nature). The mixture of sweat and oil are also useful in providing a protective barrier against temperature and wind. The low pH of the acid mantle inhibits the growth of bacteria and fungi that may be present on the surface of the skin and neutralizes foreign chemicals before they can damage the epidermis.

External Factors
The synthesis of collagen and elastin is maintained through a system of degradation and regeneration to replace older cells with new ones. Matrix metalloproteinases (MMPs) and free radicals affect the synthesis of collagen and elastin, interfering with cellular synthesis to maintain balance and restrict overproduction. However, environmental factors such as ultraviolet (UV) rays can affect this delicate balance by stimulating the production of free radicals and MMPs, which in turn block collagen and elastin synthesis and lead to structural breakdown and disrepair within the dermal layer. Luckily, changes to the structure and health of the skin are eventually visible to the naked eye and an indication of the impact of environmental stresses to the body and its proper biologic function. If caught early on, the impact of various external factors on the skin can be mitigated with behavioral changes and treatment.

UVB rays also stimulate the production of melanin in the epidermis. Melanin is a brown pigment that acts like a natural sunscreen, forming a barrier that protects the dermis by converting potentially harmful free radicals into energy that can be used by the body. Melanin is present in the epidermal layer, so over time, the pigmented cells are shed. However, continued or prolonged exposure to sunlight can overwhelm this natural protective process and impair the normal cellular cycle in the epidermis, ultimately leading to the impairment of the essential biologic processes of the dermis.

Biologic processes normally decrease with age and result in the reduced availability of key biologic components required to maintain a high level of cell growth. Supplements such as vitamins can replenish certain biologic components to promote proper function. However, supplements cannot counteract environmental factors such as smoking, sunlight, and chemicals. These factors can impair proper function by competing for biologic components or by stimulating the production of proteins that inhibit or degrade already limited factors, thereby effecting premature aging.

As the first layer of protection against the outside world, the skin is not only the bellwether of health, but a weakened or impaired skin structure is more prone to infection and disease. Once the functions of the acid mantle, epidermis, and dermis are compromised, infection can infiltrate and disease can proliferate. Exposure or injury can temporarily weaken areas of the skin. The epidermis and the dermis trigger the immune system, which repairs infected areas and prevents the spread of the invading agent.

Hydration and moisture are essential for all normal biologic activity, and healthy levels keep the body's pathways running at optimal levels: nutrients and supplements are transferred to cells in a hydrated environment; matrix turgidity and resiliency in the skin are maintained with proper hydration. Dehydrating factors can be internal (i.e., not enough water intake) or external, such as sunlight or chemicals, either of which can draw water from tissues. Without proper hydration, the process of cellular generation in the skin still continues, however, impaired. Fortunately, hydration can be improved and corrected both internally and externally: moisturizing and hydrating agents can be applied topically to promote a hydrated environment for proper cell function and repair; and removing or reducing the environmental causes of dehydration can support an improvement in health.

 The Elements of Effective Skin Care

The primary purpose of skin care is to clear away the effects of the environment to support normal epidermal function. Basic skin care is generally regarded as cleansing, however, cleansing alone is not enough to address even the superficial damage already caused by the environment.

Clean Skin Maintenance
The foundations of proper skin care comprise the removal of environmental agents and the accretion of the skin's natural biologic condition. These foundations include superficial and/or deep cleansing, moisturization, and protection. Optimized skin care expands on these basics to treat specific disorders and restore healthy skin function.

Soaps and washes serve to reduce buildup of dead skin and remove biologic and environmental agents that can affect the natural protective mechanism of the epidermis. Mass-market and specialty cleansers and detergents are often alkaline with a pH as high as 11. Alkaline ingredients such as tallow help to remove dirt and oil easily but also neutralize the natural acid mantle of the skin. Even after a cleanser is washed off, an alkaline residue can remain on the skin. Detergents are seldom completely removed after a single rinse cycle and their alkalinity can turn clothing, bedsheets, and towels into a source of chronic pH imbalance for the skin. Without repeated exposure to alkaline elements, the acid mantle can be replenished in normal, healthy skin within two hours after washing; more sensitive skin may require as long as 36 hours after washing to regain its normal pH of 5.5.

