New View: Rethinking the Skin as an Endocrine Organ

Published in Dermascope Magazine, April 2014

Did you ever get a scrape when you were young and hear someone say, “Oh it is just skin!” Just skin. You might know better, but many people continue to devalue the skin as simply an outer covering that keeps the good things in -- and the bad things out. Indeed, the skin makes for an outstanding barrier, but that understanding is only skin deep. As the body’s largest organ, the skin possesses incredible abilities. It fights infection, regulates temperature, shields our DNA from solar damage, distinguishes between the tickle of a feather and the abrasiveness of a scrub, and, we have recently discovered, manufactures an array of multi-functional molecules once thought to originate in other tissues. Perhaps this recent discovery will help shift our perspective of the skin from an undervalued protective covering to a dynamic organ that interfaces with the external world, the internal world, and acts with an independent intelligence that rivals the nervous system. But it takes time to adjust to a new way of thinking.

 Over the course of history, there have been a number of accepted truths that were later debunked. Even after science steps in to correct these errors, some people hold on to the old ideas, spurred on by bad information in the media or by a lack of exposure to the new findings.

Some misinformation that seems to circulate includes:

• Hair and fingernails keep growing after death.
• Different parts of your tongue detect different tastes. 
• You only have five senses. 
• You only use 10 percent of your brain. 
• Deoxygenated blood is blue. 
• Most body heat is lost through your head. 
• Cracking your knuckles gives you arthritis. 

The world of skin care is not exempt from misleading information. It has been said that tanning booths are safe if they do not use ultraviolet B rays. Or that the higher the SPF, the better the protection. And that washing oily skin squeaky clean will prevent breakouts; creams can erase wrinkles; and that you do not need to wear sunscreen on a cloudy day. Skin therapists worldwide crusade to educate their clients and friends about these misconceptions – yet they still exist. 

Over the past decade, science has discovered that the skin acts as a hormonal entity. This insight will undoubtedly impact future medical approaches in diagnosing and treating skin conditions. This new information also impacts the professional skin industry. New products emerging with ingredients that maintain hormonal balance on the skin and new technologies are being designed to dampen the symptoms of imbalance. 

How did this paradigm shift occur? It starts with our understanding of the endocrine system. Most of us have been taught that the endocrine system consists of special glands located throughout the body that secrete, or pump out, various chemicals known as hormones. We have known for decades how hormones impact the skin, the hair, the brain, or any target organ. For example, we know that sebaceous glands, the dermal manufacturers of sebum, are affected by the male hormones known as androgens, which travel from distant glands like the gonads or adrenals to stimulate oil production. When we think of hormones, we are typically reminded of the teenage years, a period often associated with “raging”hormones. While true, the story is actually much more complex. 

Today, we consider the endocrine system a community of organs whose cells emit, receive, and coordinate signals from other organs as well as from themselves.1 The skin also has the capacity to do this. The modern view of the skin is that it receives hormonal signals from other glands, and it produces hormones and enzymes – making it a true endocrine organ. Just as the ovaries can release hormones into the body through the bloodstream, the skin can also produce hormones that are released through blood circulation.1 In fact, the ovaries are not the only ones responsible for producing estrogen. Of course they are the main source of circulating estrogens, but this is only true in non-pregnant, pre-menopausal women.1, 4 We know female menopause reflects an end to the production of sex hormones by the ovaries, but that does not mean a woman’s body no longer produces these hormones. According to research, after a woman has reached menopause, the majority of the sex steroid hormones found in her circulation are actually produced by other organs like the skin.1 Given the impact estrogens have on skin aging, pigmentation, hair growth, sebum production and wound healing,2 it is crucial to understand how these hormones work on the skin in order to alleviate hormone-deprived skin issues.

How Do Hormones Function?
Estrogens and other hormones exert their effects on the body through several methods. Intracrine function is actually the way in which post-menopausal estrogen works – the cells of the tissues, like skin, produce their own necessary hormones for the cells to function. Clearly, sex hormones have bigger roles than simply bringing on puberty. Another important hormone that is produced in the skin is the potent androgen 5α-dihydrotestosterone (DHT). You may recognize this as the culprit responsible for oily skin breakouts. That is true, and the skin that is mostly responsible for producing this powerful hormone. Perhaps in the future, we will see a therapy that balances local skin hormones to clear up acne, without disrupting the delicate hormonal balance of the body.
Along with the sex hormones discussed, the skin as an endocrine organ produces a rich variety of other hormones for its own use, including thyroid hormones, stress hormones like cortisol, and curiously, brain-related chemical messengers (neurotransmitters) like melatonin and serotonin.3 Finally, the skin gallantly manufactures hormones for the rest of the body, the prime example being vitamin D.3 Vitamin D is not only an essential dietary vitamin, but is also a necessary hormone that impacts our overall health. The skin’s complexity should not be much of a surprise given that it is a powerful interface between the mind, the body and our external world. So let us start giving the skin more credit!

Balancing Act
Just as skin professionals teach their clients how to properly cleanse their skin and how to protect it from sun damage, so too can they educate their clients about the vast complexity of human skin. When you prepare a skin treatment or recommend products to your clients, keep in mind that their skin may be going through hormonal changes, which not be limited to life events such as puberty, pregnancy and menopause. While these are periods of particular hormonal upheaval, the skin can undergo hormonal changes on a daily basis and on a monthly basis with female clients. With age, these hormonal fluctuations become more evident. Hormonal fluctuations are reflected on the skin as papules, dehydration, stickier sebum, dryness, loss of elasticity, wrinkle development, increased inflammation, or a combination of these.
One of the greatest challenges for skin care professionals is dealing with the aftermath of hormonal fluctuation. These skin issues are difficult to prevent and will often recur on the same client, so it is important to manage expectations and control each situation as it arises. There are tools at your disposal to help correct some of the effects of hormonal imbalance on the skin.

Due to the persistent nature of these conditions, client compliance with the recommended products and skin care regimen is critical for improved outcome. We must all learn to live with our hormonal fluctuations, but understanding them will help you guide your clients through these changes and provide realistic solutions that minimize unexpected and unwanted skin changes.

References
1 CC Zouboulis, The skin as an endocrine organ. Dermato-Endocrinology (2009) 1:5; 250-252.
2 CC Zouboulis et al., Sexual Hormones in human skin. Horm Metab Res (2007) 39:85-89.
3 MA Zmijewski and AT Slominski, Neuroendocrinology of the skin: An overview and selective analysis. Dermato-Endocrinology (2011) 3:1, 3-10.
4 AT Slominski et al., Steroidogenesis in the skin: Implications for local immune functions. J Steroid Biochem. Mol. Bio. (2013)

Melasma Unmasked

Published in Dermascope Magazine, November 2013

Along with aging and acne concerns, uneven pigmentation is one of the most common complaints skin care professionals hear in the treatment room. Changes in skin pigmentation can occur due to many different factors and can be the most difficult issue to tackle in the treatment room. Perhaps one of the most challenging pigmentary conditions to treat is melasma, a common disorder of hyperpigmentation that affects more than five million Americans.1 Melasma predominantly affects women with Fitzpatrick phototypes III through VI, or those with ancestry stemming from equatorial regions where ultraviolet radiation (UVR) is highest. Although sun exposure and hormones are closely associated with triggering, much remains to be understood about the origin and development of the disorder.

Vital Pigment: Melanin

To understand disorders of pigmentation, it is important to understand the fundamentals of human skin color and its protective function. Despite the tremendous range in human skin color, all of the variations we see are due to the presence of a pigment known as melanin. Stemming from the Greek word melas, meaning black, melanin is composed of two forms: the brownish black eumelanin and the reddish yellow pheomelanin. Studies have shown that melaninproduction gives rise to skin color that ultimately protects the individual from both vitamin D deficiency and solar radiation. Thus, our ancestors' unique complexions evolved to be dark enough to protect DNA from ultraviolet (UV) damage and light enough to allow ultraviolet B (UVB) to penetrate for vitamin D synthesis, depending on the amount of UV rays available.2 That is why melanin is so vital to our health – too much and we riskvitamin D deficiency and disease; too little and we risk skin cancer and death.

