week regression study - Wiley Online Library

Journal Innoventions Journal of Cosmetic Dermatology, 11, 239–244

Does massage postapplication improve moisturizer’s efficacy? A 2-week regression study Saja H Hamed, PhD,1 Intesar Assakir, BSc,1 Abdul-Majeed Almalty, PhD,1 & Salameh Bweir, PhD2 1 2

Faculty of Allied Health Sciences, Hashemite University, Zarqa, Jordan College of Applied Medical Sciences, Al-Majmaah University, Riyadh, Saudi Arabia

Summary

Background Combining massage with moisturizer application is a popular technique in beauty spa sessions. The subjective positive psychological effects of massage with moisturizer application in hand and face beauty treatment are documented by many people attending spa sessions. The aim of this study was to objectively evaluate the effect of local effleurage massage as an external intervention on moisturizer efficacy. Methods In a regression-type study of 2-week, twice-daily application followed by 1 week of regression, 13 female subjects applied ‘‘off the shelf ’’ moisturizer twice daily on both forearms followed by 1 min superficial massage for one forearm randomized among subjects. The influence of massage after moisturizer application on skin barrier properties was evaluated by noninvasive measurements of transepidermal water loss (TEWL), skin capacitance, and skin elasticity at baseline, day 7, and day 14 during the treatment phase, and day 21 following a 1-week regression period, in which no moisturizer and no massage were performed on forearms. Results The tested ‘‘off the shelf’’ moisturizer in both ‘‘massage’’ and ‘‘no-massage’’ application protocols caused a comparable progressive improvement in skin hydration level and barrier permeability over the 2-week treatment period, which was maintained during the 1-week regression (no moisturizer) period. In addition, skin elasticity was similarly improved by both application protocols. Conclusion In this long-term study, the daily performance of massage after moisturizer application was not an effective external intervention for enhancing moisturizer efficacy. Keywords: moisturizer’s efficacy, noninvasive measurement, massage, skin hydration, regression analysis

Introduction For the skin to appear and feel normal, the water content of the stratum corneum must be >10%.1 Decreased water content in the stratum corneum (SC) can result in the commonly encountered condition of mild dry skin. Correspondence: S H Hamed, PhD, Faculty of Allied Health Sciences, Hashemite University, PO Box 150459, Zarqa 13115, Jordan. E-mail: [email protected] Accepted for publication February 5, 2012

2012 Wiley Periodicals, Inc.

Dry skin is a consequence of an increased transepidermal water loss (TEWL) that usually arises as result of a defect in the permeability barrier allowing excessive water to be lost to the atmosphere. The water-retaining capacity of the stratum corneum is highly dependent upon: (1) the presence of natural hygroscopic agents within the corneocytes (collectively referred to as natural moisturizing factor) and (2) the SC intercellular lipids orderly arrangement forming a barrier to transepidermal water loss (TEWL).2 Barrier perturbation is caused by several environmental elements that adversely affect the water-binding

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capacity of the stratum corneum such as harsh detergent, acetone, and frequent bathing. When skin becomes dry, it loses its flexibility, which leads to cracks and fissures especially in joints areas.3 The symptoms of dry skin can be treated by increasing the hydration state of the stratum corneum using ‘‘moisturizers.’’4 Moisturizers, ranked as one of the most used over-the-counter products, increase hydration state of the skin by increasing the hydration state of the stratum corneum with occlusive or humectant ingredients and by smoothing the rough surface with emollients.5 Effleurage massage is a massage technique in which the hand glides over the skin lightly without attempting to move the deep muscle tissue.6 Combining effleurage massage with moisturizer applications is frequently performed by cosmeticians in facial and hand beauty treatment. Massage treatment after moisturizer application is often perceived to be more of an art than a science. The positive physical and psychological effects of massage in rehabilitation of various conditions ranging from reducing musculoskeletal pain to decreasing depression and aggression have been documented.7 In addition, the positive effect of massage in ameliorating cosmetic-related problems such as cellulite is also reported.8 This study constitutes an objective evaluation of the effect of massage after moisturizer application on moisturizer’s efficacy and contributes to shed a light on this art frequently performed by cosmeticians after moisturizer application. Noninvasive devices for the objective assessment of moisturizers efficacy have been used. These devices are widely employed in measuring the cutaneous effect of skin-care products and provide the researcher with rapid quantitative data for nonvisible changes in skin that facilitate understanding of treatment effects on skin.9

