Dry skin has small, fine pores, even across the nose and chin areas. There may be some flaking skin. Over the cheeks, skin is thin and, in general, the skin may look transparent and delicate, as small blood vessels beneath it are easily visible. Skin is smooth looking, but it feels rough. The client may say it feels "tight" and moisturizer is used constantly to restore comfort. Harsh weather can make it feel even worse.
Normal skin has pores that are medium-size, but there may be more pores along the nose and on the chin. These areas may be oilier than the cheeks and around the eyes. There are few, if any, comedones present. The complexion is bright and feels smooth. Skin tolerates temperature extremes well and does not get irritated or chapped easily.
Oily skin has many noticeable pores. Skin tone may be sallow but appear shiny at times. It will feel oily, especially along the nose and across the forehead and chin. Skin will have fewer wrinkles than the norm according to age group. While there are few if any small wrinkles, deeper lines will predominate. This skin type tolerates cold and wind very well, but not hot, humid weather, which will make it glisten with oil.
Beyond skin type, you must consider age group, which will tell you more about the client's hormonal state, stress levels, lifestyle, and concerns. Next, you need to consider the skin's condition. Skin may have acne or inflammatory conditions; the signs of aging or hormonal imbalance; and it may be sensitive, immune compromised or under the influence of stress —
and these conditions can occur singly or simultaneously to varying degrees.

ACNE AND INFLAMMATORY CONDITIONS
While it's generally assumed that oily skin types are more prone to acne, every skin type and both sexes can be troubled with acne. There are, however, certain noticeable patterns present in women that occur according to age group:
Teenage acne—Occurs down the middle of the face; found in teens going through puberty.
Adult female acne—Includes 20-somethings who have abused their skin with "partying," poor diets, and sun. It is usually located from the nose down. Stress is a big factor as it stimulates the adrenal glands to produce DHEA (dehydroepiandrosterone), which causes acne breakouts. These clients may have some fine lines and their skin is thinner.
Hormonal acne—Includes 30-something-and-up clients who are peri-menopausal or even menopausal. Estrogen and progesterone levels are lower. (Estrogen suppresses the sebaceous activity.) Skin is much thinner and typically has excess facial hair, lackluster skin, and long-lasting acne cysts that are "underground" and occur anywhere.
Examining acne can be difficult. Keep in mind that in order for it to be acne, comedones must be present and the lesions must have plugs. Study the skin closely. Consider your client's history. It's easy to confuse acne with its imitators, which include perioral dermatitis, sebaceous hyperplasia, folliculitis, pseudofolliculitis barbae, acne excoriee, papulopustular rosacea, and MRSA. These acne imitators make up the "red-bump" diseases, which are secondary to inflammatory processes within the body's systems.
External Evaluation: Record the types of lesions, their location, and gradation. An external cause is seldom identifiable in acne, although some cosmetic agents and hair pomades may worsen acne.
Internal Evaluation: Review complications like health or hormonal issues. Certain medications can promote acne including steroids, lithium, some anti-epileptics, and iodides. If your client is sensitive to iodine, then foods like seaweed and sushi will cause breakouts. Anti-depressants have also been associated with acne breakouts, but this has not been proven. While few studies have produced conclusive results linking specific foods and acne, some recent studies have associated milk and other dairy products with the development of acne. Until your client's underlying hormonal imbalance is addressed, you will not be successful with topical acne treatments. The skin's worst hormonal enemy is androgen. Acne can be aggravated or initiated by increased androgen levels. For this reason, any disease, condition, or concomitant hormonal issue that raises androgen levels must be addressed to achieve results with acne.
Emotional Evaluation: It is thought that DHEA and glucocorticoids, such as cortisol, also exacerbate acne. Both hormones are released during periods of emotional stress.

AGING AND HORMONES
Aging is a phenomenon that occurs because of a combination of many factors. Aging causes cells to lose their valuable water within. Water is lost from the materials that keep collagen and elastin factories going and water is lost from every layer of the skin. Genetics, the environment, and hormones are what influence aging and cellular water loss. The types of aging include intrinsic, extrinsic or environmental, and hormonal aging.
Intrinsic aging is considered the natural aging process, extrinsic aging is also known as "environmental aging," and hormonal aging occurs as levels of estrogen decline. Each of your clients will experience a combination of all three types of aging to certain degrees. While there's not much that can be done about genetics, environmental aging is largely preventable. Hormonal aging, however, is the most troublesome to treat effectively as it requires a multidisciplinary approach and a great understanding of the body's systems and complex interactions.
Explained simply, hormonal aging does not turn on like a light switch, rather, it's like a dimmer switch that slowly brightens as chronological age progresses, and the speed at which it brightens is different from woman to woman. Regardless, there are certain markers that can be found during skin evaluations and these markers can tell us much about what may be happening beneath the surface.
External Evaluation: Skin symptoms at both ends of the spectrum—acne and oiliness, or dryness and dull skin; skin thinning; dead skin cell build-up; skin discoloration; brittle hair or hair loss; excessive hair growth, such as on the chin—may be present.
Internal Evaluation: Irregular periods may be present. The only predictable thing about hormones is their unpredictability. As such, one magic pill or solution just doesn't exist. In all cases, a physician can perform saliva or blood tests to determine hormone levels and the course of treatment.
Emotional Evaluation: Constant, unrelenting stress has also been shown to accelerate hormonal aging as stress hormone overproduction can cause adrenal gland fatigue. Studies have indicated that adrenal fatigue may be a factor in many related conditions, including fibromyalgia, hypothyroidism, chronic fatigue syndrome, arthritis, and premature menopause. In addition, adrenal gland fatigue can cause acne, hair loss, depression, weight gain, a decline in the immune system and insomnia. Smoking can also accelerate hormonal aging.

