All About Skin

The body’s largest organ has a tough job—protecting all other organs from the outside world. Skin’s role gets even more challenging during the summer months, when the sun’s rays are strongest, and heat and humidity are at their peak. Here, we learn how this hardworking body part functions, the most common issues that affect it during summer and beyond, and how to bolster skin health year-round

Ahh, summer. When the mercury climbs into the upper 80s and humidity reaches near 90 percent. To beat the heat, we’re baring more of our bodies than at any other time of year. But as we bask in the sun—whether we’re lounging by the pool, tending gardens, or just strolling from the car to the grocery—those sneaky ultraviolet rays are wreaking havoc on our skin in the form of burns, cancers and dark spots. The accompanying warm, wet air can also give rise to flare-ups of eczema, acne and rashes.

Skin plays an important role in the immune system, but it can’t protect us if it’s deteriorated or scorched. In the following pages, we peel back the layers on our body’s outer covering, with Roper St. Francis Healthcare affiliated dermatologist Fiona Rahbar giving us the low-down on all things derm. What exactly is skin, and what does it do? Which skin afflictions are most common? How can we protect our skin during the summer and beyond? How should we care for our skin today to ensure its health in the future? Read on to find out the answers to these questions and more.

THE SCIENCE OF SKIN

As the body’s largest organ, accounting for roughly 16 percent of our weight, skin has a big job. Not only does this stretchy waterproof barrier hold our bodies together in a way that permits movement, but it also protects us from environmental extremes and harmful microbes, helps regulate body temperature, and transmits the sensation of touch. Our bodies shed some 35,000 dead skin cells every day to allow new ones to surface; from formation to flake off, this process takes about 40 to 56 days.

Skin consists of three layers that differ in composition and depth. The deepest layer, the hypodermis, consists of insulating fatty tissue that binds the skin to muscles and bones and pads our frames from bumps and falls. Above the hypodermis lies a thicker section of fibrous and elastic tissue (primarily collagen) called the dermis. This middle layer houses follicles that root each hair, nerve endings that signal the brain through touch, sweat glands that cool the body and purge toxins, sebaceous glands that produce oil to soften and protect skin, and blood vessels that feed the skin. The outermost epidermis is comprised of tough protein cells (keratinocytes) and pigment cells (melanocytes) that constantly grow outwards.

The epidermis also holds receptor cells that convert cholesterol to vitamin D when exposed to ultraviolet B (UVB) rays. Vitamin D, commonly called the “sunshine vitamin,” plays a vital role in bone formation and immune strength. The essential nutrient has also been associated with the prevention of osteoporosis, heart disease, cancer, depression, sleep and neurological disorders, and autoimmune diseases, according to the Journal of Advanced Research. Though recommended amounts differ among authorities, the generally accepted guidelines from the National Institutes of Health assert that children and adults should receive 600IU of vitamin D daily and seniors, 800IU. “People often overestimate how much sun exposure the body requires to fulfill that need,” says Dr. Rahbar, explaining that 15 to 20 minutes of daily exposure on uncovered skin the size of one’s thigh is sufficient. “Just by living in Charleston, we’re unlikely to have a deficit.” This UV-soaked lifestyle, however, puts us at risk for developing troublesome skin conditions, so many doctors advise supplementation over sunbathing.

What’s in Skin?
According to the American Academy of Dermatology, every inch of our skin contains roughly:

• 20 blood vessels
• 650 sweat glands
• 1,000+ nerve endings
• 60,000 pigment cells 

DERM DIAGNOSES

“Our skin is the barrier between inside and out, protecting us from external influences and infection,” says Dr. Rahbar. However, summertime’s abundance of heat, humidity, and UV exposure can take a toll on that barrier, leading to several common skin maladies.

Skin Cancer
Ultraviolet radiation from the sun or tanning beds damages skin cell DNA, and that can trigger rapid multiplication of abnormal cells, a condition we know as skin cancer. Every year, U.S. doctors diagnose more people with this disease than all other cancers combined, reports the American Cancer Society—that’s one in five Americans by the age of 70.

