Healthy SkinWomen and Dermatology

Suguru Imaeda, M.D.Chief of Dermatology, Yale University Health Service

Chief of Dermatology, WHVAMCAssistant Professor, Yale Medical School

Overview

• Normal structures of the skin• Changes in the skin over time• Sun and skin• Skin cancer• Maintaining healthy skin

Periorbital - 0.02 mm

Body - 0.035-0.050 mm

Palms/Soles - 2-3 mm

Epidermis

the largest organ• key role in normal healthy functioning of the

body• Disorders range from those limited to the

skin to manifestations in the skin of internal disorders

• plays important role in social and psychosocial functioning of the individual

• undergoes changes with aging and in response to external environmental factors and internal hormonal influences

4 25

50 70

Gender differences• Fundamental differences in structure and

function of the skin• Differences impact on presentation of skin

disease and its management• Hormonal influences affect common

disorders such as acne, rosacea, lupus erythematosus, psoriasis, lichen planus, anogenital pruritus, hidradenitis suppurativa, and atopic dermatitis

Infancy• gender differences seldom play a role in

skin disease

Toddler to adolescence• few dermatologic ailments are gender specific

Adolescence

• Trichotillomania– Compulsive hair pulling

• Traction alopecia– Hair styles – tight braiding, pony tails,

corn rowing• Acne excoriee

– Compulsive picking of mild acne

Body piercing• presents risks for multiple possible

complications• nickel allergy• secondary infection with staphylococcus or

streptococcus• ear cartilage destruction from pseudomonal

infection• candidal infection of the navel or genitalia• Keloids• traumatic tears

Tattoos

• Infection • Granulomatous

reaction• Photodermatitis• Difficult to

remove

Melasma• Brown patches on

forehead and cheeks• Very sensitive to sun

exposure• More common in

Hispanics, Middle Easterners, and Asians

• Most common cause is oral contraceptive use or pregnancy

Melasma management

• Discontinuation of oral contraceptive• Avoidance of sun/tanning bed• Daily application of broad spectrum

sunscreen• 4% hydroquinone or 20% azelaic acid• ? laser

Intrinsic aging

• Changes of chronologic aging gradually become apparent

• Influenced by genetics, gravity, and hormones

• Clinically, the normal aging process leads to fine wrinkles, dryness, sallow color, thinner skin, laxity and purpura

Aging skin• Decreased function as environmental

barrier, sensory organ and immune organ• Epidermal and dermal atrophy with loss of

appendages• Decreased sweat production leads to

dryness• Decreased body and scalp hair • Decreased ovarian estrogen production

leads to decreased collagen and increased wrinkling

• Overall thinner, paler, drier, with fine wrinkling and decreased elasticity

Histologically

• dermal thinning• decreased

vascularity• decreased

subcutaneous fat• reduced cellularity of

the dermis• elastic fiber loss

Histologically

• dermal thinning• decreased

vascularity• decreased

subcutaneous fat• reduced cellularity of

the dermis• elastic fiber loss

Environmental factors on skin

• create extrinsic damage• major effect is from photoaging with

wrinkling, laxity (sagging), lentigenes, dyschromia, coarseness, sebaceous hyperplasia, and telangiectasia

• 90% of visible skin changes of aging• Visible as early as age 20

4 25

50 70

Smoking• shown to decrease both hyaluronic

acid and glycosaminoglycan synthesis

• causes decreased capillary blood flow in the skin

• changes accelerate wrinkling

The twenties• Skin is smooth and coloring is even• Little need for emollients• Skin care is simple - variety of products

are tolerated• May be persistent acne associated with

hormonal activity manifest by flaring during the week prior to the menstrual period.

