Dr. Teo Soleymani: How to Improve & Protect Your Skin Health & Appearance

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.260 | where we discuss science

00:00:03.680 | and science-based tools for everyday life.

00:00:05.920 | I'm Andrew Huberman,

00:00:10.320 | and I'm a professor of neurobiology and ophthalmology

00:00:13.480 | at Stanford School of Medicine.

00:00:15.020 | My guest today is Dr. Teo Soleimani.

00:00:17.760 | Dr. Teo Soleimani is a double board certified dermatologist

00:00:21.340 | and dermatologic surgeon.

00:00:22.920 | He did his training at Stanford University,

00:00:24.880 | and he was a clinical professor of dermatology

00:00:27.380 | and dermatologic surgery at UCLA.

00:00:29.720 | That is the University of California, Los Angeles.

00:00:33.140 | Today, we discuss all things related to skin appearance,

00:00:36.220 | skin health, and skin longevity.

00:00:39.180 | For instance, we discuss sun exposure

00:00:41.300 | and the impact it can have

00:00:42.580 | on both the appearance and health of one's skin.

00:00:45.540 | In reference to that, we discuss sunscreens,

00:00:47.940 | which ones are safe,

00:00:48.980 | which ones perhaps elicit a bit more concern

00:00:51.640 | or perhaps should be avoided.

00:00:53.180 | And we discuss the surprising relationship

00:00:55.260 | between sun exposure and skin cancer.

00:00:57.540 | We discuss laser treatments for the skin,

00:00:59.340 | both for the appearance of skin

00:01:01.560 | in order to make it appear more youthful,

00:01:03.380 | as well as to prevent certain forms of skin cancer.

00:01:06.760 | We discuss retinoids, we discuss supplements and nutrition,

00:01:10.060 | all in reference, again, to skin health and appearance.

00:01:13.460 | Thanks to Dr. Soleimani's incredible depth of expertise,

00:01:16.900 | as well as clarity of communication

00:01:18.940 | about the do's and do nots

00:01:21.100 | that relate to skin care and appearance

00:01:23.140 | and to avoiding and treating skin cancers,

00:01:25.860 | by the end of today's episode,

00:01:27.400 | you will be armed with an immense amount of knowledge

00:01:29.980 | that is the very latest in our understanding

00:01:32.420 | of how to improve and protect your skin.

00:01:35.300 | Before we begin, I'd like to emphasize

00:01:37.260 | that this podcast is separate

00:01:38.620 | from my teaching and research roles at Stanford.

00:01:40.960 | It is, however, part of my desire and effort

00:01:43.240 | to bring zero cost to consumer information

00:01:45.220 | about science and science-related tools

00:01:47.260 | to the general public.

00:01:48.620 | In keeping with that theme,

00:01:49.700 | I'd like to thank the sponsors of today's podcast.

00:01:52.440 | Our first sponsor is Roka.

00:01:54.380 | Roka makes eyeglasses and sunglasses

00:01:56.420 | that are of the absolute highest quality.

00:01:58.760 | I've spent a lifetime working on the biology

00:02:00.480 | of the visual system,

00:02:01.440 | and I can tell you that your visual system

00:02:02.880 | has to contend with an enormous number

00:02:04.600 | of different challenges

00:02:05.740 | in order for you to be able to see clearly

00:02:07.560 | from moment to moment.

00:02:08.960 | Roka understands all of that

00:02:10.720 | and has designed all of their eyeglasses and sunglasses

00:02:13.240 | with the biology of the visual system in mind.

00:02:15.880 | Roka eyeglasses and sunglasses

00:02:17.360 | were first designed for use in sport,

00:02:19.040 | in particular for things like running and cycling,

00:02:21.320 | and as a consequence, Roka frames are extremely lightweight,

00:02:24.400 | so much so that most of the time

00:02:25.480 | you don't even remember that you're wearing them,

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00:02:30.920 | Now, even though Roka eyeglasses and sunglasses

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00:02:43.080 | I wear Roka readers at night

00:02:44.560 | or Roka eyeglasses if I'm driving at night,

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00:03:09.380 | Today's episode is also brought to us by Juve.

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00:03:15.420 | Now, if there's one thing I've consistently emphasized

00:03:17.460 | on this podcast, it's the incredible impact

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00:03:22.180 | Now, in addition to sunlight,

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00:05:42.140 | And now for my discussion with Dr. Teo Soleimani.

00:05:45.620 | Dr. Teo Soleimani, welcome.

00:05:48.540 | - Thanks for having me.

00:05:49.500 | It's awesome to be here.

00:05:51.420 | Very, very privileged to be here, thank you.

00:05:53.640 | - Oh, well, it's an honor to have you.

00:05:56.100 | Let's talk about this amazing organ we call skin.

00:05:59.900 | So skin, of course, covers our other organs.

00:06:04.900 | It's its own living biological entity.

00:06:08.760 | And just for sake of educational purposes

00:06:11.580 | and to frame the rest of what we're going to talk about,

00:06:14.460 | how much turnover is there in our skin?

00:06:17.780 | Meaning the skin that I'm wearing right now,

00:06:21.700 | is that going to be 100%, 50% of the skin

00:06:26.700 | that I'm going to be wearing a year from now?

00:06:30.060 | I'm 49 years old, so.

00:06:31.740 | - Well, you look great for 49,

00:06:33.160 | so whatever you're doing, keep it up.

00:06:35.240 | So the skin's an amazing organ, just like you said.

00:06:38.220 | It's the largest organ,

00:06:39.500 | the largest dynamic organ we have in our body.

00:06:42.780 | You have new skin, brand new skin, every 28 days.

00:06:46.860 | So the surface of your skin turns over about every month.

00:06:51.640 | Now the stem cells,

00:06:52.860 | which are in the lowest portion of our epidermis,

00:06:56.940 | remain and they generate the skin cells,

00:06:59.540 | but you have brand new skin

00:07:01.180 | the same way you have new gut lining every 28 days.

00:07:04.660 | It's amazing for many reasons,

00:07:06.640 | because the skin is one of the few organs

00:07:09.580 | that can regenerate because of this.

00:07:11.700 | So you can grow new skin, you can test things on skin.

00:07:16.100 | If your skin gets injured,

00:07:17.800 | it will regenerate and heal itself.

00:07:20.260 | Whereas many other organs cannot do that.

00:07:22.900 | And because of this,

00:07:24.060 | it also allows us to use it as a model platform

00:07:27.620 | for studying diseases of all kinds.

00:07:30.060 | So skin's an amazing organ.

00:07:31.700 | I mean, I guess I'm biased, but.

00:07:33.580 | - Well, I find a 28-day turnover just to be incredible.

00:07:38.580 | The skin, as I understand it, is innervated.

00:07:42.800 | That is, it receives connections from the nervous system.

00:07:45.920 | So I think for many people,

00:07:47.740 | their interest in skin is skin appearance,

00:07:51.060 | although we will also talk about skin health.

00:07:52.880 | But in terms of skin appearance,

00:07:54.920 | how much does stress, short-term and longer-term stress,

00:07:59.880 | impact the appearance of our skin?

00:08:01.540 | And how does that work?

00:08:02.420 | I could imagine that the neurons release certain things

00:08:04.480 | into the skin.

00:08:05.440 | Does stress make our skin age faster?

00:08:09.880 | Does that mean it turns over more quickly

00:08:11.640 | or turns over more slowly?

00:08:13.400 | Maybe you could link these two aspects

00:08:14.740 | of our biology for us.

00:08:16.240 | - Yeah, that's a great question.

00:08:18.160 | So in order to understand that,

00:08:19.620 | we have to just look at the structure of the skin.

00:08:22.860 | So the skin generally is three layers,

00:08:25.560 | the epidermis, the dermis, and the subcutaneous fat.

00:08:30.960 | And the dermis is where most

00:08:33.100 | of the biologic activity resides.

00:08:34.980 | That's where our blood vessels are.

00:08:36.340 | That's where the nerves that innervate sensation

00:08:38.740 | and movement reside.

00:08:40.260 | That's where our hair follicles, oil glands,

00:08:43.260 | and sweat glands reside.

00:08:45.340 | So stress has two components.

00:08:46.980 | There's what we call acute stress,

00:08:48.420 | meaning stress that happens within a short period of time.

00:08:51.000 | And then there's long-term stress or chronic stress.

00:08:53.420 | And both have different processes in the skin.

00:08:57.120 | And you see the results of stress

00:08:59.880 | both immediately in the skin

00:09:01.480 | with release of certain chemical messengers

00:09:04.220 | in an autocrine, paracrine, and holocrine fashion.

00:09:07.580 | And then you see the long-term deleterious effects

00:09:10.580 | of stress in a different mechanism

00:09:12.500 | in which there's actually breakdown of the skin.

00:09:15.620 | The easiest way to see this is when people are stressed

00:09:19.500 | and they lose their hair.

00:09:21.260 | And the hair obviously is an extension of our skin.

00:09:23.700 | It's a biosensor of our wellbeing.

00:09:26.300 | And we see this all the time.

00:09:27.940 | You know, I see students during finals time

00:09:31.500 | where they're really stressed out

00:09:32.700 | and they're coming with their hair falling out.

00:09:34.780 | Or after a large medical illness or a pregnancy,

00:09:38.740 | patients will come in and say their hair is falling out.

00:09:41.020 | So that acute stress is seen right away.

00:09:44.140 | And that's due to several different reasons

00:09:46.720 | and release of messengers and hormones

00:09:49.860 | and chemical mediators that do this.

00:09:53.620 | Long-term stress is usually mitigated

00:09:56.300 | or caused by cortisol.

00:09:59.200 | And everybody knows cortisol.

00:10:00.700 | It's the fundamental stress hormone of our body.

00:10:05.380 | It falls in the same family

00:10:07.300 | as drugs that we give like prednisone.

00:10:10.340 | Falls in the same family

00:10:12.580 | of cholesterol, testosterone, and estrogen.

00:10:15.020 | But cortisol does something very different.

00:10:17.500 | It breaks things down to allow our body

00:10:20.580 | to utilize it in times of stress.

00:10:22.860 | 'Cause unfortunately, our body doesn't understand

00:10:25.820 | the difference between 21st century stress and old stress.

00:10:30.020 | So us being chased by a lion

00:10:32.220 | to our body's messaging system

00:10:34.500 | is the same as meeting chronic deadlines at work.

00:10:38.120 | And what happens is cortisol is responsible

00:10:40.860 | for the breakdown of things like collagen and elastin,

00:10:43.980 | thinning of vessel walls,

00:10:45.580 | which allow our skin to look supple and healthy.

00:10:49.140 | So as we have a lot of stress

00:10:50.660 | and a lot of cortisol release, we see aging.

00:10:53.060 | And there's accelerated aging studies

00:10:55.540 | that look at patients and people

00:10:57.340 | who are under high periods of stress.

00:10:59.420 | A great example of studies, we look at presidents

00:11:02.300 | in which they appear to have aged much more rapidly

00:11:05.560 | than matched controls in a four-year period of time.

00:11:09.660 | So stress plays a really important role.

00:11:11.360 | You see it both immediately and long-term.

00:11:14.120 | - I guess people rarely are sympathetic

00:11:17.840 | to presidents for aging quickly,

00:11:19.900 | because I guess if there were a president

00:11:21.820 | who did not age quickly,

00:11:23.440 | we would worry they did not work hard enough

00:11:25.700 | or something of that sort.

00:11:26.760 | But the relationship between stress and skin fascinates me

00:11:31.180 | because not just of the direct relationship,

00:11:35.660 | like when we see people and they're stressed,

00:11:37.740 | like it seems like the power of their skin changes,

00:11:41.660 | the kind of level of gleam in their eyes change.

00:11:45.500 | And of course the eyes are a direct piece

00:11:47.500 | of the nervous system, really.

00:11:48.540 | They're as close to the brain

00:11:49.460 | as one can get outside the skull.

00:11:52.380 | But it also suggests because of the dynamic turnover

00:11:55.700 | of skin every 28 days,

00:11:57.740 | that if people were to become less stressed

00:12:00.620 | that their skin health and appearance might improve.

00:12:03.380 | Is that also the case?

00:12:04.540 | - For sure.

00:12:05.380 | It's why you see people have a glow after vacation,

00:12:07.620 | but you can't quantify that in a test tube or a lab.

00:12:10.740 | So in the immediate phase,

00:12:11.940 | there's a big shift in blood flow to the skin.

00:12:15.340 | And when you're feeling very stressed out,

00:12:17.660 | immediately there's a fight or flight response

00:12:19.780 | that constricts the blood vessels in our skin

00:12:22.340 | to shuffle them to muscles

00:12:23.780 | and places where our body thinks

00:12:25.540 | we need to utilize them more.

00:12:27.040 | That's why when people are really stressed out,

00:12:28.620 | they may look pale or gaunt.

00:12:30.340 | And we see that right away.

00:12:33.020 | And then as that builds up over time,

00:12:35.880 | the health, the actual quality of our dermis and fat

00:12:39.700 | deteriorate from chronic stress changes,

00:12:42.260 | mainly due to cortisol and its sibling hormones

00:12:45.940 | and messaging systems in our skin.

00:12:48.140 | So for sure, I mean, stress is like

00:12:49.980 | something that is impossible to quantify in a lab measure,

00:12:53.940 | but very easily seen on exam.

00:12:56.100 | Just looking at your skin,

00:12:57.100 | I can tell you've had either a rough day.

00:12:59.620 | If you didn't sleep well,

00:13:00.680 | you can see it in your skin, in your eyes.

00:13:02.740 | So absolutely, I mean,

00:13:04.140 | that's why everybody likes to live a stress-free life.

00:13:06.980 | And we see changes and improvement in skin health

00:13:10.980 | when people move away from that stressor,

00:13:13.300 | whether it's a physical stressor,

00:13:14.740 | emotional stressor, psychosocial stressor,

00:13:17.720 | there is actual quantifiable improvements in skin health.

00:13:21.740 | And that's pretty fascinating.

00:13:23.780 | - It is fascinating.

00:13:25.420 | It also speaks to the value of having some immediate

00:13:29.540 | and long-term stress reduction techniques,

00:13:31.260 | just as a sort of first principle

00:13:33.220 | of taking care of one's skin.

00:13:35.860 | There are some other things that cause vasoconstriction,

00:13:38.620 | the basically the tightening of the vessels

00:13:41.020 | and capillaries to the skin, as I understand.

00:13:43.460 | Maybe we could just tick through a few of these

00:13:46.420 | and get your sense.

00:13:48.360 | I consume caffeine every morning,

00:13:50.220 | usually yerba mate tea, some coffee a little bit later.

00:13:53.240 | Those will increase vasoconstriction to some extent,

00:13:59.000 | although chronic caffeine intake may cause vasodilation.

00:14:02.800 | So I'd like to know the relationship between caffeine

00:14:05.100 | and blood flow to the skin and skin health and appearance.

00:14:07.760 | That's the first question.

00:14:08.800 | And then dovetailed with that question is nicotine,

00:14:11.800 | which is also thought to be a vasoconstrictor.

00:14:15.000 | It raises blood pressure because it's a vasoconstrictor.

00:14:17.940 | What are the effects of caffeine,

00:14:19.940 | both acutely and chronically, and nicotine?

00:14:22.460 | Let's assume that nicotine is consumed either by smoking

00:14:25.220 | or oral ingestion on skin appearance and health.

00:14:29.100 | - That's a good question.

00:14:29.940 | So caffeine is a known vasoconstrictor.

00:14:33.260 | Fortunately, when it's consumed in quantities

00:14:36.580 | that we have in coffee, tea, and equivalent beverages,

00:14:40.620 | the amount that affects the tiny capillaries

00:14:43.800 | and arterioles in our skin is minute and transient.

00:14:47.180 | So you may get a transient vasoconstriction

00:14:50.380 | with high caffeine intake,

00:14:52.220 | but usually there's a compensatory vasodilation

00:14:54.900 | as a result.

00:14:56.420 | So the effects on skin are not as dramatic

00:14:59.440 | as people may make it seem.

00:15:00.580 | Now, one thing that we do see,

00:15:02.260 | and it's a little unclear as to why,

00:15:05.080 | is that people who have chronic high caffeine intake

00:15:09.420 | tend to produce more sebum in their skin.

00:15:11.860 | And it may be a result of vasoconstriction,

00:15:15.120 | may be a result of something that we don't understand

00:15:17.700 | that's compensatory as a result of those changes.

00:15:21.340 | So a lot of people who consume coffee

00:15:24.520 | may experience a little bit oilier skin.

00:15:27.600 | That being said, the data's equivocal

00:15:30.640 | as to whether or not caffeine has a deleterious,

00:15:34.160 | beneficial, or net neutral effect on the skin.

00:15:37.000 | I drink a lot of coffee.

00:15:38.480 | I haven't found that the vasoconstriction

00:15:40.320 | is something that's noticeable,

00:15:41.640 | but there are people who have different skin types,

00:15:45.300 | patients who have rosacea, for example,

00:15:47.800 | who are much more sensitive to those changes.

00:15:49.960 | They may notice that change in the color

00:15:52.640 | in the vasoconstriction more with caffeine consumption.

00:15:56.360 | What used to be thought was that caffeine itself

00:15:59.800 | was a problem for flushing and redness.

00:16:02.760 | And now we've realized it's actually not so much

00:16:05.320 | the caffeine because the concentration

00:16:07.080 | that reaches the skin is so minuscule.

00:16:09.320 | It's actually the temperature of the beverages we drink.

00:16:12.360 | So hot beverages can affect the color of your skin,

00:16:16.120 | can make you flush more, make the redness more pronounced.

00:16:19.360 | Cold beverages tend not to have that effect.

00:16:22.280 | So it used to be an old adage

00:16:23.420 | in people who had like rosacea, for example,

00:16:25.300 | we'd say don't drink coffee, don't drink tea.

00:16:27.040 | It's actually the temperature of the beverage,

00:16:28.920 | not so much the caffeine content.

00:16:30.960 | - Interesting, and what about nicotine?

00:16:33.160 | - So nicotine, great question.

00:16:34.760 | It is a known vasoconstrictor.

00:16:37.020 | Now, the concentration of nicotine when smoked

00:16:41.380 | is higher in the skin because of inhalational effects

00:16:44.760 | and the local effect of nicotine on our skin.

00:16:47.440 | So you do see a measurable vasoconstriction in the skin

00:16:52.000 | that becomes a problem,

00:16:53.480 | which is why patients who smoke age faster.

00:16:57.440 | Patients who had surgery who smoke have a higher risk

00:17:00.320 | for poor wound outcomes, for poor healing

00:17:03.440 | because of that vasoconstriction.

00:17:05.160 | Usually people who use or consume nicotine

00:17:08.720 | aren't doing it once a week.

00:17:10.280 | Most people are using it daily or multiple times a day.

00:17:14.680 | So that chronic vasoconstriction adds up

00:17:17.520 | and has a net negative effect on the skin.

00:17:19.800 | So if you want to keep your skin healthy,

00:17:21.880 | if you want to look younger,

00:17:22.920 | I would refrain from nicotine use.

00:17:25.720 | - What about vaping nicotine or oral use of nicotine?

00:17:28.700 | So nicotine gum, mints, pouches.

00:17:31.560 | And let's touch on vaping first

00:17:33.560 | because that's becoming more common.

00:17:35.360 | - So with vaping, we see the same problems in the skin.

00:17:37.980 | We don't know if it's an inhalational issue

00:17:41.200 | or if it's actually the same concentration of nicotine

00:17:43.900 | that's reaching local skin causing the effect,

00:17:46.940 | but we see the same vasoconstriction

00:17:49.620 | when you match cigarette smoke with vaping

00:17:52.440 | if you have the same nicotine content.

00:17:54.960 | Now for patches and gum, it's less of a problem.

00:17:59.080 | And why that is, is the concentration of nicotine

00:18:01.240 | that reaches the skin is much lower.

00:18:03.840 | Usually when you chew it,

00:18:05.040 | it has to go through your digestive tract,

00:18:07.040 | then enter your bloodstream,

00:18:09.100 | then reach the surface of the skin.

00:18:10.560 | When you have a transdermal patch,

00:18:12.000 | it still goes through the bloodstream,

00:18:13.580 | then ends up in the skin.

00:18:14.720 | So because of how much it has to be processed,

00:18:17.400 | the concentration that reaches the skin is much lower.

00:18:20.280 | When we operate, when we do surgery,

00:18:21.960 | with any surgery of any kind,

00:18:23.960 | we try to transition people who smoke or vape

00:18:26.960 | to at least gums or patches

00:18:28.840 | to mitigate their withdrawal effect,

00:18:30.880 | but, you know, so they don't have the feelings,

00:18:33.960 | but, you know, it doesn't have

00:18:35.320 | the same constrictive effects on their skin.

00:18:37.760 | - What about alcohol?

00:18:39.720 | You know, I did an episode of this podcast on alcohol,

00:18:42.880 | which somewhat to my surprise, you know,

00:18:46.320 | was very widely shared, only to my surprise,

00:18:48.920 | because I've never been a big consumer of alcohol,

00:18:52.080 | but apparently many out there are.

00:18:54.460 | And the data came back, at least to my understanding,

00:18:58.000 | that zero alcohol is healthier than any,

00:19:01.600 | and that up to two drinks per week is probably okay,

00:19:05.440 | as long as you're an adult of drinking age

00:19:08.000 | and not an alcoholic.

00:19:09.000 | You don't have issues with alcohol use disorder,

00:19:10.720 | as it's now called, probably okay.

00:19:13.200 | But beyond that, you start running into some health issues

00:19:16.140 | that can be offset by better behaviors of other types.

00:19:20.040 | But what about the direct effects of alcohol on skin

00:19:23.640 | in the short term?

00:19:25.120 | Does it increase blood flow and therefore improve skin?

00:19:28.320 | Are there long-term indirect effects?

00:19:31.640 | I could imagine that alcohol disrupts the gut microbiome,

00:19:34.720 | which then disrupts skin, et cetera.

00:19:36.600 | So maybe we could break this down into direct acute effects,

00:19:40.920 | meaning immediate effects that are really direct

00:19:42.860 | from consuming alcohol that day, that week, let's say,

00:19:46.580 | versus chronic effects through other systems

00:19:48.640 | like disruption of sleep and microbiome.

00:19:50.760 | - Yeah, great question.

00:19:52.920 | Alcohol and skin connections, complicated, convoluted,

00:19:57.480 | but generally thought to be a net negative,

00:19:59.240 | both short-term and long-term.

00:20:01.120 | So first, alcohol tends to be a mild diuretic.

00:20:04.780 | So it makes our body dispose of water

00:20:08.440 | a little bit more frequently.

00:20:10.820 | What happens short-term is that, one,

00:20:16.080 | you get almost a mild diuretic effect

00:20:19.260 | from alcohol consumption,

00:20:20.440 | which is why you tend to be thirsty

00:20:21.840 | in the middle of the night and wake up in the morning,

00:20:23.620 | tend to be parched.

00:20:24.680 | As a result, you see that diuretic effect on our skin.

00:20:29.360 | You see a little bit of hollowing in areas

00:20:31.040 | that you'd have normal volume and suppleness,

00:20:33.000 | which is why people tend to see bags under their eyes

00:20:35.720 | or they look like they had a hangover

00:20:37.400 | is from that mild diuretic effect.

00:20:39.760 | Also, as a compensatory mechanism,

00:20:42.400 | the skin produces a bit more sebum

00:20:44.840 | to compensate for that drying out effect.

00:20:47.040 | So in the acute phase, your skin dries out,

00:20:49.460 | you look a little bit worse

00:20:51.480 | because of that diuretic effect.

00:20:53.780 | In patients who cannot,

00:20:55.160 | or people who cannot tolerate alcohol,

00:20:58.000 | and there are genetics in Asian populations

00:21:01.200 | and Southeast Asians that have a difficulty

00:21:03.640 | in breaking down acetaldehyde,

00:21:05.880 | that is a toxin that shows up in the skin

00:21:08.880 | and makes the skin vasodilate as a result.

00:21:11.760 | So that common college term that we used to hear,

00:21:15.080 | you know, the flush or the glow,

00:21:16.440 | or incorrectly called the Asian glow,

00:21:19.120 | is as a result of the inability to break down alcohol.

00:21:22.800 | And that usually you see immediately.

00:21:24.640 | People get a very bright red flush in their skin

00:21:29.200 | because of the acetaldehyde buildup in the skin.

00:21:31.820 | Long-term, one, the diuretic effect becomes a problem.

00:21:36.760 | So over time, your skin's producing constantly more sebum

00:21:39.360 | to keep the skin supple.

00:21:40.960 | Your skin is drying out.

00:21:42.240 | And as a result, you run into things like breakouts

00:21:44.760 | and congested skin, you know, blackheads, whiteheads,

00:21:47.480 | things like that.

00:21:48.320 | And long-term alcohol use is also associated

00:21:52.200 | with lifestyle choices that may make your skin health worse.

00:21:56.600 | Generally speaking, when people are out binge drinking,

00:21:59.360 | they tend not to come home

00:22:00.760 | and do things that'll maintain their skin.

