Problem skin or medical indication? That is the question arising in the case of barrier disorders. Dry skin belongs into the category of problem skin and can be identified by a high TEWL (transepidermal water loss) and low skin hydration, easily measurable with the Corneometer® probe. If the barrier disorder already is much more pronounced and shows signs of inflammation and pruritus, it may be atopic skin (neurodermatitis). Both cases demand for an appropriate and individually adapted skin care. In case of neurodermitic skin, it is recommended to seek medical advice as this condition definitely is a medical indication.
The appropriate cosmetic care of dry skin is a lipid-enriched cream enhanced with a NMF (Natural Moisturizing Factor, as e.g. amino acids, urea) and hyaluronic acid. Recommended for the atopic skin also are additional active agents with anti-inflammatory potential (essential fatty acids, boswellia) possibly also components to soothe the itching (as e.g. urea, allantoin and other amides). All these substances sound like medical drugs, however, they still belong to the cosmetic area as long as the cosmetic skin care abstains from explicitly promising the healing and soothing of diseases.
Adequate skin care concepts should go beyond this scope, though: emulsifiers may intensify barrier disorders, for instance. Hence, they should be avoided just as allergenic preservatives and perfumes which easily may penetrate through the disordered skin barrier. Mineral oils also are counterproductive as they form superficial films on the skin and thus impede its natural recovery.
So far, we are still discussing within the principles of corneotherapy. As experience teaches, a systematic selection of cream components and cosmetic active agents will lead to a significant recovery of the skin condition, sometimes even to a freedom from symptoms. The theory is scientifically supported by very successful clinical studies (cf. references hereto).
The following survey shows a summary of medical indications, pharmaceutical active agents and the adjuvant cosmetic skin care based on cosmetic active agents - the list is not intended to be exhaustive, though. It should be mentioned that the target-oriented approach may frequently switch the focus from the pharmaceutical treatment towards an adequate skin care. Indication | Pharmaceutical active agents (partly also oral applications) | Cosmetic active agents | acne (oily skin)
oily skin with efflorescences and comedones | benzoyl peroxide, retinoids, erythromycin and other antibiotics, azelaic acid, linoleic acid, salicylic acid, hormones, fruit acids, zinc oxide | phosphatidylcholine (liposomes)1), linoleic acid, salicylic acid, azelaic acid, betulinic acid, vitamin A, yeast, ribwort, berberine | acne (dry skin)
low fat skin with efflorescences and comedones; from the 3rd decade of life | benzoyl peroxide, retinoids, erythromycin and other antibiotics, azelaic acid, linoleic acid, salicylic acid, hormones, fruit acids, zinc oxide. | vegetable triglycerides3), phosphatidylcholine (nanodispersions)1), linoleic acid, salicylic acid, azelaic acid, betulinic acid, amino acids (NMF), vitamin A, yeast, ribwort, berberine, phytohormones (red clover, soybean) | actinic keratosis
premalignant chronic solar damage | diclofenac, 5-fluorouacil, 5-aminolevulinic acid, photodynamic therapy (PDT) | boswellia | allergic contact eczema (contact dermatitis)
erythema, blisters, nodules, weeping blemishes after contact with allergens as e.g. nickel | corticoids, antihistamines, local anaesthetics | vegetable triglycerides3) and phytosterols to stabilize the skin barrier, avoiding dry skin | couperosis
weak connective tissue with vascular dilation | retinoids, antibiotics (minocycline, doxycycline, metronidazole), azelaic acid | vegetable triglycerides3), linseed oil, evening primrose oil, azelaic acid, betulinic acid, phosphatidylcholine (liposomes, nanodispersions)1), echinacea, butcher's broom | decubitus (bedsores) | D-panthenol, antibiotics, anti-inflammatory and re-fattening cream bases (prevention) | non-aqueous base of vegetable triglycerides3), phosphatidylcholine, hydrogenated phosphatidylcholine1), and phytosterols (prevention) | dry skin
skin barrier disorder: increased TEWL, low skin hydration | urea, linoleic acid, re-fattening cream bases | vegetable triglycerides3), linoleic acid, ceramides, CM-glucan, amino acids (NMF), phosphatidylcholine (nanodispersions)1), hydrogenated phosphatidylcholine (DMS base)2), aloe vera, hyaluronic acid, CM-glucan | gamma-radiation
erythema and dry skin due to radiotherapy | anti-inflammatory and re-fattening cream bases | phosphatidylcholine (nanodispersions)1), evening primrose oil, linseed oil, amino acids (NMF), CM-glucan, urea, aloe vera, boswellia, echinacea | hyper pigmentations
