A Guide To Dry Skin Disorders In The Lower Extremity

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Author(s): 
M. Joel Morse, DPM

   Diabetes. People with diabetes have a high incidence of xerosis of the feet, especially on the heels. While assessing for predictors of foot lesions in patients with diabetes, one study found that 82.1 percent of their patients had skin with dryness, cracks or fissures.25 An unpublished survey of 105 consecutive patients with diabetes conducted by one of the authors revealed that 75 percent had clinical manifestation of dry skin. Dry skin often leads to cracks and fissures, which can serve as a portal of entry for bacteria.

   Despite possible “dry skin” definition discrepancies across the studies, it is clear that the skin dryness is one of the earliest and most common manifestations of type 1 diabetes. The clinical observations are supported by objective findings of a reduced hydration state of the stratum corneum and decreased sebaceous gland activity in patients with diabetes without any impairment of the stratum corneum barrier function.26

   Liver disease. The liver neutralizes toxins and filters bile salts. If the liver’s function is impaired, these materials can accumulate in the body and deposition in the skin causes irritation and itching. In cholestatic liver disorders such as primary sclerosing cholangitis and obstructive gallstone disease, pruritus tends to be generalized but is worse on the feet and hands.27

In Conclusion

Dry skin can be persistent and recurring due to the long list of possible causes. Clinicians often treat dry skin with hydrophilic and/or lipophilic moisturizers. Hydrophilic moisturizers must penetrate the stratum corneum deeply to function properly whereas lipophilic moisturizers should remain in the upper stratum corneum layers.28

   Traditionally, clinicians used humectant and occlusive technologies to treat dry skin. Originally, non-lamellar forming ingredients such as petrolatum were in use but recent research has shown an advantage of using lamellar-forming factors such as ceramides, pseudoceramides and phospholipids.29

   As with all topical treatments, adherence is the great challenge one faces in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance.30

   The number of studies on skin barrier function and hydration is endless. There is a long list of products available and some may work better depending on certain skin characteristics of the person. Many podiatry friendly companies have products that include CeraVe (Valeant), Eucerin, AmLactin (Upsher Smith), Cetaphil (Galderma), Borage Therapy (ShiKai), Uramaxin (Medimetriks), Carmol 40, Lubriderm (Johnson and Johnson), and Aveeno (Johnson and Johnson).

   Dr. Morse is the President of the American Society of Podiatric Dermatology. He is a Fellow of the American College of Foot and Ankle Surgeons, and the American College of Foot and Ankle Orthopedics and Medicine. Dr. Morse is board certified in foot surgery. He is on the Podiatric Residency Educational Committee at the MedStar Washington Hospital Center in Washington, D.C.

References

1. Nolan K, Marmur E. Moisturizers: Reality and the skin benefits. Dermatologic Therapy. 2012; 25(3):229-233.

2. Coderch L, López O, de la Maza A, Parra JL. Ceramides and skin function. Am J Clin Dermatol. 2003; 4(2):107-29.

3. Watkins P. Using emollients to restore and maintain skin integrity. Nursing Standard. 2008; 22(41):51-57.

4. Pons-Guiraud A. Dry skin in dermatology: a complex physiopathology. J Eur Acad Dermatol Venereol. 2007; 21(Supp 2):1-4.

5. Vorgeli D. The vital role of emollients in the treatment of eczema. Br J Nursing. 2011; 20(2):74-80.

6. Choi MJ, Maibach HI. Role of ceramides in barrier function of healthy and diseased skin. Am J Clin Dermatol. 2005; 6(4):215-23.

7. Johnsen G, Haugsnes A. A new approach for an estimation of the equilibrium stratum corneum water content. Skin Research Technology. 2010; 16(2):142-145.

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