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Women & skin health.

Marsha Shapiro grew up next to the resort city of Virginia Beach, VA, so as a teenager she spent hours baking herself on the hot sand, her body slathered in baby oil, covered with just the tiniest of bikinis. But today Ms. Shapiro, 37, who lives in Atlanta, GA, gets an unpleasant reminder of those days whenever she peers in the mirror.

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"Lines and wrinkles around my eyes," she says. "Brown spots and freckles all over my body." Does she regret those summer days of yore? "Absolutely," she says. "I think my skin is much worse off because of that."

She's not alone. Because so much of what we know about the damaging effects of sun on our skin has only come about in the past 20 years or so, millions of women who spent their youths in search of the perfect tan are finding that their earlier vanity has left them with less-than-perfect skin and, in far too many instances, cancer.

"Women always ask me how they can get a healthy tan," says Maryland dermatologist Elizabeth A. Liotta, MD. "I tell them there is no such thing. A tan is your body's reaction to being damaged." And, contrary to popular belief, a tan gained in a tanning bed is no less damaging. No wonder, then, that skin cancer is the most common cancer in the United States, with more than one million skin cancers diagnosed each year. (1) Overall, one in six Americans will develop skin cancer at some point in their lives. (4)

Most frightening: the most lethal form of skin cancer, called melanoma, is increasing rapidly, particularly in women. In fact, it is the most frequent cancer in women ages 25 to 29 and the second most frequent cancer behind breast cancer in women between the ages of 30 and 34. (2) Overall, melanoma is the most rapidly increasing cancer in the U.S., growing from 17,000 cases in 1979 to 53,600 in 2002, including 7,000 deaths. That's a 68 percent increase. (3) The good news: most skin cancers are nearly 100 percent curable if discovered early and treated promptly.

The disease also knows no ethnic boundaries. For while African-American women are less likely to get the disease, they're more likely to die from it, probably because they tend to develop more aggressive tumors that are diagnosed later. (4) Overall, men are more likely than women to develop skin cancer, but women under age 40 comprise the fastest growing group of skin cancer patients, with an estimated 25,200 women diagnosed with melanoma this year. (1)

But skin cancer is just one of many things that can go wrong with a woman's skin. Acne, psoriasis, rosacea ... when it comes to your skin--which, by the way, is your largest organ--what can go wrong often does.

Acne: You're Never Too Old

The most common skin problem dermatologists see in middle-age women is, believe it or not, acne. "Adult acne in women is alive and well and I think it's really underreported," says Dr. Liotta. In fact, some women may find acne at mid-life worse than the acne they experienced as teens.

African-American, Latino and Asian women get a double whammy when it comes to perimenopausal pimples, she says. Not only do they have to cope with the zits, but once the acne disappears, inflammation leaves brown spots on their skin that may take up to six months to fade.

Don't blame hygiene or chocolate for your outbreaks. Instead, blame hormones, particularly as you move into perimenopause, that period of months or years before menopause. An increase in androgen hormones, aka "male" hormones, is to blame. Once you pass menopause, however, things should improve. "I rarely see women over 50 with acne," says Dr. Liotta.

Treating acne now, as an adult, is a bit more difficult than when you were a teenager, she notes, because your skin is probably drier. So the last things you need are products targeted to teenagers, which will only dry out your skin even more. Instead, Dr. Liotta uses milder retinoidal agents (made with vitamin A), like the prescription drug Differin (adapalene), which are less drying and come in cream form. Birth control pills can also help.

Unfortunately, she notes, you might get hassled by your insurance company if you try to get Differin covered; the drug is also used to reverse skin damage. "Insurance companies assume that if you're over 35, you don't have acne anymore, which is not true," says Dr. Liotta.

Rosacea: Beyond W.C. Fields

Often called "adult acne," rosacea is actually an entirely separate condition from acne. It gets its name from the reddish blush that spreads across your face, triggered by everything from spicy foods to alcohol to stress. It's what gave W.C. Fields his distinctive red nose (don't worry, the form of the disease that causes the nose to redden is more prevalent in men).

An estimated 14 million Americans suffer from rosacea. The disease is diagnosed more often in women than men and most often in light-skinned women of Northern European descent. Its symptoms can be as mild as a slight redness, or can cause embarrassing bumps and pustules on the face and other parts of the body, which is why it's often compared with acne. It can also affect your eyes, causing watering and itchy eyes, and may even lead to vision loss from corneal damage. (5)

No one knows what causes rosacea, says Cleveland dermatologist Amy H. Kassouf, MD, with University Dermatologists, Inc., but it tends to appear in middle age. It is usually treated with topical or oral antibiotics, she says, which reduce inflammation, and topical cleansers containing sulfa-based ingredients. In the past year, new drugs have become available, like Finacea (azelaic acid), which is applied to the skin twice a day.

