Conflict of interest The authors have no conflict of interest to declare. All the authors approved the final version of manuscript and submission. All authors have participated sufficiently to take public responsibility for appropriate portions of the work.
Relationship between food intake and cutaneous solar elastosis adjacent to basal cell carcinoma
Article first published online: 24 NOV 2011
© 2011 The Authors. Journal of the European Academy of Dermatology and Venereology © 2011 European Academy of Dermatology and Venereology
Journal of the European Academy of Dermatology and Venereology
Volume 27, Issue 1, pages 25–30, January 2013
How to Cite
Husein-ElAhmed, H., Aneiros-Fernandez, J., Gutierrez-Salmeron, M.T., Aneiros-Cachaza, J. and Naranjo-Sintes, R. (2013), Relationship between food intake and cutaneous solar elastosis adjacent to basal cell carcinoma. Journal of the European Academy of Dermatology and Venereology, 27: 25–30. doi: 10.1111/j.1468-3083.2011.04344.x
Funding sources None.
- Issue published online: 18 DEC 2012
- Article first published online: 24 NOV 2011
- Received: 7 June 2011; Accepted: 26 October 2011
Background/Objective Studies suggest that diet may influence in skin ageing and skin appearance. However, the effect of diet in the elastotic changes of dermis, which is the main histological sign of ageing, has not been studied previously. The objective was to investigate if the dietary habits influence the dermal elastosis observed in BCCs.
Materials and methods The 136 patients with facial BCCs, who underwent surgery, were interviewed to assess the consumption of fruit, vegetables, fat, red meat, coffee and tea. We reviewed 136 specimens of BCC to identify the presence of solar elastosis. We also analysed clinical variables such as gender, age, phototype and smoking.
Results Severe solar elastosis was found in 22 patients (16%), middle reticular dermis in 37 (27 %) and 77 patients (57%) had abscence or light elastosis. Fat consumption was reported by most of participants from our sample, while fruit and tea consumption was less common. Intakes of fat, vegetables and coffee were not associated with the grade of elastosis whereas Vitamin E and C-rich fruits and tea were correlated with less risk of elastosis. Smokers showed higher grades of elastosis than non-smokers.
Conclusion Our study provides evidence that the presence of dermal elastosis and cutaneous ageing may be influenced by the type of food intake: Vitamin E and C-rich fruit and tea are positively associated with less elastosis.
Sking ageing is a process which remains partially unresolved and particularly important due to its social impact. Clinical changes of aged skin are xerosis, laxity, wrinkles, slackness and the occurrence of benign neoplasms such as seborrhoeic keratoses and cherry angiomas. One of the most relevant histological features that accompany these clinical changes is the solar elastosis.
Solar elastosis is the deposit of altered elastin in the dermis. Elastotic changes of the dermis are the primary sign of cutaneous ageing process and thought to be an essential indicator of the cumulative sun exposure which is associated with non-melanoma skin cancer, such as basal cell carcinoma (BCC). BCC is the most common cancer in humans with more incidences in the elderly population. The exposure to ultraviolet (UV) light is the first environmental cause of skin ageing and the main risk factor of BCC. Both UVB (290–320 nm) and UVA (320–400 nm) are responsible of skin ageing; however, the exact mechanism of how UV radiation causes skin ageing is not completely clear. UVA penetrates more deeply than UVB damaging both epidermis and dermis, and plays an essential role in the pathogenesis of ageing.
There are increasing line of evidences that show that the photodamaged skin can be modified by dietary factors such as vitamin C, vitamin E and carotenoids.1,2 However, these studies present limitations by the use of supplements, which makes it difficult to determine if dose of nutrient is enough to display an effect.
The purpose of this study is to assess the possible effect of nutrient intakes, rather than supplement, in the ageing process through the assessment of cutaneous elastosis, observed in the skin immediately adjacent to the dermal portion of BCC.
Materials and methods
The 136 patients with facial BCC undergoing surgery were included in the study. They were interviewed to assess the consumption of fruit, vegetables, fat and oils, red meat, coffee and tea. Participants were asked to estimate the average frequency of consumption of each food over the past 5 years in terms of a standard portion size. The sizes of portions were expressed in appropriate units of the each food. From the average intakes of different items, subjects were classified into three frequency categories, ranging from daily to weekly and monthly, in each food group. All food groups (with the items) are shown in Table 1. We reviewed 136 specimens of BCC to identify the presence of solar elastosis associated with the tumouration. Elastosis is readily recognized with the routine haematoxilin & eosine stain as an increase in the coalescence of light blue to grey elastin fibres and in photodamaged skin, elastosis displaces ordinary colagen. Three grades of elastosis were considered using immediately adjacent to the dermis in the tumour: Abscense or Light (Without elastosis or to superficial dermis), Moderate (to mild dermis) and Heavy (to deep dermis) (Figs 1,2). Histological variant of BCC was also identified (data not included). We analysed others clinical variables which could be confounding factors such as gender, age, phototype, average lifetime exposure to UV-light and smoking.
