Everyday Skin Care: Maintaining Skin Integrity and Avoiding Inflammation
Excerpted from a presentation by Peter Lio, MD, at the 2010 National Eczema Association Patient Conference. Dr. Lio is Assistant Professor of Dermatology and Pediatrics at Northwestern University’s Feinberg School of Medicine and a Founding Director of the Eczema Care & Education Center.
I’m excited to talk to you about everyday skin care, about how to prevent infection and avoid inflammation. Soaps and moisturizers represent the most important daily rituals that we do with our skin and are how we interact with our skin the most.
What are soaps and what are “syndets,” or synthetic detergents? Soaps have been part of our lives for many millennia. We know that soap begins with an animal fat that then gets rendered with a base. Usually it’s something like sodium hydroxide or lye used to create a detergent that is very harsh. It’s very basic in terms of its pH. It strips off oils, dirt and gunk.
It turns out that soaps are pretty harsh for anyone, but especially for people with sensitive skin, with eczematous skin or open skin. We’re lucky that in the past few decades we’ve had this huge proliferation of syndets or synthetic detergents. These are a little bit different because they are designed to pull out some oily molecules and some water molecules like soap does, but they can be much milder and have a pH or acid value that’s much closer to our skin. Very basic things like liquid drain cleaner, caustic sodas, and oven cleansers have a high pH of 13 or 14. Just below that, with a pH of 12, is soapy water with real soap. So just one little notch below your oven cleaner, which clearly says do not get this anywhere near your skin, is the soap that people use to wash. At the other end of the pH scale, at 0, 1, and 2, we have things like battery acid, stuff coming out of your stomach lining, lemon juice and vinegar. Our skin is normally around a pH of 5½, so it’s a bit on the acidic side. What’s interesting is that when we use real soaps like we used to do in the old days, they just destroy the acid mantle, or acid background, of your skin. Some of the newer cleansers are a little bit closer to your skin’s 5½ pH, and we think that this is probably pretty important.
Staphylococcus bacteria multiplies as you get farther away from this ideal pH, so if you use soaps and your skin pH goes up, you get both more irritation and more potential for Staph.
The perfect balance for someone with sensitive skin might be a pH of 5½ or maybe even a little bit lower, a little more acidic to help restore that acid mantle. The ultimate goal is to repair and restore that barrier, to help rebuild our skin.
A lot of folks ask, “How often should I bathe, or how often should I bathe the baby? One doctor told me once a year, another doctor told me five times a day. . . . Why is this so confusing?” It is confusing because in the old days there was just soap. Soap, as we now know, was harsh, and it was very reasonable to say don’t bathe a lot. Because we have some milder options now, it’s a lot easier. What we’re seeing is that if we don’t destroy the acid mantle of the skin, we actually get some benefits out of bathing a little bit more. We definitely need to put moisturizers on after we bathe. If we use the right things, we’re probably not doing too much damage by bathing once a day, or even in some situations twice a day, and we’re getting other important benefits as well.
What kinds of cleansers are out there? The things we want to look for are non-soaps, or synthetic detergents. We want things that don’t have any fragrance. That’s really important because a lot of folks get allergic to fragrance over time. We definitely don’t want things with scrubbing beads or plant extracts, even though “natural” products are very appealing. We try to avoid those things and keep it simple.
Most modern moisturizers are really good. That being said, there are a lot of nuances still to talk about. One thing I like to discuss is how thick or occlusive the moisturizer is. We have an opportunity to pick one that fits you.
There has been some research in the past few years talking about what could be done to make the moisturizer more than just a barrier. We know if we take petroleum and smear it over the skin then you have a perfect barrier. The water stays in, bad stuff stays out, it’s great. The problem is, it doesn’t really do much for the skin beyond being a shield. Once that petroleum wears off, you’re kind of back where you started.
People began to consider that in eczema the barrier is broken down ¬sometimes from scratching, but also probably directly from the inflammation going on in there. What if we could put the right ingredients in to help the body rebuild the barrier? Cholesterol, the thing we try to get rid of in our diet, is important in our skin. Ceramide is another type of fat that plays an important role in our skin. And these two types of free fatty acids, essential and nonessential, are also highlighted. It turns out that if you mix them in a particular ratio, you get this powerful mixture that restores the skin barrier better than other combinations.
