Aged and damaged skin exhibits certain classic issues (areas where the skin starts behaving differently from the skin around it), and this week I wanted to talk about the most common ones. I’m sure some of you are thinking “enough with the basics, let’s get on to the solutions already.” But I thought it was worth discussing these, because some treatments promise to address them, and I wanted to nail down the terminology first.
Classic skin “irregularities” basically fall into two groups:
1) Pigmented (anything that shows up as a different color than surrounding skin)
2) Topographic (a 3-D change to the skin. Anything that is visible because of the way it reflects light or casts a shadow.)
a) Telangiectasias: These are commonly called “spider veins” or “broken capillaries.” They’re actually abnormal blood vessels — tangled and floppy, like a bundle of old socks. These usually form in response to long term exposure to UV light (because UV light tends to accelerate the formation of blood vessels, which leads to uncontrolled growth). They’re red because of the oxygenated blood flowing through them.
b) Varicose veins: These are not abnormally formed vessels; they’re dilated veins. They’re usually found in the legs (because, over time, pressure stretches the vessels). They’re deeper than skin-level, but they do cause bumpiness in the skin. They’re bluish because they’re returning deoxygenated blood to the heart.
c) Freckles: Also called ephiledes. These are small islands of skin containing a larger-than-usual number of melanin-producing cells — each “island” only a few millimeters in size (a tenth of a centimeter). The cells are present from birth, BUT the spot (the darker color) doesn’t show up without sun exposure. Freckles fade away in the absence of sun exposure, so they lighten in winter and darken in the summer. They usually appear on the face, arms, and shoulders.
d) Solar lentigo: Also called age spots or liver spots. These are larger (half a centimeter and larger) islands of skin containing fewer than normal melanin cells (surprising, right?). But the cells aren’t normal, so actually they make the skin darker. Once they’ve formed, solar lentigines don’t go away, even if you stay out of the sun. These also appear on sun-exposed areas of skin.
At a minimum, you’ve probably seen phenomena A – D.
e) Lentigo maligna: This is a collection of out-of-control melanin cells — again, darker than surrounding skin.
Melanoma (the skin cancer that everyone is most concerned about) is also the result of out-of-control melanin cells, but lentigo maligna is not necessarily cancer. In lentigo maligna, these cells are corralled into a small island, and tend not to spread. A lentigo maligna can become a melanoma, however.
Lentigo maligna, melanoma, and solar lentigo can be difficult to distinguish from one another, so it’s best to see a dermatologist to verify whether a lesion is dangerous or not. I’m not trying to freak you out; I just think knowledge is power.
f) Actinic keratosis: This is an area of epidermis that has become abnormal, and is usually rough, scaly, and reddish. It is closely associated with exposure to UV light. It is also a “pre-cancerous” lesion — there is a chance that it will become a non-melanoma skin cancer. About 1 in 50 of these will become a cancer after four years. Actinic keratosis is very common, and very easy to treat.
a) Wrinkles: Also called “rhytids.” Wrinkles are formed by a fairly complex series of changes in all layers of the skin (we alluded to this last week). When you compare a wrinkle to the normal skin just next to it: (1) The epidermis is thinner, except for sun-exposed epidermis, which is actually thicker. (2) The border between the epidermis and dermis is flattened. (3) The dermis is thinner and weaker. The abnormal increase in dermis proteins found in sun-exposed skin is actually reduced under a wrinkle. (4) Finally, the hypodermis is thinner as well. All of these changes combine to make a depression in the skin, forming a wrinkle.
b) Cellulite: This is the dimpled, lumpy-bumpy skin on the buttocks and thighs, which occurs almost exclusively in women (so unfair). It is caused by an abnormal arrangement of the fat cells in these areas.
There’s no definitive answer yet on what causes cellulite, but there are several theories. One possibility is that the blood supply to the fat cells is compromised in some way, and this causes the tissues around them to become hardened and scarred.
Another possibility is that the dermis is weakened and stretched out with age, but the strong fibrous bands that divide the fat cells into groups (like a quilt or a mattress) remain strong. So as more fat is deposited, it pooches out into the dermis, causing dimpling.
Two things are for sure: cellulite is definitely caused by fat deposition (and will decrease if you lose weight), and it is definitely associated with the presence of estrogen and the lack of androgens (male hormones).
Okay, next week we’ll start on how to treat the signs of aging: lasers, peels, creams, and all the other techniques and products out there.
1) Br J Dermatol. 1990 Apr;122 Suppl 35. Pigmentary changes of the ageing skin. Ortonne JP
2) J Invest Dermatol. 1998 Nov;111(5). Molecular regulation of UVB-induced cutaneous angiogenesis. Bielenberg DR, Bucana CD, Sanchez R, Donawho CK, Kripke ML, Fidler IJ.
3) Am Fam Physician. 2009;79(2). Common Pigmentation Disorders. Plensdorf, S, Martinez, J
4) Br J Dermatol. 1999;140(6). A histological study of human wrinkle structures: comparison between sun-exposed areas of the face, with or without wrinkles, and sun-protected areas. Contet-Audonneau JL, Jeanmaire C, Pauly G.
5) J Am Acad Dermatol. 2006 Jul;55(1). Photoaging: mechanisms and repair. Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN.