As a referral-only clinical dermatologist, I often see patients with severe skin diseases that the patient has been struggling with for a long period of time.

The problem is, as I mentioned in my previous articles this year, (in March and April, Skin Conditions and Disorders part one and part two) many skin diseases are multi-factorial. In other words, multiple processes account for the visible lesions. This means that simply prescribing a single oral or topical prescription medication will likely not clear the disease. Similarly, providing one type of office treatment focusing on fixing the symptoms and not the underlying complex processes will not keep the patient in long-term remission. It should be the goal of any skin care professional to assist your patients and clients in finding solutions that will work best with the individual’s unique circumstances to provide complete and long-term relief. This article will look at a variety of lifestyle choices that your clients can do at-home to improve and prolong the results of the treatment and medication options you provide. While these may appear to be fairly common sense suggestions, you may be surprised to find how few individuals implement these basic actions into their daily routine, primarily because they fail to realize the interconnection between the organ systems and the value of a healthy body for healing diseased skin.

Exercise
There are a plethora of articles touting the benefits of exercise from weight loss, prolonged life, circulation improvement, surviving surgery, cardiac events prevention, control of diabetes mellitus, cholesterol lowering affects, to prevention of cancer. It has also been documented that exercise modulates immunity, thus affecting inflammation responses. Moderate exercise improves immunity and stimulates increased synthesis of antioxidants and anti-inflammatory molecules present in the body. It also increases blood flow and joint flexibility. One additional benefit that is rarely mentioned, though, is the affects of exercise on skin health.
The American Heart Association and the American College of Sports Medicine released updated exercise guidelines in 2007. For individuals under 65 years of age, at least 30 minutes of moderate cardio exercise should be done five times a week or 30 minutes of intense cardio exercise at least three times a week. 1 Moderate is defined as able to speak while performing the exercise. Walking for 10 minutes three times daily produces 80 percent of the benefits of a 30 minute workout. Often patients will find these types of stipulations daunting. In these cases, the best approach is to encourage them to start small. Making minor changes in their daily routine to include some form of exercise can gradually increase to the recommendations listed above. Any exercise is helpful even if one has minimal mobility. For example, I had a patient who was in very poor health. After some discussion, I discovered that she would watch television every evening for a few hours in her wheelchair. My recommendation was that during every commercial break she do simple calf and foot raises as well as raise her arms above her head for the duration of the commercial break. At the next appointment, the patient excitedly told me about how much better she felt by incorporating this small change into his normal routine. In addition, her injected insulin requirement for diabetes dropped nearly 10 percent due to better control of her blood sugar.
Take the opportunity to listen to your client’s lifestyle history and help provide guidance. Perhaps your client lives or works in a building with stairs. If he or she normally takes the elevator, suggest walking up one or two flights of stairs before taking the elevator the rest of the way as a small start. The possibilities are endless, so try to be creative and help your client see what those small changes can be. Then continue to encourage additional small steps with the goal of being able to comfortably perform the 30 minutes of moderate exercise.

