skin care

A guide to skin care Dr Justine Hextall FRCP Consultant Dermatologist

Tackling skin textural changes

One of the most common complaints we have from individuals from their 30’s onwards is that they feel their skin looks dull, pores are more prominent and their skin has an uneven tone, often with areas of pigmentation.

There is much that can be done to help this. Firstly we start with diet and skin care regime . If you are dehydrated, not having a healthy diet with sufficient fruit and vegetables you will notice this reflected in skin.

Skin care regime is so important and technology has moved on significantly in this area. Topical vitamins and antioxidants will protect skin from everyday stresses that are difficult to avoid such as UV exposure, pollution amongst others can be mitigated against with topical active treatments, particularly at night when our skin regenerates. During the day I advocate a high factor sun cream preferably with antioxidants that can mitigate against damage caused by UVB and UVA and also longer wavelengths that we now know affect our collagen and elastin.

Once I am happy that we have a healthy skin care regime, I may suggest corrective treatments such as microneedling. This is a type of treatment that uses small needles to cause tiny punctures in the skin. These small contact points encourage the body to create a wound healing response and renew the skin cells. As your skin repairs, the production of collagen and elastin is triggered to give an almost immediate plumping effect. It can also help tackle other skin damage such as scarring, dark marks, sun damage and ageing. We use a Dermapen device that can penetrate at different levels in the skin. By using different depth needles we can ensure that the collagen is reached at different depths of your skin from the delicate skin around the eyes to the firmer skin of your mid-face. We combine this treatment with hyaluronic acid and anti-oxidants to give you that glow. We recommend a course of 3 treatments.

How do you define combination skin?

Combination skin is in my view skin that has areas that could be described as oily in combination with drier areas. In fact due to the distribution of the oil secreting (sebaceous) glands of our face we all have combination skin to some degree. In some individuals I feel that skin care regime causes areas of dryness and sensitivity, hence the term combination. It is very tempting to use heavy, often alcohol based cleansers when oiliness is a concern. The issue with this is that the skin barrier can become unbalanced and become inflamed, dry and in fact often produce more oil in areas to compensate . This may be referred to as ‘combination skin‘ when in fact it is unbalanced skin as a result of the wrong skin care regime.

What skincare routine would you recommend for combination skin?

I recommend a gentle wash, preferably mildly acidic ,matching the skin’s natural pH. When skin is rinsed it should feel calm and hydrated not tight. This skin friendly approach stops the over production of oil to compensate. A light moisturizing lotion keeps skin hydrated without being comedogenic.

Should you exfoliate combination skin?

Exfoliation is helpful to remove dead skin cells and excessive oil. I recommend this no more than twice a week though and often a hot flannel rubbed firmly over the skin will effectively remove any build up on skin.

How should you treat acne if you have combination skin?

The same rules apply. A gentle wash stops the skin becoming to dry and sensitive. light skin peels and light moisturizer. Salicylic acid in washes and masks works to both breakdown the build up of skin and oil in blocked follicles and also soothe skin. benzyl peroxide again helps to unblock pores and reduce inflammation. Interestingly studies have shown that benzyl peroxide reduces vitamin E in skin a natural anti-oxidant so I always recommend applying a light vitamin E cream when treating acne.

How should you treat areas of dry/flaky skin?

Again gently exfoliate skin once or twice a week. Apply a calming and hydrating mask looking for ingredients such as vitamin E, glycerin , salicylic acid, calendula and aloe vera. Remember it may be your cleanser unbalancing your skin. Try a cleansing lotion rinsing with a mineral water spray such as Avene eau thermale or Cetaphil gentle wash.


Are there any make-up tips to share?

Avoid heavy coverage and powder based bases as oily bases may exacerbate acne and powder compacts will highlight areas of dryness and make skin appear dull and lifeless. I love Nars sheer glow , it is light and lifts skin reflecting light away from problem areas giving the illusion and clear hydrated skin. Dark circles can be a problem as we age. Hyaluronic acid serums are light in texture but are excellent at plumping skin. When the skin around the eyes is hydrated it reflecte light better and the dark circles are less pronounced. I love Lemonaid by Benefit. It helps to neutralize dark shadows and reflects light beautifuly. Crucially it stays in place.

1.What changes or additions in our skincare routine should be made if you’re affected by pollution? Those affected by pollution the city often don’t need reminding as it is obvious when cleansing as the cleansing pad is often black

The pollution that is referred to as fine particulate matter i.e. is 2.5 microns in diameter and less. Is the most damaging as it that penetrates our skin and lungs . It is now emerging that inhaled particles will also damage skin indirectly which makes sense. The smaller particles that penetrate skin cause free radical damage which in turn leads to the breakdown of collagen and elastin. This leads to skin wrinkles and sagging. We also know from studies that pollution causes skin pigmentation and this is exacerbated by exposure to certain wavelengths of light. So if you are a city dweller it is even more important to make sure you have adequate sun protection.

