Treatment of Dry Skin Syndrome

Marie Lodn Howard I. Maibach

Editors

Treatment of Dry Skin

Syndrome
The Art and Science of Moisturizers
Editors
Marie Lodn, M.Sc. Pharm. Howard I. Maibach, M.D.
Eviderm Institute Department of Dermatology
Solna, Sweden University of California
San Francisco School of Medicine
San Francisco, California
USA

ISBN 978-3-642-27605-7 ISBN 978-3-642-27606-4 (eBook)

DOI 10.1007/978-3-642-27606-4
Springer Heidelberg Dordrecht London New York

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Preface

Our desire to apply oily materials to the skin is almost instinctive and may be
as old as mankind itself. This is related to our physical and psychological
functioning which is facilitated by gentle touch, particularly in terms of
reducing stress, relieving pain, and in the improvement of skin characteris-
tics. Moisturizing creams contain a great variety of ingredients that give rise
to different sensory and functional effects when applied to the skin. For
example, treatment of children with atopic dermatitis may feel soothing and
comforting, punitive and intrusive, or functional and neutral. Treatment of
normal and diseased skin also shows different effects on the epidermal bio-
chemistry and functional characteristics, with consequences for the outbreak
of inflammation, eczema and potentially asthma.
The development of moisturizers is a scientific and artistic discipline,
including both formulation technology and consumer insights. This new book
aims to bridge the gap between the moisturizers and the skin. The composi-
tion and development of moisturizing creams are discussed in the book,
including the value of lipids, humectants, natural raw materials, and preserva-
tives. Overviews and updates on dry skin disorders and their treatments are
also covered, along with regulatory aspects and claim substantiation. In addi-
tion, the exciting sensory systems of epidermal keratinocytes are explained,
and new insights into stratum corneum biomechanics, molecular organiza-
tion, desquamation, and barrier function are discussed. The authors represent
a cross section of the international well-known scientists from academia to
industrial research.
With the use of the knowledge in this book, we anticipate that cosmetic
scientists, researchers and dermatologists will go beyond the traditional
thinking of skin care. The readers will have new insights that suggest the
properties required for a new generation of moisturizing treatments, improv-
ing quality of life.

Solna, Sweden Marie Lodn,

San Francisco, CA, USA Howard I. Maibach

v
Introduction

Corneobiology and Corneotherapy: A Final Chapter

A. M. Kligman

Reprinted from: International Journal of Cosmetic Science, 2011, 33, 197209

with permission.

The text obtained for this review from Professor Albert Kligman was drawn
posthumously from a variety of notes that he had been planning to use to write
a review on corneobiology and corneotherapy. It was a review that he had dearly
hoped to complete his final magnum opus with reflections on the subject.
The review is reprinted with permission from Kligman, A.M. Corneobiology
and Corneotherapy a final chapter. International Journal of Cosmetic
Science, 2011, 33, 197209.

Introduction

Corneobiology refers to that broad range of experimental studies that are

focused on the anatomy, physiology and biology of the stratum corneum,
centred particularly on the human horny layer that has features uniquely dif-
ferent from other mammals. Corneobiology has a very broad reach, encom-
passing studies that deal with immunology, endocrinology, neurobiology and
psychology, comprising a network of complex interactions that have connec-
tions to the central nervous system. It has attracted the attention of a confed-
eration of scientists from very different disciplines, including molecular
biologists, anatomists, physiologists, pharmacologists, geneticists, psycholo-
gists and still others. However, it was not until the latter half of the twentieth
century that the stratum corneum began to be viewed as much more than a
dead, inert passive membrane, a Saran-type wrapping around the integument
with the sole function of limiting the movement of substances into and out of
the viable tissues, featuring the special functions of preventing diffusional
water loss against a hostile, dessicating environment and limiting the penetra-
tion of exogenous toxic chemicals with antigens [1].

vii
viii Introduction

I have given an historical account of the evolution, one might say revolu-
tion, regarding the new appreciation of the horny layer as having multiple,
dynamic functions in a previous treatise entitled How the dead stratum cor-
neum became alive [2]. Before then, the established dogma was that the
principal biologic mission of the epidermis was to create the impermeable
stratum corneum barrier, essentially sealing the body from the outside world,
leading some authorities to label the stratum corneum as the ultimate shield
against mechanical, chemical and physical external threats. For instance, in
1958, S. Rothman in his seminal text on the Physiology and Biochemistry of
Skin depicted the stratum corneum as a loose, amorphous mass of keratin
filaments, the product of the holocrine degeneration of epidermal keratino-
cytes, epitomized in dermatologic texts as the basket weave horny layer
[3]. This view of the horny layer as a loose collection of filaments separated
by wide empty spaces, as seen in H&E-stained histologic specimens, posed
a paradox for physiologists who universally held that the stratum corneum
constituted a barrier to the penetration of exogenous substances preventing
diffusional water loss to a hostile dry environment. The basket weave
image turned out to be an artefact of formalin fixation of H&E-stained
sections.
In 1964, myself and Enno Christophers showed that the horny layer floated
off as thin, tough, transparent membrane when full-thickness specimens of
skin were immersed for 1 min in water at 60C [4]. In unfixed sections swol-
len by 1 N NaOH, we subsequently demonstrated that the membrane was a
coherent tissue composed in most body regions of 1416 cornified cells, later
called corneocytes. These findings showed unequivocally that the stratum
was a cellular tissue, not an amorphous filamentous graveyard of degenerated
keratinocytes. My 1964 landmark paper, entitled The biology of the stratum
corneum, marked the inauguration of a new cutaneous discipline,
Corneobiology, which centred on the structure and function of the horny
layer [1]. This paper, however, propagated a serious misconception. The
teaching of the time was that the stratum corneum was a dead, inert, passive
membrane, a Saran Wrap-like impermeable shroud, encasing the body, pro-
tecting it from chemical and physical exogenous threats. In fact, this was but
one of many errors regarding the structure and function of the horny layer,
which has taken many years to correct, a process of deconstruction that con-
tinues to this very day.
No area of cutaneous biology has attracted more investigative attention
than the stratum corneum. A multitude of studies in the last few decades have
shown that the horny layer is a very complex, dynamic tissue whose forma-
tion involves many highly orchestrated metabolic enzymatic functions. The
horny layer has become very much alive. It was holy doctrine in major text-
books of dermatology that the sole function of the horny layer was to provide
an impermeable barrier to the inward and outward diffusion of substances,
especially toxic exogenous chemicals. The synonym for the stratum corneum
was the barrier, a term which still remains popular. It is now known with
certainty that the horny layer has diverse and numerous functions, indispens-
able for maintaining cutaneous homeostasis.
Introduction ix

Corneobiology Enthusiasts

It is appropriate to mention briefly the academicians whose early investi-

gations created the background for the concepts underpinning corneobiology.
It was left to many scientists but most notably Professor Elias the mae-
stro to articulate the concept that the epidermis had many diverse func-
tions and that most of these localized to the stratum corneum, which in
turn had many diverse functions, elevating the stratum corneum as a key
player in the many biologic processes of the integument [5]. Elias, in fact,
laid down the fundamental principals underlying the science of corneobi-
ology, listing in detail ten major horny layer functions, linking each one
to specific constituents, a brilliant, original, systematic exposition. For
example, the linkages of each function were first to its basic principal
compartment, such as the extracellular matrix or the corneocyte; then the
linkage to its structural basis, such as the bilaminar membranes of the
extracellular domain, corneodesmosomes, cornified envelopes and keratin
filaments and cytosols; next, the chemical basis, specifically ceramides,
cholesterol, antimicrobial peptides, barrier lipids, filaggrin derivatives,
glycerol and proteases; and finally linkage to regulatory scientists,
glucocorticosteroids, etc.
Although it may seem tedious to list individually each of Elias ten func-
tions, it is exceedingly informative and edifying to grasp the scope and diver-
sity of these functions. These are as follows:
1. Permeability
2. Antimicrobial
3. Antioxidant
4. Cohesion (integrity) desquamation (shedding)
5. Mechanical/rheological
6. Chemical, exclusion of antigens
7. Psychosensory
8. Hydration
9. Protection against electromagnetic radiation
10. Initiation of inflammation (cytokine activation)
Although the above inventory of multiple functions is impressive, it does
not tell the whole story; this is a work in progress. Searching the rapidly
expanding literature furnishes further examples of the diversity of functions
displayed by the horny layer. To Elias list, one may add the following:
1. A biosensor of meteorological conditions, especially humidity.
2. Regulator of innate and adaptive immunity.
3. A storage site of chemical mediators, topical drugs, cosmeceuticals,
cosmetics.
4. Protection against carcinogenesis and photoageing.
5. An organ of social communication dry, scaly, rough stratum corneum is
unappealing to touch and light, engendering repulsion, inducing anxiety,
anger and depression in those afflicted by ichthyotic skin.
6. Generation of natural moisturizing factors, a mixture of low molecular
weight substances that are hygroscopic (urea, amino acids, glycerol).
x Introduction

The upshot of these disparate observations is that the conventional view of

the stratum corneum as a passive, inert, metabolically lifeless membrane is
obviously archaic. The stratum corneum has obviously become very much
alive. The recent publication in 2006 by Elias and Feingold, titled The Skin
Barrier, is obligatory reading, covering every aspect of corneobiology. It is
an unparalleled source of references [6].
The scientific basis of corneobiology is experimental quantification and
not simply empirical observation, further strengthened by the development of
non-invasive methods that allow repeated, sequential observations of the
same site without damaging the tissue, as is the case of biopsies. For example,
the integument is constantly being deformed by stretching by mechanical
forces, about which knowledge is scanty, lacking measurable data. To fill this
gap, recent studies show that using a suction device to apply strengths of
400600 mbar to the forearms results in significant increases in transepider-
mal water loss (TEWL), signifying increased permeability, and marked
decrease in capacitance, signifying less ability to take up and hold water,
making the horny layer less resilient [7]. This is echoed by the work of
Rawlings et al. [8] further demonstrating in vitro disruption of lipid bilayers
with extension of the stratum corneum, resulting in increased water vapour
transport rates. These results are rather surprising, considering the rheological
stresses that the integument experiences in daily living, not to mention sports,
and not everyone concurs with these findings.
Contributors to building the edifice, we now call corneobiology, are a mot-
ley, diverse crew of investigators, mainly situated in industry and academia
from around the world. These individuals are all individually acknowledged
in the delightful, historical, narrative essay by the indefatigable master of
masters, Dr. Anthony Rawlings of Great Britain, entitled 50 years of stratum
corneum research and moisturization, laying out decade by decade the most
innovative discoveries, starting in the 1950s [9]. Rawlings and his collabora-
tors are best known for their exhaustive, comprehensive works on moisturiza-
tion, culminating in the Rawlings magnum opus in 2004 on Stratum corneum
moisturization at the molecular level, which is a must-read for all parvenus
to the field of corneobiology, covering in exquisite detail every aspect of
moisturization, including the development of an impressive assay of modern
multidimensional products for effectively treating the common dry, scaling,
ichthyotic conditions, a far cry from our forefathers who advocated such
primitive remedies as goose grease, vegetable oils and animal fats [10].
Another distinguished name must be added to those who have made out-
standing contributions to corneobiology, namely, Professor Ronald Marks of
Cardiff, Wales. Dr. Marks has sponsored six international symposia, focused
entirely on the stratum corneum. In 1971, he invented the cyanoacrylate skin
surface biopsy technique that enables the microscopic visualization of bacte-
ria, fungi, bacteria and demodectic mites in the superficial, desquamating
portion of the stratum corneum [11]. He was also among the first to show that
the impermeable dressings with no active pharmacologic agents could clear
psoriatic plaques and that supposedly inert ointments, such as petrolatum,
could have anti-inflammatory effects [12].
Tagami in Japan realized in 1998 that the stratum corneum was a rich reser-
voir of cytokines, including IL-8, IL-6, IL-10, TNF-a and others, enabling an
Introduction xi

explosive inflammatory tissue whenever fragments of the horny layer are

extruded into the dermis, heralding the idea that the horny layer could start
chronic inflammatory disorders [13]. Tagami immersed a sheet of normal stra-
tum corneum in buffered saline for 2 days and found a large quantity of IL-12
in the supernatant. Marks had earlier demonstrated that a suspension of corneo-
cytes obtained by scrubbing callus tissue initiated a severe, long-lasting, inflam-
matory granuloma when injected into the dermis [14]. Spontaneous examples
of this response occur when epidermal cysts rupture, dumping their contents
into the dermis, and also when acne comedones rupture to form papulo-pus-
tules. Frenetic scratching can mimic this phenomenon by dislodging keratinous
fragments into viable tissue. Nickoloff and Naidu had also foreseen the poten-
tial of the stratum corneum to initiate inflammatory and immune-mediated reac-
tions [15]. They found, by immunostaining biopsied tissue, marked increases in
TNF-a, IL-a, IL-16, intercellular adhesion molecules and growth factors as
early as 6 h after tape stripping. They were among the first to appreciate that the
epidermis vigorously participates in a multitude of homeostatic responses, well
beyond producing the horny layer barrier. Nickoloff then went on to show that
there was a rapid release of cytokines after topical application of irritants, as
well as after application of allergens in sensitized subjects, indicating a com-
mon triggering, a pathway after injury to the stratum corneum [16].
It is appropriate to point out that the remarkable advances in our under-
standing of the horny layer have been made possible by the utilization of
highly sophisticated, modern technology, including TEM, SEM, cryofixation,
spectroscopy, staining of immunologic markers, optical coherent tomography
and histochemical and other non-invasive methodologies. Some recent illu-
minating studies are worth mentioning.
We have been taught, since the early in vitro diffusional studies of
Scheuplein and Blank, that all layers of the stratum corneum contribute to its
barrier properties [17]. Now we learn, in a recent paper by Richter et al. of
Beiersdorf, Hamburg, Germany, using cryofixation and scanning electron
microscopy, that skin specimens immersed in 520% salt solutions show
three distinct hydration zones within the horny layer [18]. The outermost
zone where desquamation occurs shows massive swelling, whereas the inner-
most zone shows that the granular layer swells to more than double its normal
thickness, associated with massive water inclusions between adjacent cell
layers. By contrast, the middle zone remains compact, without water pools.
The authors conclude that the middle zone constitutes the vaunted permeabil-
ity barrier, a near heresy to conventional thinking.
An earlier paper by the same group using high-pressure cryofixation com-
pels us to reconsider how our conventional concepts need serious revision
[19]. The most surprising finding is that organelles and tonofilaments within
the cytoplasm of keratinocytes are not uniformly distributed as usually
depicted but instead are organized instead into microdomains, clusters of
organelles separated by relatively empty spaces, a startling new concept of
keratinocyte morphology. New knowledge is occurring so rapidly that we are
no longer shocked when our conventional dogmas are overturned. The famous
impermeability of the horny layer turns out to be an oversimplification, even
to the point where physicists can proclaim boldly that the vaunted barrier may
have porous domains.
xii Introduction

It is now understood that permeability can be enhanced by a variety of

chemical and physical techniques, including simple occlusion. The normal
stratum corneum contains widely separated lacunar dilatations in the extra-
cellular domains that can be enlarged to form continuous pore pathways,
allowing for the ready penetration of both polar and non-polar molecules
attesting to the new awareness of the dynamic nature of the horny layer [20].

Emollients and Moisturizers:

The Beginnings of Corneotherapy

It was not long ago when dermatologists were scorned and mocked for their
primitive, empirical topical therapies. The therapeutic credo was: If its dry,
wet it. If its wet, dry it. The ointments followed the rule of the three Ss.
Their efficacy was thought to be proportionate to the degree to which they
stained, stunk or stung. However, corneobiology, which has revealed the
inner workings of the horny layer barrier, has revolutionized topical thera-
pies, allowing striking improvements, which can be epitomized in a few sen-
tences. They are more effective; safer, using lower concentrations of active
agents, with fewer adverse side effects such as stinging, burning and irri-
tancy; free of allergens, fragrances and preservatives; more easily and conve-
niently applied; more agreeable to use, being colourless and odourless,
rubbing in easily and leaving no residue; more stable with a longer shelf life
and compatible with other daily treatments such as sunscreens, moisturizers
and cleansers. A wave of new topical drugs and cosmeceuticals has entered
the market place, whose benefits are more likely to be substantiated by evi-
dence-based medicine.
The use of bland, non-medicated emollients for treating a variety of der-
matologic disorders is as old as dermatology itself. Dermatologists in
European centres extensively used emollients in the nineteenth and twentieth
centuries to treat a variety of chronic, inflammatory disorders. The term
emollient (from the Greek, meaning to soften) refers to oily substances,
such as ointments and creams, which are used to moderate rough, scaling,
xerotic, erythematous, often pruritic conditions to make the skin flexible, soft
and agreeable to the touch and sight. More recently, the term moisturizers,
a creation of Madison Avenue merchandizers, has come into use to denote
substances, usually in the form of emulsions, that moisten and hydrate dry
skin conditions. The two terms are now used interchangeably to encompass a
huge variety of commercial formulations possessing attributes that go well
beyond merely moistening and softening. It should be made clear that emol-
lients are not drugs in the FDA sense and technically contain no pharmaco-
logically active substances; nonetheless, they may have drug-like effects and
are best classified in the category of cosmeceuticals.
The corneotherapy story begins with some prescient observations by Tree
and Marks in a 1975 paper having the provocative title of An explanation for
the placebo effect of bland ointment bases [12]. These authors were trying
to explain how bland emollients, without pharmacologically active ingredi-
ents, could be effective in moderating common inflammatory disorders such
Introduction xiii

as psoriasis and atopic dermatitis. They showed that several bland agents
could inhibit and prevent the increased epidermal mitotic rate, which occurred
when the skin of hairless mice was tape-stripped. They found that the vener-
able ointment, petrolatum, exerted the greatest anti-mitotic effect among
other creams and pastes. They had no explanation for this.
Penney later proffered the explanation that petrolatum might be acting as
an anti-inflammatory agent [21]. He could show, at least in vitro, that petro-
latum inhibits the prostaglandin-mediated formation of the pro-inflammatory
arachidonic acid. In 1976, Comaish and Greener showed that petrolatum had
an inhibitory effect using a quite different model [22]. Their study was based
on the renowned Kbner phenomenon in which insults to the uninvolved skin
of patients with active psoriasis provoke new psoriatic lesions at the trauma-
tized sites. They provoked the Kbner reaction by making 1-cm-long deep
scratches. By pretreating uninvolved skin for 3 weeks before scratching, they
found that new lesions were generally inhibited.
In still another model, myself and Lorraine investigated the ability of
emollients to inhibit ultraviolet-induced carcinogenesis in hairless mice [23].
The mice were irradiated thrice weekly for 20 weeks with broad-spectrum
UVB. The selected emollient was applied just before each irradiation. We
found that petrolatum gave almost complete protection against the formation
of tumours. Another hydrophobic emollient, lanolin, was only 50% effective.
By contrast, tumour formation was greatly enhanced by mineral oil in this
animal model, which contains lower molecular weight hydrocarbons than
petrolatum, with a potential for irradiation. USP cold cream had no protective
effect. Interestingly, a modest protective effect, about 20%, was determined
even when petrolatum was applied after each irradiation. It was shown that
petrolatum had a negligible sunscreen effect, with an SPF of <2.
In my own studies of bland emollients for the correction of varied xerotic
states with defective horny layer barriers, I have found that ancient war
horse petrolatum to be highly effective. My assessment of moisturization
efficacy was based on the dry skin regression method that determines the
time after cessation of a 3-week treatment for skin to return to the original
state [24].
The chief complaint against petrolatum, which strongly limits its accep-
tance, is its greasiness and disagreeable feel. After experimenting with a vari-
ety of oil-rich emollients, which are clearly superior to lotions, we have
concluded that Aquaphor is second only to petrolatum for repairing defective
barriers in chronic dermatoses. Patients have to be taught that once rubbed in,
its perceived oiliness mostly disappears.
I proffer the following experimental example of the high efficaciousness
of Aquaphor in repairing the markedly defective barrier by oral administra-
tion of 13-cis-retinoic acid (Accutane). I treated three men with severe acne
conglobata of the face and back with 80 mg of cis-retinoic acid daily for
4 months with excellent therapeutic results but which resulted in marked
scaling, even bruising and purpura after moderate erythema in two, associ-
ated with itching and dryness to touch and sight. One dorsal forearm, from
the wrist to antecubital space, was treated with Aquaphor b.i.d. for 5 week-
days for 1 month, whereas the opposite forearm served as an untreated
xiv Introduction

control. Dryness, scaling, itching and fragility disappeared completely in

2 weeks. The following measurements were made 3 days after the end of
4 weeks of treatment, expressed in averages. Transepidermal water loss
(estimated by Servomed) was 22.3 mg m2/h on the untreated side and
5.2 mg m2/h on the treated side, a value within the normal range of the
forearm. The number of corneocyte layers determined by the alkali swell-
ing technique on a razor slice biopsy was 6.1 on the untreated side and 10.3
on the treated side, within the normal range. Twelve Scotch tape strips
induced purpura on the control side but not on the treated side.
Videomicroscopy (by Hi-Scope, 20) showed near-normal glyphic mark-
ings of primary and secondary lines on the treated side with near oblitera-
tion of glyphics on the untreated side. Despite the facial sample, the
near-normal restoration of the defective barrier by b.i.d. applications of
Aquaphor can scarcely be queried.
Subsequently, petrolatum in many reports has been found to be beneficial
in a variety of clinical settings, for example, after chemical and laser peels,
after dermabrasion, in promoting wound healing and for relieving chronic,
inflammatory disorders. A noteworthy effect of petrolatum is enhanced repair
of the disrupted horny layer barrier in human skin. For example, Herd and
Agner examined the ability of six different moisturizers to repair the horny
layer barrier damaged by a 24-h patch test of 0.5% sodium lauryl sulphate, a
classic anionic detergent that makes the barrier extremely permeable, increas-
ing TEWL to 20 times normal [25]. All six moisturizers accelerated barrier
repair, measured quantitatively by a variety of bioengineering techniques,
with petrolatum the best performer. The key finding in that study was that the
rate of repair was directly proportioned to the respective oil content of
the moisturizers. They recommended this model as a reliable way to estimate
efficacy. Although still elusive, we are coming closer to understanding the
mechanism by which moisturizers work.
The momentous increase in knowledge of the intricacies of stratum cor-
neum anatomy and physiology has paid off handsomely in the way in which
topical drugs are formulated to enhance penetration, thereby increasing effi-
cacy at lower concentrations, also diminishing adverse reactions. Topical
drugs can be targeted to preferentially enter follicular pathways in disorders
such as acne.

Corneotherapy Is the Basis

for a New Wave of Improved Topical Treatments

Corneotherapy refers to therapeutic interventions, usually topical, which are

aimed at repairing stratum corneum barriers that are impaired in a wide vari-
ety of unrelated dermatologic disorders. Corneotherapy applies most often to
the treatment of common chronic inflammatory disorders such as atopic der-
matitis and psoriasis but also to a wide spectrum of skin diseases of very
different origins, viz. occupational diseases, irritant and allergic contact der-
matitis, congenital ichthyotic diseases, keloids and hypertrophic scars,
Introduction xv

severely premature neonates, the photoaged face because of excessive solar

radiation and others, which are classically manifested by dry, xerotic, scaling,
often pruritic cutaneous surfaces. A variety of objective non-invasive mea-
surements are available to characterize and quantify these diverse conditions
that invariably exhibit increased TEWL and decreased capacity to maintain
hydration resulting in viable dry scaly skin among other impairments of the
horny layer barrier.
Actually, corneotherapy has been practised unwittingly by dermatologists
from the earliest times, encompassing different approaches and basically
targeting defective horny layers ranging from traditional ancient approaches
such as emollients, occlusive dressings, hydrotherapy (spas), ultraviolet light,
natural and artificial, arriving at modern resurfacing strategies for correcting
photoaged faces (lasers, chemical peels, dermabrasions, etc.).
Corneotherapy refers to preventive interventions that are primarily directed
to the correction and restoration of the stratum corneum barrier that has been
rendered defective and impaired by disease, genetics and a variety of mechan-
ical, physical, chemical and psychological exogenous insults and stresses.
Invariable and characteristic features of defective horny layer are marked
increases in diffusional TEWL to a hostile dessicating environment; a
decreased capacity to take up and retain sufficient water to maintain a supple,
soft, resilient, smooth horny layer and a host of structural imperfections,
which degrade the ability of the horny layer to carry out its multiple and
diverse protective functions.
Great advances in our knowledge of the structure and function of the stra-
tum corneum, the science of corneobiology, have formed the background for
a wave of improved, novel products that have recently entered the market-
place for the treatment of common dermatologic conditions. These products
cover a wide range, including drugs, moisturizers, cleansers, sunscreens, bar-
rier repair, enhanced wound healing, etc. Big Pharma, until recently, has
essentially abandoned dermatology in favour of billion-dollar blockbuster
drugs, opening up a marketing need for smaller companies that are dedicated
exclusively to dermatology. The result has been a stunning variety of innova-
tive products that have not only improved the efficacy and safety of tradi-
tional remedies but have made them more convenient, pleasant and easier to
use. These innovations encompass new delivery systems to enhance penetra-
tion; new modes of application, including sprays, foams, gels and encapsula-
tion in microspheres; stable, fixed combinations that were formerly
incompatible; metered applications that reduce waste; packaging kits that
provide complete treatment programs and formulations of active agents,
which also reduce disagreeable adverse sensory responses such as itching,
burning and stinging, enhancing compliance and even enhancing sleep
patterns.
Many of these are available without prescriptions and, being produced by
dermatologic companies, have passed the usual toxicity tests for allergic and
irritant contact dermatitis, phototoxicity, comedogenicity, etc. The following
section provides a selected few informative examples out of a number too
great to review in detail.
xvi Introduction

Coal Tar

Coal tar has been a venerable treatment for plaque-type psoriasis for centu-
ries but suffers from poor compliance because of its bad odour, messiness and
dark staining of skin. These disagreeable factors have all been eliminated by
its new presentation in a 2% quick-breaking foam that dries rapidly and
spreads easily and is at least as effective as calcipotriol, an effective vitamin
D derivative.

Region-Specic Products

Corneobiologists have demonstrated that the stratum corneum barrier varies

greatly in various body regions, being very thick on the palms and soles, very
thin on the eyelids and vulva, and has poor barrier properties of the face to
immature corneocytes, mostly because of photoageing. Accordingly, products
are now available that are specifically designed for each region; for example,
keratolytics, such as salicylic acid, are included for the feet, moisturizers and
sunscreens for the face.

Fixed Combinations for ACNE Therapy

Separate applications of a retinoid and benzoyl peroxide are highly effective

for the treatment of acne vulgaris. These are incompatible when applied
together because the retinoid becomes degraded by the oxidizing activity of
benzoyl peroxide. A pharmacologic breakthrough has been released by a fixed
combination of 0.1% adapalene and 2.5% benzoyl peroxide in a microsponge
formulation. It should be noted that benzoyl peroxide is half the concentration
of most stand-alone benzoyl peroxides. This is a synergistic combination of
two drugs with different modes of action and has the highly valuable added
advantage of lessening adverse sensory reactions (stinging, burning). Once-
daily applications are sufficient, which greatly enhance compliance.

Azelaic Acid Gel

A 20% azelaic acid cream has been available for the treatment of rosacea for the
last 20 years, often accompanied by irritancy and sensory discomforts. Modern
formulations of topical drugs have come to appreciate that in addition to the
usual toxicity tests to ascertain safety, also adverse sensory reactions, such as
itching, burning and stinging are addressed. Patients will not use products, no
matter how effective, if they cause disagreeable sensations. A new formulation
(Finacea) containing 15% azelaic acid in the form of a gel is more agreeable to
use, spreading easily, leaving no residue, less irritating, with minimal itching
and stinging. Like most other dermatologic disorders, monotherapy is not opti-
mal. Greater improvement is achieved by the addition of a mild cleanser and an
emollientmoisturizer. The manufacturer is following a new trend, making
Introduction xvii

available Finacea Plus, a packaging kit that includes a moisturizer and cleanser,
adequately tested and relieving the consumer of having to buy these separately
and having to make choices among scores of competing manufacturers.

5-Fluorouracil (5-FU) for the Treatment of Actinic Keratosis

For many decades, 5% 5-FU cream has been shown to be highly effective for
the treatment of actinic keratosis in a 3-week b.i.d. course. A limitation that
has greatly restricted its use has been the severe, painful, erosive, crusted,
irritating reactions, which all patients experience. An ingenious solution to
the intolerable irritancy problem has been the development of a 0.5% 5-FU
cream (Carac), which is usually well tolerated, notably because of a tenfold
reduction in concentration and because it is a slow-release microsponge for-
mulation that allows a steady release of the drug, greatly reduced toxicity,
rather than a sudden burst of; moreover, once-daily application to each head
and neck lesion is often sufficient to bring about complete clearing of more
than 50% of AKs in 1 week. Treatment of the remaining lesions is continued
until clearing in the next week or two, a flexible arrangement. This is an
excellent example of employing innovative pharmaceutical knowledge to
solve a dreadful problem.

The Scientic Validation of the Efcacy of Glycerine

as an Effective Component of Skin Care Formulations

Glycerol is well known to the cosmetic industry as a humectant that can take
up three times its weight from a water-saturated atmosphere. It has been used
extensively since its discovery in 1799 to improve dry skin conditions, based
on empirical observations. Now in an ingenious study, Hora and Verkman
have proved conclusively that glycerol is a major determinant of stratum cor-
neum water retention and has other beneficial effects on stratum corneum
biophysical properties [26]. This study used aquaporin-deficient mice, but the
results doubtless hold for human skin. In brief, the horny layer of these mice
had multiple defects manifested by markedly evaluated TEWL, decreased
hydration (dryness) and poor elasticity after being deformed by suction and
extremely impaired barrier repair after tape stripping. After oral intraperito-
neal and topical applications of glycerol, these deficiencies were completely
corrected using quantitative, sophisticated and biophysical methods. Another
important finding was that glycerol enhanced the biosynthesis of the physio-
logic lipids that are responsible for barrier function.
Interestingly, corneobiologists, but few others, are unaware that glycer-
ine mediates still other functions beyond its spectacular humectancy, namely,
in regulating orderly shedding of corneocytes at the surface, thus keeping
the horny layer at a steady state of thickness during desquamation. It accom-
plishes this by enhancing proteolytic activity and promoting the dissolution
of corneodesmosomes near the surface, which are responsible for the cohe-
sion of corneocytes below the surface as shown by Rawlings et al. [27].
xviii Introduction

Equally, glycerol also has effects on cornified envelopes, a previously

unrecognized structural component of the horny layer that provides a new
target for cutaneous therapeutics. The famous brick and mortar mould of the
structural architecture of the horny layer failed to appreciate the presence of
rigid, insoluble structures that surrounded the horny cells (corneocytes) and
were composed of a mixture of proteins assembled during differentiation.
Hirao et al. in Japan have now demonstrated that cornified envelopes are criti-
cal elements in the construction of the barrier and in mediating its functions
[28]. These workers collected corneocytes by tape stripping the outermost
layers of the stratum corneum and then stained these to determine the degree
of maturation of cornified envelopes using Nile red to assay their acquiring
hydrophobicity during maturation and anti-involucrin antibodies to evaluate
loss of antigenicity during maturation. This ingenious method enabled them
to differentiate immature corneocytes, which are fragile and in varying sizes
and shapes, from mature ones which are rigid, flat and sturdy.
The findings of this elaborate and ingenious study are groundbreaking and
very illuminating. The story begins with the discovery of the common disor-
ders that are characterized by dysfunctional, impaired barriers, such as pso-
riasis and atopic dermatitis, and immature cornified envelopes were abundant
in the outermost stratum corneum in contrast to the normal body areas such
as the trunk and extremities where the envelopes were fully mature, whether
the subjects were Caucasians, Japanese or Afro-Americans. On the other
hand, immature cornified envelopes were frequently found on the face,
especially in winter, explained by the fact that the facial horny layer is a poor
barrier, thinner and more permeable, qualifying as dysfunctional, an unpracti-
cal area exposed to environmental stresses, such as arsenic damage. It is now
firmly established that immature fragile corneocytes inevitably signify an
impaired barrier [29].
Next, ex vivo incubation of corneocytes from the face in a humidified
environment for a few days resulted in a rapid maturation of the corneocyte
envelopes. Interestingly, exposure to facial corneocytes to commercial mois-
turizers accomplished the same degree of maturation, attributable simply to
increased water content. To complete this picture, in vivo treatment of the
face with a moisturizer had the beneficial effect of eliminating immature cor-
neocyte envelopes, associated with improved barrier functions, such as
decreased TEWL [30]. These findings are consistent with those of Rawlings
and collaborators who showed that fragile corneocyte envelopes, which are
increased in dry skin conditions, are converted into mature, rigid corneocytes
by the application of moisturizers to the face [31].
The practical clinical message of this innovative investigation is that cor-
neocyte envelopes should become a target for evaluating the efficacy of mois-
turizers in promoting the function of the horny layer barrier.

Effect of Emollients on Very Premature Infants

In no other skin disorder is the beneficial effect of an oil-rich, non-medicated

emollient so striking on the general parameters of well-being as in very
Introduction xix

premature infants. Premature infants with an estimated gestational age of less

than 33 weeks are born with an extremely impaired horny layer barrier.
Transepidermal water loss may be 15 times greater than in the full-term
infant, with drastic immediate consequences relating to dehydration, electro-
lyte imbalance and thermal instability. Topically applied drugs may penetrate
the highly permeable stratum corneum so easily as to produce toxic systemic
reactions [32]. Monitoring devices such as transcutaneous intravascular lines,
urine catheters, chest tubes, etc., lead to nosocomial infection, as high as 30%
[33]. Increases in the density of bacterial and fungal microflora may lead to
bacteraemia and sepsis.
In a model systematic study, Nupper et al. [34] applied Aquaphor
(Beiersdorf) ointment twice daily for 2 weeks to 30 very premature infants
while monitoring a matched untreated control group of 30 premature infants.
Aquaphor is a hydrophobic ointment that contains no preservatives and is
water miscible, whose ingredients consist entirely of petrolatum, lanolin min-
eral oil and lanolin alcohols. They found that TEWL decreased 67% 30 min
after application, greatly enhancing repair of the severely defective barrier
throughout the 2-week study in relation to untreated skin. Bacterial cultures
of the skin revealed significantly decreased colonization by the resident
microflora, chiefly S. epidermidis. Positive blood and cerebrospinal cultures
were 33% in the treated group and 20.7% in the untreated group. Clinical
evaluation of the general condition of the skin showed increased scaling in
the control group and no xerosis in the treated group. Mild dermatitis (not
defined) was less apparent in the treated group.
My own group has previously conducted a pilot study on eight children
with comparable lesions of severe, itchy atopic dermatitis on opposite ante-
cubital spaces, comparing once-daily applications of the vehicle, which was
not oil rich, on one side, to Eucerin Cream on the opposite side. At the end of
3 weeks, there were no differences between the two sides in any clinical cri-
teria of improvement. However, there was a marked difference in the time to
first relapse when treatment was discontinued. In three of the eight subjects,
the relapse time was the same, approximately 23 weeks. For the other five,
the vehicle-treated side showed a relapse time that was 2 weeks greater on the
Eucerin side in three subjects and 34 weeks greater in the remaining two.
The message here is that relapse times are relevant in comparing efficacy.

Treatments for Atopic Dermatitis

Awareness of the primary role of the stratum corneum in the pathogenesis

of chronic inflammatory diseases, of which atopic dermatitis is the best
example, has opened up new therapeutic options. Depletion of physiologic
lipid, especially ceramides, is a fundamental biochemical marker that
accounts for increased TEWL, decreased hydration and the signs of xerotic
dry skin [35]. Old-fashioned, traditional moisturizers, such as lanolin and
petrolatum, are helpful but remain trapped in the horny layer and do not
reach the viable epidermis. The newest formulations by contrast contain
physiologic ceramide-dominant lipids that penetrate the viable epidermis,
xx Introduction

are taken up by keratinocytes and then secreted into the intercellular lipid
domains of the stratum corneum, repairing the defective, leaky barrier
[36]. Barrier repair creams are now very popular moisturizers, on full
display on the shelves of pharmacies [12]. One of these physiologic lipid
creams, EpiCeram, containing the correct molar 1:1:1 ratio of ceramides,
cholesterol and fatty acids, employed as monotherapy for atopic dermati-
tis, has been shown to be as effective as a mid-potency corticosteroid fluti-
cortisone (Cuterate) [37]. Another very welcome advantage of these
ceramide-dominant creams is their preparation in the form of foams that
leave no residue and are pleasant to use, completely avoiding the messi-
ness of ointments.
The historical origins of corneotherapy for this application derive from the
numerous, innovative works of Elias and co-workers in San Diego, California.
They first laid out this approach in a 2001 paper with this interesting title,
Does the tail wag the dog?, in which they introduced the concept of out-
side-in therapy, a novel and radical notion in the current age of immunology
which holds that in common chronic inflammatory disorders, such as psoria-
sis, the abnormal T cells in the circulation become trapped in the dermis,
which causes derangements in the overlying epidermis and stratum corneum
[38]. Which Elias et al. have dubbed the inside-out concept of pathogenesis,
the stratum corneum alterations are secondary downstream events [39, 40].
Accordingly, the rational therapeutic approach is the use of anti-inflammatory
agents, notably corticosteroids and immunosuppressives, such as calcineurin
inhibitors, to suppress the dermal inflammatory reaction that in turn leads to
the normalization of the impaired horny layer barrier. By contrast, outside-in
therapy assumes that the abnormal horny layer is the primary pathologic
event, the correction that mitigates the underlying dermal inflammatory reac-
tion. This turns the conventional anti-inflammatory approach upside down;
clinical clearing occurs as a downstream event secondary to restoration of the
affected horny layer barrier. Incidentally, this highlights an unusual feature of
corneotherapy, which in its form does not require the use of pharmacologi-
cally active drugs, a case in point being bland emollients and occlusive dress-
ings. In this sense, corneotherapy is more benign as it avoids atrophogenic
events such as atrophy and striae. It should be noted that the inside-out and
outside-in approaches are not actually exclusive but are often complimentary
in the real world.
Perturbations of the permeability barrier regardless of type, solvents, tape
stripping, detergents, burns and mechanical, physical and chemical injuries
all result in the stimulation of metabolic responses in the underlying epider-
mis aimed at normalizing the stratum corneum. The most notable response is
the initiation of the cytokine and chemokine cascade, referring to the release
of preformed pools of IL-Ia and TNF-b adhesion molecules, including
Langerhans cell activation, inducing further downstream effects leading to
trapping of circulating inflammatory cells in the dermis, angiogenesis and
fibroplasia.
The cytokine cascade can provoke and sustain several important chronic
inflammatory dermatoses accompanied by the accumulation of abnormal T
cells in psoriasis and atopic dermatitis.
Introduction xxi

These changes are followed by barrier repair mechanisms, which these

workers divide into three types:
1. Dressings containing no active pharmacologic ingredients
2. Non-physiologic lipids such as petrolatum and hydrophobic emulsions
(Aquaphor)
3. Physiologic lipids comprising cholesterol, ceramides and free fatty acids
in proper proportions
Non-physiologic lipids, for example, hydrophobic emulsions, such as
Eucerin or Aquaphor, are indicated in extremely low-birth weight, prema-
ture infants, as they entirely lack a lamellar body secretory system and have
no way to process physiologic lipids. On the other hand, physiologic lipids
are indicated in atopic dermatitis and photoaged skin where depletion of
ceramides has been demonstrated. In these cases and other disorders, a defi-
ciency of lipids, application of ceramide-dominant physiologic lipids is the
preferred strategy for barrier repair as the mechanism for exocytic process-
ing of lamellar bodies into intercorneocytic bilamellar membranes is already
in place.
Defective barriers can arise in a wide range of dermatologic disorders; for
example, in bullous diseases, chronologic ageing and phototoxic reactions.
Barrier defects associated with immunologic or pathophysiologic changes are
common and familiar examples, including psoriasis, irritant and allergic con-
tact dermatitis, hypertrophic scars and keloids, occupational dermatitis and
congenital ichthyosis, and, of course, atopic dermatitis has yielded new insights
regarding pathogenesis and has suggested novel approaches to treatment.
Originally it was thought that abnormalities of the adaptive immune func-
tions were key features in pathogenesis involving Th1/Th2 cell dysregulation,
increased IgE production, dendritic cell (Langerhans) signalling and produc-
tion of mast cell mediators, resulting in the intense pruritus and chronic
inflammatory changes that characterize this disorder. These clinical manifes-
tations have been widely assumed to reflect downstream consequences of the
immunologic abnormalities, the basis for the historical insideoutside con-
cept, promoting the use of anti-inflammatory agents to effect clinical clearing
[3840]. This traditional view has been challenged, indeed completely reori-
ented as a primary disorder of the structure and function of the stratum cor-
neum. Accordingly, the well-known permeability barrier abnormality in AD
is not merely an epiphenomenon, a downstream consequence of inflamma-
tion, but is in fact the very revision, the driver of disease activity, the newly
constructed outsideinside view of pathogenesis. This revision is strength-
ened by the observation that the barrier abnormality persists years after clini-
cal clearing, both in involved and uninvolved skin, and that specific
replacement of the depleted physiologic lipids that are a hallmark feature not
only corrects the barrier deficiency but comprises effective anti-inflammatory
activities, replacing the use of atrophogenic corticosteroids. Furthermore, the
characteristic increase in surface pH, increased serum protease activity, expo-
sure to low environmental relative humidity, increased use of detergents for
washing and barrier impairment by psychologic stress all point to weakening
of the barrier as a primary factor in pathogenesis. The ascending view is that
atopic dermatitis represents a genetically determined broad barrier failure.
xxii Introduction

These convergent pathologic features create a strong rationale for the deploy-
ment of specific strategy to restore barrier function, ranging from a simple
reduction in pH (acidification), application of well-described effective mois-
turizers that have been shown to steroid-sparing application of serine protease
inhibitors, culminating in the recent commercial development of ceramide-
rich, triple lipid, barrier repair creams, notably EpiCeram (Ceragenix
Pharmaceuticals, Denver, Colorado), which has been shown to be therapeuti-
cally equivalent to a high-potency corticosteroid, fluticasone [41]. For a more
complete discussion of the genetic factors underlying atopic dermatitis, the
essay by Michael Cork entitled Epidermal barrier dysfunction in atopic der-
matitis, is a splendid, highly informative review of current knowledge [42].
Finally, the paper by Voegeli, Rawlings and collaborators on increased
stratum corneum protease actively provides a detailed account of recent
developments and novel therapeutic options [43]. These investigators demon-
strated increased protease activity in atopic dermatitis, including tryptase-like
enzyme, plasmin, urokinase and leucocyte elastase, associated with impaired
barrier function, irritation and reduced capacitance (hydration). These find-
ings suggest that serine protease inhibitors present a new option for the effec-
tive treatment of atopic dermatitis.

The Steroid-Sparing Effects of Emollients

Physicians, including dermatologists, have fallen into the habit, long sanc-
tioned by tradition, of prescribing topical drugs to be applied twice and even
three times daily. This is almost a reflex decision, not validated by evidence-
based medicine. In no instance is this practice less rational and potentially
more harmful than in the case of topical corticosteroids, which are first-line
treatments for chronic inflammatory disorders. Recent studies have made it
abundantly clear that once-daily applications of corticosteroids alternating
with an emollient, usually the vehicle, are therapeutically equivalent to twice-
daily applications of the corticosteroid.
Once-daily applications are salutary for two obvious reasons: the savings
in cost are considerable, especially for the most potent steroids that are outra-
geously expensive; additionally, once-daily applications reduce the threat of
adverse reactions such as atrophy, striae, rebound flares and inhibition of the
pituitaryadrenal axis, especially when long-term use is required. Convincing
examples of the benefits of once-daily applications abound, especially for
atopic dermatitis.
In 25 children with atopic dermatitis, Lucky et al. compared the efficacy
of twice-daily applications of 2.5% hydrocortisone cream to once-daily appli-
cations of the steroid alternating with an oil-rich emollient once daily (Eucerin
Cream, Beiersdorf) [44]. There were no differences between the two groups
at the end of 3 weeks of treatment. Both were equally effective. A high degree
of satisfaction was registered by the parents and the investigators for the alter-
nating regimen. Note that the emollient was Eucerin, not the vehicle base of
the hydrocortisone cream. The vehicle is generally inferior to a time-tested
oil-rich emollient.
Introduction xxiii

In a similar large, multi-centred study in the United Kingdom, Bleehen

et al. [45] treated 275 patients with moderate to severe atopic dermatitis,
comparing twice-daily applications of 0.05% fluticasone propionate cream to
once-daily application of the steroid alternating with the vehicle base. No
differences were noted in therapeutic efficacy.
Kanzler treated 24 patients with plaque-type psoriasis, comparing twice-
daily applications of 0.1% triamcinolone acetonide cream, a mid-potency
corticosteroid, to once-daily application of the steroid alternating with its
vehicle base, as in the earlier studies [46]. At the end of 4 weeks and all inter-
vals in between, no differences in efficacy could be discerned. He also made
the important observation that emollients alone can improve psoriatic plaques
by as much as 25%. He urged, as we and others concur, to break the habit of
twice-daily applications of corticosteroids, especially when using high-
potency steroids.
Watsky et al. [47], continuing in the same vein, treated 56 male and 40
female psoriatic patients with twice-daily application of a high-potency
steroid, betamethasone dipropionate, in comparison with once-daily
application of the steroid alternating with once-daily application of an oil-
rich emollient (Eucerin Cream; Beiersdorf, Hamburg, Germany) for
4 weeks.
Again, at all intervals, the two regimens gave identical results in respect of
all clinical signs and symptoms of plaque-type psoriasis as well as clinical
grading. It is noteworthy that the subjects themselves uniformly expressed
satisfaction with the alternating regimen. These investigators also showed
that the alternating regimen was superior to once-daily betamethasone
dipropionate.
Finally, application of a potent steroid under a hydrocolloid dressing
(DuoDERM) was determined to be a steroid-sparing strategy par excellence.
Volden treated 48 patients with therapy-resistant atopic dermatitis including
hand eczema, nummular eczema, prurigenous lichenoid papules and lichenifi-
cations, with once-weekly applications of clobetasol propionate cream, under
occlusive DuoDERM hydrocolloid patches [48]. Complete clearing was
obtained in 44 of the 48 patients, generally by 2 weeks. Volden estimated that
the amount of steroid required to obtain these impressive results was one-
twentieth to one-hundredth of the amount used in daily unocclusive
applications.

The Stratum Corneum as a Depot for Topically Applied Drugs

In 1955, Malkinson and Ferguson, studying the penetration of radiolabelled

hydrocortisone in humans, proposed that the stratum corneum might serve as a
depot for topical drugs [49]. They suggested, wrongly as it turned out, that the
open spaces within the airy basket weave stratum corneum might allow the
accumulation of drugs. It was Vickers in 1963 who unequivocally showed, in a
series of simple but elegant studies, that the horny layer was a reservoir for topi-
cal drugs [50]. He applied the corticosteroids, fluocinoline acetonide and triam-
cinolone acetonide, under Saran Wrap, an impermeable plastic film, which in
xxiv Introduction

less than a day produced visible vasoconstriction, lasting for 1012 h after
removing the film. He then showed that vasoconstriction (blanching) could be
recalled for up to 2 weeks by simply reapplying Saran Wrap. This manoeuvre
released the steroid stored from within the interstices of the horny layer.
Since then, many examples of the depot effect have been reported using a
variety of lipid-soluble drugs. Roberts, Gross and Anissimov have developed
rigorous pharmacokinetic models of the various factors, such as partition
coefficients and diffusivity, which predict deposition of the drug [51].
One of the earliest examples of the depot effect, not understood at the time,
relates to systemic toxicity, including death of newborn babies by using a
hexachlorophene-containing detergent to wash the diaper area. Hexachlorophene
had been used for decades with no hint of adverse events, having achieved an
excellent safety record. It turned out that while single washings were innocuous,
repeated washings led to a build-up of hexachlorophene in the stratum corneum.
Wetness of the diaper area increased permeability, as is now well known [52].
Unawareness of the depot effect can be harmful. For example, shower and
bath oils are now very popular for their convenience in treating dry skin over
the whole body. Consumers of these bath oils have been led to believe that
these products are unusually safe and are in addition an effective way to
deliver oils to combat xerosis. Loden and co-workers, however, have called
attention to an unexpected adverse effect especially when used by people
with sensitive skin. They applied 10% solutions of eight popular bath oils in
Finn chambers for 24 h, followed by rinsing. Surprisingly, four of the oils
produced a clear-cut irritant reaction, verified by increased TEWL and
increased blood flow by laser Doppler velocimetry. Three other oils had neg-
ligible effects similar to a negative water control. They then rubbed some of
each undiluted bath oil for 5 s over each rinsed site, followed by another 5 s
rinsing with tap water. The sites were then covered with empty Finn cham-
bers for 24 h with the intent of hydrating the skin by preventing TEWL. One
of the oils, containing MIPA-laureth sulphate, showed an irritant reaction
under the empty chambers. Thus, so-called protective oil films may increase
the risk of an irritant by inducing a subclinical, invisible injury [53].
The depot effect may turn up unexpectedly under rather surprising circum-
stances. For example, the application of 10% lactic acid to the nasalar cheek
for 10 min, followed by rinsing, is often used to identify persons with sensi-
tive skin, who typically experience stinging, peaking in about 8 min, as orig-
inally described by Frosch and Kligman in 1977 [54]. The site was rinsed
with tap water at the end of the test to remove the residue. We studied many
factors that influence the stinging reaction but did not anticipate one feature
that was brought to our attention by some subjects, namely that taking a
shower hours after the application of 10% lactic acid resulted in recall of
stinging to the original level.
We examined the recall phenomenon more closely in five women who
were moderate lactic acid stingers. Recall was provoked at various inter-
vals by covering the site with a 2 square of non-woven cloth (Webril) satu-
rated with water, sealed under impermeable tape for 10 min, thoroughly
wetting the site. After a 1-h interval, wet Webril fully restored stinging to the
original degree. After 3 h, the stinging was slightly less. By 6 h, stinging was
Introduction xxv

barely perceptible in three of five subjects and was no longer evident by

24 h. In another study of the same five subjects, the lactic acid site was not
rinsed off after the 10-min application. In that case, moderate stinging was
recalled in four of the five subjects after a 48-h interval but was no longer
perceptible after 72 h. Our interpretation is that lactic acid established a
depot in the horny layer of the face, known to be more permeable than other
body areas. Wetting the site swelled the horny layer, releasing the stored
lactic acid.
Knowledge of the storage effect, presently underappreciated, may impact
clinical practices. A good example is the use of topical anaesthetics to reduce
pain from minor surgical procedures or exposure to lasers. Friedman et al.
[55] compared the efficacy of four topical anaesthetics applied for 1 h under
occlusion and tested for the degree of induced anaesthesia by pulses from a
Q-switched Nd:Yag laser.
Two of the four yielded more anaesthesia at the end of 60 min. The most
interesting finding, however, was that the anaesthesia increased with all four
when tested 30 min after the 60-min exposure. The authors correctly sur-
mised that a reservoir had been stored in the upper skin layers, doubtless the
horny layer, supporting the practical suggestion of ArendsNielson and
Bjerring that patients should apply the anaesthetic under occlusion for 1 h at
home before going to the office for painful laser treatment [56].

The Effect of Dressings on Disorders in Which the Human

Barrier Layer Is Defective

In 1985, R. Shore, a practising dermatologist, made the serendipitous obser-

vation that a Band-Aid left in place over a psoriatic plaque for 3 weeks
resulted in clinical clearing of the plaque, surprising enough to warrant pub-
lication in the New England Journal of Medicine [57]. One year later, he
looked at various factors that might enable impermeable dressing to resolve
psoriatic plaques. He found that:
1. It was best to leave the tapes in place continuously for at least 1 week.
2. Two- to 3-week continuous applications were necessary for complete
clearing.
3. Occlusive tapes were more effective than semipermeable ones.
4. Application of a moderately potent corticosteroid under the tapes enhanced
efficacy.
5. The occluded sites stayed clear for at least 2 weeks and sometimes as long
as 1 year.
Shore could offer no plausible explanation for the effects of occlusion, a
mystery that remains mostly unsolved to this very day. Earlier in 1970, Fry
et al. [58] had made some preliminary observations that occlusive dressings
might cause clearing of psoriatic plaques, but the findings were inconclusive
and did not stimulate further work. It is worth noting, for historical accuracy,
that Tree and Marks in 1975 had noted incidentally, while trying to explain
the placebo effect of bland ointments, that occlusion alone inhibited the
increased mitotic rate induced by tape stripping of hairless mice [12].
xxvi Introduction

Interestingly, India-rubber (gutta-percha) dressing, which is occlusive,

had been intensively used in the latter half of the nineteenth century in Hebras
clinic in Vienna to treat various dermatologic disorders, apparently with suc-
cessful outcomes in many cases. India-rubber was eventually abandoned
when it was determined that it often induced allergic contact dermatitis.
Actually, it was Winters classical observations in 1962 that scabs would
not form over wounds that were kept moist under semipermeable dressings,
warning that complete occlusion might be harmful by inducing maceration
[59]. In any case, it is relevant to the thesis of corneotherapy, which we are
proposing, that the horny layer barrier is invariably defective in all chronic
inflammatory dermatoses, such as atopic dermatitis and psoriasis, and that
repair of the barrier by whatever means, pharmacologically or by dressings,
is a prerequisite for healing. Furthermore, a great variety of dressing devices
have flooded the marketplace, whose efficacy in correcting barrier-impaired
dermatoses can no longer be questioned.
My intent in this section is to review the results of various experimenters,
including my own group, to exploit the dressing technologies to promote
repair of impaired barrier in various disease states. A good place to begin is
the extensive studies by Visscher et al. [60] on the effect of semipermeable
dressings in superficial, non-ablative wounds, inflicted on forearm skin by
partial tape stripping of the stratum corneum. They found that semipermeable
dressings provided the optimal water gradient for repair of the defective horny
layer, while complete occlusion actually retarded healing as measured by sev-
eral bioengineering techniques. I strongly recommend close reading of this
paper for the insights it provides, especially for bringing forward and elabo-
rating the new concept of comfort science. In this view, the stratum corneum
functions as a biological smart material important for imparting the visual
and tactile sensory signal processing, which determines fabrics that are most
comfortable to wear. I have also identified the stratum corneum as a smart
tissue that acts as a biosensor of external environmental changes, reacting
adaptively to restore homeostatic equilibrium. I note that this is the first paper
to use the term corneotherapy, borrowed from me, which in this case is an
illustration of the practical application of comfort science. The most complete
scientific analysis of comfort science is to be found in the publication by
Hoath et al. titled Sensory transduction and the mammalian epidermis [61].
The area that has received the greatest amount of experimental attention
regarding dressings and which has provided the most information and insights
regarding mechanisms relates to the treatment of psoriatic plaques following
the footsteps of Shores Band-Aid discoveries [57]. The 1995 paper by
Christophers et al. [62] is perhaps the most informative and revealing regard-
ing problems encountered. They begin at the outset with the frank statement
that the mechanisms are unknown. Their focus was on the diverse immuno-
logic events in psoriatic plaques under occlusion therapy for 1 week. They
compared occlusion alone, fluocinomide alone for 3 weeks and the combina-
tion of the two, finding by global clinical estimation that occlusion alone was
just as effective as fluocinomide alone, whereas, of course, the combination
of the two was the most effective compared to the untreated control. They
Introduction xxvii

used a battery of immunohistologic techniques in a quest to explain the

beneficial effects of a 1-week course of occlusive dressings now that it is
understood that psoriasis is an activated T-cell dependent, immunologic-
mediated disorder. The epidermal immunologic tests included CD4-T cells,
CT8-T cells, Langerhans cells, keratinocyte ICAM-I, IL-8 and others. The
dermal tests added endothelial E-selections. The startling finding was that
none of these tests were effective by any of the three treatment groups, prof-
fering not even a clue to the mode of action.
These findings were mostly an agreement with Gottlieb et al. [63] who
after 2 weeks of occlusion could detect no reduction in immunological mark-
ers. Likewise, van Vlijmen-Willems et al. [64] found no reduction along epi-
dermal keratinocytes after 3 weeks of occlusion. The startling disparity
between clinical clearing and total lack of immunologic changes is a paradox
yet to be resolved. In a way, the absence of immunologic changes is consis-
tent with my earlier findings in my thesis of Invisible dermatology that the
characteristic histologic changes of psoriasis, acanthosis and lymphocytic
infiltrates were still present many months after clearing of psoriatic plaques
by potent corticosteroids [65].
The later report by Hwang et al. [66] in 2001 was fortunately more enlight-
ening than the previous negative reports. These workers focused on the effects
of prolonged occlusion in calcium gradients that are known to be disturbed in
psoriasis, along with histologic changes revealed by electron microscopy.
After 7 days of occlusion, they observed dramatic changes in the parameters
under study. They found by light microscopy that 7 days of occlusion resulted
in markedly decreased parakeratosis, hyperkeratosis and neutrophilic infil-
trates. By electron microscopy, utilizing ruthenium staining of the intercel-
lular spaces, they were able to show striking changes, viz. decreased epidermal
thickness and decreased lipid droplets in the stratum corneum, and normal-
ization of intercorneocyte lipid layers, which are scanty and dressed in
untreated prose. Increased secretion of lamellar bodies was also noted; in
short, almost complete restoration of the abnormal TEM changes. Moreover,
the markedly distorted loss of the normal calcium gradient was completely
restored to the normal gradient in which Ca deposition is very low in the
basal cell layer, reaching a peak level in the outer stratum corneum. Thus,
normalization of the epidermal calcium gradient appears to be responsible
for the correction of the proliferation and differentiation defects in psoriatic
plaques. Although immunologic markers may not be altered by occlusive
dressings, it has been shown that for 3 weeks of occlusion therapy with
hydrocolloid dressings in psoriasis, expression of differentiating markers
such as filaggrin and involucrin was normalized. This has important implica-
tions in that these two markers are important for the generation of natural
moisturizing factors (NMF) that keep the stratum corneum hydrated even in
a dry environment.
Occlusive therapy has become a field unto itself and has resulted in the
industrial manufacture of a variety of devices, notable among which are
hydrocolloid dressings that are not only occlusive but have the special feature
of providing hydration.
xxviii Introduction

Effect of Occlusive Dressing on Keloids and Hypertrophic Scars

In studies of the pathogenesis of keloids and hypertrophic scars, investigators

have focused almost exclusively on the prominent changes of the dermal
matrix, viz. increased deposition of collagen resulting in elevated indurated
lesions, increased production of glycosaminoglycans (GAGs) and increased
density of mast cells throughout the upper and lower dermis. Mast cells have
received particular attention because they secrete a variety of chemical medi-
ators that could explain the symptoms of itching, pain and inflammation asso-
ciated with these scars. Little thought has been given to the possible role of
the epidermis and stratum corneum when the pathologic changes are consid-
ered downstream, events secondary to alterations of the dermal matrix.
An alternative view was proposed by Suetake and co-workers in Japan who
undertook an analysis of the functional changes of the stratum corneum overlying
hypertrophic scars and keloids reported in 1996 [67]. Clinically, the surface
seemed rather dry but they found by non-invasive hygrometric measurements that
the surface was actually more hydrated than the surrounding skin. They deter-
mined that the horny layer was markedly defective as shown by a great increase
in TEWL, indicating a leaky, permeable barrier. Moreover, the turnover time of
the horny layer was decreased at least twofold, reflecting increased proliferative
activity in the basal layer of the epidermis. Unlike other proliferative disorders,
such as atopic dermatitis and psoriasis, they found that the water-holding capacity
of the horny layer was increased, not decreased, as is usually the case.
Four years later, this same group, intrigued by the observation of a number
of researchers that silicone gel sheets flattened and resolved keloid and hyper-
trophic scars, undertook a functional analysis of the horny layer overlying
these scars [68]. Having found that the horny layer over scars was more
hydrated than the surrounding skin, they questioned the prevalent idea that
water retention induced by occlusion could be a factor in the efficacy of sili-
cone sheets. They compared silicone sheets to an impermeable plastic, Saran
Wrap, renewed daily for 1 week, having established that the TEWL of both
devices was equal, 0.5 g m2/h. They first studied two subjects, one on the
normal forearm of a young woman and another on a split-thickness donor
graft site. They undertook a functional analysis of the stratum corneum on
days 1 and 7, using qualitative non-invasive methodologies described by
Tagami. The stratum corneum changes were strikingly different for the two
impermeable dressings. After 1 day, water uptake (hygroscopicity) was much
greater with Saran Wrap than the silicone sheet, indicating increased hydra-
tion. After 7 days, the hydration level fell with the silicone sheet and stayed
the same with Saran Wrap. After 1 day, TEWL was measured 30 min after
removal of the dressings and was much greater with Saran Wrap than with
silicone, increasing further after 7 days, staying the same after 7 days and
again reflecting greater uptake of water by Saran Wrap. The capacity to hold
water (hydrophilicity), revealed by sorptiondesorption kinetics, was as
expected greater after Saran Wrap than silicone, increasing further after
7 days of Saran Wrap. Additionally, two subjects with hypertrophic scars
were subjected to the same analysis of stratum corneum functions, with
Introduction xxix

results comparable to those described previously for normal skin. Interestingly,

these investigators likened the Saran Wrap results to those that were charac-
teristic of the changes induced by an effective moisturizer (Tagami).
The conclusion was that silicone sheets maintained a mild level of hydra-
tion, falling with continued exposures, compared to excessive hydration and
water-holding capacity with Saran Wrap. Clinicians were aware that exces-
sive exposure to water in such occupations as hair tending, cannery workers
and dishwashers experienced adverse effects that Kligman described under
the heading of hydration dermatitis [69].
Finally, Elias et al. [70] (P.M. Elias, unpublished data) treated six keloid
patients with silicone gel sheets for 24 weeks and demonstrated unequivocal
benefits in regard to reductions in itching, pain, redness and elevation, already
evident by 4 weeks, with steady improvements over 24 weeks, with complete
disappearance of itching and pain.
My group performed pilot studies on two young men with extremely dense
and elevated hypertrophic scars associated with severe acne conglobata of the
upper back. We compared three treatments on 3-in. squares with symmetrical
scars: (1) silicone gel sheets changed daily for 4 weeks, except on weekends;
(2) Saran Wrap changed every 3 days for 4 weeks, sealed under occlusive
Blenderm tape; and (3) water-saturated non-woven cotton pads (Webril)
sealed under Blenderm tape, changed every 3 days. By the end of 4 weeks, we
estimated a modest flattening of the scars with fading of erythema with sili-
cone sheets, somewhat less so with Saran Wrap. By contrast, we had to stop
the wet Webril applications after 6 and 9 days, respectively, owing to a fierce
exacerbation of inflammation, pain, exudation, maceration and oedema, signs
that slowly resolved after b.i.d. applications of 0.05% clobetasol propionate
cream. This was a dramatic illustration of hydration dermatitis.
Perhaps the most instructive finding of the study by Elias et al. [70] (P.M.
Elias, unpublished data) was a decreased density of mast cells throughout the
upper and lower dermis, revealed by toluidine blue staining. Mast cells are
known to secrete a number of chemical mediators, especially histamine and
substance P, which presumably explains the relief of itching, pain and redness
by silicone sheets, which are valuable not only for treatment but for the pre-
vention of emerging scars after surgical excisions (Fulton).
Elias et al. [70] (P.M. Elias, unpublished data) have synthesized these
findings into a plausible hypothesis of the mechanisms by which silicone
sheets exert their beneficial effects, starting with the proved demonstration
that the horny layers overlying keloid and hypertrophic scars are defective,
structurally deranged and functionally more permeable, known also to be
a reservoir or storage depot of pro-inflammatory substances. Accordingly,
primary cytokines are released that stimulate the formation of additional
cytokines, resulting in a downstream cascade of additional cytokines,
adhesion molecules and other mediators. Fibroplasia and angiogenesis
are subsequently engendered, which lead to increased production of col-
lagen and GAGs, prominent features of scars. The therapeutic end game is
restoration of the impaired barrier that would interrupt this pathogenic
sequence.
xxx Introduction

Conclusions

Corneobiology refers to that broad range of experimental studies that are

focused on the anatomy, physiology and biology of the stratum corneum,
centred particularly on the human horny layer that has features uniquely dif-
ferent from other mammals. Corneobiology has a very broad reach, encom-
passing studies that deal with immunology, endocrinology, neurobiology and
psychology, comprising a network of complex interactions that have connec-
tions to the central nervous system. It has attracted the attention of a confed-
eration of scientists from very different disciplines, including molecular
biologists, anatomists, physiologists, pharmacologists, geneticists, psycholo-
gists and still others. Corneotherapy refers to preventive interventions that are
primarily directed to the correction and restoration of the stratum corneum
barrier that has been rendered defective and impaired by disease, genetics and
a variety of mechanical, physical, chemical and psychological exogenous
insults and stresses. Contributors to building the edifice, we now call corneo-
biology, are a motley, diverse crew of investigators, mainly situated in indus-
try and academia from around the world.
AV Rawlings has recently named me as the father of corneobiology [71], a
high tribute that I hope represents the consensus of the world of corneobiologists.

Acknowledgements

The compilation of this review was initiated by Lorraine Kligman in memory

of her husband. Dr. AV Rawlings assisted in compiling the document in coop-
eration with Ms. Anne Rulinski, Department of Dermatology, University of
Pennsylvania, USA.

References
1. Kligman AM (1964) The biology of the stratum corneum. In: Montagna W, Lobitz WB
(eds) The epidermis. Academic Press, New York, pp 387433
2. Kligman AM (2006) A brief history of how the dead stratum corneum became alive.
In: Elias PM, Feingold KR (eds) Skin barrier. Taylor & Francis, New York, pp 1524
3. Rothman S (1954) Physiology and biochemistry of skin. University of Chicago Press,
Chicago, pp 64
4. Christophers E, Kligman AM (1964) Visualization of the cell layers of the stratum
corneum. J Invest Dermatol 42:407409
5. Elias PM (2005) Stratum corneum defensive functions: an integrated view. J Invest
Dermatol 125(2):183200
6. Elias PM, Feingold KR (2006) Skin barrier. Taylor & Francis, New York
7. Pedersen L, Jemec GB (2006) Mechanical properties and barrier function of healthy
human skin. Acta Derm Venereol 86(4):308311
8. Rawlings AV, Watkinson A, Harding C, Hope J, Scott IR (1995) Changes in stratum
corneum lipid structure and water barrier function during mechanical stress. J Soc
Cosmet Chem 46:141151
9. Rawlings A (2009) Fifty years of stratum corneum and moisturisation research. IFSCC
Mag 12:169170
Introduction xxxi

10. Rawlings AV, Scott IR, Harding C, Bowser P (1994) Stratum corneum moisturisation
at the molecular level. J Invest Dermatol 103:731740
11. Marks R (1972) Histochemical applications of skin surface biopsy. Br J Dermatol
86(1):2026
12. Tree S, Marks R (1975) An explanation for the placebo effect of bland ointment
bases. Br J Dermatol 92(2):195198
13. Takematsu H, Ohmoto Y, Tagami H (1990) Decreased levels of IL-1 alpha and beta in
psoriatic lesional skin. Tohoku J Exp Med 161(3):159169
14. Dalziel K, Dykes PJ, Marks R (1984) Inflammation due to intra-cutaneous implanta-
tion of stratum corneum. Br J Exp Pathol 65(1):107115
15. Nickoloff BJ, Naidu Y (1994) Perturbation of epidermal barrier function correlates
with initiation of cytokine cascade in human skin. J Am Acad Dermatol
30(4):535546
16. Nickoloff BJ (1995) Immunological reactions triggered during irritant contact derma-
titis. Am J Contact Dermat 9:107109
17. Scheuplein RJ, Blank IH (1971) Permeability of the skin. Physiol Rev 51(4):702747
18. Richter T, Peuckert C, Sattler M et al (2004) Dead but highly dynamic the stratum
corneum is divided into three hydration zones. Skin Pharmacol Physiol
17(5):246257
19. Pfeiffer S, Vielhaber G, Vietzke JP, Wittern KP, Hintze U, Wepf R (2000) High-pressure
freezing provides new information on human epidermis: simultaneous protein antigen
and lamellar lipid structure preservation. Study on human epidermis by cryoimmobili-
zation. J Invest Dermatol 114(5):10301038
20. Menon GK, Elias PM (1997) Morphologic basis for a pore-pathway in mammalian
stratum corneum. Skin Pharmacol 10(56):235246
21. Penneys NS, Eaglstein W, Ziboh V (1980) Petrolatum: interference with the oxidation
of arachidonic acid. Br J Dermatol 103(3):257262
22. Comaish JS, Greener JS (1976) The inhibiting effect of soft paraffin on the Kobner
response in psoriasis. Br J Dermatol 94(2):195200
23. Kligman LH, Kligman AM (1992) Petrolatum and other hydrophobic emollients
reduce UVB-induced damage. J Dermatolog Treat 3:37
24. Kligman AM (1978) Regression method for testing the efficacy of moisturizers.
Cosmet Toilet 93:2736
25. Held E, Sveinsdottir S, Agner T (1999) Effect of long-term use of moisturizer on skin
hydration, barrier function and susceptibility to irritants. Acta Derm Venereol
79(1):4951
26. Hara M, Verkman AS (2003) Glycerol replacement corrects defective skin hydration,
elasticity, and barrier function in aquaporin-3-deficient mice. Proc Natl Acad Sci U S
A 100(12):73607365
27. Rawlings AV, Watkinson A, Hope J, Harding C, Sabin R (1995) The effect of glycerol
and humidity on desmosome degradation in stratum corneum. Arch Dermatol Res
36:19361944
28. Hirao T, Denda M, Takahashi M (2001) Identification of immature cornified envelopes
in the barrier-impaired epidermis by characterization of their hydrophobicity and anti-
genicities of the components. Exp Dermatol 10(1):3544
29. Hirao T, Takahashi M, Kikuchi K, Terui T, Tagami H (2003) A novel non-invasive
evaluation method of cornified envelope maturation in the stratum corneum provides a
new insight for skin care cosmetics. IFSCC Mag 6(2):103109
30. Kikuchi K, Tagami H (2008) Noninvasive biophysical assessments of the efficacy of a
moisturizing cosmetic cream base for patients with atopic dermatitis during different
seasons. Br J Dermatol 158(5):969978
31. Harding CR, Long S, Richardson J et al (2003) The cornified cell envelope: an impor-
tant marker of stratum corneum maturation in healthy and dry skin. Int J Cosmet Sci
25(4):157167
32. Barker N, Hadgraft J, Rutter N (1987) Skin permeability in the newborn. J Invest
Dermatol 88(4):409411
33. Gladstone IM, Clapper L, Thorp JW, Wright DI (1988) Randomized study of six
umbilical cord care regimens. Comparing length of attachment, microbial control, and
satisfaction. Clin Pediatr (Phila) 27(3):127129
xxxii Introduction

34. Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ, Lane AT (1996)
Topical ointment therapy benefits premature infants. J Pediatr 128(5 Pt 1):
660669
35. Imokawa G, Abe A, Jin K, Higaki Y, Kawashima M, Hidano A (1991) Decreased level
of ceramides in stratum corneum of atopic dermatitis: an etiologic factor in atopic dry
skin? J Invest Dermatol 96(4):523526
36. Elias PM (2006) Epilogue: fixing the barrier theory and rationale deployment. In:
Elias PM, Feingold KR (eds) Skin barrier. Taylor & Francis, New York, pp 591600
37. Sugarman JL (2008) The epidermal barrier in atopic dermatitis. Semin Cutan Med
Surg 27(2):108114
38. Elias PM, Feingold KR (2001) Does the tail wag the dog? Role of the barrier in the
pathogenesis of inflammatory dermatoses and therapeutic implications. Arch Dermatol
137(8):10791081
39. Elias PM, Hatano Y, Williams ML (2008) Basis for the barrier abnormality in atopic
dermatitis: outside-inside-outside pathogenic mechanisms. J Allergy Clin Immunol
121(6):13371343
40. Elias PM, Steinhoff M (2008) Outside-to-inside (and now back to outside) patho-
genic mechanisms in atopic dermatitis. J Invest Dermatol 128(5):10671070
41. Sugarman JL, Parish LC (2009) Efficacy of a lipid-based barrier repair formulation in
moderate-to-severe pediatric atopic dermatitis. J Drugs Dermatol 8(12):11061111
42. Cork MJ, Danby SG, Vasilopoulos Y et al (2009) Epidermal barrier dysfunction in
atopic dermatitis. J Invest Dermatol 129(8):18921908
43. Voegeli R, Rawlings AV, Breternitz M, Doppler S, Schreier T, Fluhr JW (2009)
Increased stratum corneum serine protease activity in acute eczematous atopic skin. Br
J Dermatol 161(1):7077
44. Lucky AW, Leach AD, Laskarzewski P, Wenck H (1997) Use of an emollient as a ste-
roid-sparing agent in the treatment of mild to moderate atopic dermatitis in children.
Pediatr Dermatol 14(4):321324
45. Bleehen SS, Chu AC, Hamann I, Holden C, Hunter JA, Marks R (1995) Fluticasone
propionate 0.05% cream in the treatment of atopic eczema: a multicentre study com-
paring once-daily treatment and once-daily vehicle cream application versus twice-
daily treatment. Br J Dermatol 133(4):592597
46. Kanzler MH, Chui C, Gorsulowsky DC (2001) Once-daily vs twice-daily triamcino-
lone acetonide cream for psoriasis. Arch Dermatol 137(11):15291532
47. Watsky KL, Freije L, Leneveu MC, Wenck HA, Leffell DJ (1992) Water-in-oil emol-
lients as steroid-sparing adjunctive therapy in the treatment of psoriasis. Cutis
50(5):383386
48. Volden G (1992) Successful treatment of therapy resistant atopic dermatitis with clo-
betasol propionate and a hydrocolloid occlusive dressing. Acta Derm Venereol Suppl
(Stockh) 176:126128
49. Malkinson FD, Ferguson EH (1955) Percutaneous absorption of hydrocortisone-4-C14
in two human subjects. J Invest Dermatol 25(5):281283
50. Vickers CF (1963) Existence of reservoir in the stratum corneum. Experimental proof.
Arch Dermatol 88:2023
51. Roberts MS, Cross SE, Anissimov YG (2004) Factors affecting the formation of a skin
reservoir for topically applied solutes. Skin Pharmacol Physiol 17(1):316
52. Marzulli FN, Maibach HI (1975) The hexachlorophene story. In: Maibach HI (ed)
Animal models in dermatology. Charles Livingston, New York, pp 156159
53. Loden M, Buraczewska I, Edlund F (2004) Irritation potential of bath and shower oils
before and after use: a double-blind randomized study. Br J Dermatol
150(6):11421147
54. Frosch PJ, Kligman AM (1977) A method of appraising the stinging capacity of topi-
cally applied substances. J Soc Cosmet Chem 28:197209
55. Friedman PM, Fogelman JP, Nouri K, Levine VJ, Ashinoff R (1999) Comparative
study of the efficacy of four topical anesthetics. Dermatol Surg 25(12):950954
56. Arendt-Nielsen L, Bjerring P (1988) Laser-induced pain for evaluation of local analge-
sia: a comparison of topical application (EMLA) and local injection (lidocaine). Anesth
Analg 67(2):115123
57. Shore RN (1985) Clearing of psoriatic lesions after the application of tape. N Engl J
Med 312(4):246
Introduction xxxiii

58. Fry L, Almeyda J, McMinn RM (1970) Effect of plastic occlusive dressings on psori-
atic epidermis. Br J Dermatol 82(5):458462
59. Winter GD (1995) Formation of the scab and the rate of epithelisation of superficial
wounds in the skin of the young domestic pig. 1962. J Wound Care 4(8):366367;
discussion 368371
60. Visscher M, Hoath SB, Conroy E, Wickett RR (2001) Effect of semipermeable mem-
branes on skin barrier repair following tape stripping. Arch Dermatol Res
293(10):491499
61. Hoath SB, Donnelly MM, Boissy RE (1990) Sensory transduction and the mammalian
epidermis. Biosens Bioelectron 5(5):351366
62. Christophers E, Griffiths CEM, Tranfaglia MG (1995) Prolonged occlusion in the treat-
ment of psoriasis. A clinical and immunochemical study. J Am Acad Dermatol
32:618622
63. Gottlieb AB, Staiano-Coico L, Cohen SR, Varghese M, Carter DM (1990) Occlusive
hydrocolloid dressings decrease keratinocyte population growth fraction and clinical
scale and skin thickness in active psoriatic plaques. J Dermatol Sci 1(2):9396
64. van Vlijmen-Willems IM, Chang A, Boezeman JB, van de Kerkhof PC (1993) The
immunohistochemical effect of a hydrocolloid occlusive dressing (DuoDERM E) in
psoriasis vulgaris. Dermatology 187(4):257262
65. Kligman AM (1966) Blind man dermatology. J Soc Cosmet Chem 17:505509
66. Hwang SM, Ahn SK, Menon GK, Choi EH, Lee SH (2001) Basis of occlusive therapy
in psoriasis: correcting defects in permeability barrier and calcium gradient. Int J
Dermatol 40(3):223231
67. Suetake T, Sasai S, Zhen YX, Ohi T, Tagami H (1996) Functional analyses of the stra-
tum corneum in scars. Sequential studies after injury and comparison among keloids,
hypertrophic scars, and atrophic scars. Arch Dermatol 132(12):14531458
68. Suetak T, Sasai S, Zhen YX, Tagami H (2000) Effects of silicone gel sheet on the stra-
tum corneum hydration. Br J Plast Surg 53(6):503507
69. Kligman AM (1996) Hydration injury to human skin. In: Van der Valk PGM, Maibach
HI (eds) The irritant contact dermatitis syndrome. CRC Press, Boca Raton, pp
187194
70. Elias PM, Ansel JC, Woods LD, Feingold KR (1996) Signaling networks in barrier
homeostasis. The mystery widens. Arch Dermatol 132(12):15051506
71. Rawlings AV (2008) What is the cutaneous barrier? Nouv Dermatol 27:9398
Contents

Part I The Marketplace and Treatment Aspects

1 Moisturizers as Cosmetics, Medicines, or Medical Device?
The Regulatory Demands in the European Union . . . . . . . . . . . 3
Amy Srensen, Peter Landvall, and Marie Lodn
2 Design of Claims Support for Moisturizers . . . . . . . . . . . . . . . . 17
Judith K. Woodford
3 Educational Interventions for the Management
of Children with Dry Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Steven J. Ersser and Noreen Heer Nicol
4 Dry Skin in Childhood and the Misery of Eczema
and Its Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Susan Lewis-Jones
5 Use of Moisturizers in Patients with Atopic Dermatitis . . . . . . 59
Kam Lun Ellis Hon and Alexander K.C. Leung

Part II Skin Essentials

6 Sensory Systems of Epidermal Keratinocytes . . . . . . . . . . . . . . 77
Mitsuhiro Denda
7 Sensitive Skin: Intrinsic and Extrinsic Contributors . . . . . . . . . 95
Miranda A. Farage and Michael K. Robinson
8 Electron Tomography of Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Lars Norln
9 Filaggrin Gene Defects and Dry Skin Barrier Function . . . . . . 119
Martin Willy Meyer and Jacob P. Thyssen
10 Molecular Organization of the Lipid Matrix
in Stratum Corneum and Its Relevance for
the Protective Functions of Human Skin. . . . . . . . . . . . . . . . . . . 125
Mila Boncheva
11 Desquamation: It Is Almost All About Proteases . . . . . . . . . . . . 149
Rainer Voegeli and Anthony V. Rawlings

xxxv
xxxvi Contents

12 Endogenous Retroviral-Like Aspartic Protease,

SASPase as a Key Modulator of Skin Moisturization . . . . . . . . 179
Takeshi Matsui
13 Vernix Caseosa and Its Substitutes:
Lipid Composition and Physicochemical Properties . . . . . . . . . 193
Marty O. Visscher and Steven B. Hoath
14 The Role of Tight Junctions and Aquaporins
in Skin Dryness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
J.M. Brandner
15 Biomechanics of the Barrier Function of Human
Stratum Corneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Kemal Levi and Reinhold H. Dauskardt

Part III Dry Skin Disorders and Treatments

16 Update on Atopic Eczema with Special Focus
on Dryness and the Impact of Moisturizers . . . . . . . . . . . . . . . . 257
Eric Simpson
17 Update on Hand Eczema with Special Focus
on the Impact of Moisturisers . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Christina Williams and Mark Wilkinson
18 Update on Ichthyosis with Special Emphasis on Dryness
and the Impact of Moisturizers . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Johannes Wohlrab
19 Psoriasis and Dry Skin: The Impact of Moisturizers. . . . . . . . . 285
Joachim W. Fluhr, Enzo Berardesca, and Razvigor Darlenski
20 Update on Infant Skin with Special Focus on Dryness
and the Impact of Moisturizers . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Georgios N. Stamatas and Neena K. Tierney

Part IV Ingredients and Treatment Effects

21 The Composition and Development of Moisturizers . . . . . . . . . 313
Steve Barton
22 Ungual Formulations: Topical Treatment of Nail Diseases . . . . 341
Kenneth A. Walters
23 Preservation of Moisturisers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
D. Godfrey
24 Potential Allergens in Moisturizing Creams . . . . . . . . . . . . . . . . 367
Ana Rita Travassos and An Goossens
25 Formulating Moisturizers Using Natural Raw Materials . . . . . 379
Swarnlata Saraf
26 Chemical and Physical Properties of Emollients . . . . . . . . . . . . 399
Jari T. Alander
Contents xxxvii

27 Polyfunctional Vehicles by the Use of Vegetable Oils . . . . . . . . . 419

Luigi Rigano and Chiara Andolfatto
28 The Effect of Natural Moisturizing Factors on the Interaction
Between Water Molecules and Keratin . . . . . . . . . . . . . . . . . . . . 431
Noriaki Nakagawa
29 Impact of Stratum Corneum Damage on Natural
Moisturizing Factor (NMF) in the Skin . . . . . . . . . . . . . . . . . . . 441
Lisa M. Kroll, Douglas R. Hoffman,
Corey Cunningham, and David W. Koenig
30 Water and Minerals in the Treatment of Dryness . . . . . . . . . . . 453
Ronni Wolf, Danny Wolf, Donald Rudikoff,
and Lawrence Charles Parish
31 Hyaluronan Inside and Outside of Skin . . . . . . . . . . . . . . . . . . . 459
Aziza Wahby, Kathleen Daddario DiCaprio, and Robert Stern
32 Glycerol as a Skin Barrier Influencing Humectant . . . . . . . . . . 473
Laurne Roussel, Nicolas Atrux-Tallau, and Fabrice Pirot
33 The Use of Urea in the Treatment of Dry Skin . . . . . . . . . . . . . . 481
Marie Lodn
34 Urea and Skin: A Well-Known Molecule Revisited . . . . . . . . . . 493
Alessandra Marini, Jean Krutmann, and Susanne Grether-Beck
35 The Influence of Climate on the Treatment of Dry Skin
with Moisturizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
C. Stick and E. Proksch
36 Emollient Therapy and Skin Barrier Function . . . . . . . . . . . . . 513
Majella E. Lane
37 Skin Barrier Responses to Moisturizers: Functional
and Biochemical Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Izabela Buraczewska-Norin
38 Changes in Stratum Corneum Thickness, Water Gradients
and Hydration by Moisturizers . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Jonathan M. Crowther, Paul J. Matts, and Joseph R. Kaczvinsky
39 Skin Moisture and Heat Transfer . . . . . . . . . . . . . . . . . . . . . . . . 561
Jerrold Scott Petrofsky and Lee Berk
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
 Part I
The Marketplace and Treatment Aspects
 Moisturizers as Cosmetics,
Medicines, or Medical Device? 1
The Regulatory Demands
in the European Union

Amy Srensen, Peter Landvall, and Marie Lodn

1.1 Introduction The regulatory requirements and the approval

processes for the three product categories are not
Moisturization of the skin is important for both the same; for example, cosmetics, and class I
cosmetic and medical purposes. The majority of medical devices are not approved by any (out-
moisturizing creams on the market are regulated as side) external/third party organization or author-
cosmetics; however, they may also be classified as ity before being placed on the market. On the
pharmaceuticals (equivalent to medicinal prod- other hand, medical devices class IIa, IIb, and III
ucts) or as a medical device within the European need third party (Notified Body) verification of
Member States. When they are regulated as phar- fulfilling medical device regulation while phar-
maceuticals or medical devices, they can also be maceuticals go through rigorous evaluation and
marketed for treatment or prevention of diseases, are granted a marketing authorization.
such as atopic eczema, psoriasis, ichthyosis, and The present chapter will give an overview of
other hyperkeratotic skin diseases. There has been the similarities and differences between the
an increase in topically applied semi-solid formu- different regulatory categories. The borders will be
lations certified as medical devices used for the described to help the reader understand the gray
treatment of skin diseases in recent years [1]. areas in classification between the categories.
Moisturizing creams contain a number of dif-
ferent ingredients which can affect their suitabil-
ity for the different types of dry skin conditions. 1.2 Regulations and Classications
In addition, these products come into close con-
tact with our body, and they are generally used Cosmetic products are currently regulated under
for long periods of time, which makes their com- the Cosmetic Directive 76/768/EEC and its amend-
patibility with our body important. ments [2]. In late 2009, a Cosmetic Regulation
was adopted, 1223/2009/EC, which replaces the
above directive and comes into force on 11th July
A. Srensen 2013, with some elements earlier [3].
Sorensen Consulting, Cosmetic Regulatory Department, Medicinal Products for Human Use (pharma-
Hllviken, Sweden
ceuticals) is regulated under Directive 2001/83/
P. Landvall EC and its amendments [4].
Cellwell, Medical Device Regulatory Department,
Medical devices are regulated under the
kersberga, Sweden
Medical Device Directive 93/42/EEC and its
M. Lodn ()
amendments [5].
Eviderm Institute, Research and Development,
Bergshamra All 9, SE-17077 Solna, Sweden Other regulations may also be applicable, such
e-mail: [email protected] as Regulation (EC) 1272/2008, classification,

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 3

DOI 10.1007/978-3-642-27606-4_1, Springer-Verlag Berlin Heidelberg 2012
4 A. Srensen et al.

Fig. 1.1 A schematic

Topical application
view on the classification
of a medical device,
a pharmaceutical and
a cosmetic product Treating, alleviating Other
or preventing disease

Restoring, correcting or modifying Cleaning,

physiological functions perfuming, changing
the apperance,
Pharmacological, odors, protecting, or
Mechanical/ keeping in good
physical immunological or metabolic
action condition

Medical device Pharmaceutical Cosmetic

labeling and packaging of substances and mix- Any substance or combination of substances
tures, [6] and the General Product Safety Directive which may be used in or administered to human
beings either with a view to restoring, correcting
2001/95/EC. or modifying physiological functions by exerting
The borderlines between the different product a pharmacological, immunological or metabolic
categories may be difficult to demarcate. The action, or to making a medical diagnosis.
intended use, mode of action, composition, physi-
ological properties, and the risks of use are the The terms for the actions are defined accord-
bases to determine which set of regulations should ing to the following [8]:
be applied to a topical formulation, Fig. 1.1 [7, 8]. Pharmacological action: interaction
The definition of a cosmetic product is based between the molecules of the substance in
on target of the application and the intended func- question and a cellular constituent, usually
tion [3]: referred to as a receptor, which either results
in a direct response, or which blocks the
Any substance or mixture intended to be placed in response to another agent. Although not
contact with the various external parts of the hu- a completely reliable criterion, the presence of
man body (epidermis, hair system, nails, lips and
external genital organs) or with the teeth and the a dose-response correlation is indicative of a
mucous membranes of the oral cavity with a view pharmacological effect.
exclusively or mainly to cleaning them, perfuming Immunological action: action in or on the
them, changing their appearance and or/correcting body by stimulation and/or mobilisation of
body odours and/or protecting them or keeping
them in good condition. cells and/or products involved in a specific
immune reaction.
The definition is thus based on two cumulative Metabolic action: action which involves an
aspects, i.e. the target site of application and the alteration, including stopping, starting or chang-
intended main (cosmetic) function. ing the speed of the normal chemical processes
A medicinal product is defined either by vir- participating in, and available for, normal body
tue of its presentation or its function [4]. A function. The fact that a product is metabolised
product constitutes a medicinal product if it falls by the human body does not necessarily mean
within either of these two categories: that the substance contained in the product has a
metabolic action upon the body.
Any substance or combination of substances pre-
sented as having properties for treating or prevent- A Medical Device is Defined in Article 1(2) of
ing disease in human beings; or the Medical Device Directive as:
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 5

Any instrument, apparatus, appliance, software, replace, or restore biological functions or struc-
material or other article, whether used alone or in tures with a view to treatment or alleviation of an
combination, including the software intended by its
manufacturer to be used specifically for diagnostic illness, injury, or handicap.
and/or therapeutic purposes and necessary for its Non-invasive devices, which come into con-
proper application, intended by the manufacturer tact with skin, are in class I (low risk), if they are
to be used for human beings for the purpose of: intended to be used as a mechanical barrier, for
diagnosis, prevention, monitoring, treatment or
alleviation of disease, compression or for absorption of exudates (e.g.
diagnosis, monitoring, treatment, alleviation of simple wound dressings), whereas they belong to
or compensation for an injury or handicap, class IIb (moderate-high risk), if they are intended
investigation, replacement or modification of to be used principally with wounds which have
the anatomy or of a physiological process,
control of conception, breached the dermis and can only heal by second-
and which does not achieve its principal intended ary intent (e.g. chronic ulcerated wounds, dress-
action in or on the human body by pharmacologi- ings for severe burns). Other non-invasive devices
cal, immunological or metabolic means, but which are in class IIa (low-moderate risk), including
may be assisted in its function by such means.
devices principally intended to manage the micro-
Medical devices are divided into different environment of a wound.
classes which are determined by the hazardous use The authorities have clearly stated that a
at the intended use of the device and mode of product cannot fall into more than one category.
action [5] (outlined in Annex IX of the Medical A medical device should not achieve its princi-
Device Directive 93/42/EEC). There are four med- pal intended action in or on the human body by
ical device classes class I, class IIa, class IIb and pharmacological, immunological or metabolic
class III. The higher the classification, the more means, but may be assisted in its function by
hazards are connected to usage for the patient. The such means. For example, a pharmacological
classification depends on rules that involve the and metabolic action is demonstrated by zinc
medical devices duration of body contact, its inva- oxide containing products; for example, it may
sive character, if it has an active substance or not play a role in enzymatic processes for support of
and if it is in connection with the central circula- wound granulation. The pharmacological action
tory system or central nervous system. may, however, be ancillary when the product
Medical devices with a transient use are nor- concerned is primarily a barrier cream. In such
mally intended for continuous use for less than cases, the qualification of zinc oxide containing
60 min. Those for short-term use are normally products is defined as medical device taking into
intended for continuous use for between 60 min account the claims, the intended purpose and the
and 30 days, and those for long-term use are nor- relevant primary mode of action. Hence, the
mally intended for continuous use for more than product is regulated in accordance with rule 13
30 days. Invasive devices are those which, in of Annex IX of Directive 93/42/EEC and not in
whole or in part, penetrate inside the body, either accordance with Article 2(b) of Directive
through a body orifice (any natural opening in the 2001/83/EC. However, medical devices that
body, as well as the external surface of the eye- contain a substance which separately can be
ball) or through a surgical opening of the body. considered as a medicinal substance (as defined
Medical devices can also be denoted as active in Article 1 of Directive 2001/83/EC) belong to
medical device and active therapeutical device. class III devices (high risk). For example, corn
An active medical device relies on an external plasters containing salicylic acid will be consid-
source of power (e.g. electrical energy) to exert ered as a class III medical device due to the
its function (e.g. laser, photodynamic therapy), analgesic properties of salicylic acid, whereas
whereas the active therapeutical device uses those containing trichloroacetic acid for the
energy, such as electricity, to support, modify, treatment of corns are considered as class IIa
6 A. Srensen et al.

devices as this other acid is considered a assigned national Competent Authority. In addi-
chemical substance [9]. tion, a class I medical device that is placed on the
In case of doubt, where taking into account all market in a sterile condition or that is used to
product characteristics, and provided that the measure a function must apply to a Notified Body
product in question meets both the definitions of for assessment in regards to aspects of these
a pharmaceutical and of a medical device, the functions.
provisions of Directive 2001/83/EC applies. A Notified Body must be involved at the pro-
However, the national Competent Authorities act duction stage for class IIa devices, whereas
under the supervision of the national courts which devices with a high-risk potential, classes IIb and
determines, on a case-by-case basis, which regu- III, require inspection by a Notified Body with
latory framework applies to a certain product. For regard to both the design and manufacture of the
that reason, the regulatory status for a certain device. The Notified Body will issue a certificate
product may differ between countries. verifying that the product fulfills the relevant
requirements in the medical device directive.
This is not an actual approval, but its issue means
1.3 Notications, Registration, that the product is in compliance and can be
and Market Authorizations placed on the market. Medical devices class IIa,
IIb, and III are not required to be registered at the
Cosmetic products do not require any pre-market national medical device Competent Authority;
authorization (approval). Instead, cosmetic prod- however, various countries have added rules
ucts need only to be notified. This process is typi- requiring registration of some or all of these
cally simple and varies from country to country. classes.
The individual country notification systems will The national Competent Authority for medi-
be replaced by a single EU Notification System cal devices conducts regular market surveillance
that should go into effect in 2012. This system to review products and their documentation. Any
will be connected to the various Poison Control nonconformity can mean a marketing ban on the
Centres in the Member States. While no product product and withdrawal of the CE mark.
approval is necessary, cosmetic manufacturers
are expected to have a Product Information File
(PIF) prepared for each cosmetic product prior to
the products placement on the market. 1.4 Manufacturing and Supply
Pharmaceuticals are the most stringently regu-
lated product category. A marketing authoriza- Manufacturing practice plays an important role
tion needs to be granted by the competent in the quality of topical products. One important
authority before the product can be placed on the difference between pharmaceuticals and other
market. Separate approvals are needed for each topical products is the approval process for both
country, but this process is usually straightfor- the manufacturing facility and the manufacturing
ward once an initial marketing authorization has process prior to the release of the pharmaceutical
been granted. to the market, Table 1.1.
A medical device class I does not require Cosmetic products do not require any external
pre-market authorization, but is instead guaran- approvals for the manufacturing process or the
teed by a Declaration of Conformity made by facility. Manufacturers should fulfill the appro-
the manufacturer/authorized representative. The priate testing and production to ensure that the
risks connected with class I devices are low, product is ready for the consumer in accordance
which allow the manufacturer to take full respon- with the regulation [3] and the manufacturing
sibility to assess the conformity of these devices standard for cosmetics (ISO 22716:2007).
to the legislation and certify the product. All class In contrast, manufacturing units for pharma-
I medical devices have to be registered with the ceuticals are regularly inspected by the Competent
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 7

Table 1.1 Overview of differences and similarities in regulatory requirements for topical products
Medical devices
(Class I non-sterile
and non-measuring
Parameter Cosmetics Pharmaceuticals and Class IIa)
Targeted body Skin, hair, teeth, outer Skin, hair, teeth, inner and Skin, hair, teeth,
regions genitalia and mucosa in the outer genitalia/vulva, nasal inner and outer genitalia/
mouth cavity, mucosa in the mouth, vulva, nasal cavity, mucosa
ear canal, and eyes in the mouth,
ear canal, and eyes
Common formulation Emulsions, ointments, Emulsions, ointments, Emulsions, ointments,
types liquids, gels liquids, gels liquids, gels
Marketing, presentation No reference to diseases is Treatment and/or Treatment and/or preven-
allowed prevention of diseases tion of diseases
Pre-market No Yes No
authorization
of product
Authorization of Good No Yes No
Manufacturing Practice
(GMP) by Competent
Authority
Mode of action of Mainly physical, no Changes of physiological Mainly via physical effects,
actives significant modification of functions via pharmacologi- may include changes of
physiological functions via cal, immunological and/or physiological functions
pharmacological, immuno- metabolic action
logical and/or metabolic
action
Ingredient labeling All ingredients must appear All ingredients must appear Not mandatory to label
on the labeling using on the labeling. Excipients ingredients considered
International Nomenclature should be referred to by their to be innocuous
of Cosmetic Ingredients recommended international
(INCI) non-proprietary name (INN),
the European Pharmacopoeia
name or failing this, their
usual common name
Efficacy studies May be inspected by Competent Authority Competent Authority is
Competent Authority approves protocol and informed about study
receives information on protocol and may ban the
study results study based on consideration
of public health and safety
Safety studies Animal experiments on Studies on animals and Studies on animals and
finished product are not humans are performed if humans are performed if
allowed, and ban on raw considered relevant considered relevant
materials testing are being
implemented
Consumer information May be labeled, but is Product Information Leaflet In Instructions For Use
on risks for adverse available on demand by the (PIL) (IFU)
effects affected consumer

Authority and receive a Good Manufacturing manufacturer fulfills the requirements for the pro-
Practice certificate upon approval of the routines. duction of all classes (except class I non-sterile).
The manufacturing process is evaluated and The frequency of the assessment depends on the
reviewed during the approval process. classification of the product.
Medical device manufacturers are regularly All three product types have requirements for
assessed by the Notified Body to verify that the traceability both at the production stages (where
8 A. Srensen et al.

ingredients and components do come from) and e-mark, which is a mark appended to the nominal
in the marketing stage (to whom the products are mass or volume printed on pre-packaged goods
sold). The new Cosmetic Regulation states that for sale. Cosmetic products are required to have
the responsible person needs to identify down- batch numbers and to state the country of origin
stream distributors and that a distributor has to (if imported into the EU).
identify its upstream suppliers and the responsi- The labels for pharmaceuticals are reviewed
ble persons. Both are obliged to do so for the and approved by the Competent Authorities prior
3 years that follow the batch of the cosmetic to product approval. These labels have a pre-
product being made available to the distributor. scribed format and content, and the size of the
letters should be at least Times New Roman 9
point. Pharmaceuticals also have a Product
1.5 Labeling and Markings Information Leaflet (PIL) which is approved by
the authorities.
The Cosmetic Regulation has basic requirements The following is a general list of items that
for cosmetic labeling: function of the product, shall appear on the label of a pharmaceutical
net contents, manufacturer/distributor name and product.
address, and an ingredient listing. Directions are Name of the pharmaceutical, followed by
not necessarily required. Warning statements strength and pharmaceutical form
may be required depending on the presence of Statement of active substances expressed
certain ingredients or to prevent harm to the qualitatively and quantitatively per dosage
consumer. unit or according to the form of administration
Cosmetic products are required to have a best for a given volume or weight, using their com-
used before the end of date. If the product has mon names
a shelf life greater than 30 months, instead of a Pharmaceutical form and the net contents
best used before the end of date, it can carry an either by weight, by volume or by number of
open jar symbol together with a number denoting doses of the product
a period of time after opening for which the prod- List of excipients
uct can be used the Period After Opening (PAO) Method of administration and if necessary, the
Symbol. The Cosmetic Regulation also allows route of administration
cosmetic products to carry the same type of sym- Special warning to store out of reach and sight
bol as used on medical devices to denote an of children
expiry as opposed to stating, best used before Warnings
the end of, Fig. 1.2. Expiry date
Product labels may contain a Hand and Special storage precautions
Book symbol to indicate that further informa- Specific precautions relating to the disposal of
tion, often in other languages, is contained within unused pharmaceuticals or waste derived from
the package. Certain products also contain an the product

Fig. 1.2 Hand and Book

Symbol. Period After
Opening (PAO) Symbol.
Date of minimum durability
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 9

Name and address of the marketing authoriza- Medical devices are also permitted to use
tion holder other types of international symbols which can
The number of the authorization (MT number) be used without any explanation within Europe.
Batch number There is a special harmonized European Standard
Instructions for use in the case of non-pre- (EN 980:2008) which lays out the authorized
scription pharmaceuticals symbols. Use of these symbols simplifies the
A medical device presentation (label, Instruction labeling, helps to prevent the need for multiple
for Use (IFU), packaging) has many of the same translations, and prevents separate development
basic requirements as the label for a pharmaceuti- of different symbols to convey the same informa-
cal (trade name, manufacturer and address, batch tion. The use of any other symbols not specified
code/serial number, warnings/precautions, instruc- in EN 980:2008 has to be explained in the
tions for use and storage, etc.). The major differ- Instruction for Use.
ence between a medical device label and the label While the product label for the three categories
of other products is the use of the CE mark and has distinct differences, there are similar require-
other symbols according to the ISO standard EN ments which are handled differently by the regula-
980. Furthermore, ingredients considered to be tions. These differences can cause confusion for
innocuous do not need to be labeled. the consumer. For example, the nomenclature for
The CE mark guarantees the compliance of ingredient labeling is not harmonized for the three
the product with the medical device regulations regulatory categories of products although there is
and is placed on the device or its package in a overlap. Cosmetic products use INCI nomenclature
way that it will be separated from other sym- (International Nomenclature Cosmetic Ingredients)
bols. The CE marking is an assurance by the while pharmaceuticals typically use International
manufacturer that the device will perform as Nonproprietary Names (INN) or the European
stated, the product is safe and that the clinical Pharmacopoeia (Ph Eur) nomenclature, if avail-
benefit of the device outweighs any side effects able. This can make it complicated for the consum-
when it is used as intended. With few excep- ers to avoid products with substances for which
tions, medical devices cannot be sold without they have a known contact allergy, such as preser-
the CE mark, and the CE mark cannot be affixed vatives [10]. Certain ingredients can also trigger
unless the product is in compliance with medi- specific warning statements, which may differ
cal device regulation. between the product categories, Table 1.2.

Table 1.2 Examples of differences in the nomenclature of ingredients in cosmetics, pharmaceuticals, and medical
device, and potential mandatory warnings
INCI name INN/Ph Eur Wording of warnings on the label
Arachis hypogaea oil Peanut oil/arachidis (Medicinal product) contains arachis oil (peanut oil).
oleum If you are allergic to peanut or soya, do not use this
medicinal product[18]
Benzalkonium chloride -Benzalkonii chloridum When used in cosmetics Avoid contact with eyes [3]
(This substance is frequently used as a preservative
in products for the treatment of the eyes)
When used in pharmaceuticals Irritant, may cause
skin reactions [18]
When used in medical devices, warning is not mandatory
Benzoic acid Benzoic acid/acidum When used in pharmaceuticals: Mildly irritant to the
benzoicum skin, eyes and mucous membranes [18]. (Frequently
used as preservative in cosmetics)
Cetyl alcohol Cetyl alcohol/alcohol When used in pharmaceuticals: May cause local skin
cetylicus reactions (e.g. contact dermatitis) [18]. (Frequently used
as thickener in cosmetics)
10 A. Srensen et al.

1.6 Responsible and Qualied system to ensure that information about all sus-
Persons, and Notied Bodies pected adverse reactions is collected and collated
in order to be accessible in at least one point
Regulations in all three product categories have within the community. A Responsible Person
requirements for specific personnel to take respon- should also be appointed in each distribution
sibility for some or all aspects of the product. point to ensure that a quality system for Good
The new Cosmetic Regulation requires that a Distribution Practice of pharmaceuticals is imple-
legal or natural person be designated as the mented and maintained.
Responsible Person for any cosmetic product A manufacturer without a registered place of
placed on the market. The Responsible Person business in a Member State needs to have a
should ensure compliance with the relevant obli- European Authorized Representative in accor-
gations set out in the regulations. This person dance with the Medical Device Directive 93/42/
needs to make sure that the PIF, including the EEC and IVD Directive 98/79/EC, if he places
Cosmetic Product Safety Report, is up to date, products on the market under his own name.
complete, and accurate. The name of this person A Notified Body, in the context of medical
will be included in the new notification system devices, is a certified organization which a national
that goes into effect in 2012. This person needs Competent Authority of a Member State desig-
to be aware of how the product is sold or distrib- nates to carry out one or more of the conformity
uted in the EU and to be a part of the companies assessment procedures described in the Annexes
adverse event reporting system. The Responsible of the Directives [11]. A Notified Body must
Person is expected to notify the authorities in the be qualified to perform all of the functions set out
event of a serious undesirable event in respect to in any annex for which it is designated. Except
a cosmetic product and to cooperate with the for a class 1, non-sterile and non-measuring
authorities either when a product presents a risk device, a medical device manufacturer is required
to human health or when other inquiries are to use the services of a Notified Body to demon-
made. For imported products, the Responsible strate that the device complies with the applicable
Person needs to be established within the EU. requirements in the regulation. When a Notified
A burden is placed upon this person to ensure Body is involved in the conformity assessments
compliance, and if they believe the product is for a medical device, the manufacturer can only
not in compliance, they are required to take the place the CE mark on the product when they
appropriate corrective measures to bring the receive a certificate from the Notified Body. The
product into compliance, withdraw or recall it, identification number assigned to that Notified
as appropriate. Body by the Commission will appear below the
Pharmaceuticals are required to have Qualified CE mark.
Persons (QP), who fulfill their responsibilities
personally and are resident within the European
Economic Area. One type of Qualified Person is 1.7 Efcacy Testing and Claim
responsible for ensuring that each batch of the Substantiation
pharmaceutical is manufactured and checked in
compliance with applicable laws and in accor- New substances and new mode of actions require
dance with the marketing authorization. This scientific studies and clinical testing to demonstrate
Qualified Person also ensures that the pharma- performance and safety. Irrespective of product
ceutical imported into the EU has undergone (and category, randomized, controlled and blinded stud-
passed) the appropriate analytical testing in the ies are the preferred strategy to identify valuable
importing Member State. Another Qualified performance and discriminate between products.
Person monitors the safety of the companys Human investigations must be performed under
product and focuses on the pharmacovigilance the responsibility of a medical practitioner or
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 11

other qualified person in accordance with the rec- well-established use, evidence to support claims
ommendations guiding physicians in biomedical may be available in the literature or already
research that was adopted in 1964 by the 18th accepted by the authorities. In such cases, addi-
World Medical Assembly, in Helsinki, Finland, tional testing may not be required, but instead,
Helsinki declaration, with later revisions. In only data proving the bioavailability of the active
addition to international guidelines, human stud- substance is needed. New substances, new claims,
ies should always be performed in compliance or new combinations will typically require clinical
with the national regulations of the country where testing. The clinical testing protocol for a pharma-
the testing is being conducted. In addition, an ceutical has to be approved by the Competent
ethical committee needs to approve the protocol Authority prior to commencement of the study.
of the study. Ethics can be considered as a per- Furthermore, the test results have to be submitted
sonal attitude towards what is right or wrong, but to the authority after completion of the study.
it must be subordinated to and coordinated with a Medical devices, irrespective of their classi-
public norm. fication, have to present clinical data to comply
The cosmetic regulation requires substantia- with the Medical Device Directive [5]. This
tion for all claims to be held in the PIF. The extent does not necessarily mean an obligation to
of testing, if any, depends on the type of product accomplish a clinical trial, as citation of pub-
and the claims being made. Data obtained from lished research on identical or similar products
previous studies may well be applied to new for- which have been clinically tested may be accept-
mulations to substantiate their effects. Results able. The adequacy of the clinical data must be
from in vitro tests of the active cosmetic ingre- based on scientific evidence from the available
dients in combination with open-label consumer literature.
trials of the final product have also gained The clinical investigation of a medical device
increased popularity in the marketing of cosmet- must be performed on the basis of an appropriate
ics. However, in vitro parameters have to be care- plan of investigation (Clinical Investigation
fully validated for the clinical endpoint in order Plan, CIP according to standard International
to make sense for the consumers and not be Organization for Standardization, ISO, 14155),
misleading. Any laboratory conducting clinical reflecting the latest scientific and technical
tests needs to follow good laboratory practices, knowledge. These investigations must include an
but clinical testing of cosmetics does not need adequate number of observations to guarantee the
approval from any Competent Authority. scientific validity of the conclusions and confirm
The new Cosmetic Regulation requires stan- the safety and performance of intended use. The
dards to be set for substantiation of claims. For clinical investigations must be performed in cir-
example, in order to reduce the variability in cumstances similar to the normal conditions of
labeling of sunscreen products, the testing and use of the device. The manufacturer may com-
labeling of sunscreens were recently agreed on mence the relevant clinical investigation at the
by international industry organizations [12] and end of a period of 60 days after the notification,
adopted by the European Commission [13]. Upon unless the Competent Authorities have notified
request, the substantiation for the claims on a the manufacturer within that period of a decision
cosmetic product can be reviewed by the Competent to the contrary based on considerations of public
Authority. The consumer has no insight into the health or public policy.
efficacy data. There are no restrictions regarding the start of
The claims allowed for a pharmaceutical are the marketing of cosmetics, whereas marketing
carefully reviewed by the competent authority. of pharmaceuticals is not allowed before authori-
The active/product must have demonstrable zation. Medical devices may be displayed at trade
efficacy and safety (or at least safety with pre- fairs, exhibitions, demonstrations, etc., provided
scribed cautions). If an active has an already that a visible sign clearly indicates that such
12 A. Srensen et al.

devices cannot be marketed or put into service cosmetic products. In addition, approximately
until they have been made to comply with the 150 colorants, almost 30 ultraviolet filters and
valid medical device regulation. almost 60 preservatives are approved to be used
in cosmetics [14].
The Cosmetic Regulation helps to clarify the
1.8 Safety Assessment and Risk obligations of manufacturers in the product
Management safety assessment process. Safety Assessments
for cosmetic products are done by a qualified
The safety of any finished products is of critical safety assessor. The Cosmetic Product Safety
importance; however, the degree of evaluation Report, which includes the Safety Assessment,
and substantiation varies between the different is included in the PIF and shall be kept for a
categories. Safety is assessed by taking into con- period of 10 years following the date on which
sideration the toxicological profile of the ingredi- the last batch of the cosmetic product was placed
ents, their chemical structure, and the level of on the market.
exposure. The safety assessment of a pharmaceutical has
The toxicological evaluation of ingredients for to be approved by the Competent Authority
cosmetics is made challenging by a phase out of before the product is approved for the market.
animal testing in the 7th Amendment to the Actives, excipients, potential impurities, and
Cosmetic Directive [2]. A testing ban on finished decomposition products go through an extensive
cosmetic products has applied since September review process. If adequate information already
2004, and a testing ban on ingredients or combi- is available on a specific ingredient, no further
nation of ingredients has applied since March toxicological tests are needed.
2009. A marketing ban has also been in place A medical device class I needs to have a risk
since March 2009 which prohibits marketing in assessment made according to the Medical
the European Union finished cosmetic products Device Directive, Essential Requirements,
or finished products with ingredients which were although there is no requirement for third party
tested on animals after the cut-off dates. There review of the assessment. Risk management
were exceptions for some of the more complex for medical devices with higher risk classifica-
tests; in this case, the ban will apply step by step tion (class IIa, IIb, and III) is reviewed and
as soon as alternative methods are validated and verified by the Notified Body prior to certifica-
adopted, but with a maximum cut-off date of tion of conformity.
10 years after entry into force of the Directive, Manufacturers of pharmaceuticals and medi-
i.e. March 2013, irrespective of the availability of cal devices are obliged to try to look into the
alternative non-animal tests. A great deal of future to predict possible hazards resulting from
research into alternative test methods is currently all potential uses of their product. Known or
ongoing, and while good progress has been made, foreseeable hazards based upon safety charac-
there is still work to be done. The Commission is teristics could be listed as well as reasonably
required to determine whether or not validated foreseeable misuse related to the safety of the
methods will be available by the 2013 deadline. product. The risk analysis should include an esti-
In order to increase the safety and to facilitate mation of the risks for each hazard, where the
safety assessment of cosmetics, the Cosmetic probability, severity, and consequence are ana-
Directive has lists of prohibited and restricted lyzed separately. The acceptability of the risks
substances among the 15,000 chemical sub- and the possibility to reduce the risk also have to
stances that are found in the European Inventory be decided. This process is generally referred to
of Cosmetic Ingredients. More than 1,000 sub- as a Risk Management Plan (RMP) [15] and such
stances are identified as forbidden and almost an organized approach is essential for good risk
300 substances may be used only in accordance management. The organized plan provides the
with the restrictions laid down in the regulation in roadmap for risk management, and encourages
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 13

objectivity and helps prevent essential elements If the symptoms are covered by the reference
being forgotten. safety information, the adverse event may be
regarded as expected. A serious adverse event is
any event that [16]:
1.9 Denition of Undesirable Is fatal
Events and Effects Is life threatening
Is permanently/significantly disabling
Undesirable effects caused by topical products Requires or prolong hospitalization
may lead to acute and chronic suffering, for Causes congenital anomaly/birth defect
example, lifelong intolerance to specific sub- Requires intervention to prevent permanent
stances implying negative consequences for the impairment or damage
individual as well as for the health care and social In the Medical Devices Directive, the term
insurance systems. The majority of negative skin incident is used, which is defined as [5]:
reactions from topical products are however tran-
Any malfunction or deterioration in the character-
sient smarting and stinging reactions in the skin. istics and/or performance of a device, as well as
Other examples of undesirable effects are: irritant any inadequacy in the labelling or the instructions
and allergic effects, cosmetic acne, phototoxic for use which, directly or indirectly, might lead to
effects, photosensitivity, anaphylactic shock, and or might have led to the death of a patient or user
or of other persons or to a serious deterioration in
itching. their state of health.
A cosmetic product must be suitable for its
purpose and may not lead to adverse reactions All incidents are events, but not all events
under normal use that are disproportional in rela- are incidents; events may be complaints or
tion to the intended effect of the product. An something else, for example, unanticipated
undesirable effect for a cosmetic product is adverse reactions or unanticipated side effects.
defined as [3]: Side effects are not covered by the incident
An adverse reaction for human health attrib- definition in the directive unless the change in the
uted to the normal or reasonably foreseeable risk-benefit ratio is considered as a deterioration
use of a cosmetic product. in the performance of the device.
In the Cosmetic Regulation, a serious undesir-
able effect is defined as:
An undesirable effect which results in tempo- 1.10 Post-marketing Surveillance
rary or permanent functional incapacity, dis- and Vigilance
ability, hospitalisation, congenital anomalies
or an immediate vital risk or death Safety for the consumer is of primary importance
For pharmaceuticals, adverse events are in all three product categories. No matter the
defined as [16]: effort put in to evaluate safety before a product is
Any untoward medical occurrence that may launched, data are inevitably incomplete.
present during treatment with a medicine but The regulation of a product as a cosmetic,
which does not necessarily have a causal rela- pharmaceutical, or medical device will determine
tionship with this treatment. which procedure should be followed for the
An Adverse Drug Reaction (ADR) is defined reporting of an adverse incident. The Cosmetic
as [4, 16]: Regulation requires manufacturers of cosmetic
A response which is noxious and unintended, products to maintain data on undesirable effects
and which occurs at doses normally used in on human health, resulting from the use of the
humans for the prophylaxis, diagnosis, or cosmetic product. The vigilance system for
therapy of disease, or for the modification of cosmetics does not need any external approvals,
physiological function. but the authorities have the right to audit them.
14 A. Srensen et al.

The new Cosmetic Regulation requires that, in of the incident; the report should be made within
the event of a serious undesirable effect, the 230 calendar days (in general). Also depending
Responsible Person should, without delay, notify on the severity of the event, a Field Safety
the Competent Authority in the Member State in Corrective Action (FSCA) may need to be taken;
which the event occurred. Information on unde- this is typically done to reduce a risk of death or
sirable effects must also be made available to the serious deterioration in the state of health associ-
public upon request. Undesirable effects accessi- ated with the use of the device. FSCAs are com-
ble to the public do not include, for example, municated to users or customers via a Field
those resulting from abuse or misuse of the prod- Safety Notice (FSN).
uct and those related to associated items, such as The manufacturer of a medical device should
the packaging. also have routines to periodically evaluate, group,
The manufacturer of a pharmaceutical is and trend product events, adverse effects, and
required to have a pharmacovigilance system in adverse incidents. Trend reports should be writ-
place to track and respond to adverse events. This ten at least annually and presented at a manage-
process is audited and approved by the authori- ment quality review to discuss, and if appropriate,
ties. Furthermore, the analysis of safety is regu- take necessary action(s). The Notified Body, if
lated, and so-called Periodic Safety Update involved with the device, would review these
Reports (PSUR) are written and submitted to the reports.
medical authorities at specified intervals (2004/27/ Vigilance for medical devices in the EU is
EC). This report contains a description of the effectively tied together by European Database
adverse events reported for the product, along for Medical Devices (EUDAMED) which in part
with an analysis of the relationship to the prod- includes data on vigilance. This in conjunction
uct. Furthermore, other types of new information with a NCAR (National Competent Authority
on the drug should also be addressed. Scientific Report) allows communication between Member
literature and other media should be watched for States to protect human health in the event of a
new findings. Scientific reports, daily press, and serious incident.
web-based search sites (PubMed, Toxnet, etc.)
constitutes the base for this information search.
The PSUR is submitted every 6 months the first Conclusion
2 years after placing the product on the market, Products for topical use include semi-solid
then once a year, the following 2 years and there- formulation types, such as creams (emul-
after at three yearly intervals. Furthermore, the sions), ointments, liquids, and gels. Products
PSUR should be enclosed with each renewal may look the same, have similar indications
application. and be placed next to each other on the shelf at
Medical device manufacturers are also obli- pharmacies or drug stores, but their regulatory
gated to set up and maintain a vigilance system classifications are different. Moisturizers reg-
to ensure that any problems or risks associated ulated as pharmaceuticals or medical devices
with use of the device are indentified early, can be marketed for prevention or treatment of
reported and acted upon to thus reduce the likeli- dry skin in connection with diseases, such as
hood of reoccurrence of an incidence [17]. Such atopic dermatitis, ichthyosis, and psoriasis.
a system maintains records of adverse incident Cosmetics are allowed to be marketed for the
reports received from any source. It also describes treatment of temporary dryness caused by
how the reports are investigated by competent environmental impact, such as low tempera-
personnel and the corrective and preventative ture. The users of the products and those
action processes. An incident which meets the approving and recommending the products to
reporting criteria will require reporting to the patients and consumers should preferably be
Competent Authority. This is done through an aware of the regulatory status of the products
electronic system and depending on the severity and the differences in their quality assurance.
1 Moisturizers as Cosmetics, Medicines, or Medical Device? The Regulatory Demands in the European Union 15

Informed product choices should also

be facilitated by a transparent system that product and the differences in quality
enables both the consumers and professionals assurance among different categories.
to take part in the scientific evidence regarding A transparent system that enables both
the claimed effect of the skin as well as of the the consumers and professionals to take
safety assessment and potential adverse part in the scientific evidence regarding
effects. the claimed effect of the skin, as well as
of the safety assessment and potential
adverse effect, should facilitate informed
Take Home Messages product choices.
The majority of moisturizing creams on
the market are regulated as cosmetics
although they may also be classified as
pharmaceuticals (equivalent to medici- References
nal products) or as medical devices
within the European Member States. 1. Korting HC, Schollmann C (2012) Medical devices in
Moisturizers regulated as pharmaceuti- dermatology: topical semi-solid formulations for the
treatment of skin diseases. J Dtsch Dermatol Ges
cals or medical devices are allowed to 10:103109
be marketed for treatment of dry skin in 2. Council Directive 76/768/EEC on the approximation
connection with diseases, such as atopic of the laws of the Member States relating to cosmetic
dermatitis, ichthyosis, and psoriasis. products (1976) OJ L 262/169. Non-official consoli-
dated version at http://eur-lex.europa.eu/LexUriServ/
The efficacy and safety of a cosmetic LexUriServ.do?uri=CONSLEG:1976L0768:2010030
product is not approved or reviewed by 1:en:PDF. Accessed May 2011
an outside body. The extent of testing, 3. Buzek J, Ask B (2009) Regulation (EC) No 1223/2009
if any, depends on the type of product of the European Parliament and of the Council of 30
November 2009 on cosmetic products. Official Journal
and the claims being made. An animal of the European Union, L342/59L342/209
testing ban on finished cosmetic prod- 4. Directive 2001/83/EC of the European Parliament and
ucts has been applied since 2004, of the Council on the Community code relating to
whereas a testing ban on ingredients or medicinal products for human use (2001) OJ L 311/67
as amended. Non-official consolidated version at:
combination of ingredients is applied http://ec.europa.eu/health/documents/eudralex/vol-1/
step by step as soon as alternative meth- index_en.htm. Accessed May 2011
ods are validated and adopted, but with 5. Council Directive 93/42/EEC concerning medical
a maximum cut-off date in March 2013. devices (1993) OJ L 169/1 as amended. Non-official
consolidated version at: http://eur-lex.europa.eu/
The efficacy and safety of pharmaceuti- LexUriServ/LexUriServ.do?uri=CONSLEG:1993L0
cals must be approved by the Competent 042:20071011:en:PDF. Accessed May 2011
Authority before the product is released 6. CLP, Regulation (EC) 1272/2008 of the European
to the market. Actives, excipients, poten- Parliament and of the Council on classification, label-
ing and packaging of substances and mixtures (2008)
tial impurities, and decomposition prod- OJ L 353/1 as amended. http://eur-lex.europa.eu/
ucts go through a review process. LexUriServ/LexUriServ.do?uri=OJ:L:2008:353:0001
The effectiveness and safety of medical :1355:en:PDF. Accessed May 2011
devices with higher risks must be veri- 7. Guidance document on the demarcation between the
cosmetic products directive 76/768 and the medicinal
fied by a Notified Body before CE label- products directive 2001/83 as agreed between the
ing of the product. commission services and the competent authorities of
The users of moisturizers and those member states. http://ec.europa.eu/consumers/sec-
approving and recommending the prod- tors/cosmetics/files/doc/guidance_doc_cosm-medici-
nal_en.pdf. Accessed Feb 2012
ucts to patients and consumers should 8. MEDICAL DEVICES (2010) Guidance document.
be aware of the regulatory status of the Borderline products, drug-delivery products and
medical devices incorporating, as an integral part, an
16 A. Srensen et al.

ancillary medicinal substance or an ancillary human products and the claims made relating thereto. Off J
blood derivative. Guidelines relating to the application Eur Union 265:265/39265/43
of: the council directive 90/385/EEC on active implant- 14. SCCS (2010) The SCCSs notes of guidance for the
able medical devices the council directive 93/42/EEC testing of cosmetic ingredients and their safety evalu-
on medical devices. MEDDEV 2. 1/3 rev 3. http:// ation, 7th revision. http://ec.europa.eu/health/scien-
ec.europa.eu/consumers/sectors/medical-devices/ tific_committees/consumer_safety/docs/sccs_s_004.
files/meddev/2_1_3_rev_3-12_2009_en.pdf. Accessed pdf. Accessed Feb 2012
Feb 2012 15. Medical devices application of risk management to
9. MHRA (2011) Bulletin no. 17. Medical devices and medical devices. ISO 14971:2007. http://www.iso.
medicinal products. http://www.mhra.gov.uk/home/ org/iso/iso_catalogue/catalogue_tc/catalogue_detail.
groups/es-era/documents/publication/con007498.pdf. htm?csnumber=38193. Accessed Sept 2011
Accessed Sept 2011 16. WHO (2002) Safety of medicines a guide to detect-
10. de Groot AC (1990) Labelling cosmetics with their ing and reporting adverse drug reactions - why health
ingredients. BMJ 300(6740):16361638 professionals need to take action. http://apps.who.int/
11. MEDDEV 2.102 Rev. 1. Designation and monitoring medicinedocs/en/d/Jh2992e/. Accessed Feb 2012
of notified bodies within the framework of EC direc- 17. MEDDEV 2.121 rev 6 (2009) Guidelines on a medi-
tives on medical devices. http://ec.europa.eu/health/med- cal devices vigilance system. http://ec.europa.eu/
ical-devices/files/meddev/2_10_2date04_2001_en.pdf. health/medical-devices/files/meddev/2_12_1-
Accessed Sept 2011 rev_6122009_en.pdf. Accessed Sept 2011
12. Gardiner J et al. (2006) International sun protection 18. Guidelines. Medicinal products for human use. Safety,
factor (SPF) test method. Colipa Guideline www.cos- environment and information. Excipients in the label
meticseurope.eu/downloads/86.html. Accessed Feb and package leaflet of medicinal products for human
2012 use, in Notice to applicants, E.C.E. directorate-
13. Verheugen G (2006) Commission recommendation general, Editor. 2003
of 22 September 2006 on the efficacy of sunscreen
 Design of Claims Support
for Moisturizers 2
Judith K. Woodford

2.1 Introduction to support the claims that marketing departments

believe are key to the commercial success of a
One may question the need for an entire chapter moisturizer or other personal care product.
devoted to claims support testing. After all, there
are many studies and methodologies reviewed in
other sections of this book. However, the end goal 2.2 Claims and Advertising
of claims support testing is inherently different
than that of the prior studies. There are many rea- Before designing a study, it is important to recog-
sons to conduct scientific studies in the moistur- nize both what is a claim and what is advertising.
ization field ranging from the purest basic research Advertising is any communication that is intended
to technology and methods development to opti- to convince the consumer to purchase a product
mization of treatments and products. In each of or service. Advertising is not limited to the obvi-
these areas, the scientist is either functioning in ous such as television, magazine, or radio. It
an exploration mode or is testing hypotheses. The encompasses all spaces of communication includ-
key difference in claims support testing is that the ing package, store displays, and digital media as
result is already known. The purpose of the claims detailed in Table 2.1.
support test is not to discover if something is true, Claims are communicated within the advertis-
but rather to demonstrate to a relevant authority ing. Claims are not just the benefit the product deliv-
that the specific claim being made for the product ers, such as moisturization. They are much more they
is true and is adequately supported. are the specific words, the specific communication
This end goal of claims support testing impacts of the benefit. Claims concerning the moisturization
the details of a suitable study design. The impact benefit could include immediately improves visible
may be subtle, and at a high level glance may not dryness, moisturizes all day, or hydrates better
even be apparent. But if not recognized and than Claims testing is required to support not just
accounted for can lead to rejection of a study and the general benefit but also the specific claim con-
loss of a desirable, compelling claim. The focus of cerning the benefit. Each of the three examples
this chapter is not detailed methodology, but rather, above requires unique data for support.
the process to design a readily defensible protocol Advertising laws across the globe typically
include a stipulation that advertising not be mis-
leading to the consumer [58]. In addition, there
may be Advertising Codes governing the imple-
J.K. Woodford, Ph.D.
Research and Development, Kao Corporation, 2535
mentation of the laws [911]. To determine if an
Spring Grove Avenue, 45214 Cincinnati, OH, USA advertisement is misleading, one must first
e-mail: [email protected] establish what claims have been made within the

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 17

DOI 10.1007/978-3-642-27606-4_2, Springer-Verlag Berlin Heidelberg 2012
18 J.K. Woodford

Table 2.1 Advertising venues Table 2.2 Television preclearance and self-regulatory
agencies
Product/package
Traditional Digital media based Country TV preclearance Self-regulatory agency
Television Company websitea Packaging US Individual NAD
Radio Facebook In-store displays networks
Magazine Twitter Brochures UK Clearcast ASA
Billboards YouTube Coupons Canada ASC; MIJO ASC
Advertorials Email blasts Direct mailers/ Australia CAD ACB; ACCC; FTCPA
sampling NAD National Advertising Division of the Better Business
a
UK (United Kingdom) under ASA (Advertising Bureau, ASA Advertising Standards Authority, ASC
Standards Authority) remit as of March 2011 [1, 2]; USA Advertising Standards Canada, MIJO MIJO Corporation,
(United States of America) FDA (Food and Drug formerly Broadcast Clearance Advisory, CAD
Administration) views as part of package label if the web- Commercials Advice Pty Limited, ACB Advertising
site is declared on the label [3, 4] Claims Board of Advertising Standards Bureau, ACCC
Australian Competition and Consumer Commission,
FTCPA Fair Trading and Consumer Protection Agencies
advertisement. One way to group claims is by
explicit and implicit classification. Explicit are
direct, straightforward claims: moisturizes for (USA) that also routinely request claims support
8 hours. Implicit, or implied, claims are subjec- prior to running print ads. The USA television
tive and open to interpretation. For example, now approval process is unique in that the individual
made with aloe, moisturizes even longer, can be television networks review the data and approve
interpreted as either two distinct explicit claims the ad, requiring approval by multiple agencies. In
or the two explicit claims plus a third implied contrast, in the United Kingdom (UK), Canada,
claim. The explicit claims are now made with and Australia, a single approval is sufficient to air
aloe and now moisturizes even longer. The on all networks. In the UK and Australia, there is a
implied claim is the addition of the aloe makes single option available, Clearcast and CAD
the moisturization last longer. If this implied (Commercials Advice Pty Limited), respectively.
claim is factual and supported, there is no prob- In Canada, the agencies are private companies, and
lem. But, if the longer duration is instead due to at least two are currently in operation; Advetising
an increase in glycerin level, then the claim is not Standards Canada and MIJO Corporation (for-
supported and is misleading to the consumer. merly Broadcast Clearance Advisory).
Another difference between the four regions is
the level of scrutiny given to the claims support.
2.3 Authorities Examining Claims Canada is the least rigorous. In this case, the
Support Testing authorities require a letter of attestation as assur-
ance that the company has done due diligence in
Various external agencies may examine claims supporting the claims. In special cases, such as
support data. The purpose typically falls into one linking a claim to a single ingredient, the agen-
of four categories: advertising preclearance, in- cies will request submission of the supporting
market advertising challenge, routine regulatory data. In the USA and Australia, the agencies
review, and regulatory investigation of a specific desire to assure themselves that the claims have
issue. been adequately supported and will require sub-
mission of the study methods and results.
Clearcast, in the UK, is the strictest. Inclusion of
2.3.1 Advertising Preclearance all study support and information is requested
with the initial submission of the script. Clearcast
Preclearance is predominantly utilized for televi- rigorously reviews the methodology in relation to
sion advertising, Table 2.2. However, there are the specific claim and takes a conservative stance
several magazines in the United States of America that the support portfolio should be robust enough
2 Design of Claims Support for Moisturizers 19

to withstand any challenge and preferably would public alongside senior members of the advertising
not give rise to a challenge in the first place. industry. Council decisions are reported at www.
adstandards.com. Australias complaint system
differs from the others in that there are multiple
2.3.2 In-Market Advertising Challenge agencies involved. Competitive complaints are
reviewed by the Advertising Claims Board of the
As detailed in Table 2.2, there are self-regulatory Advertising Standards Bureau. The Board is com-
agencies in place in the USA, the UK, Canada, prised of lawyers and their case reports are listed at
and Australia to handle complaints of false or www.adstandards.com.au. Additionally, mislead-
misleading advertising. If a complaint is investi- ing claims may be investigated by either the
gated, it is expected that the advertiser provide Australian Competition and Consumer Commission
the agency with the relevant data to support the (ACCC) or individual territory Fair Trading and
claims in question. The NAD (National Consumer Protection Agencies.
Advertising Division of the Better Business
Bureau), in the USA, is staffed entirely by law-
yers. NAD decisions are published at www.
NADreview.org. It is clear from the detail within 2.3.3 Regulatory Review
the descriptions that the team reviews the submit-
ted data and methodology in detail, and though Review by a governmental regulatory agency can
not scientists themselves, apply a strict logic to be divided into two groups. The first includes
their decisions. The NAD will make educated routine reviews. In the EU (European Union) and
determinations concerning implied claims and the ASEAN (Association of Southeast Asian
will ensure the study design matches the actual Nations) regions, there are regulations in place
claim. The FTC (Federal Trade Commission) is for postmarket surveillance of personal care
the federal agency in the USA with oversight of products [13, 14]. In both regions, there is a
false and misleading advertising. The two agen- requirement that POEs (Proof of Effect docu-
cies have a working relationship and the NAD ments) be made available at the request of the
refers cases to the FTC if the advertiser declines designated competent authority. As these agen-
to participate. Similar to the NAD, the ASA cies are conducting routine monitoring, their pri-
(Advertising Standards Authority) in the UK will mary purpose is to receive assurance that the
review the data and determine the applicability to company has used due diligence in supporting
the claim. However, there are two key differences the relevant claims. As such, high level descrip-
from the USA: (1) clearcast will also be in front tions of the data are typically sufficient.
of the ASA, defending their decision to approve In contrast, nonroutine investigations are typi-
the ad, and (2) ASA has been noted for applying cally initiated because the authorities are con-
a more extensive interpretation of implied claims. cerned about the product in question. Common
The Advertising Codes in the UK stipulate that reasons for concern include safety and drug/cos-
implied claims are those that the average con- metic issues. In these cases, the agency will be
sumer would take away [9, 10]. In a report pub- looking for the full details of the claims support.
lished by the ASA after a review of their processes In the case of the FDA (Food and Drug
in 2010, the agency indicated that they would be Administration) in the USA, the agency can
more clear in regard to misleading claims in that request complete files related to the product,
the claim in dispute must be likely to mislead as extending beyond the testing intended to support
opposed to having a slight chance of misleading the claims. Similarly, if involved within a court
[12]. ASA adjudications are reported at www. case, the discovery process will result in disclo-
asa.org.uk. sure of all material, not just the studies the com-
Advertising Standards Canada (ASC) relies pany wishes to divulge. Understanding these
on a volunteer board of representatives from the agencies and instances where data may be shared
20 J.K. Woodford

externally helps to shape the design in conjunc- Single Repeated

tion with the two elements detailed in the next application application

section.

2.4 Analysis Prior to Study Design

Prior to completing the study design, two addi-

tional elements need to be evaluated. First, the
wording of the specific claim should be examined
for both explicit and implicit claims. The com-
pany making the claims is responsible to support
all the claims, not just those that the marketing
department intended to convey. As will be
detailed in the section below, the way the claim is Fig. 2.1 Representation of timecourse for delivery of
worded will impact the study design. benefit in relation to product application. The black line
illustrates a product which delivers the benefit immedi-
Secondly, the product itself should be charac- ately after a single application. The dashed line illus-
terized. As stated in the Introduction, the results trates a product which delivers the benefit after a single
of a claims support study should already be application; however, the delivery is delayed by period of
known prior to the execution of the protocol. The hours. The dotted line illustrates a product which does not
deliver the benefit until after repeated application
support study is not intended to discover what the
product can do, it is intended to provide a demon-
stration that a specific claim is true under condi- benefit delivery. Responses to the questions above
tions tailored to the wording of the claim. will factor into the study design.
Therefore, a solid knowledge of the product is
important. For example, consider:
Details such as how the product is applied and 2.5 Study Design for Claims
how the application is communicated to the Support Testing
consumer through the package instructions.
Where the product is applied, the intended With the product and claims information in hand,
usage. the study design can be tailored to the wording of
By what mechanism the benefit is delivered. the claim. The elements of the design are the
Is the product providing hydration, exfoliating same as for other types of product testing and are
the surface, or masking imperfections with listed in Table 2.3.
colored or light diffusing pigments?
What is the temporal relationship between the
application of the product and measurable 2.5.1 Measurement Details
delivery of the benefit?
Represented in Fig. 2.1 are three products with There are often multiple tools available to mea-
three different temporal patterns. The black sure a benefit. However, the appropriate tool for
arrows along the top indicate product application claims support may be dependent upon the spe-
timepoints. The product represented by the solid cific wording of the claim. Shown in the example
black line delivers the benefit immediately after a in Table 2.4 are four methods to examine dry skin
single application. The dashed-line product also and two hypothetical claims for a product. While
delivers the benefit after a single application, but all four provide valid measures, the first claim,
the benefit development is delayed by a few visibly reduces dryness, requires a method that
hours. The last sample product, dotted line, addresses the visible aspect of the condition.
requires repeated application prior to measurable Likewise, the second claim, increases hydration,
2 Design of Claims Support for Moisturizers 21

Table 2.3 Elements of a claims support study explicit; however, the actual timepoint may be
Measurement Product application Control site impacted by the limitations of the device taking
Tools Test site Untreated the measurement. Observer dryness scoring may
Frequency Method Placebo be conducted immediately, but an instrumental
Timing Frequency Competitor measure such as conductance will require a short
Timing Established delay to avoid artifacts from product residue on
positive the skin. The last example, moisturizes all day,
would typically require statistical significance at
Table 2.4 Picking an appropriate measurement tool. least 8 h after application, although longer time-
Match the tool to the wording of the claim points may be chosen.
Visibly reduces Increases The frequency of application prior to mea-
Tool dryness hydration surement is also impacted. Claims such as
Observer dryness instantly moisturize or 24 hour moisturization,
scoring without additional context, imply the benefit is
Digital imaging delivered with a single product application. On
Conductance the other hand, the claim of moisturizes in just
Raman
1 week would typically require daily or repeated
spectroscopy
applications. The context of the claim should
make it clear to the consumer the expected fre-
Table 2.5 Selecting a suitable time for postapplication quency of application to achieve the benefit.
measuresa. Match the timing to the wording of the claim
Time lapse between
Claim application and measure 2.5.2 Product Application Details
Instantly moisturizes Noneb
Moisturizes all day 8h As mentioned in Sect. 2.4, the details of product
24 hour moisturization 24 h
application will be determined by the characteris-
Improved moisture in 1 weekc
just 1 week
tics of the product and the wording of the claim.
a
The four elements of product application include
For purposes of this illustration, a single postapplication
measure is assumed. the site, the frequency, the timing in relation to
b
As close to application as feasible, taking into account the measurements to be taken, and the applica-
potential artifacts from limitations of the measurement tion process.
device.
c
Ideally, the test site will be at the intended site
Assumes repeated application over the 1 week period.
of application by the consumer. However, there
may be occasion where an alternate site would be
is most appropriately supported with data gener- acceptable. For example, facial moisturizers
ated by a technique that either directly or indi- could be applied on the volar forearms in support
rectly measures the water content of the skin. of a qualitative moisturization claim. This strat-
The timing of the measurement(s) may also be egy allows for multiple samples to be tested in a
dependent on the wording of the claim. In the single panel.
example detailed in Table 2.5, it is assumed that The frequency and timing of application
there is a single postapplication measurement should follow the package instructions as closely
available. The most appropriate timepoint for this as possible while bearing in mind the actual claim.
measurement is listed for each hypothetical Consider the example of an undereye product
claim. The two explicit claims, 24 hour moistur- which claims lightly moisturizes from the first use
ization and improved moisture in just 1 week, are on the back panel of the package and wake up to
easy to assign the timepoint is stated within the diminished dark circles prominently on the front
claim. The other two claims are not as straight- panel. The instructions read apply liberally before
forward. Instantly moisturizes appears to be bed for visible results in just 1 week. The frequency
22 J.K. Woodford

of application will be different for the two claims. Table 2.6 Suitable study controls
For the moisturization claim, a single application Control type Typical applications
is sufficient, while for the dark circle claim, Positive Demonstrate subjects within panel are
repeated application over 1 week will be required control capable of developing the attribute to
following package instructions. For the repeated be measured
Placebo Benefit within the claim is attributed to
application study, there is also the question of
control a single or to a limited group of
how many applications per day. In this example, a ingredients
single daily application would be most appropri- Placebo To blind subjects to the untreated site
ate as the common consumer practice is to go to control if self-assessments are measured
bed a single time each day. Untreated To measure effect of external and
The timing of the application may also be dif- control periodic factors in extended duration
studies
ferent between the two studies. In the case of the
dark circle claim, the product should be applied
in the evening as close to bed as possible. The conditioning benefits similar to alpha-hydroxy
wording wake up to diminished dark circles adds lotions but without irritation. The inclusion crite-
a time element to the claim. The consumer has ria for the panel require dry skin and poor texture
been promised that the product will work over- associated with aging. Observer erythema scoring
night with results visible upon rising in the morn- and self-assessed discomfort ratings are the mea-
ing. In contrast, the moisturization claim does not surement tools chosen. In the absence of a positive
include any time elements, and it may be accept- control, there is a glaring vulnerability if the study
able to conduct the single application study dur- is exposed externally. An astute reviewer will
ing daytime hours which are more convenient to immediately question whether the individual sub-
the subjects and the testing facility. jects would be capable of developing erythema or
The method of application must also be con- experiencing discomfort. In contrast, if an alpha-
sidered. While it is ideal to follow package hydroxy lotion was included as a positive control
instructions as closely as possible, it may also be and the subjects reacted at that site, there would be
advantageous to control the exact amount of prod- no question of the suitability of the panel.
uct applied and other factors such as time. For A placebo control is necessary in situations
example, hand and body lotions may have simple where a benefit is ascribed specifically to one or
instructions such as apply daily or apply liberally a limited group of ingredients within a product.
to dry areas. In a consumer usage study utilizing In the case of the claim rich shea butter softens
self-application, this level of instruction may be and conditions skin, the appropriate study design
sufficient. But in a clinical setting, it is advisable will include a placebo lotion containing all but
to have a clinician apply a standard dosage and to the shea butter. To support the claim, the lotion
rub the product in for a set amount of time. with shea butter would need to provide statisti-
Especially if the product is to be compared to any- cally improved softness and skin conditioning
thing other than an untreated control. compared to the placebo. In contrast, the claim
Rich lotion softens and conditions skin. Made
with shea butter does not state that the shea butter
2.5.3 Suitable Study Controls is providing the benefit, but rather that the full
lotion is. Therefore, the study design in that case
The most common types of controls in claims would not require the placebo control.
studies are untreated, placebo, or positive con- Another situation in which a placebo control
trols, Table 2.6. The positive control is necessary is relevant is a study design where subjects are
in instances when it must be established that the providing a self-assessment and need to be
individual subjects within the panel are respon- blinded as to which site is untreated. Assume
sive to the benefit to be measured. Assume a new the subjects are to rate their lower legs for the
product has been developed to provide skin appearance of dryness or roughness. The test
2 Design of Claims Support for Moisturizers 23

products can be masked during application with

Study (a)
the actual moisturizer applied by a clinician to test
one leg and a gelled water applied to the other untreated
leg. The subject will not know which leg had the
actual test product applied and should not be
biased to rate that leg better than the other.
An untreated control is suitable for most claims
studies and is necessary in studies of long dura-
tion. For example, the dryness level on the lower
legs is not anticipated to change much within 12 h
if a short-term single application study baseline week 4
is to be conducted under controlled conditions.
If instead the study is to be conducted over several Study (b)
weeks, there is a high probability that the dryness test
level will change due to external factors such as untreated
washing and climatic changes. Even over a period
of a day or 24 h, there may be either diurnal
rhythms or environmental factors impacting the
measures. Therefore, an untreated control is nec-
essary to demonstrate the changes measured are
due to the product applied and not due to the envi-
ronment. Represented in Fig. 2.2 are illustrative
charts for two hypothetical studies of 4 weeks baseline week 4
duration. As seen by the solid lines, the product-
treated site was substantially improved by the end Fig. 2.2 Results from two hypothetical 4-week skin con-
dition studies. The results at the product-treated site are
of both studies. However, only the data in study (a) represented by solid lines. The results at the untreated
supports the desired claim improved skin condition control site are represented by dashed lines. The results of
within 4 weeks. The data in study (b) does not sup- study (a) support the desired claim improved skin condi-
port the claim because it is seen that the values at tion within 4 weeks. The claim is not supported for the
product in study (b) as the results at the untreated site are
the untreated control site, dashed line, changed to comparable to those at the product-treated site
the same extent as at the product-treated site the
observed change was due to an external factor.
The untreated control site is commonly If the stated claim is lightweight formula dimin-
untouched for the duration of the study. ishes dark circles, testing would require the ball
However, there are several points to take into be applied at the untreated site to isolate the mea-
consideration. If the study is of long duration, it sured difference to the formula. In contrast, the
is important that any other products applied to alternate claim daily application of ultra eye
the untreated site are the same as at the treated tonic diminishes dark circles could be supported
site. For example, the same cleanser should be by comparison to an untouched, untreated site as
used throughout and the same cleansing device the claim specifies the application diminishes
(hands, sponge, washcloth). Additionally, if the the dark circles and the application includes
test product is intended to be applied using a spe- both the massaging and the lotion.
cialized applicator, such as with a massaging
ball, the specific claim must be evaluated to Conclusion
determine if the untreated site should also be In todays regulatory and advertising environ-
treated with a massaging ball. For example, con- ment, claims support study design is diverging
sider the case of an undereye product that is from that of basic research and formulation
applied from a container with a ball applicator. development. Prior to planning the claims
24 J.K. Woodford

support study, it is key to understand what Abbreviations

exactly is being communicated to the con-
sumer both explicitly and implied. The sup- ACB Advertising Claims Board of Advertis-
port portfolio must cover all claims being ing Standards Bureau (Australia)
made, not just those intended to be conveyed. ACCC Australian Competition and Consumer
The details of product application, measure- Commission (Australia)
ment, timing, and study control should be ASA Advertising Standards Authority (UK)
based on the claims in the advertisement, ASC Advertising Standards Canada (Canada)
application instructions to the consumer, and ASEAN Association of Southeast Asian Nations
practical considerations of the measurement CAD Commercials Advice Pty Limited
method. The depth of the support portfolio (Australia)
will also be influenced by the intended pur- EU European Union
pose. External authorities that may be examin- FDA Food and Drug Administration (USA)
ing the study data range in their expectations FTC Federal Trade Commission (USA)
and in how deeply the study details will be FTCPA Fair Trading and Consumer Protection
scrutinized. Agencies (Australia)
MIJO MIJO Corporation, formerly Broadcast
Clearance Advisory (Canada)
NAD National Advertising Division of the
Better Business Bureau (USA)
USA United States of America
Take Home Messages UK United Kingdom
All claims, both explicit and implied,
require support.
Authorities that may be examining sup-
port data include governmental regula- References
tory agencies, advertising preclearance
agencies and advertising self-regulatory 1. United Kingdom Committee of Advertising Practice
agencies. (2010) ASA digital remit extension: we have the
answers. http://www.copyadvice.org.uk/News/2010/
Claims support methods should be tai- Digital-remit-extension.aspx. Accessed 2 Sept 2010
lored to the specific wording of the claim. 2. United Kingdom Advertising Standards Authority
Suitable measurement tools should be (2010) Landmark agreement extends ASAs digital
chosen based on the specific benefit remit. http://asa.org.uk/Media-Centre/2010/ASA-
digital-remit-extension.aspx. Accessed 2 Sept
communicated. 2010
The timing of the measurements should be 3. United States Food & Drug Administration (2009)
based on any temporal elements within the Warning Letter Nestle USA. http://www.fda.gov/
claim and upon the action of the product. ICECI/EnforcementActions/WarningLetters/
ucm194122.htm. Accessed 23 Mar 2010
Application of the product should be as 4. United States Food & Drug Administration (2010)
close to package instructions as possible Warning Letter Unilever, Inc. http://www.fda.gov/
with the frequency and timing in rela- ICECI/EnforcementActions/WarningLetters/
tion to the measurement being deter- ucm224509.htm. Accessed 8 Sept 2010
5. United States Federal Trade Commission (2001)
mined by the specifics of the claim. Advertising practices frequently asked questions
Potential study controls should include answers for small business. http://business.ftc.gov/
an untreated site, a placebo-treated site, documents/bus35-advertising-faqs-guide-small-busi-
and/or a positive-control-treated site. The ness. Accessed 28 Sept 2009
6. European Union Parliament (2008) Statutory instru-
suitability of the control is determined by ments 2008 No. 1277 Consumer Protection. The con-
both the claim and the study design. sumer protection from unfair trading regulations
2008
2 Design of Claims Support for Moisturizers 25

7. Health Canada (2006) Guidelines for cosmetic adver- 11. Advertising Standards Canada (2007) Canadian code
tising and labelling claims. http://www.hc-sc.gc.ca/ of advertising standards. http://www.adstandards.com/
cps-spc/pubs/indust/cosmet/index-eng.php. Accessed en/Standards/theCode.aspx. Accessed 13 July 2010
31 July 2008 12. Advertising Standards Authority (2010) More effec-
8. Australian Government ComLaw (1974) Trade tive, efficient, cost-effective and in tune with our
Practices Act 1974 No. 51, 1974. http://www.comlaw. stakeholders. The ASAs Preliminary Response to the
gov.au/Details/C2004A00109. Accessed 5 Nov 2008 Process Review. http://www.asa.org.uk/Media-
9. United Kingdom Committee of Advertising Practice Centre/2010/ASA-update-on-process-review.aspx.
(2010) The UK code of non-broadcast advertising, Accessed 24 June 2010
sales promotion and direct marketing (CAP Code). 13. European Parliament (2009) Regulation (EC) No
http://www.cap.org.uk/The-Codes/CAP-Code.aspx. 1223/2009 of the European Parliament and of the Council
Accessed 30 Nov 2010 of 30 November 2009. J Euro Union 52:59209
10. United Kingdom Committee of Advertising Practice 14. Association of Southeast Asian Nations (2003)
(2010) The UK code of broadcast advertising (BCAP Agreement on the ASEAN harmonized cosmetic regu-
Code). http://www.cap.org.uk/The-Codes/BCAP-Code. latory scheme. http://www.aseansec.org/20705.htm.
aspx. Accessed 6 May 2011 Accessed 12 Jan 2010
 Educational Interventions
for the Management of Children 3
with Dry Skin

Steven J. Ersser and Noreen Heer Nicol

3.1 Introduction use of cleansers and emollients [7, 22]. If educa-

tional approaches are to be effective in managing
Dry skin or xerosis is a common and important dry skin in children, especially if of a chronic
problem of children. Dry skin often reveals a dis- nature, then attention needs to be given to the
ruption to the protective skin barrier, increasing parents and childs knowledge and behaviour.
its vulnerability, and is often accompanied by Lack of knowledge and skills lead to poor treat-
uncomfortable symptoms. The skin is often ment adherence and ineffective therapy, and this
underrated in regard to its vital roles as a barrier, may in turn compound the problem as treatments
foundation and calorie reserve, as well as those of are erroneously abandoned as ineffective [25].
temperature regulation, sensation, insulation, Further examination of treatment adherence is
psychosocial impact and self-image [26]. Xerosis discussed elsewhere in this text.
contributes to the development of epithelial This chapter highlights several key themes
microfissures, which favours the entry of micro- including the importance of education in the
bial organisms, irritants and allergens. This prob- management of dry skin in children, the nature of
lem can become aggravated during the dry winter educational interventions to support effective
months and in certain living environments. treatment application, some key evidence related
Dry skin management includes basic proper to the educational process and the key resources
daily skin care including appropriate bathing and available. Related issues such as pharmaceutical
factors, emollient selection criteria and applica-
tion effectiveness are discussed elsewhere in this
book.
S.J. Ersser, Ph.D. (Lond), RN, CertTHEd ()
Faculty of Health and Social Care, University of Hull,
Cottingham, Hull, HU6 7RX, UK
e-mail: [email protected] 3.1.1 Behavioural Pattern
N.H. Nicol, Ph.Dc., RN, FNP, NEA-BC
and Management of Dry Skin
Professional Development,
Childrens Hospital Colorado, The management of chronically dry skin requires
Denver, CO, USA addressing a number of factors to sustain effective
National Jewish Health, health behaviour [9]. The factors to be considered
Denver, CO, USA include the knowledge, skills and attitudes of
Clinical Sciences, both the parent and child, dependent on age, and
University of Colorado, Denver, CO, USA specifically their health behaviour and adaptive
e-mail: [email protected]
self-management. These require professional

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 27

DOI 10.1007/978-3-642-27606-4_3, Springer-Verlag Berlin Heidelberg 2012
28 S.J. Ersser and N.H. Nicol

Table 3.1 Self-management knowledge and skills related to the management of chronic dry skin
Self-management competence
in dry skin management Knowledge required Skill required
Manage symptoms and Demonstrate understanding of Adapt treatment to change in condition
medication use symptoms and their triggers
Describe beliefs and Apply topical treatments effectively
understanding of treatment
Use appropriate judgement Use prescribed therapies effectively
when treatment is not working Adapt treatment to changes in their condition (e.g.
during acute episodes of a chronic skin condition)
Judge the limits of self-management and when to
seek help
Communicate effectively with Describe self/family beliefs, Adapt treatment to their lifestyle, whilst maintain-
health professionals understanding, and prefer- ing effectiveness
ences about their condition Exercise treatment choices adapted to preferences/
and treatment lifestyle
Recognize when to intervene Communicate preferences and needs to members
in self-manage and its of the health care team
limitations (when to self-refer)
Adapted from Ersser [9]

assessment and support, especially if the skin Patient surveys can provide an indication of
problem is moderate to severe. patterns of need that practitioners can plan to
The severity and chronicity of dry skin will address; several highlight the difficulties people
influence the nature and degree to which educa- may find in using topical treatments, for exam-
tional intervention will be required. A key ele- ple, [5, 18]. Some of these needs are reflected in
ment to achieve effective self-management is the Table 3.1. They convey a necessity to under-
need to be clear about the expectations of the per- stand their condition, those factors that
son and their caregivers. Educational intervention adversely affect and improve it and their treat-
needs to be planned and systematically delivered, ment. Dissatisfaction with the effectiveness of
addressing that which supports the required treat- treatments is a theme running through research
ment for the child and parent. It will need to findings such as those cited on the management
reveal where there are unmet or poorly met edu- of chronic dermatoses, which are often accom-
cational and support needs, and the assessed lim- panied by dry skin. This has been validated
its to self-management or the process of self-care through recent qualitative evidence, reflecting
fails. self-management needs in other areas where
Table 3.1 outlines some of the knowledge and management of dry skin is required, as with
skills needed to self-manage dry skin effectively. psoriasis, albeit in adults [10].
It illustrates some of the complexity of helping Table 3.1 also reflects the fact that effective
patients to use their treatment optimally and the use of treatment requires an exploration of what
educational and support challenges for health the patient understands by their treatment regi-
professionals. It also provides an illustration of men within the consultation. Research evidence
common areas of educational need that supports suggests that problems of adherence stem more
self-management for those with chronic skin from a disbelief in their efficacy to use prescribed
conditions [9]. These areas of health care need medication effectively than from disease activity
present nurses and other health professionals [34]. Practitioners also need to explore expecta-
with significant therapeutic opportunities to sup- tions of treatments to manage dry skin. Qualitative
port the person and their family to engage actively research evidence suggests that dermatology
in the self-management of dry skin. patients may not share precisely the same views
3 Educational Interventions for the Management of Children with Dry Skin 29

with dermatology professionals about what crite- general colonization by Staphylococcus aureus.
ria are important in judging treatment effective- A Cochrane review of interventions to reduce
ness; as in the case of those living with psoriasis S. aureus in the management of atopic eczema, a
[15]. Also, if a person expects their treatment to common cause of dry skin in children, [4] con-
work quickly but in practice, the medication is cluded that they failed to find evidence that com-
effective only after sustained treatment over a monly used antistaphylococcal interventions are
period of time, such as with the application of clinically helpful in people with eczema that is
emollient therapy, there is a high risk that such not clinically infected. Therefore, their continued
treatment may be abandoned prematurely. There use should be questioned in such situations, until
is a need to give consideration therefore to the better and longer-term studies show clear evi-
range of factors affecting both the patients or car- dence of clinical benefit.
ers treatment choice (preference) and use in prac- Guidance on reducing skin irritation is sum-
tice and to recognise the related educational marised in Appendix 1.
opportunities.

3.2.1 Cleansers

3.2 Daily Skin Care and Hydration The use of appropriate cleansers plays an impor-
tant role in managing dry skin conditions. It is
Daily skin care emphasizing prevention and important that patients are not using cleansers
hydration remains a cornerstone to a successful that have ingredients which are drying or irritat-
dry skin care. At the US authors centre, soak ing. Cleansers with minimal defatting activity
and seal was developed as a fundamental con- and a neutral pH are preferred. Formulations that
cept for proper skin care emphasizing use of are dye-free and fragrance-free are less irritating
hydration, moisturizers, cleansers and topicals to and more appropriate for dry, sensitive skin.
help maintain an intact skin barrier [6, 21, 24]. Patients should be instructed not to scrub with a
Confusion about how to hydrate and moisturize washcloth/flannel.
the skin still exists. Typically, evaporation and
microfissuring occur when wet skin is not imme-
diately covered by a protective layer of moistur- 3.3 Emollients and Moisturizer
izer, occlusive or medication. In contrast, the Usage
soak-and-seal method leads to rehydration, by
sealing in of moisture and assisting the repair of Studies have shown that patients fail to receive
the damaged epidermal barrier. adequate explanation of the causes and triggers
Bathing or soaking the affected area is of dry skin or are not taught how to apply topi-
recommended once per day for approximately cals, even though instruction and practical dem-
1015 min in warm water. A wet washcloth or onstrations may be associated with dramatic
towel can be used to cover the face, head, neck or improvement in the treatment outcomes [22].
body not covered by water to increase hydration. Patients frequently do not understand the vari-
Adding age-appropriate toys will help young ous vehicles of skin care products such as oint-
children cooperate with the bath. Young children ments, creams, lotions and oils and how they can
must be supervised during baths. Water tempera- affect treatment outcomes. In general, ointments
ture should feel comfortable to the patient, as the are more effective sealants and can be the most
oft recommended tepid is usually too cool for hydrating when used after bathing; they are also
most patients. Showers may be appropriate in formulated with the fewest additives. Since they
patients with mild xerosis. are the most occlusive, in a hot, humid environ-
Bathing, showering and cleansing may also ment, they may trap perspiration, which may
remove allergens from the skin surface and reduce result in increased pruritus. Lotions and creams
30 S.J. Ersser and N.H. Nicol

may be irritating due to added preservatives or national formulary, such as the British National
fragrances. In addition, lotions contain more Formulary or Nurse Prescribers Formulary in
water than creams and may have a drying effect the UK, to obtain up to date information on suit-
due to evaporation. While oils may go on easily, able on availability and formulation.
they are often less-effective moisturizers. Patients Patients and caregivers need to understand
should be encouraged to carry moisturizers in that petroleum jelly is a good occlusive prepara-
small tubes with them at all times and to keep a tion to seal in water; it should be used after
separate supply in the day care, school or work hydrating the skin. Of note, even young patients
environment. can be taught to apply these products, which
Topical therapy to replace abnormal epider- allow them to participate in their skin care and
mal lipids, improve skin hydration, and decrease develop skills in self-management.
skin barrier dysfunction may be useful therapeu-
tically [23]. Recommending the use of moistur-
izers together with hydration may help re-establish 3.4 Key Educational
and preserve the skin barrier. Patients, caregivers Challenges for Emollient
as well as health care providers all over the world and Moisturizer Use
acknowledge they are frequently confused about
which moisturizer or emollient to use and how to Emollients are important for promoting skin
best use it [13]. health, especially in vulnerable groups such as
Following hydration of the skin, patients the very young and very old, and for treating dry
should gently pat away excess water with a soft skin diseases such as eczema and psoriasis. A
towel and apply the appropriate topical moistur- survey of the literature indicates that there is little
izer or medication to prevent evaporation, which primary evidence as to how emollients should be
completes the soak and seal process. Application effectively used [13]. The advice and common
of appropriate moisturizers or medications should practice that have arisen are reflected in the clini-
occur within 3 min (3 minute rule). This rule cal literature (e.g. see summary in [13]); key
has been promoted to patients by organizations issues and guidance sources are highlighted in
such as the National Eczema Association (www. this chapter. Emollient issues that the healthcare
nationaleczema.org) in the USA. practitioners need to answer for patients are
Moisturizers should be obtained in the largest dependent on individual patient need, for exam-
size available (typically 500 g/one pound jars or ple, how dry the skin is and the size of the person.
pump packs) since they typically need to be The teaching encompasses all the important
applied several times each day on a chronic basis. dimensions of what, when, where how, and why.
Plastic spoons or wooden tongue depressors Table 3.2 below outlines some of the key point
(sticks) can be used to remove the product, espe- areas related to emollient and moisturizer usage.
cially ointments or creams from large jars to avoid Direct demonstration of effective skin care
contamination. Commonly recommended emol- includes the use topical application of agents
lients and moisturizers which are available in a [6, 23, 24]. Demonstration should be followed up
500 g/one pound jar or tub include Aquaphor with observation of the patient doing a self-
Ointment, Vanicream, CeraVe Cream, Cetaphil application. This will allow confidence and per-
Cream and Eucerin Crme. The availability of formance accomplishment to be achieved by the
these products of course varies across countries; individual. Watching the patients or caregivers
all are available in the USA. In the UK, commonly current technique often reveals fundamental errors
used moisturizers (or emollients) include aqueous which may give providers valuable insights into
cream, emulsifying ointment, diprobase ointment why a patient may not be showing the expected
or cream, doublebase gel, E45 cream, Epaderm, therapeutic response. A typical example is that of
Balenum plus and Eucerin. Health professionals the patient who was observed to apply a very
are advised to consult the latest edition of their small quantity of medication from a small-sized
3 Educational Interventions for the Management of Children with Dry Skin 31

Table 3.2 Key points to consider when teaching about Table 3.3 Dry skin education and communication for
emollient or moisturizer use caregivers within consultations
What product to choose (difference between types) Spend time listening to the patient and/or the parent
When to apply emollients (best after bath or shower) beliefs and expectations
Where to apply emollients or other topical s (order of Deal sensitively with patients emotions and concerns
application) Individualize treatment
How to and how much emollient (ensuring continuous Explain the nature of the condition and clarify the goal
and adequate supply) is control
How to change application with a change in symptoms Demonstrate the technique and how much to apply
When and why to liaise with a health professional various topical agents (e.g. emollients, sealers,
medications)
Reinforce the need to use emollients frequently and
liberally
tube over a large area. On examination of their
Explain how skin infection (bacterial or viral) can
dispensed medication, the tube which should have cause deterioration in condition and teach the signs and
lasted for only 2 weeks still remained partially symptoms of skin infection
full at the 3-month period [25]. This type of edu- Provide written recommendations with step care
cational interaction provides a teaching opportu- moving up and down regarding all therapies including
nity to discuss these practical points. bathing and/or showering
Include written instructions for prescription as well as
over-the-counter products
Distribute carefully selected patient education
3.4.1 Promoting Adherence Through brochures individualise information where necessary
Concordance Check patients understanding and commitment to
recommendations
The effective use of treatments requires adher- Recommend psychosocial support or counselling as
ence which conforms to best evidence on their appropriate
optimal application. This includes ensuring that Adapted from Nicol and Ersser [25], p. 378
the emollient appropriate to the dryness of the
skin is used; emollients of adequate quantity are To achieve concordance, the patient and health
plied using an appropriate technique. Therefore, care professional must actively negotiate an
there is a need to demonstrate to patients the agreement on the nature of the problem (illness)
correct method of application. For emollients, and the treatment plan that draws on the experi-
this includes application in a downward direc- ences, beliefs and wishes of the patient to decide
tion, in the direction of hair growth to prevent when, how and why to use medicines [19]. It is
folliculitis [13]. For many people living with essential and crucial to take account of the views
chronic dermatoses, often associated with dry of the child and parents when making decisions
skin, they have to manage a number of medica- about what is suitable for use to ensure a match to
tions which they have been recommended for their preferences and lifestyle. Through this
use. If they fail to utilize their treatment effec- approach treatment adherence, and therefore
tively; this may be due to a lack of knowledge, treatment effectiveness, is more probable. The
skill, confidence or motivation. Patients are following strategies can assist the process of
often unclear or unaware of the different proper- negotiation within a consultation (Table 3.3).
ties of emollients and the importance of their Atopic eczema is a common source of dry skin
(and their childs) preference to choose specific in children [6]. Treatment adherence problems
emollients that will be utilised. are a common cause of apparent treatment fail-
To improve adherence, the consultation must ure. These include factors such as the patient or
involve actively engaging with the person or parent parental carer having a poor understanding of
and child based on a negotiation about medication disease [17]. In this context, there may be an edu-
between health care professional and patient that cational discussion to enhance the parents capac-
respects patients beliefs and wishes [29]. ity to avoid or manage trigger factors, managing
32 S.J. Ersser and N.H. Nicol

the childs sleep disturbance (dry skin may be Parents have to potentially deal with a large
more pruritic) or finding better ways of commu- range of information of dry skin and related prob-
nicating with professionals regarding treatment. lems such as eczema from wide range of sources,
Consideration needs to be given to the parents the media, industry, popular magazines, the inter-
and, in some cases, the childs ability to manage net and social networking sources, patient sup-
successfully topical applications such as emol- port group leaflets as well as formal information
lients, antibiotic and steroid creams. that may be available from health services.
Information may also come from family and
friends, all of which may influence their decision-
3.5 The Nature of Educational making. Ersser [9] has highlighted that the task
Interventions of identifying reliable information sources of
quality information is a challenge for patients
When considering educational interventions to who can become bombarded with information
manage dry skin in children, it is helpful to sources. The quality of information from health-
address the various dimensions what is an opti- related websites has been found to be a problem
mal and minimal therapeutic approach in terms from a systematic review of studies reviewing
of (1) how the format of how best to deliver such sites, with the finding that in 70% of cases,
the information and promote understanding, (2) the quality of information was a problem [16].
considering the what the content of the mes- The complexity of the process by which parents
sages; (3) when the timing of the education, need to establish if the source of information is
which includes consideration of frequency and reliable and beneficial or not in helping them to
duration; (4) who delivers the education; (5) manage their childs eczema has been highlighted
why providing some rationale for the educa- by Surridges [33] investigation.
tional episode, which underpins each of the ratio- Some programmes have been established to
nales given for the foregoing, 14; and finally (6) assist consumers in the difficult process of navi-
where education is best delivered. Consideration gating the complexity of information directed at
is needed of some of the key content or review eczema and sensitive skin patients and to evalu-
of what dimensions have been discussed above, ate the myriad of personal care and household
to ensure that key messages help develop the nec- products on the market. One such example is the
essary skill and confidence in the parent and or Eczema & Sensitive-Skin Education (EASE)
the child. As such, this section will focus on the Program (see: www.easeeczema.org). This is a
format of delivery and its timing, with reference patient empowerment program that is intended to
to multi-professional involvement. improve patient outcomes and the quality of life
for millions of persons who suffer from eczema
and severe sensitive skin conditions. It provides
3.5.1 How: Educational Formats educational tools and resources relating to the
care and treatment of eczema and sensitive skin.
Educational material for managing problem skin A key consideration when using pre-prepared
is now available in multiple formats, ranging from educational material is the need to ensure that the
the conventional paper pamphlet to now techno- generic material presented address the individu-
logically based material, which ranges from alized need for the parent/child. Key messages
patient advice websites to hard copy in the form and variations need to be highlighted. Standard
of DVDs or CDs to the use of smartphones. materials can be supplemented with a brief writ-
Educational resources come in a variety of ten or annotated sheet of key points relevant to
format, but are essentially either paper-based or the particular child.
are technological in nature; the latter is a devel- Careful attention is needed to the ways in
oping area. An illustrative outline of the range of which patients are guided to information sources
resources available are summarised in Table 3.4. and how best to utilise resources due to the high
3 Educational Interventions for the Management of Children with Dry Skin 33

Table 3.4 Educational resources related to managing chronically dry skin: examples
Websites
Dermatology professionals:
British Association of Dermatologists information sheets www.bad.org.uk/public/leaflets/
International widely regarded dermatology sites (advanced): www.dermnet.org.nz/
Generic sites: National Health Service (UK) NHS Direct www.nhsdirect.nhs.uk/
Condition specific sites:
National Eczema Society (UK)*: www.eczema.org/ email [email protected]
National Eczema Association (USA) www.nationaleczema.org/ email [email protected]
www.eczema.org/abouteczema.html
Psoriasis Association (UK)*: www.psoriasis-association.org.uk/
National Psoriasis Foundation (USA): www.psoriasis.org/home/
Ichthyosis: www.ichthyosis.org.uk/
Printed materials
Dermatology professionals: American Academy of Dermatology: www.aad.org/forms/pamphlets/default.aspx:
produce a catalogue of patient education resources including a leaflet on Dry skin and Keratosis Pilaris (www.aad.org/)
Patient groups: materials can be ordered from many organisations (see above)*
Pharmaceutical companies make some materials and so may have commercial influences; as such, these require
careful review before use. However, useful unbiased resources can still be found, for example, some companies do
produce useful tear-off pads depicting and explaining the maintenance of the skin barrier using emollients. Material
also comes in other formats, such as posters, for example, depicting emollients to highlight the range and different
types available
Guidebooks, for example, Eczema and your child: a parents guide by Mitchell et al. [20], although over 10 years
old, this book remains a popular resource in the UK
Audiovisual materials
These are limited. Again, pharmaceutical companies make some materials and so these may have commercial
influences, unless independently verified and endorsed
Podcasts these are underdeveloped at present; however, they are likely to expand, for example, now available
from the Psoriasis Association: www.psoriasis-association.org.uk/ (November 2008)

volumes of education material of variable quality. considering the common learning needs that can
There is a need to assess the parents and childs be efficiently delivered in a group context. This
educational needs, and ideally their preferred can provide the added benefit of group support
methods of learning and the means of access and vicarious learning from others and how they
(paper versus technological) and the level and adapt to their condition and treatment. Group
complexity of information required. It would support and learning may apply to, say, parents of
seem to be commonplace to indiscriminately hand children with eczema, who will learn from each
out of generic information leaflets is invariably other. To ensure time is used efficiently, learning
ineffective and may well be misleading since it needs should be identified. Educational aids may
may lack necessary modification for the individ- be used such as the appropriate use of a video,
ual. Furthermore, evaluation of the educational discussion time, and time for practical demon-
material is needed during follow-up assessing strations and for questions.
the effectiveness of the source material given as A major web-based educational development
part of a package of care. This may be done in and evaluation initiative is being undertaken by
follow-up clinics or possibly telephone consulta- Santer et al. [30] in the UK within a study entitled,
tions to review learning, remaining areas of help Supporting parents and carers of children with
needed and changing educational needs. eczema: development of a web-based intervention
It is essential to ensure that educational oppor- and pilot RCT, which is funded by the National
tunities are planned and individually tailored; Institute for Health Research (UK). Building on
however, resource efficiencies can be gained by qualitative research, an intervention is being
34 S.J. Ersser and N.H. Nicol

developed; it supports parents of children with when best to deliver education and under what
eczema, and so dry skin, which is mediated by the conditions. This will depend on the childs devel-
web and will then be subsequently evaluated. opmental stage and readiness to engage in learn-
ing. The issues include those of what opportunities
3.5.1.1 Smartphones and Mobile there are for education and the balance of the tim-
Computers ing of professional-led education and service-
Various mobile or mHealth devices, such as user-led education at home. Consideration is also
Mobile (cell) phones, smartphones, smart watches, needed of the timing of education for the parent
wireless tablets, laptops, e-mail, text and USB alongside or with the child and the duration and
drives, are increasingly being used by patients and frequency of the education process, which will
providers to store and exchange health informa- vary with different health systems. The Cochrane
tion [35]. Tessier argues that their value is in their review of educational interventions for childhood
ability to access, record and transmit data any- eczema revealed that temporal issues were a key
place, anytime and by anyone. Health profession- variant in the delivery of education, which in turn
als are using them to improve their productivity may influence its effectiveness [12]. These are
and service users (or their carers) to manage their primarily issues of what duration of education is
conditions effectively, such as those with diabetes possible. These issues will be shaped by the
or in this context those with eczema, experiencing severity of the dry skin, whether a transient
chronically dry skin. Increasingly, applications encounter being managed in the community by
are being developed on smartphones to promote say a community pharmacist or a practice nurse
effective self-management, and this is likely to or a more complex case in which the child has a
include dermatological care. severe chronic dermatoses, such as atopic eczema,
In the case of dry skin management, Pena- where more intensive education will be needed
Robichaux et al.s study [28] has demonstrated and opportunities present themselves for interac-
how text messages (TMs) may be used as a tion with other health professionals, such as spe-
reminder aid and educational tool in for both cialist nurses.
adults and adolescents with atopic dermatitis; as
such, these may have potential use for the parents
of children with chronic dry skin. Daily TMs pro- 3.5.3 Who
vided medication reminders and AD education.
The study found that user feedback on the TM Patients, parents and even healthcare providers
system was positive with the vast majority of par- may have difficulty evaluating what constitutes
ticipants reporting that the reminder TMs and solid, reliable dermatological information to guide
educational TMs were helpful. They concluded routine practices, such as skin moisturization [14].
that the study participants were receptive to using Parents have to potentially deal with a large range
TMs as a reminder aid and educational tool and of information of dry skin and related problems
that this lays the ground work for further studies such as eczema from wide range of sources. Who
needed to elucidate the full potential of this sim- delivers this information and the process of vali-
ple and cost-effective intervention. dation is a key consideration. In the clinic context,
nurses are often well placed to deliver structured
education within nurse-led clinics, allowing time
3.5.2 When: Temporal Factors, for clarification and follow-up. Whichever profes-
Timing, Duration, Key Messages, sional takes this on, they will require planned and
Staging Information structured opportunities to ensure education is
effective and evaluated. This is highlighted fur-
Key issues in the education of parents of children ther under the rationale Sect. 3.5.4.
or the child themselves with dry skin are those Sources of information often arise from out-
related to timing of the education. This includes side of the health care setting, namely, via the
3 Educational Interventions for the Management of Children with Dry Skin 35

media, industry, popular magazines, the internet manage the pruritus that can result from dry skin.
and social networking sources, patient support In this context, the self-efficacy concept predicts
group leaflets as well as formal information that that the parent or child is more likely to engage in
may be available from health services. Information certain behaviours when they believe they are
may also come from family and friends, all of capable of carrying them out successfully, that is,
which may influence their decision-making. The when they have high self-efficacy developed
task of identifying reliable information sources through the acquisition of the mastery or acquisi-
of quality information is a challenge for patients tion of self-management skills.
who can become bombarded with information During the educational process, it is important
sources has been highlighted [9]. The quality of to note that learning may or may not result in
information from health-related websites has behavioural change. For example, a parent may
been found to be a problem from a systematic be taught to apply their topical treatments; how-
review of studies reviewing such sites, with the ever, they may not have the confidence to apply
finding that in 70% of cases, the quality of infor- them or, say, the skill to effectively apply a wrap-
mation was a problem [16]. ping bandage. It is fundamental for the carer to
have sufficient degree of self-belief by the person
in their capacity to act as well as knowledge, skill
3.5.4 Why and indeed motivation. Education needs to be
directed to enhancing the parents or childs
The effectiveness of educational intervention for capacity to make choices in managing their dry
the management of dry skin in children can be skin to help them to adapt effectively. Self-efficacy
assisted by some theoretical considerations. is recognised as a key basis for effective self-care
Again, this has most relevance when dealing with ability for those with chronic conditions.
chronically dry skin that requires sustained man- Bandura [3] summarises strategies to enhance
agement over time and integration with the par- or provide sources of self-efficacy.
ent-childs lifestyle. One key set of ideas are Their practical application will now be illustrated
those regarding the parents belief in their ability within the context of a dermatology consultation.
to help their child self-manage and how they may 1. Personal accomplishment and verbal persua-
learn from one another in social groups to enhance sion: can lead to stronger efficacy beliefs than
the effectiveness of learning. other strategies of influence. This involves
For the parent managing a child with chroni- reinforcing (acknowledging and encouraging)
cally dry skin, there is a need to build confidence instances when patients effectively engage in
in their and perhaps their childs self-management successful health behaviour, such as managing
ability. Self-efficacy is an important concept to apply topical medications in the correct
which is similar to but technically distinct from order. It is important to assess the patients
that of confidence. It provides a key motivational self-management ability and to give them per-
force, which health professionals need to support. formance feedback, including verbal persua-
Bandura [1, 2] defined self-efficacy as an indi- sion to encourage them to build on what they
viduals belief in their capacity to successfully are already doing well.
execute a health-related behaviour. It is based on 2. Vicarious experience or social modelling:
Banduras Social Learning Theory [1], which highlights the importance of opportunities
indicates that people learn by observing the for parents or children to learn from others.
behaviour of others within a social context. The importance of demonstrating has been
Practically, this would be relevant when planning highlighted earlier in this chapter. This may
perhaps group education for parents who are include health professionals demonstrating
trying to manage their childs chronically dry effective practices, such as a wet wrapping
skin and the way in which they may learn from technique by a parent or creating group-
each other, how best to apply emollients or say learning opportunities where there is sharing of
36 S.J. Ersser and N.H. Nicol

good practice by a patient or parental carer with conditions some of which are subject to sys-
others in a similar social learning situation. tematic reviews. A Cochrane systematic review
3. Regulation of emotional behaviour: Bandura of psychological and educational interventions to
[3] highlights how emotional and physical manage childhood atopic eczema [12] identified
arousal, such as anxiety and stress, may inter- only four educational studies that met the inclu-
fere with the performance of a desired behav- sion criteria on methodological rigour, which
iour. Chronically dry skin may be stressful for included those of [8, 27, 32, 31]. For each of
parent and child, especially if accompanied by these studies, the intervention was an adjunct to
regular scratching and damage to the skin. The conventional therapy, not a substitute for it. It
patient can be directed to strategies to help them was not possible to synthesise the data due to the
manage stress and anxiety more effectively variation in the type of data available, especially
through pursuing relaxation opportunities, such its heterogeneity. However, it was possible to
as returning to social hobbies which have been provide an extensive critical appraisal of the
curtailed due to a lack of self-esteem or engag- included studies.
ing them in the use of relaxation methods. The studies by Niebel et al. [27] and Staab
Work is at an advanced stage of developing et al. [31, 32] identified that education can lead to
and testing measure of parental, self-efficacy in an improvement in clinical severity and in paren-
managing their childs eczema, through the devel- tal quality of life [31], but only marginal improve-
opment of the Parental Self-Efficacy with Eczema ment was seen in the latter within [8] study. For
Self-Care Index (PASECI tool), which will be each study, a systematic approach to education
published in due course [11]. was implemented using one of two models of ser-
vice delivery, either (1) an eczema school multi-
disciplinary approach, which are more typical in
3.5.5 Where Germany or (2) nurse-led clinics that are more
typical in the UK. The focus of all four studies
Consideration needs to be given to the optimal envi- was directed towards parental education. It was
ronments for the education of the parent and child; concluded that the Eczema School model was
however, there may be very limited opportunities to much more likely to be resource intensive com-
provide effective support. Furthermore, many par- pared to the nurse-led clinic model [12], although
ents will have limited consultation times with health no comparative studies have been undertaken as
professionals and so will need to be guided to sources yet of their relative effectiveness. Education was
of remote education and support, such as through the delivered in both hospital outpatient settings
internet or being guided to read approved educational (Niebel and both Staab studies) and in primary
resources such as leaflets or a DVD at home. This care (Chinn) and with and without the use of
may include telephone consultation, the use of e-mail technology. The use of technology was revealed
and other internet-mediated contact, such as Skype in Niebels study where video-assisted education
and smartphone. In some facilities, the available was used and found to be more effective in
physical space for consultation may be an issue, to improving severity than direct education and the
ensure that the educational process is not disrupted. control (discussion) (p < 0.001). The most rigor-
ous study found to date was that of Staab et al.
[31], which evaluated long-term outcomes.
3.6 Outline of Evidence on the Significant improvements were found in both
Effectiveness of Educational disease severity (3 months to 7 years, p = 0.0002;
Intervention 812 years, p = 0.003; 1318 years, p = 0.0001)
and parental quality of life (3 months to 7 years,
There are a small but growing number of stud- p = 0.0001; 812 years p = 0.002) for children
ies developing and testing interventions to sup- with atopic eczema. The [12] review is being
port the management of specific dermatology updated in 2012.
3 Educational Interventions for the Management of Children with Dry Skin 37

As a limited number of studies to date address

the effectiveness of educational approaches to Take Home Messages
improve dry skin conditions in children, such as Behaviour of the parent and their child
atopic dermatitis, the authors recommend that an who have dry skin has a significant impact
international priority be given to assessing the on the effectiveness of moisturizer use,
impact of patient and parental education by especially when the condition is chronic.
nurses and other care providers for children with Consumers with dry skin are often
skin diseases with a dry skin component in chil- unsure how to effectively manage their
dren. Research studies designed to address the condition.
common weaknesses of existing randomized Planned and systematic education is an
studies should be utilized. International collabo- essential preparation for the effective
ration will help to establish greater clarity on self-management to ensure parents and
developing more effective evidence-based mod- or their children with dry skin have the
els for delivering dry skin education and support knowledge, skill and confidence that
by healthcare teams for children living with underpins effective treatment adherence.
chronically dry skin across differing health Generic information invariably needs to
systems [25]. be adapted for the individual child and
family.
Management of dry skin, especially when
chronic, requires moisturization to become
Appendix 1 a part of routine skin care and hygiene.
Effective adherence to the use of mois-
Guidance on reducing skin irritation through effective
turizers depends on the adoption of a
skin care
concordance approach to consultations
Wash all new clothes before wearing them. This
removes irritating chemicals, such as formaldehyde in which patient beliefs and preferences
Add a second rinse cycle to ensure removal of are taken into account in the decision-
detergent. Residual laundry detergent, particularly making process.
accompanying perfume or dye, may be irritating when Educational interventions vary according
it remains in the clothing. Changing to a liquid and
fragrance-free, dye-free detergent may be helpful.
to how they are delivered (format), when,
Some liquid detergents are branded as being suitable why and where this takes palace. Each
for sensitive skin but such claims needed to be tested element requires consideration within
in practice for the individual the planning of the educational process.
Wear garments that allow air to pass freely to your skin. Parents self-efficacy, akin to confidence
Open weave, loose-fitting, cotton-blend clothing may be
most comfortable in the management process, is an impor-
Work and sleep in comfortable surroundings with a tant factor affecting their effective use
fairly constant temperature and humidity level. of moisturisers.
Adequate ventilation is important Evidence on the educational process related
Fingernails should be kept very short and smooth to to moisturiser use is limited but indicates
help prevent damage due to scratching
the different models by which health profes-
Carry a small tube of moisturizer/sunscreen at all
times. Such a separate supply of moisturizer enables sionals can deliver education and variation
regular access for application throughout the day when on the components described above (how,
at school or work. For young children, other carers, when, etc.). Attention needs to be given to
such as those at play group, need to be instructed in the importance in the variation of these
effective application
components (e.g. technological versus
Shower or bathe after swimming in chlorinated pool or
using hot tub using a gentle cleanser to remove irritating paper-based) and a comparison of different
chemicals and then apply moisturizer service delivery models within the health
Adapted from National Jewish Atopic Dermatitis Program system, when managing chronic dry skin.
Step-Care AD Action Plan. ([24], p. 8)
38 S.J. Ersser and N.H. Nicol

References 17. Fischer G (1996) Compliance problems in paediatric

atopic eczema. Australas J Dermatol 37(Suppl 1):
S10S13
1. Bandura A (1977) Social learning theory. Prentice
18. Krueger G, Koo J et al (2001) The impact of psoriasis
Hall, Englewood Cliffs
on quality of life Results of a 1998 National Psoriasis
2. Bandura A (1989) Human agency in social cognitive
Foundation Patient-Membership Survey. Arch
theory. Am Psychol 44(9):11741184
Dermatol 137(3):280284
3. Bandura A (1997) Self-efficacy: the exercise of con-
19. Medicines Partnership (2003) Medicines partnership
trol. Freeman, New York
project evaluation toolkit. Medicines Partnership,
4. Bath-Hextall FJ, Birnie AJ, Ravenscroft JC, Williams
London
HC (2010) Interventions to reduce Staphylococcus
20. Mitchell T, Paige D, Spowart K (1998) Eczema and
aureus in the management of atopic eczema: an updated
your child: a parents guide. Class Publishing, London
Cochrane review. Br J Dermatol 163(1):1226
21. Nicol NH (1987) Atopic Dermatitis: The (wet) wrap-
5. Beresford A (2002) Psoriasis Association Members
up. Am J Nurs 87:15601563
Questionnaire Survey. Psoriasis Association,
22. Nicol NH (2005) Use of moisturizers in dermatologic
Northampton
disease: The role of healthcare providers in optimiz-
6. Boguniewicz M, Nicol NH (2008) General manage-
ing treatment outcomes. Cutis 76(suppl 6):2631
ment of patients with atopic dermatitis. In: Reitamo S,
23. Nicol NH (2011) Efficacy and safety considerations
Luger TA, Steinhoff M (eds) Textbook of atopic der-
in topical treatments for atopic dermatitis. Pediatric
matitis. Informa UK Ltd, Andover, pp 147164
Nursing 37(6):295302
7. Boguniewicz M, Nicol NH, Kelsay K, Leung DYM
24. Nicol NH, Boguniewicz M (2008) Successful strate-
(2008) A multidisciplinary approach to evaluation
gies in atopic dermatitis management. Dermatol Nurs
and treatment of atopic dermatitis. Semin Cutan Med
(Suppl):318
Surg 27(2):115127
25. Nicol NH, Ersser SJ (2010) The role of the nurse
8. Chinn DJ, Poyner T et al (2002) Randomized con-
educator in managing atopic dermatitis. In:
trolled trial of a single dermatology nurse consultation
Boguniewicz M (ed) Immunology and Allergy Clinics
in primary care on the quality of life of children with
of North America: atopic dermatitis. Saunders/
atopic eczema. Br J Dermatol 146(3):432439
Elsevier, Philadelphia, 30(3):369383
9. Ersser SJ (2010) Helping patients make the most of
26. Nicol NH, Huether SE (2010) Alterations of the integ-
their treatment. In: Penzer R, Ersser SJ (eds) Principles
ument in children. In: McCance KL, Huether SE,
of skin care: a guide for nurses and other health care
Brasher VL, Rote NS (eds) Pathophysiology the
professionals. Wiley-Blackwell, Oxford
biologic basics for disease in adults and children,
10. Ersser SJ, Cowdell F, Latter SM, Healy E (2010)
6th edn. Mosby-Year Book, Inc, St. Louis, pp
Self-management experiences in adults with mild-
15731607
moderate psoriasis: an exploratory study and implica-
27. Niebel G, Kallweit C et al (2000) Direct versus video-
tions for improved support. Br J Dermatol 163(5):
based parental education in the treatment of atopic
10441049
eczema in children. A controlled pilot study [Direkte
11. Ersser SJ, Farasat H, Jackson K, Dennis H, Hind M
versus videovermittelte Elternschulung bei ato-
(2011) Parental Self-Efficacy with Eczema Self-care
pischem Ekzem im Kindesalter als Erganzung facha-
Index (PASECI tool), Unpublished document.
rztlicher Behandlung. Eine Kontrollierte Pilotstudie].
University of Hull, Hull, UK
Hautarzt 51:401411
12. Ersser SJ, Latter S et al (2007) Psychological and edu-
28. Pena-Robichaux V, Kvedar JC, Watson AJ (2010)
cational interventions for atopic eczema in children.
Text messages as a reminder aid and educational tool
Cochrane Database Syst Rev (3), Art. No.: CD004054.
in adults and adolescents with atopic dermatitis: a
doi: 10.1002/14651858. CD004054.pub2
pilot study. Dermatol Res Pract Article ID: 894258:6
13. Ersser SJ, Maguire S, Nicol N, Penzer R, Peters J
doi: 10.1155/2010/894258
(2009) Best practice in emollient therapy; a statement
29. Royal Pharmaceutical Society of Great Britain (1997)
for health care professionals, 2nd edition. Dermatol
From compliance to concordance: achieving shared
Nurs (Suppl) 8(3):122
goals in medicine taking. Report of the working group
14. Ersser SJ, Nicol NH (2010) The challenges of evi-
at the Royal Pharmaceutical Society which enquired
dence-based practice for the dermatology nurse: when
into the causes of medicine taking problems, RPSGB,
should you believe what is being presented? Dermatol
London
Nurs 22(1):13
30. Santer M, Little P, Yardley L, Lewis-Jones S, Ersser
15. Ersser SJ, Surridge H et al (2002) What criteria do
SJ et al (2011-ongoing) National Institute for Health
patients use when judging the effectiveness of psoria-
Research (UK) funded study (unpublished) proposal.
sis management? J Eval Clin Pract 8(4):367376
Supporting parents and carers of children with
16. Eysenbach G, Till J (2001) Ethical issues in qualita-
eczema: development of a web-based intervention
tive research on internet communities. Br Med J
and pilot RCT. University of Southampton, UK
323(7321):11031105
3 Educational Interventions for the Management of Children with Dry Skin 39

31. Staab D, Diepgen TL et al (2006) Age related struc- 33. Surridge HR (2005) Exploring parental needs and
tured educational programmes for the management of knowledge when caring for a child with eczema.
atopic dermatitis in children and adolescents: multi- Exchange. The National Eczema Society, London
centre randomised controlled trial. Br Med J 332: 34. Taal E, Rasker E et al (1993) Health status, adherence
933938 with health recommendations, self -efficacy and social
32. Staab D, von Rueden U et al (2002) Evaluation of support in patients with rheumatoid arthritis. Patient
a parental training program for the management of Educ Couns 20:6376
atopic dermatitis. Pediatr Allergy Immunol 13: 35. Tessier C (2010) Management and security of health
8490 information on mobile devices. AHIMA Press, Chicago
 Dry Skin in Childhood and the
Misery of Eczema and Its Treatments 4
Susan Lewis-Jones

4.1 Dry Skin in Childhood Eczema tisation [4]. However, ORegan and colleagues
have suggested that the sequence of biologic,
Dry skin is a general term used to describe the physicochemical, and aberrant regulatory events
clinical appearance of superficial scaling, peeling that constitute the transition from an inher-
and fissuring of the skin that may be associated ited barrier defect to clinical manifestations of
with a build-up of scales and hyperpigmenta- inflammatory eczematous lesions and suscepti-
tion. It is seen almost universally in eczema, bility to related atopic disorders is still largely
psoriasis and ichthyosis, although the abnormal unknown [4].
epidermal structural and immunopathological
changes differ. The term xerosis is often used
to describe mildly dry skin in eczema, and 4.2 Skin Barrier Structure
although there may not be overt clinical signs of and Function
inflammation, it has been shown that there are
functional as well as biochemical abnormali- The epidermal barrier performs a large number
ties which reflect a subclinical inflammation of functions including physical and immunologi-
[1]. Dry skin in eczema represents a breakdown cal protection, absorption of substances, regula-
of normal epidermal barrier function caused by tion of heat and water loss and sensory messaging.
complex gene-environmental interactions. The Importantly, it is the most visual body organ, and
end result is cellular dehydration and loss of the obvious disruption of the skin barrier may affect
lipid bilayer with a resultant increase in trans- psychosocial functioning which is a particular
epidermal water loss and reduction in the func- problem for eczema sufferers.
tional integrity of the cornified cell envelope At a very simplistic level, the integrity of
forming the outer skin barrier [2, 3]. Defective the skin barrier is maintained by the corneocyte
barrier function permits penetration of irritants, cell envelope, a network of mature corneocytes
allergens and microbiological agents into the linked together by corneodesmosomes and
epidermis causing an inflammatory immune lying within a complex lipid bilayer. An essen-
response with the potential for allergic sensi- tial balance is maintained between the forma-
tion of new epidermal cells at the basement
layer and desquamation of surface corneocytes
aided by proteases which break down the cor-
S. Lewis-Jones, FRCP, FRCPCH neodesmosomal connections. The initial cuboi-
Department of Dermatology,
dal shape of basal epidermal cells is maintained
Ninewells Hospital and Medical School,
Dundee, Tayside, Scotland DD1 9SY, UK by a cytoskeleton of keratin filaments but dur-
e-mail: [email protected] ing migration of the cells through the epider-

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 41

DOI 10.1007/978-3-642-27606-4_4, Springer-Verlag Berlin Heidelberg 2012
42 S. Lewis-Jones

mis towards the Stratum corneum alignment, 4.2.2 Environmental Factors Causing
and aggregation of the keratin filaments occurs Dry Skin in Eczema
by action of the structural protein filaggrin
(FLG), resulting in flattening of the cells [5]. It seems self-evident that physical factors such as
The nucleus is lost at this stage, and other com- mechanical friction, exposure to chemicals, ther-
plex changes occur in the cell envelope to form mal damage or ultraviolet light should impair
mature corneocytes or squames. FLG is subse- epidermal barrier integrity, but there is currently
quently further metabolised to produce natural scant confirmatory evidence to support the major-
moisturising substance which is part of the ity of environmental factors which have been
lipid bilayer essential to normal skin barrier suggested as a trigger for eczema [10, 11]. The
function [5]. Many other epidermal proteins risk of developing eczema seems to be increased
are known to be vital for normal skin barrier in urban compared with rural areas [12], suggest-
function and integrity. For a more detailed ing a role for environmental pollution. Schmitt
description of the function and structure of epi- et al. [13] have performed a systematic review on
dermis, see Chaps. 814. the effectiveness and safety of interventions on
breastfeeding, controlling house-dust mite levels,
corticosteroids, dietary exclusion of eggs or cows
4.2.1 Genetic Factors Implicated milk, elementary diets, emollients, essential fatty
in Atopic Dry Skin oils, few-foods diet, multivitamins, pimecroli-
mus, probiotics, pyridoxine, reducing maternal
The FLG gene is located on chromosome 1q21 at dietary allergens, tacrolimus, vitamin E and zinc
the site of a large gene cluster known as the epi- supplements [13]. The role of soaps and deter-
dermal differentiation locus. Genetic studies gents remains unproven [10], although alkaline
suggest that inheritance of loss-of-function (null) soaps dissolve the lipid bilayer and increased pH
mutations of the FLG gene is a major cause of results in up-regulation of serine protease activity
impaired skin barrier function, is responsible for and an increase in epidermal cell desquamation
the clinical manifestations of ichthyosis vulgaris and dryness [2], so the use of soap substitutes
[5] and carries a high risk of the development of seems sensible despite a lack of confirmatory evi-
atopic eczema [6]. There is mounting evidence dence [14]. Hard water has been thought to be a
that possession of FLG null mutations is associ- cause of dry skin and eczema, but a recent UK
ated with early-onset eczema [3] persistent in to study [Softened Water Eczema Trial [SWET]] on
adulthood [7] and an increased risk of allergic the use of water softeners in hard water areas did
sensitisation [4]. A report of another single not show any overall statistical significance to
nucleotide polymorphism independent of the justify their use in treating eczema [15].
FLG risk alleles but with a strong association
with atopic eczema suggests that it may be mul-
tiplicative in its effect [8]. Genetic and environ- 4.2.3 The Role of Emollients
mental factors that govern enhanced protease in Dry Skin
activity and decreased synthesis of the lipid
lamellae are also recognised to play a part in Emollients are used to hydrate the skin to improve
eczema causation [2], but their role and that of the appearance of dryness, to reduce itching [16]
others governing inflammation, cytokine release and have a cooling effect through evaporation in
and IgE function are not fully elucidated [9]. A the case of water-based emollients. They are used
recent review provides a fuller account of the in all types of dry skin conditions as wash or bath
current state of knowledge and future goals of products and as leave on emollients. Guidelines
eczema genetics [9]. for the care of eczema such as those by the
For a more detailed account of the role of fil- National Institute for Clinical Excellence [NICE]
aggrin in dry skin, see Chapter 9. [17, 18], the European ETFAD/EADV eczema
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 43

task force [19], SIGN [Scottish Intercollegiate A current UK pilot study into the use of
Guidelines network] [20] and the American emollients on healthy skin of infants to prevent
Academy of Dermatology Association [21] all the development of atopic eczema in high-risk
recommend the regular daily use of emollients in groups is almost complete, and the results are
the treatment of eczema even during periods of shortly to be published (Williams HC, personal
disease quiescence to prevent flares. communication to the author).
The choice of emollient is largely patient-cen-
tred, but generally speaking, water-based creams
or lotions are helpful for acutely hot, inflamed 4.2.4 Harmful Effects of Emollients
eczema because of the cooling effect from evapo- in Eczema (See also Chap. 26)
ration, whereas greasy ointments are used for very
dry skin. Fissuring is common in severely dry skin, Occasionally, the effects of emollients are not
especially in the creases of the digits, wrists, ankles beneficial, especially to children with eczema.
and heels, and clinical experience suggests that the Excipients such as preservatives in creams and
use of greasy emollients under occlusion is benefi- lotions often cause stinging which affects patient
cial in these sites. Emollients are thought to have acceptability. Other excipients often included for
antioxidant, anti-protease, anti-inflammatory their humectant effect are glycerol, propylene
activity and aid in restoring the natural balance of glycol, sorbitol and others. Significant absorption
lipids in atopic eczema, thus restoring barrier func- of additives such as urea or lactic acid can lead to
tion [22]. They vary greatly in their types of base dangerous toxicity if used over large body surface
(see Chap. 24) and other constituents (excipients/ areas in younger children, particularly neonates
additives), and this affects their action, water- and preterm infants who have a much thinner
retaining potential and patient acceptability. See immature epidermis. This is exaggerated in atopic
also Chaps. 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, eczema because of impaired epidermal barrier
31, 32, 33, 34, 35, 36, 37, 38 and 39 on Ingredients function. In preterm infants, use of emollients
and treatment effects. Emollient treatment has should be confined to simple paraffin-based prod-
been demonstrated to significantly reduce the use ucts without preservatives. Ointments generally
of high-potency topical corticosteroids by 4050% lack preservatives and are therefore less likely to
in infants with atopic eczema compared to con- cause irritancy and stinging, but they may cause
trols, [16, 23]. In one small study on eczema, the folliculitis, particularly if used under occlusion
response to treatment with topical corticosteroids [27].They are unsuitable for pump dispensation
seemed to be enhanced by an emollient containing and are usually supplied in open containers such
urea [24]. Another study on the use of emollients as tubs. These can easily become secondarily
to treat eczema in 48 children concluded that the contaminated with microbes from repeated finger
liberal usage of emollients and bathing cleanser application, and theses may be one possible rea-
alone does not seem to alter disease severity or son for recurrent episodes of bacterial infection in
trans-epidermal water loss within 2 weeks, imply- eczema (Cork M, personal communication to
ing that additional treatments are necessary to author). To prevent contamination, children and
manage atopic eczema [25]. There is little pub- their parents/carers should be counselled to use a
lished evidence to show the superior effect of one clean implement to remove sufficient ointment
emollient over another in the treatment of eczema, for their needs from the container and warned not
and it is vital to take into account patients personal to return any residual unused preparation to the
preference in order to encourage treatment adher- container. Ointments have been reported to solid-
ence [17, 18]. The GREAT [Global Resource of ify and block plumbing in cold weather (patients
EczemA Trials] database lists all recent ran- personal communications to author).
domised controlled trials [RCTs] for eczema and Emollient creams or lotions are water-based
contains a short list of those involving emollient and contain preservatives making them more
therapy in eczema [26]. likely to cause irritant contact eczema or more
44 S. Lewis-Jones

rarely allergic sensitisation, either of which may 4.3 The Misery of Living
not be recognised in chronic eczema. It is there- with Eczema
fore vital to patch test all young children with
chronic eczema or inexplicable flares and includ- 4.3.1 The Psychosocial Effects
ing emollients in the series [28]. There are a few of Eczema on Children
reports of cutaneous allergy occurring in children and Their Families
from the use of emollients containing food pro-
teins such as oatmeal [29]. There has been con- Children with eczema and their families have a
cern about the use of such emollients in infants at miserable time whenever the eczema flares
high risk of food allergy, but at this time, there is [3437], and this may be a constant feature in the
insufficient evidence to recommend avoiding more severe and chronic cases. Data taken directly
such products routinely in young infants with from children and their parents [34, 35] and many
eczema. Those emollients containing arachis oil subsequent quality of life studies suggest that
should be avoided in cases of peanut allergy or if eczema affects all aspects of their lives and may
there is a family history of it, and it would seem cause psychological disturbance in the child or
wise to avoid topical use of any nut oil in nut its family unit [38].
allergy sufferers. It should be remembered that Sleep Disturbance: The inflammatory nature
many families use over the counter (OTC) of eczema causes intense pruritus and often
emollients for treating eczema that often contain intractable scratching which affects sleep in
perfumes or other excipients which may cause between 66% and 80% of children compared to
contact eczema. Many of the fashionable so- less than 45% of normal children [35, 3941]. It
called natural products contain plant extracts also affects family members of younger children
which may sensitise, especially in those with with eczema, especially siblings, and parents
atopic eczema. There is a cultural preference in may lose an average of 2.5 h of sleep per night
many communities for using olive oil to treat during flares [39]. Sleep disturbance can manifest
eczema; however, it has been shown to cause as an increase in sleep latency (getting to sleep)
both irritant and allergic contact eczema, espe- and increased frequency and length of night-time
cially if used under occlusive bandages [30]. wakening and restlessness during sleep. Sleep
Some excipients used in emollients may disturbance occurs in 39% of normal infants, but
actually damage epidermal barrier function. eczema causes a pattern of much more severe
Commonly used aqueous cream was designed night-time wakening and reduced sleep efficiency
as a wash product but is frequently used as a [42]. Pruritus causing sleep loss and tiredness is
leave on emollient. It usually contains sodium amongst the most important problems relating to
lauryl sulphate (SLS), a known skin irritant. eczema according to children and their parents
Recent work has shown that application of aque- [34, 35, 43]. The use of sedating antihistamines
ous cream reduces Stratum corneum thickness for pruritus or to aid sleep may further increase
and increases the rate of trans-epidermal water day-time tiredness and impair concentration [37].
loss (TEWL) during tape stripping [31] and is Sleeping with parents (co-sleeping) is normal in
associated with reduced maturity and size of cor- many societies, but even in those where it is
neocytes and increased desquamatory and inflam- uncommon, parents often take the affected child
matory protease activity [32]. into their bed with consequent negative effects on
A recent review of comparison and suitabil- their own sleeping patterns [44].
ity of emollients used in young children sug- Physical Effects [34, 36, 37]: These include
gested that emollients should be chosen to itching, burning, tiredness, loss of concentration,
minimise the risk of contact sensitisation. The etc. Excoriations often sting with treatment appli-
authors noted that emulsifiers can promote skin cation or when exposed to chlorinated water, so
dryness by emulsification of the endogenous children often refuse treatment or to go swim-
epidermal lipids [33]. ming. Painful fissuring is seen in hand and foot
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 45

dermatitis, and children report problems with Other Social Aspects [34, 35]: Bedding and
writing, unscrewing bottle tops, riding their bikes, clothes are frequently soiled or bloodied from
handling sports equipment and wearing sports scratching or the use of greasy emollients and
shoes or activities involving running or jumping. require frequent washing and replacement. This
Parents report problems with discomfort and pain is often quoted as a reason for avoiding hotel holi-
in infants during bathing or dressing [35]. days or overnight stays at friends houses. Those
Performance and Schooling: The resultant with real or suspected food allergy may also have
tiredness from sleep deprivation causes irritabil- problems away from home, especially at parties
ity and mood swings which may affect concen- or eating out with the family. Other things of
tration, school performance and sporting activities major concern to children are the restriction on
[34]. In infants, tiredness leads to an increase in owning or having contact with furry pets or other
tantrum behaviour [36]. Time lost from school- animals, and this may also prevent visits to rela-
ing is a problem for those with the more severe or tives or friends houses. In one small utility study
chronic spectrum of disease, and school avoid- in younger children when asked about their favou-
ance sometimes occurs, especially if there has rite things, children specified their pet as one of
been teasing or bullying [37]. A US Study on par- the top three items demonstrating the importance
ents of over 400 children up to age 15 years children place on pet ownership [46]. In family
reported difficulties with schooling, daily, social studies, parents reported that not being able to
and leisure activities in 60% [45]. Ultimately, own a pet affected other family members [35].
having chronic eczema may affect career choices, Mealtime and Dietary Problems: Parents fre-
for example, having to avoid wet work because of quently blame foods as a cause of eczema, often
the risk of hand eczema in the catering, hairdress- with no confirmation of true allergy, and as a
ing or medical professions or in manual occupa- result a significant majority report increased time
tions such as the mechanical or building trades. spent shopping, preparing food and difficulty at
Embarrassment and Psychosocial Reactions mealtimes as major problems [35]. They also fre-
to Eczema [34, 37, 38, 45]: The visual nature of quently spend money on Allergy tests on the
eczema causes loss of confidence even if com- High Street or increasingly on the internet,
ments or questions are kindly meant. Teasing and although there is no evidence of the benefit of
bullying are common and may lead to peer group these [17]. Children on food-restricted diets have
ostracisation resulting in anxiety, mood swings, especial problems at parties, when staying with
sadness, anger and depression. Occasionally, friends or at school. True food allergy occurs
other psychological problems arise, including mainly in infants, usually those with moderate to
behavioural problems and school avoidance. severe eczema cases where foods may be a trig-
Embarrassment about their appearance when gering factor for eczema in about a third of cases
undressing in front of others, especially for com- [17]. Mild eczema occurs in 80% of cases, and
munal changing such as for sporting activities, is food allergy in these cases is much less likely to
a frequently mentioned problem so that children be a triggering factor. Milk, egg and peanut
seek to avoid such situations. They also have to allergy account for about 75% of food allergy
contend with the necessity of wearing different cases triggering eczema, and although milk and
clothes from their peers, either as cover to hide egg allergy usually remit in early childhood, pea-
the eczema or because certain materials such as nut allergy tends to persist throughout life in the
synthetics which may cause increased sweating majority [17]. Food allergy should be suspected
and irritation. Eczema of the face or hands is a in those infants with gastrointestinal disturbance
particular embarrassment because it is difficult to such as reflux, vomiting, colic and diarrhoea and
conceal, and using make-up for camouflage often should alert physicians to possible food allergy
irritates or stings. Embarrassment about the shiny/ [17]. Unfortunately, some children suffer from
greasy appearance of skin or clothes due to emol- severe restriction of their diet, often unnecessar-
lient use may contribute to treatment refusal. ily. It is therefore vital that suspected cases are
46 S. Lewis-Jones

properly investigated so that appropriate advice this did not relate to the eczema severity [50]. In
can be given where indicated and unnecessary this study, the childs rating of the impact of
dietary restriction avoided in those not requiring eczema on their QoL was significantly related to
it. In particular, a few infants on long-term unsu- their psychological symptoms. In an Australian
pervised milk-free or other restricted diets may study, maternal stress in caring for children with
develop faltering growth [17], and there are eczema was found to be equivalent to that associ-
occasional reports of severe nutritional deficiency ated with the care of children with severe devel-
and the development of rickets [47]. A Cochrane opmental and physical problems [51].
review of nine randomised controlled trials con- In contrast Absolon et al. found levels of men-
cluded that there is no benefit from the use of a tal distress to be no greater in mothers of children
milk- or egg-free diet, elemental or few-foods with eczema than in parents of the control group.
diet in unselected patients with atopic eczema However, they did find twice the rate of psycho-
[48]. Those children with proven food allergy logical disturbance in children with moderate to
should be referred for paediatric dietetic advice, severe eczema compared to the control group, but
and all prepubertal children with moderate to not in those with mild eczema [52]. There was no
severe eczema should be monitored for growth on difference in the degree of social support experi-
a regular basis [17]. enced by the eczema families in this study. A
small study from India (n = 22) found that an
increased number of mothers of affected children,
4.3.2 Psychological Impairment 59%, were submissive when compared to 10% in
in Children with Eczema the control group (p < 0.01) [53].
and Their Parents In adults, Schmitt et al. found that eczema was
independently associated with affective and
A study of 30 preschool children with severe stress-related behaviour, and in particular, the
atopic eczema compared with 20 matched con- risk of developing schizophrenic disorders had an
trols found that minor behaviour problems and odds ratio (OR) of 2.12 (95%, CI 1.223.71) [54].
parenting distress were important features of These risks increased with the number of physi-
severe atopic eczema in early childhood [40]. cian attendances, suggesting a higher risk for
The levels of stress were much higher (85%) in those with severe disease [54]. Since eczema in
those with more severely affected children. The children with severe eczema often persists into
authors found significantly higher levels of adult life, it is vitally important to search for and
behavioural problems in 23%, dependency/cling- treat any psychological disturbances early in life
iness in 50% and fearfulness in 40%, but no dif- to try to prevent problems in adulthood.
ference between the two groups in the security of
attachments. Mothers felt particularly stressed in
relation to their parenting and less efficient in 4.3.3 The Effect of Eczema on Family
their disciplining of the affected child, although Life and Members
they did not display negative attitudes towards
their child. Only 1/3 of mothers in the eczema Eczema is a chronic disease affecting the func-
group felt socially supported compared to 2/3 of tioning of the whole family so that the impact on
controls [40]. A German study on the psycho- the child cannot be viewed in isolation. In ethno-
logical adjustment in parents of young children graphic interviews of 33 families [35] with young
found high rates of psychological distress that children with atopic eczema, 11 main domains of
were directly related to the severity of the eczema life were reported to be affected in descending
[49]. However, although Titman also found order of frequency, see Table 4.1. Over 90% of
chronic eczema to cause higher levels of psycho- families reported on the practical difficulties of
logical distress in both parents and children com- caring for a child with eczema, and this was one
pared to those in a general paediatric population, of their major concerns [35]. Other problems
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 47

Table 4.1 The effects of eczema on family functioning

Practical care problems, for example, time pressures to apply treatments and for nurse/family doctor/hospital visits,
increased washing of clothes/bedding, house-dust avoidance measures, preparing special foods for food allergic
children, shopping for cotton clothing/bedding, etc.
Psychological and physical pressures, for example, stress, anxiety about childs future and worry about treatment
side effects, depression, frustration, anger, coping with child problems, exhaustion from sleep loss and extra
housework
Alteration in family life style, for example, unable to keep pets, restriction of family diet if child has food allergy,
restriction of visits to houses with furry pets
Sleep disturbance from sleep latency and frequent night-time wakening causes parents to lose an average of 2 h per
night during eczema flares causing physical and mental exhaustion and poor performance and may affect sleep
patterns of siblings
Schooling problems include child care problems when children are off school because of the eczema and time lost
from work for parents. Children may develop school phobia especially if teased or bullied. Siblings and affected
child school performance may be affected by sleep loss
Coping with childs behavioural problems, for example, increased crying and tantrums in infants, refusal to
cooperate with treatment application, difficulties at mealtimes and bath times, negative or difficult behaviour
Social life of family members, for example, too tired to go out, difficulty in finding babysitters, fear of leaving child
with eczema with others
Interpersonal relations, for example, increased stress, reported as a major cause of marriage break down in 2/33
families
Practical support, for example, lack of help or support from other family members or outside agencies including the
medical profession
Holiday difficulties, for example, avoiding sunny holidays because of heat worsening the eczema or anxiety about
staying in hotels or with friends because of special diets or ruining bedclothes
Financial problems in this UK study were not of great concern except for two single parent families where it was a
major problem. However, many hidden costs caused by having a child with eczema were reported
Adapted from the DFI [35]
These data were used to develop the Dermatitis Family Impact score (DFI)

encountered included the physical effects of tired- would be the single most important improvement
ness and exhaustion from lack of sleep, psycho- to their or their childs quality of life [35].
logical pressures such as anxiety, guilt, frustration, Insufficient support from medical and social sup-
resentment and helplessness and even depression port, conflicting advice from friends, relatives
occurred in 71%. Two thirds of families said that and healthcare workers all increase the anxiety
they did not have a normal lifestyle because of and guilt [35, 41, 45, 55]. Time taken to treat
restrictions on owning pets, foods, household eczema may amount to as much as 23 h per day
products and interference with holidays, and a and is a significant drain on parents time [56] and
third reported that they rarely went out socially energy. Parental loss of sleep can cause a deterio-
because of tiredness, difficulty in obtaining a ration of work-related performance, and they
babysitter and fear of leaving a child with eczema. may miss time off work to cover child care dur-
Twenty-nine percent felt that having a child with ing eczema flares [57]. Negative comments from
eczema affected their interpersonal relationships. others about a childs appearance and fears of
Parents describe being disheartened and frus- possible contagion from eczema are very dis-
trated about the management of eczema and com- tressing to parents, and blame is often felt to be
plain of lack of knowledge and information with apportioned by their spouse or relatives [55].
resultant confusion over the use of treatments Financial Costs: Having a child with eczema
[35]. Only 24% of patients and caregivers feel places a large burden on the family and healthcare
confident they can manage AD flares adequately. resources [5660]. Costs to managing eczema are
Seventy-five percent of caregivers and patients overt and hidden and are higher if it is severe and
feel that being able to effectively control AD require frequent hospital visits [56]. Su et al. [56]
48 S. Lewis-Jones

showed that this cost was higher than that for 4.4 Quality of Life Measurement
asthma, but equivalent to caring for a child with in Children with Eczema
diabetes. Other factors influencing costs include
the type of healthcare system and local, religious A definition of QoL in children suggests that it
or ethnic preferences or beliefs about health care. can be defined as how a child views their life
Where health care is free, there is less impact on and their reasonable expectations of how they
the family budget, and therefore, cost is a lower would like it to be [64]. This is dependent upon
priority in terms of need in many cases, but even in many factors including age, gender, education,
the UK, a utility study demonstrated that to single cognitive ability, culture and ethnicity, and psy-
parent families, the cost related to eczema may be chosocial adaptation to life experiences [38].
an important negative factor [35]. In countries HRQoL scales are widely used as outcome
without free medical aid, low income families can measures for assessing disease severity, treat-
have major problems in paying for consultation or ment effects and monitoring disease control,
hospital fees, tests and drugs and some will be both in the clinical setting and in clinical stud-
unable to afford them at all [57]. Hidden costs to ies. They usually contain a mixture of objective
eczema care include travel costs for health care, measures which focus on physical ability and
which rise with eczema severity, reducing the subjective measures which reflect on the mean-
allergen load by increased house cleaning or pur- ing to the individual [65]. Used correctly
chase of hypoallergenic bedding. Clothes and bed- HRQoL measures can give additional informa-
ding soiled or damaged from blood or emollients tion to that from clinical measures of disease
require increased washing or replacement. activity alone and provide great insight into a
Emollients also speed up the perishing of washing persons perspective of their disease and the
machine seals causing extra repair bills. Buying practical and emotional life problems that they
cotton clothes and bedding or special foods for face. They are now considered to be a key con-
food allergy sufferers all add to the cost, and many sideration in the management of eczema [65],
parents report spending on over the counter and use of HRQoL measures in children and
preparations, alternative therapies or High their families suggests that eczema has a nega-
Street allergy testing. One study found that fam- tive effect on all aspects of their lives [38].
ily costs accounted for 36% of total costs for Although some studies have shown a reason-
eczema [60]. A UK community-based study took ably good correlation between objective mea-
into account these multiple factors including visits sures of disease severity in eczema and impact
to health professionals, time lost off work or pay- on QoL [66], they are not always well corre-
ing for childcare during eczema flares. It found lated. This is because two individuals with the
that the cost to both family and community of same objective disease severity may have very
managing eczema was equivalent to the cost of different subjective perceptions [38]. The
treating chronic venous leg ulcers at that time [61]. impact of a disease is also dependent upon a
A recent European study on the costs of treating childs (and their parents) adaptation to the
eczema concluded that the mean annual health- disease or coping ability so that a child with
care costs and family costs varied considerably in chronic severe life-long eczema who copes well
six identified studies, but in their study, substitut- may appear to suffer less measurable impact of
ing a specialised nurse practitioner for follow-up their HRQoL than a child with mild eczema
rather than using dermatologists was both cost- who has an occasional sudden exacerbation to
saving and cost-effective [62]. The avoidable sec- which they are poorly adapted [38]. Measurement
ondary economic cost of AD has been estimated at of coping ability is not the same as HRQoL
2 billion Euros per year across the European Union assessment, and more research of the two is
[63]. Carroll et al. [59] estimated the personal and essential to our understanding of patients per-
medical costs of eczema in the USA as 1 billion ceptions and adaptation to their disease. One
dollars per annum in 2005. study using a structural educational programme
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 49

in the management of eczema found a greater Score (CADIS) [55], the Parents Index of Quality
improvement in childrens coping behaviour of Life in atopic Dermatitis (PIQoL-AD) [69].
and the parents ability to handle the children The Childrens Dermatology Life Quality
compared to the control group [67]. Index (CDLQI)* [34] is a dermatology-specific
scale (completed by the child) which can be
used to compare eczema with any other derma-
4.5 Types of Quality of Life tological disease. It is also available in cartoon
Measures format [70] (Table 4.2).It is a simple 10-ques-
tion validated scale that has been the most
It is essential that all HRQoL questionnaires widely used in dermatology and is currently
should be correctly validated for content, con- translated into 24 languages. A high score
struct and criterion and tested for reliability, indicates a greater negative impact on QoL. It
repeatability and internal consistency for use in was designed from data taken from children
the study population [38]. In young children or themselves about the problems they encoun-
those with cognitive impairment, proxy measures tered from having a skin disease. These prob-
are often employed, using responses from another lems are described more fully under the
person such as the parent/carer or the attending psychosocial effects of eczema. It has been
medical professional. In addition to the factors used in clinical settings as a monitor for dis-
affecting response listed in the preceding section, ease impact and the effect of treatment and as
the ratings in proxy measures will be influenced an outcome measure in many clinical and
by the proxy providers own psychosocial circum- research trials on eczema (38SL-J).
stances and beliefs [38]. When comparing a Eczema causes many and various effects on a
childs rating versus that of their parent/carer, they childs quality of life. Use of the CDLQI shows
demonstrate much more agreement on physical
ability rather than on emotional response, for
example, they will usually agree on the effect that Table 4.2 Validated HRQoL scales used in studies of
childhood eczema
disease has on a childs ability to do a sport but
Eczema specific
may differ widely on a childs subjective assess-
Infants Dermatitis Quality of Life (IDQoL)a [36]:
ment about their emotional responses to their dis-
A 10-item scale for infants up to the age of 4 years,
ease [65]. Generic and specialty-specific measures includes 1 question on eczema severity as perceived by
are useful for disease comparison but give less the parent/carer and scored separately. Translated into
detailed information than a disease-specific mea- 20 languages
sure, so often, more than one type is employed in Dermatitis Family Impact (DFI)a [35]: A 10-item
scale measuring the impact of eczema on families.
a particular study. HRQOL measurement in Translated into 14 languages
eczema shows that it may affect most aspects of a The Childrens Atopic Dermatitis Impact Score
childs life and have a more major impact than (CADIS) [55]: A 45-item scale validated for use in the
many other chronic childhood diseases [43]. In a United States for parents and children up to age 6 years
comparative study, the impact of eczema was [4 child subscales; 4 family subscales]
Parents Index of Quality of Life in Atopic Dermatitis
greater than that of enuresis, epilepsy, diabetes,
(PIQoL-AD) [69]: Constructed and validated from data
asthma and equivalent to renal disease and cystic of several European countries for use in commercial
fibrosis [43]. Another study found the disease bur- studies on pimecrolimus in the treatment of eczema
den of atopic diseases was greater than all other Specialty specific
childhood diseases [68]. Childrens Dermatology Life Quality Index
There are several validated eczema-specific QOL (CDLQI)a [34]: A 10-item scale for children aged
416 years which can be used for all childhood skin
scales for use in childhood eczema including the diseases. It is now translated into 40 languages. The
Infants Dermatitis Quality of Life score (IDQoL)* cartoon version is available in 5 languages
[36], the Dermatitis Family Impact score (DFI)* a
The IDQoL, DFI and CDLQI can be downloaded at
[35], The Childrens Atopic Dermatitis Impact www.dermatology.org.uk/
50 S. Lewis-Jones

that the highest scoring questions pertain to itch, 4.5.2 Health-Related Quality of Life
sleep loss, difficulties with or loss of schooling Family Measures
and difficulties with treatment. A good correla-
tion between eczema severity and HRQoL impair- The Dermatitis Family Impact Scale (DFI)* [35]
ment has been seen in several studies using the is a 10-item scale focussing on the effect of eczema
CDLQI, and one study showed that every 1 unit on the family (Table 4.1). It was constructed from
change in SCORAD was associated with a 0.12 data obtained by ethnographic and brainstorming
change in the CDLQI score [66]. Amongst com- techniques and showed good correlation between
mon childhood skin diseases, eczema has been clinical eczema severity and impact on family
shown to cause the most impact on quality of life, QoL [35]. It is often used in conjunction with the
although other itchy dermatoses such as scabies IDQoL scale [36] as an outcome measure in clini-
and urticaria also score highly [34]. In clinical tri- cal practice and research. It is now translated into
als on the use of eczema treatments, the CDLQI 14 languages. Using the DFI, Ben Gashir and col-
has shown to be sensitive to clinical change prov- leagues found family life to be affected in 45% of
ing its use as an outcome measure [38]. children with eczema [72], which related to objec-
tive eczema severity, and this has been confirmed
in other studies [73]. The PIQol-AD was validated
4.5.1 Infantile Eczema and Quality for use in multicentre European studies on pime-
of Life Impairment crolimus in the treatment of eczema [69]. Use of
the PIQol-AD found positive but low levels of
The Infants Dermatitis QoL[IDQoL]* [36] is a association between the QoL scores and disease
10-question scale similar to the CDLQI but with severity and showed that family QoL improved
an additional but separately scored question on the greatest in the pimecrolimus-treated group
the parental perception of eczema severity. It has [69]. In the USA, Chamlin and colleagues devel-
demonstrated particular problems in infants with oped a scale for young children with eczema and
eczema with itching and sleeping, bathing and their parents using directed focus sessions which
mood changes such as tantrums. Use of the provided 181 specific QoL effects that related to
IDQoL for monitoring showed that consultation either the child or the family. These were used to
with a physician led to significantly increased develop a conceptual framework containing
quality of life for the infant with eczema and their domains of physical and emotional health and
parents [71]. It has also been used successfully in functioning [55]. In their further validation stud-
many clinical trials [38]. In a study by Beattie ies, they also showed a correlation between eczema
et al., the highest IDQoL scores were for itching, severity and HRQoL impairment [74].
scratching, bath-time problems and time taken to
fall asleep, and those in the DFI were for tired-
ness/exhaustion, sleep loss and emotional distress 4.5.3 Utility Studies
[71]. These domains correlated well with the
severity of eczema. Children were seen by a der- Whilst utility measures are much favoured by
matologist, and majority also had face to face health economists because they give information
nurse consultation or via telephone. Those with on patient preferences, they are difficult to perform
the most severe eczema (median score 14) even in older children, and there are no reported
improved the most by 64%, and the domains studies on their use in children with eczema. There
showing the greatest improvement were time to is one small study in normal young children who
get to sleep, and meal-time difficulties. For the were asked to list their three favourite things which
parents, the most improved domains were tired-
ness and exhaustion and emotional distress.
Statistical significance of improvement between * author declaration of interest: co-copyright holder of
visits was p = 0.0001. these measures
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 51

they reported as their pet, playing with friends and reported psychiatric morbidity [78]. In an
their favourite toy [46]. Parents are particularly objective assessment of compliance with psoria-
keen for their child to be able to cope with their sis therapy amongst adults, non-compliance was
eczema, and in a utility study amongst families, associated with being male, single, unemployed,
they scored it as the first most important factor drinking alcohol, smoking, paying for treatment,
after coping with the practical difficulties and hav- side effects of therapy, twice-daily treatment and
ing satisfactory family relationships [35]. These oral therapy [79]. The same group studied com-
findings are borne out by the ISOLATE study pliance with acne treatments and found that non-
(International Study of Living with Atopic compliance was associated with a younger age,
Eczema) where eczema sufferers also rated being higher impairment with QoL and smoking and
able to cope with their eczema as their most impor- alcohol abuse, whereas good compliance was
tant goal [63]. Utility studies in adults with chronic seen in married females, those in employment
severe eczema found that they were willing to pay and where there were no treatment costs [80].
up to 80 per month for a cure [75]. Carroll et al. showed that compliance in psoriasis
More detailed accounts of QoL measurement therapy gradually reduced over an 8-week period
in children with eczema are found elsewhere [37, from 84.6% to 51%, although there was slightly
38] and a list of reference of their use at www. better adherence in older females [81]. They used
dermatology.org.uk/. three methods of adherence monitoring and found
that electronic monitoring caps were more accu-
rate for assessing actual treatment usage than
4.6 Difculties Associated medication logs or medication usage by weight.
with Using Topical Treatments Another small study used electronic monitors to
in Eczema compare adherence in psoriatics to that observed
in clinical trials of hand eczema and atopic
4.6.1 Problems with Adherence eczema. Adherence was shown to be better
to Therapy around the time of office visits or during clinical
trials with close follow-up [82].
The problem of lack of use of treatments is com-
plex and encompasses incorrect use. There is little
doubt amongst dermatologists that failure to 4.6.2 Lack of Knowledge About
adhere to therapy is the main cause of poor control Treatments and How
of eczema and is likely to lead to a state of disease to Use Them
chronicity. However, very little is known about
adherence to therapy in childhood eczema since The most fundamental problem is lack of knowl-
most studies have been conducted with adults. edge by parents, children, healthcare profession-
One study in children using a method of stealth als and the general public about eczema and its
monitoring suggested that adherence to eczema treatment and the necessity for provision of ade-
therapies in childhood eczema is very poor [76]. quate support and follow-up [41, 83]. Lack of
Bradley looked at adherence to oral therapy in knowledge often leads to conflicting and mis-
adults and devised the concept of the rule of leading advice that heightens parental and child
thirds, i.e. one third of patients take their treat- anxiety and causes confusion. Parents and adults
ment correctly, one third take it intermittently but with eczema report that they want easy access to
to some effect and one third do not take it at all, more understandable information [41, 63]. It is
suggesting that only 50% of patients take oral vital that information should be available in a lan-
treatments effectively [77]. A review on the use guage understood by the family. Eczema treat-
of dermatological therapies in adults concluded ments are often prescribed by healthcare
that poor adherence was seen in at least 3540% professionals who have little knowledge about
of patients and is also associated with self- the practicalities of their use, and parents rarely
52 S. Lewis-Jones

receive any instructions on their use. In a study older children are often late home because of
by the National Eczema Society, only 53% of outside activities.
responders were given advice on daily cleansing Lack of Availability of Treatments: Parents
and moisturising routine, and only 25% of those often run out of treatment for many reasons
who were prescribed emollients had been given that include laziness, lack of time, inability to
demonstrations of their use [41]. pay for treatment, forgetting to order the med-
Problems with use of treatments (see also prob- ication or to take it if staying away from home.
lems associated with emollient usage, 4.2.4) Children living in more than one home require
Adverse Reactions: Children often refuse to enough therapy at each abode. Medication
use cream or lotion preparations which sting or may be lost or damaged or out of date.
cause irritation because of the preservative Healthcare professional often fail to prescribe
content, and in a minority, there may be actual sufficient quantities [86]. This is a particular
allergic contact dermatitis. Absorption of prod- problem with emollients which are sometimes
ucts through the skin is commoner in children, viewed as non-essential therapy. A commu-
especially neonates and premature infants. nity study looked at dispensed prescriptions
Urea and lactic acid in some emollients may for topical corticosteroid preparations and
cause toxicity or, in the case of topical corti- emollients in over 25,000 children in Tayside
costeroids, excessive absorption causing aged 6 years over a 17-month period. It found
cushingoid features or thinning of the skin and that 22.8% of children were supplied with a
telangiectasia. Evidence from a study on anti- prescription for a topical corticosteroid, but
retroviral therapy showed that those who suf- half of these (50.6%) were not prescribed any
fered adverse events were 12.8 times less likely emollients [87]. Parents are also much less
to maintain a 95100% adherence [84]. likely to pay for treatments such as emollients
Anxiety About Potential Side Effects: when the disease is quiescent leading to poor
Especially of topical corticosteroids is also a disease control.
major problem for non-adherence [85]. In the Child Refusal: Children and their parents fre-
ISOLATE study, 66% of patients used steroids quently complain that treatments are messy,
as a last resort, and 39% used them less fre- often sting and take too long to apply [34, 35].
quently than recommended because of a the Refusal may be due to stinging, fear of side
fear of side effects [63]. Beattie found that effects, dislike of the texture or it may represent
parental knowledge of the potency of topical a behavioural problem. Children are also embar-
corticosteroids was very poor [83]. Steroid rassed by the appearance of the greasy effect of
phobia is not confined to patients, and igno- emollients on skin and clothes and do not like to
rance and over-exaggeration of side effects are draw attention to their disease or apply treat-
common in all types of healthcare profession- ments in front of others. Children may also
als. There may also be dislike of conventional refuse therapy for gain in order to avoid school
therapy and preference for natural products or sports or to get attention, and some learn that
or alternative therapies. they can punish or control parents by scratching
Lack of Time: The necessity of using topical to maintain disease activity [88].
therapy on a regular basis in skin diseases such Failure to Maintain Therapy During Remis-
as eczema causes problems for children that sion: Eczema is a chronic problem which is
are not seen in other common chronic child- often not perceived as such by patients but
hood diseases such as diabetes, asthma or epi- also many healthcare professionals so that
lepsy [43]. Topical therapy is time-consuming therapies are stopped as soon as the eczema
to apply and is cited as a major problem, par- clears. This reflects what has been observed
ticularly if the parent is single or both parents in asthma where good adherence is associ-
are working [35, 43]. There is often little time ated with understanding the disease and
in the morning before work or school, and accepting its chronic nature, whereas poor
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 53

adherence is found in those who perceive problems [88], and such cases require assessment
that no symptoms means no disease and by a clinical psychologist. There are, however,
view asthma as an episodic rather than a a small minority of children with extremely
chronic disease [89]. It has been suggested severe atopic eczema who may require systemic
that education of patients and parents/carers therapies.
to accept eczema as a chronic disease and
that dryness represents the early occult stages
should lead to better control of disease flares 4.7 Factors Thought to Improve
and possibly to prevention if used early in Treatment Adherence
life in high-risk patients. This underscores
the necessity of using emollient therapy on a If treatment is perceived to be effective and safe
regular daily basis as the mainstay treatment and patients understand how to use it correctly,
for childhood eczema, even when the eczema then they are more likely to use it. Patient satis-
is clear [17, 18]. faction with care seems to be an important factor
Loss of Faith in Treatment and/or Physician: [91]. According to Kjellgren, providers and
Good doctor-patient relationships are essen- patients felt that factors affecting adherence to
tial in the treatment of eczema [90], but unfor- dermatological therapy were: patients expecta-
tunately parents and children often lose faith tions and experiences of therapeutic effect,
in treatments and also faith in the healthcare patients taking an active part in treatment deci-
professional [41]. This may be partly due to sions and the mode of administration and type of
the fact that many family doctors and other medication [92]. A Japanese study showed that
health care professions know very little about the most important factor in compliance with
eczema and its treatment and fail to follow-up therapy was a good doctor-patient relationship
after an initial consultation. and the willingness to use therapies [90]. A
review on adherence to therapy concluded that
major determinants of good adherence are a good
4.6.3 Failure to Control Eczema doctor-patient interaction and good patient satis-
Despite Adequate Treatment faction [78].
Compliance Feldman et al. concluded that frequent fol-
low-up visits in clinical trials increase patients
Sometimes, appropriate treatments seem ineffec- adherence to medications. They proposed the
tive because there is failure to increase the corti- use of a follow-up visit shortly after initiating
costeroid potency when the eczema worsens. It treatment as an effective way to boost patients
must be clearly explained that treatment should use of their medication with the object of achiev-
be stepped up when eczema flares [17, 18]. ing better treatment outcomes [82].
Alternatively, it may be due to the provision of Studies on demonstration of treatments by a
too weak a potency of a topical corticosteroid in specialist nurse have shown the benefit of this
cases of severe eczema. There may be additional [9396]. Carroll et al. [59] suggested that the cost
complications such as secondary infection, sca- of treating eczema could be reduced by targeting
bies infestation or the development of contact parents and caregivers with education and psy-
irritancy or allergy. In infants with severe eczema chosocial support that might decrease family
who fail to respond to adequate therapy, food and personal burden. The most comprehensive
allergy should be considered as a possible trig- study reported on education used a structured
gering factor [17, 18]. In severe cases, it is impor- education programme for parents and children
tant to review the diagnosis particularly if there is with eczema and showed that the intervention
evidence of severe recurrent infection or faltering group did better than the control group, an effect
growth that might reflect an underlying immuno- maintained at 12 months [97]. They concluded
deficiency. Sometimes, it is due to behavioural that Education must therefore underpin all
54 S. Lewis-Jones

management for eczema for treatment to be

successful [97]. An international collaboration social functioning of children and their
of paediatric dermatologists OPENED has col- families, preventing a normal lifestyle.
lated educational tools from different centres Quality of life studies in children show
used for eczema patients in an attempt to share that eczema has an effect equal to or
knowledge Stalder et al. [98]. See also a Cochrane greater than the impact caused by diabe-
review on RCTs of psychological and education tes, asthma or epilepsy.
interventions in eczema [99]. Psychological distress due to eczema
A Key recommendation from the NICE guide- has been found to be higher than nor-
lines states provide information in verbal and mal in children and their mothers and is
written forms with practical demonstrations that significantly related to disease severity
cover in most cases.
How much treatment to use Emollients of a patients own choice
How often to apply treatments should be used regularly in eczema and
When and how to step treatment up or down during periods of disease remission to
How to treat atopic eczema prevent flares.
There is also a recommendation on treating Education is essential for patients, parents
flares which suggests that treatment should be and healthcare workers involved in the
started as soon as signs and symptoms appear. management of eczema to improve adher-
Continue for 48 h after symptoms subside. Older ence to therapy and improve outcomes.
children should be encouraged to do their own Patients and parents of children with
treatment, but parents/carers should oversee this eczema need simple, clear information
initially to ensure it is being done and especially on eczema and its treatments in a verbal
if treatment starts to fail. and written format with practical dem-
If the management of eczema is to progress onstrations on applying treatments.
favourably, then more investigation is required in Patient satisfaction and a good patient-
the field of patients needs and education, espe- physician rapport are essential for good
cially on the complex reasons for failure of adher- adherence to therapies.
ence to treatment. Patients should be followed up soon
after initial consultation to improve
adherence to therapy.

