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Original Paper
Skin Pharmacol Physiol 2012;25:78–85
DOI: 10.1159/000335259
Received: April 5, 2011
Accepted after revision: November 17, 2011
Published online: January 12, 2012
Differences in Susceptibility to Oxidative Stress
in the Skin of Japanese and French Subjects and
Physiological Characteristics of Their Skin
Y. Yamashita a Y. Okano b T. Ngo c P. Buche c A. Sirvent c F. Girard c
H. Masaki b
a
Nikkol Group, Nikoderm Research Inc., Osaka, and b Tokyo University of Technology School of Bioscience and
Biotechnology, Tokyo, Japan; c Laboratoire Dermscan, Villeurbanne, France
Key Words
Catalase ⴢ Protein carbonylation ⴢ Oxidative stress ⴢ
Ethnic groups
Abstract
Background: Many researchers have studied differences in
conditions of ethnic skin using biophysical measurements.
However, few studies to date have focused on the antioxidative capacity of the skin. Methods: We measured two parameters of oxidative stress in the stratum corneum, catalase activity and protein carbonylation of the stratum corneum
(SCCP), in two ethnic groups, Japanese and French subjects,
to characterize the susceptibility to oxidative stress. We also
measured several physiological parameters at three different skin sites, two sun-exposed sites (cheek and dorsal aspect of the hand) and a sun-protected site (inner upper arm),
in both ethnic groups. Results: Transepidermal water loss
(TEWL), the size of corneocytes and skin color showed differences between sun-exposed and sun-protected sites regardless of ethnicity. Regarding ethnic differences, catalase
activities and parameters of skin hydration and barrier function of Japanese subjects were higher than those of French
subjects. However, SCCP values showed a trend contrary to
catalase activity. The difference in the b* value indicated that
the melanin content of Japanese skin was higher than that
© 2012 S. Karger AG, Basel
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of French skin. Pearson’s correlation analyses showed that
catalase activity and SCCP values had weak relationships
with water content, TEWL and skin color in both ethnic
groups. Conclusion: Differences in susceptibility to oxidative stress, namely melanin content and catalase activity in
the skin, induce the better skin condition of Japanese compared with French subjects.
Copyright © 2012 S. Karger AG, Basel
Introduction
Ethnic differences in skin conditions are obvious and
their characteristics have been investigated from various
angles. Parameters of skin physiology and morphology,
such as surface hydration, barrier function, surface lipids,
surface textures, wrinkles and pores as well as skin color
have been studied for various ethnic groups, and differences in some factors have been found, such as variations
with age and reactive characteristics to environmental
stress [1–5]. In addition, it has been shown that differences between Caucasian and African skin affect the
functions of the epidermis and dermis and their cellular
interactions [6]. Recently, it has also been reported that
races which have differently pigmented skin types show
differences in epidermal barrier function which can be
Yuki Yamashita
Nikoderm Research Inc.
1-6-14, Azuchimachi
Chuoku, Osaka 541-0052 (Japan)
Tel. +81 6 6125 3501, E-Mail yamashita @ nikoderm.com
attributed to the pH of the stratum corneum based on the
melanin content [7].
As UV light, ozone and pollution affect the skin [8], it
can be easily predicted that there are differences in the
susceptibility of the skin to oxidative stress among ethnic
groups. However, few studies to date have focused on the
anti-oxidative capacity of the skin according to ethnic
background. Therefore, we conducted biophysical measurements (water content of the skin surface and transepidermal water loss, TEWL) and determined the size of
superficial corneocytes and the integrity/cohesion of the
stratum corneum in addition to the susceptibility to oxidative stress in the skin of Japanese (Asians living in Japan) and of French (Caucasians living in France) subjects.
