What’s my skin type? - The Fitzpatrick Skin Type Scale And Its Flaws

In 1972 Thomas B. Fitzpatrick introduced the Fitzpatrick Skin Type Scale which describes an individual’s skin color and their tendency to burn or tan after being exposed to sunlight. It was created so that dermatologists could use this classification to anticipate skin reactions to phototherapy. Phototherapy is used in several dermatological treatments which use filtered UVA or UVB lights as an immunosuppresants to treat inflammatory diseases. Basically, a lower Fitzpatrick skin type means that you tend to burn more easily and tan less compared to a higher Fitzpatrick skin type (IV-VI).

It’s important to note the scale was originally limited to skin types I-VI and that the scale was later extended to include phototype V-VI. At this time you might sense the problems with the scale (all shades of brown and black were summarized in V and VI...). 

But first let's define Fitzpatrick Scale I-VI:

The obvious controversy with this scale is it does not adequately address the various shades of skin of color.

Another issue is that it makes assumptions about sun sensitivity.

For example, when I told my colleagues that my sister is sensitive to direct and long sun exposure and reacts in an almost allergic manner, they could not believe it...

Assuming a skin type V does not burn and always has high UV-light tolerability is simply FALSE!

Another issue: The scale is fully subjective!

Many research groups have proposed several other ways to categorize skin types which are important especially in dermatology (mostly in phototherapy and laser and cosmetic therapies). However, at this point, none of the proposals can comprehensively account for what we see in clinical practice. 

Since we all still use the Fitzpatrick scale, I find it extremely important to also point out it’s flaws.The right estimation of your Fitzpatrick skin types has important “therapeutic consequences” for in Lasertherapie has important “therapeutic consequences” ( Ajay N Sharma, Laser Fitzpatrick Skin type Recommendations). And, most importantly, it is  intended to reflect sun sensitivity and is NOT a characterization for race phenotypes.

Xx Mimi

Acne 101

One of the most frequently treated skin concerns in Dermatology is acne vulgaris, the type of acne which typically causes inflammation in your face and upper back. 

As a common skin condition, acne affects people of all ethnic backgrounds, gender and ages beyond puberty. Acne can also cause post-inflammatory hyperpigmentation (PIH) and severe scarring, especially in skin of color.

– Interestingly, many patients come to see their doctor because they want to get rid of their PIH when they should be treated for the primary cause: their acne –

A good acne treatment doesn’t only consist of the proper agents. Having a good doctor-patient relationship is important as well because patient compliance and trust is of utmost importance when dealing with a visible skin condition. Acne can involve long treatment periods and even lead to body dysmorphia . Additionally, acne usually begins in teenage years when most of us aren’t too confident anyways.  

To understand the treatment, let’s take a closer look at the central causes for acne:

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Causes of Acne Vulgaris

These are the main causes of the development of acne vulgaris simplified:

• Excessive Sebum

  • oil produced in the glands of our skin

•  Follicular Hyperproliferation (German: Verhornungsstörung)

  • excessive build up of the uppermost layer of skin

•  Inflammation 

  • in short: a process of the immune system to protect your body from potential harm

•  Cutibacterium Acnes 

  • a bacteria found on everyone’s skin, yet it is overproduced in acne prone skin (former name: propionibacterium acnes)

Other Factors that may cause Acne with particular focus on skin of color:

• Skin Bleaching Cream that contain Corticosteroids 

  • dermatologists refer to this as steroid acne and it can severely worsen hyperpigmentation and also causes more discoloration

• Comedogenic Skin Products 

  • like cocoa butter, coconut oil etc.

Also, beware of hair products!

Things like pomade (hair gel, olive oil, beeswax, mineral oil, petroleum jelly) can easily cause acne.  Pomade acne causes small papules along the hairline and sideburns. 

Treatment approaches

Keeping these causes in mind, we can discuss ways to treat and prevent acne vulgaris: Your treatment regime should target the following:

• reduce sebum production

• reduce inflammation

• reduce amount of cutibacterium acnes

• exfoliate the upper layer of the epidermis
  

—When treating skin of color, it is important to always keep in mind that harsh treatment agents or irritants can cause PIH —

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To reduce inflammation and bacteria, there are topical and systemic antibiotics as well as a topical antimicrobial agent called BPO (benzoyl peroxide). Certain popular combinations are BPO + Retinol (like Adapalene).  This combination is what we call an all-rounder, targeting follicular hyperproliferation, hyperpigmentation and oil production. However, irritation and dryness are common and even are expected side effects of retinol. To make this more tolerable we advise to start by using topicals which contain retinol every other night and in low concentration. 

Remember, when using Vitamin A derivatives like retinol, UV Protection is highly recommended.

Any acne treatment, whether topical or systemic, should include gentle cleansers and hydrating moisturizers in order to reduce additional irritation of the skin. The formulation plays a big role — cream is preferred over gels as gels have higher water content and can cause more dryness. Don’t be misguided: Acne skin is sensitive to irritants,  so physical exfoliators should not be used. 

