Improved Outcomes With Holistic Approaches to Dermatology

Traditional dermatology is often practiced as a field separate from the rest of medicine, utilizing therapies and technologies to treat cutaneous complaints and skin cancers in isolation from primary care and subspecialty fields.

In recent decades, dermatology practice has been shifting from simply localized treatments of specific symptoms to the recognition of the skin as a general reflection of total body health.¹ In a review of cutaneous markers for diseases specific to lower extremities, podiatrist Joseph Vella wrote  that “the skin can be a window to people’s health.”² The skin is often the first point of access for infection and cutaneous symptomatology may sometimes signal developing disease or even fulminant systemic disorders. “Dermatologists are particularly well equipped—thanks to their highly specialized and robust 3-year dermatology residency training—to recognize the signs of systemic disease,” explained Torunn Sivesind, MD, a dermatology fellow at the University of Colorado Anschutz Medical Campus in Colorado.

Managing the Skin as an Organ System

Although traditional dermatology often responded to symptoms reported by patients looking for relief, holistic dermatology seeks to determine the overall health of the skin, identifying areas of where the integrity may be compromised.¹ More importantly, it asks the question: Why?

Holistic approaches look beyond superficial symptoms for the underlying causes, which requires a broader scope of knowledge and careful attention to seemingly unimportant details. According to Dr Sivesind, the holistic approach “relies on careful history-taking of the patient’s current skin complaints, and a complete skin examination. An assessment of the patient’s general medical history, family history, and medications should be taken. Often, history and visual clues provide the primary means of identifying skin disease, although additional tests such as blood tests and skin biopsies may also be needed to make or confirm a diagnosis.”

Skin Disorders as Potential Markers for Systemic Diseases

Cutaneous symptoms are common to people with long-active systemic diseases, but may be early signs of unrecognized disorders. Multiple types of skin lesions are associated with diabetes, including diabetic dermopathy, present in 40% of patients with diabetes, Bullosis Diabeticorum, a rare early sign of diabetes, and lipid deposits known as diabetic eruptive xanthomas.² 

The skin often manifests signs of disruption of the immune system. Recent updates on the pathogenesis of psoriasis, for example, suggest that the cutaneous plaques and pain are caused by an immune-mediated inflammatory response to physiologic and environmental triggers in genetically susceptible individuals.³ Psoriasis is also associated with the comorbid presence of many systemic diseases, including hyperlipidemia, hypertension, coronary artery disease, type 2 diabetes, and obesity. Most often it is linked with the development of systemic psoriatic arthritis.³

Necrobiosis lipoidica (NL) is a condition that starts with papules that evolve into plaques and is associated with sarcoidosis, inflammatory bowel disease, autoimmune thyroiditis, rheumatoid arthritis, and monoclonal gammapathy.² More than 75% of patients presenting with NL will develop diabetes.²

Cutaneous vasculitis, in which cellular extravasation from the blood vessels produces a range of lesions that often erupt on the legs, arms and torso, may be a self-limiting or a sign of pronounced rheumatologic dysfunction associated with systemic lupus erythematosus, Sjögren syndrome or rheumatoid arthritis. It may also signal underlying infection or an adverse reaction to a drug therapy.⁴ Patients who have more than a cutaneous form of vasculitis cannot be successfully treated symptomatically, and are at higher risk for poor outcomes.⁴

Raynaud’s syndrome may be suggestive of a number of underlying diseases, such as systemic sclerosis, systemic lupus erythematosus, dermatomyositis, Buerger disease, cryoglobulinemia and cold agglutinin disease. 

