Download Skin - Seattle Healing Arts Center

SKIN
AND
SKIN CARE
Angela Heithaus, MD
Internal Medicine
Seattle Healing Arts
December 8, 2006
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True or False?
• The way to find the right skin care product is by buying lots of
different products until you find the one that works for you (if
you’re lucky)
• The more expensive a product, the better it will work
• Fragrance-free products contain no perfume or fragrance
• Ivory soap is for sensitive skin
• The food I eat won’t affect my skin
• Paying attention to my skin is a waste of time!
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The Skin
• Anatomy, Histology, Physiology
• Intrinsic aging/Photoaging
• SKIN CARE
• OBAGI pharmaceutical grade products
• Ablative vs non ablative procedures
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The skin says it’s so!
How do we judge a person’s age?
By surveying numerous changes on the
surface of the skin!
• Wrinkling
• Pigmented blotches
• Sagging
• Sallowness
• Dry, leathery look and texture
• Various growths
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Skin: The Largest Body Organ!
• Architecturally the skin is probably the most
complex body organ
• Skin layers
– Epidermis (including
stratum corneum)
– Dermis
– Subcutaneous tissue
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Functions
• Epidermis
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Stratum corneum: barrier + natural moisturizing factor
50,000 nucleated cells/mm
Keratinocytes (supports S. corneum)
Melanocytes (pigmentation)
Langerhans cells (immune function)
• Dermis
– Collagen, elastin (provides structural
support to the Epidermis)
• Subcutaneous Tissue
support from shock, heat modulation,
circulation, calorie storage
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Epidermis
Keratinocyte: Produces Keratin
90% of cells
• Half the cells remain in place
– Distributed along the rete ridges
Anchor the epidermis onto the dermis
• Other half undergo differentiation
– Changes from a nucleated (living) cell
To a non-nucleated (dead) cell
• The keratinocytes travel towards the skin surface
– Remains in the stratum corneum for two weeks
Exfoliates off thereafter
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Epidermis
Melanocyte: Produces pigment
Responsible for color and
variation in color
•Number of melanocytes to
keratinocytes
•Size of the melanocytes,
•Distribution of melanosomes
•Quantity of melanin produced
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Epidermis
Langerhans Cells: Immune Function
• spread out amongst the keratinocytes
• mop up invading foreign substances that
have found their way into the body
• Transport IFS to special white cells
(lymphocytes) in the lymph glands
where they are neutralized
Compliments: Dr. John Gray
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Dermis
Fibroblasts: Produce ground substance and
fibers in connective tissue
• Collagens
Possesses high strength and prevents the skin from being
torn from overstretching
• Elastic fibers
Provides elasticity, ‘give’
• Ground Substance: Hyaluronic Acid, GAG
Most important constituent in the ground substance; lubricant
that allows collagen fiber to slide past each other
Has extraordinary water holding capacity at least 1000 times
its dry weight
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Collagen/Elastic Fiber
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Subcutaneous Tissue
Contains Fat and Connective
Tissue
• Supports blood vessels and
nerves
• Supplies energy reserve
• Regulates body temperature
• Contains deeper hair follicles
and sebaceous and sweat
glands (apocrine, eccrine)
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Aging vs. Photoaging
Intrinsic Aging: Inevitably occurs
as an organism progresses in
chronological age
Extrinsic Aging: Results from
environmental effects such as
UV exposure, pollution
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Aged Epidermis
• In the very young, cell turnover
averages 20 days
• By the 30’s, cell cycle begins to
gradually slow down
• Decrease in number and function of
cells-keratinocytes,melanocytes,
Langerhans cells
• Renewal of skin becomes slower
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Aged Dermis
• Decrease in activity and number of fibrocytes
• Loss of collagen, elastin and hyaluronic acid
• Rete ridges (pegs) reabsorb and the dermalepidermal junction flattens
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Photoaging from the Sun
• Up to 90% of the visible
skin changes attributed
to aging are caused by
sun exposure
• Everybody regardless of
race or ethnicity is
vulnerable
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UV light
• On a typical summer’s day, the UV
energy received
– 3.5% UVB and 96.5% UVA
• Of the UVB reaching the skin:
– 70% is absorbed by the stratum
corneum; 20% reaches the
viable epidermis and 10%
reaches the upper dermis
• UVA (I,II) radiation is absorbed
partly by the epidermis, but 20-30%
of this radiation reaches the deep
dermis
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DNA Damage
• Damage to DNA causes most of the adverse effects
of photo-damage skin
• Cellular DNA directly absorbs UVB which causes lesions
– The lesions block transcription and replication
– If not repaired, it can lead to misreading of the
genetic code – cause cell mutations and cell death
• UVA also damages the DNA but not directly
– UVA damage is induced indirectly through absorption
by chromophores that release reactive forms of
oxygen
– These free radicals cause breaks in the DNA strand
Lisa Graft
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Other culprits in increasing free radicals
• Diet
• Stress
• Pollution
• Cigarette smoke
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Sun Exposure Accelerates Aging
• Damage to DNA, causing cells to go
awry, leading to cancer
• Disintegration of enzymes
necessary for production of
important cell components
• Breakdown of collagen, the
supporting structure
• Breakdown of elastin, which gives
resilience and bounce
• Loss of hyaluronic acid, which holds
water and gives volume
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Skin Cancers
• Basal Cell – Forms in the basal layer of
epidermis
• Sqaumous Cell – Forms in the middle portion
of epidermis
– Typically neither Basal nor Sqaumous metastasize
and are rarely fatal
• Melanoma – Begins in the melanocyte
– Much more fatal; killing 1 in 4 that develop it
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Basal Cell Carcinoma
• Basal cell carcinoma is the most
common type of skin cancer
• Fortunately, it is also the least
aggressive form of skin cancer
• People with fair skin, blond or red
hair and blue or green eyes are at
the highest risk of developing
basal cell carcinoma.
