Diseases and Conditions Overcoming Inflammation

Can UV light trigger lupus flares?

July 12, 2017

Now that summer is finally in full swing, I’d like to remind everyone to use broad spectrum sunscreen while enjoying the sun! This is especially important for people living with systemic lupus erythematosus (SLE). Ultraviolet (UV) light is a known trigger of SLE flares BOTH involving the skin and major organs. Many people also report joint pain, weakness, and headaches. These flares can be very serious.

Although we know UV light is a trigger for SLE flares, we still don’t fully know how it happens. This is what we do know.

UV light directly damages the DNA of skin cells.
The cells release inflammatory cytokines, most notably interleukin-1α and tumor necrosis factor-α.
UV light also increases interferon-α signaling. People with high levels of interferon-α signaling often develop fevers, fatigue, and low white cell count (leukopenia). Interferon-α signaling is thought to be an important part in the development of SLE.

Take home points

So while you’re enjoying the sun remember to:

Avoid the sun when UV light is strongest, between 10 AM and 3 PM. If you use IFTTT, check out this app. You will get a notification on your phone when the UV index is high… and it’s free!
Use broad spectrum UVA/UVB sunscreen. Try to aim for a SPF higher than 30.
Try wearing clothing that have vivid colors and a tight weave. The Skin Cancer Foundation has a great article regarding this topic: “What is Sun-Safe Clothing?”
Wear a broad-brimmed hat when spending time in the sun.

Be safe and please leave your comments below!

References

Fernandez D, Kirou KA. What causes lupus flares? 2016 Mar;18(3):14. doi: 10.1007/s11926-016-0562-3.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions

Will hydroxychloroquine hurt my eyes?

May 24, 2017

I love hydroxychloroquine. Honestly, I really do. It’s simple, easy, it works, and for the most part it’s benign especially when compared to the rest of the medications I prescribe. Rheumatologists use hydroxychloroquine (Plaquenil) to treat of lupus, mild cases of rheumatoid arthritis, and many other autoimmune diseases.

Now I said benign. Well I actually said, “for the most part it’s benign”. Allergic reactions are always a concern but the main concern I have with hydroxychloroquine is the possibility of developing eye toxicity. More specifically, hydroxychloroquine maculopathy. But before I continue, I think it’s important to go through some anatomy.

Anatomy of the Eye

The following is a simplified version of the human eye. The cornea is the clear part of the eye that lets you focus light into your eye. The iris regulates the amount of light you let into your eye. The pupil is the dark part of the eye. This is where light actually goes into the eye. The lens focuses light so that it hits the retina just right and the retina actually senses light. This info is then condensed onto the optic disc and then sent to the optic nerve then into your brain.

Where does hydroxychloroquine fit in?

Now this is the important part because this is where hydroxychloroquine can cause problems: the macula. The macula is a specialized place on your retina that has cells that enable you to see fine details with high acuity. We call these specialized cells cones and they are found in high density in this area. The macula is then made up of the fovea, foveal avascular zone, parafovea, and the perifovea. The following is a real life example courtesy of Danny Hope.

By Photograph: Danny Hope from Brighton & Hove, UK Diagram: User:Zyxwv99 [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Now the prospect of losing the ability to see things clearly sounds absolutely terrible. I’ve been wearing glasses since I was 13. Without them, everything is blurry. I can’t even imagine the blow to my quality of life, if I didn’t have my glasses. Hydroxychloroquine is kind of like that. Your vision becomes blurry, except glasses won’t help, and the vision loss is permanent.

So why would anyone go on this medication and why would your doctor even suggest it?

Well… because it’s actually a pretty good medication. Just like most medications, you need to take it as safely as possible. The American Academy of Ophthalmology released a statement last year about monitoring hydroxychloroquine. Let’s go over these recommendations together!

Recommendations on Screening for Hydroxychloroquine Retinopathy (2016 Revision)

First of all, it’s still unclear how exactly hydroxychloroquine causes eye toxicity. In a nutshell the outer layer of the retina gets damaged and then it deepens and spreads around the fovea. People tend not to notice anything at this stage. Over time, if the medication is not stopped, the fovea becomes involved and visual acuity drops. It’s also important to note that hydroxychloroquine can worsen even after stopping the medication. If it’s caught early on, it probably won’t affect vision. If there already was a lot of damage to begin with, then the risk is higher. So the real question is what is the real risk of developing toxicity, what are the factors that increase that risk, and how often should you get screened by an ophthalmologist?