Toners provide more specific treatments to penetrate pores to remove dirt and bacteria. The ingredients in toners combine with sebum to draw out deeper comedone-forming cellular debris; however, this means that along with the debris, natural oils and moisture on the skin are also removed, leading to a dehydrated layer that is vulnerable to infection or hyperstimulation by body processes seeking to restore balance.

Many mass-market moisturizers provide transient restoration of matrix turgidity within the epidermis but may not transfer supplements to the deeper dermal layer. Conventional moisturizers generally contain emollients (such as lanolin), artificial fragrances, and preservatives, which can be effective for areas with thicker epidermal layers, but may cause irritation in areas with thinner epidermal tissue such as the face, neck, and hands. Specialized, high-impact moisturizers contain humectants (such as hyaluronic acid), which produce superficial hydration and promote deeper (internal) hydration. Additionally, specialized moisturizers are often pH-balanced (slightly acidic) to avoid any disruption to the acid mantle. Extended use of ineffective moisturizers can lead to dermal dehydration, reduced cellular repair and regeneration in the dermis, and the onset of premature aging.

The significance of supplemental protection from the effects of sunlight has grown with a more comprehensive understanding of UV radiation on cellular function. Many conventional products with higher UV protection may include additional ingredients that limit skin function, cause irritation, or pose other risks to the body; care should be taken with any protective product to determine its risk/benefit profile.

 Product Proficiency

A solid understanding of ingredients is essential in the proper selection of effective skin care products to reduce the risk of irritation and maintain optimal health. The ingredient profile of any skin product can determine its short-term and long-term effectiveness.

Active Ingredients
Every product's impact in the treatment of a given skin condition can be quantified by examining the product's active ingredients and their respective dosages in formulation. And because certain actives can be optimally effective at specific stages of treatment, it is also important to assess when to introduce them into your regimen. Skin care from products containing ineffective actives or effective actives with ineffective dosages may prove more costly over time if skin conditions worsen.

•  Cleansers can contain antibacterial or medicated ingredients that temporarily disrupt the superficial protection of the skin to deliver supplements to underlying tissue, such as sulfur, glycolic acid, and essential oils.
•  The active ingredients in toners address pore-related skin conditions and supplement skin repair; mild dehydration may result from regular use and adequate moisturization is recommended. Ingredients in toners include therapeutic salicylic acid and resorcinol.
•  Effective moisturizers include both humectants and emollients to improve turgidity in superficial cells and supplement hydration in deeper layers. Humectants include glycolipids, hyaluronic acid, and glycolic acid; emollients can be water-based or oil-based, such as glycerin or lanolin, respectively.
•  Use of broad-spectrum sunblocks are recommended by the FDA and all healthcare providers to minimize exposure to harmful UV rays that can lead to skin cancer (melanoma) and other acute skin conditions. Active ingredients in sunscreens are designed to block or absorb UVA and UVB rays. Currently, the SPF (Sun Protection Factor) measures effectiveness against UVB rays; the level of UVA protection should also be noted on products.

UVB ProtectionSPF
Low2 to 14
Medium15 to 29
High30 to 49
Highest50 and above

Vehicles and Additives (Inactive Ingredients)
The formulation of a skin care product also comprises a set of inactive ingredients, such as vehicles and additives, required to optimally deliver the active ingredients to the target. These ingredients are responsible for dissolving the actives at just the right ratios for the most effective penetration. With many mass market products, manufacturers pay less attention to the potentially deleterious effects these inactives can have on the skin's pH balance. Inactives that are natural, water-soluble, and biocompatible can maximize the potency of a product's active ingredients and offer less chance for irritation and inflammation.

 Special Considerations

Sensitive, oily, dry, or combination skin usually require specialty products to restore balance and to maintain proper texture and tone. An effective strategy involves selecting products designed for special skin needs and adding specific treatments as needed to address skin conditions.

