Skin Barrier: Irritated skin, rashes, and eczema
Intro
All throughout this month of May, I am diving into different topics in skin health, with recent topics being hormonal acne & melasma. For this week’s blog post, I am going to dive into the skin barrier and the conditions associated with skin barrier disruption.
The skin barrier is one of the body’s first defenses against UV radiation, environmental exposures, chemicals, disease-causing bacteria, and more; AND is meant to keep water in the skin and keep the skin hydrated. With that, disruption to the skin barrier has been associated with skin irritation, eczema/rashes, skin dryness, acne, and more. In this blog, you will learn:
What is the skin barrier
Conditions caused by a disrupted skin barrier
Causes of skin barrier disruption
Integrative management options to support skin barrier health
Skincare ingredients for skin barrier support
1) What is the skin barrier?
The skin barrier has 4 different layers that depend on each other’s function for the entirety of the skin barrier to work effectively. The 4 layers of the skin barrier from the outermost to the innermost are:
Microbiome layer: This layer consists of all of the bacteria and other living organisms on the skin. The microbiome layer is usually kept at-bay with the acidic pH of the chemical layer. When at balance, the microbiome layer is mainly composed of Staphylococcus epidermis and Corynebacterium bacteria. But, when the acidic pH of the chemical layer is off, it allows for the growth of Staphylococcus aureus and other disease-causing bacteria.
Chemical layer: The chemical layer is made up of natural moisturizing factors (NMF) and other compounds that naturally make the skin acidic with a pH of 4-6. This layer can be disrupted by skincare products with more-alkaline pH.
Physical layer: The physical layer’s purpose is to keep water in the skin. This layer is composed of the stratum corneum, which is the outermost-layer of the skin/epidermis, in addition to a fatty layer (called the lipid matrix). Corneocytes (the skin cells in the stratum corneum) naturally make the the lipid matrix by making enzymes and releasing lipids that make fats, such as ceramides and cholesterols. This layer can be disrupted when there is an imbalance in the types of fatty acids, such as omega-6 to omega-3 ratio, and changes in stratum corneum thickness.
Immune layer: This layer is composed of immune cells that prevent microbes from entering past the epidermis and play a role in regenerating the skin barrier.
2) skin barrier disruption conditions
7 conditions that are caused by or lead to skin barrier dysfunction include:
Dryness (xerosis): Skin dryness can happen because of water loss from the skin (called transepidermal water loss), and this can happen because of changes to skin barrier function. What we see in those with high transepidermal water loss is that there are reductions in NMF in the chemical layer and ceramide deficiencies in the physical layer.
Eczema (atopic dermatitis): In eczema, we see all 4 layers of the skin barrier disrupted, leading to chronic and recurrent rashes with dry skin. What we see in eczema is that there is an immunological component in addition to changes in ceramides, filaggrin (a protein that plays a role in the integrity of the physical layer), and the skin microbiome. What we also see in eczema is that as the skin barrier gets more and more disrupted, there is a possibility of bacterial infections with Staphylococcus aureus - demonstrating how important the skin barrier is at preventing infections.
Rashes (chronic dermatitis): Systemic contact dermatitis is when someone experiences skin irritation/rashes when exposed to food allergens. In addition to experiencing rashes, they can experience general symptoms, such as gut symptoms, headache, fatigue, runny nose, and more.
Acne (Acne vulgaris): Acne can be described as a chronic, immune-mediate inflammatory disease of the skin that is, in part, due to changes in the microbiome layer of the skin barrier. Beyond Proprionobacterium playing a role in the development of acne (click here to read my blog post about acne), naturally-occurring beneficial skin bacteria Cutibacterium acnes play a role in the development of acne. Literature reveals that lower numbers of C. acnes causes a state of skin microbiome imbalance triggering the development of acne. In addition to this, Malessezia furur, a type of yeast naturally found on the skin, can lead to the development of fungal acne when the skin barrier is disrupted (click here to read blog post about fungal acne).