Skin color is beyond skin deep. The same embryonic tissue that gives rise to the neurons of the brain also gives rise to the melaninfound in our skin, eyes and hair. Melanin production in the skin, known as melanogenesis, is under the influence of various internal and external factors. In addition to UV rays, hormones and inflammatory signals can stimulate the melanocyte to increase themelanin production and/or increase transfer of melanin to keratinocytes. In both cases, the result is a darkening of the skin. Since so many key factors affect skin pigmentation, the changes seen can be transient (during pregnancy), permanent (intrinsic aging), environmental (upon UV exposure), and external (certain drugs or medications).3 Even though melasma was thought to be a pregnancy-related and/or contraceptive-related disorder in the past, new research shows that for many people, including men, it is a chronic disorder that lasts for decades.

Melasma: A New Understanding

Historically, melasma was considered a disorder ofhyperpigmentation in women who were experiencing hormonal changes. Today, we know that it is more complicated than that. While we have yet to find the exact cause, current theories suggest that hormones, UV exposure and genetics are all major influencers of the disorder. Melasma is more common in darker skin types, particularly Fitzpatrick skin types III and IV, and is estimated to affect 8.8 percent of Hispanic females in the United States and about 40 percent of Southeast Asian women.1 The relatively new finding that this condition runs in families stems from studies on different ethnic populations. For example, 55 percent of pregnant Iranian women reported having a family member with melasma, while 70 percent of Puerto Rican women reported the same family link.4 Interestingly, melasma runs in families regardless of whether a man or woman inherits the disease. One study showed that 70 percent of Latino men with melasma also had a family member with melasma.1 Clearly, there is a genetic component that is not exclusive to women.

In many people who get melasma without the hormonal component, a combination of factors (including family history, age and UV exposure) can trigger the disease. Melasma usually occurs in sun-exposed areas where UV rays have either triggered or worsened pigmentation. Under the microscope, melasma skin can even resemble photodamaged skin with hallmarks such as solar elastosis.6 Inflammation is likely to play a large role in sun exposed skin considering that UV stimulated inflammatory signals, including cytokines and the peptide alpha-melanocyte-stimulating hormone (α-MSH), can also trigger melanogenesis. With UV exposure, there is a direct and indirect way of stimulating themelanocyte to produce more pigment.1,6 As new research emerges, we may find that infrared, or even visible light, may be a triggering factor for those susceptible to getting melasma. Since sun exposure is a critical factor in the development of melasma for both men and women, educating the client on appropriate sun protection as part of their regular skin care regimen is important advice to give them.

Hormonal Triggers

Pregnancy is a time when you can expect the unexpected. In addition to the variety of skin changes a woman can experience during pregnancy, some degree of hyperpigmentation affects nearly all women. However, in some women the level of hyperpigmentationis noticeably increased. Melasma generally occurs in 10 to 15 percent of pregnant women and in 10 to 25 percent of women taking oral contraceptives.6 For decades, melasma was known as the mask of pregnancy, with the assumption that it must be caused by an increase in female hormones due to pregnancy or birth control pills. The reality is that we still do not clearly understand the hormonal link to melasma. 
Melasma skin is more estrogen-responsive than non-melasmaskin.1,6 Nevertheless, other hormones involved in a woman's menstrual cycle and pregnancy, including progesterone and α-MSH, can also stimulate pigmentation. Just as melasma skin is more estrogen-responsive, it has also been shown to be more progesterone-responsive than normal skin.9 The notion that oral contraceptives can lead to skin changes is not a new one. In 1967, dermatologist Sorrel Resnik, M.D. showed that melasma developed in women as a direct result of taking oral contraceptives.8 Today, several forms of hormonal contraceptives are available including combination oral contraceptives, progestin-only oral contraceptives, combination patch contraceptives, combination vaginal ring, and the progestin contraceptive implant. The combination methods have forms of estradiol and progesterone to stop a woman from ovulating. The progestin-only methods typically affect the cervical and uterine environment so that pregnancy is avoided. In all cases, sex hormonesare introduced, which play many different roles in our body and ultimately lead to skin changes in some women. If you browse skin care forums online, you will see many women who recommend trying a progestin-only form of contraception for alleviating melasma; however, there is no proof that this helps to treat the condition. In fact, Resnik reduced the estrogen component of the oral contraceptive to see whether it could alleviate melasma signs, but it had no effect.8 Even so, the only way to alleviate contraceptive-induced melasma is to stop taking the medication. While pregnancy-induced melasma will usually fade within a year after delivery, contraceptive-induced melasma will persist as long as the medication is used. In some cases, this can take years to fully resolve. In addition to the sex hormones, thyroid hormones may also play a role in melasma development. People with melasma are four times as likely to have a thyroid abnormality than those with normal skin pigmentation.1 While a number of hormones are involved in triggeringmelasma, their elevated levels are not always found in melasma skin, meaning they are not the ultimate factor in developing the disease.

A Vascular Disorder

Regardless of gender, melasma can appear on sun-exposed areas of the face as a flat, distinct area of discoloration. These dark patches typically appear on the forehead, cheeks and chin in a symmetrical fashion.1 Interestingly, vascular diseases like rosacea can also appear on these facial regions. Looking at the role that blood vessels play in the development of melasma in both men and women, scientists have found that melasma skin has a bigger quantity of large blood vessels than non-melasma skin.1,10 Not surprisingly, the vascular disease rosacea is also a common affliction among women. Eventually, new research will emerge that will look at the specific role that hormones play in vascular and pigmentary changes in order to grasp a better understanding of this frustrating condition.

The Three Ps

When it comes to treating a client with melasma, it is important to adhere to the three Ps for maximum results – patience, persistence and precaution. You and your client will need patience in getting results and you will need to manage your client's expectations. Since melasma is persistent, it will take regular visits to a skin care center along with daily care to manage and resolve this condition. Remember that hormones continuously trigger the condition so treatment of hormone-induced melasma should only begin after the client has finished breastfeeding or changed their contraceptive medication. Finally, precaution is crucial because you could inadvertently worsen the melasma pigmentation by triggering inflammation in the skin. Chemical peels can improve the appearance of epidermal melasma skin, but utmost care is needed when choosing the correct peel formulation and treatment protocol to avoid hyperpigmentation. Clients who tend to get melasma are also more sensitive to UV and harsh chemicals which can trigger hyperpigmentation; recommending the correct daily care products is very important for treatment outcome. Even though clients come in regularly for treatment, their skin may be different each time they visit. Pay special attention to your client's stress level as the stress hormone cortisol can sensitize skin and trigger inflammation. Since melasma pigmentation can worsen if the client is stressed, you may want to tackle the inflammation before the pigmentation.

Melasma, being a highly visible disorder, causes significant distress. With an arsenal of topical skin-lightening ingredients, laser technologies and education, skin care professionals can have a powerful effect not only on the skin's appearance, but also on the client's life and overall happiness.

References:

1. Sheth, V. M., & Pandya, A. G. (2011). Melasma: a comprehensive update: Part I. Journal of the American Academy of Dermatology, 65(4), 689-697.
2. Jablonski, N. G., & Chaplin, G. (2012). Human skin pigmentation, migration and disease susceptibility. Philosophical Transactions of the Royal Society B: Biological Sciences, 367(1590), 785-792.
3. Costin, G. E., & Hearing, V. J. (2007). Human skin pigmentation: melanocytes modulate skin color in response to stress. The FASEB Journal, 21(4), 976-994.
4. Paek, S. Y., & Pandya, A. G. (2013). Disorders of Hyperpigmentation. In Skin of Color (pp. 139-160). Springer New York.
5. Ortonne, J. P., et al. (2009). A global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma. Journal of the European Academy of Dermatology and Venereology, 23(11), 1254-1262.
6. Kang, H. Y., & Ortonne, J. P. (2010). What should be considered in treatment of melasma. Annals of Dermatology, 22(4), 373-378.
7. Victor, F. C., Gelber, J., & Rao, B. (2004). Melasma: a review. Journal of Cutaneous Medicine and Surgery: Incorporating Medical and Surgical Dermatology, 8(2), 97-102.
8. Resnik, S. (1967). Melasma induced by oral contraceptive drugs. JAMA: the journal of the American Medical Association, 199(9), 601-605.
9. Jang, Y. H., et al. (2010). Oestrogen and progesterone receptor expression in melasma: an immunohistochemical analysis. Journal of the European Academy of Dermatology and Venereology, 24(11), 1312-1316.
10. Jang, Y. H., et al. (2012). The histopathological characteristics of male melasma: Comparison with femalemelasma and lentigo. Journal of the American Academy of Dermatology, 66(4), 642-649.

