Skin Barrier Spotlight
When you visit the Dermatologist for a skin concern, you might think that your presentation is unique and highly individual. While shades of your perspective are true, there’s a good chance we’ve already seen a few patients with the same or similar condition in the hours before your scheduled appointment.
Just as no two snowflakes are the same, they certainly have alot in common… that’s what makes them snowflakes, afterall, right?
Dermatologists have the privilege of treating a number of presentations a day, all unique to the patient and the variables leading up to their present appearance. For this reason, treatment plans are customized with respect to the patient’s past and present medical history, the sensitivity and reactiveness of their skin, and likely anticipated exposures and lifestyle.
However…
There’s one thing that you, your grandmama, your tia, your roofer, your PTO president, and everyone in between should know that not every Dermatologist shares during their five minutes of face time with you. The conversation we need to be having with almost everyone concerns the health of your skin barrier.
The Skin Barrier Breakdown
To have a healthy skin barrier is like having a good defense system around the castle that is your body. Your skin is your first line of defense, so this is not a stretch. The skin acts as an immune organ, an interactive network of multiple systems ranging from chemical and physical factors to microbiome and immune barriers. When the skin barrier is depleted, we see a number of Dermatologic conditions which result directly as well as indirectly, with a neglected barrier network often compounding the problem. You want the walls of your castle to be strong and effectively maintained so that they can provide the functions for which they were built.
To better do this, it doesn’t hurt to understand the four distinct protective systems which make up the outermost layer of your skin.
Microbiome
This aspect of skin ecology is alive and active. Bacteria, fungi, and viruses native to a healthy skin environment behave protectively to reduce pathogenic (bad) bacteria from overgrowing or creating opportunistic infections. They do this by producing molecules that inhibit the colonization of other microorganisms or alter their behaviour.1 Many of the bacteria and yeast found on the body have preferential locations based on proximity to oil or moisture, or other environmental factors they’ve adapted to live in harmony with specific to certain locations of the body. The behavior of these living organisms respond to and influence the other components of the skin barrier equally.
Physical
Keratinocytes, and their later form of corneocytes form the skin’s physical layer. Keratinocytes are the biologically active skin cells responsible for protecting from microbial invasion, shielding UV exposure, and maintaining adequate skin hydration by secreting keratin, a protein that is a primary component of the stratum corneum—he outermost layer of skin.
Immune
Your keratinocytes have the ability to sense the presence of organisms through pattern recognition receptors. When they’re activated, they secrete antimicrobial peptides with the ability to rapidly kill and deactivate microorganisms. However, the skin’s immune system cannot function independent of the native microbiome. When you’re first born, the immune system allows for colonization of the skin with microorganisms without producing an inflammatory response in an adaptive effort to welcome new symbiotic friends. Depending on the activity of the bacteria and the chemical, physical, and microbial features of the area of colonization, the skin’s own immune system which is comprised of T-Cells and macrophages and more - may elicit an inflammatory response (which is at the heart of most skin conditions we see in clinic).
Chemical
The chemical barrier of the skin maintains moisture and supports waterproofing, while working with the immune and microbial systems to balance skin pH and inhibit the growth of bacterial pathogens. A large component of the chemical system of the skin is the lipid matrix, composed of cholesterol, free fatty acids, and ceramides. These ingredients are crucial for the skin barrier function.(1)
Now that you have an understanding of each of the main systems and the simplified roles that each play in the function of the outermost layer of the skin, you can get a better idea of why it’s so important to support and maintain your skin barrier. In clinic, I often say “we need to beef up your skin barrier.” (I’m vegan so I’m not sure exactly why I use this terminology, but I feel like it gives a relatable context for patients to visualize.)
So HOW does one BEEF UP their skin barrier?
It’s actually really easy, all the average person has to do is make a few small lifestyle modifications and changes in daily habits to make a noticeable difference.
Habit 1) Trade the Bath in for a Shower
Excessive water exposure has the opposite effect of hydration on the skin. Overexposure to water dehydrates the skin by depleting that ceramide and lipid bilayer, leaving skin vulnerable and with an altered pH, chemistry, and microbiome. This can lend itself to a reactive immune system which makes you more prone to dryness, inflammation, and itching.
Habit 2) Time Your Showers
Showers should take no longer than 5 minutes, unless you’re full body shaving (nothing wrong with a little manscaping!), and even then - you can turn the water off and not only save on the water bill, but save your skin while you’re at it. Excessive water exposure is not your friend, especially if you are already dealing with a condition like eczema, atopic dermatitis, or skin viruses like molluscum contagiosum where the skin’s immune system needs to be at optimal strength to rally and heal.
