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Skin. It’s our largest organ and our first line of defense against the outside world. Most of us are born with beautiful skin — fine-grained and unblemished. Then, thanks to the environment, our diet, our health, and how we treat our hides, it changes.

������ϲ�ͼ������ interviewed six metro Detroit dermatologists and a licensed esthetician (a person with advanced training in administering facials, advising on skin and hair care, applying makeup, and aromatherapy) to find out what’s happening, what’s best, and what’s new with skin and skin care.

Are you seeing any trends in skin conditions and ailments? Is there anything on the rise?

The answer is unanimous: Skin cancer is, and has been, on the rise. Not only is it becoming more common, it’s also becoming more dangerous: Doctors are seeing more of the malignant melanoma type of skin cancer — and more young people with all types.

In fact, skin cancer is the most common of all cancers, accounting for about half of all cancers in the United States each year, according to the American Cancer Society.

Dr. Michael Dorman, who practices in West Bloomfield Township, Novi, and Commerce Township, says he attributes at least part of the increase in skin cancer to the Baby Boomer generation. Boomer tanning addicts used to surround themselves with the covers of record albums wrapped in aluminum foil to intensify the sun’s rays, he says.

Of course, because there are more people, there’s more skin cancer. But that increase is outstripping population growth. The Boomers were the last generation to grow up without knowing enough about what causes skin cancer as well as the importance and wide availability of sunscreens.

Fortunately, more people are becoming aware of skin cancer and the need to take steps to prevent it or, at least, detect it earlier.

“We encourage people to have a full skin exam, and within the last five years there’s been a tremendous change in patients, especially new ones, who agree to this,” Dorman says. “Previously, about 20 percent agreed, and now it’s well over 60 percent.”

The doctors we surveyed agreed that exposure to ultraviolet radiation — whether from the sun or tanning beds — should be avoided, that small amounts of exposure add up, and that applying sunscreen should be part of everyone’s daily skin-care regimen — whether they work or play much outside, or not.

Happily, there’s good news about skin cancer, too. Dr. Lydia Juzych, division head of Dermatology at the Henry Ford Medical Center in Troy, is excited about new, year-old medications for metastatic melanoma that stimulate a person’s immune system to attack cancer cells. “It’s actually giving some patients some hope,” Juzych says.

Skin cancer isn’t the only condition trending upward right now.

Dr. Bobbi Edwards, a St. John Providence Health System dermatologist, says one of the most common concerns among her female patients involves their scalp: hair loss. “I don’t know if it’s actually on the rise,” she says. “Or if women are just more aware of it and coming in.”

The hair loss may be due to genetics or styling-related damage from excessive heat, too much handling, or, in the case of women of color, chemicals from permanents or relaxers. All can inflame the scalp, which then thins the tresses. If the cause is genetic, the drug Minoxidil is the treatment of choice; for styling-related damage, Edwards uses topical or injected steroids.

Lydia Juzych, M.D., 40

Dermatology Division head, Henry Ford Medical Center, Troy

* Pale skin is at a higher risk for cancer. Darker Mediterranean or African-American skin, which has more melanin, almost has an SPF of maybe four or eight. Lighter skin needs more protection.
* Collagen can be rebuilt or plumped up. Tretinoin cream thickens collagen. Collagen looks like thick tubes of spaghetti or penne pasta. It frays on the end, which gives an older look.
* There’s no safe tanning. There are no safe tanning beds. They’re concentrated ultra-violet A light.
* I apply sunscreen every morning — winter, spring, summer, fall, sleet, snow, shine — on my face, neck, hands, and chest (if I’m wearing a scoop neck).
If I’m outside for a long time, I wear a hat and reapply SPF every two hours. At night, before bed, I apply
a tretinoin cream.
* One sunburn puts you at a higher risk for developing skin cancer later in life. Run that by your teenagers. Repetition is the way we learn.
* Having more moles puts you at a greater risk for cancer. Half of melanomas arrive within an existing mole. Do monthly skin exams and, in moles, look for:
A: Asymmetry.
B: Borders becoming uneven.
C: Color. You want a solid color. If different colors appear, see a doctor.
D: Diameter and whether it gets larger. Everything over 6 millimeters should be looked at.
E: Evolving or changing moles should be looked at.
* With physical sun blocks, sun rays bounce off. They contain zinc oxide or titanium dioxide. With sunscreens (as opposed to blocks), think of a screen porch; a big fly can’t get in, but a gnat can.

