DRY SKIN IN DIABETIC PATIENTS E. UHODA (1), B. DEBATISSE (2), P. PAQUET (3), C. PIÉRARD-FRANCHIMONT (4), G.E. PIÉRARD (5) SUMMARY : Rough skin or xerosis, commonly referred to as LA PEAU DITE SÈCHE DU PATIENT DIABÉTIQUE dry skin, results from a defect in the stratum corneum desqua- RÉSUMÉ :La peau rêche ou xérose, communément appelée mation which normally remains imperceptible. This condition sèche, résulte d’un déficit de la desquamation normalement is negatively influenced by winter climatic conditions. Atopic imperceptible de la couche cornée. Cette situation est influencée dermatitis and trophic changes related to post-menopause, négativement par des conditions climatiques hivernales. La der- ageing, diabetes mellitus and other endocrine and metabolic matite atopique et les troubles trophiques liés à la post-méno- disorders are also involved in this process. Xerosis can be pause, au vieillissement, au diabète sucré et à diverses autres improved to varying degrees by emollients, humectants, hydra- anomalies endocriniennes et métaboliques sont aussi impliqués. ting agents and squamolytic agents. La xérose peut être améliorée à des degrés divers par des émol- KEYWORDS : Diabetes mellitus – Stratum corneum – Trophic alte- lients, des humectants, des hydratants et des agents squamoly- ration – Season – Xerosis tiques. MOTS -CLÉS : Diabète – Couche cornée – Trouble trophique – Sai- W H AT I F L I F E W E R E TO D E P E N D O N son – Xérose D E AT H ? The harmony of the structure and the function This apparently ridiculous question is worth of the stratum corneum are altered by extreme asking because the answer is yes. The subject of climatic conditions and by all of the physiopa- this discussion is found in the skin, more speci- thological processes that affect the life of the fically in the most superficial part, the stratum epidermis. The latter include malnutrition, corneum epidermidis. As everyone knows, this various vitamin deficiencies, parainfectious or stratum is formed of a few layers of dead cells paraneoplastic conditions, ageing, kidney failure called the corneocytes. This may seem derisory and various hormonal changes, including the compared with all of the noble organs of the post-menopause period, dysthyroid conditions body. However, removing the stratum corneum, and diabetes mellitus. Clinical manifestations of which is only a few dozen microns thick, would these changes include the appearance of xerosis, lead to the rapid and inescapable death of the commonly referred to as “dry skin” (Fig. 2). individual. No other organ has a survival func- tion as important as that of such a delicate group of dead cells. THE H I D D E N FAC E O F D RY S K I N What is so important about the stratum cor- The only real dry skin is that of mummies. To neum? It is effectively a structure that confines be more precise, in the field of medicine and living matter in an envelope and protects it from dermocosmetology, which helps enormously to the environment. This barrier function prevents analyse problems, you have to substitute the the escape of bodily fluids, electrolytes and all term rough skin for dry skin (5, 6). From a scien- other biomolecules (1). In the opposite direction, tific standpoint, the term xerosis is preferable it prevents or limits the intrusion of xenobiotics into the body. This vital barrier function depends on the histological structure and physical inte- grity of the stratum corneum (2). This structure is regulated by the biological activity and matu- ration process of keratinocytes present in the living layers (Fig. 1). It is also influenced by environmental conditions (temperature, humi- dity, dew point, etc.), which interfere with the hydration and physical properties of the corneo- cytes and affect the flexibility and structural homeostasis of the stratum corneum (3, 4). (1) Assistant, (2) DES Cosmetology Student, (3) Qua- lified researcher, (4) Assistant Course Leader, Head of Laboratory, (5) Course Leader, Head of Department, Fig. 1: Structure of the epidermis formed of slimy Malpighian S a r t Ti l m a n U n i v e r s i t y H o s p i t a l , D e r m a t o p a t h o l o g y bodies (living matter) topped by the stratum corneum epidermidis Department, Dermocosmetology Unit. (dead matter) Rev Med Liege 2005; 60 : 1 : 1 AUTEUR OBJECTIVE A S S E S S M E N T O F X E RO S E S The opinion of xerosis sufferers and clinical examination certainly play an important role in assessing the gravity of a xerosis and how to remedy it with medicinal or cosmetic treatment. However, objective measurements are necessary to achieve the level required for evidence-based medicine. In dermocosmetology, the arguments are borrowed from dermometrology based on advances in cutaneous bio-engineering (17, 18). The main methods used measure the hydration of the stratum corneum (17-21), the water cap- ture and retention capacity of the stratum cor- neum (22-24), imperceptible water loss (17, 18) and intercorneocyte cohesion (4, 19, 25-27). DIABETIC X E RO S I S I N P E R S P E C T I V E Fig. 2: Xerosis, commonly called dry skin Diabetes mellitus affects the skin (28). In par- because its definition covers disorders of the ticular, a xerotic state can appear where there are conformation of the stratum corneum caused by secondary trophic vasculopathic and neuropa- different mechanisms. This could be an anomaly thic disorders. In addition to the unpleasant in the cohesion between the corneocytes