Research Article
Open Access
The Skin Barrier in Patients with Lichen Simplex
Chronicus
Georgieva F, *Bakardzhiev I
Department of Dermatology and Venerology, MedicalUniversity of Varna, MedicalUniversity of Varna
*Corresponding author: Assoc. Prof. Ilko Bakardzhiev, Medical College ,Medical University of Varna, Tsar Osvo boditel 84, Bulgaria, Tel: +359 888 768
413; E-mail:
@
Received: May 10, 2016; Accepted: May 20, 2016; Published: May 27, 2016
Citation: Georgieva F, Bakardzhiev I (2016) The Skin Barrier in Patients with Lichen Simplex Chronicus. Clin Res Dermatol Open
Access 3(3): 1-4. DOI: http://dx.doi.org/10.15226/2378-1726/3/3/00131
Abstract
Background: The main function of the skin is to protect body
from environmental factors. The intact skin is a barrier to the
uncontrolled water loss, proteins and plasma components from the
organism. Lichen Simplex Chronicus (LSH) is a common extremely
scratching disease. Prurituselicits a scratch response, initiating the
itch-scratch cycle, which in turn aggravate the inflammatory response
and damaged the normal epidermal barrier status.
Objective: The purpose of this study is to evaluate changes in barrier functions of skin and distinguish its role in pathogenesis of LSH. Materials and Methods: Transepidermal Water Loss (TEWL) and Hydratation (H) of epidermis in healthy and damaged skin were measured in 56 non-hospitalized patients.
Results: The most visible pathological changes were found in patients with duration of LSH 19-24 months-TEWL mean 27.30g.m2.h and H mean 23.15 (p=0.003). Strong correlation between pathological levels of TEWL and H and severity of disease was obtained. Thus in group of patients stage II TEWL was mean 31.22g.m2.h, while in group stage I TEWL was mean 16.23g.m2.h. (p=0.005) Similar wеre results from measurement of H: in group of patients stage III H was mean 20.25, while in group stage I H was mean 28.46 (p=0.003) .
Conclusion: All the reported and analyzed results indicate that disorders of skin barrier are connected with severity and duration of LSH. This is the first study in our country, which aims to measure the impact of changes in skin barrier on clinical characteristics of LSC.
Keywords: Lichen Simplex Chronicus; Skin Barrier Evaluation; TEWL; Hydratation
Objective: The purpose of this study is to evaluate changes in barrier functions of skin and distinguish its role in pathogenesis of LSH. Materials and Methods: Transepidermal Water Loss (TEWL) and Hydratation (H) of epidermis in healthy and damaged skin were measured in 56 non-hospitalized patients.
Results: The most visible pathological changes were found in patients with duration of LSH 19-24 months-TEWL mean 27.30g.m2.h and H mean 23.15 (p=0.003). Strong correlation between pathological levels of TEWL and H and severity of disease was obtained. Thus in group of patients stage II TEWL was mean 31.22g.m2.h, while in group stage I TEWL was mean 16.23g.m2.h. (p=0.005) Similar wеre results from measurement of H: in group of patients stage III H was mean 20.25, while in group stage I H was mean 28.46 (p=0.003) .
Conclusion: All the reported and analyzed results indicate that disorders of skin barrier are connected with severity and duration of LSH. This is the first study in our country, which aims to measure the impact of changes in skin barrier on clinical characteristics of LSC.
Keywords: Lichen Simplex Chronicus; Skin Barrier Evaluation; TEWL; Hydratation
Introduction
Lichen Simplex Chronicus (LSH) is a common skin disorder
characterized by lichenification of skin as a result of excessive
scratching [1] LSH is distributed worldwide and affects adults
with a mild preference for female [2]. Pathogenesis of this
dermatosis is not well distinguished. Disorders of skin barrier are
described as a trigger or enhance pathological symptoms of LSH
[3]. There is an altered skin barrier with varying combination of
allergens, irritants and skin pathogens that result in a changed
immuno regulatory process [4]. This study explores the possible
correlation or predomination of changes in skin barrier function and characteristic of LSH disease.
Material and Methods
Settings and sample
The study was conducted among 56 non-hospitalized patients
(35 female and 21 male; mean age 49.46years; range 29-64 years)
who visit dermatology unit in medical center "Medeia" between
January 2013 and January 2015.Patients has the following
inclusion criteria: one or more lichen plaques, highly pruritic,
accumulation of normal skin lines, excoriations. Diagnosis was
based on clinical observation and dates from patient's history.
Socio demographic data are shown in table 1. The characteristics
connected to the disease (duration and severity) are shown on
Table 1: Health care events used for lead times.
|
Patients |
Age |
mean age 49.46 years; range 29-64 years |
Gender Male Female |
21-37.5% 35-62.5% |
Employment Employed Unemployed Students Retiree |
36- 64.28% 15-26.78% 2-3.57% 3-5.35% |
Education Primary Secondary High |
5-8.92% 14-25% 37-66.07% |
[1] Referral from primary care or self-referral via website or by phone
(booking).
