Zgryźliwość kojarzy mi się z radością, która źle skończyła.
Mineral Waters: Instead of
Cosmetics or Better Than
Cosmetics?
ILARIA GHERSETICH, MD
BENEDETTA BRAZZINI, MD
JANA HERCOGOVA, MD
TORELLO M. LOTTI, MD
Definition of Cosmetics
C
osmetics are regarded as products, other than
sible to include in this group scalp seborrhoea, which in
mild cases can be considered to be simple greasy skin.
Dry skin appears rough, scaly, and cracked, and
patients refer to a sensation of tightness. Dry skin is
usually caused by increased transepidermal water loss,
consequent to a decrease in the stratum corneum bar-
rier function. Dry skin can be caused by the action of
external factors on normal or, rarely, greasy skin; it can
also be a constitutional condition, such as fragile skin,
senile skin, and the dry skin of atopic dermatitis.
3,4
Combined skin, or mixed skin, constitutes a frequent
variant of greasy skin. This type of skin is characterized
by the association, on the face, of areas of thickened skin
with a shiny aspect and slightly marked keratosis (se-
borrheic plaques) and areas of epidermal atrophy and
slight desquamation (plaques of dry skin). Usually
these subjects have an oily forehead and nose and very
dry cheeks and chin. In addition, in some cases high
levels of sebum and skin dryness may occur on the
same areas. This condition has been observed in pa-
tients who have excessive sebum secretion and who
define themselves as having greasy skin. This also in-
creased transepidermal water loss, which is indicative
for dry skin. Commonly, sebum is considered able to
retain water inside the skin and therefore increase skin
moisturization. Dry skin covered by big quantities of
sebum does not look dry because the sebum keeps the
dry skin cells glued onto the skin surface, reducing the
greyish, scaly, rough appearance of dry skin.
Combined skin is frequently observed in women
who choose the wrong cosmetics in trying to remove
the large amount of sebum that covers the skin; this also
induces more skin dryness by removing lipids neces-
sary for the correct equilibrium of the skin.
Sensitive skin has been defined by Maibach and
colleagues
5
as many clinical (and frequent) conditions
characterized by erythema, xerosis, pytiriasic desqua-
mation, and often associated with subjective sensations
such as burning or itching. The etiopathogenesis of this
condition is not completely known, but it has been
hypothesized that an altered degranulation of cutane-
soaps, intended to be rubbed, poured, sprinkled
or sprayed on, or otherwise applied to, the hu-
man body for cleansing, beautifying, promoting attrac-
tiveness, or altering the appearance of the skin.
1
This
definition includes such products as skin creams, lo-
tions, perfumes, cleansers, lipsticks, deodorants, and
face makeup.
Cosmetics are able to improve the structure, mor-
phology, and appearance of the skin through the activ-
ity of very specific ingredients; however, these changes
are not permanent and interrupting the cosmetic pro-
cess, will cause the reappearance of the skin problems.
Cosmetics are mostly used for the care of nonaffected
skin or as an adjuvant therapy for moderate skin dis-
orders. Advances in biochemistry and physiology of the
skin have enabled the development of specific products
for different skin types, divided according to cosmeto-
logic characteristics, particularly for moderate skin dis-
orders. When we observe our patients’ skin, it is possi-
ble to identify different types of skin, each one with
specific characteristics.
Normal skin has no visible lesions or sensations of
discomfort. It results from the equilibrium of various
continuous biological processes, which create a harmo-
niously balanced state of suppleness, elasticity, and
color.
Greasy skin
2
is characterized by skin thickening and
an increase in sebaceous secretion, giving the face a
shiny appearance, especially on the nose and forehead.
Complications frequently associated with greasy skin
include acne and seborrhoeic dermatitis. It is also pos-
From the Department of Dermatology, University of Florence, Florence,
Italy and the Department of Dermatology, University of Prague, Prague,
Czech Republic
Address correspondence to Torello M. Lotti, MD, Department of Der-
matology, University of Florence, Via Alfoni 37, 50121 Florence, Italy.
E-mail address: tlotti@unifi.it.
© 2001 by Elsevier Science Inc. All rights reserved.
0738-081X/01/$–see front matter
655 Avenue of the Americas, New York, NY 10010
PII S0738-081X(01)00186-9
Clinics in Dermatology
Y
2001;19:478 – 482
479
MINERAL WATERS: INSTEAD OF COSMETICS OR BETTER THAN COSMETICS?
ous basophils might have a role in its pathogenesis. This
skin condition needs particular care and attention when
treated with cosmetics.
In view of this classification, it seems very important
to consider the correct cosmetic for each specific skin
type to improve the structure and appearance of the
skin and to avoid inducing additional disorders. Not
only dry, mixed, and greasy skin types need attention
and the use of correct cosmetics, but also normal skin
needs care to maintain a correct equilibrium and to
protect it from external agents (especially from the sun).
Normal skin care is based on the use of hygiene
products, sunscreens, and hydrating agents. Fre-
quently, hygiene products, because of their powerful
detergent action, are hazardous to the skin, and their
overuse may decrease or even eliminate the protective
surface lipid film, which is important for physiological
balance of the skin, and induce irritation. Hydrating
agents are used primarily to protect the skin from ex-
ternal agents, such as wind and cold, and are frequently
used with sunscreens to protect the skin from the sun
and delay photoaging.
In caring for simple greasy skin, the essential re-
quirement is the reduction of the excess surface sebum
without inducing total delipidization. Frequently,
cleansing products are too aggressive and lead to severe
degreasment followed by an exacerbation of sebaceous
secretion, which defeats the initial desired aim. Facial
cleansing may be done with oily soaps or syndets fol-
lowed by copious rinsing; however, when treating
greasy skin it is very important to avoid comedogenic
products, and particular attention must be paid to the
choice of the oils used for the preparation of oily soaps.