For example, sensitive skin can be treated to reduce hyperpigmentation using non-inflammatory actives such as alpha arbutin with mild peels as an adjunct until treatment goals are achieved. To maintain results without irritating sensitive skin, employ basic skin care products designed to protect the skin and promote continued repair and regeneration.

Combination skin that has acne can be treated using toners and cleansers that will reduce bacterial infection and restore natural pH without clogging pores. Peels can be employed to promote epithelial shedding (keratolysis) to remove dead skin and restore texture and tone. Healthy skin can be maintained using specific formulations that supplement the skin's function to clear infection and hydrate the deeper layers for regeneration and repair.

 Skin Conditions

While unresolved or persistent irritation and infection can result from ineffective skin care or products, advice and treatment from a skin care professional are prudent practices to promptly alleviate skin conditions and concerns. A medical professional should always be consulted when unusual symptoms including pain, fever, irregular patches or growths occur.

Below are some general symptoms for possible skin conditions (provided for illustration purposes and not intended to diagnose or treat conditions in place of medical care):

SymptomsPossible ConditionSelf Care
Dark bump that may have started within a mole or blemish, or a spot or mole anywhere on the skin that is painful, itchy, or has changed in color, size, or shapeMelanomaSeek medical attention right away.
Small, pus-filled sacs or pimples, blackheads, or sore, red bumpsAcneOver-the-counter acne treatments, specialty skin care products, prescription medications. Seek medical help if symptoms don't resolve or worsen.
Darkened spots or patches on the face, hands, or areas exposed to the sunHyperpigmentationSun protection and normal skin care; specialized peels and ointments are optional to promote even skin tone. Seek medical help if condition spreads or worsens despite sun protection and skin care.
Flushed appearance, such as redness around cheeks, chin, forehead, or noseRosaceaElective skin care treatment, prescription medications such as antibiotics for moderate to severe symptoms.
Red, itchy, scaly, and oily rash, usually affecting areas around eyebrows, nose, or scalpSeborrheic DermatitisTopical medications and shampoos
White, scaly rash over red, thickened, and irritated skinFlexor areas (inside elbows or knees): EczemaMild conditions: specialty peels, ointments, and moisturizers to gently reduce thickened skin. Advanced conditions: Seek medical attention to diagnose condition and obtain prescription medication.
Extensor areas (elbows or knees): Psoriasis
Small, red, flat spots that appear as dry, rough patches in areas exposed to sunlightActinic KeratosisTopical treatments to gently remove epidermal layer such as glycolic acid peels; sunscreens and skin care that include humectants to promote regeneration and repair. Seek medical attention to rule out precancerous lesions.
Thickened, dry patches that may be discoloredHyperkeratosisTopical treatment to reduce the thick epidermal layer (such as peels). Skin care should include moisturizers containing humectants to promote normalized skin regeneration. Seek medical attention if hyperkeratotic areas affect daily functions (such as hands or feet).
Painful red bump or cluster of painful red bumpsBoil (single) or carbuncle (cluster)Warm compresses and antibiotic ointments as needed. Seek medical attention if the boils persist or the redness spreads.
Soft bumps (single or clustered) that don't itch or cause other symptomsWartsElective topical removal of clusters such as peels, laser surgery, scraping or cryosurgery by a medical professional.
Round, flattened discolored and irregularly shaped spot that may be clustered, appearing with ageSeborrheic KeratosisElective topical peels to gently remove superficial layers. Consult a medical professional to rule out precancerous lesions or if it becomes irritated, bleeds or continues to grow.
Rash or bumps suddenly appear on face or bodyHives or contact dermatitis if localizedAntihistamine and cool compresses, remove contact with irritant. Seek medical attention if hives persist or other symptoms arise such as swelling.
Small, reddened patches or bumps primarily around hair follicles such as the upper arms, legs, and face.Keratosis PilarisRegular, gentle exfoliation and moisturizing using skin care products that soften thickened patches, reduce infection and hydrate skin tissue.

 Beauty and Brains

Specialized skin care products formulated to address specific needs and conditions can provide effective and lasting results. An investment in knowledge and consideration regarding skin care reflects a proactive commitment to optimizing your overall health.

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