Sun exposure is a major concern, but not the only one
[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. A huge industry exists around anti-aging skincare products, and it can be overwhelming to figure out what's what. Here to help us understand what's important to know about caring for aging skin is dermatologist Ramsay Farah. Dr. Farah is an associate professor and division chief of dermatology at Upstate. Welcome to "The Informed Patient," Dr. Farah.
[00:00:35] Ramsay Farah, MD: Thank you. It's good to be here.
[00:00:38] Host Amber Smith: Before we get into the details of skin care, can you explain what happens naturally to human skin as we age?
[00:00:46] Ramsay Farah, MD: Sure. Skin changes really are related to environmental factors and genetic makeup, but they're also related to other factors such as nutrition. I would say the greatest single factor is probably sun exposure, though. And you can see this by comparing areas of your body that have regular sun exposure with areas that are protected from the sunlight, because all of the other factors, like your nutrition and genetic makeup, are the same for your entire skin. But what's different is areas of sun exposure and areas of non sun exposure. And you can look at your skin and kind of compare the two. So I would say that of all of those factors, it's sun exposure that's the most important thing.
And sun exposure probably accelerates what is already a natural aging process. There are a lot of things that happen with aging that are, like I said, accelerated, but with the sun. So what are some of those things? Well, for one thing, your outer skin layer, which is called the epidermis, it begins to thin. Even though the number of cell layers remains unchanged, the actual cells and the skin becomes thinner.
There's also changes in the connective tissue. So there are fibers in your connective tissue, which is called the dermis, and these fibers are called elastin and collagen fibers. And they naturally degrade, but the sun exposure degrades them as well. And so, certain things happen when that occurs. For example, the blood vessels that are housed within that connective tissue sort of pad. When that pad gets thinner, the blood vessels get more exposed and prone to injury. So oftentimes older individuals find that they bruise much more easily. And the reason is -- in apparent minor trauma of day-to-day activities that we all experience -- those blood vessels now have less of a cushioning, and so they sometimes burst open, and people get bruises and so forth.
And similarly, things like the fat layer, which is also part of our skin, that becomes thinner with aging. That's probably less related to sun exposure than normal aging processes because the sun doesn't necessarily reach that deep down into the skin to affect the fat. But there are natural aging processes that make the fat layers thinner. And so we wind up having less insulation. So to speak when we get older, and so we get colder more easily. Also, you know, many medicines are absorbed by our fat layer, and so when the fat layer gets thinner, some of those medicines are not stored or metabolized in quite the same way. So elderly individuals often require smaller doses of a medicine because of those changes in the fat body content. So all of those things occur as we age naturally in all three layers of the skin, the top layer, the epidermis, which gets thinner; the second layer, the dermis, which is our connective tissue, which also gets thinner; and finally, the fat, which is also part of the skin, which also gets thinned as well.
[00:04:20] Host Amber Smith: So with the skin thinning as we get older, is that what causes wrinkles?
[00:04:25] Ramsay Farah, MD: Well, that's one of the things that causes wrinkles, yes, because you know when the skin thins from sun exposure, the process of the sun exposure really disorganizes those collagen and elastin fibers in the second layer of the skin in the dermis. And so when your connective tissue is disorganized, that's one reason why we get wrinkles.
But of course, on the face, especially -- I mean, we get wrinkles everywhere, but most markedly on the face. One of the other reasons that we get wrinkles on the face is because the muscles of facial expression directly are connected to the skin. And so with a lifetime of smiling and frowning and laughing and muscle movement, those muscles when they create our expression are also bending your skin over and over again. And those movements of the skin bending from the muscles of facial expression in conjunction with the physiologic changes that we just talked about from normal aging and from sun exposure, all of those things mix together and cause us to wrinkle.
[00:05:47] Host Amber Smith: So in addition to wrinkles, what about age spots, or I think people have called them liver spots, that kind of emerge? Is that because of the thinning, or is that sun damage?
[00:06:00] Ramsay Farah, MD: That's more from sun damage. Those brown spots, they're traditionally called liver spots. The medical term is solar lentigos. And what happens as we age is the number of pigment containing cells, the melanocytes, the number actually decreases. So what happens is, to compensate, the remaining melanocytes increase in size. And they try to produce pigment, but they produce pigment in a somewhat disorganized way. And because there's lots of them, the distribution of the pigment becomes less uniform, and we wind up forming these sun spots, or liver spots, or solar lentigos.