00:22:02.560 | Now, that's not a fixed rule,

00:22:04.240 | but most of the time when you're out, you know,

00:22:06.040 | having a few beers or cocktails at the bar,

00:22:08.560 | you tend to come home

00:22:09.420 | and not do your diligent skincare routine,

00:22:12.160 | or you may not be up, you know,

00:22:13.920 | with your hydration status or your dietary habits.

00:22:17.040 | So that's something we can't quantify easily,

00:22:19.680 | but contributes significantly

00:22:21.480 | to faster aging, poor skin health.

00:22:23.800 | Then the gut microbiome question.

00:22:26.160 | This is a great question

00:22:27.160 | because the data is widely variable for alcohol consumption

00:22:32.160 | and the effects or changes permanent or transient

00:22:36.440 | in the gut microbiome.

00:22:38.280 | There are some alcohol products like kombucha

00:22:41.000 | that has a higher alcohol concentration

00:22:44.240 | that's healthy for your gut.

00:22:46.780 | Then there's hard alcohols with a higher concentration

00:22:49.760 | that act as anesthetics and act as gut paralytics.

00:22:54.040 | So one of the things we see in people

00:22:56.760 | who consume a lot of high percentage alcohols

00:23:00.080 | is actually gut immobility and gut paralysis,

00:23:04.840 | partly because of the anesthetic effect,

00:23:06.620 | partly because of the analgesic effect of alcohol,

00:23:10.080 | and also because it affects gut motility as a toxin.

00:23:14.400 | So generally speaking, the gut health,

00:23:17.500 | depending on your consumption patterns,

00:23:20.780 | use and concentration can be very deleterious.

00:23:24.300 | Some people are very sensitive

00:23:26.140 | and they have changes that reflect in the skin

00:23:28.980 | as a result of drinking a lot.

00:23:30.860 | And then there are some people who tolerate it more

00:23:32.900 | or maybe consuming things that are healthier

00:23:36.220 | for the gut microbiome,

00:23:37.380 | like things like fermented alcohols,

00:23:40.060 | like kombucha and things like that.

00:23:42.240 | So generally speaking, the higher the concentration,

00:23:44.760 | the greater the problems,

00:23:46.400 | the higher the percentage of alcohol,

00:23:47.840 | the greater the problems.

00:23:49.080 | That includes the diuretic effects,

00:23:52.040 | that includes effects on the gut microbiome,

00:23:54.880 | that includes lifestyle habits.

00:23:56.700 | If you're drinking a lot of higher percentage alcohols,

00:23:58.920 | you tend to feel the effects,

00:24:02.040 | not just in the skin cognitively, behavior-wise,

00:24:05.400 | that can affect you.

00:24:06.240 | Whereas sometimes lower concentration alcohols,

00:24:10.080 | depending on the setting and lifestyle,

00:24:11.760 | may be net neutral, may be positive.

00:24:14.980 | I'm clear on that part.

00:24:16.120 | - But I'm not hearing any positive effects of alcohol

00:24:19.700 | on skin health or any of this.

00:24:21.540 | - Generally not, generally not.

00:24:22.900 | Same as what we've seen with other organ systems,

00:24:25.840 | the brain, the liver, the skin reflects the same thing.

00:24:29.340 | If anything, it may be a net neutral.

00:24:31.380 | Most of the time, it's a net negative.

00:24:33.740 | - And what I'm pulling from all of the discussion

00:24:36.500 | we've had up until now is that improved blood flow

00:24:40.880 | and strong hydration status are both important.

00:24:44.700 | Do you recommend patients drink a certain amount of fluid

00:24:47.980 | each day or maintain adequate hydration

00:24:50.940 | as a means to build or maintain skin health and appearance?

00:24:54.620 | - Great question.

00:24:55.460 | So that's another common misconception that I see

00:24:59.120 | in that thinking drinking a lot of water will,

00:25:01.820 | or drinking a lot of fluids will directly affect

00:25:04.860 | the hydration status of their skin.

00:25:06.900 | And while there's a certain degree of truth to that,

00:25:10.080 | if you're dehydrated and that you need replenishment

00:25:13.940 | of fluid systemically, every study that's looked

00:25:18.220 | at transepidermal water loss has not shown

00:25:21.100 | a great connection with regular fluid intake

00:25:25.500 | and water intake and skin hydration status.

00:25:28.660 | We find that that tends to be genetically defined

00:25:31.100 | and genetically encoded.

00:25:32.140 | Some people have drier skin.

00:25:33.880 | They need more methods to moisturize their skin.

00:25:36.680 | Some people have oilier skin and their sebum provides

00:25:39.820 | that moisturization.

00:25:40.820 | Now, if you're doing things, if you're active,

00:25:43.100 | if you're an athlete, if you're doing things

00:25:46.340 | in which you are dehydrated, then totally different story.

00:25:50.500 | But if you're living a more or less balanced life

00:25:52.980 | or a sedentary life and you're doing all the regular things,

00:25:55.540 | drinking a lot of water or fluids has not been shown

00:25:57.760 | to improve skin health.

00:25:59.320 | So that's why generally speaking,

00:26:01.020 | most dermatologists will recommend some sort

00:26:02.820 | of moisturizer to replenish that.

00:26:04.280 | But you gotta know your skin.

00:26:05.940 | For example, my skin, I tend to be oilier.

00:26:08.340 | I don't usually need a moisturizer as much.

00:26:10.980 | Whereas somebody who is drier will need some sort

00:26:14.060 | of barrier protection to allow,

00:26:16.060 | to minimize that trans-epidermal water loss.

00:26:18.860 | - What are some of the parameters

00:26:21.420 | for selecting a moisturizer?

00:26:23.360 | - Yeah, there's a lot of stuff.

00:26:26.620 | - People are immediately gonna go into say,

00:26:28.180 | well, what constitutes a good moisturizer?

00:26:30.620 | What should it have in it?

00:26:31.700 | What are some things to avoid?

00:26:32.980 | - Yeah, it's a crazy market.

00:26:34.540 | There's a lot of things out there.

00:26:36.100 | You can Google skin snail moisturizer

00:26:39.940 | and you'll find people putting snail mucin

00:26:41.660 | on their skin as a moisturizer.

00:26:43.340 | - You were telling me before this recording started,

00:26:45.580 | there are people who, and forgive me

00:26:47.660 | for those that cringe when I say this,

00:26:50.000 | that put placental extract.

00:26:52.500 | - Human placenta as a means

00:26:55.220 | of rejuvenating their skin health.

00:26:56.940 | I don't advocate it or don't say anything against it,

00:26:59.860 | but I probably wouldn't recommend it.

00:27:02.500 | There's better, safer, more cost-effective ways

00:27:05.920 | of doing this.

00:27:07.340 | Simple things you wanna look for.

00:27:09.460 | One, is it non-comedogenic?

00:27:11.460 | That's a word you wanna look for

00:27:12.580 | for any moisturizer that's been tested

00:27:14.300 | not to clog your pores.

00:27:16.080 | That's a basic thing to look for

00:27:17.940 | where you won't cause another problem

00:27:19.760 | in trying to fix one problem.

00:27:21.820 | Number two, how oily or dry are you?

00:27:25.580 | Generally speaking, there are three flavors of moisturizers.

00:27:29.200 | There's ointments, there's creams, and there's lotions.

00:27:32.460 | Ointments are greasy.

00:27:33.740 | They're like petrolatum jelly or Vaseline-based.

00:27:36.060 | Those are the best for moisturizing your skin,

00:27:40.200 | but they're greasy.

00:27:41.600 | Then there's creams, which are water emulsions

00:27:44.460 | with oil suspended in it.

00:27:47.100 | And then there's lotions, which are generally powders

00:27:49.420 | that are resuspended with water.

00:27:51.060 | We as dermatologists tend to like the greasier the better.

00:27:55.500 | It provides the best barrier protection,

00:27:57.340 | but you have to know your skin.

00:27:58.740 | If you're somebody that is eczema-prone,

00:28:01.220 | you will need something that is an ointment

00:28:03.540 | that does better to protect the skin from drying out.

00:28:07.340 | If you're somebody that is acne-prone,

00:28:10.060 | you won't tolerate greasy things.

00:28:11.900 | You'll break out more.

00:28:12.800 | So you wanna look for a lighter moisturizer

00:28:15.100 | that's non-comedogenic.

00:28:16.560 | So in a long story short,

00:28:19.400 | it's very person-to-person specific.

00:28:22.540 | You gotta know your skin,

00:28:23.520 | but the fundamental things you wanna look for is

00:28:26.000 | has this been tested to not clog pores?

00:28:30.660 | And is it in a pump bottle or is it in a jar?

00:28:34.100 | Jars tend to be more occlusive.

00:28:37.120 | They tend to provide more moisturization,

00:28:39.660 | but they can lead to problems like acne and breakouts.

00:28:43.340 | Whereas things in a pump bottle,

00:28:45.500 | because they're powders in suspension

00:28:48.560 | and they have to put alcohol in the product

00:28:51.180 | to allow it to come out of the pump mechanism,

00:28:52.940 | they tend to be lighter

00:28:53.980 | and not provide as much moisturization.

00:28:56.460 | - I see.

00:28:58.140 | So when I think about something in a jar,

00:28:59.660 | you have something like Aquaphor or something,

00:29:02.580 | which is pretty thick, thick stuff.

00:29:05.220 | So that would be fine for someone with eczema,

00:29:07.980 | not okay for somebody with acne.

00:29:10.580 | - Yeah, exactly, exactly.

00:29:12.140 | The greasier, the more occlusion it provides,

00:29:15.100 | but in doing so, it clogs everything.

00:29:17.580 | Now, if you're one that has some sort of skin issue

00:29:21.260 | in which you need that, it's the best thing.

00:29:23.820 | If you're one that is breaking out all the time,

00:29:26.180 | you want something lighter.

00:29:28.100 | - I'd like to take a quick break

00:29:29.340 | and acknowledge our sponsor, AG1.

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00:29:33.580 | that if I could take just one supplement,

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00:29:39.940 | and most complete

00:29:40.860 | of the foundational nutritional supplements available.

00:29:43.600 | What that means is that it contains

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00:29:46.420 | but also probiotics, prebiotics, and adaptogens

00:29:49.820 | to cover any gaps you may have in your diet

00:29:52.220 | and provide support for a demanding life.

00:29:54.500 | For me, even if I eat mostly whole foods

00:29:56.340 | and minimally processed foods,

00:29:57.560 | which I do for most of my food intake,

00:29:59.500 | it's very difficult for me to get enough fruits

00:30:01.500 | and vegetables, vitamins and minerals,

00:30:03.300 | micronutrients, and adaptogens from food alone.

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00:30:09.820 | and often twice a day, once in the morning or mid-morning,

00:30:12.500 | and again in the afternoon or evening.

00:30:14.500 | When I do that, it clearly bolsters my energy,

00:30:16.900 | my immune system, and my gut microbiome.

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00:30:40.880 | Why do people wake up with bags under their eyes

00:30:44.760 | if they just slept for six or eight hours?

00:30:47.560 | - Yeah, well, maybe you need a little bit more sleep

00:30:49.680 | or maybe you had a wild night, I can't tell,

00:30:51.360 | but generally, the bags are caused by two things.

00:30:54.900 | One, fluid retention.

00:30:57.560 | So there's some lymphatic change that occurs under the eyes

00:31:00.440 | that's most noticeable because the skin under our eyes

00:31:02.960 | and on the surface of our eyelids is the thinnest.

00:31:05.760 | So fluid changes are seen the quickest there.

00:31:08.320 | And as we're in a supine or prone position,

00:31:11.560 | fluid moves from our extremities

00:31:13.440 | back to our central venous system,

00:31:16.120 | and it's easier to collect in the face.

00:31:18.120 | So we see it around the face.

00:31:20.160 | The other thing that we do notice with bags

00:31:22.280 | is just age-related fat herniation that shows up more

00:31:25.920 | as we wake up because of positional changes.

00:31:29.740 | So if you've had a heavy meal the night before,

00:31:34.740 | something that has a high salt content,

00:31:36.960 | you're gonna retain a little bit more water

00:31:39.940 | because of that solute shift.

00:31:41.560 | You may notice your eyes are puffier in the morning.

00:31:44.800 | If you have allergies, seasonal allergies,

00:31:49.820 | asthma, eczema, they run in a family,

00:31:52.760 | that tends to make your skin retain a little bit more water

00:31:56.360 | as a result of that allergy response.

00:31:59.800 | So people will notice springtime or fall time,

00:32:03.600 | their eyes are swollen or their eyes are puffy,

00:32:06.080 | especially when their allergies are flaring.

00:32:08.520 | It's a product of water retention

00:32:10.520 | from all the histamine release

00:32:12.560 | and changes that occur in the skin.

00:32:14.320 | - Skin cleansing is a topic that gets a lot of coverage.

00:32:19.860 | And I sometimes get chuckles or even attacks

00:32:24.220 | for saying I've always just used unscented dove soap,

00:32:29.220 | the bar, not the liquid soap, or like a Cetaphil soap.

00:32:33.460 | And this is because when I was younger, like much younger,

00:32:36.500 | I had very sensitive skin when I was like a kid,

00:32:39.620 | seven, eight, nine years old.

00:32:40.700 | I think I just started using unscented dove soap

00:32:43.820 | at some point and things like it,

00:32:45.620 | gentle soaps without fragrances.

00:32:49.700 | What are your thoughts on those?

00:32:51.860 | And I ask not for my own purposes,

00:32:54.780 | I'm gonna stick with it because it works for me,

00:32:56.300 | unless you tell me I shouldn't,

00:32:57.900 | but I see this enormous market for skin cleansers

00:33:01.900 | that includes a range of costs

00:33:04.500 | from relatively low to near astronomical.

00:33:08.980 | And if you tell me that this unscented dove soap

00:33:13.220 | or Cetaphil soap is the way to go,

00:33:14.940 | and by the way, I'm not sponsored by either of those,

00:33:16.860 | I don't even know who they're manufactured by,

00:33:19.260 | so there's no commercial angle here,

00:33:21.140 | but I'll be relieved because they tend to fall

00:33:24.980 | on the lower end of the cost bracket

00:33:26.500 | relative to some of these astronomically priced cleansers.

00:33:30.940 | - Skincare is a incredible multi-billion dollar market.

00:33:34.580 | That being said, there is not a shred of evidence

00:33:38.740 | that anything more expensive works better

00:33:40.940 | than anything cost-effective, so that's first and foremost.

00:33:43.720 | Number two, dove white bar soap is amazing.

00:33:47.780 | It's what we recommend for newborns and kids

00:33:50.140 | with sensitive skin.

00:33:51.500 | Generally, when we say sensitive skin,

00:33:53.620 | especially in kids, toddlers, and adolescents,

00:33:57.380 | there's a component of some sort of eczema

00:33:59.580 | or atopic dermatitis that is not bad enough

00:34:02.500 | to have a diagnosis, but enough to say,

00:34:04.900 | I had sensitive skin.

00:34:06.720 | So dove white bar soap is what I use for my kids,

00:34:10.360 | and I'm not sponsored by anybody either,

00:34:13.000 | but I think it's an amazing product because it's safe,

00:34:16.220 | it's effective, it has the least amount of ingredients,

00:34:18.860 | no fragrances, these are all things that can irritate

00:34:22.340 | or cause an allergic response to skin that is sensitive,

00:34:25.900 | meaning your skin mounts an immune response

00:34:30.420 | to some sort of environmental allergen or trigger.

00:34:32.860 | That's what we generally mean

00:34:33.820 | when we talk about sensitive skin.

00:34:35.740 | I personally use Cetaphil, that's my face wash.

00:34:39.520 | I have oily skin, and I use the one

00:34:40.960 | that takes off more of the oil.

00:34:42.820 | So what you're looking for is defined by what bothers you

00:34:47.300 | or what your skin predicament is.

00:34:49.140 | What I do see as a problem nowadays

00:34:54.020 | is particularly in the United States,

00:34:55.740 | we're a hyper-hygienic society.

00:34:58.160 | So what people tend to do is over-cleanse,

00:35:01.140 | and they over-cleanse for several reasons.

00:35:03.340 | One, because they are told that cleansing

00:35:06.420 | will fix their skin issue,

00:35:08.980 | or number two, they're told that some sort of organism

00:35:12.580 | is on their skin or some sort of bacteria

00:35:15.100 | that needs to be cleansed off to keep their skin healthy.

00:35:17.860 | Neither are true.

00:35:18.940 | The first thing you want in terms of a cleanser

00:35:22.620 | is something that's mild, fragrance-free,

00:35:24.240 | and has been tested to be hypoallergenic or non-comedogenic.

00:35:28.420 | That's first.

00:35:29.260 | Cetaphil, Dove, CeraVe, great, great stuff.

00:35:31.680 | No association with any of them.

00:35:35.220 | - The unscented, non-fragranced versions of them.

00:35:38.220 | - Exactly, that's first.

00:35:40.060 | Fragrances tend to be a problem for sensitive skin

00:35:42.780 | in patients who have atopic dermatitis or eczema.

00:35:45.580 | They tend to trigger allergic responses

00:35:47.700 | or exacerbations of their eczema flare,

00:35:49.880 | so we try to avoid fragrances by all means.

00:35:52.720 | Then, things that are gels or liquids

00:35:57.060 | tend to have preservatives in them

00:35:58.940 | to increase shelf stability, whereas bars tend not to.

00:36:02.340 | So if you are gonna pick something

00:36:04.180 | that is a gel, a liquid,

00:36:07.620 | look for one that's been tested by a dermatology group

00:36:10.340 | or verified by the American Academy of Dermatology

00:36:12.780 | as one that is not allergenic or has multiple preservatives

00:36:17.780 | because that's another well-known

00:36:21.020 | but unidentified source of problems.

00:36:24.340 | Well-known to the dermatology world,

00:36:26.260 | not known to the average person

00:36:28.780 | that the preservatives in our cleansers are a problem.

00:36:31.960 | Over-cleansing becomes really problematic

00:36:35.660 | in eradicating the skin microbiome.

00:36:40.420 | So what we see a lot of times are cleansers

00:36:43.460 | that are either bactericidal, bacteristatics,

00:36:48.460 | things like benzoyl peroxide, things like salicylic acid,

00:36:52.300 | things like certain astringent toners

00:36:54.140 | that are alcohol-based, and what they do

00:36:56.460 | is not only do they strip the normal oils from our skin

00:36:59.540 | that keep our skin supple and healthy,

00:37:01.620 | but they eradicate the normal host skin microbiome.

00:37:06.020 | Those are all the microorganisms that live on our skin,

00:37:08.820 | and we have trillions of them actively surveying our skin,

00:37:12.820 | living in normal symbiotic homeostasis,

00:37:16.380 | meaning they're our friends,

00:37:17.660 | they're living there for a reason,

00:37:18.940 | they don't cause any problems.

00:37:20.600 | But when you cleanse them off,

00:37:22.480 | you open up an area for pathogens to take effect,

00:37:27.140 | and that's when we see a lot of problems,

00:37:29.780 | more so in industrialized countries.

00:37:32.900 | The United States is a notorious place for washing,

00:37:35.060 | especially after COVID, wash, wash, wash, wash more,

00:37:38.780 | use a toner, wash some more,

00:37:41.220 | and that becomes really problematic

00:37:42.940 | because it sets up for organisms to take seed

00:37:46.240 | when they shouldn't be there.

00:37:47.700 | So overall, cleansing is great,

00:37:52.260 | and the amount that you need to cleanse

00:37:53.580 | is based on how oily or sebaceous your skin is.

00:37:57.740 | The older you get, you may not need to cleanse as much.

00:38:01.100 | Older patients don't need to cleanse their skin

00:38:03.980 | at all every day because they don't produce

00:38:06.780 | as much sebum or oil as younger patients.

00:38:10.100 | But everything should be defined

00:38:12.580 | by your skin's characteristics.

00:38:15.780 | So if you are one in which you notice,

00:38:19.020 | by the end of the day, I'm oily, I'm breaking out,

00:38:23.000 | cleansing may be something that's beneficial for you

00:38:25.380 | to take off that excess sebum.

00:38:27.460 | If you're one that has dry skin,

00:38:29.100 | if you're one that had sensitive skin as a child,

00:38:32.100 | then over-cleansing is gonna be a problem.

00:38:33.980 | You're gonna wanna minimize that

00:38:35.780 | and keep that moisturization

00:38:37.560 | or that barrier protection going.

00:38:39.900 | - So does that mean that people should bathe

00:38:41.860 | probably once or twice a day,

00:38:44.380 | but the people that are bathing three times a day,

00:38:46.660 | it's probably excessive?

00:38:47.900 | I mean, are we saying that you can't get into water?

00:38:50.500 | I mean, when you say cleansing,

00:38:51.580 | you're talking about face cleansing.

00:38:52.980 | I realize this is going to be highly individual,

00:38:54.820 | but some people are just out of habit,

00:38:59.380 | shower and use cleanser twice a day or once a day.

00:39:04.380 | I think for me, it's in the morning or in the evening,

00:39:07.820 | sometimes both.

00:39:08.660 | If I do a workout, I try and shower

00:39:11.140 | as close as possible after the workout,

00:39:13.380 | as soon as possible after the workout, rather,

00:39:15.500 | because otherwise I will break out.

00:39:18.740 | So it sounds like one has to kind of learn

00:39:21.020 | what their cadence is, and that's going to vary by age.

00:39:24.660 | There's a lot of factors to this.

00:39:26.420 | I think Ashton Kutcher and Mila Kunis

00:39:29.580 | famously said they shower, I think,

00:39:30.700 | once a week or something like that,

00:39:32.020 | and it stirred up a lot of conversation when that came out.

00:39:34.980 | Truth be told, you don't have to cleanse every day

00:39:40.780 | if your skin is otherwise fine and healthy

00:39:44.180 | and you're not bothered by anything.

00:39:45.980 | You live a lifestyle in which you're not sweating excessively

00:39:50.820 | or producing a lot of sebum.

00:39:53.220 | I, myself, same thing.

00:39:54.340 | I work out, so I shower after working out,

00:39:57.620 | and I usually shower before I get into bed

00:39:59.260 | because after a long day of work,

00:40:00.540 | I tend to have things on my skin that shouldn't be there.

00:40:03.880 | That's only fitting for me because if I don't,

00:40:07.100 | I tend to have problems.

00:40:08.220 | I tend to break out.

00:40:09.100 | I tend to have things that shouldn't happen

00:40:12.380 | because of my hygiene habits.

00:40:14.440 | That said, there is no indication or no medical necessity

00:40:21.620 | to have to cleanse your skin even once a day.

00:40:25.420 | Oftentimes, older patients cleanse or shower once a week,

00:40:29.620 | and they're totally fine,

00:40:31.380 | but it'll have to be defined by your skin

00:40:34.080 | and what problems or ailments are specific to you.

00:40:37.900 | Generally, if you work out,

00:40:40.860 | if you let sweat dry on your skin,

00:40:42.780 | it causes several problems.

00:40:44.260 | Number one is irritation itself from the salts

00:40:47.620 | that crystallize from the sweat drying off.

00:40:49.980 | Number two, the sweat itself is a source of food

00:40:52.980 | for certain yeasts that are normal symbiotic yeasts

00:40:55.340 | that live on our skin,

00:40:56.500 | so it contributes to things like dandruff,

00:40:59.380 | what we call tinea versicolor,

00:41:01.020 | which is a type of yeast that grows on our skin.

00:41:03.260 | So generally, if you work out,

00:41:04.540 | try to wash those things off.

00:41:07.980 | Also, if you are one of acne-prone skin,

00:41:11.740 | if you're an adolescent, if you're a teenager,

00:41:13.560 | if you're an adult dealing with acne,

00:41:15.820 | the sebum that your body's producing

00:41:18.360 | is food for the bacteria that cause this.

00:41:20.900 | So you tend to want to clean some of that excess sebum off.

00:41:23.900 | Those are simple indications

00:41:25.520 | to cleanse both your face and your body.

00:41:28.340 | But if you're not having any problems,

00:41:29.420 | you actually don't need to do any of that.

00:41:31.000 | In Europe, they shower and cleanse

00:41:34.020 | at a fraction of the frequency

00:41:36.500 | that we do in the United States.

00:41:38.020 | And when you look at incidences

00:41:39.660 | of the most common skin conditions, they're the same.

00:41:43.260 | - Including things like acne, psoriasis.

00:41:46.300 | You know, most people think about

00:41:47.840 | shampooing for sake of hair,

00:41:49.920 | but there's the scalp component.

00:41:51.680 | And since you're an expert in skin,

00:41:53.160 | we should probably spend a bit of time on this.

00:41:56.080 | For people that tend to have a dry or flaky scalp,

00:42:00.680 | what should they do about that?

00:42:02.360 | My understanding is that some of the more

00:42:04.440 | typical commercial anti-dandruff shampoos

00:42:07.660 | can contain things that might cause issues for hair itself.

00:42:10.720 | So they might help with the flaking

00:42:13.000 | and drying of the scalp,

00:42:14.160 | but damage other aspects of, you know,

00:42:17.860 | either appearance or health of hair.

00:42:19.660 | What are some really good options

00:42:23.180 | for people that have dry scalp?

00:42:24.700 | What are some great options

00:42:25.660 | for people that have oily scalp?