leading appearance of the skin, other consequences are to desquamation (7). The intercorneocyte lipids likely to occur. The adherence of micro-orga- can be abnormal in composition or relative pro- nisms (various bacteria, Candida spp) increases (29). The mass of biocenosis (group of different portions (8). Hydration of the corneocytes can populations of micro-organisms) increases due be impaired, as can their ability to retain water. to the presence of anfractuosities in the rough There can be a disturbance of the barrier func- stratum corneum. The reduced flexibility of the tion. All of these factors can occur either toge- stratum corneum leads to the formation of ther or separately. microfractures that provide points of entry for infectious agents. Xerosis can also aggravate the The most severe and disabling cases of xerosis pruritis that affects certain diabetic patients. are classed as illnesses and genetic syndromes in The use of excessively aggressive cleaning the context of ichthyoses and ichtyosiform condi- agents and repeated contact with other types of tions. They are treated with oral retinoids and with irritant products can aggravate the xerotic condi- RAMBAs (“Retinoic Acid Metabolism Blocking tion. The application of antiseptics for preven- Agent”) (9). Much more frequent are xeroses such tive or therapeutic purposes can also act on the as atopic dermatitis and physiological or basic texture of the stratum corneum. We have shown deficiency xeroses, possibly accompanied by an that iodised povidone (Iso-Betadine®, Uniwash, internal pathology (10). Emollients and various Viatris) is significantly less aggressive than appropriate cosmetic preparations can perform chlorhexidine (Hibiscrub®) and quaternary marvels in record time (11-13). Most people know ammonium (RBS HDS 10®) (30). the instantaneous effect of a so-called hydrating cream on a stratum corneum that has lost its flexi- T R E AT M E N T O F D I A B E T I C X E RO S I S bility, lustre and softness. If all medications acted The treatment of diabetic xerosis should as fast and as well on their targets as dermocos- improve the quality of life of patients and boost metics on xerotic conditions, many people suffe- preventive anti-infectious measures. Very few ring from illnesses would be more than happy! It dermocosmetic products are specifically aimed is true that emollients are not always sufficient. at controlling diabetic xerosis and very few stu- Sometimes they need to include hydrating, dies have been dedicated to them (31, 32). We humectant or squamolytic agents (14-16). The lat- have identified three formulations: Atrac-Tain® ter are incorrectly called keratolytics because they (Coloplast), Naqi Body Lotion® (Naqi) and Naqi detach corneocytes from the corneodesmosomes, Body Care® (Naqi). which are intercellular bridges, but they have no Atrac-Tain® is a hydrating cream containing effect in the intercellular keratins (15). 4% lactic acid and 10% urea. These ingredients 2 Rev Med Liege 2005; 60 : 1 : TITRE are reputed to act on any type of xerosis of what- using an instrument that measures the electrical ever origin. Twice daily treatment during four conductance of the skin (Corneometer®, C+K weeks was reported to be significantly (p < 0.01) electronic). The difference in capacitance was more effective that a neutral cream on xerosis of calculated and the median value for the group of the heel in diabetic patients (30). However, no subjects was recorded (Fig. 3). Non-significant objective quantitative method has been formula- erratic fluctuations were observed on the test ted to support these observations. Xerosis reci- site. However, a similar rise in capacitance indi- divism proved to be much slower (p<0.05) cating better hydration of the stratum corneum during the two weeks following the application was observed on the sites treated with Naqi of Atrac-Tain®. Body Lotion® or Naqi Body Care®. There was a significant effect (p < 0.05) by the end of the The Naqi Body Lotion® and Naqi body Care® first week. The clinical improvement observed preparations were designed more specifically to by the volunteers and researchers was evident at correct diabetic xerosis. Some of their consti- this time. tuents were chosen to try to correct some of the biological deficiencies of diabetic skin. In parti- cular, the CM-glucan in Naqi Body Care® is CONCLUSION likely to act as an immunostimulant and epider- Diabetic xerosis deserves to be treated. It is mal repair accelerator (33-35). It helps to main- unsightly, can cause unpleasant pruritis and pro- tain a protective film on the surface of the skin. vide a refuge for an undesirable population of The L-carnosine in the same preparation is a micro-organisms. Certain dermocosmetics pro- neuropeptide whose effects include the preven- vide a suitable means of controlling this cuta- tion of protein glycation and hence the forma- neous anomaly. tion of AGEs (Advanced Glycation End products) (36, 37). The corn oil peroxide pro- duces an anti-inflammatory effect (38) by inhi- REFERENCES biting the enzyme 5-lipoxygenase. Various other 1. Tsuruta D, Green K, Gessios S, et al.— The barrier func- ingredients in the two Naqi formulations are tion of skin: how to keep a tight lid on water loss. Trends intended to change the lamellar lipid structure of Cell Biol, 2002, 12, 355-357. the stratum corneum in order to improve its bar- 2. 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