Essentially any skin regime will need to include careful cleansing at the end of the day. Be careful to use a gentle cleanser however that will not strip the skin barrier as we know that pollution leaves our skin often drier , more irritated and inflamed. Choose a gentle wash that matches the skin’s mildly acidic pH . If your skin feels tight after cleansing, it is likely you have disrupted your skin barrier.

After this I recommend an active serum that contains anti-oxidants such as vitamin C , to help mitigate against free radical damage. Vitamin C also inhibits the enzyme Tyrosinase, so it helps prevent melanin production reducing pigmentation and helping to keep an even skin tone . A diet rich in anti-oxidants will also help to support skin against daily damage from UV exposure and pollution. There are some very good anti-oxidant supplements out there that will also help. Always wear a high factor sun cream. The physical blocks particularly containing iron oxide and large particle titanium dioxide and zinc oxide can help to protect against the longer wavelengths we see with visible light . We now know that visible light play a part in both damage to collagen and elastin and skin pigmentation I.e. sun spots and melasma.

I wash my face with water . Is this an issue?

On the whole no . Tap water is usually fine unless you have naturally dry or sensitive skin.

For many years now there have been studies associating hard water areas and an increase in skin dryness and an exacerbation of eczema. A recent study published in Journal of Allergy and Clinical Immunology looked at 1300 babies from across the UK and the author stated :”Our study builds on growing evidence of a link between exposure to hard water and the risk of developing eczema in childhood.

It’s not yet clear whether calcium carbonate has a direct detrimental effect on the skin barrier, or whether other environmental factors directly related to water hardness, such as the water’s pH, may be responsible.” As a dermatologist I am frequently told by eczema sufferers that their skin often improves when spending time in soft water areas.

What is hard water and why does it affect our skin?

Hard water is a common problem for many households. This type of water contains many minerals, particularly calcium and magnesium occurs when ground water seeps through the soil and rocks. There are many theories as to why hard water seems to cause skin dryness and irritation . It is most likely that deposits are left on the skin after washing causing irritation and there is also a suggestion that the minerals change the skin pH, disrupting the skin barrier.

Chlorine in water, especially in high concentration in swimming pools for example will definitely change skin pH and affect the skin’s natural microbiome . I always recommend rinsing swimming pool water off immediately preferably with a mildly acidic cleanser and moisturize well.

What is the story with waterless cleansers?

These waterless cleansers tend to have a skin barrier friendly pH and tend to not unbalance the skin. If the skin pH is maintained then the skin barrier is less likely to be disrupted , as a consequence skin is calmer, maintains its hydration more effectively and is less likely to be dry and irritated. This is important particularly in the context of an inflammatory skin condition such as acne or rosacea. One of the first changes I suggest to acne sufferers is to adopt a simple cleansing routine that does not strip the skin barrier . There are very gentle water sprays that do not contain the minerals that constitute so called hard water. This really can make a difference, the most likely benefit to these cleansers is the fact that the skin pH is not changed. The skin barrier is not disrupted and as a consequence skin is calm and hydrated.

The benefit of powder cleansers is that you make them up when you need to use them. A such, they do not require preservatives which is ideal if you have sensitive skin. My only concern is that some constantly exfoliate skin. Daily scrubbing can leave sensitive skin red and inflamed and can exacerbate for example visible thread veins.

How do I get my skin to glow ?

Glowing skin is the holy grail of dermatology. What gives this appearance and what can we do to help our skin?

Healthy skin looks calm, hydrated and even-toned, this reflects light better and is described as skin glow. Our skin cells are always renewing, from time to time gentle exfoliation allows the removal of dead skin cells again this makes skin appear brighter and allows better penetration of topical serums and emollients.

At night time skin renewal is at its peak, this is the time to apply active ingredients such as vitamin C and other anti-oxidants. Tackle pigmentation with vitamin C and liquorice. Dry inflamed skin is a common problem I encounter. I tackle this by looking firstly at skin care regime. I would say 50% of those I see in my clinic have too complicated a regime that is actually damaging the skin barrier and unbalancing the natural acidic pH. Finding a gentle cleanser is the most important part of a good skin care regime.

Applying anti-oxidant serums and oils will help to reduce inflammation and mitigate against the free radical damage caused by UV exposure, pollution amongst other common daily stresses our skin experiences. To help hydrate skin I recommend applying the active serum and then applying a moisturizer. Once a week I recommend a hydrating facial mask.