Dry skin care is mainly based on avoiding harsh
rinsing and protecting from external agents with hy-
drating products. Ordinary soaps must always be
avoided, and only mild detergents can be used; even
very mild surfactants can induce an inflammatory re-
action on this delicate and very sensitive skin. Hydra-
tion of dry skin is of fundamental importance and can
be done by decreasing transepidermal water loss, using
an occlusive lipid film, or increasing the input of exter-
nal water, which is retained in the stratum corneum by
the addition of humectants.
Combined skin is probably the most delicate skin
type to treat, because it is frequently caused by using
the wrong cosmetics. Light oil-in-water emulsion
cleansers can be used to remove excess sebum from the
T-zone, as well as cleansers that contain a combination
of fatty acids and wax esters in a light emulsion to
ameliorate dry skin areas.
Even if the correct cosmetic is used, patients fre-
quently undergo adverse reactions to cosmetics. Reac-
tions to cosmetics can have a variety of presentations,
including subjective and objective irritation, allergic
contact dermatitis, contact urticaria, photosensitivity,
delayed hypersensitivity reactions, pigmentation, and
hair and nail changes. When these conditions occur, it is
necessary
to
substitute
the
cosmetic
products
with
agents free of adverse effects.
Mineral waters can be an effective substitute for
cosmetics being used as additional products for the
treatment of moderate skin disorders. They can also be
used for daily skin care of various cosmetic skin types.
The Use of Mineral Waters Instead of
Cosmetics
Mineral waters are natural solutions with three main
characteristics: spring origin, bacteriological pureness,
and therapeutic potentials.
6
Mineral waters may be
classified according to their chemical and physical char-
acteristics (capacity, temperature, fixed balance, molec-
ular concentration, chemical composition, presence of
distinctive oligoelements) or to their supposed or dem-
onstrated therapeutic actions. According to the temper-
ature at the spring, mineral waters may be classified as:
cold (less than 20°C); and hot (hypothermal between 20
and 30°C; thermal between 30 and 40°C; hyperthermal
over 40°C). On the basis of their chemical characteris-
tics, waters may be classified as oligomineral waters
(mineral balance of water less than 0.2 g/l), medium
mineral waters (mineral balance of water between 0.2
g/l and 1 g/l), and mineral waters (mineral balance of
water above 1 g/l).
6
To understand the specific indications in cosmetol-
ogy of the different types of spring waters, it is useful to
report a classification of mineral waters based on their
chemicophysical
characteristics.
Mineral
waters
can
therefore be classified as:
Y sulfurous, when at least one sulfur grade is present
Y arsenical,
when
arsenic
is
present
in
a
ponderal
amount
Y bromic,
when
bromine
is
present
in
a
ponderal
amount
Y iodic, when iodine is present in a ponderal amount
Y radioactive, when in a liter of water at least 1 mil-
limicrocurie is dissolved
Y carbonic, when it contains at least 300 ml of CO
2
per
liter.
6
Sulfurous waters have been considered for centuries to
be clinically valid for their detergent, keratoplastic, and
antimicrobic properties. Sulfur may be present in sul-
furated water as a free or combined ion.
7,8
Sulfur water
may comprise various combinations of sulfur ions, wa-
ter, and other ions; these include sulfur simple water,
sulfur sulfate water, sulfur carbonic water, and sulfur
salsobromoidic water.
The sulfur activity in the skin seems to be related
mainly to the interaction between this substance with
cysteine and with its catabolites. Sulfur, reacting with
480
Clinics in Dermatology
Y
2001;19:478 – 482
GHERSETICH ET AL.
cysteine, interacts with hydrogen sulfide (H
2
S), promot-
ing keratinization at low concentrations, a well-known
keratolytic effect that determines keratin proteolyti-
sis.
9,10
Sulfur may also interact with the oxygen radicals in
the deeper layers of the epidermis, producing sulfur
and disulfur hydrogen, which may in turn be trans-
formed into H
2
S
5
O
6
; this may be the source of the
antibacterial and antifungal activity of sulfur water.
11
Histological alterations of the skin caused by baths in
sulfur waters have been described. They include hyper-
keratosis, parakeratosis, and keratolysis that occur at
different concentrations of sulfur ions. After sulfurous
baths, dermal vessels are dilated and surrounded by a
perivascular infiltrate of mononuclear cells.
12
The efficacy of sulfur water in dermatology has been
described for both cosmetologic and moderate patho-
logic conditions. In particular, its detergent properties
can be used for greasy and mixed skin to remove excess
sebum without inducing skin delipidization and its
consequent irritation. This same property together with
its antimicrobic and keratolytic effects can be can be
used to treat mild acne.
The antibacterial and antifungal properties of sulfur
waters can explain why this type of mineral water is
effective in the treatment of infected leg ulcers, tinea
versicolor, tinea corporis, and tinea capitis.
13,14
Sulfur spa baths have also been successfully used as
an adjuvant treatment, instead of cosmetics, of moder-
ate manifestations of immune-mediated conditions
such as atopic dermatitis, contact dermatitis, and pso-
riasis, suggesting that the active principles of sulfurous
waters could play a role in regulating the immune
system of the skin.
15
Avne thermal water is an oligomineral water (min-
eral balance of water 210 mg/l), characterized by a high
concentration of silicates and trace elements, and a
neutral pH. Avne thermal water is very well tolerated
and has demonstrated dermatocosmetologic effects. It
is a valid hydrating agent that is very useful for dry skin
and itching conditions.
In vivo studies have also shown that this water is
able to reduce clinical parameters such as erythema,
itching, scaling, and burning in patients with sensitive
skin. Sensitive skin is defined as a group of conditions
characterized by slight or absent clinical and his-
topathological alterations and modified skin sensitivi-
ty
5,16
and intolerance to skin care and cosmetic prod-
ucts. Patients complain of facial itching, burning, and
discomfort accompanied, or not, by mild objective signs
such as erythema and scaling. In most cases, the sever-
ity of symptoms does not match the objective signs.
