Skin Care 101: Beyond Soap and Water

Posted By SHL Librarian

Presented by: Hayes Gladstone, MD
Director Dermatologic Surgery
Stanford University Medical Center
May 12, 2010

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Lecture Overview:

  • Overcleansing can dry the skin, so use moisturizing soap.
  • Don’t let the skin dry out: Moisturize two or more times a day.
  • Stay out of the sun and use sunblock with an SPF of 30 or more that contains titanium dioxide or zinc oxide.
  • Prescription and over-the-counter cosmeceuticals may help repair skin damage, although the science is inconclusive in many current products.
  • Don’t believe all the advertising hype, and be sure to stay away from harsh chemicals.

Open the pages of a magazine or enter the doors of any department store and consumers are barraged with products to keep skin fresh and wrinkle-free. But what products actually do work? And, with so much conflicting information, what is the best way to take care of the body’s largest and most resilient organ?

Hayes Gladstone, MD, an associate professor of dermatology, took time to separate the hype from scientific fact at a presentation sponsored by the Stanford Health Library. “The skin is the organ most exposed to the environment and its evolution has been designed to preserve it from cold, heat, moisture, and other external elements,” he said.

Effective skin care involves three basic steps: cleansing; moisturizing, and avoiding sun damage. From there, a range of products known as cosmeceuticals may improve skin function and prevent signs of aging. Cosmeceuticals are a huge and lucrative business, said Gladstone, and because most products are not regulated by the Food and Drug Administration, many claims are not backed up by scientific research.

Many people have dry skin because of their cleansing routines, not because their skin is normally dry. Most people tend to overdo skin hygiene by using soap that actually dries out the skin, causing flaking, itching, and irritation. Dry skin remains one of the top reasons people turn to a dermatologist, said Gladstone.

Dryness causes a cascade of events that can lead to cracks and fine wrinkles, which decrease the skin’s effectiveness as a barrier and can cause itchiness, an immune system response. Scratching simply exacerbates the reaction, creating a vicious cycle and sometimes introducing infection.

“The most important aspect of skin care is prevention,” said Gladstone. “By the time you see flakiness and cracks, it’s already too late.”

Use soap with a high moisture content (like Dove) rather than a harsh product like Irish Spring. Since water can also dry the skin by wicking moisture from the lipid base layer, use gloves when doing dishes or housework, and keep showers short.

Moisturizers prevent water loss by creating a barrier over the skin. The most effective agent remains petrolatum (petroleum jelly), which has been shown to aid in wound healing and alleviate the symptoms of itching. Many people find petrolatum too greasy, so some products add dimethicone, an emollient that fills in minute gaps in the skin surface to make it appear smoother. Other products include glycerin, which creates a stronger barrier and lasts longer.

While these products do hydrate the skin, the protective coating does not last, so it’s important to reapply moisturizer two or three times a day. For over-the-counter products, Gladstone recommends Eucerin, Cetaphil, and Aquaphor. He suggested moisturizing creams as a first step, followed by topical creams containing retinol or vitamin A.

Sun Protection
Dermatologists recognize that the most potent product on the market today to prevent and reverse the signs of aging is sun protection, said Gladstone. The sun’s ultraviolet spectrum includes UVB radiation, which causes sunburn, and UVA radiation, which causes premature aging and skin cancer.

Skin damage is caused by both UVA and UVB rays, so select a sunscreen or sunblock that protects against both. If using a sunscreen, pick one with SPF of 30 to 60; under 30 is insufficient coverage and over 60 appears to be more of a marketing concept, he said. Gladstone recommends using a sunblock with titanium or zinc oxide, which is made of microparticles to deflect the sun’s rays. He recommends Blue Lizard, T-Silc Sheer, Tizo3, and sunscreens using mexoryl, including Shaka Shake. Higher concentrations are still not available in the United States.

Since sunscreens only go so far, Gladstone also recommends wearing long sleeves and using specially treated clothing like CoolBar apparel, which are made with titanium dioxide fibers, and wearing hats with wide brims to protect the neck and ears. And no direct sun from 11 am to 3 pm, he advised.

Gladstone acknowledged the current debate over Vitamin D deficiency, but explained that most people get enough sun exposure for sufficient Vitamin D production even when using sunblock.

Alpha Hydroxy acids remove the outer layer of skin cells through a process known as exfoliation. Commonly used hydroxy acids include glycolic acid and salicylic acid. Hydroxy acids can be added to daily-use moisturizers or can be incorporated into solutions used in dermatologists’ offices, such as chemical peels.