Take Home Messages

Eczema is caused by a complex interplay
of genetic and environmental factors References
leading to a breakdown in epidermal
barrier function. 1. Tagami H, Kobayashi H, Ogoshi K, Kikuchi K (2006)
Atopic xerosis: employment of noninvasive biophysi-
Ichthyosis vulgaris, the main cause for cal instrumentation for the functional analyses of the
dry skin in eczema, is due to loss-of- mildly abnormal stratum corneum and for the efficacy
function mutations in the protein filag- assessment of skin care products. J Cosmet Dermatol
grin that is essential for normal epidermal 5(2):140149
2. Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J,
cell maturation. Lane ME, Moustafa M, Guy RH, Macgowan AL,
Possession of FLG null mutations is Tazi-Ahnini R, Ward SJ (2009) Epidermal barrier
highly associated with early-onset severe dysfunction in atopic dermatitis. J Invest Dermatol
eczema often persisting into adult life. 129(8):18921908, Epub 2009 Jun 4
3. Flohr C, England K, Radulovic S, McLean WH,
Eczema may have a profoundly negative Campbel LE, Barker J, Perkin M, Lack G (2010)
effect on the quality of life and psycho- Filaggrin loss-of-function mutations are associated
with early-onset eczema, eczema severity and
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 55

transepidermal water loss at 3 months of age. Br J Burrows N, Pollock I, Graham-Brown R, OToole E,

Dermatol 163(6):13331336 Potter D, Williams HC (2011) A multicentre
4. ORegan GM, Sandilands A, McLean WH, Irvine AD randomised controlled trial and economic evaluation
(2008) Filaggrin in atopic dermatitis. J Allergy Clin of ion-exchange water softeners for the treatment of
Immunol 122(4):689693, Epub 2008 Sep 5 eczema in children: the Softened Water Eczema Trial
5. Smith FJ, Irvine AD, Terron-Kwiatkowski A, (SWET). Health Technol Assess 15(8):vvi, 1156
Sandilands A, Campbell LE, Zhao Y, Liao H, Evans 16. Lucky AW, Leach AD, Laskarzewski P, Wenck H
AT, Goudie DR, Lewis-Jones S, Arseculeratne G, (1997) Use of an emollient as a steroid sparing agent
Munro CS, Sergeant A, ORegan G, Bale SJ, Compton in the treatment of mild to moderate atopic dermatitis
JG, DiGiovanna JJ, Presland RB, Fleckman P, McLean in children. Pediatr Dermatol 14:321324
WH (2006) Loss-of-function mutations in the gene 17. NHS (2007) NICE guidelines on management of atopic
encoding filaggrin cause ichthyosis vulgaris. Nat eczema in children from birth up to the age of 12 years,
Genet 38(3):337342 CG057, http://guidance.org.uk/CG57, Dec 2007
6. Palmer CN, Irvine AD, Terron-Kwiatkowski A, Zhao Y, 18. Lewis-Jones S, Mugglestone MA, Guideline
Liao H, Lee SP, Goudie DR, Sandilands A, Campbell Development Group (2007) Management of atopic
LE, Smith FJ, Oregan GM, Watson RM, Cecil JE, eczema in children aged up to 12 years: summary of
Bale SJ, Compton JG, Digiovanna JJ, Fleckman P, NICE guidance. BMJ 335(7632):12631264
Lewis-Jones S, Arseculeratne G, Sergeant A, Munro 19. Darsow U, Wollenberg A, Simon D, Taeb A,
CS, El Houate B, McElreavey K, Halkjaer LB, Werfel T, Oranje A, Gelmetti C, Svensson A,
Bisgaard H, Mukhopadhyay S, McLean WH (2006) Deleuran M, Calza AM, Giusti F, Lbbe J, Seidenari
Common loss-of-function variants of the epidermal S, Ring J, European Task Force on Atopic
barrier protein filaggrin are a major predisposing fac- Dermatitis/EADV Eczema Task Force (2010)
tor for atopic dermatitis. Nat Genet 38(4): ETFAD/EADV eczema task force 2009 position
441446, Epub 2006 Mar 19 paper on diagnosis and treatment of atopic derma-
7. Barker JN, Palmer CN, Zhao Y, Liao H, Hull PR, Lee titis. J Eur Acad Dermatol Venereol 24(3):317328,
SP, Allen MH, Meggitt SJ, Reynolds NJ, Trembath Epub 2009 Aug 31
RC, McLean WH (2007) Null mutations in the filag- 20. SIGN: Management of atopic eczema in primary care
grin gene (FLG) determine major susceptibility to SIGN guideline 125. http://sign.ac.uk/guidelines/full-
early-onset atopic dermatitis that persists into adult- text/125/index.html 2011 accessed 31.1.12
hood. J Invest Dermatol 127(3):564567, Epub 2006 21. Hanifin JM, Cooper KD, Ho VC, Kang S, Krafchik
Sep 21 BR, Margolis DJ et al (2004) Guidelines of care for
8. ORegan Grinne M, Campbell Linda E, Cordell atopic dermatitis, developed in accordance with the
Heather J, Irvine Alan D, Irwin McLean WH, Brown American Academy of Dermatology (AAD)/
Sara J (2010) Chromosome 11q13.5 variant associated American Academy of Dermatology Association
with childhood eczema: an effect supplementary to Administrative Regulations for Evidence-Based
filaggrin mutations. J Allergy Clin Immunol 125(14): Clinical Practice Guidelines. J Am Acad Dermatol
170174 50:391404
9. Brown SJ, McLean WHI (2009) Eczema genetics: 22. Frankel A, Sohn A, Patel RV, Lebwohl M (2011)
current state of knowledge and future goals. J Invest Bilateral comparison study of pimecrolimus cream
Dermatol 129:543552 1% and a ceramide-hyaluronic acid emollient foam in
10. Langan SM, Williams HC (2006) What causes wors- the treatment of patients with atopic dermatitis. J
ening of eczema? A systematic review. Br J Dermatol Drugs Dermatol 10(6):666672
155(3):504514 23. Grimalt R, Mengeaud V, Cambazard F, Study
11. Langan SM, Silcocks P, Williams HC (2009) What Investigators Group (2007) The steroid-sparing effect
causes flares of eczema in children? Br J Dermatol of an emollient therapy in infants with atopic dermatitis:
161(3):640646, Epub 2009 Jun 5 a randomized controlled study. Dermatology 214(1):
12. Shams K, Grindlay DJ, Williams HC (2011) Whats 6167
new in atopic eczema? An analysis of systematic reviews 24. Kantor I, Milbauer J, Psoner M, Weinstock IM, Simon A,
published in 20092010. Clin Exp Dermatol 36(6): Thormahlen S (1993) Efficacy and safety of emol-
573577. doi:10.1111/j.13652230.2011.04078.x;quiz lients as adjunctive agents in topical corticosteroid
5778. Epub 2011 Jul 1 therapy for atopic dermatitis. Today Ther Trends 11:
13. Schmitt J, Apfelbacher CJ, Flohr C (2011) Eczema. 157166
Clin Evid (Online) pii:1716 25. Hon KL, Wang SS, Lau Z, Lee HC, Lee KK, Leung TF,
14. Blume-Peytavi U, Cork MJ, Faergemann J, Szczapa J, Luk NM (2011) Pseudoceramide for childhood eczema:
Vanaclocha F, Gelmetti C (2009) Bathing and cleans- does it work? Hong Kong Med J 17(2):132136
ing in newborns from day 1 to first year of life: recom- 26. Global Resource of EczemA Trials (GREAT data-
mendations from a European round table meeting. J base) 20002011. www.greatdatabase.org.uk/
Eur Acad Dermatol Venereol 23(7):751759 27. Beattie PE, Lewis-Jones MS (2004) A pilot study on
15. Thomas KS, Koller K, Dean T, OLeary CJ, Sach TH, the use of wet wraps in infants with moderate atopic
Frost A, Pallett I, Crook AM, Meredith S, Nunn AJ, eczema. Clin Exp Dermatol 29:348353
56 S. Lewis-Jones

28. Fonacier LS, Aquino MR (2010) The role of contact pruritus: sleep disturbance and cosleeping in atopic
allergy in atopic dermatitis. Immunol Allergy Clin dermatitis. Arch Pediatr Adolesc Med 159(8):
North Am 30(3):337350 745750
29. Boussault P, Laut-Labrze C, Saubusse E, Maurice- 45. Paller AS, McAlister RO, Doyle JJ, Jackson A (2002)
Tison S, Perromat M, Roul S et al (2007) Oat sensiti- Perceptions of physicians and pediatric patients about
zation in children with atopic dermatitis: prevalence, atopic dermatitis, its impact, and its treatment. Clin
risks and associated factors. Allergy 62:12511256, Pediatr (Phila) 41(5):323332
Allergy (2008) 63:781782 46. Aledan M, Gonzales M, Finlay AY (2000) Utility
30. Krnke B, Komericki P, Aberer W (1997) Olive oil- measures for children with skin disease. J Eur Acad
contact sensitizer or irritant? Contact Dermatitis 36(1): Dermato Venereol 14(S1):281 (Abstract)
510 47. Carvalho NF, Kenney RD, Carrington PH, Hall DE
31. Tsang M, Guy RH (2010) Effect of Aqueous Cream (2001) Severe nutritional deficiencies in toddlers
BP on human stratum corneum in vivo. Br J Dermatol resulting from health food milk alternatives. Pediatrics
163(5):954958 107(4):E46
32. Mohammed D, Matts PJ, Hadgraft J, Lane ME (2011) 48. Bath-Hextall FJ, Delamere FM, Williams HC. Dietary
Influence of Aqueous Cream BP on corneocyte size, exclusions for established atopic eczema. Cochrane
maturity, skin protease activity, protein content and Database of Systematic Reviews 2008, Issue 1. Art.
transepidermal water loss. Br J Dermatol No.: CD005203. DOI: 10.1002/14651858.CD005203.
164(6):13041310 pub2. Published Online:8 OCT 2008
33. Wolf G, Hger PH (2009) Hypoallergenic and non- 49. Warschburger P, Buchholz HT, Petermann F (2004)
toxic emollient therapies for children. J Dtsch Psychological adjustment in parents of young children
Dermatol Ges 7(1):5060 with atopic dermatitis: which factors predict parental
34. Lewis-Jones MS, Finlay AY (1995) The childrens quality of life? Br J Dermatol 150(2):304311
dermatology life quality index (CDLQI): initial vali- 50. Titman PS, Barker C, Smith CH (2001) The psycho-
dation and practical use. Br J Dermatol 132:942949 logical impact of chronic eczema on children and
35. Lawson V, Lewis-Jones MS, Finlay AY, Reid P, their families. Br J Dermatol 145(S59):128129
Owens RG (1998) The family impact of childhood (Abstract)
atopic dermatitis: the dermatitis family impact ques- 51. Faught J, Bierl C, Barton B, Kemp A (2007) Stress in
tionnaire. Br J Dermatol 138:107113 mothers of young children with eczema. Arch Dis
36. Lewis-Jones MS, Finlay AY, Dykes P (2001) The Child 92(8):683686, Epub 2007 Apr 5
infants dermatitis quality of life index (IDQOL). Br J 52. Absolon C, Cottrell D, Eldridge S, Glover M (1997)
Dermatol 144:104110 Psychological disturbance in atopic eczema: the
37. Lewis-Jones S (2006) Quality of life and childhood extent of the problem in school aged children. Br J
atopic dermatitis: the misery of living with childhood Dermatol 137:241245
eczema. Int J Clin Pract 60(8):984992 53. Sarkar R, Raj L, Kaur H, Basu S, Kanwar AJ, Jain RK
38. Lewis-Jones MS, Charman CR (2011) Atopic (2004) Psychological disturbances in Indian children
Dermatitis: scoring severity and quality of life assess- with atopic eczema. J Dermatol 31(6):448454
ment. In: Irvine A, Hoeger P, Yan A (eds) Harpers 54. Schmitt J, Romanos M, Pfennig A, Leopold K, Meurer
textbook of pediatric dermatology (third Edition) Vol 1 M (2009) Psychiatric comorbidity in adult eczema. Br
chapter 29 pp 29.9-29.16 Publisher Wiley-Blackwell J Dermatol 161(4):878883, Epub 2009 Jul 14
39. Reid P, Lewis-Jones MS (1995) Sleep disturbance in 55. Chamlin SL, Cella D, Frieden IJ, Williams ML,
preschoolers with atopic eczema. Clin Exp Dermatol Mancini AJ, Lai JS, Chren MM (2005) Development
20:3841 of the Childhood Atopic Dermatitis Impact Scale: ini-
40. Daud LR, Garralda ME, David TJ (1993) Psychosocial tial validation of a quality-of-life measure for young
adjustment in preschool children with atopic eczema. children with atopic dermatitis and their families.
Arch Dis Child 69(6):670676 J Invest Dermatol 125(6):11061111
41. Long CC, Funnell CM, Collard R, Finlay AY (1993) 56. Su J, Kemp A, Varigos G, Nolan T (1997) Atopic
What do members of the National Eczema Society eczema: its impact on the family and financial cost.
really want? Clin Exp Dermatol 18(6):516522 Arch Dis Child 76(2):159162
42. Stores G, Burrows AB, Crawfors C (1998) 57. Lapidus CS, Kerr PE (2001) Social impact of atopic
Physiological sleep disturbance in children with dermatitis. Med Health R I 84(9):294295
atopic eczema: a case controlled study. Pediatr 58. Balkrishnan R, Housman T, Carroll C, Feldman S,
Dermatol 15:264268 Fleischer A (2003) Disease severity and associated
43. Beattie PE, Lewis-Jones MS (2006) A Comparative family impact in childhood atopic dermatitis. Arch
study of impairment of Quality of Life (QoL) in chil- Dis Child 88(5):423427
dren with skin disease and children with other chronic 59. Carroll CL, Balkrishnan R, Feldman SR, Fleischer
childhood diseases. Br J Dermatol 155:145151 AB Jr, Manuel JC (2005) The burden of atopic derma-
44. Chamlin SL, Mattson CL, Frieden IJ, Williams ML, titis: impact on the patient, family, and society. Pediatr
Mancini AJ, Cella D, Chren MM (2005) The price of Dermatol 22(3):192199
4 Dry Skin in Childhood and the Misery of Eczema and Its Treatments 57

60. Emerson R, Williams HC, Allen BR (2001) What is 73. Aziah MS, Rosnah T, Mardziah A, Norzila MZ (2002)
the cost of atopic dermatitis in preschool children? Br Childhood atopic dermatitis: a measurement of qual-
J Dermatol 144:514522 ity of life and family impact. Med J Malaysia
61. Herd RM, Tidman MJ, Prescott RJ, Hunter JA (1996) 57(3):329339
The cost of atopic eczema. Br J Dermatol 74. Chamlin SL, Lai JS, Cella D, Frieden IJ, Williams
135(1):2023 ML, Mancini AJ, Chren MM (2007) Childhood Atopic
62. Schuttelaar ML, Vermeulen KM, Coenraads PJ (2011) Dermatitis Impact Scale: reliability, discriminative
Costs and cost-effectiveness analysis of treatment in and concurrent validity, and responsiveness. Arch
children with eczema by nurse practitioner vs. derma- Dermatol 143(6):768772
tologist: results of a randomized, controlled trial and a 75. Lundberg L, Johannesson M, Silverdahl M,
review of international costs. Br J Dermatol 165(3): Hermansson C, Lindberg M (1999) Quality of life,
600611 health-state utilities and willingness to pay in patients
63. Zuberbier T, Orlow SJ, Paller AS, Taeb A, Allen R, with psoriasis and atopic eczema. Br J Dermatol
Hernanz-Hermosa JM, Ocampo-Candiani J, Cox M, 141(6):10671075
Langeraar J, Simon JC (2006) Patient perspectives on 76. Krejci-Manwaring J, Tusa MG, Carroll C, Camacho
the management of atopic dermatitis. J Allergy Clin F, Kaur M, Carr D, Fleischer AB Jr, Balkrishnan R,
Immunol 118(1):226232 Feldman SR (2007) Stealth monitoring of adherence
64. Collier J, MacKinlay D, Phillips D (2000) Norm val- to topical medication: adherence is very poor in chil-
ues for the Generic Childrens Quality of Life Measure dren with atopic dermatitis. J Am Acad Dermatol
(GCQ) from a large school-based sample. Qual Life 56(2):211216, Epub 2006 Nov 13
Res 9(6):617623 77. Bradley C (1999) Compliance with drug therapy.
65. Eiser C, Morse R (2001) Can parents rate their childs Prescribers J 39(1):4450
health-related quality of life? Results of a systematic 78. Serup J, Lindblad AK, Maroti M, Kjellgren KI,
review. Qual Life Res 10(4):347357 Niklasson E, Ring L, Ahlner J (2006) To follow or not
66. Ben-Gashir MA, Seed PT, Hay RJ (2004) Quality of to follow dermatological treatment a review of the
life and disease severity are correlated in children with literature. Acta Derm Venereol 86(3):193197
atopic dermatitis. Br J Dermatol 150(2):284290 79. Zaghloul S, Goodfield M (2004) Objective assess-
67. Kupfer J, Gieler U, Diepgen TL, Fartasch M, Lob- ment of compliance with psoriasis treatment. Arch
Corzilius T, Ring J, Scheewe S, Scheidt R, Schnopp Dermatol 140:408414
C, Szczepanski R, Staab D, Werfel T, Wittenmeier M, 80. Zaghloul S, Cunliffe W, Goodfield M (2005) Objective
Wahn U, Schmid-Ott G (2010) Structured education assessment of compliance with treatments in acne. Br
program improves the coping with atopic dermatitis J Dermatol 152(5):10151021
in children and their parents-a multicenter, random- 81. Carroll CL, Feldman SR, Camacho FT, Manuel JC,
ized controlled trial. J Psychosom Res 68(4): Balkrishnan R (2004) Adherence to topical therapy
353358 decreases during the course of an 8-week psoriasis
68. Emerson RM, Williams HC, Allen BR (1997) How clinical trial: commonly used methods of measuring
much disability does childhood atopic eczema cause adherence to topical therapy overestimate actual use.
compared to other childhood problems. Br J Dermatol J Am Acad Dermatol 51(2):212216
137:19 (Abstract) 82. Feldman SR, Camacho FT, Krejci-Manwaring J,
69. McKenna SP, Whalley D, Dewar AL, Erdman RA, Carroll CL, Balkrishnan R (2007) Adherence to topi-
Kohlmann T, Niero M, Bar E, Cook SA, Crickx B, cal therapy increases around the time of office visits. J
Frech F, van Assche D (2005) International develop- Am Acad Dermatol 57(1):8183, Epub 2007 May 10
ment of the Parents Index of Quality of Life in Atopic 83. Beattie PE, Lewis-Jones MS (2003) Parental
Dermatitis (PIQoL-AD). Qual Life Res 14(1):231241 Knowledge of topical therapies used in the treatment
70. Holme SA, Man I, Sharpe JL, Dykes PJ, Lewis-Jones of atopic dermatitis. Clin Exp Dermatol 28:549553
MS, Finlay AY (2003) The Childrens Dermatology 84. Ickovics JR (2002) Consequences and determinants
Life Quality Index: validation of the cartoon version. of adherence to antiretroviral medication. Antivir
Br J Dermatol 148(2):285290 Ther 7(3):185193
71. Beattie PE, Lewis-Jones MS (2006) An audit of the 85. Charman C, Williams H (2003) The use of corticos-
impact of a consultation with a paediatric dermatology teroids and corticosteroid phobia in atopic dermatitis.
team on quality of life in infants with atopic eczema Clin Dermatol 21(3):193200
and their families: further validation of the Infants 86. Long C, Finlay AY (1993) Perceived under prescrip-
Dermatitis Quality of Life Index and Dermatitis tion of topical therapy. Br J Gen Pract 43:305
Family Impact score. Br J Dermatol 155(6): 87. Santer M, Lewis-Jones S, Fahey T (2006)
12491255 Appropriateness of prescribing for childhood eczema:
72. Ben-Gashir MA, Seed PT, Hay RJ (2002) Are quality evidence form a community-based study. Clin Exp
of family life and disease severity related in childhood Dermatol 31:671673
atopic dermatitis? J Eur Acad Dermatol Venereol 16(5): 88. Vaughan V (1966) Emotional undertones in eczema in
455462 children. J Asthma Res 3:193
58 S. Lewis-Jones

89. Halm EA et al (2006) No symptoms, no asthma: the free up consultants time? Br J Dermatol 147(3):
acute episodic disease belief is associated with poor 513517
self-management among inner-city adults with persis- 96. Moore EJ, Williams A, Manias E, Varigos G, Donath S
tent asthma. Chest 129:573580 (2009) Eczema workshops reduce severity of child-
90. Ohya Y, Williams H, Steptoe A, Saito H, Iikura Y, hood atopic eczema. Australas J Dermatol 50(2):
Anderson R, Akasawa A (2001) Psychosocial factors 100106
and adherence to treatment advice in childhood atopic 97. Staab D et al (2006) Age related, structured educa-
dermatitis. J Invest Dermatol 117(4):852857 tional programmes for the management of atopic der-
91. Renzi C et al (2001) Factors associated with patient matitis in children and adolescents: multicentre,
satisfaction with care among dermatological outpa- randomised controlled trial. BMJ 332(7547):933938
tients. Br J Dermatol 145(4):617623 98. Stalder JF, Bernier C, Ball A, De Raeve L, Gieler U,
92. Kjellgren KI, Ring L, Lindblad AK, Maroti M, Serup Deleuran M, Marcoux D, Eichenfield L, Lio P, Lewis-
J (2004) To follow dermatological treatment regi- Jones S, Gelmetti C, Takaoka R, Chiaverini C, Misery L,
mens-patients and providers views. Acta Derm Barbarot S, for the Oriented Patient-Education
Venereol 84(6):445450 Network in Dermatology (OPENED) (2011)
93. Broberg A, Kalimo K, Lindblad B, Swanbeck G (1990) Therapeutic patient education on atopic dermatitis:
Parental education in the treatment of childhood atopic worldwide experiences. Br J Dermatol http://opened-
eczema. Acta Derm Venereol 70(6):495499 dermatology.com/ (accessed 31.1.12)
94. Cork MJ, Britton J, Butler L, Young S, Murphy R, 99. Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne
Keohane SG (2003) Comparison of parent knowl- S. Psychological and educational interventions for
edge, therapy utilization and severity of atopic eczema atopic eczema in children. Cochrane Database of
before and after explanation and demonstration of Systematic Reviews 2007, Issue 3. Art. No.:CD004054.
topical therapies by a specialist dermatology nurse. Br DOI: 10.1002/14651858.CD004054.pub2. Published
J Dermatol 149(3):582589 Online: 21 JAN 2009
95. Gradwell C, Thomas KS, English JS, Williams HC
(2002) A randomized controlled trial of nurse
follow-up clinics: do they help patients and do they
 Use of Moisturizers in Patients
with Atopic Dermatitis 5
Kam Lun Ellis Hon and Alexander K.C. Leung

5.1 Atopic Dermatitis: United States [3, 912]. AD occurs more fre-
An Overview quently in temperate rather than tropical areas [13]
and is more prevalent in children that belong to
Atopic (Greek atopos, meaning strange or advantaged socioeconomic classes, smaller family
unusual) dermatitis (AD) is a chronically relaps- sizes, and families with overzealous hygiene [14].
ing dermatosis characterized by pruritus, erythema, Approximately 3050% of children with one
vesiculation, papulation, exudation, excoriation, affected parent and 5080% with two affected par-
crusting, scaling, and sometimes lichenification ents develop the disorder [15]. In terms of disease
[15]. Atopic eczema (Greek ekzema, meaning burden, it is the most common chronic skin disease
erupt or boil over) is synonymous with atopic in new referrals and requires the most frequent
dermatitis. The prevalence of atopic dermatitis has follow-ups [16]. Secondary bacterial infection,
increased two- to threefolds over the past three most commonly with Staphylococcus aureus, is
decades in industrialized countries, and there is the main complication of atopic dermatitis [3, 17].
evidence to suggest that this prevalence is continu- Purulent oozing, honey-color crusting, folliculitis,
ing to increase [1, 3, 68]. The increase in preva- and pyoderma indicate secondary infection with S.
lence may be due to increased access to medical aureus. The anterior nares are an important reser-
care, improved recognition, better epidemiological voir of S. aureus [17].
reporting, or increased environmental allergens AD is uncomfortable and distressing to
due to industrialization and pollution. AD affects patients because of the associated pruritus and
1020% of children and 13% of adults in the unsightly lesions [13]. Children with AD may
suffer from lack of sleep, irritability, daytime
tiredness, emotional stress, lowered self-esteem,
and psychological disturbance [18, 19]. The dis-
ruption of school, family, and social interactions
K.L.E. Hon, M.B.B.S., M.D., FAAP, FCCM ()
can severely impair the quality of life and
Department of Pediatrics, The Chinese University
of Hong Kong, Prince of Wales Hospital, extends beyond the child [18, 2022]. Parents
Shatin, Hong Kong may experience guilt, frustration, resentment,
e-mail: [email protected] exhaustion, and helplessness due to their childs
A.K.C. Leung, M.B.B.S., FRCPC, FRCP(UK & Irel), condition [8]. There are also considerable eco-
FRCPCH, FAAP nomic costs associated with caring for children
Department of Pediatrics, The University of Calgary,
with AD [8].
Alberta Childrens Hospital,
Calgary, Alberta, Canada AD most often presents in infancy or early
e-mail: [email protected] childhood [2, 3]. Approximately 60% of children

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 59

DOI 10.1007/978-3-642-27606-4_5, Springer-Verlag Berlin Heidelberg 2012
60 K.L.E. Hon and A.K.C. Leung

with AD manifest the disease by the first year of The pathogenesis of AD involves complex
life and an additional 30% before the age of interactions between susceptible genes, immu-
5 years [1, 2, 23]. In infants, the eruption often nological factors, skin barrier defects, infec-
affects the face and scalp, although the extensor tions, neuroendocrine factors, and environmental
surfaces of the extremities and the trunk may also factors [3]. There is a strong genetic predisposi-
be affected [2, 24]. In older children and adoles- tion, as evidenced by the familial nature of the
cents, the neck and antecubital and popliteal fos- disease and the high concordance in monozy-
sae usually display the eruption [2, 24]. gotic twins [3, 31]. It has been shown that loss-
Lesions are classified as acute, subacute, or of-function mutations in the filaggrin (FLG)
chronic and are usually symmetrical [25]. Acute gene predispose to AD [3234]. Five FLG null
lesions are intensely pruritic, erythematous pap- mutations, namely, R501X, 2282del4, R2447X,
ules, papulovesicles, or weeping lesions [25]. S2554X, and S2889X, are some of the more
Subacute lesions are erythematous scaling papules popular mutations identified in Caucasian and
or plaques [1]. Chronic lesions are characterized by Japanese populations [35].
prominent scaling, excoriations, and lichenifica- Impairment of the barrier function of the skin
tion in affected body areas [1]. Exacerbations and is an important etiologic factor in the pathogene-
remissions are common and to be expected [1]. sis of AD [3]. FLG, an epidermal barrier protein,
The diagnosis of AD is predominantly clini- plays an important role in the barrier function of
cal, based on a constellation of clinical features. the skin [36]. FLG protein is present in the granu-
Firm criteria to define atopic dermatitis were first lar layers of the epidermis, and the keratohyalin
established by Hanifin and Rajka [3, 26]. granules in the granular layers are predominantly
AD involves defective cell-mediated immu- composed of profilaggrin [37]. FLG proteins
nity related, in part, to an imbalance in two sub- aggregate the keratin cytoskeleton system to form
sets of CD4 T cells that creates a predominance a dense proteinlipid matrix that is cross-linked
of T-memory cells in the T-helper 2 pathways and by transglutaminases to form a cornified cell
preferential apoptosis of interferon-gamma-pro- envelope [36, 37]. The latter prevents epidermal
ducing T-helper 1 memory and effector T cells water loss and impedes the entry of allergens,
[2, 27, 28]. T-helper 2 cells express a set of cytok- infectious agents, and chemicals [36]. It is
ines (interleukin-4, -5, -6, -10, and -13) [27, 29]. believed that defective epidermal function is
These cytokines stimulate the proliferation and related to the downregulation of the FLG gene
differentiation of B lymphocytes, upregulate the and reduced ceramide levels [38].
expression of adhesion molecules on endothelial A reduced content of ceramides has been
cells, and contribute to the hypereosinophilia, noted in both normal and affected skin of patients
high serum IgE levels, sustained cutaneous with AD [39]. The reduction in ceramides may
inflammation, histamine release, and pruritus result from increased sphingomyelin deacylase
characteristic of AD [13]. activity and reduced production of ceramides by
keratinocytes [27]. Ceramides serve as important
water-holding molecules in the extracellular
5.2 The Pathogenesis of Dry Skin space in the horny layer [7]. A deficiency in cer-
amides results in enhanced transepidermal water
Xerosis or dry skin results from reduced amount loss, dry skin, and increased permeability to envi-
of ceramides in the skin with enhanced transepi- ronmental irritants and allergens [27]. In addi-
dermal water loss. It is seen in 6798% of patients tion, keratinocyte-derived antimicrobial peptides
with AD [30]. Xerosis predisposes to the devel- known as cathelicidins and b-defensins are defi-
opment of microfissures and cracks in the epithe- cient in the skin of patients with AD [40]. These
lium which favor the entry of allergens and peptides help in the host defense against bacteria,
microorganisms [11]. viruses, and fungi.
5 Use of Moisturizers in Patients with Atopic Dermatitis 61

5.3 Assessment of Severity the assessment of sleep loss and pruritus and
of Atopic Dermatitis adopt a more objective approach. Kunz and
and Psychosocial Impact coworkers, for instance, suggested that a modified
SCORAD index (without the pruritus and sleep-
Physicians in their busy clinics often claim to be loss components) is more objective and accurate
able to take a glance at the patients and be able to in defining the disease severity of AD [43].
determine the disease severity by their experi- The Nottingham Eczema Severity Score
ence. This is neither objective nor evidence (NESS) is a three-part score developed for popu-
based. There are many scoring systems and indi- lation-based research in the United Kingdom and
ces for the assessment of disease severity in chil- has the advantage of being very easy to perform
dren with AD. However, many of these scales [44, 45]. It is a less comprehensive scoring sys-
have not been adequately tested [41]. These tem and only gives a final grading of the severity
scores are often used to objectively evaluate ther- of AD as being mild, moderate, or severe. There
apeutic efficacy of both topical and systemic are good agreement and correlation among the
treatments. The SCORing Atopic Dermatitis NESS scores, severity grades, and the SCORAD
(SCORAD) system is a comprehensive index scale [45, 46]. The self-administered question-
utilized extensively in Europe as a research tool naire measures disease severity over a 12-month
for the assessment of AD severity. It is the only period. The disease severity is determined by
severity index for which published data could be evaluating three elements, namely, clinical course,
found on validity, reliability, sensitivity, and disease intensity, and extent of the examined
acceptability, although problems occur with lesion. Equal weighting is applied to the three
interobserver variation [41]. SCORAD consists parameters; each carries a score of 15. A final
of observations of signs and the assessment of score is achieved by adding each score to produce
symptoms and takes approximately 10 min to a possible range of scores from 3 to 15, with
perform by trained physicians who recognize the higher scores indicating more severe disease [44].
various components of this score. The SCORAD The NESS is simple and quick to use.
(score range, 0103) measures the extent, inten- The eczema and severity index (EASI) incor-
sity, pruritus, and sleep loss over the preceding porates body surface area involvement into the
3 days [42]. It uses a body diagram to record the measurement. The index assigns proportionate
extent and area of involvement. It also records values to four body regions, namely, head (10%),
the intensity of six signs, namely, erythema/ trunk (30%), upper limbs (20%), and lower limbs
darkening, edema/papulation, oozing/crust, (40%) in patients 8 years and older, and is slightly
excoriation, lichenification/prurigo, and dryness. modified for younger patients [47, 48]. The six
It is a weighted index, with less weight on the signs of AD, namely, erythema, edema/indura-
extent (by multiplying a factor of 0.2) but more tion/papulation, excoriation, oozing/weeping/
emphasis on symptomatology of pruritus and crusting, scaling, and lichenification, are graded
sleep loss (by multiplying a factor of 1), and the on a 4-point scale, ranging from absent (0) to
intensity (by multiplying a factor of 3.5) [42]. severe [3]. The EASI score ranges from 0 (clear)
The SCORAD is weighted toward pediatric pop- to 72 (very severe).
ulations and is a rather complex tool not regu- Scratching lacks objectivity and is difficult to
larly used by the general practitioners. Although study. Limb-worn digital accelerometers have
not the gold standard, SCORAD has been vali- been shown to be a useful and practical way of
dated and widely quoted as a reliable research assessing nocturnal scratching in the patients
and clinical tool for the assessment of AD sever- own home [49, 50]. It has been shown that noc-
ity [42]. Scratching and sleep disturbance are turnal wrist activities measured with DigiTrac
subjective symptoms that are difficult to study. wrist motion monitor (IM Systems, Baltimore,
Some scoring systems, therefore, have bypassed MD, USA) were closely correlated with the
62 K.L.E. Hon and A.K.C. Leung

objective clinical scores and serum levels of measurements are useful for clinical trials espe-
chemokine markers [50]. Sleep efficiency is also cially involving topical treatment. Indeed, Hon
reduced in patients with AD and can be objec- et al. proposed a holistic evaluation approach to
tively demonstrated [51]. study the efficacy of any treatment to include
In recent years, skin hydration and transepi- severity scores, quality of life assessment, bio-
dermal water loss (TEWL) have been objectively physiological measurements (skin hydration,
measured in various sites including the antecu- TEWL, scratching activities), surrogate sero-
bital fossae, forearm, face, abdomen, and the leg markers, and amounts of concomitant topical and
[5259]. The biophysical properties of skin have systemic medications [6365].
been extensively studied in patients with AD. A number of indices have been designed to
Lodn et al. characterized the biophysical proper- measure the impact of the disease on the quality
ties of noneczematous skin at three locations in of life of affected children and the parents.
atopics and nonatopics using noninvasive physi- Although some studies have shown a positive
cal methods [60]. Skin friction was measured correlation between childrens and parents qual-
with a sliding friction instrument, the degree of ity of life and disease severity on cross-sectional
hydration was measured with a capacitance meter and over-time observation [22, 66], there is not
(Corneometer CM 820), and the TEWL was necessarily a direct relation between the severity
determined using an Evaporimeter model EP1 of atopic dermatitis and its impact on quality of
(Servomed Inc., Stockholm, Sweden). The areas life [67]. The quality of life measurement pro-
examined (dorsum of the hand, volar forearm, vides additional information to the objective clin-
and lower back) showed lower values of friction ical scoring systems [66]. The Childrens
and capacitance in the atopic patients than did Dermatology Life Quality Index (CDLQ1) for
corresponding sites in the normal controls. The patients 316 years of age is a self-administered
TEWL was increased in atopic skin, but TEWL validated simple tool to measure the impact of a
seemed to correlate neither to friction nor to skin condition on the quality of life over the past
capacitance [60]. Sakurai et al. studied normal- 7 days [66]. The index covers 16 areas including
appearing skin in patients with active AD and effects on emotions, social development, sleep
suggested that an impaired barrier function often disturbance, schooling, hobbies, and treatment
seen in normal-appearing skin in AD patients issues [68]. The score range is 030; a high score
was secondary to subclinical eczematous change indicates diminished life quality [66]. The refined
in the area [61]. Nevertheless, skin barrier func- version of Childhood Atopic Dermatitis Scale
tion is not disturbed in patients with completely (CADIS) consists of a five-scale framework,
healed AD [62]. The study of these epidermal namely, family and social function scale, emo-
biophysical parameters not only helps throw tion scale, sleep scale, symptom scale, and activ-
lights on the understanding of the pathophysiol- ity limitations and behavior scale [69]. It has 45
ogy of AD but also allows investigators to gauge items and a score ranging from 0 to 180. The
the therapeutic efficacy of various topical and CADIS which assesses the impact of AD on both
systemic treatment modalities. the child and the parent in the same measure has
There is no unified opinion as to which of been developed to assess outcome in clinical
these sites should be standardized for evaluation. studies [70].
Among the sites evaluated, the antecubital flex- The Parents Index of Quality of Life in Atopic
ural area has often been suggested to show the Dermatitis (PIQoL-AD) is a quality of life instru-
most consistent correlations with disease severity. ment specific to parents of children with atopic
However, the flexural surface is angulated, uneven dermatitis [71, 72]. It has 28 items, covering a
and not ideal for measurement in children. range of parental needs that can be influenced by
Hon et al. demonstrated that standardized mea- a child with AD, such as need for rest and relax-
surements of skin hydration and TEWL can be ation, need for self-respect, need for indepen-
made at the right antecubital fossa [63]. These dence, and need for personal space and time [71].
5 Use of Moisturizers in Patients with Atopic Dermatitis 63

This scale is particularly useful in those studies in ness, reduce the pruritus, and restore the disturbed
which study participants are too young to provide skins barrier function and is of paramount impor-
information about their quality of life [70]. tance both in the prevention and management of
Suffice to say, the scoring systems for assessment patients with AD [3, 38]. In the brick-and-mortar
of disease severity and psychosocial impact have hypothesis, the stratum corneum, the outermost
often been used to assess outcomes in clinical layer of the epidermis, normally consists of fully
trials [73, 74]. They are rarely used in clinical differentiated corneocytes surrounded by a lipid-
practice. rich matrix containing cholesterol, free fatty
acids, and ceramide; the structure of this matrix
closely resembles that of bricks and mortar in a
5.4 Optimal Skin Care: wall. In AD, lipid metabolism is abnormal, caus-
Moisturizers and Emollients ing a deficiency of ceramide that leads to tran-
for Atopic Dermatitis sepidermal water loss [5, 76, 77]. The underlying
genetic deficit might be due to null mutation in
AD is frustrating to both patients and caregivers. the filaggrin gene [34].
The pruritus can be intractable, and the disease Hydration of the skin can be achieved by daily
has important physical and psychological impli- baths in lukewarm (not hot) water for approxi-
cations. Because of associated emotional stress mately 510 min, followed by patting the body
and sleep disruption, the impact on the quality of dry with a towel [1, 3]. Fragrance-free soap and
life of patients and families can be significant [3, cleansers are preferred [3]. The use of shampoo,
19, 64]. Successful treatment requires a holistic bubble bath, and dishwater detergent to cleanse
approach that consists of avoidance of triggering the body should be avoided [3]. Rubbing should
factors, optimal skin care, pharmacotherapy dur- also be avoided as such maneuver may precipi-
ing acute exacerbations, and education and of tate the sensation of pruritus.
patients/caregivers [3]. Although there is no cure, Regular topical application of a moisturizer is
control is possible in most patients with optimal key in the management of patients with AD. A
skin care, pharmacotherapy, and adherence to pre- moisturizer or emollient should be applied within
ventive measures [65, 75]. Pharmacotherapy usu- 3 min to prevent evaporation and keep the skin
ally consists of topical application of corticosteroids soft and flexible, which helps to prevent the
or calcineurin inhibitors [3]. In a subgroup of chil- penetration by bacteria, irritants, and allergens
dren with severe AD, the disease is recalcitrant to [1, 3, 78]. This soak and seal method helps to
conservative and topical therapy alone. These improve the integrity of the skin barrier and pre-
children may require systemic treatments such as vents the penetration by bacteria, irritants, and
oral antihistamines, antibiotics, leukotriene recep- allergens. Bathing without the use of moisturizer
tor antagonists, and systemic immunosuppres- may compromise skin hydration [79].
sants [3]. Emotional stress often exacerbates the The use of moisturizers helps the skin main-
skin lesions of AD. If avoidance is not possible, tain a defensive barrier effect, which is defective
coping mechanisms should be tried [2, 3]. in AD [80]. Moisturizers can be in the form of
Dry skin is more prone to itch and chapping creams, emollients, lotions, or ointments [8183].
and hence secondary infection and subsequent Creams are semisolid emulsions (mixtures of oil
perpetuation of AD. Hydration of the skin and water). Creams are either water-miscible and
increases drug penetration as hydration causes readily washed off, or oily and not so easily
swelling of the stratum corneum rendering it washed off. They are divided into two types: oil-
more permeable to drug molecules. The key to in-water creams which are composed of small
management of AD and dry skin conditions, droplets of oil dispersed in a continuous phase,
especially in-between episodes of flare-ups, is the and water-in-oil creams which are composed of
frequent use of an appropriate moisturizer [1]. small droplets of water dispersed in a continuous
Hydration of the skin helps to improve the dry- oily phase. Oil-in-water creams are more
64 K.L.E. Hon and A.K.C. Leung

comfortable and cosmetically acceptable as they Ointments are semisolid substances that are
are less greasy and more easily washed off using greasy, normally anhydrous, and insoluble in
water. Water-in-oil creams are more difficult to water. The most commonly used ointment bases
handle, but many drugs which are incorporated consist of soft paraffin or a combination of soft
into creams are hydrophobic and will be released paraffin with liquid paraffin and hard paraffin.
more readily from a water-in-oil cream than Due to their anhydrous nature, ointments do not
an oil-in-water cream. Water-in-oil creams are require any preservatives. They have the advan-
also more moisturizing as they provide an oily tages of being more moisturizing, more occlusive
barrier which reduces water loss from the stratum than creams and form a protective film over the
corneum. Barrier creams often contain water- skin. Because of their marked occlusive effect,
repellent substances such as dimethicone or other ointments are not suitable for acute weeping,
silicones that protect against irritation or repeated crusting skin conditions, particularly in the inter-
hydration. They are useful in the treatment of triginous areas. Today, there are ointments that
napkin rash and bedsores. They are the preferred possess both hydrophilic and lipophilic propri-
forms of treatment for exudative dermatoses. eties so that they become water-soluble and can
Creams are often massaged on the affected area be washed off readily. Ointments are very useful
twice daily in patients with AD and xerosis. They particularly for chronic dry skin.
can be used with other topical agents such as cor- A number of topical preparations are available
ticosteroids to enhance penetration. Creams con- in the market. The actual ingredients in most of
tain water and are liable to fungal and bacterial these products are a commercial secret of individ-
contaminations, and therefore, preservatives are ual pharmaceutical companies. However, the active
usually added. Commonly used preservatives in ingredients are quoted in the packaging. These
creams are chlorocresol and hydroxybenzoates; products include Ego Skin cream, Keri lotion,
both of which may cause skin allergy. Lactacyd, Lacticare, QV cream, QV skin lotion,
Emollients are fats or oils in a two-phase sys- Sebamed, Urederm, Urecare, Cetaphil, Glaxal
tem (one liquid is dispersed in the form of small base, and many more. The commonly used and
droplets throughout another liquid). Emollients inexpensive moisturizers include aqueous cream,
soften the skin by forming an occlusive oil film emulsifying ointment, and urea cream. Aqueous
on the stratum corneum, preventing drying by cream BP contains emulsifying wax (9%), white
evaporation from the deeper layers of skin and soft paraffin (15%), liquid paraffin (6%), phenoxy-
rendering it more pliable in dry eczema, ichthyo- ethanol (1%), and purified water to make up to
sis, and psoriasis. Emollients minimize dryness 100%. It is an oil-in-water emulsion with phenoxy-
and are the mainstay in treating mild AD. There ethanol as the preservative. Emulsifying ointment
is a wide range of emollients with different greas- BP contains white soft paraffin (50%), emulsifying
iness available, and it is important to find the one wax (30%), and liquid paraffin (20%). Urederm
that the patient is most willing to use. The rule is (urea cream 10%) contains 10% by weight of urea
to use emollients thinly and frequently, and not with carbomer 934, paraffin (light liquid), glyc-
thickly and occasionally. It is believed that regu- erol, cetostearyl alcohol, mixed parabens, white
lar and frequent use of emollients can reduce soft paraffin, cetomacrogol, triethanolamine, and
1020% of the amount of topical steroid used in purified water. In general, ointments are most
the treatment of AD. Some emollients contain effective but messy; creams are often better toler-
lanolin that may sensitize skin. ated. The type of moisturizer or emollient should
Lotions are aqueous solutions or suspensions be tailored to the individual skin conditions as well
that cool diffusely inflamed unbroken skin by as the childs needs and preferences [15, 67].
evaporation. They should be applied frequently. AD is associated with dry skin, and skin
Lotions are also used to apply drugs to the skin hydration correlates with disease severity. It is
when only a thin layer of the preparation is thus sensible to encourage patients to use mois-
intended to apply over a large surface area. turizers regularly [9, 75]. The skin condition may
5 Use of Moisturizers in Patients with Atopic Dermatitis 65

improve significantly with the liberal use of her life over the past week. The patients also
moisturizers such that the use of topical corticos- judged the severity of AD daily on a visual ana-
teroids or calcineurin inhibitors could be mini- logue scale. The authors found that both groups
mized. Patients should be given practical advice improved in terms of AD and DLQI. However,
in their daily skin care. In areas rich with seba- the clinical scoring demonstrated that once daily
ceous glands such as the face, formulations application of corticosteroid and a urea-contain-
should contain less oil than on other body areas ing moisturizer was superior to twice daily appli-
[15]. Lotions, which have a high water and low cation of corticosteroid in diminishing AD,
oil content, can worsen xerosis via evaporation especially in the group of patients with lower AD
and should therefore be avoided. A dye-free, fra- scores at inclusion. Frankel et al. evaluated the
grance-free moisturizer should be used [38]. short-term effectiveness and appeal of a cer-
Frequent applications of moisturizers throughout amide-hyaluronic acid emollient foam as com-
the day help to maintain a high level of hydration pared to pimecrolimus cream 1% in the treatment
in the stratum corneum [3]. Moisturizers contain- of AD within a wide age group of subjects with
ing urea, alpha-hydroxy acids, glycyrrhetinic active AD at baseline [89]. In this study, both
acids, hyaluronic acids or, ceramides have been pimecrolimus cream and the ceramide-hyaluronic
shown to improve the integrity of stratum cor- acid emollient foam exhibited efficacy in mild-
neum [76, 78, 8486]. Moisturizers should to-moderate AD. Primary efficacy was measured
always be used, even when the skin is clear of by Investigators Global Assessment. After
active lesions, recognizing that normal-appearing 4 weeks of treatment with the ceramide-
skin in patients with AD may not be immuno- hyaluronic acid emollient foam, 82% of target
logically normal [67]. lesions were scored clear or almost clear com-
Proper moisturizer therapy can reduce the fre- pared to 71% of target lesions under the pime-
quency of flares and reduce the demand of crolimus arm. The authors concluded that
topical corticosteroids or topical calcineurin ceramide-hyaluronic acid emollient foam and
inhibitors [12, 8790]. In an open, randomized, pimecrolimus cream 1% work well in the treat-
prospective, parallel group study, Lodn et al. ment of AD in both children and adults with no
compared the time to relapse of AD during associated adverse effects.
treatment with a barrier-strengthening moisture
(5% urea) with no treatment (no medical or non-
medicated preparations) in 53 patients with suc- 5.5 Measurement of Efcacy
cessfully treated AD affecting the hands [87]. of Moisturizer Therapy
The median time to relapse was 20 days in the
moisturizer group compared with 2 days in the A number of studies have been done to demon-
no treatment group (p = 0.04). In addition, Lodn strate how the efficacy of moisturizer therapy can
et al. conducted a parallel, double-blind, ran- be objectively measured. Chamlin et al. assessed
domized, clinical trial on 44 patients with a the efficacy of a newly developed, ceramide-
recent relapse of AD affecting the hands [88]. In dominant, physiologic lipid-based emollient,
this study, twice daily application of a strong when substituted for currently used moisturizers,
corticosteroid cream (betamethasone valerate in 24 children who were also receiving standard
0.1%) was compared with once daily applica- therapy for stubborn-to-recalcitrant AD [76]. All
tion, where a urea-containing moisturizer was subjects continued prior therapy (e.g., topical
substituted for the corticosteroid cream in the tacrolimus or corticosteroids), only substituting
morning. The investigator scored the presence of the barrier repair emollient for their prior mois-
AD, and the patients judged the health-related turizer. Follow-up evaluations, which included
quality of life (HRQoL) using the Dermatology SCORAD values and several biophysical mea-
Life Quality Index (DLQI), which measures how sures of stratum corneum function, were per-
much the patients skin problem has affected his/ formed every 3 weeks for 2021 weeks. SCORAD
66 K.L.E. Hon and A.K.C. Leung

values improved significantly in 22 of 24 patients was applied for this study. The authors compared
by 3 weeks, with further progressive improve- stereoimage optical topometer, other bioengineer-
ment in all patients between 6 and 20 or 21 weeks. ing methods, and the SCORAD index. After 3 h of
TEWLs, which were elevated over involved and application with moisturizer, the results measured
uninvolved areas at entry, decreased in parallel by stereoimage optical topometer, conventional
with SCORAD scores and continued to decline optical profilometer, D-Squame, and corneometer
even after SCORAD scores plateaued. Both stra- showed significant differences (p < 0.05). After 1
tum corneum integrity (cohesion) and hydration and 2 weeks, there were significant changes in the
also improved slowly but significantly during results measured by stereoimage optical topome-
therapy. Finally, the ultrastructure of the stratum ter, conventional optical profilometer, D-Squame,
corneum, treated with ceramide-dominant emol- corneometer, spectrophotometer, and SCORAD
lient, revealed extracellular lamellar membranes, index. The authors observed a significant correla-
which were largely absent in baseline stratum tion between bioengineering methods and the
corneum samples. The authors concluded that a SCORAD index (p < 0.05) and concluded that
ceramide-dominant, barrier repair emollient rep- morphological study of skin surface contours is
resents a safe, useful adjunct to the treatment of useful in the evaluation of AD severity. They fur-
childhood AD, and TEWL is at least as sensitive ther suggested that a combination of methods to
an indicator of fluctuations in AD disease activity evaluate the physiologic changes and those such
as are SCORAD values. The study supports the as stereoimage optical topometer to measure the
outside-inside hypothesis as a component of morphological changes of skin surface could eval-
pathogenesis in AD and other inflammatory der- uate more objectively and quantitatively the sever-
matoses that are accompanied by a barrier abnor- ity of AD. In this study, however, quality of life,
mality. In this study, no quality of life or global patient global acceptability of treatment, quality
assessment of acceptability of treatment was and quantity of the moisturizer used were not
documented. assessed.
Son et al. demonstrated that the regular appli- Rosmarinic acid (a-o-caffeoyl-3,4-dihydroxy-
cation of a moisturizer for 2 weeks would improve phenyl lactic acid), a naturally occurring hydroxylated
SCORAD, skin hydration, TEWL, and other cuta- compound, is known to have anti-inflammatory
neous parameters [59]. The authors rightly and immunomodulatory activities [91]. A double-
addressed the problem that wide variation in blind, vehicle-controlled, randomized trial was
outcome methodology could make the interpreta- performed to evaluate the clinical effects of a
tion of patient outcomes confusing and the com- cream containing 0.3% rosmarinic acid on patients
parison of the results of different studies almost with AD over an 8-week period [91]. Rosmarinic
impossible, and that it was important to objec- acid (0.3%) cream was topically applied to the
tively measure and record the severity of AD for elbow flexures of 21 patients (14 females and 7
routine clinical practice and research. The authors males, aged 528 years) twice a day. Cream with-
evaluated whether morphological study of skin out 0.3% rosmarinic acid was applied to the elbow
surface contours might be helpful to objectively flexures of control subjects twice a day. The mean
quantify the severity of AD. Thirty patients with SCORAD index decreased from 7.37 0.32 before
AD (12 females, 18 males) participated in this treatment to 3.27 0.21 after treatment with ros-
study. Moisturizer was applied twice daily for marinic acid-containing cream for 8 weeks
2 weeks. Bioengineering methods such as (p < 0.05). However, in the control group, no sig-
D-Squame, corneometer, evaporimeter, and spec- nificant change of SCORAD score was observed.
trophotometer were measured at the start of the Transepidermal water loss of the antecubital fossa
study and after 1 and 2 weeks. In addition, the was significantly reduced at 8 weeks compared to
authors assessed moisturizer effects after 3 h of before treatment (p < 0.05). In this study, the out-
moisturizer application. The stereoimage optical come measures only included SCORAD and
topometer based on a new concept of stereoimage TEWL with a very small number of patients. No
5 Use of Moisturizers in Patients with Atopic Dermatitis 67

assessment of quality of life or global acceptabil- may be considered as one of the available regi-
ity of treatment was documented. mens effective in the treatment of mild-to-mod-
EpiCeram consists of a specific combination erate AD in children and adolescents. Although
of ceramides, cholesterol, and fatty acids (in the it was a randomized trial, the sample size was
ratio of 3:1:1) that mimics those naturally found small, and only Investigators Global Assessment
in the skin [92, 93]. Recent studies have shown score was used.
that EpiCeram has similar efficacy compared to a In another randomized, double-blind, vehicle-
mid-potency topical corticosteroid but has a controlled clinical study, Boguniewicz et al.
favorable safety profile [92, 93]. However, these administered MAS063DP (n = 72) or vehicle
studies did not report objective measurements to (n = 70) cream to 142 patients aged 6 months to
demonstrate efficacy of treatment. 12 years 3 times per day to affected areas and
Atopiclair, also known as MAS063DP or sites prone to develop AD [94]. The primary end-
Zarzenda, a hydrolipidic cream, has been found point for efficacy was the Investigators Global
effective in the treatment of mild-to-moderate Assessment at day 22. Secondary endpoints
AD in both children and adults [94, 95]. The included Investigators Global Assessment at
cream contains Vitis vinifera (grapevine) extract other time-points, patients/caregivers assess-
with antioxidant and antiprotease activity, gly- ment of pruritus, onset, duration of itch relief,
cyrrhetinic acid with antipruritic and anti-inflam- EASI, patients/caregivers assessment of global
matory properties, and hyaluronic acid which response, and need for rescue medication in the
helps to moisturize the epidermis and restore event of an AD flare. The authors found that
barrier function [12, 94, 95]. Patrizi et al. con- MAS063DP cream was statistically more effec-
ducted a multicenter, randomized, double-blind, tive (p < 0.0001) than vehicle cream for the pri-
vehicle-controlled clinical study to evaluate the mary endpoint and all secondary endpoints.
efficacy and safety of MAS063DP in 60 pediat- Treatment discontinuation as a result of an
ric patients affected by AD, aged between 2 and adverse event occurred in 9.9% of patients using
17 years [95]. Using the Investigators Global MAS063DP cream and 16% of patients using
Assessment score for AD, patients with a score vehicle cream. The authors concluded that
of 2 (mild) or 3 (moderate) were enrolled in the MAS063DP cream is effective and safe as mono-
study. Patients were randomly assigned to receive therapy for the treatment of mild-to-moderate
MAS063DP (20 patients), MAS060 (20 patients, AD in infants and children.
a similar formulation with lower key ingredients Increased TEWL and downregulated antimi-
concentration and no preservatives), or vehicle crobial peptides are observed in patients with
(20 patients).The study consisted in a treatment AD. Park et al. investigated the relationship
period of 43 days, with clinical evaluations at between antimicrobial and barrier factors by
baseline (day 1), days 8, 15, 22, 29, and 43, at measuring the changes of TEWL and antimicro-
which time the treatment was stopped. bial peptides after topical application of tacroli-
MAS063DP showed nearly 80% improvement in mus and ceramide-dominant emollient in patients
Investigators Global Assessment score at day with AD [96]. A total of three patients with AD
22, compared with 16.6% and 26.3% with the were treated with tacrolimus in one lesion and
MAS060 and vehicle, respectively. A statisti- ceramide-dominant emollient in another lesion
cally significant difference was found by com- for 4 weeks. RT-PCR and Western blotting
paring MAS063DP with MAS060 (p < 0.0001); revealed that the mRNA and protein expression
a similar result was evidenced comparing levels of hBD-2 and LL-37 were increased on
MAS063DP and vehicle (p = 0.001). By contrast, both study sites. Immunohistochemical analysis
no significant difference was found between showed significant increase of antimicrobial pep-
MAS060 and vehicle. A statistically significant tides and interleukin-1a, while interleukin-4 was
difference was sustained until the end of the decreased on both study sites. The mean changes
study. The authors concluded that MAS063DP of TEWL and antimicrobial peptides showed no
68 K.L.E. Hon and A.K.C. Leung

statistical difference between both sites. The integrity. However, liberal usage of emollients
authors concluded that tacrolimus and ceramide- and bathing cleanser alone does not seem to alter
dominant emollient influence on both TEWL and disease severity or TEWL within 2 weeks, imply-
antimicrobial peptides expression in patients with ing that additional treatments are necessary to
AD. It should be noted that in this study, the sam- manage AD. Hence, liberal amounts of moistur-
ple size was small, and outcome measurements izers should be used which can be conveniently
were focused. estimated based on body surface area instead of
Hon et al. evaluated whether the amount of the less readily available tools for disease sever-
emollient and skin cleanser used correlates with ity, degree of skin hydration, or skin integrity
eczema severity, skin hydration, or TEWL, and [65]. The outcome measures in this study
whether liberal usage alters disease severity, skin included clinical scores, skin hydration, TEWL,
hydration, and TEWL [65]. The authors studied and global assessment of treatment measure-
skin hydration and TEWL at three common mea- ments. In addition, the amount of emollient usage
surement sites on the forearm (antecubital flex- per unit body surface area per unit time was also
ure, 20 mm below the antecubital flexure, assessed.
mid-forearm) and determined the SCORAD In another study, Hon et al. recruited 33
score, NESS, CDLQI, and the amount of emol- patients (mean age 12 years, SD 4 years) with
lient and cleanser usage over a 2-week period in AD to study the clinical and biophysiological
consecutive new patients seen at the pediatric effects of twice-daily application of a pseudocer-
skin clinic of a teaching hospital in Hong Kong. amide-containing cream [97]. Four weeks fol-
In total, 48 subjects and 19 controls were lowing the use of the pseudoceramide cream, the
recruited. Patients with AD had significantly skin hydration significantly improved [mean
higher TEWL and lower skin hydration in the (SD) from 30 (15) to 38 (15), p = 0.039]. There
studied sites. Emollient and cleanser usage was was no deterioration in TEWL, eczema severity,
significantly higher (p = 0.001 and p = 0.041, or quality of life in these patients. The pseudo-
respectively) in patients with AD than in con- ceramide cream improved the skin hydration but
trols. The amount of emollient usage was corre- not the severity or quality of life over a 4-week
lated with NESS, SCORAD, CDLQI, TEWL, usage. In this study, skin hydration and TEWL,
and mid-forearm skin hydration. No such corre- disease severity (SCORAD index), CDLQI,
lation was found with cleanser usage. Regardless amount of topical corticosteroid usage, and a
of SCORAD, prescribing 130 g/m2/week of global assessment of treatment score were used
emollient met the requirement of 95.8% of as outcome measurements [97].
patients, and 73 g/m2/week of emollient met that In recent years, aqueous cream has been
of 85.4%. As far as the cleanser is concerned, studied by a number of investigators. Aqueous
prescribing 136 g/m2/week met the requirement cream BP is widely prescribed to patients with
of 91.7% of patients. Although both skin dryness AD to relieve skin dryness. The formulation
and skin hydration were improved, there was no contains sodium lauryl sulfate, a chemical that
significant improvement in SCORAD or TEWL is a known skin irritant and a commonly used
after 2 weeks. In terms of global acceptability of excipient in personal care and household prod-
treatment, three-quarters of patients with AD and ucts. Tsang et al. characterized and assessed
controls rated the combination of cream and skin barrier function of healthy skin after appli-
cleanser as good or very good. The authors cation of aqueous cream BP and studied the
concluded that adequate amounts of emollient physical effects of the formulation on the stra-
and bathing cleanser should be prescribed to tum corneum [98]. In this study, the left and
patients with AD. These amounts can be conve- right volar forearms of six human volunteers
niently estimated based on body surface area were each separated into treated and control
instead of the less readily available tools for dis- sides. The treated sides of each forearm were
ease severity, degree of skin hydration, or skin subjected to twice daily applications of aqueous
5 Use of Moisturizers in Patients with Atopic Dermatitis 69

cream BP for 4 weeks at the end of which con- amount of protein removed from deeper layers
comitant tape stripping and TEWL measure- of treated sites was significantly lower than from
ments were made. The untreated sides of the untreated sites. The authors concluded that treat-
forearms were not exposed to any products con- ment with aqueous cream BP is associated with
taining sodium lauryl sulfate during the study increased desquamatory and inflammatory pro-
period. Changes in stratum corneum thickness, tease activity. Changes in corneocyte maturity
baseline TEWL, and rate of increase in TEWL and size are also indicative of accelerated skin
during tape stripping were observed in skin turnover induced by chronic application of this
treated with aqueous cream BP. The mean emollient. The authors question firmly the rou-
decrease in stratum corneum thickness was tine prescription of this preparation as a moistur-
1.1 mm (12%) (p = 00015), and the mean izer in patients with AD. No clinical scores are
increase in baseline TEWL was 2.5 g/m2/h used in this study.
(20%) (p < 0.0001). Reduced stratum corneum
thickness and an increase in baseline TEWL, as Conclusion
well as a faster rate of increase in TEWL during Usage of moisturizers is a very important
tape stripping, were observed in 16 out of 27 albeit often neglected components of AD
treated skin sites. The investigators concluded management, and the relevant advice is often
that the application of aqueous cream BP, con- not evidence based [100]. Investigators should
taining approximately 1% sodium lauryl sulfate, use both clinical as well as biophysiological
reduced the stratum corneum thickness of tools to evaluate efficacy of moisturizers.
healthy skin and increased its permeability to Aqueous cream is appropriate for use as a
water loss, and called into question the contin- soap substitute but is a less effective emol-
ued use of this emollient on the already compro- lient than white petroleum [101, 102], emul-
mised barrier of atopic skin [98]. sifying ointment, or white soft paraffin mixed
Aqueous cream BP is known to induce sensi- with liquid paraffin [103]. Physicians should
tivity in certain patients and also to decrease the assist patients with AD and their parents to
thickness of the stratum corneum [99]. establish a good routine as to the use of an
Mohammed and colleagues investigated changes appropriate type and amount of moisturizer.
in corneocyte size, corneocyte maturity, selected Regular assessment of compliance to its use
protease activities, protein content, and TEWL is crucial.
in normal skin after a 28-day application of
aqueous cream BP [99]. In this study, the left
and right mid-volar forearms of six healthy Take Home Messages
female volunteers were selected as the study Frequent and proper application of skin
sites. Aqueous cream BP was applied twice daily moisturizers is a very important albeit
to treated sites for 28 days. At the end of this often neglected components of AD man-
period, the site was tape-stripped and corneocyte agement, and the relevant advice is often
maturity, corneocyte size and protease activity not evidence based.
of the desquamatory kallikrein proteases, KLK5, Both clinical and biophysiological tools
KLK7, inflammatory proteases tryptase, and should be used to evaluate efficacy of
plasmin were measured. Protein content and moisturizers.
TEWL measurements were also recorded. The Physicians should assist patients with
authors found that corneocyte maturity and size AD and their parents to establish a good
decreased with increasing number of tape strips routine as to the use of an appropriate
and were significantly lower in treated sites com- type and amount of moisturizer.
pared with untreated sites. Protease activity and Regular assessment of compliance to its
TEWL values were higher (p < 0.05) for the use is crucial.
treated sites compared with untreated sites. The
70 K.L.E. Hon and A.K.C. Leung

References 19. Hon KL, Leung TF, Wong K, Chow C, Chuh A, Ng P

et al (2008) Does age or gender influence quality of
life in children with atopic dermatitis? Clin Exp
1. Leung AK, Hon KL (2011) Atopic dermatitis: a
Dermatol 33(6):705709
review for the primary care physician. Nova Science
20. Ben Gashir MA, Seed PT, Hay RJ (2002) Are quality
Publishers, Inc., New York, pp 1111
of family life and disease severity related in childhood
2. Leung AKC, Barber KA (2003) Managing childhood
atopic dermatitis? J Eur Acad Dermatol Venereol
atopic dermatitis. Adv Ther 20(3):129137
16(5):455462
3. Leung AK, Hon KL, Robson WL (2007) Atopic der-
21. Ben Gashir MA (2003) Relationship between quality
matitis. Adv Pediatr 54:241273
of life and disease severity in atopic dermatitis/eczema
4. Leung DY (1995) Atopic dermatitis: the skin as a win-
syndrome during childhood. Curr Opin Allergy Clin
dow into the pathogenesis of chronic allergic diseases.
Immunol 3(5):369373
J Allergy Clin Immunol 96(3):302318
22. Ben Gashir MA, Seed PT, Hay RJ (2004) Quality of
5. Sehra S, Tuana FM, Holbreich M, Mousdicas N,
life and disease severity are correlated in children with
Tepper RS, Chang CH et al (2008) Scratching the sur-
atopic dermatitis. Br J Dermatol 150(2):284290
face: towards understanding the pathogenesis of
23. Rudikoff D, Lebwohl M (1998) Atopic dermatitis.
atopic dermatitis. Crit Rev Immunol 28(1):1543
Lancet 351(9117):17151721
6. Williams HC (1992) Is the prevalence of atopic der-
24. Kristal L, Klein PA (2000) Atopic dermatitis in infants
matitis increasing? Clin Exp Dermatol 17(6):
and children. An update. Pediatr Clin North Am
385391
47(4):877895
7. Leung DY, Boguniewicz M, Howell MD, Nomura I,
25. Eigenmann PA (2001) Clinical features and diagnos-
Hamid QA (2004) New insights into atopic dermati-
tic criteria of atopic dermatitis in relation to age.
tis. J Clin Invest 113(5):651657
Pediatr Allergy Immunol 12(Suppl 14):6974
8. Grillo M, Gassner L, Marshman G, Dunn S, Hudson P
26. Hanifin JMRG (1980) Diagnostic features of atopic
(2006) Pediatric atopic eczema: the impact of an edu-
dermatitis. Acta Derm Venereol (Stockh) 2:4447
cational intervention. Pediatr Dermatol 23(5):428436
27. Leung DY, Jain N, Leo HL (2003) New concepts in
9. Leung R, Wong G, Lau J, Ho A, Chan JK, Choy D
the pathogenesis of atopic dermatitis. Curr Opin
et al (1997) Prevalence of asthma and allergy in Hong
Immunol 15(6):634638
Kong schoolchildren: an ISAAC study. Eur Respir J
28. Leung DY, Bieber T (2003) Atopic dermatitis. Lancet
10(2):354360
361(9352):151160
10. Wong GW, Hui DS, Chan HH, Fok TF, Leung R,
29. Hon K, Leung TF (2010) Seromarkers in childhood
Zhong NS et al (2001) Prevalence of respiratory and
atopic dermatitis. Expert Rev Dermatol 5(3):299314
atopic disorders in Chinese schoolchildren. Clin Exp
30. Hanifin JM (1982) Atopic dermatitis. J Am Acad
Allergy 31(8):12251231
Dermatol 6(1):113
11. Leung DY, Nicklas RA, Li JT, Bernstein IL, Blessing-
31. Leung TF, Ma KC, Hon KL, Lam CWK et al (2003)
Moore J, Boguniewicz M et al (2004) Disease man-
Serum concentration of macrophage-derived chemokine
agement of atopic dermatitis: an updated practice
may be a useful inflammatory marker for assessing
parameter. Joint task force on practice parameters.
severity of atopic dermatitis in infants and young chil-
Ann Allergy Asthma Immunol 93(3 Suppl 2):S1S21
dren. Pediatr Allergy Immunol 14(4):296301
12. Simpson EL (2010) Atopic dermatitis: a review of
32. Marenholz I, Nickel R, Ruschendorf F, Schulz F,
topical treatment options. Curr Med Res Opin
Esparza-Gordillo J, Kerscher T et al (2006) Filaggrin
26(3):633640
loss-of-function mutations predispose to phenotypes
13. Abramovits W (2005) Atopic dermatitis. J Am Acad
involved in the atopic march. J Allergy Clin Immunol
Dermatol 53(1 Suppl 1):S86S93
118(4):866871
14. Simpson EL, Hanifin JM (2005) Atopic dermatitis.
33. Palmer CN, Irvine AD, Terron-Kwiatkowski A, Zhao
J Am Acad Dermatol 53(1):115128
Y, Liao H, Lee SP et al (2006) Common loss-of-func-
15. Roos TC, Geuer S, Roos S, Brost H (2004) Recent
tion variants of the epidermal barrier protein filaggrin
advances in treatment strategies for atopic dermatitis.
are a major predisposing factor for atopic dermatitis.
Drugs 64(23):26392666
Nat Genet 38(4):441446
16. Hon KL (2004) Skin diseases in Chinese children at a
34. Sandilands A, Terron-Kwiatkowski A, Hull PR,
Pediatric Dermatology Center. Pediatr Dermatol
ORegan GM, Clayton TH, Watson RM et al (2007)
21(2):109112
Comprehensive analysis of the gene encoding filaggrin
17. Hon KL, Lam MC, Leung TF, Kam WY, Li MC, Ip M
uncovers prevalent and rare mutations in ichthyosis
et al (2005) Clinical features associated with nasal
vulgaris and atopic eczema. Nat Genet 39(5):650654
Staphylococcus aureus colonisation in Chinese chil-
35. Ching G, Hon KL (2009) Filaggrin null mutations in
dren with moderate-to-severe atopic dermatitis. Ann
childhood atopic dermatitis among the Chinese. Int J
Acad Med Singapore 34(10):602605
Immunogenet 36(4):251254
18. Chamlin SL, Frieden IJ, Williams ML, Chren MM
36. Enomoto H, Hirata K, Otsuka K, Kawai T, Takahashi
(2004) Effects of atopic dermatitis on young American
T, Hirota T et al (2008) Filaggrin null mutations are
children and their families. Pediatrics 114(3):607611
5 Use of Moisturizers in Patients with Atopic Dermatitis 71

associated with atopic dermatitis and elevated levels children with atopic dermatitis. J Dermatolog Treat
of IgE in the Japanese population: a family and case- 16(1):2225
control study. J Hum Genet 53(7):615621 52. Pinnagoda J, Tupker RA, Agner T, Serup J (1990)
37. Candi E, Schmidt R, Melino G (2005) The cornified Guidelines for transepidermal water loss (TEWL)
envelope: a model of cell death in the skin [Review, measurement. A report from the Standardization
142 refs]. Nat Rev Mol Cell Biol 6(4):328340 Group of the European Society of Contact Dermatitis.
38. Krakowski AC, Eichenfield LF, Dohil MA (2008) Contact Dermatitis 22(3):164178
Management of atopic dermatitis in the pediatric pop- 53. Serup J (1992) Characterization of contact dermatitis
ulation. Pediatrics 122(4):812824 and atopy using bioengineering techniques. A survey.
39. Hara J, Higuchi K, Okamoto R, Kawashima M, Acta Derm Venereol 177:1425
Imokawa G (2000) High-expression of sphingomy- 54. Kim DW, Park JY, Na GY, Lee SJ, Lee WJ (2006)
elin deacylase is an important determinant of cer- Correlation of clinical features and skin barrier func-
amide deficiency leading to barrier disruption in tion in adolescent and adult patients with atopic der-
atopic dermatitis. J Invest Dermatol 115(3):406413 matitis. Int J Dermatol 45(6):698701
40. Ong PY, Ohtake T, Brandt C, Strickland I, Boguniewicz 55. Proksch E, Nissen HP, Bremgartner M, Urquhart C
M, Ganz T et al (2002) Endogenous antimicrobial (2005) Bathing in a magnesium-rich Dead Sea salt
peptides and skin infections in atopic dermatitis [see solution improves skin barrier function, enhances skin
comment]. N Engl J Med 347(15):11511160 hydration, and reduces inflammation in atopic dry
41. Charman C, Williams H (2000) Outcome measures of skin. Int J Dermatol 44(2):151157
disease severity in atopic eczema. Arch Dermatol 56. Ogoshi K, Serup J (2005) Inter-instrumental varia-
136(6):763769 tion of skin capacitance measured with the
42. (1993) Severity scoring of atopic dermatitis: the Corneometer. Skin Res Technol 11(2):107109
SCORAD index. Consensus Report of the European 57. Seidenari S, Giusti G (1995) Objective assessment of
Task Force on Atopic Dermatitis. Dermatology the skin of children affected by atopic dermatitis: a
186(1):2331 study of pH, capacitance and TEWL in eczematous
43. Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, and clinically uninvolved skin. Acta Derm Venereol
Taieb A (1997) Clinical validation and guidelines for 75(6):429433
the SCORAD index: consensus report of the European 58. Choi SJ, Song MG, Sung WT, Lee DY, Lee JH, Lee
Task Force on Atopic Dermatitis. Dermatology ES et al (2003) Comparison of transepidermal water
195(1):1019 loss, capacitance and pH values in the skin between
44. Emerson RM, Charman CR, Williams HC (2000) The intrinsic and extrinsic atopic dermatitis patients.
Nottingham Eczema Severity Score: preliminary J Korean Med Sci 18(1):9396
refinement of the Rajka and Langeland grading. Br J 59. Son SW, Park SY, Ha SH, Park GM, Kim MG, Moon
Dermatol 142(2):288297 JS et al (2005) Objective evaluation for severity of
45. Hon KL, Ma KC, Wong E, Leung TF, Wong Y, Fok atopic dermatitis by morphologic study of skin sur-
TF et al (2003) Validation of a self-administered ques- face contours. Skin Res Technol 11(4):272280
tionnaire in Chinese in the assessment of eczema 60. Lodn M, Olsson H, Axell T, Linde YW (1992)
severity. Pediatr Dermatol 20(6):465469 Friction, capacitance and transepidermal water loss
46. Sturgill S (2004) Atopic dermatitis update. Curr Opin (TEWL) in dry atopic and normal skin. Br J Dermatol
Pediatr 16(4):396401 126(2):137141
47. Rajka G, Langeland T (1989) Grading of the severity 61. Sakurai K, Sugiura H, Matsumoto M, Uehara M
of atopic dermatitis. Acta Derm Venereol 144:1314 (2002) Occurrence of patchy parakeratosis in normal-
48. Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte appearing skin in patients with active atopic dermati-
SJ, Graeber M (2001) The eczema area and severity tis and in patients with healed atopic dermatitis: a
index (EASI): assessment of reliability in atopic der- cause of impaired barrier function of the atopic skin.
matitis. EASI Evaluator Group. Exp Dermatol 10(1): J Dermatol Sci 30(1):3742
1118 62. Matsumoto M, Sugiura H, Uehara M (2000) Skin bar-
49. Benjamin K et al (2004) The development of an objec- rier function in patients with completely healed atopic
tive method for measuring scratch in children with dermatitis. J Dermatol Sci 23(3):178182
atopic dermatitis suitable for clinical use. J Am Acad 63. Hon KL, Wong KY, Leung TF, Chow CM, Ng PC
Dermatol 50(1):3340 (2008) Comparison of skin hydration evaluation
50. Hon KL, Lam MC, Leung TF, Kam WY, Lee KC, Li sites and correlations among skin hydration, tran-
MC et al (2006) Nocturnal wrist movements are cor- sepidermal water loss, SCORAD index, Nottingham
related with objective clinical scores and plasma eczema severity score, and quality of life in patients
chemokine levels in children with atopic dermatitis. with atopic dermatitis. Am J Clin Dermatol
Br J Dermatol 154(4):629635 9(1):4550
51. Hon KL, Leung TF, Ma K, Li A, Wong Y, Yin JA et al 64. Hon KL, Kam WY, Lam A et al (2006) CDLQI,
(2005) Resting energy expenditure, oxygen consump- SCORAD and NESS: are they correlated? Qual Life
tion and carbon dioxide production during sleep in Res 15:15511558
72 K.L.E. Hon and A.K.C. Leung

65. Hon KL, Ching GK, Leung TF, Choi CY, Lee KK, Ng 81. Cork M (1998) Complete emollient therapy. The
PC (2010) Estimating emollient usage in patients with National Association of Fundholding Practices
eczema. Clin Exp Dermatol 35(1):2226 Official Yearbook, London, pp 159168
66. Holm E, Wulf HC, Stegmann H, Jemec GBE (2006) 82. Cork MJ, Danby S (2009) Skin barrier breakdown: a
Life quality assessment among patients with atopic renaissance in emollient therapy. Br J Nurs 18(14):
eczema. Br J Dermatol 154(4):719725 872877
67. Baumer JH (2008) Atopic eczema in children, NICE. 83. Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J,
Arch Dis Child Educ Pract 93(3):9397 Lane ME, Moustafa M et al (2009) Epidermal barrier
68. Lewis-Jones MS, Finlay AY (1995) The Childrens dysfunction in atopic dermatitis. J Invest Dermatol
Dermatology Life Quality Index (CDLQI): initial 129(8):18921908
validation and practical use. Br J Dermatol 84. Bissonnette R, Maari C, Provost N, Bolduc C, Nigen
132(6):942949 S, Rougier A et al (2010) A double-blind study of tol-
69. Chamlin SL, Cella D, Frieden IJ, Williams ML, erance and efficacy of a new urea-containing moistur-
Mancini AJ, Lai JS et al (2005) Development of the izer in patients with atopic dermatitis. J Cosmet
Childhood Atopic Dermatitis Impact Scale: initial Dermatol 9(1):1621
validation of a quality-of-life measure for young chil- 85. Miller DW, Koch SB, Yentzer BA, Clark AR, ONeill
dren with atopic dermatitis and their families. J Invest JR, Fountain J et al (2011) An over-the-counter mois-
Dermatol 125(6):11061111 turizer is as clinically effective as, and more cost-
70. McKenna SP, Doward LC (2008) Quality of life of effective than, prescription barrier creams in the
children with atopic dermatitis and their families. treatment of children with mild-to-moderate atopic
Curr Opin Allergy Clin Immunol 8(3):228231 dermatitis: a randomized, controlled trial. J Drugs
71. McKenna SP, Whalley D, Dewar AL, Erdman RA, Dermatol 10(5):531537
Kohlmann T, Niero M et al (2005) International devel- 86. Chamlin SL, Frieden IJ, Fowler A, Williams M, Kao
opment of the Parents Index of Quality of Life in J, Sheu M et al (2001) Ceramide-dominant, barrier-
Atopic Dermatitis (PIQoL-AD). Qual Life Res repair lipids improve childhood atopic dermatitis.
14(1):231241 Arch Dermatol 137(8):11101112
72. Meads DM, McKenna SP, Kahler K (2005) The qual- 87. Lodn M, Wirn K, Smerud K, Meland N, Honnas H,
ity of life of parents of children with atopic dermatitis: Mork G et al (2010) Treatment with a barrier-strength-
interpretation of PIQoL-AD scores. Qual Life Res ening moisturizer prevents relapse of hand-eczema.
14(10):22352245 An open, randomized, prospective, parallel group
73. Drake L, Prendergast M, Maher R, Breneman D, study. Acta Derm Venereol 90(6):602606
Korman N, Satoi Y et al (2001) The impact of tacroli- 88. Lodn M, Wirn K, Smerud KT, Meland N, Hnns
mus ointment on health-related quality of life of adult H, Mrk G et al (2011) The effect of a corticosteroid
and pediatric patients with atopic dermatitis. J Am cream and a barrier-strengthening moisturizer in hand
Acad Dermatol 44(1 Suppl):S65S72 eczema. A double-blind, randomized, prospective,
74. Whalley D, Huels J, McKenna SP, van Assche D parallel group clinical trial. J Eur Acad Dermatol
(2002) The benefit of pimecrolimus (Elidel, SDZ ASM Venereol. doi:10.1111/j.1468-3083.2011.04128.x
981) on parents quality of life in the treatment of pedi- 89. Frankel A, Sohn A, Patel RV, Lebwohl M (2011)
atric atopic dermatitis. Pediatrics 110(6):11331136 Bilateral comparison study of pimecrolimus cream
75. Hon KL, Leung T, Wong Y, Li A, Fok T et al (2005) 1% and a ceramide-hyaluronic Acid emollient foam
A survey of bathing and showering practices in chil- in the treatment of patients with atopic dermatitis.
dren with atopic eczema. Clin Exp Dermatol 30(4): J Drugs Dermatol 10(6):666672
351354 90. Grimalt R, Mengeaud V, Cambazard F, Study
76. Chamlin SL, Kao J, Frieden IJ, Sheu MY, Fowler AJ, Investigators Group (2007) The steroid-sparing effect
Fluhr JW et al (2002) Ceramide-dominant barrier of an emollient therapy in infants with atopic dermati-
repair lipids alleviate childhood atopic dermatitis: tis: a randomized controlled study. Dermatology
changes in barrier function provide a sensitive indica- 214(1):6167
tor of disease activity. J Am Acad Dermatol 47(2): 91. Lee J, Jung E, Koh J, Kim YS, Park D (2008) Effect
198208 of rosmarinic acid on atopic dermatitis. J Dermatol
77. Maintz L, Novak N (2007) Getting more and more 35(12):768771
complex: the pathophysiology of atopic eczema. Eur J 92. Draelos ZD (2008) The effect of ceramide-contain-
Dermatol 17(4):267283 ing skin care products on eczema resolution dura-
78. Dohil MA, Eichenfield LF (2005) A treatment tion. Cutis 81(1):8791
approach for atopic dermatitis. Pediatr Ann 34(3): 93. Madaan A (2008) Epiceram for the treatment of
201210 atopic dermatitis. Drugs Today 44(10):751755
79. Lancaster W (2009) Atopic eczema in infants and 94. Boguniewicz M, Zeichner JA, Eichenfield LF, Hebert
children. Community Pract 82(7):3637 AA, Jarratt M, Lucky AW et al (2008) MAS063DP
80. Tarr A, Iheanacho I (2009) Should we use bath emol- is effective monotherapy for mild to moderate atopic
lients for atopic eczema? BMJ 339:b4273 dermatitis in infants and children: a multicenter,
5 Use of Moisturizers in Patients with Atopic Dermatitis 73

randomized, vehicle-controlled study. J Pediatr 99. Mohammed D, Matts PJ, Hadgraft J, Lane ME
152(6):854859 (2011) Influence of aqueous cream BP on corneo-
95. Patrizi A, Capitanio B, Neri I, Giacomini F, Sinagra cyte size, maturity, skin protease activity, protein
JL, Raone B et al (2008) A double-blind, random- content and transepidermal water loss. Br J Dermatol
ized, vehicle-controlled clinical study to evaluate the 164(6):13041310
efficacy and safety of MAS063DP (ATOPICLAIR) 100. Hoare C, Li Wan PA, Williams H (2000) Systematic
in the management of atopic dermatitis in paediatric review of treatments for atopic eczema. Health
patients. Pediatr Allergy Immunol 19(7):619625 Technol Assess (Winchester, England) 4(37):1191
96. Park KY, Kim DH, Jeong MS, Li K, Seo SJ (2010) 101. Raimer SS (2000) Managing pediatric atopic derma-
Changes of antimicrobial peptides and transepider- titis. Clin Pediatr 39(1):114
mal water loss after topical application of tacrolimus 102. Tofte SJ, Hanifin JM (2001) Current management
and ceramide-dominant emollient in patients with and therapy of atopic dermatitis. J Am Acad
atopic dermatitis. J Korean Med Sci 25(5):766771 Dermatol 44(1 (Part 2)):S13S16
97. Hon KL, Wang SS, Lau Z, Lee HC, Lee KK, Leung 103. Fischer G (1996) Compliance problems in paediatric
TF et al (2011) Pseudoceramide for childhood eczema: atopic eczema. Australas J Dermatol 37(Suppl 1):
does it work? Hong Kong Med J 17(2):132136 S10S13
98. Tsang M, Guy RH (2010) Effect of aqueous cream
BP on human stratum corneum in vivo. Br J Dermatol
163(5):954958
 Part II
Skin Essentials
 Sensory Systems of Epidermal
Keratinocytes 6
Mitsuhiro Denda

6.1 Introduction Moreover, we have shown that a variety of

environmental factors, including visible light,
Epidermal keratinocytes have long been recog- sound, and external electrical potential, influence
nized to form the water-impermeable stratum epidermal permeability barrier homeostasis [21,
corneum, and this barrier function is critical, 22, 23, 24, 34]. These results led us to hypothesize
especially for terrestrial animals. However, recent that epidermal keratinocytes might sense these
findings have dramatically changed the picture of environmental factors. Indeed, we found that pho-
epidermal keratinocytes, placing them at the fore- toreceptor proteins, which are expressed in retina,
front of the sensory system [39]. are also expressed in epidermal keratinocytes
The traditional view of the skin surface sen- [107]. In addition, voltage-gated calcium chan-
sory system for environmental factors, such as nels are expressed in keratinocytes [38]. These
temperature and chemical stimuli, has been proteins might be associated with other unknown
focused on C fibers, which penetrate into the epi- sensory systems of epidermal keratinocytes.
dermis. In the case of mechanical stimuli, other Information derived from the environment is
peripheral nerve endings, such as Merkel cells or transferred by afferent nerve fibers to the central
Pacinian capsules or Meissner capsules, were nervous system, and processed in the brain, with
thought to act as sensors in the skin [98]. However, the aid of a series of neurotransmitters and spe-
over the past two decades, it has become apparent cific receptors. We have shown that a variety of
that keratinocytes contain sensory systems for a neurotransmitter receptors, originally found in
variety of environmental factors. Thus, epidermal the central nervous system, are also expressed in
keratinocytes may play a key role in skin surface epidermal keratinocytes [39]. Interestingly, many
perception [39]. This idea has been supported by of them also influenced epidermal permeability
the recent cloning of a series of receptors, which barrier homeostasis. Epidermal keratinocytes also
are activated by temperature, mechanical stress, generate various messenger molecules, such as
osmotic pressure and chemical stimuli, and the neurotransmitters, neuropeptides, and hormones.
subsequent demonstration that at least some of Thus, it is reasonable to consider the possibility
them are expressed in epidermal keratinocytes that epidermal keratinocytes sense environmental
(Fig. 6.1). factors, process the information, and pass mes-
sages to the central nervous system.
In this chapter, I would like to focus on the
various sensory systems of epidermal keratino-
M. Denda, Ph.D.
cytes and to discuss the potential role of the epi-
Shiseido Research Center,
Yokohama, Japan dermis as the border between the living system
e-mail: [email protected] and the environment.

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 77

DOI 10.1007/978-3-642-27606-4_6, Springer-Verlag Berlin Heidelberg 2012
78 M. Denda

Fig. 6.1 Schematic Traditional View New View

illustration of the hypotheti-
cal skin surface sensory a b
system. (a) Traditional view,
with C fibers at the forefront Keratinocytes
of the sensory system. sense
(b) Proposed new view, with Information
epidermal keratinocytes at Epidermis processing
the forefront of the sensory
system. A signal is sensed by
keratinocytes, processed, and C-fibers
transferred to C-fiber sense
terminals (Arranged from
figure by Sakura Kogeisha
Co. Ltd)
Dermis

Nerve C-Terminal

6.2 Humidity dermis [3] in a dry environment. Hosoi et al. dem-

onstrated that the allergic response was enhanced
Seasonal changes affect the condition of normal by low environmental humidity [55]. These stud-
skin and may trigger various cutaneous disorders ies provide evidence that changes in environmental
[96, 119]. Abundant indirect evidence indicates that humidity contribute to the seasonal exacerbations/
decreased humidity precipitates these disorders, amelioration of cutaneous disorders, such as atopic
whereas, in contrast, increased skin hydration dermatitis and psoriasis, which are characterized
appears to ameliorate these conditions. However, by a defective barrier, epidermal hyperplasia, and
the mechanisms by which alterations in relative inflammation (Table 6.1).
humidity might influence cutaneous function and The signaling system through which environ-
induce cutaneous pathology are poorly understood. mental humidity influences epidermal homeosta-
We have evaluated the effects of low environ- sis is not yet clear. We previously demonstrated
mental humidity on skin pathology [18]. We first that calcium propagation plays a crucial role in
demonstrated that low humidity stimulates epider- epidermal homeostasis when the epidermis is
mal DNA synthesis and amplifies the hyperprolif- exposed to a dry environment [45]. We further
erative response to barrier disruption [28]. Stratum showed that calcium propagation was induced
corneum morphology was also influenced by a dry by air exposure of cultured human keratinocytes
environment [27, 94], and abnormal desquamation [20]. A transient increase of intracellular calcium
was observed under low humidity [93]. When ani- concentration appeared, followed by a wave-like
mals were kept in a dry condition for more than increase in adjacent unexposed keratinocytes,
1 week, the barrier function was enhanced [27]. showing oscillations with a frequency that varied
On the other hand, a drastic decrease of environ- from cell to cell. The increase of calcium concen-
mental humidity induced barrier abnormality [95], tration did not appear when calcium was removed
and a decrease in the water retention capacity of from the medium or when suramin, a purinergic
the stratum corneum [67]. Ashida et al. demon- receptor antagonist, was added. The ATP concen-
strated an increase of IL-1a in the epidermis [4] tration also increased immediately after keratino-
and an increase of histamine and mast cells in the cytes were exposed to air. Thus, we speculated that
6 Sensory Systems of Epidermal Keratinocytes 79

ATP is secreted from keratinocytes on exposure to potential (TRP) family. These polymodal receptors
air and induces an increase of intracellular cal- were discovered mainly in the nervous system,
cium concentration. Calcium propagation and where some of them act as sensors of tempera-
ATP secretion in epidermal keratinocytes might be ture or other physical or chemical factors [43].
associated with the signaling system of epidermis However, various thermosensitive TRP receptors
in response to environmental low humidity [109]. were found to be expressed in epidermal kerati-
The sensor of the environment humidity was nocytes [25] (Table 6.2). We first discovered the
not identified. But, as discussed below, TRPV4 expression and function of TRPV1 (VR1) in epi-
(transient receptor potential subtype V4) is acti- dermal keratinocytes [33, 61]. TPRV1 is activated
vated by osmotic pressure and so might serve as by heat (>43C), acidic conditions (pH < 6.6), and
a sensor of environmental humidity. capsaicin [13, 104]. Subsequently, expression of
TRPV3 and TRPV4 in keratinocytes was also
reported [14, 91]. TRPV3 is activated by heat
6.3 Transient Receptor Potential (around 30C) mechanical stress, camphor, and
(TRP) Family 2-aminoethoxydiphenyl borate. TRPV4 is acti-
vated by heat (around 30C), osmotic pressure,
In the last decade, a series of receptors, which and 4a-phorbol 12,13-didecanone (4a-PDD)
are activated at defined temperatures, have been [56, 103, 121].
cloned. They were named the transient receptor Previous studies have also identified cold-
sensitive proteins, TRPA1 and TRPM8, that are
activated by low temperature (<22C) in periph-
Table 6.1 Effects of dry environment (low humidity) on
skin pathophysiology eral nerve cells [90, 102]. Recently, expression
of TRPA1, which is activated by low temperature
Amplification of hyperproliferative response to barrier
disruption [28] (<17C), was also found in epidermal cells [6].
Abnormal desquamation of the stratum corneum [93] We demonstrated that exposure of cultured human
Elevation of DNA synthesis in basal layer of the keratinocytes to low temperature induced elevation
epidermis [92] of intracellular calcium [108]: as the temperature
Enhancement of barrier function [27] of the medium was reduced, elevation of intra-
Appearance of abnormal skin surface morphology [94] cellular calcium was observed at 1722C. The
Amplification of allergic reaction [55] extent of elevation was greater in nondifferenti-
Elevation of IL-1a mRNA and protein [4] ated cells than in differentiated cells. Application
Amplification of proliferative response induced by of ruthenium red (a nonselective TRP blocker)
surfactant [19]
and HC030031 (a specific antagonist of TRPA1)
Decrease of water-holding capacity and free amino acid
content in stratum corneum [67, 94] reduced the elevation. These results suggested that
Abrupt decrease in environmental humidity induces TRPA1 serves as a functional cold-sensitive cal-
abnormalities in barrier homeostasis [95] cium channel in human epidermal keratinocytes.
Alteration of calcium distribution in epidermis [45] We also established that TRPM8 was expressed in
Increase of mast cell number and histamine content in epidermal keratinocytes, by means of immunohis-
dermis [3] tochemical study and RT-PCR [41].

Table 6.2 Thermosensitive transient receptor potential proteins expressed in keratinocytes

Name Activator (s) References
TRPV1 >43C, low pH (<6.6), capsaicin, etc. [33, 61]
TRPV2 >52C [111]
TRPV3 > around 30C, camphor, eugenol, etc. [90]
TRPV4 > around 30C, osmotic pressure, mechanical stimuli, etc. [14]
TRPA1 <17C, allyl isothiocyanate, cinnamaldehyde, etc. [6, 108]
TRPM8 <22C, menthol, etc. [41]
80 M. Denda

Previously, we had found that calcium We next examined the effect of topical
dynamics was associated with epidermal perme- application of TRPM8 modulators on epidermal
ability barrier homeostasis [35]. The thermosen- permeability barrier homeostasis [41]. Topical
sitive TRPs described above are cation-permeable application of TRPM8 agonists, menthol and
channels. Thus, we hypothesized that activation WS12, accelerated barrier recovery after tape
of these TRPs might influence barrier homeosta- stripping. The effect of WS12 was blocked by a
sis. To evaluate the influence of these receptors nonselective TRP antagonist, ruthenium red, and a
on the barrier homeostasis, we kept both hairless TRPM8-specific antagonist, BTCT. Topical appli-
mouse skin and human skin at various tempera- cation of WS12 also reduced epidermal prolifera-
tures immediately after tape stripping. At tem- tion associated with barrier disruption under low
peratures from 36C to 40C, the barrier recovery humidity, and this effect was blocked by BTCT.
was accelerated in both cases compared with that Our results indicate that TRPM8 or a closely
at 34C. At 34C or 42C, the barrier recovery related protein in epidermal keratinocytes plays a
was delayed. Topical application of 4aPDD, a role in epidermal permeability barrier homeostasis
specific agonist of TRPV4, accelerated the bar- and epidermal proliferation after barrier insult.
rier recovery, while ruthenium red, a blocker of It has long been recognized that peripheral
TRPV4, delayed the barrier recovery. Capsaicin, nerve fibers play a major role in cutaneous ther-
an activator of TRPV1, delayed the barrier recov- mosensation. However, as described above, multi-
ery, while capsazepine, an antagonist of TRPV1, ple thermosensitive TRP receptors are expressed
blocked this delay. 2-Aminoethoxydiphenyl in epidermal keratinocytes. Thus, keratinocytes
borate and camphor, TRPV3 activators, did not may be the main thermosensory cells for detecting
affect the barrier recovery rate. Since TRPV4 is skin surface temperature. Moreover, some of the
activated at about 35C and above, while TRPV1 receptors were associated with epidermal permea-
is activated at about 42C and above, these bility homeostasis. Other studies also indicated
results suggest that TRPV1 and TRPV4 both that TRPs were related to keratinocyte differentia-
play important roles in skin permeability barrier tion, proliferation, and inflammation [25]. The
homeostasis. Previous reports suggest the exis- TRP family might play an important role not only
tence of a water flux sensor in the epidermis, and as a thermosensory system but also in the pathol-
as TRPV4 is known to be activated by osmotic ogy and physiology of the epidermis.
pressure, our results indicate that it might be this
sensor [40].
We also examined the effects of topical appli-
cation of agonists of TRPA1 and brief cold expo- 6.4 Mechanical Stress
sure on the barrier recovery rate after barrier
disruption [42]. Topical application of a TRPA1 The traditional view of tactile perception has been
agonist, allyl isothiocyanate or cinnamaldehyde, that the key sensors are the peripheral nerve end-
accelerated the barrier recovery after tape strip- ings and fibers [118]. However, the terminals of
ping. The effect of both agonists was blocked by the nerve fibers are quite sparse. For example, the
HC030031, an antagonist of TRPA1. Brief expo- pressure points, which detect mechanical stimuli,
sure (1 min) to cold (1015C) also accelerated the are localized at distances of millimeters from each
barrier recovery, and this acceleration was also other [98]. The skin can detect pattern on a much
blocked by HC030031. Electron-microscopic smaller scale [64, 85, 113, 114] than would be
studies indicated that brief cold exposure acceler- expected on the basis of sampling theory if the
ated lamellar body secretion between stratum cor- nerve terminals were the only sensors [76].
neum and stratum granulosum, while pretreatment We recently demonstrated that female finger-
with HC030031 inhibited the secretion. These tip can recognize micron-level randomness as
results suggest that TRPA1 is associated with epi- unpleasant [81]. We studied the ability of the
dermal permeability barrier homeostasis. human fingertip to distinguish three different
6 Sensory Systems of Epidermal Keratinocytes 81

micron-level patterns (which were not distin- sensory system. To further examine this idea, we
guishable with the naked eye) on plastic plates. investigated the intracellular calcium responses
There were two ordered patterns of 1 10 mm and of cultured keratinocytes to external hydraulic
3 30 mm ripples, and one random pattern (ran- pressure [51]. First, we compared the responses
domly mixed 1 10 mm and 3 30 mm ripples). of undifferentiated and differentiated keratino-
All 10 female subjects reported the random pat- cytes with those of fibroblasts, vascular endothe-
tern, but not the regular patterns, as unpleasant, lial cells, and lymphatic endothelial cells.
while the majority of the male subjects did not. Elevation of intracellular calcium was observed
Nine out of ten female subjects continued to after application of pressure to keratinocytes,
report the random pattern as unpleasant even fibroblasts, and vascular endothelial cells. The
after their fingertip had been coated with a collo- calcium propagation extended over a larger area
dion membrane. The frictional coefficients of the and continued for a longer period of time in dif-
three patterns did not differ greatly. The mecha- ferentiated keratinocytes, as compared with the
nism of the recognition of ordered and disordered other cells. The response of the keratinocytes was
patterns is unknown. Yamada et al. reported a dramatically reduced when the cells were incu-
model of artificial finger skin having ridges [123] bated in medium without calcium. Application of
and presented a simulation of shear strain distri- a nonselective TRP (transient receptor potential)
bution inside the ridges. The principal component channel blocker, ruthenium red, also attenuated
of the shear strain was concentrated in a smaller the calcium response. These results suggest that
area than the ridges. There are Merkel terminals differentiated keratinocytes are sensitive to exter-
at the bottom of the epidermis. With the aid of the nal pressure and that TRP might be involved in
ridges, finger skin could detect pattern at a scale the mechanism of their response.
smaller than the separation distance of the We also evaluated the mechanism of cal-
C-terminals. In our study, however, almost all of cium propagation induced by mechanical stress
the females could detect the disordered pattern [112]. Before differentiation, mechanical stress
even when the ridges were covered with a collo- induced a calcium wave over a limited area, and
dion film. This result implied that the apprecia- this was completely blocked by apyrase, which
tion of fine surface structure in humans cannot be degrades ATP. In the case of differentiated kera-
explained only in terms of the mechanoreceptors tinocytes, the calcium wave propagated over a
beneath the fingerprint structure, but must involve larger area, and application of apyrase did not
some additional mechanism. completely inhibit the wave. Thus, in differen-
In our study, we did not define the velocity of tiated cells, induction of calcium waves might
fingertip stroking. All subjects stroked a 10-cm involve not only ATP but also another factor.
pattern for 0.51.0 s per stroke. In the whole Immunohistochemical study indicated that con-
10-cm pattern, 10,000 ripples of 10 mm exist, so nexins 26 and 43, both components of gap junc-
stroking the 1 10 mm pattern might generate a tions, were expressed in the cell membrane of
1020-kHz vibration, while the 3 30 mm pattern differentiated keratinocytes. Application of
might generate a 3.36.7-kHz vibration. Pacinian octanol or carbenxolone, which blocks gap junc-
corpuscles in the dermis can recognize up to kilo- tions, significantly reduced calcium wave propa-
hertz-order vibration [116], but it is not yet well gation in differentiated keratinocytes. These
known whether they can distinguish ordered and results suggest that signaling via gap junctions
random vibrations. A system that is able to rec- might be involved in the induction of calcium
ognize randomness might require highly sophis- waves in response to mechanical stress at the
ticated information processing. upper layer of the epidermis.
Among the TRP family members, some were If epidermal keratinocytes act as a sensory
reported to act as sensors of mechanical stress system for external mechanical stress, the signal
[43]. Thus, we hypothesized that epidermal should be transferred to the peripheral nerve sys-
keratinocytes might contribute to the skin tactile tem. Several reports have demonstrated indirect
82 M. Denda

a b c

Keratinocytes

Stimulus

Nerve fibers

Fig. 6.2 Calcium imaging of keratinocytes and DRG-cell calcium propagation in keratinocyte aggregates and nerve
co-culture system. (a) Image of keratinocyte aggregates fibers (arrows). (c) Image of the same area in the presence
before mechanical stimulation. (b) Immediately after of apyrase before mechanical stimulation (arrowheads)
mechanical stimulation. Mechanical stimulation induced [110]

or direct communication between keratinocytes In our study [81], female subjects readily
and nerve cells. Koizumi and his coworkers dem- recognized a random pattern as unpleasant in the
onstrated that mechanical stimulation of cultured absence of other information, and so it appears
keratinocytes induced calcium waves, and the that the micron-level random pattern provided a
calcium propagation was also transferred to co- specific signal to the skin, and this signal affected
cultured nerve cells [72]. In their study, they indi- emotional judgment, i.e., pleasant or unpleasant.
cated that ATP, which is secreted from Thus, invisible tactile patterns could influence
keratinocytes, played a crucial role in the signal human emotion in daily life. This might be con-
transmission, because the calcium propagation sistent with Damasios idea that the human mind
was completely blocked by the application of is generated by interaction between brain and
apyrase, an enzyme that degrades ATP. On the body physiology [17]. Epidermal keratinocytes
other hand, we recently demonstrated that the might play an important role as a skin tactile sen-
calcium wave, which was induced in differenti- sory system, which could influence our emotional
ated keratinocytes, resulted in elevation of intrac- state at the subconscious level.
ellular calcium in co-cultured nerve cells, and the
signal transmission was not completely blocked
by apyrase (Fig. 6.2) [110]. Huang and his
coworkers demonstrated that prostaglandin E2 6.5 Sound
played an important role in the signal transmis-
sion between keratinocytes and nerve cells [58]. The frequency range of audible acoustic sound
These results suggested that a variety of factors for adult humans is approximately 2016,000 Hz
might indirectly or directly mediate signal trans- [54]. However, Oohashi and his coworkers dem-
mission between keratinocytes and the peripheral onstrated that ultrasound at a frequency above
nerve system. 20,000 Hz (20 kHz) influences human brain elec-
The series of study described above suggested trical activity and systemic hormonal levels
that each keratinocyte in the epidermis could [69, 87, 88, 122]. Interestingly, these effects did
contribute to tactile perception. That is, each cell not occur via the ears [88]. On the other hand, a
might serve as a sensor for mechanical stress, and recent study demonstrated that a slight, inaudible
so the potential resolution of tactile sensation air puff on the skin influenced auditory percep-
might reach cellular dimensions, i.e., micrometer tion [50]. These findings suggested that an
order. This speculation could account for the unknown system that is responsive to ultrasound
observed tactile resolution of human skin. exists at the human body surface. Based on the
6 Sensory Systems of Epidermal Keratinocytes 83

above findings, we speculated that audible or are generated and secreted by keratinocytes [34,
inaudible sound frequencies might influence 49, 59]. Thus, sound might be sensed by keratino-
epidermal barrier homeostasis. cytes, and the signals might be processed and then
To test this idea, we first evaluated the effects transferred to the nervous system directly or via
of 5, 10, 20, and 30 kHz sound on intact skin of neurotransmitters. Inaudible sound might be
hairless mice [24]. We disrupted the permeability sensed by epidermal keratinocytes and influence
barrier by tape stripping and immediately exposed the endocrine system or emotional state.
the skin to sound for 1 h. The speaker cone lightly
touched one side of the flank, and we attached a
silent speaker cone to the other flank as a control.
Application of sound at a frequency of 10, 20, or 6.6 Visible Light
30 kHz accelerated the barrier recovery, while
5 kHz sound had no effect. The effects on barrier The effects of ultraviolet or infrared radiation on
recovery were observed 23 h after cessation of skin are well known, but only a few reports
the sound application. describe the effect of visible light.
To determine whether the effect was induced We previously demonstrated that visible light
by sound or skin vibration, we next placed the influenced the epidermal barrier recovery rate
speaker 1 or 3 cm away from the skin surface. In after disruption [21]. The effects of visible light
this case too, significant acceleration of the bar- on epidermal permeability barrier recovery were
rier recovery by sound was observed. The sound evaluated by using light-emitting diodes as light
pressure levels were as follows: 0 cm, 83 dB; sources. The flank skin of hairless mice was tape-
1 cm, 78 dB; and 3 cm, 70 dB. stripped and immediately exposed to blue (430
We also evaluated the effect of different sound 510 nm), green (490560 nm), red (550670 nm),
pressures on the barrier recovery rate. The sound or white (400670 nm) light (20 W each) for 1 h,
source was placed 1 cm away from the skin sur- followed by measurement of transepidermal
face, and the frequency was 20 kHz. The barrier water loss. Control mice were kept in a dark box
recovery rate increased with increasing sound during the experiments. During the irradiation,
pressure. An electron-microscopic study indicated the skin surface temperature was kept constant at
that exposure to sound at a frequency of 20 kHz 37C in all mice. Irradiation with red light sig-
accelerated lamellar body secretion between stra- nificantly accelerated the barrier recovery, while
tum corneum (SC) and stratum granulosum (SG) irradiation with blue light delayed it, compared
Oohashi and his coworkers demonstrated that with the control. White or green light did not
inaudible sound was sensed at the body surface, affect the barrier recovery rate. We next carried
excluding the ears, and influenced brain electrical out a study using hairless mouse skin organ cul-
activity [88], but the mechanism involved is still ture. The permeability barrier was disrupted by
unknown. Feldmann has suggested that a struc- means of acetone treatment, then each section
ture in human eccrine gland has the ability to was incubated afloat on the medium (37C) and
detect very high frequency (gigahertz) sound [46]. irradiated with blue, red, or white light (20 w) for
However, we used hairless mice, which do not 1 h. Immediately after the end of irradiation, we
have eccrine glands, and much lower frequency evaluated the barrier function. Again, red light
sound. Another study demonstrated that human accelerated the barrier recovery, while blue
epidermis had a piezoelectric sensory system [5]. delayed it. An electron-microscopic study sug-
As described above, individual keratinocytes gested that red light accelerated lamellar body
showed elevation of intracellular calcium eleva- secretion, while blue light blocked it. These
tion in response to external mechanical stress [51, results indicate that visible radiation affects skin
112]. Thus, they could sense sound, an oscillating barrier homeostasis. That is, epidermal keratino-
mechanical stress. Moreover, several neurotrans- cytes appear to have a sensory system for visible
mitters, such as ATP, dopamine, and nitric oxide, radiation.
84 M. Denda

Rhodopsin is a well-known photosensitive photoreceptors were found in pineal body of

protein found in rod cells of the retina and detects chicken and rat [86, 125]. However, in humans,
light/dark contrast. Cone opsins are also photo- the pineal body is located in a deeper area of the
sensitive receptors in the cone cells of the retina brain. On the other hand, exposure to bright light
and detect color. We carried out immunochemi- was shown to influence the circadian rhythm of
cal studies using antirhodopsin and antiopsin blind patients [16]. This result suggested the
antibodies on human skin [107]. Both mouse existence of a photosensitive system on the sur-
retina and human epidermis showed clear immu- face of the human body. Thus, visible light might
noreactivity with each antibody. Interestingly, influence endocrinological condition via photo-
immunoreactivity against longer-wavelength receptor proteins and the energy transduction
opsin antibody was observed in the basal layer of system in epidermal keratinocytes.
the epidermis, while immunoreactivity against
rhodopsin and shorter-wavelength opsin was
observed in the upper layer. PCR analysis con-
firmed the expression of rhodopsin- and opsin- 6.7 Electrical Potential
like genes in both human retina and skin. These
results suggest that a series of proteins, which Nishimura demonstrated that cultured human
play a crucial role in visual perception, are keratinocytes migrate to the negative pole in
expressed in human epidermis. direct-current electrical fields [84]. This result
In retina, transducin and phosphodiesterase 6 suggested that keratinocytes might have a sen-
play key roles in signal transmission. Thus, we sory system for the external electrical field. Thus,
hypothesized that these proteins might exist in epi- we hypothesized that external electrical potential
dermal keratinocytes and be associated with barrier would influence epidermal barrier homeostasis.
homeostasis. Immunohistochemical studies and We applied negative and positive electrical poten-
reverse transcription-PCR assays confirmed the tial (0.5 V) to the hairless mice flank skin imme-
expression of both transducin and phosphodi- diately after barrier disruption for 1 h and
esterase 6 in epidermal keratinocytes [52]. Topical evaluated barrier recovery by the measurement of
application of 3-isobutyl-1-methylxanthine, a non- transepidermal water loss. At the area where neg-
specific phosphodiesterase inhibitor, blocked the ative potential was applied, the barrier recovery
acceleration of the barrier recovery by red light. rate was significantly accelerated, while the
Topical application of zaprinast, a specific inhibitor recovery was delayed at the area where positive
of phosphodiesterases 5 and 6, also blocked the potential was applied [22].
acceleration, while T0156, a specific inhibitor of Subsequently, we demonstrated that several
phosphodiesterase 5, had no effect. Red-light expo- interfacial electrical conditions also affect bar-
sure reduced the epidermal hyperplasia induced by rier homeostasis. For example, topical applica-
barrier disruption under low humidity, and the tion of barium sulfate or aqueous solution of ionic
effect was blocked by pretreatment with zaprinast. polymers formed an electrical double layer on
These results indicate that phosphodiesterase 6 is the skin surface and affected the barrier recovery
involved in the recovery-accelerating effect of red rate [37, 48]. Moreover, the barrier recovery was
light on the disrupted epidermal permeability bar- accelerated just by placing metals on the skin sur-
rier and that epidermal keratinocytes have a similar face after barrier disruption, presumably because
energy conversion system to the retina. free electrons were supplied from metal to the skin
In our studies described above, we focused surface [23]. When chemically different materials
only on the effect of visible light on epidermal are in contact, electrochemical phenomena, such
barrier homeostasis. However, several other as formation of an electrical double layer, would
reports have described nonvisual photorecep- be induced. We previously demonstrated that
tors. Reptiles have photoreceptors in the brain, voltage-gated calcium channels are expressed in
and they form the parietal eye [99]. Several the upper layer of the epidermis [38]. Thus, when
6 Sensory Systems of Epidermal Keratinocytes 85

the skin touches other materials, physiological epidermis disappears in aged skin [36, 47] and in
phenomena might be induced. experimentally induced dry skin [48, 68]. We
The mechanism through which skin surface recently demonstrated that aging and surfactant
electrical potential influences epidermal permea- treatment also influence skin surface electrical
bility barrier homeostasis was not clarified. potential [71]. The skin surface electrical potential
However, one of the important steps of the barrier was significantly increased after sodium dodecyl
recovery is the phase transition of the lipid bilayer sulfate treatment, and the alteration was much more
when the lamellar bodies fuse with the cell mem- marked than that of transepidermal water loss
brane. The electrical field at the surface of the (TEWL). Further, a significant difference in skin
skin might affect the phase transition. surface electrical potential was observed between
On the other hand, skin surface electrical young and aged volunteers, whereas there was no
potential is considered to reflect the pathophysio- significant difference in TEWL between the two
logical condition of the epidermis [70]. Skin sur- groups. These results are all consistent with the
face electrical potential has long been recognized idea that skin surface electrical potential may be a
as a parameter of emotional state [82], and it was good indicator of the pathophysiological state of
believed that sweat glands generated the poten- the living layer of epidermis.
tial [115]. However, Baker et al. reported that not
only sweat glands but also epidermis produced the
potential [7]. Moreover, we observed skin surface
electrical potential in a hairless skin organ cul- 6.8 Oxygen
ture, which does not have any sweat glands [32],
and we showed that the potential was influenced Keratinocytes express proteins that influence the
by modulators of ion pumps and channels [32]. level of erythropoietin synthesis. Hypoxia-
These results indicated that ion dynamics in the inducible factor (HIF) recognizes the level of oxy-
epidermis generates the skin surface potential. gen, and when the level of oxygen is decreased,
Maintenance of an ion gradient, especially of erythropoietin synthesis is increased. Von Hippal
calcium, is strongly associated with epidermal Lindau factor (VHL) perturbs the function of HIF.
homeostasis [45]. The concentration of calcium is Keratinocyte-specific HIF knockout mice have a
highest in the uppermost region of the epidermis decreased level of erythropoietin in the blood,
(the epidermal granular layer) in healthy normal while VHL knockout mice have an increased level
skin, and the gradient disappears immediately after of erythropoietin in the blood [10]. Thus, the level
barrier disruption in mice and humans [30, 78]. of erythropoietin, i.e., the number of red blood
Abnormal calcium gradients in the epidermis have cells in the blood, is influenced not only by respi-
been observed in a variety of skin diseases [47]. ration but also by the oxygen level at the surface
Thus, we hypothesized that skin surface electrical of the skin. Another study confirmed that kerati-
potential might be a good indicator of calcium gra- nocytes synthesize erythropoietin [97].
dation in the epidermis. In healthy skin, calcium Thus, epidermal keratinocytes might sense the
ions were localized in the uppermost epidermis, environmental concentration of oxygen and be
and the calcium gradient disappeared upon tape involved in appropriately modulating the number
stripping. Skin surface potential also disappeared of red blood cells in the blood.
after tape stripping. Moreover, environmental
humidity affected the potential, whereas temporary
hydration of the stratum corneum had no effect.
These results suggest that the skin surface electrical 6.9 Endogenous Factors
potential may be an indicator of the pathophysiol-
ogy of the living layer of epidermis, and thus may Epidermal keratinocytes are also influenced by
be useful as a new parameter to evaluate skin con- endogenous factors, such as hormones. Previously,
dition [70]. Further, the calcium gradient in the we demonstrated that emotional stress delayed
86 M. Denda

epidermal permeability barrier recovery after was activated by menthol [90], and TRPA1 was
disruption [29, 31]. In that study, we also demon- activated by allyl isothiocyanate and cinnamalde-
strated that glucocorticoid in the serum plays an hyde [8, 65]. TRPA1 was also activated by acidic-
important role as a mediator of emotional stress. ity and alkalinity [44].
Another stress hormone, testosterone, delayed We previously demonstrated that a variety of
the barrier recovery [66]. We also demonstrated neurotransmitter receptors, originally found in
that topical application of sex hormones influenced the nervous system, are expressed in epidermal
barrier homeostasis [105]. Application of androgen keratinocytes [39]. Several amino acids, e.g., glu-
(testosterone or androsterone) delayed the barrier tamate, glycine, serine, and alanine, are agonists
recovery, and the delay was overcome by applica- of these receptors. That is, keratinocytes can sense
tion of beta-estradiol. Progesterone also delayed amino acids.
the barrier recovery, but in this case, the delay was
enhanced by beta-estradiol. These results indicated
that epidermal keratinocytes might have sensory
systems that respond to hormones. 6.11 Pain and Itching
As described above, skin surface electrical
potential is influenced by emotional condition Recently, many reports have suggested that TRP
[82]. Thus, we hypothesized that signals from the family members might be strongly associated
brain or peripheral nervous system might affect with pain and/or itching. In particular, TRPV1
the skin surface potential. To test this idea, we and TRPA1 have attracted attention as potential
evaluated the skin surface electric potential of target of pain relief strategies [89]. As described
cultured skin of hairless mouse [32] and demon- above, TRPV1 was activated by heat, low pH, and
strated that application of substance P and corti- capsaicin [103]. That study was carried out with
cotropin-releasing factor influenced the potential. nerve cells, but epidermal keratinocytes also have
These results suggested that hormones from the these receptors (Fig. 6.3). For example, activation
brain and/or peptides from the nervous system of TRPV1 by the agonist capsaicin induced dose-
might be sensed by epidermal keratinocytes. dependent increases of cyclooxygenase-2, inter-
The epidermis is the interface between the leukin-8, and prostaglandin 2 expression in HaCaT
environment and body systems, and since epider-
mal keratinocytes can sense not only environmen-
tal factors but also endogenous factors, they may
broadly responsive to, and reflective of, our whole
body physiology and emotional condition.

TRPV 1
6.10 Chemical Stimuli

As described above, many TRPs are activated by

chemical stimuli. TRPV1 is activated by protons
(pH < 5.4) and capsaicin [104]. TRPV3 in epider-
mal keratinocytes is activated by oregano, thyme,
P2X3
and clove-derived flavor components, such as car-
vacrol, eugenol, and thymol [121]. Interestingly,
TRPV3 in epidermal keratinocytes is activated by Fig. 6.3 Expressions of pain receptors in human
epidermis. TRPV1 is strongly expressed in the uppermost
camphor, whereas TRPV3 in sensory neurons is
and basal layers of the epidermis. P2X3 is strongly
not [80]. Thus, TRPV3 in epidermal keratinocytes expressed in the upper area of the epidermis (Denda
might be a sensor of these herbal extracts. TRPM8 2001c) [34]
6 Sensory Systems of Epidermal Keratinocytes 87

keratinocytes, and these increases were blocked by Gly573 in the TRPV3 gene is associated with
capsazepine, a specific antagonist of TRPV1 [100]. defective hair growth and dermatitis in mice [2].
Matrix metalloproteinase-1 (MMP-1) induces col- It has been speculated that TRPV3Gly573Ser mutation
lagen degradation and inflammatory responses. is a cause of pruritus and dermatitis [124].
Activation of TRPV1 by heat induced MMP-1 We reported that topical application of unsatu-
mRNA and protein in a temperature-dependent rated fatty acid induced abnormal keratinocyte
manner in human keratinocytes [75]. This response differentiation and barrier dysfunction [68]. We
was blocked by capsazepine. Moreover, knock- also found that application of unsaturated fatty
down of TRPV1 decreased MMP-1 expression acid to cultured human keratinocytes induced
in keratinocytes. Thus, TRPV1 might be associ- elevation of intracellular calcium. Hu et al.
ated with skin inflammatory responses. Ultraviolet showed that elevation of intracellular calcium
(UV) radiation appears to induce the expression of was induced by unsaturated fatty acids in TRPV3-
TRPV1 in human epidermal keratinocytes [73]; expressing oocytes [57]. TRPV3 might be associ-
acute UV radiation increased TRPV1 in human ated with abnormal keratinization induced by
skin, and moreover, TRPV1 expression in sun- unsaturated fatty acids, such as comedogenesis.
exposed skin was significantly higher than that in Another interesting receptor was also found in
sun-protected skin. They also demonstrated that epidermal keratinocytes. In the nervous system,
UV radiation induced matrix metalloproteinase-1 two distinct families of ATP receptors exist [11].
in cultured HaCaT cells [74]. One is the P2X family, the members of which are
TRPA1 was activated by low temperature and ligand-gated ion channels, and the other is the P2Y
by a variety of pungent chemicals such as isothio- family of metabotropic, heptahelical G-protein-
cyanate (present in horseradish and mustard), alli- coupled receptors. P2X3 was first demonstrated as
cin (present in garlic), and bradykinin [8, 65, 77]. a pain receptor in the peripheral nervous system
Moreover, TRPA1 mediated aldehyde-evoked [15]. In the case of tissue injury, ATP is released
pain [9, 79]. Although these studies carried out in and activates P2X3 receptors. Thus, P2X3 was first
nerve cells, we recently demonstrated that appli- recognized as a pain receptor in the case of inflam-
cation of isothiocyanate and cinnamaldehyde in mation. We found that P2X3 is expressed in human
cultured human keratinocytes induced elevation epidermal keratinocytes (Fig. 6.2). The expression
of intracellular calcium [108]. Thus, epidermal of P2X3 was greater in the upper area of the epider-
keratinocytes might be associated with pain mis. We demonstrated that P2X3 was produced at
induced by pungent compounds. the terminal differentiation state in a keratinocyte
Previous study demonstrated that there was a culture system [62]. Thus, at the uppermost layer of
significant difference in brain processing of his- the epidermis, P2X3 might play an important role
tamine-induced itch between patients with atopic as a mediator of pain or itching induced by ATP
dermatitis and healthy subjects [63]. The result secreted from inflammatory tissue.
suggested that brain activity of acute itch in atopic Recent work suggested that protease-activated
dermatitis might be different from in healthy sub- receptors in peripheral nerves might be associ-
ject. Recent study demonstrated that TRPA1 and ated with itching [1]. On the other hand, another
mas-related G-protein-coupled receptor were study demonstrated that protease-activated recep-
associated with histamine-independent itch [120]. tor 2 was expressed in epidermal keratinocytes
Studies of these receptors would be necessary for and was associated with permeability barrier
the understanding of histamine-independent itch homeostasis [53]. We previously demonstrated
such as acute itch of atopic dermatitis. that topical application of a serine-type protease
Steinhoff and Biro suggested that TRPV3 might inhibitor accelerated barrier recovery and also
play an important role in itching [101]. A previous prevented epidermal hyperplasia induced by
study had suggested that TRPV3 was involved in repeated barrier disruption [26]. Modulation of
inflammatory responses, pain, and itching sensa- proteases in the epidermis might be another tar-
tion [124]. Asakawa et al. showed that mutation at get to treat itching or sensitive skin.
88 M. Denda

As described above, a variety of receptors, 6.13 Multilayered Organization

considered to be mediators of pain or itching, of Epidermal Keratinocytes
are expressed in epidermal keratinocytes. Thus,
epidermal keratinocytes might be strongly As mentioned above, differentiated keratinocytes
associated with unpleasant skin sensations, were more sensitive to mechanical stimuli [51].
and further research on such receptors in kera- Moreover, cell-cell connection via gap junctions
tinocytes might be important for clinical was more marked at the upper layer of the epi-
dermatology. dermis [112]. On the other hand, sensitivity to
ATP, an important second messenger in the epi-
dermis, was higher in undifferentiated keratino-
cytes in the culture system and at the bottom
6.12 Peripheral Circulation layer of the epidermis in skin slices [106]. Those
results suggested that the superficial layer of the
We recently demonstrated that epidermal kerati- epidermis is a good sensor of external mechani-
nocytes influence the peripheral circulation [60]. cal stimuli, while signals such as ATP released
The source of nitric oxide (NO) in the cutaneous from the upper layer of the epidermis are sensed
circulation remains controversial. We have more efficiently at the bottom layer of the epi-
found that barrier disruption induced NO secre- dermis, where peripheral nerve endings are
tion from epidermis [59]. Thus, we hypothesized located.
that epidermal cells might generate NO in As regards low temperature, undifferentiated
response to mechanical stimulation [60]. In keratinocytes were more sensitive to cold than
hairless mouse skin organ culture, mechanical differentiated cells [108]. On the other hand,
stimulation resulted in NO release, which there was no significant difference between the
declined within 30 min after cessation of stimu- responses of undifferentiated and differentiated
lation. Similar NO release occurred from a keratinocytes to high temperature [111]. These
reconstructed skin model containing only kera- results indicate that, although the superficial layer
tinocytes and fibroblasts and was suppressed of the epidermis might be less sensitive to low
after detachment of the epidermal layer. temperature than the deeper layer, the response to
Moreover, the stimulation-induced NO release high temperature is homogeneous throughout the
was significantly lower in skin organ culture of epidermis. TRPV1 is activated not only by high
neuronal NO synthase knockout (nNOS-KO) temperature but also by low pH or chemical stim-
mice, compared with wild-type (WT) mice. uli, such as capsaicin [13, 104]. Thus, TRPV1
Mechanical stimulation of skin organ cultures might function throughout the epidermis as a
of HR-1, nNOS-KO, endothelial NOS-KO multimodal sensor. On the other hand, TRPA1
(eNOS-KO), and WT mice caused enlargement might be involved in homeostasis of internal
of cutaneous lymphatic vessels. The enlarge- organs, and this would be consistent with local-
ment was significantly lower after detachment ization in a deeper layer of the epidermis.
of the epidermal layer than for normal skin sam- Generally, expression levels of proteins in the
ples and was significantly lower for nNOS-KO upper layer of the epidermis are different from
than for WT mice. Skin blood flow in nNOS-KO those in the bottom layer, i.e., keratinocytes
mice after stimulation was significantly lower express different proteins, or at least different
than in WT mice. eNOS-KO mice also showed levels of proteins, depending on their differentia-
lower responses than WT mice, and the differ- tion state. Thus, epidermis is not a homogeneous
ence was similar to that in the case of nNOS-KO tissue but is a multilayered organ, like the brain.
mice. These results are consistent with the idea One of its functions is to form a water-imperme-
that NO generated by epidermal nNOS plays a able barrier. However, the variation of sensitivity
significant role in the cutaneous circulatory to external or endogenous factors with depth in
response to mechanical stimulation. the epidermis suggests that the multilayer
6 Sensory Systems of Epidermal Keratinocytes 89

Fig. 6.4 Multilayered

organization of epidermal
keratinocytes. The uppermost
layer of the epidermis might
be more sensitive to
mechanical stimuli than the Sensitive to
deeper layer [51], and there mechanical stimuli
is cell-cell communication
via gap junctions at the upper Cell-cell
layer of the epidermis [112]. communication
via gap junctions
On the other hand, the deeper
layer of the epidermis is
more sensitive to ATP than
the upper layer [106]. The
deeper layer of the epidermis
might be more sensitive to
cold than the upper layer
[108] (Arranged from figure
by Sakura Kogeisha Co. Ltd)
Sensitive to ATP

Sensitive to cold

structure would provide a sophisticated and flex- Although the meaning and role of these processes
ible sensory system (Fig. 6.4). in keratinocytes remain to be fully clarified, the
epidermis seems to have the potential for high-
level information processing.
6.14 Potential Sensory Functions Epidermal keratinocytes also generate a vari-
of Epidermal Keratinocytes ety of neurotransmitters, neuropeptides, and hor-
mones. It has been long recognized that many of
As described above, epidermal keratinocytes have these molecules are produced in the brain. For
a variety of sensory systems for environmental example, a recent study indicated that the neuro-
factors. Thus, they might play an important role in peptide hormone oxytocin influences human
regulating whole body homeostasis in a constantly emotion [83]. Originally, oxytocin was thought
changing environment, especially considering to be generated in the hypophysis cerebri.
that they cover the whole body. Moreover, epider- However, we recently discovered that epidermal
mal keratinocytes are constantly being renewed. keratinocytes also generate oxytocin (Denda,
That is, their sensory systems might be well main- unpublished data). Thus, stimulation of the epi-
tained at consistent levels of sensitivity. dermis, e.g., massage, might induce oxytocin
Epidermal keratinocytes also have a series of release and influence human emotional state.
neurotransmitter receptors, which play a crucial Cortisol is well known as a stress hormone
role in information processing in the brain and and plays an important role in suppression of
nervous systems [39]. In the brain, information the immune system. It has been long recognized
processing is carried out via excitation and inhi- that cortisol is produced by the adrenal gland.
bition processes. Similar processes have also Under stress conditions, corticotropin-releasing
been observed in epidermal keratinocytes [49]. hormone is released from hypothalamus and
90 M. Denda

induces secretion of adrenocorticotropic hormone

(ACTH). However, it was recently demonstrated Photoreceptor proteins (rhodopsin and
that epidermal keratinocytes also produce corti- opsin) and energy-transfer proteins
sol [117]. Tissue injury and IL-1beta secretion (transducin and phosphodiesterase 6),
trigger cortisol generation in the epidermis. Thus, which are expressed in retina, are also
epidermal injury might induce the same physio- expressed in keratinocytes and appear to
logical response as emotional stress. influence epidermal barrier homeostasis.
The functions of the brain include information Epidermal barrier homeostasis is influ-
sensing, processing, and regulation of the whole enced by sound in the 1030 kHz range.
body system via neuropeptides and hormones. External electrical potential and materi-
On the other hand, epidermal keratinocytes have als that produce an electrical double
a variety of sensory systems, neurotransmitter layer influence barrier homeostasis.
receptors, and the ability to generate Epidermal keratinocytes are involved in
neurotransmitters, neuropeptides, and hormones. peripheral circulation and red blood cell
Thus, one could consider that the epidermis is an generation.
extension of the brain to the surface of our body. Epidermal barrier homeostasis is influ-
Life is a nonequilibrium, open system. At the enced by several sex hormones.
border between the living body and the environ- Itching or skin sensitivity may be caused
ment, energy flow and information flow are con- by interaction between keratinocytes
trolled to maintain homeostatic processes [12] and the peripheral nervous system.
and to maintain high-order architecture and func-
tion in the body. For multicellular animals, the
skin, and in particular the epidermis, forms the
boundary of the body. Therefore, it seems to be a
reasonable hypothesis that epidermal keratino-
cytes contain a variety of sensory systems that
References
can respond to the ever-changing environment, 1. Akiyama T, Carstens MI, Carstens E (2010) Enhanced
and that the resulting information would be pro- scratching evoked by PAR-2 agonist and 5-HT but not
cessed in the epidermis via a series of neurotrans- histamine in a mouse model of chronic dry skin itch.
mitters and receptors, and passed to the brain and Pain 151:378383
2. Asakawa M, Yoshioka T, Matsutani T et al (2006)
central nervous system to contribute to whole Association of a mutation in TRPV3 with defective hair
body homeostasis and modulation of emotional growth in rodents. J Invest Dermatol 126:26642672
state. Indeed, there is accumulating evidence that 3. Ashida Y, Denda M (2003) Dry environment increases
this is the case. It seems likely that further mast cell number and histamine content in dermis in
hairless mice. Br J Dermatol 149:240247
research will continue to extend the range of 4. Ashida Y, Ogo M, Denda M (2001) Epidermal IL-1
sensory and functional capabilities of epidermal alpha generation is amplified at low humidities: impli-
keratinocytes and the skin. cations for the pathogenesis of inflammatory derma-
toses. Br J Dermatol 144:238243
5. Athenstaedt H, Claussen H, Schaper D (1982)
Epidermis of human skin: pyroelectric and piezoelec-
Take Home Messages tric sensor layer. Science 216:10181020
Epidermal keratinocytes express a series 6. Atoyan R, Shander D, Botchkarvera NV (2009) Non-
of thermo-activated receptors, called the neural expression of transient receptor potential type
A1 (TRPA1) in human skin. J Invest Dermatol
transient receptor potential (TRP) family.
129:23122315
The TRP proteins in epidermal keratino- 7. Baker AT, Jaffe LE, Vanable JW (1982) The glabrous
cytes may serve as sensors not only of epidermis of cavies confaius a powerful battery. Am J
environmental temperature but also of Physiol 242:R358R366
8. Bandell M, Story GM, Hwang SW, Viswanath V, Eid
humidity, mechanical stress, and chemi-
SR, Petrus MJ, Earley TJ, Patapoutian A (2004)
cal stimuli. Noxious cold ion channel TRPA1 is activated by pun-
gent compounds and bradykinin. Neuron 41:849857
6 Sensory Systems of Epidermal Keratinocytes 91

9. Bang S, Kim KY, Yoo S, Kim YG, Hwang SW (2007) 25. Denda M, Tsutsumi M (2011) Roles of transient
Transient receptor potential A1 mediates acetalde- receptor potential proteins (TRPs) in epidermal kera-
hyde-evoked pain sensation. Eur J Neurosci 26: tinocytes. In: Islam MS (ed) Transient receptor poten-
25162523 tial channels. Advances in experimental medicine and
10. Boutin AT, Weidemann A, Fu Z, Mesropian L, Gradin biology, vol 704. Springer, Berlin, pp 847860
K, Jamora C, Wiesener M, Eckardt KU, Koch CJ, 26. Denda M, Kitamura K, Elias PM, Feingold KR (1997)
Ellies LG, Haddad G, Haase VH, Simon MC, Trans-4-(aminomethyl)cyclohexane carboxylic acid
Poellinger L, Powell FL, Johnson RS (2008) (t-AMCHA), an anti-fibrinolytic agent, accelerates
Epidermal sensing of oxygen is essential for systemic barrier recovery and prevents the epidermal hyperpla-
hypoxic response. Cell 133:223234 sia induced by epidermal injury in hairless mice and
11. Burnstock G, Williams M (2000) P2 purinergic recep- humans. J Invest Dermatol 109:8490
tors: modulation of cell function and therapeutic 27. Denda M, Sato J, Masuda Y, Tsuchiya T, Kuramoto
potential. J Pharmacol Exp Ther 295:862869 M, Elias PM, Feingold KR (1998) Exposure to a dry
12. Camazine S, Deneubourg JL, Franks NR, Sneyd J, environment enhances epidermal permeability barrier
Theraulaz G, Bonabeau E (2001) Characteristics of function. J Invest Dermatol 111:858863
self-organizing systems. In: Anderson PW et al (eds) 28. Denda M, Sato J, Tsuchiya T, Elias PM, Feingold KR
Self-organization in biological systems. Princeton (1998) Low humidity stimulates epidermal DNA syn-
University Press, Princeton, pp 2946 thesis and amplifies the hyperproliferative response to
13. Caterina MJ, Schumacher MA, Tominaga M, Rosen barrier disruption: implication for seasonal exacerba-
TA, Levine JD, Julius D (1997) The capsaicin recep- tions of inflammatory dermatoses. J Invest Dermatol
tor: a heat-activated ion channel in the pain pathway. 111:873878
Nature 389:816824 29. Denda M, Tshuchiya T, Hosoi J, Koyama J (1998)
14. Chung MK, Lee H, Caterina MJ (2003) Warm tem- Immobilization-induced and crowded environment-
peratures activate TRPV4 in mouse 308 keratinocytes. induced stress delay barrier recovery in murine skin.
J Biol Chem 278:3203732046 Br J Dermatol 138:780785
15. Cockayne MJ, Hamilton SG, Zhu QM, Dunn PM, 30. Denda M, Hosoi J, Ashida Y (2000) Visual imaging
Zhone Y, Novakovic S, Malmberg AB, Cain G, Berson of ion distribution in human epidermis. Biochem
A, Kassotakis L, Hedley L, Lachnit WG, Burnstocks Biophys Res Commun 272:134137
G, McMason SB, Ford APDW (2000) Urinary blad- 31. Denda M, Tsuchiya T, Elias PM, Feingold KR (2000)
der hyporeflexia and reduced pain-related behavior in Stress alters cutaneous permeability barrier homeo-
P2X3-deficient mice. Nature 407:10111015 stasis. Am J Physiol 278:R367R372
16. Czeisler CA, Shanahan TL, Klerman EB, Martens H, 32. Denda M, Ashida Y, Inoue K, Kumazawa K (2001)
Brotman DJ, Jonathan SE, Klein T, Rizzo JF (1995) Skin surface electric potential induced by ion-flux
Suppression of melatonin secretion in some blind through epidermal cell layers. Biochem Biophys Res
patients by exposure to bright light. N Eng J Med Commun 284:112117
332:611 33. Denda M, Fuziwara S, Inoue K, Denda S, Akamatsu
17. Damasio AR (1994) The body-minded brain. In: H, Tomitaka A, Matsunaga K (2001) Immunoreactivity
Descartes error. Emotion, reason, and the human of VR1 on epidermal keratinocyte of human skin.
brain. Penguin Putnam, New York, pp 223243 Biochem Biophys Res Commun 285:12501252
18. Denda M (2000) Influence of dry environment on epi- 34. Denda M, Inoue K, Fuziwara S et al (2002) P2X puri-
dermal function. J Dermatol Sci 24(Suppl 1):S22S28 nergic receptor antagonist accelerates skin barrier repair
19. Denda M (2001) Epidermal proliferative response and prevents epidermal hyperplasia induced by skin
induced by sodium dodecyl sulphate varies with envi- barrier disruption. J Invest Dermatol 119:10341040
ronmental humidity. Br J Dermatol 145:252257 35. Denda M, Fuziwara S, Inoue K (2003) Influx of cal-
20. Denda M, Denda S (2007) Air-exposed keratinocytes cium and chloride ions into epidermal keratinocytes
exhibited intracellular oscillation. Skin Res Technol regulates exocytosis of epidermal lamellar bodies and
13:195201 skin permeability barrier homeostasis. J Invest
21. Denda M, Fuziwara S (2008) Visible radiation affects Dermatol 121:362367
epidermal permeability barrier recovery: selective 36. Denda M, Tomitaka M, Akamatsu H, Matsunaga K
effects of red and blue light. J Invest Dermatol (2003) Altered distribution of calcium in facial
128:13351336 epidermis of aged adults. J Invest Dermatol 21:
22. Denda M, Kumazawa N (2002) Negative electric 15571558
potential induces epidermal lamellar body secretion 37. Denda M, Nakanishi K, Kumazawa N (2005) Topical
and accelerates skin barrier recovery after barrier dis- application of ionic polymers affects skin permeabil-
ruption. J Invest Dermatol 118:6572 ity barrier homeostasis. Skin Pharmacol Physiol
23. Denda M, Kumazawa N (2010) Effects of metals on 18:3641
skin permeability barrier recovery. Exp Dermatol 38. Denda M, Fuziwara S, Hibino T (2006) Expression of
19:e124e127 voltage-gated calcium channel subunit C1 in epider-
24. Denda M, Nakatani M (2010) Acceleration of perme- mal keratinocytes and effects of agonist and antago-
ability barrier recovery by exposure of skin to 1030 nists of the channel on skin barrier homeostasis. Exp
kilohertz sound. Br J Dermatol 162:503507 Dermatol 15:455460
92 M. Denda

39. Denda M, Nakatani M, Ikeyama K, Tsutsumi M, Denda 54. Heffner RS (2004) Primate hearing from a mamma-
S (2007) Epidermal keratinocytes as the forefront of lian perspective. Anat Rec A Discov Mol Cell Evol
the sensory system. Exp Dermatol 16:157161 Biol 281:11111122
40. Denda M, Sokabe T, Tominaga T, Tominaga M (2007) 55. Hosoi J, Hariya T, Denda M, Tsuchiya T (2000)
Effects of skin surface temperature on epidermal per- Regulation of the cutaneous allergic reaction by
meability barrier homeostasis. J Invest Dermatol humidity. Contact Dermatitis 42:8184
127:654659 56. Hu HZ, Gu Q, Wang C, Colton CK, Tang J, Kinoshita-
41. Denda M, Tsutsumi M, Denda S (2010) Topical Kawada M, Lee LY, Wood JD, Zhu MX (2004)
application of TRPM8 agonists accelerates skin per- 2-aminoethoxydiphenyl borate is a common activator
meability barrier recovery and reduces epidermal pro- of TRPV1, TRPV2, and TRPV3. J Biol Chem 279:
liferation induced by barrier insult: the role of 3574135748
cold-sensitive TRP receptors in epidermal permeabil- 57. Hu HZ, Xiao R, Wang C et al (2006) Potentiation of
ity barrier homeostasis. Exp Dermatol 19:791795 TRPV3 channel function by unsaturated fatty acids.
42. Denda M, Tsutsumi M, Goto M, Ikeyama K, Denda S J Cell Physiol 208:201212
(2010) Topical application of TRPA1 agonists and 58. Huang SM, Lee H, Chung MK et al (2008) Overexpressed
brief cold exposure accelerate skin permeability bar- transient receptor potential vanilloid 3 ion channels in
rier recovery. J Invest Dermatol 130:19421945 skin keratinocytes modulate pain sensitivity via prosta-
43. Dhaka A, Viswanath V, Patapoutian A (2006) TRP glandin E2. J Neurosci 28:1372713737
ion channels and temperature sensation. Annu Rev 59. Ikeyama K, Fuziwara S, Denda M (2007) Topical
Neurosci 29:135161 application of neuronal nitric oxide synthase inhibitor
44. Dhaka A, Uzzell V, Dubin AE, Mathur J, Petrus M, accelerates cutaneous barrier recovery and prevents
Bandell M, Patapoutian A (2009) TRPV1 is activated epidermal hyperplasia induced by barrier disruption.
by both acidic and basic pH. J Neurosci 29:153158 J Invest Dermatol 127:17131719
45. Elias PM, Ahn SK, Denda M, Brown BE, Crumurine 60. Ikeyama K, Denda S, Tsutsumi M, Denda M (2010)
D, Kinutai LK, Komuves L, Lee SH, Feingold KR Neuronal nitric oxide synthase in epidermis is involved
(2002) Modulations in epidermal calcium regulate the in cutaneous circulatory response to mechanical stim-
expression of differentiation-specific proteins. J Invest ulation. J Invest Dermatol 130:11581166
Dermatol 119:11281136 61. Inoue K, Koizumi S, Fuziwara S, Denda S, Inoue K,
46. Feldman Y, Puzenko A, Ben Ishai P et al (2008) Denda M (2002) Functional vanilloid receptors in cul-
Human skin as arrays of helical antennas in the milli- tured normal human keratinocytes. Biochem Biophys
meter and submillimeter wave range. Phys Rev Lett Res Commun 291:124129
100:128102 62. Inoue K, Denda M, Tozaki H, Fujishita K, Koizumi S,
47. Forslind B, Werner-Linde Y, Lindberg M, Pallon J Inoue K (2005) Characterization of multiple P2X
(1999) Elemental analysis mirrors epidermal differen- receptors in cultured normal human epidermal kerati-
tiation. Acta Derm Venereol 79:1217 nocytes. J Invest Dermatol 124:756763
48. Fuziwara S, Ogawa K, Aso D, Yoshizawa D, Takata S, 63. Ishiuji Y, Coghill RC, Patel TS, Oshiro Y, Kraft RA,
Denda M (2004) Barium sulfate with a negative z Yosipovitch G (2009) Distinct patterns of brain activ-
potential accelerates skin permeable barrier recovery ity evoked by histamine-induced itch reveal an asso-
and prevents epidermal hyperplasia induced by bar- ciation with itch intensity and disease severity in
rier disruption. Br J Dermatol 151:557564 atopic dermatitis. Br J Dermatol 161:10721080
49. Fuziwara S, Suzuki A, Inoue K, Denda M (2005) 64. Johansson RS, Trulsson M, Olsson KA, Westberg
Dopamine D2-like receptor agonists accelerate bar- K-G (1988) Mechanoreceptor activity from the human
rier repair and inhibit the epidermal hyperplasia face and oral mucosa. Exp Brain Res 72:204208
induced by barrier disruption. J Invest Dermatol 65. Jordt SE, Bautista DM, Chuang HH, McKemy DD,
125:783789 Zygmunt PM, Hgesttt ED, Meng ID, Julius D
50. Gick B, Derrick D (2009) Aero-tactile integration in (2004) Mustard oils and cannabinoids excite sensory
speech perception. Nature 462:502504 nerve fibres through the TRP channel ANKTM1.
51. Goto M, Ikeyama K, Tsutsumi M, Denda S, Denda M Nature 427:260265
(2010) Calcium ion propagation in cultured keratino- 66. Kao JS, Garg A, Mao-Qiang M, Crumrine D,
cytes and other cells in skin in response to hydraulic Ghadially R, Feingold KR, Elias PM (2001)
pressure stimulation. J Cell Physiol 224:229233 Testosterone perturbs epidermal permeability barrier
52. Goto M, Ikeyama K, Tsutsumi M, Denda S, Denda M homeostasis. J Invest Dermatol 116:443451
(2011) Phosphodiesterase inhibitors block the accel- 67. Katagiri C, Sato J, Nomura J, Denda M (2003)
eration of skin permeability barrier repair by red light. Changes in environmental humidity affect the water-
Exp Dermatol 20:568571 holding property of the stratum corneum and its free
53. Hachem JP, Houben E, Crumrine D, Man MQ, Schurer amino acid content, and the expression of filaggrin in
N, Roelandt T, Choi EH, Uchida Y, Brown BE, the epidermis of hairless mice. J Dermatol Sci
Feingold KR, Elias PM (2006) Serine protease signal- 31:2935
ing of epidermal permeability barrier homeostasis. 68. Katsuta Y, Iida T, Inomata S et al (2005) Unsaturated
J Invest Dermatol 126:20742086 fatty acids induce calcium influx into keratinocytes
6 Sensory Systems of Epidermal Keratinocytes 93

and cause abnormal differentiation of epidermis. J 83. Neumann ID (2007) Oxytocin: the neuropeptide of
Invest Dermatol 124:10081013 love reveals some of its secrets. Cell Metab
69. Kawai N, Honda M, Nakamura S et al (2001) 5:231233
Catecholamines and opioid peptides increase in plasma 84. Nishimura KY, Isseroff RR, Nuccitelli R (1996)
in humans during possession trances. Neuroreport Human keratinocytes migrate to the negative pole in
12:34193423 direct current electric fields comparable to those
70. Kawai E, Nakanishi J, Kumazawa N, Ozawa K, Denda measured in mammalian wounds. J Cell Sci
M (2008) Skin surface electric potential as an indica- 109:199207
tor of skin condition: a new, non-invasive method to 85. Nordin M (1990) Low threshold mechanoreceptive
evaluate epidermal condition. Exp Dermatol 17: and nociceptive units with unmyelinated (C) fibres in
688692 the human supraorbital nerve. J Physiol 426:
71. Kawai E, Kumazawa N, Ozawa K, Denda M (2011) 229240
Skin surface electrical potential as an indicator of skin 86. Okano T, Yoshizawa T, Fukada Y (1994) Pinopsin is a
condition: observation of surfactant-induced dry skin chicken pineal photoreceptive molecule. Nature
and middle-aged skin. Exp Dermatol 20:757759 372:9497
72. Koizumi S, Fijishita K, Inoue K, Shigemoto-Mogami Y, 87. Oohashi T, Nishina E, Honda M et al (2000) Inaudible
Tsuda M, Inoue K (2004) Ca2+ waves in keratinocytes high-frequency sounds affect brain activity: hyper-
are transmitted to sensory neurons: the involvement of sonic effect. J Neurophysiol 83:35483558
extracellular ATP and P2Y2 receptor activation. 88. Oohashi T, Kawai N, Nishina E et al (2006) The role
Biochem J 380:329338 of biological system other than auditory air-conduc-
73. Lee YM, Kim YK, Chung JH (2009) Increased tion in the emergence of the hypersonic effect. Brain
expression of TRPV1 channel in intrinsically aged Res 10731074:339347
and photoaged human skin in vivo. Exp Dermatol 89. Patapoutian A, Tate S, Woolf CJ (2009) Transient
18:431436 receptor potential channels: targeting pain at the
74. Lee YM, Kim YK, Kim KH et al (2009) A novel role source. Nat Rev Drug Discov 8:5568
for the TRPV1 channel in UV-induced matrix metal- 90. Peier AM, Moqrich A, Hergarden AC et al (2002) A
loproteinase (MMP)-1 expression in HaCaT cells. J trp channel that senses cold stimuli and menthol. Cell
Cell Physiol 219:766775 108:705715
75. Li WH, Lee YM, Kim JY et al (2007) Transient recep- 91. Peier AM, Reeve AJ, Andersson DA, Moqrich A,
tor potential vanilloid-1 mediates heat-shock-induced Earley TJ, Hergarden AC, Story GM, Colley S,
matrix metalloproteinase-1 expression in human Hogenesch JB, McIntyre P, Bevan S, Patapoutian A
epidermal keratinocytes. J Invest Dermatol 127: (2002) A heat-sensitive TRP channel expressed in
23282335 keratinocytes. Science 296:20462049
76. Loomis JM, Collins CC (1978) Sensitivity to shifts of 92. Sato J, Denda M, Ashida Y, Koyama J (1998) Loss of
a point stimulus; an instance of tactile hyperacuity. water from the stratum corneum induces epidermal
Percept Psychophys 24:487492 DNA synthesis in hairless mice. Arch Dermatol Res
77. Macpherson LJ, Geierstanger BH, Viswanath V, 290:634637
Bandell M, Eid SR, Hwang S, Patapoutian A (2005) 93. Sato J, Denda M, Nakanishi J (1998) Dry condition
The pungency of garlic: activation of TRPA1 and affects desquamation of stratum corneum in vivo.
TRPV1 in response to allicin. Curr Biol 15:929934 J Dermatol Sci 18:163169
78. Mauro T, Bench G, Sidderas-Haddad E et al (1998) 94. Sato J, Yanai M, Hirao T, Denda M (2000) Water con-
Acute barrier perturbation abolishes the Ca2+ and K+ tent and thickness of stratum corneum contribute to
gradients in murine epidermis: quantitative measure- skin surface morphology. Arch Dermatol Res
ment using PIXE. J Invest Dermatol 111:11981201 292:412417
79. McNamara CR, Mandel-Brehm J, Bautista DM, 95. Sato J, Denda M, Chang S, Elias PM, Feingold KR
Siemens J, Deranian KL, Zhao M, Hayward NJ, (2002) Abrupt decreases in environmental humidity
Chong JA, Julius D, Moran MM, Fanger CM (2007) induce abnormalities in permeability barrier homeo-
TRPA1 mediates formalin-induced pain. Proc Natl stasis. J Invest Dermatol 119:900904
Acad Sci USA 104:1352513530 96. Sauer GC, Hall JC (1996) Seasonal skin diseases. In:
80. Moqrich A, Hwang SW, Earley TJ et al (2005) Sauer GC, Hall JC (eds) Manual of skin diseases.
Impaired thermosensation in mice lacking TRPV3, a Lippincott-Raven, Philadelphia, pp 2328
heat and camphor sensor in the skin. Science 97. Scheidemann F, Lser M, Niedermeier A,
307:14681472 Kromminga A, Therrien JP, Vogel J, Pftzner W
81. Nakatani M, Kawasoe T, Denda M (2011) Sex differ- (2008) The skin as a biofactory for systemic secre-
ence in human fingertip recognition of micron-level tion of erythropoietin: potential of genetically modi-
randomness as unpleasant. Int J Cosmet Sci 33: fied keratinocytes and fibroblasts. Exp Dermatol
346350 17:481488
82. Neuman E, Blanton R (1970) The early history 98. Shephered GM (1994) The somatic senses. In:
of electrodermal research. Psychophysiology 6: Shephered GM (ed) Neurobiology. Oxford University
453475 Press, Oxford, pp 265293
94 M. Denda

99. Solessio E, Engbretson GA (1993) Antagonistic 113. Vallbo A, Olausson H, Wessberg J, Norrsell UA
chromatic mechanisms in photoreceptors of the pari- (1993) System of unmyelinated afferents for innocu-
etal eye of lizards. Nature 364:442445 ous mechanoreception in the human skin. Brain Res
100. Southall MD, Li T, Gharibova LS et al (2003) 628:301304
Activation of epidermal vanilloid receptor-1 induces 114. Vallbo AB, Olausson H, Wessberg J (1999)
release of proinflammatory mediators in human Unmyelinated afferents constitute a second system
keratinocytes. J Pharmacol Exp Ther 304:217222 coding tactile stimuli of the human hairy skin.
101. Steinhoff M, Br T (2009) A TR(I)P to pruritus J Neurophysiol 81:27532763
research: role of TRPV3 in inflammation and itch. 115. Venables PH, Martin I (1967) The relation of palmar
J Invest Dermatol 129:531535 sweat gland activity to level of skin potential and
102. Story GM, Peier AM, Reeve AJ et al (2003) conductance. Psychophysiology 3:302311
ANKTM1, a TRP-like channel expressed in nocice- 116. Verrillo RT (1979) Change in vibrotactile thresholds
ptive neurons, is activated by cold temperatures. Cell as a function of age. Sens Processes 3:4959
112:819829 117. Vukelic S, Stojadinovic O, Pastar I, Rabach M,
103. Tominaga M, Caterina MJ (2004) Thermosensation Krzyzanowska A, Lebrun E, Davis SC, Resnik S,
and pain. J Neurobiol 61:312 Brem H, Tomic-Canic M (2011) Cortisol synthesis
104. Tominaga M, Caterina MJ, Malmberg AB, Rosen TA, in epidermis is induced by IL-1 and tissue injury.
Gilbert H, Skinner K, Raumann BE, Basbaum AI, Julius J Biol Chem 286:1026510275
D (1998) The cloned capsaicin receptor integrates mul- 118. Wang L, Hillinges M, Jernberg T, Wiegleb-Edstrom
tiple pain-producing stimuli. Neuron 21:531543 D, Johansson O (1990) Protein gene product
105. Tsutsumi M, Denda M (2007) Paradoxical effects of 9.5-immunoreactive nerve fibres and cells in human
beta-estradiol on epidermal permeability barrier skin. Cell Tissue Res 261:2533
homeostasis. Br J Dermatol 157:776779 119. Wilkinson JD, Rycroft RJ (1992) Contact dermatitis.
106. Tsutsumi M, Denda S, Inoue K, Ikeyama K, Denda In: Burton JL, Ebling FJG (eds) Champion relative
M (2009) Calcium ion gradients and dynamics in cul- humidity, 5th edn, Textbook of dermatology. Blackwell
tured skin slices of rat hind-paw in response to stimu- Scientific Publications, Oxford, pp 614615
lation with ATP. J Invest Dermatol 129:584589 120. Wilson SR, Gerhold KA, Bifolck-Fisher A, Liu Q,
107. Tsutsumi M, Ikeyama K, Denda S, Nakanishi J, Patel KN, Dong X, Bautista DM (2011) TRPA1 is
Fuziwara S, Aoki H, Denda M (2009) Expressions required for histamine-independent. Mas-related G
of rod and cone photoreceptor-like proteins in human protein-coupled receptor-mediated itch. Nat Neurosci
epidermis. Exp Dermatol 18:567570 14:595602
108. Tsutsumi M, Denda S, Ikeyama K, Goto M, Denda 121. Xu H, Delling M, Jun JC et al (2006) Oregano,
M (2010) Exposure to low temperature induces ele- thyme and clove-derived flavors and skin sensitizers
vation of intracellular calcium in cultured human activate specific TRP channels. Nat Neurosci
keratinocytes. J Invest Dermatol 130:19451948 9:628635
109. Tsutsumi M, Kitahata H, Nakata S, Sanno Y, 122. Yagi R, Nishina E, Honda M et al (2003) Modulatory
Nagayama M, Denda M (2010) Mathematical analy- effect of inaudible high-frequency sounds on human
sis of intercellular calcium propagation induced by acoustic perception. Neurosci Lett 351:191195
ATP. Skin Res Technol 16:146150 123. Yamada D, Maeno T, Yamada Y (2002) Artificial
110. Tsutsumi M, Goto M, Denda S, Denda M (2011) finger skin having ridges and distributed tactile sen-
Morphological and functional differences in co-cul- sors used for grasp force control. J Robot
ture system of keratinocytes and dorsal root gan- Mechatronics 14:140146
glion-derived cells depending on time of seeding. 124. Yoshioka T, Imura K, Asakawa M et al (2009)
Exp Dermatol 20:464467 Impact of the Gly573Ser substitution in TRPV3 on
111. Tsutsumi M, Kumamoto J, Denda M (2011) the development of allergic and pruritic dermatitis in
Intracellular calcium response to high temperature is mice. J Invest Dermatol 129:714722
similar in undifferentiated and differentiated cultured 125. Zhao X, Haeseleer F, Fariss RN, Huang J, Baehr W,
human keratinocytes. Exp Dermatol 20:839840 Milam AH, Palczewski K (1997) Molecular cloning
112. Tsutusmi M, Inoue K, Denda S, Ikeyama K, Goto M, and localization of rhodopsin kinase in the mamma-
Denda M (2009) Mechanical-stimulation-evoked lian pineal. Vis Neurosci 14:225232
calcium waves in proliferating and differentiated
human keratinocytes. Cell Tissue Res 338:99106
 Sensitive Skin: Intrinsic
and Extrinsic Contributors 7
Miranda A. Farage and Michael K. Robinson

7.1 Introduction This phenomenon, originally believed to be an

abnormal response to common products afflicting
Manufacturers of moisturizers and emollients only a small minority of product users, was termed
conduct extensive premarket testing to confirm sensitive skin, a term defined at that time, as any
product efficacy and safety, including the poten- unpleasant sensory reaction to cosmetics, soaps,
tial for these products to irritate the skin. Such lotions, toiletries, or other products upon contact
goals represent a significant challenge, as with skin [2]. Although mild and transient physi-
todays consumers are a global audience with cal signs (e.g., erythema, dryness, wheals, or scal-
substantial variability in gender, age, ethnicity, ing) [35] could occasionally accompany the
skin type, living environments, and cultural adverse sensory response, more often, the sensa-
habits. Testing is performed, therefore, with a tions occurred in the absence of any visible signs
wide variety of test subjects and conditions to of irritation [6]. The problem of sensitive skin was
ensure skin compatibility for all consumers. therefore viewed with skepticism by many derma-
Despite rigorous premarket safety testing, how- tologists and labeled early on as a princess and
ever, some consumers consistently report unpre- the pea phenomenon, exacerbated by ubiquitous
dicted and unpleasant sensory effects related to advertising and modern culture and without any
product use. These purely sensory perceptions, real physiological origin [7].
furthermore, influence product sales: 78% of Epidemiological investigations worldwide,
consumers who experience these transient sen- however, observe a substantial and steadily
sory effects report avoiding some products increasing prevalence of sensitive skin in the
because of the negative sensations evoked [1]. industrialized world (Table 7.1). Currently, the
majority of women surveyed believe that they
have sensitive skin. The finding of a very similar
prevalence in women in two studies on separate
continents (69% in the USA [11] compared to
M.A. Farage, Ph.D. ()
64% in Greece [16]) suggests a genuine physio-
Clinical Sciences, The Procter & Gamble Company,
Winton Hill Business Center, logical disorder. Although the etiology of the dis-
6110 Center Hill Rd, P.O. Box 136, order is still murky, and meaningful diagnostic
Cincinnati, OH 45224, USA tests remain elusive, continuing research is begin-
e-mail: [email protected]
ning to unravel the physiological basis of this
M.K. Robinson, Ph.D. widespread phenomenon. Sensitive skin is now
Global Biotechnology Division,
largely recognized as a genuine dermatological
Miami Valley Innovation Center,
11810 East Miami River Road, condition, one of physiological origin [17] and
Cincinnati, Ohio 45252-1038, USA long duration. A survey of 1,039 subjects found

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 95

DOI 10.1007/978-3-642-27606-4_7, Springer-Verlag Berlin Heidelberg 2012
96 M.A. Farage and M.K. Robinson

Table 7.1 Prevalence of sensitive skin perception in women in the industrialized world
Percentage of
women who
Population claimed sensitive
Population(s) studied characteristics Definition of sensitive skin skin References
Japan, USA, Europe 15,000 men and Unusual skin reactivity to 50% (25% very [8]
(1992) questionnaire women specific insult sensitive skin)
France (2000) 319 women Cutaneous discomfort in the 90% (23% very [9]
interview absence of clinical and histologic sensitive skin)
evidence of skin lesions
England (2001) 3,300 women Intolerance to cosmetics 51% (6% very [10]
questionnaire and toiletries, including both sensitive skin)
sensory and visible signs
USA (San Francisco) 800 women Sensitive facial skin 52% [1]
(2002) interview
USA (Cincinnati) 869 women Sensitive skin 69% [11]
(2009) questionnaire
France (2008) 18 women Sensitive skin 50% [12]
questionnaire
France (2008) 400 women Sensitive skin 85% [13]
questionnaire
France (2005) 1,006 men and Sensitive skin 59% [14]
questionnaire women
France (2006) 5,074 women Sensitive skin 61% [15]
questionnaire
Greece (2008) 25 women Sensitive skin 64% [16]
questionnaire

that 53% of those who self-reported sensitive Other irritants employed have included
skin claimed duration of more than 5 years [18]. dimethyl sulfoxide (DMSO), benzoic acid, trans-
In the quest to understand the physiological cinnamic acid, acetic acid, octanoic acid, decanol,
mechanisms behind sensitive skin, testing has sodium dodecyl sulfate (SDS), and vasodilators
involved three basic endpoints of chemical expo- and many others of commercial interest [24].
sure: neurosensory response (sensory reactivity Mechanical irritation methods evaluate irrita-
tests), visible cutaneous signs of irritation (irri- tion from products like paper or tissue products.
tant reactivity tests), and structural and physio- All forms of irritant reactivity testing often rely
logical changes in the skin as indicators of irritant on exaggerated exposure testing to achieve chem-
effect (dermal function tests) [19] (Table 7.2). ical or product differentiation. Dermal function
Sensory reactivity tests focus on the neurosen- tests measure structural or physiological changes
sory response to a known irritant; most popularly in the skin that can be associated with the neuro-
lactic acid (although capsaicin, ethanol, menthol, sensory responses in sensitive skin.
sorbic acid, and benzoic acid have also been Despite a variety of testing strategies, progress
employed) is applied to the skin [21]. in understanding sensitive skin has been ham-
Tape stripping, a procedure that removes the pered by several issues. The condition is, by defi-
stratum corneum, is sometimes performed before nition, based on subjective sensory perceptions,
irritants are applied [22]. Irritant reactivity tests which can be defined as stinging, itching, or burn-
attempt to measure objective signs of irritation ing and which may range from very mild and
following application of a known irritant, most transient to intense. These subjective reports of
commonly sodium lauryl sulfate (SLS), a pri- negative sensations may or may not be accompa-
mary irritant which damages skin by direct cyto- nied by a diverse assortment of objective signs of
toxic action, without prior sensitization [23]. irritation. In addition, no consistent correlation of
 7
Table 7.2 Methodological approaches to understanding sensitive skin
Name Assessment methodology Provocative agent Advantages Disadvantages
Sensory reactivity tests
Surveys Questionnaire Varies by subject Useful for large-scale epidemiological Time-consuming, self-reported data
report studies, no instrumentation required
Stinger test Questionnaire Lactic acida Quick, easy, no instrumentation required Often nonreproducible, not predictive of general
sensitivity, subjective and difficult to quantify
response, not correlatable to objective irritation
Irritant reactivity tests
Visual erythema Visual scoring SLSa Relatively inexpensive, fast, require no Subjective, often not reproducible, not able to
instrumentation correlate with sensory responses
Laser Doppler velocimetry Skin irritation by blood SLSa Noninvasive, objective Requires expensive instrumentation, indirect
flow measure, less sensitive than TEWL, minimally
quantitative, not relevant to irritation by some
agents (NaOH, dithranol)
Color reflectance Colorimeter SLSa Noninvasive, objective, accurate, Requires expensive instrumentation, indirect
reproducible, allows quantitative compari- measure, less sensitive than TEWL
Sensitive Skin: Intrinsic and Extrinsic Contributors

son within and between individuals

TEWL, Irritation by changes Evaporimeter SLSa Biochemical indicator of skin damage, Requires expensive instrumentation, requires
in barrier integrity quantitative stringent conditions, easily confounded by
temperature, humidity, host factors
Electrical capacitance, Corneometer SLSa Quantitative, relatively fast Units arbitrary, difficult to standardize,
irritation by skin hydration confounded by skin surface features and salt
content, little correlation with irritant testing
Structural sensitivity testing
Ultrasound Skin thickness SLSa Quantitative, quick highly accurate, Requires expensive instrumentation
noninvasive, suitable for any anatomical
site
Light microscopy Skin thickness SLSa Quantitative, highly accurate, requires no Labor intensive, invasive, not suitable for any
expensive instrumentation site
Confocal light microscopy Skin thickness SLSa Quantitative, accurate, allows direct Requires specialized expensive instrumentation
measurement on skin, allows assessment
below surface
UV light Skin penetrability SLSa Correlates well with skin sensitivity, Requires specialized expensive instrumentation
permits analysis
Source: Berardesca et al. [20]
NaOH sodium hydroxide, SLS sodium lauryl sulfate, TEWL transepidermal water loss, UV ultraviolet
97

a
Most common
98 M.A. Farage and M.K. Robinson

objective signs of irritation with a persons sub- p = 0.004) or genitals (58.1% vs 41.9%,
jective perceptions has been defined [4, 25, 26]. p = 0.001) than women [17] and were less likely
Many people who profess sensitive skin do not to report changes in sensitivity over time
predictably experience visible signs of the sensa- (p = 0.0263) [18]. Even in populations where
tions reported, while some who describe them- men and women claimed equal prevalence of
selves as nonsensitive react strongly to tests of sensitive skin, men were observed to be much
objective irritation [27]. less likely to consider skin sensitivity in buying
For example, an irritant dose in one study that decisions (67.5% vs 47.2%, p < 0.0001) or to
was observed to cause no perception or sign of look specifically for products that claimed to be
irritation in 99 subjects caused pronounced irrita- safe for sensitive skin (3.7% vs 13.1%,
tion in the hundredth; in another study which p = 0.0006) [17].
tested three irritants in 200 subjects, 197 subjects Many gender-based physiological differences
reacted to at least one of three irritants, yet 3 sub- in skin have the potential to influence skin
jects did not respond at all [28]. sensitivity. Mens and womens skin differs in
In addition, the severity of individual response hormone metabolism, hair growth, sweat rate,
to irritants tested varies tremendously [6], even sebum production, surface pH, fat accumulation
among chemicals with similar modes of action [49], and collagen content [50]; mens skin is
and/or equivalent overall irritancy profiles. thicker [51]. Women, in specimens of skin
Significant variation in response occurs within directly overlying the infraorbital nerve foramen,
the same individual [29] or at different anatomi- were observed to have double the nerve fiber den-
cal sites [23, 30]. sity of men [52]. However, no gender differences
The existence of significant interpersonal and were observed in the integrity of the skin barrier
intrapersonal variation with regard to the percep- or time to recovery after tape stripping [53].
tion of sensitive skin implies that both intrinsic Estrogen also acts to increase skin thickness,
and extrinsic factors play a significant role in the increase collagen production, inhibit collagen
development of skin sensitivity. Numerous intrin- breakdown, decrease sebum production, increase
sic and extrinsic factors affect sensory responses skin hydration, increase vasodilation, increase
[6] (Table 7.3). A substantial body of research elasticity, and decrease cellular immune response
has now evaluated the contributions of both [54]. Many dermatological conditions are affected
intrinsic factors (e.g., gender, age, ethnicity, ana- by estrogen levels [55].
tomical site, concomitant disease) and extrinsic The menstrual cycle represents an additional
(cultural and environmental factors) to the phe- gender-related contributor to sensitive skin.
nomenon of sensitive skin. This chapter will The cyclical variations of progesterone and
review what is currently known with regard to estrogen that define the menstrual cycle repre-
contributors to sensitive skin. sent a major biological influence on the female
body. Estrogen receptors are found on virtually
every tissue in the female body [54], and it is
7.2 Intrinsic Contributors known that fluctuating levels of sex hormones
over the menstrual cycle have the potential to
7.2.1 Gender affect both skin and immune function. Response
to irritants was observed to peak at the begin-
Epidemiological studies across the industrial- ning of the menstrual cycle, when estrogen
ized world consistently find that women self- levels are low [56, 57].
report sensitive skin more often than do men Allergic responses to nickel have been demon-
with reported prevalence ranging from 30% to strated to be significantly more intense during the
64% in men as compared to 5069% in women luteal phase, when estrogen levels are falling
(Table 7.4). Men were less likely to report sen- [58]. Mast cell degranulation is increased around
sitivity specific to the face (31.9% vs 21.4%, the point of ovulation, when estrogen levels are
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 99

Table 7.3 Potential contributors to sensitive skin

Intrinsic factors
Factor Parameter Risk factor References
Genetic Gender Female [10]
Skin pigmentation Light-skinned [31, 32]
Skin type Susceptibility to blushing and/or flushing [10]
Physiologic Age Youth [30]
Hormonal status High estrogen levels (neurosensory pathway), low [3335]
estrogen levels (immunogenic pathway)
Stratum corneum Thin stratum corneum [3, 36]
thickness
Stratum corneum Dehydration [37, 38]
hydration
Stratum corneum Disruption of stratum corneum [3]
integrity High baseline TEWL [23]
Skin components Increased epidermal innervation [39]
Increased number of sweat glands [31]
Increased neutral lipids and decreased sphingolipids [40]
Decreased lipids [41]
Anatomical site Vulvar [35]
Facial [39]
Concomitant Contact allergies [42, 43]
disease Atopic dermatitis [3, 10, 44]
Rosacea [45]
Extrinsic factors
Environmental Weather Cold weather [46]
Warm weather [18, 47]
Wind [1]
Personal products Cosmetics and hygiene products [18]
Fabric and paper Rough fabric [46]
Psychosocial Stress [46]
Marketing and advertising [18, 48]
TEWL transepidermal water loss

Table 7.4 Comparison of prevalence of sensitive skin in men and women in the industrialized world
Population(s) Population Definition of Percentage of subjects
studied characteristics sensitive skin who claimed sensitive skin References
Japan, USA, Europe 15,000 men People whose skin reacts to 50% women [8]
(1992) questionnaire and women particular insults more than 30% men
the majority of people
England (2001) 500 men and Intolerance to cosmetics and 51% women [10]
questionnaire 3,300 women toiletries, including both 38% men
sensory and visible signs
USA (Cincinnati) 1,039 men Sensitive skin 69% women [11]
(2009) questionnaire and women 64% men
France (2005) 1,006 men Sensitive skin 59% women [14]
questionnaire and women 4% men
France (2006) 8,522 men Sensitive skin 61% women [15]
questionnaire and women 32% men
100 M.A. Farage and M.K. Robinson

highest [33]. In general, an increased reactivity to absorption of benzoic acid, caffeine, and acetyl-
antigen is observed in the premenstrual phase, salicylic acid was demonstrated to be higher in
with inhibition of antigen reactivity in the follicu- Asians as compared with Caucasians but lower in
lar phase and at ovulation [59]. Although specific Blacks [31]. Reduced skin penetration in Black
investigations into the effect of fluctuating levels skin is likely responsible for a reduced suscepti-
of estrogen over the menstrual cycle and the per- bility to skin irritants and allergens in Blacks vs
ception of pain have been relatively few and col- Caucasians [80].
lectively nonconclusive, there has been some Sensory and irritant response testing has also
evidence that pain perception may increase in the revealed ethnic differences. Tristimulus colorim-
periovulatory period [34]. eter assessment of skin reflectance showed that
Specific sensory and irritant reactivity tests skin pigmentation was inversely associated with
have been ambiguous. A 2003 facial sting test in susceptibility to irritation, supported by the find-
men and women demonstrated a trend toward ing that irritant susceptibility to SLS is decreased
increased sensitivity in women, but no differ- after ultraviolet B (UVB) exposure (tanning)
ences were observed at any specific facial site [23]. Asians have been reported to complain of
[39, 60]. Although no gender differences were unpleasant sensory responses more often than
observed in one study with respect to reactivity to Caucasians, with higher dropout rates in testing
11 different irritants (including SLS) [30], a com- due to adverse events [31]. Asian subjects can
pilation of results from multiple skin irritation also be shown to respond significantly more vig-
studies demonstrated an increase in reactivity in orously or rapidly to chemical probes; however,
older subjects (significant in some studies) to this is often subtle and not always reproducible
four commonly used irritants in patch testing, from study to study [25, 81, 82].
with male subjects either directionally or signifi- While the overall prevalence of skin sensitiv-
cantly more reactive [25]. ity is similar across skin types and ethnic groups,
recent studies have observed differences with
regard to what causes discomfort and how sensi-
7.2.2 Ethnicity tivity is expressed. Asians had higher sensitivity
to spicy food, and Hispanics had relatively less
Ethnic differences in skin structure and function reactivity to alcohol than Caucasian individuals
are an important consideration in the formulation [1]. Euro-Americans were found to have higher
of moisturizers, cosmetics, and skin hygiene prod- susceptibility to wind relative to other ethnic
ucts, as distinct differences in skin have been asso- groups [1]. Caucasian-Americans were more
ciated with ethnicity and skin coloration (Table 7.5). likely to report visual effects related to product
Most of the large-scale epidemiological surveys of use (19% of subjects), while African-Americans
sensitive skin have either focused on Caucasian (27% of subjects) were more likely to report sen-
skin or failed to address the issue of skin type and sory effects (p = 0.053) [18]. Although the rela-
sensitivity. Two large-scale studies that did investi- tive numbers were inadequate to demonstrate
gate racial differences found no different in self- statistical significance, Hispanics reported sen-
reports of product sensitivity [1, 10]. sory effects much less frequently (5%) than the
Structural differences based on skin color population as a whole (17%); Asians reported
which may influence sensitivity have been sensory effects much more frequently (32% as
observed. Epidermal thickness has been observed compared to 17%) [18]. In addition, African-
to be associated with pigmentation (p = 0.0008) Americans of both genders were more likely to
[79]; Blacks and Asians have higher baseline report sensitivity in the genital area than other
transepidermal water loss (TEWL) values than groups (66.4% of African-Americans vs 52.4%
Caucasians [64], although in another study, no of white Americans (p = 0.0008)) [11, 17],
differences in barrier function between Caucasian although the racial disparity was more pro-
and Asians were observed [31]. Percutaneous nounced in men.
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 101

Table 7.5 Comparison of skin properties in Caucasian and in Black skin

Comparison Skin property References
Higher in Number of cell layers in stratum corneum [61]
Black skin Stratum corneum resistance to stripping [61]
Lipid content in stratum corneum [62]
Electrical resistance of stratum corneum [37]
Desquamation of stratum corneum (twofold) [38]
Variability of structural parameters of stratum corneum [61]
UV protection factor of epidermis (three- to fourfold, 13.4 vs 3.4) [63]
Baseline TEWL [64, 65]
Reactivity to SLS (measured by TEWL) [20]
Lower in Amount of ceramides in stratum corneum [66]
Black skin Spectral remittance (above 300 nm, two- to threefold) [67]
UVB transmission through epidermis fourfold (7.4 vs 29.4) [63]
Stratum corneum UVB transmission (30.0 vs 47.6) [63]
Topical application of anesthetic mixture [68]
In vivo penetration of C-labeled dipyrithione (34% lower) [69]
In vivo penetration of cosmetic vehicle [69]
Methylnicotinate-induced vasodilation [64, 70, 71]
Reactivity to dichlorethylsulfide (1%) (measured by erythema, 15% vs 58%) [72]
Reactivity to 0-chlorobenzylidene malonitrile [73]
Reactivity to dinitrochlorobenzene [74]
Stinging response [75]
No observed Stratum corneum thickness trend toward equalization after removal of stratum [36, 76]
difference corneum
Corneocyte size [38]
In vitro penetration of water [77, 78]
SLS sodium lauryl sulfate, TEWL transepidermal water loss, UV ultraviolet, UVB ultraviolet B

Interesting patterns of specific sensory of the elderly is also characterized by an increase

responses associated with ethnicity also emerged in permeability but reduction in elasticity, tensile
[18]. Caucasian subjects listed weather-related strength, cellularity, and vascularization [83].
factors as a principal irritant, with 25% claiming Clinical assessments of the erythematous
weather sensitivity as compared to only 19% response in older people, however, suggest that
reporting sensitivity to product exposure. Only susceptibility to skin irritation generally decreases
19% of African-Americans, on the other hand, with age, as does the capacity to produce visible
reported weather sensitivity. Although the num- physiological signs of cutaneous irritation [30].
ber of Asians tested was much smaller, 32% A compilation of the results of skin-patch tests
claimed sensory effects to topical products as conducted among older people over a period of
their chief complaint [18]. 4 years demonstrated a trend toward lower reac-
tivity to four common irritants in the elderly as
compared to younger subjects [25, 60]. However,
7.2.3 Age as is common to sensitive skin complaints, no
correlation was observed between the severity of
Dramatic changes in the structure and functional a visual response after exposure to an irritant
capacity of skin occur with age that would pre- showed and the subjects perceptions of skin sen-
sumably predispose the skin toward an increased sitivity [25, 60]. In a large Italian study that per-
susceptibility to irritation. The skin becomes thin- formed lactic-acid sting tests on more than 100
ner, drier, and replaces itself more slowly. The skin elderly subjects, the intensity of the stinging
102 M.A. Farage and M.K. Robinson

response was inversely proportional to age [84]. The structure and physiology of the skin do
In fact, elderly subjects were also shown by dif- differ among body sites. Structurally, the stratum
ferent authors to have decreased cutaneous inner- corneum is thickest on the palms and soles and
vation as well as sensory nerve function [85]. thinnest in the region of the genitalia [87].
Epidemiological studies, however, have found Replacement of the stratum corneum is faster on
that older subjects who experience skin sensitiv- the face than in other anatomical regions [26].
ity report that their sensitivity has increased over Surprisingly large variations in skin sensitivity
time [18, 46]. A study of sensory perceptions of have been observed associated with specific ana-
sensitive skin conducted on 1,039 individuals in tomical sites, most notably, a patch test using
Ohio, USA, stratified subjects into four age SLS which tested the irritant on identical loca-
groups (subjects under 30, subjects in their 30s, tions on both arms and found differences in irri-
subjects in their 40s, and those over 50) and found tant response on the respective limbs in 47% of
that those in the over-50 group were more likely the subjects tested [23].
to claim sensitive skin than younger adults and Most sensory reactivity testing has focused on
more likely to perceive genital skin (to the exclu- the facial skin. Marriott et al. evaluated different
sion of other body sites) to be more sensitive areas of the face to determine which regions
[46]. Men older than 50 years of age, however, experienced the greatest stinging response to the
were less likely to report general skin sensitivity application of lactic acid as an irritant. Ten per-
than younger males, making the gender-associ- cent lactic acid was applied to the nasolabial fold,
ated difference in the prevalence of sensitive skin forehead, chin, and cheek of 45 volunteers under
highest in older people, with 78.6% of women both occluded and nonoccluded conditions for
over 50 reporting general skin sensitivity as com- 8 min. The nasolabial fold was observed to be the
pared to only 52.9% of men. Sensitivity of geni- most sensitive region of the facial area, followed
tal skin was also reported at significantly lower by the malar eminence, chin, forehead, and upper
proportions in younger men (less than 40) than in lip, respectively [39]. Subjects who experienced
women [17]. Additionally, it was observed that stinging on the nasolabial fold did not necessarily
older subjects who claimed skin sensitivity were experience stinging in other areas [39]. Green
more likely to have medically diagnosed skin observed order of magnitude differences in sen-
allergies than younger subjects and more likely to sory reactivity of the face and forearm to capsai-
name hot weather and use of antiperspirants as a cin and methanol, with face being much more
contributing factor to sensitive skin; younger susceptible [88].
individuals were more likely to name cold SLS-sensitivity testing found that sensitivity
weather and stress as triggers [46]. increased from the wrist to the cubital fossa area
[23]. Interestingly, although a study performed in
women with preexisting dermatologist-identified
7.2.4 Anatomic Site vulvar irritation found no increased genital sensi-
tivity to sanitary pads as compared to normal
An epidemiological study which surveyed 1,039 controls, women with vulvar erythema did report
people with regard to perceptions of sensitive increased facial erythema with the use of cosmet-
skin in general and at specific body sites (face, ics, reflecting possibly the higher visibility of
body, and genital area) found that, while overall facial skin [89].
68.4% of the subjects questioned claimed general Besne et al. evaluated the effect of age and
skin sensitivity, 77.3% felt that their facial skin anatomical site with regard to the density of sen-
was sensitive, 60.7% claimed sensitivity of the sory innervation in the epidermis using biopsy
trunk or limbs, and 56.3% claimed genital sensi- samples from 82 patients ranging in age from 20
tivity [11]. In a representative study of a French to 93. Specimens were taken from either the face
population, 44.2% reported experiencing skin (upper eyelid and preauricular areas) or the abdo-
sensitivity of the scalp [86]. men and mammary areas. Facial specimens had
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 103

significantly increased epidermal innervation Atopic dermatitis (AD) was implicated early
than did the truncal areas evaluated, with highest on as a potential contributor to skin sensitivity
density of epidermal nerve fibers occurring on [10]. The density of cutaneous nerves has been
the upper eyelid [85]. demonstrated to be higher in atopic skin than in
Genital skin differs from exposed skin in being normal skin [45], and an association has been
dramatically thinner [87] and to varying degrees made between AD and positive response to the
nonkeratinized and occluded. These differences sting test [3]. Also, baseline TEWL in uninvolved
may make the genital area in women more per- skin in AD patients, which is higher than that of
meable than exposed keratinized skin [2]. normal subjects, was shown to predict suscepti-
There have been reported differences with bility to irritants in other sites [44].
regard to race and its influence on the perception An initial study compared women with clini-
of sensitive skin in the genital area. African- cally diagnosed AD to a group of women with
Americans report the sensitivity of genital skin at other dermatological diseases and found that
a higher frequency than do Caucasian-Americans, atopic individuals were significantly more likely
a difference more pronounced in men [17, 90]. to describe their skin as very or moderately sensi-
However, younger men report genital skin sensi- tive, describing weather-related factors, rough
tivity much less frequently than older men [17]. It fabric, personal-hygiene products, laundry prod-
was also observed that women are more likely to ucts, perfumes, and stress as significant triggers.
report an increase in the sensitivity of the genital A statistical association was observed between
skin as they age than are their male counterparts, clinically diagnosed atopic dermatitis and self-
(p = 0.12) [46]. perceived skin sensitivity. Atopy was also associ-
ated with genital sensitivity to hygiene pads.
Patients with AD were also significantly more
7.2.5 Sensitive Skin and Concomitant likely to report family history of sensitive skin,
Disease (p = 0.004). Interestingly, 48% of patients with
AD reported that their sensitive skin had been
Several research groups have found an associa- present as long as they could remember, a
tion between sensitive skin and atopy and allergy. response absent completely from the control
Individuals with contact allergies have higher group. Of the AD patients, 80% said that the sen-
rates of skin sensitivity, implying the possibility sitive skin had been present all of their adult life,
of an underlying immune component; similar while only 20% of non-AD subjects reported that
cytokines have been found in the development of long of a duration [16].
skin irritation and contact allergy [42]. In a study Recently, our research group administered a
in the Midwest USA, 1,039 subjects who claimed nine-item skin questionnaire on self-perceived
skin sensitivity were demonstrated to be signifi- skin sensitivity to two groups of dermatological
cantly more likely (five times more likely) to patients: one with clinically diagnosed AD and
have medically diagnosed skin allergies as well. one with unrelated dermatological complaints
In addition, those who claimed sensitive skin (25 subjects in each group). We observed an asso-
were 3.5 times more likely to report a family ciation between AD and sensitive skin in that
member that also had sensitive skin, implying a self-perceived skin sensitivity, preference for
genuine physiological cause [91]. hypoallergenic products, and avoidance of alpha-
Loffler et al. also observed a significant asso- hydroxy acids were highly predictive of AD.
ciation between the perception of sensitive skin Those three factors correctly classified 88% of
and nickel allergy but, in contrast, found no dif- the patients with prior AD and 92% of patients
ferences between those who claimed sensitive without AD [92].
skin as compared to controls with regard to phys- Incontinence, with its chronic exposure to
iological indicators such as skin hydration, skin known irritants in urine, could be expected to be
blood flow, and TEWL analysis [43]. associated with skin sensitivity. Extremely com-
104 M.A. Farage and M.K. Robinson

mon in elderly women, it has a variety of poten- wet wipes asked 180 women, both pre- and
tial dermatologic ramifications, including postmenopausal, to use wet wipes in lieu of toilet
irritation leading to various forms of dermatitis tissue for 4 weeks. No evidence of vulvar skin
[93]. It was expected that women with urinary irritation was observed [96]. In a study that
incontinence (UI) may report more sensitivity in recruited eight subjects with specifically self-
the genital area. Twenty Nine (29) women aged declared sensitive skin who reported adverse skin
at least 50 years old and suffering from mild uri- responses to everyday products and/or clothing,
nary incontinence filled out questionnaires sanitary napkins were patch tested on the forearm
designed to evaluate their perceptions of sensitive for four consecutive 24-h periods. No difference
skin. Surprisingly, although significantly more in erythema between the test pads and physiolog-
women with UI perceived themselves to have ical saline was observed [97].
sensitive skin in general, those women were no Environmental factors are consistently
more likely than controls to report sensitivity of reported as a primary trigger for sensitive skin,
the genital area in particular [90]. particular weather-related issues such as cold
A possible link between sensitive skin and temperatures, wind, heat, and sun exposure
rosacea has also been postulated. In one study of [1, 3]. Subjects in a French study (77%) described
rosacea patients, 64% were found to respond pos- themselves as experiencing at least some skin
itively to a sting test; additionally, pulsed-dye sensitivity related to warm weather, with 87%
laser treatment of rosacea was demonstrated to reporting at least some sensitivity related to
result in decreased stinging [45]. winter weather [47]. Our research confirmed
environmental triggers as a major contributor
to sensitive skin in a group of 1,039 subjects,
7.3 Extrinsic Contributors both male and female, who believed themselves
to have sensitive skin. Severe weather was the
The concept of sensitive skin arose primarily out most common contributor reported in this group,
of unexpected reactions to cosmetics, personal claimed by 24% of respondents as a factor in
cleansers, and other personal care products but their skin sensitivity [18].
grew to include a wide variety of other consumer It has been proposed by research scientists
products including fabrics, household cleaners, that the increasing incidence of sensitivity
paper products, sanitary napkins, and topical represents a cultural phenomenon wherein it
medications. It has been demonstrated that long- has become culturally fashionable to claim
term use of personal care products, particularly sensitive skin. The percentage of people sur-
medicaments containing corticosteroids, can pro- veyed who perceive themselves to have sensi-
duce allergenic sensitivity; [3] chronic use of tive skin has risen steadily over the decade of
topical medications has been observed to be the existing epidemiological research, particularly
origin of up to 20% of vulvar dermatitis [94]. among men [17]. The fact that the majority of
The vulva is exposed to other products such as women in the industrialized world now claim
sanitary napkins and hygienic wipes that may sensitive skin defies its initial perception as a
contribute to skin sensitivity as well. Although minority complaint and tends to support at least
the vulvar skin differs from exposed skin in ways some cultural component, as does its more dra-
that would imply a potential for increased sus- matic rise among men, a rise observed to be
ceptibility to irritation (nonkeratinized, occluded parallel to the increase in marketing of sensi-
skin), the use of various sanitary napkin designs tive skin products for men (ostensibly creating
has demonstrated a negligible occurrence of a more culturally acceptable climate for male
visual signs of irritation, with only a low fre- self-identification) [18].
quency of mild and transient sensory effects A recent epidemiological study in Europe
associated with their use [95]. A study evaluating would seem to confirm a cultural component.
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 105

A comparison of self-reported skin sensitivity in 7.5 Conclusions

eight European countries found dramatic
differences between genetically similar national It is clear that certain individuals have exagger-
populations (Portugal, Italy, and Spain, e.g., ated sensitivity to specific sensory and physical
reporting 8090% of their population as experi- irritants. There is now widespread agreement that
encing at least some sensitivity, while Germany, sensitive skin is a genuine condition with physi-
Belgium, and Switzerland reported just a little ological origin [26] and which can significantly
more than half). The authors attributed these impact quality of life [101]. Nonetheless, mean-
unexpected findings to substantially more fash- ingful correlation between sensory perceptions
ion and beauty-related advertising in the coun- and physical signs of irritation are weak and any
tries where self-reports of sensitive skin were underlying pathophysiology poorly understood.
also high [48]. Sensitive skin appears to represent an abrogation
of the skins tolerance threshold [48] which may
stem from several different pathological pro-
7.4 The Relationship Between cesses. It is likely that the phenomenon of sensi-
Irritation and Sensitivity tive skin, when unraveled, will prove to be an
umbrella classification comprised of distinct sub-
The relationship between irritant stimulation groups of clinical sensitivities with different
and sensory response has been an area of strong physiological mechanisms. Pons-Guiraud has
research interest, as a consistent correlation proposed three subgroups as follows: very sensi-
between objective indications of irritation and tive skin, reactive to a wide variety of both endog-
subjective sensory perceptions has been enous and exogenous factors with both acute and
elusive. chronic symptoms and a strong psychological
Our laboratory has sought to explore this component; environmentally sensitive, comprised
enigma through more sensitive methodology. of clear, dry, thin skin with a tendency to blush or
One testing approach tested catamenial prod- flush and reactive to primarily environmental fac-
ucts in the popliteal fossa (behind the knee or tors; and cosmetically sensitive skin, transiently
BTK approach) and observed a correlation reactive to specific and definable cosmetic prod-
between the magnitude of the irritation score ucts [3]. Muizzuddin et al. defined three sub-
(an objective measure) and sensory reports of groups somewhat differently. His classifications
irritation in 13 out of 15 participants [98]. include delicate skin, characterized by easily dis-
Another study included participants with sensi- rupted barrier function not accompanied by a
tive and normal skin in the evaluation of facial rapid or intense inflammatory response; reactive
tissues and found that sensory effects were most skin, characterized by a strong inflammatory
reliable indicator of product differences, as response without a significant increase in perme-
opposed to measures of erythema and dryness ability; and stingers, characterized by a height-
[22]. Another approach has employed enhanced ened neurosensory perception to minor cutaneous
visual scoring of erythema using cross-polar- stimulation [102].
ized light [99]. Use of enhanced visual scoring Subclinical irritation may be the key to under-
enabled detection of subclinical irritation that standing sensitive skin. The lack of correlation
was not apparent using traditional scoring between sensory and visual physiological
[100]. Use of the BTK method as well as the response may be at least practically temporal:
enhanced visual scoring allowed detection of sensory perceptions of irritation occur almost
erythema that distinguished between products immediately, while physiological sequelae will
in a way that mirrored consumer feedback on take time to develop. Visual irritation tests by
the product, a goal formerly unobtainable definition measure lasting effects, while sensory
through traditional testing [99]. effects are immediate. Methodologies with the
106 M.A. Farage and M.K. Robinson

capacity to detect subclinical irritation have dem-

onstrated better correlation between objective of certain consumer products, despite
and subjective parameters of sensitive skin than extensive premarket testing demonstrating
earlier testing. a lack of irritant effect.
An understanding of this phenomenon
has been hampered by the diversity of
7.6 Future Directions both sensory perceptions and signs
reported and a lack of correlation
Understanding the pathophysiology of sensitive between subjective sensory perceptions
skin is essential for the development of diagnos- and objective signs.
tic criteria and treatment options. An additional A variety of physiological factors have
need is a classification system for sensitive skin been associated with the consumer
that meaningfully synthesizes intrinsic and experience of sensitive skin.
extrinsic factors, thereby laying a foundation for A variety of external exposures have been
effective treatments. reported as provoking irritant reactions.
The most promising research has involved the Cultural factors such as advertising
development of enhanced methodological tools appear to influence consumer percep-
that are capable of detecting very subtle, subclini- tions of skin sensitivity.
cal skin effects related to skin sensitivity and Improved testing methods are beginning
which focus specifically on subjects found to have to reveal the physiological mechanisms
sensitive skin. Larger study populations composed which underlie the consumer experience
specifically of those who believe they have sensi- of sensitive skin.
tive skin are required to overcome the substantial Sensitive skin may ultimately prove to
level of individual variability and therefore pro- be comprised of subgroups of exagger-
duce meaningful results. Another important ated sensitivity stemming from different
research goal would be the development of meth- physiological mechanisms.
odological tools that can further exaggerate expo-
sures, enhance ability to clinically score irritation
(visually or via instrumentation), and identify new
Abbreviations
objective endpoints for subjective sensory effects
[103, 104]. For maximal usefulness, developed
AD Atopic dermatitis
methods will need to be cost efficient, minimally
BTK Behind the knee
invasive, and consistently reproducible.
DMSO Dimethyl sulfoxide
Ultimately, the goal of research into sensitive
SDS Sodium dodecyl sulfate
skin will be to synthesize data involving the skin,
SLS Sodium lauryl sulfate
the nervous system, intrinsic components of sen-
TEWL Transepidermal water loss
sitive skin, as well as the patients environment,
UI Urinary incontinence
lifestyle, and culture in order to meaningfully
UVB Ultraviolet B
describe the currently mysterious relationship
between sensitive skin, sensory responses, and
objective evidence of irritation.
References
1. Jourdain R, de Lacharrire O, Bastien P, Maibach HI
Take Home Messages (2002) Ethnic variations in self-perceived sensitive
skin: epidemiological survey. Contact Dermatitis
A majority of consumers in industrial- 46(3):162169
ized countries report sensitive skin: 2. Farage MA, Katsarou A, Maibach HI (2006) Sensory,
unpleasant sensations related to the use clinical and physiological factors in sensitive skin: a
review. Contact Dermatitis 55(1):114
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 107

3. Pons-Guiraud A (2004) Sensitive skin: a complex and of nicotinates and sensitive skin. Contact Dermatitis
multifactorial syndrome. J Cosmet Dermatol 3(3): 25(1):3538
145148 21. Robinson MK, Perkins MA (2001) Evaluation of a
4. Marriott M, Holmes J, Peters L, Cooper K, Rowson quantitative clinical method for assessment of sensory
M, Basketter DA (2005) The complex problem of sen- skin irritation. Contact Dermatitis 45(4):205213
sitive skin. Contact Dermatitis 53(2):9399 22. Farage MA (2005) Assessing the skin irritation potential
5. Farage MA (2005) Are we reaching the limits or our of facial tissues. Cutan Ocul Toxicol 24(2):125135
ability to detect skin effects with our current testing 23. Lee CH, Maibach HI (1995) The sodium lauryl sul-
and measuring methods for consumer products? fate model: an overview. Contact Dermatitis 33(1):
Contact Dermatitis 52(6):297303 17
6. Farage MA, Maibach HI (2008) Sensitive skin syn- 24. Basketter DA, York M, McFadden JP, Robinson MK
drome: sensory response and classification. Cosmet (2004) Determination of skin irritation potential in the
Toil 123(7):2630 human 4-h patch test. Contact Dermatitis 51(1):
7. Farage MA, Maibach HI (2010) Sensitive skin: clos- 14
ing in on a physiological cause. Contact Dermatitis 25. Robinson MK (2002) Population differences in acute
62(3):137149 skin irritation responses. Race, sex, age, sensitive skin
8. Johnson A, Page D (1992) Making sense of sensitive and repeat subject comparisons. Contact Dermatitis
skin. Congress of the International Federation of 46(2):8693
Society of Cosmetic Chemists, Yokohama, Poster 700 26. Farage MA, Maibach HI (2008) Sensitive skin syn-
9. Morizot F, Guinot C, Lopez S, Le Fur I, Tschachler E, drome: relationships among factors. Cosmet Toil
Wood C (2000) Sensitive skin: analysis of symptoms, 123(11):2831
perceived causes and possible mechanisms. Cosmet 27. Farage M, Maibach HI (2004) The vulvar epithelium
Toil 115:8389 differs from the skin: implications for cutaneous test-
10. Willis CM, Shaw S, De Lacharrire O, Baverel M, ing to address topical vulvar exposures. Contact
Reiche L, Jourdain R, Bastien P, Wilkinson JD (2001) Dermatitis 51(4):201209
Sensitive skin: an epidemiological study. Br J Dermatol 28. Basketter DA, Wilhelm KP (1996) Studies on non-
145(2):258263 immune immediate contact reactions in an unselected
11. Farage MA (2009) How do perceptions of sensitive population. Contact Dermatitis 35(4):237240
skin differ at different anatomical sites? An epidemio- 29. Robinson MK (2001) Intra-individual variations in
logical study. Clin Exp Dermatol 38(8):e521e530 acute and cumulative skin irritation responses. Contact
12. Querleux B, Dauchot K, Jourdain R, Bastien P, Dermatitis 45(2):7583
Bittoun J, Anton J, Burnod Y, de Lacharrire O (2008) 30. Cua AB, Wilhelm KP, Maibach HI (1990) Cutaneous
Neural basis of sensitive skin: an fMRI study. Skin sodium lauryl sulphate irritation potential: age and
Res Technol 14(4):454461 regional variability. Br J Dermatol 123(5):607613
13. Saint-Martory C, Roguedas-Contios AM, Sibaud V, 31. Aramaki J, Kawana S, Effendy I, Happle R, Lffler H
Degouy A, Schmitt AM, Misery L (2008) Sensitive skin (2002) Differences of skin irritation between
is not limited to the face. Br J Dermatol 158(1):130133 Japanese and European women. Br J Dermatol 146(6):
14. Misery L, Myon E, Martin N, Verrire F, Nocera T, 10521056
Taieb C (2005) Sensitive skin in France: an epidemio- 32. Berardesca E, Maibach HI (1988) Racial differences
logical approach. Ann Dermatol Venereol 132(5): in sodium lauryl sulphate induced cutaneous irrita-
425429 tion: black and white. Contact Dermatitis 18(2):
15. Guinot C, Malvy D, Mauger E, Ezzedine K, Latreille 6570
J, Ambroisine L, Tenenhaus M, Prziosi P, Morizot F, 33. Kalogeromitros D, Katsarou A, Armenaka M,
Galan P et al (2006) Self-reported skin sensitivity in a Rigopoulos D, Zapanti M, Stratigos I (1995) Influence
general adult population in France: data of the SU. of the menstrual cycle on skin-prick test reactions to
VI.MAX cohort. J Eur Acad Dermatol Venereol histamine, morphine and allergen. Clin Exp Allergy
20(4):380390 25(5):461466
16. Farage MA, Bowtell P, Katsarou A (2008) Self- 34. Farage MA, Osborn TW, Maclean AB (2008)
diagnosed sensitive skin in women with clinically diag- Cognitive, sensory, and emotional changes associated
nosed atopic dermatitis. Cli Med Dermatol 2:2128 with the menstrual cycle: a review. Arch Gynecol
17. Farage MA (2010) Does sensitive skin differ between Obstet 278(4):299307
men and women? Cutan Ocul Toxicol 29(3):153163 35. Britz MB, Maibach HI, Anjo DM (1980) Human per-
18. Farage MA (2008) Perceptions of sensitive skin: changes cutaneous penetration of hydrocortisone: the vulva.
in perceived severity and associations with environmen- Arch Dermatol Res 267(3):313316
tal causes. Contact Dermatitis 59(4):226232 36. Thomson ML (1955) Relative efficiency of pigment
19. Farage MA, Maibach HI (2008) Sensitive skin syn- and horny layer thickness in protecting the skin of
drome: methodological approaches. Cosmet Toil 123(9): Europeans and Africans against solar ultraviolet radi-
2833 ation. J Physiol 127(2):236246
20. Berardesca E, Cespa M, Farinelli N, Rabbiosi G, 37. Johnson LC, Corah NL (1963) Racial differences in
Maibach H (1991) In vivo transcutaneous penetration skin resistance. Science 139(3556):766767
108 M.A. Farage and M.K. Robinson

38. Corcuff P, Lotte C, Rougier A, Maibach HI (1991) 56. Agner T, Damm P, Skouby SO (1991) Menstrual cycle
Racial differences in corneocytes. A comparison and skin reactivity. J Am Acad Dermatol 24(4):566570
between black, white and oriental skin. Acta Derm 57. Agner T (1992) Noninvasive measuring methods for the
Venereol 71(2):146148 investigation of irritant patch test reactions. A study of
39. Marriott M, Whittle E, Basketter DA (2003) Facial patients with hand eczema, atopic dermatitis and con-
variations in sensory responses. Contact Dermatitis trols. Acta Derm Venereol Suppl (Stockh) 173:126
49(5):227231 58. Rohold AE, Halkier-Srensen L, Andersen KE,
40. Lampe MA, Burlingame AL, Whitney J, Williams Thestrup-Pedersen K (1994) Nickel patch test reactiv-
ML, Brown BE, Roitman E, Elias PM (1983) Human ity and the menstrual cycle. Acta Derm Venereol
stratum corneum lipids: characterization and regional 74(5):383385
variations. J Lipid Res 24(2):120130 59. Farage MA, Berardesca E, Maibach HI (2009) The
41. Seidenari S, Francomano M, Mantovani L (1998) effect of sex hormones on irritant and allergic
Baseline biophysical parameters in subjects with sen- response: possible relevance for skin testing. Br J
sitive skin. Contact Dermatitis 38(6):311315 Dermatol 160(2):450451
42. Loffler H (2006) Contact allergy and sensitive skin. 60. Robinson MK (2006) Age and gender as influencing
In: Berardesca E, Fluhr J, Maibach H (eds) Sensitive factors in skin sensitivity. In: Berardesca E, Fluhr J,
skin syndrome. Taylor and Francis, New York Maibach H (eds) Sensitive skin syndrome. Taylor &
43. Lffler H, Dickel H, Kuss O, Diepgen TL, Effendy I Francis, New York
(2001) Characteristics of self-estimated enhanced skin 61. Weigand DA, Haygood C, Gaylor JR (1974) Cell lay-
susceptibility. Acta Derm Venereol 81(5):343346 ers and density of Negro and Caucasian stratum cor-
44. Effendy I, Loeffler H, Maibach HI (1995) Baseline neum. J Invest Dermatol 62(6):563568
transepidermal water loss in patients with acute and 62. Reinertson RP, Wheatley VR (1959) Studies on the
healed irritant contact dermatitis. Contact Dermatitis chemical composition of human epidermal lipids.
33(6):371374 J Invest Dermatol 32(1):4959
45. Lonne-Rahm S, Berg M, Mrin P, Nordlind K (2004) 63. Kaidbey KH, Agin PP, Sayre RM, Kligman AM (1979)
Atopic dermatitis, stinging, and effects of chronic stress: a Photoprotection by melanin a comparison of black and
pathocausal study. J Am Acad Dermatol 51(6):899905 Caucasian skin. J Am Acad Dermatol 1(3):249260
46. Farage MA (2010) Perceptions of sensitive skin with 64. Kompaore F, Marty JP, Dupont C (1993) In vivo eval-
age. In: Farage MA, Miller KW, Maibach HI (eds) uation of the stratum corneum barrier function in
Textbook of aging skin. Springer, Berlin, Heidelberg blacks, Caucasians and Asians with two noninvasive
47. Misery L, Myon E, Martin N, Consoli S, Nocera T, methods. Skin Pharmacol 6(3):200207
Taieb C (2006) Sensitive skin: epidemiological 65. Wilson D, Berardesca E, Maibach HI (1988) In vitro
approach and impact on quality of life in France. In: transepidermal water loss: differences between black
Berardesca E, Fluhr JW, Maibach HI (eds) Sensitive and white human skin. Br J Dermatol 119(5):
skin syndrome. Taylor & Francis, New York 647652
48. Misery L, Boussetta S, Nocera T, Perez-Cullell N, 66. Sugino K, Imokawa G, Maibach H (1993) Ethnic dif-
Taieb C (2009) Sensitive skin in Europe. J Eur Acad ference of stratum corneum lipid in relation to stratum
Dermatol Venereol 23(4):376381 corneum function. J Invest Dermatol 100:587
49. Giacomoni PU, Mammone T, Teri M (2009) Gender- [Abstract 594]
linked differences in human skin. J Dermatol Sci 67. Anderson RR, Parrish JA (1981) The optics of human
55(3):144149 skin. J Invest Dermatol 77(1):1319
50. Wines N, Willsteed E (2001) Menopause and the skin. 68. Hymes J, Spraker M (1986) Racial differences in the
Australas J Dermatol 42(3):1498; quiz 159 effectiveness of a topically applied mixture of local
51. Leong PL (2008) Aging changes in the male face. anesthetics. Reg Anesth 11:1113
Facial Plast Surg Clin North Am 16(3):277279, v 69. Wedig JH, Maibach HI (1981) Percutaneous penetra-
52. Mowlavi A, Cooney D, Febus L, Khosraviani A, tion of dipyrithione in man: effect of skin color (race).
Wilhelmi BJ, Akers G (2005) Increased cutaneous J Am Acad Dermatol 5(4):433438
nerve fibers in female specimens. Plast Reconstr Surg 70. Guy RH, Tur E, Bjerke S, Maibach HI (1985) Are
116(5):14071410 there age and racial differences to methyl nicotinate-
53. Reed JT, Ghadially R, Elias PM (1995) Skin type, but induced vasodilatation in human skin? J Am Acad
neither race nor gender, influence epidermal permea- Dermatol 12(6):10011006
bility barrier function. Arch Dermatol 131(10): 71. Berardesca E, Maibach HI (1990) Racial differences
11341138 in pharmacodynamic response to nicotinates in vivo
54. Farage MA, Neill S, MacLean AB (2009) Physiological in human skin: black and white. Acta Derm Venereol
changes associated with the menstrual cycle: a review. 70(1):6366
Obstet Gynecol Surv 64(1):5872 72. Marshall E, Lynch V, Smith H (1919) Variation in
55. Farage MA, Berardesca E, Maibach H (2010) The susceptibility of the skin to dichlorethylsulfide.
possible relevance of sex hormones on irritant and J Pharmacol Exp Ther 12:291301
allergic responses: their importance for skin testing. 73. Weigand D, Mershon M (1970) The cutaneous irritant
Contact Dermatitis 62(2):6774 reaction to agent O-chlorobenzylidene malonitrile
7 Sensitive Skin: Intrinsic and Extrinsic Contributors 109

(CS); quantitation and racial influence in human sub- 91. Farage MA (2008) Self-reported immunological and
jects. Edgewood Arsenal 4332 familial links in individuals who perceive they have
74. Weigand DA, Gaylor JR (1974) Irritant reaction in sensitive skin. Br J Dermatol 159(1):237238
Negro and Caucasian skin. South Med J 67(5):548551 92. Farage MA, Bowtell P, Katsarou A (2010) Identifying
75. Frosch P, Kligman A (1981) A method for appraising patients likely to have atopic dermatitis: develop-
the stinging capacity of topically applied substances. ment of a pilot algorithm. Am J Clin Dermatol
J Soc Cosmet Chem 28:197209 11(3):211215
76. Freeman R, Cockerell E, Armstrong J et al (1962) 93. Farage MA, Miller KW, Berardesca E, Maibach HI
Sunlight as a factor influencing the thickness of epi- (2008) Psychosocial and societal burden of inconti-
dermis. J Invest Dermatol 39:295298 nence in the aged population: a review. Arch Gynecol
77. Berardesca E, Maibach H (1996) Racial differences in Obstet 277(4):285290
skin pathophysiology. J Am Acad Dermatol 34(4): 94. Farage MA, Miller KW, Ledger WJ (2008)
667672 Determining the cause of vulvovaginal symptoms.
78. Bronaugh RL, Stewart RF, Simon M (1986) Methods Obstet Gynecol Surv 63(7):445464
for in vitro percutaneous absorption studies. VII: use of 95. Farage MA, Katsarou A, Tsagroni E, Bowtell P,
excised human skin. J Pharm Sci 75(11):10941097 Meyer S, Deliveliotou A, Creatsas G (2005)
79. Sandby-Mller J, Poulsen T, Wulf HC (2003) Cutaneous and sensory effects of two sanitary pads
Epidermal thickness at different body sites: relation- with distinct surface materials: a randomized pro-
ship to age, gender, pigmentation, blood content, skin spective trial. Cutan Ocul Toxicol 24:227241
type and smoking habits. Acta Derm Venereol 96. Farage MA, Stadler A, Chassard D, Pelisse M (2008)
83(6):410413 A randomized prospective trial of the cutaneous and
80. Robinson MK (1999) Population differences in skin sensory effects of feminine hygiene wet wipes.
structure and physiology and the susceptibility to irri- J Reprod Med 53(10):765773
tant and allergic contact dermatitis: implications for 97. Farage MA, Stadler A (2005) Cumulative irritation
skin safety testing and risk assessment. Contact patch test of sanitary pads on sensitive skin. J Cosmet
Dermatitis 41(2):6579 Dermatol 4(3):179183
81. Rapaport MJ (1984) Patch testing in Japanese sub- 98. Farage MA, Santana M, Henley E (2005) Correlating
jects. Contact Dermatitis 11(2):9397 sensory effects with irritation. Cutan Ocul Toxicol
82. Robinson MK (2000) Racial differences in acute and 24(1):4552
cumulative skin irritation responses between 99. Farage MA (2009) Detecting skin irritation using
Caucasian and Asian populations. Contact Dermatitis enhanced visual scoring: a sensitive new clinical
42(3):134143 method. In: Barel AO, Paye M, Maibach HI (eds)
83. Farage MA, Miller KW, Elsner P, Maibach HI (2008) Handbook of cosmetic science and technology, 3rd
Intrinsic and extrinsic factors in skin ageing: a review. edn. Informa Healthcare, New York
Int J Cosmet Sci 30(2):8795 100. Farage MA (2009) Sensory effects and irritation: a
84. Sparavigna A, Di Pietro A, Setaro M (2005) Healthy strong relationship. In: Barel A, Paye M, Maibach H
skin: significance and results of an Italian study on (eds) Handbook of cosmetic science and technology.
healthy population with particular regard to sensi- Informa Healthcare USA, Inc, New York
tive skin. Int J Cosmet Sci 27(6):327331 101. Misery L, Myon E, Martin N, Consoli S, Boussetta
85. Besn I, Descombes C, Breton L (2002) Effect of age S, Nocera T, Taieb C (2007) Sensitive skin: psycho-
and anatomical site on density of sensory innervation in logical effects and seasonal changes. J Eur Acad
human epidermis. Arch Dermatol 138(11):14451450 Dermatol Venereol 21(5):620628
86. Misery L, Sibaud V, Ambronati M, Macy G, Boussetta 102. Muizzuddin N, Marenus KD, Maes DH (1998)
S, Taieb C (2008) Sensitive scalp: does this condition Factors defining sensitive skin and its treatment. Am
exist? An epidemiological study. Contact Dermatitis J Contact Dermat 9(3):170175
58(4):234238 103. Perkins MA, Osterhues MA, Farage MA,
87. Tagami H (2002) Racial differences on skin barrier Robinson MK (2001) A noninvasive method to
function. Cutis 70(6 Suppl):67; discussion 2123 assess skin irritation and compromised skin con-
88. Green B (1996) Regional and individual differences ditions using simple tape adsorption of molecular
in cutaneous sensitivity to chemical irritants: capsai- markers of inflammation. Skin Res Technol 7(4):
cin and menthol. Cutan Ocul Toxicol 15:277295 227237
89. Farage M, Bowtell P, Katsarou A (2006) The relation- 104. Perkins MA, Osterhues MA, Vogelpohl S, Robinson
ship among objectively assessed vulvar erythema, MK (2000) A clinical skin sampling approach to
skin sensitivity, genital sensitivity, and self-reported assess sensory skin irritation. Toxicological Sciences
facial skin redness. J Appl Res 6:272281 54:146
90. Farage MA (2009) Perceptions of sensitive skin:
women with urinary incontinence. Arch Gynecol
Obstet 280:4957, Epub 2008 Dec 14
 Electron Tomography of Skin
8
Lars Norln

8.1 Introduction 8.2 Cryo-Electron Microscopy

of Vitreous Skin Sections
The native structure of skin can be visualized at
molecular resolution with cryo-transmission A major drawback with conventional electron
electron microscopy (CEMOVIS) and tomogra- microscopy (EM) is the need for complete speci-
phy (TOVIS) of vitreous sections [13, 13, 14]. men dehydration. Skin dehydration results in par-
Micrographs of vitrified native skin obtained tial loss of material, and remaining structures are
by CEMOVIS not only show more detail but subject to aggregation. Further, because of the sig-
sometimes also differ dramatically from those nificant background noise derived from the plastic
obtained by conventional methods (Figs. 8.1 and embedding medium, conventional EM uses heavy
8.2). The reason is a better structure preservation metal staining in order to increase image contrast.
and the absence of a plastic embedding medium It is thus not the biological material per se that is
in the native cryo-preserved skin samples. observed in the micrographs but stain deposited on
When CEMOVIS is combined with tomogra- aggregated biological remnants.
phy (TOVIS), molecular resolution 3D recon- When preparing skin for CEMOVIS, the
structions may be obtained [12, 15]. However, in samples are fixed by ultra rapid (~20 ms) cool-
electron tomography, both data acquisition and ing (below 140C) under high pressure
data analysis are far from trivial. This limits the (~2,000 bar) [4]. The high-pressure frozen, vit-
practical applications of TOVIS in skin science rified skin sample is then cut into ultrathin (25
and in particular its widespread usage within der- 50 nm) sections in a cryo-microtome and finally
matology and cosmetology. Here we outline the observed in a cryo-electron microscope. In this
major difficulties and how they are presently way, the molecular organization of skin can be
dealt with. We will also propose some future studied in its native state, without any treatment
applications of TOVIS for skin science. such as chemical fixation, dehydration or
staining.

8.3 Electron Tomography

L. Norln
Department of Cellular and Molecular Biology (CMB),
In electron tomography (ET), a series of elec-
Medical Nobel Institute, Karolinska Institute,
Stockholm, Sweden tron microscopy images recorded at different tilt
angles is used to three-dimensionally (3D) recon-
Dermatology Clinic, Karolinska University Hospital,
Stockholm, Sweden struct a sample. Single-axis tilting is the most
e-mail: [email protected] common data acquisition geometry. The vitrified

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 111

DOI 10.1007/978-3-642-27606-4_8, Springer-Verlag Berlin Heidelberg 2012
112 L. Norln

Fig. 8.1 Conventional sample preparation for electron so-called keratohyalin granules (d, white asterix).
microscopy results in important losses of epidermal bio- Furthermore, the rich variety of cytoplasmic organelles
material. Low magnification transmission electron micro- and multigranular structures present in the stratum cor-
graphs of human epidermis at the interzone between neum/stratum granulosum transition (T) cells of native
viable and cornified cell layers (a, b: lowermost stratum epidermis (c) (white arrows) are replaced by empty space
corneum; c, d: uppermost stratum granulosum). (a, c) in resin-embedded samples (d) (black asterix). Inner and
Cryo-electron micrographs of vitreous sections of native outer nuclear envelopes and nuclear pores are clearly dis-
epidermis. (b, d) Conventional electron micrographs of tinguished in the native cryo-fixed non-stained specimen
resin-embedded sections. In the vitreous cryo-fixed epi- (c) (black arrow) while they are difficult to distinguish in
dermis (a, c), cellular as well as intercellular space the conventionally fixed stained specimen (d) (black
appears densely packed with organic material, while, in arrow). Electron dense single spot in (a) and double spot
the conventionally fixed epidermis (b, d), the distribution in (c) correspond to surface ice contamination. SG upper-
of biomaterial is characteristically inhomogeneous. Loss most stratum granulosum cell, T transition cell, SC low-
of biomaterial appears to have taken place in (b, d), both ermost stratum corneum cell, N nucleus, open white
in the cytoplasmic (black asterix) and intercellular (white double arrow. (a, c) Section cutting direction. Section
arrow) space. Large portions of the biomass of the viable thicknesses: ~100 nm (a, c), ~50 nm (b, d). Scale bars:
cells appear as aggregated, heavily stained clusters, 500 nm (ad) (Adapted from [13] with permission)
8 Electron Tomography of Skin 113

data prevents stable inversion [16]. This leads

to instability in the 3D reconstruction proce-
dure. Furthermore, one cannot exactly recon-
struct an objects scattering potential as only
a subregion of the cryo-section (i.e. the region
of interest (ROI)) is exposed to electrons.
As the section is tilted, scattered electrons
from outside the ROI enter the ROI images.
Consequently, one must make assumptions
regarding the scattering potential of the section
outside the ROI when reconstructing an object
inside the ROI [15].
The missing tilt-angle problem, the scattering
from outside the ROI and the low signal-to-noise
ratio make the 3D reconstruction in skin TOVIS
difficult. This is presently dealt with by recon-
structing only some information about the speci-
Fig. 8.2 High magnification cryo-electron micrograph of
desmosomes at the midportion of the viable part of human
men that can be stably retrieved or by the
epidermis. The plasma membranes appear as ~4 nm thick introduction of prior information about the speci-
high-density bilayers. The extracellular core domain is men into the reconstruction scheme [15].
~33 nm thick and contains transverse electron dense lines The first approach is exemplified by filtered
with an ~5 nm periodicity corresponding to cadherin
adhesion molecules. On the cytoplasmic side, an ~11 nm
and weighted back-projection methods (FBP
thick zone of medium electron density separates the elec- and WBP) [19, 20, 27] (Fig. 8.3a), in which
tron dense plasma membrane from two parallel electron regularization is simply achieved by low-pass
dense layers, situated ~7 nm apart and interconnected by filtering, and in the simultaneous iterative
traversing electron dense lines with an ~6 nm periodicity.
Thin white arrows: very weak electron dense lines associ-
reconstruction technique (SIRT) [10], where it
ated with the desmosome cytoplasmic plaque, open white is achieved by stopping the iteration after a lim-
double-arrow: section cutting direction. The imaging con- ited number of cycles and by not allowing the
ditions were identical to those given in Fig. 8.1. Section predicted changes to be fully used between the
thickness: ~50 nm. Scale bar: 50 nm (Adapted from [3]
with permission)
iterations. The approach taken by the recently
introduced L-tomography technique [17] is
to reconstruct only the information about the
sample that can be stably retrieved. This is
skin sample is here rotated around a single axis. achieved by only reconstructing the boundaries
The rotation angle range is usually 60. The 30 of the scattering potential, which in turn provide
missing region in a single-axis 60 tilt series the shape of the boundaries of the molecules in
results in an about 50% loss of resolution along the specimen [15].
the beam direction in the 3D reconstruction [18], The second approach is to stabilize the 3D
something that has to be taken into account when reconstruction algorithm in ET by introducing
interpreting tomographic 3D reconstructions. additional a priori information. An example is
Also, there are several problems associated the variational regularization methods [22]
with the calculation of the scattering potential (Fig. 8.3b), which are defined as the solution to
of the specimen from the tilt-series electron an optimization problem, and, more recently, l1-
micrographs. The main limitation is the low regularization and the associated total variation
signal-to-noise ratio in tomographic low-dose (TV) regularization [68] where the principle is
cryo-electron micrographs. Another problem is to choose the 3D structure that is as sparse as pos-
that the 30 missing region in the tilt-series sible [15].
114 L. Norln

Fig. 8.3 Molecular skin TOVIS in situ 3D reconstruction collected with two-degree increments covering the range
with weighted back projection (a) and refinement with from 50 to +60. The images were displayed in the
COMET regularization (b) of individual cadherin adhe- XPIX program and fiducial marker positions determined
sion molecules inside the extracellular domain of a in a semi-automated way. A least-squares procedure was
desmosome inside native human epidermis. The 3D used to align the images. The average alignment error was
reconstructions were obtained from the area marked by a 1.467 pixels (0.825 nm), as estimated from the mean devi-
white box in Fig. 8.3. The quality of the 3D reconstructions ation of measured marker positions from positions pre-
(a, b) was not sufficient to deduce the native 3D arrange- dicted from the geometry of the tilts. The 3D reconstructions
ment of the desmosomal cadherins, essentially because of were made using weighted back projection (a) and analy-
smearing in the z-direction secondary to the missing data sed in either the BOB (available at http://www.3tag.com/
(limited tilt angle) problem. We used a single-axis GATAN bobicol.html) or XTV programs. The COMET reconstruc-
model 626 cryo-holder (GATAN, Pleasanton, CA) at tion (b) was performed using the COMET software ver-
180C. Tilt series were collected at 200 kV in a FEG sion 4.5. The reconstructed volume obtained by weighted
CM200 FEI microscope, equipped with a cooled slow scan back projection (a) and low-pass filtered to a resolution of
2,048 2,048 TemCam-F214 CCD camera (pixel size 7 nm was used as the prior. The amplitude contrast ratio
14 mm) and software for automated data collection (TVIPS, was set to 0.15 and the defocus to 4 mm. DPM1 desmo-
Gauting, Germany). The images were recorded at 4 mm some plasma membrane of the lower cell, DPM2 desmo-
defocus (first CTF zeros at 3.1 nm) at the dose of approxi- some plasma membrane of the upper cell, C1 cadherin
mately 60 electrons/nm2 per image (total dose 3,900 elec- molecule belonging to the lower cell, C2 cadherin mole-
trons/nm2) and a total magnification of 25,000 (pixel size cule belonging to the upper cell. Scale bar: 5 nm (Adapted
corresponds to 5.63 in the specimen). The tilt series was from [15] with permission)

technically demanding and allows for routine

8.4 Immuno-tomography acquisition of dual-tilt series, which reduces the
missing tilt-angle problem. However, the most sig-
CEMOVIS and TOVIS allow for structure deter- nificant advantage of freeze-substitution ET is that
mination in skin at near-native conditions. They it is compatible with immuno-labelling and thus
are however costly, time-consuming and techni- allows for immuno-ET. Electron tomography of
cally demanding. Freeze-substitution ET may antibody-labelled tissues and cells makes it possi-
therefore constitute an attractive complement for ble to reconstruct antibodyantigen complexes in
questions not requiring molecular resolution. The 3D in situ with a resolution of a few nm [11]
advantages of freeze-substitution ET are that the (Fig. 8.4). The major practical problem is that con-
signal-to-noise ratio is better as the tissue samples taminating antibodies usually cluster around the
are stained and that higher electron doses are toler- gold particle conjugated to the secondary IgG anti-
ated. Freeze-substitution ET is also much less body and thereby sometimes obscure the structural
8 Electron Tomography of Skin 115

complicated by the noisy and incomplete data,

but also by the three-dimensional image
complexity and the lack of efficient visualization
tools for distinguishing overlapping structural
components. To facilitate interpretation, certain
features can be extracted from the 3D reconstruc-
tions and analysed separately via image segmen-
tation. Manual segmentation is still predominantly
used. It is, however, of low reproducibility.
Computer-based image segmentation algorithms
have therefore been developed among which
crisp segmentation, i.e., assigning each voxel in
the image either to the background or to the
object based exclusively on grey-level informa-
tion, is the most widely used [5, 28]. Crisp seg-
mentation is, however, complicated by the
absence of a distinct border between object and
Fig. 8.4 Molecular 3D immuno-EM tomography recon-
struction of an epidermal growth factor receptorantibody background in the low-contrast skin TOVIS set-
complex on the cell surface of a squamous carcinoma ting. An alternative approach is segmentation
(A431) cell prepared by the Tokuyasu technique. Yellow based on fuzzy set theory, using both grey-level
sphere represents a 6-nm colloidal gold particle conju- and shape information. Here each voxel is
gated to a goat anti-human IgG antibody (Adapted from
[11] with permission) assigned a membership value describing to what
degree it belongs to an object [9, 24].
details of the primary antibodyantigen interaction.
Another limitation is that antibodies only identify
antigens that protrude from the section surface and
therefore require fairly high antigen concentra- 8.5.2 Docking of X-Ray Data
tions in the freeze-substituted specimen. For anti- into Segmented ET Data
gens that are less abundant, Tokuyasu sample
preparation [25] may constitute an alternative to Docking of x-ray crystallography data or atomic
freeze substitution, as antibodies then to some models into segmented electron tomography
extent may bind antigen also inside the sections. data could aid biological interpretation of skin
Tokuyasu-prepared samples are however less well TOVIS experiments. Presently, rigid docking
preserved and express a lower signal-to-noise ratio procedures dominate. A major problem here is
than corresponding freeze-substituted samples. A that these do not work well in the presence of
combination of TOVIS and immuno-ET based on conformational variation and molecular flexibil-
both freeze-substituted and Tokuyasu-prepared ity. However, flexible docking procedures based
samples may therefore be optimal for many appli- on molecular dynamics simulation that bring
cations in skin science. deviating global molecular features into register
while preserving the crystal structure locally
have recently been developed [26, 29].

8.5 Analysis of Tomograms

8.5.1 Segmentation 8.5.3 Electron Microscopy Simulation

As mentioned above, interpretation of tissue ET A new tool to identify and characterize biological
reconstructions is not trivial. Extraction of bio- structures in cryo-electron images is electron micros-
logically meaningful information is not only copy simulation [23]. It consists of a phantom
116 L. Norln

generator that generates an atomic model of a bio-

logical structure adapted for simulation and a trans- Electron tomography of antibody-
mission electron microscope simulator that calculates labelled tissues (immuno-ET) allows
the electronspecimen interaction, the electron direct molecular 3D reconstruction in
optics in the microscope and a noise model that situ of antibody-labelled proteins in
includes detector noise. A simulator can be used to skin, in addition to determining their
find structures in electron images, as well as assist in intracellular localization to a resolution
the docking of x-ray data into segmented ET data. It of about 23 nm.
can further be used to test whether a proposed atomic Presently, electron tomography, and espe-
model of a biological structure is in agreement with cially TOVIS, is practically very difficult,
the features observed in the electron micrographs. very costly and very time-consuming and
therefore not suited for scientific routine
work. However, in the near future, TOVIS
(and hopefully soon immuno-ET) data
8.6 Future Applications of ET collection and data treatment will be made
in Skin Science on a contract basis in specialized national/
international electron microscopy centre
The combination of CEMOVIS, TOVIS and facilities. This will make the access to the
immuno-ET with molecular modelling and elec- above-mentioned techniques relatively
tron microscopy simulation allows for the identifi- simple, fast and cheap for any researcher
cation and structure determination in native skin in or clinician.
situ down to a resolution of about 15 nm. The TOVIS is particularly well suited for the
more ordered the target molecules are, the more study of the stratum corneum, dry skin
suitable they will be for analysis. Highly ordered and desquamation as both the ceramide-
molecular assemblies like membrane structures [cf. enriched extracellular, the keratin-enriched
3, 14], cytoskeletal components like keratin fila- intracellular and the cadherin-enriched
ments [cf. 13] and cell adhesion components such cell adhesion compartments are highly
as desmosomal cadherins [cf. 1, 2] are therefore structured.
well-disposed target structures. Scientific studies
of the molecular mechanisms underlying skin dis-
eases involving skin barrier deficiency, such as
atopic dermatitis; scaling diseases, such as dry skin,
the ichtyoses and psoriasis; as well as blistering
References
diseases may all benefit from ET in the not too dis-
tant future. Further, molecular aspects of skin pen- 1. Al-Amoudi A, Castao-Dieza D, Devosa DP, Russell
etration of drugs as well as local drug skin-target RB, Johnson GT, Frangakis A (2011) The three-
interactions and the effect on skin structure of dif- dimensional molecular structure of the desmosomal
plaque. PNAS 108(16):64806485
ferent topical applications, such as skin moisturiz-
2. Al-Amoudi A, Dez DC, Betts MJ, Frangakis AS
ers, are other foreseeable applications. (2007) The molecular architecture of cadherins in
native epidermal desmosomes. Nature 450:832837
3. Al-Amoudi A, Dubochet J, Norln L (2005)
Nanostructure of the epidermal extracellular space as
observed by cryo-electron microscopy of vitreous
sections of human skin. J Invest Dermatol 124:
Take Home Messages 764777
The three-dimensional structure of native 4. Al-Amoudi, A. Norln, L. Dubochet, J (2004) Cryo-
skin can be studied by electron tomogra- electron microscopy of vitreous sections of native bio-
logical cells and tissues. J Struct Biol. 148(1):1315
phy of vitreous skin sections (TOVIS) 5. Baker ML, Yu Z, Chiu W, Bajaj C (2006) Automated
down to a molecular resolution in situ. segmentation of molecular subunits in electron cryo-
microscopy density maps. J Struct Biol 156:432441
8 Electron Tomography of Skin 117

6. Cands EJ (2006) Compressive sampling. Proc. Int. 18. Radermacher M (1988) Three-dimensional recon-
Congress Math, Madrid, Spain, pp 120 struction of single particles from random and nonran-
7. Cipra BA (2006) l1-magic. SIAM News 39(9) dom tilt series. J Electron Microsc Tech 9:359394
8. Fanelli D, ktem O (2008) Electron tomography: a 19. Radermacher M (1992) Weighted back-projection
short review with an emphasis on the absorption methods. In: Frank J (ed) Electron tomography three-
potential model for the forward problem. Inverse dimensional imaging with the transmission electron
Problems 24 013001 (51 pp) microscope, Chapter 5. Plenum Press, New York
9. Garduno E, Wong-barnum M, Vilkmann N, Ellisman 20. Ramachandran GN, Lakshminarayanan AV (1971)
MH (2008) Segmentation of electron tomographic Three-dimensional reconstruction from radiographs
data sets using fuzzy set theory principles. J Struct and electron micrographs: application of convolutions
Biol 162:368379 instead of Fourier transforms. Proc Natl Acad Sci
10. Gilbert PFC (1972) Iterative methods for the three- USA 68:22362240
dimensional reconstruction of an object from projec- 21. Rullgrd H (2008) A new principle for choosing regu-
tions. J Theor Biol 36:105117 larization parameter in certain inverse problems.
11. Lammerts van Bueren JJ, Bleeker WK, Brnnstrm arXiv:0803.3713v2
A, von Euler A, Jansson M, Peipp M, Schneider- 22. Rullgrd, H. ktem, O. Skoglund, U (2007) A com-
Merck T, Valerius T, van de Winkel JBJ, Parren PWHI ponentwise iterative relative entropyregularization
(2008) The antibody zalutumumab inhibits epidermal method with updated prior and regularization param-
growth factor receptor signaling by limiting intra- and eter. Inverse Problems 23:21212139
intermolecular flexibility. PNAS 105(16):61096114 23. Rullgrd, H. fverstedt, L-G. Masich, S. Daneholt, B.
12. Masich S, stberg T, Norln L, Shupliakov O, ktem, O (2011) Simulation of transmission electron
Daneholt B (2006) A procedure to deposit fiducial microscope images of biological specimens. J.
markers on vitreous cryo-sections for cellular tomog- Microscopy 243(3):234256
raphy. J Struct Biol 156:461468 24. Svensson S (2007) A decomposition scheme for 3D
13. Norln L, Al-Amoudi A (2004) Stratum corneum fuzzy objects based on fuzzy distance information.
keratin structure, function, and formation: the cubic Pattern Recognit Lett 28:224232
rod-packing and membrane templating model. J Invest 25. Tokuyasu KT (1973) A technique for ultracryotomy of
Dermatol 123(4):715732 cell suspensions and tissues. J Cell Biol 57:551565
14. Norln L, Al-Amoudi A, Dubochet J (2003) A cryo- 26. Trabuco LG, Villa E, Mitra K, Frank J, Schulten K
transmission electron microscopy study of skin bar- (2008) Flexible fitting of atomic structures into elec-
rier formation. J Invest Dermatol 120:555560 tron microscopy maps using molecular dynamics.
15. Norln L, ktem O, Skoglund U (2009) Molecular Structure 16(5):673683
cryo-electron tomography of vitreous tissue sections: 27. Vainshtein BK (1970) Finding the structure of objects
current challenges. J Microsc 235:293307 from projections. Krystallograftya 15:894902;
16. Penczek PA, Frank J (2006) Resolution in electron Vainshtein BK (1970) Crystallography 15:781787
tomography, Chapter 10. In: Frank J (ed) Electron (Transl. in Soviet Physics)
tomography methods for three-dimensional visual- 28. Volkmann N (2002) A novel three-dimensional vari-
ization of structures in the cell, 2nd edn. Springer, ant of the watershed transform for segmentation of
New York, pp 307330 electron density maps. J Struct Biol 138:123129
17. Quinto ET, ktem O (2008) Local tomography in elec- 29. Wriggers W (2004) Spanning the length scales of
tron microscopy. SIAM J Appl Math 68(5):12821303 biomolecular simulation. Structure 12(1):12
 Filaggrin Gene Defects and Dry Skin
Barrier Function 9
Martin Willy Meyer and Jacob P. Thyssen

9.1 Filaggrin: The Multifunctional carboxylic acid, their metabolites, and various
Protein ions make up the so-called natural moisturizing
factor (NMF) [20]. The N-terminal portion of
Filaggrin (filament-aggregating protein) has an profilaggrin is a calcium-binding domain. It may
important function in epidermal differentiation be involved in the regulation of calcium-depen-
and barrier function, but the relative importance dent events during epidermal differentiation [3].
of the different functions of filaggrin proteins In 2006, in Dundee, Scotland, Smith et al.
remains to be elucidated. reported that two common loss-of-function muta-
The filaggrin gene encodes a large insoluble tions within the filaggrin gene, R501X and
polyprotein called profilaggrin [3]. Profilaggrin 2282del4, were associated with ichthyosis vul-
is cleaved to produce multiple filaggrin peptides garis. Using improved sequencing strategies, they
[7]. Within the cytoskeleton of keratinocytes, fil- were finally able to report what had been long
aggrin aggregates keratin 1, keratin 10 as well as suspected [24]. The same year, Palmer et al.
other intermediate filaments and forms macrofi- showed that these loss-of-function genetic vari-
brils [3]. The protein-lipid cornified cell envelope ants were very strong predisposing factors for
forms an important permeability barrier against atopic dermatitis. They were detected by using
water and other environmental agents such as long-range sequencing and multiple alignment
microbes, irritants and allergens. Filaggrin is a techniques, revealing a semidominant pattern of
major component of this barrier function [19]. inheritance with incomplete penetrance [18].
Filaggrin is producing a mixture of hygro- Approximately 9% of people of European ori-
scopic acids that may contribute to epidermal gin are carrying these variants [18, 27]. More than
barrier function by retaining water. Among oth- 40 loss-of-function mutations within the filaggrin
ers, histidine is released by filaggrin proteolysis. gene have now been reported [30]. Each is pre-
It helps to maintain the pH gradient of the epider- dicting nonsense or out-of-frame deletion/inser-
mis by being converted to transurocanic acid. tion mutations, with population-specific patterns
This acid is then undergoing photoisomerization emerging worldwide [17]. Five null mutations are
and has local and systemic immunosuppressive prevalent within the European population. This
effects [3]. A pool of hydrophilic amino acids, strikingly high prevalence of filaggrin null muta-
including urocanic acid, alanine, and pyrrolidone tions suggests a possible heterozygote advantage
[3]. Natural vaccination mediated by the mildly
perturbed skin barrier in heterozygotes has been
M.W. Meyer, M.D. () J.P. Thyssen, M.D., Ph.D.
hypothesized. Hereby atopy could be a modern
Department of Dermato-Allergology, Gentofte Hospital,
Niels Andersens Vej 65, 2900 Hellerup, Denmark plague that is enriched among the survivors of
e-mail: [email protected] ancient bacterial plagues [11, 23].

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 119

DOI 10.1007/978-3-642-27606-4_9, Springer-Verlag Berlin Heidelberg 2012
120 M.W. Meyer and J.P. Thyssen

9.2 Skin Dryness 9.4 Atopic Dermatitis

It has been suggested that filaggrin may play a Atopic dermatitis is a common, chronic, and
role in determining the degree of skin dryness. relapsing skin disease. It is particularly common
This is based on filaggrin repeat number polymor- during infancy and childhood. Scaly, itchy, and
phisms. A polypeptide that has a variable number dry skin with excoriations is typically observed
of genetically determined filaggrin-repeat units clinically. Furthermore, cutaneous infections fre-
(10, 11, or 12 repeats) is encoded by the profilag- quently occur. Atopic dermatitis is often seen
grin gene. The repeat copy number was correlated together with asthma and/or allergic rhinitis.
with self-perceived episodes of dry skin in one Atopic dermatitis has a strong genetic predisposi-
study. It revealed that the filaggrin gene might tion but also a significant environmental compo-
serve as a genetic marker for dryness of the skin, nent. A major predisposing genetic factor includes
because of an inverse association between the null mutations in the filaggrin gene [13, 18].
12-repeat allele and perceived dryness. Individuals Palmer et al. showed that atopic dermatitis was
with an absence of the 12-repeat profilaggrin were manifested in heterozygous carriers of the above
over four times more likely to report skin dryness mentioned filaggrin null mutations with a relative
than those who carried one or two 12-repeat risk for atopic dermatitis of 3.1, implying a causal
alleles [8]. The natural moisturizing factor com- relationship [18]. Several European countries as
prises a mixture of amino acids, derived primarily well as China and Japan have demonstrated that
from the degradation of filaggrin. It has been sug- filaggrin null mutations in their populations are
gested that these acids serve as humectants and associated with atopic dermatitis following the
maintain hydration as well [20]. initial findings by Palmer et al. [13]. Other stud-
ies have shown that null mutations in the filaggrin
gene predispose to early-onset atopic dermatitis
9.3 Ichthyosis Vulgaris which persist into adulthood [1] and increase the
risk of developing allergic sensitization as well as
Ichthyosis vulgaris, a member of the ichthyosis allergic rhinitis [28]. Despite the most widely and
family of diseases, is the most common inherited strongest replicated genetic risk for atopic der-
disorder of keratinization and is one of the most matitis is filaggrin null mutations, 50% of patients
frequent single-gene disorders. It is an autosomal with moderate to severe atopic dermatitis do not
semidominant disease with incomplete penetrance have these null mutations, and 60% of all carriers
( 90% in homozygotes). The incidence is approx- of filaggrin-null alleles have never had atopic
imately 1 in 250. Ichthyosis vulgaris has some dermatitis. Finally, individuals with null muta-
phenotypic characteristics: palmar hyperlinearity, tions often outgrow their disease [16]. There
keratosis pilaris, and fine scaly skin [13]. seem to be other important candidate genes for
Homozygous or compound heterozygous atopic dermatitis, and furthermore the findings
mutations R501X and 2282del4 in filaggrin is the underscore that atopic dermatitis is caused both
cause of moderate to severe icthyosis vulgaris. by a deficient skin barrier and also by an elevated
The study of Smith et al. showed that heterozy- or skewed immune response [13].
gotic individuals displayed mild scaling or no A recent comprehensive meta-analysis on filag-
phenotype at all, whereas homozygotic or com- grin null mutations showed that filaggrin haploin-
pound heterozygotic individuals had a severe suffiency is associated with severe atopic dermatitis
form of icthyosis vulgaris (dry, scaly skin and an and strongly increases the risk of atopic dermatitis
altered skin barrier function) [3, 13, 24]. [21]. It is evident that environmental factors,
A diagnosis of icthyosis vulgaris is primarily modifier genes, and other primary gene defects are
based on clinical observations including family his- relevant for the variable manifestations of atopic
tory, but also by histopathological demonstration and dermatitis in different individuals [13]. Another
now mutation analysis of the filaggrin gene [13]. hypothesis is that individuals carrying null
9 Filaggrin Gene Defects and Dry Skin Barrier Function 121

mutations in more than one candidate gene have a is multifactorial and involves both endogenous
multiplicative or additive effect. Approximately, predisposition and environmental triggers. CHE
50% of moderate-severe cases may be attributed at has various risk factors of which atopic dermati-
least in part to filaggrin null mutations. Of the tis is known to be one of the most important.
mild-severe cases, only 15% may be explained by Also, wet work and contact allergy are known
filaggrin on a population scale [3]. risk factors. Since a deficient skin barrier func-
The filaggrin story is of great importance of tion increase the risk of CHE, null mutations in
the subcategorization of different forms of atopic filaggrin might also contribute to CHE. Several
dermatitis. The discovery of structural protein studies have investigated whether certain filag-
gene mutations in atopic dermatitis is ground- grin variants might be associated with CHE in
breaking and deviate our understanding from the general. Some also investigated certain CHE sub-
previous immune centric view [13]. types [4, 9, 12, 14, 26].
Probably the most convincing evaluation of
the possible association between hand eczema
9.5 Psoriasis and filaggrin null mutations was provided by
a recent general population study including
Psoriasis is a chronic inflammatory skin disease 3,471 adults. It showed that subjects with atopic
with a strong genetic background. dermatitis and filaggrin null mutation status had a
Genome-wide scans of psoriasis patients have significantly higher prevalence of hand eczema,
suggested an association with the epidermal dif- as well as earlier onset of disease and higher per-
ferentiation complex (EDC) on chromosome sistence of disease when compared with subjects
1q21. The EDC is a cluster of many genes, includ- who did not report atopic dermatitis and who had
ing filaggrin, which is expressed during epithelial wild-type filaggrin status [26]. Carlsen et al.
differentiation. Psoriasis susceptibility locus 4 found no association between, respectively,
(PSORS4) linked psoriasis to this region located nickel allergy, polysensitization, hand eczema at
at 1q21 [5, 13]. first appearance or occurrence of dermatitis, and
Despite this potential link, several studies have filaggrin null mutations [4]. Molin et al. found
concluded that there is no association of filaggrin that heterozygosity for null mutations in the fil-
null alleles (particularly R501X and 2282del4) aggrin gene may contribute to the manifestation
and psoriasis (or psoriatic arthritis). The studies and maintenance of a particular CHE subtype
also conclude that the genetic background under- that is characterized by the combination of aller-
lying the epidermal barrier defect in psoriasis is gic and irritant contact dermatitis [14]. In a small
distinct from that found in atopic dermatitis and twin study, Lerbaek et al. found no association
remains unknown [10, 29, 31]. A study from between the filaggrin null alleles and hand eczema
Taiwan confirms previous findings but finds an or contact allergy [12]. Yet another study found
association between P478S polymorphism of the that filaggrin null alleles were associated with
filaggrin gene and psoriasis [5]. increased susceptibility to chronic irritant contact
It appears that the EDC psoriasis gene, dermatitis [6].
PSORS4, is not filaggrin [31]. However, the fil- It remains unclear whether or not filaggrin
aggrin gene may still be a modifier gene contrib- gene null mutations increase the overall risk of
uting to the susceptibility for psoriasis [5]. hand eczema or only increase the risk of hand
eczema in subjects with atopic dermatitis. A typi-
cal phenotype of hand eczema in subjects with
9.6 Hand Eczema the filaggrin null genotype has been defined based
on a small case series [25]. These patients tend to
Chronic hand eczema (CHE) is a common persis- have palmar hyperlinearity, absence of palmar
tent noninfectious eczematous skin inflammation dermatitis, and presence of dermatitis on the dor-
restricted to the hands. The pathogenesis of CHE sal aspects of the hands.
122 M.W. Meyer and J.P. Thyssen

9.7 Allergic Contact Sensitization no evidence to suggest that filaggrin null muta-
tions cause alopecia areata [2].
Contact allergy is one of the most frequent der-
matological problems. It is a delayed type hyper-
sensitivity reaction caused by cutaneous exposure 9.9 Filaggrin Haploinsufency: A
to metals and chemicals. Contact allergy affects Potential Therapeutic Target
1520% of the general population and is a persis-
tent condition. Few studies have investigated a The discovery of filaggrin null mutations has
possible association between contact allergy and been a major breakthrough, but it has not been
the filaggrin null genotype. Novak et al. showed translated into therapeutic advances for patients
that filaggrin gene null mutations were associated with dermatitis or other skin diseases yet. The
with nickel sensitization and self-reported nickel wild-type allele carried by heterozygotic individ-
dermatitis in a general population study [15]. uals might be upregulated by small molecules
Thyssen et al. later refined these findings when acting on pathways controlling filaggrin gene
they showed that a positive association could expression and therefore theoretical have a poten-
only be detected in subjects without ear piercing tial therapeutic target [3].
[27]. This finding was explained by the bypass Most of the null mutations identified so far in
theory which suggest that ear piercing is a much the filaggrin gene are premature termination
stronger risk factor for nickel allergy than filag- codons causing nonsense mutations. These con-
grin genotype [15, 22, 27]. In further analyses, ditions are potential targets for treatment that
Thyssen et al. showed that fragrance allergy was enable read through of stop codons and permit
more prevalent in subjects with self-reported translation of a full-length protein. This type of
atopic dermatitis and the filaggrin null genotype treatment is already being tested in other diseases
when compared to subject without atopic derma- such as Duchennes muscular dystrophy and cys-
titis and with the filaggrin wild genotype [26]. tic fibrosis but will be even more suitable in atopic
Finally, a study based on dermatitis patients with dermatitis and ichthyosis vulgaris because of the
contact allergy found no association between possibility of topical application [13].
nickel allergy, polysensitization, hand eczema at
first appearance or occurrence of dermatitis, and
filaggrin null mutations [4]. Take Home Messages
Filaggrin has an important function in
epidermal differentiation and skin bar-
9.8 Alopecia Areata rier function
Null mutations within the filaggrin gene
Alopecia areata is a common dermatological dis- cause ichthyosis vulgaris
ease that affects up to 2% of the general popula- Null mutations are very strong predis-
tion. Alopecia areata has been suggested to be posing factors for atopic dermatitis
associated with filaggrin null mutations. Null mutations are associated with hand
Examination of a large cohort showed that in eczema and alopecia areata in atopics
patients with atopic dermatitis, filaggrin null but not with psoriasis
mutations were associated significantly with 910% of people of European origin
occurrence of alopecia areata. It also showed that are carrying these variants
filaggrin null mutations might serve as a modifier The discovery of filaggrin genotyping
of the clinical presentation of alopecia areata has been a major breakthrough for der-
because mutations were associated with the more matology, but it has not been translated
severe form of alopecia areata. However, there is into therapeutic advances yet
9 Filaggrin Gene Defects and Dry Skin Barrier Function 123

References associated with hand eczema or contact allergy. Br J

Dermatol 157:11991204
13. McGrath JA, Uitto J (2008) The filaggrin story: novel
1. Barker JN, Palmer CN, Zhao Y, Liao H, Hull PR, Lee
insights into skin-barrier function and disease. Trends
SP, Allen MH, Meggitt SJ, Reynolds NJ, Trembath
Mol Med 14:2027
RC, McLean WH (2007) Null mutations in the filag-
14. Molin S, Vollmer S, Weiss EH, Ruzicka T, Prinz JC
grin gene (FLG) determine major susceptibility to
(2009) Filaggrin mutations may confer susceptibility
early-onset atopic dermatitis that persists into adult-
to chronic hand eczema characterized by combined
hood. J Invest Dermatol 127:564567
allergic and irritant contact dermatitis. Br J Dermatol
2. Betz RC, Pforr J, Flaquer A, Redler S, Hanneken S,
161:801807
Eigelshoven S, Kortum AK, Tuting T, Lambert J, De
15. Novak N, Baurecht H, Schafer T, Rodriguez E,
WJ, Hillmer AM, Schmael C, Wienker TF, Kruse R,
Wagenpfeil S, Klopp N, Heinrich J, Behrendt H, Ring
Lutz G, Blaumeiser B, Nothen MM (2007) Loss-of-
J, Wichmann E, Illig T, Weidinger S (2008) Loss-of-
function mutations in the filaggrin gene and alopecia
function mutations in the filaggrin gene and allergic
areata: strong risk factor for a severe course of disease
contact sensitization to nickel. J Invest Dermatol
in patients comorbid for atopic disease. J Invest
128:14301435
Dermatol 127:25392543
16. ORegan GM, Irvine AD (2010) The role of filaggrin
3. Brown SJ, McLean WH (2009) Eczema genetics: cur-
in the atopic diathesis. Clin Exp Allergy 40:965972
rent state of knowledge and future goals. J Invest
17. ORegan GM, Sandilands A, McLean WH, Irvine AD
Dermatol 129:543552
(2009) Filaggrin in atopic dermatitis. J Allergy Clin
4. Carlsen BC, Johansen JD, Menne T, Meldgaard M,
Immunol 124:R2R6
Szecsi PB, Stender S, Thyssen JP (2010) Filaggrin
18. Palmer CN, Irvine AD, Terron-Kwiatkowski A, Zhao
null mutations and association with contact allergy
Y, Liao H, Lee SP, Goudie DR, Sandilands A,
and allergic contact dermatitis: results from a tertiary
Campbell LE, Smith FJ, ORegan GM, Watson RM,
dermatology clinic. Contact Dermatitis 63:8995
Cecil JE, Bale SJ, Compton JG, DiGiovanna JJ,
5. Chang YC, Wu WM, Chen CH, Hu CF, Hsu LA
Fleckman P, Lewis-Jones S, Arseculeratne G, Sergeant
(2008) Association between P478S polymorphism of
A, Munro CS, El HB, McElreavey K, Halkjaer LB,
the filaggrin gene and risk of psoriasis in a Chinese
Bisgaard H, Mukhopadhyay S, McLean WH (2006)
population in Taiwan. Arch Dermatol Res 300:
Common loss-of-function variants of the epidermal
133137
barrier protein filaggrin are a major predisposing fac-
6. de Jongh CM, Khrenova L, Verberk MM, Calkoen F,
tor for atopic dermatitis. Nat Genet 38:441446
van Dijk FJ, Voss H, John SM, Kezic S (2008) Loss-
19. Presland RB, Coulombe PA, Eckert RL, Mao-Qiang
of-function polymorphisms in the filaggrin gene are
M, Feingold KR, Elias PM (2004) Barrier function in
associated with an increased susceptibility to chronic
transgenic mice overexpressing K16, involucrin, and
irritant contact dermatitis: a casecontrol study. Br J
filaggrin in the suprabasal epidermis. J Invest Dermatol
Dermatol 159:621627
123:603606
7. Gan SQ, McBride OW, Idler WW, Markova N,
20. Rawlings AV, Harding CR (2004) Moisturization and
Steinert PM (1991) Organization, structure, and poly-
skin barrier function. Dermatol Ther 17(Suppl 1):
morphisms of the human profilaggrin gene.
4348
Biochemistry 30:5814
21. Rodriguez E, Baurecht H, Herberich E, Wagenpfeil S,
8. Ginger RS, Blachford S, Rowland J, Rowson M,
Brown SJ, Cordell HJ, Irvine AD, Weidinger S (2009)
Harding CR (2005) Filaggrin repeat number polymor-
Meta-analysis of filaggrin polymorphisms in eczema
phism is associated with a dry skin phenotype. Arch
and asthma: robust risk factors in atopic disease.
Dermatol Res 297:235241
J Allergy Clin Immunol 123:13611370
9. Giwercman C, Lerbaek A, Bisgaard H, Menne T
22. Ross-Hansen K, Menne T, Johansen JD, Carlsen BC,
(2008) Classification of atopic hand eczema and the
Linneberg A, Nielsen NH, Stender S, Meldgaard M,
filaggrin mutations. Contact Dermatitis 59:257260
Szecsi PB, Thyssen JP (2011) Nickel reactivity and
10. Huffmeier U, Traupe H, Oji V, Lascorz J, Stander M,
filaggrin null mutations - evaluation of the filaggrin
Lohmann J, Wendler J, Burkhardt H, Reis A (2007)
bypass theory in a general population. Contact
Loss-of-function variants of the filaggrin gene are not
Dermatitis 64:2431
major susceptibility factors for psoriasis vulgaris or
23. Sandilands A, Terron-Kwiatkowski A, Hull PR,
psoriatic arthritis in German patients. J Invest
ORegan GM, Clayton TH, Watson RM, Carrick T,
Dermatol 127:13671370
Evans AT, Liao H, Zhao Y, Campbell LE, Schmuth M,
11. Irvine AD, McLean WH (2006) Breaking the (un)
Gruber R, Janecke AR, Elias PM, van Steensel MA,
sound barrier: filaggrin is a major gene for atopic der-
Nagtzaam I, van GM, Steijlen PM, Munro CS, Bradley
matitis. J Invest Dermatol 126:12001202
DG, Palmer CN, Smith FJ, McLean WH, Irvine AD
12. Lerbaek A, Bisgaard H, Agner T, Ohm KK, Palmer
(2007) Comprehensive analysis of the gene encoding
CN, Menne T (2007) Filaggrin null alleles are not
124 M.W. Meyer and J.P. Thyssen

filaggrin uncovers prevalent and rare mutations in ich- mutations in the filaggrin gene and contact sensitiza-
thyosis vulgaris and atopic eczema. Nat Genet tion to nickel and other chemicals in the general popu-
39:650654 lation. Br J Dermatol 162(6):12781285
24. Smith FJ, Irvine AD, Terron-Kwiatkowski A, 28. van den Oord RA, Sheikh A (2009) Filaggrin gene
Sandilands A, Campbell LE, Zhao Y, Liao H, Evans defects and risk of developing allergic sensitisation
AT, Goudie DR, Lewis-Jones S, Arseculeratne G, and allergic disorders: systematic review and meta-
Munro CS, Sergeant A, ORegan G, Bale SJ, Compton analysis. BMJ 339:b2433
JG, DiGiovanna JJ, Presland RB, Fleckman P, McLean 29. Weichenthal M, Ruether A, Schreiber S, Nair R,
WH (2006) Loss-of-function mutations in the gene Voorhees JJ, Schwarz T, Kabelitz D, Christophers E,
encoding filaggrin cause ichthyosis vulgaris. Nat Elder JT, Jenisch S (2007) Filaggrin R501X and
Genet 38:337342 2282del4 mutations are not associated with chronic
25. Thyssen JP, Carlsen BC, Johansen JD, Meldgaard M, plaque-type psoriasis in a German cohort. J Invest
Szecsi PB, Stender S, Menne T (2010) Filaggrin null- Dermatol 127:15351537
mutations may be associated with a distinct subtype 30. Zhang H, Guo Y, Wang W, Shi M, Chen X, Yao Z
of atopic hand eczema. Acta Derm Venereol 90:528 (2011) Mutations in the filaggrin gene in Han Chinese
26. Thyssen JP, Carlsen BC, Menne T, Linneberg A, patients with atopic dermatitis. Allergy 66(3):
Nielsen NH, Meldgaard M, Szecsi PB, Stender S, 420427
Johansen JD (2010) Filaggrin null mutations increase 31. Zhao Y, Terron-Kwiatkowski A, Liao H, Lee SP,
the risk and persistence of hand eczema in subjects Allen MH, Hull PR, Campbell LE, Trembath RC,
with atopic dermatitis: results from a general popula- Capon F, Griffiths CE, Burden D, McManus R,
tion study. Br J Dermatol 163:115120 Hughes R, Kirby B, Rogers SF, Fitzgerald O, Kane D,
27. Thyssen JP, Johansen JD, Linneberg A, Menne T, Barker JN, Palmer CN, Irvine AD, McLean WH
Nielsen NH, Meldgaard M, Szecsi PB, Stender S, (2007) Filaggrin null alleles are not associated with
Carlsen BC (2010) The association between null psoriasis. J Invest Dermatol 127:18781882
 Molecular Organization of the Lipid
Matrix in Stratum Corneum 10
and Its Relevance for the Protective
Functions of Human Skin

Mila Boncheva

10.1 Introduction differentiated cells, corneocytes, or the extracel-

lular, predominantly lipidic, matrix surrounding
Despite the age-old awareness of the skin as a them [710]. A number of defensive properties
sheath protecting the living organism from its are enabled solely by the chemical identity of
environment, the first studies that pinpointed its the responsible ingredients; examples include
topmost layer, the stratum corneum (SC), as the the antimicrobial activity of peptides, ceramides,
most crucial element in this defense appeared only and fatty acids [11], the retention of water by the
in the 1940s [1, 2]. Our understanding of the struc- components of the natural moisturizing factor
ture and function of the SC has come a long way (NMF) and glycerol [12], and the triggering of
from the early notions of a passive, physical bar- inflammatory and immune-mediated reactions
rier against desiccation, xenobiotics, and patho- by cytokines [13]. The molecular properties and
gens [35]. The current view of the SC is that it is quantities of the SC constituents alone, however,
a complex, dynamic tissue capable of adapting its cannot explain its formidably low permeability
composition, organization, and activity in response to exogenous chemicals, its ability to adjust the
to environmental pressures, thus ensuring the rate of evaporation of water in response to the
homeostasis of the skin. In addition to protecting ambient humidity and temperature, its resistance
against loss of water, entry of chemicals, and to normal and sheer stress, or its impaired func-
microorganisms, it protects the underlying living tionality in disease; these characteristics exist
tissues from oxidative and UV damage, provides a largely because of the unique three-dimensional
constantly renewing barrier of high mechanical (3D) organization of the extracellular SC
integrity, flexibility, and cohesive strength, partic- domain. Thus, understanding the molecular
ipates in the psychosensory and neurosensory details of the organization within the SC lipid
interface of the organism, and is involved in the matrix is essential both for understanding the
initiation of inflammation and in the regulation of biophysics and physiology of skin and for the
innate and adaptive immunity [5, 6]. development of efficient therapies for disorders
The diverse protective tasks performed by and diseases of skin.
the SC typically localize in one of its two princi- This chapter will summarize the current
pal structural compartments the terminally knowledge of the composition and molecular
organization of the lipids found in the SC, review
the evidence connecting the structure of the lipid
M. Boncheva matrix with the efficient performance of the SC,
Corporate R&D Division, Firmenich SA,
and outline possibilities to improve the function-
Route des Jeunes 1, P.O. Box 239, CH-1211 Geneva 8,
Geneva, Switzerland ality of SC by modulating the 3D organization of
e-mail: [email protected] its lipids.