If despite these changes to your skin care regime skin still looks dull or lacking hydration, there more active steps you can take. I recommend skin needling especially when combined with anti-oxidants and plumping hyaluronic acid. This will stimulate new collagen. Skin appears firm and clearer. A course of 3 treatments is recommended. If down time is an issue then IPL laser in my view is an excellent solution. By varying the wavelengths different issues can be tackled, reducing pigmentation, thread veins and stimulating new collagen.

Finally to really plump and hydrate skin, skin boosters work incredibly well. Here hyaluronic acid, a natural substance found in skin is injected into the skin attracting water and giving deep long lasting hydration and skin glow.

Our skin reflects our lifestyle, especially as we age. regular exercise and a healthy balanced diet is wonderful for skin health.

A diet rich fruit and vegetables will supplement our bodies natural anti-oxidant defences. Yellow and orange peppers for example contain caretinoids, powerful anti-oxidants. Tomatoes contain lycopene that protect against sun exposure .Advocados contain high levels of Vitamin E, an important skin anti-oxidant. Oily fish and nuts help to maintain a healthy skin barrier and swapping your daily latte for a cup of green tea will significantly boost anti-oxidants and protect your skin.

What can a cream actually do?

The area of the skin where the collagen and elastin are found is in the dermis, these structures keep skin firm, the so-called skin’s scaffolding. As we get older intrinsic ageing and the effects of environment e.g. UV exposure, stress, pollution, smoking etc start to degrade the collagen and elastin. As a consequence wrinkles develop and skin starts to sag. It makes sense therefore that it would be unlikely that applying a cream would immediately correct this deficit. Although newer technologies allow for deeper penetration of topical preparations I am not aware of any cream that can truly firm skin after a few applications with lasting results. That said serums and creams with anti-oxidants can protect skin and mitigate against the free radical damage from the effects of pollution and sun exposure amongst other things. So in effect they can protect against damage to the skin’s collagen and elastin over time, if used regularly.

What can you do to prevent sagging where possible?

Over time we inevitably lose volume in our faces this is though loss of dermis, fat and muscle and bony changes. That said there is increasing evidence that external factors such as sun exposure, pollution, stress etc. have a significant effect on skin .A healthy diet with anti-oxidants, stopping smoking, reducing alcohol and stress and wearing an effective sun screen can dramatically reduce these extrinsic ageing factors. Twin studies increasingly show that these external variables can be more important than genetics in how our skin ages.

Can non-surgical procedures actually lift skin?

I am a believer in maintaining skin health and having a good skin care regime, healthy diet and having intermittent non-surgical interventions such as micro-needling, Mesotherapy and laser treatments can over time significantly slow skin ageing. Micro-needling works by mechanically damaging collagen, thus stimulating new collagen. Fractional laser causes multiple so called microthermal treatment zones in the epidermis and dermis. The damaged cells are expelled and this stimulates new collagen. Mesotherapy works by injecting a cocktail of vitamins into the skin to aid development of new collagen and give skin its glow.

What can I do to prevent or at least reduce skin sagging?

Always look for skin creams with active ingredients that protect skin from external damage. Always wear a sun cream even in winter. Remember although there is less UVB around in Winter, levels of UVA are still significant. UVA is a longer wavelength that can penetrate through glass. UVA ( or UV-ageing ) will over time cause a breakdown in collagen and elastin. It is vital therefore to make sure your sun cream not only protects against UVB, but also UVA. There is also a lot of talk now about the damaging effects of even longer wavelengths such as Infra red A and high energy visible light ( HEVL) that is emitted by screens. With this in mind physical blocks such as zinc oxide may be important as they simply work by reflecting light away from skin. There are also sun creams with anti-oxidants that also help to mitigate against the free radical damage from light exposure.

Any lifestyle tips that you recommend?

Firstly stop smoking. Smoking like sun exposure causes free radical damage. This damage causes the up-regulation of enzymes such as MMP-1 that breakdown collagen and elastin. There is increasing evidence now that pollution particularly in conjunction with UV exposure causes skin ageing. Topical and oral ant-oxidants can help to protect against free radical damage from the above. A diet rich fruit and vegetables will supplement our bodies natural anti-oxidant defences. Yellow and orange peppers for example contain caretinoids, powerful anti-oxidants. Tomatoes contain lycopene that protect against sun exposure .Advocados contain high levels of Vitamin E, an important skin anti-oxidant. A healthy diet, gentle exercise and sun protection will all help to protect skin and ultimately reduce skin sagging.