Written by, Lillian Soohoo, MD
In this article, I will share my experience treating Asian patients over the years and examine some of the specific concerns regarding Asian skin. The topics will include a discussion of the characteristics of Asian skin, sun protection, and specific tips to improve the appearance of aging skin.
The US Census in 2020 reported nearly 20 million people of Asian descent in the US. An additional 4 million respondents identified as being Asian in combination with another race. Thus, the total Asian American population in 2020 was about 24 million people or 7.2% of the total US population. This represents an increase of over 2 million Asian Americans compared to the 2018 US census (Figure 1).
(Figure 1, 2018 US Census)
The US government predicts that Asian Americans will total 40 million people by the year 2050. Although typically classified as a large homogenous population in US political discourse, Asian Americans represent many nationalities and cultures. General physical characteristics of Asians are well-known and recognized worldwide as dark brown to black hair and dark eye color. These are gross generalizations that are rapidly becoming less relevant due to interracial mixing and fashion trends. There is also much diversity in the degree of skin pigmentation in Asians and this ranges from very light, pale skin to more medium and deeper brown skin tones.
So…what is different about Asian skin?
Characteristics of Asian Skin
Asian skin has an increased amount of melanin (or dark brown pigment) as well as the melanin-producing cells known as melanocytes. Asians in general have more melanin and more numerous melanocytes in the skin compared to Caucasian skin. Even fair-skinned Asians have more melanocytes than most Caucasians. These pigment-producing cells or melanocytes in Asians tend to be more sensitive to ultraviolet light (UV), such as the sun and tanning booths.
In Asians, pigment-producing melanocytes are also more easily stimulated to make brown pigment in response to any type of skin irritation or inflammation such as pimples, insect bites, rashes, cuts and scratches. So all of these factors: sunlight, irritation, inflammation and trauma, will result in more brown pigment (darkening) in Asian skin as compared to Caucasian skin.
This tendency for Asian skin to produce more brown color is noticeable as the unwanted brown spots caused from pimples, bug bites and other sources of skin irritation. This is known in dermatology as post inflammatory hyperpigmentation (PIH). Asians and other darker skin types share this skin characteristic of post inflammatory hyperpigmentation whenever there is skin trauma and inflammation.
Another big difference in Asian skin as compared to Caucasian skin is in the dermis. This is the second layer of skin below the topmost layer, known as the epidermis. The dermis is the deeper second skin layer which contains most of the collagen-producing cells and also contains blood vessels.
Asians have thicker skin because we have a thicker dermis due to larger and more numerous collagen-producing cells (known as fibroblasts) in this second layer of our skin. All those extra fibroblasts produce extra collagen which helps to preserve our skin’s elasticity. This means less obvious wrinkling and sagging from aging and sun damage. This also helps explain why sun damage typically appears 10 to 20 years later in Asians as compared to Caucasians.
The downside to having more collagen-producing fibroblasts in the dermis is the increased tendency in Asians to form thick, rubbery keloid scars after skin injury, such as surgery. These thicker keloid scars can grow to be even larger than the original wound and can become extremely itchy and unattractive. In Asian women, for example, the surgical scar from childbirth after a cesarean section is quite common and may be unsightly and itchy for years.
Types of Skin Aging
Aging is a biological reality. Asians show signs of skin aging much later, about 10-20 years later than Caucasians. The changes appear early on as brown spots and discoloration of the skin. It progresses to rougher skin with uneven texture. Sagging of the skin is due to loss of skin elasticity and gravity results in the descent or “falling down” of the midface. In Asians, this results in further flattening of the cheeks under the eyes and sagging of both the upper and lower eyelids. This commonly causes jowls or sagging at the jawline and upper and lower eyelid bags. Eyes also gradually appear smaller in size due to drooping of the upper eyelids. Wrinkles form as a much later sign of aging in Asians.
There are two types of skin aging. The first type of skin aging is called chronologic or intrinsic aging that occurs naturally with just the passage of time. Usually the skin is unblemished with only fine wrinkles and loss of fat or thinning of the skin. This type of skin aging is often delayed in Asians, mostly because of a thicker dermis. An example of purely chronologic or intrinsic aging on your own body is easy to see. Look at the clothing covered areas of your body such as the buttocks or in women, the breasts. Since these areas are not exposed to the sun or environment, your skin may look the same in these areas as you did in childhood.
The second type of skin aging is environmental or extrinsic aging, which is primarily due to environmental factors such as health status and lifestyle habits such as sun exposure, tobacco, alcohol use and diet. These environmental or external factors are by far the most important determinants of skin aging. Environmental factors such as sun exposure and smoking significantly accelerate aging of the skin. The face can look decades older than covered areas of the body which are protected from daily sun exposure.
It is estimated that 90% of the skin changes associated with aging are due to ULTRAVIOLET or UV exposure to sunlight.
So how can you prevent most skin changes associated with aging? Avoiding the sun is the best way.