Hormones and Your Skin

Published in Dermascope Magazine, October 2011

About one hundred years ago humans doubled their life expectancy. This was a monumental feat, given that the number of years the average person was expected to live was a relatively constant number throughout most of human history. Nutrition, modern medicine and technology were mostly responsible for this dramatic change. In 2007, average life expectancy was 80.4 years for women, and 75.3 years for men.1 This gap may be narrowing, but one thing is clear – there is virtually a new population in the human experience, and women are the chief contributors. The aging female client is the backbone of our industry. Anti-aging skin care, led by cosmeceutical sales, is the leader in the multibillion dollar skin care industry, and it is not going away anytime soon.

Female life expectancy has increased dramatically over the years, while the age of menopause onset has remained stable at around 50 years of age. This means more and more women live in a hormone-deprived state, a relatively new phenomenon in human existence.4 There is no decisive reason as to why women in particular live long past their reproductive years, but there is an interesting hypothesis that may shed some light. In fact, it is called the “grandmother hypothesis” and it argues that having an older female to help nurture children ensures that the younger generation reaches its maximal evolutionary potential. That is, having Granny around the house to help with the kids ensures they are well-behaved, fed and safe so they too can have long, healthy lives. Although extended longevity seems like a great advantage of the 21st century, it opens up a lot of doors for age-related changes and disease. Many of these changes also take place on the skin, so having a full understanding of how hormones – and the lack of them – affect skin will benefit the professional skin therapist in everything from consultation and skin analysis to providing effective and realistic solutions to the aging, hormone deprived client.

The Role of Hormones

One of the most important factors involved in the initiation of aging is the endocrine system. Particularly important for women, the endocrine system produces and regulates hormones, which decline, sometimes drastically, with age. Hormones are chemical messengers that are produced in organs such as the ovaries, adrenal glands and thyroid glands. Sex steroid hormones, thyroid and growth hormones are involved in many different functions such as growth, immune, reproductive and metabolic functions, and even hunger and stress. Unlike extrinsic aging, which requires external factors like ultraviolet (UV) radiation, lifestyle and pollution to cause deep wrinkling and photodamage, intrinsic skin aging is governed by our own body’s biological clock. Dryness, fine wrinkling and paleness is all part of the natural process of skin aging. Many factors are involved in intrinsic skin aging: genetic mutations, increased inflammatory signals, decreased lipid production and decreased hormone levels. These hormone changes are now being more closely examined to reveal just how important they are to skin health, especially in women. How do these hormones act on the skin? And specifically how do they impact skin aging?

Estrogen

When it comes to popular hormones, estrogen takes the prize for most widely known and discussed. However, there are many misconceptions about this elusive and incredibly important substance. First of all, it is not purely a female hormone. True, it is primarily made in the ovaries and is abundant in females, but it is also found in males and made in different tissues outside of the ovaries. Secondly, the word estrogen actually encompasses a group of chemically similar hormones, so it is not a single substance. Estrogens include estradiol, the most abundant form in adult females, estriol, the primary estrogen during pregnancy and estrone, which is produced during menopause. Interestingly, in females, estrogens are made by converting the male hormones, known collectively as androgens, into estrogens. And these androgens are initially derived from cholesterol, the primary steroid that gives rise to many steroid hormone families. The conversions from cholesterol to androgens, or from androgens to estrogens, is all made via the actions of certain key enzymes. Without these enzymes, conversion would not be possible. The skin, among its myriad of functions, also has the necessary components to produce both cholesterol – and derive sex steroids from it – within the skin.

In the skin, estrogens affect skin thickness, wrinkle formation and skin moisture. Estrogens can increase glycosaminoglycans (GAGs), such as Hyaluronic Acid, to maintain fluid balance and structural integrity. They can also increase collagen production in the skin, where they maintain epidermal thickness and allow skin to remain plump, hydrated and wrinkle-free.2 During periods of elevated hormonal activity, such as pregnancy or with some oral contraceptives, skin pigmentation is exacerbated in certain sun-exposed areas such as the forehead, nose and cheeks. This phenomenon, known as melasma, is strictly hormone-related and is a clear example of hormonal effects on the skin pigmentation. The skin is not the only external feature that benefits from estrogens. Besides resulting in plump, healthy skin, estrogens can also make hair grow long and healthy. During pregnancy, women often experience hair growth, where the anagen phase is prolonged. The plummeting post-partum and even menopausal estrogenic levels cause thinning and falling hair, sometimes resulting in clinically significant hair loss, the so-called telogen effluvium.

In essence, estrogens help our skin and hair remain youthful. Of course, with puberty, menstruation and menopause, progesterone is also a key player. However, the research is still scant in this area. Future research will hopefully shed some light on the interactions between estrogens and progesterone, to better understand these described changes in skin and hair.

Testosterone

Testosterone is the chief male sex hormone and is the primary reason for everything that makes a man, well… male. Coarser hair, thicker and oilier skin, and generally a later onset for showing signs of skin aging are all due to testosterone. Female pattern alopecia, or baldness, is attributed to increased androgen levels and is the most common cause of hair loss in women. With age, the estrogen-androgen ratio becomes unbalanced, and changes are seen following menopause. Since androgens, and in particular testosterone, are involved in skin sebum production, females may experience increased oiliness or even adult acne when hormones become unbalanced during menstruation or menopause. The effects of androgens on skin are important in both male and female clients, as both can experience effects of altered androgen levels.

Thyroid Hormones

The thyroid is a small butterfly-shaped gland situated just in front of the voice box. The thyroid gland makes two thyroid hormones which affect metabolism, brain development, breathing, body temperature, muscle strength, bone health, skin dryness, menstrual cycles, weight and cholesterol levels. Again, balance is key when it comes to these hormones. Too much, and skin can become warm, sweaty and flushed. Too little, and skin becomes dry, coarse, thick and even sweating is decreased. Thyroid dysfunction can also lead to thinning hair and eventual hair loss.

The Female Menopause

In our culture, menopause is frequently seen in a negative light, as something that requires medical attention and signifying a time of loss. Women are bombarded with messages about the impending doom of menopause even before they begin to have children. It is no wonder, then, that women tend to develop a negative body image during this transitional period. However, this transitional period is a completely natural process that must be understood in order to be appreciated. Only then can women take charge of their bodies and transition to menopause in a healthy and positive manner. So what occurs on the skin during perimenopause – the transitional period before menopause – and after menopause?

During the transition into menopause, often characterized by hot flashes, female skin may appear flushed, red and blotchy. Estrogens have anti-inflammatory properties, so the loss of these hormones can also lead to increased inflammation, which can exacerbate certain conditions like rosacea. As discussed, estrogens play a major role in the collagen and elastin network of the skin. Losing estrogens means losing dermal collagen production. So skin thins out, loses elasticity and sets the stage for wrinkle formation. Estrogens also regulate GAGs in the skin, and losing these hormones results in dehydrated, itchy skin. Estrogenic loss also reduces the number of blood vessels in the skin, resulting in pale skin with a lack of nutrients traveling to the skin’s surface.2 In all, we get pale, thin and dry skin. Since the drop in estrogen is sudden and more drastic than other hormones such as testosterone, it can also lead to an increase in androgenic characteristics such as increased facial hair. This is a sensitive time in a woman’s life, and it is imperative to treat the aging female client undergoing this hormonal transition with respect and understanding. Given the severity of the biological changes, is there anything we can do to rejuvenate the skin in an older woman?

Is Hormone Replacement Therapy the Answer?

At the forefront of the menopausal skin treatments are topical steroid hormones. A relatively new field in skin care, it is not yet a plausible solution due to lack of research and existing side effects. Nevertheless, research has shown improvements in skin elasticity, moisture and skin thickness in women using either topical or oral hormone replacement therapy (HRT). However, HRT does not always prove to be fully beneficial. For example, a recent study showed that sun-damaged skin does not improve with estrogen treatment.3 Moreover, side effects have even shown increased pigmentation on cheeks after hormonal therapy.2 The research on male skin and hormone therapy is even more scant. So you can see that much more work is needed in this general area.

What Can We Do For the Menopausal Skincare Client?