Diet
Although the wives’ tale about chocolate making your face breakout is a myth, a “poor” diet has been documented to contribute to exacerbation and severity of skin lesions, preventing proper healing and reducing remission time. As with exercise, sometimes it is better for your client to encourage small improvements that can gradually be added over time. An easy way is to recommend that with the largest meal your client takes a daily multi-vitamin with minerals. Incorporating at least one additional serving of preferably fresh fruits or vegetables a day should be encouraged. The reduction of sugar consumption is also critical in optimizing health.
Ingesting a multi-vitamin will help ensure that the appropriate levels of all the required nutrients, especially certain micronutrients, are being consumed. It is important to realize that nutritional supplements, including vitamins, are not controlled by the FDA. So be sure to ask for quality control dates on the product by the manufacturer. If you are concerned about your client’s diet, it may be beneficial to recommend a dietician speak with the client to assist in developing a food plan.
There are times when change in diet can dramatically impact specific skin diseases as well. Actinic keratosis growth can be stimulated by a high fat diet. Patients with atopic dermatitis, eczema, and psoriasis should avoid caffeine, chocolate, alcohol, and refined sugar to reduce itch and redness. Additionally, a high protein diet and often iron supplementation are needed to counteract the loss of protein and iron in the severe scaling of skin in those diseases. For acne and rosacea patients, foods and drinks that cause flushing such as spicy, hot temperature, or caffeine and alcohol aggravate inflammatory pustular lesions. A low glycemic load/high protein diet for 12 weeks produced a statistically significant decrease in total acne lesions from 21.9 to 13.8 percent compared to a conventional diet as well as decreased body weight and free androgen index.2 High anti-inflammatory diets appear to be beneficial for acne, rosacea, dermatitis, psoriasis and skin aging.
Photoprotective supplements can be very valuable for clients suffering with skin conditions which are sensitive to UV exposure. These include a combination of vitamins C, E, and melatonin. Individually, oral consumption of ferulic acid, green or black teas, alpha lipoic acid, oatmeal, soy, feverfew, goldenfern, and silymarin all reduce UV induced erythema. Some of these can be found in traditional multi-vitamins, but for some of the others your client may need to contact their local health food store to purchase. Vitamin D supplementation of 2,000 IU per day is recommended to prevent internal cancer. Half should come from sunlight, which can be obtained by the exposure of the head and neck for 20 minutes.

Protection from Environmental Factors
The majority of skin aging is directly tied to external factors, such as sun exposure. It is never too late to try to incorporate these good practices into ones routine. These are particularly important for patients who have a history of sun sensitivity or suffer from a disease linked to sun sensitivity.

1. Avoid being outdoors during the hours of 10 a.m. to 2 p.m. This is when the UV rays are the strongest. Remember that window glass does not screen out UVA light.
2. Apply broad spectrum sunscreen with at least SPF 30 daily. The American Academy of Dermatology recommends two applications 30 minutes apart to cool dry skin in the morning. Each application should contain two to four medium pea sized dabs to each side of the face.
3. Wear a cloth hat with a four to five inch brim when outdoors. Straw hats are not protective against invisible UV.
4. UV protective clothing, called UPF clothing, should be worn when outdoors for an extended period of time. There has been a movement toward creating fashionable and cost-effective UPF clothing so it is easy to incorporate.
5. No sunscreen can block all the UV rays. A sunscreen containing anti-inflammatory and antioxidant ingredients will be most protective. They help stop the damaging reactions from the UV that does penetrate the sunscreen. This prevents activation of the damaging chronic inflammatory cascades resulting in skin disease.

Topical Products
Now that we have discussed all the other things your client can be doing at home to help gain and maintain skin health, it is important to review their skin care regimen of products as well. Ensure that one product in the regimen has barrier repair properties. A healthy skin barrier is vital for the long-term health of the skin and helps prevent disease activation, prolong remissions, and limit severity and area of disease involvement. Products providing daily barrier repair will minimize the risk of penetration of pro-inflammatory environmental insulting including UV, while reducing destructive chronic inflammation.
In conclusion, your client must understand that there are limitations to the benefits that a skin care professional can provide. Rather, it is a partnership between the skin care professional and the client in order for the client to see great results. This includes not only compliance for product usage and post-treatment care, but also by incorporating the elements discussed in this article. Simply providing one type of treatment or topical products will most likely not provide the best results for a client.

References:
1 Haskell W, Lee I, Pate R, et al. Physical Activity and Public Health: Updated Recommendation for Adults from the American College of Sports Medicine and the American Heart Association. Medicine & Science in Sports & Exercise. 2007. 1423 – 1434.
2 Smith R, Mann N et al. The effect of a high protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris. J Am Acad Dermatol 2007; 57: 247-256.

Dr. Carl R. Thornfeldt is President, CEO, and Chief Scientific Officer of Episciences, Inc. He is a practicing dermatologist with 24 years of skin research experience, 21 U.S. patents granted, and over 19 scientific publications in the area of treatment of skin diseases and conditions, including chapters in five dermatological textbooks. Along with these accomplishments, he has also spent nearly two decades focusing on researching the skin barrier and cutaneous inflammatory conditions. Dr. Thornfeldt received his M.D. from the Oregon Health Sciences University, and completed his dermatology residency at University Hospital, San Diego, Calif.