Two uncommon and extreme forms of this disorder are
represented by the so called “status cosmeticus” and
the cosmetic intolerance syndrome.
17,18
Status cosmeticus is a condition in which patients
experience subjective and objective irritation from cos-
metics (and frequently also to many other topical
agents) and can no longer tolerate their use. Some pa-
tients have seborrheic-rosacea diathesis that flares
when soap and water are abandoned and cleansers and
emollients are overused; other patients instead display
irritant dermatitis, allergic contact dermatitis, or contact
urticarial reactions caused by cosmetics. Only cosmetic
elimination is able to reduce these symptoms. In these
cases, it is useful to replace cosmetics with Avne ther-
mal water that can be used by patients as a cleanser and
is also able to reduce skin irritation and sensations of
discomfort until the patients can return to using cos-
metics (not before 8 –12 months).
The cosmetic intolerance syndrome represents the
extreme example of “status cosmeticus” and needs the
same treatment.
Many in vitro studies have been performed to un-
derstand how Avne thermal water exerts its effects.
These studies have demonstrated that this silicate-rich
oligomineral water is able to reduce the production of
IL-4 from Th2 cells and favor Th1 cell activity.
19
In
addition, Avne thermal water is able to reduce baso-
phil degranulation in atopic patients.
20
These data also
partially explain why an adjuvant therapy with this
water is effective in the treatment of atopic dermatitis,
allergic rhinitis, and conjunctivitis.
An other interesting thermal water with important
dermatocosmetologic effects is La Roche-Posay mineral
water. This water contains low levels of minerals, bi-
carbonate, calcium, and silicate, and has a particularly
high selenium content. Selenium is essential for normal
cell metabolism and has a protective effect on human
cells. Selenium plays a fundamental role in maintaining
cell integrity and neutralizing free radicals and toxic
organic peroxides in cells and tissues by virtue of its
glutathione peroxidase coenzyme activity.
21,22
Recently,
particular attention has been given to the effects of
selenium in dermatologic disorders. Selenium has been
demonstrated to be valid as an additional therapeutic
agent in the treatment of eczema, psoriasis, acne, and
burns, and it has been demonstrated to be protective
against photoaging because of its antioxidant proper-
ties.
Three studies have demonstrated the value of using
mineral water to prevent free radical damage. The first
two demonstrated the antioxidant activity of selenium-
rich mineral water on human cutaneous fibroblasts.
23,24
This in vitro study was performed on human fibroblast
cell cultures, compared the effects of mineral water,
demineralized water, and selenium-enriched deminer-
alized water. It was found that uptake of selenium, zinc,
and copper by fibroblasts was higher, and that cell
mortality due to oxidative stress (UVB and UVA radi-
ation, and hydrogen peroxide) was significantly re-
duced when mineral water was added to the culture
Clinics in Dermatology
Y
2001;19:478 – 482
481
MINERAL WATERS: INSTEAD OF COSMETICS OR BETTER THAN COSMETICS?
medium. The activity of the enzyme superoxide dis-
mutase in fibroblasts was greater in cells cultured with
mineral water. Selenium increased resistance to UVB
radiation, which neutralized free radicals, and zinc,
whose uptake was greater from mineral water than
from selenium-enriched demineralized water, pro-
tected thiol groups and strengthened lysosomal mem-
branes and microsomes.
The third study
25
analyzed the protection afforded
by the percutaneous application of selenium-rich min-
eral water against lipid peroxidation and skin carcino-
genesis induced by UVB radiation. This study, per-
formed on hairless mice subjected to repeated UVB
radiation for 25 weeks, compared the development of
skin tumors and analyzed skin samples taken from
three groups of mice: one group treated with a cream
containing selenium-rich mineral water, one treated
with a cream containing demineralized water, and one
that received no treatment.
There was a significant reduction in the rate of ap-
pearance of UVB-induced skin tumors, a reduction of
membrane lipid peroxidation, and an increase of sele-
nium-dependent glutathione peroxidase activity in the
group treated with cream containing mineral water.
Selenium-rich mineral water inhibited lipid peroxida-
tion and slowed down the rate of incidence of UVB-
induced carcinogenesis.
These studies thus demonstrate that oligoelements
(selenium and zinc) contained in mineral water are
effective in reinforcing the defensive system against
free radicals.
The anti-inflammatory activity of selenium-rich min-
eral water has been demonstrated in vitro through stud-
ies performed on Langerhans cells.
26,27
These studies
aimed to demonstrate the in vitro effects of mineral
water on the modulation of the cytokine production,
phenotype modulation, and migratory and stimulatory
capacities of Langerhans cells. The first study
26
ana-
lyzed the effect of selenium-rich mineral water on the
spontaneous or mitogen-derived proliferation of pe-
ripheral blood mononuclear cells (PBMC) and on the
stimulatory capacity of epidermal Langerhans cells in
the mixed skin–lymphocyte reaction. As controls, ly-
ophilized medium reconstituted with Millipore water
was employed. The PBMC did not show significant
variations of the spontaneous proliferation when cul-
tured alone in either medium. Instead, a strong inhibi-
tion of their proliferative response was observed after
coculture with allogenic epidermal cells in the medium
reconstituted with thermal water. The stimulatory abil-
ity of Langerhans cells is regulated by different cyto-
kines, i.e., interleukin (IL)-1, granulocyte macrophage-
colony stimulating factor (GM-CSF), or tumor necrosis
factor
be related to (1) a direct effect of one or more compo-
nents of thermal water on the functional maturation of
Langerhans cells; (2) an indirect effect by the induction
of TNF-
secretion by keratinocytes, which blocks the
stimulatory activity of Langerhans cells; (3) the inhibi-
tion of the secretion of cytokines by keratinocytes,
which may support the functional maturation of Lang-
erhans cells in vitro, like IL-1 and/or GM-CSF; or (4) by
a combined effect of all these mechanisms.