What are the most common skin ailments you see in your practice?

In addition to skin cancer, the doctors listed acne, acne rosacea, psoriasis, warts, dermatitis (a fancy word for rash), and eczema.

“Regardless of the primary reason for a patient’s visit, I encourage everyone to have a check of all of their skin,” says Dr. Wendy Sadoff, a Beaumont Health System dermatologist. “Even younger patients benefit from having a baseline examination, and this gives me time to discuss skin care.”

What are the most important things we can do for our skin?

“Sunscreen, sunscreen, sunscreen,” says Dr. Ali Moiin, of Troy. Sunscreen labels beginning in 2013 must adhere to new FDA guidelines intended to better inform consumers about what sunscreens actually do. According to the American Academy of Dermatology, key changes will include distinguishing whether a product is capable of helping to prevent sunburn and skin cancer. To do both, the product must be labeled as being “broad-spectrum (blocking both UVA and UVB rays), and having an SPF of at least 15. Labels can no longer indicate that sunscreens are “waterproof,” either, since according to the academy, there is no such thing. Aside from practicing safe sun care to best protect skin, Moiin notes the next best thing to do is not smoke.

Edwards and Sadoff both say it’s important to do a self-exam of your skin every month or two in addition to having a doctor take a look once a year. Have someone you feel comfortable with to scan your back or any other hard-to-see area.

“That way, you know what’s on your body and can identify what’s changing,” Edwards says. “It greatly helps whatever dermatologist you would go to; very often people discover their own skin problem.” Sadoff says: “One year is a long time to wait if a spot begins to grow or change shortly after their visit.”

Are you seeing improvements in self-care? Is there anything we could do better?

Everyone agrees that patients they see are more aware of avoiding ultraviolet exposure, using sunscreen, and getting skin checks by a doctor.

“However, the skin also suffers from small, incremental exposure daily,” Sadoff says. “So I recommend they apply [sunblock] product as a part of a morning routine.”

Moiin agrees, and uses humor when educating the people he treats.

“I tell my patients if you just buy the cream you won’t be protected,” he says. “You have to use it.”

For those with sun-damaged skin, Dorman recommends using a retinoid, which can even reverse sun-related skin changes that can lead to cancer.

Edwards recommends whole-body exfoliation — scrubbing the old skin off all over — once or twice a week with a loofah or body puff. She’s also in favor of all-over moisturizing, including the back and the skin surrounding the under arms, with a cream or ointment instead of a lotion.

“Very often, in Michigan, a pump product is too thin,” she says.

Linda F. Stein Gold, M.D., 49

Staff dermatologist, Henry Ford Health System, Detroit

* “I had a lot of sun exposure as a child and young adult. I would go on vacation and bake in the sun. I thought a tan would look good. Now I really try not to go in the sun at all. I want to look my best, and protecting skin from the sun is one of the best things you can do.”
* Skin care doesn’t have to be complicated. “I still suffer from occasional acne, so I use a topical retinoid [which is also good to combat wrinkles] and a broad-spectrum sunscreen every day.”
* Speaking of acne, there are some “new, exciting” treatments undergoing clinical trials to more effectively treat this common condition. “But the treatments available today are still very good. There’s no reason that anyone today should suffer from any type of acne.”
* Acne develops under the skin before you can even see it. If you’re only spot-treating the lesions, “you’ll chase your acne forever.” Acne needs to be treated over the entire face, and on a daily basis. “You can’t ever stop. Acne requires constant maintenance.”
* “A lot of the products at the drugstore are as good or better than expensive ones. Brands like Olay and Neutrogena are healthy for the skin, and not nearly as expensive.”

What are the greatest misconceptions about our skin and skin care?

Moiin doesn’t miss a beat with his answer: “That food causes acne. What causes acne, in general, is plugging up the pores.”