Seborrheic dermatitis/Dandruff: Dandruff is considered a mild form of seborrheic dermatitis. And, seborrheic dermatitis is characterized with a red scaly rash that affects the face, scalp, upper chest, and back and affects all ages, especially infants and those in early adulthood. Seborrheic dermatitis is considered a condition with a disrupted skin barrier since there is a change in the microbiome layer of the skin barrier that causes Malessezia to overgrow in affected areas. Malessezia then produces lipase, which is an enzyme that breaks down lipids on the skin, causing an immunological cascade that leads to the generation of inflammation and disruption in the cells of the physical layer of the skin barrier. Disruption of the microbiome layer and physical layer then leads to the redness, itchiness, and scaling that we see in seborrheic dermatitis/dandruff.
Psoriasis: Psoriasis is an autoimmune skin condition that is characterized with raised, red, scaling, oval-shaped plaques on the skin, and tends to happen on the lower back, elbows, knees, legs, soles of the feet, scalp, face, and palms. Psoriasis is considered a condition with a disrupted skin barrier since literature reveals that changes to the microbiome layer leads to provoking or exacerbating symptoms of psoriasis, and that the physical layer of the skin is disturbed with increased turnover of skin cells with immune layer activation. More will be talked about psoriasis next week in a separate blog post!
Rosacea: In rosacea, we see that there is chronic inflammation of the skin, particularly in parts of the skin where there are a lot of oil glands. This inflammation leads to symptoms of redness and dryness. What we see in rosacea in regards to the skin barrier is that there is changes to the chemical layer of the skin, where there is a higher pH than normal; and a change to the physical barrier that leads to increased transepithelial water loss.
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3) Causes of skin barrier disruption
Some external causes of skin barrier disruption include:
Skincare products/Physical irritants/Chemical irritants: Facial cleanser incompatibility, product pH incompatibility, over-exfoliation, retinoids, perfumes, allergy to ingredients, and more can cause disruption to different layers of the skin barrier, leading to dryness, irritation, and other symptoms of skin barrier dysfunction.
Frequent hand washing: Repeated washing, especially with harsh soaps, pulls lipids out of the physical layer and NMF from the chemical layer, causing skin barrier disruption and skin dryness.
Sunlight/UV exposure: UV exposure has been shown to affect the physical layer by disrupting cell-to-cell adhesion and fatty acid composition, leading to water loss.
Weather: Cold weather has been shown to cause skin barrier disruption and skin dryness by reducing NMF. Dry and windy weather have also been implicated in the development of skin barrier disruption.
Face masks: Recent reports that revealed that long-term wearing of face masks lead to skin irritation, worsening acne, worsening rosacea, and other skin conditions.
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Some internal causes of skin barrier disruption include:
Inherited predisposition/genetics
Food intolerances/allergies: Allergens that can cause systemic contact dermatitis include some spices, food additives, some herbs, balsam of peru, seafoods (due to nickel). In regards to eczema, we also know that there is a connection between food intolerances triggering or exacerbating eczema.
Gut microbiome: A small study completed on those with acne revealed that those with acne had different gut bacteria profiles compared to those without acne. And, is has been hypothesized that these acne-causing changes to gut microbiome/bacteria populations could arise because of bacteria-related products that cause the release of inflammatory markers into circulation. There is also literature that suggests that there are associations between small intestinal bacterial overgrowth and Helicobacter pylori infection with rosacea; gut microbiome imbalance and eczema; and gut bacteria imbalance and psoriasis.
Low thyroid hormone (hypothyroidism): Thyroid hormone is essential for controlling healthy epidermis development and function with animal models indicating that thyroid hormone being involved in skin cell production, wound healing, and hair growth. And, those with hypothyroidism have low thyroid hormone, and can experience dry skin in addition to many other symptoms.
Estrogen deficiency: Estrogen plays a role in maintaining skin thickness, water content, and more. And, low levels of estrogen have the potential to lead to skin thinning and transepithelial water loss.
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4) Integrative options for skin barrier support
Naturopathic medicine is all about identifying the root cause for targeted treatment. And, licensed naturopathic doctors (NDs) are trained to provide integrative medical care with pharmaceutical and natural therapies that treat the root cause of a patient’s symptoms in addition to directly treating the symptoms themselves.