The second study
27
demonstrated that La Roche-
Posay thermal water inhibits the migration of sensitized
Langerhans cells and reduces the expression of the
activating molecules, HLA-DR, B7-2, and ICAM-1,
thereby enhancing its anti-inflammatory properties.
a
Conclusions
The detergent, anti-inflammatory, keratoplastic, anti-
pruriginous, and antioxidant properties of mineral wa-
ters can be used together with, or instead of, cosmetics.
Mineral waters do not have side effects and rarely
induce inflammatory reactions; therefore, they can be
safely employed in all skin conditions characterized by
extreme sensitivity and cosmetic intolerance.
Many mineral waters are available, each with its
specific chemical and physical characteristics. Before
treating dermatological disorders with mineral waters,
it is important to consider the specific indications of
each spa and select the correct waters for each clinical
case.
29
References
1. Federal Food, Drug and Cosmetic Act. Title 21, Part 1,
Section 201, US Department of Health, Education, and
Welfare, Food and Drug Administration. FDC Act and
Part 1 Regulations, 1964.
2. Daniel F. La peau sborrhique. Dermatologie 1985;35:
3215–24.
3. Curtil L. Amliorer les peaux sches. Rev Eur Dermatol
MST 1991;3:457– 64.
4. Gougerot A, Enjolras O. Amliorer les peaux sches
pathologiques. Rev Eur Dermatol MST 1992;4:75– 82.
5. Maibach HI, Lammintausta K, Berardesca K, Freeman S.
Tendency to irritation: sensitive skin. J Am Acad Derma-
tol 1989;21:833–5.
6. Lotti T, Ghersetich I. Le basi della dermocosmetologia
termale. In: Caputo R, M. Monti M, editors. Manuale di
dermocosmetologia,
Milan:
Raffaello
Cortina,
1995;62:
751– 62.
7. Scalabrino A, Galassi A, Pierallini F, et al. Le acque sul-
furee e le loro applicazioni in medicina termale. Current
1994;1:11–2.
8. Lotti T, Ghersetich I. Mineral waters: instead of soap or
better than soap? Clin Dermatol 1996;14:101– 4.
9. Benci M. L’impiego dello zolfo nella terapia dermato-
logica. Current 1994;1:17– 8.
10. Zunz E. Elements de pharmacodynamie special. Paris:
Masson & Cie, 1932.
). These cytokines are released by ker-
atinocytes during different activation states.
28
The suppressive activity shown in the study
28
could
a
(TNF-
a
482
Clinics in Dermatology
Y
2001;19:478 – 482
GHERSETICH ET AL.
11. Mc Murtry CW. Dermatologic therapeutics: Sulphur. J
Cutan Dis 1913;322:399 – 408.
12. Lorenc E, Winkelmann RK. Evaluation of dermatologic
therapy. Arch Dermatol 1961;83:761–7.
13. Salter WT. A textbook of pharmacology. Philadelphia: WB
Saunders, 1952.
14. Parish LC, Witkowski JA. Dermatologic balneology: The
American view of waters, spas, and hot springs. J Eur
Acad Dermatol Venereol 1994;3:465–7.
15. Ghersetich I, Lotti T. Immunologic aspects: Immunology
of mineral water spas. Clin Dermatol 1996;14:563– 6.
16. Ghersetich I, Tsampau D, Lotti T. L’eau termale d’Avene
nel trattamento della pelle sensibile. G Ital Dermatol Ve-
nereol 1992;127:29 –31.
17. Fisher A. Cosmetic actions and reactions: therapeutic,
irritant, and allergic. Cutis 1980;26:22–9.
18. Maibach HI. The cosmetic intolerance syndrome. Ear,
Nose Throat J 1987;66:49 –53.
19. Clot J. Effet de I’Eau d’Avne sur la production de cyto-
kines TH1 et TH2 dpendantes par des cellules mononucles
sanguines normales. 1994-Laboratoire d’immunologie (IN-
SERM Unit 291).
20. Sainte-Laudy J, Sambucy JL. Inhibition of human basophil
degranulation by Avne spring water. Int J Immunother
1987;4:307–12.
21. Rotruck JT, Pope AL, Ganther HE, et al. Selenium bio-
chemical role of component of glutathione peroxidase.
Science 1973;179(73):588 –90.
22. Peretz A. Selenium inflammation and immunity. In: Sele-
nium in medicine and biology. JN Favier JN, editor. Ber-
lin-New York: Walter de Gruyter & Co., 1988, 235– 46.
23. Richard MJ, Guiraud P, Arnaud J. Pouvoir antioxydant
d’une eau thermale slnie sur des fibroblasts cutans
humains
diploids.
Les
Nouvelles
dermatologiques,
1990;9.
24. Moysan A, Morli`re P, Marquis I, et al. Effects of selenium
on UVA-induced lipid peroxidation in cultured human
skin fibroblasts. Skin Pharmacol 1995;8:139 – 48.
25. Cadi R, Beani JC, Belanger S, et al. Effect protecteur de
l’application percutane d’eau theramle de la Roche-Po-
say vis- -vis de la peroxydation lipidique et de la carci-
nognse cutane induites par les UVB. Nouv Dermatol
1991;10:266 –72.
26. Staquet MJ, Peguet-Navarro J, Latourre F, et al. In vitro
effects of thermal water on the migratory and stimulatory
capacities of human epidermal Langerhans cells. Eur J
Dermatol 1997;7:339 – 42.
27. Wollenberg A, Richard A, Bieber T. In vitro effect of the
thermal water from La Roche-Posay on the stimulatory
capacity of epidermal Langerhans cells. Eur J Dermatol
1992;2:128 –9.
28. Ansel J. Perry P, Brown J. Cytokine modulation of kera-
tinocyte cytokines. J Invest Dermatol 1990;94:S101–7.
