I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
A Review of Skin and the Effects of Aging on Skin Structure and Function
- Wed, 9/3/08 - 10:25am
- 1 Comments
- 14510 reads
Skin, the largest and most visible organ of the body, undergoes an aging process that presents multiple clinical manifestations and problems. Comorbidities that frequently increase as the body ages cause further deterioration in this important organ. Organ aging and failure, not usually visible processes, become evident when the skin is affected. In the failing individual, skin deterioration is the outward manifestation of faltering physiology. Even in the healthy aged population, normal and expected changes occur, leading to problems.
Functional skin changes over time produce many problems, but in the case of this visible organ, the physical changes also have significant psychological impact, affecting interpersonal interactions, body image, and the overall image of a person’s health.1 Understanding the changes in the skin associated with aging will aid the practitioner caring for the older individual. With the shift in the demographics of aging, understanding chronological skin changes is of increasing importance. By the year 2030, one in five Americans is expected to be 65 years or older; according to the 2000 US census, approximately one in eight people are over 65, an 11-fold increase since 1900.2,3
The changes associated with the aging process are best understood when compared with normal, young skin.4 Aging is a complex process leading to biologic attrition at the cellular level that is manifested in many ways. Senescence and apoptosis play a role in the aging processes of all cells — review articles affirm they are influenced by cumulative DNA damage from external and internal insults.5-8 These accumulated cellular changes likely contribute to the anatomical, functional, and physiologic changes of aging skin6,9 and likely account for much of the slowing of wound healing observed with aging.
Skin aging involves chronological or intrinsically aged skin and photoaged skin changes. As reviewed in the literature, photoaging is caused by repeated exposure to ultraviolet radiation; whereas, intrinsic skin aging is related to naturally occurring biological aging processes in sun-protected areas.10 A majority of the skin changes associated with aging are due to intrinsic aging rather than photodamage or lifestyle.11-13 The accumulation of cellular damage due to intrinsic aging and photoaging is not fully understood but the stress of free radicals from excess reactive oxygen species as a result of oxidative metabolism may lead to DNA mutations, oxidation of proteins resulting in reduced function, and oxidation of membrane lipids, resulting in abnormal transmembrane signaling and reduced transport efficiency. Incomplete repair of this damage over time leads to abnormal structure and function.5,6 Ultraviolet exposure will speed up chronological skin changes, suggesting similar molecular mediators and some similar outcomes of damage. With increasing age, the impact of photoaging increases and the effect of the underlying genetic tendencies decreases.12
References:
1. Gupta M, Gilchrest B. Psychosocial aspects of aging skin. Dermatol Clin. 2005:23:643–648.
2. US Bureau of the Census. An Aging World: 2001. Available at: www.census.gov/prod/2001pubs/p95-1.pdf. Accessed April 1, 2002.
3. Kosmadaki MG, Gilchrest BA. The demographics of aging in the United States. Arch Derm. 2002;138:1427–1428.
4. Kanitakis J. Anatomy, histology and immunohistochemistry of normal human skin. Eur J Dermatol. 2002;12:390–401.
5. Fisher G, Kang S, Varani J, et al. Mechanisms of photoaging and chronological skin aging. Arch Dermatol. 2002;38:1462–1470.
6. Yaar M. Mechanisms of aging. Arch Dermatol. 2002;138:1429–1431.
7. Campisi J. The role of cellular senescence in skin aging. J Invest Dermatol Symp Proc. 1998;3:1–5.
8. Jenkins G. Molecular mechanisms of skin ageing. Mech Ageing and Develop. 2002;123:801–810.
9. Chung JH, Yano K, Lee MK, et al. Differential effects of photoaging vs intrinsic aging on the vascularization of human skin. Arch Dermatol. 2002;138:1437–1442.
10. Fenske NA, Lober CS. Structural and functional changes of normal aging skin. J Am Acad Dermatol. 1986;15:571–585.
11. Montagna W, Carlisle K. Structural changes in aging human skin. J Invest Dermatol. 1979;73:47–53.
12. Guinot C, Malvy D, Ambroisine L, et al. Relative contribution of intrinsic vs extrinsic factors to skin aging as determined by a validated skin age score. Arch Dermatol. 2002;138:1454–1460.
13. Shekar SN, Luciano M, Duffy DL, Martin NG. Genetic and environmental influences on skin pattern deterioration. J Invest Dermatol. 2005;125:1119–1129.