The thirties• thinning of the skin beneath the eyes• skin is less elastic• Fine wrinkles begin to appear around

the mouth and lateral periorbital region

• Increased fat and sluggish blood flow contribute to puffiness and darkening of the skin beneath the eyes

The forties• More sallow and less supple• Skin surface not as smooth• Liver spots, solar lentigenes, appear on

areas of chronic low grade sun exposure - face, dorsal hands, back or dorsal feet

• Thin red spider angiomas appear on the legs

• Weight gain leads to sagging skin• Cellulite appears on thighs and buttocks• Deep furrows develop on forehead and

lateral periorbital areas (crow’s feet)• Skin becomes drier - sweat glands grow

smaller and become less effective

The fifties and sixties• Wrinkles are deeper - skin begins to sag and droop• Skin tone is lighter from decreased circulation• More solar lentigines form• Collagen and elastin are thinner• Collagen is estrogen dependent therefore skin is

both thinner and drier• Dryness occurs from thickening of the stratum

corneum• Moisturizers help keep the skin moist and supple• Alpha hydroxy acid-containing products help by

reducing the thickness of the stratum corneum, promoting thickening of the epidermis and dermis, and promoting synthesis of collagen, elastin, protein and glycosaminoglycan

Pregnancy• rosy complexion -

increase in vascular circulation

• hyperpigmentation on the nipples, vulva, anus and inner thighs from hormonal stimulation

• Freckles (ephelids) and birthmarks may also darken

• Melasma, the mask of pregnancy, from hormonal changes, sun exposure and genetic factors

• Skin tags develop on the neck, chest, inframammary area, inner thighs, and face

• Spider angiomas, purpura and capillary hemangiomas

• Stretch marks, striae distensae

• Varicosities and hemorrhoids

Sun protection

• Signs of extrinsic photoaging not intrinsic genetic aging usually prompts the visit to the dermatologist

• Therefore, it is most important to incorporate into the daily routine a sun protection regimen

Tan

• Coco Chanel declares tanning “in” in 1920’s

• Suntan seen as symbol of health, youth, status

• Skin’s reaction to damage from UV radiation

• Melanocytes produce melanin

Indoor tanning• Increasingly popular, esp among young

women in 20’s• Advertised as safe, “healthy glow”,

little risk of skin cancer• Controlled tanning protects against

sunburn by building up melanin• Vitamin D helps prevent breast,

prostate, colon cancer

Dripping faucet• Your skin = empty glass• Dripping water = ultraviolet radiation• Rate of drip = amount of sun exposure• Rate of evaporation of water = skin’s ability

to repair DNA damage caused by UV radiation

• Your glass is full = you’ve reached your limit of sun exposure

• Water starts spilling over the top = getting skin cancers

Ultraviolet radiation• UVA

– Long wavelength = low energy = penetrates deep into skin

• UVB– Intermediate wavelength = higher energy =

penetrates less into skin• UVC

– Short wavelength = high energy = germicidal– Primarily absorbed by ozone layer

UVA• 95% of solar UVR• Present during all daylight hours year

round• UVB varies by season, location, time

of day• Exacerbates cancer-causing effects

of UVB• Photoaging

Sun myths• Sunscreen use causes Vit D

deficiency• Don’t need sunscreen on a cloudy day

– 40% of sun’s UVR• 80% of sun exposure occurs during

childhood– <25% of total sun exposure by age 18– Men over 40 spend most time outdoors

2007 Skin Cancer Facts

• Skin cancer = most common cancer in US• Lifetime risk = 1:5 Americans

1:3 Caucasians• >90% skin cancer caused by sun exposure• Doubled lifetime risk with 5+ sunburns• BCC > 1,000,000/yr • SCC = 250,000/yr + 2,500 deaths/yr• Melanoma = 59,940/yr + 8,110 deaths

Basal cell carcinoma and Squamous cell carcinoma

Melanoma

Probability of Melanoma (2001-2003)

Men Women<39 1:775 1:46740-59 1:187 1:23760-69 1:178 1:347>70 1:76 1:163

Lifetime 1:49 1:73

Age

Sunburn is bad

• Blistering sunburn - >2-fold increased lifetime risk for melanoma

• Lifetime sun exposure – increases risk of SCC and BCC

Melanoma• Incidence 59,940• Deaths 8,110• Men 33,910 5,220 deaths• Women 26,030 2,890• One person per hour dies from melanoma• 1:59 lifetime risk• Cost of care = >$740 million annually

