Skin barrier tenuous first line of defense

National report - Many skin conditions are a manifestation of an insult to the skin barrier, so an awareness of that barrier, what affects it and how, is imperative for a physician to effectively manage his or her dermatologic patients.

"As a dermatologist, you have to treat the whole triad," Dr. Draelos says.

"The asthma and hay fever must be brought under control simultaneously with the skin to get good clearance. In that case you want to prescribe oral antihistamines," she says.

Nuts and bolts of skin barrier

The skin barrier can be disrupted with too much transepidermal water loss (TEWL), Dr. Draelos explains.

Indeed, some topical products can dehydrate the skin and thus break down the skin barrier; other products, such as moisturizers, can restore function to the skin barrier. The function of the skin barrier can be monitored through TEWL and corneometry.

Research has shown that alterations in the skin barrier can have an impact on the phenotypic presentation of dermatologic conditions like psoriasis and rosacea. Elements such as the sun, wind and environmental hazards like pollution have an extensive impact on the skin barrier and its function, Dr. Draelos says.

Additionally, while genetics play a role in the integrity of the skin barrier, occupational and environmental influences can also impact the skin barrier, Dr. Draelos notes.

"If you work in a factory making school buses, it doesn't matter how tough your hands are, you will experience some damage. Some of it is environmental and occupational. Household cleansers like Ajax, Windex and dish-washing soap, basically anything that removes lipids, can have an impact. In cooking, if you handle meats and raw fruits and vegetables, those actions would have a negative impact," Dr. Draelos says.

Other common activities can have deleterious affects. Children who swim in chlorinated swimming pools, for instance, should wash off with warm water and use moisturizer to protect their skin barrier, Dr. Draelos adds.

Too much of a good thing

Because the overuse of skin products can disrupt the skin barrier, it's recommended to minimize exfoliative polypharmacy, Dr. Draelos says.

"There is the possibility that some people are using too many products, such as dermabrasion and at-home face peels or using numerous exfoliants or products with low pH levels designed to remove keratinoctyes. You can indeed get polypharmacy and patients can damage their barrier themselves."

If patients are susceptible to marketing and advertising pressures, they may be quick to add the newest device, scrub, cloth or cleanser to their skincare regimens, Dr. Draelos says.

"There is the possibility that people are doing too much for the skin and causing injury," she says.