29. Lotti T, Ghersetich I. How spring waters work on the skin.
Life Chem Reports 1996;14:113– 8.
zanotowane.pl doc.pisz.pl pdf.pisz.pl hannaeva.xlx.pl
Cosmetics or Better Than
Cosmetics?
ILARIA GHERSETICH, MD
BENEDETTA BRAZZINI, MD
JANA HERCOGOVA, MD
TORELLO M. LOTTI, MD
Definition of Cosmetics
C
osmetics are regarded as products, other than
sible to include in this group scalp seborrhoea, which in
mild cases can be considered to be simple greasy skin.
Dry skin appears rough, scaly, and cracked, and
patients refer to a sensation of tightness. Dry skin is
usually caused by increased transepidermal water loss,
consequent to a decrease in the stratum corneum bar-
rier function. Dry skin can be caused by the action of
external factors on normal or, rarely, greasy skin; it can
also be a constitutional condition, such as fragile skin,
senile skin, and the dry skin of atopic dermatitis.
3,4
Combined skin, or mixed skin, constitutes a frequent
variant of greasy skin. This type of skin is characterized
by the association, on the face, of areas of thickened skin
with a shiny aspect and slightly marked keratosis (se-
borrheic plaques) and areas of epidermal atrophy and
slight desquamation (plaques of dry skin). Usually
these subjects have an oily forehead and nose and very
dry cheeks and chin. In addition, in some cases high
levels of sebum and skin dryness may occur on the
same areas. This condition has been observed in pa-
tients who have excessive sebum secretion and who
define themselves as having greasy skin. This also in-
creased transepidermal water loss, which is indicative
for dry skin. Commonly, sebum is considered able to
retain water inside the skin and therefore increase skin
moisturization. Dry skin covered by big quantities of
sebum does not look dry because the sebum keeps the
dry skin cells glued onto the skin surface, reducing the
greyish, scaly, rough appearance of dry skin.
Combined skin is frequently observed in women
who choose the wrong cosmetics in trying to remove
the large amount of sebum that covers the skin; this also
induces more skin dryness by removing lipids neces-
sary for the correct equilibrium of the skin.
Sensitive skin has been defined by Maibach and
colleagues
5
as many clinical (and frequent) conditions
characterized by erythema, xerosis, pytiriasic desqua-
mation, and often associated with subjective sensations
such as burning or itching. The etiopathogenesis of this
condition is not completely known, but it has been
hypothesized that an altered degranulation of cutane-
soaps, intended to be rubbed, poured, sprinkled
or sprayed on, or otherwise applied to, the hu-
man body for cleansing, beautifying, promoting attrac-
tiveness, or altering the appearance of the skin.
1
This
definition includes such products as skin creams, lo-
tions, perfumes, cleansers, lipsticks, deodorants, and
face makeup.
Cosmetics are able to improve the structure, mor-
phology, and appearance of the skin through the activ-
ity of very specific ingredients; however, these changes
are not permanent and interrupting the cosmetic pro-
cess, will cause the reappearance of the skin problems.
Cosmetics are mostly used for the care of nonaffected
skin or as an adjuvant therapy for moderate skin dis-
orders. Advances in biochemistry and physiology of the
skin have enabled the development of specific products
for different skin types, divided according to cosmeto-
logic characteristics, particularly for moderate skin dis-
orders. When we observe our patients’ skin, it is possi-
ble to identify different types of skin, each one with
specific characteristics.
Normal skin has no visible lesions or sensations of
discomfort. It results from the equilibrium of various
continuous biological processes, which create a harmo-
niously balanced state of suppleness, elasticity, and
color.
Greasy skin
2
is characterized by skin thickening and
an increase in sebaceous secretion, giving the face a
shiny appearance, especially on the nose and forehead.
Complications frequently associated with greasy skin
include acne and seborrhoeic dermatitis. It is also pos-
From the Department of Dermatology, University of Florence, Florence,
Italy and the Department of Dermatology, University of Prague, Prague,
Czech Republic
Address correspondence to Torello M. Lotti, MD, Department of Der-
matology, University of Florence, Via Alfoni 37, 50121 Florence, Italy.
E-mail address: tlotti@unifi.it.
© 2001 by Elsevier Science Inc. All rights reserved.
0738-081X/01/$–see front matter
655 Avenue of the Americas, New York, NY 10010
PII S0738-081X(01)00186-9
Clinics in Dermatology
Y
2001;19:478 – 482
479
MINERAL WATERS: INSTEAD OF COSMETICS OR BETTER THAN COSMETICS?
ous basophils might have a role in its pathogenesis. This
skin condition needs particular care and attention when
treated with cosmetics.
In view of this classification, it seems very important
to consider the correct cosmetic for each specific skin
type to improve the structure and appearance of the
skin and to avoid inducing additional disorders. Not
only dry, mixed, and greasy skin types need attention
and the use of correct cosmetics, but also normal skin
needs care to maintain a correct equilibrium and to
protect it from external agents (especially from the sun).
Normal skin care is based on the use of hygiene
products, sunscreens, and hydrating agents. Fre-
quently, hygiene products, because of their powerful
detergent action, are hazardous to the skin, and their
overuse may decrease or even eliminate the protective
surface lipid film, which is important for physiological
balance of the skin, and induce irritation. Hydrating
agents are used primarily to protect the skin from ex-
ternal agents, such as wind and cold, and are frequently
used with sunscreens to protect the skin from the sun
and delay photoaging.
In caring for simple greasy skin, the essential re-
quirement is the reduction of the excess surface sebum
without inducing total delipidization. Frequently,
cleansing products are too aggressive and lead to severe
degreasment followed by an exacerbation of sebaceous
secretion, which defeats the initial desired aim. Facial
cleansing may be done with oily soaps or syndets fol-
lowed by copious rinsing; however, when treating
greasy skin it is very important to avoid comedogenic
products, and particular attention must be paid to the
choice of the oils used for the preparation of oily soaps.