|*Fat and oils (Margerine, Butter, Eggs, Cheese, Oils dressing, Oils –corn, satflower or soybean-, Fried food – hot dog or hamburger)|
|†Red meat (Beef, Pork, Lamb)|
|‡Vegetables (Green leafy vegetables, Onions, Corn, Peas, Garlic, Cauliflower, Carrots, Tomatoes)|
|§Vitamin E or C-rich fruits (Mango, Orange, Grapefruits, Strawberry, Pineapple, Watermelon, Apple, Apricot, Kiwi, Banana, Peach)|
|¶Tea (Green and black tea)|
Using the spss version 15 software (SPSS, Chicago, IL, USA) we performed Pearson’s chi-squared test to evaluate the association between qualitative variables and elastosis. We used a P-value <0.05 for significance and all tests were two-sides. To assess the relative risk a binary logistic regression test was performed for those variables with significance.
Table 2 shows the distribution of cutaneous elastosis by gender, age, phototype and average exposure to UV-light. Of 136 participants, 77 (56%) participants showed abscence or light elastosis in the specimens, 37 (27%) mild elastosis and 22 (17%) heavy elastosis. The grade of elastosis was independent of sex (P = 0.64). While it is well-established that grade of elastosis is heavier in lower phototypes of skin, we found no significant difference amongst the cutaneous phototypes. Nevertheless, statistical significance was almost reached (P = 0.06). We found statistical differences (P = 0.05) in grade of elastosis when considering the average exposure to UV-light. Data regarding food intake of participants are shown in Table 3. No differences in grade of elastosis was observed between patients taking fat and oils (P = 0.739), vegetables (P = 0.387), red meat (P = 0.204) and coffee (P = 0.441). Consumption of fruit (P = 0.0001; RR: 0.231; 95% CI: 0.096–0.557) and tea (P = 0.001; RR: 0.34; CI 95%: 0.139–0.831) were correlated with less grade of cutaneous elastosis. Fruit consumption was associated with 23% less risk of mild and heavy elastosis, while tea with 34% less risk. We found significant differences in skin elastosis between non-smoker participants and smoker and former participants (P = 0.016; RR: 0.253; 95% CI: 0.109–0.584). Non-smokers have 25% less risk of higher grades of elastosis.
|Abscence or light elastosis (%)||Mild elastosis (%)||Heavy elastosis (%)||Total (%)||P-value|
|Female||22 (29)||8 (22)||7 (32)||37 (27)||0.64|
|Male||55 (71)||29 (78)||15 (68)||99 (73)|
|Total||77 (100)||37 (100)||22 (100)||136 (100)|
|Age||70.82 (±11.60)||73.11 (±11.29)||76.86 (±8.16)|
|I||9 (12)||6 (16)||7 (32)||22 (16)||0.06|
|II||41 (53)||16 (44)||13 (59)||70 (52)|
|III||20 (26)||8 (21)||1 (5)||29 (21)|
|IV||7 (9)||7 (19)||1 (5)||15 (11)|
|Total||77 (100)||37 (100)||22 (100)||136 (100)|
|Average exposure to UV-light (h/week)||7.5||15.3||20.6||0.05|
|Abscence or light elastosis (%)||Mild elastosis (%)||Heavy elastosis (%)||*P-value|
|Fat and oils|
|Daily||15 (20)||7 (19)||3 (14)||0.739|
|Weekly||35 (45)||21 (57)||12 (55)|
|Monthly||27 (35)||9 (24)||7 (31)|
|Daily||2 (3)||0 (0)||0 (0)||0.204|
|Weekly||19 (25)||14 (37)||3 (14)|
|Monthly||56 (72)||23 (62)||19 (86)|
|Daily||9 (12)||6 (16)||4 (18)||0.387|
|Weekly||24 (31)||16 (43)||5 (23)|
|Monthly||44 (57)||15 (41)||13 (59)|
|Vitamin E or C-rich fruits|
|Daily||25 (33)||19 (51)||11 (50)||0.0001 †RR: 0.231 (95% CI: 0.096–0.557)|
|Weekly||16 (21)||16 (43)||3 (14)|
|Monthly||36 (46)||2 (6)||8 (36)|
|Daily||29 (38)||2 (5)||7 (32)||0.001 ‡RR: 0.34 (95% CI: 0.139–0.831)|
|Weekly||14 (18)||16 (43)||3 (14)|
|Monthly||34 (44)||19 (52)||12 (54)|
|Daily||12 (16)||7 (19)||5 (23)||0.441|
|Weekly||24 (31)||8 (22)||9 (41)|
|Monthly||41 (53)||22 (59)||8 (36)|
|Yes||22 (29)||17 (46)||12 (55)||0.016 §RR: 0.253 (95% CI: 0.109–0.584)|
|Former||16 (21)||11 (30)||6 (27)|
|No||39 (50)||9 (24)||4 (18)|
Skin ageing is determined by several causes including ageing obviously, but also by environmental factors, such as smoking, pollution, psychological stress, menopause-induced oestrogen deficiency, but exposure to sunlight is the most important risk factor particularly in fair-skinned individuals. Solar elastosis is the most prominent histological feature of photoageing change and is visible on the face as a yellowish skin criss-crossed by wrinkles. On limbs and neck, the skin shows atrophic and dyschromic changes. Excessive exposure to the sun is also responsible for most skin cancers. These cancers occur mainly on exposed parts, with BCC as the most prevalent type.
