What doctors wish patients knew about maintaining healthy skin

Skin is the body’s largest organ, so it is important to take care of it. That’s because when skin is healthy, its layers work hard to protect us. But when it is not, the skin’s ability to work as a protective barrier is impaired. Knowing how to achieve healthy skin from head to toe can help support it in maintaining its protective role.

Our skin has many functions, including protecting us from bacteria, viruses, and pollution and chemical substances. It also regulates body temperature, maintains fluid balance, controls moisture loss, acts as a barrier and shock absorber, recognizes pain sensations and protects us from the sun’s harmful ultraviolet rays. Many factors affect your skin, but knowing how to maintain healthy skin is key.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Lawrence Cheung, MD, a dermatologist and delegate in the AMA House of Delegates for the California Medical Association, took time to discuss what doctors wish patients knew about maintaining healthy skin.

“In terms of starting out for basic skin hygiene, the most important thing to consider is that the simpler the better,” said Dr. Cheung. “People don’t realize that a lot of things that they purchase and are applying to their skin actually can be allergenic.”

“What that means is that for all my patients, I always start out with saying that simple is better and I usually recommend only two items that they use daily—a moisturizer and sunscreen,” he said, adding “if patients want to use additional things to be aware because you could be allergic to it and you could develop allergies to it down the road.”

Dr. Cheung personally recommends three brands for third-generation moisturizers and wash: Aveeno, Cetaphil and CeraVe.

“One of the most important things that I hear from my patients that is wrong is this preconceived notion that a lot of these natural oils and natural things are good because it is natural,” said Dr. Cheung. “But the fact is that fragrances and preservatives are two of the most common things that people are allergic to.

“And I’m talking about fragrances, which are things that are naturally derived, and preservatives, which are artificial,” he added. “For example, rose hip and chamomile. Yes, it’s all natural, but so is poison oak and poison ivy—are you going to touch that and put that in your lotion?”

“So, you have to understand that just because it’s natural doesn’t mean that you’re not going to be allergic to it,” Dr. Cheung said. 

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“The important thing about a moisturizer is that it used to be considered that the stickier it is—like Vaseline ointment—the better,” said Dr. Cheung. “Now that is still true from a hypoallergenic perspective because there’s nothing more neutral than white petrolatum, which is Vaseline ointment, but nobody wants to put that on their skin because it’s so sticky and oily.”

“What I have to consider as a dermatologist is I can recommend something until I am blue in the face, but if you’re not going to use it, you’re not going to use it and that is no help to you or me,” he explained. “So, I recommend things that are a little more elegant.”

“In moisturizers, we talk about the first set of moisturizers. Then we have the second generation and the third generation,” Dr. Cheung said. “The first generation is the Vaseline ointment where it’s just a moisturizer. It’s a thick oil and it just locks in the water and that’s it.”

“The second-generation moisturizers tend to have a delayed release, so it’s not as sticky. You put it on, and it releases the moisture over 24 hours,” he said. “And the third-generation moisturizer actually has chemicals, which are naturally occurring. That helps to repair the skin when it’s damaged.”

“I like the third-generation moisturizer because I just put it on after my shower and that’s the best time to apply it,” said Dr. Cheung. “The best time to apply the moisturizer is after a shower when your skin is already soaked in with moisture and you’re just putting the moisturizer on just to lock it in.”

“And that could be in the morning after a shower or at night after a shower,” he said, emphasizing that “after the shower is the best time to put it on because you’re already naked, so just slathering the whole body and you’re good for the rest of the day.”

“People often ask me about cosmetics, and I have nothing against cosmetics, but the fragrances and coloring tend to be on the higher end of things that cause skin allergies,” said Dr. Cheung. “You just have to be aware of what put on. A line you like or items that you like that don’t cause any problems, you can probably continue with that.

“But, again, the thing to remember is just because you don’t have problems for 10 years, it doesn’t mean you’re not going to be allergic to it down the road,” he added. “The interesting thing is that a lot of the cosmetics and everything that’s over the counter are not regulated by the Food and Drug Administration, so they can change the active ingredient any time, batch to batch.”

“The incidence of skin cancer is going up and that has to do with two reasons. There’s obviously global warming, and we’re detecting it earlier because we have better equipment to do so,” said Dr. Cheung, noting that “previously dermatologists used a magnifier but now they are using a dermatoscope, which allows us to look at skin in a much better way so we can detect skin cancer much earlier.”

“But before you get to that point where you have the abnormal skin cell, you want to prevent it. Obviously prevention is better than actual detection, so sunscreen is really the most important thing that a person can use,” he said. “And that does apply across all skin types.”

“What you’re doing is you’re artificially scrubbing up the top layer of the skin, which comes off on its own anyway,” said Dr. Cheung, who is not a fan of the practice. “So, if you feel like you’re dirty and you want to exfoliate, you can forget that because it is going to exfoliate off on its own anyway.”