Materials and methods Subjects

Healthy female adult volunteers (n = 13); aged 19– 24 years (20.23 year ± 1.17) participated in this study after giving their informed consent. Each volunteer served as her own control. The exclusion criteria were as follows: subjects with dermatitis, erythema, psoriasis, skin cracking, tattoos, or any lesions on their forearms; subjects receiving any local or systemic treatments (i.e., contraceptive bills, hormones, acne treatment, hypertension therapy, corticosteroids); and subjects who were pregnant or lactating.

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Product

The components of the ‘‘off the shelf’’ oil-in-water moisturizer are listed in Table 1. It is manufactured by an international reputable company and contains the widely used humectant glycerin as a second-listed ingredient. Glycerin is well known for its high moisturizing effect as well as for its confirmed physiological role.10 Study design

A single-blinded intra-individual controlled regression design was used to determine the long-term effect of daily, 1-min superficial massage on moisturizer efficacy. The protocol was designed based on the regression method,11,12 the most widely used clinical method for assessing the efficacy of moisturizers. The regression protocol was composed of a 2-week treatment period followed by a 1-week regression (no treatment). Prior to baseline measurements, subjects were asked to refrain from using moisturizers on their volar forearms 1 week before the study and to wash their forearms during this week in a prescribed manner twice daily (morning and evening) with a regular soap supplied by the researcher. On day 0, following the washout period, baseline values of transepidermal water loss (TEWL) using Tewameter TM 300 (CK electronics GmbH, Ko¨ln, Germany), hydration level using Corneometer CM 825 (CK electronics GmbH), and skin elasticity using Cutometer MPA 580 (CK electronics GmbH) were measured on predetermined three circular areas on midaspect of each forearm. The massage-treated and untreated forearms were randomized among subjects. Then subjects were trained to apply the same amount (one pump) of the ‘‘off the shelf’’ moisturizer to one forearm using only 10 standard strokes and to the other forearm using 10 standard strokes followed by 1-min superficial massage starting from the wrist and going upward in a horizontal direction, then going downward in a vertical direction relative to that of arm muscle fibers as shown in Figure 1. Subjects were asked to

Table 1 ‘‘Off the shelf’’ moisturizer ingredients list Ingredients: Water, Glycerin, Cetearyl Alcohol, Cetyl Esters, Ceteareth-20, Aloe Barbadensis Leaf Juice, Cucumis sativus (Cucumber) Fruit Extract, Dimethicone, C12-15 Alkyl Benzoate, Glyceryl Dilaurate, Mineral Oil, Stearic Acid, Cetyl Alcohol, Isopropyl Myristate, Propylene Glycol, Carbomer, Sodium Hydroxide, Methylparaben, Propylparaben, DMDM Hydantoin, Fragrance.



Figure 1 Massage performance technique after moisturizer application. Subjects performed 1-min superficial massage with their opposite forearm starting from the wrist and going upward in a horizontal direction then going downward in a vertical direction.

repeat the two application protocols twice daily for 2 weeks. All measurements were conducted at baseline, day 7, day 14, and day 21. The final evaluation was carried out on day 21 following a 1-week regression period, in which no moisturizer and no massage were performed on forearms as shown in Figure 2. To prevent the influences of nonabsorbed moisturizer components on the instruments readings, subjects were instructed to wash their forearm at least 2h before scheduled measurements and to skip applying the moisturizer on the morning before measurements at 1-week and 2-week time points.

