Moisturizer And Elderly Skin

By Dr Foram Parikh

This essay was written as a part of Essay writing competition organised by the IADVL EC, IADVL Academy and SIG Geriatric Dermatology, on the occasion of celebrating the International Day of Older Persons on October 1, 2021.

“Sometimes, the hardest thing to wear, is your own skin.”

“What can be more fulfilling than a nice moisturised, radiant skin? And trust me, this has the least to do with age. It is all about what you put ‘on’ the skin and ‘in’ the body.”

The incidence of dryness related dermatoses are on the rise; thanks to urbanization, adulteration, pollution, increased life span, and abandonment of traditional oil massages and baths. And hence, moisturizers are, and should be, an integral part of a dermatologist's prescription. Dryness is not an entity per se, but is characterized by differences in chemistry and morphology in the epidermis depending on the internal (physiological- aging, or pathological) and external stressors.

How exactly does our skin dry up? When the moisture content of stratum corneum (SC) is <10%, and there is a loss of continuity of the outermost layer. Now, stratum corneum is the topmost layer of the skin, made of corneocytes. Though they are made of dead cells without nuclei, they contain various substances that hold water. For our skin to feel smooth and supple, the stratum corneum has to be at least 10% water; ideally, it's 20% to 30%. This layer can absorb as much as five to six times its own weight and increase its volume threefold when soaked in water. Without water, the corneocytes accumulate, so skin becomes flaky and parched. The stratum corneum gets disorganized, resembling ‘hills and valleys’ instead of being tightly packed.

Traditionally, moisturizers were believed to inhibit the Trans epidermal water loss (TEWL) by occlusion. But now we know that, it is the loss of intercellular lipids, i.e., the ceramides, cholesterol, and fatty acids forming the bilayers; that damages the water barrier formation, thus leading to dry skin.

“I’m a better person when I’m moisturised.”

And rightly said, it does have a psychosocial impact. No one would ever want to show up with a flaky or parched skin.

Dry skin per se isn't a medical worry, although serious cases can result in cracks and fissures that invite infection and inflammation. The real issue is discomfort — dry skin can be sore, tender to touch, and often itchy.

WHY MOISTURIZERS?

Because: “MOIST SKIN IS HAPPY SKIN!!”

Moisturizers increase the water content of the SC. Hydration smoothens the skin surface by flattening the valleys between the skin contour ridges. It also makes the skin surface soft, more extensible, and pliable.

Many moisturizers inhibit the production of pro inflammatory prostanoids by blocking cyclooxygenase activity, thus have a soothing effect on inflamed skin.

Moisturizers containing mineral oils have low-grade antimitotic action on the epidermis and thus are useful in inflammatory dermatoses.

A possible strengthening of a weakened skin barrier function may also occur, and this makes skin less susceptible to attacks from noxious substances and prevents the development of eczema. No wonder why moisturizers are a useful adjunct in the treatment of inflammatory dermatoses as steroid-sparing therapy.

Emollients downregulate the cytokines thus reducing the itching. Furthermore, cooling effect following evaporation of water from the skin surface after using water based moisturizers has antipruritic effect.

These days’ sunscreens with variable sun protection factor are incorporated in the moisturizers providing additional sun protection.

SKIN OF THE OLDIES

Dr Howard Murad quoted,

“Aging is a fact of life.

But looking your age is not.”

What do you think he meant? It is never too early to age elegantly.

The most characteristic signs of aging skin are atrophy, laxity, wrinkling, sagging, dryness, pigmentary changes, and sparse and grey hair. In many areas of the skin, the epidermis becomes thinner with age and the cell turnover is halved between the thirties and seventies.

The main structural changes are observed in the deeper layers of the skin. With age, the solubility and the turnover rate of collagen decrease and degenerative changes in the elastic tissue lead to fragmentation of elastic fibres. There is a decrease in the hyaluronic acid content of the dermis. Hyaluronic acid, being a humectant; its decrease leads to loss of moisture from the outer layers of skin. Thus, replenishing moisture from the outside becomes of utmost importance. This depleted hydration leads to facial wrinkles, accentuation of forehead lines and nasolabial folds, drooping eyelids, and fan-shaped radiating lines around the mouth. The pliability and resiliency of the skin is reduced.

The permeability of the skin also changes with age. Though substances enter aged skin more easily than young skin, they are removed slowly into the circulation because of the changes in the dermal matrix and reduction in the vasculature. Sebum production lessens with aging. Hence, replenishing water along with adding the oil content gives a better sheen to the skin.

Because moisturizers contain oil, it's a common misconception that they are replacing lost oil. But most young children have wonderfully smooth skin, and the sebaceous glands in the skin don't start producing oily sebum until puberty. Dry skin is about lack of water, not oil; though, the oil in it does help hold the water in, by preventing evaporation through the surface.

Oestrogens have been shown to prevent skin aging by increasing collagen content, skin thickness, and moisture-retaining capacity of the skin. So, post menopause, there is thinning of the epidermis and dermis, and loss of dermal elasticity, due to low oestrogen levels.

Xerosis occurs most often on the legs of elderly patients but may be present on the hands and trunk. The appearance of xerotic skin is like a pattern of cracked porcelain. Xerosis preys upon the elderly. This is primarily due to the fact that these individuals have decreased sebaceous and sweat gland activity; this reduced activity predisposes the aged skin to moisture depletion.

There are a number of situations that deplete the skin's moisture. For example, xerosis tends to relapse in the winter when a lower humidity environment predominates. Another contributor is the daily use of cleansers, because they try to get rid of everything that your skin actually needs – not just the surface oils, but the deeper natural oils as well. So maybe, it’s time to switch your cleanser.