[00:06:49] Host Amber Smith: What about sweating? As we age, we don't sweat the same way as when we were young, is that right?
[00:06:55] Ramsay Farah, MD: That's right.We don't sweat the same way. Our sweat glands become less physiologically active. And it's, again, it's one of those things that occurs with the normal aging process as well. So, temperature regulation becomes more of an issue when we get older because on one level, we can't retain heat as well because our fat pad lessens, but also when it's really hot, we can't cool down as efficiently because our sweat glands sweat less, right? And so you become more prone to overheating with heat strokes and so forth depending on the environment. But definitely as we age, sweat glands produce less sweat, and so we cool less.
[00:07:44] Host Amber Smith: In general, are there ways to prevent this natural occurrence of our skin aging? I'm looking for things that we can do starting in childhood, and I know you're going to talk about sun protection, but in addition to that?
[00:07:58] Ramsay Farah, MD: You know, the No. 1 thing we can do is protect ourselves from the sun, right? So that means wearing sunscreens, and starting at an early age in childhood as you suggested. And, it's interesting because a lot of the studies show that quite a bit of the sun damage we see in ourselves as an adult, we've acquired in our childhood. But there's a long latency period of it, so you don't notice it immediately when you're a child playing outside, but decades after is when the chickens come to roost, so to speak, and we start to see it on our skin. So sun protection is the No. 1 thing that we can do starting from early childhood and continuing on into adulthood.
Now the other thing, that we can do is, we can have a healthy lifestyle. And that really, in a roundabout way, not in a very direct way, but in a very real way and meaningful way, has an effect on how we age. And so, what do I mean by lifestyle changes? Well, good sleep habits so that your hormone levels are always more uniform and not going up and down; a good diet that is high in antioxidants, which can help absorb some of the what are called free radicals from developing. And free radicals are the byproduct of sun exposure and other physiologic stresses.
So when the system is stressed, it produces these chemicals called free radicals, and they damage the cells, and they age the cells. And antioxidants, whether they're in your food or whether they're through topical creams, can absorb those free radicals and help decrease the physiologic stress that adds to aging.
So, I think in short: sunscreen; as healthy a lifestyle as possible with things like a healthy diet that includes antioxidants; and other general measures, like good sleep habits, stress reduction techniques. All of those, I think over the years do make a difference for sure. And the other thing I want to mention is those healthy lifestyle habits and the antioxidants in our diet, those also promote skin health by improving our immune system. And the immune system is extremely important in skin physiology and also has a function, I think, in the aging process as well.
[00:10:41] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Ramsay Farah. He's the division chief of dermatology at Upstate, and we're talking about aging skin. There are many products on the market that promise to reverse aging, and without endorsing one brand over another, can you tell us whether any of them work or actually make visible changes?
[00:11:06] Ramsay Farah, MD: Sure. So I think, the No. 1 product, and again I don't want to try and repeat myself, is a good sunscreen. So that's one large category that we can recommend.
Another category that one can find over the counter are products that contain what are called retinols. And so I can explain that in a few minutes. But retinols are another large category of products that I think are quite helpful. And then the third category of products are things that contain antioxidants in them, specifically things that contain vitamin C. Vitamin C is one of the more common antioxidants, but there are others.
So I'll go back and give a bit more detail about that. You know, the sunscreens we kind of talked about already and their importance. What I would say is that you really need a sunscreen of about an SPF of 30 and above. I'm partial to the physical sunscreens rather than the chemical sunscreens, and the physical sunscreens contain zinc oxide or titanium dioxide. And the other thing that I would say about the sunscreens is that if you're out in direct sun, you really should apply them every two to three hours to get that SPF number. Otherwise, you're probably only getting half the SPF number. So that's sunscreens.