Dry skin care is mainly based on avoiding harsh
rinsing and protecting from external agents with hy-
drating products. Ordinary soaps must always be
avoided, and only mild detergents can be used; even
very mild surfactants can induce an inflammatory re-
action on this delicate and very sensitive skin. Hydra-
tion of dry skin is of fundamental importance and can
be done by decreasing transepidermal water loss, using
an occlusive lipid film, or increasing the input of exter-
nal water, which is retained in the stratum corneum by
the addition of humectants.
Combined skin is probably the most delicate skin
type to treat, because it is frequently caused by using
the wrong cosmetics. Light oil-in-water emulsion
cleansers can be used to remove excess sebum from the
T-zone, as well as cleansers that contain a combination
of fatty acids and wax esters in a light emulsion to
ameliorate dry skin areas.
Even if the correct cosmetic is used, patients fre-
quently undergo adverse reactions to cosmetics. Reac-
tions to cosmetics can have a variety of presentations,
including subjective and objective irritation, allergic
contact dermatitis, contact urticaria, photosensitivity,
delayed hypersensitivity reactions, pigmentation, and
hair and nail changes. When these conditions occur, it is
necessary
to
substitute
the
cosmetic
products
with
agents free of adverse effects.
Mineral waters can be an effective substitute for
cosmetics being used as additional products for the
treatment of moderate skin disorders. They can also be
used for daily skin care of various cosmetic skin types.
The Use of Mineral Waters Instead of
Cosmetics
Mineral waters are natural solutions with three main
characteristics: spring origin, bacteriological pureness,
and therapeutic potentials.
6
Mineral waters may be
classified according to their chemical and physical char-
acteristics (capacity, temperature, fixed balance, molec-
ular concentration, chemical composition, presence of
distinctive oligoelements) or to their supposed or dem-
onstrated therapeutic actions. According to the temper-
ature at the spring, mineral waters may be classified as:
cold (less than 20°C); and hot (hypothermal between 20
and 30°C; thermal between 30 and 40°C; hyperthermal
over 40°C). On the basis of their chemical characteris-
tics, waters may be classified as oligomineral waters
(mineral balance of water less than 0.2 g/l), medium
mineral waters (mineral balance of water between 0.2
g/l and 1 g/l), and mineral waters (mineral balance of
water above 1 g/l).
6
To understand the specific indications in cosmetol-
ogy of the different types of spring waters, it is useful to
report a classification of mineral waters based on their
chemicophysical
characteristics.
Mineral
waters
can
therefore be classified as:
Y sulfurous, when at least one sulfur grade is present
Y arsenical,
when
arsenic
is
present
in
a
ponderal
amount
Y bromic,
when
bromine
is
present
in
a
ponderal
amount
Y iodic, when iodine is present in a ponderal amount
Y radioactive, when in a liter of water at least 1 mil-
limicrocurie is dissolved
Y carbonic, when it contains at least 300 ml of CO
2
per
liter.
6
Sulfurous waters have been considered for centuries to
be clinically valid for their detergent, keratoplastic, and
antimicrobic properties. Sulfur may be present in sul-
furated water as a free or combined ion.
7,8
Sulfur water
may comprise various combinations of sulfur ions, wa-
ter, and other ions; these include sulfur simple water,
sulfur sulfate water, sulfur carbonic water, and sulfur
salsobromoidic water.
The sulfur activity in the skin seems to be related
mainly to the interaction between this substance with
cysteine and with its catabolites. Sulfur, reacting with
480
Clinics in Dermatology
Y
2001;19:478 – 482
GHERSETICH ET AL.
cysteine, interacts with hydrogen sulfide (H
2
S), promot-
ing keratinization at low concentrations, a well-known
keratolytic effect that determines keratin proteolyti-
sis.
9,10
Sulfur may also interact with the oxygen radicals in
the deeper layers of the epidermis, producing sulfur
and disulfur hydrogen, which may in turn be trans-
formed into H
2
S
5
O
6
; this may be the source of the
antibacterial and antifungal activity of sulfur water.
11
Histological alterations of the skin caused by baths in
sulfur waters have been described. They include hyper-
keratosis, parakeratosis, and keratolysis that occur at
different concentrations of sulfur ions. After sulfurous
baths, dermal vessels are dilated and surrounded by a
perivascular infiltrate of mononuclear cells.
12
The efficacy of sulfur water in dermatology has been
described for both cosmetologic and moderate patho-
logic conditions. In particular, its detergent properties
can be used for greasy and mixed skin to remove excess
sebum without inducing skin delipidization and its
consequent irritation. This same property together with
its antimicrobic and keratolytic effects can be can be
used to treat mild acne.
The antibacterial and antifungal properties of sulfur
waters can explain why this type of mineral water is
effective in the treatment of infected leg ulcers, tinea
versicolor, tinea corporis, and tinea capitis.
13,14
Sulfur spa baths have also been successfully used as
an adjuvant treatment, instead of cosmetics, of moder-
ate manifestations of immune-mediated conditions
such as atopic dermatitis, contact dermatitis, and pso-
riasis, suggesting that the active principles of sulfurous
waters could play a role in regulating the immune
system of the skin.
15
Avne thermal water is an oligomineral water (min-
eral balance of water 210 mg/l), characterized by a high
concentration of silicates and trace elements, and a
neutral pH. Avne thermal water is very well tolerated
and has demonstrated dermatocosmetologic effects. It
is a valid hydrating agent that is very useful for dry skin
and itching conditions.
In vivo studies have also shown that this water is
able to reduce clinical parameters such as erythema,
itching, scaling, and burning in patients with sensitive
skin. Sensitive skin is defined as a group of conditions
characterized by slight or absent clinical and his-
topathological alterations and modified skin sensitivi-
ty
5,16
and intolerance to skin care and cosmetic prod-
ucts. Patients complain of facial itching, burning, and
discomfort accompanied, or not, by mild objective signs
such as erythema and scaling. In most cases, the sever-
ity of symptoms does not match the objective signs.