What is the deal with adult acne and why do I still break out in my 30s ?

Adult acne basically has the same causes as “teen acne”. Also, any changes in hormones (like menstruation or pregnancy) can trigger oil production. Many will notice a flare up just before their menstruation for example. 

Other causes like stress, lack of sleep, lifestyle or diet play a role too… so get them in check.

We also take into account that an oilier skin type and a family history of acne will lead to more acne prone skin. 

Atopic Dermatitis

When we talk about atopic dermatitis (AD),  we are referring to a skin condition which is one of the causes of eczema. Eczema is basically inflamed skin that can lead to itchiness and chronic flare ups. Some common and related symptoms of AD are allergic rhinitis (a fancy medical term for allergies to things like grass, trees, and moss that can trigger nose and sinus inflammation, also known as “hay fever”)  and asthma. 

AD is very common in all populations and frequently first appears with more severe symptoms in childhood and young adolescence with a tendency of such individuals to “ outgrow” this chronic condition as they age.  We emphasize the chronic nature of AD because it is important to understand that this is a persistent, often inherited skin condition which is prone to relapses. The ones suffering from AD will always have to take constant care of their skin and avoid factors which can trigger eczema.

It is important to understand that regardless of whether you are currently symptomatic or not, AD is a chronic disease. Minimizing potential triggers and maintaining a good skincare practice is essential!

The mechanism behind AD explained in a nutshell...

If there is one key point I want you to take home from this article it would be that what causes AD is the fact that the epidermal barrier is disturbed! Imagine a sheet of paper with little holes so that anything on that paper will find its way through these little gaps. Now imagine your skin integrity has loosened up, so things like allergens, bacteria, dust, dirt, and toxins can pass the barrier easily to attack the layers of your skin. Itching makes this process even worse since you contribute to destroying your epidermal barrier, making it even easier for exogenous factors (factors that come from the outside) to pass through. 

Typical findings are a low hydration of the stratum corneum which is the top layer of your epidermis and a higher TEWL (transepidermal water loss, for those who missed this: go back to our lesson on the epidermal barrier), a higher PH and an alteration of the microbiome (which increases your risk of skin infections). 

What does atopic dermatitis look like ?

Typical symptoms of eczema are inflammation, itchiness, redness and edema (swelling). In adults, AD can sometimes present as ‘only’ dry skin with a tendency to redness especially with changes in weather. Common problem areas in both children and adults are the head (specifically the eyelids for some people), neck, flexor surfaces (legs and arms), hands, and feet. 

Let’s talk about potential trigger factors !

Fragrances (also a very common cause for contact allergies), food allergies, citrus fruits, dry dusty environments, winter, harsh detergents, stress, smoking,  over-bathing… to name the most common.

Winter often leads to flare-ups because of the amount of time we spend in indoor heated areas and with lower humidity. On the other hand, while many people experience symptom relief with exposure to the sun and warmth, excess heat, humidity, and sweat may also be counterproductive. 

Of course, this is not a one-size-fits-all situation. Paying attention to how your skin reacts to certain things will help you to notice what triggers your eczema or skin rashes in general.

CLINICAL PRESENTATION

In skin of color , just more pigmented skin, redness (a sign of inflammation) can be less notable leading to false assessment of the severity. Furthermore, small and densely positioned papules are another common presentation beyond the typical signs.

Hyperpigmentation is the result of chronic inflammation, and if it remains under-treated, it can then result in dyschromia which are lighter and darker patches of skin. 

Practical tips:

• Look for products labeled “sensitive-skin” including detergent, hand soap, etc.

• Choose cotton clothing and undergarments whenever you can.

• Be selective with your jewelry. (Nickel is a common allergen, fake jewellery that rubs off on your neck is an obvious no no...)

• Avoid long hot showers and long baths when possible. (Learn more about bathing with skin soothing ingredients)

• Moisturize with a lipid rich barrier protective cream from head to toe within minutes after bathing to lock in that moisture. (check out our skincare section for our favourite hydrating moisturizer) 

• Cream is always better than lotion, milk or gel formulations, since the higher the water percentage in lotions, milks, and gels will tend to dry out already dehydrated skin. The thinner the texture, the more water based it is. (For example, compare shea butter cream to aloe vera gel)

• In skin of color, erythema (redness) might disguise by its more violet or greyish tone which causes under-diagnosis and under-treatment. Learn to recognize if you suffer from redness and point them out if you have to!

• Sometimes redness might also appear as a post inflammatory hyperpigmentation (PIH) even though it is still an inflamed area! Therefore it is always important to search for healthy skin first as a baseline in order to properly categorize the hyperpigmented skin area.

Sometimes inflamed skin in darker skin tones seems to look like a PIH even though it is still inflamed! Very important: search for healthy skin first, then compare it to the eczema patch. 