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 125

DOI 10.1007/978-3-642-27606-4_10, Springer-Verlag Berlin Heidelberg 2012
126 M. Boncheva

Table 10.1 The ceramides of human stratum corneum

Non-hydroxy -hydroxy Esterified -hydroxy
Fatty acid fatty acid fatty acid fatty acid
[N] [A] [EO]
OH o
o o o
Sphingoid base o OH
OH OH
Dihydrosphingosine Cer [NDS]
[DS]
H 2N
OH CER [NDS] CER [ADS] CER [EODS] OH
OH o OH
NH
Sphingosine
[S] H2N CER [NS] CER [AS] CER [EOS]
OH
(Cer 2) (Cer 5) (Cer 1)
OH

Phytosphingosine
[p] H2N CER [NP] CER [AP] CER [EOP]
OH
(Cer 3) (Cer 6) (Cer 9)
OH
OH

6-hydroxy sphingosine
[H] H2N CER [NH] CER [AH] CER [EOH]
OH (Cer 8) (Cer 7) (Cer 4)
OH
OH

Modified with permission from [18]. 2008 The American Society for Biochemistry and Molecular Biology. All rights
reserved. The ceramide subclasses are indicated according to the classification of Motta et al. [21] (in capital letters) and
according to the earlier classification based on chromatographic mobility (in parentheses). Each ceramide molecule
contains one sphingoid and one fatty acid residue, amide-linked as shown next to the table for Cer [NDS]

10.2 Composition of the Lipid the SC ceramides. The SC ceramides display a

Matrix in SC distribution of lengths in both the base and the
acid chains; this variety results in the existence of
The lipids of the SC intercellular matrix differ over 340 different ceramide species [15, 17, 18].
considerably from those typical of the membranes Most often, the short (sphingoid) hydrocarbon
in viable mammalian cells [14, 15]. Three classes chain comprises 1820 carbon atoms. The length
of lipid molecules account for over 8595% of distribution of the long (fatty acid) chains is
the dry mass of SC matrix: ceramides (about 50% broader: it varies between 20 and 32 carbon
by mass), fatty acids (1020% by mass), and cho- atoms and peaks at 24 carbons [15]. The majority
lesterol (about 25% by mass). In addition to this of the ceramide classes are extractable, i.e., they
approximately equimolar lipidic mixture, the SC exist unattached to other molecular species. Most
contains also several minor lipid ingredients of the w-hydroxy ceramides, however, are cova-
cholesterol sulfate (07%, playing an important lently linked to proteins of the corneocyte enve-
role in the processes of desquamation), choles- lope by esterification of their w-hydroxyl groups
teryl esters (020%), and small amounts of di- or of one of the hydroxyl groups on the long-
and triglycerides, probably of sebaceous origin chain base moiety [14, 22]; approximately one-
[16]. The phospholipids typical of the membranes third of the Cer [EOS] moiety (and probably also
of viable cells are notably absent. some Cer [EOP] and Cer [EOH]) is present in the
The ceramide composition of the lipid matrix interior of the bilayer lamellae [23]. The fatty
is extremely complex [15, 1720]. These long- acid esterified to the w-hydroxyl groups of Cer
chain lipid molecules consist of fatty acids amide- [EOS] is most often linoleic acid, occasionally
linked to sphingoid bases. Twelve ceramide replaced by oleic and stearic acid residues [24].
subclasses have been identified so far in the extra- In principle, the ceramide molecules can adopt
cellular space of SC. Table 10.1 summarizes the three different conformations, depending on their
known sphingoids and fatty acids that constitute environment (mixed or pure crystals) and the
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 127

degree of hydration of their head groups [25, 26]: ensure lower permeability than lipid membranes
hairpin, with the two hydrocarbon chains point- comprising unsaturated or branched hydrocarbon
ing in the same direction; splayed, with the two chains, and a broader range of phase-transition
hydrocarbon chains pointing in opposite direc- temperatures than membranes comprising a sin-
tions away from the head group; and V-shaped, gle chain length [3234].
with the two hydrocarbon chains forming an The presence of cholesterol in the SC lipid
angle of approximately 60 with the head group matrix is hardly surprising. This lipid ubiqui-
positioned at the angle origin. The conformations tous in biological membranes is known for its
existing in the native SC lipid matrix are still role in regulating the packing density of lipid
under debate. membranes [3537] and, thereby, their permea-
Several structural features of the SC ceramides bility [33]. Despite considerable research effort
make them uniquely well-suited for their role as over almost a century [38], the exact molecular
barrier lipids: (1) The asymmetry and the poly- mechanism by which cholesterol exerts its action
dispersed lengths of the hydrocarbon chains is still debatable [39]. Cholesterol also broadens
facilitate the intermolecular mixing between dif- the region of phase-transition temperature, favors
ferent ceramide subclasses and between cer- intermixing of different lipid species, and, at high
amides, free fatty acids, and cholesterol [27], and concentrations, promotes the formation of lamel-
enable the formation of regions of high chain lar structures [40, 41].
mobility without affecting the head group pack- The precursors of the three major SC lipid
ing [28]. (2) The presence of unsaturated fatty classes are synthesized locally, in the epidermis,
acid esterified to the long (up to 34 carbon atoms) with the notable exception of the essential fatty
w-hydroxy fatty acids in the [EO] ceramides per- acids included in the [EO] ceramides; by defini-
mits the formation of disordered (liquid-crystal- tion, these unsaturated fatty acids cannot be syn-
line) phases and lamellar structures with large thesized in the body and have to be obtained from
repeat distances. (3) The polar head groups are dietary sources [42]. The extent to which extracu-
small and match closely the cross-section of the taneous sources (nutritional or from topical appli-
hydrocarbon chains and thus enable the forma- cation) contribute to the lipid pool in the cells in
tion of bilayer lamellar structures. (4) The small the stratum granulosum and the extent to which
size of the functional groups in the head group they can modulate or replace the epidermal
region precludes its excessive hydration and loss sources are not clearly determined, although such
of rigidity in conditions of high humidity. (5) a possibility clearly exists [43].
The presence of both donor and acceptor groups
in the ceramide head groups enables the forma-
tion of extended network of hydrogen bonding 10.3 Molecular Organization
between molecules located within the same and of the SC Lipids
within neighboring bilayer leaflets, thus enhanc-
ing the impermeability and stability of the lamel- The lamellar organization of the lipid matrix,
lae [2931]. later identified as stacked lipid bilayers roughly
The free fatty acids present in SC (i.e., those parallel to the large faces of the corneocytes,
existing as individual molecules, and not as a part has been known since the 1970s [4447]. Despite
of the ceramide species) have a fairly broad dis- the enormous activity in the field, and the excit-
tribution of chain lengths (between 20 and 30 ing progress achieved since then, however, the
carbon atoms), peaking at the length of 2226 molecular details of the lipid organization within
carbons a value unusually high for most bio- and across the lamellar planes have not yet been
logical membranes [32]. They are exclusively proven unequivocally and are still a hot topic in
nonbranched and saturated. These structural fea- SC research (reviewed in [48]). The field built
tures have important physiological consequences upon the extensive knowledge and savoir-faire
for the performance of the lipid matrix: they accumulated in more than a century of studies in
128 M. Boncheva

the biophysics and physical chemistry of cellular denoted as La) phase (LIQ), the chains exhibit a
and subcellular membranes, based for the most high degree of gauche isomerization, and the lat-
part on model systems derived from phospholip- eral organization is entirely lost; the lipid mole-
ids [49]. The exceptional composition of the lipid cules have high rotational and translational
matrix and the existence of steep gradients of mobility in the bilayer plane.
water, pH, and cations in it, however, preclude All three lipid phases are present in the SC
assuming direct analogy with other biological lipid lamellae, with a marked prevalence of the
membranes and lipid structures; relying on such OR phases. Their coexistence was demonstrated
analogies can be grossly misleading. in vitro (in mixtures of extracted SC lipids or
A vast array of complementary experimental their synthetic analogues [7073]), ex vivo (in
techniques has been applied to determine the isolated SC and in SC flakes removed by tape-
organization of the lipids in SC. These include stripping [50, 62, 74, 75]), and in vivo (in human
electron diffraction [9, 50], small- and wide-angle volunteers [76]). The abundance of crystalline
X-ray diffraction [9, 51], neutron diffraction [26, OR phases in the SC lipids lamellae is in stark
52, 53], electron microscopy [5458], Raman contrast with the predominance of LIQ phases in
[59, 60] and IR spectroscopy [31, 6164], differ- the plasma membranes of living cells [77, 78];
ential scanning calorimetry [60, 62], 2H NMR this difference in phase composition reflects the
spectroscopy [27, 65], electron paramagnetic different requirements to the permeability of the
resonance [66, 67], fluorescence microscopy two types of lipid structures and the different
[68], and atomic force microscopy [69]. The dif- environmental pressures to which they are
ferent sensitivity of these techniques to the lipid exposed.
arrangement in the plane of the lamellae and nor- The amount of extracellular lipids and the
mal to it, the different level of detail that they can relative content of the three phases are not homo-
provide, the different propensity they have to arti- geneous throughout the SC thickness. The amount
facts related to sample preparation, the different of lipids is highest at the SC surface and progres-
time and length scales in which they can operate, sively decreases toward the inner layers [61].
and the different possibility to apply them in vivo The topmost SC layers often contain disordered
or in vitro clearly indicate that in structural stud- phases, a consequence of the intermixing of
ies, it is preferable to use them in combination sebum and endogenous SC lipids [61, 79, 80].
rather than to rely exclusively on any single one. The middle layers have the highest extent of OR
phases [50, 76], and the innermost layers have a
lower degree of lateral order than the middle
10.3.1 Lateral Molecular Organization ones, possibly as a result from the incomplete
structural reorganization of lipids close to the
Figure 10.1 shows schematically the possible interface between the stratum corneum and stra-
chain conformations and lateral packing arrange- tum granulosum [16, 81]. In human SC, the lipid
ments that are believed to exist in lamellar lipid content and the depth profiles of the lateral orga-
bilayers (reviewed in [63]). In the most densely nization do not correlate with age or gender.
packed, orthorhombic phase (OR), the lipid chains The molecular composition of the three lipid
adopt all-trans conformation and are organized in phases is still debatable (see also the next sec-
a rectangular crystalline lattice with no rotational tion). There are indications that the majority of
or translational mobility. In the hexagonal (also the free fatty acids and ceramides participate in
denoted as gel or Lb) phase (HEX), the all-trans one and not in several different OR phases; most
lipid chains are tilted in respect to the crystal probably, only a small fraction of the free fatty
plane and form a less dense, hexagonal lattice; the acids phase-separates into pure OR domains [82].
lipid molecules have some rotational mobility Phase-separated, crystalline cholesterol frequently
along their long axis, but their translational mobil- exists along with the mixed crystalline phases
ity is restricted. In the liquid-crystalline (also [83, 84]. The unsaturated linoleate moiety of Cer
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 129

a OR HEX LIQ

Chain
packing

Chain
conformation

b c d

Fig. 10.1 Lateral molecular organization of SC lipids. (a) domain mosaic model (b), the sandwich models (c), and
Scheme of the lateral chain packing (top row) and chain the single gel-phase model (d). Ceramides and fatty acids
conformation (bottom row) in orthorhombic (OR), hexago- are represented with the schematic drawing of long-chain
nal (HEX), and liquid-crystalline (LIQ) phases of long- lipids used in (a); the presence of cholesterol is explicitly
chain lipids. (bd) Models of the molecular organization of shown only in (d) by the smaller of the two symbols. The
the SC lipid matrix displaying different content and distri- different lipid phases are represented by the conformational
bution of the lipid phases. The schemes illustrate the order of the long hydrocarbon tails as indicated in (a)

[EOS] is most probably located in the highly dis- different lipid species play in the lateral organiza-
ordered LIQ phase [82, 85]. Despite its high con- tion is still not fully understood. Extensive work
formational disorder, however, this fatty acid using simplified model lipid mixtures, however,
chain has none of the translational mobility char- has helped to establish several important correla-
acteristic for a LIQ phase (because of its covalent tions: (1) The presence of Cer [EOS] stabilizes the
attachment to the fatty acid chain of the ceramide), OR phase regardless of the degree of saturation in
and thus, in its presence the phase has the modi- the esterified w-hydroxy fatty acid [86]. (2) A
fied characteristics of a pseudo-fluid one [82]. reduction of the content of free fatty acids to less
Because of the complex composition of the SC than approximately equimolar with ceramides and
lipid matrix and the impossibility to vary system- cholesterol results in decreased content of OR
atically its composition in vivo, the role that the phases [87]. (3) The length of the alkyl chains of
130 M. Boncheva

the free fatty acids is important for the type of simplified model mixtures containing only a few
lipid phases that can form: mixtures of ceramides, lipid species. Despite the undoubted usefulness
cholesterol, and fatty acids with long chains (i.e., of this approach, however, it is important to keep
having 22 and 24 carbon atoms) form prevalently in mind that systems of extremely simplified
OR phases (together with some LIQ phases), composition represent only a rough approxima-
while similar mixtures containing fatty acids with tion of the rich molecular variety existing in the
short chains (i.e., having 16 and 18 carbon atoms) native SC and, thus, cannot be expected to give
form exclusively HEX phases [48, 88]. (4) The more than a rough approximation of the native
architecture of the ceramide head group is impor- molecular organization. For experimental conve-
tant for the chain packing: the propensity of sphin- nience, the selection of the molecules comprising
gosine ceramides to form OR domains induces these mixtures has often been limited to species
the alkyl chains of the free fatty acids to pack in of well-known behavior (such as phospholipids
OR domains; in contrast, the propensity of phy- and fatty acids with short chains) or easily avail-
tosphingosine ceramides to form domains of more able ones (such as those isolated from animal
open HEX structure entails the same HEX organi- instead of human SC and those commercially
zation in the alkyl chains of the free fatty acids available) instead of those most abundant and
[30, 82]. (5) The type of fatty acid linked to the characteristic for the SC.
ceramide base can also influence the chain pack- The currently existing models proposed for the
ing, as the additional hydroxyl group in the molecular organization of the SC lipids can be
a-hydroxy compared to nonhydroxy fatty acids is grouped in three major categories according to the
also located in the head group region [82]. presence and the distribution of the main lipid
phases: (1) The domain mosaic model of Forslind
[90, 91] describes the lipid matrix as a two-phase
10.3.2 Lamellar Molecular Organization system in which discontinuous crystalline domains
(OR) are embedded in a continuous gel (HEX) or
In the direction normal to the surface of the cor- liquid-crystalline (LIQ) phase (Fig. 10.1b), and
neocytes, the lipid bilayers are stacked on top of each lamellar layer contains laterally adjacent
each other and form a repeating pattern of struc- impermeable and permeable domains. The molec-
tural units (lamellae). Two types of lamellar struc- ular transport across the lamellae proceeds by dif-
tures exist in the SC lipid matrix, which differ in fusion through disordered phases situated around
their characteristic repeat distance, that is, their the borders of the OR domains. Further refine-
thickness: one with a thickness of approximately ments of this model suggested that both the
13 nm, denoted long periodicity phase (LPP), and penetrable and impenetrable SC domains are het-
another with a thickness of approximately 6 nm, erogeneous and comprise lipidic and proteina-
denoted short periodicity phase (SPP). Most ceous elements [92, 93]. (2) The sandwich-type
often, the LPP is found between the large, flat sur- models of Bouwstra et al. [94], Swartzendruber
faces of adjacent corneocytes and the SPP close et al. [55], Wertz et al. [89], and McIntosh [95]
to their edges [89]. In electron micrographs, the describe the lipid matrix as a multiphase system in
LPP lamellae appear as centrosymmetric stacks which the lamellae contain a central zone of higher
of broad-narrow-broad bands [14]. mobility (HEX or LIQ, in some models forming a
There is still no general consensus concerning discontinuous phase in an OR matrix) sandwiched
the localization and the arrangement of the lipid between two zones of lower lipid mobility (OR,
molecules within the lamellae. Obtaining data gel, or ordered liquid phase) (Fig. 10.1c). The
with high resolution from native, isolated SC molecular transport across the lamellae is slowed
is not straightforward, and their interpretation by the preferential lateral diffusion of the mole-
(especially in the case of diffraction experiments) cules within the central zone of higher mobility.
is sometimes not trivial. Numerous studies have (3) The single gel-phase model of Norln [96]
attempted to circumvent these problems by using describes the lipid matrix as a single and coherent
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 131

gel phase with no true phase separation in either lamellae. An extended conformation for Cer [AP]
direction but containing cholesterol-rich domains is supposed to serve as an armature-like rein-
(organized in closely packed, liquid-crystalline forcement preventing the expansion of the lipid
structures) of high permeability and cholesterol- bilayers in the course of hydration; Kiselev et al.
poor domains of low permeability (Fig. 10.1d). later suggested that this ceramide undergoes
Some crystalline domains may form in the upper chain-flip transitions between its splayed confor-
layers of the SC as a result of the processes of mation in partially hydrated SC and hairpin con-
desquamation. Despite its attractive simplicity, formation in excessively hydrated SC [97].
however, this model does not accommodate the The model proposed by McIntosh [95] differs
irrefutable experimental evidence for the exis- from the previously described ones in that the
tence of highly ordered OR domains within the centrosymmetric unit cell comprises only two
SC lipid lamellae in vivo and in vitro; thus, its lipid bilayers of uniform (4.7 nm) thickness
validity is questionable. (Fig. 10.2c). Each of these bilayers has a sym-
Several sandwich-type models exist for the metric arrangement of most of the SC ceramides
molecular distribution and organization within but an asymmetric arrangement of Cer [EOS]
the LPP. In the model of Bouwstra et al. (first pro- (with the linoleate moiety situated in the inner
posed in [94] and refined subsequently), the cen- leaflets of the bilayers) and cholesterol (enriched
trosymmetric unit cell comprises three lipid in the outer leaflets of the bilayers). It is possible
bilayers of very similar thicknesses 4.5, 4.0, that some of the ceramides adopt a splayed con-
and 4.5 nm (Fig. 10.2a). The long alkyl chains of formation. The model also suggests a water layer
ceramides and free fatty acids form tightly packed next to the head groups of the outer leaflets of the
(OR) outer bilayers, while the unsaturated bilayers.
linoleate chains of Cer [EOS] slightly interdigi- At present, it is very difficult to affirm unequiv-
tating form domains with high mobility of the ocally the superiority of all features of one over
lipid chains (HEX or pseudo-fluid ones) located the other models. Notwithstanding the different
in the middle bilayer [82]. The ceramides adopt interpretations of the experimental data, and the
hairpin conformation, with the hydrocarbon lack of sufficient molecular detail in the resolved
chains interdigitating partially (in the outer bilay- structures, the lipid systems that served to develop
ers) or fully (in the middle bilayer). Cholesterol the models differ considerably in both their com-
is most probably asymmetrically enriched in the position and their preparation. The models
outer lipid bilayers. There is a gradual change of described here have undergone substantial devel-
the chain mobility across the thickness of each opment and revision since their original versions
LPP lamella. owing to the development of better extraction
In the model proposed by Swartzendruber protocols for native SC lipids, the broader avail-
et al. [55] and later refined by Wertz et al. [34, ability of synthetic analogues of the native SC
89], the unit cell comprises three lipid bilayers of ceramides, and the use of more advanced tech-
uniform (4.3 nm) thickness (Fig. 10.2b). The two niques for structure determination. Undoubtedly,
outer bilayers are organized in relatively rigid, detailed studies of the lamellar molecular organi-
gel, or liquid-ordered phases. The unsaturated zation of the SC lipids continuing in these and
linoleate chains of ceramides [EO] are situated in other groups will greatly contribute to advance
the middle, relatively fluid (possibly LIQ) bilayer. our understanding of the system.
The ceramides (with the exception of Cer [EO]), The existence and the structure of the LPP
free fatty acids, and cholesterol are distributed are extremely sensitive to the lipid composition.
randomly within the subunits. In all three sub- Ceramides and cholesterol can form an LPP
units, the lipid chains do not interdigitate. It is in absence of free fatty acids or in presence of
possible that some of the ceramide molecules short-chain free fatty acids, but it lacks domains
adopt splayed conformation, with one aliphatic with OR organization [87]. In absence of acylcer-
chain inserting in each of a pair of adjacent amides, and, in particular, of Cer [EOS], the
132 M. Boncheva

a b c

LPP
~13 nm

d e
Key

Cer [EO]

ceramide in
4.2 hairpin conformation
5.4 4.8
SPP
nm nm ceramide in
splayed conformation

free fatty acid

cholesterol

Fig. 10.2 Lamellar molecular organization of the SC lip- main features of the models. The solid lines indicate the
ids. Schematic drawings of the models proposed for the borders of one lamella, the dashed arrows indicate the
long periodicity phase (LPP; ac) and the short periodic- characteristic periodic repeat distances of the phases, and
ity phase (SPP; d, e); see the text for a discussion of the the dotted lines delimit the individual lipid bilayers

fraction of lipids forming the LPP is extremely capable of forming a phase of high mobility [86].
small [85, 98]. The replacement of the linoleic Lack of variety in the architecture of the head
with saturated residue in the Cer [EOS] molecule groups in the ceramide molecules and a narrow
prevents the formation of LPP, indicating that the distribution of the lengths of the lipid chains reduce
formation of LPP necessitates a fraction of lipids the ability to form LPP reproducibly [52, 82].
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 133

Several recent studies focused on the struc- molecular diversity of the endogenous SC lipids
tural features of the other lamellar phase present will shed more light on the molecular organiza-
in the SC, the short periodicity phase (SPP). A tion and composition of the SPP in healthy SC.
report by Bouwstra et al. described the formation
of SPP in an equimolar mixture of synthetic cer-
amides (Cer [NS], Cer [NP], and Cer [AS]), cho- 10.4 Self-Assembly
lesterol, and fatty acids (comprising 1626 carbon of the Lipid Matrix
atoms, in a ratio typical for human SC) [99]. Cer
[EOS] was not included in the lipid mixture The 3D organization of the lipid lamellae is a
because of its prominence in the LPP. In the result of hierarchical, templated self-assembly
molecular model of SPP proposed in this work processes that occur at the border between the
(Fig. 10.2d), the unit cell has a repeat distance of topmost layer of viable epidermal cells, the stra-
5.4 nm and comprises one lipid bilayer. The cer- tum granulosum, and the inner layers of SC. The
amides have a symmetric arrangement in a exact sequence of events in the cascade of pro-
splayed or hairpin conformation, with interdigi- cesses leading to the formation of the lipid lamel-
tating acyl chains in the middle of the bilayer. lae and the concomitant terminal differentiation
The majority of the ceramides, cholesterol, and of the keratinocytes is not yet fully understood
fatty acids are mixed homogeneously, with only a [102]; new participants and effectors in this cas-
small fraction of phase-separated cholesterol. cade are still being identified [103]. In broad,
The SPP is weakly hydrated and probably con- simplified terms, the lamellar assembly proceeds
tains two water molecules per lipid head group. through the following steps: The precursors of
Neubert et al. also reported the formation of the main SC lipids glucosyl-ceramides, sphin-
phases of short periodicity in quaternary lipid gomyelin, cholesterol, and phospholipids are
mixtures composed of Cer [AP], Cer [EOS], cho- synthesized in the keratinocytes of stratum spino-
lesterol, and a fatty acid comprising 16, 22, 24, or sum. There, they are organized in flattened, short
26 carbon atoms [52, 100], or composed of Cer bilayer stacks within lamellar bodies (LB)
[AP], cholesterol, cholesterol sulfate, and palm- secretory granules that contain in addition an
itic (C16) or behenic (C22) acid [26, 101]. The array of catabolic enzymes, antimicrobial pep-
unit cells of the observed SPPs contained one tides, and other proteins [10, 104107]. The
bilayer and had repeat distances of 4.24.8 nm lamellar bodies are stored in the keratinocytes of
(Fig. 10.2e). Not surprisingly, even the mixtures stratum spinosum and stratum granulosum. While
containing Cer [EOS] did not form LPP, as they under basal conditions they are secreted at low
lacked the characteristic for SC polydispersity in rates, an acute barrier disruption generates a
the lengths of the fatty acids and in the architec- number of signals (e.g., changes in the concentra-
tures of the ceramide head groups. The molecular tion gradients of cations and water [108, 109]) for
arrangement proposed for the SPP consists of rapid enhancement of their secretion and the
one bilayer in which the Cer [AP] molecules induction of terminal differentiation of corneo-
adopt splayed conformation and connect leaflets cytes [103]. In response to these signals, the kera-
of adjacent bilayers or adopt hairpin conforma- tinocytes secrete the content of the LB in the
tion within one bilayer leaflet, and the linoleate extracellular space surrounding the corneocytes
moiety of Cer [EOS] protrudes into the adjacent of SC, and it anchors onto the desmosomes [102].
bilayer. The model based on behenic acid allows The w-hydroxy ceramides that are covalently
for interdigitation of the hydrocarbon chains bound to the corneocyte envelope (in particular
in the middle of the bilayer, and the model based Cer [OS]) play an important role in templating
on palmitic acid does not. In both these model the proper orientation and alignment of the
systems, a small fraction of the cholesterol phase- bilayer stacks. Following their alignment at the
separates. Clearly, only further work using model corneocyte surface, the short lipid stacks fuse
systems with composition approaching the into long lamellae and are processed by the
134 M. Boncheva

enzymes coextruded from the LB into the ulti- maintain their molecular order which corresponds
mate SC lipids of considerably higher hydropho- to the minimum thermodynamic potential of the
bicity [30, 102, 110]. Driven by the spontaneous system; in other words, the lipid organization in
organization of the intercellular lipids, the pro- an appropriately preserved, isolated sheet of SC
teinaceous portion of the LB content is displaced and in the same SC still attached to a living body
toward the hydrophilic loci represented by the (i.e., to a source of energy) would not differ, pro-
extracellular portions of the corneodesmosomes; vided the temperature and humidity conditions
thus, the newly formed lipid lamellae indirectly are the same. Furthermore, subjected to minor
aid the colocalization of the SC enzymes and (e.g., thermal) perturbations, the system will tend
their substrates [111]. to return to its initial state and assume its initial
The interactions that hold together the final molecular organization. The fact that the molecu-
3D structure of the lipid lamellae are van der lar organization within the lipid matrix corre-
Waals forces existing between the long hydrocar- sponds to a (global or local) thermodynamic
bon chains of ceramides and fatty acids in the minimum indicates that it is possible to repro-
plane normal to the lamellae, and hydrogen bonds duce it in model systems by mixing and equili-
existing between the polar head groups of the brating the components and that it is possible to
ceramides in the lateral plane of the lamellae and study lipid biophysics in isolated SC sheets ex
between neighboring lamellae [25, 29, 30, 112]. vivo.
During the formation of the lamellae, hydropho- Despite the extensive research effort during
bic interactions (i.e., those combining van der the last few decades, the thermodynamics of the
Waals interactions with the enthalpic and entropic processes leading to the formation of the intricate
consequences of restricting the hydrogen bond- 3D structure of the lipid matrix is not fully under-
ing of water in the vicinity of the apolar lipid stood [62]. Because of the low strength of the
chains) provide additional contribution to the molecular interactions between the SC lipids,
driving forces involved in the lipid self-assembly. the enthalpies of the interactions holding together
All these reversible, noncovalent interactions are the matrix structure are relatively weak (if com-
relatively weak and comparable in strength to the pared, for example, to those of the covalent bonds
~2.5 kJ/mol of thermal energies (e.g., the van der binding the w-hydroxy ceramides to the corneo-
Waals attraction between two small alkane mol- cyte envelope); the interplay between enthalpy
ecules in water is approximately 10 kJ/mol, and and entropy during the self-assembly process is,
most hydrogen bonds contribute between 10 and therefore, significant and should not be ignored.
40 kJ/mol [113115]); nonetheless, they com- As the self-assembly can be driven by purely
pound in the extensive lipid lamellae to give a enthalpic effects, purely entropic effects, or a
robust structure. combination of both, the relative contributions of
It is important to emphasize that the 3D struc- both to the reduction of the overall free energy of
ture of the SC lipids represents a static self- the system must be considered [113].
assembled structure and not a dynamic one, as
sometimes assumed [96, 116]. By definition, this
distinction refers to the energetics of the struc- 10.5 Correlation Between the
tures resulting from self-assembly processes and Molecular Organization
not to the process itself. Thus, static self-assem- of the Lipid Matrix
bled structures are equilibrium ones, existing in and the SC Performance
global or local energy minima; in contrast,
dynamic self-assembled structures are nonequi- In numerous skin conditions (e.g., dry, environ-
librium, energy dissipating ones that are main- mentally stressed, and chronologically aged skin)
tained in a steady state by constant supply of and diseases (e.g., type 2 Gauchers disease,
energy [117, 118]. Following their formation, the Niemann-Pick disease, many ichthyoses, atopic
lipid lamellae do not need an influx of energy to dermatitis, psoriasis, and essential fatty acid
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 135

deficiency), the lipid composition and quantities The well-known correlation between the con-
differ from those in healthy SC due to perturbations formational ordering of the hydrocarbon chains
in the synthesis, delivery, or extracellular pro- in phospholipid membranes and the membrane
cessing of one or several classes of SC lipids [10, permeability has been examined in human SC
104, 119]. The way that the abnormal lipid com- both ex vivo and in vivo [125130]. These stud-
position translates into impaired SC functional- ies have clearly established that an increase in the
ity, however, has been investigated in detail only content of disordered phases in the SC correlates
in few cases, for example in dry skin and in skin with increased molecular diffusion. In addition, a
from patients with atopic dermatitis, lamellar ich- recent in vivo study demonstrated the existence
thyosis, and psoriasis (reviewed in [8] and [9]). of a direct linear correlation between the lateral
These studies have clearly demonstrated the molecular organization of the SC lipids and the
importance of the molecular organization of the efficacy of SC as a barrier to water transport: the
SC lipids in the etiology of the diseases. higher the fraction of lipids involved in OR
phases, the lower the TEWL [76]. In principle,
the direction of transport outside-in or inside-
10.5.1 Permeability of the SC out should not influence the SC permeability to
a given class of molecules [131]; thus, it would
In general terms, the key parameters that deter- be very interesting to examine if the same corre-
mine the permeability of the SC to a given mole- lation holds for topically applied, small hydro-
cule are the partition coefficient of the molecule philic molecules.
between its external (e.g., topically applied drug The relative importance of the lamellar and
formulation) or internal (e.g., highly hydrated the lateral molecular organization of the SC lip-
cells of the viable tissue) reservoir and the struc- ids for its permeability to molecules of medium
tural components of the SC (the corneocytes and and high lipophilicity is not yet well understood.
the lipid matrix), the diffusion coefficient of the There are strong indications that the LPP which
molecule within the SC, and the length of the dif- is present in the SC of all species investigated to
fusional pathway [120]. All three parameters date plays an important role in SC permeability
depend heavily on the molecular organization of [9]. In the SC of patients with lamellar ichthyo-
the lipid lamellae. Depending on their physico- sis, a disease characterized by abnormally high
chemical properties (e.g., molecular size and skin permeability, the periodicity of the LPP is
shape, lipophilicity, polarity, and hydrogen bond- decreased, and its general appearance is signifi-
ing ability), molecules cross the SC at different cantly altered; concomitantly, the content of Cer
rates and following different pathways [121 [EOS], the ceramide crucial for the formation of
123]; as a consequence, different aspects of the the LPP, is reduced (reviewed in [9]). A study
molecular organization can be expected to be with synthetic SC membranes demonstrated that
important for the penetration of small, polar, in the absence of LPP, the permeability of the
hydrophilic molecules like water and the penetra- membranes to molecules of medium hydropho-
tion of large, apolar, lipophilic molecules like bicity increased twofold compared to the one
many cosmetic ingredients and topical drugs. observed in the presence of LPP. This observa-
While in some cases the skin permeability for tion indicates that at least a part of the SC barrier
both hydrophilic and lipophilic molecules is of the diseased skin is due to a reduced LPP con-
abnormally high (e.g., in skin diseases related to tent [132]. It is, however, difficult to separate the
failure in the formation of LB like harlequin ich- effect of the lamellar and lateral lipid organiza-
thyosis [16]), the two are not necessarily identi- tion in these cases: besides having abnormal
cal; thus, the SC permeability to water measured lamellar structure, atopic SC also has a markedly
as transepidermal water loss (TEWL) does not reduced content of OR, and in SC of skin with
always reflect the SC permeability to other lamellar ichthyosis, the HEX content is predomi-
molecular species [124]. nant, possibly together with nonlamellar LIQ
136 M. Boncheva

phases [133]. A recent work elaborated further the relative contributions of the lipidic and the
on the relative contributions of the lamellar and proteinaceous components of the SC to the per-
the lateral lipid organization to the permeability turbed cohesion and integrity in topically stressed
of the SC for small hydrophobic molecules by and diseased skin [119, 135]. Thus, for example,
comparing the activation energies for the penetra- a sustained increase of pH of the skin surface
tion of benzoic acid across synthetic SC ana- causes the formation of incomplete lamellae and
logues containing or lacking the LPP [53]. The accelerates the degradation of corneodesmo-
study showed that the presence of LPP probably somes [139, 141], while elevated levels of cho-
leads to an increase of the activation energy of lesterol sulfate (e.g., those observed in recessive
the transport of benzoic acid across the lipid X-linked ichthyosis) provoke abnormal appear-
matrix. It will be very interesting to examine the ance of the lamellae and abnormally high cohe-
importance of the LPP with molecules having sion in the superficial layers of SC [104]. In vitro
different physicochemical characteristics, while studies using SC models have shown that a pH of
following in detail the effect that these molecules 7.4 and relatively high content of cholesterol sul-
exert on the lateral lipid molecular organization fate, two conditions typical for the inner SC lay-
during their transit through the lipid layers. The ers, promote the formation of the LPP phase;
role of SPP in maintaining the barrier efficiency their drop in the superficial SC layers may help to
is not yet fully understood [134]. destabilize the lipid lamellar organization, thus
facilitating desquamation [134, 142].
Several mechanisms might explain how an
10.5.2 Integrity and Cohesion of the SC altered lipid organization can lead to abnormal
desquamation and loss of integrity in SC [104];
The maintenance of a competent barrier across the these include abnormal hydrogen bonding bet-
SC requires that it has the capacity to resist minor ween the SC ceramides [66], abnormal Ca2+-
external insults, a property denoted as integrity. In mediated ionic interactions [143], abnormally
addition, the homeostasis of the SC barrier neces- high content of phase-separated lipids [134], and
sitates the maintenance of a gradient of intercel- abnormal ratio of ordered and disordered lipid
lular cohesion within the SC, ranging from strong phases. The experimental evidence connecting
in the inner SC layers (to ensure the mechanical the phase content of the lipid matrix and the
stability of the tissue) to weak in the surface layers integrity and cohesion of SC is still incomplete.
(to ensure the normal desquamation of terminally As discussed earlier, the presence of some lipids
differentiated corneocytes) [135, 136]. Integrity adopting LIQ organization is necessary for the
and cohesion are often not discriminated in the formation of the LPP phase and for maintaining
literature and are measured experimentally by the its elasticity; in the absence of disordered phases,
damage expressed as the change of TEWL the lamellae might be unable to follow closely
(integrity) or as the amount of removed protein the contours of the corneocytes, thereby weaken-
(cohesion) caused by tape-stripping. ing the intercellular cohesion [134]. Studies of
The current understanding of the role of SC the mechanical properties of isolated SC, how-
lipids, and especially of their molecular organiza- ever, have shown that the lipid disordering is not
tion, for the integrity and cohesion of SC is enough to weaken the intercellular cohesion
incomplete. The difficulty in investigating this [144]. The extent of lipids participating in OR
correlation stems from the fact that several com- phases correlates well with the degree of integrity
mon factors that is, the local concentrations of (measured by the change of basal TEWL follow-
water, Ca2+, and cholesterol sulfate, and the pH ing tape-stripping) but does not correlate with the
influence both the lamellar organization of the degree of cohesion (measured by the protein con-
SC lipids and the activity of the hydrolytic tent of the tapes) in healthy human skin in vivo
enzymes responsible for corneodesmosomal deg- [145]. Most probably, this observation reflects a
radation [136140]; it is not easy to disentangle different, indirect mechanism by which the lipid
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 137

molecular organization can impact the integrity overcoming the SC barrier to penetration is of
and cohesion of SC: by enabling the diffusion of enormous interest for the dermal and transdermal
the SC enzymes and of their respective activators delivery of drugs, local anesthetics, vaccines, and
and inhibitors to their substrates [105, 136], such cosmeceuticals [149, 150].
as proteolytic enzymes necessary for degradation
of the corneodesmosomes [111, 146] and lipid
hydrolases necessary to transform precursors 10.6.1 Strengthening the SC Barrier
secreted form the LB into SC components [104].
The topical application of lipids nonphysio-
logic, occlusive ones, or ones similar to those
10.6 Skin Therapies Based typically found in healthy SC has long been the
on Topical Modulators therapy of choice for strengthening the barrier to
of the SC Lipid Organization penetration in diseased and damaged skin and in
accelerating its formation in underdeveloped and
The direct correlation between the organization wounded skin [10, 151154]. Because of the
of the lipid matrix and key properties of SC such equimolar ratio between ceramides, fatty acids,
as permeability and integrity implies that topi- and cholesterol necessary to achieve and main-
cally applied chemicals, capable of admixing tain the 3D organization of the lipid matrix in
with the endogenous SC lipids and changing their healthy SC, the types and relative contents of the
3D organization, can be used to influence the per- lipids are of paramount importance for the effi-
formance of the SC. Both reduction and enhance- ciency of the therapy. In diseases in which this
ment of the SC permeability are therapeutically ratio is abnormal (e.g., the characteristic for
relevant. Efficient strategies for barrier strength- atopic dermatitis ceramide deficiency and enha-
ening are important in a number of circumstances nced cholesterol levels, the complete absence of
[147, 148]: (1) in the treatment of skin diseases polyunsaturated fatty acid moieties in the cer-
linked to misbalance of the main SC lipids and amide molecules in essential fatty acid deficiency,
consequent defective barrier properties; (2) in and the reduced content of free fatty acids in
acquired dermatoses resulting from occupational lamellar ichthyosis [155]), the composition of the
hazards (e.g., frequent contact with water and topically applied lipids is most efficient when it
detergents), sustained exposure to moisture and compensates for the imbalance [147]. In other
elevated pH (e.g., in infants and incontinent words, cure-all creams for barrier repair cannot
adults), and extreme or quickly changing envi- be expected to and do not work equally well
ronmental conditions; (3) to remedy immature on skin with all kinds of barrier damage [148].
and underdeveloped skin (e.g., the skin of infants The efficient performance of the SC as a bar-
and preterm babies) and chronologically aged rier to water evaporation strongly depends on its
skin; and (4) to assist the healing of severely state of hydration. This correlation is at the origin
damaged skin (e.g., resulting from burns or other of the initiation and perpetuation of the vicious
wounds). Strengthening the SC barrier to limit cycle of dry skin, one of the most common skin
penetration of exogenous chemicals also offers disorders: a drop in the SC barrier efficiency and
an interesting alternative for the design of topical a lessening of its integrity lead to a reduction of
products intended to prevent the systemic absorp- the SC hydration, which in turn enhances further
tion of harmful pollutants, toxins, irritants, sensi- the SC permeability for water [140]. Besides hav-
tizers, and warfare agents. The exceptional ing a cosmetically unpleasing appearance and
impermeability of the healthy SC has also a reduced flexibility and resistance, dry SC is
downside: beneficial topically applied chemicals chronically inflamed, is prone to attacks from
also have limited access to the inner SC layers pathogenic microorganisms, and often provides
and the underlying viable tissues. Thus, in decreased protection against the penetration of
addition to strengthening, the inverse effect chemicals [105]. Importantly, improving the SC
138 M. Boncheva

barrier efficiency to permeation of water can increasing the water content of SC is evident;
interrupt the cycle of dry skin at any stage [156]. indeed, chemicals of similar structure have been
With the increasing occurrence of this disorder, long used empirically as ingredients in moistur-
the search for more efficient strategies for skin izing formulations [157].
moisturization is intense. The further development of moisturizers that
Traditionally, moisturizers were thought to act act solely by this mechanism has, however, to
either by their ability to penetrate the SC and take into account the change of the overall
retain moisture in its inner layers (a mechanism content of OR phases in the SC needed for
attributed to small and highly hygroscopic poly- the required change in TEWL. The correlation
hydroxy molecules like glycerol, glycols, glu- between the two parameters observed in normal,
cose, and sorbitol) or by their ability to form an healthy skin indicates that to reduce the TEWL
occlusive film at the skin surface (a mechanism by 5 g/m2h, the content of OR phases has to
attributed to long-chain typically containing increase by approximately 50% [76]; depending
1540 carbon atoms lipophilic molecules like on the degree of damage to the SC barrier for
the hydrocarbon mixtures in mineral oil and pet- water, it is possible that the most efficient prod-
rolatum). The finding of a correlation between ucts for improving the SC moisturization would
the molecular organization of the SC lipids and be those that make use of all three mechanisms
the permeability of SC for water led to the dis- water retention, external occlusion, and internal
covery of a novel mechanism for improving the occlusion acting simultaneously. It is also
SC hydration by creating an occlusive effect important to consider that the content of OR
within the SC, termed internal occlusion [157]. phase is not the only factor contributing to
As discussed earlier, the OR phases have the low- TEWL: together with the water permeability of
est permeability for water among the lipid phases the SC lipid matrix, the presence of fully matured
present in the SC matrix [9], and their content corneocytes [111, 146] and water-retaining con-
determines the water loss due to TEWL [76]; the stituents of NMF [156] also contribute to the
mechanism of internal occlusion consists in sta- sustaining of SC hydration. Furthermore, it is
bilizing the OR phases within the SC lipid matrix, generally accepted that the presence of the LPP
and thereby increasing its water content by reduc- is important for maintaining an efficient barrier
tion of TEWL. This effect was first described for to the transport of exogenous chemicals across
isostearyl and isopropyl isostearate, lipophilic the SC. Importantly, the proper formation of the
molecules capable of penetrating the SC in vivo LPP necessitates a fraction of lipids organized in
without visibly changing the general appearance LIQ phases [73]; the relative content of OR and
of the lamellar lipid phases. These molecules LIQ lipid phases thus has to be properly bal-
incorporate partially within the LPP phase, pro- anced to maintain the homeostasis of the SC
mote its formation at the expense of SPP, and par- barrier.
tition between the OR phase formed by SC lipids This mechanism for strengthening the barrier
and a pure disordered phase [158, 159]. Their to evaporation of water through the SC cannot,
presence increases the thermotropic stability of unfortunately, be generalized as the universal
the OR phases and makes them capable of per- solution to making the SC impermeable to all
sisting at temperatures above 30 C, the phase- types of molecules. As discussed earlier, differ-
transition temperature between the OR and HEX ent aspects of the molecular organization of the
phases observed in the endogenous SC lipids. SC lipids can be expected to govern the SC per-
The molecular mechanism of this stabilization is meability to molecules of different physicochem-
not well understood; it is possible that internally ical properties; it is far from certain that the extent
occluding molecules broaden the extent of the of OR phases correlates with the penetration of
OR phase by partitioning in it and/or by facilitat- molecules of moderate to high lipophilicity.
ing the incorporation of free fatty acids into the Another possible way to reinforce the SC
OR domains [160]. Nonetheless, their efficacy in barrier might be to change the pattern of lateral
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 139

hydrogen bonding between the ceramides in a 10.7 Conclusions and Outlook

way that renders the lamellae more compact
without necessarily augmenting the content of The molecular organization of the SC lipid
OR phases [161]. This mechanism of action matrix has been an extremely active field of
was suggested to explain the effect of retarding research during the last few decades. The con-
the penetration of other chemicals observed for tinuing interest in this area comes from two
one structural analogue of Azone [162] and sev- powerful sources: one is our fascination with
eral oxazolidone derivatives [163]. Despite the the unsolved riddles in lipid biophysics and, in
broad potential applications of penetration general, in molecular self-assembly [172, 173],
retardants ranging from localized targeting of and the other one the paramount importance
therapeutic agents, sunscreen products, and of the SC lipids for maintaining the homeosta-
insect repellents in the superficial SC layers to sis of human skin and the therapeutic relevance
protection from systemic absorption of chemi- of enhancing or reducing its barrier efficiency.
cal warfare, toxic spills, and pesticides not The picture that we now have of the extracel-
many studies have investigated possible mecha- lular lipids as an intricate, 3D ensemble with
nisms to retard the penetration through SC modular composition, organization, and func-
[164168]. tionality has a level of detail closer to reality
than the early concept of a homogeneous mor-
tar holding together corneocyte bricks. Despite
10.6.2 Overcoming the SC Barrier the progress achieved so far, however, quite a
few elements in this picture remain obscure or
In addition to strategies for overcoming the SC at best incomplete: (1) Our knowledge of the
barrier based on physical disruption, heat, formu- composition of the SC lipid matrix is still not
lation effects, and providing external driving definite, as illustrated by the uninterrupted
forces for the penetration, the use of chemical stream of newly identified molecules present in
enhancers capable of disrupting the highly SC. (2) With few exceptions, the role that the
ordered SC lipids has been widely explored. The individual subclasses of the SC lipids play in
majority of the chemical penetration enhancers achieving an optimally functional 3D structure
developed so far act either by insertion in the of the lipid matrix is not definitely established;
bilayers or by extracting lipids from them. thus, our understanding of the correlation
Extensive research effort has been dedicated to between SC functionality, composition, and
screening potential candidates and to attempting structure in healthy and diseased skin remains
to build structure-activity relationships to under- incomplete. (3) The role played by the minor
stand their action and to facilitate their rational ingredients of the intracellular space (e.g., cho-
design [169]. The biggest hurdle to the wide lesterol sulfate and other cholesteryl esters)
practical application of chemical enhancers, how- which are essential for the correct SC function
ever, is not their insufficient enhancement potency in the organization of lipids is largely unknown.
but the fact that high enhancement potency typi- (4) There are still considerable gaps in our
cally correlates with high irritation potency [149]; understanding of the 3D structure of the lipid
the scope of molecules capable of strongly disor- matrix. Overall, it appears that both crystalline
ganizing the SC lipids without penetrating into and disordered lipid phases are present in SC,
the viable tissues is extremely limited. Recent but the way they are organized within the lipid
studies have demonstrated that synergistic com- lamellae is yet to be established beyond rea-
binations of chemical enhancers can exhibit sig- sonable doubt. (5) The extent of compositional
nificantly higher potency in enhancement and yet and structural variations within the lamellae
cause lower irritation than their individual ingre- due to body site, gender, age, race, and depth
dients [170, 171]; this approach is now being within the SC is, for the most part, unknown
actively pursued. [174176].
140 M. Boncheva

Model systems of simplified lipid composi- largely unknown. When designing such topical
tion have proven to be extremely useful in studies effectors, it is extremely important to keep in
designed to elucidate the molecular organization mind the complex interconnections that exist
of the native SC lipid matrix and to determine the between the defensive functions of the SC and to
role of the individual SC lipid subclasses in it. remember that the same parameter might influ-
Their preparation is relatively easy, they can read- ence several properties in opposing directions
ily accommodate both synthetic and endogenous [10]. Thus, for example, an exceedingly high
SC lipids, and, provided appropriate composition content of densely packed lipid phases might
and preparation protocol, they can reproduce the improve the skin moisturization by reducing the
native molecular organization of SC with fair loss of water through the SC; at the same time,
fidelity. Compared to working with isolated SC, however, the diffusion of corneodesmolytic enz-
they offer the advantages of precisely controlled ymes to their substrates in such densely packed
chemical identity of the ingredients, uniform lipid matrix would be extremely difficult and
thickness, reproducibility, and ease of interpreta- might result in impaired SC desquamation. An
tion of the data. Their undoubted usefulness appropriate ratio between the lipid phases present
aside, using these systems in structural studies in the SC is apparently vital for the performance
always carries the inherent danger that the data of key functions of the SC, ranging from perme-
obtained from such simplified systems may be ability to flexibility to normal desquamation, but
irrelevant to the native SC, which displays an the limits within which the phase ratio can vary
amazingly broad spectrum of different chemical while still assuring proper SC performance are
species. Limiting the number of ceramide species yet to be defined. Establishing the timescale and
and narrowing the distribution of chain lengths in reversibility of reformation following structural
both ceramides and fatty acids seriously impede perturbation is also of utmost importance for the
the ability to reproduce the native organization of design of effectors of the molecular organization;
the SC lipid matrix. Thus, conclusions based in addition to being efficient and harmless for the
of systems of extremely simplified composition viable tissues, the modifiers of SC permeability
should always be checked against data obtained have to exert only transient and reversible effect
from more complex systems or, ideally, from to avoid subsequent entry of undesirable sub-
native SC. Despite their attractively ready avail- stances and microorganisms in the layers beyond
ability and low cost, lipids isolated from animal the SC. Work in this direction is in its early stages
skin are not always the best alternative to model [75, 177].
the polydispersity in chain lengths and head Besides influencing the SC health and cosmetic
groups of the human SC lipids and, therefore, to appearance from the outside, using topically
reproduce their organization. Properly composed applied products, the possibility to manipulate
and formed, however, synthetic SC models and these characteristics from the inside, through
substitutes will continue to be of great use for nutrition, is clearly indicated [178, 179]. Systematic
future structural studies. In view of the high cost, studies and solid epidemiologic evidence correlat-
inherent high inter-individual variability, and ing the nutrition and the optimal performance of
body-site dependence of the permeability of the SC, however, exist for only a handful of ingre-
excised human skin, their use in high-throughput dients. Further work in the development of prod-
screening of effectors of the skin penetration ucts specifically targeting the SC barrier (i.e., the
would be extremely valuable. lipids of the SC extracellular matrix) is warranted
While it is, in principle, possible to advanta- to realize the full potential for health promotion
geously modulate the SC performance by manip- and disease prevention of functional foods and
ulating the molecular organization of its lipids neutraceuticals designed for the skin.
with topical products, the details and, often, the In addition to its primary objective tackling
nature of the correlation between the structure the correlation between lipid composition, struc-
of the lipid matrix and the SC properties are ture, and performance of the SC the research in
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 141

model and native SC membranes can, potentially,

also benefit the understanding of the formation, The unique lamellar organization of the
properties, and functionality of lipid rafts in lipids, resulting from their exceptional
plasma membranes. Lipid rafts are membrane composition, ensures the low permeabil-
domains enriched in sphingolipids and choles- ity of the skin for xenobiotics, limits the
terol, proposed to be important for lipid and pro- loss of water from the living tissues, and
tein transport across the membranes, in intracellular contributes to the formation of a barrier
signaling, and in regulating the activity of mem- layer of high mechanical integrity, flex-
brane-associated proteins [180, 181]. Paralleling ibility, and cohesive strength.
the essential problems in the SC lipid organiza- Both crystalline and disordered lipid
tion, the questions of the role of the acyl chain phases exist in the lamellae, but their 3D
packing and cholesterol in membrane stabiliza- organization remains to be definitely
tion, the preferential association between different established.
lipid classes, the coexistence of lipid phases, and Understanding the correlation between
the formation of domains are central to under- composition, molecular organization, and
standing the formation and stability of structures properties of the lipid matrix helps to
such as fluctuating raft assemblies [182, 183]. elucidate the etymology of skin diseases
Despite the obvious differences in the composi- and disorders and offers the potential to
tion and the local environment of the lipid lamel- develop new, efficient skin therapies.
lae in SC and the lipid rafts in plasma membranes,
they illustrate two sides of the general question of
how the living organisms use lipids to control
composition, structure, and functionality. Abbreviations
The lipid matrix of the stratum corneum is
yet another example in the long list of intricate 3D three-dimensional
functionality achieved by molecular self-assem- HEX hexagonal phase
bly in biological systems [184]. Further exten- LB lamellar body
sion of our understanding of the correlation LIQ liquid-crystalline phase
between its molecular organization and its LPP long periodicity phase
meso- and macroscopic properties will doubt- NMF natural moisturizing factor
lessly be beneficial for establishing the molecu- OR orthorhombic phase
lar bases of skin health and disease; in addition, SC stratum corneum
it has the potential to contribute to the design of SPP short periodicity phase
synthetic biomimetic smart materials and sys- TEWL trans-epidermal water loss
tems [172, 185, 186], such as advanced encap-
sulating materials for slow release of drugs and
cosmeceuticals [187, 188], protective cover lay-
ers for biomedical applications [189] and wound References
healing [190], selectively permeable mem-
branes for molecular separations [191], and 1. Winsor T, Burch GE (1944) Differential roles of lay-
artificial cells [192]. ers in human epigastric skin on diffusion rate of water.
Arch Intern Med 74:428435
2. Blank IH (1952) Factors which influence the water
content of the stratum corneum. J Invest Dermatol
Take Home Messages 18:433440
The extracellular matrix of stratum cor- 3. Elias PM (2004) The epidermal permeability barrier:
from the early days at Harvard to emerging concepts.
neum participates actively in the defen- J Invest Dermatol 122:xxxvixxxix
sive performance of human skin. 4. Kligman AM (2006) A brief history of how the dead stra-
tum corneum became alive. In: Elias PM, Feingold KR
142 M. Boncheva

(eds) Skin barrier. Taylor and Francis, New York, 22. Wertz PW, Madison KC, Downing DT (1989)
pp 1524 Covalently bound lipids of human stratum corneum.
5. Kligman AM (2011) Corneobiology and corneo- J Invest Dermatol 92:109111
therapy a final chapter. Int J Cosm Sci 33: 23. Hill J, Paslin D, Wertz PW (2006) A new covalently
197209 bound ceramide from human stratum corneum
6. Elias PM (2006) Defensive functions of the Stratum w-hydroxyacylphytosphingosine. Int J Cosmet Sci
corneum: Integrative aspects. In: Elias PM, Feingold 28:225230
KR (eds) Skin barrier. Taylor and Francis, New York, 24. Wertz PW, Miethke MC, Long SA et al (1985) The
pp 514 composition of the ceramides from human stratum
7. Brody I (1966) Intercellular space in normal human corneum and from comedones. J Invest Dermatol
stratum corneum. Nature 209:472476 84:410412
8. Harding CR (2004) The stratum corneum: structure 25. Dahln B, Pascher I (1979) Thermotropic phase
and function in health and disease. Dermatol Ther behaviour of tetracosanoylphytosphingosine. Chem
17:615 Phys Lipids 24:119133
9. Bouwstra JA, Ponec M (2006) The skin barrier in 26. Kiselev MA, Ryabova NY, Balagurov AM et al (2005)
healthy and diseased state. Biochim Biophys Acta- New insights into the structure and hydration of a stra-
Biomembranes 1758:20802095 tum corneum lipid model membrane by neutron dif-
10. Elias PM (2005) Stratum corneum defensive functions: fraction. Eur Biophys J 34:10301040
an integrated view. J Invest Dermatol 125:183200 27. Brief E, Kwak S, Cheng JTJ et al (2009) Phase behav-
11. Di Nardo A, Gallo RL (2006) Cutaneous barriers in ior of an equimolar mixture of N-palmitoyl-d-erythro-
defense against microbial invasion. In: Elias PM, sphingosine, cholesterol, and palmitic acid, a mixture
Feingold KR (eds) Skin barrier. Taylor and Francis, with optimized hydrophobic matching. Langmuir
New York, pp 363378 25:75237532
12. Rawlings AV (2006) Sources and role of Stratum cor- 28. OMalley B, Moore DJ, Noro M, et al. (2005) Towards
neum hydration. In: Elias PM, Feingold KR (eds) a mechanical model of skin: Insights into Stratum cor-
Skin barrier. Taylor and Francis, New York, neum mechanical properties from hierarchical models
pp 399426 of lipid organization. Mat Res Soc Symp Proc 844:
13. Nickoloff BJ, Stevens SR (2006) What have we Y5.7
learned in dermatology from the biologic therapies? 29. Pascher I (1976) Molecular arrangements in sphingo-
J Am Acad Dermatol 54:S143S151 lipids: conformation and hydrogen bonding of cer-
14. Wertz PW, van der Bergh B (1998) The physical, amide and their implication on membrane stability
chemical, and functional properties of lipids in the and permeability. Biochim Biophys Acta 455:
skin and other biological barriers. Chem Phys Lipids 433451
91:8596 30. Rerek ME, Moore DJ (2007) Skin lipid structure:
15. Wertz PW, Downing DT (1991) Epidermal lipids. In: Insight into hydrophobic and hydrophilic driving
Goldsmith LA (ed) Physiology, biochemistry, and forces for self-assembly using IR spectroscopy. In:
molecular biology of the skin. Oxford University Rhein LD, Schlossman M, OLenick A, Somasundran P
Press, Oxford, pp 205236 (eds) Surfactants in personal care products and deco-
16. Feingold KR (2007) The role of epidermal lipids in rative cosmetics. CRC Press, Boca Raton, Surfactant
cutaneous permeability barrier homeostasis. J Lipid science series, pp 189209
Res 48:25312546 31. Mendelsohn R, Rerek ME, Moore DJ (2000) Infrared
17. Wertz PW, Swartzendruber DC, Madison KC et al spectroscopy and microscopic imaging of stratum
(1987) Composition and morphology of epidermal corneum models and skin. Phys Chem Chem Phys
cyst lipids. J Invest Dermatol 89:419425 2:46514657
18. Masukawa Y, Narita H, Shimizu E et al (2008) 32. Norln L, Nicander I, Lundsj A et al (1998) A new
Characterization of overall ceramide species in human HPLC-based method for the quantitative analysis of
stratum corneum. J Lipid Res 49:14661476 inner stratum corneum lipids with special reference to
19. Harding CR, Moore DJ, Rawlings AV (2010) the free fatty acid fraction. Arch Dermatol Res
Ceramides and the skin. In: Baran R, Maibach HI 290:508516
(eds) Textbook of cosmetic dermatology. Informa 33. Fettiplace R, Haydon DA (1980) Water permeability
Healthcare, New York, pp 150164 of lipid membranes. Physiol Rev 60:510550
20. van Smeden J, Hoppel L, van der Heijden R et al 34. Wertz PW (1996) Integral lipids in hair and Stratum
(2011) LC/MS analysis of stratum corneum lipids: corneum. In: Jolles P, Zahn H, Hocker H (eds) Hair:
ceramide profiling and discovery. J Lipid Res 52: Biology and structure. Birkhauser Verlag, Basel,
12111221 pp 227238
21. Motta S, Monti M, Sesana S et al (1993) Ceramide 35. Daly TA, Wang M, Regen SL (2011) The origin of
composition of the psoriatic scale. Biochim Biophys cholesterols condensing effect. Langmuir 27:
Acta 1182:147151 21592161
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 143

36. de Meyer F, Smit B (2009) Effect of cholesterol on the 53. Groen D, Poole D, Gooris GS et al (2011) Is an orthor-
structure of a phospholipid bilayer. Proc Natl Acad hombic lateral packing and a proper lamellar organi-
Sci USA 106:36543658 zation important for the skin barrier function? Biochim
37. Maxfield FR, Tabas I (2005) Role of cholesterol and Biophys Acta 1808:15291537
lipid organization in disease. Nature 438:612621 54. Swartzendruber DC (1992) Studies of epidermal lip-
38. Leathes JB (1925) Croonian lectures on the role of ids using electron microscopy. Semin Dermatol
fats in vital phenomena. Lancet 205:853856 11:157161
39. Rg T, Pasenkiewicz-Gierula M, Vattulainen I et al 55. Swartzendruber DC, Wertz PW, Kitko DJ et al (1989)
(2009) Ordering effects of cholesterol and its ana- Molecular models of the intercellular lipid lamellae
logues. Biochim Biophys Acta 1788:97121 in mammalian stratum corneum. J Invest Dermatol
40. Takahashi H, Sinoda K, Hatta I (1996) Effects of cho- 92:251257
lesterol on the lamellar and the inverted hexagonal 56. Schreiner V, Gooris GS, Pfeiffer S et al (2000) Barrier
phases of dielaidoylphosphatidylethanolamine. Biochim characteristics of different human skin types investi-
Biophys Acta 1298:209216 gated with X-ray diffraction, lipid analysis, and electron
41. McMullen TPW, McElhaney RN (1995) New aspects microscopy imaging. J Invest Dermatol 114:654660
of the interaction of cholesterol with DPPC bilayers 57. Norln L (2010) Molecular cryo-electron tomography
as revealed by high-sensitivity differential scanning of skin. Open Derm J 4:4647
calorimetry. Biochim Biophys Acta 1234:9098 58. Al-Amoudi A, Dubochet J, Norln L (2005)
42. Feingold KR (2009) The outer frontier: the impor- Nanostructure of the epidermal extracellular space as
tance of lipid metabolism in the skin. J Lipid Res observed by cryo-electron microscopy of vitreous
50:S417S422 sections of human skin. J Invest Dermatol 124:
43. Krahn-Bertil E, Hazane-Puch F, Lassel T et al (2009) 764777
Skin moisturization by dermonutrition. In: Rawlings AV, 59. Percot A, Lafleur M (2001) Direct observation of
Leyden JJ (eds) Skin moisturization. Informa Healthcare domains in model stratum corneum lipid mixtures by
USA, Inc., New York, pp 411425 Raman microspectroscopy. Biophys J 81:21442153
44. Martinez RI, Peters A (1971) Membrane-coating 60. Wegener M, Neubert RHH, Rettig W et al (1997)
granules and membrane modifications in keratinizing Structure of stratum corneum lipids characterized by
epithelia. Am J Anat 130:93120 FT-Raman spectroscopy and DSC. III. Mixtures of
45. Lavker RM (1976) Membrane coating granules: the ceramides and cholesterol. Chem Phys Lipids
fate of the discharged lamellae. J Ultrastruct Res 88:7382
55:7986 61. Bommannan D, Potts RO, Guy RH (1990) Examination
46. Elias PM, Goerke J, Friend DS (1977) Mammalian of stratum corneum barrier function in vivo by infra-
epidermal barrier layer lipids: composition and influ- red spectroscopy. J Invest Dermatol 95:403408
ence on structure. J Invest Dermatol 69:535546 62. Babita K, Kumar V, Rana V et al (2006) Thermotropic
47. Madison KC, Swartzendruber DC, Wertz PW et al and spectroscopic behavior of skin: relationship with
(1987) Presence of intact intercellular lamellae in the percutaneous permeation enhancement. Curr Drug
upper layers of the stratum corneum. J Invest Dermatol Deliv 3:95113
88:714718 63. Mendelsohn R, Flach CR, Moore DJ (2006)
48. Bouwstra JA (2009) Lipid organization of the skin Determination of molecular conformation and perme-
barrier. In: Rawlings AV, Leyden JJ (eds) Skin mois- ation in skin via IR spectroscopy, microscopy, and
turization. Informa Healthcare USA, Ins, New York, imaging. Biochim Biophys Acta 1758:923933
pp 1740 64. Boncheva M, Damien F, Normand V (2008) Molecular
49. van Meer G, Voelker DR, Feigenson GW (2008) organization of the lipid matrix in intact stratum
Membrane lipids: where they are and how they corneum using ATR-FTIR spectroscopy. Biochim
behave. Nature Rev Molec Cell Biol 9:112124 Biophys Acta 1778:13441355
50. Pilgram GSK, Engelsma-van Pelt AM, Bouwstra JA 65. Kitson N, Thewalt J, Lafleur M et al (1994) A model
et al (1999) Electron diffraction provides new infor- membrane approach to the epidermal permeability
mation on human stratum corneum lipid organization barrier. Biochemistry 33:67076715
studied in relation to depth and temperature. J Invest 66. Rehfeld SJ, Plachy WZ, Williams ML et al (1988)
Dermatol 113:403409 Calorimetric and electron spin resonance examination
51. Friberg SF, Osborne DW (1985) Small angle X-ray of lipid phase transitions in human stratum corneum:
diffraction patterns of stratum corneum and a model molecular basis for normal cohesion and abnormal
structure for its lipids. J Dispers Sci Technol desquamation in recessive X-linked ichthyosis.
6:485495 J Invest Dermatol 91:499505
52. Schroeter A, Kessner D, Kiselev MA et al (2009) 67. Queiros MP, Sousa Neto D, Alonso A (2005)
Basic nanostructure of stratum corneum lipid matri- Dynamics and partitioning of spin-labelled stearates
ces based on ceramides [EOS] and [AP]: a neutron into the lipid domain of stratum corneum. J Control
diffraction study. Biophys J 97:11041114 Release 106:374385
144 M. Boncheva

68. Norln L, Placsencia I, Bagatolli LA (2008) Stratum 85. Bouwstra JA, Gooris GS, Dubbelaar FER et al
corneum lipid organization as observed by atomic force (2002) Phase behavior of stratum corneum lipid
microscopy, confocal and two-photon excitation fluo- mixtures based on human ceramides: the role of
rescence microscopy. Int J Cosmet Sci 30:391411 natural and synthetic ceramide 1. J Invest Dermatol
69. Norln L, Plasencia Gil I, Simonsen A et al (2007) 118:606617
Human stratum corneum lipid organization as 86. Sousa Neto D, Gooris GS, Bouwstra JA (2011)
observed by atomic force microscopy of Langmuir- Effect of w-acylceramides on the lipid organization
Blodgett films. J Struct Biol 158:386400 of stratum corneum model membranes evaluated by
70. Lafleur M (1998) Phase behaviour of model stratum X-ray diffraction and FTIR studies (Part I). Chem
corneum lipid mixtures: an infrared spectroscopy Phys Lipids 164:184195
investigation. Can J Chem 76:15011511 87. Bouwstra JA, Gooris GS (2010) The lipid organiza-
71. Moore DJ, Rerek ME, Mendelsohn R (1997) FTIR tion in human stratum corneum and model systems.
spectroscopy studies of the conformational order and Open Derm J 4:1013
phase behavior of ceramides. J Phys Chem B 101: 88. Caussin J, Gooris GS, Janssens M et al (2008) Lipid
89338940 organization in human and porcine stratum corneum
72. Moore DJ, Rerek ME (2000) Insight into the molecu- differs widely, while lipid mixtures with porcine cer-
lar organization of lipids in the skin barrier from infra- amides model human stratum corneum lipid organiza-
red spectroscopy studies of stratum corneum lipid tion very closely. Biochim Biophys Acta 1778:
models. Acta Derm Venereol Supp 208:1622 14721482
73. Bouwstra JA, Gooris GS, Ponec M (2002) The lipid 89. Hill JR, Wertz PW (2003) Molecular models of the
organization of the skin barrier: liquid and crystalline intercellular lamellae from epidermal stratum cor-
domains coexist in lamellar phases. J Biol Phys neum. Biochim Biophys Acta 1616:121126
28:211223 90. Forslind B (1994) A domain mosaic model of the
74. Bouwstra JA, de Graaff A, Gooris GS et al (2003) skin barrier. Acta Derm Venereol 74:16
Water distribution and related morphology in human 91. Forslind B, Engstrom S, Engblom J et al (1997) A
stratum corneum at different hydration levels. J Invest novel approach to the understanding of human skin
Dermatol 120:750758 barrier function. J Dermatol Sci 14:115125
75. Pensack RD, Michniak BB, Moore DJ et al (2006) 92. Potts RO, Francoeur ML (1991) The influence of
Infrared kinetic/structural studies of barrier reforma- stratum corneum morphology on water permeability.
tion in intact stratum corneum following thermal per- J Invest Dermatol 96:495499
turbation. Appl Spectrosc 60:13991404 93. Kitson N, Thewalt JL (2000) Hypothesis: the epider-
76. Damien F, Boncheva M (2010) The extent of orthor- mal permeability barrier is a porous medium. Acta
hombic lipid phases in the stratum corneum deter- Derm Venereol Supp 208:1215
mines the barrier efficiency of human skin in vivo. 94. Bouwstra JA, Dubbelaar FER, Gooris GS et al
J Invest Dermatol 130:611614 (2000) The lipid organization in the skin barrier.
77. Gennis RB (1989) Biomembranes: molecular struc- Arch Dermatol Res Supp 208:2330
ture and function. Springer-Verlag Inc., NY 95. McIntosh TJ (2003) Organization of skin stratum
78. Mukherjee S, Maxfield FR (2000) Role of membrane corneum extracellular lipid lamellae: diffraction evi-
organization and membrane domains in endocytic dence for asymmetric distribution of cholesterol.
lipid trafficking. Traffic 1:203211 Biophys J 85:16751681
79. Nicolaides N (1974) Skin lipids: their biochemical 96. Norln L (2001) Skin barrier structure and function:
uniqueness. Science 186:1926 the single gel phase model. J Invest Dermatol
80. Yagi E, Sakamoto K, Nakagawa K (2006) Depth 117:830836
dependence of stratum corneum lipid ordering: a 97. Kiselev MA (2007) Conformation of ceramide 6
slow-tumbling simulation for electron paramagnetic molecules and chain-flip transitions in the lipid
resonance. J Invest Dermatol 127:895899 matrix of the outmost layer of mammalian skin, the
81. Madison KC (2003) Barrier function of the skin: La stratum corneum. Crystallogr Rep 52:525528
raison dtre of the epidermis. J Invest Dermatol 98. McIntosh TJ, Stewart ME, Downing DT (1996)
121:231241 X-ray diffraction analysis of isolated skin lipids:
82. Janssens M, Gooris GS, Bouwstra JA (2009) Infrared reconstitution of intercellular lipid domains. Bioc-
spectroscopy studies of mixtures prepared with syn- hemistry 35:36493653
thetic ceramides varying in head group architecture: 99. Groen D, Gooris GS, Barlow DJ et al (2011)
coexistence of liquid and crystalline phases. Biochim Disposition of ceramide in model lipid membranes
Biophys Acta 1788:732742 determined by neutron diffraction. Biophys J 100:
83. Garson J-C, Doucet J, Lvque J-L et al (1991) 14811489
Oriented structures in human stratum corneum 100. Kessner D, Kiselev MA, Dante S et al (2008)
revealed by X-ray diffraction. J Invest Dermatol Arrangement of ceramide [EOS] in a stratum corneum
96:4349 lipid model matrix: new aspects revealed by neutron
84. Bouwstra JA, Gooris GS, Salomons-de Vries JA et al diffraction studies. Eur Biophys J 37:989999
(1992) Structure of stratum corneum as a function of 101. Schroeter A, Kiselev MA, Hauss T et al (2009)
temperature and hydration: a wide-angle X-ray dif- Evidence of free fatty acid interdigitation in stratum
fraction study. Int J Pharm 84:205216 corneum model membranes based on ceramide [AP]
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 145

by deuterium labeling. Biochim Biophys Acta 1788: 121. Bunge AL, Cleek RL (1995) A new method for esti-
21942203 mating dermal absorption from chemical exposure.
102. Menon GK (2002) New insights into skin structure: 2. Effect of molecular weight and octanol-water par-
scratching the surface. Adv Drug Deliv Rev 54 titioning. Pharm Res 12:8895
(suppl 1):S3S17 122. Guy RH (2010) Predicting the rate and extent of fra-
103. Roelandt T, Giddelo C, Heughebaert C et al (2009) grance chemical absorption into and through the
The caveolae brake hypothesis and the epidermal skin. Chem Res Toxicol 23:864870
barrier. J Invest Dermatol 129:927936 123. Mitragotri S (2003) Modeling skin permeability to
104. Menon GK, Ghadially R, Williams ML et al (1992) hydrophilic and hydrophobic solutes based on four
Lamellar bodies as delivery systems of hydrolytic permeation pathways. J Control Release 86:6992
enzymes: implications for normal and abnormal 124. Levin J, Maibach HI (2005) The correlation between
desquamation. Br J Dermatol 126:337345 transepidermal water loss and percutaneous absorp-
105. Rawlings AV, Matts PJ (2005) Stratum corneum tion: an overview. J Control Release 103:291299
moisturization at the molecular level: an update in 125. Golden GM, McKie JE, Potts RO (1987) Role of
relation to the dry skin cycle. J Invest Dermatol stratum corneum lipid fluidity in transdermal drug
124:10991110 flux. J Pharm Sci 76:2528
106. Hachem J-P, Houben E, Crumrine D et al (2006) Serine 126. Golden GM, Guzek DB, Kennedy AH et al (1987)
protease signaling of epidermal permeability barrier Stratum corneum phase transitions and water barrier
homeostasis. J Invest Dermatol 126:20742086 properties. Biochemistry 26:23822388
107. Voegeli R, Rawlings AV, Doppler S et al (2007) 127. Potts RO, Francoeur ML (1990) Lipid biophysics of
Profiling of serine protease activities in human stra- water loss through the skin. Proc Natl Acad Sci USA
tum corneum and detection of a stratum corneum 87:38713873
tryptase-like enzyme. Int J Cosmet Sci 29:191200 128. Potts RO, Mak VHW, Guy RH et al (1991) Strategies
108. Grubauer G, Elias PM, Feingold KR (1989) to enhance permeability via stratum corneum lipid
Transepidermal water loss: the signal for recovery of pathways. Adv Lipid Res 24:173210
barrier structure and function. J Lipid Res 30:323333 129. Naik A, Guy RH (1997) Infrared spectroscopic and
109. Feingold KR, Schmuth M, Elias PM (2007) The differential scanning calorimetric investigations of
regulation of permeability barrier homeostasis. the Stratum corneum barrier function. In: Potts RO,
J Invest Dermatol 127:15741576 Guy RH (eds) Mechanisms of transdermal drug
110. Landmann L (1986) Epidermal permeability barrier: delivery. Marcel Dekker, NY, pp 87162
transformation of lamellar granule-disks into inter- 130. Naik A, Kalia YN, Pirot F et al (1999) Characterization
cellular sheets by a membrane-fusion process, a of molecular transport across human Stratum cor-
freeze-fracture study. J Invest Dermatol 87:202209 neum in vivo. In: Bronaugh RL, Maibach HI (eds)
111. Haftek M, Teillon M-H, Schmitt D (1998) Stratum Percutaneous adsorption. Marcel Dekker, Inc., NY,
corneum, corneodesmosomes and ex vivo percuta- pp 149175
neous penetration. Microsc Res Tech 43:242249 131. Imhof RE, Xiao P, De Jesus MEP et al (2009) New
112. Loefgren H, Pascher I (1977) Molecular arrange- developments in skin barrier measurements. In:
ment of sphingolipids: the monolayer approach. Rawlings AV, Leyden JJ (eds) Skin moisturization.
Chem Phys Lipids 20:273284 Informa Healthcare USA, Inc., New York, pp 463479
113. Whitesides GM, Mathias JP, Seto CT (1991) 132. de Jaeger M, Groenink W, Bielsa i Guivernau R et al
Molecular self-assembly and nanochemistry: a (2006) A novel in vitro percutaneous penetration
chemical strategy for the synthesis of nanostructures. model: evaluation of barrier properties with p-amin-
Science 254:13121319 obenzoic acid and two of its derivatives. Pharm Res
114. Atkins PW (1997) Physical Chemistry. Oxford 23:951960
University Press, Oxford, UK 133. Pilgram GSK, Vissers DCJ, van der Meulen H et al
115. Bishop KJM, Wilmer CE, Soh S et al (2009) (2001) Aberrant lipid organization in stratum cor-
Nanoscale forces and their uses in self-assembly. neum of patients with atopic dermatitis and lamellar
Small 5:16001630 ichthyosis. J Invest Dermatol 117:710717
116. Norln L (2002) Does the single gel phase exist in 134. Bouwstra JA, Gooris GS, Dubbelaar FER et al
stratum corneum? J Invest Dermatol 118:899901 (1999) Cholesterol sulfate and calcium affect stra-
117. Whitesides GM, Grzybowski B (2002) Self-assembly tum corneum lipid organization over a wide temper-
at all scales. Science 295:24182421 ature range. J Lipid Res 40:23032312
118. Grzybowski BA, Wilmer CE, Kim J et al (2006) 135. Milstone LM (2004) Epidermal desquamation.
Self-assembly: from crystals to cells. Soft Matter J Dermatol Sci 36:131140
5:11101128 136. Harding CR, Watkinson AC, Rawlings AV et al
119. Williams ML, Elias PM (1987) The extracellular (2000) Dry skin, moisturization and corneodesmoly-
matrix of stratum corneum: role of lipids in normal sis. Int J Cosm Sci 22:2152
and pathological function. CRC Crit Rev Therap 137. Fluhr JW, Elias PM (2002) Stratum corneum pH:
Drug Carrier Syst 3:95122 formation and function of the acid mantle.
120. Mitragotri S, Anissimov YG, Bunge AL et al (2011) Exogenous Dermatol 1:163175
Mathematical models of skin permeability: an over- 138. Fluhr JW, Kao JS, Jain M et al (2001) Generation of
view. Int J Pharm 418:115129 free fatty acids from phospholipids regulates stratum
146 M. Boncheva

corneum acidification and integrity. J Invest Dermatol 155. Lavrijsen AP, Bouwstra JA, Gooris GS et al (1995)
117:4451 Reduced skin barrier function parallels abnormal
139. Hachem J-P, Crumrine D, Fluhr J et al (2003) pH stratum corneum lipid organization in patients with
directly regulates epidermal permeability barrier lamellar ichthyosis. J Invest Dermatol 105:619624
homeostasis, and stratum corneum integrity/cohe- 156. Rawlings AV, Harding CR (2004) Moisturization
sion. J Invest Dermatol 121:345353 and skin barrier function. Dermatol Ther 17
140. Rawlings AV, Harding CR, Watkinson AC et al (suppl 1):4348
(2002) Dry and xerotic skin conditions. In: Leyden 157. Wiechers JW, Dederen JC, Rawlings AV (2009)
JJ, Rawlings AV (eds) Skin moisturization. Marcel Moisturization mechanisms: Internal occlusion by
Dekker, Inc., New York, N.Y, pp 119143 orthorhombic lipid phase stabilizersa novel
141. Hachem J-P, Man M-Q, Crumrine D et al (2005) mechanism of action of skin moisturization. In:
Sustained serine protease activity by prolonged Rawlings AV, Leyden JJ (eds) skin moisturization.
increase in pH leads to degradation of lipid processing Informa Healthcare USA, Inc., New York,
enzymes and profound alterations of barrier function pp 309321
and stratum corneum integrity. J Invest Dermatol 158. Caussin J, Gooris GS, Groenink W et al (2007)
125:510520 Interaction of lipophilic moisturizers on stratum cor-
142. Arseneault M, Lafleur M (2007) Cholesterol-sulfate neum domains in vitro and in vivo. Skin Pharmacol
and Ca2+ modulate the mixing properties of lipids Physiol 20:175186
in stratum corneum model mixtures. Biophys J 92: 159. Caussin J, Rozema E, Gooris GS et al (2009)
99114 Hydrophilic and lipophilic moisturizers have similar
143. Epstein EHJ, Williams ML, Elias PM (1981) Steroid penetration profiles but different effects on SC water
sulfatase, X-linked ichthyosis and stratum corneum distribution in vivo. Exper Dermatol 18:954961
cell cohesion. Arch Dermatol 117:761763 160. Caussin J, Gooris GS, Bouwstra JA (2008) FTIR
144. Wu KS, van Osdol WW, Dauskardt RH (2006) studies show lipophilic moisturizers to interact with
Mechanical properties of human stratum corneum: stratum corneum lipids, rendering them more densely
effects of temperature, hydration, and chemical treat- packed. Biochim Biophys Acta 1778:15171524
ment. Biomaterials 27:785795 161. Hadgraft J, Finnin BC (2006) Fundamentals of
145. Berthaud F, Boncheva M (2011) Correlation between retarding penetration. In: Smith EW, Maibach HI
the properties of the lipid matrix and the degrees of (eds) Percutaneous penetration enhancers. Taylor
integrity and cohesion in healthy human stratum cor- and Francis, Boca Raton, pp 361371
neum. Exper Dermatol 20:255262 162. Hadgraft J, Peck J, Williams DG et al (1996)
146. Brandner JM, Haftek M, Niessen CM (2010) Mechanisms of reaction of skin penetration enhanc-
Adherens junctions, desmosomes and tight junctions ers/retardants: azone and analogues. Int J Pharm
in epidermal barrier function. Open Derm J 4:1420 141:1725
147. Elias PM (2008) Skin barrier function. Curr Alergy 163. Peck JV, Minaskanian G, Hadgraft J (2000) Topical
Asthma Rep 8:299305 compositions useful as skin penetration retardants.
148. Elias PM (2010) Therapeutic implications of a bar- US patent 6,086,905
rier-based pathogenesis of atopic dermatitis. Ann 164. Kaushik D, Batheja P, Kilfoyle B et al (2008)
Dermatol 22:245254 Percutaneous penetration modifiers: enhancement ver-
149. Prausnitz MR, Mitragotri S, Langer R (2004) Current sus retardation. Expert Opin Drug Deliv 5:517529
status and future potential of transdermal drug deliv- 165. Kim N, El-Khalili M, Henary MM et al (1999)
ery. Nature Rev Drug Disc 3:115124 Percutaneous penetration enhancement activity of
150. Prausnitz MR, Langer R (2008) Transdermal drug aromatic S, S-dimethyliminosulfuranes. Int J Pharm
delivery. Nature Biotech 26:12611268 187:219229
151. Loden M, Anderson A-C (1996) Effect of topically 166. Brain KR, Watkinson AC, Walters KA (1999)
applied lipids on surfactant-irritated skin. Br J Reduction of the skin penetration of xenobiotics
Dermatol 134:215220 using chemical penetration retarders. In: Sohns T,
152. Darmstadt GL, Mao-Qiang M, Chi E et al (2002) Voicu VA (eds) NBC risks: Current capabilities and
Impact of topical oils on the skin barrier: possible future perspectives for protection, NATO Science
implications for neonathal health in developing Series: Disarmament Technologies. Kluwer
countries. Acta Paediatr 91:546554 Academic Publishers, Dordrecht, pp 271277
153. Menon GK, Duggan M (2006) Strategies for improv- 167. Li N, Su Q, Tan F et al (2010) Effect of 1,4-cyclo-
ing the skin barrier by cosmetic skin care treatments. hexanediol on percutaneous absorption and penetra-
In: Wille JJ (ed) Skin delivery systems: Transdermals, tion of azelaic acid. Int J Pharm 387:167171
dermatologicals, and cosmetic actives. Blackwell 168. Braue EH Jr, Doxzon BF, Lumpkin HL et al (2006)
Publishing, Ames, pp 2542 Military perspectives in chemical penetration retar-
154. Jelenco C 3rd, McKinley JC (1976) Studies in burns: dation. In: Smith EW, Maibach HI (eds) Percutaneous
XV. Use of a topical lipid in treating human burns. penetration enhancers. Taylor and Francis, Boca
Am Surg 42:838848 Raton, pp 385398
10 Molecular Organization of the Lipid Matrix in Stratum Corneum 147

169. Smith EW, Maibach HI (eds) (2006) Percutaneous 181. Lingwood D, SImons K (2010) Lipid rafts as mem-
penetration enhancers. Taylor and Francis, Boca brane-organizing principle. Science 327:4650
Raton 182. Dietrich C, Bagatolli LA, Volovyk ZN et al (2001)
170. Mitragotri S (2000) Synergistic effects of enhancers Lipid rafts reconstituted in model membranes.
for transdermal drug delivery. Pharm Res 17: Biophys J 80:14171428
13541359 183. London M, London E (2004) Ceramide selectively
171. Karande P, Jain A, Ergun K et al (2005) Design prin- displaces cholesterol from ordered lipid domains
ciples of chemical penetration enhancers for trans- (rafts): Implications for lipid raft structure and func-
dermal drug delivery. Proc Natl Acad Sci USA tion. J Biol Chem 279:999710004
102:46884693 184. Boncheva M, Whitesides GM (2005) Making things
172. Whitesides GM (1995) Self-assembling materials. by self-assembly. MRS Bull 30:736742
Sci Am 273:146149 185. Alivisatos AP, Barbara PF, Castelman AW et al
173. Lehn J-M (2004) Supramolecular chemistry: from (1998) From molecules to materials: current trends
molecular information towards self-organization and and future directions. Adv Mater 10:12971336
complex matter. Rep Prog Phys 67:249265 186. Boncheva M, Whitesides GM (2004) The biomi-
174. Lampe MA, Burlingame AL, Whitney J et al (1983) metic approach to the design of functional self-
Human stratum corneum lipids: characterization and assembling systems. In: Schwarz JA, Contescu CI,
regional variations. J Lipid Res 24:120130 Putyera K (eds) Dekker encyclopedia of nanoscience
175. Gunathilake R, Schurer N, Shoo BA et al (2009) pH- and nanotechnology, vol 1. CRC Press, Boca Raton,
regulated mechanisms account for pigment-type dif- pp 287294
ferences in epidermal barrier function. J Invest 187. Schaefer-Korting M, Mehnert W, Korting H-C
Dermatol 129:17191729 (2007) Lipid nanoparticles for improved topical
176. Meidan VM, Roper CS (2008) Inter- and intra-indi- application of drugs for skin diseases. Adv Drug
vidual variability in human skin barrier function: a Deliv Rev 59:427443
large scale retrospective study. Toxicol In Vitro 188. Mueller RH, Petersen RD, Hommoss A et al (2007)
22:10621069 Nanostructured lipid carriers (NLC) in cosmetic der-
177. Moore DJ, Snyder RG, Rerek ME et al (2006) mal products. Adv Drug Deliv Rev 59:522530
Kinetics of membrane raft formation: fatty acid 189. Castner DG, Ratner BD (2002) Biomedical surface
domains in stratum corneum lipid models. J Phys science: foundations to frontiers. Surf Sci 500:
Chem B 110:23782386 2860
178. Boelsma E, Hendriks HFJ, Roza L (2001) Nutritional 190. Martin P (1997) Wound healing aiming for perfect
skin care: health effects of micronutrients and fatty skin regeneration. Science 276:7581
acids. Am J Clin Nutr 73:853864 191. Ball P (2002) Natural strategies for the molecular
179. McDaniel JC, Beluri M, Ahijevych K et al (2008) engineer. Nanotechnology 13:R15R28
Omega-3 fatty acids effect on wound healing. Wound 192. Noireaux V, Maeda YT, Libchaber A (2011)
Rep Reg 16:337345 Development of an artificial cell, from self-organiza-
180. Munro S (2003) Lipid rafts: elusive or illusive? Cell tion to computation and self-reproduction. Proc Natl
115:377388 Acad Sci USA 108:34733480
 Desquamation: It Is Almost
All About Proteases 11
Rainer Voegeli and Anthony V. Rawlings

11.1 Introduction transition phase between the stratum granulosum

(SG) and the SC, the final stages of programmed
A principal biological mission of the epidermis is cell death await the epidermal keratinocytes. This
to create the stratum corneum (SC) to protect the necessary step results in the production of cor-
body from the outside world. The SC is a coher- neocytes and the integration of the cornified
ent tissue composed in most body regions of envelope (CE) with the extracellular lipid matrix.
approx. 15 corneocyte layers corresponding to a This occurs as the lamellar bodies (LBs) are
thickness of 1020 mm. No area of cutaneous secreted in the extracellular spaces at the SGSC
biology has attracted more investigative attention interface, the nuclei are defragmented, and trans-
than the SC. A multitude of studies in the last few glutaminase cross-linked proteins are deposited
decades have shown that the SC is a very com- under the plasma membrane leading to CE for-
plex, dynamic tissue whose formation involves mation. This specialized form of cell death in the
many highly regulated metabolic enzymatic func- epidermis is thus intrinsic and programmed [3].
tions maintaining cutaneous homeostasis [1]. The The terminally differentiated corneocytes that
epidermis has many diverse functions, and a vari- are shed from the skin surface are continuously
ety of these are localized to the SC, elevating the replaced from underneath by keratinocytes. Thus,
SC as a key player in the many protective pro- under normal conditions, there is a delicate bal-
cesses of the integument [2]. ance between basal cell proliferation and shed-
In the viable epidermis, several mechanisms ding of corneocytes (desquamation) maintaining
are initiated to generate the SC. The final step in an epidermis of a constant thickness [4]. Roughly
these processes is the transformation from kerati- estimated, every day one new cell layer appears in
nocytes to corneocytes. During this maturation, the deeper SC, and one old layer is lost off its sur-
major changes in cell morphology occur. At the face. In other words, every day we lose 2 m2 of
skin without recognizing it. During a lifetime, this
accounts for the area of about 6 football fields.
Unlike the keratinocytes in the viable epider-
R. Voegeli ()
DSM Nutritional Products Ltd., mis, the corneocytes of the SC are no longer able
Bldg. 203-4/86, P.O. Box 2676, Basel CH-4002, to synthesize new proteins, but enzymes, particu-
Switzerland larly transglutaminases, are involved in anabolic
e-mail: [email protected]
processes. Moreover, several highly specialized
A.V. Rawlings and dynamic metabolic activities continue or
AVR Consulting Ltd.,
even start to occur in the SC, due to the presence
26 Shavington Way, Kingsmead, Northwich Cheshire
CW9 8FH, UK of numerous enzymes and their substrates that
e-mail: [email protected] are produced prior to keratinization. The extent

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 149

DOI 10.1007/978-3-642-27606-4_11, Springer-Verlag Berlin Heidelberg 2012
150 R. Voegeli and A.V. Rawlings

of the changes and their speed are autoregulated Michaels [8] and later Elias [9] visualized the SC
and rather constant under physiological condi- as being similar to a brick wall, with the corneo-
tions, but the environment still has some influ- cytes analogous to bricks, and the lipid lamellae
ence, e.g., through modification of the SC acting as mortar. However, lipids are not the
hydration or a disruption of the SC barrier with major cohesive forces holding corneocytes
the subsequent repair-related changes [5]. together [10]. Extending this model, the cor-
The SC has a depth-dependent dynamic struc- neodesmosomes may be thought of as analogous
ture in which multiple enzymatic reactions are to iron rods that act as molecular rivets between
balanced to ensure its mechanistic, cohesive, and the bricks to give the wall its tensile strength [11].
desquamatory properties are maintained [6]. The term corneodesmosome was first proposed
However, still little is understood of the molecu- 20 years ago by Serre, Haftek, and coworkers
lar activation mechanisms of enzymes within the [12], and the same group found that corneodes-
SC. Obviously pH, water, and Ca2+ gradients as mosomes contain a unique adhesive glycoprotein
well as barrier competence influence enzymatic in their extracellular space, known as corneodes-
activities. Proteases play important roles in the mosin (CDSN) [13].
keratinization process but are also involved in tis-
sue remodeling, lipid barrier homeostasis, and 11.2.1.2 Structures and Molecules
inflammatory conditions. As a consequence, the of (Corneo)Desmosomes
activity of certain proteases is increased in skin Constant formation and removal of desmosomes
disorders in which the epidermal barrier is is required to allow the keratinocytes to move from
impaired. It has also been generally acknowl- the epidermal basal layer to the granular layer. The
edged that the appearance of dry skin is mainly differentiation-dependent composition of desmo-
the result of an alteration in the desquamatory somes coincides with the increase of their mechan-
process of the normal SC maturation. ical stability. In the basal layer, desmosomes are
In this chapter, we review the structure, func- infrequent and small; their size and number rise
tion, and formation of the SC, how it is perturbed significantly in the spinous layers and decrease
in a variety of conditions, as well as the proteases subsequently in the granular compartment [14].
and their inhibitors that play a role in desquama- Desmosomes have round or oval, button-like
tion of healthy and pathological skin. structures with a diameter of 0.21 mm [15]. The
morphology of desmosomes changes dramatically
during the transition from the SG to the SC
11.2 CellCell Junctions (Fig. 11.1) [5]. The intercellular portion of the
in the Stratum Corneum junction loses its electron-dense central band
flanked by symmetric light band and becomes
11.2.1 Corneodesmosomes and Their homogeneous, whereas the intracellular plaque
Highly Orchestrated Digestion becomes embedded within the cross-linked CE.
Products resulting from proteolysis and from the
11.2.1.1 The Iron Rods: Molecular dispersion of keratohyalin granules fill the interior
Rivets in the Brick and Mortar of corneocytes tightly and make the remnants of
Construction keratin cytoskeleton disappear, so even the points
Corneodesmosomes are modified desmosomes of insertion of keratin bundles into desmosomal
found in the SC, the uppermost layers of the epi- plaque become invisible. Such a drastic modifica-
dermis. Here they mediate strong intercellular tion of the desmosome structure once made the
cohesion to provide enough tensile strength to desmosomal plugs between corneocytes to be
resist shearing forces that is crucial for the physi- considered as nonfunctional remnants [5].
cal barrier function of the epidermis. Ultimately, There is a clear direct relationship between the
the final stages of corneodesmosomal degrada- number of corneodesmosomes and the strength of
tion occur at the time of desquamation [7]. cellular cohesion [12]. In the stratum disjunctum,
11 Desquamation: It Is Almost All About Proteases 151

Fig. 11.1 Comparison of the ultrastructure of the spinous White arrows in (a) point to the internal and external desmo-
layer desmosome (a) and a corneodesmosome (c). Transition somal plaques, the latter being associated with keratin fila-
from the granular layer to the SC is shown in (b) with a cor- ments. The white rectangle spans the extracellular portion of
neodesmosome showing asymmetrical intracellular features. the junction the desmosome core. Bar 100 nm [5]. DP
Arrowhead points to the cell membranes or lipid cell enve- desmosomal plaque, CE cornified envelope (Reproduced
lopes in the living and cornified keratinocytes, respectively. with permission of TAYLOR & FRANCIS GROUP LLC)

fewer corneodesmosomes are present compared As keratinocytes are pushed to the surface lay-
to the stratum compactum [16, 17]. In the stratum ers of the skin, they constantly form and retrieve
compactum, one finds one corneodesmosome per desmosomes at the cell periphery. During this
mm2 on average. This means that there exist turnover, the cadherins that compose the junctions
approx. 400600 corneodesmosomes per corneo- are also constantly replaced even without physi-
cyte and per site [18]. cal dissociation of the structure. According to the
The (corneo)desmosome proteins originate level of keratinocyte differentiation, DSG2 and
from three major gene families [1921]: DSG3 from the lower epidermal compartment are
Cadherins (desmogleins, desmocollins) progressively substituted by DSG1 and DSG4 in
Armadillo proteins (plakoglobin, plakophilins) the upper viable epidermal layers. In the same
Plakins (desmoplakin, envoplakin, periplakin, way DSC3 is replaced by DSC1 (Fig. 11.3) [14].
plectin) Thus, DSC1, DSG1, and DSG4 are strongly asso-
Analogous to the desmosomes mediating kera- ciated with terminally differentiating layers, while
tinocyte cohesion, corneodesmosomes maintain the remaining isoforms are associated with the
corneocyte adhesion via a Ca2+-dependent inter- lower, proliferating cell layers, suggesting that
action in their extracellular space between the this differentiation-specific pattern may regulate
two cadherin families: the desmogleins and the epidermal development and differentiation [23].
desmocollins. To date, four isoforms of desmog-
leins (DSG14) and three isoforms of desmocol- 11.2.1.3 Peripheral and Nonperipheral
lins (DSC13) have been identified in the human Corneodesmosomes
epidermis [20]. The transmembranal cadherins The process of SC desquamation is complex and
are linked to the keratin intermediate filaments by is only apparent at the surface of the skin.
the armadillo proteins, which are in turn attached However, desquamation is not simply a process
to desmoplakin that is essential for linkage to the that spontaneously occurs in the upper layers of
intermediate filaments (Fig. 11.2) [22]. the SC, but is a self-regulating process that is
152 R. Voegeli and A.V. Rawlings

a b

DSG PG DP

DSC PKP IF

Fig. 11.2 (a) Schematic illustration of a desmosome and further stabilized by lateral interactions among these pro-
(b) electron micrograph onto which are super-imposed the teins, anchors the intermediate filaments (IF) cytoskeleton
major desmosomal protein constituents from three fami- to the desmosome [20] (Reprinted with permission from
lies. Transmembrane cadherins, DSG and DSC, bind pla- Macmillan Publishers Ltd: J Invest Dermatol 127(11): p.
koglobin (PG), which in turn anchors desmoplakin (DP) 24992515, copyright (2007))
and plakophilin (PKP). The cytoplasmic plaque, which is

Extracellular
Calcium pH
corneodesmosomal proteins
DSC/DSG4

CDSN
DSG1

SC 5

SG

7
SS
DSG3/DSC3
DSG2

DSC2

SB

Fig. 11.3 Expression gradients of extracellular corneodesmosomal proteins, calcium, and pH in the epidermis (SC
stratum corneum, SG stratum granulosum, SS stratum spinosum, SB stratum basale (Modified from [14, 20, 22, 171])

initiated in the lower layers of nonpalmoplantar organizing lamellar lipids. Once degraded these
SC [24] except for the face which appears to be areas become very hydrophilic due to the pres-
mediated more superficially [25]. Desquamation ence of amino acids and peptides derived from
very likely occurs via a regulated multistep prote- the original corneodesmosomal proteins. In the
olysis. Corneodesmosomes interconnect the cor- uppermost granular layer, the LBs secrete a cock-
neocytes through the intercorneocyte spaces tail of serine, cysteine, and aspartic proteases into
which themselves are occupied largely by self- the intercellular space between SG and SC [5]
11 Desquamation: It Is Almost All About Proteases 153

Fig. 11.4 Hydration of the SC promotes the lateral dis- hydrophilic lacunae embedded in the intercellular lipids,
placements, coalescence, and increase in volume of the but these domains are more discrete. The hydrophilic
extracellular hydrophilic microdomains, leading to the nature of the intercellular lacunae is compatible with the
increased frequency of their association with corneodes- presence of extracellular enzymes involved in the pro-
mosomes (RuO4 staining). (a) In the occluded skin, the cesses of maturation and desquamation of the SC. Bars =
well-hydrated SC shows voluminous hydrophilic lacunae 200 nm [5] (Reproduced with permission of TAYLOR &
(white arrowheads) in the proximity of corneodesmosomes FRANCIS GROUP LLC)
(black arrows). (b) The nonoccluded SC also contains

(Fig. 11.4). This region is a zone of enormous An additional protection from degradation of
metabolic activity [2628]. Central, nonperipheral the peripheral junctions by supplementary
corneodesmosomes in the stratum compactum structures, like remnants of strategically
are initially hydrolyzed resulting in retention of placed tight junctions cross-linked to CEs at
corneodesmosomes only at peripheral edges of the periphery of corneocytes [14]
corneocytes in the stratum disjunctum [16]. This A change in frequency and size of corneodes-
results in reduced cohesion in the perpendicular mosomes is obvious between the deeper and the
plane of the skin, but it still has tremendous resis- more superficial layers of the SC. On nonpalmo-
tance to shearing forces in the horizontal plane. plantar SC, corneodesmosomes occupy approxi-
The retained peripheral corneodesmosomes in the mately 30% of the cell surface in the stratum
stratum disjunctum are degraded later, leading to compactum, but represent less than 7% of the cell
ordered corneocyte shedding at the skin surface. surface in the stratum disjunctum [29]. The situa-
Reasons for the preferential digestion of nonpe- tion is quite different in palmoplantar SC, where
ripheral corneodesmosomes may include: more than 50% of the intercellular spaces are occu-
A higher impact of shearing forces on junc- pied by corneodesmosomes up to the upper SC.
tions between flat rigid surfaces, when applied
to the skin or naturally occurring during 11.2.1.4 Importance of Controlled
changes of the corneocyte volume due to varia- Desquamation for SC
tions in the water content Homeostasis
Easier access for the enzymes, displaced The process of the gradual disappearance of
by self-organizing lipid bilayers, when com- corneodesmosomes in the stratum disjunctum [16,
pared to the convoluted lateral intercorneocyte 30] and the parallel disappearance of desmog-
spaces leins, desmocollins, and CDSN [31, 32] during
154 R. Voegeli and A.V. Rawlings

desquamation is not completely understood.

Nevertheless, a growing number of enzymes have
been identified and linked to this process [26].
It appears likely that in certain diseases or after
external impairment to the skin, the physiologic
cascade of desquamation is altered [3338]. Yet
the physiological role and the endogenous targets
of the majority of these proteases have not been
identified; the conditions required for activation,
precise localization, and interdependence still
await clarification.
Persistence of peripheral corneodesmosomes
can be related to several hyperkeratotic condi-
tions like certain ichthyoses, xerotic diseases,
senile dry skin, and winter and soap-induced
xerotic skin. The lack of the proteolytic degrada-
tion of DSC1, DSG1, and CDSN is a key event in
these skin disorders [3944].
Tight junctions (TJs) have only been described in
the superficial granular layer until recently [45, 46].
By ultrastructural examination, Haftek et al. [47]
demonstrated that TJs become cross-linked to the
cornified envelopes during the process of cornifi-
cation and thus contribute to the compartmental-
ization of the intercorneocyte spaces in the SC. Fig. 11.5 Hook and clip-like structures of the corneocytes
in the SC [10]. (a) transmission electron micrograph of the
The authors hypothesize that such TJ-derived riv- outer layer of the SC with corneodesmosomes (arrows),
ets distributed at the corneocyte periphery may (b) raster electron microscopic top view on a corneocyte
significantly delay protease access to peripheral in the medial SC with clip-like hooks (Reproduced with
corneodesmosomes when compared to the unpro- permission of INFORMA HEALTHCARE)
tected junctions located in between the succes-
sive layers of SC cells. Therefore, peripheral if the tension increases and finally also the hook-
corneodesmosomes remain relatively intact up to like structures can be dismantled. Within the hook-
the skin surface. Indeed, Igawa et al. [48] observed like rims, extended corneodesmosomal structures
persistence of these TJ-like structures up to the are found, which seem to be the last docking point
eighth deepest cornified layers. Immunoelectron of a corneocyte during desquamation.
microscopy also detected clusters of the TJ
marker proteins occludin and claudin-1 at the
corneocyte periphery, whereas kallikrein 7 11.3 pH of the Stratum Corneum:
(KLK7) immunolabeling was found outside of Its Important and
TJ-derived structures in the extracellular space of Misinterpreted Role
the lower cornified layers.
According to Wepf et al., corneocytes are held The pH is a critical factor regulating skin barrier
in position not only by corneodesmosomes but homeostasis and controls lipid interactions, enzy-
also by hook-like structures at the periphery of the matic activities, corneodesmosomal degradation,
cells [10] (Fig. 11.5). Hyperhydrated SC exposes and microbial defense [49]. However, the SC is
large water inclusions between the single corneo- not an aqueous solution, and the definition of
cyte layers. These water inclusions disrupt the cor- pH should not be directly applied for its acidity
neodesmosomes and resist longest at the hook-like measurement. The pH of the epidermis is sug-
structures. These structures are only disrupted gested to follow a sharp gradient across the SC
11 Desquamation: It Is Almost All About Proteases 155

(Fig. 11.3), which seems to play an important role imaging studies revealed that SC acidification
in controlling the enzymatic activities involved in does not occur through a uniform gradient, but
cellular metabolism and renewal [50]. through the progressive accumulation of acidic
The outermost layer of the SC exhibits an microdomains. These findings not only visualize
acidic surface pH. The surface pH measured with the spatial distribution of the SC pH gradient but
a flat electrode on normal human skin ranges also demonstrate a role for NHE1 in the genera-
between 4 and 5.5, whereas the pH at its base tion of acidic extracellular domains of the lower
approaches neutrality. From a biological point of SC, thus providing the acidification of deep SC
view, a change in pH of about 2 units over a tiny interstices necessary for both lipid processing and
distance as 1020 mm is an important event [51]. barrier homeostasis and putting this pathway at
However, what is measured at the skin surface is the center of establishing and maintaining SC pH
in fact an apparent pH due to extracted material and epidermal permeability function [52].
from the SC diffusing into water applied at the It remains suggestive if the pH or its gradient
surface. pH values recorded at the surface of the within the SC exerts a major influence on desqua-
semihydrophobic milieu of the SC should be mation, either via effect on corneodesmosomes
interpreted with great caution because it is obvi- or via activation of serine proteases in the SC
ous that hydrogen ions are not in a pure solution [27, 54].
at the surface of the skin [50]. Newer, high-reso-
lution microscopic methods could not confirm
the existence of a pH gradient. The measured 11.4 The Calcium Gradient
change in pH in tape-stripping experiments must in the Epidermis
therefore be viewed as a result of injury to the
epidermal permeability barrier, removing part of In the epidermis, an increasing extra- and intrac-
the acidic compartment and leading to loss of ellular Ca2+ gradient is established toward the
components from the neutral SG, resulting in a SG, after which it declines in the SC (Fig. 11.3).
mixed or diluted pH measured [52]. As already mentioned, cadherins maintain cor-
Three classes of molecules have been sug- neocyte adhesion via a Ca2+-dependent interac-
gested as the most likely source of hydrogen ions tion in their extracellular space. Thus, the
in normal SC [2, 50]: elevated extracellular calcium levels in the upper
Certain NMFs including amino acids and fil- epidermis (Fig. 11.3) certainly contribute to the
aggrin-related breakdown products, such as desmosome stabilization [14]. In addition, the
urocanic acid and pyrrolidone carboxylic acid activity of several cysteine and serine proteases
Alpha-hydroxy acids, such as lactic acid and requires the presence of Ca2+ [55]. High concen-
hydroxybutyric acid, which are present in tration of extracellular Ca2+ has been shown
sweat induced KLK5 and KLK7 expression on mRNA
Acidic lipids, such as cholesterol sulfate and and protein levels in cultured normal human
free fatty acids derived from sebum, ceramide, keratinocytes [56].
and phospholipid hydrolysis When the epidermal permeability barrier is
However, Na+/H+ exchanger (NHE1) in human disrupted, the extracellular concentration of Ca2+
and mouse epidermis has been identified as the decreases in the outer epidermis. This process
crucial source of SC acidity at the SG/SC inter- mimics the decrease in the concentration of Ca2+
face [52, 53]. NHE1 is the only Na+/H+ antiporter in intact SC and triggers the LBs to extrude their
isoform in keratinocytes and epidermis and has content into the intercellular space to initiate
been shown to regulate intracellular pH. A novel repair [57]. However, barrier disruption also leads
function for NHE1 demonstrated that it also con- to increased serine protease activity, which results
trols acidification of extracellular microdomains in activation of proteinase-activated receptor-2
in the SC that are essential for activation of pH- (PAR2) and influx of Ca2+, thereby counteracting
sensitive enzymes and the formation of the epi- and regulating LB secretion and reestablishing
dermal permeability barrier. Fluorescence lifetime cornification [58, 59].
156 R. Voegeli and A.V. Rawlings

11.5 Epidermal Proteases Involved in 1987 by Bisset et al. who reported that topical
in Desquamation application of trypsin or the protease inhibitor
phenylmethylsulfonyl fluoride to pig and human
The proteases mentioned in this section are SC greatly accelerated or inhibited the rate of
mainly reviewed in respect of their activities in desquamation, respectively [63]. Subsequently,
desquamation only although they exert many Egelrud and Lundstrm initiated studies on the
other biological roles in the body. SC proteases that greatly contributed to the cur-
An interest in proteases in skin arose with the rent understanding of the role of proteases in
realization of the important role of proteolysis in desquamation [6470].
many biological phenomena. Early work of
Sexsmith and Petersen in 1918 [60] showed that
there is considerable proteolytic activity in human 11.5.1 Serine Proteases
skin. Since then huge efforts have been made to
characterize the pattern of the proteolytic enzymes The serine protease family uses a highly con-
and the pathways of proteolysis in normal and served catalytic triad in the substrate-binding
pathological skin. pocket (Ser, His, Asp) to hydrolyze peptide bonds.
Proteases are currently classified into six Based on their substrate specificity, serine pro-
groups: teases can be subdivided into three groups [55]:
Serine proteases The trypsin-like proteases (cleavage preferred
Cysteine proteases at the basic amino acids Arg and Lys)
Aspartate proteases The chymotrypsin-like proteases (cleavage
Metalloproteases preferred at aromatic or bulky nonpolar amino
Threonine proteases acids, such as Trp, Phe, Tyr, and Leu)
Glutamic acid proteases The elastase-like proteases (cleavage preferred
Of 699 proteases in man, 178 are serine pro- at small to medium hydrophobic amino acids,
teases and 138 of them belong to the trypsin pro- such as Ala)
tease family. Abundance of these proteases
suggests the protein fold presents a selective 11.5.1.1 Kallikreins
advantage relative to other proteases [61]. Kallikreins are serine proteases expressed by a
Proteases are often activated through highly wide range of tissues and are implicated in a great
orchestrated proteolytic cascades. Due to the irre- number of physiological functions, among many
versible nature of proteolytic activation, these others in skin desquamation [62] where they rep-
cascades are tightly regulated through a series of resent the most intense investigated protease fam-
feedback loops and inhibitors. Proteolytic regula- ily. Between 1994 and 2001, the kallikrein family
tory mechanisms are critical in preventing delete- expanded from 3 to 15 genes, and a complete
rious effects due to uncontrolled protease description of the human kallikrein locus was
activation [62]. A cocktail of proteases is secreted reported. Kallikreins represent the largest contigu-
at the SGSC interface to facilitate the break- ous cluster of protease genes in the human genome.
down of corneodesmosomes [2628]. Inactive The newly discovered kallikreins all map to the
protease precursors are activated and regulated same chromosomal region (19q13.4) as the three
by a complementary cocktail of protease inhibi- classical ones (KLK1, KLK2, and KLK3) [71].
tors [32]. The enzymes responsible for the cleav- Each of the 15 kallikreins is synthesized as a
age of corneodesmosomal proteins and their single-chain preproenzyme, containing each a
regulation are still not well characterized. signal presequence of 1630 amino acids that is
However, serine, cysteine, and aspartic acid pro- cleaved from the N-terminus prior to secretion
teases have been identified in the SC and might [72]. Prodomains are short peptide sequences,
play a central role in desquamation. Involvement i.e., 37 amino acids in proKLK5 and 49 amino
of proteases in desquamation was first postulated acids in the other kallikreins, and are cleaved
11 Desquamation: It Is Almost All About Proteases 157

Table 11.1 Enzymatic classification of the 15 kallikreins present in active forms in SC [27, 34, 37, 38, 54,
Chymotrypsin-like Trypsin-like 68, 70, 73, 74, 76, 77].
KLK1 The proteolytic activity of kallikreins seems to
KLK2 be cascade mediated and may crosstalk with
KLK3 other proteases. These cascades are highly regu-
KLK4 lated through a series of feedback loops, inhibi-
KLK5 tors, (auto)degradation, and internal cleavage.
KLK6 Uncontrolled proteolytic activity of kallikreins is
KLK7 implicated in a large number of pathological con-
KLK8 ditions [62].
KLK9
KLK10
11.5.1.2 Proteases of the Thrombostasis
KLK11
Axis: The Plasminogen System
KLK12
KLK13
Like the kallikreins, the trypsin-like serine pro-
KLK14 KLK14 teases urokinase (uPA) and plasmin are also
KLK15 involved in many physiological and pathological
The proteases that have been found in the SC are blue
conditions especially in hemostasis, carcinogen-
shaded in bold esis, and skin inflammation. Both proteases are
secreted as the zymogens plasminogen and pro-
upon activation [62]. KLK3, KLK7, KLK9, and uPA. Suzuki et al. first described plasmin and
KLK15 have chymotrypsin-like activity, and the uPA activities in human SC [54]. Although both
rest shows trypsin-like activity. KLK14 exerts a proteases are present in the SC, they may not nec-
high catalytic efficiency and is the only member essarily directly be involved in the desquamatory
that cleaves both trypsin-like and chymotrypsin- process. To our knowledge, there is no evidence
like peptide substrates (Table 11.1). With chro- of uPA or plasmin-induced hydrolysis of extra-
mogenic peptide substrates, essentially all cellular components of corneodesmosomes.
chymotrypsin-like kallikrein activity in the SC However, there are indications of activation of
can be ascribed to KLK7. On the other hand, at certain kallikrein zymogens and vice versa which
most 50% of the total trypsin-like kallikrein may lead to aberrant desquamation [78, 79].
activity in SC extracts was due to KLK5, whereas pro-uPA contains 411 amino-acid residues
a major part of the remaining activity was associ- arranged in two chains and three domains: the so-
ated with KLK14 [73, 74]. called A-chain includes the N-terminal growth-
Komatsu et al. performed the most extensive factor-like domain and the central kringle domain,
studies on kallikreins in the SC and in sweat. The and the B-chain includes the C-terminal catalytic
following eight kallikreins were identified in SC domain. Activation of pro-uPA occurs via the
and in sweat extracts by ELISA: KLK5, KLK6, cleavage of the Lys158Ile159 bond between the
KLK7, KLK8, KLK10, KLK11, KLK13, and A-chain and the catalytic domain containing
KLK14 [75, 76]. They found that the relative pro- B-chain, generating a two-chain molecule (HMW-
portions of each kallikrein in sweat were similar uPA) held together by a single disulfide bond. A
to those in the SC, suggesting that kallikrein further cleavage at Lys135Lys136 releases the
expression in sweat and SC could be regulated N-terminal growth factor and the kringle domains
via a shared mechanism [76]. Sweat might be a (amino acids 1135). The remaining carboxy-ter-
fluid facilitating transport of kallikreins toward minal region (LMW-uPA, amino acids 136411)
the skin surface [76]. As kallikreins have also retains full ability to activate plasminogen [80]. A
been identified in sebaceous glands, these could number of serine proteases can activate pro-uPA
contribute to the kallikrein levels in sweat such as plasmin, cathepsin B, mast cell tryptase,
samples [36]. KLK5, KLK7, KLK8, and KLK14 and KLK2 [80, 81]. uPA interacts with the cell
are the only kallikreins currently known to be surface receptor urokinase-type plasminogen
158 R. Voegeli and A.V. Rawlings

activator receptor (uPAR) [82], which shows affin- matriptase is an efficient activator of epidermal
ity for the N-terminal region of uPA only (HMW- prokallikreins [93]. Therefore, its participation in
uPA). This binding is important for cell-associated the cleavage of corneodesmosomes cannot be
plasminogen activation and proteolysis. Like other ruled out. Indeed, matriptase-deficient mice die
serine proteases, uPA can be inhibited by plasmi- within 48 h after birth as a consequence of severe
nogen activator inhibitors (PAIs) [83]. loss of the epidermal and oral barrier [94].
Plasminogen is a single-chain glycoprotein Abnormal filaggrin processing, LB disorganiza-
containing 791 amino-acid residues and six struc- tion, and impaired desquamation have been
tural domains, each with different properties. Its described [95, 96].
natural activators, one of them is uPA, cleave Furin is a calcium-dependent serine endopro-
plasminogen specifically at Arg561Val562, tease. It is enriched in the Golgi apparatus, where
which gives rise to plasmin, a two-chain mole- it efficiently cleaves downstream precursor pro-
cule linked by two disulfide bonds [81]. uPA- teins at their basic amino-acid target sequence.
dependent activation is thought to occur primarily Furin is a key enzyme for intracellular LEKTI
in association with the cell surface uPAR. processing [97] (cf. inhibitor chapter below).
Plasminogen is bound to the cell surface via its
lysine-binding sites in a relatively low affinity but
high capacity interaction. Cell surface bound 11.5.2 Cysteine and Aspartic Acid
plasmin is resistant to inactivation as it is pro- Proteases and Other Enzymes
tected from endogenous inhibitors [84].
On the contrary, uPA is expressed predomi- Cathepsins are a class of globular lysosomal pro-
nantly in basal keratinocytes [85, 86] and is the teases, most of which contain an active-site
predominant plasminogen activator in epidermal cysteine or aspartic acid residue. Although most
extracts of normal skin [87]. uPA activity was studies of desquamation have concentrated on
also found to be present in the SC, as well as the serine proteases especially kallikreins, other
basal layer after barrier disruption by tape-strip- classes of proteases have also been identified in
ping and sodium lauryl sulfate [88, 89]. Recently the SC. Among these are the two cysteine pro-
it was shown that uPA activation might occur in teases cathepsin L2 (CTSL2) and cathepsin L-like
the SC itself [88]. uPA and uPAR were reported (CTSL-like), and the aspartic acid protease cathe-
to be synthesized and secreted in human kerati- psin D (CTSD).
nocytes exposed to UVB [90, 91]. uPA, uPAR, Synthesized as proenzymes, cathepsins
and plasmin-mediated proteolysis are also undergo proteolytic maturation, sometimes in an
reported to be increased by proinflammatory autocatalytic way, and are active in an acidic
cytokines, interleukin-1b, and tumor necrosis environment. CTSD and CTSL2 are secreted by
factor-a, which are known to be synthesized and LBs into the extracellular spaces around cor-
secreted in UVB-exposed skin [92]. neodesmosomes in the SC [28, 98]. CTSD has
The plasminogen system in the epidermis is been localized in plantar SC [99]. Although
thought to be the major protease activity involved CTSD is associated with the final stage of desqua-
in the delay of barrier recovery [58, 88, 89]. mation [100], its role in corneodesmosomal deg-
Repeated barrier disruption induces epidermal radation remains uncertain, and other cathepsins
hyperplasia and is thought to lead to dry skin. are likely to compensate for CTSD deficiency.
Further investigations are necessary to provide a
11.5.1.3 Other Serine Proteases clear understanding of the role of each of these
Matriptase is a transmembrane serine protease proteases in keratinization and desquamation.
that is very unusual for a trypsin-like serine pro- Desquamation is also regulated by an inter-
tease in that it undergoes efficient autoactivation action of proteases and glycosidases. Bernard
and therefore has the capacity to initiate prote- et al. identified an endoglycosidase, heparanase
olytic cascade reactions. It has been shown that 1, that can play a preproteolytic role toward
11 Desquamation: It Is Almost All About Proteases 159

glycosylated moieties protecting corneodesmo- Cholesterol sulfate also inhibited the protease-
somal proteins [101]. induced cell dissociation of human SC sheets.
These results indicate that cholesterol sulfate
retards desquamation by acting as a serine pro-
11.6 Endogenous Protease tease inhibitor [106] or affects lipid phase behav-
Inhibitors in the Epidermis ior that then impacts protease activity.

The wide-ranging impact of SC protease activi-

ties on barrier function and structure, including 11.6.3 Relevant Epidermal
desquamation, means that regulation of their Proteinaceous Protease
activity is crucial. The activities of these proteases Inhibitors
are regulated by several protease inhibitors local-
ized to the extracellular spaces of the SC. Some of 11.6.3.1 LEKTI-1, LEKTI-2, and LEKTI-3
them are involved in the regulation of desquama- The lymphoepithelial Kazal-type 5 serine pro-
tion-associated proteolysis. Disturbance of the tease inhibitor (LEKTI-1) is encoded by the ser-
delicate protease/inhibitor balance may have dra- ine protease inhibitor Kazal-type 5 gene
matic consequences. To date, a great variety of (SPINK5). LEKTI-1 is expressed in the granular
endogenous inhibitors with physiological signifi- layer of the epidermis and is composed of 15 ser-
cance in the activity regulation of proteases are ine protease inhibitory domains (D1D15) [107,
known. They range from single metal ions to large 108]. The full-length protein is an inactive inhibi-
protein complexes of more than 700 kDa [102]. tor for kallikreins but inhibits trypsin, plasmin,
and elastase [71] and is rapidly cleaved via a
furin-mediated intracellular reaction into active
11.6.1 Metal Ions single and multidomains that are delivered in LBs
into the intercellular space of the SGSC inter-
The activity of several serine proteases is regu- face. Here, it is colocalized with kallikreins where
lated by endogenous cations. Interestingly, alkali the pH is near neutral. Under these conditions,
and alkaline earth ions tend to stimulate protease LEKTI-1 domains are potent inhibitors of KLK5,
activity at distinct binding sites. Zn2+ is a metal KLK7, and KLK14 [97]. As the pH becomes
ion with manifold functions in living organisms more acidic (Fig. 11.3), the inhibitory potential
and is present in about 300 human enzymes. It of LEKTI-1 is diminished. In the superficial lay-
may play a dual role in some activity regulation ers of the SC, inhibition by LEKTI-1 is suffi-
and inhibit other ones. Strikingly, for KLK5, ciently reduced to support localized desquamation.
KLK7, KLK8, and KLK14, inhibition by Zn2+ in Therefore, LEKTI-1 is an important, pH-depen-
the low mM range has been reported repeatedly dent, regulator of desquamation.
[73, 103105]. Thus, Zn2+ should be considered To date, LEKTI-1 is the only known protease
as an attenuator of KLK activity, which binds inhibitor thought to physiologically target epider-
in a reversible manner to the targets possibly for mal trypsin-like kallikrein inhibition. Several
fine tuning of their proteolytic action [102]. recombinant LEKTI-1 domains showed inhibi-
tory activity for members of the kallikrein family
[97, 109111]. For instance, recombinant
11.6.2 Cholesterol Sulfate LEKTI-1 domains D5, D6, D8D11, and D9D15
exhibited specific and differential inhibition of
Topically applied cholesterol sulfate inhibits pro- KLK5, KLK7, and KLK14. Further studies dem-
teases that are involved in desquamation. SC onstrate the selective efficiency of recombinant
thickness was increased in cholesterol-sulfate- LEKTI-1 domains D6D9 and D9D12 in inhib-
treated mice, and the number of desmosomes was iting KLK5 and KLK14. A significant finding is
higher than in the vehicle-treated group. that the LEKTI-1 domain D1D6 is the most
160 R. Voegeli and A.V. Rawlings

potent inhibitory fragment for all the kallikreins specific complexes with KLK7 in vitro [119].
tested. Furthermore, LEKTI-1 D12D15 was With a preferential inhibition toward the chy-
selective in inhibiting only KLK5. The ability of motrypsin-like and cysteine proteases, A2ML1
all LEKTI-1 domains (except D1) to strongly could count cathepsins among its physiological
inhibit KLK5 confirms that KLK5 is a major pro- targets and may represent an important regulator
tease target of LEKTI-1 in human SC. of desquamation in vivo.
Recently LEKTI-2 has been discovered in pal-
mar and plantar SC [112, 113] and LEKTI-3 in 11.6.3.4 Plasminogen Activator
SG at various anatomical localizations [114]. The Inhibitor-2
proteins are encoded by SPINK9 and SPINK6 Plasminogen activator inhibitor-2 (PAI-2) is a
gens, respectively, and are highly homologous to fast-acting inhibitor of urokinase. PAI-2 is con-
LEKTI-1, but contain only one Kazal-type sidered an important regulatory element of the
domain. Recombinant LEKTI-2 inhibited KLK5 plasminogen activation cascade controlling tis-
only, whereas LEKTI-3 inhibited KLK5, KLK7, sue remodeling and fibrinolysis [120]. PAI-2 is
and KLK14. Other serine proteases including the predominant epidermal plasminogen activa-
trypsin, plasmin, and thrombin are not inhibited. tor inhibitor throughout the normal epidermis
Thus, the authors suggest that LEKTI-2 and [121]. It is localized predominantly in the SG,
LEKTI-3 contribute to the regulation of the which implies a possible role in the terminal dif-
desquamation process in human skin. ferentiation of epidermis [122] and that it is a
precursor protein for the CE. Therefore, it is
11.6.3.2 SLPI and Elan speculated that PAI-2 is involved in the patho-
Secretory leukocyte protease inhibitor (SLPI) and genesis of certain cornification disorders, namely,
elafin are detected in the upper layers of the epi- congenital ichthyosis [120].
dermis and have been shown to prevent the
detachment of corneocytes from human plantar 11.6.3.5 Cystatin M/E
epidermis in vitro and to inhibit KLK7 activity in Finally, human epidermis contains specific
synthetic substrates [115, 116]. Elafin has been cysteine protease inhibitors, particularly cystatin
shown to covalently bind to corneocytes [117]. M/E, whose expression is restricted to the skin.
Interestingly, SLPI can be cleaved and inactivated Importantly, cystatin M/E and CTSL2 are sepa-
by members of the cathepsin family in vitro [118], rately transported in LBs and colocated on cor-
suggesting the possibility of retrocontrol of KLK7 neodesmosomes [98].
activity by these proteases. In vitro elafin and
SLPI inhibit chymotrypsin-like KLK7, but not 11.6.3.6 Pathological Inhibitor
trypsin-like KLK5, KLK13, and KLK14 activi- Deciency: Netherton Syndrome
ties [109]. Although elafin is a weak but efficient Failure of these inhibitory systems can lead to
inhibitor of KLK7, it significantly reduces cor- certain pathophysiological conditions. One of
neocyte shedding in vitro [32]. SLPI is may be a the most prominent examples is the Netherton
major physiological inhibitor of KLK7 in the epi- syndrome, which is caused by mutations in the
dermis, but it is also likely to be involved in the SPINK5 gene [123, 124] leading to dysfunctional
innate immune function of the SC [115]. domains of LEKTI-1 which fail to appropri-
ately regulate kallikreins in the SC, and conse-
11.6.3.3 a2-Macroglobulin-Like 1 quently to unrestricted kallikrein activity [102].
a2-Macroglobulin-like 1 (A2ML1) is a recently Interestingly, a strong overexpression of PAI-2 has
discovered member of the a2-macroglobulin been found in patients with Netherton syndrome
protease inhibitor family, which is specifically [120]. The Netherton syndrome is an autosomal
expressed in the epidermis. A2ML1 is located recessive ichthyotic skin disorder characterized
within the extracellular space between the upper- by severe SC barrier dysfunction with SC loss,
most granular layer and the SC, and can form chronic skin inflammation, atopic features, and
11 Desquamation: It Is Almost All About Proteases 161

hair shaft defects. This enhanced protease activ- in which the active form of one kallikrein cata-
ity results in premature corneodesmosome deg- lyzes activation of the next zymogen (Fig. 11.6)
radation and overdesquamation [125]. All the [127]. The occurrence of such a cascade in the
central manifestations of Netherton syndrome in skin is supported by the coexpression of multiple
LEKTI-1-deficient mice depend on the epidermal kallikreins in upper epidermal layers and sweat at
expression of matriptase [93]. These studies sug- varying concentrations, and by the ability of some
gest that protease inhibitors other than LEKTI-1 of these kallikreins to autoactivate and activate
may only have a minor role to play in the control other prokallikreins [73, 128]. A kallikrein may
of desquamation. take on the role of initiator, propagator, and/or
executor within the cascade, depending on its con-
centration, specificity, and activity level. However,
11.7 Regulation of Desquamation minute amounts of the initiator are sufficient to
by Proteolytic Cascades Within trigger the whole process owing to its catalytic
the Stratum Corneum nature [127]. Initially, kallikrein actions in the
skin were exclusively attributed to KLK5 and
The turnover of the epidermis normally proceeds KLK7. In 1988, Lundstrm and Egelrud first
in about four weeks. During that time, cells are suggested that corneocyte shedding is mediated
part of the SC for about two weeks. The normal by an endogenous enzyme-catalyzed reaction [65,
physiology of the skin requires both the proper 69, 70] and that this process is accompanied by
formation and the controlled desquamation of the endogenous degradation of DSG1, which was
cornified layers. This tightly regulated equilib- inhibited by application of serine protease inhibi-
rium is regulated in a way to give a cell shedding tors (Fig. 11.7) [67]. Furthermore, CDSN was
from the skin surface which balances de novo found to be progressively modified and proteo-
production of the SC without interfering with the lyzed by serine proteases during SC turnover [13,
barrier functions of the tissue. The normal appear- 32, 129], whereas CDSN is thought to protect
ance of the skin surface requires orderly shedding DSC1 and DSG1 against premature proteolysis
of outermost corneocytes as single cells in an [41]. Convincing data generated by many investi-
invisible manner, whereas the integrity of the gators led to the conclusion that proteolytic degra-
cornified layers depends on the competency of dation of cadherins and CDSN by serine proteases
the barrier lipids and the corneodesmosomes is a prerequisite for desquamation to occur.
[126]. The continuous process of keratinocyte However, wider kallikrein roles in the skin
proliferation, migration, differentiation, cell were identified as the concept of a catalytic acti-
death, and shedding of corneocytes ensures a per- vation cascade emerged. At the close-to-neutral
manent regeneration and a constant thickness of pH of the deepest layers of the SC, KLK5 under-
the epidermis. Hydrolytic activities of proteases goes autoactivation or activation by other pro-
are essential in several parts of this cycle. teases such as KLK14. Active KLK5 starts to
Regulation of protease activity in the living activate proKLK7 at a rate, which, due to the pH
organism is a highly complex task that involves tolerance of this reaction, is maintained through-
all levels of cellular organization. Control and out the SC [73]. Due to the slow rate of KLK7
timing of protease activity starts with gene activation, significant amounts of proKLK7 will
expression, transcription, and translation, and remain also in layers close to the skin surface
continues with protein targeting and zymogen [27]. As a consequence, there will be a concen-
activation. Once activated, the protease is often tration gradient of active KLK7 between deep
kept in check by endogenous inhibitors, while the and superficial layers of the SC, and hence also
last steps of protease regulation may be limited an increase in the rate of degradation of intercel-
proteolysis and final degradation [102]. lular cohesive proteins as the corneocytes move
Prokallikreins are very likely activated in a toward the skin surface [73]. Yoon et al. charac-
stepwise manner involving an activation cascade, terized comprehensively the activation cascade
162 R. Voegeli and A.V. Rawlings

pro KLK6

pro KLK5 pro KLK11

pro KLK7 pro KLK14 KLK6

KLK5 KLK11
KLK8 KLK10

KLK7 KLK14 KLK13 ?

pro uPA
?
Plasminogen

pro MMPs uPA

Conversion
Plasmin
Activation
MMPs
Autoactivation

Fig. 11.6 Activation cascades of kallikreins (pink) and KLK5 can activate both pro-uPA and plasminogen.
the plasminogen system (blue). Plasmin can activate However, not much is known about the interaction of
zymogens of KLK5, KLK6, KLK7, KLK8, KLK11, desquamatory kallikreins and proteases of the throm-
KLK13, and KLK14 and MMPs (gray). On the other side, bostasis axis

Fig. 11.7 Serine protease

CDSN CDSN CDSN CDSN
inhibition and targeting
Hydrolysis

of corneodesmosomal proteins DSG1 DSG1

DSC1 DSC1 DSC1

KLK7 KLK5 KLK14 CTSD CTSL2 CTSL-like uPA

LEKTI LEKTI LEKTI PAI-2

LEKTI-2
Inhibition

Cystatin Cystatin
LEKTI-3 LEKTI-3 LEKTI-3 M/E M/E
A2ML1 A2ML1 A2ML1

Elafin

SLPI

of the kallikrein family [128] upon examining the epidermal kallikrein activation cascade to
the hydrolysis of 15 prokallikreins by 12 acti- include two additional kallikrein members
vated kallikreins, excluding KLK9, KLK10, and known to be expressed in the SC, KLK6 and
KLK15. Their novel findings allow expansion of KLK11, in which proKLK11 is activated by
11 Desquamation: It Is Almost All About Proteases 163

itself and KLK6, and proKLK14 is activated by KLK14 also activates PAR4 and disharms/inhib-
KLK11 (Fig. 11.6) [127]. its PAR1, whereas KLK5 and KLK6 do not
Since at least eight kallikreins are present in [127, 132].
human SC and sweat, more crosstalk among kal-
likreins and/or other epidermal proteins may 11.7.1.2 Plasminogen System
occur, as yet undisclosed. The contribution of It is proposed that one of the functions of epider-
KLK8, KLK10, and KLK13 to the skin activa- mal uPA is to promote keratinocyte proliferation,
tion cascade remains to be elucidated. e.g., by activation of growth factors or by pro-
Furthermore, the characterization of initiators, moting vertical migration of basal keratinocytes
propagators, and executors in the kallikrein pro- into the suprabasal layers, thereby aiding in tis-
teolytic activation cascade poses a challenge that sue remodeling that must accompany epidermal
remains to be solved, although KLK5 is believed hyperproliferation [86, 121].
to be the cascade initiator [73, 76]. Plasmin is a relatively unspecific protease.
Proteases of the thrombostasis family can effi- Once activated, it performs a number of functions
ciently activate specific prokallikreins, demon- important in tissue remodeling. Plasmin degrades
strating the potential for important regulatory several components of the extracellular matrix
interactions between these two major serine pro- including fibrin, fibronectin, laminin, and proteo-
tease families. Plasmin can activate zymogens of glycans [81]. In addition, plasmin can activate its
KLK5, KLK6, KLK7, KLK8, KLK11, KLK13, own activator uPA itself as well as a number of
and KLK14 [78]. On the contrary, KLK12 (not latent matrix metalloproteases (proMMPs) lead-
present in the SC) can activate uPA [62], and ing to collagen degradation (Fig. 11.6) [80].
KLK5 can activate both pro-uPA and plasmino-
gen [79]. 11.7.1.3 Cathepsin D
In vitro CTSL2 appears to be able to cleave CTSD is crucially involved in the activation of
DSC1 [28, 98], and CTSL-like has been shown to transglutaminase 1 and reduced protein levels of
cleave CDSN [99, 130]. the cornified envelope proteins involucrin and
loricrin during epidermal differentiation, which
results in dry skin and hyperkeratosis [133].
11.7.1 Selection of Protease Activities
Beside Desquamation
11.8 Detection of Proteases in
11.7.1.1 Kallikreins Healthy and Pathological Skin
Certain kallikreins have been shown in vitro to
selectively activate protease-activated receptor SC integrity and cohesion are inversely related to
(PAR) signaling. PARs are a family of four desquamation and are pH-dependent functions.
G-protein-coupled cell-surface receptors (PAR1 Although a large family of serine proteases is
PAR4) that are activated by serine proteases. present in SC, KLK5 and KLK7 appear to be the
PAR signaling has been implicated in a variety of important mediators of the final stages of desqua-
physiological processes, including regulation of mation [2]. Both proteases show maximal enzy-
muscle contraction, inflammation, cell adhesion, matic activity at pH 89 in vitro [54, 134, 135];
metastasis, and proliferation along with apopto- however, they could sustain low rates of desqua-
sis. The evidence that kallikreins are functionally mation in normal SC at an acidic pH, because
associated and interact with specific cell-surface these enzymes exhibit residual activity against
receptors raises the possibility that they may be physiologic substances, where aspartate and
able to regulate their own expression through cysteine proteases, with acidic pH optima, could
these signal transduction pathways [34, 71]. become operative. KLK5 and KLK7 would exhibit
KLK5, KLK6, and KLK14, but neither KLK7 higher activities when SC pH increases, as in
nor KLK8, induced PAR2 signaling [127, 131]. inflammatory dermatoses or by using alkaline
164 R. Voegeli and A.V. Rawlings

PAR2 Desquamation
Cytokines Stratum corneum thickness

Serine protease activity

Epidermal barrier
TEWL

Skin surface pH LB response

Glc Cerase / aS Mase

Fig. 11.8 Enhanced serine protease activation and its key lipid processing enzymes, b-glucocerebrosidase and
functional consequences may lead to a vicious circle. An acid sphingomyelinase, are degraded by proteolytic
excess of serine protease activity is associated with attacks. When the SC pH increases and shifts closer to the
increased desquamation and SC thinning. Impaired bar- activity optimum of serine proteases, then the cycle starts
rier functions are also based on overactivity of serine pro- again under amplified conditions. Moreover, uncontrolled
teases. Serine proteases suppress the LB secretory serine protease activity may lead to an overactivation of
responses to acute barrier perturbations. Moreover, two PAR-2 and certain cytokines (Modified from [124])

soaps. In the epidermis, proteolytic activity Table 11.2 Concentration range of kallikreins in SC
increases 12 h [49] following acute barrier dis- extracts of forearm and upper arm
ruption [58, 89]. Serine protease activation may as Concentration range(ng/mg
a second signal regulate the LB secretory response. Kallikrein dry SC)
Elevated pH leads to premature degradation of KLK5 24
corneodesmosomes, inactivation of the key lipid KLK6 0.10.3
synthesizing enzymes b-glucocerebrosidase and KLK7 714
KLK8 614
acidic sphingomyelinase, and subsequent impair-
KLK10 0.71.0
ment of the epidermal barrier and decrease in SC
KLK11 614
cohesion [49]. Moreover, uncontrolled serine pro-
KLK13 0.020.2
tease activity may lead to an overactivation of KLK14 0.10.3
PAR-2 and release of cytokines (Fig. 11.8). It is
Modified from [75]
likely that KLK5 and KLK7 activities dominate at
all levels of SC in pathological skin, which is
characterized by optimal conditions for serine levels were found to be consistent among differ-
protease activation, i.e., increased pH, hydration, ent age groups, whereas total chymotrypsin-like
and Ca2+ levels [2]. Furthermore, epidermal over- kallikrein mass declined with age. On the con-
expression of KLK7 in transgenic mice results in trary, overall trypsin-like kallikrein activity did
severe pruritus [112, 136]. not differ across age groups but was higher in sub-
jects <11 years, and overall chymotrypsin-like
activity was not related to age. However, Koyama
11.8.1 Healthy Skin et al. did find a reduction in SC trypsin-like activ-
ity with increasing age [137]. Conversely, in the
11.8.1.1 Quantication of Kallikreins SC, not only the concentration of each kallikrein
in the SC: Dependence of Age but also the overall SC enzymatic activities were
Komatsu et al. quantified kallikrein mass and highly consistent among body regions, suggesting
activities in SC extracts of healthy subjects [75, that the kallikrein expression and the enzymatic
76]. The concentration ranges are listed in activities may be regulated similarly throughout
Table 11.2. Total trypsin-like kallikrein mass the SC, at least in the body regions studied (forearm,
11 Desquamation: It Is Almost All About Proteases 165

Fig. 11.9 The rate of

desquamation depends on
relative humidity. Skin with a
reduced water-holding
capacity (gray line) may be
more sensitive to low relative

Rate of desquamation
humidity conditions than
normal hydrated skin (black
line) (Modified from [140])

Relative humidity

abdomen, back, thigh) [76]. Unfortunately the [139]. This suggests that deficiency of water in the
authors did not evaluate facial skin which has SC may suppress desquamation through reduc-
been shown to have elevated protease activity on tion of protease activities. Skin with a low water-
SC extract (cf. posterior chapter) [138]. holding capacity may be more sensitive to dry
skin conditions and show more scaliness in dry
11.8.1.2 Inuence of Relative Humidity season (Fig. 11.9) [140].
on Desquamation Skin chronically exposed to a hot, dry environ-
Exposure to a dry environment leads to depletion ment exhibits strong skin barrier functions and low
of water from the outermost SC layers in a process basal transepidermal water loss (TEWL). The
dependent on the relative humidity (RH) and the amount of active KLK7 was found to be higher in
water-holding capacity of the tissue. Desmosomal the skin of subjects exposed to low RH, suggesting
degradation was shown by Rawlings et al. to be a that upregulation of the amount of active proteases
humidity-dependent event, being significantly may be part of an adaptation response to ensure
reduced at low RH [43]. Moreover, Watkinson proper desquamation at low humidity. Interestingly,
et al. demonstrated that by modulating the water human skin can adapt to a low humidity environ-
content in the surface layers of the SC, RH effects ment by increasing epidermal barrier function and
the rate of desquamation by modulating the activ- modulating desquamation [141].
ity of desquamatory enzymes, specifically KLK7
[24]. Below 80% RH, corneocyte release was 11.8.1.3 Depth Proling of
decreased, and KLK7 activity was significantly Desquamatory and
higher at 100% than at 44% RH. Furthermore Inammatory Serine Protease
increases in KLK7 activity was induced by apply- Activities in the SC on Different
ing a 10% glycerol solution. KLK7 showed a Body Sites
small tolerance to water restriction, which may be In a study with healthy Caucasian subjects in win-
an adaptation to maintain enzyme activity even ter season, we compared SC cohesion, SC hydra-
within the water-depleted SC intercellular space. tion, and TEWL with depth profiles of enzymatic
In a study on mice, Sato et al. found that dry SC activities of desquamatory serine proteases (trypsin-
(10% RH) contains the same activity of trypsin- like and chymotrypsin-like kallikreins) and inflam-
like protease as the control in an aqueous based matory serine proteases (plasmin-, uPA-, and SC
assay but more undegraded desmosomal protein tryptase-like proteases) on SC extracts of ventral
166 R. Voegeli and A.V. Rawlings

40
p < 0.001
p < 0.01
35 p = 0.3

30

p < 0.001
SC protein [g cm2]

25

20

15

10

0
Forearm 13 Forearm 46 Forearm 79 Cheek 13 Cheek 46 Cheek 79

Fig. 11.10 Cohesion of healthy forearm and cheek SC. Protein content (mean per tape SEM, n = 14 subjects) on tape
stripping pools (tapes 13, 46, 79) of forearm and of cheek (Modified from [138])

Table 11.3 (a) Biometric data of the subjects and (b) SC serine protease activities on 9 consecutive tape stripping
extracts of healthy forearm and facial skin (mean SEM; n = 14 per group)
(a)
Biometric data Forearm Cheek
Skin surface pH 4.75 0.08 4.93 0.04
SC hydration (DPM) 104 4 110 3
TEWL (gm2 h1) 13.5 0.9 28.6 2.8**
SC cohesion (mg protein cm2), 28.5 4.0 21.0 4.0**
9 tape strippings
Protease activity
(b) (mU/mg SC protein)
Serine protease Forearm (F) Cheek (C) Factor C/F
Trypsin-like kallikreins 3.20 0.47 12.05 1.57** 3.8
Chymotrypsin-like kallikreins 1.45 0.35 3.77 0.48** 2.6
SC tryptase-like 1.62 0.58 13.44 1.50** 8.3
Plasmin-like 1.39 0.29 9.91 1.25** 7.1
Urokinase-like 0.92 0.16 6.99 1.31** 7.6
Modified from [138]
*p < 0.05; **p < 0.01 for cheek vs. forearm

forearm and facial tape strippings [138]. There was [142], TEWL, and protease activities were incr-
no difference in SC hydration, whereas SC cohe- eased on the cheek (Tables 11.3a, b). Inflammatory
sion, determined via IR densitometry (Fig. 11.10) enzymes showed 78 times and desquamatory
11 Desquamation: It Is Almost All About Proteases 167

Fig. 11.11 Depth profiling of 7

serine protease activity (mean
Plasmin-like activity
SEM, n = 14 subjects) on

SC protease activity [U/mg SC protein]

6 Urokinase-like activity
tape stripping pools (tapes
13, 46, 79) of healthy SC tryptase-like activity
forearm and cheek SC. The 5
TEWL of the cheek is twice as Trypsin-like kallikrein activity
much the one of the forearm, Chymotrypsin-like kallikrein activity
indicating an impaired barrier 4
(Modified from [138]) TEWL forearm: 13.5 3.4 g m2 h1
TEWL cheek: 28.6 0.6 g m2 h1
3

0
Forearm Forearm Forearm Cheek Cheek Cheek
13 46 79 13 46 79

enzymes 2.54 times greater activities. Except the Differences in the control mechanisms of activa-
chymotrypsin-like kallikreins, all tested protease tion of these enzymes may occur on these two
activities positively correlated with TEWL and different skin areas.
negatively with SC hydration [143]. On the fore- Mohammed et al. found similar results [144];
arm, all serine proteases showed a distinct gradient moreover, they report decreased corneocyte
with highest activity in the outermost layers of the maturity and surface area with increasing number
SC (Fig. 11.11), whereas on the cheek area, the of tape strippings similar to Hirao [145] and
activity gradients were less distinct except for Harding et al. [146].
chymotrypsin-like kallikrein activity which, like Although the subjects of our study had clini-
the samples from the forearm, showed increased cally normally looking facial skin, TEWL values
activation toward the surface layers of the SC. were clearly above the values of the forearm (29
There was a greater trypsin-like kallikrein than a vs. 14 gm2h1) indicating a barrier disturbance
chymotrypsin-like kallikrein activity on both (Table 11.3a). Thus, the elevated serine protease
body sites. activities on the face may be due to a subclinical
Many authors [27, 73] describe that process- microinflammatory or preinflammatory condi-
ing of kallikreins probably occurs within early tion induced, e.g., by environmental influences.
SC development. Conversely, using a sensitive Serine proteases might represent key markers for
approach, we have established that both trypsin- underlying and sometimes nonobservable skin
and chymotrypsin-like kallikreins show increased abnormalities.
activities toward the surface layers of the SC on Reduced SC thickness, corneocyte size [147,
samples from the forearm skin. Like we, Chang-Yi 148] and maturity, elevated SC cohesion, and
et al. have found higher chymotrypsin- and TEWL indicate that facial SC disjunctum is not
trypsin-like protease activities in the outer part of existing probably due increased proteolytic activ-
the SC [134]. Presumably, the processing of these ity leading to premature corneodesmosomal deg-
enzymes is occurring much later than assumed radation. Facial skin is the most exposed skin of
by others. Similar activation processes can be the body and is submitted to numerous environ-
observed for chymotrypsin-like kallikreins on mental attacks for long periods each day as it is
samples from the face, but on this body site, not protected by clothing. Paradoxically, facial
trypsin-like kallikreins seem to be activated con- skin is particularly sensitive because it possesses
sistently throughout the inner and outer SC. a thin epidermis and a thin SC [149].
168 R. Voegeli and A.V. Rawlings

11.8.1.4 Desquamation in Dry Skin, SC samples from the cheek in subjects with visi-
Winter Xerosis, and Soap- bly dry skin and subjects with TEWL levels
Induced Xerotic Skin above 16 gm2h1. In subjects with normal
In xerotic skin, the degradation of corneodesmo- appearing skin and a TEWL below 16 gm2h1,
somes is perturbed, and the proteolysis of their no activity was found.
components is impaired [44]. This is also the case
in psoriatic scales [41]. As demonstrated by
Rawlings et al. and Simon et al., the persistence 11.8.2 Psoriasis and Ichthyosis
of DSG1 is a characteristic of hyperkeratosis
[41, 42]. DSC1 proteolysis is reduced in dry skin In several hyperkeratotic disorders, such as pso-
[41, 146], and degradation of the DSG1, DSC1, riasis and ichthyosis, corneodesmosome reten-
and CDSN is reduced in winter and soap-induced tion is elevated and corneocyte cohesion increased
xerotic skin [4244]. [16, 154]. Psoriasis is a chronic inflammatory
Harding et al. and van Overloop et al. observed skin disease. It is characterized by hyperprolifer-
a chronic decrease in KLK5 and KLK7 and a ation and altered differentiation of keratinocytes
diminished protease activity that may contribute leading to red, scaly skin, abnormal desquama-
to the induction of a scaly dry skin. Inverse cor- tion, and a defective epidermal barrier. Currently,
relation between skin scaliness and KLK5 and psoriasis is considered a T-cell-mediated inflam-
KLK7 activities [150] and reduced expression of matory disease [155].
KLK5 and KLK7 has been shown in the outer KLK7 has been proposed to be a candidate
layers of the SC in dry skin [31, 150]. marker for psoriasis as increased amount of the
Interestingly surfactants lead to contrary zymogen and the activated protease in lesional
effects. While soap decreases the activity of psoriatic skin have been shown [35, 156]. On the
KLK7 [31] and SLES the activity of KLK5 [135], other hand, there has no significant genetic asso-
SLS increases the activities of KLK 5 and KLK7 ciation been found between psoriasis and KLK7.
[54] after topical application. The differences are These findings suggest that KLK7 is unlikely to
due to the application regimes. Single application be involved in psoriasis and that the overexpres-
of surfactants leads to irritation in the epidermis sion of KLK7 observed in lesional psoriatic skin
and the up regulation of gene synthesis. Chronic could be the consequence of an unspecific
application, as in the examples with soap wash- response to epidermal hyperproliferation and
ing, leads to lipid lamellae disruption and either inflammation [157].
leaching or denaturing of the SC proteases. The SC of lesional psoriatic skin was immu-
Alternatively there may be changes to the nochemically shown by Komatsu et al. to contain
LEKTI inhibition system as there is after UV irra- significantly higher amounts of all SC kallikreins,
diation. Reduced expression of LEKTI-1 and including KLK7, as compared with normal SC
increased expression of KLK5 and KLK7 in human [34, 36]. Enzymatic assays showed that the plas-
epidermal keratinocytes after UVB irradiation may min-like, furin-like, and overall trypsin-like kal-
contribute to desquamation of the SC [151]. likrein activities were significantly elevated in
Disturbances to the plasminogen system have lesional psoriatic SC, whereas the chymotrypsin-
also been described in dry skin. Kitamura et al. like kallikrein activity was only slightly elevated.
[152] demonstrated that plasminogen that was Such an increased expression of proteases in the
only located at the basal layer in healthy subjects psoriatic scales is apparently contradictory to a
was expressed in all epidermal cell layers in dry reduced proteolysis of corneodesmosomes. How-
skin. Moreover, Kawai et al. [153] reported that ever, overexpression does not obligatorily mean
uPA was also present in the SC especially in higher activity in situ, as protease activity in the
experimentally induced dry skin on back skin of SC is controlled by protease inhibitors, such as
individuals. They further demonstrated that the LEKTIs, and by physicochemical properties,
increased extractable uPA activity was present in such as SC pH or water content [32, 49, 158].
11 Desquamation: It Is Almost All About Proteases 169

Also the intercellular lipids are altered in the SC that KLK7 could be a key enzyme in AD skin
of psoriatic skin, especially the level and nature lesions. However, trypsin-like and chymotrypsin-
of ceramides [159, 160]. As the corneodesmo- like kallikrein activities were not increased, in
somes directly interact with the lipid lamellae marked contrast to the plasmin-like and furin-like
and the kallikreins are present within the lipids, enzyme activities.
the physical properties of these lipids probably
influence the enzyme activity and the corneodes- 11.8.3.2 Serine Protease Proling in
mosome degradation. One may speculate that, in Acute Eczematous Atopic Skin
psoriasis, KLK7, even present in large amounts We compared physiological changes in acute
in the SC, is inhibited or may not be able to cleave eczematous lesional skin of AD patients, with
corneodesmosome components. As a feedback nonlesional AD skin and skin of healthy subjects
mechanism, other kallikreins are overexpressed. on ventral forearms, and determined protease
However, because they are not able to degrade mass levels (KLK5, KLK7, KLK11, KLK14,
corneodesmosomes for similar reasons, they do plasmin, and uPA) and enzyme activities on 15
not permit the defect to be overcome. Finally, consecutive tape strippings [38, 163].
other proteases potentially involved in desqua- TEWL levels were elevated before and after
mation, e.g., cathepsins, may be downregulated tape stripping in lesional skin compared with
in psoriatic skin. As a whole, this results in nonlesional and healthy skin. Conversely, the
reduced desquamation and scale retention [41]. amount of SC removed by sequential tape strip-
ping was decreased in L skin, indicating increased
intracorneocyte cohesion. By correlating recipro-
11.8.3 Atopic Dermatitis cal TEWL values and the amount of SC removed
[164], we estimated a significantly thinner SC in
Atopic dermatitis (AD) is a chronic inflamma- lesional skin compared with both nonlesional and
tory disease associated with changes in SC struc- healthy skin (Table 11.4a).
ture and function. The breakdown of epidermal There were no differences in the mass levels
barrier function in AD is associated with changes of KLK5, KLK14, and uPA between healthy,
in corneocyte size and maturation, desquama- nonlesional, and lesional skin. KLK5 mass levels
tion, lipid profiles, and some protease activities. were large, whereas KLK14 and uPA levels were
Changes in the expression and activity of serine very low and close or even at detection limit.
proteases in skin have been reported in epidermal However, there was a trend of increasing KLK7
samples taken from subjects with AD [37, 38, levels (3x), and the levels of KLK11 (4x) and
161163]. plasmin (83x) were significantly elevated in
lesional skin (Table 11.4b). Although mass levels
11.8.3.1 Serine Protease Proling of serine proteases tended to be higher in the
in Atopic Xerosis deeper SC layers for lesional skin, there was
Komatsu et al. compared SC mass levels of all no change in the mass levels of any enzyme
the eight SC kallikreins together with the trypsin- measured with increasing depth from either
like kallikrein, chymotrypsin-like kallikrein, and nonlesional or healthy skin (data not shown).
plasmin-like and furin-like enzyme activities on Unfortunately we did not succeed to establish
the outermost SC of the forearms from AD useful antibody constructs for leukocyte elastase,
patients having very mild lichenification with tryptase, and KLK8. KLK8 has been of interest
skin from healthy subjects [37]. In the SC of AD as it has been suggested to be involved in patho-
skin, the mass levels of all kallikreins, except for genesis of inflammatory skin diseases [77].
KLK11, were found to be elevated. The increase In contrast to protease mass levels, the enzyme
of the mass level of chymotrypsin-like KLK7 activities of all the tested SC serine proteases
was predominant compared with the trypsin-like were elevated in lesional skin (11.4c). The order
kallikreins. Therefore, Komatsu et al. hypothesize compared to healthy skin was plasmin (69x), SC
170 R. Voegeli and A.V. Rawlings

Table 11.4 (a) Biometric data of the subjects, (b) SC serine protease mass, and (c) activities on 15 consecutive tape
stripping extracts of healthy (H), nonlesional (NL), and lesional (L) atopic dermatitis skin (mean SEM; n = 6 per
group)
(a)
Biometric data Healthy Nonlesional Lesional
Local SCORAD 0.0 0.0 0.2 0.4 7.0 1.2
Irritation score 0.0 0.0 0.0 0.0 5.8 1.8
Mexameter data 203 60 162 30 323 73*
Skin surface pH 6.1 0.7 6.4 0.7 6.0 0.4
SC hydration (AU) 29.6 3.2 26.9 5.0 13.4 1.5*
TEWL (gm2 h1) before tape 8.2 1.9 12.5 3.4 41.8 9.5*
stripping
TEWL (gm2 h1) after 20 tape 34.9 5.5 27.3 6.9 81.3 7.1
strippings
SC thickness [mm] 17 1.13 20 2.84 10 1.80*
SC cohesion (mg protein cm2), 20.8 1.4 17.8 2.6 7.2 1.7
20 tape strippings
(b) Protease mass (ng protease/mg SC protein)
Serine protease Healthy Nonlesional Lesional Factor L/H Factor L/NL
KLK5 (trypsin-like) 234 69 151 34 190 75 0.8 1.3
KLK7 (chymotrypsin-like) 21.9 5.2 18.3 3.9 62.0 26.0 2.8 3.4
KLK11 (trypsin-like) 7.18 0.80 7.20 1.07 29.0 9.7** 4.0 4.0
KLK14 (trypsin- and 0.26 0.11 0.28 0.12 0.21 0.09 0.7 0.8
chymotrypsin-like)
Plasmin 0.54 0.14 1.09 0.41 45.0 10.7** 83 41
Urokinase 0.036 0.007 0.040 0.010 0.052 0.018 1.4 1.3
(c) Protease activity (mU/mg SC protein)
Serine protease Healthy Nonlesional Lesional Factor L/H Factor L/NL
Trypsin-like kallikreins 1.40 0.27 1.26 0.25 7.29 1.48** 5.2 5.8
Chymotrypsin-like 0.84 0.18 0.42 0.09 1.62 0.28* 1.9 3.8
kallikreins
SC tryptase-like 0.71 0.29 0.87 0.32 39.4 10.8* 55 45
Plasmin-like 0.53 0.11 1.22 0.34 36.4 10.4* 69 30
Urokinase-like 0.40 0.13 0.46 0.12 3.25 0.75* 8.1 7.1
Leukocyte elastase-like 0.01 0.01 0.16 0.16 3.13 1.45* n.a. n.a.
Modified from [38, 163]
*p <0.05; **p <0.01 for L vs. H

tryptase-like enzyme (55x), uPA (8x), trypsin- desquamatory proteases showed no obvious gra-
like kallikreins (5x), and chymotrypsin-like kal- dient (data not shown).
likreins (2x). Leukocyte elastase showed The mass levels of KLK14 in lesional skin
considerable activity in lesional skin indicating were very low and not elevated compared with
an infiltration of neutrophils, whereas in the SC nonlesional or healthy skin. These results would
samples from nonlesional and healthy skin, no suggest that the increases in SC chymotrypsin-
activity was found. Analyzing these enzymes like kallikrein activity we observed are probably
with depth showed increased extractable protease due to the increased mass levels of KLK7,
activity toward the surface of the SC in nonle- although KLK14 exerts a high catalytic efficiency
sional and healthy skin. Conversely, the activities (Tables 11.4b, c) [73, 74]. As we did not measure
of inflammatory proteases were elevated in the the mass levels of all SC trypsin-like kallikreins
deeper layers of lesional SC, whereas the but did not observe increased KLK5 mass levels
11 Desquamation: It Is Almost All About Proteases 171

in lesional skin, other trypsin-like kallikrein increased in barrier-compromised conditions

activities are probably contributing to the even in nondiseased skin [138, 143]. However,
increased SC trypsin-like kallikrein activity. we did not observe any impaired barrier function
KLK11 would appear to be a candidate but not or increased serine protease activity in nonle-
KLK14. sional skin sites, implying that the impairment of
For the first time we report massively increased barrier function is not intrinsic in subjects with
mass levels and activity of plasmin in SC extracts AD, as reported by Kikuchi et al. [167].
from atopic patients with acute eczema; the cor- The question remains, do these elevated pro-
relation between mass levels and activity was sta- tease levels impair SC or epidermal functioning?
tistically highly significant (R2 = 0.822, p = 105). Statistically significantly increased irritation,
uPA, the major plasminogen activator, is present increased TEWL, and decreased hydration levels
at very low concentration within the studied SC were found in lesional skin. It is highly likely that
layers, although uPA-like activity levels were the elevated levels of serine proteases in patients
increased in lesional skin. This fact raises the with active lesions were contributing to their
question: is plasminogen activated at the basal apparently thinner SC. The increased cohesion in
layer only by uPA/uPAR or are there other plas- the remaining SC probably indicates that the
minogen activators than uPA within the SC such desquamation is occurring above the stratum
as KLK5 [79]? Not much is known about the compactum and not at the stratum compactum/
interaction of desquamatory kallikreins and pro- SG interface.
teases of the thrombostasis axis. Yoon et al. [78] While Komatsu et al. [37] found increased
demonstrated the potential for important regula- mass levels of all kallikreins in lesional skin
tory interactions between these two major pro- except KLK11, we only observed increased mass
tease families. It might be hypothesized that levels of KLK11 but not of KLK5 or KLK14 but
activation of proKLK7 and/or proKLK11 by with a tendency of KLK7 to be increased. We
plasmin in AD and vice versa may occur and that also observed greater quantities of KLK5 but
these KLKs may play a role in the inflammatory similar quantities of KLK7, KLK11, and KLK14.
cascade in AD. Moreover, in contrast to our study, Komatsu et al.
There exists a discrepancy between protease did not measure increased trypsin-like and chy-
mass levels and the corresponding enzyme activi- motrypsin-like kallikrein activities in lesional
ties that could be explained by the facts (1) that skin.
antibodies do not differentiate between inactive The differences in protease mass and activity
zymogen, active protease, and inactive protease/ levels to the Komatsu et al. study [37] may be
inhibitor complex and (2) that enzyme substrates related to the differences in the skin condition of
may exhibit a certain unspecificity. the AD patients as well as to different sampling
The reason for the increased protease mass procedures and assays having been used. We
levels and activities in AD is not known. The examined subjects with active lesions having an
study results imply that there is insufficient exacerbated inflammatory condition, whereas the
amount of LEKTIs, or any other inhibitor, to subjects of the Komatsu et al. study showed very
inhibit the elevated protease activity in chronic mild lichenification only, a condition with reten-
lesions [165]. Increased expression may occur tion hyperkeratosis and not premature desquama-
due to kallikrein gene polymorphisms such as tion. Komatsu et al. collected uppermost
those reported for KLK7 by Vasilopoulous et al. corneocytes only, whereas we did 15 subsequent
who suggest that this enzyme could have an tape strippings, allowing depth profiling. Perhaps
important role in the development of AD [157]. one of the major reasons for the differing results
Barrier perturbation also leads to increased between the two studies is the corticosteroid
inflammatory protease levels, e.g., uPA after tape medication of the AD patients in the Komatsu
stripping the SC of a mouse model of AD [166]. et al. study. It has been shown that the application
We have shown SC protease activities are also of clobetasol propionate to normal human skin
172 R. Voegeli and A.V. Rawlings

induces the expression of the mRNA for KLK7

[168, 169]. Obviously the results of the two stud- ber of cell layers in the SC. Excess of
ies cannot be directly compared. protease activity can lead to SC thin-
ning, while reduced protease activity
can lead to SC thickening.
11.8.4 Effect of Topically Applied In healthy skin, serine protease activity in
Protease Inhibitors on SC Barrier the SC varies on skin areas. Compared to
Function and Dry Skin other body sites, facial skin shows higher
proteolytic activity resulting in premature
Several topically applied trypsin-like serine pro- corneodesmosomal degradation. This
tease inhibitors have been shown by Denda et al., indicates that facial SC disjunctum is
Kitamura et al., and Hachem et al. to accelerate probably not present. The elevated serine
barrier recovery in experimentally damaged protease activities on the face may be due
(sodium lauryl sulfate, acetone, tape stripping) to a subclinical microinflammatory or
mouse and human skin models [58, 89, 152]. preinflammatory condition induced, e.g.,
Inhibitors for chymotrypsin-like serine proteases, by environmental impacts.
aspartic proteases, cysteine proteases, and matrix Delayed desquamation is the accumula-
metalloproteases had no beneficial effects on bar- tion of corneocytes on the surface of the
rier recovery. The uPA and plasmin inhibitor SC that leads ultimately to the cosmetic
trans-4-(aminomethyl) cyclohexane carboxylic condition commonly termed as dry
acid (t-AMCHA) and the dual tryptic/chymotryp- skin and which has been described best
tic inhibitor aprotinin showed accelerated barrier as a cyclical model [158]. Much more is
recovery, paralleled by decreased serine protease known about body dry skin rather than
activity and improved hydration on damaged dry facial skin. The latter tends to
skin. become rough rather than flaky. The
Interestingly, neither lipid synthesis nor lipid biology of skin moisturization, of which
processing was altered by serine protease inhibi- hydration is only one benefit, is highly
tors. Instead, serine protease inhibitor treatment complex. We are convinced that the
accelerated LB secretion. These observations future of all new moisturizers lies in the
suggest that serine proteases suppress the LB fully understanding of the control and
secretory responses to acute barrier perturbations impairment of desquamation [170].
(Fig. 11.8) [58]. Changes in the proteolytic balance of
the skin can result in inflammation,
which leads to the typical clinical signs
of redness, scaling, and itching.
Increased serine protease activity occurs
Take Home Messages in most, if not all, inflammatory derma-
Corneodesmosomes, modified desmo- toses, ranging from genetic disorders,
somes, are the primary mediator of such as Netherton syndrome, psoriasis,
intercorneocyte cohesion between cor- and AD, to subclinical barrier abnor-
neocytes. Their transmembranal, inter- malities induced, e.g., by alkaline soaps
cellular components are composed of or by environmental influences. Serine
desmogleins, desmocollins, and cor- proteases might represent key markers
neodesmosin. Desquamation is medi- for underlying and sometimes nonob-
ated by their degradation. servable skin abnormalities.
Epidermal proteases control desquama- Better understanding of the multistep
tion, corneocyte maturity, and the num- proteolytic events and of the regulatory
11 Desquamation: It Is Almost All About Proteases 173

KLK5 stratum corneum trypsin-like en-

mechanisms involved in desquamation zyme = SCTE
should enable the design of new treat- KLK7 stratum corneum chymotrypsin-like
ments for the skin disorders associated enzyme = SCCE
with disturbance in the SC turnover. LB lamellar bodies = lamellar granules =
This will be the ultimate approach to Odland bodies = keratinosomes
corneocare. LEKTI-1 lymphoepithelial Kazal-type 5
A vast number of data and hypothesis serine protease inhibitor
have been generated on SC proteases LEKTI-2 lymphoepithelial Kazal-type 9
and their influences to the skin. Some of serine protease inhibitor
them are contradictory due to the chosen LEKTI-3 lymphoepithelial Kazal-type 6 ser-
variable conditions; most of them are ine protease inhibitor
fragmentary making it difficult to PAI-2 plasminogen activator inhibitor-2 =
assemble the complete puzzle with SERPINB2
pieces that do not fit exactly. To get a PAR protease-activated receptor
holistic view of the picture, a broad sci- RH relative humidity
entific collaboration is needed mutually SC stratum corneum
discussing and investigating the profil- SG stratum granulosum
ing of proteases and other enzymes, SLPI secretory leukocyte protease inhibi-
inhibitors, as well as desmosomal and tor = antileukoprotease (ALP)
CE proteins to fully understand the mat- SPINK5 serine protease inhibitor Kazal-type
uration and desquamation of the SC in 5 gene
healthy and diseased skin. An open and SPINK6 serine protease inhibitor Kazal-type
informal scientific desquamation com- 6 gene
munity should regularly meet to discuss SPINK9 serine protease inhibitor Kazal-type
the mechanisms of human desquama- 9 gene
tion. Perhaps through a workshop in t-AMCHA trans-4-(aminomethyl) cyclohexane
association with the Stratum Corneum carboxylic acid
Conference series. TEWL transepidermal water loss
TJ tight junction
UPA urokinase = urokinase-type plasmi-
nogen activator
Abbreviations and Synonyms UPAR urokinase-type plasminogen activa-
tor receptor
A2ML1 a2-macroglobulin-like 1
AD atopic dermatitis
CE cornified envelope References
CDSN corneodesmosin
CTSD cathepsin D 1. Kligman AM (2011) Corneobiology and corneother-
CTSL2 cathepsin L2 = cathepsin V = apy a final chapter. Int J Cosmet Sci 33(3):197209
stratum corneum thiol protease= 2. Elias PM (2005) Stratum corneum defensive functions:
an integrated view. J Invest Dermatol 125(2):183200
SCTP 3. Chaturvedi V et al (2006) Defining the caspase-con-
CTSL-like cathepsin L-like taining apoptotic machinery contributing to cornifica-
DSC desmocollin tion in human epidermal equivalents. Exp Dermatol
DSG desmoglein 15(1):1422
4. Egelrud T (1993) Purification and preliminary charac-
Elafin skin-derived antileukoprotease = terization of stratum corneum chymotryptic enzyme:
SKALP a proteinase that may be involved in desquamation.
KLK kallikrein J Invest Dermatol 101(2):200204
174 R. Voegeli and A.V. Rawlings

5. Haftek M, Simon M, Serre G (2006) Corneodesmosomes: 24. Watkinson A et al (2001) Water modulation of stra-
Pivotal Actors in the Stratum Corneum Cohesion and tum corneum chymotryptic enzyme activity and
Desquamation. In: Elias PM, Feingold KR (eds) Skin desquamation. Arch Dermatol Res 293(9):470476
barrier. Taylor & Francis, New York, pp 171189 25. Naoe Y et al (2010) Bidimensional analysis of des-
6. Marks R (2004) The stratum corneum barrier: the moglein 1 distribution on the outermost corneocytes
final frontier. J Nutr 134(8 Suppl):2017S2021S provides the structural and functional information of
7. Jonca N et al (2002) Corneodesmosin, a component of the stratum corneum. J Dermatol Sci 57(3):192198
epidermal corneocyte desmosomes, displays homophilic 26. Horikoshi T et al (1999) Role of endogenous cathep-
adhesive properties. J Biol Chem 277(7):50245029 sin D-like and chymotrypsin-like proteolysis in human
8. Michaels AS, Chandrasekaran SK, Shaw JE (1975) Drug epidermal desquamation. Br J Dermatol 141(3):
permeation through human skin: Theory and invitro 453459
experimental measurement. AIChE J 21(5):985996 27. Ekholm IE, Brattsand M, Egelrud T (2000) Stratum
9. Elias PM (1983) Epidermal lipids, barrier function, and corneum tryptic enzyme in normal epidermis: a miss-
desquamation. J Invest Dermatol 80(Suppl):44s49s ing link in the desquamation process? J Invest
10. Wepf R et al (2007) Multimodal imaging of skin Dermatol 114(1):5663
structures: imagining imaging of the skin. In: Wilhelm 28. Watkinson A (1999) Stratum corneum thiol protease
K-P et al (eds) Bioengineering of the skin: skin imag- (SCTP): a novel cysteine protease of late epidermal
ing and analysis. Informa Healthcare, New York differentiation. Arch Dermatol Res 291(5):260268
11. Cork MJ et al (2009) Epidermal barrier dysfunction in 29. Skerrow CJ, Clelland DG, Skerrow D (1989) Changes
atopic dermatitis. J Invest Dermatol 129(8):18921908 to desmosomal antigens and lectin-binding sites dur-
12. Serre G et al (1991) Identification of late differentia- ing differentiation in normal human epidermis: a
tion antigens of human cornified epithelia, expressed quantitative ultrastructural study. J Cell Sci 92(4):
in re-organized desmosomes and bound to cross- 667677
linked envelope. J Invest Dermatol 97(6):10611072 30. Chapman SJ et al (1991) Lipids, proteins and corneo-
13. Lundstrm A et al (1994) Evidence for a role of cor- cyte adhesion. Arch Dermatol Res 283(3):167173
neodesmosin, a protein which may serve to modify 31. Harding CR et al (2000) Dry skin, moisturization and
desmosomes during cornification, in stratum corneum corneodesmolysis. Int J Cosmet Sci 22(1):2152
cell cohesion and desquamation. Arch Dermatol Res 32. Caubet C et al (2004) Degradation of corneodesmo-
286(7):369375 some proteins by two serine proteases of the kallikrein
14. Brandner JM, Haftek M, Niessen CM (2010) Adherens family, SCTE//KLK5//hK5 and SCCE//KLK7//hK7. J
junctions, desmosomes and tight junctions in epider- Invest Dermatol 122(5):12351244
mal barrier function. Open Dermatol J 4:1420 33. hman H, Vahlquist A (1998) The pH gradient over
15. Egelrud T (1999) Desquamation. In: Loden M, the stratum corneum differs in X-linked recessive and
Maibach H (eds) Dry skin and moisturizers. CRC autosomal dominant ichthyosis: a clue to the molecu-
Press, Boca Raton, pp 109117 lar origin of the acid skin mantle? J Invest Dermatol
16. Chapman SJ, Walsh A (1990) Desmosomes, cor- 111(4):674677
neosomes and desquamation. An ultrastructural study 34. Komatsu N et al (2007) Aberrant human tissue kal-
of adult pig epidermis. Arch Dermatol Res 282(5): likrein levels in the stratum corneum and serum of
304310 patients with psoriasis: dependence on phenotype,
17. Fartasch M, Bassukas ID, Diepgen TL (1993) Structural severity and therapy. Br J Dermatol 156(5):875883
relationship between epidermal lipid lamellae, lamellar 35. Simon M et al (2002) Abnormal proteolysis of cor-
bodies and desmosomes in human epidermis: an ultra- neodesmosin in psoriatic skin. Br J Dermatol
structural study. Br J Dermatol 128(1):19 147(5):1053
18. Neubert RHH, Wepf R (2008) Das stratum corneum 36. Komatsu N et al (2005) Multiple tissue kallikrein
struktur und morphologie einer hoch effizienten bar- mRNA and protein expression in normal skin and skin
riere. Medicos 4:2128 diseases. Br J Dermatol 153(2):274281
19. Stokes DL (2007) Desmosomes from a structural per- 37. Komatsu N et al (2007) Human tissue kallikrein
spective. Curr Opin Cell Biol 19(5):565571 expression in the stratum corneum and serum of atopic
20. Green KJ, Simpson CL (2007) Desmosomes: new dermatitis patients. Exp Dermatol 16(6):513519
perspectives on a classic. J Invest Dermatol 127(11): 38. Voegeli R et al (2009) Increased stratum corneum ser-
24992515 ine protease activity in acute eczematous atopic skin.
21. Green KJ, Gaudry CA (2000) Are desmosomes more Br J Dermatol 161:7077
than tethers for intermediate filaments? Nat Rev Mol 39. Cork MJ et al (2006) New perspectives on epidermal
Cell Biol 1(3):208216 barrier dysfunction in atopic dermatitis: gene-envi-
22. Kottke MD, Delva E, Kowalczyk AP (2006) The des- ronment interactions. J Allergy Clin Immunol 118(1):
mosome: cell science lessons from human diseases. J 321, quiz 223
Cell Sci 119(5):797806 40. Haftek M et al (1997) Expression of corneodesmosin
23. Garrod D, Chidgey M, North A (1996) Desmosomes: in the granular layer and stratum corneum of normal
differentiation, development, dynamics and disease. and diseased epidermis. Br J Dermatol 137(6):
Curr Opin Cell Biol 8(5):670678 864873
11 Desquamation: It Is Almost All About Proteases 175

41. Simon M et al (2008) Alterations in the desquama- 57. Menon GK et al (1992) Localization of calcium in
tion-related proteolytic cleavage of corneodesmosin murine epidermis following disruption and repair of the
and other corneodesmosomal proteins in psoriatic permeability barrier. Cell Tissue Res 270(3):503512
lesional epidermis. Br J Dermatol 159(1):7785 58. Hachem J-P et al (2006) Serine protease signaling of
42. Rawlings AV et al (1994) Abnormalities in stratum epidermal permeability barrier homeostasis. J Invest
corneum structure, lipid composition, and desmosome Dermatol 126(9):20742086
degradation in soap-induced winter xerosis. J Soc 59. Demerjian M et al (2008) Acute modulations in per-
Cosmet Chem 45:203220 meability barrier function regulate epidermal cornifi-
43. Rawlings AV et al (1995) The effect of glycerol and cation. Role of caspase-14 and the protease-activated
humidity on desmosome degradation in stratum cor- receptor type 2. Am J Pathol 172(1):8697
neum. Arch Dermatol Res 287(5):457464 60. Sexsmith E, Petersen WF (1918) Skin ferments. J Exp
44. Simon M et al (2001) Persistence of both peripheral Med 27(2):273282
and non-peripheral corneodesmosomes in the upper 61. Di Cera E (2009) Serine proteases. IUBMB Life
stratum corneum of winter xerosis skin versus only 61(5):510515
peripheral in normal skin. J Invest Dermatol 116(1): 62. Emami N, Diamandis EP (2007) Human tissue kal-
2330 likreins: a road under construction. Clin Chim Acta
45. Brandner JM (2009) Tight junctions and tight junc- 381(1):7884
tion proteins in mammalian epidermis. Eur J Pharm 63. Bissett DL, McBride JF, Patrick LF (1987) Role of
Biopharm 72(2):289294 protein and calcium in stratum corneum cell cohesion.
46. Schlter H et al (2004) Sealing the live part of the Arch Dermatol Res 279(3):184189
skin: the integrated meshwork of desmosomes, tight 64. Egelrud T, Hofer PA, Lundstrom A (1988) Proteolytic
junctions and curvilinear ridge structures in the cells degradation of desmosomes in plantar stratum cor-
of the uppermost granular layer of the human epider- neum leads to cell dissociation in vitro. Acta Derm
mis. Eur J Cell Biol 83(1112):655665 Venereol 68(2):9397
47. Haftek M et al (2011) Compartmentalization of the 65. Lundstrm A, Egelrud T (1988) Cell shedding from
human stratum corneum by persistent tight junction- human plantar skin in vitro: evidence of its depen-
like structures. Exp Dermatol 20(8):617621 dence on endogenous proteolysis. J Invest Dermatol
48. Igawa S et al (2011) Tight junctions in the stratum 91(4):340343
corneum explain spatial differences in corneodesmo- 66. Egelrud T, Lundstrom A (1990) The dependence of
some degradation. Exp Dermatol 20(1):5357 detergent-induced cell dissociation in non-palmo-
49. Hachem JP et al (2005) Sustained serine proteases plantar stratum corneum on endogenous proteolysis. J
activity by prolonged increase in pH leads to degrada- Invest Dermatol 95(4):456459
tion of lipid processing enzymes and profound altera- 67. Lundstrm A, Egelrud T (1990) Evidence that cell
tions of barrier function and stratum corneum integrity. shedding from plantar stratum corneum in vitro involves
J Invest Dermatol 125(3):510520 endogenous proteolysis of the desmosomal protein des-
50. Parra JL, Paye M (2003) EEMCO guidance for the moglein I. J Invest Dermatol 94(2):216220
in vivo assessment of skin surface pH. Skin Pharmacol 68. Lundstrm A, Egelrud T (1990) Cell shedding from
Appl Skin Physiol 16(3):188202 human plantar skin in vitro: evidence that two differ-
51. hman H, Vahlquist A (1994) In vivo studies con- ent types of protein structures are degraded by a chy-
cerning a pH gradient in human stratum corneum and motrypsin-like enzyme. Arch Dermatol Res
upper epidermis. Acta Derm Venereol 74(5):375379 282(4):234237
52. Behne MJ et al (2002) NHE1 regulates the stratum 69. Egelrud T, Lundstrm A (1991) A chymotrypsin-like
corneum permeability barrier homeostasis. proteinase that may be involved in desquamation in
Microenvironment acidification assessed with fluo- plantar stratum corneum. Arch Dermatol Res
rescence lifetime imaging. J Biol Chem 277(49): 283(2):108112
4739947406 70. Lundstrm A, Egelrud T (1991) Stratum corneum
53. Behne MJ et al (2003) Neonatal development of the chymotryptic enzyme: a proteinase which may be
stratum corneum pH gradient: localization and mech- generally present in the stratum corneum and with a
anisms leading to emergence of optimal barrier func- possible involvement in desquamation. Acta Derm
tion. J Invest Dermatol 120(6):9981006 Venereol 71(6):471474
54. Suzuki Y et al (1993) Detection and characterization of 71. Paliouras M, Diamandis EP (2006) The kallikrein
endogenous protease associated with desquamation of world: an update on the human tissue kallikreins. Biol
stratum corneum. Arch Dermatol Res 285(6):372377 Chem 387(6):643652
55. Ovaere P et al (2009) The emerging roles of serine 72. Clements JA et al (2004) The tissue kallikrein family
protease cascades in the epidermis. Trends Biochem of serine proteases: functional roles in human disease
Sci 34(9):453463 and potential as clinical biomarkers. Crit Rev Clin
56. Morizane S et al (2010) Kallikrein expression and Lab Sci 41(3):265312
cathelicidin processing are independently controlled 73. Brattsand M et al (2005) A proteolytic cascade of kal-
in keratinocytes by calcium, vitamin D(3), and retin- likreins in the stratum corneum. J Invest Dermatol
oic acid. J Invest Dermatol 130(5):12971306 124(1):198203
176 R. Voegeli and A.V. Rawlings

74. Stefansson K et al (2006) Kallikrein-related peptidase 91. Miralles F et al (1998) UV irradiation induces the
14 may be a major contributor to trypsin-like prote- murine urokinase-type plasminogen activator gene
olytic activity in human stratum corneum. Biol Chem via the c-Jun N-terminal kinase signaling pathway:
387(6):761768 requirement of an AP1 enhancer element. Mol Cell
75. Komatsu N et al (2005) Quantification of human tissue Biol 18(8):45374547
kallikreins in the stratum corneum: dependence on age 92. Oxholm A et al (1988) Immunohistological detec-
and gender. J Invest Dermatol 125(6):11821189 tion of interleukin I-like molecules and tumour
76. Komatsu N et al (2006) Quantification of eight tissue necrosis factor in human epidermis before and after
kallikreins in the stratum corneum and sweat. J Invest UVB-irradiation in vivo. Br J Dermatol 118(3):
Dermatol 126(4):927931 369376
77. Kishibe M et al (2007) Kallikrein 8 is involved in skin 93. Sales KU et al (2010) Matriptase initiates activation
desquamation in cooperation with other kallikreins. J of epidermal pro-kallikrein and disease onset in a
Biol Chem 282(8):58345841 mouse model of Netherton syndrome. Nat Genet
78. Yoon H et al (2008) Activation profiles of human 42(8):676683
kallikrein-related peptidases by proteases of the 94. List K et al (2002) Matriptase/MT-SP1 is required
thrombostasis axis. Protein Sci 17:19982007 for postnatal survival, epidermal barrier function,
79. Debela M et al (2008) Structures and specificity of the hair follicle development, and thymic homeostasis.
human kallikrein-related peptidases KLK 4, 5, 6, and Oncogene 21(23):37653779
7. Biol Chem 389(6):623 95. List K et al (2003) Loss of proteolytically processed
80. Alfano D et al (2005) The urokinase plasminogen filaggrin caused by epidermal deletion of Matriptase/
activator and its receptor: role in cell growth and MT-SP1. J Cell Biol 163(4):901910
apoptosis. Thromb Haemost 93(2):205211 96. List K et al (2006) Delineation of matriptase protein
81. Rockway TW, Nienaber V, Giranda VL (2002) expression by enzymatic gene trapping suggests
Inhibitors of the protease domain of urokinase-type diverging roles in barrier function, hair formation,
plasminogen activator. Curr Pharm Des 8(28): and squamous cell carcinogenesis. Am J Pathol
25412558 168(5):15131525
82. Mondino A, Resnati M, Blasi F (1999) Structure and 97. Deraison C et al (2007) LEKTI fragments specifi-
function of the urokinase receptor. Thromb Haemost cally inhibit KLK5, KLK7, and KLK14 and control
82(Suppl 1):1922 desquamation through a pH-dependent interaction.
83. Ogura Y et al (2008) Plasmin induces degradation and Mol Biol Cell 18(9):36073619
dysfunction of laminin 332 (laminin 5) and impaired 98. Zeeuwen PL et al (2007) Colocalization of cystatin
assembly of basement membrane at the dermal-epi- M/E and cathepsin V in lamellar granules and cor-
dermal junction. Br J Dermatol 159(1):4960 neodesmosomes suggests a functional role in epider-
84. Rosenberg S (2001) New developments in the uroki- mal differentiation. J Invest Dermatol 127(1):120128
nase-type plasminogen activator system. Expert Opin 99. Igarashi S et al (2004) Cathepsin D, but not cathep-
Ther Targets 5(6):711722 sin E, degrades desmosomes during epidermal
85. Schaefer BM et al (1995) Differential expression of desquamation. Br J Dermatol 151(2):355361
urokinase-type plasminogen activator (uPA), its 100. Meyer-Hoffert U (2009) Reddish, scaly, and itchy:
receptor (uPA-R), and inhibitor type-2 (PAI-2) during how proteases and their inhibitors contribute to
differentiation of keratinocytes in an organotypic inflammatory skin diseases. Arch Immunol Ther
coculture system. Exp Cell Res 220(2):415423 Exp (Warsz) 57(5):345354
86. Jensen PJ, Lavker RM (1999) Urokinase is a positive 101. Bernard D et al (2001) Purification and characteriza-
regulator of epidermal proliferation in vivo. J Invest tion of the endoglycosidase heparanase 1 from
Dermatol 112(2):240244 human plantar stratum corneum: a key enzyme in
87. Spiers EM, Lazarus GS, Lyons-Giordano B (1994) epidermal physiology? J Invest Dermatol 117(5):
Expression of plasminogen activator enzymes in pso- 12661273
riatic epidermis. J Invest Dermatol 102(3): 102. Goettig P, Magdolen V, Brandstetter H (2010)
333338 Natural and synthetic inhibitors of kallikrein-related
88. Katsuta Y et al (2003) Urokinase-type plasminogen peptidases (KLKs). Biochimie 92(11):15461567
activator is activated in stratum corneum after barrier 103. Borgono CA et al (2007) Expression and functional
disruption. J Dermatol Sci 32(1):5557 characterization of the cancer-related serine pro-
89. Denda M et al (1997) trans-4-(aminomethyl)cyclo- tease, human tissue kallikrein 14. J Biol Chem
hexane carboxylic acid (T-AMCHA), an anti-fibrin- 282(4):24052422
olytic agent, accelerates barrier recovery and prevents 104. Debela M et al (2007) Structural basis of the zinc
the epidermal hyperplasia induced by epidermal inhibition of human tissue kallikrein 5. J Mol Biol
injury in hairless mice and humans. J Invest Dermatol 373(4):10171031
109(1):8490 105. Debela M et al (2007) Chymotryptic specificity
90. Marschall C et al (1999) UVB increases urokinase- determinants in the 1.0 A structure of the zinc-inhib-
type plasminogen activator receptor (uPAR) expres- ited human tissue kallikrein 7. Proc Natl Acad Sci
sion. J Invest Dermatol 113(1):6976 USA 104(41):1608616091
11 Desquamation: It Is Almost All About Proteases 177

106. Sato J et al (1998) Cholesterol sulfate inhibits pro- 123. Chavanas S et al (2000) Mutations in SPINK5,
teases that are involved in desquamation of stratum encoding a serine protease inhibitor, cause Netherton
corneum. J Invest Dermatol 111(2):189193 syndrome. Nat Genet 25(2):141142
107. Ishida-Yamamoto A et al (2005) LEKTI is localized 124. Hachem J-P et al (2006) Serine protease activity and
in lamellar granules, separated from KLK5 and residual LEKTI expression determine phenotype in
KLK7, and is secreted in the extracellular spaces of Netherton syndrome. J Invest Dermatol 126(7):
the superficial stratum granulosum. J Invest Dermatol 16091621
124(2):360366 125. Komatsu N et al (2002) Elevated stratum corneum
108. Roelandt T et al (2009) LEKTI-1 in sickness and in hydrolytic activity in Netherton syndrome suggests
health. Int J Cosmet Sci 31(4):247254 an inhibitory regulation of desquamation by SPINK5-
109. Borgono CA et al (2007) A potential role for multi- derived peptides. J Invest Dermatol 118(3):436443
ple tissue kallikrein serine proteases in epidermal 126. Sevilla LM et al (2007) Mice deficient in involucrin,
desquamation. J Biol Chem 282(6):36403652 envoplakin, and periplakin have a defective epider-
110. Egelrud T et al (2005) hK5 and hK7, two serine pro- mal barrier. J Cell Biol 179(7):15991612
teinases abundant in human skin, are inhibited by 127. Eissa A, Diamandis EP (2008) Human tissue kal-
LEKTI domain 6. Br J Dermatol 153(6):12001203 likreins as promiscuous modulators of homeostatic
111. Schechter NM et al (2005) Inhibition of human kal- skin barrier functions. Biol Chem 389(6):669680
likreins 5 and 7 by the serine protease inhibitor lym- 128. Yoon H et al (2007) Activation profiles and regula-
pho-epithelial Kazal-type inhibitor (LEKTI). Biol tory cascades of the human kallikrein-related pepti-
Chem 386(11):11731184 dases. J Biol Chem 282(44):3185231864
112. Meyer-Hoffert U, Wu Z, Schroder JM (2009) 129. Simon M et al (2001) Refined characterization of
Identification of lympho-epithelial Kazal-type inhib- corneodesmosin proteolysis during terminal differ-
itor 2 in human skin as a kallikrein-related peptidase entiation of human epidermis and its relationship to
5-specific protease inhibitor. PLoS One 4(2):e4372 desquamation. J Biol Chem 276(23):2029220299
113. Brattsand M et al (2009) SPINK9: a selective, skin- 130. Bernard D et al (2003) Analysis of proteins with
specific Kazal-type serine protease inhibitor. J Invest caseinolytic activity in a human stratum corneum
Dermatol 129(7):16561665 extract revealed a yet unidentified cysteine protease
114. Meyer-Hoffert U et al (2010) Isolation of SPINK6 in and identified the so-called stratum corneum thiol
human skin: selective inhibitor of kallikrein-related protease as cathepsin L2. J Invest Dermatol
peptidases. J Biol Chem 285(42):3217432181 120(4):592600
115. Franzke C-W et al (1996) Antileukoprotease inhibits 131. Stefansson K et al (2008) Activation of proteinase-
stratum corneum chymotryptic enzyme. Evidence activated receptor-2 by human kallikrein-related
for a regulative function in desquamation. J Biol peptidases. J Invest Dermatol 128(1):1825
Chem 271(36):2188621890 132. Oikonomopoulou K et al (2006) Proteinase-activated
116. Tian X et al (2004) Expression of human kallikrein 7 receptors. Targets for kallikrein signaling. J Biol
(hK7/SCCE) and its inhibitor antileukoprotease Chem 281(43):3209532112
(ALP/SLPI) in uterine endocervical glands and in 133. Egberts F et al (2004) Cathepsin D is involved in the
cervical adenocarcinomas. Oncol Rep 12:10011006 regulation of transglutaminase 1 and epidermal dif-
117. Molhuizen HO et al (1993) SKALP/elafin: an ferentiation. J Cell Sci 117(11):22952307
elastase inhibitor from cultured human keratino- 134. Chang-Yi C, Takahashi M, Tezuka T (1997) 30-kDa
cytes. Purification, cDNA sequence, and evidence trypsin-like proteases in the plantar stratum cor-
for transglutaminase cross-linking. J Biol Chem neum. J Dermatol 24(8):504509
268(16):1202812032 135. Schepky AG et al (2004) Influence of cleansing on
118. Taggart CC et al (2001) Cathepsin B, L, and S cleave stratum corneum tryptic enzyme in human skin. Int J
and inactivate secretory leucoprotease inhibitor. J Cosmet Sci 26(5):245253
Biol Chem 276(36):3334533352 136. Hansson L et al (2002) Epidermal overexpression of
119. Galliano MF et al (2006) A novel protease inhibitor stratum corneum chymotryptic enzyme in mice: a
of the alpha2-macroglobulin family expressed in the model for chronic itchy dermatitis. J Invest Dermatol
human epidermis. J Biol Chem 281(9):57805789 118(3):444449
120. Oji V et al (2006) Plasminogen activator inhibitor-2 137. Koyama J et al (1996) The mechanism of desquama-
is expressed in different types of congenital ichthyo- tion in the stratum corneum and its relevance to skin
sis: in vivo evidence for its cross-linking into the care. In: Proceedings of the 19th IFSCC congress,
cornified cell envelope by transglutaminase-1. Br J Sydney, 1996
Dermatol 154(5):860867 138. Voegeli R et al (2007) Profiling of serine protease
121. Hibino T et al (1999) Suppression of keratinocyte activities in human stratum corneum and detection
proliferation by plasminogen activator inhibitor-2. J of a stratum corneum tryptase-like enzyme. Int J
Invest Dermatol 112(1):8590 Cosmet Sci 29(3):191200
122. Lian X, Yang T (2004) Plasminogen activator inhibi- 139. Sato J et al (1998) Dry condition affects desquama-
tor 2: expression and role in differentiation of epider- tion of stratum corneum in vivo. J Dermatol Sci
mal keratinocyte. Biol Cell 96(2):109116 18(3):163169
178 R. Voegeli and A.V. Rawlings

140. Sato J (2002) Desquamation and the Role of Stratum 156. Ekholm E, Egelrud T (1999) Stratum corneum chy-
Corneum Enzymes. In: Leyden JJ, Rawlings AV motryptic enzyme in psoriasis. Arch Dermatol Res
(eds) Skin moisturization. Marcel Dekker, New 291(4):195200
York, pp 8194 157. Vasilopoulos Y et al (2004) Genetic association
141. Declercq L et al (2002) Adaptation response in between an AACC insertion in the 3UTR of the stra-
human skin barrier to a hot and dry environment. tum corneum chymotryptic enzyme gene and atopic
J Invest Dermatol 119(3):716 dermatitis. J Invest Dermatol 123(1):6266
142. Voegeli R et al (2007) Efficient and simple quantifi- 158. Rawlings AV, Matts PJ (2005) Stratum corneum
cation of stratum corneum proteins on tape strip- moisturization at the molecular level: an update in
pings by infrared densitometry. Skin Res Technol relation to the dry skin cycle. J Invest Dermatol
13(3):242251 124(6):10991110
143. Voegeli R et al (2008) Increased basal transepider- 159. Choi MJ, Maibach HI (2005) Role of ceramides in
mal water loss leads to elevation of some but not all barrier function of healthy and diseased skin. Am
stratum corneum serine proteases. Int J Cosmet Sci J Clin Dermatol 6(4):215223
30(6):435442 160. Holleran WM, Takagi Y, Uchida Y (2006) Epidermal
144. Mohammed D et al (2011) Depth profiling of stra- sphingolipids: metabolism, function, and roles in
tum corneum biophysical and molecular properties. skin disorders. FEBS Lett 580(23):54565466
Br J Dermatol 164(5):957965 161. Redoules D et al (1999) Characterisation and assay
145. Hirao T (2003) Involvement of transglutaminase in of five enzymatic activities in the stratum corneum
ex vivo maturation of cornified envelopes in the stra- using tape-strippings. Skin Pharmacol Appl Skin
tum corneum. Int J Cosmet Sci 25(5):245257 Physiol 12(4):182192
146. Harding CR et al (2003) The cornified cell envelope: 162. Tarroux R et al (2002) Variability of enzyme mark-
an important marker of stratum corneum maturation ers during clinical regression of atopic dermatitis.
in healthy and dry skin. Int J Cosmet Sci 25(4): Skin Pharmacol Appl Skin Physiol 15:5562
157167 163. Voegeli R et al (2011) Increased mass levels of ser-
147. Hadgraft J, Lane ME (2009) Transepidermal water ine proteases in the stratum corneum in acute eczem-
loss and skin site: a hypothesis. Int J Pharm atous atopic skin. Int J Cosmet Sci 33(6):560565
373(12):13 164. Kalia YN et al (2001) Assessment of topical bio-
148. Machado M, Hadgraft J, Lane ME (2010) Assessment availability in vivo: the importance of stratum cor-
of the variation of skin barrier function with ana- neum thickness. Skin Pharmacol Appl Skin Physiol
tomic site, age, gender and ethnicity. Int J Cosmet 14(suppl 1):8286
Sci 32:397409 165. Roedl D et al (2009) Serine protease inhibitor lym-
149. Proksch E (2008) Protection against dryness of facial phoepithelial Kazal type-related inhibitor tends to be
skin: a rational approach. Skin Pharmacol Physiol decreased in atopic dermatitis. J Eur Acad Dermatol
22(1):37 Venereol 23(11):12631266
150. Van Overloop L, Declercq L, Maes D (2001) Visual 166. Descargues P et al (2006) Corneodesmosomal cad-
scaliness of human skin correlates to decreased cer- herins are preferential targets of stratum corneum
amide levels and decreased stratum corneum pro- trypsin- and chymotrypsin-like hyperactivity in
tease activity. J Dermatol 117(3):811 Netherton syndrome. J Invest Dermatol 126(7):
151. Nina M et al (2009) Dichotomous effect of ultraviolet 16221632
B on the expression of corneodesmosomal enzymes 167. Kikuchi K et al (2006) Impairment of skin barrier
in human epidermal keratinocytes. J Dermatol Sci function is not inherent in atopic dermatitis patients:
54(1):1724 a prospective study conducted in newborns. Pediatr
152. Kitamura K (2002) Advances in dry skin care tech- Dermatol 23(2):109113
nology extend beyond the category of cosmetic 168. Cork MJ et al (2006) Interaction of topical corticos-
products. IFSCC Mag 5(3):177187 teroids and pimecrolimus with the skin barrier:
153. Kawai E et al (2002) Can inorganic powders provide Implications for efficacy and safety of treatment for
any biological benefit in stratum corneum, while atopic dermatitis. J Am Acad Dermatol 54(suppl
residing on skin surface. IFSCC Mag 5(4):269275 S):AB3 P10
154. Suzuki Y et al (1996) The role of two endogenous 169. Sugarman JL (2008) The epidermal barrier in atopic
proteases of the stratum corneum in degradation of dermatitis. Semin Cutan Med Surg 27(2):108114
desmoglein-1 and their reduced activity in the skin of 170. Rawlings AV (2009) 50 years of stratum corneum and
ichthyotic patients. Br J Dermatol 134(3):460464 moisturization research. IFSCC Mag 12(3):169172
155. Bowcock AM, Krueger JG (2005) Getting under the 171. Jonca N et al (2009) Corneodesmosomal Proteins.
skin: the immunogenetics of psoriasis. Nat Rev In: Rawlings AV, Leyden JJ (eds) Skin moisturiza-
Immunol 5(9):699711 tion. Informa Healthcare, New York, pp 99123
 Endogenous Retroviral-Like
Aspartic Protease, SASPase as a Key 12
Modulator of Skin Moisturization

Takeshi Matsui

12.1 Introduction prevention of the invasion of microorganisms,

chemical compounds, and allergens [50, 66]. This
About 360 million years ago (the late Devonian layer is also crucial in the maintenance of mois-
period), the first terrestrial vertebrate amphibian ture levels of the skin. It composed of the stratum
emerged from water and adapted to life on land. basale (SB), stratum spinosum (SS), stratum
These animals evolved their skin epidermis into a granulosum (SG), and stratum corneum (SC).
keratinized stratified squamous epithelium, baring Epidermal differentiation consists of a multiple-
the stratum corneum (SC) as the outermost layer, to step process accompanied by various gene expres-
prevent water loss and as protection from sunlight sion and concomitant morphological changes [18,
[1, 67]. Genomic analysis of various vertebrate 19, 68, 77] Keratinocytes proliferate and differen-
species reveals that dynamic changes in epithelia tiate as they move upward from the SB. Gene
are correlated with the integration of new stratified expression is finished in the living SG by matu-
epithelia-specific genes (Fig. 12.1). Therefore, ration of intra/extracellular processes. Intracellular
identification and deletion of these genes in mam- changes consist of the formation of a protein-rich
mals such as mice may help us to understand the envelope and an outer lipid membrane that pro-
molecular mechanisms of adaptive evolution of vides flexibility to the SC [11, 72]. At the extra-
epithelium, termed epithelial evolution. cellular level, the extrusion of lamellar granules
Skin is composed of three layers: the epider- occurs to produce waterproof barrier lipids by
mis, dermis, and hypodermis. The epidermis is a secreting membrane-coating granules. At the
keratinized stratified squamous epithelium and dead SC, corneocytes and intracellular lipids
forms an effective barrier between the organism form a functional barrier between the organism
and the environment that is indispensable for the and the environment, i.e. air-liquid interface, which
is indispensable for the physiology of the skin
[11]. At the SG-to-SC transition stage, keratino-
cytes dramatically transform themselves from liv-
ing cells to flat-shaped dead cells with loss of
intracellular organelles and contain keratin bundles
and lipids to constitute the SC [39]. During this
T. Matsui, Ph.D. dynamic terminal differentiation with cell death,
Hiiragi Laboratory, Institute for Integrated keratinocytes still express various proteins, such as
Cell Material Sciences (iCeMS), Kyoto University,
keratins, profilaggrin/filaggrin, involucrin, small
iCeMS Complex2, Yoshida-Honmachi, Sakyo-ku,
Kyoto 606-8501, Japan proline-rich proteins, loricrin, cystatin A, and
e-mail: [email protected] elafin, which participate in forming the cornified

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 179

DOI 10.1007/978-3-642-27606-4_12, Springer-Verlag Berlin Heidelberg 2012
180 T. Matsui

Adaptive evolution of the skin

Aves

(360 my ago)
Amphibians Mammals
(Frog) Reptiles

Amphibians
Fishes (Tadpole)
(Platypus) (Mouse)
(Ichthyostega)

Multilayered epithelia Keratinized stratified squamous epithelia

+ Skin-specific genes
+ Stratum corneum
(Filaggrin etc.)

? ?

SASPase
Barrier
? Cornification
Retrovirus

Epithelial evolution

Fig. 12.1 Adaptive evolution of the skin. About 360 mil- terrestrial vertebrate species reveals that new stratified
lion years ago (the late Devonian period, 360 my ago), the epithelia-specific genes including filaggrin and SASPase
first terrestrial vertebrate amphibian (e.g., Ichthyostega) were integrated into their genome. SASPase may have
emerged from the water and adapted to life on land. They derived from an ancient retroviral infection. Therefore,
evolved their surface epithelium from multilayered epi- the identification of skin-specific genes and generation of
thelia into keratinized stratified squamous epithelia, bar- knockout mice may aid our understanding of the molecu-
ing the stratum corneum to prevent water loss and for lar mechanisms of epithelial evolution
protection from sunlight. Genomic analysis of various

envelope of mature corneocytes [11]. Therefore, linked to 1012 tandem filaggrin monomer
the SG-expressing genes/proteins serve impor- repeats [15, 25, 37]. At the SG-to-SC transition,
tant roles in the final stage of epidermal differentia- each filaggrin repeat is cleaved by a particular
tion, cornification, and barrier function. protease(s) to generate the filaggrin monomer
(37 and 28 kDa in humans and mice, respec-
tively). The cleaved filaggrin monomer strongly
12.2 The Skin-Specic binds to keratin, and the resulting keratin bun-
and SG-Specic Protein, dles are thought to contribute to the production
Filaggrin of functional SC [13, 24]. Regions of the filag-
grin-keratin complex are cross-linked by trans-
Filaggrin is known as a skin-specific protein glutaminase to build the skin barrier [11, 12,
that is expressed from the SG as a phosphory- 25, 69]. Keratin-bound filaggrin is citrullinated
lated profilaggrin of >400 kDa in humans and is and degraded into amino acids, which consti-
a major component of keratohyalin granules in tutes the major part of the natural moisturizing
the SG of the epidermis [15, 49]. Profilaggrin is factor (NMF) in the upper SC [8, 17, 2830, 38,
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 181

41, 54, 74]. Therefore, at the SG-to-SC invertebrates, fungi, plants, and retroviruses
transitional stage, the processing from profilag- [52, 73]. Eukaryotic aspartic proteases are ~330
grin to filaggrin is the rate-limiting step for the residues and are monomeric enzymes that consist
profilaggrin processing cascade. of two homologous domains (the structure is anal-
Several proteases are reported to be involved ogous to a pair of scissors connected by a rope).
in the profilaggrin-to-filaggrin processing [44, 62, Each domain contains an active site centered on a
10]. Calpain I and profilaggrin endopeptidase I catalytically essential aspartic acid residue. On the
(PEP-I) are reported to cleave the linker peptides other hand, retroviral aspartic proteases are
of profilaggrin in vitro [5659, 79]; furin or con- encoded in the retroviral genome and are expressed
vertase has been demonstrated to be involved in as part of a large polyprotein precursor that under-
the cleavage of the N-terminus from profilaggrin goes autoprocessing in viral particles to produce
[47]; and matriptase/MT-SP1- and prostasin an active enzyme that exists as a homodimer (like
(CAP1/Prss8)-deficient mice show aberrant pro- a pair of scissors) (See Fig.12. 9). These proteases
cessing of profilaggrin to filaggrin [32, 33]. The are essential for maturation and assembly of infec-
possible linker cleavage sites of mouse, rat, and tious virus particles [53].
human profilaggrin have been determined from A number of retroviral protease sequences
endogenous filaggrin [5759, 75, 76]. It remains with retroviral elements are integrated in every
to be elucidated that the corresponding linker eukaryotic genome as endogenous retroviruses
sequences of profilaggrin are cleaved by [51]. Most of these human endogenous retrovi-
matriptase or prostasin in vitro. ruses have been acquired 10100 million years
Historically, the existence of a certain herita- ago [34]. Krylov and Koonin have described new
ble component for the development of atopic der- subfamilies of predicted retroviral-like aspartic
matitis (AD) has long been known [3, 9, 40]. proteases that were not embedded within endog-
Filaggrin was reported to have nonsense muta- enous retroviral elements throughout the eukary-
tions in ichthyosis vulgaris (IV) patients and is otic and prokaryotic genomes [31].
the major predisposing factor for atopic eczema, Bernard et al. have identified a novel retroviral-
asthma, and allergies [45, 62, 63, 10]. It was indi- like aspartic protease, SASPase (skin aspartic
cated that the early onset of AD is caused by protease; Asprv1) from total protein extracts of
outside-to-inside paradigms, namely a primary the human reconstructed epidermis [4]. Using
barrier abnormality [20]. Filaggrin null mutations high-throughput in situ hybridization screening, we
showed population specificity [10]. For instance, have also identified a mouse homolog of SASPase
filaggrin nonsense mutations are carried by ~9% [35] as an SG-expressing gene. This protease has
of the Irish population. Such filaggrin mutations also been cloned as a 12-O-tetradecanoylphorbol-
are found in ~50% and 20% of Irish and Japanese 13-acetate (TPA)-induced gene (Taps) from cDNA
AD patients, respectively [2, 42, 62, 63]. The of mouse back skin epidermis [60]. Human and
remaining patients with AD who have normal fil- mouse SASPase/Asprv1/Taps were primarily
aggrin alleles are likely to be affected by other expressed in skin and exclusively expressed in the
predisposing factors [22, 46, 71]. SG of the epidermis (Fig. 12.2). This retroviral-
like aspartic protease was only found in mammals.
Immunoblotting of human and mouse epidermal
extracts revealed the expression of two forms of
12.3 Skin-Specic and SG-Specic the enzyme: the 28 and 14 kDa forms in human
Protease, SASPase and the 32 and 15 kDa forms in mouse. Although
there are putative transmembrane domains in
Proteases play an important role in many physio- human and mouse SASPase, the full-length pro-
logical processes [5]. Proteases are classified into tein was not detected in epidermal lysates of
five distinct classes: aspartic, metallo, cysteine, human and mouse. It has also been demonstrated
serine, and threonine proteases. Aspartic proteases that mouse SASPase is found in the medium when
are expressed in various species such as vertebrates, the full-length protein was expressed in the HeLa
182 T. Matsui

Fig. 12.2 Retroviral-like a

aspartic protease, SASPase. 1 56 77 191 326 343aa
(a) Schematic representation
of human and mouse Human SASPase Protease
SASPase. At the amino acid
sequence level, human and 72% identity
mouse SASPase show 72%
identity. The putative 1 55 76 189 324 339aa
transmembrane domain is Mouse SASPase Protease
denoted as a black square.
Arrows indicate the autopro-
cessing sites. (b) In situ
hybridization signals obtained
b in situ hybridization
with the mouse SASPase
antisense probe in sections of
adult mouse foot pad
epidermis. The SASPase
probe gives an intense signal
in the granular layer of the
epidermis. A dashed line
represents the border between
the epidermis and dermis.
(c) The expression of mouse
SASPase mRNA in various
tissues in northern blotting.
SASPase was expressed in the
stomach, skin, and weakly in

cle
the lung (arrow). The

e
c

in

us
st
control-GAPDH probe was

in l m
lo inte
Co all h
also hybridized (This was

Sk leta
c
Ki en
St ey
Smma

Sk n
Lu t
n
ar
ng

le
Sp r

dn

e
reproduced and modified from
ai

ve

o
He
Br

Li

Matsui et al. [35]. Reprinted

with permission. 2006 The (kb)
American Society for 4.7-
Biochemistry and Molecular
Biology. All rights reserved) 1.8-

Mouse SASPase

GAPDH

cell line [60]. Thus, the function of the transmem- optimum pH for HIV protease activity. Interestingly,
brane domain of SASPase remains to be eluci- this pH corresponds to the pH of the upper surface
dated. Similar to other retroviral proteases such as of the epidermis. Recently, aberrant SASPase
the HIV protease, recombinant human 28 kDa and expression in transgenic mice was reported to
mouse 32 kDa SASPase forms undergo autoacti- cause impaired skin regeneration and remodeling
vation processing in vitro, and this cleavage event after cutaneous injury and chemically induced
generates a 14-kDa (human)/15-kDa (mouse) hyperplasia, suggesting that when expressed
derived protease domain [4, 35]. We also demon- in skin, SASPase cleaves particular substrates
strated that the optimum pH of the active form of involved in these processes [27].
mouse SASPase is 5.77, which is similar to the
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 183

12.4 The Phenotype of SASPase- As shown in Fig. 12.4, SASP/ hairless mice
Decient Hairless Mice had more fine wrinkles and drier, rougher skin
than their SASP+/+ and SASP+/ counterparts [36].
To understand the physiological role of evolution- Electron microscopic analysis of SASP/ hair-
ally conserved SASPase in mammals, we have less mice showed that the epidermis had more
generated SASPase-deficient mice. These mice tightly and electron densely compacted cornified
were found to show fine wrinkles that ran parallel cells. Moreover, the number of layers was found
on the lateral trunk at 5 weeks of age (Fig. 12.3; to have increased when compared with SASP +/+
[35]). This phenotype indicated that SASPase is mice (Fig. 12.5) [36].
involved in the prevention of fine wrinkle forma- Physiological characterization of the epidermal
tion. As SASPase is an SG-expressing gene, these surface of the SASP/ hairless mice revealed a
fine wrinkles of SASPase-deficient mice were marked decrease in SC hydration without altera-
hypothesized to be derived from the aberrant tion to the barrier function (TEWL: trans-epidermal
functions of the SG and/or SC. To further analyze water loss) (Fig. 12.6) [36]. Decreased SC hydra-
the phenotype on the epidermal surface physiol- tion is found in several diseases, such as AD,
ogy of SASPase-deficient mice, we transferred eczema, or psoriasis [26]. Consistent with our
the ablated allele to a Hos:HR-1 hairless back- results, although the TEWL is an important hall-
ground [36]. mark for skin barrier function, TEWL has been

SASP+/ SASP/

Fig. 12.3 Wrinkle formation in SASPase-deficient mice. were more enhanced by stretching the hind legs backward
A lined appearance on the skin surface of the lateral trunk (lower panel) (This was reproduced and modified from
of SASPase-deficient mice is observed. Static state of Matsui et al. [35]. Reprinted with permission. 2006 The
14-week-old female heterogenic (SASP+/) and homoge- American Society for Biochemistry and Molecular
nic (SASP/) mice (upper panel). In SASP/ mice, lined Biology. All rights reserved)
grooves appear parallel to the body axis. These grooves
184 T. Matsui

Fig. 12.4 Dry skin-like phenotype in hung SASP/ hairless mice when compared with SASP+/ hairless
hairless mice. When hung by the tail, more wrinkles mice (Copyright 2011 Wiley. Used with permission
appeared on the surface of the back skin in SASP/ from Mastui et al. [36])

a +/+ b /
SC

SG SC

SG
SS

SS

Fig. 12.5 SASP/ hairless mouse epidermis shows an dermis showed an increase in the number of electron dense
increase in the number of layers in the aberrant SC. layers in the SC of SASP/ mice compared with SASP+/+
Sections of SASP+/+ (a) and SASP/ (b) epidermis exam- mice. Scale bars: 4 mm. SC stratum corneum, SG stratum
ined by electron microscopy are shown. Transmission granulosum, SS stratum spinosum (Copyright 2011 Wiley.
electron microscopic analysis of SASP+/+ and SASP/ epi- Used with permission from Mastui et al. [36])

reported to be sometimes not correlated with human staining with an antifilaggrin antibody revealed
dry skin [6, 21, 78]. the accumulation of aberrant dimeric and tri-
meric filaggrin, i.e., premature profilaggrin
processing (Fig. 12.7) [36]. We also showed
12.5 SASPase as a Prolaggrin that recombinant human SASPase (14 kDa
Processing Enzyme form) directly cleaves the human profilaggrin
linker sequence in vitro. Considering that the
The expression of several epidermal differen- processing of mouse profilaggrin occurs in a
tiation markers (keratin 14, keratin 10, involu- two-step process via two types of profilaggrin
crin, loricrin) revealed normal expression and linker sequences (with or without FYPV), aber-
localization in SASP/ hairless mice, whereas rant accumulation of dimeric- and trimeric-like
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 185

a 8 ns b 30 p = 0.0006

SC hydration (uS)
20
TEWL (g/h/m2)
4

10
2

0 0
+/+ / +/+ /
(n = 7) (n = 11) (n = 7) (n = 11)

Fig. 12.6 Trans-epidermal water loss (TEWL) (a) and mean values SD). The SC hydration of SASP. The SC
SC hydration levels (b) of SASP+/+ and SASP/ hairless hairless mice hydration levels were significantly lower
mice were measured, respectively. The numbers of ani- than the SASP+/+ and SASP+/ hairless mice hydration lev-
mals tested were: SASP+/+, n = 7 and SASP/, n = 11. Each els (Copyright 2011 Wiley. Used with permission from
p value is indicated above the bar (Mann Whitney test on Mastui et al. [36])

profilaggrin in the mouse SASP/ SC suggests mechanism that is important in the maintenance
that SASPase may be involved in either pro- of the moisturization levels of the skin.
cessing steps in mouse [56, 59].
As described in Sect. 12.2, filaggrin is thought
to have two major functions in the SC: the forma- 12.6 Human Mutations of SASPase
tion of keratin microfibrils in the lower SC and the
production of NMFs in the upper SC [54]. It is We have performed a mutation search on the
widely believed that SC hydration is closely linked human SASPase gene against a Japanese cohort.
and dependent on the three-dimensional keratin Two types of missense mutations (D232Y and
structural organization. Accumulation of aberrant V243A: 3.5% [1/28]) in the 28 control subjects,
profilaggrin in the lower SC may affect the cubic- four types of missense mutations (A54S: 0.5%
like, rod-packing symmetry of keratin filaments at [1/196], I186T: 0.5% [1/196], V187I: 1.5%
the lower SC, resulting in the alteration of the [3/196], R311C: 0.5% [1/196]), and three types
hydration level and the texture of SCin the SASP/ of silent mutations (F101F: 0.5% [1/196],
epidermis [43]. In support of this concept, on the P206P: 3.1% [6/196], N276N: 1.5% [3/196]) in
contrary to SASP/ hairless mice, it was reported the 196 AD patients were identified (Fig. 12.8)
that the SC of flaky tail mice, in which filaggrin is [36]. All mutations were identified as heterozy-
absent, showed normal SC hydration and numbers gous. V187I was the most frequently identified
of SC layers [23, 48, 64]. It is possible that in addi- (three AD patients). Biochemical analysis has
tion to profilaggrin, SASPase may also cleave other shown that among these, the V243A mutation
substrates and effect SC hydration via, for instance, abolished protease activity in vitro, whereas the
abnormalities in the intercellular lamellar lipids V187I mutation was observed to induce a
barrier formation, the diffusion path length, and/or marked decrease in protease activity. In the
the composition of nonfilaggrin-derived NMFs future, it will be necessary to perform a large-
[54, 55]. These possibilities will be clarified by scale cohort analysis to clarify the clinicopatho-
crossing SASP/ mice with filaggrin-deficient logical significance of these heterogenic
mice. Future detailed analysis of SASP/ hairless loss-of-function mutations of SASPase and
mice SC will provide additional molecular whether they affect human skin physiology (See
186 T. Matsui

+/+ +/ /
a +/ / b
Profilaggrin

(kDa)
180
Upper SC 130
100
Lower SC
3 Filaggrin
75
SG
63
2 Filaggrin
48

35
Filaggrin
28

17
Filaggrin/nucleus 10
Anti-filaggrin
immunoblotting

Fig. 12.7 Aberrant expression of filaggrin in SASP/ hair- SASP+/ (n = 2), and SASP/ (n = 2) mice were immunob-
less mice. (a) Immunofluorescence staining of frozen sec- lotted with antifilaggrin antibodies, demonstrating that an
tions of the back skin of SASP+/ and SASP/ mice stained accumulation of aberrant filaggrin degradation products
with an antifilaggrin antibody (red). Nuclei were counter- (dimer and trimer sizes) was detected (2 filaggrin and 3
stained with bisbenzimide (blue). The SASP/ epidermis filaggrin), whereas mature filaggrin (filaggrin) was rarely
showed an increase in the amount of filaggrin-positive detected. As equivalent amounts of SC extracts were
staining in the lower SC. Dashed lines represent the border loaded, the intensity of the profilaggrin band (profilaggrin)
between the epidermis and dermis. SC stratum corneum, had decreased in SASP/, possibly due to an increase in the
SG stratum granulosum. (b) Equivalent amounts of tape- concentrations of other smear proteins (Copyright 2011
stripped extracts (10 times, 5 mg) from SASP+/+ (n = 2), Wiley. Used with permission from Mastui et al. [36])

also Sect. 12.7). We also performed mutation Therefore, it is possible that patients who do
searches against South African and Irish atopic not have a nonsense mutation of filaggrin, but
eczema cases and Scotish dry skin cases. who exhibit xerosis or AD, may have an aberrant
However, we failed to find an association profilaggrin processing pattern. The involvement
between SASPase mutations and atopic eczema of SASPase in the progression of these diseases
or clinically dry skin in the European popula- from the viewpoint of the profilaggrin processing
tions, suggesting the possibility that these muta- pathway should be examined. The profilaggrin
tions are likely to be specific to the Japanese degradation pattern may prove useful in the diag-
population [65]. Due to complex disorders, like nosis of xerosis and the early onset of AD.
AD, it is particularly difficult to establish a
direct role of these sequence variants in the
pathogenesis of known disease states. 12.7 Possible Physiological Role
Of note, there are various human epidermal of SASPase
diseases with aberrant expression and processing
of profilaggrin to filaggrin (reviewed in [14]). Our findings of the analysis of SASPase-deficient
Bernard et al. have also shown high expression of hairless mice are summarized in Fig. 12.9
active SASPase in the SC of psoriasis patients by (Modified from [36]). In normal mice and
immunoblotting and immunofluorescence [4]. human epidermis, phosphorylated profilaggrin is
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 187

D232Y V243A

I186T R311C*
A54S*

1 191 326 343aa

Human Protease
SASPase

187 190 191 194

Val- Phe - Ala - Asn - Ser - Met - Gly - Lys
Autoprocessing site

V1871

Fig. 12.8 Schematic representation of human mutations that these mutations were found in the same patient and in
identified in Japanese AD patients (n = 196; closed circles) the same allele. The V243A mutation abolished protease
and case controls (n = 28; open circles). The amino acid activity, whereas the V187I mutation induced a marked
sequence of the autoprocessing site (between Asn190 and decrease in protease activity in vitro (underlined). (Copyright
Ser191) is indicated. Asterisks of A54S and R311C indicate 2011 Wiley. Used with permission from Mastui et al. [36])

dephosphorylated and processed into filaggrin 12.8 Origin of SASPase and

monomers and bundle keratin filaments at the Adaptation to Life on Land
lower SC. They are subsequently further
degraded to free amino acids that constitute most Collectively, these results indicate that the activity
of the NMFs in the upper SC. SASPase defi- of SASPase plays a key role in determining the tex-
ciency causes incomplete linker cleavage of pro- ture of the SC by modulating SC hydration, as well
filaggrin resulting in the accumulation of trimeric as profilaggrin-to-filaggrin processing. Moreover,
and dimeric profilaggrins in the lower SC. Such these results, in combination with clinicopathologi-
aberrant profilaggrin may bind to keratin fila- cal investigations of epidermal diseases derived
ments and then degrade into a normal composi- from the aberrant processing of profilaggrin by
tion of free amino acids in the upper SC. Overall, mutation or decreased activity of SASPase should
the SC of the SASP/ epidermis has an increase in provide valuable data that enable researchers to
the number of layers and produces a wrinkled, dissect the complex mechanisms of percutaneous
dry, rough skin. SASPase, as a retroviral aspartic antigen priming in atopic diseases.
protease, must undergo homodimeric formation SASP/ hairless mice have provided the first
for its protease activity (Fig. 12.9, [4, 35]). In the evidence that one of the genome-integrated retro-
case of the human epidermis with a heterogenic viral-like aspartic protease family members is
mutation of SASPase (such as V187I or V243A), functionally important in mammalian tissue archi-
the dominant negative effects would expect to tecture. Interestingly, the SASPase gene is only
lead to one functional domain of the SASPase found in the mammalian genome. Although it has
(Fig. 12.9, see the picture of the scissors). This not been proven that the SASPase gene in mam-
postulate is consistent with the HIV protease, mals is derived from an ancient retroviral infec-
where a subunit exchange reaction of the protease tion into the germline, this molecular mechanism
with a catalytically inactive mutation results in would be the first example of a virus-related
50% inhibition of enzymatic activity [16]. element that has contributed to the evolution of
188 T. Matsui

Mouse Human
Wrinkled, dry, rough skin
decreased SC hydration ?

+/+ -/- SASP:SASP(V1871)

SASP epidermis SASP epidermis SASP:SASP(V243A)

?
Free amino acids Free amino acids

Cit Cit Citrullinated

Upper filaggrin
SC Accumulation of unprocessed profilaggrin
Lower SC
Keratin
SG

Filaggrin ?
SS

SASPase SASPase
Protease

Protease
SB Protease

Profilaggrin
P P P
Dephosphorylation

P P P P P P P P P P P P P P P P P P P P P P P P P P P P

Phosphorylated profilaggrin

Fig. 12.9 Schematic representation of the possible profil- plete linker sequence cleavage. Aberrantly processed pro-
aggrin processing pathway observed in the SASP+/+ and filaggrin binds to keratin filaments and degrades into free
SASP/ epidermis. In the mouse SASP+/+ epidermis, amino acids without the production of monomeric filag-
highly phosphorylated profilaggrin expressed in the SG is grin. Finally, aberrant SC causes wrinkled, dry, rough skin
dephosphorylated in the uppermost SG. The linker with decreased SC hydration. In the case of the human epi-
sequence that connects each filaggrin monomer is then dermis which has heterogenic mutations of SASPase (such
cleaved by SASPase at the SG-to-SC transition. Monomeric as V187I or V243A), dominant negative effects would be
filaggrin strongly binds to keratin filaments in the lower expected to be observed because one side of the scissors is
SC to form bundled keratin filaments. After citrullination, dysfunctional. The clinicopathological significance of
filaggrin is released from keratin and further degraded to these heterogenic loss-of-function mutations of SASPase
form free amino acids, which constitute most of the NMFs has not been fully determined. SC stratum corneum, SG
in the upper SC. In the mouse SASP/ epidermis, trimeric stratum granulosum, SS stratum spinosum, SB stratum
and dimeric profilaggrins are slightly degraded from either basale (Copyright 2011 Wiley. Used with permission from
N- or C-terminal ends and accumulate because of incom- Mastui et al. [36])

vertebrate skin [7, 70]. Therefore, the study of the

SASPase physiological function should provide SASPase-deficient hairless mice show
valuable clues that reveal the role of the SC in drier and more wrinkled skin.
mammals and how they adapted to life on land. SASPase activity is indispensable for
SC hydration.
SASPase activity is indispensable for
profilaggrin processing.
Take Home Messages SASPase directly cleaves the profilag-
SASPase is a retroviral-like aspartic grin linker peptide in vitro.
protease that is expressed primarily in Loss-of-function mutations of SASPase
the skin and exclusively in the stratum in the human genome have been
granulosum. identified.
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 189

Acknowledgments I thank Itsumi Ohmori and Sayaka skin barrier function in netherton syndrome through
Katahira-Tayama for their technical assistance. I thank filaggrin and lipid misprocessing. J Clin Invest
Keiko Mizuno and Kaoru Orihashi for critical reading of the 120(3):871882. doi:41440 [pii] 10.1172/JCI41440
manuscript. I thank Drs. Masayuki Amagai, Akiharu Kubo, 9. Brown SJ, McLean WH (2009) Eczema genetics: cur-
Jun Kudoh and Kenichi Miyamoto (Keio University) and rent state of knowledge and future goals. J Invest
Dr. Johji Inazawa (Tokyo Medical and Dental University) Dermatol 129:543552
for supporting this project and Mr. Yoshihiko Tsuda (Davinci 10. Brown SJ, McLean WH (2012) One remarkable mole-
Medical Illustration Office) for illustration of figures. I also cule: filaggrin. J Invest Dermatol 132(3 Pt 2):751762
thank KAN Research Insitute Inc. for provising materials. 11. Candi E, Schmidt R, Melino G (2005) The cornified enve-
This work was supported by a Grant-in-Aid for Scientific lope: a model of cell death in the skin. Nat Rev Mol Cell
Research to Takeshi Matsui, Program for Improvement of Biol 6(4):328340. doi:nrm1619 [pii] 10.1038/nrm1619
Research Environment for Young Researchers from the 12. Candi E, Tarcsa E, Digiovanna JJ, Compton JG, Elias
Ministry of Education, Culture, Sports, Science and PM, Marekov LN, Steinert PM (1998) A highly con-
Technology (MEXT) of Japan to Takeshi Matsui, research served lysine residue on the head domain of type II
grants from the Nakatomi Foundation, the Cosmetology keratins is essential for the attachment of keratin inter-
Research Foundation, and the Naito Foundation to Takeshi mediate filaments to the cornified cell envelope
Matsui, and Health and Labour Sciences Research Grants through isopeptide crosslinking by transglutaminases.
for Research on Allergic Diseases and Immunology from Proc Natl Acad Sci USA 95(5):20672072
the Ministry of Health, Labour, and Welfare. 13. Dale BA, Holbrook KA, Steinert PM (1978) Assembly
of stratum corneum basic protein and keratin fila-
ments in macrofibrils. Nature 276(5689):729731
14. Dale BA, Resing KA, Haydock PV (1990) Filaggrins.
References In: Goldman RD, Steinert PM (eds) Cellular and
molecular biology of intermediate filaments, 1st edn.
1. Alibardi L (2003) Adaptation to the land: the skin of Plenum Press, New York, London, pp 393412
reptiles in comparison to that of amphibians and endo- 15. Dale BA, Resing KA, Lonsdale-Eccles JD (1985)
therm amniotes. J Exp Zool B Mol Dev Evol Filaggrin: a keratin filament associated protein. Ann
298(1):1241. doi:10.1002/jez.b.24 N Y Acad Sci 455:330342
2. Barker JN, Palmer CN, Zhao Y et al (2007) Null 16. Darke PL (1994) Stability of dimeric retroviral pro-
mutations in the filaggrin gene (FLG) determine major teases. Methods Enzymol 241:104127
susceptibility to early-onset atopic dermatitis that per- 17. Denecker G, Hoste E, Gilbert B, Hochepied T, Ovaere
sists into adulthood. J Invest Dermatol 127:564567 P, Lippens S, Van den Broecke C, Van Damme P,
3. Barnes KC (2010) An update on the genetics of DHerde K, Hachem JP, Borgonie G, Presland RB,
atopic dermatitis: scratching the surface in 2009. Schoonjans L, Libert C, Vandekerckhove J, Gevaert
J Allergy Clin Immunol 125(1):1629 e1111; quiz K, Vandenabeele P, Declercq W (2007) Caspase-14
3011. doi:S00916749(09)017229 [pii] 10.1016/j. protects against epidermal UVB photodamage and
jaci.2009.11.008 water loss. Nat Cell Biol 9(6):666674. doi:ncb1597
4. Bernard D, Mehul B, Thomas-Collignon A, Delattre [pii] 10.1038/ncb1597
C, Donovan M, Schmidt R (2005) Identification and 18. Eckert RL (1989) Structure, function, and differentia-
characterization of a novel retroviral-like aspartic pro- tion of the keratinocyte. Physiol Rev 69(4):13161346
tease specifically expressed in human epidermis. J 19. Eckert RL, Crish JF, Robinson NA (1997) The epider-
Invest Dermatol 125(2):278287. doi:JID23816 [pii] mal keratinocyte as a model for the study of gene
10.1111/j.0022-202X.2005.23816.x regulation and cell differentiation. Physiol Rev 77(2):
5. Barret AJ, Rawlings ND, Woessner JF (eds) (1998) 397424
Handbook of proteolytic enzymes. Academic, San Diego 20. Elias PM, Steinhoff M (2008) Outside-to-inside (and
6. Berry N, Charmeil C, Goujon C, Silvy A, Girard P, now back to outside) pathogenic mechanisms in atopic
Corcuff P, Montastier C (1999) A clinical, biometro- dermatitis. J Invest Dermatol 128:10671070
logical and ultrastructural study of xerotic skin. Int J 21. Engelke M, Jensen JM, Ekanayake-Mudiyanselage S,
Cosmet Sci 21(4):241252. doi:ICS196570 [pii] Proksch E (1997) Effects of xerosis and ageing on epi-
10.1046/j.1467-2494.1999.196570.x dermal proliferation and differentiation. Br J Dermatol
7. Blikstad V, Benachenhou F, Sperber GO, Blomberg J 137(2):219225
(2008) Evolution of human endogenous retroviral 22. Esparza-Gordillo J, Weidinger S, Folster-Holst R et al
sequences: a conceptual account. Cell Mol Life Sci (2009) A common variant on chromosome 11q13 is
65(21):33483365. doi:10.1007/s00018-008-8495-2 associated with atopic dermatitis. Nat Genet 41:
8. Bonnart C, Deraison C, Lacroix M, Uchida Y, Besson 596601
C, Robin A, Briot A, Gonthier M, Lamant L, Dubus P, 23. Fallon PG, Sasaki T, Sandilands A, Campbell LE,
Monsarrat B, Hovnanian A (2010) Elastase 2 is Saunders SP, Mangan NE, Callanan JJ, Kawasaki H,
expressed in human and mouse epidermis and impairs Shiohama A, Kubo A, Sundberg JP, Presland RB,
190 T. Matsui

Fleckman P, Shimizu N, Kudoh J, Irvine AD, Amagai Morita K, Miyachi Y, Tsukita S (2006) Mouse homo-
M, McLean WH (2009) A homozygous frameshift logue of skin-specific retroviral-like aspartic protease
mutation in the mouse Flg gene facilitates enhanced involved in wrinkle formation. J Biol Chem 281(37):
percutaneous allergen priming. Nat Genet 41(5):602 2751227525. doi:M603559200 [pii] 10.1074/jbc.
608. doi:ng.358 [pii] 10.1038/ng.358 M603559200
24. Gruber R, Elias PM, Crumrine D et al (2011) Filaggrin 36. Matsui T, Miyamoto K, Kubo A et al (2011) SASPase
genotype in ichthyosis vulgaris predicts abnormalities regulates stratum corneum hydration through profilag-
in epidermal structure and function. Am J Pathol grin-to-filaggrin processing. EMBO Mol Med 3:
178:22522263 320333
25. Harding CR, Scott IR (1983) Histidine-rich proteins (fil- 37. McGrath JA, Uitto J (2008) The filaggrin story: novel
aggrins): structural and functional heterogeneity during insights into skin-barrier function and disease. Trends
epidermal differentiation. J Mol Biol 170(3):651673 Mol Med 14(1):2027. doi:S1471-4914(07), 00221-3
26. Harding CR, Watkinson A, Rawlings AV, Scott IR [pii] 10.1016/j.molmed.2007.10.006
(2000) Dry skin, moisturization and corneodesmolysis. 38. Mechin MC, Enji M, Nachat R, Chavanas S, Charveron
Int J Cosmet Sci 22:2152 M, Ishida-Yamamoto A, Serre G, Takahara H, Simon
27. Hildenbrand M, Rhiemeier V, Hartenstein B, M (2005) The peptidylarginine deiminases expressed
Lahrmann B, Grabe N, Angel P, Hess J (2010) in human epidermis differ in their substrate specifici-
Impaired skin regeneration and remodeling after cuta- ties and subcellular locations. Cell Mol Life Sci
neous injury and chemically induced hyperplasia in 62(17):19841995. doi:10.1007/s00018-005-5196-y
taps-transgenic mice. J Invest Dermatol 130(7):1922 39. Montagna W, Parakkal PF (1974) The structure and
1930. doi:jid201054 [pii] 10.1038/jid.2010.54 function of skin. Academic Press, Orlando
28. Hoste E, Kemperman P, Devos M, Denecker G, Kezic 40. Morar N, Willis-Owen SA, Moffatt MF, Cookson WO
S, Yau N, Gilbert B, Lippens S, De Groote P, Roelandt (2006) The genetics of atopic dermatitis. J Allergy
R, Van Damme P, Gevaert K, Presland RB, Takahara Clin Immunol 118:2434; quiz 3536
H, Puppels G, Caspers P, Vandenabeele P, Declercq W 41. Nachat R, Mechin MC, Takahara H, Chavanas S,
(2011) Caspase-14 is required for filaggrin degrada- Charveron M, Serre G, Simon M (2005) Peptidylarginine
tion to natural moisturizing factors in the skin. J Invest deiminase isoforms 13 are expressed in the epidermis
Dermatol 131(11):22332241. doi:jid2011153 [pii] and involved in the deimination of K1 and filaggrin. J
10.1038/jid.2011.153 Invest Dermatol 124(2):384393. doi:JID23568 [pii]
29. Ishida-Yamamoto A, Senshu T, Eady RA, Takahashi 10.1111/j.0022-202X.2004.23568.x
H, Shimizu H, Akiyama M, Iizuka H (2002) Sequential 42. Nomura T, Akiyama M, Sandilands A, Nemoto-
reorganization of cornified cell keratin filaments Hasebe I, Sakai K, Nagasaki A, Ota M, Hata H, Evans
involving filaggrin-mediated compaction and keratin AT, Palmer CN, Shimizu H, McLean WH (2008)
1 deimination. J Invest Dermatol 118(2):282287. Specific filaggrin mutations cause ichthyosis vulgaris
doi:1671 [pii] 10.1046/j.0022-202x.2001.01671.x and are significantly associated with atopic dermatitis
30. Kamata Y, Taniguchi A, Yamamoto M, Nomura J, in Japan. J Invest Dermatol 128(6):14361441.
Ishihara K, Takahara H, Hibino T, Takeda A (2009) doi:5701205 [pii] 10.1038/sj.jid.5701205
Neutral cysteine protease bleomycin hydrolase is 43. Norlen L, Al-Amoudi A (2004) Stratum corneum keratin
essential for the breakdown of deiminated filaggrin structure, function, and formation: the cubic rod-packing
into amino acids. J Biol Chem 284(19):1282912836. and membrane templating model. J Invest Dermatol
doi:M807908200 [pii] 10.1074/jbc.M807908200 123(4):715732.doi:10.1111/j.0022-202X.2004.23213.x
31. Krylov DM, Koonin EV (2001) A novel family of pre- JID23213 [pii]
dicted retroviral-like aspartyl proteases with a possible 44. Ovaere P, Lippens S, Vandenabeele P, Declercq W
key role in eukaryotic cell cycle control. Curr Biol (2009) The emerging roles of serine protease cascades
11(15):R584R587. doi:S0960-9822(01), 00357-8 [pii] in the epidermis. Trends Biochem Sci 34(9):453463.
32. Leyvraz C, Charles RP, Rubera I, Guitard M, Rotman doi:S0968-0004(09), 00136-4 [pii] 10.1016/j.tibs.
S, Breiden B, Sandhoff K, Hummler E (2005) The 2009.08.001
epidermal barrier function is dependent on the serine 45. Palmer CN, Irvine AD, Terron-Kwiatkowski A, et al.
protease CAP1/Prss8. J Cell Biol 170(3):487496. (2006) Common loss-of-function variants of the epi-
doi:jcb.200501038 [pii] 10.1083/jcb.200501038 dermal barrier protein filaggrin are a major predispos-
33. List K, Szabo R, Wertz PW, Segre J, Haudenschild ing factor for atopic dermatitis. Nat Genet 38,
CC, Kim SY, Bugge TH (2003) Loss of proteolyti- 441446
cally processed filaggrin caused by epidermal dele- 46. Paternoster L, Standl M, Chen CM et al (2011) Meta-
tion of matriptase/MT-SP1. J Cell Biol 163(4):901910. analysis of genome-wide association studies identifies
doi:10.1083/jcb.200304161 jcb.200304161 [pii] three new risk loci for atopic dermatitis. Nat Genet
34. Lower R, Lower J, Kurth R (1996) The viruses in all 44:187192
of us: characteristics and biological significance of 47. Pearton DJ, Nirunsuksiri W, Rehemtulla A, Lewis SP,
human endogenous retrovirus sequences. Proc Natl Presland RB, Dale BA (2001) Proprotein convertase
Acad Sci USA 93(11):51775184 expression and localization in epidermis: evidence for
35. Matsui T, Kinoshita-Ida Y, Hayashi-Kisumi F, Hata multiple roles and substrates. Exp Dermatol 10(3):
M, Matsubara K, Chiba M, Katahira-Tayama S, 193203. doi:exd100307 [pii]
12 Endogenous Retroviral-Like Aspartic Protease, SASPase as a Key Modulator of Skin Moisturization 191

48. Presland RB, Boggess D, Lewis SP, Hull C, Fleckman function and disease. J Cell Sci 122(Pt 9):12851294.
P, Sundberg JP (2000) Loss of normal profilaggrin doi:122/9/1285 [pii] 10.1242/jcs.033969
and filaggrin in flaky tail (ft/ft) mice: an animal model 63. Sandilands A, Terron-Kwiatkowski A, Hull PR,
for the filaggrin-deficient skin disease ichthyosis vul- ORegan GM, Clayton TH, Watson RM, Carrick T,
garis. J Invest Dermatol 115(6):10721081. doi:jid178 Evans AT, Liao H, Zhao Y, Campbell LE, Schmuth M,
[pii] 10.1046/j.1523-1747.2000.00178.x Gruber R, Janecke AR, Elias PM, van Steensel MA,
49. Presland RB, Rothnagel JA, Lawrence OT (2006) Nagtzaam I, van Geel M, Steijlen PM, Munro CS,
Profilaggrin and the fused S100 family of calcium- Bradley DG, Palmer CN, Smith FJ, McLean WH,
binding proteins. In: Elias PM, Feingold KR (eds) Skin Irvine AD (2007) Comprehensive analysis of the gene
barrier. Taylor & Francis, New York, pp 111140 encoding filaggrin uncovers prevalent and rare muta-
50. Proksch E, Brandner JM, Jensen JM (2008) The skin: an tions in ichthyosis vulgaris and atopic eczema. Nat
indispensable barrier. Exp Dermatol 17(12):10631072 Genet 39(5):650654. doi:ng2020 [pii] 10.1038/
51. Puente XS, Sanchez LM, Overall CM, Lopez-Otin C ng2020
(2003) Human and mouse proteases: a comparative 64. Scharschmidt TC, Man MQ, Hatano Y, Crumrine D,
genomic approach. Nat Rev Genet 4(7):544558. Gunathilake R, Sundberg JP, Silva KA, Mauro TM,
doi:10.1038/nrg1111 nrg1111 [pii] Hupe M, Cho S, Wu Y, Celli A, Schmuth M, Feingold
52. Rao JK, Erickson JW, Wlodawer A (1991) Structural KR, Elias PM (2009) Filaggrin deficiency confers a
and evolutionary relationships between retroviral and paracellular barrier abnormality that reduces inflam-
eucaryotic aspartic proteinases. Biochemistry 30(19): matory thresholds to irritants and haptens. J Allergy
46634671 Clin Immunol 124(3):496506, 506 e491496.
53. Ratner L, Haseltine W, Patarca R, Livak KJ, Starcich doi:S00916749(09)010124 [pii] 10.1016/j.
B, Josephs SF, Doran ER, Rafalski JA, Whitehorn jaci.2009.06.046
EA, Baumeister K et al (1985) Complete nucleotide 65. Sandilands A, Brown SJ, Goh CS et al (2012) Mutations
sequence of the AIDS virus, HTLV-III. Nature in the SASPase gene (ASPRV1) are not associated with
313(6000):277284 atopic eczema or clinically dry skin. J Invest Dermatol.
54. Rawlings AV, Harding CR (2004) Moisturization and doi:10.1038/jid.2011.479
skin barrier function. Dermatol Ther 17(Suppl 1):43 66. Schauber J, Gallo RL (2009) Antimicrobial peptides
48. doi:04S1005 [pii] and the skin immune defense system. J Allergy Clin
55. Rawlings AV, Matts PJ (2005) Stratum corneum mois- Immunol124(3Suppl2):R13R18.doi:S0091-6749(09),
turization at the molecular level: an update in relation to 01124-5 [pii] 10.1016/j.jaci.2009.07.014 http://books.
the dry skin cycle. J Invest Dermatol 124:10991110 google.co.uk/books/about/Cellular_and_molecular_
56. Resing KA, al-Alawi N, Blomquist C, Fleckman P, biology_of_interm.html?id =uYXwAAAAMAAJ&re
Dale BA (1993) Independent regulation of two cyto- dir_esc=y
plasmic processing stages of the intermediate fila- 67. Schempp C, Emde M, Wolfle U (2009) Dermatology in
ment-associated protein filaggrin and role of Ca2+ in the Darwin anniversary. Part 1: evolution of the integu-
the second stage. J Biol Chem 268(33):2513925145 ment. J Dtsch Dermatol Ges 7(9):750757.
57. Resing KA, Johnson RS, Walsh KA (1993) doi:DDG7193 [pii] 10.1111/j.16100387.2009.07193.x
Characterization of protease processing sites during 68. Simpson CL, Patel DM, Green KJ (2011) Deconstructing
conversion of rat profilaggrin to filaggrin. Biochemistry the skin: cytoarchitectural determinants of epidermal
32(38):1003610045 morphogenesis. Nat Rev Mol Cell Biol 12:565580
58. Resing KA, Thulin C, Whiting K, al-Alawi N, Mostad 69. Steinert PM, Marekov LN (1995) The proteins elafin,
S (1995) Characterization of profilaggrin endoprotei- filaggrin, keratin intermediate filaments, loricrin, and
nase 1. A regulated cytoplasmic endoproteinase of small proline-rich proteins 1 and 2 are isodipeptide
epidermis. J Biol Chem 270(47):2819328198 cross-linked components of the human epidermal
59. Resing KA, Walsh KA, Haugen-Scofield J, Dale BA cornified cell envelope. J Biol Chem 270(30):
(1989) Identification of proteolytic cleavage sites in 1770217711
the conversion of profilaggrin to filaggrin in mamma- 70. Stocking C, Kozak CA (2008) Murine endogenous
lian epidermis. J Biol Chem 264(3):18371845 retroviruses. Cell Mol Life Sci 65(21):33833398.
60. Rhiemeier V, Breitenbach U, Richter KH, Gebhardt doi:10.1007/s00018-008-8497-0
C, Vogt I, Hartenstein B, Furstenberger G, Mauch C, 71. Sun LD, Xiao FL, Li Y et al (2011) Genome-wide
Hess J, Angel P (2006) A novel aspartic proteinase- association study identifies two new susceptibility
like gene expressed in stratified epithelia and loci for atopic dermatitis in the Chinese Han popula-
squamous cell carcinoma of the skin. Am J Pathol tion. Nat Genet 43:690694
168(4):13541364. doi:168/4/1354 [pii] 72. Swartzendruber DC, Wertz PW, Madison KC,
61. Rodriguez E, Baurecht H, Herberich E et al (2009) Downing DT (1987) Evidence that the corneocyte has
Meta-analysis of filaggrin polymorphisms in eczema a chemically bound lipid envelope. J Invest Dermatol
and asthma: robust risk factors in atopic disease. 88(6):709713
J Allergy Clin Immunol 123:136170 e7 73. Tang J, Wong RN (1987) Evolution in the structure
62. Sandilands A, Sutherland C, Irvine AD, McLean WH and function of aspartic proteases. J Cell Biochem
(2009) Filaggrin in the frontline: role in skin barrier 33(1):5363. doi:10.1002/jcb.240330106
192 T. Matsui

74. Tarcsa E, Marekov LN, Mei G, Melino G, Lee SC, 77. Watt FM (1989) Terminal differentiation of epidermal
Steinert PM (1996) Protein unfolding by peptidylargi- keratinocytes. Curr Opin Cell Biol 1(6):11071115
nine deiminase. Substrate specificity and structural 78. Wilhelm KP, Cua AB, Maibach HI (1991) Skin aging.
relationships of the natural substrates trichohyalin and Effect on transepidermal water loss, stratum corneum
filaggrin. J Biol Chem 271(48):3070930716 hydration, skin surface pH, and casual sebum content.
75. Thulin CD, Taylor JA, Walsh KA (1996) Arch Dermatol 127(12):18061809
Microheterogeneity of human filaggrin: analysis of a 79. Yamazaki M, Ishidoh K, Suga Y, Saido TC,
complex peptide mixture using mass spectrometry. Protein Kawashima S, Suzuki K, Kominami E, Ogawa H
Sci 5(6):11571164. doi:10.1002/pro.5560050618 (1997) Cytoplasmic processing of human profilaggrin
76. Thulin CD, Walsh KA (1995) Identification of the by active mu-calpain. Biochem Biophys Res Commun
amino terminus of human filaggrin using differential 235(3):652656. doi:S0006-291X(97), 96809-1 [pii]
LC/MS techniques: implications for profilaggrin pro- 10.1006/bbrc.1997.6809
cessing. Biochemistry 34(27):86878692
 Vernix Caseosa and Its Substitutes:
Lipid Composition and 13
Physicochemical Properties

Marty O. Visscher and Steven B. Hoath

13.1 Introduction terminal differentiation, programmed cell death,

and orderly corneocyte incorporation into the
Appropriate moisturization is essential for opti- inner SC with balanced pH-dependent desqua-
mum stratum corneum (SC) function [1, 2]. mation of the outer SC. Overhydration can cause
Among the multiple functions of the skin affected maceration, disruption of the intercellular lipid
by SC water content are desquamation and self- bilayers, degradation of desmosomes and cre-
renewal, restoration of barrier integrity after ation of amorphous regions, corneocyte swelling,
wounding, acid mantle formation, microbial col- and enhanced molecular transport with increased
onization, tactile discrimination, infection con- permeability [46], as well as inflammation, irri-
trol, immunosurveillance, and protection against tation, and urticaria [712]. Low hydration can
ultraviolet light and environmental irritants [3]. cause visible dryness/scaling, aberrant desqua-
Operationally, appropriate hydration may be mation via reduced enzyme activity, cracking,
defined as: that amount of SC water which opti- reduced flexibility, tightness, and itching. On bal-
mizes local SC biomechanics while facilitating ance, the SC water-handling properties must be
sufficiently robust to respond to local, potentially
disruptive forces, for example, friction, heat,
humidity, bathing, clothing, secretions, and topi-
M.O. Visscher, Ph.D. cal product applications [13].
Skin Sciences Program, Cincinnati Childrens Throughout life, the SC must adapt quickly to
Hospital Medical Center, Cincinnati,
OH, USA sudden changes in hydration imposed by open
arid environments, topical occlusion, and immer-
Division of Plastic Surgery, College of Medicine,
University of Cincinnati,Cincinnati, sion in water of varying salinities. In humans,
OH, USA birth marks a sudden transition from a controlled
e-mail: [email protected] aqueous environment to a dry extrauterine state.
S.B. Hoath, M.D. (*) A mature, flexible, relatively impermeable SC is
Skin Sciences Program, Cincinnati Childrens essential to life after birth, and, yet, this structure
Hospital Medical Center, Cincinnati, develops in utero under aqueous conditions in the
OH, USA
amniotic fluid. Recent evidence supports the
Perinatal Institute, Cincinnati Childrens Hospital, notion that epidermal barrier maturation in utero
Medical Center, Cincinnati,
is a function of the direction of nutrient delivery,
OH, USA
i.e., from bottom to top [14]. Structures which
Department of Pediatrics, College of Medicine,
University of Cincinnati, Cincinnati,
influence nutrient and water gradients in utero,
OH, USA therefore, may be important modifiers of fetal
e-mail: [email protected] skin maturation under submerged conditions.

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 193

DOI 10.1007/978-3-642-27606-4_13, Springer-Verlag Berlin Heidelberg 2012
194 M.O. Visscher and S.B. Hoath

Vernix caseosa, from the Greek word for var-

nish and the Latin word for cheese, is defined
as a grayish-white cheese-like substance, con-
sisting of sebaceous gland secretions, lanugo,
and desquamated epithelial cells, that covers the
skin of the fetus and newborn [15]. This chapter
addresses the lipid composition and physico-
chemical properties of vernix caseosa and its sub-
stitutes. Within the theme of skin moisturization,
specific vernix constituents and functions are
closely related to epidermal barrier development
in utero and adaptation after birth. The potential
applications of vernix and synthetic analogs for
Fig. 13.1 Phase contrast image of native vernix showing
the treatment of compromised skin for neonatal, dense packing of fetal corneocytes surrounded by a thin
pediatric, and adult populations are discussed. lipid matrix. The cells are heterogenous in size and struc-
ture. Many nuclear ghosts are evident. Scale bar is shown
in the figure
13.2 Vernix Composition,
Formation, and Impact space as well as discrete waxy material [20].
on Cornication Keratinized cells are present along the hair folli-
cle and the interfollicular spaces around week
Vernix is a complex mixture of 80% water, 10% 23.5, and the periderm disappears around this
protein, and 10% lipid fractions, consisting pri- time [20]. During fetal (human and animal)
marily of cornified cells embedded in an amor- development, the barrier forms around the hair
phous lipid matrix [1618]. The remarkably high follicle beginning at 1819 gestational weeks and
water content is associated with, i.e., packaged along the hair canal by week 21 [21]. Interfollicular
within, the cellular component. The densely development occurs in a programmatic fashion,
packed, flattened cells are differentiated corneo- initially at week 23 on the head and week 25 on
cytes with cell envelopes approximately 12 mm the abdomen. This folliculocentric pattern of
thick which lack distinct nuclei and have lower organized intrauterine epidermal maturation sup-
keratin levels than fully mature stratum corneum ports an important role for the hair follicle in bar-
cells (Fig. 13.1) [17]. There is no evidence of cor- rier formation.
neodesmosomes or distinct cellular organization. Of note, vernix can be observed around the
Ultrastructural evaluation shows the individual eyebrows as early as gestational week 17. During
cells in vernix to be variable with respect to the the last trimester, vernix begins to coat the fetal
stage of keratinization [19]. skin surface from head to toe and back to front,
An understanding of the potential roles of presumably under hormonal control. In one form
vernix in neonatal development begins with con- of this working hypothesis, corticotropin-releas-
sideration of fetal skin formation. In an elegant ing factors (CRF) from either the placenta or
electron microscopy investigation, Holbrook and hypothalamus initiate adrenocorticotropic hor-
Odland showed eight distinct stages of fetal epi- mone (ACTH) release from the pituitary gland.
dermal differentiation from approximately ACTH adrenal gland stimulation promotes syn-
526 weeks gestation occurring under the influ- thesis and release of androgenic steroids (e.g.,
ence of the periderm (Fig. 13.2) [20]. The perid- dehydroepiandrosterone) which are converted to
erm appears to protect the developing epidermis active androgens within the sebaceous gland.
from amniotic fluid and to manage secretory pro- More recent data support the hypothesis of a local
cesses such as the uptake of glucose. By 20 weeks hypothalamic-pituitary-adrenal-like axis in the
(stage 7), keratin-containing squames and follic- hair follicle itself [22]. Concordant with this
ular regions appear within the interfollicular hypothesis, vernix lipids include types produced
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 195

1 2 3

4 5 6

7 8

Fig. 13.2 Schematic diagram of the eight stages of periderm (6) 95120 days, (7) 110160 days, and (8) >160 days.
development and epidermal differentiation. Corresponding Vernix production corresponds to the loss of periderm and
estimated gestation ages for each stage are (1) <36 days, (2) the transition from stage 7 to stage 8 (Modified from
3555 days, (3) 5575 days, (4) 6595 days, (5) 85110 days, Holbrook and Odland [20])

by the sebaceous glands [18, 23], and the corni- mechanisms involving increased DNA and lipid
fied fetal cells may originate from the hair folli- synthesis. The asymmetric submerged culture
cles, analogous to the production of terminally model of Thakoersing et al. is consistent with this
differentiated infundibular keratinocytes in acne hypothesis [14].
[24]. In this scenario, vernix is extruded or
squeezed out through the hair shaft and onto the
interfollicular epidermis, eventually spreading 13.3 Vernix Lipid Composition
over the entire surface as production continues and Structural Organization
throughout gestation [25]. The superficial vernix
film is hydrophobic due to the lipids which coat Vernix contains both free lipids and lipids bound
the hydrated cells [26]. During gestation, vernix to corneocytes. The components of free lip-
presumably protects the underlying epidermis ids include sterol esters, wax esters, dihydroxy
from exposure to water [26]. Normal stratum cor- wax esters, squalene, triglycerides, diacylglyc-
neum has a water gradient with higher levels in erol, monoacylglycerol, phospholipids, choles-
the lower layers and reduced hydration toward terol, fatty acids, and ceramides [18, 35]. The
the surface [2729]. Repair of superficial SC bound lipids in vernix include w-hydroxy acids
wounds is regulated by the transepidermal water (bound to corneocyte envelope), fatty acids,
gradient via increased synthesis of DNA and lip- w-hydroxyceramides CerA (sphingosine), and
ids [3033]. Vernix films are semipermeable to CerB (6-hydroxysphingosine) [18].
water vapor transport ex utero [34]. Presumably, Early work on vernix lipid composition
fetal epidermis has a high water flux potential focused on the free lipid component containing
driven by osmotic gradients since cornification is both squalene and triglycerides [23, 3638], sup-
not complete. Therefore, vernix may impose a porting the conjecture that vernix was, in part, of
semiregulated barrier and/or physiological gradi- sebaceous origin. Rissmann et al. analyzed the
ent for transepidermal water and nutrients free lipid fraction from vernix samples derived
in utero, thereby facilitating cornification via from term infants by high-performance thin-layer
196 M.O. Visscher and S.B. Hoath

Fig. 13.3 (a) Comparison a 45

of total lipids in vernix 40 Vernix
caseosa and stratum Stratum Corneum
corneum (Adapted from 35

Total Lipids % (wt)

Rissmann et al. [18]). (b) 30
Comparison of different
25
classes of ceramides in
vernix caseosa and stratum 20
corneum (Adapted from 15
Rissmann et al. [18])
10
5
0
squalene SEWE diol chol sulfate FFA triglycerides cer chol sulfate

b 30
Vernix
Stratum Corneum
25
Total Ceramides % (wt)

20

15

10

0
EOS NS EOP NP EOH AS/NH AP AH

chromatography (Fig. 13.3) [18]. Approximately dominant polyunsaturated fatty acid is C18:2n-6
11% of the total weight of vernix is comprised of (9.6%) [35]. Branched-chains account for 29% of
lipids with nonpolar lipids predominating. As the fatty acids and include 30 different chain
opposed to native SC wherein barrier lipids such lengths, from 11 to 26 carbons (Fig. 13.4) [40]. In
as cholesterol, free fatty acids, and ceramides contrast, SC fatty acids are straight-chained and
constitute 80% of total lipids, these lipid classes generally 22 or 24 carbons [41]. Ran-Ressler
represent only 10% of total lipids in vernix. et al. investigated branched-chain fatty acids
Nonpolar lipids are the major components of (BCFA) in vernix in relation to meconium in the
vernix. fetal gut [40]. They found a reduction of BCFA in
More recent analyses have shed light on the meconium and speculated that BCFA in vernix,
highly complex lipid species present in vernix swallowed by the fetus, was absorbed or modi-
including branched-chain fatty acids and lipids fied within the healthy term gastrointestinal tract,
bound to the cornified cell envelope [16, 18, 35, thus playing a putative nutritional, adaptive, or
39, 40]. The free fatty acid component of vernix anti-infective role. BCFA are known membrane
is particularly complex and includes oleic, lino- constituents of many commensal bacteria, includ-
leic, long-chain species between 14 and 32 car- ing lactobacilli, which are considered probiotic
bons long, and branched-chain types (Tables 13.1 candidates promoting colonization of the GI tract
and 13.2) [18, 40]. The FFA profile is dominated [42, 43]. Tollin et al. observed that free fatty acids
by saturated chain lengths C16:0 (14%) and in vernix exhibit antibacterial activity [35].
C24:0 (24.5%). The predominant monounsatu- Both vernix and stratum corneum exhibit
rated fatty acid is C18:lin-9 (6.4%), and the pre- structures consisting of hydrophilic corneocytes
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 197

Table 13.1 Composition of free fatty acids in vernix A major difference between vernix and SC is
caseosa [35] the lack of corneodesmosal linkages in the for-
Species %, weight/weight mer. Corneocytes in vernix are therefore amena-
Saturated fatty acids 50.1 ble to shear force application and can be spread
C14:0 2.0 on a flat surface (Fig. 13.1). Despite the lack of
C15:0 1.0 desmosomes, vernix does contain bound lipids
C16:0 14.0 covalently linked to the cornified envelope. After
C17:0 0.4
saponification and extraction, these lipids consti-
C18:0 2.0
tute approximately 1% of the total vernix weight
C20:0 0.8
[18]. In general, vernix-bound lipids are the
C22:0 5.4
C24:0 24.5
same as those found in the SC, i.e., fatty acids,
Monounsaturated fatty acids 11.4
w-hydroxy acids, w-hydroxyceramides CerA
C16:ln-9 2.0 (sphingosine), and CerB (6-hydroxysphingosine)
C16:ln-7 1.3 [47]. Compared to SC, however, vernix has
C18:ln-9 6.4 higher levels of w-hydroxyeicosanoic acid and
C18:ln-7 1.7 nearly absent levels of w-hydroxyacid with
Polyunsaturated fatty acids 15.0 30 C-atoms [18].
C18:2n-6 9.6
C20:2n-6 1.3
C22:4n-6 4.1 13.4 Comparison: Epidermal
Unidentified fatty acids 23.0 Lipids and Vernix Lipids

Table 13.2 Profile of total fatty acid classes in vernix

During fetal development, the epidermal lipid
caseosa from term infants composition is relatively constant from gesta-
Species %, weight/weight
tional week 8 through 16 [48]. By week 19, the
Saturated fatty acids 34.0
fraction of sterol esters and wax esters is substan-
Monounsaturated fatty acids 31.0 tially higher with an increase in epidermal trig-
Polyunsaturated fatty acids 3.9 lycerides. Interestingly, sterol esters/wax esters
Branched-chain fatty acids 29.1 (SEWE) are the largest fraction of vernix lipids,
Data adapted from Ran-Ressler et al. [40] followed by triglycerides [18]. The presence of
epidermal SEWE is an indicator of fetal cornifi-
embedded in a hydrophobic lipid matrix; there cation [48, 49]. An examination of the epidermal
are important architectural differences. Vernix is lipids from fetal samples of 1417 and
a malleable cream which can be spread manually 2028 weeks gestation compared with samples
over the skin surface or detached in bulk into the from full terms (n = 1) and adults showed a
amniotic fluid [44]. In SC, the free lipids consist marked difference in the sterol ester/wax ester
primarily of cholesterol, free fatty acids, and fraction between the 1417- and 2028-week
ceramides which form a tightly organized lamel- groups [50]. Additionally, fatty acids were lower
lar pattern with repeat distances of 6 and 13 nm and ceramides increased, although the compari-
[45, 46]. Presumably, these alternative struc- son is limited by only one sample from a 38-week
tures reflect important physiological differences. infant. Interestingly, the triglyceride level was
Rissmann et al. have proposed that the lower lev- much higher in vernix than any other epidermal
els of ceramides with long fatty acid chains in or SC sample. The high triglyceride and SEWE
vernix coupled with the high proportion of unsat- fractions in vernix likely reflect the contribution
urated or branched fatty acids may lead to the of sebaceous lipids which are dominated by
more fluid, nonlamellar organization seen in triglyceride (41%) and SEWE (27%) [51].
vernix [18]. They note that the majority of lipids Cholesterol levels were much higher in fetal and
in SC have straight unsaturated fatty acid chains. infant epidermis compared to adults and vernix
198 M.O. Visscher and S.B. Hoath

Fig. 13.4 Branched-chain a

fatty acids in vernix caseosa

Anteiso Branched Chain Fatty

5
(Adapted from RanRessler
4.5
et al. [40]). (a) Anteiso 4

Acids % (w/w)
branched-chain fatty acids. (b) 3.5
Iso branched-chain fatty acids. 3
(c). Dimethyl branched-chain 2.5
fatty acids 2
1.5
1
0.5
0
13:0 15:0 17:0 21:0 25:0
carbon chain length
b 5
Iso Branched Chain Fatty Acids

4.5
4
3.5
3
% (w/w)

2.5
2
1.5
1
0.5
0
12:0 13:0 14:0 15:0 16:0 18:0 18:1 20:0 22:0 24:0 25:0
c carbon chain length
Dimethyl Branched Chain Fatty Acids

5
4.5
4
3.5
3
% (w/w)

2.5
2
1.5
1
0.5
0
9:0 10:0 11:0 11:0 12:0 13:0 14:0 14:0 15:0 15:0
4,7 4,8 4,8 4,9 4,10 4,11 4,12 4,10 4,11 4,13
carbon chain length - Methyl Positions (italics)

[18]. Free fatty acid levels were considerably the vernix lipid composition as a function of gesta-
higher in all fetal, neonatal, and infant samples tional age among infants of 3140 weeks gestation
compared to vernix. [52]. The cholesterol/squalene ratio decreases
Given that the composition of epidermal lipids around 36 weeks GA, i.e., it is higher for premature
changes during gestation, it is possible that the infants and lower at term. This change reflected an
composition of vernix also changes throughout the increase in squalene content relative to other vernix
last trimester as the infant prepares to transition to lipids, indicating a possible surge in fetal sebaceous
the dry environment. To date, there is one report on gland function near the time of delivery.
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 199

0.8 100
Average wet to dry
0.6 PLM 80 weight ratio = 4.24
Survanta
O.D.at 650 nm

Weight %
0.4 50

0.2 40

0.0 20

0.2
0 20 40 60 80 100 120 0
Wet weight Dry weight
Phospholipid concentration (g/ml)
Fig. 13.6 Wet weight and dry weight of fresh native
Fig. 13.5 Increase in solution turbidity arising from vernix caseosa prior to dehydration postnatally. The ratio
vernix-coated microfuge tubes following incubation over- of the average wet-to-dry weight dose is shown [54]
night with increasing concentrations of the bovine pulmo-
nary surfactant Survanta [53]. Incubation with an
equimolar phospholipid mixture not containing surfactant energy measurements show vernix to be unwetta-
proteins had no effect. This in vitro experiment is consis- ble, suggesting that it forms a hydrophobic coating
tent with an effect of pulmonary surfactant to induce for the developing infant with water-proofing
vernix detachment from the fetal skin surface, thereby effects to exogenous water and materials of high
giving rise to amniotic fluid turbidity seen in the last tri-
mester of human pregnancy [53] critical surface tension [26].