Protecting Your Skin from the Sun
The most effective way to protect your skin from the effects of sun exposure are all of the following:
Clothing: UPF is the measure of how much ultraviolet protection is given to clothing, hats and fabrics. This number indicates what fraction of the sun’s UV rays can penetrate the fabric. A shirt labeled UPF 50 allows 1/50th of the UV radiation to reach your skin. The higher the UPF, the better. In general, The darker the fabric color and the tighter weave of your clothing fabric is best. A white t-shirt which is light in color and has a relatively loose weave, only provides a UPF of 4 to 6 and when it gets wet, and the fibers stretch out even more, its UPF is reduced to about 2. Appropriate clothing with at least an UPF of 50 will always be superior to sunscreen for skin protection, since it is a more consistent and effective barrier to UV.
Shade is the obvious best choice for sun protection, but not always considered. If possible, schedule your outdoor activities (such as children’s pool parties and swim lessons) outside the peak daylight hours of 10 am to 4 pm. Even outside these peak times, you will be exposing your skin to damaging UV rays. If you can see light through your shade, you are still receiving UV radiation.
Sunscreen affords important sun protection, but is not as effective as most people believe. SPF stands for sun protective factor and refers only to protection from UVB rays, not UVA rays, which are also present in sunlight and can cause premature aging and skin cancer. Daily sunscreen use has been shown to reduce the risk of developing all forms of skin cancer by 50%. A broad spectrum sunscreen blocks both UVB and UVA. Using one with an SPF of at least 30 is the best and you should reapply every 2 hours or after sweating or toweling off when swimming. Most people do not apply enough to receive the actual SPF on the label since it takes a shot glass full of sunscreen (six teaspoons) to adequately cover the body. Sunscreen should never be considered as complete skin protection.
Sunscreen ingredients can be confusing, but knowing the difference is important so you can select the right one for you. Zinc-oxide-containing sunscreens are better for sensitive skin. Zinc-oxide is a non-irritating mineral that covers the skin like a blanket to block the sun’s rays. This is different from chemical sunscreen ingredients such as oxybenzone, avobenzone and others (eg, octisalate, octocrylene, homosalate and octinoxate). These chemical sunscreen ingredients actually absorb UV rays away from skin cells. Chemical sunscreens should be applied at least 20 minutes before sun exposure so that they can be adequately absorbed into the skin. Many of these chemical ingredients can be irritating or cause allergic rashes in people with sensitive skin.
Remember that wearing sunscreen, whether mineral (zinc-oxide) or chemical, is better than not wearing sunscreen at all. It is well-established that sunlight is cancer-causing and that protection from all forms of UV will reduce the chances of developing skin cancer. Also, it is not known if there are any long-term consequences from using chemical sunscreen ingredients. My personal preference has always been to stick to zinc-oxide-only sunscreens, if available. Zinc-oxide is as effective as chemical sunscreen ingredients and formulated such that it cannot be absorbed through the skin. There are many brands of zinc-oxide-only sunscreens that you can Google, just be sure to read the label to make sure you know what you’re applying onto your skin.
And finally, always go see your dermatologist for an annual total body skin check. This is recommended by The American Academy of Dermatology for all adults. Skin cancer is the most common type of cancer in humans and early detection can be lifesaving.
Improving Skin Appearance
The number one anti-aging tip is to protect your skin from all sources of UV light, especially the sun. Remember 90% of aging changes in the skin such as freckles, wrinkling and roughness are due to photo damage from sunlight.
Avoiding skin irritation is also advisable, since post-inflammatory hyperpigmentation or darkening can occur easily in Asian skin. Remember that it is important to use non-irritating skin products for routine and cosmetic skin care. You should also treat common inflammatory skin conditions such as acne to avoid undesirable brown spots.
Asian individuals frequently seek cosmetic skin treatments to achieve smooth skin and flawless complexions, but careful consideration to prevent scarring and hyperpigmentation due to irritation is essential.
Avoid fads and always consult an experienced dermatologist for skin care guidance to ensure that you are using the right products for your skin.
Many over-the-counter skin care products aimed at removing unwanted brown spots and other signs of skin damage just don’t contain sufficient levels of active ingredients to provide the most effective results. For example, most skin lightening products available at the dermatologist’s office are far stronger in concentration while also formulated to be gentler-to-the-skin than the products you find at high-end department stores or online. Dermatologists can create an individualized skin care plan for you to target your specific skin concerns while taking into consideration your Asian skin type and skin sensitivities as well as your lifestyle.
Procedures such as chemical peeling, laser or light treatments (Fraxel, Clear and Brilliant, PiQO4 laser, Intense Pulsed Light of IPL), and even liquid nitrogen (freezing) are all effective in improving brown spots, but only when performed under the direction of an experienced dermatologist who has extensive knowledge of Asian skin and the risks for post-inflammatory hyperpigmentation.
In most cases, pretreatment of the skin with the use of prescription-strength topical fading products both before and after the chemical peel or laser treatment is strongly recommended in Asians to ensure the longest-lasting results. It is important to remember that meticulous sun protection of your skin is as important as any treatment choice when considering removal of brown spots in Asian skin.
Dr. Lillian Soohoo is a board-certified general and pediatric dermatologist who has been practicing in the Silicon Valley for over 25 years.