Healthy Skin Women and Dermatology

1. Healthy SkinWomen and Dermatology Suguru Imaeda, M.D. Chief of Dermatology, Yale University Health Service Chief of Dermatology, WHVAMC Assistant Professor, Yale Medical School

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

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

7. 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

8. 25 4 50 70

9. 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

10. Infancy • gender differences seldom play a role in skin disease Toddler to adolescence • few dermatologic ailments are gender • specific

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

12. 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

13. Tattoos • Infection • Granulomatous reaction • Photodermatitis • Difficult to remove

14. 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

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

16. 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

17. 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

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

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

20. 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

21. 25 4 50 70

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

23. 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.

24. 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

25. 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

26. 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

27. 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 Pregnancy

28. 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

30. 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

31. 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

32. 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

33. 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

35. 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

36. 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

37. 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

38. Basal cell carcinoma and Squamous cell carcinoma

39. Melanoma

40. Probability of Melanoma (2001-2003) MenWomen <39 1:775 1:467 40-59 1:187 1:237 60-69 1:178 1:347 >70 1:76 1:163 Lifetime 1:49 1:73 Age

41. Sunburn is bad • Blistering sunburn - >2-fold increased lifetime risk for melanoma • Lifetime sun exposure – increases risk of SCC and BCC

42. 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

43. 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

44. 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

45. 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

46. Sunless tanning • Dihydroxyacetone • Safe • Dyes outer dead layer (corneal layer)

47. Tanning pills • Canthaxanthin – carotenoid found in carrots • Hepatitis • Urticaria

48. Sun Protection Factor In vitroCTFL • 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

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

50. 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