Despite the growing research on medicated hormonal treatments on the skin, there are many options available already to turn dry, itchy and thinning skin into smoother, fresher skin. Since collagen production is drastically affected during hormonal loss, it is imperative to use ingredients that boost collagen production in the skin. Retinoids, including Retinol, are part of the Vitamin A family with a great track record in increasing collagen and controlling pigmentation. Vitamin C, which has also been shown to boost collagen production, also brightens skin and evens out skin tone. Peptides that increase production of elastin, collagen and GAGs like Palmitoyl Tripeptide-38 and Palmitoyl Pentapeptide will benefit dry, loose skin by plumping and firming skin effectively. To battle the fires brought on by hot flashes and increased inflammation, look for anti-inflammatory ingredients like Avena Sativa Extracts, Chamomile and Bisabolol, even peptides that control neurogenic inflammation, as this can exacerbate symptoms. A dehydrated epidermal barrier benefits greatly from essential fatty acids, phytosterols and ceramides. Of course during hot flashes, we may want to constrict the capillaries with topical caffeine and avoid lifestyle trigger factors such as heat, sun and alcohol. Antioxidants can be an amazing powerhouse of rejuvenation – ingredients such as Superoxide Dismutase, Gingko Biloba, and White and Green Tea extracts to further protect the skin from oxidative damage.

Professional treatments for the aging client should take into consideration the loss of these vital hormones, so design a menu to specifically address these concerns. Focus on increasing hydration, stimulating collagen production and re-energizing the skin. Aside from the above ingredients, the use of invigorating essential oils can also provide hydration, nourish and heal skin. Using oils like Rosewood and Jasmine to provide intense hydration and Carrot Seed, Argan and Rosehip Oils to boost antioxidants, improve elasticity and reinforce the epidermal lipid barrier are all great treatment options with the added bonus of providing aromatherapy during this particularly stressful time. Exfoliation is a key step in rejuvenating aging skin with slowed cell renewal. Heavier moisturizers are appropriate for an aging skin client, so be prepared to use rich emollients that hydrate and protect chronically dry skin. Despite the fact that women experience the most drastic skin changes, men also lose testosterone leading to the same dry skin condition, so the same protocol can be used for an aging male client. Educating your clients for proper at-home care is imperative in maintain youthful skin during the latter decades. The earlier they use proper skin care the better, but some helpful tips are always appreciated. A diet rich in healthy fats, like Omega-3s found in salmon and nuts, will help nourish skin from the inside. Extrinsic aging is practically inescapable, so daily use of sun protection is a must in everyone’s skin care regimen. This is particularly important in aged skin, as it is thinner and allows even more penetration by damaging UV rays.

Stop Being So “Hormonal”

Perhaps it is time, what with all the research devoted to hormonal effects on the body and mind, to remove the negative connotations when it comes to hormones. They truly are powerful substances involved in just about every asset of human biology and behavior. The aging population is increasing and women are at the forefront of this growth. It is no surprise the vast majority of anti-aging products and treatments are targeted at women. In fact, almost eight million nonsurgical cosmetic procedures were performed in 2010 at a cost of $4.1 billion dollars, according to the American Society of Cosmetic Dermatology and Aesthetic Surgery. Although this is can be a distressing and uncomfortable stage of life, it is important for our industry to provide comfort as well as solutions to the people affected by hormonal loss. Understanding the power of these hormones on the skin will allow you, the skin therapist, to better treat your clients and form long-lasting relationships at any age.

References:

1. National Center for Health Statistics, National Vital Statistics Reports, vol. 54, no. 19, June 28, 2006.
2. Verdier-Sévrain, S., et al. (2006), Biology of estrogens in skin: implications for skin aging. Experimental Dermatology, 15: 83–94.
3. Rittie, L., et al. (2008), Induction of Collagen by Estradiol: Difference Between Sun-Protected and Photodamaged Human Skin In Vivo. Arch Dermatol, 144(9): 1129-1140.
4. Aguirre, C., et al. (2010), Progesterone inhibits estrogen-mediated neuroprotection against excitotoxicity by down-regulating estrogen receptor-β. Journal of Neurochemistry, 115: 1277–1287

Understanding Male Skin

Published in Dermascope Magazine, January 2011

All men are created equal. While this may ring true in the political realm of society, it is far from true when it comes to the physiology and care of men’s skin. Men, just like women, deal with issues like aging, pigmentation, sensitivity, and acne. However, just as there are keen differences between the skin conditions of men and women, every man’s skin is as unique as his fingerprint. His skin health is shaped not only by his genes, but also by his lifestyle choices. A 20-year-old surfer’s skin is different than a 50-year-old businessman’s skin- and will require different targeted products.

Treating a man’s skin effectively begins with an understanding of physiology, but, like all professional skin care, depends ultimately upon listening to the client’s needs in a very specific and personal way.

The biggest difference between male and female skin is due to the male sex hormones known collectively as androgens. The chief sex hormone of this group is testosterone, which is primarily secreted by the testes and ovaries (yes, women produce it, too!).

Although there is variability, adult males produce about 10 times as much testosterone as women. Testosterone exerts its effects by acting on androgen receptors found throughout the body. It does this directly, or by being converted into dihydrotestosterone (DHT), a much more potent activator of the androgen receptors. At birth, baby boys have already experienced the effects of this powerful hormone. Testosterone secretions have triggered the development of his internal and external reproductive organs. Throughout childhood, testosterone levels remain relatively constant until the big upsurge hits with puberty. After puberty, males continuously secrete higher levels of testosterone that result in all the characteristics of an adult male; muscle development and greater upper body strength, facial and body hair growth, deepened voice, and ‘manly’ odor, as well as a tendency toward more active and aggressive behavior.

Beginning with middle age, testosterone levels steadily decline every year, and may be accountable for the changes in men’s skin and hair during a man’s later years. Testosterone is potent stuff, and we must understand its effects upon the psyches, bodies, and skin of men in order to fully embrace the rapidly growing male skin care market. American consumers spent $4.8 billion on male grooming products in 2009, a figure that is doubled over the past decade according to market data firm Euromonitor. And this number is only expected to keep rising. In order to better understand and create products directed at male skin, it is imperative to understand what makes male skin ‘male’- namely, testosterone.

Testosterone and His Hair

Beginning with the obvious – men can grow a beard and women cannot. Androgens, in particular testosterone, drive hair growth. In areas sensitive to androgen modulation, such as the face, underarms and genital area, testosterone triggers the production of terminal body hair. In men, this extends to the arms, legs, chest and pretty much the rest of his body. Androgens also control hair growth in women, though to a much lesser extent. The result is dark, coarse facial and body hair. Facial hair is thicker than scalp hair, and has a flatter shaped follicle, making it curlier. This can be a distressing quality, especially for males who experience razor-burn after shaving. This occurs when the freshly cut end of a curly hair re-enters the skin, causing inflammation. Sharp razors and shaving creams that minimize friction can reduce the occurrence of razor burn. For men with coarser hair, applying a pre-shave product to soften the beard hair may be a key step in minimizing razor burn and bumps.

Unlike men, women only develop fine vellus facial hair, giving their skin more surface area. Why the big difference? There is not a definitive answer, but looking into our ancestral past may reveal answers. A beard is the best protection a man’s face has against the powerful and damaging effects of UV rays. Perhaps there is some evolutionary reason for the beard. Males had to spend more time outdoors in the elements hunting for food, while females remained in the hut tending families. Maybe they needed the extra sun protection? Aid with temperature regulation? Or perhaps added camouflage during hunting? According to anthropologist Desmond Morris, women lost their facial hair to enable human infants to recognize their mothers more easily, creating a greater infant-mother bond. And the coarse, androgen-controlled, body hair remained in those areas nearest the sweat glands that produce aromatic sweat, such as the underarms and genital areas of both males and females. Since testosterone also produces aromatic sweat, also known as apocrine sweat, skin care targeted at men must address the characteristic male odor without simply masking it with fragrance. All these traits provide both challenges and opportunities for creating male grooming products in the ever-expanding skin care market. Paradoxically, the same androgens responsible for the growth of facial and body hair can trigger hair loss on the scalp. DHT, and to a lesser extent testosterone, can stimulate the scalp hair follicles to shrink and eventually die off, resulting in a condition called androgenetic alopecia, or male pattern baldness. This condition has become an important facet of male skin care, and has boomed into a billion dollar industry.

Testosterone and His Skin

The effect of androgens on hair growth lends itself to the observed differences in facial skin between men and women. Men’s terminal hairs are coarse, pigmented, and take up much of the surface area of the skin compared to female skin. By providing effective sun protection, the damaging UV rays are not able to penetrate through a beard to the dermis and cause collagen degradation. It is no surprise then, that shaving greatly increases the risk of UV damage and premature aging. Moreover, fair-skinned men with finer hair will display photo-damage more easily than their darker-skinned counterparts, much like women.