SENSITIVE SKIN AND IMMUNITY
Sensitive skin indicates that there's a barrier function problem—cells will be damaged, water loss will occur, and inflammation will set in as germs and viruses infiltrate. Inflammation is a key to the immune system. It tells us our immune system is working. Without inflammation, we'd all die. The goal is to control inflammation and make sure that the skin's immune response is not an overreaction.
External Evaluation: Skin may be red or inflamed. Areas around the nose, mouth, and eyes may sting or burn. Sensitivity could be the result of overexposure to the sun or environmental factors. Healing slows. Skin texture may be rough and dry with discoloration from post-inflammatory hyperpigmentation.
Internal Evaluation: Inflammatory diseases may be present such as Crohn's disease, ulcerative colitis, nephritis, and systemic lupus erythematosus. In addition, diabetes, heart disease, arthritis, and cancer can cause inflammatory responses as well.
Emotional Evaluation: Stress has a negative influence on all of the body's systems. It can lead to bad lifestyle choices, poor diets, and lack of sleep, which is essential to health and immunity.

STRESS AND SKIN
Stress is like inflation—it just keeps increasing for most of us. Stress can be divided into four categories: acute stress, episodic acute stress, chronic stress, and cultural stress.
Acute stress is the most common kind of stress. It's short term and can come from things like taking a test or giving a speech. Episodic acute stress occurs with those whose lives are so disordered that they thrive in chaos and crisis—people who are always rushed, but perpetually late. Chronic stress is the stress people feel when they cannot see a way out of a miserable situation, like poverty. Cultural stress is constant, pervasive, and super-imposed on all other types of stress and is the result of lifestyle and who we are.
External Evaluation: Skin may be oily with acne. Dark under-eye circles and puffiness may occur from sleeplessness. In addition, muscular problems; back and jaw pain; sweaty palms; cold hands or feet; and shortness of breath may all be present.
Internal Evaluation: Digestive problems, constipation, diarrhea, high blood pressure, dizziness, tension headaches, chest pain, heart disease, panic attacks, and irregular periods might exist.
Emotional Evaluation: Emotional distress, a combination of anger or irritability, anxiety, and depression are considered the stress emotions.

TWO BASIC PRINCIPLES
I have come to realize that everything I do to help people renew, rejuvenate, and protect their skin is based on two basic principles: to maintain the barrier function of the skin and to help the skin hold as much water as possible. Once the skin barrier is addressed, you can focus on increasing cellular water and keeping it inside of the cells. Hydrated cells renew properly, function optimally, and are more resilient to stressors that cause inflammation. To do this, the body needs to be flushed with nutrients that will help increase water from within and repair cell damage. Drinking water does little to help intracellular water.
Skin is a water gauge. Dry, thin, sagging skin, suggests that the problem doesn't stop there. The damaged, water-deprived fibers and cells and the gel-like substance in which they are all embedded, indicate that similar situations exist in the cells of the heart, the muscles, the liver, the walls of the blood vessels, and the joints.
The goal for aestheticians is to treat what they see and to consider everything they don't see. And this begins with an evaluation that explores external, internal, and emotional factors. With this approach, I guarantee that you'll never look at skin the same way again. Everything is indeed connected. Recognizing this fundamental fact is half the battle.

Howard Murad, M.D., FAAD, is recognized as one of the world's foremost authorities on skin health. A board-certified dermatologist, pharmacist, and Associate Clinical Professor of Medicine at UCLA, Dr. Murad oversees the Murad Inclusive Health® Center and Spa, Murad Medical Group, and an active clinical research laboratory. He is a practicing dermatologist, author of two successful books; Wrinkle-Free Forever and The Cellulite Solution, and is the CEO and founder of Murad, Inc. For more information, call 310-726 3335, or visit www.murad.com.