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Healthy Skin Women and Dermatology Suguru Imaeda, M.D. Chief of Dermatology, Yale University Health Service Chief of Dermatology, WHVAMC Assistant Professor, Yale Medical School Overview Normal structures of the skin Changes in the skin over time Sun and skin Skin cancer

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Healthy skin women and dermatology l.jpg

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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  • Normal structures of the skin

  • Changes in the skin over time

  • Sun and skin

  • Skin cancer

  • Maintaining healthy skin

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- 0.02 mm


- 0.035-0.050 mm


- 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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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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  • gender differences seldom play a role in skin disease

Toddler to adolescence

  • few dermatologic ailments are gender

  • specific

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  • 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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  • Infection

  • Granulomatous reaction

  • Photodermatitis

  • Difficult to remove

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  • 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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  • dermal thinning

  • decreased vascularity

  • decreased subcutaneous fat

  • reduced cellularity of the dermis

  • elastic fiber loss

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  • 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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  • 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 (crow’s 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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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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  • 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

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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

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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 = 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

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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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  • 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

  • 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

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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

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Probability of Melanoma (2001-2003)


<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


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Sunburn is bad

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

  • Lifetime sun exposure – increases risk of SCC and BCC

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  • 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

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  • 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

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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 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

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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 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

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New proposed labeling guidelines for sunscreens


Low 2-14 SPF

Medium 15-29

High 30-50

Highest 50+






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  • 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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Chemical peels




$35 billion/year industry

Anti-aging treatments

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  • 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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  • 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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  • 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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  • 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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  • 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

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  • 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

  • Don’t smoke

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SPF > 30