What is the real risk of developing hydroxychloroquine eye toxicity?

In the past, we thought the risk of developing eye toxicity from hydroxychloroquine was very low. New data suggests otherwise. Although the risk is still low, we were probably underestimating the risk. Researchers following 2,361 people using hydroxychloroquine, found that about 7.5% of those people had eye toxicity. The most important risk factors included the daily dose of hydroxychloroquine and duration of use.

People who took 4 to 5 mg/kg/day of hydroxychloroquine had a much lower cumulative risk as compared to people you took a higher dose: 1% risk in the first 5 years and less than 2% up to 10 years. After 20 years the risk dramatically increased to 20%.

When I mean mg/kg/day, I mean the amount of drug for every kilogram of body weight over a 24 hour period. To calculate the dosage of hydroxychloroquine you need to use your real weight, NOT your ideal weight. For some medications, it’s the opposite. Let’s say you were taking hydroxychloroquine 200 mg twice a day and then you started dieting and exercising, and then you shed a lot of weight. You now may need to decrease your daily dose of hydroxychloroquine because your real weight decreased. In the study, the researchers found that thin people tended to have more eye toxicity because they tended to get more than 4 – 5 mg/kg/day of hydroxychloroquine.

FYI When calculating your body weight to verify your hydroxychloroquine dose, you need to use metric. This is not optional.

1 kilogram = 2.2 pounds

Other Significant Risks

Initially we thought hydroxychloroquine gets stored in fat cells. In actuality, recent lab studies show that the medication is mostly stored in melanotic tissue, liver, and in the kidneys. Muscle, fat, and other organs not so much. That being said, people with severe kidney disease are at higher risk of developing eye toxicity. These people may need more frequent eye testing and they may not need as high of a dose.

Other significant risks includes concurrent use of tamoxifen, which is a medication commonly used to help treat breast cancer. The researchers found that there was a 5-fold increase of toxicity in people taking tamoxifen and hydroxychloroquine. Why? Tamoxifen itself can affect the retina, so maybe having both on board simultaneously isn’t such a great idea.

Finally, people with macular or retinal issues, like having macular degeneration, may also be at higher risk. There wasn’t enough results to confirm this, but it kind of makes sense. If he retina isn’t too hot to begin with, it’ll probably be difficult for the ophthalmologist to decide whether future changes are medication-related versus disease-related, in this case macular degeneration. Do you need to stop hydroxychloroquine? Or do you need to start ranibizumab (i.e., a medication FDA approved for macular degeneration)?

Screening Schedule

As I mentioned before, hydroxychloroquine eye toxicity is not reversible. Once it happens, it happens. So the trick is to catch it early. Fortunately, the changes occur VERY slowly. The American Academy of Ophthalmology recommends the following:

Obtain a baseline eye exam within the first year of starting hydroxychloroquine to document any complicating eye problem.
Annual screening beginning after 5 years of use.
Sooner if there are major risk factors.
Check the dose of hydroxychloroquine based on your weight at your doctor’s appointment.
Inform your doctor if there’s been any significant change in your health: significant weight loss (intentional or unintentional), kidney disease, or if you’ve been prescribed tamoxifen.

Now you may wonder why your rheumatologist insists on annual eye checks even though you’ve been on hydroxychloroquine for less than 5 years. This is probably a matter of style. Personally, I’m one of those rheumatologists that insists on annual eye checks. I wouldn’t feel comfortable NOT seeing my ophthalmologist if I was taking a medication that had retinal toxicity.

Screening Tests

There are many different techniques to screen for toxicity. I won’t go into specifics because, well, I’m not an ophthalmologist. However, here is a list of techniques that the American Academy of Ophthalmology approved to screen for hydroxychloroquine eye toxicity.

Automated visual fields
Spectral-domain optical coherence tomography
Multifocal electroretinogram
Fundus autofluorescence
Microperimetry – newer test, possible value in future
Adaptive optics retinal imaging – newer test, possible value in future

These tests are not recommended for screening

Fundus examination
Time-domain optical coherence tomography
Fluorescein angiography
Full-field electroretinogram
Amsler grid
Color testing
Electro-oculogram

If you have any questions about these tests, please ask you ophthalmologist.

Conclusion

Hydroxychloroquine is truly wonderful and useful medication for the treatment of multiple different types of autoimmune diseases. Although eye toxicity is a real danger, the risk is usually small especially in the short-term. But like I said at the beginning, like medications you need to take it safely and responsibly. To learn more about medication safety, please read my article regarding the 10 most frequently asked questions when starting methotrexate.