If someone is frequently exposing themselves to irritating chemicals and/or using harsh soaps, it will be worth their while to avoid such exposure to heal the skin barrier in addition to topical products (see skin care products below). Additionally, working with a provider who will be able to identify what skincare products may be too harsh to the skin will be worth while to help you understand what products to use and how often to prevent exacerbation of skin barrier disruption.
Below, you will find some conventional and natural treatments that a licensed ND may recommend for skin barrier support:
Conventional therapies
General conventional approach to most skin barrier conditions is avoidance in addition to treating symptoms the patient is experiencing. Conventional treatment may also dive into treating physiological & biochemical root cause of conditions with the use of pharmaceuticals.
Eczema: General conventional approach to managing eczema is to eliminate allergens and maintaining skin hydration with moisturizers and optimizing bathing practices. Pharmaceuticals can be recommended to control itching, such as topical anti-inflammatories, topical corticosteroids, or oral anti-histamines. Oral corticosteroids may be prescribed for those with acute exacerbations of chronic eczema, and antibiotics will be prescribed to those who are experiencing infection due to eczema.
Contact dermatitis: General management for contact dermatitis involved avoiding the irritant or the allergen, and topical corticosteroids may be prescribed in addition to moisturizing topicals.
Seborrheic dermatitis: Typical conventional management of seborrheic dermatitis involves the use of anti-fungal shampoos or other anti-fungal topical preparations. For severe disease, topical salicylic acid, coal tar, corticosteroids, and/or isotretinoin may be prescribed.
Psoriasis: Conventional management for psoriasis includes the use of topical moisturizers, topical corticosteroids, coal tar, and more. for more-severe psoriasis, a doctor may administer corticosteroid injections or oral medications, such as oral retinoids, methotrexate, and cyclosporine. Ultraviolet therapies may also be recommended as a conventional treatment for psoriasis.
Rosacea: General recommendations for rosacea include using mild skin cleansers, avoiding irritating skin care products (astringents, toners, abrasives, and fragrances), using broad-spectrum SPF with zinc oxide or titanium oxide, and avoiding triggers. Beyond this, topical metronidazole, azelaic acid, and others and/or laser administration may be recommended to reduce redness. Oral retinoid and/or antibiotics and be prescribed for more-severe cases of rosacea.
Acne: There are various pharmaceuticals that can be prescribed for acne. To learn more about acne treatment from an integrative perspective, click here to read my blog post.
Hypothyroidism: Conventional management for hypothyroidism involves the use of pharmaceutical thyroid hormone replacement therapy, which should reduce the symptoms of dry skin in addition to all other symptoms of low thyroid hormone.
Natural therapies
Natural treatments may be recommended on their own or combined with conventional therapies, depending on severity of disease, patient preference, and other factors; and, are meant to treat the root cause of symptoms by supporting affected underling organ systems and supporting foundational health and wellness.
Food intolerances/allergies: Food intolerances and allergies can be treated once they are identified. Most integrative providers complete food allergy testing via skin prick test and/or blood work to identify allergies/intolerances, while others may do a targeted elimination diet to do the same thing. Once food intolerances/allergies are identified, this could possibly reduce severity of chronic rashes and more.
Nutraceuticals: There is literature that indicates that probiotics, prebiotics, and omega-3 fatty acids may be helpful to support skin barrier health. Literature also suggests that daily supplementation of collagen could increase skin hydration, especially when combined with vitamins. However, we are still yet to understand if collagen supplementation preferentially goes to the skin opposed to other parts of the body.
Herbal medicine: Certain herbs and/or plant extracts may be recommended by an integrative provider that addresses the root cause of symptoms. There are various options that address gut microbiome imbalance, thyroid health, hormone balance, and more.
Bioidentical hormone replacement therapy: If someone experiences hypothyroidism, natural/bioidentical hormone replacement therapy may be recommended by an integrative provider.
Platelet rich plasma: Platelet rich plasma is a nutrient-dense product made from someone’s own blood that has been shown to increase skin fibroblast activity and increase type I collagen and also “rejuvenate” skin appearance by reducing the appearance of fine lines and wrinkles.
