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The Female Body: An Owner's Manual: Skin

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Skin

Skin is the wrapping that holds your body together. It keeps out harmful environmental elements such as radiation, bacteria, viruses and dangerous chemicals. Without it you would literally fall apart.

Of course, none of that covering is either permanent or wrinkle-free. Smile lines around your eyes tell the world that you've been living and laughing for a long time--certainly nothing to be ashamed of. Expression lines eventually crease your forehead, the skin between your eyes and the delicate skin around your eyes. They are the result of constantly moving your face in the same patterns over a long period of time.

But of all the potential agers facing your skin, none is a tenth as destructive as the sun. A common figure cited by several doctors is that 80 percent or more of the visible aging that occurs on the skin is a result of sun exposure--a process called photoaging.

Fry Now, Pay Later

Behind every wrinkle, every age spot, every freckle and every skin cancer there is an afternoon spent at the beach or a picnic or a simple walk in the sunshine. More accurately, a lifetime of such moments waits until your thirties and forties to show up on your face.

Unfortunately, lots of women don't realize that every unprotected minute spent in the sun as a child--and for most of us, there were thousands of them--would show up on their faces years later, says William Coleman, M.D., clinical associate professor of dermatology at Tulane University in New Orleans. People who have stayed out of the sun look a lot younger than those who haven't, he observes. "Research shows that many children, by age ten, have enough sun damage to develop severe wrinkling and skin cancer later on. It's a delayed phenomenon."

Were it not for a lifetime of sun exposure, it's possible that your skin could be relatively youthful-looking up until your seventies. That's the age when intrinsic aging of skin kicks in, and studies back this up.

For an objective test, one panel of judges viewed pictures of 41 Caucasian women who lived in Tucson, Arizona--one of the sunniest places in the United States. The women in one group had been exposed to fewer than two hours of sun a week. In the second group the women had been exposed to more than 12 hours weekly. Viewing the pictures, the judges consistently guessed that the women with the greater sun exposure were, on average, 11 years older than their actual ages. The women in the low-exposure group were thought to be only 5 years older than they were.

Rays from the Sun

How could the good old sun--that comforting, glowing orb that feels so good--turn out to be such a traitor?

When the sun is at peak power--between 10:00 a.m. and 3:00 p.m. each day--you're getting a blast of ultraviolet (UV) rays that do the dirty work. The UV rays are divided into three segments: UVA, UVB and UVC. Luckily for us, atmospheric oxygen and the ozone filter out UVC rays, which are the shortest, most powerful and most highly destructive rays, before they reach the Earth.

Of the radiation that gets to us, UVB rays are more destructive to the skin and are thought to cause most of the aging. UVA rays have a relatively low energy content, but since there are more UVAs than UVBs in sunlight, UVA damage can be significant, too.

When the sun hits the skin, ultraviolet radiation penetrates into the nucleus of each cell. That's where much of the damage is done. The nucleus stores DNA, the string of molecules that makes up the "message center," controlling the activity of each individual cell as well as the information that travels to other cells. The radiation breaks down the DNA, damaging the cells that produce collagen and elastin, proteins that make up the bulk of your skin and help keep it taut and resilient. "It's like microwaving the collagen until you end up with broken and destroyed tissue," says Melvin Elson, M.D., medical director of the Dermatology Center in Nashville and director of the Cosmeceutical Research Institute in New York City.

Thinning Skin

To see the effect of the sun, doctors have looked at what happens to the outer two layers of skin, the dermis and the epidermis.

The dermis is the thicker layer, which houses the sebaceous glands, or oil ducts, and the sweat glands. This layer is also filled with the collagen and elastin that make your skin tight but flexible. At the base of all that is the subcutaneous fat, which separates the dermis from the muscle and bone, insulating you from the cold.

