In the early 1900s, the legendary Helena Rubinstein, who created a cosmetics empire and influenced generations of women on beauty, identified four skin types: dry, oily, combination and sensitive.1 Back then, far fewer skincare products existed, but today the market for skincare products has expanded exponentially.
How can we guide our patients toward making good skincare choices? Education is paramount. We must first educate patients about what their individual skincare needs are, and then we should inform them what ingredients have been shown to target those needs. I have found that the most effective way to accomplish this is to help the patient to correctly determine their skin type. But what I have found is that patients often have no idea what their skin type is. In fact, patients’ subjective assessments of their own skin types have been shown not to correspond to certain measurements such as sebum production.2
Objective standards are needed. I have developed a system of skin typing based on our modern understanding of four basic skin parameters: dry or oily; sensitive or resistant; pigmented or non-pigmented; and wrinkled or unwrinkled (tight). Here, I’ll provide insight into this new skin typing system and offer product choices for sunscreens, and other products that help prevent photodamage, based on the different skin types.
The New Skin Typing System at a Glance
The key to my new skin typing system is that the qualities assigned to the four basic skin parameters are not mutually exclusive. Therefore, suggesting that there are merely four skin types limits our understanding of the dynamic nature of the skin.
The various permutations from the four skin-type parameters yield 16 possible skin types (in a manner that is similar to the Myers-Brigg personality scale). For example, a person may have dry, sensitive, pigmented, wrinkled skin. The various skin-type profiles are rendered by a self-administered questionnaire with a battery of 64 items. Once the questionnaire, known as the Baumann Skin Type Indicator (BSTI), is completed and the patient knows his or her skin type, the patient is equipped with much more
information about what areas to focus on in skin care.
It is my belief that this will result in better skincare choices, leading to better compliance with products such as a daily sunscreen, anti-oxidants and retinoids, which have been shown to have efficacy in preventing photo damage.
The Four Skin Type Parameters
Skin Hydration: Dry (D) vs. Oily (O)
Maintaining sufficient skin hydration is a complex process involving numerous factors, such as lipids in the stratum corneum, natural moisturizing factor (NMF), hyaluronic acid (HA), and sebum production. Those who have a history of frequent sun exposure tend to have drier skin. Educating patients with dry skin to avoid ultraviolet exposure would give them the instant gratification of smoother more hydrated skin, but more importantly would serve to protect them long term from the other havoc that UV can cause: photoaging and skin cancer.
The stratum corneum is surrounded by a watertight lipid bi-layer composed primarily of ceramides, fatty acids and cholesterol. When present in the proper proportion, these constituents form the skin barrier that functions similarly to a brick wall (keratinocytes) surrounded by mortar (lipid bilayer), protecting the skin and keeping it watertight.
Trans-epidermal water loss (TEWL) results from defects in the stratum corneum and leads to xerotic or dry skin that is rough in texture and characterized by an elevated number of ridges.3
Barrier disruption can also lead to increased skin sensitivity with an increased incidence of contact dermatitis or eczema. Patients with barrier disruption fall into the category of DS (dry, sensitive) skin types. Ultraviolet light has been proven to cause defects in the skin barrier.4 After UV radiation, TEWL increases until day 4 when it peaks and begins to return to normal levels.5 The barrier perturbation has been shown to be related to detrimental UV effects on lamellar body generation capacity,6 and decreased amounts of covalently bound ceramides in the stratum corneum.7,8
Topical skincare products that are aimed at barrier repair focus on delivering the three key components to the stratum corneum: ceramides, fatty acids and cholesterol. Because fatty acids and cholesterol are derived from the diet, a healthy diet can also enhance the skin barrier. By the same token, cholesterol-reducing drugs can disrupt the barrier.9 Evening primrose oil, borage oil, and omega-3 fatty acids are healthy additions to a diet that have potential to alleviate dry, sensitive skin by replenishing essential components of the stratum corneum.
Natural moisturizing factor (NMF), a compound that holds water inside keratinocytes, rendering them plump, is derived from the hydrolysis of the protein filaggrin, which imparts structural support to the lower levels of the stratum corneum, and breaks down into amino acids known as NMF in the upper levels of the epidermis. Filaggrin decomposition is known to adapt to changes in climate, so that after several days in a new low-humidity environment, an individual would produce more NMF. However, UV exposure is known to interrupt the enzymatic hydrolysis of filaggrin to NMF, suggesting that skin dryness due to low NMF might be ameliorated by decreasing sun exposure.10 Low levels of NMF may be implicated in dryness observed in dry skin types that do not exhibit increased sensitivity. These types are known as DR or dry, resistant types.
The wax esters, triglycerides, and squalene found in sebum help protect the skin from the environment.11 Lipid films on the skin, formed from sebum-derived fats, also help prevent TEWL. However, no association has been shown between low sebum production and xerosis, and the impact of sebum on dry skin is poorly understood.12 In fact, not all people with dry skin have diminished sebum production, which is influenced by genetics, diet, stress and hormones.13 More research is needed on the affect of sebum on DR skin.
Most studies assessing the influence of sebum on xerosis have been conducted on DS skin types (e.g., patients with atopic dermatitis), but not DR types with an intact skin barrier.
Many skincare formulations are available to treat xerosis. Recommending one with a sunscreen will help prevent exacerbation of skin dryness, in addition to preventing skin cancer and photoaging. For DS types, I usually recommend cream formulations that contain ceramides, fatty acids and cholesterol to repair the damaged stratum corneum by replenishing its essential components. For DR types, I suggest sunscreen products with both a humectant and an occlusive component. Glycerin, safflower oil and shea butter are some of the best ingredients for DR skin. In addition, all dry skin types should avoid foaming detergents and soaps in laundry cleansers, body cleansers and face cleansers.
