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Results and discussion
The water consumption pattern was crucial to assess the impact of dietary water on the cutaneous physiology within this population. Previous results have drawn attention to the importance of DiW in quantitative terms, representing more than 50% of the total water related to diet.1,21,31 DiW includes water from food, juices and soup, and in accordance with those results, our FFQ detected that DiW contributed 57.2% of the total water accounted within these patients’ diets, stressing the need to consider all sources of water input to calculate the total water consumption (Figure 1).
Results obtained from both groups having different daily water consumptions revealed no relevant changes regarding epidermal barrier and TEWL. As shown in Table 1, we found a progressive decreasing gradient from the face, the highest (forehead and zygomatic area), to the forearm and leg, where the lowest values were recorded in both groups. This is in accord with the known expected anatomical and functional variation.32-35 Thus, our methodology did not significantly change the epidermal barrier in both groups. Regarding epidermal hydration, however, a dramatically different reality was registered, with a consistent improvement of superficial and deep hydration in both groups, although with different magnitudes (Table 2). In fact, changes observed in the group with lower initial water consumption (Group 1) were significantly greater and present in all anatomical areas, relative to the (reduced) impact observed in Group 2. Similar results were previously reported in individuals with dry skin, leading the authors to suggest that increasing the dietary water intake would affect the skin the same way as a topical moisturizer.2 In our current study, impact on epidermal hydration was consistently noticed in both surface and deep hydration variables, which may signify that more water is available for the normal physiological processes (Table 2). These effects are especially detectable in Group 1, from T1 forward.
In order to look further into the impact of this dietary water overload on the skin’s physiology, we also assessed the so-called “envelope” function. Skin hydration has been related to skin mechanics to justify preservation of a younger, healthier looking skin. Dermal water was reported to decrease the friction between fibers, acting as a “lubricant”, including in the upper layers, thus facilitating the dynamics of the overall structure.26,36 However, a direct relationship between skin hydration and biomechanics has not been clearly demonstrated.37-39
Biomechanical descriptors such as maximum extensibility (Uf), the ability to return to the original state (Uf – Ua), total elasticity (Ua/Uf), elastic function (Ur/Ue), and the viscoelastic ratio (Uv/Ue) were chosen as the most relevant, in accordance to several authors40,41 and because they have been referred as the most useful to detect improvements in the plasticity of skin41-45 (Table 3). As mentioned previously, our experimental methodology did impact skin biomechanics in both groups with different magnitudes, and statistically significant evidence of biomechanical changes could be found in Group 1 (Table 3). Total extensibility (Uf) significantly improved in all body areas except the face after the 2 weeks of the test. By the end of the study, these improvements were still present in all the tested regions, with significant differences present in the leg, forearm, hand, and in the forehead (Table 3). Similar impact was registered for the ability of the skin to return to its original state (Uf – Ua), which significantly increased after the 2 weeks (T1) and 4 weeks (T2) of the water surplus in all the tested areas, except the zygomatic region in the face. This consistent increase of Uf and Uf – Ua throughout the study seems to be related with the highest amount of water available in the epidermis of these volunteers, facilitating deformation and recovery after stress, as has been previously suggested.25,46 The evolution of the other ratios are more difficult to follow. Total elasticity (Ua/Uf) was significantly reduced in all tested areas except the zygomatic, especially in T2, and this reflects a higher impact of the water surplus on skin extensibility (Table 3) rather than in the elastic recovery (Ua). The elastic function Ur/Ue and viscoelasticity (Uv/Ue) do not follow this pattern. However, these descriptors are closely age-related, thus they depend primarily on the dermal components whose contribution(s) cannot be specifically quantified with these methods.28,40,47,48 A decrease in the viscoelasticity index has been reported after regular long-term use of topical moisturizers.26,43
We have finally analyzed a potential relationship between the most relevant descriptors representing epidermal hydration and biomechanics. In fact, many of the factors that modify skin mechanical properties have been identified, but relationships between epidermal structure and these characteristics are still insufficiently documented. Although suggested for many years,49 experimental evidence is still recent (although rare), and are frequently obtained from other perspectives.50-52 Moreover, the in vivo approach is particularly difficult, considering the close relationship between cutaneous tissues and the poor discriminative capacity of currently available technology. Recent results from a three-layer computational skin model53 and from a new dynamic mechanical device,54 both assessing mechanical properties of skin under different conditions, suggested that the epidermis, the statum corneum in particular, and different factors such as hydration, do influence skin mechanical properties in vivo as well.
After calculating a confidence range for each anatomical area, our data was tested by the Spearman correlation coefficient, a well-known determinant for these properties.41,45 In this way, an estimated interval allowed a mean value calculation for each variable in the face, upper limb (forearm and hand), and leg in both groups. As shown in Table 4, clear, consistent relationships between epidermal hydration and biomechanical descriptors could not be found under the present experimental conditions. Nevertheless, significant relationships are nearly absent in both groups at T0. The water stress test seems to contribute to the significant relationships found, especially at T2 and in particular within Group 1. The progressive reduction of these relationships from the face to the leg areas should also be mentioned (Table 4). More sensitive, discriminative technology may be a key aspect behind this apparent absence of differential data.