13.5.1 Water Content

13.5 Vernix: Physical Properties
Vernix specimens have a remarkably high and
The lipid-coated, high-water-containing cellular consistent water content of approximately
architecture of vernix gives rise to interesting physi- 80.7 2.2% [54]. In determining the water con-
cal and water-handling properties. Rheological tent of vernix, care must be taken to prevent con-
measurements indicate a much higher shear rate densation of water on the inner surface of the
(flow) at body temperature than at ambient (room storage container. Ex utero studies of isolated
temperature) conditions, consistent with vernix vernix corneocytes demonstrate that these cells
spreading and coating the fetal skin surface in utero, can swell and contract as a function of a
while becoming increasingly viscous and immobile hypoosmotic or hyperosmotic environment
following birth [53]. The addition of native, protein- [55], supporting a potential role for vernix in
containing pulmonary surfactant to vernix increases osmoregulation intra-amniotically. Of theoreti-
its flow and ability to spread, an effect which does cal interest, the wet to dry weight ratio of vernix,
not occur with phospholipids alone [53] (Fig. 13.5). i.e., 4.24 (Fig. 13.6), is indistinguishable from the
As the fetal lungs mature, increasing amounts of cube of the golden section ratio (phi), i.e., 1.61803
pulmonary surfactant are secreted into the amniotic [55]. Bulienkov has postulated that water struc-
fluid. Hypothetically, as term approaches, the quan- tures found in self-organizing biological sys-
tity is sufficient to detach vernix from the skin sur- tems are a power function of phi [56]. Based on
face thereby increasing the turbidity of the amniotic empirical data, phi proportionality figures promi-
fluid (which is used as an indirect indicator of lung nently into the cellular organization of the human
maturity) (Fig. 13.4). Surface tension measurements epidermis [57]. The proposition that synthetic
indicate that vernix has a critical surface tension of vernix-based analogs and skin creams based on
39 dyne/cm which is comparable to that of petrola- phi-proportional water structures might synergize
tum (100% lipid) and much lower than water, particularly well with human epidermis has not
despite its high water content [26]. Surface free been rigorously tested.
200 M.O. Visscher and S.B. Hoath

Fig. 13.7 Dehydration 100

kinetics of vernix caseosa
compared to a typical 90
oil-in-water emulsion over
80
3 h [17, 59]
70

60

% Water
Vernix
50
Oil-in-Water Emulsion
40

30

20
Amount = 3 mg/cm2
10

0
0 20 40 60 80 100 120 140 160 180 200
Time (minutes)

Whereas most of the water content in vernix is the vernix films and thicker films lose water more
localized to the intracorneocyte region, several slowly [60]. The water behavior of native vernix
studies have noted apparent hydrated domains in and isolated vernix corneocytes (lipid removed)
the nonlamellar lipid matrix [17, 18]. Thus, cryo- has been quantified by measuring the water sorp-
SEM shows small round structures within the tion and desorption over varying (high to low)
lipid domains which may represent water drop- water activities [54]. At equilibrium, the vernix
lets. The origin and function of these structures water content decreases with decreasing water
remain unclear, but they may represent a pool of activity (relative humidity) and regains water as
rapidly releasable extracorneocyte water [54]. the humidity is increased again. This behavior
Larger, hydrated inclusion bodies containing suggests the presence of an internal, structured
antimicrobial peptides such as lysozyme and lac- microenvironment responsible for the water-
toferrin have been described by Akinbi et al. [58]. binding properties. The behavior of vernix at low
The larger size of the inclusions in the latter study humidity is comparable to that of native stratum
may result from process-induced coalescence. corneum indicating a small, constant amount of
The presence of a quick release pool of soluble bound water [54]. As humidity increases, the
antimicrobials would be a major benefit for the cells swell to expose more water-binding sites,
fetus faced with chorioamnionitis or other intra- thereby increasing the water content. When the
uterine infection. This physicochemical hypoth- lipid fraction was removed, the water sorption/
esis has not yet been tested. desorption profile differed from that of native
vernix especially between water activities of 0.64
and 0.75, i.e., before the normal inflection point
13.5.2 Water Binding for water binding, suggesting that the lipid com-
ponent is important for the normative sorption
Despite a high (80%) water content, vernix films desorption behavior of vernix (Fig. 13.8) [54].
lose water slowly compared to standard water-in-
oil emulsions and display first order kinetics con-
sistent with a biphasic release process (Fig. 13.7) 13.5.3 Water Vapor Transport
[17, 59, 60]. Complete water loss may take days,
depending upon environmental conditions. The Water vapor transport (WVT) of vernix films in vitro
rate of water loss depends upon the thickness of was measured quantitatively by application of
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 201

a superficial SC damage with semipermeable films

Native vernix
100
results in more rapid barrier recovery than dam-
aged skin treated with either complete occlusion
Desorption
80 (no water vapor transport) or no occlusion [62].
Sorption
The water vapor transport results suggest that
60
vernix films may promote the formation of the
stratum corneum in premature infants and the
W

40
barrier repair process in damaged skin.
20

0
13.5.4 Skin Cleansing
0.0 0.2 0.4 0.6 0.8 1.0
aw The effectiveness of native vernix as a skin
b cleanser was evaluated following application of
Vernix corneocytes a simulated soil (uniform carbon particles) to
100
adult volar forearm skin [63]. Vernix was compa-
Sorption
80 rable to or superior to standard skin cleansers.
Desorption
Visualization of the skin dermatoglyphics in
60
high-resolution images suggests that vernix inter-
colates or penetrates into skin furrows, pores, and
W

40
around the hair shaft to remove the soil. This
20 effect is most likely due to the compatability of
vernix with cutaneous lipids and an expected tro-
0
pism to follicular pores [21, 64]. These results are
consistent with vernix as both a naturally occur-
0.0 0.2 0.4 0.6 0.8 1.0
ring emollient (moisturizer) and a skin cleanser.
aw

Fig. 13.8 Equilibrium water sorptiondesorption behav-

ior from Tansirikongkol et al. [54]. (a) Native vernix 13.6 Vernix: Biochemical Properties
(n = 4) and (b) isolated vernix corneocytes (n = 6) expressed
as weight % water in the tissue (mean SD) versus water Multiple other biological functions have been
activity. Key: () Sorption experiment, () Desorption
experiment. Equilibrium water content within all test demonstrated or proposed for vernix [55]. They
materials is water activity dependent are discussed in the following sections.

vernix to a highly porous membrane over 13.6.1 Antimicrobial/Anti-infective

water with equilibration at room temperature. Agents
Gravimetric measurements were made at multi-
ple intervals to derive the rate of water loss. Water Vernix contains antimicrobial agents, including
vapor transport measurements indicate that vernix proteins and lipids, and exhibits a range of bioac-
films are semipermeable, with transmission rates tivity against common fungal and bacterial patho-
of 1970 g/m2/h, depending upon thickness gens [35, 58, 65, 66]. The protein human
(19 for 5 mg/cm2 and 70 for 0.5 mg/cm2) [59, 60]. cathelicidin (hCAP18) is part of the cutaneous
Petrolatum-based films have low water vapor innate immune system with antimicrobial proper-
transport, i.e., 1.5 g/m2/h for films of 2 mg/cm2, ties and protection against keratinocyte apoptosis
indicating that they are almost fully occlusive attributed to the 37 amino acids in the C-terminal
compared with vernix films (at 2 mg/cm2) that portion, known as LL-37 [67]. Vernix from full-
have a WVT of 45 g/m2/h [61]. Treatment of term infants contains lysozyme and LL-37, the
202 M.O. Visscher and S.B. Hoath

latter of which had antimicrobial activity against arm skin (2.5 mg/cm2) significantly increased the
B. megaterium Bm11 (gram-positive) [65]. A water-holding capacity (WHC) versus an
second study on vernix and amniotic fluid from untreated control (p < 0.05) [69]. In contrast,
healthy infants showed activity to Bm11 and to treatment with a water-in-oil cream (Eucerin),
C. albicans [66]. The antimicrobial proteins an anhydrous barrier (petrolatum), and a low-
a-defensins (HNP13), lysozyme, and LL-37 water cream (Aquaphor) did not differ in WHC
were identified. Two other peptides, ubiquitin from untreated skin. The water-binding capacity
and psoriasin, were in the lysozyme-containing (peak sorption following application of exoge-
fraction, so their antimicrobial activity could not nous water) of vernix-treated skin was signifi-
be differentiated. A series of proteonomic and cantly higher than the untreated control, while
fractionation experiments identified five addi- values for Eucerin, petrolatum, and aquaphor
tional proteins of the innate immune system, i.e., were significantly lower. Along with baseline
calgranulin A, B, and C; cystatin A; and UGRP-1 hydration and moisture accumulation rate, these
[35]. The antimicrobial efficacy of 88 vernix measures show a unique temporal change in skin
samples against B. megaterium, group B hydration which is different from common topi-
Streptococcus, C. albicans, and E. coli was great- cal treatments.
est for B. megaterium and group B. Streptococcus The provision of skin hydration for the new-
[35]. All of the vernix samples inhibited B. mega- born infant is of interest. Within minutes to hours
terium and C. albicans; 78% inhibited group B after birth, newborn skin hydration varies with
strep; and 31% were active against E. coli. body site (chest, back, forehead) and time under
Combinations of vernix lipids and LL-37 in ratios the radiant warmer [70]. Hydration decreases
of 3:1 and 7:1 displayed greater antimicrobial rapidly in the first day and then increases during
inhibition than LL-37 alone, indicating syner- the first 2 weeks, in contrast to mothers skin
getic innate immunity for the mixtures. In another where hydration is relatively constant. Water-
study, the antimicrobial proteins lactoferrin, binding capacity increases over this period as
lysozyme, secretory leukocyte protease inhibitor, well, suggesting adaptive changes to the postna-
and human neutrophil peptides 13 were found tal environment [71]. Newborn skin is signifi-
in vernix from healthy full-term births [58]. cantly drier than the skin of their mothers and
Vernix samples had muramidase activity and older infants (1, 2, and 6 months) [72]. In various
were active against the growth of group B settings worldwide, vernix is removed immedi-
Streptococcus, L. monocytogenes, and K. pneu- ately after birth. Visscher et al. examined the
moniae. However, these samples did not contain effect of vernix retention at birth by comparing
detectable levels of human beta defensin-2, lac- parallel groups of healthy full-term newborns. In
toperoxidase, or LL-37. Ceramides, sterols, and one group, vernix was wiped off immediately at
fatty acids on the SC surface inhibit attachment delivery following common local hospital prac-
of C. albicans in vitro [68]. These lipid compo- tices at the time. In the second group, vernix was
nents of vernix left on the skin surface after birth retained on the skin and allowed to rub in natu-
may also serve the same function. rally. Vernix retention led to significantly higher
skin hydration at birth and 24 h later (p < 0.05)
[73]. Vernix-treated skin was significantly less
13.6.2 Skin Hydration/Moisturization erythematous versus skin for which vernix
removed. In another study among healthy full-
The high water content, the slow water release term newborn infants, vernix was removed at
from the cellular component, and the resorption delivery and saved. Following delivery, a small
of water suggest that vernix might function as an area on the chest was treated with alcohol
ideal skin moisturizer, i.e., to promote hydration to remove residual vernix. A sample of vernix
for optimum stratum corneum function. was then reapplied to one side of the chest. The
Application of native vernix to adult volar fore- alcohol-treated contralateral site was used as the
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 203

control. The water-handling behavior was evalu- synthesis, and desquamation [75, 76], as well as
ated 24 h later, and no additional treatments (e.g., bacterial homeostasis, skin colonization, and
bathing, lotions) were applied. The vernix-treated inhibition of pathogenic bacteria [7779]. At
site had a significantly higher water-holding birth, the pH of full-term skin following vernix
capacity than the control site. removal is relatively neutral, decreases signifi-
To further probe the cause of low skin hydra- cantly during the first 14 days, and continues to
tion at birth, the levels of free amino acids (FAA) drop during the first 3 months as the enzymes
were determined [74]. Free amino acids are needed to generate acidic components are acti-
water-binding moieties that constitute about 40% vated [71, 80, 81]. Topical treatment of the SC
of natural moisturizing factor in the upper SC. In with PPARa activators increases the rate of skin
the absence of vernix, FAA levels were extremely pH lowering after birth in neonatal animals, dem-
low at birth, increased over the first month but onstrating that the adaptive mechanisms can be
remained markedly lower than typical adult quan- influenced with exogenous materials [82].
tities [74]. The FAA levels in newborn skin were Acidification of the SC enhances its integrity and
also examined as a function of vernix treatment cohesion, in part by improving lipid processing
with the hypothesis that FAA would be higher and decreasing corneodesmosomal degradation
following vernix retention after birth. Vernix [83] as well as improving SC barrier homeostasis
itself contains FAA at levels corresponding to in neonatal and aged skin [84]. The application of
about 0.3 mmol/cm2 which may account in part acidic treatments has been proposed as a method
for the slow water release and water resorption. for treating inflammation and normalizing SC
The relative amounts of histidine and glutamic structure and function [83].
acid in vernix were higher than expected from
filaggrin proteolysis alone, indicating that vernix
may contain other sources of soluble amino acids 13.6.4 Lipids and SC Barrier
[74]. Vernix retention led to higher levels of FAA
24 h after birth (p < 0.05). The three most abun- The lipid components of vernix may facilitate SC
dant FAAs, i.e., glycine, serine, and glutaminic barrier development in utero or as a topical treat-
acid (p < 0.005), as well as arginine (p = 0.05) ment for underdeveloped skin, for example, pre-
and citrulline (p = 0.03), were significantly higher mature infants. Fatty acids, particularly linoleic
for VC-retained samples. FAAs at 24 h paral- acid, activate peroxisome proliferator-activated
leled the higher SC hydration. The results sug- receptor-a (PPARa) which increases the rate of
gest another adaptive function of vernix, namely barrier formation [85]. Linoleic acid has anti-
to provide water-binding FAAs to plasticize the inflammatory properties [86]. The postnatal
skin before the longer-term adaptive epidermal application of linoleic-containing sunflower seed
changes and subsequent increased SC hydration oil to the skin of premature infants less than
have occurred [71, 74]. 33 weeks gestational age reduced the incidence
of nosocomial blood infections by 41% [87].
Treatment of tape-stripped skin with SC lipids
13.6.3 Skin Surface Acidity increases the barrier repair rate [88]. The cer-
amide component of the treatment, i.e., the type
In a study of the effect of vernix retention versus and ratio of ceramides to other lipid classes, influ-
removal at birth, the skin surface acidity was sig- ences the barrier properties in SC model systems
nificantly lower in the vernix-retained group at [89]. A mixture of physiological barrier lipids,
birth and 24 h later, suggesting that vernix assists viz., cholesterol, ceramide, palmitate, and
in the development of the acid mantle [73]. An linoleate (ratio 3:1:1:1), is optimum for barrier
acid surface is necessary for the effective func- repair [90]. Future studies on the effects and fate
tioning of enzymes in SC formation and integrity, of vernix components for premature SC matura-
i.e., lipid metabolism, bilayer structure, ceramide tion are warranted.
204 M.O. Visscher and S.B. Hoath

13.6.4.1 Physical Barrier Neonates <28 weeks gestation lack significant

The juxtaposition of vernix between the fetal skin vernix caseosa. The potential effects of vernix on
surface and the amniotic fluid suggests that it skin barrier maturation for restoration of SC
functions as a physical barrier and perhaps regu- compromise in premature infants and for epider-
lates the transport of in utero agents either by mal wound healing are of interest. The relevance
keeping them away from the developing skin, fil- for premature infants can be determined by inves-
tering desirable substances to the skin surface, or tigating the effects using animal models, for
by sequestering epidermal products from loss in example, removal of SC to simulate premature
the amniotic fluid. Exposure of the nascent stra- skin possessing only a few cornified layers, and
tum corneum to chymotrypsin enzyme and other using tape-stripped human adult skin to replicate
protease or lipase agents in amniotic fluid, for superficial wounds. Lower extremity wounds
example, could have deleterious effects on the improved following treatment with vernix [103].
skin. Meconium (fetal stool) is commonly passed Vernix may also serve as a natural wound healing
prenatally and is particularly noxious if aspirated agent for the maternal perineum at birth [55].
by the fetus. Neutralization or binding of meco-
nium by vernix would be advantageous. 13.6.5.2 Animal and Human Studies
Tansirikongkol et al. evaluated the effect of vernix In the hairless mouse model, one application of
in vitro on the penetration of exogenous chy- vernix (5 mg/cm2) increased the rate of barrier
motrypsin. Films of vernix provided a protective relative to no treatment following complete
barrier impeding the penetration of the exogenous removal of the SC via tape stripping [104]. A
chymotrypsin [91]. This effect was due to petrolatum-based treatment also accelerated bar-
mechanical obstruction and not to enzyme inhibi- rier repair, but the skin was more erythematous,
tion. Hypothetically, vernix in vivo protects and the epidermis was thickened compared to
against penetration of exogenous proteolytic vernix-treated skin (Fig. 13.9a, b). In the murine
enzymes while facilitating production and/or tape-stripped model, native vernix elicits epider-
localization of endogenous materials involved in mal cornification within 26 h, suggesting that
normal cornification and desquamation. Vernix the effects of vernix on epidermal cornification
may also act as a sump mechanism clearing the may be very rapid [104].
amniotic fluid of unwanted hydrophilic or hydro- In the Yorkshire hybrid minipig, minor epider-
phobic agents passed in the fetal urine. Vernix mal wounds were made with a dual-mode
has been reported to bind bile pigments and bili- erbium:YAG laser at nominal depths of 20 and
rubin in vitro [92]. 25 mm. Five sites at each level were treated twice
a day with 2.5 mg/cm2 of vernix caseosa or a
petrolatum-based cream (Aquaphor, Beiersdorf
AG, Hamburg, Germany). Untreated (no occlu-
13.6.5 Skin Barrier Maturation, SC sion) sites served as controls [105]. TEWL values
Compromise, Wound Healing after wounding and prior to treatment ranged
from 29 to 50 g/m2/h, comparable to values for
13.6.5.1 Signicance infants <30 weeks gestation [106]. Vernix and the
Premature infants have an incompetent SC bar- petrolatum-based treatment produced signifi-
rier, leading to problems with fluid balance, tem- cantly greater barrier repair than the untreated, no
perature control, infection, and skin damage [93, occlusion site for both ablation levels.
94]. The premature SC is functionally compro- In a human trial, tape-stripped maternal volar
mised for several weeks after birth [95], and esti- forearm skin (a common model for premature
mates of the time to complete barrier maturation skin) was used to compare the effects of vernix,
vary from 2 to 9 postnatal weeks [9699]. a petrolatum-based cream (Aquaphor), and an
Attempts to improve barrier function with topical oil-in-water cream (Hand Medic, GOJO
treatments have had limited success [100102]. Industries, Inc., Akron, OH, USA) on the rate of
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 205

Fig. 13.9 (a). Rapid a 100

recovery of barrier function Untreated
measured as return of 90 Vaseline

Percent Barrier Recovery (%)

transepidermal water loss to Vernix
80
baseline levels following
epidermal damage due to 70
tape stripping. Vernix
60
treatment was superior to
Vaseline (petrolatum) 50
compared to control results.
(b). Increase in epidermal 40
thickening observed in 30
untreated epidermis and
following Vaseline applica- 20
tion in the tape-stripped 10
murine mouse model.
* Indicates significant 0
0 10 25 50 75 100 125 150 175 200
difference versus untreated
skin (p < 0.05), # indicates Time in hours
significant difference versus b 100 undamaged
Vaseline treatment (p < 0.05) untreated
(Data modified and adapted 90
vaseline
from Oudshoorn et al. [112]) 80 varnix caseosa
Epidermal Thickness (m)

70

60

50

40 #
*
30
* *
20

10
0
recovery day 3 recovery day 8

SC barrier repair, skin hydration, erythema, and vernix than the oil-in-water cream. The initial
dryness [105]. Vernix and the creams were hydration for vernix-treated skin was direction-
applied twice daily at 2.5 mg/cm2. The vernix ally higher than NO. These findings suggest that
was from each mothers own infant to address the SC recovering with vernix may be more
potential safety issues posed by human-derived hydrated than with the oil-in-water cream or no
materials. Additional stripped sites were treated occlusion. Skin dryness was higher for the pet-
with full occlusion (FO, impermeable to water rolatum treatment than no occlusion and direc-
vapor); a semipermeable film (SP) and no occlu- tionally higher for the petrolatum treatment
sion (NO) were controls for comparison with compared to vernix and the oil-in-water cream,
previous work [62, 107]. The semipermeable suggesting a difference in desquamation and/or
film produced more rapid barrier recovery than hyperproliferation among them. Overall, the
FO and NO, consistent with previous findings. findings suggest that vernix-based topical
Barrier recovery was greater for vernix than FO creams may be effective for the treatment of
and similar for the petrolatum-based cream, the epidermal wounds and show promise to aug-
oil-in-water cream, and no occlusion. The mois- ment SC repair and maturation in infants [105,
ture accumulation rate tended to be higher for 108, 109].
206 M.O. Visscher and S.B. Hoath

13.7 Vernix Substitutes: Synthetic Table 13.3 Lipid mixture used to formulate synthetic
Analogs vernix [111]
Lipid Amount (%)
It is not feasible to topically apply vernix from Sterol ester/wax ester 48.0
one infant to another or to anyone other than the Triglycerides
infants mother due to the limitations on the use Trinervonin 11.9
of human-derived materials. Therefore, there is a Tripalmitolein 11.9
Triolein 11.9
need to formulate topical creams based on native
Cholesterol 3.5
vernix caseosa as a prototype. Formulation of
Fatty acids
high-water-phase emulsions with lipid mixtures
Palmitic 0.8
resulted in several stable creams with high water
Palmitoleic 0.3
content and slow water release [34]. Preparations Steric 0.1
with vernix-like lipids demonstrated water release Oleic 0.3
profiles closer to the native vernix benchmark Ceramides
than those with conventional lipids. In addition, EOS 0.7
the water vapor transport rates were in the range NS 1.0
to facilitate barrier repair [34]. NP (C24) 0.4
Lipid mixtures, based on the composition of NP (C16) 0.4
native vernix lipids, were formulated and evalu- AS 0.8
ated for their effects on stratum corneum barrier AP 1.6
formation in the tape-stripped hairless mouse Squalene 6.4
model [110]. Triglycerides, cholesterol, fatty
acids, ceramides, and squalene were combined
with sterol esters and wax esters isolated from presence of lipid particle coating (with, without),
lanolin in order to include the branched-chain vernix lipids only (no particles), and vernix lipids
component of the native vernix lipid matrix [110]. (no hydrated component) minus barrier lipids
The formulas that matched the thermal and struc- (i.e., sterol esters/wax esters, squalene, triglycer-
tural properties of native vernix were evaluated ides) (Table 13.4) [112]. The synthetic versions
for effect on barrier repair. The synthetic lipid were compared to native vernix, a petrolatum
mixtures were comparable to native vernix and cream (Vaseline), and a water-in-oil emulsion
provided increased barrier repair versus a petro- (Eucerin) at a single application dose of 5 mg/cm2.
latum treatment [110]. Their efficacy for SC barrier repair was evaluated
Synthetic vernix formulations were made with with multiple measures including evaluation of
microgels of hyperbranched polyglycerol glyci- barrier recovery rate (measured as TEWL) at spe-
dyl methacrylate to simulate the water-containing cific time points, epidermal thickness, and ery-
cells in vernix [111]. In some formulations, the thema and crust formation (measures of quality
hydrated particles were coated with lipids to more of recovering SC). The findings are summarized
closely simulate the native vernix structure. The as follows (Table 13.5) [112]. Overall, the for-
lipid fraction was constituted as shown in mula (B1) with microgel particles, 50% initial
Table 13.3. The formula with lipid-coated micro- water content, a particle-to-lipid ratio of 2:1, and
gel particles in a ratio of 2:1 particles/lipid had an a lipid mixture based on vernix (i.e., including
experimental water level of 57% and most closely barrier lipids) resulted in SC barrier repair com-
resembled the water release profile of native parable to that of native vernix [112]. This
vernix [111]. formulation produced no erythema or crust
In further work, Oudshoorn et al. examined formation early in the recovery period and did
the following effects of synthetic formulations not cause epidermal thickening. In contrast, for-
on SC barrier recovery in the hairless mouse: mulas with a higher microgel particle-to-lipid
hydrated particle/lipid ratio (2:1 and 5:1), ratio (5:1) resulted in a thickened epidermis at
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 207

Table 13.4 Synthetic vernix formulations used in evaluation of SC barrier recovery [112]
Particle/lipid Formulated Initial water
Code Lipids ratio Lipid coated water level (%) release profile
L1 Lipid mixture only n/a n/a n/a n/a
(Table 13.3)
L2 Lipids without barrier n/a n/a n/a n/a
lipids (cholesterol, fatty
acid, ceramide)
B1 L1 2:1 n/a 50
B1c L1 2:1 Coated 50
B2c L1 2:1 Coated 80
B4 L1 5:1 n/a 80 Greater than
B1, B1c, B2

day 3 and intermediate erythema and crust for- Vernix has been implicated in the establishment
mation over time. The formulas containing only of the high electrical resistance of fetal skin dur-
the lipid component (L1) showed comparable SC ing the last trimester of pregnancy [113]. In ani-
repair to B1, and therefore native vernix, except mals with barrier compromise (via tape stripping),
for a markedly thickened SC at 3 h. The lipid for- vernix enhances SC formation without increasing
mulation without cholesterol, fatty acids, and epidermal thickness [104]. Vernix functions as a
ceramides was not as effective for SC repair. natural moisturizing agent [54, 69] and as a skin
Results of treatment with a higher dose, 15 mg/cm2, cleanser [63], although it is often viewed as a soil
for B1 were comparable to those of the lower itself [63]. In vitro measurements indicate a low
dose. Both formula B1 and the vernix-lipid-only surface energy for vernix, suggesting that it cre-
treatment resulted in faster SC repair than petro- ates a protective hydrophobic layer around the
latum (Vaseline) from 8 h after initial application. fetus [26]. Vernix contains multiple cytokines
Barrier repair was slower than with native vernix such as IL1a, IL1b, TNFa, IL-6, IL-8, and MCP1
and was complete 150 h after treatment with the [44]. The role of these cytokines is the subject of
water-in-oil system (Eucerin). For SC barrier future investigations, but the association of spe-
repair, the permeable lipid-based systems, i.e., cific antimicrobials with hydrated granules within
synthetic formulations with hydrated moieties, vernix supports a mechanism for quick release
the physiological lipid mixture (L1), and native in the presence of chorioamnionitis [58]. Vernix
vernix, were more effective than occlusive treat- contains cholesterol, ceramides, and a number of
ments (i.e., petrolatum) [112]. fatty acids (including oleic, linoleic, and long-
chain species) [18, 35]. Fatty acids, particularly
linoleic, activate peroxisome proliferator-acti-
13.8 Summary vated receptor-a (PPARa) which increases the
rate of barrier formation [85]. Linoleic acid has
Vernix caseosa has multiple physical and biologi- anti-inflammatory properties [86]. Overall, vernix
cal functions [55]. It contains lysozyme, lactofer- facilitates development of the stratum corneum
rin, and other microbials with demonstrated protective barrier in the normal, full-term infant
anti-infective properties [35, 58, 65, 66]. Films of through a variety of protective and adaptive
vernix in vitro impede penetration of the exoge- mechanisms. These functions, coupled with its
nous enzyme chymotrypsin (found in meconium) anti-infective properties, are essential for a pre-
[91] and, hypothetically, serves to establish epi- mature infant who may not have exposure to
dermal-amniotic fluid gradients of water, nutri- vernix in utero. The findings provide support for
ents, and electrolytes necessary for normal inside/ the practice of vernix retention (rather than
outside architecture and barrier formation [14]. removal) at birth. The World Health Organization
 208

Table 13.5 Effects of synthetic vernix formulations on SC barrier repair and histological properties [112]
Erythema and crust Epidermal thickness Stratum corneum barrier recoverya
Code (Table 13.4) Initial Over time Day 3 Day 8 Initial <3 h 375 h 100 h 150 h
B1 None Slight Normal skin, no Normal skin, no Similar to native Similar to native Faster than native
thickening, similar thickening VC VC VC, complete
to native VC
B1c Slight Slight Similar to native Slower than native Same as native
VC VC VC
B2c Slight Slight Thicker by 4 vs. Normal skin, Similar to native Slower than native Same as native
untreated skin no thickening VC VC VC, complete
B4 Slight Intermediate Thicker by 4 vs. Normal skin, More rapid than Complete
untreated skin no thickening B1, B2
L1 None Slight Very thickened SC Normal skin, Similar to B1c, Similar to B1,
no thickening B2c vernix
L2 Slight Slight Thickened vs. L1 Normal skin, Delayed vs. L2, B1 Delayed vs. L2 B1 Complete
Very thin SC no thickening
Petrolatum Slight Slight Thicker by 2.5 vs. Similar to damaged, Low TEWL (3 g/ Delayed vs. native Delayed vs. native Complete
(Vaseline) untreated skin untreated skin m2/h) due to VC TEWL ~ pre- VC
occlusion treatment at 4 h
Water in oil Slight Slight Thicker by 2.5 vs. Similar to damaged, Delayed vs. native Delayed vs. native Delayed vs. native Complete
(Eucerinb) untreated skin untreated skin VC VC VC
a
Tape-stripped, untreated skin required 200 h for complete SC recovery
b
Water content ~50%
M.O. Visscher and S.B. Hoath
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 209

recommends that vernix be left in place and that

caregivers wait for at least 6 h prior to bathing The very premature infant is deprived of
newborn infants [114]. the benefits of vernix in utero, and treat-
ments based on vernix biology may pro-
tect them from vulnerabilities including
Take Home Messages delayed barrier maturation, delayed acid
Vernix caseosa is a naturally occurring, mantle formation, infection, and water
uniquely human fetal skin cream which loss.
exhibits multiple positive physical and The demonstrated properties of vernix
biological functions during the last tri- caseosa support retention at birth. The
mester of gestation. In conjunction with World Health Organization recommends
pulmonary surfactant, vernix detaches retention and delay of bathing for at
from the skin surface and is swallowed least 6 h after birth.
by the fetus. Vernix retained on the skin Vernix substitutes have been success-
surface aides in the transition to a dry, fully formulated with stratum corneum
microbe-laden environment after birth. barrier repair rates and water release
Vernix is a complex mixture of proteins profiles comparable to native vernix.
and lipids with a highly conserved water The effects of some of these formula-
content present primarily within fetal tions on SC barrier repair have been
corneocytes surrounded by an amor- demonstrated. An important next step is
phous lipid matrix. The composition to evaluate these systems in trials in pre-
and structure of vernix confer water mature infants to determine effects on
handling and rheological properties that SC barrier maturation and infection con-
differ from typical oil-in-water or water- trol and in pediatric and adult patients
in-oil topical skin creams. with SC barrier compromise, epidermal
Vernix is putatively produced under hor- wounds, and dry skin.
monal control by coextrusion of seba-
ceous secretions and cells from the hair
follicle onto the fetal skin surface first
around the hair shaft and then spreading References
onto the interfollicular areas.
Vernix contains antimicrobial agents, 1. Blank IH (1952) Factors which influence the water con-
including proteins and lipids, and exhib- tent of the stratum corneum. J Invest Dermatol
its a range of bioactivity against com- 18:433440
2. Gloor M, Bettinger J, Gehring W (1998) Modification
mon fungal and bacterial pathogens. of stratum corneum quality by glycerin-containing
The moisturization effects of vernix on external ointments. Hautarzt 49(1):69
normal skin, both adults and infants 3. Rawlings AK, Leyden JJ (eds) (2009) Skin moistur-
after birth, may be due to its slow water ization, 2nd edn. Informa Healthcare, New York
4. Warner RR et al (1999) Water disrupts stratum cor-
release and the presence of the free neum lipid lamellae: damage is similar to surfactants.
amino acid component of natural mois- J Invest Dermatol 113(6):960966
turizing factor. 5. Warner RR, Stone KJ, Boissy YL (2003) Hydration
Vernix-based topical treatments may be disrupts human stratum corneum ultrastructure. J
Invest Dermatol 120(2):275284
effective for the treatment of epidermal 6. Zimmerer RE, Lawson KD, Calvert CJ (1986) The
wounds, for the repair of SC compro- effects of wearing diapers on skin. Pediatr Dermatol
mise, and to facilitate maturation of an 3(2):95101
effective SC barrier in premature 7. Halkier-Sorensen, Petersen BH, Thestrup-Pedersen K
(1995) Epidemiology of occupational skin diseases in
infants. Denmark: notification, recognition and compensation.
In: Van der Valk PGM, Maibach HI (eds) The irritant
210 M.O. Visscher and S.B. Hoath

contact dermatitis syndrome. CRC Press, Boca Raton, 25. Hardman MJ, Sisi P, Banbury DN, Byrne C (1998)
pp 2352 Patterned acquisition of skin barrier function during
8. Hurkmans JF, Bodde HE, Van Driel LM, Van Doorne development. Development 125(8):15411552
H, Junginger HE (1985) Skin irritation caused by 26. Youssef W, Wickett RR, Hoath SB (2001) Surface
transdermal drug delivery systems during long-term free energy characterization of vernix caseosa.
(5 days) application. Br J Dermatol 112(4):461467 Potential role in waterproofing the newborn infant.
9. Kligman AM (1996) Hydration injury to human skin. Skin Res Technol 7(1):1017
In: van der Valk P, Maibach H (eds) The irritant con- 27. Caspers PJ, Lucassen GW, Puppels GJ (2003)
tact dermatitis syndrome. CRC Press, Boca Raton, pp Combined in vivo confocal Raman spectroscopy and
187194 confocal microscopy of human skin. Biophys J
10. Medeiros M Jr (1996) Aquagenic urticaria. J Investig 85(1):572580
Allergol Clin Immunol 6(1):6364 28. Verdier-Sevrain S, Bonte F (2007) Skin hydration: a
11. Rustemeyer T, Frosch PJ (1996) Occupational skin review on its molecular mechanisms. J Cosmet
diseases in dental laboratory technicians. (I). Clinical Dermatol 6(2):7582
picture and causative factors. Contact Dermatitis 29. Warner RR, Myers MC, Taylor DA (1988) Electron
34(2):125133 probe analysis of human skin: determination of the
12. Willis I (1973) The effects of prolonged water expo- water concentration profile. J Invest Dermatol
sure on human skin. J Invest Dermatol 60:166171 90(2):218224
13. Visscher MO, Chatterjee R, Ebel JP, LaRuffa AA, 30. Denda M et al (1998) Exposure to a dry environment
Hoath SB (2002) Biomedical assessment and instru- enhances epidermal permeability barrier function. J
mental evaluation of healthy infant skin. Pediatr Invest Dermatol 111(5):858863
Dermatol 19(6):473481 31. Denda M, Sato J, Tsuchiya T, Elias PM, Feingold KR
14. Thakoersing VS, Ponec M, Bouwstra JA (2010) (1998) Low humidity stimulates epidermal DNA syn-
Generation of human skin equivalents under sub- thesis and amplifies the hyperproliferative response to
merged conditions-mimicking the in utero environ- barrier disruption: implication for seasonal exacerba-
ment. Tissue Eng Part A 16(4):14331441 tions of inflammatory dermatoses. J Invest Dermatol
15. Anonymous (2009) Mosbys medical dictionary. 111(5):873878
Elsevier, Amsterdam, Netherlands 32. Fluhr JW, Lazzerini S, Distante F, Gloor M, Berardesca
16. Hoeger PH et al (2002) Epidermal barrier lipids in E (1999) Effects of prolonged occlusion on stratum
human vernix caseosa: corresponding ceramide pat- corneum barrier function and water holding capacity.
tern in vernix and fetal skin. Br J Dermatol 146(2): Skin Pharmacol Appl Skin Physiol 12(4):193198
194201 33. Proksch E, Feingold KR, Man MQ, Elias PM (1991)
17. Pickens WL, Warner RR, Boissy YL, Boissy RE, Barrier function regulates epidermal DNA synthesis. J
Hoath SB (2000) Characterization of vernix caseosa: Clin Invest 87(5):16681673
water content, morphology, and elemental analysis. J 34. Tansirikongkol A, Visscher MO, Wickett RR (2007)
Invest Dermatol 115(5):875881 Water-handling properties of vernix caseosa and a
18. Rissmann R et al (2006) New insights into ultrastruc- synthetic analogue. J Cosmet Sci 58(6):651662
ture, lipid composition and organization of vernix 35. Tollin M et al (2005) Vernix caseosa as a multi-com-
caseosa. J Invest Dermatol 126(8):18231833 ponent defence system based on polypeptides, lipids
19. Agorastos T, Hollweg G, Grussendorf EI, Papaloucas and their interactions. Cell Mol Life Sci 62(1920):
A (1988) Features of vernix caseosa cells. Am J 23902399
Perinatol 5(3):253259 36. Fu HC, Nicolaides N (1969) The structure of alkane
20. Holbrook KA, Odland GF (1975) The fine structure of diols of diesters in vernix caseosa lipids. Lipids
developing human epidermis: light, scanning, and 4(2):170175
transmission electron microscopy of the periderm. J 37. Haahti E, Nikkari T, Salmi AM, Laaksonen AL (1961)
Invest Dermatol 65(1):1638 Fatty acids of vernix caseosa. Scand J Clin Lab Invest
21. Hardman MJ, Moore L, Ferguson MW, Byrne C 13:7073
(1999) Barrier formation in the human fetus is pat- 38. Kaerkkaeinen J, Nikkari T, Ruponen S, Haahti E
terned. J Invest Dermatol 113(6):11061113 (1965) Lipids of vernix caseosa. J Invest Dermatol
22. Ito N et al (2005) Human hair follicles display a func- 44:333338
tional equivalent of the hypothalamic-pituitary-adre- 39. Hauff S, Vetter W (2010) Exploring the fatty acids of
nal axis and synthesize cortisol. FASEB J 19(10): vernix caseosa in form of their methyl esters by off-
13321334 line coupling of non-aqueous reversed phase high per-
23. Nicolaides N, Fu HC, Ansari MN, Rice GR (1972) formance liquid chromatography and gas
The fatty acids of wax esters and sterol esters from chromatography coupled to mass spectrometry. J
vernix caseosa and from human skin surface lipid. Chromatogr A 1217(52):82708278
Lipids 7(8):506517 40. Ran-Ressler RR, Devapatla S, Lawrence P, Brenna JT
24. Kurokawa I et al (2009) New developments in our (2008) Branched chain fatty acids are constituents of
understanding of acne pathogenesis and treatment. the normal healthy newborn gastrointestinal tract.
Exp Dermatol 18(10):821832 Pediatr Res 64(6):605609
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 211

41. Wertz PW (2006) Biochemistry of human stratum 59. Gunt H (2002) Water handling properties of vernix
corneum lipids. In: Elias P, Feingold K (eds) Skin bar- caseosa. University of Cincinnati, Cincinnati
rier. Taylor & Francis, New York, pp 3342 60. Tansirikongkol A (2006) Development of a synthetic
42. Huang HY et al (2007) Basic characteristics of sporo- vernix equivalent, and its water handling and barrier
lactobacillus inulinus BCRC 14647 for potential pro- protective properties in comparison with vernix
biotic properties. Curr Microbiol 54(5):396404 caseosa. PhD, University of Cincinnati, Cincinnati
43. Veerkamp JH (1971) Fatty acid composition of bifido- 61. Visscher M, Narendran V, Joseph W, Gunt H, Hoath S
bacterium and lactobacillus strains. J Bacteriol (2002) Development of topical eqidermal barriers for
108(2):861867 preterm infant skin: comparison of aquaphor and
44. Narendran V, Visscher MO, Abril I, Hendrix SW, vernix caseosa. Pediatric Academic Society Annual
Hoath SB (2010) Biomarkers of epidermal innate Meeting, May 4-7, Baltimore, MD, USA
immunity in premature and full-term infants. Pediatr 62. Visscher M, Hoath SB, Conroy E, Wickett RR (2001)
Res 67(4):382386 Effect of semipermeable membranes on skin barrier
45. Bouwstra JA et al (1996) Phase behavior of isolated repair following tape stripping. Arch Dermatol Res
skin lipids. J Lipid Res 37(5):9991011 293(10):491499
46. Bouwstra JA et al (1991) Structural investigations of 63. Moraille R, Pickens WL, Visscher MO, Hoath SB
human stratum corneum by small-angle X-ray scatter- (2005) A novel role for vernix caseosa as a skin
ing: phase behavior of isolated skin lipids. J Invest cleanser. Biol Neonate 87(1):814
Dermatol 97(6):10051012 64. Hashimoto K (1970) The ultrastructure of the skin of
47. Swartzendruber DC, Wertz PW, Madison KC, human embryos. IX. Formation of the hair cone and
Downing DT (1987) Evidence that the corneocyte has intraepidermal hair canal. Arch Klin Exp Dermatol
a chemically bound lipid envelope. J Invest Dermatol 238(4):333345
88(6):709713 65. Marchini G et al (2002) The newborn infant is pro-
48. Williams ML, Hincenbergs M, Holbrook KA (1988) tected by an innate antimicrobial barrier: peptide anti-
Skin lipid content during early fetal development. J biotics are present in the skin and vernix caseosa. Br J
Invest Dermatol 91(3):263268 Dermatol 147(6):11271134
49. Freinkel RK, Fiedler-Weiss V (1974) Esterification of 66. Yoshio H et al (2003) Antimicrobial polypeptides of
sterols during differentiation and cornification of human vernix caseosa and amniotic fluid: implica-
developing rat epidermis. J Invest Dermatol tions for newborn innate defense. Pediatr Res 53(2):
62(4):458462 211216
50. Tachi M, Iwamori M (2008) Mass spectrometric char- 67. Bouzari N, Kim N, Kirsner RS (2009) Defense of the
acterization of cholesterol esters and wax esters in skin with LL-37. J Invest Dermatol 129:814
epidermis of fetal, adult and keloidal human skin. Exp 68. Law S, Fotos PG, Wertz PW (1997) Skin surface lip-
Dermatol 17(4):318323 ids inhibit adherence of candida albicans to stratum
51. Downing DT, Strauss JS, Pochi PE (1969) Variability corneum. Dermatology 195(3):220223
in the chemical composition of human skin surface 69. Bautista MI, Wickett RR, Visscher MO, Pickens WL,
lipids. J Invest Dermatol 53(5):322327 Hoath SB (2000) Characterization of vernix caseosa
52. Wysocki SJ, Grauaug A, ONeill G, Hahnel R (1981) as a natural biofilm: comparison to standard oil-based
Lipids in forehead vernix from newborn infants. Biol ointments. Pediatr Dermatol 17(4):253260
Neonate 39(56):300304 70. Visscher M, Maganti S, Munson KA, Bare DE, Hoath
53. Narendran V, Pickens W, Wickett R, Hoath S (2000) SB (1999) Early adaptation of human skin following
Interaction between pulmonary surfactant and vernix: birth: a biophysical assessment. Skin Res Technol
a potential mechanism for induction of amniotic fluid 5:213220
turbidity. Pediatr Res 48(1):120124 71. Visscher MO, Chatterjee R, Munson KA, Pickens
54. Tansirikongkol A, Hoath SB, Pickens WL, Visscher WL, Hoath SB (2000) Changes in diapered and non-
MO, Wickett RR (2008) Equilibrium water content in diapered infant skin over the first month of life. Pediatr
native vernix and its cellular component. J Pharm Sci Dermatol 17(1):4551
97(2):985994 72. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC
55. Hoath SB, Pickens WL, Visscher MO (2006) The (2008) Barrier function and water-holding and trans-
biology of vernix caseosa. Int J Cosmet Sci 28(5): port properties of infant stratum corneum are different
319333 from adult and continue to develop through the first
56. Bulienkov NA (2003) The role of system-forming year of life. J Invest Dermatol 128(7):17281736
modular water structures in self-organization of bio- 73. Visscher MO et al (2005) Vernix caseosa in neonatal
logical systems. J Mol Liquids 106(23):257275 adaptation. J Perinatol 25(7):440446
57. Hoath SB, Leahy DG (2003) The organization of 74. Visscher MO et al (2011) Neonatal skin maturation-
human epidermis: functional epidermal units and phi vernix caseosa and free amino acids. Pediatr Dermatol
proportionality. J Invest Dermatol 121(6):14401446 28(2):122132
58.Akinbi HT, Narendran V, Pass AK, Markart P, Hoath SB 75. Schmid-Wendtner MH, Korting HC (2006) The pH of
(2004) Host defense proteins in vernix caseosa and amni- the skin surface and its impact on the barrier function.
otic fluid. Am J Obstet Gynecol 191(6):20902096 Skin Pharmacol Physiol 19(6):296302
212 M.O. Visscher and S.B. Hoath

76. Rippke F, Schreiner V, Schwanitz HJ (2002) The 91. Tansirikongkol A, Wickett RR, Visscher MO, Hoath
acidic milieu of the horny layer: new findings on the SB (2007) Effect of vernix caseosa on the penetra-
physiology and pathophysiology of skin pH. Am J tion of chymotryptic enzyme: potential role in epi-
Clin Dermatol 3(4):261272 dermal barrier development. Pediatr Res
77. Aly R, Shirley C, Cunico B, Maibach HI (1978) Effect 62(1):4953
of prolonged occlusion on the microbial flora, pH, 92. Narendran V, Pickens WL, Visscher MO, Alla SK,
carbon dioxide and transepidermal water loss on Hoath SB (2010) Binding of unconjugated bilirubin
human skin. J Invest Dermatol 71(6):378381 to human epidermis and vernix caseosa: the physio-
78. Puhvel SM, Reisner RM, Amirian DA (1975) logical basis of jaundice. Society for Pediatric
Quantification of bacteria in isolated pilosebaceous Research, May 1-4, Vancouver, Canada
follicles in normal skin. J Invest Dermatol 93. Hoath S, Narendran V (2000) Adhesives and emol-
65(6):525531 lients in newborn care. Semin Neonatol 5(289296)
79. Fluhr JW et al (2001) Generation of free fatty acids 94. Rutter N (1996) The immature skin. Eur J Pediatr
from phospholipids regulates stratum corneum acidifi- 155(Suppl 2):S18S20
cation and integrity. J Invest Dermatol 117(1):4451 95. Darmstadt GL, Dinulos JG (2000) Neonatal skin
80. Hoeger PH, Enzmann CC (2002) Skin physiology of care. Pediatr Clin North Am 47(4):757782
the neonate and young infant: a prospective study of 96. Agren J, Sjors G, Sedin G (1998) Transepidermal
functional skin parameters during early infancy. water loss in infants born at 24 and 25 weeks of ges-
Pediatr Dermatol 19(3):256262 tation. Acta Paediatr 87(11):11851190
81. Yosipovitch G, Maayan-Metzger A, Merlob P, Sirota 97. Harpin VA, Rutter N (1983) Barrier properties of the
L (2000) Skin barrier properties in different body newborn infants skin. J Pediatr 102(3):419425
areas in neonates. Pediatrics 106(1 Pt 1):105108 98. Kalia YN, Nonato LB, Lund CH, Guy RH (1998)
82. Fluhr JW et al (2009) Topical peroxisome proliferator Development of skin barrier function in premature
activated receptor activators accelerate postnatal stra- infants. J Invest Dermatol 111(2):320326
tum corneum acidification. J Invest Dermatol 99. Nonato LB, Lund CH, Kalia YN, Guy RH (2000)
129:365374, Epub 2008 Aug 14 Transepidermal water loss in 24 and 25 weeks gesta-
83. Hachem JP et al (2010) Acute acidification of stratum tional age infants. Acta Paediatr 89(6):747748
corneum membrane domains using polyhydroxyl 100. Edwards WH, Conner JM, Soll RF (2004) The effect
acids improves lipid processing and inhibits degrada- of prophylactic ointment therapy on nosocomial sep-
tion of corneodesmosomes. J Invest Dermatol sis rates and skin integrity in infants with birth weights
130(2):500510 of 501 to 1000 g. Pediatrics 113(5):11951203
84. Hatano Y et al (2009) Maintenance of an acidic stra- 101. Nopper AJ et al (1996) Topical ointment therapy
tum corneum prevents emergence of murine atopic benefits premature infants. J Pediatr 128(5 Pt 1):
dermatitis. J Invest Dermatol 129(7):18241835 660669
85. Darmstadt GL et al (2002) Impact of topical oils on 102. Pabst RC, Starr KP, Qaiyumi S, Schwalbe RS,
the skin barrier: possible implications for neonatal Gewolb IH (1999) The effect of application of aqua-
health in developing countries. Acta Paediatr phor on skin condition, fluid requirements, and bac-
91(5):546554 terial colonization in very low birth weight infants.
86. Schurer NY (2002) Implementation of fatty acid car- J Perinatol 19(4):278283
riers to skin irritation and the epidermal barrier. 103. Zhukov BN, Neverova EI, Nikitin KE, Kostiaev VE,
Contact Dermatitis 47(4):199205 Myshentsev PN (1992) A comparative evaluation of
87. Darmstadt GL et al (2005) Effect of topical treatment the use of vernix caseosa and solcoseryl in treating
with skin barrier-enhancing emollients on nosocomial patients with trophic ulcers of the lower extremities.
infections in preterm infants in Bangladesh: a ran- Vestn Khir Im I I Grek 148(6):339341
domised controlled trial. Lancet 365(9464):10391045 104. Oudshoorn MH et al (2009) Development of a murine
88. Yang L, Mao-Qiang M, Taljebini M, Elias PM, model to evaluate the effect of vernix caseosa on skin
Feingold KR (1995) Topical stratum corneum lipids barrier recovery. Exp Dermatol 18(2):178184
accelerate barrier repair after tape stripping, solvent 105. Visscher MO, Barai N, LaRuffa AA, Pickens WL,
treatment and some but not all types of detergent Narendran V, Hoath SB (2011) Epidermal barrier
treatment. Br J Dermatol 133(5):679685 treatments based on vernix caseosa. Skin Pharmacol
89. Kessner D, Ruettinger A, Kiselev MA, Wartewig S, Physiol 24:322329
Neubert RH (2008) Properties of ceramides and their 106. Sedin G, Hammarlund K, Stromberg B (1983)
impact on the stratum corneum structure. Part 2: Transepidermal water loss in full-term and pre-term
Stratum corneum lipid model systems. Skin Pharmacol infants. Acta Paediatr Scand Suppl 305:2731
Physiol 21(2):5874 107. Visscher M, Robinson M, Wickett R (2011) Stratum
90. Elias PM, Mao-Qiang M, Thornfeldt CR, Feingold corneum free amino acids following barrier pertur-
KR (1999) The epidermal permeability barrier: effects bation and repair. Int J Cosmet Sci 33(1):8089
of physiologic and non-physiologic lipids. In: Hoppe 108. Barai N (2005) Effect of vernix caseosa on epidermal
U (ed) The lanolin book. Beiersdorf AG, Hamburg, pp barrier maturation and repair: implications in wound
253279 healing. PhD, University of Cincinnati, Cincinnati
13 Vernix Caseosa and Its Substitutes: Lipid Composition and Physicochemical Properties 213

109. Oudshoorn MH et al (2009) Development of a 112. Oudshoorn MH et al (2009) Effect of synthetic

murine model to evaluate the effect of vernix caseosa vernix biofilms on barrier recovery of damaged
on skin barrier recovery. Exp Dermatol 18(2): mouse skin. Exp Dermatol 18:695703
178184 113. Wakai R, Lengle J, Leuthold A (2000) Transmission
110. Rissmann R et al (2008) Lanolin-derived lipid mix- of electric and magnetic foetal cardiac signals in a
tures mimic closely the lipid composition and orga- case of ectopia cordis: the dominant role of the
nization of vernix caseosa lipids. Biochim Biophys vernix caseosa. Phys Med Biol 45(7):19891995
Acta 1778(10):23502360 114. Anonymous (2009) Newborn care until the first
111. Rissmann R et al (2009) Mimicking vernix caseosa week of life. World Health Organization, Geneva,
preparation and characterization of synthetic bio- Switzerland
films. Int J Pharm 372(12):5965
 The Role of Tight Junctions
and Aquaporins in Skin Dryness 14
J.M. Brandner

14.1 Introduction The concentration profile of water in the epi-

dermis is very characteristic. While water con-
The water content of the stratum corneum (SC) tent in the viable epidermis is high (up to 70%),
and the viable layers of the epidermis have a it distinctly decreases at the border between stra-
major influence on physical properties and tum granulosum (SG) and SC (1535% water)
appearance of the skin. Adequate water supply (for review see [110]). Water transport through
is necessary for enzymatic processes which are, the epidermis can occur transcellular, i.e. through
e.g. required for normal desquamation and bar- the cells, e.g. via aquaporins (AQPs), and para-
rier formation/maintenance. Further, SC hydra- cellular, i.e. through the extracellular space,
tion also seems to fulfil a biosensor function, as which is controlled by tight junctions (TJs)
it appears to be directly linked to epidermal (Figs. 14.1 and 14.2). Of note, AQPs are only
hyperplasia and inflammation [20, 71]. To present in the living cell layers with a (slight)
obtain optimal water content, water uptake into decrease of the main AQP, AQP3, in the SG, and
the epidermis, water (and solute) transport barrier-forming TJs are only found in the SG.
through the epidermis, water binding in the SC This hints for a role of these proteins/structures
and the transepidermal water loss (TEWL) have in formation of the water gradient and therefore
to be orchestrated. Imbalance results in rough- of skin hydration. Several experimental data
ness, scaling, flaking and dryness of the skin. strengthen this hypothesis as will be shown in
Reduced SC hydration is found in several skin the following sections.
diseases, including psoriasis, atopic dermatitis,
eczema, hereditary ichthyosis as well as in
senile xerosis and UV-exposed skin (for review 14.2 Aquaporins
see [110]).
AQPs are six-membrane spanning transmem-
brane proteins with a molecular weight of ca.
30 kDa. They are thought to form tetramers in the
membrane with independently functioning pores
[28, 109]. In mammalian, the family of aqua-
porins comprises 13 members (AQP012). All of
J.M. Brandner them transport water in response to osmotic gra-
Department of Dermatology and Venerology, dients, but a subgroup, the so-called aquaglycer-
University-Hospital Hamburg-Eppendorf,
Martinistrasse 52, Hamburg,
oporins (AQP3, 7, 9, 10), also transports glycerol
20246, Germany and (possibly) other small molecules (for reviews
e-mail: [email protected] see [2, 9, 111, 122]).

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 215

DOI 10.1007/978-3-642-27606-4_14, Springer-Verlag Berlin Heidelberg 2012
216 J.M. Brandner

Aquaporin3 functions Aquaporin localization

SC hydration sc

Barrier recovery
sg
AQP9
Ocln
Epidermal water flux (?)

Differentiation (?) ssp

AQP3 (human)

Migration
Wound
healing sb AQP3 (mouse)
Proliferation

transcellular
Skin elasticity pathway

Fig. 14.1 Schematic drawing of the localization of neum, SG stratum granulosum, SSP stratum spinosum, SB
aquaporins in human and mouse epidermis and the (puta- stratum basale. Grey circles: lamellar bodies; (?): function
tive) functions of AQPs. mRNA coding for AQP10 has proposed and experimentally supported but not as yet
also been demonstrated in human keratinocytes, but its unambiguously shown. Blue arrow: AQPs facilitate the
localization has not been shown as yet. SC stratum cor- transcellular pathway of water and glycerol

TJ /TJ protein functions Localization of TJ proteins

TJ structures

sc
Cingulin
Desquamation (?)
(Cldn - 5)
Barrier functionSkin hydration ms(add): Par6,
sg
Polarisation (?) tricellulin
Ocln
Cldn-4
ZQ-1
Differentiation ssp (Cldn - 3)
Cldn-7 ms(add): cldn-18
Cldn-1 ms(add):
Proliferation Cldn - 6, -11,-12
JAM-A
sb MAUPP-1
ms(add):
paracellular Par3*,**
pathway aPKC*,**

Fig. 14.2 Schematic drawing of the localization of TJ stratum spinosum, SB stratum basale. Grey circles: lamel-
structures and TJ proteins in human and mouse epidermis lar bodies. *: different isoforms show different localiza-
and the (putative) functions of TJs and TJ proteins. tion; **: membrane and cytoplasmic localization; (): very
mRNAs coding for Cldn-8 (human and mouse) and Cldn- faint staining; (?): function proposed and experimentally
2, -11, -12, -15, 17 and 23 (human) have also been detected supported but not as yet unambiguously shown. Red
in keratinocytes, but their localization has not been shown arrow: TJ are barriers for the paracellular pathway of
as yet. SC stratum corneum, SG stratum granulosum, SSP solutes
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 217

Mammalian AQPs are found in simple 14.2.2 Functions of Epidermal

epithelial and endothelial cells involved in fluid Aquaporins
transport (e.g. kidney), in brain glial cells, in the
epidermis and in adipocytes. Their functions Because skin hydration mainly depends on epi-
often demonstrated by knockout mice and by the dermal AQP function, this chapter will concen-
rare patients with loss of AQP subtypes are as trate on aquaporins present in keratinocytes, i.e.
manifold as their localizations. For example, they AQP3, 9 and 10, even though it cannot be
are involved in the urinary-concentrating func- excluded that AQPs of, e.g. sebaceous glands,
tion (AQP14, kidney), glandular fluid secretion may be involved in skin hydration [27].
(e.g. AQP5, AQP1 salivary and airway submu-
cosal glands, choroid plexus and ciliary epithe-
lium), brain water balance (AQP4), cell migration 14.2.2.1 AQP3
(e.g. AQP1, AQP3; brain astroglial cells, corneal AQP3 is an aquaglyceroporin, i.e. it transports
epithelial cells, skin cells and tumour cells), cell water and glycerol. Also a permeability for urea
proliferation (e.g. AQP3), epidermal hydration is discussed [48]. In keratinocytes, AQP3 colo-
(AQP3) and adipocyte function (AQP7) (for calizes with phospholipase D2 in caveolin-rich
review see [112]). membrane microdomains (lipid rafts) and might
transport glycerol to phospholipase D2 which
synthesizes phophatidylglycerol, a bioactive lipid
14.2.1 Aquaporins in the Skin involved in keratinocyte function [126]. In addi-
tion, a colocalization with E-cadherin was
Several aquaporins have been identified in the described [51], a protein important for the forma-
skin: AQP1 was found by immunostaining in tion of cell-cell contacts.
capillary endothelial cells [81] as well as by Mice deficient of AQP3 exhibit impaired SC
RT-PCR in cultured melanocytes [12]. AQP3 was hydration, reduced skin elasticity and delayed
demonstrated in keratinocytes (e.g. [41, 68, 72, recovery of barrier function after removal of the
97, 100]) and fibroblasts [16] as well as Langerhans SC. In addition, slowed wound healing was
cells and dermal dendritic cells [70]. In addition, observed [38, 41, 42, 68]. Epidermal cells of
it was found in hair follicles and sebaceous glands AQP3 KO mice showed more than fourfold
[3]. Interestingly, while AQP3 was described to reduced osmotic water permeability and more
be mainly restricted to the basal cell layer of adult than twofold reduced glycerol permeability [68].
mouse skin (e.g. [12, 40, 41, 68]), it was detected The authors demonstrated a significantly reduced
in several layers of human skin with a (slightly) glycerol content in SC and epidermis while there
more intense staining in the basal cell layer. It is was no difference in SC structure and its content
absent in the (uppermost) granular layer(s) and in of ions and small solutes as well as lipids and free
the SC (Fig. 14.1) ([8, 12, 40, 51, 65, 97], slight amino acids [41, 42]. Further investigations
differences of stainings are seen between differ- showed that the reduced levels of glycerol in skin
ent publications). AQP5 is present in sweat glands were responsible for the decreased SC hydration
and was shown to play a role in sweat secretion as well as delayed barrier recovery and reduced
[81]. AQP7 was found in adipocytes and seems to skin elasticity because these deficiencies could
be important for glycerol release into the plasma be corrected by supplementation with glycerol
[37]. AQP9 was described in the SG of mouse (topical, oral and intraperitoneal), but not by
epidermis [89]; its presence was also confirmed occlusion or high humidity [42]. However,
in differentiated cultured human keratinocytes because oral and i.p. supplementation improved
[100] and human skin [99]. mRNA coding for epidermal and SC glycerol content as well as SC
AQP10 was identified in (undifferentiated) human hydration and barrier recovery in wild-type and
keratinocytes [12, 100]. Its localization is still in AQP3-deficient mice, there have to be AQP-3-
unknown. independent pathways for the uptake of glycerol
218 J.M. Brandner

into the epidermis. One possibility could be the ATP levels in AQP3-deficient cells [39]. Of
glycerol provided from sebaceous glands [26]. note, wound healing cannot be completely
Boury-Jamot (2006) demonstrated that after restored by addition of glycerol, emphasizing the
consecutive tape stripping in wild-type (wt) as important role of water movement for migration
well as AQP3-deficient mice, hyperplasia was and therefore wound healing [38].
observed. In wild-type mice, AQP3 was localized The importance of AQP3 for cell migration
in all hyperplastic layers. Interestingly, in knock- and wound healing is also confirmed by further
out (KO) mice, intercellular oedema was present data. Epidermal growth factor (EGF) increases
in the hyperplastic layers. This hints for a role of cell migration and wound healing in human fibro-
AQP3 in water movement especially in thicker blasts and HaCaT keratinocytes [16]. This is
epidermis which might therefore also apply accompanied by a time- and dose-dependent
especially for human skin. This is supported by increase of AQP3. EGF-induced cell migration is
Agren et al. [3] who described in rat embryonic reduced by inhibitors of water and glycerol trans-
skin which has increased transepidermal water port through AQPs and by a knockdown of AQP3.
loss (TEWL) an elevated expression of AQP3 EGF receptor, ERK and PI3K are likely to play a
and a localization of the proteins in more layers role in the AQP3-mediated cell migration [16].
compared to adult skin. The role of AQP3 in cell proliferation is sup-
Delayed wound healing in AQP3-deficient ported by findings that overexpression of AQP3 in
mice was shown to be a consequence of impaired human keratinocytes results in increased [79]
migration as well as decreased proliferation of decrease of AQP3 in decreased cell counts [51],
keratinocytes [38]. Knockdown of AQP3 in even though the authors did not specifically look
human and mouse keratinocytes results in for proliferation in their experiments. Straseski
decreased lamellipodia formation at the leading et al. [98] have shown that hypoxia results in a
edge of the cells, impaired migration in a chemot- downregulation of APQ3, and this is accompanied
actic driven transwell assay and delayed wound by a decrease of basal keratinocyte proliferation
healing in a cell scratch assay. Because the migra- in human skin equivalents. Further, treatment with
tion defect can be rescued by transfection with retinoic acid resulted in a less increase of prolif-
AQP3 as well as AQP1 the latter being an exclu- erative cells in the epidermis of AQP3 KO mice
sive water channel the involvement of water flux than in wild-type mice [40]. And finally, mice
in migration is likely. Further, KO mice as well as which are deficient for 3b-hydroxysterol-D24-re-
AQP3-siRNA-treated human keratinocytes show ductase, an enzyme converting desmosterol to
decreased numbers of proliferative cells at the cholesterol, exhibit increased proliferation as well
wound margins, a mechanism which seems to as elevated levels of AQP3 and increased water
involve p38 (and JNK). The impaired prolifera- and glycerol content in the epidermis. This hints
tion can be rescued by oral glycerol supplementa- for a correlation of AQP3 levels and proliferation,
tion in mice, and AQP3, but not AQP1, transfection even though the epidermis also shows further
in cultured keratinocytes, hinting for a major alterations, e.g. decreased levels of cholesterol
effect of glycerol in proliferation [38]. Glycerol and impaired differentiation which also may play
may play an important role for the generation of a role in altered proliferation [74, 75]. Summarizing
energy in form of ATP which, in turn, is necessary all these data, proliferation of keratinocytes clearly
to drive the cellular processes of proliferation. seems to be associated with AQP3 levels.
Decreased levels of ATP were detected in mouse The role of AQP3 in differentiation of kerati-
AQP3 KO keratinocytes as well as human AQP3- nocytes is a matter of debate. Zheng and Bollinger-
siRNA-treated keratinocytes and a positive corre- Bollag [126] described that the induction of
lation between glycerol content, ATP content and differentiation by 1,25 dihydroxyvitamin D3 or
proliferation of the cells was observed. Addition high concentrations of extracellular calcium result
of glycerol-3-phosphate, an important intermedi- in a downregulation of AQP3 in murine keratino-
ate for glycerol-driven ATP generation, restores cytes [126]. In addition, this group showed that
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 219

overexpression of AQP3 decreased the promoter deficits in skin hydration. Therefore, it is of spe-
activity of keratin 5 and increased that of keratin cial interest to investigate the role of AQPs in
10 [10], again hinting for an inhibiting effect of these diseases.
AQP3 on differentiation. In line with these results, In atopic dermatitis (AD), an upregulation of
Kim and Lee [51] observed a decrease of the dif- AQP3 was observed on mRNA and protein level,
ferentiation markers K10, involucrin and loricrin and immunostaining revealed increased staining
in AQP3-deficient human keratinocytes, even intensity especially in the stratum spinosum
though they did not find an alteration for K14 (SSP). Also in non-lesional skin, a mild alteration
(which is coexpressed with K5 in undifferentiated of AQP3 staining was observed [84]. The authors
keratinocytes). However, the group of Hara- suggest that increased AQP3 expression results in
Chikuma did not observe a difference of K5, K14, enhanced water transport to the SC and might,
K10, involucrin or loricrin in low or high Ca con- together with the impaired water holding capacity
ditions or in the course of differentiation induced in skin of patients with atopic dermatitis, result in
by VD3 in knockdown experiments of human and increased loss of water and dry skin. The upregu-
mouse keratinocytes [40], and overexpression of lation of AQP3 in AD, especially in suprabasal
AQP3 resulted in increased mRNA levels of K5 layers, was confirmed by Nakahigashi et al. [79].
and K14 while there was no alteration for K1 and They further investigated AQP3 in an AD mouse
K10 [79]. The causes for these discrepancies are model where they also found an upregulation of
not clear at the moment; different experimental AQP3. CCL17, which is highly expressed in AD
systems may play a role. skin, induces upregulation of AQP3 and leads to
Interestingly, Roudier et al. [90] described two an AQP3-dependent increase of proliferation in
AQP3-deficient patients who were identified dur- HaCaT keratinocytes. Consequently, when induc-
ing the screening of individuals producing alloan- ing AD in AQP3-deficient mice, they observed
tibodies against so far unidentified high-frequency decreased hyperplasia and decreased numbers of
antigens on red blood cells. These patients did proliferative cells [79]. These data suggest that
not show any obvious clinical symptoms. AQP3 not only plays a role in increased TEWL
However, the same is true for AQP1-deficient but also in hyperproliferation in AD.
patients, but they show defects in stress condi- In a study investigating three patients suffer-
tions [52]. Therefore, future investigations are ing from eczema, with or without intercellular
necessary to clarify the phenotype of AQP3- oedema, AQP3 was absent in cases with oedema.
deficient patients in non-normal conditions. This might hint for a relationship between the
loss of AQP3 and intercellular oedema, i.e. defect
14.2.2.2 AQP9 and 10 in water movement, and supports data found in
AQP9 and 10 are also aquaglyceroporins. Up to AQP3-deficient mice after consecutive tape strip-
now, their roles in the epidermis are unknown. ping (see also above; [12]).
AQP9 localization is found in more layers in hyper- In 8 out of 10 patients with psoriasis, cyto-
trophic skin after wounding compared to normal plasmic instead of cell border staining of AQP3
mouse skin. However, AQP9-deficient mice do was observed [114]. A comparison of mRNA lev-
neither show a wound healing defect nor any other els of lesional versus non-lesional skin before
obvious skin phenotype [89]. Of note, AQP9 is and 12 weeks after etanercept a TNFa and
downregulated in psoriatic lesions (see below). TNFb binding protein treatment showed a
downregulation of AQP9 in lesional skin which
is not completely reversed by etanercept [99]. As
14.2.3 AQPs in Skin Diseases AQP3 is not mentioned in this manuscript, its
and Skin Ageing expression does not seem to be significantly dif-
ferent between lesional and non-lesional skin.
Several skin diseases, as well as aged skin, are In depigmented areas of vitiligo patients which
characterized by dry skin and therefore have exhibit reduced SC hydration but no alteration of
220 J.M. Brandner

TEWL [66] decreased levels of AQP3 were 14.2.4 Alteration of AQPs by External
observed. A downregulation of AQP3 via RNAi in Stimuli
human primary keratinocytes results in decreased
levels of phospho-PI3K, E-cadherin, b-catenin and UV irradiation of HaCaT keratinocytes results in
g-catenin, molecules known to be downregulated a dose- and time-dependent downregulation of
in vitiligo [51]. In addition, it results in reduced cell AQP3 by a signalling pathway which involves
counts (see above). The authors suggest that the MEK/ERK, but not p38 and JNK. It might be
decreased amount of keratinocytes results in mediated by reactive oxygen species [17]. This is
decreased levels of growth factors and therefore accompanied by decreased water permeability of
demise of melanocytes. the HaCaT cells [50]. A slight decrease of AQP3
A decrease of AQP3 expression was also expression was also described in a group of 10
described during skin ageing [21, 65]. Of note, Asian women in sun-exposed skin. Of note, this
the loss of AQP3 was mainly found in the supra- decrease is only observed in females more than
basal layers [65]. 40 years of age [22].
The role of AQP3 in skin cancer is a matter of Hypoxia leads to a reversible decrease of
debate. The group of Verkman showed that AQP3, especially in the granular cell layer, of
AQP3-deficient mice develop less papilloma in a human skin equivalents (HSEs). In addition, fil-
two-step skin carcinoma model, mainly due to aggrin, E-cadherin and b-catenin are downregu-
decreased susceptibility to tumour promoter lated, and the transcription factor slug is
(TPA)-induced proliferation. In addition, they upregulated. The HSEs further exhibit reduced
described strong expression of AQP3 in 40 cases proliferation of basal keratinocytes and swelling
of squamous cell carcinoma (SSC) [39] and sug- in the stratum granulosum [98].
gest therefore a tumour-promoting potential of H2O2 leads to a time- and dose-dependent
AQP3. Unfortunately, it was not shown whether downregulation of AQP3 in HaCaT cells [17].
the expression of AQP3 in SSC compared to nor- Tape stripping results in an upregulation of
mal skin is up- or downregulated (or not changed AQP3 in human skin explants [22, 31]. Dumas
at all). Voss et al. [114] demonstrated a down- et al. suggest that the upregulation of AQP3
regulation of AQP3 in basal cell carcinoma com- ensures that the cells have the necessary water-
pared to normal skin and a patchy staining in rich environment to rebuild skin barrier. More
SCC with decreased staining intensity in highly detailed investigation of AQP3 after barrier dis-
proliferative areas and suggest therefore that ruption will surely be interesting. Consecutive
downregulation of AQP3 may be a marker for tape stripping of mouse skin results in hyperpla-
tumourigenic potential, but the number of cases sia and a localization of AQP3 in all living layers,
investigated was quite small (13 BCC, 5 SCC). comparable to human skin [12].
Horie and colleagues [46] demonstrated the pres- Osmotic stress by various molecules results in
ence of AQP3 in the cutaneous squamous cell an upregulation of AQP3 mRNA [31, 100].
carcinoma cell line DJM-1, Nakakoshi et al. [80]
in one out of three keratocarcinoma cell lines.
Further investigations using a larger number of 14.2.5 Inuence of Cytokines and
SCC but also precursor lesions, e.g. actinic kera- Growth Factors on AQP3
tosis and Bowens disease, and comparison of the
stainings with healthy skin as well as correlating TNFa a cytokine often increased in inflamma-
them with different grades of SCC and its precur- tory dermatoses characterized by dry skin
sors may help to elucidate the role of AQP3 in decreases AQP3 protein expression levels and
skin cancer. However, as long as there are doubts water permeability in the cutaneous squamous
about the impact of upregulation of AQP3 on cell carcinoma line DMJ1. The mechanism
skin carcinogenesis, this should be carefully involves TNF receptor 1 as well as p38 and ERK,
observed. but not NFkB [46].
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 221

EGF induces an upregulation of AQP3 in a rain forest, increases the mRNA levels of AQP3
time- and dose-dependent manner in cultured in human keratinocytes in a dose- and time-
human fibroblasts and HaCaT keratinocytes. dependent manner. In addition, also the levels
EGFR, PI3K and ERK are involved in this upreg- of filaggrin and involucrin are increased.
ulation which is accompanied by accelerated Investigation of volunteers treated with HEPC
migration of the cells [16]. or placebo showed an increased glycerol con-
tent and increased skin capacitance in the HEPC
group, but the authors did not specifically inves-
14.2.6 Inuence of External Applied tigate the levels of AQP3 (and filaggrin and
Substances on AQP3 involucrin) n these volunteers [86]. The same
group also described an upregulating effect of
All-trans retinoic acid (ATRA), a substance often green Coffea Arabica L. seed oil (GCO) on
used in dermatology, results in an upregulation of AQP3 in keratinocytes (as well as collagen,
mRNA and protein levels of AQP3 in human pri- elastin, glycosaminoglycan, TGF-b1 and
mary keratinocytes and HaCaT cells, in topically GM-CSF) [108].
treated human skin explants and in mouse skin Trans-zeatin, a cytokinin plant growth fac-
[8, 17, 40]. The upregulation is likely (among tor derived from Zea Mays, induces AQP3
others) to be mediated by transactivation of expression and reduces UV-induced loss of
EGFR and ERK signalling because their inhibi- AQP3 and activation of MEK/ERK. In addi-
tion abolishes the effect of ATRA on AQP3 in tion, it attenuates UV-induced decreased water
HaCaT cells [17, 96]. Upregulation of AQP3 is permeability and wound healing delay in
accompanied by an upregulation of K5 and K14 HaCaT keratinocytes [50].
as well as an increase of BrdU-labelled cells A purified Ceratonia siliqua (carob) seed
which are absent/reduced in AQP3 KO mice [40]. extract which is rich in amino acids and peptides
Pre-treatment of cells with ATRA attenuates UV corresponding to conserved motifs in the pore
(and H2O2)-induced downregulation of AQP3 in channel of aquaporins also results in an increased
HaCaT cells [17]. On the other hand, pre-treat- staining intensity of AQP3 in human keratino-
ment of cells with nicotinamide attenuates the cytes. It also further increases the osmotic stress
effect of ATRA on AQP3, even though nicotin- (sorbitol) or tape-stripping-induced upregulation
amide itself only decreases AQP3 expression at of AQP3 in keratinocytes/skin. Of note, the
very high concentrations [96]. This is of special upregulation of AQP3 seems to protect keratino-
interest as topical treatment of skin with ATRA cytes from cold stress. Treatment of volunteers
improves the clinical and histological appearance with dry skin with the carob seed extract result in
of photo-damaged skin [25] but frequently shows healthier appearance; a correlation to AQP3
skin dryness as a side effect. Topical nicotin- levels was not investigated [31].
amide application on dry human skin seems to A diet for 4 weeks with 4.5% Bakkokinanjinto
improve epidermal barrier function, and myristyl (BKN), a herbal medicine which reduces diuresis,
nicotinate provides tolerability of retinoic acid thirst and pruritus in patients with diabetes mel-
[49, 101]. litus results in an increase of AQP2 in kidney and
An extract from Ajuga turkestanica, a plant AQP3 in the skin in KKAy mice, a model system
from Central Asia, was described to increase for diabetes type 2. The authors suggest that the
AQP3 in human-reconstructed epidermis. In upregulation of AQP may contribute to the reduc-
in vivo studies, the extract resulted in decreased tion of pruritus in skin which is in turn caused by
TEWL after 21 days of treatment in tape-stripped dry skin [1]. It is not known whether KKAy mice
skin, but a direct correlation of AQP3 and this show reduced levels of AQP3 in skin compared
effect was not investigated in the volunteers [22]. to wild-type mice of the same background which
A hydroglycolic extract of Piptadenia colu- would be a very interesting information concern-
brina (HEPC), a tree from the South American ing the role of AQP3 in pruritus in diabetes.
222 J.M. Brandner

14.2.7 Specic Modulation of AQPs membrane contact (kissing points); in freeze

fracture electron microscopy, networks of TJ
An up- or downregulation of AQP3, dependent strands are typical for simple epithelia. TJs were
on skin condition and additional external influ- identified in simple and multilayered epithelia as
ences, might be beneficial to restore normal AQP well as endothelia. TJ proteins are also found in
levels in the skin and therefore improve skin dry- additional cell types, e.g. neutrophils or dendritic
ness and clinical symptoms. For example, in cells. TJs and TJ proteins are involved in (1) bar-
atopic dermatitis or ATRA-pre-treated skin which rier function for the paracellular pathway of ions,
show increased AQP3 levels, a downregulation water, small molecules and inflammatory cells,
might be advantageous, while in UV-irradiated or (2) the formation of a barrier between the apical
aged skin, which show decreased levels, an and the basolateral plasma membrane domains of
upregulation may be favourable. The putative the cells to prevent intramembrane diffusion of
influence of AQP3 levels on skin carcinogenesis lipids and proteins (fence function) which is
should be kept in mind. important for cell polarity, (3) the regulation of
For an optimized modulation of AQPs, specific gene expression on transcriptional and transla-
inhibitors or activators are desirable. However, tional level, (4) cell proliferation, (5) cell differ-
even though several AQP inhibitors exist, e.g. entiation and (6) vesicle transport (for reviews
sulfhydryl-reactive mercurials, they are non-selec- see: [4, 7, 23, 30, 55, 57, 93, 107]).
tive between the various AQPs and toxic. The
development of subtype specific inhibitors, which
also have access to the appropriate organs (e.g. 14.3.1 TJs and TJ Proteins in the Skin
inhibitors for AQP4 will have to cross the blood
brain barrier), will be a challenge for the future. A variety of TJ transmembrane proteins, i.e. sev-
The same is true for AQP enhancers. Because eral Cldns, Ocln, tricellulin and JAM-A as well as
AQPs may already have maximal per channel TJ plaque proteins, e.g. the TJ scaffolding/adaptor
function, an increase of function can only be proteins ZO-1, ZO-2 and MUPP-1 and the cell
achieved on expression level. Substances used so polarity proteins aPKC, Par3 and Par6, have been
far to upregulate AQP3 also influence other pro- identified in mammalian epidermis (Fig. 14.2; for
teins. Therefore, the development of AQP-selective reviews see: [15, 82]). Further, several TJ proteins
transcriptional upregulators will be necessary. were identified in hair follicles and sweat glands
in human and murine skin [14, 61, 76, 118] as
well as in dermal blood vessels [67, 77].
14.3 Tight Junctions The localization patterns of TJ proteins in the
epidermis are very complex. For example, Cldn-1
Tight junctions (TJs) are cell-cell junctions local- is found in all epidermal layers, while Ocln is
ized at the apical part of the lateral plasma mem- restricted to the stratum granulosum (SG) and
branes of cells. They are composed of Cldn-4 is found in the upper layers of the epider-
transmembrane proteins, e.g. the family of clau- mis. All TJ proteins colocalize in the SG, and in
dins (Cldns), occludin (Ocln), tricellulin and the horizontal sections, it could be shown that the TJ
family of junctional adhesion molecules (JAMs), proteins encircle the cells entirely in this layer [13,
as well as cytoplasmic plaque proteins, e.g. 58]. In addition, typical TJ structures were found
zonula occludens (ZO) proteins, MUPP-1, cingu- at the lateral plasma membranes of SG cells by
lin, symplekin and the cell polarity complex pro- transmission electron microscopy [13, 29, 55, 87,
teins aPKC, Par3 and Par6. The particular 123]. However, typical extended networks of TJ
composition of TJs depends on the cell type, dif- strands known from freeze-fracture experiments
ferentiation of the cells and physiologic and non- of simple epithelia remain to be shown in the SG,
physiologic stimuli. In transmission electron even though TJ-like structures have been demon-
microscopy, TJs are identified as sites of close strated at the border between SG and SC [92].
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 223

14.3.2 Functions of TJs and TJ Proteins by acetone TEWL is profoundly increased in KO

in the Epidermis mice compared to WT mice [95]. Therefore, it
will be of great interest to elucidate the molecular
The skin provides an important barrier for the link between leaky TJ and TEWL/impaired bar-
body. It prevents the uncontrolled loss of water rier function of the skin. Putatively, not the loss
and solutes and protects the body from external of the TJ barrier is the primary cause for the water
assaults (e.g. invasion of pathogens, penetration loss, but it results in a change of ion gradients or
of harmful substances and UV irradiation). cell polarity which leads to an alteration of the
Besides the very well-established contribution of SC. Indeed, an alteration of SC structure was
the SC, TJs have also been shown to be involved observed in Cldn-1-deficient mice [29]. In addi-
in barrier function of the skin. The function of tion, the impairment of TJs by sodium caprate
TJs as a barrier for dermal supplied tracers was results in an alteration of Ca2+ gradient in epider-
first suggested in human skin by electron micro- mis equivalents [59]. However, because sodium
scopical investigations using lanthanum [43] and caprate targets phospholipase C and results in
was later confirmed in mouse and men for the increased intracellular IP3, DAG and Ca2+ levels
first time on light microscopic level by using a which lead to several cellular alterations includ-
biotinylation reagent which biotinylate proteins ing an opening of TJ [44], it remains to be shown
extracellular and is stopped at TJs [29, 55]. whether this is indeed a TJ-specific effect.
Several authors have confirmed these experi- The establishment of barrier-forming TJs in
ments (e.g. [64, 95, 105, 125]). The importance keratinocyte cultures depends on Ca2+ concentra-
of the TJ barrier for skin barrier function is dem- tion. Ca2+ induces a continuous localization of TJ
onstrated by Cldn-1 KO mice which exhibit leaky proteins at the cell-cell borders [13, 45, 73, 87, 124]
TJs for the biotinylation reagent and which die at and subsequently leads to the generation of a tran-
the first day of birth due to a tremendous TEWL sepithelial resistance (TER), a measure for ion per-
[29]. The same is true for epidermal E-cadherin- meability of TJs, and reduced paracellular
deficient mice which also exhibit a loss of Cldn-1 permeability for larger molecules [45, 73, 124]. For
in the SG [105]. In human, the loss of Cldn-1 is the establishment of a TER, the cell polarity com-
apparently not lethal but results in the NISCH plex Par3/Par6/aPKC is necessary [45]. Tiam1
syndrome (neonatal ichthyosis sclerosing cho- (T-lymphoma invasion and metastasis), an exchange
langitis; [24, 34]; OMIM # 607626) which com- factor for the small GTPase Rac, is involved through
prises a severe skin disease with dry skin. the activation of Rac and aPKC [73]. One putative
However, one cannot completely exclude lethal- target molecule of aPKC in TJs of keratinocytes is
ity in human, because up to now, only very few Cldn-4 which was shown to be phosphorylated dur-
cases of Cldn-1-deficient patients have been iden- ing TJ formation in HaCaT cells [5].
tified, which might be due to high lethality during Downregulation of Cldn-1 in human keratino-
development without diagnosis. On the other cytes results in decreased transepithelial resis-
hand, the period of embryonic development is tance (TER) and increased paracellular
much longer in human than in men; therefore, permeability for larger molecules, e.g. FITC
compensation mechanism might take effect in albumin [19, 120]. Also the downregulation of
human which are not present in mice, preventing Ocln by RNAi was shown to decrease TJ barrier
the death of the patients. Of note, skin from Cldn- function in cultured keratinocytes [120]. However,
1-deficient mice transplanted onto nude mice is Ocln-deficient mice do not show any obvious
characterized by epidermal thickening [29], hint- defect in skin barrier [91], again hinting for a
ing for compensation. Interestingly, a leaky TJ compensation mechanism.
barrier does not necessarily result in increased In addition to play a pivotal role in TJ barrier
TEWL. TRPV4 channel-deficient mice show function, Cldn-1 was also shown to play a role in
permeable TJs but exhibit no difference in TEWL. proliferation and differentiation. Downregulation
Only after additional alteration of the SC barrier of Cldn-1 results in increase of proliferation in
224 J.M. Brandner

human [19] and a downregulation of the differen- tion in the SG of KO mice during embryonic
tiation markers filaggrin and loricrin in mouse development [56]. This also strongly suggests for
keratinocytes [56]. Also the overexpression of a role of TJs in cell polarity. However, again, also
Cldn-6, as well as specific deletion mutants of the absence of CD44 influences other proteins in
this molecule, results in increased proliferation of addition to TJs; therefore, it cannot be excluded
keratinocytes and dysregulated epidermal and that other molecules might also be involved in
hair follicle differentiation [102104, 106]. perturbed polarity. Nonetheless, both findings
TJs/TJ proteins are also known to participate clearly suggest the involvement of TJs in kerati-
in the paracellular migration of inflammatory nocyte polarity which should be further clarified
cells through endothelia and simple epithelia (for in future experiments.
reviews see [4, 93, 116]). This might also be true Lastly, Cldn-1 and Ocln, as well as TJ-related
for the skin. TJ proteins are downregulated in structures, were also found in the lower layers of
psoriasis near specific subgroups of inflammatory SC and were suggested to play a role in protec-
cells, particularly neutrophils [54], and one could tion of corneodesmosomes at the lateral plasma
suggest that neutrophils migrate through the skin membranes from precocious degradation, there-
by downregulation of TJ proteins. In mouse skin, fore contributing to orchestrated desquamation
it was shown that dendrites of activated [35, 47, 36].
Langerhans cells (LHC) are positive for Cldn-1
and ZO-1 and that functional bicellular and tricel-
lular TJs form between Langerhans cells and 14.3.3 TJs and TJ Proteins in Skin
keratinocytes [58]. This may preserve TJ integ- Diseases
rity during external antigen uptake by Langerhans
cells. Also in human skin, Cldn-1, as well as Alterations of TJ proteins have been observed in
JAM-A, is present in LHC [53, 127, 128]. several skin diseases with dry skin. They are
For the formation of a functional SC, it is nec- often characterized by impaired skin barrier func-
essary that cells of the SG secrete their lamellar tion, altered proliferation/differentiation of the
bodies only to the apical site but not to the baso- epidermis and/or infiltration of inflammatory
lateral sites of the cells. Therefore, cell polarity cells.
with directed vesicle transport has to be estab- In psoriasis, a broader expression of TJ pro-
lished in SG cells. Because TJs are known to be teins which are normally restricted to the SG/
involved in cell polarity in simple epithelia and SSP, i.e. Ocln, ZO-1 and Cldn-4, and a (restricted
are localized in the SG, it is tempting to speculate to the uppermost and lowermost layers) down-
that they are involved in this mechanism. Indeed, regulation of proteins, which are normally found
Kuroda et al. [60] observed that treatment of in all layers, i.e. Cldn-1 and Cldn-7, were
human skin equivalents and cultured keratino- observed [53, 54, 87, 115, 123]. Even though
cytes with sodium caprate results in altered intra- these alterations are already observed in early
cellular localization of a fluorescent ceramide stage psoriasis [53], there is no obvious alteration
(BODIPY) and decreases the secretion of this in non-lesional skin, and the alterations are
ceramide as well as of the lymphoepithelial widely reversed in healed psoriatic plaques [85].
Kazal-type-related inhibitor LEKTI. However, as The alteration of localization of TJ proteins
mentioned above, due to the fact that sodium results in a relocation of their colocalization from
caprate increases the levels of several second the SG to the upper spinous cell layers which is
messengers which also influence other molecules reflected by a relocation of TJ structures in elec-
than TJ proteins, it is not sure whether this effect tron microscopy [123] and a relocation of the TJ
is TJ specific. CD44-deficient keratinocytes show barrier function for the biotinylation reagent [54].
prominent decreased levels of TJ proteins and The biological meaning of this relocated TJ bar-
impaired cell polarity formation in cultured cells, rier function is not clear yet. It might be a rescue
as well as lost polarity of lamellar body localiza- mechanism to compensate for the impaired SC
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 225

barrier already in deeper layers. Suarez-Farinas Skin infection (impetigo contagiosa) leads to a
et al. [99] found in their comparison of mRNA downregulation of all TJ proteins in the areas of
levels of lesional versus non-lesional skin before acute invasion, while there is an upregulation of
and 12 weeks after etanercept treatment (see also Ocln and ZO-1 in areas with colonization of bac-
AQP section) also a downregulation of Cldn-8 teria [83].
and Cldn-10 which is not completely reversed by Alterations of TJ protein expression and local-
etanercept. In addition, they confirmed the upreg- ization have also been described in keratinocytic
ulation of Ocln and ZO-1 and showed that it is skin carcinomas, Merkel cell carcinomas and mel-
normalized after etanercept treatment. As Cldn-1 anomas [18, 33, 62, 63, 78, 94, 117]. In a two-step
is not mentioned in this manuscript, its expres- mouse carcinogenesis model, Arabzadeh and co-
sion might not have been investigated or does not workers [6] noted a downregulation of Cldn-1 in
seem to be significantly different between lesional the basal cell layer and of Cldn-1, 6,-11, -12 and
and non-lesional skin. 18 in the lower suprabasal epidermal layers. The
In non-lesional skin of atopic dermatitis (AD) impact of these alterations on tumourigenesis still
patients, a downregulation of Cldn-1 and Cldn- has to be elucidated, but the fact that in psoriasis,
23 was observed in the epidermis [19]. The non-lesional skin from AD patients and squamous
authors further describe a negative correlation cell carcinoma (SSC), which are all characterized
between Cldn-1 expression and total serum IgE by hyperproliferation and altered differentiation, a
and eosinophils. Skin barrier function of suction (limited) downregulation of Cldn-1 is found ([6,
blisters was impaired, as shown by Ussing cham- 19, 53, 62, 78, 115], submitted) and an influence
ber experiments, but TJ-specific barrier experi- of Cldn-1 on proliferation/differentiation was
ments in the skin were not performed. Of note, shown in knockdown experiments [19, 56] hints
the authors found preliminary results hinting for for an involvement of Cldn-1 in proliferation/dif-
a correlation of specific CLDN-1 SNPs with AD ferentiation of the tumours.
[19]. It is tempting to speculate that the impair-
ment of both barriers, SC and TJs, results in
increased uptake of antigens leading in turn to 14.3.4 Inuence of External Stimuli
increased skin inflammation. Yang et al. [121] on TJs/TJ Proteins
described that the downregulation of FGF recep-
tor 1 and 2 in mice results in a downregulation of UV exposure of mouse and human keratinocytes,
TJ proteins, including Cldn-1, and a loss of seba- as well as skin explants and skin equivalents,
ceous glands and, subsequently, in the develop- results in a decreased TJ barrier function. Chronic
ment of an inflammatory skin disease. UV exposure as found in sun-exposed skin results
Unfortunately, assays for in vivo TJ permeability, in a downregulation of Cldn-1 in the lowermost
i.e. penetration of the biotinylation reagent could layers and a broader expression of Ocln, ZO-1
not be performed in these mice because the and Cldn-4 (Rachow et al.).
method is only established for newborn/embry- Tape stripping of mouse skin results in an
onic mice but the phenotype of these mice only upregulation of Cldn-4 mRNA 1 and 3 h after
developed later. tape stripping, while there was no significant
In ichthyosis vulgaris patients with filaggrin change for Ocln and Cldn-1 [56]. Malminen et al.
mutation, a downregulation of Ocln and ZO-1 [69] also did not observe an effect of tape strip-
was described. Of note, the downregulation was ping on Ocln (and ZO-1) in human skin 24 h, 2d,
more pronounced in homozygous compared to 3d and 5d after tape stripping. They did not inves-
heterozygous filaggrin carriers [32]. On the other tigate Cldn-4.
hand, as already described before, Cldn-1- Transient receptor potential vanilloid 4
deficient patients suffer from the NISCH syn- (TRPV4) channel is a physiological sensor for
drome which shows an ichthyosis skin phenotype hypo-osmolarity, mechanical deformation and
[24, 34]. warm temperature. TRPV4-deficient mice show
226 J.M. Brandner

leaky TJ and the absence of typical TJ structures hyaluronic acid (HA), but the large-size form of
while there is no obvious change in protein levels HA, which is known to influence differentiation
of Cldn-1 and Ocln [95]. Up to now, nothing is as well as lamellar body formation and secretion
known about changes in TJ function as a result of in keratinocytes [11], does not influence TJ bar-
physiologic stimulation of TRPV4, but due to the rier function [56]. Therefore, the appropriate
knockout results, an influence can be expected. ligand to influence TJs via CD44, which might be
HA of a different size or other glycosaminogly-
cans, still has to be identified.

14.3.5 Inuence of Extracellular

Signalling Molecules on
Epidermal TJs 14.3.6 Inuence of External Substances
on Epidermal TJs
The proinflammatory cytokines IL-1b and TNFa
lead to an upregulation of Ocln and ZO-1 in ex Soybean-derived phospholipids modified with
vivo skin models. In addition, they increase and phospholipase A2 and C (lysophospholipids;
decrease TER in a time- and dose-dependent LPL) stimulate the expression of Cldn-1 and
manner in primary keratinocytes [53]. IL-1b also Ocln (in addition to profilaggrin and serine
results in a downregulation of Cldn-1 in human palmitoyltransferase) in human keratinocytes.
primary [53] and HaCat [112] keratinocytes and Treatment of human volunteers for 6 weeks
reduces Cldn-1 immunostaining after injection in with LPL resulted in increased SC hydration,
human volunteers [115]. but no direct correlation to TJ proteins was
IL-4 and IL-13 result in an upregulation of investigated [118].
Cldn-1 levels in primary human keratinocytes,
while there is no change of Ocln and ZO-1. In
addition, IL-4 results in an increase of TER. 14.3.7 Specic Modulation of TJs
These data render it unlikely that the decreased
level of Cldn-1 in non-lesional skin from patients Regarding the observations in mouse models and
with AD is just a simple result of increased levels human diseases, an upregulation of Cldn-1 in dis-
of IL-4 and IL-13 [19]. eased skin might be beneficial, also to improve
TGF-1 decreases the levels of ZO-1 (and skin dryness. However, as seen for Cldn-6, not
E-cadherin), markers for epithelial-mesenchymal only downregulation but also overexpression of a
transition, in HaCaT cell subtypes of various Cldn can disturb TJ barrier homeostasis.
malignancy [88]. Therefore, the effect of Cldn-1 overexpression
FGF7 increases Cldn-1 and Cldn-3 levels on (and other TJ proteins) should be clarified first to
mRNA and protein levels in cultured mouse kera- evaluate the benefit of upregulation of TJ
tinocytes [121]. proteins.
Somatostatin (SST) increases TER in cultured In addition, as already mentioned for AQPs,
human keratinocytes via the SST receptor 3. This specific upregulation of genes on transcriptional
is accompanied by an upregulation of Cldn-4 on level is not easily achieved and will be a chal-
mRNA and protein level [113]. lenging task for the future.
CD44-deficient keratinocytes show alterations
of TJ protein composition in the course of barrier Conclusion
formation during embryonic development, after Aquaporins and tight junctions are both
tape stripping and in cell culture. In addition, they involved in skin hydration. In addition, they
show delayed TJ barrier formation in cell culture are involved in various other functions. Their
and impaired skin barrier formation in embryonic expression patterns are characteristically
and adult mice [56]. The main ligand of CD44 is changed in skin diseases associated with dry
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 227

skin and are influenced by cytokines and Abbreviations

external stimuli known to change skin hydra-
tion. Knockout models of key epidermal aqua- AQP Aquaporin
porins (AQP3) and TJ proteins (Cldn-1) result Cldn Claudin
in dry skin/increased TEWL. Approaches to Ocln Occludin
modify AQPs as well as the various proteins SC Stratum corneum
of TJs to improve skin dryness may therefore SG Stratum granulosum
be reasonable but have to take into account the TJ Tight junctions
particular skin condition to which treatment is
applied and other functions of AQPs/TJs
which also might be influenced. References
1. Aburada T, Ikarashi N, Kagami M, Ichikawa Y, Sugitani M,
Maniwa A, Ueda H, Toda T, Ito K, Ochiai W, Matsushita
R, Miyamoto K, Sugiyama K (2011) Byakkokaninjinto
Take Home Messages prevents body water loss by increasing the expression of
Aquaglyceroporins are pore-forming kidney aquaporin-2 and skin aquaporin-3 in KKAy
transmembrane proteins. They transport mice. Phytother Res 25:897903
2. Agre P (2006) The aquaporin water channels. Proc
water and glycerol into or out of the Am Thorac Soc 3:513
cells. In keratinocytes, AQP3, 9 and 10 3. Agren J, Zelenin S, Hakansson M, Eklof AC, Aperia A,
are present. Nejsum LN, Nielsen S, Sedin G (2003) Transepidermal
The major aquaglyceroporin in skin, water loss in developing rats: role of aquaporins in the
immature skin. Pediatr Res 53:558565
AQP3, is (putatively) involved in skin 4. Aijaz S, Balda MS, Matter K (2006) Tight junctions:
hydration, proliferation (differentia- molecular architecture and function. Int Rev Cytol
tion), migration, wound healing, barrier 248:261298
recovery, skin elasticity (and skin 5. Aono S, Hirai Y (2008) Phosphorylation of claudin-4
is required for tight junction formation in a human
carcinogenesis). keratinocyte cell line. Exp Cell Res 314:33263339
An up- or downregulation of AQP3 might 6. Arabzadeh A, Troy TC, Turksen K (2007) Changes in
be beneficial to improve skin moisturiza- the distribution pattern of Claudin tight junction pro-
tion depending on the skin condition and teins during the progression of mouse skin tumorigen-
esis. BMC Cancer 7:196
additional external influences. 7. Balda MS, Matter K (2009) Tight junctions and the
Tight junctions are complex cell-cell regulation of gene expression. Biochim Biophys Acta
junctions that control the paracellular 1788:761767
pathway of molecules in the stratum 8. Bellemere G, Von Stetten O, Oddos T (2008) Retinoic
acid increases aquaporin 3 expression in normal
granulosum. TJ proteins are found in human skin. J Invest Dermatol 128:542548
various expression patterns in several 9. Benga G (2009) Water channel proteins (later called
layers of the epidermis. aquaporins) and relatives: past, present, and future.
TJs and TJ proteins are (putatively) IUBMB Life 61:112133
10. Bollag WB, Xie D, Zheng X, Zhong X (2007) A
involved in skin hydration, proliferation, potential role for the phospholipase D2-aquaporin-3
differentiation, (stratum granulosum signaling module in early keratinocyte differentiation:
polarization) and (desquamation). production of a phosphatidylglycerol signaling lipid.
An upregulation of Cldn-1, a major TJ J Invest Dermatol 127:28232831
11. Bourguignon LY, Ramez M, Gilad E, Singleton PA,
protein, might be beneficial for skin Man MQ, Crumrine DA, Elias PM, Feingold KR
moisturization, as its downregulation is (2006) Hyaluronan-CD44 interaction stimulates kera-
observed in several skin diseases charac- tinocyte differentiation, lamellar body formation/
terized by dry skin, but the consequence secretion, and permeability barrier homeostasis.
J Invest Dermatol 126:13561365
of a putative Cldn-1 overexpression is 12. Boury-Jamot M, Sougrat R, Tailhardat M, Le Varlet
not clarified yet. B, Bonte F, Dumas M, Verbavatz JM (2006)
Expression and function of aquaporins in human skin:
228 J.M. Brandner

Is aquaporin-3 just a glycerol transporter? Biochim transduction cascades that induce Ap-1-regulated
Biophys Acta 1758:10341043 matrix metalloproteinases that degrade human skin
13. Brandner JM, Kief S, Grund C, Rendl M, Houdek P, in vivo. J Investig Dermatol Symp Proc 3:6168
Kuhn C, Tschachler E, Franke WW, Moll I (2002) 26. Fluhr JW, Mao-Qiang M, Brown BE, Wertz PW,
Organization and formation of the tight junction sys- Crumrine D, Sundberg JP, Feingold KR, Elias PM
tem in human epidermis and cultured keratinocytes. (2003) Glycerol regulates stratum corneum hydration
Eur J Cell Biol 81:253263 in sebaceous gland deficient (asebia) mice. J Invest
14. Brandner JM, McIntyre M, Kief S, Wladykowski E, Dermatol 120:728737
Moll I (2003) Expression and localization of tight 27. Fluhr JW, Darlenski R, Surber C (2008) Glycerol and
junction-associated proteins in human hair follicles. the skin: holistic approach to its origin and functions.
Arch Dermatol Res 295:211221 Br J Dermatol 159:2334
15. Brandner JM (2009) Tight junctions and tight junc- 28. Fujiyoshi Y, Mitsuoka K, de Groot BL, Philippsen A,
tion proteins in mammalian epidermis. Eur J Pharm Grubmuller H, Agre P, Engel A (2002) Structure and
Biopharm 72:289294 function of water channels. Curr Opin Struct Biol
16. Cao C, Sun Y, Healey S, Bi Z, Hu G, Wan S, Kouttab N, 12:509515
Chu W, Wan Y (2006) EGFR-mediated expression of 29. Furuse M, Hata M, Furuse K, Yoshida Y, Haratake A,
aquaporin-3 is involved in human skin fibroblast Sugitani Y, Noda T, Kubo A, Tsukita S (2002) Claudin-
migration. Biochem J 400:225234 based tight junctions are crucial for the mammalian
17. Cao C, Wan S, Jiang Q, Amaral A, Lu S, Hu G, Bi epidermal barrier: a lesson from claudin-1-deficient
Z, Kouttab N, Chu W, Wan Y (2008) All-trans retin- mice. Journal of Cell Biology 156:10991111
oic acid attenuates ultraviolet radiation-induced 30. Furuse M, Tsukita S (2006) Claudins in occluding
down-regulation of aquaporin-3 and water permea- junctions of humans and flies. Trends Cell Biol 16:
bility in human keratinocytes. J Cell Physiol 215: 181188
506516 31. Garcia N, Gondran C, Menon G, Mur L, Oberto G,
18. Cohn ML, Goncharuk VN, Diwan AH, Zhang PS, Guerif Y, Dal Farra C, Domloge N (2011) Impact of
Shen SS, Prieto VG (2005) Loss of claudin-1 expres- AQP3 inducer treatment on cultured human keratino-
sion in tumor-associated vessels correlates with acqui- cytes, ex vivo human skin and volunteers. Int J Cosmet
sition of metastatic phenotype in melanocytic Sci 33:432442
neoplasms. J Cutan Pathol 32:533536 32. Gruber R, Elias PM, Crumrine D, Lin TK, Brandner JM,
19. De Benedetto A, Rafaels NM, McGirt LY, Ivanov AI, Hachem JP, Presland RB, Fleckman P, Janecke AR,
Georas SN, Cheadle C, Berger AE, Zhang K, Vidyasagar S, Sandilands A, McLean WH, Fritsch PO, Mildner M,
Yoshida T, Boguniewicz M, Hata T, Schneider LC, Tschachler E, Schmuth M (2011) Filaggrin genotype in
Hanifin JM, Gallo RL, Novak N, Weidinger S, Beaty ichthyosis vulgaris predicts abnormalities in epidermal
TH, Leung DY, Barnes KC, Beck LA (2011) Tight structure and function. Am J Pathol 178:225263
junction defects in patients with atopic dermatitis. J 33. Haass NK, Houdek P, Wladykowski E, Moll I,
Allergy Clin Immunol 127(77386):e1e7 Brandner JM (2003) Expression patterns of tight junc-
20. Denda M, Sato J, Tsuchiya T, Elias PM, Feingold KR tion proteins in Merkel cell carcinoma. In: Baumann
(1998) Low humidity stimulates epidermal DNA syn- KI, Halata Z, Moll I (eds) The Merkel Cell. Springer,
thesis and amplifies the hyperproliferative response to Berlin, Heidelberg
barrier disruption: implication for seasonal exacerba- 34. Hadj-Rabia S, Baala L, Vabres P, Hamel-Teillac D,
tions of inflammatory dermatoses. J Invest Dermatol Jacquemin E, Fabre M, Lyonnet S, De Prost Y,
111:873878 Munnich A, Hadchouel M, Smahi A (2004) Claudin-1
21. Dumas M, Langle S, Noblesse E, Bonnet-Duquennoy M, gene mutations in neonatal sclerosing cholangitis
Pelle de Queral D, Tadokoro T, Bonte F (2005) associated with ichthyosis: a tight junction disease.
Histological variation of Japanese skin with aging. Int Gastroenterology 127:13861390
J Cosmet Sci 27:4750 35. Haftek M (2009) Tight junction-like structures con-
22. Dumas M, Sadick NS, Noblesse E, Juan M, Lachmann- tribute to the lateral contacts between corneocytes and
Weber N, Boury-Jamot M, Sougrat R, Verbavatz JM, protect corneodesmosomes from premature degrada-
Schnebert S, Bonte F (2007) Hydrating skin by stimu- tion. J Invest Dermatol 129:S65
lating biosynthesis of aquaporins. J Drugs Dermatol 36. Haftek M, Callejon S, Sandjeu Y, Padois K, Falson F,
6:s20s24 Pirot F, Portes P, Demarne F, Jannin V (2011)
23. Ebnet K, Suzuki A, Ohno S, Vestweber D (2004) Compartmentalization of the human stratum corneum
Junctional adhesion molecules (JAMs): more mole- by persistent tight junction-like structures. Experimental
cules with dual functions? J Cell Sci 117:1929 Dermatology 20:617621
24. Feldmeyer L, Huber M, Fellmann F, Beckmann JS, 37. Hara-Chikuma M, Sohara E, Rai T, Ikawa M, Okabe M,
Frenk E, Hohl D (2006) Confirmation of the origin of Sasaki S, Uchida S, Verkman AS (2005) Progressive
NISCH syndrome. Hum Mutat 27:408410 adipocyte hypertrophy in aquaporin-7-deficient
25. Fisher GJ, Voorhees JJ (1998) Molecular mechanisms mice: adipocyte glycerol permeability as a novel
of photoaging and its prevention by retinoic acid: regulator of fat accumulation. J Biol Chem 280:
ultraviolet irradiation induces MAP kinase signal 1549315496
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 229

38. Hara-Chikuma M, Verkman AS (2008) Aquaporin-3 51. Kim NH, Lee AY (2011) Reduced aquaporin3 expres-
facilitates epidermal cell migration and proliferation sion and survival of keratinocytes in the depigmented
during wound healing. J Mol Med 86:221231 epidermis of vitiligo. J Invest Dermatol 130:22312239
39. Hara-Chikuma M, Verkman AS (2008) Prevention of 52. King LS, Choi M, Fernandez PC, Cartron JP, Agre P
skin tumorigenesis and impairment of epidermal cell (2001) Defective urinary-concentrating ability due to
proliferation by targeted aquaporin-3 gene disruption. a complete deficiency of aquaporin-1. N Engl J Med
Mol Cell Biol 28:326332 345:175179
40. Hara-Chikuma M, Takahashi K, Chikuma S, Verkman 53. Kirschner N, Poetzl C, von den Driesch P,
AS, Miyachi Y (2009) The expression of differentia- Wladykowski E, Moll I, Behne MJ, Brandner JM
tion markers in aquaporin-3 deficient epidermis. Arch (2009) Alteration of tight junction proteins is an early
Dermatol Res 301:245252 event in psoriasis: putative involvement of proinflam-
41. Hara M, Ma T, Verkman AS (2002) Selectively matory cytokines. Am J Pathol 175:10951106
reduced glycerol in skin of aquaporin-3-deficient 54. Kirschner N, Houdek P, Fromm M, Moll I, Brandner
mice may account for impaired skin hydration, JM (2010) Tight junctions form a barrier in human
elasticity, and barrier recovery. J Biol Chem 277: epidermis. Eur J Cell Biol 89:839842
4661646621 55. Kirschner N, Bohner C, Rachow S, Brandner JM
42. Hara M, Verkman AS (2003) Glycerol replacement (2010) Tight junctions: is there a role in dermatology?
corrects defective skin hydration, elasticity, and bar- Arch Dermatol Res 302:483493
rier function in aquaporin-3-deficient mice. Proc Natl 56. Kirschner N, Haftek M, Niessen CM, Behne MJ,
Acad Sci U S A 100:73607365 Furuse M, Moll I, Brandner JM (2011) CD44 regu-
43. Hashimoto K (1971) Intercellular spaces of the human lates tight-junction assembly and barrier function. J
epidermis as demonstrated with lanthanum. Journal of Invest Dermatol 131:932943
Investigative Dermatology 57:1731 57. Kohler K, Zahraoui A (2005) Tight junction: a co-
44. Hayashi M, Sakai T, Hasegawa Y, Nishikawahara T, ordinator of cell signalling and membrane trafficking.
Tomioka H, Iida A, Shimizu N, Tomita M, Awazu S Biol Cell 97:659665
(1999) Physiological mechanism for enhancement of par- 58. Kubo A, Nagao K, Yokouchi M, Sasaki H, Amagai M
acellular drug transport. J Control Release 62:141148 (2009) External antigen uptake by Langerhans cells
45. Helfrich I, Schmitz A, Zigrino P, Michels C, Haase I, with reorganization of epidermal tight junction barri-
le Bivic A, Leitges M, Niessen CM (2007) Role of ers. J Exp Med 206:29372946
aPKC isoforms and their binding partners Par3 and 59. Kurasawa M, Maeda T, Oba A, Yamamoto T, Sasaki H
Par6 in epidermal barrier formation. J Invest Dermatol (2011) Tight junction regulates epidermal calcium ion
127:782791 gradient and differentiation. Biochem Biophys Res
46. Horie I, Maeda M, Yokoyama S, Hisatsune A, Katsuki H, Commun 406:506511
Miyata T, Isohama Y (2009) Tumor necrosis factor- 60. Kuroda S, Kurasawa M, Mizukoshi K, Maeda T,
alpha decreases aquaporin-3 expression in DJM-1 Yamamoto T, Oba A, Kishibe M, Ishida-Yamamoto A
keratinocytes. Biochem Biophys Res Commun 387: (2010) Perturbation of lamellar granule secretion by
564568 sodium caprate implicates epidermal tight junctions in
47. Igawa S, Kishibe M, Murakami M, Honma M, lamellar granule function. J Dermatol Sci 59:107114
Takahashi H, Iizuka H, Ishida-Yamamoto A (2011) 61. Langbein L, Grund C, Kuhn C, Praetzel S, Kartenbeck J,
Tight junctions in the stratum corneum explain spatial Brandner JM, Moll I, Franke WW (2002) Tight junc-
differences in corneodesmosome degradation. Exp tions and compositionally related junctional structures
Dermatol 20:5357 in mammalian stratified epithelia and cell cultures
48. Ishibashi K, Sasaki S, Fushimi K, Uchida S, Kuwahara M, derived therefrom. Eur J Cell Biol 81:419435
Saito H, Furukawa T, Nakajima K, Yamaguchi Y, 62. Langbein L, Pape U-F, Grund C, Kuhn C, Praetzel S,
Gojobori T et al (1994) Molecular cloning and expres- Moll I, Moll R, Franke WW (2003) Tight junction-
sion of a member of the aquaporin family with permea- related structures in the absence of a lumen: Occludin
bility to glycerol and urea in addition to water expressed claudins and tight junction plaque proteins in densely
at the basolateral membrane of kidney collecting duct packed cell formations of stratified epithelia and
cells. Proc Natl Acad Sci U S A 91:62696273 squamous cell carcinomas. European Journal of Cell
49. Jacobson EL, Kim H, Kim M, Williams JD, Coyle Biology 82:385400
DL, Coyle WR, Grove G, Rizer RL, Stratton MS, 63. Leotlela PD, Wade MS, Duray PH, Rhode MJ, Brown
Jacobson MK (2007) A topical lipophilic niacin deriv- HF, Rosenthal DT, Dissanayake SK, Earley R, Indig
ative increases NAD, epidermal differentiation and FE, Nickoloff BJ, Taub DD, Kallioniemi OP, Meltzer P,
barrier function in photodamaged skin. Exp Dermatol Morin PJ, Weeraratna AT (2007) Claudin-1 overexpres-
16:490499 sion in melanoma is regulated by PKC and contributes
50. Ji C, Yang Y, Yang B, Xia J, Sun W, Su Z, Yu L, Shan to melanoma cell motility. Oncogene 26:38463856
S, He S, Cheng L, Wan Y, Bi Z (2011) Trans-Zeatin 64. Leyvraz C, Charles RP, Rubera I, Guitard M, Rotman S,
attenuates ultraviolet induced down-regulation of Breiden B, Sandhoff K, Hummler E (2005) The epi-
aquaporin-3 in cultured human skin keratinocytes. Int dermal barrier function is dependent on the serine
J Mol Med 26:257263 protease CAP1/Prss8. J Cell Biol 170:487496
230 J.M. Brandner

65. Li J, Tang H, Hu X, Chen M, Xie H (2011) Aquaporin-3 skin. Journal of Investigative Dermatology 110:
gene and protein expression in sun-protected human 862866
skin decreases with skin ageing. Australas J Dermatol 77. Morita K, Sasaki H, Furuse K, Furuse M, Tsukita S,
51:106112 Miyachi Y (2003) Expression of claudin-5 in dermal
66. Liu J, Man WY, Lv CZ, Song SP, Shi YJ, Elias PM, vascular endothelia. Exp Dermatol 12:289295
Man MQ (2010) Epidermal permeability barrier 78. Morita K, Tsukita S, Miyachi Y (2004) Tight junc-
recovery is delayed in vitiligo-involved sites. Skin tion-associated proteins (occludin, ZO-1, claudin-1,
Pharmacol Physiol 23:193200 claudin-4) in squamous cell carcinoma and Bowens
67. Ludwig RJ, Zollner TM, Santoso S, Hardt K, Gille J, disease. Br J Dermatol 151:328334
Baatz H, Johann PS, Pfeffer J, Radeke HH, Schon MP, 79. Nakahigashi K, Kabashima K, Ikoma A, Verkman AS,
Kaufmann R, Boehncke WH, Podda M (2005) Miyachi Y, Hara-Chikuma M (2011) Upregulation of
Junctional adhesion molecules (JAM)-B and -C con- aquaporin-3 is involved in keratinocyte proliferation
tribute to leukocyte extravasation to the skin and and epidermal hyperplasia. J Invest Dermatol 131:
mediate cutaneous inflammation. J Invest Dermatol 865873
125:969976 80. Nakakoshi M, Morishita Y, Usui K, Ohtsuki M,
68. Ma T, Hara M, Sougrat R, Verbavatz JM, Verkman AS Ishibashi K (2006) Identification of a keratinocarci-
(2002) Impaired stratum corneum hydration in mice noma cell line expressing AQP3. Biol Cell 98:95100
lacking epidermal water channel aquaporin-3. J Biol 81. Nejsum LN, Kwon TH, Jensen UB, Fumagalli O,
Chem 277:1714717153 Frokiaer J, Krane CM, Menon AG, King LS, Agre
69. Malminen M, Koivukangas V, Peltonen J, Karvonen PC, Nielsen S (2002) Functional requirement of aqua-
SL, Oikarinen A, Peltonen S (2003) Immunohistological porin-5 in plasma membranes of sweat glands. Proc
distribution of the tight junction components ZO-1 Natl Acad Sci U S A 99:511516
and occludin in regenerating human epidermis. Br J 82. Niessen CM (2007) Tight junctions/adherens junc-
Dermatol 149:255260 tions: basic structure and function. J Invest Dermatol
70. Marchini G, Stabi B, Kankes K, Lonne-Rahm S, 127:25252532
Ostergaard M, Nielsen S (2003) AQP1 and AQP3, 83. Ohnemus U, Kohrmeyer K, Houdek P, Rohde H,
psoriasin, and nitric oxide synthases 13 are inflam- Wladykowski E, Vidal S, Horstkotte MA, Aepfelbacher
matory mediators in erythema toxicum neonatorum. M, Kirschner N, Behne MJ, Moll I, Brandner JM
Pediatr Dermatol 20:377384 (2008). Regulation of epidermal tight-junctions (TJ)
71. Matsuki M, Yamashita F, Ishida-Yamamoto A, during infection with exfoliative toxin-negative
Yamada K, Kinoshita C, Fushiki S, Ueda E, Morishima Y, Staphylococcus strains. J Invest Dermatol 128:90616
Tabata K, Yasuno H, Hashida M, Iizuka H, Ikawa M, 84. Olsson M, Broberg A, Jernas M, Carlsson L, Rudemo
Okabe M, Kondoh G, Kinoshita T, Takeda J, M, Suurkula M, Svensson PA, Benson M (2006)
Yamanishi K (1998) Defective stratum corneum and Increased expression of aquaporin 3 in atopic eczema.
early neonatal death in mice lacking the gene for Allergy 61:11321137
transglutaminase 1 (keratinocyte transglutaminase). 85. Peltonen S, Riehokainen J, Pummi K, Peltonen J
Proc Natl Acad Sci U S A 95:10441049 (2007) Tight junction components occludin, ZO-1,
72. Matsuzaki T, Suzuki T, Koyama H, Tanaka S, Takata and claudin-1, -4 and 5 in active and healing psoria-
K (1999) Water channel protein AQP3 is present in sis. Br J Dermatol 156:466472
epithelia exposed to the environment of possible water 86. Pereda Mdel C, Dieamant Gde C, Eberlin S, Werka
loss. J Histochem Cytochem 47:12751286 RM, Colombi D, Queiroz ML, Di Stasi LC (2010)
73. Mertens AE, Rygiel TP, Olivo C, van der Kammen R, Expression of differential genes involved in the main-
Collard JG (2005) The Rac activator Tiam1 controls tenance of water balance in human skin by Piptadenia
tight junction biogenesis in keratinocytes through colubrina extract. J Cosmet Dermatol 9:3543
binding to and activation of the Par polarity complex. 87. Pummi K, Malminen M, Aho H, Karvonen S-L,
J Cell Biol 170:10291037 Peltonen J, Peltonen S (2001) Epidermal tight junc-
74. Mirza R, Hayasaka S, Takagishi Y, Kambe F, Ohmori tions: ZO-1 and occludin are expressed in mature,
S, Maki K, Yamamoto M, Murakami K, Kaji T, developing, and affected skin and in vitro differentiat-
Zadworny D, Murata Y, Seo H (2006) DHCR24 gene ing keratinocytes. Journal of Investigative Dermatology
knockout mice demonstrate lethal dermopathy with 117:10501058
differentiation and maturation defects in the epider- 88. Rasanen K, Vaheri A (2011) TGF-beta1 causes epi-
mis. J Invest Dermatol 126:638647 thelial-mesenchymal transition in HaCaT derivatives,
75. Mirza R, Hayasaka S, Kambe F, Maki K, Kaji T, but induces expression of COX-2 and migration only
Murata Y, Seo H (2008) Increased expression of aqua- in benign, not in malignant keratinocytes. J Dermatol
porin-3 in the epidermis of DHCR24 knockout mice. Sci 58:97104
Br J Dermatol 158:679684 89. Rojek AM, Skowronski MT, Fuchtbauer EM,
76. Morita K, Itoh M, Saitou M, Ando-Akatsuka Y, Fuchtbauer AC, Fenton RA, Agre P, Frokiaer J,
Furuse M, Yoneda K, Imamura S, Fujimoto K, Tsukita Nielsen S (2007) Defective glycerol metabolism in
S (1998) Subcellular distribution of tight junction- aquaporin 9 (AQP9) knockout mice. Proc Natl Acad
associated proteins (occludin, ZO-1, ZO-2) in rodent Sci U S A 104:36093614
14 The Role of Tight Junctions and Aquaporins in Skin Dryness 231

90. Roudier N, Ripoche P, Gane P, Le Pennec PY, Daniels barrier formation and hair follicle aberrations in
G, Cartron JP, Bailly P (2002) AQP3 deficiency in Inv-Cldn6 mice. Mech Dev 122:805819
humans and the molecular basis of a novel blood 103. Troy TC, Turksen K (2007) The targeted overexpres-
group system, GIL. J Biol Chem 277:4585445859 sion of a Claudin mutant in the epidermis of trans-
91. Saitou M, Furuse M, Sasaki H, Schulzke J-D, genic mice elicits striking epidermal and hair follicle
Fromm M, Takano H, Noda T, Tsukita S (2000) abnormalities. Mol Biotechnol 36:166174
Complex phenotype of mice lacking occludin, a 104. Troy TC, Arabzadeh A, Lariviere NM, Enikanolaiye
component of tight junction strands. Mol Biol Cell A, Turksen K (2009) Dermatitis and aging-related
11:41314142 barrier dysfunction in transgenic mice overexpress-
92. Schlter H, Wepf R, Moll I, Franke WW (2004) ing an epidermal-targeted claudin 6 tail deletion
Sealing the live part of the skin: the integrated mutant. PLoS One 4:e7814
meshwork of desmosomes, tight junctions and cur- 105. Tunggal JA, Helfrich I, Schmitz A, Schwarz H,
vilinear ridge structures in the cells of the upper- Gunzel D, Fromm M, Kemler R, Krieg T, Niessen
most granular layer of the human epidermis. Eur J CM (2005) E-cadherin is essential for in vivo epider-
Cell Biol 83:655665 mal barrier function by regulating tight junctions.
93. Schneeberger EE, Lynch RD (2004) The tight junc- Embo J 24:11461156
tion: a multifunctional complex. Am J Physiol Cell 106. Turksen K, Troy TC (2002) Permeability barrier
Physiol 286:C1213C1228 dysfunction in transgenic mice overexpressing clau-
94. Smalley KS, Brafford P, Haass NK, Brandner JM, din 6. Development 129:17751784
Brown E, Herlyn M (2005) Up-regulated expression 107. Van Itallie CM, Anderson JM (2006) Claudins and
of zonula occludens protein-1 in human melanoma epithelial paracellular transport. Annu Rev Physiol
associates with N-cadherin and contributes to inva- 68:403429
sion and adhesion. Am J Pathol 166:15411554 108. Velazquez Pereda Mdel C, Dieamant Gde C, Eberlin
95. Sokabe T, Fukumi-Tominaga T, Yonemura S, S, Nogueira C, Colombi D, Di Stasi LC, de Souza
Mizuno A, Tominaga M (2011) The TRPV4 channel Queiroz ML (2009) Effect of green Coffea arabica
contributes to intercellular junction formation in L. seed oil on extracellular matrix components and
keratinocytes. J Biol Chem 285:1874918758 water-channel expression in in vitro and ex vivo
96. Song X, Xu A, Pan W, Wallin B, Kivlin R, Lu S, human skin models. J Cosmet Dermatol 8:5662
Cao C, Bi Z, Wan Y (2008) Nicotinamide attenu- 109. Verbavatz JM, Brown D, Sabolic I, Valenti G,
ates aquaporin 3 overexpression induced by retinoic Ausiello DA, Van Hoek AN, Ma T, Verkman AS
acid through inhibition of EGFR/ERK in cultured (1993) Tetrameric assembly of CHIP28 water chan-
human skin keratinocytes. Int J Mol Med 22: nels in liposomes and cell membranes: a freeze-frac-
229236 ture study. J Cell Biol 123:605618
97. Sougrat R, Morand M, Gondran C, Barre P, Gobin R, 110. Verdier-Sevrain S, Bonte F (2007) Skin hydration: a
Bonte F, Dumas M, Verbavatz JM (2002) Functional review on its molecular mechanisms. J Cosmet
expression of AQP3 in human skin epidermis and Dermatol 6:7582
reconstructed epidermis. J Invest Dermatol 118: 111. Verkman AS (2005) More than just water channels:
678685 unexpected cellular roles of aquaporins. J Cell Sci
98. Straseski JA, Gibson AL, Thomas-Virnig CL, Allen- 118:32253232
Hoffmann BL (2009) Oxygen deprivation inhibits 112. Verkman AS (2009) Aquaporins: translating bench
basal keratinocyte proliferation in a model of human research to human disease. J Exp Biol 212:
skin and induces regio-specific changes in the distri- 17071715
bution of epidermal adherens junction proteins, 113. Vockel M, Breitenbach U, Kreienkamp HJ, Brandner
aquaporin-3, and glycogen. Wound Repair Regen JM (2010) Somatostatin regulates tight junction
17:606616 function and composition in human keratinocytes.
99. Suarez-Farinas M, Fuentes-Duculan J, Lowes MA, Exp Dermatol 19:888894
Krueger JG (2011) Resolved psoriasis lesions retain 114. Voss KE, Bollag RJ, Fussell N, By C, Sheehan DJ,
expression of a subset of disease-related genes. J Bollag WB (2011) Abnormal aquaporin-3 protein
Invest Dermatol 131:391400 expression in hyperproliferative skin disorders. Arch
100. Sugiyama Y, Ota Y, Hara M, Inoue S (2001) Osmotic Dermatol Res 303:591600
stress up-regulates aquaporin-3 gene expression in 115. Watson RE, Poddar R, Walker JM, McGuill I, Hoare
cultured human keratinocytes. Biochim Biophys LM, Griffiths CE, ONeill CA (2007) Altered clau-
Acta 1522:8288 din expression is a feature of chronic plaque psoria-
101. Tanno O, Ota Y, Kitamura N, Katsube T, Inoue S sis. J Pathol 212:450458
(2000) Nicotinamide increases biosynthesis of cer- 116. Weber C, Fraemohs L, Dejana E (2007) The role of
amides as well as other stratum corneum lipids to junctional adhesion molecules in vascular inflamma-
improve the epidermal permeability barrier. Br J tion. Nat Rev Immunol 7:467477
Dermatol 143:524531 117. Werling AM, Doerflinger Y, Brandner JM, Fuchs F,
102. Troy TC, Rahbar R, Arabzadeh A, Cheung RM, Becker JC, Schrama D, Kurzen H, Goerdt S, Peitsch
Turksen K (2005) Delayed epidermal permeability WK (2011) Homo- and heterotypic cell-cell contacts
232 J.M. Brandner

in Merkel cells and Merkel cell carcinomas: hetero- 123. Yoshida Y, Morita K, Mizoguchi A, Ide C, Miyachi
geneity and indications for cadherin switching. Y (2001) Altered expression of occludin and tight
Histopathology 58:286303 junction formation in psoriasis. Archives of
118. Wilke K, Wepf R, Keil FJ, Wittern KP, Wenck H, Dermatological Research 293:239244
Biel SS (2006) Are sweat glands an alternate pene- 124. Yuki T, Haratake A, Koishikawa H, Morita K,
tration pathway? Understanding the morphological Miyachi Y, Inoue S (2007) Tight junction proteins in
complexity of the axillary sweat gland apparatus. keratinocytes: localization and contribution to bar-
Skin Pharmacol Physiol 19:3849 rier function. Exp Dermatol 16:324330
119. Yahagi S, Koike M, Okano Y, Masaki H (2011) 125. Yuki T, Hachiya A, Kusaka A, Sriwiriyanont P,
Lysophospholipids improve skin moisturization by Visscher MO, Morita K, Muto M, Miyachi Y,
modulating of calcium-dependent cell differentia- Sugiyama Y, Inoue S (2011) Characterization of
tion pathway. Int J Cosmet Sci 33:251256 tight junctions and their disruption by UVB in human
120. Yamamoto T, Saeki Y, Kurasawa M, Kuroda S, epidermis and cultured keratinocytes. J Invest
Arase S, Sasaki H (2008) Effect of RNA interference Dermatol 131:744752
of tight junction-related molecules on intercellular 126. Zheng X, Bollinger-Bollag W (2003) Aquaporin 3
barrier function in cultured human keratinocytes. colocates with phospholipase d2 in caveolin-rich
Arch Dermatol Res 300:517524 membrane microdomains and is downregulated upon
121. Yang J, Meyer M, Muller AK, Bohm F, Grose R, keratinocyte differentiation. J Invest Dermatol 121:
Dauwalder T, Verrey F, Kopf M, Partanen J, Bloch 14871495
W, Ornitz DM, Werner S (2010) Fibroblast growth 127. Zimmerli SC, Hauser C (2007) Langerhans cells and
factor receptors 1 and 2 in keratinocytes control the lymph node dendritic cells express the tight junction
epidermal barrier and cutaneous homeostasis. J Cell component claudin-1. J Invest Dermatol 127:23812390
Biol 188:935952 128. Zimmerli SC, Kerl K, Hadj-Rabia S, Hohl D, Hauser
122. Yasui M (2004) Molecular mechanisms and drug C (2008) Human epidermal Langerhans cells express
development in aquaporin water channel diseases: the tight junction protein claudin-1 and are present in
structure and function of aquaporins. J Pharmacol human genetic claudin-1 deficiency (NISCH syn-
Sci 96:260263 drome). Exp Dermatol 17:2023
 Biomechanics of the Barrier
Function of Human Stratum 15
Corneum

Kemal Levi and Reinhold H. Dauskardt

15.1 Introduction growth factors may be affected by mechanical

loading [37]. As the outermost layer of skin,
The outermost layer of skin, the stratum corneum the SC, acts as the principal mechanical inter-
(SC), provides mechanical protection and a con- face between the epidermal and dermal layers
trolled permeable barrier to the external environ- and the exterior environment and thus plays a
ment. It is subject to highly variable conditions crucial role in determining the stress state in
including changing temperature, humidity, mech- skin. Surprisingly, the connection to the mechan-
anical and abrasive contact. In addition, the SC ical properties and stresses in the skin remain
must withstand daily application of topical clean- elusive due in part to a paucity of mechanical
ing agents and potentially damaging acute and properties of the skin layers as a function of tis-
chronic chemical exposure. The mechanical sue condition and treatment.
properties of the SC are crucial not only for its
mechanical and biophysical function [1], but are
also a vital factor in the cosmetic aspects of skin
appearance, feel and firmness. In addition, 15.2 Drying Stress and Relationship
they play a central role in skin chapping and to Tissue Damage
cracking associated with dry skin conditions [2].
Mechanical behavior of the SC is also impor- Daily exposures to variable temperature and
tant for wound healing, adhesive dressings, and moisture conditions, together with application of
emerging biosensor and drug delivery technolo- cleansing agents, lead to skin dryness and
gies which must all have a reliable mechanical tightness. If left untreated, dry skin conditions
interface with skin. Residual stress in the SC can lead to tissue damage in the form of chapping
affects the growth and healing of skin. Fibrosis, and cracking, which is directly related to intercel-
scar formation, and various tissue responses lular delamination and fracture of the SC layer.
including inflammation and expression of Such damage can ultimately lead to tissue
responses including inflammation, scarring, and
abnormal desquamation and further exacerbate
the effects of skin disorders such as atopic der-
K. Levi R.H. Dauskardt () matitis, ichthyosis vulgaris, and chronic xerosis
Department of Materials Science and Engineering, [28]. Skin tightness is likely related to changes
Stanford University,
in the stiffness of the SC layer and the buildup of
496 Lomita Mall, Durand Bldg., Rm 121, Stanford,
CA 94305, USA tensile biaxial SC drying stresses in the plane of
e-mail: [email protected]; [email protected] the SC layer [911]. The presence of these

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 233

DOI 10.1007/978-3-642-27606-4_15, Springer-Verlag Berlin Heidelberg 2012
234 K. Levi and R.H. Dauskardt

Fig. 15.1 A schematic

illustration showing typical
dry skin cracking and
chapping processes that
result from the development
of drying stresses in SC. The
driving force for these
damage processes, G, can be
quantified in terms of the SC
stress, elastic properties and
thickness. The parameter Z is
determined by the cracking
configuration only. The
resistance to SC damage is
given in terms of the
intercellular delamination
energy, Gc. Damage occurs
when G Gc as indicated

stresses and their potential role in skin damage information about the specific cracking type
processes have been well cited, and connections (peeling, channel cracking, delamination, etc.).
have been suggested to water loss during drying Note that the mechanics presented here assumes
of treated tissue [9, 10, 1214]. However, quanti- that the SC is a linear elastic thin film on an elas-
tative methods to characterize these stresses have tic substrate and has been shown to be accurate
been still lacking until very recently, and little for the low strains, hydration conditions, and time
understanding existed regarding the effects of scales important for dry skin damage processes
drying environment, chemical exposures, and [16]. Cracking and chapping will develop in the
moisturizing treatments. SC during drying when the value of G exceeds
From a mechanics viewpoint, the SC drying the intercellular delamination energy, Gc, which
stress, sSC, provides a mechanical driving is a property of the tissue and provides a measure
force for dry skin damage such as cracking and of tissue resistance to cracking [1719]. Then,
chapping of the SC as shown in Fig. 15.1. The the ratio between G and Gc, G/Gc, can then be
stressed SC layer can then be treated as a thin used to infer the propensity of cracking in the tis-
(1530 mm) stiff film on a thick (13 mm) sub- sue following its exposure to a certain condition
strate consisting of the epidermal and dermal or treatment.
layers. The driving force for crack propagation
for the cracking configurations shown in
Fig. 15.1 can be quantified in terms of the strain 15.3 Measurement of Drying Stress
energy release rate, G, [15]:
15.3.1 Microtension
Z h 2
G= SC SC
(15.1) It is well known that isolated SC exhibits signifi-
ESC
cant shrinkage when dried from a hydrated con-
dition. If the SC is constrained from shrinking,
G depends on the SC stress squared divided by then stresses develop as it dries and attempts to
the SC biaxial elastic modulus, SC, which pro- contract. (Note that, in vivo, the constraint results
vides a measure of the elastic strain energy den- from the underlying skin layers which resist SC
sity stored in the film, the SC thickness, hSC, and shrinking in the plane of the SC). The develop-
a nondimensional parameter Z which provides ment of uniaxial drying stresses in isolated SC
15 Biomechanics of the Barrier Function of Human Stratum Corneum 235

4 ness and stress measurements. Also, the micro-

7% RH, 22C
tension technique simulates neither the in vivo
DIW treatment
drying conditions where moisture can only escape
SC stress, SC (MPa)

3
25 min from the outer SC surface nor the roughly equal
in vivo biaxial stress state of SC.
2 5 min

1 min

1 15.3.2 Substrate Curvature

The substrate curvature technique is widely used

0
0 2 4 6 8 in thin-film materials science to quantify the
Time, t (h) stresses of thin films on elastic substrates [2124],
and was recently adapted to measure SC drying
Fig. 15.2 The uniaxial sSC for tissue initially treated with
distilled water (DIW) for 1, 5, and 25 min and then stresses from the curvature of an elastic substrate
exposed to 7% RH and 25C air onto which the SC adhered [16]. Briefly, inplane
tensile or compressive stresses that develop in a
film adhered to an elastic substrate result in a con-
can be shown with microtension experiments cave or convex elastic curvature of the substrate,
where following treatment or conditioning the respectively. This elastic curvature, K, can be
wet tissue is clamped between two fixed grips of measured using optical, interferometric or capac-
a tensile testing unit and exposed to a certain dry- itative methods [2325]. In recent studies, a scan-
ing environment [16, 20]. The sSC values are then ning laser substrate curvature instrument was
determined using the measured loads and the SC used to measure the substrate angle of deflection,
thickness. a, in terms of the dimensions Ly and Lz, as a func-
The microtension technique can be used to tion of position, y as defined in Fig. 15.3. K was
detect sensitivity of SC to changes in hydration subsequently calculated from a linear regression
[16, 20]. The reported sSC for tissue initially analysis of a versus position data [16].
treated with distilled water (DIW) for 1, 5, and Using this technique, the biaxial SC film
25 min and then exposed to 7% RH and 25C air stress, sSC, adhered to an elastic substrate can be
is shown in Fig. 15.2. The sSC values for all spec- determined from K using the Stoneys equation
imens rise immediately after exposure to dry air [16, 26]:
and begin to stabilize after ~2 h. Note that the
E h2
final sSC values increase with increasing expo- SC = sub sub K , (15.2)
sure to hydration due to greater water loss during 1 - vsub 6hSC
drying.
The microtension technique provides a quick where Esub, nsub, hsub and hSC are the Youngs mod-
method to measure the SC drying stress. However, ulus, Poissons ratio, and thickness of the sub-
microtension experiments are challenging since strate and SC specimen thickness, respectively.
the SC is mechanically fragile and difficult to This relationship is based on the thin-film
handle after isolation and treatment. The transfer assumption that generally requires the product of
of the wet tissue to the grips of the tensile testing the film biaxial modulus and thickness to be
unit, particularly after exposure to damaging 1/80 of the equivalent product for the substrate
treatments (e.g., sodium dodecyl sulfate, ace- to ensure an error less than ~5% in the resulting
tone), is quite difficult. Often, wet tissue has been film stress. An important advantage of this
observed to curl or fold onto itself after being assumption and Stoneys equation is that the film
clamped between the two fixed grips of a tensile elastic properties are not required to calculate the
testing unit. This may result in inaccurate thick- film stress, making the SC stress analysis
236 K. Levi and R.H. Dauskardt

Fig. 15.3 The experimental SC stresses

arrangement for the substrate develop due to
curvature technique showing exposure or
the SC mounted on a glass treatment SC (~ 1525m)
substrate. A scanning laser Glass substrate
equipped with detector (179 m)
measures the angle of
deflection, a, versus position, z
y, on the substrate. The Substrate curves in
average curvature is calcu- response to SC
lated from a linear regression y
stresses
of the deflection angle

y Lz

Ly
Detector plane
Laser to measure
curvature

particularly straightforward in terms of the mea- out the use of an epoxy. Furthermore, digital
sured elastic curvature of the substrate using image correlation studies have shown there are
Stoneys equation. Nevertheless, as the SC film no net displacement of strains in the SC while
thickness is quite large compared to the substrate drying [16], proving that an adhesive is not
thickness, a more complete thick-film analysis required for accurate substrate curvature mea-
has been undertaken to validate the thin-film surements on SC.
approach, and sSC values have been reported to The reported sSC for DIW-treated tissue mea-
be insensitive to ESC and nSC as anticipated by the sured using the substrate curvature technique as a
thin-film assumption [16]. function of drying time in 15% RH and 25C air
As discussed, in vivo wet SC is constrained is shown in Fig. 15.4 [16]. The sSC of the wet tis-
from shrinking in-plane by the underlying epi- sue is ~0 MPa and does not change for a period of
dermal and dermal skin layers as it dries and 2 h. The sSC then rapidly increases and stabilizes
attempts to contract. The out-of-plane SC dimen- after ~4 h to a final value of ~2.5 MPa at 8 h. The
sion is not constrained and free to contract with- uniaxial drying stress measured using the micro-
out any through-thickness stress buildup. The tension technique under identical drying condi-
substrate curvature technique provides the same tions is included in the figure for comparison. By
type of biaxial constraint with an artificial sub- contrast, the uniaxial sSC values rise immediately
strate. There are two important requirements for after exposure to the drying air and stabilize after
the accuracy of this method. First, the mechani- ~4 h to a final value of ~1.48 MPa at 8 h. However,
cal properties of the substrate must be elastic for the time after which the drying stress stabilizes is
the range of strains experienced during drying of similar in both cases following the onset of the
the SC. Second, the tissue must be well adhered first drying stresses.
to the substrate. An epoxy can certainly be used The immediate development of drying stresses
to adhere the tissue to the substrate. However, in the microtension test is attributed to the fact
this can further complicate the method, as the that both sides of the SC specimen are exposed to
curvature of the added epoxy layer will also have the drying environment, thus allowing faster
to be taken into account for stress measurements water loss [16]. In the substrate curvature test,
with the possibility of epoxy impregnation into water can only escape from the original outer sur-
the SC layer. As such, the SC has been shown to face of the SC. Although the final sSC value mea-
naturally adhere well to clean glass surface with- sured using substrate curvature is significantly
15 Biomechanics of the Barrier Function of Human Stratum Corneum 237

3 treatment. The tissue is positioned on the sub-

15% RH, 25C strate while it is still inside the treatment solu-
tion. As the solution is removed, SC settles onto
SC stress,sSC (MPa)

Substrate curvature
the substrate. This prevents SC from curling or
2
(biaxial) folding onto itself as experienced in tensile test-
ing. In addition, if SC mechanical properties and
thickness compared to those of the substrate
Microtension
1 employed for curvature measurements satisfy the
(uniaxial)
thin-film assumption, SC mechanical proper-
ties are not required to determine the SC stresses.
This simplifies the stress analysis significantly
0
compared to other methods.
0 2 4 6 8
Time, t (h)

Fig. 15.4 The biaxial and uniaxial SC drying stress as a 15.4 Effect of Environmental
function of drying time for DIW-treated tissue exposed to Conditions and Chemical
15% RH and 25C air
Treatment on Drying Stress

15.4.1 Overview of Water Effects

higher than the microtension value, they are on Tissue Structure and Its
entirely consistent with simple elastic predictions Mechanical Properties
for films that are constrained under biaxial and
uniaxial conditions, while undergoing a transfor- The hydration characteristics of SC have been
mation (drying) strain. Using Hookes laws for extensively investigated using methods such as
linear elastic films, the relationship between the gravimetry [2729] and spectroscopic techniques
biaxial and uniaxial sSC is given by: including infrared [30], Raman [31], and nuclear
magnetic resonance spectroscopy [32, 33]. These
studies have shown that the water content of the
SC
biaxial
1 (15.3) tissue and its microstructure is very sensitive to
= .
SC
uniaxial
1 - SC the RH and temperature of the environment it is
conditioned at. In dry environments (<20% RH),
Using nSC ~ 0.4 for dried SC, the expected ratio of SC has a dense, semicrystalline structure. There
1.8 from Eq. 15.3 is close to the measured stress is a strong interaction between the keratin chains
ratio of 1.7. This means that the biaxial constraint due to hydrogen bonding between the polar-side
of the SC in the substrate curvature method groups of the keratin chains [34, 35]. The inter-
results in stresses that are consistent with the uni- cellular lipids are closely packed and rigid. As
axial microtension results. the tissue hydrates, the primary hydration sites,
The measured biaxial SC stresses in substrate such as the strong polar groups of keratin chains
curvature measurements more closely approxi- in corneocytes, covalently bound lipids of the
mate the biaxial in vivo stress state of SC com- cellular protein envelope and intercellular lipids,
pared to uniaxial stresses measured in a uniaxial become saturated and then additional water binds
tension test. Furthermore, water loss occurs only to the secondary hydration binding sites, namely,
through the outer SC surface, again more closely tightly bound water and dipolar sites on the pro-
approximating in vivo drying conditions. The tein [36]. This reduces the interaction between
substrate curvature technique also has experi- the keratin chains [37]. In the case of the lipids,
mental advantages compared with tensile testing. increasing water presence reduces the intermo-
SC can be more easily transferred to the substrate, lecular forces between the intercellular lipids and
particularly when it is mechanically fragile after loosens their packing [38]. As the tissue continues
238 K. Levi and R.H. Dauskardt

to hydrate, secondary hydration binding sites of the tissue has been shown to increase from 580
become saturated and water can no longer be to 1,390 J/m2 with increasing RH from 35% to
sorbed locally. Consequently, water condenses as 85% [48]. This trend is not observed for out-of-
unbound water [36]. The unbound water disrupts plane fracture properties due to constrained plas-
the hydrogen bonding between the keratin chains ticity [17]. The intercellular delamination energy
allowing them to be less constrained and move of the tissue has been shown to decrease from ~4
more easily relative to each other while being to ~1 J/m2 with increasing RH from 40% to 100%.
strained [34, 39]. Meanwhile, the intercellular This decrease has been associated with the sepa-
lipids of the hydrated tissue are less tightly packed ration of interfaces in the presence of water in the
and more fluid and permeable. intercellular space [18].
SC can be further hydrated if conditioned at
very moist environments (>90% RH) or soaked in
water. Increasing unbound water in the tissue has 15.4.2 Water Effects
been reported to have damaging effects on SC
depending on the length of exposure to hydration. SC drying stresses have been shown to be strongly
While short exposures to water (<1 h), even with dependent on the hydration level of the drying
repetitive applications during a day or over many environment [16]. The reported sSC values for
days, have no damaging effect on SC intercellular DIW-treated tissue as a function of drying time in
lipids [40, 41], long exposures (>1 h) cause sig- 15%, 30%, 45%, and 100% RH and 25C air are
nificant swelling in the corneocytes followed by shown in Fig. 15.5a. As moisture increases in the
formation of amorphous-appearing material and drying environment, both the drying stress rate
pooling of water in the intercellular lipids [41, 42]. (the increase in sSC with time following treatment
The dilation of the lipids due to pooling of water and exposure to air), dsSC/ dt, and the plateau sSC
has been shown to disrupt SC lamellar lipid ultra- values significantly decrease. No drying stresses
structure and produce corneocyte separations are observed for SC exposed to the 100% RH air
[41]. Furthermore, degradation of corneodesmo- as the tissue remains fully hydrated in a 100% RH
somes between corneocytes has been associated environment. The sSC also changes rapidly in
with increased hydration content [43, 44]. response to changes in the hydration level of the
The hydration state of SC has direct implica- drying environment as shown in Fig. 15.5b. This is
tions on its mechanical properties and propensity not surprising considering that SC is a biosensor
for cracking. With respect to elastic behavior, tis- which communicates outside changes to the under-
sue modulus has been reported to decrease from lying skin layers. The sSC values alternate between
~265 to 14 MPa with increasing humidity [16]. ~2.1 to 2.8 MPa and ~0 MPa as the tissue is cycled
This is associated with the effect of water on between 15% and 100% RH over 2-h periods after
molecular mobility in the SC. With increasing an initial drying period in 15% RH air.
water content, the interaction between keratin The sensitivity of sSC values to the hydration
chains is progressively weakened as discussed level of the drying environment is strongly linked
above. This involves substitution of existing pro- to the moisture content of the tissue, which is
teinprotein hydrogen bonds with water-medi- determined by how much water SC loses based
ated bonding to facilitate greater chain mobility on the chemical potential of water, mw, in the
[34, 45, 46]. Similar trends have been observed environment [16]. mw is a function of both RH
with nanoindentation measurements to obtain the and temperature and is defined by:
compression modulus of porcine SC, and the SC
modulus has been measured to decrease from w = 0 + RT ln (aH2 O ), (15.4)
~120 to 26 MPa with increasing humidity [47].
Interestingly, the effect of hydration on the SC where m0 is the standard chemical potential, R the
in-plane and out-of-plane fracture properties is universal gas constant, T the temperature in
different. The in-plane fracture (tearing) energy Kelvin, and aH2O the activity of water in the drying
15 Biomechanics of the Barrier Function of Human Stratum Corneum 239

a 4 environment given by [49]. The strong linear

25C relationship apparent between sSC and mw values
Drying air RH
shown in Fig. 15.5c for conditions listed in fur-
SC stress, sSC (MPa)

3 15% RH
ther proves that desorption of water from SC
during drying is the main driving force for evolu-
2 30% RH tion of drying stresses in the tissue.

45% RH
1
15.4.3 Modeling Water Effects
100% RH
0 A thin-film mechanics model that predicts the
0 2 4 6 8 amount of water loss from the SC during drying
Time, t (h)
from measured values of SC drying stress, elastic
b 4 modulus, and SC thickness has recently been
25C
reported [16]. Using this model, the shrinkage of
Dry at 15% RH Cyclic RH conditions
SC stress, sSC (MPa)

3 the tissue during drying, Ddry, can now be written

15% RH in terms of measured quantities:
2
1 - SC h f - h0 2 SC
D dry = -2 SC + + ^ SC , (15.5)
1
ESC h0 ESC
100% RH
where ESC, ESC ^
, h0 and hf are the in-plane and
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 out-of-plane Youngs modulus of the SC and ini-
Time, t (h) tial and final tissue thickness, respectively. Then,
c 4 the mass of water lost during drying of the SC
that accounts for the drying stress can be
obtained from:
SC stress, sSC (MPa)

mw = wVwet D dry , (15.6)

2

where rw is the density of water, and Vwet is the

1
volume of the wet tissue.
From the measured drying stress, modulus,
0 and SC thickness measurements, the predicted
244 242 240 238 236 water loss is compared to the measured water
Chemical potential of water, mw (kJ/mol)
loss in Fig. 15.6. The calculated water loss only
slightly exceeds the measured values by up to
Fig. 15.5 (a) SC drying stress as a function of drying
time for DIW-treated tissue exposed to 15%, 30%, 45%, ~16% for the SC dried in 45% RH air. The
and 100% RH air at 25C for up to 8 h. (b) SC drying strong linear relationship between the predicted
stress as a function of drying time for specimen exposed and measured water loss suggests that the SC
to 15% RH and 25C drying environment for ~8 h and
drying stress is mainly related to the reduction
then cycled between 100% RH and 15% RH at 2-h inter-
vals. (c) SC final drying stress as a function of chemical of the volume occupied by water, regardless of
potential of water in the drying environment. The linear fit the bound states of water that were discussed.
shows a strong correlation between the drying stress and This result also suggests that that the reorienta-
the chemical potential of water (R2 = 0.999)
tion of proteins and lipids which have com-
monly been thought to provide a significant
240 K. Levi and R.H. Dauskardt

5 into the tissue during treatment. SDS also binds

25C
Calculated moisture loss, mw (mg)

to SC proteins resulting in conformational

4 15% RH changes in their structure leading to transient
30% RH swelling and hyperhydration of corneocytes
3 45% RH
[9, 14, 53, 54]. Thus, the water content of the tis-
sue during exposure to SDS is much higher com-
pared to that of the tissue exposed to DIW.
2
cal meas Additionally, following exposure to SDS, SC has
mW = mW
been reported to return to a lower hydration state
1 compared to that of the tissue exposed to DIW
because surfactant binding reduces the ability of
100% RH
0 SC proteins to bind and hold water [9].
0 1 2 3 4
The increased sSC values of SDS-treated tis-
Measured moisture loss, mw (mg)
sue compared to DIW-treated tissue has been
Fig. 15.6 The predicted moisture loss as a function of the mainly linked to the increased volume of water
measured moisture loss. The linear fit shows a strong cor- lost during drying which is anticipated from our
relation between the two (R2 = 0.998) model in the previous section [16]. The other
possible causes of high SC drying stress values
contribution to the drying strains and stresses may be conformational changes in the keratin
may in fact be quite small. Based on this result, chains following SDS binding and contraction of
the relationship between the drying stresses and lipids due to extraction of a fraction of the inter-
the water loss can be used to understand how a cellular lipids or changes in the lipid composition
certain treatment affects the water retention in and content. The sSC of the SDS-treated tissue is
the tissue. We will use this relationship later in significantly reduced when the availability of
the chapter. water in the drying environment increases sug-
gesting that the damage caused by SDS may be
suppressed when the tissue is conditioned at
15.4.4 Chemical Treatment Effects moist environments.
In contrast to the harsh SDS treatment, the sSC
The substrate curvature technique has also been of the tissue treated with GLY is significantly
used to characterize SC drying stresses following lower than that of the control-treated tissue for
exposure to different treatments [16]. The both drying conditions. This trend is expected
reported final sSC values of SC initially treated considering that the GLY is a well-known mois-
with surfactant sodium dodecyl sulfate (SDS), turizing treatment which increases water-holding
moisturizing glycerin (GLY), and DIW (control) capacity of SC and accelerates the recovery of its
for 25 min and then dried for 8 h in 15% RH and barrier function after exposure to damaging treat-
25C or 27% RH and 32C air are plotted as a ments [55, 56]. Following exposure to GLY, cor-
function of the chemical potential of water, mw, in neocytes and SC intercellular spaces have been
the drying environment in Fig. 15.7. For both observed to expand, and the tissue has been
drying conditions, the sSC of the tissue treated reported to be at a higher hydration state com-
with the harsh cleanser surfactant, SDS, is sig- pared to that of the tissue exposed to DIW [57].
nificantly higher than that of the control-treated Additionally, after exposure to GLY, SC in-plane
tissue. SDS treatment is known to have damaging modulus significantly decreases with respect to
effects on all SC components and is widely used that of the DIW-treated tissue and the extensibil-
to study surfactant-induced dry scaly skin [50, 51]. ity of SC significantly increases [43].
It disrupts the barrier properties of the intercel- The reported effects of GLY above on SC
lular lipids increasing their fluidity and permea- hydration and mechanical properties suggest that
bility [52]. As a result, more water can penetrate the decreased sSC values of GLY-treated tissue
15 Biomechanics of the Barrier Function of Human Stratum Corneum 241

5 on the perception of skin dryness and tight-

ness. It also remains unclear whether these per-
4 25C, 15% RH ceptions are related to the drying of the coating
(MPa)

itself or the interaction of the coating with the

underlying SC. For example, the coating may
3
SC

Control affect the water content of the SC or may contain

SC stress,

molecules that diffuse into the SC and change its

32C, 27% RH
2 mechanical properties and stress state. In addi-
Control tion, the coating may itself develop drying stresses
that may be perceived as skin tightness. This sec-
1
SDS DIW GLY
tion first describes the application of the substrate
SDS DIW GLY
curvature technique to characterize stresses in
0 241.72 239.15 drying and nondrying occlusive topical coatings
Chemical potential of water, mw (kJ/mol) and then extensions of the technique to measure
the effects of the coating applied to the SC where
Fig. 15.7 SC final drying stress as a function of chemical the overall drying stresses may have contributions
potential of water for specimens treated with GLY, SDS from the coating, the SC, and the interaction of
and DIW (control) and exposed to either 15% RH and the coating with the SC. This section also dis-
25C or 27% RH and 32C air
cusses how these separate contributions in the
coating and SC layers can be differentiated.
compared to DIW-treated tissue may be due to the
decreased volume of water lost during drying and
the decreased SC modulus. The other possible 15.5.1 Substrate Curvature Technique
cause of low drying stress may be expansion of for Multiple Layers
lipids due to GLY increasing their fluidity. The
effects of corneodesmosome degradation are not The theory behind the substrate curvature method
considered since it is reported to occur when the and the relationship between the SC stresses and
tissue is conditioned at moist environments (>80% curvature have been described in detail in
RH) [43]. Note that the sSC of the GLY-treated Sect. 15.3.2. The extension of the substrate cur-
tissue remained the same at different drying con- vature technique to characterize the effects of
ditions. This means that the tissue maintains a topical coatings on SC stresses requires taking
certain level of hydration independent of the avail- the contribution of the coating to the overall cur-
ability of water in the drying environment after vature of the specimen into account. If the treat-
being treated with GLY. Altogether, the data in ment involves a coating applied to the SC that
Fig. 15.7 suggests that the substrate curvature develops stresses after application, the total sub-
technique can be used to easily detect and distin- strate curvature, KT, will be given by [5961]:
guish the sSC of SC treated with different
chemicals. K T = KSC + K coat , (15.7)

where Kcoat is the curvature associated with the

15.5 Extension of the Substrate stress developed in the treatment coating, and KSC
Curvature Method to Assess is the curvature associated with the drying stress
the Effect of Topical Coatings of the underlying SC. If the coating does not
on Stratum Corneum develop any stresses, then Kcoat = 0 and the curva-
ture measured is related to the stress in the SC,
Topical coatings are extensively used in medical sSC, only. On the other hand, if the treatment
and cosmetic formulations [58]. Despite their coating hardens and develops stresses of its own,
extensive use, little is understood of their effects scoat, then these will add to the curvature measured.
242 K. Levi and R.H. Dauskardt

If the multiple films together satisfy the thin-film detected, indicating zero coating stress. This also
assumption, then Stoneys equation can be suggests that there is no moisture diffusing out of
applied to relate the contribution of individual the coating.
film stresses to the substrate curvature. Any sig- Prior to the application of coatings on the SC,
nificant changes in the SC and coating thickness, the curvature and sSC of isolated SC should be
hcoat, during the experiment must be taken into measured as control in the same drying environ-
account in Stoneys equation (Eq. 15.2). Note ment as shown in Figs. 15.8b and c. Both NDO
that the overall substrate curvature is measured, and DO are then applied to the SC, and the sub-
and the individual SC and coating stresses cannot strate curvature is measured as a function of time
be deconvoluted without additional information. (Fig. 15.8b).
For example, if the coating stresses are separately The NDO coating does not harden, and the
measured, then their contribution to the substrate results shown in Fig. 15.8a show that no coating
curvature can be determined and subtracted from stresses develop. The curvature measured is
the total curvature using Eq. 15.7 to obtain the therefore associated with stresses in the SC only
curvature related to the SC stresses provided that which are calculated using Stoneys equation
the presence of the SC under the coating does not (Eq. 15.2) and shown in Fig. 15.8c. In the pres-
change the coating stresses. ence of NDO, the plateau sSC is significantly
lower than that of the control.
For the DO-coated specimen, it is assumed
15.5.2 Effects of Topical Coatings that the coating hardens and develops the same
on Stratum Corneum stresses as it does when applied directly to the
substrate. Using Eq. 15.7, the curvature associ-
Stresses that develop in topical coatings can be ated with the DO coating stresses (Fig. 15.8a) can
measured by applying the topical coating directly be subtracted from the total curvature (Fig. 15.8b)
to a glass substrate. Characterizing the stresses in to obtain just the curvature associated with stresses
topical coatings helps to isolate their effect on the in the SC. The sSC value can then be determined
SC. Since when they are applied to the SC, the using Stoneys equation (Eq. 15.2) as shown in
overall drying stresses have contributions from Fig. 15.8c. Interestingly, the sSC values stabilize
the coating, the SC, and the interaction of the for the DO-coated SC at values almost identical to
coating with the SC. This section reviews the those of the SC with the NDO coating.
effects of nondrying and drying occlusive barri- The principal effect of the occlusive coatings
ers (NDO and DO) on SC. on the SC is to maintain higher moisture content in
The reported coating stress and associated the SC when exposed to the drying environment.
substrate curvature for a drying occlusive barrier For the NDO- and DO-coated tissue, the final dry-
(DO) and a nondrying occlusive barrier (NDO) ing stresses are observed to be the same despite the
applied directly to a glass substrate and exposed initial difference in the stress profiles following
to the 26% RH and 26C drying environment are application of the coatings (Fig. 15.8c). This obser-
shown as a function of time in Fig. 15.8a. The vation demonstrates that both coatings are equally
DO coating hardens in the drying environment, effective at maintaining higher moisture content in
and a positive curvature develops in the substrate SC. To better understand the effect of occlusive
as a result of the presence of tensile drying barriers in maintaining higher moisture content in
stresses in the coating. These stresses have been SC, the relationship between the SC drying stresses
linked to the loss of water bound to the humectant and the chemical potential of water in the drying
molecules in the DO coating or contractions as a environment (Fig. 15.5c) shown in Sect. 15.4.2
result of cross-linking of emollient molecules in can be used. The decreased sSC values observed in
the coating when exposed to air. the presence of the occlusive barriers are equiva-
The NDO coating does not harden in the dry- lent to SC stresses that would be observed in a
ing environment, and no substrate curvature is 49% RH, 26C drying environment without any
15 Biomechanics of the Barrier Function of Human Stratum Corneum 243

a 0.05 0.8 3.0

26% RH, 26C

Coating stress, sCoat (MPa)

0.04 2.5 26% RH
DO 0.6
Curvature, K (m1)

SC Stress, SC (MPa)
drying air
0.03
2.0
0.4 Equivalent to
0.02 49% RH
1.5 drying air
0.2
0.01 with barrier
SC stress
NDO 1.0
withe barrier
0.00 0.0
0 2 4 6 8
Time, t (h) 0.5
b 0.15
26 % RH, 267C 0.0
244 242 240 238 236
Curvature, K (m1)

0.10 SC + DO Chemical potential of water, mw (kJ/mol)

SC only

Fig. 15.9 SC final drying stress as a function of chemical

SC + NDO potential of water in the drying environment. The
0.05 decreased SC stresses observed in the presence of the
occlusive barriers are equivalent to SC stresses that would
be observed in a 49% RH, 26C drying environment with-
0.00 out any occlusive barrier
0 2 4 6 8 10 12 14 16 18
Time, t (h)
c 3.0
26C, 26% RH and softening the tissue. This behavior is similar
2.5
SC only to the behavior observed in other studies where
SC stress, s SC(MPa)

SC + (DO)
2.0 diffusion of emollient molecules in the occlusive
1.5
coating into the intercellular boundaries of SC
causes significant softening of the tissue within
SC + (NDO)
1.0 minutes of application [60, 61].
0.5 The methodology presented in this study pro-
vides direct opportunities for studying the effects
0.0
of moisturizing treatments and occlusive barrier
0 2 4 6 8 10 12 14 16 18
Time, t (h) films used to control water loss on SC and allevi-
ate the propensity for dry skin damage. This will
Fig. 15.8 (a) The curvature and stress values as a func- be discussed in the next section.
tion of drying time for drying occlusive (DO) and nondry-
ing occlusive (NDO) coatings exposed to 26% RH and
26C air. (b) The total curvature values as a function of
drying time for stratum corneum (SC) treated with DO 15.6 Assessing Moisturizer Efcacy
and NDO coatings and exposed to 26% RH and 26C air. with the Substrate Curvature
(c) SC drying stress as a function of drying time for SC
treated with DO and NDO coatings and exposed to 26%
Method
RH and 26C air
Topical moisturizer products are formulated
occlusive barrier as shown in Fig. 15.9. This sug- based on their molecular, biochemical, and mois-
gests that the SC retains some water in the pres- ture occlusive properties to improve skin sensory
ence of the occlusive barriers. properties and alleviate dry skin [1, 911].
For the DO-treated SC, the stress relaxation Control of transepidermal water loss (TEWL),
following initial stress increase to a peak stress effects on skin components including lipid orga-
value may be the diffusion of moisturizing mole- nization, irritation potential, optical spectroscopy,
cules such as emollients in the coating into the SC and imaging together with consumer product
244 K. Levi and R.H. Dauskardt

Table 15.1 The treatments used in this study, their compositions, their physical states, and their mechanism of action
to moisturize skin are listed
Treatment Composition Physical state Type
GLY 10%, 30%, and 100% (v/v) in DIW Liquid Humectant
GLY-A 4050% (v/v) Glycerin Solid (gel) Humectant
4050% (v/v) Water
15% (v/v) Glyceryl polyacrylate
GLY-B 40% Glycerin (v/v),cetearyl alcohol, stearic acid, sodium Solid (cream) Oil/lamellar gel/
cetearyl sulfate, methylparaben, propylparaben, dilauryl water emulsion
thiodipropionate, sodium sulfate
AL C12C15 Alkyl esters (lactic acid, lauryl and myristyl Liquid Emollient
alcohol)
DA Diisopropyl adipate (adipic acid, isopropyl alcohol) Liquid Emollient
EP Ethylhexyl palmitate (palmitic acid, 2-ethylhexanol) Liquid Emollient
IN Isostearyl neopentanoate (neopentanoic acid, isostearyl Liquid Emollient
alcohol)
ISS Isocetyl steaoryl stearate (stearic acid, isocetyl alcohol) Liquid Emollient
OSS Octyldodecyl stearoyl stearate (atearic acid, octyldodecanol) Liquid Emollient
PET 100% White petrolatum USP Solid (gel) Occlusive
For the emollients, the main component of the composition is listed first. The remaining ingredients of the composition
which were used to construct the emollient molecule are in parenthesis

perceptions are used to assess efficacy [62]. various concentrations and different formulations
However, these do not measure the effects of of the nonvolatile trihydroxylated humectant,
moisturizing treatments on skin biomechanical glycerin (GLY), widely used as a hydrating agent
function, which affect not only the perception of in personal care products; and a range of undi-
dry skin stiffness and tightness but also underlie luted ester-based emollients with diverse physic-
the biomechanical component for dry skin dam- ochemical properties including alkyl lactate
age [16, 59]. (AL), diisopropyl adipate (DA), ethylhexyl palm-
This section discusses the application of the itate (EP), isostearyl neopentanoate (IN), isocetyl
substrate curvature technique to measure the effi- stearoyl stearate (ISS), and octyldodecyl stearoyl
cacy of selected moisturizers commonly used in stearate (OSS).
topical moisturizing products using the method-
ology presented in Sect. 15.5 [60, 61]. SC is
shown to have distinct drying stress profiles after 15.6.1 Petrolatum
application of various moisturizers. The section
also discusses how these moisturizers reduce sSC PET is regarded as one of the most effective
and alleviate the propensity for mechanically occlusive emollients for skin care, and its topical
induced dry skin damage. The effect of the mois- application is used as a standard to achieve
turizers on the SC drying stresses is explained in reduced TEWL following insults to the SC bar-
terms of SC water loss and the chemical state of rier [6365]. This section reviews drying stress
the SC components. measurements on PET-coated SC and demon-
The moisturizers discussed in this section are strates how the principal effect of the occlusive
listed in Table 15.1 and classified according to PET coating on the SC stresses is achieved
their mechanism of action to moisturize skin. through control of the SC water content.
These moisturizers include the purified mixture The reported sSC of PET-coated SC exposed to
of hydrocarbons taken from petroleum, petrola- 7% RH and 22C air is shown as a function of dry-
tum (PET), long considered as the gold stan- ing time in Fig. 15.10a [61]. Note that these sSC
dard occlusive treatment in cosmetic science; values are determined by taking the contribution
15 Biomechanics of the Barrier Function of Human Stratum Corneum 245

a 8 h drying 2 h at 8 h drying compared to DIW (control) is ~13% as shown in

at 7% RH 100% RH at 7% RH
Fig. 15.10b. As expected, a small reduction in the
5
22C water lost is enough to fully account for the
reduced drying stresses, given the sensitivity of
4 DIW SC drying stresses to SC water content. The
SC stress, sSC (MPa)

retention of water in the SC in the presence of

3 PET occlusive PET coating is also consistent with
reported reduced TEWL following insults to the
2 SC barrier [6365].
SC humidified
at 100% RH The other possible reason for lower sSC values
1 following PET treatment may be related to
increased intercellular lipid fluidity reported using
0 attenuated total reflectance Fourier transform
0 2 4 6 8 10 12 14 16 18 infrared spectroscopy (ATR FTIR) as a function
Time, t (h) of tissue depth [61]. This would act to reduce the
b 4 drying stresses by viscous flow allowing some cor-
DIW
neocyte movement in the plane of the SC, particu-
larly in the outer SC layers where there are few
SC stress, sSC (MPa)

3
corneodesmosomes connecting corneocytes. The
PET relaxation in SC stresses after ~4 h in the drying
2 environment strengthens this argument [61].

1 15.6.2 Glycerin-Based Humectants

Glycerin-based humectants have a significant

0
0 20 40 60 80 100 proclivity to bind with water and attract water
Water loss ratio, m/mdry (%) from the viable skin layers to the SC and from the
environment if the ambient RH exceeds 70%
Fig. 15.10 (a) SC drying stress as a function of drying [66]. This section reviews reported drying stress
time for SC treated with the occlusive PET coating and
measurements on SC following application of
exposed to 7% RH and 22C air. (b) SC drying stress as a
function of % water loss. The final stress value of PET- humectant GLY coatings listed in Table 15.1 and
coated SC and the corresponding percentage water loss the contribution of reduced water loss to the
value is plotted with dashed lines resulting decrease in sSC values.
Following application of GLY coatings, the
of the coating to the overall substrate curvature reported sSC values are observed to rapidly
into account as described in Sect. 15.5.2. The sSC increase and stabilize after ~2 h in the drying
values of PET-coated SC rise rapidly to a peak sSC environment where they remain relatively con-
value, remain relatively constant for ~2 h, and then stant as shown in Fig. 15.11a [61]. Since no
slowly relax to a final sSC value of ~2.3 MPa, ~37% stresses develop in the humectant coatings when
lower than the DIW (control)-treated tissue. applied directly on the glass substrate, the sSC
The contribution of reduced water loss to the values are determined from the overall substrate
reduced final sSC values following PET treatment curvature as described for NDO coatings in
can be determined using the mechanics model Sect. 15.5.2.
presented in Sect. 15.4.3 assuming that the stress With increasing GLY concentration, the dry-
is generated only by the strain change associated ing stress rate and the final sSC values are observed
with the volume of water lost to the drying envi- to decrease compared to DIW (control). This
ronment. The predicted reduction in water lost decrease, along with observed penetration of
246 K. Levi and R.H. Dauskardt

a 8 h drying
at 7% RH
2 h at
100% RH
8 h drying
at 7% RH
The contribution of water loss to the reduced
final sSC values following GLY application can be
5 determined from the relationship between mea-
10% GLY GLY A
30% GLY sured sSC values and water loss ratio [61]. Using
SC stress, sSC (MPa)

4 100%GLY
DIW this relationship, the predicted reduction in water
3
loss compared to the control is ~2%, 4%, and 8%
after 10%, 30%, and 100% GLY application,
GLY B
2 respectively (Fig. 15.11b). So again, given the
SC humidified sensitivity of SC drying stresses to SC water con-
at 100% RH
1 tent, only a small reduction in the water lost due
22C to the treatment may fully account for the reduced
0 drying stresses. The observed retention of water
0 2 4 6 8 10 12 14 16 18
Time, t (h)
in the SC in the presence of GLY is consistent
b 4 with reported corneocyte and SC intercellular
DIW
space expansion together with higher hydration
10% GLY
SC stress, sSC (MPa)

3 30% GLY states reported for GLY-treated SC [57].

100% GLY The other possible reason for lower sSC values
with increasing glycerin concentration may be the
2
reported increase in intercellular lipid fluidity
after application of the GLY coatings [61]. In
1 addition, when GLY is added to SC lipids in vitro,
it has been reported to interact with the intercel-
0
lular lipids and maintain the intercellular lipid
0 20 40 60 80 100
matrix in a fluid, liquid crystalline phase [55, 67].
Water loss ratio, m/mdry (%)
Considering that the SC lipids alone account for
Fig. 15.11 (a) SC drying stress as a function of drying ~530 vol.% of the total tissue volume, their
time for SC treated with the humectant coatings and expansion could act to reduce drying stresses by
exposed to 7% RH and 22C air. (b) SC drying stress as a viscous flow and increased movement of the cor-
function of % water loss. The final stress values of GLY- neocytes. The extent to which the observed drying
treated specimens and the corresponding % water loss
values are plotted with dashed lines stress reductions are related to such viscous flow
associated with increased lipid fluidity is not cur-
rently known. Also, although the final sSC values
GLY into the SC, suggests that GLY reduces are lower for GLY-coated SC compared to con-
water loss from the SC due to its proclivity to trol, the sSC values stabilize after ~2 h in the dry-
bind with water. The penetration of GLY coatings ing environment, and there is no evidence of
into the SC has been measured with ATR-FTIR further relaxation that would be expected in the
measurements as a function of tissue depth using case of viscous flow. Note that viscous intercellu-
a delamination technique [61]. Additionally, in lar boundary sliding could be arrested by stretch-
reported substrate curvature measurements, the ing of the corneodesmosomes to establish force
humectant GLY coatings are applied to the SC equilibrium after a predetermined amount of slid-
adhered to a glass substrate. These coatings can ing. Such mechanisms for drying stress reduction
neither attract water from the underlying glass are currently speculative and await further study.
substrate as they will in vivo nor can they draw While different concentrations of GLY in DIW
from the external dry (7% RH) environment. have been observed to reduce SC stresses, the
Therefore, the resulting drying stresses can be efficacy of other GLY-containing formulations in
explained solely in terms of the effect of humec- reducing these stresses has been shown to vary.
tant coatings on SC water loss and the SC com- The reported sSC values following application of
ponents themselves. two different formulations, GLY-A and GLY-B,
15 Biomechanics of the Barrier Function of Human Stratum Corneum 247

containing 4050% (v/v) glycerin are shown in These reported results show that the effective
Fig. 15.11a. sSC values of GLY-A-coated speci- delivery of GLY into the SC is crucial for it to
mens increase rapidly to a peak and then decrease reduce water loss from the tissue. Otherwise, the
to a final sSC value higher than that of the control. presence of a humectant coating on SC can
In contrast, the sSC values of specimens coated actually increase water loss from the tissue for
with GLY-B increase and stabilize at sSC values the isolated SC experimental model discussed in
lower than that of the control after ~2 h in the this section.
drying environment.
These drastically different stress profiles fol-
lowing application of two formulations contain- 15.6.3 Ester-Based Emollients with
ing similar amounts of GLY have been discussed Partially Occlusive Behavior
in terms of the effect of these coatings on SC
water loss and its components [61]. The signifi- Emollients are used as key ingredients in mois-
cantly higher final sSC and dsSC / dt values for turizing and cleansing formulations to improve
specimens coated with GLY-A suggest that SC skin sensory properties and alleviate dry skin.
is more sensitive to water loss following expo- They provide an oily partially occlusive film over
sure to this treatment despite the high GLY con- the surface of the skin which fills in the interstices
tent and humectancy of GLY-A. This nondrying between the desquamating corneocytes abundant
gel with a simple chemical composition consist- in dry skin conditions, smoothing the rough SC
ing of GLY and glyceryl polyacrylate does not surface and increasing the ability of the skin to
readily release the water contained within its hold water [66, 69]. Their occlusivity depends in
molecular structure even under severe drying part on their molecular weight, viscosity, and
conditions due to its clathrate (group of mole- spreading characteristics on SC. If the emollient
cules that form a cage-like matrix) structure. molecules penetrate into the SC, they may interact
Water molecules are held within the glyceryl with the intercellular lipids or corneocytes
polyacrylate clathrate matrix and released when depending on their hydrophilicity/lipophilicity,
disrupted by the salt content, pH and surface and in vivo, they may eventually be metabolized
temperature of skin [68]. and modify lipid secretory mechanisms [7072].
The increased sSC and dsSC /dt values follow- This section discusses reported effects of emol-
ing application of GLY-A has been associated lient molecules listed in Table 15.1 on SC drying
with the poor diffusion of the gel ingredients into stresses in terms of their direct effects on the
the SC and the strong affinity of both glycerin and components of the SC and moisture exchange
glyceryl polyacrylate in the gel to absorb water with the environment.
from the humid SC in the meantime. Finally, the The molecular structure of these emollients
significantly larger stress relaxation observed for together with their calculated partition coefficient,
GLY-A compared to GLY coatings has been log P, used to measure the hydrophilic/lipophilic
linked to increased lipid fluidity due to penetra- balance, and other salient physical characteristics
tion of glyceryl polyacrylate into the SC [61]. (molecular weight (MW), viscosity and spread-
The final sSC values of GLY-B-coated SC is ing characteristics) are listed in Table 15.2.
similar to the sSC values observed for tissue coated Among these treatments, DA is the least lipophilic
with 100% (v/v) GLY although the formulation (log P ~ 2.8) and likely to diffuse rapidly into the
contains only 4050% (v/v) GLY. The lower sSC SC and partition well between its hydrophilic and
values observed with GLY-B have been associated lipophilic lipid domains [73]. The other emol-
with the increased GLY penetration in the pres- lients are unlikely to partition into the hydrophilic
ence of the emulsifiers used in the treatment [61]. domains of the SC with log P values increasing
The formulation also contains an oil/lamellar gel-/ above 5. Rather, they are expected to partition
water-type emulsion that forms a hydrophobic film into the skin lipids and have extreme difficulty
on SC that further reduce water loss. partitioning out of the SC [74].
248 K. Levi and R.H. Dauskardt

Table 15.2 The molecular structure of the emollient coatings, their corresponding calculated log P values and other
salient physical characteristics (molecular weight (MW), viscosity and spreading characteristics) are listed
Viscosity
Treatment Molecular structure log P MW (g) (Pas) Spreading
DA O 2.79 230.2 0.004 High
O
O
O
AL O 5.92 286.5 0.018 High

R = C1215
OR

OH
IN O 10.25 354.4 0.015 Medium

EP O 11.15 368.4 0.014 Medium

O
ISS O C6H13 O 20.02 791.4 0.090 Low

C6H13
C17H35 O (CH2)10 O
C8H17
OSS O C6H13 O 26.92 846.9 0.083 Low

C10H21
C17H35
O (CH2)10 O
C8H17

Following application of emollient coatings 8 h drying 2 h at 8 h drying

on SC, the reported sSC values are nonzero; they at 7% RH 100% RH at 7% RH

increase rapidly to initial peak values in <1 h and 7

22C, 7% RH
relax to final values that are significantly lower 6
than DIW (control)-treated tissue as shown in
SC stress, sSC (MPa)

Fig. 15.12 [60]. Since no stresses develop in the 5

emollient coatings when applied directly on the
4
glass substrate, the sSC values are determined DIW
OSS
from the overall substrate curvature as described 3 DA
for NDO coatings in Sect. 15.5.2.
2 SC humidified IN
The complex drying stress profiles for emol- at 100% RH EP
lient-coated SC have been associated with the 1 ISS
AL
effects of emollient molecules on lipid extraction
0
and fluidity together with their effects on control 0 2 4 6 8 10 12 14 16 18
of SC water content [60]. The initial nonzero sSC Time, t (h)
values have been linked to contraction of SC lipids
due to extraction of a fraction of intercellular Fig. 15.12 SC drying stress as a function of drying time
for SC treated with the emollient coatings (DA, AL, IN,
lipids immediately following application of the EP, ISS, OSS) and exposed to 7% RH and 22C air
15 Biomechanics of the Barrier Function of Human Stratum Corneum 249

2 proclivity to bind with water and the perturbation

of the SC barrier properties due to extraction of a
A symmetric C-H
fraction of SC lipids with emollient penetration
stretching into the tissue as confirmed by spectroscopy
Absorbance (A.U.)

Symmetric C-H results. Additionally, the possibility of the DA

EP stretching treatment to dissolve and remove the natural
IN
1 moisturizing factor components of SC has been
AL

DA
suggested. This can reduce the natural humec-
tancy of the tissue as DA can penetrate into both
the hydrophilic and lipophilic domains of the tis-
Symmetric C-H
stretchin/Amide II
sue (based on its calculated log P value). On the
other hand, the high peak sSC values observed
0 following exposure to ISS and OSS (high-MW
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Initial SC stress, sSC (MPa) emollients with high lipophilicity) have been
attributed to two contributing effects. First, the
Fig. 15.13 The first stress values following application of emollients act to fluidize the lipids and in doing
emollient coatings as a function of the height of asym- so they free bound water, which can escape from
metric and symmetric CH bond stretching peak and the the SC. This is consistent with a reported increase
ratio of the height of symmetric CH stretching peak to
the height of the amide II peak. The linear fits show a in water loss from the SC with increasing lipid
strong correlation between the drying stress and the height fluidity as measured by the increase in lipid sym-
of the asymmetric and symmetric CH bond stretching metric stretching frequency [75]. The second is
peaks and the ratio of the height of symmetric CH related to the inability of these emollients to form
stretching peak to the height of the amide II peak
a continuous occlusive coating and their subse-
quent failure to prevent water loss from the tis-
emollient molecules. The extraction of SC lipids sue, which includes the previously bound water.
has been measured with ATR-FTIR by monitoring Finally, the relaxation of SC stresses from a
changes in the height of the symmetric and anti- peak sSC value to a final sSC value has been linked
symmetric CH stretching peaks and the ratio of to changes in the lipid fluidity of the tissue due to
the height of symmetric CH stretching peak to penetration of emollients into the SC. The pene-
the height of the amide II peak [60]. These peaks tration of GLY coatings into the SC has been
and ratios are indicators of lipid extraction. For the measured with ATR-FTIR measurements as a
emollients that resulted in lipid extraction, the ini- function of tissue depth using a delamination
tial sSC values have been observed to correlate well technique [60]. For the low-MW emollients, the
with the height of the symmetric and assymetric sudden rapid decrease in SC stresses has been
CH stretching peaks and the ratio of the height of attributed to the increase in lipid rigidity. On the
the symmetric CH stretching peak to the height other hand, the gradual stress relaxation for
of the amide II peak as shown in Fig. 15.13. medium and high-MW emollients has been attrib-
The reported high dsSC /dt and peak sSC val- uted to the ability of the corneocytes to move
ues following application of the emollient coat- somewhat due to increased fluidity of the lipid
ings have been associated with the humectancy matrix and gradual softening of the tissue due to
of the emollient coating on the SC, the extraction increased penetration of the emollients.
of a fraction of intercellular lipids with emollient We conclude by noting that the drying stress pro-
penetration into the SC, or the increased water files of the emollient-treated SC are more complex
loss from the tissue as the emollients fluidize the than those observed for DIW-treated specimens or
SC lipids [60]. The high initial and peak sSC val- after application of humectant or occlusive treat-
ues following exposure to DA and AL (low-MW ments where the major contribution to the drying
emollients with low lipophilicity) have been stresses is primarily due to the volume of water lost
attributed to the ability of these coatings to extract as discussed in Sects. 15.6.1 and 15.6.2. The drying
moisture out of SC due to their significant stress profiles following application of humectant or
250 K. Levi and R.H. Dauskardt

occlusive treatments does not exhibit the peaks and 1.5

8 h 25C

Strain energy release rate, G (J/m2)

significant relaxation exhibited after the emollient
Surface
treatments where both lipid extraction and changes cracking
in lipid fluidity contributed to the drying stresses in
addition to the volume of water lost. For the emol- 1.0

lients discussed in this section, the effects of other Channel

SC components on the resulting drying stresses are carcking
not expected to be significant because these emol-
0.5
lients (excluding DA) are likely to strongly partition
into the SC lipids based on their high partition coef-
Delamination
ficient value. However, we note that the extraction
of the lipids and changes in lipid fluidity may be 0.0
encountered by reorientation of the covalently 0 20 40 60 80 100
linked protein scaffolding constituted by the corni- Relative humidity, RH (%)

fied SC envelope and stretching of corneodesmo- Fig. 15.14 Crack driving force, G, values that result from
somes to establish force equilibrium. This can the SC drying stresses for surface cracking, channel crack-
especially play a role to arrest viscous intercellular ing and delamination as a function of the RH of the drying
boundary sliding or movement of corneocytes due environment for DIW-treated tissue exposed to air at 15%,
30%, 45%, and 100% RH and 25C for 8 h
to increased fluidity of the lipid matrix. The effect
of such mechanisms on the SC drying stresses is
currently speculative and awaits further study. the literature range from ~0.5 to 8 J/m2 for human
SC treated in different drying environments [17
19]. The G values estimated clearly equal or
15.6.4 Implications for Damage exceed Gc values in the lower part of the range
that we have previously reported (they are likely
We now consider the biomechanics model described to be higher due to the epidermal/dermal vis-
in Sect. 15.2 to infer the propensity for dry skin coelastic relaxation processes mentioned in the
damage by computing the strain energy release rate, introduction). Taken together, the results for the
G, from the reported values of sSC and ESC and com- value of G and the associated Gc values for dry
paring them to the SC resistance to cracking, Gc. G skin strongly suggest that the drying stress in SC
values of DIW-treated SC for the cracking configu- provides the principal mechanical driving force
rations shown in Fig. 15.1 are shown as a function for the formation and propagation of dry skin
of the RH of the drying environment in Fig. 15.14 damage. The results shown in Fig. 15.14 also
[16]. It is clear from the figure that G values increase suggest that the driving force for surface cracking
with decreasing RH of the drying environment. We which involves the propagation of a through
note that the mechanical driving force for skin dam- thickness SC crack into the underlying epidermal
age is particularly sensitive to the SC stress since G layers has the largest value of G making this the
scales with the square of sSC. On the other hand, the most prevalent form of skin damage. These
reported increasing stiffness of the SC with decreas- results are suggested from the mechanical mod-
ing RH of the drying environment would act to els for the different possible SC cracking config-
decrease G values since ESC appears on the denomi- urations but are clearly consistent with clinical
nator of Eq. 15.1. However, the SC stress dominates observations of severe dry skin damage. The sur-
and the values of G increase markedly with decreas- face cracking configuration provides a direct path
ing RH suggesting that the driving force for dry skin for environmental species to penetrate the SC
cracking and chapping damage increases as the skin barrier and enter the underlying skin layers.
is exposed to increasingly dry environments. Using the biomechanics model, it is also pos-
The G values determined must exceed the SC sible to predict the effect of chemical and mois-
resistance to cracking, Gc, in order for such skin turizing treatments discussed in this chapter on
damage processes to occur. Gc values reported in skin damage processes. By observing the ratio of
15 Biomechanics of the Barrier Function of Human Stratum Corneum 251

Fig. 15.15 (a) SC drying a 5 2

stress, sSC, intercellular

Normalized cracking force, G/Gc

Delamination energy, Gc (J/m2)
delamination energy, Gc, and Cracking
4 SC stress, sSC (MPa) enhanced
the normalized crack driving
1.5
force, G/Gc, shown as a
Cracking
function of chemical treatment
3 suppressed
(SDS, DIW and GLY) for SC
1.0
exposed to 15% RH air at
25C. The cracking potential is 2
significantly increased after
the SC is damaged by the SDS 0.5
1
treatment, and the cracking
potential is markedly reduced
after moisturizing with GLY. 0 0
(b) SC drying stress, sSC, DIW GLY SDS
intercellular delamination
energy, Gc, and the normalized
b 7 1.5
Delamination energy, Gc (J/m2)

Normalized cracking force, G/Gc

Cracking
crack driving force, G/Gc, 6 enhanced SC stress, sSC (MPa)
shown as a function of
emollient coatings 5 1.0
4 Cracking
suppressed
3
0.5
2

0 0
DIW AL DA EP IN ISS OSS

G/Gc and using the values for DIW-treated tissue DA-coated SC is higher compared to control sug-
exposed to a drying environment as a control, the gesting that this treatment may cause damage to
propensity for SC cracking for SDS- and GLY- the tissue. Our visual observations of a dry SC
treated tissue exposed to the same 15% RH and surface with evidence of cracking and flaking fol-
25C drying environment can immediately be lowing exposure to this treatment and the drying
observed (Fig. 15.15a). The normalized cracking environment strengthen this argument.
ratio for SDS-treated tissue increased significantly
with the higher drying stresses compared to the Conclusion
DIW-treated control, suggesting that the harsh The research described in this chapter involves
SDS treatment enhances the propensity for crack- synergistic experimental and mechanics mod-
ing. In contrast, the normalized cracking ratio for eling efforts to provide a fundamental scien-
the GLY-treated tissue with the lower drying tific and clinically relevant basis from which
stresses is significantly reduced compared to the skin damage processes associated with dry
control, indicating the beneficial effects of mois- skin conditions in isolated human SC can be
turizing treatments on reducing dry skin damage. quantitatively characterized and understood.
The same model can also be used to show the This research also provides the basis from
efficacy of emollient coatings discussed in this which biomechanical models can be employed
chapter as shown in Fig. 15.15b. The propensity to evaluate the efficacy of treatments on the
for cracking is significantly reduced for SC treated propensity for dry skin damage. Thin-film
with the emollient coatings (excluding DA) indi- mechanics techniques currently used to char-
cating again the beneficial effects of moisturizing acterize skin stresses are reviewed. The rela-
treatments on reducing dry skin damage. On the tionship of these stresses to tissue components
other hand, the propensity for cracking for and moisture content is discussed by using
252 K. Levi and R.H. Dauskardt

environmental, damaging and moisturizing References

chemical treatments to systematically manip-
ulate and influence components of the SC 1. Harding CR (2004) The stratum corneum: structure and
tissue including intercellular lipids, corneodes- function in health and disease. Dermatol Ther 17:615
2. Harding CR, Long S, Richardson J, Rogers J, Zhang
mosomes, and intracellular keratin. Finally, a Z, Rawlings AV (2003) The cornified envelope: an
mechanics framework is used to evaluate the important marker of stratum corneum in healthy and
efficacy of moisturizing treatments in alleviat- dry skin. J Cosmet Sci 25:157163
ing the potential for dry skin damage. Taken 3. Mustoe TA, Cooter RD, Gold MH, Hobbs FD,
Ramelet AA, Shakespeare PG et al (2002) International
together, this chapter discusses new and clinical recommendations on scar management. Plast
unique approaches to characterize and model Reconstr Surg 110:560571
the fundamental biomechanics of human SC 4. Longacre JJ, Berry HK, Basom CR, Townsend SF
and skin damage processes. (1976) The effects of Z plasty on hypertrophic scars.
Scand J Plast Reconstr Surg 10:113128
5. Scars BM (1998) Can they be minimised? Aust Fam
Physician 27:275278
Take Home Messages 6. Edlich RF, Carl BA (1998) Predicting scar formation:
from ritual practice (Langers lines) to scientific disci-
We review the application of the sub-
pline (static and dynamic skin tensions). J Emerg Med
strate curvature technique to character- 16:759760
ize drying stresses in human stratum 7. Atkinson JM, Barnett AG, McGrath DJ, Rudd M
corneum (SC) following environmental (2005) A randomized controlled trial to determine the
efficacy of paper tape in preventing hypertrophic scar
preconditioning, chemical and moistur-
formation. Plast Reconstr Surg 116:16481656
izing treatment in a range of drying 8. Gaul LE, Underwood GB (1952) Relation of dew
environments. point and barometric pressure to chapping of normal
We describe a biomechanical model that skin. J Invest Dermatol 19(1):919
9. Ananthapadmanabhan KP, Moore DJ, Subramanyan K,
explains how these stresses provide the
Misra M, Meyer F (2004) Cleansing without compro-
propensity for dry skin damage such as mise: the impact of cleansers on the skin barrier and
cracking and chapping. the technology of mild cleansing. Dermatol Ther
We review extensions of the substrate 17(Suppl 1):1625
10. Subramanyan KF (2007) Advances in the materials
curvature technique to measure the effi-
science of skin: a composite structure with multiple
cacy of topical coatings applied to SC functions. MRS Bull 32(10):770
where the overall drying stresses may 11. Rudikoff D (1998) The effect of dryness on skin. Clin
have contributions from the coating, the Dermatol 16:99107
12. Rawlings AV, Matts PJ (2005) Stratum corneum mois-
SC, and the interaction of the coating
turization at the molecular level: an update in relation to
with the SC. the dry skin cycle. J Invest Dermatol 124:10991110
We elucidate the effects of occlusive, 13. Harding CR, Watkinson A, Rawlings AV, Scott IR
humectant, and emollient moisturizers (2000) Dry skin, moisturization and corneodesmoly-
sis. Int J Cosmet Sci 1:2152
on the mechanical properties and drying
14. Rhein L, Robbins C, Fernee K, Cantore R (1986)
stresses in SC. Surfactant structure effects on swelling of isolated human
We explain how moisturizers affect the stratum corneum. J Soc Cosmet Chem 37:125139
water content and structural compo- 15. Hutchinson JW, Suo Z (1992) Mixed mode cracking
in layered materials. Adv Appl Mech 29:63191
nents of the tissue and how these subse-
16. Levi K, Weber RJ, Do JQ, Dauskardt RH (2009)
quently determine the stress state in the Drying stress and damage processes in human stratum
tissue. corneum. Int J Cosmet Sci 32(4):276293
Using the biomechanical model reviewed 17. Wu KS, Van Osdol WW, Dauskardt RH (2005)
Mechanical properties of human stratum corneum:
in the chapter, we demonstrate how dam-
effects of temperature, hydration, and chemical treat-
aging treatments enhance and moisturiz- ment. Biomaterials 27(5):785795
ing treatments alleviate the propensity 18. Wu KS, Li J, Ananthapadmanabhan KP, Dauskardt RH
for dry skin damage. (2006) Time-dependent intercellular delamination of
human stratum corneum. J Mater Sci 42(21):8986
15 Biomechanics of the Barrier Function of Human Stratum Corneum 253

19. Wu KS, Stefik MM, Ananthapadmanabhan KP, in vitro proton nuclear magnetic resonance spectros-
Dauskardt RH (2006) Graded delamination behavior copy. Int J Cosmet Sci 20(2):117
of human stratum corneum. Biomaterials 27: 34. Takahashi M, Kawasaki K, Tanaka M, Ohta S, Tsuda Y
58615870 (1981) The mechanism of stratum corneum plastici-
20. Mukherjee S, Richardson J, Margosiak M, Lei X (1999) zation with water. In: Marks RM, Payne PA (eds)
Understanding dry rough skin: a physical basis for the Bioengineering and the skin. MTP Press Ltd,
effects of dry environment and surfactant treatment on Lancaster, pp 6773
corneum fracture. In: Lal M, Lillford PJ, Naik VM, 35. Jokura Y, Ishikawa S, Tokuda H, Imokawa G (1995)
Prakash V (eds) Supramolecular and colloidal struc- Molecular analysis of elastic properties of the stratum
tures in biomaterials and biosubstrates Proceedings of corneum by solid-state 13C-nuclear magnetic reso-
the fifth royal society-Unilever Indo-UK forum in nance spectroscopy. J Invest Dermatol 104(5):806812
materials science and engineering, held in Mysore, 36. Guo X, Imhof RE, Rigal J (2001) Spectroscopic study
India, on January 1014, 1999. World Scientific of water-keratin interactions in stratum corneum. Anal
Publishing Company, Singapore, pp 306324 Sci 17:s342
21. Flinn PA, Gardner DS, Nix WD (1987) Measurements 37. Leveque JL (2004) Bioengineering of the skin: water
and interpretation of stress in aluminum-based metal- and the stratum corneum. CRC Press, Boca Raton
lization as a function of thermal history. IEEE Trans 38. Barry BW (1988) Action of skin penetration enhanc-
Electron Dev ED-34(3):689699 ers-the lipid protein partitioning theory. Int J Cosmet
22. Gardner DS, Flinn PA (1988) Mechanical stress as a Sci 10(6):281
function of temperature in aluminum films. IEEE 39. Wu KS (2006) Mechanical behavior of human stra-
Trans Electron Dev 35(12):21602169 tum corneum: relationship to tissue structure and con-
23. Moske M, Samwer K (1988) New UHV dilatometer for dition. Stanford University, Stanford
precise measurement of internal stresses in thin binary- 40. Ramsing DW (1997) Effect of water on experimen-
alloy films from 20750K. Rev Sci Instrum 59:2012 tally irritated human skin. Br J Dermatol 136(3):364
24. Bader S, Kalaugher EM, Arzt E (1995) Comparison 41. Warner RR, Boissy YL, Lilly NA, Spears MJ,
of mechanical properties and microstructure of Al (1 McKillop K, Marshall JL et al (1999) Water disrupts
wt. % Si) and Al (1 wt. % Si, 0.5 wt. % Cu) thin films. stratum corneum lipid lamellae: damage is similar to
Thin Solid Films 262:175184 surfactants. J Invest Dermatol 113(6):960966
25. Keller RM, Baker SP, Arzt E (1998) Quantitative 42. Van Hal DA, Jeremiasse E, Junginger HE, Spies F,
analysis of strengthening mechanisms in thin cu films: Bouwstra JA (1996) Structure of fully hydrated human
effects of film thickness, grain size, and passivation. stratum corneum: a freeze-fracture electron micros-
J Mater Res 13(5):13071317 copy study. J Invest Dermatol 106(1):8995
26. Stoney GG (1909) The tension of metallic films 43. Rawlings A, Harding C, Watkinson A, Banks J,
deposited by electrolysis. Proc R Soc Lond B Biol Ackerman C, Sabin R (1995) The effect of glycerol
82(553):172 and humidity on desmosome degradation in stratum
27. Anderson RL, Cassidy JM, Hansen JR, Yellin W corneum. Arch Dermatol Res 287(5):457464
(1973) Hydration of stratum corneum. Biopolymers 44. Bouwstra JA, de Graaff A, Gooris GS, Nijsse J,
12(12):27892802 Wiechers JW, van Aelst AC (2003) Water distribution
28. Liron Z, Wright RL, McDougal JN (1994) Water dif- and related morphology in human stratum corneum at
fusivity in porcine stratum corneum measured by a different hydration levels. J Invest Dermatol
thermal gravimetric analysis technique. J Pharm Sci 120(5):750758
83(4):457462 45. Wilkes GL, Wildnauer RH (1973) Structureproperty
29. Kasting GB, Barai ND (2003) Equilibrium water relationships of the stratum corneum of human and
sorption in human stratum corneum. J Pharm Sci neonatal rat. II. Dynamic mechanical studies. Biochim
92(8):16241631 Biophys Acta 304(2):276289
30. Potts RO, Guzek DB, Harriss RR, McKie JE (1985) A 46. Wilkes GL, Nguyen AL, Wildnauer R (1973)
non invasive, in vivo, technique to quantitatively mea- Structureproperty relations of human and neonatal
sure water concentration of the stratum corneum using rat stratum corneum. I. Thermal stability of the crys-
attenuated total-reflectance infrared spectroscopy. talline lipid structure as studied by X-ray diffraction
Arch Dermatol Res 277:489495 and differential thermal analysis. Biochim Biophys
31. Caspers PJ, Lucassen GW, Wolthuis R, Bruining HA, Acta 304(2):265275
Puppels GJ (1998) In vitro and in vivo Raman spec- 47. Yuan Y, Verma R (2006) Measuring microelastic prop-
troscopy of human skin. Biospectroscopy 4(5 erties of stratum corneum. Colloids Surf B 48(1):6
Suppl):9 48. Nicolopoulos CS, Giannoudis PV, Glaros KD,
32. Hansen JR, Yellin W (1972) NMR and infrared spec- Barbenel JC (1998) In vitro study of the failure of skin
troscopic studies of stratum corneum hydration. surface after influence of hydration and precondition-
Plenum Press, New York ing. Arch Dermatol Res 290(11):638640
33. Gilard V (1998) Measurement of total water and 49. Murray FW (1967) On the computation of saturation
bound water contents in human stratum corneum by vapor pressure. J Appl Meteorol 6:203204
254 K. Levi and R.H. Dauskardt

50. Imokawa G, Akasaki S, Minematsu Y, Kawai M Baran R, Maibach HI (eds) Textbook cosmetic derma-
(1989) Importance of intercellular lipids in water- tology. Taylor & Francis Group, Boca Raton
retention properties of the stratum corneum: induction 63. Loden M (1992) The increase in skin hydration after
and recovery study of surfactant dry skin. Arch application of emollients with different amounts of
Dermatol Res 281(1):4551 lipids. Acta Derm Venereol 72:327330
51. Fulmer AW, Kramer GJ (1986) Stratum corneum lipid 64. Ghadially R, Halkier-Sorensen L, Elias PM (1992)
abnormalities in surfactant-induced dry scaly skin. Effects of petrolatum on stratum corneum structure
J Invest Dermatol 86(5):598602 and function. J Am Acad Dermatol 26(3 Pt 2):
52. Downing DT, Abraham W, Wegner BK, Wilman KW, 387396
Marshall JL (1993) Partition of sodium dodecyl sul- 65. OGoshi KI, Tabata N, Sato Y, Tagami H (2000)
fate into stratum corneum lipid liposomes. Arch Comparative study of the efficacy of various moistur-
Dermatol Res 285(3):151 izers on the skin of the ASR miniature swine. Skin
53. Ananthapadmanabhan KP, Lips A, Vincent C, Meyer F, Pharmacol Appl Skin Physiol 13(2):120127
Caso S, Johnson A et al (2003) pH-induced alterations in 66. Draelos ZD (2000) Therapeutic moisturizers.
stratum corneum properties. Int J Cosmet Sci 25(3):103 Dermatol Clin 18(4):597607
54. Putterman GJ, Wolsejsza NF, Wolfram MA, Laden K 67. Hara M, Verkman AS (2003) Glycerol replacement
(1977) The effect of detergents on swelling of stratum corrects defective skin hydration, elasticity, and bar-
corneum. J Soc Cosmet Chem 28:521532 rier function in aquaporin-3-deficient mice. Proc Natl
55. Froebe CL, Simion FA, Ohlmeyer H, Rhein LD, Acad Sci USA 100(12):7360
Mattai J, Cagan RH (1990) Prevention of stratum cor- 68. Greff, D. (2000). Cosmetic, dermopharmaceutical or vet-
neum lipid phase transitions in vitro by glycerol an erinary compositions for disinfecting human or animal
alternative mechanism for skin moisturization. J Soc skin. U.S. Patent 6,123,953, filed February 20, 1997, and
Cosmet Chem 41:51 issued September 26, 2000
56. Fluhr JW, Gloor M, Lehmann L, Lazzerini S, Distante F, 69. Cork MJ (1997) The importance of skin barrier func-
Berardesca E (1999) Glycerol accelerates recovery of tion. J Dermatolog Treat 8:7
barrier function in vivo. Acta Derm Venereol 70. Kucharekova M, Van de Kerkhof PCM, Van der Valk
79(6):418421 PGM (2003) A randomized comparison of an emol-
57. Orth DS, Appa Y (1999) Glycerine: a natural ingredient lient containing skin-related lipids with a petrolatum-
for moisturizing skin. In: Loden M, Maibach HI (eds) based emollient as adjunct in the treatment of chronic
Dry skin and moisturizers. CRC Press, Boca Raton hand dermatitis. Contact Dermatitis 48(6):293299
58. Loden M (2003) Role of topical emollients and mois- 71. Wertz PW, Downing DT (1990) Metabolism of topi-
turizers in the treatment of dry skin barrier disorders. cally applied fatty acid methyl esters in BALB/C
Am J Clin Dermatol 4(11):771788 mouse epidermis. J Dermatol Sci 1(1):33
59. Levi K, Dauskardt RH (2010) Application of substrate 72. Mao-Qiang M, Brown BE, Wu-Pong S, Feingold KR,
curvature method to differentiate drying stresses in Elias PM (1995) Exogenous nonphysiologic vs physi-
topical coatings and human stratum corneum. Int J ologic lipids: divergent mechanisms for correction of
Cosmet Sci 32(4):294298 permeability barrier dysfunction. Arch Dermatol
60. Levi K, Kwan A, Rhines AS, Gorcea M, Moore DJ, 131:809816
Dauskardt RH (2010) Emollient molecule effects on 73. Hadgraft J (2001) Skin, the final frontier. Int J Pharm
the drying stresses in human stratum corneum. Br J 224(12):1
Dermatol 163(4):695703 74. Hadgraft J, Finnin BC (2006) Fundamentals of retard-
61. Levi K, Kwan A, Rhines AS, Gorcea M, Moore DJ, ing penetration. In: Smith EW, Maibach HI (eds)
Dauskardt RH (2011) Effect of glycerin on drying Percutaneous penetration enhancers. CRC Press, Boca
stresses in human stratum corneum. J Dermatol Sci Raton
61(2):129131 75. Potts RO, Francoeur ML (1990) Lipid biophysics of
62. Hannon W, Maibach HI (1998) Efficacy of moistur- water loss through the skin. Proc Natl Acad Sci USA
izers assessed through bioengineering techniques. In: 87:38713873
 Part III
Dry Skin Disorders and Treatments
 Update on Atopic Eczema
with Special Focus on Dryness 16
and the Impact of Moisturizers

Eric Simpson

16.1 Clinical Presentation

Atopic dermatitis (AD) is the most common

skin disease of childhood and is characterized
by erythematous papules and papulovesicles
during its initial presentation, followed by sub-
acute lesions that are crusted, weeping, scaling,
and excoriated. Chronic lesions show skin thick-
ening, xerosis, and exaggerated skin markings
(lichenification) that are the skins response to
rubbing (Fig. 16.1). Sites of predilection are the
face and extensor extremities in infancy, with Fig. 16.1 Erythematous papules, crusting, and licheni-
more frequent involvement of the flexural areas fied plaques on the flexural ankles typical of atopic derma-
titis in a pediatric patient with moderate disease
after age 1 [27]. Skin lesions are accompanied
by intractable pruritus, the primary symptom
leading to the reduced quality of life observed in Several other neuropsychiatric conditions have
these children. recently been reported to be associated with AD
including anxiety, depression, and autism [83].
These associations display a dose-dependent
16.2 Impact on Quality of Life response based on AD severity. A childs AD
often affects an entire family as well. Caring for a
Children with AD display measurable emotional child with AD impacts a family to a greater degree
and behavioral differences compared to their peers than caring for a child with type I diabetes [70].
without AD [10]. Recent data show that the sleep
loss associated with AD increases the prevalence
of attention deficit hyperactivity disorder [55]. 16.3 Nomenclature

Historically, the terms prurigo of Besnier, neuro-

E. Simpson, MD, M.C.R dermatitis, and allergic eczema all represented
Department of Dermatology, Oregon Health & Science what we now know as AD. Even today, there are
University, Center for Health and Healing,
3303 SW Bond Ave, MC: CH16D, Portland, OR 97239,
many attempts to rename AD based on whether
USA the disease is accompanied by IgE sensitization or
e-mail: [email protected] not. The role of IgE in AD has been a controversial

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 257

DOI 10.1007/978-3-642-27606-4_16, Springer-Verlag Berlin Heidelberg 2012
258 E. Simpson

subject for many years, but several studies have a 1-year period prevalence ranging between 10%
shown that the IgE need not be present to make a and 18% in the United States [62] and 20% in
diagnosis. Flohr found no association between IgE Northern Europe [51]. Similar to asthma and food
sensitization and flexural eczema in rural environ- allergy, the prevalence of AD has increased over
ments [23]. We recommend and continue to use the past 50 years and continues to increase in
the term atopic dermatitis for all children who developing countries [60] for unclear reasons [81].
meet standard criteria for the disease [28]. Environmental factors associated with industrial-
Documenting the presence or absence of IgE may ization likely play a role [51]. In high prevalence
be of use when managing concomitant type I aller- areas of Europe and Asia, this increase appears to
gic diseases or performing genetic studies but be stabilizing at approximately 20% [81, 85].
should not be an essential component to establish-
ing the diagnosis of AD or to influence the treat-
ment of the skin. 16.6 Allergic Comorbidity

Between 60% and 80% of patients with AD have

16.4 Diagnostic Criteria specific IgE sensitization, although the strength
of this association varies by disease severity, the
In 1980, Hanifin and Rajka proposed their criteria age of the patient, and geographical location. The
for diagnosing AD after input from experts from etiologic basis of IgE sensitization in AD is not
around the world during the first International clear and is likely multifactorial. IgE sensitiza-
Symposium of Atopic Dermatitis in Stockholm tion may occur before or after AD development
[29]. These criteria represent the gold standard for [44], so the cause-and-effect relationship between
the diagnosis of AD, although the large number of AD and IgE is unclear. In theory, children may be
minor criteria makes it somewhat cumbersome to born with a genetic predisposition to the develop-
use in the clinic. Similar to AD nomenclature, ment of IgE, and genetic polymorphisms in Th2
numerous criteria for the diagnosis of AD have been cytokine pathways that could be responsible for
proposed. Most sets of criteria have not undergone this predisposition have been found in AD. On
formal validation studies. The criteria that have the other hand, several lines of evidence suggest
been most extensively validated are the UK Working elevated IgE levels may develop secondarily from
Party criteria, a systematic distillation of the Hanifin- a genetically disrupted skin barrier [20, 58].
Rajka criteria designed for epidemiological studies. Mouse models reveal that a disrupted skin barrier
The millennium criteria have been recently validated leads to significant IgE production targeted to
[59]. While being a more concise instrument than skin-applied protein antigens [33, 68]. Lack and
the Hanifin-Rajka criteria, the millennium criteria colleagues first provided clinical evidence of epi-
contain the requirement that IgE sensitization be cutaneous sensitization when his group showed
present in order to establish a diagnosis of AD. As that the strongest predictor of peanut allergy was
discussed previously, the significance of IgE for AD the previous use of peanut oil on the skin [40].
diagnosis and therapy has not been established. The Most recently, genetic defects in the gene encod-
American Academy of Dermatology Consensus ing the skin barrier protein filaggrin have been
criteria may serve as a more practical guide to AD shown to be associated with peanut allergy inde-
diagnosis in the clinical setting, although they have pendent of eczema development, suggesting early
not yet been validated [15]. peanut exposure to a disrupted skin barrier may
promote type I peanut allergy [7]. As a conse-
quence of IgE sensitization, patients with AD are
16.5 Prevalence at increased risk for developing asthma, allergic
rhinitis, and food allergy. The prevalence of
There is significant worldwide variation in the asthma in patients with AD varies depending
prevalence of AD [51]. A higher disease preva- upon AD severity and ranges between 14.2% and
lence exists in more industrialized countries, with 52.7% according to a systematic review of cohort
16 Update on Atopic Eczema with Special Focus on Dryness and the Impact of Moisturizers 259

studies [78]. Children with eczema prior to the 16.8 Genetic Factors
age of 4 had a greater than twofold odds increased
risk of asthma at age 6. While over 20 genes have been associated with
atopic dermatitis, defects in the skin barrier gene
filaggrin (FLG) have emerged as the most repli-
16.7 Pathogenesis Overview cated and most important to date [2]. Candidate
gene studies have found polymorphisms in sev-
Twin studies reveal that AD has a strong genetic eral components of various immune pathways,
basis, although the inheritance pattern is non- but, unlike FLG studies, most have failed study
Mendelian, suggesting that multiple genes and/or replication [2]. Over 30 papers examining popu-
external factors contribute to its development lations primarily in Asia and Europe have con-
[75]. While most experts agree that the disease is firmed the importance of FLG mutations in AD
characterized by immune hyperactivity and skin [1]. Over 40 mutations have been described, all
barrier dysfunction, there has been significant leading to an absence of protein expression
disagreement regarding what constitutes the most through nonsense or frame-shift mutations [1].
important driving force for expression of the dis- Both mouse and human studies suggest the
ease. There are those who propose the underlying mechanism by which FLG deficiency leads to
and most influential defect in AD lies within the AD is through impaired barrier function.
epidermis (outside-in hypothesis), and there are Filaggrin deficiency leads to a dry and impaired
those who propose that the initiating event lies skin barrier through reduced NMF levels (see
within a dysregulated immune system (inside-out Sect. 16.11), a paracellular lipid defect, and an
hypothesis) [16]. In recent years, it is becoming elevated stratum corneum pH. An elevated pH
clear that there is a complex relationship between may have multiple negative downstream effects
the epidermis and the immune system in this dis- on barrier function such as a reduction in lamel-
order and that the disease may develop from con- lar body secretion and activation of serine pro-
tributions from both defects in the structural teases [18]. Mouse models of filaggrin deficiency
components of the skin barrier and from aberrant reveal this skin barrier defect alone leads to
immune responses, with environmental factors increased transepidermal water loss, cutaneous
modifying this relationship [17] (Fig. 16.2). inflammation, the development of Th2-dominant
inflammation, and IgE sensitization to topically
applied allergens [20]. A meta-analysis of FLG
Environment associations reveals that people with AD and
FLG mutations have earlier onset disease, more
severe disease, more IgE sensitization, and
asthma than AD controls without an FLG defect
[77]. The mechanisms underlying the relation-
Immune Epidermal ship between an epidermal FLG defect and the
Dysfunction/ Barrier increased risk of IgE sensitization and asthma
Inflammation Dysfunction are not yet known, but mouse models confirm
that protein exposed to the filaggrin-deficient
epidermis leads to epicutaneous sensitization
and markedly elevated IgE [20, 58]. More
research is needed regarding the full downstream
Genetics
molecular effects of FLG deficiency.
While filaggrin mutations have been the stron-
Fig. 16.2 The pathogenesis of atopic dermatitis involves gest risk factor ever found for this disease, in
the interplay between genetic defects in the skin barrier,
population-based studies of children with more
hyperactive immune responses, skin barrier abnormalities
that are not genetically determined, and environmental mild disease, the percent of the total AD burden
factors that may be explained by FLG mutations may be
260 E. Simpson

as low as 13% (attributable risk) [80]. This fact defects in AD may be explained by the effects of
and the increase in disease prevalence over time Th2 inflammation on epidermal function. Th2
suggest environmental factors play a role in AD cytokines have been shown to downregulate filag-
expression. grin expression, ceramide synthesis, and antimi-
crobial production [35, 36]. Recently, Surez-Farias
and colleagues showed that nonlesional skin in
16.9 Environmental Factors atopic dermatitis has a significantly altered epider-
mal differentiation program, suggesting systemic
Environmental factors likely play a role in AD inflammation plays a role in epidermal dysfunction
given the significant geographic variability found in AD [71]. Treatment of lesional skin with topical
in the disease [51, 62] and the changes in disease steroids or topical pimecrolimus upregulates mul-
prevalence over time. Children who immigrate to tiple terminal differentiation markers in the lesional
a new country adopt the AD risk of the destina- skin of AD [38]. In addition, intermittent anti-
tion country, strongly suggesting environmental inflammatory treatment, even of normal-appearing
factors play a role [41]. Observational studies skin, can have beneficial effects on AD [52].
have shown factors such as urban living and prox-
imity to pollution may modify ones risk of devel-
oping AD [48, 62]. Exposure to hard water had 16.11 Etiology of Atopic Dry Skin
been associated with a higher prevalence of AD,
but a recent randomized controlled trial failed to Virtually all children with atopic dermatitis have
find utility in water softeners as an adjunct to AD xerosis [6]. Xerosis has been reported in both
therapy [74]. Repeated skin exposure to water lesional and nonlesional skin in AD, and the degree
and detergents during infancy has also been pro- of xerosis often corresponds to the overall severity
posed as a cause of the increasing prevalence of of the disease [73]. The etiology of xerosis in AD
AD [53]. We recently showed a large proportion is multifactorial, but reduced NMF levels play a
of parents use fragranced lotions on a regular major role. A reduction of NMF is likely a global
basis on their infants, supporting this hypothesis feature of atopic dermatitis and can be caused by
[54]. Most recently, the complex interactions either filaggrin deficiency or inflammation. Kezic
between FLG mutations and environmental fac- and colleagues recently found the primary deter-
tors are being elucidated; for example, the com- minant of reduced NMF levels in AD was filaggrin
bination of an FLG mutation plus cat ownership genotype [39]. Filaggrin is normally proteolyti-
increased the risk of AD development in two cally processed into the primary components of
studies [4, 61]. Deciphering these complex gene- NMF-polycarboxylic acids and hygroscopic amino
environmental interactions is the first step toward acids [57]. NMF levels as measured by Raman
the development of comprehensive prevention spectroscopy accurately correlate to FLG geno-
strategies. type [50]; however, Kezics study also found that
filaggrin genotype is not the only determinant of
NMF levels. Disease severity, independent of the
16.10 Immunological and FLG genotype, also correlated directly with NMF
Proinammatory Factors levels, suggesting the inflammatory process may
further influence NMF levels possibly by altering
In some cases of AD, a genetically determined pre- FLG expression as discussed earlier.
disposition toward immune dysregulation could In addition to reduced levels of NMF, altera-
primarily drive the disease. Examples of this are tions in lipid composition and organization con-
seen with common variable immunodeficiency or tribute to the xerosis seen in AD by increasing
autosomal recessive hyper-IgE syndrome: Both are water permeability. Several studies have found
primarily immune disorders that have AD as an reduced levels of ceramide species in the lesional
associated feature. In addition, many epidermal skin of patients with AD [5, 14, 37, 84]. Imokawa
16 Update on Atopic Eczema with Special Focus on Dryness and the Impact of Moisturizers 261

found reduced levels of ceramide in both lesional For eczema that quickly recurs despite proper
and nonlesional skin, suggesting a ceramide defi- emollient use, topical steroids may be used twice
ciency may be a primary defect in AD. Farwanah, weekly to recurrent disease. Topical calcineurin
however, was unable to confirm these results in inhibitors may also be initiated to early disease
nonlesional skin [21]. Altered sphingomyelin recurrence twice daily to reduce steroid use [79].
metabolism likely explains the lipid abnormali- In patients with moderate to severe disease, treat-
ties in lesional skin [49]. Hatano showed that the ment of normal skin frequent flare sites repre-
Th2 cytokine, IL-4, downregulates ceramide syn- sents a new paradigm of anti-inflammatory use.
thesis probably by reducing the expression of Intermittent topical steroids or calcineurin inhibi-
sphingomyelinase and glucocerebrosidase [31]. tors, when applied to normal skin frequent flare
Mouse models of FLG deficiency reveal a para- sites, dramatically increase the number of days
cellular permeability defect due to disorganized without flare [3, 52].
lamellar lipid sheets [58] that has recently been Even with the best maintenance program, flares
confirmed in human subjects with genetically of AD will occur. This phase is treated by identi-
confirmed filaggrin deficiency [25]. Abnormal fying and correcting flare factors such as a cutane-
lamellar body loading and unloading of lipids ous infection or xerosis and reinstituting the
likely underlies the lipid disorganization caused induction phase therapy for 34 days. Patients
by filaggrin deficiency. Tight junctions and cor- with moderate to severe disease failing this aggres-
neodesmosome numbers were also reduced in sive topical approach often need phototherapy or
FLG deficient patients, likely contributing to the systemic therapy with cyclosporine, azathioprine,
permeability barrier defect. methotrexate, or mycophenolate mofetil.
Lastly, effective patient and parental educa-
tion regarding the risks and benefits of topical
16.12 Therapeutic Overview steroids, proper application of topical therapies,
proper bathing, and clarifying the role of food
The overall strategy for control of atopic derma- allergy are all essential to achieving successful
titis can be divided into the three following outcomes in this disease. Studies of nurse educa-
phases: clearance, maintenance, and rescue of tors in AD illustrate the importance of education
flares [64]. The clearance phase usually involves in achieving successful outcomes in AD [11].
the application of a medium potency topical ste- A discussion of factors that worsen itch is also
roid in an ointment base to all affected surfaces important and patients should be instructed to
after twice daily bathing. A bland emollient is avoid contact with wool, irritating over-the-coun-
used on nonaffected skin. Application should be ter products, and low-humidity environments.
714 days, and, if the proper strength of topical Attempting to improve adherence to the treat-
steroid is used, this should lead to significant ment regimen is also important. One study found
clearing in nearly all patients in 12 weeks. frequent follow-up visits may be one potentially
The maintenance phase of therapy then begins useful strategy [56].
and consists of primarily emollient therapy on a
daily basis for patients with mild to moderate
disease as the topical steroids are tapered. The 16.13 Emollients in AD
use of a bland petrolatum-based emollient can
drastically improve disease control and reduce 16.13.1 Overview
topical steroid use [11, 72]. Petrolatum incorpo-
rates into the interstitial space of the stratum cor- Despite the fact that emollients are considered
neum and improves skin barrier function, likely first-line treatment for AD in several published
explaining its efficacy in atopic dermatitis [24]. guidelines [15, 19, 30], there is a paucity of data
The optimal emollient formulation for AD man- examining the optimal emollient for this condi-
agement is not known. tion. Most oil-in-water emollients improve skin
262 E. Simpson

barrier function, which likely explains their clini- Emollients containing niacinamide, urea, vitamin
cal benefit; however, some emollient formulations B12, ceramides, and natural moisturizing factor
may have detrimental effects on the skin barrier. components have all been shown to improve skin
Held and colleagues showed a slight increase in barrier function in AD skin and in some cases to
irritant response in normal skin after treatment improve clinical outcomes [42, 67, 69, 82]. The
with an oil-in-water emollient but no negative most commonly added ingredients in moisturiz-
effect on TEWL was seen [32]. Buraczewska and ers designed to address the skin of AD patients
colleagues showed pretreatment of normal skin are ceramides. A recent study revealed a cer-
with an emollient containing canola oil and urea amide-containing moisturizer led to improve-
worsened the skin barrier function after challenge ments in transepidermal water loss and skin
with a skin irritant [8]. Mustard oil, commonly hydration [66]. The question remains whether
used on infant skin in India, negatively affected any of the new moisturizers with AD-specific
skin barrier recovery kinetics in a mouse model in ingredients perform better than simple and less
contrast to petrolatum [12]. Water itself has also expensive petrolatum-based moisturizers on clin-
been shown to be a skin irritant making emollients ical outcomes such as flare prevention or reduc-
high in water content (e.g., lotions) less appealing tions in topical steroid use. Few comparative
for AD therapy [26, 76]. studies have been performed to date. A ceramide-
rich emollient was shown to be more effective in
improving TEWL levels and clinical disease
16.13.2 Simple Oil-in-Water scores than routine emollients in one poorly con-
Emollients trolled study [9]. In contrast, a study by Loden
and colleagues did not see a benefit of skin-iden-
Petrolatum-based emollients have been the work- tical lipids over pure petrolatum in repairing the
horse for flare prevention in AD. The lipids found skin barrier after experimental perturbation [43].
in petrolatum permeate the interstitial compartment Most recently, a study found a petrolatum-based
of the stratum corneum and enhance the lipid bar- emollient to yield similar or better outcomes than
rier [24]. The other advantage of plain petrolatum a ceramide-dominant cream while being consid-
is that it does not need preservatives or fragrances, erably more cost effective [47].
two potential sources of contact sensitization. Most
simple emollients improve barrier function and
improve long-term control of the disease while 16.13.4 Emollients for Primary
reducing topical steroid use [45, 72]. A study of Prevention of AD
nurse education in AD illustrates the power of sim-
ple petrolatum-based emollients in AD therapy. While emollients represent the gold standard for
Patients randomized to a nurse education program secondary prevention of AD (flare prevention),
experienced significant improvements in disease their use as a potential primary prevention strat-
severity, with a concomitant decrease in topical ste- egy is just now being realized. The dramatic rise
roid use. The authors attributed this effect to an of AD prevalence over the past 50 years and asso-
800% increase in emollient use [11]. ciated comorbidity makes AD prevention an
important goal. Hoares Health Technology
Assessment from 2000 listed AD prevention as
16.13.3 Emollients Specially an urgent call for research [34]. Atopic derma-
Designed for AD titis prevention strategies have primarily focused
on allergen avoidance such as maternal allergen
As advances in the laboratory shed light on the avoidance and child dietary manipulation,
various epidermal defects in AD, new emollient although no allergy-based strategy has been con-
formulations are arriving in the marketplace that sistently effective [63]. Most recently, probiotic
attempt to tailor their effects to AD skin. supplementation and hydrolyzed formula feeding
16 Update on Atopic Eczema with Special Focus on Dryness and the Impact of Moisturizers 263

have had some positive results, although studies

have been conflicting. These disappointing results Emollients correct skin barrier dysfunc-
coupled with new data implicating the skin bar- tion in atopic dermatitis, reduce the need
rier to be central to initiating AD make emollient for topical steroid, and their use leads to
intervention from birth an intriguing new AD improved outcomes.
prevention strategy. New information regarding the defec-
Several lines of evidence suggest that emollient tive skin barrier in atopic dermatitis is
therapy from birth may delay the onset or prevent driving the development of disease-
the development of AD. Topical petrolatum or specific emollients, but comparative
sunflower oil improved the skin barrier function of effectiveness studies are needed.
premature infants and can prevent skin inflamma-
tion in several studies [13]. A case-control study
from Kenya found the early use of petrolatum to Conclusions
be protective from AD development in neonates Atopic dermatitis represents a complex disor-
[46]. Finally, Flohr was able to detect altered der whose expression is modified by both
TEWL readings prior to the onset of inflammatory genetic and environmental factors. Skin bar-
lesions [22], suggesting early correction of an rier dysfunction is a hallmark of the disease,
altered barrier can prevent the development of making moisturizer therapy integral to the
inflammation. We previously showed that apply- management of AD. Recent genetic discover-
ing a simple moisturizer starting near birth is both ies have refocused interest on the epidermal
safe and feasible in a small cohort of infants [65]. barrier, spurring new developments in mois-
Controlled studies from various groups, including turizer technology. Further studies are needed
our own, are currently ongoing. to clarify the comparative effectiveness of
specially designed moisturizers, and more
data regarding moisturizers as a primary pre-
vention strategy are eagerly awaited.
Take Home Messages
Atopic dermatitis is a common skin dis-
order affecting children on a worldwide References
scale.
Asthma, skin infections, and mental 1. Akiyama M (2010) FLG mutations in ichthyosis vul-
health disorders are important comor- garis and atopic eczema: spectrum of mutations and
bidities found in atopic dermatitis. population genetics. Br J Dermatol 162(3):472477
2. Barnes KC (2010) An update on the genetics of atopic
The pathogenesis of atopic dermatitis dermatitis: scratching the surface in 2009. J Allergy
involves a combination of dysfunctional Clin Immunol 125(1):1629
immune responses, abnormal skin bar- 3. Berth-Jones J, Damstra RJ, Golsch S, Livden JK, Van
rier function, genetic factors, and envi- Hooteghem O, Allegra F, Parker CA, Group MS
(2003) Twice weekly fluticasone propionate added to
ronmental influences. emollient maintenance treatment to reduce risk of
Functional mutations in the gene encod- relapse in atopic dermatitis: randomised, double blind,
ing the skin barrier protein filaggrin rep- parallel group study. Br Med J 326(7403):1367
resent the strongest risk factors for atopic 4. Bisgaard H, Simpson A, Palmer CN, Bnnelykke K,
McLean I, Mukhopadhyay S, Pipper CB, Halkjaer
dermatitis development identified to date. LB, Lipworth B, Hankinson J, Woodcock A, Custovic
Filaggrin gene mutations and inflamma- A (2008) Gene-environment interaction in the onset
tion both contribute to reduced natural of eczema in infancy: filaggrin loss-of-function muta-
moisturizing factor in the stratum cor- tions enhanced by neonatal cat exposure. PLoS Med
5(6):e131
neum in atopic dermatitis leading to a 5. Bleck O, Abeck D, Ring J, Hoppe U, Vietzke JP,
dry barrier. Wolber R, Brandt O, Schreiner V (1999) Two cer-
amide subfractions detectable in Cer(AS) position by
264 E. Simpson

HPTLC in skin surface lipids of non-lesional skin of 18. Elias PM (2010) Therapeutic implications of a bar-
atopic eczema. J Invest Dermatol 113(6):894900 rier-based pathogenesis of atopic dermatitis. Ann
6. Bhme M, Svensson A, Kull I, Wahlgren CF (2000) Dermatol 22(3):245254
Hanifins and Rajkas minor criteria for atopic derma- 19. Ellis C et al (2003) International Consensus
titis: which do 2-year-olds exhibit? J Am Acad Conference on Atopic Dermatitis II (ICCAD II): clin-
Dermatol 43(5 Pt 1):785792 ical update and current treatment strategies. Br J
7. Brown SJ, Asai Y, Cordell HJ, Campbell LE, Zhao Y, Dermatol 148(Suppl 63):310
Liao H, Northstone K, Henderson J, Alizadehfar R, 20. Fallon PG, Sasaki T, Sandilands A, Campbell LE,
Ben-Shoshan M, Morgan K, Roberts G, Masthoff LJ, Saunders SP, Mangan NE, Callanan JJ, Kawasaki H,
Pasmans SG, van den Akker PC, Wijmenga C, Shiohama A, Kubo A, Sundberg JP, Presland RB,
Hourihane JO, Palmer CN, Lack G, Clarke A, Hull Fleckman P, Shimizu N, Kudoh J, Irvine AD, Amagai
PR, Irvine AD, McLean WH (2011) Loss-of-function M, McLean WH (2009) A homozygous frameshift
variants in the filaggrin gene are a significant risk fac- mutation in the mouse FLG gene facilitates enhanced
tor for peanut allergy. J Allergy Clin Immunol 127(3): percutaneous allergen priming. Nat Genet 41(5):
661667 602608
8. Buraczewska I, Berne B, Lindberg M, Torma H, Loden 21. Farwanah H, Raith K, Neubert RH, Wohlrab J (2005)
M (2007) Changes in skin barrier function following Ceramide profiles of the uninvolved skin in atopic
long-term treatment with moisturizers, a randomized dermatitis and psoriasis are comparable to those of
controlled trial. Br J Dermatol 156(3):492498 healthy skin. Arch Dermatol Res 296(11):514521
9. Chamlin SL, Kao J, Frieden IJ, Sheu MY, Fowler AJ, 22. Flohr C, England K, Radulovic S, McLean WH,
Fluhr JW, Williams ML, Elias PM (2002) Ceramide- Campbel LE, Barker J, Perkin M, Lack G (2010)
dominant barrier repair lipids alleviate childhood Filaggrin loss-of-function mutations are associated
atopic dermatitis: changes in barrier function provide with early-onset eczema, eczema severity and tran-
a sensitive indicator of disease activity. J Am Acad sepidermal water loss at 3 months of age. Br J
Dermatol 47:198208 Dermatol 163(6):13331336
10. Chamlin SL (2006) The psychosocial burden of 23. Flohr C, Weiland SK, Weinmayr G, Bjorksten B,
childhood atopic dermatitis. Dermatol Ther 19(2): Braback L, Brunekreef B et al (2008) The role of
104107 atopic sensitization in flexural eczema: findings from
11. Cork MJ et al (2003) Comparison of parent knowl- the International Study of Asthma and Allergies in
edge, therapy utilization and severity of atopic eczema Childhood Phase Two. J Allergy Clin Immunol
before and after explanation and demonstration of 121(1):141147
topical therapies by a specialist dermatology nurse. Br 24. Ghadially R, Halkier-Sorensen L, Elias PM (1992)
J Dermatol 149:582589 Effects of petrolatum on stratum corneum structure
12. Darmstadt GL, Mao-Qiang M, Chi E, Saha SK, Ziboh and function. J Am Acad Dermatol 26(3 Pt 2):
VA, Black RE, Santosham M, Elias PM (2002) Impact 387396
of topical oils on the skin barrier: possible implica- 25. Gruber R, Elias PM, Crumrine D, Lin TK, Brandner
tions for neonatal health in developing countries. Acta JM, Hachem JP, Presland RB, Fleckman P, Janecke
Paediatr 91(5):546554 AR, Sandilands A, McLean WH, Fritsch PO, Mildner
13. Darmstadt GL, Saha SK, Ahmed AS, Ahmed S, M, Tschachler E, Schmuth M (2011) Filaggrin geno-
Chowdhury MA, Law PA, Rosenberg RE, Black RE, type in ichthyosis vulgaris predicts abnormalities in
Santosham M (2008) Effect of skin barrier therapy on epidermal structure and function. Am J Pathol 178(5):
neonatal rates in preterm infants in Bangladesh: a ran- 22522263
domized, controlled, clinical trial. Pediatrics 121(3): 26. Grunewald AM et al (1995) Damage to the skin by
522529 repetitive washing. Contact Dermatitis 32(4):225232
14. Di Nardo A, Wertz P, Giannetti A, Seidenari S (1998) 27. Halkjaer LB, Loland L, Buchvald FF, Agner T, Skov
Ceramide and cholesterol composition of the skin of L, Strand M, Bisgaard H (2006) Development of
patients with atopic dermatitis. Acta Derm Venereol atopic dermatitis during the first 3 years of life: the
78(1):2730 Copenhagen prospective study on asthma in child-
15. Eichenfield LF, Hanifin JM, Luger TA, Stevens SR, hood cohort study in high-risk children. Danish
Pride HB (2003) Consensus conference on pediatric Pediatric Asthma Centre, Department of Pediatrics,
atopic dermatitis. J Am Acad Dermatol 49(6): Copenhagen University Hospital. Arch Dermatol
10881095 142(5):561566
16. Elias PM, Feingold KR (2001) Does the tail wag the 28. Hanifin JM (2002) Atopiform dermatitis: do we need
dog? Role of the barrier in the pathogenesis of inflam- another confusing name for atopic dermatitis? Br J
matory dermatoses and therapeutic implications. Arch Dermatol 147(3):430432
Dermatol 137(8):10791081 29. Hanifin JM, Rajka G (1980) Diagnostic features of
17. Elias PM, Steinhoff M (2008) Outside-to-inside atopic dermatitis. Acta Dermatovener (Suppl) 92:4447
(and now back to outside) pathogenic mechanisms 30. Hanifin JM et al (2004) Guidelines of care for atopic
in atopic dermatitis. J Invest Dermatol 128(5): dermatitis, developed in accordance with the American
10671070 Academy of Dermatology (AAD)/American Academy
16 Update on Atopic Eczema with Special Focus on Dryness and the Impact of Moisturizers 265

of Dermatology Association Administrative Regu- 43. Loden M, Barany E (2000) Skin-identical lipids ver-
lations for Evidence-Based Clinical Practice sus petrolatum in the treatment of tape-stripped and
Guidelines. J Am Acad Dermatol 50(3):391404 detergent-perturbed human skin. Acta Derm Venereol
31. Hatano Y, Katagiri K, Arakawa S, Fujiwara S (2007) 80(6):412415
Interleukin-4 depresses levels of transcripts for acid- 44. Lowe AJ, Abrahamson MJ, Hosking CS, Carlin JB,
sphingomyelinase and glucocerebrosidase and the Bennett CM, Dharmage SC, Hill DJ (2007) The tem-
amount of ceramide in acetone-wounded epidermis, poral sequence of allergic sensitization and onset of
as demonstrated in a living skin equivalent. J Dermatol infantile eczema. Clin Exp Allergy 37:536542
Sci 47(1):4547 45. Lucky AW, Leach AD, Laskarzewski P, Wenck H
32. Held E, Sveinsdottir S, Agner T (1999) Effect of long- (1997) Use of an emollient as a steroid-sparing agent
term use of moisturizer on skin hydration, barrier in the treatment of mild to moderate atopic dermatitis
function and susceptibility to irritants. Acta Derm in children. Pediatr Dermatol 14:321324
Venereol 79(1):4951 46. Macharia WM, Anabwani GM, Owili DM (1991)
33. Herrick CA et al (2000) Th2 responses induced by Effects of skin contactants on evolution of atopic der-
epicutaneous or inhalational protein exposure are dif- matitis in children: a case control study. Trop Doct
ferentially dependent on IL-4. J Clin Invest 105: 21(3):104106
765775 47. Miller DW, Koch SB, Yentzer BA, Clark AR, ONeill
34. Hoare C, Li Wan Po A, Williams H (2000) Systematic JR, Fountain J, Weber TM, Fleischer AB Jr (2011) An
review of treatments for atopic eczema. Health over-the-counter moisturizer is as clinically effective
Technol Assess 4(37):1191 as, and more cost-effective than, prescription barrier
35. Howell MD, Novak N, Bieber T, Pastore S, Girolomoni creams in the treatment of children with mild-to-mod-
G, Boguniewicz M, Streib J, Wong C, Gallo RL, erate atopic dermatitis: a randomized, controlled trial.
Leung DY (2005) Interleukin-10 downregulates anti- J Drugs Dermatol 10(5):531537
microbial peptide expression in atopic dermatitis. 48. Morgenstern V, Zutavern A, Cyrys J, Brockow I,
J Invest Dermatol 125(4):738745 (Erratum in: Koletzko S, Krmer U, Behrendt H, Herbarth O, Von
J Invest Dermatol (2005) 125(6):1320) Berg A, Bauer CP, Wichmann HE, Heinrich J, GINI
36. Howell MD, Kim BE, Gao P, Grant AV, Boguniewicz Study Group, LISA Study Group (2008) Atopic dis-
M, Debenedetto A, Schneider L, Beck LA, Barnes eases, allergic sensitization, and exposure to traffic-
KC, Leung DY (2007) Cytokine modulation of atopic related air pollution in children. Am J Respir Crit
dermatitis filaggrin skin expression. J Allergy Clin Care Med 177(12):13311337
Immunol 120(1):150155 49. Murata Y, Ogata J, Higaki Y, Kawashima M, Yada Y,
37. Imokawa G, Abe A, Jin K, Higaki Y, Kawashima M, Higuchi K, Tsuchiya T, Kawainami S, Imokawa G
Hidano A (1991) Decreased level of ceramides in (1996) Abnormal expression of sphingomyelin acylase
stratum corneum of atopic dermatitis: an etiologic in atopic dermatitis: an etiologic factor for ceramide
factor in atopic dry skin? J Invest Dermatol 96(4): deficiency? J Invest Dermatol 106(6):12421249
523526 50. ORegan GM, Kemperman PM, Sandilands A, Chen
38. Jensen JM, Pfeiffer S, Witt M, Brutigam M, Neumann H, Campbell LE, Kroboth K, Watson R, Rowland M,
C, Weichenthal M, Schwarz T, Flster-Holst R, Puppels GJ, McLean WH, Caspers PJ, Irvine AD
Proksch E (2009) Different effects of pimecrolimus (2010) Raman profiles of the stratum corneum define
and betamethasone on the skin barrier in patients with 3 filaggrin genotype-determined atopic dermatitis
atopic dermatitis. J Allergy Clin Immunol 124(3 endophenotypes. J Allergy Clin Immunol 126(3):
Suppl 2):R19R28 574580
39. Kezic S, ORegan GM, Yau N, Sandilands A, Chen H, 51. Odhiambo JA, Williams HC, Clayton TO, Robertson
Campbell LE, Kroboth K, Watson R, Rowland M, CF, Asher MI (2009) Global variations in prevalence
Irwin McLean WH, Irvine AD (2011) Levels of filag- of eczema symptoms in children from ISAAC phase
grin degradation products are influenced by both fil- three. J Allergy Clin Immunol 124(6):12511258
aggrin genotype and atopic dermatitis severity. Allergy 52. Paller AS, Eichenfield LF, Kirsner RS, Shull T, Jaracz
66(7):934940 E, Simpson EL, US Tacrolimus Ointment Study Group
40. Lack G, Fox D, Northstone K, Golding J (2003) Avon (2008) Three times weekly tacrolimus ointment
Longitudinal Study of Parents and Children Study reduces relapse in stabilized atopic dermatitis: a new
Team. Factors associated with the development of paradigm for use. Pediatrics 122(6):e1210e1218
peanut allergy in childhood. N Engl J Med 348(11): 53. Proksch E, Elias PM (2002) Epidermal barrier in
977985 atopic dermatitis. In: Bieber T, Leung DYM (eds)
41. Leung R (1994) Asthma, allergy and atopy in South- Atopic dermatitis. Marcel Dekker, Inc, New York
east Asian immigrants in Australia. Aust N Z J Med 54. Rendell ME, Baig-Lewis SF, Berry TM, Denny ME,
24(3):255257 Simpson BM, Brown PA, Simpson EL (2011) Do early
42. Loden M, Andersson AC, Lindberg M (1999) skin care practices alter the risk of atopic dermatitis?
Improvement in skin barrier function in patients with A case-control study. Ped Dermatol 28(5):593595
atopic dermatitis after treatment with a moisturizing 55. Romanos M, Gerlach M, Warnke A, Schmitt J (2010)
cream (Canoderm). Br J Dermatol 140:264267 Association of attention-deficit/hyperactivity disorder
266 E. Simpson

and atopic eczema modified by sleep disturbance in a peutic approach in atopic dermatitis evaluation of
large population-based sample. J Epidemiol Community efficacy and tolerability in a randomized placebo-
Health 64(3):269273 controlled multicentre clinical trial. Br J Dermatol
56. Sagransky MJ, Yentzer BA, Williams LL, Clark AR, 150(5):977983
Taylor SL, Feldman SR (2010) A randomized con- 70. Su JC, Kemp AS, Varigos GA, Nolan TM (1997)
trolled pilot study of the effects of an extra office visit Atopic eczema: its impact on the family and financial
on adherence and outcomes in atopic dermatitis. Arch cost. Arch Dis Child 76(2):159162
Dermatol 146(12):14281430 71. Surez-Farias M, Tintle SJ, Shemer A, Chiricozzi A,
57. Sandilands A, Sutherland C, Irvine AD, McLean WH Nograles K, Cardinale I, Duan S, Bowcock AM,
(2009) Filaggrin in the frontline: role in skin barrier Krueger JG, Guttman-Yassky E (2011) Nonlesional
function and disease. J Cell Sci 122(Pt 9):12851294 atopic dermatitis skin is characterized by broad termi-
58. Scharschmidt TC, Man MQ, Hatano Y, Crumrine D, nal differentiation defects and variable immune abnor-
Gunathilake R, Sundberg JP, Silva KA, Mauro TM, malities. J Allergy Clin Immunol 127(4):954964
Hupe M, Cho S, Wu Y, Celli A, Schmuth M, Feingold 72. Szczepanowska J, Reich A, Szepietowski JC (2008)
KR, Elias PM (2009) Filaggrin deficiency confers a Emollients improve treatment results with topical cor-
paracellular barrier abnormality that reduces inflam- ticosteroids in childhood atopic dermatitis: a random-
matory thresholds to irritants and haptens. J Allergy ized comparative study. Pediatr Allergy Immunol
Clin Immunol 124(3):496506 19(7):614618
59. Schram ME, Leeflang MM, DEN Ottolander JP, Spuls 73. Tagami H, Kobayashi H, Ogoshi K, Kikuchi K (2006)
PI, Bos JD (2011) Validation and refinement of the Atopic xerosis: employment of noninvasive biophysi-
millennium criteria for atopic dermatitis. J Dermatol cal instrumentation for the functional analyses of the
[epub ahead of print] mildly abnormal stratum corneum and for the efficacy
60. Schultz Larsen F, Hanifin JM (1992) Secular change assessment of skin care products. J Cosmet Dermatol
in the occurrence of atopic dermatitis. Acta Derm 5(2):140149
Venereol (Stockh) 176(Suppl):712 74. Thomas KS, Dean T, OLeary C, Sach TH, Koller K,
61. Schuttelaar ML, Kerkhof M, Jonkman MF, Koppelman Frost A, Williams HC (2011) SWET Trial Team. A
GH, Brunekreef B, de Jongste JC, Wijga A, McLean randomised controlled trial of ion-exchange water
WH, Postma DS (2009) Filaggrin mutations in the softeners for the treatment of eczema in children.
onset of eczema, sensitization, asthma, hay fever and PLoS Med 8(2):e1000395
the interaction with cat exposure. Allergy 64(12): 75. Thomsen SF, Ulrik CS, Kyvik KO, Hjelmborg JB,
17581765 Skadhauge LR, Steffensen I, Backer V (2007)
62. Shaw TE, Currie GP, Koudelka C, Simpson EL (2010) Importance of genetic factors in the etiology of atopic
Eczema prevalence in the United States: data from the dermatitis: a twin study. Allergy Asthma Proc
2003 National Survey of Childrens Health. J Invest 28(5):535539
Dermatol 131(1):6773 76. Tsai TF, Maibach HI (1999) How irritant is water? An
63. Simpson EL (2006) Atopic dermatitis prevention. overview. Contact Dermatitis 41(6):311314
Dermatol Ther 19(2):108117 77. van den Oord RA, Sheikh A (2009) Filaggrin gene
64. Simpson EL (2010) Atopic dermatitis a review of defects and risk of developing allergic sensitisation and
topical treatment options. Curr Med Res Opin allergic disorders: systematic review and meta-analysis.
26(3):633640 Br Med J 339:b2433. doi: 10.1136/bmj.b2433
65. Simpson EL, Berry TM, Brown PA, Hanifin JM 78. van der Hulst AE, Klip H, Brand PL (2007) Risk of
(2010) A pilot study of emollient therapy for the pri- developing asthma in young children with atopic
mary prevention of atopic dermatitis. J Am Acad eczema: a systematic review. J Allergy Clin Immunol
Dermatol 63(4):587593 120(3):565569
66. Simpson EL, Dutronc Y (2011) A new body moistur- 79. Wahn U, Bos JD, Goodfield M, Caputo R, Papp K,
izer increases skin hydration and improves atopic der- Manjra A, Dobozy A, Paul C, Molloy S, Hultsch T,
matitis symptoms among children and adults. J Drugs Graeber M, Cherill R, de Prost Y (2002) Flare
Dermatol 10(7):744749 Reduction in Eczema with Elidel (Children)
67. Soma Y, Kashima M, Imaizumi A, Takahama H, Multicenter Investigator Study Group. Efficacy and
Kawakami T, Mizoguchi M (2005) Moisturizing safety of pimecrolimus cream in the long-term man-
effects of topical nicotinamide on atopic dry skin. Int agement of atopic dermatitis in children. Pediatrics
J Dermatol 44(3):197202 110(1 Pt 1):e2
68. Spergel JM, Mizoguchi E, Brewer JP, Martin TR, 80. Weidinger S, OSullivan M, Illig T, Baurecht H,
Bhan AK, Geha RS (1998) Epicutaneous sensitization Depner M, Rodriguez E, Ruether A, Klopp N,
with protein antigen induces localized allergic derma- Vogelberg C, Weiland SK, McLean WH, von Mutius
titis and hyperresponsiveness to methacholine after E, Irvine AD, Kabesch MJ (2008) Filaggrin muta-
single exposure to aerosolized antigen in mice. J Clin tions, atopic eczema, hay fever, and asthma in
Invest 101:16141622 children. J Allergy Clin Immunol 121(5):12031209
69. Stcker M, Pieck C, Stoerb C, Niedner R, Hartung J, 81. Williams H, Stewart A, von Mutius E, Cookson W,
Altmeyer P (2004) Topical vitamin B12 a new thera- Anderson HR (2008) Is eczema really on the increase
16 Update on Atopic Eczema with Special Focus on Dryness and the Impact of Moisturizers 267

worldwide? J Allergy Clin Immunol 121(4): 84. Yamamoto A, Serizawa S, Ito M, Sato Y (1991)
947954 Stratum corneum lipid abnormalities in atopic derma-
82. Woods MT, Brown PA, Baig-Lewis SF, Simpson EL titis. Arch Dermatol Res 283(4):219223
(2011) Effects of a novel formulation of fluocinonide 85. Yura A, Kouda K, Iki M, Shimizu T (2011) Trends of
0.1% cream on skin barrier function in atopic derma- allergic symptoms in school children: large-scale
titis. J Drugs Dermatol 10((2):171176 long-term consecutive cross-sectional studies in
83. Yaghmaie P, Koudelka CW, Simpson EL (2011) Osaka Prefecture, Japan. Pediatr Allergy Immunol 5.
Psychiatric comorbidity in pediatric eczema. J Invest doi:10.1111/j.1399-3038.2011.01159.x [Epub ahead
Dermatol 131(Suppl 1):41 (Abstract #246) of print]
 Update on Hand Eczema
with Special Focus on the Impact 17
of Moisturisers

Christina Williams and Mark Wilkinson

17.1 Hand Eczema adults reporting moderate and severe atopic der-
matitis in childhood has been reported as 25%
The hands are a common site of dermatitis as and 41%, respectively [3]. Atopic dermatitis
they are often exposed to irritants and allergens associated with null mutations within the gene
in the home and work environments. Contact encoding the key epidermal protein filaggrin is
irritants are the most common exogenous cause particularly associated with an earlier onset and
of hand eczema, but chronic hand eczema is usu- higher persistence of hand eczema [4]. Other
ally due to a combination of various interacting endogenous risk factors include psoriasis and
factors that cannot be viewed in isolation. The subclinical barrier deficiency. Hand eczema has
effects of these factors may be cumulative and a relapsing course and variable disease duration
exacerbated by water, humidity, dryness, friction [5]. Approximately half of cases develop into a
and cold. chronic disease, and symptoms may persist for
many years or may recur after disease-free inter-
vals [5, 6].
17.1.1 Epidemiology

According to a review of studies performed 17.1.2 Diagnosis

between 1964 and 2007, the point prevalence of
hand eczema in the general population is around An accurate diagnosis of hand eczema leads to
4%, the one year prevalence nearly 10% and the better management, but no single classification of
lifetime prevalence almost 15% [1]. The median hand eczema has been satisfactory. The morphol-
incidence rate is 5.5 cases/1,000 person-years ogy can often change in an individual case, and
with a high incidence rate associated with female one morphology can have several different causes;
sex, contact allergy especially nickel allergy, hence, a new classification of hand eczema has
wet work or frictional irritancy and atopic der- recently been proposed for use in clinical practice
matitis [2]. The prevalence of hand eczema in and research applications [7]. Based on an analy-
sis of patients attending European patch-testing
centres, it defines seven subgroups according to
demographics, medical history and lesion mor-
phology. The most common subgroups are irritant
(27%), allergic (19%) and combined irritant and
C. Williams () M. Wilkinson
allergic hand eczema (19%). Atopic hand eczema
Department of Dermatology, Leeds General Infirmary,
Great George Street, Leeds, LS1 3EX, UK and atopic in combination with irritant hand
e-mail: [email protected]

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 269

DOI 10.1007/978-3-642-27606-4_17, Springer-Verlag Berlin Heidelberg 2012
270 C. Williams and M. Wilkinson

eczema constitute 18%, with other endogenous found that 20% of reported cases led to the indi-
forms constituting only a minor group. vidual requiring time off work and 16% did not
The differential diagnosis of a dermatological improve at repeat assessment [5]. In a 15-year
dermatosis affecting the hand includes psoriasis/ follow-up of a Swedish general population sam-
pustulosis, fungal infection, keratoderma, lichen ple, the majority of patients with hand eczema
planus, granuloma annulare and infection/infes- had ongoing symptoms, about a third needed
tation. The pattern of skin lesions may suggest ongoing medical treatment, and 5% experienced
the diagnosis, but patch testing, considered in the long periods of sickness absence, loss or change
context of the patients history, is essential for of job and ill-health retirement [5]. The 12-year
patients with chronic hand eczema. Patch testing prognosis of hand dermatitis in a study of Finnish
with a standard series of allergens will often iden- farmers was equally poor, with 26% of men and
tify substances to which the patient is allergic, 21% of women reporting current symptoms at
and avoidance can lead to an improvement in follow-up [14]. It seems that hand dermatitis
their hand eczema. tends to persist with exposure to wet work, irri-
tants or allergens, and a high proportion of work-
ers change job as a result. This productivity loss
17.1.3 Quality of Life and sick leave can result in high costs [8]. In the
Netherlands, annual costs of medical care, absen-
Hand dermatitis accounts for up to 90% of all teeism and disability pensions attributable to
occupational skin diseases [8, 9], with important occupational skin disease in employees are esti-
issues regarding the use of medical resources, mated to be 98.1 million [9].
productivity loss, disability and litigation [1, 10].
The burden of hand dermatitis is therefore high
for individual patients and for society. 17.2 Prevention
Chronic hand eczema has been shown to
adversely affect quality of life. A survey in the The management of patients with chronic hand
USA found that people with chronic hand eczema eczema can often be unsatisfactory [15]. For this
report worse quality of life and impaired activity reason, primary and secondary prevention is
and work performance compared with those potentially an important strategy, especially in
without hand eczema [11]. A study of 416 professions known to have an increased risk of
patients with hand eczema recruited from hand dermatitis. A systematic review of the liter-
European patch test clinics found that quality of ature by van Gils et al. [16] assessed the effec-
life (measured by the DLQI) correlated with dis- tiveness of prevention programmes for hand
ease severity (measured by the Hand Eczema dermatitis. They found that there is moderate evi-
Severity Index) [12], but the validity of this find- dence for the effect of prevention programmes,
ing is not supported by the fact that there was no including skin care education, on lowering occur-
difference in quality of life between men and rence and improving adherence to preventive
women, although disease severity was signifi- measures, and low evidence for the effect on
cantly worse in men. improving clinical outcomes and self-reported
US national statistics suggest that 15% of peo- outcomes. No studies reporting on the cost-effec-
ple with contact dermatitis have limitation of tiveness of prevention however were found.
activity due to hand involvement. In Denmark, Primary prevention aims to reduce the inci-
follow-up after 10 years in a cohort of 274 people dence of hand eczema by targeting the healthy
with hand eczema found that 12.4% had taken population. The regulation of exposure to aller-
sick leave and 8.5% had changed jobs [13]. The gens either by legislation on threshold values or
prognosis for moderately severe hand dermatitis regulations on precautions in the handling of
is poor. A UK-reporting scheme (EPIDERM) allergenic products reduces allergen exposure
17 Update on Hand Eczema with Special Focus on the Impact of Moisturisers 271

and subsequently reduces the frequency of aller- 17.3 Treatment

gic contact dermatitis [17]. Exposure to wet work
is a particular risk factor for the development of 17.3.1 Soap Substitutes
hand eczema, and the use of gloves in wet work
has generally been recommended and accepted Careful hand washing to remove irritants and
as an important preventive measure, particularly allergens is an important part of skin care in
when combined with other preventative mea- any high-risk occupation. However, the
sures. Compliance with this recommendation is mechanical trauma of repeated washing and
good in some but not all occupations [18]. drying and the detergents themselves can give
However, gloves may also sometimes be the rise to skin irritation, particularly in the finger
cause of hand eczema, since protective rubber web spaces. Emollient soap substitutes con-
gloves may cause irritant dermatitis from heat taining nonionic surface active agents may be
and sweating, or allergic contact dermatitis from beneficial in these circumstances. In an attempt
contact sensitisation to rubber additives or con- to improve compliance with infection control
tact urticaria caused by immediate allergy to nat- procedures in the health-care setting, the intro-
ural rubber latex [1921]. duction of alcohol-based gels for hand decon-
Secondary prevention strategies are recom- tamination as a substitute for hand washing
mended when skin manifestations are apparent with conventional soaps and disinfectants
on the hands. The objective of secondary preven- when the hands are not visibly soiled has been
tion is to spot early skin changes in order to rap- advocated by the World Health Organization,
idly implement corrective measures. Outpatient the Centres for Disease Control in the USA,
skin-protection seminars have been suggested for and the National Patient Safety Agency and
those in wet work occupations such as health- Infection Prevention Society (formerly Infection
care workers, hairdressers, cooks, caterers and Control Nurses Association) in the UK. Most of
other food handlers and cleaners [2224]. These the studies that evaluate different hand hygiene
provide theoretical background knowledge and regimens are focused on their effectiveness at
training in the selection and use of adequate skin- reducing skin colonisation [26]. In a recent
protection strategies. They are aimed at helping study by Loffler et al., it was suggested that
people keep working in their occupation and to alcohol hand rubs cause less skin irritation than
motivate people to use adequate skin protection. hand washing with detergents/soaps and should
Although this area still needs more research, the therefore be preferred from the dermatological
results are very promising. viewpoint. They went on to state that alcohol
Lifestyle change is therefore recommended hand rubs may even decrease rather than
for all patients, particularly those involved in wet increase skin irritation after a hand wash due to
work or high-risk occupations. This involves a partial mechanical elimination of the deter-
avoidance of relevant allergens and irritants, sub- gent [27]. It is still not clear however, whether
stituting alternatives where possible, use of hand different hand hygiene regimens have an impor-
protection such as occlusive gloves and/or barrier tant impact on the prevention or management of
creams and avoidance of wet work and mechani- dermatitis in health-care workers.
cal irritation. A skin-protection programme
should be tailored to individual need, and this
should include education about hand eczema 17.3.2 Pre-work Creams
with the aim of giving the patient realistic expec-
tations of treatment outcomes [25]. Working Pre-work creams are designed for application at
organisations should play an active role in pro- the start of work or after rest breaks. Many pre-
viding opportunities for prevention and making work creams have oily formulations and there-
protection measures available [14]. fore have emollient properties. They also make it
272 C. Williams and M. Wilkinson

easier to wash off contaminants, allowing milder oil-in-water preparations with a variable fat
cleansing agents to be used. Therefore, they can content (commonly petrolatum, paraffins, glycer-
play a useful role in an overall skin management ides or lanolin). The development of topical
programme. agents that improve skin barrier function is a
They are sometimes referred to as barrier promising approach for the prevention and man-
creams. However, this term can be misleading, agement of hand dermatitis. A good skin barrier
giving rise to a perception that these agents form helps to avoid the penetration of both allergens
a physical barrier to protect skin and are a substi- and irritants. Well-selected moisturisers that
tute for wearing gloves or other protective equip- maintain and support skin barrier function are
ment. In fact, evidence from animal studies therefore considered useful treatment adjuncts
indicates that they are very limited in forming a for hand eczema [37, 38]. However, more rigor-
true barrier [28, 29]. ous data on the preventive effectiveness of mois-
A systematic review revealed that there is turisers are required [39], as moisturisers have
mixed evidence for the effectiveness of pre-work different effects on the skin and some formula-
creams [30]. Limitations of pre-work creams tions may deteriorate skin barrier function and
include a well-recognised failure of users to apply increase susceptibility to irritants, with possible
them properly [31], uncertainty about penetration negative consequences for the eczema [4043].
or permeation rates for many substances [29] and Earlier studies suggested that moisturisers
difficulty for workers in recognising when the help to re-establish normal skin physiology in
creams wear off during a shift. While some are various diseases characterised by abnormal bar-
effective in preventing irritant contact dermatitis rier function, with those containing humectants,
or allergic contact dermatitis for specific aller- for example, urea or glycerine, being typically
gens, there are limitations in the extent to which more efficacious than those without humectants
this finding can be generalised. Three studies [44], and that they may be effective in the preven-
explored the use of prework creams as a preven- tion of contact and occupational irritant dermati-
tative measure against specific agents (epoxy res- tis. One field study indicated a positive effect on
ins, glass fibres, sodium lauryl sulphate and skin hydration from the use of moisturisers in 55
toluene) and found that they offered no or very cleaners and kitchen assistants exposed to water
limited protection [3234]. A randomised con- and detergents [45], and another study found that
trolled trial of workers in the building and timber moisturisers prevented cumulative irritant con-
trades found no clinical evidence that pre-work tact dermatitis and speeded healing [46].
creams alone prevent dermatitis, although such Hannuksela and Kinnunen asked their subjects to
creams in combination with cleansing and after- wash their upper arms with a liquid detergent and
work creams were effective in improving skin applied eight moisturisers after each wash in the
condition, measured by trans-epidermal water first week to one upper arm and twice daily with-
loss [35]. A systematic review of latex allergy out wash in the second week. Evaluation of skin
concluded that prior use of protective hand blood flow and TEWL concluded that the regular
creams cannot be recommended for people who use of emollients prevented irritant dermatitis
wear latex gloves and found some indication that from this detergent. In a single-blinded study,
such creams may favour the uptake of allergens Loden reported that urea-containing moisturiser
from gloves [36]. speeds healing and decreases susceptibility to
sodium lauryl sulphate SLS [47]. TEWL and skin
capacitance of surfactant-damaged skin and nor-
17.3.3 Moisturisers mal skin were measured at baseline and after
14 days of treatment with the moisturiser. The
Emollients or moisturisers are preparations that authors found that barrier recovery and influence
increase skin hydration and replace depleted of irritant stimuli in skin treated with a moisturis-
skin lipids that form an important part of the bar- ing cream were significantly more favourable
rier function of normal healthy skin. Most are than untreated skin.
17 Update on Hand Eczema with Special Focus on the Impact of Moisturisers 273

Other reports further support the role of by a detergent. On the contrary, daily use of mois-
moisturisers in preventing irritant contact der- turizers under these conditions may increase skin
matitis. Ramsing and Agner [38], using the hand- susceptibility to irritants. The authors suggested
immersion test, studied the effect of a moisturiser that increasing the hydration level of the stratum
on experimentally irritated human skin using corneum progressively may reduce its barrier
SLS and found that moisturiser was not only efficiency and allow the permeation of noxious
effective in preventing the development of irritant substances into the skin with greater ease.
contact dermatitis but also significantly acceler- In summary, it would appear that most studies
ated skin barrier repair, judged by measurement support the protective effects of moisturisers
of TEWL and electrical capacitance, and it against skin irritants. However, the protective
improved the clinical signs, which were observed effects of moisturisers may not be broad spec-
on the control hand. Held and Agner also reported trum, and different moisturisers with different
that moisturiser speeds healing in hand-immer- constituents may be specifically more effective
sion and SLS-patch tests [48]. Goh et al. showed against different skin irritants and in different
that an after-work moisturiser appeared to reduce individuals. A number of practical factors might
the incidence of irritant dermatitis, and reduced also limit clinical efficacy in the workplace,
TEWL increase from cutting oil, among metal including compliance, availability, interaction
workers [49]. A recent study modelling an almost with other substances and removal by repeated
real work situation assessed the effect of the reg- washing. Further field studies, however, are there-
ular use of detergents and emollients in a wash fore required to evaluate skin care programmes in
test [50]. This double-blind, randomised study a practical workplace environment.
examined whether the regular use of a moisturis-
ing product after repeated washing of the hands
over a 2-week period in healthy adult volunteers 17.3.4 Types of Moisturisers
would maintain skin barrier function compared
to a soap-only control group not exposed to mois- Lipid content and natural moisturising factors
turiser over the same time period. Objective sub- such as urea have been suggested to be the most
clinical assessment of the skin barrier function important constituents of emollients. Emollients
using TEWL and epidermal hydration showed with high lipid content accelerate the healing
that three of the five moisturisers tested were after experimental damage to the skin [52].
more effective in increasing epidermal hydration Humectants may sometimes improve barrier
and one moisturiser out of five led to a significant function, mainly by increasing the hydration of
reduction in TEWL. These results supported the the stratum corneum and for some humectants
findings of previous studies that the regular appli- also by anti-irritant capacity [53]. Efforts to
cation of moisturisers to normal skin does offer a improve the efficacy of moisturisers have
protective effect against repeated exposure to included using skin-related lipids (e.g. cer-
irritants. amides) in formulations. However, no superior-
In contrast, however, Held et al. in 1999 and ity of an emollient containing ceramide used
2001 reported that moisturisers, which improve twice daily over an ordinary petrolatum emol-
stratum corneum hydration, may increase skin lient used twice daily was observed in patients
susceptibility to contact irritants [48, 51]. In these with chronic hand dermatitis [54]. A similar
studies, a 4-week treatment of normal skin with result was seen in experimentally irritated skin
moisturiser three times a day increased suscepti- [55], where two models for barrier deterioration
bility to SLS as demonstrated by a statistically were used. One reflected irritant contact derma-
significant higher TEWL on the treated forearm titis, caused by exposure to an aqueous solution
compared with the other untreated forearm. The of a surfactant and in the other model, TEWL
results suggest that long-term treatment with was increased by mechanical removal of the
moisturisers on normal skin may not necessarily outer layers of the stratum corneum by stripping
offer any protection against irritant trauma caused the skin with adhesive tape.
274 C. Williams and M. Wilkinson

Repairing the barrier or preventing barrier with mometasone furoate cream [61]. The adverse
dysfunction are important strategies for reducing the effects of topical steroids include cutaneous atro-
risks for eczema. Elias et al. suggested that patho- phy, tachyphylaxis and adrenal suppression after
genesis-based therapy with an ideal ratio of lipid to systemic absorption.
ceramide, directed at the lipid biochemical abnor- Two topical calcineurin inhibitors are licensed
mality that is responsible for the barrier defect in for the treatment of atopic dermatitis when topical
atopic dermatitis, could be an effective treatment steroids have failed or not been tolerated: tacroli-
model [56]. One 5% urea-containing moisturiser has mus for moderate to severe disease and pimecroli-
repeatedly been shown to improve skin barrier func- mus for mild to moderate disease. Tacrolimus has
tion in dry atopic skin [57, 58]. In a single blinded been shown to be as effective as mometasone
study, Loden et al. [58] showed that the susceptibil- furoate [62] whereas pimecrolimus appears to be
ity to irritation by SLS decreased, as measured by equivalent to a mildly potent topical steroid [63].
skin blood flow and TEWL, and skin capacitance Adverse effects include transient stinging, flushing
was significantly increased in cream-treated skin, with alcohol and skin infection. There has been no
indicating increased hydration. Similar findings short- or intermediate-term evidence of systemic
were also reported by Buraczewska et al. in normal immunosuppression or an increased risk for malig-
skin [40]. Maintenance treatment with this urea-con- nancy, although long-term data collection is ongo-
taining moisturiser was recently found to reduce the ing. Other topical agents include the retinoid
relapse of flares of eczema on corticosteroid-healed bexarotene, which is licensed in a gel formulation
sites in atopic dermatitis patients to approximately in the USA for the treatment of lymphoma. This
one-third of that of patients with no such mainte- has been shown to improve severe chronic hand
nance treatment [59]. In a study by Loden et al. [60], eczema. Adverse effects include irritation, sting-
the time to relapse of eczema during treatment with ing or burning and flare of dermatitis [64]. Other
a barrier strengthening moisturiser (5% urea) was treatments include superficial X-ray and particu-
compared with no treatment (no medical or non- larly Grenz rays [65], botulinum toxin [66] and
medicated preparations) in 53 randomised patients iontophoresis [67].
with successfully treated hand eczema. The median
time to relapse was 20 days in the moisturiser group
compared with 2 days in the no-treatment group
(p = 0.04). Eczema relapsed in 90% of the patients 17.3.6 Phototherapy
within 26 weeks. No difference in severity was noted
Small trials have shown that ultraviolet (UV) B
between the groups at relapse. Dermatology Life
may improve chronic hand eczema over a period
Quality Index (DLQI) increased significantly in both
of 10 weeks, but topical psoralen UVA (PUVA) is
groups, from 4.7 to 7.1 in the moisturiser group and
superior [68]. Most dermatologists would use topi-
from 4.1 to 7.8 in the no treatment group (p < 0.01) at
cal PUVA rather than systemic PUVA as it likely
the time of relapse. Hence, the application of mois-
to be safer. UVA1 may also be effective, although
turisers seems to prolong the disease-free interval in
provision of this in the UK is very limited [69].
patients with controlled hand eczema.

17.3.5 Other Topical Therapies 17.3.7 Systemic Therapies

After barrier creams, soap substitutes and emol- The systemic therapies most widely used in the
lients, the topical treatment of choice is a topical treatment of chronic hand eczema include corti-
steroid. These agents are very effective in the costeroids, azathioprine, cyclosporine, metho-
short term, but they inhibit repair of the stratum trexate and acitretin. The only systemic agent
corneum and may interfere with recovery in the licensed for treatment of hand eczema is the oral
long term. There is some evidence for long-term retinoid alitretinoin, which is specifically
intermittent treatment of chronic hand eczema approved for the treatment of adults with hand
17 Update on Hand Eczema with Special Focus on the Impact of Moisturisers 275

eczema unresponsive to topical steroids, and is for a maximum of 6 months at the lowest thera-
supported by evidence from a large randomised peutic dose, followed by a dose reduction over a
trial [70]. period of 3 months.

17.3.7.1 Systemic Corticosteroids 17.3.7.4 Methotrexate

Systemic corticosteroids can be used briefly to treat Case reports have shown that low doses of meth-
acute severe hand eczema (generally 0.51 mg/kg otrexate led to improvement or clearing of hand
body weight per day prednisolone equivalent, for dermatitis, together with a decreased need for
a maximum period of 3 weeks). Systemic corti- concomitant systemic corticosteroids [75]. Long-
costeroids are not appropriate for use in the term use of methotrexate is associated with sig-
chronic phases of chronic hand eczema, as they nificant potential for side effects including
are associated with long-term side effects such as hepatitis, liver cirrhosis, pancytopenia, pulmo-
osteoporosis, glaucoma, cataracts, hypothalamic- nary fibrosis and teratogenicity, but these can be
pituitary-adrenal axis suppression, hyperglycae- minimised if it is appropriately dosed, and
mia, hypertension and immunosuppression patients are selected and monitored carefully.

17.3.7.5 Acitretin
17.3.7.2 Azathioprine Acitretin is currently not licensed for the treat-
Azathioprine has been reported to improve atopic ment of hand dermatitis. There are limited data
eczema and pompholyx [71]. Patients on azathio- on its efficacy, but a small, open-label study of 29
prine require regular blood monitoring, as it can patients with hyperkeratotic dermatitis of the
cause a reduction of the white blood cell count. palms, 30 mg daily for 4 weeks was associated
Measurement of blood levels of thiopurine meth- with a 51% reduction of all symptoms, compared
yltransferase (TPMT) before initiating therapy is to only 9% in a placebo control group. No further
helpful to find the suitable dose for each individ- improvement was seen with 4 additional weeks
ual patient. of treatment [76]. Being a retinoid, acitretin is
teratogenic, and therefore, pregnancy prevention
17.3.7.3 Cyclosporine measures are indicated during treatment and for
In a double-blind study of 41 patients with severe at least 23 years after discontinuation.
chronic hand eczema randomised to either oral Additionally, in combination with alcohol, acitre-
cyclosporine (3 mg/kg/day) or 0.05% betametha- tin has been associated with the formation of
sone dipropionate cream, disease activity etretinate, which increases the duration of terato-
decreased by 50%, compared to 32% in the ste- genic potential for female patients.
roid group, which was not statistically signifi-
cantly different. The relapse rate for both groups 17.3.7.6 Alitretinoin (9-Cis Retinoic Acid)
was 50% after 2 weeks of follow-up [72]. In a Alitretinoin is approved for use in treating severe,
second, open-label study, 75 patients treated for chronic hand eczema that does not respond, or
6 weeks with oral cyclosporine 3 mg/kg/day responds inadequately, to topical corticosteroids.
showed 1-year success rates of 79% and 74% for Alitretinoin is an agonist of both vitamin A acid
atopic and chronic hand eczema, respectively receptors. Its main mechanism of action is immu-
[73]. A recent meta-analysis suggested the effi- nomodulatory and anti-inflammatory (and, in
cacy of cyclosporine after 68 weeks of treatment contrast to retinoids, it has a minimal drying
was 55% in atopic eczema [74]. effect). Treatment should be stopped if no effect
The use of cyclosporine also requires careful has occurred after 3 months. In 1,032 patients with
monitoring, as it can be associated with poten- severe refractory HE, 48% of randomised patients
tially serious adverse events including nephro- treated with alitretinoin were clear (Physician
toxicity, risk of malignancy, increased blood Global Assessment) or almost clear within
pressure and increased risk of infection. In gen- 1224 weeks compared with 17% assigned to pla-
eral, therapy with cyclosporine is recommended cebo [70]. The commonest adverse effect was
276 C. Williams and M. Wilkinson

headache, reported by 11% and 20% of patients at References

doses of 10 and 30 mg daily compared with 6%
with placebo. The response was more marked in 1. Thyssen JP, Johansen JD, Linneberg A, Menne T
patients with hyperkeratotic hand eczema (49% at (2010) The epidemiology of hand eczema in the gen-
eral population prevalence and main findings.
30 mg daily, 28% at 10 mg daily) than in those Contact Dermatitis 62:7587
with vesicular disease (33% and 23%, respec- 2. Meding B (1990) Epidemiology of hand eczema in
tively). Alitretinoin is associated with an increase an industrial city. Acta Derm Venereol Suppl (Stockh)
in plasma cholesterol, thyroid function and triglyc- 153:143
3. Rystedt I (1985) Long term follow-up in atopic der-
eride levels, and these should be monitored during matitis. Acta Derm Venereol Suppl (Stockh) 114:
therapy. Like all retinoic acid derivatives, alitretin- 117120
oin is teratogenic. Pregnancy prevention 1 month 4. Thyssen JP, Carlsen BC, Menne T et al (2010)
before, during and for 1 month after cessation of Filaggrin null mutations increase the risk and persis-
tence of hand eczema in subjects with atopic dermati-
treatment is therefore required in women of child- tis: results from a general population study. Br J
bearing potential. Dermatol 163:115120
5. Meding B, Wrangsjo K, Jarvholm B (2005) Fifteen-
year follow-up of hand eczema: persistence and con-
sequences. Br J Dermatol 152:975980
6. Halkier-Sorensen L (1996) Occupational skin dis-
eases. Contact Dermatitis 35(Suppl 1):1120
7. Diepgen TL, Andersen KE, Brandao FM et al (2009)
Take Home Messages Hand eczema classification: a cross-sectional, multi-
Initial management should include a full centre study of the aetiology and morphology of hand
eczema. Br J Dermatol 160:353358
history, exclusion of infection and 8. Koch P (2001) Occupational contact dermatitis.
advice on a skin-protection programme. Recognition and management. Am J Clin Dermatol
Skin barrier function should be main- 2:353365
tained and supported by preventive mea- 9. Dickel H, Kuss O, Blesius CR, Schmidt A, Diepgen
TL (2001) Occupational skin diseases in Northern
sures, for example, emollients, barriers Bavaria between 1990 and 1999: a population-based
and soap substitutes, if avoidance of study. Br J Dermatol 145:453462
contact factors is not possible. 10. Cvetkovski RS, Rothman KJ, Olsen J, Mathiesen B,
Moisturisers differ in composition and Iversen L, Johansen JD, Agner T (2005) Relation
between diagnoses on severity, sick leave and loss of
in their influence on skin properties. job among patients with occupational hand eczema.
Further field studies are required to Br J Dermatol 152:9398
investigate this objectively. 11. Fowler JF, Ghosh A, Sung J et al (2006) Impact of
Initial treatment should include a trial of chronic hand dermatitis on quality of life, work pro-
ductivity, activity impairment, and medical costs. J
treatment with a topical steroid. Am Acad Dermatol 54:448457
Systemic therapies include cyclosporine 12. Agner T, Andersen KE, Brandao FM et al (2008)
and azathioprine. Alitretinoin is a new Hand eczema severity and quality of life: a cross-sec-
option licensed for severe chronic hand tional, multicentre study of hand eczema patients.
Contact Dermatitis 59:4347
eczema and showing good clearance 13. Lerbaek A, Kyvik KO, Ravn H et al (2008) Clinical
rates in a clinical trial that included characteristics and consequences of hand eczema an
patients with all forms of hand eczema 8-year follow-up study of a population-based twin
PUVA and/or acitretin may be considered cohort. Contact Dermatitis 58:210216
14. Susitaival P, Hannuksela M (1995) The 12-year prog-
first for hyperkeratotic hand eczema. nosis of hand dermatosis in 896 Finnish farmers.
Oral steroids can be considered when Contact Dermatitis 32(4):233237
rapid control is needed. 15. Diepgen TL, Agner T, Aberer W, Berth-Jones J,
Options after other systemic therapies Cambazard F, Elsner P, McFadden J, Coenraads PJ
(2007) Management of chronic hand eczema. Contact
have failed include methotrexate and Dermatitis 57:203210
mycophenolate mofetil. 16. van Gils RF, Boot CRL, van Gils PF et al (2011)
Effectiveness of prevention programmes for hand
17 Update on Hand Eczema with Special Focus on the Impact of Moisturisers 277

dermatitis: a systematic review of the literature. ing system decreases unprotected areas on the hands.
Contact Dermatitis 64:6372 Contact Dermatitis 49(3):159160
17. Nielsen NH, Linneberg A, Menn T, Madsen F, 32. Bendsoe N, Bjornberg A, Lowhagen GB, Tengberg JE
Frolund L, Dirksen A, Jrgensen T (2002) The asso- (1987) Glass fibre irritation and protective creams.
ciation between contact allergy and hand eczema in Contact Dermatitis 17:6972
two cross-sectional surveys 8 years apart. Contact 33. Elsner P (2007) Skin protection in the prevention of
Dermatitis 47:7177 skin diseases. Curr Probl Dermatol 34:110
18. Wrangsjo K, Wallenhammar LM, Ortengren U, 34. Krajewska D, Rudzki E (1976) Sensitivity to epoxy
Barregard L, Andreasson H, Bjorkner B, Karlsson S, resins and triethylenetetramine. Contact Dermatitis
Meding B (2001) Protective gloves in Swedish den- 2:135138
tistry: use and side effects. Br J Dermatol 145:3237 35. Winker R, Salameh B, Stolkovich S, Nikl M, Barth A,
19. Ramsing DW, Agner T (1996) Effect of glove occlu- Ponocny E et al (2009) Effectiveness of skin protec-
sion on human skin. (I). Short-term experimental tion creams in the prevention of occupational derma-
exposure. Contact Dermatitis 34(1):15 titis: results of a randomized, controlled trial. Int Arch
20. Ramsing DW, Agner T (1996) Effect of glove occlu- Occup Environ Health 82:653662
sion on human skin (II). Long-term experimental 36. (NHS Plus 2008) NHS Plus/Royal College of
exposure. Contact Dermatitis 34(4):258262 Physicians (2008) Latex allergy: occupational health
21. Strauss RM, Gawkrodger DJ (2001) Occupational aspects of management: a national guideline. Royal
contact dermatitis in nurses with hand eczema. College of Physicians, London
Contact Dermatitis 44:293296 37. Loden M, Andersson AC (1996) Effects of topically
22. Schrer NY, Klippel U et al (2005) Secondary indi- applied lipids on surfactant irritated skin. Br J
vidual prevention of hand dermatitis in geriatric Dermatol 134:215220
nurses. Int Arch Occup Environ Health 78:149157 38. Ramsing DW, Agner T (1997) Preventive and thera-
23. Schwanitz HJ, Riehl U et al (2003) Skin care manage- peutic effects of a moisturizer. Acta Derm Venereol
ment: educational aspects. Int Arch Occup Environ 77:335337
Health 76(5):374381 39. Hoare C, Li Wan Po A, Williams H (2000) Systematic
24. Weisshaar E, Radulescu M et al (2007) Secondary review of treatments for atopic eczema. Health
individual prevention of occupational skin diseases in Technol Assess 4:1191
health care workers, cleaners and kitchen employees: 40. Buraczewska I, Berne B, Lindberg M, Torma H,
aims, experiences and descriptive results. Int Arch Loden M (2007) Changes in skin barrier function fol-
Occup Environ Health 80(6):477484 lowing long-term treatment with moisturizers, a ran-
25. English J, Aldridge R, Gawkrodger DJ, Kownacki S, domized controlled trial. Br J Dermatol 156:
Statham B, White JM et al (2009) Consensus state- 492498
ment on the management of chronic hand eczema. 41. Held E, Sveinsdottir S, Agner T (1999) Effect of long-
Clin Exp Dermatol 34:761769 term use of moisturizer on skin hydration, barrier
26. Boyce JM, Pittet D, Healthcare Infection Control function and susceptibility to irritants. Acta Derm
Practices Advisory Committee et al (2000) Guideline Venereol 79:4951
for Hand Hygiene in Health-Care Settings. 42. Zachariae C, Held E, Johansen JD, Menne T, Agner T
Recommendations of the Healthcare Infection Control (2003) Effect of a moisturizer on skin susceptibility to
Practices Advisory Committee and the HICPAC/ NiCl2. Acta Derm Venereol 83:9397
SHEA/APIC/IDSA Hand Hygiene Task Force. 43. Vilaplana J, Coll J, Trulls C, Axn A, Pelejero C
Society for Healthcare Epidemiology of America/ (1992) Clinical and non-invasive evaluation of 12%
Association for Professionals in Infection Control/ ammonium lactate emulsion for the treatment of dry
Infectious Diseases Society of America. MMWR skin in atopic and non-atopic subjects. Acta Derm
Morb Mortal Wkly Rep 51(RR-16):145 Venereol 72:2833
27. Loffler H, Kampf G, Schermund D, Maibach HI (2007) 44. Loden M (2005) The clinical benefit of moisturizers.
How irritant is alcohol? Br J Dermatol 157:7481 J Eur Acad Dermatol Venereol 19:672688
28. Frosch PJ, SchulzeDirk A, Hoffmann M et al (1993) 45. Halkier-Sorensen L, Thestrup-Pedersen K (1993) The
Efficacy of skin barrier creams. (I). The repetitive irri- efficacy of a moisturizer (Locobase) among cleaners
tation test (RIT) in the guinea pig. Contact Dermatitis and kitchen assistants during everyday exposure to
28(2):94100 water and detergents. Contact Dermatitis 29:16
29. Kresken J, Klotz A (2003) Occupational skin-protec- 46. Hannuksela A, Kinnunen T (1992) Moisturizers pre-
tion products a review. Int Arch Occup Environ vent irritant dermatitis. Acta Derm Veneroel (Stockh)
Health 76(5):355358 72:4244
30. Saary J, Qureshi R, Palda V, DeKoven J, Pratt M, 47. Loden M (1997) Barrier recovery and influence of
Skotnicki-Grant S et al (2005) A systematic review of irritant stimuli in skin treated with a moisturizing
contact dermatitis treatment and prevention. J Am cream. Contact Dermatitis 36:256260
Acad Dermatol 53:845855 48. Held E, Agner T (1999) Comparison between 2 test
31. Kelterer D, Fluhr JW, Elsner P (2003) Application of models in evaluating the effect of a moisturizer on
protective creams: use of a fluorescence-based train- irritated human skin. Contact Dermatitis 40:261268
278 C. Williams and M. Wilkinson

49. Goh CL, Gan SL (1994) Efficacies of a barrier cream 63. El-Batawy MM, Bosseilo MA, Marshaly HM et al
and an afterwork emollient cream against cutting fluid (2009) Topical calcineurin inhibitors in atopic derma-
dermatitis in metalworkers: a prospective study. titis: a systematic review and meta-analysis. J
Contact Dermatitis 31:176180 Dermatol Sci 54:7687
50. Williams C, Wilkinson SM, McShane P et al (2010) A 64. Hanifin JM, Stevens V, Sheth P et al (2004) Novel
double-blind, randomized study to assess the effec- treatment of chronic severe hand dermatitis with bex-
tiveness of different moisturizers in preventing der- arotene gel. Br J Dermatol 150:545553
matitis induced by hand washing to simulate healthcare 65. Lindelof B, Wrangsjo K, Liden S (1987) A double-
use. Br J Dermatol 162(5):10881092 blind study of Grenz ray therapy in chronic eczema of
51. Held E (2001) So moisturizers may cause trouble! Int the hands. Br J Dermatol 117:7780
J Dermatol 40:1213 66. Wollina U, Karamfilov T (2002) Adjuvant botulinum
52. Held E, Lund H, Agner T (2001) Effect of different toxin A in dyshidrotic hand eczema: a controlled pro-
moisturizers on SLS-irritated human skin. Contact spective pilot study with left-right comparison. J Eur
Dermatitis 44:229234 Acad Dermatol Venereol 16:4042
53. Loden M (2004) Do moisturizers work? J Cosmet 67. Odia S, Vocks E, Rakoski J, Ring J (1996) Successful
Dermatol 2:141149 treatment of dyshidrotic hand eczema using tap water
54. Kucharekova M, Van De Kerkhof PC, Van Der Valk iontophoresis with pulsed direct current. Acta Derm
PG (2003) A randomized comparison of an emollient Venereol 76:472474
containing skin related lipids with a petrolatum-based 68. Rosen K, Mobacken H, Swanbeck G (1987) Chronic
emollient as adjunct in the treatment of chronic hand eczematous dermatitis of the hands. A comparison of
dermatitis. Contact Dermatitis 48:293299 PUVA and UVB treatment. Acta Derm Venereol
55. Lodn M, Barany E (2000) Skin-identical lipids ver- 67:4854
sus petrolatum in the treatment of tape-stripped and 69. Schmidt T, Abeck D, Boeck K et al (1998) UVA1 irra-
detergent-perturbed human skin. Acta Derm Venereol diation is effective in treatment of chronic vesicular
80:412415 dyshidrotic hand eczema. Acta Derm Venereol
56. Elias PM, Hatano Y, Williams ML (2008) Basis for 78:318319
the barrier abnormality in atopic dermatitis: outside- 70. Ruzicka T, Lynde CW, Jemec GB et al (2008) Efficacy
inside-outside pathogenic mechanisms. J Allergy Clin and safety of oral alitretinoin (9-cis retinoic acid) in
Immunol 121:13371343 patients with severe chronic hand eczema refractory
57. Andersson A-C, Lindberg M, Lodn M (1999) The to topical corticosteroids: results of a randomized,
effect of two urea-containing creams on dry, eczema- double-blind, placebo-controlled, multicentre trial. Br
tous skin in atopic patients. I. Expert, patient and J Dermatol 158:808817
instrumental evaluation. J Dermatol Treat 71. Scerri L (1999) Azathioprine in dermatological prac-
10:165169 tice. An overview with special emphasis on its use in
58. Lodn M, Andersson A-C, Lindberg M (1999) non-bullous inflammatory dermatoses. Adv Exp Med
Improvement in skin barrier function in patients with Biol 455:343348
atopic dermatitis after treatment with a moisturizing 72. Granlund H, Erkko P, Eriksson E et al (1996)
cream (Canoderm). Br J Dermatol 140:264267 Comparison of cyclosporine and topical betametha-
59. Wirn K, Nohlgrd C, Nyberg F, Holm L, Svensson sone-17,21-dipropionate in the treatment of severe
M, Johannesson A et al (2009) Treatment with a bar- chronic hand eczema. Acta Derm Venereol
rier-strengthening moisturizing cream delays relapse 76:371376
of atopic dermatitis: a prospective and randomized 73. Granlund H, Erkko P, Reitamo S (1998) Long-term
controlled clinical trial. J Eur Acad Dermatol Venereol follow-up of eczema patients treated with cyclosporine.
23:12671272 Acta Derm Venereol 78:4043
60. Loden M, Wiren K, Smerud K et al (2010) Treatment 74. Schmitt J, Schmitt N, Meurer M (2007) Cyclosporin
with a barrier-strengthening moisturizer prevents in the treatment of patients with atopic eczema a
relapse of hand eczema: an open, randomized, pro- systematic review and meta-analysis. J Eur Acad
spective, parallel group study. Acta Derm Venereol Dermatol Venereol 21(5):606619
90:602606 75. Egan CA, Rallis TM, Meadows KP, Krueger GC
61. Veien NK, Olholm Larsen P, Thestrup-Pedersen K (1999) Low-dose oral methotrexate treatment for
et al (1999) Long-term, intermittent treatment of recalcitrant palmoplantar pompholyx. J Am Acad
chronic hand eczema with mometasone furoate. Br J Dermatol 40:612614
Dermatol 140:882886 76. Thestrup-Pedersen K, Andersen KE, Menn T et al
62. Schnopp C, Remling R, Mhrenschlager M et al (2001) Treatment of hyperkeratotic dermatitis of the
(2002) Topical tacrolimus (FK506) and mometasone palms (eczema keratoticum) with oral acitretin. A
furoate in treatment of dyshidrotic palmar eczema: a single-blind placebo-controlled study. Acta Derm
randomized, observer-blinded trial. J Am Acad Venereol 81:353355
Dermatol 46:7377
 Update on Ichthyosis with Special
Emphasis on Dryness and the 18
Impact of Moisturizers

Johannes Wohlrab

18.1 Introduction are not known for all forms and are also heterog-
enous in most types. However, the ichthyoses
Patients with ichthyoses typically suffer their have a more or less functionally effective micro-
whole life under the hereditary keratosis of the structural alteration of the physicochemically
skin organ. Depending on heredity, genetic char- complex milieu of the stratum corneum and its
acteristics and clinical expression patterns, reten- microcompartments. Since state-of-the-art molec-
tion hyperkeratosis or alternatively proliferation ular and genetic methods have allowed ever deeper
hyperkeratosis [25] result. This causes functional insights into the etiopathogenetic contexts of dis-
damage to the layers of the stratum corneum, orders of cornification (DOC), but are not avail-
which causes the typical clinical phenotype, i.e. able for area-covering routine diagnostics, an
raw, dry skin. Some ichthyoses are frequent gen- international expert commission worked out a
odermatoses. In particular, the autosomal domi- new systematics and nomenclature in 2009, which
nant form of ichthyosis vulgaris with 1:300 is the is more strongly oriented toward clinical criteria
most frequently occurring within genetically and includes the molecular and pathogenetic rela-
conditioned skin disorders [25]. tionships if known [14]. The historically charac-
The historical systematics of ichthyoses terized concept of the ichthyoses, which is
describes two main types: oriented to the phenotypical picture, particularly
1. Common ichthyoses (without concomitant of the lamellar ichthyoses, and refers to the
inflammation) appearance of fish skin, is ultimately inapplicable
2. Congenital lamellar ichthyoses (with concom- and has therefore faded into the background in the
itant inflammation) new pathophysiologically oriented nomenclature
Both types have numerous genetic and pheno- (Fig. 18.1). Nevertheless, in analogy to historical
typic variants and occur as isolated disorders, but systematics, two main groups are differentiated:
they can rarely also display additional symptoms non-syndromal ichthyoses (exclusively cutaneous
in extracutaneous organ systems as ichthyosis manifestations) and syndromal ichthyoses (cuta-
syndromes with many clinical variants. The neous manifestation in combination with partici-
molecular etiopathogenesis and the genetic defect pation of other organs) [14]. For the much more
frequent and thus also more practically relevant
non-syndromal forms, five pathogenetic patterns
J. Wohlrab, M.D., Ph.D. have been defined (Fig. 18.1) [14]. To understand
Department of Dermatology and Venereology, this systematics, the processes of the keratinocyte
Martin Luther University Halle-Wittenberg,
differentiation as well as the functional structure
Ernst-Grube-Strae 40, D-06097
Halle (Saale), Germany of the stratum corneum (bricks-and-mortar model)
e-mail: [email protected] are an essential foundation [3].

