Hello all! Thank you to Vidya and DPM for providing us the hosting space for our thoughts on all things derm related! And thank you for visiting!
Brought to you by the DPM Beauty and Brains Committee, Chairsister Dr. Shabreen Haque
Who Are We?
Hello, My name is Sheila and I am a board certified dermatologist, wife, and mom, living in sunny San Diego. I practice dermatology full time, and love what I do! Moreover, I love sharing what I do with others, particularly to educate and empower patients to make the best decisions they can for their skin health and body health.
And my name is Chethana, and I am also a board certified dermatologist, wife and mom, living in the FINALLY warm and sunny suburbs of Detroit in Michigan. I am opening my own practice this summer, the Art of Dermatology, and firmly believe that developing a skin care regimen is an “art” and not an exact science. I would love to help all of you to learn more about how to take care of your skin! I have ultra sensitive, very intolerant to anti-aging products type of skin, so much of my advice will incorporate advice on products for super sensitive skin.
Full credit goes to Sheila in writing this first blog post! We are going to alternate posting on a regular interval basis, but we will be sure to include specific product advice from both of us in each post.
Why write about this?
When I joined DPM, I was impressed by the range and experience of this talented group of women. I also noticed a lot of dermatology questions! And that makes sense, because the information out there on skin related subjects is confusing, conflicting and, most importantly, not always targeted to women with skin of color. And while I enjoyed the many and sundry questions on the site, I feel a blog posting like this will provide a framework to the questions and better explain how it all comes together.
So my goal here, along with generous help of Dr. Chethana Gottam, is to help elucidate some concepts about skin care and skin physiology in skin of color, along with basics that apply to everyone. But don’t worry, even though I’m a huge nerd about skin, I promise not to bore you! Just the basics….then we can have some fun and talk product, because that’s what everyone loves right?!
Nota Buena
One last note before diving in, you will notice that in many of my comments, I will end with “check in with a board certified dermatologist for a detailed consult.” This is not just CYA (I have a detailed disclaimer for that!), it’s also to stress the importance of working with a board certified dermatologist on your skin issues.
A board certified dermatologist might work with a PA, NP, esthetician, and all of these folks are a wonderful part of the care team, but the BCD should always be the one managing you and your skin. Remember the old SOAP note format? Well, here it’s Supervision, Oversight, Assessment, and Plan- by a BCD! So that’s my two cents on that 🙂 And if you’re in San Diego, come see me! (Sheila)
Structure and Function of Skin
What’s the basic structure and function of the skin? How is skin of color different?
I promised not to make this section boring, so let’s organize this by the main determinants of skin appearance and aging.
Many of my patients come in saying they want to look younger and don’t know where to start. So I have a rubric (mentally! I am not grading them and handing out a report card!)
When I assess them, I think of three factors, which I call the”triple threat”- Texture, Tone, and Volume (TTV).
Texture is the appearance of the skin surface- ie oily, dry, scaly, etc.
Tone is the color- are their dark spots, light spots, or other color disturbances?
Volume is the deep structure of the skin- when volume is lost, the skin will appear sunken in or hollow.
Texture
The skin is comprised of layers that include the epidermis, dermis and subcutaneous tissues.
The epidermis is a bricks and mortar structure. The bricks are mainly comprised of keratinocytes, which go through a life cycle, usually around a month or so, of growing, migrating up and shedding. These dead, shed skin cells are the stratum corneum and accumulation of these cells causes skin to feel rough or dull.
Keratinocytes are surrounded by a mortar comprised of lipids (remember that first year bio lipid bilayer- here it is!) including ceramides, cholesterols and free fatty acids. These form a flexible, supple sponge like network for the keratinocytes to live in. When the mortar is impaired in any way, keratinocytes will appear more dry and flaky on the skin.
The dermis the second layer of skin, where sweat glands, hair follicles, nerves and vessels live. The pilosebaceous unit (ie sweat glands and follicles) is the source of acne, whether comedonal, hormonal, or otherwise. Excess sebaceous oil production will also cause an oily appearance, as can excess hair growth.
Tone
Tone! Tone aberrations, ie dark spots, light spots, speckled spots, are at the heart of a lot of concerns when it comes to skin of color.
Along with keratinocytes, the epidermis is also where melanocytes live, which are the pigment producing cells of our skin. People with skin of color have the same number of melanocytes as those with very light skin; however the amount of melanin in each melanocyte is increased and more widely dispersed.
All this melanin lives in small packets called melanosomes. Melanosomes are delicate, and easily scatter their contents or double up their defenses when stressed. This can be due to sun exposure, inflammation, or even just plain genetics. (See mom, you’re why I have stressed out melanosomes!) This can cause lentigos, post inflammatory hyperpigmentation and melasma.
Volume
The dermis and subcutaneous tissues are filled with collagen fibers, hylauronic acid (HA), and more, which allows the skin to stretch, flex, and heal. Collagen and HA fibers are plentiful in youth but begin to diminish with sun exposure, smoking, and aging. Luckily for skin of color, the collagen tends to be more plentiful and more robust to the infuence of sun, but age catches up with us all, and by the 50s-60s, collagen and HA thinning is in swing.