In addition to increased protection from collagen and elastin degradation, male skin can also thank its increased thickness to androgens. Androgens, including testosterone, yield a denser network of collagen fibers than that found in female skin.1 The firm collagen and elastin network, coupled with the presence of terminal hair follicles, results in thick facial skin in men. Whereas, females may show and be concerned about the signs of photo-aging, males traditionally do not begin to show these signs until later in life. Therefore, men are not easily persuaded into using moisturizing creams early in life due to the nature of their thicker facial skin. It does not hurt that the rugged and weathered look is a sign of masculinity in many cultures. Despite their thicker skins, American men have a greater incidence of skin cancer than women. According to the Centers for Disease Control and Prevention (CDC), in 2006, 57 percent of people diagnosed with melanomas of the skin were men, and 65 percent of those that died were men.6 These scary statistics should serve as an impetus to educate men about the need for daily defense against sun damage while providing solutions targeted to male skin.

He is More Sensitive Than You Think

The epidermal barrier is a highly organized tissue that responds efficiently and rapidly to the changing environment in order to maintain a state of homeostasis, or perfect balance. Comprised of a mixture of ceramides, cholesterol, and fatty acids, the lipid bi-layer mediates both trans-epidermal water loss and penetration of foreign materials into the skin. Once the epidermal barrier is disturbed, either by penetration of foreign material or dehydration, signals are sent by the lipids to replenish the lipid barrier system and remove any foreign material. However, studies have shown that testosterone can have negative effects on epidermal barrier function.

There is still much research to be done, but there are some initial studies that suggest diseases associated with barrier abnormalities, such as psoriasis and atopic dermatitis, are more common in men than in women.2 Even in men who do not have these skin diseases, testosterone can slow down barrier development and recovery.2 A major role of the skin is repair – when you get a cut, the skin must be able to repair the wound quickly and efficiently. Clinical observations suggest that men, in particular older men, are not able to heal their skin wounds as quickly as women. Lab studies have also implicated testosterone and DHT as major factors that impede wound healing.3, 4 Together, these studies suggest that men may not be able to heal wounds as readily as women. This is especially important in facial skin because many men shave on a regular basis, leading to frequent nicks and cuts. Men’s skin care must therefore be formulated to assist the skin repair itself and protect the integrity of the epidermal barrier layer.

Testosterone and Acne: Boys vs. Girls

While boys may be excited at the advent of their ‘manhood’, they are probably not too thrilled about the effect of testosterone on their skin’s appearance. Testosterone increases oil secretion all over the body, as is particularly evident on the face. This increase begins at puberty and remains relatively constant thereafter. On the plus side, sebum provides natural moisturization for the skin. Sebum is produced by the sebaceous glands and is a complex made up of cholesterol, free fatty acids, glycerides, squalene, and wax esters. Sebum and sweat, along with the epidermal lipids discussed earlier, make up the oil on the surface of the skin. Although this mixture provides protection from environmental agents and prevents water loss, it also provides the perfect breeding ground for the bacteria Proprionibacterium acnes. The presence of these bacteria, along with the excess pore-clogging oil, sets the stage for the onset of acne.5 During puberty, more sebum is produced than can be effectively secreted, resulting in sebum accumulation in the hair follicle and eventual inflammation. Thus, it is no surprise that acne in young males is more severe and long-lasting than in females. By adulthood, most men normalize their oil production so that acne is not a life-long skin problem.

Androgens can also trigger acne in women. Women with higher hormonal levels of androgens, such as those with polycystic ovarian syndrome, have a higher risk of developing acne than normal females. Clearly, hormonal control of the pilosebaceous unit – comprised of hair follicles and sebaceous glands – is a risk factor in developing acne. Men using anabolic steroids, a testosterone-like substance, can also experience increased bouts of acne. However, it must be noted that there is not a single, “silver bullet” cause and cure for acne. Other factors, including cellular and immune function, are also major players in the development of acne.

Male Skin Care: Fiction vs. Future

Women experience a precipitous decline in the female sex hormones estrogen and progesterone during menopause. The ‘male menopause’ or ‘andropause’ condition has been in the limelight recently. However, this is not a proper representation of the changes associated with aging males. True, men do experience declines in hormonal levels but not nearly to the extent that females do. Nevertheless, the decline in androgens may be responsible for some of the changes associated with aging in men. Loss of muscle tone and bone density, depression, decreased libido, sexual dysfunction – even memory loss – have all been linked to aging males and decreased testosterone. But perhaps these are just a part of aging. Aging is a natural process that affects both men and women physiologically, emotionally, socially, spiritually, and of course hormonally. The physical characteristics of aging bodies cannot be solely attributed to one substance like estrogen or testosterone. Despite the complexities, male hormones, in particular testosterone, govern much of the male physiology and behavior and this powerful chemical remains the crucial component for understanding male skin.

Today’s man is waking up to the benefits of high-tech grooming. More and more, men are making efforts in taking care of their health and overall appearance – and this is reflected in their skin. Current fashion calls for tailored, clean lines and a move away from the sloppy and slouchy. Men’s grooming habits are following this trend as well. The smash television series “Mad Men” depicts a dashing Don Draper as an icon of retro masculinity. Men today are seeing more and more personal care products targeted towards them. Viral marketing campaigns focused on men’s grooming have been hugely popular this year. This may be a reflection of the societal changes that impact men in this day and age. Men today are feeling the pressures that many women are already used to. Working later in life means competing with younger men in the workforce, a phenomenon heightened by today’s economic state. Men must mobilize every personal asset in order to compete effectively. Trends in the plastic surgery arena also reflect these changes. Men are heading to their doctor’s offices to get nipped, tucked, and polished before heading out into the workforce for a second chance. This second chance is not confined to his career. With divorce rates as they are, it is safe to assume that many men are on their way to their second or third marriages. This means a renewed competition for older men, where youth and health are still regarded as proofs of power by the women selecting them. Although men are beginning to be more concerned about wrinkles and skin elasticity, they are not going to fall for claims of overnight miracle cures. Men know that toned abs take time, so toned skin must. Men’s skin care is being refined for all of the issues that women have been targeting for so long. No longer will a man be a soap-and-shampoo kind of man. In fact, Euromonitor predicts an 18 percent increase in men’s anti-aging products in Europe over the next couple of years.

Today, whether men admit they have looked or not, retailers provide toners, cleansers, masks, balms, creams, scrubs, even concealers, and anti-shine powders, all targeted toward men. The skin therapist now has a unique opportunity to create a bridge to the male consumer, beginning with targeted mini-treatments for common male skin complaints like an ingrown hair in the beard-line, or a blemish the day before the big presentation. By keeping initial skin care experiences brief, specific, results and performance-oriented, therapists invite men to become curious, ask questions about products and treatments, and the long-term effects of informed skin care. This dialogue may then become the basis for a dependable client-therapist relationship – statistics show that men rarely “price-hop” and show greater loyalty to their service providers than women.

1.  Journal of Investigative Dermatology (2004) 123, 1052–1056

2.  Journal of Investigative Dermatology (2001) 116, 443–451

3.  Journal of Cell Science (2006) 119, 722-732

4.  Journal of Clinical Investigation (2002) 110, 615–624

5.  Baumann, L. (2002). Chapter 9: Acne. In L. Baumann & E. Weisberg (Eds.), Cosmetic Dermatology: Principles and Practice (55-61). New York: McGraw-Hill.

The Biology Behind Eczema and Psoriasis

Published in Skin Inc Magazine, July 2012

Eczema and psoriasis are some of the most challenging skin conditions encountered by skin care professionals. Often, there will simply be a little red rash on the skin and you may be left scratching your own head trying to figure out how it came to be. Up to 20% of the world’s children suffer from eczema (1, 2) and up to 3% of adults suffer from either eczema or psoriasis (3). Given that the world population just reached the 7 billion mark, that’s a lot of people. Eczema, along with asthma and allergies, are on the rise; in fact, eczema is much more common today than it was 30 years ago, especially in children. This rapid spike in apparent incidence is cause for concern, and may be due to many factors, such as inadequate diet, pollution and other environmental stressors. The truth is, it isn’t known exactly what causes eczema or psoriasis. The good news is, more and more is being learned about these inflammatory skin diseases and strategies are being developed to effectively manage their symptoms.

It is significant to note that neither condition is contagious, nor are they infections; and they aren’t transmitted by external contact or exposure. The origins of eczema and psoriasis are genetic; however, the triggers that cause their distressing and visible symptoms may include stress and environmental factors.