Vitamin A products, or retinoids, are founded on the strongest science, said Gladstone. Vitamin A, found in foods like carrots, citrus, and tomatoes, is important to both skin and eye health. Topical formulations of Vitamin A can cause increase cell turnover and diminish fine lines.

The best-acting retinoid is tretinoin (Renova or RetinA), which is available only by prescription. Retinol is a less potent cosmeceutical form of Vitamin A available over the counter, including products made by Neutrogena. Because prescription Vitamin A can cause skin irritation and sun sensitivity, many people respond well to the less potent over-the-counter versions, said Gladstone.

Antioxidants, which prevent oxygen molecules from damaging cells, are found in many botanicals. Ingredients such as Vitamin E and Vitamin C, copper peptides, and niacinamide (Vitamin B3) may work by scavenging for free radicals or assist in wound healing but seem to work at the same level as regular moisturizers, he said. As far as antioxidant moisturizers with vitamin C or E, he said some studies, particularly in Europe, appear to support the benefit of topical antioxidants, but Vitamin E can cause an allergic reaction that can cause redness. Flavinoids, found in soy and green tea, may enhance collagen production but also have not been researched sufficiently, he added.

“You don’t need to use all the vitamins. Choose one that works for you,” he said. “You may want to stick with a cleanser, a moisturizer, a sunscreen, and RetinA. That should be sufficient for most people.”

Bleaching agents appear to stop pigment creation but can take several months and can even induce dark granules in some skin types. For dark spots, first make sure they’re not cancerous, and then try a bleaching cream, such as Lustra Cream (with 2 percent glycolic acid and 4 percent hydroquinone). Tri-Luma, another good selection, contains steroids so should be used only for a short term.

“There are limitations to any products, so it’s important to look into what works and what is only hype,” said Gladstone. “Cosmeceuticals can only go so far. Often it takes more than just a cream to make skin look great.”

Gladstone suggested a routine that includes a sunblock with titanium dioxide, a bleaching agent (Lustra Cream) and an antioxidant in the morning, a retinoid (Renova) at night, and moisturizer two times a day.

About the Speaker
Hayes Gladstone, MD, director of the division of dermatologic surgery at Stanford, is an associate professor of dermatology and, by courtesy, of otolaryngology – head and neck surgery. He specializes in minimally invasive procedures for the cosmetic and therapeutic surgery, wound healing, and using new technologies including Mohs micrographic surgery to diagnose and treat skin cancer.

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Don’t Scratch That: Rashes

Posted By SHL Librarian

Presented by: David Peng, MD, MPH
Clinical Associate Professor of Dermatology
Stanford University Medical Center
November 18, 2010

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Lecture Overview:

  • The skin is an immune system organ, and the system can be activated by a number of external causes.
  • The most common cause of itching is dry skin. Other widespread causes include fungus, insect bites, and contact allergies.
  • Water (especially hot water) can actually worsen the problem of dry skin by removing normal, protective skin oils.
  • Contact allergens include rubber, adhesives, nail polish, hair dye, and metal-particularly nickel, which is used in earrings, belt buckles, waistband snaps, and watchbands.
  • A dermatologist can provide a test to find the trigger of your allergic response and prescribe the most appropriate treatment.

Your mother was right: Don’t scratch! Tempting as it is, one of the worst things you can do to an itch is to scratch it.  While a good scratch can sometimes be the ultimate pleasure, the fact is an itch is a physical response that involves the skin’s receptors, your immune system, and your brain. Unchecked scratching can often damage the skin and not address the source of the physical stimulus, said David Peng, MD, a clinical associate professor of dermatology, who spoke at a presentation sponsored by the Stanford Health Library..

The most common cause of itching is dry skin, known clinically as xerosis. Most people experience a normal seasonal variation in skin dryness caused by low environmental humidity. For many, the first step is a moisturizer, but Dr. Peng warns that not all moisturizers are the same and vary in strength depending on the ratio of water to oil in the mixture. Solutions have the highest proportion of water, which is like trying to moisturize with pure water. Water alone can actually worsen the problem of dry skin by removing the normal, protective skin oils.

Next in strength are lotions, which feel good on the skin but evaporate rapidly, making the skin drier. Creams and ointments have more oil content-they tend to moisturize and don’t evaporate. While this attribute is good for the skin, it may cause lifestyle complications, said Dr. Peng, referring to the mess a common ointment like Vaseline Petroleum Jelly can make. Moisturizers should be reapplied liberally during the day and evening, especially to areas prone to dryness (hands, arms, legs) and when your skin feels itchy.

“”Extremely dry skin may require moisturization with an ointment,” said Dr. Peng. “Otherwise most people will find that a cream will get them through the day.”

Hot, soapy water depletes the natural skin oils and may be dry skin’s worst enemy. Dr. Peng recommended using lukewarm-not hot-water and patting dry-not rubbing. Follow the three-minute rule for showers, applying moisturizer within three minutes after getting out of the water.

“The top layer of skin is like a sponge. You have about three minutes until it evaporates. Applying moisturizer within that window of time traps water inside the skin, where you want it,” he said.

Another common cause of itching can be a fungus. Athlete’s foot, the most common skin fungus, affects about 10 percent of the entire U.S. population every year and can involve other parts of the body besides the feet. Skin fungus infections cause an inflammatory response by the body’s immune system, which brings on itching, flaking, redness, and thickened skin. The condition is treated by antifungal ointments like Lamisil (available over the counter) or Clotrimazole (by prescription).

Insect bites can affect people in different degrees, from simple irritation to hives and swelling. Bedbugs and fleas are common pests that can cause a reaction from their saliva.

Mosquitoes are attracted to the lactic acid in your sweat: Use DEET to prevent them from biting and hydrocortisone to treat the bites afterward, said Dr. Peng. Scabies, a skin infection caused by a parasitic mite, tend to create a circular pattern of itching that includes the nipples, armpits, wrists, bellybutton, and genitals. Most cases can be treated with Elimite cream, he said.

Allergic contact dermatitis is caused by direct physical contact with your skin. Unlike food allergies, which are usually identified with a prick test, Type IV hypersensitivity is tested with stickers applied directly to the skin. A full-spectrum antigen test uses a grid of patches containing common household products to induce a reaction. Common allergens include rubber, adhesives, nail polish, hair dye, and metal-particularly nickel, which is used in earrings, belt buckles, waistband snaps, and watchbands.

More than half of Americans are allergic to poison ivy, which can last for months on clothing after initial exposure. Many people develop contact dermatitis from fragrances used in detergent, toothpaste, perfume, or lotions.

The first step in treating any itch should be a good medical evaluation. Your dermatologist or allergist may discover the “trigger factors” in your environment and encourage you to minimize or avoid them. “The most important thing is to find what you are allergic to and avoid it,” said Dr. Peng. “Your dermatologist should go on a hunt to find your trigger-a systematic process of identification and elimination.”

Medical care will focus on diminishing the itchy sensation, using various classes of topical steroids. Treatments range from Class I, which includes clobestasol to treat thick plaque, to Class 5, which is prescribed for short-term daily maintenance, to Class 7, which includes over-the-counter creams like hydrocortisone.

“There are side effects to topical steroids so these treatments should not be used for the long term,” said Dr. Peng.

About the Speaker
David Peng, MD, MPH, is a clinical associate professor of medicine and director of the dermatology residency program. He was an assistant professor of clinical dermatology, director of the dermatology resi­dency training program, director of the Pigmented Lesion Clinic, and direc­tor of Contact and Occupational Dermatitis at University of Southern California before joining the Stanford faculty in 2010. Dr. Peng received his medical degree from University of California, San Diego, where he completed his residency in dermatology, and he earned his master’s in public health from UCLA. Dr. Peng is Board Certified by the American Board of Dermatology.

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The Sun and Skin Cancer

Posted By SHL Librarian

Presented by: Sumaira Z. Aasi, MD
Clinical Associate Professor, Dermatology
October 10, 2012

Skin is the largest organ of the human body. It serves a tremendous immune defense system designed to protect you from the environment, regulates internal temperature, and keeps out infection. It’s also a window to your overall health.

Because it is bombarded by so many external elements, skin reflects changes that can be noticed and tracked, from innocuous freckles and moles to dangerous forms of skin cancer. In fact, skin cancer is at epidemic levels, says Sumaira Z. Aasi, MD, a clinical associate professor of dermatology, who spoke at a presentation sponsored by Stanford Hospital Health Library.

Skin cancer is the most common form of cancer in the United States. More than 1.3 million cases are diagnosed each year—20 percent of all Americans. It is usually curable if caught early and treated appropriately, she says.

Sun damage is the primary cause of skin cancer, intensified by the depletion of the ozone layer, an outdoors lifestyle, minimal clothing, and a population that is living longer. People most at risk have fair skin, blue eyes, and blonde or red hair. Though genetics and other environmental exposures can also cause skin cancer, unprotected sun exposure is the biggest cause of basal cell carcinoma, squamous cell carcinoma, and melanoma.