Table 2: Disease duration.
Disease duration in months |
Frequency (%) |
|
12 |
40.5 34.2 10.0 11.6 96.3 3.7 |
|
13-24 |
||
25 - 36 |
||
37+ |
||
total |
||
Don't know |
||
total |
56 |
100.0 |
Table 3: Disease severity.
Stage of disease severity |
Frequency (%) 0 0.52 21.57 62.10 10.52 |
|
Stage 0 |
||
Stage I |
||
Stage II |
||
Stage III |
||
Stage IV |
||
Total |
56 |
100.0 |
Table 4: Distribution of measuring points.
Localization of measuring points |
Frequency |
|
Damaged |
Distal zone |
|
Nuchal areas |
Interior surface of hands |
14 (25%) |
Ankles |
Interior surface of hands |
11 (19, 65%) |
Anterior tibial |
Interior surface of hands |
9 (16, 09%) |
Extensor surface of forearms |
Interior surface of hands |
7 (12, 5%) |
Inner thighs |
Interior surface of hands |
3 (5, 4%) |
Anogenital area |
Interior surface of hands |
12 (21, 43%) |
Table 2 and Table 3.
Measures
We used instrumental methods, including, measuring H and
TEWL in healthy and damaged skin to evaluate the functioning
of Stratum Corneum (SC). The degree of H was measured with
a capacitance meter (Corneometer CM 825), and the TEWL was
determined using a measurement instrument Tewameter® TM
300. The areas examined were closely and in distance of the
pathologic lesions. The exact localization of measuring points are
shown on table 4.
The severity of the disease was evaluated by EASI score. (Eczema Area and Severity Index) [5]. According to this scale patients were divided in 5 groups. Stage 0 without skin changes; Stage 1 up to 29% of skin surface is damaged, Stage 2 up to 49% of skin surface is damaged, Stage 3 up to 69% of skin surface is damaged, Stage 4 more than 69% of skin surface is damaged.
The statistical analysis was performed with SPSS v.21.0 for Windows. Hypotheses were tested using χ²-criteria (for the descriptive profile data). Construct validity was tested by factor analysis. Results with p<0.001 were interpreted as statistically significant
The severity of the disease was evaluated by EASI score. (Eczema Area and Severity Index) [5]. According to this scale patients were divided in 5 groups. Stage 0 without skin changes; Stage 1 up to 29% of skin surface is damaged, Stage 2 up to 49% of skin surface is damaged, Stage 3 up to 69% of skin surface is damaged, Stage 4 more than 69% of skin surface is damaged.
The statistical analysis was performed with SPSS v.21.0 for Windows. Hypotheses were tested using χ²-criteria (for the descriptive profile data). Construct validity was tested by factor analysis. Results with p<0.001 were interpreted as statistically significant
Results And Discussion
The results obtained from measuring TEWL in healthy and
damaged skin show that the levels of TEWL in healthy skin are
normal (0-15g.m2.h/ range from 8g.m2.h to 17.8g.m2.h.) The
levels of TEWL in damaged skin were higher. The pathological
changes were more visible in patients from age group 56+ – range20-32(mean27.2) and in group 46-50 years range 19-
38(mean 27.88).There were no significant differences in patients
from different age groups. We compare the TEWL dividing
patients according the duration of the disease. The pathological
changes were more visible in patients with duration of LSH 19-24
months- mean 27.30g.m2.h and more than 24 months from 20g.
m2.h to 32g.m2.h-mean 27g.m2.h.(p=0.003). Most distinct trend
for correlation was accounted comparing TEWL in pathological
skin and severity of disease. In group of patients stage II TEWL
was mean 31.22g.m2.h, while in group stage I TEWL was mean
16.23g.m2.h.( p=0.005).
The results obtained from measuring H in healthy skin are normal (26.07/ range from 20 to 30.) The levels of H in damaged skin were lower (23.32/ range from 10 to 30.). The pathological changes show no differences compare to the age of participants. Also we compare the H dividing patients according the duration of the disease. The pathological changes were more visible in patients with duration of LSH 19-24 months- mean 23.15 and more than 24 months 18.75( p=0.008) Most distinct trend for correlation was accounted comparing H in pathological skin and severity of disease. In group of patients stage III H was mean 20.25, while in group stage I H was mean 28.46(p=0.003)
The results from measuring TEWL and H are shown in table 5 (according age), table 6 (according duration) and table 7 (according stage).
The results obtained from measuring H in healthy skin are normal (26.07/ range from 20 to 30.) The levels of H in damaged skin were lower (23.32/ range from 10 to 30.). The pathological changes show no differences compare to the age of participants. Also we compare the H dividing patients according the duration of the disease. The pathological changes were more visible in patients with duration of LSH 19-24 months- mean 23.15 and more than 24 months 18.75( p=0.008) Most distinct trend for correlation was accounted comparing H in pathological skin and severity of disease. In group of patients stage III H was mean 20.25, while in group stage I H was mean 28.46(p=0.003)
The results from measuring TEWL and H are shown in table 5 (according age), table 6 (according duration) and table 7 (according stage).