“If you’re exfoliating because you’ve got a bunch of dry skin, the answer is to use more moisturizer,” he said. “It’s not to exfoliate because not only will you take out the protection layer—it’s there for a reason—but you’re going to cause microtraumas to your skin, which sets you up for skin irritation.”

“There are chemical ways of doing exfoliation that’s a little bit safer and it’s more advanced,” Dr. Cheung said. “Sometimes you can use salicylic acid, which is available over the counter as a moisturizer. And the only time I really recommend that is for people who have eczema or early eczema, and they have this rough chicken skin on the back of their arms called keratosis pilaris.”

“Eczema and psoriasis are important skin conditions to be aware of, especially in the winter months because these two conditions can flare up with the cold and the dryness,” said Dr. Cheung. “A lot of people have eczema—it’s about 20% to 30% of the general population who have it to some degree.”

“A lot of people think mild eczema is just dry skin. It probably is,” but can become eczema, he said. “You might as well think about using the third-generation moisturizers because they incorporate chemicals that are naturally occurring in the body that is not naturally produced in high enough quantities in patients with skin conditions like atopic dermatitis eczema.”

“There are no vitamins or supplementations that you can really take by mouth to improve your skin health, and certainly not with foods,” said Dr. Cheung. “There are certain antioxidants that are available over the counter that may or may not help. The one that I personally use on my patients is vitamin C.”

“The reason why some antioxidants help topically is that even though sunscreens work really well—both chemical and physical sunscreen block sunlight—they sequester UV light, so that renders it harmless,” he explained. “It’s not perfect and there’s a degree and an amount of UV light that do penetrate through the physical and chemical sunblock.

“When you use the antioxidant on a daily basis, it does repair some of the oxidative damage that occurs with UV light on the skin,” Dr. Cheung added. “The antioxidant is really an additional item that you could use and pair with sunscreen to augment your protection against the sun.”

“Smoking and alcohol don’t directly cause problems with the skin, but they are both considered proinflammatory products,” Dr. Cheung said. “For patients with skin conditions like psoriasis and eczema, it is important to avoid smoking and alcohol because they're proinflammatory and they increase the inflammatory cascade that actually leads to those conditions.

“There's definitely no benefit to smoking whatsoever. Alcohol once in a while is fine—I’m not going to go against it,” he said. “But I would say: If you’ve got bad control of a disease, you may want to cut down on that because there’s no benefit and there’s only harm.”

“It is interesting. Stress and sleep actually factor quite significantly in skin diseases and we don’t know why. That is an active area of research,” said Dr. Cheung. “People who have high levels of stress and who have sleep cycle dysregulation actually have worse skin conditions.”

“If you have no skin problems whatsoever, stress and sleep are not going to be an issue, but if you’ve got eczema or psoriasis, for sure that is an issue,” he said. “In fact, when I do research in eczema and psoriasis, we monitor patients’ sleep, and we ask them how much their sleep is disturbed and how much they’re sleeping because it is a big issue.

“The less sleep and more stress you have, the worse your condition gets,” Dr. Cheung added. “We still haven’t figured out why, but we believe it’s probably because with not enough sleep and high stress levels, you’re probably increasing your overall proinflammatory environment in your body that’s exacerbating the skin condition.”

“Drinking water is great, but if you have a skin condition, function is compromised,” said Dr. Cheung. “Think of it as a puncture in a tire. The tire is the skin, and the air is water. When you have a skin disease, you’ve got a bunch of holes in your tires and it doesn’t matter how much air you put in your tire, the air will come out.”

“The treatment isn’t to put more air in the tire. Treatment is the patch, so you don’t have any more leaks,” he said. “People with skin disease have a higher degree of what’s called transepidermal water loss—they lose water through evaporative process through the skin because there’s a barrier dysfunction.

“Moisturizers—particularly the third-generation ones—actually plug the holes in the skin to decrease transepidermal water loss so that you keep the moisture in your skin and not let it evaporate,” Dr. Cheung added.

“A lot of people focus on showers and baths as being bad for people with skin conditions and that is false. There’s no real limit to how much you want to bathe or shower,” said Dr. Cheung. “The key is to use the right soap and to moisturize afterward.”

“The confusion comes from back when we had first-generation soaps that the detergent level was a lot higher and it stripped the oil off the skin easily and we didn’t have great moisturizers back then,” he said. “But we're in 21st century here and we have great soap, so you can take as much time in your bath and shower as you want as long as you put moisturizer on.”

“Now, I don't recommend super hot showers. Warm and warm-to-hot showers or baths are fine, but scalding hot is bad for your skin,” Dr. Cheung cautioned.

“If you don’t have any history of skin cancer in the family and you have no problems, visit your dermatologist on an as-needed basis,” said Dr. Cheung. “If you’ve got some moles that need to be looked at and you are fair skin, start getting a full body skin exam in your 30s and 40s to get a baseline.

“Then based on that I can tell my patients how often you need to come in,” he added, noting that “some people who grow up in the tropics, I have to start seeing them every year because of the cumulative sun exposure.”