In this study, we investigated the possible association between diet intake and the grade of elastosis, and therefore skin ageing.
According to our results, a high dietary intake of fats was very common amongst participants of our samples. However, fat intake had no effect in grade of cutaneous elastosis independent of gender, age and phototype. To our knowledge this is the first work studying this possible association. In a well-designed study, Cosgrove et al3 found that a high intake of fats had a negative effect in the wrinkled appearance, senile dryness and skin atrophy in 4025 middle-aged women. Although a large sample was studied, those studied outcomes might be difficult to be measured objectively and men were not included in the study.
Animal experiments have consistently showed that high fat intake may increase the sensitivity of the skin towards ageing.4 In addition, lutein and zeaxanthin (carotenoids contained in eggs) have been shown to protect the skin of mice against photoageing by decreasing the inflammation.5,6 In humans, results are inconsistent, showing that the issue of fat intake and skin ageing is apparently more complex and may involve several other factors such as family history and genetics, action of other nutrients such as vitamins, minerals, antioxidants and the composition of dietary fats. Nevertheless, our findings have to be interpreted with caution and more researches are needed to clarify this association, particularly regarding composition of dietary fats.
Intrinsic factors regarding skin ageing and solar elastosis are correlated with different markers of oxidative stress including the accumulation of lipid peroxidation and glycation products.7,8 Antioxidants provide protection against this oxidative stress, especially in stratum corneum lipids. These antioxidants include superoxide dismutase, catalase, alpha-tocopherol, ascorbic acid, ubiquinone (Coenzyme Q10) and glutathione. Many of them are inhibited by UV and visible light.9 Alpha-tocopherol (vitamin E) and ascorbic acid (vitamin C) are antioxidants in the superficial epidermal layers, participating in collagen synthesis, the regeneration process and wound repair.10 Air pollutants such as nitrogen oxides and volatile organic compounds created from fossil fuel combustion reduces these antioxidants of the skin in the superficial epidermal layers leading to an accelerated skin ageing.11 Our results suggest that a higher dietary intake of vitamin C and E-rich fruit was associated with lower grades of skin elastosis. However, it is possible that the effect of fruit may not be explained by their provision of vitamin C and E and other candidate components, or synergies which fruits provide are more likely to be relevant such as phenolics and flavonoids. In this way Liu et al.12 has suggested that the antioxidant activity of fruit may not come from the amount of vitamins, but from the synergistic effect of these phytochemicals. Previous works regarding vitamin C supplements and skin ageing are inconsistent: Findings from a cross-sectional study suggested that low intakes of vitamin C were associated with wrinkled appearance.3 Furthermore, in other studies vitamin C decreased the presence of wrinkles and senile dryness by its actions as antioxidants.10 Different studies about vitamin C as topical application or oral supplementation trials showed similar results.13,14 In the other hand, Martalena et al.15 found that vitamin C supplements may have a harmfull effect on skin.
High intake of red meat has been associated with cardiovascular diseases and other disorders involving chronic inflammation and oxidative stress.16–18 With respect to the relation of red meat with cutaneuous inflammation and ageing, the evidence remains unclear. Martalena et al.15 found that high intake of processed red meat was associated with higher grades of skin wrinkling. Our results are inconsistent and show that red meat (beef, pork and lamb) are not correlated with the grade of elastosis. There is insufficient evidence to draw solid conclusions of red meat and skin ageing, and more research is needed.
