We're back with another skincare Q+A with dermatology resident, Rachel Maiman, MD.
Q: What happens to skin in your 20s, 30s, 40s?
Skin is prime in your 20s. It is loaded with collagen and elastin. Collagen, the main component of the dermis (the “meat” of your skin) is why young skin appears plump. Elastin, as its name suggests, gives skin elasticity, meaning the ability to return to its normal shape once stretched. Along with collagen, this explains why, for most, wrinkles do not set in until one’s late 20s or 30s - you can smile, laugh and frown all you want without any permanent creases! Your skin is also full of hyaluronic acid, a gooey substance that surrounds collagen and binds water molecules. For this reason, skin in the 20s is, on the whole, less dry. It is more resilient and thus capable of tolerating a broad array of products with more ease, and is not subject to the sallow, dull appearance that often plagues older skin.
Unfortunately, however, the processes that result in loss of collagen, elastin and hyaluronic acid all begin in our 20s,
also. Owing to normal physiologic processes out of our control, all three of these critical components are produced at a slower rate and degraded more quickly over time. In fact, starting at age 20, your skin produces 1% less collagen per year (yikes)! However, the free radical damage induced by UV radiation has the same effect, and in and of itself degrades all three of these structural proteins. This means it is critical to be diligent about sun protection and not wait until you already see changes beginning to set in.
The other struggle for some in their 20s is a recurrence or persistence of acne. While many rejoice that their acne finally clears after the teenage years, this is not universally the case. In fact, we are seeing more and more women, in particular, who are bothered by acne that persists well through their 20s and beyond or which erupts new despite never having had acne in the past. Owing to the hormonal changes during this period, women with adult acne tend to notice pre-menstrual flares in the week before their period and a predilection for breakouts on the chin, jawline and cheeks.
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Your 30s are when age-related changes in the skin start to become noticeable and truly accelerate. It is at this time that the rate of cellular turnover slows, taking up to 60 days to completely renew the top layer of cells compared to 40 days, on average, for someone in their 20s. Because dead cells sit on the surface, they interfere with the way light is reflected off the skin and cause it to lose its natural glow. Instead, the skin is dull and can even appear sallow. This is also because skin at this age begins to lose ceramides, critical lipids (fats) that comprise the skin’s barrier. Ceramides are like mortar between bricks (where the bricks are your skin cells). They prevent moisture from seeping out and pollution, as well as other environmental stressors, from entering. Without them, skin is dry, rough, and easily irritated. Owing to ongoing and now more rapid loss of collagen, elastin and hyaluronic acid, skin loses its turgor, resulting in fine wrinkles. Gravity, paired with loss of elasticity, may produce subtle sagging, which can manifest as under-eye bags and/or more prominent laugh lines (called the nasolabial folds). Skin appears less plump and the face begins to lose some of its prominent architecture. This is in part due to slow declines in estrogen, which result in a loss of overall volume and bone mass in the skull, cheekbones and jawline. As if that isn’t enough, the hormonal acne some begin to experience in their 20s really tends to kick into full gear during this decade. And with decades of sun exposure under your belt, mottled discoloration and dark spots begin to appear. Even those spots not induced by the sun, but rather by things like acne (remember post-inflammatory hyperpigmentation?) take longer to fade, thanks again to slower cellular turnover.
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Signs of skin aging that first begin to show in one’s 30s - fine lines, increased pigmentation, poor texture, moisture
loss, and deeper expression lines all become more pronounced in one’s 40s. In addition, lymphatic drainage begins to slow at this age, resulting in puffiness around the eyes and in the cheeks. As is the trajectory, the results of cumulative sun exposure are even more prominent in this decade. In addition to more numerous and more pronounced dark spots and discoloration, if sun damage is significant enough, the skin attempts to protect itself by thickening the top layer (called the epidermis), which can result in a leathery appearance. Not cute!
Q: Ok - let's talk about hormonal acne. What's the best way to manage it?
First, it’s important to understand what causes hormonal acne. As was alluded to briefly earlier, hormonal acne is typically related to fluctuations in estrogen and progesterone that come with a woman’s menstrual cycle. The ratio of these two hormones impacts testosterone levels, which are known to have a direct stimulatory effect on oil production. Specifically, the higher the progesterone level, the greater the testosterone level. It is for this reason that this type of acne tends to flare the week before one’s period, the time in the menstrual cycle when progesterone levels are at their peak.
Aside from recognizing pre-menstrual flares, another way to identify if this is the type of acne you are struggling with is to pay attention to where your breakouts occur. If your breakouts tend to be around the mouth, chin, jawline and lower cheeks, particularly if they are more deep-seated, tender and stubborn to resolve, you’re probably dealing with hormonal acne.
Before jumping into some treatment strategies, it is important to recognize that some women with hormonal acne have an underlying hormonal imbalance, such as occurs with Polycystic Ovarian Syndrome (PCOS). If, in addition to hormonal breakouts, you also experience unwanted facial hair, irregular periods, unintentional weight gain, hair loss and/or have been told you are pre-diabetic or diabetic, you should speak with your primary care doctor or OB/GYN.
Because blood sugar spikes are known to cause inflammation and hormonal fluctuations, some patients notice improvement in hormonal acne with diet modification, specifically cutting down on simple sugars as can be found in white rice, white potatoes, candy, cake, soda, juice and processed foods. In addition, because skim milk in particular, as well as low fat milk, have a higher sugar content than whole milk, studies have shown a direct correlation between consumption of skim and low-fat milk and acne. Some dermatologists feel strongly that cutting dairy as a whole is beneficial, but I find omitting entire food groups to be a challenge most find difficult to adhere to (which is TOTALLY understandable).
From a product perspective, hormonal acne is known to be relatively refractory to a lot of the ingredients used to treat comedonal and inflammatory acne. This is not to say that staples of an acne regimen such as a topical retinoid and benzoyl peroxide are not helpful, but the truth is that oral medications are most often required. Something to consider if you are not already on one is a combination oral contraceptive. Unlike contraceptives that are progestin-only and send acne into overdrive, such as the “mini pill” and IUDs such as Mirena, Skyla and Kyleena, a combination OCP containing both estrogen and progestin can help balance out the ratio that, when skewed, drives hormonal acne. If your acne persists despite a combination OCP, then it’s time to see your dermatologist, who can talk to you about spironolactone, an FDA off-label medication for hormonal acne which works wonders.
Whew! That's a lot to digest. Stay tuned for more next week. We ask Rachel whether acids are for everyone, how long to use a product before you expect to see results, and how often we should (or shouldn't) be switching up our routines.