Healthy Skin Women and Dermatology

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Healthy SkinWomen and Dermatology

• Suguru Imaeda, M.D.
• Chief of Dermatology, Yale University Health
  Service
• Chief of Dermatology, WHVAMC
• Assistant Professor, Yale Medical School

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Overview

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

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Epidermis
Periorbital - 0.02 mm Body - 0.035-0.050
mm Palms/Soles - 2-3 mm
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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

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25
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50
70
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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

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Infancy

• gender differences seldom play a role in skin
  disease

Toddler to adolescence

• few dermatologic ailments are gender
• specific

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Adolescence

• Trichotillomania
• Compulsive hair pulling
• Traction alopecia
• Hair styles tight braiding, pony tails, corn
  rowing
• Acne excoriee
• Compulsive picking of mild acne

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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

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Tattoos

• Infection
• Granulomatous reaction
• Photodermatitis
• Difficult to remove

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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

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Melasma management

• Discontinuation of oral contraceptive
• Avoidance of sun/tanning bed
• Daily application of broad spectrum sunscreen
• 4 hydroquinone or 20 azelaic acid
• ? laser

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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

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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

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Histologically

• dermal thinning
• decreased vascularity
• decreased subcutaneous fat
• reduced cellularity of the dermis
• elastic fiber loss

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Histologically

• dermal thinning
• decreased vascularity
• decreased subcutaneous fat
• reduced cellularity of the dermis
• elastic fiber loss

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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

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25
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50
70
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Smoking

• shown to decrease both hyaluronic acid and
  glycosaminoglycan synthesis
• causes decreased capillary blood flow in the skin
• changes accelerate wrinkling

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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.

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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

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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 (crows feet)
• Skin becomes drier - sweat glands grow smaller
  and become less effective

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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

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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

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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

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Tan

• Coco Chanel declares tanning in in 1920s
• Suntan seen as symbol of health, youth, status
• Skins reaction to damage from UV radiation
• Melanocytes produce melanin

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Indoor tanning

• Increasingly popular, esp among young women in
  20s
• 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

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Dripping faucet

• Your skin empty glass
• Dripping water ultraviolet radiation
• Rate of drip amount of sun exposure
• Rate of evaporation of water skins ability to
  repair DNA damage caused by UV radiation
• Your glass is full youve reached your limit of
  sun exposure
• Water starts spilling over the top getting skin
  cancers

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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

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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

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Sun myths

• Sunscreen use causes Vit D deficiency
• Dont need sunscreen on a cloudy day
• 40 of suns UVR
• 80 of sun exposure occurs during childhood
• lt25 of total sun exposure by age 18
• Men over 40 spend most time outdoors

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2007 Skin Cancer Facts

• Skin cancer most common cancer in US
• Lifetime risk 15 Americans
• 13 Caucasians
• gt90 skin cancer caused by sun exposure
• Doubled lifetime risk with 5 sunburns
• BCC gt 1,000,000/yr
• SCC 250,000/yr 2,500 deaths/yr
• Melanoma 59,940/yr 8,110 deaths

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Basal cell carcinoma and Squamous cell carcinoma
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Melanoma
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Probability of Melanoma (2001-2003)

• Men Women
• lt39 1775 1467
• 40-59 1187 1237
• 60-69 1178 1347
• gt70 176 1163
• Lifetime 149 173

Age
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Sunburn is bad

• Blistering sunburn - gt2-fold increased lifetime
  risk for melanoma
• Lifetime sun exposure increases risk of SCC and
  BCC

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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
• 159 lifetime risk
• Cost of care gt740 million annually

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Melanoma

• White men gt 50 yo
• 1 cancer in men gt 50 yo (prostate, lung, colon)
• 3 cancer in women 20-39
• Men gt 40 yo spend most time outdoors highest
  annual exposure to UVR
• Women lt40 yo BCC rate 3x in last 30 yrs
• SCC rate 4x in last 30 yrs

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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

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IARC (International Agency for Research on Cancer)

• Clear increase in melanoma risk associated with
  sunbed use in ones teens and twenties
• 75 increased risk
• Similar increase in risk of SCC for those who
  used sunbed tanning as teenagers
• Possible decrease in skins immune response

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Sunless tanning

• Dihydroxyacetone
• Safe
• Dyes outer dead layer
• (corneal layer)

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Tanning pills

• Canthaxanthin carotenoid
• found in carrots
• Hepatitis
• Urticaria

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Sun Protection Factor
In vitro CT FL

• 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

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New proposed labeling guidelines for sunscreens
UVB Low 2-14 SPF Medium 15-29 High 30-50 Hig
hest 50 UVA Low Medium High Highest
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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

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UV Index

• Scale 1-15
• Predicts ultraviolet radiation level
• Calculated daily
• Adjusted for ozone level
• Cloudiness
• Altitude
• Latitude
• Season

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Anti-aging treatments

• Prevention
• Retinoids
• Lasers
• Chemical peels

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

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Prevention

• Daily use of sunscreen or moisturizer with
  sunscreen SPF 15
• Clothing
• Avoiding unnecessary UV exposure
• Avoiding sun exposure between 10a-4p

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Retinoids

• Tretinoin and tazarotene
• Vitamin A derivatives
• Even out skin tone
• Rebuild collagen
• Repair minor sun damage
• Inhibit tumor growth
• Decrease inflammation

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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

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Chemical peels

• Chemical ablation of superficial skin layers
• Mild to moderately strong acid solution
• Recovery period needed
• Lunchtime peels

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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

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Botox

• Botulinum toxin
• Temporarily paralyzes muscle to relax furrowing
  of skin
• Frown lines between eyebrows, horizontal forehead
  lines, crows feet, vertical lip lines, neck
  banding

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Fillers

• Injected under skin to round out contours,
  correct wrinkles, furrows, hollows
• Bovine collagen
• polymer implants
• hyaluronic acid
• autologous fat

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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

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Skin Care Tips

• Sun protection
• Hydration
• Healthy diet fruits, vegetables, fish
• Gentle skin care products soaps
• Moisturize
• Dont smoke

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Sunscreen SPF gt 30
Sun Protection Factor