Vegetables provide several of the antioxidants referred above, particularly carotenoides and Coenzyme Q10 (CoQ10). CoQ10, also known as ubiquinone, is a naturally occurring antioxidant found in spinach, parsley and broccoli.19 The cellular levels of CoQ10 decreases with age.20 In addition, CoQ10 is the first skin antioxidant agent which is destroyed by UV light in epidermis and dermis.19 In our study, no association of vegetables intakes and elastosis was found. Nevertheless, other work suggests onions, garlic and spinach have a preventive effect on skin wrinkling.15 A potential explanation of the lack of effects of vegetables in our study is the minor reported consumption of them in our sample, leading to a type II error (false negative result).
Green and black tea demonstrate anti-inflammatory activity even when administered after UV exposure in animal models.21,22 Both types of tea contain polyphenols, antioxidants that scavenge reactive oxygen and nitrogen species. Green tea contains a lower proportion of caffeine than black tea and a higher proportion of polyphenols, of which epigallocatechin-3-gallate may have the greatest antioxidant activity.23 Given this knowledge about tea consumption, there appears to be plausible grounds for considering that tea may influence in skin ageing. Although tea consumption is relatively low in Spain and so on in our sample, we found that those subjects who take it showed a protector effect against skin ageing. This may be explained by the presence of polyphenols in tea leaf, which exert a much stronger oxygen free radical scavenging effect than vitamin C and E,24,25 giving the tea consumption one of the highest preventive effect in skin ageing from dietary, even higher than fruit and vegetables. Other study in mice have found the similar results: The use of tea pigment reduced the skin photoageing.26
Recent studies have found that coffee consumption reduces the effect of UVB on the skin preventing non-melanoma skin cancers by inducing the apoptosis in photodamaged keratinocites27 and inhibing the synthesis of PGE.28 Whether these effects in the keratinocites have an impact on the skin ageing is unclear. No works have investigated the possible correlation of coffee consumption and human skin ageing in the current literature. UV-induced infiltration of neutrophils into the skin is relevant to the process of photoageing.29 In this way, Mitani et al.30 found that topical application of plant extracts with xanthine derivates prevented UV-induced wrinkling in mice by suppressing that infiltration of neutrophils. Coffee is well-known to contain xanthines. Nevertheless, our study shows no significant differences in cutaneous elastosis between participants who had coffee and those who did not. One possible explanation is that the oral consumption of coffee does not reach enough concentrations of xanthines in the skin to suppress the neutrophil cells. More investigations in this way are needed.
It is important to highlight that the future researches investigating the association of coffee and skin ageing should include one confounding factor which is strongly associated with coffee consumption and may lead to misinterpret the results: Smoking.
Smoking is a well-established environmental factor contributing to premature skin ageing. ‘Smoker’s face’ or ‘cigarette skin’ is characteristic and implies increased facial wrinkling and an ashen and grey skin appearance.31,32 A premature old appearance with yellow and irregularly thickened skin is a symptom of long-term smokers. Smoking was collected amongst participants of our study as being a possible cofounding factor. We found smoking is an independent factor of skin elastosis. Our results support the contributing role of smoking in skin ageing with smokers showing heavier grades of elastosis than non-smokers.
Major strengths of this study are, first, data regarding food intake were obtained by a physician-conducted interview and second, the analysis of skin ageing was performed by obtaining skin specimen and assessing the histological dermal elastosis. We assessed the presence of elastosis depending on depth in the dermis instead of thick and fine elastic fibres. We think this assessment is more objective and reprodutible and avoid possible bias induced by phototype and history of burns. Main limitations of our study are the small sample and the possibility of false-negative findings for some food, such as vegetables, as this study was carried out in a population in which low or no consumption of some food group was relatively common.
Our findings add more evidence to the hypothesis that, what we eat affects our skin ageing appearance; eating healthy food such as fruit, dark green leafy vegetables and black and green tea prevents cutaneous elastosis and improves skin ageing appearance, and this may motivate people for healthy life style.
Our study provides evidence that the presence of dermal elastosis and cutaneous ageing may be influenced by the type of food intake. Vitamin E and C-rich fruit and tea are positively associated with less elastosis.
An intervention study is warranted to investigate whether the skin ageing could be prevented in part with higher intakes of Vitamin E and C-rich fruit, tea and possible green-leaf vegetables.
- 19The antioxidant role of coenzyme Q. In: Lenaz G, Barnabeiv O, Battinc M eds. Highlights in Ubiquinone Research. Taylor & Francis, London, 1990: 191–213., .
- 26Protective effect of tea pigments on mice skin photoaging induced by UV irradiation. Zhong Yao Cai 2002; 25: 29–31. Chinese., , , .