That layer is topped off by the epidermis, a protective shield that is constantly reinforced as cells at its bottom divide and multiply, pushing the cells above them to the surface. When the very top cells get sloughed off, they're just dry and useless flakes--a miniature, invisible dust storm. These used-up cells are the material that makes up your bathtub ring and some of the dust in your house.

As sunlight exposure continues, the ridges between your epidermis and dermis keep flattening out until they completely disappear. To make things worse, the thinner the skin gets, the less tissue there is to absorb the UV rays, and the more harmful even a small dose can be.

Even reflected sunlight is damaging--and the light can be reflected off everything it touches. Sand reflects 17 percent of the UV rays. Freshly fallen snow reflects more than 80 percent. This reflection can send sunlight upward to delicate areas that burn very easily, such as the top of your nose and underside of your chin.

Photoaging doesn't just show up in the form of wrinkles. Age spots, also known as solar lentigines, are brown splotches that commonly appear on the hands and face. They're a result of the skin trying to protect itself from sun overexposure by producing an overabundance of melanin--the pigmented cells in your skin that are responsible for tanning--in uneven patches. Photoaging is also the cause of 90 percent of all skin cancer.

Exposure: It All Adds Up

The reality is that you can avoid the sun. Every minute spent in it has a cumulative effect over a lifetime.

Say you spend 7 minutes walking to and from work every day. That's 14 minutes in the sun a day. Then you go out for lunch and sit for 10 minutes outside, or you spend 5 minutes outside talking to someone. It all adds up, says Michael Martin, M.D., assistant clinical professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco, and author of How to Outsmart the Sun. "Think of it like the fading of a piece of furniture. Put it in direct light, and it happens fairly quickly, but with a little bit of exposure over a period of time, it still fades. Add up 30 two-minute exposures, and it's as damaging to your skin as a continuous full hour of sun."

How much will that affect you?

In part the answer depends on heredity. You inherit your skin type, your ability to tan and your resistance to burning--the factors that largely determine how you will wrinkle. If you're a sun-loving, fair-skinned blond with northern European ancestors, you'll probably age more quickly than an African-American.

It comes down to melanocytes, which are pigmented cells in your skin that produce color, or melanin. When the sun hits your skin, the melanocytes go to work, putting some color in your skin to protect it from harmful UV rays. The additional color helps prevent the rays from penetrating the deeper layers of skin.

One way to measure skin tolerance is by calculating the sun protection factor (SPF), the measurement used on sunscreens. The darkest African-American has a built-in SPF of 10 in her skin, which means that it takes ten times as long for her skin to burn as a Caucasian woman's.

It's All in the Pigment

The darker your skin, the better your built-in protection against skin cancer. The following chart summarizes findings about some specific ethnic groups. The lightly pigmented groups, such as the Irish and Scottish, are at much higher risk of getting skin cancer than the darker groups, such as the Greek or Spanish.

*Highest Risk*	/td>	*Moderate Risk*	/td>	*Lowest Risk*
Scottish		Scandinavian		Polish
Irish		German		Italian
English-Welsh		French		Greek
Russian		Slavic		African
				Spanish

While a lifetime of sun exposure won't age the African-American much, the blond Caucasian has practically no natural melanin. This means that the UV rays will go directly to the deep layers of skin and cause tissue damage.

Saving Face--With Prevention

As far as sun damage goes, what's done is done. But it's never too late to ward off crow's-feet and worry lines, says Michael Bilkis, M.D., assistant professor of dermatology at New York University Medical School in New York City. Here are some tactics.

Slather on sunscreen. Dermatologists sound like broken records on this point: Of everything you can do to ward off wrinkles and age spots, wearing sunscreen is the most important.

Go 15 or over. Choosing the right sunscreen can be a challenge, with SPF numbers ranging from 5 all the way up to 50. How can you determine how much protection you'll get from a sunscreen?

It all depends on your skin type. Take the number of minutes that it takes your skin to turn red and multiply it by the SPF. If you normally burn after 20 minutes in the sun, an SPF 15 will protect you for 300 minutes, or five hours.