Skin Sensitivity: Sensitive (S) vs. Resistant (R)
The Baumann Skin Type Indicator, which is the questionnaire used to determine the skin type, asks many questions about history of acne, facial flushing or stinging, and frequent redness and scaling. Those who have low scores on this scale, meaning they do not have a significant history of these issues, are said to have resistant skin or to fall into the R skin type. While people with resistant skin can often use any skincare product without side effects, these individuals may derive few benefits because many products are insufficiently potent to penetrate the stratum corneum and adequately treat concerns such as melasma, solar lentigos or wrinkles.
Vitamin C, retinoids and hydroxy acids are among the product types I recommend to R types who often exhibit a strong skin barrier.
Sensitive skin, believed to affect as much as 40% of the population,14 is made of four subtypes: acne, rosacea, stinging, and allergic. The common denominator is inflammation, and its alleviation is a focus of treatment as is eliminating its cause(s).
People with an oily sensitive (OS) profile are the most likely to develop acne. They may mistakenly believe that sun exposure will treat their acne; however, studies have suggested that this is not true.15 In fact, one study showed that acne worsens in summer.16 Non-comedogenic gel, powder or lotion suncreens are beneficial in OS types with acne. In addition, the salicylic acid- and SPF-containing facial foundations are great for this skin type.
Fair-skinned OSW (oily, sensitive and wrinkled) types with a strong history of sun damage are the most likely to suffer from rosacea. Rosacea is thought to arise more commonly in very photodamaged individuals.17 For these patients, recommend sunscreen products containing anti-inflammatory ingredients and antioxidants. Facial powders containing sunscreen can help mask the redness while providing more sun protection.
Stinging, which is not an allergic response, results from what is thought to be amplified neural sensitivity. Known as “stingers,” these individuals experience subjective cutaneous irritation in reaction to specific ingredients to which others do not. The lactic acid stinging test, in 5% and 10% lactic acid concentrations, has demonstrated that a subset of patients experience stinging sensations in the treated nasolabial fold area whereas healthy controls do not.18,19 Rosacea patients with facial flushing are more prone to experience stinging to lactic acid,20 but “stingers” do not often experience redness or visible cutaneous irritation.21
S types identified as “stingers” should avoid the following ingredients: benzoic acid, bronopol, cinnamic acid compounds, Dowicel 200, formaldehyde, lactic acid, propylene glycol, quaternary ammonium compounds, sodium lauryl sulfate, sorbic acid, urea, vitamin C and alpha hydroxy acids (particularly glycolic acid). Achieving broad-spectrum sun protection in stingers can be challenging because they may sting upon exposure to chemical sunscreens such as PABA or avobenzone. If this is the case, suggest broad spectrum sunscreens containing micronized zinc oxide, titanium dioxide or Mexoryl.
The “allergic” subset is the fourth type of sensitive skin. Allergic responses to cosmetic ingredients can be elicited by patch testing, which has been used to determine that up to 10% of dermatologic patients patch tested exhibit allergic responses to at least one cosmetic product ingredient.22 The actual percentage could be much higher, given that few patients consult a physician after reacting to newly purchased cosmetics. An individual is more likely to develop an allergy to cosmetic ingredients as the frequency of exposure to ingredients and the number of ingredients increase. Allergic reactions have been described to many sunscreen ingredients including aminobenzoic acid, benzophenones, and avobenzone. Patch testing may be necessary to find out which sunscreens are best tolerated by these individuals.
Skin Pigmentation: Pigmented (P) vs. Nonpigmented (N)
Removing unwanted pigmentation is thought to be the motivation for at least 21% of all visits to the dermatologist and more than 80,000 people annually purchase OTC skin formulations in order to lessen or eliminate facial dyschromias.23 This skin parameter refers to the proclivity to develop these undesired dark spots on the face or chest (e.g., melasma, solar lentigos, ephelides), but not to ethnicity. For example, both a red-haired, freckled Caucasian and an African American with melasma or unwanted hyperpigmentation would be considered pigmented (P) types. The P skin category is usually linked with the wrinkled (W) type in people with fair skin due to the causal association between solar exposure and rhytids and solar lentigos. Many people with dark skin are more accurately identified as pigmented, tight (PT) types, however, as a result of a significantly lower tendency to wrinkle.
Diagnosing a patient as a P type is the perfect opportunity to educate them about sun protection and use of antioxidants and retinoids. This is particularly important in the red-headed freckled patients who are at a higher risk of melanoma. P types are often very motivated to get rid of the undesired dark patches such as melasma and they often do not understand the important role that sun plays in these types.
Of course, sun protection is very important in non-pigmented (N) types as well but appealing to them about wrinkle prevention is often more fruitful than discussing prevention of solar lentigos.
There’s No Such Thing as a Healthy Tan
Dermatologists have been fairly successful in recent years in broadcasting the message that sun exposure poses several significant risks, the most dangerous of which is skin cancer. Habitual sun exposure is also believed to account for 80% of facial aging.24 Still, too many people insist on sunbathing and tanning their skin. The prevailing defense seems to be that they think they look better with a tan. Few, if any, I suspect, would think they look better with wrinkles. Frightening them about future wrinkling may motivate them to use sun protection, which would help protect the skin from skin cancer.
Skin Aging: Wrinkled (W) vs. Tight (T)
In the BSTI questionnaire section that determines whether a patient is a wrinkled (W) skin type or a tight (T) type, genetic factors are considered in questions about the skin appearance of patients’ ancestors. The questionnaire also asks about smoking history, diet, daily sun exposure, tanning habits, tanning bed use, exposure to pollution, use of retinoids, and ethnicity.
