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.

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