00:42:28.020 | And let's leave aside the frequency of use

00:42:30.080 | and just perhaps just put it on the shelf

00:42:32.660 | as much as you need it, but not more.

00:42:35.180 | So that could be once a week, it could be daily.

00:42:37.060 | Could be twice a day if in extreme cases, it sounds like.

00:42:39.900 | - So when we think about the scalp,

00:42:41.340 | when we think about dry or flaky scalp,

00:42:43.520 | we think about two main conditions,

00:42:45.100 | either seborrheic dermatitis,

00:42:46.740 | which is medical grade dandruff,

00:42:49.100 | or, or the medical name for dandruff, or psoriasis.

00:42:52.560 | They're two different entities,

00:42:53.820 | but they generally contribute to the same problem,

00:42:55.820 | which is redness, flaking, and dryness of the scalp.

00:42:58.780 | Now, it's important to note

00:42:59.780 | that the hair on your head is dead.

00:43:02.820 | It's not alive.

00:43:04.140 | The only area that's alive

00:43:05.900 | is two and a half millimeters in the skin.

00:43:08.920 | So the hair that we see on our scalp is not a living entity.

00:43:13.080 | So there's a common misconception

00:43:14.940 | that you can affect the health or quality of your hair

00:43:19.780 | by putting things on the hair.

00:43:21.700 | And I'll go into that in just a minute.

00:43:24.500 | But the hair itself that you see is not living.

00:43:28.340 | The only area that's living are the stem cells

00:43:30.980 | in the papilla of the hair,

00:43:32.860 | and in the bulge region of the hair,

00:43:34.580 | which reside in the skin.

00:43:36.140 | So nothing that you put on your scalp

00:43:38.500 | will make you lose your hair,

00:43:40.660 | will make you grow new hair for the most part.

00:43:44.060 | Why that's important.

00:43:45.260 | When we treat dry or flaky scalp,

00:43:48.700 | we treat it with several things.

00:43:50.220 | The most common cause is an overgrowth of yeast

00:43:53.280 | from the sweat and oil that is produced from our scalp.

00:43:58.280 | And that's seborrheic dermatitis.

00:44:00.580 | That's the medical name for dandruff.

00:44:02.580 | And so we treat it by, one,

00:44:03.940 | lowering the amount of that yeast that's living,

00:44:06.980 | and that's usually with shampoos that are prescription,

00:44:10.600 | or over-the-counter.

00:44:12.220 | Things like zinc or ketoconazole shampoos

00:44:15.260 | are very common things.

00:44:16.820 | And then the other thing that we do

00:44:18.580 | is to dampen the immune response

00:44:22.700 | to this overgrowth of yeast.

00:44:24.140 | So the reason our skin flakes and gets red and proliferates

00:44:27.460 | is our immune system's responding to something.

00:44:30.840 | It's either responding to the yeast

00:44:32.660 | or it's responding to itself,

00:44:35.220 | which is what psoriasis is.

00:44:37.020 | It's an immune-mediated overproliferation of skin cells

00:44:41.240 | because the immune system is overactive in the skin.

00:44:44.460 | And the way we treat that is just topicals

00:44:47.240 | or certain medications that suppress

00:44:48.840 | the skin's immune system or immune activity.

00:44:52.920 | None of that affect the actual hair itself.

00:44:56.420 | What does happen is shampoos tend to have things

00:45:01.000 | that strip oils as a mechanism of cleaning.

00:45:04.380 | So when you take a cross-section of the hair,

00:45:06.360 | there are seven layers.

00:45:07.800 | And the layer that provides that color, sheen,

00:45:11.360 | and structure is called the cuticle.

00:45:14.040 | As we age, we lose the cuticle.

00:45:16.880 | And that's a common problem,

00:45:18.760 | what we see in male and female pattern hair loss

00:45:21.040 | or androgenetic alopecia, is we lose that cuticle,

00:45:24.200 | which makes us lose the shine and the structure

00:45:27.200 | and the strength of our hair.

00:45:29.360 | Our body tries to replenish that with the oils.

00:45:32.260 | So when people wash their hair,

00:45:34.360 | sometimes they feel like the hair becomes more limp

00:45:37.640 | or dull or lifeless.

00:45:39.320 | It's because we've taken that artificial oil coating

00:45:43.000 | that replaced the cuticle and washed it off.

00:45:46.080 | So good news is you're not gonna do any harm

00:45:48.400 | putting any of the topicals on your scalp.

00:45:51.140 | Bad news is you probably won't bring a lot of it

00:45:55.380 | back to life either.

00:45:56.440 | But when we treat flakiness, redness, things like that,

00:45:59.920 | we're treating two entities, usually with topicals,

00:46:02.440 | and because we're either trying to treat

00:46:04.040 | overproliferation of something,

00:46:05.880 | or trying to calm down the skin's immune system.

00:46:08.920 | - Got it.

00:46:09.760 | So it sounds like the best options for cleansing skin,

00:46:14.480 | for shampooing, really stem from knowing

00:46:17.680 | whether or not your skin tends to air oily or dry,

00:46:21.520 | figuring out how often to cleanse.

00:46:23.920 | And then as you pointed out before,

00:46:25.240 | even though there's an enormous range of costs

00:46:27.040 | for these things, none of the solutions

00:46:29.360 | that you're describing sound like they fall

00:46:31.440 | on the high end of cost, or even in the middle end of cost,

00:46:34.680 | which is a bit surprising to me.

00:46:36.440 | This might be one of the few areas where,

00:46:38.560 | like if I had a magic wand, I would make for all organic,

00:46:43.560 | non-processed and minimally processed foods

00:46:49.120 | to be very inexpensive.

00:46:50.240 | But it turns out those things tend to be more expensive.

00:46:52.580 | You can go to farmer's markets

00:46:53.780 | and cut back on the cost, et cetera.

00:46:55.200 | But there seems to be an unfortunate trade-off

00:46:57.960 | between availability and cost and benefit,

00:47:02.640 | or at least risk.

00:47:03.640 | But it doesn't sound like that's the case

00:47:05.120 | with skincare or scalp care,

00:47:07.000 | that one can exercise really excellent skin and scalp care

00:47:10.660 | without having to go into a range

00:47:12.960 | of spending an outrageous amount of money.

00:47:15.480 | - No, I think, one, you're absolutely right.

00:47:18.160 | The more expensive does not mean better.

00:47:20.920 | In fact, they sometimes become more problematic

00:47:23.760 | because there's more ingredients

00:47:25.040 | in the more expensive products,

00:47:26.520 | including elegant fragrances and stuff like that,

00:47:28.920 | which can be problematic.

00:47:30.240 | That's number one.

00:47:31.580 | The second thing to know is that,

00:47:34.200 | generally speaking, there's some connection

00:47:37.000 | between skin health, skincare, and this realm of beauty,

00:47:42.000 | which people overlap a lot in.

00:47:44.560 | And when we trend into this realm of beauty,

00:47:48.360 | glamor, et cetera, price and objectivity are taken out.

00:47:53.360 | And that's why you see a lot of skincare products

00:47:55.280 | that are so expensive,

00:47:56.400 | because they draw towards another level of desire

00:48:01.400 | that's not just medical, it's aesthetic.

00:48:05.160 | And that's where you'll find creams

00:48:07.400 | that are $200, $300 for a little amount of cream

00:48:10.720 | that does the same thing that your jar of petrolatum

00:48:13.400 | or Vaseline or Aquaphor does.

00:48:14.960 | That part is really hard to mitigate.

00:48:18.120 | But in general, almost everything that we as dermatologists

00:48:22.000 | and skin cancer surgeons and experts in the field recommend

00:48:25.920 | are really cheap, cost-effective,

00:48:28.000 | and they have the least amount of ingredients in them.

00:48:31.040 | And that's what I would recommend.

00:48:32.360 | That's what I recommend for my family and for my patients.

00:48:34.720 | You don't have to spend a lot to have excellent skincare,

00:48:37.120 | and you don't need to have it be a multi-step routine.

00:48:40.480 | Oftentimes people overdo it.

00:48:43.200 | The more steps that there are,

00:48:44.960 | there's more chances that something your skin

00:48:47.360 | will respond to negatively.

00:48:49.360 | The more chances you are to have a bad outcome

00:48:51.980 | to an ingredient of a product you're putting on your skin.

00:48:54.280 | So keep it simple, keep it cheap, and you'll do great.

00:48:56.980 | - It's going to be very reassuring to many people.

00:49:00.320 | It's also going to be somewhat destabilizing

00:49:04.940 | to people who are really attached to the idea

00:49:07.040 | that the more expensive products are really doing something

00:49:09.960 | that much more beneficial for them.

00:49:11.600 | - Not much at all, not anything.

00:49:13.640 | Another important thing to consider

00:49:17.280 | when looking at skincare, skin health,

00:49:20.640 | and then trending into that area of aesthetics and beauty

00:49:23.620 | is that most active ingredients,

00:49:27.580 | if they're really active, tend to be controlled by the FDA.

00:49:33.120 | So most things that are sold over the counter

00:49:36.480 | have actives that are not at a concentration high enough

00:49:40.560 | to be considered therapeutic,

00:49:42.440 | because that's when you get into the definition of a drug.

00:49:45.200 | So looking at things like anti-dandruff shampoos,

00:49:50.200 | anti-aging creams, acne medications,

00:49:55.520 | they work a little bit.

00:49:58.040 | If they work perfectly,

00:49:59.300 | then most medical dermatologists

00:50:01.280 | would be ahead of a lot of patients,

00:50:02.960 | and we see a lot of skin disease that still continues

00:50:05.460 | because the active ingredients

00:50:07.480 | aren't at a concentration high enough

00:50:09.200 | to provide therapeutic benefit.

00:50:11.160 | So save your money if you really need something

00:50:13.460 | to change some part of your skin,

00:50:15.240 | see a good dermatologist, see an expert,

00:50:17.840 | and see what they can come up with.

00:50:20.120 | - So this seems like an appropriate time

00:50:21.720 | to ask about sun exposure.

00:50:23.880 | And then we'll also talk about sunscreen,

00:50:25.440 | sunblocks, skin cancer.

00:50:27.840 | - Sure.

00:50:28.680 | - But what is the relationship

00:50:31.120 | between sun exposure and skin health specifically,

00:50:35.560 | meaning how much sun exposure is healthy for our skin?

00:50:40.320 | I'm a big believer in getting sun exposure to the eyes

00:50:43.200 | early in the day,

00:50:44.160 | blinking as needed to protect the eyes, of course,

00:50:46.120 | but in order to set one's circadian rhythm

00:50:48.600 | for elevated daytime mood, focus and alertness,

00:50:51.880 | and improved nighttime sleep.

00:50:53.000 | There's just so much data to support

00:50:54.960 | setting one's circadian rhythm properly for sake of health.

00:50:57.840 | And there's so much data to support the fact

00:50:59.840 | that sunlight viewing in particular

00:51:02.280 | is the best way to do that.

00:51:03.960 | And sunlight viewing in the early part of the day

00:51:06.680 | in particular is the best way to do that.

00:51:08.640 | But beyond that,

00:51:11.520 | how much sun exposure to the skin is good for us?

00:51:15.480 | Is it zero?

00:51:16.440 | Is it five minutes?

00:51:17.600 | Does it depend?

00:51:18.560 | - Great, like great controversial question.

00:51:24.120 | And it depends on which school of thought

00:51:27.640 | or camp you belong in.

00:51:29.600 | As a skin cancer surgeon

00:51:31.240 | and somebody who's developed a reputation

00:51:33.800 | for seeing some of the worst,

00:51:35.780 | most complicated and life-threatening skin cancers

00:51:38.300 | in Los Angeles,

00:51:40.760 | obviously I see some of the consequences

00:51:43.160 | of long-term sun exposure and chronic photo aging.

00:51:47.380 | That being said,

00:51:50.040 | I absolutely think that getting sun is healthy for us.

00:51:53.940 | Now, why?

00:51:56.120 | The studies that talk about vitamin D,

00:51:58.960 | and we'll touch on vitamin D as its own entity,

00:52:01.580 | and then overall health as another entity,

00:52:04.280 | but most of the studies that look at vitamin D synthesis

00:52:07.560 | from UV exposure on the skin

00:52:09.200 | suggest that you only need about 15 minutes

00:52:11.600 | and that you don't need a broad surface area of exposure.

00:52:15.920 | You can get enough vitamin D formation

00:52:18.520 | with just about 15 to 20 minutes of sun on your forearms.

00:52:22.240 | So there's a whole school of thought

00:52:24.560 | by a lot of experts who think

00:52:25.800 | there's no amount of UV exposure

00:52:27.560 | that's healthy for the skin.

00:52:29.000 | And I tend to be on the other camp for several reasons.

00:52:32.440 | One, there is a component of feel-goodness

00:52:37.880 | if that's a word from being in the sun

00:52:41.460 | that affects overall skin and physical biology.

00:52:46.460 | When you're out in a sunny day,

00:52:50.160 | you tend to be less stressed.

00:52:52.520 | You tend to be a little happier.

00:52:54.880 | Now, it's a generalization,

00:52:56.520 | but most of the time when you get outdoors,

00:52:59.800 | you get outside and it's a nice sunny day, you feel better.

00:53:03.160 | And although you can't quantify that feeling better,

00:53:06.280 | there are some parameters that can be measured.

00:53:09.000 | Decreases in cortisol response,

00:53:11.280 | improvements in skin appearance and texture.

00:53:15.660 | The other important thing about being out in the sun

00:53:20.400 | is finding out your own tolerance, right?

00:53:23.400 | So I have a little bit more olive skin

00:53:25.480 | and I can tolerate the sun a little bit longer

00:53:27.800 | than somebody who is fairer and lighter eyes.

00:53:30.200 | In my opinion, I don't think in most of the evidence,

00:53:34.480 | there isn't a finite amount of time

00:53:36.840 | because that time is dictated by your skin's ability

00:53:39.440 | to tolerate the UV.

00:53:40.560 | But I absolutely do not think that sun avoidance

00:53:43.280 | is a healthy thing.

00:53:44.400 | And this is coming from somebody who operates

00:53:47.300 | on head and neck skin cancers literally every day.

00:53:50.360 | I think there is a component of sun exposure

00:53:52.560 | that's not just for vitamin D synthesis,

00:53:54.860 | but something that improves your overall wellness

00:53:57.680 | that is visible and maybe not laboratory measurable,

00:54:02.960 | but you definitely are healthier

00:54:05.800 | when you're feeling better and you're happier.

00:54:07.960 | I lived on the East Coast

00:54:09.360 | in places that had lower days of sun

00:54:12.840 | and I had seasonal affective disorder.

00:54:14.880 | It bothered me.

00:54:15.720 | My mood was lower.

00:54:16.620 | I felt not as healthy.

00:54:19.160 | I'd come home, my family would say,

00:54:20.640 | "Hey, you look sick."

00:54:21.840 | And it just, I wasn't sick.

00:54:23.240 | I hadn't had any sun and I was lighter than I was.

00:54:26.040 | And my family interpreted that as not being healthy.

00:54:30.080 | My wife, on the other hand, didn't.

00:54:31.440 | She didn't mind the grayness.

00:54:32.700 | So there's a timeline for biologic processes

00:54:36.040 | like vitamin D formation that's helpful.

00:54:38.560 | People can argue that you can get it

00:54:39.920 | through supplementation and food and that's correct,

00:54:42.780 | but there is a component of sun exposure

00:54:44.700 | that makes you feel better overall

00:54:46.600 | and provide some sort of wellness

00:54:47.960 | that you may not be able to quantify,

00:54:49.700 | but you see an appearance and in discussion and longevity.

00:54:54.360 | So absolutely, I think you should be out in the sun.

00:54:57.120 | I don't think you should burn

00:54:58.680 | and I don't think you should be out long enough

00:55:00.520 | where your skin starts to turn red.

00:55:02.640 | That's the first sign that you're reaching

00:55:04.900 | kind of critical mass in terms of UV exposure,

00:55:07.160 | but I absolutely think the sun is a good thing for us.

00:55:10.080 | - So even midday sun,

00:55:12.480 | maybe if there's some cloud cover

00:55:14.300 | or if we have some sunscreen on or a physical barrier

00:55:18.180 | like sun and long, excuse me, like hat and long sleeves,

00:55:22.420 | then getting some sun exposure in your mind

00:55:25.900 | is good for our overall wellbeing, mood, et cetera.

00:55:29.520 | - Yeah, I think, I mean, midday sun has a higher UV index,

00:55:32.880 | so you're more likely to burn

00:55:34.400 | and have a problem with prolonged exposure,

00:55:36.660 | but yeah, absolutely.

00:55:37.560 | I think there's been numerous studies

00:55:40.480 | that have looked at people who go out for a walk

00:55:43.320 | in busy urban cities in work environments.

00:55:47.320 | If they go out for a walk in the sun, they feel better.

00:55:49.620 | Their stress responses are lower,

00:55:51.920 | their questionnaires in responding to life stressors

00:55:54.360 | and day-to-day stressors are decreased.

00:55:56.480 | There's a lot of studies that look at being outside

00:55:58.920 | as a measure of wellbeing, mental health wellbeing

00:56:02.880 | is improved with outdoor sun exposure,

00:56:06.320 | so there's a lot of that.

00:56:07.160 | Now, can I quantify it in the skin?

00:56:10.080 | Hard to say.

00:56:11.360 | One thing we do know is that obviously

00:56:13.880 | too much sun exposure, like anything,

00:56:15.880 | too much of a good thing can be a bad thing,

00:56:17.760 | but I really do think that being out in the sun

00:56:20.200 | for the amount that your skin can tolerate is a good thing.

00:56:24.040 | - I'd like to take a brief break

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00:57:35.880 | - What about sunscreens and sunblocks?

00:57:38.520 | And I think we should distinguish between those two labels.

00:57:42.100 | You know, in the old days, as I understand sunscreen

00:57:46.520 | was the word used to describe stuff

00:57:49.360 | that you put on your skin that absorbs UV

00:57:51.800 | and then sunblock is the stuff that you put on your skin

00:57:55.160 | to reflect UV.

00:57:57.040 | Typically nowadays, people say sunscreen

00:58:00.520 | more than they say sunblock,

00:58:01.840 | or they use them interchangeably

00:58:03.160 | without any knowledge of the underlying mechanism.

00:58:05.660 | So first of all, let's clarify sunscreen versus sunblock.

00:58:10.400 | - Yeah, so a lot of the nomenclature data,

00:58:14.040 | understanding chemicals,

00:58:16.620 | things that were considered okay to be used

00:58:18.720 | came from an original FDA 1999 manuscript.

00:58:22.320 | And that data hadn't changed for almost 20 something years.

00:58:27.640 | And more recently, in 2021,

00:58:31.480 | the FDA released a proposed final order

00:58:34.480 | for the term sunscreens as a whole.

00:58:37.900 | Now, when we talk about sunscreens,

00:58:41.320 | sunscreens are considered

00:58:43.800 | an over-the-counter non-prescription drug.

00:58:47.180 | So they're regulated tightly by the FDA.

00:58:50.200 | They're in the same category as any over-the-counter drug.

00:58:53.640 | So before this decision ruling,

00:58:58.280 | there was a lot of nomenclature, wording, confusion.

00:59:01.440 | Sunblock seemed better than sunscreen,

00:59:04.400 | sun tan, sun tan oil.

00:59:08.200 | All of that's been changed recently

00:59:11.200 | or has been proposed to get rid of

00:59:13.240 | to unify the field and make it very clear what the goal is.

00:59:16.820 | So no longer do we use the term sunblock,

00:59:19.240 | although in the past,

00:59:20.760 | that had been used for things like zinc

00:59:23.280 | or zinc and titanium-based creams,

00:59:25.680 | like the old 1980s or 1990s white lifeguard noses,

00:59:28.920 | if you remember.

00:59:29.860 | That used to be thought of sunblock,

00:59:31.700 | whereas less protective chemicals were used as sunscreen.

00:59:36.700 | Now that's changing.

00:59:38.800 | And the FDA 2021 proposed order says

00:59:42.000 | we need to unify everything and call it a sunscreen.

00:59:45.180 | Now, sunscreens being regulated drugs

00:59:49.960 | take a lot of scrutiny for many reasons.

00:59:52.800 | They take scrutiny from the FDA

00:59:54.320 | in terms of proving efficacy and safety.

00:59:57.120 | They take a lot of scrutiny in society

00:59:59.100 | for being dangerous or not dangerous,

01:00:01.880 | effective or not effective,

01:00:03.600 | causing downstream effects

01:00:04.840 | or not causing downstream effects.

01:00:07.360 | So that's been a big point of contention

01:00:09.620 | in terms of the population,

01:00:12.640 | the American Academy's stance, dermatologist's stance,

01:00:16.820 | and then the skin cancer patients' beliefs,

01:00:20.940 | the beauty experts' beliefs,

01:00:23.740 | and average person's opinions.

01:00:25.900 | Sunscreens generally fall into creams,

01:00:30.220 | lotions, topical products

01:00:32.220 | that protect the skin against sunburn.

01:00:35.520 | We used to be able to suggest

01:00:38.740 | that they reduce the risk of skin cancer,

01:00:41.780 | prevent it premature aging,

01:00:43.340 | but that can be a little convoluted.

01:00:45.820 | And the FDA is rewording that

01:00:48.020 | into not being able to say that anymore

01:00:49.860 | in their proposed order.

01:00:51.740 | But what sunscreen's intention is

01:00:53.680 | is to protect the skin against excess UV exposure.

01:00:57.120 | And they come in two flavors.

01:00:58.380 | They come in mineral-based sunscreens,

01:01:00.980 | which tend to be in the category

01:01:03.020 | of zinc and titanium minerals.

01:01:05.020 | And they tend to be chemical sunscreens,

01:01:07.100 | which are a bunch of different chemicals.

01:01:09.060 | - Mineral-based sunscreens

01:01:10.620 | are sometimes called inorganic, correct?

01:01:12.300 | - Yeah, inorganic or physical sunscreens,

01:01:15.220 | whereas the chemicals are considered organic

01:01:17.560 | or chemical sunscreens.

01:01:19.380 | Totally right.

01:01:20.580 | - Is the mechanism for these two the same?

01:01:22.940 | Because I was under the impression

01:01:25.180 | that the mineral-based inorganic sunscreens

01:01:27.380 | reflected back UV rays,

01:01:32.180 | whereas the chemical-based sunscreens absorbed UV rays.

01:01:36.420 | But there's a bit of a online debate about this,

01:01:40.700 | claiming that they all absorb UV rays.

01:01:43.500 | - Yeah, so historically it had been thought

01:01:45.900 | that mineral or physical sunscreens,

01:01:49.060 | zinc, zinc, and titanium sunscreens,

01:01:51.220 | worked by basically acting as a metal reflecting shield.

01:01:54.380 | And for the most part, that thinking is not incorrect.

01:01:59.340 | There was a new study that showed

01:02:01.780 | that they work by actually absorbing them,

01:02:05.300 | but not having any sort of chemical change.

01:02:08.100 | So the way chemical organic sunscreens work

01:02:11.060 | is they absorb the ultraviolet radiation,

01:02:14.260 | they undergo a chemical reaction to reduce its energy

01:02:17.620 | and dissipate that energy as heat.

01:02:20.380 | So chemical sunscreens work by actually absorbing it

01:02:23.420 | and undergoing a change,

01:02:25.260 | whereas mineral or physical sunscreens don't do that.

01:02:28.300 | I still think of them simply as minerals

01:02:31.220 | basically shield the skin like armor,

01:02:34.220 | whereas chemicals act as a sink

01:02:36.420 | and undergo a change to reduce that energy.

01:02:39.220 | So that's kind of the simplistic way

01:02:42.420 | that topical sunscreens work.

01:02:44.420 | - So what is your recommendation

01:02:46.860 | about protecting oneself from the sun?

01:02:49.580 | And maybe for the moment, let's just set aside sunscreens

01:02:52.420 | and acknowledge that a physical barrier

01:02:54.700 | like hat, long sleeves, long pants,

01:02:57.500 | provides a pretty good barrier to the sun, correct?

01:02:59.940 | - Yeah, in fact, physical barriers like shade, clothing,

01:03:04.940 | hats have been shown to be more effective

01:03:07.940 | than topical sunscreens for several reasons.

01:03:11.540 | But there are many ways to protect your skin

01:03:14.300 | and you have to ask why you're protecting your skin.

01:03:16.820 | So is it because you're worried about premature aging,

01:03:21.820 | photo damage and things like of that nature?

01:03:25.660 | Are you worried about your risk for skin cancer?

01:03:29.260 | Do you have a sun sensitive skin condition

01:03:31.900 | like lupus or PMLE that is sensitive to UV exposure?

01:03:35.860 | So the first question is, why are you worried?

01:03:39.620 | Or why are you taking protection?

01:03:41.260 | And then you customize your approach to that.

01:03:43.980 | Now, sunscreen, topical sunscreens are not the only form.

01:03:46.980 | By and large, there are many other forms,

01:03:49.580 | both physical blockers and certain things

01:03:52.540 | in the supplement world that can protect your skin.

01:03:55.980 | For example, I myself take a product called sun powder

01:03:59.700 | that provides an internal sun shield

01:04:01.980 | and allows me to be in the sun longer

01:04:04.580 | without the need to reapply or if I can't reapply.