Eczema

A rash by any other name is still a rash. The terms “eczema” or “dermatitis” are very broad and can mean a whole family of skin conditions, ranging from dandruff, to contact dermatitis to atopic dermatitis. This can lead to many a confused client and skin care professional. In dermatology and skin care, the word “eczema” typically refers to atopic dermatitis (AD), a chronic inflammatory skin disease. It causes dry, itchy, irritated skin that requires daily care. Genetic defects in eczema result in abnormal skin cell differentiation. During differentiation, keratinocytes move from the basal cell layer of the epidermis through the granular layer to a group of flattened dead cells in the stratum corneum. This process of epidermal differentiation, or keratinization, involves a variety of proteins responsible for different functions at each stage.

One of these proteins, filaggrin, plays a major role in epidermal homeostasis; it has two main functions. First, it stacks the keratin filaments into dense bundles, allowing for easy desquamation. Imagine how much easier it is to move flattened boxes than propped-open boxes. It is then converted into the skin’s natural moisturizing factor (NMF) along with other byproducts. So if filaggrin does not work very well, it can have adverse effects, not only on the process of epidermal differentiation, but also on the skin’s natural moisture levels and protective lipid barrier. This seems to be the biological basis of dry skin.

In the past five years, researchers have established the link between filaggrin mutations and developing ichthyosis vulgarism (4), atopic eczema (5) and, most recently, peanut allergies (6). Ichthyosis is another skin disease characterized by very dry skin. The word itself is Greek for “fish,” suggesting the scaly nature of the lesions. Indeed, scientists are getting closer to understanding the genetic connection between allergic diseases, bringing hope for a future therapy not only for eczema clients, but also for those with allergies and ichthyosis.

There’s another type of eczema that shows up as the same itchy rash, but does not involve allergic responses. This is known as nonatopic eczema, and it affects millions of adults. Although most—about 90%—develop atopic dermatitis before age 5, nonatopic dermatitis develops in adolescence or adulthood, typically by age 15 (7, 8). These people don’t have heightened allergic responses or specific allergies, but still get dry, itchy skin. Keep in mind that even if a client is classified as atopic or nonatopic, the end result is the same itchy patch of skin, which must be cared for in the same manner.

Psoriasis

Psoriasis has been confused with eczema, lupus, boils, vitiligo and leprosy. Because of the confusing connection with leprosy in ancient times, psoriasis sufferers were even made to wear special suits and carry a rattle or bell, like lepers, announcing their presence. Only in the 19th century was a distinction made between psoriasis and leprosy, alleviating some of the psychosocial impact of this highly visible and distressing skin disease.9 As with eczema, it presents as itchy, red skin and involves altered immunity. However, its complexities reach far beyond the surface of the skin. People with psoriasis have an increased risk of cardiovascular disease, metabolic syndrome, obesity and other immune-related inflammatory diseases—even cancer. The mysteries behind this complicated and debilitating skin disease are only beginning to be unraveled. Psoriasis is a chronic, inflammatory multisystem disease affecting 1–3% of the world’s population (3). Whereas the rashes on eczematous skin can have irregular edges and texture, psoriatic lesions tend to be more uniform and distinct. Red or pink areas of thickened, raised and dry skin typically present on the elbows, knees and scalp. This presentation tends to be more common in areas of trauma, abrasions or repeated rubbing and use, although any area may be affected. Unlike eczema, psoriasis comes in five different forms: plaque, guttate, pustular, inverse and erythrodermic.

Plaque psoriasis affects about 80% of those who suffer from psoriasis, making it the most common type. You’re likely to encounter this type in a skin care facility, so it’s important to know how to identify and understand it to help you better manage your client’s needs. It may initially appear as small red bumps that can then enlarge and form scales. The hallmarks of this type are raised, thickened patches of red skin covered in silvery scales. The other types are less common and present inflamed skin with red bumps; pustules; cracked, dry skin; and even burned-looking skin. Clients will most likely be under a physician’s care, who will diagnose the type of psoriasis present.

As of today, psoriasis has no cure. A single cause of the disease has yet to be uncovered, but it is known that developing the disease involves the immune system, genetics and environmental factors. In psoriasis, aberrant immune activity causes inflammatory signals to go haywire in the epidermis, causing a buildup of cells on the surface of the skin. While normal skin takes 28–30 days to mature, psoriatic skin takes only 3–4 days to mature and, instead of shedding off, the cells pile up on the surface of the skin, forming plaques and lesions. The underlying reason may be due to the hyperactivity of T-cells, which end up on the skin and trigger inflammation and keratinocyte overproduction. Although it is not known why this happens, it is known that the end result is a cycle of skin cells growing too fast, dead cell-debris accumulation and resulting inflammation.

Managing the symptoms

Although there is no cure for eczema or psoriasis, there are ways to manage symptoms, and gaining this knowledge will lead to more satisfied and educated clients. Although eczema and psoriasis are clinically distinct from one another, they do share some common features that may be addressed in the treatment room. Both eczema and psoriasis clients have impaired barrier function and increased inflammation, so your goal will be to protect and repair. Remember to always check first with your client’s physician for contraindications to medications and therapies, because some ingredients may counteract each other. For example, salicylic acid may seem a likely choice for exfoliating psoriatic skin, but could, in fact, inactivate a common topical treatment for psoriasis.

Once a full consultation with the client and possibly her physician is completed, proceed with a treatment using minimal products and procedures. A good way to compensate for minimal skin treatment time is to add on stress-relieving techniques, because there is a psychological component to eczema and psoriasis. Complementary therapies, such as aromatherapy, acupressure, reflexology, massage and inhalation techniques can be coupled with skin treatments to lower stress hormones and control inflammation.

Gentle cleansing and exfoliation is crucial to allow the penetration of rich, emollient moisturizers used on dry, sensitive skin. Avoid harsh exfoliants and detergents, and look for ingredients, such as lactic acid. Use anti-inflammatory ingredients, such as red hogweed, ginger, oats and chamomile, coupled with barrier-repairing oils, including evening primrose, borage, argan and sea buckthorn. Finishing a treatment with a physical sunscreen, such as zinc oxide or titanium dioxide will ensure that harmful UV rays do not cause further damage.

Coaching the client on home care is also an integral part of skin health maintenance. Not only will they need to comply with their prescribed skin care regimen; they will also need to have realistic expectations in terms of time, and expect to see the extended benefits of their treatments long after they are performed. Because these are chronic inflammatory skin conditions, these clients can be a valuable business opportunity, with an increased likelihood of return bookings. Both eczema and psoriasis present highly visible symptoms, and because of this, clients are motivated to help skin improve. Skin health management is a top-of-mind priority for this client’s lifestyle, distinguishing your services from occasional treatments. Don’t be afraid to tackle these skin diseases in the treatment room; the reward could be greatly beneficial to you and your clients.

REFERENCES

1. L Maintz and N Novak, Getting more and more complex: the pathophysiology of atopic eczema, Eur J Dermatol, 17 4 267–283 (2007)

2. HW Walling and BL Swick, Update on the management of chronic eczema: new approaches and emerging treatment options, Clinical, Cosmetic and Investigational Dermatology 3 99–117 (2010)

3. AM Bowcock and W Cookson, The genetics of psoriasis, psoriatic arthritis and atopic dermatitis, Human Molecular Genetics 13 R43–R55 (2004)

4. FJ Smith, et al, Loss-of-function mutations in the gene encoding filaggrin cause ichthyosis vulgaris, Nat Genet 38 337–342 (2006)

5. CN Palmer, et al, Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis, Nat Genet 38 441–446 (2006)

6. SJ Brown, et al, Loss-of-function variants in the filaggrin gene are a significant risk factor for peanut allergy, J Allergy Clin Immunol 127 661–667 (2011)

7. www.niams.nih.gov/health_info/atopic_dermatitis/default.asp#b (Accessed May 3, 2012)

8. S Jacob, M Miller and EM Herro, Atopic Dermatitis—A historical review, Skin & Aging 19 (Suppl) 1–11 (2011)

9. A Cowden and A Van Voorhees, Treatment of Psoriasis (1–9), Switzerland, Birkhäuser Verlag (2008)

MIND MATTERS

Published in Dermascope Magazine, April 2015

We are in the midst of one of the biggest movements the wellness industry has ever seen. In the beginning of 2014, TIME magazine published an article titled “The Mindful Revolution,” and 2014 has been dubbed the “year of mindful living.” The word mindfulness has been so pervasive in the media and social networks that you would think the biggest buzzword of the year was a newly-discovered concept. Mindfulness is rooted in Eastern philosophy, specifically Buddhism. While Buddhist principles and ideologies have been around for centuries and the word was introduced into the English language over a century ago by British scholar Thomas W. Rhy Davids, there is a new scientific edge to mindfulness that has spurred its popularity in both theory and practice in this day and age.