increased melanin formation | chemical peelings, hydrochinone | ascorbyl phosphate (vitamin C-phosphate); vitamin A, azelaic acid, phosphatidylcholine (liposomes, nanodispersions)1), extracts: mallow, peppermint, cowslip, lady's mantle, veronica, lemon balm, ribwort | ichthyosis (fish scale disease)
disorder of corneocyte desquamation | retinoids, urea (keratolytic) | vegetable triglycerides3), phytosterols, vitamin A, phosphatidylcholine (nanodispersions)1), hydrogenated phosphatidylcholine (DMS-base)2) | inflammation (dermatitis)
(cf. eczema, dermatoses, neurodermatitis etc.) | antibiotics, antimycotics, antihistamines, immunosuppressive agents, corticoids, chamomile, calendula, D-panthenol | evening primrose oil, linseed oil, boswellia, D-panthenol, phosphatidylcholine (nanodispersions)1), echinacea | laser treatments
pre- and follow-up care to impede melanin formation | --- | ascorbyl phosphate (vitamin C-phosphate), phosphatidylcholine (liposomes)1), extracts: mallow, peppermint, cowslip, lady's mantle, veronica, lemon balm, ribwort | neurodermatitis
inflammatory barrier disorder with pruritus, with varying degree of severity | antiseptics, corticoids, immunosuppressive agents, antihistamines, urea (skin hydration, pruritus), polidocanol (pruritus), evening primrose oil, D-panthenol | vegetable triglycerides3), linseed oil, evening primrose oil, linoleic acid, phytosterols, ceramides, urea, allantoin and other amides, phosphatidylcholine (nanodispersions)1), boswellia, hydrogenated phosphatidylcholine (DMS base)2) | perioral dermatitis
small red or inflamed nodules/blisters around the mouth | erythromycin, minocycline, metronidazole, azelaic acid, tannins | boswellia, phosphatidylcholine (nanodispersions)1), azelaic acid, green tea, hamamelis, echinacea, butcher's broom | perianal barrier disorder
sore areas on the buttocks, frequently caused by excessive body hygiene | antiseptics, hamamelis, D-panthenol, anti-inflammatory and re-fattening cream bases | non-aqueous base of vegetable triglycerides3), phosphatidylcholine1), hydrogenated phosphatidylcholine2), phytosterols | psoriasis
exfoliative dermatitis with inflammatory skin condition due to increased and accelerated cornification (hyperkeratosis) | dithranol (cignolin), salicylic acid, urea, tar preparations, corticoids, calcipotriol, retinoids, cyclosporin A, psoralen, fumaric acid, fumaric acid ester | evening primrose oil, linseed oil, phosphatidylcholine (liposomes, nanodispersions)1), fumaric acid, urea | rosacea
erythema and connective tissue disorder | retinoids, antibiotics (minocycline, doxycycline, metronidazole), azelaic acid | vegetable triglycerides3), linseed oil, azelaic acid, betulinic acid, phosphatidylcholine (nanodispersions)1), vitamin A | scars
indurations of the connective tissue with varying degree of severity | retinoids, heparin, chemical peeling | vitamins A, C, E, coenzyme Q10, D-panthenol, phosphatidylcholine (nanodispersions)1), hydrogenated phosphatidylcholine (DMS-base)2) | striae
scarred tissue caused by hyperextension | vitamin A acid, trichloroacetic acid (chemical peeling) | prevention: rose hip seed oil, linseed oil, vitamin E, coenzyme Q10, phosphatidylcholine (nanodispersions)1) | sun burns and burns
(erythema) | antiseptics, NSAID, D-panthenol | linseed oil, linoleic acid, D-panthenol, phosphatidylcholine (nanodispersions)1), echinacea, boswellia | toxic degenerative eczema
chronic cumulative toxic contact eczema | corticoids, allantoin, hamamelis, antiseptics, D-panthenol, anti-inflammatory and re-fattening cream bases | vegetable triglycerides3), evening primrose oil, linseed oil, phytosterols, hydrogenated phosphatidylcholine (DMS cream base)2), ceramides, urea, allantoin, D-panthenol, hamamelis |
Annotations to table: Phosphatidylcholine itself is a very effective active agent due to its linoleic acid content. On the other hand, it serves as an intensifying agent for the penetration of polar aqueous agents (in liposomes) and lipophilic agents (in biologically degradable nanodispersions). In particular fat oils as e.g. linseed oil, evening primrose oil as well as fat-soluble vitamins become better available for the metabolism and more acceptable for the customers in terms of sensorial properties. Besides triglycerides, phytosterols, squalan and ceramides, hydrogenated phosphatidylcholine is a texturing component of emulsifier and preservative free DMS base creams with skin-related membrane structure. Vegetable triglycerides can be neutral oils (medium-chain triglycerides), avocado oil, wheat germ oil, almond oil, or the like. Specific triglycerides like evening primrose oil (main active agent: gamma-linolenic acid), linseed oil (main active agent: alpha linolenic acid), rose hip seed oil (linoleic acid & alpha-linolenic acid) are listed separately. The active agents listed in the table above are used separately or in adequate combinations depending on the specific skin condition.
If the medical treatment with pharmaceutical active agents is combined with an adapted skin care, we refer to adjuvant corneotherapy. Quite often even identical active agents are used, however, with differing functional properties. But what is to be said against the use of azelaic acid (up to 1 per cent) as a consistency substance in a cosmetic skin care product for the rosacea skin? It can be assumed that specifically in liposomal preparations this component will synergistically contribute to the recovery process. An overview on pharmaceutical active agents in cosmetic preparations has been recently published in Kosmetische Praxis 2010 (3), 10-13. There is an optimal interaction, if both pharmaceutical and cosmetic area apply the same base creams. Another alternative may be the use of sera respectively tinctures instead of cream bases, particularly in case of weeping or heavily fattening skin areas. References and studies
Wolf G, Höger PH, Dermatologische Basistherapie mit hyperallergenen und noxenfreien Externa im Kindesalter, Journal der Deutschen Dermatologischen Gesellschaft 2008; 7 (1): 50-61 Lübbe J, Evidence-Based Corneotherapy, Dermatology 2000; 200: 285-286 Tabata N, O'Goshi K, Zhen YX, Kligman AM, Tagami H, Biophysical assessment of persistent effects of moisturizers after their daily Applications: Evaluation of Corneotherapy, Dermatology 2000;200:308-313 Suvorova K, Korneotherapie der Hautkrankheiten, die von der Störung der Epidermis begleitet werden (in Russisch), Les Nouvelles Esthétiques (Russische Version) 2004;4:28 Lautenschläger H, Geschichte und aktuelle Gesichtspunkte der Korneotherapie, Kosmetische Medizin 2005; 26 (2): 58-60 Schöffling U, "High Tech" und "Bio" im Cremetopf, Neuer Ansatz bei Dermokosmetika verbessert das Hautbild bei trockener, geschädigter und empfindlicher Haut, PTA heute 2002; 2: 8-18 Reinhardt HW, Gedanken zur sinnvollen Magistral-Rezeptur, Kosmetische Medizin 2006; 27 (1): 30-31 Valenta C, Stabilität: Cyproteronacetat in magistralen Zubereitungen, Österreichische Apotheker-Zeitung. 56 (2002) 676-678 Valenta C, Salbengrundlagen; ÖAZ 16 (2005), 770-773 Eberlein-König B, Eicke C, Reinhardt H-W, Ring J, Adjuvant Treatment of Atopic Eczema: Assessment of an Emollient Containing N-palmitoylethanolamide (ATOPA Study). JEADV 2008, 22: 73-82 Lautenschläger H, Liposomes, Handbook of Cosmetic Science and Technology (Barel AO, Paye M and Maibach HI), 155-163, CRC Press Taylor & Francis Group, Boca Raton 2006 Lautenschläger H, Dermopharmazie - Dekorative Kosmetik für die Problemhaut, Pharmazeutische Zeitung 153 (8), 28-30 (2008) Lautenschläger H, Universelle Basiscremes mit Membran-Struktur für Hautpflege, Hautschutz und Dermatika, Österreichische Apothekerzeitung 56 (14), 679 (2002)
Dr. Hans Lautenschläger |
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