Two uncommon and extreme forms of this disorder are
represented by the so called “status cosmeticus” and
the cosmetic intolerance syndrome.
17,18
Status cosmeticus is a condition in which patients
experience subjective and objective irritation from cos-
metics (and frequently also to many other topical
agents) and can no longer tolerate their use. Some pa-
tients have seborrheic-rosacea diathesis that flares
when soap and water are abandoned and cleansers and
emollients are overused; other patients instead display
irritant dermatitis, allergic contact dermatitis, or contact
urticarial reactions caused by cosmetics. Only cosmetic
elimination is able to reduce these symptoms. In these
cases, it is useful to replace cosmetics with Avne ther-
mal water that can be used by patients as a cleanser and
is also able to reduce skin irritation and sensations of
discomfort until the patients can return to using cos-
metics (not before 8 –12 months).
The cosmetic intolerance syndrome represents the
extreme example of “status cosmeticus” and needs the
same treatment.
Many in vitro studies have been performed to un-
derstand how Avne thermal water exerts its effects.
These studies have demonstrated that this silicate-rich
oligomineral water is able to reduce the production of
IL-4 from Th2 cells and favor Th1 cell activity.
19
In
addition, Avne thermal water is able to reduce baso-
phil degranulation in atopic patients.
20
These data also
partially explain why an adjuvant therapy with this
water is effective in the treatment of atopic dermatitis,
allergic rhinitis, and conjunctivitis.
An other interesting thermal water with important
dermatocosmetologic effects is La Roche-Posay mineral
water. This water contains low levels of minerals, bi-
carbonate, calcium, and silicate, and has a particularly
high selenium content. Selenium is essential for normal
cell metabolism and has a protective effect on human
cells. Selenium plays a fundamental role in maintaining
cell integrity and neutralizing free radicals and toxic
organic peroxides in cells and tissues by virtue of its
glutathione peroxidase coenzyme activity.
21,22
Recently,
particular attention has been given to the effects of
selenium in dermatologic disorders. Selenium has been
demonstrated to be valid as an additional therapeutic
agent in the treatment of eczema, psoriasis, acne, and
burns, and it has been demonstrated to be protective
against photoaging because of its antioxidant proper-
ties.
Three studies have demonstrated the value of using
mineral water to prevent free radical damage. The first
two demonstrated the antioxidant activity of selenium-
rich mineral water on human cutaneous fibroblasts.
23,24
This in vitro study was performed on human fibroblast
cell cultures, compared the effects of mineral water,
demineralized water, and selenium-enriched deminer-
alized water. It was found that uptake of selenium, zinc,
and copper by fibroblasts was higher, and that cell
mortality due to oxidative stress (UVB and UVA radi-
ation, and hydrogen peroxide) was significantly re-
duced when mineral water was added to the culture
Clinics in Dermatology
Y
2001;19:478 – 482
481
MINERAL WATERS: INSTEAD OF COSMETICS OR BETTER THAN COSMETICS?
medium. The activity of the enzyme superoxide dis-
mutase in fibroblasts was greater in cells cultured with
mineral water. Selenium increased resistance to UVB
radiation, which neutralized free radicals, and zinc,
whose uptake was greater from mineral water than
from selenium-enriched demineralized water, pro-
tected thiol groups and strengthened lysosomal mem-
branes and microsomes.
The third study
25
analyzed the protection afforded
by the percutaneous application of selenium-rich min-
eral water against lipid peroxidation and skin carcino-
genesis induced by UVB radiation. This study, per-
formed on hairless mice subjected to repeated UVB
radiation for 25 weeks, compared the development of
skin tumors and analyzed skin samples taken from
three groups of mice: one group treated with a cream
containing selenium-rich mineral water, one treated
with a cream containing demineralized water, and one
that received no treatment.
There was a significant reduction in the rate of ap-
pearance of UVB-induced skin tumors, a reduction of
membrane lipid peroxidation, and an increase of sele-
nium-dependent glutathione peroxidase activity in the
group treated with cream containing mineral water.
Selenium-rich mineral water inhibited lipid peroxida-
tion and slowed down the rate of incidence of UVB-
induced carcinogenesis.
These studies thus demonstrate that oligoelements
(selenium and zinc) contained in mineral water are
effective in reinforcing the defensive system against
free radicals.
The anti-inflammatory activity of selenium-rich min-
eral water has been demonstrated in vitro through stud-
ies performed on Langerhans cells.
26,27
These studies
aimed to demonstrate the in vitro effects of mineral
water on the modulation of the cytokine production,
phenotype modulation, and migratory and stimulatory
capacities of Langerhans cells. The first study
26
ana-
lyzed the effect of selenium-rich mineral water on the
spontaneous or mitogen-derived proliferation of pe-
ripheral blood mononuclear cells (PBMC) and on the
stimulatory capacity of epidermal Langerhans cells in
the mixed skin–lymphocyte reaction. As controls, ly-
ophilized medium reconstituted with Millipore water
was employed. The PBMC did not show significant
variations of the spontaneous proliferation when cul-
tured alone in either medium. Instead, a strong inhibi-
tion of their proliferative response was observed after
coculture with allogenic epidermal cells in the medium
reconstituted with thermal water. The stimulatory abil-
ity of Langerhans cells is regulated by different cyto-
kines, i.e., interleukin (IL)-1, granulocyte macrophage-
colony stimulating factor (GM-CSF), or tumor necrosis
factor
be related to (1) a direct effect of one or more compo-
nents of thermal water on the functional maturation of
Langerhans cells; (2) an indirect effect by the induction
of TNF-
secretion by keratinocytes, which blocks the
stimulatory activity of Langerhans cells; (3) the inhibi-
tion of the secretion of cytokines by keratinocytes,
which may support the functional maturation of Lang-
erhans cells in vitro, like IL-1 and/or GM-CSF; or (4) by
a combined effect of all these mechanisms.