There are three main types of skin cancer: basal cell carcinomas, squamous cell carcinomas, and melanoma. Basal cell carcinomas emerge as small, oftentimes shiny bumps on the skin, frequently on the face, ears, neck, and shoulders. Squamous cell carcinomas usually appear as red, scaly patches on the rim of the ear, face, lips, or mouth. These two cancers are most common but less likely to spread and become life-threatening with early treatment. Doctors tailor treatment, which can take the form of surgery, topical creams, or chemo injections, according to the cancer’s level of aggression.

The deadliest form of skin cancer, melanoma, is also fairly treatable, with a 99 percent five-year survival rate if caught before it spreads to the lymph nodes. “The key is to catch it early,” says Dr. Rahbar, who explains that a change in the appearance of the skin is one of the biggest red flags. “When a mole that you’ve had for a long time suddenly gets larger, changes color, starts bleeding or tingling, or becomes more raised, that’s an indicator that it might be biologically active.”

She also points to the “ugly duckling”—a mole that differs from others on your body—as a warning sign. Half of malignant melanomas are self-detected, so the American Academy of Dermatology (AAD) emphasizes checking yourself regularly.

Though skin cancer can affect anyone, those with fair skin and who burn easily are most susceptible. In people of color, the disease frequently develops in places not commonly exposed to sunlight, such as the palms, soles, groin, inside of the mouth, and under one’s nails, reports the AAD. In these patients, diagnoses typically occur in the cancer’s later stages when treatment proves more difficult. No matter your skin tone, however, the best way to minimize risk is by limiting exposure to UV rays with protective clothing, sunscreen and shade.

Sunburn
Sunburn can happen in just 15 minutes. We’re all familiar with the painful redness that arises several hours to a day after unprotected exposure to ultraviolet rays. To treat, use soothing emollients and aloe to cool, apply cool (but not cold) compresses, drink extra fluids, gently exfoliate peeling skin, and take ibuprofen or acetaminophen for pain. Avoid further sun exposure by keeping irritated skin covered. The AAD warns against treating sunburns with bothersome “-caine” products such as benzocaine and lidocaine or heat-trapping petroleum. Sunburn usually resolves in two to five days, though dry, dead skin may peel for a week or more.

When sunburn is so severe that it leads to blisters or rash/hives, fever, swelling, dehydration, and nausea, the concern becomes sun poisoning, an allergic reaction to excessive UV rays. “Seek medical attention if you have blisters or a rash, experience flu-like symptoms, or if a burn isn’t healing,” advises Dr. Rahbar. 

Eczema
From a Greek word meaning “to boil over,” eczema is a generic term for inflamed skin, explains Dr. Rahbar. Affecting more than 30 million Americans of all ages and races, according to the National Eczema Association (NEA), this chronic condition can be genetically determined, called atopic dermatitis, or a reaction to external allergens, known as contact dermatitis. Eczematous skin is marked by round, itchy patches with scaling, flaking, and/or weeping (small blisters may even appear on the hands). Broken-down skin allows moisture to escape and environmental allergens to enter.

For many eczema sufferers, a seasonal shift from cool to hot triggers flare-ups, with higher temperatures and increased sweating exacerbating itchiness. Our humid climate also makes the condition difficult to control. Doctors often treat the symptoms using topical steroid creams along with generous use of unscented moisturizers, known as emollients, after showering with mild soap. The NEA also recommends increasing water intake, trying to avoid or minimize stress, wearing loose-fitting cotton clothing, promptly rinsing salt and chlorinated water off of skin, changing out of sweaty garments as soon as possible, and applying unscented moisturizer and hypoallergenic sunscreen. Oral antihistamines (Claritin, Allegra, and Zyrtec) may prove beneficial, as well. For chronic cases of eczema, your dermatologist may recommend additional treatment options, such as biologic immunomodulators, which work to regulate and change the behavior of the immune system. 

