Are you seeking to solve skin problems such as pigmentation, acne and other skin disorders and gain the trust of current and future clients? Then stepping up your knowledge is the most credible way to achieve this. There is nothing like a strong reputation for results as a foolproof way to achieve business growth and client loyalty. Here we ask Gay Wardle to share with us some fundamental education on skin biology and physiology that will uncover the most vital knowledge you will need to solve the more challenging skin conditions.
APJ 1: Please explain to us the difference between the role of collagen and elastin in the skin. What are the symptoms of their degeneration and how would you treat them differently?
Collagen fibres are very strong and resist pulling forces, which allows tissue flexibility. We have many different types of collagen fibres in our body that vary from tissue to tissue. The collagen fibres found in cartilage, for example, attract more water molecules than those in bone which gives cartilage a cushioning effect. Collagen is a protein which is the most abundant in our body, representing about 25% of the total amount found in our body. In fact, collagen is actually a complex family of 18 proteins 11 are present in the dermis.
Very fine collagen bundles with a coating of glycoprotein are found in reticular fibres. These reticular fibres support the walls of blood vessels and form a network around the cells in some tissues such as the areolar connective tissue, adipose tissue and smooth muscle tissue. The fibroblast cells produce reticular fibres, which are thinner than collagen fibres, these fibres help form the basement membrane.
Type I collagen makes up approximately 80% of the dermal matrix. Type I collagen is abundant during our youth and growing years, however, sadly there is considerable decrease in collagen I in photo-aged skin and ageing skin. The collagen thickens and becomes more fibrous as we age.
Type III collagen is approximately 15% present in the dermis. Type III collagen has a smaller diameter, which creates much smaller bundles than type I allowing for more skin flexibility. During embryonic stages type III is more predominate around the blood vessels and in the epidermis.
Type IV collagen is found in the fascia septa and type V collagen creates approximately 5% of the matrix.
On the other hand, elastin fibres are smaller in diameter than collagen fibres. They branch and join together to form a network within a tissue. Elastin is also a protein, which is surround by a glycoprotein called fibrillin that adds strength and stability. Because of their unique molecular structure, elastic fibres are very strong and can be stretched up to 150% of their relaxed length without breaking. Once stretched elastin has the ability to return to their original shape after the stretching is completed.
We find elastin in the skin, blood vessel walls and lung tissue – areas where expansion is important. Elastin develops during fetal stages of life and is maximised close to birth. Looking at the distribution of elastin we find that 3% constitutes the dry weight of skin, 7% is found in the lungs 30% make up major blood vessels and approximately 50% is found in ligaments. Elastin is produced from tropoelastin in the fibroblast cell as well as endothelial cells and vascular smooth muscle cells.
As with collagen there are different forms of elastin throughout the body. The covalent binding of collagen, elastin and hyaluronic acid creates a three-dimensional structure that becomes impaired with ageing. In order to have younger-looking skin as we age these elements become a high focus when treating skins.
With environmental exposure combined with intra body ageing collagen and elastin fibres are degraded somewhat with their own enzymes. The organelles lysosomes play an integral part in protecting protein from these enzymes.
Signs of deteriorating elastin and collagen will be lax, saggy skin, wrinkles and thinning skin that can appear visually thick. Along with this we see pigment changes, telangiectasia, changes to secretions in the skin and age-related lesions.
Vertical lines normally represent collagen deterioration and horizontal lines represent elastin deterioration with early signs being detected in the eye region.
Both elastin and collagen play an integral part in wound repair hence clinical treatments that are provided often create inflammation. The options are brilliant provided the skin is healthy enough to respond.
The many options for treating both collagen and elastin deterioration, which include actives being topically applied and both non-inflammatory and inflammatory treatments such as needling, laser, RF and many more. All of these treatments options require a complete and comprehensive understanding of the condition that is being treated – Comprehensive SKIN ASSESSMENTS are CRUCIAL.
APJ. 2: How can advanced training in skin biology help a therapist address the problem of pigmentation differently? How is the approach different?
Most often we put pigmentation into two categories environmental and hormonal. When it comes to environmental the blame is directed mainly at UV exposure and yes, that is a major cause, but understanding the sequence of events will give us a greater understanding to the condition. UV increases reactive oxygen species (ROS), which in turn has an effect on DNA, it also increases enzyme activity within the cell that darkens melanosomes. I think all too often in a consultation process comment is made that UV caused the pigment. When we understand the pathways, it gives therapists the ability to demonstrate how the UV causes damage that causes pigmentation. The explanations will build confidence with the client that will lead to stronger commitment towards treatment programs.
When we are talking about hormonal pigment, well, that is a different ball game. What hormonal pathways are creating the pigment? Is it stress related? Is it stimulated by medications? Has it been created because of disease such as diabetes, or has it happened because of other inflammatory conditions occurring in the body? Is it diet related? Is it an immune disorder? It could be a pulmonary disorder. The list is a very comprehensive one that often occurs because of multi facets of anyone of these conditions.
Not to mention self-infliction reasons, such as smoking and other substance abuse. Post-inflammatory pigmentation is also a very comprehensive skin disorder.