Discussion
An understanding of the structure, the integrity and function
of the stratum corneum of the skin is closely connected with
pathogenesis of several dermatoses [6]. Many authors point out
that in dermatoses with a clinical picture of extreme dryness
and scratching there are the changes in skin barrier [7, 8, 9].
Clinical picture of LSC is represented by areas with dry, itchy
skin [10]. Greaves (2010) argues that the main symptom of
LSC - itch- causes constant scratching, which leads to additional
physical disturbance of the integrity of the surface layer of the
epidermis, and to further dysfunction of the skin barrier [11].
Information about the state of the lipid matrix, and consequently
to the integrity of skin barrier under various conditions gives the
measurement of TEWL and H of stratum corneum [12]. Darlenski
et al (2009 ) reported that quantitative indicators such TEWL
, H of the stratum corneum and the pH of the skin surface are
reliable, non-invasive techniques for monitoring the physical
properties of the skin barrier invivo [13]. All this give us grounds
to assess the levels of damage of the skin barrier by measuring
TEWL , and H of stratum corneum of the skin Measurement in
two zones (healthy and damaged skin) allow us to define the
role of the skin barrier status in pathogenesis of LSC. All these
scientific facts correlate closely with export results in our study.
Bouwstra and associates (2006) reported a correlation between clinical characteristics of skin diseases and changes in barrier function [14]. Other authors found no statistically significant relationship between disturbed homeostasis of the skin barrier and the expression of the disease symptoms [15]. The results from our study show the presence of such dependence
Bouwstra and associates (2006) reported a correlation between clinical characteristics of skin diseases and changes in barrier function [14]. Other authors found no statistically significant relationship between disturbed homeostasis of the skin barrier and the expression of the disease symptoms [15]. The results from our study show the presence of such dependence
Table 5: The results from measuring TEWL and H according age.
Table 6: The results from measuring TEWL and H according duration.
Table 7: The results from measuring TEWL and H according stage.
in dividing patients by disease severity. Thus, in patients with
moderate severity of disease mean value of TEWL was 31.22 g
/ m2 / h, while those with mild severity of disease have mean
value of 16.23 g / m2 / h.) (p = 0.009). Regarding the indicator
H in patients with moderate disease severity H in pathological
lesion was reported a mean of 25.88 units, while those with mild
severity of disease account mean 28.46 units) (p = 0.048) At the
same time dividing patients according the duration of disease
showed small differences between different groups. As the
most significant TEWL near pathological lesion was reported in
patients with disease duration of 19-24 months mean value of
27.30 g / m2 / h and those with duration longer than 24 months
- .mean value of '20 / m2 / h to 32 g / m2 / h (P = 0.003) Low
levels of H in the area to pathological lesions were measured in
patients with disease duration of 19-24 months- (median 23.15
units ) and those lasting longer than 24 months .from - 15 units to
22 units. (mean18. 75 units) (p = 0.001).
6 In 1985 Werner and associates published data for increase TEWL in healthy and pathological skin in a study of patients with atopic dermatitis. As a result, the authors presume primary defect in the epidermal barrier [16] Our results showed that from all included in the study patients only 30.95% had pathology in skin barrier(increased TEWL and decreased H ) in measuring of healthy skin stretch. Disturbed pathological function of skin barrier (increased TEWL and reduced H) in measuring of damaged skin was reported in 85.71%. These results questioned the existence of a primary defect in the epidermal barrier and its leading role in unlocking LSC. The correlation between the degree of damage of the skin barrier and severity of the disease give reason to assume that itch aggravate the disease and leads to the dysfunction of barrier homeostasis.
6 In 1985 Werner and associates published data for increase TEWL in healthy and pathological skin in a study of patients with atopic dermatitis. As a result, the authors presume primary defect in the epidermal barrier [16] Our results showed that from all included in the study patients only 30.95% had pathology in skin barrier(increased TEWL and decreased H ) in measuring of healthy skin stretch. Disturbed pathological function of skin barrier (increased TEWL and reduced H) in measuring of damaged skin was reported in 85.71%. These results questioned the existence of a primary defect in the epidermal barrier and its leading role in unlocking LSC. The correlation between the degree of damage of the skin barrier and severity of the disease give reason to assume that itch aggravate the disease and leads to the dysfunction of barrier homeostasis.
Conclusion
The absence of correlation between changes in hydration
and TEWL and some of the characteristics connected to the
disease means that in patients suffering from LSH there are
different independent pathological ways of development of
illness. Disorders of skin barrier could be described as a trigger
only of pruritoceptive pruritusin LSC. This study does not include
monitoring of patients before and after treatment but the results
suggest that the inclusion of local therapy which improves the
quality of skin barrier would have a good therapeutic effect.
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