Juzych says: “I think many people don’t realize that 80 percent of the damage you do to your skin is by age 18.” That doesn’t mean it’s all right to be a fatalist and skip the sunscreen.

“You can still add insult to injury,” Juzych says. “It might take just that little bit of ultraviolet exposure to start a skin cancer.”

Edwards says that because skin constantly and quickly renews itself, a lot of skin conditions recur unless the treatment for it is repeated as needed.

Jennifer Szakal, a licensed esthetician who works with Dorman, offers a shopping tip of sorts: “One of the biggest things I see is that when patients purchase products, they think the more money they spend, the better the product will be for their skin. Just because it’s expensive doesn’t mean it works better.”

To make handing over more money pay off, Szakal says you have to buy medical-grade products in a doctor’s office, such as the Neocutis brand or the private label products sold through Dorman’s office. That’s because the ingredients are different, and the amount of active ingredients is much higher than in drugstore or department-store brands, she says.

Do cosmetic concerns and fears of aging skin lead us to doing any things that actually damage the skin?

Edwards says she sees women applying thick layers of cosmetics to hide acne or eczema. A better solution would be to take a break from makeup to give the skin a chance to recover, she says.

Sadoff says it’s important if you’re using several products to layer them so skin can absorb ingredients. Apply serums and gels first, because the skin will absorb them, and then smooth on creams and ointments. It’s also possible that individual products may contain ingredients that, used alone, are mildly irritating, but turn into big trouble when used with other mild irritants. One solution is to use one product at night and one in the morning, Sadoff says.

Szakal says that too many women in their 40s go for radical procedures to improve the look of their skin, such as face-lifts or CO2 lasers.

“If someone has very severe acne scarring that’s really deeply pitted, that’s when I would advise using the laser,” she says. “But otherwise, I advise waiting. If you have it done in your 40s, you’ll likely have to repeat the procedure in your 60s.”

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Ann LaFond, M.D., 63

Canton Dermatology, Canton Township

Personal routine: “I get red and itchy,” says LaFond, who has very sensitive skin. So she keeps it simple, using Dial gentle liquid cleanser and Aveeno Ultra-Calming moisturizer daily. She recommends over-the-counter retinol and prescription retinoids to her patients who can tolerate these wrinkle fighters.
* “Celebrate your life. Treasure every moment. That happiness will shine through your face to make your skin glow.”
* Five tips for facial skin care.
1. Avoid tanning booths and sun exposure. The UV exposure will prematurely age your skin.
2. Avoid cigarette smoking. It will age your skin, causing more wrinkles and slowing healing.
3. Apply a gentle sunscreen with broad-spectrum (UVA/UVB) coverage every morning. The SPF should be 30 or higher. Be sure to cover your face, neck, and upper chest with the sunscreen, as these areas are frequently burned. Sun protective clothing and hats are helpful.
4.�� Use a gentle facial cleanser and a gentle moisturizer at night. These products are available in your pharmacy or the cosmetic counter.
* There are many who claim to be skin specialists. Buyer beware. Dermatologists (M.D.s and D.O.s) complete a four-year residency after medical school before being board certified. They’re trained in medical dermatology for pediatric and adult patients. They study all skin diseases, including hair and nail diseases. Lasers and cosmetic procedures are part of their training, as well as skin-cancer examinations.

Is skin more durable or fragile than we think?

“It’s a great protection,” says Dr. Daniel Stewart, of Clinton Township. “Sadly, as you get older, your skin gets more friable, but it’s done the trick for a long, long time.”

What’s the best way to care for rosacea?

Acne rosacea includes a flushing of the skin, possibly with visible blood vessels and bumpy or pimply appearance, according to the American Academy of Dermatology. Famous people with rosacea include Bill Clinton, Princess Diana, and W.C. Fields.

The doctors agree that it’s important for someone with rosacea to identify what triggers it. Troublemakers include sun exposure, alcohol, spicy food, tomatoes and tomato-based foods, chocolate, hot weather, exercise, stress, and certain cheeses. Most of the doctors also included caffeine, but Stewart says it’s the heat from coffee that aggravates rosacea. If you drink coffee, sip it over ice, he advises.