The size of corneocytes is closely related to the turnover
time of the stratum corneum [1], so the condition of cornification of the epidermis can be judged from this parameter. It has been reported that the strength of cohesion of the stratum corneum can be judged from the state
of the stratum corneum removed by tape-stripping [9]. A
thicker stratum corneum abraded by the adhesive tape
means a lower integrity/cohesion of the stratum corneum
and leads to reduced barrier function of the epidermis
[10]. We analyzed the degree of stratum corneum abrasion by the tape-stripping method and used this parameter as an indicator of the integrity/cohesion of the
stratum corneum. In addition, we examined two characteristics of the skin associated with oxidation, the antioxidative capacity of the stratum corneum, namely catalase activity, and carbonylated proteins in the stratum
corneum (SCCP). Catalase is one of the foremost antioxidant defense enzymes in the stratum corneum, and it
is closely related to skin conditions [11–13]. Proteins in
the stratum corneum, such as keratins, are modified by
oxidation or glycation reactions to produce carbonylation proteins [14–16]. Therefore, SCCP is an excellent
marker to show the degree of skin damage due to oxidative stress, and it has been reported that SCCP levels increase at sun-exposed body sites [17]. Several noninvasive
methods have been reported that are useful for the determination of oxidative stress and antioxidative capacity of
human skin. For example, the interaction between carotenoids and free radicals can be investigated using electron paramagnetic resonance spectroscopy or resonance
Raman spectroscopy [18, 19]. Chemiluminescence decay
analyses are also useful tools to measure the effects of
topically applied antioxidants under in vivo conditions
[20]. On the other hand, reactive carbonyl compounds of
lipid peroxides in skin lipids can be detected in trace levels using analytical instruments in vitro [21]. However,
Oxidative Stress in the Skin of Japanese
and French Subjects
those methods are not adequate to study large numbers
of specimens. Therefore, we measured catalase activity
and SCCP levels using tape-stripped stratum corneum
which is one of the simplest non-invasive measurement
methods for skin antioxidative capacity.
In this study, we measured these parameters on sunexposed and on sun-protected sites of the body in both
ethnic groups, and considered their locational and ethnic
differences in relation to the susceptibility of the skin to
oxidative stress. Moreover, to clarify the effect of differences in the susceptibility to oxidative stress on skin conditions, we used Pearson’s correlation analysis between
catalase activities/SCCP values and the biophysical parameters.
Materials and Methods
Subjects
This study was conducted to determine the skin characteristics of two different ethnic groups, 92 Asian subjects living in Japan (Japanese; 43 males and 49 females, 22–64 years old) and 104
Caucasian subjects living in France (French; 52 males and 52 females, 18–64 years old). In both groups, the number of subjects
in 10-year age groups and their mean ages were adjusted to be approximately the same. The mean ages of the Japanese and French
subjects were 41.1 8 12.8 and 40.4 8 14.4 years, respectively.
Written informed consent was obtained from each subject before
the study.
Biophysical Measurements
The water content of the skin surface was measured using a
skin hygrometer SKICON 200EX (IBS Ltd., Japan) for Japanese
subjects and using a Corneometer CM825 (Courage and Khazaka, Germany) for French subjects. The values obtained using the
SKICON 200EX were converted to the Corneometer CM825 values using a calibration curve reported in a previous paper [22].
TEWL was measured using an AS-CT1 (Asahi Biomed) for Japanese subjects and using an AquaFlux AF100 for French subjects.
The measurement values obtained using the AquaFlux AF100
were converted to AS-CT1 values based on the results of a validation study using both instruments, as follows: y = 0.8482x – 1.4002
(y: values obtained by AS-CT1, x: values obtained by AquaFlux
AF100). Skin color was measured using a CM-2600d (Konica Minolta, Japan) for Japanese subjects and using a CR300 (Konica
Minolta) for French subjects. These instruments have different
measuring diameters (CM-2600d: ⌽ 3 mm; CR300: ⌽ 8 mm), but
L* (lightness), a* (redness) and b* (yellowness) values of the skin
can be obtained using each of them.
The superficial stratum corneum was removed using an adhesive Sellotape (Nichiban, Japan) and was then stained with an
aqueous solution containing 0.5% brilliant green (Aldrich Chemical Institutes Inc., Japan) and 1.0% gentian violet (Sigma-Aldrich
Co., Japan) [23].