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 279

DOI 10.1007/978-3-642-27606-4_18, Springer-Verlag Berlin Heidelberg 2012
280 J. Wohlrab

Fig. 18.1 Overview of the

disorders of cornification localized and
DOC
(DOC) (adapted from miscellaneous
Oji et al. [14])

lchthyosis

non-syndromic syndromic

lipid
filaggrin lipid transport
metabolism

cornified protease/ DNA

envelope antiprotease synthesis

keratino-
gap junctions
pathies

18.2 Defects of the Corneocyte mutations in the filaggrin gene (FLG) is recog-
Proteins nized as being the causal factor as heterozygotic
form they are usually mild and as homozygotic
The defined group of keratinopathic ichthyoses form they express the full phenotype. In this case,
(KPI) subsumes all subtypes of the epidermolytic overlaps to atopic dermatitis exist for which
ichthyoses (EI) [14]. Spontaneous mutations in mutations in the FLG gene are known [2]. Pro-
genes that code for keratins (in particular K1, K2 FLG, the translation product of the FLG gene, is
or K10) [18, 19] are typical. The functional defi- located in the keratohyalin granules in the granu-
cits frequently clinically result, even prenatally lar layer, which is reduced or absent in cases
or perinatally, in blister formation and exfoliation involving existing mutation or mutations. The fil-
without syndromal phenotype. However, defects aggrin defect results in a reduction in the intrac-
can also first manifest themselves postnatally as a orneocytic amino acid concentration produced by
consequence of the functional decomposition of proteolysis and thus reduces the hygroscopic
the epidermal barrier [25]. In this context, the binding capacity of the stratum corneum. The
barrier damage is primarily due to the fragility of altered swelling behaviour of corneocytes then
the upper nucleated cell layers. effects a retention of the stratum corneum and a
Disorders of the corneocyte envelope, particu- reduced acidification and forms the basis for a
larly in the form of ichthyosis vulgaris (IV), scaling abnormality [21].
are frequent [23]. A clinical differentiation to More rarely, loss-of-function mutations of the
atopical dermatitis or xerosis, respectively, can be transglutaminase 1 (TGM1) gene occur under the
difficult, particularly since the type IV ichthyosis clinical phenotype of an autosomal recessive
typically establishes itself only in the first few congenital ichthyosis (ARCI) [1, 20]. Moreover,
months of life. Either insertion or deletion clinically variable, erythrodermic pictures are
18 Update on Ichthyosis with Special Emphasis on Dryness and the Impact of Moisturizers 281

observed, which are subsumed under the pheno-

type of an ichthyosis en confetti (IEC) [14].

18.3 Defects of Keratinocyte Lipid

Transport

Disturbances of the exocytosis-like processes of

secretion of the lipid fractions, which are synthe-
sized in the keratinocytes, from the lamellar
bodies are functionally more severe [26]. The
lysosome-like lamellar bodies additionally con- Fig. 18.2 A 2-day-old girl with harlequin ichthyosis
tain a series of enzymatically active substances,
which belong to the group of the lipid hydro-
lases, proteases or anti-proteases, respectively. 18.5 Defects of the Keratinocyte
Additionally, apolipoproteins, anti-microbial Lipid Metabolism
peptides (b-defensin hBD2, cathelicidin LL-37)
and additional functional peptides are separated The broad spectrum of lipids and their functional
with the lipid fractions which contribute to the significance in the particular organizational struc-
particular organizational structure of the inter- ture of the lamellar and extralamellar phases
cellular lipid matrix. To achieve this, the organ- of the stratum corneum are only partially known
elles must migrate centrifugally to the cell to date. Nevertheless, defined defects of lipid
membrane, which is regulated by special pro- metabolism clearly illustrate which effects the
teins. The motor and non-motor proteins lack or the functional failure of certain fatty
(e.g. CLIP-170, Cdc42, Arf, Rab7, Rab 11) are acids can have non-syndromally (e.g. autosomal
very significant, and functional deficits of this recessive congenital ichthyoses, ARCI) or syn-
system result in severe phenotypes of the disease dromally (e.g. Chanarin-Dorfman syndrome,
(e.g. harlequin ichthyosis), mostly even as syn- Sjgren-Larsson syndrome, Morbus Refsum). In
dromal form (e.g. CEDNIK Syndrome, MEDNIK addition, disorders of the cholesterol (e.g. CHILD
Syndrome) [8, 17]. syndrome, Conradi-Hnermann-Happle syn-
drome) or sphingolipid metabolism (e.g. Gaucher
disease) have syndromal phenotypes [14].
18.4 Protease/Anti-protease Defects

The process of desquamation is enzymatically 18.6 Therapeutic Options

controlled and thus represents a biochemically
active process. The interaction of proteases and Because of the multifarious pathological con-
anti-proteases is to be understood as a type of cepts of the DOC, it is clear that ichthyoses do
equilibrium process. An enzyme that regulates not represent a uniform entity and therefore no
the activity of serine proteases is LEKTI-1, uniform therapy approach can be propagated
which is encoded by the SPINK5 gene and, as [11]. From a clinical point of view, however,
is well known, exhibits mutations in the depending on the ichthyosis (DOC) type and
Netherton syndrome or in the peeling skin syn- manifestation pattern, the following significant
drome [14]. In the meantime, it has become aspects can be considered in therapeutic manage-
additionally clear that LEKTI-1 also partici- ment after meticulous consideration of the indi-
pates in inducing and maintaining an inflamma- vidual benefit-risk ratio:
tory response [6]: For this reason, parallels are Barrier substitution (moisturizer) [4, 12, 22]
also drawn to the pathogenetic concept of atopic Anti-proliferative therapy (retinoids (Figs. 18.2,
dermatitis [2]. 18.3), Vitamin D analogues) [7, 9, 13]
282 J. Wohlrab

Fig. 18.3 The girl of Fig.

18.2 after perinatal 6 month of
oral 1 mg/kg body weight/day
acitretin in combination with
5% urea, 5% glycerol, 20%
water in cold cream TID

Anti-septic measures (triclosan, octenidine, and the individual impairment of quality of life,
polyhexanide, chlorhexidine) the affected person should be given individually
Anti-inflammatory therapy (glucocorticoids, selected, barrier-effective and optionally pharma-
calcineurin inhibitors) ceutical therapy options so that an individualized,
Anti-pruritic therapy (polidocanol) symptom-oriented therapy for the patient is
Keratolytic/keratoplastic therapy (210% enabled.
urea, 1025% propylene glycol, a-hydroxy
acids, e.g. 515% lactic acid, salicylic acid,
bath additive of approximately 2050 g/bath 18.7 Signicance of Moisturizers
sodium hydrogen carbonate) [5, 1012]
Nutritional counselling (elevated basal metab- A great significance is frequently ascribed to
olism) [11] the application of moisturizers in the manage-
Measures for anhidrosis (e.g. cooling) ment of ichthyoses. However, depending on the
Psychosocial counselling individual circumstances and the disease type,
The criteria for evidence-based medicine can a critical assessment of the individual therapy
only be conditionally applied because of the rar- options should be performed. As is well known,
ity of most ichthyoses and the lack of prospec- the application of false or falsely concentrated
tive, controlled therapy studies according to GCP moisturizer can also result in irritations or toxi-
standard. Fundamentally, the active-substance cologically relevant side effects [16]. Hence, a
specific risks of the individual therapy options generalized recommendation is not advisable
and the special resorption conditions of the patho- and also not professional. Similarly to the man-
logically altered skin as well as the extent of the agement of atopic dermatitis, adherence of the
affected skin area are to be considered. The com- affected person to the therapy regime is of deci-
pliance of those affected and their social environ- sive importance in the middle- and long-term.
ment are of great importance, and judging from Not only the optimized composition of the
my own experience can only be maintained by an therapeutic concept, but above all the regu-
empathic and patient informative guidance by a lar and consequent application is decisive for
competent and experienced therapist. Depending the effect [22]. Therefore, the acceptance of the
on the extent of the diseases clinical relevance therapeutic preparations is so important; this
18 Update on Ichthyosis with Special Emphasis on Dryness and the Impact of Moisturizers 283

can only be achieved when the appropriate

moisturizer mixtures are selected and tested in Therapeutic options are the topical and/
a dynamic process, quasi-empirically, in coop- or systemic administration of anti-prolif-
eration with the patient. In this context, the erative (retinoids, Vitamin D analogues),
patients expectations, which are normally anti-inflammatory (glucocorticoids, cal-
shaped by a generally defined ideal (i.e. ideal cineurin inhibitors), anti-septic (triclosan,
of beauty), are also to be taken into consider- octenidine, polyhexanide, chlorhexidine)
ation to ensure therapeutic success. The defini- and/or anti-pruritic (polidocanol) active
tion of a realistic therapeutic objective is substances.
particularly relevant for the orientation of the Nutritional counselling, measures for
patient and the trust-based physician-patient anhidrosis and psychosocial counselling
relationship. Additionally, there are slightly can be important.
different experiences in the use of moisturizers
in individual countries. In Germany (and as far
as the author knows, also in other European
countries), urea (210%) alone and in combi- References
nation with glycerol (5%) are frequently rec-
1. Akiyama M, Takizawa Y, Kokaji T (2001) Novel muta-
ommended. However, in the USA, a-hydroxy tions of TGM1 in a child with congenital ichthyosi-
acids and propylene glycol (up to 20%) are pre- form erythroderma. Br J Dermatol 144:401407
ferred. Basically, combination preparations of 2. Elias PM, Hatano Y, Williams ML (2008) Basis for
the barrier abnormality in atopic dermatitis: outside-
at least two, better three, moisturizers is to be
inside-outside pathogenic mechanisms. J Allergy Clin
preferred to a monotherapy. The use of mois- Immunol 121:13371343
turizers is an essential component of basic 3. Elias PM, Schmuth M, Uchida Y, Rice RH, Behne M,
therapeutic management for the majority of Crumrine D, Feingold KR, Holleran WM, Pharm D
(2002) Basis for the permeability barrier abnormality
ichthyoses [12, 16, 22].
in lamellar ichthyosis. Exp Dermatol 11:248256
4. Ganemo A, Virtanen M, Vahlquist A (1999) Improved
topical treatment of lamellar ichthyosis: a double-
blind study of four different cream formulations. Br J
Dermatol 141:10271032
5. Goldsmith LA, Baden HP (1972) Propylene glycol
Take Home Messages with occlusion for treatment of ichthyosis. JAMA
Since 2009, there is a revised pathophys- 220:579580
iologically oriented nomenclature and 6. Hachem JP, Wagberg F, Schmuth M, Crumrine D,
Lissens W, Jayakumar A, Houben E, Mauro TM,
classification of inherited ichthyoses.
Leonardsson G, Brattsand M, Egelrud T, Roseeuw D,
Two main groups, non-syndromal and Clayman GL, Feingold KR, Williams ML, Elias PM
syndromal ichthyoses, are differentiated. (2006) Serine protease activity and residual LEKTI
The classification is oriented at (1) defects expression determine phenotype in Netherton syn-
drome. J Invest Dermatol 126:16091621
of the corneocyte proteins, (2) defects of
7. Hofmann B, Stege H, Ruzicka T, Lehmann O (1999)
keratinocyte lipid transport, (3) protease/ Effect of topical tazarotene in the treatment of con-
anti-protease defects and (4) defects of genital ichthyoses. Br J Dermatol 141:642646
the keratinocyte lipid metabolism. 8. Ishida-Yamamoto A, Kishibe M, Takahashi H, Iizuka H
(2007) Rab11 is associated with epidermal lamellar
The use of moisturizers and the basis of
granules. J Invest Dermatol 127:21662170
therapeutic management are established. 9. Kragballe K, Steijlen PM, Ibsen HH, Van de Kerkhof
There are different experiences in the use PC, Esmann J, Sorensen LH, Axelsen MB (1995)
of moisturizers in individual countries. Efficacy, tolerability, and safety of calcipotriol oint-
ment in disorders of keratinization. Results of a ran-
Urea, glycerol, a-hydroxy acids and
domized, double-blind, vehicle-controlled, right/left
propylene glycol alone or in combina- comparative study. Arch Dermatol 131:556560
tion are frequently recommended. 10. Kster W, Bohnsack K, Rippke F, Upmeyer HJ, Groll S,
Traupe H (1998) Efficacy of urea therapy in children
284 J. Wohlrab

with ichthyosis. A multicenter randomized, placebo- 18. Rothnagel JA, Dominey AM, Dempsey LD, Longley
controlled, double-blind, semilateral study. Dermatology MA, Greenhalgh DA, Gagne TA, Huber M, Frenk E,
196:217222 Hohl D, Roop DR (1992) Mutations in the rod
11. Kster W (2006) Ichthyosen: Vorschlge fr eine domains of keratins 1 and 10 in epidermolytic hyper-
verbesserte therapie. Dt rzteblatt 103:A1684A1689 keratosis. Science 257:11281130
12. Lodn M (2003) Role of topical emollients and mois- 19. Rothnagel JA, Wojcik S, Liefer KM, Dominey AM,
turizers in the treatment of dry skin barrier disorders. Huber M, Hohl D, Roop DR (1995) Mutations in the 1A
Am J Clin Dermatol 4:771788 domain of keratin 9 in patients with epidermolytic pal-
13. Nikhar B, Atherton DJ, Harper JI (1996) An appraisal moplantar keratoderma. J Invest Dermatol 104:430433
of acitretin therapy in children with inherited disor- 20. Russell LJ, DiGiovanna JJ, Rogers GR, Steinert PM,
ders of keratinisation. Br J Dermatol 134:10231029 Hashem N, Compton JG, Bale SJ (1995) Mutations in
14. Oji V, Tadini G, Akiyama M, Blanchet Bardon C, the gene for transglutaminase 1 in autosomal reces-
Bodemer C, Bourrat E, Coudiere P, DiGiovanna JJ, Elias sive lamellar ichthyosis. Nat Genet 9:279283
P, Fischer J, Fleckman P, Gina M, Harper J, Hashimoto 21. Scott IR, Harding CR (1986) Filaggrin breakdown to
T, Hausser I, Hennies HC, Hohl D, Hovnanian A, Ishida- water binding compounds during development of the
Yamamoto A, Jacyk WK, Leachman S, Leigh I, rat stratum corneum is controlled by the water activity
Mazereeuw-Hautier J, Milstone L, Morice-Picard F, of the environment. Dev Biol 115:8492
Paller AS, Richard G, Schmuth M, Shimizu H, 22. Simion FA, Abrutyn ES, Draelos ZD (2005) Ability
Sprecher E, Van Steensel M, Taeb A, Toro JR, Vabres of moisturizers to reduce dry skin and irritation and to
P, Vahlquist A, Williams M, Traupe H (2010) Revised prevent their return. J Cosmet Sci 56:427444
nomenclature and classification of inherited ich- 23. Steinert PM, Marekov LN (1999) Initiation of assem-
thyoses: results of the first ichthyosis consensus con- bly of the cell envelope barrier structure of stratified
ference in Sorze 2009. J Am Acad Dermatol squamous epithelia. Mol Biol Cell 10:42474261
63:607641 24. Sybert VP, Dale BA, Holbrook KA (1985) Ichthyosis
15. Oren A, Ganz T, Liu M, Meerloo T (2003) In human vulgaris: identification of a defect in synthesis of fil-
epidermis, beta-defensin 2 is packaged in lamellar aggrin correlated with an absence of keratohyaline
bodies. Exp Mol Pathol 74:180182 granules. J Invest Dermatol 84:191194
16. Rawlings AV, Scott IR, Harding CR, Bowser PA 25. Traupe H (1989) The ichthyoses: a guide to clinical
(1994) Stratum corneum moisturization at the molec- diagnosis, genetic counselling, and therapy. Springer,
ular level. J Invest Dermatol 103:731741 New York, p. 253ff
17. Raymond AA, de Gonzalez de Peredo A, Stella A, 26. Williams ML, Coleman RA, Placezk D, Grunfeld C
Ishida-Yamamoto A, Bouyssie D, Serre G, Monsarrat (1991) Neutral lipid storage disease: a possible func-
B, Simon M (2008) Lamellar bodies of human epider- tional defect in phospholipids-linked triacylglycerol
mis: proteomics characterization by high throughput metabolism. Biochim Biophys Acta 1096:162169
mass spectrometry and possible involvement of CLIP- 27. Zeeuwen PL (2004) Epidermal differentiation: the
170 in their trafficking/secretion. Mol Cell Proteomics role of proteases and their inhibitors. Eur J Cell Biol
7:21512175 83:761773
 Psoriasis and Dry Skin: The Impact
of Moisturizers 19
Joachim W. Fluhr, Enzo Berardesca,
and Razvigor Darlenski

19.1 Introduction and SC dryness. Today, psoriasis is accepted as a

disease characterized by chronic systemic inflam-
Psoriasis is a chronic, systemic, inflammatory mation and enhanced secretion of proinflamma-
disorder with predominant affection of the skin. tory cytokines that are capable of inducing
It affects around 2% of the general population pathological skin changes [5].
[1]. The disease has a serious impact on the qual- The chronic-relapsing course of psoria-
ity of life of the patients [2]. Psoriasis is clinically sis requires lifelong management in most of
heterogeneous disease, characterized by variable the patients. To date, only disease control or
clinical features, with plaque type being the most immune suppressive therapy is possible [6].
common clinical form [3]. The available treatments are intended to mini-
The pathophysiological mechanisms include mize the development of new skin lesions and
epidermal hyperproliferation and inflammatory the associated symptoms [1, 7]. The aim of
reactions of the dermis and epidermis [4]. any treatment is the decrease or remission of
Psoriasis is characterized by an elevated turnover inflammation, scaling, subjective symptoms and
rate of keratinocytes and a shortened cell cycle. skin dryness. The classical topical treatment
Furthermore, the desquamation process is altered. includes dithranol (anthralin), vitamin D ana-
Inflammation is characterized by the release of logues, topical glucocorticosteroids, vitamin A
cytokines in psoriatic lesions of the affected derivates, coal tar, keratolytic agents and emol-
patients. Scaling marks the clinical feature associ- lients. Photochemotherapy with systemic PUVA,
ated with hyperkeratosis, pruritus, inflammation bath PUVA and cream PUVA, and phototherapy
with UVB light have shown to be effective.
Methotrexate, cyclosporine, etretinate, fumaric
acid and recently biologicals (ustekinumab,
J.W. Fluhr M.D. ()
alefacept, etanercept, infliximab, adalimumab)
Department of Dermatology, Venereology and
Allergology, Charit - Universittsmedizin Berlin, have shown their efficacy upon systemic admin-
Charitplatz 1, Berlin 10117, Germany istration [8].
e-mail: [email protected]
E. Berardesca, M.D.
San Gallicano Dermatological Institute, 19.2 Topical Therapy of Psoriasis:
Rome, Italy
e-mail: [email protected]
The Place of Moisturizers
R. Darlenski, M.D., Ph.D.
Topical therapies are adequate in patients with
Department of Dermatology and Venereology,
Tokuda Hospital Sofia, Sofia, Bulgaria limited plaque psoriasis or less than 20% involved
e-mail: [email protected] body surface area. The variables to be considered

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 285

DOI 10.1007/978-3-642-27606-4_19, Springer-Verlag Berlin Heidelberg 2012
286 J.W. Fluhr et al.

when choosing topical agents include patients 19.3 Moisturizers and Emollients
age, skin type, affected anatomical site, patients in Psoriasis
preference (in order to increase the treatment
adherence), cost of medication, likelihood of Emollients are agents designed to soften the SC
remission and possible side effects. In some corneum and to render the skin more supple by
cases, a combination therapy with more than one increasing its hydration and by reducing superfi-
medication may be indicated [7]. The aim of the cial scales. They are the most frequently used
present chapter is to summarize the knowledge products in dermatology [13]. A study found that
and clinical value on moisturizing agents and the application of emollients took in average 25
emollients in the topical treatment of psoriasis. h/year for psoriasis patients [14]. More than 76%
The most important indications of emollients and of patients had to cover a part or the entire cost of
moisturizing agents are as an adjuvant therapy of these products.
classical psoriasis treatment modalities and the Emollients induce an occlusive film that limits
supportive treatment in remission phases. evaporation of water from deeper parts of the skin
For topical therapy, Greaves and Weinstein and allows the SC to be rehydrated by endogenous
[9] scored emollients lowest taking into account supply of water. Furthermore, by including natu-
relapse rate, side effects, cosmetic acceptance ral moisturizing factors, they induce an increase
and efficacy, followed by keratolytic agents, in water-binding capacity of the SC. Regular use
coal tar, dithranol and corticosteroids. For the over a sufficiently long period of emollients and/
adjuvant therapy of mild cases of psoriasis, a or moisturizers is important. Several products are
low risk rate (side effects, cosmetic problems) available today, e.g. moisturizing creams and oint-
and no necessity for a strong and rapid efficacy ments, as well as bath oils. Creams or ointments
is required. These requirements are met by are preferable to lotions. They tend to be thicker,
emollients, moisturizing and keratolytic agents more occlusive and therefore more effective in the
reducing scaling, itch and subjective discomfort induction of occlusion and rehydrating the SC [7].
and inducing an increased hydration of dry SC Emollients do not work as a monotherapy in an
and barrier repair. Altered structure and func- already fully developed psoriasis. They should be
tion of the skin measured by increased transepi- used in combination with other therapies. For
dermal water loss, dysfunction of skin lipid chronic plaque psoriasis, it has been reported that
barrier, augmented skin permeability and water-in-oil emollients are useful as steroid-spar-
increased skin roughness can be improved, ing agent [15]. The use of an emollient limited
relieving clinical symptoms and decreasing relapses after the end of therapy with topical ste-
relapses [10]. Regular application of moisturiz- roids and maintained the improvement obtained
ers helps to maintain hydration and overall after 1-month corticotherapy [1]. The hydration
integrity of the SC [11]. of the SC leads to an enhanced delivery of topical
A second indication for keratolytic and some glucocorticosteroids. The replacement of one of
moisturizing agents (e.g. urea), when co-applied, the twice daily application of betamethasone
is the penetration enhancement of other topical dipropionate treatment by a water-in-oil emollient
antipsoriatic drugs. A frequently used com- showed the same efficacy. A paper summarizing
pound is salicylic acid in dithranol, coal tar or topical therapies in psoriasis found that vehicle
glucocorticosteroid treatment modalities. This (or placebo) was efficient in a broad range from
may result in an economical benefit by reducing 15% to almost 50% of cases [16]. These results
the required amount of topical drug and confirm the positive response to an emollient-only
decreased side effects with a better adherence to treatment.
the therapeutic regimen [10]. One has to be In an early study, it could be demonstrated
aware of the potential induction of toxic effects that white soft paraffin may inhibit the develop-
when large surface areas are treated with sali- ment of Koebner response in psoriasis [17].
cylic acid (salicylism) [12]. Finlay reported of an effective cream therapy
19 Psoriasis and Dry Skin: The Impact of Moisturizers 287

adjunct to dithranol for the treatment of chronic hair washing, lotions with keratolytic agents
plaque psoriasis [18]. Nola showed that the elec- should be applied into the dry hair, especially
trical properties of the SC change after applica- onto the scalp. Polidocanol-containing formula-
tion of an emollient and that there is also an tions might relieve the symptoms of itch. At cur-
anti-inflammatory activity of these substances rent, phytoproducts should be avoided since UV
[13]. Witman proposed that patients with psoria- therapy is a central part of the treatment, and
sis should be encouraged to take a daily bath in undesired side effects like allergic contact derma-
warm water followed by generalized application titis are frequent with the combination of phyto-
of cream or ointment containing moisturizers products and extended UV exposure. Rim et al.
[7]. A second or third application of a moistur- could show a good correlation between skin
izer during the day should exert an additional capacitance and TEWL with the visual assess-
benefit [7]. A study on palmoplantar psoriasis ment of skin dryness. Both TEWL and capaci-
showed that adding an emollient to the topical tance values improved in psoriatic lesions in a
corticosteroid therapy significantly reduced the 6 weeks trial [26].
desquamation, affected surface area and subjec- An emollient-based mild psoriasis treatment
tive symptoms at week 4 [19]. induced normalization of several proliferation
Tanghetti performed an observational study and differentiation markers, while the clinical
evaluating the treatment of plaque psoriasis with response hardly showed any changes after 2
tazarotene gels alone and an emollient and/or weeks [27]. A point of discussion was raised
corticosteroid to investigate whether the efficacy on the blocking effect of petrolatum pretreat-
and tolerability of tazarotene treatment can be ment in phototherapy. While petrolatum was
optimized through the additional use of an emol- recommended before UVB 311313 nm photo-
lient and/or a topical corticosteroid [20]. The use therapy by one group [28], a petrolatum and
of an emollient and/or a corticosteroid enhanced salicylic acid in petrolatum treatment just
the efficacy of tazarotene treatment and increased before PUVA therapy was not recommended
the percentage of patients who were satisfied due to their blocking effects in another publi-
with their treatment [20]. cation [29]. The latter group also showed a
Two randomized controlled studies revealed blocking effect for petrolatum and salicylic
controversial results on the efficacy of aloe vera gel acid formulated in petrolatum in the UVB
containing topical cream, with one study showing treatment of plaque psoriasis [30].
superiority of the product over placebo [21] and the The patient acceptance of emollients is gener-
other one no difference between both [22]. ally excellent. An additional advantage of emol-
Emollients can cause a few side effects, such lient therapies is the fact that they are relatively
as irritant dermatitis, allergic contact dermatitis, inexpensive (for the health care system). However,
fragrance allergy or allergy to other constituents, in many countries, no reimbursement is available
stinging, cosmetic acne and pigmentary disorders for emollients in psoriasis. More controlled, ran-
[13]. However, some reports indicate a poten- domized trials with a high evidence level might
tially negative effect of emollients on the suscep- help to change the lack of reimbursement since
tibility of the SC to irritants after long-term use these patients might use, in severe SC dryness,
[23, 24]. more than 250 g of emollients per day.
Additionally, regular full-body baths should A moisturizing cream was studied in partici-
be performed in order to reduce the scale load pants with mild to moderate plaque psoriasis who
and to increase the SC hydration. Two forms of were not treated or had discontinued the use of all
bath formulations are available: dispersion bath topical psoriasis medications and all other mois-
oils and spreading bath oils, with the latter being turizers. The use of the product resulted in
more effective in SC hydration and barrier repair improvement of skin hydration and desquama-
[25]. Furthermore, a shampoo with compounds tion and no further increase in the skin barrier
enhancing desquamation should be used. After damage [31].
288 J.W. Fluhr et al.

Table 19.1 Critical points in moisturizer therapy of localized psoriasis [32]. Moncorps reported as
psoriasis early as 1929 about different penetration proper-
How often to apply 13 times/day ties of salicylic acid from different vehicles [33].
a moisturizer The delivered concentration does not only depend
How much to apply Use fingertip units if applicable;
on the original concentration within the vehicle
if not enough to create a smooth
film over the entire skin surface but also on the type of ointment [33]. The resorp-
Where to apply Entire skin, not just the affected tion rate of salicylic acid on psoriatic lesions is
sites higher, with a faster and longer resorption than
Which moisturizer Individual, depends on the patient on skin of healthy subjects [34]. The resorption
to choose preference, financial status, rate also depends on the severity of the inflamma-
cosmetic properties of the product
tion [34]. However, the liberation of salicylic acid
Contraindications Uncommon and rare, most
often- irritation, contact allergy, from different formulations did not correlate with
cosmetic acne the penetration rate into the skin [35]. An addi-
Pregnancy/nursing Considered safe tional study of the same group showed a dose-
Use in children Generally safe dependent percutaneous absorption of salicylic
(paediatric patients) acid in vivo [36]. In contrast to the antihyperplas-
tic properties of salicylic acid on pathological
hyperproliferation of the epidermis, a promotion
A guideline from the American Academy of of the epidermopoiesis in normal guinea pig skin
Dermatology summarized the current view on has been shown with a 1% salicylic acid-acetone-
the application of moisturizers on psoriasis [16]. ethanol solution [37]. The mitotic index was
Table 19.1 is reviewing the critical points in increased by 17%, epidermis thickness by 40%
moisturizer therapy of psoriasis. and the thickness of the deep epidermis by 19%
[37]. Pullman et al. reported an increase of the
proliferation rate of psoriatic epidermal cells in
19.4 Effects of Moisturizer humans in an autoradiographic study [38].
and Keratolytic Agents Roberts et al. could show a reduction of SC cell
in Psoriasis layers after 3 weeks [39]. The keratolytic effect
was visualized with the surfometry and scanning
19.4.1 Salicylic Acid electron microscopy by Davies and Marks [40].
Huber and Christophers could show for a 50%
Since the beginning of the twentieth century, sali- salicylic acid solution that corneocytes did not
cylic acid is known to exert a specific effect on change their morphology while the intercellular
the SC. Salicylic acid is widely used as a kera- structure was altered [41]. This treatment resulted
tolytic (facilitating the desquamation process) in desquamation of the corneocytes. In vivo, with
agent in the treatment of hyperkeratotic derma- the silver nitrate staining technique, Nook could
toses, e.g. psoriasis [32]. It is mainly used in con- provide evidence for a keratolytic effect for the
centrations of 0.560% in almost any vehicle. As combination of a water-soluble ointment contain-
mechanism of action for topical salicylic acid ing 5% salicylic acid and 10% urea in compari-
corneocyte intercellular bonding, corneocyte son to 5% and 10% salicylic acid alone in
desquamation, SC hydration, corneocyte swell- petrolatum [42]. The combination therapy was as
ing and SC softening has been proposed [32]. effective as 10% salicylic acid and significantly
Salicylic acid is most beneficial in thick or scaly more effective than a 5% salicylic acid formula-
psoriatic plaques [7]. It is the most effective of tion. The keratolytic effect of salicylic acid 6% in
the known keratolytic compounds. Several over- an isopropyl solution has been shown with the
the-counter medicated shampoos and scalp solu- cantharidin blister method [43]. Going et al.
tions aimed for treatment of the scaly scalp reported the successful treatment of scalp
contain salicylic acid. Furthermore, compounded psoriasis with a salicylic acid gel with a negligi-
ointments with salicylic acid are helpful for ble systemic absorption of salicylic acid [44].
19 Psoriasis and Dry Skin: The Impact of Moisturizers 289

The negative interaction of dithranol and zinc 19.4.2 Urea

oxide in pastes could be partly inhibited by com-
bining them with salicylic acid [45]. The addition The moisturizing effect of urea in dry and scaly
of salicylic acid to dithranol formulations skin conditions is widely studied and accepted
improves the clinical efficacy of dithranol due to [6063]. Urea is known to exert a proteolytical,
the antioxidant properties of salicylic acid [46]. mild keratolytic, hydrating, hygroscopical,
Salicylic acid can be helpful as a monotherapy. penetration-enhancing, epidermis thinning and
Witman reported an enhanced penetration of glu- antipruritic effect [64]. An increased water-
cocorticosteroids. Concentration of salicylic acid binding capacity could be shown under a treat-
used for this purpose is 210% [7]. Such combi- ment with w/o-emulsions containing 10% urea
nations require compounding by a pharmacist and [65]. An increased hydration comparing 10%
carry the risk of imprecise formulations that are urea to 5% was not detectable in both o/w- and
potentially unstable, unsafe or ineffective [7]. w/o-emulsions [66]. This indicates that 5%
The major problem in the topical treatment of urea is sufficient for a good hydration effect
psoriasis with salicylic acid is the potential in the SC.
chronic and/or acute systemic intoxication (called In vitro and in vivo data showed a decreased
salicylism), with the symptoms of burning of oral DNA synthesis index, with a thinning of the epider-
mucosa, frontal headache, CNS symptoms, pH mis and a reduction of epidermal cells [67]. The
deviation (metabolic acidosis), tinnitus, nausea, mechanisms of urea on epidermal function result in
vomiting and gastric symptoms [4749]. These an epidermal thinning (~ 20%). Furthermore, a
symptoms may occur in topical treatment of large reduction of the cells in the DNA synthesis in basal
body surfaces, especially in children [5052]. layers (~ 45%) and a prolongation of the genera-
Even lethal cases are reported [53, 54]. Therefore, tion time of postmitotic epidermal cells were
a concentration higher than 10%, and an applica- detectable [68]. There is data suggesting that lipid
tion on larger body surface areas, especially in biosynthesis may be increased by topical applica-
children, is not recommended. Salicylic acid tion of high concentration of urea [60].
should not be applied to more than 20% of the An improved drug liberation of steroids with
body surface area [32]. If larger surfaces need ointments containing urea has been reported [69].
salicylic acid treatment, e.g. for initial keratolysis Furthermore, penetration enhancement for gluco-
with an important hyperkeratosis, a sequential corticosteroids by urea is well studied [7076].
treatment is useful (e.g. affected areas in the Such a penetration enhancement leads to a ste-
upper part of the body at night time and the lower roid-sparing effect and an increased clinical effi-
part in the morning). Careful clinical monitoring cacy of steroid ointments containing urea. The
helps to avoid salicylic acid intoxication. It should maximum of the steroid penetration is within
be noted that some topical treatments of psoriasis psoriatic lesions. But it has still not been studied
such as calcipotriol are inactivated by salicylic whether the penetration enhancement improves
acid [55]. It has been shown that salicylic acid the clinical outcome in psoriasis.
exerts a more superficial keratolytic effect com- Dithranol in combination with urea is a stan-
pared to benzoyl peroxide and retinoic acid in a dard combination used in psoriasis to improve
test model using chromameter measurements and the clinical efficacy. This effect minimizes the
sequential tape stripping [56]. Bashir et al. used a dithranol concentration and shortens the contact
comparable model with squamometry, protein time. Furthermore, a better hydration of the SC
measurements after sequential tape stripping to and a decreased proliferation rate of the kerati-
assess the scaliness and desquamation for differ- nocytes can be achieved. Gabard and Bieli
ent formulations of salicylic acid [57]. Local irri- showed an increased keratolytic effect of sali-
tation but not the clinical efficacy was increased cylic acid by adding 10% urea [77]. Hagemann
by an acidic pH of the preparation. A constant and Proksch [78] showed with a 10% urea oint-
drug penetration rate was measured for salicylic ment in 10 psoriasis patients an increased SC
acid using microdialysis techniques [58, 59]. hydration and a small decrease in TEWL, a
290 J.W. Fluhr et al.

reduction in epidermal thickness (29%) and a compared to glycolic acid. Redness (chromame-
decreased epidermal proliferation (51%). The try a* values) decreased significantly during the
altered expression of involucrin and cytokeratins treatment without significant differences between
as marker for epidermal proliferation was par- glycolic acid- and betamethasone valerate-treated
tially reversed [78]. Sasaki et al. showed for topi- lesions. Laser Doppler values decreased signifi-
cally applied 10% urea ointment an improvement cantly during the study, with lower values in the
of SC hydration, water-binding capacity and steroid treated site induced by the known vaso-
TEWL in patients with psoriasis vulgaris [79]. constrictive activity of glucocorticosteroids. The
Shemer reported a treatment of scalp sebor- measurement results were clinically confirmed
rheic dermatitis and psoriasis with a 40% urea- with a reduction of hyperkeratosis and erythema
1% bifonazole ointment [80]. This study showed induced by both treatment modalities. The study
a benefit of the combination of urea and bifon- shows that AHA are useful not only in the control
azole over bifonazole alone by enhancing the of hyperkeratosis but also in the modulation of
bifonazole penetration. These authors reported keratinocyte proliferation.
that urea reduces the plaque thickness [80]. Gloor
et al. showed a significant keratolytic activity of
five different salicylic acid and high-dose urea 19.4.4 Omega (w)-Fatty Acids
compounded formulations from the German
pharmacopoeia (NRF) in an in vivo study [81]. Oral or topical supplementation of eicosapen-
taenoic acid (EPA) and/or w-3 derivatives can
decrease not only skin dryness and scaling but also
19.4.3 Alpha Hydroxy Acids the severity of inflammatory skin diseases such as
psoriasis [86, 87]. Omega (w)-3 derivatives can be
Alpha hydroxy acids(AHA), such as glycolic incorporated into cell membranes. They are uti-
acid or lactic acid, are organic acids present in lized as substrate for phospholipase activity. This
natural sources (e.g. fruits, wine and milk). may lead to an increase of free EPA, which can be
They exert specific benefits on structure and used as substrate for cyclooxygenase and lipooxy-
function of the skin [82]. AHA have been pro- genase activities resulting in an increased produc-
posed as therapeutic options against hyperkera- tion of anti-inflammatory leukotrienes LTB5 and
totic skin conditions. They penetrate the PG3 [88]. Abnormal serum fatty acid profiles in
epidermis, inducing an increased SC turnover. Dariers disease, ichthyosis vulgaris, psoriasis and
The precise mechanism by which AHA regu- Sjgren-Larsson syndrome have been reported
late desquamation is not fully understood [82]. [89]. Berardesca et al. tested topical corticosteroids
AHA appear to decrease cohesion of the cor- in combination with 5% linoleic acid. An improve-
neocytes [83]. Kostarelos revealed synergistic ment of epidermal barrier function was reported.
effects between AHA and betamethasone Formulations containing omega-3 and omega-6
lotions in the topical treatment of scalp psoria- fatty acids may help in the restoration of bar-
sis [84]. Moreover, the therapeutic synergy rier properties. Higher efficacy of these products
between AHA and topical glucocorticosteroids may be achieved by combining different classes
was evident without systemic or topical side of SC lipids [90]. However, in a double-blind,
effects in this clinical trial. placebo-controlled multicentre study with highly
Berardesca et al., in a controlled study, treated purified omega-3-polyunsaturated fatty acids for
12 psoriasis patients with a glycolic acid lotion topical treatment in psoriasis, no statistical or clini-
15% versus a 0.05% betamethasone valerate cal differences between the omega-3-polyunsat-
cream [85]. TEWL, blood perfusion (laser urated fatty acid and the placebo-treated lesions
Doppler) and skin colour (chromametry) were were found [91]. Escobar et al. [86] showed a clini-
assessed on psoriatic lesions. The TEWL values cal improvement of scaling and plaque thickness
decreased significantly. Betamethasone valerate for topical fish oil compared to the base-treated site
exerted no significant better TEWL improvement in a 4-week treatment.
19 Psoriasis and Dry Skin: The Impact of Moisturizers 291

Conclusion 4. Zeichner JA, Lebwohl MG, Menter A et al (2010)

Moisturizers and emollients have a central role in Optimizing topical therapies for treating psoriasis: a
consensus conference. Cutis 86:531; quiz 2
topical treatment modalities of psoriasis. They are 5. Guttman-Yassky E, Krueger JG (2007) Psoriasis: evo-
adjuvants for classical treatments and help to lution of pathogenic concepts and new therapies
reduce the scale load of the individual patient. The through phases of translational research. Br J Dermatol
major role for emollients and moisturizers is to 157:11031115
6. Wippel-Slupetzky K, Stingl G (2009) Future perspec-
support the improvement in dermal hyperprolif- tives in the treatment of psoriasis. Curr Probl Dermatol
eration, differentiation and apoptosis. The anti- 38:172189
inflammatory effect and the stabilization of 7. Witman PM (2001) Topical therapies for localized
epidermal barrier function reduce the induction of psoriasis. Mayo Clin Proc 76:943949
8. Garcia-Valladares I, Cuchacovich R, Espinoza LR
Kbner phenomena. Co-administration of mois- (2011) Comparative assessment of biologics in
turizers and emollients to the specific antipsoriatic treatment of psoriasis: drug design and clinical
agents improves the course of psoriasis and is a effectiveness of ustekinumab. Drug Des Devel Ther
helpful tool in the hands of the dermatologist. 5:4149
9. Greaves MW, Weinstein GD (1995) Treatment of pso-
riasis. N Engl J Med 332:581588
10. Schopf E, Mueller JM, Ostermann T (1995) Value of
adjuvant basic therapy in chronic recurrent skin dis-
Take Home Messages eases. Neurodermatitis atopica/psoriasis vulgaris.
Psoriatic skin is characterized by increa- Hautarzt 46:451454
sed dryness and impeded epidermal bar- 11. Bikowski J (2001) The use of therapeutic moisturizers
in various dermatologic disorders. Cutis 68:311
rier function. 12. Brubacher JR, Hoffman RS (1996) Salicylism from
Moisturizers and emollients are indivis- topical salicylates: review of the literature. J Toxicol
ible and integral part of the topical pso- Clin Toxicol 34:431436
riasis therapy. 13. Nola I, Kostovic K, Kotrulja L et al (2003) The use of
emollients as sophisticated therapy in dermatology.
Moisturizers pursue the classical and Acta Dermatovenerol Croat 11:8087
novel treatment modalities for the life- 14. Meyer N, Paul C, Feneron D et al (2010) Psoriasis: an
long therapy of psoriasis. epidemiological evaluation of disease burden in 590
The major effects of moisturizers are based patients. J Eur Acad Dermatol Venereol 24:
10751082
on their adjuvant role in reducing the scal- 15. Watsky KL, Freije L, Leneveu MC et al (1992) Water-
ing, supporting the normalizing of hyper- in-oil emollients as steroid-sparing adjunctive therapy
proliferation and differentiation as well as in the treatment of psoriasis. Cutis 50:383386
on exerting anti-inflammatory effects. 16. Menter A, Korman NJ, Elmets CA et al (2009)
Guidelines of care for the management of psoriasis
Moisturizers increase skin hydration and psoriatic arthritis. Section 3. Guidelines of care
and improve the epidermal barrier func- for the management and treatment of psoriasis with
tion thus reducing the risk for the devel- topical therapies. J Am Acad Dermatol 60:643659
opment of Kbner phenomenon. 17. Comaish JS, Greener JS (1976) The inhibiting effect
of soft paraffin on the Kobner response in psoriasis.
Br J Dermatol 94:195200
18. Finlay AY (1997) Emollients as adjuvant therapy for
psoriasis. J Dermatolog Treat 8(Suppl 1):S25S27
References 19. Cassano N, Mantegazza R, Battaglini S et al (2010)
Adjuvant role of a new emollient cream in patients
1. Seite S, Khemis A, Rougier A et al (2009) Emollient with palmar and/or plantar psoriasis: a pilot random-
for maintenance therapy after topical corticotherapy ized open-label study. G Ital Dermatol Venereol
in mild psoriasis. Exp Dermatol 18:10761078 145:789792
2. Murphy G, Reich K (2011) In touch with psoriasis: 20. Tanghetti EA (2000) An observation study evaluating
topical treatments and current guidelines. J Eur Acad the treatment of plaque psoriasis with tazarotene gels,
Dermatol Venereol 25(Suppl 4):38 alone and with an emollient and/or corticosteroid.
3. Christopheres E, Mrowietz U (2003) Psoriasis. In: Cutis 66:411
Freedberg IR, Eisen AZ, Wolff K et al (eds) Fitzpatricks 21. Syed TA, Ahmad SA, Holt AH et al (1996)
dermatology in general medicine, McGraw-Hill Management of psoriasis with Aloe vera extract in a
Professional, New York City, USA, vol, 6th edn, pp hydrophilic cream: a placebo-controlled, double-blind
407427 study. Trop Med Int Health 1:505509
292 J.W. Fluhr et al.

22. Paulsen E, Korsholm L, Brandrup F (2005) A double- 38. Pullmann H, Lennartz KJ, Steigleder GK (1975) The
blind, placebo-controlled study of a commercial Aloe effect of salicylic acid on epidermal cell proliferation
vera gel in the treatment of slight to moderate psoria- kinetics in psoriasis. Autoradiographic in vitro-
sis vulgaris. J Eur Acad Dermatol Venereol 19: investigations(authors transl). Arch Dermatol Forsch
326331 251:271275
23. Held E, Sveinsdottir S, Agner T (1999) Effect of long- 39. Roberts DL, Marshall R, Marks R (1980) Detection of
term use of moisturizer on skin hydration, barrier the action of salicylic acid on the normal stratum cor-
function and susceptibility to irritants. Acta Derm neum. Br J Dermatol 103:191196
Venereol 79:4951 40. Davies M, Marks R (1976) Studies on the effect of sali-
24. Gloor M, Hauth A, Gehring W (2003) O/W emulsions cylic acid on normal skin. Br J Dermatol 95:187192
compromise the stratum corneum barrier and improve 41. Huber C, Christophers E (1977) Keratolytic effect
drug penetration. Pharmazie 58:709715 of salicylic acid. Arch Dermatol Res 257:293297
25. Fluhr JW, Gloor M, Bettinger J et al (1998) On the 42. Nook TH (1987) In vivo measurement of the kera-
influence of bath oils with different solvent character- tolytic effect of salicylic acid in three ointment formu-
istics and different amounts of a non-ionic tenside on lations. Br J Dermatol 117:243245
the hydration and barrier function of the stratum cor- 43. Gloor M, Beier B (1984) Keratoplastic effect of sali-
neum. J Cosmet Sci 49:343350 cyclic acid, sulfur and a tensio-active mixture.
26. Rim JH, Jo SJ, Park JY et al (2005) Electrical mea- Z Hautkr 59:16571660
surement of moisturizing effect on skin hydration and 44. Going SM, Guyer BM, Jarvie DR et al (1986) Salicylic
barrier function in psoriasis patients. Clin Exp acid gel for scalp psoriasis. Clin Exp Dermatol
Dermatol 30:409413 11:260262
27. van Duijnhoven MW, Hagenberg R, Pasch MC et al 45. Hulsebosch HJ, Ponec-Waelsch M (1972) The inter-
(2005) Novel quantitative immunofluorescent tech- action of anthralin, salicylic acid and zinc oxide in
nique reveals improvements in epidermal cell popula- pastes. Dermatologica 144:287293
tions after mild treatment of psoriasis. Acta Derm 46. Runne U (1974) Anthralin-salicylic acid therapy of
Venereol 85:311317 psoriasis. Cignolin-salicylic acid-vaseline treatment
28. Penven K, Leroy D, Verneuil L et al (2005) Evaluation and Lasan paste in a right-left comparison. Hautarzt
of Vaseline oil applied prior to UVB TL01 photother- 25:199200
apy in the treatment of psoriasis. Photodermatol 47. Diem E, Fritsch P (1973) Salicylate poisoning by per-
Photoimmunol Photomed 21:138141 cutaneous resorption. Hautarzt 24:552555
29. Birgin B, Fetil E, Ilknur T et al (2005) Effects of topi- 48. Zesch A (1986) Short and long-term risks of topical
cal petrolatum and salicylic acid upon skin photoreac- drugs. Br J Dermatol 115(Suppl 31):6370
tion to UVA. Eur J Dermatol 15:156158 49. Chapman BJ, Proudfoot AT (1989) Adult salicylate
30. Fetil E, Ozka S, Soyal MC et al (2002) Effects of topi- poisoning: deaths and outcome in patients with
cal petrolatum and salicylic acid on the erythemoge- high plasma salicylate concentrations. Q J Med 72:
nicity of UVB. Eur J Dermatol 12:154156 699707
31. Draelos ZD (2008) Moisturizing cream ameliorates 50. Pec J, Strmenova M, Palencarova E et al (1992)
dryness and desquamation in participants not receiv- Salicylate intoxication after use of topical salicylic
ing topical psoriasis treatment. Cutis 82:211216 acid ointment by a patient with psoriasis. Cutis 50:
32. Lebwohl M (1999) The role of salicylic acid in the 307309
treatment of psoriasis. Int J Dermatol 38:1624 51. Luderschmidt C, Plewig G (1975) Chronic percutane-
33. Moncorps C (1929) Untersuchungen ber die ous salicylic acid poisoning. Hautarzt 26:643646
Pharmakologie und Pharmakodynamik von Salben 52. Germann R, Schindera I, Kuch M et al (1996) Life
und salbeninkorporierten Medikamenten II. threatening salicylate poisoning caused by percutane-
Mitteilung: ber die Resorption und Pharmakodynamik ous absorption in severe ichthyosis vulgaris. Hautarzt
der salbeninkorporiereten Salizylsure. Arch Exp 47:624627
Path Pharm 155 (12): 5169 53. Vonweiss JF, Lever WF (1964) Percutaneous salicylic
34. Arnold W, Trinnes F, Schroeder I (1979) Skin resorp- acid intoxication in psoriasis. Arch Dermatol 90:
tion of salicylic acid in psoriasis patients and persons 614619
with healthy skin. Beitr Gerichtl Med 37:325328 54. Taylor JR, Halprin KM (1975) Percutaneous absorp-
35. Gabard B, Treffel P, Schwarb F, Surber C, Bieli E, tion of salicylic acid. Arch Dermatol 111:740743
Ldi S (1997) Salicylic acid release from topical for- 55. van de Kerkhof PC, Vissers WH (2003) The topical
mulations does not predict in vitro skin absorption. treatment of psoriasis. Skin Pharmacol Appl Skin
Dermatology 195:3743 Physiol 16:6983
36. Schwarb F, Gabard B, Jost G, Rufli Th, Surber C 56. Waller JM, Dreher F, Behnam S et al (2006)
(1997) Percutaneous absorption of salicylic acid in Keratolytic properties of benzoyl peroxide and
man following topical administration of different for- retinoic acid resemble salicylic acid in man. Skin
mulations. Dermatology 195 Pharmacol Physiol 19:283289
37. Weirich EG, Longauer JK, Kirkwood AH (1978) 57. Bashir SJ, Dreher F, Chew AL et al (2005) Cutaneous
Effect of topical salicylic acid on animal epidermopoi- bioassay of salicylic acid as a keratolytic. Int J Pharm
esis. Dermatologica 156:8996 292:187194
19 Psoriasis and Dry Skin: The Impact of Moisturizers 293

58. Klimowicz A, Farfal S, Bielecka-Grzela S (2007) International Symposium (ISICD). Medical Publishing
Evaluation of skin penetration of topically applied & New Media, Milano, pp 291307
drugs in humans by cutaneous microdialysis: acyclo- 76. Mller KH, Pflugshaupt Ch (1979) Harnstoff in der
vir vs. salicylic acid. J Clin Pharm Ther 32:143148 Dermatologie. Zbl Haut 1:1415
59. Klimowicz A, Bielecka-Grzela S, Groth L et al (2004) 77. Gabard B, Bieli E (1989) Salicylic acid and urea
Use of an intraluminal guide wire in linear microdi- possible modification of the keratolytic effect of sali-
alysis probes: effect on recovery? Skin Res Technol cylic acid by urea. Hautarzt 40(Suppl 9):7173
10:104108 78. Hagemann I, Proksch E (1996) Topical treatment by
60. Loden M (1996) Urea-containing moisturizers influ- urea reduces epidermal hyperproliferation and induces
ence barrier properties of normal skin. Arch Dermatol differentiation in psoriasis. Acta Derm Venereol
Res 288:103107 76:353356
61. Loden M (1997) Barrier recovery and influence of 79. Sasaki Y, Tadaki T, Tagami H (1989) The effects of a
irritant stimuli in skin treated with a moisturizing topical application of urea cream on the function of
cream. Contact Dermatitis 36:256260 pathological stratum corneum. Acta Dermatol Kyoto
62. Treffel P, Gabard B (1995) Stratum corneum dynamic 84:31
function measurements after moisturizer or irritant 80. Shemer A, Nathansohn N, Kaplan B et al (2000)
application. Arch Dermatol Res 287:474479 Treatment of scalp seborrheic dermatitis and psoriasis
63. Bettinger J, Gloor M, Gehring W, Wolf W (1995) with an ointment of 40% urea and 1% bifonazole. Int
Influence of emulsions with and without urea an J Dermatol 39:532534
water-binding capacity of the stratum corneum. J Soc 81. Gloor M, Fluhr J, Wasik B et al (2001) Clinical effect
Cosmet Chem 46:247254 of salicylic acid and high dose urea applied according
64. Muller KH, Pflugshaupt C (1989) Urea in dermatol- to the standardized New German Formulary.
ogy I. Hautarzt 40(Suppl 9):112 Pharmazie 56:810814
65. Wohlrab W (1988) Effect of urea on the water binding 82. Hardening CR, Watkinson A, Rawlings AV, Scott IR
capacity of the human stratum corneum. Dermatol (2000) Dry skin, moisturization and corneodesmoly-
Monatsschr 174:622627 sis. Int J Cosmet Sci 22:2152
66. Fluhr JW, Vrzak G, Gloor M (1998) Hydratisierende 83. Lynde CW (2001) Moisturizers: what they are and
und die Steroidpenetration verbessernder Effekt von how they work. Skin Therapy Lett 6:35
Harnstoff und Glycerin in Abhnigkeit von der ver- 84. Kostarelos K, Teknetzis A, Lefaki I et al (2000)
wendeten Grundlage. Z Hautkr 73:5559 Double-blind clinical study reveals synergistic action
67. Wohlrab W, Schiemann S (1976) Investigations on the between alpha-hydroxy acid and betamethasone
mechanism of the activity of urea upon the epidermis lotions towards topical treatment of scalp psoriasis.
(authors transl). Arch Dermatol Res 255:2330 J Eur Acad Dermatol Venereol 14:59
68. Wohlrab W (1992) Harnstoff-ein bewhrter Wirkstoff 85. Berardesca E, Piero Vignoli G, Distante E (1998)
in der Dermatologie und Kosmetik. P Z 33:24832489 Effects of glycolic acid on psoriasis. Clin Exp
69. Wohlrab W (1986) Recovery rate of externally admin- Dermatol 23:190191
istered glucocorticoids on the skin surface. Dermatol 86. Escobar SO, Achenbach R, Iannantuono R et al (1992)
Monatsschr 172:615619 Topical fish oil in psoriasis a controlled and blind
70. Feldmann RJ, Maibach HI (1974) Percutaneous pen- study. Clin Exp Dermatol 17:159162
etration of hydrocortisone with urea. Arch Dermatol 87. Dewsbury CE, Graham P, Darley CR (1989) Topical
109:5859 eicosapentaenoic acid (EPA) in the treatment of pso-
71. Wohlrab W (1984) The influence of urea on the pen- riasis. Br J Dermatol 120:581
etration kinetics of topically applied corticosteroids. 88. Kragballe K, Voorhees P, Darley CR, Goetzl EJ (1985)
Acta Derm Venereol 64:233238 Leukotriene B5 derived from eicosapentaenoic acid
72. Stuttgen G (1989) Promoting penetration of locally does not stimulate DNA synthesis of cultured human
applied substances by urea. Hautarzt 40(Suppl 9): keratinocytes but inhibits the stimulation induced by
2731 leukotriene B4. J Invest Dermatol 84:349
73. Gloor M, Lindemann J (1980) The influence of cera- 89. Williams ML (1991) Lipids in normal and pathologi-
tolytics and moisturizers on the bio-availability of tri- cal desquamation. Adv Lipid Res 24:211262
amcinolone acetonide following topical application 90. Berardesca E, Borroni G (1998) Oral and topical sup-
(authors transl). Dermatol Monatsschr 166:102106 plementation of linoleic acid and skin disease.
74. Kalbitz J, Neubert R, Wohlrab W (1996) Modulation of Medecine, Biologie, Environnement 26(2):159163
drug penetration in the skin. Pharmazie 51:619637 91. Henneicke-von Zepelin HH, Mrowietz U, Farber L
75. Fluhr JW, Gloor M, Gehring W (2000) Physiology of et al (1993) Highly purified omega-3-polyunsaturated
Skin cleaning and functional mechanism of bath oils. fatty acids for topical treatment of psoriasis. Results
In: Berardesca E, Picardo M, Pigatto P (eds) Irritant of a double-blind, placebo-controlled multicentre
contact dermatitis proceedings of the 3 rd study. Br J Dermatol 129:713717
 Update on Infant Skin with Special
Focus on Dryness and the Impact 20
of Moisturizers

Georgios N. Stamatas and Neena K. Tierney

20.1 Introduction bilayers that predominantly contain ceramides,

fatty acids, and cholesterol [3]. Differentiated kera-
Healthy skin is a reflection of its integrity as physi- tinocytes (corneocytes) are encapsuled in the corni-
cal barrier against, among others, external mechan- fied envelope (CE) which consists of highly linked,
ical, microbial, and oxidative insults and loss of insoluble proteins, mostly loricrin, small proline-
moisture and nutrients. This barrier is mostly pro- rich proteins, and involucrin [4], that are cross-
vided by the superficial layers of the epidermis, the linked to the cytoplasmic keratin filaments and to
stratum corneum (SC), and is sustained by a con- the lipid matrix [5]. Ten to 15 layers of corneocytes
stant process of cell proliferation, differentiation, embedded in the lipid matrix make up the SC, the
and shedding that involves a specialized form of end point of the differentiation process. In the SC,
programmed cell death [1]. The basal layer (stra- the CE and the corneodesmosomes (specialized
tum basale) of the epidermis is mostly comprised desmosomes of the SC) confer the mechanical
of keratinocytes, rapidly replicating cells, part of strength and the intercellular lipid matrix provid-
which migrate toward the skin surface and differ- ing the structural foundation for its permeability
entiating into flat, nonnucleated cells (squames) properties [6]. Before the corneocytes are shed
[2]. In the basal layer, keratinocytes are connected from the skin surface in the desquamation process,
to each other via protein-rich desmosomes. During the corneodesmosomes are degraded mainly by
the differentiation process, keratin and lamellar serine proteases [7].
bodies are synthesized in the stratum spinosum Keratinization starts around 23 weeks of gesta-
and stratum granulosum, respectively, and cell tion with ongoing expression of CE precursor
organelles including the nucleus are degraded proteins and lamellar granule-associated proteins.
through nonapoptotic programmed cell death. The At this point, the ultrastructure of the keratinocyte
lamellar bodies are precursors of the intercellular cell membrane resembles that of the CE in the
lipid matrix and are discharged into the extracel- adult epidermis with about 15 nm thickness [8].
lular space where they organize into stacks of Histologically, a well-defined SC emerges at
34 weeks of gestation in the developing fetus, and
babies born at full term have a developed epider-
G.N. Stamatas, Ph.D. () mis several layers thick [9].
Research and Development, Johnson & Johnson Sant Yet, the skin of babies is markedly distinct
Beaut France, 1, rue Camille Desmoulins,
from adults with regard to its structural, composi-
Issy-les-Moulineaux 92787, France
e-mail: [email protected] tional, and functional properties [1012]. Among
the prominent differences are a thinner epidermis
N.K. Tierney, Ph.D
Research and Development, Johnson & Johnson and smaller cells [11]. Together with the relatively
Consumer Companies Inc, Skillman, NJ, USA higher surface area to body weight, this implies

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 295

DOI 10.1007/978-3-642-27606-4_20, Springer-Verlag Berlin Heidelberg 2012
296 G.N. Stamatas and N.K. Tierney

the possibility of a more readily percutaneous and composition of the intercellular lipid matrix
absorption of substances through infant skin. [21], the natural moisturization factors (NMF)
Infant skin is more hydrated than that of adults which are comprised of hygroscopic components
[10, 13]; nevertheless, atopic dermatitis, an inflam- and exclusively found in the SC [22], and by the
matory skin condition marked by extreme skin permeation path length through the SC [23]. On
dryness, is a common affliction at young age [14]. the other hand, the water content of the skin influ-
The acid mantle of the skin is not yet developed ences barrier function by regulating hydrolytic
in newborns [13], and the high skin pH and hydra- enzyme activities involved in SC maturation and
tion levels in part contribute to frequent damage to desquamation of corneocytes [24].
diapered skin [15, 16]. Furthermore, sebaceous NMF components are highly concentrated in
glands and eccrine sweat glands are not function- the corneocytes and make up 2030% of the SC
ing maturely yet [17, 18]. High pH and reduced or dry weight [25]. Due to their hygroscopic proper-
lacking sebum and sweat production imply that ties, they bind and retain water in the corneocytes,
the antimicrobial properties of the skin are not which contain most of the water in the SC [26],
fully developed. Baby skin provides less protec- thereby keeping the SC hydrated. Proteolytic
tion against the damaging effect of UV radiation activity degrades the epidermal protein filaggrin
because of limited skin pigmentation [19]. to produce the free amino acids that make up the
Accordingly, skin water barrier function is not major components of the NMF [27, 28]. Filaggrin
fully mature early on in life [10]. proteolysis is regulated by the water activity in the
Nowadays, we possess numerous and comple- tissue, with too humid or too dry conditions inhib-
mentary methods that are suitable to study epi- iting the process [27]. Another component of the
dermal barrier physiology in infants in vivo. This NMF is glycerol, which is derived endogenously
allows us to document the uniqueness of infant either from hydrolysis of sebum triglycerides by
skin and to study the conditions that relate to dry lipases within the SC or taken up from the circula-
skin in infants. We discuss particular issues of tion into the epidermis by aquaporin channels
infant skin health and how moisturizers can help [29]. This explains why skin rich in sebaceous
to keep baby skin healthy. We will limit this glands has higher SC hydration than skin with few
review to healthy babies from 0 to 36 months of such glands and is supported by the correlation of
life. The SC barrier and hydration needs of pre- hydration levels and SC glycerol content [29, 30].
term infants are out of scope of the present work. It was suggested that components of the NMF,
including lactate, amino acids, and potassium
[31], also contribute to skin pH regulation.
20.2 Skin Barrier Function The perpetual sloughing off of corneocytes
and How It Is Assessed from the outermost SC through desquamation is
required to maintain epidermal homeostasis. The
20.2.1 Physiological Aspects of Skin process whereby corneodesmosomes are digested
Barrier Function is regulated by a combination of proteases (pre-
dominantly by the serine proteases SC chy-
A series of intrinsic and extrinsic factors regulate motryptic and tryptic enzymes) and their inhibitors
epidermal barrier function. An important regula- [32]. Environmental humidity influences desqua-
tory role is attributed to the hydration status of mation, such that dry conditions have an inhibi-
the skin. The SC with its layers of corneocytes tory effect on the desquamation process [24] and
embedded in the intercellular lipid matrix pro- high humidity stimulates protease activity [33],
vides an efficient protective barrier that, among suggesting that the water content of the SC has an
others, prevents uncontrolled transcutaneous loss important role in desquamation by regulating
of water [20]. Barrier function and the hydration protease activity. The desquamatory proteases are
status of the skin are interdependent factors. The contained in lamellar bodies and secreted into the
latter is largely influenced by the organization SC intercellular space together with lipids. One
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 297

Table 20.1 Methods for the assessment of skin hydration and epidermal barrier function used on infants
Skin hydration
Microscopy Skin surface appearance In vivo microscopy
D-squames
CLSM
Electrical measurements SC water content (indirect) Capacitance
Impedance
Conductance
Spectroscopy SC water content (direct) Raman confocal microspectroscopy
FTIR
Epidermal barrier function
TEWL Inside-out water barrier Open chamber
Simple closed chamber
Closed ventilated chamber
Closed condenser chamber
Sorptiondesorption Water barrier (both directions) One of the electrical methods above

of the components of the lipid matrix, cholesterol 20.2.2 Assessment of Skin Barrier
sulfate, also acts as regulator of the desquamation Structure and Function
process and inhibits serine protease activity [34].
Barrier homeostasis and SC integrity are also A series of noninvasive techniques is at the dis-
controlled by skin pH and calcium concentration. posal of researchers to quantitatively study the
The proteases and their inhibitors involved in des- biophysical properties, including barrier function
quamation each have their own optimal pH [35, 36], and hydration of human skin, in vivo under phys-
and shifts in pH induce abnormal desquamation iological, pathological, and experimental condi-
[37]. In addition, aberrations in the skin pH also tions. Since these techniques are noninvasive in
affect lipid processing and maturation of lamellar nature and measurements can mostly be taken in
membranes through the pH-sensitive enzyme beta- a matter of seconds and by simply holding a small
glucocerebrosidase [38]. Enhanced protease activ- probe against the skin surface, they are suitable
ity and decreased synthesis of the lipid lamellae for the use in infants (Table 20.1).
lead to exacerbated breakdown of the epidermal Superficial structures of the SC can be visual-
barrier when elevated pH is sustained. Keratinocyte ized with in vivo microscopy [43]. Topographical
differentiation processes, including lamellar body features include the microrelief lines (crisscross-
secretion [39], and the processing of CE precursors ing the skin surface), the SC island structures
[40] are also regulated by calcium. Calcium con- between the lines, skin pores, hair follicles, etc.
centration in the epidermis follows a vertical gradi- The dryness of the surface correlates with the
ent with a low concentration in the basal layers and size of shed corneocytes. Well-hydrated skin
a progressively higher concentration to reach a sheds individual corneocytes, whereas dry skin
maximum concentration in the stratum granulo- with disrupted desquamation sheds scales con-
sum and a subsequent decline in the SC [41]. It sisting of partly cross-linked corneocytes. These
was found that the formation of the calcium gradi- can be collected with adhesive tape strips
ent is regulated by the epidermal barrier function (D-squames) and the desquamation rate esti-
and that the gradient disappears upon epidermal mated as a function of the area covered by cor-
barrier disruption [42]. neocytes in conjunction with video microscopy
It is thus evident that different homeostatic [44]. This method also provides information
mechanisms regulate skin hydration and barrier about corneocyte size.
function and that these processes are mutually Features within the skin can be revealed by
dependent. in vivo confocal laser scanning microscopy
298 G.N. Stamatas and N.K. Tierney

(CLSM). This method creates images composed epidermis and reaches into the papillary dermis.
of serial optical sections in the horizontal plain This method allows also measuring the concen-
and allows to section tissue at different depths and tration of NMF and other skin components with
to gain information of the whole epidermis, characteristic Raman signals.
underlying dermal papillae (undulating structures Attenuated total reflectance Fourier transform
at the interface between dermis and epidermis), infrared (ATR-FTIR) spectroscopy is another
and dermal structures [45]. Analysis of confocal means to measure the molecular composition of
images provides information on microrelief line the skin in vivo. This method collects reflection
depth, the projected area of cells in different epi- spectra in the mid-IR region of molecules with
dermal layers, the thickness of the layers, struc- characteristic vibrational modes and distinct IR
ture and distribution of dermal papillae, etc. [11]. absorbance bands. The SC surface water content
As emphasized above, skin water content is a and lipid types, concentration, and ordering in
decisive factor in skin barrier homeostasis; mea- the SC can be recorded [50].
suring the hydration status can thus give impor- A widely accepted surrogate marker for SC
tant insights into skin pathophysiology. The ease barrier function is the assessment of transepider-
of flow of electrons in the skin depends on the mal water loss (TEWL). TEWL measurements
water content of the SC and increases with register water vapor loss other than through
increasing hydration. Skin hydration can thus be sweating [51]. The rate of water loss is indirectly
indirectly assessed with methods that measure proportional to the integrity of the water barrier
the electrical properties of the skin, including function. At least four distinct methods exist to
skin capacitance, impedance, and conductance measure TEWL: the simple closed chamber, the
[46]. Depending on the chosen method, these closed ventilated chamber, the closed condenser
measurements permit the assessment of the chamber, and the open chamber method [52, 53].
hydration status of superficial SC layers or much The simple closed chamber approach measures
deeper layers including parts of the viable epider- the relative humidity inside a chamber. Its rapid
mis [46, 47]. A small probe is brought into con- response makes it suitable for measurements on
tact with the skin, and measurements are taken in infant skin. In the closed ventilated method, a
a matter of seconds, which allows repetitive mea- carrier gas is used to eliminate water, but this
surements. Environmental parameters such as may influence evaporation if the gas is too dry. In
ambient temperature and relative humidity influ- the condenser chamber method, the carrier gas
ence the readings. It is thus important to control mechanism is replaced by water condensation at
and record these parameters and to let study par- the top of the chamber. Both the ventilated and
ticipants acclimate to the given conditions. the closed condenser chamber method may be
In addition to these indirect measurements, forcing water evaporation beyond the nominal
the concentration of water and other substances state. When performed properly, the open cham-
in the skin can be directly measured with spectro- ber method appears to be more accurate but takes
scopic techniques, such as Raman confocal long and can be impractical in certain cases, such
microspectroscopy [48, 49]. The physical princi- as measuring infants. Ambient temperature,
ple of this method is the inelastic scattering of humidity, air movement, and direct light are envi-
laser light (Raman scattering) that results from ronmental factors that influence TEWL measure-
the interaction between the light and the vibra- ments in addition to subject-specific parameters
tions of chemical bonds of the molecules in the such as sweating, stress, etc. [52, 54].
sample. Based on the shift in the energy of the The capacity of the skin to absorb and retain
laser photons, information about the identity and water can be assessed with sorptiondesorption
concentration of the molecules present is tests that consist of repeated electromeasure-
obtained. The sampling penetration depth in the ments (conductance or capacitance) before and
skin for this technique is up to about 120 mm after application of water on the skin surface [55].
[48], which encompasses the SC and the viable The rates of sorption and desorption are inversely
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 299

related to the water barrier function of the skin cell proliferation rate observed using fluores-
area tested, and the time for desorption relates to cence microscopy in young infants which
the water-holding capacity of the SC. decreases with age. Structural differences are
Other methods used to assess skin barrier also observed in the dermis with less dense bun-
function rely on measurement of skin reaction dling of collagen fibers [57].
(erythema) following the uptake of specific mol- Considerable differences between infants and
ecules, such as the methyl nicotinate, into the SC adults are also manifested in skin composition as
or measurement of the concentration of a dye indicated by the electrical measurements men-
after a defined time following topical application. tioned above. Skin hydration goes through sig-
Due to skin permeation concerns, these methods nificant changes during infancy. At birth, the SC
are not used on infants. of babies is drier compared to older infants, chil-
dren, and adults [5860]. The difference between
infants and adults is reversed through a signifi-
20.3 Baby Skin Properties cant increase in skin hydration during the first
Differ Compared to Those month of life [58, 61] that leads to higher skin
of Adult Skin hydration in older infants (324 months) com-
pared to adults [10, 13]. Together with increasing
20.3.1 Infant Skin Maturation hydration, the initially relatively rough skin
smoothens during the first month [58]. Raman
The skin of newborns is markedly distinct from spectroscopy indicated that compared to adults,
adults in structure, function, and composition and infants have a higher total water concentration
remains different throughout infancy while skin and a steeper water gradient in the SC [10].
maturation continues [19]. At birth, the skin is Despite the high moisture content of infant
covered with a protective layer with high water skin, the NMF is significantly lower compared to
content, the vernix caseosa, composed of corneo- adult skin as measured by Raman spectroscopy
cytes and lipids similar to SC but with a distinct [10]. The surface of infant skin is also less rich in
architecture [56]. As part of the developing epi- sebaceous lipids [17]. This seemingly paradoxi-
dermal barrier, the vernix provides numerous cal observation of a high water content in spite of
functions to fetal and newborn skin, including relatively low NMF and lipid levels and an appar-
waterproofing in the womb and anti-infectious, ently shorter pathway for water molecules to
moisturizing, and cleansing properties, as well as evaporate from skin as suggested by the smaller
promotion of the acid mantle development in cell size and thinner SC [11] indicates that there
newborns. are regulatory mechanisms at work that control
The surface structure of infant skin is charac- skin hydration in infants that are different from
terized by a denser network of the microrelief those of adults.
lines and smaller and less flat island structures A thin, highly hydrated SC as is the case in
compared to adult skin, as analyzed by in vivo infants [10, 11, 13] presumably causes reduced
video microscopy [11]. CLSM showed that the light scattering. This, together with lower levels
islands are matched in a one-to-one ratio to the of photoprotective melanin compared to adults
underlying dermal papillae, which is not seen in [62], may increase the probability of UV-induced
adults. Furthermore, the dermal papillae are of damage in childhood and could explain the
more homogenous distribution, size, and density increased risk for malignant skin tumors through
than in adult skin. The SC and the suprapapillary sunburns incurred in childhood [63, 64].
epidermis are on average 30% and 20% thinner, After birth, the surface of infant skin undergoes
respectively. Both corneocytes and keratinocytes rapid bacterial colonization [65]. In parallel to the
are smaller in infants compared to adults. The ongoing changes in skin structure and function,
smaller cell size and higher cell density observed the composition of the cutaneous microflora
in this age group may be explained by the higher evolves over the first year of life [66]. While adult
300 G.N. Stamatas and N.K. Tierney

skin is mostly colonized by the phyla Proteobacteria, to adults [13]. This relatively high pH most likely
Actinobacteria, and Firmicutes [6770], infant influences skin barrier function, as a number of
skin is colonized predominantly by Firmicutes process in the skin that are crucial for maturation
(predominantly Staphylococci), followed by or maintenance of the epidermal barrier are pH
Actinobacteria, Proteobacteria, and Bacteroidetes. sensitive, such as bacterial proliferation on the
Originally dominated by Staphylococci, the rela- skin [75, 76], processing of intercellular lipids
tive abundance of the genera present grows more [36, 77], and desquamation [35]. The diapered
even during the first year. Similar to adults, the area with pH values even higher than other regions
composition of infant skin microflora appears to is in particular prone to skin irritation (diaper rash)
be site specific. Cutaneous bacteria modulate the that is accompanied by a broken barrier [16].
innate immune response [71] and may be involved A further difference with adult skin is the imma-
in the maturation of other skin barrier functions. ture activity of sebaceous and sweat glands in
The structural differences together with the babies. Maternal hormones stimulate sebum pro-
distinct composition of infant skin probably duction in the uterus, and the residual presence of
explain the functional differences in barrier func- these hormones is thought to induce high sebum
tion and water-handling properties compared to production in newborns [78]; however, sebum lev-
adult skin. In analogy to a brick wall, where the els diminish during the first year [17], and the sebum
corneocytes represent the bricks and the intercel- glands remain quiescent until puberty. Eccrine
lular lipids the mortar [72], smaller cell size and sweat glands are fully developed in utero. Eccrine
less abundant lipids in infants may account for an glands of palms and soles of the feet are functioning
immature barrier. at birth, and their activity is related to the emotional
As mentioned above, the barrier function of the state [79]. However, the thermoregulatory function
SC is commonly indirectly assessed by measuring of sweat glands is minimal in babies [80].
TEWL. Although contradictory data exist [13, 59,
60] (possibly due to the susceptibility of the method
to external and subject specific parameters), we 20.3.2 Infant Skin Reaction to
and others found a significantly higher TEWL rate Environmental Factors
in infants compared to adults [10, 60] together with
a large interperson variability [10], which is indica- Exposure to the elements (hot or cold climate,
tive of an immature barrier function. Furthermore, sun, wind) can leave skin red, dry, and scaly.
the water-holding capacity of infant skin is reduced Infants are at a particular risk to react to environ-
as suggested by its water sorption and desorption mental factors due to the immature protective
properties [10]. Infant skin absorbs larger amounts function of their skin, such as the abovemen-
of water which is then lost more quickly than in tioned scarcity of melanin [81]. In addition to the
adults. A possible explanation for the high desorp- temporary discomfort or pain, accumulating
tion rate in infants is the relative scarcity of water- damage through repeated sunburns in childhood
retaining NMF [10] or a larger surface area due to can have long-term consequences, such as pre-
higher density of the microrelief structures [10]. mature aging and skin cancer [82].
Compared to the acidic skin of adults with a Clinical features of skin reactivity of the face
pH in the range of 4.56.7 [60, 73, 74], the skin and body show a seasonal dependence as demon-
pH of newborns is close to neutral, with values strated in a study on infants conducted in Beijing
ranging from 6.6 to 7.5, depending on the body [83]. The stark difference in climatic characteris-
site [13, 58, 60, 61]. Skin acidification commences tics between summer (hot and humid summers
rapidly after birth, causing a drop in pH within a and dry, cold, and windy winters) correlated with
few days [60] that continues to decrease during significantly more cases with skin dryness and
the first month [58]. Nevertheless, skin pH remains erythema in winter compared to summer, with
significantly higher throughout infancy compared erythema being most prominent on cheeks and
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 301

the chin (Fig. 20.1, Table 20.2). The exact physi- a

ological mechanism that underlies the suscepti-
bility to seasonal differences has not been studied
in infants. We know however from studies in
adults that ceramides and total SC lipids get
depleted in winter [84]. Furthermore, the concen-
tration of lactate and potassium (both components
of the NMF) diminishes in winter, and this cor-
relates with decreased skin hydration, increased
stiffness, and increased pH [31]. It remains to be
tested if this is also the case in infants.
Skin reactivity can be measured by assessing
the ratio of the concentration of the cytokine inter- b
leukin-1 receptor antagonist (IL-1RA) to that of
interleukin-1a (IL-1a) in the SC. These concen-
trations are measured by collecting tape strips
from the SC and analyzing the obtained soluble
fraction by enzyme-linked immunosorbent assays
(ELISA) [85]. It was suggested that IL-1RA mod-
ulates inflammatory responses of the skin, as the
IL-1RA/IL-1a ratio is increased in UV-exposed
areas as opposed to protected areas of healthy skin
and in lesions of inflammatory diseases including
psoriasis and atopic dermatitis in adults [85, 86]
as well as in infant skin exhibiting diaper dermati- c
tis, heat rash, or erythema [87]. Thus, assessing
the IL-1RA/IL-1a ratio as a nonspecific indicator
of skin reactivity and in the absence of any par-
ticular stressors, we found that healthy infant skin
is significantly more reactive to the external envi-
ronment than adult skin [88] (Fig. 20.2).

20.4 Specic Dry Skin Problems

in Infants

Dry scaly skin is very common in newborns [59] Fig. 20.1 Skin dryness and erythema are evident during
but can appear at any stage of development result- winter but not during summer in infants in Beijing. Skin
ing from environmentally induced hydration loss reactions are documented by high-resolution digital
imaging at different imaging modalities (a regular visi-
of the SC (low humidity, wind, cold). However,
ble photo, b orthogonal polarization imaging, c
the need of protection and moisturization may UV-excitation fluorescence imaging). Orthogonal polar-
not always be recognized. In a recent study, 90% ization imaging minimizes surface glare and is used to
of the mothers surveyed believed that their childs document skin erythema in winter: blood vessels and
uneven erythema are visible on the cheek. UV-excitation
skin was not dry, although according to clinical
fluorescence imaging is used to document skin dryness
evaluation, only 37% of the children had nondry as dry corneocytes show as white flakes under this
skin, while the rest had clinical signs of low to modality. The images below the full face pictures are
moderately dry skin (unpublished results). magnified areas of the left cheek
302 G.N. Stamatas and N.K. Tierney

Table 20.2 Percentage of infant subjects (aged factors weaken the barrier function and contribute
336 months) with clinical signs of dryness or erythema to the risk of developing diaper dermatitis.
in Beijing
Prevention or treatment of mild cases involve fre-
Winter (%) Summer (%) quent diaper changes, use of gentle cleansers to
Dryness (face) 49.6 1.6 remove fat-containing feces, keeping the skin as
Dryness (body) 50.4 0.0
dry as possible, and application of a barrier cream
Erythema (face) 68.1 1.6
[92, 9597], while severe cases that involve sec-
Erythema (body) 16.0 0.0
ondary yeast or bacterial infections require medi-
cal treatment in addition [98].
12 AD concerns around 20% of children [99101].
* *
10 In 60% of those afflicted, the onset occurs before
the first birthday [101]. The clinical features of
8
IL-1RA / IL-1

AD vary with age: infants usually have extremely

6 pruritic erythematous papules and vesicles on the
4 cheeks, forehead, or scalp, while chronic disease
characteristics in children involve lichenified
2
papules and plaques [14]. The etiology of this
0 disease is not yet fully elucidated; however, a
Infant (613 Infant (17 Adult (30 combination of environmental and genetic fac-
months) 24 months) 40 years)
tors appears implicated [102]. Genetic predispo-
Fig. 20.2 Infants appear to have more reactive skin than sition involves mutations in structural proteins,
adults. The ratio of IL-1RA/IL-1a is calculated from the epidermal proteases, and protease inhibitors. The
normalized values of IL-1RA and IL-1a from tapes sam- most significant genetic factors predisposing to
pled from the volar forearms of infants and adults. The
star (*) indicates statistical difference of the two groups AD appear to be loss-of-function mutations in
joined by the line on top at the level of p < 0.05 the filaggrin-encoding gene [102]. Among the
environmental risk factors are sensitization to
food allergens and aeroallergens [14]. AD that
20.4.1 Allergic and Irritant Contact arises in childhood is frequently a precursor of
Dermatitis allergic asthma and allergic rhinitis acquisition
[103]. One study found that in a population of
Cutaneous disturbances are frequent in childhood children with AD, 43% developed asthma and
and include allergic and irritant types of dermatitis. 45% allergic rhinitis [104]. When asthma coex-
Atopic dermatitis (AD) is an allergic inflammatory ists with AD, it is more severe and persistent than
skin condition that features as key characteristic without it [105].
extremely dry and scaly skin. The opposite of dry TEWL and pH are higher [106] and the lipid
skin, excessive skin hydration, is at the core of content is reduced in skin with AD lesions [30].
another inflammatory skin condition, irritant dia- However, a defective skin barrier function in AD
per dermatitis or diaper dermatitis (DD). is not limited to lesional skin only. Even unaf-
DD is among the leading issues in infant skin fected skin appears frequently dry. Moreover,
health. More than half of the infant population has TEWL and pH values of noninvolved skin in
at least one episode during the diaper-wearing children with AD are different from that in
phase [89, 90]. This condition afflicts the but- healthy children [106]. Possibly related to the
tocks, perianal region, inner thighs, and abdomen obvious barrier dysfunction is the risk of micro-
and presents with redness and scaling of the skin bial infection in children with AD [107].
and in severe cases with papules and edema [91]. The following scenario may explain how AD
Diapering creates an environment with distinct predisposes to allergenic airway diseases: barrier
characteristics that comprise skin occlusion and dysfunction may constitute the primary event in
friction [92], fecal enzyme activity [93], excessive the disease development [102] and subsequently
hydration, and increased pH [16, 94]. All these enable the penetration of allergens and irritants
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 303

through the skin. As a consequence of this aller- Depending on their water content, moisturiz-
gen sensitization, a systemic allergic response ers are either lotions (with high water content),
may be provoked, characterized by elevated lev- creams (with less water and more oils or occlu-
els of serum IgE antibodies, eosinophils, mac- sive agents), or ointments (oil-based compounds
rophages, and T cells, which are biological with little or no water in the product).
markers of leukocyte activation [108]. It was sug- The increased reactivity and reduced barrier
gested that the systematic sensitization may facil- function of infant skin as well as conditions of
itate the infiltration of respiratory mucosa with inflammatory skin disease have implications for
primed T cells, eosinophils, and macrophages skin care in this age group. Specific guidelines
after allergen infiltration [108]. This is supported developed by dermatologists, pediatricians, and
by the evidence that avoidance of food- and air- midwives and based on scientific evidence give
derived allergens can reduce the development of advice on topics such as the first bath, routine
AD and allergic disease [109]. bathing, vernix care, dry skin care, and manage-
Besides airborne and food-borne allergens, ment of AD and DD in babies [97, 113]. Infant
irritants such as clothing, soaps, hot water, micro- bathing, including that of newborns, is consid-
organisms, and stress may act as triggers for AD ered a safe practice when performed for a few
or worsen existing conditions. Special care has to minutes, not more than 23 times per week at
be taken not to exacerbate skin barrier dysfunc- 3740C and preferably with a gentle, pH-neutral
tion in AD through inadequate skin care practices cleanser. A comparative study between cloth
(discussed below). washing and bathing in newborns found no clini-
cal harm elicited by either method [114].
Nevertheless, bathing is considered preferable to
20.4.2 Baby Skin Moisturization and cloth washing [97] based on evidence that it may
Barrier Function Protection better protect barrier function (with lower TEWL
and higher SC hydration in some body areas
Moisturizers are hydrating agents that increase [114]) and thermal stability [115, 116].
the water content of the SC and result in skin that To soothe dry and flaking skin, emollients
feels and looks smoother. Key ingredients are may be applied after bathing [97]. Emollient for-
emollients (lipids of mineral, animal, or vegetal mulations can be either oil-in-water emulsions
origin, such as mineral oils, waxes, triglycerides, (creams) or water-in-oil emulsions (ointments).
lanolin, etc.), emulsifiers (which blend the mois- Current guidelines on AD treatment consider
turizer ingredients and prevent them from sepa- emollients as effective first-line agents in the
rating), and humectants (e.g., alpha-hydroxy management of this skin condition [14, 117]. It
acids, urea, glycerin) [110]. Fats such as petrola- is recommended to bath children with AD using
tum (petroleum jelly) have an occlusive effect a moisturizing cleanser and to use emollients
and increase skin hydration by preventing water after bathing either alone or in combination with
from escaping. More than just creating a water- topical medication. Repeated application is
impermeable layer, petrolatum penetrates the SC advised, even in the absence of obvious skin
and aids in epidermal barrier repair [111]. lesions.
Humectants, including glycerol, increase skin
hydration by binding and holding water. Glycerol
provides also other benefits for dry skin. It acts as 20.4.3 Improvement of Baby Skin
occlusive agent (although to a lesser degree Barrier Function and Hydration
than petrolatum), it may reduce water loss by pre- with Moisturizers
venting lipid crystal-phase transitions, and it
enhances corneodesmolysis [112]. Emulsifiers The benefit of application of a topical cream
are surfactants (surface active agents) that also after bathing was shown in a study that evaluated
affect the phase behavior of lipids and facilitate the effect of twice weekly bathing with water
desquamation. alone or with a pH 5.5 wash gel with or without
304 G.N. Stamatas and N.K. Tierney

Fig. 20.3 Significant improve- a 5

ment in the skin condition of
infants with dry skin and

Improved Skin Condition

4

CLINICAL GRADING
extradry patches 24 h after a
single application of a moistur-
izer and after 1 week of 3
following a regimen consisting
of use of a mild cleanser 2
combined with the same
moisturizer. The effect of the *
1 *
regimen on the skin condition
* *
was evaluated in a blinded, *
0 *
1-week clinical study under the
supervision of a pediatrician. Dryness Flaking Roughness
Parents bathed their infants daily Baseline 24 Hours Week 1
using the moisturizing wash and
applied the lotion twice daily, b 5
with one application being
Improved Skin Condition

immediately after the bath. The 4

CLINICAL GRADING

skin condition was assessed

using clinical grading of 3
dryness, flaking, and tactile
roughness. (a) Improvements of *
dry skin and (b) improvements 2
of extradry patches. The star (*) *
1 * *
indicates statistical difference
*
from baseline at the level of *
p < 0.05 0
Dryness Flaking Roughness
Baseline 24 Hours Week 1

cream application for 2 months in newborns 20.4.4 Water Alone Does Not
[118]. Babies bathed with or without the wash Moisturize Skin: The Complete
gel and treated with cream had higher SC hydra- Skin Care Regimen Is Important
tion and lower TEWL than those that were
bathed only. Excessive exposure to water damages skin by
Moisturizers can exert their beneficial effect disrupting the intercellular lipid lamellae in the
on skin properties after a single application. In a SC accompanied with the appearance of large
study, we tested a daily regimen using a gentle, water pools in the intercellular space [121]. It is
moisture-rich cleanser with twice daily applica- thus somewhat counterintuitive that washing with
tion of a nourishing moisturizer on 636-month- water alone does not increase skin hydration.
old infants with mild to moderate dry and When 312-month-old babies underwent a regi-
chapped facial skin. The skin condition showed men of twice daily washing for 2 weeks, their
significant improvement 24 h after the first skin water barrier function showed a small but
application of the moisturizer [119]. After significant decrease, as indicated by TEWL
1 week of using this regimen, skin conditions (authors unpublished results). At the same time,
remained significantly improved according to neither a positive nor negative effect on barrier
both clinical evaluation (Fig. 20.3) and assess- function was observed for the adults who partici-
ment by the parents. We obtained similar results pated in this study. However, another study that
on dryness, erythema, and roughness with the evaluated the effect of twice weekly bathing with
daily use of a moisturizing balm used without water alone or with a pH 5.5 wash gel for 2 months
any specifically defined washing regimen in newborns did not find any nonphysiological
(Fig. 20.4) [120]. values for SC hydration and TEWL despite the
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 305

Improved Skin Condition

3
CLINICAL GRADING
*

2 *

*
*

1 *
*

0
Dryness Erythema Roughness
Baseline 24 Hours Week 1

Fig. 20.4 Significant improvement in the skin condition instructed to use the balm on their babys face daily and to
of mild to moderate dry/chapped facial infant skin 24 h apply to other body areas as needed. The skin condition
after a single application of a balm and after 1 week of was assessed using clinical grading of dryness, flaking,
twice daily application. The effect of the balm on the skin and tactile roughness. The star (*) indicates statistical dif-
condition was evaluated in a blinded, 1-week clinical ference from baseline at the level of p < 0.05
study under the supervision of a pediatrician. Parents were

observation that bathing with or without the wash Some of these products had a damaging effect on
gel and application of cream resulted in lower skin as evidenced by erythema and increased
TEWL rates and higher SC hydration than bath- TEWL after patch testing and left skin reaction-
ing alone [118]. It is conceivable that the observed inducing residues after washing. The composi-
divergence in results depends on the physical tion of the formulations is necessarily decisive
properties of the water used, in particular its hard- for their effect on skin barrier function. It remains
ness (i.e., its calcium content). Hard water can to be demonstrated which ingredients in particu-
increase the irritant potential of harsh surfactants lar or combinations thereof have an enhancing or
[122] and was found to correlate with the preva- weakening effect. In a study conducted in adults,
lence of AD in children [123]. twice daily application for 7 weeks of moisturiz-
ers with simplified (40% lipids of mineral or veg-
etable origin) or complex (20% lipids of mineral
20.4.5 Infant Moisturizers Need and vegetable origin) creams demonstrated
to be Safe and Effective increased TEWL rates and increased susceptibil-
ity to sodium lauryl sulfate with the simplified
Naturally, skin care products, including moistur- creams, while the opposite was true for the com-
izers, intended for the use in infants as well as in plex cream [125].
adults should in no way negatively affect skin We found that neonatal skin does not show any
function. They should be clinically tested for clinical signs of irritation or erythema after 6 weeks
safety and tolerance and for their efficacy to pro- of washing with a mild baby cleanser in combina-
vide moisture and maintain barrier function. tion with the application of an appropriately for-
Sometimes even skin care products that are mulated baby lotion (unpublished results). In
claimed to be in particular suited for sensitive accordance with this, a previous study on
skin may have irritant potential as shown in a 36-month-old infants bathed with a liquid cleanser
comparative study on commercial shower and found no negative effect on barrier function mea-
bath oils designed for dry skin in adults [124]. sured with TEWL 15 min after the bath [126].
306 G.N. Stamatas and N.K. Tierney

We observed differences in efficacy of different

formulation when assessing the impact of regular regulate water handling and may explain
moisturizer utilization on skin barrier function the immature barrier function.
and hydration in 312-month-old babies. After Atopic dermatitis has higher frequency
twice daily lotion application during a period of in infants compared to adults.
6 weeks, we found significant changes in barrier In atopic dermatitis, inhibiting the entry
function compared to baseline as indicated by of allergens and other irritants by keep-
TEWL. The nature of the changes depended on ing the barrier function intact may pos-
the chemical composition of the test products sibly prevent disease progression to
used (authors unpublished results). Two differ- allergic airway disease.
ent oil-in-water lotions resulted in elevated Moisturizers alleviate dry skin due to their
TEWL and thus decreased water barrier func- occlusive and/or humectant properties.
tion, which was sustained after the daily lotion Water alone does not provide moistur-
applications were terminated. In contrast, a third ization and may even dry skin.
oil-in-water lotion with silicon, glycerol, and Appropriate formulation is key for the
petrolatum improved the skin water barrier func- efficacy of a moisturizer.
tion (reduced TEWL) even after application ces-
sation. Among the test products, only the third
lotion increased skin hydration and improved Abbreviations
the water-holding capacity of the skin during the
entire application period. AD Atopic dermatitis
This data suggest that the choice of a suitable ATR-FTIR Attenuated total reflectance Fourier
moisturizing product is crucial to support baby transform infrared spectroscopy
skin moisturization. CE Cornified envelope
CLSM Confocal laser scanning microscopy
Conclusion DD Diaper dermatitis
The skin barrier of infants continues to develop ELISA Enzyme-linked immunosorbent
during the first years of life, which reaffirms assays
that infant skin is different than adult skin and IL-1a Interleukin-1a
remains so for an extended period of child- IL-1RA Interleukin-1 receptor antagonist
hood. Moisturizers for infants should have IR Infrared
clinically proven safety, tolerance, and suit- NMF Natural moisturizing factor
ability for the use on infant skin, as well as SC Stratum corneum
efficacy in maintaining barrier integrity and TEWL Transepidermal water loss
providing moisture. UV Ultraviolet

Acknowledgement The authors would like to thank

Dr. Beate Gerstbrein of Ascopharm for editorial
assistance.

Take Home Messages

Infant skin displays a developing barrier References
function and water-handling properties
that are distinct from those in adults. 1. Lippens S, Hoste E, Vandenabeele P, Agostinis P,
The unique characteristics of infant skin Declercq W (2009) Cell death in the skin. Apoptosis
14:549569
in structure and composition suggest the 2. Williams AC (2003) Structure and function of human
presence of distinct mechanisms that skin. Transdermal and topical drug delivery.
Pharmaceutical Press, London
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 307

3. Elias PM (1991) Epidermal barrier function: intercel- ing the first years of life: a review of recent findings
lular lamellar lipid structures, origin, composition and based on in vivo studies. Int J Cosmet Sci 33:1724
metabolism. J Control Release 15:199208 20. Lee SH, Jeong SK, Ahn SK (2006) An update of the
4. Candi E, Oddi S, Terrinoni A, Paradisi A, Ranalli M defensive barrier function of skin. Yonsei Med J
et al (2001) Transglutaminase 5 cross-links loricrin, 47:293306
involucrin, and small proline-rich proteins in vitro. 21. Rawlings AV (2003) Trends in stratum corneum
J Biol Chem 276:3501435023 research and the management of dry skin conditions.
5. Pillai S, Cornell M, Oresajo C (2010) Epidermal bar- Int J Cosmet Sci 25:6395
rier. In: Draelos ZD (ed) Cosmetic dermatology. 22. Rawlings AV, Scott IR, Harding CR, Bowser PA
Wiley-Blackwell, Chichester, pp 312 (1994) Stratum corneum moisturization at the molec-
6. Wertz PW (2000) Lipids and barrier function of the ular level. J Invest Dermatol 103:731741
skin. Acta Derm Venereol Suppl (Stockh) 208:711 23. Machado M, Salgado TM, Hadgraft J, Lane ME
7. Suzuki Y, Nomura J, Koyama J, Horii I (1994) The (2010) The relationship between transepidermal water
role of proteases in stratum corneum: involvement in loss and skin permeability. Int J Pharm 384:7377
stratum corneum desquamation. Arch Dermatol Res 24. Rawlings A, Harding C, Watkinson A, Banks J,
286:249253 Ackerman C et al (1995) The effect of glycerol and
8. Akiyama M, Smith LT, Yoneda K, Holbrook KA, Hohl D humidity on desmosome degradation in stratum cor-
et al (1999) Periderm cells form cornified cell envelope neum. Arch Dermatol Res 287:457464
in their regression process during human epidermal 25. Rawlings AV, Harding CR (2004) Moisturization and
development. J Invest Dermatol 112:903909 skin barrier function. Dermatol Ther 17(Suppl 1):
9. Evans NJ, Rutter N (1986) Development of the epi- 4348
dermis in the newborn. Biol Neonate 49:7480 26. Wertz PW (2004) Stratum corneum lipids and water.
10. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC Exog Dermatol 3:5356
(2008) Barrier function and water-holding and trans- 27. Scott IR, Harding CR (1986) Filaggrin breakdown to
port properties of infant stratum corneum are different water binding compounds during development of the
from adult and continue to develop through the first rat stratum corneum is controlled by the water activity
year of life. J Invest Dermatol 128:17281736 of the environment. Dev Biol 115:8492
11. Stamatas GN, Nikolovski J, Luedtke MA, Kollias N, 28. Bouwstra JA, Groenink HW, Kempenaar JA, Romeijn
Wiegand BC (2010) Infant skin microstructure assessed SG, Ponec M (2008) Water distribution and natural
in vivo differs from adult skin in organization and at moisturizer factor content in human skin equivalents
the cellular level. Pediatr Dermatol 27:125131 are regulated by environmental relative humidity. J
12. Chiou YB, Blume-Peytavi U (2004) Stratum corneum Invest Dermatol 128:378388
maturation. A review of neonatal skin function. Skin 29. Choi EH, Man MQ, Wang F, Zhang X, Brown BE
Pharmacol Physiol 17:5766 et al (2005) Is endogenous glycerol a determinant of
13. Giusti F, Martella A, Bertoni L, Seidenari S (2001) stratum corneum hydration in humans? J Invest
Skin barrier, hydration, and pH of the skin of infants Dermatol 125:288293
under 2 years of age. Pediatr Dermatol 18:9396 30. Sator PG, Schmidt JB, Honigsmann H (2003)
14. Akdis CA, Akdis M, Bieber T, Bindslev-Jensen C, Comparison of epidermal hydration and skin surface
Boguniewicz M et al (2006) Diagnosis and treatment lipids in healthy individuals and in patients with atopic
of atopic dermatitis in children and adults: European dermatitis. J Am Acad Dermatol 48:352358
Academy of Allergology and Clinical Immunology/ 31. Nakagawa N, Sakai S, Matsumoto M, Yamada K,
American Academy of Allergy, Asthma and Nagano M et al (2004) Relationship between NMF
Immunology/PRACTALL Consensus Report. J (lactate and potassium) content and the physical prop-
Allergy Clin Immunol 118:152169 erties of the stratum corneum in healthy subjects. J
15. Berg RW, Milligan MC, Sarbaugh FC (1994) Invest Dermatol 122:755763
Association of skin wetness and pH with diaper der- 32. Sato J (2002) Desquamation and the role of stratum cor-
matitis. Pediatr Dermatol 11:1820 neum enzymes. In: Leyden JJ, Rawlings AV (eds) Skin
16. Stamatas GN, Zerweck C, Grove G, Martin KM moisturization. Marcel Dekker Inc, New York, pp 7992
(2011) Documentation of impaired epidermal barrier 33. Watkinson A, Harding C, Moore A, Coan P (2001)
in mild and moderate diaper dermatitis in vivo using Water modulation of stratum corneum chymotryptic
noninvasive methods. Pediatr Dermatol 28:99107 enzyme activity and desquamation. Arch Dermatol
17. Agache P, Blanc D, Barrand C, Laurent R (1980) Res 293:470476
Sebum levels during the first year of life. Br J Dermatol 34. Sato J, Denda M, Nakanishi J, Nomura J, Koyama J
103:643649 (1998) Cholesterol sulfate inhibits proteases that are
18. Behrendt H, Green M (1969) Drug-induced localized involved in desquamation of stratum corneum. J Invest
sweating in full-size and low-birth-weight neonates. Dermatol 111:189193
Am J Dis Child 117:299306 35. Deraison C, Bonnart C, Lopez F, Besson C, Robinson
19. Stamatas GN, Nikolovski J, Mack MC, Kollias N R et al (2007) LEKTI fragments specifically inhibit
(2011) Infant skin physiology and development dur- KLK5, KLK7, and KLK14 and control desquamation
308 G.N. Stamatas and N.K. Tierney

through a pH-dependent interaction. Mol Biol Cell 50. Brancaleon L, Bamberg MP, Sakamaki T, Kollias N
18:36073619 (2001) Attenuated total reflection-Fourier transform
36. Hachem JP, Man MQ, Crumrine D, Uchida Y, Brown infrared spectroscopy as a possible method to investi-
BE et al (2005) Sustained serine proteases activity by gate biophysical parameters of stratum corneum
prolonged increase in pH leads to degradation of lipid in vivo. J Invest Dermatol 116:380386
processing enzymes and profound alterations of bar- 51. Levin J, Maibach H (2005) The correlation between
rier function and stratum corneum integrity. J Invest transepidermal water loss and percutaneous absorp-
Dermatol 125:510520 tion: an overview. J Control Release 103:291299
37. Hachem JP, Crumrine D, Fluhr J, Brown BE, Feingold 52. Distante F, Berardesca E (1995) Transepidermal water
KR et al (2003) pH directly regulates epidermal per- loss. In: Berardesca E, Elsner P, Wilhelm K-P,
meability barrier homeostasis, and stratum corneum Maibach HI (eds) Bioengineering of the skin: meth-
integrity/cohesion. J Invest Dermatol 121:345353 ods and instrumentation. CRC Press, Boca Raton/
38. Choi EH, Man MQ, Xu P, Xin S, Liu Z et al (2007) New York/London/Tokyo, pp 14
Stratum corneum acidification is impaired in moder- 53. Imhof RE, De Jesus ME, Xiao P, Ciortea LI, Berg EP
ately aged human and murine skin. J Invest Dermatol (2009) Closed-chamber transepidermal water loss
127:28472856 measurement: microclimate, calibration and perfor-
39. Menon GK, Price LF, Bommannan B, Elias PM, mance. Int J Cosmet Sci 31:97118
Feingold KR (1994) Selective obliteration of the epi- 54. Pinnagoda J, Tupker RA (1995) Measurement of the
dermal calcium gradient leads to enhanced lamellar transepidermal water loss. In: Serup J, Jemec BE (eds)
body secretion. J Invest Dermatol 102:789795 Handbook of non-invasive methods and the skin. CRC
40. Hitomi K (2005) Transglutaminases in skin epidermis. Press, Boca Raton/Ann Arbor/London/Tokyo, pp
Eur J Dermatol 15:313319 173178
41. Menon GK, Grayson S, Elias PM (1985) Ionic cal- 55. Tagami H, Kanamaru Y, Inoue K, Suehisa S, Inoue F
cium reservoirs in mammalian epidermis: ultrastruc- et al (1982) Water sorptiondesorption test of the skin
tural localization by ion-capture cytochemistry. J in vivo for functional assessment of the stratum cor-
Invest Dermatol 84:508512 neum. J Invest Dermatol 78:425428
42. Elias P, Ahn S, Brown B, Crumrine D, Feingold KR 56. Hoath SB, Pickens WL, Visscher MO (2006) The
(2002) Origin of the epidermal calcium gradient: biology of vernix caseosa. Int J Cosmet Sci
regulation by barrier status and role of active vs 28:319333
passive mechanisms. J Invest Dermatol 119: 57. Vitellaro-Zuccarello L, Cappelletti S, Dal Pozzo Rossi V,
12691274 Sari-Gorla M (1994) Stereological analysis of colla-
43. Chu M, Kollias N (2011) Documentation of normal gen and elastic fibers in the normal human dermis:
stratum corneum scaling in an average population: variability with age, sex, and body region. Anat Rec
features of differences among age, ethnicity and body 238:153162
site. Br J Dermatol 164:497507 58. Hoeger PH, Enzmann CC (2002) Skin physiology of
44. Schatz H, Altmeyer PJ, Kligman AM (1995) Dry skin the neonate and young infant: a prospective study of
and scaling evaluated by D-squames and image analy- functional skin parameters during early infancy.
sis. In: Serup J, Jemec GBE (eds) Handbook of non- Pediatr Dermatol 19:256262
invasive methods and the skin. CRC Press, Boca 59. Saijo S, Tagami H (1991) Dry skin of newborn infants:
Raton, pp 377384 functional analysis of the stratum corneum. Pediatr
45. Corcuff P (2004) In vivo confocal microscopy. In: Dermatol 8:155159
Agache P, Humbert P (eds) Measuring the skin. 60. Yosipovitch G, Maayan-Metzger A, Merlob P, Sirota L
Springer, Berlin/Heidelberg/New York, pp 183193 (2000) Skin barrier properties in different body areas
46. Berardesca E (1997) EEMCO guidance for the assess- in neonates. Pediatrics 106:105108
ment of stratum corneum hydration: electrical meth- 61. Visscher MO, Chatterjee R, Munson KA, Pickens
ods. Skin Res Technol 3:126132 WL, Hoath SB (2000) Changes in diapered and non-
47. Blichmann CW, Serup J (1988) Assessment of skin diapered infant skin over the first month of life. Pediatr
moisture. Measurement of electrical conductance, Dermatol 17:4551
capacitance and transepidermal water loss. Acta Derm 62. Mack MC, Tierney NK, Ruvolo E Jr, Stamatas GN,
Venereol 68:284290 Martin KM et al (2010) Development of solar UVR-
48. Caspers PJ, Lucassen GW, Bruining HA, Puppels GJ related pigmentation begins as early as the first sum-
(2000) Automated depth-scanning confocal Raman mer of life. J Invest Dermatol 130:23352338
microspectrometer for rapid in vivo determination of 63. Gallagher RP, Hill GB, Bajdik CD, Fincham S,
water concentration profiles in human skin. J Raman Coldman AJ et al (1995) Sunlight exposure, pigmen-
Spectrosc 31:813818 tary factors, and risk of nonmelanocytic skin cancer. I.
49. Caspers PJ, Lucassen GW, Carter EA, Bruining HA, Basal cell carcinoma. Arch Dermatol 131:157163
Puppels GJ (2001) In vivo confocal Raman microspec- 64. Mills O, Messina JL (2009) Pediatric melanoma: a
troscopy of the skin: noninvasive determination of review. Cancer Control 16:225233
molecular concentration profiles. J Invest Dermatol 65. Dominguez-Bello MG, Costello EK, Contreras M,
116:434442 Magris M, Hidalgo G et al (2010) Delivery mode
20 Update on Infant Skin with Special Focus on Dryness and the Impact of Moisturizers 309

shapes the acquisition and structure of the initial Mumbai and markedly different in Beijing in winter
microbiota across multiple body habitats in newborns. (abstract 253). J Invest Dermatol 130(S1):S43
Proc Natl Acad Sci U S A 107:1197111975 84. Rogers J, Harding C, Mayo A, Banks J, Rawlings A
66. Capone K, Dowd SE, Stamatas GN, Nikolovski J (1996) Stratum corneum lipids: the effect of ageing
(2010) Survey of bacterial diversity on infant skin and the seasons. Arch Dermatol Res 288:765770
over the first year of life (abstract 744). J Invest 85. Hirao T, Aoki H, Yoshida T, Sato Y, Kamoda H
Dermatol 130(S1):S124 (1996) Elevation of interleukin 1 receptor antagonist
67. Costello EK, Lauber CL, Hamady M, Fierer N, in the stratum corneum of sun-exposed and ultravio-
Gordon JI et al (2009) Bacterial community variation let B-irradiated human skin. J Invest Dermatol 106:
in human body habitats across space and time. Science 11021107
326:16941697 86. Terui T, Hirao T, Sato Y, Uesugi T, Honda M et al
68. Gao Z, Tseng CH, Pei Z, Blaser MJ (2007) Molecular (1998) An increased ratio of interleukin-1 receptor
analysis of human forearm superficial skin bacterial antagonist to interleukin-1alpha in inflammatory
biota. Proc Natl Acad Sci U S A 104:29272932 skin diseases. Exp Dermatol 7:327334
69. Grice EA, Kong HH, Conlan S, Deming CB, Davis J 87. Perkins MA, Osterhues MA, Farage MA, Robinson
et al (2009) Topographical and temporal diversity of MK (2001) A noninvasive method to assess skin irri-
the human skin microbiome. Science 324:11901192 tation and compromised skin conditions using sim-
70. Grice EA, Kong HH, Renaud G, Young AC, Bouffard ple tape adsorption of molecular markers of
GG et al (2008) A diversity profile of the human skin inflammation. Skin Res Technol 7:227237
microbiota. Genome Res 18:10431050 88. Tierney NK, Kothari PD, Martin KM (2010)
71. Wanke I, Steffen H, Christ C, Krismer B, Gotz F et al Investigation into skin reactivity as a function of age:
(2011) Skin commensals amplify the innate immune a focus on children less than 2 years of age.
response to pathogens by activation of distinct signal- International Pediatric Association 26th International
ing pathways. J Invest Dermatol 131:382390 Congress of Pediatrics. Johannesburg, South Africa
72. Elias PM (1983) Epidermal lipids, barrier function, and 89. Adalat S, Wall D, Goodyear H (2007) Diaper derma-
desquamation. J Invest Dermatol 80(Suppl):44s49s titis-frequency and contributory factors in hospital
73. Braun-Falco O, Korting HC (1986) Normal pH value attending children. Pediatr Dermatol 24:483488
of human skin. Hautarzt 37:126129 90. Jordan WE, Lawson KD, Berg RW, Franxman JJ,
74. Fluhr JW, Pfisterer S, Gloor M (2000) Direct compari- Marrer AM (1986) Diaper dermatitis: frequency and
son of skin physiology in children and adults with bio- severity among a general infant population. Pediatr
engineering methods. Pediatr Dermatol 17:436439 Dermatol 3:198207
75. Matousek JL, Campbell KL (2002) A comparative 91. Visscher MO, Chatterjee R, Munson KA, Bare DE,
review of cutaneous pH. Vet Dermatol 13:293300 Hoath SB (2000) Development of diaper rash in the
76. Korting HC, Hubner K, Greiner K, Hamm G, Braun- newborn. Pediatr Dermatol 17:5257
Falco O (1990) Differences in the skin surface pH and 92. Atherton DJ (2001) The aetiology and management
bacterial microflora due to the long-term application of irritant diaper dermatitis. J Eur Acad Dermatol
of synthetic detergent preparations of pH 5.5 and pH Venereol 15(Suppl 1):14
7.0. Results of a crossover trial in healthy volunteers. 93. Buckingham KW, Berg RW (1986) Etiologic factors
Acta Derm Venereol 70:429431 in diaper dermatitis: the role of feces. Pediatr
77. Mauro T, Holleran WM, Grayson S, Gao WN, Man Dermatol 3:107112
MQ et al (1998) Barrier recovery is impeded at neu- 94. Berg RW, Buckingham KW, Stewart RL (1986)
tral pH, independent of ionic effects: implications for Etiologic factors in diaper dermatitis: the role of
extracellular lipid processing. Arch Dermatol Res urine. Pediatr Dermatol 3:102106
290:215222 95. Benjamin L (1987) Clinical correlates with diaper
78. Henderson CA, Taylor J, Cunliffe WJ (2000) Sebum dermatitis. Pediatrician 14(Suppl 1):2126
excretion rates in mothers and neonates. Br J Dermatol 96. Atherton D, Mills K (2004) What can be done to
142:110111 keep babies skin healthy? RCM Midwives
79. Harpin VA, Rutter N (1982) Development of emo- 7:288290
tional sweating in the newborn infant. Arch Dis Child 97. Blume-Peytavi U, Cork MJ, Faergemann J, Szczapa
57:691695 J, Vanaclocha F et al (2009) Bathing and cleansing in
80. Rutter N (2003) Eccrine sweating in the newborn. In: newborns from day 1 to first year of life: recommen-
Hoath SB, Maibach HI (eds) Neonatal skin structure dations from a European round table meeting. J Eur
and function. Marcel Dekker, New York Acad Dermatol Venereol 23:751759
81. Brenner M, Hearing VJ (2008) The protective role of 98. Gupta AK, Skinner AR (2004) Management of dia-
melanin against UV damage in human skin. Photochem per dermatitis. Int J Dermatol 43:830834
Photobiol 84:539549 99. Laughter D, Istvan JA, Tofte SJ, Hanifin JM (2000)
82. Berneburg M, Surber C (2009) Children and sun pro- The prevalence of atopic dermatitis in Oregon
tection. Br J Dermatol 161(Suppl 3):3339 schoolchildren. J Am Acad Dermatol 43:649655
83. Chu M, Tierney N, Ruvolo E, Stamatas GN, Kollias N 100. Schultz Larsen F, Diepgen T, Svensson A (1996)
et al (2010) Infant skin is similar in New Jersey and The occurrence of atopic dermatitis in north Europe:
310 G.N. Stamatas and N.K. Tierney

an international questionnaire study. J Am Acad 114. Garcia Bartels N, Mleczko A, Schink T, Proquitte H,
Dermatol 34:760764 Wauer RR et al (2009) Influence of bathing or wash-
101. Kay J, Gawkrodger DJ, Mortimer MJ, Jaron AG ing on skin barrier function in newborns during the
(1994) The prevalence of childhood atopic eczema first four weeks of life. Skin Pharmacol Physiol
in a general population. J Am Acad Dermatol 22:248257
30:3539 115. Bryanton J, Walsh D, Barrett M, Gaudet D (2004) Tub
102. Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J, Lane bathing versus traditional sponge bathing for the new-
ME et al (2009) Epidermal barrier dysfunction in born. J Obstet Gynecol Neonatal Nurs 33:704712
atopic dermatitis. J Invest Dermatol 129:18921908 116. Henningsson A, Nystrom B, Tunnell R (1981) Bathing
103. Spergel JM, Paller AS (2003) Atopic dermatitis and or washing babies after birth? Lancet 2:14011403
the atopic march. J Allergy Clin Immunol 112: 117. Eichenfield LF, Hanifin JM, Luger TA, Stevens SR,
S118S127 Pride HB (2003) Consensus conference on pediatric
104. Gustafsson D, Sjoberg O, Foucard T (2000) atopic dermatitis. J Am Acad Dermatol 49:
Development of allergies and asthma in infants and 10881095
young children with atopic dermatitis a prospec- 118. Garcia Bartels N, Scheufele R, Prosch F, Schink T,
tive follow-up to 7 years of age. Allergy 55: Proquitte H et al (2010) Effect of standardized skin
240245 care regimens on neonatal skin barrier function in
105. Eichenfield LF, Hanifin JM, Beck LA, Lemanske RF different body areas. Pediatr Dermatol 27:18
Jr, Sampson HA et al (2003) Atopic dermatitis and 119. Telofski LS, Niciporciukas C, Kurtz ES (2007)
asthma: parallels in the evolution of treatment. Regimen of a moisturizing cleanser and gentle mois-
Pediatrics 111:608616 turizer provides soothing relief of dry skin and extra-
106. Seidenari S, Giusti G (1995) Objective assessment dry patches for infants. International Pediatric
of the skin of children affected by atopic dermatitis: Association 25th International Congress of Pediatrics.
a study of pH, capacitance and TEWL in eczematous Athens, Greece
and clinically uninvolved skin. Acta Derm Venereol 120. Telofski LS, Niciporciukas C, Kurtz ES (2007)
75:429433 Evaluation of tolerance and efficacy of an infant
107. Krakowski AC, Eichenfield LF, Dohil MA (2008) facial balm on mild to moderate dry/chapped facial
Management of atopic dermatitis in the pediatric skin. International Pediatric Association 25th
population. Pediatrics 122:812824 International Congress of Pediatrics. Athens, Greece
108. Beck LA, Leung DY (2000) Allergen sensitization 121. Warner RR, Stone KJ, Boissy YL (2003) Hydration
through the skin induces systemic allergic responses. disrupts human stratum corneum ultrastructure. J
J Allergy Clin Immunol 106:S258S263 Invest Dermatol 120:275284
109. Arshad SH, Bateman B, Sadeghnejad A, Gant C, 122. Warren R, Ertel KD, Bartolo RG, Levine MJ, Bryant
Matthews SM (2007) Prevention of allergic disease PB et al (1996) The influence of hard water (cal-
during childhood by allergen avoidance: the Isle of cium) and surfactants on irritant contact dermatitis.
Wight prevention study. J Allergy Clin Immunol Contact Dermatitis 35:337343
119:307313 123. McNally NJ, Williams HC, Phillips DR, Smallman-
110. Loden M (2003) Role of topical emollients and Raynor M, Lewis S et al (1998) Atopic eczema and
moisturizers in the treatment of dry skin barrier dis- domestic water hardness. Lancet 352:527531
orders. Am J Clin Dermatol 4:771788 124. Loden M, Buraczewska I, Edlund F (2004) Irritation
111. Stamatas GN, de Sterke J, Hauser M, von Stetten O, potential of bath and shower oils before and after
van der Pol A (2008) Lipid uptake and skin occlu- use: a double-blind randomized study. Br J Dermatol
sion following topical application of oils on adult 150:11421147
and infant skin. J Dermatol Sci 50:135142 125. Buraczewska I, Berne B, Lindberg M, Torma H,
112. Harding CR, Watkinson A, Rawlings AV, Scott IR Loden M (2007) Changes in skin barrier function
(2000) Dry skin, moisturization and corneodesmoly- following long-term treatment with moisturizers, a
sis. Int J Cosmet Sci 22:2152 randomized controlled trial. Br J Dermatol 156:
113. Lund CH, Kuller J, Raines DA, Ecklund S, Archambault 492498
ME et al (2007) Neonatal skin care evidence-based 126. Visscher MO, Chatterjee R, Ebel JP, LaRuffa AA,
clinical practice guideline. Association of Womens Hoath SB (2002) Biomedical assessment and instru-
Health, Obstetric and Neonatal Nurses and the National mental evaluation of healthy infant skin. Pediatr
Association of Neonatal Nurses, Washington Dermatol 19:473481
 Part IV
Ingredients and Treatment Effects
 The Composition and
Development of Moisturizers 21
Steve Barton

21.1 Overview The concept of the dry-skin cycle has shifted

thinking on the dermatological abnormality
Moisturizer is such a commonplace term from a dry versus moisturised state to a dynamic
undoubtedly meaning many things to different model [2, 3]. This helps explain why moisturiza-
people. So while the common feature of skin tion remains the top unmet consumer skin needs,
needing moisturization is a loss of the natural a constant point of reference in this chapter and
stratum corneum moisture content, the quantita- further defined in Sect. 21.2.
tive and qualitative extent will vary. According to Given this background, it is no surprise that
Marie Lodn, moisturizers should be tailored while the fundamental principles will be similar,
with respect to the dermatological abnormality there exist a number of strategies to moisturize
[1]. Defining the dermatological abnormality the skin. As discussed by Lodn, terms such as
may help understand the consumer need, but moisturizers and emollients are often used
acceptance by the end user, whether patient or interchangeably, highlighting the focus on the
cosmetic user, may be driven by other factors. mode of action (adding moisture) and the benefit
Individuals with a xerosis arising from pathol- (skin softening). Over time, and with advances
ogy e.g. ichthyosis or eczema may have simi- in understanding dry skin, such terms have
lar needs to someone with senile xerosis, but the become imprecise, with a recognition that mois-
intensity, persistence and cosmetic properties of turising ingredients have a number of benefits.
the treatment may vary, as may the appropriate Hydrophilic systems deliver water and humec-
ingredients. Likewise, there may be subtle differ- tants providing optimum conditions for desqua-
ences between the needs of those who seek mation. Lipophilic materials (emollients)
improvement in skin moisturization as a result reduce water loss, trap existing moisture into
of environmental challenges such as surfactant the skin and improve skin softness and flexibil-
drying, short-term sun exposure and ageing. ity. Section 21.3 develops these ideas.
Between the hydrophilic and lipophilic extremes,
there exist emulsions offering the best of both
worlds. Whether the moisturizer is designed to
reduce skin roughness or improve skin flexibility,
this end point should be delivered at least in part
S. Barton on first application. If any long-term effect is to be
Skincare and Claim Support, achieved, it needs to be perceived. This is where
Oriflame Research and Development Ltd,
Bray Business Park, Kilruddery, Bray,
emulsions come into their own, with many
Co.Wicklow, Ireland aesthetic possibilities. The focus of Sect. 21.4 will
e-mail: [email protected] be the characteristics of emulsions and the

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 313

DOI 10.1007/978-3-642-27606-4_21, Springer-Verlag Berlin Heidelberg 2012
314 S. Barton

implications of efficacy, sensory characteristics, to improve different skin needs may not be
format, etc. on their composition and development. satisfied at the same rate. As referenced earlier,
The most important constraint of using ther- this gives rise to the need for early perception of
modynamically unstable systems in emulsion benefit so that any longer-term strategy is given a
moisturizers stability will be covered in chance to work. This is where the developer has to
Sect. 21.5. Together with other influences on the consider carefully the aesthetic characteristics
choice of ingredient regulatory compliance, that influence positive perception (see Sect. 21.4).
quality, manufacture this section will further Targeting one, some or all of these and their
emphasise that moisturizers are multi-phase prod- different levels of severity will raise different con-
ucts, whose ingredients contribute more than one siderations from a formulation development and
function. Ingredients contributing to stability can ingredient standpoint. Figure 21.1 outlines how
also contribute to aesthetics and physiologically. these two different needs can be brought together
The foregoing hopefully explains the number to help define the compositional needs of a mois-
of ingredients used in a moisturizer product. turizer under development.
Whilst some examples and variants will be refer- Further considerations of consumer need will
enced, this chapter will not be a formulary. There be driven by demographics motivation, age, eth-
are many such sources [49]. The composition nicity and geographical location. Motivation will
and development of moisturizers is not only a differ between those in search of therapeutic relief
technological process. Moisturizers compounded from serious pathological condition and those who
in a pharmacists dispensary for specific derma- believe their skin is losing its youthful appearance.
tological needs or manufactured on a large scale The latter beauty moisturizer users in general
for mass consumption will have different com- may have less to provide them with early evidence
mercial constraints. This will impact on choice of of benefit and thus more likely to cease use if dis-
ingredients and production methods what is satisfied (and more alternatives to try until their
deemed commercially acceptable for one appli- needs are met). By contrast, a medicinal moistur-
cation may find no place in others. izer user may tolerate poorer cosmetic properties
if the product is being applied for them or health-
care professionals underwrite the relief of the more
21.2 Consumers Skin Needs serious skin symptoms. Self-application of medic-
inal moisturizers may have driven different accept-
There are many levels of consumer need. The ability parameters [10].
subjective level that the consumer directly expe- Age and ethnicity carry with them similar
riences scaling, stiffness, tightness, irritation, considerations [11] what constitutes moistur-
reactivity, sensitivity, dullness, softness, smooth- ized skin varies with age and ethnicity. The geo-
ness and powdery appearance are amongst these. graphical and climatic factors influencing dry
At another level, functional need is the dermato- skin and its successful treatment are covered
logical abnormality referred to by Lodn elsewhere in this book.
correction of a biological or physiological process
that can be measured in some way. Such mea-
surement should preferably relate to the con- 21.3 Correcting the Dermatological
sumer perception; this may not always be possible Abnormality
(see Sect. 21.3.1).
The dry-skin cycle [3] view of skin moistur- 21.3.1 Just Add Water and Test?
ization focuses the product developer on the
potential to interrupt at any stage of this cycle and Blank described the need for a minimal level of
thus helps skin recover its inherent self-preserving water within the stratum corneum if plasticity
moisturising systems. The dry-skin cycle view was to be retained [12] and the role of low levels
emphasises increasing severity of the skin changes of humidity in decreased stratum corneum flexi-
as an important consumer need especially time bility. Although water is the principal plasticiser
 21

Correcting
a Targeting consumer b
dermatological
needs
abnormality

Surface dehydration; Simple humectants; light

Reduce dullness; soften;
enzyme action Humectants; acids emollient oils, optical
smoothen skin texture
impaired diffusers

F
Heavier emollient oils or Reduce powdery appearance;
Increased Humectants; occlusive lipids; o waxes; light exfoliants; improve flexibility; improve
water loss (TEWL) film formers;
hydrating ingredients smoothness
r

Physical or chemical
NMF replacement; more m exfoliators; richer emollients;
Loss of NMF & further Reduce flaking; improve
complex humectant blends; skin calming agents; hydrating
dehydration; further flexibility; reduce roughness;
occlusive ingredients; evaporative
loss of enzyme activity u improve skin comfort
lipids;skin identical lipids ingredients
The Composition and Development of Moisturizers

l
Incomplete barrier occlusive lipids; Skin calming ingredients;
a Reduce sensitivity; Reduce
allows irritants skin identical gentle exfoliators; rich
scaling; Reduce tightness
into skin lipids; emollient blends;
Increasing consumer needs

Increasing dermatological abnormality*

i Calming agents; lightly
Irritants trigger low
pigmented ingredients; Reduce redness, reduce
level inflammation Anti-inflammatories
gentle exfoliators; rich scaling; reduce stiffness
(Cytokine release) o
emollient blends;

n
Hyper-responsive cell Calming agents; gentle
differentiation; dysfunctional Reduce stinging, reduce
exfoliators; rich emollient
barrier & dysfunctional Differentiation modulators reactivity; reduce stiffness;
blends; protective lipids or
desquamation Reduce cracking
silicones

Fig. 21.1 Formulation strategy drivers. Formulation of moisturiser requires bringing together the functional and aesthetic needs. The dermatological abnormality can
be increasingly severe (block a). A number of ingredient options exist to help correct these dermatological abnormalities. These are discussed in Sect. 21.3. Consumer
needs may or may not be consistent with a dermatological abnormality but also can be described in terms of increasing severity (block b). Targeting these consumer
needs gives rise to a number of ingredient options. These are discussed in Sect. 21.4. There may be some commonality across these ingredients, and the composition
and development of a moisturiser involve balancing these factors along with others discussed in Sect. 21.5 (Modified after Rawlings and Matts [3])
315
316 S. Barton

of the stratum corneum, the water within a mois- 21.3.2 Skin Biology as a Guide
turizer delivers only transient effectiveness when to Developing Moisturizers
assessed by skin extensibility [13]. Indeed, water
alone may have deleterious effects on stratum Stratum corneum biology, with its hydrophilic
corneum lipid-phase structure [14]. The develop- and lipophilic domains, suggests that combina-
ment and composition of moisturizers focus on tions of such constituents offer a good approach
maintaining an optimally hydrated state within to dealing with the biological problems underly-
the stratum corneum. ing dry skin. Whilst some products use a single
Hydration can be assessed in a number of lipid or aqueous phase to deliver moisturization,
ways see [15], Chaps. 35, 36, 37 and 40. Stratum the majority comprise different combinations and
corneum electrical properties, barrier properties levels of hydrophilic ingredients (salts, amino
(TEWL) and flexibility offer indirect ways of acids, humectants, etc.) together with lipophilic
assessing skin hydration. More direct spectro- materials (oils, waxes, etc.) properties not dis-
scopic methods (e.g. Raman spectroscopy) have similar to stratum corneum chemistry.
become more practical [16, 17].These methods For simplicity, here the two physico-chemical
can be applied to normal or clinically dry skin. domains will be used to describe the types of
Alternatively, they can be used to assess the ingredients and their role.
recovery on stratum corneum compromised with
soap, SLS or tape stripping. Whether these repre-
sent the true picture of dry-skin cycle or are pre- 21.3.3 Hydrophilic Materials
dictive of efficacy in all cases of dry skin is
debatable. These ensure that the hydrophilic domain(s)
From the 1970s onward, these techniques pro- within the skin are optimally hydrated and/or that
vided an array of insights into skin hydration and some of the components responsible for this in
thus means of assessing moisturizer develop- the skin (but have been depleted for some reason)
ment. Unfortunately, in addition to the shortcom- are replaced in fact or by action.
ings of the methods themselves, at a more Many of the hydrophilic materials used for
fundamental level, a direct relationship between this purpose may have little direct sensory impact.
any given measurement of hydration and an end- Whilst water itself only adds temporary benefit,
user perception of moisturization is challeng- from a commercial standpoint, it adds to cost-
ing given the variety of expectations. The clinical effectiveness of the final formulation. Its solvent
improvement of dry skin reduced skin rough- capabilities provide the means of adding benefits
ness, improved skin flexibility, decreased scaling via other materials. The most important materi-
and reduced sensitivity as well as beauty bene- als, humectants, work by physico-chemical cova-
fits decreased dullness, a more youthful com- lent binding of water into the desiccated stratum
plexion and plumped surface micro-relief can corneum. The most important class of these mate-
be related to hydration, but for greater consumer rials is polyols and especially glycols.
effectiveness, additional measures of end-user Glycerol appears to be a special case, backed
satisfaction are required. up the fact that skin generates its own endoge-
This factor was highlighted in studies showing nous glycerol [20]. Its performance, better than
that, though water is the principle plasticizer in its humectant properties would suggest, may be
stratum corneum, plasticization also correlated due to its small molecular size in proportion to its
with product greasiness [18]. In addition, the sug- covalent binding. A comparison of several gly-
gestion that moisturization and elasticity originate cols, their in vitro water uptake and their in vivo
from different mechanisms [19] confirm the empir- water binding found that glycerol, though having
ical knowledge that a good moisturizer needs to the lowest humectancy in vitro, had better in vivo
combine water with other materials that help main- moisturizing effects than other glycols with bet-
tain the functions of hydrated stratum corneum. ter in vitro performance [21]. Similar conclusions
21 The Composition and Development of Moisturizers 317

were made by Takahashi et al. [22] comparing and PCA within the stratum corneum during
stratum corneum water-binding capacity in the keratinisation [33]. Generating NMF has been
presence of several humectants, including glyc- proposed as one of the many functions of stratum
erol, pyrrolidone carboxylic acid (PCA) and corneum [34] providing an essential role in main-
sodium lactate. taining hydration and maturation of stratum cor-
Humectancy ensures some important stratum neum. The trigger for filaggrin breakdown is
corneum properties are enhanced. Glycerol pro- water gradient found in stratum corneum; effec-
vides more rapid induction of hysteresis (creep), tive moisturization thus has a potential role in the
but not distensibility, compared to water alone natural moisturization process in the epidermis.
[23], thus enhancing mechanical flexibility. Dry-skin conditions have been found lacking in
Glycerol has barrier stabilization properties and NMF, correlated with the state of hydration, and
thus important for skin homeostasis [24]. Stratum moisturizer use can improve stratum corneum
corneum extensibility improvements were con- amino acid content [35]. Recent findings show
firmed by Rawlings et al. [25] after 7 days use of loss of function mutations in filaggrin, and this
lotions containing 5% or 10% glycerol. Their takes the idea of diversity of end-user need to a
observations also suggested that glycerol exerted new level, and NMF quality [36] may influence
its effects via insertion into the lipid lamellae, a future moisturizer formulation strategy. NMF
mechanism proposed by Batt et al. [26] to explain replacement is a common strategy prolonged
the persistence of glycerols effectiveness after application of a lotion containing PCA has been
product use stopped. more effective than a placebo [37].
The role of glycerol in controlling desquama- Urea is a common ingredient used in therapeu-
tion has been further defined in particular pro- tic moisturizers; its influence and action are dealt
viding the correct water content for the enzymes with elsewhere in this book. The choice between
responsible for breakdown of desmosomes in the this and glycerol tends to be driven by regional
superficial layers of xerotic stratum corneum [27, market expectations. Comparative performance
28]. Moisturizers containing glycerol are supe- has been studied showing superior clinical effec-
rior in this regard [29]. Glycol humectants have tiveness in atopic dermatitis patients using a mois-
other attributes associated with their humectancy turizer containing urea [38]. However, the study
and solvent characteristics enhanced percutane- used a level of glycerol far higher than usual, and a
ous penetration [30] and as a vehicle for anti- different result was obtained in soap-dried winter
microbial materials also influence its use. There xerosis [39]. Like glycerol, urea improves barrier,
are stability considerations from this as glycols the latter producing improved resistance to an SLS
can interfere with emulsion structure and rheo- challenge [40]. Unlike glycerol, its charged nature
logical behavior. Polyols also improve measures can give rise to poor formulation stability (includ-
of stratum corneum hydration and barrier e.g. ing formation of ammonia) and skin tolerance;
panthenol [31] and are common components of thus, pH and concentration are important consider-
moisturizers. ations. Levels of use vary one study showed 10%
Stratum corneum hydration is naturally main- and 3% urea similar for subjectively assessed effi-
tained via a number of processes. The term natural cacy, though 10% proved better by objective mea-
moisturizing factor (coined by Jacobi [32] and sures of barrier improvement [41]. Urea formulated
often termed NMF) describes the mixture of amino at 10% was effective in both water-in-oil (W/O)
acids, organic acids, urea and inorganic ions found and oil-in-water (O/W) emulsions [42] and with-
to make up about 10% of the dry weight of the stands the influence of other charged aqueous com-
stratum corneum. These materials have found use ponents sodium chloride [43], ammonium lactate
in skincare products for many years. or urea combinations in O/W or W/O emulsions
Special prominence was given to the NMF [44] showed similar improvements in hydration.
resulting from the breakdown of the histidine-rich Studies on short-term benefit of urea have been
protein filaggrin including sodium lactate, urea shown to be predictive of longer-term benefit [45].
318 S. Barton

Other charged NMF ingredients are the have been produced to help the formulator create
organic acids. The alpha hydroxy acids (AHA) in better, and a number of strategies exist to allow
particular showed powerful therapeutic action in successful benefits with reduced irritation [58].
several common xerotic dermatoses [46]. Like Similar management of the benefit/tolerability
urea, despite formulation and tolerability factors, paradox has been achieved for salicylic acid [59],
AHA have become useful ingredients in cosmetic a beta hydroxy acid with an exfoliating action.
skincare. Hyperacidification of stratum corneum Other common hydrophilic materials in mois-
has recently been proposed as a means of improv- turizers include osmoprotectants extracted from
ing stratum corneum integrity and cohesion [47]. plants. Aloe vera, possibly the best known, com-
Lactic acid enhances the pliability of stratum prising polysaccharides, glycoproteins and miner-
corneum [48] independently of the hydrating effect als, has benefits beyond simple moisturization
of lactate in cosmetic moisturizers. A further study [60]. Soothing components may help deliver this
clearly demonstrated the pH dependencies of AHA requirement sought as a desirable consumer end
action [49]. Both pH and concentration are critical point. There are many grades available including
in the lactic acid effect. At a fixed lactic acid con- freeze-dried powders, reconstituted concentrates
centration, the desquamative effect was highly pH and native juices. Aloe vera gel can be used alone
dependent. At a fixed pH, the turnover rate of skin or as the major component of an aqueous mois-
was concentration dependent. Though chain length turising gel designed for use in conditions such as
is important, glycolic, lactic, tartaric and glu- sunburn. Incorporation into emulsions is common,
conolactone formulated at 8% in a common base and the potential interactions with other ingredi-
[50] all improved skin barrier. The early site of ents are an important stability consideration.
action of AHA appears to be the outer layers (stra- Similarities can be found in extracts of certain
tum disjunctum) [51] emphasizing their role as seaweed species. Both plants survive long periods
exfoliants in moisturizers. of water deprivation and have adapted their own
Further specificity of the effects of AHA has ways of resisting desiccation. Like aloe vera, the
been demonstrated; the L isomer acid (rather than benefits of seaweed may go beyond simple mois-
the D isomer) of lactic or glycolic acid were the turization [61]. Water-holding properties of the
most effective, primarily on the basis of their complex polysaccharides that comprise the alg-
greater consumer tolerability [52]. The L isomers inates and carrageenans may account for their
also have a role in stimulating ceramide biosyn- moisturizing properties, but like aloe, these gels
thesis, hence improving barrier function [53]. also modify the sensory perception on the skin.
AHA are used in cosmetics at up to 8% but at Enhancing the sensory properties, stability and
higher concentrations [54] increase skin thick- rheological properties of the formulation adds to
ness, peel significant layers of stratum corneum the reasons for their use. This highlights again the
and epidermis, and improvements in the histo- multi-functional properties of moisturizing ingre-
logical signs of photoageing were noted without dients (a theme reiterated throughout this chap-
any signs of inflammation. Even citric acid, ter). Trehalose is another material that absorbs
which is relatively ineffective at low concentra- and retains water in biological systems, and this
tions, has been shown to have effects similar to too finds use in moisturizers.
other more effective AHA [55]. Oats provide another source of material with
There has been concern about the safety in the use in dry-skin conditions colloidal prepara-
use of AHA in daily skincare products. Studies tions contain starch and beta-glucans with water-
showing an increased sensitivity to UV after use binding properties as well as avenanthramides
of AHA [56] brought about a practice advising that may help skin barrier recovery properties
sun protection whilst using AHA-based products. [62, 63]. The husk of oats also finds use as an
Consumer tolerability is a key determinant exfoliating agent.
when formulating with AHA free acid, counter- These large molecules with water-binding
ion, chain length and formulation vehicle are all capability, and others such as hyaluronic acid,
important [57]. Commercially available AHA unlike glycerol are too large to insert into the
21 The Composition and Development of Moisturizers 319

stratum corneum. Their moisturizing action, apart definitive study [65] showed petrolatum to
from sensorial, probably derives from coating the gradually and temporarily improve the signs of
skin with a hydrated buffer at the skin surface. skin dryness in vivo using clinical grading. The
Smaller-molecular-size fractions of hyaluronic various grades of solid and liquid paraffins in a
acid may have greater penetration into stratum range of combinations, in W/O or O/W emul-
corneum and thus have greater effectiveness. sions, can be tailored to reflect sensory require-
Two per cent nicotinamide in a moisturizer has ments. Their limited reactivity provides good
been shown to improve atopic dry skin over an stability, and they remain common moisturizer
8-week period [64]. Nicotinamide reduced TEWL ingredients. As a commodity material, they also
whereas petrolatum did not, and whilst both treat- have the advantages of low price, though recent
ments improved measures of hydration, nicotin- cost fluctuations and concerns about the long-
amide was superior. Together with vitamin B3, it term sustainability are just two factors changing
also improved skin barrier function [16]. patterns of use. A more important factor is the
increasing sophistication of consumer needs,
driving incorporation of other materials to miti-
21.3.4 Lipophilic Materials gate the coated and greasy end-feel sensory
properties characteristic of paraffins.
Whilst glycerol may soften the skin as an undi- Lanolin as a naturally occurring keratin condi-
luted material, this is not a universal effect of tioner compensates for many of the deficiencies
hydrophilic moisturizer ingredients at normal use of petrolatum with similar effectiveness detect-
levels. Lipophilic materials by contrast will pos- able 14 days after ceasing product use. Lanolin is
sess emollient properties slip, glide and lubric- a complex material predominantly comprising
ity forming a soft layer on the skin surface. sterol esters but also sterols and acids. Its appeal
They also change the optical properties of the arises from its spreading properties, melting point
skin. As such, they address many of the consumer close to skin temperature and water absorbency.
needs required to correct dry skin (thus mois- The sterol content also has relevance because
turising). Many lipophilic materials will have of the importance of these materials in skin biol-
occlusive effects on the skin, thereby reducing ogy. Lanolin appears to penetrate and integrate
water loss, further enhancing their moisturiza- itself into the lipid structure within the stratum
tion capabilities. corneum [66], thus explaining its persistent
The chemistry of emollients can be roughly effects. Lanolin has been used alone as an emol-
broken down into different classes hydrocar- lient and also in moisturizer formulations with
bons, fatty alcohols, fatty acids, esters, ethers, ingredients of different grades of lanolin alco-
glycerides and complex mixtures. Selection of hols. By analogy, the role of human sebum has
particular materials depends on a number of similar spreading properties and complexity.
criteria all of which are driven by consumer Artificial sebum has been proposed comprising
need spreading characteristics, sensory impact, 17% fatty acid, 44.7% triglyceride, 25% wax
stability, solubilising properties and skin compat- monoester (jojoba oil) and 12.4% squalene
ibility. In turn, these performance characteristics [67]. The latter material a triterpene that is an
evolve from a number of chemical properties intermediate of the cholesterol biosynthesis path-
molecular structure (straight chain versus way is a major component of shark oil that used
branched; saturation), molecular species (alkane to be a common cosmetic ingredient; more sus-
versus alcohol versus aldehyde versus acid tainable alternatives include olive oil containing
versus amide) and molecular size. Examples 0.20.7% squalene [68].
of some commonly used emollient materials Vegetable sources of oils easily replace min-
together with their characteristics can be found in eral oil in cosmetic moisturizers with parity in
the Table 21.1 (see also Chap. 27). their efficacy and safety [69]. Commonly sources
Hydrocarbon oils and waxes have been use- are selected on the basis of their sensory proper-
ful ingredients in formulations, and Kligmans ties, but biological activity can influence choice.
Table 21.1 Emollient classes and some characteristics that influence their inclusion in moisturiser formulations
320

Spreading Viscosity at 20C

INCI name properties Polarity Cloud point HLB value (mPas) Comments
Esters
Dicaprylyl carbonate Fast Weak <20C 7 Velvety, dry skin feel, solubilizing capability
of UV filters
Isononyl isononanoate Fast Weak <25C 12 6 Light emollient with medium to velvety,
slippery skin feel; non-greasy with excellent
spreadability
Isopropyl myristate Fast Medium <2C 11.5 5 Good spreading; dry after feel; comedogenic
potential
Propylheptyl caprylate Fast Medium <20C Luxurious soft; silky; velvety. Hydrolytically
stable; supports incorporation of powdery
ingredients and UV filters
Cetearyl ethylhexanoate (and) Fast Weak <1C 8.22 10.4 Forms water repellent films, imparts gloss.
isopropyl myristate Mineral oil alternative
Isopropyl palmitate Fast Medium <15 7 Comedogenic potential
Pentaerythrityl tetracaprylate/ Medium <2C 10.59 56 High viscosity; light emollience; high resistance
caprate to rub off
Ethylhexyl palmitate Medium Low/medium <2C 8.5 12
Pentaerythrityl tetraisostearate Slow Strong <10C 7.67 Rich, imparts a soft cushiony feel to skin, water
repellent, excellent wetting agent
Myristyl myristate Wax Medium 41C 7.52 Dry emollient feel, liquefies at body tempera-
ture. Improves emulsion stability and texture.
Comedogenic potential
Cetyl palmitate Wax <54C Dry emollient, improves emulsion texture and
stability
Ethers
Dicaprylyl ether Fast Weak <5C 4 Dry skin feel, hydrolytically stable and
particularly suitable for formulations with
extreme pH values
PPG-15 stearyl ether Fast Strong <1C 7 90 (25C) Excellent spreader and lubricant with velvety
skin feel. Acts as an excellent solvent for a wide
range of actives and component of early liquid
crystal emulsions
S. Barton
 21

PPG-3 myristyl ether Slow Strong <3C 25 Good spreading, lubricating and co-solvency
benefits
Hydrocarbons
Hydrogenated polyisobutene Fast Non-polar <55C 7 1525 (40C) Soft feel, restores skin suppleness
Isohexadecane Fast Non-polar <70C 12 4.1 Light, velvety, dry skin feel, excellent cleansing
(=freezing properties; good alternative to mineral oil
point)
Paraffinum liquidum Medium/fast Non-polar 15.1 (40C)
Hydrogenated polydecene Medium Non-polar 9 1620 (40C) Light, silky, non-oily feel, ideal for dry or
damaged skin, replacement for mineral oil
Squalane Medium Weak <0C 7 Emollient with structures similar to those found
in the skin
Octyldodecanol Medium Medium <20C 61 Hydrolytically stable emollient, particularly
suitable for formulations with extreme pH
values
Glycerides
Caprylic/capric triglyceride Medium Medium <5C 30 Good fatting agent and solubiliser
PEG-6 caprylic/capric glycerides Slow Strong <68C 13.2 150 Superfatting agent and mildness additive,
The Composition and Development of Moisturizers

emollient/solubiliser
Caprylic/capric triglyceride Medium Medium <10C 30
Materials are classified by their INCI name the international standard adopted for pack labelling. The characteristics of importance are spreading properties speed of response
when spread; polarity indicative of solubilisation properties for other formulation materials; cloud point indicative of stability at low temperature; HLB indicative of stabil-
ity requirements in emulsions (see Sect. 21.3.3); viscosity contributory to spread and sensory characteristics; comments on sensory and skin compatibility factors. Words in
italics are key criteria for selection of a particular emollients (see Sect. 21.3.2.2)
321
322 S. Barton

Virgin coconut oil and virgin olive oil both branched chain/straight chain, chain length and
reduced severity of atopic dermatitis, but the for- saturation provide these materials with their
mer was superior clinically and resulted in greater often unique sensory properties. Incorporation of
reduction of S. aureus colonisation [70]. Olive oil any unsaturated lipid into moisturizers brings sta-
has shown effectiveness post-UV challenge [71]. bility and efficacy concerns, and in the case of
Lanolin/olive oil ointment showed superiority materials like echium oil, odour is a significant
over a commercial moisturizer formulation in disincentive for use. Oxidation of the unsaturated
managing dermatitis in pre-term infants [72]. components of a formulation may drive the need
The positive health messages about essential for anti-oxidants such as butylated hydroxytolu-
fatty acids (EFA) and their profile of stratum cor- ene (BHT) or those from natural sources. Plant
neum lipids have been a justification for inclu- oils comprising both EFA and significant levels of
sion of EFA-rich sources of lipids in moisturizers. natural anti-oxidants prove useful e.g. sesame
Early examples investigated include sunflower seed oil [81], sea buckthorn oil [82] and many
seed oil [73], and evening primrose oil or borage others [83] with anti-oxidant species from tocoph-
oil, following their oral use in the management of erols to anthocyanins and ellagitannins. Thermal
atopic eczema [74] topical efficacy was only and chemical stability of the anti-oxidant itself is
demonstrated in W/O emulsion [75]. The role of important, and the variation in source resulting
essential fatty acids may be more fundamental from processing [84], climate and harvesting [85],
than modification of stratum corneum properties. and storage [86] are important considerations. In
Effects on cell proliferation [76], wound healing addition to protecting the formulation from oxida-
[77] and complementary cancer care [78] whilst tion, plant anti-oxidants also protect skin lipids
outside the remit of this chapter offer potential [87] further contributing to the moisturization.
for future applications of moisturizers. The structural chemistry of the stratum cor-
Natural oils, waxes and natural butters offer neum has influenced the choice of lipophilic
greater breadth of sensorial and functional material in formulations with skin-identical lip-
benefit in moisturizers. Shea butter, the non- ids (cholesterol, free fatty acids and ceramides)
saponifiable component of the fats and oils and their contribution to moisturization [88]
derived from the nut of the shea tree (or karite correcting the dermatological abnormality (see
tree, Butyrospermum parkii) contains complex Table 21.2). Surfactants selectively reduce cho-
mixture of palmitic, stearic, oleic, linoleic and lesterol, cholesterol ester, free fatty acid and
arachidic acid. This material melts at skin tem- sphingolipids from stratum corneum inducing
perature thus absorbing well into the skin adding dry skin. Re-incorporation of these molecules via
to its sensory appeal in use. a W/O emulsion resulted in improvement of the
As with other products, sustainability of contin- dry-skin condition [89]. Their importance in
ued use is an important factor in commercialisation water uptake was demonstrated ex vivo [90] by
of many natural sources of fats and oils. As with using de-lipidised corneocytes. However, skin-
glycols another consideration when using lipophilic identical lipids in a petrolatum-rich base pro-
materials is potential for enhancing skin penetration duced no discernable benefit over placebo over a
[79]. The relationship between emollient action and 14-day period of use [91]. Contrary to this, others
stratum corneum biomechanics was recently inves- showed that an optimal ratio of skin-identical lip-
tigated [80] and dealt with elsewhere in this book. ids is required to achieve barrier recovery in
Changes in lipid conformation with treatments pen- chronically aged skin [92]. Further studies
etrating into the SC show the potential for emol- showed the extent of the ratios and species of
lients to change skin barrier properties, and this skin-identical lipid used [93]; a more complete
needs consideration when selecting ingredients. mixture initiating a more rapid barrier recovery
The benefit (and the challenge) of using these [94] but differences in experimental results
natural lipids is their complexity. The complex appear dependent on the type of stratum corneum
mixtures with different combinations of insult [95, 96].
21 The Composition and Development of Moisturizers 323

Table 21.2 Fatty acid chain length of lipophilic species found within the skina and some common moisturiser
ingredientsb

Palmitic acid Palmitoleic acid Stearic acid Oleic acid Linoleic acid
C16:0 C16:1 C18:0 C18:1 C18:2
Additional
Skin 25 22 3 3 0.5 comments
Butyrospermum 3.5 43 44 6.5 Also contains
parkii (shea butter) catechin
anti-oxidants
Theobroma cacao 26 36 33 3 Contains
(cocoa butter) theobromine,
sterols and
tocopherol
Olea europaea 13 2.5 71 11 Contains sterols,
(olive oil) tocopherols and
squalene
Brassica rapa, 4 1.5 60 20 Lowered content
canola (rapeseed) of erucic acid
oil ensures better
tolerability
Oenothera biennis 8 2 11 69
(evening primrose)
Cocos nucifera 8.5 2.5 7 1.5 Sterols and
(coconut oil) tocopherols
Gossypium 22 0.5 3 17 55 High level
herbaceum of tocopherols
(cottonseed oil) and sterols
Sesamum indicum 9 4 41 45 ~10%
(sesame oil) tocopherols
Glycine max 10 4 23 54
(soybean oil)
Helianthus annuus 5.5 4 25 64 Also contains
(sunflower oil) tocopherols and
sterols
a
Common components of stratum corneum and sebaceous lipids from various published sources
b
Handbook Vegetable Oils and Fats; Pubs Karlshamms AB; first edition 2002

There was some indication of ceramide benefit loss, initial slip and flow in use are required. Non-
in a study on the recovery of tape-stripped skin volatile types, e.g. dimethicones, also confer
improved erythema, TEWL and a decrease in good skin feel but leave a better film (without
numbers of cycling epidermal cells were shown shine) and even waterproof the skin. They confer
[97]. However, use of a synthetic ceramide a sensory property of penetrating and one study
showed clear benefits over vehicle control in suggested little in the way of interference with
another study [98]. the physico-chemical structures important for
Other occlusive materials can be introduced to maintaining hydration of the skin [99].
improve the aesthetics and barrier-enhancing prop- The choices of hydrophilic and lipophilic
erties of a formulation. Silicones are a major class composition of a moisturizer outlined above
of such materials which partition into the oil phase clearly generate a vast number of options. Whilst
and have the advantage of being inert and chemi- there are standard materials such as glycerol
cally well defined. Volatile silicones usually and mineral oil, other materials can be included
cyclomethicones are preferred where vaporative as a result of previous experience, market or
324 S. Barton

prescriber expectations and cost. Many ingredi- consumer trialling using a number of bench-
ents will also have supplementary reasons for marks. Having understood these needs, there fol-
inclusion an oil with good levels of self-protec- lows the task of designing a product to deliver the
tion due to anti-oxidant content and a humectant key consumer needs. Sensory evaluation methods
with good solvent properties for other ingredi- of candidate formulations are valuable tools in
ents. There is also the factor of impact on other this respect.
factors such as aesthetics. Sensory evaluation is a science in itself, and
the reader is referred to other sources for a full
explanation [101, 102]. The value is that quanti-
21.4 Targeting Consumer Needs: tative and qualitative comparisons can be derived
Aesthetics for the formulations aesthetics, textural proper-
ties and in-use perception. There are number of
Aesthetic factors not only drive success in the ways the product developer can use sensory eval-
beauty moisturizer arena but also contribute to uation to better target these needs. One of the
tolerability and acceptability in use for topical most common is to use trained and validated pan-
therapeutic products. The skin is a sensory organ, els to agree a subjective grading scale with an
and this plays an important role in self-perception agreed language to assess the candidate formula-
of skin quality [100]. From Sect. 21.2, it is clear tions. A benchmark is essential in this model
that unacceptable sensory perception of the skin since it allows the language and grading scale to
may be the primary dermatological abnormality be generated and form a reliable basis for mea-
to some patients. Many ingredients in moisturiz- suring product attributes. The developer can then
ers provide positive aesthetics (or counteract evaluate the elimination of negative attributes,
negative characteristics) and improve skin com- the retention or improvement of positive
fort, both during application and for minutes or attributes and even the introduction of missing
hours after first use. Aesthetic characteristics also attributes.
apply to products ease of application; rub-in The major challenge encountered with this
period; absorbance into the skin; greasiness and useful technique is that it cannot act as anything
tackiness in use and after use; skin feel (product more than a guide to an experienced formulator.
and skin); product greasiness on the skin; odour. Here, as so often when developing a moisturizer,
Whilst these factors may not get to the heart of it is rare that changing one material changes one
the dermatological abnormality, they have a attribute e.g. reducing tackiness in use could
great influence in end users assessment of suc- involve introduction of a silicone, reduction or
cessful treatment of the abnormality. In practice, change in a particular wax or oil or all of these.
it may be difficult to differentiate product and Success is driven by the experience of the formu-
substrate aesthetic. lator and their knowledge of the attributes of the
Perceptions will differ. Depending on the raw materials at their disposal, though mathemat-
dermatological abnormality, there will be dif- ical models have been used to optimize formula-
ferent levels of initial dryness, roughness and tion characteristics [103].
tightness. In addition, there will be individual Having established prototypes, the next step
variation in sensory acuity. As a result, it will would be to go to end-consumer trialling to quali-
prove difficult to satisfy all these needs on an tatively assess how well the desired aesthetics
individual basis. The art of formulating a suc- have been fulfilled and quantitatively assess
cessful moisturizer will be to ensure that the most preference.
important sensory requirements are identified It is a generalization to say that for therapeutic
and delivered. Understanding which are the most products, the balance between aesthetic factors and
important can be achieved in a number of ways therapeutic benefit weighs in favour of the thera-
from simple questionnaire analysis and focus peutic benefit. However, most commercial devel-
groups to more sophisticated pre-development opment will focus on improving the aesthetics
21 The Composition and Development of Moisturizers 325

as this has an indirect impact on perception of stratum corneum water content 10 h after product
therapeutic benefit. Creating the correct aesthetic application and prolonged 2 days after product
characteristics is central to the art of developing a use had stopped [105]. One per cent glycerol is
good moisturizer. ineffective alone but not so in combination with
an occlusive material in the formulation the
nature of the lipid influenced the beneficial effects
21.4.1 Skin Tolerability of moisturizers. The combined effect of a bilayer-
as an Aesthetic Need forming mixture of phospholipids, cholesterol,
and fatty acid and glycerol was greater than non-
The safety of topical products is given, and toler- polar petrolatum [106].
ability may be considered a special case of antici- Many other studies demonstrate this principle,
pated sensory expectations. This is true of mass but this highlights a real issue with moisturizer
market and dermatological products alike, but the development studies on individual ingredients
target skin need(s) may have an influence on the can act as a guide to their inclusion, but ultimately
criteria for any given product. At one extreme, most commercial moisturizers are multi-component
moisturizers designed for the broken and com- systems where almost every ingredient may con-
promised eczema skin will demand far greater tribute to at least one of the target end points.
skin tolerability than an everyday moisturizer Nowhere else is this more true than when creating
pharmaceutical regulations are designed to ensure sensorial properties of the moisturizer. Blending
this by way of the permitted ingredients. waxes, oils, humectants and water into emulsions
Replenishment of the lost lipids and NMF will be offers such a wide range aesthetic possibilities the
a key requirement for products designed for dam- cosmetic benefits. Creation of an emulsion adds
aged or sensitive skin [104]. In some dermatoses, another variable the emulsifiers which, as
microbial control is important to reduce risk of described later, do more than simply bring the
infection through skin with incomplete barrier hydrophilic and lipophilic domains together in a
whilst reducing risks of sensitization to anti- relatively stable form. Studying the behaviour of
microbial ingredients. the three phases lipophilic, hydrophilic and
In the cosmetic arena, there are some product emulsifier as a function of concentration and
categories where expectations may be higher than plotting this as a triangular graph (ternary dia-
the norm. One example would be moisturizers gram) is a practical way to go beyond single
targeted to needs of babies. Whilst these are regu- ingredient studies. This provides an understand-
lated as cosmetics, there may be a higher expec- ing of the systems properties in terms of
tation on level of safety testing and even higher emulsion structure, rheology, stability, sensory
expectations of ingredients that should or should properties, etc., [107].
not be included.
21.4.2.1 Emulsiers
An emulsifier will have a polar species (often
21.4.2 Hydrophilic and Lipophilic referred to as the head group) inserting itself into
Mixtures: Why Emulsions? the water domain whilst the non-polar, the other
part (or the tail group) partitions, into the oil
Delivering moisturization via an emulsion has phase (see Fig. 21.2). The electrostatic and/or
many advantages hydrophilic and lipophilic stereochemical repulsion of head and the lipophi-
materials can be mixed to provide the different licity of the tail will affect the packing and emul-
modes of action and ingredients required to sat- sion behaviour. The position of the emulsifier
isfy consumer need and dermatological abnor- across the interface will determine droplet size,
mality. Using infrared spectroscopy, the effects stability and fluidity of this boundary. In practice
of petrolatum use over 1 week could not be dem- mixing emulsifiers to create complementary
onstrated whereas an O/W emulsion improved spatial distribution at the interface utilizing the
326 S. Barton

Fig. 21.2 Emulsifiers. (a) a

Emulsifier properties.
Emulsifiers act at the Hydrophilic Lipophilic
interface between the
hydrophilic and lipophilic
domains to reduce surface Emulsifier A
tension and allow suspension
of one phase in the other.
This figure demonstrates Emulsifier B
some of the factors that
influence the behaviour of a
particular emulsifier. Emulsifier C
Hydrophilicity can be the
result of larger numbers of
hydrophilic sites and/or their
stereochemistry. Likewise, Emulsifier D
lipophilicity increases with
increasing molecular size and
shape. (b) Emulsifier
behaviour. The properties Emulsifier E
described in (a) dictate how a
particular emulsifier is
arranged in an emulsion.
Emulsifier A may be effective b
but due to the stereochemis-
try may allow droplets closer
association with the risk of
instability by flocculation or
coalescence. By using a
combination of two
emulsifiers with complemen-
tary stereochemistry, the
packing may help stabilise
the interface and thus provide
greater stability

Emulsifier A Emulsifier B+D

repulsive factors, relative solubility in oil- and instability at high pH and negative ion concentra-
water-phase components is central to stabilising tion. The skin surface has a net negative charge,
complex mixtures of oil and water (rarely do we and cationic emulsifiers may thus bind to the sub-
wish to produce an emulsion of a single oil with strate this can be beneficial in terms of condi-
pure water). tioning but can also give rise to irritancy.
Emulsifiers can be defined by their chemical The best anionic emulsifier example is soap.
nature or by their emulsification behaviour. Soaps have a charged hydrophilic group and a fatty
Chemically, there are amphoteric, anionic, cat- hydrophobic portion. Heterogeneity in the fatty-
ionic and non-ionic emulsifiers. The most com- acid carbon-chain lengths in starting materials
monly used are the anionic and non-ionic. (e.g. coconut oils) calls for careful specification of
Examples of cationic emulsifiers are lecithin and starting material to ensure predictable performance.
some quaternary amines such as stearalkonium Their alkaline pH can be problematic for stability
chloride. Cationic emulsifiers may be prone to intolerance to salts in the formulation and also for
21 The Composition and Development of Moisturizers 327

skin compatibility. Surface deposits can form leav- the development of natural alternatives to ethoxy-
ing the skin looking dull, or irritation develops lated surfactants emulsifiers based on sucrose and
from the high pH. Sodium lauryl sulphate is a glucose and even glycolipids [110]. Glycolipid-
milder and more stable anionic emulsifier choice. based surfactants have also been identified from
However, aqueous cream BP contains emulsifying surprising sources microorganisms of Candida
wax with sodium lauryl sulphate as a component, or Pseudomonas genus [111]. Lipopeptides have
and this has been implicated in low skin tolerance classical structure for an emulsifier hydrophile-
of aqueous cream [108]. However, another anionic lipophile nature [112].
emulsifier potassium cetyl phosphate has good All these sources can be combined together to
skin compatibility, and magnesium stearate is a provide a variety of emulsifiers, each with their
common emulsifier for basic W/O emulsions. own attributes and cost. See Table 21.3.
Overall emulsification behaviour is also depen- Many raw material suppliers combine anionic
dent on their preference for hydrophilic or lipo- and non-ionic emulsifiers as a blend for commer-
philic domain. A means of characterizing this was cial purposes. For many therapeutic applications,
developed for non-ionic emulsifiers HLB this provides a good starting point for formulation
(hydrophile-lipophile balance) system a scale and is often self-emulsifying waxes. Choice of
between 1 and 50 where 1 shows tendency to far emulsifier is not always that straightforward but
greater lipophilic nature and 50 shows greater depends on the consumer needs to be delivered
hydrophilicity [109]. Cosmetic emulsifiers tend to the sensory properties, the cost and the desired
be between 1 and 20, with HLB 46 being useful benefits. The reason behind this is that emulsifier
for W/O and HLB 818 for O/W emulsions. As type(s), oil loading and rheological properties of
mentioned earlier, the HLB for many emollients the emulsion arise from the emulsion droplet size,
can be estimated in simple experimental determi- oil (including emulsifier) spreading properties, as
nations to determine the HLB requirements of an well as other features. At one extreme, silicone
oil system and emulsifiers selected accordingly. emulsifiers offer very light, quick-break, cooling
The HLB values are normally published in sup- emulsions; at the other, stearate-based systems
pliers literature and are therefore often readily generally give long rub-in and heavy feel.
available. Two conclusions will be provided, one Another important and useful variation is to
for O/W, the other for W/O systems. use a combination of a low and high HLB emulsi-
The amphipathic nature of non-ionic emulsi- fier of the same carbon-chain length. This allows
fiers derives from their lipophilic long chains for better packing of the emulsifiers at the
species (e.g. fatty alcohols) with the hydrophilic interface. The same principle applies to the use of
part coming from substitutions with molecules co-emulsifiers materials with hydrophile-
such as ethylene oxide. This process of ethoxyla- lipophile balance between the continuous phase
tion can be carried out to varying degrees on the and emulsifier phase.
same starting material to give a range of different Generally, the smaller the particle size, the
hydrophilic tendencies. Other starting sources greater the stability, so mechanical energy can
are sorbitol and sorbitan esters, again these may contribute greatly to the overall emulsion stabil-
be further modified by ethoxylation or esterfica- ity and aesthetics (Sect. 21.5.5).
tion with polyethylene glycol. Other types Emulsifiers are not inert and have the potential
include polyethylene glycol esters, monoglycer- to improve or degrade the moisture-binding capa-
ides, and polyglyceride esters. Silicone-based bility of the stratum corneum. Gloor suggested
polymers have also become popular as a result of that presence of glycerol in O/W emulsions miti-
the specific sensory properties that silicones pos- gated their drying effects; however, W/O emul-
sess. Modification by ethylene glycol or propyl- sions without glycerine were suitable for atopic
ene oxide provides the amphipathic nature. dermatitis. Also in stress tests with wash solu-
Pursuit of more sustainable ingredients (and the tions, the damage to the horny layer is reduced by
availability of natural by-products) has brought glycerol-containing O/W emulsions. Whereas
328 S. Barton

Table 21.3 Identity and properties of some ingredients commonly used to create emulsions
INCI name Type Comments/properties
Glyceryl stearate Non-ionic HLB 3.8
PEG-100 stearate Non-ionic HLB 18.8; commercially available as a blend with glyceryl
stearate HLB = 11; O/W emulsions; good to build viscosity
for sensory and stability benefit
Polyglyceryl-3-oleate Non-ionic HLB 5 for W/O but also a co-emulsifier for O/W systems
Cetyl dimethicone copolyol Non-ionic W/O and co-emulsifier in O/W systems; adds spreading,
waterproofing and cooling effect
Steareth-2 Non-ionic HLB 4.9 but commonly used in combination with steareth-21
(HLB 15.3) for O/W systems; can form liquid crystals
Cetearyl alcohol Non-ionic Co-emulsifier, viscosity enhancer; also adds to the liquid
crystalline properties with steareth-2/steareth-21 systems
Polysorbate 20 Non-ionic HLB 16.7; solubiliser for lipophilic materials in aqueous gel
moisturisers
Sorbitan stearate and sucrose Non-ionic HLB 6; O/W emulsion; alternative to ethoxylates steareth-2/
cocoate steareth-21 for liquid crystalline emulsions
Acrylates/C1030 alkyl Polymeric O/W systems; benefit from electrolyte instability by rapidly
acrylate cross polymer breaking on contact with the skin leaving oil phase layer
Stearic acid Anionic Sometimes added to anhydrous formulations to enhance
dispersion of lipids; co-emulsifier and viscosity enhancer in W/O
or O/W systems; neutralisation may be required
Potassium cetyl phosphate Anionic Phosphoric acid esters of fatty acids; good pH stability;
some similarity in structure to phospholipids

the penetration-promoting effect of O/W emul- this penetration targeting the materials to where
sions without glycerol is best, only W/O emulsions they are required is also a theoretical possibility
or glycerol-containing O/W emulsions are suit- utilizing the relative polarity of the active ingre-
able for atopic dermatitis. A hydrating effect on dient, the emulsifier and emollient compared to
the stratum corneum was also found in a propyl- that of the stratum corneum [118]. Lipid content,
ene glycol ointment [113]. emollient and emulsifier, will also influence skin
In another study, a range of emulsifiers, in a tolerance.
50:50 mineral to oil water solution, was tested in The potential impact of emulsifier on stratum
normal and SLS-damaged skin [114]. This short- corneum has generated interest in emulsifier-
term test showed that some emulsifiers produced free formulations actually, this means avoid-
significant change in TEWL (but not blood flow) ance of the use of classical emulsifiers and
in normal skin, and some had TEWL-reducing reliance on polymeric emulsifiers. Examples
effects in SLS-treated skin. The role of the emul- include those based on polyacrylic acids e.g.
sifier cannot therefore be excluded in the design carbomers. These are synthetic high-molecular-
of a moisturizer, and it has been suggested that weight polymer of acrylic acid also used to
long-term use of a moisturizer could reduce the increase stability and improve suspension of
skins barrier [115]. Emulsifier type may be influ- added ingredients. They are based on polymers
ential, and partition between product and skin of acrylic acid, cross-linked with an allyl ether
lipid phases should be a consideration for select- pentaerythritol or sucrose or propylene. These
ing emulsifiers for moisturizer formulation. polymers distribute themselves along the oil/
The potential for an emulsified system to water interface with side groups of lipophilic and
interfere with the stratum corneum lipid domain hydrophilic nature inserted into their respectively
may also represent a therapeutic opportunity, e.g. preferred phase. One of the most widely used
enhancing bioavailability of therapeutic materi- applications for such emulsifiers is where quick-
als [116] or getting anti-oxidants deeper into the break properties are required. This can provide
skin is formulation dependent [117]. Controlling a number of sensory and efficacy benefits.
21 The Composition and Development of Moisturizers 329

The immediate breakdown or separation of the against no treatment controls, the benefits were
oil and water phase delivers a cooling effect; it prolonged beyond the cessation of treatment
also allows this rapid evaporation to leave a func- [122].
tional oil behind for rapid spreading and drying. It is not simply the type of emulsion that can
influence the enhancement of skin hydration.
21.4.2.2 Emulsions Other factors such as droplet size, surfactant
There are two fundamental ways of bringing organisation and species of lipid are also impor-
together lipophilic and hydrophilic materials. tant [123]. Surfactant organization (micelles, lyo-
Lipid droplets dispersed in a hydrophilic continu- tropic liquid crystals) in the emulsion may also
ous phase O/W emulsions (e.g. milk) or affect the cutaneous and percutaneous absorp-
hydrophilic droplets dispersed in a continuous tion. This further emphasises the multi-functional
lipophilic phase W/O emulsions as exempli- mature of moisturising formulations, and the fact
fied by butter, also find their application. There that constituents such as emollients and emulsi-
are other variants multiple emulsions where an fiers should be selected carefully for optimal effi-
O/W emulsion is created within an external oil ciency of the formulation.
phase (O/W in oil O/W/O) or vice versa The short-term effects of product application
(W/O/W). These and liquid crystalline-structured have been demonstrated. Loden showed that
emulsions are dealt with in Sect. 21.4.2.3. water loss from the skin could not be changed
Consumer need will influence choice of emul- after a 5-min exposure to petrolatum compared to
sion type, oil/water ratio, efficacy and sensory moisturizers with different oil loading (where the
characteristics and even appearance conven- loss of water was proportional their aqueous
tional emulsion droplet size is large enough to component), whereas after 40 min, the occlusive
interfere with the pathway of light, hence their effects of petrolatum were seen to be superior to
white appearance. When droplet size falls these moisturizers [124]. The importance of oil-
below the wavelength, not only do these micro- phase loading is emphasised by these results.
emulsions become clear, the interactions with W/O emulsions have thus been proposed as more
the substrate change. likely to deliver prolonged hydration.
Experimental studies have shown that moistur- Oil loading, emollient species and emulsifier
izer effectiveness (targeting the dermatological type affect the emulsion droplet size and viscos-
abnormality) is independent on their penetration ity and are all factors that can have an impact on
profiles into the skin [119]. According to these overall efficacy of a moisturizer [125, 126].
authors, hydrophilic and lipophilic moisturizers Gemec and Wolf [19] compared several commer-
have similar penetration profiles but different cial moisturizers containing different levels of
effects on SC water distribution in vivo. Three- lipids. Lipid-rich creams (assessed by residual
hour treatment with lipophilic moisturizer did not greasiness) conferred greater skin distensibility,
result in increased water levels in the SC, whereas whilst moisturizers with lower level of lipid gave
hydrophilic moisturizers retained water where higher measures for skin capacitance. The insu-
they are located. O/W emulsions offer a common lating influence of the lipids and short-term nature
method of enhancing moisturization using the of the study may account for this conclusion.
benefits of water phase (e.g. humectant) and oil
phase (e.g. occlusion). Blichmann et al. [120] 21.4.2.3 Advanced Emulsion Systems
showed the short-term effects whereas Serup et al. For most practical cases, simple emulsions (O/W
were able to demonstrate cumulative moisturiza- or W/O) produced by conventional methods
tion (cf untreated skin as control) after 2 days of (Sect. 21.5.5) will be sufficient to deliver the needs
product use and continued enhancement of skin of dry skin. However, there are a number of systems
hydration for at least 2 days after product use had where more complex emulsification creates products
ceased [121]. In a separate study, using D-Squame with interesting properties. These include liquid
sampling to assess scaling, the same group crystalline emulsions, multiple emulsions, micro-
showed the cumulative effects of a moisturizer emulsions, nano-emulsions and PIT emulsions.
330 S. Barton

Liquid crystal emulsions are characterized by

a
their macroscopic and microscopic appearance.
They tend to have an opalescent rather than bright
white appearance to the eye and contain birefrin-
A
gent bodies under polarizing microscopy. The
B
most commonly quoted example is generated
in emulsions formed by steareth-2/steareth-21
emulsifiers in the presence of PPG-15 stearyl
ether and cetylstearyl alcohol. In these systems,
the oil and water phases become distributed as
lamellar structures around oil droplets (see
C
Fig. 21.3a). The lamellar phases also surround
larger oil droplets and this results in the fluidity
and opalescence of such products. The resulting
sensory, stability and efficacy from such emul-
sions has created much interest, as has the homol-
b
ogy between these structured emulsions and the
organization of the specialized lipids of the inter-
corneocyte space [127]. The potential for these
emulsions to act as controlled delivery of mois-
turization or of actives in either aqueous or oil
phase continues to create interest [128].
Other multiple emulsions (see Fig. 21.3b)
are formed by adding the third phase and another
emulsifier to a two-phase system oil to an O/W
or water to a W/O. The main interest is in their
potential to deliver controlled release of moistur-
ization but also to allow incorporation of unstable
or incompatible materials within one product
e.g. vitamin C [129]. The complexity and expense Fig. 21.3 Complex emulsions. (a) Liquid crystal emul-
of these systems tend to limit their utilization in sions. These emulsions are not simple droplets of disperse
phase suspended in a continuous phase. Arrangement of
consumer products. the emulsifiers includes multiple layers around a droplet
The smaller droplet size of nano-emulsions (A), secondary oil droplets (B) and formation of sheets
offers better spreading and delivery of disperse- (C). The layering of hydrophilic phases ( ) and lipophilic
phase components. Smaller droplet size can be phases ( ) is achieved by apposition of hydrophilic and
lipophilic domains of the emulsifier trapping lipophilic
created using specialised high-pressure homoge- and hydrophilic materials within these structures. These
niser equipment. Alternative methods utilise the systems have potential for sustained release of oil- and
phase inversion temperature PIT of the emul- water-phase ingredients and also reflect organisation of
sion system, the temperature at which the drop- lipids in the inter-corneocyte space. (b) Multiple emul-
sions. An example of an oil-in-water-in-oil (O/W/O)
lets are at their smallest [130]. PIT is determined emulsion. Systems such as this also offer potential for sus-
by the nature of the oils and the emulsifier tained release but also the advantage of separating incom-
concentration (relatively high by comparison to patible actives into two compartments
conventional emulsions). W/O PIT emulsions
can have higher oil loading whilst remaining and palmitic acid similar to those found in stratum
more fluid than the conventional systems with corneum showed enhanced moisturization proper-
high oil. ties [131].
Nano-emulsions comprising charged lipids phy- There are applications for micro-emulsions
tosphingosine together with ceramide 3, cholesterol where the droplet size is so small that it does not
21 The Composition and Development of Moisturizers 331

interfere with light and whilst this tends to stem An essential part of emulsion use is deposition
from the novelty of their clarity, they do have of an emollient onto the surface of the skin. This
other benefits of good thermodynamic stability, has been shown to be influenced by the emollient
high solubilization power and ease of prepara- rather than the emulsifier/co-emulsifier [136].
tion. Again, the cost of bulk high oil loading; However, overall hydration is equally important.
high emulsifier content is a prime consider- In studies where the hydration measurements
ation. These systems find use in enhancing skin increase early (after one day) moisturizer use and
delivery [132, 133]. remained higher through the 14-day period, the
Water in silicone emulsions are another variant barrier improved and provided better protection
that could be classed as advanced, finding use in against challenge from SLS [137]. A similar con-
sophisticated cosmetic applications and sunscreens. clusion came from a study using SLS challenge
showing a moisturizer conferred both protective
and therapeutic effects [138].
21.4.3 Moisturizer: Skin Interaction The longer-term interactions between skin and
moisturizers are dependent on repeated use,
The act of rubbing a moisturizer into the skin will though their cumulative benefit has been dem-
begin to disrupt the emulsion structure. It is this onstrated [139] and whilst various ingredients
interaction that defines consumer perception and such as retinol derivatives may act at a more fun-
influences the successful targeting of the derma- damental level to re-instate the skins own mech-
tological abnormality. The dynamics and impact anisms of moisturization, this has not been proven
of this process will be dependent on rheological for many other ingredients.
factors (see below). The behavior will also depend
upon the state of the skin the level of desicca-
tion, roughness and scaling. 21.4.4 Consistency and Rheology
Water will begin to evaporate depending on Modiers
proportion in the formula, and this can be
enhanced by incorporation of ingredients such Consistency and body of a moisturizer what
as alcohols and volatile silicones that evapo- makes it a thick cream, a pourable lotion or a
rate on application. It is difficult to evaluate sprayable milk are dictated by many factors
how the various components of emulsions including (but not limited to) the type of emul-
behave in this initial phase, though studies sion system, droplet size, oil loading and the
have been conducted of the microscopic types of oils used. The response of a product to
changes seen on evaporation of emulsions on forces its rheological properties impacts on
inert models [134]. Gradual evaporation over manufacturing requirements (e.g. pumping man-
an hour on an inert substrate showed a linear ufactured bulk into pack), the delivery from pack
relationship between water loss and capaci- onto the skin and the sensory properties of a
tance [135]; however, the role of humectant moisturizer in use. In addition, the rheological
concentration in this study cannot be dis- properties can be an important indicator of
counted since materials with a high dielectric stability.
constant may be being measured directly. The The main contributor to these behaviours is
persistence of product on the skin surface the mobility of the disperse (droplet) phase
also highlights the need for care in design and through the continuous phase under forces of
interpretation of instrumental studies [119]. shear (short-term breakdown during rub-in) or
This study showed whilst water evaporated after gravity (long-term separation of phases caus-
15 min, lipids took longer to disappear from the ing instability). Controlling this mobility can
skin (between 2 and 3 h after application). be achieved by thickening the disperse phase,
However, hydration remained elevated through- stabilizing the interface between oil and water
out as assessed by conductance. phases or both [140].
332 S. Barton

Many natural high-molecular-weight polysac- act as co-emulsifiers and as demonstrated in the

charides thicken the water phase of an O/W case of emulsions comprising a significant pro-
emulsion, and their water-binding capacity may portion of liquid crystals, the rheological proper-
also contribute a film of hydration at the skin-air ties of a moisturizer are rarely dictated by one
interface. The starting materials include starches, ingredient.
celluloses, alginates and pectins. Industrial pro- Given their physical properties in controlling
cessing allows the properties of these naturally flow of oil through water (and vice versa), it is no
occurring materials to be modified for different surprise that thickeners have been investigated as
applications. In the case of xanthan gum, the alternatives to conventional emulsifiers. Carbomer
material is derived from industrial fermentation and clay-based emulsions have been used as the
with Xanthomonas campestris, providing a highly basis emulsifier-free products.
reproducible quality material.
Mineral clays are also useful water-phase
thickeners such as those based on montmoril- 21.5 Secondary Consumer Needs:
lonite clays (bentonite clays). Clays may also Hygiene Factors
have an impact on skin feel and even optical
changes to skin surface, another example of Moisturizer users should expect certain proper-
multi-functionality for moisturizing ingredients. ties without question quality, safety, legality
Other mineral sources can act as oil-phase and reliability. Developers respond to this by
thickeners metal stearates and hydroxystearates applying quality standards to aspects during
and again can modify sensory properties of a development and production. Since this is not
product. something that can be reverse engineered, it
Synthetic water-phase thickeners the car- becomes one of the factors influencing ingredient
bomers being the most common provide the selection. The approaches to this will be guided
advantage of reliability of chemical identity over by local regulations and best practice. Good man-
the natural and naturally derived thickeners. One ufacturing practices adopted by the various
early disadvantage of these materials, the use of national and regional bodies for medicines cover
benzene during the processing, has been improved many aspects of product development from train-
with alternatives using cyclohexane and/or ethyl ing of personnel, documentation control, testing
acetate as solvent. Polyacrylic acids and amides of the product through to ingredient and final
are also common aqueous thickeners in commer- product batch traceability. These guidelines also
cial moisturizers. influence how developers and manufacturers of
Carbomers, and other water-phase thickeners, cosmetics conduct their business. The following
require adequate hydration and swelling to opti- sections touch on how these indirect consumers
mize their performance. In the case of carbomers, needs impact on ingredient selection and product
this requires high shear, adequate neutralization development.
and use of sequestrants such as ethylenedi-
aminetetraacetic acid. Salt tolerance, thermal tol-
erance and rheological properties of the gels 21.5.1 Microbial and Physical Stability
formed by water-phase thickeners are consider-
ations when choosing which thickener(s) to A successful moisturiser needs to be effective
include in the formulation. over a period of use. For this, a number of charac-
Thickening of oil phases can be achieved by teristics will need to be assured at the very least
including materials that are solid at ambient tem- resistance to microbial spoilage and retention of
peratures thickeners waxes are common start- the physical stability. For the latter case, many of
ing points for this. Again, the quality of the wax the determinants of ingredients have been dealt
can also help provide skin feel and occlusion to with in earlier sections emollient choice, emul-
the product in use. Other oil-phase thickeners can sifier choice and rheological modifier.
21 The Composition and Development of Moisturizers 333

21.5.1.1 Microbial Stability light. In some cases, especially medicinal prod-

There are a number of sources of microbial con- ucts, it will also be essential to monitor the per-
tamination from raw materials (e.g. natural sistence and activity of active ingredients.
extracts) through the manufacturing process,
packaging, storage and end-user interaction.
Where water is a major component of the formu- 21.5.2 Ingredient Quality
lation controlling microbial growth requires pre-
servatives with or without ingredients that reduce When developing products for markets with dif-
water activity. The contribution of product pack- ferent regulations, this can constrain choice in
aging to microbial resistance is also important ingredient selection. Whilst these are dealt with
pumps and tubes not only reduce entry of more fully elsewhere, they are another factor the
microorganisms from atmospheric or direct skin consumer unknowingly relies upon the developer
contact, they may, depending on design and mate- to protect them. Ensuring the safety and reliability
rial type, also reduce water availability. of performance of a formulation, particularly its
Introduction of these materials into emul- stability, requires a comprehensive understanding
sions requires careful consideration. Pre- of the chemical and physico-chemical properties
dispersion or solubilisation into glycols or other of its ingredients. Working with defined material
solvents may be required, and their partitioning sources, extraction process and ingredient speci-
into the oil and water domains can change the fications reduces risks as does implementation of
overall emulsion stability as can preservation quality assurance procedures.
aids materials that reduce water activity in the Ingredients in moisturizers are not only
product or otherwise enhance resistance to selected on the basis of their effectiveness.
microbial contamination. Commercial availability is an important consid-
eration. Ingredients for a pharmaceutical product
21.5.1.2 Physical Stability may be prescribed by the appropriate pharmaco-
Whether it is breakdown of lipids in anhydrous poeia and even demand a chemically pure ingre-
ointments or separation of emulsions, physical dient. This may also be the case for some cosmetic
stability may not just spoil the appearance of the ingredients, but for the most part, there will be a
moisturizing preparation a separated product number of commercially available sources. Even
cannot be guaranteed to deliver the required needs. single ingredients, e.g. lanolin, are complex
Any separation of the emulsion can be seen with mixtures with many different grades. The detailed
the naked eye as creaming or sedimentation, but specification of two apparently identical materi-
microscopic evaluation provides early warning of als from different sources may differ, and, as with
this. Microscopy is also useful to check for insol- naturally occurring materials, whilst the minor
ubilities of materials and acts as an essential check details of variance may not require recording,
that processing has been successful. logging batch numbers in manufacture provides
Other product stability characteristics are vis- an essential record for product specification.
cosity, pH and odour each of which is sugges- From a safety assessors standpoint, the more
tive of change in the physical and chemical nature complex the material, the more complex will be
of the product with implications on the safety, the safety assessment. Future European regula-
efficacy or tolerability. Rheological assessments tion (EU Regulation redraft 2013), requiring an
are also helpful. additional toxicity end points on all raw materials
In all cases, testing conditions are designed to in cosmetic products, will emphasize the impor-
accelerate any instability that might occur in tance of ingredient quality in selection and inclu-
normal in-use conditions. Stability protocols sion into final formulation. Natural, nature-derived
therefore include exposing moisturizer formula- or modified natural materials are becoming
tions to extremes of temperature, cycling between increasingly sought after by consumers, and their
ambient and cool temperature and exposure to complexity creates a challenge for the safety
334 S. Barton

assessor as well as an impact on an already com- product. These include, but are not limited to,
plex formulation. batch size, shear rate, temperature, order of ingre-
As a final comment, once selected, the reliabil- dient addition and cooling rate. The process must
ity and consistency of supply are considerations also be within the commercial constraints cost,
in ingredient selection. The availability of many volume and unit size dictated by the product
naturally occurring materials can be subject to and the intended market. Often the grade or for-
variability seasonal; climate-dependent growth mat of the particular ingredient is chosen on the
and harvest. Many synthetic materials rely on the basis of enhancing manufacturability pelletting
availability of a common commodity (e.g. petro- of waxes, commercial availability of compounded
leum) and thus subject to market price fluctua- combinations of emulsifiers, may enhance com-
tions and scarcity of these starting materials. mercial viability of a product. In other cases, it
can be that certain conditions need to be placed
on inclusion of a particular ingredient because of
its lability (e.g. retinol; where packaging is also
21.5.3 Cost-Effectiveness an essential consideration) or that particular
ingredients can only be introduced into certain
For all consumer products, this factor affects pur- types of formulation. Finally, the physical condi-
chase and thus choice of ingredients. At the ther- tions of manufacturing may also result in certain
apeutic end of the spectrum, the cost and quality ingredients or formulation types being favoured
of ingredients may have significant commercial for a given application.
impact on the cost of the product hence its viabil- An essential step in developing a moisturizer
ity and sustainability in the market. This is one is transfer from bench formulation to factory
reason for the resurgence in emollient use in scal- scale production. Most new product development
ing dermatoses [141144]. The size of the mar- will include an interim scaling batch to ensure
ket, the frequency and intensity of use and the this transfer is successful, whilst not utilizing
acceptability and recommendation by health pro- large volumes of expensive ingredients and
fessionals may all influence commercialization. energy.
Whether the product is aimed at mass market The normal manufacturing conditions will
or niche, the overall cost of the product will not have oil-phase ingredients heated to above the
only be influenced by cost of ingredients. Market melting point of the waxes used and water intro-
size, frequency of use and area of use also influ- duced at the same temperature to avoid micro-
ence the size and frequency of batch production, crystallization of waxes. Rheological modifiers
which in turn influences the minimum order are added according to their solubility and tem-
quantities of bulk and special raw materials used perature stability. Adequate homogenization and
in the formulation all of these influence overall mixing are also essential; the whole manufactur-
cost. ing vessel construction should ensure this, and
heating/cooling is uniformly achieved. As the
emulsion cools, other ingredients can be added as
appropriate. For O/W emulsions, the mixture will
21.5.4 Manufacturability invert from a W/O to O/W, and after this has
occurred, other water-phase ingredients can be
Once a successful product has been developed, it added as can any heat labile materials provided
has to be reproducibly produced. Processing is a they are sufficiently solubilised. Choice of ingre-
hidden ingredient. During development, it is dient once again has an impact here, and com-
important to consider the conditions of manufac- pounded or multi-functional ingredients may offer
ture that may influence the quality of the final advantages.
21 The Composition and Development of Moisturizers 335

Acknowledgments I would like to thank my colleagues

Take Home Messages Adam Muggleton and Mark Hanlon in preparing the fig-
ures and tables, Alain Mavon and Aurelie Laloeuf for
Composition and development of mois- helpful comments on the text and my wife Julia for assis-
turizers is driven by two separate factors tance in preparing the document.
the dermatological abnormality and how
the sufferer of this abnormality views
successful resolution. There is some References
common ground between the techno-
logical routes to addressing these 1. Lodn M (2003) Role of topical emollients and mois-
needs. turizers in the treatment of dry skin barrier disorders.
Am J Clin Dermatol 11(4):771788
There is a diversity of needs that drives 2. Lodn M (2003) Do moisturizers work? J Cosmet
very different formulation strategies for Dermatol 2(34):141149
moisturizers designed to address the dif- 3. Rawlings AV, Matts PJ (2005) Stratum corneum mois-
ferent aspects of dry skin across the turization at the molecular level: an update in relation to
the dry skin cycle. J Invest Dermatol 124(6):10991110
spectrum from diseased skin to environ- 4. de Polo KF (1998) Chapter 8 Cosmetic emulsions. In:
mentally compromised skin and on to A short textbook of cosmetology. Verlag fur Chemische
skin that is perceived to be less beautiful Industrie, H Ziolkowsky GmbH, pp 234299
and healthy looking than it should. 5. Hunting ALL (1993) Creams, lotions and milks: a for-
mulary of cosmetic preparations, vol 2. Micelle Press,
Formulation of moisturizers is the art of Dorset, UK
balancing functional, sensorial and com- 6. h t t p : / / m e d i a . a l l u r e d . c o m / d o c u m e n t s /
mercial factors to ensure the needs of CT0801+Formulary.fcx-WEB.pdf
the target end user are met. 7. http://www.cosmeticsandtoiletries.com/formulating/category/
skincare/13041522.html?utm_source=Most+
Commercial moisturizers are multifunc- Read&utm_medium=website&utm_
tional systems where one or more end- campaign=Most+Read
user needs can be addressed through the 8. http://www.happi.com/formulary/2009/01/
same formulation via its different ingre- 9. Barton S (2002) Formulation of skin moisturizers. In:
Leyden JJ, Rawlings AV (eds) Skin moisturization,
dients, and one ingredient can contrib- vol 25, Cosmetic science and technology series.
ute a number of benefits. This makes Marcel Dekker, New York, pp 547584
placebo versus active studies very 10. Cork MJ, Britton J, Butler L, Young S, Murphy R,
challenging for many materials with Keohane SG (2003) Comparison of parent knowl-
edge, therapy utilization and severity of atopic eczema
moisturizing properties. before and after explanation and demonstration of
The role of stratum corneum as biologi- topical therapies by a specialist dermatology nurse. Br
cal sensor to external conditions and the J Dermatol 149(3):582589
known effects of some moisturizer 11. Mahado M, Hadgraft J, Lane ME (2010) Assessment
of the variation of skin barrier function with anatomic
ingredients on the systems responsible site, age, gender and ethnicity. Int J Cosmet Sci
for this demand care in formulating 323(6):397409
products for dry-skin conditions. There 12. Blank IH (1953) Further observations on factors
will be continuing focus on delivering which influence the water content of the stratum cor-
neum. J Invest Dermatol 21:259271
the benefits of moisturized skin whilst 13. Auriol F, Vaillant L, Machet L et al (1993) Effects of
supporting the skins own systems for short-time hydration on skin extensibility. Acta Derm
retaining its moisturized state. Venereol 73:344347
Research into stratum corneum biology 14. Warner RR, Boissy YL, Lilly NA, McKillop K,
Marshall JL, Stone KJ (1999) Water disrupts stratum
will continue to drive new end points and corneum lipid lamellae: damage is similar to surfac-
modes of action for moisturizers to address tants. J Invest Dermatol 113(6):960966
the dermatological abnormalities. 15. Byrne AJ (2010) Bioengineering and subjective
approaches to the clinical evaluation of dry skin. Int
J Cosmet Sci 32:410421
336 S. Barton

16. Crowther JM, Sieg A, Blenkiron P, Marcott C, Matts PJ, rat stratum corneum is controlled by the water activity
Kaczvinsky JR, Rawlings AV (2008) Measuring the of the environment. Dev Biol 115(1):8492
effects of topical moisturizers on changes in stratum 34. Kligman AM (2011) Corneobiology and corneother-
corneum thickness, water gradients and hydration apy the final chapter. Int J Cosmet Sci 33:197209
in vivo. Br J Dermatol 159(3):567577 35. Horii I, Nakayama Y, Obata M et al (1989) Stratum
17. Frster M, Bolzinger MA, Ach D, Montagnac G, corneum hydration and amino acid content in xerotic
Brianon S (2011) Ingredients tracking of cosmetic skin. Br J Dermatol 121:587592
formulations in the skin: a confocal Raman micros- 36. Kezic S, Kemperman PM, Koster ES et al (2008) Loss-
copy investigation. Pharm Res 28(4):858872 of-function mutations in the filaggrin gene lead to
18. Jemec GB, Wulf HC (1999) Correlation between the reduced level of natural moisturizing factor in the stra-
greasiness and the plasticizing effect of moisturizers. tum corneum. J Invest Dermatol 128(8):21172119
Acta Derm Venereol 799(2):115117 37. Middleton JD, Roberts ME (1978) Effect of a skin
19. Wiechers JW, Barlow T (1999) Skin moisturization cream containing the sodium salt of pyrollidone car-
and elasticity originate from at least two different boxylic acid on dry and flaky skin. J Soc Cosmet
mechanisms. Int J Cosmet Sci 21:425 Chem 29(4):201205
20. Choi EH, Man MQ, Wang F et al (2005) Is endogenous 38. Loden M, Andersson AC, Andersson C, Frodin T,
glycerol a determinant of stratum corneum hydration Oman H, Lindberg M (2001) Instrumental and derma-
in humans? J Invest Dermatol 125(2):288293 tologist evaluation of the effect of glycerine and urea
21. Sagiv AE, Marcus Y (2003) The connection between on dry skin in atopic dermatitis. Skin Res Technol
in vitro water uptake and in vivo skin moisturization. 7(4):209213
Skin Res Technol 9(4):306311 39. Byrne AJ, Davis M, Laloeuf A, Rawlings AV (2009)
22. Takahashi M, Yamada M, Machida Y (1984) A new Glycerol-containing moisturizers are more effective
method to evaluate softening effects of cosmetic ingre- than urea-containing moisturizers in the relief of soap
dients on the skin. J Soc Cosmet Chem 35:171181 induced winter xerosis. Poster presentation Stratum
23. Pedersen LK, Jemec GB (1999) Plasticising effect of Corneum VI, Boston
water and glycerin on human skin in vivo. J Dermatol 40. Loden M, Andersson AC, Lindberg M (1999)
Sci 19(1):852 Improvement in skin barrier function in patients with
24. Smith W (1999) Stratum corneum barrier integrity con- atopic dermatitis after treatment with a moisturizing
trols skin homeostasis. Int J Cosmet Sci 21:99106 cream (Canoderm). Br J Dermatol 140(2):264267
25. Rawlings AV, Watkinson A, Harding CR et al (1995) 41. Serup J (1992) A double-blind comparison of two
Changes in stratum corneum lipid and desmosome creams containing urea as the active ingredient.
structure together with water barrier function during Assessment of efficacy and side-effects by non-inva-
mechanical stress. J Soc Cosmet Chem 46:151 sive techniques and a clinical scoring scheme. Acta
26. Batt M et al (1988) Changes in physical properties of Derm Venereol Suppl (Stockh) 177:3443
stratum corneum following treatment with glycerol. 42. Bettinger JG (1995) Influence of emulsions with and
J Soc Cosmet Chem 39:367381 without urea on water- binding capacity of the stratum
27. Rawlings AV, Scott IR, Harding CR et al (1994) corneum. J Soc Cosmet Chem 46:247254
Stratum corneum moisturization at the molecular 43. Kuzmina N, Hagstromer L, Entestam L (2002) Urea
level. J Invest Dermatol 103:731741 and sodium chloride in moisturisers for skin of the
28. Rawlings A, Harding C, Watkinson A et al (1995) The elderlya comparative, double-blind, randomised
effect of glycerol and humidity on desmosome degra- study. Skin Pharmacol Appl Skin Physiol 15(3):
dation in stratum corneum. Arch Dermatol Res 166174
287:457464 44. Gloor M, Fluhr J, Lehmann L, Gehring W, Thieroff-
29. Chander P et al (1996) Superiority of glycerol con- Ekerdt R (2002) Do urea/ammonium lactate combina-
taining moisturisers on desquamation and desmosome tions achieve better skin protection and hydration than
hydrolysis. J Invest Dermatol 106:919 either component alone? Skin Pharmacol Appl Skin
30. Faergemann J, Wahlstrand B, Hedner T, Johnsson J, Physiol 15(1):3543
Neubert RH, Nystrom L, Maibach H (2005) Pentane- 45. Serup J (1992) A three hour test for rapid comparion
1,5-diol as a percutaneous absorption enhancer. Arch of effects of moisturisers and active ingredients (urea).
Dermatol Res 297(6):261265 Measurement of hydration, scaling and skin surface
31. Gehring W, Gloor M (2000) Effect of topically applied lipidisation by noninvasive techniques. Acta Derm
dexpanthenol on epidermal barrier function and stra- Venereol 177(Suppl):2933
tum corneum hydration. Results of a human in vivo 46. Van Scott EJ, Yu RJ (1989) Alpha hydroxy acids: pro-
study. Arzneimittelforschung 50(7):659663 cedures for use in clinical practice. Cutis 43:222228
32. Jacobi O (1959) About the mechanism of moisture 47. Hachem JP et al (2010) Acute acidification of stratum
regulation in the horny layer of the skin. Proc Sci Sect corneum membrane domains using polyhydroxyl
Toilet Goods Assoc 31:2226 acids improves lipid processing and inhibits degrada-
33. Scott IR, Harding CR (1986) Filaggrin breakdown to tion of corneodesmosomes. J Invest Dermatol 130(2):
water binding compounds during development of the 500510
21 The Composition and Development of Moisturizers 337

48. Takahashi M, Machida Y, Tsuda Y (1985) The influ- 66. Clark S (1993) Investigations into biomechanisms of
ence of hydroxy acids on the rheological properties of the moisturising function of lanolin. J Soc Cosmet
stratum corneum. J Soc Cosmet Chem 36:177187 Chem 44:181195
49. Thueson DO, Chan EK, Oechsli LM et al (1998) The 67. Wertz PW (2009) Human synthetic sebum formula-
roles of pH and concentration in lactic acid-induced tion and stability under conditions of use and storage.
stimulation of epidermal turnover. Dermatol Surg Int J Cosmet Sci 31(1):2125
24:641645 68. Smith TJ (2000) Squalene: potential chemopreventive
50. Berardesca E, Distante F, Vignoli GP et al (1997) agent. Expert Opin Investig Drugs 9(8):18411848
Alpha hydroxyacids modulate stratum corneum bar- 69. Agero AL, Verallo-Rowell VM (2004) A randomized
rier function. Br J Dermatol 137:934938 double-blind controlled trial comparing extra virgin
51. Fartasch M, Teal J, Menon GK (1997) Mode of action coconut oil with mineral oil as a moisturizer for mild
of glycolic acid on stratum corneum: ultrastructural to moderate xerosis. Dermatitis 159(3):109116
and functional evaluation of the epidermal barrier. 70. Verallo-Rowell VM, Dillague KM, Syah-Tjundawan
Arch Dermatol Res 289:404409 BS (2008) Novel antibacterial and emollient effects of
52. Smith WP (1996) Comparative effectiveness of alpha- coconut and virgin olive oils in adult atopic dermati-
hydroxy acids on skin properties. Int J Cosmet Sci tis. Dermatitis 19(6):308315
18:7583 71. Ichihashi M, Ahmed NU, Budiyanto A, Wu A, Bito T,
53. Rawlings AV, Davies A, Carlomusto M et al (1996) Ueda M, Osawa T (2000) Preventive effect of antioxi-
Effect of lactic acid isomers on keratinocyte ceramide dant on ultraviolet-induced skin cancer in mice.
synthesis, stratum corneum lipid levels and stratum J Dermatol Sci 23(Suppl 1):S45S50
corneum barrier function. Arch Dermatol Res 72. Kiechl-Kohlendorfer U, Berger C, Inzinger R (2008)
288:383390 The effect of daily treatment with an olive oil/lanolin
54. Ditre CM, Griffin TD, Murphy GF et al (1996) Effects emollient on skin integrity in preterm infants: a random-
of alpha-hydroxy acids on photoaged skin: a pilot ized controlled trial. Pediatr Dermatol 25(2):174178
clinical, histologic, and ultrastructural study. J Am 73. Prottey C, Hastop PJ, Press M (1975) Correction of
Acad Dermatol 34:187195 the cutaneous manifestations of essential fatty acid
55. Bernstein EF, Underhill CB, Lakkakorpi J et al (1997) deficiency in man by application of sunflower seed oil
Citric acid increases viable epidermal thickness and to the skin. J Invest Dermatol 64:228234
glycosaminoglycan content of sun-damaged skin. 74. Lovell CR, Burton JL, Horrobin DF (1981) Treatment
Dermatol Surg 23:689694 of atopic eczema with evening primrose oil. Lancet
56. Kaidbey K et al (2003) Topical gycolic acid enhances 1(8214):278
photodamage by ultraviolet light. Photodermatol 75. Gehring W, Bopp R, Rippke F, Gloor M (1999) Effect
Photoimmunol Photomed 19(1):2127 of topically applied evening primrose oil on epider-
57. Kornhauser A, Coelho SG, Hearing VJ (2010) mal barrier function in atopic dermatitis as a function
Applications of hydroxyacids: classification, mecha- of vehicle. Arzneimittelforschung 49(7):635642
nisms and photoactivity. Clin Cosmet Invest Dermatol 76. Morris GM, Hopewell JW, Harold M et al (1997)
24(3):135142 Modulation of the cell kinetics of pig skin by the topi-
58. Green BA, Yu RJ, Van Scott EJ (2009) Clinical and cal application of evening primrose oil or lioxasol.
cosmeceutical uses of hydroxyl acids. Clin Dermatol Cell Prolif 30:311323
27(5):495501 77. Delair V (1997) The usefulness of topical application
59. Merinville E et al (2010) Three clinical studies show- of essential fatty acids (EFA) to prevent pressure
ing anti-aging benefits of sodium salicylate in human ulcers. Ostomy Wound Manage 43(5):4852
skin. J Cosmet Dermatol 9(3):174184 78. Haley AC, Calahan C, Gandhi M et al (2011) Skin
60. Reynolds T, Dweck AC (1999) Aloe vera leaf gel: a care management in cancer patients: an evaluation of
review update. J Ethnopharmacol 68(13):337 quality of life and tolerability. Support Care Cancer
61. Fujimura T et al (2002) Treatment of human skin with 19(4):545554
an extract of Fucus vesiculosus changes its thickness 79. Ibrahim SA, Li S (2010) Efficiency of fatty acids as
and mechanical properties. J Cosmet Sci 53(1):19 chemical penetration enhancers: mechanisms and
62. Kurtz ES (2007) Colloidal oatmeal: history, chemistry structure enhancement relationship. Pharm Res 27(1):
and clinical properties. J Drugs Dermatol 6(2):167170 115125
63. Cerio R et al (2010) Mechanism of action and clinical 80. Levi K, Kwan A, Rhines AS, Gorcea M, Moore DJ,
benefits of colloidal oatmeal for dermatologic prac- Dauskardt RH (2010) Emollient molecule effects on
tice. J Drugs Dermatol 9(9):11161120 the drying stresses in human stratum corneum. Br J
64. Soma Y, Kashima M, Imaizumi A, Takahama H, Dermatol 163(4):695703
Kawakami T, Mizoguchi M (2005) Moisturizing 81. Nasirullah LRB (2009) Storage stability of sunflower
effects of topical nicotinamide on atopic dry skin. Int oil with added natural antioxidant concentrate from
J Dermatol 44(3):197202 sesame seed oil. J Oleo Sci 58(9):453459
65. Kligman A (1978) Regression method for assessing 82. Yang B, Kallio HP (2001) Fatty acid composition of
the efficacy of moisturisers. Cosmet Toilet 93:27 lipids in sea buckthorn (Hippophae rhamnoides L.)
338 S. Barton

berries of different origins. J Agric Food Chem emollient containing ceramide 3 in experimentally
49(4):19391947 induced skin barrier dysfunction. Contact Dermatitis
83. Kahkonen MP, Hopia AI, Heinonen M (2010) Berry 46(6):331338
phenolics and their antioxidant activity. J Agric Food 98. Lintner K, Mondon P, Girard F et al (1997) The effect
Chem 49(8):40764082 of a synthetic ceramide-2 on transepidermal water
84. Kasparaviciene G, Briedis V, Ivanauskas L (2004) loss after stripping or sodium lauryl sulfate treatment:
Influence of sea buckthorn oil production technology an in vivo study. Int J Cosmet Sci 1:1525
on its antioxidant activity. [Article in Lithuanian] 99. Glombitza B, Muller-Goymann CC (2001)
Medicina (Kaunas) 40(8):753757 Investigation of interactions between silicones and
85. Andersson SC, Rumpunen K, Johansson E, Olsson stratum corneum lipids. Int J Cosmet Sci 23:2534
ME (2008) Tocopherols and tocotrienols in sea buck- 100. Arbuckle R, Atkinson MJ, Clark M et al (2008)
thorn (Hippophae rhamnoides L.) berries during rip- Patient experiences with oily skin: the qualitative
ening. J Agric Food Chem 56(15):67016706 development of content for two new patient reported
86. Kochhar SP, Henry CJ (2009) Oxidative stability and outcome questionnaires. Health Qual Life Outcomes
shelf-life evaluation of selected culinary oils. Int J 6:80
Food Sci Nutr 60(Suppl 7):289296 101. Meilgaard M, Civille GV, Carr BT (2007) Sensory
87. Lalouef A (2006) Patent WO 2006134583 (A1) evaluation techniques, 4th edn. Taylor & Francis,
cosmetic compositions containing lingonberry (vac- Boca Raton
cinium vitis idea) extracts 102. Kemp S, Hollowood T, Hort J (2009) Sensory
88. Vacata V, Gertchen OB, Ghyczy M (2001) Topical evaluation: a practical handbook. Wiley-Blackwell,
formulations conforming to the structure of the skin. Oxford, UK
Cosmet Toilet 5(116):6774 103. Balfagon AC et al (2010) Comparative study of neu-
89. Imokawa G, Akasaki S, Minematsu Y et al (1989) ral networks and lest mean square algorithm applied
Importance of intercellular lipids in water-retention to optimisation of cosmetic formulations. Int J
properties of the stratum corneum: induction and Cosmet Sci 32:376386
recovery study of surfactant dry skin. Arch Dermatol 104. Trapp M (2007) Is there room for improvement in
Res 281:4551 the emollients for adjuvant therapy? J Eur Acad
90. Friberg SE, Kayali I, Rhein LD et al (1990) The Dermatol Venereol 21(Suppl 2):1418
importance of lipids for water uptake in stratum cor- 105. Petersen EN (1991) The hydrating effect of a cream
neum (Limportance des lipides dans labsorption and white petrolatum measured by optothermal
deau par le stratum corneum). Int J Cosmet Sci infrared spectrometry in vivo. Acta Derm Venereol
12:512 71(5):373376
91. Loden M, Barany E (2000) Skin-identical lipids ver- 106. Summers RS, Summers B, Chandar P et al (1996)
sus petrolatum in the treatment of tape-stripped and The effect of lipids, with and without humectant, on
detergent-perturbed human skin. Acta Derm Venereol skin xerosis. J Soc Cosmet Chem 47:2739
80(6):412415 107. Auguste F, Levy F (2009) Emulsion science and
92. Zettersten EM, Ghadially R, Feingold KR et al (1997) technology. Wiley-VCH Verlag GmbH & Co, KGaA,
Optimal ratios of topical stratum corneum lipids Weinheim
improve barrier recovery in chronologically aged 108. Tsang M, Guy RH (2010) Effect of aqueous cream
skin. J Am Acad Dermatol 37:403408 BP on human stratum corneum in vivo. Br J Dermatol
93. Man MQ, Feingold KR, Thornfeldt CR et al (1996) 163(5):954958
Optimization of physiological lipid mixtures for bar- 109. Griffin WC (1949) Classification of surface-active
rier repair. J Invest Dermatol 106:10961101 agents by HLB. J Soc Cosmet Chem 1:311
94. de Paepe K, Roseeuw D, Rogiers V (2002) Repair of 110. Faivre V, Rosilio V (2010) Interest of glycolipids in
acetone- and sodium lauryl sulphate-damaged human drug delivery: from physicochemical properties to drug
skin barrier function using topically applied emul- targeting. Expert Opin Drug Deliv 7(9):10311048
sions containing barrier lipids. J Eur Acad Dermatol 111. Lourith N, Kanlayavattanakul M (2009) Natural sur-
Venereol 16(6):587594 factants used in cosmetics: glycolipids. Int J Cosmet
95. Yang L, Mao QM, Taljebini M et al (1995) Topical stra- Sci 31(4):255261
tum corneum lipids accelerate barrier repair after tape 112. Kanlayavattanakul M, Lourith N (2010) Lipopeptides
stripping, solvent treatment and some but not all types in cosmetics. Int J Cosmet Sci 32(1):18
of detergent treatment. Br J Dermatol 133:679685 113. Gloor M (2004) How do dermatological vehicles
96. Kucharekova M, van der Kerkhof PC, van der Valk PG influence the horny layer. Skin Pharmacol Physiol
(2003) A randomized comparison of an emollient 17(6):267273
containing skin-related lipids with a petrolatum-based 114. Barany E, Lindberg M, Loden M (2000) Unexpected
emollient as adjunct in the treatment of chronic hand skin barrier influence from nonionic emulsifiers. Int
dermatitis. Contact Dermatitis 48(6):293299 J Pharm 195(12):189195
97. Kucharekova M, Schalkwijk J, van der Kerkhof PC, 115. Held E, Sveinsdottir S, Agner T (1999) Effect of
van der Valk PG (2002) Effect of a lipid-rich long-term use of moisturizer on skin hydration,
21 The Composition and Development of Moisturizers 339

barrier function and susceptibility to irritants. Acta 131. Yilmaz E, Borchert HH (2006) Effect of lipid-con-
Derm Venereol 79:4951 taining, positively charged nanoemulsions on skin
116. Wirn K, Frithiof H, Sjqvist C, Lodn M (2009) hydration, elasticity and erythemaan in vivo study.
Enhancement of bioavailability by lowering of fat Int J Pharm 307(2):232238
content in topical formulations. Br J Dermatol 132. Boonme P (2007) Applications of microemulsions
160(3):552556 in cosmetics. J Cosmet Dermatol 6(4):223228
117. Richert S, Schrader A, Schrader K (2003) 133. Kogan A, Garti N (2006) Microemulsions as trans-
Transdermal delivery of two antioxidants from dif- dermal drug delivery vehicles. Adv Colloid Interface
ferent cosmetic formulations. Int J Cosmet Sci Sci 123126:369385
25(12):513 134. Bergamaschi MM, Santos OD, Rocha-Filho PA et al
118. Wiechers JW, Kelly CL, Blease TG, Dederen JC (2008) A simple analysis of the changes during
(2004) Formulating for efficacy. Int J Cosmet Sci evaporation of a commercial emulsion of unknown
26(4):173182 composition. J Cosmet Sci 59(1):1532
119. Caussin J, Rozema E, Gooris GS et al (2009) 135. Jemec GB, Na R, Wulf HC (2000) The inherent
Hydrophilic and lipophilic moisturizers have similar capacitance of moisturising creams: a source of false
penetration profiles but different effects on SC water positive results? Skin Pharmacol Appl Skin Physiol
distribution in vivo. Exp Dermatol 18(11):954961 13(34):182187
120. Blichmann CW, Serup J, Winther A (1989) Effects 136. Mehling A, Haake H-M, Poly W (2010) Differential
of single application of a moisturizer: evaporation of deposition of emollients from tripartite formulation
emulsion water, skin surface temperature, electrical systems. Int J Cosmet Sci 32:117125
conductance, electrical capacitance, and skin surface 137. Loden M (1997) Barrier recovery and influence of
(emulsion) lipids. Acta Derm Venereol 69:327330 irritant stimuli in skin treated with a moisturizing
121. Serup J, Winther A, Blichmann CW (1989) Effects cream. Contact Dermatitis 36(5):256260
of repeated application of a moisturizer. Acta Derm 138. Ramsing DW, Agner T (1997) Preventive and thera-
Venereol 69(5):457459 peutic effects of a moisturizer. An experimental study
122. Serup J, Winther A, Blichmann C (1980) A simple of human skin. Acta Derm Venereol 77:335337
method for the study of scale pattern and effects of a 139. Nogueira A, Sidou F, Brocard S (2010) Effect of a
moisturizerqualitative and quantitative evaluation new moisturizing lotion on immediate and cumula-
by D-squame tape compared with parameters of epi- tive skin hydration: two randomized, intra-individual,
dermal hydration. Clin Exp Dermatol 14:277282 vehicle- and comparator-controlled studies. J
123. Otto A, du Plessis J, Wiechers JW (2009) Formulation Dermatolog Treat. doi:10.3109/09546631003762647
effects of topical emulsions on transdermal and der- 140. Tadros T (2006) Principles of emulsion stabilization
mal delivery. Int J Cosmet Sci 31(1):119 with special reference to polymeric surfactants.
124. Loden M (1992) The increase in skin hydration after J Cosmet Sci 57(2):153169
application of emollients with different amounts of 141. Wirn K, Nohlgrd C, Nyberg F et al (2009)
lipids. Acta Derm Venereol 72(5):327330 Treatment with a barrier-strengthening moisturizing
125. Machado M, Bronze MR, Ribeiro H (2007) New cream delays relapse of atopic dermatitis: a prospec-
cosmetic emulsions for dry skin. J Cosmet Dermatol tive and randomized controlled clinical trial. J Eur
6(4):239242 Acad Dermatol Venereol 23(11):12671272
126. Dayan N, Sivalenka R, Chase J (2009) Skin moistur- 142. Cork MJ, Danby S (2009) Skin barrier breakdown:
ization by hydrogenated polyisobutenequantitative a renaissance in emollient therapy. Br J Nurs 18(14):
and visual evaluation. J Cosmet Sci 60(1):1524 872877
127. Friberg SE (1990) Micelles, microemulsions, liquid 143. Hjalte F, Asseburg C, Tennvall GR (2010) Cost-
crystals and the structure of the stratum corneum lip- effectiveness of a barrier-strengthening moisturizing
ids. J Soc Cosmet Chem 41:155171 cream as maintenance therapy vs. no treatment after
128. Chorillia M, Prestesb PS, Rigonb RB et al (2011) an initial steroid course in patients with atopic der-
Structural characterization and in vivo evaluation of matitis in Sweden with model applications for
retinyl palmitate in non-ionic lamellar liquid crystal- Denmark, Norway and Finland. J Eur Acad Dermatol
line system. Colloids Surf B Biointerfaces 85(2): Venereol 24(4):474480
182188 144. Simpson EL, Berry TM, Brown PA, Hanifin JM
129. Farahmand S, Tajerzadeh H, Farboud ES (2006) (2010) A pilot study of emollient therapy for the pri-
Formulation and evaluation of a vitamin C multiple mary prevention of atopic dermatitis. J Am Acad
emulsion. Pharm Dev Technol 11(2):255261 Dermatol 63:587593
130. Shinoda K, Friberg S (1986) Emulsions and solubili-
sation. Wiley, New York
 Ungual Formulations: Topical
Treatment of Nail Diseases 22
Kenneth A. Walters

22.1 Introduction have been indicative of the in vivo situation.

Overall, however, the advice of many dermatolo-
The human nail can be afflicted by several disease gists is that the strength and flexibility of brittle
states including paronychia, psoriasis and infec- nails can be improved using humectant compounds
tions due to bacteria, viruses or fungi. While rarely that will increase the water content of the nail plate
life threatening, these generate self-consciousness (see e.g. [31]). For the topical treatment of nail
and psychological stress. Approximately 50% of diseases, however, it is a prime requirement that
all problems result from fungal infections, onycho- the active ingredient, be it a humectant or an
mycoses, and the prevalence of these may be as antifungal agent, is capable of penetrating into and
high as 27% in Europe [27] and 10% in the USA diffusing though the nail plate.
[15]. Brittle nail syndrome affects approximately Experimental techniques for investigation of
20% of the population, with occurrence in females the penetration and distribution of chemicals into
being twice that of males. Brittle nails can be the and through the nail plate have demonstrated that
result of both internal and external factors, includ- it is possible to deliver drugs to the nail following
ing aging, other nail problems such as psoriasis topical application. This research has led the
and fungal infections, exposure to irritants, such as development of newer more effective topical
solvents, and excessive water exposure. Although products and regimens for treatment of onycho-
the precise pathogenesis leading to brittle nails is mycoses and other nail diseases (see examples in:
unknown, the involvement of nail coenocytes [16, 39, 44, 53, 57, 65]). In this chapter, nail
intercellular adhesion factors seems the most likely structure and chemical composition will be dis-
explanation [67]. There is certainly evidence to cussed together with an overview of the perme-
suggest that dry nails are brittle [17], but earlier ation of molecules through the nail plate, and this
work indicated that the water content of normal will be followed by a review of selected clinical
and brittle nails was similar [61]. In the latter work, studies designed to determine the efficacy of top-
however, the authors found that nail samples were ical treatment for nail diseases.
losing water between clipping and analysis and
that the moisture content determinations may not
22.2 Nail Structure

The nail plate is composed of layers of flattened

K.A. Walters, Ph.D. keratinized cells fused into a dense but some-
An-eX Analytical Services Ltd,
what elastic mass set within periungual grooves
14/16 CBTC2, Capital Business Park, Cardiff
CF3 2PX, UK (Fig. 22.1). Nail plate cells grow distally from
e-mail: [email protected] the germinative nail matrix at a rate of about

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 341

DOI 10.1007/978-3-642-27606-4_22, Springer-Verlag Berlin Heidelberg 2012
342 K.A. Walters

Fig. 22.1 Anatomical a Free margin

features of the human nail
plate. (a) Top view showing Nail plate
the area of the germinative
nail matrix. (b) Cross section
of the matrix
Eponychium

Lunula

Proximal end of
nail matrix

b
Eponychium

Dorsal nail plate

Ventral nail plate Dorsal matrix

Nail bed

Ventral matrix

23 mm per month. During keratinization, cells Table 22.1 Water content of human fingernails as a
undergo shape and other changes similar to function of relative humidity (RH). RH was controlled
using saturated salt solutions, and nail clippings were
those experienced by the epidermal cells form- positioned above the saturated solutions and exposed for
ing the stratum corneum. There are three very at least 48 h (Data from [17])
tightly knit keratinized layers, a thin outermost RH (%) Nail water content (%)
dorsal lamina, a thicker intermediate lamina and 0 6
an innermost ventral layer [54]. Keratins in hair 33 9
and nail are classified as hard trichocyte 50 13
keratins. 65 18
As a cornified epithelial structure, the chemical 75 25
composition of the nail plate has many similarities 85 37
to hair [2]. The major components are hard 100 64
(8090%) and soft (1020%) keratin proteins
with small amounts (0.11.0%) of lipid, the latter
presumably located in the intercellular spaces. In lipid content of the nail plate is between 0.1% and
addition, intermediate filament-associated pro- 1%, which is considerably different to that of the
teins and trichohyalin are also found within the stratum corneum (~10%). The principal plasti-
nail [7]. Sulphur content of the nail amounts to cizer of the nail is water, the content of which var-
about 10% and is mainly present within the cys- ies widely dependent on prevailing relative
tine disulphide bonds that contribute to nail ten- humidity (Table 22.1), but it is normally present
sile strength by linking the keratin fibres. The nail at around 18%. When the water content is less
contains significant amounts of phospholipid, than 16%, the nail plate becomes brittle, and when
mainly in the dorsal and intermediate layers, the nail is hydrated to water levels of ~25%, it
which contribute to its flexibility. Glycolic and becomes soft. Minerals are also important con-
stearic acids are also found in the nail. The total stituents of nails. Lack of selenium and magnesium
22 Ungual Formulations: Topical Treatment of Nail Diseases 343

can have a profound effect on the health of the 30

nail plate [4, 35].

10
22.3 Nail Plate Permeability

Permeability coefficient (cm h-1) x 103

Early investigations of nail plate permeability 3
indicated that the nail was significantly more per-
meable to water than was the stratum corneum [6,
60, 71]. Indeed, when the relative thicknesses 1
were taken into account, water was found to dif-
fuse through the nail plate at approximately 100-
fold faster than through the stratum corneum.
0.3
Given our current knowledge on the role of lipids
in the barrier function of the stratum corneum,
this is perhaps not surprising. However, at the
0.1
time the finding that hydrophilic materials could
pass through the nail plate with relative ease was
viewed with scepticism.

1 2 4 6 8 10
22.3.1 In Vitro Investigations Alkyl chain length

The first systematic studies on nail plate perme- Fig. 22.2 Permeation rates for the n-alkanols crossing
ability were carried out in the late 1970s [7274]. full-thickness human nail plates mounted in stainless steel
side-by-side diffusion chambers in vitro. The alkanols
These studies indicated that there were marked (methanol through decanol) were applied as dilute aque-
differences between the permeability characteris- ous solution, and samples taken from the receptor cham-
tics of the nail plate and stratum corneum. These ber over an 8-h period. Note that the y-axis is logarithmic
differences were attributed to the relative amounts (Data from [72])
of lipid and protein within the structures and pos-
sible differences in the physicochemical nature of
the respective phases. The nail plate was perme- and hoof membranes did not increase with
able to dilute aqueous solutions of a series of low increasing oil-water partition coefficient (range 7
molecular weight homologous alcohols, but per- to >51,000) or lipophilicity, indicating that these
meation decreased as a function of increasing barriers behaved like hydrophilic gel membranes
alkyl chain length up to octanol (Fig. 22.2). It rather than lipophilic partition membranes (as in
was suggested that the nail plate possessed a stratum corneum). Further studies with paraceta-
highly polar penetration route that was capable mol and phenacetin showed that maximum flux
of excluding permeants on the basis of their was a function of drug solubility in water or in
hydrophobicity. The existence of a minor lipid the swollen keratin. Mertin and Lippold were
pathway through the nail plate, which could able to predict the maximum flux of ten antimy-
become rate controlling for hydrophobic solutes, cotics through the nail plate on the basis of their
was suggested based on the significant decrease water solubilities and their penetration rates
in permeation of hydrophobic n-decanol follow- through hoof membrane. Their speculative
ing nail plate delipidization. extrapolation on permeation of amorolfine was in
In the mid-1990s, Mertin and Lippold [4042] remarkably close agreement to the value obtained
studied nail and hoof penetration in vitro. by Franz [18] using human nail plate. Bovine
Permeability coefficients through both nail plate hoof membranes were also used by Monti et al.
344 K.A. Walters

[44] to evaluate the effect of formulation on the Table 22.2 Nail permeability coefficients (Kp) and
transungual permeation of ciclopirox. Comparison molecular weights (MWt) for several model compounds.
Note that for the p-hydroxybenzoic acid esters, permea-
of an experimental water-soluble lacquer (based bility rates tend to decrease with increasing lipophilicity.
on hydroxypropyl chitosan) with the marketed Permeation studies were carried out over 517 days, and
water-insoluble lacquer (Penlac) showed that, Kp calculated from steady-state regions of cumulative
although steady-state permeation rates were sim- permeation plots (Data from [38])
ilar, lag times were considerably less for the Model permeant MWt Kp (107 cm/s)
experimental lacquer. This was tentatively attrib- Methyl 152.2 3.68 0.08
uted to a strong adhesion between hydroxypropyl p-hydroxybenzoate
Ethyl 166.2 2.43 0.48
chitosan and nail plate keratin. Further work con-
p-hydroxybenzoate
firmed the validity of using bovine hoof slices as Propyl 180.2 2.01 0.35
a model for infected human toenails [45, 46]. p-hydroxybenzoate
This group also used bovine hoof membrane to Butyl 194.2 2.38 0.32
determine penetration of piroctone olamine into p-hydroxybenzoate
keratinous matrices [11]. Although no transmem- Amyl 208.3 2.24 0.39
p-hydroxybenzoate
brane permeation was observed, following 30 h
Hexyl 222.3 1.24 0.32
exposure, approximately 11% of the drug pene- p-hydroxybenzoate
trated into the hoof. Pyridine 79.1 6.36 0.40
Measurement of the nail permeation of several Benzoic acid 122.1 12.84 0.05
model compounds, including a series of p-hydroxy- Sodium benzoate 121.1 0.91 0.14
benzoic acid esters, indicated that, in broad agree- 5-Fluorouracil 130.1 2.08 0.13
ment with earlier work, permeation decreased with Antipyrine 188.2 0.53 0.07
increasing hydrophobicity (Table 22.2). It was Aminopyrine 232.3 0.09 0.02
suggested that molecular size was the principal Lidocaine 234.3 0.39 0.14
determinant of the rate and extent of permeation Lidocaine HCl 235.3 0.031 0.003
across nail plate [38]. Very importantly, their Procaine HCl 237.3 0.11 0.02
studies also showed that, for the model permeant Isosorbide dinitrate 236.1 1.51 0.29
5-fluorouracil, normal nail plate had similar Sodium nicotinate 122.1 0.61 0.20
permeation characteristics to infected nail plate, Barbital sodium 183.2 0.14 0.02
Mexiletine HCl 179.3 0.20 0.06
suggesting that normal plates can be used to predict
Isoproterenol HCl 211.2 0.084 0.013
drug distribution in diseased plates.
Croconazole HCl 311.8 0.017 0.009
Recognizing the possibility of photodynamic
therapy for onychomycosis [32, 59], Donnelly et al.
[10] investigated the delivery of 5-aminolevulinic
acid (ALA) to the nail from a bioadhesive patch penetration enhancers that produce their effects
in vitro. After 72 h, approximately 90% of the mainly by delipidization or fluidization of inter-
applied drug had penetrated the nail, with an aver- cellular lipids. The nail plate is incapable of
age flux of 2.54 104 mg/cm2/s. This was quite a absorbing DMSO to any great degree [36], and a
remarkable rate of penetration and, given that ALA decrease in absorption of methanol and hexanol
is a small highly polar molecule, further confirma- applied with DMSO has been noted [74]. On the
tion of the hydrophilic nature of the nail barrier. other hand, an increase in nail plate content of
Hui et al. [30] developed a drilling technique econazole when applied in a formulation contain-
for assessing drug delivery to the inner nail plate ing DMSO was reported [62], and following pre-
in vitro and used it to determine the effect of dim- treatment with DMSO, an increase in the nail
ethyl sulfoxide (DMSO) on the penetration of absorption of the antifungal amorolfine was dem-
urea, salicylic acid and ketoconazole. Nail plate onstrated [18]. Hui et al. [28] determined that
composition suggests that it would be compara- DMSO was capable of enhancing the concentra-
tively insensitive to the effects of stratum corneum tion of all three permeants in the ventral region of
22 Ungual Formulations: Topical Treatment of Nail Diseases 345

the nail plate but, paradoxically, reduced the con- diffusion in nails [77]. The permeation rates of
centration of ketoconazole and salicylic acid in decanol, glycerol and butyl acetate were success-
the dorsal regions. The data for the effects of fully monitored, and it is interesting to note that
DMSO on the nail, therefore, remain ambiguous. the rates of permeation increased with increasing
In later experiments, Hui et al. determined the solvent polarity. An advantage of the OTTER
effects of the lipophilic skin penetration enhancer technique is that it provides a means of monitor-
2-n-nonyl-1,3-dioxolane on the in vitro nail ing diffusion into nails in vivo.
delivery of econazole [29] and evaluated the nail The influence of keratolytic agents (papain,
penetration of ciclopirox from three topical urea and salicylic acid) on the permeability of
formulations [30]. In the first study, lacquer for- three imidazole antimycotics (miconazole nitrate,
mulations containing econazole with and without ketoconazole and itraconazole) using healthy
the enhancer (18%) were applied twice daily for human nails in vitro has been evaluated [51]. In
14 days to human nail plates. The amounts of the absence of any keratolytics, the nail was rela-
econazole in the inner part of the nail plate were tively impermeable to these antimycotics.
11.1 mg/mg and 1.78 mg/mg nail powder (with Furthermore, permeation of these antimycotics
and without enhancer, respectively). The amounts was not improved by pretreatment with salicylic
of econazole that had permeated through the nail acid alone (20% for 10 days) or by application of
plates with the enhancer were 48 mg and without the drug in a 40% urea solution. The combined
enhancer 0.2 mg. In a separate study, radiola- effects of papain (15% for 1 day) and salicylic
belled 2-n-nonyl-1,3-dioxolane was found not to acid (20% for 10 days) were capable of enhanc-
significantly penetrate the nail, and the mecha- ing nail plate permeability.
nisms of penetration enhancement were pre- In contrast, Mohorcic et al. [43], evaluating
sumed to be at the formulation/nail interface. In the use of keratinolytic enzymes to decrease bar-
the subsequent study over 14 days, Penlac lac- rier properties, found that keratinase acted on the
quer (8% ciclopirox) was evaluated alongside the intercellular regions and caused corneocytes on
gels Loprox (0.77% ciclopirox) and an experi- the dorsal surface to separate. Permeation studies
mental formulation containing 2% ciclopirox. using bovine hoof membranes showed that the
Ciclopirox delivery into and through the nail was enzyme doubled the flux and membrane-vehicle
greater from the marketed gel than from either partition coefficient of the model penetrant, met-
the experimental gel or the nail lacquer. The formin, but had little effect on the diffusion coef-
amount of drug that penetrated into and through ficient. This suggested that the effect of the
the nail was also greater from the marketed gel. It enzyme was confined to the outer surface layers
was concluded that the delivery of ciclopirox was of the hoof membrane.
influenced by the nature of the applied formula- Brown et al. [5] investigated the nail permea-
tion. Notwithstanding the differences in the bility of caffeine, methylparaben and terbinafine
amount of ciclopirox delivered, all three formula- and determined the effect of two novel penetra-
tions delivered sufficient drug to generate in tion enhancers (thioglycolic acid and urea hydro-
nail concentrations far in excess of the minimum gen peroxide) on their permeation using human
inhibitory concentrations (MICs) for most nail nails in vitro. The penetrants were applied as
invasive dermatophytes and yeasts. saturated solutions. In the absence of penetration
In our laboratory, we have modified the nail enhancement, steady-state flux through nails was
drilling technique to allow determination of drug more dependent on penetrant molecular weight
distribution in three layers of the nail plate than lipophilicity. While thioglycolic acid increased
(dorsal, intermediate and ventral) and success- the flux of caffeine and methylparaben, urea
fully adapted the technology as a rapid in vitro hydrogen peroxide proved ineffective. Interest-
formulation-screening tool. More recently, opto- ingly, sequential application of thioglycolic acid
thermal transient emission radiometry (OTTER) followed by urea hydrogen peroxide increased
has been shown to be capable of monitoring terbinafine flux considerably, but when the
346 K.A. Walters

Table 22.3 Flux rates of terbinafine (mg/cm2/h, They are extremely surface active and form an
mean SD, n = 38) across nails pretreated with either amphipathic film at interfaces that render hydro-
thioglycolic acid (TA) or urea hydrogen peroxide (UP) or
both TA and UP sequentially. Single enhancers were philic surfaces hydrophobic and hydrophobic
applied (0.5 ml) in solution for 20 h, nails were washed surfaces hydrophilic. They possess eight cysteine
with water, and, if applicable, the second enhancer was residues that form four disulphide bridges that
applied for a further 20 h. Terbinafine was applied in satu- prevent self-assembly of the hydrophobin in the
rated solution (in 50% ethanol in phosphate-buffered
saline), and permeation monitored over about 9 days (Data absence of a hydrophilic-hydrophobic interface.
from [5]) Hydrophobins are subdivided into classes I and
Terbinafine flux II, in which the amino acid sequences diverge
Pretreatment regimen (mg/cm2/h) ER considerably. This is reflected in the biophysical
None 0.55 0.71 properties of these proteins such that assemblages
5% TA 4.73 1.01 8.6 of class I hydrophobins are highly insoluble,
17.5% UP 0.43 0.29 0.8 while those of class II hydrophobins readily dis-
5% TA then 17.5% UP 10.22 5.22 18.6 solve in a variety of solvents. These proteins have
17.5% UP then 5% TA 1.25 0.80 2.3 been evaluated as potential enhancers to increase
drug delivery to the nail plate. Vejnovic et al. [69]
evaluated several nail plate permeation enhancers
penetration enhancer application order was using caffeine as the model drug. Formulations
reversed, the enhancement effect was consider- were prepared in water and 20% (v/v) ethanol/
ably reduced (Table 22.3). These findings led to water solutions. The potential enhancers evalu-
the development and in vitro evaluation of a ated were urea, DMSO, methanol, N-acetyl-L-
potential treatment modality for onychomycosis cysteine, sodium docusate, boric acid and
consisting of a pretreatment dose of thioglycolic hydrophobins. Cadaver nails were used in modi-
acid followed by application of a formulation fied Franz-type diffusion cells. The permeability
containing urea hydrogen peroxide and the anti- coefficients of caffeine were increased by
fungal agent terbinafine [64]. It was clearly dem- N-acetyl-L-cysteine, but formulations containing
onstrated that this system (MedNail, MedPharm methanol generated the highest permeability
Ltd) was effective at delivering therapeutic levels coefficients for the model drug. The enhancers
of terbinafine to the nail. Furthermore, the were classified according to their permeation
enhancer system was also shown to enhance the enhancement. Methanol generated the greatest
efficacy of existing antifungal topical formula- increase in caffeine permeability over class II
tions. Both thioglycolic acid and urea hydrogen hydrophobins. DMSO was more effective than
peroxide most likely alter barrier function by dis- class I hydrophobins and urea. Vejnovic et al.
rupting the a-keratin disulfide links. The authors [70] went on to determine the amount of terbin-
went on to determine how the altering of the afine that permeated through the human nail
reduction/oxidation environment of nail keratin plate, from formulations containing hydropho-
using thioglycolic acid and urea hydrogen perox- bins at 0.1% (w/v), again using cadaver nails and
ide influenced the barrier properties of the nail Franz diffusion cells. Terbinafine remaining in
[34]. The investigation demonstrated that the nail the nail was extracted using 96% ethanol. The
permeability of terbinafine was greatest when hydrophobins tested increased terbinafine perme-
relatively low concentrations of the thiolate ion ation after 10 days with a maximum enhancement
were present in the applied solution and that free factor of 13-fold over the reference vehicle (10%
radical generation was fundamental in facilitat- terbinafine in a 60% v/v ethanol in water solu-
ing the redox-mediated keratin disruption of the tion). The authors concluded that hydrophobins
nail plate. could be included in the list of potential enhanc-
Hydrophobins are fungal proteins, of about ers for treatment of fungal nail infections.
100 amino acids, that function by self-assembly There is certainly little doubt that effective
at hydrophobic-hydrophilic interfaces [9, 76]. topical treatment of nail diseases will require
22 Ungual Formulations: Topical Treatment of Nail Diseases 347

Table 22.4 Enhancement ratios (ER) of terbinafine hydrochloride penetration into nails pretreated with several
enhancer candidates (sequential ER) or simultaneous application of drug and enhancer candidate (simultaneous ER)
using the TranScreen-NTM method, compared with enhancement ratios obtained for permeation across nails using a
simultaneous application in Franz diffusion cells (permeation ER) (Data from [48])
Enhancer candidate Sequential ER Simultaneous ER Permeation ER
Hydrogen peroxide 1.12 0.03 1.41 0.38 1.16 0.11
Salicylic acid 0.87 0.20 0.84 0.02 1.03 0.06
Glycolic acid 0.24 0.07 0.30 0.12 0.83 0.06
Thioglycolic acid 0.89 0.11 0.99 0.09 1.10 0.01
Urea 1.10 0.24 0.84 0.02 1.51 0.09
Thiourea 0.94 0.08 0.92 0.16 1.10 0.02
Cysteine 1.43 0.34 1.29 0.39 1.81 0.08
Sodium lauryl sulphate 2.24 0.03 1.65 0.42 1.76 0.31
Ethanol 1.11 0.04 0.64 0.14 1.00 0.16
Citric acid 1.01 0.11 0.44 0.04 0.60 0.08
Polysorbate 20 0.95 0.01 0.99 0.08 1.10 0.07
Ammonium phosphate 1.25 0.02 9.98 1.44 8.49 0.70
Ammonium carbonate 1.65 0.17 9.31 1.14 9.33 0.85
Potassium phosphate 2.74 0.34 9.98 1.02 8.32 0.64
Sodium phosphate 1.91 0.52 8.85 0.06 6.57 0.33
Sodium carbonate 1.75 0.22 6.90 1.15 4.98 0.20

some form of penetration and/or permeation were evaluated simultaneously (Table 22.4).
enhancement to facilitate drug delivery [47]. It is Surprisingly, and in contrast to Kobayashi et al.
important to note that selecting an effective [37] and Khengar et al. [33], the keratolytic
chemical enhancement system for a given drug enhancer candidates, such as salicylic acid and
and a given formulation is highly critical for the thiolytic agents, cysteine and thioglycolic
therapeutic success. An obvious problem is that acid, demonstrated no enhancement activity in
there is a large pool of potential enhancers that all of the evaluated scenarios. As the first indica-
may be useful for ungual therapy, and a high- tion that simple inorganic salts may be useful as
throughput method for screening nail permeation nail permeation enhancers, the sodium salts,
enhancers would be a useful investigational tool. sodium carbonate, phosphate and citrate pro-
Murthy et al. [48] developed a microwell plate vided significant enhancement of terbinafine
method (TranScreen-N) that involved two treat- uptake into and permeation across the nails, as
ment procedures, simultaneous exposure (drug did potassium phosphate and ammonium car-
and enhancer) and sequential exposure (enhancer bonate. Perhaps unsurprisingly, the simultaneous
followed by drug). The drug used was terbinafine exposure scenario gave the closest correlation
hydrochloride. The TranScreen-N method used between techniques, which provided validity to
nail segments, and these were incubated for 24 h the screening method that will undoubtedly
at 35oC with drug plus enhancer solutions or prove useful in future studies. The TranScreen-N
with enhancer solutions (24 h exposure) fol- model was also used to evaluate the effect of
lowed by drug solutions (2 h exposure). At the chemical etchants, phosphoric acid and lactic
end of the incubation period, the nail segments acid, on the permeation of terbinafine hydrochlo-
were washed and dissolved in sodium hydrox- ride and 5-fluorouracil into and across human
ide, and the drug content determined. Several nail [66]. Pretreatment with phosphoric acid was
chemical enhancers were evaluated and com- effective in improving drug delivery whereas
pared with diffusion studies in the Franz diffu- pretreatment with lactic acid failed to improve
sion cell in which drug and enhancer solutions drug penetration or permeation.
348 K.A. Walters

Other potential nail permeation enhancement group subsequently evaluated the possibilities of
strategies that have been evaluated include the enhancing the delivery of ciclopirox across
use of polyethylene glycols and iontophoresis. human nail plates and sustaining drug delivery
The effect of polyethylene glycols (PEGs) on the from drug reservoirs in the nail plates with con-
nail delivery of terbinafine was determined by stant voltage iontophoresis [26]. Transungual
in vitro permeation studies using passive and ciclopirox delivery from Penlac was the control.
iontophoretic (0.5 mA/cm2) techniques [49] and Iontophoresis increased the flux of ciclopirox
gel formulations containing different molecular across the nail by approximately tenfold com-
weight PEGs at 30% w/w. There was a moderate pared to passive delivery from the investigational
enhancement in the permeation using formula- formulation or from Penlac. A significant amount
tions containing low molecular weight PEGs of ciclopirox, estimated to be above the minimum
(200 and 400 MW) compared to the control for- inhibitory concentrations of the drug for der-
mulation. The effect of low molecular weight matophytic moulds, was loaded into the nail. The
PEGs was greater during iontophoresis. High data suggested that iontophoresis was able to
molecular weight PEGs (1,0003,350 MW) deliver an effective amount of ciclopirox into and
were not effective. The authors suggested that across the nails.
enhancement in drug permeation by low molecu- The work of Dutet and Delgado-Charro
lar weight PEGs was probably due to their abil- [1214] further characterized the iontophoretic
ity to increase hydration of the nail plate. The properties of nail plate transport in vivo. They
same group then incorporated polyethylene gly- demonstrated several parameters with regard to
col 400 into a composite nail lacquer comprising cation transport numbers and found nail permse-
an underlying drug-loaded hydrophilic layer and lectivity to cations at pH 7 but concluded that
overlying hydrophobic vinyl layer. The hydro- electroosmotic flow across the nail may not be
philic drug-containing layer also consists of easily predictable.
hydroxypropyl methylcellulose and PEG 400. In The importance of water to the flexibility of
vitro permeation studies using Franz diffusion the nail plate has been mentioned previously.
cells indicated that the amount of terbinafine Studies using Raman spectroscopy indicated that
hydrochloride that permeated across the human the water content of the different strata in the nail
cadaver nail in 6 days from the bilayer lacquer was variable [75]. Water diffusivity studies
containing PEG 400 was 1.42 0.53 mg/cm2, a showed that there was a non-linear steady-state
threefold enhancement over the lacquer without concentration profile for water [21], and equilib-
PEG 400. Drug loading within the nail was also rium sorption studies confirmed that the water
enhanced [58]. was strongly bound to the protein matrix [19].
Early work to determine the feasibility of tran- Gunt and Kasting [20] went on to demonstrate
sungual iontophoresis had been carried out by that the penetration of ketoconazole into human
Lis group at the University of Cincinnati. The nail was enhanced threefold when the nail plate
initial studies confirmed that hydrated nail plates samples were fully hydrated.
exhibited electrophoresis-dominant iontophoretic
transport [24]. The effects of the chemical
enhancers thioglycolic acid (TGA), glycolic acid 22.3.2 In Vivo Investigations
(GA) and urea (UR) on nail iontophoretic trans-
port of mannitol and tetraethylammonium were The pharmacokinetics of sertaconazole, an imi-
subsequently investigated [25]. Nails treated with dazole antifungal drug, following topical applica-
GA and UR did not show any transport enhance- tion was evaluated in vivo [63]. Sixteen healthy
ment. Treatment with TGA at 0.5 M enhanced adults were treated with nail patches containing
the passive and iontophoretic transport of man- sertaconazole (3.63 mg), which were placed on a
nitol, urea and tetraethylammonium. The effect thumbnail of each subject. Patches were replaced
of TGA on the nail plates was irreversible. This weekly over 6 weeks. Nail clippings, used
22 Ungual Formulations: Topical Treatment of Nail Diseases 349

Fig. 22.3 Uptake of 4.5

ciclopirox into human
fingernails in vivo. Ciclopirox 4.0
(8%) varnish was applied
daily to fingernails of nine
3.5
volunteers. Residual varnish

Ciclopirox in nall (g/g)

from previous applications
3.0
was removed prior to
application of fresh varnish
and prior to sampling. Nail 2.5
clippings were taken on days
7, 14 and 30. Data shown are 2.0
mean standard error (Data
from [8]) 1.5

1.0

0.5

0.0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Time (days)

nail patches and blood samples were analysed in the oxiconazole lotion), a compound that will
for sertaconazole. Concentrations >100 mg/g, disrupt keratin disulfide bonds, generated a statis-
exceeding the MICs for all relevant dermato- tically significant prolonged residence time of
phytes, were detected in all treated nail samples. oxiconazole in the 51100 mm nail layers. Peak
Analysis of the residual patches indicated that drug levels in the upper 050 mm layer increased
1671% of the drug had penetrated into the nail. from 790 ng/mg to 1,570 ng/ml. They concluded
No sertaconazole was detected in plasma sam- that the effect of acetylcysteine was related
ples. It was concluded that nail patches should to increased binding of oxiconazole to nail
have beneficial therapeutic effects. constituents.
Ceschin-Roques et al. [8] assessed the bio-
availability of 8% ciclopirox from a lacquer for-
mulation. Nail lacquer was applied to the 22.4 Clinical Data Supporting
fingernails of healthy volunteers, and the total Topical Therapy of Nail
amount of ciclopirox in the nail was 3.35 mg/mg Diseases
following 30 days treatment, and this was consid-
ered sufficient to kill the fungal pathogens For many years, dermatologists believed that
(Fig. 22.3). Similarly, van Hoogdalem et al. [68] topical treatment for anything other than the most
evaluated the in vivo nail penetration of oxicon- superficial infections of the nail plate was futile.
azole. Six healthy volunteers were treated with The nail plate was viewed as an impermeable
1% w/v oxiconazole lotion applied to the nail barrier only to be breached via the blood supply
twice daily for 6 weeks, and nail clippings were to the nail matrix, and prolonged oral dosing with
collected every 2 weeks over an 8-week period. powerful antifungal agents was the order of the
Maximum drug levels in the upper 050 mm lay- day. However, as our knowledge of the nail plate
ers varied between 120 and 1420 ng/mg. Total barrier has improved, our ability to rationally
nail uptake was less than 0.2% of the topical develop antifungal and other agents and delivery
dose. Co-delivery with acetylcysteine (15% w/v vehicles specifically for the topical treatment of
350 K.A. Walters

nail diseases has increased. The dermatologists Candida. Ninety patients with Candida finger-
armamentarium has been supplemented with nail nail were randomized into two treatment groups
lacquers and other formulations including those of 45. Group 1 received itraconazole pulse ther-
containing tioconazole, amorolfine, ciclopirox, apy for 2 months with amorolfine 5% solution
clobetasol-17-propionate, calcipotriol and tazar- nail lacquer application for 6 months, while
otene. However, the true test of any therapeutic group 2 received monotherapy with three pulses
regimen is efficacy. of itraconazole. Eighty-five patients, with a
The conservative approach is to supplement mean duration of onychomycosis of 11 months,
oral therapy with topical treatment. Nakano et al. were analysed. After three months of therapy,
[50] performed a pilot study to assess the safety mycological cure was seen in 32 (74%) of 43
and efficacy of pulse therapy with oral terbinafine patients in group 1 and in 25 (60%) of 42
in 66 patients with onychomycosis. Each pulse patients in group 2. Following 9 months therapy,
consisted of oral terbinafine (500 mg/day) for a global cure was seen in 40 patients (93%) in
1 week followed by a 3-week interval. Topical group 1 and in 34 patients (81%) in group 2.
1% terbinafine cream was applied daily. Efficacy Compared with oral itraconazole alone, the
was assessed 1 year after treatment initiation. combination achieved greater mycological cure
There was a complete cure in 51 patients (approx- and increased total cure rate. Although statisti-
imately 77%), marked improvement in five cal analysis showed no statistically significant
patients, improvement in five patients and slight difference (P > 0.1) between the two treatment
improvement in one patient. Four patients showed groups, the combination of topical amorolfine
no change. Although they concluded that terbin- and oral itraconazole exhibited considerable
afine pulse therapy in combination with topical synergy.
application of terbinafine cream was safe and Baran and Coquard [3] treated 13 onychomy-
effective, it was not possible to determine whether cotic patients, aged 2578 years, with a solution
the topical applications improved the outcome. of 1% fluconazole and 20% urea in an ethanol-
An earlier study [1] using a similar oral treatment water mixture, applied once daily. There was
regimen but with no supplemental topical therapy complete resolution of the condition in four
reported 74% cure rate, suggesting that topical cases, and four patients demonstrated a 90%
application was of little additive benefit. However, improvement. Of four patients with onychomy-
it is important to appreciate that the application coses in both big toenails, two showed 50%
vehicle is a very important determinant for suc- improvement bilaterally, and in the remaining
cessful delivery of drug to the nail and that the two patients, there was a 90% improvement in
cream used in the Nakano study was probably not one nail and a 50% improvement in the other.
optimized in this respect. Furthermore, the highly Overall the response to local therapy was
lipophilic nature of terbinafine suggests that it appreciable.
would not penetrate into the nail to any great Gupta et al. [22] reviewed the efficacy and
extent. safety of 8% ciclopirox nail lacquer in the treat-
A better indication of the usefulness of sup- ment of onychomycosis. In one study, 223
plemental topical therapy can be obtained from patients were randomized to treatment, and in
the work of Rigopoulos et al. [52] who evalu- another, 237 subjects were randomized. Both
ated the combination of systemic and topical studies were conducted in the USA. The active
antifungals to improve the cure rates and reduce and placebo formulations were applied daily for
the duration of systemic treatment for onycho- 48 weeks, and mycologic evaluation was per-
mycoses. They used itraconazole pulse therapy formed every 12 weeks. Data from these pivotal
combined with amorolfine and compared this trials demonstrated that ciclopirox nail lacquer
with itraconazole alone in the treatment of nail was significantly more effective than placebo in
22 Ungual Formulations: Topical Treatment of Nail Diseases 351

the treatment of onychomycosis. At the end 31 patients with fingernail psoriasis were ran-
of the treatment period, the mycologic cure rate domized to receive tazarotene or vehicle gel,
in the first study was 29% and 11% in the which was applied daily for up to 24 weeks to
ciclopirox and vehicle groups, respectively, and two target fingernails, one under occlusion and
in the second study, the cure rate was 36% and one unoccluded [56]. Tazarotene treatment
9%, respectively. In non-US studies, mycologic resulted in a significantly greater reduction in
cure rates ranged from 47% to 86%, and the lac- onycholysis (loosening of the nail plate-nail bed
quer demonstrated a broad spectrum of activity connection) in both occluded and non-occluded
showing efficacy against Candida species and nails together with a significantly greater reduc-
some non-dermatophytes. The authors con- tion in pitting in occluded nails. The gel was well
cluded that the nail lacquer provided a treatment tolerated. Nail psoriasis was also improved fol-
choice with a favourable benefit-to-risk ratio. In lowing topical application of calcipotriol and
subsequent studies, topical ciclopirox efficacy betamethasone dipropionate ointment applied
has been confirmed, and more recently, the effi- once daily for 12 weeks [53].
cacy of the lacquer in a case of infantile con- As noted earlier, brittle nail syndrome is a
genital candidal onychomycosis was reported to common problem and refers to nails that exhibit
be excellent [78]. surface roughness, raggedness and peeling.
Malay et al. [39] randomly allocated 55 Sherber et al. [57] evaluated the usefulness of
patients to either nail debridement (27 patients) tazarotene cream (0.1%) for the treatment of brit-
or debridement plus application of a topical tle nails. Patients applied tazarotene cream to the
antifungal nail lacquer containing 8% ciclopirox nails twice daily for 24 weeks. All participants
(28 patients). After a median follow-up of achieved improvement of the target nails at week
10.5 months, patients in the antifungal nail lac- 12, and 16 participants (88.9%) at week 24. The
quer group showed statistically significantly study showed that tazarotene was effective at
improvement over those in the debridement-alone reducing the symptoms of brittle nail syndrome
group, with an ~77% rate of mycological cure. with minimal to no irritation.
None of the patients in the debridement-alone
group experienced mycological cure.
As previously pointed out, not all nail diseases 22.5 Concluding Remarks
are fungal or bacterial infections. Psoriasis can
affect the entire nail plate and is a common fea- The permeability characteristics of the human
ture in psoriasis patients. A lacquer formulation nail plate are reasonably well understood, and
containing 8% clobetasol-17-propionate was topical formulations can be designed to optimize
evaluated for the efficacy and safety [55]. Ten drug delivery into the nail. Successful methods of
patients, with both nail bed and matrix psoriasis, penetration and permeation enhancement are
were treated with the nail lacquer applied once available. For the most part, topical preparations
daily for 21 days and subsequently twice weekly are well tolerated upon prolonged use. Upon clin-
for 9 months. There was a reduction of all the nail ical examination, the topical formulations have
alterations, including nail pain, within 4 weeks of been found to be reasonably effective as either
initiating therapy, and response was directly mono- or dual therapies and have been shown to
related to the length of treatment. The lacquer be synergistic with oral therapy. Treatment with
was a safe and effective treatment for nail bed topical agents has been described as cost-effective
and matrix psoriasis. [23]. Further investigation into means to enhance
Tazarotene gel has also been evaluated as a penetration into and permeation across the nail
therapy for nail psoriasis. In a double-blind, ran- plate will inevitably lead to more effective topical
domized, vehicle-controlled, parallel-group trial, preparations.
352 K.A. Walters

4. Bauer F, Stevens B (1983) Investigations of trace

Take Home Messages metal content of normal and diseased nails. Australas
J Dermatol 24:127129
Nail structure and morphology: The 5. Brown MB, Khengar RH, Turner RB, Forbes B,
anatomical and chemical differences Traynor MJ, Evans CRG, Jones SA (2009) Overcoming
between stratum corneum and nail plate the nail barrier: a systematic investigation of ungula
are discussed. The properties that make chemical penetration enhancement. Int J Pharm
370:6167
the permeability characteristics of the 6. Burch GE, Winsor T (1946) Diffusion of water
two structures so different are detailed through dead plantar, palmar and torsal human skin
with an illustration of the importance of and through toe nails. Arch Derm Syphilol 53:3941
water in the nail plate. 7. Cashman MW, Sloan SB (2010) Nutrition and nail
disease. Clin Dermatol 28:420425
Nail plate permeability in vitro evidence: 8. Ceschin-Roques CG, Hanel H, Pruja-Bougaret SM,
Given that there is so little lipid in the Luc J, Vandermander J, Michel G (1991) Ciclopirox
nail plate, is there any chance that thera- nail lacquer 8%: in vivo penetration into and through
peutic molecules can get into and across nails and in vitro effect on pig skin. Skin Pharmacol
4:8994
this tissue? The answer is yes, and this 9. de Vocht ML, Reviakine I, Wsten HAB, Brisson A,
has been shown by in vitro techniques. Wessels JGH, Robillard GT (2000) Structural and
The potential usefulness of penetration functional role of the disulfide bridges in the hydro-
and permeation enhancement strategies phobin SC3. J Biol Chem 275:2842828432
10. Donnelly RF, McCarron PA, Lightowler JM, Woolfson
is also discussed in this section. AD (2005) Bioadhesive patch-based delivery of 5-ami-
Nail plate permeability in vivo evidence: nolevulinic acid to the nail for photodynamic therapy
If compounds have been shown to get of onychomycosis. J Control Release 103:381392
into and through the nail in vitro, will 11. Dubini F, Bellotti MG, Frangi A, Monti D, Saccomani
L (2005) In vitro antimycotic activity and nail perme-
they do the same in vivo? Again the ation models of a piroctone olamine (octopirox) con-
answer is yes. taining transungual water soluble technology.
Clinical data supporting topical therapy Arzneimittelforschung 55:478483
of nail diseases: The fact that therapeu- 12. Dutet J, Delgado-Charro MB (2009) In vivo transun-
gual iontophoresis: effect of DC current application
tic molecules can penetrate into and per- on ionic transport and on transonychial water loss.
meate across nails in vivo does not J Control Release 140:117125
necessarily indicate that they will have 13. Dutet J, Delgado-Charro MB (2010) Transungual ion-
therapeutic effect. Clinical studies are tophoresis of lithium and sodium: effect of pH and
co-ion competition on cationic transport numbers.
discussed that illustrate that the topical J Control Release 144:168174
treatment of nail diseases is partially 14. Dutet J, Delgado-Charro MB (2010) Electroosmotic
successful, but there remains much room transport of mannitol across human nail during con-
for improvement. stant current iontophoresis. J Pharm Pharmacol 62:
721729
15. Elewski E (1998) Onychomycosis: pathogenesis,
diagnosis, and management. Clin Microbiol Rev
11:415429
16. Elkeeb R, AliKhan A, Elkeeb L, Hui X, Maibach HI
References (2010) Transungual drug delivery: current status. Int J
Pharm 384:18
1. Alpsov E, Yilmaz E, Basaran E (1996) Intermittent 17. Farran L, Ennos AR, Eichhorn J (2008) The effect of
therapy with terbinafine for dermatophyte toe- humidity on the fracture properties of human finger-
onychomycosis: a new approach. J Dermatol 23: nails. J Exp Biol 211:36773681
259262 18. Franz TJ (1992) Absorption of amorolfine through
2. Baden HP, Goldsmith LA, Fleming B (1973) A com- human nail. Dermatology 184(Suppl 1):1820
parative study of the physicochemical properties of 19. Gunt HB, Kasting GB (2007) Equilibrium water sorp-
human keratinized tissues. Biochim Biophys Acta tion characteristics of the human nail. J Cosmet Sci
322:269278 58:19
3. Baran R, Coquard F (2005) Combination of flucon- 20. Gunt HB, Kasting GB (2007) Effect of hydration on
azole and urea in a nail lacquer for treating onycho- the permeation of ketoconazole through human nail
mycosis. J Dermatolog Treat 16:5255 plate in vitro. Eur J Pharm Sci 32:254260
22 Ungual Formulations: Topical Treatment of Nail Diseases 353

21. Gunt HB, Miller MA, Kasting GB (2007) Water diffu- 38. Kobayashi Y, Komatsu T, Sumi M, Numajiri S,
sivity in human nail plate. J Pharm Sci 96:33523362 Miyamoto M, Kobayashi D, Sugibayashi K, Morimoto
22. Gupta AK, Fleckman P, Baran R (2000) Ciclopirox Y (2004) In vitro permeation of several drugs through
nail lacquer topical solution 8% in the treatment of the human nail plate: relationship between physico-
toenail onychomycosis. J Am Acad Dermatol 43(4 chemical properties and nail permeability of drugs.
Suppl):S70S80 Eur J Pharm Sci 21:471477
23. Gupta AK, Lynde CW, Barber K (2006) 39. Malay DS, Yi SY, Borowsky P, Downey MS,
Pharmacoeconomic assessment of ciclopirox topical Mlodzienski AJ (2009) Efficacy of debridement alone
solution, 8%, oral terbinafine, and oral itraconazole versus debridement combined with topical antifungal
for onychomycosis. J Cutan Med Surg 10(Suppl 2): nail lacquer for the treatment of pedal onychomyco-
S54S62 sis: a randomized, controlled trial. J Foot Ankle Surg
24. Hao J, Li SK (2008) Transungual iontophoretic trans- 48:294307
port of polar neutral and positively charged model 40. Mertin D, Lippold BC (1997) In vitro permeability of
permeants: effects of electrophoresis and electroos- the human nail and of a keratin membrane from
mosis. J Pharm Sci 97:893905 bovine hooves: influence of the partition coefficient
25. Hao J, Smith KA, Li SK (2008) Chemical method to octanol/water and the water solubility of drugs on
enhance transungual transport and iontophoresis effi- their permeability and maximum flux. J Pharm
ciency. Int J Pharm 357:6169 Pharmacol 49:3034
26. Hao J, Smith KA, Li SK (2009) Iontophoretically 41. Mertin D, Lippold BC (1997) In vitro permeability of
enhanced ciclopirox delivery into and across human the human nail and of a keratin membrane from
nail plate. J Pharm Sci 98:36083616 bovine hooves: penetration of chloramphenicol from
27. Hay R (2005) Literature review. Onychomycosis. lipophilic vehicles and a nail lacquer. J Pharm
J Eur Acad Dermatol Venereol 19(Suppl 1):17 Pharmacol 49:241245
28. Hui X, Shainhouse Z, Tanojo H, Anigbogu A, Markus 42. Mertin D, Lippold BC (1997) In vitro permeability of
GE, Maibach HI, Wester RC (2002) Enhanced human the human nail and of a keratin membrane from
nail drug delivery: nail inner drug content assayed by bovine hooves: prediction of the penetration rate of
new unique method. J Pharm Sci 91:189195 antimycotics through the nail plate and their efficacy.
29. Hui X, Chan TCK, Barbadillo S, Lee C, Maibach HI, J Pharm Pharmacol 49:866872
Wester RC (2003) Enhanced econazole penetration 43. Mohorcic M, Torkar A, Friedrich J, Kristl J, Murdan
into human nail by 2-N-nonyl-1,3-dioxolane. J Pharm S (2007) An investigation into keratolytic enzymes to
Sci 92:142148 enhance ungual drug delivery. Int J Pharm
30. Hui X, Wester RC, Barbadillo S, Lee C, Patel B, 332:196201
Wortzmman M, Gans EH, Maibach HI (2004) 44. Monti D, Saccomani L, Chetoni P, Burgalassi S,
Ciclopirox delivery into the human nail plate. J Pharm Saetttone MF, Mailland F (2005) In vitro transungual
Sci 93:25452548 permeation of ciclopirox from a hydroxypropyl chito-
31. Hui X, Hornby SB, Wester RC, Barbadillo S, Appa Y, san-based, water-soluble nail lacquer. Drug Dev Ind
Maibach H (2007) In vitro human nail penetration and Pharm 31:1117
kinetics of panthenol. Int J Cosmet Sci 29:277282 45. Monti D, Saccomani L, Chetoni P, Burgalassi S,
32. Kamp H, Tietz H-J, Lutz M, Piazena H, Sowyrda P, Senesi S, Ghelardi E, Mailland F (2010) Hydrosoluble
Lademann J, Blume-Peytavi U (2005) Antifungal medicated nail lacquers: in vitro drug permeation and
effect of 5-aminolevulinic acid PDT in Trichophyton corresponding antimycotic activity. Br J Dermatol
rubrum. Mycoses 48:101107 162:311317
33. Khengar RH, Jones SA, Turner RB, Forbes B, Brown 46. Monti D, Saccomani L, Chetoni P, Burgalassi S,
MB (2007) Nail swelling as a pre-formulation screen Tampucci S, Mailland F (2011) Validation of bovine
for the selection and optimisation of ungual penetra- hoof slices as model for infected human toenails:
tion enhancers. Pharm Res 24:22072212 in vitro ciclopirox transungual permeation. Br J
34. Khengar RH, Brown MB, Turner RB, Traynor MJ, Holt Dermatol. doi:10.1111/j.1365-2133.2011. 10303.x.
KB, Jones SA (2010) Free radical facilitated damage of [Epub ahead of print]
ungual keratin. Free Radic Biol Med 49:865871 47. Murdan S (2008) Enhancing the nail plate permeabil-
35. Kien CL, Ganther HE (1983) Manifestations of ity of topically applied drugs. Expert Opin Drug Deliv
chronic selenium deficiency in a child receiving total 5:116
parenteral nutrition. Am J Clin Nutr 37:319328 48. Murthy SN, Vaka SRK, Sammeta SM, Nair AB (2009)
36. Kligman AM (1965) Topical pharmacology and toxi- TransScreen-NTM: method for rapid screening of
cology of dimethylsulfoxide. J Am Med Assoc 193: trans-ungual drug delivery enhancers. J Pharm Sci
796804 98:42644271
37. Kobayashi Y, Miyamoto M, Sugibayashi K, Morimoto 49. Nair AB, Chakraborty B, Murthy SN (2010) Effect of
Y (1998) Enhancing effect of N-acetyl-L-cysteine or polyethylene glycols on the trans-ungual delivery of
2-mercaptoethanol on the in vitro permeation of 5-flu- terbinafine. Curr Drug Deliv 7:407414
orouracil or tolnaftate through the human nail plate. 50. Nakano N, Hiruma M, Shiraki Y, Chen X, Porgpermdee
Chem Pharm Bull 46:17971802 S, Ikeda S (2006) Combination of pulse therapy with
354 K.A. Walters

terbinafine tablets and topical terbinafine cream for 64. Traynor MJ, Turner RB, Evans CR, Khengar RH,
the treatment of dermatophyte onychomycosis: a pilot Jones SA, Brown MB (2010) Effect of a novel pene-
study. J Dermatol 33:753758 tration enhancer on the ungula permeation of two
51. Quintanar-Guerrero D, Ganem-Quintanar A, Tapia- antifungal agents. J Pharm Pharmacol 62:730737
Olguin P, Kalia YN, Buri P (1998) The effect of kera- 65. Ujiie H, Shibaki A, Akiyama M, Shimizu H (2010)
tolytic agents on the permeability of three imidazole Successful treatment of nail lichen planus with topical
antimycotic drugs through the human nail. Drug Dev tacrolimus. Acta Derm Venereol 90:218219
Ind Pharm 24:685690 66. Vaka SR, Murthy SN, OHaver JH, Repka MA (2011)
52. Rigopoulos D, Katoulis AC, Ionnides D, Georgaia S, A platform for predicting and enhancing model drug
Kalogeromitros D, Bolbasis I, Karistinou A, delivery across the human nail plate. Drug Dev Ind
Christofidou E, Polydorou D, Balkou P, Fragouli E, Pharm 37:7279
Katsambas AD (2003) A randomised trial of 67. van de Kerkhof PC, Pasch MC, Scher RK, Kerscher
amorolfine 5% solution nail lacquer in association M, Gieler U, Haneke E, Fleckman P (2005) Brittle
with itraconazole pulse therapy compared with itra- nail syndrome: a pathogenesis-based approach with a
conazole alone in the treatment of Candida fingernail proposed grading system. J Am Acad Dermatol
onychomycosis. Br J Dermatol 149:151156 53:644651
53. Rigopoulos D, Gregoriou S, Danielli CR, Belyayeva 68. van Hoogdalem EJ, van den Hoven WE, Terpstra IJ,
H, Larios G, Verra P, Stamou C, Kontochristopoulos van Zijtveld J, Verschoor JSC, Visser JN (1997) Nail
G, Avgerinou G, Katsambas A (2009) Treatment of penetration of the antifungal oxiconazole after
nail psoriasis with a two-compound formulation of repeated topical application in healthy volunteers, and
calcipotriol plus betamethasone dipropionate oint- the effect of acetylcysteine. Eur J Pharm Sci 5:
ment. Dermatology 218:338341 119127
54. Runne U, Orfanos CE (1981) The human nail struc- 69. Vejnovic I, Huonder C, Betz G (2010) Permeation
ture, growth and pathological changes. Curr Probl studies of novel terbinafine formulations containing
Dermatol 9:102149 hydrophobins through human nails in vitro. Int J
55. Sanchez Regana M, Martin Ezquerra G, Umbert Pharm 397:6776
Millet P, Llambi Mateos F (2005) Treatment of nail 70. Vejnovic I, Simmler L, Betz G (2010) Investigation of
psoriasis with 8% clobetasol nail lacquer: positive different formulations for drug delivery through the
experience in 10 patients. J Eur Acad Dermatol nail plate. Int J Pharm 386:185194
Venereol 19:573577 71. Walters KA, Flynn GL, Marvel JR (1981)
56. Scher RK, Stiller M, Zhu YI, 5 (2001) Tazarotene Physicochemical characterization of the human nail:
0.1% gel in the treatment of fingernail psoriasis: a I. Pressure sealed apparatus for measuring nail plate
double-blind, randomised, vehicle-controlled study. permeabilities. J Invest Dermatol 76:7679
Cutis 68:355358 72. Walters KA, Flynn GL, Marvel JR (1983)
57. Sherber NS, Hoch AM, Coppola CA, Carter EL, Physicochemical characterization of the human nail:
Chang HL, Barsanti FR, Mackay-Wiggan JM (2011) permeation pattern for water and the homologous
Efficacy and safety study of tazarotene cream 0.1% alcohols and differences with respect to the stratum
for the treatment of brittle nail syndrome. Cutis corneum. J Pharm Pharmacol 35:2833
87:96103 73. Walters KA, Flynn GL, Marvel JR (1985) Penetration
58. Shivakumar HN, Vaka SR, Madhav NV, Chandra H, of the human nail: the effects of vehicle pH on the
Murthy SN (2010) Bilayered nail lacquer of terbin- permeation of miconazole. J Pharm Pharmacol
afine hydrochloride for treatment of onychomycosis. 37:498499
J Pharm Sci 99:42674276 74. Walters KA, Flynn GL, Marvel JR (1985)
59. Smijs TGM, Schuitmaker HJ (2003) Photodynamic Physicochemical characterization of the human nail:
inactivation of the dermatophyte Trichophyton solvent effects on the permeation of homologous
rubrum. Photochem Photobiol 77:556560 alcohols. J Pharm Pharmacol 37:771775
60. Spruit D (1971) Measurement of water vapor loss 75. Wessel S, Gniadecka M, Jemec GB, Wulf HC (1999)
through human nail in vivo. J Invest Dermatol Hydration of human nails investigated by NIR-FT-Raman
56:359361 spectroscopy. Biochim Biophys Acta 1433:210216
61. Stern DK, Diamantis S, Smith E, Wei H, Gordon M, 76. Wsten HA, de Vocht ML (2000) Hydrophobins, the
Muigai W, Moshier E, Lebwohl M, Spuls P (2007) fungal coat unravelled. Biochim Biophys Acta
Water content and other aspects of brittle versus nor- 1469:7986
mal fingernails. J Am Acad Dermatol 57:3136 77. Xiao P, Zheng X, Imhof RE, Hirata K, McAuley WJ,
62. Stuttgen G, Bauer E (1982) Bioavailability, skin and Mateus R, Hadgraft J, Lane ME (2011) Opto-thermal
nail penetration of topically applied antimycotics. transient emission radiometry (OTTER) to image dif-
Mycosen 25:7480 fusion in nails in vivo. Int J Pharm 406:111113
63. Susilo R, Korting HC, Greb W, Strauss UP (2006) 78. Sardana K, Garg VK, Manchanda V, Rajpal M (2006).
Nail penetration of sertaconazole with a sertacon- Congenital candidal onychomycoses: effective cure
azole-containing nail patch formulation. Am J Clin with ciclopirox olamine 8% nail lacquer. Br J Dermatol
Dermatol 7:259262 154:573575
 Preservation of Moisturisers
D. Godfrey
23

23.1 The Consequences of Microbial common is the possibility of contaminated

Growth in Cosmetics product entering the eye. For example, suffi-
cient numbers of Pseudomonas aeruginosa in
There are several possible adverse effects that the eye will cause blindness [1].
may occur in the absence of a sufficiently robust It is essential, therefore, from the dual consid-
preservation system, and these may be broadly erations of product integrity/aesthetics and con-
divided into aesthetics and safety issues: sumer safety that cosmetic products are sufficiently
1. Visible growth is one of the more obvious well-preserved to withstand any possible micro-
signs of microbial contamination, whether it bial contamination from reasonably foreseeable
be a black mould (e.g. Aspergillus brasilien- conditions of use.
sis, formerly A. niger) or other discolorations The regulation of cosmetics around the world
from various different bacteria (e.g. varies considerably, but no cosmetic product
Pseudomonas aeruginosa can produce a blue/ should be unsafe for use, either from a toxico-
green, yellow/green or a red/brown colour). logical or a microbiological point of view. It is,
The metabolites produced by microbes are therefore, essential that steps be taken to ensure
often acidic, and the reduction in pH may lead that the product is proven to be adequately
to breakdown of the emulsion. Additionally, preserved.
the emulsifiers themselves may be used as
nutrient source, and this may also lead to
phase separation. Microbial growth can also
produce unpleasant odours. 23.2 Sources of Microbial
2. There are also clear safety issues with micro- Contamination
bial contamination. The presence of patho-
genic organisms in a product being applied to There are three principal sources of microbial
skin, especially if the skin is damaged, may contamination in cosmetics:
lead to infection. Staphylococcal infections 1. During the manufacturing process. Unless the
are particularly easily spread in this manner. product is manufactured in totally sterile con-
Far more seriously but, fortunately, far less ditions, there will be contamination from the
atmosphere and from the skin and clothes of
the operators. This is unavoidable, but should
D. Godfrey
Azelis Ltd,
be kept to a minimum by using the best manu-
Hertford, UK facturing practise with an emphasis on plant
e-mail: [email protected] hygiene.