The second study
27
demonstrated that La Roche-
Posay thermal water inhibits the migration of sensitized
Langerhans cells and reduces the expression of the
activating molecules, HLA-DR, B7-2, and ICAM-1,
thereby enhancing its anti-inflammatory properties.
a
Conclusions
The detergent, anti-inflammatory, keratoplastic, anti-
pruriginous, and antioxidant properties of mineral wa-
ters can be used together with, or instead of, cosmetics.
Mineral waters do not have side effects and rarely
induce inflammatory reactions; therefore, they can be
safely employed in all skin conditions characterized by
extreme sensitivity and cosmetic intolerance.
Many mineral waters are available, each with its
specific chemical and physical characteristics. Before
treating dermatological disorders with mineral waters,
it is important to consider the specific indications of
each spa and select the correct waters for each clinical
case.
29
References
1. Federal Food, Drug and Cosmetic Act. Title 21, Part 1,
Section 201, US Department of Health, Education, and
Welfare, Food and Drug Administration. FDC Act and
Part 1 Regulations, 1964.
2. Daniel F. La peau sborrhique. Dermatologie 1985;35:
3215–24.
3. Curtil L. Amliorer les peaux sches. Rev Eur Dermatol
MST 1991;3:457– 64.
4. Gougerot A, Enjolras O. Amliorer les peaux sches
pathologiques. Rev Eur Dermatol MST 1992;4:75– 82.
5. Maibach HI, Lammintausta K, Berardesca K, Freeman S.
Tendency to irritation: sensitive skin. J Am Acad Derma-
tol 1989;21:833–5.
6. Lotti T, Ghersetich I. Le basi della dermocosmetologia
termale. In: Caputo R, M. Monti M, editors. Manuale di
dermocosmetologia,
Milan:
Raffaello
Cortina,
1995;62:
751– 62.
7. Scalabrino A, Galassi A, Pierallini F, et al. Le acque sul-
furee e le loro applicazioni in medicina termale. Current
1994;1:11–2.
8. Lotti T, Ghersetich I. Mineral waters: instead of soap or
better than soap? Clin Dermatol 1996;14:101– 4.
9. Benci M. L’impiego dello zolfo nella terapia dermato-
logica. Current 1994;1:17– 8.
10. Zunz E. Elements de pharmacodynamie special. Paris:
Masson & Cie, 1932.
). These cytokines are released by ker-
atinocytes during different activation states.
28
The suppressive activity shown in the study
28
could
a
(TNF-
a
482
Clinics in Dermatology
Y
2001;19:478 – 482
GHERSETICH ET AL.
11. Mc Murtry CW. Dermatologic therapeutics: Sulphur. J
Cutan Dis 1913;322:399 – 408.
12. Lorenc E, Winkelmann RK. Evaluation of dermatologic
therapy. Arch Dermatol 1961;83:761–7.
13. Salter WT. A textbook of pharmacology. Philadelphia: WB
Saunders, 1952.
14. Parish LC, Witkowski JA. Dermatologic balneology: The
American view of waters, spas, and hot springs. J Eur
Acad Dermatol Venereol 1994;3:465–7.
15. Ghersetich I, Lotti T. Immunologic aspects: Immunology
of mineral water spas. Clin Dermatol 1996;14:563– 6.
16. Ghersetich I, Tsampau D, Lotti T. L’eau termale d’Avene
nel trattamento della pelle sensibile. G Ital Dermatol Ve-
nereol 1992;127:29 –31.
17. Fisher A. Cosmetic actions and reactions: therapeutic,
irritant, and allergic. Cutis 1980;26:22–9.
18. Maibach HI. The cosmetic intolerance syndrome. Ear,
Nose Throat J 1987;66:49 –53.
19. Clot J. Effet de I’Eau d’Avne sur la production de cyto-
kines TH1 et TH2 dpendantes par des cellules mononucles
sanguines normales. 1994-Laboratoire d’immunologie (IN-
SERM Unit 291).
20. Sainte-Laudy J, Sambucy JL. Inhibition of human basophil
degranulation by Avne spring water. Int J Immunother
1987;4:307–12.
21. Rotruck JT, Pope AL, Ganther HE, et al. Selenium bio-
chemical role of component of glutathione peroxidase.
Science 1973;179(73):588 –90.
22. Peretz A. Selenium inflammation and immunity. In: Sele-
nium in medicine and biology. JN Favier JN, editor. Ber-
lin-New York: Walter de Gruyter & Co., 1988, 235– 46.
23. Richard MJ, Guiraud P, Arnaud J. Pouvoir antioxydant
d’une eau thermale slnie sur des fibroblasts cutans
humains
diploids.
Les
Nouvelles
dermatologiques,
1990;9.
24. Moysan A, Morli`re P, Marquis I, et al. Effects of selenium
on UVA-induced lipid peroxidation in cultured human
skin fibroblasts. Skin Pharmacol 1995;8:139 – 48.
25. Cadi R, Beani JC, Belanger S, et al. Effect protecteur de
l’application percutane d’eau theramle de la Roche-Po-
say vis- -vis de la peroxydation lipidique et de la carci-
nognse cutane induites par les UVB. Nouv Dermatol
1991;10:266 –72.
26. Staquet MJ, Peguet-Navarro J, Latourre F, et al. In vitro
effects of thermal water on the migratory and stimulatory
capacities of human epidermal Langerhans cells. Eur J
Dermatol 1997;7:339 – 42.
27. Wollenberg A, Richard A, Bieber T. In vitro effect of the
thermal water from La Roche-Posay on the stimulatory
capacity of epidermal Langerhans cells. Eur J Dermatol
1992;2:128 –9.
28. Ansel J. Perry P, Brown J. Cytokine modulation of kera-
tinocyte cytokines. J Invest Dermatol 1990;94:S101–7.
29. Lotti T, Ghersetich I. How spring waters work on the skin.
Life Chem Reports 1996;14:113– 8.