01:04:07.460 | But by and large, the best way to protect your skin

01:04:11.860 | is some sort of shield, whether it's clothing, hat,

01:04:15.660 | or some sort of cream that you put on.

01:04:17.420 | Now, for patients who are worried,

01:04:20.100 | or for people who are worried about premature aging,

01:04:24.500 | they don't have a strong family history of skin cancer.

01:04:26.860 | They've never had one before themselves.

01:04:29.460 | Then the approach to that is a little bit different

01:04:33.020 | than people who are worried about skin cancer development,

01:04:37.380 | strong family history of skin cancer.

01:04:39.180 | They're worried about losing a part of their ear

01:04:41.820 | or a part of their nose to skin cancer development.

01:04:45.580 | And that's very different from medical conditions

01:04:48.180 | that are very sun sensitive.

01:04:49.940 | By and large, the patients who have medical conditions

01:04:54.900 | that are sun sensitive,

01:04:56.100 | the large one being lupus, for example,

01:04:58.340 | need the most sun protection

01:05:00.540 | because they are so inherently sensitive to UV exposure.

01:05:03.820 | Something that's very interesting.

01:05:06.740 | We know without a doubt that every common skin cancer,

01:05:12.500 | there's many, many skin cancer types,

01:05:14.380 | but the three most common are basal cell carcinoma,

01:05:17.020 | squamous cell carcinoma, and melanoma.

01:05:18.540 | Those are the three most common ones we see.

01:05:21.100 | They have all been shown to have UV mutation signatures

01:05:25.500 | when we sequence the tumors.

01:05:27.060 | However, in every single clinical trial

01:05:31.780 | and every single randomized trial

01:05:33.340 | that looked at topical sunscreens

01:05:35.660 | as a means of reducing risk,

01:05:39.340 | there has not been a single study

01:05:41.500 | that showed any sort of risk reduction

01:05:44.500 | in the development of the most common skin cancer,

01:05:47.060 | which is basal cell carcinoma.

01:05:48.500 | One in four Americans will develop this.

01:05:50.500 | Also, there hasn't been a single study to date

01:05:54.940 | that showed that diligent sunscreen use,

01:05:57.260 | topical sunscreens, will reduce disease-specific death

01:06:01.380 | or dying from skin cancer.

01:06:03.700 | So if you think every skin cancer is sun driven,

01:06:07.140 | there are UV mutation profiles in these tumors,

01:06:10.060 | then by using sunscreen should reduce that, right?

01:06:13.740 | And it's not that clear.

01:06:15.220 | We don't understand fully the drivers of this.

01:06:18.220 | So why I bring this up

01:06:20.300 | and why we talk about sunscreens

01:06:21.940 | and barriers to blockade?

01:06:23.660 | First, topical sunscreens are not the only form.

01:06:27.060 | In fact, clothing and shields, shade and hat

01:06:29.700 | are, in my opinion, better,

01:06:31.140 | and a lot of studies suggest that they're better.

01:06:34.180 | There are oral supplements

01:06:35.380 | that can also protect your skin from burning

01:06:37.260 | and reduce your skin cancer risk.

01:06:39.100 | And number three, not everything is sun driven.

01:06:42.780 | We do know that diligent sunscreen use

01:06:45.820 | decreases the incidence

01:06:47.500 | or the amount of melanoma formation

01:06:50.780 | and squamous cell formation,

01:06:52.140 | but we still don't know whether that reduction

01:06:54.740 | has changed the number of patients dying from that.

01:06:58.500 | We also know that it has no bearing

01:07:00.780 | in the development of the most common skin cancer,

01:07:02.820 | which is basal cell.

01:07:03.700 | So we go back to the drawing board

01:07:05.620 | and scratch our heads saying,

01:07:06.540 | "Hey, what is the trigger?"

01:07:09.500 | The genetics loads the gun, for example,

01:07:12.380 | and maybe even pulls the hammer,

01:07:13.820 | but what in the environment is the trigger?

01:07:17.140 | Is it strictly UV?

01:07:19.060 | Is it some other culprit?

01:07:20.700 | So sunscreens are a really hotly debated topic.

01:07:23.620 | So many things to talk about in terms of sunscreen.

01:07:26.380 | - So if I understand correctly,

01:07:29.280 | you're saying that the use of sunscreen

01:07:31.460 | can protect against premature aging.

01:07:33.940 | Let's say sunblock,

01:07:36.100 | because I think we're going to arrive

01:07:37.420 | at mineral-based sunscreens

01:07:38.780 | probably being the better option,

01:07:40.380 | but we can make sure that we double-click on that,

01:07:43.520 | so to speak.

01:07:44.600 | But that sun exposure itself

01:07:48.240 | perhaps is not linked to the most deadly of skin cancers.

01:07:51.360 | That tells me two things.

01:07:52.740 | It doesn't tell me that I can just spend as much time

01:07:55.640 | as I want in the sun,

01:07:57.360 | but it does tell me that I should probably look

01:08:00.080 | into the things that cause the most deadly skin cancers.

01:08:03.040 | - Yeah. - Okay.

01:08:03.880 | But I'm also hearing that regular application of sunblock

01:08:08.800 | and/or physical barrier will protect my skin

01:08:11.980 | against some forms of premature aging

01:08:14.560 | caused by sun exposure,

01:08:16.400 | but will not necessarily protect me

01:08:19.380 | against the most common forms of skin cancer.

01:08:22.840 | That is peculiar in the sense that,

01:08:26.320 | or even baffling to the non-dermatologist, me,

01:08:31.320 | because we already know that sun exposure

01:08:34.560 | causes UV mutations.

01:08:36.120 | Mutations in the DNA of cells

01:08:38.400 | is one of the kind of core components of cancer.

01:08:41.000 | So how do we square all of this?

01:08:43.200 | - Great question.

01:08:44.120 | And the more we dive into this

01:08:46.600 | and the more experts we look at

01:08:48.440 | and the more data we collect,

01:08:50.520 | the more we're scratching our head as to,

01:08:52.880 | we don't know, and why this occurs.

01:08:54.680 | Now, I'm not saying don't use sunscreen.

01:08:57.960 | Let's just let that be known.

01:08:59.160 | I think sunscreens are excellent forms

01:09:02.780 | to protect against premature photo-aging

01:09:05.760 | and signs of sun damage.

01:09:08.360 | I think sunscreens help reduce

01:09:10.960 | the incidence of common garden variety skin cancers,

01:09:15.560 | but they are not the only form of protection

01:09:18.760 | and they seem to not be as important

01:09:21.760 | or have as much effect

01:09:24.160 | in reducing the incidence of our most common skin cancer,

01:09:27.640 | which is basal cell carcinoma.

01:09:29.260 | Moreover, I would say,

01:09:31.200 | and the data unfortunately shows

01:09:34.000 | that the majority of skin cancers

01:09:36.200 | that we see that end up hurting people or killing patients

01:09:41.200 | don't arise in chronic sun-exposed areas to begin with.

01:09:45.720 | I have a 27-year-old patient right now

01:09:48.080 | dying of a metastatic melanoma

01:09:49.520 | that arose in completely sun-protected skin.

01:09:52.920 | I have a 56-year-old mechanic right now

01:09:56.040 | who's dying of a squamous cell carcinoma

01:09:57.960 | that arose from the back of his ear.

01:09:59.600 | And most experts who have this type of experience

01:10:04.160 | dealing with these patients have the same observation.

01:10:07.160 | So the question is, what's pulling the trigger?

01:10:10.360 | For the most part, UV plays a big role.

01:10:14.680 | The mechanism in which cancer forms,

01:10:19.840 | if we believe the basic high school biology is,

01:10:24.120 | you know, hyperplasia, metaplasia, dysplasia, carcinoma.

01:10:27.600 | So there's a trajectory of changes that are occurring

01:10:32.120 | as a result of cumulative mutations in the skin.

01:10:35.320 | If we believe that trajectory,

01:10:37.320 | then every skin cancer should see that change,

01:10:41.760 | and we just don't see that.

01:10:44.040 | Also, we know that skin cancers that arise

01:10:46.560 | in sun-damaged skin behave differently

01:10:49.820 | than the ones that are very lethal.

01:10:52.040 | So why I bring this up, I think sunscreen is very helpful,

01:10:55.960 | but we have this unfortunate trend in medicine,

01:10:59.800 | particularly in dermatology,

01:11:01.880 | to guilt people into thinking

01:11:04.520 | that they cause this to themselves.

01:11:06.120 | And I don't think that's right nor okay,

01:11:08.040 | and I don't like that.

01:11:09.680 | Because they make it seem that,

01:11:11.440 | oh, the sun you got in 1987,

01:11:13.640 | that one sunburn in Hawaii did it to you.

01:11:15.960 | And that's absolutely not the case.

01:11:18.200 | There are many things at play,

01:11:20.460 | fundamentally your genetics and immune system,

01:11:23.560 | that play a huge role in skin cancer development

01:11:26.080 | that sunscreen cannot address and will not address.

01:11:29.240 | Now, the wild card is, okay, what are my genetics?

01:11:34.240 | And that's the part we don't know,

01:11:36.200 | which is why dermatologists say,

01:11:37.780 | okay, let's at least control the thing that we can,

01:11:39.940 | which is UV exposure.

01:11:41.920 | But I bring this up because,

01:11:44.560 | don't feel bad about getting some sun,

01:11:48.400 | and don't feel guilted into something that,

01:11:51.120 | if something bad occurs, it's not your fault.

01:11:54.160 | Some of it is out of your control.

01:11:56.320 | And that's really important,

01:11:58.000 | 'cause I see a lot of very bad skin cancers in my practice.

01:12:00.780 | And I hate this feeling of patients

01:12:02.960 | feeling like they did it to themselves.

01:12:05.000 | - I think most people would prefer

01:12:06.360 | not to have the premature aging caused by sun exposure.

01:12:09.560 | So what should those people do?

01:12:13.080 | I've taken on a practice of putting a mineral-based,

01:12:17.040 | inorganic sunscreen on my face,

01:12:20.520 | my arms if they're going to be exposed,

01:12:22.400 | back of my neck, tops of my ears.

01:12:24.240 | If I'm going to be out in midday or late day sun

01:12:27.440 | that feels intense,

01:12:28.860 | and I'll do that every single time I go out now.

01:12:34.700 | On overcast days, not so much.

01:12:37.180 | For viewing morning sunlight, I don't do that.

01:12:39.840 | In fact, when the sun is low in the sky,

01:12:42.520 | I don't tend to wear sunblock.

01:12:43.760 | That's me, that's been my choice.

01:12:46.800 | There were a few years there where

01:12:48.300 | I didn't put on sunscreen,

01:12:50.240 | or if I did, it was like on a camping trip

01:12:52.880 | or skiing or something where the sun felt very intense.

01:12:56.280 | And in that case, I would just reach

01:12:57.400 | for whatever sunscreen or sunblock was available

01:12:59.480 | because I wasn't aware that some of the ingredients

01:13:02.160 | in certain chemical-based sunscreens may be problematic.

01:13:05.760 | So I think I fall into the typical category

01:13:09.360 | of a lot of people.

01:13:10.500 | But of course, there's the category of people

01:13:13.760 | that are like, nope, sunscreen sunblock

01:13:15.760 | is terrible all the time,

01:13:17.120 | or they're just too lazy or uninterested in applying it.

01:13:20.240 | But then there's this whole category of people

01:13:21.880 | that are putting it on every single time they go outside

01:13:25.300 | in hopes that that's going to keep their skin

01:13:28.040 | appearing much younger,

01:13:29.360 | and just generally are kind of afraid of the sun.

01:13:32.720 | - A lot of good points.

01:13:33.640 | So there's that famous New England Journal of Medicine

01:13:36.420 | picture of the truck driver that got chronic sun exposure

01:13:39.200 | on the left side of his face,

01:13:40.280 | and you see all this wrinkling and modeling

01:13:42.880 | of the skin on the left side and nothing on the right side.

01:13:46.040 | So by absolute measure, sun protection or UV protection

01:13:51.000 | will reduce premature aging.

01:13:52.440 | Now, interestingly, that guy did not develop anything

01:13:54.920 | in that area.

01:13:55.760 | So again, it goes back to, well,

01:13:57.500 | what's pulling the trigger? - No skin cancers.

01:13:59.160 | - So the question is, what's pulling the trigger?

01:14:01.240 | Is it truly UV, or is there something else we're missing?

01:14:03.960 | - If you tell me that he got skin cancer

01:14:05.600 | on the opposite side, I'm really gonna gasp, but no.

01:14:08.760 | - I don't know if he's had any on the opposite side,

01:14:12.000 | but in that photo, it's purely premature aging.

01:14:15.160 | So things that you wanna do.

01:14:16.480 | Obviously, don't let your skin turn red.

01:14:18.980 | Take some form of barrier protection,

01:14:22.120 | whether it's a sunscreen, a supplement like polypodium,

01:14:25.640 | something that protects your skin from the inside out.

01:14:27.800 | And skin changes are cumulative.

01:14:31.320 | So what we can tolerate in our teens and 20s

01:14:35.080 | is very different than what we can tolerate

01:14:36.600 | in our 40s, 50s, and 60s,

01:14:37.840 | because there's a cumulative mutation profile burden

01:14:40.860 | that we see.

01:14:42.400 | Interestingly, there was an eyelid study

01:14:44.220 | that was published recently that looked at eyelid skin

01:14:47.640 | that was removed during cosmetic surgery,

01:14:49.680 | upper eyelid lifts, that was otherwise discarded.

01:14:52.960 | And when they ran genetic sequencing on normal eyelid skin,

01:14:57.920 | they saw the same mutations that they would see

01:15:01.080 | in matched skin cancers,

01:15:03.700 | but the eyelids didn't have any skin cancer.

01:15:06.180 | So we know UV triggers these mutations,

01:15:09.860 | and we know UV degrades collagen and elastin.

01:15:13.180 | It thins blood vessel walls

01:15:15.200 | as a mechanism of its effects on the dermis.

01:15:19.100 | The data is equivocal as to how those mutations

01:15:23.680 | trigger skin cancer formation,

01:15:25.120 | but in terms of premature aging, absolutely.

01:15:27.500 | So you wanna take some form of protection.

01:15:29.160 | Now, what type of protection do you take?

01:15:31.060 | Depends on your genetics, how much you can tolerate,

01:15:33.580 | and what your family lineage looks like.

01:15:36.160 | Some people have the genetics of early aging.

01:15:39.360 | It's part of their skin biology,

01:15:41.480 | and you can't change that,

01:15:42.520 | but you can mitigate that risk

01:15:44.240 | with more strict UV avoidance.

01:15:47.160 | Some people, they look young, longer.

01:15:50.000 | Some family lineages just have great genetics in their skin.

01:15:53.600 | They can tolerate a little bit more sun.

01:15:56.080 | In terms of physical sunscreens versus chemical sunscreens,

01:16:00.400 | that's a hotly debated topic.

01:16:02.520 | In my personal practice and for my family,

01:16:05.680 | I tend to only recommend mineral zinc

01:16:09.280 | or zinc and titanium sunscreens for several reasons.

01:16:13.680 | In the original set of sunscreens

01:16:16.640 | that were approved by the FDA that came out in 1999,

01:16:20.380 | there wasn't enough data to look at biologic effects,

01:16:25.380 | efficacy, internal organ involvement, et cetera.

01:16:29.340 | Fast forward 20 years,

01:16:33.360 | and we've gathered a lot more information

01:16:35.560 | about these chemical organic compounds.

01:16:38.840 | There was an amazing 2020 study

01:16:41.320 | that looked at absorption of chemical sunscreens

01:16:45.680 | when they're applied onto the skin.

01:16:47.440 | They looked at absorption with single application,

01:16:50.720 | and they looked at absorption over four days of application.

01:16:54.040 | Now, in the study, they applied a little bit more

01:16:56.580 | than real world experience would,

01:17:00.880 | but even with single application,

01:17:03.480 | they saw blood plasma absorption of these chemicals

01:17:07.640 | that were 100 to 500 times greater

01:17:11.120 | than the upper threshold defined by the FDA.

01:17:13.880 | Now, the question exists, okay, what does that mean?

01:17:18.240 | Is this healthy?

01:17:19.360 | Is this not healthy?

01:17:20.640 | Is it neither?

01:17:22.540 | That's still up for debate,

01:17:25.360 | but in looking at the more recent literature

01:17:27.960 | and looking at the chemical structure of these compounds,

01:17:31.040 | a lot of these are phenolic compounds,

01:17:33.920 | meaning they have one or two,

01:17:36.480 | usually two benzene rings attached together,

01:17:39.280 | and they look very similar to one another.

01:17:42.560 | There's been a lot of basic science, animal study,

01:17:46.360 | and retrospective human studies

01:17:48.500 | in the last two or three years

01:17:49.980 | that suggest that some of these chemical compounds,

01:17:53.760 | particularly oxybenzone, particularly octocrylene,

01:17:57.520 | particularly octinoxinate,

01:18:01.840 | that can have endocrine disruption

01:18:04.260 | or affect the nervous system

01:18:06.520 | because they mimic a lot of biologic phenolic compounds

01:18:09.840 | and a lot of biologic hormones.

01:18:12.120 | If you actually look at the structure of oxybenzone,

01:18:14.520 | it looks very similar to the structure of bisphenol A,

01:18:17.320 | which has been now banned

01:18:18.560 | in a lot of the lining of plastic bottles.

01:18:20.440 | Why? Because of the same concept.

01:18:22.040 | Now, the data's not 100% one way or another,

01:18:26.600 | but there's enough smoldering evidence

01:18:29.200 | that makes me think, hmm, we should reinvestigate this.

01:18:32.800 | And in fact, the FDA's proposed final order in 2021

01:18:37.800 | changed these chemicals from GRACE,

01:18:41.800 | generally recognized as safe and effective,

01:18:44.040 | to not-GRACE because of these concerns.

01:18:47.800 | There's data that suggests that the chemicals

01:18:50.120 | are found in breast milk, amniotic fluid,

01:18:53.640 | blood plasma, urine.

01:18:56.240 | So there's a lot of things that we don't know,

01:18:57.760 | and I always say this in science.

01:18:58.820 | We take two steps forward

01:18:59.880 | and then maybe one step diagonally or sideways

01:19:02.520 | 'cause we ran into unexpected things.

01:19:05.000 | I tend to recommend mineral sunscreens

01:19:07.320 | because they don't have any of that data.

01:19:10.000 | They haven't for the last 30, 40 years.

01:19:12.200 | They're considered safe.

01:19:13.260 | And in fact, for young kids,

01:19:15.840 | particularly those six months and under,

01:19:17.900 | the American Academy of Dermatology

01:19:19.400 | and the American Academy of Pediatrics

01:19:21.240 | generally recommends avoiding chemical sunscreens.

01:19:24.080 | Why? Children's skin, particularly infants and toddlers,

01:19:28.240 | behaves more like mucous membranes than adult skin.

01:19:31.840 | Their barrier is not as tightly woven,

01:19:34.000 | so they absorb these things at a much higher concentration.

01:19:37.840 | So if you are to apply something on kids,

01:19:40.000 | especially young kids six months or under,

01:19:42.320 | we recommend minerals to begin with.

01:19:44.960 | So I say, if you have a pool of compounds

01:19:48.120 | that has maybe even smoldering evidence

01:19:50.200 | on the basic science level that something's off

01:19:53.160 | versus a group of compounds that have really no data,

01:19:58.920 | which one would you pick?

01:19:59.760 | And they do the same thing.

01:20:00.880 | I naturally gravitate towards that.

01:20:03.760 | - So the takeaway for me is physical barrier, no issues.

01:20:08.760 | Mineral-based sunscreen, safest.

01:20:14.960 | So that zinc oxide, titanium dioxide.

01:20:18.080 | - And that's mineral, not like powder,

01:20:21.080 | not mineral powder, but mineral topicals

01:20:23.200 | because mineral powders are a whole other issue

01:20:25.400 | we'll talk about, but.

01:20:26.720 | - Okay, and then chemical-based sunscreens,

01:20:29.840 | probably best avoided.

01:20:32.200 | And then you mentioned polypodium.

01:20:36.480 | So this is a pill, it's a supplement basically

01:20:38.800 | that one can take.

01:20:39.720 | I only call it a supplement

01:20:40.960 | because it's not a prescription drug, correct?

01:20:44.280 | - Yeah.

01:20:45.360 | - That protects your skin from UV damage from the inside.

01:20:49.600 | - Yeah, so exactly right.

01:20:51.680 | Mineral-based creams and lotions,

01:20:54.720 | I tend to prefer and recommend in my practice

01:20:57.320 | and most people will if you're worried about any risk,

01:21:00.600 | any consequence.

01:21:02.280 | Chemicals, I tend to personally avoid.

01:21:05.240 | Now, this may not be in line

01:21:07.380 | with all my dermatology colleagues,

01:21:08.920 | but I tend to avoid them

01:21:09.960 | and I do not recommend them for kids.

01:21:12.720 | In terms of things that you can do in addition

01:21:14.620 | to provide sun protection, polypodium's a fern

01:21:17.520 | from the Amazon rainforest that was discovered

01:21:20.640 | when they studied an indigenous population

01:21:22.760 | that would eat this fern before they would go

01:21:24.760 | on their fishing expeditions on the Amazon.

01:21:27.480 | And they'd be gone for three days,

01:21:29.040 | they'd eat this fern and come back not burned.

01:21:32.080 | So a lot of studies were done on this fern

01:21:34.160 | in the last five, 10 years

01:21:36.480 | that showed it increases your skin's minimal erythema dose,

01:21:40.760 | the amount of redness your skin gets from UV exposure.

01:21:44.180 | That's our general barometer for effectiveness

01:21:48.460 | without any topicals.

01:21:49.760 | It's taken or ingested orally.

01:21:51.480 | I personally use a form called sun powder

01:21:53.960 | that also has nicotinamide in it,

01:21:55.760 | and we can talk about nicotinamide later.

01:21:57.160 | But if in and of itself, it works great,

01:22:00.400 | in conjunction with topicals,

01:22:02.040 | you get the best of both worlds.

01:22:03.500 | You get internal shielding and external shielding.

01:22:06.000 | Now it is a supplement, so it's not a controlled drug

01:22:09.480 | the way the FDA regulates sunscreen.

01:22:11.160 | So it isn't really a sunscreen,

01:22:13.680 | but it's a way to prevent sunburns,

01:22:17.300 | increase the amount of time you can be outside,

01:22:19.840 | and increase the efficacy of your topicals.

01:22:22.440 | So if you're somebody who has very fair skin,

01:22:24.080 | who burns all the time,

01:22:25.760 | or if you're somebody who has what we call sun hives

01:22:29.760 | or prickly sun rash, PMLE,

01:22:34.520 | this is an added thing that you can use

01:22:36.640 | that will boost your sun protective factors.

01:22:38.880 | It's awesome.

01:22:39.720 | And if you're somebody who's active,

01:22:41.560 | like you're in the water or you're exercising

01:22:44.920 | or you're playing a sport and you can't reapply,

01:22:46.880 | I love polypodium for that added benefit.

01:22:50.060 | - What are the dosages of polypodium that are useful

01:22:52.880 | and are there any side effects?

01:22:54.440 | - Yeah, great question.

01:22:55.320 | So there's been a wide variety of doses investigated,

01:23:00.000 | anywhere from 50, 100, 240, 480, generally-

01:23:05.000 | - You said 1500?

01:23:06.360 | - No, sorry, 50 milligrams, 100 milligrams, 240, 480.

01:23:14.640 | Somewhere in the, between 50 and 480 milligrams

01:23:19.640 | is what's commonly used.

01:23:21.000 | The most common side effect can be a little upset stomach

01:23:23.920 | if you can't tolerate the plant for whatever reason.

01:23:26.360 | - It's taken daily?

01:23:27.240 | - It's taken, you can either take it daily

01:23:29.560 | as a method of preventing premature photoaging

01:23:32.600 | and pigmentary change,

01:23:34.760 | or you can take it as an as-needed,

01:23:37.280 | an hour before you get sun to shield you from the sun.

01:23:41.920 | The other thing that it helps prevent

01:23:43.840 | that some sunscreens cannot,

01:23:46.920 | particularly the chemical sunscreens cannot,

01:23:49.680 | is the effects of visible light.

01:23:51.680 | So there are certain skin conditions,

01:23:53.760 | the most common is melasma,

01:23:56.040 | which a lot of women have,

01:23:58.320 | it's I think the bane of their existence.

01:24:00.100 | It used to be called the mask of pregnancy.

01:24:03.000 | And melasma is something that is very sensitive

01:24:06.320 | to both UV and visible light.

01:24:09.720 | Chemical sunscreens don't do a good job

01:24:11.240 | blocking visible light.

01:24:12.960 | Polypodium has been shown to help block

01:24:15.280 | the effects of visible light as well,

01:24:16.920 | which makes melasma worse.

01:24:18.300 | It's this discoloration that we see mostly in women,

01:24:21.540 | usually after pregnancy or women who are on birth control.

01:24:24.400 | It is really challenging to treat.

01:24:26.800 | And sun protection is the first line,

01:24:29.500 | like diligent sun protection.