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 355

DOI 10.1007/978-3-642-27606-4_23, Springer-Verlag Berlin Heidelberg 2012
356 D. Godfrey

2. Raw materials. Some raw materials may have 3. Yeasts Candida albicans
levels of microbial contamination, especially if 4. Moulds Aspergillus brasiliensis
they are natural in origin. This should be con- These cultures are inoculated in separate sam-
trolled by the supplier to ensure that any con- ples and then checked for surviving colonies at
tamination is kept to acceptably low levels. specified time points. There are different criteria
3. Consumer use. This source of contamination for success for bacteria than for fungi; both are
is almost entirely unavoidable, as the con- measured on the degree of logarithmic reduction
sumer will inevitably have some contact with in colony numbers.
the product unless it is supplied in packs In order to pass the criteria for bacteria, the
designed to eliminate contact, or in single-use colony count must be reduced by at least log 2
packs. within 2 days and by at least log 3 within 7 days,
with no increase in numbers thereafter (being
tested also after 14 and 28 days).
23.3 What Is Preservation? In order to pass the criteria for fungi, the col-
ony count must be reduced by at least log 2 within
Preservation may be defined as the art of protect- 7 days, with no increase thereafter, and again, up
ing products against microbial attack during their to 28 days.
shelf life. The criteria described here, from the Ph. Eur.,
It should not be used to compensate for unhy- are the A criteria. There are also B criteria,
gienic manufacturing conditions, but only to which are less stringent, but these would not
allow for the contamination introduced during apply to moisturising products.
consumer use. The USP criteria include the Gram-negative
bacterium, Escherichia coli, and are less strin-
gent than those of the Ph. Eur., requiring only that
23.4 What Is a Preservative? there is no increase in the initial numbers of A.
brasiliensis and C. albicans up to 28 days and
Any substance used to kill or prevent the growth only a 1 log reduction of bacteria by 7 days and
of microorganisms which, by their growth, will then a 3 log reduction by 14 days, with no increase
spoil or contaminate a raw material or product. at 28 days.

23.5 Microbial Challenge Testing

23.6 Minimum Inhibitory
The most effective and consistent means of estab- Concentration Values
lishing the efficacy of a preservation system is to
subject the product to a microbial challenge test. When evaluating preservatives and preservative
There are many variations on this test but, in its combinations in the development stage of the
most simple form, the methods prescribed by process, it is common practice to determine the
various pharmacopoeia are a good basis, e.g. minimum inhibitory concentration (mic) value.
United States Pharmacopoeia (USP) and This is the lowest concentration at which the test
Pharmacopoeia Europa (Ph. Eur.). In the Ph. Eur. substance prevents further growth of the test
method, the product is inoculated with cultures of organism. This value is specific to both the sub-
organisms representative of the four main sub- stance and the organism tested. The concentra-
groups of likely contaminants: tion required to kill the organism is usually much
1. Gram-negative bacteria Pseudomonas aerug- higher than the mic value. Manufacturers of pre-
inosa servatives usually offer mic data in support of
2. Gram-positive bacteria Staphylococcus their products, but this information should be
aureus treated with a little caution. There is no standard
23 Preservation of Moisturisers 357

method for the mic test, and the results are sub- two of these areas. If the proposed preservation
ject to wide variability, as there are several fac- system for any given product is not effective
tors that have a significant effect on the result. against any of these subgroups, or even just one
The most important variables are the inoculum specific common microorganism, it is not suit-
count employed and the actual strain of the test able for use without another substance being
organism. The lower the inoculum count, the included that will control the gap in the activity
lower the concentration of test substance required spectrum. For example, Pseudomonas aerugi-
to prevent cells from growing, and it is possible nosa is a common Gram-negative bacterium that
to manipulate the data by using a low inoculum is relatively difficult to control. If the preserva-
count to produce low mic figures, thereby mak- tion system controlled all other microorganisms,
ing the test substance appear unduly active. but allowed P. aeruginosa to survive, these bacte-
Microbial cells from all species evolve and adapt ria would grow even faster than normal due to the
to their surroundings, and microbial resistance, absence of competitive organisms. Partial preser-
or tolerance, can develop in laboratory strains, vation is barely more effective than the complete
leading to incorrect mic results. There is also the absence of preservation. Broad-spectrum antimi-
potential for huge variability in response between crobial protection is the key to a safe and stable
the different strains of the same species. (A strain product.
is a subset of a bacterial species differing from The components of the preservation system
other bacteria of that species by some minor, but must be compatible with the other ingredients
identifiable difference). used in the formulation. Any interaction may
The result of these potential variations within result in reduced activity; this would become
the mic test is that direct comparison of mic data apparent in the results of the microbial challenge
should only be made for the data on one specific test, unless the interaction develops over a more
substance (i.e. comparing the mic of the sub- prolonged period.
stance for all the organisms tested at the same The preservation system should be effective at
time) and should not be read across to other the target pH of the product. Not all preservatives
substances tested separately, other than with a are equally effective across the entire pH range
high degree of caution. typically seen in moisturisers.
For the above reasons, there are no mic data The preservation system should not be prone
quoted for the preservatives being discussed, only to discoloration, especially if being considered
general statements for guidance on the types of for use in non-coloured products, and should not
organisms against which they are effective. impart any detectable/undesirable odour. It may
be possible to mask any odour, but this is not
ideal.
23.7 Criteria for Preservatives/ The preservation system must be appropriate
Preservation Systems for the intended use of the final product a sub-
stance permitted only in rinse-off products is
In order to determine the usefulness of a preser- clearly not suitable for a moisturising lotion.
vative, or a preservation system, it is important to The preservation system must be as safe as pos-
understand the attributes required for successful sible. It is inherent amongst biologically active sub-
preservation of a product. stances to have some potential for skin irritation
The most important criterion is broad-spectrum and, albeit a lower potential, for sensitisation. The
preservation, i.e. the system must be effective choice of preservative is a balance between efficacy
against bacteria (normally divided into Gram- and risk of a skin response. As a general rule, the
negative bacteria and Gram-positive bacteria) more potent the antimicrobial activity, the higher
and fungi (normally divided into yeasts and the risk of a skin response (in relative terms), but
moulds). These subdivisions are important, as this is usually mitigated by the use of lower con-
some preservatives are only effective in one or centrations due to the more powerful activity.
358 D. Godfrey

23.8 Commonly Used Preservatives Frequently, combinations of parabens are

employed in order to maximise the total concen-
There are 58 entries on Annex VI of the EU tration available in the aqueous phase and also,
Cosmetics Directive (list of permitted preserva- therefore, the antimicrobial activity. It is rela-
tives), some covering multiple substances and tively unusual to use a single paraben ester in a
other antimicrobial substances are also employed preservation system. Methylparaben is typically
in the EU and in other markets. However, the used at 0.10.25%, and propylparaben, typically
number of commonly used preservatives is rela- at 0.10.15% (as a combination), with the other
tively low, and the majority of these are discussed parabens being mostly used as components of
here: more complex blends, rather than being added as
individual ingredients. The typical total parabens
concentration is 0.20.4%.
In a hot process (c. 80C), the parabens may be
23.8.1 Parabens added to either phase prior to emulsification. It is
sometimes recommended to split the parabens addi-
INCI names: tion between the two phases, but this is of limited or
Methylparaben no value as the parabens will partition between the
Ethylparaben phases during the emulsification/mixing process.
Propylparaben For cold processes, given the difficulty of dis-
Isopropylparaben solving the parabens at low temperatures, the
Butylparaben sodium parabens may be used. These are highly
Isobutylparaben water soluble (<50%), but will exert a very high
Parabens is a contraction of esters of para- pH, which will require adjustment. A 0.1% aque-
hydroxybenzoic acid. The methyl-, ethyl-, pro- ous solution of sodium methylparaben is approx-
pyl-, isopropyl-, butyl- and isobutyl esters are the imately pH 9, so an adjustment is important.
ones in general use as preservatives, along with The parabens are compatible with most com-
their respective sodium salts (INCI names monly used cosmetic ingredients, but they may be
sodium methylparaben, etc.). inactivated by some nonionic species. This effect
Parabens have been used as preservatives in is strongly concentration dependent, as the para-
personal care products since the late 1920s and ben ester may be encapsulated within any micelles
have a long and successful history of use, being in the system. Below the critical micelle concen-
amongst the preservatives with the lowest rates of tration (CMC), therefore, there is no inactivation,
irritation and sensitisation, with sensitisation with a progressive reduction in activity above the
rates amongst dermatological patients as low as CMC. There is little effect on the activity of para-
1.2% [2]. bens from the pH, within the range pH 48.
The parabens are primarily active against Parabens are permitted globally for use in per-
fungi, but they also generally have moderate sonal care products, but with differing maximum
activity against bacteria. permitted concentrations:
Methylparaben is the least active of the group, European Union
and the antimicrobial activity increases with the Methylparaben 0.4%
increasing carbon chain length of the ester group. Ethylparaben 0.4%
The activities of ethylparaben and propylparaben lie Propylparaben + butylparaben total 0.19%
between those of methylparaben and butylparaben. Maximum total parabens concentration 0.8%
All the parabens have relatively low water sol-
ubility, and this decreases with the increasing car- At the time of writing, isopropylparaben and
bon chain length of the ester group, methylparaben isobutylparaben have been judged to have insuf-
being soluble up to 0.25% in water (25C) and ficient data available to assess fully their safety
butylparaben being only 0.02% soluble [3, 4]. and may be phased out of use.
23 Preservation of Moisturisers 359

USA activity over a broad pH range from pH 39.

Safe as used Typical use concentrations are 0.10.3%.
Japan Diazolidinyl urea is permitted in many territo-
Total maximum parabens 1.0% (Japanese ries, with the following restrictions:
name: parahydroxybenzoate esters) European Union
Maximum 0.5%
USA
23.8.2 Imidazolidinyl Urea Maximum 0.5%
Japan
Imidazolidinyl urea is primarily an antibacterial Not permitted
preservative, with very little antifungal activity. It
has been widely used in many markets since its
introduction in the 1980s. 23.8.4 DMDM Hydantoin
Imidazolidinyl urea is highly water soluble
and should be added to the product at tempera- DMDM hydantoin is a broad-spectrum preserva-
tures below 40C to avoid decomposition. It tive, but has better activity against bacteria than
retains its activity over a broad pH range from against fungi. It is classified as a formaldehyde
pH 39. Typical use concentrations are 0.20.5%. donor. (See General Note on Formaldehyde
The potential for imidazolidinyl urea to release Donors below.)
very low levels of formaldehyde is perceived by DMDM hydantoin is highly water soluble (it is
some to be a disadvantage. (See General Note on usually supplied as a 55% aqueous solution) and
Formaldehyde Donors below.) should be added to the product at temperatures
Imidazolidinyl urea is permitted globally, with below 40C to avoid decomposition. It retains its
the following restrictions: activity over a broad pH range from pH 39.
European Union Typical use concentrations are 0.150.4%.
Maximum 0.6% DMDM hydantoin is permitted in many terri-
USA tories, with the following restrictions:
Safe as used European Union
Japan Maximum 0.6%
In rinse-off products only, with a maximum of USA
0.075% (expressed as free formaldehyde) and Safe as used
with special labelling requirements should not Japan
be used by infants, or by people who are hyper- In rinse-off products only, with a maximum of
sensitive to formaldehyde 0.075% (expressed as free formaldehyde), with
special labelling requirements should not be
used by infants, or by people who are hypersensi-
23.8.3 Diazolidinyl Urea tive to formaldehyde

Diazolidinyl urea is primarily an antibacterial

preservative, with activity against moulds, but 23.8.5 Quaternium 15
fairly weak anti-yeast activity. It has been widely
used in many markets since its introduction in the Quaternium 15 is a broad-spectrum preserva-
1980s. It is classified as a formaldehyde donor. tive, but has better activity against bacteria than
(See General Note on Formaldehyde Donors against fungi. It is classified as a formaldehyde
below.) donor. (See General Note on Formaldehyde
Diazolidinyl urea is highly water soluble and Donors below.) The rate of sensitisation has
should be added to the product at temperatures been reported as high as 10.3% amongst derma-
below 40C to avoid decomposition. It retains its tological patients [2], which is higher than most
360 D. Godfrey

commonly used preservatives. This is still very ficient exposure to formaldehyde to be of con-
low in overall terms, given that dermatological cern. Historically, available formaldehyde levels
patients probably comprise much less than 1% in cosmetic products have been exaggerated due
of the general population. to a flaw in the standard methods used to detect
Quaternium 15 is highly water soluble and formaldehyde [5, 6]. In the case of formaldehyde
should be added to the product at temperatures donors, the donor molecule exists in equilibrium
below 40C to avoid decomposition. It retains its with free formaldehyde and the other reaction
activity over a broad pH range from pH 39. product. The standard method for determining
Typical use concentrations are 0.050.2%. formaldehyde requires a derivatisation step,
Quaternium 15 is permitted in some territo- which disturbs the equilibrium, thereby produc-
ries, with the following restrictions: ing more free formaldehyde, i.e. formaldehyde
European Union that is not actually present in the product prior to
Maximum 0.2% the analytical method being performed.
USA
Safe as used
Japan 23.8.7 Phenoxyethanol
Not permitted
Phenoxyethanol is one of the most widely used
preservatives. It is a broad-spectrum preservative,
23.8.6 Sodium but it is slightly weaker against Gram-positive
Hydroxymethylglycinate bacteria than the other species types.
Phenoxyethanol is slightly water soluble
Sodium hydroxymethylglycinate (sodium HMG) (approximately 2.4%) and is preferably added to
is a broad-spectrum preservative, but has slightly the product at temperatures below 40C to reduce
better activity against bacteria than against the possibility of evaporative loss, although this
fungi. It is classified as a formaldehyde donor. is only likely to be an issue should the manufac-
(See General Note on Formaldehyde Donors tured batch be held at a high temperature (>80C)
below.) for a prolonged period. It retains its activity over
Sodium HMG is highly water soluble and a broad pH range from pH 39. Typical use
should be added to the product at temperatures concentrations are 0.41.0%. Phenoxyethanol is
below 40C to avoid decomposition. It retains its more commonly used in combination with other
activity over a broad pH range from pH 39. preservatives and is rarely used alone.
Typical use concentrations are 0.40.8%. Phenoxyethanol is permitted in most territo-
Sodium HMG is permitted in many territories, ries, with the following restrictions:
with the following restrictions: European Union
European Union Maximum 1.0%
Maximum 0.5% USA
USA Safe as used
Safe as used Japan
Japan Maximum 1.0%
Not permitted

General Note on Formaldehyde Donors 23.8.8 Methylchloroisothiazolinone/

Formaldehyde is classified as a category 1 car- Methylisothiazolinone
cinogen (i.e. a proven human carcinogen), and
this has led to concerns over the safety of sub- Methylchloroisothiazolinone/methylisothiazoli-
stances having the potential to release formalde- none (MCI/MI) is one of the most widely used
hyde. There is no proof, however, that the use of preservatives. It is a broad-spectrum preservative
formaldehyde donors in cosmetics results in suf- system, effective at extremely low concentrations.
23 Preservation of Moisturisers 361

It is usually supplied as a 1.5% active aqueous more commonly used in combination with other
solution, stabilised with high concentrations of preservatives and is rarely used alone.
magnesium salts to prevent degradation of the Benzyl alcohol is permitted in most territories,
MCI component. with the following restrictions:
Methylisothiazolinone (MI) is also available European Union
as a single component. Maximum 1.0%. Benzyl alcohol is one of the
MCI/MI retains its activity over a broad 26 designated fragrance allergens, and products
pH range from pH 37.5, but MCI breaks down containing it must be labelled accordingly.
rapidly above pH 8. MI does not contribute towards USA
any antimicrobial activity in this combination Safe as used
product. Typical use concentrations are 7.515 ppm Japan
(0.000750.0015%) of active MCI/MI. Maximum 5.0%
MI is highly stable and retains its activity from
pH 39. Typical use concentrations are
0.0050.01%.
23.8.10 Sorbic Acid/Potassium Sorbate
The MCI/MI combination is permitted in most
territories, with the following restrictions:
Sorbic acid/potassium sorbate are food-approved
European Union
preservatives. They are broad-spectrum preser-
Maximum 0.0015% (active MCI/MI)
vatives, but they are slightly weak against
USA
bacteria.
Maximum 0.0015% (active MCI/MI)
Sorbic acid is very slightly water soluble, but
Japan
the potassium salt is highly soluble. They retain
Maximum 0.0015% (active MCI/MI) rinse-
their activity over a narrow pH range from pH
off products only.
36. Typical use concentrations are 0.30.5%.
Methylisothiazolinone is permitted in most
(See General Note on Organic Acids below.)
territories, with the following restrictions:
Sorbic acid/potassium sorbate are permitted in
European Union
most territories, with the following restrictions:
Maximum 0.01% (active MI)
European Union
USA
Maximum 0.6% (as the acid)
Maximum 0.01% (active MI)
USA
Japan
Safe as used
Maximum 0.01% (active MI) rinse-off and
Japan
leave-on products
Maximum 0.5%

23.8.9 Benzyl Alcohol

23.8.11 Benzoic Acid/Sodium Benzoate
Benzyl alcohol is a widely used preservative. It is
broad spectrum in its range of activity, but it is Benzoic acid/sodium benzoate are food-approved
slightly weak against Gram-positive bacteria. preservatives. They are broad-spectrum preser-
Benzyl alcohol is slightly water soluble vatives, but they are slightly weak against
(approximately 2%) and is preferably added to bacteria.
the product at temperatures below 40C to reduce Benzoic acid is very slightly water soluble,
the possibility of evaporative loss, although this but the sodium salt is highly soluble. They retain
is only likely to be an issue should the manufac- their activity over a narrow pH range from pH
tured batch be held at a high temperature (>80C) 35. Typical use concentrations are 0.20.4%.
for a prolonged period. It retains its activity over (See General Note on Organic Acids below.)
a broad pH range from pH 38.5. Typical use Benzoic acid/sodium benzoate are permitted in
concentrations are 0.41.0%. Benzyl alcohol is most territories, with the following restrictions:
362 D. Godfrey

European Union within the specification range, it will pass easily

Rinse-off products, except oral care products: at any other pH within the specification.
2,5 % (as acid)
Oral care products: 1,7 % (as acid)
23.8.13 Chlorphenesin
Leave-on products: 0,5 % (as acid)
USA
Chlorphenesin has broad-spectrum antimicrobial
Safe as used
activity against bacteria and fungi, being also
Japan
effective against Pseudomonas spp. and other
Maximum 0.2%
problematic Gram-negative bacteria.
Chlorphenesin maintains its activity over the
23.8.12 Dehydroacetic Acid/Sodium range from pH 3.08.0 and is compatible with most
Dehydroacetate personal care ingredients. It is only slightly soluble
in water (<1%) and may need heating to dissolve in
Dehydroacetic acid/sodium dehydroacetate are systems with a high water content. Typical use
broad-spectrum preservatives, but they are concentrations range from 0.1% to 0.3%.
slightly weak against bacteria. Chlorphenesin is permitted in most territories,
Dehydroacetic acid is very slightly water solu- with the following restrictions:
ble, but the sodium salt is highly soluble. They European Union
retain their activity over a narrow pH range from Maximum 0.3%
pH 36.5. Typical use concentrations are 0.30.5%. USA
(See General Note on Organic Acids below.) Safe as used
Dehydroacetic acid/dehydroacetate are per- Japan
mitted in most territories, with the following Maximum 0.3% (not permitted for use in
restrictions: product intended to come into contact with
European Union mucous membranes)
Maximum 0.6% (as the acid)
USA
Safe as used 23.8.14 Iodopropynyl Butylcarbamate
Japan
Maximum 0.5% Iodopropynyl butylcarbamate (IPBC) has power-
ful activity against fungi, but very little antibacte-
rial activity at permitted use concentrations.
General Note on Organic Acids IPBC is compatible with most personal care
The organic acids described here are only active ingredients. It is virtually insoluble in water and
in their undissociated form the ionic species may need heating to dissolve in systems with
have zero antimicrobial activity; hence the high water content. Typical use concentrations
restrictive pH range over which they retain their range from 0.01% to 0.02%.
activity. All three acids are 100% active at pH3 IPBC is permitted in many territories, with the
because they are completely undissociated at this following restrictions:
pH, but as the pH increases, the concentration of European Union
ionic species increases and the activity drops Maximum 0.01% in leave-on products (but
rapidly. For example, benzoic acid is approxi- 0.0075% in deodorants and antiperspirants)
mately twice as active at pH 5.0 than at pH 5.5. Maximum 0.02% in rinse-off products
For this reason, it is vital that any finished prod- Must not be used in lip or oral products, or in
uct being submitted for microbial challenge test- products intended for children under 3 years of age,
ing has the pH adjusted to the highest end of the except for bath products, shower gels and shampoo
pH specification for that product. This is then USA
testing the worst case scenario, i.e. the pH at As for the European Union
which the antimicrobial protection is at its weakest. Japan
It the product passes challenge at the highest pH Maximum 0.02% in all product categories
23 Preservation of Moisturisers 363

23.8.15 Bronopol 23.10 Secondary Preservatives

and Preservative Free
INCI name: 2-bromo-2-nitropropane-1,3-diol
Bronopol has extremely powerful antibacte- In more recent years, there have been an increas-
rial activity, but very little antifungal activity at ing number of adverse reports about some spe-
permitted use concentrations. It is especially cific preservatives and preservatives in general,
effective against the Gram-negative bacterium mostly based on little or suspect science.
Pseudomonas aeruginosa, which, as stated ear- Parabens have been especially affected by these
lier, can cause permanent blindness if sufficient recent developments. This is not the forum to
numbers enter the eye. discuss these issues in detail, but there is plenty
Bronopol is highly water soluble and compat- of further reading available for the diligent
ible with most types of cosmetic ingredients. It researcher [717].
should not be used in combination with amines The result of the pressure, mostly from non-
due to the increased potential for nitrosamine governmental organisations leading to consumer
formation. It is important to note that bronopol concerns, is that many manufacturers have been
cannot form nitrosamines in the absence of looking at alternative ways of preserving their
amines. products, simply to avoid having to include a
Typical use concentrations are 0.010.04%. dangerous ingredient on the label. This has
Bronopol should be added below 40C as it is paved the way for the fairly recent phenomenon
increasingly unstable above this temperature. of using secondary preservatives and, in some
European Union cases, making overt claims of preservative
Maximum 0.1% free.
USA Within the EU, preservatives are strictly regu-
Maximum 0.1% lated by the EU Cosmetics Directive [18], which
Japan must be enacted into law in each member state
Not permitted (to be replaced by the Cosmetics Regulation in
2013, which will apply automatically to all mem-
ber states). Permitted preservatives are listed in
Annex VI of the Directive (which will become
23.9 Preservative Blends Annex V in the Regulation), alongside the vari-
ous restrictions and maximum permitted
It may be clear from the descriptions of the indi- concentrations.
vidual preservatives above that there is no single There is much less formalised regulation in
perfect preservative. Many do not have a com- the USA, and ingredients have their function(s)
plete spectrum of activity, or have weaknesses declared alongside their entry in the International
against certain organisms. In most cases, for good Cosmetic Ingredient Dictionary and Handbook
preservation, a broad-spectrum preservation sys- [19]. The Cosmetic Ingredients Review (CIR)
tem is essential (unless there is inherent activity Panel assess ingredients along similar lines
against certain organisms from other formulation to the SCCS (see later under Sect. 23.11) in
ingredients). This may be achieved in one of two the EU.
ways. Either the formulator can make the deci- The Japanese regulations also include a posi-
sion to test various combinations of the individual tive list of permitted preservatives.
preservatives or they can test premixed proprie- In the preamble to Annex VI of the EU
tary blends. The use of proprietary blends facili- Directive, it states:
tates ease of handling and accuracy, both on a 1. Preservatives are substances which may be
laboratory scale and in production as it is easier added to cosmetic products for the primary
to handle a single preservative blend (they are purpose of inhibiting the development of
usually in liquid form) than several individual microorganisms in such products.
components, some used in very small quantities. 3. Other substances used in the formulation of
There are also benefits in inventory reduction. cosmetic products may also have antimicrobial
364 D. Godfrey

properties and thus help in the preservation of colorant or a mouthwash, and the only possible
the products..... these substances are not explanation for the presence of caprylyl glycol
included in this Annex. would be for its antimicrobial activity. And this
Therefore, if a substance has antimicrobial would not be legal within the EU.
activity, but has an alternative (primary?) func- The issue of preservative-free claims is a sepa-
tion in a cosmetic product, it is not officially a rate matter, in some respects. Whilst, from a legal
preservative. This makes it unclear as to what is point of view, a product preserved entirely with
not a preservative is it a substance with little or secondary preservatives may be preservative
no antimicrobial activity, or is it simply a sub- free, scientifically, it is preserved and contains a
stance that is not listed on Annex VI of the definable preservation system. Preservative free
Cosmetics Directive? is, therefore, a questionable position, but more-
Examples of secondary preservatives are given over, there are other implications. The use of this
below, with the approximate concentration claim may be taken to imply that this has increased
required if being used as the sole agent for the safety of the product and, by further implica-
preservation: tion that product containing preservatives are,
Glycerine (40%) therefore, less safe. This is not the case.
Propylene glycol (2025%) Continuing or increasing use of this claim may
Butylene glycol (1015%) lead the EU Commission to look again at how
Ethanol (510%) preservatives are regulated within the Cosmetics
Caprylyl glycol (0.51.5%) Directive/Regulation.

The first three substances listed work mostly

by binding much of the available water, thereby 23.11 Safety of Preservatives
reducing the water activity of the end product
beyond the point where microorganisms can sur- Preservatives are biologically active substances
vive. Are they antimicrobial? There are many and, therefore, have an inherent potential to have
other substances that behave similarly over a an adverse effect on any living cells, not only
range of different concentrations at what point microbial cells. For this reason, it is obviously
does the substance become antimicrobial? important to take all steps to ensure that preserva-
It is possible to protect a product from micro- tives are used safely. It is simply not possible to
bial contamination without the use of legal pre- guarantee that no consumer will experience any
servatives (in EU terms), but it is not possible to adverse reaction (not only to preservatives other
protect a product from microbial attack without ingredients may have the ability to elicit an
the use of a preservation system (unless the prod- adverse skin reaction but their biological activ-
uct is totally anhydrous and, even in this instance, ity does increase the potential, as a general rule),
there is an argument for a preservation system). but it is the case that all available information is
Below is a list of increasingly frequently used evaluated prior to approval. Different markets
secondary preservatives with their primary have different ways of evaluating preservatives,
functions: but perhaps the most stringent is the European
Caprylyl glycol (emollient) Union. The EU has appointed a specific body, the
Ethylhexylglycerine (emollient) Scientific Committee for Consumer Safety (SCCS
Pentylene glycol (emollient) also previously known as the SCCP and, before
Levulinic acid (perfume) that, the SCCNFP), one of three safety groups set
p-Anisic acid (perfume) up to advise the EU Commission on safety mat-
It is perfectly legal to use these, and similar ters [20]. The Committee provides opinions on
ingredients, provided there is a full justification health and safety risks (chemical, biological,
for their inclusion. For example, it would be dif- mechanical and other physical risks) of non-food
ficult to justify the use of an emollient in a hair consumer products (e.g. cosmetic products and
23 Preservation of Moisturisers 365

their ingredients, toys, textiles, clothing, personal into consideration, there is unlikely to be any
care and household products) and services (e.g. measurable impact on the aquatic environment.
tattooing, artificial sun tanning). A general video Taking the parabens as a useful example, given
about the work of the three safety groups is avail- their status of being by far the most widely used
able online [21]. preservatives [2], a study by Lee et al. measured
The SCCS have evaluated all the preservatives the concentrations of the different parabens in the
listed on Annex VI since 1976, some of them on inflow of a sewage treatment facility and also at
several occasions, and draw conclusions from all the outflow [23]. The highest concentration
available data. The main role is to determine a detected in the inflow to the sewage treatment
maximum permitted concentration, but other plant was of propylparaben, rather than meth-
restrictions may also be considered (e.g. specific ylparaben, as might be anticipated from the
product types, not for use on children under known usage in cosmetics. The reason for the
3 years of age, etc.). This is usually based on higher concentration of propylparaben may be
allowing a margin of safety factor of at least due to its greater chemical stability, compared
100 times the exposure of the lowest no observed with methylparaben. The actual propylparaben
adverse effect level (NOAEL) (if any) across all concentration detected was 2.43 parts per trillion
the available studies. The Final Opinion document (0.000000000243%), and even more importantly,
produced by the SCCS contains a detailed discus- the concentration detected after treatment in the
sion of the thorough process that led to the deci- immediate outflow was reduced to 0.04 parts per
sion, where appropriate, and the details of the trillion (ppt). The comparative figures for meth-
calculation employed, and examples may be found ylparaben were 1.47 ppt and 0.03 ppt, respec-
by following the link referenced below [22]. tively. These concentrations are taken directly
Successful preservation is a balance between from the immediate vicinity of the outflow, and
controlling all potential contaminant microorgan- so much greater dilution follows on dispersion
isms and ensuring that the risk of irritation or sen- within the wider environment. These concentra-
sitisation is minimised. It is important to avoid tions are many orders of magnitude below the
over-preservation. The best method of achieving levels where the substances have been shown to
this is to test several different concentrations of be toxic to aquatic organisms. For example, the
one or more preservation systems. This will better acute fish toxicity for methylparaben is:
optimise the preservation system. Most manufac-
turers tend to test only one preservation option, 48 h LC (Leuciscus idus Golden Orfe)

but this may be a false economy, especially when 50mg/1
this increases the possibility of over-preservation.
50 mg/l is equivalent to 50 ppm a figure approx-
imately 1.67 trillion times higher than the con-
23.12 Environmental Issues centration of methylparaben (0.03 ppt) detected
in the sewage outflow. It may be concluded,
If there is a failing in the EU Cosmetics Directive, therefore, that methylparaben is unlikely to have
it could be argued that it is the lack of consider- any measurable environmental impact.
ation for possible environmental effects, both in Whilst it would be unwise to attempt to extrap-
general, and specifically for preservatives. Again, olate these figures directly to all preservatives
as with the aspect of human safety, preservatives used in cosmetics, it does allow a sense of con-
are biologically active substances and, if they are text, given the huge dilution factors involved.
entering the environment, there is a potential for
adverse effects to aquatic species in particular. General Note on Regulations
Preservatives are used at relatively low concen- Science never stands still, and new data some-
trations (rarely more than 1% in cosmetics), and times become available on substances that have
when breakdown and dilution factors are taken been in use for many years, and the new data can
366 D. Godfrey

potentially change the risk assessment of the sub- References

stance in question. In such cases, the SCCS are
asked to review the new information and consider 1. Engel LS, Hill JM, Moreau JM, Green LC, Hobden
whether the previous risk assessment is still valid. JA, OCallaghan RJ (1998) Pseudomonas aeruginosa
protease IV produces corneal damage and contributes
Where the SCCS determine that the risk has to bacterial virulence. Invest Ophthalmol Vis Sci
changed in the light of the new data, then the 39(3):662665
regulations may be changed to reflect this situa- 2. Steinberg D (2010) Cosmetics & Toiletries magazine,
tion. For this reason, it is advisable to check the 125:4651
3. Azelis product literature http://azelis.com
latest position with regard to SCCS opinions to 4. Clariant product literature http://clariant.com
confirm that the information provided on any 5. Tallon M, Merianos JJ, Subramanian S (2009) Non-
specific preservative in this chapter remains up to destructive method for determining the actual concen-
date [22]. tration of free formaldehyde in personal care
formulations containing formaldehyde donors. SOFW
J 135(5):2232
6. Winkelman JGM et al (2002) Kinetics and chemical
equilibrium of the hydration of formaldehyde. Chem
Eng Sci 57:40674076
Take Home Messages
7. http://personalcaretruth.com/2012/02/parabens-
Cosmetic products susceptible to micro- in-perspective-an-introduction/
bial growth must be preserved for aes- 8. http://personalcaretruth.com/2012/02/parabens-
thetic reasons, but also, more importantly, in-perspective-part-i/
9. http://personalcaretruth.com/2012/02/parabens-
for consumer safety.
in-perspective-part-ii/
The combination of preservatives used 10. http://personalcaretruth.com/2012/02/parabens-
must endow broad-spectrum protection in-perspective-part-iii/
against bacteria and fungi. 11. http://personalcaretruth.com/2012/02/parabens-
in-perspective-part-iv/
Microbial challenge testing is vital to
12. http://personalcaretruth.com/2012/02/parabens-
ensure that products are adequately pro- in-perspective-part-v/
tected against microbial growth. 13. http://personalcaretruth.com/2012/02/parabens-
Preservative blends offer more robust in-perspective-part-vi/
14. http://personalcaretruth.com/2012/02/parabens-
protection than most single substances.
in-perspective-part-vii/
Preservatives must be used carefully and 15. http://personalcaretruth.com/2012/02/parabens-
at the lowest concentration required to in-perspective-part-viii/
achieve sufficient antimicrobial protec- 16. http://personalcaretruth.com/2012/02/parabens-
in-perspective-part-ix/
tion to ensure safety in use and to reduce
17. http://personalcaretruth.com/2012/02/parabens-
the low risk of skin response even fur- in-perspective-part-x/
ther, as much as possible. 18. http://tiny.cc/o904y/2012/02
Preservatives are tightly regulated, and 19. Gottschlack TE, Bailey JE (eds) (2012) International
cosmetic ingredient dictionary and handbook.
it is important to be aware of the restric-
Personal Care Products Council, Inc, Washington
tions in target markets and equally 20. http://ec.europa.eu/health/scientific_committees/con-
important to be aware of changes to reg- sumer_safety/index_en.htm/2012/02
ulations as they occur. 21. http://ec.europa.eu/health/scientific_committees/vid-
eos/videos/video_committees_en.htm/2012/02
Preservative free claims are conten-
22. http://ec.europa.eu/health/scientific_committees/con-
tious and may be best avoided. sumer_safety/opinions/index_en.htm/2012/02
There is no evidence of any adverse 23. Lee HB, Peart TE, Svoboda ML (2005) Determination
environmental impact resulting from the of endocrine-disrupting phenols, acidic pharmaceuti-
cals, and personal-care products in sewage by solid-
use of preservatives in cosmetics.
phase extraction and gas chromatography-mass
spectrometry. J Chromatogr A 1094:122129
 Potential Allergens
in Moisturizing Creams 24
Ana Rita Travassos and An Goossens

24.1 Introduction by the partner, or any other person in close contact

with (connubial or consort dermatitis); or photo-
These days, everyone is using cosmetic products, induced, resulting from contact with a photoaller-
and allergic reactions are increasingly observed gen and exposure to sunlight (particularly UV-A
[1]. Indeed, in our department during the last light). An allergic contact dermatitis may some-
11 years, 21% of the patients tested suffered from times spread to other areas of the body not in direct
adverse reactions to cosmetics compared to 16% contact with the allergen, which is comparable to a
in the previous decade. reaction by systemic exposure (in which the aller-
Contact allergic reactions to cosmetics may be gen may reach the skin through the circulatory sys-
delayed-type reactions resulting in allergic or tem and produce a systemic contact-type dermatitis),
photoallergic contact dermatitis. More exception- the latter being extremely rare with cosmetics [1].
ally, immediate-type allergic reactions occur, In our Contact Allergy Unit in Leuven, we
such as the contact urticaria (syndrome). recorded using a standardized form [2] positive
The cosmetic allergens involved can reach the patch-test reactions or positive usage tests to cos-
skin in several different ways: direct application; metic products (from different cosmetic catego-
occasional contact with an allergen-contami- ries) responsible for allergic contact dermatitis or
nated surface; airborne contact; transfer by the contact urticaria, as well as positive reactions to
hands to more sensitive areas (e.g., the eyelids), specific ingredients in them. Moisturizers were
so-called ectopic dermatitis, by a product used the main causal cosmetic products involved, i.e.,
responsible for 33% of 992 allergic reactions, the
results of which will be discussed here.
A.R. Travassos
Clnica Universitria de Dermatologia Hospital de
Santa Maria,
Avenida Professor Egas Moniz, 1649-035 24.2 Allergic Contact Dermatitis
Lisbon, Portugal (ACD) Due to Moisturizers
e-mail: [email protected]
A. Goossens () 24.2.1 Diagnosis
Contact Allergy Unit Department of Dermatology,
University Hospital St. Rafal,
Taking the history of the patient and inspecting
Katholieke Universiteit Leuven,
Kapucijnenvoer 33, B-3000, Leuven, Belgium the clinical symptoms and localization of
e-mail: [email protected] the lesions frequently suggest the etiological

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 367

DOI 10.1007/978-3-642-27606-4_24, Springer-Verlag Berlin Heidelberg 2012
368 A.R. Travassos and A. Goossens

factor(s). Allergen identification for a patient with FM 2, which consists of hydroxyisohexyl 3-cyclo-
a possible allergic contact dermatitis from cos- hexene carboxaldehyde (HICC), farnesol, citral,
metics is performed by means of patch testing citronellol, coumarin, and alfa-hexyl cinnamalde-
with the baseline (standard) series, cosmetic hyde [52], detects additional cases [2], underlin-
series, and the product(s) used by the patient and, ing its importance as a screening agent [1].
if possible, also with the ingredients present. If a Fragrance components may be allergenic by
photoallergic contact dermatitis is suspected, pho- themselves, but may, as in the case of terpenes
topatch tests with the suspected agents are needed such as limonene [53] and linalool [54], form
[3]. Moreover, semi-open tests (in case of possible sensitizing oxidation products; they sometimes
irritants), usage tests, and repeated open applica- also contain contaminants. For example, resin
tion tests (ROAT) may also be performed [1]. acids and their oxidation products are the main
Once an allergen has been identified, it is the der- allergens in colophonium and the widely used
matologists task to provide specific advice about perfume ingredient Evernia furfuracea (or tree
the products that can be used safely and the spe- moss, also obtained from pine species); however,
cific ingredients that must be avoided [1, 4]. they were found as contaminants in Evernia
prunastri (oakmoss), both in the qualities used by
the fragrance industry and in patch-test materials.
24.2.2 Causal Allergens Besides, atranol and chloratranol have been iden-
tified as being the most potent allergens in oak
According to our study, fragrances together with moss ever described [1, 55].
preservatives were the most frequent classes of Moreover, multiple positive patch-test reac-
allergens in moisturizers, followed by vehicle com- tions are frequently associated with fragrance
ponents, emulsifiers, and conditioning agents allergy and often indicate the presence of com-
(Table 24.1). Figure 24.1 illustrates the relative fre- mon or cross-reacting ingredients in natural prod-
quency of reactions to the allergens classes, while ucts [1, 56], cross-reactions between simple
Tables 24.2 and 24.3 give the reactions to the indi- fragrance chemicals, or concomitant reactions.
vidual nonfragrance and fragrance allergens, Sensitization to fragrance components is most
respectively, the first along with the corresponding often induced by highly perfumed products, such
literature references. The nature of the individual as toilet waters, aftershave lotion, and deodorants
fragrances having caused reactions in moisturizers [4], followed by moisturizers, in which they
has been discussed in detail in a previous study [2]. became relatively more important during the last
decade (Table 24.1; Fig. 24.1). HICC and limonene
were the most frequent individual fragrance aller-
24.3 Specic Allergens gens in them (Table 24.3; Fig. 24.2) [2].
in Moisturizers

24.3.1 Fragrances 24.3.2 Preservatives

Currently, fragrance mix (FM) 1 and 2, Myroxylon Preservatives, used to prevent microbiological
pereirae and to a minor extent colophonium, are contamination that may spoil cosmetic or other
the diagnosis markers of perfume allergy in the products [57], are important sensitizers in water-
baseline series [2]. based products, such as moisturizers. The
FM 1 contains amyl cinnamal, cinnamal, cin- proportion of positive reactions to them in
namyl alcohol, hydroxycitronellal, eugenol, moisturizers did not differ in the two periods
isoeugenol, geraniol, and Evernia prunastri (oak- studied (Table 24.1; Fig. 24.1). Historically,
moss) and remains the best screening agent for changing contact allergy epidemics have been
contact allergy to perfumes because it is said to observed [57], as well as variations between
detect some 7080% of all perfume allergies [51]. different countries in the spectrum of the
24 Potential Allergens in Moisturizing Creams 369

allergenic preservatives [4]. During the last 24.3.2.1 Formaldehyde and

decades, a considerable number of newly devel- Formaldehyde Releasers
oped preservatives, such as MCI/MI, formalde- The use of formaldehyde has decreased markedly
hyde releasers, and methyldibro glutaronitrile in cosmetics, but at the same time, the use of
were found to be sensitizers and were added to the formaldehyde releasers did increase [58]. In our
baseline series or to special patch-test series [13]. department, 58% of allergic reactions to preser-
vatives in moisturizers were due to formaldehyde
and formaldehyde releasers (Fig. 24.3). They
Table 24.1 Total number of positive reactions to aller- have been shown to be present, for example, in
gens in moisturizers approximately 20% of cosmetics and personal
Classes of care products in the USA [5] and 25% of cosmet-
allergens 20002005 20062010 Total (%) ics in Sweden [7].
Fragrances 9 108 117 (35.5) Formaldehyde releasers are chemicals that in
Preservatives 23 90 113 (34.3)
the presence of water release formaldehyde by
Vehicle 22 40 62 (18.8)
components
hydrolysis [59]. The antimicrobial activity of
and emulsifiers these preservatives most likely results from form-
Conditioning 6 9 15 (4.5) aldehyde release, but it has also been postulated
agentsa that at least some of these substances both act as
Plant extracts 9 4 13 (3.9) preservatives [60] and contact allergens indepen-
Antioxidants 1 5 6 (1.8) dently [61].
UV absorbers/ 2 2 4 (1.2) Moreover, many patch-tested patients react
filters
both to the formaldehyde releasers diazolidinyl
Totals 72 258 330 (100)
a
urea and imidazolidinyl urea [62], which may
Conditioning agents are ingredients that may have sev-
eral other functions, such as, for example, preservative
be explained by sharing a common metabolite:
(i.e., ethylhexylglycerin) or disinfectant properties (i.e., (4-hydroxymethyl-2,5-dioxo-imidazolidin-4-yl)
propolis extract) urea (compound HU) [63].

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
2000_2005 2006_2010
Fig. 24.1 Relative frequency
(%) of allergens in moisturiz- Fragrances Preservatives Vehicle components and emulsifiers
ers during the periods: 2000 Conditioning agent Plant Extracts Antioxidants
2005 and 20062010 UV Absorbers/Filters
370 A.R. Travassos and A. Goossens

Table 24.2 Allergic reactions to nonfragrance allergens in moisturizers

Nonfragrance allergens Literature references 20002005 20062010 Total
Preservatives (113)
Benzoic acid 1 1
2-Bromo-2-nitropropane-1,3-diol [57] 2 7 9
Chlorphenesin [8, 9] 1 2 3
Diazolidinyl urea [57] 2 12 14
Dichlorobenzyl alcohol [10] 1 1 2
DMDM hydantoin [57] 2 4 6
Farnesola [11, 12] 1 1
Formaldehyde [57] 5 18 23
Imidazolidinyl urea [57] 2 10 12
Methyldibromo glutaronitrile [7, 13, 14] 3 2 5
Methylchloro- and [7, 13] 6 6
methylisothiazolinone
Methylisothiazolinone [7, 13, 15, 16] 2 2
Parabens [7, 17] 3 14 17
Phenoxyethanol [7, 14, 18] 2 7 9
Potassium sorbate [19, 20] 2 2
Quaternium-15 [57] 1 1
Vehicle components and emulsifiers (62)
Arachidyl glucoside 1 1
Butyrospermum parkii butter 4 4
Cetearyl glucoside [21] 1 1
Cetyl alcohol [22] 4 4
Decyl glucoside [2325] 1 1
Hydroxyethyl acrylate [26] 1 1
Isononyl isononanoate [27] 2 2
Isopropyl myristate [28] 1 1
Lanolin alcohols [29, 30] 9 13 22
Lauroyl collagen amino acids 1 1
Lauryl alcohol [31] 3 3
Methoxy peg-22/dodecyl glycol [31, 32] 4 4
copolymer
Propylene glycol [33] 3 4 7
Tetrahydroxypropyl ethylenediamine [34] 5 5
Sorbitan oleate [35] 1 1
Sorbitan sesquioleate [35] 2 2 4
Conditioning agents (15)
Bisabolol [36, 37] 1 2 3
Ethylhexylglycerin [23, 38] 2 4 6
Panthenol [39, 40] 2 2 4
Propolis extract [41] 1 1 2
Plant extracts (13)
Achillea millefolium extract 1 1
Arnica montana extract [42] 1 1
Avena sativa extractb [43] 1 1
Calendula officinalis extract [42] 2 2
Compositae mixture [42] 2 2
Euphorbia extract 1 1
Melaleuca alternifolia leaf oil [44] 4 1 5
24 Potential Allergens in Moisturizing Creams 371

Antioxidants (6)
Ascorbyl tetraisopalmitate [45] 1 1
Propyl gallate [46] 1 1 2
Sodium metabisulfite [47] 1 1
Tocopherol [48] 2 2
UV absorbers/filters (4)
Benzophenone-3 [49] 1 1
Ethylhexyl methoxycinnamate 1 1
Methylene bis-benzotriazolyl [50] 1 1
tetramethylbutylphenol
Terephthalylidene dicamphor sulfonic 1 1
acid
63 150 213
a
Farnesol, which is a fragrance allergen, has also antimicrobial properties
b
Immediate type I reaction to Avena sativa extract

Table 24.3 Number of reactions to fragrance allergens in moisturizers

Fragrance allergens Presence confirmed Presence not confirmed Total
FM 1 4 29 33
FM 2 10 11 21
Hydroxycitronellal 3 6 9
Geraniol 7 4 11
Eugenol 1 1
Isoeugenol 3 3
Oak Moss 3 3
Hydroxyisohexyl 3-cyclohexene 11 10 21
carboxaldeyde (Lyral)
Citral 2 2
Farnesol 1 1 2
Citronellol 3 1 4
Coumarin 1 1
Limonene 13 1 14
Linalool 4 4
Butylphenyl methylpropional 2 2
a-isomethyl ionone 1 1
Menthol 1 1
Perfume 7 7
Eucalyptus oil 1 4 5
Lavender oil 1 1
Neroli oil 2 2 4
Niaouli oil 1 1
Orange peel oil 1 1
Rose oil 2 2
Tea tree oil 1 1
77 78 155
Adapted from [2]
The presence of a fragrance allergen was considered confirmed when, according to the label, it was present in the sus-
pect product and not confirmed, when its presence was only suspected
372 A.R. Travassos and A. Goossens

Fig. 24.2 Proportion of the FM 1

reactions to fragrance
allergens in moisturizers FM 2
(Adapted from [2])
Hydroxycitronellal

Geraniol
Hydroxyisohexy13-cy
clohexene
carboxaldeyde (Lyral)
Limonene

Perfume

Other

24.3.2.2 Methylchloro- and [17]. In Sweden, methylparaben was the most

Methylisothiazolinone frequently identified preservative in cosmetics
Methylchloro- and methylisothiazolinone mix- and in 44% of the cosmetic products at least one
ture (MCI/MI), commonly used since the 1980s, paraben was present [7]; in the USA, this per-
previously became an important cause of contact centage was also more than 35% [64].
allergies, and its frequency is actually rising Parabens are rare causes of ACD, and when it
again. MCI/MI had been recommended (first up occurs, the primary sensitization source is most
to 30, later 15 ppm) to be used only in rinse-off often a topical pharmaceutical product [1, 4].
products; however, it is still found in several They are actually banned from use in cosmet-
leave-on products, such as moisturizers [1]. ics by several companies, which is a consumer
Recently, it has been replaced by methyliso- and political issue since carcinogenic and estro-
thiazolinone (MI) alone, once thought to be a genic effects have not been demonstrated in
weaker allergen [1, 15]. However, MI is also a humans and seem unlikely from its use in cos-
less efficient preservative, which requires larger metic [65]. However, in Denmark they are no
use concentrations [1], i.e., in cosmetics it is longer allowed in products for children under the
allowed up to 100 ppm [16]. age of 3.
Sensitization seems to be particularly related
to its presence in intimate hygiene products, i.e., 24.3.2.4 Other Preservatives
wipes (or moist toilette paper) for babies and Methyldibromo glutaronitrile, used as a mixture
adults [1, 15], in which MCI/MI used to be the with phenoxyethanol (Euxyl K400), became such
allergenic culprit previously. The use of such an important allergen that it was banned from
products (or any other leave-on product contain- cosmetic products in the EU in 2007 [66], which
ing MCI/MI or MI) in nonkeratinized areas or was followed by a decrease of positive reactions
under occlusion enhances their sensitizing poten- observed [13].
tial [15]. Phenoxyetanol that is considered a rare aller-
gen [18] was, in our department, responsible for
24.3.2.3 Parabens 8% of the positive reactions to preservatives in
Parabens have a broad spectrum of activity, and moisturizers (Table 24.2; Fig. 24.3).
enhancement of microbial coverage is achieved by Chlorphenesin may cross-react with mephen-
combining them with other biocides (such as form- esin, a rubefacient used in topical pharmaceutical
aldehyde releasers, MCI/MI, or phenoxyetanol) products [9].
24 Potential Allergens in Moisturizing Creams 373

Formaldehyde*
2-Bromo-2-intropropane-1,3,-
diol *
Diazolidinylurea*

DMDM hydantoin*

Imidazolidinyl urea*

Quaternium-15* * Formaldehyde
and formaldehyde
Chlorphenesin releasers (58%)

Dichlorobenzyl alcohol
Methyldibromo
glutaronitrile
Methyl chloroisothiazolinone

Parabens

Phenoxyethanol

Other

Fig. 24.3 Proportion of reactions to the preservative allergens in moisturizers

24.3.3 Vehicle Component, Emulsiers, alcohol derived from Matricaria chamomilla that
Humectants, and Conditioning has been included in several cosmetic products
Agents because of its anti-inflammatory and skin-soothing
properties [36].
The classical examples of potential allergenic Other possible allergens include ethylhexylg-
vehicle components are lanolin alcohols lycerin (syn.: octoxyglycerin), a skin conditioning
(Table 24.2) [29, 30], fatty alcohols (e.g., cetyl agent [38], and copolymers, such as methoxy
alcohol) [22], and propylene glycol [33]. More PEG-17 and PEG-22/dodecyl glycol copolymers
recently, several esters such as dicaprylyl maleate (alkoxylated alcohols and synthetic polymers used
[67], isononyl isononanoate and trioleyl phos- as emulsion stabilizers, suspending and viscosity-
phate [27], as well as humectants such as buty- increasing agents, and also as skin conditioners)
lene glycol [68] and pentylene glycol [69] were [31, 32] and polyvinylpyrrolidone (PVP)/eicosene,
identified as potential allergens. which was reported as a cause of a generalized
Alkyl glucosides, i.e., condensation products reaction [70]. We do not know whether allergic
of fatty alcohols with glucose such as coco- and reactions are due to the copolymers themselves or
lauryl glucosides [21] are often used as mild sur- to degradation products in them, larger molecules
factants, but also as emulsifiers, particularly cet- being less likely to induce sensitization.
earyl- and decyl glucoside [24, 25]. They may Some other rare allergens in moisturizers
cross-react with other alkyl glucosides and also reported are, for example, alkyl rhamnoside-C5
with methyl glucoside dioleate (a chemically (a sugar derivate used as a cosurfactant for micro-
closely related surfactant) [23]. emulsions) in a product particularly recom-
We also observed some cases of sensitization to mended for use in atopic skin [71] and phytantriol
bisabolol (Table 24.2), a monocyclic sesquiterpene (3,7,11,15-tetramethylhexadecane-1,2,3-triol), a
374 A.R. Travassos and A. Goossens

fatty alcohol used as a surfactant, penetration (vitamin C) [82], and its tetraisopalmitate ester
enhancer, and humectant in a facial cream [72]. [45]; also, ubiquinone and idebenone or
hydroxydecyl ubiquinone (a synthetic analog of
coenzyme Q10) are potential allergens [8385].
24.3.4 Plant Extracts

Plant extracts have become very popular in recent 24.3.6 UV Absorbers/Filters

years and may give rise to severe ACD [1, 73,
74]. Melaleuca alternifolia, frequently used for Because of media attention being given to the
its antibacterial or antifungal properties [44], was carcinogenic and accelerated skin-aging effects
the most frequent plant extract allergen respon- of sunlight, UV absorbers are increasingly used,
sible for positive reactions to moisturizers in our not only in sunscreen products, but also in other
unit (Table 24.2). cosmetic products including moisturizers [1].
Protein-derived ingredients are often used in Recently, contact and photocontact allergy to
moisturizers, for atopic skin (often in children). octocrylene has been increasingly observed, also
Oatmeal (Avena) [75], hydrolyzed wheat [76], or in children [86]. As with benzophenone com-
soybean extracts [77] may sometimes induce pounds, photoallergic reactions to octocrylene
ACD, although immediate-type reactions are more occur particularly in patients previously photo-
frequently seen [1]. We observed an immediate- sensitized by ketoprofen, a nonsteroidal anti-
type reaction to Avena sativa (wild oat) extract inflammatory drug, which is attributed to
from a moisturizer in an atopic patient. The diag- cross-reactivity [1, 87].
nosis was confirmed by prick tests and detection of
specific IgE antibodies (by ELISA) in the patients
serum [43]. In fact, the use of cosmetics with oat Conclusion
(or other flour extracts) in atopic patients is still In agreement with the literature, the main
controversial. Some authors suggest their avoid- allergens in moisturizers were found to be fra-
ance, based on the possible risk of subsequent sen- grance components and preservative agents;
sitization to food proteins [78], while others have hence, the most frequent allergens, such as
considered the evidence for sensitization from HICC and limonene and MCI/MI and MI,
these products to be insufficient [79, 80]. respectively, should perhaps be avoided.
Tanacetum parthenium (feverfew) is a recog- Special care should be taken regarding prod-
nized Compositae plant sensitizer, especially due ucts recommended for use in atopic skin, par-
to its content of parthenolide. Recently, allergic ticularly those containing protein-derived
reactions to a parthenolide-free feverfew materials. Indeed, their use is still controver-
extract, used because of its anti-inflammatory sial because of a possible risk of subsequent
properties, have been reported, the presence of sensitization to food.
traces of parthenolide not being excluded [81].
Patients allergic to plants belonging to this family
also often react to fragrance allergens, which is
probably due to the common presence of (oxi- Take Home Messages
dized) terpenes [42]. Contact allergic reactions to cosmetics
(such as moisturizers) are increasingly
observed.
24.3.5 Antioxidants The most frequent allergic reactions to
moisturizers are allergic contact derma-
Certain antioxidants are used in moisturizing titis (ACD), but also immediate-type
products to prevent aging, some of which reactions (such as contact urticaria syn-
responsible for ACD, i.e., tocoferol (vitamin E), drome) may occur.
retinol palmitate and acetate [48], ascorbic acid
24 Potential Allergens in Moisturizing Creams 375

cosmetics: relationship to formaldehyde contact

Patch tests are the gold standard for allergy. Part 1. Characterization, frequency and rele-
vance of sensitization, and frequency of use in cos-
diagnosing contact dermatitis, while metics. Contact Dermatitis 62:217
prick tests for contact urticaria. 6. de Groot A, White IR, Flyvholm MA, Lensen G,
The most important sensitizing culprits Coenraads PJ (2010) Formaldehyde-releasers in cos-
in moisturizers are fragrances and preser- metics: relationship to formaldehyde contact allergy.
Part 2. Patch test relationship to formaldehyde contact
vatives. allergy, experimental provocation tests, amount of form-
Currently, FM 1 and 2, Myroxylon perei- aldehyde released, and assessment of risk to consumers
rae and, to a lesser extent colophonium, allergic to formaldehyde. Contact Dermatitis 62:1831
are the diagnostic markers for perfume 7. Yazar K, Johnsson S, Lind ML, Boman A, Lidn C
(2011) Preservatives and fragrances in selected con-
allergy in the baseline series. Although sumer-available cosmetics and detergents. Contact
FM 1 can detect some 7080% of all Dermatitis 64:265272
perfume allergies, testing with addi- 8. Brown VL, Orton DI (2005) Two cases of facial der-
tional markers increases sensitivity. matitis due to chlorphenesin in cosmetics. Contact
Dermatitis 52:4849
Variations in the spectrum of the aller- 9. Wakelin SH, White IR (1997) Dermatitis from chlo-
genic preservatives are continuously rphenesin in a facial cosmetic. Contact Dermatitis 37:
observed. As new preservatives are 138139
introduced and found to be sensitizers, 10. Thormann H, Kollander M, Andersen KE (2009)
Allergic contact dermatitis from dichlorobenzyl alco-
they are progressively added to the base- hol in a patient with multiple contact allergies. Contact
line or to special patch test series Dermatitis 60:295296
(i.e., MCI/MI and MI). 11. Katsuyama M, Kobayashi Y, Ichikawa H, Mizuno A,
Plant extracts and fragrances may con- Miyachi Y, Matsunaga K, Kawashima M (2005) A
novel method to control the balance of skin microflora
tain common allergens; hence, patients Part 2. A study to assess the effect of a cream contain-
may develop multiple allergies. ing farnesol and xylitol on atopic dry skin. J Dermatol
Antioxidants and sunscreens have been Sci 38:207213
progressively introduced into moistur- 12. Gilpin S, Maibach H (2010) Allergic contact dermati-
tis caused by farnesol: clinical relevance. Cutan Ocul
izing products in order to prevent age- Toxicol 29:278287
ing; however, they add to the sensitization 13. Schnuch A, Lessmann H, Geier J, Uter W (2011)
potential in them. Contact allergy to preservatives. Analysis of IVDK
data 1996 2009. Br J Dermatol 164:13161325.
doi:10.1111/j.13652133.2011.10253.x, Epub ahead
of print
14. Tosti A, Guerra L, Bardazzi F, Gasparri F (1991)
References Euxyl K 400: a new sensitizer in cosmetics. Contact
Dermatitis 25:8993
1. Goossens A (2011) Contact-allergic reactions to cos- 15. Garca-Gavn J, Vansina S, Kerre S, Naert A, Goossens A
metics. J Allergy 2011:467071. Epub 2011 Feb 21 (2010) Methylisothiazolinone, an emerging allergen
2. Nardelli A, Drieghe J, Claes L, Boey L, Goossens A in cosmetics? Contact Dermatitis 63:96101
(2011) Fragrance allergens in specific cosmetic 16. Ackermann L, Aalto-Korte K, Alanko K, Hasan T,
products. Contact Dermatitis 64:212219 Jolanki R, Lammintausta K, Lauerma A, Laukkanen A,
3. Bruynzeel DP, Ferguson J, Andersen K, Gonalo M, Liippo J, Riekki R, Vuorela AM, Rantanen T (2011)
English J, Goossens A, Holzle E, Ibbotson SH, Lecha Contact sensitization to methylisothiazolinone in Finland
M, Lehmann P, Leonard F, Moseley H, Pigatto P, a multicentre study. Contact Dermatitis 64:4953
Tanew A, European Taskforce for Photopatch Testing 17. Cashman AL, Warshaw EM (2005) Parabens: a review
(2004) Photopatch testing: a consensus methodology of epidemiology, structure, allergenicity, and hor-
for Europe. J Eur Acad Dermatol Venereol 18: monal properties. Dermatitis 16:5766
679682 18. Lovell CR, White IR, Boyle J (1984) Contact derma-
4. Goossens AE (2006) Sensitizing substances. In: titis from phenoxyethanol in aqueous cream BP.
Loden M, Maibach HI (eds) Dry skin and moisturiz- Contact Dermatitis 11:187
ers: chemistry and function. CRC Press, Boca Raton, 19. Raison-Peyron N, Meynadier JM, Meynadier J (2000)
pp 515522 Sorbic acid: an unusual cause of systemic contact
5. de Groot AC, White IR, Flyvholm MA, Lensen G, dermatitis in an infant. Contact Dermatitis 43:
Coenraads PJ (2010) Formaldehyde-releasers in 247248
376 A.R. Travassos and A. Goossens

20. Patrizi A, Orlandi C, Vincenzi C, Bardazzi F (1999) 36. Russell K, Jacob SE (2010) Bisabolol. Dermatitis
Allergic contact dermatitis caused by sorbic acid: rare 21:5758
occurrence. Am J Contact Dermat 10:52 37. Wilkinson SM, Hausen BM, Beck MH (1995) Allergic
21. Goossens A, Decraene T, Platteaux N, Nardelli A, contact dermatitis from plant extracts in a cosmetic.
Rasschaert V (2003) Glucosides as unexpected aller- Contact Dermatitis 33:5859
gens in cosmetics. Contact Dermatitis 48:164166 38. Linsen G, Goossens A (2002) Allergic contact dermati-
22. Kiec-Swierczynska M, Krecisz B, Swierczynska- tis from ethylhexylglycerin. Contact Dermatitis 47:169
Machura D (2005) Photoallergic and allergic reaction 39. Roberts H, Williams J, Tate B (2006) Allergic contact
to 2-hydroxy-4-methoxybenzophenone (sunscreen) dermatitis to panthenol and cocamidopropyl PG
and allergy to cetyl alcohol in cosmetic cream. Contact dimonium chloride phosphate in a facial hydrating
Dermatitis 53:170171 lotion. Contact Dermatitis 55:369370
23. Pascoe D, Moreau L, Sasseville D (2010) Emergent 40. Stables GI, Wilkinson SM (1998) Allergic contact
and unusual allergens in cosmetics. Dermatitis 21: dermatitis due to panthenol. Contact Dermatitis 38:
127137 236237
24. Blondeel A (2003) Contact allergy to the mild surfac- 41. Ting PT, Silver S (2004) Allergic contact dermatitis to
tant decylglucoside. Contact Dermatitis 49:304305 propolis. J Drugs Dermatol 3:685686
25. Andersen KE, Goossens A (2006) Decyl glucoside 42. Paulsen E, Chistensen LP, Andersen KE (2008)
contact allergy from a sunscreen product. Contact Cosmetics and herbal remedies with Compositae plant
Dermatitis 54:349350 extracts are they tolerated by Compositae-allergic
26. Lucidarme N, Aerts O, Roelandts R, Goossens A patients? Contact Dermatitis 58:1523
(2008) Hydroxyethyl acrylate: a potential allergen in 43. Vansina S, Debilde D, Morren MA, Goossens A
cosmetic creams? Contact Dermatitis 59:321322 (2010) Sensitizing oat extracts in cosmetic creams: is
27. Goossens A, Verbruggen K, Cattaert N, Boey L (2008) there an alternative? Contact Dermatitis 63:169171
New cosmetic allergens: isononyl isononanoate and 44. Fritz TM, Burg G, Krasovec M (2001) Allergic contact
trioleyl phosphate. Contact Dermatitis 59:320321 dermatitis to cosmetics containing Melaleuca alternifo-
28. Bharati A, King CM (2004) Allergic contact dermati- lia (tea tree oil). Ann Dermatol Venereol 128:123126
tis from isohexadecane and isopropyl myristate. 45. Swinnen I, Goossens A (2011) Allergic contact der-
Contact Dermatitis 50:256257 matitis caused by ascorbyl tetraisopalmitate. Contact
29. Lee B, Warshaw E (2008) Lanolin allergy: history, Dermatitis 64:241242
epidemiology, responsible allergens, and manage- 46. Foti C, Bonamonte D, Cassano N, Conserva A, Vena GA
ment. Dermatitis 19:6372 (2010) Allergic contact dermatitis to propyl gallate
30. Warshaw EM, Nelsen DD, Maibach HI, Marks JG, and pentylene glycol in an emollient cream. Australas
Zug KA, Taylor JS, Rietschel RL, Fowler JF, Mathias J Dermatol 51:147148
CG, Pratt MD, Sasseville D, Storrs FJ, Belsito DV, 47. Malik MM, Hegarty MA, Bourke JF (2007) Sodium
DeLeo VA (2009) Positive patch test reactions to lan- metabisulfite a marker for cosmetic allergy? Contact
olin: cross-sectional data from the North American Dermatitis 56:241242
contact dermatitis group, 1994 to 2006. Dermatits 48. Manzano D, Aguirre A, Gardeazabal J, Eizaguirre X,
20:7988 Daz Prez JL (1994) Allergic contact dermatitis from
31. Goossens A, Armingaud P, Avenel-Audran M, Begon- tocopheryl acetate (vitamin E) and retinol palmitate
Bagdassarian I, Constandt L, Giordano-Labadie F, (vitamin A) in a moisturizing cream. Contact
Girardin P, Coz CJ, Milpied-Homsi B, Nootens C, Dermatitis 31:324
Pecquet C, Tennstedt D, Vanhecke E (2002) An epi- 49. Silva R, Almeida LM, Brando FM (1995)
demic of allergic contact dermatitis due to epilating Photoallergy to oxybenzone in cosmetic creams.
products. Contact Dermatitis 47:6770 Contact Dermatitis 32:176
32. Le Coz CJ, Heid E (2001) Allergic contact dermatitis 50. Gonzlez-Prez R, Trbol I, Garca-Ro I, Arregui
from methoxy PEG-17/dodecyl glycol copolymer MA, Soloeta R (2007) Allergic contact dermatitis
(Elfacos OW 100). Contact Dermatitis 44:308309 from methylene-bis-benzotriazolyl tetramethylbu-
33. Warshaw EM, Botto NC, Maibach HI, Fowler JF Jr, tylphenol (Tinosorb M). Contact Dermatitis 56:121
Rietschel RL, Zug KA, Belsito DV, Taylor JS, DeLeo 51. Frosch PJ, Pilz B, Andersen KE et al (1995) Patch
VA, Pratt MD, Sasseville D, Storrs FJ, Marks JG Jr, testing with fragrances: results of a multi-center study
Mathias CG (2009) Positive patch-test reactions to of the European Environmental and Contact Dermatitis
propylene glycol: a retrospective cross-sectional anal- Research Group with 48 frequently used constituents
ysis from the North American Contact Dermatitis of perfumes. Contact Dermatitis 33:333342
Group, 1996 to 2006. Dermatitis 20:1420 52. Frosch PJ, Johansen JD, Menn T et al (1999) Lyral is
34. Goossens A, Baret I, Swevers A (2011) Allergic con- an important sensitizer in patients sensitive to fra-
tact dermatitis caused by tetrahydroxypropyl ethyl- grances. Br J Dermatol 141:10761083
enediamine in cosmetic products. Contact Dermatitis 53. Matura M, Goossens A, Bordalo O, Garcia-Bravo B,
64:161164 Magnusson K, Wrangsjo K, Karlberg AT (2003) Patch
35. Pereira F, Cunha H, Dias M (1997) Contact dermatitis testing with oxidized R- (+)-limonene and its
due to emulsifiers. Contact Dermatitis 36:114 hydroperoxide fraction. Contact Dermatitis 49:1521
24 Potential Allergens in Moisturizing Creams 377

54. Skld M, Brje A, Matura M, Karlberg AT (2002) testing with 1,3-butylene glycol from 1994 to 1999.
Studies on the autoxidation and sensitizing capacity Environ Dermatol 8:15
of the fragrance chemical linalool, identifying a 69. Gallo R, Viglizzo G, Vecchio F, Parodi A (2003)
linalool hydroperoxide. Contact Dermatitis 46: Allergic contact dermatitis from pentylene glycol in
267272 an emollient cream, with possible co-sensitization to
55. Johansen JD, Bernard G, Gimnez-Arnau E et al resveratrol. Contact Dermatitis 48:176177
(2006) Comparison of elicitation potential of chloroa- 70. Gallo R, Sacco DD, Ghigliotti G (2004) Allergic con-
tranol and atranol 2 allergens in oak moss absolute. tact dermatitis from VP/eicosene copolymer (Ganex
Contact Dermatitis 54:192195 V-220) in an emollient cream. Contact Dermatitis
56. Paulsen E, Andersen KE (2005) Colophonium and 50:261
Compositae mix as markers of fragrance allergy: 71. Kgler K, Mydlach B, Frosch PJ (2009) Contact
cross-reactivity between fragrance terpenes, colopho- allergy from alkyl rhamnoside-C5. Contact Dermatitis
nium and compositae plant extracts. Contact 61:352353
Dermatitis 53:285291 72. Brasch J, Lipowsky F, Kreiselmaier I (2008) Allergic
57. Thyssen JP, Engkilde K, Lundov MD, Carlsen BC, contact dermatitis to phytantriol. Contact Dermatitis
Menn T, Johansen JD (2010) Temporal trends of pre- 59:251252
servative allergy in Denmark (19852008). Contact 73. Kiken DA, Cohen DE (2002) Contact dermatitis to
Dermatitis 62:102108 botanical extracts. Am J Contact Dermat 13:148152
58. Lundov MD, Johansen JD, Carlsen BC, Engkilde K, 74. Thomson KF, Wilkinson SM (2003) Allergic contact
Menn T, Thyssen JP (2010) Formaldehyde exposure dermatitis to plant extracts in patients with cosmetic
and patterns of concomitant contact allergy to formalde- dermatitis. Br J Dermatol 142:8488
hyde and formaldehyde-releasers. Contact Dermatitis 75. Pazzaglia M, Jorizzo M, Parente G, Tosti A (2000)
63:3136 Allergic contact dermatitis due to avena extract.
59. Emeis D, de Groot AC, Brinkmann J (2010) Contact Dermatitis 42:364
Determination of formaldehyde in formaldehyde- 76. Sanchez-Prez J, Sanz T, Garca-Dez A (2000)
releaser patch test preparations. Contact Dermatitis Allergic contact dermatitis from hydrolyzed wheat
63:5762 protein in a cosmetic cream. Contact Dermatitis
60. Flyvholm M-A, Andersen P (1993) Identification of 42:360
formaldehyde releasers and occurrence of formalde- 77. Shaffrali FC, Gawkrodger DJ (2001) Contact derma-
hyde and formaldehyde releasers in registered chemi- titis from soybean extract in a cosmetic cream. Contact
cal products. Am J Ind Med 24:533552 Dermatitis 44:5152
61. Kireche M, Gimenez-Arnau E, Lepoittevin JP (2010) 78. Boussault P, Laut-Labrze C, Saubusse E, Maurice-
Preservatives in cosmetics: reactivity of allergenic Tison S, Perromat M, Roul S, Sarrat A, Taeb A,
formaldehyde-releasers towards amino acids through Boralevi F (2007) Oat sensitization in children with
breakdown products other than formaldehyde. Contact atopic dermatitis: prevalence, risks and associated
Dermatitis 63:192202 factors. Allergy 62:12511256
62. Garca-Gavn J, Gonzlez-Vilas D, Fernndez- 79. Goujon-Henry C, Hennino A, Nicolas J-F (2008) Do
Redondo V, Toribo J (2010) Allergic contact dermati- we have to recommend not using oat-containing emol-
tis in a girl due to several cosmetics containing lients in children with atopic dermatitis? Allergy
diazolidinyl-urea or imidazolidinyl-urea. Contact 63:781782
Dermatitis 63:4950 80. Ranc F, Dargassies J, Dupuy P, Schmitt AM, Gerin L,
63. Lehmann SV, Hoeck U, Breinholdt J, Olsen CE, Dutau G (2001) Faut-il contre-indiquer lutilisation
Kreilgaard B (2006) Characterization and chemistry des mollients base davoine chez lenfant atopique?
of imidazolidinyl urea and diazolidinyl urea. Contact Rev Fr Allergol Immunol Clin 41:477483
Dermatitis 54:5058 81. Paulsen E, Christensen LP, Frett XC, Andersen KE
64. Lundov MD, Moesby L, Zachariae C, Johansen JD (2010) Patch test reactivity to feverfew-containing
(2009) Contamination versus preservation of cosmet- creams in feverfew-allergic patients. Contact
ics: a review on legislation, usage, infections, and Dermatitis 63:146150
contact allergy. Contact Dermatitis 60:7078 82. Belhadjali H, Giordano-Labadie F, Bazex J (2001)
65. Revuz J (2009) Long live parabens. Ann Dermatol Contact dermatitis from vitamin C in a cosmetic anti-
Venereol 136:403404 aging cream. Contact Dermatitis 45:317
66. European-Communities (2007) Directive EU 2007/ 83. Sasseville D, Moreau L, Al-Sowaidi M (2007)
17/EC 22 March 2007 Allergic contact dermatitis to idebenone used as an
67. Lotery H, Kirk S, Beck M, Burova E, Crone M, Curley antioxidant in an anti-wrinkle cream. Contact
R, Downs A, Hill G, Horne H, Iftikhar N, Lovell C, Dermatitis 56:117
Malanin K, Orton D, Powell S, Sansom J, Sonnex T, 84. Natkunarajah J, Ostlere L (2008) Allergic contact der-
Todd D, Tucker S, Wilkinson M, Haworth A (2007) matitis to idebenone in an over-the-counter anti-age-
Dicaprylyl maleate. Contact Dermatitis 57:169172 ing cream. Contact Dermatitis 58:239
68. Sugiura M, Hayakawa R, Kato Y, Sugiura K, 85. Fleming JD, White JM, White IR (2008) Allergic
Hashimoto R, Shamoto M (2001) Results of patch contact dermatitis to hydroxydecyl ubiquinone: a
378 A.R. Travassos and A. Goossens

newly described contact allergen in cosmetics. Contact 87. Karlsson I, Vanden Broecke K, Mrtensson J,
Dermatitis 58:245 Goossens A, Brje A (2011) Clinical and experimen-
86. Avenel-Audran M, Dutartre H, Goossens A, Jeanmougin tal studies of octocrylenes allergenic potency. Contact
M, Comte C, Bernier C, Benkalfate L, Michel M, Dermatitis. doi:10.1111/j.16000536.2011.01899.x,
Ferrier-Leboudec MC, Vigan M, Bourrain JL, Outtas Epub ahead of print
O, Peyron JL, Martin L (2010) Octocrylene, an emerg-
ing photoallergen. Arch Dermatol 146:753757
 Formulating Moisturizers
Using Natural Raw Materials 25
Swarnlata Saraf

25.1 Introduction more unwanted after effects, skin allergies and

cost effectiveness [2]. Natural raw materials
Traditionally, cosmetics were the substances used for formulating moisturizers could be of
applied to the human body for cleansing, beau- plant origin like dry exudates or herbal extracts,
tifying, perfuming or changing the appearance from animal origin like gelatine, cholesterol and
except soap and must not cause damage to the lanolin; from marine sources like sphingolipids
human health. The use of herbal beauty prod- or from minerals like bentonite and Veegum.
ucts dates back to ancient times. In fact, virtu- As compared to synthetic cosmetic products,
ally, every ancient culture recorded the use of natural products are mild, biodegradable and
native herbs for a beautiful healthy complexion. have low toxicity profile. To enhance these prop-
This evidence supports herbal skin cares effi- erties, researches are being done in the develop-
cacy, with recipes once highly reputed being ment of newer approaches, which could improve
lost for a time and rediscovered in recent his- both the aesthetic appeal and performance of a
tory. Furthermore, modern science has evalu- cosmetic product. But the latest trend is to com-
ated and confirmed the cleansing, healing bine clinically proven natural ingredients with
and protective qualities of many herbs. Herbs patented delivery systems and the aesthetics of
and spices have been used in maintaining and fine cosmetics [15].
enhancing human beauty since naturals have a The appearance and function of the skin are
lot of properties like sunscreen effect, anti-age- maintained by an important balance between the
ing, moisturizing, antioxidant, anti-cellulite and water content of the stratum corneum and skin
antimicrobial effect. In early 1920s, a big popu- surface lipids [36, 39]. When this balance is dis-
lation started using cosmetic preparations con- rupted, skin mechanical properties and water
taining synthetic ingredients for their instant content get disturbed; hence, skin becomes dry
effects with some advantages like less time con- and loses its elasticity. In these cases, effective
suming, ease of application, high aesthetic dermato-cosmetic products must be used to
appeal, ease to store, easy to carry, etc., with improve the skin hydration and viscoelasticity
some limitations like sporadically deterioration, not only for aesthetic purposes but also to main-
tain the normal conditions of skin and to prevent
dry skin alterations [30].
The stratum corneum is the main barrier of the
S. Saraf skin and prevents dehydration. Water plays an
Department of Pharmacy,
important role in respect to the normal function of
Guru Ghasidas Central University,
Koni Bilaspur, Chhattisgarh 495009, India the epidermal barrier, which is also reflected in the
e-mail: [email protected] differing water contents of the stratum corneum

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 379

DOI 10.1007/978-3-642-27606-4_25, Springer-Verlag Berlin Heidelberg 2012
380 S. Saraf

Structure of different layers of skin

Stratum
disjunctum

Stratum Mechanism 1: generation of natural

corneum Corneocytes
moisturizing factors in the skin
Intercellular
Epidermal cells mature in the middle layer
Epidermis

lipids
Tight of skin
Stratum junctions
Natural defense
granulosum
Keratinocytes mechanisms Filaggrin protien clumps into granules in
against decrease in the granular cell layer
Stratum
Melanin
hydration
spinosum Filaggrin and keratin protein are complexed
Melanocyte
to protect from proteolytic degradation
AQP3
Stratum
basale Corneocytes develope which are protein
Keratinocyte
envelops filled with filaggrin-keratin
complex, these corneocytes move upwards
Dermis

Fibroblasts
to outer layer of skin

Enzymes break down filaggrin-keratin
complex to filaggrin and keratin proteins

Mechanism 3: Intercellular lipid layers Decreased water content stratum
Mechanism 2: Desquamation of Lipids in granular cell layer of skin form corneum
cells granules
Intact corneocytes in upper level of Proteolytic enzymes get activated
hydrated stratum corneum Degeneration of granular cells releases
lipid granules into intercellular spaces Filaggrin is degraded into individual amino
Proteolytic enzymes break protein acids
connections between corneocytes Lipids released from degeneration of cells
and lipid granules complex together to form Amino acids combines with other chemicals
Corneocytes desquamate intercellular stacked lipid structures to form natural moisturizing factors
(NMFs) in stratum corneum
Skin stays normal without dry Lipid layers hold water and surround
scales corneocytes to provide permeability barrier NMFs holds water to rehydrate stratum
corneum

Fig. 25.1 Physiology of skin hydration and dehydration

(1015%) and viable epidermis (about 60%). The been boosted by increasing demand for natural
water content in the stratum corneum is mostly alternative medicines. World demand for herbal
bound to the head group of ceramides and to pro- products has been growing at a rate of 1015%
teins and is an essential prerequisite for the barrier per annum. The medicinal plants-related trade in
function. Thus, a decrease in water content below India alone is approximately Rs. 5.5 billion.
the minimum level is associated with skin mal- World Health Organization (WHO) has fore-
function [19]. The moisture content of the skin is casted that the global market for herbal products
of particular interest in cosmetic applications. would be worth $5 trillion by the year 2050.
Cosmetic care is therefore concerned to equilibrate Europe and the United States are the two major
the moisture balance of the skin (Fig. 25.1). herbal products markets in the world, with a
According to market survey, the global mar- market share of 41% and 20%, respectively.
ket for cosmetics and toiletries reached nearly According to the World Bank, the global market
$150 billion in 2004, increase by more than 4% for medicinal plants and their products includes
from 2003, which highlights major growth in the potential sectors of pharmaceuticals, nutra-
key developing markets. The herbal market has ceuticals and cosmeceutical to be estimated of
25 Formulating Moisturizers Using Natural Raw Materials 381

worth US$ 62 billion and offers a plethora of increases [47]. The hydration level of the stra-
opportunities for the Indian pharma and cosmetic tum corneum affects its mechanical and electri-
companies [2]. cal properties [52]. Age-related changes in the
By adopting proper methodologies and tech- skins appearance are dryness, wrinkling and
niques, risk factors of ingredients incorporated laxity. Xerosis with pruritus and scleroderma
in cosmetics can be determined and managed at like skin changes are observed in persons having
safety level. The toxicological evaluation of a diabetes mellitus [49]. Moisturizing formula-
cosmetic product should be certainly carried tions play significant aspect in rectifying dry
out with full knowledge of the pharmacotech- skin by softening the skin as water is important
nical, toxicological, pharmacokinetic, regula- for maintaining the flexibility and softness of
tory, clinical phases areas and Scientific skin. But specifically, the moisture-related skin
Committee of Cosmetics and Non-Food types could be determined as very dry skin (cor-
Products Intended (SCCNFP), Organization for neometer unit below 30), dry skin (between 30
Economic Cooperation and Development and 40) and normal skin (higher than 40 arbi-
(OECD), European Cosmetic, Toiletry and trary units) [21]. The selection of moisturizing
Perfumery Association (COLIPA), Cosmetics, formulation is very important according to the
Toiletries and Fragrances Association (CTFA), skin type, condition and body part. Similarly,
Bureau of Indian Standard (BIS) and World designing of safe and effective moisturizers with
Health Organization (WHO) guidelines [17, 24, suitable raw materials is also a challenging
25]. Cosmetic products are regulated in various aspect.
countries according to their own legislations
like EU Cosmetic Directives in European Union
(EU), Food Drug and Cosmetics Act in USA, 25.3 Natural Raw Materials
Pharmaceutical Affairs Law (PAL) in Japan and Improving Skin Hydration
Legislations of Canada, India, Australia, China
and other Asian countries [40]. Various moisturizers are available under the
label of natural, safe, organic and herbal, while
the basic properties of humectancy, occlusivity
and emolliency are consistent across all mois-
25.2 Problems Related to Skin turizers. Most of the available moisturizers use
synthetic adhesives, emulsifiers, perfuming
Commonly, skin types are categorized as normal agents, pigments, surfactants and thickeners to
skin, dry skin, oily skin, combination skin and form the base. There is extensive need to replace
sensitive skin. The disturbance in balance toxic synthetic agent from base using natural
between water content of the stratum corneum agents [26]. Table 25.1 summarizes the cate-
and skin surface lipids causes dry skin [5]. Dry gory of natural substances associated with the
skin could be caused by a dry climate, winter enhancement of skin hydration through various
weather and deficiency of vitamin A, systemic mechanisms.
illness, overexposure to sunlight, medication or In the study of comparison of hydration effect
by medical conditions like diabetes and psoria- of various moisturizers, it was observed that the
sis. The skin loses moisture resulting in crack formulation having wheat germ oil, Aloe vera
and peel, or it may become irritated, inflamed, and turmeric extract in combination showed sig-
and itching, leading to serious skin problems. nificant moisturizing effects [44]. Wheat germ oil
Dry skin is also observed in patients with atopic is rich in vitamins A, D and E, used for its anti-
dermatitis [5]. When photo-stress is applied on oxidant effects on free radicals in the skin as
the skin, the sebum quantity decreases, the natural preservative. Herbs like Aloe vera, com-
hydration index reduces and the melanin index frey, calendula, dandelion, chamomile, fennel
 382

Table 25.1 Natural moisturizing raw materials categorized on the basis of mechanism of action
Category Mechanism of action Examples
Moisturizers They add moisture or water to the skin D-Panthenol and sorbitol present in fruits and berries
Emollients They soften and smoothen the skin and are used to correct Jojoba oil, black cohosh, soy extract and vitamin A and E
dryness and scaling of the skin by preventing water loss
Humectants Are substances that have a molecular structure that enables them Glycerin, honey, silk protein and natural phospholipids, from
to retain water and bind it in the skin. Humectants are also lecithin
capable penetrating the skin. They are introduced into the
stratum corneum to increase its water-holding capacity
Occlusives Provide a layer of oil on the surface of the skin to slow water Paraffin oils/waxes
loss and thus increase the moisture content of the stratum
corneum
Substantives Substantives are substances or ingredients that attach themselves Algae products
very well to the surface of the skin, then spread across the skin to
protect and to hydrate it
Natural antioxidants Natural antioxidants quench free radicals and are an essential Flavonoids like apigenin, Catechin, Epicatechin, alpha glycosyl
component of anti-ageing formulations. They potentially offer rutin and Silymarin are polyphenolic and antioxidant
protection against damage to the tissues by environmental and Vitamins: ascorbic acid, alpha-tocopherol, retinol
other agents Natural oils such as rapeseed oil, sunflower oil and soybean oil
Natural anti-inflammatory agents They sooth, heal and protect skin tone and integrity Liquorice (G. glabra), marigold (C. officinale), varuna (C.
nurvala), etc. are the potent anti-inflammatory herbs
Anti-irritant They improve hydration and elasticity and help to prevent skin Essential fatty acids
breakdown
Keratolytic agents They prevent accumulation of excessive stratum corneum and Glycolic acids, retinoic acids and lactic acid
remove the cohesive attachment of cornified cells
S. Saraf
25 Formulating Moisturizers Using Natural Raw Materials 383

and peppermint are very effective for preventing the ability to reduce the oxidative damage [29].
dry skin, soothing the discomfort of dry skin and The formulations composed of such extracts
healing the symptoms of dry skin, while essential could be utilized for the protection of photo-
oils help lubricate the skin to curb dryness, herbs induced intrinsic oxidative stress as well as struc-
work by softening and moisturizing the skin. tural alteration in skin [4, 14]. It has been observed
Vegetable oils like peanut oil, almond oil, ses- by our research group that the products which
ame oil and olive oil are important oleaginous contains either herbal extract/seed/oil/juice/gel of
raw material used for the preparation of creams. aloe vera, grape, almond, olive, wheat germ, san-
Stearic acid is used as an emulsifier to develop dalwood and cucumber shown better viscoelastic
consistency in the cream and to give a matt effect and hydration effect as compared to other prod-
on the skin. Stearyl alcohol and cetyl alcohol are ucts [27]. The herbal cosmetic cream formula-
used as emollients and stabilizers. Waxes of ani- tions were designed by Ashawat et al. [3] using
mal and vegetable origin like lanolin, beeswax ethanolic extracts of Glycyrriza glabra, Curcuma
and carnauba wax also constitute important com- longa (roots), seeds of Psorolea corylifolia,
ponent in the formulation of moisturizing formu- Cassia tora, Areca catechu, Punica granatum,
lations. Natural gums are polysaccharides of fruits of Embelica officinale, leaves of Centella
natural origin, capable of causing a large viscos- asiatica, dried bark of Cinnamon zeylanicum and
ity increase in solution, even at small concentra- fresh gel of Aloe vera in varied concentrations
tions. They are used as thickening agents, gelling (0.120.9%w/w) and observed the improvement
agents, emulsifying agents, binding agents and in skin viscoelastic and hydration properties [3].
stabilizers. Natural gums could be obtained from Table 25.3 shows some of the important herbs
sea weeds, bacterial fermentation and from non- with their chemical constituents and functional
marine botanical resources. Glycerin and sorbitol properties that could be used to formulate herbal
(70%) are used as humectants which enhance the moisturizers.
spreadability, improve consistency and prevent In the study performed by Kapoor and Saraf,
the cream from drying out [31]. The raw materi- various marketed herbal moisturizers were com-
als could also be categorized on the basis of their pared and concluded that presence of Aloe vera
source of origin as depicted in Table 25.2. (Ghrit kumari) extract, which is rich composition
in hygroscope mono- and polysaccharides and in
the amino acids, improves water retention in the
25.4 Herbal Extracts as Raw stratum corneum [26]. The silica in cucumber
Materials for Moisturizing (Cucumis sativum) is an essential component of
Formulations healthy connective tissue, which includes mus-
cles, tendons, ligaments, cartilage and bone, and
Due to the harmful effects of chemicals, the is an excellent source of potassium, vitamin C
researchers are shifting towards herbal cosmet- and folic acid. The high water content makes
ics. The poly-herbal cosmetic formulations have cucumbers good for moisturizing effect. Methi
been recommended for the management of skin (Trigonella foenum-graecum) seed extract con-
properties for a long time, and their effects are tains 4560% carbohydrates, 510% fixed oils
also well accepted [3]. Formulating cosmetics (lipids), flavonoids and free amino acids that pro-
using completely natural raw materials is a diffi- vide softening, cleansing and soothing properties
cult task. The need is to substitute synthetic base to skin. Sandalwood (Santalum alba) the main
from naturals while maintaining the same func- constituent of sandalwood oil is santalol, credited
tional effects acquiring from synthetic one [26]. for its moisturizing and viscoleastictity property.
Extracts of many plants, citrus fruits and leafy Almond oil (Prunus amygdalus) contains folic
vegetables as source of ascorbic acid, vitamin E acid, alpha-tocopherol and zinc, which are use-
and phenolic compounds and enzymes possess ful in skin disorders. Wheat germ oil (Triticum
Table 25.2 Various types of raw materials based on origin constituting moisturizing formulations
384

Category/type Name of materials Source Uses

Plant-originated raw materials Acacia Dry exudates from species of Acacia Emulsifying agent
Tragacanth Dry gummy exudates from species of Stabilizer, thickener and emulsifier
Astragalus
Agar, carrageenan and alginates Extracted from sea weeds like red algae Suspending and gelling agent
Seed gum, guar gum, psyllium seed gum Seed gums or extracts Emulsifier
Soy lecithin Is manufactured from soybean oil seeds. Emulsifiers, antioxidants, stabilizers and
The major phospholipids for soy lecithin wetting agents
are phosphatidylcholine, phosphatidyle-
thanolamine and phosphatidylinositol
Animal-originated raw materials Gelatin Partial hydrolysis of collagen derived Stabilizer and thickener
from skin, connective tissues and bones
of animals
Cholesterol Obtained by saponification and Stabilizers
fractionation of wool fat
Lanolin and lanolin alcohols Lanolin material derived from wool; it is Used as base of cosmetic formulations
a mixture of cholesterol esters and and emulsifiers
higher fatty acid esters.
Lanolin alcohols are obtained by
hydrolysis of lanolin
Beeswax Purified wax from the honeycomb of Emulsion stabilizer, skin-conditioning
Apis mellifera bee agent, thickening agent and has
emollient, soothing and softening
properties
Egg lecithin Produced from egg yolk and consists of Emulsifiers, soothing and softening
phosphatidylethanolamine and properties
phosphatidylcholine
Casein Is a milk protein which can be prepared Emulsifiers, thickeners and gelling
by isoelectric precipitation or enzyme agents
precipitation
Chitosan Natural polymer obtained by deacetyla- Gelling agent, increases viscosity
tion of chitin. Present in shell fish
S. Saraf
 25
Mineral-originated raw materials Bentonite Is natural colloidal-hydrated aluminium Has swelling property and thickener,
silicate used in forming gels
Veegum Is colloidal magnesium aluminium Suspending agent and thickener
silicate
Attapulgite Obtained from Attapulgus and is Suspending agent and thickener
hydrous magnesium aluminium silicate
Fermentation product Xanthan gum Produced by culture fermentation of Stabilizer, thickener and emulsifier
carbohydrate with Xanthomonas
campestris
Marine-originated raw materials Marine phospholipids (eicosapentaenoic Antartic krill (Euphausia superba) and Novel vesicular system development
and docosahexaenoic acid) fish Roe like Marinosomes
Sphingolipid (sphingomyelin) Mammals milk, preferably bovine milk; Novel vesicular system development
brain; egg yolk and erythrocytes from like Sphingosomes
animal blood, preferably sheep
Formulating Moisturizers Using Natural Raw Materials
385
Table 25.3 List of herbs with their chemical constituents and functional properties to formulate herbal moisturizers
386

Herbs Chemical constituents Functional properties

Aloe barbadensis (leaf extract) Barbaloin, aloe emodin, aloesin, amino acid, enzymes, Moisturizing agent and impart elasticity
vitamin
Areca catechu (seeds) High amounts of tannic acid and gallic acid. Polyphenols Antimicrobial, anti-inflammatory, anti-melanogenesis,
and tannins are the major constituent of the nut anti-elastase and antioxidant activity
Azadirachta indica (leaf extract) Nimbin, nimbinin and nimbidin Rejuvating and extrafoliating agent and as preservative
Centella asiatica (leaves) Triterpene glycosides such as centella saponin, asiatico- Antioxidant, wound healing, in skin improver tonics,
side, madecassoside and sceffoleoside and also asiatic acid anti-ageing and as cooling agents
and madecassic acid
Cinnamon zeylanicum (bark) Phenolic compounds, such as catechin, epicatechin, and Antioxidants, antiseptic, astringent, and antibacterial
procyanidin B2, phenol polymers and polyphenols
Cocos nucifera (oil) Lauric oils Soothing agent
Cucumis sativus (main fruit juice) Silica, vitamin C and folic acid Moisturizing and firming agent
Curcuma caesia (rhizomes) Oil of Curcuma caesia contain ar-turmerone, (Z)-b- Rhizomes are useful in treating leucoderma, tumours,
ocimene, camphor, ar-curcumene, 1,8-cineole, b-elemene, inflammations and allergic eruptions
borneol, bornyl acetate and g-curcumene as the major
constituents
Emblica officinalis Vitamin C Antioxidant
Glycerrhiza glabra (bark extract) Estragole, anethole, flavonoids Astringent
Oleum olivae (oil) Prevent drying and chafing
Prunus amygdalus (oil) Amandin, folic acid, alpha-tocopherol and zinc Hydrating and firming agent
Santalum alba (oil) Santalol Alleviate itching and cooling agent
Tamarindus indica (fruit) Mineral elements, saponins alkaloids and glycosides and Anti-fungal, antibacterial, anti-inflammatory and antioxi-
with a high antioxidant capacity associated with high dant properties
phenolic including gallic acid
Trigonella foenum-graecum (seed extract) Carbohydrates, lipids, flavonoids and free amino acids Softening and soothing agent
Triticum sativum (oil) Vitamin E and carbohydrate Nourishing and occlusive agent
S. Saraf
25 Formulating Moisturizers Using Natural Raw Materials 387

sativum) is a rich source of tocopherols with high substances collectively result in stable moistur-
vitamin E potency that nourishes and prevents izing formulations [1].
loss of moisture from the skin. Red apple (Pyrus Development of moisturizing formulations
malus) is a rich source of various vitamins, trace taking natural raw materials is a challenging
elements, amino acids and flavonoids due to task. Since skin pH is towards acidic range [22],
which it acts as humectant and provides moistur- vegetable-oil-based formulations are developing
izing and viscoelasticity property. Coconut as they are acidic in nature, easily biodegradable
(Cocos nucifera) oil helps keep skin soft and and skin lipid compatible, too [38]. Selection of
smooth. Lauric oils, the dominant fatty acid (45 emulsifying agent to prepare stable formulation
48%) in coconut oil, are used in cosmetics. is also important task. Hydrophilic lipophilic
Yashtimadhu (Glycyrrhiza glabra) extract is balance system of Griffin is very supportive in
helpful to formulate cosmetic products for the this contest and helps in deciding appropriate
protection of skin and hair against oxidative pro- emulgents. Natural raw materials could be used
cesses. Grape seed (Vitis vinifera) contain pycno- as additives for the preparation of various mois-
geneol, which is responsible for its cosmetic turizing formulations, for example, spice extrac-
properties [26]. tives having aromatic principles could act as
flavouring agents, gums as viscosity modifiers or
thickeners, fruit acids for pH adjustment, vegeta-
25.5 Preparation of Moisturizing ble oils as emollients and vehicles, waxes as
Formulations thickeners and emollients, plant extracts as con-
ditioners and vitamins and fatty acids as mois-
Pharmaceutically, cosmetic moisturizers like turizers and antioxidants. Caramel, carmine and
creams, lotions and milks are emulsion systems beta-carotene are approved natural colourants.
varying in consistency and rheological character Natural preservatives include fruit extracts
on the basis of their constituents and purpose. (grapefruit seed and rosemary), essential oils
Creams are semisolid viscous with opaque (tea tree, neem seed, thyme) and vitamins (vita-
appearance having apparent viscosity, while min E and vitamin C).
lotions are pourable with low viscosity. Gels are
semisolid system in which a liquid phase is con-
strained within a 3-D polymeric matrix (consist- 25.5.1 Techniques of Herbal
ing of natural or synthetic gum) having a high Moisturizing Formulation
degree of physical or chemical cross-linking.
Jellies are transparent or translucent non-greasy Moisturizing formulations could be prepared by
semisolids to thick viscous fluids that consist of using a phase inversion technique [18]. Initially,
submicroscopic particles in plastic or rigid base- natural oil and other ingredients (like sesame oil,
like natural gums. The cosmetic emulsions almond oil, cetyl alcohol, stearic acid, sorbitan
could be oil-in-water type, water-in-oil type or stearate and sorbitan monooleate) are mixed
oil-in-water-in-oil or water-in-oil-in-water type. using an overhead stirrer at 200 25 rpm at
All cosmetic formulations can be categorized 6575C on a hot plate. After the complete melt-
into four major groups: cleansing, moisturizing, ing and homogenous mixing, a 50-ml portion of
all-purpose and protective products based on deionized water (70 2C) and glycerine are
their functional properties [32]. Majority of added at a rate of 30 ml/min1 at increased speed
cosmetic creams and lotions contain lipid (275 25 rpm) along with the herbal extracts.
(oil) and water as their major components and When the temperature of the internal phase is
other minor ingredients like surface active reduced to 50C, phase inversion occurs and the
agents, moisturizers, emollients, waxes, thick- solution becomes viscous; the remaining aqueous
eners, active ingredients, sunscreens, antioxi- phase containing propylene glycol is then added.
dants, colours, preservative, etc. All of these When the temperature is reduced to 40C, honey
388 S. Saraf

Fig. 25.2 Schematic Water Mechanical Water Mechanical

representation of development energy energy
of moisturizing formulation Extracts
addition

Oil Slow speed

Phase
phase inversion

Tem.
Oil in water cream and lotion system

is added to this mixture [3]. Schematic represen- evaluation and safety analysis. On the basis of
tation of development of cosmetic moisturizing these parameters, they are further taken for psy-
formulation is shown in Fig. 25.2. chometric analysis, biological studies and bio-
Another combination of natural raw materials engineering methods of evaluation. After the
for the preparation of water in oil emulsion cream analysis of all the obtained evaluation parame-
is by initially melting bees wax at 6070C, then ters, the prepared moisturizing formulations are
to this, added lanolin, almond oil, olive oil, neem completely developed. The detailed steps are
oil and tocopherol. Then, aqueous phase along depicted in Fig. 25.3.
with neem extract is taken and heated at 50C, to
this, glycerine and rose water are added, and after 25.5.2.1 Example for the Development of
cooling up to 40C, sandalwood stick aq extract Herbal Moisturizing Formulation
is added to it. Both the phases were mixed con- Preparation of Natural Base
tinuously for homogenous dispersion and cooled Phase inversion technique was used to prepare
slowly for fragrance peppermint oil and sandal- natural base [M5]. The internal phase was pre-
wood oil added [46]. pared by using several ingredients, and emulsifi-
cation was carried out in the mortar and pastel.
Initially, grated and melted bees wax, natural oil
25.5.2 Development of Herbal of T. sativum, C. nucifera, P. amygdalus, O. oli-
Moisturizing Formulations vae and S. alba and other ingredients acacia, soy
lecithin and glycerin were mixed using an homog-
Moisturizing formulations could be cream, enizer at 200 25 rpm at 6575C. After the com-
lotion or milk preparation. For the development plete homogenous mixing, a 50-ml portion of
of herbal moisturizing formulation, first step is triple distilled water [70 2C] was added at a rate
the extraction of herbal active constituents of 45 ml/min at increased speed [250 25 rpm].
according to the well-established methods like When the temperature of the internal phase was
hot extraction method for volatile constituents, reduced to 50C, phase inversion took place and
cold maceration process for thermolabile phyto- the solution became viscous. When the tempera-
constituents, etc. Then, the herbal extracts or ture was reduced to 40C, honey [2% w/w] was
juices obtained undergo qualitative and quanti- added to this mixture [27].
tative evaluation for the standardization and
purity of the obtained phytoconstituents. Next Formulation of Herbal Moisturizer
step is preparation of cream base and inclusion Different concentrations, i.e., 0.1350.9% w/w of
of herbal extract/juices in that base. They could Cucumis sativus, Glycerrhiza glabra, Emblica
be either included during cream formation or officinalis, Azadirachta indica, Trigonella foe-
could be incorporated in the prepared base num-graecum, Aloe barbadensis extracts, juice
cream. The prepared herbal cream formulation and gel prepared in ethanol were incorporated
is then evaluated for stability, physicochemical into the natural base and coded as M1. Natural
25 Formulating Moisturizers Using Natural Raw Materials 389

Phytochemical
evaluation of
extracts/juices/gels
Preparation of
In vitro sun protection herbalextracts
factor (SPF)
determination of extract
and of prepared cream Quantification of
extracts/juices/gels

Physicochemical evaluations
of cream
Physical stability of
Preparation of
Physical appearence Net cream formulation
content herbal cream
formulation
pH of cream Ash
value
Non-volatile matter Acid Safety analysis
value Microbiological
specification and sensitivity
Saponification value profile.
Viscosity

Psychomatric evaluations
Biological studies
Bioengineering methods of
evaluation
Appearance, irritation, In vivo lipid damege Viscoelastic properties
determination measurement
Stickiness, smoothness, Skin hydration detrmination
Quantification of UV induced
Sebum concentration
DNA demage
after effect of skin, fragrance, determination
Erythema determination
lathery feel, softness Melanin and erythema
Edema determination
determination
Epidermal cell tumover
determination
Sunburn cell count
Enzyme estimation

Fig. 25.3 Various steps for the development of herbal moisturizing formulation

base M5 was used as the control product, while were enrolled in the study. The results showed
commercial herbal moisturizer having similar that M1 and M4 had increased skin hydrations
ingredients with synthetic base was coded as M4. levels [30.97 0.55% and 31.77 0.59%], respec-
tively, after 3 weeks which were more than the
Skin Viscoelasticity Evaluation control formulation M5 [5.40 2.51%]. The
of Herbal Moisturizer improvement in skin firmness was found to
Quantity of herbal constituents present in M1 are increase up to 30.46 0.86% and 30.35 0.91%,
Cucumis sativus (0.70% w/w), Glycerrhiza respectively, for M1 and M4. The improvement
glabra (0.75% w/w), Emblica officinalis (0.210% in the skin viscoelasticity was found to be
w/w), Azadirachta indica (0.75% w/w), increased for M1, 30.27 0.55%, and M4,
Trigonella foenum-graecum (0.583% w/w) and 29.69 0.82% as compared to the control product
Aloe barbadensis (0.78% w/w). Twenty subjects M5, 5.76 0.30%. These improvements may be
390 S. Saraf

a 40
Hydration ingredients to the skin with a continuous release
35 M5 over a prolonged time thus maintains skin appear-
% Skin hydration

30 M1
ance [41]. The formulation and selection of
25 M4
20
approach to be used for herbal cosmetics will
15 depend upon purpose of preparation that is for
10 topical or deep effect; inherent properties of drug
5 or herb extract such as hydrophilic or hydropho-
0
5 1st 2nd 3rd bic; surface characteristics of a system-like per-
Time period (week) meability and charges; degree of biodegradability,
biocompatibility and toxicity; release profile and
b Firmness
35
M5
size of the product required and anti-genicity of
% Skin firmness

30 the final product [15]. Modified nanovesicles

M1
25 penetrate the stratum corneum and supply the
M4
20
15
nutrients to skin [8]. Important novel approaches
10 that could be used for formulating moisturizers
5 include microemulsions, multiple emulsions,
0 liposomes transfersomes, lipid complex system,
1st 2nd 3rd cubosomes and various other nanosystems
Time period (week)
[20, 37, 50]. By nanoparticles, controlled release
c Viscoelasticity of active ingredients, pigment effect and improved
% Skin viscoelasticity

35 skin hydration and protection through film for-

M5
30 mation on the skin is obtained. The amalgama-
25 M1
20 M4 tion of use of properties of phytoconstituents
15 along with the characteristics of novel delivery
10 systems are used as base for the formulation of
5 moisturizing formulations with better an enhanced
0
1st 2nd 3rd
efficacy.
Time period (week)

Fig. 25.4 (a) Increase in percentage of skin hydration. (b) 25.6.1 Various Novel Systems and Their
Increase in percentage of skin firmness. (c) Increase in per- Mechanism of Hydration
centage of skin viscoelasticity after 3-week period [27]

Vesicular systems are widely used in skin for-

due to the synergistic effects of active constitu- mulations due to the similarity of the bilayer
ents present in the ethanolic extracts of selected structure of lipid vesicles to that of natural
herbs [27] (Fig. 25.4). membranes. The ability of liposomal formula-
tions, depending on lipid composition, to alter
cell membrane fluidity and to fuse with cells
25.6 Novel Approaches for the help the delivering of active constituents to the
Development of Moisturizing target site and thereby improve skin properties.
Formulations Specially designed lipid vesicles (transfersomes
and ethosomes) penetrate into deeper layers of
Recent advances in nanotechnology show their the skin. Ultradeformable vesicles are delivered
promise as potential cosmetics for poorly soluble, to the deeper epidermal layers through dehy-
poorly absorbed and labile herbal extracts and dration of the lipid vesicles within the stra-
phytochemicals. The application of novel tum corneum. Therefore, liposome uptake is
approaches retains moisture and restores the bar- driven by the hydration gradient that exists
rier functions of the skin. They deliver active across the epidermis, stratum corneum and
25 Formulating Moisturizers Using Natural Raw Materials 391

ambient atmosphere [53]. The presence of etha- Mix oily constituents (cety1
alcohol, stearic acid, glycerin,
nol in ethosomes influences the stratum corneum propylene glycol, olive oil,
penetration and permeation of drugs [54]. almond oil) in a beaker
Liposomes as a drug delivery system can
improve the therapeutic activity and safety of Keep stirring till
drugs, mainly by delivering them to their site of semisolid state
Stirr continuously at speed
appears
200 20 rpm at 75C
action and by maintaining therapeutic drug lev-
els for prolonged periods of time. Complexation
of herbal active constituents with certain other
Add water/
clinically useful nutrients like phospholipids treansfersome/novel system
Phase separation
improves their absorption and bioavailability. suspension to completely
occurs at 30C
melted oily phase, reducing
temperature 30C

25.6.2 Role of Constituents of Novel Fig. 25.5 Preparation of novel herbal moisturizing
Delivery Systems formulations

The composition and properties of liposomes play lysis, have better drug retention characteristics
an important role in their interaction with and than liposomes and better skin compatibility with
possible penetration into the epidermis. In addi- enhanced penetration [43].
tion, liposomes provide valuable raw material for
the regeneration of skin by replenishing lipid mol-
ecules and moisture. Lipids are well hydrated and, 25.6.3 Preparation of Herbal Novel
even in the absence of active ingredients, humid- Cosmetic Formulations
ify the skin [9]. Liposome formulations have been
implied for skin moisturization, due to the poten- Initially, the herbal constituents are extracted,
tial occlusive effect of the phospholipid film and novel systems are developed according to the
deposited on the skin surface. Egg and soya phos- solubility and nature of the extracts. Then, these
pholipids are widely used natural lipids for for- novel systems are evaluated for their size, struc-
mulating vesicular systems. An o/w microemulsion ture, surface properties, zeta potential, entrap-
formulated using lecithin and an alkyl glucoside ment efficiency, drug release and stability. The
as mild, non-irritant surfactants was proposed as a stable herbal novel delivery systems are then
cosmetic vehicle for arbutin and kojic acid, natu- incorporated into topical delivery systems like
rally occurring whitening agents. The stability of creams, gels or lotions. These developed herbal
these compounds is higher in microemulsions delivery system incorporated topical formula-
than in aqueous solutions [11, 42]. By combining tions are evaluated for physicochemical, psycho-
the emulsifying action of the phospholipids, with metric and biological parameters, and the stable
the standardized botanical extracts, the phyto- formulations are ready for use. Figure 25.5
some form provides dramatically enhanced bio- depicts laboratory preparation of novel herbal
availability and delivers faster and improved cream formulations.
absorption through the skin [34]. Transfersomes
are applied in a non-occluded method to the skin,
which permeate through the stratum corneum 25.7 Quality Control Parameters
lipid lamellar regions as a result of the hydration of Formulations
or osmotic force in the skin. It can be applicable
as drug carriers for a range of small molecules, Quality control evaluation is an important part of
peptides, proteins and nutraceuticals [12, 15]. product/formulation development. The evaluation
Sphingosomes prepared from sphingolipids of of a cosmetic product should be carried out with full
natural origin are much more stable to acid hydro- knowledge of the pharmacotechnical, toxicological,
392 S. Saraf

pharmacokinetic, regulatory, clinical phases areas tions reflects the presence of free esters, which may
and Scientific Committee of Cosmetics and Non- influence the formula stability, pH and cleansing
Food Products Intended [45], Organization for properties. Spreadability and layer thickness are
Economic Cooperation and Development (OECD), the measure of consistency of the product.
European Cosmetic, Toiletry and Perfumery Asso-
ciation [13], Cosmetics, Toiletries and Fragrances
Association (CTFA), Bureau of Indian Standard 25.7.2 Physical Stability
[10] and World Health Organization [51] guide-
lines. To access the risk and the safety of cosmetic Stability of prepared formulation is determined
products, it is necessary to determine the character- by centrifugation and freeze thaw method. During
istics and toxicological data of cosmetic ingredients. centrifugation study, cream is centrifuged at
Risk factors for a cosmetic ingredient are calculated 3,50013,500 rpm at the intervals of 500 rpm for
in terms of margin of safety, systemic exposure dos- 10 min and further observed for phase separation.
age and lifetime cancer risk [25]. In freeze thaw study, all the formulations are kept
Regulatory frameworks differ significantly alternatively at 20C and 40C, then observed for
between the different markets. Regulatory frame- colour change and phase separation. All evalua-
works for cosmetics adopted by major markets tions were carried out in triplicate.
(include EU, USA, Japan and Canada countries),
emerging markets (include China, India, ASEAN,
Mercosur and the Comunidad Andina countries) 25.7.3 Safety Analysis
and third countries (include Russia, Ukraine,
Korea and Taiwan) act as a model for other coun- Safety analysis includes determination of micro-
tries of the world [40]. biological specification and sensitivity profile.
Microbial examination of 1-ml cream is tested
according to COLIPA guidelines and Indian
25.7.1 Physicochemical Evaluations Standards methods IS 11648; 1999. Total
numbers of viable mesophilic microorganism
The physical parameters of the formulations are are recorded by using a colony counter. The
evaluated to analyse the appearance and stability of sample is determined for the presence or absence
the formulations. Colour and odour of the formula- of Pseudomonas aeruginosa, Staphylococcus
tions is checked carefully, and net content is deter- aureus and Candida albicans. To ensure that for-
mined. Viscosity profile of cream formulation is to mulation is free from any adverse effect, a sensi-
be measured using a Brookfield viscometer at tivity study using a patch-test design is conducted
10100 rpm. The pH, thermal stability, fatty con- on all volunteers. After 24 h, volunteers are
tent and non-volatile content of the prepared for- observed for any irritation, erythema score [red-
mulations could be determined according to Indian ness] and oedema. Cream formulation is applied
Standard Guideline (IS: 6608-1978B-1, IS: 6608- on the back of forearm with the help of surgical
1978B-2, IS: 6608-19 78B-3). Human skin is cov- gauze (0.5 mg/cm2), and the erythema score
ered with an acid mantle having acidic pH, but due [redness] is determined using the scale defined
to frequent washing and use of soap, the acidity is in the Indian Standards. Average erythemal
lost, and hence to normalize the skin, moisturizers score = total score of each product/total number
used should have acidic range. Acceptable pH of volunteers. Erythema score 0 indicates that
range of moisturizers should be 58. Other param- the formulation is free from irritation, and a
eters include assessment of ash value, acid value, score of 1 indicates slight redness of skin by
saponification value, spreadability and layer thick- visual observation according to COLIPA and
ness [31]. The saponification value of the formula- BIS guidelines [3].
25 Formulating Moisturizers Using Natural Raw Materials 393

25.7.4 Psychometric Evaluations where CF = correction factor (10), EE(l) = erythe-

mogenic effect of radiation with wavelength l,
The products are compared based on sensory I(l) = intensity of solar light of wavelength l and
evaluation, and ranking is done as per score Abs(l) = spectrophotometric absorbance values at
obtained according to the hedonic scale. The wavelength l. The values of EE(l) I(l) are con-
cream formulations are applied twice a day stant. They are determined by Sayre et al. [48].
once in morning and once in evening at the The ultraviolet (UV) absorption ability of various
same time over volunteers up to 6 weeks, and volatile and non-volatile herbal oils used in sun-
observations are made by ranking method, vari- protective moisturizing formulations were evalu-
ous questions were asked to volunteers and ated and found that, among fixed oils taken, the
according to their answers, ranking is done SPF value of olive oil and coconut oil was high
between 0 and 9 of hedonic scale; ranking is around 8 and, among essential oils taken, the SPF
done as follows: 89 (extremely liking), 57 value of peppermint oil and tulsi oil was found
(medium), 13 (dislike), 6 (in between extreme around 7 [28]. These studies could be helpful
liking and medium), 4 (in between medium and while selection of oil phase in the designing of
dislike), verbally for appearance, fragrance, formulations.
lathery feel, softness, irritation, stickiness,
smoothness and after-effect of skin [3, 23].
Overall ranking is done on the basis of average 25.7.6 In Vivo Method Sun Protection
score of each product. Factor (SPF) Determination

This method is based on subjective evaluation of

25.7.5 In Vitro Sun Protection Factor human volunteers. The sun protection factor
(SPF) Determination of Extracts (SPF) value of a product is defined as the ratio of
and Formulation the minimal erythema dose on product protected
skin (MEDp) to the minimal erythema dose on
For the development of moisturizers having sun unprotected skin (MEDu) of the same subject
protection properties, the extracts of photopro- [volunteer].
tective herbs like Aloe vera, Curcuma longa,
MEDp [protected skin]
Punica granatum and Areca catechu are included; SPF =
further sun protection factor of these herbal MEDu [unprotected skin].
extracts and the prepared herbal moisturizing for-
mulations are evaluated in vitro and in vivo. Ratio The minimal erythema dose (MED) in human
of ultraviolet (UV) minimum erythemal doses skin is defined as the lowest ultraviolet UV dose
protected to unprotected gives the SPF. The that produces the first perceptible unambiguous
in vitro method measures the reduction of the erythema with defined borders appearing over
irradiation by measuring the transmittance after most of the field of UV exposure, 1624 h after
passing through a film of product. The most com- UV exposure [7, 23].
mon in vitro technique involves measuring the
spectral transmittance at UV wavelengths from
280 to 400 nm [28, 35]. The observed absorbance 25.7.7 Bioengineering Methods
values at 5-nm intervals are calculated using for- of Evaluation
mula as follows:
320
The evaluation of the effect of formulation on
SPFspectrophotometric = CF EE( ) I( ) Abs( ), change in skin properties is determined by the
290 application of formulation on the skin of human
394 S. Saraf

volunteers, and the change in skin viscoelasticity, of the epidermis, which regulates the water con-
skin hydration, sebum content, melanin and ery- tent of the skin, its integrity, softness, plasticity,
thema are observed by the use of Cutometer and hydration and aspect [33]. The lipid concentra-
their probes. tion is measured using Sebumeter SM 815
The viscoelastic properties are measured (Courage and Khazaka, Germany). The test prod-
using Cutometer MPA 580 (Courage and uct is applied twice daily to the body site (volar
Khazaka, Germany). The measuring principle is forearm or forehead) for a period of 6 weeks.
suction/elongation. An optical system detects A clinical assessment and instrumental measure-
the decrease of infrared light intensity depending ments are done before and after the treatment
on the distance the skin is being sucked into the period. Casual sebum level is determined.
probe. In this study, the strain time mode was Mexameter MX 18 is a narrow band reflectance
applied. A probe with a 2-mm opening is used, spectrophotometer and measures the intensity of
and a pressure of 450500 mbar is applied in erythema and melanin pigmentation (Fig. 25.6).
order to suck the skin into the probe. Each mea-
surement consisted of five suction cycles (23 s
of suction followed by 23 s of relaxation) and is 25.7.8 Toxicological Prole Analysis
performed in triplicate on body skin (volar fore-
arm). The following parameters (absolute and Cosmetic products should be free from side
relative) are analyzed: Ue, elastic deformation; effects as their use is concern to human health. To
Uv, viscoelasticity; [R0] Uf, total deformation; access the risk and the safety of cosmetic prod-
Ur, retraction; [R2] Ua/Uf, overall elasticity of ucts, it is necessary to determine the characteris-
the skin; [R5] Ur/Ue, pure elasticity of the skin tics and toxicological data of cosmetic ingredients
without viscous deformation; [R7] Ur/Uf, bio- [25]. Important parameters for the determination
logical elasticity, i.e., the ratio of retraction to of toxicological profile of the ingredients include
extension; [R6] Uv/Ue, the ratio of viscoelastic- acute toxicity, irritation and corrosivity, skin irri-
ity to elastic deformation and R8 or (Ua), pli- tation and skin corrosivity, mucous membrane
ability, i.e. ability of the skin to return into its irritation, skin sensitization, dermal/percutane-
original state [16, 23]. ous absorption, repeated dose toxicity, mutagen-
Hydration of the epidermis (stratum corneum) icity/genotoxicity, carcinogenicity, reproductive
is determined with a non-invasive, skin capaci- toxicity, toxicokinetic studies and photo-induced
tance meter (Corneometer CM 820, Courage toxicity measured in terms of photoirritation and
Khazaka, Ko ln, Germany). Corneometry is an photomutagenicity of cosmetic ingredients [25].
established method for the determination of skin
hydration [6]. The acceptance is due to high
reproducibility, easy handling, short measuring 25.7.9 Biological Studies
time and economy [21]. The device determines
the water content of the superficial epidermal lay- UV protecting effects of cream formulation is
ers down to a depth of about 0.1 mm and expresses studied by estimation of biochemical parameters,
the values in arbitrary units. For single applica- i.e. catalase, superoxide dismutase, malondialde-
tion studies after the baseline measurement, each hyde, ascorbic acid and total protein in each set
formulation is applied to the volunteers, and mea- of experiment. Ultraviolet radiation induces
surements are carried out after 0.5, 1, 2 and 3 h of changes in superoxide dismutases, catalase,
application. Similarly, for multiple application, malondialdehyde, ascorbic acid and total protein
formulations are applied twice daily, in the morn- level in skin. Microscopically, as the skin ages
ing and in the evening; for 1, 2 and 6 weeks, the normally, the des becomes hypocellular, the
measurements are carried out. vasculature remains intact and collagen forms
Sebum consists of a mixture of lipids and cel- a stable with increased cross-linked matrix.
lular debris that form a lipidic film on the surface By contrast, the epidermis of photoaged skin
25 Formulating Moisturizers Using Natural Raw Materials 395

Fig. 25.6 Curves produced by Cutometer (skin viscoelasticity), Corneometer (skin hydration), Sebumeter (Sebum
content) and Mexameter (melanin and erythema value)

becomes thickened and the vessels tortures. that treatment with such herbal extracts contain-
Antioxidants protect the human body against ing creams could be utilized for the protection of
damage by reactive oxygen species [4]. photo-induced intrinsic oxidative stress as well as
Ashawat et al. prepared and characterized structural alterations in skin (Fig. 25.7).
herbal cosmetic cream comprising extracts of G.
glabra, C. longa (roots), seeds of P. corlifolia, C. Conclusion
tom, A. catechu, P. granatum, fruits of E. offici- Formulation of moisturizing cosmetic formu-
nale, leaves of C. asiatica, dried bark of C. zey- lations with the maximum use of natural raw
lanicum and fresh gel of A. vera for the protection materials is the present need for cosmeticians.
of skin against UV-induced ageing and observed Research is continuously been done to develop
396 S. Saraf

a b

Fig. 25.7 Microphotograph of rat skin (a) after ultraviolet radiation exposure (b) after formulation pretreatment before
ultraviolet radiation exposure

stable cosmetic formulations using additives assessed by skin bioengineering techniques. Skin Res
of natural origin which could be effective for Technol 12:241246
6. Barel AO (1995) Clarys measurement of epidermal
all skin types. Cosmetic formulations with capacitance. In: Bioengineering of the skin: water and
herbal extracts are developing as they yield the stratum corneum. CRC Press, Boca Raton, pp
mild, non-irritant, safe products with enhance- 165170
ment of skin properties. Research is moving in 7. Bendova H, Akram J, Krejci A, Kubac L, Jirova D,
Kejlova K, Kolarova H, Brabec M, Maly M (2007) In
the direction of developing moisturizing for- vitro approaches to evaluation of sun protection fac-
mulations with photoprotective effects. tor. Toxicol In Vitro 21:12681275
8. Benson HA (2006) Transferosomes for transdermal
drug delivery. Expert Opin Drug Deliv 3(6):727737
Acknowledgements Author is thankful to the student 9. Betz G, Aeppli A, Menshutina N et al (2005) In vivo
Chanchal Deep Kaur for his assistance during formatting comparison of various liposome formulations for cos-
the work. metic application. Int J Pharm 296:4454
10. BIS (Bureau of Indian standard) (2006) General
guidelines for herbal cosmetics. PCD-19:6/T-1 C 16
11. Carlotti ME, Gallarate M, Rossatto V (2003) O/W
References microemulsion as a vehicle for sunscreens. J Cosmet
Sci 54(5):451462
1. Andrade FF, Santos ODH, Oliveira WP, Rocha-Filho 12. Cevc G (2004) Lipid vesicles and other colloids as
PA (2007) Influence of PEG-12 dimethicone addition drug carriers on the skin. Adv Drug Deliv Rev
on stability and formation of emulsions containing 56(5):675711
liquid crystal. Int J Cosmet Sci 29:211218 13. COLIPA (2001) Evaluation of the efficacy of cos-
2. Ashawat MS, Banchhor M, Saraf S et al (2009) Herbal metic products. COLIPA Guidelines 116
cosmetics: trends in skin care formulation. Phcog Rev 14. Deep C, Saraf S (2009) Herbal photoprotective for-
3(5):7279 mulations and their evaluation. Open Nat Prod J
3. Ashawat MS, Saraf S, Saraf S (2008) Preparation and 2:5762
characterisation of herbal creams for improvement of 15. Deep C, Saraf S (2008) Novel approaches in herbal
skin viscoelastic properties. Int J Cosmet Sci 30: cosmetics. J Cosmet Dermatol 7:8995
183193 16. Escoffer C, Rigal JD, Rochefort R et al (1989) Age
4. Ashawat MS, Saraf S, Saraf S (2007) Biochemical related mechanical properties of human skin: an
and histopathological studies of herbal cream against in vivo study. J Invest Dermatol 93:353357
UV radiation induced damage. Trends Med Res 17. European Chemicals Bureau, ECB (2003) Technical
2(3):135141 guidance document on risk assessment in support of
5. Belo SED, Gaspar LR, Campos RMBGM (2006) Commission Directive 93/67/EEC on risk assessment
Moisturizing effect of cosmetic formulations contain- for new notified substances, Commission Regulation
ing Aloe vera extract in different concentrations (EC) No 1488/94 on risk assessment for existing
25 Formulating Moisturizers Using Natural Raw Materials 397

substances and Directive 98/8/EC of the European 37. Niemiec SM, Ramachandran C, Weiner N (1995)
Parliament and of the Council concerning the placing Influence of nonionic liposomal composition on topi-
of biocidal products on the market. Doc. EUR 20418 cal delivery of peptide drugs into pilosebaceous units:
EN/1, European Communities an in vivo study using the hamster ear model. Pharm
18. Forster T, Tesmann H (1991) Phase inversion emulsi- Res 12(8):11841188
fication. Cosmet Toil 11:106 38. Oyedeji FO, Okeke IE (2010) Comparative analysis
19. Gregoriadis G (1994) Liposomes and anti-ageing of moisturising creams from vegetable oils and paraf-
creams: the facts beneath the face. Biochemist Feb/ fin oil. Res J Appl Sci 5(3):157160
Mar 39. Rawlings AV, Harding CR (2004) Moisturization and
20. Gupta A, Ashawat MS, Saraf S, Swarnlata S (2007) skin barrier function. Dermatol Ther 17:4348
Phytosome: a novel approach towards functional cos- 40. Saraf S, Kapoor S (2008) Cosmetic legislation, Istth edn.
metics. J Plant Sci 2(6):644649 Nirali Prakashan, Pune. ISBN 9788196396138
21. Heinrich U, Koop U, Leneveu Duchemin MC et al 41. Saraf S, Kaur CD (2010) Phytoconstituents as photo-
(2003) Multicentre comparison of skin hydration in protective novel cosmetic formulations. Pharmacog
terms of physical, physiological and product depen- Rev 4(7):111
dent parameters by the capacitive method 42. Saraf S (2010) Application of nanosystem in cosmet-
(Corneometer CM 825). Int J Cosmet Sci 25:4553 ics. In: Chaughule RS, Ramanujan RV (eds)
22. Jacobi O, Heinrich (1954) The acid mantle of the skin. Nanoparticles synthesis, characterization and applica-
Proceedings Science Sector of Toilet Goods tions. American Scientific Publication, Stevenson
Association, 21, 6 Ranch, pp 379399. ISBN 1588831809
23. Kapoor S, Saraf S (2009) Age dependent studies as 43. Saraf S, Paliwal S, Kaur CD, Saraf S (2011)
various skin parameters using cutometer. Indian J Sphingosomes a novel approach to vesicular drug
Pharm Educ Res 43(4):338345 delivery. Res J Pharm Tech 4(5):661666
24. Kapoor S, Swarnlata S (2008) A note on dire need of 44. Saraf S, Sahu S, Kaur CD, Saraf S (2010) Comparative
harmonisation of cosmetic legislation. Int J Trade measurement of hydration effects of herbal moistur-
Glob Mark 1(4):419431 izers. Pharmacog Res 2(3):146151
25. Kapoor S, Saraf S (2008) Risk analysis tools for toxico- 45. Scientific Committee of Cosmetics and Non-Food
logical profile of cosmetics. Internet J Toxicol 5(2):113 Products (SCCNFP) (2003) Notes of guidance for
26. Kapoor S, Saraf S (2010) Assessment of viscoelasticity testing of cosmetic ingredients and their safety
and hydration effect of herbal moisturizers using bioen- evaluation by the SCCNFP. SCCNFP/0690/03 Final
gineering techniques. Phcog Mag 6(24):298304 1102
27. Kapoor S, Saraf S (2010) Formulation and evaluation 46. Thomssen EG (2006) Modern cosmetics. Universal
of moisturizer containing herbal extracts for the man- Publishing Corporation, Bombay, 101
agement of dry skin. Phcog J 2(11):409418 47. Yamaguchi M, Tahara Y, Teruhiko M et al (2009)
28. Kaur CD, Saraf S (2010) In vitro SPF determination Comparison of cathepsin l activity in cheek and fore-
of herbal oils used in cosmetics. Pharmacog Res arm stratum corneum in young female adults. Skin
2(1):2225 Res Technol 15:370375
29. Kaur CD, Saraf S (2011) Photochemoprotective activ- 48. Sayre RM, Agin PP, Levee GJ et al (1979) Comparison
ity of alcoholic extract of Camellia sinensis. Int of in vivo and in vitro testing of sunscreening formu-
J Pharmacol 7(3):400404 las. Photochem Photobiol 29:559566
30. Lachapelle JM (1996) Efficacy of protective creams 49. Yoon HS, Baik SH, Oh CH (2002) Quantitative mea-
and/or gels. Prevention of contact dermatitis. Curr surement of desquamation and skin elasticity in dia-
Probl Dermatol 25:182192 betic patients. Skin Res Technol 8:250254
31. Lachman L, Herbert AL, Joseph LK (1999) The the- 50. Khan Y, Talegaonkar A, Zeenat SI et al (2006)
ory and practice of industrial pharmacy, IIIth edn. Multiple emulsions: an overview. Curr Drug Deliv
Varghese Publ. House, Bombay, p 569 3(4):429443
32. Latuen AR (1958) Fundamental and comparative 51. World Health Organization (WHO) (1998) Quality
actions of cleansing cream. Am Perfumes 72:29 control methods for medicinal plant materials. WHO,
33. Leydenn JJ (1995) New understanding of the patho- Geneva, pp 1122
genesis of acne. J Am Acad Dermatol 32:S15S25 52. Murray BC, Wickett RR (1996) Sensitivity of
34. Loggia RD, Sosa S, Tubaro A, Morazzoni P, Cutometer data to stratum corneum hydration level. A
Bombardelli E, Griffin A (1996) Anti-inflammatory preliminary study. Skin Res Technol 2:167172
activity of some Gingko biloba constituents and 53. Cevc G, Blume G (1992) Lipid vesicles penetrate into
of their phospholipids- complexes. Fitoterapia 3: intact skin owing to the transdermal osmotic gradients
257273 and hydration force. Biochim Biophys Acta 1104:
35. Mansur JS, Breder MNR, Mansur MCA et al (1986) 226232
Determinao Do Fator De Proteo Solar Por 54. Touitou E, Dayan N, Bergelson L (2000) Ethosomes-
Espectrofotometria. An Bras Dermatol 61:121124 novel vesicular carriers for enhanced delivery: charac-
36. Marty JP (2002) NMF and cosmetology of cutaneous terization and skin penetration properties. J Control Rel
hydration. Ann Dermatol Venereol 129:131136 (65)3: 403-418
 Chemical and Physical Properties
of Emollients 26
Jari T. Alander

26.1 Introduction This chapter reviews several emollient tech-

nologies used in skin care products and describes
Emolliency can be translated as softening abil- the similarities and differences between the differ-
ity, and emollients are substances that make ent substances that are commonly used for emol-
something softer to the touch. In cosmetic and liency. The focus is on chemical and physical
personal care applications, an emollient is usu- parameters differentiating the different emollient
ally an oily substance, which when applied to the types, with the purpose of giving the formulator
skin, makes it softer and more lubricated, enhanc- better understanding of this ingredient group.
ing the sensory properties of the skin. Emolliency
is also an important parameter in skin moisturiza-
tion as many emollients also contribute to regu- 26.2 Emollient Functionality
lating the moisture balance in the skin. In clinical Is Complex
practice, the term emollient is also used for for-
mulated products used for treating dry skin Emollients are, along with emulsifiers and actives,
conditions. the most important functional ingredient groups
Emollients are normally volume-wise the big- in skin care formulations. The emollient will
gest ingredient group in a skin care formulation, influence the performance of the formulation in
after water. The emollient phase may comprise several ways: consistency of the formulation,
530% of the formulation in oil-in-water emul- skin feel, moisturization and lubricity on skin,
sions. Anhydrous systems and water-in-oil emul- delivery of actives, and the marketability of the
sions can contain even higher emollient product. It is therefore important to be able to
concentrations. Understanding the different optimize the properties of the emollients phase
emollient types and their chemical and physical and tailor-make it for the intended use.
behavior is consequently important for the for-
mulator, especially when optimizing the emol-
lient composition to meet requirements on 26.2.1 Emollients Determine the
functionality and cost. Structure of the Formulation

In the formulation, the emollient phase composi-

tion will determine the consistency of the cream
or lotion. The viscosity and polarity, together
J.T. Alander
with the presence of solid emollients, can be used
Lipids for Care, AarhusKarlshamn AB, Vstra Kajen,
Karlshamn, Sweden to make the formulation more fluid or more solid,
e-mail: [email protected] depending on the intended use.

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 399

DOI 10.1007/978-3-642-27606-4_26, Springer-Verlag Berlin Heidelberg 2012
400 J.T. Alander

The emollient polarity will determine the problems due to emollient behavior. The
solubility of active components, especially lipo- classification of emollients can be based on the
philic ones. Correct choice of emollients can chemistry of the substances used, but sometimes,
potentiate the activity of an active substance by especially when dealing with complex ingredi-
controlling its bioavailability, by considering the ents or mixtures of ingredients, a physicochemi-
properties of the active ingredient, stratum cor- cally based classification is more appropriate.
neum and the formulation [1].
The interaction with emulsifiers and the choice
of emulsifiers are also determined by the polarity 26.3.1 Emollient Classication Based
and viscosity of the emollient. The solubility of on Molecular Structure
the emulsifier and its ability to form liquid crys-
tals and other surfactant aggregates are strongly From a chemical point of view, most commer-
dependent on the polarity of the oil phase in the cially available emollients come from three dif-
system. This phenomenon is reflected in the use ferent types of chemistries: hydrocarbon based,
of the HLB system for characterizing emulsifiers ester based, or silicone based. Emollients utiliz-
as well as the phase inversion temperature (PIT) ing moieties containing nitrogen and phosphorus
concept [2, 3]. are not common, and combinations with halo-
gens are normally too toxic to be of interest.
Table 26.1 illustrates some typical emollient
26.2.2 Skin Feel Is Inuenced structures and structural variations in each
by the Choice of Emollient group.
Hydrocarbons, in this case without functional
When applied to the skin, the polarity and vis- groups other than unsaturation and ring forma-
cosity of the emollient phase will determine tion, are the common base for many classes of
the skin feel. This elusive term is a concen- emollients. In this group, we find naturally occur-
trate of everything which can be classified as ring hydrocarbons such as squalene and squalane
the sensory properties of the formulation: lubric- derived from biomaterials, simple hydrocarbons
ity, spreadability, absorption into the skin, and from mineral oil deposits (petroleum based), and
duration on the skin surface. These factors are synthetic hydrocarbons, normally derived from
closely linked to the molecular structure of the petroleum sources. Saturated hydrocarbons are
emollients [46]. usually chemically inert, being resistant to oxida-
The functionality of the emollient when tion and hydrolysis.
absorbed into the skin is also important to con- Fatty alcohols such as oleyl alcohol or
sider. In contrast to common belief, the emollient isostearyl alcohol are also frequently used as
is seldom an inert substance that does not influ- emollients or emollient modifiers in skin care
ence the physiology of the skin. The emollient formulations. These substances combine a long
may interact with the skin lipids and also be hydrocarbon chain with a primary hydroxyl
metabolized in the skin if the chemical structure group. In some cases, especially in short chain
is suitable [7, 8]. alcohols used in esters, the alcohol group can
also be a secondary one.
Ester-based emollients combine a carboxylic
26.3 Principles for Emollient acid with an alcohol. Depending on the chemical
Classication structure of the acid and the alcohol, we can talk
about simple esters, polyhydric alcohol (polyol)
There are many reasons to classify emollients: esters, and complex esters. A specific group of
for understanding the behavior of emollients in polyhydric alcohol esters are the naturally occur-
formulations, for simplifying formulations, for ring vegetable and animal oils and fats, which are
making alternative formulations, and for solving based on fatty acid esters of glycerol. The common
26 Chemical and Physical Properties of Emollients 401

Table 26.1 Grouping of commonly used skin care emollients and typical structural variations
Emollient type Examples Variations Molecular structure
Mineral oil Paraffin oil Chain length and
hydrocarbons branching

Naturally Squalane Unsaturation

occurring
hydrocarbons
Synthetic Isohexadecane Monomer type,
hydrocarbons chain length, and
branching

Fatty alcohols Cetearyl alcohol Chain length and HO

unsaturation
Guerbet and 2-octyldodecanol Chain length and HO
oxo alcohols branching

Natural fatty Oleic acid Chain length and

acids unsaturation
O

HO
Synthetic fatty Isostearic acid Chain length and O
acids branching
HO

Simple esters Isopropyl Acid and alcohol O

myristate structure
O
Natural Olive oil Fatty acid and R1 O
triglycerides triglyceride O
composition
O
O R2
O

R3
O
Synthetic Caprylic/capric Fatty acid type
triglycerides triglyceride and ratio
O

O
O
O
O
O

(continued)
402 J.T. Alander

Table 26.1 (continued)

Emollient type Examples Variations Molecular structure
Complex esters Diisopropyl Acid and alcohol O
adipate structure
O
O

trait of all esters is their ability to react with water, The polarizability of double bonds increase in
releasing acid and alcohol, making esters sensitive the following order: isolated double bonds < con-
to formulation conditions. Unsaturated esters are jugated double bonds < aromatic double bonds as
also sensitive towards oxidation reactions. the presence of mobile electrons increases.
The fourth group of emollients, based on sili- Isolated ester bonds are less polarizable than con-
con chemistry, is usually referred to as silicone jugated ones of the same reason.
oils. More appropriately named siloxanes, they Polarizable groups can also present permanent
are combinations of silicon, oxygen, and hydro- dipoles if the functional groups are separated by
carbons, offering a different set of physicochemi- an appropriate distance.
cal behavior compared to the hydrocarbons and Permanent polarity is also caused by hydrogen
esters. This group of emollients, although com- bonding. Here, free carboxylic acid, alcohol, and
mercially and technically important, will not be amino groups are important functionalities to
covered in this chapter. consider.
A classification of emollients based on polar-
ity looks into the presence and concentration of
26.3.2 Classication Based these polarizable structural elements, permanent
on Physical Properties dipoles, and the presence or absence of hydrogen
bonding.
Many different approaches to classifying emol-
lients based on their physicochemical properties 26.3.2.2 Rheology as a Tool to Describe
have been proposed [9]. The methods used should Emollients
be easy to apply but also give enough information The viscosity of a substance is to a large degree
to distinguish between closely related substances. dependent on the size of the constituent mole-
Methods proposed for the classification include cules, larger molecules have larger surface areas,
rheology, interfacial and surface tension mea- increasing the possibility of van der Waals inter-
surements, thermal properties, dielectric con- actions. Structural factors such as branching and
stants, and partition coefficients. The main cyclization will affect the molecular size and
directions for all the different methods can be shape leading to effects on viscosity and self dif-
divided into polarity and rheology. fusion coefficients [11]. Increasing the molecular
interactions by introducing polarizability and
26.3.2.1 Factors Affecting the Polarity polarization will also strongly influence the rheo-
of Emollients logical properties.
The polarity of a substance can be described in In complex emollient mixtures comprising
many ways and is manifested in a variety of solid crystals, such as in petrolatum, the rheology
directions, depending on the chemistry involved is more complex, and viscoelasticity is commonly
[10]. The first prerequisite for polarity is the pres- encountered. For viscoelastic systems, viscosity
ence of polarizable functional groups in the as commonly measured is an insufficient tool to
molecular structure. In emollients such functional describe the rheological properties, and more
groups include double bonds, aromatic structures, sophisticated rheometers must be used to get a
ester groups, and carboxylic acids and alcohols. correct evaluation of such systems. The elastic
26 Chemical and Physical Properties of Emollients 403

modulus is often giving good correlation to for- value was tested and shown to be comedogenic.
mulation stability and to sensory properties [12]. After purification to remove the oxidized
Classification of emollients based on rheology squalene, the comedogenicity disappeared, link-
is a simple tool and gives a rough guideline for the ing oxidized lipids to inflammatory reactions
estimation of the applicability of each emollient. associated with comedogenesis [1518].
The squalene is hydrogenated to produce
squalane, a very stable, low-melting branched
26.4 Individual Emollient Groups hydrocarbon with low viscosity. It is used to
decrease the oiliness of the formulation, increas-
The commercially available emollients can be ing the slip and for a generally pleasant and light
described in order of increased complexity, starting skin feel.
with simple hydrocarbons and adding functional
groups to influence the physicochemical properties. Petrolatum and Mineral Oil
Petrolatum is a fraction of mineral oil with semi-
solid consistency. Physicochemically, it is an
26.4.1 Hydrocarbon-Based Emollients oleogel, an oil-based, lipophilic, gel stabilized by
network forming crystals of high-melting hydro-
Although emollients based on vegetable and ani- carbons. The composition of petrolatum is usu-
mal oils and fats were probably the first ones to ally complex, comprising hundreds of individual
be used in skin care, petroleum-based materials hydrocarbons [19, 20]. It is derived from paraf-
rapidly became the standard when the cosmetic finic mineral oils which is purified and hydroge-
industry developed in the early 1900s. Petroleum- nated to remove unsaturation and improve
based materials were abundant, had good techno- stability and color. Liquid mineral oils or paraffin
logical properties, and gave an excellent oils are chemically similar to petrolatum but do
moisturization and emolliency. Petrolatum and not contain the high-melting waxes that give pet-
mineral oil are still the most commonly used rolatum its consistency.
emollients globally although alternative technol-
ogies are being developed, basically due to the 26.4.1.2 Synthetic Hydrocarbons
nonrenewability of the petroleum resources. Synthetic hydrocarbons are obtained from simple
building blocks such as ethene, propene, isobutene,
26.4.1.1 Naturally Occurring and decene by oligomerization reactions. Ethene
Hydrocarbons produces polyethylene which is a linear hydrocar-
Squalane and Squalene bon resulting rapidly in high melting points with
Squalene and squalane are naturally occurring increased molecular weight while propene,
hydrocarbons with a specific metabolic function, isobutene, and decene can be used to make low-
being precursors for the formation of steroidal melting branched hydrocarbons. These saturated,
components in animals and plants [13]. Pure branched, emollients are hydrophobic and stable
squalene is extracted from shark liver oil and against oxidation. Synthetic hydrocarbons can also
from olive oil processing residuals. The shark oil be obtained by catalytic cracking of heavier min-
squalene is not a sustainable alternative due to eral oils and fractional distillation to obtain frac-
overfishing of the shark, and most squalene on tions with desired melting points and viscosities.
the market is now from vegetable sources. The
main raw material is olive oil deodorizer distil-
late which can contain sufficiently high levels of 26.4.2 Alcohol-Based Emollients
squalene to be commercially viable [14].
Squalene is highly unsaturated and oxidizes A few long chain alcohols are used as emollients
rapidly. Oxidized squalene is associated with on their own, but both long-chain and short-
comedogenicity. Squalene with a high peroxide chain alcohols are important building blocks for
404 J.T. Alander

ester-based emollients. They also introduce an alcohols with a long hydrocarbon branching in
important additional functionality to the hydro- the beta position. Typical Guerbet alcohols are
carbons: the hydroxyl group. Free hydroxyl 2-ethylhexanol (from n-butanol), 2-octyldode-
groups increase the polarity and have the capac- canol (from n-decanol), and 2-hexyldecanol
ity of forming hydrogen bonds with water, allow- (from n-octanol). The branched Guerbet alcohols
ing alcohols to participate in liquid crystals and have lower melting points than their correspond-
interact with skin lipids. ing linear isomers with the same carbon number.
Being saturated, Guerbet alcohols are normally
26.4.2.1 Long Chain Fatty Alcohols resistant against oxidation.
Saturated fatty alcohols such as cetyl (palmitoyl), Synthetic alcohols from petroleum sources
stearyl, or cetostearyl alcohols are not primarily include the oxo alcohols which are derived from
used as emollients in skin care creams and lotions, unsaturated hydrocarbons by the addition of car-
their primary function being emulsion stabilizer bon monoxide and hydrogen in a hydroformula-
and consistency factor. They do, however, con- tion process. The resulting aldehydes can further
tribute to the moisturization and emolliency by react by the aldol condensation forming branched
interacting with the emulsifier system when for- alcohols after reduction of the aldehyde. Oxo
mulated at 12% in the formulation. These satu- alcohols are available in chain lengths from C8
rated alcohols are obtained from fully saturated (2-ethylhexanol) to C15.
palm oil, soybean oil, or animal fats after a cata-
lytic reduction of the corresponding acids or
methyl esters. 26.4.3 Ester-Based Emollients
Oleyl alcohol is a constituent of some plant
and animal waxes. A traditional source is whale Esters are a popular and versatile group of emol-
oil which was obtained from the blubber of the lients, due to the availability of a large number of
sperm whale. Small amounts of oleyl alcohol are ingredients with large differences in properties.
present in jojoba oil (Simmondsia chinensis) This versatility can be used by the formulator to
where the seed oil contains esters of unsaturated bring various functions to the skin care product,
long chain alcohols with long chain fatty acids influencing stability, aesthetics, skin feel, and
(wax esters) [21]. Most industrial oleyl alcohol is delivery of actives.
produced by catalytic reduction of oleic acid or
its methyl esters. Oleyl alcohol is available in dif- 26.4.3.1 Simple Esters
ferent grades characterized by the iodine value, Simple esters can be defined as esters of monohy-
reflecting the degree of unsaturation. Stearyl and dric alcohols with acids with only one acid group.
palmitoyl alcohol are present as by-products, When used as emollients, the molecular weights,
depending on the raw material origin (palm oil or expressed as carbon numbers, range from C16 to
animal fats). C36, and the melting points from about 30C up
Isostearyl alcohol is a branched fatty alcohol to 40C. If the melting points exceed 40C, the
which is formed by a high-temperature isomer- ingredients are often too waxy and hard to be
ization reaction of unsaturated fatty acids, pro- used alone. However, high melting esters can be
ducing a mixture of randomly branched isomers. used at low concentration to modify the consis-
After hydrogenation to remove remaining double tency and skin feel of the formulations.
bonds and to convert the acid to alcohol, isostearyl
alcohols with a low melting point and high stabil- Raw Materials for Simple Esters
ity are obtained. Two types of raw materials are needed for ester
Guerbet alcohols are a special class of production: an alcohol and a fatty acid. As there
branched alcohols formed from primary alcohols are numerous possibilities of combining an acid
via an oxidation and aldol condensation mecha- with an alcohol, a large variety in properties and
nism [22]. The resulting alcohols are primary behavior can be seen. Many groups of emollients
26 Chemical and Physical Properties of Emollients 405

are the result of the development of oleochemis- indicates the position of the first double bond,
try which combines a natural raw material with a when calculated from the terminal end of the fatty
synthetic one. acid chain. Oleic acid is thus an omega-9 fatty
acid, linoleic acid an omega-6 fatty acid, and
Carboxylic Acids for Ester Production alpha-linolenic acid is an omega-3 fatty acid.
All types of carboxylic acids are useful reactants Gamma-linolenic acid, in contrast, is an omega-6
for the formation of esters. Emollient esters, how- fatty acid with three double bonds, changing its
ever, are usually based on acids that are longer functionality and metabolism in the skin.
than 8 carbons due to the higher aggressiveness Unsaturated fatty acids from plants are nor-
of shorter acids and due to the normally offensive mally in the all-cis configuration. Partially hydro-
smell associated with shorter fatty acids. These genated fatty acids and animal fatty acids can
long chain carboxylic acids are normally called also contain trans-configured double bonds.
fatty acids, especially if they originate in natural Natural-based fatty acids also comprise
raw materials. hydroxy acids which are found in, for example,
Several types of structural variations are rele- castor oil and in lanolin (wool fat). Lanolin is
vant when describing the fatty acids used in also a source for branched fatty acids as well as
emollient esters: chain length, even/odd carbon dicarboxylic acids.
chains, unsaturation, branching, position on the
chain of various functional groups, and so on. All Synthetic Fatty Acids
these parameters contribute to the performance Isostearic acid is produced as a by-product from
of the resulting ester as a cosmetic emollient. oleic acid dimerization by a high-temperature
reaction using montmorillonite clay or zeolites as
Natural Fatty Acids catalyst [24]. Other long chain branched fatty
Natural fatty acids are obtained from vegetable or acids are obtained by oxidation of the corre-
animal oils and fats by splitting (hydrolysis) of sponding Guerbet alcohol or oxo alcohol.
the fat into glycerol and acids [23]. The most
important sources for fatty acids are coconut/ Alcohol Sources for Esters
palm kernel oil for lauric and myristic acids, palm Alcohols and acids are related to each other in
oil for palmitic and oleic acids, and soybean/ many ways. During chemical synthesis, an acid
rapeseed oil for oleic, linoleic, and linolenic may be formed which is later reduced to an
acids. Palm oil, soybean oil, and rapeseed oil are alcohol via an aldehyde. In a similar fashion, the
also important sources of stearic acid after hydro- first step in a chemical synthesis may result in
genation. Animal fats such as lard and tallow are an alcohol which later is oxidized to an acid.
sources of palmitic, oleic, and stearic acids but This means that for many alcohols and acids,
are also often used after hydrogenation produc- there is a common hydrocarbon background,
ing palmitic and stearic acids. and the chemistry of these substances has many
Vegetable-derived fatty acids are usually even properties in common.
numbered with chain lengths ranging from C8 to
C24, with predominance for C12C18. Fatty Low Molecular Weight Alcohols
acids derived from animal fats can also contain Low molecular weight alcohols used in the man-
fatty acids with an uneven number of carbons, ufacture of cosmetic emollients include isopropa-
typically C15 and C17. nol and ethanol as well as methanol and
The longer chain length fatty acids, starting 2-ethylhexanol. Isopropanol and 2-ethylhexanol
from C16, can contain one or more double bonds. are obtained from petrochemistry while ethanol
The number of double bonds and their location and methanol are also available through
are important characteristics for unsaturated fatty fermentation.
acids. In life sciences, the normally used nomen- Low molecular weight polyhydric alcohols
clature is the n-x or omega-x system which are also often used, for example, 1,2-propandiol
406 J.T. Alander

(propylene glycol). Glycerol (1,2,3-propantriol) 26.4.3.2 Emollients Based

is available both from natural sources (vegetable on Triglycerides
and animal oils and fats) and from petroleum Triglycerides are naturally occurring, renewable
chemistry. sources of emollients that can be used directly in
skin care formulations. Plants and animals use trig-
Long Chain Alcohols lycerides to store energy for future uses. The plants
All types of long chain fatty alcohols described need energy in the seeds to produce a seedling that
above are also useful as reactants in ester forma- can start to photosynthesize. Animals store energy
tion. Branched alcohols are often used due to in fat depots to be used when the availability of food
their stability and low melting points. The nomen- is scarce due to seasonal variations. Triglycerides
clature does not always reveal if the alcohol is are also a good source of raw materials for further
branched or not: octanol can be either n-octanol processing to oleochemical derivatives.
obtained from caprylic acid or 2-ethylhexanol
obtained from petrochemical sources. Natural Oils and Fats
The fat depots in vegetable material and in ani-
Production Methods mal material can be used to obtain triglyceride
Classic Methods: Direct Esterification oils and fats that can be further developed into
and Transesterification cosmetic ingredients. Many emollients and emul-
Any carboxylic acid and alcohol may be used to sifiers used in skin care formulations are derived
produce an ester by direct esterification. Normally, from the easily accessible vegetable and animal
catalysts such as strong acids or tin derivatives oils and fats.
are used, together with a sufficiently high tem- Due to purity and sustainability considerations,
perature to remove the water produced in the the vegetable fats have grown in importance over
reaction. A more efficient route to esters is to do the last years and constitute an important raw
transesterification reactions starting from a vege- material base for the cosmetic industry.
table or animal triglyceride-based oil [25]. In the
first step, the oil can be reacted with methanol to Raw Materials Based on Natural Oils and Fats
produce methyl esters which can be further trans- There are many possible raw materials available
esterified with other alcohols, releasing the meth- for making emollients based on natural oils and
anol. The methanol is subsequently removed by fats; however, most of them are produced in small
distillation and recycled. quantities and are not always commercially fea-
Esters of high molecular weight alcohols can sible. Table 26.2 lists the vegetable oils and fats
also be produced by direct transesterification that are most common as raw materials for mak-
from the triglyceride oil, but reaction conditions ing cosmetic ingredients.
and yields will be dependent on the structure of Animal fats are principally available from
the alcohol used. Secondary alcohols will be less three sources: tallow from cattle, lard from pigs,
reactive in the transesterification process, and bet- and fish oil from marine fish species. Other
ter yields are obtained via the methyl ester route. sources do exist, but these are the main ones from
an industrial point of view. Of these sources, the
New Developments in Esterication: fish oil triglycerides are less common as very few
Enzyme Catalysis fisheries remain to produce a cheap raw material.
Biocatalysis, such as enzymatic catalysis using Lard and tallow are also less attractive today as
lipases supported by a carrier are increasingly raw materials due to issues related to sustainabil-
used for the production of emollient esters. The ity, social, and cultural preferences.
reaction can be run at lower temperatures, saving The majority of industrially produced vegeta-
energy but also leading to decreased formation of ble oils and fats come from four sources: palm oil,
byproducts [26, 27]. soybean oil, rapeseed oil, and sunflower seed oil.
 26

Table 26.2 Approximative fatty acid composition ranges for commonly used vegetable oil raw materials
C8 C10 C12 C14 C16 C18:0 C18:1 C18:2 C18:3 C22:1
Soybean oil 913 35 1730 4858 511
Rapeseed oil (LEAR) 45 12 6064 1821 710
Rapeseed oil (HEAR) 27 13 1222 1016 412 4050
Chemical and Physical Properties of Emollients

Rapeseed oil (HORO) 34 12 7378 1116 24

Sunflower seed oil 49 17 1440 4874
High-oleic SFO 24 34 8084 710
Shea butter 45 4043 4546 67
Liquid shea butter 46 2528 5658 89
Olive oil 720 04 5685 420 01
Sweet almond oil 49 03 6286 1730
Palm oil 01 4345 45 3842 910
Coconut oil 511 49 4050 1520 712 15 410 13
Source: AarhusKarlshamn Sweden AB, Karlshamn, Sweden
407
408 J.T. Alander

Pressing and Refining

extraction Degumming
Neutralization
Bleaching Deodorization
Natural oils and
fats

Modification:
Hydrogenation
Oilseeds Interesterification
fractionation

Cosmetic
ingredients
Derivatization:
Alcohols
Esters
Surfactants

Fig. 26.1 Oilseeds of different kinds are converted to emollients, emulsifiers, and surfactants for skin care use via refin-
ing, modification, and derivatization steps

The three latter are liquid oils with high degree of oils are the main raw material sources for produc-
unsaturation as they have high levels of linoleic ing surfactants and simple esters used in cosmet-
(C18:2) and linolenic acids (C18:3). The unsatu- ics and personal care applications.
ration of soybean, rapeseed, and sunflower oil
restricts their use in skin care as they are difficult Extraction, Purication, and Modication
to stabilize against oxidation. However, they are of Vegetable Oils and Fats
good starting points for modification as they are Naturals oils and fats which are used as cosmetic
easily accessible and cost-effective. emollients need to be purified to remove unde-
Palm oil is a source for oleic (C18:1) and sired naturally occurring seed constituents and
palmitic (C16:0) acids. It has a semisolid consis- environmental pollutants [29]. Apart from unde-
tency at room temperature and is taken from the sired minor components, vegetable oils usually
fruit pulp of the oil palm (Elaeis guineensis). The also contain functional lipids such as tocopherols
widespread cultivation of palm oil in Malaysia (vitamin E) and phytosterols. A balanced produc-
and Indonesia has lead to concerns about habitat tion efficiently removes the contaminants but
destruction and deforestation, and mechanisms preserves the functional minor lipids in the oil.
for sustainable production of palm oil have been Figure 26.1 gives a simplified outline of the pro-
implemented. The Round Table for Sustainable cessing involved in converting oilseeds to cos-
Palm Oil (RSPO) is a multistakeholder organiza- metic ingredients.
tion for promoting and certifying the production The first step in all oil processing is to remove
of palm oil which do not contribute to social and the oil from the seeds, kernels, fruits, and nuts.
environmental degradation in the producing This is usually done by decorticating and drying
counties [28]. the seed raw material before crushing it by differ-
There are two major sources of short and ent types of mills. The resulting cake is pressed
medium chain fatty acids (C8, C10, C12, and to extract the oil. For most seed materials, the
C14): palm kernel oil and coconut oil. These two resulting pressed seed cake is further extracted
26 Chemical and Physical Properties of Emollients 409

with a solvent, usually hexane. The crude oil is This process rearranges the fatty acids on the
sometimes used as such, but normally the oil is glycerol backbone and with an altered triglycer-
further processed via refining, bleaching, and ide composition, the melting behavior and sen-
deodorization. sory properties are modified. Oxidative stability
The refining of a vegetable oil can be regarded is not affected as the fatty acid composition is not
as a washing process using water with different changed.
pH values. The first washing, the degumming, is The physicochemical properties as well as
done using acidic water and removes phospholip- chemical behavior can also be modified using
ids, gums, and sugars and decreases the level of fractionation techniques [31]. Methods which
metals and proteins present in the oil. The second can be used for low molecular weight sub-
washing is done with a weak alkali to remove stances, such as fatty acids, alcohols, and esters,
free fatty acids. Again, water-soluble substances are not suitable for triglyceride oils. The high
and metals are decreased. After drying, the oil is boiling point of triglycerides is due to their
now ready for bleaching. large size and prevents separation based on dis-
The bleaching step in vegetable oil refining tillation. Instead, high-melting solids can be
comprises adding one or more absorbents to the frozen out of the oil phase by lowering the tem-
oil and filtering off the absorbent after sufficient perature. Dry fraction is the term used when the
contact time. The absorbent is usually activated cooling of the oil is done without solvent and is
montmorillonite clay, also known as bleaching frequently used for palm oil and its derivatives.
earth. The oil can also be treated with activated Dry fractionation uses high-pressure filters to
carbon to remove oil soluble contaminants. After separate the solid and liquid fractions from
the bleaching, the oil is free from phospholipids, each other. If a better separation of the solid
free fatty acids, metal traces, protein residuals, and liquid fractions is needed, a solvent must
and other degradation products and be used for the fractionation process. Hexane or
contaminants. acetone is the industrially used solvent for this
The final step in oil refining is the deodoriza- type of process.
tion. This step, which is a steam distillation in After physical or chemical modification pro-
vacuum, removes volatile components that cause cesses, the solvents, catalysts, and by-products
odor and flavor. It also eliminates the last traces are removed by bleaching and deodorization to
of free fatty acids. If done at too high temperature produce an emollient with optimized properties
and extreme vacuum, this process also removes and high purity.
tocopherols and phytosterols, substances that are
beneficial in skin care. Some Common Natural Oil-Based Emollients
In case the properties of the oil are not suitable and Their Properties [23]
for the intended application, the vegetable oil can Soybean oil is the oil from the soya bean,
be modified using chemical and physical meth- Glycine soja, of the Leguminosae family. It is
ods [30]. The most common method to modify highly unsaturated and has a short shelf life in
the properties of unsaturated oils is to use hydro- cosmetic applications. Soybean oil is a good
genation. Hydrogen is added to the double bonds source for linoleic and linolenic acids; tocoph-
removing the unsaturation step by step. The melt- erols, especially gamma-tocopherol; and phy-
ing point increases, but also the oxidative stabil- tosterols. Soybean oil is frequently derived
ity. Fully saturated vegetable oils are often used from GMO soybeans, and special care must be
for further processing into esters and emulsifiers. taken in sourcing if non-GMO soybean oil is
Chain lengths from C14C18 are preferred in required. Soybean oil can be used in skin care
this context. to provide essential fatty acids (linoleic and
Interesterification is another chemical modifi- linolenic acids), but due to the low oxidative
cation method which is used to modify the melt- stability, the level in the formulation is usually
ing and crystallization properties of oils and fats. lower than 12%.
410 J.T. Alander

Rapeseed oil is found at high concentration in The uniqueness of shea butter also lies in the
the seeds of the oil rape, Brassica campestris. presence of high concentrations of triterpene
The dominant fatty acids are oleic acid and cinnamates and acetates which are sometimes
linoleic acid, but also, linolenic acid is abundant. useful as bioactive additives in skin care [34]. A
Several varieties of oil rape have been developed variety of shea butter, meeting the criteria on
over the years. Currently, at least three different stability and low melting point, is liquid shea
types of rapeseed oil are available: low-erucic butter, obtained by fractionation of the semi-
acid rapeseed (LEAR, canola oil), high-erucic solid material. It has a high level of oleic acid
acid rapeseed oil (HEAR), and high-oleic rape- but contributes also with a significant level of
seed oil (HORO). HEAR oil has a high level of triterpene esters.
the long-chain monounsaturated erucic acid Two oils with a high content of monounsatu-
(C22:1) while high-oleic rapeseed oil has a sig- rated fatty acids are olive oil and sweet almond
nificantly lowered content of linolenic and lino- oil. These oils are both popular in skin care for-
leic acids for improved oxidation stability. mulations. Olive oil can be used as nonrefined
Rapeseed oil is also rich in tocopherols and phy- but contributes with a typical greenish color and
tosterols. Hydrogenated and fractionated rape- olive flavor to the formulation. These two oils are
seed oil having an elevated level of tocopherols reasonably stable against oxidation due to the
and phytosterols can be used to increase recovery lack of sensitive linolenic acid and a moderate
of surfactant damaged skin [32]. The high oleic content of linoleic acid.
and the hydrogenated rapeseed oil can be used at Numerous other vegetable oils are used in
15% in the formulation without adverse effects cosmetic formulations, mainly due to their use-
on smell and stability. fulness as marketing ingredients. The composi-
Sunflower seed oil is obtained from the seeds tion normally falls into one of the four groups
of the sunflower plant (Helianthus annuus). The described above. In this group, we find vegetable
traditional sunflower oil has a high content of oils and fats such as cocoa butter, murumuru but-
linoleic acid and is prone to oxidation. Newer ter, avocado oil, and babassu oil.
varieties with low-linoleic and high-oleic acid
content are also available (high-oleic sunflower Synthetic Triglycerides and Analogues
oil). Sunflower oil is rich in tocopherols but The most common synthetic triglyceride used as
requires normally removal of the seed coat waxes emollient in skin care formulations is caprylic/
by winterization to obtain clear oil. Sunflower capric triglyceride, also known as medium chain
seed oil of the traditional, high-linoleic acid type triglyceride (MCT). This synthetic triglyceride
can be used to provide essential fatty acids to the has intermediate viscosity and polarity and a high
formulation. Low oxidative stability limits the resistance against oxidation as it is fully
use to 12% in the formulation. High-oleic sun- saturated.
flower seed oil can be used as a basic emollient at Caprylic/capric triglycerides are produced by
higher concentrations. esterification of glycerol by a mixture of caprylic
Shea butter is a unique vegetable fat with a and capric acids. Coconut oil or palm kernel oil is
high functionality in skin care [33]. The main hydrolyzed to fatty acids and glycerol; the fatty
fatty acids are stearic (C18:0) and oleic (C18:1) acids are separated by distillation into fractions
acids. The triglyceride composition yields a (C8C10, C12C14, and C16C18). The C8C10
solid fraction primarily comprising stearic- fraction is added to glycerol, and the esterifica-
oleic-stearic triglycerides and a liquid fraction tion reaction is carried out by removing reaction
dominated by stearic-oleic-oleic triglycerides. water. The process can be run without added cat-
This combination gives shea butter a semisolid alyst or using tin-based acidic catalysts. After
consistency and high emolliency and moistur- reaction, the oil can be deodorized to improve fla-
ization when added to a skin care formulation. vor and odor.
26 Chemical and Physical Properties of Emollients 411

Emollients which are analogues to the caprylic/ 26.5 Important Properties to

capric triglycerides are, for example, diesters of Consider When Selecting
propylene glycol and triesters of glycerol and Emollients
synthetic ethylhexanoic acid (octanoic acid).
When formulating skin care products, the emol-
26.4.3.3 Complex Esters lient is often combined with water, actives, and
Esters with poorly defined compositions and emulsifiers. In the formulation, several aspects
which are often made from constituents with sev- must be optimized: stability, aesthetics, and deliv-
eral reaction centers can be summarized by the ery of actives. By a careful selection of emollients
name complex esters. This group also comprises and by systematic variation of the emollient com-
lanolin, which is a natural product with complex position, formulations meeting the desired char-
composition. acteristics may be developed.

Polyacid and Polyhydric Esters

In the last years, a new group of emollient 26.5.1 Compositional Aspects
esters have been introduced. These complex of Emollient Selection
esters are based on different combinations of
polybasic acids and polyhydric alcohols and The composition of commercially available
are usually more viscous than traditional esters. emollients is usually difficult to investigate and
They have also higher molecular weights, and analyze. Two emollients with the same INCI
by the selection of constituents, the polarity name, for example, isopropyl palmitate may
can be modified. differ in properties because the palmitate part
Esters based on polyhydric alcohols such as may be derived from different starting materials.
trimethylolpropane (three hydroxyl groups) and The palmitic acid used for this ester is seldom
pentaerythritol (four hydroxyl groups) are also pure, and various amounts of stearic acid may be
available. These complex esters are normally present as well as shorter fatty acids such as
produced using branched fatty acids or unsatu- myristic and lauric. If the palmitic acid is derived
rated acids as the long chain linear esters tend to from animal fats, it may also contain fatty acids
become too high melting. with 15 and 17 carbons as well as branched fatty
Esters based on polycarboxylic acids with acids.
simple alcohols are also available. In this case, Many other types of emollients are equally
the viscosities are low, and the polarity is high difficult to characterize due to the complex com-
due to the presence of several ester groups. position of structurally similar and isomeric
Examples of this category include esters of adipic forms. This can be the case with petrolatum and
acid and citric acid with low molecularweight mineral oils which can have different composi-
alcohols. tions depending on their origin. For this reason, it
is important to remember that there cannot be a
Lanolin and Lanolin Derivatives direct comparison from a technological point of
Lanolin is another naturally occurring oleogel, view of two emollients, even if they are nomi-
characterized by having a high content of cho- nally the same and fulfill the same specification.
lesterol and lanosterol esters. It is also rich in
esters between dicarboxylic acids, long-chain 26.5.1.1 Contaminants: Environmental
diols, and hydroxy acids. Lanolin can be frac- and Processing Dependent
tionated to yield different qualities of emol- All raw materials can be more or less contami-
lients, and it can be derivatized to increase and nated with environmental pollutants. Such pollut-
tailor-make the functionality for different ants come from the soil, from air, from the
applications [3538]. processing, and from transports of raw materials
412 J.T. Alander

and intermediates. Contaminants can also leach that degrade the emollients and can have large
into the emollient from packaging materials and impact on the quality and shelf life of the
from process equipment. Since contaminants of formulation.
different types are ubiquitous and often represent
higher toxicity than the emollients themselves, 26.5.2.1 Oxidation: Rancidity and Skin
monitoring the presence of contaminants is impor- Damage
tant and constitute a part of the new Cosmetic In emollient technology, oxidation can be regarded
Regulation of the European Union [39]. as a simple reaction between oxygen and the
Contaminants which are of specific concern emollient. The oxidation results in breakdown
for emollients are heavy metals, pesticide residu- products which can be smelly or irritating, depend-
als for plant derived materials, and polyaromatic ing on their size and volatility. Oxidation can also
hydrocarbons. Allergens, both those associated cause changes in the color and appearance of the
with skin sensitization as well as food allergens, formulation. In the worst case, oxidation can cause
should be absent. Even if emollients normally do changes in metabolic pathways in the skin, result-
not sustain microbial growth due to low water ing, for example, in inflammatory reactions, muta-
activity in the ingredient itself, packaging materi- tions, and apoptosis [40, 41]. Understanding
als, and insufficiently heated materials can cause emollient oxidation is therefore important for the
transfer of microbial contamination. formulator and product designer.
Oxidation requires an activated reaction cen-
26.5.1.2 By-Products, Processing Aids, ter to proceed rapidly. Saturated hydrocarbons
and Other Residues from contain few activated carbons that can serve as
Manufacturing reaction centers and are usually resistant against
Normally, emollients do not contain high levels oxidation. The introduction of one double bond
of toxic or irritating by-products from the reac- creates two active reaction centers adjacent to the
tions used to manufacture the ingredient, unless double bond, and oxidation rates are more than
the material is highly unsaturated or has been doubled. When more double bonds are added,
subjected to very high temperatures for a pro- more active reaction centers are introduced and
longed time. It is important to check the level of the oxidative stability decreases rapidly.
residual processing aids and catalysts. Processing Carboxylic acids and hydroxyl groups also con-
aids include solvents, filter aids, and acids/alkalis tribute to active reaction centers. In case an oxy-
used to neutralize the material after esterification gen molecule reacts with an activated carbon
or other reactions. Catalyst residuals may be moiety, a hydroperoxide is formed. This hydroper-
strongly acidic or alkaline or contain heavy met- oxide is a primary oxidation product and is mea-
als such as nickel or tin. sured by the peroxide value which is normally
stated as a quality parameter for emollients.
If more oxygen is available, the oxidation pro-
26.5.2 Chemical Properties to Consider cess can proceed in two directions: formation of
when Selecting Emollients additional hydroperoxides or further oxidation of
the hydroperoxide to form aldehydes, ketones,
Chemical reactions usually need a reaction center and hydrocarbons. This secondary oxidation
and one or more reactants and frequently the breaks the hydrocarbon chains and produces
presence of a catalyst. In emollients, the reaction fragments of different sizes and polarities.
centers can either be located in the hydrocarbon Fragments with low molecular weights are vola-
chain or it can be one or more of the functional tile and enter the headspace above the emollient.
groups present in the structure. Only two reac- These volatile aldehydes and hydrocarbons have
tants will be considered in this review: oxygen low odor thresholds and can be detected by the
and water. The two reaction types are conse- human nose in concentrations that are in the ppb-
quently oxidation and hydrolysis, two reactions ppm range. If the oxidized fragment is larger, it
26 Chemical and Physical Properties of Emollients 413

does not volatilize and stays in the emollient. alcohol. As this is an equilibrium reaction, esteri-
These components are usually not smelly, but fication occurs if the water is continuously
they can contribute to skin irritation. removed while the hydrolysis takes place when
Oxidation is catalyzed by metal ions, by cer- there is an excess of water. Hydrolysis of esters is
tain enzymes and by the presence of oxidation catalyzed by strong alkalis, strong acids, and by
products (autocatalysis) [42]. Iron and copper are enzymes such as lipases and esterases. Most
the most active oxidation catalysts seen in emol- esters are stable in the pH range 58, especially if
lient systems, and already, ppm levels of these they are encapsulated inside emulsion droplets.
metals can cause problems. Oxidation is also Hydrolysis of esters in skin care formulation can
catalyzed by UV radiation and by visible light cause the emulsion structure to change, leading
(photooxidation). Unstable emollients, such as to texture changes and instability. The pH value
highly unsaturated oils, as well as sensitive of the formulation drops, and the liberated acid or
actives need to be formulated with care and the alcohol can increase the irritancy of the formula-
product packaged in opaque packaging to prevent tion. High molecular weight esters with low
photooxidation. polarity have better hydrolysis resistance as the
Oxidation can be prevented by the use of anti- ester bond concentration is lower and because
oxidants. Most antioxidants are free radical scav- water solubility in the ester is restricted.
engers and will eliminate the oxygen before it Formulating with barrier forming emulsifiers and
reacts with the activated reaction centers, alterna- polymers can also protect the oil phase against
tively deactivating the hydroperoxide and pre- hydrolysis.
venting the secondary oxidation. A good principle
to prevent oxidation in formulations is to com-
bine a water-soluble antioxidant with an oil-solu- 26.5.3 Selecting Emollients Based
ble one. Further protection is obtained if a surface on Physicochemical Behavior
active antioxidant is added to act at the interface
between oil and water. The choice of antioxidant Controlling the polarity and rheology of the
is often regulated by the legal restrictions, and emollient blend in a formulation is necessary in
care must be taken to use only permitted order to obtain the desired skin feel and stability
antioxidants. of the product. Many practical emollient mixtures
Avoiding oxidation is also important from a contain high- and intermediate-melting compo-
product safety aspect. Free radicals and reactive nents which give a semisolid consistency to the
oxygen species can start and maintain inflamma- ingredient. Understanding crystallization and
tory reactions in the skin. They can also contrib- melting behavior for texture and rheology control
ute to the oxidation of proteins and structural is important, especially when formulating anhy-
lipids in the skin, reducing the ability of the skin drous ointments and high emollient content W/O
to maintain its elasticity and moisture barrier emulsions.
properties.
26.5.3.1 Melting Points Versus Melting
26.5.2.2 Hydrolysis of Esters Gives Ranges
Texture Changes in the For many semisolid emollients and for mixtures
Formulation of emollients, the melting behavior is an impor-
A second chemical reaction of importance for tant selection criterion. As most emollients and
ester-based emollients is hydrolysis. Obviously, emollient mixtures have complex compositions,
hydrocarbons and alcohols do not react with the melting point is no longer a good characteris-
water, but all esters are more or less sensitive tic for comparison. In this case, the melting range
towards hydrolysis. The hydrolysis is the reversed or the melting profile is a more appropriate
version of the esterification reaction: water reacts parameter. The melting profiles can easily be
with the ester bond and liberates the acid and the measured using differential scanning calorimetry
414 J.T. Alander

(DSC), also in formulations. The DSC results, In order to manipulate the skin feel and the
when standardized, give a direct comparison of solubility of actives, changing the polarity of the
the melting behavior of an emollient mixture and emollient system is a useful tool. A hydrocarbon-
can also give insight into interactions between based emollient is normally nonpolar, and adding
the emollients and emulsifiers. Pure emollients a more polar emollient such as an ester or a fatty
and emollient blends can be characterized using alcohol can strongly influence the behavior.
low-resolution NMR techniques. These measure-
ments are strongly influenced by water so the 26.5.3.3 Controlling Viscosity and
measurements are restricted to dry emollients Lubricity for Improved Skin Feel
and to anhydrous systems. Viscosities of emollient blends in the liquid state
Analysis of the emollient melting behavior are normally additive, and the viscosity of the
can be used to optimize the formulation proper- blend usually reflects the composition of the mix-
ties. Important temperature ranges to consider ture and its individual constituents. Viscosity and
are storage temperatures (normal, too low, too perceived lubricity are often connected, but quite
high), body temperature, and temperatures dur- often there is an optimal viscosity associated with
ing product stability testing. The formulation best skin feel and other sensory properties. If the
should be possible to dispense from its container emollient viscosity is too low, the skin feel is thin
(at storage temperature), meaning that the solids and watery while too high viscosities are perceived
content must not be too high. On the other hand, greasy and unpleasant. For sensitive skin, a high
in order to achieve high temperature stability and viscosity can also be disadvantageous as the drag
stability at varying storage conditions, increas- will be perceived as irritating. High emollient vis-
ing the solids content can be the solution as the cosity is often preferred to reduce emulsifier and
solids will help the emulsifier and stabilizer sys- stabilizer content. High-viscosity oils can reduce
tem to maintain consistency. Finally, the solids emulsion instability, especially as higher viscosity
can also be used to modify skin feel and moistur- is also often associated with higher density.
ization. The higher the solids content, the heavier
the skin feel is, but the perceived moisturization 26.5.3.4 Spreading and Spreadability
is improved. Spreading and spreadability of the formulation on
skin are important parameters for consumer
26.5.3.2 Optimizing the Polarity appeal and acceptance. A formulation should be
by Mixing Emollients easy to apply, spread rapidly on the skin, and give
As the polarity of an emollient or an emollient a rapid disappearance from the skin surface. The
mixture is difficult to measure directly, the selec- spreading ability of emollients and emollient mix-
tion of emollients to optimize properties is at best tures directly on skin is difficult to measure accu-
a semiempirical procedure. In general, the polar- rately, and various techniques have been applied
ity is additive, meaning that mixtures of emol- to estimate the spreading properties [10, 43].
lients have properties proportional to the mixing Spreadability and viscosity are dependent on each
proportions. However, some properties associ- other as a rapid spreading is often observed for
ated with polarity are strongly influenced by the low-viscosity emollients. The rapid spreading is
purity of the system. For example, interfacial and also associated with lubricity or slip, again favor-
surface tension of an emollient is sometimes used ing emollients of low viscosity. Equilibrium
to evaluate polarity. These two parameters are spreadability, on the other hand, is a different
strongly influenced by the presence of small parameter and also important for the perceived
amounts of surface active contaminants, and the emolliency of the formulation. High equilibrium
measured values can be strongly misleading if spreading will yield a thin film on the skin surface
the emollients are not properly purified before and may lead to a disappearance of the perceived
the measurements are taken. emolliency and moisturization over time.
26 Chemical and Physical Properties of Emollients 415

26.5.4 Environmental Properties cosmetics are also safe in this aspect. Again, high
molecular weight lipophilic substances with high
Although the environmental properties of emol- melting points are more of a problem, especially
lients are usually not considered to be a primary since the data available is scarce.
concern for skin care products, recent changes in
legislation, especially in Europe, has brought the Conclusions
focus to this issue. When considering the use of Emollients are necessary ingredients for skin
skin care product, it is obvious that part of the care preparations, and the selection of ingredi-
emollients and other ingredients are absorbed ents is a difficult task when optimizing proper-
into the skin, while other parts are rubbed off into ties and performance. This chapter has
clothes or washed off during showering and reviewed hydrocarbons, alcohols, and esters
cleansing procedures. Other aspects concern the used for emolliency and pointed to important
manufacturing, storage, and transport of emol- chemical and physical properties that must be
lients in large scale and the results locally and considered when selecting emollients.
regionally of accidental discharge of chemicals Each group of emollient technologies has its
into the environment. All this points to the impor- benefits and disadvantages, and it is obvious
tance of environmentally safe ingredients, and that the perfect emollient does still not exist. A
emollients, being used in relatively high concen- skilled formulator can utilize the benefits of
trations in the formulations, are of special each emollient while minimizing the adverse
concern. effects. It is also evident that many of the
Biodegradability has become an important properties of a finished formulation are the
property for emollients and other cosmetic ingre- result of ingredient interactions, and the win-
dients in the past few years. In a sustainability ning formulation is often achieved by skillful
perspective, with life cycle analysis as a defining manipulation of the interactions.
principle, not only the production and use of
chemical substances but also the disposal after
use and accidental discharge into the environ- Take Home Messages
ment have become important to consider. Most When reading this chapter you should
straight-chain hydrocarbon-based emollients are learn about the following points:
readily degraded by sewage bacteria and can be Emollient classification based on chem-
considered readily biodegradable. This is also the istry of physical properties
case for straight chain fatty acids and alcohols. The importance of optimizing physical
Esters are usually first hydrolyzed to the constitu- properties for the application
ents which are then degraded. High-melting and The chemical reactions that must be
high molecular weight substances are generally considered for emollients
degraded more slowly due to low solubility and How emollients are produced
bioavailability. Although ultimately biodegrad- Different raw materials for emollients
able, they can sometimes cause visible problems Considerations when selecting emollients
and disturb flora and fauna locally.
Another aspect of biological degradation is
the possibility for substances to accumulate in References
the environment. Lipophilic substances, such as
emollients, have a higher potential for bioaccu- 1. Wiechers JW, Kelly CL, Blease TG, Dederen JC
mulation. However, since chemical structures (2004) Formulating for efficacy. Int J Cosmet Sci
26:173182
that are known to cause toxic metabolites and
2. Shinoda K, Friberg S (1986) Concepts of HLB, HLB
show a high tendency to accumulate in the envi- temperature and HLB number. In: Emulsions and
ronment are today not used as emollients, most solubilization. Wiley, New York, pp 5593
416 J.T. Alander

3. Shinoda K, Kunieda H (1983) Phase poperties of 19. Barry BW, Grace AJ (1971) Structural rheological
emulsions: PIT and HLB. In: Becher P (ed) and textural properties of soft paraffins. J Texture Stud
Encyclopedia of emulsion technology, vol 1. Marcel 2:259279
Dekker, Inc, New York, pp 337368 20. Morrison DS (1996) Petrolatum: a useful classic.
4. Parente ME, Gambaro A, Solana G (2005) Study of Cosmet Toiletries 111:5969
sensory properties of emollients used in cosmetics 21. Busson-Breysse J, Farines M, Soulier J (1994) Jojoba
and their correlation with physicochemical properties. wax: its esters and some of its minor components. J
Int J Cosmet Sci 27:354 Am Oil Chem Soc 71:9991002
5. Goldemberg RL, de la Rosa CP (1971) Correlation of 22. OLenick A (2001) Guerbet chemistry. J Surfactants
skin feel of emollients to their chemical structure. Deterg 4:311315
J Soc Cosmet Chem 22:635654 23. Gunstone FD, Harwood JL (2007) Occurrence and
6. Wortel VAL, Verboom C, Wiechers JW (2005) characterisation of oils and fats. In: Gunstone FD,
Linking sensory and rheology characteristics. Cosmet Harwood JL, Dijkstra AJ (eds) The lipid handbook
Toiletries 120:5766 with CD-ROM. CRC Press, Boca Raton, pp 37142
7. Otto A, Du Plessis J, Wiechers JW (2009) Formulation 24. Biermann U, Metzger JO (2008) Synthesis of alkyl-
effects of topical emulsions on transdermal and der- branched fatty acids. Eur J Lipid Sci Technol
mal delivery. Int J Cosmet Sci 31:119 110:805811
8. Friberg SE (1990) Micelles, microemulsions, liquid 25. Schuchardt U, Sercheli R, Matheus Vargas R (1998)
crystals, and the structure of stratum corneum lipids. Transesterification of vegetable oils: a review. J Braz
J Soc Cosmet Chem 41:155171 Chem Soc 9:199210
9. Hughes KJ, Lvovich VF, Woo J, Moran B, Suares A, 26. Thum O, Oxenboll KM (2008) Biocatalysis: a sus-
Truong MHT (2006) Novel methods for emollient tainable process for production of cosmetic emollient
characterisation. Cosmet Toiletries Manuf Worldwide esters. SFW-J 134:4447
93:1924 27. Hills G (2003) Industrial use of lipases to produce fatty
10. Gorcea M, Laura D (2010) Evaluating the phys- acid esters. Eur J Lipid Sci Technol 105:601607
iochemical properties of emollient esters for cosmetic 28. RSPO promoting the growth and use of sustainable
use. Cosmet Toiletries 125:2633 palm oil (2011) http://www.rspo.org/[On-line]
11. Iwahashi M, Kasahara Y (2007) Effects of molecular 29. Dijkstra AJ, Segers JC (2007) Production and refining
size and structure on self-diffusion coefficient and of vegetable oils. In: Gunstone FD, Harwood JL,
viscosity for saturated hydrocarbons having six car- Dijkstra AJ (eds) The lipid handbook with CD-ROM.
bon atoms. J Oleo Sci 56:443448 CRC Press, Boca Raton, pp 143262
12. Barry BW (1975) Viscoelastic properties of concen- 30. Dijkstra AJ (2007) Modification processes and food
trated emulsions. Adv Colloid Interface Sci 5: uses. In: Gunstone FD, Harwood JL, Dijkstra AJ (eds)
3775 The lipid handbook with CD-ROM. CRC Press, Boca
13. Huang Z-R, Lin Y-K, Fang JY (2009) Biological and Raton, pp 263354
pharmacological activities of squalene and related 31. Padley FB (1994) Fractionated products: a brief sur-
compounds: potential uses in cosmetic dermatology. vey of the application of fractions of edible oils and
Molecules 14:540554 fats. Society of Chemical Industry, London, 22pp
14. Bondioli P, Mariani C, Lanzani A, Fedeli E, Muller A 32. Loden M, Andersson AC (1996) Effect of topically
(1993) Squalene recovery from olive oil deodorizer applied lipids on surfactant-irritated skin. Br J
distillates. J Am Oil Chem Soc 70:763766 Dermatol 134:215220
15. Chiba K, Yoshizawa K, Makino I, Kawakami K, 33. Alander J (2004) Shea butter - a multifunctional
Onoue M (2000) Comedogenicity of squalene mono- ingredient for food and cosmetics. Lipid Technol
hydroperoxide in the skin after topical application. J 16:202205
Toxicol Sci 25:7783 34. Akihisa T, Kojima N, Kikuchi T, Yasukawa K, Tokuda
16. Motoyoshi K (1983) Enhanced comedo formation in H, Masters T, Manosroi A, Manosroi J (2010) Anti-
rabbit ear skin by squalene and oleic acid peroxides. inflammatory and chemopreventive effects of triter-
Br J Dermatol 109:191198 pene cinnamates and acetates from shea fat. J Oleo
17. Saint-Leger D, Bague A, Lefebvre E, Cohen E, Chivot Sci 59:273280
M (1986) A possible role for squalene in the patho- 35. Motiuk K (1979) Wool wax alcohols: a review. JAOCS
genesis of acne. II. In vivo study of squalene oxides in 56:651658
skin surface and intra-comedonal lipids of acne 36. Motiuk K (1979) Wool wax acids: a review. JAOCS
patients. Br J Dermatol 114:543552 56:9197
18. Saint-Leger D, Bague A, Cohen E, Chivot M (1986) 37. Schlossman M, McCarthy J (1978) Lanolin and its
A possible role for squalene in the pathogenesis of derivatives. J Am Oil Chem Soc 55:447450
acne. I. In vitro study of squalene oxidation. Br J 38. Motiuk K (1980) Wool wax hydrocarbons: a review. J
Dermatol 114:535542 Am Oil Chem Soc 57:145146
26 Chemical and Physical Properties of Emollients 417

39. Regulation (EC) No 1223/2009 of the European 42. Shahidi F, Zhong Y (2010) Lipid oxidation and
Parliament and of the Council of 30 November 2009 improving the oxidative stability. Chem Soc Rev
on cosmetic products (2009) Official Journal of the 39:40674079
European Union [On-line], L 342/59, 59209 43. Bruns C, Mller RH, Prinz D, Kutz G (2006)
40. Kohen R (1999) Skin antioxidants: their role in aging Identification of topical excipients with high perfor-
and in oxidative stressnew approaches for their eval- mance spreadability. Poster, 5th world meeting on
uation. Biomed Pharmacother 53:181192 pharmaceutics, Biopharmaceutics and Pharmaceutical
41. Thiele JJ, Schroeter C, Hsieh SN, Podda M, Packer L Technology, Geneva
(2001) The antioxidant network of the stratum
corneum. Curr Probl Dermatol 29:2642
 Polyfunctional Vehicles
by the Use of Vegetable Oils 27
Luigi Rigano and Chiara Andolfatto

27.1 Introduction protect the skin and guarantee its metabolic

functions [22]. Therefore, the epidermal horny
Skin is regularly softened and lubricated by the layer consists of keratinized cells surrounded by
water arriving from deep dermis or produced a lipid matrix that hinders water evaporation and
from sweat glands. Some water content is released the diffusion of water and electrolytes. Such
to the external environment, determining a structure builds the permeable moisturizing bar-
dynamic equilibrium. Water loss by evaporation rier of the skin [4].
is regulated by the physiological cutaneous
barrier that lays at the horny layer level. The
horny layer is made of corneocytes, keratinocytes 27.2 Cutaneous Lipids
that have reached the final differentiation steps. and Moisturization
They are rich in keratin, responsible of the
mechanical resistance of the skin and immersed The main responsible of the cutaneous modifica-
in a permeable matrix. This last one is formed by tion which leads to dryness is the hydro-lipidic
water emulsified by substances of fatty nature, unbalance, both qualitative and quantitative, of
produced by the sebaceous glands, deriving from the more external cutaneous layers. Moisturization
the degradation of mature skin cells reaching the and barrier effects being strictly related to the lip-
stratum corneum level or directly synthesized by ids of the horny layer are supported by the fact
keratinocytes [6]. It consists of lipids and amphi- that increased permeability of the cutaneous bar-
phile molecules, like cholesterol (25%), cer- rier is induced by its disruption after lipids
amides (50%) and free fatty acids (15%) removal by means of organic solvents (i.e. ace-
especially those bearing unsaturated chains [10] tone), following mechanical stress (i.e. sequential
[5]. Moreover, squalene and small amounts of tape stripping) or the action of cleansing surfac-
phospholipids are also present. They create an tants (i.e. SLS). This is evidenced by an increase
ordered structure with the aqueous phase, form- of trans-epidermal water loss and of newly pro-
ing a series of bilayers (aqueous and lipid) that duced epidermal lipids [5]. The level of stimula-
tion of the lipid synthesis is related to the extent
of damage of the skin barrier. Moreover, when
the cutaneous barrier functionality is recovered,
also the synthesis of epidermal lipids turns to its
average normal values. The re-establishment of
L. Rigano () C. Andolfatto
the equilibrium water content in the horny layer,
Rigano Industrial Consulting and Research,
via Bruschetti 1, 20125 Milano, Italy on the other side, takes place proportionally and
e-mail: [email protected] as the last step [6].

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 419

DOI 10.1007/978-3-642-27606-4_27, Springer-Verlag Berlin Heidelberg 2012
420 L. Rigano and C. Andolfatto

The external supplement of topically applied all small seeds contain fatty materials. In general,
oils may solve the problems of disequilibrium of cells generally contain more oils when they
the cutaneous hydro-lipidic film. The main evi- belong to the aleuronic layer that coats the cereal
dences derive from studies carried out with new- grains of the germ and the seed. Oils are reserve
borns and premature babies. Indeed, their skin substances accumulated by the plants in variable
structure is not yet completely developed, and extent in dependence of the involved vegetal spe-
they have reduced barrier function. It has been cies, during growth. Moreover, they are found in
shown that the cutaneous application of vegetal the pericarp of some fruits and, to a lower degree,
oils, followed by massage, can significantly in pollens, spores and vegetative organs.
increase moisturization and improve their barrier All lipid molecules in the vegetal world are
function. As a positive set of accompanying fundamentally characterized by the content of
effects, this compensates the deficiency of essen- one or more fatty acids with aliphatic chains, i.e.
tial fatty acids, reduces the nosocomial infections aliphatic carboxylic acid with an even number of
(verified with sunflower oil), improves the carbon atoms.
somatic cells growth (verified with soy oil) and When taking into account the lipid storage
quickly re-equilibrates the cutaneous comfort in reserves localized in plants, except palm and coco-
cases of dermatological affections [20]. nut oil, the other vegetal oils are dominated by the
As oils have hydrophobic nature, moisturiza- group of unsaturated fatty acids with 18 carbon
tion does not derive from an external water sup- atoms. Indeed, for each oleaginous plant species
ply but is given by the integration with lipids actually used, more than 80% of the fatty acids
already existing in the epidermis. The use of non- content is generally represented by oleic (C18:1),
physiological lipids as petrolatum, lanolin or linoleic (C18:2) and linolenic (C18:3). The same
beeswax may quickly restore the normal perme- prevalence of fatty acids C18 mono-, di-, and tri-
ability of the cutaneous barrier but only at a par- unsaturated, about 60% of the total fatty acids, is
tial level [5]. Clinical studies confirm that, observed in the seed of cereals [14].
following the application of a vegetal oil
(sweet almond oil) and of a liquid vegetal wax
(jojoba oil), a mild but significant increase of 27.3.1 Triglycerides
total lipids in the first 68 mm of the horny layer
can be measured [18]. Vegetal oils are formed by about 95% of a blend
A support to the barrier effect is so obtained: of triglycerides that altogether represent a fairly
the water content in the horny layer changes fol- homogenous complex, from the chemical point
lowing the application of oils onto the skin sur- of view, called saponifiable fraction [8].
face. Oils determine an emollient effect on the Indeed, triglycerides treated with concentrated
skin, they modify its physical properties and aqueous alkali give rise to soaps, i.e. the alkaline
make the skin softer and more even. An interest- salts of fatty acids, and to glycerine. The remain-
ing antimicrobial activity has been associated to ing part is called unsaponifiable, as it cannot
some specific fatty acids [4]. react with alkali and therefore does not give rise
to soaps. Vegetal triglycerides structurally are
triesters of the polyol (polyalcohol) glycerine,
27.3 Vegetal Oils with long-chain mono-carboxylic fatty acids.
Other glycerides, that are present in minor
Fats, oils and waxes represent for plants a way to amounts in the saponifiable fraction of oils, are
store energy, in a concentrated and little volumi- mono- and diglycerides, compounds where glyc-
nous way, that is necessary for seeds germination. erine is esterified only with one, or respectively
Moreover, they can play the role of a protective two, fatty acid molecules. Consequently, the
coating layer, especially for their hydro-repel- glycerides category is subdivided, in increasing
lency and thermal insulation property. In general, polarity order, in:
27 Polyfunctional Vehicles by the Use of Vegetable Oils 421

Triglycerides: three fatty acid chains are bound cation induced by physico-chemical treatments,
to glycerine, three ester bonds, no free alcohol as those taking place during some oils refining
group process.
Diglycerides: two fatty acid chains are bound An additional subdivision applies to unsatu-
to glycerine, two ester bonds and one free rated fatty acids, according to the position of the
alcohol group double bond in the alkyl chain. The most wide-
Mono-glycerides: only one fatty acid bound to spread in the vegetal world are three, all related
glycerine, one ester bond and two free alcohol in the plants biosynthesis, i.e. the family of w9, w6
groups in the structure and w3 fatty acids. The official nomenclature
In spite of the increasing polarity of the mol- applies the Greek letter omega w to the distance
ecules in this series and the consequent possibil- of the first double bond from the first terminal
ity of establishing some attraction forces for methyl group in the chain, and the accompanying
water molecules, all these substances are insolu- number gives the position of the double bond.
ble in water but soluble in several organic sol- For instance, the symbol w3 indicates that the first
vents, at room temperature. Nevertheless, at high position where the double bond is found is situ-
temperature, melted mono- and diglycerides can ated on the third carbon atom, starting the count
be easily dispersed in water. of carbon atoms from the first methyl group. The
The different chemical and physical character- position of the double bond, together with the
istics of the different glycerides need to be ascribed special configuration (cis or trans) determine the
to the different nature of the esterifying acids, to biological properties of unsaturated fatty acids.
the substitution degree of the alcohol groups in The family of w9 fatty acids includes monoun-
glycerine and to the mutual position of the acyl saturated structures, where the cis configuration
chains within the molecule. Differences are even of the molecule, from the point of view of the
more detectable in the solid state, as all glycerides alkyl chains attached to the double bond, is nec-
exhibit polymorph, temperature and cooling-rate essary in order to guarantee the correct smooth-
dependant crystallization states. Acids participat- ness to the membranes of vegetal cells. Indeed,
ing to the formation of glycerides possess more they are essential components of such mem-
frequently a linear alkyl chain, with an even num- branes, and oleic acid is the most abundant repre-
ber of carbon atoms. In nature, we find fatty acids sentative of this category.
with a number of carbon atoms varying from 2 to Vegetal polyunsaturated fatty acids belong to
30, but the most represented are the 18 or 16 car- the groups w6 and w3. Linoleic acid, that is con-
bon atom chains. Differences of relevant proper- tained in oil seeds at high percentage and at a
ties, in all those cases, are only related to the chain fairly good amount also in olive oil, and g-lino-
lengths, to the presence or absence of double lenic acid belong to the w6 family, while a-lino-
bonds and their position in the acyl chains. lenic acid, that is very abundant in linseeds,
Fatty acids can be saturated or unsaturated. In eicosapentaenoic acid (EPA) and docosaesaenoic
the saturated acids family, the acyl chain does not acid (DHA) are in the w3 group.
have any double bond between carbon atoms, The presence of one or more double bonds
while unsaturated acid possess one or more dou- makes the unsaturated fatty acid very sensitive
ble bonds. When containing one double bond to auto-oxidation reactions that are the ground
only, they are called monounsaturated fatty acids, of the oxygen-induced degradation of oils. The
while the definition of polyunsaturated character- triglycerides of unsaturated fatty acids go rancid
izes those having two or more double bonds in very easily, especially when exposed to sunlight
one acyl chain. In nature, the unsaturated fatty and atmospheric oxygen. The reaction is cata-
acids with cis configuration (when both chains lyzed by the presence of traces of metallic ions.
separated by the double bond lie on the same side As smaller dimensions, volatile molecules are
of a plane) are very abundant, while the trans formed in the process, the peroxidation of dou-
configuration may be produced following modifi- ble bonds is accompanied by the development
422 L. Rigano and C. Andolfatto

Table 27.1 The most Designation (C atoms

represented fatty acids in n: double bonds n) Traditional name Chemical name Formula
plants
6:0 Caproic acid Hexanoic acid C6H12O2
8:0 Caprylic acid Octanoic acid C8H16O2
10:0 Capric acid Decanoic acid C10H20O2
12:0 Lauric acid Dodecanoic acid C12H24O2
14:0 Myristic acid Tetradecanoic acid C14H28O2
14:1 Myristoleic acid Tetradec-9-enoic acid C14H26O2
16:0 Palmitic acid Hexadecanoic acid C16H32O2
16:1 Palmitoleic acid Hexadec-9-enoic acid C16H30O2
18:0 Stearic acid Octadecanoic acid C18H36O2
18:1 Oleic acid Cis-9-octadecenoic acid C18H34O2
18:2 Linoleic acid All-cis-9,12- C18H32O2
octadecadienoic acid
18:3 Linolenic acid All-cis-9,12,15- C18H30O2
octadecatrienoic acid
20:0 Arachidic acid Eicosanoic acid C20H40O2
20:1 Gadoleic acid Cis-11-eicosenoic acid C20H38O2
22:0 Behenic acid Docosanoic acid C22H44O2
22:1 Erucic acid Cis-13-docosenoic acid C22H42O2
24:0 Lignoceric acid Tetracosanoic acid C24H48O2

of bad smell. Consequently, the oxidative stabil- liquid at room temperature, while triglycerides
ity of vegetal oils is determined by their fatty rich in saturated fatty acids are consistent or solid
acids composition, in particular by the unsatura- and are called butters. Oils can be transformed
tion degree and, to a lesser extent, by the position in solid fats via saturation of the double bonds of
of double bonds inside the triglyceride mole- the fatty acids in a more or less complete process
cule. A fundamental role in this process is of hydrogenation.
played by the system of antioxidant molecules Indeed, the so-called saponifiable fractions do
present in vegetal oils, such as those of the vita- not include only the esters of fatty acids with
min E group, which belongs to the unsaponifi- glycerine, even if they represent the absolute
able fraction [8]. majority, but also the esters of different alcohols
The most common fatty acids in the vegetal or sterols, phospholipids and glycolipids (accom-
domain are reported in Table 27.1. panying ingredients) [15].
In general, a vegetal oil is a complex blend of
triglycerides, where fatty acids that esterify the
alcohol functions of glycerine vary in their acyl 27.3.2 Secondary Ingredients
chain length and for their unsaturation degree and
position of double bonds. In other words, triglyc- Secondary ingredients in vegetal oils are gener-
erides in vegetal oils are heterogeneous. The ally present in moderate amounts and represent
composition of fatty acids in any specific oil type the non-glyceride fraction. We could subdivide
is variable in a determined interval. This mainly these secondary ingredients in saponifiable com-
depends on the cultivated variety and from the ponents (phospholipids, waxes and sphingolipids,
temperature in the area of farming of the plant. for instance) and in unsaponifiable ingredients
Moreover, the ripening degree is a contributing (hydrocarbons, tocopherols and tocotrienols,
factor in determining the composition of the fatty superior fatty alcohols, sterols, methyl sterols,
acids blend. The higher the unsaturation, the diterpene and triterpenes alcohols, vitamins, pig-
lower the melting point: Oils are by definition ments and ubiquinones).
27 Polyfunctional Vehicles by the Use of Vegetable Oils 423

Similarly to triglycerides, phospholipids are (the second category). The carotenoids fraction
made essentially of glycerine, fatty acids, a phos- includes b-carotene, lutein, neoxanthine and vio-
phoric group and a hydroxylated compound, fre- let xanthine. While carotenoids develop an anti-
quently choline, cholamine or serine, all bound oxidant action by neutralizing the singlet oxygen,
together by ester bonds. Consequently, phospho- chlorophylls perform pro-oxidant properties, as
lipids can be considered as derivatives of the they catalyze the formation of singlet oxygen
glycerophosphoric acid, such as phosphatidyl- species under the action of sunlight. Therefore, a
choline and phosphatidylethanolamine: They are right ratio between chlorophyll and carotenoids
present variable amounts, but never abundant, in pigments is essential for an adequate oil fastness
vegetal oils. toward oxidation. -carotene, or pro-vitamin A,
Glycolipids and sulpholipids are compounds is responsible for the yellow colour that is char-
where two hydroxyl groups of glycerine are acteristic of olive oils and many other vegetal
esterified by fatty acids, while the third engaged oils. Corn oil is one of the richest oils in beta-
in a glycoside bond with galactose or one of its carotene; nevertheless, the industrial refining
derivatives. Finally, sphingolipids are combina- process can deplete the oil of this substance,
tions were one molecule of fatty acid is bound to resulting in a colourless appearance.
a long-chain amino alcohol (sphingosine and
derivatives) to form a ceramide. 27.3.2.3 Vitamin E
Waxes are complex blends of esters of long- Natural vitamin E, as synthesized by plants, is a
chain fatty acids with higher alcohols, such as mix of tocopherols and tocotrienols, that can be
docosanol, tetracosanol and esacosanol. distinguished according to the number and posi-
The unsaponifiable fraction is represented by tions of the methyl groups attached to the chro-
substances which do not undergo any modifica- man ring. The different isomers take the names of
tion, when submitted to the action of concentrated a-, b-, g- and d-tocopherol and of a-, b-, g- and
alkali. The ingredients in the unsaponifiable frac- d-tocotrienol, respectively. They are very power-
tion are low molecular-weight compounds, lipo- ful vegetal antioxidants that hinder the develop-
philic or amphiphilic, that may noticeably ments of oil rancidity. Among tocopherols,
influence the oxidation speed of vegetal oils [15]. a-tocopherol is considered to have superior bio-
logical activity and is also by far the most abun-
27.3.2.1 Hydrocarbons dant isomer in human plasma and tissues. Many
Hydrocarbons are minor components of the unsa- recent studies evidence that the biological activ-
ponifiable fraction, a heterogeneous group of ity of tocotrienols is higher in comparison to that
saturated and unsaturated molecules that are of tocopherols (4060 times higher than that of
present in vegetal fatty materials. Among the a-tocopherol).
unsaturated hydrocarbons, the most frequently All molecules belonging to the family of vita-
found molecule is squalene, a terpene with 30 min E are very powerful antioxidant. They partici-
carbon atoms with six double bonds. This sub- pate in many metabolic processes of human tissues
stance is outstandingly important from the human and prevent the oxidative damages of induced by
biology point of view, as it is the biosynthetic UV rays exposure. In particular, vitamin E is
precursor of all sterols. involved in the biochemical protection strategy of
lipoproteins from oxidation. Its radicals trap
27.3.2.2 Pigments action (radical scavenging + quenching) is syner-
Also, pigments belong to the group of the minor gic with that of beta-carotene, of vitamin C and of
ingredients in vegetal oils. Pigments can be sub- glutathione that are normally present in biological
divided into two main categories: carotenoids tissues. Vitamin C functions with a different mech-
and chlorophyll (a and b types chlorophylls and a anism: It operates as a regenerative player for vita-
and b type pheophytins) that are responsible of min E from its tocopheryl radical that is formed
yellow tones (the first ones) and of the green hues following the elimination of peroxide radicals.
424 L. Rigano and C. Andolfatto

27.3.2.4 Phytosterols tures. The composition of their typical blend

Phytosterols are lipophilic compounds of the trit- among the unsaponifiable matters characterizes
erpenes family. They possess a structure similar to the different vegetal oil. Some of them are inter-
that of cholesterol. It is made of tetracyclic ring mediates in the biosynthesis of sterols [15]; some
and a long flexible side chain at the C-17 carbon others posses anti-inflammatory and germicide
atom site. They are different from cholesterol for properties. g-oryzanol is a group of ferulic esters
the presence of methyl or ethyl groups in the side of triterpene alcohols, present in rice oil. The
chain attached to the C-24 carbon atom. Saturated anti-inflammatory properties of this cosmetic
sterols, called stanols, are also present in vegetal ingredient are attributed to the cinnamates of trit-
oils. They are characterized by the absence of the erpene alcohols present in shea butter [17].
double bond at the position D-5 of the sterol ring
and are less abundant in nature of the correspond-
ing unsaturated parents [9] [13]. In common sense, 27.4 Vegetal Oils of Common
the term phytosterols is generally used to denote Cosmetic Use
altogether sterol and stanols. Although more than
250 different phytosterols have been identified, the 27.4.1 Corn Oil
most common are sitosterol, campesterol and stig-
masterol [12]. The composition of the sterols frac- Corn oil is obtained from the annual plant Zea
tion may change consistently from plant to plant: mays that is mainly harvested for fodder but also
For this reason, phytosterols constitute a kind of for human consumption and industrial uses. Corn
vegetal fingerprint of each vegetal oil. Indeed, is a cereal of cosmetic interest for getting starch
some sterols are specific of unique vegetal oils. and its derivatives. During the process of starch
preparation, corn germs are recovered, that are
27.3.2.5 Polyphenols rich of oil. The crude oil has a dark amber-red
The term polyphenols includes several classes of colour and contains high amounts of phospholip-
compounds sharing a common chemical struc- ids, together with traces of waxes. The refined
ture: They are benzene derivatives with one or oil, devoid of waxes and phospholipids, is one of
more hydroxyl groups associated to the aromatic the seed oils most frequently used in the food
ring. Such structures allow these compounds to industry. The glyceride fraction is rich in linoleic
work actively as radical scavenger and to stabi- (4562%), oleic (2433%), palmitic (813%)
lize free radicals, as reducing agents, as chelating and linolenic acid (~1%). The unsaponifiable
compounds of the pro-oxidant metals and as fraction can represent up to 2% of the oil and
quenchers of the process of formation of singlet is characterized by the presence of fairly
oxygen. They are necessary to the plant metabo- high amounts of beta-sitosterol, campesterol and
lism in order to avoid the auto-oxidation of the g- and a-tocopherol [2].
oil. In general, the richer in unsaturated triglycer-
ides a vegetal oil is, the higher its content of poly- 27.4.1.1 Cosmetic Use
phenols. The main classes of polyphenols are Corn oil is used as emollient and moisturizer in
separated into flavonoids, phenolic acids, stil- emulsions and cosmetic oils. It is frequently
benes and lignans, as a function of the number of employed as vehicle to dissolve lipo-soluble
phenolic rings and of the structural elements active ingredients (e.g. retinol).
binding such rings. The most common vegetal
polyphenols are derivatives of benzoic and cin-
namic acids, or of tirosol and hydroxytirosol [3]. 27.4.2 Coconut Oil

27.3.2.6 Triterpene Alcohols Cocoa butter, better known as coconut oil, is

Simple alcohols and diols belong to the group of obtained from the endosperm of the fruit, i.e. the
terpene alcohols, having complex chemical struc- white flesh of the nut of the plant Cocos nucifera
27 Polyfunctional Vehicles by the Use of Vegetable Oils 425

L. Below 2527C, it is an ivory coloured solid, the production of surfactants, emulsifiers, cleans-
with a characteristic pleasant odour. Its unsaponi- ing products and skin care emulsions [7].
fiable fraction is very low (0.10.3%), while the
trigliceride fraction is rich of saturated fatty acids
(about 95%) as lauric (4551%), myristic (17 27.4.4 Soybean Oil
20%), caprylic (710%), capric (411%) and
palmitic acid (49%). It contains only a modest Soybean oil is derived from one of the most
amount of unsaturated fatty acids, like oleic ancient plants cultivated by man, diffused in Asia,
(211%). Europe and America. The crude oil is mainly
obtained by solvent extraction (especially
27.4.2.1 Cosmetic Use n-hexane) of seeds, with a yield of 1822%. The
Triglycerides obtained from coconut oil are used residue from extraction is a flour, constituting the
mainly as they show marked sebum-restitution main protein source for animal farming. The raw
properties. For its high amount of lauric acid and oil deriving from gone bad seeds has a dark colour,
also of short chain fatty acids, coconut oil is high content of free fatty acids and modified lip-
largely used on a world scale as intermediate for ids. When the quality of the seeds is good, it has
the preparation of surfactants [16]. an amber colour. The strong tendency of soybean
oil to oxidize is due mainly to its high linolenic
acid content (~6%); this is decreased when the oil
27.4.3 Palm Oil is submitted to partial hydrogenation. It is also
rich in oleic (~29%), linoleic (~54%), palmitic
Palm oil is obtained from the plant Elaeis (~7%) and stearic acids (~4%) [2] [11].
guineensis, native of the African continent, but
successively widespread also in Asia and south 27.4.4.1 Cosmetic Use
and central America. The fruit is a bunch made of For its sensitivity to oxidation, soybean oil is
20200 individual fruits: From their mesocarp, quite unstable to light and heat; therefore it is not
the palm oil is obtained, while palm kernel oil frequently used as such in cosmetic formulations,
comes from the fruit stones. Raw palm oil, as it increases their potential development of
obtained both via centrifugation or by hydraulic rancidity.
compression of the pulp, is orange red for its high
amount of carotenoids. Its viscosity is variable
according to the extraction process used. The raw 27.4.5 Olive Oil
oil is normally neutralized, bleached and deodor-
ized in one step. It is mainly made of oleic (40 Virgin olive oil is obtained from olives, drupe of
50%) and palmitic acids (3247%), but it also the plant Olea europea L, belonging to the family
contains linoleic (512%), stearic (19%) and of Oleacee. The cultivation of olive trees dates
myristic acid, (~1%) together with 1% unsaponi- back to ancient era but remains till now in the
fiable matters. Palm kernel oil, obtained from the Mediterranean continent a very common agri-
nut of the seeds, is very similar to coconut oil, for cultural practice, together with the related pro-
its physico-chemical characteristics and as it con- duction of the oil. Fatty acids contained in olive
tains lauric (4652%), myristic (1417%), oleic oil have a medium unsaturation degree, with a
(1319%) and palmitic acids (69%) [11]. low content of saturated fatty acids. Oleic acid
(C18:1) is the most abundant among the constitu-
27.4.3.1 Cosmetic Use ent fatty acids (7080%). The high level of this
It is mainly used as a starting material for the monounsaturated fatty acid makes the olive oil
industrial production of chemical derivatives particularly stable toward oxidative degradation.
(fatty acids, alcohols, esters and glycerine) which In the composition, also linoleic (47%), palmi-
show a wide range of application. Among them, toleic (0.51%), palmitic (711%) and stearic
426 L. Rigano and C. Andolfatto

acids are well represented (14%). The unsaponi- ity specific of avocatine). The result is the
fiable fraction of olive oil (0.51.5%) is made by effective stimulation to the cutaneous turn over,
more than 80% by squalene. improving skin moisturization and elasticity.
Tocopherols in the unsaponifiable fraction, per-
27.4.5.1 Cosmetic Use forming antioxidant and anti-free radicals activ-
Squalene being one of the main constituents of ity, defend the skin in inflammatory process,
human sebum, the unsaponifiable fraction of thus reducing the cell and tissues damages
olive oil is especially interesting for the sebum- induced by radical species, and improve skin
restitutive and emollient action. Its stimulating properties as they promote the firmness of epi-
power for the cutaneous reparation process has dermis. Avocado unsaponifiable can therefore
been demonstrated, together with a protective be seen as a special blend with antioxidant, pro-
action from sunburn. Olive oil fats are also used tective and lenitive system. For these character-
for preparing green surfactants and emulsifiers istics, cosmetics containing avocado oil and its
characterized by low irritation power and good unsaponifiable fraction are especially used in
cutaneous compatibility [16]. anti-age and anti-striae treatments, firming and
sun protection products [16].

27.4.6 Avocado Oil

27.4.7 Borage and Evening Primrose Oils
Avocado oil is obtained from the dried pulp of the
fruit of Persea americana Mill. The plant, an Borage (Borrago officinalis L.) is a Mediterranean
evergreen tree native of central America, is now plant cultivated for its seed oil and for decorative
widely cultivated in all tropical areas. Avocado reasons. Borage oil, obtained by cold pressing
oil is made of oleic (5574%), linoleic (1014%), from the seeds, is very rich in polyunsaturated
palmitic (922%) and palmitoleic acid (37%) fatty acids. Moreover, some of them are essential
glycerides. Nevertheless, the most interesting for the human organism, in particular those belong-
component of avocado oil is its abundant unsa- ing to the series w6. Essential fatty acids are so-
ponifiable fraction (212%) rich in branched called as the body cannot synthesize them but is
chain hydrocarbons, phytosterols, terpene alco- obliged to have them with the diet. Linoleic and
hols, avocatine, volatile acids and vitamins. a-linolenic acid are the true essential fatty acids.
They are key components of cell membranes and
27.4.6.1 Cosmetic Use the hydro-lipidic film on the skin surface. They
While the triglycerides are responsible for the play an essential role in the cutaneous barrier and
sebo-restitutive properties of avocado oil, its are precursors for the synthesis of other key mol-
unsaponifiable fraction is frequently used, after ecules for the cutaneous tissues. Borage oil is
separation from the oil, in moisturizing cosmet- therefore a natural precious source of linoleic (32
ics and for the protection from environmental 38%), oleic (1423%), g-linolenic (2225%),
damages (e.g. UV rays) for the normalizing palmitic (1114%), and stearic acids (~5%).
properties of the hydro-lipidic barrier. Avocado Evening primrose oil is extracted from the
oil unsaponifiable is mainly made of saturated seeds of the plant Oenothera biennis L. Its glyc-
and unsaturated hydrocarbons, terpenes like erides profile resembles borage oil: Rich in essen-
carotenoids, sterols, triterpenes and fatty alco- tial fatty acids, especially the w6 family, it is an
hols, tocopherols and tocotrienols. The func- excellent source of g-linolenic (710%) and lino-
tional substances of the unsaponifiable fraction leic acid (up to 70%) [19]. For their high content
can stimulate the dermal fibroblasts activity, of polyunsaturated fatty acids, oils of borage and
therefore promoting the collagen neo-synthesis evening primrose exhibit oxidative stability
and inhibiting the activity of collagenase which is highly dependent on their content of
enzymes that degrade the collagen fibres (activ- antioxidant polyphenols [21].
27 Polyfunctional Vehicles by the Use of Vegetable Oils 427

27.4.7.1 Cosmetic Use 27.4.9 Shea Butter

w6 fatty acids of which borage oil is rich con-
tribute to the maintenance of normal barrier The shea tree (Vitellaria paradoxa) produces a
function and perform moisturizing and restitu- nut that is very rich in fatty materials. Shea (also
tive action, thereby facilitating the physiologi- called karit) butter is a slightly yellowish or
cal restoration of chapped and dry skin. It has ivory pasty material, obtained from the nuts by
been shown that w6 fatty acids, after topical crushing, roasting, boiling in water and stirring.
application, are integrated directly into the Water is then separated and evaporated. Shea
hydro-lipid film of the skin, where they improve fats melt at about 3035C [1]; therefore their
the state of dryness, reduce irritation and blend is indeed a butter that may also be used in
strengthen the barrier function, which is regu- food preparation. It contains oleic (4060%),
lated by lipid structure. It has also been shown stearic (2050%), linoleic (311%), pamitic
that oils rich in w6 fatty acids oppose the exces- (29%) linolenic and arachidic acids (<1%), but
sive trans-epidermal water loss and improve of outmost importance is its high unsaponifiable
skin moisturization and elasticity. The use of fraction (8%) with triterpene alcohols cinna-
borage and enothera oil is therefore particularly mate, tocopherols (100150 ppm). Triterpene
advisable in many states of imbalance in the alcohols such as lupeol and alpha-/beta-amyrin
skin, caused for example by excessive exposure have been shown to possess anti-inflammatory
to sunlight, environmental stress and aging. effects, especially in their esterified forms, which
These oils are used in cosmetic products for can be only ten times lower than those of
problem skin, seborrhoeic dermatitis, atopic hydrocortisone.
skin, psoriasis, chronic irritation and flaking of
the skin for their soothing and decongestant 27.4.9.1 Cosmetic Use
effect [16]. It is widely used in cosmetics as a moisturizer,
emollient and healing agent, also in sunburn
cases. It has been claimed that its use is helpful in
27.4.8 Limnanthes alba Oil diseased skin conditions, like eczema, burn and
rashes and for the reduction of psoriasis discom-
The oil of Limnanthes alba is also called fort. It is absorbed easily into the skin, without
Meadowfoam (seed) oil because after the winter leaving any greasy feel and reduces severe skin
growth in mild climates of the northwest USA, dryness. It can also be introduced in soaps a
the plant blooms in May, densely covering the super-fatting agent.
fields with small white flowers that seem to foam.
A bright yellow oil is extracted from the seeds,
accounting for more than 90% of long-chain 27.4.10 Other Oils
monounsaturated fatty acids (C20C22). The oil
is also rich in antioxidants such as gamma- All seeds used in the food industry are used in
tocopherol (0.020.05%). For this particular cosmetics also for their moisturizing properties.
composition, the oil is very stable to oxidation They share the favourable toxicology profile,
and rancidity. their comparably high polarity in comparison to
other fatty esters, the frequently interesting con-
27.4.8.1 Cosmetic Use tent in unsaponifiable fractions which interact
The long-chain fatty acids of Limnanthes alba oil positively with the skin properties. Here, it can be
are similar to sebum like and easily penetrate into mentioned that Argania spinosa oil, Macadamia
the skin through pores and interstices of the stra- oil and Jojoba oil are exotic sources while
tum corneum cell. Its rapid absorption makes it a sweet almond oil and wheat germ oil are more
non-occlusive emollient oil, restorative and mois- common in the western countries. Rice oil is also
turizing [16]. an interesting moisturizing emollient from Asia
428 L. Rigano and C. Andolfatto

and also some European countries. The long his-

tory of familiarity of mankind with edible oils vegetal oil. Polyphenols work actively
accounts for their safe use and high tolerability. as radical scavengers.
Indeed, they are very powerful tool for skin main- Vegetal oils of common cosmetic use:
tenance and protection. Corn oil, coconut oil, palm oil, soybean
oil, olive oil, avocado oil, borage oil, eve-
ning primrose oil, Limnanthes alba oil
Take Home Messages and shea butter are among the most fre-
State of the art: Keratinocytes that have quently used vegetal oils in cosmetics.
reached the final differentiation stage,
surrounded by a lipid matrix that hin-
ders water evaporation and the diffusion
of water and electrolytes, form the epi-
References
dermal horny layer. Epidermal moistur-
ization level and barrier effects are 1. Alander J, Andersson AC, Lindstrom C (2006)
strictly related to the amount and struc- Cosmetic emollients with high stability against photo-
ture of lipids in such layer. The supple- oxidation. Lipid Technol 18:226230
2. Bruneton J (1999) Pharmacognosie: Phytochimie,
ment of topically applied oils may solve
Plantes mdicinales, 3rd edn. Editions Tec & Doc
the disequilibrium problems of the Lavoisier, Paris
hydro-lipidic film in the horny layer. 3. Carrat B, Sanzini E (2005) Biologically active sub-
Function and composition of vegetal stances present in vegetal derived food. Ann Ist Super
Sanita 1:716 (in Italian)
oils: Vegetal oils are complex blend of
4. Drake DR, Brogden KA, Dawson DV, Wertz PW
triglycerides, where fatty acids that (2008) Antimicrobial lipids at the skin surface. J Lipid
esterify glycerine vary for (1) their acyl Res 49:411
chain length, (2) their insaturation 5. Feingold KR (2007) The role of epidermal lipids in
cutaneous permeability barrier homeostasis. J Lipid
degree and (3) position of double bonds.
Res 48:25312546
Vegetal oils triglyceride composition is 6. Grubauer G, Elias PM, Feingold KR (1989)
dominated by the group of unsaturated Transepidermal water loss: the signal for recovery of
fatty acids derivatives. barrier structure and function. J Lipid Res 30:
323333
Vegetal triglycerides: Vegetal triglycer-
7. Gunstone FD (2001) Palm oil supplying much of
ides are triesters of the polyalcohol world demand for fats and oil. Inform 12:141146
glycerine, with several types of long- 8. Kamal-Eldin A (2006) Effect of fatty acids and
chain mono-carboxylic fatty acids. tocopherols on the oxidative stability of vegetable
oils. Eur J Lipid Sci Technol 58:10511061.
Accompanying ingredients: Secondary
doi:10.1002/ejlt.200600090
ingredients in vegetal oils represent the 9. Moreau RA, Whitaker BD, Hicks KB (2002)
non-glyceride (unsaponifiable) fraction, Phytosterols, phytostanols, and their conjugates in
generally present in moderate amounts. foods: structural diversity, quantitative analysis, and
health-promoting uses. Prog Lipid Res 41(6):457500
Such ingredients may noticeably influ-
10. Nikkari T, Schreibman PH, Ahrens EH Jr (1974) In
ence the oxidation speed of vegetal oils. vivo studies of sterol and squalene secretion by human
In vegetal oils, an equilibrated ratio skin. J Lipid Res 15:563573
between chlorophyll and carotenoid pig- 11. OLenick AJ, Steinberg DC, Klein K, LaVay C (2008)
Oils of nature. Allured, Carol Stream
ments is essential for an adequate oil
12. Patel MD, Thompson PD (2006) Phytosterols and
fastness toward oxidation. All molecules vascular disease. Atherosclerosis 186:1219
in the unsaponifiable fraction belonging 13. Piironen V et al (2000) Plant sterols: biosynthesis,
to the family of vitamin E are very pow- biological function and their importance to human
nutrition. J Sci Food Agric 80:939966
erful antioxidant. Phytosterols consti-
14. Quarantelli A et al (2003) Oxidation process in vege-
tute a kind of vegetal fingerprint of each tal derived food. Ann Fac Medic Vet Parma XXIII:
181202 (in Italian)
27 Polyfunctional Vehicles by the Use of Vegetable Oils 429

15. Radaelli R (1986) Fundamentals of vegetal chemistry 20. Vaivre-Douret L, Oriot D, Blossier P, Py A, Kasolter-
(in Italian). Edagricole, Bologna Pr M, Zwang J (2008) The effect of multimodal
16. Rigano L, Boncompagni E, Giogli A, Occhionero G stimulation and cutaneous application of vegetable
(2003) Vegetal substances in cosmetics (in Italian). oils on neonatal development in preterm infants: a
Aboca S.p.A, Sansepolcro randomized controlled trial. Child Care Health Dev
17. Safayhi H, Sailer ER (1997) Anti-inflammatory 35(1):96105
actions of pentacyclic triterpenes. Planta Med 63: 21. Wang M, Li J, Shao Y, Huang TC, Huang MT, Chin
487493 CK, Rosen RT, Ho CT (1999) Antioxidants of eve-
18. Stamatas GN, Sterke JD, Hauser M, Stetten OV, Pol ning primrose. In: Shahidi F, Ho CT (eds)
AVD (2008) Lipid uptake and skin occlusion follow- Phytochemicals and phytopharmaceuticals. AOCS
ing topical application of oils on adult and infant skin. Press, Champaign
J Dermatol Sci 50:135142 22. Ziboh VA, Miller CC, Cho Y (2000) Metabolism of
19. Szterk A, Roszko M, Sosinska E, Derewiaka D, polyunsaturated fatty acids by skin epidermal
Lewicki PP (2010) Chemical composition and oxida- enzymes: generation of anti-inflammatory and anti-
tive stability of selected plant oils. J Am Oil Chem proliferative metabolites. Am J Clin Nutr 71(Suppl
Soc 87:637645 1):361S366S
 The Effect of Natural Moisturizing
Factors on the Interaction Between 28
Water Molecules and Keratin

Noriaki Nakagawa

28.1 Introduction tory disease [7, 8]. Recently, it was reported that
filaggrin mutation was a predisposing factor for
The stratum corneum (SC) is the outermost layer atopic dermatitis and ichthyosis [9] and that the
of the skin and plays the role of a barrier between amino acid content of the SC was lower in carri-
the interior of the body and the external environ- ers of filaggrin mutation than in healthy subjects
ments. SC plasticity is maintained by its water [10]. The sodium salt of PCA, a derivative of
content, which makes the SC flexible in the face amino acid, also increased the water content of
of external physical stress. Natural moisturizing the dry skin [11]. Urea is also known as an NMF.
factors (NMFs) play a major role in maintaining The urea content in the SC was significantly
the water content and the physical properties of decreased in patients with atopic dermatitis [12],
the SC [13]. For example, the water content and and an increase in SC water content as a result of
elastic properties of the NMF-extracted SC were the topical application of urea [13] has been
significantly decreased (Figs. 28.1 and 28.2) and reported by earlier studies.
the stiffness of the NMF-extracted SC was sig- Another NMF, lactate, also has a moisturizing
nificantly increased, compared with no-treatment effect on the SC. Lactate treatment alleviated
SC (Fig. 28.1) [1]. NMFs are composed of water- symptoms of dry skin [14, 15]. Treatment using
soluble compounds, such as amino acids, pyrroli- lactate salts softened the SC [16] and increased
done carboxylic acid (PCA), urea, lactate, its water retention [17]. Among healthy subjects,
inorganic ions, etc. [4, 5]. the lactate content was higher in young subjects
Of the various NMFs, many researchers have than in old subjects [18]. Previously, we demon-
focused mainly on amino acids. Amino acids are strated that potassium lactate plays an important
degraded from filaggrin in the SC during cornifi- role in maintaining the SC physical properties as
cation [5, 6] and play the role of an NMF. For an NMF and that potassium lactate increased the
example, the amino acid content of the SC was water content of the SC more than sodium lactate
lower in diseases displaying symptoms of dry did [1]. Moreover, to evaluate the change of elas-
skin, such as atopic dermatitis and atopic respira- tic properties of the SC due to potassium lactate,
we examined whether potassium lactate changed
the tan d of the plantar SC. The tan d represents
the ratio between the dynamic elastic modulus
N. Nakagawa and the dynamic loss modulus. The higher the tan
Innovative Beauty Science Laboratory, Kanebo d is, the higher the elastic properties are. As a
Cosmetics Inc.,
result, the tan d of the SC treated with potassium
3-28, 5-Chome, Kotobuki-Cho, Odawara-Shi,
Kanagawa-Ken 250-0002, Japan lactate increased more than that of NMF extrac-
e-mail: [email protected] tion and was the same as that of nontreated SC

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 431

DOI 10.1007/978-3-642-27606-4_28, Springer-Verlag Berlin Heidelberg 2012
432 N. Nakagawa

SC hydration state 0.3

60
***
50
Conductance(S)

40

30 0.2

20

Tan
10

0 No-treat
0.1
SC stiffness
4 Potassium lactate
***
NMF extraction
2

0
2
f (Hz)

0
4 0.1 1 10 100
6 Hz

8 Fig. 28.2 The effect of potassium lactate on the SC elas-

10 tic properties

12
Before After
NMF extraction NMF extraction helical amino terminal domain, and the carboxyl
terminal domain. It is known that keratin gene
Fig. 28.1 The effect of NMF extraction on the SC physi- mutations cause dry skin symptoms such as epider-
cal properties
molytic hyperkeratosis [2224], nonepidermolytic
palmar-plantar keratoderma [25], and epidermo-
(Fig. 28.2), suggesting that the treatment of potas- lytic hyperkeratosis [26], suggesting that keratin
sium lactate on the SC increased the elastic prop- structure also affects the moisturization of the SC.
erties of the SC more than that of NMF extraction, Research into the mechanism of the moistur-
and that the elastic properties of the SC treated ization of the SC is, however, sparse. Jokura et al.
with potassium lactate were the same as that of [4] reported that keratin became flexible with an
nontreated SC. increase in water content and that the nonhelical
On the other hand, there are some reports domain of keratin became more flexible than the
regarding the bound water content of the SC. For a-helical domain with the increase in the water
example, the bound water content of the SC was content. Yadav et al. [27] reported that water
lower in subjects with diseases displaying dry sorption converted a fraction of keratin a-helix to
skin symptoms than in healthy subjects [19], and b-sheets, turns, and random coils. These results
the carbonylation of the SC caused a reduction in suggest that the moisturization of the SC may be
its bound water content [20] and changed the ker- caused due to an increase in the water molecules
atin structure [21]. These results suggest that the interacting with SC keratin associated with its
interaction of bound water with the SC keratin structural change. Recently, we [28] have reported
may contribute to the moisturization of the SC. the mechanism of the moisturizing effect of
In the SC, 10-nm keratin filaments are com- potassium lactate on the SC in more detail. In this
posed of two types of keratins, K1 and K10. The chapter, comments on the mechanism of the
secondary structure of keratin consists of three moisturizing effect of potassium lactate as an
domains: the a-helical central rod domain, the non- NMF are provided.
28 The Effect of Natural Moisturizing Factors on the Interaction Between Water Molecules and Keratin 433

28.2 The Effect of Natural Table 28.1 The bound water content of the SC treated
Moisturizing Factors on the with lactate salts
Interaction Between Water The bound water content (%;
Molecules and Keratin Treatment of SC mg/mg dry SC)
Potassium lactate 37.7
Sodium lactate 33.3
We have demonstrated that potassium lactate
NMF extraction 29.2
plays an important role in maintaining the SC
physical properties as an NMF [1] and that potas-
sium lactate increased the water-holding capacity Table 28.2 The bound water content of lactate salts in
(WHC) of the SC more than sodium lactate did aqueous solution
[28]. Therefore, we have examined the effect of The bound water content
potassium lactate on the interaction between Aqueous solutions (%)
water molecules and the SC keratin by compar- Potassium lactate 39.1
ing it with that of sodium lactate. We used two Sodium lactate 51.1
methods. The bound water content of the SC was
lower in subjects with diseases displaying dry cantly more than sodium lactate did (Table 28.1).
skin symptoms than in healthy subjects [19], sug- However, the bound water content of potassium
gesting that the interaction of bound water with lactate in aqueous solution was less than that of
the SC may contribute to the moisturization of sodium lactate (Table 28.2). These results sug-
the SC. We used differential scanning calorimetry gest that the WHC of potassium lactate itself is
(DSC) to examine whether potassium lactate not related to the WHC of the SC and that potas-
increased the bound water content of the SC more sium lactate interacts with SC components and
than sodium lactate did. Keratin became flexible increases their bound water content. Takenouchi
with the increase in its water content [4], suggest- et al. [19] reported that the SC-bound water con-
ing that the component interacting with water tent was lower in subjects with dry skin disease
molecules may be the SC protein. To examine conditions than in healthy subjects. They pointed
whether the SC protein interacts with water mol- out that the low WHC of the pathologic SC was
ecules, we used the attenuated total reflectance due to its smaller capacity for bound water.
infrared (ATR-IR) spectroscopy with hydrogen/ Therefore, the interaction of bound water with
deuterium exchange. the SC components may contribute to the mois-
turization of the SC.

28.2.1 The Bound Water Content of the

SC Treated with Potassium Salts 28.2.2 The Domain of Keratin
Interacted with Water Molecules
We [1, 28] demonstrated that potassium lactate
increased the WHC of the SC more than sodium Keratin became more flexible with an increase in
lactate did. This result does not, however, explain water content [4], suggesting that hydrophilic
whether the increased WHC of the SC was due to amino acids in keratin may be interacting with
the WHC of potassium lactate itself or the WHC the water molecules. In the nonhelical domain of
of SC components. The DSC experiment was keratins K1 and K10, the amino acid composition
performed in an effort to gain a clear understand- ratio of serine is 23%, the highest ratio among
ing of the cause of the increased WHC of the SC. hydrophilic amino acids [29, 30]. From these
We found that both potassium lactate and sodium facts, we hypothesized that the OH group of ser-
lactate treatment caused a significant increase in ine in keratin interacted with the water molecules.
the bound water content compared with NMF Because the absorption region of the OH group
extraction (Table 28.1). Moreover, potassium lac- of alcohol is from 1,390 to 1,280 cm1 [31], there
tate increased the bound water content signifi- was a possibility that the 1,340-cm1 band
434 N. Nakagawa

D A decrease in this ratio means an increase in

D O-D the ratio of hydrogen/deuterium exchange.
NMF extraction caused a change in the SC
O-D
spectrum and a reduction in the absorbance of the

O-H
1,340-cm1 band (Fig. 28.4a). However, even
after the extraction of lipids and NMFs, a portion
C=O

N-H
of the 1,340-cm1 band still remained (Fig. 28.4a).
Ser
These results suggest that the compound in the
Keratin 1,340-cm1 band is derived from SC protein and
NMFs in a nontreated SC. In the case of NMF-
Hydrogen/deuterium exchange extracted SC, however, the compound in the
1,340-cm1 band is derived from SC protein.
D
Moreover, the absorbance of the 1,340-cm1 band
D O-H in the NMF-extracted SC decreased as a result of
O-H hydrogen/deuterium exchange (Fig. 28.4b), sug-
gesting that SC protein in the 1,340-cm1 band
O-D

interacts with water molecules.

C=O

To confirm that the 1,340-cm1 band was

N-D

Ser derived from the OH group of serine, we made a

Keratin comparison of the spectral changes in amino
acids with an OH group before and after hydro-
Fig. 28.3 The scheme of hydrogen/deuterium exchange gen/deuterium exchange. Our results showed that
near the 1,340-cm1 band, a band in the spectrum
of serine and threonine was found before hydro-
(Fig. 28.4) was derived from the OH group of gen/deuterium exchange (Fig. 28.5). The band of
amino acids in the SC protein. To prove the above serine was nearest to 1,340 cm1 among these
hypothesis, we used ATR-IR spectroscopy with bands. Moreover, as a result of hydrogen/deute-
hydrogen/deuterium exchange. rium exchange, the absorbance of the serine band
The principle of ATR-IR spectroscopy decreased, but that of the threonine band did not
with hydrogen/deuterium exchange can be (Fig. 28.5), suggesting that the 1,340-cm1 band
explained as follows: The hydrogen/deuterium is derived from the OH group of serine. The com-
exchange represents a change of the hydrogen position ratio of serine among free amino acids in
of NH, COOH, and OH groups, etc., to deute- the NMF is 30% [32] and the decreased absor-
rium by exposing a protein to deuterium oxide bance of the 1,340-cm1 band after NMF extrac-
(Fig. 28.3). This hydrogen/deuterium exchange tion also supported the theory that this band
had a significant effect on the IR spectrum consists of the OH group of serine. Our results
(Fig. 28.4b) because the absorbance of these suggest that the OH group of serine in the SC
groups decreases and the absorbance of ND, protein interacts with water molecules. The com-
COOD, and OD groups increases. Therefore, position ratio of keratin and filaggrin were about
the ratio of absorbance before and after hydro- 60% and less than 40% (by weight) respectively
gen/deuterium exchange represents the degree in the entire SC layer of mice [33], and filaggrin
of the interaction between water molecules and is degraded during cornification [5, 6]. These
the functional group in a protein. In this study, findings suggest that the protein component of
the ratio of hydrogen/deuterium exchange was the superficial SC is mainly keratin. Because the
calculated as follows: measurement range of depth by ATR-IR spec-
The ratio = absorbance after deuterium oxide troscopy was less than 1.5 mm [34], the 1,340-
treatment/absorbance before deuterium oxide cm1 band of the NMF-extracted SC is mostly
treatment derived from keratin. Seventy-six percent of the
28 The Effect of Natural Moisturizing Factors on the Interaction Between Water Molecules and Keratin 435

Fig. 28.4 (a) Spectra of

a
plantar SC. Thin Gray line:
no-treatment, Thick gray line:
NMF extraction, Black line:
NMF and lipids extraction.
(b) Spectra of NMF extracted 1340 cm1

Absorbance
SC before or after deuterium
oxide treatment. Gray line:
before treatment, Black line:
after treatment.

1) No-treatment

2) NMF and lipids extraction

3) NMF extraction

1900 1800 1700 1600 1500 1400 1300 1200

b
Before D2O treatment
Absorbance

1340 cm1

After D2O treatment

1900 1800 1700 1600 1500 1400 1300 1200

Wave number (cm1)

serine residue in keratins K1 and K10 exists in significantly more than sodium lactate and NMF
the nonhelical domain [29, 30]. The nonhelical extraction did (Fig. 28.6). Sodium lactate also
domain of keratin became more flexible than the increased the exchange ratio at 1,340 cm1 signifi-
a-helical domain with the increase in the water cantly more than NMF extraction did (Fig. 28.6).
content [4], suggesting that water molecules may These results suggest that potassium lactate
interact with the OH group of serine in the non- increases the interaction between water molecules
helical domain of keratin. and serine in the SC keratin to a greater extent
than sodium lactate or NMF extraction. This result
corresponds with the result of the bound water
28.2.3 The Effect of NMF on the content by DSC experiment (Table 28.1). These
Interaction Between Water findings suggest that potassium lactate as an NMF
Molecules and Keratin increases the WHC of the SC by increasing the
interaction between water molecules and the OH
With the 1,340-cm1 band, we elucidated the effi- group of serine in the SC keratin. We also found
cacy of potassium lactate in the interaction that the exchange ratios at amide II of the SC
between water molecules and the OH group of treated with lactate salts and NMF-extracted SC
serine in the SC keratin. We found that potassium were not different from each other [28], suggest-
lactate increased the exchange ratio at 1,340 cm1 ing that the change in exchange ratio was not due
436 N. Nakagawa

*
Serine
***
After D2O treatment
1
Absorbance

***

0.8

hydrogen/deuterium exchange
Before D2O
treatment
0.6

Ratio of
1400 1380 1360 1340 1320 1300
0.4
Tyrosine
Before D2O treatment
0.2
Absorbance

0
NMF Potassium Sodium
extraction lactate lactate

Fig. 28.6 The effect of potassium lactate on the ratio of

After D2O treatment hydrogen/deuterium exchange

1400 1380 1360 1340 1320 1300

Threonine was more stable against thermal denaturation in

After D2O treatment the presence of potassium than in the presence of
sodium [36]. Recently, ion-protein interaction
according to the Hofmeister series was explained
Absorbance

using computational chemistry techniques, such

as classical molecular dynamics simulation. The
binding activity between potassium and the car-
boxyl group was weaker than that of sodium with
Before D2O treatment
the same [37, 38]. The affinity of sodium to glu-
tamate and aspartate was higher than that of
potassium [39]. Glutamate and aspartate are the
1400 1380 1360 1340 1320 1300
Wave number (cm1) components of the nonhelical domain of keratins
K1 and K10 [29, 30]. These findings suggest that,
Fig. 28.5 The spectra of the amino acids with OH group in the presence of sodium, the structure of the
before and after deuterium oxide treatment
nonhelical domain of keratin may be more cohe-
sive due to the strong interaction of sodium to
to a change in the overall structure of an SC pro- glutamate and/or aspartate than in the presence of
tein but due to the structural change in a specific potassium and that the OH group of serine in the
domain of an SC protein. presence of sodium may interact with water mol-
Monovalent cations change the structure and ecules less than in the presence of potassium.
activity of various enzymes according to the However, further study will be needed to eluci-
Hofmeister series. For example, lysozyme was date the difference in the mechanism by which
more soluble in the presence of potassium than in potassium lactate and sodium lactate enhance the
the presence of sodium [35]. Glucose oxidase WHC of the SC.
28 The Effect of Natural Moisturizing Factors on the Interaction Between Water Molecules and Keratin 437

Fig. 28.7 The effect of other ***

NMFs on the ratio of
***
hydrogen/deuterium exchange **
1

0.8

hydrogen/deuterium exchange
0.6
Ratio of

0.4

0.2

0
NMF Glycerol PCANa Urea
extraction

tion between water molecules and the OH

We made a preliminary examination to eluci-
group of serine in the SC keratin. Other NMFs,
date the efficacy of other NMFs, such as glycerol,
such as sodium salt of PCA, also increase the
sodium salt of PCA, and urea. We found that three
interaction, but the mechanism of moisturiz-
NMFs increased the exchange ratio at 1,340 cm1
ing effects may differ from one NMF to
more than NMF extraction did, but the difference
another. In the future, the experiments on the
was not significant (Fig. 28.7). Only sodium salt
structural change of keratin by NMFs will be
of PCA increased the exchange ratio at 1,340 cm1
needed in order to reveal the precise mecha-
significantly more than the other treatment did
nism of the moisturizing effect of NMFs.
(Fig. 28.7), suggesting that the mechanism of
moisturizing effect may be different from each
NMF. It is known that glycerol itself has a high
Take Home Messages
WHC. Glycerol may have a moisturizing effect
Natural moisturizing factors (NMFs)
on the SC due to its own WHC. Urea is known as
play a major role in maintaining the water
a denaturing agent of protein. The moisturizing
content and the physical properties of the
effect of urea on the SC may be due to the overall
SC. Among NMFs, potassium lactate
structural change of an SC keratin, which may
plays an important role in maintaining
cause the increase in the interaction between water
the SC physical properties as an NMF.
molecules and the other domain of SC keratin.
The interaction of bound water with the
However, this experiment was done at a concen-
SC keratin may contribute to the moistur-
tration of 100 mM. Further study, such as experi-
ization of the SC. Keratin structure also
ments at higher doses, is needed in order to make
affects the moisturization of the SC.
conclusions about the mechanism of the moistur-
Potassium lactate interacts with SC
izing effect of these NMFs.
components and increases their bound
water content.
Conclusion
Potassium lactate increases the bound
We demonstrated that potassium lactate as an
water of the SC by increasing the inter-
NMF interacts with the SC protein and
increases its WHC by increasing the interac-
438 N. Nakagawa

10. Kezic S, Kemperman PM, Koster ES, de Jongh CM,

action between water molecules and the Thio HB, Campbell LE et al (2008) Loss-of-function
mutations in the filaggrin gene lead to reduced level of
OH group of serine in the SC keratin natural moisturizing factor in the stratum corneum. J
associated with its structural change. Invest Dermatol 128:21172119
The mechanism of moisturizing effect 11. Middleton JD, Roberts ME (1978) Effect of a skin
may differ from one NMF to another. cream containing the sodium salt of pyrrollidone car-
boxylic acid on dry and flaky skin. J Soc Cosmet
In the future, the experiments on the Chem 29:201
structural change of keratin by NMFs 12. Wellner K, Wohlrab W (1993) Quantitative evaluation
will be needed in order to reveal the pre- of urea in stratum corneum of human skin. Arch
cise mechanism of the moisturizing Dermatol Res 285:239240
13. Grice K, Sattar H, Baker H (1973) Urea and retinoic
effect of NMFs. acid in ichthyosis and their effect on transepidermal
water loss and water holding capacity of stratum cor-
neum. Acta Derm Venereol 53:114118
14. Dahl MV, Dahl AC (1983) 12% lactate lotion for the
treatment of xerosis. Arch Dermatol 119:2730
References 15. Van Scott EJ, Yu RJ (1984) Hyperkeratinization, cor-
neocyte cohesion, and alpha hydroxy acids. J Am
1. Nakagawa N, Sakai S, Matsumoto M, Yamada K, Acad Dermatol 11:867879
Nagano M, Yuki T et al (2004) Relationship between 16. Takahashi M, Machida Y (1985) The influence of
NMF (lactate and potassium) content and the physical hydroxy acids on the rheological properties of stratum
properties of the stratum corneum in healthy subjects. corneum. J Soc Cosmet Chem 36:177187
J Invest Dermatol 122:755763 17. Gournay A, Navarro R, Mathieu J, Riviere M (1995)
2. Visscher MO, Tolia GT, Wickett RR, Hoath SB (2003) Water retention of treated stratum corneum measured
Effect of soaking and natural moisturizing factor on by a coupling method: thermal desorption-mass spec-
stratum corneum water-handling properties. J Cosmet trometry. Int J Cosmet Sci 17:165172
Sci 54:289300 18. Egawa M, Tagami H (2008) Comparison of the depth
3. Robinson M, Visscher M, Laruffa A, Wickett R (2010) profiles of water and water-binding substances in the
Natural moisturizing factors (NMF) in the stratum stratum corneum determined in vivo by Raman spec-
corneum (SC). II. Regeneration of NMF over time troscopy between the cheek and volar forearm skin:
after soaking. J Cosmet Sci 61:2329 effects of age, seasonal changes and artificial forced
4. Jokura Y, Ishikawa S, Tokuda H, Imokawa G (1995) hydration. Br J Dermatol 158:251260
Molecular analysis of elastic properties of the stratum 19. Takenouchi M, Suzuki H, Tagami H (1986) Hydration
corneum by solid-state 13C-nuclear magnetic reso- characteristics of pathologic stratum corneum eval-
nance spectroscopy. J Invest Dermatol 104:806812 uation of bound water. J Invest Dermatol 87:574576
5. Rawlings AV, Harding CR (2004) Moisturization and 20. Iwai I, Hirao T (2008) Protein carbonyls damage the
skin barrier function. Dermatol Ther 17:4348 water-holding capacity of the stratum corneum. Skin
6. Kamata Y, Taniguchi A, Yamamoto M, Nomura J, Pharmacol Physiol 21:269273
Ishihara K, Takahara H et al (2009) Neutral cysteine 21. Iwai I, Ikuta K, Murayama K, Hirao T (2008) Change
protease bleomycin hydrolase is essential for the in optical properties of stratum corneum induced by
breakdown of deiminated filaggrin into amino acids. J protein carbonylation in vitro. Int J Cosmet Sci
Biol Chem 284:1282912836 30:4146
7. Tanaka M, Okada M, Zhen YX, Inamura N, Kitano T, 22. Yang JM, Chipev CC, DiGiovanna JJ, Bale SJ,
Shirai S, Sakamoto K, Inamura T, Tagami H (1998) Marekov LN, Steinert PM et al (1994) Mutations in
Decreased hydration state of the stratum corneum and the H1 and 1A domains in the keratin 1 gene in epi-
reduced amino acid content of the skin surface in dermolytic hyperkeratosis. J Invest Dermatol 102:
patients with seasonal allergic rhinitis. Br J Dermatol 1723
139:618621 23. Yang JM, Nam K, Park KB, Kim WS, Moon KC, Koh
8. Tagami H, Kobayashi H, Ogoshi K, Kikuchi K (2006) JK et al (1996) A novel H1 mutation in the keratin 1
Atopic xerosis: employment of noninvasive biophysi- chain in epidermolytic hyperkeratosis. J Invest Dermatol
cal instrumentation for the functional analyses of the 107:439441
mildly abnormal stratum corneum and for the efficacy 24. Chipev CC, Korge BP, Markova N, Bale SJ, DiGiovanna
assessment of skin care products. J Cosmet Dermatol JJ, Compton JG et al (1992) A leucine proline muta-
5:140149 tion in the H1 subdomain of keratin 1 causes epidermo-
9. Sandilands A, Sutherland C, Irvine AD, McLean WH lytic hyperkeratosis. Cell 70:821828
(2009) Filaggrin in the frontline: role in skin barrier 25. Kimonis V, DiGiovanna JJ, Yang JM, Doyle SZ, Bale
function and disease. J Cell Sci 122:12851294 SJ, Compton JG (1994) A mutation in the V1 end
28 The Effect of Natural Moisturizing Factors on the Interaction Between Water Molecules and Keratin 439

domain of keratin 1 in non-epidermolytic palmar- sis on the amino acid composition of human skin. J
plantar keratoderma. J Invest Dermatol 103:764769 Invest Dermatol 95:296300
26. Sprecher E, Yosipovitch G, Bergman R, Ciubutaro D, 33. Steinert PM, Cantieri JS, Teller DC, Lonsdale-Eccles
Indelman M, Pfendner E et al (2003) Epidermolytic JD, Dale BA (1981) Characterization of a class of cat-
hyperkeratosis and epidermolysis bullosa simplex ionic proteins that specifically interact with interme-
caused by frameshift mutations altering the v2 tail diate filaments. Proc Natl Acad Sci USA 78:
domains of keratin 1 and keratin 5. J Invest Dermatol 40974101
120:623626 34. Brancaleon L, Bamberg MP, Sakamaki T, Kollias N
27. Yadav S, Wickett RR, Pinto NG, Kasting GB, Thiel (2001) Attenuated total reflection-Fourier transform
SW (2009) Comparative thermodynamic and spectro- infrared spectroscopy as a possible method to investi-
scopic properties of water interaction with human gate biophysical parameters of stratum corneum
stratum corneum. Skin Res Technol 15:172179 in vivo. J Invest Dermatol 116:380386
28. Nakagawa N, Naito S, Yakumaru M, Sakai S, 35. Annunziata O, Paduano L, Pearlstein AJ, Miller DG,
10 (2011) Hydrating effect of potassium lactate is Albright JG (2006) The effect of salt on protein chem-
caused by increasing the interaction between water ical potential determined by ternary diffusion in aque-
molecules and the serine residue of the stratum cor- ous solutions. J Phys Chem B 110:14051415
neum protein. Exp Dermatol 20:826831. doi:doi: 36. Ahmad A, Akhtar MS, Bhakuni V (2001) Monovalent
10.1111/j.16000625.2011.01336.x cation-induced conformational change in glucose oxi-
29. Zhou XM, Idler WW, Steven AC, Roop DR, Steinert dase leading to stabilization of the enzyme. Biochemistry
PM (1988) The complete sequence of the human 40:19451955
intermediate filament chain keratin 10. Subdomainal 37. Jagoda-Cwiklik B, Vacha R, Lund M, Srebro M,
divisions and model for folding of end domain Jungwirth P (2007) Ion pairing as a possible clue for
sequences. J Biol Chem 263:1558415589 discriminating between sodium and potassium in bio-
30. Steinert PM, Parry DA, Idler WW, Johnson LD, Steven logical and other complex environments. J Phys Chem
AC, Roop DR (1985) Amino acid sequences of mouse B 111:1407714079
and human epidermal type II keratins of Mr 67,000 38. Hess B, van der Vegt NF (2009) Cation specific bind-
provide a systematic basis for the structural and func- ing with protein surface charges. Proc Natl Acad Sci
tional diversity of the end domains of keratin interme- USA 106:1329613300
diate filament subunits. J Biol Chem 260:71427149 39. Vrbka L, Vondrek J, Jagoda-Cwiklik B, Vcha R,
31. Socrates G (2001) Hydroxyl group compounds: O-H Jungwirth P (2006) Quantification and rationalization
group. In: Socrates G (ed) Infrared and Raman char- of the higher affinity of sodium over potassium to pro-
acteristics group frequencies: tables and charts. Wiley, tein surfaces. Proc Natl Acad Sci USA 103:
West Sussex, pp 94100 1544015444
32. Jacobson TM, Yksel KU, Geesin JC, Gordon JS,
Lane AT, Gracy RW (1990) Effects of aging and xero-
 Impact of Stratum Corneum
Damage on Natural Moisturizing 29
Factor (NMF) in the Skin

Lisa M. Kroll, Douglas R. Hoffman,

Corey Cunningham, and David W. Koenig

29.1 Introduction 29.2 Mechanisms and Impact of

Stratum Corneum Damage
The stratum corneum (SC) is a complex struc-
ture that protects our bodies and makes it possi- Damage to the SC can lead to multiple skin health
ble for mammalian life on this planet. The SC impairments including increased transepidermal
employs a combination of both physical and bio- water loss, redness, and susceptibility to infec-
chemical processes to limit the movement of tion or irritation by external factors. The magni-
water in and out of the body although clearly it tude of these injuries is often influenced by the
is the latter that is of most importance. The SC mechanism of SC damage, chronic or acute expo-
can be disturbed by comparatively minor injury sure, and the anatomical location of the damage.
caused by mechanical, occlusive, enzymatic, Underlying deficiencies in the processes respon-
and chemical damages. Lipids and a family of sible for development of a normal, healthy SC
hygroscopic molecules known as natural mois- barrier have been linked to the etiology of skin
turizing factor (NMF) are vital to the SCs abil- disorders including psoriasis, eczema, and atopic
ity to regulate epidermal permeability. This dermatitis [14].
chapter reviews what is known about the impact Mechanical damage is one mechanism that
of barrier disruption on key skin components can impact skin barrier function by damaging the
and provides new insights into NMF responses skin through actions such as scraping, abrasion,
following damage induced by sodium lauryl sul- or removal of SC by adhesives. The end result of
fate (SLS). these actions is the physical removal of corneo-
cytes from the skin surface and increased barrier
permeability. Maintaining adequate skin flexibil-
ity and elasticity is a primary defense against
mechanical damage. Aging decreases the skins
flexibility and elasticity, increasing susceptibility
to mechanical damage [5].
Overhydration and ultraviolet (UV) damage
the skin in a more complex way involving both
L.M. Kroll D.R. Hoffman C.T. Cunningham biochemical and chemical changes. Occlusion or
D.W. Koenig () excessive water exposure disrupts the SC water
Corporate Research & Engineering, balance increasing its permeability and suscepti-
Kimberly-Clark Corporation,
2100 Winchester Road, Neenah 54956, WI, USA
bility to irritation [6]. Exposure to UV radiation
e-mail: [email protected]; [email protected]; represents a common type of SC damage. UV
[email protected]; [email protected] exposure induces oxidation and subsequent loss

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 441

DOI 10.1007/978-3-642-27606-4_29, Springer-Verlag Berlin Heidelberg 2012
442 L.M. Kroll et al.

Fig. 29.1 Stylized diagram

of biochemical changes Top
associated with barrier
damage. Shape is an Healthy SC
approximate representation
of the amount of each Bottom
component relative to
position in the stratum
corneum (SC). Top = SC Water Ca2+ pH NMF Filaggrin Lipids
surface. Bottom = SC viable
epidermal interface Top

Damaged SC

Bottom

of functionality of SC lipids, proteins, and anti- (<2.9 nm) being the most damaging [12].
oxidants. Reductions in SC antioxidant levels, Alcohol and acetone are common solvents
including a-tocopherol, the most predominant encountered. The primary mechanism for sol-
antioxidant in the SC, have been reported with vent-induced damage is disruption of SC lamel-
UV exposure [79]. lae resulting in increased solute permeability
Biochemically induced SC damage such as into the epidermis [13].
enzymatic degradation of lipids and proteins can Barrier disruption, whether caused by chemi-
eventuate in damage to skin barrier function. For cal, physical, or biochemical means, alters the SC
example, enzyme-induced damage is commonly composition and structure required to maintain
associated with the use of absorbent articles for barrier homeostasis. The water gradient, pH gra-
fecal incontinence [10]. Feces contain a number dients, ion gradients, NMF, and lipid configura-
of proteases and lipases that can degrade key SC tions, are all impacted by barrier disruption
components, resulting in loss of barrier function. (Fig. 29.1). The impact of disruption on SC lipids
Serine proteases such as trypsin and chymotrypsin is well documented [1422]. A significant reduc-
are the most prevalent enzymes present in fecal tion in ceramide, cholesterol, and free fatty acid
insults [10]. concentrations occurs after disruption followed
Surfactants and solvents are a common chem- by a rapid secretion of lipids to the upper SC as
ical means of SC damage. In consumer markets, an initial step towards reestablishing healthy bar-
exposure to surfactants and solvents are com- rier homeostasis.
monly the result of using personal hygiene prod- Disruption has also been shown to alter pH
ucts such as soaps, cleansers, and acne treatments. and ion gradients, both of which can impact the
Likewise, workplace exposures are not uncom- functionality of key enzymes involved in
mon. Frequent hand washing in health care, the epidermal differentiation and lipid processing
daily work of hair dressers, and food and metal [2326]. Under normal conditions, the surface
workers are examples of occupations that fre- of the SC maintains a slightly acidic (~46) pH.
quently experience skin damage due to routine Following barrier disruption, the SC surface pH
chemical exposures. Surfactants impact barrier increases, dissolving the pH gradient through-
function by several means including damage to out the SC. Lipid processing is dependent on
SC proteinaceous material and lipids [11]. The two pH-dependent lipid hydrolases (b-glucocer-
net charge and micelle size affect the likelihood ebrosidase and acid sphingomyelinase). These
of surfactants to cause damage, with anionic enzymes are activated by the acidity in the extra-
surfactants (e.g., sodium lauryl sulfate, sodium cellular spaces and lose activity as pH increases.
dodecyl sulfate) that form small micelles Not only does an increased pH render these
29 Impact of Stratum Corneum Damage on Natural Moisturizing Factor (NMF) in the Skin 443

enzymes inactive but it also activates other as ichthyosis, atopic dermatitis, and scaling disorder
enzymes (serine proteases) which degrade cor- [2830]. In addition to amino acids, other key com-
neodesmosomes, resulting in loss of SC integ- ponents of NMF include lactate, urea, and sugars.
rity [2325]. The amino acid fraction of NMF primarily exists
Skin barrier disruption can also disturb ion within corneocytes following filaggrin degradation
gradients present in the SC. Changes in the Ca2+, whereas lactate, urea, and sugars are derived from
K+, and Cl ionic gradients following barrier dis- and exist in extracellular spaces [31]. In concert with
ruption have been shown to impact the secretion lipids, which slow water diffusion by providing the
of lamellar bodies (LB) into extracellular spaces SC with a torturous hydrophobic path, NMF help
[23, 25]. Influx of cytosolic Ca2+ into epidermal corneocytes hold a normal flattened, elongated shape
keratinocytes inhibits LB secretion and delays by selectively binding and retaining water. The pla-
epidermal recovery. Exposure to a high level of nar geometry of corneocytes is a key factor in main-
Ca2+ following barrier disruption has a similar taining the tortuous path; the flattened, elongated
effect [25], indicating normal barrier function is shape allows corneocytes to maintain a strong attach-
dependent on a specific Ca2+ range. Epidermal ment to each other via corneodesmosomes [32]. The
Ca2+ levels are also associated with a decrease in ability to maintain cell shape also makes NMF a key
mRNA levels for specific differentiation-linked contributor to maintaining skin flexibility [33].
proteins such as loricrin [25]. Increased extracel- Changes in filaggrin processing and NMF
lular K+ shows similar effects. Conversely, the concentrations have been reported following
influx of Cl into keratinocytes accelerates LB acute barrier disruption induced by physical or
secretion and consequently barrier recovery rate chemical means [3440]. Different types of dam-
after disruption [23]. age induce different effects on specific NMF
components (Table 29.1).
Literature suggests that many key SC NMF
29.3 Impact of Stratum Corneum components are reduced following barrier dis-
Damage on Natural ruption [3437, 40]. A study was recently com-
Moisturizing Factor pleted to investigate the impact of SLS barrier
disruption on NMF using noninvasive measure-
Less understood is the effect of acute disruption ments (Fig. 29.2) [35]. In agreement with previ-
on NMF and its precursors, profilaggrin and fil- ous reports [34, 36], results suggest that
aggrin. NMF serves as the primary humectant in SLS-induced damage decrease SC levels of ala-
skin. It is principally comprised of hygroscopic nine, glycine, pyrrolidone carboxylic acid (PCA),
amino acids and derivatives that absorb moisture and serine. trans-Urocanic acid is also reduced
from the surrounding environment and retain the along with its precursor histidine [3436].
water inside the lipid-protected corneocytes [27]. Other studies have also developed evidence to
NMF is derived from a large histidine-rich pro- suggest that other types of barrier damage can
tein called filaggrin, which functions to aggregate impact NMF levels [37, 40]. For instance, tape
keratin in the final stages of epidermal differen- stripping followed by occlusion was found to
tiation [28]. After undergoing internal charge reduce levels of SC free amino acids including
reorganization during differentiation, filaggrin is citrulline [40]. Repeated UV irradiation lowered
no longer bound to the keratin of the keratino- SC concentrations of glutamic acid, arginine,
cytes. The result is filaggrin is susceptible to pro- citrulline, and histidine by ~20% but had no
tease activity and subsequently is hydrolyzed into effect on urea, serine, glutamine, and tyrosine
individual amino acids and derivatives. levels [37].
The importance of the NMF contribution to bar- However, some NMF components do increase
rier homeostasis is evidenced by reported links after barrier damage. Most notably, specific types
between abnormalities in profilaggrin/filaggrin pro- of damage appear to increase the concentration
duction and/or processing with skin conditions such of products and intermediates of urea cycling.
444 L.M. Kroll et al.

Table 29.1 Barrier disruption and impact on natural moisturizing factor (NMF)
NMF Response
Reference Damage Mechanism Increase Decrease No Change
Koyama [34]a Surfactant (SLS) Lactateb Alanineb,c Lactatec
Ornithinea,b,c Argininea
Prolinea,b Citrullinea
Kroll [35]b Ureaa,b Glycineb,c
Porcheron [36]c Histidinea,b,c
PCAb
Serineb,c
Urocanic acida,b
Pratzel [37] Ultraviolet Glycine Arginine Glutamine
irradiation Isoleucine Citrulline Serine
Proline Glutamic acid Tyrosine
Urocanic acid Histidine Urea
Valine
Visscher [40] Tape stripping Glutamic acid Citrulline
Histidine
Serine
Visscher [40] Tape stripping Citrulline
followed by Glutamic acid
occlusion Histidine
Serine
SLS sodium lauryl sulfate, PCA pyrrolidone carboxylic acid

Both urea and ornithine have been reported to grin processing is a complex process involving
increase following SLS-induced barrier perturba- multiple enzymes [41], and barrier disruption
tion [3436]. An increase in lactate was reported likely impacts the stability and/or activity of
by Kroll [35]; however, Porcheron [36] found no each. During normal epidermal differentiation,
impact on SC lactate. Increases in proline have profilaggrin is dephosphorylated and cleaved to
also been observed [34, 35]. Tape stripping fol- filaggrin monomers [4247]. Filaggrin mono-
lowed by occlusion increased glutamic acid lev- mers are deiminated by the peptidylarginine
els [40] while UV irradiation increased SC levels deiminases (PAD1 and PAD3), converting filag-
of urocanic acid, proline, glycine, valine, and iso- grin-associated arginine residues to citrulline
leucine by ~20% [37]. [4850]. The deiminated filaggrin is then hydro-
lyzed into peptide fragments and eventually to
individual amino acids and derivatives likely
involving multiple enzymatic steps [5156]. A
29.4 Sodium Lauryl Sulfate Impact recent study has shown bleomycin hydrolase
on Natural Moisturizing Factor (BH), a neutral cysteine protease identified in
Processing the rat epidermis, likely plays a substantial role
in the final stages of NMF generation. BH was
Continued research to understand the biochem- found to readily hydrolyze deiminated filaggrin
istry of NMF production is essential to fully that was partially degraded by a calcium-depen-
appreciate its role in barrier disruption and dent cysteine protease called calpain 1 [56].
repair. While the entire process has not been SLS-induced barrier disruption has been
fully elucidated, Fig. 29.3 provides a plausible reported to reduce the expression of profilaggrin
pathway for NMF generation. Profilaggrin/filag- genes within 6 h of exposure [39]. However, this
29 Impact of Stratum Corneum Damage on Natural Moisturizing Factor (NMF) in the Skin 445

10 20 30 40 50 Proline Ornithine Lactate pH4 Urea

50 100 150 200

80

25
60

20
40

15
20

10
0
0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20

Alanine Glycine His pH4 His pH7

5 10 15 20
20 0 20

10 20 30
80 60 40 20 0
Arbitrary units

100 60

5 0

10 0
0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20

PCA Serine tUca pH4 tUca pH8

5 10 15 20 25 30 35

4
80

10

2
60

0
5
40

4 2
20

0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20
Stratum corneum depth (m)

Fig. 29.2 Raman profiles of natural moisturizing factor 24 h. Patches were removed, sites were allowed to accli-
(NMF) components after sodium lauryl sulfate (SLS) mate for 30 min, and the distribution of key SC NMF con-
exposure. Dashed line = SLS-exposed stratum corneum stituents determined using in vivo confocal Raman
(SC). Solid line = water-exposed stratum corneum. spectroscopy [35]. His Histidine, PCA pyrrolidone car-
Forearm sites were patched with 1% SLS or water for boxylic acid, tUCA trans-Urocanic acid

observation did not translate to the protein level enzymes capable of utilizing these amino acids
as no change in filaggrin levels was detected. as substrates have increased kinetics following
This implies the most prominent effect of SLS disruption. These types of responses may help
disruption on NMF generation is in the deimina- explain the NMF concentrations observed fol-
tion and/or hydrolysis of filaggrin. The NMF lowing SLS-induced disruption, specifically
responses to barrier damage (Table 29.1) infer those NMF components derived from urea
that the activity of key enzymes may be univer- cycling (Fig. 29.4).
sally reduced by barrier disruption. Reductions in A reduction in arginine following SLS exposure
histidine, citrulline, serine, and arginine appear to appears to coincide with an increase in ornithine
be most common irrespective of the mechanism and urea [3436], the products of arginase-
of barrier disruption, suggesting the enzymes mediated breakdown of arginine [55]. This sug-
involved in their release may be more susceptible gests an increase in arginase activity. Alterations in
to loss of activity. Another possibility is that the arginase activity as a function of barrier damage
substrates are altered or that the downstream have not been investigated to date and warrant
446 L.M. Kroll et al.

Stratum Profilaggrin
granulosum Furin
PEP-I
Calpain 1
Caspase- 14
Transition PADs 1 &3 Calpain Deiminated filaggrin
layer Filaggrin-Arg Filaggrin-Cit peptides
Bleomycin
hydrolase
Cathepsine
B, L

Eccrine
sweat

Urea
His pH4 His pH7 Ser Gly Ala Glu Pro Cit Orn Lactate

Stratum Ornithine carbamoyl-

corneum Histidase g-glutamyl-AA transferase Arginase
synthetase
Cit Urea
tUca tUca Glu acid cycle
pH4 pH8
g-glutamyl-AA
cyclotransferase
Arginino succinate

PCA

Fig. 29.3 Putative pathway for natural moisturizing factor ornithine, Pro proline, Glu glutamine, Glu acid glutamic
production. PEP1 profilaggrin endoproteinase 1, PAD pep- acid, PCA pyrrolidone carboxylic acid, Ala alanine, Gly
tidylarginine deiminase, Arg arginine, Cit citrulline, Orn glycine, Ser serine, His histidine, tUca trans-Urocanic acid

Arginino
succinate

Deiminated
filaggrin Urea
Arg Cit
peptides cycle

Arginase Orn Ornithine carbamoyl-

Urea transferase

Fig. 29.4 Hypothetical model of sodium lauryl sulfate arrows represent amino acids that decreased or enzymes
(SLS) mediated impact on stratum corneum (SC) natural hypothesized to have lower kinetics. Decreased arginine
moisturizing factor derived from urea cycling. Forearm and increased ornithine/urea levels may be due to increased
sites were patched with 110% SLS for up to 24 h and arginase activity following disruption. Conversely, reduced
compared to a site patched with water alone. Open, upward citrulline levels may result from reduced activity of orni-
facing arrows represent amino acids that increased with thine carbamoyltransferase. Arg arginine, Cit citrulline,
SLS exposure or enzymes hypothesized to have higher Orn ornithine (Model derived from observations reported
kinetics with SLS. Similarly, filled, downward facing in Koyama [34], Kroll [35], and Porcheron [36])
29 Impact of Stratum Corneum Damage on Natural Moisturizing Factor (NMF) in the Skin 447

Deiminated filaggrin
peptides

Bleomycin hydrolase
cathepsins B, L

His pH4 His pH7 Ser Gly Ala Glu Pro Cit

Histidase g-glutamyl-AA
synthetase

tUca tUca Glu acid

pH4 pH8
g-glutamyl-AA
cyclotransferase

PCA

Fig. 29.5 Hypothetical model of sodium lauryl sulfate lowing SLS exposure. This would imply proline is
(SLS) mediated impact on stratum corneum (SC) natural released in the SC independent of or downstream of the
moisturizing factors derived from bleomycin hydrolase other amino acids and the mechanism of its release is
(BH), cathepsin B, and cathepsin L-mediated hydrolysis enhanced by SLS exposure. Alternatively, increased pro-
of filaggrin Forearm sites were patched with 110% SLS line may be attributed to SLS-induced denaturation of
for up to 24 h and compared to a site patched with water small proline-rich proteins (SPRPs) that provide struc-
alone. Open, upward facing arrows represent amino acids tural support to the cornified envelope. Cit Citrulline, Pro
that increased following SLS exposure or enzymes Proline, Glu Glutamine, Glu acid Glutamic acid, PCA
hypothesized to have higher kinetics with SLS. Similarly, Pyrrolidone carboxylic acid, Ala Alanine, Gly Glycine,
filled, downward facing arrows represent amino acids that Ser Serine, His = Histidine, tUca = trans-Urocanic acid
decreased or enzymes hypothesized to have lower kinet- (Model derived from observations reported in Koyama
ics. Other than proline, all amino acids are decreased fol- [34], Kroll [35] and Porcheron [36])

further research. Altered conditions of pH, ion Following SLS exposure, the majority of NMF
concentrations, or substrate may explain the derived components outside of urea cycling are at
increase in arginase activity under damaged condi- reduced levels in the SC (histidine, serine, gly-
tions. Also coinciding with decreased arginine and cine, alanine, PCA, and citrulline) (Table 29.1
increased ornithine levels is a decrease in citrul- and Fig. 29.2). This observation could be attrib-
line, implying a reduction in the activity of orni- uted to direct enzyme inactivation by SLS or
thine carbamoyltransferase, the enzyme responsible SLS-mediated denaturation of filaggrin at enzyme
for converting ornithine to citrulline during urea recognition sites, or other pleiotropic events that
cycling [55]. A similar response is observed fol- have yet to be elucidated. Levels of the down-
lowing UV damage, with increased trans-Urocanic stream breakdown products of these amino acids
levels coinciding with decreased histidine [37], are also decreased (trans-Urocanic acid and
implying an increase in histidine breakdown with PCA), likely due to lack of substrate amino acids
UV-mediated disruption (Fig. 29.5). or enzyme inactivation by SLS.
448 L.M. Kroll et al.

Proline levels in the SC appear to increase fol- olism and gene expression. Both avenues are
lowing SLS exposure (Table 29.1 and Fig. 29.2). It important in understanding the control of NMF
is not known which specific enzyme is responsible processing during SC development and repair.
for generating free proline during normal epider- With damage the skin loses direct control of
mal differentiation. Recent analyses of BH activ- factors such as pH and ion gradients; however,
ity against aminoacyl-b-naphthylamide substrates the skin can rebalance these factors during repair.
indicate that it is capable of releasing all amino This rebalancing requires an orchestrated execu-
acids except proline [56]. Additionally, experi- tion of enzyme activity as well as the availability
ments investigating BH hydrolysis of recombinant of respective substrates. Surfactants can alter the
filaggrin failed to detect released proline. This tertiary structure of both the enzymes and sub-
implies free SC proline may be generated inde- strates involved in this rebalancing process, thus
pendent of or downstream of BH-mediated filag- changing enzyme kinetics and, in some cases,
grin hydrolysis. Alternatively, increased proline substrate recognition.
may be arising from the breakdown or denatur- The second research avenue of SC damage and
ation of proteins other than filaggrin. The corni- repair is associated with alterations in gene expres-
fied envelope is partially comprised of the sion and cellular functions important to repair
structural pancorulin and cornifin proteins which processes. Barrier disruption can have an effect
are predominantly comprised of proline, com- beyond the SC, directly impacting cellular func-
monly referred to as small proline-rich proteins tion in the viable epidermis [39, 57, 58]. It is
(SPRPs). SLS-mediated denaturation of these expected that both chemical and biochemical
SPRPs may contribute to the observed SC proline insults will have a greater influence on cellular
increase. functions than would mechanical insults such as
abrasion. Unlike mechanical insults whose dis-
ruption is by and large focused on the upper SC,
chemical and biochemical insults permeate the
29.5 Implications for Future SC providing a greater ability to impact cellular
Research processes. The effective concentration of the insult
reaching the cells will be paramount in the type
Mammalian skin is a complex organ with an and magnitude of damage and cellular response.
innate ability to respond to its environment. Specifically looking at the impact of surfactants
SC damage by chronic or acute exposure to on the damage and repair of the SC, it would appear
chemical, physical, or biochemical agents initiates that both cellular and biochemical regulatory path-
an important repair process. For mammals, this ways are impacted. The loss of enzyme functional-
repair function is an absolute requirement for ity can address some of the observed changes in
survival. Accordingly, these processes are pre- the NMF products. However, alterations in NMF
sumed to be highly conserved and tightly processing enzymology alone seem unlikely to
controlled. completely account for the observed outcomes of
With regard to surfactant damage to the SC, SC damage by SLS. It is anticipated that cellular
at least two intersecting research avenues are responses to SLS occurs and further studies are
envisioned to investigate both the impact of required to elucidate these mechanisms.
damage on SC biochemistry and subsequent To dissect the impact of SLS on SC enzymol-
SC repair. The first avenue includes work to ogy, it may be necessary to provide chronic expo-
elucidate the regulation and control of SC enzy- sure to lower levels of SLS and measure NMF
mology as a function of factors including pH, responses. The studies presented in Table 29.1
ion concentration, substrate availability, and employed an acute exposure to a relatively large
the absence/presence of inhibitors. The second amount of SLS. This method of exposure likely
avenue is to better appreciate the alteration of impacted cellular functions beyond the SC, mak-
the viable epidermis with regard to cell metab- ing it difficult to isolate a direct impact to enzyme
29 Impact of Stratum Corneum Damage on Natural Moisturizing Factor (NMF) in the Skin 449

processes specific to the SC. Nondestructive

in vivo measurements such as Raman spectros- Further research is needed to elucidate the
copy can be used to measure these responses. In regulation and control of SC enzymology
parallel, changes in gene expression using gene as a function of factors including pH, ion
arrays can provide a means to measure cellular concentration, substrate availability, and
responses to these insults. the absence/presence of inhibitors.
The advancement of knowledge on the bio- Continued work is also needed to better
chemical processes and repair functions of the SC understand the alteration of the viable
are an important study area impacting the study of epidermis following barrier damage and
both cosmetic and dermatological skin conditions. during repair with regard to cell metabo-
Elucidating the enzymology and cellular aspects lism and gene expression.
of NMF processing is a key step in reaching that More studies are needed that utilize a
goal. More studies are needed that utilize a sys- systems biology approach to provide a
tems biology approach to provide a holistic view holistic view of SC damage and repair
of SC damage and repair processes. Understanding processes.
these processes at a cellular and biochemical level
will provide new opportunities to give comfort to
those with cosmetic skin issues as well as those
suffering from dermatological diseases. Abbreviations

Ala Alanine
Take Home Messages BH Bleomycin hydrolase
Skin barrier disruption, whether caused by Cit Citrulline
chemical, physical, or biochemical means, FFA Free fatty acids
alters the SC composition and structure Gly Glycine
required to maintain barrier homeostasis. His pH4 Histidine pH4
The water gradient, pH gradient, ion gra- His pH7 Histidine pH7
dients, NMF, and lipid configurations are LB Lamellar bodies
all impacted by barrier disruption. NMF Natural moisturizing factor
NMF serves as the primary humectant PAD1
in skin. It is principally comprised of and PAD3 Peptidylarginine deiminases
hygroscopic amino acids and derivatives PCA Pyrrolidone carboxylic acid
that absorb moisture from the surround- Ser Serine
ing environment and retain water inside SPRPs Small proline-rich proteins
the lipid-protected corneocytes. SLS Sodium lauryl sulfate
During normal epidermal differentiation, SC Stratum corneum
profilaggrin is processed to NMF via a tUca trans-Urocanic acid
cascade of multiple enzymatic activities. UV Ultraviolet
Different types of barrier disruption
induce different effects on specific NMF References
components. Many key NMF compo-
nents are reduced following barrier dis- 1. Motta S, Monti M, Sesana S, Caputo R, Carelli S,
ruption while some increase. Ghidoni R (1993) Ceramide composition of the psori-
Changes in the activity of key enzymes atic scale. Biochim Biophys Acta 1182(2):147151
2. Cookson WO, Ubhi B, Lawrence R, Abecasis GR,
and/or the availability of substrates Walley AJ, Cox HE, Coleman R, Leaves NI, Trembath
likely impact observed changes in NMF RC, Moffatt MF, Harper JI (2001) Genetic linkage of
concentrations. childhood atopic dermatitis to psoriasis susceptibility
loci. Nat Genet 27(4):372373
450 L.M. Kroll et al.

3. Sator PG, Schmidt JB, Hnigsmann H (2003) 19. Mao-Qiang M, Elias PM, Feingold KR (1993) Fatty
Comparison of epidermal hydration and skin surface acids are required for epidermal permeability barrier
lipids in health individuals and in patients with atopic function. J Clin Invest 92(2):791798
dermatitis. J Am Acad Dermatol 48(3):352358 20. Mao-Qiang M, Feingold KR, Jain M, Elias PM (1995)
4. Proksch E, Elias PM (2002) Epidermal barrier in Extracellular processing of phospholipids is required
atopic dermatitis. In: Beiber T, Leung DY (eds) Atopic for permeability barrier homeostasis. J Lipid Res
dermatitis. Marcel Dekker, New York 36(9):19251935
5. Schulze C, Wetzel F, Kueper T, Malsen A, Muhr G, 21. Proksch E, Holleran WM, Menon GK, Elias PM,
Jaspers S, Blatt T, Wittern KP, Wenck H, Ks JA Feingold KR (1993) Barrier function regulates epidermal
(2010) Stiffening of human skin fibroblasts with age. lipid and DNA synthesis. Br J Dermatol 128(5):473482
Biophys J 99(8):24342442 22. Takagi Y, Kriehuber E, Imokawa G, Elias PM,
6. Fluhr JW, Akengin A, Bornkessel A, Fuchs S, Holleran WM (1999) b-Glucocerebrosidase activity
Praessler J, Norgauer J, Grieshaber R, Kleesz P, Elsner in mammalian stratum corneum. J Lipid Res 40(5):
P (2005) Additive impairment of the barrier function 861869
by mechanical irritation, occlusion, and sodium lauryl 23. Choi EH, Man MQ, Xu P, Xin S, Liu Z, Crumrine DA,
sulphate in vivo. Br J Dermatol 153(1):125131 Jiang YJ, Fluhr JW, Feingold KR, Elias PM, Mauro
7. Shindo Y, Witt E, Han D, Packer L (1994) Doseresponse TM (1991) Stratum corneum acidification is impaired
effects of acute ultraviolet irradiation on antioxidants in moderately aged human and murine skin. J Invest
and molecular markers of oxidation in murine epider- Dermatol 127(12):28472856
mis and dermis. J Invest Dermatol 102(4):470475 24. Denda M, Tsutsumi M, Inoue K, Crumrine D,
8. Shindo Y, Witt E, Packer L (1993) Antioxidant Feingold KR, Elias PM (2007) Potassium channel
defense mechanisms in murine epidermis and dermis openers accelerate epidermal barrier recovery. Br J
and their responses to ultraviolet light. J Invest Dermatol 157(5):888893
Dermatol 100(3):260265 25. Elias PM, Ahn SK, Denda M, Brown BE, Crumrine
9. Thiele JJ, Traber MG, Packer L (1998) Depletion of D, Kimutai LK, Kmves L, Lee SH, Feingold KR
human stratum corneum vitamin E: an early and sen- (2002) Modulations in epidermal calcium regulate the
sitive in vivo marker of UV-induced photooxidation. J expression of differentiation-specific markers. J Invest
Invest Dermatol 110(5):756761 Dermatol 119(5):11281136
10. Andersen PH, Bucher AP, Saeed I, Lee PC, Davis JA, 26. Mauro T, Holleran WM, Grayson S, Gao WN, Man
Maibach HI (1994) Faecal enzymes: in vivo skin irri- MQ, Kriehuber E, Behne M, Feingold KR, Elias PM
tation. Contact Dermatitis 30(3):152158 (1998) Barrier recovery is impeded at neutral pH,
11. Trm H, Berne B (2009) Sodium lauryl sulphate independent of ionic effects: implications for extra-
alters mRNA expression of lipid-metabolizing cellular lipid processing. Arch Dermatol Res 290(4):
enzymes and PPAR signaling in normal human skin 215222
in vivo. Exp Dermatol 18(12):10101015 27. Rawlings AV, Scott IR, Harding CR, Bowser PA
12. Moore PN, Shiloach A, Puvvada S, Blankschtein D (1994) Stratum corneum moisturization at the molec-
(2003) Penetration of mixed micelles into the epider- ular level. J Invest Dermatol 103(5):731741
mis: effect of mixing sodium dodecyl sulfate with dode- 28. Sandilands A, Sutherland C, Irvine AD, McLean
cyl hexa (ethylene oxide). J Cosmet Sci 54(2):143159 WH (2009) Filaggrin in the frontline: role in skin
13. Fartasch M (1997) Ultrastructure of the epidermal barrier function and disease. J Cell Sci 122(Pt 9):
barrier after irritation. Microsc Res Tech 12851294
37(3):193199 29. McGrath JA, Uitto J (2008) The filaggrin story: novel
14. Feingold KR (1991) The regulation of epidermal lipid insights into skin-barrier function and disease. Trends
synthesis by permeability barrier requirements. Crit Mol Med 14(1):2027
Rev Ther Drug Carrier Syst 8(3):193210 30. Palmer CN, Irvine AD, Terron-Kwiatkowski A, Zhao
15. Grubauer G, Feingold KR, Harris RM, Elias PM (1989) Y, Liao H, Lee SP, Goudie DR, Sandilands A,
Lipid content and lipid type as determinants of the epi- Campbell LE, Smith FJ, ORegan GM, Watson RM,
dermal permeability barrier. J Lipid Res 30(1):8996 Cecil JE, Bale SJ, Compton JG, DiGiovanna JJ,
16. Harris IR, Farrell AM, Grunfeld C, Holleran WM, Elias Fleckman P, Lewis-Jones S, Arseculeratne G, Sergeant
PM, Feingold KR (1997) Permeability barrier disrup- A, Munro CS, El Houate B, McElreavey K, Halkjaer
tion coordinately regulates mRNA levels for key LB, Bisgaard H, Mukhopadhyay S, McLean WH
enzymes of cholesterol, fatty acid, and ceramide synthe- (2006) Common loss-of-function variants of the epi-
sis in the epidermis. J Invest Dermatol 109(6):783787 dermal barrier protein filaggrin are a major predispos-
17. Holleran WM, Takagi Y, Menon GK, Jackson SM, ing factor for atopic dermatitis. Nat Genet
Lee JM, Feingold KR, Elias PM (1994) Permeability 38(4):441446
barrier requirements regulate epidermal b-glucocere- 31. Rawlings AV (2006) Sources and role of stratum cor-
brosidase. J Lipid Res 35(5):905912 neum hydration. In: Elias PM, Feingold KR (eds)
18. Lasch J, Schnfelder U, Walke M, Zellmer S, Beckert Skin barrier. Taylor & Francis, New York
D (1997) Oxidative damage of human skin lipids. 32. Harding CR, Watkinson A, Rawlings AV, Scott IR
Dependence of lipid peroxidation on sterol concentra- (2000) Dry skin, moisturization and corneodesmoly-
tion. Biochim Biophys Acta 1349(2):171181 sis. Int J Cosmet Sci 22(1):2152
29 Impact of Stratum Corneum Damage on Natural Moisturizing Factor (NMF) in the Skin 451

33. Nakagawa N, Sakai S, Matsumoto M, Yamada K, 47. Yamazaki M, Ishidoh K, Suga Y, Saido TC,
Nagano M, Yuki T, Sumida Y, Uchiwa H (2004) Kawashima S, Suzuki K, Kominami E, Ogawa H
Relationship between NMF (lactate and potassium) con- (1997) Cytoplasmic processing of human profilaggrin
tent and the physical properties of the stratum corneum by active mu-calpain. Biochem Biophys Res Commun
in healthy subjects. J Invest Dermatol 122(3):755763 235(3):652656
34. Koyama J, Horii I, Kawasaki K (1984) Free amino acids 48. Tarcsa E, Marekov LN, Mei G, Melino G, Lee SC,
of stratum corneum as a biochemical marker to evaluate Steinert PM (1996) Protein unfolding by peptidy-
dry skin. J Cosmet Chem Japan 35(4):183195 larginine deiminase. Substrate specificity and struc-
35. Kroll LM, Hoffman DR, Basehoar A, Cunningham C, tural relationships of the natural substrates
Reece B, Koenig DW (2011) Confocal Raman study trichohyalin and filaggrin. J Biol Chem 271(48):
of stratum corneum changes after damage with sodium 3070930716
lauryl sulfate. In: International Society for Biophysics 49. Vossenaar ER, Zendman AJ, van Venrooij WJ, Pruijn
and Imaging of the Skin (ISBS). US technical sympo- GJ (2003) PAD, a growing family of citrullinating
sium of ISBS, Tampa Bay, 69 Apr 2011 enzymes: genes, features and involvement in disease.
36. Porcheron A, Mauger E, Guinot C, Tschachler E, Bioessays 25(11):11061118
Morizot F (2007) Abstracts from the stratum corneum 50. Chavanas S, Mchin MC, Nachat R, Adoue V,
V conference 2007. Int J Cosmet Sci 29(3):219228 Coudane F, Serre G, Simon M (2006) Peptidylarginine
37. Pratzel H, Fries P (1977) Modification of relative deiminases and deimination in biology and pathol-
amount of free amino acids in the stratum corneum of ogy: relevance to skin homeostasis. J Dermatol Sci
human epidermis by special factors of the environ- 44(2):6372
ment. I. The influence of UV irradiation. Arch 51. Elias PM (2004) The epidermal permeability barrier:
Dermatol Res 259(2):157160 from the early days at Harvard to emerging concepts.
38. Scott IR (1986) Alterations in the metabolism of filag- J Invest Dermatol 122(2):xxxvixxxix
grin in the skin after chemical- and ultraviolet-induced 52. Kawada A, Hara K, Hiruma M, Noguchi H, Ishibashi
erythema. J Invest Dermatol 87(4):460465 A (1995) Rat epidermal cathepsin L-like proteinase:
39. Trm H, Lindberg M, Berne B (2008) Skin barrier purification and some hydrolytic properties toward
disruption by sodium lauryl sulfate-exposure alters the filaggrin and synthetic substrates. J Biochem 118(2):
expressions of involucrin, transglutaminase 1, profil- 332337
aggrin, and kallikreins during the repair phase in 53. Kawada A, Hara K, Morimoto K, Hiruma M, Ishibashi
human skin in vivo. J Invest Dermatol 128:12121219 A (1995) Rat epidermal cathepsin B: purification and
40. Visscher M, Robinson M, Wickett R (2011) Stratum characterization of proteolytic properties toward filag-
corneum free amino acids following barrier perturba- grin and synthetic substrates. Int J Biochem Cell Biol
tion and repair. Int J Cosmet Sci 33(1):8089 27(2):175183
41. Presland RB, Rothnagel JA, Lawrence OT (2006) 54. Benavides F, Starost MF, Flores M, Gimenez-Conti
Profilaggrin and the fused S100 family of calcium- IB, Gunet JL, Conti CJ (2002) Impaired hair follicle
binding proteins. In: Elias PM, Feingold KR (eds) morphogenesis and cycling with abnormal epidermal
Skin barrier. Taylor & Francis, New York differentiation in nackt mice, a cathepsin L-deficient
42. Presland RB, Kimball JR, Kautsky MB, Lewis SP, Lo mutation. Am J Pathol 161(2):693703
CY, Dale BA (1997) Evidence for specific proteolytic 55. Tabachnick J, LaBadie JH (1970) Studies on the bio-
cleavage of the N-terminal domain of the human pro- chemistry of epidermis. IV. The free amino acids,
filaggrin during epidermal differentiation. J Invest ammonia, urea, and pyrrolidone carboxylic acid con-
Dermatol 108(2):170178 tent of conventional and germ-free albino guinea pig
43. Pearton DJ, Nirunsuksiri W, Rehemtulla A, Lewis epidermis. J Invest Dermatol 54(1):2431
SP, Presland RB, Dale BA (2001) Proprotein con- 56. Kamata Y, Taniguchi A, Yamamoto M, Nomura J,
vertase expression and localization in epidermis: evi- Ishihara K, Takahara H, Hibino T, Takeda A (2009)
dence for multiple roles and substrates. Exp Dermatol Neutral cysteine protease bleomycin hydrolase is
10(3):193203 essential for the breakdown of deiminated filaggrin
44. Resing KA, Walsh KA, Haugen-Scofield J, Dale BA into amino acids. J Biol Chem 284(19):
(1989) Identification of proteolytic cleavage sites in 1282912836
the conversion of profilaggrin to filaggrin in mamma- 57. Gibson WT, Teall MR (1983) Interactions of C12 sur-
lian epidermis. J Biol Chem 264(3):18371845 factants with the skin: changes in enzymes and visible
45. Resing KA, al-Alawi N, Blomquist C, Fleckman P, and histological features of rat skin treated with
Dale BA (1993) Independent regulation of two cyto- sodium lauryl sulphate. Food Chem Toxicol
plasmic processing stages of the intermediate fila- 21(5):587594
ment-associated protein filaggrin and role of Ca2+ in 58. Le M, Schalkwijk J, Siegenthaler G, Van De Kerkhof
the second stage. J Biol Chem 268(33):2513925145 PCM, Veerkamp JH, Van Der Valk PGM (1996)
46. Resing KA, Thulin C, Whiting K, al-Alawi N, Mostad Changes in keratinocyte differentiation following
S (1995) Characterization of profilaggrin endoprotei- mild irritation by sodium dodecyl sulfate. Arch
nase 1. A regulated cytoplasmic endoproteinase of Dermatol Res 288(11):684690
epidermis. J Biol Chem 270(47):2819328198
 Water and Minerals in the
Treatment of Dryness 30
Ronni Wolf, Danny Wolf, Donald Rudikoff,
and Lawrence Charles Parish

Part of this article was adapted with permission from: Wolf R, Parish LC, Davidovici B,
et al (2007) Drinking 6 to 8 glasses of water a day is essential for skin hydration: myth or
reality? Skinmed 6:9091.

30.1 The Apparent Paradox 30.2 Drinking Water and Skin

Hydration
There is no generally accepted definition of what
constitutes dry skin, but low water content of the 30.2.1 The Media
stratum corneum (SC) and lower layers of the
skin definitely play a role in the pathomechanism. The sanctity of the sacred cow has been chal-
Therefore, it would seem obvious that the right lenged! We will start with a few among dozens of
way to combat and reverse dry skin is by giving it links extolling the beneficial effect of drinking
what it lackswater. Put another way, if dry skin eight glasses of water on skin before we put in
is deficient of water, it makes sense that hydrat- our 2 cents worth.
ing/wetting it is the most direct way of reversing http://whatscookingamerica.net/
the condition. But, is it? The present chapter will HealthBeauty/Water-TheFountainOfYouth.htm
deal with the issues of internal water consump- Now that I have hopefully convinced you of the
tion and external application of water and their benefits of drinking water for your skin and health,
effects (or lack of) on dry skin. how much should your drink a day? The Mayo
Clinic suggests using 8 8 as a guideline: 8
glasses (8 ounces each) = a minimum of 64 ounces
of fluid (water) daily. You may need even more
R. Wolf, M.D. () as exercising, hot weather, offices with exposure
The Dermatology Unit, Kaplan Medical Center, to central heating, air conditioning, and electrical
76100, Rechovot, Israel equipment all cause your body to lose water.
Hebrew University Hadassah Medical School,
http://www.happyhealthylonglife.com/happy_
Jerusalem, Israel
e-mail: [email protected] healthy_long_life/2008/06/how-much-water-do-
i-need-to-drink-what-the-experts-say.html
D. Wolf, M.D.
Pediatric Outpatient Clinic, Sherutei Briut Clalit, Now all of a sudden the press is saying Forget
Hasharon Region, Natanya, Israel about forcing down those 8 glasses of 8! I de-
cided to read the studies myself and separate the
D. Rudikoff, M.D.
truth from the fiction. I also know how I feel when
The Division of Dermatology,
I drink my usual 64 ounces (8 glasses) of water
Bronx Lebanon Hospital Center,
(& other fluids) a day, and when I dont. For me,
Albert Einstein College of Medicine,
its all about evidence-based living! Last week-
Bronx, NY, USA
end in Chicago, I didnt lug around my stainless
L.C. Parish, M.D., M.D. (Hon) steel water bottle, or down nearly enough liquid
The Department of Dermatology and Cutaneous Biology to fill my usual quota. And yes, my body noticed
and the Jefferson Center for International Dermatology, it. Wont do that again! Needless to say, my trips
Jefferson Medical College of Thomas Jefferson University, to the bathroom were not what they should have
Philadelphia, PA, USA been. And as Dr. Goldfarb would say, There was

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 453

DOI 10.1007/978-3-642-27606-4_30, Springer-Verlag Berlin Heidelberg 2012
454 R. Wolf et al.

definitely less turgor in my skin. (I looked wrin- critically reviewed this issue [1]. The question
kled.) As far as Im concerned, water works! I look
asked was: There are certainly well-recognized
better, my digestion is better, I feel better & even
think better. You can decide for yourself, but heres disease states, such as nephrolithiasis, for which
what I learned about water. increased fluid intake is therapeutic, but do aver-
age, healthy individuals living in temperate cli-
http://www.smartskincare.com/nutrition/diet.
mate need to drink extra fluid even when not
html
thirsty to maintain health? The authors exam-
A well-moisturized skin is somewhat less prone to ined several claims of a benefit for extra water
developing of wrinkles. Drinking plenty of fluids
throughout the day ensures proper hydration of the
drinking, e.g., it leads to more toxin excretion
body and helps reduce skin dryness. Experts usu- through the kidneys; it improves skin tone, and it
ally recommend drinking 68 glasses of water a reduces hunger and headache frequency. They
day. came to the conclusion that There is no clear
http://www.iloveindia.com/nutrition/water/ evidence of benefit from drinking increased
index.html amounts of water. Although we wish we could
demolish all of the urban myths found on the
Water forms a major part (2/3) of our body weight.
Blood is 83% water, muscles are 75% water, brain
Internet regarding the benefits of supplemental
is 74% water and bone is 22% water. Water is nec- water ingestion, we concede there is also no clear
essary for the very survival of human beings, as it evidence of lack of benefit. In fact, there is sim-
ensures the smooth functioning of body systems. ply a lack of evidence in general. We could not
Skin cells, like any other cell in the body, are al-
most entirely made up of water. Without water the
agree more with those authors.
organs in the body - and the skin is the biggest The conclusions of another review article [2]
will not function properly. Loss of hydration in the were similar: Thus I have found no scientific proof
skin is expressed in a variety of ways, such as dry- that we must drink at least eight glasses of water a
ness, tightness, flakiness. Dry skin has less resil-
ience and is more prone to wrinkling. Water is es-
day, nor proof, it must be admitted, that drinking
sential to maintain skin moisture and is the vehicle less does absolutely no harm. However, the pub-
for delivering essential nutrients to the skin cells. lished data available to date strongly suggest that,
Given that water is lost in large quantities every with the exception of some diseases and special cir-
day, it stands to reason that it needs to be replaced
somehow.
cumstances, such as strenuous physical activity,
long airplane flights, and climate, we probably are
In summary, the argument for high water currently drinking enough and possibly even more
intake, as presented in the media, is: because our than enough. The authors continues with
body is almost entirely made up of water and osmotic regulation of vasopressin secretion and
because water is essential for living tissues and thirst is so sensitive, quick, and accurate that it is
humans cannot survive for more than a few days hard to imagine that evolutionary development left
without ingesting water, we, therefore, need to us with a chronic water deficit that has to be com-
drink large quantities of water, and the more the pensated by forcing fluid intake.
better. Applying this kind of logic to gasoline and
motor vehicles, the reasoning would be: because
gasoline is essential for the car to function, we 30.2.3 The Alleged Benecial Effect of
need to maintain large amounts of gasoline in the Drinking 8 8 Glasses of Water
vehicles tank, and the more the better. on the Skin

We are aware of only one study [3] relating to the

30.2.2 The Alleged Benecial Effect effect of long-term water intake (2.25 L/day of
of Extra Fluid Intake on General either mineral water or tap water) on skin physi-
Health ology. After 4 weeks of drinking water in excess,
the mineral water group measurements revealed a
An excellent editorial recently published in the significant decrease in skin density and an
Journal of the American Society of Nephrology increased skin thickness (significantly only in the
30 Water and Minerals in the Treatment of Dryness 455

subjects who routinely drank comparably little otherwise healthy individuals over a long period of
before the start of the study). Skin density time will do the opposite, namely, increase turgor?
increased significantly, and skin thickness The answer is a resounding No!
decreased significantly in the tap water group.
Finger circumference decreased noticeably in the
mineral water group and increased in tap water 30.2.4 Starlings Equation
group. Objective skin surface morphology did
not change in any group. As the authors admitted, Although the main water reservoir of the skin is
not all of the objectively measured changes the dermis, it is the SC water content which plays
can be explained straightforwardly, as the exact a crucial role in maintaining many of the skins
mechanisms necessitate further research in this biophysical properties, such as elasticity and sur-
area. This report leaves more questions than face roughness. The connective tissue of the skin
answers, particularly concerning the differences is crucial for water storage in the body. The skin
and contradictory results between measurements tissue volume of a man with a body weight of
of the group that drank mineral water compared 70 kg is about 7 L. The extracellular matrix com-
to the group that drank tap water. The clinical rel- prises two-thirds of this volume and consists of
evance of the results is unclear; however, the about 50% fluid. Thus, one-third of the tissue
study is important by being the first to demon- layer consists of interchangeable water.
strate that the consumption of more than 2 L of Proteoglycans, a major component of the extra-
water per day can have a measurable influence on cellular matrix, can bind one-third of the total
skin physiology in healthy volunteers. interstitial amount of fluid [7]. It is noteworthy
Noteworthy, objective assessment of the skin sur- that this interstitial fluid confers a degree of tur-
face profile did not reveal any significant changes gor to the skin. Although modest expansion of
in either group. This is interesting, the authors interstitial fluid volume may not be detected, an
noted, as it is generally claimed that drinking excess of several liters causes visible and palpa-
lots of water might reduce visible signs of cuta- ble swelling termed edema. The interstitial
neous ageing such as wrinkles and lines. We fluid volume and the net flux through the capil-
could not confirm any objective improvement of lary wall are regulated by the forces of the Starling
wrinkles or skin surface roughness after increas- equation, according to which the movement of
ing the daily water uptake to more than 2 liters fluid depends on six variables: (1) capillary
over weeks (our underline). hydrostatic pressure, (2) interstitial hydrostatic
In our opinion, the lack of association between pressure, (3) capillary oncotic pressure, (4) inter-
excessive fluid intake and skin surface profile (e.g., stitial oncotic pressure, (5) filtration coefficient
wrinkles, skin surface roughness) as demonstrated (of the capillary wall), and (6) reflection coeffi-
in Williams et al.s study [3] provides the main cient (a correction factor that also describes the
take-home message of the current presentation as permeability of the capillary wall). The main
well. The lack of any convincing evidence for a value of this equation lies in its didactic logical
benefit of the 8 8 rule in other fields also applies explanation of the forces involved in fluid move-
to dermatology, including skin wrinkling and sur- ment from one compartment to anotherin our
face roughness in otherwise healthy people. case, from blood vessels to the interstitial spaces
We are taught in medical school how to evalu- of the skinespecially when pathologic pro-
ate dehydration by assessing skin turgor. The skin cesses grossly alter one or more of the variables.
should be pinched and lifted to create a fold over The equation is not meant to be used for clinical
the sternum, the abdomen, or the arm. In cases of purposes because it is almost impossible to mea-
decreased skin turgor, the skin fold will hold or sure all six variables together in actual patients.
tent for up to 30 s, whereas in normal conditions, According to Starlings equation, increasing
it returns immediately to its original state [46]. capillary hydrostatic pressure and decreasing col-
Does the fact that severe dehydration can decrease loid osmotic pressure or increased permeability
skin turgor indicate that excessive fluid intake in of the capillary wall leads to increasing fluid shift
456 R. Wolf et al.

from the intravascular space to the interstitial tis- conditions) or skin diseases (e.g., atopic dermati-
sue. There is enough evidence to show that exces- tis or psoriasis). Notably, this was before active
sive and rapid fluid intake/infusion may lead to and specific drugs became available. Depending
increasing interstitial volume and edema. In a on the culture of individual countries, hydrother-
recent study using a canine model [8], dermal apeutic approaches were endorsed by physicians,
echogenicity decreased significantly (Note: der- health care personnel, patients, and the media.
mal water content is negatively correlated with There has recently been a resurgence of interest
dermal echogenicity due to interstitial edema, in the role of water in the treatment of several
which leads to a decrease in the strong echoge- skin diseases, as witnessed by the tremendous
nicity of collagen bundles) and skin thickness increase in the popularity and demand for hydro-
increased significantly after hydration via intra- therapy, perhaps as part of the general tendency
venous administration of an isotonic crystalloid to switch to complementary, alternative, and
solution (30 mL/kg/h for 30 min). In another unconventional medicine.
study on 20 healthy men, dermal thickness Various researchers [1013] were able to show
increased significantly 30 min after infusion of the manifold effect of spa waters on various com-
10 mL/kg body weight of Ringers solution given ponents of the skin, particularly on the immune
over 15 min [7], whereas rapid removal of fluids system (on TNF-alpha, interleukin [IL]-8, IL-6)
and water from the body during dialysis had an on endorphin levels, on keratinocyte differentia-
opposite effect. Removal of fluid after hemodial- tion via receptor potential vanilloid (TRPV6), on
ysis was associated with a significant decrease in free radical levels, and many others.
skin thickness, skin elasticity, stratum corneum With all these therapeutic effects on various
water content, and skin distensibility [9]. chronic inflammatory skin diseases, the immune-
Does the fact that changes in plasma colloid modulating effects, and other beneficial and valu-
osmotic pressure after excessive and abrupt fluid able biological properties of mineral waters
intake (a change that may also be detected by notwithstanding, we found no specific claim on
hematocrit and electrolyte changes, as well as their effect on skin moisture or hydrating proper-
changes in the variables of Starlings equation) ties. This is particularly germane to the treatment
may influence water content of the skin indicate of atopic dermatitis. Although dry skin is a hall-
that excessive fluid intake throughout the day and mark of atopic dermatitis and plays a major role
over long periods of time do the same? No! There in its pathogenesis, the therapeutic effects of
is no scientific proof that drinking habits may thermal waters on the disease is attributed mainly
intervene or cause a change in Starlings equation to their immune-modulatory, anti-inflammatory,
and thus that they have any influence on the water antibacterial, and vasoactive properties and not to
content of the skin. their effect on skin moisture/hydration. Histo-
rically, there have been multitudinous variations
in expert recommendations for optimal bathing
30.3 Applying Water Externally, practices in the management of atopic dermatitis.
Hydrotherapy, and Skin The most widely accepted recommendation in
Hydration recent times was that of daily bathing followed
by immediate application of topical emollient or
The issues concerning the effect of water applied topical medication. This is what we, the authors,
to the skin externally on skin hydration are also recommend to our patients. It is our empiri-
entirely different than those associated with water cal (not evidence-based) experience that applica-
consumption. Water applied externally through tion of a moisturizer directly onto the moist skin
bathing/immersion has historically been consid- within 3 min after bathing will soothe the skin
ered an important therapeutic tool, especially in and keep it hydrated. However, Chiang and
the management of patients suffering from Eichenfields recent study [14] analyzed this pre-
chronic inflammatory diseases (e.g., rheumatoid cise issue, and their findings did not support the
30 Water and Minerals in the Treatment of Dryness 457

postbathing moisturizer approach. According to

those authors, bathing without moisturizer may system and the vasculature, as well as a
compromise skin hydration, and bathing followed significant therapeutic effect on various
by moisturizer application provides modest inflammatory skin diseases.
hydration benefits, though less than that of sim- There is no convincing evidence that
ply applying moisturizer alone. Whatever the water applied externally has any effect
conclusions on the values of moisturizers, the on skin moisture or skin hydration.
study results showed that bathing per se does not
add hydration to the skin.
Finally, we are all aware of the ancient treat-
ment principle of wet-to-moist dressings aimed References
at irrigating, cleaning, absorbing exudate, and
drying the surface of the skin. We would be hard 1. Negoianu D, Goldfarb S (2008) Just add water. J Am
Soc Nephrol 19:10411043
pressed to find a better way to emphasize that 2. Valtin H (2002) Drink at least eight glasses of water
putting water/saline on the skin and allowing it to a day. Really? Is there scientific evidence for 8
evaporate will have the effect of drying the skin 8? Am J Physiol Regul Integr Comp Physiol
by transferring the water/fluid from the skin to 283:R993R1004
3. Williams S, Krueger N, Davids M et al (2007) Effect
the air and not hydrating it. of fluid intake on skin physiology: distinct differences
between drinking mineral water and tap water. Int J
Cosmet Sci 29:131138
4. Otieno H, Were E, Ahmed I et al (2004) Are bedside
features of shock reproducible between different
Take Home Messages
observers? Arch Dis Child 89:977979
Although there is no generally accepted 5. McGarvey J, Thompson J, Hanna C et al (2010)
definition of what constitute dry skin, Sensitivity and specificity of clinical signs for assess-
low water content probably plays a role. ment of dehydration in endurance athletes. Br J Sports
Med 44:716719
The media is saturated with assays/arti- 6. Aguilar OM, Albertal M (1998) Images in clinical
cles about the beneficial effect of drink- medicine. Poor skin turgor. N Engl J Med 338:25
ing eight glasses of water on our skin 7. Eisenbeiss C, Welzel J, Eichler W et al (2001)
and skin hydration. Influence of body water distribution on skin thick-
ness: measurements using high-frequency ultrasound.
The Mayo Clinic favors the 8 8 rule Br J Dermatol 144(5):947951
for drinking, translated into the consump- 8. Diana A, Guglielmini C, Fracassi F et al (2008) Use
tion of 8 glasses 8 ounces each daily, of high-frequency ultrasonography for evaluation of
but rules out any effect on the skin. skin thickness in relation to hydration status and fluid
distribution at various cutaneous sites in dogs. Am J
There is no convincing evidence that water Vet Res 69(9):11481152
drinking habits have any effect on our 9. Brazzelli V, Borroni G, Vignoli GP et al (1994) Effects
skin, including skin wrinkling and surface of fluid volume changes during hemodialysis on the
roughness, in otherwise healthy people. biophysical parameters of the skin. Dermatology
188:113116
Bathing, particularly in mineral and 10. Bieber T (2011) Evidence-based efficacy of Avene
thermal waters, has historically been thermal spring water. J Eur Acad Dermatol Venereol
considered an important therapeutic tool 25:134
in the management of musculoskeletal/ 11. Ghersetich I, Freedman D, Lotti T (2000) Balneology
today. J Eur Acad Dermatol Venereol 14:346348
rheumatoid conditions and various skin 12. Chiarini A, Dal PI, Pacchiana R et al (2006) Comanos
diseases. (Trentino) thermal water interferes with interleukin-6
Modern research has provided evidence production and secretion and with cytokeratin-16
to scientifically confirm the numerous expression by cultured human psoriatic keratinocytes:
further potential mechanisms of its anti-psoriatic
beneficial effects of spa waters on vari- action. Int J Mol Med 18:10731079
ous components of the skin, the immune 13. Dal PI, Chiarini A, Pacchiana R et al (2007) Comanos
(Trentino) thermal water interferes with tumour
458 R. Wolf et al.

necrosis factor-alpha expression and interleukin-8 14. Chiang C, Eichenfield LF (2009) Quantitative assess-
production and secretion by cultured human psoriatic ment of combination bathing and moisturizing regi-
keratinocytes: yet other mechanisms of its anti-psori- mens on skin hydration in atopic dermatitis. Pediatr
atic action. Int J Mol Med 19:373379 Dermatol 26:273278
 Hyaluronan Inside and Outside
of Skin 31
Aziza Wahby, Kathleen Daddario DiCaprio,
and Robert Stern

31.1 Introduction water surrounds the molecule in an attempt to

neutralize the charge. It is this particular quality
The glycosaminoglycan hyaluronic acid (also which provides the hydrating functions of HA,
called hyaluronan or hyaluronate and abbreviated with the simultaneous ability to expand tissues
as HA) is a major component of the extracellular and to open spaces for cell movement.
matrix (ECM) of skin and plays an important role Extrinsic aging in the human skin, compared
in the metabolism of both the epidermis and der- with photo-protected skin is associated with
mis. Hyaluronan is responsible for hydration, alterations in the expression of HA and its metab-
nutrient exchange, and protects against free radi- olizing enzymes, both the hyaluronidases and the
cal damage via a multitude of signaling pathways. HA synthase complex of enzymes [58], as
It is also involved in basic biologic processes described below. It is clear that the dried
such as cell differentiation and motility. An over- appearance of aging skin is intimately associated
view is provided here that provides recent infor- with changes in apparent levels and types of HA
mation, bringing up-to-date advances in matrix deposition, dependent on changes in controls of
biology relevant for dermatology and skin care, its underlying metabolism.
with a particular emphasis on skin moisture. Hyaluronan is involved in multiple aspects of
skin biology, responsible not only for skin hydra-
tion but also for nutrient exchange, tissue homeo-
31.2 Hyaluronan stasis, repair processes, protection against free
radical damage, cell differentiation, and cell
Hyaluronan is a highly anionic molecule. At the motility. Native and formulated preparations of
bodys pH, it is one of the most highly charged HA, applied exogenously, help skin regain elas-
molecules in biology, which provides HA with ticity, turgor, as well as moisture. Understanding
some of its unique qualities. A massive cloud of HA metabolism may provide clues for reversing
some of the processes that lead to skin aging, loss
of moisture, and wrinkling.

31.3 Hyaluronan in Skin

A. Wahby K.D. DiCaprio R. Stern () There are numerous reports of decreased
Department of Basic Medical Sciences,
amounts of HA in aging skin. These observa-
Touro College of Osteopathic Medicine,
New York, NY 10027, USA tions are based on histochemical stains, such as
e-mail: [email protected] Alcian blue, and affinity histochemistry with the

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 459

DOI 10.1007/978-3-642-27606-4_31, Springer-Verlag Berlin Heidelberg 2012
460 A. Wahby et al.

HA-binding peptide. However, actual biochemi- Hyaluronan is most prominent in the upper
cal extraction techniques, using progressively spinous and granular, where much of it is extra-
potent extraction solutions, indicate that the HA cellular. In the basal layer, HA is predominantly
content remains constant with age. The differ- intracellular and is not easily eluted out during
ence is that the HA becomes increasingly tissue aqueous fixation. Basal keratinocyte HA is
associated, becoming more and more resistant involved in mitotic events, presumably, while
to extraction [32]. The apparent results from extracellular HA in the upper layers of the epi-
histochemical investigations are perhaps best dermis is involved in barrier disassociation and
explained by increasing competition between sloughing of cells.
tissue proteins for HA binding sites and the Tissue cultures of keratinocytes have facilitated
HA-binding peptide as a function of age. The studies of epithelial HA metabolism. These cul-
HA, encased within tissue proteins, may be tured cells synthesize large quantities of HA. When
restricted from functioning as a hydrating mol- Ca++ concentrations of the culture medium are
ecule. This proviso also indicates that the increased from 0.05 to 1.20 mM, basal-like cells
HA-staining procedure, as normally performed begin to differentiate, HA synthesis levels drop,
with an HA-binding peptide, is not a quantita- and hyaluronidase activity is induced [28, 57].
tive procedure. This increase in calcium that appears to simulate in
culture the natural in situ differentiation of basal
keratinocytes parallels the increasing calcium gra-
31.3.1 Distribution of Hyaluronan dient observed in the epidermis. There may be
in Skin intracellular stores of calcium that are released as
keratinocytes mature. Alternatively, the calcium
Hyaluronan in skin occurs in both dermis and epi- stores may be concentrated by lamellar bodies
dermis, with dermis containing the greater pro- from the intercellular fluids released during termi-
portion. Epidermal HA is more loosely associated nal differentiation. The lamellar bodies are thought
and is more easily extracted from tissue. Formalin, to be modified lysosomes containing hydrolytic
an aqueous fixative, easily removes most of the enzymes and a potential source of the hyaluroni-
HA from epidermis. It is less able to extract HA dase activity.
from dermis. Alcoholic formalin enhances histo- The lamellar bodies fuse with the plasma
localization of epidermal HA and indicates con- membranes of the terminally differentiating kera-
siderable levels are contained therein [30]. tinocytes, increasing the plasma membrane sur-
Skin HA has a very rapid turnover, with a half- face area. Lamellar bodies are also associated
life of 12 days in the epidermis [47]. The turn- with proton pumps that enhance acidity. A proton
over rate in the dermis is similar, with catabolism pump, specifically Na+-H+ exchanger1 (NHE1),
occurring in liver and lymph nodes, following is part of a complex involved in the internaliza-
lymphatic drainage [46]. tion and degradation of HA of the ECM [10].
The turnover mechanism in the epidermis is This same pump also creates localized areas of
not clear and may be a combination of free radi- acidity on the cell surface, presumably within
cal fragmentation, stimulated by UV light, and lipid rafts where CD44, the predominant HA
enzymatic degradation (vide infra). receptor, is localized [39].
The lamellar bodies also acidify, and their
31.3.1.1 Hyaluronan in the Epidermis polar lipids become partially converted to neutral
Until recently, it was assumed that only mesen- lipids, thereby participating in skin barrier func-
chymal cells were capable of synthesizing HA. tion. Diffusion of aqueous material through the
With newer techniques, evidence for HA being epidermis is blocked by these lipids synthesized
made in the epidermis became apparent. by keratinocytes in the stratum granulosum, the
Techniques for separating dermis and epidermis boundary corresponding to the level at which
facilitated detection of HA in each compartment. HA-staining ends. This constitutes part of the
31 Hyaluronan Inside and Outside of Skin 461

barrier function of skin. The HA-rich area infe- A clue to the vigorous HA synthetic capacity
rior to this layer may obtain water from the of dermal fibroblasts comes from an unexpected
moisture-rich dermis. And the water contained direction. Adiponectin, a cytokine produced by
therein cannot penetrate beyond the lipid-rich adipose tissue, stimulates HA synthesis in dermal
stratum granulosum. The HA-bound water in fibroblasts [3]. Sebaceous glands of the skin pro-
both the dermis and in the vital area of the epider- duce adiponectin as well, and dermal fibroblasts
mis is critical for skin hydration. And the stratum are demonstrated to have specific adiponectin
granulosum is essential for maintenance of that receptors, producing HA by upregulation of their
hydration, not only for the skin, but also for the HA synthase 2 (HAS2). The female breast is a
body in general. Profound dehydration is a seri- modified sebaceous gland, with associated lipid
ous clinical problem in burn patients with exten- tissue. The bodys fat tissue is an endocrine gland
sive losses of the stratum granulosum. that is largely overlooked. The sebaceous glands
Hyaluronan of the epidermal ECM forms two of the skin may hold a key to the problem of loss
different structures: a pericellular coat close to of skin moisture, in light of the observation that
the plasma membrane, forming an intimate peri- adiponectin levels decrease markedly with age.
cellular matrix, and HA chains that coalesce into
large cables. Such cables, induced by inflamma-
tory agents, bind leukocytes, whereas the pericel- 31.3.2 Hyaluronan in the Basal Lamina
lular HA does not. Thus, under inflammatory
conditions, epidermal keratinocytes are able to Hyaluronan deposition occurs most prominently
form HA cables that can bind leukocytes [26]. in the papillary dermis and in the basement mem-
brane zone of skin. Hyaluronan is a component
31.3.1.2 Hyaluronan in the Dermis of all basement membranes, but its role in that
The HA content of the dermis is far greater than barrier between dermis and epidermis is entirely
that of the epidermis and accounts for most of the unknown. Ultrastructural and immunohistochem-
50% of total body HA present in skin. The papil- ical studies have not contributed to our under-
lary dermis has a more prominent level of HA standing of HA in basement membrane, nor is the
than does the reticular dermis. The HA of the der- relationship between HA and other components
mis is in direct continuity with both the lymphatic of that structure known, such as type IV collagen,
and vascular systems, which epidermal HA laminins, and fibronectin. Stoichiometric mea-
apparently does not. surements make no sense, given that HA is a
Exogenous HA is cleared from the dermis and polymer that varies so widely in size. Decreased
rapidly degraded [46]. The dermal fibroblast pro- levels of HA and decreased thickness of the basal
vides the synthetic machinery for endogenous der- lamina occur in diabetic skin, contributing to
mal HA, and should be the target for any thick skin syndrome [8]. Hyaluronan has a key
pharmacological attempts to enhance skin hydra- role in cell motility. Penetration and movement of
tion. The fibroblasts of the body, the most banal of tumor cells from epidermis to dermis through the
cells from a histologic perspective, are probably basal lamina defines a key event in the metastatic
the most diverse of all vertebrate cells with the spread of a malignancy. Understanding the nature
broadest repertoire of biochemical reactions and of HA in basement membranes and identifying
potential pathways for differentiation. Much of this its interactions with proteins and other matrix
diversity is site-specific. What makes the papillary polymers would seem to be an important matter.
dermal fibroblast different from other fibroblasts is Addition of exogenous HA to an organotypic
not known. However, these cells have an HA syn- keratinocyte-fibroblast coculture model enhances
thetic capacity similar to that of the fibroblasts that epidermal proliferation, resulting in a thicker epi-
line joint synovium or the hyalocytes of the eye, dermis. Hyaluronan also improves basement
responsible for the HA-rich synovial fluid and the membrane assembly as evidenced by an increased
vitreous of the ocular chambers, respectively. expression of laminin-332 and collagen type IV
462 A. Wahby et al.

at the epidermal-dermal junction. Furthermore, A major conundrum remains regarding the

development of the epidermal lipid barrier struc- hydration properties of HA. The number of
ture is enhanced [19]. water molecules in the hydration shell of HA
of different molecular sizes and in the presence
of various counterions has not been deter-
31.4 Hyaluronan and Edema mined. It is certain to be a nonlinear relation-
ship. Intuitively, it is predicted that large HMW
Hyaluronan in skin becomes much more promi- chains of HA are more effective hydrating mol-
nent with edema. Tissue swelling is one of the ecules, that they carry larger numbers of water
five cardinal signs of inflammation, and that molecules per disaccharide unit. But this must
swelling is comprised predominantly of HA [37, be demonstrated experimentally. An approach
52, 61]. This is a concept not sufficiently appreci- to this question has been described, though no
ated. Indeed, many of the inflammatory cytokines clear relationship was demonstrated [45]. A caveat
induce HA production, and conversely, HA frag- in such studies, and a major experimental prob-
ments induce such cytokine synthesis in a self- lem, is that the results are highly dependent
stimulatory cycle [22, 25]. The HA content of the upon the methods used to isolate and prepare
various bullous lesions of skin is another area of the HA [20].
potential importance. High levels of HA have
been documented in the blister fluid from patients
with active psoriatic lesions [31]. 31.6 CD44

The most prominent receptor for HA is CD44, a

31.5 Hyaluronan and Fragment Size transmembrane glycoprotein that occurs in a
wide variety of isoforms, products of a single
Despite its simple repeating structure, HA has a gene with variant exon expression, all inserted
wide range and occasionally contradictory func- into a single extracellular position near the mem-
tions, even though it is without branch points and brane insertion site. CD44 is coded for by 10
without sulfation or other secondary modifica- constant exons, plus from 0 to 10 variant exons.
tions. The multiple functions are in part attributed The standard form, CD44s, contains no variant
to variations in chain length. The variation in size exons and is distributed exclusively on the cell
is an extraordinarily rich informational system surface, while variant exon-bearing isoforms can
[53, 56]. In general, high molecular weight HA have additional intracellular localization (unpub-
occurs in normal healthy tissues, while frag- lished observations). CD44 is able to bind a vari-
mented HA is highly inflammatory, angiogenic, ety of other ligands including fibronectin,
and immune-stimulatory, a reflection of tissues collagen, and heparin-binding growth factors.
under stress. The large HA polymers are, in CD44 is distributed widely, being found on virtu-
marked contrast, anti-inflammatory, antiangio- ally all cells. It participates in cell adhesion,
genic, and immunosuppressive. migration, lymphocyte activation and homing,
Many injectable cosmetic and dermal prepara- and in cancer metastasis. The appearance of HA
tions contain HA in various concentrations and in dermis and epidermis parallels the histolocal-
cross-linked using a number of reactions. There ization of CD44.
is an intrinsic need to ensure that such materials The nature of the CD44 variant exons in skin
do not contain short HA chains that could stimu- at each location has not been determined. It would
late an inflammatory response. An additional be important to establish whether modulation
caution is the generation of short HA fragments occurs in CD44 variant exon expression with
that could be cleaved from those cross-linked changes in the state of skin hydration and as a
polymers and that could also be highly function of age, particularly in wrinkled and
inflammatory. UV-exposed skin.
31 Hyaluronan Inside and Outside of Skin 463

31.7 RHAMM the kinetics of the TGF-b response between

HAS1 and HAS2 and between the two compart-
Another receptor for HA is the receptor for ments, suggesting that the two genes are regu-
HA-mediated motility (RHAMM). This receptor lated independently.
is involved in cell locomotion, focal adhesion
turnover, and contact inhibition. Like CD44, it
also is expressed in a number of variant isoforms 31.9 The Hyaluronidases
and occurs as a cell surface receptor as well as
having multiple intracellular isoforms. The inter- Hyaluronan is very metabolically active, with a
actions between HA and RHAMM regulate loco- half-life of 35 min in the circulation, less than
motion of cells by a complex network of signal 1 day in skin, and in, apparently, an inert a tissue
transduction events and interaction with the such as cartilage, the HA turns over with a half-
cytoskeleton of cells. It is also an important regu- life of 13 weeks. This catabolic activity is pri-
lator of cell growth. marily the result of hyaluronidases, endoglycolytic
In a murine system, blocking expression of the enzymes with a specificity, except for the leech
RHAMM protein, either by gene deletion or by a enzyme, for the b14 glycosidic bonds. The
blocking reagent, selectively induces the genera- human genome project has also promoted expli-
tion of fat cells to replace those lost in the aging cation at the genetic level, and a virtual explosion
process. This has promise as a technique to of information has ensued [55].
improve the appearance of aging skin and a The mammalian hyaluronidases are endo-b-
potential source of the adiponectin, as discussed hexosaminidases and function as hydrolases, in con-
below. trast to prokaryotic hyaluronidases that cleave the
glycosidic bond using an eliminase mechanism of
action. They lack substrate specificity, able to digest
31.8 The Hyaluronan Synthases chondroitin sulfates (CS), albeit at a slower rate.
Six hyaluronidase-like sequences are present
Three isoforms of a single enzyme synthesize in the human genome, while most other mammals
HA. These are dual-headed transferases that uti- have seven such sequences. All are transcription-
lize as substrates alternately UDP-glucuronic ally active with unique tissue distributions. In the
acid, and UDP-N-acetylglucosamine. These are human, three genes (HYAL1, HYAL2, and HYAL3)
membrane proteins, located on the inner surface are found tightly clustered on chromosome
of the plasma membrane. They extrude their 3p21.3. Another three genes HYAL4, PHYAL1 (a
product through the plasma membrane into the pseudogene), and PH20 and sperm adhesion mol-
extracellular space as the HA is being synthe- ecule1 (SPAM1) are clustered similarly on chro-
sized. This permits unconstrained polymer mosome 7q31.3.
growth, without destruction of the cell. There are The enzymes HYAL1 and HYAL2 constitute
three synthase genes in the mammalian genome, the major hyaluronidases in somatic tissues;
coding for HAS1, HAS2, and HAS3. They are HYAL1, an acid-active lysosomal enzyme, was
located on three separate chromosomes and are the first somatic hyaluronidase to be isolated and
differentially regulated, with each producing a characterized. Why an acid-active hyaluronidase
different size polymer (for review, see [24, 62]). should occur in plasma is not clear. HYAL1 is
These homologous isoenzymes contain seven able to utilize HA of any size as a substrate and
membrane-associated regions and a central cyto- generates predominantly tetrasaccharides. HYAL2
plasmic domain possessing several consensus is also acid-active, anchored to plasma mem-
sequences that are substrates for phosphorylation branes by a GPI (glycosylphosphatidylinositol)-
by protein kinase C. The HAS1 and HAS2 genes link. HYAL2 cleaves high molecular weight HA
are upregulated in skin by TGF-b in both dermis to a limit product of approximately 20 kDa, or
and epidermis, but there are major differences in about 50 disaccharide units.
464 A. Wahby et al.

Not all tissues that contain HYAL1 activity and a Na+-H+ exchanger (NHE1) for creating
synthesize that enzyme. Active endocytosis of acidic foci on plasma membrane indentations
the protein from the circulation occurs [17]. termed lipid rafts [10]. This putative cell organ-
Monocytes contain no mRNA for HYAL1, yet elle could be a functional unit that provides
have very high levels of enzyme activity (unpub- response mechanisms dependent on the meta-
lished observations). Megakaryocytes and plate- bolic state of the cell. A search should be taken
lets contain no HYAL1, [12] perhaps because for such an organelle in the robust HA synthesiz-
they lack the receptors for endocytosis of circu- ing fibroblasts of the papillary dermis.
lating HYAL1. Suggestive evidence for the existence of the
hyaluronasome comes from several sources.
Treating cultured cells with very low concen-
31.10 The Hyaluronasome trations of hyaluronidase has the anomalous
effect of increasing levels of HA synthesis
It is possible to invoke the existence of a new and [29, 43, 44]. Even treatment of isolated mem-
novel organelle, the hyaluronasome. Parallels brane preparations with low levels of hyaluroni-
between glycogen and HA metabolism are the dase has a similar effect [43], suggestive of a
basis of such a formulation. Both are monoto- feedback mechanism that instructs the cell on
nous, unadorned carbohydrate polymers of repeat- how much HA has been made. Constant clip-
ing sugars. A glycogen organelle can be visualized ping of the polymer as it is being extruded from
in liver, where it is prominent following a period the cell provides the misinformation that little
of starvation or prolonged intravenous feeding, HA has been deposited into the extracellular
when the organelles have been emptied of their space. The plasma membrane-bound receptor
glycogen substrate. CD44 is an ideal candidate for providing such a
feedback mechanism.
Readily visualized by the electron microscope, Treating cells with higher levels of hyaluroni-
glycogen granules appear as bead-like structures
localized to specific subcellular locales. Each gly-
dase modulates the expression profile of the vari-
cogen granule is a functional unit, not only con- ant exons of CD44, thus providing exquisite
taining carbohydrate, but also enzymes and other control mechanisms for the metabolic control of
proteins needed for its metabolism. These proteins HA deposition [54]. An organelle in which all
are not static, but rather associate and dissociate,
depending on the carbohydrate balance of the tis-
components are tethered together would provide
sue. Regulation takes place not only by allosteric the structural organization for such reactions to
regulation of enzymes, but also due to other fac- occur with maximum efficiency.
tors, such as sub-cellular location, granule size, and
association with various related proteins. (Shearer
and Graham [51])
31.11 Hyaluronan Protects Against
Such observations may be applicable to HA UV Damage
and the proteins related to its metabolism and
regulation in an organelle termed the hyalurona- UVB represents only 0.5% of the sunlight that
some. Indeed, such a complex was described in reaches the Earths surface, but accounts for
fibroblasts several decades ago for the synthetic much of the acute and chronic sun-related dam-
apparatus [33, 34]. This may be a component of age to skin. UVB-irradiation accelerates skin
an even larger complex that contains not only the aging, in part by disruption of the turnover of its
synthetic but also the degradative enzymes, asso- ECM. Among the changes that have been docu-
ciated regulatory proteins and peptides, as well as mented are enhanced expression of the MMPs
receptors and other binding proteins. A quasi- (matrix metalloproteinases), the attendant cleav-
complex has been described for the apparatus age of collagen, and reduced levels of HA. The
that brings HA chains into the cells for degrada- collagen fragments themselves are a component
tion, containing HA, the CD44 receptor, HYAL2, of the mechanism for the suppression of HA
31 Hyaluronan Inside and Outside of Skin 465

deposition; a direct effect on HAS2 expression ascorbate, a reaction that may occur at a greater
has been documented [11, 49]. Chronic UVB level in skin than in any other tissue.
irradiation causes loss of HA from mouse dermis It would be of intrinsic interest to examine
because of downregulation of HA synthase levels of HA in the skin of severely ascorbate
expression. Exogenous HA minimizes the effects deficient or anemic patients. Human beings are
of UV irradiation when added to cultures of among the few vertebrates in whom the enzy-
human keratinocytes, protecting against the sup- matic pathway for ascorbate synthesis has been
pression of CD44 and TLR-2 expression [21]. inactivated. Our hairlessness may be the basis of
this mutation, as a selective force, as a survival
mechanism. In humans, the entire pathway is
31.12 Hyaluronan Protects Against extant, except for the final enzymatic step. Could
Free Radical and Reactive this inactivation have correlated with loss of body
Oxygen Species Damage hair in the course of human evolution?
Another concept to be kept in mind is that
Reactive oxygen species (ROS) are generated products of enzymatic cleavage of HMW HA
during the metabolic reactions in which oxygen generate products that have structures that are,
participates. These ROS moieties facilitate the excepting for chain length, identical to the origi-
catabolism of HMW HA within dermis and epi- nal substrate. On the other hand, the products of
dermis by mechanisms that are not well under- free radical cleavage contain oxidized carboxyl
stood [2]. The proportion of HA degradation and hydroperoxide functional groups. These are
between enzymatic catalysis and ROS scission is reactive moieties that can interact with other tis-
also unknown. There are low levels of HYAL1 sue molecules. This may be the basis of the
and HYAL2 in skin, as established in an expres- sequentially more insoluble HA content of skin,
sion library. Effectiveness of ROS is enhanced by the HA that becomes increasingly resistant to
iron and copper ions, as well as by ions of other extraction as a function of age [32]. This also
transition metals, especially in the presence of suggests that the proportion of HA degraded by
ascorbic acid. Part of this is offset by the ability oxidative reactions generates a greater portion of
of Vitamin C to enhance the activity of hyaluroni- permanent structural tissue HA than that degraded
dase inhibitors [9, 35, 55]. There is apparently an enzymatically. Further documentation of this
entire system of checks and balances for main- sequestering of HA phenomenon as a function of
taining levels of HA deposition in skin that is age has been documented. The apparent decrease
unknown. Many commercial skin serums contain in HA staining of skin with age [38] can be
high levels of Vitamin C. Their effectiveness may explained. Binding sites on the HA substrate for
be due to the ability to tilt the balance toward the biotinylated HA-binding peptide, the basis of
enhanced HA deposition, an effect achieved the staining reaction, become progressively less
entirely by accident. available with age.
The ROS free radicals are highly unstable, Extrinsic aging in human skin is associated
reactive, and toxic. It is hardly conceivable that with alterations in the metabolizing enzymes of
they participate as intermediates or as regulatory HA. There is considerable increase in HA of
agents in biologic reactions. Yet, their high levels lower molecular mass with aging, and with UV
in skin and their generation with the constant skin exposed skin, compared to photo-protected skin
bombardment by UV irradiation suggests their of the buttocks. This increase is associated with
involvement in such reactions occurs through decreased HAS1 expression and increased
evolutionary forces. Controlled oxidative-reductive expression of HYAL1-3. The receptors CD44
degradation of HA chains by the combined effect and RHAMM are also significantly downregu-
of oxygen, transition metal cations, and ascorbate lated [58].
is entirely plausible. Reduction of oxidized tran- Inspection of the images of HA staining in for-
sitional metal ions occurs in the presence of malin-fixed skin, compared to alcoholic-acid for-
466 A. Wahby et al.

malin fixed skin, demonstrates that epidermis indicated that topical retinyl retinoate increased
contains HA that is easily eluted, barely surviving HA staining in the murine skin. Moreover, topi-
the aqueous formalin fixation. The dermal HA cal retinyl retinoate increased CD44 expression.
remains more tissue associated, the greater portion Using reverse transcription polymerase chain
remaining present following aqueous fixation. reaction, the expression level of the HAS2 gene in
From this, it follows that dermal HA, the more tis- primary human keratinocytes and in hairless
sue associated, may be the result of a greater pro- mouse epidermal skin was assessed. It was found
portion being modified by free radicals. that retinyl retinoate upregulates mouse and
Another proviso is that free radicals, and par- human HAS2 mRNAs. Application of retinyl
ticularly ROS cleave HA, and the fragments gen- retinoate induced increasing transepidermal
erated are more susceptible to subsequent water loss less than retinol, retinoic acid, and reti-
hyaluronidase cleavage than are the parent poly- naldehyde. Taken together, retinyl retinoate is
mers [13]. more effective on HA production and less of an
irritant than other retinoids. But the proper form
of Vitamin A for human oral consumption and
31.13 Stem Cells of Skin and the for maximal effect has still not been established.
Hyaluronan Connection Synergistic effects of hyaluronate fragments
occur in retinaldehyde-induced skin hyperpla-
Hyaluronan has a general effect of suppressing sia, which appears to be a CD44-dependent
differentiation. Hyaluronan suppresses epidermal phenomenon [6].
differentiation in organotypic cultures of rat kerati-
nocytes [40]. The concentration of HA is most
prominent in tissues undergoing rapid growth and 31.15 Corticosteroids and Skin
has been identified in the stem cell niche. Atrophy
Hyaluronan provides an environment for maintain-
ing the undifferentiated stem cell state, as well as Systemic corticosteroids induce skin dehydration
expansion of the stem cell population. Cells must and atrophy, as does topical applications. The par-
exit from this HA-rich environment in order to allel decrease with HA concentrations indicates a
undergo differentiation. The reservoir of stem cells cause and effect relationship, as confirmed in a
for skin occurs in the bulge regions of hair follicles. skin organ culture system [1]. Topical application
They exit the bulge and migrate to areas where skin of glucocorticoids causes a rapid reduction of der-
cell expansion and growth must occur [59]. One of mal HA, a phenomenon caused by suppressed HA
the unsolved mysteries in dermatology is the source synthase activity, without an effect on hyaluroni-
of skin stem cells in patients with alopecia areata. dase [18]. Glucocorticoids induce a nearly total
They appear to be spared in this disorder. inhibition of HAS2 mRNA in dermal fibroblasts,
the predominant HA synthase therein [4].

31.14 Retinoids
31.16 Estrogen Effects
The synthesis of HA in vitro can be stimulated
by several growth factors, including retinoids, The influence of estrogen on aging has been
dibutyryl cyclic adenosine monophosphate, and examined in many organ systems, but there is
peroxisome proliferator-activated receptor-a ago- surprisingly little information on the effect of
nists. The effect of retinyl retinoate, a novel estrogen on skin HA [50]. As the population ages,
retinol derivative, on HA expression, was exam- interest in skin moisture in postmenopausal
ined in primary human keratinocytes cultures and women grows proportionately, as does the effect
in hairless mouse epidermal skin. Histochemistry of estrogen on preventing skin aging.
31 Hyaluronan Inside and Outside of Skin 467

This estrogen effect is best exemplified by the 31.18 Applications of Hyaluronan

aging and drying of skin after menopause, when from Outside Skin
ovarian estrogen synthesis ceases. Women with
full figures have increased levels of estrogens in In cultured fibroblasts, exogenously added HA is
their fat stores. These act as estrogen slow-release incorporated into fine HA filaments of the peri-
capsules long after ovaries stop estrogen produc- cellular fibroblast matrix. This indicates that sol-
tion. This accounts in part for the moisture and uble HA facilitates assemble of a supramolecular
more youthful appearing skin of such women. pericellular structure [48]. Whether cross-linked
Another example of the natural estrogen effect HA has this property has not been established,
on skin is the sex skin of baboons. The increased nor whether injected stabilized HA can perform
redness and fullness of the female sex skin is such functions. It would also be important to
largely HA and its associated solvent water [7]. determine whether any topically applied HA to
From this, it is possible to extrapolate that the skin in vivo has this effect, whether it is size
fullness of the perineal skin of the sexually dependent, and whether any such materials can
aroused female primate is also based on HA. The permeate human skin.
fullness of the perilabial and perineal skin may
also serve the secondary purpose of holding on to
the male member more firmly. Direct experimen- 31.18.1 Cross-Linked Hyaluronan
tal evidence also comes from observations that and Injectable Fillers
HA synthase levels are induced by estrogens in
mouse skin [60]. In its natural state, HA exhibits poor biomechani-
cal properties as a dermal filler. As a soluble
polymer, it is cleared rapidly when injected into
31.17 Vitamin C (Ascorbic Acid) normal skin. To provide the ability fill wrinkles in
skin, several chemical modifications have been
Vitamin C is added to many skin preparations employed. The two most common functional
that promise moisturizing effects, occurring groups that can be modified are the carboxylic
occasionally at very high concentrations. The acid and the hydroxyl alcohol moieties. Many
mechanisms of action behind such assurances are methods for cross-linking HA are available using
varied. Vitamin C has pronounced HA-stimulating these two reactive groups. Biomaterials have
effects in fibroblasts. The deposition of HA is been produced through modification of the car-
stimulated when Vitamin C is added to cultured boxyl acid group by esterification and through
fibroblasts. The most profound changes occur in the use of cross-linkers such as dialdehydes and
the compartmentalization of HA. The preponder- disulfides. The most commonly employed cross-
ance of the enhanced HA becomes cell layer linkers for dermal fillers are divinyl sulfone and
instead of being secreted into the medium [23, diglycidyl ethers (Restylane) and bis-epoxides.
27]. The chemical reactions catalyzed by ascor- The Restylane family of products is the first
bic acid that bind HA to cell or matrix compo- HA-derived materials to be approved by the FDA
nents are undefined. Derivatives of Vitamin C for skin injection.
and their analogs can function as hyaluronidase Additional injectable, long-lasting, resorb-
inhibitors, in particular l-ascorbic acid-6-hexade- able HA-modified fillers have recently become
canoate [9]. Some of the ability of Vitamin C to available, such as Juvderm Voluma,
enhance HA deposition may be attributed to its though the nature or number of the cross-links
inhibition of hyaluronidase activity. But its oxi- have not become available [15]. The manufac-
dizing activity, in the presence of divalent cations, turers claim it is a novel version of the usual
particularly iron and copper, complicates the role HA filers comprised of a homogenized gel that
of Vitamin C in HA metabolism. is not a gel-particle suspension. It uses a high
468 A. Wahby et al.

concentration of cross-links and manages to Administration of HA also suppresses tumor

retain a gelatinous texture. Interestingly, it has growth [36]. It would be essential that the turn-
been effective in the treatment of focal steroid over of such HA be measured in an experimental
atrophy [14]. animal system, accompanied by observations on
chain length. Whether the systemic administra-
tion of HA can enhance skin hydration to any
31.18.2 Topical Applications degree would be the next step.
of Hyaluronan

A new HylaSponge system promises to be an 31.20 Oral Administration

effective treatment modality for moisturizing skin of Hyaluronan
[5, 41, 42]. Topical application of the HylaSponge
system enhances the moisture of underlying epi- The literature on the effects of orally adminis-
dermis and extends down into the upper layers of tered HA is vast, contradictory, and very con-
the dermis. A free radical polymerization process fusing. Chain lengths of the polymer used in
is used to cross-link high molecular weight HA such studies are often not provided. As docu-
polymers into a coil-coil system generating mented, this may be the source of much confu-
spheres of infinite size. These dry sponge-like sion. Controlled, prospective clinical trials are
spheres, applied to the skin, take on large volumes necessary with a need to demonstrate strict
of water that remain associated with the skin. The dose-dependent effects. It has not been estab-
nonhydrates spheres are 2050 mm in diameter lished whether HA survives oral administration
and grow typically to 400 800 mm spheres when and whether absorption through the small intes-
hydrated, the hydrated sphere being less than 1% tine takes place. And, whether skin moisture
HA, and the rest, water, i.e., the sponges, take on can be modified by oral HA is the critical
100 times their weight in water. The fully hydrated question.
sponges constitute an HA gel system that retains
moisture in intimate contact with the skin Conclusion
surface. Skin contains 50% of body HA. It is a major
A new potential for the application of HA to component of the ECM of skin, appearing in
skin has been initiated with studies on transder- epidermis, dermis, as well as in the basal
mal delivery of nanoparticles. Successful treat- lamina that lies between. Hyaluronan is also
ment of photo-damaged skin was accomplished observed intracellularly. This GAG plays an
using nanoscale retinoic acid particles in a novel important role in metabolism, cell turnover,
transdermal delivery system [63]. Whether differentiation, cell movement, tissue repair,
HA-coated nanoparticles can be used in a similar hydration, nutrient exchange, and protection
system to enhance skin moisture and overall against free radical damage. Its rapid turn-
appearance of aging and photo-damaged skin over suggests that it may also be important as
awaits further studies. a conduit for the removal of toxic materials.
It plays key roles in signal transduction path-
ways, an area of the literature that is so volu-
31.19 Systemic Administration minous that it could not be summarized in
of Hyaluronan the present communication. Native HA as
well as modified cross-linked HA has been
An interesting era of HA biology has begun, employed to help skin maintain and even
with the documentation that systemic adminis- regain elasticity, turgor, as well as moisture.
tration of HA can have system-wide effects. The literature on HA is growing rapidly.
Intraperitoneal injection of HMW HA stimu- Dermatology benefits disproportionately as
lates wound healing in diabetic mice [16]. new breakthroughs occur.
31 Hyaluronan Inside and Outside of Skin 469

References 13. Duan J, Kasper DL (2011) Oxidative depolymeriza-

tion of polysaccharides by reactive oxygen/nitrogen
species. Glycobiology 21(4):401409
1. Agren UM, Tammi M, Tammi R (1997) Hydrocortisone
14. Elliott L, Rashid RM, Colome M (2010) Hyaluronic
regulation of hyaluronan metabolism in human skin
acid filler for steroid atrophy. J Cosmet Dermatol 9:
organ culture. J Cell Physiol 164(2):240248
253255
2. Agren UM, Tammi RH, Tammi MI (1997) Reactive
15. Fischer TC (2010) A European evaluation of cosmetic
oxygen species contribute to epidermal hyaluronan
treatment of facial volume loss with Juvderm
catabolism in human skin organ culture. Free Radic
Voluma in patients previously treated with Restylane
Biol Med 23(7):9961001
SUB-Q. J Cosmet Dermatol 9(4):291296
3. Akazawa Y, Sayo T, Sugiyama Y, Sato T, Akimoto N,
16. Galeano M, Polito F, Bitto A, Irrera N, Campo GM,
Ito A, Inoue S (2011) Adiponectin resides in mouse
Avenoso A, Cal M, Cascio PL, Minutoli L, Barone
skin and upregulates hyaluronan synthesis in dermal
M, Squadrito F, Altavilla D (2011) Systemic adminis-
fibroblasts. Connect Tissue Res 52(4):322328
tration of high-molecular weight hyaluronan stimu-
4. Averbeck M, Gebhardt C, Anderegg U, Simon JC
lates wound healing in genetically diabetic mice.
(2010) Suppression of hyaluronan synthase 2 expres-
Biochim Biophys Acta 1812(7):752759
sion reflects the atrophogenic potential of glucocorti-
17. Gasingirwa MC, Thirion J, Mertens-Strijthagen J,
coids. Exp Dermatol 19(8):757759
Wattiaux-De Coninck S, Flamion B, Wattiaux R,
5. Balazs EA (1981) Hyaluronan-based composition and
Jadot M (2010) Endocytosis of hyaluronidase-1 by
cosmetic formulations containing same. US Patent
the liver. Biochem J 430(2):305313
#4,303,676
18. Gebhardt C, Averbeck M, Diedenhofen N, Willenberg
6. Barnes L, Tran C, Sorg O, Hotz R, Grand D, Carraux P,
A, Anderegg U, Sleeman JP, Simon JC (2010) Dermal
Didierjean L, Stamenkovic I, Saurat JH, Kaya G (2010)
hyaluronan is rapidly reduced by topical treatment
Synergistic effect of hyaluronate fragments in retinal-
with glucocorticoids. J Invest Dermatol 130(1):
dehyde-induced skin hyperplasia which is a CD44-
141149
dependent phenomenon. PLoS One 5(12):e14372
19. Gu H, Huang L, Wong YP, Burd A (2010) HA modula-
7. Bentley JP, Brenner RM, Linstedt AD, West NB,
tion of epidermal morphogenesis in an organotypic
Carlisle KS, Rokosova BC, MacDonald N (1986)
keratinocyte-fibroblast co-culture model. Exp Dermatol
Increased hyaluronate and collagen biosynthesis and
19(8):336339
fibroblast estrogen receptors in macaque sex skin.
20. Hargitai I, Hargittai M (2008) Molecular structure of
J Invest Dermatol 87(5):668673
hyaluronan: an introduction. Struct Chem 19:
8. Bertheim U, Engstrm-Laurent A, Hofer PA, Hallgren
697717
P, Asplund J, Hellstrm S (2002) Loss of hyaluronan
21. Haov M, Crhk T, Safrnkov B, Dvo kov J,
in the basement membrane zone of the skin correlates
Muthn T, Velebn V, Kubala L (2011) Hyaluronan
to the degree of stiff hands in diabetic patients. Acta
minimizes effects of UV irradiation on human kerati-
Derm Venereol 82(5):329334
nocytes. Arch Dermatol Res 303(4):277284
9. Botzki A, Rigden DJ, Braun S, Nukui M, Salmen S,
22. Heldin P, Karousou E, Bernert B, Porsch H, Nishitsuka
Hoechstetter J, Bernhardt G, Dove S, Jedrzejas MJ,
K, Skandalis SS (2008) Importance of hyaluronan-
Buschauer A (2004) L-ascorbic acid 6-hexadecano-
CD44 interactions in inflammation and tumorigenesis.
ate, a potent hyaluronidase inhibitor. X-ray structure
Connect Tissue Res 49(3):215218
and molecular modeling of enzyme-inhibitor com-
23. Huey G, Moiin A, Stern R (1990) Levels of [3H]glu-
plexes. J Biol Chem 279(44):4599045997
cosamine incorporation into hyaluronic acid by fibro-
10. Bourguignon LY, Singleton PA, Diedrich F, Stern R,
blasts is modulated by culture conditions. Matrix
Gilad E (2004) CD44 Interaction with
10(2):7583
Na + H + exchanger (NHE1) creates acidic microen-
24. Itano N, Sawai T, Yoshida M, Lenas P, Yamada Y,
vironments leading to hyaluronidase-2 and cathepsin
Imagawa M, Shinomura T, Hamaguchi M, Yoshida Y,
B activation and breast tumor cell invasion. J Biol
Ohnuki Y, Miyauchi S, Spicer AP, McDonald JA,
Chem 279(26):2699127007
Kimata K (1999) Three isoforms of mammalian
11. Dai G, Freudenberger T, Zipper P, Melchior A,
hyaluronan synthases have distinct enzymatic proper-
Grether-Beck S, Rabausch B, de Groot J, Twarock S,
ties. J Biol Chem 274(35):2508525092
Hanenberg H, Homey B, Krutmann J, Reifenberger J,
25. Jiang D, Liang J, Noble PW (2011) Hyaluronan as an
Fischer JW (2007) Chronic ultraviolet B irradiation
immune regulator in human diseases. Physiol Rev
causes loss of hyaluronic acid from mouse dermis
91(1):221264
because of down-regulation of hyaluronic acid syn-
26. Jokela TA, Lindgren A, Rilla K, Maytin E, Hascall
thases. Am J Pathol 171(5):14511461
VC, Tammi RH, Tammi MI (2008) Induction of
12. de la Motte C, Nigro J, Vasanji A, Rho H, Kessler S,
hyaluronan cables and monocyte adherence in epider-
Bandyopadhyay S, Danese S, Fiocchi C, Stern R
mal keratinocytes. Connect Tissue Res 49(3):115119
(2009) Platelet-derived hyaluronidase 2 cleaves
27. Kao J, Huey G, Kao R, Stern R (1990) Ascorbic acid
hyaluronan into fragments that trigger monocyte-
stimulates production of glycosaminoglycans in cul-
mediated production of proinflammatory cytokines.
tured fibroblasts. Exp Mol Pathol 53(1):110
Am J Pathol 174(6):22542264
470 A. Wahby et al.

28. Lamberg SI, Yuspa SH, Hascall VC (1986) Synthesis 44. Philipson LH, Westley J, Schwartz NB (1985) Effect
of hyaluronic acid is decreased and synthesis of proteo- of hyaluronidase treatment of intact cells on
glycans is increased when cultured mouse epidermal hyaluronate synthetase activity. Biochemistry 24(27):
cells differentiate. J Invest Dermatol 86(6):659667 78997906
29. Larnier C, Kerneur C, Robert L, Moczar M (1989) 45. Prusova A, Smejkolova D, Chytil M, Velebny V,
Effect of testicular hyaluronidase on hyaluronate syn- Kucerik J (2010) An alternative DSC (differential
thesis by human skin fibroblasts in culture. Biochim scanning colorimetry) approach to study the hydra-
Biophys Acta 1014(2):145152 tion of hyaluronan. Carbohydr Polym 52(2):498503
30. Lin W, Shuster S, Maibach HI, Stern R (1997) Patterns 46. Reed RK, Laurent UB, Fraser JR, Laurent TC
of hyaluronan staining are modified by fixation tech- (1990) Removal rate of [3H] hyaluronan injected sub-
niques. J Histochem Cytochem 45(8):11571163 cutaneously in rabbits. Am J Physiol 259(2 Pt 2):
31. Lundin A, Engstrm-Laurent A, Michalsson G, H532H535
Tengblad A (1987) High levels of hyaluronate in suc- 47. Reed RK, Lilja K, Laurent TC (1988) Hyaluronan in
tion blister fluid from active psoriatic lesions. Br J the rat with special reference to the skin. Acta Physiol
Dermatol 116(3):335340 Scand 134(3):405411
32. Meyer LJ, Stern R (1994) Age-dependent changes of 48. Rck K, Fischer K, Fischer JW (2010) Hyaluronan
hyaluronan in human skin. J Invest Dermatol 102(3): used for intradermal injections is incorporated into the
385389 pericellular matrix and promotes proliferation in
33. Mian N (1986) Analysis of cell-growth-phase-related human skin fibroblasts in vitro. Dermatology
variations in hyaluronate synthase activity of isolated 221:219228
plasma-membrane fractions of cultured human skin 49. Rck K, Grandoch M, Majora M, Krutmann J, Fischer
fibroblasts. Biochem J 237(2):333342 JW (2011) Collagen fragments inhibit hyaluronan
34. Mian N (1986) Characterization of a high-Mr plasma- synthesis in skin fibroblasts in response to UVB: new
membrane-bound protein and assessment of its role as insights into mechanisms of matrix remodelling.
a constituent of hyaluronate synthase complex. J Biol Chem 286(20):1826818276
Biochem J 237(2):343357 50. Shah MG, Maibach HI (2001) Estrogen and skin. An
35. Mio K, Stern R (2002) Inhibitors of the hyaluroni- overview. Am J Clin Dermatol 2(3):143150
dases. Matrix Biol 21(1):3137 51. Shearer J, Graham TE (2002) New perspectives on the
36. Mueller BM, Schraufstatter IU, Goncharova V, storage and organization of muscle glycogen. Can J
Povaliy T, DiScipio R, Khaldoyanidi SK (2010) Appl Physiol 27(2):179203
Hyaluronan inhibits postchemotherapy tumor 52. Stair S, Carlson KW, Shuster S, Wei ET, Stern R
regrowth in a colon carcinoma xenograft model. Mol (2002) Mystixin peptides reduce hyaluronan deposi-
Cancer Ther 9(11):30243032 tion and edema formation. Eur J Pharmacol
37. Nettelbladt O, Tengblad A, Hllgren R (1989) Lung 450(3):291296
accumulation of hyaluronan parallels pulmonary 53. Stern R, Asari AA, Sugahara KN (2006) Hyaluronan
edema in experimental alveolitis. Am J Physiol fragments: an information-rich system. Eur J Cell
257(6 Pt 1):L379L384 Biol 85(8):699715
38. Oh JH, Kim YK, Jung JY, Shin JE, Chung JH (2011) 54. Stern R, Shuster S, Wiley TS, Formby B (2001)
Changes in glycosamino-glycans and related proteo- Hyaluronidase can modulate expression of CD44.
glycans in intrinsically aged human skin in vivo. Exp Exp Cell Res 266(1):167176
Dermatol 20(5):454456 55. Stern R, Jedrzejas MJ (2006) Hyaluronidases: their
39. Oliferenko S, Paiha K, Harder T, Gerke V, Schwrzler genomics, structures, and mechanisms of action.
C, Schwarz H, Beug H, Gnthert U, Huber LA (1999) Chem Rev 106(3):818839
Analysis of CD44-containing lipid rafts: recruitment 56. Sugahara KN (2009) Hyaluronan fragments: informa-
of annexin II and stabilization by the actin cytoskele- tional polymers commandeered by cancers. In: Stern
ton. J Cell Biol 146(4):843854 R (ed) Hyaluronan in cancer biology. Academic, San
40. Passi A, Sadeghi P, Kawamura H, Anand S, Sato N, Diego, pp 221254. ISBN 9780123741783
White LE, Hascall VC, Maytin EV (2004) Hyaluronan 57. Tammi R, Smnen AM, Maibach HI, Tammi M
suppresses epidermal differentiation in organotypic (1991) Degradation of newly synthesized high molec-
cultures of rat keratinocytes. Exp Cell Res 296(2): ular mass hyaluronan in the epidermal and dermal
123134 compartments of human skin in organ culture. J Invest
41. Phillips GO, du Plessis TA, Al-Assaf S, Williams PA Dermatol 97(1):126130
(2003) US Patent #6,610,810 58. Tzellos TG, Klagas I, Vahtsevanos K, Triaridis S,
42. Phillips GO, du Plessis TA, Al-Assaf S, Williams PA Printza A, Kyrgidis A, Karakiulakis G, Zouboulis CC,
(2005) US Patent #6,841,644 Papakonstantinou E (2009) Extrinsic ageing in the
43. Philipson LH, Schwartz NB (1984) Subcellular local- human skin is associated with alterations in the
ization of hyaluronate synthetase in oligodendro- expression of hyaluronic acid and its metabolizing
glioma cells. J Biol Chem 259(8):50175023 enzymes. Exp Dermatol 18(12):10281035
31 Hyaluronan Inside and Outside of Skin 471

59. Underhill CB (1993) Hyaluronan is inversely corre- edema in experimental myocardial infarction. J Clin
lated with the expression of CD44 in the dermal con- Invest 88(5):16221628
densation of the embryonic hair follicle. J Invest 62. Weigel PH, Hascall VC, Tammi M (1997) Hyaluronan
Dermatol 101(6):820826 synthases. J Biol Chem 272(22):1399714000
60. Uzuka M, Nakajima K, Ohta S, Mori Y (1981) Induction 63. Yamaguchi Y, Nagasawa T, Nakamura N, Takenaga
of hyaluronic acid synthetase by estrogen in the mouse M, Mizoguchi M, Kawai S, Mizushima Y, Igarashi R
skin. Biochim Biophys Acta 673(4):387393 (2005) Successful treatment of photo-damaged skin
61. Waldenstrm A, Martinussen HJ, Gerdin B, Hllgren of nano-scale atRA particles using a novel transder-
R (1991) Accumulation of hyaluronan and tissue mal delivery. J Control Release 104(1):2940
 Glycerol as a Skin Barrier Inuencing
Humectant 32
Laurne Roussel, Nicolas Atrux-Tallau,
and Fabrice Pirot

Glycerol, also named glycerin, is found in many 32.1 Fundamentals About Glycerol
industries as nitroglycerin production in explo-
sives manufacture, as food preservative, sweet- Glycerol, etymologically from Greek word
ening agent, and solvent in food industries. Due sweet, also called glycerin (propane-1,2,3-
to its high hygroscopic and hyperosmotic pro- triol), is a natural compound found in living
perties, glycerol is widely used in cosmetic and organisms and extensively used in pharmaceuti-
pharmaceutical formulations (e.g., as laxative cal and cosmetic formulations. Main physico-
in suppositories, as brain edema treatment in chemical properties of glycerol are reported in
infusion, and mainly as humectant in topical Table 32.1. Glycerol has three hydrophilic
preparations). hydroxyl groups that are responsible for its
The glycerol physicochemical properties will hygroscopicity and excellent water solubility.
be defined as its synthesis, metabolism, and Glycerol can be dissolved easily into alcohols
medicinal uses. (e.g., ethanol and methanol) and water but not
In the skin, endogenous glycerol has been into oils. Glycerol is widely used as antimicrobial
identified. The understanding of its effects, preservative, emollient (i.e., having the power of
into the skin, is important to promote the glycerol softening or relaxing the skin), and humectant
cutaneous application. The properties of glycerol (i.e., water absorption tendency of a substance
will be defined to explain the role of glycerol in from the surroundings) (Table 32.2). Furthermore,
the skin. glycerol might be handled with many other sub-
stances. It is a product which is viscous, odorless,
and sweet-tasting fluid.
Glycerin is nontoxic to the environment and to
human health; it presents few side effects. It has
nonirritating effect when applied externally. It is
biocompatible and considered as a safe chemical
L. Roussel N. Atrux-Tallau F. Pirot () agent by the Food and Drug Administration.
Laboratoire de Recherche de Dveloppement de
Pharmacie Galnique Industrielle,
EA 4169 Lyon, France
32.2 Glycerol Production
Universit Lyon 1,
8 Avenue Rockefeller, 69373 Lyon Cedex 08, France
and Metabolism
Universit Claude Bernard Lyon,
Glycerin is produced either by hydrolysis or
Lyon, France
e-mail: [email protected]; saponification of oils or fats (Fig. 32.1).
[email protected]; [email protected] Alternatively, alcoholic fermentation of sugar

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 473

DOI 10.1007/978-3-642-27606-4_32, Springer-Verlag Berlin Heidelberg 2012
474 L. Roussel et al.

Table 32.1 Physicochemical properties of glycerol bloodstream. Serum glycerol concentrations

Physicochemical approximate 0.05 mmolL1 at rest and can
propertie Value increase up to 0.30 mmolL1 during increased
Chemical formula HO OH lipolysis [44]. Then, glycerol could be used for
OH gluconeogenesis in the liver.
Molecular weight 92.09 gmol1
Density 1.26 gcm3 at 25C
Boiling point 290C 32.3 Glycerol Therapeutic Uses
Melting point 17.8C
Surface tension 63.4 mNm1 at 20C Glycerol can be useful for the treatment of some
Dynamic viscosity at 5% aqueous solution (w/w): diseases. In fact, glycerol, as hyperosmolar agent,
20C 1.14 mPas
has been used in research settings in the short-
83% aqueous solution (w/w):
111 mPas term treatment of cerebral edema resulting from
Water solubility 1,000 gL1 at 20C ischemic stroke [42, 43]. Glycerols infusion has
Acetone solubility Slightly soluble at 20C become a standard practice for the management
Oil solubility Practically insoluble at 20C of head-injured patients with suspected or actual
Ethanol (95) and Soluble at 20C intracranial hypertension [10].
methanol solubility Glycerol ingestion with added fluid has been
Osmolarity 2.6% (v/v) aqueous solution used to create an osmotic gradient in the circula-
is isosmotic with serum
tion favoring fluid retention, thereby facilitating
pKa 14.4
hyperhydration. Thus, glycerol provides benefits
Log K (octanol/water) 1.98
Log Kp 8.27
during endurance exercise or exposure to warm
environments by inducing hyperhydration and
Adapted from [40]
Log K (octanol/water) is octanol/water partition, deter- rehydration [22].
mined by using ProLog software (ChemCAD, Obernai, Glycerol-preserved skin allografts (GPA) are
France) mainly used in the management of severe burn
Permeability coefficient of glycerol within the SC calculated
injuries, chronic ulcers, and complex, traumatic
as [39]: log Kp (cms1) = 6.3 + 0.71 log K 0.0061 MW
wounds. The selective and strategic use of
the GPA in major burn patients ensures optimal
Table 32.2 Uses of glycerol benefits in the management of burns [28].
Use Concentration (%) 50% Glycerol has been used for a long time as
Humectant 30 a viral preservation medium in tissue samples
Emollient 30 [53]. Preservation in 85% glycerol allowed to
Antimicrobial preservative <20 GPA to maintain its suppleness mandatory during
Adapted from [40] surgery.

gives glycerol, especially when the reaction is 32.4 Endogenous Glycerol Content
done in presence of sodium sulphite (Na2SO3). into the Skin
Industrial production is based essentially on dif-
ferent reactions from propylene (chlorination and Endogenous glycerol is actually known to be an
saponification) [16]. essential component to maintain stratum corneum
In living organisms, glycerol results from fat (SC) hydration. In humans, glycerol skin content
hydrolysis [27]. Lipolysis in adipocytes is acti- differs as a function of the body site. Onto the
vated during fasting or exercise for giving cheek, concentration is around 0.7 mgcm2 while
energy. A phosphorylated hormone-sensitive in the forearm, glycerol content reaches
lipase hydrolyzes triglycerides to free fatty acid 0.2 mgcm2. Glycerol content seems dependent
and glycerol, and both are released into the on the sebaceous gland density [54].
32 Glycerol as a Skin Barrier Influencing Humectant 475

Fig. 32.1 Synthesis of O

glycerol O R1
O O
O Hydrolysis
R2 + 3H2O HO OH + R OH
1
O OH
O
O R3 R2 OH
O
R3 OH
O
O R1
O O
Saponification
O R2 + 3 NaOH (or KOH) HO OH + R1 ONa
OH
O O
O R3 R2 ONa
O
R3 ONa

Glycerol is a byproduct of the triglycerides AQP3 synthesis appears to occur early in

lipolysis within pilosebaceous gland [33]. The basal cells with a predominant cytoplasmic dis-
lipolysis of triglycerides is more efficient within tribution, and the differentiation process could
the pilosebaceous apparatus than within the SC induce AQP3 translocation to the plasma mem-
[52]. In the SC, the level of triglycerides avail- brane [49].
able for lipolysis is low [47]. The importance of endogenous glycerol is now
It is also possible that there are sources of gly- established in the SC hydration. Glycerol belongs
cerol in SC other than those derived from seba- to the natural moisturizing factor (NMF).
ceous glands. Indeed, SC phospholipid catabolism The decrease of the endogenous glycerol in
generates a family of nonessential free fatty acids SC is correlated to a decrease in SC hydration
required for the barrier function which might [16, 18, 26]. Choi [13] confirmed that variation in
simultaneously generate glycerol in the SC inter- SC hydration is correlated with variations in both
stices. The glycerol is formed by the breakdown blood and sebaceous gland glycerol content.
of phospholipids by phospholipases [15]. In asebia mice [18], with a large depletion of
Glycerol diffuses from the dermis and is trans- sebaceous gland, the SC hydration was also
ported into basal cells of the epidermis through decreased. As well, the glycerol content in SC
aquaporin 3 (AQP3), a transmembrane water/ decreased by 83%. The addition of sebum-like lipids
glycerol transporting protein. Indeed, in AQP3 (triglycerides) did not restore the normal SC hydra-
knockout mice [25], deletion produced a signifi- tion while topical addition of glycerol did.
cant reduction in glycerol content in SC and epi- In AQP3 deficient mice, the glycerol content
dermis but not in dermis or blood. Therefore, decreased by 50% in the SC as compared to wild-
glycerol transport via AQP3 occurs solely across type mice and by 37% in the epidermis. Additional
the relatively glycerol-impermeable basal layer skin phenotype analysis highlighted a delayed
of epidermis in response to a steady-state dermal- barrier recovery after SC removal by tape strip-
to-epidermal glycerol gradient. ping in AQP3 null mice, as well as delayed wound
AQP3 is expressed in the innermost layer of healing [25].
keratinocytes in mammalian epidermis. By indi- Reduction in skin conductance in AQP3 null
rect immunofluorescence and electron micros- mice was not corrected by occlusion or exposure
copy gold labeling on human epidermis sections, to a humidified atmosphere, suggesting an intrin-
AQP3 was primarily and abundantly localized in sic defect in SC water-holding capacity (WHC).
plasma membrane of the keratinocytes in epider- Thus, the water transporting function of AQP3
mal human skin [49, 50]. did not appear to be responsible for the reduced
476 L. Roussel et al.

superficial skin conductance. However, when of the SC in a high proportion [35]. Indeed, in vivo
glycerol is topically added, the hydration defect determination of skin water content with a confo-
is corrected in AQP3 knockout mice [26]. cal Raman optical microprobe, revealed an
Glycerol improvement by topical routes increased increase of the water content after glycerol appli-
SC water content, with excellent correlation cation with no dependence on the SC depth [14].
between SC water and glycerol content in AQP3 Nevertheless, in guinea pig model, diglycerol
null mice. and triglycerol, with a higher humectant activity
The relationship between AQP3 and skin in vitro than glycerol, showed less effective action
disorders associated with abnormal water homo- on skin dryness improvement as compared to
eostasis (atopic dermatitis, psoriasis, xeroderma, glycerol [46]. The chemical properties deter-
and ichthyosis) needs to be investigated. mined in vitro could not be sufficient to predict
Modulation of AQP3 functions by different the molecule effect on SC hydration.
compounds could be interesting in activating the The SC water content in a healthy skin is around
water/glycerol transport from the dermis to the 2030% by weight [48]. The SC needs to be
basal layers of epidermis. An AQP3 upregulation hydrated to maintain its integrity. SC hydration
may increase SC water content and improve the variations can influence the SC barrier function [16].
barrier function. Glycerol prevents damaging effect on the SC.
Hara-Chikuma and Verkman [24] provided Glycerol pretreatment decreases irritancy caused by
evidence for involvement of AQP3-facilitated alkali solution (e.g., sodium hydroxide), dimethyl
water transport in epidermal cell migration and sulfoxide, and sodium lauryl sulphate (SLS) [16].
for AQP3-facilitated glycerol transport in epider- Glycerol leads to a more rapid reconstitution
mal cell proliferation during repair of skin of the protective skin barrier following mechani-
wounds. Pharmacological modulation of AQP3 cal (tape stripping) or chemical (repeated SLS
could be also therapy to accelerate wound hea- application, acetone) damage. It can absorb water
ling in traumas, burns, and other forms of injury. and thus creating water flux in the SC which may
lead to a stimulus for barrier repair [17]. In
Andersen et al. studies [13], only glycerol treat-
32.5 Effects of Cutaneous Exposure ment improved skin barrier recovery after acute
to Glycerol and cumulative irritations induced by SLS or
nonanoic acid applications in hairless guinea pig
Glycerol is widely used in different dermatologi- model and in human volunteers. The high hygro-
cal and cosmetic preparations. It acts as natural scopicity of glycerol can be involved in this action,
moisturizer and preserves the SC barrier func- supporting transepidermal water loss (TEWL)
tion. It also influences the skin surface mechani- and ion movement (especially calcium) [8].
cal properties by plasticizing SC and inducing In the case of aqueous solution, after SLS-
smoothing effect [9, 36] (by cell shrinking of the induced irritation on skin, it appears that glycerol
superficial corneocytes). It can also increase skin efficacy on hydration (evaluated by capacitance
elasticity [36]. measurement) and TEWL reached a plateau
It is actually known that the skin care benefits phase when enhancing glycerol concentration,
of glycerol are due to different properties of the resulting in a maximal WHC value [5]. The
compounds: attraction of moisture, maintenance recovery of the water barrier function with gly-
of crystallinity/fluidity of cell membranes and cerol by skin rehydration is thus saturable. The
intracellular lipids [31], keratolytic effect, and its WHC of stratum corneum is related to hygro-
ability to diffuse and penetrate into the SC [6]. scopic compounds and to SC osmotic pressure.
Glycerol is a hygroscopic compound, limiting The WHC and skin hydration were found to be
thus water evaporation and improving SC hydra- correlated with SC osmolality, varied as a func-
tion. Glycerol efficiency is also due to its capacity tion of the osmolality of solutions (Fig. 32.2),
to diffuse and accumulate in the entire thickness and the SC permeability of osmolytes [37, 38].
 32 Glycerol as a Skin Barrier Influencing Humectant 477

300 Thus, the proportion of lipophilic components

y = 3.99x 13.68, r = 0.975, p < 0.01
in solid state was noted in skin exhibiting SC bar-
250 rier damage [19].
Formamide Froebe et al. [19] showed, from an in vitro
SC osmolality (%)

200
experiment, that by glycerol adding to the SC
lipids, the transition of the lipophilic components
150
from the liquid crystalline phase to the solid
Urea
crystalline phase can be prevented at low relative
100
Glycerol humidity. It has been hypothesized that glycerol
50 Glucose
can interact with polar head groups of the lipid
Mannitol bilayers rather than by penetrating the alkyl
0
chains. Consequently, maintaining the fluidity
0 10 20 30 40 50 60 of the lipid membrane improves skin conditions
Osmotic pressure (atm)
in dry climates. Thus, glycerol decreases SC
Fig. 32.2 Linear relationship between DSC osmolality (%) permeability to water but enhances SC barrier
and the osmotic pressure (atm) of donor solutions. Each function.
data point is the mean standard deviation of 3 or 5 experi- Batt and Fairhurst [7] postulated that a depot
mental determinations [38]. = Mannitol, = Glucose,
= Glycerol, = Urea, = Formamide
formation of glycerol in the depth of the horny
layer lipids occurs because of glycerol persistent
effects after discontinuation of the therapy over
A low-dose topical application of glycerol 24 h. This would suggest that the effect on the SC
was shown to restore the water barrier func- lipids is present not only to the upper layers, but
tion of SLS-damaged skin. The beneficial also to the SC lipids deeper layers.
effect of glycerol on skin barrier function, dis- Glycerol-containing moisturizers continue to
rupted by acute chemical, acts throughout the improve barrier function for at least a week after
increase of WHC [5]. WHC reflects an equi- cessation of treatment [4].
librium between bound and free water deter- Furthermore, 10% glycerol addition in an
mined, respectively, by hydration measurement aqueous solution of SLS prevents the skin barrier
and TEWL. perturbation induced by the surfactant in vitro by
In normal SC, it is thought that the ratio of reducing the skin aqueous pore radius and the
lipids in ordered and disordered (liquid crystal- aqueous pore number density [20]. Glycerol pre-
line) phases modulates the SC barrier function sent in the SC is able to bind water in the SC and
properties [11]. thus reduce the mobility of water. In hydrated
The entity of the skin barrier is ensured by the skin, aqueous pores are constituted by lacunar
optimal organization and the interactions of the domains within water is mobile. The limited
SC components, i.e., corneocytes and the intercel- mobility of water may result in lacunar domains
lular lipids bilayers. The lipid bilayers disorgani- structural continuity loss within the SC extracel-
zation, rather than lipid extraction, is responsible lular lipid bilayers [34]. Ghosh et al. [20] sug-
for barrier impairment. gested that it may involve the reduction of the
A pure liquid crystal system, produced by an radius of the aqueous pore if the loss of continuity
all-unsaturated fatty acid mixture, allows a rapid is partial and the reduction of the aqueous pore
water loss through the bilayers with a moderate number density if the loss is complete. Moreover,
barrier action. The solid system produced with an the glycerol property to maintain the intercellular
all-saturated fatty acid mixture causes an extreme lipid mortar in liquid phase can also lead to mini-
water loss due to breaks in the solid crystal phase mize the lacunar domains and thus reduce the
[16]. Maintaining the balance between the two continuity of it.
phases is required for optimal barrier function in The glycerol-hydrating property occurs not only
preventing water loss [51]. on healthy skin but also on skin affected by xerosis.
478 L. Roussel et al.

The understanding of skin moisturization distur- emulsion [21, 23]. The quantity of absorbed
bances is of major importance for new treatment of humectant in the SC influences the glycerol mois-
pathologies such as atopic dermatitis, eczema. turization effect [35]. Furthermore, glycerol
Glycerol seems to be a relevant treatment in moisturizing efficiency depends on solvents in
atopic dermatitis (AD). However, Lodn et al. which it is dissolved. Therefore, glycerol acts as
[30] were not able to detect differences in the bio- an effective humectant only when it is dissolved
physical assessment of epidermal functions in a in water [45].
placebo-controlled AD study. Thirty days gly- Gloor [21] showed that the pretreatment with
cerin treatment versus placebo in atopic dermati- oil in water emulsions containing glycerol pre-
tis patient showed no differences in TEWL. vents dehydration, barrier perturbation, and irri-
Breternitz et al. [12] investigated lesional skin tation caused by washing with SLS. In the case of
of atopic patients and detected a positive (but not oil in water emulsions, the proportion of glycerol
significant) effect of glycerol for recovery of should not be less than 8.5%. However, glycerol
altered epidermal barrier function. Concerning high concentration application results in dehy-
hydration, glycerol cream has significant advan- dration of the skin because of the osmotic water
tages as compared to the glycerol-free formula- extraction from the SC caused by glycerol.
tion. The erythema values as a marker of skin However, in aqueous solution, glycerol con-
irritation or inflammation were slightly lower in centration must not exceed 5% to restore barrier
the group of patients treated with glycerol. function [5].
However, any significant differences were distin- In addition, it has been reported that glycerol
guished between the glycerol-based formulation facilitated skin penetration of topically applied
and glycerol-free formulation regarding improve- drugs [17, 29]. After tape stripping, glycerol
ment of epidermal barrier function, irritation could have penetration-enhancing effect mainly
parameters, surface pH, and clinical scores. by the glycerol action on SC lipid organization
The recent observation that xerotic skin is [8], whereas protective and curative effect against
associated with incomplete desmosome digestion irritants was reported [16].
suggests that moisturizers improve the desqua- Recently, glycerol-derived compounds have
mation process in such conditions. been identified and could be efficient as moisturi-
Glycerol seems to have keratolytic properties. zer treatment: Glycerol quat (dihydroxypropyltri-
After first week of glycerol treatment, an activa- monium chloride) is a combination of glycerin and
tion of SC protease activity occurs (simply by ele- a quat (i.e., a positively charged group of molecules
vated water activity). This protease is responsible attached to negatively charged skin proteins). Such
of the regulation of corneocytes desquamation, compound is less lipophilic (allowing it to remain
resulting in more efficient reduction in SC thick- at the outermost layers) and binds four times more
ness. The desmosome degradation is essential to water molecules than glycerol. The objective is to
maintain a healthy skin which requires an equilib- compensate glycerol poor moisturizing efficiency
rium between degradation and synthesis of desmo- at skin surface outermost layers [32].
some. Furthermore, glycerol desmolytic effect,
demonstrated by Rawlings et al. [41], causes a
decrease in intraepidermal pressure on the bila- Take Home Messages
mellar intercellular lipids and, therefore, indirectly Endogenous glycerol represents an
causes an increase in the liquid crystalline state interesting compound in the epidermis.
lipids. The dry skin scaliness is thus reduced, and It maintains the hydration properties of
the SC barrier is maintained in xerotic skin. the SC and thus the barrier function.
Investigations on the influence of the vehicle The AQP3 functions modulation by dif-
used showed that the beneficial effect of glycerol ferent compounds could be interesting
on skin was more pronounced in using oil in in order to activate the water/glycerol
water emulsion compared with water in oil
32 Glycerol as a Skin Barrier Influencing Humectant 479

7. Batt MD, Fairhust E (1986) Hydration of the stratum

transport from the dermis to the epider- corneum. Int J Cosmet Sci 8:253264
8. Bettinger J, Gloor M, Peter C et al (1998) Opposing
mis basal layers. effects of glycerol on the protective function of the
AQP3 expression pharmacological horny layer against irritants and on the penetration of
modulation could be benefit in a number hexyl nicotinate. Dermatology 197:1824
of skin disorders, burn repair, and other 9. Bettinger J, Gloor M, Vollert A et al (1999)
Comparison of different non-invasive test methods
wounds. with respect to the different moisturizers on skin. Skin
Glycerol, by its high hygroscopic pro- Res Technol 5:2127
perties, acts as a humectant. 10. Biestro A, Alberti R, Galli R et al (1997) Osmotherapy
Glycerol leads to maintain crystallinity/ for increased intracranial pressure: comparison
between mannitol and glycerol. Acta Neurochir
fluidity of cell membranes and intracel- (Wien) 139:725732; discussion 732723
lular lipids. 11. Boncheva M, Damien F, Normand V (2008) Molecular
Glycerol prevents damaging effect organization of the lipid matrix in intact Stratum cor-
induced by alkali, surfactant, and organic neum using ATR-FTIR spectroscopy. Biochim
Biophys Acta 1778:13441355
solvent on the SC. 12. Breternitz M, Kowatski D, Langenauer M et al (2008)
The recovery of the water barrier func- Placebo controlled, double blind, randomized prospec-
tion induced by glycerol after chemical tive study of a glycerol-based emollient on eczematous
damage can be explained by the skin in atopic dermatitis: biophysical and clinical eval-
uation. Skin Pharmacol Physiol 21:3945
improvement of WHC and skin hydra- 13. Choi EH, Man MQ, Wang FS et al (2005) Is endoge-
tion which are correlated with SC osmo- nous glycerol a determinant of stratum corneum
lality and the SC permeability of hydration in humans? J Invest Dermatol 125:
osmolytes. 288293
14. Chrit L, Bastien P, Sockalingum GD et al (2006) An
In xerotic skin, its keratolytic property in vivo randomized study of human skin moisturiza-
confers to glycerol the capacity to tion by a new confocal Raman fiber-optic microprobe:
improve skin barrier function and assessment of a glycerol-based hydration cream. Skin
decrease its scaliness. Pharmacol Physiol 19:207215
15. Feingold KR (2007) Thematic review series: skin lip-
ids. The role of epidermal lipids in cutaneous permea-
bility barrier homeostasis. J Lipid Res 48:25312546
16. Fluhr JW, Darlenski R, Surber C (2008) Glycerol and
References the skin: holistic approach to its origin and functions.
Br J Dermatol 159:2334
1. Andersen F, Hedegaard K, Fullerton A et al (2006) 17. Fluhr JW, Gloor M, Lehmann L et al (1999) Glycerol
The hairless guinea-pig as a model for treatment of accelerates recovery of barrier function in vivo. Acta
acute irritation in humans. Skin Res Technol Derm Venereol 79:418421
12:183189 18. Fluhr JW, Mao-Qiang M, Brown BE et al (2003)
2. Andersen F, Hedegaard K, Petersen TK et al (2006) Glycerol regulates stratum corneum hydration in
Anti-irritants I: doseresponse in acute irritation. sebaceous gland deficient (asebia) mice. J Invest
Contact Dermatitis 55:148154 Dermatol 120:728737
3. Andersen F, Hedegaard K, Petersen TK et al (2006) 19. Froebe CL, Simion AF, Ohlmeyer H et al (1990)
Anti-irritants II: efficacy against cumulative irritation. Prevention of stratum corneum lipid phase transitions
Contact Dermatitis 55:155159 in vitro by glycerol an alternative mechanism for
4. Appa Y, Hemingway L, Orth D et al (1997) High skin moisturization. J Soc Cosmet Chem 41:5165
glycerine therapeutic moisturizers. In: Poster pre- 20. Ghosh S, Blankschtein D (2007) The role of sodium
sented at the 55th annual meeting of the American dodecyl sulfate (SDS) micelles in inducing skin bar-
Academy of Dermatology, San Francisco, CA rier perturbation in the presence of glycerol. J Cosmet
5. Atrux-Tallau N, Romagny C, Padois K et al (2010) Sci 58:109133
Effects of glycerol on human skin damaged by acute 21. Gloor M (2004) How do dermatological vehicles
sodium lauryl sulphate treatment. Arch Dermatol Res influence the horny layer? Skin Pharmacol Physiol
302:435441 17:267273
6. Batt MD, Davis WB, Fairhurst E et al (1988) Changes 22. Goulet ED, Robergs RA, Labrecque S et al (2006)
in the physical-properties of the stratum-corneum fol- Effect of glycerol-induced hyperhydration on thermo-
lowing treatment with glycerol. J Soc Cosmet Chem regulatory and cardiovascular functions and endur-
39:367381 ance performance during prolonged cycling in a 25
480 L. Roussel et al.

degrees C environment. Appl Physiol Nutr Metab 38. Pirot F, Morel B, Peyrot G et al (2003) Effects of
31:101109 osmosis on water-holding capacity of stratum cor-
23. Grunewald AM, Lorenz J, Gloor M et al (1996) neum and skin hydration. Exog Dermatol 2:252257
Lipophilic irritants. Protective values of urea and 39. Potts RO, Guy RH (1992) Predicting skin permeabil-
glycerol containing oil in water emulsions. Dermatosen ity. Pharm Res 9:663669
44:8186 40. Price J (2005) Glycerin. In: Rowe RC, Sheskey P,
24. Hara-Chikuma M, Verkman AS (2008) Aquaporin-3 Owen SC (eds) Handbook of Pharmaceutical Exci-
facilitates epidermal cell migration and proliferation pients. Fifth edition, p 301303
during wound healing. J Mol Med 86:221231 41. Rawlings A, Harding C, Watkinson A et al (1995) The
25. Hara M, Ma T, Verkman AS (2002) Selectively effect of glycerol and humidity on desmosome degra-
reduced glycerol in skin of aquaporin-3-deficient mice dation in stratum corneum. Arch Dermatol Res
may account for impaired skin hydration, elasticity, 287:457464
and barrier recovery. J Biol Chem 277:4661646621 42. Righetti E, Celani MG, Cantisani T et al (2004)
26. Hara M, Verkman AS (2003) Glycerol replacement Glycerol for acute stroke. Cochrane Database Syst
corrects defective skin hydration, elasticity, and bar- Rev (2):CD000096
rier function in aquaporin-3 deficient mice. Proc Natl 43. Righetti E, Celani MG, Cantisani TA et al (2002)
Acad Sci USA 100:73607365 Glycerol for acute stroke: a cochrane systematic
27. Hibuse T, Maeda N, Nagasawa A et al (2006) review. J Neurol 249:445451
Aquaporins and glycerol metabolism. Biochim 44. Robergs RA, Griffin SE (1998) Glycerol. Biochemistry,
Biophys Acta 1758:10041011 pharmacokinetics and clinical and practical applica-
28. Khoo TL, Halim AS, Saad AZM et al (2010) The tions. Sports Med 26:145167
application of glycerol-preserved skin allograft in the 45. Sagiv AE, Dikstein S, Ingber A (2001) The efficiency
treatment of burn injuries: an analysis based on indi- of humectants as skin moisturizers in the presence of
cations. Burns 36:897904 oil. Skin Res Technol 7:3235
29. Kiwada H, Barichello JM, Yamakawa N et al (2008) 46. Sagiv AE, Marcus Y (2003) The connection between
Combined effect of liposomalization and addition of in vitro water uptake and in vivo skin moisturization.
glycerol on the transdermal delivery of isosorbide Skin Res Techol 9:306311
5-nitrate in rat skin. Int J Pharm 357:199205 47. Schurer NY, Plewig G, Elias PM (1991) Stratum-
30. Lodn M, Andersson AC, Andersson C et al (2001) corneum lipid function. Dermatologica 183:7794
Instrumental and dermatologist evaluation of the 48. Silva CL, Topgaard D, Kocherbitov V et al (2007)
effect of glycerine and urea on dry skin in atopic der- Stratum corneum hydration: phase transformations and
matitis. Skin Res Technol 7:209213 mobility in stratum corneum, extracted lipids and isolated
31. Lodn M, Maibach HI (2000) Dry skin and moistur- corneocytes. Biochim Biophys Acta 1768:26472659
izers: chemistry and function. CRC Press, Boca Raton 49. Sougrat R, Morand M, Gondran C et al (2002)
32. Lu N, Chandar P, Nole G et al (2010) Development Functional expression of AQP3 in human skin epider-
and clinical analysis of a novel humectant system of mis and reconstructed epidermis. J Invest Dermatol
glycerol, hydroxyethylurea, and glycerol quat. Cosmet 118:678685
Dermatol 23:8694 50. Sugiyama Y, Ota Y, Hara M et al (2001) Gene expres-
33. Marples RR, Kligman AM, Downing DT (1971) sion of the water channels, aquaporins, in human
Control of free fatty acids in human surface lipids by keratinocyte and skin-equivalent cultures, and osmotic
corynebacterium-acnes. J Invest Dermatol 56:127131 stress induction of aquaporin-3 mRNA in cultured
34. Menon GK, Elias PM (1997) Morphologic basis for a keratinocytes. J Invest Dermatol 117:410
pore-pathway in mammalian stratum corneum. Skin 51. Thau P (2002) Glycerin (glycerol): current insights
Pharmacol 10:235246 into the functional properties of a classic cosmetic
35. Okamoto T, Inoue H, Anzai S et al (1998) Skin- raw material. J Cosmet Sci 53:229236
moisturizing effect of polyols and their absorption into 52. Thody AJ, Shuster S (1989) Control and function of
human stratum corneum. J Cosmet Chem 49:5758 sebaceous glands. Physiol Rev 69:383416
36. Olsen OL, Jemec GBE (1993) The influence of water, 53. Vanbaare J, Buitenwerf J, Hoekstra MJ et al (1994)
glycerin, paraffin oil and ethanol on skin mechanics. Virucidal effect of glycerol as used in donor skin pres-
Acta Derm Venereol 73:404406 ervation. Burns 20:S77S80
37. Pirot F, Falson F, Pailler-Matti C et al (2004) Stratum 54. Yoneya T, Nishijima Y (1979) Determination of free
corneum: an ideal osmometer? Exog Dermatol glycerol on human skin surface. Biol Mass Spectrom
3:339349 6:191193
 The Use of Urea in the Treatment
of Dry Skin 33
Marie Lodn

33.1 Introduction This chapter will review the data on the

influence of urea on the skin. Folklore is rich in
Moisturizing creams contain a great variety of references to the healing properties of urea. The
ingredients. They also have different effects on Babylonians of about 800 bc are known to have
the skin structure and function. Their influence used it. In the beginning of this century, urea
on skin barrier function has become more impor- was employed in the treatment of infections,
tant after the findings that mutations in the filag- particularly those involving wounds and ulcers,
grin gene may weaken skin barrier function and the ears, tooth sockets, malignant growths and
cause eczema [1]. Mutations in the filaggrin gene of burns [8, 9]. This chapter will focus on more
have been identified as the major predisposing recent clinical findings, such as the effects on
factor for atopic eczema [1, 2]. Filaggrin forms dry skin disorders and the effects on barrier
the natural moisturizing factor (NMF) in the stra- function.
tum corneum and is essential during formation of
the cornified envelope of corneocytes [3, 4].
Individuals with mutations in the filaggrin gene 33.2 Chemistry
are more likely to report skin dryness [5].
Therefore, moisturizers that not only diminish Urea (carbamide, carbonyl diamide, CAS no.
the signs of dryness but also strengthen skin bar- 57-13-6, molecular weight 60.1) is a colourless
rier function are likely to reduce the prevalence or white, crystalline powder. Soluble 1 in 1.5 of
of inflammatory dermatosis [6, 7]. Thus, mea- water, 1 in 10 of alcohol and 1 in 1 of boiling
surement of skin barrier function may be a rele- alcohol, practically insoluble in chloroform and
vant surrogate parameter for the changed risks in ether. Solutions are neutral to litmus. Urea is
for eczema. readily incorporated in topical formulations by
virtue of its solubility. However, urea gradually
develops carbon dioxide and ammonia [10].
Unstable preparations may need to be stored in a
refrigerator.

33.3 Biochemistry
M. Lodn
Eviderm Institute AB, Research and Development,
Urea is a physiological substance occurring in
Bergshamra All 9,
SE-17077 Solna, Sweden human tissues, blood and urine [10]. The amount
e-mail: [email protected] in urine is of the order of 2%. The extraction of

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 481

DOI 10.1007/978-3-642-27606-4_33, Springer-Verlag Berlin Heidelberg 2012
482 M. Lodn

pure urea from urine was first accomplished by 120 p = 0.185 p = 0.541
Proust in 1821, and urea was first synthesized by
100
Whler in 1828 [11].

Thickness [m]
Urea is a major constituent of the water-solu- 80

ble fraction of the stratum corneum. It is present 60

there as a major component of NMF [12]. 40
Filaggrin is the main source of NMF, and the lev-
20
els of filaggrin degradation products are influ-
enced by both filaggrin genotype and atopic 0
Untreated Treated Untreated Treated
dermatitis severity [13]. In patients with atopic Stratum corneum Epidermis
dermatitis, the content of urea in the stratum cor-
neum is significantly reduced [14]. Fig. 33.1 Thickness of stratum corneum and epidermis in
untreated and in barrier-improved normal skin after treat-
Urea attracts water, and immersion of psori-
ment with 5% urea in a medicinal cream (Modified from
atic and ichthyotic scales in 5 M urea shows that Buraczewska et al. [31])
they will absorb 38% of water at 85% relative
humidity [15]. Furthermore, the water-holding
capacity of ichthyotic scales has been shown to there was no tendency for atrophy during this
increase from 9% to 18% by the treatment with a period [ 26, 27 ] .
urea cream (10%) for 3 weeks [16]. Reduction in epidermal DNA synthesis and
Urea can cause uncoiling of DNA, a property epidermal proliferation in psoriasis has also been
used in many DNA studies, but this in vitro activ- reported, measured as an altered expression of invo-
ity is not linked to any in vivo genotoxic activity lucrin and cytokeratins [28]. Involucrin is involved
[17]. Urea also unfolds proteins, thus solubiliz- in the assembly of the densely packed cornified cell
ing and/or denaturing them [9, 18, 19]. Pieces of envelope and functions as a scaffold for lipid and
upper epidermis kept in saturated urea solutions protein attachment. Decreased involucrin [29]
lose their original quaternary structure and expression and incomplete maturation of the corni-
change mechanically [18]. High concentrations fied envelope [30] are observed in atopics.
of urea (2040%) are used to detach dystrophic Treatment of normal skin with 5% urea in a
nails [20]. However, no changes in the binding medicinal cream has repeatedly been shown to
forces within the stratum corneum have been improve skin barrier function (see later part of
found after exposure of normal skin to 10% for this chapter). This improvement appears not to be
6 h [21]. The lipid matrix of the skin seems not to accompanied by significant changes in the thick-
be affected by urea since the transition tempera- ness of the stratum corneum or of the epidermis,
tures of mouse skin lipids was not changed by Fig. 33.1 [31]. Moreover, immunofluorescence
exposure to 12% urea [22]. Urea could also pro- staining of skin biopsies did not show any changes
tect against osmotic stress by replacing water in the protein expression of involucrin and trans-
and retaining the liquid crystalline phase at lower glutaminase, although a slight tendency of
humidity [23]. increased filaggrin level was noted (p = 0.07)
Treatment of hyperkeratotic skin with [31]. Furthermore, no changes in the mRNA
10% urea reduces the number of stratum cor- expression of genes involved in synthesis of invo-
neum cell layers [ 24, 25 ] . Urea influences lucrin, transglutaminase and filaggrin and in the
epidermal proliferation in healthy human genes involved in the process of desquamation
skin and in guinea pigs [ 26, 27 ] . After short- (SCCE and SCTE) were found [31]. Only cyclin-
term contact with a saturated urea solution, dependent kinase inhibitor 1A (also known as
incorporation of thymidine in DNA was p21, WAF1/CIP1) was slightly decreased [31].
reduced, and a thinning of the epidermis was The cyclin-dependent kinase inhibitor 1A modu-
found. After exposure to urea for more than lates cell cycle, apoptosis, senescence and
26 weeks, no further thinning occurred, and differentiation.
33 The Use of Urea in the Treatment of Dry Skin 483

33.4 Side Effects 33.5 Clinical Effects in Dry Skin

Disorders by Urea
Urea is a normal physiological metabolite and is
generally regarded as safe as used in topical prod-
ucts [17]. No report on sensitization has been The clinical efficacy of 410% urea in the treat-
found despite its wide use in dermatological ment of dry skin in patients with atopic dermatitis
preparations. In 1943, Rattner patch tested 500 is demonstrated in several studies, Table 33.1 [37,
hospital patients, 66 of whom had skin disease, 4346, 48, 49]. In a study on atopic dry skin, a 4%
with a 3% urea cream and found no adverse reac- urea formulation was superior to a glycerin-con-
tion [8]. Clinical and patient assessments of the taining cream to reduce clinical symptoms of dry-
use of creams with 10% urea or lower showed no ness [49]. A 10% urea cream produced improvement
evidence of inflammation and barrier damage of the xerosis and the pruritus, but somewhat less
[32], although occlusive exposure to 20% urea in of erythema compared to those of a base cream
petrolatum for 24 h causes significant inflamma- [37]. A 5% urea cream increased skin hydration
tion (i.e. increase in blood flow and skin thick- (measured as capacitance) [48] and showed similar
ness) and increases TEWL [33]. Despite these efficacy to a 4% urea cream in a double-blind study
studies, some patients reported disagreeable skin on 48 atopic patients [46]. The clinical and instru-
sensations from urea treatments, such as redness, mental assessment showed improvements in both
stinging and smarting [15, 32, 3438]. Application groups during the treatment period [46]. A water-
of urea to freshly excoriated areas and to skin in-oil emulsion with 10% urea induced signifi-
lesions can give burning sensations [39]. This is cantly higher skin capacitance than the
not irritation in the ordinary sense and usually corresponding placebo lotion [45]. Improvement
does not cause clinically noticeable damages to in clinical skin condition could be observed in par-
the skin, but the disagreeable sensations will allel to the increase in skin hydration [45].
reduce compliance, especially in children [11]. Several studies also support clinical efficacy
Furthermore, it may be difficult to treat sensitive of 10% urea in the treatment of psoriasis vulgaris
body areas, for example, the face, since stinging [15, 28, 44, 50] and ichthyosis [11, 15, 16, 34,
and other side effects from topical treatment are 44, 51, 52], Table 33.2. In the treatment of pso-
mainly perceived there [40, 41]. A recent study riasis, five psoriatic patients with chronic therapy-
suggests that urea affects cutaneous arterial sym- resistant lesions obtained soft and pliable skin
pathetic nerve activity and elevates blood flow after treatment with 10% urea, but no effect on
via histaminergic H3 receptor [42]. erythema was observed [15]. Psoriatic lesions on

Table 33.1 Treatment of atopic dermatitis with urea formulations

Design (number of patients) Conc. % Outcomes
Open, uncontrolled 5, 10 Urea formulations increase skin hydration [43]
Randomized, double-blind, bilateral (18) 10 No difference to aqueous cream [44]
Single-blind, placebo-controlled (20) 10 Clinical improvement, decreased TEWL [37]
Randomized, bilateral, double-blind, 10 Clinical improvement, increased hydration (capaci-
placebo (38) tance) [45]
Randomized, double-blind, parallel, 4, 5 Clinical improvements, no difference between
4% vs. 5% (48) products[46]
Randomized, double-blind, parallel, 5% 5, 10 Clinical improvement, no difference between
vs. 10% (100) products [47]
Bilateral, blind evaluation, untreated 5 Increased hydration (capacitance) reduced suscepti-
control (15) bility to sodium lauryl sulphate (SLS) [48]
Randomized, double-blind, parallel, vs. two 4 Clinical improvement, urea superior[49]
reference creams (109)
484 M. Lodn

Table 33.2 Treatment of psoriasis vulgaris and ichthyosis with urea formulations
Diagnosis Design (number of patients) Conc. % Outcomes
Psoriasis Open (5) 10 Softening effects [15]
Psoriasis Randomized, double-blind, 10 No difference to aqueous cream [44]
bilateral, vs. reference (4)
Psoriasis Randomized, bilateral (10) 10 Increased hydration compared to petrolatum [50]
Psoriasis Randomized, bilateral, 10 Clinical evaluation and capacitance measurement
double-blind, placebo (10) show superiority to placebo [28]
Ichthyosis Open, bilateral (7) 10 Improvement, better than control cream [15]
Ichthyosis Open, no control (17) 10 Improvement [11]
Ichthyosis Randomized, double-blind, 10 Better than other preparations [51]
parallel, vs. references (84)
Ichthyosis Randomized, double-blind, 10 No difference to aqueous cream [44]
bilateral, vs. reference (7)
Ichthyosis Randomized, double-blind, 10 Better than placebo [16]
bilateral (14)
Ichthyosis Randomized, double-blind, 10 Both creams effective, the one with pH 6 preferred to
bilateral, reference cream with the one with pH 3 [34]
10% urea (30)
Ichthyosis Randomized, double-blind, 10 Better than placebo [52]
bilateral (60)

the extremities also showed clinical improve- results showed a statistically significant
ment after treatment with an ointment containing improvement, although the patients assessment
10% urea in a placebo-controlled study on ten did not reveal any statistically significant dif-
patients [28]. Higher values of skin capacitance ference between the groups. Significant clinical
were noted on urea-treated areas. Increased improvement was also noted in 14 patients with
hygroscopicity and water content were also ichthyosis after treatment for 3 weeks with 10%
obtained after treatment with 10% urea ointment urea compared with treatment with the base
in patients with psoriasis vulgaris [50]. However, [16]. In another study, 60 children with ich-
early data from a clinical study on various types thyosis showed pronounced improvement in
of hyperkeratosis showed no superior effects the area treated with a 10% urea lotion com-
from a 10% urea cream compared to aqueous pared to the corresponding placebo-treated area
cream [44]. [52].Two preparations containing 10% urea
The efficacy of urea in the treatment of ich- tested on 30 patients with ichthyosis associated
thyosis has been investigated in several clinical with atopic dermatitis showed improved skin
studies. In seven patients with severe ichthyo- conditions equally well [34].
sis, a pronounced keratolytic effect was noticed Studies also show evidence for clinical effi-
after treatment with high concentrations (about cacy of 410% urea in hands, feet and legs of
10%) [15]. The number of stratum corneum elderly patients, Table 33.3. Creams containing
cell layers was reduced in 6 of 11 patients with 4% urea [38] or 10% [53, 54] were significantly
ichthyosis after treatment with 10% urea [24]. better than corresponding placebo in improving
In a double-blind trial on 84 outpatients with dry legs. Moreover, studies on hyperkeratosis in
ichthyosis vulgaris or X-linked ichthyosis, a feet support the use of urea (1040%). In volar
10% urea cream was better in controlling the forearms, creams with 3% and 10% urea improved
clinical signs of ichthyosis than three other the skin with respect to dryness characteristics
preparations (salicylic acid ointment, an oily [32]. In one of the first clinical studies on urea,
cream and another cream) [51]. The clinical published 1943, its effect on hand eczema was
33 The Use of Urea in the Treatment of Dry Skin 485

Table 33.3 Treatment of other types of dryness with urea formulations

Diagnosis Conc. % Design (number of individuals) Outcomes
Dry skin 3, 10 Randomized, blind evaluation, untreated Less scaling, improved hydration [32]
control (47)
Dry senescent skin 4 Randomized, double-blind, bilateral, Clinical improvement, urea cream
placebo-controlled (26) better than placebo [38]
Dry senescent skin 10 Randomized, double-blind, bilateral, Clinical improvement in both groups,
placebo-controlled (36 + 36) higher moisture values in active [53]
Dry senescent skin 10 Randomized, double-blind, bilateral, Differences in skin capacitance, not
placebo-controlled (60) clinically [54]
Dry senescent skin 4 Randomized, bilateral, Improved, no difference to reference
double-blind (23) cream without sodium chloride [55]
Hyperkeratosis feet 40 Randomized, bilateral, double-blind vs. More rapid effect from urea [56]
reference with 12% ammonium lactate (18)
Hyperkeratosis feet 10 Randomized, double-blind, bilateral (8) No difference to aqueous cream [44]
Hyperkeratosis feet 10 Randomized, bilateral, double-blind (40) Urea superior [57]
Hyperkeratosis feet 30 Randomized, bilateral, double-blind Urea superior to comparator [58]
Hyperkeratosis feet 10 Open (24) Decreased thickness [25]
Hyperkeratosis 30 Observational, prospective, open-label Significant improvement [59]
case study (10)
Dry hands 3 Bilateral, placebo (250) Urea cream better [8]
Dry hands 10 Randomized, double-blind, bilateral (18) No difference to aqueous cream [44]
Dry hands 10 Randomized, double-blind, bilateral, Both creams effective, the one with pH
reference cream with 10% urea (30) 6 preferred to the one with pH 3 [34]

investigated [8]. Two hundred and twenty-five 33.6 Combinations with

hospital personnel were given two jars of cream, Corticosteroids
one with 3% urea and one without urea, and were
requested to use one on each hand. Both the The beneficial effects of corticosteroids in
investigators and the patients experienced better inflammatory skin conditions are well known,
results with the urea cream, in that the skin but corticosteroids reduce barrier lipid synthesis
seemed softer, smoother and even whiter [8]. and the density of corneodesmosomes, which
Patches of slight dermatitis were reported to leads to an increased skin sensitivity and a weak-
improve by the application of urea cream [8]. ened cutaneous permeability barrier homeostasis
However, in a more recent clinical study from [6265]. Therefore, the combination of moistur-
1973, on cracked, chapped hands, the effect from izers with corticosteroids could be of clinical
a 10% urea cream was not superior to that of significance.
aqueous cream [44]. Urea has been studied in combination with
In other types of dryness diseases, 3% urea steroids. In a recent study on hand eczema, a
has been shown to reduce the incidence and larger clinical benefit was obtained when the
severity of radio-induced dermatitis, which is a morning application of betamethasone was
frequent side effect of radiotherapy. Intensive replaced by a 5% urea cream, i.e. once daily treat-
use of the lotion doubled the likelihood that ment with betamethasone combined with 5%
breast cancer patients will not developed radio- urea cream was superior to twice daily applica-
dermatitis during radiotherapy [60]. A urea/ tion of betamethasone [66]. This finding was
lactic acid-based topical keratolytic moistur- especially pronounced in the group of patients
izer did not prevent capecitabine-induced with moderate eczema at inclusion [66].
hand-foot syndrome in a double-blind, pla- The addition of 10% urea to a betamethasone
cebo-controlled trial [61]. cream also gave superior results compared to the
486 M. Lodn

steroid cream alone in subacute atopic eczema treatments. In vitro measurements on piglet
[67]. Moreover, treatment with a 10% urea cream- stratum corneum suggest that urea markedly
containing hydrocortisone has been shown to be decreases TEWL [77]. Studies on humans indi-
clinically better than treatment with other hydro- cate that treatment for a limited number of days
cortisone preparations in a single-blind and bilat- (1 to 2 days) with 510% urea may increase
eral study on 12 patients with atopic eczema [15]. TEWL, whereas longer treatment periods (10
All patients became more soft and smooth in the 20 days) decrease TEWL, Table 33.4 [37,
skin. A 4% urea cream in combination with 7981].
hydrocortisone was also superior to an ordinary Measurements of TEWL have also been com-
hydrocortisone cream in the treatment of dry bined with skin challenge by an irritant (sodium
eczema [38]. A combination of a 10% urea mois- lauryl sulphate, SLS) to elucidate possible
turizer and one hydrocortisone preparation with changes in susceptibility to irritation [80, 81].
10% urea was evaluated in an open, uncontrolled, These studies show that the irritant reaction after
multicenter study on 1,905 patients with atopic exposure to SLS was significantly lower after
dermatitis [35]. Over the 12-month observational urea treatment compared to the untreated skin
period, a total of 84% of the patients were [80, 81]. A decreased susceptibility to SLS was
exclusively treated with the two trial prepara- also noticed after three applications of both
tions, and only 16% required additional treatment 5% and 10% urea moisturizers, although this
with other corticosteroids. decrease in susceptibility was not accompanied
by a prior reduction in TEWL [80]. The improve-
ment in skin barrier function has been confirmed
33.7 Inuences on Normal Skin in a placebo-controlled study, where a signifi-
Barrier Function by Urea cantly lower TEWL and reduced susceptibility to
SLS were found in the urea-treated skin com-
Urea is easily absorbed into normal skin [14, 21] pared to the placebo-treated skin [83]. However,
and has been reported to promote the absorption no change in skin reactivity to nickel in sensitized
of different drugs, for example, hydrocortisone, individuals was found after 3-week treatment
triamcinolone acetonide, dithranol and retinoic with 5% urea [79].
acid [6873]. The penetration of ketoprofen Hence, evidence exists for lowering of TEWL
through isolated rat skin was also enhanced by and decreased susceptibility to SLS of 410%
the addition of urea [72]. Furthermore, it has been urea in normal skin, Table 33.4. Evidence for
shown that the time of onset of erythema, induced changed susceptibility to other noxious sub-
by hexyl nicotinate, is reduced by simultaneous stances is scarcer.
exposure to an oily cream-containing urea [71].
However, not all studies support the belief that
urea is an effective penetration promoter 33.8 Changes in Skin Barrier
[22, 7477]. For instance, the latency time to Function in Diseased and
induce erythema was not changed by 3-weeks Experimentally Damaged Skin
treatment with a moisturizer containing 5% urea
[78] or by pretreatment of forearm skin with an In several, but not in all studies on barrier dam-
aqueous solution of 10% urea [75]. Moreover, urea aged skin, urea has been shown to improve bar-
(10%) had a minimal effect on the penetration of rier function, Table 33.5. In ichthyotic skin,
hydrocortisone through excised human and guinea TEWL has been found to be slightly reduced by
pig skin [74]. Hydrocortisone acetate was even the application of 10% urea for 3 weeks [16].
retarded through hairless mouse skin with increas- Moreover, in patients with dry atopic skin, a 5%
ing concentrations of urea (up to 12%) [22]. urea cream has been found to reduce TEWL on
Measurement of TEWL is another way to the back of the hands [46] and also to make skin
study the effect on skin barrier function by various less susceptible to irritation by SLS [48]. In
 33

Table 33.4 Influence of urea treatment on skin barrier function in normal skin
No. of days of
Design (number of individuals) Conc. % treatment Marker of barrier function Outcomes
Randomized, untreated control, 5, cream 20 Time to erythema from hexyl nicotinate No difference [78]
blind evaluation (28)
Bilateral, water control (10) 10, solution One exposure Time to erythema from benzyl nicotinate No difference [75]
Not reported (20) 5, 10, cream Simultaneous exposure Time to erythema from hexyl nicotinate Shorter from 10% [71]
Randomized, untreated control, 5, cream 20 TEWL, nickel reactivity Reduced TEWL, no change in reactivity [79]
The Use of Urea in the Treatment of Dry Skin

blind evaluation (25)

Randomized, controlled, bilateral, 5, lotion 14 TEWL, Reduced TEWL and reduced reactivity [83]
double-blind vs. placebo (28) SLS reactivity
Randomized, untreated control, 10, cream 20 TEWL, SLS reactivity Reduced TEWL days 10 and 20. Reduced
blind evaluation (12) reactivity day 20 [80]
Randomized, untreated control, 10, gel 20 TEWL, SLS reactivity Reduced TEWL days 10 and 20. Reduced
blind evaluation (14) reactivity day 20 [80]
Randomized, untreated control, 5, cream 14 TEWL, SLS reactivity Reduced TEWL, reduced reactivity [81]
blind evaluation (13)
Randomized, double-blind (12) 5, gel 1,5 TEWL, SLS reactivity Reduced TEWL, reduced reactivity [80]
Randomized, double-blind (12) 10, gel 1,5 TEWL, SLS reactivity No change in TEWL, reduced reactivity [80]
Randomized, untreated control 5 49 TEWL, SLS reactivity Increased TEWL and reactivity [82]
Randomized 5 49 TEWL, SLS reactivity Decreased TEWL and reactivity [82]
487
488 M. Lodn

Table 33.5 Influence of urea treatment on skin barrier function in dry skin disorders
No. of days
Disorder Design (number of patients) Conc. % of treatment Outcomes
Psoriasis Randomized, double-blind, bilateral (10) 10 14 Decrease, not significant
[28]
Ichthyosis RCT, double-blind, bilateral (14) 10 21 Reduced TEWL [16]
Atopics Single-blind, placebo-controlled (14) 10 7 Reduced TEWL [37]
Atopic Randomized, parallel, double-blind, 4% 5 30 Reduced TEWL [46]
urea reference (48)
Atopic Randomized, parallel, three groups, 4 30 Reduced TEWL [49]
glycerin-controlled (109)
Atopic Randomized (22) 4 14 No change [84]
Dry skin Randomized, untreated control, bilateral 3, 10 21 No change from 3%, but
(23 + 24) 10% decreased [32]
Hyperkeratosis Randomized, double-blind, bilateral, vs. 40 14 No change in TEWL [56]
feet 12% ammonium lactate (25)

another double-blind study on atopic patients, a However, to our knowledge, there is only one
4% urea formulation was superior to a 20% glyc- clinical study available where the preventative
erin moisturizer in lowering TEWL [49]. Two effect on the recurrence of eczema in atopic
days treatment of atopic patients with 10% urea patients has been investigated [85]. In that study,
cream tended to increase TEWL, which then sig- the patients were instructed to use the 5% urea
nificantly decreased after 7 days of treatment cream at least twice daily or abstain from using
[37]. In dry skin of environmental origin, no any moisturizer after clearance of the eczema with
influence on TEWL was noted after treatment strong corticosteroid cream (betamethasone valer-
with a 3% urea cream, whereas TEWL decreased ate). The time until recurrence of eczema was then
in skin treated with 10% urea cream [32]. measured during a maximum period of 6 months.
In SLS-damaged skin, a 5% urea cream has Within a 6-month period, approximately 35% of
been shown to promote barrier recovery, mea- the cream-treated patients reported eczema,
sured as TEWL [81, 83]. Furthermore, in a pla- whereas twice as many obtained eczema in the
cebo-controlled study, it has been shown that untreated group during the same time period. The
urea was responsible for the accelerated barrier medium number of eczema-free days was more
recovery and decreased susceptibility to SLS than 180 in the cream group and 18 in the control
[83]. Twice daily exposures to SLS and treat- group. The probability of not having a relapse dur-
ment with a 5% urea cream for 15 days induced ing the 26-week period was 68% in the moisturizer
a slight but significant barrier damage, mea- group and 32% for those not using the moisturizer,
sured as TEWL, but the urea-treated sites which resulted in a 53% relative risk reduction and
appeared less damaged than the vehicle-treated 36% absolute risk reduction. Whether a similar
areas [83]. delay in the flare-up of eczema in atopics should
have been noted with a moisturizer without bar-
rier-improving properties has yet to be studied.
33.9 Prevention of Eczema The costs for the maintenance treatment with
the 5% urea cream have also been evaluated using
Atopic dermatitis affects health and quality of life a Markov simulation model. The results showed
and has great impact on both health-care costs and the maintenance treatment to be a cost-effective
costs to the society. Health-care professionals option compared with no treatment in eczema-
emphasize the use of moisturizers in treating free periods in adult patients with atopic dermati-
eczema, even when the eczema is cleared. tis in the four Nordic countries [86].
33 The Use of Urea in the Treatment of Dry Skin 489

In another clinical study, patients with hand

eczema prolonged the time to eczema relapse by Take Home Messages
the use of a urea-containing cream [87]. The A defect skin barrier function is considered
median time to relapse showed a tenfold differ- to be a critical exacerbant of dermatitis.
ence between the urea moisturizer and no treat- Moisturizing creams contain a great
ment (20 days vs. 2 days, respectively). The variety of ingredients and induce differ-
shorter time to relapse in the hand eczema patients ent types of effects on the skin structure
compared to the atopic patients was likely due to and function.
the higher vulnerability of hands, which are fre- The content of the humectant urea in the
quently exposed to external stressors. stratum corneum is decreased in certain
dry skin conditions.
Topically applied urea influences the
33.10 Discussion and Conclusion expression of enzymes in the skin and
the epidermal proliferation.
Clinical studies demonstrate beneficial effects of Urea has been reported to be a penetra-
urea-containing moisturizers in the treatment of tion enhancer but also to retard
dry skin conditions. Urea formulations are penetration.
effective for the symptomatic relief of psoriasis, A urea-containing moisturizer has been
ichthyosis, dry atopic skin and senescent skin. shown to prevent relapse of eczema in
Furthermore, evidence shows barrier-improving atopic patients and in those with hand
effects of urea in both normal and in dry skin dis- eczema.
orders (atopic skin, ichthyosis). Since the barrier The maintenance treatment with the
abnormality is considered a critical exacerbant of moisturizing cream during eczema-free
the dermatitis, urea-containing moisturizers may periods in patients with atopic dermati-
also reduce the prevalence of certain dermatitis tis has been found cost-effective com-
by strengthening of the skin barrier function. This pared with no treatment in the four
has also been proven in two clinical studies on a Nordic countries.
urea moisturizer, where the recurrence of eczema
was delayed by the treatment.
However, conflicting results have been reported
from clinical studies. These may be due to differ- References
ences in the compositions of the urea formula-
tions. Moisturizers show large variability in 1. Palmer CN et al (2006) Common loss-of-function
variants of the epidermal barrier protein filaggrin are a
compositions, and not only the concentration of major predisposing factor for atopic dermatitis. Nat
urea but also the types of emulsions and stabilizers Genet 38(4):441446
differ between moisturizers. For example, pH and 2. Weidinger S et al (2006) Loss-of-function variations
the formation of ammonia have to be taken into within the filaggrin gene predispose for atopic derma-
titis with allergic sensitizations. J Allergy Clin
account in urea-containing products. Moreover, Immunol 118(1):214219
the content of emulsifiers, lipids, chelators and 3. Rawlings AV, Harding CR (2004) Moisturization and
preservatives may influence the effect [88]. Failure skin barrier function. Dermatol Ther 17(Suppl
to strengthen the barrier is most likely due to the 1):4348
4. Candi E, Schmidt R, Melino G (2005) The cornified
impact on the skin from the other ingredients in envelope: a model of cell death in the skin. Nat Rev
the formulation. Mol Cell Biol 6(4):328340
Urea is a promising tool in the treatment of 5. Ginger RS et al (2005) Filaggrin repeat number poly-
dry skin disorders; however, more work is needed morphism is associated with a dry skin phenotype.
Arch Dermatol Res 297(6):235241
to fully understand the mechanisms for its effects 6. Taieb A (1999) Hypothesis: from epidermal barrier
and to optimize its efficiency on the skin barrier dysfunction to atopic disorders. Contact Dermatitis
function. 41(4):177180
490 M. Lodn

7. Elias PM, Wood LC, Feingold KR (1999) Epidermal 26. Wohlrab W, Schiemann S (1976) Investigations on the
pathogenesis of inflammatory dermatoses. Am J mechanism of the activity of urea upon the epidermis
Contact Dermat 10(3):119126 [authors transl]. Arch Dermatol Res 255(1):2330
8. Rattner H (1943) Use of urea in hand creams. Arch 27. Wohlrab W, Bohm W (1975) Reaction of epidermis
Dermatol Syph 48:4749 after long-term action of urea. Dermatologica
9. Ashton H, Frenk E, Stevenson CJ (1971) Therapeutics 151(3):149157
XIII. Urea as a topical agent. Br J Dermatol 84: 28. Hagemann I, Proksch E (1996) Topical treatment by
194196 urea reduces epidermal hyperproliferation and induces
10. Sweetman SC (ed) (2005) Martindale: the complete differentiation in psoriasis. Acta Derm Venereol Suppl
drug reference. Pharmaceutical Press, London (Stockh) 76:353356
11. Rosten M (1970) The treatment of ichthyosis and 29. Sugiura H et al (2005) Large-scale DNA microarray
hyperkeratotic conditions with urea. Australas J analysis of atopic skin lesions shows overexpression
Dermatol 11:142144 of an epidermal differentiation gene cluster in the
12. Jacobi OK (1959) Moisture regulation in the skin. alternative pathway and lack of protective gene
Drug Cosmet Ind 84:732812 expression in the cornified envelope. Br J Dermatol
13. Kezic S et al (2011) Levels of filaggrin degradation 152(1):146149
products are influenced by both filaggrin genotype 30. Hirao T et al (2003) Ratio of immature cornified
and atopic dermatitis severity. Allergy 66(7): envelopes does not correlate with parakeratosis in
934940 inflammatory skin disorders. Exp Dermatol 12(5):
14. Wellner K, Wohlrab W (1993) Quantitative evaluation 591601
of urea in stratum corneum of human skin. Arch 31. Buraczewska I, 2 et al (2009) Long-term treatment
Dermatol Res 285:239240 with moisturizers affects keratinocyte differentiation
15. Swanbeck G (1968) A new treatment of ichthyosis and desquamation on the mRNA level. Arch Dermatol
and other hyperkeratotic conditions. Acta Derm Res 301:175181 [Epub 2008 Oct 11]
Venereol Suppl (Stockh) 48:123127 32. Serup J (1992) A double-blind comparison of two
16. Grice K, Sattar H, Baker H (1973) Urea and retinoic creams containing urea as the active ingredient.
acid in ichthyosis and their effect on transepidermal Assessment of efficacy and side-effects by non-inva-
water loss and water holding capacity of stratum cor- sive techniques and a clinical scoring scheme. Acta
neum. Acta Derm Venereol Suppl (Stockh) 54: Derm Venereol 177:3443
114118 33. Agner T (1992) An experimental study of irritant
17. CIR Expert Panel. (2005) Final report of the safety effects of urea in different vehicles. Acta Derm
assessment of urea. Int J Toxicol 24(Suppl 3): 156 Venereol Suppl (Stockh) 177:4446
18. Hellgren L, Larsson K (1974) On the effect of urea on 34. Fredriksson T, Gip L (1975) Urea creams in the treat-
human epidermis. Dermatologica 149:8993 ment of dry skin and hand dermatitis. Int J Dermatol
19. Kunz D, Brassfield TS (1971) Hydration of macro- 32:442444
molecules. II. Effects of urea on protein hydration. 35. Burkard G, Schmitt S (1992) Langzeitstudie
Arch Biochem Biophys 142:660664 Neurodermitis-Therapie mit harnstoffhaltigen externa.
20. Farber EM, South DA (1978) Urea ointment in the Hautarzt 43:1317
nonsurgical avulsion of nail dystrophies. Cutis 22: 36. Lodn M, Andersson A-C, Lindberg M (1999) The
689692 effect of two urea-containing creams on dry, eczema-
21. Lodn M, Bostrom P, Kneczke M (1995) Distribution tous skin in atopic patients. II. Adverse effects.
and keratolytic effect of salicylic acid and urea in J Dermatolog Treat 10:171175
human skin. Skin Pharmacol 8(4):173178 37. Pigatto PD et al (1996) 10% urea cream (Laceran) for
22. Bentley MVLB et al (1997) The influence of lecithin atopic dermatitis: a clinical and laboratory evaluation.
and urea on the in vitro permeation of hydrocortisone J Dermatolog Treat 7:171175
acetate through skin from hairless mouse. Int J Pharm 38. Frithz A (1983) Investigation of Cortesal, a hydro-
146:255262 cortisone cream and its water-retaining cream base in
23. Costa-Balogh FO et al (2006) How small polar mole- the treatment of xerotic skin and dry eczemas. Curr
cules protect membrane systems against osmotic Ther Res 33:930935
stress: the urea-water-phospholipid system. J Phys 39. Gabard B, Nook T, Muller KH (1991) Tolerance of
Chem B 110(47):2384523852 the lesioned skin to dermatological formulations.
24. Blair C (1976) The action of a urea-lactic acid oint- J Appl Cosmetol 9:2530
ment in ichthyosis. With particular reference to the 40. Frosch PJ, Kligman AM (1977) A method for apprais-
thickness of the horny layer. Br J Dermatol 94: ing the stinging capacity of topically applied sub-
145153 stances. J Soc Cosmet Chem 28(28):197209
25. Borelli C et al (2011) Cream or foam in pedal skin 41. De Groot AC et al (1988) Adverse effects of cosmet-
care: towards the ideal vehicle for urea used against ics and toiletries: a retrospective study in the general
dry skin. Int J Cosmet Sci 33(1):3743 population. Int J Dermatol Sci 9:255259
33 The Use of Urea in the Treatment of Dry Skin 491

42. Horii Y et al (2011) Skin application of urea-contain- 57. Pham HT et al (2002) A prospective, randomized,
ing cream affected cutaneous arterial sympathetic controlled double-blind study of a moisturizer for
nerve activity, blood flow, and water evaporation. Skin xerosis of the feet in patients with diabetes. Ostomy
Res Technol 17(1):7581 Wound Manage 48(5):3036
43. Taube KM (1992) Moisture retaining effect and toler- 58. Sadick NS et al (2010) Efficacy and safety of a new
ance of urea-containing Externa in neurodermatitis topical keratolytic treatment for localized hyperkera-
patients. Hautarzt 43(Suppl 11):3032 [Article in tosis in adults. J Drugs Dermatol 9(12):15121517
German] 59. Goldstein JA, Gurge RM (2008) Treatment of hyperk-
44. Baillie ATK et al (1973) General practitioner research eratosis with Kerafoam emollient foam (30% urea) to
group. Carbamide in hyperkeratosis. Report no 179. assess effectiveness and safety within a clinical set-
Practitioner 210:294296 ting: a case study report. J Drugs Dermatol 7(2):
45. Bohnsack K et al (1997) Wirksamkeit auf das symp- 159162
tom trockene haut und langzeitvertrglichkeit von 60. Pardo Masferrer J et al (2010) Prophylaxis with a
Laceran lotion 10% urea bei patienten mit atopischem cream containing urea reduces the incidence and
ekzem. Z Hautkr 72:3439 severity of radio-induced dermatitis. Clin Transl
46. Andersson A-C, Lindberg M, Lodn M (1999) The Oncol 12(1):4348
effect of two urea-containing creams on dry, eczema- 61. Wolf SL et al (2010) Placebo-controlled trial to deter-
tous skin in atopic patients. I. Expert, patient and mine the effectiveness of a urea/lactic acid-based topi-
instrumental evaluation. J Dermatolog Treat 10: cal keratolytic agent for prevention of
165169 capecitabine-induced hand-foot syndrome: North
47. Bissonnette R et al (2010) A double-blind study of Central Cancer Treatment Group Study N05C5. J Clin
tolerance and efficacy of a new urea-containing mois- Oncol 28(35):51825187
turizer in patients with atopic dermatitis. J Cosmet 62. Demerjian M et al (2009) Activators of PPARs and
Dermatol 9(1):1621 LXR decrease the adverse effects of exogenous gluco-
48. Lodn M, Andersson A-C, Lindberg M (1999) corticoids on the epidermis. Exp Dermatol 18(7):
Improvement in skin barrier function in patients with 643649
atopic dermatitis after treatment with a moisturizing 63. Jensen JM et al (2009) Different effects of pimecroli-
cream (Canoderm). Br J Dermatol 140:264267 mus and betamethasone on the skin barrier in patients
49. Lodn M et al (2001) Instrumental and dermatologist with atopic dermatitis. J Allergy Clin Immunol 124(3
evaluation of the effect of glycerine and urea on dry Suppl 2):R19R28
skin in atopic dermatitis. Skin Res Technol 7(4): 64. Kao JS et al (2003) Short-term glucocorticoid treat-
209213 ment compromises both permeability barrier
50. Sasaki Y, Tadaki T, Tagami H (1989) The effects of a homeostasis and stratum corneum integrity: inhibi-
topical application of urea cream on the function of tion of epidermal lipid synthesis accounts for func-
pathological stratum corneum. Acta Dermatol Kyoto tional abnormalities. J Invest Dermatol 120(3):
84(1989):581 456464
51. Pope FM et al (1972) Out-patient treatment of ich- 65. Kolbe L et al (2001) Corticosteroid-induced atrophy
thyosis: a double-blind trial of ointments. Br J and barrier impairment measured by non-invasive
Dermatol 86:291296 methods in human skin. Skin Res Technol 7(2):
52. Kuster W et al (1998) Efficacy of urea therapy in chil- 7377
dren with ichthyosis. A multicenter randomized, pla- 66. Loden M et al (2011) The effect of a corticosteroid
cebo-controlled, double-blind, semilateral study. cream and a barrier-strengthening moisturizer in hand
Dermatology 196:217222 eczema. A double-blind, randomized, prospective,
53. Schlermann A et al (1999) Wirksamkeit und ver- parallel group clinical trial. J Eur Acad Dermatol
trglichkeit von Eucerin salbe 10% urea bei xero- Venereol. doi:10.1111/j.1468-3083.2011.04128.x
tischer altershau.: Ergebnisse einer [Epub ahead of print]
vehikel-kontrollierten klinischen doppelblindstudie. 67. Hindson MTC (1971) Urea in the topical treatment of
Z Hautkr 74:557562 atopic eczema. Arch Dermatol 104:284285
54. Schlermann A et al (1998) Efficacy and safety of 68. Wohlrab W (1990) The influence of urea on the pen-
Eucerin 10% urea lotion in the treatment of symptoms etration kinetics of vitamin-A-acid into human skin. Z
of aged skin. J Dermatolog Treat 9:175179 Hautkr 65:803805
55. Kuzmina N, Hagstromer L, Emtestam L (2002) Urea 69. Wohlrab W (1984) The influence of urea on the pen-
and sodium chloride in moisturisers for skin of the etration kinetics of topically applied corticosteroids.
elderly a comparative, double-blind, randomised study. Acta Derm Venereol 64(3):233238
Skin Pharmacol Appl Skin Physiol 15(3):166174 70. Wohlrab W (1989) Significance of urea in external
56. Ademola J et al (2002) Clinical evaluation of 40% therapy. Hautarzt 40(Suppl 9):3541
urea and 12% ammonium lactate in the treatment of 71. Beastall J et al (1986) The influence of urea on percu-
xerosis. Am J Clin Dermatol 3:217222 taneous absorption. Pharm Res 3:294297
492 M. Lodn

72. Kim CK et al (1993) Effect of fatty acids and urea on 82. Buraczewska I et al (2007) Changes in skin barrier
the penetration of ketoprofen through rat skin. Int J function following long-term treatment with moistur-
Pharm 99:109118 izers, a randomized controlled trial. Br J Dermatol
73. Allenby AC et al (1969) Mechanism of action of acce- 156(3):492498
lerants on skin penetration. Br J Dermatol 81(suppl 83. Lodn M et al (2004) The influence of urea treatment
4):4755 on skin susceptibility to surfactant-induced irritation:
74. Wahlberg JE, Swanbeck G (1973) The effect of urea a placebo-controlled and randomized study. Exogen
and lactic acid on the percutaneous absorption of Dermatol 3:16
hydrocortisone. Acta Derm Venereol 53(3): 84. Hagstrmer L, Nyrn M, Emtestam L (2001) Do urea
207210 and sodium chloride together increase the efficacy of
75. Lippold BC, Hackemuller D (1990) The influence of moisturizers for atopic dermatitis skin. A compara-
skin moisturizers on drug penetration in vivo. Int J tive, double-blind and randomised study. Skin
Pharm 61:205211 Pharmacol Appl Skin Physiol 14:2733
76. Stuttgen G (1989) Penetrationsfrderung lokal appli- 85. Wirn K et al. (2009) Treatment with a barrier-
zierter Wirkstoffe durch Harnstoff. Hautarzt 40(Suppl strengthening moisturizing cream delays relapse of
9):2731 atopic dermatitis. A prospective and randomized con-
77. McCallion R, Po ALW (1994) Modelling transepider- trolled clinical trial. JEADV, 23:12671272.
mal water loss under steady-state and non-steady-state 86. Hjalte F, Asseburg C, Tennvall GR (2010) Cost-
relative humidities. Int J Pharm 105:103112 effectiveness of a barrier-strengthening moisturizing
78. Duval D et al (2002) Differences among moisturizers cream as maintenance therapy vs. no treatment after
in affecting skin susceptibility to hexyl nicotinate, an initial steroid course in patients with atopic derma-
measured as time to increase skin blood flow. Skin titis in Sweden with model applications for Denmark,
Res Technol 8:15 Norway and Finland. J Eur Acad Dermatol Venereol
79. Kuzmina N et al (2004) Effects of pre-treatment an 24(4):474480
emollient containing urea on nickel allergic skin reac- 87. Loden M et al (2010) Treatment with a barrier-
tions. Acta Derm Venereol 84:14 strengthening moisturizer prevents relapse of hand-
80. Lodn M (1996) Urea-containing moisturizers influ- eczema. An open, randomized, prospective, parallel
ence barrier properties of normal skin. Arch Dermatol group study. Acta Derm Venereol 90(6):602606
Res 288(2):103107 88. Lodn M (2003) Role of topical emollients and mois-
81. Lodn M (1997) Barrier recovery and influence of turizers in the treatment of dry skin barrier disorders.
irritant stimuli in skin treated with a moisturizing Am J Clin Dermatol 4(11):771788
cream. Contact Dermatitis 36(5):256260
 Urea and Skin: A Well-Known
Molecule Revisited 34
Alessandra Marini, Jean Krutmann, and Susanne
Grether-Beck

34.1 The Importance of Urea propylene glycol, and glycerin. The chemical
in Topical Treatment and physical characteristics of the individual
ingredients determine the performance of the
Since topical treatment is fundamental to main- formulation and their influence on the superfi-
tain skin functions and to treat skin diseases, cial and deep layers of the skin [1]. Large differ-
many strategies have been developed to repair ences exist between the different moisturizers.
the barrier or prevent barrier dysfunction. Leite and coworkers [4] evaluate in vivo stratum
However, many patients overlook the impor- corneum hydration after treatment with different
tance of moisturizers considering them not real moisturizers presented in gel base. In this study,
treatments. Patient adherence and compliance urea, a herbal extract from Imperata cylindrical,
is a great challenge faced in the management of the components of the natural moisturizing fac-
skin diseases. Strong odor, low pH, and sensory tors, and carbohydrate derivate compound such
reactions may reduce patient acceptance [1]. as xylitylglucoside, anhydroxylitol, and xylitol
Urea has been used for over a century in topi- were used as active substances. The gel-con-
cal preparation to improve the surface proper- taining urea and the carbohydrate derivate com-
ties of human skin in strengths ranging from 3% pound gel promoted the most intense moisture
to 50% including cream, lotion, shampoo, gel, effect compared with the other formulations [4].
gel stick, wipe, emulsion, solution, suspension, Penetration of the moisturizers in the layers of
spray, ointment, paste, foam, and shower/bath the stratum corneum is also dependent on the
wash [2]. Side effects of urea are mild and may vehicle. The galenics play an important role, and
include cutaneous eruptions, stinging, irritation, an unbalanced composition can lead to poor
and allergic contact dermatitis [3]. In addition results [5]. Savica and coworkers [6] showed that
to urea, other humectants include amino acids, barrier-improving and hydrating abilities of urea
are bidirectional and dependent on the appropri-
ate vehicle and the state of skin. Moreover, if the
moisturizers are used in not appropriate quanti-
ties, they will have limited value. During the
years, a variety of studies have assessed the utility
A. Marini, M.D. J. Krutmann, M.D. ()
S. Grether-Beck, Ph.D. of urea in a variety of different formulations. In
IUF Leibniz Research Institute for Environmental addition, new vehicles have been developed to
Medicine at the Heinrich-Heine-University Dsseldorf, make urea more cosmetically acceptable.
Aufm Hennekamp 50, D-40225 Dsseldorf, Germany
Moreover, studies supporting the beneficial effects
e-mail: [email protected];
[email protected]; of urea have been performed. In a 3-h short-term
[email protected] test and in a 7-day long-term test, Taube [5]

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 493

DOI 10.1007/978-3-642-27606-4_34, Springer-Verlag Berlin Heidelberg 2012
494 A. Marini et al.

assessed the moisture level of the corneal layer Psoriasis

Eczema
and showed that urea in hydrous topical agents
Atopic dermatitis
ensures acceleration of corneal hydration and
Hand dermatitis
helps retain water in the corneal layer. A signifi-
cant increase in skin moisture and an improve- Urea
ment in skins smoothness after application of a Xerosis
urea-containing cream were noticed in a large
Seborrheic dermatitis
number of volunteers with healthy skin and in Dystrophic toenails
atopic dermatitis patients compared with untreated Onychomycotic nails
skin and with the placebo [7].Treatment of 25 Psoriatic nails
patients with moderate to severe xerosis shows Ingrown nails

that an improvement of the skin is achieved Fig. 34.1 Urea: a therapeutic agent for many skin disor-
quicker with 40% urea cream than with 12% ders. Urea has been shown useful in treating many skin
ammonium lactate lotion [8]. A 40% urea emul- diseases. Some of those are schematic summarized
sion in a vehicle system containing Butyrospermum
parkii fruit oil, Helianthus annuus oil, glycine as an extraordinary therapeutic agent for different
soja sterol, and stearic acid significantly improves skin disorders such as atopic dermatitis, psoriasis,
barrier function in the stratum corneum after tape and ichthyosis in a variety of formulations [16].
stripping [9]. Used in women presenting with a Corticosteroids represent the standard treatment
chronically dry, rough, thick, scaly skin, this prep- for a wide range of inflammatory and proliferative
aration decreased roughness, pigmentation, and dermatoses; urea is often added as important treat-
microtopography of the legs with no reports of ment adjunct. Stttgen used for the treatment of
side effects [10]. A 40% urea foam formulation 1,905 patients ranging from small children to
reduced the signs and symptoms associated with adults suffering from atopic dermatitis a combina-
dry skin [11]. Based on the patient assessment, tion of urea and hydrocortisone to treat acute
urea foam formulation increased acceptance and attacks and urea ointment for the chronic therapy
patients compliance because of the attributes: [17]. Eighty-four percent of the patients showed
creaminess, lack of oiliness, lack of stickiness, good to very good results. Urea is often added to
ease of rub in, and overall feel [12]. a variety of formulations to enhance their effects.
Emollients can damage the stratum corneum and
lead to desiccation and a disturbance of the barrier
34.2 Urea and Skin Diseases: [18]. The damaging effect of O/W emulsions,
Overview of Clinical Studies which dry the skin, can be reduced by the addition
of urea and glycerol [18].
Urea has been shown useful in treating many skin Urea has been used to treat hand dermatitis [19],
diseases (Fig. 34.1). Urea is a natural compound scalp seborrheic dermatitis [20], and psoriasis [21].
synthesized mainly in the liver serving to excrete Topical treatment by 10% urea significantly reduces
nitrogen via the kidneys. In addition, urea is also epidermal hyperproliferation and induces differen-
found in the outermost layer of skin as part of the tiation in plaque type psoriasis versus the vehicle
natural moisturizing factor consisting besides treatment in ten patients [21]. Kster [22] shows
urea of amino acids, their derivatives, lactic acid, that 10% urea lotion has a strong positive effect on
sugars, and pyrrolidone carboxylic acid [1315]. generalized ichthyotic keratinization disorders in
Healthy epidermis presents a concentration of childhood in a multicenter randomized, placebo-
urea of about 28 mg per square inch, while in controlled, double-blind, semilateral study. Acc-
xerotic skin the urea concentration is cut in half, ordingly, 60 children between 1 and 16 years were
in psoriatic and in actively atopic skin is decreased treated with 10% urea lotion over 8 weeks. The
by 40% and by 85%, respectively [2]. During the response rates were 65% after 4 weeks and 78%
years, a variety of studies have assessed the utility after 8 weeks for 10% urea lotion, 50% after
of urea as a moisturizer, keratinolytic product and 4 weeks and 72% after 8 weeks for the urea-free
34 Urea and Skin: A Well-Known Molecule Revisited 495

lotion base [22]. Topical urea is useful for the deb- research assessing the utility of urea. In summary,
ridement and promotion of normal healing of urea represents in the right concentration, quan-
hyperkeratotic surface lesions [2]. In a prospective, tity and vehicle an extraordinary therapeutic
randomized, controlled double-blind study, enroll- agent for skin disorders.
ing 40 patients a moisturizer for xerosis of the feet
in patients with diabetes was studied [23]. The
verum consisting of 10% urea and 4% lactic acid in 34.3 Molecular Approaches
patients with diabetes provided faster and better to Understand the Effects
improvement after 4 weeks of treatment. In addi- of Urea on Skin
tion, significantly less xerosis regression than its
emulsion base was determined after 2 weeks fol- It is widely assumed that urea acts by virtue of its
lowing discontinuation of the treatments [23]. capacity as a natural moisturizing factor [14, 30, 31].
Borelli [24] evaluated different urea-containing Recent findings, however, indicate that urea may
cosmetic preparations designed for foot care in dia- have more pronounced effects in the skin than
betic patients reporting that the cream vehicles previously considered. Accordingly, we have
would be the better choice compared to the foam shown that this well-known molecule possesses
formulation. The first study in which the potential gene regulatory activities and affects mRNA
of a moisturizer to prevent relapse of hand eczema expression of certain genes involved in keratino-
in patients with a controlled state of their eczema cyte differentiation which can be used to enhance
was addressed has been examined in 1943. Urea- barrier function and innate immunity of human
containing moisturizer was found to be superior to skin especially in patients suffering from atopic
a urea-free cream in inducing softer, smoother, and dermatitis [32].
even whiter hands in 225 hospital personnel [25]. According to the so-called brick and mortar
Since then, a large number of studies on the effi- model of permeability barrier in the stratum cor-
cacy of moisturizers in the treatment of dry skin neum, protein-enriched corneocytes are embed-
have been published. Wirn [26] demonstrated that ded in a continuous lipid-enriched, intercellular
maintenance treatment with a barrier-improving matrix [33]. The constantly renewing epidermis is
urea moisturizer on previous eczematous areas formed via a differentiation process where con-
reduced the risk of relapse to approximately one stantly dividing basal keratinocytes form asym-
third of that of no treatment. Recently, Lodn [27] metric daughter cells: one daughter cell retains
investigated the time to relapse of eczema during stem cell characteristics and one daughter cell
treatment with a barrier-strengthening moisturizer joins the pathway towards differentiation moving
(5% urea) in 53 randomized patients with success- from the basal layer at the innermost location to
fully treated hand eczema. In this study, application the stratum corneum at the outermost layer of the
of urea-containing moisturizer seems to prolong epidermis. During this process of differentiation,
the disease-free interval in patients with controlled the nucleus of keratinocytes degenerates and large
hand eczema [27]. keratin macromolecules align in parallel to the
Urea has been used in topical preparation in keratinocyte membrane and cross-linking enzymes
strengths ranging from 1% to 50%. In lower con- interconnect the various proteins to the cell mem-
centrations of 120%, urea acts as a humectant branes creating the so-called cornified envelope.
and has the most cosmetic benefits. In higher While differentiating, the cells change morphol-
concentrations, urea also has concentration- ogy from a small and round shape to a larger size
dependent keratolytic effects. Products with urea and even more dramatic change their metabolic
concentrations of 4050% often cannot be toler- activity. Genes encoding proteins being used for
ated by the bodies and serve as a debriding agent creation of the fully keratinized epidermissuch
in diseases such as dystrophic toenails, as involucrin, loricrin, filaggrin, and transglutami-
onychomycotic nails, psoriatic nails, and ingrown nase 1start to be expressed in the spinous layer
nails [2, 28, 29]. In this chapter, only a few stud- during this differentiation process [34]. Involucrin,
ies are mentioned despite the great variety of one of the earliest markers of terminal
496 A. Marini et al.

differentiation, serves as a scaffolding component enrolling 21 volunteers with healthy skin once
of the cornified envelope structure, which replaces daily during 4 weeks. Accordingly, 10% urea
as a complex protein-lipid composite the plasma treatment caused a significant upregulation of skin
membrane of terminally differentiated keratino- differentiation markers such as transglutaminase
cytes and originates from the cross-linkage of pre- 1, involucrin, filaggrin, and loricrin on the mRNA
cursor proteins including involucrin, small proline level versus untreated and, more importantly, ver-
rich proteins, and loricrin. Transglutaminase 1 sus vehicle-treated skin. In addition, a significant
serves as a membrane-bound keratinocyte specific increase of cathelicidin and b-defensin-2 mRNA
transglutaminase which is largely responsible for was observed in the same samples versus untreated
the cross-linking of involucrin and loricrin to form and vehicle-treated skin. Moreover, histochemical
the cornified envelope. analysis of the named markers on the protein level
Antimicrobial peptides such as LL-37 pro- and of total lipid content also indicated an increase
cessed from cathelicidin and b-defensin-2, which upon treatment with 10% urea as compared to the
are expressed in the outer layers of human epi- vehicle treatment. These changes on the molecu-
dermis and secreted into the stratum corneum lar level were determined on the buttock of the
interstices, are an evolutionarily conserved com- volunteers. Skin physiological parameters such as
ponent of the innate immune response. b-defensins the gold standard for barrier function that is tran-
are small cysteine-rich cationic proteins expressed sepidermal water loss were measured on the volar
by leucocytes and keratinocytes and can form forearm. While a 10% urea treatment only resulted
pore-like membrane defects in bacteria, fungi, in a slight decrease of transepidermal water loss, a
and many viruses. From this location in the stra- 20% urea treatment significantly diminished this
tum corneum interstices, they are positioned to parameter for skin barrier function.
interdict invading pathogens. Importantly, at least The mechanism underlying these gene
LL-37 is also necessary for normal permeability regulatory activities was found to be specific.
barrier function, demonstrating the convergence Urea-induced gene regulation was not due to a
of these two critical defense functions [33, 35]. urea-induced osmotic stress response [37, 38],
Urea appears to be a highly active substance; it but mediated by specific urea transporters [32].
stimulates epidermal differentiation and lipid syn- In many cells, exogenous urea is taken up by
thesis and increases the synthesis of antimicrobial specific urea transporters (UT). Two genes spe-
peptides in the epidermis which in turn helps to cific for these transporters have been identified
reinforce skins immune system [32]. Accordingly, in mammals, the renal UT-A (slc14a2) subfam-
in vitro stimulation of primary human epidermal ily, and the erythrocyte UT-B (slc14a1) family
keratinocytes with physiological doses of urea in [39], both expressing several isoforms. Grether-
the low millimolar range induced an increased Beck et al. showed that normal human kerati-
transcriptional expression of transglutaminase 1, nocytes take up urea via a specific mechanism
involucrin, filaggrin, and loricrin, i.e., genes, involving UTA1 and UTA2 and that urea uptake
which play an important role in keratinocyte dif- increased the expression of those urea transport-
ferentiation, and the antimicrobial peptides ers [32]. Hints that besides these urea transport-
b-defensin-2 and the LL-37 precursor cathelici- ers senso stricto, also other transporters might
din, which are expressed in the outer layers of the be involved in urea uptake in keratinocytes came
epidermis [36]. In addition, expression of enzymes from experiments where uptake of radio-labelled
involved in sphingolipid metabolism such as ser- urea could only be partially inhibited by classic
ine palmitoyltransferase and acidic sphingomy- inhibitors of urea uptake such as thiourea and
elinase, and also the rate-controlling enzyme of phloretin. In this context, we have to remind that
the cholesterol synthesis 3-hydroxy-3-methyl- urea can also be transported by a subgroup of
glutaryl-CoA reductase were found to be upregu- the water-transporting aquaporin family, the so-
lated. Essentially identical data were obtained if called aquaglyceroporins which can be inhibited
normal human skin was topically treated with by mercury or copper [40]. Accordingly, basal
urea in a vehicle-controlled, double-blinded study human keratinocytes express mainly UTA1,
34 Urea and Skin: A Well-Known Molecule Revisited 497

UTA2, and aquaglyceroporin 3, while expression hapten challenges was not able to reverse the
of aquaglyceroporins 7 and 9 plays only a minor expected decline in expression of antimicrobial
role [32]. Evidence for the functional relevance peptides, while 20% urea normalized cathelin-
of these transporters for urea-induced skin dif- related antimicrobial peptide and mouse
ferentiation and expression of antimicrobial pep- b-defensin-2 expression. In addition, 10% and
tides comes from inhibitor experiments where 20% urea significantly improved stratum cor-
urea-induced upregulation of skin differentiation neum hydration and barrier function assessed as
markers and antimicrobial peptides was assessed transepidermal water loss [36].
in the presence of thiourea, phloretin, mercury, or As already mentioned before, the urea content
copper. Interestingly, urea-induced upregulation in the stratum corneum is significantly decreased
of the skin differentiation markers transglutami- in patients suffering from atopic dermatitis
nase 1, involucrin, filaggrin, and loricrin could [2, 43]. An indirect approach to overcome this
completely be inhibited by thiourea or phloretin deficit was performed by Haustein and colleagues
but only partially by mercury and copper. In con- in a placebo-controlled, blinded study [43]. They
trast, urea-induced mRNA expression of cathe- treated 16 patients with chronic atopic eczema
licidin or b-defensin-2 was decreased by about with either 2.5% arginine hydrochloride or the
50% no matter which of the named inhibitors has corresponding vehicle and compared urea con-
been employed [36]. tent in stratum corneum, hydration, and transepi-
Involucrin and loricrin mRNA and protein dermal water loss before and after a 4 weeks
expression are diminished in affected, but also in twice daily treatment [43]. The rationale for this
unaffected skin of atopic dermatitis patients [41]. study is based on the fact that keratinocytes
The observations from Grether-Beck provide a express an extrahepatic arginase, which allows
rational for the beneficial effects of urea treat- keratinocytes to synthesize urea themselves from
ment in atopic dermatitis and other skin diseases. l-arginine [44]. Accordingly, a transient but sig-
Interestingly, filaggrin expression showed the nificant increase of urea content within the stra-
strongest upregulation upon urea treatment as tum corneum in arginine hydrochloride but not in
compared to transglutaminase 1, filaggrin, and vehicle-treated patients with atopic eczema was
loricrin [32]. Loss-of-function mutations in the observed. With regard to hydration and transepi-
profilaggrin gene are associated with ichthyosis dermal water loss, verum treatment reached a
vulgaris and atopic dermatitis [42]. Mildner significant increase already after 2 weeks, while
demonstrated that knockdown of filaggrin vehicle treatment did not reach significance prior
expression in an organotypic skin model repro- to 4 weeks.
duced epidermal alterations caused by filaggrin In addition, it might be of value to combine
mutations in vivo. Filaggrin-deficient skin mod- low doses of urea such as 5% with other actives to
els presented a loss of keratohyalin granules, improve skin physiology in patients suffering
impaired lamellar body formation, and a dis- from dry skin. Accordingly, we could demonstrate
turbed barrier function [42]. In order to address that the improved skin hydration and the decreased
whether urea might be helpful in atopic condi- transepidermal water loss obtained with a 5% urea
tions, this molecule has been topically applied oil-in-water cream could be significantly further
on a murine hairless mouse atopic dermatitis increased when ceramides and vitamins have been
model. In this model, atopic dermatitis-like der- added [45]. On a molecular level, both prepara-
matoses can be generated by nine to ten repeated tions caused in these 10 volunteers a significantly
oxazolone challenges resulting among others in increased expression of the genes encoding invo-
permeability barrier abnormality and a decrease lucrin, loricrin, and filaggrin [45].
in antimicrobial peptides such as murine cathe- The studies by Grether-Beck analyze the
lin-related antimicrobial peptide and mouse mechanism of action of urea from a new point of
b-defensin-2 (the murine homologues to human view and show that urea has more effects in the
cathelicidin and b-defensin-2) [36]. Interestingly, skin than previously thought. Its beneficial effects
concurrent treatment of mice with vehicle and are not only due to a passive role as moisturizers
498 A. Marini et al.

but also due to its capacity to modulate keratino- moisture, surface lipids, and transepidermal
cyte gene expression and in that way to actively water loss of atopic skin [50]. Following a single
improve the properties of human skin. The effects wash with either cleanser, low corneometry and
and the mechanisms of action of urea on the skin sebumetry values increased and elevated tran-
are complex and need to be further investigated sepidermal water loss values decreased. The
in future studies. changes gradually return to their starting points
The mechanistic effects discussed above pro- after more than 6 h, but those induced by the
vide a rationale for the described action that urea urea emulsion lasted significantly longer than
reduces transepidermal water loss, an effect those caused by the detergent cleanser [50].
which cannot be explained by urea acting as a Topical urea can be used successfully in a
natural moisturizing factor. variety of different preparations to improve the
Accordingly, 47 patients presenting with a barrier function of the skin, alone or in combina-
dry skin were treated over 3 weeks with 3% and tion. The application of the combination prepara-
10% urea cream. Both formulations were found tion containing urea, vitamins, and ceramides
efficient, resulting in improvement of hydration was significantly superior to the urea-only prepa-
and reduction of scaling. Of interest, in skin ration in respect to reduction of transepidermal
treated with 10% urea cream, the transepidermal water loss and skin hydration levels [45]. In
water loss decreased, indicating an improved Fig. 34.2, most of the beneficial effects observed
water barrier function [31]. In double-blinded after urea treatment are depicted.
studies, moisturizers with urea have been shown
to reduce transepidermal water loss in atopic and
ichthyotic patients and to make skin less suscep-
tible against irritation to sodium lauryl sulfate Skin
[1, 4648]. Lodn evaluated the influence of dif- Moisturization
ferent moisturizers on normal skin barrier prop-
Minimizes water loss
erties by measuring transepidermal water loss,
skin capacitance, and skin reactivity to the topi- Increases skin barrier function
cally applied surfactant, sodium lauryl sulfate
Urea Increases the hydration
[47]. Treatment with two urea-containing mois-
turizers decreased transepidermal water loss and Improves penetration of other
the irritant reactions after exposure to sodium skin care products
lauryl sulfate. Skin capacitance increased after Enchances innate immunity
three applications of urea-containing moisturiz-
ers and was still increased after 10 days, but not Stimulates epidermal
differentiation, lipid synthesis
after 20 days of this treatment [47]. Treatment and increases the synthesis of
for 20 days with two moisturizers without urea antimicrobial peptides
did not influence either transepidermal water
loss or the susceptibility to irritation from sodium
lauryl sulfate, but it increased the skin capaci-
tance significantly [47]. In 1999, 15 patients with Fig. 34.2 Beneficial effects of urea. Urea is a natural
atopic dermatitis were treated twice daily for moisturizing factor; creating a barrier that prevents tran-
sepidermal water loss urea helps to increase the hydration
20 days with a 5% urea cream. Skin capacitance
of the skin and the skin barrier function. Urea is a highly
and transepidermal water loss increased by the active substance; it possesses gene regulatory activities
treatment, and the skin susceptibility to sodium and affects mRNA expression of certain genes involved in
lauryl sulfate was significantly reduced [49]. A keratinocyte differentiation which can be used to enhance
barrier function and innate immunity of human skin. It
non-detergent urea emulsion cleanser and a
stimulates epidermal differentiation and lipid synthesis
detergent cleanser with added moisturizers were and increases the synthesis of antimicrobial peptides in the
compared for their effects on stratum corneum epidermis which helps reinforce skins immune system
34 Urea and Skin: A Well-Known Molecule Revisited 499

Conclusion
Urea is a humectant which attracts water to the Urea is a natural moisturizing factor;
skin and plays an important role in maintaining however, its beneficial effects are not
the epidermal water level. It has the capacity to exclusively due to this passive role.
serve as natural moisturizing factor of the stratum Recent findings indicate that urea may
corneum and to preserve its moisture. Creating a have more pronounced effects in the
barrier that prevents transepidermal water loss skin than previously considered.
urea helps to increase the hydration of the skin Urea is a highly active substance; it pos-
and the skin barrier function. The beneficial sesses gene regulatory activities and
effects are numerous, and the mechanisms of affects mRNA expression of certain
action only partly known. However, recent find- genes involved in keratinocyte differen-
ings provide a rational for the beneficial effects of tiation which can be used to enhance bar-
urea and indicate that its effects are not exclu- rier function and innate immunity of
sively due to a passive role as a moisturizer but to human skin especially in patients suffer-
specific gene regulatory activities which affect ing from atopic dermatitis. It stimulates
mRNA expression of certain genes involved in epidermal differentiation and lipid syn-
keratinocyte differentiation. These later effects thesis and increases the synthesis of anti-
can be used to enhance barrier function and innate microbial peptides in the epidermis which
immunity of human skin especially in patients helps reinforce skins immune system.
suffering from atopic dermatitis and other skin Urea-induced gene regulation is medi-
diseases. Accordingly, urea is much more than ated by specific urea transporters.
just a moisturizer; it is a highly active substance;
it stimulates epidermal differentiation and lipid
synthesis and increases the synthesis of antimi-
crobial peptides in the epidermis. These peptides Abbreviations
help to reinforce skins immune system and
improve barrier function even in normal skin. O/W emulsions Oil-in-water emulsions
Urea increased expression of the genes encoding UT Urea transporter
transglutaminase 1, involucrin, loricrin, and filag-
grin. This gene regulation is mediated by specific
urea transporters. Additional but not yet identi-
fied transporters could also be involved. The References
effects and the mechanisms of action of urea on
1. Loden M (2003) Role of topical emollients and mois-
the skin are complex; the signal pathways turizers in the treatment of dry skin barrier disorders.
involved in urea-induced changes in gene expres- Am J Clin Dermatol 4:771788
sion are currently still not completely known and 2. Scheinfeld NS (2010) Urea: a review of scientific and
clinical data. Skinmed 8:102106
need to be investigated in future studies; a further
3. Cramers M, Thormann J (1981) Skin reactions to a
understanding of the mechanisms involved may urea-containing cream. Contact Dermatitis 7:189191
help to fully exploit this extraordinary therapeutic 4. Leite e Silva VR, Schulman MA, Ferelli C, Gimenis JM,
agent for skin disorders. Ruas GW, Baby AR, Velasco MV, Taqueda ME,
Kaneko TM (2009) Hydrating effects of moisturizer
active compounds incorporated into hydrogels: in vivo
assessment and comparison between devices.
J Cosmet Dermatol 8:3239
Take Home Messages 5. Taube KM (1992) Moisture retaining effect and toler-
Urea is a humectant, a substance that ance of urea-containing Externa in neurodermatitis
patients. Hautarzt 43(Suppl 11):3032
attracts water to the skin and preserves 6. Savica S, Tamburic S, Savic M, Cekic N, Milic J, Vuleta
its moisture. G (2004) Vehicle-controlled effect of urea on normal
and SLS-irritated skin. Int J Pharm 271:269280
500 A. Marini et al.

7. Puschmann M, Gogoll K (1989) Improvement of skin 25. Rattner H (1943) Use of urea in hand creams. Arch
moisture and skin texture with urea therapy. Hautarzt Dermatol Syph 48:4749
40(Suppl 9):6770 26. Wiren K, Nohlgard C, Nyberg F, Holm L, Svensson
8. Ademola J, Frazier C, Kim SJ, Theaux C, Saudez X M, Johannesson A, Wallberg P, Berne B, Edlund F,
(2002) Clinical evaluation of 40% urea and 12% Loden M (2009) Treatment with a barrier-strengthen-
ammonium lactate in the treatment of xerosis. Am J ing moisturizing cream delays relapse of atopic der-
Clin Dermatol 3:217222 matitis: a prospective and randomized controlled
9. Rizer R, Elias P, Mills OH (2006) Urea (40%) in an clinical trial. J Eur Acad Dermatol Venereol
essential fatty acid vehicle improves barrier function 23:12671272
in the stratum corneum. J Am Acad Dermatol 54:602 27. Loden M, Wiren K, Smerud K, Meland N, Honnas H,
10. Kligman A, Stoudemayer S, Yaxian Zhen Y (2006) Mork G, Ltzow-Holm C, Funk J, Meding B (2010)
Improving chronically dry skin: clinical, patient, and Treatment with a barrier-strengthening moisturizer
laboratory evaluations. J Am Acad Dermatol 54:571 prevents relapse of hand-eczema. An open, random-
11. Bikowski J (2007) The treatment of xerosis with a ized, prospective, parallel group study. Acta Derm
new 40% urea foam. J Am Acad Dermatol 56:AB40 Venereol 90:602606
12. Gurge R (2007) Evaluation of the aesthetic attributes 28. Bonifaz A, Ibarra G (2000) Onychomycosis in chil-
of topical products containing high concentrations of dren: treatment with bifonazole-urea. Pediatr Dermatol
urea. J Am Acad Dermatol 56:AB45 17:310314
13. Jacobi OK (1959) Moisture regulation in the skin. 29. Niewerth M, Korting HC (1999) Management of ony-
Drug Cosmet Ind 84:732812 chomycoses. Drugs 58:283296
14. Jacobi OK (1970) The composition of normal human 30. Grice K, Sattar H, Baker H (1973) Urea and retinoic
stratum corneum and callus. 3. Lactic acid, creatine, acid in ichthyosis and their effect on transepidermal
creatinine, urea and choline. Arch Dermatol Forsch water loss and water holding capacity of stratum cor-
240:107118 neum. Acta Derm Venereol 53:114118
15. Loden M (1967) Natural moisturizing factors in skin. 31. Serup J (1992) A double-blind comparison of two
Am Perfum Cosmet 82:7779 creams containing urea as the active ingredient.
16. Loden M (2005) The clinical benefit of moisturizers. Assessment of efficacy and side-effects by non-inva-
J Eur Acad Dermatol Venereol 19:672688, quiz sive techniques and a clinical scoring scheme. Acta
686677 Derm Venereol Suppl (Stockh) 177:3443
17. Stttgen G (1992) Results and consequences of long- 32. Grether-Beck S, Felsner I, Brenden H, Reinhold K,
term urea therapy for clinical practice. Hautarzt Jaenicke T, Trullas C, Elias PM, Krutmann J (2009)
43(Suppl 11):912 Urea revisited: a well known molecule with previ-
18. Gloor M, Gehring W (2003) Effects of emulsions on ously unrecognized gene regulatory properties.
the stratum corneum barrier and hydration. Hautarzt J Invest Dermatol 129(S75):A449
54:324330 33. Elias PM (2007) The skin barrier as an innate immune
19. Fredriksson T, Gip L (1975) Urea creams in the treat- element. Semin Immunopathol 29:314
ment of dry skin and hand dermatitis. Int J Dermatol 34. Candi E, Schmidt R, Melino G (2005) The cornified
14:442444 envelope: a model of cell death in the skin. Nat Rev
20. Shemer A, Nathansohn N, Kaplan B, Weiss G, Mol Cell Biol 6:328340
Newman N, Trau H (2000) Treatment of scalp sebor- 35. Aberg KM, Man MQ, Gallo RL, Ganz T, Crumrine D,
rheic dermatitis and psoriasis with an ointment of 40% Brown BE, Choi EH, Kim DK, Schrder JM, Feingold
urea and 1% bifonazole. Int J Dermatol 39:532534 KR, Elias PM (2008) Co-regulation and interdepen-
21. Hagemann I, Proksch E (1996) Topical treatment by dence of the mammalian epidermal permeability and
urea reduces epidermal hyperproliferation and induces antimicrobial barriers. J Invest Dermatol 128:
differentiation in psoriasis. Acta Derm Venereol 917925
76:353356 36. Grether-Beck S, Felsner I, Brenden H, Kohne Z,
22. Kuster W, Bohnsack K, Rippke F, Upmeyer HJ, Groll Majora M, Marini A, Jaenicke J, Rodriguez-Martin M,
S, Traupe H (1998) Efficacy of urea therapy in chil- Trullas C, Hupe M, Elias PM, Krutmann J Urea uptake
dren with ichthyosis. A multicenter randomized, pla- enhances barrier function and antimicrobial defense in
cebo-controlled, double-blind, semilateral study. humans by regulating epidermal gene expression.
Dermatology 196:217222 J Invest Dermatol doi:10.1038/jid.2012.42
23. Pham HT, Exelbert L, Segal-Owens AC, Veves A 37. Rosette C, Karin M (1996) Ultraviolet light and
(2002) A prospective, randomized, controlled double- osmotic stress: activation of the JNK cascade through
blind study of a moisturizer for xerosis of the feet in multiple growth factor and cytokine receptors. Science
patients with diabetes. Ostomy Wound Manage 274:11941197
48:3036 38. Schliess F, Reinehr R, Haussinger D (2007)
24. Borelli C, Bielfeldt S, Borelli S, Schaller M, Korting Osmosensing and signaling in the regulation of mam-
HC (2011) Cream or foam in pedal skin care: towards malian cell function. FEBS J 274:57995803
the ideal vehicle for urea used against dry skin. Int J 39. Smith CP (2009) Mammalian urea transporters. Exp
Cosmet Sci 33:3743 Physiol 94:180185
34 Urea and Skin: A Well-Known Molecule Revisited 501

40. Rojek A, Praetorius J, Frokiaer J, Nielsen S, Fenton 46. Loden M, Andersson AC, Andersson C, Frodin T,
RA (2008) A current view of the mammalian Oman H, Lindberg M (2001) Instrumental and derma-
aquaglyceroporins. Annu Rev Physiol 70:301327 tologist evaluation of the effect of glycerine and urea
41. Kim BE, Leung DY, Boguniewicz M, Howell MD on dry skin in atopic dermatitis. Skin Res Technol
(2008) Loricrin and involucrin expression is down- 7:209213
regulated by Th2 cytokines through STAT-6. Clin 47. Loden M (1996) Urea-containing moisturizers influ-
Immunol 126:332337 ence barrier properties of normal skin. Arch Dermatol
42. Mildner M, Jin J, Eckhart L, Kezic S, Gruber F, Res 288:103107
Barresi C, Stremnitzer C, Buchberger M, Mlitz V, 48. Buraczewska I, Berne B, Lindberg M, Torma H,
Ballaun C, Sterniczky B, Fdinger D, Tschachler E Loden M (2007) Changes in skin barrier function fol-
(2010) Knockdown of filaggrin impairs diffusion bar- lowing long-term treatment with moisturizers, a ran-
rier function and increases UV sensitivity in a human domized controlled trial. Br J Dermatol 156:492498
skin model. J Invest Dermatol 130:22862294 49. Loden M, Andersson AC, Lindberg M (1999)
43. Nenoff P, Donaubauer K, Arndt T, Haustein UF (2004) Improvement in skin barrier function in patients with
Topically applied arginine hydrochloride. Effect on atopic dermatitis after treatment with a moisturizing
urea content of stratum corneum and skin hydration in cream (Canoderm). Br J Dermatol 140:264267
atopic eczema and skin aging. Hautarzt 55:5864 50. Rudolph R, Kownatzki E (2004) Corneometric, sebu-
44. Wohlrab J, Siemes C, Marsch WC (2002) The influ- metric and TEWL measurements following the clean-
ence of L-arginine on the regulation of epidermal argi- ing of atopic skin with a urea emulsion versus a
nase. Skin Pharmacol Appl Skin Physiol 15:4454 detergent cleanser. Contact Dermatitis 50:354358
45. Grether-Beck S, Muhlberg K, Brenden H, Krutmann J
(2008) Urea plus ceramides and vitamins: improving
the efficacy of a topical urea preparation by addition
of ceramides and vitamins. Hautarzt 59:717723
 The Inuence of Climate
on the Treatment of Dry Skin 35
with Moisturizer

C. Stick and E. Proksch

35.1 Introduction the skin. Also, artificial ventilation by air condi-

tion may lead to dry skin. Air condition may
The climate influences the development of dry lead to a pronounced skin drying because it
skin, and the treatment of dry skin must be reduces the water content of the air. This is a
adapted according to the climate. Therefore, it desirable effect in hot and wet climate, for
is important to know how the climate influences example, on the east cost of the USA in summer
the development of xerosis. It is well known time, but it may lead to problems in desert zones
that dry skin most often occurs during winter at like in the US southern mountain region (e.g., in
temperatures below freezing point. That means Phoenix) where the relative humidity is low.
that dry skin occurs more often in the colder
climate zones of the earth, well known from
northern Europe, northern states of the USA, 35.2 How Climate Can Cause
and Canada. Also, a high altitude predisposes to Dry Skin
dry skin, not only high in the mountains, but
also in the highland of Mexico. In the cold cli- To answer the question why skin becomes dry
mate zones in Europe, often people have the and rough, why lips become chapped under cer-
impression that indoor radiator heating leads to tain climate conditions, one need to know some
dry skin, whereas heating by an old fashion facts on air humidity on the one hand and on the
oven as was often used in private homes until properties of the skins stratum corneum physiol-
the 1970s was more pleasant to the skin. It is ogy on the other.
also known that strong winds lead to dryness of

35.3 Water in the Air, Evaporation,

and Condensation

Water is a constitutive component of the atmo-

sphere that is not only involved in the physical
processes, which make up weather and climate,
but also influences the skin.
Contrary to the constant fractions of nitrogen
C. Stick E. Proksch ()
Institute of Medical Climatology,
and oxygen in dry air, the water vapor content of
University of Kiel, Kiel, Germany air is highly variable. There are several measures
e-mail: [email protected] to quantify atmospheric moisture. With respect to

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 503

DOI 10.1007/978-3-642-27606-4_35, Springer-Verlag Berlin Heidelberg 2012
504 C. Stick and E. Proksch

the skin, however, the decisive ambient factor rough and cracked when relative humidity is
that acts on the hydration of the stratum corneum low. Shrinking of the corneocytes is an impor-
is relative humidity. tant feature of dry skin.

35.3.1 Changes in Relative Humidity 35.3.2 Relative Humidity and Dew

Cause the Horny Layer Point Are Related to Each Other
to Expand or Contract
Measurements of the relative humidity are fre-
The outermost layer of the skin, the stratum cor- quently used to quantify the content of water vapor
neum (horny layer), is in direct contact with the in the air. Why is it called relative humidity? Air
environment including the ambient air. The cannot absorb an unlimited quantity of moisture,
stratum corneum consists of protein-enriched but rather is saturated at some point. The maxi-
cells, the corneocytes, and a lipid-enriched mum water vapor content in the air is limited by
intercellular domain [1]. The hydrophobic inter- the so-called saturation or dew point. Once the dew
cellular lipid layer does not contain water. The point is reached, any surplus of water vapor will
corneocytes bind water by the so-called natural begin to condense into liquid water. The atmo-
moisturizing factors which are, however, not spheric relative humidity is always related to the
well characterized [2]. Parts of the natural mois- dew point.
turizing factors are the filaggrin break down To explain the situation of the skin under dif-
products pyrrolidone carbon acid and urocanic ferent climatic conditions and to define relative
acid which may have hygroscopic properties humidity, it is necessary to introduce another
[3]. The corneocytes and the entire stratum cor- quantity, namely, water vapor pressure. Let us
neum layer shrink and expand depending on the assume a closed vessel is partially filled with pure
environmental water content. It is well known water (cf. Fig. 35.1). The space above the water
that prolonged bathing or wearing occlusive may contain dry air at the beginning (Fig. 35.1a).
gloves for hours leads to swelling of the skin, With time, some water molecules will evaporate,
meaning the stratum corneum. Similar effects, that is, they will leave the liquid water and enter
less pronounced, occur in dry or humid ambient the gaseous phase. The evaporated water vapor
air. A water content of the stratum corneum of exerts a certain pressure, which is called vapor
<10% leads to dry skin [4]. Shrinking of the pressure. The more water is evaporated and con-
corneocytes is visible in very dry skin. It is well tained in a volume of gas, the higher is the vapor
known that in very dry skin on the lower legs, pressure (Fig. 35.1b). Net evaporation of water,
cracks occur called eczema craquele which however, will gradually be limited by the oppo-
resembles the cracking occurring in very dry site process: condensation of water vapor to liq-
soil [5, 6]. Shrinking of the corneocytes depends uid water. The more molecules are in the gaseous
on the relative humidity of the air. A hair, for phase, the more will change again into the liquid
example, grows if the relative humidity is high, phase. Eventually, a steady state between evapo-
while it shrinks if the atmospheric relative ration and condensation is reached. In this state
humidity is low. This property of the horny sub- of equilibrium, the air is saturated with water
stance is so pronounced that the change in the (Fig. 35.1c). The pressure of the water vapor at
length of hair serves as a sensor to measure the this dew point is called saturation pressure, which
relative humidity of the air. Instruments which cannot be exceeded at a given temperature.
use this principle are called hair hygrometers or The relative humidity is defined as a ratio
hygrographs [7]. Stratum corneum behaves in a of the actual vapor pressure in the air parcel to
similar manner. It shrinks and becomes dry, the saturated vapor pressure at the respective
35 The Influence of Climate on the Treatment of Dry Skin with Moisturizer 505

a Start b Transition stage c Steady state

Vapor pressure= 0 Vapor pressure =increasing Vapor pressure = saturation pressure

Fig. 35.1 (ac) Evaporation, saturation

60
100
temperature. It is usually expressed as a
90
Water vapor pressure (mmHg)

percentage 50
80

Relative humidity (%)

40 70
35.3.3 Saturation Pressure Is Strongly 60
Dependent upon Air 30 50
Temperature 40
20
30
The saturation pressure is not constant, but rather 20
10
strongly dependent upon temperature, meaning
10
that temperature determines the maximum quan-
0
tity of moisture the air can contain. The air can 10 0 10 20 30 40
hold much more water at higher temperatures Temperature (C)
than at lower temperatures. The graph shown in
Fig. 35.2 The function of saturation pressure, i.e., 100%
Fig. 35.2 illustrates this relationship: The x-axis relative humidity, on temperature (bold line). The family
represents the temperature in the range from 0C of curves below shows the relative humidity in intervals of
to 40C. The vapor pressure expressed in mmHg 10% [8]
is plotted on the left y-axis. The bold line (top
curve) shows the saturation pressure correspond-
ing to 100% relative humidity. This vapor The set of curves below the line showing the
pressure increases disproportionately with tem- saturation pressure indicates relative humidity in
perature. In the range between 10C and 50C, increments of 10%. So, in accordance with the
it roughly doubles with every 11C temperature definition of relative humidity, these curves
increase. express the ratio between the vapor pressure and
Beyond the borders of the range shown in the the saturation pressure in percent. For the sake of
diagram of Fig. 35.2, the vapor pressure would completeness, it should be noted that the curve
reach 760 mmHg at 100C, i.e., it would reach shown here applies to the saturation pressure
normal atmospheric pressure and water would above a flat surface of pure water or ice,
begin to boil. respectively.
506 C. Stick and E. Proksch

35.4 High and Low Relative Relative

Humidity at the Same Vapor 10
100% 50% 30% 20%
Pressure

Humidity
Water vapor pressure (mmHg)
8
Since in the moderate climates on mid-latitudes
dryness of skin prevails or aggravates during the
cold winter season, the situation may serve as 6
10%
examples.
In the wintertime when outdoor temperatures A B C
4
are about 0C or 1C, the indoor climate is typi-
cally characterized by a very low level of relative
humidity. This even holds true when the relative 2
humidity is extremely high outdoors with the air
at 90% relative humidity or even higher, for
0 0%
example. What are the reasons for this low rela- 0 5 10 15 20 25 30 35 40
tive humidity in indoor environments? The Temperature (C)
attempt to improve the situation by replacing
dry room air with moist air from outside Fig. 35.3 Dependence of saturation pressure and relative
humidity on temperature (enlarged detail from Fig. 35.2).
through ventilation can serve as a suitable sce- The vertical lines mark the temperatures at the outset
nario to explain the mechanisms at work. (point A) and the end of the scenarios assumed in the text
Figure 35.3 shows an enlarged detail of (point B: ambient temperature in a room and C: mean skin
Fig. 35.2. Let us assume the outdoor air tempera- temperature). Starting with an air temperature of 1C and
90% relative humidity (A), the broken, horizontal line
ture is 1C and the relative humidity 90%. At a shows that the 4.4 mmHg vapor pressure remains constant
temperature of 1C, the saturation pressure is when the cold air is heated. Due to the extreme increase in
4.9 mmHg. In such a scenario, a relative humid- saturation pressure with rising temperatures, this horizon-
ity of 90% would amount to an actual vapor pres- tal line reaches the range of low relative humidity
sure of 4.4 mmHg. If this outdoor air is heated up
to 22C in the indoor environment, for example, Ventilating rooms in cold, wintry conditions
the vapor pressure as the absolute measure of actually does lead to a lowered humidity in heated
water vapor contained in the air remains at a con- rooms. On the one hand, air containing little
stant 4.4 mmHg, because the air flowing into the moisture because of the low outdoor tempera-
room through the open window will neither gain tures despite the high relative humidity is trans-
nor lose moisture. The saturation pressure, on the ported into the room. On the other hand, water
other hand, which is related to the relative humid- vapor previously expelled indoors by plants and
ity, is approximately five times higher at a tem- humans or other sources like kitchens and bath-
perature of 22C than at 1C (cf. Fig. 35.2). If the rooms is removed through the exchange of air.
temperature is 22C, the saturation pressure is The described situation becomes all the more
19.9 mmHg. Set in relation to this value, a pres- pronounced, the greater the differences in indoor
sure of 4.4 mmHg amounts to merely 22%. So, and outdoor temperatures. In principle, this effect
the relative humidity of the outdoor air, which also applies when the outside temperatures are
still was 90% at 1C, is only 22% once it is heated below freezing (cf. Fig. 35.2). The saturation
up to room temperature. pressure above ice is even a little lower than
Given that the relative humidity of the air above liquid water.
plays a decisive role in the expansion or con- The scenario offers an explanation for the very
traction of the horny layer of the epidermis, as low humidity that generally prevails in the indoor
mentioned at the beginning, the conditions environment during wintertime. Not only does
described above can easily make the skin such low relative humidity affect the skin, which
become dry and rough. becomes dry and rough because its horny layer
35 The Influence of Climate on the Treatment of Dry Skin with Moisturizer 507

shrinks, it also has a detrimental effect on furni- drying of the skin. Very occlusive wraps like latex
ture, for example. (Dry cabin air that may cause gloves which nearly totally prevent water evapo-
discomfort to some people on long-haul flights ration may, however, lead to hyperhydration
can also be explained by this scenario.) which may irritate the skin together with the
mechanical forces between glove and skin [1].

35.5 Clothing and Ventilation

of the Boundary Layer Modify 35.6 Outdoor Climate Is a Personal
Skin Moisture Matter as Well

As far as the skin is concerned, at least two addi- We still need to clarify why our skin also becomes
tional factors modify the situation, even though dry when we are staying outside under cold and
they act in opposite directions. On the one hand, wintry conditions even if relative humidity is
skin temperature is normally higher than ambient quite high outdoors. Humans are only able to
room temperature. In thermal comfort conditions, spend longer periods of time outdoors if they
the mean skin temperature would be in the range wear clothing to increase thermal insulation so
between 33C and 34C. At this temperature, the that their mean skin temperature is in the neigh-
saturation pressure, which functions as the refer- borhood of 33C once again. At the same time,
ence value for relative humidity, stands at local skin temperatures, particularly in the periph-
3840 mmHg. In terms of the example given eral regions of the body, like hands, feet, ears, the
above, this would mean that relative humidity on nose, the face, etc., may be substantially lower.
the skin would be a mere 1112% (cf. Fig. 35.3, The skin temperature may also be slightly lower
point C). when an increased heat loss to the environment is
But another factor actually counteracts this compensated for by higher endogenous heat pro-
effect: There is an increased humidity very close duction. In a cold environment, people almost
to our skin due to the so-called perspiration insen- invariably generate such endogenous heat through
sibilis, i.e., imperceptible water evaporation from physical activity. And yet, the decrease in aver-
the skin, nowadays far better known as transepi- age skin surface temperature is relatively low
dermal water loss (TEWL). TEWL can easily under these various conditions. The resulting sit-
determined by using a measurement device like uation, therefore, is more or less similar to the
the Tewameter. It is well known that there are one described above: The cold air from the envi-
several inflammatory diseases with a high TEWL ronment, which does in fact have a high relative
[1, 9]. TEWL is a marker of the inside-outside humidity but low moisture content and hence low
barrier. It is well accepted that in eczema and in vapor pressure, is warmed up in the insulating
psoriasis, the disrupted skin barrier is of impor- layer of clothing by the heat produced by the
tance for the pathophysiology of these diseases body so that the temperatures reach app. 30C
[1, 9]. The transport of this water vapor is inhib- across many areas of the skin. The saturation
ited by our clothing. So in fact, relative humidity pressure is much higher at this temperature than
in the boundary layer, which is the thin air layer at the low temperatures of the cold outdoor air.
right in contact with the surface of the skin, actu- Consequently, the relative humidity of the skin
ally will not drop to the low levels calculated in decreases, and the horny layer shrinks and
our example and shown in Fig. 35.3. That means becomes cracked. As described above, the quan-
adequate clothing reduces the water loss and may tity of moisture evaporating from our skin is too
prevent dry skin. This may explain why we often low to increase the vapor pressure sufficiently to
have dry skin in areas of the body which are not prevent this effect from happening. In principal,
covered with clothes, the hands and the face. the scenario of ventilating a room and staying
Excessive water loss is also prevented by greasy outside under cold and wintry conditions resem-
ointments, and it is well known that this prevents bles each other.
508 C. Stick and E. Proksch

Factors like wind or clothing ventilation Under summer conditions, i.e., at tempera-
through physical activity, for example, let water tures of about 20C or 22C, the vapor pressure is
vapor escape from the boundary layer at the skin app. 10 mmHg even if relative humidity is only
surface causing the skin to become even drier. about 5060%. In many places in moderate cli-
mates, the mean vapor pressure approximates or
exceeds this value during the summer months.
35.7 Direct Exposure to Cold Compared to the conditions assumed for the win-
Air Means Double the Stress try scenario discussed above (1C, 90% relative
for Your Skin humidity, 4.4 mmHg), this represents more than a
twofold increase in vapor pressure, after all.
The skin temperatures of those parts of the body
that are directly exposed to cold air, such as the
hands or the face, may drop well below the aver- 35.8 Physiological Reactions
age skin temperature, meaning that the difference Intensify Itching
between this temperature and the ambient air
temperature is smaller than below the warming Let us discuss another observation. Many people
layer of clothing. On the other hand, clothing feel that dry skin is particularly bothersome
cannot fulfill its function of conserving moisture when they enter a warm room after having spent
in the boundary layer of the skin in these circum- a longer period of time out in the cold. Vapor
stances. Thus, it is precisely this combination of content and vapor pressure in the air do not
wind and low air temperature which lets the skin change very much, as was described above.
exposed directly to the elements become dry. However, the higher indoor temperatures bring
The water vapor produced by the skin is trans- about a reduction in relative humidity, leading
ported through the boundary layer by a process to the consequences we already discussed.
called diffusion. Diffusion flow rate depends on Moreover, a physiological reaction occurs that
the difference between the vapor pressure at the intensifies these effects considerably: Cutaneous
skin surface and the vapor pressure in the ambient circulation which was reduced in the cold envi-
air, and the thickness of the arrested air layer adja- ronment reacts to warm temperatures by increas-
cent to the skin. So, in terms of water vapor trans- ing dramatically. The skin becomes flushed and
port, relative humidity is not the decisive factor skin temperature rises. Increased blood flow and
but rather vapor pressure gradient between skin higher transcapillary filtration make the skin
and ambient air. Since vapor pressure is always plump up. The horny layer becomes dry and
comparatively low at cold outside temperatures, rough or cracked. In addition to the physical con-
the pressure gradients in the boundary layer are ditions, the physiological mechanism of reactive
steeper in cold environments, and thus the dis- hyperemia thus helps create a situation which
charge of water vapor from the skin is greater. intensifies itching.
Wind intensifies water vapor diffusion through All in all, one can state that with respect to the
convection. The air currents reduce the thickness skin, cold climate conditions always are dry
of the boundary layer of arrested air adjacent to conditions.
the skin, resulting in a steeper vapor pressure gra-
dient. Outside this boundary layer, water vapor is
transported by way of turbulent air currents. As a 35.9 Dry and Hot Climates: The
result, two mechanisms contribute to skin dry- Wind Makes the Skin Go Dry
ness under direct exposure to cold air: reduced
relative humidity due to the warming of the air In hot and dry climates, skin is typically be mois-
and increased water vapor diffusion because of turized by sweat that is secreted because of ther-
steep vapor pressure gradients between skin and moregulation demands. Strong winds, however,
ambient air. may dry the skin as well, because the air currents
35 The Influence of Climate on the Treatment of Dry Skin with Moisturizer 509

carry the moisture away and by thinning the

100%
boundary layer steepen the gradient of water 50 90%
vapor pressure. This will increase water loss from 80%

Water vapor pressire (mmHg)

the skin in particular on those areas that are 40 70%
unclothed and thus directly exposed to the dry
60%
and windy air. Wearing clothes in hot and dry
30
climate conditions, which protect against solar 50%
radiation in the first instance, may also be helpful B A 40%
in protecting the skin from excessive loss of 20
30%
moisture.
20%
10
C D 10%

0
35.10 Articial Indoor Climate 0 5 10 15 20 25 30 35 40
Temperature (C)

A more modern climate influence on the skin is Fig. 35.4 Schematic diagram showing how air is dried at
owed to the artificial cooling by air-conditioning the heat exchanger of an air-conditioning plant. Let be the
devices. Keeping in mind the explanation made temperature of the uncooled air 35C at 50% rel. humidity
(point A), as the air is cooled down, the water vapor pres-
above that heating cold air decreases the relative sure remains constant while the relative humidity increases
humidity lets the statement that cooling air can until the dew point is reached at point B. Continuing cool-
make air dry as well seem to be paradoxical. ing the air water vapor will condensate following the satu-
Indeed, looking at the diagrams of Figs. 35.2 and ration curve to point C. The condensation of water removes
moisture from the air and thus reduces the vapor pressure.
35.3, it becomes obvious that cooling humid air When the air is ventilated to the room and reheated to
will increase the relative humidity. The fact that ambient temperature, the relative humidity decreases
people staying in air-conditioned rooms never- (point D). Actually, the relative humidity in the room
theless often suffer from dry skin is due to techni- depends on the temperature at the heat exchanger of the
air-conditioning plant
cal reasons regarding the construction of the
air-conditioning devices. In order to cool a large
volume of air, let us say the air of a common hotel
room, by a small air conditioner, the temperature Typically the air is recirculated between the
of the heat exchanger has to be very low. Indeed, room and the air conditioner in order to reach the
the relative humidity increases as the air is cooled desired room temperature and to compensate for
down by the heat exchanger, which takes up the the heat produced by persons and electrical
heat of the air (cf. Fig. 35.4, points A and B). On devices being in the room and for the heat flow-
most occasions, the air will eventually reach the ing from the walls, the windows, and so on into
dew point when cooled down. In this case, satu- the air-conditioned room. This circulation will
rated vapor will condense at the surface of the not only keep the room cool but will also remove
heat exchanger. The condensed water drops from some moisture from the air in the room again and
the cooler and is collected and drained from the again. Finally, the relative humidity in an air-
air conditioner by a tube. This means that mois- conditioned room will mostly depend on the tem-
ture is removed from the air, and thus the vapor perature at the heat exchanger and the ambient
pressure is reduced (Fig. 35.4, points B and C). room temperature (Fig. 35.4, points C and D).
The water deprived air returning from the cooler Moreover, the air condition needs fans for
will be mixed with the air in the room and thus moving the air, which cause a draught of cool air.
reheated to a certain amount. This again reduces As mentioned above, air movement will increase
the relative humidity. In total, this means that the water loss of skin as well. All in all air-
both absolute and relative humidity are lowered conditioning can have unpleasant and adverse
by the process of cooling the air. effects by drying the skin.
510 C. Stick and E. Proksch

35.11 Water Helps Dry Your Skin legs and arms, greasy ointments can be applied.
Under extreme weather conditions, greasy, water-
So how can one protect the skin from this loss of free ointments like petrolatum or a mixture of dif-
moisture? Examples that point to the need and the ferent hydrocarbons can be used on the extremities.
possibility of skin protection actually seem to be These ointments even can be used in the face to
somewhat paradoxical at first glance: Many peo- protect against harsh water conditions in windy
ple are quite familiar with the wintertime phe- and in very cold weather at temperature well below
nomenon that their skin starts to itch right after an freezing temperature. A cream with high water
intense exposure to water, during a swim in the content would possibly lead to freezing on the
pool, a stay in the sauna or a long shower, etc., skin. On the other hand, at high temperature which
even though one would think that the skin has leads to sweating, an occlusive ointment hinders
become saturated with moisture on such occa- water evaporation and leads to an unpleasant feel-
sions. But in fact, the water is diffused very rap- ing. This may lead to irritation of the skin by hype-
idly from the horny layer and what is crucial in rhydration. Chronic use of greasy ointment in the
this connection is that this diffusion occurs espe- face, in particularly based on petrolatum, may also
cially fast because intense exposure to hot water lead to a perioral or rosacea-like dermatitis.
and soap elutes lipids and possibly water binding Therefore, even people with dry skin in the face
compounds from the skin which would otherwise must avoid chronic treatment with grease oint-
slow down and reduce the discharge of moisture. ments in this region. Chronic use of greasy oint-
The demoisturizing, negative effect of too intense ments may be suitable for the dry skin on the
body care becomes particularly apparent when air extremities. The use of creams with high water
humidity is low as is typically the case in the win- content may not be sufficient at those body areas.
tertime. Applying a lotion or cream or an occlu-
sive ointment, on the other hand, is very useful to
reduce water loss of the horny layers and to
diminish shrinkage of the corneocytes. 35.13 Summary
The influence which the surface curvature of a
human body has on the exchange of water might The climate is of crucial importance for the devel-
be a plausible explanation for the observation that opment of dry skin conditions. Dry skin usually
convex formed skin areas suffer more from low occurs in cold weather conditions in winter time
humidity than concave ones. It is well known that and in the colder climate zones of the earth. Cold
dry skin occurs on the face, back of the hands, and air can only bind a low amount of water because
the outside of extremities, whereas the body folds of a low dew point. Therefore, the outdoor cli-
and the inside of the upper legs never get dry. mate leads to dry skin. The relative humidity is
Taken all together, the symptoms of dry skin low indoors in winter time because of ventilation
which one experiences in the wintertime can which leads to an influx of air with a low amount
largely be explained by the basic properties of of water, and therefore the indoor climate in win-
water vapor in the air. However, such general cli- ter time may also lead to dry skin. Dry skin may
mate physiological considerations cannot clarify even occur during summer time indoors if air
the issue of individual differences in sensitivity. condition reduces too much of the water. The
draft by a fan from an air-conditioning device or
outdoor wind aggravates dry skin. Treatment of
35.12 Treatment of Dry Skin dry skin must be performed according to the cli-
Depending on the Climate mate. A greasy ointment can be applied during
Conditions winter time especially on the extremities. During
summer time, in the face, an ointment may be too
The treatment of the skin depends on the body greasy and may lead to side effects. Therefore, a
region and on the climate conditions. In cold win- water-enriched cream is appropriate to treat dry
ter conditions and in people with very dry skin on skin during that season.
35 The Influence of Climate on the Treatment of Dry Skin with Moisturizer 511

2. Johnsen GK, Norlen L, Martinsen OG, Grimnes S

Take Home Messages (2011) Sorption properties of the human stratum cor-
neum. Skin Pharmacol Physiol 24:190198
The climate is of crucial importance for
3. Kezic S, ORegan GM, Yau N, Sandilands A, Chen H,
the development of dry skin. Campbell LE, Kroboth K, Watson R, Rowland M,
Dry skin occurs in cold weather condi- Irwin McLean WH, Irvine AD (2011) Levels of filag-
tions during winter time. grin degradation products are influenced by both filag-
grin genotype and atopic dermatitis severity. Allergy
Cold air can only bind a low amount of
66:934940
water. 4. Papir YS, Hsu KH, Wildnauer RH (1975) The mechan-
Outdoor and indoor climate in winter ical properties of stratum corneum. I. The effect of
time lead to dry skin because of low water and ambient temperature on the tensile proper-
ties of newborn rat stratum corneum. Biochim Biophys
absolute and relative low air water con-
Acta 14(399):170180
tent, respectively. 5. Proksch E, Lachapelle JM (2005) The management of
Strong wind and artificial ventilation dry skin with topical emollientsrecent perspectives.
aggravate dry skin. J Dtsch Dermatol Ges 3:768774
6. Proksch E (2008) The role of emollients in the man-
Air condition induced strong reduction of
agement of diseases with chronic dry skin. Skin
water content may also lead to dry skin. Pharmacol Physiol 21:7580
A greasy ointment should be applied 7. World Meteorological Organisation (2008) Guide to
during winter time especially on the meteorological instruments and methods of observa-
tion. Part I: measurement of meteorological variables.
extremities for the treatment of dry skin.
Chapter 4: measurement of humidity, WMO-No. 8,
A water-enriched cream is appropriate Geneva
to treat dry skin during summer espe- 8. Lide DR (1995) CRC handbook of chemistry and
cially in the face. physics, 76th edn. CRC Press, Boca Raton
9. Proksch E, Flster-Holst R, Brutigam M,
Sepehrmanesh M, Pfeiffer S, Jensen JM (2009) Role
of the epidermal barrier in atopic dermatitis. J Dtsch
Dermatol Ges 7:899910
References
1. Proksch E, Brandner JM, Jensen JM (2008) The skin:
an indispensable barrier. Exp Dermatol 17:10631072
 Emollient Therapy and Skin
Barrier Function 36
Majella E. Lane

36.1 Introduction
SC
The skin is the largest organ of the human body
and serves the vital function of protection of
human beings from excessive water loss in a ter-
Viable epidermis
restrial environment and from insult from xeno-
biotics. Disorders of the skins finely tuned barrier
function are associated with a variety of condi- Dermal blood
tions including dermatitis and atopic eczema.
supply
Conventional treatment of such conditions
involves the chronic application of emollients or Fig. 36.1 Schematic representation of the stratum cor-
moisturisers in order to replace the skins water neum and viable epidermis
content and restore barrier integrity. However, a
number of studies in the literature have also high- ological functions. In essence, the skin consists
lighted the ability of specific emollient products of three functional layers: the epidermis, the der-
to compromise the skins protective role. These mis and the subcutaneous tissue also known as
studies are reviewed in this chapter, and the pos- the hypodermis. Appendages such as hair, folli-
sible reasons underlying the effects of these cles, sebaceous glands and sweat glands are also
products are considered. found in human skin. The outermost layer, the
epidermis, is generally divided into two distinct
layers: the stratum corneum (SC) and the viable
36.2 Skin Structure and the Stratum epidermis (VE) (Fig. 36.1). The epidermis is a
Corneum non-vascular tissue with a thickness that varies
between 60 and 800 mm, depending on the body
The skin represents, in adults, 10% of the total site. The VE is a multilayer tissue that is tradi-
body mass with an average total surface area of tionally identified in terms of cell location and
2 m2 [1]. It is a complex living organ with a appearance: stratum basale, stratum spinosum,
diverse cellular population and a range of physi- stratum granulosum and stratum lucidum. These
layers represent the several stages of mitosis and
keratinocyte differentiation, which ultimately
contribute to the regeneration of the SC.
M.E. Lane
The SC is the most superficial layer of the
Department of Pharmaceutics, School of Pharmacy,
29-39 Brunswick Square, WC1N 1AX London, UK skin, and it is the principal barrier to percutane-
e-mail: [email protected] ous absorption of exogenous substances. Removal

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 513

DOI 10.1007/978-3-642-27606-4_36, Springer-Verlag Berlin Heidelberg 2012
514 M.E. Lane

of the SC by tape stripping increases the measure of maturity involves immunostaining of

permeability of water and other compounds by the cornified envelope with antibodies specific for
approximately 1,000 times [2]. The water perme- the precursor protein, e.g. involucrin [11]. This
ability of the SC is also much lower than most allowed Hirao and colleagues to distinguish
other biological membranes. Several factors con- between the mature rigid CEs isolated from the
tribute to the ability of the SC to control the loss outermost layer of SC and the fragile, less mature
of water and the permeation of exogenous com- CEs which are present in deeper layers of the SC
pounds, such as high density, low hydration (15 as well as in psoriatic and eczematous skin [11].
20% w/w) and low surface area for diffusion Between the cells (~75-nm gap), there is a com-
(assuming that the main route is via the intercel- plex matrix of lipids arranged in bilayers and in
lular pathways) [3]. Constant renewal of the cells parallel orientation to the cells surfaces [12]. The
in this layer by desquamation/regeneration also number of lipid bilayers varies between 4 and 20
maintains a very effective protection barrier [4]. [13]. These lipids are formed during the differentia-
Structurally, the SC is composed of 1520 tion from the stratum granulosum and begin with
layers (with a thickness of 1020 mm) of pen- the extrusion of the lamellar granules to the extra-
tagonal or hexagonal, stacked and terminally dif- cellular space. In this space, acid hydrolases break
ferentiated corneocytes, surrounded by a complex down the phospholipids into free fatty acids and
mixture of intercellular lipids. A brick and convert glucosylceramides to ceramides [14, 15].
wall analogy is usually used to describe the SC Additionally, following the extrusion of the lamel-
structure: the keratinised cells are the bricks lar granule contents, the stacks of lamellar mem-
whereas the intercellular lipids are the mortar brane are rearranged edge to edge and then fuse to
[5]. Each cell is about 3446 mm long, 2536 mm form continuous intercellular lamellae [16].
wide and 0.51 mm thick [2]. These dimensions
are subject to variation according to age, ana-
tomical location and external factors (e.g. UV 36.3 Skin Turnover and
radiation) [2]. SC is mainly composed of intra- Desquamation
corneocyte insoluble protein (~75% w/w),
whereas the intercellular lipids account for Skin turnover is a critical factor and plays a major
515% w/w and the cornified cell envelope rep- role in skin barrier function. The cells of the SC
resents ~5% w/w of the total dry weight [6, 7]. (corneocytes) result from the differentiation of the
The cornified cell envelope is a 1520-nm- keratinocytes from the stratum granulosum. The
thick protein shell that surrounds each cell. It is migration from this layer to the surface takes
composed of ~15-nm layer of defined structural between 12 and 14 days, during which the cells
proteins and ~5-nm-thick layer of specialised lip- differentiate and begin to die. The life span of the
ids [8]. It results from the differentiation of the corneocytes in the SC is 23 weeks, as the superfi-
keratinocytes which originated in the stratum cial part of the SC is continuously desquamated at
spinosum [9]. The cornified cell envelope has an a balanced rate with the formation of new cell [17].
important role in the organisation of the intercel- The terminally differentiated corneocytes are
lular lipid domain, inter-corneocyte cohesion and devoid of nuclei or other cellular organelles, but
resistance of the SC to proteolytic enzymes [2]. are filled with keratin intermediate filaments, cross
Michel et al. reported two types of CEs: polygo- linked by intermolecular disulfide bonds [18, 19].
nal mature rigid CEs and irregularly shaped In normal healthy skin, the process of stratum
immature fragile CEs [10]. Hirao et al. demon- corneum (SC) maturation is finely regulated, and
strated that mature corneocytes are more hydro- the loss of surface corneocytes is precisely bal-
phobic than immature cells. While Nile Red is anced by the underlying rate of proliferation
reported to stain the mature corneocytes, it can (Fig. 36.2). For desquamation to occur, the cohesive
also stain immature cells [11]. A more specific corneodesmosomes which bind the corneocytes
36 Emollient Therapy and Skin Barrier Function 515

in the SC must be degraded by enzymes, i.e.

proteases which catalyse peptide bond hydrolysis
[20, 21]. Human tissue kallikreins (KLKs) are a
family of trypsin- or chymotrypsin-like-secreted Desquamation
serine proteases (KLK1-KLK15) found in a variety
of tissues [22]. The KLKs have been suggested to
function as an enzymatic cascade pathway [2325].
Corneocyte
Corneodesmosomes are broken down by several
desquamatory-related serine proteases, such as
KLK5, KLK6, KLK7, KLK8, KLK10, KLK11
Corneodesmosome
and KLK13, present within the SC [26, 27]. As
well as having a vital role in the proteolysis of the Keratin
SC corneodesmosomes, KLKs are also reported to
be involved in degradation of lipid-processing Fig. 36.2 The desquamation process (adapted from
Milstone [21])
enzymes, such as b-glucocerebrosidase [28].
Reduced expression of tryptic (e.g. KLK5)
and chymotryptic (e.g. KLK7) enzymes has been from the cheeks of subjects with dry skin [41].
reported in the outer layers of the SC in dry skin More recently, Voegeli et al. observed a positive
[29]. In contrast, increased expression of KLK7 correlation between the activity of trypsin-like
has been reported in two major chronic inflam- KLKs, tryptase, plasmin and urokinase with SC
matory diseases: psoriasis and atopic dermatitis barrier impairment [42]. However, chymotryptic-
[26, 30]. Alteration in the activity of serine pro- like enzymes showed no such correlation [42].
teases KLK5 and KLK7 appears to be associated
with skin barrier disturbances [3133]. This may
partly be due to uncontrolled corneodesmolysis, 36.4 Biophysical and
which leads to weakening of the SC integrity and Pharmacodynamic
cohesion [28, 34]. Measurements of Skin
Other enzymes such as plasmin, tryptase and Barrier Function
urokinase are also reported to be present in the SC
but are not necessarily involved in the desquama- 36.4.1 Transepidermal Water
tory process. However, these enzymes may have Loss (TEWL)
an important role in skin inflammation [30, 35].
Several trypsin-like protease inhibitors, such as The SC receives water by diffusion mostly from the
leupeptin, are reported to elevate barrier repair underlying tissues and also from the sweat glands
[36]. Leupeptin is reported to inhibit the activity with constant evaporation to the outside environ-
of, e.g. plasmin [36, 37]. This suggests that ment. The water that is constantly lost diffuses
increased activity of plasmin may impair barrier through the skin by a passive mode of transport,
recovery. Tryptase concentration is reported to be from the region of high water concentration inside
high in those with allergic contact dermatitis [38]. the body to the low concentration at the surface.
Transepidermal water loss (TEWL) is a fre- Transepidermal water loss (TEWL) corresponds
quently used non-invasive technique for elucida- to the steady-state water vapour flux density pass-
tion of skin barrier function [39]. When the skin ing through the SC to the exterior (Fig. 36.3).
barrier integrity is damaged, TEWL increases Under these conditions, baseline TEWL can be
[39, 40]. The activity of certain proteases has described by Ficks first law of diffusion [43]:
been correlated with the TEWL. Kawai and col-
leagues showed that the activity of urokinase Dc (36.1)
J = -D
increased as TEWL increased in tape stripping Dz
516 M.E. Lane

Fig. 36.3 Transepidermal

water loss through intact
stratum corneum

Water Corneocyte Intercellular

lipids

where: a
J = water vapour flux density TEWL CH3
(kg m2 s1)
D = diffusion coefficient of water in the SC
(m2 s1)
c = positive concentration difference across
the membrane (kg m3)
z = membrane thickness (m)
TEWL measurements are regarded as an indi- N
cator of barrier function and allow an assessment
of any macroscopic changes in the SC barrier
b
function [43]. A range of instrumentation has
been developed to measure TEWL, and both open
and closed chamber devices are currently in use.