There’s help on the way in the form of a prescription product that can be used at home.

“In the next year, two companies are going to come out with new drugs that are based on the premise of applying something to the skin that causes the blood vessels to shrink,” says Dorman.

Darius J. Karimipour, M.D., 42

Karimipour Dermatology and Aesthetic Surgery, Bloomfield Hills

* Skin cancer is the most common type of cancer in young adults 25 to 29. I see kids in the prime of their lives who come in and can be stopped dead in their tracks from this disease.
* I [recently] removed a basil-cell lesion from an older man’s face, which left a 4-inch hole in his cheek. He wanted me to take a photo to send to his granddaughter, who uses tanning beds.
* A lot of people think they can get a “base tan” at a tanning salon before [vacation], but it’s a false sense of security. The only protection might be an SPF of five, which is nothing. That’s why we always say, there’s no safe tan.
* When you’re exposed to sun, the skin produces enzymes that are actually meant to aid in the healing of wounds. Over time, these enzymes break down the collagen in the skin, which causes wrinkles. Smoking also causes the body to produce these same types of enzymes.
* Sun exposure produces vitamin D, but vitamin-D levels vary a lot. There are studies that show that surfers in Hawaii can have vitamin-D deficiencies, so the sun shouldn’t be the primary source. Vitamin D really needs to come from the diet.
* As far as anti-aging, I always tell people that if you want to spend the money, buy something with good science behind it. Retinoids are good for anti-aging, and there are studies that show products with the lowest concentration are just as effective as higher concentrations.

What’s the best way to care for acne?

Acne is the most common skin disorder in the United States, and is caused by dead skin cells and sebum trapped in a pore, according to the AAD. This mixture provides fertile ground for bacteria to grow.

Most of the doctors recommend washing twice a day with a mild cleanser containing benzoyl peroxide or salicylic acid, followed by oil-free, non-comedogenic moisturizer and makeup. If you have persistent pustules or cysts, it’s best to see a doctor who can prescribe topical antibiotics or keratolytics (they make skin cells shed faster), oral antibiotics, and isoretinoin. A doctor can also use laser therapy for more serious acne, says Juzych.

What’s the best way to care for psoriasis?

The AAD says psoriasis results when a person’s immune system tells skin cells to grow too fast.

Only one doctor recommended self-care for psoriasis with an emollient like petroleum jelly applied to the whitish plaques that form. The other specialists recommend treatment with topical steroids, tar, or vitamin-D type compounds; oral anti-inflammatories or methotrexate, a chemotherapy drug; or a newer class of medications called “biologics” that are injected or administered into a vein.

“Sometimes exposure to specific wavelengths of ultraviolet light given under the care of a physician [can help],” Sadoff says.

Wendy Sadoff, M.D., 51

Sadoff Dermatology, Farmington Hills

* It’s the small, incremental exposure to sun over time that can do the most damage. “I always use a sunblock, even when I have no plans to be outdoors for a long period of time.”
* Sunscreen recommendation: EltaMD, which uses effective zinc oxide but is less opaque on the skin. “It’s much more cosmetically elegant.”
* In addition to daily sunscreen, a “well-rounded regimen” to keep skin looking its best should always include products that contain a retinoid, exfoliating acids, antioxidants, and growth factor. Moisturizers? “A moisturizer is just a water-oil emulsion applied to skin to help seal in moisture.” You can buy good moisturizers at the drugstore — CeraVe, Aveeno, Cetaphil — but it’s worth it to invest in higher-quality products from the doctor that contain essential ingredients for healthy, youthful skin like growth factors and antioxidants. “Certain [ingredients], in order to maintain the biologic activity of the skin, are just more expensive.”
* “Growth factors” originally were studied in research on healing burns and wounds. Out of that science came the thinking that growth factors could be useful for aging skin, since aging skin can be considered “wounded.” Recommendation: Neocutis Bio-Serum.
*�� “If you’ve got the kind of lines created by movement of muscles, until you inject a toxin [such as Botox] to weaken those muscles, those lines will not go away.” Even people as young as 18 can develop lines on the face if they’re repeatedly “scowling” or making extreme expressions when showing emotion. Targeted injections can help “soften”— not freeze — the muscles so those lines don’t form in the first place.