The size of corneocytes was calculated by obtaining the number of pixels using Photoshop 5.0 (Adobe) on images obtained using an optical microscope at 200-fold magnification [23]. The
Skin Pharmacol Physiol 2012;25:78–85
79
Cheek
a
French
Dorsal
hand
Measured site
18
16
14
12
10
8
6
4
2
0
**
25
**
**
b
**
15
10
5
0
Cheek
Upper
arm
**
**
20
b* value
a* value
L* value
Japanese
80
70
60
50
40
30
20
10
0
Dorsal
hand
Cheek
Upper
arm
Measured site
c
Dorsal
hand
Upper
arm
Measured site
Fig. 1. Differences in skin color between measurement sites and ethnic groups. The parameters of skin color
(L*, a* and b* values) were measured. The cheek and the dorsal aspect of the hand were defined as sun-exposed
sites, and the inner upper arm as a sun-protected site. Significant differences between Japanese and French subjects are shown at all sites for a* (b) and b* values (c), but not for L* values (a). ** p ! 0.01 (Student’s t test).
thick abrasion, which is an indicator of the integrity/cohesion of
the stratum corneum, is the ratio of the number of pixels of the
overlapped area of corneocytes to the total number of pixels of
corneocytes.
All skin measurements were performed on two sun-exposed
sites (the cheek and the dorsal aspect of the hand) and on a sunprotected site (inner upper arm).
Measurement of Catalase Activity and SCCP Levels
Catalase activity and SCCP levels were measured in tapestripped stratum corneum. Tape strips were taken sequentially
using adhesive Sellotape (Nichiban). The first tape strip was discarded, the second was used to measure the SCCP level and the
third was used to measure catalase activity. Catalase activity was
measured based on the scavenging of hydrogen peroxide (H2O2)
[13]. Briefly, each piece of tape with the stratum corneum was
punched out with a 6-mm diameter punch, was placed into a BM15 1.5-ml tube (BM Equipment Co. Ltd., Japan) containing 250
nmol H2O2 (Wako, Japan) and was mixed for 120 min. After the
incubation, the solution was used to quantify the remaining
H2O2. H2O2 levels were determined by reaction with 4-aminoantipyrine (Wako) and phenol (Wako) in the presence of horseradish peroxidase. Reaction products were quantified by measuring
the absorbance at 550 nm. Catalase activity is defined as the
amount of scavenged H2O2 normalized to the total protein of the
stripped stratum corneum.
SCCP levels were determined using a previously reported
method [17]. Briefly, the tape-stripped stratum corneum was
fixed on a glass slide and was stained with 40 mM fluorescein-5thiosemicarbazide (AnaSpec Inc., USA) in 0.1 M 2-morpholinoethane sulfonic acid-Na buffer (pH 5.5; Dojindo Laboratories, Japan) and was then observed using a fluorescence microscope
Eclipse-80i (Nikon, Japan). Fluorescence images were captured
with a CCD camera DS-U1 (Nikon) and were analyzed using Pho-
80
Skin Pharmacol Physiol 2012;25:78–85
toshop 5.0 (Adobe). SCCP levels are defined as the average fluorescence intensity of the stratum corneum area in a test image. All
measurements were performed on skin of the cheek, of the dorsal
aspect of the hand and of the inner upper arm.
Statistical Analysis
Tukey’s test was performed to compare the parameters of the
measured sites. Student’s t test was performed to compare the skin
characteristics between Japanese and French subjects, and Pearson’s correlation analysis was also performed between catalase
activity/SCCP values and the other skin physiological parameters
using software for statistical analysis, SPSS Statistics 17.0 (SPSS
Inc.). Correlation analysis was performed on both original and
logarithm-converted data.
Results
Locational Differences
At first, we compared differences between sun-exposed and sun-protected skin sites. As described in the
Materials and Methods, we defined the cheek and the dorsal aspect of the hand as sun-exposed sites, and the inner
upper arm as a sun-protected site considering topical sun
exposure frequencies. In skin from both ethnic groups,
the L* value was significantly higher in sun-protected skin
of the inner upper arm compared to sun-exposed skin of
the dorsal aspect of the hand (table 1). In contrast, the a*
and b* values were lower on the inner upper arm than on
the dorsal aspect of the hand (fig. 1, table 1). These results
Yamashita /Okano /Ngo /Buche /Sirvent /
Girard /Masaki
80
70
60
50
40
30
20
10
0
**
20
**
15
10
Upper
arm
Cheek
b
1,400
SC thick abrasion (%)
Size of corneocytes (mm2)
Dorsal
hand
Measured site
1,000
25
5
a
1,200
**
30
0
**
800
600
400
200
0
Cheek
c
suggest that the skin color is darker in sun-exposed skin
than in sun-protected skin in both ethnic groups.
