Journal of Clinical and Aesthetic Dermatology

Epidermal Barrier Supplement 2016

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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U nderstanding the Epidermal Barrier in Healthy and Compromised Skin: Clinically Relevant Information for the Dermatology Practitioner [APRIL 2016 • VOLUME 9 • NUMBER 4 • SUPPLEMENT 1] SUPPLEMENT TO THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY S7 mois t uriz e r/ ba rrie r re pa ir f ormula t ion c a n c ont ribut e t o imp rovemen t of d is eas e-as s ociated s ign s an d s ymp toms an d can mitigate cu tan eou s irritation cau s ed by certain top ical med ication s . 3 , 2 3 – 2 7 Th e d is tin ction betw een mois tu riz ers an d t o p i cal b ar r i e r r e p ai r p r o d u ct s i s n o t cl e ar l y d e f i n e d . C o n v e n t i o n a l m o i s t u r i z e r s , a v a i l a b l e o v e r- t h e - c o u n t e r ( O TC) , can be p u rely occlu s ive ( i.e., p etrolatu m, lan olin ) , or c a n c o n t a i n b o t h o c c l u s i v e a g e n t s ( i . e . , p e t r o l a t u m , occlu s ive/ p rotective emollien ts ) an d h u mectan t in gred ien ts ( i.e., glycerin , h yalu ron ic acid ) , d es ign ed p rimarily to red u ce T E W L a n d i n c r e a s e S C h y d r a t i o n . 2 5 , 2 6 , 4 0 B a r r i e r r e p a i r f o r m u l a t i o n s , u s u a l l y m a d e a v a i l a b l e a s p r e s c r i p t i o n p r o d u c t s , c o n t a i n t h e f u n d a m e n t a l i n g r e d i e n t s o f a con ven tion al mois tu riz er alon g w ith s p ecific "p h ys iologic" i n g r e d i e n t s ( i . e . , c e r a mi d e s , e s s e n t i a l f a t t y a c i d s ) a n d formu lation d es ign ch aracteris tics th at d irectly target barrier re pa ir ( i.e ., re ple nishme nt of t he SC int e rc e llula r lipid m e m b r ane ). 2 6 H o we ve r, t he r e ar e al so O TC m o i st ur i ze r formu lation s th at con tain p h ys iologic lip id s ( i.e., ceramid es , ceramid e p recu rs ors , fatty acid s ) an d oth er s p ecial ad d itives (i.e., niacinamide) that can assist in barrier repair. 26 The following are examples of clinical use of moisturizers and barrier repair formulations, which contributed to favorable therapeutic outcomes: • The effectiveness of a moisturizer used as an adjunct to topical corticosteroid therapy for the treatment of mild-to- moderate atopic dermatitis was studied in comparison to low-potency topical corticosteroid alone for three weeks in children 3 to 15 years of age. Adjunctive moisturizer therapy provided a steroid-sparing alternative to topical corticosteroids alone in the treatment of mild-to-moderate atopic dermatitis. 41 • A six-week cohort study evaluated the effectiveness of a twice-daily regimen of a ceramide-containing cleanser and moisturizer in children and adults with atopic dermatitis ( N = 151) . T h e r e s u l t s s h ow e d t h a t t h e c e r a m i d e - containing cleanser and moisturizer regimen substantially improved clinical outcomes with reduction in disease severity and improvement in quality-of-life parameters. 42 • A ceramide-dominant, physiologic lipid-based emollient, substituted for currently used moisturizers, was studied in children undergoing topical therapy with a calcineurin in h ib ito r o r co rtico stero id fo r recalcitran t ato p ic d ermatitis. S everity sco rin g o f ato p ic d ermatitis (SCORAD) markedly improved significantly in 22 of 24 p atien ts b y th ree w eek s, w ith fu rth er p ro gressive improvement in all patients between 6 and 20 or 21 we e ks . TEWL de cr e as e d in dir e ct cor r e la t ion w it h SCORAD scores and continued to decline even after SCORAD scores plateaued. SC cohesion and hydration also improved progressively over the course of therapy. Ultrastructure of the SC treated with ceramide-dominant emollient revealed defined intercellular lamellar lipid membranes, which were mostly absent in baseline SC skin samples. 