Mindfulness is the discipline of being fully engaged in the present moment, without distractions from the past or anxiety about the future. This state of mind can be achieved through the practice of meditation, which serves as a form of brain exercise to achieve a mindful state. Undoubtedly, the cultural shift in how we think and talk about mindfulness and meditation has been brought about by today’s supercharged world of gadgets, tech-dependence, and hyper-connectedness. Technology has dramatically increased the convenience of ordering food while sitting in traffic, working with someone half-way around the world, booking appointments while waiting at a doctor’s office, and so on. But with constant multitasking, we are in many different places at once, and not fully present where we should be. Enter mindfulness. A simple and compelling solution for a distracted populace. From the yoga studio to Silicon Valley to your smartphone, mindfulness is the mega-trend that is on everyone’s lips (or minds). You can be mindful about working, eating, parenting, exercising – you name it. Because it is universal in nature, mindfulness is making its way to just about every sector of society. This highlights its importance: At the 2013 Global Spa and Wellness Summit, the Dalai Lama noted that “We spend so much energy on physical health and hygiene – but we need to spend more on mental hygiene and the ‘hygiene’ of emotion.”

Trends in Neuroscience
It is undeniable that people are embracing mindfulness and meditation now more than ever. How did this movement grow from a new-age fad to being embraced, and even championed, by Silicon Valley CEOs, celebrities, and political figures? Neuroscience. Today, there are well-documented health benefits associated with mindfulness and meditation in both illness and wellness. As modern neuroscience unravels the mysteries behind the brains’ ability to rewire and adapt, a phenomenon known as neuroplasticity, we are better able to see the concrete benefits that meditation and mindfulness has on our mental well-being. By using techniques like brain imaging, electrical brainwave readings, and physiological measures, neuroscience has shown that practicing mindfulness can affect the brain’s structure and function. For example, meditation activates areas of the brain associated with decision-making, planning, and social emotion processing (such as empathy, love, and self-awareness). This implies that mindful meditation can regulate attention and emotion – two processes shrinking in the digital age. And it does not take a lifetime. Recent research suggests that practicing regular meditation can cause beneficial structural changes in the brain in as little as eight weeks.
There is enough evidence on regular meditators to convince the medical community that there is another powerful way to combat stress and anxiety besides pharmaceutical intervention. Therapies like mindfulness-based stress reduction (MBSR) are effective and low-cost ways to lower stress levels, reduce anxiety and depression, and promote emotional well-being, all without the risk of side effects! Mindfulness has been shown to help smokers kick the habit and allow people with obsessive-compulsive disorder (OCD) to take control of their thoughts and actions. The study of mindfulness is still in its infancy and there is much to learn, but future studies could shed light on its potential to enhance longevity, decrease age-related conditions, and maximize performance in both mind and body.
Due to the wealth of neuroscientific and psychological data generated over the past decade, mindfulness is gaining traction with those who once raised an eyebrow to “alternative therapies.” In the United Kingdom, the National Institute for Health and Care Excellence has approved mindfulness as a treatment for depression and is embracing its holistic nature. In the United States, the National Center for Complementary and Alternative Medicine (NCCAM) is the Federal Government’s leading agency for scientific research on complementary and alternative medicine, including mind-body research. Outside of the scientific community, mindfulness is even more pervasive. Splashed onto magazine and newspaper covers, followed by Hollywood celebrities, and endorsed by thought-leaders – mindfulness is definitely having its moment right now (ironically). Global conferences like “Wisdom 2.0” and Arianna Huffington’s “Third Metric,” as well as Oprah’s “21-Day Meditation Experience” (an online collaborative initiative with Deepak Chopra), just goes to show how much this field has grown.

Trends in the Wellness Industry
According to the Global Wellness Institute, “wellness” is a $3.4 trillion mega-industry as of 2013. The concept of wellness is more than just the absence of disease and illness – it is a conscious, evolving process of achieving a state of complete physical, mental, and social well-being. Methods used to achieve mental wellness (such as cognitive training, mindfulness, and biofeedback) are steadily growing into a sizable portion of the global wellness industry. According to a study by SharpBrains, the market for brain health software alone grew from $600 million in annual revenues in 2009 to more than $1 billion by the end of 2012. Researchers forecast this market to reach $6 billion by 2020. Applications such as Headspace are bridging the worlds of Eastern philosophies with modern technology. Brain-training has even reached the travel industry. Back in 2008, Westin® Hotels & Resorts launched a wellness initiative called “BrainBody Fitness,” a program connecting mental and physical fitness, whereby guests were given brain challenges and games along with physical stretching. In 2012, the Intercontinental Hotels Group’s Trend Report predicted that the future hotel would allow guests to de-stress in special sleeping laboratories or stimulate their minds through in-room brain spa menus. Recently, British Airways began testing blankets with woven-in neurosensors and fiber optics that measure a passenger’s brainwaves to predict stress and improve in-flight experience. Clearly, technology has extended its reach on us, even while we sleep!

Trends in the Treatment Room
While we do not see brain-spas on every corner, we do see a need for the over-worked and stressed client to find a haven – in the form of silence, aromatherapy, music, or even reading a book. With the wellness tourism economy estimated at $494 billion in 2013, you can be sure there will be changes to spa menus worldwide. We have known for decades that spa and wellness activities can reduce stress and relax our bodies and now, we are beginning to understand exactly how certain techniques do so. With the explosion of mindfulness across various industries, you can expect more treatment menus to incorporate this concept and take clients to whole new levels of zen.

Have you noticed that it is becoming harder for clients (and maybe even the professional) to relax during a treatment or massage? Even while focusing on relaxing, the effort to focus means telling oneself: Do not worry about that noise and stop thinking about things like what happened at work, what the treatment will feel like, and if it will be worth it. And if you think clients cannot tell that their aesthetician’s head is somewhere else when they are physically in contact with the client – think again. Incredibly, the power of touch transmits something as esoteric as being present very well. Mindfulness has always been a part of giving a treatment in some way. Today, there are ways to create a profoundly relaxing experience by blending the principles of mindfulness with the techniques of massage. In 2013, the “mindfulness massage” was highlighted as a top trend in SpaFinder® Wellness’ annual forecast of global spa and wellness trends. Fusing mindfulness-based approaches like breath work and guided visualization with traditional bodywork, the mindfulness massage aims to help the client reach a level of deep relaxation quickly and easily. This, of course, also allows the therapist to remain emotionally present, not thinking about the next session or their busy schedule. In essence, this technique is a powerful and calming treatment, resulting in a rewarding experience for both parties. 

The beautiful thing about wellness is that it is both integrative and interdisciplinary, much like neuroscience. Methods can be taken from one area of discipline and applied to another. For example, you can have a client take a couple of deep breaths or you can introduce yogic breathing techniques for a more profound experience. Ujjayi (pronounced oo-ja-ee) is an ancient yogic breathing technique that helps calm the mind and body, with a balancing influence on the entire cardiorespiratory system. To perform Ujjayi breath, the client should
begin by breathing slightly deeper than normal. With the mouth closed, the client should exhale through the nose while constricting the throat muscles. This is especially helpful for talkative clients who are anxious and need extra help calming down. Active breathing takes some practice, but can be reinforced outside the treatment room, particularly during yoga practice.

Walking a client through a few minutes of visualization will focus their mind on your touch and their body, replacing stressful thoughts and allowing them to focus on healing rather than pain. If visualization can help a public speaker or professional athlete, it can certainly benefit the skin care or massage therapist to get in the zone before and during a treatment.

The Stress Epidemic
Mindfulness massage is a trend that is picking up steam and it is easy to see why. Today’s workplace culture is practically fueled by stress, sleep deprivation, and burnout. About 600,000 Chinese people die every year from working too hard, according to the China Youth Daily, and work-related stress is costing the British economy a whopping £6.5 billion a year. Clearly, the global population is suffering from a stress epidemic and stress-reduction therapies are needed now more than ever. Cutting-edge neuroscience research has shed light on the power of mindfulness therapies, but spas are still focusing almost exclusively on the body and physical wellness. Emphasizing the mind-body connection will increase opportunities for practitioners, reinforce the client-therapist relationship, and ultimately provide tools that help clients feel, think, and act better.