The W/T score that results can be used by the physician to determine a patient’s propensities and behaviors that might warrant modification as well as appropriate treatments. Higher scores are associated with a greater incidence of photoaging. It is logical to assume that higher W scores would also correspond to an increased incidence of skin cancer. It is currently unknown whether there is a correlation between wrinkling amount and the incidence of skin cancer.
Interestingly, in a recent questionnaire-based case-referent study of 118 successive hospital patients admitted for surgical treatment of basal cell carcinoma (BCC) compared with 121 controls without skin cancer, researchers identified an inverse relationship between significant facial wrinkling and BCC, this despite the fact that BCC patients were older.25 The investigators concluded that either the causal pathways for the respective conditions were independent or that facial wrinkling might have played a protective role against BCC. Much remains to be discovered regarding this potential phenomenon as well as any correlations between wrinkling and other forms of skin cancer.
Given the well-documented relationship between exogenous influences and observable cutaneous effects, it becomes patently clear that the W/T is the only skin-type parameter within an individual’s control. In other words, a person can alter one’s behavior to reduce the risk of photo-induced extrinsic aging, which results from external factors such as smoking, excessive use of alcohol, poor nutrition, exposure to pollution, and habitual exposure to the sun. Reducing one’s exposure to such factors that stimulate the production of reactive oxygen species will not demonstrably affect the genetic or intrinsic aging process, but it undoubtedly confers health benefits and can be shown to impart dramatic improvements in appearance, which is likely the dermatologist’s greatest trump card in trying to influence patients.
Of course, behavior modification, even if accepted by the patient, might not be sufficient if some or significant wrinkling has already begun. It is important to explain to patients that there are several treatments in the dermatologic armamentarium, but no cure. I explain to patients that while wrinkles originate in the dermis, many skin care products do not have the capacity to penetrate deeply enough into the lower layers of the skin to reverse or affect wrinkles. The oft-advertised and highly touted “Better than Botox” creams fall into this category, as they cannot penetrate deeply enough into the dermis, despite manufacturer claims. Steering patients away from such nostrums, I cite the studies that demonstrate that there are products that demonstrate efficacy in affecting wrinkles. In fact, if they have not already heard of these products, they are usually impressed or relieved to know that two products, Renova and Avage, have received FDA approval for ameliorating wrinkles and are available by prescription.
Our First Priority
Clearly, preventing the formation of wrinkles is the first priority. Avoiding prolonged sun exposure, particularly during peak hours, using sunscreen, avoiding cigarette smoke and pollution, taking antioxidant supplements, and eating a diet high in fruits and vegetables remain the best ways to prevent and reduce skin aging. Regularly using prescription retinoids can also help. In addition, several years of clinical experience with patients has suggested to me that Botox injections can prevent wrinkles incurred in areas of movement by temporarily paralyzing the muscles, thus decreasing movement, in those areas. Ultimately, the take-home message for patients is that changing their habits can change one aspect of their skin type from a W to a T.
Making Better Skincare Choices
Although we are unsure of the relationship between skin cancer and skin aging, we are certain about the facts that cigarette smoking, sun exposure, and tanning bed exposure can lead to both skin cancer and skin aging. Using the BSTI questionnaire to ascertain one’s skin type will help determine those at greatest risk for developing these undesirable outcomes due to their behavioral habits.
The BSTI assigns individuals to 16 skin types based on the parameters described above. Sun protection is important in all four parameters. For example, a dry, sensitive, pigmented, wrinkled (DSPW) skin type would greatly benefit from sun protection because UV damages the skin barrier, making the skin drier and more sensitive, contributes to acne and worsens dyspigmentation in addition to causing wrinkles.
“Photoaged skin” is not just about wrinkles anymore, but showing people who fall into the “W” skin type category that they’re at risk for wrinkling before significant wrinkling occurs. This may be the best way to influence them to make lifestyle changes that will also have the benefit of lowering their skin cancer risk.
In the early 1900s, the legendary Helena Rubinstein, who created a cosmetics empire and influenced generations of women on beauty, identified four skin types: dry, oily, combination and sensitive.1 Back then, far fewer skincare products existed, but today the market for skincare products has expanded exponentially.
How can we guide our patients toward making good skincare choices? Education is paramount. We must first educate patients about what their individual skincare needs are, and then we should inform them what ingredients have been shown to target those needs. I have found that the most effective way to accomplish this is to help the patient to correctly determine their skin type. But what I have found is that patients often have no idea what their skin type is. In fact, patients’ subjective assessments of their own skin types have been shown not to correspond to certain measurements such as sebum production.2
Objective standards are needed. I have developed a system of skin typing based on our modern understanding of four basic skin parameters: dry or oily; sensitive or resistant; pigmented or non-pigmented; and wrinkled or unwrinkled (tight). Here, I’ll provide insight into this new skin typing system and offer product choices for sunscreens, and other products that help prevent photodamage, based on the different skin types.
The New Skin Typing System at a Glance
The key to my new skin typing system is that the qualities assigned to the four basic skin parameters are not mutually exclusive. Therefore, suggesting that there are merely four skin types limits our understanding of the dynamic nature of the skin.
The various permutations from the four skin-type parameters yield 16 possible skin types (in a manner that is similar to the Myers-Brigg personality scale). For example, a person may have dry, sensitive, pigmented, wrinkled skin. The various skin-type profiles are rendered by a self-administered questionnaire with a battery of 64 items. Once the questionnaire, known as the Baumann Skin Type Indicator (BSTI), is completed and the patient knows his or her skin type, the patient is equipped with much more
information about what areas to focus on in skin care.
It is my belief that this will result in better skincare choices, leading to better compliance with products such as a daily sunscreen, anti-oxidants and retinoids, which have been shown to have efficacy in preventing photo damage.
