Dermatologist Debriefs

Rethinking Skin Types

• Stefanie Williams

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Have you been misdiagnosing your own skin? That seemingly simple question sits at the heart of Dr. Stefanie's revelation about the flawed skin type classification system most of us have followed for years.

Dr. Stefanie takes aim at the traditional four-category skin type model and proposes a practical revision that could transform your skincare routine. For example, if you've ever felt caught in the frustrating cycle of treating skin that feels dry but still breaks out, this may not be dry skin at all, but rather skin experiencing microinflammation creating a sensation of dryness. 

This explains why your skincare routine may have been making matters worse instead of better—you may well have been treating the wrong condition! 

By expanding to a five-category system, Dr. Stefanie provides a simple yet significantly more effective framework for understanding our skin's needs which is an important step in helping to break the frustrating cycle of mismatched skincare products and disappointing results.

Speaker 1:

Dermatologist debriefs. Join no-nonsense dermatologist Dr Stephanie Williams as she debunks myths and shares her professional insights, separating facts from fiction, in just a few minutes.

Speaker 2:

I promise to speak about skin types and have a look at the usual four group classification, which often is quoted as dry skin, oily skin, combination and normal skin. Firstly, we do, of course, need to acknowledge that no simple skin type categorization can ever be perfect, as our skin is so highly individual and just putting it into less than 10 categories will never be perfect. However, I do think that there is a merit in having a simple grouping similar to this one, as it can be really helpful when choosing skin care, for example. So what I didn't want to do is create a super complex classification system which I've seen other dermatologists do, which is then simply not fit for purpose in daily life. For that reason, what I would much prefer is to speak about a very simple tweak to the existing skin type regime, which keeps it super simple, easy to remember, very user-friendly, but it simply fixes a major flaw in it. That just to say that the term normal skin is, of course, a little bit problematic, as it implies that the other skin types are abnormal and therefore inferior, which is, of course, not the case. So what I prefer to call this group is uncomplicated skin, as it sounds a little less judgmental compared to normal skin. But my main point today is to fix that major functional flaw, so to say, the current system has, which is the dry skin category, and that's because dry skin is a group that really needs dividing into two separate categories, namely dry skin without breakouts, which is the classic real dry skin group, and perceived dry skin, where the person reports they do have dry skin but at the same time suffers with congestion or breakouts, like acne blemishes, for example. This is a really common skin type and I know this because I ask my patients every single time what skin type they believe they fit into, and this is the most common one that is reported to me. However, while these individuals report their skin as dry to me, report their skin as dry to me, it isn't really dry skin in many cases, but bear with me.

Speaker 2:

So firstly, I want to talk about what is truly dry skin. So if you really suffer with dry skin, then this is characterized by a lack of sebum, so the oil that's produced in our skin's oil glands, sebum, so the oil that's produced in our skin's oil glands. There may be some deficiencies in certain types of ceramides or other changes, which then leads to excess trans-epidermal water loss and ultimately results in a too low water content in the stratum corneum. This is the outer layer, the stratum corneum. This is the outer layer, the outermost layer of our skin.

Speaker 2:

Dry skin often feels tight and uncomfortable and may look dull, rough or or flaky, but one thing real dry skin does not do is being congested, meaning showing blackheads or whiteheads or breaking out with acne blemishes. So what then? Is that very commonly reported skin type where the person feels they've got dry skin but they also suffer with occasional breakouts or congestion? And, as mentioned, I see this in clinic all the time patients reporting that their skin is dry or dehydrated but they are also breaking out really common indeed. And what I see is when patients reporting this to me, it is usually based on a misinterpretation of how the skin feels.

Speaker 2:

So where the perceived dry skin is not real dryness but actually a sign of micro inflammation. This is common in rosacea prone skin, for example. The skin feels dry, tight and sensitive and is reactive, but this sensation is due to a low-grade inflammation, not to dryness real dryness in the skin. The mechanism of action of this misperception is that microinflammation can cause a nerve hypersensitivity, leading to sensations of dryness, burning or stinging, even when the skin's oil and water content may actually be normal. And here's the problem treating this perceived dry skin with lipid-rich, occlusive creams that real dry skin benefits from will actually worsen the congestion and the breakouts. So this is not the solution.

Speaker 2:

Instead, what we want to do is use anti-inflammatory ingredients, but in a very lightweight yet hydrating product base, and these anti-inflammatories may be over-the-counter skincare ingredients for mild cases, or there may be prescription strengths anti-inflammatory topicals for more pronounced cases. And I'm not talking about topical steroids here, by the way way, but about anti-inflammatories like metronidazole, ivermectin, azelaic acid, all of which have anti-inflammatory benefits in addition to their other properties. So the key for these cases of perceived dry skin where breakouts or congestion are present, is not to use lipid-rich skincare, because that will backfire big time, but to use anti-inflammatory ingredients which will get rid of that dry skin feeling and the perceived need for rich moisturizers. I do this in clinic all the time. I introduce anti-inflammatory topicals and change my new patient's skincare regime to lightweight products, and after three months, when I see them again, they come back and almost always report. I can't believe I'm using less rich skincare now, but my skin feels less dry.

Speaker 2:

So, in summary, today's take-home message is that we should subdivide the dry skin category into two groups, which would then give us five groups in total instead of the usual four. Give us five groups in total instead of the usual four, namely uncomplicated skin, oily skin, true dry skin, which does not come with congestion or breakouts, and perceived dry skin with congestion or breakouts. And then, of course, there's combination skin, which is also very common skin, which is also very common, as the T-zone is often more oily than, say, the cheek area. I highly recommend using these five skin types instead of the usual four, and I do understand that this system is by no means perfect, but it is still very simple and miles better than the four category system and, most importantly, it really offers real life benefits when selecting skincare, as understanding the nuances between skin sensations and real symptoms is key to effective skincare personalization skincare personalization.

Speaker 2:

And before I finish, let me just reiterate that sensitive skin is not a diagnosis or a skin type, but a mere symptom that can be triggered by a variety of causes and affect various skin types. And also, in one of the following weeks, I should really speak about the difference between dry and dehydrated skin. Spoiler alert there isn't a clear difference, but more about that in the future. It's very complex, but I will dissect it for you For today. I hope this all makes sense and I will speak to you soon.