2014年7月16日水曜日

Topical steroids cause two kinds of atrophy – the epidermal atrophy and the dermal atrophy

  It is well known that topical steroids cause atrophy of the skin. However few people recognize that there are two kinds of atrophy. They are the epidermal atrophy and the dermal atrophy. 

The skin consists of three layers, i.e., epidermis, dermis and subcutaneous tissue. Topical steroids affect epidermis and dermis. The turnover of the epidermis is about 4-8 weeks while the dermis much longer. So the effect of topical steroids appears on the epidermis first. The epidermis becomes atrophic after two weeks’ application of topical steroids as shown in the following photo.

 Upper: before application of topical steroids. Lower: after application of topical steroids for two weeks.

 The macroscopic appearance of the epidermal atrophy can’t be distinguished from the normal skin. The thickness of the normal epidermis is about 0.2mm which is equal to the thickness of two sheets of copy paper. The thickness of the atrophic epidermis is equal to that of one copy paper. One can’t discriminate the difference of the two only by observation from outside though functional barrier ability is weakened in the atrophic epidermis of course.

 So the atrophic skin which is to be imaged by patients is not the epidermal atrophy but the dermal atrophy. The appearance of the dermal atrophy is so called paper-like skin, fine wrinkles or unevenness of the skin between follicles.
 Macroscopic appearence of the dermal atrophy

 The dermal atrophy is developed by the decrease of collagens in the dermis. The collagens are produced by fibroblasts very slowly and steroids suppress the activity of the production. So the dermal atrophy becomes visible after long-term application of steroids for more than several months or years. There is no mechanism which causes the dermal atrophy in atopic dermatitis itself. So I suspect most of dermal atrophy is the result of long term use of the topical steroids.

 The illustrated conceptual explanation of the two kinds of atrophy is as follows.

 When we discuss the atrophy of the skin due to topical steroids, we should be careful which of the atrophy is discussed. For example, one person might say ‘I don’t believe the skin atrophy occurs in only two weeks.’  He must be talking about the atrophy of the dermis. He is right in the dermal atrophy but the epidermal atrophy surely occurs in every human being in only two weeks though it is not visible and instinctively unacceptable.

 The epidermal atrophy occurs more rapidly than the dermal atrophy and it is reversibly recovered by discontinuance of topical steroids. The dermal atrophy is hard to be developed but the recovery after withdrawal from steroids is also slow and delayed. Both atrophies occur by aging also. Maybe the mechanism of atrophy due to steroids and aging is alike.

Hyaluronan (HA) lotion works on keratinocytes through the receptor of CD44 against atrophy due to steroids. How can the atrophy of the dermis be treated other than the passing of time? There is one method which I know, i.e., the PRP (platelet rich plasma) therapy.

PRP is rather common in the field of sports medicine or anti-aging medicine. It is rather an expensive treatment. However, I developed the economic method for preparing PRP. Please refer to the medical article which I published last month .
 http://journals.lww.com/prsgo/Citation/2014/06000/A_New_Economic_Method_for_Preparing_Platelet_rich.7.aspx

Platelets contain several growth factors which stimulate fibroblasts in the dermis. The activated fibroblasts produce collagens for several months and the macroscopic appearance is improved.
The following photos are before and after the treatment.

  Before PRP treatment

 Two months after PRP treatment

  The enlarged before and after photos.

 I believe the PRP therapy is very safe because PRP is prepared from the blood of the patient one’s self. I also believe the cost of PRP therapy becomes much more reasonable by adopting my method.
 There is a Youtube movie which I uploaded showing how PRP can be prepared by my economic method.
https://www.youtube.com/watch?v=gpeikkJhm0s

 The mainstay for the healing of topical steroid addiction is the time. It is surely the safest one but there are some other useful methods. PRP therapy is one of them for patients annoying delayed recovery of the dermal atrophy.
 Time can heal the topical steroid addiction. But time is not only one which helps your recovery. Believe and try to find your own way to exit.

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P.S. A figure from Dr. Sato’s medical article written in 1996 (As an answer to Dan.D in the below comment)