Most doctors recommend an SPF of 15 or higher, says Jonathon Weiss, M.D., assistant clinical professor of dermatology at Emory University School of Medicine and Clinic in Atlanta. "I prefer one with a factor of 30 or higher."

Don't wait to renew. If you're wondering how often to put on more sunscreen, the answer is, the more frequently the better. Sunscreen gradually loses its protective power. If an SPF 15 sunscreen promises to block out 92 percent of UV radiation, for instance, it's only doing that at first. After a period of time (two hours or less), it may have diminished to an SPF of about 7. Every sunscreen has a half-life, when it's only half as effective, according to Dr. Weiss.

Up the ante to avoid beach burns. For folks who wear sunscreen every day and spend most of their days indoors, a nonwaterproof SPF 15 is adequate. Long days outside and on the beach, however, require heavy-duty protection of at least SPF 30, says Dr. Bilkis. If you spend a considerable part of your day under the sun, apply a nonwaterproof SPF 30, reapplying the sunscreen often as the day goes on.

"The lower number is for when you're not in the sun or sweating for a long time," he notes. "The other is for the beach. If you're outside sweating, you want something that will stay on your skin." A sunscreen that is truly waterproof--indicated by the label--should maintain its SPF after 80 minutes of water exposure.

Never trust a cloud. You need protection even on cloudy days, says Dr. Bilkis. Some of the ultraviolet rays aren't absorbed by the clouds; they come right through. And because you don't feel the heat, your body doesn't tell you when it's time to come inside. "The worst sunburn I ever saw was on a man who was out on his boat on a foggy day."

Make it a daily habit. Get used to putting on a dab of sunscreen every morning, suggests Harold Brody, M.D., clinical associate professor of dermatology at Emory University School of Medicine in Atlanta. He recommends a combination sunscreen moisturizer with an SPF of 15, applied after you've washed and dried your face in the morning--preferably, at least 30 minutes before you go outside. Just rub a pea-size drop on each cheek and another on your forehead. Then moisten your fingertips and work the sunscreen, along with the water, into your skin.

Beware: If a moisturizer simply says that it prevents aging or contains a sunscreen but doesn't list an SPF, chances are that it won't be an effective sunscreen on its own.

Have it made with shades. Wear sunglasses every time you head outside, says Dr. Weiss. They protect the eye skin to some extent and help prevent squinting, which plays a big role in expression wrinkles.

Dress for sun excess. Choose clothes that won't let those harmful rays in. Darker colors protect better than lighter ones, and tight-weave clothes are better than loose-weave clothes, notes Dr. Weiss. "A wet white T-shirt allows UVB rays to penetrate."

One good test for a protective garment: If you can see through it only by holding it very close to your eyes, it has an SPF of at least 15.

Delay that jog. Rather than worry about sweating off your sunscreen, plan outdoor exercises like biking or jogging either before or after the sun's peak burning hours of 10:00 a.m. to 3:00 p.m. Even then, you should be smeared with sunscreen, since daily application should be a regular habit.

Keep a hat on. A hat with at least a two-inch brim that goes all around the head offers good protection. "It should protect your ears and neck as well as your face," says Dr. Martin.

Screen your kids. If you have children, it's never too early to start slathering sunscreen on their exposed noses, shoulders, tummies--and don't forget the tops of their ears and feet. "You should definitely start putting sunscreen on as a child," notes Barbara Gilchrest, M.D., professor and chairman of dermatology at Boston University Medical Center. "People get most of their lifetime sun exposure when they're outside playing."

Avoid fry shops. Spending time in a tanning salon is absolutely the worst thing that you can do to your skin, says Dr. Weiss.

These places hype the fact that their lightbulbs emit relatively low-energy UVA rays rather than UVBs. UVA rays go deeper into the skin, actually penetrating to the level of some hair follicles and sweat glands. This can cause damage that could lead to cancers of the skin. Also, the tan from a tanning bed doesn't protect you from a UVB burn once you go outside.