Please leave your comments below!

By Jessica Chapman, M.D.

References

https://commons.wikimedia.org/wiki/File:Schematic_diagram_of_the_human_eye_en.svg

https://commons.wikimedia.org/wiki/File:Macula.svg

Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF, American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). Ophthalmology. 2016 Jun;123(6):1386-94.

UpToDate

1 Comments

Diseases and Conditions

How to prepare for pregnancy with an autoimmune disease

April 5, 2017

Pregnancy can be a major concern for women living with an autoimmune disease. How will it affect baby? How will if affect mommy? If you so happen to be one of those women and you thought that pregnancy was out of the question for you because of your illness… think again.

Pregnancy with an autoimmune disease

Pregnancy with an autoimmune disease requires careful planning. First, it’s extremely important to have an open and honest discussion with your rheumatologist before thinking about conceiving, preferably 6 to 12 months before. In fact, you should have a similar discussion with everyone on your care team: primary care provider, hematologist, nephrologist, pulmonologist, cardiologist, etc. It’s also important to establish care with a high-risk OB-GYN, preferably someone who has experience caring for people with your condition and who delivers in a hospital staffed by rheumatologists.

During this time your care team plan will work with you to:

Make sure your disease is well controlled on a stable regimen for at least 6 months.
Remove medications that could potentially cause problems for your baby and replace them with safe alternatives.
Identify and anticipate for potential risks that could negatively affect your pregnancy.

High risk medications

Because it would be completely unethical to conduct a randomized controlled study on pregnancy outcomes and exposure to disease modifying agents (DMARDs), the vast majority of evidence regarding the safety of medications during pregnancy comes from animal models and registries such as OTIS: autoimmune diseases in pregnancy project. The following are considered safe to use during pregnancy:

Hydroxychloroquine
Azathioprine

What about biologics?

Again, available data is limited due to the fact that you can’t recruit people into studies to answer these sort of questions. Mounting evidence suggests that TNF-inhibitors are probably safe. However, if I were to choose one biologic, I would probably go with certolizumab for the simple reason that very little if any of it crosses the placenta.

Follow this link from the American College of Rheumatology regarding medication safety during pregnancy.

What about breastfeeding?

The NIH maintains a database called LactMed that contains information about medications and how they affect breastfeeding. The information is free and available to the public.

What does it mean to be high-risk?

Previous pregnancy with complications
Kidney disease
Heart disease
Lung disease (including pulmonary hypertension), very high risk
Flare of a rheumatic illness
A history of previous blood clot
Presence of SSA and SSB antibodies
Presence of antiphospholipids
IVF (in vitro fertilization)
Pregnancy with twins, triplets, etc.
Mother being over 40

SSA and SSB antibodies

SSA and SSB increase the risk of neonatal lupus. The risk is small, 1-2% of cases but the risk significantly increases in women who have already borne a child with neonatal lupus.

Children that are born with neonatal lupus may have a rash, liver problems, and low blood cell counts but thankfully, these symptoms disappear completely after about six months. Having neonatal lupus does NOT increase the risk systemic lupus erythematosus (SLE).

The most dreaded complication of neonatal lupus is complete heart block, which typically occurs at weeks 20 – 22. Your high risk OB-GYN will conduct frequent fetal cardiac tests during the “high risk period” +/- a few weeks. While it’s currently not recommended to use prophylactic steroids to prevent this from happening, if congenital heart block does occur, your doctor will most likely use steroids and in utero pacing.

Antiphospholipid antibodies

There are three types of antiphospholipids: lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoproteins. The presence of these antibodies, particularly at high titers, are associated with something called the antiphospholipid syndrome. People that have this condition have a higher risk of developing blood clots. Hence, they tend to get DVTs and pulmonary embolisms. Moreover, women tend to get miscarriages, stillbirths, pre-term deliveries, and preeclampsia. Since antiphosplipid antibodies increase the risk of clots, to prevent complications, women that have antiphospholipids should take “pregnancy-safe” blood thinners.

How does pregnancy affect disease activity?

It all depends on the disease. Typically SLE becomes more active during pregnancy, whereas rheumatoid arthritis and psoriatic arthritis tends to improve.

Lupus nephritis

HOWEVER, there are a few notable circumstances where pregnancy is risky for both the mother and the child. It’s generally not safe to conceive during a period of very high disease activity. This includes lupus nephritis. It’s generally discouraged to conceive when lupus nephritis is active, but when things are controlled it’s okay with very close monitoring. Patients with lupus nephritis commonly flare, are at higher risk of preeclampsia, and HELLP syndrome.