43 • The use of a moisturizer alone was studied over four weeks duration in mild-to-moderate plaque psoriasis (5–10% body surface area) in patients who either were not being treated or h ad d is con tin u ed th e u s e of all top ical p s orias is med ication s an d all p reviou s mois tu riz ers ( N = 30) . Res u lts from objective evalu ation s s h ow ed s tabiliz ation of TEW L an d an in creas e in s kin h yd ration over th e cou rs e of th e s tu d y. D es qu amation meas u remen ts s h ow ed a s ign ifican t p ercen tage of p articip an ts w ith s kin imp rovemen ts from very d ry to d ry or n ormal ( P< 0.0001 for all time p oin ts ) . T h e i n v e s t i g a t o r c o n c l u d e d t h a t m o i s t u r i z e r u s e i s ap p rop riate an d can be h elp fu l in th e man agemen t of p laqu e p s orias is . 4 4 • T he e f f ic a c y o f a c e ra m ide - do m ina nt , t riple - lipid ba rrie r re pa ir t o pic a l e m ulsio n (3 :1 :1 c e ra m ide s t o c ho le st e ro l t o f a t t y a c ids ra t io ) wa s c o m pa re d t o f lut ic a so ne pro pio na t e c re a m in a f iv e - c e nt e r, inv e st ig a t o r- blinde d, ra ndo m ize d t ria l in pa t ie nt s wit h m o de ra t e - t o - se v e re a t o pic de rm a t it is (N=1 2 1 ). T he 3 :1 :1 ba rrie r re pa ir f o rm ula t io n re duc e d c l i n i c a l d i s ea s e s ev er i ty, d ec r ea s ed p r u r i tu s , a n d im pro v e d sle e p ha bit s bo t h 1 4 a nd 2 8 da y s a f t e r init ia t io n o f t he ra py. T he o nse t o f e f f ic a c y in t he f lut ic a so ne - t re a t e d g roup wa s more ra pid, showing sig nif ic a nt ly g re a t e r improvement at 14 days; SCORAD, pruritus, and sleep habit scores did not differ significantly among both study groups by 28 days. 4 5 References 1. Harding CR. The stratum corneum: structure and function in health and disease. Dermatol Ther. 2004;17:6–15. 2. Proksch E, Elias PM. Epidermal barrier in atopic dermatitis. In: Bieber T, Leung DYM, eds. Atopic Dermatitis. New York: Marcel Dekker; 2002:123–143. 3. Del Rosso JQ, Levin J. The clinical relevance of maintaining the functional integrity of the stratum corneum in both healthy and disease-affected skin. J Clin Aesthet Dermatol. 2011;4(9): 22–42. 4. Thiboutot D, Del Rosso JQ. Acne vulgaris and the epidermal barrier: is acne vulgaris associated with inherent epidermal abnormalities that cause impairment of barrier functions? Do any topical acne therapies alter the structural and/or functional integrity of the epidermal barrier? J Clin Aesthet Dermatol. 2013;6(2):18–24. 5. Dirschka T, Tronnier H, Folster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol. 2004;150:1136–1141. 6. Ghadially R. Psoriasis and ichthyosis. In: Leyden JJ, Rawlings AV, eds. Skin Moisturization , 1st ed. New York: Marcel- Dekker; 2002:165–178. 7. Dasgupta BR, Bajor J, Mazzati DJ, Manoj M. Cosmeceuticals: f u n c t i o n a n d t h e s k i n b a r r i e r. I n : D r a e l o s ZD , e d . Cosmeceuticals, 3rd ed. Elsevier: Philadelphia; 2016:3–10. 8. Elias PM. The epidermal permeability barrier: from Saran Wrap to biosensor. In: Elias PM, Feingold KR, eds. Skin Barrier. New York: Taylor Francis; 2006:25–32. 9. Menon GK, Norlen L. Stratum corneum ceramides and their role in skin barrier function. In: Leyden JJ, Rawlings AV, eds. Skin Moisturization , 1st ed. New York: Marcel-Dekker; 2002:165–178.

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