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Healthy, Skin-Deep

Skin consultation: prevention is better than cure. How can I examine myself?

  • What skin type am I?
  • Do I have dry or oily skin – and where can I tell?
  • How sun-sensitive am I, and which sunscreen protects me sufficiently?
  • Which skin care suits me – and do I have to buy expensive products?
  • I have many moles – can I do something about them?

To these many questions there are also many answers.

Dry or Oily Skin?

Healthy, balanced skin produces its own moisturizing cream all by itself – additional creams from outside are not part of nature’s plan. Two of the skin’s own sources supply it with lipids: the sebaceous glands and the epidermis.

The sebaceous glands sit in the dermis, the second layer of skin, and empty into the channels that hold hairs. The sebum is guided outward along the hair shaft and settles protectively over the epidermis. Sebaceous glands are especially numerous on the scalp and in the T-zone: forehead, nose, chin, ears, upper back, chest, and nipples. On the arms and legs they are much smaller and more sparsely distributed – which is why you can have an oily face or scalp and dry arms and legs at the same time. Over the course of life, sebum production declines, since the sebaceous glands are stimulated by male hormones, which are present in women as well.

The epidermis consists of many layers of keratinocytes (keratin-forming cells), which need about four weeks to migrate from the lowest layer to the outer horny layer. Along the way, they form tiny granules of lipids and protein that create a kind of mortar between the horny cells. The horny layer, made of dead horny cells embedded in this mortar, provides robust protection: it keeps out chemicals, pathogens, and allergens and prevents the body from losing too much water. These epidermal lipids are the foundation of our skin’s protective barrier. If it is destroyed by excessive washing, soaps, chemicals, and disinfectants, dryness eczema develops, with fine skin cracks, itching, flaking, and redness – and the tendency to allergies rises massively.

The point, then, is to find the balance between naturally balanced skin and modern notions of personal hygiene. Healthy skin has a silky sheen, no redness, no flakes, and does not itch.

People with dry skin often have a dry scalp too, which barely re-oils – washing the hair once or twice a week is enough. Acne rarely develops, since the sebaceous glands are small. Outwardly, you can recognize dry facial skin by the absence of an oily sheen and by delicate-looking pores. Frequent washing and lots of care products can bring a hidden dryness to the surface: feelings of tightness, redness, itching, and flaking appear. Dry skin looks dull and depleted.

If dry skin occurs as part of an atopic disposition, characteristic features appear. Atopic individuals have a genetic predisposition to dry skin, allergies such as hay fever, allergic asthma, and food allergies, and eczema (atopic dermatitis) – corresponding histories are often found in the family as well. Typical are shadowed eyes with a darker ring, eyebrows thinned at the outer edges, and a double crease of the lower eyelid. Interestingly, atopic individuals often have a reduced gag reflex and tolerate a throat examination without batting an eye.

The tendency to eczema shows itself in fine white flakes, redness, small bumps, blisters, or thickened, itching skin in the crooks of the arms, on the wrists, and in the hollows of the knees; occasionally the earlobes or corners of the mouth are cracked.

In infants, milk crust is well known – an intensely itching scalp eczema that looks like dried milk. It should not be confused with the greasy, yellowish flakes (cradle cap) of many babies: cradle cap does not itch. These flakes develop because babies temporarily produce more sebum – triggered by male hormones. A benign yeast multiplies, metabolizes the sebum, and releases skin-irritating fatty acids. Cradle cap flakes are greasy, yellow, and large; if you rub them between your fingers, you can detect the greasy sheen – that is how you distinguish them from the milk crust of atopic dermatitis.

In toddlers, the eczema usually sits on the extensor sides of the arms and legs, and the skin feels rough. Whitish, cloud-like patches often appear on the cheeks and do not tan in the sun. Also typical are visible skin fold lines: with persistent eczema, the skin thickens due to inflammatory cells and the otherwise barely visible lines emerge.

Atopic individuals are also prone to skin infections such as herpes, molluscum contagiosum, and warts. Their skin carries increased numbers of staphylococci, which can repeatedly stimulate eczema. Creams with microsilver can push back these germs, regenerate the skin barrier, and reduce new flare-ups.

Easy to test yourself is white dermographism: if you scratch across the skin of an atopic person, the scratch marks appear as white, poorly perfused lines – the vessels contract, and the skin’s defenses drop briefly. In non-atopic individuals, red dermographism predominates: red scratch marks, because the vessels dilate and the defenses are briefly enhanced.

Case Study

Case study, male patient, 40 years old.

Patient: I’ve come because I suffer from dry skin on my face. I put Nivea® hand cream on every day, because otherwise I get lots of flakes on my nose and eyebrows.

Physician: Do you have this all year round?

Patient: It’s worst in winter. It itches and looks unpleasant.

Physician: How long does it take for your hair to get oily?

Patient: I wash my hair daily, otherwise it gets greasy and stringy.

Physician: Your skin is not too dry – you only think so because flakes are usually associated with dryness. You suffer from seborrheic eczema, the opposite of dry skin. With the rich hand cream you soften the visible flakes, but the redness and itching underneath remain – and you increase the amount of grease on the skin. Your testosterone stimulates the sebaceous glands; in the hair canals lives the harmless yeast Malassezia furfur, which multiplies when more sebum is on offer and breaks the sebum down into free fatty acids. These irritate your skin, and it develops an eczema – not a dry one, but an oily one. In winter the sun is missing, whose UV rays suppress inflammation in the skin; that is why your predisposition is surfacing now.