The differences of skin physiological parameters between sun-exposed and sun-protected sites in both ethnic
groups are summarized in table 1. In the French subject
group, significant differences were shown between the
dorsal aspect of the hand and the inner upper arm in all
physiological parameters measured (fig. 2) and catalase
activity and SCCP levels. The same tendencies were found
in the Japanese group except for water content. However,
in both ethnic groups, differences in skin physiological
parameters between the cheek and the inner upper arm
were smaller than those between the dorsal aspect of the
hand and the inner upper arm. Catalase activity was significantly higher on the sun-protected inner upper arm
than on the sun-exposed dorsal aspect of the hand in both
ethnic groups. The SCCP level was lower on the inner upper arm than on the dorsal aspect of the hand (table 1,
fig. 3). However, similar to some of the biophysical parameters, the SCCP levels in French subjects and both of the
oxidative stress markers in Japanese subjects showed no
differences between the cheek and the inner upper arm.
Oxidative Stress in the Skin of Japanese
and French Subjects
35
**
**
Cheek
Fig. 2. Locational and ethnic differences in
physiological parameters of the skin. Several skin physiological parameters – water
content (a), TEWL (b), size of corneocytes
(c) and thick abrasion of the stratum corneum (SC, d) – were measured. The cheek
and the dorsal aspect of the hand were defined as sun-exposed sites, and the inner
upper arm as a sun-protected site. Significant differences between Japanese and
French subjects are shown at all sites for
water content and thick abrasion of the
stratum corneum, at the dorsal aspect of
the hand, the inner upper arm for TEWL
and at the cheek for size of corneocytes.
** p ! 0.01 (Student’s t test).
French
TEWL (g/m2/h)
Water content (AU)
Japanese
Dorsal
hand
Upper
arm
Measured site
50
45
40
35
30
25
20
15
10
5
0
Upper
arm
Measured site
Dorsal
hand
**
**
**
Cheek
Dorsal
hand
Upper
arm
d
Measured site
Table 1. Locational difference of skin physiological parameters
Parameters
Water content
TEWL
Size of corneocyte
SC thick abrasion
L*
a*
b*
CAT
SCCP
Japanese
French
cheek
vs. arm
hand
vs. arm
cheek
vs. arm
hand
vs. arm
0.000**
0.000**
0.000**
0.008**
0.000**
0.000**
0.000**
0.921
0.190
0.293
0.000**
0.000**
0.001**
0.000**
0.000**
0.000**
0.000**
0.000**
0.957
0.000**
0.000**
0.980
0.000**
0.000**
0.000**
0.000**
0.157
0.000**
0.000**
0.000**
0.028*
0.000**
0.000**
0.000**
0.000**
0.000**
Tukey’s tests were carried out between the cheek and the inner
upper arm (cheek vs. arm), and between the dorsal aspect of the
hand and the inner upper arm (hand vs. arm). SC = Stratum corneum; CAT = catalase. * p < 0.05, ** p < 0.01: significant difference between the two parameters.
Skin Pharmacol Physiol 2012;25:78–85
81
Japanese
oxidative stress markers of the skin. Two
parameters of oxidative stress, catalase activity (a) and SCCP level (b), were measured. The cheek and the dorsal aspect of
the hand were defined as sun-exposed
sites, and the inner upper arm as a sunprotected site. Significant differences between Japanese and French subjects are
shown at all sites for both catalase activity
and SCCP level. ** p ! 0.01 (Student’s t
test).
**
120
**
25
100
**
20
SCCP level
Catalase activity
(nmol/μg protein)
Fig. 3. Locational and ethnic differences in
French
**
30
15
10
5
**
**
80
60
40
20
0
0
Dorsal
hand
Cheek
a
Upper
arm
Dorsal
hand
Cheek
b
Measured site
Upper
arm
Measured site
Table 2. Correlation analysis between catalase activity and skin physiological parameters
Water
content
TEWL
Size of
corneocytes
SC thick
abrasion
SCCP
L*
a*
b*
Cheek
Japanese
French
0.517**
–0.071
–0.221*
0.177
0.162
–0.136
–0.228*
–0.124
–0.137
0.048
0.326**
0.252*
–0.258*
–0.194
0.114
0.148
Hand
Japanese
French
0.013
0.047
–0.044
–0.018
–0.057
0.043
–0.174
0.174
–0.105
–0.189
0.332**
0.278**
–0.269**
–0.162
0.009
–0.244*
Arm
Japanese
French
–0.06
0.038
–0.238*
0.082
–0.278**
–0.040
–0.262*
–0.156
–0.206*
–0.255**
0.130
0.117
–0.249*
–0.082
–0.084
–0.064
Each number shows the correlation coefficient of Pearson’s correlation analysis. SC = Stratum corneum. * p < 0.05, ** p < 0.01: significant correlation between the two parameters.
Ethnic Differences
The a* value (which indicates redness in the skin color)
was significantly higher in French subjects compared to
Japanese subjects, but the b* value (which indicates yellowness in the skin color) was lower (fig. 1). On the other
hand, the L* value (which indicates brightness) was almost the same in the French and in the Japanese subjects
(fig. 1). Contrary to expectations, the difference in skin
color between the two ethnic groups was not reflected in
the L* value but rather in the a* and b* values.
Japanese subjects also showed a higher water content
on the skin surface, a lower TEWL, and a lower abrasion
of the stratum corneum compared with French subjects.
Those results suggest that Japanese subjects have higher
levels of skin hydration and barrier functions than French
subjects (fig. 2).
82
Skin Pharmacol Physiol 2012;25:78–85
Regarding the parameters related to susceptibility of
the skin to oxidative stress, the catalase activity of Japanese subjects was higher than that of the French subjects
(fig. 3). In contrast, SCCP levels of Japanese subjects were
higher than those of the French subjects, although higher
catalase values seemed to lead to lower SCCP levels.
Pearson’s Correlation between Physiological
Parameters and Catalase Activity/SCCP Levels
Relationships between catalase activity or SCCP level
and skin physiological parameters are summarized in tables 2 and 3. Correlation coefficients in logarithm-converted data were almost the same to those in the original
data; therefore, we show only the linear regression results.
In the cheek skin of Japanese subjects, catalase activities
had a positive correlation with water content and L* value
but were negatively correlated with TEWL, thick abraYamashita /Okano /Ngo /Buche /Sirvent /
Girard /Masaki
Table 3. Correlation analysis between SCCP level and skin physiological parameters
Water
content
Cheek
Japanese
French
–0.228*
–0.229*
Hand
Japanese
French
–0.289**
–0.226*
Arm
Japanese
French
–0.049
–0.085
TEWL
Size of
SC thick
corneocytes abrasion
Catalase
L*
a*
b*
0.040
–0.352**
0.320**
0.169
–0.137
0.048
–0.251*
–0.187
–0.020
0.191
0.260*
–0.185
–0.194
0.063
–0.134
–0.159
0.237*
0.112
–0.105
–0.189
–0.371**
–0.242*
0.151
0.136
0.05
0.103
0.176
0.000
0.144
–0.016
0.316**
0.224*
–0.206*
–0.255**
–0.177
0.056
0.148
–0.016
0.278**
–0.292**
0.228*
0.310**
Each number shows the correlation coefficient of Pearson’s correlation analysis. SC = Stratum corneum. * p < 0.05, ** p < 0.01: significant correlation between the two parameters.
sion of the stratum corneum and the a* value (table 2). On
the other hand, SCCP levels showed a negative correlation with water content and L* value, and a positive correlation with TEWL, thick abrasion of the stratum corneum and the b* value (table 3). However, in the cheek of
French people, catalase activity was only related to the L*
value.
The relationships between physiological parameters
and catalase activity/SCCP levels changed depending on
the ethnicity and the body site, and they were not definitive. Correlation coefficients were not higher in general
except for the relationship of catalase activity and water
content in the cheek skin of Japanese subjects.
Discussion
Physiological parameters of the skin (water content,
TEWL, size of corneocytes, thick abrasion of the stratum
corneum and skin color) and parameters of oxidative
stress (catalase activity and SCCP level) were initially
compared between sun-exposed and sun-protected areas
of the skin in relation to ethnic differences (Japanese and
French subjects). TEWL, the size of corneocytes, catalase
activity and SCCP levels of sun-protected skin (inner upper arm) were significantly different from sun-exposed
skin (dorsal aspect of the hand), which suggests that the
skin condition is better at sun-protected sites than at sunexposed sites in both ethnic groups. However, the behaviors of those parameters on the cheek, which is also a sunexposed site, were slightly changed from the dorsal aspect
of the hand. Judging from the difference between cheek
versus inner upper arm and dorsal aspect of the hand versus inner upper arm, it was considered that the dorsal
Oxidative Stress in the Skin of Japanese
and French Subjects
aspect of the hand is more damaged than the cheek in
both ethnic groups (table 1). This probably reflects the
fact that the cheek is protected from external stimulations by sebaceous lipids (including antioxidants) and/or
that it receives more skin care.