Now what about the retinols? So the retinols are derivatives of vitamin A, and of course vitamin A is a naturally occurring compound in nature, and we get it through our diet. But vitamin A is extremely, extremely important in our physiology. Every cell in our body has vitamin A receptors, and it does thousands of things, but it's been proven beyond any doubt that applying retinols or retinoids -- and you can think of them as being fairly equivalent. They all go to the vitamin A receptors. So retinols and retinoids have been shown to even skin pigment. They've been shown to help increase skin turnover. They've been shown to help plump up the collagen. And they've been shown to be anti-cancerous. So if you have a product that's over the counter that has a retinol or a retinoid in it, that's another good category of product that you can get for anti-aging purposes.
And then lastly, the issue of the antioxidants. So again, antioxidants kind of absorb all of the bad chemicals that are produced from the stress of living organisms. And you know, when organisms are stressed, they also age. So if you can take those chemicals out, I think you age less. And that's what an antioxidant does. And one of the more common ones, and one of the older ones that was discovered to do this, is vitamin C. So again, without endorsing specific products, you want to look for things that have vitamin C in them.
Other antioxidants are things like zinc or copper or selenium, even vitamin E. So all of those have antioxidants. I'm partial to vitamin C because vitamin C also helps promote collagen production.
There's another broad category of plant-derived antioxidants. For example, curcumin and things like that. But in terms of the products, most of them to date contain things like vitamin C, zinc, copper, selenium, vitamin E. Those are all good antioxidants to look for.
[00:15:11] Host Amber Smith: Now, these are products that you put, they're topical? You apply them to your face or your skin? Or are they pills or vitamins that you ingest?
[00:15:23] Ramsay Farah, MD: No, I'm specifically talking about topicals. I think there's just been more evidence and more research done in the topical categories. There is a growing body of evidence that taking some of these antioxidants by mouth is also helpful. There's just less work on that being done currently, but it's in progress, and I think we're going to increase our body of knowledge about it. But I'm specifically talking about topicals.
[00:15:54] Host Amber Smith: So how do these topicals work if you're also trying to moisturize your skin? Are you supposed to use both products, a moisturizer and the retinols or the antioxidants? Or do the products have moisturizers in them?
[00:16:10] Ramsay Farah, MD: No. Most of the products don't have moisturizers in them. Now of course these products come in different formulations. Some of these formulations could be a little more gentle than others, depending on how they've been put together. But generally speaking, the moisturizers are a separate step. But it's a good question to ask because it's been shown that when you moisturize your skin, you actually normalize the physiology of your skin, which means that if you put something else on your skin after it's been moisturized and well hydrated, whatever you're putting on afterwards tends to get absorbed more efficiently.
So I think it's actually quite important to moisturize again for those two reasons. It's one of the ways of promoting your skin health, normalizing the physiology of your skin, and then you increase the potency of what you're putting on your skin afterwards, these antioxidants, for example. And, I do want to add that the retinols and the retinoids, you know, one of their potential side effect is that they can be a little bit irritating. And so it's really very critical for people to moisturize their skin so that it doesn't become too dry with the application of these products.
[00:17:39] Host Amber Smith: Well, I think some women are used to wearing makeup and going through a whole facial routine that includes moisturizer, but especially as we get older, is this an important thing for men to do, as well as women?
[00:17:54] Ramsay Farah, MD: Yeah, absolutely. So, the physiology is very similar. Men's facial skin can be a little bit thicker. Their muscles of facial expression may also be a little bit thicker. So I mean, the physiology is not completely the same, but it's close enough that what I'm saying really applies to both men and women, absolutely.
[00:18:20] Host Amber Smith: If someone wants to start using a moisturizer, are there certain things they should look for that are included in a moisturizer at the drugstore?
[00:18:30] Ramsay Farah, MD: Well, rather than look for specific ingredients, I think it's probably better to consider what your skin type is, and then choose your moisturizer accordingly.
So, for example, when you consider your skin type, you should think about the texture, right? And so, for example, normal skin does best with a light kind of non-greasy moisturizer, while dry skin may need a heavier creamier formulation that kind of locks in that moisture.
And so you sort of want to see what the formulation is, whether it's a very heavy ointment-like product or it's a very sort of light more lotion-type product depending on your skin texture, just as an example.
The other thing you can consider is whether it has an SPF (sun protection factor), right? So some moisturizers have an SPF, and I think that's very useful. You want to see whether the moisturizer has a fragrance to it or not. And so, for example, if you have very sensitive skin and you have a lot of allergies, you want to try and probably avoid scented moisturizers with fragrances or perfumes.