01:24:31.720 | But we found that supplementing with polypodium

01:24:34.280 | enhances this and makes patients' treatments more effective.

01:24:38.600 | - Interesting, and you mentioned Sun Powder as a potential,

01:24:42.660 | that's a brand name?

01:24:43.740 | - So yes, Sun Powder is a brand.

01:24:46.160 | It's a product that I helped formulate

01:24:49.120 | with one of my colleagues over at Harvard,

01:24:51.480 | who's a laser and aesthetic dermatologist

01:24:54.400 | to Harvard trained.

01:24:55.240 | And this is something that we came up with

01:24:58.080 | when I was up at Stanford.

01:24:59.320 | And it's a supplement dedicated to skin health,

01:25:02.440 | and it does two things.

01:25:03.600 | I take it daily myself as a single scoop.

01:25:06.560 | It helps reduce your skin cancer risk,

01:25:08.840 | your non-melanoma skin cancer risk by up to 30%.

01:25:12.320 | And the data was published

01:25:14.000 | in the New England Journal of Medicine

01:25:15.520 | in a phase three randomized trial

01:25:17.120 | for one of the ingredients.

01:25:18.200 | The other ingredient, obviously, is polypodium.

01:25:21.160 | And I take that one to prevent sun-related changes,

01:25:24.600 | but also help reduce my risk of burning.

01:25:26.520 | Often when I personally find the need for sunscreen,

01:25:29.980 | it's when I can't apply.

01:25:31.280 | I'm always at the water, I'm swimming.

01:25:33.120 | My son, he's seven, he races on a swim team.

01:25:37.120 | I cannot get this kid to reapply sunscreen.

01:25:40.300 | So this is a supplement that I give him.

01:25:42.640 | And it took us several years of formulation and testing,

01:25:46.600 | including MED testing,

01:25:48.280 | which is minimal erythema dose testing to come up with.

01:25:51.900 | It's easy over the counter,

01:25:53.160 | and it's one of many supplements that contain polypodium.

01:25:56.240 | I just like it 'cause it's a single scoop

01:25:58.560 | and I mix it into my morning drink and I'm done.

01:26:01.320 | Terrific.

01:26:03.160 | - I think we both agree that the mineral-based sunscreens

01:26:06.080 | are going to be the best option of the ones out there,

01:26:08.560 | if one is at all concerned about some of these chemical

01:26:11.700 | components in chemical sunscreens.

01:26:13.800 | - Yeah. - Absolutely.

01:26:14.640 | - Fair enough. - Absolutely agree.

01:26:15.760 | - Yeah, so within that category,

01:26:18.600 | are there particular things to look for?

01:26:21.840 | I'm not necessarily trying to aim

01:26:23.520 | for particular brands here,

01:26:24.920 | but given that I have no relationship

01:26:26.800 | to any skincare products,

01:26:29.680 | I would just like to know which ones to look for,

01:26:32.640 | or will any zinc oxide and or titanium dioxide

01:26:37.000 | containing sunscreen,

01:26:38.240 | provided there are no chemical components in there,

01:26:41.360 | besides the inactive ingredients, of course,

01:26:44.060 | will any suffice?

01:26:45.480 | Because in that case,

01:26:46.600 | people can just shop for cost or availability.

01:26:48.840 | - Yeah, so I tend to take a pragmatic approach in this.

01:26:52.120 | My recommendation is a brand that you will use,

01:26:55.460 | because if I recommend a brand and you don't like it,

01:26:57.560 | it doesn't feel good or smell good,

01:26:58.800 | you're never gonna use it

01:26:59.680 | and it's a waste of your money and time.

01:27:01.320 | So number one, any brand that is mineral-based is fine.

01:27:05.320 | What you're looking for is broad spectrum coverage,

01:27:07.720 | which almost all mineral-based sunscreens provide.

01:27:10.360 | Broad spectrum meaning UVA and UVB.

01:27:13.560 | And we know these two UV forms

01:27:15.520 | do different things in the skin.

01:27:17.560 | We know that UVB is more implicated in redness

01:27:20.240 | and some early skin cancer changes.

01:27:22.540 | We know UVA is linked to premature photo aging

01:27:27.640 | and certain melanomas.

01:27:29.240 | So you want something that provides broad spectrum coverage.

01:27:31.600 | You're looking for a number, the SPF we talk about.

01:27:35.440 | You're looking for a number above 30.

01:27:37.800 | Why 30?

01:27:39.040 | Because every study that looked at defining the SPF

01:27:43.760 | required you to put a certain amount on the skin.

01:27:46.800 | Generally, it's an entire shot glass worth of the product

01:27:49.680 | on sun exposed skin.

01:27:50.880 | Most of the time in real world practice,

01:27:53.760 | people don't put on that much.

01:27:55.040 | They put on maybe half that.

01:27:56.440 | So what you're really getting when you buy something

01:27:58.480 | that's SPF 15 is like an SPF of eight.

01:28:01.480 | So if you're looking for something

01:28:02.720 | that provides protection, SPF 30 or greater is higher.

01:28:05.980 | Higher the zinc concentration,

01:28:07.860 | the better it protects against UV invisible light.

01:28:11.060 | The chalkier it may go on.

01:28:12.620 | So that's kind of where you find that balance.

01:28:14.900 | That's actually where the chemical sunscreens came about

01:28:18.920 | is the cosmeceutical industry finding things

01:28:21.220 | that felt nicer on the skin

01:28:23.440 | so that people could put makeup on

01:28:25.360 | without that grainy chalkiness.

01:28:27.520 | But in doing so, we ran into some issues.

01:28:30.000 | - What are some, if any, of the concerns

01:28:35.080 | that some of the components in chemical-based sunscreens

01:28:37.520 | can cross the blood-brain barrier?

01:28:39.320 | - It's not unjustified to think that.

01:28:44.300 | They are organic phenolic compounds.

01:28:47.160 | They are hydrophobic, they're lipophilic,

01:28:52.080 | meaning they can cross membranes very easily,

01:28:55.480 | which is why they run into this endocrine disruption

01:28:58.320 | and some nervous system dysregulation.

01:29:01.860 | Whether that's been validated to be problematic in humans

01:29:05.740 | has yet to be seen, but at least in vitro studies

01:29:08.320 | in certain animal models, we see this.

01:29:10.360 | So when you apply a certain concentration,

01:29:13.620 | and with that 2020 study that showed

01:29:15.520 | that we're seeing it in the blood

01:29:17.720 | at levels that are 200 to 500 times the upper limit

01:29:21.720 | of normal as defined by sunscreen criteria,

01:29:25.800 | now we have to scratch our head.

01:29:26.920 | Where is this circulating?

01:29:28.200 | Where is this going?

01:29:29.080 | Are we collecting it in our adipose tissue?

01:29:31.240 | If we're collecting it there,

01:29:32.480 | we may be collecting it up here.

01:29:33.920 | We may be collecting it in the nerves.

01:29:36.640 | So it's a really fascinating world

01:29:40.280 | to see where we're going with these.

01:29:41.840 | And in fact, the 16 most common chemicals

01:29:45.040 | that in '99 were everywhere, from spray sunscreens

01:29:48.960 | and bottles and things like that,

01:29:50.400 | are now being defied as, hmm, question mark,

01:29:52.640 | maybe not safe by the FDA,

01:29:55.120 | the very company that regulates it.

01:29:57.440 | - Another call for the mineral-based sunscreens

01:29:59.720 | just as a, you know, why take the risk?

01:30:03.800 | - Or even, you know, shade hat clothing.

01:30:06.040 | You know, if you're really worried

01:30:07.080 | about putting something on in absorption,

01:30:08.880 | you get excellent protection by natural barriers.

01:30:12.400 | - This seems like a good time to shift

01:30:15.520 | a little bit of our attention to nutrition

01:30:18.640 | and the gut microbiome.

01:30:21.320 | Now, this is an infinitely large topic.

01:30:24.320 | We could spend several episodes discussing this,

01:30:27.480 | but if you were to provide us some of the,

01:30:30.520 | kind of like major takeaways

01:30:33.000 | as it relates to nutrition and skin health,

01:30:36.240 | nutrition and skin appearance,

01:30:38.560 | gut and skin health and appearance, what would those be?

01:30:42.160 | - So there is an incredible connection

01:30:45.480 | between the gut microbiome and skin health

01:30:49.560 | and the skin microbiome,

01:30:50.920 | of which we're only now just understanding the gravity,

01:30:54.360 | the extent, and the connection.

01:30:56.760 | We know from many studies, many elegant studies,

01:30:59.480 | a lot of studies done out of my colleagues' labs

01:31:01.360 | up at Stanford, that modulating the gut microbiome

01:31:05.920 | affects inflammatory conditions of the skin.

01:31:09.480 | Meaning, if you control the dysregulation

01:31:13.920 | of the gut microbiome,

01:31:15.360 | if you have an anti-inflammatory dietary habit,

01:31:20.360 | actual skin disease decreases in intensity and severity,

01:31:24.360 | psoriasis, eczema, acne.

01:31:27.760 | And this is not just subjectively,

01:31:30.560 | it's measurable and quantifiable and reproducible.

01:31:34.000 | So the connection is fascinating.

01:31:36.280 | Now, how we modulate it, that's the unknown.

01:31:39.720 | We know in many different studies

01:31:42.520 | that some patients' gut microbiomes are wildly fluctuant

01:31:46.040 | to what they do from their environment

01:31:48.440 | in terms of dietary habits, antibiotics, things like that.

01:31:51.560 | Some people's gut microbiomes are rock solid,

01:31:54.280 | nothing changes them.

01:31:56.160 | And deciphering whose will benefit from what

01:31:59.200 | is the hardest part.

01:32:00.240 | In terms of nutrition overall,

01:32:03.200 | obviously everybody's told you this

01:32:05.480 | since the dawn of modern medicine,

01:32:07.360 | is a well-balanced diet is good for everything.

01:32:10.400 | Unfortunately, in the 21st century,

01:32:12.800 | there are a lot of diets.

01:32:15.320 | There are a lot of fad diets,

01:32:16.760 | there are a lot of restrictive diets.

01:32:19.320 | And that's where we see nutrition play an important role

01:32:22.160 | in both appearance and actual skin disease health.

01:32:25.640 | And there's so many different avenues to discuss this.

01:32:28.960 | Things like dietary habits and changes for acne.

01:32:33.000 | Things like dietary habits and changes for anti-aging.

01:32:37.200 | Things like dietary habits for rash disorders

01:32:40.600 | like psoriasis and eczema.

01:32:41.960 | It's so much to explore.

01:32:44.440 | - So my understanding, and we'll get into this more

01:32:47.120 | as it relates to acne, is that patterns of eating,

01:32:51.000 | either content, food volume, that is caloric load, et cetera,

01:32:55.540 | that increase insulin and things like mTOR

01:32:59.200 | are sort of pro-acne.

01:33:02.080 | They're gonna aggravate or increase acne.

01:33:05.640 | Whereas the things that tend to lower

01:33:07.680 | circulating blood glucose, insulin,

01:33:10.520 | and reduce inflammation tend to be kind of anti-acne,

01:33:14.040 | or sort of pull in the other direction

01:33:16.040 | towards reducing acne load.

01:33:18.540 | But if we were to just step back and say,

01:33:20.960 | okay, the typical person who wants to have

01:33:23.220 | the healthiest, best-appearing skin,

01:33:24.840 | who's not dealing with any specific issue,

01:33:26.760 | 'cause we will get into those specific issues,

01:33:29.080 | can we say they should eat a vegan diet, a vegetarian diet,

01:33:35.600 | is it okay to be an omnivore?

01:33:37.080 | Some people are on the extreme

01:33:38.400 | of this kind of carnivore-type diet.

01:33:40.720 | Some of those people actually report

01:33:42.480 | elimination of certain skin conditions.

01:33:45.860 | I don't know, I've never tried one of those extreme diets,

01:33:49.080 | but you hear this, but again, you hear a lot of things.

01:33:52.320 | So it seems to me that the relationship

01:33:56.380 | between keeping the gut microbiome healthy

01:33:59.200 | and ingesting sufficient amounts of fiber is pretty clear.

01:34:03.520 | The relationship between keeping the gut microbiome healthy

01:34:07.240 | and overall, that is, systemic inflammation low

01:34:10.820 | is pretty clear, and that eating foods

01:34:13.120 | that are mostly unprocessed or minimally processed

01:34:16.640 | keeps inflammation on the lower side,

01:34:19.440 | as opposed to eating more processed foods.

01:34:21.400 | But, you know, assuming you,

01:34:23.800 | would you agree or disagree with me on that?

01:34:25.280 | Feel free to disagree, please, yeah.

01:34:27.520 | So assuming that that's all true,

01:34:29.080 | is there any evidence that the ingestion of specific foods

01:34:32.500 | can make skin healthier?

01:34:33.680 | Like, you'll see this stuff, like, oh, you know,

01:34:35.480 | if you have two cups of blueberries a day,

01:34:36.800 | your skin is going to be healthier.

01:34:38.320 | Or is all of that indirect by virtue

01:34:41.100 | of specific micronutrients that are in those foods?

01:34:44.160 | - So there's a lot of layers to unravel on this.

01:34:47.480 | So if you're gonna pick one simple diet

01:34:51.800 | for optimal skin health,

01:34:53.800 | it's a high-protein, anti-inflammatory diet.

01:34:57.120 | So high-protein, animal-sourced proteins,

01:35:01.360 | fruits and vegetables,

01:35:02.700 | based on your ability to tolerate the fibers

01:35:04.940 | in the fruits and vegetables.

01:35:06.780 | Things that are inflammatory are inflammatory

01:35:08.980 | for two reasons.

01:35:09.820 | One, the glucose-insulin pathway,

01:35:11.840 | but number two, the bacteria in our gut process

01:35:15.860 | and release byproducts of metabolism of certain things.

01:35:19.500 | And those byproducts, basically their digestive products,

01:35:23.460 | can be very pro-inflammatory.

01:35:25.300 | So often you hear these anecdotal stories

01:35:28.140 | of I eliminated tomatoes and my psoriasis got better.

01:35:32.800 | That person may have had an inability to tolerate tomatoes

01:35:36.160 | because of their gut microbiome's ability

01:35:37.880 | to digest the lycopene or whatever it is.

01:35:40.240 | We do know for certain that anti-inflammatory diets

01:35:44.600 | do improve skin health that are measurable

01:35:47.000 | and seen in clinic.

01:35:48.560 | So absolutely high-protein, a complete protein.

01:35:53.560 | When I say complete protein,

01:35:55.640 | tends to be animal-based products, eggs, meat, chicken, fish,

01:36:00.180 | less so plant proteins just because of bioavailability

01:36:03.300 | and complete amino acid profiles.

01:36:06.820 | You want a high-protein, anti-inflammatory diet.

01:36:09.940 | That's number one.

01:36:11.500 | In terms of what you can introduce to your skin

01:36:15.060 | to improve one or two parameters,

01:36:18.060 | I don't think that's real.

01:36:19.780 | Why I bring this up, we see a lot of talk

01:36:22.940 | and you've had a lot of people discuss collagen,

01:36:26.440 | for example, and this is an incredibly popular product

01:36:30.720 | in the skin world because its claim to fame

01:36:33.880 | is it does everything, keeps you looking young,

01:36:35.760 | keeps your skin healthy, et cetera, et cetera.

01:36:38.680 | Well, we know collagen is essential to our skin health.

01:36:43.680 | Literally, it's what our dermis is made of

01:36:46.560 | that give us our suppleness, our youth, no wrinkles,

01:36:49.920 | you know, things like that.

01:36:52.040 | Collagen is made of three amino acids,

01:36:53.740 | glycine, proline, and usually hydroxyproline

01:36:56.700 | or hydroxyl lysine, okay?

01:36:58.780 | Those three amino acids are non-essential amino acids,

01:37:02.060 | meaning your body has the ability to synthesize these

01:37:05.740 | from sugars and fats that it eats.

01:37:08.680 | So collagen supplementation is not an essential protein,

01:37:13.440 | unlike animal proteins, which provide all 20 amino acids,

01:37:18.440 | including the essential ones your body cannot synthesize.

01:37:21.980 | Now, you may ask, okay, well, I see all these studies

01:37:24.620 | that suggest collagen supplementation

01:37:26.860 | improves skin health, skin appearance.

01:37:28.980 | There's several reasons for that.

01:37:30.160 | I don't think it doesn't.

01:37:31.400 | I think there is some benefit.

01:37:33.060 | The question is what are the confounding variables to this?

01:37:37.600 | Were the people in the studies on restrictive diets

01:37:41.060 | because they were thinking about beauty and aesthetic?

01:37:43.800 | Were they restricting patterns of food, dietary food,

01:37:48.440 | things like that, in which they weren't getting

01:37:51.300 | a sufficient amount of protein source to begin with?

01:37:54.540 | So when they supplemented,

01:37:55.620 | we saw improvements in their skin.

01:37:57.700 | And a lot of these studies are patient recall

01:38:01.700 | or patient questionnaire studies,

01:38:03.020 | in which there is inherent subjectivity

01:38:05.060 | and confounding variables in this.

01:38:06.900 | When people take an intervention that says,

01:38:09.180 | hey, you may look better,

01:38:10.220 | or this may improve the appearance of your skin,

01:38:12.420 | not only do you have a placebo effect in saying,

01:38:14.780 | yeah, I do look better,

01:38:16.680 | you may also do other things during your day,

01:38:20.700 | change your behaviors and lifestyle

01:38:23.240 | to fit the goal that you subconsciously want.

01:38:25.340 | So that's one.

01:38:26.280 | Number two, there is a component in,

01:38:30.020 | for example, collagen supplementation

01:38:32.260 | that is forgotten about quite a bit.

01:38:34.580 | And that's the increase in blood osmolality.

01:38:37.380 | And I learned this in the fitness world.

01:38:39.660 | I was really big into fitness in college,

01:38:41.140 | and it was my escape from life stressors.

01:38:43.820 | And we found that people who supplemented

01:38:46.740 | with any powdered protein source,

01:38:49.300 | it doesn't matter collagen, albumin, whey,

01:38:51.540 | and more so with people who supplement with creatine,

01:38:54.380 | that there is an increase in blood or plasma osmolality.

01:38:58.520 | So the solute concentration increase in the blood,

01:39:01.060 | which draws water in.

01:39:02.620 | That's predominantly how things like creatine

01:39:04.300 | make you look bigger.

01:39:05.520 | And I know we're going a little bit on a tangent,

01:39:07.120 | but one of the reasons the way collagen works

01:39:10.340 | is your blood osmolality increases,

01:39:12.460 | you draw a little bit more water into the vessels,

01:39:15.360 | which plumps up the appearance of the skin.

01:39:18.080 | So there is a hydration component from the water draw,

01:39:22.500 | and this is measurable.

01:39:23.660 | You can draw a patient's blood

01:39:25.220 | after consuming collagen protein, whey protein,

01:39:27.980 | and see this spike in plasma protein.

01:39:31.300 | So there's that component as well,

01:39:32.800 | which is not truly a benefit,

01:39:35.140 | but it's an aesthetic benefit.

01:39:39.020 | Why that tends to be a problem

01:39:40.260 | is sometimes people supplement with collagen

01:39:42.300 | end up actually having high blood pressure

01:39:44.060 | and they're otherwise healthy.

01:39:46.320 | And this was something that we saw

01:39:47.600 | in the fitness world a lot,

01:39:49.120 | is that young college athletes,

01:39:51.040 | high school athletes that would come in,

01:39:52.860 | they would otherwise be completely healthy

01:39:54.680 | and would be running high blood pressures.

01:39:56.240 | If you took away their protein and creatine supplementation,

01:39:59.840 | their blood pressures dropped.

01:40:01.320 | - Interesting.

01:40:02.160 | - And it's really fascinating stuff.

01:40:03.240 | And I used to work out at UCLA

01:40:05.720 | with one of the professors of Phi Psi,

01:40:08.920 | who was a really big dude.

01:40:10.960 | And we worked out together and we did all these studies

01:40:12.760 | and looked at young, otherwise healthy people.

01:40:15.740 | So that's one component.

01:40:17.880 | The other question is,

01:40:21.480 | do any of these food changes

01:40:26.480 | actually quantifiably increase skin collagen density,

01:40:31.480 | skin elastin density?

01:40:35.920 | There's no evidence that taking these things will traffic,

01:40:38.440 | or meaning will go to where you want them to.

01:40:41.200 | It's kind of silly to think if I drink this,

01:40:44.520 | it's gonna go into my stomach, go into my intestine,

01:40:46.660 | be absorbed and then know to go exactly to my cheek.

01:40:49.700 | Usually it doesn't occur that way.

01:40:51.580 | And when we've looked at histologic comparison studies,

01:40:54.540 | the data is equivocal.

01:40:56.300 | Some studies have shown a slightly increase

01:40:58.420 | in collagen density and you wonder,

01:41:01.020 | are those patients one that are on restrictive diets

01:41:03.220 | to begin with?

01:41:04.440 | And then there are some studies that have shown

01:41:06.180 | there's really no density change in collagen and elastin.

01:41:09.180 | So the supplements really don't actually make

01:41:11.400 | a physical difference.

01:41:12.340 | Now the other question is, is that study too short of term?

01:41:15.640 | How long do you stay on these?

01:41:17.880 | Data is wild and there's a lot to understand,

01:41:20.560 | but we do know high protein, complete proteins,

01:41:23.520 | anti-inflammatory diets, absolutely critical for skin health.

01:41:27.400 | - I guess the most direct question is,

01:41:29.640 | do you yourself consume collagen proteins

01:41:32.820 | in a supplement form or make it a point to eat things

01:41:35.080 | like bone broth, which contain high percentages of collagen?

01:41:38.800 | - Great question.

01:41:40.040 | I do supplement only in sun powder,

01:41:42.780 | which is my daily supplement.

01:41:44.060 | It contains bioactive collagen peptides.

01:41:46.900 | Aside from that, I think natural sources are better.

01:41:49.700 | So my wife cooks a lot at home, bone broth,

01:41:53.780 | beef bone broth, chicken bone broth, a lot of animal meats.

01:41:57.440 | My diet tends to be more in the, I guess old school,

01:42:00.980 | you'd call it Atkins or keto diet,

01:42:03.940 | where I eat a lot of proteins

01:42:05.660 | and mostly fruits and vegetables.

01:42:07.660 | I'm not very restrictive,

01:42:08.960 | but I know that's what's made the biggest difference.

01:42:10.980 | I know that if I go on a sugar binge in a few days,

01:42:14.840 | I'm breaking out, it's like clockwork for me.

01:42:17.140 | Some people are not as sensitive, my body is,

01:42:19.620 | and that's where the personalized medicine comes in.

01:42:23.700 | - Is there a role for omega-3 fatty acids like fish oils

01:42:26.860 | and things of that sort for skin health specifically?

01:42:29.660 | - Yes and no.

01:42:30.740 | Yes, there is some evidence that omega-3 supplementation

01:42:36.160 | and tends to be better in fish form than non-fish formats,

01:42:41.160 | but omega-3s tend to be anti-inflammatory.

01:42:44.100 | So there's an improvement in skin health because of that.

01:42:46.860 | One thing we do see is they thin the blood.

01:42:49.480 | So people tend to bruise a little bit more.

01:42:51.400 | So actually in my practice,

01:42:52.700 | I have people stop omega-3s before any sort of surgery

01:42:56.580 | because they bleed more.

01:42:58.240 | - What about some treatments that are known to be beneficial

01:43:00.980 | for the appearance and health of skin

01:43:03.380 | that people are not as aware of, right?

01:43:06.620 | Because I think people who are concerned

01:43:08.860 | with their skin health and appearance,

01:43:10.300 | they think about sunscreen

01:43:11.500 | and we've learned a lot about that from you,

01:43:13.540 | but what are some things that really work

01:43:15.400 | to improve skin health and appearance

01:43:17.620 | that perhaps require a visit to the dermatologist,

01:43:20.760 | but that you don't hear enough about?

01:43:23.700 | - Yeah, so two big categories.

01:43:26.940 | So we know the skin turns over, right?

01:43:29.140 | It turns over every 28 days.

01:43:31.040 | So in theory, if you keep turning the skin over,

01:43:34.960 | you can get rid of those mutations that occur

01:43:37.880 | in the skin that's stacking up

01:43:39.340 | and hope to bring out more vital, youthful skin

01:43:42.920 | that's not just appearing vital,

01:43:44.960 | but actually biologically healthier.

01:43:47.800 | And there's two categories of things you can do.

01:43:51.000 | The first is the family of retinoids.

01:43:54.040 | Amazing medications, amazing drugs,

01:43:57.120 | been around for 50 years.

01:43:59.100 | They come in oral form and topical form.

01:44:03.500 | And these increase the time or they shorten the time,

01:44:08.500 | they increase the skin turnover from 28 days

01:44:11.840 | to somewhere between seven to nine days.

01:44:14.360 | And in doing so, they've been shown

01:44:16.680 | to decrease skin cancer and pre-cancer formation.

01:44:19.560 | They've been actually shown to grow new collagen.

01:44:22.640 | They've been shown to increase elastin and appearance.