To correctly diagnose any skin disorder and pigmentation being right up there, you need to have advanced knowledge of the cells, the body systems and their functions. Without this knowledge you really are stabbing in the dark. Knowledge of skin cells has come so far in the last 10 or so years and we are learning all the time how these gorgeous little cells function. To look at a skin that has pigmentation and diagnose a treatment plan with identifying the origin would really be malpractice. Advanced skin biology will give the practitioner knowledge to diagnose the conditions and design an effective treatment with confidence.
APJ 3: What are Langerhans cells and where are they located? What is their significance to skin health and how can this knowledge benefit a therapist who is performing a treatment?
Langerhans cells are dendritic cells of the skin and mucosa, and contain organelles called Birbeck granules. They are present in all layers of the epidermis and are most prominent in the stratum spinosum. They also occur in the papillary dermis, particularly around blood vessels. Langerhan cells are immune cells that are derived from the bone marrow and migrate to the epidermis. As a dendritic cell they communicate with cells of the epidermis and dermis and specialise in antigen presentation and the immune system. This clever little cell acquires antigens in peripheral tissues, transport them to regional lymph nodes, present to T-cells and initiate adaptive immune response. Langerhan cells have strong immunogenic properties and are involved in antimicrobial immunity, skin immuno-surveillance, induction phase of the contact hypersensitivity and in the pathogenesis of chronic inflammatory diseases of the skin or mucosa.
These cells are greatly affected by heat related treatments and strong exposure to UV. They migrate to the dermis in these instances returning later when the heat has regressed. Failure of the mechanism of anger cells could result in chronic inflammatory skin conditions like lupus, psoriasis and other skin diseases.
In some cases, the body produces far too many Langerhan cells that can lead to a condition called Langerhans cell histiocytosis. LCH is classified as a histiocytosis, a term used to describe diseases that result from overproduction of white blood cells. One of the conditions we would see from this condition would be lymphoma. The condition often occurs with people who smoke.
Because the immune system is so relevant to treatments that are performed in clinics, it is so important that we understand the function of these cells and their reaction they will have to inflammation.
REMEMBER – Because Langerhan cells have the job of antigen presentation, the skin’s most important immune function. It is absolutely important we maintain the health of the lymphatic system by performing manual lymphatic drainage in our programs.
APJ 4: Why is gut health important to skin health and can you suggest how improving gut health can benefit a skin treatment outcome?
We are now learning a great deal more about the association the gut has to the brain and the skin. When the gut is dehydrated it causes all sorts of internal inflammatory conditions, which will in turn cause skin disorders. Inflammation of the gut can also be caused by stress.
As far back as 1916 a study demonstrated acne patients were more likely to show enhanced reactivity to bacterial strains isolated from stools. It showed 66% of the 57 subjects with acne in the study showed positive reactivity to stool-isolated bacteria compared to none of the control patients without active skin disease.
In a more recent study involving 80 subjects those with acne had higher levels of reactivity to lipopolysaccharide endotoxins in the blood. Interesting that both studies showed that an increase in intestinal permeability was an issue for a significant number of acne patients.
We know that the main function of the skin is to act as a physical, chemical and antimicrobial barrier defence system. There have been significant studies that show both stress and gut inflammation can impair the protective function of the epidermal barrier function, by having an effect to the cell membrane. The effects of this will disrupt and decrease the antimicrobial peptides that are produced in the skin, hence this can increase infection and inflammation in the skin.
Substance P is released when there is any change to the gut microbiota, which has an effect on both the gut and the skin. Gut microbiota has a huge influence on lipids and tissue fatty acid profiles therefore may influence sebum production as well as the fatty acid composition of the sebum.
A study completed in China involving subjects with seborrheic dermatitis also found that there were disruptions to the normal gut flora.
Impairment to the immune system will weaken the microbiome, which will increase the growth of opportunistic bacteria, yeast, fungus and maybe parasites. The immune system is an integral part to having a healthy skin.
There has also been links to the gut with diabetes. Diabetes increases ageing of the skin, increases glycation and has a huge impact on the health of the mitochondria. All of these conditions will have advanced intrinsic ageing where there is degradation in collagen and elastin. They will also have an impact on muscle tissue causing atrophy to muscle and subcutaneous tissue.
We could therefore safely say common diseases such as psoriasis, eczema and dermatitis will have a microbiome and inflammatory component to them. If we have inflammation to the gut, the lymphatic system, the nervous system and the endocrine system will all be affected in some way. All of these systems will then have an impact on how healthy the skin is or isn’t.
There is so much more we could add to this answer and so much more to learn about the gut and its relation to the skin. Having a healthy gut when treating any skin condition is a very important place to start. You need to ask about the digestive system in the evaluation process. Find out how often they go to the toilet, do they have constipation or diarrhea often. Do they pass unprocessed food?
I believe we should have our clients on a gut program such as a digestive enzyme when treating them. We need to reduce the inflammation otherwise the skin conditions will continue to reoccur. We need to be eating fermented foods regularly. Gut disorders increase disease and increases skin disorders.
Do you have a gut program in your practice? If not, it could be the missing link to helping you sustain skin improvement with your treatments.
If you wish to enroll in Gay Wardle’s Advanced Skin Analysis Training please contact her on firstname.lastname@example.org or phone 0418 708 455 www.gaywardle.com.au