36.4.2 Skin Capacitance

As the dielectric constant of the skin will change

with water content, the moisture content of the
Fig. 36.4 (a) Methyl nicotinate. (b) Skin erythema caused
stratum corneum, i.e. hydration, may be measured by a 0.075% w/v methyl nicotinate solution applied for
using electrical capacitance. Instruments for 20 s
hydration measurement generally use capacitance
sensors to measure the dielectric constant of the
skin [44]. Changes in the water content of the papillae, adjacent to the epidermis-dermis junc-
stratum corneum are converted to arbitrary units tion [45]. This pharmacological action has been
of hydration. used to characterise in vivo skin barrier function
by a number of research groups [46, 47]. The
most commonly used derivative to date is methyl
36.4.3 Skin Response to Vasoactive nicotinate (Fig. 36.4a) which penetrates rapidly
Compounds and causes the appearance of redness that fades
away in a few hours (Fig. 36.4b) [4850]. Hexyl
After topical application, nicotinic acid derivatives nicotinate has also been used [51]. The proposed
are known to induce vasodilatation of the mechanism of action of the nicotinates involves
peripheral blood capillaries located in the dermal receptor activation which leads to an increase of
36 Emollient Therapy and Skin Barrier Function 517

the intercellular calcium. This induces the activa- 36.5.1 Locabase

tion of a calcium-sensitive phospholipase A2
(PLA2) and the formation of arachidonic acid Locabase is an emollient product containing
(AA) which is then metabolised to PGD2 and white soft paraffin, liquid paraffin, cetostearyl
PGE2. Prostaglandins are able to induce vasodi- alcohol, cetomacrogol 1,000 as well as preserva-
lation of the blood vessels in the upper layer of tives and buffering agents. A study conducted by
the dermis by activating their Gs-coupled recep- Halkier-Srensen and Thestrup-Pedersen [57]
tors [45]. The induced erythema can be visually indicated a general benefit associated with use of
assessed by detecting its onset time or monitored the product for workers exposed to water on a
using more objective methods such as Laser daily basis, as evaluated by electrical capacitance
Doppler Velocimetry [LDV], chromametry and and clinical examination, but no changes were
photoplethysmography. observed in TEWL. The product was also shown
to be of benefit in the prevention and treatment of
irritant contact dermatitis (ICD) [58].
36.5 Moisturisers and the Skin In a later study on healthy skin, Held et al. [59]
Barrier investigated the effects of application of Loc-
abase to the forearm of 20 healthy volunteers
Disorders or diseases of the skin must inevitably three times daily for 4 weeks, the other forearm
compromise aspects of its barrier properties. acting as the untreated control. At the end of the
Extensive literature confirms that TEWL mea- study (day 28), both forearms were challenged
surements in patients suffering from dry skin or with a patch test of sodium lauryl sulphate (SLS).
atopic eczema have been reported to be higher TEWL and skin hydration measurements (electri-
compared with patients with healthy skin cal capacitance) were conducted to determine any
[ 52 55]. A rational approach to the problem of changes in skin barrier function. Electrical capac-
excessive water loss is therefore simply to restore itance increased significantly on the treated arm at
water via application of a suitable formulation days 14, 28 and 30 compared with the untreated
which either contains water or which artificially site. No statistically significant differences in
increases skin water content by occlusion. In TEWL were observed for treated versus untreated
some instances, however, the formulation com- sites. The authors also noted that the mean amount
ponents may themselves further aggravate or of moisturiser used in the study period did not
exacerbate the problem, and irritant skin reac- affect the results. After challenge with SLS,
tions are commonly observed. In general, these TEWL was significantly higher on the arm treated
reactions may be divided into three types: with moisturizer than on the control arm (p < 0.05)
(1) stinging, a subjective and transient effect suggesting that the moisturizer treatment might
which appears and disappears within a short increase skin susceptibility to irritants. A study by
period (minutes) of moisturiser application; the same group compared the short-term effects
(2) inflammation with redness, oedema, elevated of Locabase with another commercially avail-
skin temperature and discomfort; and (3) damage able product (Decubal) [60]. Decubal contains
to the skin barrier function resulting in dryness water, isopropyl myristate, glycerol, sorbitan
and scaling of the skin but not necessarily clinical stearate, lanolin, dimethicone, cetyl alcohol,
symptoms [56]. This section considers specific polysorbate 60 and sorbic acid and has a total
case studies from the literature where the skin lipid content of 38%. The products were applied
barrier is compromised following application of to the upper arm/forearm of 19 healthy volunteers
emollients. In some instances, the authors have three times daily for 5 days while the other upper
also identified the mechanism by which the for- arm/forearm served as symmetrical control. After
mulation is exerting these deleterious effects as a 24-h washout period, the skin was challenged
well as the specific component(s) most likely to with a patch test of sodium lauryl sulphate. Skin
be responsible. reactions were evaluated using TEWL, electrical
518 M.E. Lane

capacitance, laser Doppler flowmetry, chromam- patible with the earlier reports, i.e. the use of
etry and clinical scoring. The Locabase-treated Locabase appears to weaken the skin barrier to
skin sites displayed more intense irritant reactions externally applied substances.
(TEWL and chromameter measurements) to SLS
compared with untreated skin (p < 0.05) in line
with the earlier findings, but these differences 36.5.2 Aqueous Cream B.P.
were not observed for the Decubal product. The
authors also speculated that the results might be a Aqueous Cream B.P. is an oil-in-water emulsified
consequence of the relatively high lipid content in cream which first appeared as a preparation of the
the Locabase formulation compared with the British Pharmacopoeia in 1958, and its formula-
other product (70% vs 30%). tion, containing sodium lauryl sulphate (SLS),
The same workers evaluated the effect of remains largely unchanged today [62]. The other
Locabase on skin susceptibility to nickel in volun- components of the preparation are white soft par-
teers with a known nickel allergy and in volunteers affin, liquid paraffin, water, cetostearyl alcohol
with no nickel allergy [61]. The product was applied and a preservative. For the management of eczema
to the forearm three times daily for 7 days prior to and dry skin, the British National Formulary cur-
any allergy challenge. The other arm served as a rently includes Aqueous Cream BP under the
symmetrical control. Electrical capacitance was heading of emollients which are further defined
measured prior to the study and at the end of the as preparations which soothe, smooth and hydrate
study for control and treated sites. At the end of the the skin and are indicated for all dry or scaling dis-
study, baseline values for TEWL, skin colour and orders [63]. Gloor et al. investigated the effects of
skin thickness were measured at both sites, and fil- Aqueous Cream B.P. and a range of other formula-
ter discs with 1% NiCl2 solution were subsequently tions on 29 healthy volunteers over a 7-day period
applied for 24 h. Clinical scoring and measurements [64]. Laser Doppler measurements were also con-
for TEWL, skin colour and dermal thickness were ducted on 14 subjects. The products were applied
performed at the end of the 24-h period and at 72 h on one arm twice daily, and the contralateral area
after application of the filter pads. In the nickel- was left untreated. TEWL and skin redness (chro-
allergic group, the strength of patch-test reactions mameter) were measured before the start and at
was increased on the moisturizer-treated sites as the end of each study. Significant increases in
evaluated by clinical scoring after 24 h and by TEWL and laser Doppler readings were observed
TEWL and skin thickness after 72 h. In the control for treated versus untreated controls suggesting
group, no significant differences were found. The that the skin barrier had been compromised and an
authors suggested that the threshold values for elici- irritant response had been induced. At the end of
tation of allergic reactions in nickel-sensitive indi- the study, 15 subjects underwent a hydrocortisone
viduals were influenced by moisturiser application. blanching test where the hydrocortisone cream
Duval and co-workers compared Locabase was applied under occlusion for 24 h. The blanch-
with a urea-containing cream [51]. A parallel, ing-induced decrease (chromameter) for treated
randomized and double blind study was con- sites was significantly greater than for non-treated
ducted with 53 healthy volunteers. The partici- sites suggesting that treatment with the cream
pants were instructed to apply the cream twice increased penetration of hydrocortisone. After
daily for 3 weeks on the volar aspect of one of pretreatment with the cream, 14 subjects under-
their forearms. The skin was then exposed to went the SLS irritation test. TEWL, chromameter
hexyl nicotinate to induce vasodilatation. The and laser Doppler readings were obtained before
time course and magnitude of the microvascular and after this test. TEWL and chromameter values
skin changes in the two skin areas were moni- were significantly higher for the treated sites ver-
tored with laser Doppler flowmetry. A signifi- sus untreated sites compared with baseline
cantly shorter time to reach maximum blood flow measurements.
was obtained for Locabase compared with the The problem of irritant reactions following the
untreated control sites. The findings were com- use of Aqueous Cream B.P. in the UK has been
36 Emollient Therapy and Skin Barrier Function 519

highlighted by Lapsley and by Cork et al. [65, 66]. applied to half of the forearm twice daily. SC
An audit of adverse reactions to the use of thickness was also evaluated via measurement of
Aqueous Cream B.P. in children was reported in TEWL and tape stripping [68] and was found to
the UK by the latter group. The notes of 100 chil- decrease by a mean value of 12% (p = 0.0015).
dren aged 116 with atopic eczema attending a In a more recent study by Mohammed et al.
paediatric dermatology clinic were assessed. [69], the effects of Aqueous Cream B.P. at the
Fifty-six percent of the episodes of exposure to molecular and cellular level were evaluated. The
Aqueous Cream B.P. were associated with an same study design used by Tsang and Guy was
immediate cutaneous reaction. Several of the par- employed. At the end of the 28-day treatment
ticipants also reported that the cream caused irri- period, the site was tape-stripped, and corneocyte
tancy when used for prolonged periods of time, maturity; corneocyte size and protease activity of
i.e. as a leave on emollient but not when used as the desquamatory kallikrein proteases, KLK5
a soap substitute. A later study by Tsang and Guy and KLK7; and the inflammatory proteases
demonstrated a 20% increase (p < 0.0001) in tryptase and plasmin were measured. Protein
baseline TEWL for six healthy volunteers fol- content and TEWL were also measured.
lowing topical treatment of the forearm with Corneocyte maturity (Fig. 36.5) and size
Aqueous Cream B.P. for 4 weeks [67]. (Table 36.1) decreased with increasing number of
Approximately 1.6 g of Aqueous Cream B.P. was tape strips and were significantly lower in treated

Fig. 36.5 Corneocyte maturity from tape 1 of the volar forearm. (a) and (c) Are control and treated, respectively, fol-
lowing nile red staining, (b) and (d) are immuno-stained control and treated sites
520 M.E. Lane

Table 36.1 Comparison of corneocyte surface area for lipid-rich formulation (70%) while Aqueous Cream
control and treated sites with Aqueous Cream B.P. for is a water-in-oil cream containing a comparable
sequential tape strippings (n = 6; mean S.D.)
amount of water. The effects of Aqueous Cream
Tape strip Corneocyte surface area (mm2) B.P. on skin function are thought to reflect the influ-
number Non-treated Treated ence of one of the emulgents used in the formula-
1 978.22 155.15 864.99 180.33 tion (SLS). However, further studies are needed to
5 930.51 161.76 842.32 163.46
confirm this hypothesis. It is also important to note
9 844.40 133.02 774.32 169.12
that sensitisation and irritation reactions have been
13 832.82 129.77 768.44 143.87
reported to cetostearyl alcohol [7173], a compo-
17 787.21 138.13 712.75 142.26
nent of both Locabase and Aqueous Cream B.P.
With the increase in sensitivity and sophistication
of measurement techniques, it should be possible
sites compared with untreated sites. Protease to separate the different effects from the compo-
activity and TEWL values were higher (p < 0.05) nents that make up complex formulations. It may
for the treated sites compared with untreated be possible to identify constituents which have an
sites. The amount of protein removed from deeper advantageous effect on the protease activity. This
layers of treated sites was significantly lower than knowledge should allow the formulation of better
from untreated sites. The application of Aqueous emollients for the treatment of dry skin and atopic
Cream appeared to disrupt the normal maturation dermatitis, a problem that has increased signifi-
process, i.e. the corneocytes did not mature fully cantly over the past decades [74].
because of exposure to the preparation, and this is
also consistent with the observed increase in
desquamatory protease activity (KLK5, KLK7).
Elevated levels for the inflammatory enzymes Take Home Messages
also suggest inflammatory responses in sites Conventional treatment of dry skin con-
treated with this preparation, and, indeed, the ditions involves the chronic application
reduction in corneocyte surface area and maturity of emollients or moisturisers in order to
is entirely consistent with increased epidermal replace the skins water content and
turnover. Increased TEWL values are consistent restore barrier integrity.
with this disturbance in corneocyte maturation The barrier function of the skin may be
during the treatment period. The results provide a interrogated by a range of molecular and
mechanistic understanding for the observed thin- biophysical methods.
ning of the SC associated with use of Aqueous A number of studies in the literature
Cream B.P. and for the elevated TEWL and irri- have highlighted the ability of specific
tant effects reported following the use of this emollient products to compromise the
preparation in patients with atopic dermatitis and skins protective role.
in healthy subjects [70]. Efforts by clinicians and Locabase is a lipid-rich formulation
patient groups in the UK are ongoing with a view and its use in patients with healthy skin
to reclassification of this product as a soap and in patients with nickel allergy is
replacement rather than an emollient. associated with increased irritation in
the former group and a lowering of
allergy threshold in the latter group.
36.6 Summary Aqueous Cream B.P. is a water-rich
formulation and its use in healthy
The literature relating to two products which are volunteers is associated with elevated
commonly prescribed for the management of dry desquamatory and inflammatory protease
skin conditions has been reviewed. Locabase is a
36 Emollient Therapy and Skin Barrier Function 521

12. Madison KC (2003) Barrier function of the skin: La

activity, increased transepidermal water raison detre of the epidermis. J Invest Dermatol
121:231241
loss and changes in corneocyte maturity 13. Bouwstra JA, Honeywell-Nguyen PL, Gooris GS,
and size indicative of accelerated skin Ponec M (2003) Structure of the skin barrier and its
turnover. modulation by vesicular formulations. Prog Lipid Res
42:136
In the management of dry skin and
14. Elias PM, Feingold KR, Tsai J, Thornfeldt C, Menon G
eczema, the prescription of emollients (2003) Metabolic approach to transdermal drug deliv-
which are known to damage healthy ery. In: Guy RH, Hadgraft J (eds) Transdermal drug
skin must be firmly questioned. delivery, 2nd edn, Revised and expanded. Marcel
Dekker, New York, pp 285305
15. Landmann L (1986) Epidermal permeability bar-
rier: transformation of lamellar granule-disks into
intercellular sheets by a membrane-fusion process,
a freeze-fracture study. J Invest Dermatol 87:
202209
References 16. Downing DT (1992) Lipid and protein structures in
the permeability barrier of mammalian epidermis.
1. Washington C, Washington N (1989) Drug delivery to J Lipid Res 33:301313
the skin. In: Wilson CG, Washington N (eds) 17. Katz M, Poulsen BJ (1971) Absorption of drug
Physiological pharmaceutics: biological barriers to through the skin. In: Brodie BB, Gilette JR (eds)
drug absorption. Ellis Horwood Limited, Chichester, Handbook of experimental pharmacology. Springer,
pp 109120 Berlin, pp 103174
2. Walters KA, Roberts MS (2002) The structure and 18. Sun TT, Green H (1978) Keratin filaments of cultured
function of skin. In: Walters KA (ed) Dermatological human epidermal cells. Formation of intermolecular
and transdermal formulations. Marcel Dekker, Inc, disulfide bonds during terminal differentiation. J Biol
New York, pp 139 Chem 253:20532060
3. Scheuplein RJ (1971) Permeability of the skin. Physiol 19. Kurihara-Bergstrom T, Good WR (1987) Skin devel-
Rev 51:702747 opment and permeability. J Control Release 6:5158
4. Egelrud T (2000) Desquamation in the stratum cor- 20. Rawlings N, Barrett A (1999) MEROPS: the pepti-
neum. Acta Derm Venereol Suppl (Stockh) 208:4445 dase database. Nucleic Acids Res 27:325331
5. Michaels AS, Chandrasekaran SK, Shaw JE (1975) 21. Milstone LM (2004) Epidermal desquamation.
Drug permeation through human skin: theory and J Dermatol Sci 36(3):131140
in vitro experimental measurement. AIChE J 22. Yousef GM, Diamandis EP (2001) The new human
21:985996 tissue kallikrein gene family: structure, function, and
6. Suhonen TM, Bouwstra JA, Urtti A (1999) Chemical association to disease. Endocr Rev 22:184204
enhancement of percutaneous absorption in relation 23. Yousef GM, Diamandis EP (2002) Human tissue kal-
to stratum corneum structural alterations. J Control likreins: a new enzymatic cascade pathway? Biol
Release 59:149161 Chem 383:10451057
7. Kalinin AE, Kajava AV, Steinert PM (2002) Epithelial 24. Brattsand M, Stefansson K, Lundh C, Haasum Y,
barrier function: assembly and structural features of Egelrud T (2004) A proteolytic cascade of kallikreins
the cornified cell envelope. Bioessays 24:789800 in the stratum corneum. J Invest Dermatol 124:
8. Swartzendruber DC, Wertz PW, Madison KC, 198203
Downing DT (1987) Evidence that the corneocyte has a 25. Borgono CA, Michael IP, Diamandis EP (2004)
chemically bound lipid envelope. J Invest Dermatol Human tissue kallikreins: physiologic roles and appli-
88:709713 cations in cancer. Mol Cancer Res 2:257280
9. Kalinin A, Marekov LN, Steinert PM (2001) Assembly 26. Komatsu N, Saijoh K, Toyama T, Ohka R, Otsuki N,
of the epidermal cornified cell envelope. J Cell Sci Hussack G, Takehara K, Diamandis EP (2005)
114:30693070 Multiple tissue kallikrein mRNA and protein expres-
10. Michel S, Schmidt R, Shroot B, Reichert U (1988) sion in normal skin and skin diseases. Br J Dermatol
Morphological and biochemical characterization of the 153:274281
cornified envelopes from human epidermal keratino- 27. Suzuki Y, Nomura J, Hori J, Koyama J, Takahashi M,
cytes of different origin. J Invest Dermatol 91:1115 Horii I (1993) Detection and characterization of
11. Hirao T, Denda M, Takahashi M (2001) Identification endogenous protease associated with desquamation of
of immature cornified envelopes in the barrier- stratum corneum. Arch Dermatol Res 285:372377
impaired epidermis by characterization of their hydro- 28. Hachem J-P, Man M-Q, Crumrine D, Uchida Y,
phobicity and antigenicities of the components. Exp Brown BE, Rogiers V, Roseeuw D, Feingold KR,
Dermatol 10:3544 Elias PM (2005) Sustained serine proteases activity
522 M.E. Lane

by prolonged increase in pH leads to degradation of 42. Voegeli R, Rawlings AV, Doppler S, Schreier T (2008)
lipid processing enzymes and profound alterations of Increased basal transepidermal water loss leads to
barrier function and stratum corneum integrity. elevation of some but not all stratum corneum serine
J Invest Dermatol 125:510520 proteases. Int J Cosmet Sci 30:435442
29. Overloop LV, Declercq L, Maes D (2001) Visual sca- 43. Imhof RE, De Jesus MEP, Xiao P, Ciortea LI, Berg EP
liness of human skin correlates to decreased ceramide (2009) New developments in skin barrier measure-
levels and decreased stratum corneum protease activ- ments. In: Rawlings AV, Leyden JJ (eds) Skin mois-
ity. J Invest Dermatol 117:811 turization, 2nd edn, Cosmetic science and technology
30. Voegeli R, Rawlings AV, Breternitz M, Doppler S, series. Informa Healthcare, New York, pp 463479
Schreier T, Fluhr JW (2009) Increased stratum cor- 44. Frdin T, Helander P, Molin L, Skogh M (1988)
neum serine protease activity in acute eczematous Hydration of human stratum corneum studied in vivo
atopic skin. Br J Dermatol 161:7077 by optothermal infrared spectrometry, electrical
31. Egelrud T, Brattsand M, Kreutzmann P, Walden M, capacitance measurement, and evaporimetry. Acta
Vitzithum K, Marx UC, Forssmann WG, Mgert HJ Derm Venereol 68(6):461467
(2005) hK5 and hK7, two serine proteinases abundant 45. Bodor ET, Offermanns S (2008) Nicotinic acid: an old
in human skin, are inhibited by LEKTI domain 6. Br J drug with a promising future. Br J Pharmacol
Dermatol 153:12001203 153(S1):S68S75
32. Hansson L, Stromqvist M, Backman A, Wallbrandt P, 46. Cronin E, Stoughton RB (1962) Percutaneous absorp-
Carlstein A, Egelrud T (1994) Cloning, expression, tion. Regional variations and the effect of hydration
and characterization of stratum corneum chymotryp- and epidermal stripping. Br J Dermatol 74:265272
tic enzyme. A skin-specific human serine proteinase. 47. Barrett CW, Hadgraft JW, Sarkany I (1964) The influ-
J Biol Chem 269:1942019426 ence of vehicles on skin penetration. J Pharm
33. Brattsand M, Egelrud T (1999) Purification, molecular Pharmacol 16(Suppl):104T107T
cloning, and expression of a human stratum corneum 48. Tur E, Guy RH, Tur M, Maibach HI (1983) Noninvasive
trypsin-like serine protease with possible function in assessment of local nicotinate pharmacodynamics by
desquamation. J Biol Chem 274:3003330040 photoplethysmography. J Invest Dermatol 80:499503
34. Harding CR, Watkinson A, Rawlings AV, Scott IR 49. Leopold CS, Maibach HI (1996) Effect of lipophilic
(2000) Dry skin, moisturization and corneodesmoly- vehicles on in vivo skin penetration of methyl nicoti-
sis. Int J Cosmet Sci 22:2152 nate in different races. Int J Pharm 139:161167
35. Voegeli R, Rawlings AV, Doppler S, Heiland J, 50. Bonina FP, Montenegro L, Scrofani N, Esposito E,
Schreier T (2007) Profiling of serine protease activi- Cortesi R, Menegatti E, Nastruzzi C (1995) Effects of
ties in human stratum corneum and detection of a stra- phospholipid based formulations on in vitro and
tum corneum tryptase-like enzyme. Int J Cosmet Sci in vivo percutaneous absorption of methyl nicotinate.
29:191200 J Control Release 34:5363
36. Denda M, Kitamura K, Elias PM, Feingold KK (1997) 51. Duval C, Lindberg M, Boman A, Johnsson S, Edlund
Trans-4-(aminomethyl)cyclohexane carboxylic acid F, Loden M (2003) Differences among moisturizers in
(T-AMCHA), an anti-fibrinolytic agent, accelerates affecting skin susceptibility to hexyl nicotinate mea-
barrier recovery and prevents the epidermal hyperpla- sured as time to increase skin blood flow. Skin Res
sia induced by epidermal injury in hairless mice and Technol 9:5963
humans. J Invest Dermatol 109:8490 52. Thune P, Nilsen T, Hanstad IK, Gustavsen T, Lvig
37. McConnell RM, York JL, Frizzell D, Ezell C (1993) Dahl H, Thune P, Nilsen T, Hanstad IK, Gustavsen T,
Inhibition studies of some serine and thiol proteinases Lvig Dahl H (1988) The water barrier function of the
by new leupeptin analogs. J Med Chem 36:10841089 skin in relation to the water content of stratum corneum,
38. Brockow K, Abeck D, Hermann K, Ring J (1996) pH and skin lipids. The effect of alkaline soap and syn-
Tryptase concentration in skin blister fluid from det on dry skin in elderly, non-atopic patients. Acta
patients with bullous skin conditions. Arch Dermatol Derm Venereol 68(4):277283
Res 288:771773 53. Lodn M (1995) Biophysical properties of dry atopic
39. Endo K, Suzuki N, Yoshida O, Sato H, Fujikura Y (2007) and normal skin with special reference to effects of
The barrier component and the driving force component skin care products. Acta Derm Venereol Suppl
of transepidermal water loss and their application to skin (Stockh) 192:148
irritant tests. Skin Res Technol 13:425435 54. Di Nardo A, Wertz P, Giannetti A, Seidenari S (1998)
40. Farahmand S, Tien L, Hui X, Maibach HI (2009) Ceramide and cholesterol composition of the skin of
Measuring transepidermal water loss: a comparative patients with atopic dermatitis. Acta Derm Venereol
in vivo study of condenser-chamber, unventilated- 78(1):2730
chamber and open-chamber systems. Skin Res 55. Flohr C, England K, Radulovic S, McLean WH,
Technol 15:392398 Campbel LE, Barker J, Perkin M, Lack G (2010)
41. Kawai E, Kohno Y, Ogawa K, Sakuma K, Yoshikawa N, Filaggrin loss-of-function mutations are associated
Aso D (2002) Can inorganic powders provide any bio- with early-onset eczema, eczema severity and tran-
logical benefit in stratum corneum, while residing on sepidermal water loss at 3 months of age. Br J
skin surface? IFSCC Mag 5(4):269275 Dermatol 163(6):13331336
36 Emollient Therapy and Skin Barrier Function 523

56. Agner T, Held E, West W, Gray J (2000) Evaluation of 66. Cork MJ, Timmins J, Holden C, Carr J, Berry V, Tazi-
an experimental patch test model for the detection of Ahnini R, Ward SJ (2003) An audit of adverse drug
irritant skin reactions to moisturisers. Skin Res reactions to aqueous cream in children with atopic
Technol 6:250254 eczema. Pharm J 271:747748
57. Halkier-Srensen L, Thestrup-Pedersen K (1993) The 67. Tsang M, Guy RH (2010) Effect of Aqueous Cream
efficacy of a moisturizer (Locobase) among cleaners and BP on human stratum corneum in vivo. Br J Dermatol
kitchen assistants during everyday exposure to water and 163(5):954958
detergents. Contact Dermatitis 29(5):266271 68. Kalia YN, Pirot F, Guy RH (1996) Homogeneous
58. Ramsing DW, Agner T (1997) Preventive and thera- transport in a heterogeneous membrane: water diffu-
peutic effects of a moisturizer. An experimental study sion across human stratum corneum in vivo. Biophys
of human skin. Acta Derm Venereol 77(5):335337 J 71:26922700
59. Held E, Sveinsdttir S, Agner T (1999) Effect of long- 69. Mohammed D, Matts PJ, Hadgraft J, Lane ME (2011)
term use of moisturizer on skin hydration, barrier Influence of Aqueous Cream BP on corneocyte size,
function and susceptibility to irritants. Acta Derm maturity, skin protease activity, protein content and
Venereol 79(1):4951 transepidermal water loss. Br J Dermatol 164(6):
60. Held E, Agner T (2001) Effect of moisturizers on skin 13041310
susceptibility to irritants. Acta Derm Venereol 70. Danby SG, Al-Enezi T, Sultan A, Chittock J, Kennedy K,
81(2):104107 Cork MJ (2011) The effect of aqueous cream BP on
61. Zachariae C, Held E, Johansen JD, Menn T, Agner T the skin barrier in volunteers with a previous history of
(2003) Effect of a moisturizer on skin susceptibility to atopic dermatitis. Br J Dermatol 165(2):329334
NiCl2. Acta Derm Venereol 83(2):9397, ++ 71. Pecegueiro M, Brando M, Pinto J, Conalo S (1987)
62. General Medical Council (Great Britain) (1958) Contact dermatitis to Hirudoid cream. Contact
British pharmacopoeia. The Pharmaceutical Press, Dermatitis 17(5):290293
London, pp 245246, 1012 pp 72. Hannuksela M (1988) Skin contact allergy to emulsi-
63. British National Formulary 60. British Medical fiers. Int J Cosmet Sci 10:914
Association, Royal Pharmaceutical Society. Sept 73. Wilson CL, Cameron J, Powell SM, Cherry G, Ryan TJ
2010:689690 (1991) High incidence of contact dermatitis in leg-ulcer
64. Gloor M, Hauth A, Gehring W (2003) O/W emulsions patients-implications for management. Clin Exp
compromise the stratum corneum barrier and improve Dermatol 16(4):250253
drug penetration. Pharmazie 58(10):709715 74. Pltz SG, Ring J (2010) Whats new in atopic eczema?
65. Lapsley P (2000) Emollients ADR concern (letter). Expert Opin Emerg Drugs 15(2):249267
Pharm J 265:555
 Skin Barrier Responses
to Moisturizers: Functional 37
and Biochemical Changes

Izabela Buraczewska-Norin

37.1 Introduction The primary function of a moisturizer is to

smoothen the skin surface and to increase water
Moisturizers are often used as supplements to topi- content in the stratum corneum, i.e., to moistur-
cal and/or systemic anti-inflammatory drugs in ize the skin. After application, water and other
various types of skin conditions and disorders, such volatile ingredients gradually evaporate, which
as contact dermatitis, atopic dermatitis, psoriasis, may even give a cooling or calming effect.
and ichthyosis, in order to bring relief and break a Remaining ingredients form a semiocclusive
dry skin cycle (reviewed by Lodn [1, 2] and deposit which stays on the skin surface for some
Proksch et al. [3]). Such skin conditions usually time and smoothens it by filling the cracks. It
require long-lasting treatment with moisturizers, may also influence skin surface pH, depending
and in the case of atopic dermatitis, their use is rec- on applied ingredients. This deposit is usually
ommended even when the eczema is cleared [4]. removed from the skin surface within few hours
Use of moisturizers is also widespread among peo- due to washing, friction, and evaporation. During
ple who perceive their skin as dry or rough, for this time, some ingredients may also penetrate
example, in the elderly, those living in a dry cli- into the epidermis or even to the dermis and be
mate, or those in frequent contact with cleaning uptaken by the body (Fig. 37.1).
agents, and they use moisturizers to obtain relief The increase in water content is achieved by
and for smoothening of the skin. Moreover, skin the water-binding properties of humectants, i.e.,
protection creams (also called barrier creams) glycerin, urea, etc., and by formation of a semioc-
are common at various workplaces to minimize the clusive layer on the skin surface which hampers
percutaneous penetration of chemicals. Moisturizers water evaporation and increases water content in
are also used in other situations, such as when they the upper epidermis. Moreover, an immediate
serve as carriers of substances that are supposed to increase in hydration of the stratum corneum may
be delivered on the skin in order to fulfill a special be caused by an uptake of water from the applied
function, as in case of topical drugs, sunscreens, product. The increase in water content and the
makeup products, or even hand sanitizers. simultaneous filling of the fractures on the skin
Moisturizers are therefore common and used by a surface makes the skin more elastic and visibly
significant percentage of the population. and tactilely smoother as well as decreases itch
and brings relief [1, 5, 6].
Studies on the impact of moisturizers on the
I. Buraczewska-Norin, Ph.D. skin barrier have mostly focused on short-term
ACO HUD Nordic AB, Research & Development,
BOX 622, Upplands Vsby 19426, Sweden effects, showing that moisturizers are able to
e-mail: [email protected] increase skin hydration by the mechanisms

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 525

DOI 10.1007/978-3-642-27606-4_37, Springer-Verlag Berlin Heidelberg 2012
526 I. Buraczewska-Norin

a
Evaporation of volatile ingredients

EMULSION (O/W)

STRATUM CORNEUM

b Smoothening of the skin surface

Impact on skin surface pH Increased elasticity

SEMIOCCLUSIVE LAYER

Decreased TEWL
Increased water content
Penetration of ingredients

Fig. 37.1 Schematic representation of short-term effect of applied. Water content in stratum corneum increases due to
a moisturizer on the skin. (a) After application of a mois- (i) hampered water evaporation, (ii) humectants, and (iii)
turizer, e.g., in the form of oil-in-water emulsion, water uptake of water from moisturizer. Ingredients may pene-
and other volatile ingredients evaporate. (b) Remaining trate into stratum corneum, lower layers of epidermis, and
ingredients form a semi-occlusive layer, which decreases even to dermis and be uptaken by body. The semiocclusive
TEWL. Skin surface became smoother. Skin surface pH layer is removed from the skin surface within few hours
may be altered temporarily, depending on ingredients due to washing, friction, and evaporation

described above, decrease roughness and scaling, 37.2 Chemistry of Moisturizers

and improve the condition of dry skin (reviewed
by Lodn et al. [1, 2, 6, 7]). However, little is Moisturizers are formulated predominantly as
known about the effects of their long-term use, oil-in-water (o/w) emulsions, where oil droplets
lasting weeks, months, or even years, which bet- are dispersed in water and stabilized by emulsi-
ter reflects the real-life situation. If moisturizers fiers (Fig. 37.2). Reversed water-in-oil (w/o)
are used repeatedly over a long period, the conse- emulsions are used less frequently due to their
quences may be speculated upon: recurring appli- poor spreadability and the greasier feeling they
cation of various substances of exogenous origin leave on the skin; however, they can offer other
on the skin, followed by such physicochemical attributes, for example, water resistance. Emul-
changes as repeatable increase in water content in sions are categorized into creams or lotions,
the stratum corneum or change in skin surface depending on their viscosity. Moisturizers may
pH, may significantly influence the structure and also be gels containing only hydrophilic material
function of the epidermis and, therefore, the skin or ointments with only lipophilic ingredients.
barrier function. Other forms of moisturizers exist, but they are
The objective of the present chapter is to much less common, for example, multiple emul-
increase the understanding of the mechanisms by sions, silicone-in-water (si/w) emulsions, or sus-
which long-term treatment with moisturizers pensions. The choice moisturizer form depends
influences the skin and its barrier function. The on its desired effect and the ingredients that are
impact of formulation variables such as pH, lipid supposed to be incorporated.
type, and humectants is presented. Skin barrier Moisturizers may either have a simple compo-
responses are discussed from the functional and sition and contain only a few ingredients or be a
biochemical perspectives. complex mixture of many substances. In the case
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 527

a Simple oil-in-water emulsion b Complex oil-in-water emulsion

OIL

WATER

EMULSIFIER

Fig. 37.2 Schematic representation of an oil-in-water adjusters, preservatives, and thickeners (marked as blue,
emulsion. (a) Simple emulsion, containing only three ingre- green and red dots, and long lines, respectively). This type
dients: water as the continuous phase, dispersed oil drop- of emulsion represents better real-life situation, as majority
lets, and an emulsifier that stabilizes the droplets, so they do of moisturizers contain a big variety of ingredients in order
not coalesce. (b) Complex emulsion, containing more to fulfill their function, have good cosmetic properties, and
ingredients than simple emulsion, such as humectants, pH remain stable during declared shelf-life period

of o/w and w/o emulsions, the simplest possible viscosity-increasing agents must be added into the
moisturizer must contain three ingredients, formulation, such as polymers (carbomer, acry-
namely, water, a lipid (oil), and an emulsifier. lates copolymer, xanthan gum) and/or high-melt-
Lipids can be of vegetable, animal, or mineral ing waxes (glyceryl stearate, cetearyl alcohol).
origin. Emulsifiers, which stabilize the lipid drop- Sensory properties may be modified with silicones,
lets in an emulsion, can be either low-molecular such as dimethicone and cyclohexasiloxane.
substances, for example, stearic acid, or long- Additionally, moisturizers may contain several
chained polymers of large size, such as acrylates/ other ingredients, such as preservatives, antioxi-
C1030 alkyl acrylate crosspolymer or carbomer. dants, vitamins, herbal extracts, salts, and UV fil-
However, it is rare that emulsions contain only three ters. Depending on the composition of a moisturizer,
ingredients, and usually, they are mixtures of at least the pH is adjusted to between slightly acidic and
1520 substances. Moisturizers with over 5060 slightly alkaline with typical ranges from 4 to 7,
ingredients have also been encountered. Those but in case of formulations containing stearic acid
additional ingredients allow achieving desired prop- and zinc oxide, pH is slightly alkaline.
erties, efficacy, and stability of the product. Since the majority of moisturizers contain
Moisturizers usually contain humectants, such several ingredients, identification of the parame-
as: (1) polyols, e.g., glycerin, propylene glycol, ters responsible for their effects on the skin bar-
butylene glycol, and sorbitol; (2) alpha-hydroxy rier is difficult. Consequently, factors such as the
acids (AHAs) and their salts, e.g., glycolic acid, concentration and type of lipids, humectants, and
lactic acid, and sodium lactate; (3) low-molecular other ingredients, as well as pH adjustment,
substances, e.g., urea, betaine, and amino acids; should be taken into account.
and/or (4) high-molecular polymers with water-
binding capacity, e.g., sodium hyaluronate. Many
ingredients used in moisturizers are the same as 37.3 Methods Used for Evaluation
those found in the epidermis or on the skin sur- of the Skin Barrier Function
face: fatty acids, ceramides, vitamins, urea, lactic
acid, pyrrolidone carboxylic acid (PCA), etc. Methods used for evaluation of the skin and its
To increase stability of the emulsion and to barrier function, including its responses to mois-
adjust its rheology to either a cream or lotion form, turizers, are numerous. Skin condition may be
528 I. Buraczewska-Norin

assessed visually, for example, for dryness, scal- rier function, such as TEWL, skin capacitance,
ing, and redness. There are several instruments and susceptibility to an irritant, for example, SLS
available for noninvasive assessments of the skin, and nickel salts, were observed.
where no skin sampling is necessary, as they mea- Improvement of the skin barrier function was
sure the functional changes on the skin surface or reported after 2-, 3-, or 4-week treatments of nor-
within a defined skin depth, for example, TEWL, mal or atopic skin with moisturizers containing
skin capacitance, blood flow, pH, surface topogra- urea, which decreased TEWL and susceptibility
phy, and elasticity. Such equipment is often por- to sodium lauryl sulfate (SLS) or nickel [812].
table and easy to use, and consequently, Treatment with a moisturizer containing another
noninvasive measurements are a common tool in widely used humectant, glycerine, seems to have
dermatological research. Today, assessment of a less pronounced impact on the skin barrier
TEWL is the most common method for evaluation [12, 13], even if the clinical effects were similar
of the skin barrier function. TEWL is increased to urea cream [14]. On the other hand, in studies
when the skin barrier is impaired, for example, in by Held et al. [15, 16], a moisturizer containing a
dry skin disorders or after damage with an irritant, high lipid content (70%) impaired the barrier of
but also when the skin is excessively hydrated. normal skin after 5-day and 4-week treatments,
However, in order to investigate processes in measured as increased skin susceptibility to SLS,
the skin in greater detail, at the biochemical level, although no change in baseline TEWL of undam-
skin samples are required. They may be punch or aged skin was found. The same cream also
shave biopsies or samples obtained by tape strip- increased susceptibility to nickel in nickel-aller-
ping. Studies utilizing such invasive methods are gic volunteers after 7-day treatment [17]. In a
more complicated to perform and require more study on patients with lamellar ichthyosis, an
resources and assessment from ethical perspec- 8-week treatment with moisturizers containing
tives. Although they may be common in basic high amounts of lactic acid significantly increased
dermatological research, they have rarely been TEWL, while dryness and scaling decreased [18].
used in research about moisturizers and their Moisturizers have also been shown to influence
effect on the skin barrier. It is also possible to skin barrier recovery after exposure to a skin
perform studies in vivo on mice or in vitro on irritant [9, 19].
keratinocyte cultures or skin equivalents. How- The described functional changes indicate that
ever, results obtained from experiments per- moisturizers may also have an impact on the epi-
formed using animal models or in vitro systems dermis at the molecular level, even if they do not
do not always correlate to the in vivo situation in contain any substance with known pharmacologi-
humans. Analyses of human skin biopsies may cal activity, and that these functional and molecular
give a lot of information about changes in epider- changes may be linked to each other. Indeed, Short
mal structure, and gene and protein expression, et al. [20] showed that a moisturizer containing
as well as allowing for staining with antibodies high amounts of glycerin and silicones increased
against various proteins. maximum epidermal thickness, decreased epider-
mal melanin content, and altered protein expres-
sions of keratins 6, 10, and 16, as assessed with
37.4 Functional and Biochemical immunohistochemistry after a 4-week treatment.
Changes in the Skin Barrier Moreover, all these changes were accompanied by
After Long-Term Use of decreased TEWL. Another study revealed that a
Moisturizers 6-week treatment with a moisturizer containing
glycerin and erythritol increased the number of
The few studies which examined long-term treat- keratinocytes with a well-matured cornified enve-
ment with moisturizers on normal and diseased lope; also, the interleukin-1 receptor agonist/inter-
human skin have shown functional changes in the leukin-1a (IL-1ra/IL-1a) ratio in the epidermis
skin barrier, as measured by noninvasive tech- was altered [21]. Of course, it may well be indi-
niques. Both increases and decreases in skin bar- vidual ingredients that affect the skin at a molecular
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 529

level, i.e., not the moisturizer as a whole. Linoleic to date. Moreover, this time is similar or slightly
acid, found in certain vegetable oils commonly longer than the average turnover time of the
used in topical preparations, is a ligand of peroxi- epidermis, which is reported to be 4045 days
some proliferator-activated receptors (PPAR) [24, 25].
which has been found to have effects comparable to
a potent topical glucocorticoid in animal models
[22]. Another substance, nicotinamide, was shown 37.5.1 Choice of Test Moisturizers
to increase levels of ceramides and free fatty acids
and to decrease TEWL, as compared with placebo- The three test moisturizers used in the investiga-
treated skin [23]. tion were formulated in such way as to minimize
These studies demonstrate that prolonged appli- their complexity in order to diminish the number
cation of moisturizers may have a substantial of possible confounding factors. They therefore
impact on the skin and its barrier, from both a func- contained only a few ingredients and are hereaf-
tional and biochemical perspective. However, fac- ter called simple creams, in contrast to the
tors responsible for the observed effects are majority of commercially available topical prep-
unknown, especially since the studies were per- arations that contain over a dozen substances. In
formed using moisturizers containing several addition, one moisturizer, called Complex cream,
ingredients. Therefore, in order to gain further containing several ingredients and previously
understanding of the mechanism by which long- shown to influence the skin barrier in normal and
term treatment with moisturizers influences the atopic skin, was chosen as a reference for this
skin in vivo, investigations should be performed in investigation [10, 26].
a way that allows identification of ingredients The three simple creams were o/w emulsions
responsible, for example, using moisturizers con- containing 40% lipid phase consisting of either
taining as few ingredients as possible and carry out pure hydrophobic hydrocarbons derived from min-
studies that are placebo controlled. Moreover, non- eral oil (isohexadecane and paraffin = Hydrocarbon
invasive techniques should be simultaneously cou- cream) or a more polar vegetable oil consisting of
pled with other tools, allowing for investigation of triglycerides and sterols (canola oil = Canola cream
the epidermis at the molecular and cellular level, to and Canola/urea cream). The Canola/urea cream
connect functional and biochemical changes to contained additionally 5% urea. The simple creams
each other, if possible. were stabilized with a polymeric emulsifier, acry-
lates/C1030 alkyl acrylate crosspolymer, which
was not expected to penetrate or influence the skin
37.5 Effect of 7-Week Use of barrier function due to its large molecular size.
Moisturizers on the Skin A gel, consisting of water and this polymer, was
Barrier also investigated (Polymer gel). By contrast,
Complex cream contained a mixture of lipids of
In order to find out more about the mechanisms by various origins and was emulsified with a combina-
which moisturizers influence the skin, the investiga- tion of polymers and low-molecular emulsifiers.
tions presented in this chapter were performed using Due to such choice of ingredients, the following
very simple moisturizers, containing only few factors were examined: (1) the impact of a humec-
ingredients. Noninvasive techniques were per- tant (urea); (2) difference between creams of mini-
formed as well as molecular analysis of skin biop- mum complexity (Hydrocarbon, Canola and
sies, such as quantitative real-time polymerase chain Canola/urea creams) and a cream containing more
reaction (QRT-PCR), immunofluorescence, immu- ingredients (Complex cream); and (3) different
nohistochemistry, and histological evaluations. types of lipids (hydrocarbons or vegetable oil). All
To investigate the effect of long-term use of test preparations had their pH adjusted to about 5
moisturizers, the duration of use was chosen to [2729]. Table 37.1 presents detailed compositions
be 7 weeks, which is longer than the application along with the number of volunteers testing each
time in the majority of similar studies performed preparation.
 530

Table 37.1 Composition of the test moisturizers used for investigating the effect of their 7-week long use on the skin barrier in healthy human volunteers, their ingredients, and
number of volunteers testing them
Number of volunteers and type
Test preparation Lipids Emulsifiers Other ingredients Urea of investigations
Complex creama 20% 1.3% Water, propylene glycol, 5% 15, functional changes [27]
Capric/caprylic triglyceride, PEG-100 stearate, carbomer, glyceryl polymethacry- 10, functional and biochemical
canola oil, cetearyl alcohol, polysorbate 60 late, dimethicone, changes [28, 29]
paraffin, glyceryl stearate sodium lactate,
methylparaben,
propylparaben, lactic
acid, citric acid
Hydrocarbon cream 40% 0.4% Water 0% 16, functional changes [27]
Isohexadecaneb (20%), paraffinc Acrylates/C1030 alkyl 10, functional and biochemical
(20%) acrylate crosspolymer d changes [28, 29]
Canola cream 40% 0.4% Water 0% 15, functional changes [27]
Canola oile Acrylates/C1030 alkyl
acrylate crosspolymer d
Canola/urea cream 40% 0.4% Water 5% 16, functional changes [27]
Canola oile Acrylates/C1030 alkyl
acrylate crosspolymer d
Polymer gel 0% 0.4% Water, methylparabenf 0% 16, functional changes [27]
Acrylates/C1030 alkyl
acrylate crosspolymer d
Adapted from Buraczewska et al. [27], with permission
a
Canoderm krm 5%, ACO HUD NORDIC AB, Stockholm, Sweden
b
Arlamol HD, Uniqema, Gouda, The Netherlands
c
Merkur White Oil Pharma, Merkur Vaseline, Hamburg, Germany
d
Pemulen TR-2, Noveon Inc., Cleveland, OH, USA
e
Akorex L, Karlshamns AB, Karlshamn, Sweden
f
Nipagin M, Clariant International, Pontypridd, United Kingdom
I. Buraczewska-Norin
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 531

37.5.2 Experimental Design 37.5.3 Results

The studies were double blinded and random- Twice-daily treatment of normal skin of volar
ized. Only volunteers with normal, healthy skin forearms for 7 weeks with all test preparations
were used. They were allowed to wash normally, examined in this research induced changes in the
but not to use any skin care products on the test skin barrier function, as evaluated with noninva-
areas at least 3 days before, and during, the test sive methods. Hydrocarbon cream, Canola cream,
period. and Canola/urea cream appear to have a negative
In the first study, only functional changes in effect on the skin barrier, as their application
the skin barrier were investigated. Volunteers resulted in elevated TEWL and increased skin sus-
treated one volar forearm twice daily for 7 weeks ceptibility to SLS. Polymer gel, consisting of poly-
with one test preparation (Hydrocarbon cream, mer and water, had similar effects. Moreover,
Canola cream, Canola/urea cream, Polymer gel, Hydrocarbon cream decreased skin capacitance,
or Complex cream), leaving the other forearm to indicating dryness. To the authors knowledge, it is
serve as the untreated control. After 7 weeks, the first reported case of skin dryness induced by a
both volar forearms, treated and control, were moisturizer. By contrast, treatment with Complex
exposed to 1% aqueous solution SLS for 24 h. cream decreased TEWL and susceptibility to SLS
TEWL and blood flow were assessed on the SLS- (Figs. 37.3 and 37.4) [27]. Use of Hydrocarbon
exposed and undamaged skin on each forearm on and Complex creams influenced TEWL of gluteal
day 1. Skin capacitance was also measured on skin in a way similar to forearms [29].
undamaged skin [27]. Molecular analyses of skin biopsies after use
In the following studies, both functional and of Hydrocarbon cream and Complex cream on
biochemical changes in the skin after 7-week normal skin for 7 weeks revealed that these two
treatment were investigated. The volunteers creams induced different effects on the mRNA
applied one of the test preparations, Complex expression of genes involved in the keratinocyte
cream or Hydrocarbon cream, on one volar fore- differentiation, corneocyte formation and desqua-
arm and also on one buttock twice daily for mation, as well as lipid metabolism. Treatment
7 weeks, leaving the other forearm and buttock with Hydrocarbon cream changed the expression
untreated to serve as control sites. Complex cream of 11 out of 22 analyzed genes, while exposure to
and Hydrocarbon cream were chosen for the Complex cream affected expression of only two
additional investigations based on the results from of them (Table 37.2). At the same time, the mois-
the first study, which showed that these two mois- turizers had no effect on protein expression of
turizers have an opposite effect on the skin bar- three analyzed proteins: involucrin, transglutami-
rier, as seen from functional changes [27]. After nase 1, and filaggrin. Stratum corneum thickness,
7 weeks, one shave and one punch biopsy were epidermal thickness, the size of corneocytes, and
taken from each buttock, preceded by TEWL nonpolar lipid staining were also unaffected by
measurements of the biopsy area. Biopsies were the treatments [28, 29].
used for investigating the biochemical changes in The studies therefore revealed that moisturiz-
the skin: the shave biopsies were used for gene ers have different effects on the barrier function of
expression analysis using quantitative real-time normal skin and that the changes were dependent
polymerase chain reaction (QRT-PCR) and the on the composition of the moisturizer. The test
punch biopsies for histological and other molecu- preparations had an impact on the normal func-
lar evaluations. Moreover, the skin of the fore- tion and/or structure of the skin. The observed
arms was investigated for functional changes, in a changes may be caused either by the ingredients
way similar to the first study, using noninvasive of the test preparations (e.g., lipids, humectants,
methods [28, 29]. emulsifiers, or water), which have a direct or indi-
532 I. Buraczewska-Norin

200

*p = 0.018

p = 0.011

p = 0.007

p = 0.414

p = 0.016

p = 0.572

p = 0.017

p = 0.453

p = 0.006

p = 0.167
175

TEWL

*
150 Capacitance
Percentage ratio [%]

125

100

75

50
*

Hydrocarbon cream Canola cream Canola/urea cream Polymer gel Complex cream

Fig. 37.3 TEWL and skin capacitance of undamaged extend from the top and bottom of the box to the lowest
skin treated with test preparations for 7 weeks. Values are and the highest observation within a defined region, with
presented as percentage ratio of the values obtained from outliers plotted as asterisks outside this region. Reference
the corresponding control areas, which serve as 100%. line is given at 100%. N = 15 for Canola cream and
P-values relate to differences from control areas. The Complex cream and 16 for Canola/urea cream,
results are presented as box plots with the median value as Hydrocarbon cream, and Polymer gel (From Buraczewska
a line across the box and the first quartile value at the bot- et al. [27]. with permission)
tom and the third at the top. The whiskers are lines that

rect effect on skin barrier components, or by the trigger epidermal keratinocytes to alter their gene
physical effects of moisturizers on the skin, such expression. An example of such functional
as occlusion or pH. change may be the delivery of exogenous lipids
from the moisturizers into the intercellular lipids
of the stratum corneum, resulting in altered bar-
37.5.4 Possible Explanations rier function, or the impact of emulsifiers, humec-
of Observed Effects tants, or exposure to water.

Despite the apparent relationship between gene 37.5.4.1 Lipids

expression and the skin barrier function, it was Lipids in moisturizers may remain on the skin
not possible to ascertain whether the observed surface or enter the skin [30], and more physio-
functional changes, such as increased/decreased logical lipids may penetrate into the epidermis
TEWL, susceptibility to SLS or skin capacitance, and affect skin barrier structure and recovery
were the effect of molecular changes in the epi- [3133]. Changes in lateral packing of stratum
dermis or vice versa (hen-and-egg situation). corneum lipids were observed in patients with
The first possibility is that functional changes in atopic dermatitis and psoriasis after 3-week treat-
the skin barrier, induced by moisturizers, could ment with a moisturizer containing 10% petrola-
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 533

p = 0.009

p = 0.034

p = 0.044

p = 0.045

p = 0.001

p = 0.001

p = 0.036

p = 0.712

p = 0.021

p = 0.033
350

*
300
* TEWL

Blood flow
250

*
Percentage ratio [%]

*
200

*
*
150

100

50

0
Hydrocarbon cream Canola cream Canola/urea cream Polymer gel Complex cream

Fig. 37.4 TEWL and blood flow of SLS-exposed skin For explanation of the graph, see Fig. 37.3 (From
treated with test preparations, in relation to control areas Buraczewska et al. [27], with permission)
(not treated with moisturizers but also exposed to SLS).

tum [34]. Therefore, in our study, the possible be altered. Such changes may be recognized as
penetration of lipids from test moisturizers could barrier impairment by epidermal keratinocytes,
alter skin barrier properties. initiating a repair process including altered gene
The three simplified creams investigated, all expression.
of which had a negative effect on the skin barrier
(Hydrocarbon cream, Canola cream, Canola/urea 37.5.4.2 Water
cream), contained high proportions of lipids, Penetration of lipids, however, cannot explain the
40%, but the type of lipid (hydrocarbons or trig- impairment of the skin barrier obtained after treat-
lycerides) was of no importance to the effect. At ment with Polymer gel, as it contains no lipids but
the same time, Complex cream, containing 20% much more water compared with other moistur-
lipids, did not deteriorate the skin barrier. Effects izers, 99%. After application of a moisturizer,
similar to those for the simplified creams have water, which is typically one of the main ingredi-
been obtained with a moisturizer containing 70% ents, evaporates within a short time [35, 36]. The
lipids which made the skin more susceptible to effect on the skin barrier of twice-daily exposure to
SLS [15, 16]. These results suggest that differ- water for a few weeks is unknown. It has been
ences in the lipid content or uptake rate may be shown that prolonged contact with water disrupts
important for the effect of moisturizers on the the intercellular lipid lamellar structure in the
skin barrier function. As exogenous lipids may stratum corneum and may contribute to dryness
change the highly organized structure of intercel- and increased TEWL [37]. Moreover, changes in
lular lipid layers, TEWL or the ion flux may also gene expression of epidermal enzymes and
534 I. Buraczewska-Norin

Table 37.2 Summary of the gene expression analysis of skin biopsies after use of Hydrocarbon cream and Complex
cream on normal skin for 7 weeks, presented in Buraczewska et al. [28, 29]
Function Gene Complex cream Hydrocarbon cream
Proteins involved in keratinocyte IVL
differentiation TGM1
FLG
CDKN1A
Enzymes involved in the process of KLK5
desquamation KLK7
Enzymes involved in ceramide GBA
synthesis SPTLC2
SMPD1
UGCG
Enzymes involved in cholesterol HMGCS1
synthesis HMGCR
Enzymes involved in fatty acid ACACB
metabolism FASN
ACSL1
Nuclear hormone receptors PPARA
PPARB
PPARG
RXRA
Lipoxygenases ALOX12B
ALOXE3
Interleukin IL1A
Molecular analyses revealed that these two creams induced different effects on the mRNA expression of genes involved
in the keratinocyte differentiation, corneocyte formation and desquamation, as well as lipid metabolism. Treatment with
Hydrocarbon cream changed the expression of 11 out of 22 analyzed genes, while exposure to Complex cream affected
expression of only two of them
increased messenger ribonucleic acid (mRNA) expression in comparison with untreated skin, decreased mRNA
expression, no difference, ACACB acetyl-CoA carboxylase beta, ACSL1 acyl-CoA synthetase long-chain family mem-
ber 1, ALOX12B arachidonate 12-lipoxygenase, 12R type, ALOXE3 epidermal arachidonate lipoxygenase 3, CDKN1A
cyclin-dependent kinase inhibitor 1A, FASN fatty acid synthase, FLG profilaggrin, GBA b-glucocerebrosidase, HMGCR
HMG-CoA reductase, HMGCS1 HMG-CoA synthase 1, IL1A interleukin-1a, IVL involucrin, KLK5 kallikrein 5, KLK7
kallikrein 7, PPARA PPAR-a, PPARB PPAR-b, PPARG PPAR-g, RXRA RXR-a, SMPD1 acid sphingomyelinase,
SPTLC2 serine palmitoyltransferase 2, TGM1 transglutaminase 1, UGCG UDP-glucose ceramide glucosyltransferase

nonenzymatic proteins were found after exposure Furthermore, though all simple creams and
of skin to water (only) under occlusion [38]. It has Complex cream contain similar amounts of water,
also been suggested that the higher TEWL of the around 60%, they induced different changes in
dorsal surface of hands, compared with the fore- the skin barrier.
arm and back, may be due to more frequent con-
tact with water [39]. Increased TEWL and dryness 37.5.4.3 Emulsiers and Polymers
of the skin could also be caused by contact with Emulsifiers are essential in moisturizers, as they
irritants, but the test preparations, including stabilize the emulsion. Emulsifiers commonly
Polymer gel, were shown not to be irritant by an used in o/w emulsions have been shown to influ-
acute irritancy test and by blood flow measure- ence the skin barrier function in normal and SLS-
ments. Moreover, treatment with Hydrocarbon exposed skin [40]. Although the emulsifier used
cream and Complex cream did not alter expres- in the simple creams and Polymer gel, acrylates/
sion of IL1A, indicating lack of inflammation. C1030 alkyl acrylate crosspolymer, was
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 535

expected not to penetrate into the epidermis due of the moisturizers, including the lipid content.
to its large molecular size, in addition to the com- Urea has also been found to diminish epidermal
ments on water made above, its negative effect proliferation in psoriasis, measured as a decreased
could have been caused by monomers which may expression of involucrin and an increased expres-
be present at low concentrations. However, the sion of cytokeratins [46]. However, no difference
Complex cream also contained a polymeric emul- in expression of proteins or the genes involved in
sifier, carbomer, which is similar in structure to keratinocyte differentiation and desquamation,
acrylates/C1030 alkyl acrylate crosspolymer, apart from CDKN1A, was detected. Decreased
but lacked a negative impact on the skin barrier. expression of CDKN1A suggests influences in
Interestingly, it has been suggested that polymers cell cycle progression after treatment with the
themselves may have an effect on the skin bar- urea-containing Complex cream, which could be
rier, as tested on mice, accelerating or delaying interpreted as decrease in cell differentiation [47,
the barrier recovery [41]. Although this phenom- 48], though not detectable by histological evalua-
enon is not fully understood, it is possible that tions, since the thickness of the epidermis and the
polymers together with their counterions form an stratum corneum remained unchanged, as did
electric double layer on the skin surface, influ- corneocyte size.
encing the skin barrier [41].
37.5.4.5 Occlusion
37.5.4.4 Humectants As an alternative explanation, gene expression
Humectants that are added to moisturizers, such may be influenced by altered activity of various
as urea, glycerin, and propylene glycol, may pen- signaling pathways, resulting in a changed skin
etrate into the skin [42, 43]. It has been suggested barrier function. However, it is still not clear what
that the decreased TEWL and lower response to type of signal can trigger changes in gene expres-
SLS after treatment with Complex cream was sion: the changes could be due to ingredients
due to its urea content [10, 11, 26]. Moreover, it included in the moisturizers or could have been
could be expected that the addition of urea to a indirectly induced by changes in ion or water
moisturizer would be beneficial, as it has been flux. One possible signal may be a reduction in
reported that urea replaces water in the skin, TEWL due to occlusion by the topically applied
leaving the physical properties of the stratum moisturizer, hypothetically resulting in water flux
corneum intact [44]. However, the addition of changes. It was previously shown that occlusion
urea to Canola/urea cream did not improve the of the skin with a semipermeable membrane,
skin barrier. It might be that in the Canola/urea mimicking the occlusion effect by a moisturizer,
cream, penetration of urea was different than in decreased TEWL and susceptibility to an irritant,
case of Complex cream due to the different emul- in a group wearing the membrane 23 h a day for
sion system. 3 weeks, suggesting changes in skin barrier func-
Urea has been reported to act as a keratolytic tion [49]. However, there is no evidence of a cor-
agent [45]; however, absence of a measurable relation between the occlusive properties of
thinning of the stratum corneum by the 5% urea creams and their effects on the skin barrier, deter-
in Complex cream in the present investigation mined as the degree of irritation after SLS expo-
[29] does not support keratolytic properties at a sure, since Complex cream and a lipid-rich cream
concentration commonly found in moisturizing show similar occlusive capacity[49], but opposite
creams. effects on the skin barrier function [10, 11, 15,
Although treatment with Complex cream con- 16, 26]. Therefore, the detected difference in the
taining 5% urea significantly decreased TEWL effect on the skin barrier is more likely to have
and susceptibility to SLS, it had only minor causes other than difference in occlusion between
effects on the mRNA expression of the analyzed the creams. It is still not known whether a pro-
genes. Therefore, the effect of urea on the barrier longed occlusion per se influences mRNA expres-
function may depend on the whole composition sion, since no investigation of this aspect has yet
536 I. Buraczewska-Norin

been performed. It is also worth noting that the enced the skin barrier in a way detectable by non-
semiocclusive layer formed by a moisturizer is invasive measurements and molecular analyses
usually removed from the skin within a few of mRNA expression: the latter, however, were
hours. not confirmed at the protein level.

37.5.4.6 pH 37.5.5.1 Effect of Hydrocarbon Cream on

The impact of the pH of topical preparations on the the Skin Barrier
skin barrier is still not fully understood. A study Hydrocarbon cream appears to have a negative
investigating the effect of moisturizers of pH 4 and effect on the skin barrier since it elevates the
7.5 showed that the pH of moisturizers seems not TEWL and makes the skin more susceptible to
to be of major importance for their effects on the SLS. Hydrocarbon cream increased the mRNA
skin barrier: no difference in the impact on skin expression of genes responsible for the synthesis
barrier recovery or susceptibility to an irritant was of ceramides and cholesterol, GBA, SPTLC2,
found [50]. The lack of difference in effect on skin SMPD1, and HMGCS1, but not the expression of
barrier recovery of the moisturizers with acidic or free fatty acid-metabolizing enzymes. These
alkaline pH values in our study disagrees with a results can be interpreted as an epidermal response
previous study in mice, where barrier recovery was to barrier damage. The results support such a
delayed after exposure to slightly alkaline pH [51]. hypothesis since Hydrocarbon cream increased
However, the endogenous mechanisms involved in also mRNA expression of IVL and TGM1, both
the formation of a pH gradient in the stratum cor- being key proteins in formation of the cornified
neum [5256], as well as continuous exogenous envelope. Other studies of skin barrier damage
excretion of sweat and sebum and NMF, could be induced in mice by acetone, surfactant, tape strip-
expected to counteract the change in the skin sur- ping, or an essential fatty acid-deficient diet, also
face pH induced by a topical application. It has describe increased mRNA expressions or activities
been shown that after use of an alkaline soap, ini- of lipid-processing enzymes [5861]. However, in
tially elevated skin surface pH decreases back a recent study on healthy human volunteers, two
toward acidic values [57], and therefore the same creams containing 5% urea, the same amount as in
effect can be expected after a moisturizer. Complex cream, increased mRNA expression of
Moisturizers usually contain only small quantities IVL, FLG, loricrin, and TGM1 after a 2-week
of buffering ingredients, which make them unable treatment, which was also accompanied by a sig-
to produce persistent changes in the skin surface nificant decrease in TEWL [62]. This gene expres-
pH, while the mentioned skin barrier recovery sion profile is similar to the effect of Hydrocarbon
study on mice was performed using strong buffer cream, although the effect on TEWL is like that of
systems [51]. Moreover, the majority of moistur- Complex cream. This suggests that the relation-
izers have pH in a range of 46, which is in the ship between mRNA expression and TEWL is not
range of the skin surface pH. However, it cannot be so straightforward and that the gene expression
excluded that some ingredients of moisturizers profile may change during treatment time.
may penetrate into the epidermis and influence the
pH gradient there, which would have an effect on 37.5.5.2 Nuclear Receptors
the skin barrier function. and Lipoxygenases
Hydrocarbon cream decreased the mRNA expres-
sion of PPARG as well as influenced mRNA
37.5.5 Molecular Changes Induced expression of the two lipoxygenases, ALOX12B
by Hydrocarbon and Complex and ALOXE3. PPAR-g and other PPARs are
Creams involved in the regulation of keratinocyte differ-
entiation and expression of several of the lipid-
Regardless of the mechanisms involved, processing enzymes. In skin equivalent models,
Hydrocarbon cream and Complex cream influ- activation of PPAR-a receptors by synthetic
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 537

ligands resulted in an increase in the mRNA not accompanied by a corresponding increase in

expression of lipid-metabolizing enzymes, three protein expression. This may indicate that the
of which were the same as in our present study epidermis was preparing itself for possible repair
(GBA, SPTLC2, and HMGCS1) [63]. Although of the impaired skin barrier or that the repair
Hydrocarbon cream does not contain any known phase had already been completed, but there was
PPAR agonists, the elevated expressions of still ongoing transcription. Another reason for the
ALOX12B and ALOXE3, genes of lipoxyge- lack of correlation between mRNA and protein
nases that produce derivatives acting as PPAR-a expression after treatment may be that the mRNA
agonists [64], may suggest an endogenous forma- had not been translated into protein or that the
tion of PPAR-a agonists by the Hydrocarbon protein turnover had increased for unknown rea-
cream treatment. sons. The inhibition of mRNA translation has
While Hydrocarbon cream decreased the been shown to be caused by microRNA. For
mRNA expression of PPARG, Complex cream example, certain genes in the epidermis of psori-
increased it. However, no difference in protein asis patients exhibit diminished translation due to
expression of PPAR-g was found after use of any the presence of certain microRNAs [69].
of the test preparations. Nevertheless, the oppo- Furthermore, since protein and mRNA expres-
site effect on the expression of PPARG and sions were analyzed on a single occasion, after
TEWL induced by Hydrocarbon and Complex 7 weeks of treatment, it is possible that changes
cream, as well as a linear correlation between in protein levels occurred at another time, per-
these two parameters in untreated skin, suggests haps after a few days, but became normalized
an importance of PPAR-g for the skin barrier after a few weeks due to some adaptation mecha-
function. Usually, PPAR-g activation affects cell nism. As already mentioned before, a recent
proliferation, cell differentiation, immune study with two creams containing 5% urea
responses, and apoptosis in the skin. PPARg sig- showed mRNA expression profile of IVL, FLG,
naling is triggered by various types of ligands, and TGM1 which differed from our study; how-
including linoleic acid (reviewed by Feingold ever, the analysis was done after 2 weeks of treat-
[65], Schmuth et al. [66], and Sertznig et al. [67]). ment instead of 7 [62].
Although Complex cream contains a vegetable It is also possible that the analytical method
oil, which may contain a small fraction of free used was not sufficiently sensitive to detect dif-
fatty acids, for example, linoleic acid, our present ferences in protein expression. The mRNA
results do not suggest any activation of PPARs. expression increased by about 55% in the case of
A linear correlation between TEWL and IVL and 120% in the case of TGM1, which may
mRNA expression in untreated skin was found for not be enough to show in detectable differences
ACACB. The enzyme encoded by this gene is using an immunofluorescence technique. Other
involved in synthesis of fatty acids, and its impor- techniques, for example, western blot, may have
tance for the skin barrier has been shown after been more powerful, but would have necessitated
barrier disruption in mice, which increased mRNA obtaining additional biopsies from the volunteers,
expression of this enzyme [59]. The regulation of which was not possible for ethical reasons.
ACACB in keratinocytes is unknown, but in However, another study describes changes in
mouse hepatocytes, it has been shown that the mRNA expression of a magnitude similar to that
PPAR-a agonist WY-16,643 increases the expres- seen in the present study, resulted in visible
sion of ACACB [68]. increased protein levels after 17 days after expo-
sure to SLS [38]. This suggests that the effect of
37.5.5.3 Enzymes and Proteins Involved moisturizers at the protein level may also have
in Keratinocyte Differentiation occurred earlier.
and Desquamation Exposure to Hydrocarbon cream also increased
Treatment with Hydrocarbon cream increased the gene expression of KLK5 and KLK7, which
the mRNA level of INV and TGM1, but it was may suggest an excessive desquamation, since
538 I. Buraczewska-Norin

these two proteases are involved in this process However, the mechanisms behind the observed
[7073]. However, since the thickness of the stra- effects are still not fully understood. The observed
tum corneum remained unchanged, it could be outcome is most likely the combination of inter-
possible that treatment with Hydrocarbon cream play and effects of several factors, rather than
initially induced thickening of stratum corneum, only one, which makes it more difficult to draw
but increased performance of kallikreins counter- any firm conclusions. More research of this kind
acted it. Another possibility is that both prolifera- is needed to better understand the mechanism of
tion as well as desquamation increased action of moisturizers. Such research would aid
simultaneously, which would end in unchanged in the treatment of various skin disorders through
thickness. However, the altered expression of improved design of moisturizers, which can tar-
kallikreins may also be due to other, not well- get specific skin problems and conditions both
known, functions in the skin barrier since it has more efficiently and safely.
been shown that kallikrein 7 degrades some lipid- In the present investigations, traditional, non-
processing enzymes [74]. invasive methods to investigate the skin barrier
The altered expression of kallikreins may also function were used, combined with invasive tech-
be linked in some way to decreased skin capaci- niques allowing studying changes in the epider-
tance after use of Hydrocarbon cream. This may mis after use of moisturizers at the molecular and
indicate low skin hydration levels [75] since these cellular level. Analysis of gene and protein
enzymes have been found to have increased pro- expressions and histological evaluations lead to
tein expression in psoriasis [76] and atopic der- new hypotheses and answer more questions than
matitis [77]. However, the protein expression of noninvasive methods alone.
kallikreins was not assessed in the present study. The investigation showed that treatment with
Interestingly, decreased skin capacitance was not moisturizers might change gene expression of a
accompanied by any change in the mRNA expres- number of epidermal proteins, including struc-
sion of FLG or the protein expression of filag- tural proteins and enzymes. It was performed on
grin, which degrades into free amino acids and selected genes known to be important for the
PCA, the main components of NMF (reviewed skin barrier, and since their number was not very
by Rawlings et al. [78, 79]). high, QRT-PCR was used for analyses. However,
further investigations could also include cDNA
microarrays, which allow for screening several
37.6 Conclusions and Future thousands of genes at the same time. This would
Perspectives give a broader perspective over changes in gene
expression in the epidermis and help to identify
In the present investigation, after long-term treat- additional genes and proteins that should be
ment, moisturizers were examined for their effect investigated in more details.
on the skin barrier with regard to such factors as Since the research investigated the effects of
pH, lipid type, the presence of a humectant, as moisturizers after 7 weeks of treatment, one may
well as complexity of the product [2729, 50]. consider exploring also their impact on the skin
Moisturizers are able to modify the skin barrier barrier at earlier time points. The course of gene
function, detected as changes in TEWL, skin and protein expression and histological changes
capacitance, and susceptibility to an irritant, and may vary between shortly after application to
also to change the mRNA expression of certain after few-week use. It would also be interesting
genes involved in the assembly, differentiation, to continue the investigation for some time after
and desquamation of the stratum corneum, as use of a moisturizer is terminated, following the
well as lipid metabolism. Therefore, moisturizers return of the skin barrier to the state from before
should not be perceived simply as inert topical the treatment.
preparations, even if they do not contain any sub- Although molecular analyses provide plenty
stance with known pharmacological activity. of information about the skin barrier, noninvasive
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 539

evaluations should be utilized as well, as they do on the skin, and their use could worsen the skin
not require skin sampling and provide a different condition, facilitate penetration of irritants, and
type of data, i.e., skin barrier function. The new even lead to eczema. Consequently, the composi-
types of noninvasive methods developed during tion of a moisturizer should be an important issue
recent years help us acquire detailed facts about when recommending it to a patient with skin
the skin structure and function in vivo and may problems since this choice may have an impact
be used in studies investigating the effects of on the skin status and therefore on quality of life.
moisturizers. For example, Raman spectroscopy Treatment with corticosteroids and other drugs
helps to evaluate the moisturizing effect by giv- improves the condition of the skin with eczema,
ing a detailed water profile in the epidermis and but a relapse may only be a question of time.
assess stratum corneum and epidermal thickness However, while the use of a moisturizer with the
[8082], as well as to follow drug penetration skin barrier-improving effect after corticosteroid
(reviewed by Wartewig et al. [83]). Multiphoton therapy may increase an eczema-free period in
laser tomography [84] and confocal laser scan- comparison with no treatment [87], it is not
ning microscopy (reviewed by Branzan et al. known if use of a moisturizer with barrier-impair-
[85]) allow us to look inside the skin and may ing properties causes an earlier relapse of eczema.
be exploited in various ways. This issue should be investigated further, as it
The results presented in this chapter as well as may have a major impact on the approach to the
other studies demonstrate that the composition treatment of dry skin disorders.
of moisturizers plays an essential role in their Improving or maintaining the skin status and
effects on the skin and its barrier function. quality of life may also involve more than choos-
Therefore, it would seem reasonable at first to ing a proper moisturizer since compliance to
systematically test various ingredients, combina- treatment is also required. If a moisturizer is not
tions of ingredients, and complete moisturizers attractive to a patient from a cosmetic perspec-
for their effects, in order to find those giving the tive, for example, because it is too greasy and
desired efficacy, both in healthy and in diseased tacky, difficult to apply, has an unpleasant odor,
skin. However, taking into consideration that or its package is impractical, there is a high prob-
over 500 ingredients classified as humectants ability that the patient will not use it according to
and about 1,500 emollients are available [86], guidelines and as a result will require more medi-
the number of possible combinations is endless, cal attention. The same problem may exist in the
even if the number of ingredients were limited to case of barrier creams, which are supposed to
only those used more frequently. Therefore, it is inhibit penetration of irritant substances.
more realistic to continue the research about Therefore, the cosmetic properties of moisturiz-
these few ingredients, which are common in ers must be taken into consideration during the
many moisturizers and for which some data is early stages of the development, which is a chal-
already available, regarding the effect of glyc- lenge for researchers and formulating chemists,
erin, urea, vegetable oils, and hydrocarbons. as various ingredients added to make a product
As the knowledge about the effect of various more stable and attractive may weaken its perfor-
ingredients and their combinations on the skin mance or cause adverse reactions.
barrier is scarce, testing of complete moisturizers In conclusion, it is important to remember that
is currently the best way to assure benefits for the moisturizers differ in their composition, which
consumers. However, although clinical trials are determines their impact on the skin barrier.
mandatory for pharmaceuticals (over-the-counter A better understanding of the influence of mois-
or prescription drugs) to prove their efficacy, turizers on the skin barrier, obtained by combina-
moisturizers available as cosmetic products are tion of noninvasive methods and molecular
rarely evaluated for their effect on the skin bar- analyses, would facilitate in the design of skin
rier. Therefore, in theory, some commercially care products adjusted to specific skin problems.
available moisturizers may have a negative impact It would also provide more efficient management
540 I. Buraczewska-Norin

of dry skin disorders and, hopefully, help to influ- DAPI 4-6-Diamidino-2-phenylindole

ence the development of moisturizers so that fewer FASN Fatty acid synthase
products will have negative effects on the skin. FLG Profilaggrin
GBA Glucocerebrosidase beta; acid (b-
glucocerebrosidase)
Take-Home Messages HMGCR 3-Hydroxy-3-methylglutaryl-CoA
Use of moisturizers is widespread not reductase (HMG-CoA reductase)
only among people with dry skin but HMGCS1 3-Hydroxy-3-methylglutaryl-CoA
also with normal, healthy skin. synthase 1 (HMG-CoA synthase 1)
Moisturizers are not inert topical prepa- IL1A Interleukin-1a
rations, and they are able to modify skin IVL Involucrin
barrier function, even if they do not con- KLK5 Kallikrein 5
tain any substance with known pharma- KLK7 Kallikrein 7
cological activity. mRNA Messenger ribonucleic acid
Moisturizers may improve the skin bar- NMF Natural moisturizing factor
rier function, which can even lead to o/w Oil-in-water
delay of eczema relapse, but also impair PBS Phosphate-buffered saline
it, leading to increased susceptibility to PCA Pyrrolidone carboxylic acid
irritants and dryness. PPARA Peroxisome proliferator-activated
Moisturizers differ in their composition, receptor alpha (PPAR-a)
which determines their impact on the PPARB Peroxisome proliferator-activated
skin barrier. receptor beta (PPAR-b)
The mechanisms behind the impact of PPARG Peroxisome proliferator-activated
moisturizers on the skin barrier are still receptor gamma (PPAR-g)
not fully understood. QRT-PCR Quantitative real-time polymerase
Development of moisturizers should chain reaction
encompass their effect on the skin bar- RT Reverse transcription
rier and be adjusted to specific skin RXRA Retinoid X receptor alpha (RXR-a)
problems. SLS Sodium lauryl sulfate
SMPD1 Sphingomyelin phosphodiesterase 1
acid lysosomal (acid sphingomyeli-
nase)
Abbreviations SPTLC2 Serine palmitoyltransferase long
chain base subunit 2 (serine palmi-
ACACB Acetyl-CoA carboxylase beta toyltransferase 2)
ACSL1 Acyl-CoA synthetase long-chain TEWL Transepidermal water loss
family member 1 TGM1 Transglutaminase 1
ACTB Actin beta (b-actin) UGCG UDP-glucose ceramide glucosyl-
ALOX12B Arachidonate 12-lipoxygenase 12R transferase
type
ALOXE3 Epidermal arachidonate lipoxyge-
nase 3
ARCI Autosomal recessive congenital
ichthyosis Acknowledgments I wish to express my sincere grati-
tude to my supervisors: Hans Trm, Marie Lodn, Berit
CDKN1A Cyclin-dependent kinase inhibitor 1A Berne, and Magnus Lindberg. The research presented in
cDNA Complementary deoxyribonucleic this chapter was financially supported by ACO HUD
acid NORDIC AB, Uppsala University, and the Welander and
CoA Coenzyme A Finsen Foundation.
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 541

References 17. Zachariae C, Held E, Johansen JD, Menne T, Agner T

(2003) Effect of a moisturizer on skin susceptibility to
NiCl2. Acta Derm Venereol 83(2):9397
1. Lodn M (2003) Role of topical emollients and mois-
18. Ganemo A, Virtanen M, Vahlquist A (1999) Improved
turizers in the treatment of dry skin barrier disorders.
topical treatment of lamellar ichthyosis: a double-
Am J Clin Dermatol 4(11):771788
blind study of four different cream formulations. Br J
2. Lodn M (2003) Do moisturizers work? J Cosmet
Dermatol 141(6):10271032
Dermatol 2(34):141149
19. Held E, Lund H, Agner T (2001) Effect of different
3. Proksch E, Lachapelle JM (2005) The management of
moisturizers on SLS-irritated human skin. Contact
dry skin with topical emollientsrecent perspectives.
Dermatitis 44(4):229234
J Dtsch Dermatol Ges 3(10):768774
20. Short RW, Chan JL, Choi JM, Egbert BM, Rehmus
4. Lewis-Jones S, Mugglestone MA (2007) Management
WE, Kimball AB (2007) Effects of moisturization on
of atopic eczema in children aged up to 12 years: sum-
epidermal homeostasis and differentiation. Clin Exp
mary of NICE guidance. BMJ 335(7632):12631264
Dermatol 32(1):8890, Epub 2006 Nov 27
5. Lodn M (1992) The increase in skin hydration after
21. Kikuchi K, Kobayashi H, Hirao T, Ito A, Takahashi H,
application of emollients with different amounts of
Tagami H (2003) Improvement of mild inflamma-
lipids. Acta Derm Venereol 72(5):327330
tory changes of the facial skin induced by winter
6. Lodn M (2005) The clinical benefit of moisturizers.
environment with daily applications of a moisturiz-
J Eur Acad Dermatol Venereol 19(6):672688; quiz
ing cream. A half-side test of biophysical skin
686677
parameters, cytokine expression pattern and the for-
7. Lodn M, Lindberg M (1994) Product testing - testing
mation of cornified envelope. Dermatology 207(3):
of moisturizers. In: Elsner P, Berardesca E, Maibach
269275
H (eds) Bioengineering of the skin: water and the stra-
22. Sheu MY, Fowler AJ, Kao J, Schmuth M, Schoonjans
tum corneum. CRC Press, Boca Raton, pp 275289
K, Auwerx J, Fluhr JW, Man MQ, Elias PM, Feingold
8. Lodn M (1996) Urea-containing moisturizers influ-
KR (2002) Topical peroxisome proliferator activated
ence barrier properties of normal skin. Arch Dermatol
receptor-alpha activators reduce inflammation in irri-
Res 288(2):103107
tant and allergic contact dermatitis models. J Invest
9. Lodn M (1997) Barrier recovery and influence of
Dermatol 118(1):94101
irritant stimuli in skin treated with a moisturizing
23. Tanno O, Ota Y, Kitamura N, Katsube T, Inoue S
cream. Contact Dermatitis 36(5):256260
(2000) Nicotinamide increases biosynthesis of cer-
10. Lodn M, Andersson AC, Lindberg M (1999)
amides as well as other stratum corneum lipids to
Improvement in skin barrier function in patients with
improve the epidermal permeability barrier. Br J
atopic dermatitis after treatment with a moisturizing
Dermatol 143(3):524531
cream (Canoderm). Br J Dermatol 140(2):264267
24. Weinstein GD, McCullough JL, Ross P (1984) Cell
11. Lodn M, Kuzmina N, Nyren M, Edlund F, Emtestam
proliferation in normal epidermis. J Invest Dermatol
L (2004) Nickel susceptibility and skin barrier func-
82(6):623628
tion to water after treatment with a urea-containing
25. Bergstresser PR, Taylor JR (1977) Epidermal turn-
moisturizer. Exogen Dermatol 3:99105
over timea new examination. Br J Dermatol 96(5):
12. Lodn M, Andersson AC, Andersson C, Frodin T,
503509
Oman H, Lindberg M (2001) Instrumental and derma-
26. Lodn M, Barany E, Wessman C (2004) The influence
tologist evaluation of the effect of glycerine and urea
of urea treatment on skin susceptibility to surfactant-
on dry skin in atopic dermatitis. Skin Res Technol
induced irritation: a placebo-controlled and random-
7(4):209213
ized study. Exogen Dermatol 3:16
13. Lodn M, Wessman C (2001) The influence of a
27. Buraczewska I, Berne B, Lindberg M, Trm H,
cream containing 20% glycerin and its vehicle on skin
Lodn M (2007) Changes in skin barrier function fol-
barrier properties. Int J Cosmet Sci 23:115119
lowing long-term treatment with moisturizers, a ran-
14. Lodn M, Andersson AC, Anderson C, Bergbrant IM,
domized controlled trial. Br J Dermatol 156(3):
Frodin T, Ohman H, Sandstrom MH, Sarnhult T, Voog
492498
E, Stenberg B, Pawlik E, Preisler-Haggqvist A,
28. Buraczewska I, Berne B, Lindberg M, Loden M,
Svensson A, Lindberg M (2002) A double-blind study
Torma H (2009) Moisturizers change the mRNA
comparing the effect of glycerin and urea on dry,
expression of enzymes synthesizing skin barrier lip-
eczematous skin in atopic patients. Acta Derm
ids. Arch Dermatol Res 301(8):587594. doi:10.1007/
Venereol 82(1):4547
s00403-009-0958-2
15. Held E, Agner T (2001) Effect of moisturizers on skin
29. Buraczewska I, Berne B, Lindberg M, Loden M,
susceptibility to irritants. Acta Derm Venereol 81(2):
Torma H (2009) Long-term treatment with moistur-
104107
izers affects the mRNA levels of genes involved in
16. Held E, Sveinsdottir S, Agner T (1999) Effect of long-
keratinocyte differentiation and desquamation. Arch
term use of moisturizer on skin hydration, barrier
Dermatol Res 301(2):175181. doi:10.1007/s00403-
function and susceptibility to irritants. Acta Derm
008-0906-6
Venereol 79(1):4951
542 I. Buraczewska-Norin

30. Ghadially R, Halkier-Sorensen L, Elias PM (1992) systems against osmotic stress: the urea-water-phospho-
Effects of petrolatum on stratum corneum structure lipid system. J Phys Chem B 110(47):2384523852
and function. J Am Acad Dermatol 26(3 Pt 2): 45. Hellgren L, Larsson K (1974) On the effect of urea on
387396 human epidermis. Dermatologica 149(5):289293
31. Man MQ, Feingold KR, Elias PM (1993) Exogenous 46. Hagemann I, Proksch E (1996) Topical treatment by
lipids influence permeability barrier recovery in ace- urea reduces epidermal hyperproliferation and induces
tone-treated murine skin. Arch Dermatol 129(6): differentiation in psoriasis. Acta Derm Venereol
728738 76(5):353356
32. Mao-Qiang M, Brown BE, Wu-Pong S, Feingold KR, 47. Weinberg WC, Denning MF (2002) P21Waf1 control
Elias PM (1995) Exogenous nonphysiologic vs physi- of epithelial cell cycle and cell fate. Crit Rev Oral Biol
ologic lipids. Divergent mechanisms for correction of Med 13(6):453464
permeability barrier dysfunction. Arch Dermatol 48. Chang BD, Watanabe K, Broude EV, Fang J, Poole JC,
131(7):809816 Kalinichenko TV, Roninson IB (2000) Effects of
33. Wertz PW, Downing DT (1990) Metabolism of topi- p21Waf1/Cip1/Sdi1 on cellular gene expression:
cally applied fatty acid methyl esters in BALB/C implications for carcinogenesis, senescence, and age-
mouse epidermis. J Dermatol Sci 1(1):3337 related diseases. Proc Natl Acad Sci U S A 97(8):
34. Pilgram GS, Vissers DC, van der Meulen H, Pavel S, 42914296
Lavrijsen SP, Bouwstra JA, Koerten HK (2001) 49. Buraczewska I, Brostrom U, Lodn M (2007) Artificial
Aberrant lipid organization in stratum corneum of reduction in transepidermal water loss improves skin
patients with atopic dermatitis and lamellar ichthyo- barrier function. Br J Dermatol 157(1):8286, Epub
sis. J Invest Dermatol 117(3):710717 2007 Jun 6
35. Blichmann CW, Serup J, Winther A (1989) Effects of 50. Buraczewska I, Lodn M (2005) Treatment of surfactant-
single application of a moisturizer: evaporation of damaged skin in humans with creams of different pH
emulsion water, skin surface temperature, electrical values. Pharmacology 73(1):17, Epub 2004 Sep 27
conductance, electrical capacitance, and skin surface 51. Mauro T, Holleran WM, Grayson S, Gao WN, Man
(emulsion) lipids. Acta Derm Venereol 69(4): MQ, Kriehuber E, Behne M, Feingold KR, Elias PM
327330 (1998) Barrier recovery is impeded at neutral pH,
36. Rietschel RL (1978) A method to evaluate skin mois- independent of ionic effects: implications for extra-
turizers in vivo. J Invest Dermatol 70(3):152155 cellular lipid processing. Arch Dermatol Res
37. Warner RR, Stone KJ, Boissy YL (2003) Hydration 290(4):215222
disrupts human stratum corneum ultrastructure. 52. Behne MJ, Barry NP, Hanson KM, Aronchik I,
J Invest Dermatol 120(2):275284 Clegg RW, Gratton E, Feingold K, Holleran WM,
38. Trm H, Lindberg M, Berne B (2008) Skin barrier Elias PM, Mauro TM (2003) Neonatal development
disruption by sodium lauryl sulfate-exposure alters of the stratum corneum pH gradient: localization and
the expressions of involucrin, transglutaminase 1, pro- mechanisms leading to emergence of optimal barrier
filaggrin, and kallikreins during the repair phase in function. J Invest Dermatol 120(6):9981006
human skin in vivo. J Invest Dermatol 128(5):1212 53. Behne MJ, Meyer JW, Hanson KM, Barry NP, Murata S,
1219, Epub 2007 Nov 15 Crumrine D, Clegg RW, Gratton E, Holleran WM,
39. Lodn M, Olsson H, Axell T, Linde YW (1992) Elias PM, Mauro TM (2002) NHE1 regulates the stra-
Friction, capacitance and transepidermal water loss tum corneum permeability barrier homeostasis.
(TEWL) in dry atopic and normal skin. Br J Dermatol Microenvironment acidification assessed with fluo-
126(2):137141 rescence lifetime imaging. J Biol Chem 277(49):
40. Barany E, Lindberg M, Lodn M (2000) Unexpected 4739947406, Epub 2002 Sep 7
skin barrier influence from nonionic emulsifiers. Int J 54. Fluhr JW, Behne MJ, Brown BE, Moskowitz DG,
Pharm 195(12):189195 Selden C, Mao-Qiang M, Mauro TM, Elias PM,
41. Denda M, Nakanishi K, Kumazawa N (2005) Topical Feingold KR (2004) Stratum corneum acidification in
application of ionic polymers affects skin permeabil- neonatal skin: secretory phospholipase A2 and the
ity barrier homeostasis. Skin Pharmacol Physiol sodium/hydrogen antiporter-1 acidify neonatal rat
18(1):3641 stratum corneum. J Invest Dermatol 122(2):320329
42. Wellner K, Wohlrab W (1993) Quantitative evaluation 55. Fluhr JW, Kao J, Jain M, Ahn SK, Feingold KR, Elias
of urea in stratum corneum of human skin. Arch PM (2001) Generation of free fatty acids from phos-
Dermatol Res 285(4):239240 pholipids regulates stratum corneum acidification and
43. Brinkmann I, Muller-Goymann CC (2005) An attempt integrity. J Invest Dermatol 117(1):4451
to clarify the influence of glycerol, propylene glycol, 56. Fluhr JW, Mao-Qiang M, Brown BE, Hachem JP,
isopropyl myristate and a combination of propylene Moskowitz DG, Demerjian M, Haftek M, Serre G,
glycol and isopropyl myristate on human stratum cor- Crumrine D, Mauro TM, Elias PM, Feingold KR
neum. Pharmazie 60(3):215220 (2004) Functional consequences of a neutral pH in
44. Costa-Balogh FO, Wennerstrom H, Wadso L, Sparr E neonatal rat stratum corneum. J Invest Dermatol
(2006) How small polar molecules protect membrane 123(1):140151
37 Skin Barrier Responses to Moisturizers: Functional and Biochemical Changes 543

57. Korting HC, Kober M, Mueller M, Braun-Falco O 69. Sonkoly E, Wei T, Janson PC, Saaf A, Lundeberg L,
(1987) Influence of repeated washings with soap and Tengvall-Linder M, Norstedt G, Alenius H, Homey B,
synthetic detergents on pH and resident flora of the Scheynius A, Stahle M, Pivarcsi A (2007) MicroRNAs:
skin of forehead and forearm. Results of a cross-over novel regulators involved in the pathogenesis of
trial in health probationers. Acta Derm Venereol Psoriasis? PLoS One 2(7):e610
67(1):4147 70. Ekholm E, Egelrud T (2000) Expression of stratum
58. Proksch E, Elias PM, Feingold KR (1990) Regulation corneum chymotryptic enzyme in relation to other
of 3-hydroxy-3-methylglutaryl-coenzyme A reductase markers of epidermal differentiation in a skin explant
activity in murine epidermis. Modulation of enzyme model. Exp Dermatol 9(1):6570
content and activation state by barrier requirements. 71. Ekholm IE, Brattsand M, Egelrud T (2000) Stratum
J Clin Invest 85(3):874882 corneum tryptic enzyme in normal epidermis: a miss-
59. Harris IR, Farrell AM, Grunfeld C, Holleran WM, ing link in the desquamation process? J Invest
Elias PM, Feingold KR (1997) Permeability barrier Dermatol 114(1):5663
disruption coordinately regulates mRNA levels for 72. Komatsu N, Saijoh K, Toyama T, Ohka R, Otsuki N,
key enzymes of cholesterol, fatty acid, and ceramide Hussack G, Takehara K, Diamandis EP (2005)
synthesis in the epidermis. J Invest Dermatol Multiple tissue kallikrein mRNA and protein expres-
109(6):783787 sion in normal skin and skin diseases. Br J Dermatol
60. Holleran WM, Feingold KR, Man MQ, Gao WN, Lee 153(2):274281
JM, Elias PM (1991) Regulation of epidermal sphin- 73. Caubet C, Jonca N, Brattsand M, Guerrin M, Bernard
golipid synthesis by permeability barrier function. D, Schmidt R, Egelrud T, Simon M, Serre G (2004)
J Lipid Res 32(7):11511158 Degradation of corneodesmosome proteins by two
61. Ottey KA, Wood LC, Grunfeld C, Elias PM, Feingold serine proteases of the kallikrein family, SCTE/KLK5/
KR (1995) Cutaneous permeability barrier disruption hK5 and SCCE/KLK7/hK7. J Invest Dermatol
increases fatty acid synthetic enzyme activity in the 122(5):12351244
epidermis of hairless mice. J Invest Dermatol 104(3): 74. Hachem JP, Man MQ, Crumrine D, Uchida Y, Brown
401404 BE, Rogiers V, Roseeuw D, Feingold KR, Elias PM
62. Grether-Beck S, Muhlberg K, Brenden H, Krutmann J (2005) Sustained serine proteases activity by pro-
(2008) Urea plus ceramides and vitamins: Improving longed increase in pH leads to degradation of lipid
the efficacy of a topical urea preparation by addition processing enzymes and profound alterations of bar-
of ceramides and vitamins. Hautarzt 6:6 rier function and stratum corneum integrity. J Invest
63. Rivier M, Castiel I, Safonova I, Ailhaud G, Michel S Dermatol 125(3):510520
(2000) Peroxisome proliferator-activated receptor- 75. Lodn M, Lindberg M (1991) The influence of a sin-
alpha enhances lipid metabolism in a skin equivalent gle application of different moisturizers on the skin
model. J Invest Dermatol 114(4):681687 capacitance. Acta Derm Venereol 71(1):7982
64. Yu Z, Schneider C, Boeglin WE, Brash AR (2007) 76. Komatsu N, Saijoh K, Kuk C, Shirasaki F, Takehara
Epidermal lipoxygenase products of the hepoxilin K, Diamandis EP (2007) Aberrant human tissue kal-
pathway selectively activate the nuclear receptor likrein levels in the stratum corneum and serum of
PPARalpha. Lipids 42(6):491497, Epub 2007 patients with psoriasis: dependence on phenotype,
Apr 14 severity and therapy. Br J Dermatol 156(5):875883
65. Feingold KR (2007) Thematic review series: skin lip- 77. Komatsu N, Saijoh K, Kuk C, Liu AC, Khan S,
ids. The role of epidermal lipids in cutaneous perme- Shirasaki F, Takehara K, Diamandis EP (2007) Human
ability barrier homeostasis. J Lipid Res 48(12): tissue kallikrein expression in the stratum corneum
25312546, Epub 2007 Sep 13 and serum of atopic dermatitis patients. Exp Dermatol
66. Schmuth M, Jiang YJ, Dubrac S, Elias PM, Feingold 16(6):513519
KR (2008) Thematic review series: skin lipids. 78. Rawlings AV, Matts PJ (2005) Stratum corneum mois-
Peroxisome proliferator-activated receptors and liver turization at the molecular level: an update in relation
X receptors in epidermal biology. J Lipid Res to the dry skin cycle. J Invest Dermatol 124(6):
49(3):499509, Epub 2008 Jan 8 10991110
67. Sertznig P, Seifert M, Tilgen W, Reichrath J (2008) 79. Rawlings AV, Scott IR, Harding CR, Bowser PA
Peroxisome proliferator-activated receptors (PPARs) (1994) Stratum corneum moisturization at the molec-
and the human skin: importance of PPARs in skin ular level. J Invest Dermatol 103(5):731741
physiology and dermatologic diseases. Am J Clin 80. Egawa M, Hirao T, Takahashi M (2007) In vivo esti-
Dermatol 9(1):1531 mation of stratum corneum thickness from water con-
68. Guo L, Fang H, Collins J, Fan X, Dial S, Wong A, centration profiles obtained with Raman spectroscopy.
Mehta K, Blann E, Shi L, Tong W, Dragan YP (2006) Acta Derm Venereol 87(1):48
Differential gene expression in mouse primary hepa- 81. Egawa M, Tagami H (2008) Comparison of the depth
tocytes exposed to the peroxisome proliferator- profiles of water and water-binding substances in the
activated receptor a agonists. BMC Bioinformatics stratum corneum determined in vivo by Raman spec-
7(Suppl 2):S18 troscopy between the cheek and volar forearm skin:
544 I. Buraczewska-Norin

effects of age, seasonal changes and artificial forced in vivo scoring of the dermal fibre network. Exp
hydration. Br J Dermatol 158(2):251260, Epub 2007 Dermatol 17(6):519523, Epub 2008 Jan 15
Nov 28 85. Branzan AL, Landthaler M, Szeimies RM (2007) In
82. Crowther JM, Sieg A, Blenkiron P, Marcott C, Matts vivo confocal scanning laser microscopy in dermatol-
PJ, Kaczvinsky JR, Rawlings AV (2008) Measuring ogy. Lasers Med Sci 22(2):7382, Epub 2006
the effects of topical moisturizers on changes in stra- Nov 18
tum corneum thickness, water gradients and hydra- 86. Gottschalck T, Bailey J (eds) (2008) International
tion in vivo. Br J Dermatol 159(3):567577 cosmetic ingredient dictionary and handbook, 12th
83. Wartewig S, Neubert RH (2005) Pharmaceutical edn. The Cosmetics, Toiletry, and Fragrance
applications of Mid-IR and Raman spectroscopy. Adv Association, Washington, DC
Drug Deliv Rev 57(8):11441170 87. Wirn K, Nohlgrd C, Nyberg F, Holm L, Svensson
84. Koehler MJ, Hahn S, Preller A, Elsner P, Ziemer M, A, Johannesson A, Wallberg P, Berne B, Edlund F,
Bauer A, Konig K, Buckle R, Fluhr JW, Kaatz M Lodn M (2008) Treatment with a moisturizing cream
(2008) Morphological skin ageing criteria by mul- delays recurrence of atopic eczema. Forum Nord
tiphoton laser scanning tomography: non-invasive Derm Ven 13(Suppl 15):35
 Changes in Stratum Corneum
Thickness, Water Gradients 38
and Hydration by Moisturizers

Jonathan M. Crowther, Paul J. Matts,

and Joseph R. Kaczvinsky

38.1 Introduction: Stratum been developed previously to analyze concentra-

Corneum Form and Function tion gradients within the SC, until recently no
single technique has been able to quantitatively
As the outermost layer of skin, the stratum assess different chemical components as a func-
corneum (SC), plays the pivotal role in protecting tion of depth, rapidly and in vivo. Furthermore,
our bodies. It is the first line of defense against as the use of topical cosmetic products has
the outside world, providing both mechanical and become more popular and widespread, especially
chemical protection and regulating the movement in the anti-aging market, the ability to accurately
of water and other materials in and out, enabling monitor ingredients which are capable of pene-
the bodies equilibrium to be maintained. Despite trating into the skin is now a necessity. Also, it is
the relatively small dimensions of the SC over becoming more and more important to demon-
most of the body (its thickness is of the order of strate how topically applied products can improve
only 20 mm over a large portion of the body), it the skin in clinical tests; therefore, new methods
has a very complicated chemical and physical to assess the skin in greater and greater detail are
structure. Chemical concentrations and cellular constantly being explored.
structure change across its thickness, and these The aim of this chapter is to review current
changes are responsible for the properties it pos- research on assessment of chemical concentra-
sesses and for regulating the processes occurring tion gradients within the SC and provide an over-
within it. To better understand the role all of these view of the use of a relatively new technique,
components play within the SC, therefore, it is confocal Raman spectroscopy (CRS), for assess-
not only necessary to ask how much is there?, ing these changes in vivo. We will also take this
but also where is it located? and how is it dis- opportunity to share some of our recent findings
tributed? While a number of techniques have of how the use of topical moisturizers can affect
these chemical profiles and impact on changing
SC thickness.
J.M. Crowther () P. J. Matts
Beauty and Grooming, Procter & Gamble Technical
Centres Ltd., Rusham Park Technical Centre,
Whitehall Lane, Egham, Surrey, TW20 9NW, UK 38.1.1 Concentration Gradients
e-mail: [email protected]; [email protected] Within the SC
J.R. Kaczvinsky
Clinical Research and Biometrics, The Procter and Despite its small size over most of the body (typi-
Gamble Company, Sharon Woods Technical Centre,
cally around 20 mm for most sites except the
11510 Reed Hartman Highway, Cincinnati,
OH 45241, USA palms of the hands and soles of the feet), in cross
e-mail: [email protected] section the SC itself is far from homogeneous. As

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 545

DOI 10.1007/978-3-642-27606-4_38, Springer-Verlag Berlin Heidelberg 2012
546 J.M. Crowther et al.

we move up from the basal layer where keratino- a freeze-dried cryo-section of skin being inversely
cytes are birthed, we travel through regions where related to its water content). This demonstrated
they mature and differentiate during their transi- how the surface of the SC was depleted in water
tion towards the surface, gradually flattening out with respect to the live tissue within the body and
to become the familiar, flat, squamous corneo- how a water gradient existed across its thickness.
cyte cells of the SC. These differentiating cells Further advancements were made to the tech-
transition through a variety of chemical gradients nique making it simpler to perform [6] although
as they move up through the SC, including water, this was still not a technique suitable for larger
natural moisturizing factors (NMF), lipids, urea, base size sample assessment.
lactic acid and pH. This section outlines some of Cryo-SEM has been used more recently to
these gradient changes, why they are present and understand uptake and loss of water within the
how they are currently assessed. SC from salt solutions of different strengths by
Richter et al. [7]. This demonstrated that there
38.1.1.1 Water are three zones which respond differently dur-
At the surface of the skin, the SC is constantly ing the processes of hydration and dehydration,
losing water to the environment under normal the behaviour of these zones being dependent on
conditions, while at the basal layer there is con- the osmotic potential of the hydrating solution.
tinual replenishment from the wet tissue of the The concept of zones of hydration has also been
viable epidermis. This ongoing process of loss at examined before [8] showing that the central
the surface and replenishment from beneath leads portion of the SC absorbed water strongly under
to the formation of a water gradient across the SC conditions of high water activity, while the lay-
which decreases towards the outside of the body. ers closest to the stratum granulosum showed no
Maintenance of a correct equilibrium state of SC swelling under these conditions. The presence
hydration has enormous impact on its mechanical of a central zone capable of absorbing and hold-
and optical properties, as well as helping to main- ing water is in excellent agreement with the con-
tain skin barrier function and playing an impor- centration of NMF, known to reach a maximum
tant role in the regulation and activation of both in the central portion of the SC [9]. Also, the
intra- and extracellular enzymes which control the layers closest to the stratum granulosum would
desquamation process [1, 2]. Deviations from the not be expected to swell as much as the outer
normal desquamation process fundamentally layers of the SC given the mechanical con-
affect SC barrier function which in healthy indi- straints placed on them by the surrounding cel-
viduals is most commonly expressed as dry skin lular tissue. However, while cryo-SEM as a
[3]. Even given the thinness of the SC, not all the technique has been able to provide hydration
water is present in the same state, typically being profiles and detailed information on the hydra-
described as either free or bound [4]. Free, or tion processes within the SC, the necessity for
unbound, water refers to the partially mobile skin biopsies, along with the complexity of an
molecules which can be easily lost if exposed to analysis using cryo-sectioning and scanning
low humidity after exposure of the skin to an envi- electron microscopy (SEM), means that it is not
ronment of high water activity. Bound water is a technique that it would be possible to deploy
held within corneocytes by both the polar groups easily in a clinical environment for assessing the
within keratin proteins and a blend of NMF that effects of topical moisturizer application on SC
increase the hygroscopicity of these cells. hydration.
The first attempt at determining true depth- Infrared spectroscopy has been used to exam-
resolved water profiling in skin was performed ine water as a function of depth though combina-
by Warner et al. in 1988 [5]. In this initial experi- tion with tape stripping [10] and Monte Carlo
ment, electron probe analysis was carried out on simulation [11]. However, like cryo-SEM, these
biopsied skin samples which had been cryo- methods require compromises to be taken in col-
sectioned and freeze-dried (the local dry mass of lection and analysis of the data. For example, in
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 547

the work by Brancaleon et al. [10], the tape strip- The ability of the SC to control the movement
ping approach used to sample incrementally into of molecules across it is mediated not only by the
the skin was difficult to correlate with actual physical constraint of the corneocytes themselves
depth and, of course, was inherently destructive, but also chemically by the inter-cellular lipids.
thereby making it impossible to repeatedly reas- These are a mixture of ceramides, cholesterol and
sess the same site over the course of a study. The free fatty acids, as well as a small amount of non-
Monte Carlo simulation by Arimoto et al. [11] polar liquids and cholesterol sulphates, and are
relies on the assumption the water content varies organized along with a small amount of water,
linearly from 10% at the SC surface to 80% at the into a series of parallel lamellar membranes
interface with the viable epidermis, despite the between the corneocytes. However, while some
obviously more complex variation in structure water is trapped in the lipid lamellar structure,
across its thickness. most is actually held within the corneocytes
Confocal Raman spectroscopy has also been themselves [14]. It is this series of lipid bilayer
used to provide water profiles through the SC, structures, together with the tightly stacked cor-
and this will be discussed in more detail later on. neocytes, which provide a tight barrier against
trans-epidermal water loss (TEWL), making it
38.1.1.2 NMF and SC Lipids difficult for water to transfer across the SC
Two key classes of materials are present within structure.
the SC in addition to the corneocyte cellular Gradual removal of the SC results in an
structure the so-called natural moisturizing fac- increase in TEWL; however, this does not occur
tors (NMF) and inter-cellular lipids present in the at a constant rate as a function of depth. Most of
bilayer structure. Both of these classes of materi- the TEWL increase only occurs when about 75%
als will have an impact on the amount and distri- of the barrier has been removed [15]. This sug-
bution of water within the skin. NMF comprises a gests an anisotropic distribution of ingredients
collection of amino acids, salts and other small within the skin which are responsible for con-
hygroscopic molecules which are present within trolling the flow of water across it. It also sug-
the corneocytes. These are derived from proteoly- gests that people with thinner SC might have a
sis of epidermal filaggrin initiated a few cell lay- greater lipid packing density in their tissue to
ers above the stratum basale and as such are only provide the same amount of protection per per-
present in the SC. These hygroscopic NMF com- centage of depth.
ponents are efficient humectants, helping to bind Tape stripping has been used in combination
water and assisting in maintaining skin hydration with TEWL measurements to calculate SC thick-
and flexibility [9]. However, because of their ness [16]. However, measurement methods which
hydrophilic nature, they are readily removed from incorporate tape stripping are fundamentally
the surface of the SC during washing [12]. destructive to the skin which makes them unsuit-
Confocal Raman spectroscopy has been used able for repeated assessment of the same area
to measure concentration profiles of the different during a clinical trial.
NMF components non-destructively and in vivo
[13]. The concentration of most NMF compo- 38.1.1.3 pH
nents builds gradually from the stratum granulo- While the extracellular fluid within the body is
sum, peaking in the midportion of the SC and maintained at a pH of approximately 7.4, the sur-
then showing a characteristic depletion near the face of the SC is more acidic with a pH typically
surface. This seems to be associated with the between 4.5 and 6 [17, 18]. There is, therefore, a
water-labile nature of these components and their pH gradient across the SC. While this change in
propensity to be washed out by, for example, pH has been linked with a variety of skin func-
daily cleansing. Lactate and urea, as sweat- tions, such as barrier function, desquamation and
derived NMF components, are more prevalent at microbial defense, the mechanism responsible
the surface of the SC. for its presence is not fully understood. However,
548 J.M. Crowther et al.

it has been suggested that a build-up of trans- Infrared (IR) spectroscopy has been used to
urocanic acid [19], carbon dioxide diffusion [20], monitor the effects of cosmetic ingredients on SC
the presence of free fatty acids [21], lactate and chemical composition [30], and although this
lactic acid produced as a by-product of sweating technique is capable of detecting changes in lipid
[22] or active regulation by a sodium-hydrogen packing and organization as a result of using dif-
anti-porter protein [23] are all linked with this ferent products, it is not a depth-profiling tech-
observed acidic change towards the surface. nique, and it is not certain from which depth data
A number of techniques have been used to is collected. IR has been used in comparison with
determine pH as a function of depth. Tape strip- tape stripping to provide some measure of depth
ping measurements combined with pH assess- information on the penetration of ingredients from
ment have shown the existence of this gradient microemulsions into porcine skin; however, obvi-
[18, 24]. Once again, though, this is by its nature ously, this is a destructive method and therefore
an inherently destructive technique and is not not ideally suited to clinical testing [31]. Notingher
capable of discriminating between the intra- and et al. have used a modified version of IR spectros-
intercellular components. Microscopy combined copy to assess the delivery of topical components
with a pH-sensitive fluorescent marker molecule to the skin based on the principle of thermal emis-
has also been used to determine pH [25], and the sion delay from the surface after irradiation with
advent of two photon and confocal imaging has an IR light source [32]; however, this technique
pushed resolution down to submicron levels [26]. requires complex modelling of the thermal prop-
Confocal Raman spectroscopy has been used to erties of the extremely thin SC layers.
measure concentration profiles of trans-urocanic Confocal Raman spectroscopy has been used
acid and pyrrolidone carboxylic acid in vivo [13]. to monitor penetration of different lipid species
As with NMF, the concentration of these species into the SC and their corresponding effects on
is greatest in the middle portion of the SC, show- total skin lipid profiles and skin hydration [33].
ing a gradual build up from the stratum granulo- Different lipid species were absorbed to different
sum layers and depletion near the surface. degrees, with petrolatum being most strongly
absorbed, most likely due to a combination of its
38.1.1.4 Calcium relatively short chain lengths and occlusive prop-
Calcium concentration varies across the entire erties, resulting in destabilization of SC structure.
epidermis, from high levels within the stratum Chrit et al. have used confocal Raman spectros-
granulosum down to low levels in the basal layer copy to assess the extent of skin hydration
[27]. The calcium concentration is linked with changes after using a glycerol-based moisturiz-
regulation of epidermal keratinocyte prolifera- ing product in vivo [34] and were able to classify
tion and differentiation and skin structural integ- different hydrating products depending on their
rity. It is also strongly linked with rate of SC moisturizing effect on the skin. They showed that
barrier recovery after acute insult by detergents, a polyphospholipid (poly [2-methacryoyloxy-
tape stripping or organic solvents [28]. Analysis lphosphorylcholine or pMPC]) was able to
of calcium concentration as a function of depth increase water levels in the skin, both in vivo and
has been carried out using scanning electron in vitro, although it should be noted that dosing
microscopy of biopsied samples [29]. of the products was not tightly controlled, with
any excess product being removed after applica-
38.1.1.5 Cosmetic Ingredients tion and before analysis [35]. Recently, Frster
Given the enormous expansion of the cosmetic et al. used confocal Raman microscopy to moni-
product market in recent years, more attention is tor the penetration of retinol into pig skin, and
being focused on understanding how these prod- how formulation differences affect penetration
ucts partition into and interact with the skin, [36]. In their work, they demonstrated that the
both from an efficacy and a consumer safety nature of the surfactant used can have an impact
point of view. on penetration.
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 549

With quantification of any component in the O-H vibrations in water, making it a more con-
skin as a function of depth, the ideal clinical solu- sidered approach for analyzing skin (where with
tion is determination of concentration in a non- IR the high intensity of the water signal can mask
destructive manner, without the need for complex other chemical species) and indeed, a number
modelling, especially when biopsies or other of researchers in the last 15 years or so have
invasive procedures may not be viable (e.g. dur- reported varying degrees of success, principally
ing testing of moisturizing products at different using in vitro models [3739].
time points on large groups of panellists). As a The journey from measurement of in vitro
technique for materials characterization, Raman systems to in vivo capture of Raman spectra on
spectroscopy has been used for many years; how- the surface of the SC presented many challenges
ever, recently its use in the assessment of biologi- [37, 40], specifically the low signal-to-noise ratio
cal samples has become more widespread. (based upon the safety needs requirements for
relatively low laser power when used on live sub-
jects, combined with the necessity of fast acquisi-
38.2 Raman Spectroscopy tion times to minimize the effects of subject
movement). A huge leap forward in the use of
It was in 1928 that the Indian physicist C. V. in vivo Raman spectroscopy came with the instru-
Raman first reported the new type of light-scat- mental design and research of Caspers et al.
tering phenomenon that would eventually bear resulting in a system with very high optical effi-
his name. Raman reported that when a liquid was ciency, thus enabling rapid, non-invasive collec-
irradiated by light of a specific wavelength, while tion of Raman spectra [13].
most of the re-emitted photons had not changed
in energy (i.e. had been scattered elastically), an
extremely small proportion of the reflected light 38.2.1 In Vivo Confocal Raman
had a wavelength which had shifted relative to Spectroscopy
the incident source. This shift in wavelength was
directly related to the change in rotational and The holy grail of in vivo SC assessment is the
vibrational energy states of the molecules in the measurement of different components within the
liquid, thereby providing information on the skin as a function of depth in a non-destructive
energy levels of the constituent molecules. and rapid manner such that it can be routinely
Knowledge of these energy levels can be used to employed in a clinical environment. Recently,
determine what chemical species are present. As confocal Raman spectroscopy has been devel-
the Raman phenomenon is very weak (occurring oped to the point where it can be used to obtain
approximately once in a million photon interac- molecular concentration profiles real time and
tions), a well-defined monochromatic light source in vivo [13, 4144]. Building on the success of
is absolutely essential to achieving a good signal their in vivo surface measurements, River
during measurement, and practical applications Diagnostics designed and marketed the RD3100
were not readily exploited until the development in vivo confocal Raman spectrometer, capable of
of the laser in the 1960s. Improvements in detec- measuring skin chemical profiles by combining
tion equipment such as photomultiplier tubes fur- the principle of confocal microscopy with Raman
ther enhanced the appeal and applicability of spectroscopy. In operation, incident monochro-
Raman, and it has since become a well-estab- matic laser light is focussed to a point on/within
lished material analysis technique. Raman spec- the skin tissue, which can be moved by changing
troscopy is considered to be a complimentary the focal point of the microscope. When used to
technique to IR spectroscopy molecular vibra- assess skin, this light enters the SC, and while
tions which are IR active are generally not Raman most of it is scattered elastically without a change
active and vice versa. In contrast with IR spec- in energy and wavelength, a small proportion of
troscopy, Raman is relatively insensitive to the this incident light becomes Raman-scattered
550 J.M. Crowther et al.

photons. These leave the skin with minute shifts

in their wavelength as a result of interacting with 8.0105

the molecules present and changing their vibra-

tional state. On reaching the skins surface, these 6.0105

Intensity
scattered photons are re-emitted and some pass
back through the microscope objective lens. 4.0105
Given the confocal nature of the microscope
arrangement, only light re-entering the micro- 2.0105
scope from the focal plane will pass back through
the pinhole any photons re-emerging from 0
other depths are excluded hence, the chemical 4,000 3,500 3,000 2,500
Raman shift (cm1)
information is derived from specific depths
within the skin. Collection and analysis of these Fig. 38.1 Typical background-corrected Raman spectra
Raman-scattered photons from different depths from a single scan of human skin in vivo, collected at
enable the construction of molecular concentra- ~4 mm depth in the high wave number region (671-nm
laser excitation, exposure 1 s)
tion profiles for different components present as
a function of depth within the SC. Using this
technique, SC composition can be quantitatively The use of Raman spectroscopy for skin anal-
measured by optically sectioning skin tissue ysis relies on the fact that the chemical compo-
and expressing the relative chemical content as a nents of the skin possess different functional
function of depth, in a non-invasive, rapid and groups with unique vibrational frequencies.
non-destructive manner. The combination of Water and protein contain different functional
these properties makes it an ideal technique for groups in their chemical structure which vibrate
implementation in a clinical environment for at distinctly different frequencies. It is these dif-
assessing chemical composition of the skin. For ferences in vibrational frequency which enable
example, water concentration as it varies across the two species to be differentiated using Raman
the SC is calculated from ratioing the water sig- spectroscopy. To simplify the analysis of skin,
nal against the combined signal from water and the Raman spectra can be split into two distinct
protein within the skin. This method has also zones the high wave number and fingerprint
been used to estimate differences in SC thickness regions which can be probed independently
in vivo at different body sites and during aging depending on the information required and the
[45, 46] and to evaluate the effects of water and molecules being investigated. Information regard-
moisturizing ingredients on SC hydration, after ing total water content is contained within the
both short-term treatment [34, 47] and long-term high wave number region, while levels of natu-
treatment [48]. ral moisturizing factors (NMF), ceramides, cho-
The majority of current research which is lesterol, cosmetic ingredients penetrating into the
using Raman to look at the skin focuses on the SC skin etc., can be derived from the information in
and upper layers of the viable epidermis, as light the fingerprint spectra. Scans in the high wave
becomes increasingly scattered as it penetrates number region are used to calculate percentage
more deeply, reducing signal strength and mak- hydration values by taking the ratio of the inte-
ing data collection more difficult. Nonetheless, grated signals of water (i.e. the O-H stretching
Naito et al. have reported using a 1,064-nm light vibration region between 3,350 and 3,550 cm1)
source to probe the dermal chemical structure to that of protein (i.e. the CH3 stretching vibra-
[49]. The ability to measure deep within the skin tion from 2,910 to 2,965 cm1) [4144]. A typical
opens up additional possibilities of, for example, skin spectra for the high wave number spectral
probing the development of acne in teenagers, region showing the water and protein peaks col-
and the effects of aging on dermal chemical lected at a single scan at an exposure time of 1 s
composition. is given in Fig. 38.1. During measurement of a
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 551

depth profile, spectra like the one shown in 70

a
Fig. 38.1 are captured at regular depth intervals 60
from the surface of the SC down into the skin. On b
50

% Hydration
the River Diagnostics system, a correction factor,
as determined by Caspers et al. [13], is used to 40

normalize the spectral response of water and pro- 30

c
tein relative to their mass ratio. The normalized 20
water-to-protein ratios obtained from each focal
10
depth are plotted as % hydration as a function of
depth. This, therefore, leads to a direct, semi- 0
0 10 20 30
quantitative measure of amount of the water pres- Depth (m)
ent within the SC as a function of depth. Although
the signal intensity drops as the laser penetrates Fig. 38.2 Calculation of SC thickness from hydration
curve. The algorithm calculates the point where the gradi-
deeper into the skin, the fact that both the water ent equals 0.5, working from the middle of the curve (a)
and protein peaks are derived from the same scan inwards (i.e. deeper in the tissue) (b). The depth at this
enables hydration quantification throughout the point corresponds to the base of the SC (c)
range of analysis.
We however used a different (and, we believe, a
more rigorous) approach in calculating SC thick-
38.2.2 Calculation of SC Thickness ness from the water profile measurements and
have validated it via correlation with values from
It has been understood for many years that SC a known objective measure of skin thickness
thickness varies dynamically with its hydration (optical coherence tomography OCT) which is
state and in response to a variety of extrinsic fac- discussed further later in the chapter.
tors. In order to analyze and interpret SC water The inherent biological variability of the skin,
concentration profiles properly, therefore, it is combined with the fact that Raman analysis is a
essential to take into account SC thickness, as point measure, means that a more accurate mea-
well as any changes in thickness resulting from sure of thickness and hydration state can only be
the treatment regime after all, in a situation obtained through the use of an average water pro-
where SC thickness is varying dynamically, for file collected from a number of sites within the area
example, during acute swelling due to exposure of interest. After collecting a set of profiles, obvi-
to wet environment, absolute static SC depths are ous outliers (arising, e.g. from scanning through
of little meaning. It has been demonstrated in our heterogeneous structures, such as skin appendages
own laboratories that SC thickness can be deter- including hair follicles, and sebaceous glands, or
mined directly from water concentration profiles profiles recorded while the panellists were moving)
in a robust and clinically viable manner [48], and are removed. Then, an average hydration profile is
this procedure is described in more detail below. fitted through the remaining data, using a custom-
Other groups have also addressed the area of cal- ized algorithm based on a 4-parameter Weibull
culation of SC thickness, and while the work of curve. This curve is a well-accepted and widely
Egawa et al. [45, 46] has clearly demonstrated used algorithm capable of accurately modelling a
the capability of CRS for deriving SC thickness variety of profile shapes with the minimum number
estimates, these authors offered no formal valida- of parameters in the equation, producing model
tion data (establishing a direct relationship curves with very low RMS deviations from the
between their CRS-derived SC thickness data mean data. The upper levelling off point of each
and values derived from other measurements). profile is determined via a gradient threshold
More recently, Bielfeldt et al. have reported SC method by calculating the location where the gra-
thickness calculations based upon the concept of dient reaches a value of 0.5 moving from the mid-
Fickian diffusion of water across the SC [50]. point of the curve (Fig. 38.2). This point was
552 J.M. Crowther et al.

originally hypothesized to be the theoretical bound- 70 1.00

ary of the SC with the viable epidermis and serves 60 % Hydration 0.75
as the deeper limit of the SC hydration profile. The

% Hydration
NMF score

NMF value
area-under-the curve values (AUC) are determined 50 0.50
by integrating each hydration profile from the skin 40 0.25
surface (x = 0 mm on the profile) to each individual
30 0.00
SC boundary (point c in Fig. 38.2) and used to
express the total SC hydration. 20 0.25
0 10 20 30
As work with CRS has progressed, the issue
Depth (m)
of refractive index changes within skin effecting
absolute depth measures has been discussed [51]. Fig. 38.3 Comparison of hydration and NMF profiles
It has been reported that the effects of the correc- measured at the same point on the volar forearm
tion are small when the SC thickness is less than
20 mm [52]. In this circumstance, relative % curves). This is to be expected, as NMF starts to
changes from a baseline state would be a poten- be expressed a few microns above the base of the
tial route to eliminate errors introduced from SC due to the breakdown of filaggrin, and this
refractive index changes. correlates well with the behaviour for NMF
reported by Caspers [13]. While these observa-
tions provide increased confidence in the correla-
38.2.3 Validation of SC Thickness tion between the levelling off point in the
Measurements Using Confocal hydration profile and the location of the lower
Raman Spectroscopy margin of the SC, it is not definitive proof. For
example, external environmental variation can
While the control of the microscope movement also be responsible for changes in the exact loca-
can be done extremely accurately, interpreting tion of filaggrin hydrolysis. It was necessary,
where the base of the SC occurs from the water therefore, to validate empirically the levelling off
profile is not as simple a task. Without any form point as the SC lower margin, using a separate
of validation of the thicknesses being measured, objective measure of SC thickness.
the value of the technique is drastically reduced.
This section discusses how validation of the SC 38.2.3.2 Correlation Between OCT and SC
thickness measurement has been approached. Hydration Proles
OCT is a well-established technique for examin-
38.2.3.1 Correlation Between NMF and ing skin structure and thickness [53]. It is based
Hydration Proles on the principle that photons are backscattered
Using the River Diagnostics RD3100 system and from different structures within the skin. By
alternating the laser being used from 681 to using interferometry, the depth at which these
785 nm, thereby switching between the high backscattering events occur can be calculated,
wave number and fingerprint regions, it is pos- providing information on where different struc-
sible to measure hydration and NMF profiles at tures occur within the skin. During our valida-
exactly the same location on the skin while retain- tion, we measured sets of up to eight Raman
ing the volar forearm on the window of the spec- profiles from each site and analyzed these
trometer. As can be seen in the example shown in together, rather than studying each water profile
Fig. 38.3, there is a strong correlation between in isolation. Outlying scans were discarded, and
the levelling off point location of the hydration the Weibull mathematical model applied to the
profile and the position where the NMF profile remaining data point cloud representing each
starts to rise (profiles presented here are single site, resulting in an average hydration profile
scans from a specific location on the skin, which for that site. The location of the SC boundary as
is why they are not presented as smooth average a function of the CRS water concentration
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 553

a 300 1020 mm, therefore, this corresponds to only a

few pixels. For panellists who had cheek, fore-
OCT SC thickness (m)

arm and leg measures, CRS ranked the sites, in

200 terms of SC thickness, as follows: cheek < fore-
arm < leg (cheek 12.8 0.9 mm, volar forearm
18.0 3.9 mm, leg 22.0 6.9 mm), whereas OCT
100
y = 0.9603x gave very similar readings for these three differ-
r2 = 0.9339 ent locations (cheek 11.1 1.8 mm, volar forearm
10.4 0.9 mm, leg 13.7 1.4 mm). Of note, this
0
0 100 200 300 ability to rank the sites in order of thickness gave
CRS thickness (m) further confidence that the new CRS method was
b 20 giving accurate estimates of SC thickness, as it
matched exactly the trends that which would be
OCT SC thickness (m)

15 expected, based on known published values for

these sites [54]. The limitations of OCT measure-
10 ment of thinner skin sites have also been noted
recently using in vivo laser scanning fluorescence
5 microscopy [55, 56]. Overall, we believe that the
results of this work demonstrate convincingly the
0
capability of CRS in providing a new rapid,
0 5 10 15 20 25 30 35 accurate and sensitive means of measuring SC
CRS thickness (m) thickness in vivo.

Fig. 38.4 (a) Comparison of OCT- and CRS-derived SC

thicknesses at a variety of body sites. (b) Comparison of
OCT- and CRS-derived SC thicknesses on volar forearm, 38.2.4 Effects of Acute Hydration on SC
cheek and outside of lower leg (complete dataset) Water Content and Thickness

profiles was confirmed by comparing SC thick- In order to demonstrate the ability of the CRS
nesses from a number of different body sites system to measure dynamic, rapid changes in SC
obtained directly by OCT and CRS (Fig. 38.4a, b). water profiles, an initial simple study employing
Linear regression through the data shows a forced occlusion to drive maximal short-term
strong positive correlation between SC acute hydration of the volar forearm was carried
thickness derived from CRS and OCT (OCT out. A set of hydration profiles were taken on a
thickness = 0.9603 CRS thickness, r2 = 0.9339; Caucasian volar forearm after equilibration in a
p < 0.0001). Expanding the area to the lower left standardized environment (Fig. 38.5a). The fore-
of Fig. 38.4a, corresponding to the thinner skin arm was then covered in a wet towel soaked in
sites of the body (volar forearm, cheek and out- de-ionized water. The towel was wrapped in
side of lower leg), shows how the dynamic range Parafilm to help ensure complete saturation of
for OCT is compressed in this region (Fig. 38.4b). the SC by occlusive hydration, and the arm site
It can be seen that all of the OCT-derived SC was left undisturbed for 90 min. After 90 min, the
thicknesses are between 9 and 15 mm, while the wrap and towel were removed, and any excess sur-
CRS-derived thicknesses vary between 12 and face water removed by gentle patting with a dry
30 mm. This is consistent with the expected towel. Sets of hydration profiles were then mea-
behaviour of the OCT method in areas where the sured again using CRS over a time course
SC is relatively thin the sensitivity of the OCT (Fig. 38.5b). Given the complex nature of the
is limited by the pixel size of the detector shape of the hydration curve after this extreme
(approximately 5 mm for the system used here). treatment, the profiles here are represented as sim-
For sites with SC thickness in the region of ple averages of the individual sets of scans rather
554 J.M. Crowther et al.

a 70 As the post-occlusion time course is followed

and hydration profiles are measured over time,
60
also it should be noted that surface hydration val-
Hydration %

50 ues fall fastest, while the hump of hydration in

the central portion of the SC falls the slowest.
40 These observations are wholly consistent with
30 presence of higher concentrations of hygroscopic
NMF components in the central portion of the SC
20 (the lower layers containing less because of the
0 10 20
Depth (m) programmed hydrolysis of filaggrin and the upper
b 70 layers containing less because of washout of
these highly water-labile components by, e.g.
60 daily cleansing). It is also probable that the cor-
Baseline
neocytes within the central portion of the SC are
Hydration %

10 min
50 less physically constrained compared with those
25 min
40 min closer to the SC-stratum granulosum boundary
40 55 min (as discussed above) and, therefore, are poten-
70 min
30 tially more readily capable of swelling when
90 min
255 min hydrated and increasing in thickness. This vari-
20 ance in swelling ability of the SC as a function of
0 10 20 depth correlates with the work of Bouwstra et al.
Depth (m)
[8]. Remarkably, baseline conditions are only re-
Fig. 38.5 (a) Baseline volar forearm SC hydration pro- established after a period of some 4 h, demon-
file. (b) Hydration profiles of the volar forearm skin mea- strating the efficient water-binding capacity of
sured as a function of time after 90 min occlusion with a native, untreated SC.
wet towel
Further in vitro validation of CRS has been
reported by Wu and Polefka, where water content
than Weibull curve modelled fits. Between mea- as measured using CRS was correlated with Karl
surements, the arm was removed from the CRS Fischer assessment, along with water content
optical window and allowed to acclimatize within increase for a moisturizing lotion, and decrease
the measurement room, and the window of the in water content after using bar soap [58]. While
CRS cleaned with methanol to remove any residue SC thickness changes as a result of the treatment,
left behind from the skin. The hydration profiles in regimes were not taken into account, and the
Fig. 38.5b show the significant changes in SC experiments were carried out on excised pig skin;
hydration across its entire thickness, showing sig- this does demonstrate further the capability of the
nificant water uptake over the 90 min. Importantly, technique.
the point at which the hydration profile begins to
level off after enforced hydration is further from
the surface of the SC. From the OCT validation 38.2.5 Effect of Long-Term Application
study described above, we now have confidence of Moisturizers on SC Hydration
that this is because of SC swelling normal to its Proles
surface, driven by hydration. As observation only,
it is interesting to note that the magnitude of this It might be expected that long-term application of
swelling is in the region of 25%, highly consistent moisturizers to the skin would increase SC water
with that noted by Norlen [57] in ex vivo models. content and/or change the shape of the SC hydra-
It is also interesting that there appears to be a cen- tion profile. A comparison of the effect of long-
tral portion of the SC which takes up more water term application of three moisturizers on SC
than the upper or lower margins. hydration gradients has recently been reported by
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 555

Baseline 1 day 1 Week

70 70 70
60 60 60
% Hydration

% Hydration

% Hydration
50 50 50
40 A 40 A 40 A
B B B
30 30 30 C
C C
20 U 20 U 20 U
10 10 10
0 0 0
0 10 20 30 40 0 10 20 30 40 0 10 20 30 40
Depth (m) Depth (m) Depth (m)
2 Weeks Regression
70 70
60 60
% Hydration

% Hydration
50 50
40 A 40 A
30 B 30 B
C C
20 U 20 U
10 10
0 0
0 10 20 30 40 0 10 20 30 40
Depth (m) Depth (m)

Fig. 38.6 Average hydration profiles for four different treatment regimes (A, B, C and U) over the course of a 3-week
moisturizer usage study (2 weeks product usage and 1-week regression)

Crowther et al. [48]. To examine the effects of site (p = 0.0121), and this difference remained at
moisturizers on SC thickness, water gradients the 1 week regression time point (p = 0.0162). The
and total SC hydration CRS were used to com- observed change corresponded to an approximate
pare the effects of a formulation containing niaci- 10% increase in SC thickness. Total hydration in
namide (A) which is known to improve SC barrier the SC can be calculated from the area under the
function and desquamation better than two other profile (AUC; integration between x = 0 mm and
commercially available moisturizers (formula- the calculated SC levelling off point). Concomitant
tions B & C) [59]. with the increase in SC thickness, total skin hydra-
For illustration, average hydration profiles tion increased significantly following treatment
from each treatment from this work are given in with formulation A after 2 weeks product usage
Fig. 38.6. All hydration profiles start at 2030% and the 1-week regression (p = 0.0275 and
hydration at 0 microns depth (i.e. the SC surface) p = 0.0435, respectively).
and rise in a sigmoidal type curve to 6570% While it is well accepted that all moisturizers
hydration, where they plateau. While all hydra- have the effect of alleviating dry skin when for-
tion profiles at baseline and 1-day treatment show mulated appropriately, it has become apparent in
the same shape, differences in shape start to recent years that the nature of the formulation
appear after one week of treatment. By 2 weeks can impact its effects on the SC and the epider-
usage, notable differences are observed for for- mis (for review see Loden [60]). Naturally, in the
mulation A, where a laterally stretched water short-term, moisturizers will increase SC hydra-
profile is evident, which is still present even after tion given their relatively high water and humec-
1 week of regression. As a result of this stretch- tant content [34, 43, 47, 5961], and in the
ing, the levelling off point of the water profile medium-term improve desquamation [62, 63].
moved deeper in the skin indicating an increase in However, in the longer term, it has become
SC thickness. After 2 weeks treatment, the apparent that some can actually compromise
increase in SC thickness induced by formulation SC barrier function [6468], while others can
A was significantly different from the other two strengthen it [59, 61, 6971]. In vitro [7, 7275]
products being tested and the untreated control and in vivo [76, 77] studies have also demonstrated
556 J.M. Crowther et al.

the ability of some moisturizing ingredients to points in a study where SC thickness may change
influence SC thickness. Therefore, it is becom- or vary. It is, therefore, more meaningful to extract
ing increasingly apparent that not only is there a information from the profiles regarding total SC
need for longer-term studies to evaluate the thickness and express water measurement deriva-
effect of moisturizers, but that the introduction tives as a function of this (e.g. our use of total SC
of new measurements in addition to the more water content). Considering SC thickness first of
traditional electrical parameter based devices all, it can be seen that, after 2 weeks of treatment,
is needed to understand their effects on skin formulation A produced a significantly greater
more completely [67]. increase in this parameter than the other two treat-
During the moisturizer study discussed in ments and the untreated site (p = 0.0121), and this
Crowther et al., on the first day after initial prod- difference remained at the 1-week regression time
uct application, little difference in CRS-derived point (p = 0.0162). Of note, increases in SC thick-
hydration profiles is observed between any of the ness have also been reported by Jacobson et al.
treatments or the untreated control site. After the [79] using a lipophilic niacin derivative.
first week of treatment though, there was a numer- Concomitant with this increase in SC thickness,
ical diminution in SC thickness. While not statis- total SC hydration as measured by CRS increased
tically significant, it could have been be due to the significantly with use of formulation A after
osmotic effects of glycerol (which was present in 2 weeks treatment. Interestingly, this increase in
all three formulations), or it could have been total hydration level also remained at the 1-week
attributed to increased desquamation after a regression time point. However, no such effect was
period without moisturizer usage. This type of observed for treatment with formulations B and C.
behaviour has been reported before Caussin These data did not, however, correspond with
et al. [75] reported that changes in SC swelling Corneometer measurements taken at the same
can occur when examining the effects of moistur- time points. Significantly, increased Corneometer
izers on SC hydration and swelling. Lipophilic values were observed for all three products even
moisturizers increased SC thickness, whereas after 1 day of application, and indeed, values
hydrophilic moisturizers tended to reduce SC remained elevated throughout the 2-week treat-
thickness. This apparent SC thinning may, there- ment phase. Corneometer values also remained
fore, be due to osmotic effects of the moisturizing elevated for all treatments at the 1-week regression
ingredients (used at high concentration), and the (although all values were significantly lower than
work of Fluhr et al. [78] describing the effect of those at the 2-week treatment time point an effect
glycerol on reducing corneocyte surface area observed in other regression studies [70, 80]).
would tend to support this hypothesis. However, Considering the ingredients present in all three
inconsistencies remain where in vitro [75] and formulations, the capacitance effects noted may be
in vivo [76, 77] increased corneocyte swelling attributable partially to the high dielectric constant
has been reported with glycerol solutions. Another of glycerol [81, 82]. It appears from the CRS
possible explanation would be that during the first hydration profiles presented herein and their rela-
week of treatment, there was some activation of tive difference to corresponding Corneometer
SC protease activity (simply by elevated water values, however, that measured changes in capaci-
activity), resulting in more efficient desquama- tance do not directly reflect total SC hydration.
tion and an ensuing reduction in SC thickness. This raises the question as to where the capaci-
After 2 weeks of regular moisturizer usage, for- tance signal is coming from within the skin and
mulation A had induced a statistically significant what moieties are driving changes in this parame-
increase in SC thickness (2 mm average increase, ter in the context of treatment with a moisturizer.
corresponding to an approximate 10% increase in These questions are the subject of ongoing research
thickness) unlike formulations B and C. As already in our and other laboratories.
discussed, water content measurements at absolute Our initial hypothesis was that it was niacin-
depths are simply not comparable between time amide (nicotinamide, vitamin B3), present only in
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 557

a b c c
0.0 a b c d
Vehicle 5.0
TEWL change from
baseline (gm2h1)

2% Niacinamide

SC thickness change
from baseline (m)
0.5 5% Niacinamide
8% Niacinamide 2.5

1.0
0.0

1.5
2.5

Fig. 38.7 Niacinamide dose response for stratum corneum thickness and TEWL change after 4 weeks regular product
usage. Letters indicate statistical groupings at 95% confidence

formulation A, which was the agent responsible powerful new class of measurement with signifi-
for these SC effects. Recent work has been under- cant advantage over traditional measurement tech-
taken to further examine the role of niacinamide niques through its ability to assess these changes,
in SC swelling using freshly prepared biopsy cross both rapidly and in a non-destructive manner. The
sections in a vehicle-controlled study [83]. Also, advent of this new technology seems timely as we
recently, a vehicle-controlled doseresponse study consider the development of moisturizers that
was undertaken to demonstrate how the level of truly augment SC barrier function.
niacinamide formulated into a typical moisturiz- The capability of in vivo confocal Raman
ing product impacted both SC thickness changes spectroscopy for probing chemical gradients
and TEWL after 4 weeks of twice daily product within the skin has only been touched upon as the
usage, Fig. 38.7 [84]. A strong positive correlation technique is still in its infancy. Even considering
was found between niacinamide level and both its relative youth, in vivo Raman spectroscopy of
increases in SC thickness and barrier function the skin has already provided a valuable new
improvement. We therefore believe this confirms insight into SC behaviour and function and dem-
our hypothesis regarding niacinamide as being the onstrated its potential as a valuable tool for deter-
active ingredient in formulation A in our original mining chemical concentration gradients in a
work and demonstrates the validity or CRS for clinical environment, both in relation to the use
measuring and assessing the effects of topically of cosmetic products and naturally occurring
applied cosmetic formulations on skin properties. variation. As the technique becomes more estab-
lished, its ability to measure these profiles within
the skin will provide a deeper understanding of
38.3 Conclusion and the Future the interaction between chemical composition
and location and skin health and function.
While there are a number of techniques currently
available which are capable of providing informa- Acknowledgments The work was sponsored by Procter
and Gamble Technical Centres Ltd.
tion regarding distribution of different components
within the skin, until recently, none have been
capable of determining these non-destructively,
rapidly and in vivo. As such, it has been difficult to References
incorporate these into routine clinical test proto-
cols. The recent development of confocal Raman 1. Blank IH (1952) Factors which influence the water
spectroscopy has enabled the assessment of content of the stratum corneum. J Invest Dermatol
18:433440
changes in molecular concentration gradients 2. Grubauer G, Elias PM, Feingold KR (1989)
in vivo for the first time for a variety of different Transepidermal water loss: the signal for recovery of
chemical species. It is clear that CRS represents a barrier structure and function. J Lipid Res 30:323333
558 J.M. Crowther et al.

3. Loden M (1995) Biophysical properties of dry atopic 19. Krien PM, Kermici M (2000) Evidence for the exis-
and normal skin with special reference to skin care tence of self regulated enzymatic process within the
products. Acta Derm Venereol Suppl (Stockholm) human stratum corneum: an unexpected role for uro-
192:148 canic acid. J Invest Dermatol 115:414420
4. Agache P (2004) Stratum corneum histopathology. In: 20. Aberg C, Wennerstrom H, Sparr E (2008) Transport
Agache P, Humbert P (eds) Measuring the skin. processes in responding lipid membranes: a possible
Springer, Berlin mechanism for pH gradient in the stratum corneum.
5. Warner RR, Myers MC, Taylor DA (1988) Electron Langmuir 24:80618070
probe analysis of human skin: determination of the 21. Lieckfeldt R, Villalain J, Gomez-Fernandez JC, Lee
water concentration profile. J Invest Dermatol 90: G (1995) Apparent pKa of the fatty acids within
218244 ordered mixtures of model human stratum corneum
6. Warner RR, Lilly NA (1994) Correlation of water lipids. Pharmacol Res 12:16141617
content with ultrastructure in the stratum corneum. In: 22. Patterson MJ, Galloway SD, Nimmo NA (2000)
Elsner P, Berardesca E, Maibach HI (eds) Variations in regional sweat composition in normal
Bioengineering of the skin: water and the stratum cor- human males. Exp Physiol 85:869875
neum. CRC Press Inc, Boca Raton 23. Behne M, Oda Y, Murata S et al (2000) Functional
7. Richter T, Peuckert C, Sattler M et al (2004) Dead but role of the sodium-hydrogen antiporter, NHE1, in the
highly dynamic the stratum corneum is divided into epidermis: pharmacologic and NHE1 null-allele
three hydration zones. Skin Pharmacol Physiol mouse studies. J Invest Dermatol 114:797
17:246257 24. Visscher MO, Chatterjee R, Munson KS et al (2000)
8. Bouwstra JA, de Graff A, Gooris GS et al (2003) Changes in diapered and nondiapered infant skin over
Water distribution and related morphology in human the first month of life. Pediatr Dermatol 17:4551
stratum corneum at different hydration levels. J Invest 25. Hanson KM, Barry NP, Gratton E, Clegg RM (2000)
Dermatol 120(5):750758 Fluorescence lifetime imaging of pH in the stratum
9. Rawlings AV, Scott IR, Harding CR, Bowser P (1994) corneum. Biophys J Annu Meet Abstr:B588
Stratum corneum moisturization at the molecular 26. Hanson KM, Behne MJ, Barry NP et al (2002) Two-
level. J Invest Dermatol 103:731734 photon fluorescence lifetime imaging of the skin stra-
10. Brancaleon L, Bamberg MP, Sakamaki T, Kollias N tum corneum pH gradient. Biophys J 83:16821690
(2001) Attenuated total reflection-Fourier transform 27. Menon GK, Grayson S, Elias PM (1985) Ionic cal-
infrared spectroscopy as a possible method to investi- cium reservoirs in mammalian epidermis: ultrastruc-
gate biophysical parameters of stratum corneum tural localization by ion-capture cytochemistry.
in vivo. J Invest Dermatol 116:380386 J Invest Dermatol 84:508512
11. Arimoto H, Egawa M, Yamada Y (2005) Depth 28. Mauro T, Bench G, Sidderas-Haddad E et al (1998)
profile of diffuse reflectance near-infrared spectros- Acute barrier perturbation abolishes the Ca2+ and K+
copy for measurement of water content in skin. Skin gradients in murine epidermis: quantitative measure-
Res Technol 11:2735 ment using PIXE. J Invest Dermatol 111:11981201
12. Robinson M, Visscher M, Laruffa A, Wickett R (2010) 29. Elias PM, Ahn SK, Brown BE et al (2002) Origin of
Natural moisturizing factors (NMF) in the stratum the epidermal calcium gradient: regulation by barrier
corneum (SC). II. Regeneration of NMF over time status and role of active vs passive mechanisms.
after soaking. J Cosmet Sci 61(1):2329 J Invest Dermatol 119:12691274
13. Caspers PJ, Lucassen GW, Carter EA et al (2001) In 30. Prasch T, Knbel G, Schmidt-Fonk K et al (2000)
vivo confocal Raman microspectrometer of the skin. Infrared spectroscopy of the skin: influencing the stra-
Noninvasive determination of molecular concentra- tum corneum with cosmetic products. Int J Cosmet
tion profiles. J Invest Dermatol 116:434442 Sci 22:371383
14. Wertz PW (2004) Stratum corneum lipids and water. 31. Hathout RM, Mansour S, Mortada ND et al (2010)
Exogenous Dermatol 3:5356 Uptake of microemulsion components into the stra-
15. Kalia YN, Alberti I, Sekkat N et al (2000) tum corneum and their molecular effects on skin bar-
Normalization of stratum corneum barrier function rier function. Mol Pharm 7(4):12661273
and transepidermal water loss in vivo. Pharma Res 32. Notingher I, Imhof RE (2004) Mid-infrared in vivo
17(9):11481150 depth-profiling of topical chemicals on skin. Skin Res
16. Pirot F, Berardesca E, Kalia YN et al (1998) Stratum Technol 10:113121
corneum thickness and apparent water diffusivity: 33. Stamatas GN, de Sterke J, Hauser M et al (2008) Lipid
facile and noninvasive quantification in vivo. Pharma uptake and skin occlusion following topical applica-
Res 15(3):492494 tion of oils on adult and infant skin. J Dermatol Sci
17. Dikstein S, Zlotogorski A (1994) Measurement of skin 50:135142
pH. Acta Dermatol Venereol (Stockholm) 185:1820 34. Chrit L, Bastien P, Sockalingum GD et al (2006) An
18. Ohman H, Vahlquist A (1994) In vivo studies in vivo randomized study of human skin moisturiza-
concerning a pH gradient in human stratum corneum tion by a new confocal Raman fiber-optic microprobe:
and upper epidermis. Acta Dermatol Venereol assessment of a glycerol-based hydration cream. Skin
(Stockholm) 74:375379 Pharmacol Physiol 19(4):207215
38 Changes in Stratum Corneum Thickness, Water Gradients and Hydration by Moisturizers 559

35. Chrit L, Bastien P, Biatry B et al (2006) In vitro and 50. Bielfeldt S, Schoder V, Ely U et al (2009) Assessment
in vivo confocal Raman study of human skin hydra- of human stratum corneum thickness and its barrier
tion: assessment of anew moisturizing agent, pMPC. properties by in-vivo confocal Raman spectroscopy.
Biopolymers 85:359369 IFSCC Mag 12:915
36. Frster M, Bolzinger MA, Ach D et al (2011) 51. Baldwin K, Batchelder D (2001) Confocal Raman
Ingredients tracking of cosmetic formulations in the microspectroscopy through a planar interface. Appl
skin: a confocal Raman microscopy investigation. Spectrosc 55:517524
Pharm Res 28(4):858872 52. Tfayli A, Piot O, Manfait M (2008) Confocal Raman
37. Williams AC, Barry BW, Edwards HGM, Farwell microspectroscopy on excised human skin: uncertain-
DW (1993) A critical comparison of some Raman ties in depth profiling and mathematical correction
spectroscopic techniques for studies of human stra- applied to dermatological drug permeation.
tum corneum. Pharm Res 10:16421647 J Biophotonics 1:140153
38. Williams AC, Edwards HGM, Barry BW (1992) 53. Welzel J (2001) Optical coherence tomography in
Fourier transform Raman spectroscopy. A novel dermatology: a review. Skin Res Technol 7:19
application for examining human stratum corneum. 54. Ya-Xian Z, Suetake T, Tagami H (1999) Number of
Int J Pharm 81:R11R14 cell layers of the stratum corneum in normal skin
39. Lucassen GW, Caspers PJ, Puppels GJ (1998) In vivo relationship to the anatomical locations on the body,
infrared and Raman spectroscopy of human stratum age, sex and physical parameters. Arch Dermatol Res
corneum. Proc SPIE 3257:5261 291:555559
40. Shim MG, Wilson BC (1997) Development of an 55. Gambichler T, Boms S, Stacker M et al (2006)
in vivo Raman spectroscopic system for diagnostic Epidermal thickness assessed by optical coherence
applications. J Raman Spectrosc 28:131142 tomography and routine histology: preliminary results
41. Caspers PJ, Lucassen GW, Wolthuis R et al (1998) In of method comparison. J Eur Acad Dermatol Venereol
vitro and in vivo Raman spectroscopy of human skin. 20(7):791795
Biospectroscopy 4:S31S39 56. Lademann J, Otberg N, Richter H et al (2007)
42. Caspers PJ, Lucassen GW, Bruining HJ, Puppels GJ Application of optical non-invasive methods in
(2000) Automated depth-scanning confocal Raman skin physiology: a comparison of laser scanning
microspectrometer for rapid in vivo determination of microscopy and optical coherent tomography with
water concentration profiles in human skin. J Raman histological analysis. Skin Res Technol 13(2):
Spectrosc 31:813818 119132
43. Caspers PJ, Lucassen GW, Puppels GJ (2003) 57. Norlen L (2006) Stratum corneum keratin structure,
Combined in vivo confocal Raman spectroscopy and function and formation a comprehensive review. Int
confocal microscopy of human skin. Biophys J J Cosmet Sci 28(6):397425
85:572580 58. Wu J, Polefka TG (2008) Confocal Raman microspec-
44. Chrit L, Hadjur C, Morel S et al (2005) In vivo chemi- troscopy of stratum corneum: a pre-clinical validation
cal investigation of human skin using a confocal Raman study. Int J Cosmet Sci 30:4756
fiber optic microprobe. J Biomed Opt 10(4):44007 59. Matts PJ, Gray J, Rawlings AV (2005) The dry skin
45. Egawa M, Hirao T, Takahashi M (2007) In vivo esti- cycle a new model of dry skin and mechanisms for
mation of stratum corneum thickness from water con- intervention (International congress and symposium
centration profiles obtained with Raman spectroscopy. series), vol 256. The Royal Society of Medicine Press
Acta Derm Venereol 87(1):48 Ltd, London, pp 138
46. Egawa M, Tagami H (2008) Comparison of the depth 60. Loden M (2005) The clinical benefit of moisturizers.
profiles of water and water binding substances in the JEADV 19:672688
stratum corneum determined by Raman spectroscopy 61. Breternitz M, Kowatski D, Langenauer M et al (2008)
between the cheek and volar forearm: effects of age, Placebo controlled, double blind, randomized pro-
seasonal changes and artificial forced hydration. Br J spective study of a glycerol-based emollient on
Dermatol 158:251260 eczematous skin in atopic dermatitis: biophysical and
47. Chrit L, Bastien P, Biatry B et al (2007) In vitro and clinical evaluation. Skin Pharmacol Physiol 21:
in vivo confocal Raman study of human skin hydra- 3945
tion: assessment of a new moisturizing agent, pMPC. 62. Summers RS, Summers B, Chandar P et al (1996) The
Biopolymers 85(4):359369 effect of lipids with and without humectants on skin
48. Crowther JM, Sieg A, Blenkiron P et al (2008) xerosis. J Soc Cosmet Chem 47:2739
Measuring the effects of topical moisturizers on 63. Rawlings AV, Watkinson A, Hope J et al (1995) The
changes in stratum corneum thickness, water gradi- effect of glycerol and humidity on desmosome degra-
ents and hydration in vivo. Br J Dermatol 159: dation in stratum corneum. Arch Dermatol Res
567577 287:457464
49. Naito S, Min YK, Osanai O et al (2008) In vivo 64. Held E, Sveinsdottir S, Agner T (1999) Effect of long
measurement of human dermis by 1064 nm-excited term use of moisturizer on skin hydration, barrier
fiber Raman spectroscopy. Skin Res Technol 14: function and susceptibility to irritants. Acta Derm
1825 Venereol 79:4951
560 J.M. Crowther et al.

65. Zachariae C, Held E, Johansen JD et al (2003) Effect 75. Caussin J, Groenink HWW, de Graaff AM et al (2007)
of a moisturizer on skin susceptibility to NiCl2. Acta Lipophilic and hydrophilic moisturizers show differ-
Derm Venereol 83:9397 ent actions on human skin as revealed by cryo scan-
66. Berardesca E, Distante F, Vignoli GP et al (1997) ning electron microscopy. Exp Dermatol 16:891898
Alpha hydroxyacids modulate stratum corneum bar- 76. Orth DS, Appa Y, Contard P et al (1995) Effect of
rier function. Br J Dermatol 137:934938 high glycerin moisturizers on the ultrastructure of the
67. Buraczewska I, Berne B, Lindberg M et al (2007) stratum corneum. Poster at the 53rd annual meeting of
Changes in skin barrier function following long-term the American Academy of Dermatology, New
treatment with moisturizers, a randomized controlled Orleans, Feb 1995
trial. Br J Dermatol 156:492498 77. Orth DS, Appa Y (2000) Glycerine: a natural ingredi-
68. Barany E, Lindberg M, Loden M (2000) Unexpected ent for moisturizing skin. In: Loden M, Maibach HI
skin barrier influence from non-ionic emulsifiers. Int J (eds) Dry skin and moisturizers: chemistry and func-
Pharm 195:189195 tion. CRC Press, Boca Raton
69. Fluhr JW, Gloor M, Lehmann L et al (1999) Glycerol 78. Fluhr JW, Bornkessel A, Berardesca E (2006)
accelerates recovery of barrier function in vivo. Acta Glycerol-just a moisturizer? Biological & biophysical
Derm Venereol 79:418421 effects. In: Loden M, Maibach HI (eds) Dry skin and
70. Loden M, Andersson AC, Andersson C et al (2001) moisturizers, 2nd edn. CRC Press, Boca Raton
Instrumental and dermatologist evaluation of the 79. Jacobson EL, Kim H, Kim M et al (2007) A topical
effect of glycerine and urea on dry skin in atopic der- lipophilic niacin derivative increases NAD, epidermal
matitis. Skin Res Technol 7:209213 differentiation and barrier function in photodamaged
71. Rawlings AV, Conti A, Verdejo P et al (1996) The skin. Exp Dermatol 16(6):490499
effect of lactic acid isomers on epidermal lipid bio- 80. Loden M, Wessman C (2001) The influence of a
synthesis and stratum corneum barrier function. Arch cream containing 20% glycerin and its vehicle on skin
Dermatol Res 288:383390 barrier properties. Int J Cosmet Sci 23:115119
72. Norlen L, Emilson A, Forslind B (1997) Stratum cor- 81. Fluhr JW, Mao-Qiang M, Brown BE et al (2003)
neum swelling. Biophysical and computer assisted Glycerol regulates stratum corneum hydration in
quantitative assessments. Arch Dermatol Res 289: sebaceous gland deficient (Asebia) mice. J Invest
506513 Dermatol 120:728737
73. Richter T, Muller JH, Schwarz UD et al (2001) 82. Choi EH, Man MQ, Wang F et al (2005) Is endoge-
Investigation of the swelling of human skin cells in nous glycerol a determinant of stratum corneum
liquid media by tapping mode scanning force micros- hydration in humans? J Invest Dermatol 125:288293
copy. Appl Phys A A72:S125S128 83. Crowther JM, Matts PJ, publication in preparation
74. Bouwstra JA, de Graaff A, Gooris GS et al (2003) 84. Kaczvinsky JR, publication in preparation
Water distribution and related morphology in human
stratum corneum at different hydration levels. J Invest
Dermatol 120:750758
 Skin Moisture and Heat Transfer
39
Jerrold Scott Petrofsky and Lee Berk

is an important and significant means of remov-

39.1 Introduction and Overview ing heat from the body [27]. In addition to evapo-
ration, there are three other ways that heat is lost
A natural senescence of the skin occurs as a result through the body. These are radiation, convec-
of the aging process [65]. Over the life span of a tion, and conduction [27]. The skin is involved in
human being, skin moisture and skin structure all four to allow heat loss from the body.
vary [65]. In the last few centuries, the human life Radiation involves the skin producing infrared
span has nearly doubled, adding to the yearly light to lose heat from the body. The normal
chronology of stress on the skin and the deleteri- emissivity of human skin is 0.97 and is not influ-
ous effects of the aging process [79]. The skin enced by race or skin color [115]. The intensity
serves as a protective immunological barrier of the radiation emitted by the body can be viewed
between the outside world and the internal organs. through a special camera called an infrared
As such, it is exposed to the environment includ- imager. In such a photograph, the temperature of
ing UV light and environmental toxins. In addi- the skin can be measured by infrared light inten-
tion, stressors such as smoking and diet expose sity. In Fig. 39.1 below, for example, the intensity
the skin to internal stresses from increasing con- has been coded by color. The color white is used
centrations of free radicals as we age [61]. for warmer temperatures, and blue represents
While skin is a barrier, it is not a complete bar- cooler temperatures. Temperatures in the mid-
rier and is permeable to oils, and to a lesser extent dle are assigned to other colors such as red, yel-
moisture. It can gain or lose moisture. The loss of low, and green [52].
moisture through the skin takes two forms, insen- The average person loses over 1,500,00 cal
sible water loss and sweat. Water loss is a means per day in heat from the body [57]. Much of this
of removing heat from the body since the is lost through radiation (Fig. 39.2). But when
evaporation of 1 cc of water causes the loss of body heat rises rapidly, as occurs during exercise,
540 cal from the body. While sweat is a major additional mechanisms are needed to cool the
means of water loss, the insensible water loss, body. Thus, conduction and convection come into
when added to moisture lost through respiration, play and are also used in heat loss [130].
Conduction involves passive heat loss from
the skin by direct contact to another media. For
example, if a person sits on a chair with snow on
J.S. Petrofsky, Ph.D., J.D. () L. Berk, DrPH it, heat moves from the skin into the snow elicit-
Department of Physical Therapy,
ing a heat loss from the body. This mechanism
Loma Linda University,
Loma Linda, CA 92373, USA works well for the skin when exposed to the
e-mail: [email protected] environment. It is blunted with clothing since

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 561

DOI 10.1007/978-3-642-27606-4_39, Springer-Verlag Berlin Heidelberg 2012
562 J.S. Petrofsky and L. Berk

Fig. 39.1 An infrared picture

of the skin in male and female
subjects of various races

Fig. 39.2 The different

mechanisms of heat loss from
the body

Evaporation

Radiation

Convection

Conduction

heat cannot easily move through fabric due to its Another mechanism is convection. Convective
high air content [47]. Thus, the larger the surface heat loss occurs when air moves over the exposed
area of the body that is in contact with a cooler skin [44]. This causes a loss of calories directly from
object, the greater the heat loss. the skin. Finally, there is the mechanism of evapora-
39 Skin Moisture and Heat Transfer 563

tion. Through sweating or insensible water loss, The dermis also shows aging effects in terms
water changes from a liquid state to vapor and carries of integrity and function much like the epidermis.
heat away from the body due to water changing from Collagen, elastin, and hyaluronic acid in the der-
a state of liquid to gas. Each cc of water that evapo- mis are all depleted with aging [32]. This weakens
rates causes the loss of 540 cal of heat [72]. But the the integrity of the dermis [33]. Collagen turnover
reverse is also true. When water condenses on the also changes. In young skin, the ratio of type I to
skin, it gains 540 cal/cc of water that condenses. The type III collagen is 6:1. In older skin, this ratio
average person sweats between 0.8 and 1.4 l/h. Thus, drops by each decade of life [116]. Thus, the col-
if all water was evaporated, it would lead to a heat lagen becomes thicker with age. Increased colla-
loss of up to 750,000 cal/h. In fact, in athletes, even gen cross-links with age reduce skin elasticity
higher sweat losses have been reported [63]. [32]. Sensory transduction is also reduced with
All of these mechanisms rely on the skin being age. Additionally, a loss of Pacinian corpuscles
intact and circulation being normal. Aging is and Meissners corpuscles from the dermal layer
associated with an increase in tissue reactive oxy- in older skin reduces tactile sensation [26].
gen species that damages multiple pathways [40]. All of these changes lead to impaired convective
Reactive oxygen species damage circulation, and conductive heat transfer with age. Lower water
reducing radiation, convection, and conduction. content reduces the thermal coefficient of the skin
Damage to nitric oxide release in sweat glands making it easier to warm the skin when an external
associated with aging also impairs sweating caus- heat load is applied. Changes in the structural integ-
ing a reduction in evaporative loss [53]. rity also alter the skin thermal coefficient, so heat is
These same reactive oxygen species can also not transferred as easily. Thus, heat going into or
damage cellular and nuclear membranes [40]. out of the skin is altered by aging. Since the blood
Skin structure can also alter heat transfer. With flow is the most important consideration in heat
aging, cell proliferation in the skin decreases lead- loss, its control and the effects of aging and diabe-
ing to a loss of skin integrity [112]. The skin dries tes will be reviewed followed by the impact of skin
and wrinkles with age [35]. Skin dryness has been moisture on skin circulation. Further, the effect of
reported with advancing age in over 95% of the skin moisture on conductive heat transfer will also
people who were sampled in one study [59]. Skin be reviewed more specifically.
thickness rises over the first 20 years of life [41]
and then thins as age progresses [80, 110]. The epi-
dermis may either become thin or cornified, and 39.2 Modeling of Heat Exchange
the dermis may thin as much as 50% or more with Through the Skin
age [80, 131]. The loss of skin capillary density,
called rarefaction [131], is paralleled with a loss of Heat exchange through the skin was first mod-
skin collagen and elastin [11]. The basement mem- eled by Pennes. The Pennes model predicted
brane also increases in thickness with age [129]. that there were two basic ways the skin can dis-
These generalized changes in moisture con- sipate heat [81]. One of those was through con-
tent and structure in the skin can be specifically ductive heat loss. Conductive heat loss, as
addressed for each of the two major layers in the described above, involves passive properties of
skin, the epidermis and dermis. The stratum cor- the skin including skin fat content, moisture,
neum loses water content with age [43, 54, 67]. and structure [64, 85]. The other way of moving
Part of this is due to a reduction in the amino acid heat is related to skin blood flow [81]. Pennes
composition of the epidermis, which reduces its asserted that the primary site of temperature
capacity to bind water [54]. The integrity of the equilibration was the capillary bed and that all
skin also depends on the lipid content of the epi- the blood perfusing of the skin starts at the core
dermis. This decreases by as much as 65% with temperature of the body [81]. The Pennes bio-
age [124]. These age-related changes reduce the heat equation is:
ability of the skin to provide a barrier to protect
the dermis below [30, 39]. hb = V bCb (1 - )(Ta - T )
564 J.S. Petrofsky and L. Berk

where hb is the rate of heat transfer per unit vol- The factors that determine the heat exchange
ume of tissue, V is the perfusion rate per unit vol- properties of the skin are the coefficient of heat of
ume of tissue, rb is the density of blood, Cb is the the skin itself and the underlying tissue, namely
specific heat of blood, k is a factor that accounts fat. The coefficient of heat is the ease with which
for incomplete thermal equilibrium between heat passes through a structure. For example, the
blood and tissue, Ta is the temperature of arterial coefficient of heat of water is 1.0. What this
blood which is generally assumed to remain con- means is that 1 cal of heat will raise water 1C.
stant and equal to the core temperature of the Iron on the other hand has a coefficient of heat of
body, and T is the local tissue temperature [135]. 0.09. One calorie will raise the temperature of
The basic premise is that heat in is equivalent to iron about 10C. Therefore, this is an important
heat out; heat into the body is dissipated either property of a material that determines how hot it
into the blood or deeper tissues. Three major gets when heat passes through it. A measure of
advantages of the model are that it is readily the actual heat flow, which depends on the coef-
solvable for constant parameter values, gives ficient of heat, is the ability of heat to move later-
two adjustable parameters (V and Ta), and ally and deep below the skin. This is called
requires no anatomical data [93]. On the down- thermal conductivity. This number shows the
side, the model gives no prediction of actual energy loss through a substance such as the skin.
details of vascular temperatures, the assumption For human skin, thermal conductivity has been
of constant arterial temperature is not generally determined [12]. While for water, it is 0.628 W/m2.
valid, and thermal equilibration occurs prior to For fat, it is 0.33 and for blood plasma, it is 0.57 W/
the capillary bed. The Pennes model also did not m2. Thus, the greater the water content of the skin,
take into consideration skin moisture and subcu- the better the heat transfer. Some of heat applied to
taneous fat, both of which alter conductive heat the skin moves laterally, while most heat moves
exchange [82, 109]. In addition, aging and dia- into deep tissue. Thus, even if skin were very moist,
betes reduce skin blood flow [70, 71, 96] and the thickness of the subcutaneous fat layer would
may alter subcutaneous fat thickness and skin limit heat transfer out of the skin. If heat cannot
moisture, changing both conductive and blood- leave the skin, the skin will get hot very quickly
borne heat transfer. and can burn as predicted by Henriques [45, 75, 76].
The actual analysis of skin moisture and its role in
heat transfer is complex since heat movement for
39.2.1 Conductive Heat Loss Through conductive heat exchange varies in different layers
the Skin of the skin. For example, in pig skin, a model of
human skin, epidermal heat conductivity is 0.36,
Conductive heat exchange through the skin is for the dermis it is 0.54, and for fat it is 0.21 [45, 75,
governed by the structure of the skin itself and 76]. Muscle is 0.064. Thus, the movement of heat
the underlying tissues. When heat is rapidly involves a multicompartment model showing that
applied to the skin, conductive heat exchange is any change in any layer will alter conductive heat
the only means of heat removal. The circulation, movement across the skin. It can be predicted that
as described below, is a much more efficient changes in either oil or moisture content or thickness
means of removing heat. However, there is a time of any of these three layers would alter thermal
delay after heat is applied to the skin before the conductivity, but it was not until recent years that
circulation increases. Circulation takes seconds these were examined as shown below.
before it increases. Even after circulation Thus, in summary, the factors of importance
increases, conductive heat loss is still important for conductive heat transfer are:
in the heat exchange process. Further, the con- 1. The structure of the dermal and epidermal layer
ductive heat properties of the skin also govern 2. The water content of the dermal and epider-
heat loss and heat gain by radiation and convec- mal layer
tion as well. 3. The thickness of subcutaneous fat
39 Skin Moisture and Heat Transfer 565

Fig. 39.3 The changes in skin Panel A

and muscle temperature in the
quadriceps muscle in a thin 42
(Panel A) and overweight Thin hydrocollator

Temperature (c)
(Panel B) subject after 40
immersion of the leg for
15 min in a water bath. Each 38
figure shows the skin and
36 Skin
muscle temperature. Skin
temperature rises quickly, 34 Muscle
while muscle temperature is
protected by the insulating 32
capability of subcutaneous fat 0 2 4 6 8 10 12 14 5 15
and the skin Time (min)

Panel B

42
OW hydrocollator
Temperature (c)

40
38
36 Skin
34 Muscle
32
0 1 2 3 4 5 6 7 8 9 101112131415 5 1015
Time (min)

39.2.1.1 Subcutaneous Fat in the quadriceps muscle 2.5 cm below the surface
As stated previously, different thicknesses of sub- of the skin, and a second thermocouple on the skin
cutaneous fat and its effect on heat transfer were was just at the needle insertion site. After the leg
not taken into consideration by the Pennes model. was immersed in the bath water, skin temperature
Subcutaneous fat thickness has been shown to be rapidly rose toward that of the water in both sub-
greater in people who are older and who have diabe- jects. However, in the overweight subjects, there
tes compared to younger individuals [84, 101, 108]. was a slower rise in muscle temperature compared
Actual measurements of heat transfer in humans to the thinner subject due to the subcutaneous fat.
as a function of the thickness of the subcutaneous The same is true when energy is transferred from
fat layer clearly show a slowing in heat transfer muscle to skin; subcutaneous fat acts as a barrier to
with increased fat so that the time constant which energy movement. If a warm heat source is applied
predicts heat dissipation into deeper layers is to the skin, the heat is kept in the skin in someone
increased [108]. Thus, if subcutaneous fat is who is overweight causing skin temperature to rise
thickened, it is harder for muscle to lose heat out- faster and making the skin more susceptible to
ward to the skin, and if a heat load is applied to the burns. But skin moisture also plays a critical role
skin, it impairs the ability of circulation to transfer in conductive heat loss. Moisture content of subcu-
heat into deeper tissues [103, 109]. This causes taneous fat is low. But as stated above, it is critical
higher skin temperatures during both local and in heat transfer characteristics in the dermal layer.
global heating [108, 134]. For example, Fig. 39.3
illustrates the data on two typical subjects who had 39.2.1.2 Skin and Conductive
their legs immersed in a water bath for 15 min. Heat Transfer
The skin and muscle temperatures were measured Older people have thinner dermal layers than that
by thermocouples. The thermocouple was placed found in younger people [69, 95, 106]. This
566 J.S. Petrofsky and L. Berk

impacts the ability of the skin to dissipate heat. perature and pressure on the skin [55, 56] In hairy
Skin moisture is also less in older people. Previous (nonglabrous) skin, which is present over most of
studies indicate skin moisture content, as stated the body, three separate branches of the sympa-
above, alters the ability of heat to passively trans- thetic nervous system control skin blood flow:
fer through skin [64]. Skin that is dry with low adrenergic vasoconstrictor nerves that reduce
water content has a lower thermal index than (constrict) skin blood vessels [60] and cholin-
moist skin causing small amounts of heat to ergic and nitrogenergic nerves that cause vasodi-
greatly increase the temperature of the skin [14, latation of blood vessels by releasing the
82, 119]. This can lead to skin damage and burns neurotransmitters acetylcholine or nitric oxide,
[117]. For example, in a recent study, when a con- respectively [60, 87]. In addition, local effectors,
stant heat source at 42C was applied to the skin such as metabolites and changes in local skin
in the upper leg, older people required, in the first temperature or pressure, may mediate a change in
few seconds before skin blood flow could change, skin blood flow [109]. Thus, the control of the
half the calories to heat the skin to the same tem- circulation in the skin can be divided into gener-
perature compared to younger people [79]. ally two types of control: (1) the local response of
Further compounding the problems of dissi- vascular endothelial cells to metabolites and other
pating heat in older people is diabetes. When effectors (such as local pressure or shear stress on
compared to age-matched nondiabetic people, the blood vessel wall) and (2) neurogenic control
those with type II diabetes have thinner skin [10, through the sympathetic nervous system. Both
70, 96], thicker subcutaneous fat [10, 25], less sympathetic synapses and local effectors mediate
skin moisture [69, 119], and reduced skin blood their effects through the thin layer of cells lining
flow due to greater endothelial dysfunction com- blood vessels, the vascular endothelial cells [94].
pared to age matched controls [17, 18, 4851, 58, Using drugs that specifically block vasocon-
120]. When heat was applied to the skin of the leg striction (e.g., bretylium tosylate) and agents that
in individuals with diabetes and the calories inhibit vasodilatation by blocking acetylcholine
needed to increase skin temperature were mea- (cholinergic antagonistic agents) has been used to
sured, compared to age-matched controls, the confirm chemical mediators at neuronal synapses
skin required half the calories of the controls [7]. [109]. Sympathetic vasodilator and vasoconstric-
tor nerves innervate blood vessels by extensive
terminal varicosities located on the surface of vas-
39.2.1.3 Skin Circulation and Heat cular endothelial cells [31]. The vascular endothe-
Transfer lial cells, in turn, release fat soluble substances
The skin circulation plays a major role in heat that cause the vascular smooth muscle surround-
transfer. But the control of the circulation is com- ing it to relax or constrict, thereby mediating a
plex and involves balancing many factors. When change in skin blood flow. Stripping the inner
individuals are exposed to a thermally neutral layer of large conduit arteries (i.e., removing the
environment, skin blood flow averages about 5% endothelial layer) eliminates vasodilatation and
of their cardiac output [114]. However, during vasoconstriction in vascular smooth muscle [31].
whole body heating, blood flow through the skin The most important vasodilator substance is
can increase to as much as 160% of cardiac out- nitric oxide. It is released from vascular endothe-
put at rest, or about 8 l/min [114]. This provides lial cells due to a variety of stimuli including skin
a great potential for thermal cooling of the body. moisture content.
In glabrous (nonhairy) skin (e.g., palms, plantar
aspects of the feet, and lips), cutaneous arterioles Nitric Oxide
are innervated by only sympathetic adrenergic A variety of different stressors can elicit an
vasoconstrictor nerves [34, 64]. In addition to the increase or decrease in skin blood flow in hairy
sympathetic nerves, blood flow is also affected skin. The blood flow response is controlled
by local metabolites and effectors such as tem- through a range of different mechanisms. In the
39 Skin Moisture and Heat Transfer 567

Fig. 39.4 Synthesis of nitric Ca++ Acetylcholine,

oxide serotonin, bradykinin
Shear

Calmodulin, NADPH,

ENOS

L-arginine L-citrulline

NO

1990s, a number of research laboratories demon- the release of histamine from mast cells induced
strated an active role for nitric oxide as a media- by VIP also could be involved because histamine
tor of vasodilatation in the skin [29, 58, 99]. increases the bioavailability of nitric oxide in the
Historically, it had been postulated that a sub- skin [71, 96].
stance released from vascular endothelial cells Nitric oxide, once produced, diffuses both into
caused vascular smooth muscle to relax [98]. the blood and into the surrounding vascular
This substance, originally called endothelial cell- smooth muscle. In smooth muscle, nitric oxide
derived relaxation factor, is now known to be sev- activates the soluble enzyme in the cytoplasm,
eral different compounds, one of which is a guanylate cyclase, which catalyzes the produc-
fat-soluble chemical, nitric oxide [70]. tion of cyclic guanosine monophosphate (cyclic
Several lines of evidence indicate that nitric GMP) (Fig. 39.5).
oxide is produced by endothelial cells in both Cyclic GMP has several biological actions
humans and animal models and over a variety of which include decreasing calcium permeability,
species. Nitric oxide is produced from the amino inhibiting actomyosin ATPase activity, and
acid L-arginine by the enzyme endothelial nitric increasing potassium permeability in vascular
oxide synthetase (Fig. 39.4). When LNAME smooth muscle. These three functions, taken
(N-nitro-L-arginine methyl ester), an inhibitor of together, have the combined effect of relaxing
nitric oxide synthetase, is infused into the skin vascular smooth muscle.
via microdialysis in both animals and humans, Nitric oxide also has other effects on the
the increase in blood flow due to stressors such as endothelial cell and its environment. These
heat is significantly attenuated, although not autocrine and paracrine effects include nitric
completely blocked [58]. During whole body oxide being a potent anti-inflammatory agent on
heating, the bioavailability of nitric oxide blood vessel walls, inhibiting leukocyte adhe-
increases in proportion to skin blood flow. sion [89], platelet adhesion, and smooth muscle
However, nitric oxide may be generated from cell proliferation [104], promoting insulin
sources in addition to endothelial nitric oxide release [97], and mediating the immune response
synthetase. For example, evidence exists that H1 to inflammation [88].
histamine receptors on vascular endothelial cells Nitric oxide also is involved in physiologic
generate nitric oxide during cutaneous active functions outside of the vascular endothelial
vasodilation [71]. It has also been suggested that cells. These include neuronal transmission
568 J.S. Petrofsky and L. Berk

Fig. 39.5 The effect of nitric

oxide on smooth muscle
NO

Reduced Ca++
permeability

Guanylate
cyclase

Cyclic Reduced ATPase

GTP GMP

Increased k+
permeability

Smooth muscle

[91, 123], pulmonary vascular remodeling [111], cells, ENOS is normally inactive. It is activated
arterial sclerosis [86], and exercise-induced car- through a complex sequence of chemical reac-
diac protection [105]. Impaired production or tions that involve the binding of nicotinamide-
bioavailability of nitric oxide leads to endothelial adenine dinucleotide phosphate (NADPH), flavin
dysfunction and is the root cause of much differ- mononucleotide, and flavin adenosine dinucle-
ent cardiovascular pathology including diabetes, otide [128] to the enzyme. Mediated by flavin,
hypertension, heart failure, and coronary artery electrons are transferred from the carboxylate
disease [92]. (COOH) terminal bound to NADPH to the heme
Nitric oxide is derived from the bioconversion of the NH2 terminus. These electrons activate
of the amino acid, L-arginine, to the amino acid, oxygen. L-Arginine is reduced to L-citrulline in
L-citrulline. Like all amino acids, L-arginine and two phases. In the first phase, L-arginine binds to
L-citrulline are nitrogen-bearing compounds. ENOS. In the second phase, it is oxidized to
The L-arginine molecule has four nitrogens: L-citrulline and releases nitric oxide [19].
when bioconverted to L-citrulline, it loses one Intracellular calcium modulates the activity of
atom of nitrogen and oxygen to form nitric oxide ENOS through the calcium-binding subunit [37].
and yields another amino acid with three nitro- Intracellular calcium is mobilized through vari-
gens, L-citrulline. ous signaling pathways, and ENOS is ultimately
A family of enzymes called nitric oxide syn- activated by phosphorylation at one of six phos-
thetases produce nitric oxide in various organ phorylation sites [28]. Calcium-activated calm-
systems. The enzymes include neuronal nitric odulin increases the rate of transfer of electrons
oxide synthetase (NOS), inducible nitric oxide from NADPH to ENOS (Fig. 39.3). (The com-
synthetase (INOS), and endothelial nitric oxide plex system of reactions used to increase calcium
synthetase (ENOS) [19]. ENOS is the predomi- mobility from the extracellular to intracellular
nant form of nitric oxide synthetase in the vascu- space is discussed in another section of this chap-
lature [128]. There are three subunits in ENOS, a ter.) Other substances, such as proteins and free
central calmodulin-binding subunit and an oxida- fatty acids, can also modulate the activation of
tive and reductase end. In vascular endothelial ENOS [13, 37].
39 Skin Moisture and Heat Transfer 569

Phosphorylation of ENOS via protein kinases tion was preserved after inhibition of both ENOS
is a critical step in its activation [127]. To date, and cyclooxygenase (COX) [46]. Although this
six phosphorylation sites on ENOS have been shows the importance of nitric oxide and prosta-
identified, including serine 1,177, threonine 495, cyclin in regulating cutaneous circulation, it points
protein kinase b (pkb-akt) 939, adenosine mono- to other substances released by vascular endothe-
phosphate-activated kinase, protein kinase A, and lial cells, especially in younger individuals, that
protein kinase G [70, 107]. For example, the also mediate an increase in skin blood flow [46].
ENOS cascade can be activated by receptors for For example, in studies of chronic inflammation
estrogen and glucocorticoids [95], insulin and of the skin, neuropeptides such as substance P can
vascular endothelial growth factor (VEGF) [4], be released from sympathetic nerve terminals [20].
and blood flow and laminar shear stress [3, 24]. Substance P binds to the endothelial cell on the
The balance between nitric oxide production NK-1 receptor [20]. In rats, administration of the
and degradation determines the bioavailability of NK-1 receptor antagonist CP-96345 significantly
nitric oxide. When nitric oxide bioavailability is reduced the blood flow increase which occurred
reduced, heightened vasoconstriction occurs, as during sympathetic nerve stimulation [20]. Thus,
seen in hypertension, cardiovascular disease, and substance P may be responsible for the vasodilata-
diabetes [38, 45]. tion seen due to inflammation in the tissues in rats
Impairments of ENOS activity can affect nitric [6], and in response to direct electrical stimulation
oxide production. For example, instability in ENOS of sympathetic nerves [36], and other conditions
may liberate oxygen instead of nitric oxide [4]. such as electrical stimulation of the lumbar sympa-
Decreased bioavailability of L-arginine may cause thetic trunk [20]. Substance P is normally expressed
ENOS to reduce production of nitric oxide in vivo in small dorsal root ganglion neurons and in the
[21]. Oxidative stress causing reactive oxygen spe- skin and is upregulated in inflammatory conditions
cies also reduces nitric oxide bioavailability through [137]. Nerve growth factors from inflamed tissue
degradation. These oxides and superoxides degrade play a role in upregulating production of substance
nitric oxide, yielding molecules that bear three P [137]. Because sympathetic postganglionic neu-
oxygen atoms, such as peroxynitrite [78]. These rons are affected by nerve growth factors from
reactive oxygen species can in turn cause cellular chronic inflammation, it has been hypothesized
damage. Oxidative stress potentially can be moder- that upregulation of substance P alters the normal
ated via activating NADPH oxidases or xanthine sympathetic combination of neurotransmitters
oxidases in the vascular wall [28, 77]. released in sympathetic nerves [20].
Diabetes and cigarette smoking may not alter
nitric oxide production via NOS enzymatic path-
ways yet still reduce nitric oxide bioavailability 39.2.2 The Effect of Heat on Circulation
by increasing oxidative stress. The result is
impaired vasodilatation [78]. This can raise car- It is well established that when heat is applied to
diac work and blood pressure. the skin, there is an increase in skin blood flow
[89, 101, 136]. Initially, warm thermoreceptors
Other Vasodilators on skin tactile sensory nerves (TRPV1 receptors)
Prostacyclin (PGI2), a prostaglandin, is another sense the warmth and release substance P and
vasodilator released by vascular endothelial cells calcitonin gene-related peptide which cause an
[46]. In younger people, vasodilatation is medi- increase in potassium permeability in vascular
ated through the release of both nitric oxide and smooth muscle surrounding the endothelial cell
prostacyclin [46]. However, as individuals age, [15, 16, 73]. This, in turn, causes an increase in
prostacyclin production is impaired, and nitric blood flow by relaxing vascular smooth muscle.
oxide becomes the predominant vasodilator [113]. This is illustrated in Fig. 39.6.
One study of younger subjects revealed that at Here, the data represents ten subjects with a
least 60% of acetylcholine-mediated vasodilata- 44C heat source applied to their leg for 2 min.
570 J.S. Petrofsky and L. Berk

Fig. 39.6 The effect of locally Blood flow

applied heat at 44C on skin 900
blood flow (flux) over a 120 800
seconds period 700
600
500
400
Blood flow
300
200
100
0
Rest Post Post Post Post Post Post Post Post Post Post
10 20 30 40 50 60 75 90 105 120

1,400
1,200

1,000
Blood flow (flux)

800

600
Young
400
Older
200
0
Rest 30 60 90 120 180 5 7.5 10 15 20 Post Post Post Post Post
200
min min min min min 30 60 2 3 5
min min min

Fig. 39.7 Blood flow response to local heat and aging

The average data, shown in this figure in flux tors on endothelial cells themselves. These chan-
(units of blood flow from a laser Doppler imager) nels are TRPV4 voltage-gated calcium channels
shows a time delay of a few seconds followed by [132, 133]. Above a temperature of 35C, these
a linear increase in skin blood flow that was start- channels cause an exponential increase in calcium
ing to plateau after 2 min. This is a typical influx into the endothelial cell from the interstitial
response in younger subjects (2030 years old) space thereby increasing activity of endothelial
and shows the delay in increase in circulation dis- nitric oxide synthetase [136]. Nitric oxide then
cussed by Pennes [81]. dilates vascular smooth muscle [16, 18, 73, 83, 84].
This increase in blood flow in the first 2 min is This is shown in Fig. 39.7. As seen here in younger
diminished with aging, showing an age effect on and older subjects after 2 min of local heat expo-
these same TRPV1 tactile sensors. In Fig. 39.7, sure of 44C on the skin above the quadriceps
the same experiment was conducted on individu- muscle, the sustained increase in circulation is
als that were in the age range of 3060 years. As maintained by TRPV4 calcium channels. However,
shown in Fig. 39.7, the blood flow response was the absolute blood flow is lesser in older people.
diminished and sluggish with the same heat stress This is believed to be due to increased free radicals
on the skin. in cells associated with aging. Free radicals in vas-
The TRPV1 channels only elicit a vasodilata- cular endothelial cells impair production of both
tion that lasts a few minutes at best. A slower nitric oxide and also to the prostacyclin pathway,
response that eventually becomes the predominant resulting in less blood flow in response to heat in
response to heat is mediated through warm recep- older individuals [82]. The slower response to heat
39 Skin Moisture and Heat Transfer 571

in older individuals as seen in this Fig. 39.7 may mal sympathetic response to a change in central
also be related to death of sensory nerves in the arterial blood pressure is modulated by altering the
skin associated with aging, reducing the sensitivity osmotic pressure of blood. In TRPV4 knockout
to temperature in the skin [62]. mice, hearing is impaired [126].
Recent studies however have shown that the Therefore, because of the above, especially in
moisture content of skin may alter the response of the last few years, numerous papers have been
vascular endothelial cells to changes in heat [90, published on the osmoreceptors and effect of
99, 102]. These studies show that if the skin is dry dehydration and hyperhydration on the TRPV4
due to, for example, the application for the dry channels. The TRPV4 channels are multichannel
heat modality, the blood flow response is signifi- sensing devices that have multiple input sites for
cantly less than if moist heat is used [90, 99, 102]. everything from vertical and shear pressure to
temperature, osmolarity, hydrogen ions, and other
environmental factors, as well as the obvious
39.2.3 Skin Moisture, Heat, response to substances, like acetylcholine, a neu-
and Skin Blood Flow rotransmitter of the sympathetic nervous system,
making these calcium gated channels a major
The TRPV4 Ca++ channels in endothelial cells have part of most tissues in the body.
receptor sites sensitive to multiple stimuli on the If the channels are activated, then calcium per-
interior and exterior of the cell membrane. This meability in the extracellular membrane increases.
receptor has multiple binding sites and senses such In vascular endothelial cells, the influx of calcium
factors as temperature, pressure, and osmolarity causes calcium ions to bind to endothelial nitric
[83, 95]. TRPV channels are expressed in smooth oxide synthetase and increases production of nitric
muscle cells, endothelial cells, as well as in perivas- oxide and also elicits the production of prostaglan-
cular nerves [5]. Thus, these cells, and the rest of din I2, another vasodilator. If the osmotic pressure
the TRPV family of voltage-gated calcium chan- is high in and around the cell, the calcium perme-
nels, function as local cellular regulators that mod- ability is reduced, and endothelial nitric oxide syn-
ify vascular function to respond to environmental thetase is downregulated. Therefore, a positive
and local stress on the cells [66]. They are used in stimulus that would increase blood flow in tissue
many tissues in the body to maintain homeostasis. can be blunted if a negative factor such as high
For example, in bone, they sense pressure and osmolarity reduces calcium permeability.
respond by activating [22]. Local pressure on bone An example is the effect of electrical stimula-
causes osteoblasts to increase production of osteo- tion of the skin on the blood flow. Normally, if
protegerin which, in turn, reduces activity of osteo- the skin is cool, vasoconstriction predominates.
clasts, allowing for less bone desorption and more If two electrodes are applied to the skin and stim-
bone generation [125]. In rat models, the pressure ulation is increased with square wave stimulation
response of bone is altered by changing tissue at a current of 20 milliamps and 40 pulses per
osmolarity. Deletion of TRPV4 channels by remov- second, the blood flow to the skin, as measured
ing the TRPV4 gene led to a lack of osmotically by laser Doppler imagers, does not change [1,
induced Ca++ release [22]. In the salivary gland, 100, 121, 122]. However, if the skin or the room
TRPV4 channels alter the response of aquaporin 5 is warmed first to release the sympathetic vaso-
channels. Thus, TRPV4 osmoreceptors aid in cell constriction, then blood flow increases substan-
volume regulation in salivary glands and alter the tially during electrical stimulation of the skin and
response to multiple stimulate also effecting in the skin around wounds [1, 100, 121, 122].
TRPV4 channels [2]. In skeletal muscle, TRPV4 This effect of dehydration causing diminished
channels also aid in the regulation and response of blood flow response was first seen almost 20 years
skeletal muscle [42]. Even the sympathetic response ago (reference). Changing serum osmolarity,
to low and high blood pressure is interrelated with independent of changing blood volume, alters the
TRPV4 osmoreceptors in the body [68]. The nor- skin blood flow response to global heat [23, 74].
572 J.S. Petrofsky and L. Berk

Here, skin blood flow was reduced in response to sure, there was constant skin moisture with dry
whole body heating if the serum osmolarity was heat but a doubling in skin moisture with moist
increased above normal. However, with TRPV4 heat. The skin moisture at each of the three tem-
receptors found all over the body, it was unknown peratures is shown at the end of the 30-min heat
what caused the effect. Was it blood vessels inter- exposure in Fig. 39.8 for moist and dry heat. As
action of osmoreceptors on blood flow or a cen- seen here, the skin moisture, in the same ten sub-
trally mediated response in the hypothalamus jects, was substantially higher after the applica-
since thirst receptors also use the same TRPV4 tion of moist heat. In a similar manner, at each
receptors [118]. More recent experiments have skin temperature, as shown in Fig. 39.9, the skin
showed the effect of skin moisture on the local blood flow was significantly higher in the moist
response to heat. This has been demonstrated by a heat series than the dry heat series in the same
simple experiment. If two layers of towels are subjects (age 2032 years old).
placed around the arm and the arm is heated, This greater blood flow response to moist heat
blood flow under the towels can be measured with has several effects. First, skin warms faster with
a laser Doppler flow meter. Plastic wrapped moist heat than dry heat. Part of this is due to the
around the towels prevents moisture from enter- greater heat transfer properties of water than air,
ing or leaving. A thermocouple under the towels but part is due to self-heating of the skin by blood
can be used to measure skin temperature, and then flow. Normally, skin temperature is almost 8C
a feedback controller can turn an infrared lamp off below that of the core. This is due to the fact that
and on to maintain constant skin temperatures. the skin acts as a radiator to allow the transfer of
Two such experiments were conducted. In one, heat from the core to the periphery to maintain a
dry rite (a drying agent) was placed between the constant body temperature. The hands, for exam-
towels, and in the second, the towels were moist- ple, are normally between 29C and 30C.
ened with water (Fig. 39.8). The skin was warmed This has the effect of warming the skin due to
with an infrared heat lamp to 38C, 40C, or 42C both the heat source and the faster perfusion of
for 30 min. Skin moisture was measured by a blood. To illustrate this concept, three series of
Corneometer (Courage + Khazaka electronic experiments were conducted. One series assessed
GmbH, Kln (Germany)). The Corneometer uses the change in skin temperature and blood flow
a 100-kHz sine wave signal to measure moisture during 6 min of heating of the skin. In the second
content in the dermal layer; surface water has no series, the blood flow was occluded for the first
effect on the readings. Before and after the expo- minute and then released to observe the skin

120

100

Moisture post heat

80
Skin moisture

60
Dry
Wet
40
Fig. 39.8 Skin moisture
of the arm after moist and
20
dry heat applied for
30 min at skin tempera-
tures of 38C, 40C, and 0
42C. Skin Moisture is in 38 40 42
arbitrary units Skin temperature (c)
39 Skin Moisture and Heat Transfer 573

Fig. 39.9 The skin blood flow 700

in ten subjects the standard Blood Flow
deviation, measured by laser
600
Doppler imager after 30 min of
exposure to moist or dry heat.
Skin temperature was clamped 500

Blood flow (flux)

at 38C, 40C, or 42C
400

Dry
300
Wet

200

100

0
38 40 42
Skin temperature (C)

temperature and caloric absorption of the skin The results of the experiments are shown in
with the skin cool and the heat source at 44C. In Fig. 39.10.
the final series, the occlusion was maintained for As shown in Fig. 39.10, with or without occlu-
4 min so that the blood flow was interrupted until sion, skin temperature changed at the same rate
the skin temperature was at or above arterial after application of the thermode. However, as
blood temperature and then released. In this way, shown in Fig. 39.11, when the calories needed to
the effect of blood flow with the skin cool and warm the skin were measured, the calories to
warm could be differentially tested. Each of the warm the tissue were greater with occlusion for 1
experiments was conducted on a separate day or 4 min than were seen without occlusion, show-
with at least 24 h separating the experiments. The ing that part of the heat to warm the skin is from
protocol was similar. A thermode, with water tra- blood flow. With moist heat, the blood flow will
versing it at 100 cc/min at a temperate of 44C, even make the skin temperature rise quicker due
was placed on the skin above the anterior surface to higher blood flows.
of the forearm near the brachioradialis. The ther- It can be predicted from this data that moist
mode was left on for a period of 6 min. During heat will increase skin temperature faster with
the time the thermode was left on, skin tempera- deeper tissue penetration than was the case for
ture was measured under the thermode, and blood dry heat. This was tested by applying thermocou-
flow was measured continuously through a hole ples into the muscle in the quadriceps and then
in the center of thermode. In one series of experi- applying either dry or moist heat (Fig. 39.12).
ments, the skin was simply heated the entire When muscle temperature was measured over
6 min, and the parameters were measured. In a a 6-h application period of dry heat as shown in
second series of experiments, occlusion was Fig. 39.13, skin temperature and muscle tempera-
placed just above the center of the axilla with an ture rose slowly compared to that seen in moist
arterial occlusion cuff inflated to 200 mmHg for heat in Fig. 39.14. With moist heat, the muscle
the first minute that heat was applied; the cuff temperature rose to similar or greater levels in 1 h
was then released and left off for the next 5 min. than 6 h in dry heat in the same ten subjects.
In the third series of experiments, occlusion Thus, skin moisture has a strong influence ion not
remained on for the first 4 min and then was only blood flow in response to stress but also in
released for the last 2 min. transferring heat to deep tissue.
574 J.S. Petrofsky and L. Berk

Fig. 39.10 Illustrated here is 40

the average data on ten
subjects the standard 39
deviation showing the
temperature of the skin over a 38
6-min period after a thermode
37

Skin temperature (C)

was applied to the arm with no
occlusion of the circulation, a
36
1-min occlusion of the
circulation, and a 4-min
35
occlusion of the circulation
after the thermode was applied 34

33
4 min occlusion
32
Heat no occlusion
31 1 min occlusion

30
Rest
10
20
30
40
50
60
75
90
105
120
150
180
210
240
255
270
285
300
330
360
Time (s)

Fig. 39.11 Illustrated here is 14.0

the average data on ten subjects Heat no occlusion
the standard deviation
12.0 4 min occlusion
showing the calories transferred
to the skin over a 6-min period 1min occlusion
after a thermode was applied to 10.0
the arm with no occlusion of the
Calories transferred

circulation, a 1-min occlusion

of the circulation, and a 4-min 8.0
occlusion of the circulation after
the thermode was applied 6.0

4.0

2.0

0.0
Rest
10
20
30
40
50
60
75
90
105
120
150
180
210
240
255
270
285
300
330
360

2.0
Time (s)

Fig. 39.12 The 21-gauge needle was used to insert

22-gauge thermocouples 2.5 cm into the quadriceps muscle
39 Skin Moisture and Heat Transfer 575

Fig. 39.13 The skin and Dry heat

muscle temperature in ten 40.00
subjects after the application
of dry heat to the quadriceps 39.00
muscle the standard 38.00
deviation. Skin temperatures
are in degrees centigrade 37.00

36.00
35.00

34.00

33.00
32.00 Skin

31.00 Muscle

30.00
0 1 3 5 10 20 30 40 50 60 120180 240 300 360 5 10 15

Fig. 39.14 The skin and 24 cell moist

muscle temperature in ten 42.00
subjects after the application of
moist heat to the quadriceps
muscle the standard 40.00
deviation
Temperature (C)

38.00

36.00

34.00

Skin
32.00
Muscle
30.00
0 1 3 5 10 20 30 40 50 60 5 10 15
Time (min)

Conclusions
Take Home Messages
1. Skin moisture alters all modes of heat The skin plays a major role in the
transfer in tissue including conduction, exchange of heat.
convection, radiation, and evaporation. Heat can be transferred out of or into the
2. The majority of the influence of skin moisture on skin by conduction, convection, radia-
heat transfer is in the dermal layer of the skin. tion, and evaporation.
3. This effect is exacerbated with aging and
diabetes.
576 J.S. Petrofsky and L. Berk

(DUF1185) reveal a novel variant of the Bacillus cho-

Conduction, convection, evaporation, rismate mutase fold and suggest a role in amino-acid
metabolism. Acta Crystallogr Sect F Struct Biol Cryst
and radiation are all altered by the pas- Commun 66:11821189
sive heat transfer properties of the skin 5. Baylie RL, Brayden JE (2011) TRPV channels and
and skin blood flow. vascular function. Acta Physiol (Oxf) 203(1):99116.
The greater the moisture content of the skin, doi:10.1111/j.1748-1716.2010.02217.x, Epub 2010
Dec 9
the greater the passive heat transfer, making 6. Beysens D, Chatain D, Nikolayev VS, Ouazzani J,
it easier to lose heat from the body or Garrabos Y (2010) Possibility of long-distance heat
dampen a heat source applied to the skin. transport in weightlessness using supercritical fluids.
High skin blood flow, the major mecha- Phys Rev E Stat Nonlin Soft Matter Phys 82:
061126
nism used by the skin to move heat into 7. Blum K, Chen AL, Chen TJ, Prihoda TJ, Schoolfield J,
the body or out of the body, is modu- Dinubile N, Waite RL, Arcuri V, Kerner M, Braverman ER,
lated by skin moisture; TRPV4 osmore- Rhoades P, Tung H (2008) The H-Wave device is an
ceptors reduce skin blood flow if the effective and safe non-pharmacological analgesic for
chronic pain: a meta-analysis. Adv Ther 25:
skin is dry. 644657
Thus, dry skin alters the ability of the skin 8. Blum K, Ho CK, Chen AL, Fulton M, Fulton B,
to lose heat from the body and insulate the Westcott WL, Reinl G, Braverman ER, Dinubile N,
body from an external heat source. Chen TJ (2008) The H-wave((R)) device induces
NODependent augmented microcirculation and
Older people and people with diabetes, angiogenesis, providing both analgesia and tissue
as might be expected, have poor heat healing in sports injuries. Phys Sportsmed
transfer in the skin due to dry skin and 36:103114
poor circulation. 9. Blumberg HP (2008) The next wave in neuroimaging
research in pediatric bipolar disorder. J Am Acad
Child Adolesc Psychiatry 47:483485
10. Branchet MC, Boisnic S, Frances C, Robert AM
(1990) Skin thickness changes in normal aging skin.
Gerontology 36:2835
References 11. Brincat M, Kabalan S, Studd JW et al (1987) A study
of the decrease of skin collagen content, skin thick-
1. Almalty AM, Petrofsky JS, Al-Naami B, Al-Nabulsi J ness, and bone mass in the post menopausal woman.
(2009) An effective method for skin blood flow mea- Obstet Gynecol 70:840845
surement using local heat combined with electrical 12. Bronzino JD (2000) The biomedical engineering
stimulation. J Med Eng Technol 33:663669 handbook. CRC Press, Boca Raton
2. Aure MH, Roed A, Galtung HK (2010) Intracellular 13. Bui C, Petrofsky J, Berk L, Shavlik D, Remigio W,
Ca2+ responses and cell volume regulation upon cho- Montgomery S (2010) Acute effect of a single high-
linergic and purinergic stimulation in an immortalized fat meal on forearm blood flow, blood pressure and
salivary cell line. Eur J Oral Sci 118:237244 heart rate in healthy male Asians and Caucasians: a
3. Aylin K, Arzu D, Sabri S, Handan TE, Ridvan A pilot study. Southeast Asian J Trop Med Public Health
(2009) The effect of combined resistance and home- 41:490500
based walking exercise in type 2 diabetes patients. Int 14. Carmeli E, Patish H, Coleman R (2003) The aging
J Diabetes Dev Ctries 29:159165 hand. J Gerontol A Biol Sci Med Sci 58:146152
4. Bakolitsa C, Kumar A, Jin KK, McMullan D, 15. Charkoudian N, Eisenach JH, Atkinson JL, Fealey
Krishna SS, Miller MD, Abdubek P, Acosta C, RD, Joyner MJ (2002) Effects of chronic sympathec-
Astakhova T, Axelrod HL, Burra P, Carlton D, Chen C, tomy on locally mediated cutaneous vasodilation in
Chiu HJ, Clayton T, Das D, Deller MC, Duan L, Elias Y, humans. J Appl Physiol 92:685690
Ellrott K, Ernst D, Farr CL, Feuerhelm J, Grant JC, 16. Charkoudian N, Fromy B, Saumet JL (2001) Reflex
Grzechnik A, Grzechnik SK, Han GW, Jaroszewski L, control of the cutaneous circulation after acute and
Johnson HA, Klock HE, Knuth MW, Kozbial P, chronic local capsaicin. J Appl Physiol 90:18601864
Marciano D, Morse AT, Murphy KD, Nigoghossian E, 17. Charkoudian N, Johnson JM (1999) Reflex control of
Nopakun A, Okach L, Paulsen J, Puckett C, Reyes R, cutaneous vasoconstrictor system is reset by exoge-
Rife CL, Sefcovic N, Tien HJ, Trame CB, Trout CV, nous female reproductive hormones. J Appl Physiol
van den Bedem H, Weekes D, White A, Xu Q, 87:381385
Hodgson KO, Wooley J, Elsliger MA, Deacon AM, 18. Charkoudian N, Rabbitts JA (2009) Sympathetic neu-
Godzik A, Lesley SA, Wilson IA (2010) Structures of ral mechanisms in human cardiovascular health and
the first representatives of Pfam family PF06684 disease. Mayo Clin Proc 84:822830
39 Skin Moisture and Heat Transfer 577

19. Cheung K, Hume P, Maxwell L (2003) Delayed onset capacity and visceral fat but not myocyte lipid levels
muscle soreness: treatment strategies and performance predict increased insulin action after exercise in over-
factors. Sports Med 33:145164 weight and obese men. Diabetes Care 26:17061713
20. Chu KL, Chandran P, Joshi SK, Jarvis MF, Kym PR, 38. Gapanhuk E, Henriques OB (1970) Kinins released
McGaraughty S (2011) TRPV1-related modulation of from horse heat-acid-denaturated plasma by plasmin,
spinal neuronal activity and behavior in a rat model of plasma kallikrein, trypsin and Bothrops kininogenase.
osteoarthritic pain. Brain Res 1369:158166 Biochem Pharmacol 19:20912096
21. Claassen J, Hirsch LJ, Frontera JA, Fernandez A, 39. Ghadially R, Brown BE, Sequeira-Martin SM,
Schmidt M, Kapinos G, Wittman J, Connolly ES, Feingold KR, Elias PM (1995) The aged epidermal
Emerson RG, Mayer SA (2006) Prognostic signifi- permeability barrier structural, functional, and lipid
cance of continuous EEG monitoring in patients with biochemical abnormalities in humans and a senescent
poor-grade subarachnoid hemorrhage. Neurocrit Care murine model. J Clin Invest 95:22812290
4:103112 40. Ghersetich I, Troiano M, DeGiorgi V, Lotti T (2007)
22. Clark AL, Votta BJ, Kumar S, Liedtke W, Guilak F Receptors in skin ageing and antiageing agents.
(2010) Chondroprotective role of the osmotically sen- Dermatol Clin 25:655662, xi
sitive ion channel transient receptor potential vanil- 41. Grove G (1989) Physiologic changes in the older skin.
loid 4: age- and sex-dependent progression of Clin Geriatr Med 5:115125
osteoarthritis in Trpv4-deficient mice. Arthritis 42. Guilak F, Leddy HA, Liedtke W (2010) Transient
Rheum 62:29732983 receptor potential vanilloid 4: the sixth sense of the
23. Coyle EF, Montain SJ (1992) Benefits of fluid replace- musculoskeletal system? Ann N Y Acad Sci
ment with carbohydrate during exercise. Med Sci 1192:404409
Sports Exerc 24:S324S330 43. Harvell J, Maibach H (1994) Percutaneous absorption
24. Cristol DA, Brasso RL, Condon AM, Fovargue RE, and inflammation in aged skin: a review. J Am Acad
Friedman SL, Hallinger KK, Monroe AP, White AE Dermatol 31(6):10151021
(2008) The movement of aquatic mercury through ter- 44. Haymes EM, Dickinson AL, Malville N, Ross RW
restrial food webs. Science 320:335 (1982) Effects of wind on the thermal and metabolic
25. Dao H Jr, Kazin RA (2007) Gender differences in responses to exercise in the cold. Med Sci Sports
skin: a review of the literature. Gend Med 4:308328 Exerc 14:4145
26. Duncan K, Leffell D (1997) Preoperative assessment 45. Henriques FC, Moritz AR (1947) Studies of thermal
of the elderly patient. Dermatol Clin 15:583593 injury: I. The conduction of heat to and through skin
27. Edwards AM, Noakes TD (2009) Dehydration: cause and the temperatures attained therein. A theoretical
of fatigue or sign of pacing in elite soccer? Sports and an experimental investigation. Am J Pathol
Med 39:113 23:530549
28. Evans CH, Karunaratne HB (1992) Exercise stress 46. Hirose L, Nosaka K, Newton M, Laveder A, Kano M,
testing for the family physician: part I. Performing the Peake J, Suzuki K (2004) Changes in inflammatory
test. Am Fam Physician 45:121132 mediators following eccentric exercise of the elbow
29. Evans WJ (1992) Exercise, nutrition and aging. J Nutr flexors. Exerc Immunol Rev 10:7590
122:796801 47. Holmer I (2000) Strategies for prevention of cold
30. Farage MA, Miller KW, Elsner P, Maibach HI (2008) stress in the elderly. Int J Circumpolar Health 59:
Functional and physiological characteristics of the 267272
aging skin. Aging Clin Exp Res 20:195200 48. Holowatz LA, Houghton BL, Wong BJ, Wilkins BW,
31. Farage MA, Miller KW, Maibach HI (eds) (2010) Harding AW, Kenney WL, Minson CT (2003) Nitric
Textbook of aging skin. Springer, Berlin/Heidelberg oxide and attenuated reflex cutaneous vasodilation in
32. Fenske NA, Lober CW (1986) Structural and func- aged skin. Am J Physiol Heart Circ Physiol
tional changes of normal aging skin. J Am Acad 284:H1662H1667
Dermatol 15:571585 49. Holowatz LA, Kenney WL (2010) Peripheral mecha-
33. Fisher G, Varani J, Voorhees J (2006) Looking older: nisms of thermoregulatory control of skin blood flow
fibroblast collapse and therapeutic implications. Arch in aged humans. J Appl Physiol 109:15381544
Dermatol 144:666672 50. Holowatz LA, Thompson-Torgerson C, Kenney WL
34. Fox RH, Edholm OG (1963) Nervous control of the (2010) Aging and the control of human skin blood
cutaneous circulation. Br Med Bull 19:110114 flow. Front Biosci 15:718739
35. Friedman O (2005) Changes associated with the aging 51. Houghton BL, Meendering JR, Wong BJ, Minson CT
face. Facial Plast Surg Clin North Am 13:371380 (2006) Nitric oxide and noradrenaline contribute to
36. Fu Y, Hou Y, Fu C, Gu M, Li C, Kong W, Wang X, Shyy the temperature threshold of the axon reflex response
JY, Zhu Y (2011) A novel mechanism of {gamma}/ to gradual local heating in human skin. J Physiol
{delta} T-lymphocyte and endothelial activation by 572:811820
shear stress: the role of ecto-ATP synthase {beta} chain. 52. Huang J, Togawa T (1995) Improvement of imaging
Circ Res 108(4):410417, Epub 2010 Dec 30 of skin thermal properties by successive thermo-
37. Gan SK, Kriketos AD, Ellis BA, Thompson CH, graphic measurements at a stepwise change in ambi-
Kraegen EW, Chisholm DJ (2003) Changes in aerobic ent radiation temperature. Physiol Meas 16:295301
578 J.S. Petrofsky and L. Berk

53. Hubing KA, Wingo JE, Brothers RM, del Coso J, Low 68. McHugh J, Keller NR, Appalsamy M, Thomas SA,
DA, Crandall CG (2010) Nitric oxide synthase inhibi- Raj SR, Diedrich A, Biaggioni I, Jordan J, Robertson D
tion attenuates cutaneous vasodilation during post- (2010) Portal osmopressor mechanism linked to tran-
menopausal hot flash episodes. Menopause sient receptor potential vanilloid 4 and blood pressure
17:978982 control. Hypertension 55:14381443
54. Jackson S, Williams M, Feingold K, Elias P (1993) 69. McLellan K, Petrofsky JS, Bains G, Zimmerman G,
Pathobiology of the stratum corneum. West J Med Prowse M, Lee S (2009) The effects of skin moisture
158:279289 and subcutaneous fat thickness on the ability of the
55. Johnson JM (1986) Nonthermoregulatory control of skin to dissipate heat in young and old subjects, with
human skin blood flow. J Appl Physiol and without diabetes, at three environmental room
61:16131622 temperatures. Med Eng Phys 31:165172
56. Johnson JM, Brengelmann GL, Hales JR, Vanhoutte 70. McLellan K, Petrofsky JS, Zimmerman G, Lohman E,
PM, Wenger CB (1986) Regulation of the cutaneous Prowse M, Schwab E, Lee S (2009) The influence of
circulation. Fed Proc 45:28412850 environmental temperature on the response of the skin
57. Johnson RK, Appel LJ, Brands M, Howard BV, to local pressure: the impact of aging and diabetes.
Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie- Diabetes Technol Ther 11:791798
Rosett J (2009) Dietary sugars intake and cardiovas- 71. McLellan K, Petrofsky JS, Zimmerman G, Prowse M,
cular health: a scientific statement from the Bains G, Lee S (2009) Multiple stressors and the
American Heart Association. Circulation 120: response of vascular endothelial cells: the effect of
10111020 aging and diabetes. Diabetes Technol Ther 11:7379
58. Kellogg DL Jr, Crandall CG, Liu Y, Charkoudian N, 72. Mendes JC, Silva MC (2004) On the use of porous
Johnson JM (1998) Nitric oxide and cutaneous active materials to simulate evaporation in the human sweat-
vasodilation during heat stress in humans. J Appl ing process. Eur J Appl Physiol 92:654657
Physiol 85:824829 73. Minson CT, Berry LT, Joyner MJ (2001) Nitric oxide
59. Kligman A, Koblenzer C (1997) Demographics and and neurally mediated regulation of skin blood flow
psychological implications for the aging population. during local heating. J Appl Physiol 91:16191626
Dermatol Clin 15:549553 74. Montain SJ, Coyle EF (1992) Influence of graded
60. Koyama T, Hatanaka Y, Jin X, Yokomizo A, Fujiwara H, dehydration on hyperthermia and cardiovascular drift
Goda M, Hobara N, Zamami Y, Kitamura Y, Kawasaki during exercise. J Appl Physiol 73:13401350
H (2010) Altered function of nitrergic nerves inhibit- 75. Moritz AR, Henriques FC Jr et al (1947) Studies of
ing sympathetic neurotransmission in mesenteric vas- thermal injury; an exploration of the casualty-produc-
cular beds of renovascular hypertensive rats. Hypertens ing attributes of conflagrations; local and systemic
Res 33:485491 effects of general cutaneous exposure to excessive cir-
61. Langton AK, Sherratt MJ, Griffiths CE, Watson RE cumambient (air) and circumradiant heat of varying
(2010) A new wrinkle on old skin: the role of elastic duration and intensity. Arch Pathol (Chic) 43:466488
fibres in skin ageing. Int J Cosmet Sci 32(5):330339. 76. Moritz AR, Henriques FC, McLean R (1945) The
doi:10.1111/ics.2010.32.issue-5/issuetoc, Epub 2010 effects of inhaled heat on the Air passages and lungs:
Oct an experimental investigation. Am J Pathol
62. Libouton X, Barbier O, Plaghki L, Thonnard JL 21:311331
(2010) Tactile roughness discrimination threshold is 77. Muller AF, Batin P, Evans S, Hawkins M, Cowley AJ
unrelated to tactile spatial acuity. Behav Brain Res (1992) Regional blood flow in chronic heart failure:
208:473478 the reason for the lack of correlation between patients
63. Magalhaes FC, Passos RL, Fonseca MA, Oliveira KP, exercise tolerance and cardiac output? Br Heart J
Ferreira-Junior JB, Martini AR, Lima MR, Guimaraes 67:478481
JB, Barauna VG, Silami-Garcia E, Rodrigues LO 78. Muller AF, Hawkins M, Batin P, Evans S, Cowley AJ
(2010) Thermoregulatory efficiency is increased after (1992) Food in chronic heart failure: improvement in
heat acclimation in tropical natives. J Physiol central haemodynamics but deleterious effects on
Anthropol 29:112 exercise tolerance. Eur Heart J 13:14601467
64. Maglinger PE, Sessler DI, Lenhardt R (2005) 79. Oeppen J, Vaupel JW (2002) Demography. Broken
Cutaneous heat loss with three surgical drapes, one limits to life expectancy. Science 296:10291031
impervious to moisture. Anesth Analg 100:738742, 80. Oriba H, Bucks D, Maibach H (1996) Percutaneous
table of contents absorption of hydrocortisone and testosterone on the
65. Makrantonaki E, Zouboulis CC (2010) Dermato- vulva and forearm: effect of the menopause and site.
endocrinology. Skin aging. Hautarzt 61:505510 Br J Dermatol 134:229233
66. Malmberg AB, Bley KR (eds) (2005) Turning up the 81. Pennes HH (1948) Analysis of tissue and arterial
heat on pain: TRPV1 receptors in pain and inflamma- blood temperatures in the resting human forearm. J
tion. Birkhauser verlag, Basel/Boston/Berlin Appl Physiol 1:93122
67. McCallion R, Li Wan Po A (1993) Dry and photo- 82. Petrofsky J, Bains G, Prowse M, Gunda S, Berk L,
aged skin: manifestations and management. J Clin Raju C, Ethiraju G, Vanarasa D, Madani P (2009)
Pharm Ther 18:1532 Does skin moisture influence the blood flow response
39 Skin Moisture and Heat Transfer 579

to local heat? A re-evaluation of the Pennes model. J 93. Petrofsky JS (2010) A device to measure heat flow
Med Eng Technol 33:16 through the skin in people with diabetes. Diabetes
83. Petrofsky J, Bains G, Prowse M, Gunda S, Berk L, Technol Ther 12:737743
Raju C, Ethiraju G, Vanarasa D, Madani P (2009) 94. Petrofsky JS, Al-Malty AM, Prowse M (2008)
Does skin moisture influence the blood flow response Relationship between multiple stimuli and skin
to local heat? A re-evaluation of the Pennes model. J blood flow. Med Sci Monit 14:CR399CR405
Med Eng Technol 33:532537 95. Petrofsky JS, Bains G, Raju C, Lohman E, Berk L,
84. Petrofsky J, Bains G, Prowse M, Gunda S, Berk L, Prowse M, Gunda S, Madani P, Batt J (2009) The
Raju C, Ethiraju G, Vanarasa D, Madani P (2009) Dry effect of the moisture content of a local heat source
heat, moist heat and body fat: are heating modalities on the blood flow response of the skin. Arch
really effective in people who are overweight? J Med Dermatol Res 301:581585
Eng Technol 33:361369 96. Petrofsky JS, Bains GS, Prowse M, Mc Lellan K,
85. Petrofsky J, Gunda S, Raju C, Bains GS, Bogseth MC, Ethiraju G, Lee S, Gunda S, Lohman E, Schwab E
Focil N, Sirichotiratana M, Hashemi V, Vallabhaneni P, (2009) The influence of age and diabetes on the skin
Kim Y, Madani P, Coords H, McClurg M, Lohman E blood flow response to local pressure. Med Sci Monit
(2010) Impact of hydrotherapy on skin blood flow: 15:CR325CR331
How much is due to moisture and how much is due to 97. Petrofsky JS, Cuneo M, Lee S, Johnson E, Lohman E
heat? Physiother Theory Pract 26:107112 (2006) Correlation between gait and balance in peo-
86. Petrofsky J, Hinds CM, Batt J, Prowse M, Suh HJ ple with and without Type 2 diabetes in normal and
(2007) The interrelationships between electrical subdued light. Med Sci Monit 12:CR273CR281
stimulation, the environment surrounding the vascu- 98. Petrofsky JS, Focil N, Prowse M, Kim Y, Berk L,
lar endothelial cells of the skin, and the role of nitric Bains G, Lee S (2010) Autonomic stress and balance
oxide in mediating the blood flow response to elec- the impact of age and diabetes. Diabetes Technol
trical stimulation. Med Sci Monit 13: Ther 12:475481
CR391CR397 99. Petrofsky JS, Goraksh N, Alshammari F, Mohanan
87. Petrofsky J, Lee H, Trivedi M, Hudlikar AN, Yang M, Soni J, Trivedi M, Lee H, Hudlikar AN, Yang C,
CH, Goraksh N, Alshammari F, Mohanan M, Soni J, Agilan B, Pai N, Katrak V, Chindam T, Murugesan
Agilan B, Pai N, Chindam T, Murugesan V, Yim JE, V, Yim J (2011) The ability of the skin to absorb
Katrak V (2010) The influence of ageing and diabetes heat; the effect of repeated exposure and age. Med
on heat transfer characteristics of the skin to a rapidly Sci Monit 17(1):CR1CR8
applied heat source. Daibetes Technol Ther 100. Petrofsky JS, Lawson D, Berk L, Suh H (2010)
12:10031010 Enhanced healing of diabetic foot ulcers using local
88. Petrofsky J, Lee S, Cuneo ML (2005) Gait character- heat and electrical stimulation for 30 min three times
istics in patients with type 2 diabetes; improvement per week. J Diabetes 2:4146
after administration of rosiglitazone. Med Sci Monit 101. Petrofsky JS, Laymon M (2009) Heat transfer to
11:PI43PI51 deep tissue: the effect of body fat and heating modal-
89. Petrofsky J, Lohman E 3rd, Lee S, de la Cuesta Z, ity. J Med Eng Technol 33:337348
Labial L, Iouciulescu R, Moseley B, Korson R, Al 102. Petrofsky JS, Lee H, Trivedi M, Hudlikar AN, Yang C,
Malty A (2007) Effects of contrast baths on skin blood Goraksh N, Alshammari F, Mohanan M, Soni J, Agilan
flow on the dorsal and plantar foot in people with type B, Pai N, Chindam T, Murugesan V, Yim J, Katrak V
2 diabetes and age-matched controls. Physiother (2010) The influence of ageing and diabetes on heat
Theory Pract 23:189197 transfer characteristics of the skin to a rapidly applied
90. Petrofsky J, Paluso D, Anderson D, Swan K, heat source. Diabetes Technol Ther 12:10031010
Alshammari F, Katrak V, Murugesan V, Hudlikar AN, 103. Petrofsky JS, Lind AR (1975) Insulative power of
Chindam T, Trivedi M, Lee H, Goraksh N, Yim J The body fat on deep muscle temperatures and isometric
ability of the skin to absorb heat from a locally applied endurance. J Appl Physiol 39:639642
heat source; the impact of diabetes. J med eng physics 104. Petrofsky JS, Lohman E 3rd, Lee S, de la Cuesta Z,
Diabetes Technol Ther. 2011 Mar;13(3):365-72. Epub Labial L, Iouciulescu R, Moseley B, Korson R,
2011 Feb 3 AlMalty A (2006) The influence of alterations in
91. Petrofsky J, Prowse M, Bain M, Ebilane E, Suh HJ, room temperature on skin blood flow during contrast
Batt J, Lawson D, Hernandez V, Abdo A, Yang TN, baths in patients with diabetes. Med Sci Monit
Mendoza E, Collins K, Laymon M (2008) Estimation 12:CR290CR295
of the distribution of intramuscular current during 105. Petrofsky JS, Lohman E 3rd, Suh HJ, Garcia J,
electrical stimulation of the quadriceps muscle. Eur J Anders A, Sutterfield C, Khandge C (2006) The
Appl Physiol 103:265273 effect of aging on conductive heat exchange in the
92. Petrofsky J, Schwab E, Lo T, Cuneo M, George J, skin at two environmental temperatures. Med Sci
Kim J, Al-Malty A (2005) Effects of electrical stimu- Monit 12:CR400CR408
lation on skin blood flow in controls and in and around 106. Petrofsky JS, McLellan K (2009) Galvanic skin
stage III and IV wounds in hairy and non hairy skin. resistance a marker for endothelial damage in dia-
Med Sci Monit 11:CR309CR316 betes. Diabetes Technol Ther 11:461467
580 J.S. Petrofsky and L. Berk

107. Petrofsky JS, Mclellan K, Bains GS, Prowse M, heat on the healing of chronic wounds. Diabetes
Ethiraju G, Lee S, Gunda S, Lohman E 3rd, Schwab Technol Ther 11:681688
E (2009) The influence of ageing on the ability of the 123. Suhel P, Kralj B, Plevnik S (1978) Advances in non-
skin to dissipate heat. Med Sci Monit implantable electrical stimulators for correction of
15:CR261CR268 urinary incontinence. J Life Sci 8:1116
108. Petrofsky JS, McLellan K, Bains GS, Prowse M, 124. Suter-Widmer J, Elsner P (1996) The irritant contact
Ethiraju G, Lee S, Gunda S, Lohman E, Schwab E dermatitis syndrome. CRC Press, Boca Raton
(2008) Skin heat dissipation: the influence of diabe- 125. Ta HM, Nguyen GT, Jin HM, Choi J, Park H, Kim N,
tes, skin thickness, and subcutaneous fat thickness. Hwang HY, Kim KK (2010) Structure-based devel-
Diabetes Technol Ther 10:487493 opment of a receptor activator of nuclear factor-
109. Petrofsky JS, McLellan K, Prowse M, Bains G, Berk L, {kappa}B ligand (RANKL) inhibitor peptide and
Lee S (2010) The effect of body fat, aging, and dia- molecular basis for osteopetrosis. Proc Natl Acad
betes on vertical and shear pressure in and under a Sci U S A 107(47):2028120286, Epub 2010 Nov 8
waist belt and its effect on skin blood flow. Diabetes 126. Tabuchi K, Suzuki M, Mizuno A, Hara A (2005)
Technol Ther 12:153160 Hearing impairment in TRPV4 knockout mice.
110. Petrofsky JS, Prowse M, Lohman E (2008) The Neurosci Lett 382:304308
influence of ageing and diabetes on skin and subcu- 127. Thompson D, Williams C, Garcia-Roves P, McGregor
taneous fat thickness in different regions of the body. SJ, McArdle F, Jackson MJ (2003) Post-exercise
J Appl Res Clin Exp Ther 8:5561 vitamin C supplementation and recovery from
111. Petrofsky JS, Suh HJ, Gunda S, Prowse M, Batt J demanding exercise. Eur J Appl Physiol 89:
(2008) Interrelationships between body fat and skin 393400
blood flow and the current required for electrical stim- 128. Thompson PD (2003) Exercise and physical activity
ulation of human muscle. Med Eng Phys 30:931936 in the prevention and treatment of atherosclerotic
112. Puizina-Ivic N (2008) Skin aging. Acta cardiovascular disease. Arterioscler Thromb Vasc
Dermatovenerol Alp Panonica Adriat 17:4754 Biol 23:13191321
113. Reilly T, Ekblom B (2005) The use of recovery 129. Vazquez F, Palacios S, Aleman N, Guerrero F (1996)
methods post-exercise. J Sports Sci 23:619627 Changes of the basement membrane and type iv col-
114. Rowell LB (1974) Human cardiovascular adjust- lagen in human skin during aging. Maturitas 25:
ments to exercise and thermal stress. Physiol Rev 209215
54:75159 130. Waligora JM, Michel EL (1968) Application of con-
115. Sanchez-Marin FJ, Calixto-Carrera S, Villasenor- ductive cooling for working men in a thermally iso-
Mora C (2009) Novel approach to assess the emis- lated environment. Aerosp Med 39:485487
sivity of the human skin. J Biomed Opt 14:024006 131. Waller J, Maibach H (2005) Age and skin structure
116. Savvas M, Bishop J, Laurent G, Watson N, Studd J and function, a quantitative approach (i): blood flow,
(1993) Type III collagen content in the skin of post- ph, thickness and ultrasound echogenicity. Skin Res
menopausal women receiving oestradiol and testos- Technol 11:221235
terone implants. Br J Obstet Gynaecol 100:154156 132. Watanabe H, Vriens J, Suh SH, Benham CD,
117. Shai A, Halevy S (2005) Direct triggers for ulcer- Droogmans G, Nilius B (2002) Heat-evoked activa-
ation in patients with venous insufficiency. Int J tion of TRPV4 channels in a HEK293 cell expres-
Dermatol 44:10061009 sion system and in native mouse aorta endothelial
118. Sharif-Naeini R, Ciura S, Zhang Z, Bourque CW cells. J Biol Chem 277:4704447051
(2008) Contribution of TRPV channels to osmosen- 133. Watanabe M, Toma S, Murakami M, Shimoyama I,
sory transduction, thirst, and vasopressin release. Nakajima Y, Moriya H (2002) Assessment of
Kidney Int 73:811815 mechanical and thermal thresholds of human C noci-
119. Siddappa K (2003) Dry skin conditions, eczema and ceptors during increases in skin sympathetic nerve
emollients in their management. Indian J Dermatol activity. Clin Neurophysiol 113:14851490
Venereol Leprol 69:6975 134. Webb P (1992) Temperatures of skin, subcutaneous
120. Stansberry KB, Peppard HR, Babyak LM, Popp G, tissue, muscle and core in resting men in cold, com-
McNitt PM, Vinik AI (1999) Primary nociceptive fortable and hot conditions. Eur J Appl Physiol
afferents mediate the blood flow dysfunction in non- Occup Physiol 64:471476
glabrous (hairy) skin of type 2 diabetes: a new model 135. Wissler EH (1998) Pennes 1948 paper revisited.
for the pathogenesis of microvascular dysfunction. J Appl Physiol 85:3541
Diabetes Care 22:15491554 136. Wong BJ, Fieger SM (2010) Transient receptor
121. Suh H, Petrofsky J, Fish A, Hernandez V, Mendoza E, potential vanilloid type-1 (TRPV-1) channels con-
Collins K, Yang T, Abdul A, Batt J, Lawson D (2009) tribute to cutaneous thermal hyperaemia in humans.
A new electrode design to improve outcomes in the J Physiol 588:43174326
treatment of chronic non-healing wounds in diabe- 137. Xiong J, Feng L, Yuan D, Fu C, Miao W (2010)
tes. Diabetes Technol Ther 11:315322 Genome-wide identification and evolution of ATP-
122. Suh H, Petrofsky JS, Lo T, Lawson D, Yu T, Pfeifer binding cassette transporters in the ciliate tetrahy-
TM, Morawski T (2009) The combined effect of a mena thermophila: a case of functional divergence in
three-channel electrode delivery system with local a multigene family. BMC Evol Biol 10:330
 Appendix

Reference List of EEMCO Guidelines Pirard GE (1999) EEMCO guidance to the

in vivo assessment of tensile functional proper-
Berardesca E (1997) EEMCO guidance for the ties of the skin. Part 1: relevance to the structures
assessment of stratum corneum hydration: elec- and ageing of the skin and subcutaneous tissues.
trical methods. Skin Res Technol 3:126132 Skin Pharmacol Appl Skin Physiol 12:352362
Berardesca E, Lvque JL, Masson P (2002) Pirard GE, Pirard-Franchimont C, Marks R,
EEMCO guidance for the measurement of skin Paye M, Rogiers V (2000) EEMCO guidance for
microcirculation. Skin Pharmacol Appl Skin the in vivo assessment of skin greasiness. Skin
Physiol 15:442456 Pharmacol Appl Skin Physiol 13:372389
Lvque JL (1999) EEMCO guidance for the Rodrigues L (2001) EEMCO guidance to the
assessment of skin topography. The European in vivo assessment of tensile functional proper-
Expert Group on efficacy measurement of cos- ties of the skin. Part 2: instrumentation and test
metics and other topical products. J Eur Acad modes. Skin Pharmacol Appl Skin Physiol
Dermatol Venereol 12:103114 14:5267
Parra JL, Paye M (2003) EEMCO guidance Rogiers V (2001) EEMCO guidance for the
for the in vivo assessment of skin surface pH. assessment of transepidermal water loss in cos-
Skin Pharmacol Appl Skin Physiol 16:188202 metic sciences. Skin Pharmacol Appl Skin
Pirard GE (1996) EEMCO guidance for the Physiol 14:117128
assessment of dry skin (xerosis) and ichthyosis: Serup J (1995) EEMCO guidance for the
evaluation by stratum corneum shippings. Skin assessment of dry skin (xerosis) and ichthyosis:
Res Technol 2:311 clinical scoring systems. Skin Res Technol
Pirard GE (1998) EMCO guidance for the 1:109114
assessment of skin colour. J Eur Acad Dermatol
Venereol 10:111

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 581

DOI 10.1007/978-3-642-27606-4, Springer-Verlag Berlin Heidelberg 2012
 Index

A Aspergillus brasiliensis, 355, 356

Acid mantle, 296, 299 Atopic dermatitis (AD), 5963, 99, 103, 119122, 134,
Acitretin, 274276 135, 137, 151, 169172, 257263, 456, 494, 495,
Acute disruption, 443 497499
Acute eczematous, 169172 and diaper dermatitis in babies, 303
AD. See Atopic dermatitis (AD) management, 6365, 69
Adherence, 3132, 37, 38, 43, 5154 psychosocial impact, 6163
Adverse reactions, 52 Atopic eczema, 181, 186, 513, 517, 519
Advertising Standards Canada (ASC), 18, 19 ATRA. See All-trans retinoic acid (ATRA)
Aesthetic characteristics, 314, 324, 325 ATR-FTIR. See Attenuated total reflectance Fourier
Age, 95, 98, 99, 101103 transform infrared (ATR-FTIR)
Aged skin, 219, 221, 222 ATR-IR spectroscopy, 433, 434
Age groups, 164 Attenuated total reflectance Fourier transform infrared
Aging skin, 459, 463, 464, 466 (ATR-FTIR), 298
AHA. See Alpha hydroxy acids (AHA) Avena sativa, 370, 371, 374
Air conditioning, 503, 509, 510 Avocado oil, 426, 428
Alcohols, 368, 370, 373, 374 Azathioprine, 274276
Aldehydes, 404, 405, 412
Alkyl glucosides, 373
Allergen identification, 368 B
Allergic and irritant types of dermatitis, 302303 Barrier disruption, 441445
Allergic inflammatory, 302 Barrier function, 217, 221226, 513520
All-trans retinoic acid (ATRA), 221 Barrier recovery, 151, 172, 201, 205208
Almond oil, 383, 387, 388, 391 Beeswax, 383, 384
Aloe vera, 318, 381, 383, 393 Benzoic acid/sodium benzoate, 361362
Alopecia areata, 122 Benzyl alcohol, 361
Alpha hydroxy acids (AHA), 290, 318 Biochemically induced SC damage, 442
Amino acids, 493, 494 Biochemistry of NMF production, 444
Animal fats, 404406, 411 Biodegradability, 415
Antifungal, 341, 344, 346, 348351 Bleaching, 409
Antimicrobial, 200202, 207, 209 Blood flow, 563, 564, 566, 567, 569575
peptides, 496499 Borage, 426428
proteins, 202 Breakdown of lipids in anhydrous ointments, 333
Antioxidants, 379, 381, 382, 384, 386, 387, 395, 422, British National Formulary, 30
423, 426428, 442 Brittle, 341, 342, 351
Apple, 387 Bronopol, 363
AQP3, 215, 217222, 227 Butters, 422, 424, 427, 428
AQPs. See Aquaporins (AQPs) Butyrospermum parkii, 322, 323
Aquaglyceroporins, 215, 217, 219, 227
Aquaporin 3 (AQP3), 475
Aquaporins (AQPs), 215220, 222, 226 C
Aqueous Cream B.P., 518520 Cadherins, 113, 114, 116, 151, 152, 155, 161
Architecture of vernix, 199 Ca2+ gradient, 150, 155
Arginine, 443447, 497 Calcium, 7785, 87, 548
Armadillo proteins, 151 Candida albicans, 356, 392
ASC. See Advertising Standards Canada (ASC) Canola oil, 262

M. Lodn, H.I. Maibach (eds.), Treatment of Dry Skin Syndrome, 583

DOI 10.1007/978-3-642-27606-4, Springer-Verlag Berlin Heidelberg 2012
584 Index

Careful hand washing, 271 Corneocyte cell envelope, 41, 123, 133, 134
Carmine, 387 Corneocyte layers, 149, 154
Cathepsin D (CTSD), 158, 163 Corneodesmosomal degradation, 150, 154, 158, 167, 172
Cathepsins, 157, 158, 160, 163, 169 Corneodesmosomes, 150158, 160, 161, 164, 168, 169,
Cations, 159 172, 295, 296, 514, 515
CDKN1A, 534, 535, 540 Corneometer, 572
Cellular metabolism and renewal, 155 Cornified envelope, 197, 447, 448
CE mark, 6, 9, 10 Corn oil, 423, 424, 428
CEMOVIS. See Cryo-transmission electron microscopy Corticosteroids, 485486, 488
(CEMOVIS) Cortisol, 89, 90
Central, nonperipheral corneodesmosomes, 151153 Cosmetic allergens, 367
Ceramide composition, 126 Cost and quality of ingredients, 334
Ceramides, 125137, 139, 140, 195197, 202, 203, 206, Cost-effective option, 488
207, 442 Costs, 47, 48, 51, 53, 488
Ceratonia siliqua, 221 Cracking, 233, 234, 238, 250, 251
Certain kallikreins, 157, 163 Creams, 29, 30, 32, 197, 199, 202, 204206, 209,
Chapping, 233, 234, 250, 252 525526, 529, 531, 533537, 539
CHE. See Chronic hand eczema (CHE) Cross-linking HA, 467
Chemical enhancers, 139 Cryo-transmission electron microscopy (CEMOVIS),
Chemistry of emollients, 319 111, 114, 116
Childhood, 257 CTSD. See Cathepsin D (CTSD)
Childhood eczema, 41, 49, 51, 53 Cucumbers, 383
Children with eczema, 43, 44, 46, 48, 50, 51, 53, 54 Cucumis sativum, 383
Chlorphenesin, 362 Cutaneous homeostasis, 149
Cholesterol, 126131, 133, 136, 137, 139, 141, 195198, Cutaneous modification, 419
203, 206, 207, 442, 534, 536 Cyclosporine, 274276
Chronic hand eczema (CHE), 121 Cystatin A, 179
Claims support testing, 17 Cysteine protease inhibitors, 160
advertising, 1819 Cysteine proteases, 156, 158, 160, 163, 172
claim, 1824 Cytokines, 220221, 226, 227
Claim substantiation, 1012
Cleanser, 201, 207
Clearance, maintenance, and rescue of flares, 261 D
CLSM. See Confocal laser scanning microscopy 3D, 134, 139
(CLSM) Daily washing, 304
Coating stress, 242 Damage to the SC, 441, 448
Cocoa butter, 424 Decubal, 517, 518
Coconut, 387, 393 Deficient of water, 453
Coconut oil, 420, 424425, 428 Dehydroacetic acid/sodium dehydroacetate, 362
Cold climate, 503, 508 Depth profiles, 165
Colourants, 387 Dermal function tests, 96
Common ichthyoses, 279 Dermal/percutaneous absorption, 394
Complex cream, 529537 Desmocollins, 151, 153, 172
Components of the preservation system, 357 Desmogleins, 151, 153, 172
Components of vernix, 196, 202, 203 Desmosomes, 150152, 155, 159, 193, 195, 197
Composition and development of moisturizers, 313335 Desorption, 200, 201
Composition, structure, and functionality, 141 Desquamation, 149173, 514515, 531, 534, 535,
Confocal laser scanning microscopy (CLSM), 297299 537538, 546, 547, 555, 556
Confocal Raman spectroscopy (CRS), 545, 547554, 557 Developing epidermal barrier, 299
Congenital ichthyoses, 281 Development, 379, 385, 387393
Congenital lamellar ichthyoses, 279 Dew point, 504505, 509, 510
Consistency and body of a moisturizer, 331 Diabetes, 563566, 568, 569
Consumer need, 313315, 319, 324325, 327, 329, Diabetes mellitus, 381
332334 Diagnosing AD, 258
Consumer tolerability, 318 Diazolidinyl urea, 359
Consumer use, 356 Diffusion, 508, 510, 548, 551
Contact allergy, 121, 122, 367, 368, 374 Diglycerides, 420, 421
Contamination, 43 Dimethyl sulfoxide (DMSO), 344346
Control of atopic dermatitis, 261 DMDM hydantoin, 359
Index 585

Docosanol, 423 Environmental effects, 365

3D organization, 125, 133, 137, 141 Environmental factors, 42, 54, 258260, 263
Dry, 503, 504, 506510 Epidermal barrier, 4144
Dry environments, 237, 250 Epidermal barrier homeostastis, 83, 84, 90
Drying stresses, 233252 Epidermal differentiation markers, 184
Dryness, 193, 205 Epidermal homeostastis, 78, 85
Dryness of skin, 506 Epidermal hyperproliferation, 494
Dry skin, 41, 60, 63, 64, 68, 150, 154, 158, 163, 165, Epidermal keratinocytes, 7790
168, 172, 313, 314, 316318, 322, 329, 335, Epidermal lipid composition, 197
481489, 503510. See also Xerosis Epithelia-specific genes, 179, 180
climate, 503510 Erythema, 205208
damage, 234, 243, 250252 Essential fatty acid deficiency, 134135, 137
emollients, 4245, 52, 53 Essential requirements, 12
environmental factors, 42, 54 Ester-based emollients, 400, 402, 404411, 413
genetic factors, 42 Esters, 400402, 404406, 409411, 413415
management, 2737 Estrogen, 98100, 466467
Dry skin (xerosis) and ichthyosis, 581 ET. See Electron tomography (ET)
Dysregulated immune system, 259 Ethnic groups, 100
Ethosomes, 390, 391
Ethylhexylglycerin, 369, 370, 373
E Ethylhexyl palmitate, 244
Eczema, 4154, 215, 219, 481, 484486, 488489 EU Cosmetics Directive, 358, 363, 365
psychosocial effects of eczema on children and their Evernia furfuracea, 368
families, 4446 Exocytosis-like processes of secretion of, 281
school, 36 Experimental techniques, 128
Edema, 462 Extrinsic aging, 459, 465
Educational intervention, 2737
EEMCO Guidelines
Eicosapentaenoic acid (EPA), 290 F
Elaeis guineensis, 408 Factory scale production, 334
Elafin, 160 Fatty acids, 195198, 202, 203, 206, 207
Elderly, 101, 102, 104 Fatty alcohols, 400, 401, 404, 406, 414
Electrical potential, 77, 8486, 90 Filaggrin, 180181, 225, 259, 260, 263, 431, 434, 444,
Electron microscopy, 111114 481, 482, 497, 504
Electron microscopy simulation, 115116 Filament-aggregating protein (Filaggrin), 119
Electron tomography (ET), 111116 Fillers, 467468
Emollient coatings, 248, 249, 251 Financial costs, 4748
Emollients, 242244, 247252, 261263, 285288, 291, Fish oil, 406
513, 517, 518, 520 Flaggrin gene null mutations, 121, 122
contaminants, 408, 409, 411412, 414 FLG, 534, 536538
emollient classification, 400403, 415 FLG gene, 42
emollient groups, 403411 Fluid intake, 453
emollient selection, 411412 Food allergy, 4448, 53
environmental properties, 415 Formaldehyde, 359, 360, 369, 371, 372
hydrolysis, 400, 405, 412, 413 Fragrance mix (FM), 368
oxidation, 400, 402405, 408, 410, 412413 Free fatty acid (FFA), 419, 425, 442
polarity, 399, 400, 402, 404, 410414 Functional and biochemical changes, 525540
selecting emollients, 411415
spreadability, 400, 414
viscosity, 399, 400, 402, 403, 410, 411, 414 G
Emotional behaviour, 36 Gendor, 95, 98100
Emulsifier, 303, 325332, 334, 526, 527, 529532, Gene expression, 531538
534535 Genital skin, 102, 103
Emulsifier type, 327329 Global market, 380
Emulsion, 313, 314, 325334, 527, 529, 534, 535 Glycerin (GLY), 240, 244
Endogenous inhibitors, 158, 159, 161 Glycerin-based humectants, 245247
Endothelial nitric oxide synthetase (ENOS), 567571 Glycerol, 282, 283, 296, 303, 306, 316319, 323, 325,
Enhancement in the permeation, 348 327, 328, 437, 473478
Environmental, 408, 411412, 415 GLY coatings, 245247, 249
586 Index

Glycosaminoglycan, 459 I
Glycyrrhiza glabra, 382, 383, 386389, 395 Ichthyosis, 134137, 154, 279283, 483, 484, 488, 489
GLY-treated SC, 246 Ichthyosis vulgaris, 119, 120, 122, 225
GMO, 409 IgE, 257259
Good distribution practice, 10 IL, 226
Good manufacturing practice, 7 IL-1a.. See Interleukin-1a (IL-1a)
Grape seed, 387 IL-1RA. See Interleukin-1 receptor antagonist (IL-1RA)
Guidelines, 261 Imidazolidinyl urea, 359
Immune dysregulation, 260
Immunoelectron microscopy, 154
H India, 380, 381, 392
Hairless mice, 183188 Indoor climate, 506, 509, 510
Hairless mouse model, 204, 206 Industrial fermentation, 332
HA metabolism, 459, 460, 464, 467 Infantile eczema, 50
Hand dermatitis, 270, 272, 273, 275, 494 Infant skin, 295306
Hand eczema, 269276 Inflammatory, 150, 163, 165172
Hand hygiene regimens, 271 Inheritance pattern, 259
Hard water, 42 Integrity, 125, 136137, 141
Healthcare resources, 47 Intercellular cohesion, 136
Health-related quality of life (HRQoL), 4850 Interleukin-1a (IL-1a), 301
Healthy skin, 295, 296, 301 Interleukin-1 receptor antagonist (IL-1RA), 301, 302
Healthy subjects, 164, 168, 169 Internal occlusion, 138
Heat, 561575 International Organization for Standardization (ISO), 11
Heat exchange, 563564 Involucrin, 179, 184, 482, 495497, 499, 514, 531, 534,
Heat transfer 535
aging, 564 Iodopropynyl butylcarbamate (IPBC), 362
conduction, 561, 564565 Irritant dermatitis, 271273
convection, 562 Itch, 510
evaporation, 562563 Itching, 42, 44, 50, 508
Helianthus annuus, 410
Herbal market, 380
Herbal moisturizing, 387391, 393 K
Herbal skin cares, 379 Kallikreins (KLKs), 154, 156165, 167171, 515, 519,
Hereditary keratosis, 279 538
HMGCS1, 534, 536, 537 Kazal-type 5, 159
Homogenization, 334 Keratin, 116, 342344, 346, 349, 432438
Hormones, 77, 85, 86, 89, 90 Keratinization, 194
Horny layer, 504, 506508, 510 Keratinocyte differentiation, 531, 534538
HRQoL. See Health-related quality of life (HRQoL) Keratinocytes, 7790, 149151, 155, 158, 161, 163, 168
Human SASPase gene, 185 Keratinocytic skin carcinomas, 225
Humectants, 313, 316, 317, 324, 325, 329, 331, 525527, Keratinopathic ichthyoses (KPI), 280
531, 532, 535, 539
Humidity, 7880, 84, 85, 503510
Hyaluronan, 459468 L
Hyaluronate, 459, 466 Labelling, 4, 79, 11
Hydration, 316, 317, 319, 323, 329, 331, 332, 545557 Lactate, 431433, 435437
Hydration level of the drying environment, 238 Lactic acid, 318, 494, 495, 546, 548
Hydration status, 296, 298 Lactic or glycolic acid, 318
Hydrocarbon, 126, 127, 129, 131, 133135, 138, Lamellae, 126128, 130, 131, 133136, 139, 141
400405, 412415, 422, 423, 426 Lamellar bodies, 460
cream, 529538 Lamellar molecular organization of the SC lipids, 131, 132
Hydrogen bonding, 127, 134136, 139 Lamellar organization, 127, 136, 141
Hydro-lipidic unbalance, 419 Lamellar structures, 127, 130, 135
Hydrophilic/lipophilic balance, 247 Lanolin, 303, 319, 322, 333, 370, 373, 379, 383, 384,
Hydrophilic materials, 316319, 329, 330 388, 405, 411
Hydrophobic interactions, 134 Lanolin/olive oil ointment, 322
Hydrotherapy, 456457 Lateral packing arrangements, 128
w-Hydroxy ceramides, 126, 133, 134 Lecithin, 326
Hyperactivity disorder, 257 LEKTI-1, 281. See also Lymphoepithelial Kazal-type 5
Hyperhydration, 507, 510 serine protease inhibitor (LEKTI-1)
Index 587

Leukocyte, 303 Moisturizers, 138, 379396, 493495, 497499, 513,

Limnanthes alba oil, 427, 428 517520, 545557
Limonene, 368, 371, 372, 374 herbal moisturizers, 383, 386, 388390
Linalool, 368, 371 herbal moisturizing, 387391, 393
Linoleic acid, 126, 405, 410 impact on the skin barrier, 525, 526, 528, 529, 536,
Linolenic acids, 405, 408410 538, 539
Lipid, 125, 342344, 352 lipids, 532533
Lipid bilayers, 127, 128, 130133 niacinamide level, 557
Lipid content and natural moisturising factors, 273 on psoriasis, 288
Lipid matrix, 125141 Molecular composition, 128
Liposomal formulations, 390 Mono-carboxylic fatty acids, 420, 428
Liposome, 390, 391 Mono-glycerides, 421
Locabase, 517518, 520 Most common fatty acids, 422
Long chain alcohols, 403, 404, 406 mRNA, 537
Loricrin, 49, 179, 184, 495497, 536 expression, 531, 534, 536538
Lotions, 29, 30, 260, 262, 526 Multiple emulsions, 329, 330
Low and high HLB emulsifiers, 327 Multiple enzymatic reactions, 150
Low water content of the stratum corneum (SC), 453 Mutations, 181, 185188
Lymphoepithelial Kazal-type 5 serine protease inhibitor Myths, 454
(LEKTI-1), 159161, 168
Lysozyme, 200202, 207
N
Nail lacquer, 345, 348351
M Nail permeability, 344346
Mammalian genome, 187 Nail permeation, 344, 348
Management of ichthyoses, 282 enhancers, 347
Manufacturing, 331334 Nail plate, 341349, 351, 352
Manufacturing process, 355 permeability, 343349, 352
Matrix metalloproteinases, 464 National Institute for Clinical Excellence (NICE),
Maturation, 193, 194, 203205, 209 42, 54
MCI/MI. See Methylchloroisothiazolinone/ Natural fatty acids, 401, 405
methylisothiazolinone (MCI/MI) Natural gums, 383, 387
McIntosh, T.J., 130, 131 Natural moisturizing agent, 207
Meadowfoam (seed) oil, 427 Natural moisturizing factor (NMF), 259, 260, 296,
Mechanical damage, 441 298301, 317, 318, 325, 432438, 481, 482,
Mechanical friction, 42 546548, 550, 552, 554
Mechanical irritation, 96 Natural oils, 406410
Mechanical properties, 233, 236238, 240, 241 Natural raw materials, 379396
Mechanical stimuli, 77, 79, 80, 88, 89 Neonatal skin, 305
Mechanical stress, 77, 7983 Nerve fibers, 77, 80, 82
Medical device, 315 Neuropeptides, 77, 89, 90
classes, 57 Newborn infant, 202, 209
Medicinal moisturizer, 314 Newborns, 420
Medicinal product, 3, 4, 9 New emollient, 262
Melanomas, 225 Niacinamide, 555557
Merkel cell carcinomas, 225 Nickel sensitization, 122
Metal ions, 159 Nicotinamide, 319
Methotrexate, 274276 Nicotinates, 516, 518
Methylchloroisothiazolinone/methylisothiazolinone Nitric oxide, 563, 566571
(MCI/MI), 360361, 369, 372, 374, 375 Nitric oxide synthetases, 568
Methyldibromo glutaronitrile, 370, 372, 373 NMF. See Natural moisturizing factor (NMF)
Microbial challenge test, 356, 357, 362, 366 Non-glyceride fraction, 422, 424
Microbial contamination, 355356, 364 Noninvasive techniques, 297
Microbial resistance, 333 Non-ionic emulsifiers, 326, 327
Microemulsions, 390, 391 Nonlamellar lipid matrix, 200
Microorganisms, 125, 137, 140 Non-lesional skin of atopic dermatitis, 225
Microtension test, 236 Non-US studies, 351
Mineral oil, 400, 401, 403, 411 Notified body, 3, 6, 7, 10, 12, 14, 15
Mineral oils, 303 Nurse Prescribers Formulary, 30
Model systems of simplified lipid composition, 140 Nutrient exchange, 459, 468
588 Index

O Pigments, 422, 423, 428

Oatmeal, 44, 374 Placenta, 194
Occlusion, 532, 534536, 573, 574 Plakins, 151
Occlusive barrier, 242, 243 Plant extracts, 44, 369, 370, 374, 375
Occlusive coatings, 242, 243, 249 Plants, 374, 375
Occlusive emollients, 244 Plasmin, 157160, 163, 166, 168172
Occupational irritant dermatitis, 272 Plasminogen, 157158, 160, 162, 163, 168, 171
Oils, 29, 30, 316, 319333 activator, 158, 160, 171
Ointments, 29, 30, 43 Polyethylene glycols (PEGs), 348
Olea europea, 425 Polymers, 527, 529, 534535
Oleyl alcohol, 400, 404 Polymorphisms, 258, 259
Olive oil, 44, 383, 388, 393, 401, 404, 407, 410, 421, Polyol, 420
423, 425426, 428 Polyphenols, 424, 426, 428
Optical coherence tomography (OCT), 551554 Polyunsaturated fatty acids, 421, 426
Oral therapy with topical treatment, 350, 351 Post-marketing surveillance and vigilance, 1314
Organic acids, 361, 362 PPAR-g, 534, 536, 537
Osmotic, 474, 476478 Premature aging and skin cancer, 300
Osmotic pressure, 455, 456 Preservation, 355366
Overcoming the SC barrier, 137, 139 Preservatives, 333, 356366, 368374
Overhydration and ultraviolet (UV) damage, 441 Preterm infants, 43
O/W emulsions, 317, 319, 325, 327330, 332, 334 Prevalence of AD, 258, 260
Oxidation, 400, 402405, 408, 410, 412413 Prevention of AD, 262263
Oxygen, 85, 86 Pre-work creams, 271272
Primary and secondary prevention, 270
Processing of kallikreins, 167
P Product information file, 6
Palm oil, 404409, 425, 428 Profilaggrin, 187
Parabens, 358359, 363, 365, 370, 372 Proline levels, 448
Paracellular migration of inflammatory cells, 224 Protease inhibitor, 156, 159161, 168, 171, 172
Parent managing, 35 Protease mass levels, 169, 171
Patient and parental education, 261 Proteases, 150, 156
PCA. See Pyrrolidone carboxylic acid (PCA) Proteins, 194, 199, 201
Peanut oil, 383 Proteolytic activity of kallikreins, 157
PEGs. See Polyethylene glycols (PEGs) Pseudomonas aeruginosa, 355357, 363, 392
Pennes bio-heat equation, 563 Psoralen UVA (PUVA), 274, 276
Period after opening (PAO), 8 Psoriasis, 121, 122, 134, 135, 168169, 172, 215, 219,
Periodic Safety Update Reports (PSUR), 14 224, 225, 285291, 341, 351, 494
Peripheral corneodesmosomes, 151154 Psoriasis vulgaris, 483, 484
Permeability of the SC, 135136, 138 Psoriatic scales, 168
Permeation enhancement, 346348, 351, 352 PSUR. See Periodic Safety Update Reports (PSUR)
Peroxide value, 403, 412 Pump, 43
Petrolatum (PET), 244, 402, 403, 411 PUVA. See Psoralen UVA (PUVA)
Petrolatum-based emollients, 261, 262 Pyrrolidone carboxylic acid (PCA), 317, 443447, 449,
pH, 119, 150, 152, 154155, 159, 161, 163, 164, 166, 527, 538
168, 170, 296, 297, 300304, 525529, 532, 536,
538, 546548
Pharmacokinetics of sertaconazole, 348 Q
Phenotype, 183185 Qualified person (QP), 10
Phenoxyethanol, 360 Quality control parameters, 391395
Ph. Eur., 356 Quality of life, 270
phi, 199 Quality of life (QoL), 46, 4851
phi-proportional water structures, 199 Quaternary lipid mixtures, 133
Phospholipid, 342 Quaternium 15, 359360
Photoirritation, 394
Phototherapy, 285, 287
Physical barrier, 204 R
Physical stability, 392 Raman spectroscopy, 549557
Physico-chemical structures, 323 Rancidity, 412
Phytosterols, 408410, 424, 426 Rapeseed oil, 405407, 410
Index 589

Raw materials, 356 Skin capacitance, 516

Reactive oxygen species (ROS), 465466 Skin care products, 305
Redness, 516518 Skin circulation
Refining, 408, 409 heat, 566, 569
Regulation of protease activity, 161 nitric oxide, 566569
Relative humidity (RH), 165, 503510 Skin cleanser, 201, 207
Repeated open application tests (ROAT), 368 Skin colour, 581
Reproductive toxicity, 394 Skin conditions, 134
Responsible person, 10 Skin conductance, 475, 476
Restylane, 467 Skin corrosivity, 394
Retinoids, 466 Skin diseases, 215, 219220, 223227
Retinol, 466 Skin dryness, 120
Retinyl retinoate, 466 climate, 508, 509
Retrovirallike aspartic protease, 179189 Skin feel, 399, 400, 403, 404, 413, 414
Retroviral protease, 181, 182 Skin greasiness, 581
RH. See Relative humidity (RH) Skin hydration, 202203, 205, 297299, 301304, 306,
RHAMM, 463, 465 379383, 389, 390, 394, 395, 453457, 459, 461,
Rheology, 402403, 413 462, 468
Risk factors, 381, 392 Skin infection, 225
Rosacea, 99, 104 Skin management programme, 272
Skin microcirculation
Skin moisture, 561575
S Skin of babies, 295
Safety, 4, 7, 1015, 95, 381, 388, 391, 392, 394 Skin of newborns, 299
Salicylic acid, 286290 Skin sensitization, 394
Sandalwood, 383, 388 Skin-specific protein, 180
Sandwich-type models, 130, 131 Skin structure, 513514
Saponifiable fraction, 420, 422 Skin surface acidity, 203
SASPase. See Skin aspartic protease (SASPase) Skin surface pH, 581
Saturated, 421426 Skin temperature, 506508, 565, 566, 572574
Saturation pressure, 504507 Skin topography, 581
SC. See Stratum corneum (SC) Skin turnover, 514515
Scaly skin, 301, 302 Skin vibration, 83
Scanning electron microscopy (SEM), 546, 548 Sleep disturbance, 44, 47
Sebaceous gland, 474, 475 Sleep loss, 257
Sebum content, 394, 395 SLPI. See Secretory leukocyte protease inhibitor (SLPI)
Secretory leukocyte protease inhibitor (SLPI), 160 SLS. See Sodium lauryl sulphate (SLS)
Self-assembly, 133134, 139, 141 SLS exposure, 445448
SEM. See Scanning electron microscopy (SEM) SLS-induced barrier perturbation, 444
Semisolid, 403, 408, 410, 413 Soaps, 42
Senescence, 561 Soap substitutes, 271, 274, 276
Sensitive skin, 95106 Sodium hydroxymethylglycinate (sodium HMG), 360
sensitive skin and concomitant disease, 103104 Sodium lauryl sulfate (SLS), 528, 531537
Sensory evaluation, 393 Sodium lauryl sulphate (SLS), 44, 272274
Sensory properties, 243, 247, 399, 400, 403, 409, 414 Sorbic acid/potassium sorbate, 361
Sensory reactivity, 96, 97, 102 Sound, 77, 8283, 90
Serine protease, 155167, 169172 Soybean-derived phospholipids, 226
Serine protease inhibitor Kazal-type 5 (SPINK5) gene, Soybean oil, 404407, 409, 425, 428
159, 160 Specific IgE sensitization, 258
Shea, 424, 427, 428 Sphingomyelin phosphodiesterase 1 acid lysosomal (acid
Shea butter, 322, 323, 407, 410 sphingomyelinase) (SMPD1), 534, 536
Signaling system, 78, 79 Spices, 379, 387
Silicone, 323, 324, 327, 331 SPINK5, 281
Skin ageing, 219220 SPINK5 gene. See Serine protease inhibitor Kazal-type 5
Skin aspartic protease (SASPase), 179189 (SPINK5) gene
Skin barrier, 154, 165, 513520, 525540 Squalane, 400, 401, 403
disruption, 443 Squalene, 195, 198, 206, 400, 403, 419, 423, 426
function, 526529, 531539 Stability, 403, 404, 406, 409414
Skin blood flow, 571575 Staphylococci, 300
590 Index

Staphylococcus aureus, 29, 392 Tomography (TOVIS), 111, 113116

Starlings equation, 455456 Topical agents, 272, 274
Stem cell state, 466 Topical application of lipids, 137
Sterol esters, 195, 206, 208 Topical coatings, 241243, 252
Stinging, 96, 101, 102, 104 Topical effectors, 140
Stratum corneum (SC), 379383, 390, 391, 394, Topically applied chemicals, 137
493499, 503, 504, 513514, 516 Topically applied trypsin-like serine protease inhibitors,
barrier repair, 205209 172
biology, 316, 335 Topical moisturizer, 243
hydration, 317, 546, 550, 552557 Topical steroid, 274276
intercellular matrix, 126 Topical therapies, 285, 286
lipid organization, 137139, 141 TOVIS. See Tomography (TOVIS)
lipids, 547 Toxicity, 43, 52
natural moisturizing factors, 547 Toxicological evaluation, 381
pH, 547548 Transepidermal water loss (TEWL), 62, 6669, 272274,
protease, 478 297, 298, 300, 302306, 476478, 507, 515517,
structure, 545 520, 526, 528, 529, 531538, 547, 557, 581
thickness, 545, 547, 550557 Transfersomes, 390, 391
water content, 546547, 553554 Transglutaminase 1 (TGM1), 280
Study controls, 2223 Transient receptor potential (TRP) receptors, 79
placebo control, 22 TRP subtype V1 (TRPV1), 79, 80, 8688
positive control, 22 TRP subtype V3 (TRPV3), 79, 80, 86, 87
untreated control, 23 TRP subtype V4 (TRPV4), 79, 80
Subcutaneous fat thickness, 564, 565 Trans-zeatin, 221
Substrate curvature technique, 235237, 240252 Treatment, 285291, 473, 474, 476478
Sunflower seed oil, 406, 407, 410 Trigger factors, 31
Sun protection, 393 Triglycerides, 195197, 206, 296, 303, 401, 406411,
Sunscreen products, 374 420426, 428
Supplemental topical therapy, 350 TRPM8, 79, 80, 86
Suppressing differentiation, 466 TRP receptors See Transient receptor potential (TRP)
Surfactants, 313, 322, 327, 329 receptors
Surfactants and solvents, 442 Tubes, 43
Susceptibility to irritation, 274 Turmeric extract, 381
Swartzendruber, D.C., 130, 131
Sweet almond, 407, 410
Synthetic vernix formulations, 206208 U
Systemic corticosteroids, 275, 466 Ultraviolet (UV), 83, 87, 274
absorbers, 369, 371, 374
damage, 464465
T exposure, 225
Tallow, 405, 406 irradiation, 220, 223
Tape stripping, 96, 98, 546548 protection, 394, 395
Tape-stripping experiments, 155 Ultraviolet light, 42
Tazarotene gels, 287 Undesirable effects, 13, 14
Tensile functional properties, 581 Unsaponifiable, 420, 422428
Terpene alcohols, 424, 426 Unsaturated, 419421, 423426, 428
TEWL. See Transepidermal water loss (TEWL) Up-or downregulation of AQP3, 222
Texture, 413 Urea, 272274, 286, 288290, 344348, 350, 431, 437,
TGM1. See Transglutaminase 1 (TGM1) 518, 546, 547
Thermal conductivity, 564 clinical effects, 483485
Tight junctions (TJs), 153, 154, 215227 clinical studies, 494495
Tight junctions (TJs) transmembrane proteins, 215, side effects, 483
222, 227 Urocanic acid, 444
Tissue damage, 233234 Usage tests, 367, 368
TNF, 220, 226 Use in infants, 297, 305
TNFa, 219, 220 USP criteria, 356
Tocopherols, 422424, 426, 427 Utility studies, 45, 48, 5051
Tolerability, 318, 323325, 333 UV. See Ultraviolet (UV)
Index 591

V Water-in-oil emulsions, 200, 206

Vapor pressure, 5043509 Water profiling, 546
Vasodilatation, 516, 518, 566, 567, 569, 570 Water vapor transport (WVT), 200, 201
Vegetable oils, 383, 387 Waxes, 303, 316, 319, 320, 322, 324, 325, 327, 332, 334
Vegetal oils, 420428 Wax esters, 195, 197, 206
Vernix, 193209 Wheat germ oil, 381, 383
Vernix caseosa, 193209 W/O emulsions, 317, 322, 327329
Vernix contains antimicrobial agents, 201, 209
Vernix lipid composition, 195198
Vernix lipids, 194198, 202, 206, 207 X
Vernix specimens, 199 Xerosis, 27, 29, 60, 64, 65, 257, 260, 261, 381
Viscoelasticity, 379, 387, 389390, 394, 395 dry skin management, 27, 29
Viscosity, 383, 384, 387, 392 and ichthyosis, 581
Visible light, 77, 8384 Xerotic skin, 154, 168
Vitamin C, 423, 465, 467
Vitamin E, 422, 423, 428
Vitamins, 381383, 386, 387 Y
Yorkshire hybrid minipig, 204

W
Wash gel, 303305 Z
Water applied, 456, 457 Zn2+, 159
Water consumption, 453, 456
Water-holding capacity (WHC), 433, 435437