14. Madison KC. Barrier function of the skin: “La Raison d’Etre” of the epidermis. J Invest Dermatol. 2003;121:231–241.
15. Elias PM, Choi EH. Interactions among stratum corneum defensive functions. Exp Dermatol. 2005;14:719–726.
16. Marakami M, Ohtake T, Dorschner RA, Gallo RL. Cathelicidin anti-microbial peptide expression in sweat, an innate defense system for the skin. J Invest Dermatol. 2002;119:1090–1095.
17. Braverman IM. The cutaneous microcirculation. J Invest Dermatol Symp Proc. 2000;5:3–9.
18. Oaklander AL, Siegel SM. Cutaneous innervation: form and function. J Am Acad Dermatol. 2005;53:1027–1037.
19. Hsieh ST, Lin WM. Modulation of keratinocyte proliferation by skin innervation. J Invest Dermatol. 1999;113:579–586.
20. Elias PM. The epidermal permeability barrier: from the early days at Harvard to emerging concepts. J Invest Dermatol. 2004;122:36–39.
21. Fore-Pfliger J. The epidermal skin barrier: Implications for the wound care practitioner, part 1. Adv Skin Wound Care. 2004;17:417–425.
22. Fore-Pfliger J. The epidermal skin barrier: implications for the wound care practitioner, part 2. Adv Skin Wound Care. 2004;17:480–488.
23. Skobe M, Detmar M. Structure, function, and molecular control of the skin lymphatic system. J Invest Dermatol Symp Proc. 2000;5:14–19.
24. Schmuth M, Ortegon AM, Mao-Qiang M, et al. Differential expression of fatty acid transport proteins in epidermis and skin appendages. J Invest Dermatol. 2005;125:1174–1181.
25. Elias PM, Feingold KR. Does the tail wag the dog? Arch Dermatol. 2001;137:1079–1081.
26. Nickoloff BJ, Naidu Y. Perturbation of epidermal barrier function correlates with initiation of cytokine cascade in human skin. J Am Acad Dermatol. 1994;30:535–546.
27. Wood LC, Elias PM, Calhoun C, et al. Barrier disruption stimulated interleukin-1· expression and release from a preformed pool in murine epidermis. J Invest Dermatol. 1996;106:397–403.
28. Rassner U, Feingold KR, Crumrine DA, Elias PM. Coordinate assembly of lipids and enzyme proteins into epidermal lamellar bodies. Tissue Cell. 2000;31:489–98.
29. Chuong CM, Nickoloff BJ, Elias PM, et al. What is the true function of skin? Exp Dermatol. 2002;11:159–187.
30. Stucker M, Strur A, Altmeyer P, et al. The cutaneous uptake of atmospheric oxygen contributes significantly to the oxygen supply of human dermis and epidermis. J Physiol. 2002;538:985–994.
31. Wang W. Oxygen Partial pressure in outer layers of skin: simulation using three-dimensional multilayered models. Microcirculation. 2005;12:195–207.
32. Waller J, Maibach HI. Age and skin structure and function, a quantitative approach (I): blood flow, pH, thickness, and ultrasound echogenicity. Skin Res Technol. 2005;11:221–235.
33. Kligman AM. Perspectives and problems in cutaneous gerontology. J Invest Dermatol. 1979;73(1):L39–L46.
34. Neerken S, Lucassen GW, Bisschop MA, Lenderink E, Nuijs TA. Characterization of age-related effects in human skin: a comparative study that applies confocal laser scanning microscopy and optical coherence tomography. J Biomed Opt. 2004;9:274–281.
35. Engelke M, Jensen J-M, Ekanayake-Mudiyanselages S, Proksch E. Effects of xerosis and ageing on epidermal proliferation and differentiation. Brit J Derm. 1997;137:219–225.
36. Gilhar A, Ullmann Y, Karry R, et al. Ageing of human epidermis: the role of apoptosis, Fas and telomerase. Br J Dermatol. 2004;150:56–63.
37. Yaar M, Gilchrest BA. Ageing and photoageing of keratinocytes and melanocytes. Clin Exp Dermatol. 2001;26:583–591.
38. Wulf HC, Sandby-Moller J, Kobayasi T, Gniadecki R. Skin aging and natural photoprotection. Micron. 2004;35:185–191.
39. Gilchrest BA, Murphy GJ, Soter NA. Effect of chronologic aging and ultraviolet irradiation on Langerhans’ cells in human epidermis. J Invest Dermatol. 1982;79:85–88.