Dr Sivesind pointed to numerous other skin manifestations that may suggest an underlying disorder, including:  

· Pruritus (associated with renal, hepatic, hematologic, or oncologic disease) 

· Seborrheic dermatitis (Parkinson’s, HIV, stroke – appears on the scalp in a unilateral distribution corresponding to the affected hemisphere) 

· Urticaria/hives (medication or food reaction, sometimes infection) 

· Erythema multiforme (infections, such as HSV and mycoplasma pneumoniae; drug sensitivity) 

· Vitiligo (autoimmune thyroid disease, insulin-dependent diabetes, pernicious anemia, Addison’s disease) 

· Erythema nodosum (strep throat in kids, other infectious causes, drug sensitivity, inflammatory bowel disease, sarcoidosis) 

· Acanthosis nigricans (obesity, insulin resistance, malignancy – usually GI, medications) 

· Photosensitivity (lupus, drug sensitivity) 

· Patches and/or plaques (psoriatic arthritis, scleroderma, dermatomyositis, reactive arthritis)

The Skin Microbiome

General skin health depends on a the right balance of skin microbiota to provide the body’s first line of defense against infection, and the skin microbiome does so via a continuous cycle of dynamic host-bacterial reactions to the environment.^5,6 The skin microbiome is an evolving organ system throughout life, in response to constant diverse microbiotic exposure from the moment of birth.⁵

In addition to showing precursive or comorbid signs of systemic disease processes, immunologic disruption of the skin  microbiome has also been implicated in many of the common types of skin problems, such as acne, rosacea, and atopic dermatitis, and delayed wound healing.⁵ 

Holistic Approaches to Skin Health

A 2018 review by Musthaq et al⁶ referred to “the potential for therapeutic manipulation of the microbiome,” as an important area of investigation for treatments of the full range of dermatologic disorders. In recognition of the profound effects of diet on the gut microbiome, the impact of nutrition on the skin microbiome is receiving greater attention as well. Chronic nutritional deficiencies have been implicated in a range of skin disorders and contribute significantly to poor wound healing, as patients who are malnourished experience slower wound healing and are at higher risk for the development of pressure ulcers and infections.⁷ 

Prebiotics, and probiotics, are increasingly being recommended to help restore and maintain skin health.⁸ In conjunction with resident bacteria, the addition of supplemental probiotics can enhance healthy immune responses and eliminate pathogens harmful to skin.⁸ Prebiotics are often added to cosmetics for direct application to the skin to increase selective activation and growth of healthy skin microbiota.⁸

Lifestyle Modifications to Promote Good Skin Health

When approaching the body as a whole, it becomes easily recognizable how many of the lifestyle modifications that have shown benefits in systemic disease have important implications to treatment of skin disorders. “A growing body of evidence shows that modifiable lifestyle factors (smoking, alcohol, diet, exercise, sleep, stress), as well as systemic characteristics such as hormonal balance and psychological health, have an effect on dermatologic outcomes,” Dr. Sivesend reported.  “Therefore, a holistic approach that addresses the person as a whole, taking these factors into account, can augment the treatment of skin conditions and improve prognosis,” she said.

References

1. Hu S, Anand P, Laughter M, Maymone MBC, Dellavalle RP. Holistic dermatology: An evidence-based review of modifiable lifestyle factor associations with dermatologic disorders. J Am Acad Dermatol. 2020 Apr 29:S0190-9622(20)30724-6. doi:10.1016/j.jaad.2020.04.108

2.  Vella J. Cutaneous Markers of Systemic Disease in the Lower Extremity. Clin Podiatr Med Surg. 2016;33:423-40. doi:10.1016/j.cpm.2016.02.009

3.  Rendon A, Schäkel K. Psoriasis Pathogenesis and Treatment. Int J Mol Sci. 2019;20:1475. doi:10.3390/ijms20061475

4. Micheletti RG. Cutaneous vasculitis in rheumatologic disease: Current concepts of skin and systemic manifestations. Clin Dermatol. 2018;36:561-566. doi: 10.1016/j.clindermatol.2018.04.012

5. Luna PC. Skin Microbiome as Years Go By. Am J Clin Dermatol. 2020;21(Suppl 1):12-17. doi:10.1007/s40257-020-00549-5

6. Musthaq S, Mazuy A, Jakus J. The microbiome in dermatology. Clin Dermatol. 2018;36:390-398. doi: 10.1016/j.clindermatol.2018.03.012

7. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25:61-8. doi: 10.1177/0884533609358997.

8. Al-Ghazzewi FH, Tester RF. Impact of prebiotics and probiotics on skin health. Benef Microbes. 2014;5:99-107. doi: 10.3920/BM2013.0040. Abstract.