01:44:25.320 | And this has been histologically verified

01:44:27.880 | in study after study,

01:44:29.280 | meaning we take a biopsy of the skin,

01:44:32.160 | have them start a prescription retinoid,

01:44:34.560 | re-biopsy the skin and stain it for collagen or elastin,

01:44:37.800 | and you see a marked improvement.

01:44:39.660 | It's every dermatologist's well-known tool.

01:44:44.660 | And for some reason,

01:44:46.120 | it's still not well-known in the population.

01:44:48.120 | Its original indication was for acne

01:44:50.800 | and still is first line for acne,

01:44:52.580 | because what it does is it dries out the oil glands.

01:44:55.880 | But in doing so, it also helps repair skin.

01:44:59.120 | So I recommend every single person

01:45:01.680 | to be on a prescription-strength retinoid,

01:45:04.280 | which is different than over-the-counter retinol.

01:45:08.120 | And there's a lot of confusion,

01:45:10.040 | and I think the confusion is intentional

01:45:11.920 | in the cosmeceutical world as to why this is,

01:45:14.440 | but everybody should be on a prescription-strength retinoid.

01:45:17.240 | Usually topicals is all you need.

01:45:19.800 | The most common are things like tretinoin,

01:45:22.240 | adapalene, or tazerotine.

01:45:25.560 | And there's oral forms.

01:45:27.000 | The most common is Accutane or Isotretinoin,

01:45:30.200 | and to a lesser-known drug called Acetretin or Seriatane.

01:45:35.200 | And I usually reserve that

01:45:38.280 | for my high sun damage skin cancer patients.

01:45:41.140 | It really makes a difference.

01:45:42.140 | But I'm gonna touch back about retinol versus retinoids.

01:45:46.720 | So many, many years, we studied retinoids.

01:45:50.000 | The way retinoids work is they're actually,

01:45:52.160 | and they activate transcription factors,

01:45:54.080 | they're nuclear messaging hormones.

01:45:57.620 | So these compounds bind retinoic acid receptors,

01:46:02.040 | and they activate the transcription of certain genes.

01:46:05.620 | One of the genes we know that it can affect

01:46:09.920 | is the sonic hedgehog pathway

01:46:11.680 | and some of the embryologic genes.

01:46:14.840 | Why that's important is when we first studied retinoids

01:46:18.000 | in oral or cream version,

01:46:19.460 | we noticed that these can affect the development of a fetus,

01:46:23.760 | and they can be passed through breast milk

01:46:26.320 | and through sperm or semen.

01:46:29.160 | So because of this issue, the FDA regulated it very tightly.

01:46:34.160 | And it's pretty regulated worldwide

01:46:36.080 | because the effects are devastating,

01:46:38.160 | missing arms, missing legs type of birth defects.

01:46:40.680 | Because the medication was so effective

01:46:43.680 | and we saw an improvement in both quality

01:46:46.400 | and appearance of skin,

01:46:48.440 | the cosmeceutical beauty world said,

01:46:50.320 | oh, okay, this is awesome.

01:46:51.500 | We need to figure out a way to get this on the shelf,

01:46:54.080 | but not be a prescription.

01:46:56.580 | Out came retinols with an OL,

01:46:59.180 | which is the inactive version of retinoic acid,

01:47:03.340 | which is retinoids.

01:47:05.060 | And what has to happen is retinol needs to be converted

01:47:09.060 | in a two-step process to become active retinoic acid.

01:47:14.060 | Otherwise, it's a completely inactive prodrug,

01:47:17.220 | which is sold over the counter

01:47:19.260 | at concentrations that are not biologically active.

01:47:22.180 | That's how cosmeceutical companies can get away

01:47:24.380 | with prescribing this for people of childbearing age.

01:47:29.260 | In my opinion, if you want a retinoid,

01:47:31.780 | get a prescription for it.

01:47:33.140 | The over-the-counter stuff is not very effective,

01:47:35.620 | if at all.

01:47:36.540 | The shelf stability, many studies have shown

01:47:40.060 | that almost all retinoids over-the-counter,

01:47:42.900 | retinols over-the-counter

01:47:44.500 | are basically unstabilized by one year.

01:47:48.180 | So you don't even know what you're paying for.

01:47:50.260 | The prescription is easy to get.

01:47:51.700 | You can see pretty much any dermatologist,

01:47:53.220 | and it's the only version that's truly effective.

01:47:55.980 | So everybody should be on it.

01:47:57.420 | Protects your skin, keeps you looking young,

01:47:59.900 | reduces skin cancer risk, grows new collagen.

01:48:02.940 | Literally the only consequence is that when you first start,

01:48:06.260 | your skin may be a little bit red or peely

01:48:08.260 | as the skin acclimates or turns over.

01:48:10.180 | Other than that, nothing.

01:48:12.260 | - Why do you think, given the immense interest

01:48:15.860 | in skin appearance and health,

01:48:17.900 | that we don't hear more about this?

01:48:19.700 | - Because, that's a great question.

01:48:23.460 | So we hear so much about retinol.

01:48:26.340 | Every magazine you open that has anything,

01:48:28.380 | you'll see like intensive night cream,

01:48:30.340 | intensive eye serum, regenerist eye repair,

01:48:34.700 | and all of them have retinol.

01:48:36.300 | None of them have retinoid or tretinoin for many reasons.

01:48:40.020 | Originally it was made for acne.

01:48:42.300 | And the patients that came in to get them for acne

01:48:44.620 | were not necessarily in the same line of thought

01:48:46.340 | of premature aging and longevity.

01:48:48.900 | - This would be things like Retin-A.

01:48:50.500 | - Yeah, Retin-A, exactly, or Accutane, or Differin.

01:48:54.500 | These are the brand names for these products.

01:48:56.140 | So there was a disconnect between the people

01:48:58.140 | seeking the anti-aging effects

01:49:01.420 | and the people getting it as a prescription.

01:49:04.060 | That's one.

01:49:04.900 | And number two, as soon as cosmeceutical companies

01:49:07.980 | figured out a way to market

01:49:09.340 | over-the-counter inactive versions, that went haywire.

01:49:12.660 | So you can Google retinol and there's a million things.

01:49:15.580 | When you Google tretinoin, you only hear about acne.

01:49:17.940 | So there's a little bit of a disconnect,

01:49:19.260 | much like all in medicine,

01:49:20.460 | between what docs know and think the population knows

01:49:24.020 | and what the population actually knows.

01:49:25.420 | But that's the one thing I think

01:49:27.300 | we've been doing a great job on

01:49:29.060 | in modern day social media

01:49:30.300 | is advocating for these medicines.

01:49:32.420 | Now, that's one realm of things that you can do

01:49:36.140 | to absolutely improve the quality of your skin,

01:49:38.660 | long-term health, appearance,

01:49:41.300 | actually revitalize the skin.

01:49:45.340 | Then there's a whole set of procedures that can be done

01:49:48.540 | that have been shown to improve not only the appearance,

01:49:51.060 | but actual biologic health.

01:49:53.220 | So that's where we fall into the laser world.

01:49:55.660 | And somebody who's been in photobiology,

01:49:59.820 | albeit a slightly different realm,

01:50:01.660 | you know the effects of light

01:50:03.500 | and the incredible changes that it can have in biology.

01:50:07.700 | Most of what we understand for lasers in medicine

01:50:10.780 | came out of dermatology studies.

01:50:13.820 | A lot of the understanding of laser biology

01:50:16.500 | came out of the Wellman Institute over at Harvard,

01:50:18.900 | where many of my colleagues are.

01:50:21.020 | And we now know that certain laser devices,

01:50:25.340 | certain resurfacing devices,

01:50:27.500 | not only improve the appearance of your skin,

01:50:31.060 | clinically, they reduce your risk of skin cancer

01:50:33.900 | by 20%, maybe greater.

01:50:36.340 | And even more amazingly,

01:50:39.380 | is when you do microarray gene studies,

01:50:42.260 | they actually activate the genes

01:50:44.860 | of more youthful, healthy skin cells

01:50:46.900 | that were quiescent as we age.

01:50:49.460 | So there's genetic verification, clinical verification,

01:50:53.180 | and aesthetic verification.

01:50:54.540 | These things are awesome.

01:50:55.620 | Now, laser is a big umbrella term.

01:50:58.660 | Some of the devices we use are not lasers.

01:51:00.900 | They're actually light, broadband light,

01:51:03.220 | or intense pulse light.

01:51:05.380 | Some of them are lasers.

01:51:06.620 | Some of them are ablative.

01:51:08.780 | Some of them are non-ablative.

01:51:09.980 | And we get into the nuances of these things,

01:51:11.980 | but there are a few lasers

01:51:14.260 | that have been shown to make these dramatic differences.

01:51:17.180 | So if you're interested, I mean, see an expert.

01:51:19.940 | - So this would be go to your dermatologist,

01:51:22.260 | ask for some, is it laser resurfacing?

01:51:26.220 | - Yeah, yeah.

01:51:27.060 | So laser resurfacing, it tends to be,

01:51:29.100 | and what's really popular,

01:51:30.940 | there's two forms of laser resurfacing.

01:51:32.900 | There's what we call non-ablative,

01:51:34.460 | meaning it doesn't burn or vaporize the top layer of skin.

01:51:38.420 | And then there's ablative resurfacing,

01:51:40.380 | which vaporizes the top layer of skin.

01:51:42.660 | Obviously, ablative ones are much more aggressive,

01:51:46.060 | much more effective, a lot more downtime,

01:51:48.500 | and a lot riskier,

01:51:49.460 | because you're literally peeling the face off

01:51:51.460 | or any part of the body.

01:51:53.260 | And it regrows without any scarring.

01:51:54.860 | That's also another beauty of the skin

01:51:56.900 | is you can literally peel it off entirely

01:51:58.900 | and have it regrow as if nothing ever happened.

01:52:01.140 | - So people have this done once a year or so?

01:52:03.100 | - Yeah, for ablative resurfacing,

01:52:06.460 | it's like once every five years or so on.

01:52:08.980 | It's pretty dramatic.

01:52:10.380 | - And how long is the downtime?

01:52:12.500 | - For ablative resurfacing, two weeks.

01:52:16.500 | Usually two weeks, you're pretty raw and sore.

01:52:18.540 | It's fallen out of favor in most big cities

01:52:21.100 | because of the downtime and the inherent risks,

01:52:22.980 | but it's still used in the right patient.

01:52:25.020 | Non-ablative resurfacing,

01:52:28.020 | meaning it doesn't vaporize the top layer,

01:52:30.580 | but drills holes into the dermis

01:52:32.980 | and targets certain parts of the epidermis

01:52:35.540 | without causing burn injury,

01:52:38.060 | that's become much more popular

01:52:39.660 | because the downtime is markedly less.

01:52:42.220 | People can go back to work and enjoy their activities.

01:52:45.940 | While having pretty much the same benefits,

01:52:48.140 | albeit a little bit less than ablative lasers,

01:52:52.380 | these we generally recommend annually or biannually,

01:52:56.140 | depending on what you're trying to target.

01:52:58.420 | A large Harvard study just came out

01:53:00.860 | that showed that non-ablative fractionated laser resurfacing,

01:53:05.180 | particularly with a device called Fraxel,

01:53:07.860 | actually cuts your skin cancer risk by 20%

01:53:10.500 | because it eliminates those mutations

01:53:13.340 | and gets rid of those cells

01:53:14.460 | that had been collecting the stuff.

01:53:16.260 | It's amazing.

01:53:17.660 | - How is this different than exfoliating skin?

01:53:20.220 | Like if one were to just try and scrape away

01:53:23.540 | some of the dead skin through some, you know,

01:53:27.140 | semi-vigorous buffing of the skin with like a sponge.

01:53:30.540 | I've never done either of these procedures.

01:53:33.180 | Like I said, my skincare routine is very basic.

01:53:35.260 | It's the unscented dove soap.

01:53:36.620 | The shower once or twice a day and-

01:53:39.140 | - Your skin looks great, so keep doing what you're doing.

01:53:40.980 | - I mean, I feel pretty good.

01:53:41.940 | I mean, I think, you know,

01:53:44.500 | sleep seems to play a significant role for me.

01:53:48.620 | I do get probably a bit more sun exposure than most people.

01:53:51.820 | I'm conscious of checking for skin cancers

01:53:54.700 | and we'll talk about that because those do run in my family.

01:53:58.740 | But, and I try and eat right and exercise right.

01:54:02.720 | Haven't consumed much alcohol in my lifetime.

01:54:05.700 | - Well, your skin will tell you if something's wrong.

01:54:07.700 | So that's the first line.

01:54:08.860 | Now you talk about, you know,

01:54:11.220 | dermabrasion or microdermabrasion,

01:54:12.820 | the good old St. Ives apricot scrub

01:54:15.060 | that every dermatologist, you know, frowns upon.

01:54:17.540 | But ironically, I use myself after a heavy workout

01:54:20.220 | at the beach and I'm all greasy,

01:54:21.340 | but don't, you know,

01:54:23.060 | don't get mad at me for using that stuff.

01:54:24.580 | The depth is key.

01:54:26.420 | So when we do microdermabrasion

01:54:28.540 | or some sort of dermabrasion,

01:54:29.740 | the only thing we're really scraping off

01:54:31.500 | is really the stratum corneum,

01:54:33.380 | which is the highest layer of skin cells

01:54:37.220 | that don't even have a nucleus.

01:54:38.820 | They're dead skin cells.

01:54:39.860 | That's all you're scraping off.

01:54:41.220 | Whereas lasers target through the epidermis

01:54:44.640 | and into the dermis and you control for that depth.

01:54:47.980 | And what you control for is the amount of heat energy

01:54:51.180 | delivered to that depth to target a certain thing.

01:54:54.580 | So in theory, what you describe in terms of dermabrasion

01:55:00.140 | is the same premise the old school ablative lasers do.

01:55:03.940 | They just fry everything off and you grow new skin.

01:55:06.660 | And in frying everything off,

01:55:08.140 | it fries off sun damage, wrinkles,

01:55:12.220 | pre-cancers and skin cancers.

01:55:14.300 | But in doing that, you're a bloody mess for a few weeks.

01:55:17.900 | Not popular for many reasons, but very effective.

01:55:22.340 | We did a ton of this at Stanford

01:55:23.620 | and we did a ton of the other one at Stanford.

01:55:25.220 | In my practice, I do a lot of laser work as well.

01:55:28.180 | The non-ablative stuff picks and chooses.

01:55:30.300 | That was the beauty of learning about laser

01:55:33.700 | and photobiology is how we target a certain structure

01:55:38.700 | and avoid damaging all the other ones.

01:55:41.700 | That's the theory of selective photothermalysis

01:55:45.740 | that came out of Rox Anderson's lab at Harvard.

01:55:48.000 | That was the game changer.

01:55:49.740 | We can now pick any appendage in the skin

01:55:53.380 | and find a way to target it and leave the rest undisturbed.

01:55:56.500 | So if you have broken blood vessels,

01:55:58.340 | you decide to use BPC-157 and it worked great

01:56:01.100 | and the blood vessels started to grow

01:56:02.540 | and you're like, I don't like the look of them.

01:56:04.020 | There is a laser that targets solely blood vessels.

01:56:07.420 | - Is that the IPL laser?

01:56:09.540 | - IPL is okay.

01:56:11.140 | IPL stands for intense pulse light.

01:56:13.660 | It's somewhat effective, but not very effective.

01:56:16.900 | The gold standard is what we call the pulse dye laser

01:56:20.500 | or the V-beam laser.

01:56:22.220 | That is a 595 nanometer laser that targets oxyhemoglobin.

01:56:27.220 | - I've had that actually because I had an angioma.

01:56:31.380 | - Yeah.

01:56:32.220 | - Had it three times and the third time they hit this thing,

01:56:36.580 | it went away, but not without a very significant bruise

01:56:39.980 | lasting almost a month.

01:56:41.500 | I mean, it was pretty dramatic.

01:56:45.300 | - Never done it.

01:56:46.140 | - Right, but it did eliminate the vessel.

01:56:50.060 | - By any means necessary, right?

01:56:51.700 | It just nuked the skin.

01:56:52.940 | - So as long as we're on the topic of photobiomodulation,

01:56:55.900 | what about red light, near-infrared light?

01:56:58.220 | Is there any evidence

01:56:59.060 | that it can benefit skin health and appearance?

01:57:01.720 | Nowadays, you can find masks that will emit red light.

01:57:05.380 | Some people will purchase red lights.

01:57:06.780 | They stand in front of.

01:57:08.020 | - I think they're very effective.

01:57:09.060 | I think they work great.

01:57:11.000 | The question is to what extent

01:57:13.740 | is that improvement objective and measurable

01:57:16.160 | and what extent is subjective?

01:57:17.420 | That being said, there's a lot of evidence

01:57:19.460 | that shows that red light therapy

01:57:21.900 | improves vascular flow in the skin.

01:57:25.100 | We use it for things like hair restoration,

01:57:28.060 | post-procedure recovery,

01:57:30.740 | improvement in skin health after UV damage.

01:57:33.740 | We actually found a recent study

01:57:36.100 | that looked at red light therapy and irradiating mice.

01:57:41.100 | And if you pre-treat the mice with red light therapy

01:57:45.460 | before they get UV exposure compared to controls,

01:57:49.420 | the pre-treated group had much less

01:57:52.060 | of the changes with UV exposure.

01:57:53.680 | So very fascinating stuff.

01:57:55.280 | How it works, uncertain.

01:57:58.980 | We think a lot of it has to do with increased vascular flow,

01:58:02.380 | which is why a lot of times

01:58:03.580 | we recommend it for post-procedure.

01:58:06.020 | We recommend it for hair regrowth.

01:58:08.700 | There's some evidence that if you increase blood flow

01:58:10.980 | to the dermal papilla of the hair, it grows new hair.

01:58:13.540 | That's how minoxidil or Rogaine works.

01:58:16.220 | But I like it.

01:58:17.100 | I think it's a great product,

01:58:19.740 | great group of products or devices.

01:58:22.140 | As a standalone,

01:58:24.740 | uncertain as to how effective they are.

01:58:28.780 | And one of the reasons of the heterogeneity in the data

01:58:33.100 | or like so much difference

01:58:35.260 | is there's no regulation in terms of the energy,

01:58:38.220 | the density of light, the type of light,

01:58:41.280 | the duration of treatment.

01:58:43.100 | So some devices have high wattage, high energy output,

01:58:47.140 | high density of lights.

01:58:48.900 | They may be more effective than its equivalent counterpart.

01:58:51.780 | And until that gets defined more uniform in accessibility,

01:58:56.780 | I don't know which device to recommend.

01:59:01.860 | I obviously have preferences one way or another,

01:59:05.660 | but there's so much on the market

01:59:07.380 | that's marketed as red light that is not effective

01:59:10.560 | and some stuff that's really good.

01:59:12.460 | - So probably looking for something

01:59:13.820 | that's at least endorsed by dermatologists.

01:59:16.180 | - Yeah, yeah, absolutely.

01:59:17.420 | - And I should say here, I have no angle into this.

01:59:21.260 | These masks that emit red light,

01:59:23.260 | I don't have any business relationship to them.

01:59:25.860 | So that's not why I bring it up.

01:59:26.860 | I was just very curious.

01:59:27.800 | I see them in my Instagram feed,

01:59:29.460 | probably by virtue of doing public facing

01:59:32.700 | health and science information and my interest in light.

01:59:35.940 | What about, oh, yes, excuse me.

01:59:38.180 | - I was going to say the panels

01:59:39.260 | tend to be much higher in energy, much more effective.

01:59:42.020 | And most of the studies have looked at the big wall panels.

01:59:45.060 | The battery powered face masks

01:59:47.340 | just aren't powered enough to have much improvement.

01:59:50.380 | We do see some improvement when red and blue

01:59:52.580 | is used together, mostly for acne prone skin,

01:59:54.760 | because blue light alone has some antimicrobial properties.

01:59:58.840 | So when used in conjunction,

02:00:00.400 | you can get some improvement in actual skin illnesses.

02:00:04.060 | But the masks alone with just red light,

02:00:07.220 | most of them are not powered enough.

02:00:09.100 | They don't have enough energy,

02:00:10.380 | but there are some that are good.

02:00:12.460 | The wall panels tend to be better.

02:00:14.780 | - Thank you for that.

02:00:15.620 | And full disclosure, I was accurate in saying

02:00:18.500 | that I don't have any relationship

02:00:19.780 | to any red light masks companies or products,

02:00:22.540 | but this podcast is sponsored by Juve,

02:00:25.340 | which makes medical grade panels

02:00:27.420 | for red light and near infrared light.

02:00:28.660 | And I do own one of those and I use,

02:00:30.640 | I have a small portable one I use

02:00:31.900 | and then I have a panel I stand in front of.

02:00:33.380 | So that includes my face and then I'll turn around

02:00:35.940 | and do a whole body couple times a week.

02:00:39.480 | Juve is a good company.

02:00:40.460 | It's been around for a while.

02:00:41.380 | And most of the experts in laser and photobiology

02:00:44.780 | agree the panels are the way to go if you want red light.

02:00:47.840 | - It's interesting when people see and hear about red light

02:00:51.420 | and near infrared light therapies,

02:00:52.980 | I think a lot of people think,

02:00:53.820 | "Oh, this is kind of like next stage biohacking."

02:00:57.540 | But there was a Nobel prize given for photobiomodulation

02:01:00.900 | for the treatment of lupus in the early 1900s.

02:01:04.380 | So this is a longstanding thing,

02:01:06.860 | the use of light of particular wavelengths

02:01:09.140 | or combinations of wavelengths

02:01:11.040 | of which red light and blue light are, of course,

02:01:13.100 | in order to target different layers within the skin

02:01:15.180 | to get some desired effect.

02:01:16.980 | - Yeah, light has been around for a long time.

02:01:18.980 | I have a phototherapy unit in my practice

02:01:21.740 | in which we use narrow band ultraviolet B light

02:01:25.340 | to treat conditions like psoriasis,

02:01:28.060 | to treat conditions like vitiligo.

02:01:30.160 | There's a very strong immunomodulatory effect

02:01:33.940 | of light on the skin.

02:01:35.740 | It actually suppresses overactive immune activity.

02:01:39.820 | It can help increase vascularity in the skin.

02:01:43.060 | It can improve blood flow.

02:01:44.340 | So depending on the wavelength you pick

02:01:46.220 | and where it overlies on the absorption curves

02:01:49.740 | makes a big difference.

02:01:51.540 | It's interesting that we talk about light

02:01:53.820 | and as a skin cancer surgeon,

02:01:55.820 | this has always been interesting to me

02:01:59.260 | in that we use UV light to treat certain conditions

02:02:03.980 | and we assume UV light is purely pathogenic.

02:02:08.580 | And I don't think that's the case.

02:02:10.940 | And why I bring this up is one of the most common things

02:02:13.340 | we use like light therapy for is patients with vitiligo,

02:02:17.340 | which is this autoimmune condition

02:02:19.080 | in which your immune system attacks the cells

02:02:21.280 | that produce our skin color.

02:02:23.380 | And the standard treatment is certain creams

02:02:26.220 | that suppress the immune system in the skin,

02:02:28.460 | phototherapy, eczema laser, which is a UV laser.

02:02:33.800 | And then now the new world of immunotherapies by pill form,

02:02:37.620 | the Jack inhibitors have made a huge difference.

02:02:39.540 | But if we thought, and I go back on this tangent

02:02:43.540 | 'cause the more we think about it, the less we know.

02:02:46.540 | If we think UV is truly deleterious,

02:02:49.180 | then patients with vitiligo

02:02:50.500 | should have an higher incidence of skin cancer.

02:02:52.700 | And in fact, the opposite is true.

02:02:54.580 | They have a lower incidence of skin cancer

02:02:56.940 | even when you match them for amount of UV exposure over time.

02:03:01.880 | So it goes to tell us that there's so much

02:03:03.760 | about light and skin we don't understand,

02:03:05.640 | so much about sun and UV and skin we don't understand

02:03:09.080 | and an incredible component about our skin's immune system

02:03:12.840 | that we're only now figuring out that play an important role.

02:03:16.220 | Patients who have transplants, for example,

02:03:20.960 | transplant patients in the early '90s,

02:03:24.760 | the number one cause of death for transplant patients

02:03:28.200 | that was not related to their transplant

02:03:30.180 | was metastatic skin cancer.

02:03:33.120 | And this was in patients who were strictly sun protected.

02:03:37.160 | So we talk about biology, photobiology, LED, UV,

02:03:42.160 | and skin health, and there's so much we don't know

02:03:45.100 | as we gather more data and look at populations and cohorts.

02:03:48.120 | So I don't know why I brought that up as a tangent, but.

02:03:50.680 | - No, I think it's a very relevant tangent

02:03:52.160 | because the relationship between immune system function

02:03:54.520 | and skin is very clear.

02:03:56.480 | And these conditions that you're referring to,

02:03:59.040 | vitiligo, acne, psoriasis, eczema, et cetera,

02:04:02.860 | have interesting relationships to the immune system.

02:04:05.020 | So that's actually a perfect segue

02:04:07.000 | for what I'd like to talk about next.

02:04:09.000 | - Sure.

02:04:09.840 | - So let's start with psoriasis.