Pulmonary hypertension

Another very important high risk situation is pulmonary hypertension. This happens in systemic sclerosis, SLE, myositis, mixed connective tissue disease, Sjogren’s syndrome, and rheumatoid arthritis. When pulmonary hypertension is caused by an autoimmune disease, we call it connective tissue disease-related pulmonary arterial hypertension. Symptoms include:

Shortness of breath, particularly with exertion
Fatigue
Dizziness, passing out.
Chest pain
Swollen legs or swollen abdomen (ascites)
Palpitations
Bluish color

So why is this especially important for pregnancy-related matters?

A study by Qian et al. aimed to evaluate the survival of patient with SLE-associated pulmonary arterial hypertension. This was a systematic review and meta-analysis. They identified 6 studies which included a total of 323 patients. They found that 1-, 3-, and 5-year survival rates were 88%, 81%, and 68% respectively. The more severe the pulmonary hypertension, the worse the outcome.

However, high pulmonary hypertension peripartal mortality is not an isolated incident related to SLE alone. It is elevated for all connective tissue disease-related caused of pulmonary arterial hypertension.

Conclusion

In conclusion, we’ve come a long way when it comes to rheumatic diseases and pregnancy. Way back when, it was generally discouraged in practically all circumstances. But things have changed. With careful planning and monitoring, many women with autoimmune diseases can now have safe pregnancies.

Medical Disclaimer

References

Kelley and Firestein’s Textbook of Rheumatology, tenth edition

American College of Rheumatology

Pasut G. Pegylation of biological molecules and potential benefits: pharmacological properties of certolizumab pegol.BioDrugs. 2014 Apr;28 Suppl 1:S15-23.

Moroni G, et al. Maternal outcome in pregnancy women with lupus nephritis. A prospective multicenter study. J Autoimmun. 2016 Nov;74:194-200.

Thakkar V, Lau EM. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol. 2016 Feb;30(1):22-38.

Qian J, et al. Survival and prognostic factors of systemic lupus erythematosus-associated pulmonary arterial hypertension: A PRISMA-compliant systematic review and meta-analysis. Autoimmun Rev. 2016 Mar;15(3):250-7.

Diseases and Conditions

What is Raynaud’s Phenomenon?

February 1, 2017

Raynaud's phenomenon: Classic white discoloration of the pinky

What is Raynaud’s? They do say that a picture is worth a thousand words.

In a previous article about scleroderma, I alluded to something called Raynaud’s phenomenon. Tis the season of the Raynaud flare, so I thought this post would be especially relevant.

This phenomenon is super common. Some studies estimate that it occurs in 3 to 4% of the population but it’s probably a lot more than that. In colder climates its is present in up to 30% of the population. It’s more common in women, in younger people, and it tends to run in families.

Raynaud’s is a vasospastic disorder. Basically the blood vessels clamp up when exposed to the cold, when there is a sudden change in temperature, or sometimes when you are extremely stressed out. No joke! Cigarette smoking is also a known cause. Typically, the finger goes white, then dusky, and when the blood comes back, bright red. If the change in color involves the palm, this is not Raynaud’s.

Raynaud’s can be associated with many conditions. And they’re not all autoimmune.

Autoimmune – scleroderma, lupus, rheumatoid arthritis, Sjogren’s syndrome, myositis
Vibration injury – riveters, rock drillers, etc.
Frost bite
Medications and chemicals – beta blockers, cocaine, chemo
Arterial diseases – carpal tunnel, clots, pressure from a crutch
Hormonal diseases – low thyroid, pheochromocytoma
Hyperviscosity syndromes – paraproteinemia, polycythemia, cryoglobulinemia
Infections – Lyme, hepatitis, endocarditis
Cancers – ovarian cancer, lymphoma, leukemia

And then there’s the most common cause… just cause. Idiopathic primary Raynaud’s. Typically, this occurs in women during their teens or 20’s. There are a lot more causes but these are some of the common and… not so common ones.

Primary Raynaud’s vs. Secondary Raynaud’s

When Raynaud’s is idiopathic, this means that it is NOT caused my any underlying condition. This is primary Raynaud’s. When there IS an underlying condition, we are dealing with secondary Raynaud’s.

In primary Raynaud’s, the blood vessels are structurally normal. In secondary Raynaud’s, the structure of the blood vessels can deform because of the underlying cause.

Secondary Raynaud’s can cause finger ulcers, pitting, fissuring, and gangrene. People tend to have an ANA and or antibodies. In addition sometimes the doctor can actually see that the blood vessels above your nails look distorted using a pocket microscope. While, you don’t see any of these things with primary Raynaud’s.

Can people with primary Raynaud’s develop secondary Raynaud’s

The simple answer is YES. About 1% of patients with primary Raynaud’s develop some form of autoimmune disease yearly. There are a few risk factors that increase that risk.

Having any specific antibody like anticentromere antibodies
Abnormal blood vessels above your nails
Having a ANA with a nucleolar pattern
First flare after the age of 40 years
Male gender
Finger ulcers, pits, gangrene

If you have any or a few of these, it’s important to see a rheumatologist periodically to make sure that you aren’t developing an autoimmune disease. Early diagnosis is key.

How do you treat Raynaud’s?

Keep your hands and feet warm and, keep your core temperature warm. Easier said than done. I know, I grew up in Canada! The trick is layering, mittens, scarves, and warm socks. Need to remove your gloves to answer your phone? Don’t. Either wear touchscreen friendly gloves or convert them. I recently discovered nanotips. It does the job. Note, this is NOT an affiliate marketing link. Basically, try to avoid triggers like the cold, stress, or any chemicals that could cause it in the first place. Known chemicals include cigarettes, decongestants, diet pills… stimulant drugs. Some heart medications may also worsen Raynaud’s. Before making any changes, talk to your doctor.

Fish oil to treat Raynaud’s

When it comes to conventional medications, you do have a few options. Provided you are not allergic to fish, omega-3 fatty acid supplementation could be beneficial. One of my teachers/colleagues, conducted a double-blind, controlled, prospective study looking at fish oil supplementation in patients with both primary and secondary Raynaud’s phenomenon back in the 80’s. Basically, 3 grams of fish oil daily improves tolerance to cold exposure and delays the onset of vasospasm in patients with primary Raynaud’s. This effect was not seen in people with secondary Raynaud’s.

Medications for Raynaud’s

Finally, doctors sometimes prescribe medications like calcium channel blockers: amlodipine and nifedipine. These are generally considered first-line and help about 35% of people. Calcium channel blockers like verapamil and nicardipine are essentially useless. Other medications include prazosin, sildenafil, and talalafil. All of these can decrease your blood pressure. For those with normal or low blood pressure, fluoxetine is a possibility. Although this is an anti-depressent, it’s thought that the increase in serotonin dilates the blood vessels thereby alleviating Raynaud’s. Sometimes topicals are effective: nifedpine and nitroglycerine. But again, sometimes they can cause a drop in blood pressure. Again, this does not constitute medical advice. Please talk to your doctor before making any change.

What about finger or toe threatening situations

Sometimes Raynaud’s is particularly severe and refractory to medications. This tends to happen with people suffering from scleroderma. Sometimes, you can see gangrene because the decrease in blood flow is so severe. Obviously, you don’t want it to get to that point. In these situations, hospitalization often times is necessary. Consequently doctors use medications like epoprostenol or iloprost to aggressively open up those blood vessels. Surgical intervention may also be necessary: sympathectomy. It can be performed at the cervical, lumbar, wrist, or digital (finger) levels. These interventions are reserved for very severe cases.

What’s the prognosis

For primary Raynaud’s prognosis is excellent. Simply a nuisance for the most part. However, in high risk people, it’s important to see a rheumatologist on an annual basis to see if anything changes. Thankfully, in about 10% of people the attacks disappear completely with time.

In contrast, things are little more complicated with secondary Raynaud’s. It really depends on the underlying problem. Remember this is treatable. Not curable, but treatable.

I hope this has been informative and enlightening. Remember, bundle up and stay warm this winter!

References

Rheumatology Secrets, 3^rd Edition

DiGiacomb RA, Kremer JM, Shah DM. Fish-oil dietary supplementation in patients with Raynaud’s phenomenon: a double-blind, controlled, prospective study. Am J Med. 1989 Feb;86(2):158-64.

4 Comments

Tips and Tricks

Simple and easy ways to hydrate your skin

January 23, 2017

Introduction

Dry, flaky skin got you down? A lack of proper hydration is often the culprit behind dull, lackluster skin. Hydrated skin is essential for maintaining a glowing, radiant complexion. Read on to learn the science-backed methods to restore moisture, bounce, and a healthy glow to your skin.