References:
1. Harrington, A., Dunne, J. (2013). Mindfulness Meditation: Frames and Choices.
2. Gard, T., Holzel, B.K., et al., (2014). The potential effects of meditation on age-related cognitive decline: a systematic review. Annals of the New York Academy of Sciences, 1307(1): 89-103.
3. Tang, Y., & Posner, M.I. (2012). Theory and method in mindfulness neuroscience, Social cognitive and affective neuroscience, 112.
4. Rycroft-Malone, J., et al., (2014). Accessibility and implementation in UK services of an effective depression relapse prevention programme-mindfulness-based cognitive therapy (MBCT): ASPIRE study protocol, Implementation Science, 9(1): 62.
5. Baime, M., (2011). This is your brain on mindfulness, Shambhala Sun, 44-48.
6. SharpBrains: The Digital Brain Health Market 2012-2020. 
7. Intercontinental Hotels Groups Trend Report 2012.
8. 2013 Global Spa & Wellness Trends Report.

PSYCHODERMATOLOGY: THE BRAIN-­SKIN CONNECTION

Published in Les Nouvelles Esthétiques, June 2015

Emotions play a big role in skin diseases. Approximately 50% of people with acne report an emotional trigger to their breakouts. At least 80% of those with atopic dermatitis (eczema) state psychological stress aggravates or brings about their itch. More than 90% of those with rosacea say stress triggers a flare-up, making their skin hypersensitive. And about 100% of those with excessive sweating, hyperhidrosis, say emotions trigger their reaction. Recurrent flares of psoriasis have been attributed to stress in up to 80% of individuals. What’s more, in psoriasis patients with associated depression, 9.7% acknowledged a “wish to be dead,” and 5.5% reported active suicidal ideation.

Emotions, in particular stress and anxiety, are not to be dismissed when it comes to treating the skin. Not only can they trigger or exacerbate skin conditions, but they can actually affect a person so deeply that they are scarred for life, or worse yet, make them want to take their own life. As estheticians, you use your tools to help people with their skin concerns, but in reality, you have the power to help improve the quality of life for every client you touch. In understanding the intimate relationship between the mind and skin, you will be better equipped to manage a client’s expectations and deliver your very best results.

A mind­-body approach

The notion that there is a definitive mind-body relationship is not new. From the ancient Greeks, to Shakespeare, to 19th century dermatologists ­ the mind­-body connection has been a topic discussed for centuries. Eastern healing practices, such as traditional Chinese medicine and Ayurvedic medicine also highlighted the interdependence between the mind and the body. Somewhere along the lines in Western medicine, we lost this connection, focusing instead on philosophies that treated the body as a separate entity from the mind. It’s only been in the past several decades that we’ve seen the resurgence of mind-­body awareness in medicine — And only in the past decade or so have we seen an emphasis on understanding the interaction between the mind and skin diseases with modern neuroscience techniques.

Psychodermatology

Psychodermatology is a new medical subspecialty that merges two major medical specialties: psychiatry and dermatology. Psychiatry treats mental processes manifested internally, while dermatology treats skin diseases manifested externally. In medicine, there are four main categories within psychodermatology.

1) Psychophysiological disorders; 2) Primary psychiatric disorders; 3) Secondary psychiatric disorders and 4) miscellaneous conditions like neuroses.

1. Psychophysiologic disorders include skin disorders such as eczema and acne, that are triggered or worsened by emotional stress. This is the category you are most likely to encounter in the treatment room.

2. Primary psychiatric disorders refer to problems that arise in the mind, but result on the skin. For example, a habit frequently seen in clients is skin picking, where the picking makes the acne lesion worse, causing even more distress. But the picking, scratching or pulling (as in the hair­pulling disorder, trichotillomania) is anxiety­-driven, and is ultimately a compulsive behavior that is ideally corrected with psychiatric intervention.

3. Secondary psychiatric disorders are diseases of the skin that cause so much distress, they can trigger a significant psychological problems such as clinical depression and anxiety. The very visible skin disorders, such as psoriasis and vitiligo are particularly stressful for an individual, and rates of depression and anxiety are higher among them. Despite being ‘skin diseases,’ psychiatric intervention with anti­-anxiety or anti-­depressant medications may be prescribed in a medical setting.

4. Finally, there are miscellaneous conditions that include neuroses, suchas feeling ‘bugs’ crawling on the skin. These are primarily treated in a psychiatric setting.

These subcategories are not mutually exclusive. For example, stress can trigger a breakout but acne can also cause social anxiety and depression due to visible scarring. While the medical world is beginning to integrate these two fields to better treat their patients, this is still a relatively new field, leaving many without the option for integrative treatment. Perhaps more importantly, they may not be getting adequate solutions from their healthcare providers, with specific medicine prescribed to treat their symptoms, rather than unveil the root cause, which may very well come from the mind. Now think of your typical client. A skin treatment center will likely see clients with inflammatory skin diseases like acne, eczema, and rosacea. Even the destination spa will see overworked, stressed individuals wanting a respite from their day­to­day. In all cases ­ from stress to acne to eczema ­ you’re dealing with chronic inflammation, and this poses a major threat to the health and wellbeing of your clients. Now think of the many people that quietly suffer from these conditions ­ the overworked mother will likely get a facial or massage to deal with her stress levels rather than see a physician. The teenage acne client may use OTC products, but finds they are not ‘working.’ We live in a world where stress is pervasive in society, lurking behind every traffic jam and argument as fuel to the fire of inflammation in our bodies. Estheticians are uniquely qualified to provide relief from the symptoms associated with stress­related skin diseases. From the aromatherapy inhalation techniques, to pressure point massage add­ons, to the act of gently massaging the face --­ these are truly mind­-body strategies that ultimately reduce the levels of stress hormones in the body, allowing for better balance between the immune, nervous and cutaneous systems.

The Power of Touch

Today’s society is correctly described as touch­-deprived. Estheticians and massage therapists represent two professions where practitioners can touch the skin of clients --­ a rarity in this day and age. With touch, we induce hormonal signals carried via the skin to our brain’s cognitive and emotional centers, resulting in positive behavioral changes. Recent neuroscientific research has unveiled the mysteries of touch. Our skin, the largest organ, is highly innervated and connected to our brain. Our skin allows us to ‘feel,’ with some sensations calling for immediate response (like a burn) while others take some time to process, like the pleasure during a massage. The rate at which these different sensations reach our brain and create emotions arises from anatomical differences in the nerve fibers that live just beneath the surface of the skin. There are fast-­conducting fibers that are thick and highly insulated, that transmit electrical signals to our brain (ouch! or that burns!) much like a high-­speed internet connection allows you to download a movie quickly. Now if these fast­ conducting nerves are like ethernet cords, the slow-­acting nerves are more like having a dial-­up internet connection (remember those?). These slow­conducing nerve fibers are called “C-fibers” and are thin and uninsulated. And it is these very ‘slow’ nerves that are processed in the region of the human brain responsible for positive feelings, the insular cortex. To us, that means we feel pleasure from receiving a gentle caress.

When you give a facial massage, you are activating these very slow nerve fibers that result in positive feelings and ultimately reduce levels of the stress hormone, cortisol. One other mechanism by which your gentle touch reduces cortisol is by increasing it’s counterpart, oxytocin. Oxytocin, initially studied for its role in childbirth, is involved in a variety of social behaviors, including motherly care, aggression, bonding between couples, sexual behavior, social memory and trust. Oxytocin also reduces stress responses, including cortisol levels. Finally, it is hormone that’s linked to feelings of empathy.

In Your Hands

Empathy is something that is impaired in many aspects of today’s modern culture. As estheticians, you are in the business of ‘touch.’ If you were not empathic with your touch, you would likely choose a different profession. This should all make your work a little clearer ­ you are not simply breaking up knots in muscles, or cleaning and smoothing the skin ­ you are providing a mind­-body therapy that restores the cellular balance between the skin, nervous system and immune system. One treatment at a time, through touch you can help create a more connected and compassionate world, beyond the immediate effects of reducing individual stress.

REFERENCES:

1. Levin, Ethan C., and John YM Koo. "Psychodermatology: An Overview." Semin Cutan Med Surg 32 (2013): 64­67.
2. Löken L.S., Wessberg J., Morrison I., McGlone F. & Olausson H. (2009). Coding of pleasant touch by unmyelinated afferents in humans, Nature Neuroscience, 12 (5) 547­548.
3. Senra, M. S., and A. Wollenberg. "Psychodermatological aspects of atopic dermatitis." British Journal of Dermatology 170.s1 (2014): 38­43.