Patient: So if I apply even more grease, I overload my skin with fat?

Physician: Exactly. We will now treat the massively multiplied yeasts and the inflammation. You leave off your face cream, and within a few weeks your skin will improve.

Sun Type According to Fitzpatrick

To assess your own skin, you should know how sun-sensitive you are: What sun protection do you need, how do you effectively practice skin cancer prevention, how do you protect yourself from premature wrinkles? There are six major skin types (loosely based on Fitzpatrick).

Sun-Sensitive Skin Types

Northern and Central Europeans, with skin types 1–3, belong to the sun-sensitive skin types.

Skin type 1, woman: I am strawberry blonde, with light blue eyes, white skin, and many freckles. I can barely stand 5–10 minutes in the sun and immediately get a bad sunburn – I never tan. I only use self-tanner anymore. My dermatologist calls this the Celtic skin type: my ancestors came from Northern Europe, where there was little sunshine; my skin lets a lot of UV light through so that I can produce enough vitamin D. It contains mainly the reddish pheomelanin, which protects poorly against UV radiation.

Skin type 2, man: I am dark blond with green-brown eyes. After about 15 minutes of sun, my shoulders and nose sometimes burn if I forget the sunscreen. After that I tan slightly – never as dark as I would like, but I never stay pasty white either.

Skin type 3, woman: I have brown hair, brown eyes, fair skin, but I tan well. I rarely get a sunburn – without sunscreen I can easily be outside for 20 minutes before any redness develops.

Less Sun-Sensitive Skin Types

The more robust skin types 4–6 tend to originate from southern countries and regions near the equator.

Skin type 4, man: My skin has an olive tone, I have dark brown hair, and I tan really deeply. I only use sunscreen when surfing or skiing, when snow or water strongly reflect the sun. In blazing sun I can last 40 minutes without protection. My ancestors come from the Mediterranean; in my skin the brown eumelanin predominates, which protects well against UV radiation. In sun-poor latitudes I have to take vitamin D tablets, since my level drops in winter.

Skin type 5, woman: I have black hair and brown skin even in winter. I only get a sunburn on a sunny glacier. My ancestors come from Latin America; North Africans and Indians are similarly insensitive.

Skin type 6, man: I have black hair and dark brown skin and am very insensitive to the sun. My ancestors come from Africa. If I live permanently in UV-poor Northern Europe, I have to watch my vitamin D level, because less UV light penetrates my dark skin.

This classification is rough. Many Asians, for example, appear fair but, with their black hair, correspond to the sun-insensitive skin type 5. The Asian skin type ages the least – thanks to plenty of protective eumelanin, very effective repair mechanisms for sun damage, and possibly the antioxidants of green tea, which neutralize free radicals from UV light, stress, smoking, and aging.

People with skin types 1–3 should apply sunscreen daily – even in winter, a proven means of preventing wrinkles. What matters is the “UVA protection” label: if the UVA symbol is printed inside a circle, good concentrations matched to the UVB protection factor are guaranteed. A sun protection factor (SPF) alone is not enough, since it protects only against UVB, not against UVA radiation – but both are very important.

Mole Check

It is useful to have your moles examined regularly by a dermatologist. Self-examination, or a partner’s glance, can also save lives.

Man: Could you scratch my back?
Woman: Sure. Oh, what is that? This spot in the middle of your back is very dark and sticks out – I never noticed it before.
Man: Yesterday I noticed blood on the towel when drying off. I think I urgently need to see a dermatologist.
Dermatologist: Don’t worry – this is neither a mole nor skin cancer, but a seborrheic keratosis, sometimes called an age wart. It can look dramatic – brown-black-gray – and sometimes it tears off and bleeds. Still, it is good that you showed it to me, because a spot this dark can also conceal a melanoma. We can remove this seborrheic keratosis superficially – or leave it, because it never becomes malignant. But please come in once a year for skin cancer screening: you have several mottled moles that need to be monitored, and one very dark mole with an irregular pattern that should be removed as a precaution.

The ABCDE Rule

  • A: Asymmetry: not symmetrical, for example not round or oval,
  • B: Border: irregular or blurred,
  • C: Color: varying degrees of pigmentation, multiple colors,
  • D: Diameter: larger than 5 mm,
  • E: Evolution/Elevation: new and rapidly developed on previously flat ground.

The ABCDE rules are easy to apply to each individual pigmented spot. If several criteria apply, it may be an atypical, high-risk mole – in the worst case, melanoma – and a visit to the dermatologist is then essential. The earlier a melanoma is diagnosed, the more curable it is: the prognosis of a malignant melanoma less than 1 mm thick is very good, while thicker melanomas carry a high risk of metastasis.

A conspicuous, atypical mole should be removed or checked regularly. With the dermatoscope, the dermatologist analyzes the fine structure at tenfold magnification. Removal takes place under local anesthesia: the mole is excised, the small wound is closed with a few stitches, and the sutures are removed after two weeks at the latest. The tissue goes to the pathologist, who confirms the diagnosis under the microscope – a confirmed atypical mole is then called a dysplastic nevus.

Since 2008, statutory health insurers in Germany have covered skin cancer screening every two years for those insured from age 35; some insurers offer it from age 20. As a result, more skin cancer cases are diagnosed – yet mortality from melanoma has declined significantly, because it can be cured by surgical removal when detected early.