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different predetermined areas on mid-aspect of each forearm were used in subsequent calculation. The water content of the stratum corneum was measured by the widely used Corneometer CM 825 (CK electronics GmbH) that registers the electrical capacity of the skin surface. According to guidelines pertaining to this technique,14 the probe was applied perpendicularly to the skin surface with a constant pressure for 1s recording time, and the readings, expressed in arbitrary units that are proportional to the skin hydration level, were recorded. Three measurements for each predetermined area on mid-aspect of each forearm were recorded, and the average values of the nine measurements ⁄ forearm were used in subsequent calculation. Elasticity parameters of the skin were determined using Cutometer MPA 580 (CK electronics GmbH). We used a 2-mm-diameter probe and applied a constant suction of 250 mbar for 2s followed by a relaxation time for 2s in three repetitions. The curves of the obtained skin values were analyzed using the software Cutometer MPA 580, and the mechanical parameter of interest: R0 (Uf; maximal extensibility), R5 (Ur ⁄ Ue; net elasticity), and R7 (Ur ⁄ Uf; elastic recovery) were obtained. Skin elasticity was measured on three predefined circular areas in the mid-aspect of each forearm, and the average values of the three measurements ⁄ forearm were used in subsequent calculation.

Skin parameters measurement

Noninvasive measurements have been performed following an acclimation period of approximately 30 min at a temperature of 22 ± 1 C and a relative humidity of 40 ± 6. Subjects were asked to avoid drinking caffeinated beverages at least 2 h before the measurements. Transepidermal water loss was quantified using Tewameter TM 300 (CK electronics GmbH) according to the guidelines of the Standardization Group of the European Society of Contact Dermatitis.13 The TEWL readings were taken 40 s after the application of the probe to the skin, when the TEWL level had stabilized. The average values of three measurements on the three

Data analysis

The measurements made for each parameter were summarized as the mean value ±SEM. The data were subjected to statistical analysis using repeated measures anova (SPSS Inc., Chicago, IL, USA) to determine whether there were differences among massage-treated vs. untreated forearms, then multiple comparison procedures were used to isolate these differences. In addition, paired t-test was used to compare studied parameters for each treatment groups at different time points with their baseline values. Values of P < 0.05 were considered statistically significant.

Figure 2 Schematic illustration of measurement protocol. Transepidermal water loss, hydration level, and skin elasticity were measured at baseline (day 0), day 7, day 14, and day 21.


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Results and discussion

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Δ TEWL (gm/m hr)

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Figure 3 Changes in Transepidermal water loss from baseline values for both massage-treated and untreated forearms over a 2-week treatment period, followed by a 1-week period with no treatment. Data represented as mean ± SEM (n = 13).

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Δ Skin hydration (A.U.)

In this study, all volunteers reported they had refrained from using topical products on both forearms 1 week before baseline measurements and washed them twice daily with the given regular soap according to the instructions. Following the washout week, baseline value of transepidermal water loss (TEWL) using Tewameter TM 300, hydration level using Corneometer CM 825, and skin elasticity using Cutometer MPA 580 were measured on predetermined three circular areas on mid-aspect of each forearm. Regarding baseline characteristics of the measured skin parameters, no statistical differences were found between groups. Subjects were trained to apply the same amount (one pump) of ‘‘off the shelf’’ moisturizer to each forearm using only 10 standard stroking. This number of stroking for the application of the moisturizer was found to be satisfactory in achieving a subjective feeling of good distribution and absorption of the applied amount of the moisturizer based on trials by the authors during study protocol development. In addition, subjects were trained to apply light-pressure stroke coming from the flat of the hand and to maintain the hand in contact with the skin throughout the 1 min for the forearm treated with massage after moisturizer application. Transepidermal water loss (TEWL) is an important indicator of stratum corneum functioning as a protective barrier for water loss. It represents the rate of passive diffusion of water through the SC and reflects the integrity of the skin because the stratum corneum functions as the main barrier to water loss.9,15 Both moisturizers’ application protocols decreased TEWL during treatment phase at 1-week as well as 2-week time points (Fig. 3). This decrease is significantly maintained up to 1 week after stopping moisturizer application for both massage (P = 0.026) and no-massage (P = 0.007) application protocol as compared with baseline values. Reduction in TEWL indicates an improved barrier function rather than simple occlusion by moisturizer residues as subjects were asked to skip applying the moisturizer on the morning before parameter measurements at 1-week and 2-week time points, and no moisturizers were used during the regression phase (after 1 week). No significant difference between massage-treated and untreated forearm was noted regarding TEWL levels at all tested time points (Fig. 3). Both protocols resulted in significant increase in skin hydration values during the treatment phase at 1-week (P = 0.0 and P = 0.001 for massage and no-massage protocol, respectively) and 2-week (P = 0.001 for both