Psoriasis: Beyond the Heartbreak

Helen Casaccio was 26 when she was first diagnosed with psoriasis, an inherited skin disorder that affects up to seven million Americans, men as often as women. At the time, Ms. Casaccio, now 56, thought it would just be a minor irritation, requiring the application of some cream now and then. But in the past 30 years, as the disease progressed, she's learned that psoriasis is much more than "heartbreak," as one advertising campaign describes it. Psoriasis is a serious immune system disease that can greatly affect a person's quality of life.

The disease appears as cracked, itchy, scaly patches over the skin. They occur when skin cells, which normally take about 21 days to mature, pile up on the surface of the skin too quickly. In some people, like Ms. Casaccio, it can also result in psoriatic arthritis, basically, a form of arthritis related to psoriasis. (6)

Rather than hide the scales, Ms. Casaccio, who lives in suburban Philadelphia, keeps them visible whenever possible. One reason is because light therapy helps contain outbreaks. But it also gives her a chance to educate people about psoriasis when they comment on her skin.

Until recently, the primary treatments for psoriasis included corticosteroids, topical drugs such as anthralin, sunlight (this is one of the few instances where your physician will actually recommend you sit in the sun) and/or ultraviolet B phototherapy. Of course, the latter two therapies can lead to skin cancer, and many of the drugs used to treat the disease, including methotrexate and cyclosporin, also have serious side effects, including increased risk of cancer. (6)

More recently, pulsed dye and excimer laser therapy, which destroy the blood vessels responsible for skin inflammation from the inside out, are showing great promise as a temporary targeted therapy. (6) But, insurance won't cover these expensive treatments. In January 2003, the U.S. Food and Drug Administration approved the first biologic therapy for psoriasis, Amevive (alefacept), an injected medication. (7) Biologic therapies are medications that contain one or more chemicals derived from the body's immune system, antibodies, for example. Alefacept isn't a wonder drug, however. It also suppresses the immune system, leaving patients open to an increased risk of infection or other problems, possibly including cancer. (6)

Enbrel, a biologic drug therapy initially approved for psoriatic arthritis, and Raptiva, have recently been approved for psoriatic skin disease. They also are considered promising treatments and may be less risky to use in certain circumstances than traditional drug therapy, according to Dr. Kassouf. But, biologics also are very expensive treatment options. However, for people with severe enough psoriasis, biologics are usually covered by insurance. Still, there are no guarantees that they'll work, she says. And, since all biologics are relatively new drugs, all possible side effects aren't yet known.

Ms. Casaccio treats her psoriasis with light therapy, anthralin and coal tar baths with the occasional use of topical steroids and Tazorac (tazarotene), a synthetic form of vitamin A. Just as important, she tries to avoid or reduce stress whenever possible, and avoids alcohol when her symptoms flare up.

Fact and Fiction of Skin Cancer

Sunscreen doesn't work. Tanning booths don't contribute to skin cancer. Americans don't get enough sunshine. You don't need to go any higher than a 15 SPF sunscreen. Sound familiar? These are all common myths floating out there about the sun/sunscreen/skin cancer correlation, all false, yet all continue to circulate.

Listen to what the experts have to say, the very people who have to tell their patients that yes, that spot on their back is cancer. And yes, it's likely due to that sunburn you got back when you were 17, or 10, or 8.

"There is no healthy tan," says Dr. Liotta flatly. At least, not one that comes from the sun or tanning booths. However, a new generation of sunless tanners (creams that leave you with that coveted golden glow) have emerged and she and other dermatologists recommend them to people who simply must have that bronzed look.

As for sunscreen: "The higher the SPF number the better," she says. SPF is sun protection factor. Not only because of the increased protection higher SPF sunscreens provide, but because most people don't use nearly enough to begin with. You need to apply at least a shot glass' worth every couple of hours you're in the sun, she says. That means a six-ounce bottle of sunscreen should last just a couple of visits to the beach--not all summer.

The myth about whether or not sunscreen works comes from some studies showing that even people who used the stuff still got skin cancer. That's because early versions of sun lotion only protected against UVB rays, says Dr. Kassouf, and researchers now know that both UVB and UVA rays contribute to skin cancer. Plus, studies find that people think the higher the SPF rating, the longer they can stay out in the sun, and that's simply not true. (10)

There are three types of skin cancer--squamous and basal, the two most common and easily cured, and melanoma, the deadliest. UVB rays are responsible for most of the basal and squamous cell cancers, while UVA is behind most melanomas, she said. UVA rays are also the bad guys when it comes to aging your skin. Plus, genetics play a major role. In other words, if your father was prone to skin cancer, you probably will be, too.