Also with regard to your skin, if you have a tendency for allergies and sensitive skin, you want to see whether it's been allergy tested. If you have acne prone skin, you want to make sure that it doesn't cause acne. So for example, the very heavy moisturizers that someone with very dry skin might need, those might make acne worse if you apply them on acne-prone skin. So it should say non-comedogenic, which means it's not going to make acne worse.
And what I would say is oftentimes it's a little bit of trial and error. I think there are a lot of good products out there, but you want to try and see how it feels on your face, whether you like the way it feels, because if you like it, then you're going to use it. And then you want to see how your face reacts to it. If it reacts well, meaning it absorbs it and the skin looks plumper and it looks better, that's great. That's a win. If you find that your skin doesn't do well with it and gets a little bit irritated and red, then you probably want to stay away from that formulation.
[00:21:12] Host Amber Smith: What's your advice about face washing for someone age 60 or up?
[00:21:18] Ramsay Farah, MD: Well, I think it's important, and I would recommend it if nothing else, the physical act of washing and lathering your skin, can act almost like a little bit of an exfoliation process. I think it's important to do that. Again, when someone who is over 60, you probably want gentle hydrating washes versus those foaming washes where someone in their 20s may require those. It's probably better to use warm water rather than really hot water because that can wind up stripping the natural oils from the skin. And if you use cold water, very cold water, that doesn't allow the pores to kind of open up and open up enough so that they can be thoroughly cleansed.
And then, the other thing you want to do is not overuse your cleanser as well. It's almost like putting too much laundry detergent in your washer, right? So you want to use a moderate amount that's going to cover your face uniformly and you want to sort of rub in a circular motion, with that warm water. And I think those are the general recommendations that I would have for someone who's over 60 and interested in washing their face.
But I think it's important, and again, it does promote good skin health. It gets some of the dirt and grime that comes in contact with our skin and our day-to-day activities, especially, for example, if you live in a big city or an urban center with more air pollution. So all of those things are important.
[00:23:03] Host Amber Smith: So the face washing once, maybe twice a day? And then moisturize after you pat your face dry?
[00:23:10] Ramsay Farah, MD: Yes. so the number of times you wash is dependent on the type of skin, the environment that you live in. But, I think twice a day is a good general rule. If you're going to pick only once a day, I would do it after the day is done because of what we talked about. And again, moisturizing after is a good idea as well, because again, you don't want to strip too much of those natural oils off of your skin.
[00:23:42] Host Amber Smith: Well, we talked about the importance of sunscreen starting from a young age. If you're in your 60s or 70s or 80s, and your skin is starting to thin, does sunscreen become even more important, for protecting that thin skin?
[00:23:59] Ramsay Farah, MD: Yes. Older skin, remember, we said is thinner. And, thinner skin allows ultraviolet light to penetrate deeper into it comparatively. And so as your skin thins, it becomes more susceptible to that ultraviolet light damage. And so, in some respects, you can make an argument that that's all the more reason to be quite vigilant and use your sunscreens. So yeah, I mean in some sense it becomes much more important, right?
So we want to distinguish the importance of using sunscreens at the different ages, right? So when you are very young, you want to use it to minimize the sun damage that is going to show up decades later, right? And when you're old or older, I should say, you wanna use your sunscreens to minimize the risk of the acute injury that you can get, that you'll be more susceptible to as your skin gets thinner with age.
Of course when we're older and we have that sun damage, our mechanisms of repair are not quite as capable as they were when we were younger. So you want to minimize as much as possible that sun damage because we can't repair it as effectively when we're older.
[00:25:16] Host Amber Smith: And I'm guessing the sunburn takes longer to heal and maybe it might be more painful, too?
[00:25:22] Ramsay Farah, MD: Yeah. All of that is true. Again, everything takes a little bit longer to heal as we get older because our physiologic repair mechanisms are not quite as robust.
[00:25:33] Host Amber Smith: Well, Dr. Farah, thank you so much for making time for this overview about taking care of aging skin.
[00:25:38] Ramsay Farah, MD: My pleasure. Thank you.
[00:25:41] Host Amber Smith: My guest has been Dr. Ramsay Farah. He's an associate professor and division chief of dermatology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.