What is Skin Hydration?

Skin hydration refers to the process of delivering moisture to the skin cells and retaining it in the epidermis (the outermost layer of skin). Hydrated skin has enough water content for the skin to look and feel soft, plump, and supple. Skin that lacks sufficient hydration becomes dry, flaky, and tight. Properly hydrated skin is better able to withstand damage from environmental stresses like pollution, sun exposure, and harsh weather. It also has a more youthful, healthy appearance with fewer visible fine lines and wrinkles. Hydration is essential for proper skin function and homeostasis [1].

When the skin is hydrated, the cells become engorged with water, causing them to plump up. This provides structural stability and resilience to the skin. Hydration also allows skin cells to carry out normal physiological functions like tissue repair, barrier function, and shedding of dead skin cells. Skin that lacks hydration becomes less efficient at protecting against irritants, bacteria, and the early signs of aging. Furthermore, water makes up the base of the skin’s surface layer – without adequate hydration, this surface layer dries out and cracks, which can accelerate aging. Properly hydrating your skin is key to maintaining healthy, youthful skin over time [2].

Why Skin Hydration Matters

Keeping your skin properly hydrated provides many benefits for a youthful, healthy appearance. Hydrated skin is plump and supple, with a dewy, radiant glow. The skin barrier is strong to lock in moisture and keep out irritants when it has enough water content. As we age, skin naturally loses the ability to retain moisture, so it’s especially important for women over 25 to focus on hydration.

The best thing about keeping your skin hydrated is that it can help reduce the look of fine lines and wrinkles. Water makes the skin fuller, smoothing out dryness and crepey texture. By staying hydrated regularly, you can improve the elasticity and firmness of your skin, which can reduce sagging and wrinkles. Proper hydration can also help fight flakiness, tightness, and roughness.

In contrast, the consequences of dehydrated skin are amplified signs of aging. Research shows that insufficient hydration leads to up to 50% more fine lines and wrinkles by age 40. Without adequate moisture, the complexion looks dull, skin feels irritated, and makeup applies unevenly. Long term, extreme dehydration can even cause the skin to crack and become prone to infection.

By making skin hydration a priority with high quality moisturizers, humectant serums, and hydrating skin care routines, women can maintain a youthful complexion with fewer wrinkles and a healthy, radiant glow.

Causes of Dehydrated Skin

There are several factors that can cause the skin to become dehydrated and lacking in moisture. Environmental exposures like sunlight, heat, and cold temperatures can strip moisture from the skin [1]. As we age, the skin’s natural ability to retain moisture decreases leading to increased dryness [2]. Using harsh soaps, over-exfoliating, and excessive hot water can disrupt the skin barrier and deplete natural moisturizing factors [3]. Certain medical conditions like eczema, psoriasis, diabetes, and thyroid disorders can also contribute to dehydrated skin [1].

[1] https://www.medicalnewstoday.com/articles/dehydrated-skin
[2] https://bodewellskin.com/blog/dehydrated-skin/
[3] https://www.theskinsmith.co.uk/what-is-the-cause-of-dehydrated-skin/

Hydrating Ingredients

There are several ingredients that help hydrate skin in different ways:

Humectants

Humectants are ingredients that attract and bind moisture to the skin. They pull water from the dermis and the air into the epidermis. Common humectants include:

Glycerin – a natural humectant that draws moisture into the skin (https://www.paulaschoice.com/ingredient-dictionary/ingredient-skin-conditioning-ingredients.html)
Hyaluronic acid – attracts and binds up to 1000x its weight in water for plump, hydrated skin

Occlusives

Occlusives create a protective barrier on the skin to prevent moisture loss. They seal hydration into the skin. Examples include:

Petrolatum – provides an occlusive layer to lock in moisture
Dimethicone – seals hydration and smooths the skin

Emollients

Emollients fill in cracks between skin cells and smooth the skin. They help skin retain moisture. Common emollients:

Ceramides – naturally found in skin, supplementing them prevents moisture loss
Plant oils like jojoba, almond, and olive oil – nourish skin and provide fatty acids

Using a combination of humectants, occlusives, and emollients is ideal for hydrating different layers of the skin.

Maximizing Absorption

To get the most out of your hydrating skin care products, it’s important to maximize absorption. Here are some research-backed tips:

Apply products to damp skin after cleansing. Damp skin acts like a sponge, quickly absorbing serums, lotions and creams compared to dry skin [1]. Be sure to pat your face dry with a towel instead of rubbing.