So make sure your sunscreen protects against both, says Dr. Kassouf. To do that, look for one of the only three ingredients that protect against UVA rays: Parsol 1789, also called avobenzone, zinc oxide, or titanium dioxide. A new protectant that provides much greater protection against UVA rays should be available in the U.S. in the near future, she says. Called mexoryl, it has an SPF of 60 and is already available in Europe.

Also recognize that sunscreen is not the be all and end all of sun protection. In fact, research conducted by scientists at Proctor & Gamble found that the majority of sunscreens on the market fail to completely protect against the full spectrum of UVA/UVB radiation in sunlight. (8) That's why it's so important to limit your time in the sun and wear a hat and protective clothing.

Just as important as protecting yourself, says Dr. Liotta, is protecting your kids. "Most of the sun damage you see in middle age you got as a kid," she says.

Marsha Shapiro, with three children eight and younger who spend entire days at the neigh-borhood pool, says she's become downright obsessive when it comes to protecting her kids from the harsh Atlanta sun. Every hour when the whistle blows for adult swim at the pool, she reapplies high SPF sunscreen. And she carries sunscreen with her every-where: in the diaper bag, in the car, in her daughters' soccer bags.

Maybe, she hopes, when her children hit middle age, they won't look in the mirror and see the error of their ways written upon their face as she does upon hers.

Resources

American Academy of Dermatology

PO Box 4014

Schaumburg, IL 60168-4014

847-330-0230

http://www.aad.org

Provides a variety of materials on skin health and diseases for consumers.

American Society for Dermatologic Surgery

5550 Meadowbrook Drive

Suite 120

Rolling Meadows, IL 60008

1-800-441-2737 (toll-free)

http://www.aboutskinsurgery.org

Offers a range of resources for consumers about dermatologic surgery; dermasurgeon locator available.

National Psoriasis Foundation

6600 SW 92nd Avenue

Suite 300

Portland, OR 97223-7195

1-800-723-9166 (toll-free)

http://www.psoriasis.org

Offers support and resources to individuals with psoriasis and psoriatic arthritis.

National Rosacea Society

800 S. Northwest Highway

Suite 200-W

Barrington, IL 60010

1-888-668-5874 (toll-free)

http://www.rosacea.org

Provides information and support to people with rosacea.

The Skin Cancer Foundation

245 Fifth Avenue

Suite 1403

New York, NY 10016

1-800-754-6490 (toll-free)

http://www.skincancer.org

Offers wide rage of information for consumers on skin cancer diagnosis, treatment and prevention.

RELATED ARTICLE: Seeing a Dermatologist

If you thought you were finished with dermatologists when you outgrew your teenage acne, think again. Studies find that a physician's ability to identify potentially precancerous lesions is based on the doctor's training in that area, and no one is better trained to spot suspicious spots than a dermatologist. (9)

Different organizations have different recommendations when it comes to skin examinations. The American Academy of Dermatology recommends annual screenings, the American Cancer Society recommends skin exams every three years between ages 20 and 39, and annually after age 40, and the U.S. Preventive Services Task Force says there is insufficient evidence to recommend for or against routine skin examinations. (4,10) There's no controversy over the fact that the earlier skin cancers are identified, the better the outcome. So talk to your health care professional about when to be screened.

Finding a dermatologist is pretty simple-the American Academy of Dermatologist has a search function on its Web site (www.aad.org). As with most medical specialties today, you can also find specialty dermatologists. Some, called Mohs surgeons (named after the creator of a surgical technique for removing skin cancer tumors), specialize in skin cancer surgery.

Dermatopathologists focus on reading dermatological slides to identify cancers and other skin problems, while pediatric dermatologists have additional training in pediatrics. Laser specialists may have received additional training in using lasers, while dermatological immunologists specialize in autoimmune diseases like psoriasis and scleroderma. Then there are cosmetic dermatologists who often limit their practice only to cosmetic procedures.

Your best bet is to start with a general dermatologist, however. "We see all types of patients, and do some surgery, cosmetics, laser procedures and uncomplicated pathology," says Maryland dermatologist Elizabeth A. Liotta, MD. "If we can't handle a complicated case, we'll happily refer you on."
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Publication:National Women's Health Report
Date:Jun 1, 2004
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