Monthly Archives: December 2011

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Skin: Your Face to the World

Is your skin the largest organ in your body?

That is a trick question that every medical student answers wrong at least once. The answer is “yes.” (Med students think of the heart and liver etc, and don’t realize the skin is an organ.) Given your skin is your interface with the world, it takes a fair amount of abuse. Yet despite this, it is a miracle of design and mostly stays intact.

The skin has much in common with a leather armchair at home. It is pretty hard to cut, rip or tear. It lasts almost forever, but looks pretty worn, even when it’s new.

The skin is covered with layers of dead epidermal cells. This is the body’s version of GORE-TEX® breathable shell. It is waterproof but allows sweat to escape. The waterproof part is absolutely essential to life. Your blood needs to be kept in a narrow range of sodium concentration (and other elements).

If your skin was freely permeable to water vapor it would dry up like a raisin. Skin is important for maintaining body temperature by controlling your sweat glands. Your body is fussy about staying at 98.6.

Going deeper into the skin we find the dermis. This is the strength layer of the skin. It has collagen and elastin elements. The collagen is what ligaments are made of and is very strong stuff. Its job is to keep the insides where they belong. Most of us are more concerned about the elastin. The elastin puts the tone in our skin, much like the waistband on your underwear. When the elastic/elastin breaks down, your shorts sag. Ah, but if only Fruit of the Loom made faces.

Sun and time inevitably break down elastin, keeping several industries busy.

Think of yourself as a rainforest. The skin has a unique ecology with tens of thousands of different bacteria, fungi and viruses. We mostly live in peace with this community, a quiet day in the rainforest. We have various relationships with these organisms from commensal to parasitic. Mostly they take up space on our skin and prevent something worse from growing. Kind of similar to “a healthy lawn grows few weeds” sort of thing.

Now the surface of skin looks more like a Thomas’® English Muffin than porcelain when magnified. There is oil on the skin surface secreted by sebaceous glands. Most of the bacteria live in this oil layer. That’s why we wipe you off with an alcohol pad before giving an injection. The alcohol acts like a solvent to remove the oil.

When you cut or chafe the skin, your own bacteria contaminates the wound and starts to grow. If you wait 12 to 24 hours there will be enough bacteria growing in the wound to cause an infection if the wound is closed (sutured). That is why it is important to close wounds promptly. Most wounds do best if closed within 12 hours. Some doctors don’t like to suture after even eight hours.

So if you think you might need sutures, get it checked out; right away. Until we get re-upholstery shops for bodies, we’d do well to keep the skin we have in good shape.

There are several things working against our desire to remain youthful — oxygen and age. Good luck avoiding either one of these. Oxygen is absolutely essential for life, but oxidizes pigments (free radicals and all that). Sun and oxygen combine to oxidize your house paint, making the color fade and develop cracks, not unlike sun-damaged skin.

Oxygen and sun (UV radiation) also cause breakdown of the elastin fibrils as we said before. Staying out of the sun, or using sunblock, is probably the single most important thing you can do for your skin.

Skin also likes moisture. Your skin will never feel softer than after a week in the tropics (rainforest). You might be bug bitten, grow mold, and have interesting hair, but your skin will feel great. Having said that, moisture from the inside is actually much more important than moisture from the outside. Remember the dead epithelial cells layers don’t let much into the skin from the outside.

What about the cosmetic industry? All the creams in the world will only work like a good leather conditioner. They might soften up the feel and prevent some cracking but they won’t create new skin. I hate to think of how many billions is spent on magic creams; my wife must have a dozen of them.

So if magic creams don’t do much, how about more radical approaches? You can sand down some of the outer dead skin layers-dermabrasion (or facial road rash). That will soften it up, and because it is so traumatic, the skin will be swollen for a while. The swelling stretches out the wrinkles. Kind of the healthy glow of road rash.

As a last resort, simply remove loose extra skin, thus tightening up the rest. Your neighborhood plastic surgeon can help you with that. Think of your underwear again, that stretched out old elastic waistband will stay on your backside if you take out a couple of inches, with a safety pin for instance.

You will still have crackly old elastic, but it will fit better — for a while.
So be mindful of the care and feeding of your skin. It’s the only part of you the world gets to see.

Take care of yourself (really).

Dr. B

What’s Behind Those Winter Blues

'Winter Fishing on Lake McDonald' photo (c) 2011, glaciernps - license:
The season got you down? Struggling with the motivation to get moving, even though you know it will help? Do you find the color red mildly depressing?

You may have a serious case of righteous indignation with the superficiality of life, or perhaps just the winter blues. While we don’t specialize in existential funks, we know something about depression and its cousin, colorfully named Seasonal Affective Disorder (SAD).

Our brains are immersed in a neurochemical and hormonal stew that is dauntingly complex, but a lot of work in the last decade has given us understanding of at least the broad strokes. It’s pretty complicated up in the head.

It is completely normal to slow down some in the fall; your body is conserving energy to get you through the cold winter.

For up to 10% of people, this is much more than simply banking the fires; it is a life changing and unwelcome annual ordeal. An affective disorder is a fancy way of saying a mood problem. The namesake symptom of SAD is depression.

Depression is usually associated with varying degrees of fatigue, increased need for food and sleep, weight gain and difficulty concentrating.
This occurring during the holidays is particularly irksome – when the need for energy is greater than normal. The increased appetite when the house is full of Christmas cookies is torture to anyone trying to maintain an ideal body weight.

An additional 10% of people have a milder form of the condition that may only have fatigue as a symptom.

The scientists tell us that the decrease in daylight triggers a decrease in brain serotonin and increase in daytime melatonin levels. You probably remember serotonin; that is the brain chemical that Prozac increases. Serotonin is good.

You would be right in deciding that medications like Prozac would be helpful in Seasonal Affective Disorder.

For those inclined toward more natural cures, we just need to trick your body into thinking it’s summer.

Your body mostly wants a sunbeam, like a cat. That is something we know how to do. Light therapy is essentially a portable sunbeam. The UV light is filtered out so you won’t get skin cancer, or unfortunately, a suntan. Light therapy with the intensity of 10,000 Lux seems to work the best, with 30 minutes every morning commonly recommended. Sitting in your sunbeam after work can also help, but occasionally causes insomnia. This treatment actually can work in as little as a week. That is three times faster than is usually seen with medical pill treatment.

Melatonin is also commonly used to treat Seasonal Affective Disorder. Melatonin is a hormone that is produced by your body in dim light. Taking supplemental melatonin in the afternoon can reset the hormonal clock.

Light therapy isn’t the only unusual treatment for SAD. Use of a negative ion generator in the bedroom at night shows a 50% response in patients with SAD.

Medications of the SSRI class work well but take a few weeks to become effective. Prozac is the best known SSRI, but any of them are effective.

The seasonal nature of Seasonal Affective Disorder favors the non-drug approach to the disorder. In people with SAD it usually returns each winter. Light therapy can be started in the fall before symptoms occur and can be useful in preventing the onset of SAD. Many find this more palatable than starting and stopping medications every year.

Seasonal affective disorder is often the cause of winter blues. A variety of treatments are usually well tolerated and effective. In the meantime, have a Christmas Cookie, can’t hurt.

Take care,

Dr. B