The Four Skin Type Parameters
Skin Hydration: Dry (D) vs. Oily (O)
Maintaining sufficient skin hydration is a complex process involving numerous factors, such as lipids in the stratum corneum, natural moisturizing factor (NMF), hyaluronic acid (HA), and sebum production. Those who have a history of frequent sun exposure tend to have drier skin. Educating patients with dry skin to avoid ultraviolet exposure would give them the instant gratification of smoother more hydrated skin, but more importantly would serve to protect them long term from the other havoc that UV can cause: photoaging and skin cancer.
The stratum corneum is surrounded by a watertight lipid bi-layer composed primarily of ceramides, fatty acids and cholesterol. When present in the proper proportion, these constituents form the skin barrier that functions similarly to a brick wall (keratinocytes) surrounded by mortar (lipid bilayer), protecting the skin and keeping it watertight.
Trans-epidermal water loss (TEWL) results from defects in the stratum corneum and leads to xerotic or dry skin that is rough in texture and characterized by an elevated number of ridges.3
Barrier disruption can also lead to increased skin sensitivity with an increased incidence of contact dermatitis or eczema. Patients with barrier disruption fall into the category of DS (dry, sensitive) skin types. Ultraviolet light has been proven to cause defects in the skin barrier.4 After UV radiation, TEWL increases until day 4 when it peaks and begins to return to normal levels.5 The barrier perturbation has been shown to be related to detrimental UV effects on lamellar body generation capacity,6 and decreased amounts of covalently bound ceramides in the stratum corneum.7,8
Topical skincare products that are aimed at barrier repair focus on delivering the three key components to the stratum corneum: ceramides, fatty acids and cholesterol. Because fatty acids and cholesterol are derived from the diet, a healthy diet can also enhance the skin barrier. By the same token, cholesterol-reducing drugs can disrupt the barrier.9 Evening primrose oil, borage oil, and omega-3 fatty acids are healthy additions to a diet that have potential to alleviate dry, sensitive skin by replenishing essential components of the stratum corneum.
Natural moisturizing factor (NMF), a compound that holds water inside keratinocytes, rendering them plump, is derived from the hydrolysis of the protein filaggrin, which imparts structural support to the lower levels of the stratum corneum, and breaks down into amino acids known as NMF in the upper levels of the epidermis. Filaggrin decomposition is known to adapt to changes in climate, so that after several days in a new low-humidity environment, an individual would produce more NMF. However, UV exposure is known to interrupt the enzymatic hydrolysis of filaggrin to NMF, suggesting that skin dryness due to low NMF might be ameliorated by decreasing sun exposure.10 Low levels of NMF may be implicated in dryness observed in dry skin types that do not exhibit increased sensitivity. These types are known as DR or dry, resistant types.
The wax esters, triglycerides, and squalene found in sebum help protect the skin from the environment.11 Lipid films on the skin, formed from sebum-derived fats, also help prevent TEWL. However, no association has been shown between low sebum production and xerosis, and the impact of sebum on dry skin is poorly understood.12 In fact, not all people with dry skin have diminished sebum production, which is influenced by genetics, diet, stress and hormones.13 More research is needed on the affect of sebum on DR skin.
Most studies assessing the influence of sebum on xerosis have been conducted on DS skin types (e.g., patients with atopic dermatitis), but not DR types with an intact skin barrier.
Many skincare formulations are available to treat xerosis. Recommending one with a sunscreen will help prevent exacerbation of skin dryness, in addition to preventing skin cancer and photoaging. For DS types, I usually recommend cream formulations that contain ceramides, fatty acids and cholesterol to repair the damaged stratum corneum by replenishing its essential components. For DR types, I suggest sunscreen products with both a humectant and an occlusive component. Glycerin, safflower oil and shea butter are some of the best ingredients for DR skin. In addition, all dry skin types should avoid foaming detergents and soaps in laundry cleansers, body cleansers and face cleansers.
Skin Sensitivity: Sensitive (S) vs. Resistant (R)
The Baumann Skin Type Indicator, which is the questionnaire used to determine the skin type, asks many questions about history of acne, facial flushing or stinging, and frequent redness and scaling. Those who have low scores on this scale, meaning they do not have a significant history of these issues, are said to have resistant skin or to fall into the R skin type. While people with resistant skin can often use any skincare product without side effects, these individuals may derive few benefits because many products are insufficiently potent to penetrate the stratum corneum and adequately treat concerns such as melasma, solar lentigos or wrinkles.
Vitamin C, retinoids and hydroxy acids are among the product types I recommend to R types who often exhibit a strong skin barrier.
Sensitive skin, believed to affect as much as 40% of the population,14 is made of four subtypes: acne, rosacea, stinging, and allergic. The common denominator is inflammation, and its alleviation is a focus of treatment as is eliminating its cause(s).
People with an oily sensitive (OS) profile are the most likely to develop acne. They may mistakenly believe that sun exposure will treat their acne; however, studies have suggested that this is not true.15 In fact, one study showed that acne worsens in summer.16 Non-comedogenic gel, powder or lotion suncreens are beneficial in OS types with acne. In addition, the salicylic acid- and SPF-containing facial foundations are great for this skin type.
Fair-skinned OSW (oily, sensitive and wrinkled) types with a strong history of sun damage are the most likely to suffer from rosacea. Rosacea is thought to arise more commonly in very photodamaged individuals.17 For these patients, recommend sunscreen products containing anti-inflammatory ingredients and antioxidants. Facial powders containing sunscreen can help mask the redness while providing more sun protection.