5) Skin care ingredients for the skin barrier
When looking for skin care ingredients that address the skin barrier, it’s also about understanding the building blocks of what is in each layer. This means looking for moisturizing factors that pull water into the skin, and looking for elements that prevent water loss. Ingredients to look for are:
Ingredients that pull water into the skin (called humectants): Hyaluronic acid, glycerin, and gluconolactone (a type of polyhydroxy acid, or PHA)
Lipid replacement: Lipids are meant to keep water in the skin and prevent water loss. Some lipids in skincare include: Ceramides, cholesterol esters, palmitic acid, stearic acid, and candelilla wax.
Anti-inflammatories: Topical anti-inflammatories support various layers of the skin barrier. Some ingredients that are potentially anti-inflammatory include: Niacinamide, licorice extract (18-beta glycyrrhetinic acid), and gluconolactone.
In addition to these topicals, it may be worth someone’s while to consider occlusive skincare products as the last step to their routine to really seal in water in the skin and prevent water loss.
Beyond looking for the ingredients above, the following 5 elements will be worthwhile to consider to support skin barrier function:
Patch testing for skin irritation.
Making sure that the pH of the product is close to skin pH (pH 4-6) to prevent disruption of the microbiome layer.
Being mindful of when you’re excessively exfoliating as this can disrupt the physical barrier.
Watching if your current skin cleanser or any other skin products are making the skin feel too tight.
Remembering to always put on sunscreen and frequently re-apply.
5-step Skincare routine for skin barrier support
Remember to always speak to a doctor or a skin specialist before trying anything new, and make sure to ALWAYS patch test for possible irritation!!! Here is my current personal skincare routine that is aimed at supporting my skin barrier:
Step 1: Double cleanse. I double cleanse morning and night. I start with a PHA cleansing oil on dry skin and rubbing off the night cream from the night before or the SPF from the day time. Then, put on some water to emulsify the oil and rub a bit more. As my skin is still wet, I use a gel cleanser to really clean my skin.
Step 2: Essence. I use a hyaluronic acid-rich essence with niacinamide morning and night to prep my skin for the actives and serums that I use. I prefer an essence since they’re usually rich in hyaluronic acid, rich in moisture, and are not drying to the skin.
Step 3: Moisturizer. I sometimes use a hyaluronic acid moisturizer if my skin is especially dry. Note: Hyaluronic acid products work best on damp skin, and it would be best to apply hyaluronic acid right after an essence or washing the face while it is still damp.
Step 4: Lipids. I use a non-comedogenic facial oil morning and night to seal in the moisture from the hyaluronic acid.
Step 5:
Daytime SPF: My last step, if I am getting ready for the day, is a tinted sunscreen with iron oxides to protect my skin barrier from sun damage.
Nighttime sleeping mask: My last step, if I am getting ready for bed, is a ceramide-rich sleeping mask to keep all of that moisture in my skin.
Summary & takeaways
The skin barrier is important since it is one of the first-lines of defense we have. And, when the skin barrier gets disrupted, it can lead to skin dryness, rashes, irritation, acne, and many other skin conditions. Here are 5 key takeaways from this blog post:
There are various root causes of skin barrier disruption. Some causes can be external while others can be internal, and it is worthwhile for someone to identify the root cause if they have been experiencing chronic skin issues.
Once the causes are identified, there are natural and integrative options that can treat the skin from within and topically.
Gut health, diet, and the gut microbiome are important internal causes to first consider when someone is experiencing chronic skin barrier issues.
Key skincare ingredients that support skin hydration and the skin barrier include humectants, lipids, and anti-inflammatories.
When making a skincare routine for the skin barrier, there are 5 elements to consider:
Patch testing
Product pH
Exfoliation frequency
Not using products that make the skin feel tight/dry
Apply and reapply SPF
This May, I am focusing on different topics in skin health. Last week, I spoke about melasma and next week I plan on speaking more about psoriasis. To stay up-to-date about future blog posts, click here sure to sign up for my email newsletter. And, if you want to set up an appointment with me, click here.
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