So…. what do you do with all of this?
Basic Skin Care
Cleanse
First, we need to protect the skin, and not just from sun. Makeup, creams, pollution, forced air (nothing is worse than a heater IMO) and even sweat can lead to rough, dull skin.
So I’m going to start backwards, at the end of your day. The kids are finally in bed, and you’re at the mirror. Now what?
First step is to get rid of the day’s buildup- remember those shedding keratinocytes and the sebaceous oil? And maybe makeup and sweat from that face shield you had for the procedure? Yeah, it’s time to shed that layer. Feel free to make this a mindfulness exercise too, where you leave off the day you had and prepare for the next!
If you wear makeup, start with a neutrogena makeup wipe to remove the bulk of it. Then follow with a good cleanser- it can be as simple as Cetaphil for sensitive skin but I love La roche Posay Tolerance foaming cleanser. It is so well balanced and does not dry the skin but does remove the buildup. (Nerd alert: I did a makeup experiment with a wipe after using cetaphil alone, vs la roche posay alone, vs combo to see how each perfomed- combo was actually close to la roche posay alone.)
CG: For those with sensitive skin and wanting to keep chemicals to a minimum, I also like Simple brand micellar make up remover wipes. For oilier skin types, I like Epionce Lytic Gel Cleanser, and for sensitive skin types, I like Epionce Gentle Foaming Cleanser.
For eye makeup, I go simple with vaseline on a soft cotton pad. It does the job and leaves the skin feeling supple. Too many eye makeup removers are alcohol based, and leave your under eye feeling dry. Many of us are prone to under eye circles anyways and the last thing is to further irritate the area.
CG: Totally agree on the vaseline. Believe it or not, Vaseline is a dermatologist’s best friend. For those opposed to using Vaseline to clean, I really like micellar water (Garnier or Simple are good brands) on a soft cotton pad as well.
Finish the cleansing with cetaphil PM to restore moisture. Another great choice for PM is skinceuticals triple lipid- very luxurious, but might be too thick for some. For the dry skin types out there, cerave is a wonderful product with actual ceramides, like what’s found in your lipid bilayer- sorry nerd alert, just love that stuff.
CG: I also like Cerave PM, because it has niacinamide in it, which naturally calms the skin overnight. Clinique also makes a nice product called “Moisture Surge” for those desiring more hydration, and Neutrogena’s “HydroBoost Water Gel” that is a clean and lightweight HA containing hydrating gel.
So moving backwards in the day, preventing makeup and sweat build up in the pores is all important. I sweat behind my face shield so keeping some absorbent paper to blot between AM and PM clinic can be really helpful.
CG: There is also a product called OC8 mattifying gel, that can be applied throughout the day to problem areas (for me, I glisten in the T-zone midway through the day, and this gel absorbs the oil nicely!)
In the morning, the face is relatively clean usually (tip: wear a headband to keep hair off of the face at night) so really all that is needed is a simple wash like cetaphil or cerave.
CG: Totally agree, my favorite gentle morning face washes are Cetaphil, Cerave, and Purpose.
Protect
So the big dog in the AM routine is … sunscreen! of course I was going to say that, we dermatologists are slightly obsessed with the stuff. And for good reason, because the sun is just not our friend- no matter what the kids songs say!
A note on SPF, while studies have shown that lab rats do as well with SPF 30 as they do with higher numbers, none of us are lab rats! That is to say, we don’t live in ideal lab circumstances, and for us imperfect humans, higher is better. Even among dermatologists, studies have shown inadequate sunscreen use, so yeah, higher is better.
I am a fan of mineral sunblocks which are titanium, zinc, or iron oxide based. These form a literal shield against the sun. Chemical compounds such as avobenzone, oxybenzone, and mexoryl are also very good and can be used IN CONJUNCTION with a mineral based product but for darker skin types, I am partial to physical blockers.
While Consumer reports often rates the chemical ones higher I truly believe that for the physical ones work MUCH better for skin of color and are particularly effective at preventing and treating dark spots, hyperpigmentation etc.
However, Mexoryl (found in La Roche Posay products) and Helioplex (found in Neutrogena products) however, are notable exceptions that do a great job along with a mineral block. When it comes to mexoryl, La Roche Posay is doing a great job. I love La Roche Posay Anthelios Melt in Milk- it sounds so refreshing and and it feels that way too- I use it on weekends when I am out and about. To be honest, and I have zero COI here, I love most everything La Roche posay makes. They do a wonderful job and have some really good tone correcting products which I will talk about when we talk about brown spots and such. I also like Avene as well, but more on this in dark spot section.
CG: I love SkinMedical Total Defense and Repair sunscreen and Aveeno Positively Radiant sunscreen. Aveeno in particular has soy extract in it, which is known to help even out tone in the skin, one of the main reasons I love it in skin of color.
For basic physical sunscreens, and this what I use on workdays when I am indoors, I love neutrogena daily moisturizer with SPF 50 for facial use. It’s a double hitter and is non-comedogenic. For body (please don’t forget your necks and chests if exposed- nothing shows aging more than a sun damaged chest- or if you’re fancy, you can call it a décolletage) I use vanicream SPF 50-70. This brand is 100% free of all the chemicals, allergens, etc that you could imagine. Atopy runs high in my house so vanicream is a go to brand.