40. Grewe M. Chronological ageing and photoageing of dendritic cells. Clin Exp Dermatol. 2001;26:608–612.
41. Gilchrest BA, Blog FB, Szabo G. Effects of aging and chronic sun exposure on melanocytes in human skin. J Invest Dermatol. 1979;73:141–143.
42. Tobin DJ, Paus R. Graying: gerontobiology of the hair follicle pigmentary unit. Exp Gerontol. 2001;36:29–54.
43. Gibson SJ. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain. 2004;20:227–239.
44. Besné I, Descombes C, Breton L. Effect of age and anatomical site on density of sensory innervation in human epidermis. Arch Dermatol. 2002;138:1445–1450.
45. Helmbold P, Lautenschläger C, Marsch WCh, Nayak RC. Detection of a physiological juvenile phase and the central role of pericytes in human dermal microvascular aging. J Invest Dermatol. 2006;126:1419–1421.
46. Ogrin R, Darzins P, Khalel Z. Age-related changes in microvascular blood flow and transcutaneous oxygen tension under basal and stimulated conditions. J Gerontol. 2005;60A:200–206.
47. Lavker RM, Zheng P, Dong G. Aged skin: a study by light, transmission electron icroscapy, and scanning electron microscopy. J Invest Dermatol. 1987;88:44s–53s.
48. Humbert P, Sainthillier JM, Mac-Mary S, et al. Capillaroscopy and videocapillaroscopy and assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cosmetic Dermatol. 2005;4:153–162.
49. Li L, Mac-Mary S, Marsaut D, et al. Age-related changes in skin topography and microcirculation. Arch Dermatol Res. 2006;297:412–416.
50. Millis AJ, Hoyle M, McCue HM, Martini H. Differential expression of metalloproteinase and tissue inhibitor of metalloproteinase genes in aged human fibroblasts. Exp Cell Res. 1992;201:373–379.
51. Bolognia JL. Dermatologic and cosmetic concerns of the older woman. Clin Geriatr Med. 1993;9:209–229.
52. Ghersetich K, Lotti T, Campanile G, Grappone C, Dini G. Hyaluronic acid in cutaneous intrinsic aging. Int J Dermatol. 1994;33:119–122.
53. Pasquali-Ronchetti I, Baccarani-Contri M. Elastic fiber during development and aging. Microsc Res Tech. 1997;38:428–435.
54. Zouboulis CC, Boschnakow A. Chronological ageing and photoageing of the human sebaceous gland. Clin Exp Dermatol. 2001;26:600–607.
55. Cawley EP, Hsu YT, Sturgill BC, Harman LE Jr. Lipofuscin (“wear-and-tear pigment”) in human sweat glands. J Invest Dermatol. 1973;61:105–107.
56. Foster KG, Ellis FP. Sweat responses in the aged. Age Ageing. 1976;5:91–101.
57. Kelly RI, Pearse R, Bull RH, Leveque JL, deRigal J, Mortimer PS. The effects of aging on the cutaneous microvasculature. J Am Acad Dermatol. 1995;33:749–756.
58. Rossi M, Cupisti A, Mariani S, Santoro G, Pentimone F. Endothelium-dependent and endothelium-independent skin vasoreactivity in the elderly. Aging Clin Exp Res. 2002;14:343–346.
59. Ghadially R, Brown B, Sequeira-Martin SM, Feingold KR, Elias PM. The aged epidermal permeability barrier. J Clin Invest. 1995;95:2281–2290.
60. Ye J, Garg A, Calhoun C, et al. Alterations in cytokine regulation in aged epidermis: implications for permeability barrier homeostasis and inflammation. I. IL-1 gene family. Exp Dermatol. 2002;11:209–216.
61. Rawlings AV, Scott IR, Harding CR, Bowser PA. Stratum corneum moisturization at the molecular level. J Invest Dermatol. 1994;103:731–741.
62. Wilhelm KP, Cua AB, Maibach HI. Skin aging: effect on transepidermal water loss, stratum corneum hydration, skin surface pH, and casual sebum content. Arch Dermatol. 1991;127:1806–1809.