Stinging, which is not an allergic response, results from what is thought to be amplified neural sensitivity. Known as “stingers,” these individuals experience subjective cutaneous irritation in reaction to specific ingredients to which others do not. The lactic acid stinging test, in 5% and 10% lactic acid concentrations, has demonstrated that a subset of patients experience stinging sensations in the treated nasolabial fold area whereas healthy controls do not.18,19 Rosacea patients with facial flushing are more prone to experience stinging to lactic acid,20 but “stingers” do not often experience redness or visible cutaneous irritation.21
S types identified as “stingers” should avoid the following ingredients: benzoic acid, bronopol, cinnamic acid compounds, Dowicel 200, formaldehyde, lactic acid, propylene glycol, quaternary ammonium compounds, sodium lauryl sulfate, sorbic acid, urea, vitamin C and alpha hydroxy acids (particularly glycolic acid). Achieving broad-spectrum sun protection in stingers can be challenging because they may sting upon exposure to chemical sunscreens such as PABA or avobenzone. If this is the case, suggest broad spectrum sunscreens containing micronized zinc oxide, titanium dioxide or Mexoryl.
The “allergic” subset is the fourth type of sensitive skin. Allergic responses to cosmetic ingredients can be elicited by patch testing, which has been used to determine that up to 10% of dermatologic patients patch tested exhibit allergic responses to at least one cosmetic product ingredient.22 The actual percentage could be much higher, given that few patients consult a physician after reacting to newly purchased cosmetics. An individual is more likely to develop an allergy to cosmetic ingredients as the frequency of exposure to ingredients and the number of ingredients increase. Allergic reactions have been described to many sunscreen ingredients including aminobenzoic acid, benzophenones, and avobenzone. Patch testing may be necessary to find out which sunscreens are best tolerated by these individuals.
Skin Pigmentation: Pigmented (P) vs. Nonpigmented (N)
Removing unwanted pigmentation is thought to be the motivation for at least 21% of all visits to the dermatologist and more than 80,000 people annually purchase OTC skin formulations in order to lessen or eliminate facial dyschromias.23 This skin parameter refers to the proclivity to develop these undesired dark spots on the face or chest (e.g., melasma, solar lentigos, ephelides), but not to ethnicity. For example, both a red-haired, freckled Caucasian and an African American with melasma or unwanted hyperpigmentation would be considered pigmented (P) types. The P skin category is usually linked with the wrinkled (W) type in people with fair skin due to the causal association between solar exposure and rhytids and solar lentigos. Many people with dark skin are more accurately identified as pigmented, tight (PT) types, however, as a result of a significantly lower tendency to wrinkle.
Diagnosing a patient as a P type is the perfect opportunity to educate them about sun protection and use of antioxidants and retinoids. This is particularly important in the red-headed freckled patients who are at a higher risk of melanoma. P types are often very motivated to get rid of the undesired dark patches such as melasma and they often do not understand the important role that sun plays in these types.
Of course, sun protection is very important in non-pigmented (N) types as well but appealing to them about wrinkle prevention is often more fruitful than discussing prevention of solar lentigos.
There’s No Such Thing as a Healthy Tan
Dermatologists have been fairly successful in recent years in broadcasting the message that sun exposure poses several significant risks, the most dangerous of which is skin cancer. Habitual sun exposure is also believed to account for 80% of facial aging.24 Still, too many people insist on sunbathing and tanning their skin. The prevailing defense seems to be that they think they look better with a tan. Few, if any, I suspect, would think they look better with wrinkles. Frightening them about future wrinkling may motivate them to use sun protection, which would help protect the skin from skin cancer.
Skin Aging: Wrinkled (W) vs. Tight (T)
In the BSTI questionnaire section that determines whether a patient is a wrinkled (W) skin type or a tight (T) type, genetic factors are considered in questions about the skin appearance of patients’ ancestors. The questionnaire also asks about smoking history, diet, daily sun exposure, tanning habits, tanning bed use, exposure to pollution, use of retinoids, and ethnicity.
The W/T score that results can be used by the physician to determine a patient’s propensities and behaviors that might warrant modification as well as appropriate treatments. Higher scores are associated with a greater incidence of photoaging. It is logical to assume that higher W scores would also correspond to an increased incidence of skin cancer. It is currently unknown whether there is a correlation between wrinkling amount and the incidence of skin cancer.
Interestingly, in a recent questionnaire-based case-referent study of 118 successive hospital patients admitted for surgical treatment of basal cell carcinoma (BCC) compared with 121 controls without skin cancer, researchers identified an inverse relationship between significant facial wrinkling and BCC, this despite the fact that BCC patients were older.25 The investigators concluded that either the causal pathways for the respective conditions were independent or that facial wrinkling might have played a protective role against BCC. Much remains to be discovered regarding this potential phenomenon as well as any correlations between wrinkling and other forms of skin cancer.
Given the well-documented relationship between exogenous influences and observable cutaneous effects, it becomes patently clear that the W/T is the only skin-type parameter within an individual’s control. In other words, a person can alter one’s behavior to reduce the risk of photo-induced extrinsic aging, which results from external factors such as smoking, excessive use of alcohol, poor nutrition, exposure to pollution, and habitual exposure to the sun. Reducing one’s exposure to such factors that stimulate the production of reactive oxygen species will not demonstrably affect the genetic or intrinsic aging process, but it undoubtedly confers health benefits and can be shown to impart dramatic improvements in appearance, which is likely the dermatologist’s greatest trump card in trying to influence patients.
Of course, behavior modification, even if accepted by the patient, might not be sufficient if some or significant wrinkling has already begun. It is important to explain to patients that there are several treatments in the dermatologic armamentarium, but no cure. I explain to patients that while wrinkles originate in the dermis, many skin care products do not have the capacity to penetrate deeply enough into the lower layers of the skin to reverse or affect wrinkles. The oft-advertised and highly touted “Better than Botox” creams fall into this category, as they cannot penetrate deeply enough into the dermis, despite manufacturer claims. Steering patients away from such nostrums, I cite the studies that demonstrate that there are products that demonstrate efficacy in affecting wrinkles. In fact, if they have not already heard of these products, they are usually impressed or relieved to know that two products, Renova and Avage, have received FDA approval for ameliorating wrinkles and are available by prescription.