Melanoma• White men > 50 yo• #1 cancer in men > 50 yo (prostate, lung,

colon)• #3 cancer in women 20-39• Men > 40 yo spend most time outdoors;

highest annual exposure to UVR• Women <40 yo – BCC rate 3x in last 30 yrs

– SCC rate 4x in last 30 yrs

Indoor tanning• Big business - $5 billion-a-year

industry• 28 million Americans

– 2.3 million are teenagers• 70% Caucasian women 16-49 yo

• 7-fold increased risk of melanoma• 2.5 fold increased risk of SCC• 1.5 fold increased risk of BCC

IARC (International Agency for Research on Cancer)

• Clear increase in melanoma risk associated with sunbed use in one’s teens and twenties– 75% increased risk

• Similar increase in risk of SCC for those who used sunbed tanning as teenagers

• Possible decrease in skin’s immune response

Sunless tanning

• Dihydroxyacetone• Safe• Dyes outer dead layer

(corneal layer)

Tanning pills

• Canthaxanthin – carotenoid found in carrots

• Hepatitis• Urticaria

Sun Protection Factor

• SPF 15 93% blockage 90% 70%• SPF 30 97% blockage 96% 90%• SPF50 99% blockage 98% 95%

• Measures only UVB protection• Need to reapply secondary to photodegradation

In vitro CT FL

New proposed labeling guidelines for sunscreens

UVBLow 2-14 SPFMedium 15-29High 30-50Highest 50+

UVALowMediumHighHighest

Sunscreen• Apply 1 oz (shot glass full) every 2

hours• Apply 30 min before sun exposure to

allow sunscreen to bind to skin• Reapply every two hours to replenish

sunscreen• UV stabilizers – octylcrylene,

Helioplex

UV Index• Scale 1-15• Predicts ultraviolet radiation level• Calculated daily

– Adjusted for ozone level– Cloudiness– Altitude– Latitude– Season

Anti-aging treatments

• Prevention• Retinoids• Lasers• Chemical peels

• Dermabrasion• Botox• Fillers• $35 billion/year

industry

Prevention

• Daily use of sunscreen or moisturizer with sunscreen SPF 15+

• Clothing• Avoiding unnecessary UV exposure• Avoiding sun exposure between 10a-4p

Retinoids• Tretinoin and tazarotene• Vitamin A derivatives

• Even out skin tone• Rebuild collagen• Repair minor sun damage• Inhibit tumor growth• Decrease inflammation

Lasers• Ablative - vaporize top layer of skin –

softer, smoother skin surface, reduced wrinkles

• Nonablative – IPL – intense pulsed light -stimulates collagen remodeling and growth to soften fine wrinkles, remove dilated capillaries – delayed effects up to 6 mos

Chemical peels

• Chemical ablation of superficial skin layers

• Mild to moderately strong acid solution– Recovery period needed

• Lunchtime peels

Dermabrasion• Small high speed rotating metal brush or

file• Physically abrades upper layers of skin• Requires local or general anesthetic

• Microdermabrasion – tiny particles to gently scrape away superficial skin layer to stimulate new cell growth

Botox

• Botulinum toxin• Temporarily paralyzes muscle to relax

furrowing of skin• Frown lines between eyebrows,

horizontal forehead lines, crow’s feet, vertical lip lines, neck banding

Fillers

• Injected under skin to round out contours, correct wrinkles, furrows, hollows

• Bovine collagen• polymer implants• hyaluronic acid• autologous fat

General skin care• total sun protection regimen with avoidance

of unnecessary exposure to sun between 10 am and 4 pm

• daily sunscreen use with reapplication every 2 hours if exposed to sun

• performance of monthly skin self-examinations

• moisturization with changing environmental, seasonal and aging processes

• gentle products to avoid irritation from skin care products and excessive removal of skin oils which will lead to dryness and further skin irritation

Skin Care Tips

• Sun protection• Hydration• Healthy diet – fruits, vegetables, fish• Gentle skin care products – soaps• Moisturize• Don’t smoke

Sun

Protection

Factor

Sunscreen SPF > 30