What’s the best way to care for dandruff?

Dandruff, with the fancy name “seborrheic dermatitis,” is thought to be due to an overproduction of skin oil and irritation from a yeast, malassezia, according to the National Institutes of Health.

The doctors surveyed agree that over-the-counter shampoos are very effective: look for ones containing salicylic acid, sulphur, tar, selenium sulfide, or zinc pyrithione. If dandruff is stubborn, try alternate shampoos containing salicylic acid (which helps shed skin cells faster) and zinc pyrithione (an anti-yeast ingredient), Juzych advises.

For people who can’t shampoo frequently, a scalp prescription cream is available, Edwards says.

What’s the best way to care for aging skin?

“The retinoids are really the gold standard of care for aging skin,” Stewart says. “A lot of teenagers use retinoids for acne, and if they continue to use them they’ll probably not show as many signs of aging.”

For over-the-counter retinoid products, Szakal recommends the ROC brand, or a prescription product. Her daily regimen is to use an eye cream twice daily, sunscreen, moisturizer, and a growth-factor product (to stimulate cell renewal) in the morning, and a retinoid three to four times a week at night.

Juzych advises prevention: Wear sunscreen and avoid sun. She also favors retinoids, and for treatment by a doctor, chemical peels and laser treatments.

Edwards says: “There are four things I like people to do daily.” These include using different products with glycolic acid and a retinoid, a good moisturizer, and topical vitamin C. “In addition, I think people should have a monthly facial, even one at home.”

Meena Moossavi, M.D., 41

Livonia Dermatology, Livonia

* Personal skin-care routine: Dove soap for sensitive skin and Aveeno Ultra-Calming lotion with SPF 30.
* “You should always wash off makeup before you go to bed. Makeup is not designed to stay continuously on the skin. Some doctors believe [makeup left on skin at night] could increase wrinkling over time.”
* Avoiding sun exposure is definitely the best way to keep your skin looking young. Long-term exposure degrades the collagen in the skin, so the effects [loss of firmness] aren’t necessarily due to aging alone. Next to that: Don’t smoke.
* “As long as it’s used appropriately and it’s not overdone, I don’t have any negative feelings about Botox.” Small amounts of Botox, in fact, can prevent wrinkles over time by preventing the repetitive facial movements that help form wrinkles.
* “Young girls just don’t understand the long-term effects of tanning. I see these signs, ‘$20 for unlimited tanning,’ and it’s a double whammy of premature aging and skin cancer. It’s infuriating.”
* Some skin problems can be fixed just by switching your cleanser. “In general, we recommend fragrance-free, non-soap cleansers.”

What’s the best way to care for children’s skin?

Juzych recommends cleansing with very mild soap with no fragrance, followed by a thick cream moisturizer after every bath. A broad-spectrum sunscreen (with UVA and UVB protection) should be applied every day, she says. Use an SPF of 15 for everyday use and SPF 30 or higher for longer periods.

Szakal advises using a lightweight, oil-free moisturizer on a child’s face.

Which foods are good for skin? What are the worst foods for our skin?

Moiin says: “Anything that has high vitamin-D content is good for the skin. The Japanese diet is very good for our skin.”

Sadoff takes a more general approach to nutrition. “Studies are conflicting on the foods that are helpful or harmful for our skin,” she says. “One study will show dairy or simple carbohydrates to be harmful, and a subsequent study will not support this.”

Her recommendation? “The best advice is to have a balanced diet with plenty of colorful fruits and vegetables, which have been shown to have antioxidant properties.”

What’s on the horizon in terms of skin care?

“The time will come when we won’t need to inject fillers or Botox,” Moiin says. “The product will be delivered via a skin patch.”

Szakal says: “The [plant and human] growth-factor products are some of the best products out there and they keep improving all the time. People see great results and they’re non-irritating.”

Edwards anticipates more biologic medicines that can boost the immune system to heal skin diseases.

Sadoff adds a note of caution: “There are new topical products all the time,” she says. “The important thing is to select products with solid scientific studies behind them.”

What products do you recommend?