Our First Priority
Clearly, preventing the formation of wrinkles is the first priority. Avoiding prolonged sun exposure, particularly during peak hours, using sunscreen, avoiding cigarette smoke and pollution, taking antioxidant supplements, and eating a diet high in fruits and vegetables remain the best ways to prevent and reduce skin aging. Regularly using prescription retinoids can also help. In addition, several years of clinical experience with patients has suggested to me that Botox injections can prevent wrinkles incurred in areas of movement by temporarily paralyzing the muscles, thus decreasing movement, in those areas. Ultimately, the take-home message for patients is that changing their habits can change one aspect of their skin type from a W to a T.
Making Better Skincare Choices
Although we are unsure of the relationship between skin cancer and skin aging, we are certain about the facts that cigarette smoking, sun exposure, and tanning bed exposure can lead to both skin cancer and skin aging. Using the BSTI questionnaire to ascertain one’s skin type will help determine those at greatest risk for developing these undesirable outcomes due to their behavioral habits.
The BSTI assigns individuals to 16 skin types based on the parameters described above. Sun protection is important in all four parameters. For example, a dry, sensitive, pigmented, wrinkled (DSPW) skin type would greatly benefit from sun protection because UV damages the skin barrier, making the skin drier and more sensitive, contributes to acne and worsens dyspigmentation in addition to causing wrinkles.
“Photoaged skin” is not just about wrinkles anymore, but showing people who fall into the “W” skin type category that they’re at risk for wrinkling before significant wrinkling occurs. This may be the best way to influence them to make lifestyle changes that will also have the benefit of lowering their skin cancer risk.
In the early 1900s, the legendary Helena Rubinstein, who created a cosmetics empire and influenced generations of women on beauty, identified four skin types: dry, oily, combination and sensitive.1 Back then, far fewer skincare products existed, but today the market for skincare products has expanded exponentially.
How can we guide our patients toward making good skincare choices? Education is paramount. We must first educate patients about what their individual skincare needs are, and then we should inform them what ingredients have been shown to target those needs. I have found that the most effective way to accomplish this is to help the patient to correctly determine their skin type. But what I have found is that patients often have no idea what their skin type is. In fact, patients’ subjective assessments of their own skin types have been shown not to correspond to certain measurements such as sebum production.2
Objective standards are needed. I have developed a system of skin typing based on our modern understanding of four basic skin parameters: dry or oily; sensitive or resistant; pigmented or non-pigmented; and wrinkled or unwrinkled (tight). Here, I’ll provide insight into this new skin typing system and offer product choices for sunscreens, and other products that help prevent photodamage, based on the different skin types.
The New Skin Typing System at a Glance
The key to my new skin typing system is that the qualities assigned to the four basic skin parameters are not mutually exclusive. Therefore, suggesting that there are merely four skin types limits our understanding of the dynamic nature of the skin.
The various permutations from the four skin-type parameters yield 16 possible skin types (in a manner that is similar to the Myers-Brigg personality scale). For example, a person may have dry, sensitive, pigmented, wrinkled skin. The various skin-type profiles are rendered by a self-administered questionnaire with a battery of 64 items. Once the questionnaire, known as the Baumann Skin Type Indicator (BSTI), is completed and the patient knows his or her skin type, the patient is equipped with much more
information about what areas to focus on in skin care.
It is my belief that this will result in better skincare choices, leading to better compliance with products such as a daily sunscreen, anti-oxidants and retinoids, which have been shown to have efficacy in preventing photo damage.
The Four Skin Type Parameters
Skin Hydration: Dry (D) vs. Oily (O)
Maintaining sufficient skin hydration is a complex process involving numerous factors, such as lipids in the stratum corneum, natural moisturizing factor (NMF), hyaluronic acid (HA), and sebum production. Those who have a history of frequent sun exposure tend to have drier skin. Educating patients with dry skin to avoid ultraviolet exposure would give them the instant gratification of smoother more hydrated skin, but more importantly would serve to protect them long term from the other havoc that UV can cause: photoaging and skin cancer.
The stratum corneum is surrounded by a watertight lipid bi-layer composed primarily of ceramides, fatty acids and cholesterol. When present in the proper proportion, these constituents form the skin barrier that functions similarly to a brick wall (keratinocytes) surrounded by mortar (lipid bilayer), protecting the skin and keeping it watertight.
Trans-epidermal water loss (TEWL) results from defects in the stratum corneum and leads to xerotic or dry skin that is rough in texture and characterized by an elevated number of ridges.3
Barrier disruption can also lead to increased skin sensitivity with an increased incidence of contact dermatitis or eczema. Patients with barrier disruption fall into the category of DS (dry, sensitive) skin types. Ultraviolet light has been proven to cause defects in the skin barrier.4 After UV radiation, TEWL increases until day 4 when it peaks and begins to return to normal levels.5 The barrier perturbation has been shown to be related to detrimental UV effects on lamellar body generation capacity,6 and decreased amounts of covalently bound ceramides in the stratum corneum.7,8
Topical skincare products that are aimed at barrier repair focus on delivering the three key components to the stratum corneum: ceramides, fatty acids and cholesterol. Because fatty acids and cholesterol are derived from the diet, a healthy diet can also enhance the skin barrier. By the same token, cholesterol-reducing drugs can disrupt the barrier.9 Evening primrose oil, borage oil, and omega-3 fatty acids are healthy additions to a diet that have potential to alleviate dry, sensitive skin by replenishing essential components of the stratum corneum.