Next, we compared each parameter between Japanese
and French subjects. The comparison of skin color, which
clearly indicates the ethnic difference, shows that Japanese subjects have lower a* values and higher b* values
than French subjects. On the other hand, the L* values of
both ethnic groups showed no significant difference.
Skin color is affected by various factors such as melanin,
hemoglobin, carotenoid, amyloid and age. In CIE L*a*b*
colors of skin, a* values reflect skin redness according to
the blood flow, while b* values reflect skin darkness or
yellowness according to levels of epidermal melanin and
carotenoid, and L* values reflect skin brightness [3, 24–
26]. L*a*b* values vary with ethnicity, and especially epidermal melanin reflects ethnic differences in skin color
[27]. As the b* value is higher in Japanese than in French
subjects, Japanese subjects seem to have a higher melanin
content in the skin. When skin physiological parameters
were compared between the two ethnic groups, Japanese
subjects had a higher water content in the stratum corneum, a lower TEWL and a lower thick abrasion of the
stratum corneum. From these results, we can estimate
that the skin hydration and barrier functions of the skin
of Japanese subjects are greater than in the skin of French
subjects. Races with darker skin types have greater numbers of melanosomes and a more acidic pH of the stratum
corneum, which leads to higher stratum corneum integrity and increased skin barrier function [7]. Melanin in
the epidermis is also known to protect against UV damage. Judging from these considerations, it is speculated
Skin Pharmacol Physiol 2012;25:78–85
83
that the more efficient barrier function against UV and
external insults in the skin of Japanese subjects compared
with French individuals originates from the higher melanin content.
In addition, Japanese subjects have a higher catalase
activity than French subjects and are considered to have
a greater UV-protective capacity. High catalase activity
was also observed at the inner upper arm which shows a
good skin condition. We previously reported that catalase activity at sun-protected sites of atopic dermatitis patients decreased depending on the degree of severity,
which indicates that catalase activities are also affected
by endogenous oxidative stress [28]. It is also known that
the skin hydration and barrier functions of the skin of
atopic dermatitis patients are inferior to those of normal
subjects [29]. Our results show that catalase activities correlate positively with water content in the stratum corneum, negatively with TEWL and positively with the L*
value on the cheek of Japanese subjects. From these results, we conclude that the higher catalase activity helps
maintain a healthy skin condition.
On the other hand, SCCP levels, which are another
marker of oxidative stress, were higher in the skin of Japanese than in that of French subjects. This is not easily
explained because SCCP levels and catalase activity seem
to behave in opposite manners from each other. In our
results of locational differences, SCCP levels and catalase
activity showed an opposite trend in both ethnic groups
(fig. 3). In addition, Pearson’s correlation analysis also
showed a negative correlation between catalase activity
and SCCP levels, although the correlation coefficient was
low (tables 2, 3). The reason for this discrepancy is due to
the multiple factors that affect the production of SCCP.
SCCP exists as an oxidative product of stratum corneum
proteins, which are influenced by other factors in addition to UV. For example, skin dryness causes an increase
in SCCP [30–32]. Sebum is also a candidate which affects
the production of SCCP [33]. Therefore, it seems that
SCCP levels are not necessarily related to catalase activities. Further research is needed to elucidate the relationship between SCCP levels and catalase activity in the stratum corneum.
From these results, we conclude that differences in
susceptibility to oxidative stress, namely melanin content
and antioxidant enzyme activity in the skin, explain the
better skin conditions of Japanese subjects compared
with French ones. In this study, we analyzed the data of
all subjects without considering their age, sex, lifestyle
and stress condition. Lifestyle and smoking habits have
been reported to affect skin condition and skin aging
[34]. Diet and nutrition affect the antioxidative activity in
the skin [35]. Further study is needed to characterize ethnic differences of skin conditions considering lifestyle,
smoking and daily skin care.
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