Osteoporosis, a unitary hypothesis of collagen loss in skin and bone.

Progress in osteoporosis has been stultified by repetitive, statistic-driven studies and catechistic reviews; in the absence of concept and hypothesis research is aimless, and the trivial associations it continually reveals, has led to the cul-de-sac of multifactorialism. A return to hypothesis-led research which seeks major causal defects and the conclusive therapies that arise from them is essential. The hypothesis proposed evolved from research into the mechanism of senile purpura. This predicted a causal loss of skin collagen that was contrary to contemporary opinion, but was confirmed when collagen was expressed absolutely, instead as a percentage or ratio: women have less collagen than men and it decreases by 1% a year in exposed and unexposed skin. Corticosteroids (which also produce shear purpura) reduce skin collagen and androgen and virilism increase it; growth hormone produces the greatest increase, and there is a decrease in hypopituitarism. All these changes in skin collagen correspond to changes in bone density, and the circumstances are too various for coincidence. This led to the hypothesis that the changes found in skin collagen also occur in bone collagen, leading to the associated changes in bone density; thus a loss of collagen in skin and bones with aging is the causal counterpart to loss of bone density in senile osteoporosis. If this is correct then, as with aging, androgen and virilisation, corticosteroids, growth hormone and hypopituitarism, changes in bone density should correspond to systemic changes in skin collagen. This correspondence is found to occur in osteogenesis imperfecta and Ehlers-Danlos syndrome, two genetically discrete families of disordered collagen production, and other situations, e.g., scurvy and homocystinuria. A primary loss of collagen in osteoporotic bones is an essential prediction of the hypothesis; in fact this loss is well established but, inexplicably, it has been assumed to be secondary to the bone loss. Because of the comparable changes in skin and bones, the hypothesis implies that skin collagen could be used to predict the state of the bones and their response to treatment. It also implies androgen should be an effective treatment of osteoporosis, and growth hormone even more effective (likewise, of course, skin aging). More importantly, skin collagen and the production of collagen by skin fibroblasts could be used for the assay and industrial development of more potent, if not less toxic treatments and prevention of loss of bone (and skin) substance.