Additionally, pre-existing disease states, therapies, and medications make the aging individual more susceptible to xerosis. Some of these pre-existing situations include radiation, end-stage renal disease, nutritional deficiency (especially zinc and essential fatty acids), thyroid disease, and neurological disorders with decreased sweating, anti-androgen medications, diuretic therapy, human immunodeficiency virus, and malignancies.

Deficits in both skin hydration and lipid content play a key role in xerosis. Consequently, the skin's inability to retain moisture and provide an effective barrier directly impacts the development of xerosis in aging skin. Once the stage is set for xerosis development, the characters of flaking, fissuring, inflammation, dermatitis, and infection come into picture one-by-one. This xerotic vicious cycle needs to be broken to disable the process and prevent complications. Liberal use of moisturizers reduce scaling and enhance the corneodesmosome degradation process, and works great as a steroid sparing therapy.

HOW TO USE?

“I regret taking good care of my skin” said no one ever.

The right time and the right way to apply the moisturizers hold the key to maximum benefits. Except for humectants which can absorb water from atmosphere or underlying skin layers, the more commonly used occlusive oils should be applied on moist skin. The skin should be moistened first, as after dabbing it following a bath or by patting a wet cloth (sponge bath). After rubbing the moisturizer in both palms, it should be lightly applied along the direction of the hair follicles. Oil folliculitis could result due to vigorous rubbing of oily formulations.

Moisturizing after a shower is very important because hot water strips all the moisture and oils out of your skin, leaving it parched and dry. While hot water may be relaxing, it also wreaks havoc on your skin. So skipping moisturiser is like skipping breakfast, there’s absolutely nothing you can do that day to make up for the mistake.

A thick ointment (with a few percent of water) is more evenly distributed, plus helps replace moisture and seal it in. Also, it is not surprising that dispensing jars promote consumption of larger quantities, than the same quantity in a tube. Psychologically, this also implies better compliance. Once applied to the skin, the ingredients can stay on the surface, be absorbed into the skin, metabolized or disappear from the body by evaporation, and sloughing off or by contact with other material. Depending on the severity of dryness, the frequency of application can vary between 1 and 3 times daily, especially after bath.

WHICH MOISTURIZER?

An Ideal Moisturizer Should

• Reduce and prevent further TEWL

• Restore lipid barrier, i.e., duplicating and enhancing the skin's moisturizing retention mechanisms

• Hypoallergenic, non-sensitizing, fragrance free, non comedogenic

• Absorbed immediately, providing immediate hydration

• Cosmetically acceptable

• Affordable.

“Idealism is fine, but as it approaches reality, the cost becomes prohibitive.” Said William F. Buckley, Jr.

Let’s put this search to a side stand for the time being, because all moisturizers help with dry skin for a pretty simple reason: they supply a little bit of water to the skin and contain a greasy substance that holds it in. In fact, if greasiness weren't a problem, we might all go back to using the solution for dry skin that our grandparents used: 100% white petroleum, which most of us know as Vaseline. One reason for the proliferation of moisturizers is the continuing search for a mix of ingredients that holds in water like traditional petroleum but feels nicer on the skin.

CAN I MAKE LIFE SIMPLER FOR YOU FOLKS?

All said and done, let’s finally sum it all up and give a final take home message. What I would want, is simple adherence to a few things.

• Watch the temperature of water – Hot showers and baths are not good for the skin. Shower for a shorter amount of time and with lukewarm water. You’ll see the difference in your skin in no time.

• Pat dry, don’t rub dry – After the shower, gently pat dry your skin instead of rubbing it dry. Pat dry will help retain more moisture that you are going to seal in when you moisturize.

• Water! Water! Water! Drink more water – the moisture the skin receives also comes from your body. The more you put it in, the more of it will reach your skin. Drink at least 8 glasses of water every day. But, limit water intake post 7 pm, so as to avoid night time washroom visits. 7 am to 7 pm will be a good window to have as much water as possible, provided your general physician has permitted you.

• Use mild soaps and detergents – soaps and shampoos that contain alcohol, strip natural oils from the skin. Look for a mild, fragrance-free cleanser.

• Apply the moisturizer directly on damp skin, within 3 mins. That’s the 3 minute rule: You get 3 seconds to 3 minutes – to dry yourself and dab on the moisturizer. That’s what we call the 3-minute moisturizing window.

• Give extra attention to your hands – hands show the effects of a dry environment more than any other part of the body. Apply hand cream after each hand washing.

• Wear sunscreen when outdoors – nothing will save your skin more than protecting it from the harmful UV rays of the sun. No one ever said, SPF is for the young. It’s for me, you, and everyone under the Sun.

• Apply lip balm regularly – having lip balm ready and applying it frequently helps heal dry, cracked lips. Because lips lack sebaceous (oil) glands, dryness will probably seep in first through the lips.

All I want is, compliance in a way that comes naturally enough; as easily as dressing each day and eating every day. I am a big believer in that if you focus on good skin care, you really won’t need a ‘no show up’. Filters are great, but great skin is even better. And best would be, to sit side-by-side your grandchildren, while you go through your skin care routine. Teach them to invest in their skin, it’s going to represent them for a pretty long time. And take this from me: the sooner you start investing, the earlier you reap the benefits. Be comfortable in your own skin, and take care of it, while you are in it! Make skin your best accessory.

“I think it’s time … to love the skin you’re in!!”

By Dr Foram Parikh