Doing Your Part

In spite of the sun's significant influence on your skin's health, looking younger is not only about protecting your skin from UV rays. There are lots of other strategies that can stop the boots of time from marching across your face.

Stop yo-yoing. Constantly losing and gaining weight can eventually affect the elasticity of your skin, says Dr. Elson. The cells in the subcutaneous fat layer of the skin don't multiply--they enlarge. Excess weight pushes on the skin. "After seesawing for 40 years, the skin won't snap back anymore. Maintain a normal weight."

Quit smoking. Smoking is a major cau

Where to Look First When you do a self-exam for changes, discolorations or new growths in your skin, some areas deserve special attention. See the illustration to identify the places where skin cancers most frequently occur on a woman's body. If some areas are hard to see when you do a self-exam, use handheld and full-length mirrors.
Thirty-five to 40 percent of skin cancers occur on the lower extremities. Other risk areas include the upper extremities and the face, neck and head.

se of wrinkling, says Dr. Elson. It's damaging in two ways: Constant facial movements result in lines, and a buildup of tar narrows the blood vessels that in turn nourish the skin. The result is that the skin doesn't recover as well from injuries like sun damage.

Beware of anti-aging exercises. Exercises that promise to tone the muscles of the face are a bad idea, says Dr. Martin. "Any facial exercise has the effect that smiling does; you're creasing the skin over and over again in odd ways that you normally wouldn't use with facial expressions."

Stop smooshing your face. Sleeping on your stomach or side leads to facial creases, says Dr. Elson. One solution is to get a wrinkle pillow, available in many department stores. It holds your head in a certain position so that you can't roll back and forth.

Also, a satin pillowcase can help cut down on creasing of the skin, says Dr. Elson. Or try setting two pillows side by side and placing your head in the crevice where they meet to help force yourself to sleep on your back.

Skin Cancer: More Than a Scare

Crow's-feet and age spots might not be the cutest things in the world, but at least they don't hurt you. Another direct result of the sun isn't so benign: skin cancer. If you are white and live to age 65, your chances of getting it are about 50-50.

The incidence of skin cancer increases the closer you live to the equator. Someone in Texas, for example, would be expected to develop skin cancer about ten years earlier than someone in Minnesota.

It's the most common form of cancer in the United States; nearly 40 percent of all diagnosed cancers are skin-related. Despite the anxiety and fear it causes, however, when it is detected early and removed, skin cancer can be beaten by timely intervention.

There are three types of cancer: basal cell, squamous cell and malignant melanoma. Basal cell, which appears as a small, fleshy bump or nodule on the head, neck and hands, is the most common form of skin cancer. Left untreated, it will begin to repeatedly bleed and crust over. It rarely spreads to other parts of the body, but it can cause considerable local damage if let go. It is not life-threatening, however.

Squamous cell appears either as nodules

What Does Collagen Do?

If you have a collagen injection to help remove wrinkles, your doctor will inject bovine collagen--which comes from cows--into your skin in the wrinkled area. The illustrations below show a woman with nasal labial fold lines--the deep wrinkles that run from the nose to the mouth--and the results after a collagen injection treatment.

Before collagen injection.

After treatment.

or as red, scaly patches in the rims of the ears and on the face, lips and mouth. Unlike basal cell, it can spread, and it is estimated that more than 2,000 people a year die from it. If removal is potentially disfiguring, as when the cancer is located on the nose or under an eye, the lesion can be treated with radiation rather than cut off.

Unfortunately, basal cell and squamous cell cancers can recur. "Sun-damaged skin is sun-damaged skin," says Ronald Scott, M.D., Ph.D., radiation oncologist and cancer specialist at the South Coast Tumor Institute in San Diego. The incidence of recurrence is highest at the middle of the face--the nose is the top spot for skin cancer.