ABC Therapy:

In an acute phase, topical steroids will quickly do the job: decrease inflammation. A like Anti-inflammatory. Picture it as your little rescue plan! But remember that barrier treatment (redness, itchiness) is an important consideration for acute phases and constant care. Think about wounds that have to heal… you might want to apply a thick soothing cream that you use for any damaged skin. B like barrier treatment. Since it's all about maintenance, constant barrier protection helps to maintain healthier skin and lessen the occurence of flare ups. C like constant care. 

Choose a daily moisturizer to restore and protect your epidermal barrier. 

Furthermore, dermatologists also recommend a proactive treatment regime for patients who have AD. This includes the use of topical steroids that can be applied 2x/week on problem areas (not the face unless your doctor advises you to do so!) which tend to continually flare up, in addition to barrier treatment. 

Please note that since AD is a chronic skin condition we cannot recommend further treatment regimens as AD has to be treated and monitored by your doctor. 

Questions ? Don’t forget to comment below and you will hear from us !

The epidermal barrier

Did you know that your largest organ is your skin?

Our skin works 24/7 to protect us from factors that can cause imbalance and harm us in our daily lives. We all know that healthy skin is in vogue. Whether you are making a quick stop at the drugstore, scrolling through IG, or catching up with friends, the latest skincare trends and products are literally everywhere. 

“At The Questionnaire, we know that skin education is the real secret to healthy skin, so we wanted to start this journey by focusing on our most important barrier: the epidermal barrier.”

Recently I came across a great paper from a renowned dermatology journal that covered a topic that appeard to be very basic: The Epidermal Barrier. The epidermis is our outermost layer of the skin which functions as our body first defence and that is when we speak about the epidermal barrier. 

Well, it is not basic, because understanding the components, like it’s proteins and their functions, helps us physicians and pharmacologists understand the causes of skin imbalances, so that we can create targeted treatments.

I also thought about my allies who suffer from eczema (these dry itchy patches on your skin). Understanding the epidermal barrier will help you too! I am going to break down the basics so that you can look out for some key ingredients you want in your daily moisturizer .

Function of the epidermal barrier

-permeability barrier 

-antimicrobial protection and immune response function

- Protection against UV-Light

-antioxidant barrier

So what is healthy skin?

… a little more than a sun kissed even skintone with no pimple or redness: 

Per definition, healthy skin comprises  a smooth texture, no flaky skin, elasticity, the ability to respond to shearing forces (cold weather, small injuries) without being too fragile.

Transepidermal water loss (TEWL) describes the water loss through the layers of our skin (transepidermal). It is influenced by factors that are caused by our bodys (so called endogen/internal factors) and other factors which come from the environment (exogen/external factors).

If we now look at skin conditions such as atopic dermatitis which key feature are chronic eczema and is commonly associated with asthma and various allergies (in German better known as Neurodermitis – we will cover this topic soon) we can say that they have a higher transepidermal water loss compared to "normal"skin. This is often caused by a lack of production of ceramides (a key protein) and/or genetic mutations in other types of proteins, all of which play a big role in ‚locking in  moisture ’ and protecting our skin against environmental toxins.

The limits of self repair mechanisms

We all have self repair mechanisms, some of which are easy to recognize, like wound healing.  Nevertheless at times we undergo stress, experience climate change, that impacts our skin’s ability to repair itself, leading to skin irritation and can cause  allergic reactions. 

These are the signs:

• Xerosis (dry skin)

• Eczema ( dry itchy patches)

• Itchiness: Mostly because of over dryness and easy vulnerability. 

Since we @ The Questionnaire strive to be inclusive and think diverse I also want to briefly touch up on what the authors of the article found out about differences of the epidermal structure when comparing skin of different ethnicities:

-They found the lowest ceramide ratio in African when compared to Caucasian and Asian skin. Asian skin had the highest!-

Fitzpatrick skintype IV-V, which is a classification on the skin photosensitivity scale ( I always burns, VI is the darkest skintype and never burns) showed lower PH levels, an enhanced integrity of the outermost layer of the epidermis after trauma  e.g. having a wound) and a more rapid barrier recovery.

Another  important takeaway from the article was that darker skin tones have lower ceramide ratios which make it super important to maintain a  good, consistent skincare routine. You may have guessed a key ingredient to look out for in your products, especially if you suffer from dry skin: Ceramides

WE LOVE :

Ceramide (repairs barrier), Glycerin, Hyaluronic acid, and Niacinamide. Take a l

ook at the skincare section to see some examples.

Remember Ceramide and Glycerin containing lotions and daily moisturizing can help you reduce the amount of needed topical steroids when you are suffering from eczema.

Source for this blogpost was the following article: Understanding the Epidermal barrier in healthy and comprised skin: Clinically relevant information for the dermatology practitioner, James Del Rosso et al.,2016.