Natural moisturizing factor (NMF), a compound that holds water inside keratinocytes, rendering them plump, is derived from the hydrolysis of the protein filaggrin, which imparts structural support to the lower levels of the stratum corneum, and breaks down into amino acids known as NMF in the upper levels of the epidermis. Filaggrin decomposition is known to adapt to changes in climate, so that after several days in a new low-humidity environment, an individual would produce more NMF. However, UV exposure is known to interrupt the enzymatic hydrolysis of filaggrin to NMF, suggesting that skin dryness due to low NMF might be ameliorated by decreasing sun exposure.10 Low levels of NMF may be implicated in dryness observed in dry skin types that do not exhibit increased sensitivity. These types are known as DR or dry, resistant types.
The wax esters, triglycerides, and squalene found in sebum help protect the skin from the environment.11 Lipid films on the skin, formed from sebum-derived fats, also help prevent TEWL. However, no association has been shown between low sebum production and xerosis, and the impact of sebum on dry skin is poorly understood.12 In fact, not all people with dry skin have diminished sebum production, which is influenced by genetics, diet, stress and hormones.13 More research is needed on the affect of sebum on DR skin.
Most studies assessing the influence of sebum on xerosis have been conducted on DS skin types (e.g., patients with atopic dermatitis), but not DR types with an intact skin barrier.
Many skincare formulations are available to treat xerosis. Recommending one with a sunscreen will help prevent exacerbation of skin dryness, in addition to preventing skin cancer and photoaging. For DS types, I usually recommend cream formulations that contain ceramides, fatty acids and cholesterol to repair the damaged stratum corneum by replenishing its essential components. For DR types, I suggest sunscreen products with both a humectant and an occlusive component. Glycerin, safflower oil and shea butter are some of the best ingredients for DR skin. In addition, all dry skin types should avoid foaming detergents and soaps in laundry cleansers, body cleansers and face cleansers.
Skin Sensitivity: Sensitive (S) vs. Resistant (R)
The Baumann Skin Type Indicator, which is the questionnaire used to determine the skin type, asks many questions about history of acne, facial flushing or stinging, and frequent redness and scaling. Those who have low scores on this scale, meaning they do not have a significant history of these issues, are said to have resistant skin or to fall into the R skin type. While people with resistant skin can often use any skincare product without side effects, these individuals may derive few benefits because many products are insufficiently potent to penetrate the stratum corneum and adequately treat concerns such as melasma, solar lentigos or wrinkles.
Vitamin C, retinoids and hydroxy acids are among the product types I recommend to R types who often exhibit a strong skin barrier.
Sensitive skin, believed to affect as much as 40% of the population,14 is made of four subtypes: acne, rosacea, stinging, and allergic. The common denominator is inflammation, and its alleviation is a focus of treatment as is eliminating its cause(s).
People with an oily sensitive (OS) profile are the most likely to develop acne. They may mistakenly believe that sun exposure will treat their acne; however, studies have suggested that this is not true.15 In fact, one study showed that acne worsens in summer.16 Non-comedogenic gel, powder or lotion suncreens are beneficial in OS types with acne. In addition, the salicylic acid- and SPF-containing facial foundations are great for this skin type.
Fair-skinned OSW (oily, sensitive and wrinkled) types with a strong history of sun damage are the most likely to suffer from rosacea. Rosacea is thought to arise more commonly in very photodamaged individuals.17 For these patients, recommend sunscreen products containing anti-inflammatory ingredients and antioxidants. Facial powders containing sunscreen can help mask the redness while providing more sun protection.
Stinging, which is not an allergic response, results from what is thought to be amplified neural sensitivity. Known as “stingers,” these individuals experience subjective cutaneous irritation in reaction to specific ingredients to which others do not. The lactic acid stinging test, in 5% and 10% lactic acid concentrations, has demonstrated that a subset of patients experience stinging sensations in the treated nasolabial fold area whereas healthy controls do not.18,19 Rosacea patients with facial flushing are more prone to experience stinging to lactic acid,20 but “stingers” do not often experience redness or visible cutaneous irritation.21
S types identified as “stingers” should avoid the following ingredients: benzoic acid, bronopol, cinnamic acid compounds, Dowicel 200, formaldehyde, lactic acid, propylene glycol, quaternary ammonium compounds, sodium lauryl sulfate, sorbic acid, urea, vitamin C and alpha hydroxy acids (particularly glycolic acid). Achieving broad-spectrum sun protection in stingers can be challenging because they may sting upon exposure to chemical sunscreens such as PABA or avobenzone. If this is the case, suggest broad spectrum sunscreens containing micronized zinc oxide, titanium dioxide or Mexoryl.
The “allergic” subset is the fourth type of sensitive skin. Allergic responses to cosmetic ingredients can be elicited by patch testing, which has been used to determine that up to 10% of dermatologic patients patch tested exhibit allergic responses to at least one cosmetic product ingredient.22 The actual percentage could be much higher, given that few patients consult a physician after reacting to newly purchased cosmetics. An individual is more likely to develop an allergy to cosmetic ingredients as the frequency of exposure to ingredients and the number of ingredients increase. Allergic reactions have been described to many sunscreen ingredients including aminobenzoic acid, benzophenones, and avobenzone. Patch testing may be necessary to find out which sunscreens are best tolerated by these individuals.