Neutrogena and EltaMD are also solid brands for facial and body sunscreens. For the sportier types looking for something that doesn’t run, Blue Lizard, Headhunter and Solbar do not move at all! My road biking husband uses the latter and is as white when he comes home as when he left a few hours prior.
A note on makeup: I don’t endorse particular brands, but can tell you that mineral based makeups can be difficult for patients prone to acne as the small particles build up in the pores. I cannot tell you the number of teen girls with comedogenic acne that have cleared with simply stopping mineral based makeup.
Things to avoid when cleansing the skin: scrubs are too irritating, no matter how nice they smell. Since our skin can be prone to pigmentation, leave off the irritation.
Treat
Almost every comment I ever get when I tell someone I am derm is- how can I look younger? For many, the answer is botox and filler and an ablative laser! But that’s the big stuff and IMO the real work is done daily, at home, in just a couple minutes. (And don’t worry all the procedures will be covered too!)
So let’s start with our best tool ever- RETINOIDS! Truly sent from heaven for the aging, sun exposed masses, retinoids are vitamin A derivatives that pack a big punch: they exfoliate off dead keratinocytes, normalize keratinocyte production, decrease oil production and shrink sebaceous glands, improve and stabilize collagen, and more! Truly wonderful products but with so many options out there, how to choose?
Over the counter anti-aging lines generally contain retinols- I’m thinking Olay RegenerisT, Rodan and Fields products, etc. If you are sticking with over the counter, then the Olay regeneris lines and Olay total effects are actually really good. Skinceuticals also makes a nice line of retinol as well.
CG: My favorite OTC anti-aging recs: Olay Regenerist, particularly their new “whip” formulation–it is so silky smooth and well tolerated. I also like Garnier SkinActive Ultra-Lift Anti-Wrinkle Firming Night Cream–has retinol and again soybean extract to help even tone.
More powerful and effective than retinol however, is tretinoin. Tretinoin and it’s cousins (adapalene and tazorotene) are only generally available by prescription. I say generally because adapalene (Differin) is available OTC. However the only studies on photo aging have been done with tretinoin. Of note, Differin 0.1 gel is now available OTC, and may be a good starting point for those with sensitive skin, since the prescription agent is slightly less irritating than tretinoin.
Tretinoin can be found as a cream or gel. Creams tend to do well for most people, though the most oily among us might like gels. I tend to stay away from gels in almost all cases, as the alcohol base is irritating, which contributes to non-compliance with tretinoin and my concern for inflammation and PIH goes up too, especially in skin of color. So IMO stick with cream. Strengths can be 0.025, 0.05 and 0.1. (There are also some branded versions that are 0.08, and 0.04). My go to is tretinoin 0.05 cream. As a heads up, these are generally NOT covered by insurance for adults. A great option (and one that I employ) is to use goodrx.com to find the cheapest prices around you. In my area a 9 month supply of tretinoin runs about $45-50, which isn’t bad.
Whichever tretinoin you go for, you will likely experience drying and irritation. I suggest starting out every 2nd to 3rd day and then working your way up- your skin will acclimate. I also suggest creams over gels and generous use of emollient and and sunscreen as discussed above. If you’re getting red, stop for a few days, because red can lead to hyperpigmentation. As always, see a BCD to pick the right one and rx for you.
CG: Applying Cerave PM or Neutrogena HydroGel Boost on top of your retinoid at nighttime will also drastically improve tolerability.
Now onto another fantastic tool- vitamin C- and before we start, I will say, YES it is worth it. The products are not cheap, and certainly I encourage shopping around, but for anyone interested in preventing skin aging, vitamin C must be on the list. So of course, SkinCeuticals CE Ferulic is the one that everyone knows and loves- and for good reason, its a great product (albeit with a funny smell IMO) and they have the patent on the stuff. The price tag is high but it does last a while since you don’t need a lot.
If you’re looking for a lower price tag, which I always do, another one is Avene A-oxitive Antioxidant Defense Serum is nice, and also has some Vitamin E which makes it really smooth. I personally use Replenix (aka Citrix) vitamin C products, mainly because we sell it in office and I get a discount and I like the feel of it.
CG: Replenix Vitamin C cream (only sold in physicians’ offices) and Paula’s Choice (on Amazon) are also good Vitamin C options. I use the SkinCeuticals CE Ferulic, but agree with Sheila, that the consistency and smell are funny!
BTW I am working with my practice to see if we can sell to non-patients.
CG: With plans to open my practice this summer, I am still finalizing which products I am going to sell. And I will be working with Vidya and other admins to offer a discount to DPM, just need to look into legality of Rx meds being sent over state lines. More on this soon!
So there are the top three: sunscreen, retinoids and vitamin C. There are a host of other goodies that will be touched on the dark spot, acne and wrinkles sections, but these are the basic building blocks of ageless, fresh skin.
Thanks for reading this far and your comments are appreciated! We want this to be helpful and informative.
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