14 12 Δ Hydration/ No massage

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Figure 4 Changes in skin hydration level from baseline values for both massage-treated and untreated forearms over a 2-week treatment period, followed by a 1-week period with no treatment. Data represented as mean ± SEM (n = 13).

protocols) time points as compared with their baseline values as shown in Figure 4. In addition, a comparable decrease in skin hydration values were observed for both forearms 1 week after stopping moisturizer application. No significant difference between massage-treated and untreated forearm was noted regarding skin hydration levels (Fig. 4), although a slight improvement in skin hydration level was observed for the massage-treated forearm as compared to untreated one at 1-week time points. The Mean and SEM for skin elasticity’s parameters R0, R5, and R7 were obtained for massage-treated and untreated forearms at each studied time point (Figs 5–7). No significant differences were found between moisturizer’s application protocols for the studied skin elasticity parameters. Both application protocols caused parallel improvement in skin elasticity, as measured by the Ur ⁄ Ue (R5) and Ur ⁄ Uf (R7) parameters, during treatment phase at



1.08 1.07 1.06

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1.03 1.02 1.01 1.00 0.99 0.98 0

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Figure 5 Cutometer measurement of net elasticity parameter (R5, Ur ⁄ Ue) for both massage-treated and untreated forearms over a 2-week treatment period, followed by a 1-week period with no treatment. Data represented as mean ± SEM (n = 13).

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1-week as well as 2-weeks time points (Figs 5 and 6, respectively). The improvement in skin elasticity declined 1 week after stopping moisturizer for both application protocols. It is well documented that the epidermal hydration produced by moisturizer influences mechanical properties of the skin.16,17 Thus, the improvement in skin elasticity parameters during the treatment phase and the decline thereafter could be correlated to changes observed in skin hydration levels (Fig. 4). In addition, both application protocols caused a comparable decrease in skin maximum distensibility (improved skin firmness) as measured by R0 (Uf) parameter starting from 2-week treatment point (Fig. 7). This improvement was maintained during the regression phase (i.e., 1 week after stopping moisturizer) in both forearms.

Conclusions

0.850 0.845 0.840

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Figure 6 Cutometer measurement of elastic recovery parameter (R7 = Ur ⁄ Uf) for both massage-treated and untreated forearms over a 2-week treatment period, followed by a 1-week period with no treatment. Data represented as mean ± SEM (n = 13).

Acknowledgments

0.30 0.25 0.20

R0= Uf

In this long-term study, the tested ‘‘off the shelf’’ moisturizer studied caused a significant increase in the water content of the stratum corneum, regardless of the application protocol, as early as the first week of treatment. This significant increase in skin hydration was accompanied by improvement in skin mechanical properties and a simultaneous decrease in TEWL that is maintained up to 1 week after stopping moisturizer application for both forearms. Apparently, the tested moisturizer is a typical good moisturizer that modifies the dry skin process rather than concealing it temporarily by either occlusion or humectancy, and superficial massage does not enhance its efficacy in the treatment of dry skin.

R0/ No Massage

0.15

R0/ Massage

This work was supported by the Hashemite University through the use of Skin Biophysical Measurements facilities. The authors would like to acknowledge Dr. Hatim S. AlKhatib (Faculty of Pharmacy, University of Jordan) for his helpful suggestions and discussions.

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References

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Figure 7 Cutometer measurement of maximum extensibility (R0 = Uf) for both massage-treated and untreated forearms over a 2-week treatment period, followed by a 1-week period with no treatment. Data represented as mean ± SEM (n = 13).


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