Habit 3) Nix the Hot Water
Piping hot H20 feels good in the moment, but it also strips the skin of it’s natural barrier and causes your blood vessels to vasodilate. Have you ever noticed how your skin begins to turn red when it’s hot? That’s because the blood vessels widen and come closer to the surface. They also become more porous as they widen, allowing vessels to become leakier, and sometimes even triggering a histamine or inflammatory response.
Habit 4) Let the Loofa Go
A little gentle exfoliation now and again is good for most folks; however, if you struggle with eczema or any irritant or inflammatory skin condition, put the loofas and washcloths down. I often counsel patience that “less is more”, when it comes to these conditions. The skin is under enough stress as it is. We don’t need to add a violent and vigorous mechanical breakdown to an already vulnerable surface as a stressor. If this is a hard habit to break, there are certain brands I am comfortable recommending for patients who feel they need a vehicle for which to deliver their cleanser.Alternative Option: No rinse cleansing cloths , Skin Barrier Soft & Safe Wash Cloth
Habit 5) I’d Rather You Not Lather
Foaming and lathering washes are so 1900s. “As If”. Remember when we all used Zest and Dial and…heaven forbid … Irish Spring? It’s okay, we didn’t know any better. The past is in the past.Now that skin barrier is a priority, Dermatologists have been recommending gentle cleansers crafted with ceramides in mind. I recommend Unscented Dove Soap most often, because it’s so easy to find, but I also like Aveeno moisturizing wash for the little ones with eczema, and Cerave soothing body wash to maintain skin barrier balance for the general population.
Habit 6) Air Dry
Rather than rubbing your skin with a towel, pat dry, or better yet… air dry! Give yourself permission to liive a little, people.
Habit 7) Moisturizing Matters
Not only does moisturizer matter, but WHEN you apply your moisturizer can really make a difference. Before you’ve entirely air dried, slather some Cetaphil Moisturizing Cream on and lock in that hydration while the skin is still moist. Other Fantastic, effective, and Accessible moisturizers include La Roche Posay Triple Repair MOisturizer, and Aveeno Restorative Skin Therapy.
If you or someone you take care of has been diagnosed with chronic eczema or atopic dermatitis, it’s also important to make sure you avoid lotions, perfumes, or cleansers which contain fragrance or dyes. This extends to detergents as well. Detergents embraced by Dermatologists alike include: All Free & Clear, Tide Free & Gentle (available in compost friendly packaging so you can be good to the Earth while being gentle on your skin), and Ecos Hypoallergenic Detergent Sheets (my personal favorite). Before you use a product which will directly or indirectly come in contact with your skin, give it a “See & Sniff” test. Look at it and make sure you can somewhat see through it, and smell it to make sure it smells… entirely boring. There are two caveats, here:
There’s a good chance that any product that has added fragrance also has alcohol to stabilize and blend the volatile fragrance in the formulation.
Essential oils may add enjoyable scents without the addition of alcohol; however, many individuals are unknowingly allergic to specific plant based compounds when applied topically. While tea tree oil or lavender oil are known for their calming properties, clinically experienced Dermatology providers have each seen their fair ongoing share of Allergic Contact Dermatitis and Irritant Dermatitis with these same compounds. (Important fact: Even if you’ve never been allergic to a compound before, you can still develop an allergy. We see this regularly with Neosporin induced Contact Dermatitis. (3))
The takeaway here is simple:
When it comes to maintaining the skin barrier, less is more. For the vast majority of people, the networks of this water proofing, invader fighting barrier are intuitively outfitted to support one another and function harmoniously. If you or someone you care for has been diagnosed with eczema, stay tuned for an upcoming blog article to address additional considerations and explain why certain treatments have become Dermatologic staples for eczema care.
Until then, when you think about the health of your skin, remember, this large and complex organ has alot more going on than meets the eye. Handle your skin barrier with care, and be gentle with yourself out there!
(1)Byrd AL, Belkaid Y, Segre JA. The human skin microbiome. Nat Rev Microbiol. 2018 Mar;16(3):143-155. doi: 10.1038/nrmicro.2017.157. Epub 2018 Jan 15. PMID: 29332945.
(2)Franklin R. Blum, Encyclopedia of Child and Adolescent Health (First Edition), 2023, https://www.sciencedirect.com/topics/medicine-and-dentistry/molluscum-contagiosum
(3) Lipozencić J, Milavec-Puretić V, Trajković S. Neomycin--a frequent contact allergen. Arh Hig Rada Toksikol. 1993 Jun;44(2):173-80. PMID: 8240027.