63. Gallagher MD. Vitamin D metabolism and therapy in elderly subjects. Southern Med J. 1992;39:39–42.
64. Pillai S, Bikle D, Elias PM. 1,25-Dihydroxyvitamin D production and receptor binding in human keratinocytes varies with differentiation. J Biol Chem. 1988;263:5390–5395.
65. Aoyama H, Tanaka M, Hara M, Tabata N, Tagami H. Nummular eczema: an addition of senile xerosis and unique cutaneous reactivities to environmental aeroallergens. Dermatology. 1999;199:135–139.
66. Ananthapadmanabhan KP, Moore DJ, Subramanyari K, Misra M, Meyer F. Cleansing without compromise: the impact of cleansers on the skin barrier and the technology of mild cleansing. Dermatol Ther. 2004;17:16–25.
67. Hachem, JP, Crumrine D, Fluhr J, et al. pH directly regulates epidermal permeability barrier homeostasis, and stratum corneum integrity/cohesion. J Invest Dermatol. 2003;121:345–353.
68. Wilhelm KP, Wolff HH, Maibach HI. Effects of surfactants on skin hydration. In: Eisner P, Berardesca F, Maibach HI (eds). Bioengineering of the Skin: Water and the Stratum Corneum. Boca Raton, Fla: CRC Press;1994:257–274.
69. Tagami H, Kobayashi H, Zhen XS, Kikuchi K. Environmental effects on the functions of the stratum corneum. J Invest Dermatol Sym Proc. 2001;5:87–94.
70. Lodén M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am J Clin Dermatol. 2003;4:771–778.
71. Shin MH, Rhie G, Park CH, et al. Modulation of collagen metabolism by the topical application of dehydroepiandrosterone to human skin. J Invest Dermatol. 2005;124; 315–323.
72. Lenz H, Schmidt M, Welge V, et al. The creatine kinase system in human skin: protective effects of creatinine against oxidative and UV damage in vitro and in vivo. J Invest Dermatol. 2005;124:443–452.
73. Han B, Nimni ME. Transdermal delivery of amino acids and antioxidants enhance collagen synthesis: in vivo and in vitro studies. Connect Tissue Res. 2005;46:251–257.
74. Heinrich U, Tronnier H, Stahl W, Bejot M, Maurette JM. Antioxidant supplements improve parameters related to skin structure in humans. Skin Pharmacol Physiol. 2006;4:224–231.
75. Esrefoglu M, Seyhan M, Gue M, et al. Potent therapeutic effect of melatonin on aging skin in pinealectomized rats. J Pineal Res. 2005;39:231–237.
76. Bos JD, Meinardi MM. The 500 Dalton rule for the skin penetration of chemical compounds and drugs. Exp Dermatol. 2000;9:165–169
77. Berard F, Marty JP, Nicolas JF. Allergen penetration through the skin. Eur J Dermatol. 2003;13:324–330.
78. Stratigos AJ, Katsambas AD. The role of topical retinoids in the treatment of photoaging. Drugs. 2005;65:1061–1072.
79. Chiu A, Kimball AB. Topical vitamins, minerals and botanical ingredients as modulators of environmental and chronological skin damage. Br J Dermatol. 2003;149:681.
80. Tanno O, Ota Y, Kitamura N, Katsubi T, Inoues S. Nicotinamide increases biosynthesis of ceramides as well as other stratum corneum lipids to improve the epidermal permeability barrier. Br J Dermatol. 2000;143:524.
81. Mao-Qiang M, Feingold KR. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996;106:1096–1101.
82. Goldstein AM, Abramovits W. Ceramides and the stratum corneum: structure, function and new methods to promote repair. Intl J Dermatol. 2003;42:256–260.
83. Hall G, Phillips TJ. Estrogen and skin: the effects of estrogen, menopause and hormone replacement therapy on the skin. J Am Acad Dermatol. 2005;53:555–568.
84. Pinnell S. Cutaneous photodamage, oxidative stress, and topical antioxidant protection. J Am Acad Dermatol. 2003;48:1–19.
85. Rostan EF, DeBuys HV, Madey DL, Pinnell SR. Evidence supporting zinc as an important antioxidant for skin. Intl J Dermatol. 2002;41:606–611.
I can't believe I've been going for years without knowing that.
Reply to this comment »Post new comment