These experts generally recommend brands of cleansers and moisturizers that are easy on the wallet and readily available at drug and discount stores: Cetaphil, Aveeno, Neutrogena, and CeraVe.

Moiin favors Neutrogena dry-touch sunscreen, saying: “It feels like a powder on your skin, much better than most other sunscreens.”

Edwards steers her patients away from antibacterial cleansers because they’re too drying.

Sadoff also favors drugstore brands for cleansers and moisturizers, but anti-aging products are a different story for her.

“I recommend products that I dispense through my office, such as Neocutis, Biopelle, and Elta,” she says. “I will usually combine products from different companies to have an individualized regimen.”

Karen Lynne Chapel, M.D., 43

private practice, Dearborn

* Personal skin-care routine: Daily sunscreen, sometimes a tinted moisturizer with sunscreen in it; at night, an alpha hydroxy acid or a retinol; sometimes, a superficial glycolic peel.
* Especially in younger women, the pressure to look tanned supersedes the safety issues. [It would help if] magazines and Hollywood could make tanning seem less glamorous.
* Sugar can cause glycosylation [which makes collagen less elastic].
* Botox is nice in that it allows you to relax certain muscles that can draw your face down and convey emotions that aren’t there [such as anger or fatigue].
* “I probably have less sun damage as a result” [of being the daughter of dermatologist parents, M.D.s Johanna and Thomas Chapel, with whom she shares a medical practice]. “I’d try to get a tan, and my mother would come out and say, ‘You’ve been out here for 10 minutes.’”
* “There’s a public perception that, as [the character] Seinfeld said, ‘Dermatologists are one step up from the Clinique counter.’ What makes dermatology fascinating to practice is that skin can be a window into the inner workings of the body. We go a long way beyond recommending wrinkle creams. What we do on a daily basis is use skin findings to diagnose and manage a wide variety of diseases. [For example], a velvety tan/gray thickening of the skin on the neck or under the arms is often a sign that a person is at a high risk of developing diabetes. Yellow, smooth deposits around the eyelids can be a sign of high cholesterol.”

What do you treat that would be surprising?

These doctors say most people don’t know that dermatologists treat hair and nail problems in addition to skin disorders, and that some in their specialty do hair transplants.

“Stress!” Sadoff says. “Although we don’t treat stress directly, I find that when a patient more fully understands his skin condition, and can be an advocate for his care, he feels empowered.”

Moiin says patients are generally surprised that he treats sexually transmitted diseases.

And Stewart says that, although he may not necessarily treat them, that diseases in the rest of the body cause symptoms in the skin. He notes that if a patient’s psoriasis doesn’t respond to good care, often he’ll discover the person has diabetes or cardiovascular disease. Skin’s appearance can also unmask thyroid problems and, thickening skin can be a sign of an internal malignancy. There’s even a muscle disease, dermatomyocitis, that’s detected by a skin rash and a purple or violet tinge to the eyelids.

Are there any differences for people of color in caring for their skin?

Edwards says her skin-care recommendations are for everyone, regardless of skin color, with one exception. Fair skin actually requires more protection because it’s damaged by the sun more quickly than darker skin. She notes that because darker skin doesn’t show sun damage as much or as quickly as lighter skin, signs of aging appear later, too.

Something that’s unique to darker skin are dark spots that appear after mild inflammations (fancy name: post-inflammatory hyperpigmentation) like acne, rashes, or other irritations.

What is your soapbox issue or best advice for skin care and the prevention of skin problems?

Edwards says ringworm in children, which is caused by a fungus, is an epidemic.

“Parents often think symptoms of ringworm are dandruff,” she says, noting that it’s unusual for children to have the condition characterized by white flakes on the scalp. “Children with ‘dandruff’ need to be evaluated by a dermatologist.”

Edwards and her colleagues universally say that avoiding ultraviolet exposure by staying out of the sun or using a sunscreen with both UVA and UVB protection is their No. 1 message for everyone.

“Please do not tan,” says Moiin. “It damages the skin and can lead to skin cancer.”

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Photographs by Roy Ritchie // On-set grooming by Kelly Mitre, from Avatal Salon