In tropical climes there are certain times of day
When all the citizens retire
To tear their clothes off and perspire,
It's one of those rules that the greatest fools obey,
Because the sun is much too sultry
And one must avoid its ultry-violet ray,
Mad dogs and Englishmen
Go out in the midday sun
The Japanese don't care to
The Chinese wouldn't dare to,
Hindoos and Argentines sleep firmly from twelve to one.
But Englishmen detest a - Siesta.
Noel Coward, Mad dogs and Englishmen, 1930 |
In Victorian times, women quite sensibly shunned the sun and
valued porcelain-white skin. Noel Coward alluding to the harmful
effects of sunlight remarked that "Mad dogs and Englishmen
go out into the mid-day sun". So common sense seemed to
have prevailed during earlier times. Nowadays, however, people
talk of the "great tan" or a "healthy tan".
Well, the truth is there is nothing great about a tan which medically,
represents sun-damage and accelerates skin ageing and increases
the risk of skin cancers developing. Sun-damage takes place slowly
and insidiously and the signs do often do not appear until 10
- 20 years later, lulling people into complacency. The depletion
of the ozone layer has increased the amount of sunlight reaching
the earth's surface and this is thought to be partly responsible
for the increase in the incidence of skin cancers. I always tell
patients that if they want to see the effects of the sun on the
skin just look at the difference between the skin on the inside
of the upper arm (the buttocks would be a better place but its
not so convenient!) and the exposed skin on the outer part of
the forearm. I then tell them this is only the cosmetic consequence
but there is also the medical consequence which is the development
of skin cancers. My patients seem to take better notice then.
SOLAR RADIATION
The figure below shows the different types of radiation (ultraviolet
rays) emitted by the sun. Only the portion known as the terrestrial
solar spectrum reaches the earth's surface. The earth's ozone
layer absorbs ultraviolet (UV) rays below 330nm and almost all
rays below 295nm. In other words, visible light (the colours
of the rainbow with a wavelength of 400 - 700nm), some
UV-A (320 - 400nm), UV-B (290 - 320nm) and no UV-C (200 - 290nm)
reaches the earths surface. More UV-B and UV-A rays are
reaching the earth now because of the depletion of the ozone
layer and this is one of the possible reasons for the increase
in the number of cases of skin cancers. Depletion of the ozone
layer has resulted in a large hole over the Antarctic and this
is believed to have been caused primarily by the use of chlorofluorocarbons
(CFCs), hence the move to ban their use.
|
200nm |
290nm |
320nm |
400nm |
700nm |
|
Gamma rays |
X-Rays |
Ultraviolet
(UV) |
Visible
Light |
Infra
Red |
C |
B |
A |
|
|
|
Sunburn, Skin cancer,
Ageing |
Tanning, Skin cancer,
Ageing |
|
|
UV-B are short wavelength rays that penetrate the top layer
of the skin and cause sunburn. In the past, it was thought that
one could protect the skin against sun-damage by merely screening
out UV-B. This was a mistaken view. UV-A takes longer to produce
a burn but penetrates more deeply into the dermis and is now
thought to be mainly responsible for the damage to collagen and
elastin fibres that keep the skin firm and elastic. UV-B is thought
to be responsible for causing sunburn, basal cell and squamous
cell cancers. UV-A causes tanning and acts with UV-B to promote
the development of skin cancers, including malignant melanoma.
Being of a longer wavelength, UV-A can also penetrate the ozone
layer better than UVB and can penetrate glass which UV-B cannot.
The amount of UV-B varies, being maximum from 10am - 2pm (11
- 3pm during daylight saving hours) whereas the amount of UV-A
is virtually constant. This means that we are actually exposed
to more UV-A than UV-B on a day to day basis, inside buildings
and in the car. So always protect the exposed skin with sunscreens
effective against UV-A as well as UV-B.
Another surprising observation is that even incidental exposure
to the sun is harmful. Dr Nicholas Lowe and his colleagues in
the US irradiated the backs of volunteers with UV rays of a dose
that was equivalent to what most of us get by walking to and
from the car and driving a car. After 3 months, they found changes
in the melanocytes, the blood vessels in the skin and also the
elastin fibres that indicate sun-damage.
SKIN PHOTOTYPES
The degree of protection our skin has against the sun is directly
related to the amount of melanin pigment in the skin.