“The more exposure to the sun, the higher the incidence,” Dr. Aasi says. “No one wants to think about skin cancer while doing activities you enjoy, but it is really all about sun exposure. The effect is cumulative, so even if you are conscientious about covering up and using high SPF protection now, the damage started years ago, with exposure when you were young.”

Cancer Development
Exposure to the sun’s ultraviolet radiation causes mutations in the DNA of skin cells. Normally your immune system is programmed to get rid of mutated cells, which is what happens when you get a sunburn and the skin peels—your body is getting rid of the damaged skin cells. As we age, however, the immune system does not register these changes as well, and some mutations slip through the protective system. The mutations cause the cells to grow out of control and become cancerous cells.

“You may not think you have sun damage, but take a look at your arm and compare it to a part of your body that is seldom exposed, like your inner thigh or the underside of your arm,” Dr. Aasi says. “It’s an obvious demonstration of how much you have been exposed to the sun.”

Skin cancer develops primarily on areas of sun-exposed skin, including the scalp, face, lips, ears, neck, chest, arms, and hands, but it can also form on areas that rarely see the light of day. Look for a bump or mark that bleeds, changes color, doesn’t heal, or gets bigger over time, Dr. Aasi says. “No one knows your body as well as you do, so be your own best advocate and keep track of any changes.”

Basal cell carcinoma is the most common form of skin cancer. It’s slow growing and rarely spreads, so it is rarely fatal but can be highly disfiguring if allowed to grow. Look for a red, scaly patch that gets bigger or a pimple with small blood vessels.

Squamous cell carcinoma is the second most common form of skin cancer. It starts off looking like a scaly patch, flat lesion, or red nodule. Actinic keratosis are precancerous growths that also result from sun exposure and can sometimes develop into squamous cell carcinomas. These can be treated very easily in the office without surgery.

Melanoma is the most dangerous form of skin cancer because of its ability to spread into the lymph nodes. Melanoma arises from melanocytes, the cells that provide color to the skin, so it often appears black or brown but can be red or pink as well.

Skin Cancer Treatment
Usually a physician will biopsy a skin sample to determine if a lesion is a skin cancer. If it is cancer, there are multiple treatment options depending on the location and size, such as simple scraping (curettage) and burning (electrodesiccation) and as well as surgical excision. Typically surgery involves cutting the growth, along with a margin of nearby skin to make sure all the cancer cells are removed.

In certain situations an option called Mohs micrographic surgery allows surgeons to remove the cancer while sparing healthy adjacent tissue and examine the margins right away under a microscope while the patient waits. The procedure is used mostly for basal cell and squamous cell carcinoma, and has a 99 percent cure rate for most first-time cancers.

“The technique offers the highest cure rate for skin cancer removal while minimizing the size of the resulting scar,” says Dr. Aasi. “It allows us to be extremely precise, so we can preserve surrounding healthy tissue and save as much skin as possible.”

The procedure requires a special laboratory for analysis of the skin, and Dr. Aasi advises that patients check to make sure the dermatologist using Mohs has been trained through a fellowship. Stanford’s Redwood City dermatology clinic is home to one of the leading Mohs surgery programs in the region.

Cancer Prevention
The most important step to prevent the development of skin cancer is to protect your skin, Dr. Aasi says. Use sunscreen with an SPF of 30 or higher, with broad spectrum UVA and UVB protection. Use sunscreen before you go outside, and be sure to use enough.

“Most people think they are protected but they have not used the proper amount or reapplied it sufficiently,” she says. “Use about a shot glass full and remember to cover your feet, back of neck, ears, and near your eyes. There’s no such thing as waterproof sunscreen, so reapply it when you get wet or sweat. Think of it as paint —apply and then reapply a second coat to get good coverage.”

Cover yourself with loose, lightweight clothing, use a broad-brimmed hat (baseball caps do not provide coverage to the back of the neck or ears), and try to do outdoor activities in the morning or late afternoon—not during prime midday sun.

“There’s no such thing as a safe tan,” she adds. “Artificial radiation from tanning beds is as bad or worse than natural sunlight. The sun might feel good, but it is dangerous.”

Dr. Aasi also suggests you start seeing a dermatologist in your 30s to establish a baseline to track any changes in your skin and to be diligent about doing self-exams on a regular basis.

About the Speaker
Sumaira Aasi, MD, is a clinical associate professor of dermatology specializing in skin cancer and Mohs surgery. She received her MD from Northwestern University Feinberg School of Medicine and did her internship at the University of Chicago Hospitals and her residency at Northwestern University’s McGaw Medical Center. She completed her fellowship in Mohs micrographic surgery and advanced cutaneous oncology at Yale University. Dr. Aasi is Board Certified by the American Board of Dermatology.

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