• They appear as small, fleshy,
shiny or pearly bumps or nodules,
generally on sun-exposed areas of
the body (face, ears, neck, arms,
and hands)
Bolognia
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Malignant Melanoma
• Incidence has increased
dramatically over the last few
decades
• Predominant in Caucasian
skin with a lower tendency in
deeply pigmented skin
• Not usually associated with
chronic actinic damage, but is
associated with short term
extreme exposures
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Squamous Cell Carcinoma
• Actinic Keratosis are the
precursors in about 5-20% of
cases
• Found predominantly on sunexposed regions of the body,
in people with light skin, light
hair, and light eyes
• These tumors may appear as
red, scaly patches or as
raised, crusty growths
• The cure rate is over 95
percent with early diagnosis
and treatment
•Without proper treatment they can
metastasize and even be deadly
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Intrinsically Aged Skin
Photoaged Skin
Fine wrinkling – gravitational,
but smooth
Deep wrinkling – dermal
elastosis
Dry and thin appearance
Seborrheic Keratosis
Leathery appearance
Increase in cancer
Other benign proliferations
(cherry angiomas)
Reduction in pigmentation
Reduced wound healing
Delayed hypersensitivity
Pigment changes
Telangectasia
Loss of resiliency;
Increased fragility
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Summary
Skin care begins with a fundamental understanding of:
1. Skin Cell Functions
2. Individual Skin type: dry vs oily; sensitive vs
resistant; pigmented vs non-pigmented; wrinkled vs
tight
3. Effects of intrinsic and extrinsic aging factors
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Dermatologic arsenal
• Good, effective sun block
• Topical Antioxidants to neutralize free radicals
• Retinoids to increase cell renewal by stimulating
cells to reproduce
• Dipigmenting agent for hyperpigmentation
•
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Before you begin, Prep the Skin!
• Cleaners– Glycolic and lactic acids: remove dead skin and
help hydrate dry skin
– Salicylic acid (BHA), benzoyl peroxide for oily, acne
prone skin
• Toners recommended only for more resistant
and oily skin
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Topical Antioxidants
• Vitamin C (L-ascorbic acid)
– Prevents breakdown of collagen, increases production
– Reduces pigmentation
• Vitamin E (alpha tocopherol)
– Healing of skin
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Physical sunblock
Zinc Oxide (Z-Cote HP1)
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Blocks UVB, UVA I,II (290-380 nm)
2 mg/cm2
Daily SPF of at least 15
Avoid exposure from 10 AM to 4 PM
For increased exposure use SPF 45-60 reapply
every hour
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RETINOIDS
• Stimulate fibroblast growth formation
• Increase cell regeneration and turn-over
• Stimulate dermal collagen synthesis
• Increase exfoliation
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RETINOIDS
• First generation
– Trans-retinoic acid or tretinoin (retin-A)
– 13-cis-retinoic acid or isotretinoin (accutane)
• Second generation
– Etretinate and acitretin (tegison, soriatane)
• Third generation
– Arotenoids (?cancer tx)
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Hydroquinone
• Bleaching agent
• Reduction of pigmentation
– Melasma, solar lentigos, freckles
• 2% OTC, 4% Rx
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Pharmaceutical Grade Skin Care Products
Obagi
Most effective delivery of vitamin C and
hydroquinone on the market
Rx strength retinoids and hydroquinone
Particularly effective for photoaged and pigmented
skins
Used pre and post ablative procedures to prep
and heal the skin
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Obagi Systems
Obagi-C Rx
Obagi Professional-C Serums
Obagi Nu-Derm
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Non ablative /Ablative Procedures
• Non Ablative
– IPL (intense pulse light); non-ablative peels;
microdermabrasion; fillers (restylane,sculptra,radiesse);
thermage (radiofrequency affecting collagen); botox
Ablative
– Dermabrasion/dermasanding; ablative laser and
chemical peels; surgeries
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BOTOX
• Purified neurotoxin produced by Clostridium Botulinum
• Applied intramuscularly
• Deep furrows of forehead, crow’s feet, marionette lines
• Only treatment of its kind approved by FDA
• Effects last from 4-6 months
• Myoblock= 6 weeks
• New guy on the block: Reloxin
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Thank You for Your Attention
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