02:04:12.840 | - Yeah. - What is the story

02:04:13.760 | with psoriasis?

02:04:14.820 | What is it?

02:04:16.220 | What can make it worse?

02:04:17.580 | What can make it better?

02:04:19.320 | - Psoriasis is like the quintessential skin condition.

02:04:22.140 | I have it myself on my elbows and knees.

02:04:24.580 | And for about 100 years, it was thought to be a problem,

02:04:28.660 | a rash that is caused by too much skin turnover

02:04:33.180 | or excess skin proliferation.

02:04:35.780 | And for 100 years, we treated it the same way.

02:04:38.060 | We gave medicines that basically took the skin off,

02:04:41.460 | what we call keratolytics.

02:04:43.740 | We found that that wasn't very effective.

02:04:45.420 | And some people can be hospitalized

02:04:48.100 | and it can be life-threatening

02:04:49.380 | if psoriasis involves the entire body.

02:04:51.700 | It usually looks like red patches or plaques

02:04:55.460 | with kind of a silvery scale on the surface

02:04:57.880 | and starts usually elbows and knees or the scalp,

02:05:01.820 | but can involve pretty much the entirety of the body.

02:05:04.660 | And what we found in the last 30 years

02:05:06.820 | with a lot of elegant studies

02:05:08.260 | and a lot of very, very nice basic science research

02:05:11.980 | is that it's actually due to overactivity

02:05:15.140 | of our skin's immune system.

02:05:17.400 | So there's overactivity of certain interleukins,

02:05:20.740 | which are these messengers that our immune cells produce,

02:05:23.740 | that makes the skin turnover faster than it should.

02:05:27.580 | And this epiphany was remarkable

02:05:30.020 | because we found that instead of targeting the skin,

02:05:33.180 | we can target the immune system

02:05:35.780 | and we can eradicate or treat psoriasis entirely.

02:05:39.580 | And in the '90s and early 2000s,

02:05:42.120 | that targeting was very crude.

02:05:44.020 | It was a very umbrella approach.

02:05:46.400 | We suppressed the entire immune system

02:05:48.420 | and ran into the consequences of that.

02:05:50.220 | So medications that we gave for that

02:05:52.500 | increased risk for infections and skin cancers, et cetera.

02:05:57.260 | Now we have amazing drugs that target one or two molecules,

02:06:02.260 | messenger molecules of our immune system

02:06:05.220 | and clear up people's psoriasis.

02:06:06.780 | I mean, we have drugs now you take three times a year

02:06:09.180 | and you could have head-to-toe psoriasis

02:06:11.180 | and be completely clear.

02:06:13.020 | It tends to run in families.

02:06:14.540 | There is a very strong hereditary

02:06:16.460 | or genetic component to it.

02:06:18.260 | And it tends to be associated with arthritis,

02:06:21.820 | psoriatic arthritis.

02:06:24.180 | So psoriasis is like the quintessential skin condition

02:06:27.580 | that people see dermatologists and even rheumatologists for.

02:06:31.620 | - So these drugs that target these specific interleukins

02:06:34.420 | seem like the most direct way to treat psoriasis.

02:06:37.620 | Some people, for whatever reason,

02:06:39.460 | have an aversion to prescription drugs.

02:06:41.840 | - Yeah, yeah, yeah.

02:06:42.680 | - I'm not necessarily one of those people,

02:06:45.700 | but I, like everybody else, would like to know

02:06:47.260 | what we can do to reduce symptoms of things like psoriasis

02:06:50.980 | without having to "take anything."

02:06:53.100 | - Yeah, I should probably backtrack.

02:06:54.700 | So psoriasis obviously comes in severity.

02:06:57.280 | There's mild disease, which majority of people have.

02:06:59.640 | There's moderate and severe.

02:07:01.340 | And generally speaking, the most common things

02:07:03.620 | that we treat mild psoriasis with is creams and lotions,

02:07:08.340 | moisturizers, sometimes low-potency topical steroids

02:07:12.040 | or high-potency topical steroids,

02:07:13.740 | and then things like keratolytics, like salicylic acid,

02:07:17.040 | that take that excess scale off.

02:07:19.820 | We also know that there,

02:07:20.980 | because it's an immune inflammatory condition,

02:07:24.300 | that diet plays a big role

02:07:25.980 | in improving mild or moderate cases.

02:07:28.980 | And we also know that weight loss plays a very big role

02:07:32.780 | in improving the appearance of psoriasis.

02:07:34.980 | So as we lose weight,

02:07:36.820 | as there's improvement in insulin resistance,

02:07:39.460 | and as we transition diets and lifestyles

02:07:42.980 | from inflammatory to anti-inflammatory,

02:07:45.900 | psoriasis tends to clear without any intervention needed,

02:07:49.620 | without any medical intervention needed.

02:07:52.300 | If there's still continued rashes and skin activity,

02:07:56.260 | then you'd look at topicals like cortisones,

02:08:01.260 | emollients like Aquaphor and Vaseline,

02:08:05.100 | things with some sort of acid

02:08:06.940 | or a retinoid to get rid of that excess scale.

02:08:09.340 | That's the fundamental cornerstone of treating psoriasis.

02:08:12.300 | And then when it gets bad,

02:08:13.620 | we talk about additional pharmacologic interventions.

02:08:16.500 | Also, interestingly, one of the earliest conditions

02:08:21.180 | in which phototherapy was used is psoriasis.

02:08:24.220 | We know that when we shine UV light on the skin,

02:08:27.620 | that it suppresses the skin's immune system

02:08:30.300 | and clear psoriasis.

02:08:31.660 | And that's an excellent way to treat it

02:08:33.380 | without pharmacologic intervention,

02:08:35.420 | without any creams, pills, injections,

02:08:37.700 | or otherwise medication.

02:08:39.820 | It used to be used in the Dead Sea.

02:08:41.740 | People would go lather in the mud in the Dead Sea

02:08:44.940 | and sit out in the sun.

02:08:47.060 | And that was the first crude way to use phototherapy

02:08:49.820 | to treat psoriasis.

02:08:51.180 | - That was my question.

02:08:52.060 | Since the sun emits UV,

02:08:54.500 | why not just get some additional sunlight exposure

02:08:56.820 | for psoriasis?

02:08:57.820 | - So you can, most dermatologists wouldn't recommend it.

02:09:02.740 | I think it's actually not a bad thing.

02:09:04.300 | My psoriasis clears in the summertime

02:09:06.580 | and flares in the wintertime.

02:09:08.700 | The problem with pure sunlight

02:09:10.860 | is that it's a mix of rays, right?

02:09:14.180 | There's X-rays, gamma rays,

02:09:16.460 | which generally don't penetrate the atmosphere.

02:09:18.420 | There's UVC, UVB, UVA, visible light, infrared light.

02:09:22.540 | So that heterogeneous light,

02:09:24.820 | some have no improvement in psoriasis

02:09:28.900 | and some have great improvement.

02:09:30.740 | So we were able to figure out which wavelengths

02:09:33.180 | make a big difference.

02:09:34.060 | And it's around the 311, 312 nanometer range.

02:09:37.020 | But sunlight does clear people's psoriasis up.

02:09:40.020 | That's why we see in Northern latitudes

02:09:42.700 | where there's less sun intensity,

02:09:44.260 | the incidence of psoriasis is markedly higher

02:09:47.460 | than equatorial latitudes.

02:09:49.500 | And patients will say their psoriasis gets better

02:09:51.820 | when they're on a beach vacation.

02:09:53.260 | When they go back home, their psoriasis flares.

02:09:55.900 | There's also some component with vitamin D as well,

02:09:58.260 | but I think that's just secondary

02:09:59.980 | to the lack of UV exposure.

02:10:03.020 | - What about vitiligo?

02:10:04.420 | This is something I did not cover

02:10:06.740 | in the solo episode about skin health,

02:10:09.180 | but I got a lot of questions about vitiligo,

02:10:12.140 | of course, being this typically patchy,

02:10:15.180 | non-pigmented regions of skin

02:10:17.540 | that you said is at least some cases

02:10:23.060 | are related to the immune system.

02:10:25.440 | These people get skin cancers less often, is that right?

02:10:30.140 | - Yeah, so vitiligo is autoimmune,

02:10:34.900 | meaning your immune system is attacking itself,

02:10:37.900 | depigmentary skin disorder,

02:10:40.700 | meaning it's a condition in which your immune system

02:10:43.420 | attacks and kills the melanocytes,

02:10:45.740 | which are the cells that produce our skin's color.

02:10:48.580 | And we've found that it's an autoimmune condition

02:10:51.660 | from many basic science and elegant studies.

02:10:54.300 | It's also very closely associated

02:10:57.100 | with other autoimmune conditions.

02:10:59.140 | So patients tend to also have atopic dermatitis,

02:11:04.140 | autoimmune thyroid disease, autoimmune anemia.

02:11:07.140 | There's some sort of immune dyscrasia

02:11:09.140 | that involves vitiligo patients.

02:11:11.380 | And what happens is the immune system

02:11:13.660 | at first paralyzes these cells

02:11:16.940 | with immune activity attacking them.

02:11:20.100 | And over time, these cells no longer survive and die off.

02:11:23.300 | The cornerstone in treatment has always been

02:11:28.100 | some way to suppress the skin's immune response.

02:11:30.940 | When most of the time vitiligo tends to be focal,

02:11:34.140 | single areas or segmental.

02:11:37.100 | Unfortunately, in certain cases it can be whole body

02:11:39.380 | or completely depigmenting.

02:11:41.220 | Very uncommon, but we see this.

02:11:44.060 | We treat it by doing things

02:11:47.220 | that'll help quiet the immune response in the skin.

02:11:50.500 | So topical creams, topical steroids, et cetera,

02:11:52.900 | topical calcineurin inhibitors,

02:11:54.900 | which are non-steroidal anti-inflammatory medications.

02:11:58.860 | We also use certain wavelengths of UV light to treat this,

02:12:02.260 | eczema laser at 308 nanometers, UVB, UVA.

02:12:07.260 | And then the renaissance in vitiligo

02:12:09.940 | has happened in the last three or four years

02:12:12.020 | with the identification of JAK inhibitors,

02:12:15.400 | which are these drugs that block the Janus kinase pathway.

02:12:18.740 | And we found that the JAK stat pathway

02:12:21.660 | plays a really important role

02:12:23.540 | in autoimmune mediation of melanocyte death.

02:12:27.060 | So new creams and actually oral medications have come out

02:12:31.220 | for patients who have very refractory vitiligo.

02:12:34.400 | The immune component is very fascinating

02:12:37.660 | because understanding immune biology

02:12:40.420 | and the immune system's effects on skin health

02:12:43.340 | comes from studying these patients.

02:12:45.180 | When patients have vitiligo, they lose all of their color.

02:12:49.260 | So you would assume that they're much more susceptible

02:12:51.700 | to sunburns, which they are.

02:12:54.440 | But when you look at incidents of skin cancers,

02:12:57.340 | they have a significantly lower incidence of skin cancer.

02:13:01.140 | And this is because of the immune phenomenon

02:13:04.460 | in immune surveillance of cancer.

02:13:06.460 | And that occurs throughout the body,

02:13:07.780 | but the skin is a model platform for this.

02:13:10.040 | What happens is your immune system surveys

02:13:13.020 | for mutant changes that occur,

02:13:14.860 | whether it's UV related, et cetera,

02:13:17.780 | infection, toxin, whatever.

02:13:19.940 | And patients who have vitiligo have overactivity

02:13:22.540 | of these immune cells and over surveillance.

02:13:25.060 | So they are able to clear a lot of these pre-cancerous

02:13:28.420 | changes before they form into something.

02:13:31.340 | So that played a big role in not only understanding

02:13:33.380 | how to treat vitiligo, but some of our new medicines,

02:13:36.480 | actually the medicines that won the Nobel Prize in 2018

02:13:39.900 | for treating melanoma came from understanding

02:13:42.860 | immune activity and cancer pathogenesis.

02:13:47.100 | - It's fascinating.

02:13:48.060 | Again, speaking to the fact that skin is far more

02:13:51.540 | than just this protective outer sheath.

02:13:54.220 | It's a reflection of so much that's going on internally.

02:13:58.380 | And we know that intuitively also by observing others.

02:14:02.420 | I think this is one of several ways that parents

02:14:04.220 | can communicate well with their children

02:14:06.340 | or their children with their parents rather,

02:14:09.300 | in terms of how they're feeling prior to language.

02:14:11.820 | You know, they'll look at their skin, their stool,

02:14:16.820 | obviously fussiness and mood and those things too.

02:14:19.420 | But we seem to have developed an intuitive understanding

02:14:21.980 | that a shift in the kind of like tone of the skin

02:14:24.340 | or some other features of the skin signal to us

02:14:26.980 | wellness or lack of wellness.

02:14:28.780 | - Yeah, the skin's a biosensor.

02:14:30.740 | The entire skin, hair, nails is a biosensor.

02:14:33.940 | So you can utilize the skin as the first barometer

02:14:37.060 | of illness.

02:14:37.900 | I mean, from acute illness to chronic illness,

02:14:40.700 | acutely you can see changes in just like looking pal,

02:14:43.580 | you know, with pallor, looking ghastly, things like that.

02:14:46.100 | But chronic illness as well.

02:14:47.860 | You know, when you used to go to the pediatrician

02:14:49.440 | and they would do this to look at your eyes,

02:14:51.320 | what they were looking for was the color

02:14:53.120 | of the conjunctiva.

02:14:54.820 | If it was white or pale,

02:14:56.540 | they knew you had iron deficiency.

02:14:58.420 | You know, when kids get hand, foot, mouth syndrome

02:15:01.620 | and they have a high fever, they lose their fingernails.

02:15:04.420 | When college students are stressed out,

02:15:06.260 | they lose their hair.

02:15:07.500 | The body's amazing ability to tell you it's under stress

02:15:11.060 | is shown in the skin, hair and nails.

02:15:12.740 | What it does is it says, why am I wasting energy

02:15:15.060 | producing something that is not necessary

02:15:17.260 | because I'm fighting something else?

02:15:19.100 | Let's just shed this.

02:15:20.860 | And you can tell right away.

02:15:21.900 | I mean, we used to in clinic when I'd see, you know,

02:15:24.980 | medical students or college students come in,

02:15:27.380 | I knew it was finals week.

02:15:28.340 | They'd come with clumps of hair.

02:15:30.020 | And as soon as finals week passed,

02:15:32.180 | usually took a few months, their hair grew back.

02:15:35.120 | It's awesome.

02:15:36.020 | The skin's a really cool biosensor and you can tell a lot.

02:15:39.220 | - It is so cool.

02:15:40.380 | What about acne?

02:15:42.940 | - Yeah.

02:15:43.780 | - Acne seems very common, you know,

02:15:44.940 | as we progress through puberty,

02:15:47.500 | there seems to be more acne.

02:15:48.820 | Sometimes it's transient, sometimes it's not.

02:15:51.180 | - Yeah.

02:15:52.020 | - What are some things that people can do

02:15:53.380 | to prevent or reduce acne?

02:15:56.180 | - Another quintessential derm problem

02:15:59.060 | that is affects so many people.

02:16:02.460 | Acne tends to be a condition that is bimodal,

02:16:05.300 | meaning we tend to see it in adolescents.

02:16:08.500 | We tend to see it in 25 to 35 year olds.

02:16:11.980 | And for the unfortunate group of people

02:16:13.620 | that bridge that gap, we see it anywhere from 12 to 35.

02:16:19.020 | Acne is a condition that's usually seen by pimples.

02:16:22.220 | You know, what we call blackheads or whiteheads,

02:16:25.020 | zits or boils.

02:16:27.180 | And it's thought to be caused by three important things.

02:16:30.940 | It's an overproduction of sebum,

02:16:34.180 | which is the oily stuff that comes out of your skin.

02:16:37.100 | And that's dictated by your hormones.

02:16:39.400 | Your hormones will increase the output of sebum.

02:16:43.580 | And that usually occurs in puberty,

02:16:45.660 | but can also occur if you're taking medications

02:16:48.220 | like prednisone, cortisol, testosterone,

02:16:52.260 | anything that is a hormone driver.

02:16:53.840 | So sebum is the first cause.

02:16:55.900 | Sebum is the food for the bacteria that cause acne.

02:16:59.420 | So as there's more food, the bacteria proliferate.

02:17:02.520 | And in proliferation, it recruits an immune response.

02:17:05.780 | Your immune system says,

02:17:06.620 | "Hey, there's a little bit too much of these organisms.

02:17:09.700 | "Let's go and take care of them."

02:17:11.420 | That's where you get that red zit.

02:17:13.100 | So in treating acne, you gotta treat all three components

02:17:16.860 | to get really effectively clear skin.

02:17:19.780 | Somehow reduce the sebum, get rid of the bacteria,

02:17:23.580 | and calm the immune system down.

02:17:25.180 | That's done with creams, oral medications,

02:17:30.080 | a combination of both.

02:17:31.780 | Sometimes certain lasers can help eradicate the oil glands

02:17:35.460 | that feed the bacteria.

02:17:36.780 | But acne's a fascinating condition.

02:17:40.700 | Almost everybody will have it at some point in their life.

02:17:44.380 | - Is it true that eating a diet

02:17:46.140 | that is of slight excess in calories,

02:17:50.780 | because it will tend to push

02:17:52.860 | the insulin glucose regulation system

02:17:55.180 | more into the positive as opposed to,

02:17:58.380 | let's just say higher levels of insulin

02:18:00.540 | and circulating blood glucose

02:18:02.640 | than one would observe at, say, maintenance calories

02:18:05.100 | or sub-maintenance calories that, you know,

02:18:07.580 | overeating a little bit could cause acne,

02:18:10.860 | that any foods that promote increases

02:18:14.960 | in glucose and insulin,

02:18:16.820 | so sugary foods, high glycemic foods,

02:18:20.500 | these sorts of things,

02:18:21.340 | can that actually increase acne, fried foods?

02:18:24.540 | - So it's not the caloric deficit or the caloric surplus.

02:18:29.540 | It's the glycemic index or the amount of insulin response.

02:18:33.740 | So we know that high glycemic index foods

02:18:37.600 | will make acne worse.

02:18:38.780 | And almost every study that we've looked at

02:18:40.460 | in sugary processed foods will flare your acne.

02:18:44.180 | There's some component of that inflammatory response

02:18:47.220 | that not only drives even production and bacterial growth,

02:18:50.460 | but actually worsens the skin's immune response.

02:18:53.300 | The skin's immune response is a little feisty

02:18:55.220 | when you're eating pro-inflammatory things.

02:18:58.080 | The other thing that I do hear a lot about is dairy.

02:19:01.360 | And there's this misconception that dairy causes acne.

02:19:04.660 | What we really see when we looked at a really cool study

02:19:08.260 | that was done out of Penn State

02:19:09.960 | is that it's not so much whole fat dairy products,

02:19:14.340 | but skim and non-fat dairy products

02:19:16.880 | that can make your acne flare.

02:19:18.380 | And the reason for that is that usually

02:19:19.860 | in the United States,

02:19:20.740 | there's an emulsifier that's put in non-fat

02:19:23.500 | or skim products to give the same mouth feel as full fat.

02:19:26.900 | So people feel like they're getting the same

02:19:28.320 | without the calories.

02:19:29.340 | And that has a glycemic response.

02:19:31.880 | So it's usually sugary foods,

02:19:33.980 | non-fat skim dairy products

02:19:36.660 | that will make your acne flare.

02:19:38.660 | - What about rosacea?

02:19:40.860 | I hear so much about this,

02:19:42.500 | and I'm going to assume that we can mark off

02:19:45.940 | at least one thing as clear,

02:19:48.700 | which is that alcohol can exacerbate rosacea,

02:19:51.500 | maybe directly, but certainly indirectly

02:19:55.220 | by impeding some aspects of the microbiome,

02:19:58.420 | disrupting sleep, rosacea gets worse.

02:20:01.020 | But what are things that people can do?

02:20:03.820 | Do's and don'ts that is for rosacea.

02:20:07.300 | If it's mild rosacea, like excessively ruddy cheeks

02:20:10.700 | or superficial riding capillaries

02:20:14.940 | that seem to bother a lot of people.

02:20:17.100 | I know that it bothers a lot of people

02:20:18.580 | because they asked about this quite a lot

02:20:20.660 | in the questions when I solicited for questions.

02:20:24.620 | - So rosacea, it's commonly known as adult acne,

02:20:28.940 | tends to come in four flavors.

02:20:31.180 | The first form is the redness form,

02:20:34.340 | what we call erythematotelangic tatic form,

02:20:37.060 | or the ruddiness, broken blood vessels,

02:20:40.100 | redness of the cheeks and flushing.

02:20:41.820 | That's by and far the most common form.

02:20:44.260 | There's also the papulopustular form,

02:20:46.180 | which is the pimple form,

02:20:47.340 | which is what we think about in adult acne.

02:20:50.780 | There's also the fimatus form,

02:20:52.580 | which is the enlargement of the nose

02:20:54.780 | that kind of looks like toad skin.

02:20:56.540 | We used to think it was a sign of alcoholism or sailors

02:21:00.020 | or construction workers

02:21:02.780 | that would have these enlarged nose.

02:21:04.460 | We thought it was a product of their environment

02:21:06.540 | that's actually a form of rosacea.

02:21:08.180 | And then there's ocular rosacea, which affects the eyes.

02:21:11.540 | By and far, the two most common

02:21:13.420 | that we see people in practice for is the redness form,

02:21:16.740 | redness and flushing, or the pimple form.

02:21:19.460 | You're absolutely right in that alcohol

02:21:21.100 | can contribute to it and worsen it for two reasons.

02:21:23.220 | One, alcohol itself is a vasodilator

02:21:25.540 | and acetaldehyde is a much more potent vasodilator.

02:21:28.340 | So when you drink, you flush.

02:21:30.460 | Also chronic impairment of the gut microbiome

02:21:33.620 | and lifestyle changes that make you drink more

02:21:35.620 | probably will exacerbate your rosacea.

02:21:39.220 | But things that trigger the redness include UV light

02:21:42.220 | because of vasodilation, spicy foods,

02:21:45.900 | hot beverages, emotions, life stressors,

02:21:48.660 | all the things that make you flush.

02:21:50.540 | What triggers the breakouts is a little bit different.

02:21:55.660 | And why that's important is how we treat them.

02:21:57.540 | So what triggers breakouts is thought to be

02:22:00.180 | both organisms that live on our skin,

02:22:02.460 | including bacteria and certain mites,

02:22:04.980 | but also immune dysregulation in our skin.

02:22:07.780 | That we don't really understand or just now elucidating

02:22:11.860 | how the immune system in the skin becomes dysfunctional

02:22:15.020 | to show those breakouts.

02:22:16.860 | In terms of treating redness,

02:22:18.980 | we have some creams that are okay

02:22:22.380 | at temporarily blanching those vessels out,

02:22:24.860 | but they're not great and they're temporary.

02:22:27.020 | We don't have great treatments for them,

02:22:28.700 | but we have great lasers for redness.

02:22:32.020 | So when patients come to see me for redness

02:22:34.220 | or any dermatologist for redness,

02:22:35.900 | generally there's a discussion about laser destruction

02:22:38.300 | of those blood vessels.

02:22:39.540 | When we talk about breakouts or pimple form of rosacea,

02:22:43.740 | we have excellent medications in terms of both creams

02:22:46.740 | and oral medications that suppress both the bacterial

02:22:51.100 | and mite growth as well as the immune response in the skin.

02:22:55.340 | So you kind of have to take a look at what form you have

02:22:57.780 | and what will be the best treatment.

02:23:00.020 | - Eczema.

02:23:01.020 | - Umbrella term for what we generally consider

02:23:04.100 | as atopic dermatitis,

02:23:05.940 | or what used to be colloquially termed

02:23:09.460 | as sensitive skin in childhood.

02:23:12.100 | And that's a very prominent skin condition

02:23:16.340 | also dictated by the immune system, but in two forms.

02:23:21.140 | Eczema tends to be caused by three major prongs.

02:23:25.220 | The first prong is a genetic barrier defect in the skin.

02:23:30.180 | So patients with eczema tend to have a microscopic weave

02:23:33.300 | of their skin that's not as tight

02:23:35.700 | as somebody without eczema.

02:23:37.460 | And that's usually defined by a gene called filaggrin.

02:23:40.940 | That's the first reason to develop eczema.

02:23:46.380 | The second reason is an environmental allergen or trigger

02:23:51.380 | that's able to get through these weaves easier

02:23:54.620 | because of this genetic change.

02:23:57.380 | The third thing is an aberrant immune response

02:24:00.500 | to these triggers.

02:24:01.700 | So patients with eczema tend to have an immune system

02:24:04.780 | that responds a little bit more vigorously or overactively

02:24:08.780 | to the same environmental trigger,

02:24:10.860 | probably because there's more trigger getting in

02:24:12.980 | through the barrier defect than somebody who doesn't.

02:24:16.340 | So the cornerstone in treating eczema

02:24:18.660 | is treating these three things.

02:24:20.340 | Why dermatologists make a big stink

02:24:22.580 | about moisturize, moisturize, moisturize for eczema

02:24:25.620 | is to seal that barrier with a moisturizer

02:24:29.100 | because we're basically putting the mortar

02:24:30.940 | back in between the bricks, which are the skin cells,

02:24:33.900 | to seal the skin off,

02:24:35.820 | to not allow the environmental allergen to get in.