Fitzpatrick
skin phototypes (modified)
Skin type |
Reaction to sun-exposure |
Examples |
Type 1 |
Always burns, never tans |
Light-eyed, fair-skinned Northern Europeans |
Type 2 |
Always burns, sometimes tans |
Fair-skinned Europeans. |
Type 3 |
Sometimes burns, always tans |
Mediterranean origin eg. Spaniards, Italians
and Greeks |
Type 4 |
Never burns, always tans |
Hispanics and Asians. |
Type 5 |
Dark pigmented Asian skin. |
Hispanics and Asians. |
Type 6 |
Black skin. |
Darkly pigmented Africans and Southern Indians. |
The Fitzpatrick skin phototype classification is also useful
for determining suitability for resurfacing treatments such as
chemical peels, dermabrasion and laser resurfacing. Phototypes
I - II are good for all these treatments but darker skin types,
especially phototypes III and IV are more prone to develop temporary
post-inflammatory hyperpigmentation (increased pigmentation compared
to the surrounding skin. Forget about using the skin phototype
as a guide to determine the SPF of a sunscreen to use so as to
get a tan because tanned skin is simply sun-damaged skin. There
is no such thing as a healthy tan!
SIGNS OF SUN-DAMAGE
Sun-damage occurs insidiously over the years until all of
a sudden, you may realise that you have suddenly aged. Because
of the long incubation period, people participating in outdoor
sports without adequate sun-protection and sun-tanning in order
to get the healthy tan wont realise the damage
until 10 - 20 years later. You may remember the weather-beaten
face of the man in the old Marlborough advertisement. He may
appear rugged to some but medically, he has severe photoageing,
looks much older than he is and is at increased risk of developing
skin cancer. If you want to see how much of the changes are due
to photoageing just look your buttocks (in the privacy of your
home) which is shaded from the sun and hence, represents chronological
ageing and compare it with the backs of your forearm or the tops
of your hands which are exposed to the sun. Just imagine, if
you had taken precautions against the sun, your skin would look
more like your buttock skin. See how much better it is!
Effects
of sun-exposure
Acute effects |
Sunburn |
Pink, bright red, swollen and blistered skin (see Sunburn) |
|
Immediate tanning |
Skin darkens after 1 - 2 hours and explains why the person appears
darker immediately. This tan however fades after 24 hours. It
is brought about by the rearrangement of preformed melanin. |
|
Delayed tanning |
Tan appears after 48 - 72 hours and last up to 2 weeks. It is
caused by the formation of new melanin. |
Chronic effects |
Cosmetic problems |
Fine and deep wrinkles
Age spots (solar lentigines)
Idiopathic guttate hypomelanosis
Solar elastosis
Comedones (Favre-Racouchot Syndrome)
Telangiectasia (broken blood vessels)
Poikiloderma of Civatte
Purpura
Venous lakes |
|
Medical Problems |
Skin cancers
Precancers |
Key point
Dermatologists believe that we sustain most of the damage
before the age of 20 years and only develop the side effects
of sun-damage in middle-age because of the long incubation period.
The message is clear - take precautions early, preferable during
childhood. |
Just how bad is my skin in terms of photoageing,
you might ask. Doctors use a 4 grade classification and it simple
enough for you to use. The grading system is a good guide for
gauging the response to treatment, as well. As a general guide,
cosmetic procedures for ageing skin will improve matters by only
a grade, i.e., from Type III photoageing to Type II, so dont
expect miracles. It also means that, if you seek treatment early,
when photoageing is just grade I or II, you are more likely to
look better.
Classification of photoageing
Grade of photoageing |
Signs |
Patient characteristics |
Type I "no wrinkles"
Early photoageing |
Mild pigmentary changes
No solar keratoses (precancers)
Minimal wrinkles |
Patient age: twenties and thirties
Minimal or no makeup |
Type II "wrinkles in motion"
Early to moderate photoageing |
Early solar lentigines visible
Solar keratoses can be felt but are not very visible
Parallel smile lines beginning to appear |
Patient age: late thirties or forties
Usually wears some foundation |
Type III "wrinkles at rest"
Advanced photoageing |
Obvious dyschromias (uneven pigmentation), telangiectasias
Visible solar keratoses
Wrinkles even at rest |
Patient age: fifties or older
Always wears heavy foundation |
Type IV "only wrinkles"
Severe photoageing |
Yellow-grey colour of the skin
Prior skin malignancies
Wrinkled throughout, no normal skin |
Patient age: sixties or seventies
Can't wear makeup "cakes & cracks" |
(Modified from Glogan R G: Chemical Peel Symposium. Amer Acad
Dermatol Atlanta, Dec 4, 1990):
Asians and other races with skin phototypes IV and above have
more melanin pigment shield the dermis (deeper skin) and protect
them from wrinkles. However, their melanocytes bear the brunt
of the damage from UV rays leading to melasma, age spots (solar
lentigines) and idiopathic guttate hypomelanosis (reverse of
age spots) and unevenness of pigment tone. Wrinkles seem to occur
at a later age than their caucasian counterparts. |