Use gentle, circular motions when applying products. Massaging products into the skin in smooth, circular motions can increase penetration compared to simply smoothing products on [2].

Apply products from thinnest to thickest texture. Starting with lightweight serums and ending with richer moisturizers allows each layer to fully absorb before applying the next.

Finish with a protective layer like petroleum jelly. Applying an occlusive layer like petroleum jelly over hydrating products seals in moisture and prevents evaporation from the skin’s surface [3].

Signs of Properly Hydrated Skin

When your skin is properly hydrated, you’ll notice some clear signs. Hydrated skin appears plump, smooth, and dewy rather than tight or flaky. Here are the main signs your skin is getting the moisture it needs:

Plump, smooth skin texture. Hydrated skin will lack wrinkles and feel supple to the touch, rather than dry and rough.

Minimal flaking or tightness. If your skin is properly hydrated, it won’t peel, crack, or feel uncomfortably tight, especially after cleansing.

Healthy, natural glow. With adequate moisture levels, your skin will exhibit a radiant, illuminated sheen rather than looking dull.

According to experts at First Impressions Clinic https://firstimpressionsclinic.ca/2023/03/06/how-to-hydrate-your-skin-this-winter/, properly hydrated skin also does not appear thin or sunken in. The right moisture balance keeps skin looking full and firm.

Lifestyle Tips for Hydrated Skin

In addition to using topical skincare products, there are several daily habits that can help maintain well-hydrated skin:

Drink plenty of water. Getting adequate water intake helps your body stay hydrated from the inside out. Aim for the recommended 8-10 glasses per day.

Eat foods rich in omega-3 fatty acids. Foods like salmon, walnuts, and chia seeds help strengthen the skin barrier and lock in moisture. Omega-3s also help reduce inflammation that can lead to dryness.

Limit hot showers. Extremely hot water can strip the skin of oils. Keep showers warm, not steaming hot, and avoid excessive showering.

Use gentle cleansers. Harsh soaps and cleansers disrupt the skin barrier, causing moisture loss. Opt for gentle, hydrating cleansers without sulfates. Use hypoallergenic products when possible.

Protect skin from sun damage. UV exposure can dehydrate and thin the skin over time. Wear SPF 30+ sunscreen daily.

Adapting these simple lifestyle habits into your daily routine can keep your complexion hydrated, healthy and glowing.

Conclusion

Properly hydrating your skin is key to maintaining a youthful, healthy glow. By understanding what dehydrates skin and how to counteract it with both topical products and lifestyle habits, you can get your complexion looking plump and radiant. Be sure to drink plenty of water, eat omega-3 rich foods, limit hot showers, and apply hydrating serums and occlusive moisturizers. Implement a gentle but thorough skincare routine with ingredients like hyaluronic acid and glycerin to draw moisture into the skin and seal it in. With some discipline and the right products, dry, flaky skin doesn’t stand a chance. Get started today on your journey towards maximizing hydration for smooth, supple skin.

Final Topic Callouts

When your epidermis lacks water and lipids, the many essential functions of the skin become compromised. However, with knowledge of the causes, targeted ingredients, and smart skin care techniques, you can get your skin glowing again. Some key takeaways from our discussion on hydrating your skin:

Applying products to damp skin ensures better absorption of hydrating ingredients like glycerin and hyaluronic acid into the deeper layers of the skin.
Exfoliating aids hydrating products by removing dead cells that can prevent effective penetration.
Occlusive ingredients like petrolatum seal in existing moisture and prevent water loss through the skin’s outer barrier.
Limiting hot showers, staying hydrated, and eating omega-3 rich foods can support your topical routine.
Look for plumpness and a dewy glow, instead of flakiness and tightness, to assess proper hydration.

With some diligence to your skin care regimen and lifestyle, you can achieve a supple, quenched complexion.

Diseases and Conditions Featured

What is a positive ANA and what does it mean?

December 12, 2016

What does it mean to have a positive ANA also known as an antinuclear antibody? This is a loaded question and the answer is complex. The answer is usually quite personalized to the person and their symptoms. The answer also usually entails follow-up bloodwork and evaluation by a rheumatologist. But in simple terms, an ANA is an antibody directed towards the nucleus of a cell.

How is an ANA measured?

The ANA is calculated by taking a standardized cell from the lab and mixing it with a person’s blood. If a person has antinuclear antibodies, these will stick to the standardized cells’ nuclei. At this point, there’s no way for us to know whether this has happened, so the lab tech adds fluoresceinated antibodies to the mix. These antibodies bind to ANAs that stuck to a nucleus. With the help of a specialized microscope, the lab tech can now visualize the ANA because the fluoresceinated antibodies make them light up.

My doctor told me my ANA was high. What does that mean?

Unfortunately, the tech cannot count how many ANAs they see. Instead, they see how much they can dilute the blood and still see the fluoresceinated antibodies. So when you see and ANA of 1:80, that means the tech really wasn’t able to dilute very much. This is a low level. If you see a value of 1:640, that means they were able to dilute a lot more. This is a higher level.

So how much dilution is enough to consider an ANA as positive? That answer really depends on the lab. Every lab has different cut off values, but in general, an ANA of 1:80 is typically considered positive. Whether it’s clinically significant, is a whole different question. This is where the art of medicine comes into play. But before that, let’s talk about patterns because those are important too.

Positive ANA patterns

So let’s take an example. Your doctor runs an ANA and it comes back as 1:320 speckled pattern. So what does that mean? When the lab tech was looking at the fluoresceinated antibodies, it basically literally looked speckled. There are many other kinds of patterns: homogenous, centromere, nucleolar, speckled, rim etc. Each of these patterns possibly indicate the presence of specific nuclear antibodies. For example, the presence of a speckled positive ANA indicates the presence of these specific autoantibodies, SSA, SSB, RNP, Smith, and Ku antibodies. These specific nuclear antibodies are themselves associated with specific autoimmune diseases. It’s important to take ANA patterns with a grain of salt because interpretation highly depends on experience.

I’m not going to go more into details about specific nuclear antibodies because first, there’s about 150 of them and second, they’re all associated with different diseases lupus being one of them. That’s a lot of material to cover in one article.

When is a positive ANA clinically significant?

Now that we understand what an ANA actually is, we can now start to approach the subject of clinical significance AND when you should be tested.

The problem with the ANA is that it can be found in normal healthy people.

ANA 1:40 is found in 20 – 30% of healthy people
ANA 1:80 is found in 10 – 15% of healthy people
ANA 1:160 is found in 5% of healthy people
ANA 1:320 is found in 3% of healthy people
5 – 25% of healthy people with a family member suffering from lupus have a positive ANA
Up to 70% of people aged above 70 years have a positive ANA

To complicate things even more, someone who is about to have and autoimmune disease can have a positive ANA… UP TO 10 YEARS before they actually develop the disease. Cancer and infections can also cause someone to have a positive ANA. It can even be positive when people are taking certain medications. Not terribly helpful right?

Bad example

So someone runs an ANA just because and it’s positive.

Does it mean anything?
Is the person one of those healthy people that has a positive ANA?
Is the person going to develop an autoimmune disease in the future?

In this scenario, I would say that this test is of low clinical significance because that person did not have any symptoms. Because so many people who are completely healthy have an ANA, the test should only be run if a person has a symptom or better yet, multiple symptoms that potentially indicate the presence of an autoimmune disease like lupus, Sjögren’s syndrome, systemic sclerosis, mixed connective tissue disease, etc. In that situation, it is helping rule in or rule out certain diagnoses.

Good example

If you’ve read my earlier post, 8 important warning signs of scleroderma, you’ll remember that Raynaud’s phenomenon is an important red flag for scleroderma. The majority of people suffering from Raynaud’s have no underlying autoimmune disease but a small proportion does. This is the perfect scenario, where an ANA would be useful. If the ANA is negative, the person likely will NOT develop an autoimmune disease. If the ANA is positive, then the person has a high risk of developing an autoimmune disease like lupus, scleroderma or Sjogren’s syndrome.

Let’s wrap things up

Ultimately it all boils down to this simple fact: doctors treat people not numbers.

As a physician I care about symptoms and signs way more than lab tests. Don’t get me wrong, these tests are important. For example, over 99% of people suffering from systemic lupus erythematosus have a positive ANA. It’s pretty much safe to say that if someone tests negative for ANA, they likely don’t have lupus. FYI that other less than 1% usually have a positive SSA, they have a problem with their complement system, or they have a lot of protein in their urine (nephrotic syndrome).

I hope I’ve helped you better understand the elusive and mysterious positive ANA. If you’ve tested positive for an ANA and have more questions, I highly urge you to speak with your physician or local rheumatologist. And remember, doctors treat people not numbers.

References

Rheumatology Secrets 3^rd edition

Medical Disclaimer

5 Comments

Older

Newer