02:24:38.620 | That's the first.

02:24:39.460 | The second is to avoid environmental triggers.

02:24:42.540 | So fragrances, preservatives, seasonal allergies,

02:24:46.540 | pollens, things that trigger that immune response,

02:24:48.820 | we try to mitigate.

02:24:49.860 | Now, obviously trying to control environmental pollens

02:24:53.140 | is hard, but using things like we talked about earlier,

02:24:57.540 | fragrance-free cleansers, fragrance-free detergents,

02:25:00.900 | fragrance-free skincare products,

02:25:04.300 | non-preservative-based skincare products

02:25:06.660 | will mitigate the environmental triggers.

02:25:08.780 | And then the third thing

02:25:09.900 | is just calming the immune system down.

02:25:12.340 | And that can be done in a variety of ways.

02:25:14.460 | Most commonly, it's topical medications

02:25:16.780 | like topical steroids that dampen the immune system

02:25:19.260 | and the skin.

02:25:20.340 | And when eczema is really, really bad,

02:25:22.700 | there are biologic medications

02:25:25.540 | that control certain interleukins,

02:25:27.740 | and they've made an incredible advancement

02:25:31.340 | in eczema control.

02:25:32.660 | People, we can control patients for life

02:25:35.140 | with some of these injectable medicines.

02:25:37.580 | - A couple of things that you taught me

02:25:38.940 | that I just wanna pass along in short form,

02:25:41.660 | and please correct me if I have this wrong.

02:25:44.060 | One, if you can avoid popping pimples,

02:25:46.820 | definitely avoid it because it can cause damage,

02:25:49.340 | recruitment of these matrix metalloproteases,

02:25:52.220 | which essentially digest some of the deeper layers

02:25:54.540 | of the skin, leave scars.

02:25:56.380 | - Yeah, yeah, totally.

02:25:57.460 | So it's, I mean, it's very gratifying,

02:26:00.300 | and you wanna do it.

02:26:01.220 | There's like some subconscious desire to like pop a pimple.

02:26:05.220 | I have it myself.

02:26:06.060 | Anytime I see a pimple, I'm like,

02:26:07.100 | "Man, I gotta, I wanna get at this thing."

02:26:08.880 | - I think it's to eradicate the infection type of thing.

02:26:12.020 | You know, even if it's not an infection,

02:26:13.540 | I think that's the- - Possibly,

02:26:14.380 | like a evolutionary reason.

02:26:16.460 | - Yeah, very, very possible.

02:26:17.960 | The reason we don't wanna do that,

02:26:20.980 | and the reason why we always say don't pick at your skin

02:26:23.220 | is when there's an immune response in the skin,

02:26:26.840 | the immune system's trying to fix something

02:26:28.940 | and fight something,

02:26:29.780 | and in doing so, it recruits different enzymes.

02:26:33.080 | The most common enzyme is what you exactly described,

02:26:35.620 | matrix metalloproteinases,

02:26:37.580 | which are these enzymes that eat apart collagen and elastin

02:26:40.540 | to allow it to remodel.

02:26:42.140 | When you cause physical trauma in the skin,

02:26:45.900 | you recruit a much larger immune response

02:26:48.580 | than what was warranted for that insult.

02:26:51.540 | So these MMPs, these matrix metalloproteinases,

02:26:54.740 | enter at a much higher amount,

02:26:56.860 | and they eat away at the collagen and elastin.

02:26:59.460 | That's what leaves an acne scar.

02:27:01.700 | Now, people are gonna pop their pimples,

02:27:04.180 | whether we want to or not.

02:27:05.780 | So if you're gonna do it, I don't recommend it,

02:27:08.520 | but if you're gonna do it,

02:27:10.500 | generally what we recommend is if there is no tip,

02:27:14.380 | don't even think about it.

02:27:15.780 | If there is a small white tip

02:27:17.820 | and not much pain or induration,

02:27:19.620 | you can use a warm compress to see if you can soften that

02:27:22.740 | and see if it'll expel itself.

02:27:25.140 | Pushing, we don't recommend.

02:27:26.740 | Stretching can sometimes unroof a pimple,

02:27:30.860 | tends to cause less trauma.

02:27:32.960 | But again, if you listen to one thing, don't do it.

02:27:36.240 | - And if they pop on their own,

02:27:39.780 | can't believe we're having this conversation,

02:27:41.220 | but it's a skin health and appearance episode after all,

02:27:44.700 | if they pop on their own,

02:27:45.620 | then cleaning it with a gentle cleanser

02:27:48.340 | is probably the best way to go.

02:27:49.700 | No topical antibiotics, is that right?

02:27:52.700 | - Don't use any hydrogen peroxide.

02:27:54.380 | It's a common misconception thinking it fights things.

02:27:57.700 | Peroxide doesn't let wounds heal.

02:27:59.220 | It just kills anything living.

02:28:00.380 | So no peroxide and no topical antibiotics

02:28:04.460 | that are over the counter.

02:28:05.340 | Most of these don't have any antibiotic properties anyway,

02:28:07.900 | 'cause most organisms are resistant to them

02:28:09.660 | because of the widespread availability and use.

02:28:11.740 | And two, they cause a lot of allergic contact,

02:28:15.540 | dermatitis and rashes in people who are susceptible to them.

02:28:18.700 | So we just say, if it pops on its own, leave it alone.

02:28:22.380 | They wanna put a little ointment on there

02:28:23.820 | if you have a sore, but otherwise ignore it.

02:28:26.660 | - And what about the use of corticosterone cream?

02:28:30.420 | Like if somebody has a red bump

02:28:31.900 | and they're headed to an event or something

02:28:33.580 | and they wanna eliminate some of the redness and bumpiness.

02:28:39.620 | - So a common thing we see a lot of people for,

02:28:42.300 | it's like a day before their wedding

02:28:43.440 | or a day before a big social event

02:28:44.780 | and they have a zit on their forehead and they say,

02:28:46.380 | you know, what can you do for me?

02:28:47.620 | I need this gone.

02:28:49.160 | So exactly like we talked about, topical corticosteroids

02:28:52.560 | and to a greater extent injectable,

02:28:54.620 | intralesional corticosteroids

02:28:56.540 | suppress the immune response temporarily.

02:29:00.700 | So you can use them cautiously

02:29:04.180 | if you have an event within the next day or two.

02:29:07.300 | Long-term use, it causes multiple problems.

02:29:09.860 | It causes thinning of the skin

02:29:11.380 | and can increase the risk of the acne scar forming.

02:29:15.340 | And you can have rebound acne

02:29:17.280 | from topical steroids used all over the face.

02:29:20.720 | Oftentimes we see a lot of people who are in the public eye

02:29:25.580 | asking for steroid injections of their acne.

02:29:28.420 | I, as a surgeon, usually see a lot of the consequences

02:29:31.940 | of that, so I tend not to utilize

02:29:34.100 | steroid injections for acne.

02:29:36.860 | The reason for that is if you place just a little too much,

02:29:40.660 | and we're talking less than 0.1 milliliter difference,

02:29:45.660 | you can have a permanent atrophic divot in the skin

02:29:50.220 | that is only fixed by surgery.

02:29:52.300 | So I see a lot of young patients that come in

02:29:54.660 | who had an acne spot injected here

02:29:56.380 | and now that divot is left and that's permanent.

02:29:59.860 | If it's gonna be done, it should be done by a dermatologist

02:30:03.420 | who knows what they're doing.

02:30:04.860 | Low concentrations, usually bottom half of the face

02:30:07.900 | can be effective in getting rid of a really bad pimple

02:30:11.220 | that needs to be gone immediately.

02:30:12.580 | You just gotta know the risks.

02:30:14.060 | - Assuming sterile technique

02:30:18.340 | and other safety measures in place,

02:30:21.140 | are tattoos inherently bad for skin?

02:30:23.820 | - No, I don't think so.

02:30:24.700 | I think tattoos are an awesome form of art

02:30:26.860 | and I think it used to be linked to, you know,

02:30:31.100 | stereotypes that are no longer true.

02:30:33.060 | I think the challenge with tattoos is two things,

02:30:36.460 | making sure that what is being placed underneath the skin

02:30:40.460 | is not an allergen.

02:30:41.900 | We see this mostly with the reds that use cinnamates.

02:30:44.940 | They produce a lot of granulomatous reactions

02:30:48.700 | or foreign body reactions.

02:30:50.420 | One, making sure obviously they're using

02:30:52.300 | clean, safe equipment that's sterile.

02:30:54.420 | You know, you don't want the bloodborne pathogens.

02:30:57.260 | The real challenge is surveying for growths.

02:31:00.100 | In patients who have a lot of tattoos,

02:31:02.180 | it's hard to see small skin cancers form

02:31:05.460 | or changes in moles

02:31:06.860 | because usually the tattoos are of dark color.

02:31:10.020 | So the surveillance part

02:31:12.020 | becomes a little bit more challenging.

02:31:13.420 | So if you have a lot of tattoos,

02:31:14.660 | just make sure to see your dermatologist

02:31:16.340 | and somebody who feels comfortable

02:31:17.700 | and confident in screening.

02:31:19.700 | But other than that, no.

02:31:21.260 | They've been around for hundreds and hundreds of years

02:31:24.300 | and I think they're fine if done correctly.

02:31:26.980 | - That's a good segue into surveying for skin cancers.

02:31:31.780 | Earlier, you talked about some of the more common forms

02:31:34.140 | of skin cancer, squamous cell carcinoma,

02:31:37.860 | basal cell carcinoma.

02:31:39.660 | But then there's the one no one truly wants,

02:31:44.660 | which is melanoma.

02:31:47.140 | So I was taught to keep an eye on my moles.

02:31:51.420 | If they change, change in border,

02:31:52.940 | change in size, et cetera, to notify a dermatologist.

02:31:57.340 | I get my moles checked about, I don't know,

02:31:59.900 | I just had it done less than a year ago.

02:32:02.480 | But what about getting all skin checked?

02:32:06.660 | I mean, what do you, this is your area of expertise.

02:32:09.900 | So if you had a magic wand to help prevent skin cancers,

02:32:14.740 | what would you have people do?

02:32:16.720 | - That's a great, great question.

02:32:20.380 | So obviously there are many forms of skin cancer,

02:32:24.380 | but the three most common, like we talked about,

02:32:26.060 | basal cell carcinoma, squamous cell carcinoma, and melanoma.

02:32:29.940 | There are other types like Merkel cell and et cetera,

02:32:32.780 | but they're far less common.

02:32:34.240 | Now, historically, melanoma has been our number one killer

02:32:38.700 | for skin cancer until about a few years ago, around 2018,

02:32:43.700 | when the Nobel Prize was won for the new drugs

02:32:47.060 | that treated melanoma.

02:32:49.060 | This year, we expect three times as many deaths

02:32:52.580 | in the United States from squamous cell carcinoma

02:32:55.560 | than we do melanoma, but nobody talks about that.

02:32:58.480 | We lose a patient every about 62 minutes to melanoma,

02:33:02.880 | but one every 37 minutes to squamous cell carcinoma.

02:33:06.260 | First and foremost, the thing that you wanna look for

02:33:09.500 | in terms of skin cancer risk and predisposition

02:33:12.140 | is look at family history.

02:33:13.260 | Your family history and your genetics

02:33:14.860 | plays the largest role in predisposition

02:33:17.740 | for skin cancer development.

02:33:19.460 | If you can gather a family history,

02:33:20.940 | you can understand your risk in developing it,

02:33:23.260 | and it can help dictate your screening.

02:33:25.820 | Now, if you can't get a family history

02:33:27.180 | or you don't know your family history,

02:33:28.300 | not a problem.

02:33:29.540 | Generally, we recommend an annual skin exam

02:33:32.560 | by a good, reputable, board-certified dermatologist,

02:33:35.700 | and that includes every square inch of your skin,

02:33:39.020 | including your hair between your toes in the genital area.

02:33:43.240 | We can develop a skin cancer anywhere.

02:33:45.200 | Bob Marley died of a melanoma on his toenail

02:33:47.620 | that was thought to be a soccer injury.

02:33:49.820 | Jimmy Buffett died of a Merkel cell carcinoma,

02:33:52.240 | one of these rarer types that occur in sun-exposed areas.

02:33:55.660 | Anybody can get them.

02:33:57.360 | Obviously, there's predispositions

02:33:59.060 | in higher-risk populations,

02:34:00.380 | but it's such an easy, non-invasive exam to do

02:34:03.980 | that everybody should get one at least once a year.

02:34:07.180 | The other reason why I bring this up

02:34:09.020 | is skin cancers can develop in sun-protected areas.

02:34:12.740 | One of the areas that I see a rapid increase

02:34:16.260 | in skin cancer development is in genital areas

02:34:20.180 | and in the mouth due to HPV,

02:34:22.300 | and we see this a lot in younger and younger patients.

02:34:25.100 | Probably in the last month,

02:34:26.140 | I've operated on six or seven young patients

02:34:28.480 | under the age of 40 with squamous cell carcinomas

02:34:32.200 | caused by HPV in the genital region.

02:34:35.520 | This is obviously not sun-driven.

02:34:37.640 | It's not something you can put sunscreen

02:34:39.520 | or take a product to protect you from,

02:34:41.800 | but it's something that's easily monitored or surveyed.

02:34:45.160 | So I would say at the very minimum,

02:34:47.480 | get a family history or a personal history,

02:34:49.480 | get an annual surveillance exam.

02:34:51.840 | If you have a lot of moles,

02:34:53.600 | I used to direct the pigmented lesions in melanoma clinic.

02:34:56.180 | This is something that was really hard

02:34:58.520 | for a lot of dermatologists and patients to follow

02:35:02.500 | when they're covered with moles, see which one is changing.

02:35:06.180 | There are tools that can be utilized,

02:35:08.380 | including whole body photography, mole mapping,

02:35:11.220 | and some new AI-based softwares

02:35:13.860 | that basically track the moles and look for changes

02:35:17.140 | as you feed the software more and more pictures

02:35:19.460 | from the patients.

02:35:20.300 | It's fascinating.

02:35:21.120 | A lot of the stuff is developing from our,

02:35:23.380 | well, I should say my alma mater,

02:35:24.620 | but up at Stanford is these AI-based software apps

02:35:29.620 | that allow us to survey

02:35:31.180 | some of the most challenging patients.

02:35:33.220 | So if you have a lot of moles,

02:35:35.260 | your screening may be more than once a year.

02:35:38.460 | If you have a lot of moles,

02:35:39.780 | you inherently have a slightly increased risk for melanoma.

02:35:44.780 | Now, we always use these terms interchangeably,

02:35:47.620 | melanoma, skin cancer, basal, squamous, et cetera.

02:35:50.880 | Importantly to know, for every one melanoma,

02:35:54.280 | there's 10 non-melanoma skin cancers.

02:35:57.680 | That's namely basal cell and squamous cell.

02:35:59.680 | About 5 million Americans will be diagnosed

02:36:01.800 | with one of the non-melanomas this year alone.

02:36:04.600 | - 5 million. - 5 million.

02:36:05.880 | - It's a big number.

02:36:06.720 | - Yeah, it's about one in four.

02:36:08.160 | One in four Americans at some point in their lifetime

02:36:10.640 | will develop a skin cancer,

02:36:12.440 | encroaching one in three Americans by the end of 2030.

02:36:17.000 | So it's a lot.

02:36:18.280 | Majority of these are not life-threatening,

02:36:20.560 | but they're functionally and cosmetically disfiguring.

02:36:23.320 | They arise on sun-exposed areas,

02:36:25.600 | so surveillance is really important.

02:36:27.740 | - For the HPV that eventually becomes squamous cell,

02:36:33.840 | carcinoma, is the HPV vaccine effective even at older ages?

02:36:39.560 | - Yeah, great question.

02:36:41.400 | So we are seeing HPV become a real problem

02:36:46.760 | in many cancers in the body,

02:36:48.520 | not just the original cervical cancer,

02:36:51.040 | which was the number one killer in young women for cancer

02:36:53.800 | until the vaccine came out,

02:36:55.480 | but we're seeing it now as the number one cause

02:36:58.040 | of throat cancer in young adults and sexually active adults,

02:37:01.480 | significantly increased risk of squamous cell carcinomas

02:37:06.240 | in sun-protected areas, immunosuppressed patients.

02:37:10.520 | The vaccine, the Gardasil vaccine,

02:37:12.520 | which treats or builds immunity to HPV

02:37:17.520 | covers the strains that cause cancer,

02:37:20.160 | 16, 18, 31, 33, and so on.

02:37:23.640 | I recommend anybody who is either sexually active

02:37:27.200 | or anybody who, in population, literally anyone,

02:37:30.400 | should get vaccinated.

02:37:31.480 | The new guidelines have extended the age

02:37:35.480 | up until I think late 40s for both men and women.

02:37:38.520 | It used to be only for young women

02:37:40.800 | because the cervical cancer risk,

02:37:42.120 | but now we've found that so many things

02:37:43.600 | are implicated with HPV

02:37:45.520 | that the on-label use is up to the late 40s.

02:37:50.520 | So if you have any concern,

02:37:53.480 | I highly recommend getting the vaccine.

02:37:55.840 | - As I recall, planter's warts,

02:37:58.360 | which are these warts that burrow a kind of root

02:38:01.000 | into the bottom of the foot.

02:38:02.800 | They're very painful.

02:38:03.880 | That actually can be caused by HPV.

02:38:08.880 | It's a form of HPV,

02:38:10.720 | and it's not sexually transmitted.

02:38:12.240 | It's locker room transmitted.

02:38:14.720 | - Yeah, so HPV comes in about 200 strains

02:38:18.040 | or like 190 strains.

02:38:20.320 | Strains one, two, and four, for example,

02:38:22.680 | cause warts on the hands and feet.

02:38:24.640 | What you see like gym goers and kids,

02:38:27.200 | they get warts.

02:38:28.280 | HPV six and 11, for example, cause genital warts.

02:38:32.240 | HPV strains 16, 18, 31, and 33 cause cancer.

02:38:37.000 | The question is when you get something,

02:38:38.880 | does it come with its brothers or its siblings?

02:38:42.480 | And that's the question we don't know.

02:38:45.000 | The vaccine was made to treat high-risk strains,

02:38:49.460 | but because of cross-antigenicity,

02:38:51.640 | we see that patients who get vaccinated,

02:38:54.440 | their warts go away.

02:38:56.000 | And we saw this in the hospital in transplant patients

02:38:58.220 | who were covered with warts

02:38:59.420 | because of their immunosuppressed effect.

02:39:01.960 | When we would vaccinate them, their warts would get better.

02:39:04.760 | - So warts on their fingers,

02:39:05.800 | warts on their, planter's warts on their feet.

02:39:08.000 | - Yeah, transplant patients

02:39:09.120 | and anybody who is immunosuppressed,

02:39:11.640 | they have a tough time fighting plantar's warts,

02:39:14.600 | finger warts, any sort of viral-based condition

02:39:18.160 | because their immune system is suppressed

02:39:20.020 | from medications or otherwise.

02:39:22.120 | So they usually have a tough time fighting these things.

02:39:25.340 | They have a higher incidence of a lot of things,

02:39:27.680 | but the vaccine was cool, eradicating it.

02:39:30.640 | Now, I'm not saying go get a vaccine

02:39:32.240 | cause you have a plantar wart, that's silly and overkill.

02:39:35.400 | Usually warts we treat with freezing

02:39:38.240 | in office procedures, easy things, but.

02:39:40.760 | - Plantar's warts can be burnt out.

02:39:42.480 | - Yeah, we burn them or freeze them or scrape them,

02:39:45.040 | use a little medication,

02:39:46.200 | but the vaccine does improve some of the burden of disease,

02:39:51.200 | even though it doesn't target that strain.

02:39:53.500 | - Do you think soon we will be in the landscape

02:39:55.600 | of vaccines for all forms of skin cancer?

02:39:58.620 | - I think we're on the forefront.

02:40:01.260 | And the term vaccine is a really big umbrella term.

02:40:05.780 | - Loaded term too.

02:40:06.620 | - Yeah, I know, it's gonna garner a lot of questions.

02:40:09.060 | I think, yes, absolutely.

02:40:10.780 | There was a new study that showed that an mRNA vaccine,

02:40:15.780 | and that is already pretty controversial,

02:40:19.040 | was shown to improve melanoma survival

02:40:21.580 | after surgery and chemotherapy.

02:40:23.460 | So what the goal of all these things

02:40:26.740 | is to prime your immune system

02:40:29.700 | and have the immune system know what to target.

02:40:32.380 | It's to teach the immune system,

02:40:34.000 | hey, this is bad, next time you see this, go attack it.

02:40:38.900 | It's like showing a bloodhound a steak

02:40:41.380 | and then going on the hunt.

02:40:43.180 | The bloodhound now knows what to scent for

02:40:45.760 | and what is normal and what isn't.

02:40:48.100 | So the vaccines have a lot of controversial things.

02:40:51.220 | I think for medicine and cancer biology,

02:40:54.140 | it's gonna be revolutionary.

02:40:55.780 | We see it for brain tumors, we see it for glioblastoma,

02:40:58.580 | incredible changes with dendritic cell vaccines.

02:41:01.560 | We see it for melanoma now.

02:41:03.460 | And in the future, it may be used for all skin cancers

02:41:08.460 | with an asterisk, depending on how much we can activate

02:41:12.140 | the immune system to target it.

02:41:13.700 | - Fascinating, and a good place for us to probably pause

02:41:19.660 | until the next time we have you back

02:41:22.860 | to talk about where that technology evolves.

02:41:25.340 | Because today you've taught us so much

02:41:28.340 | about skin, what it is, its anatomy, its physiology,

02:41:33.020 | what it reflects in terms of our internal workings,

02:41:35.700 | health, or in some cases, challenges with health.

02:41:38.440 | Talked about various conditions such as psoriasis, acne,

02:41:42.180 | eczema, dandruff, as it's sometimes called,

02:41:46.340 | and what we can do, the role of nutrition,

02:41:50.460 | avoiding certain things like excess alcohol,

02:41:53.380 | nicotine, et cetera, but also some of the newer

02:41:56.860 | and more exciting treatments that exist

02:41:58.620 | for all these conditions,

02:42:00.500 | some merely cosmetic and uncomfortable,

02:42:04.180 | some truly life-threatening and dangerous like melanoma.

02:42:08.420 | So for all those reasons, and also for taking time

02:42:11.500 | out of your very busy clinical schedule to come talk to us,

02:42:14.600 | I really appreciate it, and I want to voice my appreciation,

02:42:19.600 | both for myself and for those listening and viewing.

02:42:23.280 | I know people will have many, many questions,

02:42:25.180 | so we will refer them to your social media accounts

02:42:28.140 | and links to your clinic and so forth

02:42:31.380 | so that they can have those questions addressed

02:42:33.580 | and who knows, maybe even get the chance to work with you.

02:42:36.740 | In the meantime, I just want to say thank you

02:42:38.540 | for this public education gift that you've given us.

02:42:42.140 | I'm thinking about skin very differently now,

02:42:44.380 | and I plan to do and not do certain things

02:42:48.180 | in light of today's conversation, no pun intended.

02:42:51.580 | - Thank you for the opportunity.

02:42:53.060 | I'm incredibly grateful to be here.

02:42:54.860 | I think teaching is really important.

02:42:57.220 | Having evidence-based discussions is really important.

02:43:00.300 | Challenging dogma is also important,

02:43:02.900 | done in the right way, in the evidence-based way.

02:43:05.260 | I love what I do.

02:43:06.460 | I love everything about the skin.

02:43:08.740 | I love seeing patients and also challenging

02:43:12.700 | the status quo on certain things.

02:43:15.300 | So thank you for the opportunity.

02:43:16.780 | It's been a lot of fun.

02:43:17.740 | There's a lot to talk about in skin.

02:43:20.060 | We can probably talk for a decade if you let me,

02:43:22.480 | but I appreciate it, thank you.

02:43:24.100 | - Well, we will certainly bring you back

02:43:25.220 | to further the discussion.

02:43:27.140 | Meanwhile, thank you ever so much, Dr. Soleimani.

02:43:30.180 | - Thank you.

02:43:31.260 | - Thank you for joining me for today's discussion

02:43:33.100 | about how to improve and protect your skin

02:43:35.340 | with Dr. Teo Soleimani.

02:43:36.980 | To learn more about his work and find links to his clinic,

02:43:39.900 | please see the show note captions.

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02:44:12.620 | For those of you that haven't heard,

02:44:13.760 | I have a new book coming out.

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02:44:16.580 | It's entitled "Protocols,

02:44:17.980 | an Operating Manual for the Human Body."

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02:44:34.340 | And of course, I provide the scientific substantiation

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02:44:39.780 | The book is now available by presale at protocolsbook.com.

02:44:43.680 | There you can find links to various vendors.

02:44:46.060 | You can pick the one that you like best.

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02:44:49.580 | an Operating Manual for the Human Body."

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02:45:48.740 | Once again, thank you for joining me

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Dr. Teo Soleymani: How to Improve & Protect Your Skin Health & Appearance

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