Rashes & Hives
Sweat glands produce salty perspiration that, when evaporated, helps lower the body’s internal temperature. But when clogged sweat ducts trap perspiration under the skin (which can happen due to extreme heat or humidity, thick creams, or heavy clothing), heat rash—also known as prickly heat—can occur, manifesting as anything from superficial blisters to deep, red lumps. Heat rash affects more than 200,000 people in the U.S. each year (infants included), with symptoms typically lasting a day or two. Overheating can also lead to itchy, tingly hives caused by nerves in the sweat glands. Mild cases of these red haloed bumps typically fade in less than an hour. A cool shower, light moisturizer, and a stint in the air conditioning go a long way to caring for both of these skin irritations. Hydrocortisone cream can also alleviate discomfort until the skin calms.

Contact with poison ivy, oak, and sumac can also cause an allergic reaction on the skin. This rash, which is usually accompanied by redness, itchiness, swelling, and blisters, typically appears within two to three days of contact with the oily resin that is found in the leaves, stems, and roots of the plants and can last for up to two weeks. These flare-ups often self resolve, but symptoms can be managed with calamine lotion, hydrocortisone, and antihistamines. To prevent brushes with these plant toxins, the American Academy of Allergy Asthma and Immunology reminds us: “Leaves of three, let it be.”

“With any rash or hives, seek treatment if you develop systemic symptoms such as fevers or chills, or if the rash is severe, blisters, covers a large area, or has affected a sensitive place like the face or genitals,” says Dr. Rahbar. “When in doubt, remember that it’s always safer to have a doctor check your rash versus waiting for it to progress.”

Acne & Rosacea
Spurred on by hormones, acne is inflammation caused by oil, debris, and bacteria trapped in the skin’s openings. “We see it so often, especially in teens and women in their 20s and 30s, 50s, and beyond,” says Dr. Rahbar. The condition affects up to 50 million Americans annually, reports the AAD, and research shows that it can be exacerbated by heat and humidity, which cause the skin to produce more pore-clogging oil, known as sebum. 

Unfortunately, summer tank tops expose the exact areas where breakouts most frequently occur besides the face—the chest, upper back, and shoulders. To help ward off summer acne flare-ups, opt for oil-free moisturizers and mineral-based sunscreens; shower soon after sweating; wear breathable, natural fibers; and avoid sitting in damp clothes for long periods.

Sometimes mistaken for acne, rosacea causes redness, visible blood vessels, and pus-filled red bumps on the face. Affecting some 16 million Americans, especially fair-skinned middle-aged women, this condition can be aggravated in summer, when blood flow to the surface of the skin increases. In National Rosacea Society surveys, 61 percent of sufferers fault sun exposure as a leading aggravator, and 53 percent reported more flare-ups when temperatures jump. Dr. Rahbar encourages acne and rosacea sufferers to seek dermatological help if their condition doesn’t resolve.

Catching Cancer
Roughly every hour, one American dies from melanoma, reports the American Academy of Dermatology. But when detected early, skin cancer is highly treatable, so the American Cancer Society recommends conducting at-home checks once a month. While in front of a mirror, look at all parts of the legs, arms, hands, and feet (including soles and between toes), then use a hand mirror to examine the back, neck, scalp, and buttocks. Keep in mind the ABCDEs of melanoma and contact a primary care doctor or dermatologist immediately if any moles or pigmented marks exhibit:

• Asymmetry, with one half unlike the other
• Borders that are irregular, scalloped, or poorly defined
• Colors that vary, with shades of tan, brown, black, and even white, red, or blue
• Diameter of greater than 6mm, or the width of a pencil eraser
• Evolution, meaning a change in size, shape, or color

Track your results with the AAD’s free downloadable body mole map: www.aad.org/public/spot-skin-cancer/free-resources.

TEND TO YOUR SKIN

Caring for your derm long-term doesn’t necessitate a complicated routine, just attention to a few daily basics: cleanse, moisturize, and protect. Product choice largely depends on your skin’s tendencies. “Different skin types require varying amounts of moisturizing and tolerate varying frequencies of exfoliation,” notes Dr. Rahbar, who dislikes microbead scrubs, which can irritate skin and pollute the environment. For all skin types, she advises daily washing with a gentle cleanser such as Cetaphil or CeraVe and application of a noncomedogenic (meaning it won’t clog pores) moisturizer immediately afterward. “Hyaluronic acid serum is a popular lightweight moisturizer right now,” she says, adding that deodorant soap and formulations containing alcohol, retinoids, and alpha hydroxy acid can be drying.

Sun damage is cumulative over our lifetimes, so protection is key, stresses Dr. Fahbar. “We get UV exposure just by driving or leaving the house. It all contributes to skin cancer, premature aging and wrinkles, and dyspigmentation.” Sunburn risk is certainly elevated on the sand and water, which reflect damaging sunrays, but beach visits aren’t the only outings that calls for sunscreen. The AAD recommends everyone use water-resistant, broad-spectrum sunscreen with a 30+ SPF every day they plan to be outside. Further fortify your skin’s defenses by seeking shade during peak daylight hours (between 10 a.m. and 3 p.m.) and donning clothing and hats with plenty of coverage.  

At least once a year, your primary care doctor or a dermatologist should evaluate your skin. Given the level of sun exposure we get here in the Lowcountry, Dr. Rahbar asks to see patients with a history of skin cancer or numerous moles at regular intervals that may be as short as three months. And the Skin Cancer Foundation stresses the importance of at-home self checks, suggesting you “check your birthday suit on your birthday” each year, if not more frequently (once a month is ideal).

Remember: We wear our largest organ on the outside and its job—protecting all other organs—is a crucial one. “Caring for your skin isn’t a superficial or vain pursuit,” says Dr. Rahbar. “It’s a vital part of overall wellness.”

Protect your Soles: Walking barefoot on the pool deck, through the backyard, and in other environments where fungi thrive can lead to itchy, scaly, cracking feet, aka athlete’s foot. To step up protection from this contagious infection, don’t skip the flip-flops.

Bee Smart: Take the sting out of insect encounters:

➊ Wash with soap and water

➋ Ice to reduce swelling

➌ Apply hydrocortisone cream/calamine lotion

➍ Take an oral antihistamine 

Wear Your Sun-Day Best: Just as sunscreen has an SPF, clothing has a UPF (ultraviolet protection factor) that quantifies how effectively the item shields against the sun. Garments made of tightly woven fabrics dyed in vivid colors provide the highest UPF levels. Here are five tips from the Skin Cancer Foundation for dressing to be outdoors:

➊ Look for garments with a UPF label of at least 30.

➋ Choose clothes that cover as much skin as possible but still suit your purpose (i.e., long-sleeve sun shirts for the beach).

➌ Select wide-brimmed hats (at least three inches in diameter) that shade your face, neck, and ears.

➍ Wear UV-filtering sunglasses to protect your eyes.

➎ Wash new cotton garments two or three times to shrink the space between fibers and permanently raise their UPF rating.

Facing the Future: What causes skin to age? “Time, genetics, and sun exposure,” explains Dr. Rahbar. Gravity certainly furthers wrinkles and sagging, but UVA rays, which penetrate deeply, are the primary culprit in the loss of skin elasticity and appearance of dark spots. Smoking and diets high in fats and carbohydrates can also advance skin’s aging process. In addition to daily use of a broad-spectrum sunscreen tailored to skin type (sensitive, dry, oily), Dr. Rahbar recommends topical retinoids to help prevent or minimize fine lines and pigmentation changes. Retinoids prompt cell turnover and clear out clogged pores, which can help with acne, as well. Your skin evolves over time, so your skin care routine should as well. Look for products containing these active ingredients:

✓ 20s: benzoyl peroxide/clindamycin (for acne), niacinamide (vitamin B3), salicylic acid 

✓ 30s & 40s: ceramide, glycolic acid, hyaluronic acid, L-ascorbic acid (vitamin C), peptides, retinoid/retinol

✓ 50s & 60s: alpha hydroxy acid, antioxidants (vitamins C and E), hydroquinone, kojic acid, peptides, retinoid/retinol

✓ 70s & beyond: antioxidants (vitamins C and E), coenzyme Q10, humectant

Sunscreen 101:
WHO needs sunscreen? Everyone! Though it’s best to keep babies under 6 months old out of direct sunlight using shade and protective clothing, the American Academy of Pediatrics recommends using sunscreen with an SPF of at least 30 on exposed areas such as the face and hands. 

WHAT kind? In all cases, choose a broad-spectrum sunscreen—products that combine several ingredients to prevent ultraviolet A and B rays from reaching the skin. For extended outdoor use, a stronger, water-resistant sunscreen will adhere better; for everyday use, an SPF-rated moisturizer may be more suitable. Chemical sunscreens have mimicked hormones in lab studies, may cause skin allergies, and could contain the environmental contaminants oxybenzone and octinoxate, so Dr. Rahbar recommends mineral (zinc- or titanium-based) sunscreens. Also take note of a sunscreen’s expiration date as it loses effectiveness once expired. 

WHEN do we need it? Apply sunscreen 30 minutes prior to sun exposure to allow the product to bind to the skin. Sunscreens are ranked with a Sun Protection Factor, or SPF, that measures their ability to prevent UVB damage to the skin. (If unprotected skin reddens in 20 minutes, SPF 15 sunscreen theoretically stops burning 15 times longer, so roughly five hours.) Regardless of strength, however, the Skin Cancer Foundation advises slathering on more sunscreen every two hours, especially if you’ve been swimming, sweating, or toweling off.  

WHERE should it be used? Apply it to any part of the body that isn’t covered by protective clothing. Don’t forget the edges of ears, tops of feet, backs of hands, any exposed scalp (think hair part), and decollage. The Skin Cancer Foundation recommends applying one ounce—roughly a shot glass worth—of sunscreen to the body and a half teaspoon (a dollop about the size of a lima bean) to the face and neck alone. 

WHY wear sunscreen daily? Our skin absorbs plenty of ultraviolet radiation as we go about our everyday activities, though this incidental exposure may not cause us to burn. Even without reddened skin, which is a reaction to UVB rays, plenty of damage can be done by UVA rays—even on cloudy days. According to the American Academy of Dermatology, just one blistering sunburn during childhood or adolescence can almost double a person’s chance of developing melanoma.

Manami Takebata, a 29-year-old West Ashley resident, has suffered from eczema her whole life. “It always appears suddenly—my skin will get itchy for no reason,” says Takebata, noting that it often flares up when she’s stressed, tired, or traveling, and when the weather changes suddenly or pollen count rises. “When my condition is bad, I don’t want to go anywhere or meet anyone,” she says. “I lose my confidence.” Since first visiting Dr. Fiona Rahbar in 2017, Takebata has been using a topical corticosteroid cream and Cetaphil moisturizer. Upon Dr. Rahbar’s advice, she recently began receiving Dupixent, which is a relatively new biologic immunomodulatory medication, as well. Though her eczema is ongoing, Takebata says she is optimistic this additional treatment will help.  

In April 2019, 55-year-old Johns Island resident Jacquelyne Fipps noticed a black dot on her hairline that scabbed over. She booked an appointment with Dr. Rahbar, who diagnosed the spot as basal cell carcinoma. Within days of the diagnosis, Dr. Rahbar removed the skin cancer during an outpatient procedure, and Fipps is now cancer free. “I always have a hat on if I’m in the sun and wear sunscreen with SPF 50 on my face every day,” says Fipps.