Then there is malignant melanoma--the pit bull of skin cancers--which strikes 32,000 Americans a year and kills nearly 7,000. Because it is almost always curable in its early stages, early detection is critical. Melanoma begins in or near a mole or other dark spot, so it is vital to be familiar with every mark on your body and to check yourself often.

Unlike the other two types of cancer, melanoma usually appears on places that are covered by clothing, says Dr. Martin. This is because melanomas are closely linked with severe sunburns--the kind that a pale person gets when she bakes on the beach for three hours. Melanoma also hits at a younger age; 20 percent of them strike people under age 40.

Your chance of getting a melanoma has skyrocketed. Fifty years ago, a person had only a 1 in 1,500 chance of acquiring one. The lifetime risk has increased to 1 in 135.

The increase is partly a result of some changes in lifestyle that have occurred over the decades. "We can travel more easily now; we can beat up our skin in a weekend," observes Dr. Coleman. "That, and wearing less clothing and exposing more of the body, contribute to melanoma."

Should you have every lump and bump that pops up on your skin removed? "Everyone gets skin growths, and they don't all turn into cancer," says Dr. Scott. If you have a strange growth that you never noticed before, have a doctor check it out. Also, be sure to notice any moles that change shape or size.

Facing Up to Wrinkle Control

Women who worship the sun often end up regretting it--and looking for solutions. Crow's-feet, fine wrinkles and the deep folds that run from the nose to near the chin are all the most common--and easiest--to erase through modern medical intervention, says Barry Resnik, M.D., clinical instructor of dermatology at the University of Miami School of Medicine. Among the available treatments are collagen injections, chemical peels and tretinoin cream, according to Dr. Resnik. In fact, collagen injections are the fourth most popular procedure for people ages 19 to 34.

With collagen injections the wrinkles are, in effect, puttied over from the inside with bovine collagen that is injected into the skin. (Collagen from cows is used, because it is most similar to that found in humans.) It lasts for anywhere from six months to a year, when the collagen is absorbed into the body. If you are allergic to bovine collagen, as 3 percent of the population is, you can ask about microlipoinjection, a nasty sounding but fairly simple procedure, which involves taking fat from the hip or abdomen and injecting it into the wrinkle.

Another procedure involves treatment with a prescription vitamin Aderivative cream called tretinoin (Retin-A), which can smooth out fine lines and even out skin tone.

Using it is extremely simple: Apply a pea-size amount to your face and the backs of your hands every night. These are the areas that are most exposed to the sun. Tretinoin penetrates the damaged skin cells and spurs them to start making collagen again, which fills in fine wrinkles. It also increases blood flow in the skin to give it a youthful, pink tone.

"It's a slow process," says Edward Jeffes, M.D., assistant chief of dermatology at the Long Beach Veterans Administration Medical Center and associate professor of dermatology at the University of California, Irvine. "It doesn't reverse severe damage, but it does erase fine lines." But be patient: It takes at least six months to see the full benefits.

Because tretinoin increases sensitivity, it means that you must always use sunscreen when you go outside. And the only way to keep reaping its benefits is to keep using it. In some people there are various unpleasant side effects, including dryness, peeling, reddening and blistering of the skin. If your reaction is severe, your doctor might advise you to use tretinoin every other day or to stop the therapy altogether for a few days.

Chemical peels are another procedure for smoothing out unwanted wrinkles. The chemicals are applied by a dermatologist, and the skin reacts to the application by sloughing off several layers of skin cells. Then new skin is regenerated, which not only looks better but also is less prone to skin cancer.

Different chemical solutions, including glycolic acid, lactic acid, trichloroacetic acid, salicylic acid and phenol, are used alone or in combination to achieve the desired effect. The strength and type of solution that the doctor uses determines whether it is a light peel--which affects light surface wrinkles--or a deep peel--which works on the deeper wrinkles. The deeper the peel, the more intricate the procedure.

Just remember that after these procedures, skin is ever so vulnerable to sunlight, and sunscreens are a necessity. Make sure that you choose an experienced dermatologist who performs chemical peels often.

Skin Care Basics

When it comes to caring for your skin, take the sage advice of Henry David Thoreau: Simplify, simplify, simplify. Here are some ways to go about it.

Be selective. "Two or three products will do everything that you need," says Dr. Weiss. "Otherwise, you're drying the skin out just to put moisture back in." For one simple cleanser to use all over your body, Dr. Weiss suggests Dove, Basis, Neutrogena, Cetaphil, or Oil of Olay--none of which contains harsh, irritating ingredients.

Go easy. Women often make the mistake of scouring their skin with loofah-type scrubbers, according to Dr. Weiss. "I recommend just using your hands." He warns that scrubbers are too abrasive for facial skin.

Get yourself into warm water. Hot, steamy water might feel like it cleans your skin better, but warm is the way to go. "Hot water tends to dry out skin," says Dr. Weiss.

Don't rough yourself up. When drying your face after washing, rubbing roughly could eventually lead to saggy skin, says Leonard Engelman, makeup artist and president of Taut Cosmetics in Chatsworth, California. "Just dab yourself dry. The concept is that rubbing roughly around your eyes can break down the skin to a certain degree."

Avoid skin booze. Astringents are alcohol-based skin toners that strip skin of natural oils, says Engelman. "The original reason for astringents goes back decades to when women used heavy cleansing creams. Astringents were needed to remove excess oil from the skin's surface." Since today's cleansers are light, astringents aren't really necessary.

Keeping Up with Moisture

You've seen all the glossy ads hyping miracle eye creams and ultra-rich moisturizers that take years off your skin. These concoctions promise to do everything but scrub your kitchen floor.

Unfortunately, a wrinkle is a wrinkle, and short of cosmetic surgery, it's there to stay.

What a moisturizer can do is help hydrate the skin, which plumps it up a bit, says Dr. Bilkis. "If the skin is dehydrated, it shrinks down and looks more wrinkled."

If your skin is dry, moisturizers replace lost oils, adds Dr. Coleman. The moisture soaks into your skin and adds volume to it. "It actually occupies space in the top layer of your skin."

Relative newcomers to the skin care world are alpha hydroxy acids (AHAs), which contain active exfoliators like glycolic and lactic acids. AHAs work by lightly peeling the top layer of skin, removing dead cells. Unlike the chemical peels given by some dermatologists, AHAs don't penetrate beyond the epidermis and thus are much gentler to the skin.

Antioxidant skin creams are another development in skin care technology. The makers of the creams claim that they neutralize free radicals--the molecules formed by sun exposure that destroy healthy skin cells. Containing vitamins C and E, these creams are touted as the answer to aging. The jury is still out, however, according to Lorraine Kligman, Ph.D., research associate professor of dermatology at the University of Pennsylvania School of Medicine in Philadelphia. "There is some evidence that they can prevent some of the acute damage done to the skin. Sunburn causes cells in the epidermis to die, and some of these preparations can reduce the number of sunburn cells. But what they do over the long term is under speculation."

Sometimes a Great Lotion

If you're using any kind of moisturizer, here are some ways to make it most effective.

Make a sandwich. When applying moisturizer, do it while your skin is still damp to help seal the moisture in. "You need to make a skin, water and moisturizer 'sandwich,' " says Dr. Resnik. "The moisturizer is like a roof that prevents evaporation of water."

Go for the grease. Did your mother recommend petroleum jelly as the moisturizer of choice? Well, guess what? She was right. It still can't be beat, says Dr. Kligman.

According to a study that Dr. Kligman did in 1992 using hairless mice, four weeks' application of the coal tarbased product actually thickened the epidermis. A mouse epidermal cell is usually condensed-looking, but treated with

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