This idea about how we can optimize moisturizers is a relatively young science, but I think this is exciting for the future. A lot of companies are looking into these new technologies. Historically, we have said “the greasier the better,” but we might be able to get gentler and lighter technologies that still do a great job. Right now I would say it’s nice to look for something that contains ceramides. If you can get a moisturizer with ceramides, I think that is important, but we still have a lot to learn.
The key thing with cleansers is to choose a mild one, to cleanse daily, and then to maybe integrate bleach baths with that. Moisturizing right after bathing is also really important. If we can choose a moisturizer with ceramides, that would be great. If we do that, we sort of seal the skin and keep our barrier functioning well. But what about irritants and allergies and allergens in the environment?
Food allergies are gigantically controversial at the allergy meetings and the dermatology meetings. What do I tell people? I say if you think a food is worsening your eczema, then by all means avoid it. If your eczema is still miserable and you haven’t eaten any ______ ( fill in the blank here: gluten, fish, pizza, tomatoes, etc.), then I’d say go back to it, barring an issue with hives or another strong reaction, of course. Part of the issue is that many patients with eczema have real food allergies—immediate hives, facial swelling, and sometimes even dangerous throat swelling. These allergic reactions are not controversial at all and the foods that cause them must be avoided at all costs. The problem is when folks get allergy tests that say they’re allergic to “everything” even though they are eating those things normally and not getting hives or having other immediate reactions. There is some confusion that the eczema itself is an allergic reaction to food. So these folks subsist only on bread and water and then they (or their child) start wasting away. And the killer is that their eczema still is bad. So if dietary changes really, reliably worked, I’d say okay, I’m with you. But they don’t seem to work for most. That being said, there are lots of stories of people who do change their diet and get better. I’m not dismissing that, but I sometimes wonder what else is going on, what other kinds of things are involved?
Clothing and Fabric
Clothing is interesting, too, because that’s the other thing that interfaces with our skin every single day, and we don’t talk much about this. There are a couple of studies that show that silk bed sheets and wearing silk clothing can actually be helpful. We’ve know for a long time that wool and other kinds of scratchy fabrics, like certain polyester blends, can make people miserable and bring out their eczema. We know that, in general, 100 percent cotton, loose-fitting clothing is a good recommendation. We want to try to avoid fabrics with chemicals like flame retardants. Wrinkle-free stuff is bad for a lot of people too. It can be both irritating and you can get allergic to it. It’d be interesting to see if we can advance this area in the future; things like antibacterial clothing are now a reality and we may see some further innovations in time.
I’d like to conclude with some thoughts about stress, the mind, and the psyche. There was a study in 2003 that showed very clearly that not only did stressful events worsen folks’ atopic dermatitis but they actually slowed down the barrier function healing of their skin. Another study of non-eczema patients found that their skin barrier function started to break down when presented with psychosocial stress or sleep deprivation.
A study that came out last year involved patients viewing a humorous film and sampling their B cells (the immune cells that make the immunoglobulin allergy proteins) before viewing and after. After the humorous film, the allergy proteins were decreased significantly. It’s interesting, this idea that your mood and your state of mind could change something so quickly. In my experience, it does seem to bear out that more optimistic patients do seem to have better outcomes and are able to get their eczema under control more easily. And this has struck me again and again as important.
Taking care of your skin and taking care of yourself from a mind/body holistic perspective, not to sound too flaky, really does seem to help. I think it helps your skin and it helps the rest of your body and mind, and that cannot be overemphasized.
On the other hand, we know that having eczema does not mean you’re doing something wrong. I want to make sure that message is clear. It doesn’t mean you screwed up, it doesn’t mean you’re a bad parent for your child with eczema, it doesn’t mean that you’re not “holistic” or “balanced.” You shouldn’t blame yourself for it. We know this is a real disease and it is not just in anybody’s mind.
Please check out our Eczema Care and Education Center web site: www.eczemacarecenter.com