Skin Pigmentation: Pigmented (P) vs. Nonpigmented (N)
Removing unwanted pigmentation is thought to be the motivation for at least 21% of all visits to the dermatologist and more than 80,000 people annually purchase OTC skin formulations in order to lessen or eliminate facial dyschromias.23 This skin parameter refers to the proclivity to develop these undesired dark spots on the face or chest (e.g., melasma, solar lentigos, ephelides), but not to ethnicity. For example, both a red-haired, freckled Caucasian and an African American with melasma or unwanted hyperpigmentation would be considered pigmented (P) types. The P skin category is usually linked with the wrinkled (W) type in people with fair skin due to the causal association between solar exposure and rhytids and solar lentigos. Many people with dark skin are more accurately identified as pigmented, tight (PT) types, however, as a result of a significantly lower tendency to wrinkle.
Diagnosing a patient as a P type is the perfect opportunity to educate them about sun protection and use of antioxidants and retinoids. This is particularly important in the red-headed freckled patients who are at a higher risk of melanoma. P types are often very motivated to get rid of the undesired dark patches such as melasma and they often do not understand the important role that sun plays in these types.
Of course, sun protection is very important in non-pigmented (N) types as well but appealing to them about wrinkle prevention is often more fruitful than discussing prevention of solar lentigos.
There’s No Such Thing as a Healthy Tan
Dermatologists have been fairly successful in recent years in broadcasting the message that sun exposure poses several significant risks, the most dangerous of which is skin cancer. Habitual sun exposure is also believed to account for 80% of facial aging.24 Still, too many people insist on sunbathing and tanning their skin. The prevailing defense seems to be that they think they look better with a tan. Few, if any, I suspect, would think they look better with wrinkles. Frightening them about future wrinkling may motivate them to use sun protection, which would help protect the skin from skin cancer.
Skin Aging: Wrinkled (W) vs. Tight (T)
In the BSTI questionnaire section that determines whether a patient is a wrinkled (W) skin type or a tight (T) type, genetic factors are considered in questions about the skin appearance of patients’ ancestors. The questionnaire also asks about smoking history, diet, daily sun exposure, tanning habits, tanning bed use, exposure to pollution, use of retinoids, and ethnicity.
The W/T score that results can be used by the physician to determine a patient’s propensities and behaviors that might warrant modification as well as appropriate treatments. Higher scores are associated with a greater incidence of photoaging. It is logical to assume that higher W scores would also correspond to an increased incidence of skin cancer. It is currently unknown whether there is a correlation between wrinkling amount and the incidence of skin cancer.
Interestingly, in a recent questionnaire-based case-referent study of 118 successive hospital patients admitted for surgical treatment of basal cell carcinoma (BCC) compared with 121 controls without skin cancer, researchers identified an inverse relationship between significant facial wrinkling and BCC, this despite the fact that BCC patients were older.25 The investigators concluded that either the causal pathways for the respective conditions were independent or that facial wrinkling might have played a protective role against BCC. Much remains to be discovered regarding this potential phenomenon as well as any correlations between wrinkling and other forms of skin cancer.
Given the well-documented relationship between exogenous influences and observable cutaneous effects, it becomes patently clear that the W/T is the only skin-type parameter within an individual’s control. In other words, a person can alter one’s behavior to reduce the risk of photo-induced extrinsic aging, which results from external factors such as smoking, excessive use of alcohol, poor nutrition, exposure to pollution, and habitual exposure to the sun. Reducing one’s exposure to such factors that stimulate the production of reactive oxygen species will not demonstrably affect the genetic or intrinsic aging process, but it undoubtedly confers health benefits and can be shown to impart dramatic improvements in appearance, which is likely the dermatologist’s greatest trump card in trying to influence patients.
Of course, behavior modification, even if accepted by the patient, might not be sufficient if some or significant wrinkling has already begun. It is important to explain to patients that there are several treatments in the dermatologic armamentarium, but no cure. I explain to patients that while wrinkles originate in the dermis, many skin care products do not have the capacity to penetrate deeply enough into the lower layers of the skin to reverse or affect wrinkles. The oft-advertised and highly touted “Better than Botox” creams fall into this category, as they cannot penetrate deeply enough into the dermis, despite manufacturer claims. Steering patients away from such nostrums, I cite the studies that demonstrate that there are products that demonstrate efficacy in affecting wrinkles. In fact, if they have not already heard of these products, they are usually impressed or relieved to know that two products, Renova and Avage, have received FDA approval for ameliorating wrinkles and are available by prescription.
Our First Priority
Clearly, preventing the formation of wrinkles is the first priority. Avoiding prolonged sun exposure, particularly during peak hours, using sunscreen, avoiding cigarette smoke and pollution, taking antioxidant supplements, and eating a diet high in fruits and vegetables remain the best ways to prevent and reduce skin aging. Regularly using prescription retinoids can also help. In addition, several years of clinical experience with patients has suggested to me that Botox injections can prevent wrinkles incurred in areas of movement by temporarily paralyzing the muscles, thus decreasing movement, in those areas. Ultimately, the take-home message for patients is that changing their habits can change one aspect of their skin type from a W to a T.
Making Better Skincare Choices
Although we are unsure of the relationship between skin cancer and skin aging, we are certain about the facts that cigarette smoking, sun exposure, and tanning bed exposure can lead to both skin cancer and skin aging. Using the BSTI questionnaire to ascertain one’s skin type will help determine those at greatest risk for developing these undesirable outcomes due to their behavioral habits.
The BSTI assigns individuals to 16 skin types based on the parameters described above. Sun protection is important in all four parameters. For example, a dry, sensitive, pigmented, wrinkled (DSPW) skin type would greatly benefit from sun protection because UV damages the skin barrier, making the skin drier and more sensitive, contributes to acne and worsens dyspigmentation in addition to causing wrinkles.
“Photoaged skin” is not just about wrinkles anymore, but showing people who fall into the “W” skin type category that they’re at risk for wrinkling before significant wrinkling occurs. This may be the best way to influence them to make lifestyle changes that will also have the benefit of lowering their skin cancer risk.
